Anastasios J. Karayiannakis

Background: Primary post-traumatic aspergillosis is an uncommon fungal infection resulting from direct inoculation of Aspergillus species into disrupted skin and soft tissue. Although it is more frequently encountered in immunocompromised patients, severe localized infection may also occur after traumatic inoculation, particularly in the presence of previously unrecognized predisposing conditions. Involvement of the hand is rare. Case Presentation: A 68-year-old man was referred to our department with a progressive necrotizing infection of the right hand following an occupational agricultural injury. The initial injury had been surgically treated at another institution. On presentation, extensive necrosis involved the palmar aspect of the hand; the index, middle, and ring fingers; and the hypothenar region. The patient had no known systemic condition predisposing him to fungal infection at presentation. During hospitalization, however, persistent hyperglycemia led to the diagnosis of previously unrecognized and uncontrolled diabetes mellitus. Surgical exploration revealed extensive soft-tissue necrosis, thrombosed vessels, poorly perfused and friable tendinous structures, and exposed bony structures of the middle and ring fingers. Aspergillus fumigatus was repeatedly isolated from wound and deep-tissue specimens. Antifungal therapy was initially started with amphotericin B but was discontinued because of a severe allergic reaction and replaced with voriconazole. Three sequential surgical debridements were performed. Magnetic resonance imaging demonstrated extensive soft-tissue involvement without evidence of osteomyelitis. A fourth operation combined further debridement with amputation of the irreversibly damaged middle and ring fingers and immediate reconstruction of the resulting defect with local flap coverage. Subsequent cultures were negative, and the postoperative course was uncomplicated. Conclusions: Post-traumatic A. fumigatus infection of the hand is rare but may lead to extensive soft-tissue destruction. An invasive fungal infection should be considered in progressive necrotizing wounds following contaminated trauma, particularly when the clinical course is atypical or refractory to conventional antibacterial treatment. Early microbiological diagnosis, systemic antifungal therapy, repeated surgical debridement, and recognition of underlying predisposing conditions are essential for successful management.

Background and Clinical Significance: Ganglioneuromas are rare benign tumors of neural crest origin, with gastrointestinal involvement being uncommon and ampullary localization exceptionally rare. Pancreatic neuroendocrine tumors (NETs) are also uncommon neoplasms with variable biological behavior. The coexistence of these two entities is unusual, particularly in the absence of an identifiable hereditary syndrome. Case Presentation: A 38-year-old man presented with hematemesis and multiple episodes of melena over 18 h and was found to have significant anemia with borderline hemodynamic stability. Upper gastrointestinal endoscopy revealed an enlarged, actively bleeding papilla of Vater, and initial hemostasis was achieved with adrenaline injection and endoscopic clipping. However, recurrent massive bleeding developed within 36 h, accompanied by hemodynamic instability. Repeat endoscopy confirmed ongoing hemorrhage, and the patient subsequently underwent emergency pancreaticoduodenectomy. Histopathological examination demonstrated an ampullary ganglioneuroma and an incidental well-differentiated pancreatic neuroendocrine tumor (WHO Grade 2). Surgical margins were negative, and no lymph node metastases were identified. Further evaluation for hereditary endocrine syndromes was unremarkable. The patient remains asymptomatic, with no evidence of recurrence during a 10-year follow-up period. This case highlights the diagnostic and therapeutic challenges associated with rare periampullary tumors. Although ganglioneuromas are typically benign, their anatomical location may result in severe clinical manifestations such as life-threatening bleeding. The coexistence with a pancreatic NET raises questions regarding potential shared pathogenesis, although no genetic syndrome was identified. Limitations of endoscopic management in uncontrolled bleeding and the importance of definitive surgical intervention are emphasized. Conclusions: This case highlights an exceptionally rare coexistence of ampullary ganglioneuroma and pancreatic neuroendocrine tumor presenting with life-threatening gastrointestinal bleeding. Although ganglioneuromas are benign, their anatomical location may result in severe clinical manifestations. Early recognition and decisive surgical management are crucial when endoscopic control fails. Favorable long-term outcomes can be achieved following complete resection.

Background: Pancreaticopleural fistula is a rare complication of chronic pancreatitis resulting from pancreatic duct disruption, typically presenting with pleural effusion and predominant respiratory symptoms. Bilateral pleural involvement is exceptionally uncommon and poses significant diagnostic and therapeutic challenges. Case Presentation: A 56-year-old man with a history of chronic alcohol abuse presented with progressive dyspnea and mild epigastric pain. Imaging revealed bilateral pleural effusions, an atrophic pancreas with a markedly dilated main pancreatic duct containing calculi, and a fistulous tract extending from the pancreatic body through the esophageal hiatus into the mediastinum. Magnetic resonance cholangiopancreatography confirmed the diagnosis of chronic calculous pancreatitis complicated by a pancreaticopleural fistula. After unsuccessful conservative management, the patient underwent distal pancreatectomy, resection of the fistulous tract, and Roux-en-Y pancreatojejunostomy. The postoperative course was uneventful, with complete resolution of pleural effusions and sustained clinical improvement. Conclusions: This case highlights the importance of considering pancreaticopleural fistula in patients with unexplained pleural effusions and minimal abdominal symptoms, particularly in the context of chronic pancreatitis. Bilateral involvement, although rare, should not preclude timely diagnosis. Appropriate diagnostic studies by computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography are crucial for establishing the diagnosis. Surgical management offers definitive treatment in patients with ductal obstruction and calculous disease, resulting in excellent long- term outcomes.

Arteriovenous malformation is a rare disease characterized by abnormal vascular connections between arteries and veins. The condition may remain asymptomatic until complicated by hemorrhage. We present a case of arteriovenous malformation in the pancreatic head complicated by upper gastrointestinal bleeding, which was successfully treated by selective transarterial embolization. A 62-year-old man presented with mild epigastric pain and several episodes of melena. Colonoscopy and upper gastrointestinal endoscopy were not diagnostic. Contrast-enhanced computed tomography revealed abnormal enhancement with multiple vascular branches in the pancreatic head, with early enhancement of the portal venous system in the arterial phase, suggesting the presence of an arteriovenous malformation. Selective angiography revealed an enlarged gastroduodenal artery feeding the malformation and subsequently draining into the portal venous circulation. Embolization of the gastroduodenal artery and of other small branches from the superior mesenteric artery resulted in complete obliteration of the feeding arteries and drainage veins. There was no bleeding recurrence, and the epigastric pain resolved. This case report demonstrates that selective transarterial embolization is a feasible and effective procedure for the treatment of a bleeding pancreatic head arteriovenous malformation.

Objective: Impairment of the Fas/FasL apoptotic pathway is a mechanism contributing to the malignant transformation of multiple cell types. This study aimed to investigate the clinical and prognostic relevance of serum soluble Fas (sFas) and soluble Fas ligand (sFasL) levels in patients with pancreatic and papilla of Vater adenocarcinomas. Methods: An ELISA was used to determine sFas and sFasL levels. Serum samples were obtained from 53 healthy controls, 82 pancreatic and 14 papilla of Vater carcinoma patients. Sera from carcinoma patients were obtained before surgery and 30 days after surgery. The relationships of preoperative levels with clinicopathological features and patient survival were evaluated. Changes in serum sFas and sFasL levels after surgery were also evaluated. Results: Higher sFas and lower sFasL levels were found in the serum of carcinoma patients in comparison to healthy controls. Serum sFas and sFasL levels correlated significantly with both lymph node and distant metastases and an advanced stage of disease. Elevated sFas and decreased sFasL levels correlated significantly with poor overall survival when the entire study population was considered with sFas being an independent prognostic factor. After patient stratification, their prognostic value was evident in pancreatic carcinoma patients only. Preoperative sFas levels decreased and sFasL levels increased after radical resection of the tumor but remained unchanged in cases of unresectable disease. Conclusions: These findings suggest that serum levels of sFas and sFasL could be useful tumor markers with prognostic value in pancreatic adenocarcinomas. Increased sFas secretion may reflect a mechanism for apoptotic escape of cancer cells.

Objective: Impairment of the Fas/FasL apoptotic pathway is a mechanism contributing to the malignant transformation of multiple cell types The aim of this study was to evaluate the clinical usefulness of soluble forms of both Fas receptor (sFas) and its ligand (sFasL) in the serum of patients with pancreatic and papilla of Vater adenocarcinomas. Methods: Soluble levels of Fas and FasL were measured by an ELISA in the serum of 53 healthy controls and in 82 pancreatic and in 14 Vater carcinoma patients both before surgery and 30 days after surgery. The association between preoperative levels, clinicopathological features and patient survival, and their changes following surgery were evaluated. Results: Cancer patients had significantly higher sFas and lower sFasL levels compared to healthy controls and correlated significantly with both lymph node and distant metastases and advance disease stage. Elevated sFas and decreased sFasL levels correlated significantly with poor overall survival with sFas being an independent prognostic factor. Following radical tumor resection preoperative sFas levels decreased whereas sFasL levels increased. These levels remained unchanged in cases of unresectable disease. Conclusions: Increased sFas secretion by pancreatic or Vater adenocarcinomas could contribute to the escape of cancer cells from apoptosis induction. Serum levels of sFas and sFasL could be useful tumor markers with prognostic value for pancreatic or Vater adenocarcinomas.

Pneumatosis intestinalis (PI) is a rare condition characterized by gas-filled cysts within the wall of the gastrointestinal tract with variable presentation. We present two patients with pneumatosis intestinalis different in their clinical presentation, clinical course, and treatment. A 79-year-old male with a history of chronic obstructive pulmonary disease presented with an acute abdomen. Clinical findings and abdominal radiography suggested perforation of the digestive tract. During emergency laparotomy, multiple cystic bubbles and perforation were found in the terminal ileum, and the affected part of the ileum was resected. The second patient was a 64-year-old female under adjuvant chemotherapy with cisplatin and paclitaxel for ovarian adenocarcinoma. She presented with signs of bowel obstruction. Abdominal computed tomography was diagnostic for intestinal pneumatosis. She was successfully treated conservatively. These two cases highlight the varied clinical presentation of pneumatosis intestinalis and differences in its treatment. High clinical suspicion, cautious judgment of clinical and laboratory findings, and careful assessment of the imaging findings are necessary for accurate diagnosis and appropriate management.

This study describes a case of an 80-year-old patient admitted to our hospital with mid-epigastric pain, nausea, vomiting, and persistent fever for the last two days, after an episode of acute gallstone pancreatitis six weeks earlier. On admission, the patient was clinically stable with leukocytosis, high serum amylase levels, and high CRP levels. An abdominal CT scan showed a well-circumscribed, thick-walled fluid collection with air-fluid levels suggestive of an infected pancreatic pseudocyst. The patient underwent exploratory laparotomy in which fluid aspiration, removal of necrotic tissue, placement of drainage tube, and cholecystectomy were performed. Cultures from the pseudocyst revealed Candida glabrata. Antibiotics were discontinued, and intravenous antifungal therapy with anidulafungin was initiated at a loading dose of 200 mg, followed by a maintenance dose of 100 mg daily. The patient's condition improved shortly thereafter, with resolution of fever and normalization of laboratory tests. After three weeks of antifungal therapy, with no positive cultures from the drainage tube and no pathological findings on repeat CT, the patient was discharged from the hospital. He was doing well at six- and 12-month follow-ups.

Intestinal obstruction after ingestion of foreign bodies is a rare condition. A wide variety of ingested foreign bodies has been reported as a cause of mechanical small bowel obstruction, with ingested fruit pits being rarely reported as causes of intestinal obstruction. Here, we report the case of a 70-year-old female diagnosed with intestinal obstruction due to swallowed olive pits tightly impacted in the distal ileum. A conclusive diagnosis was made preoperatively by computed tomography of the abdomen. After initial conservative treatment, the patient underwent laparotomy because of persistent obstruction. The ingested pits were removed through an enterotomy and the obstruction was successfully resolved.