Prevalence and Natural History of Segmental Colitis Associated With Diverticulosis

INTRODUCTION

We assessed the prevalence and clinical outcomes of segmental colitis associated with diverticulosis (SCAD) in patients with newly diagnosed diverticulosis.

METHODS

A 3-year international, multicenter, prospective cohort study was conducted involving 2,215 patients.

RESULTS

SCAD diagnosis was posed in 44 patients (30 male patients; median age: 64.5 years; prevalence of 1.99%, 95% confidence interval, 1.45%-2.66%). Patients with SCAD types D and B showed worse symptoms, higher fecal calprotectin values, needed more steroids, and reached less likely complete remission.

DISCUSSION

Although SCAD generally had a benign outcome, types B and D were associated with more severe symptoms and worse clinical course.

Diverticular Inflammation and Complication Assessment classification, CODA score and fecal calprotectin in clinical assessment of patients with diverticular disease: A decision curve analysis

BACKGROUND AND AIMS

The Diverticular Inflammation and Complication Assessment (DICA) classification and the Combined Overview on Diverticular Assessment (CODA) were found to be effective in predicting the outcomes of Diverticular Disease (DD). We ascertain whether fecal calprotectin (FC) can further aid in improving risk stratification.

METHODS

A three-year international, multicentre, prospective cohort study was conducted involving 43 Gastroenterology and Endoscopy centres. Survival methods for censored observations were used to estimate the risk of acute diverticulitis (AD) in newly diagnosed DD patients according to basal FC, DICA, and CODA. The net benefit of management strategies based on DICA, CODA and FC in addition to CODA was assessed with decision curve analysis, which incorporates the harms and benefits of using a prognostic model for clinical decisions.

RESULTS

At the first diagnosis of diverticulosis/DD, 871 participants underwent FC measurement. FC was associated with the risk of AD at 3 years (HR per each base 10 logarithm increase: 3.29; 95% confidence interval, 2.13-5.10) and showed moderate discrimination (c-statistic: 0.685; 0.614-0.756). DICA and CODA were more accurate predictors of AD than FC. However, FC showed high discrimination capacity to predict AD at 3 months, which was not maintained at longer follow-up times. The decision curve analysis comparing the combination of FC and CODA with CODA alone did not clearly indicate a larger net benefit of one strategy over the other.

CONCLUSIONS

FC measurement could be used as a complementary tool to assess the immediate risk of AD. In all other cases, treatment strategies based on the CODA score alone should be recommended.

A rare case of primary gastric Burkitt's lymphoma associated with malignant pleural mesothelioma

BACKGROUND

Primary gastric Burkitt lymphoma (PG BL) and malignant pleural mesothelioma (MPM) are rare and aggressive tumors with poor prognosis. HIV and EBV infection have a link in the aetiology of PG BL, while MPM is usually associated with asbestos exposure. Endoluminal bleeding from massive solid tumor, and dyspnea usually due to pleural effusion, are the typical clinical manifestations respectively of PG BL and MPM. In most patients just palliative treatment is indicated.

CASE REPORT

A caucasian elderly male, negative for the proven risk factors, presenting respiratory failure due to massive left pleural effusion with severe mediastinal shift. Contrast enhanced - Computed Tomography (CE-CT) showed a large mass causing circumferential thickening of the gastric fundus, infiltrating the left diaphragmatic dome and the ipsilateral crus. Macroscopically, on endoscopy the gastric fundus appeared completely occupied by an ulcerated large mass protunding in the gastric lumen. Histopathological examination from biopsy specimens taken during esophagogastroduodenoscopy and thoracoscopy allowed to make diagnosis of PG BL and MPM. The patient first underwent a placement of a chest tube drainage for the pleural effusion and then a thoracoscopic talc insufflation (TTI) in the left hemithorax. A surgical treatment of the gastric lesion was planned, due to the rapid growth and the high risk of bleeding. The patient died because of fatal cardiac arrhythmia, before undergoig abdominal surgery.

CONCLUSIONS

This report presents an unique case of PG BL associated with MPM and highlights the real challenge for the physicians to identify them in early stage, especially in patients without the proved risk factors. The onset symptoms make it a very singular case, characterized by severe dyspnea up to respiratory failure, due to massive left pleural effusion and contralateral mediastinal fluttering, without an active bleeding from the gastric mass, while CE-CT findings were instead negative for pleural thickening and positive for circumferential thickening of the gastric fundus.

KEY WORDS

Burkitt Lymphoma, Case Report, Gastric, Pleural Mesothelioma, Pleural Effusion, Respiratory Failure.

Incidental papillary thyroid microcarcinoma in consecutive patients undergoing thyroid surgery for benign disease. A single center experience

BACKGROUND

There has recently been an increase in the incidental histological diagnosis of papillary thyroid microcarcinoma (I-PTMC), that varies from 3.5% in autopsies studies, to 5.2% in thyroid specimens from thyroid surgery, up to 9.4% in patients from areas of endemic goiter.

AIM

To evaluate the incidence and the histological characteristics of I-PTMC in patients undergoing thyroidectomy for benign thyroid diseases, and to evaluate sex, age, toxic and non-toxic goiter, Hashimoto's thyroiditis as potential risk factors.

MATERIALS AND METHODS

Prospective observational study on 124 patients, median age 56.3±13.25sd range 24-80 years, 93(75%)F, 31(25%)M, with surgical indications for toxic and non-toxic uni/multinodular goiters, in pharmacological euthyroidism. An accurate histological examination (HE) of entirely embedding thyroid samples was performed to identify microscopic foci of I-PTCM. Logistic regression analysis of the abovementioned parameters was performed to identify the risk factors.

RESULTS

Total incidence of I-PTMC was 15.3%(19/124), with F/M ratio 2:1. All I-PTMCs were intraparenchymal with an intact thyroid capsule; 68.5% were bilateral-multifocal, 21% unilateral-unifocal, 10.5% unilateral-multifocal; maximum diameter was <5mm in 57.9% and ≥5mm in 42.1%; 63.1% were follicular variant, 36.9% classical variant; intra-thyroid lymphatic invasion and lymph node infiltration of the central compartment and para-tracheal was found in the only patient with "tall-cell" classical variant. No risk factors was found.

CONCLUSIONS

The incidence higher than that reported in the literature, is probably due to the accurate HE of entirely embedding thyroid samples, which is the most important tool to identify microscopic foci of I-PTCM. The highest reported rate of bilateral multifocality of the neoplasm recommend the total thyroidectomy as surgical treatment of choice, also in patients undergoing thyroid surgery for "presumptive" benign diseases.

KEY WORDS

Benign Thyroid Disease, Incidental Papillary Thyroid Microcarcinoma, I-PTCM, Thyroid Surgery.

Post-traumatic multifocal abdominal splenosis. The role of the clinical history. Case report and review of literature

BACKGROUND

Splenosis is a benign clinical condition caused by the heterotopic autotransplantation of spleen's tissue tipically occurring after spleen rupture. Splenosis may be asymptomatic and found accidentally. When signs and symptoms occur they are due to mass effect or bleeding of the splenic nodules.

CASE REPORT

74-years-old male presenting with intestinal sub-occlusion and past medical history of post-traumatic splenectomy at 18-years-old. Based on TC findings of multiple hyperenhanced solid lesions located in greater omentum, mesentery and parietal peritoneum of right pelvic walls, the presumptive diagnosis was peritoneal carcinomatosis of unknown primary site. Stenosis of a ileum loop in the right pelvis, with dilatation and faecal stasis of the upstream loops proximal, required surgical procedure. At the opening of the peritoneal cavity the multifocal lesions varied in size, were reddish blu color, sessile, lobulate and with strong adhesions to the visceral peritoneum. Omentectomy and the blunt exicision of 3 extraparietal solid nodules, which had tenacious adhesions with stenotic ileum loop serosa for the lenght of 8 cm, were performed. Histopathological examination of surgical specimens showed splenic tissue with red pulp.

CONCLUSION

CT scan usually do not allow to make a certain diagnosis of splenosis, so the clinical history of splenic trauma or splenectomy, positive in all cases reported in literature, represent the key in the diagnostic pathway of splenosis. Management should be conservative as much as possible nonetheless in abdominal splenosis the surgical approach should be chosen for the symptomatic patients who present abdominal pain, occlusion or bleeding.

KEY WORDS

Abdominal, Splenosis, Spleen, Surgery.

An uncommon clinical presentation of primary pancreatic lymphoma: Bleeding. Case report and literature review

BACKGROUND

Primary pancreatic lymphoma (PPL) represents less than 0.5% of all pancreatic neoplasms. Clinical manifestations are non-specific and diagnosis is delayed in the majority of patients.

CASE REPORT

85-year-old woman reporting accidental fall at home 20-days earlier, was admitted with diagnosed of acute abdomen from suspected two-stage rupture of the spleen. The patient complained of pain in the upper abdomen. Blood-chemical tests did not show anemia and leukocytosis, but showed increased CA19.9, CA125, LDH and beta2- microglobulin. Contrast-enhanced CT showed left pleural, perisplenic, perihepatic, and Douglas blood effusion, a neoformation of the body-tail of the pancreas with peri-pancreatic blood layer, splenomegaly due to the presence of a hypodense area as from intraparenchymal hematoma, with an apparently undamaged splenic capsule. The patient underwent emergency exploratory laparotomy, that revealed the presence of modest free serohematic effusion from oozing of the pancreatic neoformation. The local spread of the disease prevented any attempt at surgical resection. Bleeding was checked with the addition of topical hemostats (Tabotamp®) and biopsy sampling of the pancreatic mass was performed. A final histological diagnosis of large cell NHL of centro-follicular origin, double expressor for the CMYC and BCL2 protein, was achieved. The age of the patient, the poor general conditions, the associated pathologies, the locally advanced spread of the disease and the histological aggressiveness, were contraindications to chemo-radiotherapy treatments.

CONCLUSION

The initial misdiagnosis was due to the history of recent trauma, the uncommon clinical presentation, the underestimation of the serum increase in markers and the interpretation of the CT.

KEY WORDS

Acute Abdomen, Hemoperitoneum, Primary Pancreatic Lymphoma.

INCIDENTAL PARATHYROIDECTOMY DURING TOTAL THYROIDECTOMY AS A POSSIBLE RISK FACTOR OF HYPOCALCEMIA. EXPERIENCE OF A SINGLE CENTER AND REVIEW OF LITERATURE

CONTEXT

Post-operative clinical and biochemical hypocalcemia is a common complication of thyroid surgery and the correlation with incidental parathyroidectomy (IP) remains controversial.

OBJECTIVE

To evaluate the incidence of IP during TT, its correlation to early post-surgery hypocalcemia, and its potential risk factors.

PATIENTS AND METHODS

77 consecutive patients submitted to thyroid surgery between January 2018 and December 2019. Demographic, clinical, biochemical, surgical and histopathological factors were assessed. Statistical multivariate analysis was performed to identify the risk of IP.

RESULTS

IP was evident in 22 (28.5%) patients who underwent TT, TT with lymph node dissection of the central compartment (CLND) and reoperation for previous hemithyroidectomy with CLND. Early symptomatic hypocalcemia 24 hours after TT was demonstrated in 12/22 (54.5%) patients, with PTH value of <14pg/mL in 7/12 (58.3%) patients, and in 6 of these 7 patients (85.7%) the PTH value was <6.3pg/mL. In 5/22 (22.7%) patients the IP was associated with biochemical hypocalcemia <8.4mg/dL, and in 5/22 (22.7%) patients anatomical damage was not associated with a reduction in plasma calcium levels. The severity of early post-op hypocalcemia was not correlated with the number of parathyroid glands left in situ. The multivariate analysis did not show statistically significant values between the clinical-pathological variables and increased risk of IP.

CONCLUSIONS

No IP clinical-pathological risk factors have been identified during thyroid surgery. In all cases of TT, with or without CLND, the meticulous identification of the parathyroid glands, whose incidental removal is frequently associated with clinical and biochemical hypocalcemia, is recommended.

Acute pancreatitis secondary to non-functioning pancreatic neuroendocrine tumor: uncommon clinical presentation. Clinical case and review of literature

BACKGROUND

Pancreatic neuroendocrine tumors (PNETs) are uncommon, representing <5% of all pancreatic neoplasms, divided into functioning PNETs with secreted hormone cause of specific symptoms, and non-functioning PNETs (nf- PNETs) characterized by delayed diagnosis with metastases and clinical manifestations of compressive effects. Surgical approach is recommended for functioning and nf-PNETs >2 cm in diameter.

CASE REPORT

A 76-year-old woman was admitted to the UOC-University-Surgery Hospital "A. Fiorini" in Terracina for nausea and pain in the upper abdominal quadrants with dorso-lumbar irradiation, arising after the evening meal. After the haematochemistry tests and the instrumental investigations, the diagnosis of acute, severe halitiasic pancreatitis was made. Conventional US, CCT, CE-MRI and EUS showed a 2.8cm diameter lesion in the head-body junction of the pancreas. FNA-cytological examination did not found the presence of atypical pancreatic cells. Total-body scintigraphy with Octreoscan® documented a pathological hypercaptation area located in correspondence with the neoformation. The patient underwent a body-tail spleno-pancreatectomy. The histological examination showed an intermediate grade (G2) nf-PNET infiltrating the lienal vein and stenosing the Wirsung duct, with perilesional pancreatitis. Immunohistochemistry showed CAM 5.2, Synaptophysin (>95%) and Chromogranin (60%) positive immunophenotype, with negative intratumoral Somatostatin expression.

CONCLUSION

Although rarely, nf-PNETS may be the cause of severe non-biliary acute pancreatitis from pancreatic ductal system compression. In cases where PET/CT68Ga cannot be performed, total-body scintigraphy with Octreoscan® remains the most widely used method for the diagnosis of PNETs and the identification of extra-pancreatic lesions. Chromogranin and Synaptophysin are confirmed as specific markers of neuroendocrine differentiation.

KEY WORDS

Acute pancreatitis, Chromogranin, Pancreatic neuroendocrine tumor, Synaptophysin, Somatostatin.

Non-antibiotic prophylaxis in thyroid surgery. Experience of a single Institution and revision of literature

AIM

To evaluate the incidence of SSI and systemic infectious complications in a consecutive series of patients undergoing thyroid surgery in the absence of prophylactic antibiotic (NO-AP).

METHODS

Prospective observational study including 77 patients who underwent total thyroidectomy and completion of previous hemithyroidectomy in NO-AP. The surgical intervention was performed by surgeons who were experienced in the procedure, and involved the use of Ligasure Harmonic Ethicon®, absorbable hemostat in oxidized regenerated cellulose (Tabotamp®), and skin incision suture device Skin Stapler®. The following risk factors were assessed: gender, age, BMI, alcohol consumption, habitual smoking, co-morbidities, ASA score, indication to surgery, duration of anesthesia and procedure lenght, type of surgical procedure, fever, white blood cells count, dosage of the pre-operative C Reactive Protein in the five first post-operative day, and histological diagnosis. The data were collected and processed using IBM SPSS software v.23.0.

RESULTS

No factors of increased infectious risk have been identified. No infectious surgical and systemic complications have been reported causes of prolongation of the length of the hospital stay.

CONCLUSIONS

Fever, neutrophilic leukocytosis and increased PCR cannot be assessed as predictive factors of infectious complication in thyroid surgery. The cutaneous antisepsis of the operative field with chlorhexidine gluconate, the improvement of the surgical technique, the protection of the cutaneous margins of incision, the use of new devices, the accurate hemostasis and the reduction of surgery time lead to a lack of SSIs and systemic infection complications in all patients undergoing thyroid surgery in NO-AP.

KEY WORDS

Antibiotic prophylaxis, Surgical site infections, Thyroid surgery, Thyroidectomy.

Total thyroidectomy associated to chemotherapy in primary squamous cell carcinoma of the thyroid

Primary squamous cell carcinoma of the thyroid (PSCCT) is a rare malignant disease with rapid fatal prognosis. The onset is generally characterized by sudden bilateral latero-cervical lymphadenopathy. The Authors report patient of 58-year-old who referred for evaluation of rapidly aggravating bilateral latero-cervical lymphadenopathy. The US highlighted the presence of a hypoechoic nodular lesion characterized by peri and intra-nodular vascularization. Multilayer CT showed diffused involvement of mediastinal and bilateral latero-cervical lymph nodes, with no evidence of primary pulmonary neoplasia or elsewhere. The patient underwent total thyroidectomy. The peri-isthmic tissue was removed due to the presence of a small roundish formation, that was due to lymph node metastasis at histological examination. Histological diagnosis: PSCCT. The immunohistochemical panel of the thyroid lesion was indispensable for the differential diagnosis between PSCCT, medullary carcinoma, anaplastic carcinoma, and thyroid metastasis of neoplasia with unknown primitiveness. The patient underwent chemotherapeutic treatment with Carboplatin and Paclitaxel with modest improvement of dysphagia symptoms and reduction of 10-15% of the target lesions. The clinical course was characterized by loco-regional progression of the disease with exitus in 10 months after diagnosis. Survival and quality of life after surgical therapy and chemotherapy were like that of patients undergoing only chemotherapy. Due to the extreme rarity of the neoplasia, 60 cases described in Literature, no exclusive guidelines are reported for PSCCT. More extensive case studies are needed to evaluate the effects of total thyroidectomy with intent R0/R1 on improving survival and quality of life of patients with PSCCT.

Prophylactic drainage after laparoscopic cholecystectomy for acute cholecystitis: a systematic review and meta-analysis

In the literature, there is a large evidence against the use of drains in laparoscopic cholecystectomy (LC) in elective surgery. However, evidence is lacking in the setting of acute cholecystitis (AC). The present meta-analysis was performed to assess the role of drains to reduce complications and improve recovery in LC for AC. An electronic search of the MEDLINE, Science Citation Index Expanded, SpringerLink, Scopus, and Cochrane Library database from January 1990 to July 2018 was performed to identify randomized clinical trials (RCTs) that compare prophylactic drainage with no drainage in LC for AC. Odds ratio (OR) with confidence interval (CI) for qualitative variables and mean difference (MD) with CI for continuous variables were calculated. Three RCTs were included in the meta-analysis, involving 382 patients randomized to drain (188) versus no drain (194). Morbidity was similar in both the study groups (OR 1.23; 95% CI 0.55-2.76; p = 0.61) as well as wound infection rate (OR 1.98; 95% CI 0.53-7.40; p = 0.31) and abdominal abscess rate (OR 0.62; 95% CI 0.08-4.71; p = 0.31). Abdominal pain 24 h after surgery was less severe in the no drain group (MD 0.80; 95% CI 0.46-1.14; p < 0.000). A significant difference in favor of the no drain group was found in the postoperative hospital stay (MD 1.05; 95% CI 0.87-1.22; p < 0.000). No significant difference was present with respect to postoperative fluid collection in the subhepatic area and operative time. The present study shows that prophylactic drain placement is useless to reduce complications in LC performed to treat AC. Postoperative recovery is improved if drain is not present.

Polypoid lesions of the gallbladder in a consecutive series of 2631 patients. A single-center experience

BACKGROUND

Challenges in the diagnosis of polypoid gallbladder lesion (PLG) is due to the low sensibility (SE) of ultrasound scan (US), and the selection criteria of patients with PLG to be addressed to surgical treatment or followup are not yet fully defined.

MATERIALS AND METHODS

Retrospective observational study was conducted on 2631 patients, 1175(44.6%) M, mean age 56 years, 1456(55.4%) F, mean age 46 years, who underwent laparoscopic and open cholecystectomy.

RESULTS

The US diagnosis for PLG was placed in 38/2631(1.4%) patients. On histological examination (HE) the polyps were identified in 68/2631(2.6%) patients and it was associated with biliary lithiasis in 28/2631 (1.1%) cases. From the US and HE comparison, the ultrasound diagnosis was burdened by false positives (8/38; 21%) and false negatives (38/2631;1.45%), with SE 44% (95% c.i.:32.2-55.7). The histological incidence of gall bladder cancer (GBC) was 0.38%(10/2631).

DISCUSSION

US survey underestimated the incidence of PLG compared to the histological finding (p=0.021). Female gender has been shown to be a specific risk factor for benign and malignant PLG and non-polypoid mucosal lesions (p=0.041). The parietal lesion size <0.5cm does not exclude the neoplastic nature. Currently the prevention and diagnosis of GBC is based on the early detection and treatment of potentially evolutionary polypoid lesions over a period of about 15 years.

CONCLUSIONS

It is probably that early cholecystectomy in all the patients with PLG of diameter <1cm, isolated or associated with lithiasis, symptomatic and asymptomatic, can contribute to the reduction of the incidence of GBC.

KEY WORDS

Cholecystectomy, Gallbladder polyps, Gallbladder cancer, Ultrasound scan.

Pre-Operative Skin Antisepsis with Chlorhexidine Gluconate and Povidone-Iodine to Prevent Port-Site Infection in Laparoscopic Cholecystectomy: A Prospective Study

BACKGROUND

Skin preparation with antiseptic agents is commonly recommended for incisional site cleansing before surgery. We present the result of a prospective case series submitted to a scheduled pre-operative antiseptic procedure combining chlorhexidine gluconate and povidone-iodine before elective laparoscopic cholecystectomy.

PATIENTS AND METHODS

Consecutive patients underwent pre-operative standardized cleansing of the operation site combining chlorhexidine gluconate and povidone-iodine. Patients were reviewed one week and four weeks post-operatively.

RESULTS

Post-operative infection was observed in seven patients (4.3%). All observed infections were port-site infections, always located at the level of the umbilical incision. In all cases infections involved skin and subcutaneous tissue. Staphylococcus aureus was isolated in five patients (71.4%) and miscellaneous aerobic gram-positive bacteria in two subjects (28.6%). Post-operative hospital stay was the only factor significantly associated with the development of port-site infections.

CONCLUSIONS

Port-site infections are a common complication after elective laparoscopic cholecystectomy. The proposed pre-operative disinfection procedure is effective in reducing port-site infections. Reducing hospital stay may contribute to limiting the occurrence of this complication.

Subhepatic mass occurrence after using oxidized and regenerated cellulose polymer in laparoscopic cholecystectomy: a case series

BACKGROUND

Oxidized regenerated cellulose (ORC) is a bioabsorbable surgical hemostatic. We present the first prospective case series of circumscribed mass occurrence after using ORC in laparoscopic cholecystectomy.

METHODS

Tabotamp (Ethicon, Inc., Somerville, NJ) in the form of tightly woven knitted patches was used to achieve hemostasis in 83 patients submitted to LC.

RESULTS

A subhepatic mass was detected in five patients and radiologic characteristics were described. Abdominal contrast enhanced CT showed a heterogeneous soft-tissue mass. NMR was performed in one patient and showed a T2-weighted hyperintense mass.

CONCLUSION

ORC retention after surgery is not uncommon at long-term follow-up. The radiologic characteristics of a suspected ORC retention mass can differentiate it from a neoplastic lesion, so that surgery can be avoided.

Bilateral hydrocele. Uncommon clinical presentation of primary testicular lymphoma in the elderly

Primary testicular lymphoma (PLT) represents 5% of testis tumors, the incidence increases in patients older than 60 years of age. Bilateral hydrocele is an unusual clinical presentation. Relapse in the central nervous system and in the contralateral testis is often observed. The US shows hypoechoic nodular lesions with a complete structural involvement of didymus and hypervascularization at Color Doppler. Orchiectomy should be performed in all cases as it is indispensable for the histopathological diagnosis and to characterize the immunophenotypic features. The most common histotype is diffuse large-B cell lymphoma. Combined biological approach and chemotherapy with rituximab and doxorubicin has radically changed the prognosis of disease. The authors report two patients of 81 and 82 years-old who referred for evaluation of massive bilateral hydrocele causing severe limitation of deambulation. Negative cytological findings for neoplastic cells in the scrotal effusion made difficult the differential diagnosis between inflammatory and malignant disease. Histopathologic findings made a diagnosis of high grade diffuse large B-cell NHL, respectively stage IV-E and stage III-E. The 82 years old patient was treated with 6 chemotherapy cycles of rituximab, cyclophosphamide, vincristine, prednisone. The exitus was dued to the umbilical hernia complications. In the 81 years old patient, cognitive deficit and severe impairment of general conditions constituted an absolute contraindication to polychemotherapy treatment. Rapid tumor progression led the patient to exitus 2 months after diagnosis. In both patients the delayed diagnosis of PLT was probably due to the reduction of welfare protection in the elderly with adverse social conditions.

Complete mesh migration into the small bowel after incisional hernia repair: a case report and literature review

INTRODUCTION

Mesh migration into the intestine is very rare after incisional hernia repair.

CASE REPORT

We report the case of transmural mesh migration from the abdominal wall into the small bowel presenting as recurrent small bowel obstruction 18 years after repeated surgical repair of an incisional ventral hernia. At surgery, a mesh was found inside the resected ileal loop.

DISCUSSION

Mesh migration into the intestine is a possible, although very rare, complication after incisional hernia repair with nonabsorbable meshes. It tends to occur late with obstructive symptoms, especially if the small intestine is involved. Avoiding the direct contact between the mesh and the intestinal wall may help to reduce this complication.

The influence of residents in the outcome of elective laparoscopic surgery: a prospective study comparing a teaching hospital and a private community hospital in Italy

OBJECTIVES

We compared the outcome of elective laparoscopic cholecystectomy (LC) in a teaching hospital and a private communityhospital to assess the impact of the involvement of residents.

MATERIALS AND METHODS

The following parameters were studied prospectively in patients who underwent elective LC during the period from September 2014 to February 2016 in a teaching university hospital (group A) and in a private community hospital (group B): age, sex, body mass index (BMI), comorbidities, American Society of Anaesthesiologists (ASA) score, length of surgery from skin incision to skin closure, use of drain, 30-day perioperative morbidity and mortality, and length of postoperative hospital stay.

RESULTS

The group A consisted of 93 elective LC and the group B of 167 elective LC. Operative time was significantly longer in group A. Intraoperative complications were similar and no conversion was necessary in both groups. An increased rate of postoperative complications was observed in group A. All postoperative complications were managed with conservative therapy. No mortality occurred. At logistic regression analysis, the only factor favouring the occurrence of complications was the hospital type.

CONCLUSIONS

Our study shows that elective LC can be performed in a teaching hospital with comparable intraoperative morbidity and increased postoperative complications. The greater rate of morbidity found in the teaching hospital may be due to an increased vigilance linked to the presence of residents and not to the lack of expertise.

Challenging differential diagnosis between lipoma and well-differentiated liposarcoma in the retroperitoneum. A case report

Liposarcomas are the most common type of sarcomas arising in the retroperitoneum. Retroperitoneal lipomas are extremely rare. They should be distinguished from well-differentiated liposarcomas in order to provide the appropriate treatment. A 53-years-old male was admitted with the presence of a palpable mass in the upper abdomen. Contrast enhanced computerized tomography (CT) of the abdomen and pelvis showed a 20x12 cm mass arising in the retroperitoneum and inglobing the celiac and superior mesenteric trunks. Because of unresectability an open surgical biopsy was performed. Histological examination showed the presence of adipose tissue with diffuse liponecrosis without definitive features of neoplasia. At six-month follow-up a CT documented an increase of the tumor to 22x13 cm. The mass was stable at the CT, performed at 1-year follow-up. Given the impossibility to distinguish well-differentiated liposarcomas from lipomas and the in the present case of unresectable retroperitoneal mass, an observational follow-up was a justified.

Meta-analysis of drainage versus no drainage after laparoscopic cholecystectomy

Background and Objectives:

Routine drainage after laparoscopic cholecystectomy is still controversial. This meta-analysis was performed to assess the role of drains in reducing complications in laparoscopic cholecystectomy.

Methods:

An electronic search of Medline, Science Citation Index Expanded, Scopus, and the Cochrane Library database from January 1990 to June 2013 was performed to identify randomized clinical trials that compare prophylactic drainage with no drainage in laparoscopic cholecystectomy. The odds ratio for qualitative variables and standardized mean difference for continuous variables were calculated.

Results:

Twelve randomized controlled trials were included in the meta-analysis, involving 1939 patients randomized to a drain (960) versus no drain (979). The morbidity rate was lower in the no drain group (odds ratio, 1.97; 95% confidence interval, 1.26 to 3.10; P = .003). The wound infection rate was lower in the no drain group (odds ratio, 2.35; 95% confidence interval, 1.22 to 4.51; P = .01). Abdominal pain 24 hours after surgery was less severe in the no drain group (standardized mean difference, 2.30; 95% confidence interval, 1.27 to 3.34; P < .0001). No significant difference was present with respect to the presence and quantity of subhepatic fluid collection, shoulder tip pain, parenteral ketorolac consumption, nausea, vomiting, and hospital stay.

Conclusion:

This study was unable to prove that drains were useful in reducing complications in laparoscopic cholecystectomy.

Does postoperative radiation therapy represent a contraindication to expander-implant based immediate breast reconstruction? An update 2012-2014

OBJECTIVE

Post-mastectomy radiotherapy (PMRT) is well known in the plastic surgery community for having a negative impact on expander-implant based immediate breast reconstruction (IBBR), although recently some technical improvements allow better results. Very recent papers would suggest that there is no difference in postoperative complications in patients receiving post-mastectomy radiotherapy using modern techniques. However, study results are often biased by small groups of patients and by heterogeneity of radiotherapy timing, different surgical techniques and measured outcomes.

MATERIALS AND METHODS

We have conducted a MEDLINE search to summarize the latest data (2012-2014) on the topic. Search was conducted using the following parameters: breast reconstruction AND implant AND expander AND post-mastectomy radiotherapy.

RESULTS

The MEDLINE search showed 53 reports, demonstrating a great interest on this topic; among these 37 dealed specifically with post-mastectomy radiotherapy after breast reconstruction. In particular, 15 were amenable to plastic surgeons, 6 to breast surgeons, 9 to radiotherapists and 7 to oncologists. Papers amenable to plastic surgeons highlighted the highest rate of undesired results, although with recent advances such as delayed-immediate reconstruction or protective lipofilling.

CONCLUSIONS

PMRT remains an undesired event when pursuing an implant-based breast reconstruction, although it does not represent an absolute contraindication. The higher rate of complications reported by plastic surgeons and not by other specialists can be explained with the greater attention to aesthetic details, such as capsular contractures, that our community has. Technical strategies to prevent complications described in this community now allow better results, should be well known and improved if possible in the future.

Antibiotic prophylaxis in elective laparoscopic cholecystectomy is useless. A prospective multicenter study

AIM

We performed a prospective study to evaluate the effect of antibiotic prophylaxis (AP) on the incidence of infection in elective laparoscopic cholecystectomy (LC).

MATERIAL OF STUDY

All patients were at low-medium anesthetic and infectious risk and underwent LC for benign disease. At induction of anesthesia 41 patients received ampicillin-sulbactam 3g, 40 patients received ciprofloxacin 400mg intravenously, and 53 patients received no AP.

RESULTS

Postoperative infection was observed in 11 patients (8.2%) in the entire study group. All ob served infections were superficial surgical site infections (SSIs), always located at the umbilical incision. Infection occurred in 3 patients (7.3%) in ampicillin-sulbactam group, in 3 patients (7.5%) in ciprofloxacin group and in 5 patients (9.4%) in nonantibiotic group (p=0.916). Univariate analysis showed that duration of operation, placement of a drain and postoperative hospital stay were significantly associated with the development of SSIs. At multivariate analysis, only duration of operation was statistically significant in predicting SSIs.

DISCUSSION

The present study did not show any advantage in the use of AP, although in case of difficult surgery the risk of SSIs is increased, in particular in the umbilical incision. In all patients, the bile culture was sterile, then the infection of the umbilical site is not due to bacterial infection from the gallbladder.

CONCLUSIONS

AP in elective LC should not be routinely performed. A particular attention to the preoperative cleaning and topical antibiotic therapy of the umbilical area is advised.

Clinical Outcome Following Hemorrhoid Surgery: a Narrative Review

Surgical therapy guaranties satisfactory results, which are significantly better than those obtained with conservative therapies, especially for Grade III and IV hemorrhoids. In this review, we present and discuss the results of the most diffuse surgical techniques for hemorrhoids. Traditional surgery for hemorrhoids aims to remove the hemorrhoids, with closure (Fergusson's technique) or without closure (Milligan-Morgan procedure) of the ensuing defect. This traditional approach is effective, but causes a significant postoperative pain because of wide external wounds in the innervated perianal skin. Stapled hemorrhoidopexy, proposed by Longo, has gained a vast acceptance because of less postoperative pain and faster return to normal activities. In the recent literature, a significant incidence of recurrence after stapled hemorrhoidopexy was reported, when compared with conventional hemorrhoidectomy. Double stapler hemorrhoidopexy may be an alternative to simple stapled hemorrhoidopexy to reduce the recurrence in advanced hemorrhoidal prolapse. Transanal hemorrhoidal deartertialization was showed to be as effective as stapled hemorrhoidopexy in terms of treatment success, complications, and incidence recurrence. However, further high-quality trials are recommended to assess the efficacy and safety of this technique.

Risk management in surgery

Malpractice is the responsible for the greatest number of legal claims. At the present time, legal actions against physicians in Italy are 15,000 per year, and a stunning increase about costs to refund patients injured by therapeutic and diagnostic errors is expected. The method for the medical prevention is "Risk Management", that is the setting-up of organizational instruments, methods and actions that enable the measurement or estimation of medical risk; it allows to develop strategies to govern and reduce medical error. In the present work, the reconstruction about the history of risk management in Italy was carried out. After then the latest initiatives undertaken by Italy about the issue of risk management were examined.

Multiorgan female pelvic prolapse: pelvic organ prolapse suspension (P.O.P.S.) stapled transanal rectale resection (S.T.A.R.R.): new surgical tecniques and results

AIM

To demonstrate the surgical treatment validity and the post-operative complication decrease.

MATERIAL OF STUDY

Seventythree women who underwent P.O.P.S. + S.T.A.R.R. treatment, follow-up one year.

RESULTS

We observed an important reduction or a completely disappearance about pre-operative signs and symptoms.

DISCUSSION

We are aware that the proposed technique, if taken into account by urogynecologists, will raise several arguments and will raise many doubts and perplexities. For this reason we wanted develop a follow-up sufficiently long and many case studies with data to support our claims.

CONCLUSIONS

We believe that the procedure proposed by us, given the results, was excellent in patients with multiorgan pelvic prolapse, especially with the vagina walls elongated and that retain a good trophism.

Single-incision laparoscopic appendectomy is comparable to conventional laparoscopic and laparotomic appendectomy: our single center single surgeon experience

Several studies have demonstrated the clinical and technical benefits of the laparoscopic surgery for complicated and uncomplicated appendicitis. Our retrospective study included 12 patient who underwent SILS appendectomy (SILS-A), 14 who received conventional laparoscopic surgery (VL-A), and 12 who received laparotomic appendectomy (OA); performed in all cases by the same surgeon (C.F.). The aim of this study was the comparison between this three different surgical techniques on same features: post operative leukocytosis, post operative pain, need abdominal drainage, esthetic viewpoint, incidence of complication, hospital stay. The results showed no significant differences between SILS-A and VLS-A, while an evident improvement shows versus O-A, even though not statistically significative. SILS was more effective in decreasing the risk of postoperative wound infection.

Transanal haemorrhoidal dearterialisation with mucopexy versus stapler haemorrhoidopexy: a randomised trial with long-term follow-up

INTRODUCTION

The present study aimed to compare the long-term results of transanal haemorrhoidal dearterialisation (THD) with mucopexy and stapler haemorrhoidopexy (SH) in treatment of grade III and IV haemorrhoids.

METHODS

One hundred and twenty-four patients with grade III and IV haemorrhoids were randomised to receive THD with mucopexy (n=63) or SH (n=61). A telephone interview with a structured questionnaire was performed at a median follow-up of 42 months. The primary outcome was the occurrence of recurrent prolapse. Patients, investigators and those assessing the outcomes were blinded to group assignment.

RESULTS

Recurrence was present in 21 patients (16.9%). It occurred in 16 (25.4%) in the THD group and 5 (8.2%) in the SH group (p=0.021). A second surgical procedure was performed in eight patients (6.4%). Reoperation was open haemorrhoidectomy in seven cases and SH in one case. Five patients out of six in the THD group and both patients in the SH group requiring repeat surgery presented with grade IV haemorrhoids. No significant difference was found between the two groups with respect to symptom control. Patient satisfaction for the procedure was 73.0% after THD and 85.2% after SH (p=0.705). Postoperative pain, return to normal activities and complications were similar.

CONCLUSIONS

The recurrence rate after THD with mucopexy is significantly higher than after SH at long-term follow-up although results are similar with respect to symptom control and patient satisfaction. A definite risk of repeat surgery is present when both procedures are performed, especially for grade IV haemorrhoids.

Technique and outcomes about a new laparoscopic procedure: the Pelvic Organ Prolapse Suspension (POPS)

Pelvic organ prolapse suspension (POPS) is a recent surgical procedure for one-stage treatment of multiorgan female pelvic prolapse. This study evaluates the preliminary results of laparoscopic POPS in 54 women with a mean age of 55.2 and a BMI of 28.3. Patients underwent at the same time stapled transanal rectal resection (STARR) to correct the residual rectal prolapse. We had no relapses and the preliminary results were excellent. We evaluated the patients after 1 year follow-up and we confirmed the validity of our treatment. The technique is simpler than traditional treatments with an important reduction or completely disappearance of the pre-operative symptomatology.

Prevalence of adenoma of gallbladder, ultrasonographic and histological assessment in a retrospective series of 450 cholecystectomy

BACKGROUND

Adenomyomas of the gallbladder are difficult to examine during standard ultrasound examination of the abdomen. They sometimes undergo malignant transformation and their optimal management still remains a problem. The authors have aimed to investigate the ultrasonographic and histopathological prevalence of gallbladder adenomyomas focusing on the diagnostic performance of ultrasound examination.

MATERIALS AND METHODS

A retrospective series of 450 consecutive patients who underwent cholecystectomy is reported. Data regarding characteristics of the patients, US and histology examination of the gallbladder were collected. Sensitivity, specificity, positive and negative predictive values of ultrasound scan were calculated with respect to histological examination of the gallbladder.

RESULTS

The study group consisted of 261 female and 189 male. Ultrasound scan detected adenomyomas in 22 patients, confirmed by histopathology in 13 and found to be not present in 9. Incidental adenomyomas were found in 16 patients of 428 who underwent cholecystectomy for gallstones. Prevalence was 4.9% and 6.4% for ultrasound scan and histopathology respectively. Ultrasound scan showed sensitivity of 43.3% (c.i.:25.4%-62.5%), specificity of 97.8% (c.i.:95.9%-99%) with a positive predictive value of 59% (c.i.:36.3%-79.2%) and with a negative predictive value of 96.2% (c.i.:93.7%- 97.6%). On histopathology, adenomyomas localized in the fundus were predominant. Two female patients with adenomyomas of the fundus (diameter 5 mm) and single stone showed intestinal metaplasia with high-grade dysplasia.

CONCLUSIONS

The diagnosis of gallbladder adenomyomas by ultrasound scan still remains a problem because of its low sensitivity, which is mainly due to the association with gallstones. Histopathological findings in the perilesional mucosa confirm the hypothesis of a metaplasia-dysplasia-carcinoma sequence already shown in the colon-rectum. At present, the selection of patients requiring cholecystectomy is still controversial.

Evaluation of the oncogenic risk of diffuse gastric polyposis. A case report

Benign polyps of the stomach undergo malignant transformation at a rate correlating to the histological type and size of the proliferative lesion. We report a case of a 50-year-old Caucasian woman, affected by a diffuse gastric polyposis of both hyperplastic and adenomatous type. At endoscopy polyps were more than 1,000, scattered over the entire gastric cavity. The patient underwent total gastrectomy. The perilesional gastric mucosa was characterized by the presence of either atrophic or metaplastic areas and by a mild dysplasia. A single tubulo-villous adenomatous polyp was also present in the ascending tract of the colon. The absence of both high-grade dysplastic lesions and outbreaks of neoplastic transformation well correlated with the histochemical and molecular features, confirming the highly proliferative pattern of the polyps in the lack of signs of malignant progression.

Cholecystectomy by single incision laparoscopic surgery (SILS): early experience and technique standardization

Single Incision Laparoscopic Surgery (SILS) is a recent surgical technique, first described in the 1990s. Its aim is to optimize the esthetic result offered by laparoscopy by minimizing the number of abdominal incisions. Various preliminary studies have been carried out on the application of SILS, especially in cholecystectomy and appendectomy. This study evaluates the preliminary results of cholecystectomy by SILS (SILS™ Port) conducted between October 2009 and February 2011 on 21 patients (4 men and 17 women) with a mean age of 49.9 years and a mean Body Mass Index (BMI) of 22.8. All patients were treated by the same team, which had previously undergone six months' simulator training. There were two main selection criteria, both evaluated intraoperatively: absence of adhesions and of significant inflammatory sequelae from previous cholecystitis; and suitable distance between gallbladder and SILS access port. Conversion to traditional laparoscopy was necessary in just two cases, while an accessory trocar was introduced in another two cases. Conversion to open surgery was not necessary in any case. One case of SILS cholecystectomy was complicated by postoperative bile leakage, which was treated conservatively, as the fistula had a low output. The mean duration of hospitalization was 3.6 days. This preliminary experience led us to conclude that SILS is safe and highly satisfactory in the postoperative phase, thanks to the reduced need for painkillers and the improved esthetic result.

Liver resection for hemoperitoneum caused by spontaneous rupture of unrecognized hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is an increasingly common form of cancer. Although its spontaneous rupture is rare in Western countries, it constitutes a surgical emergency and is associated with high mortality. There is a lack of consensus as to the best approach and what parameters to use in choosing it. The three main approaches are conservative, endovascular and resection - the treatment of choice for acute abdominal bleeding. We report a case of hemoperitoneum following the spontaneous rupture of an unrecognized HCV-related HCC in a patient with no history of liver disease. The patient was successfully treated by emergency surgery, with resection of two segments of the left liver.

Drain after elective laparoscopic cholecystectomy. A randomized multicentre controlled trial

BACKGROUND

Routine drainage after laparoscopic cholecystectomy is still debatable. The present study was designed to assess the role of drains in laparoscopic cholecystectomy performed for nonacutely inflamed gallbladder.

METHODS

After laparoscopic gallbladder removal, 53 patients were randomized to have a suction drain positioned in the subhepatic space and 53 patients to have a sham drain. The primary outcome measure was the presence of subhepatic fluid collection at abdominal ultrasonography, performed 24 h after surgery. Secondary outcome measures were postoperative abdominal and shoulder tip pain, use of analgesics, nausea, vomiting, and morbidity.

RESULTS

Subhepatic fluid collection was not found in 45 patients (84.9 %) in group A and in 46 patients (86.8 %) in group B (difference 1.9 (95 % confidence interval -11.37 to 15.17; P = 0.998). No significant difference in visual analogue scale scores with respect to abdominal and shoulder pain, use of parenteral ketorolac, nausea, and vomiting were found in either group. Two (1.9 %) significant hemorrhagic events occurred postoperatively. Wound infection was observed in three patients (5.7 %) in group A and two patients (3.8 %) in group B (difference 1.9 (95 % CI -6.19 to 9.99; P = 0.997).

CONCLUSIONS

The present study was unable to prove that the drain was useful in elective, uncomplicated LC.

About a case of squamous cell carcinoma of the scalp. Management and aesthetic results

We present a case of squamous cell carcinoma of the scalp, treated with local excision and flap reconstruction. We discuss the treatment modalities of this pathology with particular attention to the role of surgery and adjuvant radiotherapy. The authors suggest the systematic use of subgaleal drainage to avoid the hematoma and/or seroma occurrence.

[The age factor in bilateral hydrocele diagnosis secondary to a primitive testis lymphoma: case report, diagnosis and therapy]

Primitive NHL represents 9% of testis tumours and the 85% is diagnosed in patient older thant 60 years old. Usually pain and a testis mass are the main manifestations. The Authors report the case of a 82 years-old man with bilateral hydrocele causing severe alteration in the deambulation. The cytology did not show blood cells or neoplastic cell in the FNAB. The US showed a complete modification in the testis. The patient underwent to surgery intervention of vaginalis tunic eversion and resection with the aim of control the symptoms. The histology on multiple biopsy of testis and epidydims bilaterally showed a large B-cell lymphoma. The patient was treated with 6 chemotheray cycles (Rituximab, Vincristine, Cyclophosphamide, Prednisone). Bilateral hydrocele is a rare clinical presentation of testis NHL. In this patient, blood and neoplastic cell absence in the cytology made difficult the differential diagnosis between inflammatory pathology and neoplasia. Hystopathologic study and immunologic pattern can make a certain diagnosis.

Sporadic diffuse gastric polyposis: Report of a case

A 50-year-old woman was admitted because of severe sideropenic anemia. The gastrin levels were within normal ranges. Esophagogastroduodenoscopy showed diffuse gastric polyposis with signs of diffuse oozing. Colonoscopy showed the presence of a 3-cm wide pedunculated polyp of the ascending colon, which was removed by diathermy. The patient was treated by total gastrectomy with Roux-Y esophagojejunostomy. Histological examination showed the presence of diffuse gastric polyposis with the contemporary occurrence of hyperplastic polyps and mixed hyperplastic and adenomatous polyps, with a tubular pattern and the focal aspect of serrate adenoma. This is the first case report of sporadic diffuse hyperplastic and adenomatous polyposis of the stomach.

[Mesh infection in inguinal hernioplasty by Streptococcus dysgalactiae subspecies equisimilis. Case report and review of the literature]

INTRODUCTION

Mesh infection in inguinal herniography is usually caused by Staphilococcus aureus and Staphilcoccus epidermidis. Generally it obliges to prosthesis removal with hernia relapse and increase of social costs for the prolongation of hospitalization.

CASE REPORT

A 60-year-old woman, obese, undergone 4 months before to left inguinal prosthetic herniorrhaphy complicated by infection of the surgical site which didn't require the explantation of the mesh, although determining an early hernia relapse. She is submitted by the authors to a surgical intervention for left groin hernia relapse with placement of a polypropylene monofilament fixed with prolene. Six hours after the operation she shows systemic symptoms and local signs of prosthesis infection. Cultural examination of the surgical wound secretion allows the identification of Streptococcus dysgalactiae subspecies equisimilis (SDSE). A therapy with Amoxicillin-Clavulanic Acid and Levofloxacine leads to resolution, in 10 weeks, of the infection.

DISCUSSION

In our case the infection of the new mesh, appearing prematurely, has been probably favoured by obesity and operative time longer than 3 hours. Conservative treatment has been fulfilled by success for the elevated sensitivity of the SDSE bacterium to penicillin and fluoroquinolones.

CONCLUSIONS

Recent epidemiologic studies have demonstrated an increase of infections caused by SDSE, which will probably gain clinical relevance in the next future relatively to surgical prosthetic hernioplasty. In all cases of infection the authors suggest cultural isolation of the casual germ and the execution of the antibiogram because the conservative medical treatment can avoid mesh removal with consequent elevated risk of hernia relapse.

Long-term survival after transarterial chemoembolization for hepatocellular carcinoma

Hepatocellular carcinoma is a main challenge in oncologic care. Surgery is the mainstay of treatment. Transarterial chemoembolization is the most widely used palliative treatment for hepatocellular carcinoma. The Authors present a case report of a 61-year old man with hepatocellular carcinoma, belonging to Child-Pugh class A. The advanced age and the previous history of bladder carcinoma made the patient not suitable for liver transplantation. The patient refused hepatic resection so that transarterial chemoembolization was proposed. During 14-year follow-up there was intrahepatic progression of the tumor after the first treatment, followed by reduction in size and number of the lesions after subsequent treatments. In spite of the ominous prognosis of hepatocellular carcinoma, in this case-report transarterial chemoembolization allowed us to achieve a unique long-term survival.

[Gallbladder polypoid lesions. Three clinical cases with difficult diagnosis and literature review]

INTRODUCTION

Gallbladder polypoid lesions occur in 1.3%-6.9% of cases. The preoperative diagnosis between benign, malignant and potentially malignant lesions is difficult. Therefore it is not possible any.

PATIENTS AND METHODS

The Authors describe three cases. The case 1 was a gallbladder diffuse adenomyomatosis; the ultrasound and the CT were of little help in defining preoperatively the nature and the gravity of the thickening. Case 2 was an adenomyomatosis of the fundus: the ultrasound examinations were not able to establish preoperatively lesion's nature, site and dimensions. In the case 3, ultrasounds showed polypoid lesions and calculi concrections not found in colecistectomy.

DISCUSSION

The ultrasound is the most widely used diagnostic tool in the evaluation of gallbladder polypoid lesions; its accuracy is only 66%. CT, which has an accuracy level of 75%, must be carried out there is any possibility of malignant degeneration of the polyp. If doubts persist, a MR, 93% accuracy, is indicated. In selected cases, PET can be of further help.

CONCLUSIONS

The preoperative diagnosis of the nature of gallbladder polypoid lesions is "difficult" and this justifies the lack of consensus on treatment. However, the adenoma-carcinoma sequence, widely discussed in literature, can justifies to the use of CT, MR, PET and surgical treatment after an ultrasound examination.

[A rare cause of acute abdomen: splenic infarction. Case report and review of the literature]

INTRODUCTION

Splenic infarction is a rare cause of acute abdomen. It must be suspected in patient with hematologic diseases or thromboembolic conditions. The most common onset symptom is left-upper quadrant abdominal pain. Additional symptoms include fever and anemia. Laboratory may show elevated white blood cell and platelet counts.

CASE REPORT

A 97-year-old female with a past history of atrial fibrillation presented with left-upper quadrant abdominal pain and fever since 20 days. Laboratory showed elevated white blood cell and platelet counts, increased C-reactive protein and lactate dehydrogenase. Both ultrasonographic and tomographic scans showed a large hypodense area of the spleen. The patient received intravenous antibiotic therapy, which led to significant clinical improvement with discharge 16 days after admission.

DISCUSSION

The diagnosis of splenic infarction is based both on clinical presentation and imaging studies. Angio-computed tomography is the diagnostic procedure of choice. Ultrasonography and conventional radiology are useful in the differential diagnosis with other abdominal and thoracic diseases mimicking splenic infarction. In our case the management was conservative, because the patient was hemodynamically stable and antibiotic therapy could control the sepsis. Moreover, advanced age and poor cardiac and respiratory conditions contraindicated surgery.

CONCLUSIONS

In our case splenic infarction was probably due to a thromboembolic event secondary to atrial fibrillation. In accordance with the literature, we suggest initial conservative therapy. Surgery is indicated only in the presence of complications.

Metastasis from renal cell carcinoma presenting as skeletal muscle mass: a case report

Renal cell carcinoma can metastasize to virtually any site. Skeletal muscle metastasis is not common. The correct diagnosis of metastatic renal cell carcinoma to skeletal muscle is difficult in comparison with soft-tissue metastasis diagnosis. We report the case of a 58-year-old man with skeletal muscle metastasis from a clear-type renal cell carcinoma 5 years after total nephrectomy. The tumour was located in the proximal left tight at the level of the great adductor muscle. Clinical work-up included both 18 fluorodeoxyglucose positron emission tomography combined with non-contrast computed tomography and magnetic resonance imaging. The mass was widely excised and was confirmed to be a metastasis from renal cell carcinoma. Maintaining a high degree of suspicion of metastatic renal cell carcinoma is required for patients with a history of renal cell carcinoma. Positron emission tomography, combined with computed tomography, appears to be an effective surveillance tool. Magnetic resonance imaging is helpful in the differential diagnosis from primary soft-tissue tumours.

Endoscopic sphincterotomy of the major duodenal papilla in acute relapsing pancreatitis associated with pancreas divisum: a case report

We report a case of acute relapsing pancreatitis associated with pancreas divisum, who underwent major papilla sphincterotomy after failed minor papilla cannulation. Long-term results were satisfactory. The possible explanations of the efficacy of major papilla endoscopic resection in this particular case are discussed.

Laparoscopic correction of enterocele associated to stapled transanal rectal resection for obstructed defecation syndrome

BACKGROUND AND AIMS

We report our experience of concomitant laparoscopic treatment for enterocele and stapled transanal rectal resection (STARR) for rectocele and/or rectal prolapse in patients with complex obstructed defecation syndrome (ODS).

PATIENTS AND METHODS

From June 2005 to June 2007, we submitted 20 patients with ODS due to rectal prolapse and/or rectocele, combined with stable enterocele, to STARR and laparoscopic correction of the enterocele. Preoperative assessment included symptom evaluation with standardized questionnaires, clinical examination, colonoscopy, proctoscopy, anal sphincter ultrasonography, video-defecography with synchronous opacification of the ileal loops in all patients and colpography in female patients, and anorectal manometry. Follow-up was performed in the first, third, sixth, 12th, and 24th month after surgery.

RESULTS

Eighteen (90%) patients were submitted to both procedures, simultaneously. One patient, previously submitted to STARR, underwent laparoscopic treatment of the enterocele. Postoperative complications occurred in two (10%) patients: one case of postoperative rectal bleeding and one case of retropneumoperitoneum. Median (range) preoperative and postoperative Altomare's obstructed defecation score was ten (6-14) and two (0-14), respectively (p<0.001). Median (range) preoperative and postoperative quality of life score was 79 (39-109) and 109 (50-126), respectively (p<0.001). No symptom related to ODS was detected at 6-month follow-up (19 patients) and at 24-month follow-up (19 patients).

CONCLUSION

The combination of STARR and laparoscopy provides a safe and effective method to treat ODS caused by rectal internal prolapse and/or rectocele combined with enterocele.

[Unusual cause of acute abdomen in adult patient: gallstone ileus]

INTRODUCTION

Gallstone ileus is a rare complication of cholecystolithiasis. It causes 1-3% of the mechanical obstructions of the small bowel. It often affects patients between 63 and 85 years old. Pre-operative diagnosis is usually delayed 1-10 days because there is not a specific symptomatology.

CASE REPORT

The authors report the case of a 50 year-old man with diagnosis of mechanical obstruction of the small bowel caused by a voluminous gallstone. Ileal occlusion was showed by CT. The patient underwent to one-stage emergency surgery with enterolithotomy, cholecystectomy and duodenal fistula repair. Patient's recovery was regular and he was discharged fourteen days after surgery.

DISCUSSION

In our case gallstone ileus was diagnosed with a delay of 5 days. Ultrasonography was not able to show the gallbladder. Diagnosis was made by CT, which is the diagnostic gold standard.

CONCLUSION

Patient's performance status influences surgical strategy. In our experience, the patient underwent one-stage surgery because he was considered at low risk. Instead staged procedure with enterolithotomy and delayed cholecystectomy and fistula repair, is performed only in patients at high risk.

Gallstone ileus. Report of two cases

Gallstone ileus is uncommon. Gallstone impaction in the jejunum was rarely reported. We report two cases of gallstone impaction in the proximal jejunum and in the distal ileum. One patient was treated with enterolithotomy alone and in the other one enterolithotomy was combined to cholecystectomy and repair of a cholecystoduodenal fistula. Contrast-enhanced computed tomography of the abdomen is the mainstay of diagnosis. One-stage procedure including both enterolithotomy and cholecystectomy with bilioenteric fistula repair should be reserved to low-risk patients.

[Umbilical primary endometrioma. Case report]

Umbilical primary endometrioma is a rare extra-uterine localization of endometriosis with a documented neoplastic risk. It is often difficult to distinguish primary umbilical endometriosis from other benign and malignant tumors of the abdominal wall. The Authors report a case of umbilical endometriosis in a 36-year old female. Endometriosis was suspected because of the presence of the typical cyclic bleeding and swelling. Abdominal CT excluded the presence of other endometriotic localizations. The umbilical mass was widely excised together with umbilicus, fascia and peritoneum. The tissue defect was primary closed without prosthetic mesh. Histological examination of the specimen showed the presence of endometrial glands with stromal component, compatible with the diagnosis of endometriosis. The Authors suggest that surgery should be performed in the first 3-4 days of the follicular phase, to minimize the risk of diffusion of endometriotic cells. Moreover, the excision should be wide in order to prevent local recurrence.

Spontaneous umbilical endometriosis: a case report with one-year follow-up

Umbilical endometriosis is a very rare disease. We report a case of spontaneous umbilical endometriosis in a 36-year old female. Endometriosis was suspected because of the presence of the typical cyclic bleeding and swelling. Abdominal CT excluded the presence of other endometriotic localizations. The umbilical mass was widely excised together with the umbilicus, fascia and peritoneum. The ensuing defect was primarily closed without using prosthetic mesh. Postoperative recovery was uneventful. Histological examination of the specimen showed the presence of endometrial glands with a stromal component, compatible with the diagnosis of endometriosis. At one-year follow-up the results of surgery were satisfactory with no sign of endometriosis recurrence and or parietal defect occurrence. We suggest that surgical excision should be wide in order to prevent local recurrence, and prosthetic materials should not be used to repair the ensuing umbilical defect.

[Massive haemoperitoneum due to traumatic rupture of multifocal hepatocarcinoma in the right hepatic lobe. Case report]

Abdominal blunt trauma is the main cause of death in people younger than 40 years old. The liver injury still represents a challenging problem. Isolated hepatic injury is rare and it occurs more frequentely in polytraumatizated patients and causes massive haemoperitoneum. The Authors report a case of a 83 years-old woman admitted to Emergency Department for syncope due to an active bleeding arising from a rupture of a right hepatic lobe unsuspected tumor. The computer tomography (CT) scans showed a clear pattern of liver laceration of the VI segment with contrast enhancement spreading in the surrounding tissues, and detected a multifocal hepatocarcinoma located in the VI, VII and VIII segments. Patient's haemodinamically unstable conditions suggested an urgent laparotomy. An accurate perihepatic packing with sterile-drape were successfully employed to control liver hemorrage. Temporary abdominal closure, followed by hepatic arteriography and the right hepatic artery embolization, completed the damage control. Re-exploration laparotomy after 72 hours confirmed the definitive haemostasis and the pack removal was performed without complications.

CONCLUSIONS

CT plays a leading role in the diagnosis of liver damage. The patient's haemodynamic status is the principal criterion determining conservative or operative therapy in blunt liver injury. The early perihepatic packing followed by artheriographic embolization to stop liver hemorrhage showed efficacy and safety for the patient. The packing performed with sterile-drape is able to avoid removal complications and 72 hours timing for the pack removal is effective to avoid re-bleeding.

[A case of arterial chemoembolization for hepatocellular carcinoma with 11 years of survival]

Hepatocellular carcinoma (HCC) is the most common malignancy of the liver and the third most common cause of cancer mortality worldwide. The major risk of developing HCC is associated with HBV and HCV hepatitis. Liver transplant (LT) is the gold standard for "small" HCC (HCCs) in Child-Pugh class A cirrhotic patients. However its use has been restricted by the severe shortage of donors, so that hepatic resection (HR) is often performed in these patients. In the last two decades image-guided interventional catheterization and ablative regional treatment procedures have revolutionized the therapy of unresectable primary and secondary liver tumors. The Authors present a case of a 61-years old man with Child-Pugh class A HCCs. The age and the previous history of bladder carcinoma made the patient not suitable for LT. The patient refused HR so that transarterial chemoembolization combined to thermo-ablation therapy and oral intake of tamoxifen were proposed. Patient's tolerance to the treatments has been good. During 11-year follow-up there was earlier intrahepatic progression of the tumor followed by reduction in size and number of the lesions. In spite of the scarce prognosis, chemoembolization and immunotherapy allowed to achieve a satisfactory local control of disease in our patient and guaranteed a good quality of life at long-term follow-up.