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Background Low grade fibromyxoid sarcoma (LGFMS) is a rare and benign mesenchymal tumor with indolent course, most commonly found in young or middle-aged men. The majority of the LGFMSs are located in the trunk and deep soft tissue of the lower extremities. They appear as well circumscribed, although not encapsulated, which often leads to incomplete surgical resection. Despite their seemingly benign appearance, these tumors have aggressive behavior with high metastatic and recurrence rates. Accurate histopathologic examination of the specimen and its immunohistochemical analysis are mandatory for a precise diagnosis. Case summary We report a case of a 38 year-old-man who presented with jaundice and upper abdominal discomfort. Multi-detector computed tomography and magnetic resonance imaging showed a large left liver tumor mass, extending to the hepatoduodenal ligament. Left hepatectomy was performed with resection and reconstruction of hepatic artery and preservation of middle hepatic vein. Histopathologic examination confirmed the tumor being a low-grade fibromyxoid sarcoma. Three and a half years after surgery, the patient died after being diagnosed with spine metastasis. Conclusion Due to poor response to all modalities of adjuvant treatment, we consider that the focus of treatment should be on surgery as the only option for curing the disease.

Myoid angioendothelioma (MA) represents an extremely rare nonhaematopoietic proliferation of the spleen. MA is a rare, benign, vascular tumour that consists of vascular elements and arranged stromal cells. Due to an absence of specific clinical signs and symptoms, MA is considered challenging to diagnose. Although the radiological presentation can indicate the vascular nature of the tumour, the diagnosis of MA is almost exclusively obtained from the use of histopathology after surgical excision and immunohistochemistry of the tissue. Due to its completely unclear biological behaviour and relationship with other primary and secondary tumours, the only effective therapy for MA is splenectomy and a regular postoperative follow-up. Herein, we report a case of a 26-year-old male patient with nonspecific abdominal pain and a radiologically detected tumour of the spleen who underwent a laparoscopic splenectomy. Histopathologic and immunohistochemical examinations confirmed a myoid angioendothelioma of the spleen.

Lymphangioma usually occurs in children and usually involves the skin. Mesenteric lymphangiomas are extremely rare in adults (1,2,3). Lymphangioma of the small-bowel mesentery is rare, representing less than 1% of all lymphangiomas (4). We report a case of a 62-year-old female who presented with abdominal pain, discomfort, nausea and vomiting. Pre-operative tests including abdominal ultrasonography and magnetic resonance imaging were performed, but they could not accurately determine the nature of the tumour. Laparotomy was performed; the tumour was excised completely, and a large cystic tumour of the small bowel mesentery was found. Histopathological examination diagnosed the tumour as a cystic lymphangioma. Lymphangiomas are extremely rare, especially in the abdomen of adults, and are asymptomatic for the most part; they often present as acute abdominal conditions, causing life-threatening complications such as secondary infection, rupture with haemorrhage, and volvulus or intestinal obstruction when the tumour increases in size, requiring emergent surgery. Lymphangioma is often difficult to diagnose, and surgical resection is selected in many cases for both diagnosis and treatment.

Introduction. Accessory spleens can be found in up to 10% of the population, and their intrapancreatic occurrence is considered uncommon. When present, the intrapancreatic accessory spleen is usually found in the tail of the pancreas in about 1.7% of adult individuals. The infrequent presence of the accessory spleen in the pancreatic tissue could lead to inappropriate diagnosis and hence therapeutic approach, as they are commonly presented as a hypervascular node in the tail of the pancreas on abdominal CT and MRI, mimicking a well differentiated tumor of the pancreas or non-functioning pancreatic neuroendocrine tumor. Case Outline. We present a 70-year-old female in whom a preoperative evaluation finding was highly suggestive of a non-functioning neuroendocrine tumor of the pancreatic tail. We performed spleen preserving laparoscopic distal pancreatectomy, and histopathological examination revealed the intrapancreatic accessory spleen. Conclusion. Although infrequent, the presence of the intrapancreatic accessory spleen must be considered in the differential diagnosis of pancreatic tail tumors.

The primary aim of this study was to evaluate the benefit of extended lymphadenectomy in pancreaticoduodenectomy (PD) and to estimate its impact on long-term survival in patients with pancreatic head carcinoma. Secondary endpoints included perioperative mortality, postoperative morbidity and predictors of survival in patients undergoing standard versus extended lymphadenectomy for pancreatic head carcinoma.From January 2007 to December 2010, 60 patients with potentially resectable pancreatic head carcinoma were operated using pylorus-preserving pancreatoduodenectomy (PPPD) at the Clinic for Digestive Surgery, Clinical Center of Serbia, Belgrade. Intraoperatively patients were randomly stratified into two groups: the first group (N1=30) underwent PPPD with standard lymphadenectomy whilst the second group (N2=30) was operated with PPPD with extended lymphadenectomy. None of the patients received adjuvant treatments.The number of retrieved lymph nodes, mean operating time and postoperative hospital stay were greater in patients with extended lymphadenectomy . Cox regression analysis showed that stage and lymph node metastasis were independent prognostic factors for survival.Extended lymphadenectomy in PPPD did not improve long-term survival in patients with resectable pancreatic head carcinoma and led to comparable and similar morbidity and mortality rates to those after standard lymphadenectomy.

Adrenal tumors are nowadays being detected with increasing frequency due to the widespread use of various radiological imaging techniques (CT, MRI, US). Incidentally discovered adrenal masses (incidentalomas) are shown in 1% to 5% of all abdominal CT scans performed. Cavernous hemangiomas of the adrenal gland are extremely rare, benign in nature and most usually non-functioning lesions. We report a case of a 50-year-old female who presented with flank pain and abdominal discomfort. MRI of the abdomen revealed a large, oval, adrenal tumor mass, embedded between the upper pole of the right kidney and inferior surface of the liver. Surgery was performed, and tumor was excised completely. Histopathological examination revealed a cavernous hemangioma of the adrenal gland.

Bacground. Gastric adenomyoma is a rare, hamartomatous tumor localized most frequently in the gastric antrum. Review of the available literature shows only sporadic reports or smaller series. Case reports. We presented a 72-year-old woman admitted due to epigastric pain with dyspeptic difficulties. Biochemical parameters and tumor markers were within the referential limits. Diagnostic procedures (upper endoscopy, endoscopic ultrasonography and computerized tomography) revealed an intramural tumor prominence with intact mucosa on the posterior wall of gastric antrum, not accessible for biopsy. Surgical treatment was performed with total extirpation of the tumor. Histopathological examination verified adenomyoma with focal low grade epithelial dysplasia. Cytologic immunophenotype was consistent with smooth muscle stromal and epithelial tumor (CK7 and CK20 ++ immunophenotype). Stromal component revealed low proliferative index (Ki-67 protein immunoexpression level 3%), and p53 less than 0.1% in both epithelial and stromal components. Following the operation, the patient remained in good condition. Conclusion. Uncertain malignant potential of the gastric adenomyoma in the presented case indicates that timely diagnostics with adequate surgical treatment is crucial for an adequate treatment.

Free radicals imply that every atom, molecule, ion, group of atoms, or molecules with one or several non-paired electrons in outer orbital. Among these are: nitrogenoxide (NO•), superoxide-anion-radical (O2•-), hydroxyl radical (OH•), peroxyl radical (ROO•), alcoxyl radical (RO•) and hydroperoxyl radical (HO2•). However, reactive oxygen species also include components without non-paired electrons in outer orbital (so-called reactive non-radical agents), such as: singlet oxygen (1O2), peroxynitrite (ONOO-), hydrogen-peroxide (H2O2), hypochloric acid (eg. HOCl) and ozone (O3). High concentrations of free radicals lead to the development of oxidative stress which is a precondition for numerous pathological effects. However, low and moderate concentrations of these matter, which occur quite normally during cell metabolic activity, play multiple significant roles in many reactions. Some of these are: regulation of signal pathways within the cell and between cells, the role of chemoattractors and leukocyte activators, the role in phagocytosis, participation in maintaining, changes in the position and shape of the cell, assisting the cell during adaption and recovery from damage (e.g.caused by physical effort), the role in normal cell growth, programmed cell death (apoptosis) and cell ageing, in the synthesis of essential biological compounds and energy production, as well as the contribution to the regulation of the vascular tone, actually, tissue vascularization. Slobodni radikali podrazumevaju svaki atom, molekul, jon, grupu atoma ili molekula sa jednim ili više nesparenih elektrona u spoljašnjoj orbtali. U njih spadaju: azot-oksid (NO•), superoksid anjon radikal (O2•-), hidroksilni radikal (OH•), peroksilni radikal (ROO•), alkoksilni radikal (RO•) i hidroperoksilni radikal (HO2•-). Međutim, u reaktivne kiseonične vrste ubrajamo i komponente bez nesparenih elektrona u spoljašnjoj orbitali (tzv. reaktivni neradikalski agensi), kao što su: singlet kiseonik (1O2), peroksinitrit (ONOO-), vodonik-peroksid (H2O2), hipohlorasta kiselina (npr. HOCl) i ozon (O3). Visoke koncentracije slobodnih radikala izazivaju oksidativni stres koji je preduslov mnogobrojnih patoloških efekata. Međutim, niske i umerene koncentracije ovih materija, koje nastaju sasvim normalno tokom metaboličke aktivnosti ćelije, igraju višestuke značajne uloge u mnogim reakcijama. Neke od njih su: regulacija signalnih puteva unutar ćelije i među ćelijama, uloga hemoatraktanata i aktivatora leukocita, uloga u fagocitozi, učešće u održavanju, promeni položaja i oblika ćelije, pomoć ćeliji tokom adaptacije i oporavka od oštećenja (npr. izazvanih fizičkim radom), uloga u normalnom ćelijskom rastu, programiranoj ćelijskoj smrti (apoptozi) i ćelijskom starenju, u sintezi esencijalnih bioloških jedinjenja i proizvodnji energije, kao i doprinos regulaciji vaskularnog tonusa, odnosno vaskularizacije tkiva.

Introduction. Autoimmune cholangitis or immunoglobulin G4-associated cholangitis (IAC) has been recently regarded as a new clinical and histopathological entity and is a part of a complex autoimmune disorder - IgG4-related systemic disease (ISD). ISD is an autoimmune disease with multi-organic involvement, characterized with IgG4-positive plasmocytic infiltration of various tissues and organs with a consequent sclerosis, which responds well to steroid therapy. Most commonly affected organs are the pancreas (autoimmune pancreatitis, [AIP]) and the common bile duct (IAC). IAC and cholangiocarcinoma (CCA) share many clinical, laboratory and imaging findings. Case Outline. We present a case of a 60-year-old male with a biliary stricture of a common bile duct, which was clinically considered as a bile duct carcinoma and treated surgically. Definite histopathological findings and immunohistochemistry revealed profound chronic inflammation, showing lymphoplasmacytic IgG-positive infiltration of a resected part of a common bile duct, highly suggestive for the diagnosis of IAC. In addition, postoperative IgG4 serum levels were also increased. Conclusion. It is of primary clinical importance to make a difference between IAC and CCA, in order to avoid unnecessary surgical intervention. Therefore, IAC should be considered in differential diagnosis in similar cases.

Primary retroperitoneal mucinous cystic tumors are extremely rare. These tumors can be classified as a primary retroperitoneal mucinous cystadenoma with or without borderline malignancy or primary retroperitoneal mucinous cystadenocarcinoma. The most common of these is primary retroperitoneal mucinous cystadenoma, which almost always occurs in female patients; only ten cases have been reported in males. The most common clinical findings for this tumor type include nonspecific abdominal pain and a palpable abdominal mass. A definitive diagnosis is usually obtained from histopathology after surgical excision. Here, we report the case of a 60-year-old female patient who complained of abdominal pain that had been present for 3 mo and presented with a palpable abdominal mass. Multidetector computed tomography scanning revealed a large, unilocular cystic mass in the left retroperitoneal space. Surgical intervention was performed and the tumor was completely removed. Histopathologic examination confirmed that the tumor was a primary retroperitoneal mucinous cystadenoma. Two years after surgery, the patient remains disease free.

Introduction: Endometriosis is the presence of endometrial glands and stroma outside of uterine cavity. It may occur in the abdominal wall scar after the operation in which uterus was opened. In cesarean section scar it occurs in 0.4%. It is in 2/3 patients characterized with triad of: tumor, periodic pain associated with menses and history of cesarean section. The mechanism of endometriosis occurring in the cesarean scar is felt to be secondary to iatrogenic transplantation of endometrium or extrauterine decidual tissue into the incision during the cesarean section. Case outline. Forty years old patient with tumor 4,5x4 cm that appeared in abdominal wall scar one year after second cesarean section, followed by periodic pain and macroscopic changes associated with menses. First diagnosis was granuloma in the surgical scar, but as she had periodic symptoms, diferential diagnosis was endometriosis. Hormonal therapy with contraceptive drugs was ordered. As it was no improvement she was operated. The surgical excision of the tumor including fascia and muscle tissue was done. Sample revealed endometrium after histopathologic examination. Patient was completely recovered and without relapse of symptoms during follow up to date. Conclusion. When there is a tumor in the cesarean section scar or scar after the operation in which uterus or ovarial tube was opened, followed with periodical pain and macroscopic changes associated with menses, endometriosis should be considered. Surgical excision of the tumor is sufficient and patohistological examination confirms diagnosis. .

There is ever increasing data indicating the vmast contribution of oxidative stress to the pathogenesis of numerous diseases (atherosclerosis, hypertension, heart failure, diabetes mellitus, stroke, rheumatoid arthritis, and others). Thus, in the pathogenesis of atherosclerosis the primary role is held by reactive oxygen species that are synthetized by endothelial cells of arterial blood vessels, leukocytes and macrophages. Furthermore, native particles of lipoproteins of small density become atherogenic through oxidation caused by reactive oxygen species. The oxidation of small-density lipoproteins stimulates the inflammatory process, and it in turn steps up adhesion and the inflow of monocytes and affects the synthesis and release of numerous proinflammatory cytokines involved in the further course of the process. One of the reasons for the development of arterial hypertension is the simultaneous activation of NAD(P)H oxidase and 12/15-lipoxygenase, since it results in the stepped up production of reactive oxygen species. These stimulate the production of matrix metalloproteinase 2, which lead to vascular remodelling and to increased apoptosis of heart muscle cells. Stepped up apoptosis is linked with myocardial infarction, cardiomyopathies and the development of heart failure. The sensitivity of β-cells of the endocrine part of the pancreas to reactive oxygen species favor the naturally low concentrations of the collectors of free radicals in them, as well as an increase in the concentration of proinflammatory cytokines, glucosis and lipids that induce a reduction in the mass and function of β-cells. Hyperglycemia in diabetes mellitus causes tissue damage through non-enzyme glycosylation of intracellular and extracellular proteins, which results in: reduced enzyme activity, damaged nucleic acid, disrupted natural decomposition of proteins, and activation of cytotoxic pathways. These processes are the basis of the pathogenesis of numerous complications of diabetes mellitus. Since inducible nitrogen-oxide synthesis launches processes that stimulate apoptosis of cerebral endothelial cells, and superoxide-anion radicals, hypochloric acid and hydrogen peroxide damage the parenchyma of an ischemic brain and biomacromolecules (causing lipid peroxidation, oxidation of proteins and deoxyribonucleic acid), brain damage occurs during cerebral ischemia and reperfusion. Sve više podataka ukazuje na veliki doprinos oksidativnog stresa patogenezi brojnih bolesti (aterosklerozi, hipertenziji, srčanoj insuficijenciji, šećernoj bolesti, moždanom udaru, reumatoidnom artritisu i dr.). Tako, u patogenezi ateroskleroze primarno mesto zauzimaju reaktivne kiseonične vrste koje sintetišu endotelne ćelije arterijskih krvnih sudova, leukociti i makrofagi. Uz to, nativne čestice lipoproteina male gustine postaju aterogene, oksidacijom izazvanom reaktivnim kiseoničnim vrstama. Oksidacija lipoproteina male gustine stimuliše zapaljenjski proces, a on pojačava adheziju i dotok monocita i utiče na sintezu i oslobađanje brojnih proinflamatornih citokina uključenih u dalji tok procesa. Jedan od razloga za razvoj arterijske hipertenzije je istovremena aktivacija NAD(P)H oksidaza i 12/15-lipoksigenaze, jer rezultira pojačanom proizvodnjom reaktivnih kiseoničnih vrsta. One podstiču proizvodnju metaloproteinaza-2 matriksa, koje dovode do vaskularnog remodeliranja i do pojačane apoptoze srčanih mišićnih ćelija. Pojačana apoptoza je povezana sa infarktom miokarda, kardiomiopatijama i razvojem srčane insuficijencije. Osetljivosti β-ćelija endokrinog dela pankreasa na reaktivne kiseonične vrste pogoduju prirodno niske koncentracije skupljača slobodnih radikala u njima, kao i porast koncentracije proinflamatornih citokina, glukoze i lipida koji indukuju smanjenje mase i funkcije β-ćelija. Hiperglikemija kod šećerne bolesti izaziva oštećenja tkiva neenzimskim glikozilovanjem intracelularnih i ekstracelularnih proteina, usled čega se smanjuje enzimska aktivnost, oštećuju nukleinske kiseline, re meti prirodna razgradnja proteina i aktiviraju citotoksični putevi. Ovi procesi su i osnova patogeneze mnogih komplikacija šećerne bolesti. S obzirom na to da inducibilna azot-oksid sintaza pokreće procese koji podstiču apoptozu cerebralnih endotelnih ćelija, a superoksid-anjon radikal, hipohlorna kiselina i vodonik-peroksid oštećuju parenhim ishemičnog mozga i biomakromolekule (izazivaju peroksidaciju lipida, oksidaciju proteina i dezoksiribonukleinske kiseline), tokom cerebralne ishemije i reperfuzije nastaju oštećenja mozga.

Purpose The primary aim of this study was to evaluate the benefit of extended lymphadenectomy in pancreaticoduodenectomy (PD) and to estimate its impact on long-term survival in patients with pancreatic head carcinoma. Secondary endpoints included perioperative mortality, postoperative morbidity and predictors of survival in patients undergoing standard versus extended lymphadenectomy for pancreatic head carcinoma. Methods From January 2007 to December 2010, 60 patients with potentially resectable pancreatic head carcinoma were operated using pylorus-preserving pancreatoduodenectomy (PPPD) at the Clinic for Digestive Surgery, Clinical Center of Serbia, Belgrade. Intraoperatively patients were randomly stratified into two groups: the first group (N1=30) underwent PPPD with standard lymphadenectomy whilst the second group (N2=30) was operated with PPPD with extended lymphadenectomy. None of the patients received adjuvant treatments. Results The number of retrieved lymph nodes, mean operating time and postoperative hospital stay were greater in patients with extended lymphadenectomy . Cox regression analysis showed that stage and lymph node metastasis were independent prognostic factors for survival. Conclusion Extended lymphadenectomy in PPPD did not improve long-term survival in patients with resectable pancreatic head carcinoma and led to comparable and similar morbidity and mortality rates to those after standard lymphadenectomy.

Free radicals occur constantly during metabolism and take part in numerous physiological processes, such as: intra-cellular and inter-cellular signalization, gene expression, removal of damaged or senescent cells, and control of the tone of blood vessels. However, there is an increased quantity of free radicals in situations of so-called oxidative stress, when they cause serious damage to cellular membranes (peroxidation of their lipids, damage of membrane proteins, and similar), to interior cellular protein molecules, as well as DNA molecules and carbohydrates. This is precisely why the organism has developed numerous mechanisms for removing free radicals and/or preventing their production. Some of these are enzyme-related and include superoxide-dismutase, catalase, glutathione-peroxidase, and others. Other, non-enzyme mechanisms, imply antioxidative activities of vitamins E and C, provitamin A, coenzyme Q, reduced glutation, and others. Since free radicals can leave the cell that has produced them and become dispersed throughout the body, in addition to antioxidative defense that functions within cellular structures, antioxidant extra-cellular defense has also been developed. This is comprised by: transferrin, lactoferrin, haptoglobin, hemopexin, ceruloplasmin, albumins, extra-cellular isoform SOD, extracellular glutathione-peroxidase, glucose, bilirubin, urates, and many other molecules. Slobodni radikali neprekidno nastaju tokom metabolizma i učestvuju u brojnim fiziološkim procesima, kao što su: unutarćelijska i međućelijska signalizacija, genska ekspresija, uklanjanje oštećenih i ostarelih ćelija i kontrola tonusa krvnih sudova. Međutim, količina slobodnih radikala je pojačana u stanju tzv. oksidativnog stresa, kada izazivaju ozbiljna oštećenja ćelijskih membrana (peroksidaciju njihovih lipida, oštećenje membranskih proteina i sl.), unutarćelijskih proteinskih molekula, kao i molekula DNA i ugljenih hidrata. Upravo zbog toga, organizam ima razvijene brojne mehanizme za uklanjanje slobodnih radikala i/ili sprečavanje njihove proizvodnje. Neki od njih su enzimski a obuhvataju superoksid-dismutazu, katalazu, glutation-peroksidaze i sl. Drugi, neenzimski mehanizmi, podrazumevaju antioksidativno delovanje vitamina E i C, provitamina A, koenzima Q, redukovanog glutationa i dr. S obzirom da slobodni radikali mogu da napuste ćeliju koja ih je proizvela i raznesu se po telu, osim antioksidativne odbrane koja funkcioniše unutar ćelijskih struktura razvila se i vanćelijska odbrana antioksidanasa. Nju obavljaju: transferin, lakroferin, haptoglobin, hemopeksin, ceruloplazmin, albumini, ekstracelularna izoforma SOD, ekstracelularna glutation-peroksidaza, glukoza, bilirubin, urati i mnogi drugi molekuli.

s / Pancreatology 15 (2015) S1eS141 S97 Patients & methods: From 1/1/2010 to 1/1/2014 183 patients underwent a resective procedure in our institution for pancreatic adenocarcinoma. 25 had a preoperative value of CA19-9>1000 u/ml with serum bilirubin 0,05). Mean DFS was 23.1 vs 25.0 months (p1⁄40.49) (groupC vs M) and OS 28.6 vs 30.3 months (p>0,05). In the same period only 5 patients with CA 19-9>1000 u/ml underwent non-resective surgery after exploration. In C group 10 patients were alive 2 year after the resection. Conclusion: Despite CA19-9 prognostic role OS DFS of groupC patients are comparable with others resected patients and superior to non resected patients. High serum CA19-9 is not a contraindication to surgery if a correct preoperative workout is done.

s / Pancreatology 12 (2012) 502–597 567 Objective: Analysis of patients operated for pancreatic pseudocysts during 5 year period Patients and methods: During the period from 2005 to 2010, a total of 101 patients were treated for pancreatic pseudocysts in our depatement at First Surgical Clinic, Belgrade, Serbia. They were retrospectively reviewed and followed up. There were 68% men, between 18 and 85-years-old (mean age 58,3 years). Results: Dominating symptoms in most patients were epigastric pain, palpable mass, nausea, vomiting, fever and leukocytosis, and persistent elevationof serumamylase. Imaging studies, such asultrasound, CTscan, and ERCP were were used in establishing the diagnosis. Operative procedures consisted of external drainage (ED, 9 cases), internal drainage using cystojejunostomy (CJ, 85% cases) and cystogastrostomy (CG,10 cases), and distal pancreatectomy (4 cases). The following complications were observed including recurrence of cyst (1 patient with ED and 1 with CJ), delayed massive bleeding (1 with CG), pancreatic fistula (3 with ED, 3 with CJ, 1 with CG), pancreatic abscess (1 with CJ) and persistent pain (1 with CG). Reinterventionwasneeded to stopbleeding in1patientwithCG.Nodeathsoccurred. Conclusion: Although complications do occur in surgical treatment, cystojejunostomy is still gold standard for treatment of pancreatic pseudocysts.