INTRODUCTION: The presence of the appendix in a femoral hernia sac is known as de Garengeot's hernia. We report a rare case of an elderly woman with femoral hernia appendicitis and discuss the surgical pitfalls and considerations through a literature review. PRESENTATION OF CASE: An 83-year-old woman presented with fever and right lower quadrant abdominal pain. Clinical examination revealed a femoral hernia. Ultrasonography confirmed bowel was present in the hernia sac. In the operation room, an acutely inflamed appendix was recognized within the sac. The patient underwent appendectomy and hernia repair with sutures. DISCUSSION: Acute appendicitis within a femoral hernia is rare and multiple dilemmas exist regarding its treatment. An incision below the inguinal ligament is a reasonable choice in order to access the hernia sac. A mesh should be placed in non-infectious appendectomy while herniorrhaphy is preferred in cases of appendicitis. CONCLUSION: The presence of the vermiform appendix in a femoral hernia sac is rare but the surgeon should be aware of this clinical entity. Prompt diagnosis and appropriate surgical treatment is the key to avoid complications.

Purpose. Thorough understanding of biliary anatomy is required when performing surgical interventions in the hepatobiliary system. This study describes the anatomical variations of right bile ducts in terms of branching and drainage patterns, and determines their frequency. Methods. We studied 73 samples of cadaveric material, focusing on the relationship of the right anterior and posterior segmental branches, the way they form the right hepatic duct, and the main variations of their drainage pattern. Results. The anatomy of the right hepatic duct was typical in 65.75% of samples. Ectopic drainage of the right anterior duct into the common hepatic duct was found in 15.07% and triple confluence in 9.59%. Ectopic drainage of the right posterior duct into the common hepatic duct was discovered in 2.74% and ectopic drainage of the right posterior duct into the left hepatic duct in 4.11%. Ectopic drainage of the right anterior duct into the left hepatic ductal system and ectopic drainage of the right posterior duct into the cystic duct was found in 1.37%. Conclusion. The branching pattern of the right hepatic duct was atypical in 34.25% of cases. Thus, knowledge of the anatomical variations of the extrahepatic bile ducts is important in many surgical cases.

Endometriosis is a multifactorial disease with unclear pathogenesis. Urinary tract endometriosis occurs in about 1% of all endometriotic lesions while isolated ureteral endometriosis is extremely rare. We present a case of intrinsic ureteral endometriosis causing ureteral stenosis in a 40-year's old woman, in combination with intestinal, extensive peritoneal and ovarian endometriosis. The clinicopathological features and investigation methods used, as well as the treatment approach are discussed. An individual therapy plan depending mainly on the patient's age, desire for children and the extent of the endometriotic foci should always be attempted. Collaboration between gynecologists and urologists was essential in our cases.

Placement of peripherally inserted central catheters (PICCs), definitely offers a clear advantage over any other method regarding central venous catheterization. Its ultrasonographic orientation enhances significantly its accuracy, safety and efficacy, making this method extremely comfortable for the patient who can continue his or her therapy even in an outpatient basis. We present the first reported case of a PICCS insertion in Greece, which has been performed by a university-degree nurse. The aim of this review of literature was to present the evolution in nursing practice in Greece. A PICC was inserted in a 77-year-old male patient suffering from a recent chemical pneumonia with a history of Alzheimer's disease. A description of all the technical details of this insertion is reported, focusing on the pros and cons of the method and a thorough review of the history and advances in central venous catheterization throughout the years is also presented. PICCs provide long-term intravenous access and facilitate the delivery of extended antibiotic therapy, chemotherapy and total parenteral nutrition. We strongly believe that PICCs are the safest and most effective method of peripherally inserted central venous catheterization. Larger series are necessary to prove the above hypothesis, and they are under construction by our team.

BACKGROUND: Mucinous tubular and spindle cell carcinoma (MTSC) is a rare and newly described type of renal cell carcinoma (RCC) with relatively indolent behavior. Although there are small series of this clinical entity in the literature, its histogenetic origin or line of differentiation remains unclear. PATIENTS AND METHODS: A 67-year-old woman was hospitalized for flank pain; imaging studies revealed a 6.5-cm mass in the right kidney. She was referred for fine needle aspiration of the lesion, which showed an epithelial tumor with round to oval nuclei associated with strands of metachromatic stromal tissue. Cytopathologic diagnosis was consistent with RCC. RESULTS: Subsequent right heminephrectomy was performed and the surgical pathology specimen showed an MTSC of the kidney. The patient has done well postoperatively, with 24 months of benign follow-up. CONCLUSION: A precise differential diagnosis between MTSC and other renal carcinomas (e.g. papillary RCC with sarcomatoid transformation) is important for predicting patient prognosis. Even though MTSC is a rare cause of renal masses, it should be included in the differential diagnosis, especially because its imaging might be misleading, mimicking other benign renal diseases. Heminephrectomy is the preferred treatment in these subjects.

Intercellular adhesion molecule-1 (ICAM-1), a cell adhesion molecule with a key role in inflammation and immunosurveillance, has been implicated in carcinogenesis by facilitating instability of the tumor environment. The K469E single nucleotide polymorphism (SNP) (G>A) affects the ICAM-1 mRNA splicing pattern; the alternatively spliced isoform (ICAM-1-S) lacks transmembrane and intracellular domain, which affects the structural and signal transduction properties. Moreover, the expression of ICAM-1 is transcriptionally regulated by p53, and this SNP has been shown to be related with apoptosis. PCR-RFLP analysis was used to assess the K469E SNP status comparatively in 203 non-small cell lung cancer patients and 175 healthy sex-matched controls. This SNP was examined in relation to tumor kinetic parameters (Ki-67 immunohistochemical evaluation and Tdt-mediated dUTP nick end labeling assay), p53 immunohistochemistry status, and clinicopathological data in patients with operable stages. Both the genotype and allele frequency did not differ significantly between patients and controls. However, patients with the AG/AA genotypes had worse survival (39 vs 45 months, p = 0.036) and tended to be present in advanced stages (p = 0.057). Moreover, the AG/AA genotypes exerted a synergistic effect with aberrant p53 on tumor progression, while the GG genotype retained a better apoptotic index. The AG/AA genotypes correlated with worse survival and advanced stages probably due to defective immunosurveillance and apoptosis. These genetic backgrounds may confer a selective advantage for dissemination of tumor cells with high metastatic potential compared to GG genotype.

Giant paraesophageal hernias (PEHs) are associated with progression of symptoms in up to 45 per cent of patients. Recently, many series have reported that laparoscopic repair of PEH is technically feasible, effective, and safe. A retrospective review of the University of Athens tertiary care hospitals patient database and the patient medical records identified 45 patients who underwent elective repair of a giant PEH between 2002 and 2009. Elective laparoscopic repair of a giant PEH was attempted in 45 patients who were treated with Gore-Tex dual mesh with or without Nissen fundoplication. They all had a mesh repair. Intraoperative complications included one pulmonary embolism and one recurrent hernia. The use of a mesh seems to be effective in the treatment of large hernias. It appears to offer the benefit of a shorter hospital stay and a quicker recovery.