Transmesocolic hernia with sigmoid colon strangulation without surgical history: a series of two case reports.

The incidence of internal hernias is rare (0.2-0.9%). The prevalence of intestinal obstruction for an internal hernia is low (0.5-5%), however if strangulation is present the overall mortality is higher than 50%. There are multiple places where an internal hernia may be localized, with transmesenteric: transmesocolic (8%) and transomental (1-4%) as the rarest. We report a series of two cases (men with 40 years-old and women with 92 years old) of volvulus of colon sigmoid in a strangulated transverse and descendent transmesocolic hernia, with one case associated also to a transomental hernia. Both patients were submitted to a Hartmann procedure and on follow-up remained free of complains. In conclusion, transmesenteric internal hernia should be included as diagnosis hypothesis for intestinal occlusion and if the diagnosis is made, the patient should be submitted to emergency surgery due to high rates of complications, high morbidity and mortality.

Supralevator abscess: New treatment for an uncommon aetiology: Case report.

INTRODUCTION: Supralevator abscess is the least common type of anorectal abscess. Its diagnosis can be hard and treatment difficult. PRESENTATION OF THE CASE: A 48-year-old men was diagnosed in the emergency department with a supralevantor abscess. Under general anaesthesia, the abscess drainage was accomplished after removal of a fish bone, who was perforating the rectum. Due to persistent rectal purulent discharge, a pelvic Magnetic Resonance (MRI) was performed: a supralevator abscess adjacent to the internal obturator muscle and an inter-sphincteric fistulae from the inferior margin of this collection were identified. A Pezzer® drain was placed through the fistula tract. After radiological resolution, under general anaesthesia, the patient was submitted to extraction of the drain and marsupialization of the path left using an ENDO GIA®. At two year follow up he remained asymptomatic. DISCUSSION: Despite of the abscess aetiology, the principles of treatment are the same: good radiological characterization and proper drainage. An adequate radiological characterization is important to avoid iatrogenic creation of a complex fistulae. CONCLUSION: If a supralevator abscess diagnosis is made, fistulae trajectory should be studied. If no clear internal opening is evident, a pelvic MRI should be done followed by drainage of the abscess. After resolution the drain should be taken off and marsupialization with ENDO GIA® should be performed.

High-risk features in potentially resectable colon cancer: a prospective MDCT-pathology agreement study.

PURPOSE: Neoadjuvant chemotherapy in potentially resectable high-risk Stage II and Stage III colon cancer has demonstrated promising results in the PRODIGE 22-ECKINOXE Phase II trial. Identification of adverse morphologic features, namely T3 with >5 mm extramural extension/T4 stages and/or N2, is fundamental and requires accurate noninvasive imaging. Our aim was to assess the value of optimized preoperative MDCT to stratify potentially resectable colon cancer patients for neoadjuvant therapy. METHODS: this is an observational prospective cross-sectional radiologic-pathologic agreement study. All patients with colon cancer referred to our Institution's Radiology department for preoperative MDCT staging between 01-10-2013 and 11-02-2015 underwent independent reading based on axial and multiplanar reconstruction images by 3 radiologists with 3, 6, and 20 years of experience in gastrointestinal radiology. T stage, extramural extension if T3 (≤5 mm or >5 mm), and N stage were recorded. Surgical specimens subsequently obtained underwent micro-pathologic analysis by a gastrointestinal pathologist with 9 years of experience in gastrointestinal pathology. Main outcome measures were sensitivity, specificity, PPV, NPV, AUROC, diagnostic accuracy, and interobserver agreement of optimized MDCT, and pathologic analysis of the surgical specimen considered the reference standard. RESULTS: 74 patients [43 males; median age 73 (45-89)] were eligible. MDCT sensitivity, specificity, PPV, NPV, AUROC, and diagnostic accuracy ranged between 42.9-76.2, 75.5-90.6, 55.2-76.2, 80.0-90.6, 0.67-0.83 and 0.76-0.86%, respectively, for the identification of T3 > 5 mm/T4 disease, with moderate interobserver agreement (0.49); and 8.3-33.3, 93.5-98.4, 20-66.7, 84.1-88.2, 0.51-0.65 and 0.80-0.86%, respectively, for the identification of N2 disease, with absent interobserver agreement (0.10). CONCLUSIONS: Specificity of MDCT in the stratification of patients for neoadjuvant therapy may be high enough to prevent overtreatment. However, it may lead to undertreatment in a meaningful proportion of patients. Observer performance may benefit from targeted training programs, given the variability and observer dependence of the results. Limitations include 4-slice MDCT equipment, time to surgery and lack of long-term outcome information based on imaging parameters per se.

Impact of bowel resection margins in node negative colon cancer.

PURPOSE: Surgical intestinal resection margins in colon cancer are a longstanding debate in terms the optimal distance between the tumor and the colonic section line. The aim of this study is to define the oncological outcomes in relation to surgical margins, measured in terms or recurrence rate, time-to-recurrence, disease-free survival and overall survival in a population of node negative colon cancer patients. METHODS: We conducted a retrospective observational longitudinal single institution study. All patients submitted to colon cancer surgery between January 2006 and December 2010 were analyzed. Only node negative patients were included in the study, with analysis of 215 patient charts, divided in two groups (Intestinal margin lower than 5 cm-group 1; and 5 cm or higher-group 2). RESULTS: Mean age of patients was 70.4 years (±11.7), with a male predominance (57.7%). Group 2 more frequently corresponded to Stage II (83 vs 71%; p = 0.05). Global mean total lymph nodes harvested were 12, and were higher in group II than in group I (13.8 ± 8.2 vs 10.4 ± 5.7; p = 0.001). In terms of time-to-recurrence patients of group 2 had longer time than patients of group 1 (32.3 ± 12.1 vs 21.8 ± 13.8 months; p = 0.03), as well as a lower recurrence rate in group I (13.7 vs 17.2%), despite not statistically significant. CONCLUSIONS: This study has showed that patients with 5 cm or higher bowel resection margins had longer time-to-recurrence that was statistically significant. Recurrence rates were lower in the group of patients with longer surgical margins, however not statistically significant.

Laparoscopic upper pole splenectomy of the simple splenic cyst.

Splenic cysts are rare clinic entities. Non-parasitic cysts are the most frequent cystic lesions of the spleen. In the last decade acknowledgment of the importance of the spleen function, along with development of imaging methods and surgery technics, allowed a conservative approach to be increasingly considered as the best approach in splenic cysts treatment. We present the case of a 34-year-old woman with an asymptomatic simple splenic cyst in the upper pole incidentally diagnosed in a thoracic CT. A laparoscopic upper pole splenectomy was performed on the patient, with no complications. Despite the rareness of this procedure and the fact that it was used in a simple splenic cyst, this article emphasises the idea that this approach is safe, reproducible and advantageous for the patient.