The purpose of this study was to examine the usefulness and the validity of spiral computerized tomography (CT) in assessing acute segmental intestinal ischemia. We present the spiral CT imaging findings in surgically proven cases of intestinal ischemia. 46 patients were admitted to our facility over a five-year period with suspicion of acute enteric ischemia. 34 were first examined with spiral CT and underwent surgery. In 24 of the 34 patients (sensitivity 70.6%), at least one imaging finding specific for segmental intestinal ischemia was recognised (true positive examinations). Spiral-CT examination demonstrated non-specific or normal findings in 7 out of 34 patients with proven intestinal ischemia (20.6% false negative studies). In conclusion, spiral CT can be used in the investigation of patients with suspected acute intestinal ischemia to confirm or suggest the diagnosis or exclude other potential diagnoses.

This retrospective study aimed to estimate the value of spiral Computerized Tomography (sCT) in patients with suspected appendicitis who remained undiagnosed after 48 hours of expectant management. We assessed a cohort of 150 patients by focused unenhanced sCT. According to the clinical scenario we occasionally employed contrast media and extended the scanned area. The major radiological signs were appendiceal enlargement and inflammatory changes of periappendiceal tissue and mesenteric fat. Regarding acute appendicitis the examination was 95.8% sensitive, 97.4% specific, had a positive predictive value of 97.18%, a negative predictive value of 96.2% and an accuracy of 96.7%. It also provided alternative diagnoses in 55 patients leading correctly 31 of them to the theatre for a variety of abdominal surgical diseases. For abdominal surgical pathology in general, sCT was 97.1% sensitive, 95.7% specific, had a positive predictive value of 98% and a negative predictive value of 93.8%. The importance of good communication between the clinicians and radiologists was pointed out by the correct alternative diagnoses set by imaging in the 55 patients after modifying the sCT protocol and was highlighted by the unnecessary appendectomy of three patients with negative imaging. Our results verify the accuracy and value of unenhanced sCT in patients with a clinical picture which remains inconclusive after an initial period of expectant management.

AIM: To evaluate whether the cellular proliferation rate in the large bowel epithelial cells is characterized by circadian rhythm. METHODS: Between January 2003 and December 2004, twenty patients who were diagnosed as suffering from primary, resectable, non-metastatic adenocarcinoma of the lower rectum, infiltrating the sphincter mechanism, underwent abdominoperineal resection, total mesorectal excision and permanent left iliac colostomy. In formalin-fixed and paraffin-embedded biopsy specimens obtained from the colostomy mucosa every six hours (00:00, 06:00, 12:00, 18:00 and 24:00), we studied the expression of G(1) phase cyclins (D(1) and E) as well as the expression of the G(1) phase cyclin-dependent kinase (CDK) inhibitors p16 and p21 as indicators of cell cycle progression in colonic epithelial cells using immunohistochemical methods. RESULTS: The expression of both cyclins showed a similar circadian fashion obtaining their lowest and highest values at 00:00 and 18:00, respectively (P<0.001). A circadian rhythm in the expression of CDK inhibitor proteins p16 and p21 was also observed, with the lowest levels obtained at 12:00 and 18:00 (P<0.001), respectively. When the complexes cyclins D(1) -p21 and E-p21 were examined, the expression of the cyclins was adversely correlated to the p21 expression throughout the day. When the complexes the cyclins D(1) -p16 and E-p16 were examined, high levels of p16 expression were correlated to low levels of cyclin expression at 00:00, 06:00 and 24:00. Meanwhile, the highest expression levels of both cyclins were correlated to high levels of p16 expression at 18:00. CONCLUSION: Colonic epithelial cells seem to enter the G(1) phase of the cell cycle during afternoon (between 12:00 and 18:00) with the highest rates obtained at 18:00. From a clinical point of view, the present results suggest that G(1) -phase specific anticancer therapies in afternoon might maximize their anti-tumor effect while minimizing toxicity.

BACKGROUND/AIMS: Blunt trauma to the extrahepatic biliary tract is a rare and challenging injury The purpose of this paper is to review our experience of these injuries, with special reference to their clinical presentation. PATIENTS AND METHODS: In a retrospective multicenter study of the records of a trauma-admitting in three hospitals, seven patients with blunt extrahepatic biliary tract trauma were identified, one with combined gallbladder and common bile duct injuries and six with a ruptured gallbladder. RESULTS: Except for the patient with the common bile duct injury developing peritoneal signs during observation and being operated 24 hours post-admission, all other patients underwent early laparotomy for shock, peritonitis or positive diagnostic peritoneal lavage (DPL) caused by associated injuries. The common bile duct injury was treated with suture repair over a T tube and the gallbladder injuries with cholecystectomy, except for two cases in which a cholecystostomy was performed. CONCLUSIONS: In patients with blunt trauma, especially to the right upper quadrant, a high index of suspicion and liberal use of diagnostic studies to exclude an isolated extrahepatic biliary tract injury is recommended.

The aim of this study is to describe an alternative technique, using radio frequency energy to perform pericystectomy for hepatic echinococcosis. We present 3 patients with hepatic echinococcosis who were treated with radio frequency ablation (RFA)-assisted pericystectomy. A Radionics Cooltip Radio Frequency System (Tyco, Greece, Radionics) with a single shaft 15 cm long needle electrode and a 2 cm exposure tip, was used. The needle electrode was inserted in consecutive sites into the "healthy" hepatic parenchyma close to the cyst wall, so that a tissue zone around the cystic cavity was gradually ablated. The complete ablation of a site was followed by sharp division of the parenchyma. The operation completed successfully in all patients. Minor bleeding and/or bile leakage were successfully controlled with RFA coagulation. No other hemostatic method was used. The postoperative course was uneventful. No evidence of recurrent disease, or any other cause of morbidity, has been demonstrated at follow up (2 y). RFA-assisted pericystectomy for hepatic hydatid disease in experienced hands, might be useful to perform a "sterile" resection, eradicating single or multiple cysts and preventing local recurrence, with minimal morbidity.

BACKGROUND: Achalasia is a progressive motility disorder of the esophagus, without a definitive cure. The principal method of palliation is myotomy of the distal esophagus. We analyzed the 5-year experience at our institution with laparoscopic Heller myotomy without an antireflux procedure to determine its results, particularly regarding postoperative gastroesophageal reflux. MATERIALS AND METHODS: Thirty-three patients, mean age 43 years (range, 29-62 years) with clinical, manometric, x-ray, and endoscopic proof of achalasia were operated on and followed up for 24 months. Prior to being referred to surgery they had all undergone at least one pneumatic balloon dilation. The operative technique was a 7-cm myotomy that included the lower esophageal sphincter but did not exceed 5 mm of the gastric cardia. Follow-up consisted of clinical observation, cineesophagography, and 24-hour pHmetry. RESULTS: All patients reported satisfactory to excellent results regarding dysphagia and no heartburn two years after the operation. The 24-hour pHmetry and the radiographic investigation showed no evidence of gastroesophageal reflux. CONCLUSION: It seems that the risk of gastroesophageal reflux is very low when the cardiomyotomy does not exceed the length of 5 mm. Our results are in accordance with other observational studies as well as larger cohort and meta-analysis studies. Prospective randomized studies are needed to clarify the role of an antireflux procedure after laparoscopic Heller myotomy.

Pancreatic tuberculosis is a rare clinical setting manifesting in various ways. Most often, enlarged peripancreatic lymph nodes or growing tuberculomas compress adjacent organs, leading to biliary tract or gastrointestinal obstruction. Clinical examination, laboratory data, and imaging are all unspecific. Diagnosis is frequently misguided toward neoplasia requiring surgical intervention. However, the role of surgery in pancreatic tuberculosis ends in tissue sampling, abscess drainage, and bypassing obstruction. We present three cases of pancreatic tuberculosis: two caused by obstructive jaundice and the third caused by gastric outlet obstruction. All patients were operated on. Whipple's procedure was performed in one patient, and biliary and duodenal bypassing in the remaining patients. Diagnosis was decided by histopathology in all three cases. Medical treatment was effective in all patients. Although pancreatic tuberculosis is a medical disease, surgery is frequently used. Maintaining a high level of suspicion can assist in avoiding unnecessary laparotomies and solving this medical dilemma.