Squamous carcinoma in pilonidalis sinus: case report and review of literature.

AIM: We report a case of squamous carcinoma arising from a pilonidal sinus. CASE REPORT: Patient of 83 years old, that after 30 years had a recurrence of pilonidal sinus revealed by a sacral abscess studied with pelvic CT scan and MRI. After clinical investigation, traditional open surgical technique was performed and pathologic studies revealed a squamous carcinoma. The patient performed a new CT scan with persistence of disease, and a second surgical look with mass excision until the presacral fascia and V-Y flap was performed. Histological exami-nation was found to be positive for squamous carcinoma on the margin and the patient underwent adjuvant radiotherapy cycles with a close follow-up with evidence of free disease survival. He died after 5 years for old age. DISCUSSION: The incidence of carcinoma arising from a pilonidalis sinus is about 0.1% and the most important risk factor is represented by a chronic abscess from 20-30 years. In literature there are about 100 cases. Gold standard treatment is surgery with complete excision of the presacral fascia, while radiotherapy decrease the risk of recurrence. CONCLUSION: All cases reported in literature are submitted as case report. Sacro-coccyxal fistula should be treated early because chronic inflammation can determine neoplastic degeneration. Histological examination should be performed routinely. Gold standard is surgery with wide excision. There is no evidence about the gold standard for the reconstructive time.

Complicated duodenal-jejunal diverticulosis: case report.

BACKGROUND: Bleedings such as melaena are related to diseases in the upper gastrointestinal tract. In 0.06% - 5% of cases these incidents are due to the presence of diverticula of the small intestine, which are asymptomatic and unrecognized in most patients and are only fully diagnosed in cases when complications occur. CASE REPORT: An 88-year old male patient presented with severe anaemia, asthenia and melaena in the previous days. An esophagogastroduodenoscopy (EGDS) was performed with evidence of stenosis in the second part of the duodenum and a blood clot in the posterior wall without signs of active bleeding. A complete CT scan was carried out of the thorax, abdomen and pelvis using a contrast medium, which revealed a dilation of the stomach and of the first part of the duodenum with a diverticulum of the second. On the fourth day following admission the patient suffered a haemorrhagic shock and underwent an emergency surgical procedure with a bleeding diverticulum on the posterior wall of the duodenum tightly adhering to the pancreas being found. Therefore an atypical duodenal-jejunal resection was performed using a gastrojejunal Roux-en-Y bypass and the closure of the duodenal stump. CONCLUSION: Diverticulosis of the duodenum and small intestine is considered a rare disease. According to the literature, treatment should be conservative, and surgical options considered only in those very rare cases of complicated and life-threatening diverticulosis.

Total laparoscopic splenectomy for giant epidermoid cyst: a case report.

INTRODUCTION: Splenic cysts are benign tumors, accidentally detected using US or CT scan. They are classified into true cyst (primary, 25%) and pseudocyst (secondary, 75%). Conventional treatment of splenic cyst, especially giant, symptomatic and complicated has been open or laparoscopic total splenectomy. Recently, partial splenectomy is recommended as well to preserve its hematopoietic function and homeostasis of blood, but it is not considered safe for complications as intra and post operative bleeding. CASE REPORT: A 46 years old man, martial arts practitioner, underwent US abdomen scan because of left upper quadrant pain, with evidence of a splenic mass. He underwent also CT and MRI, which revealed "oval giant splenic mass of 12 cm diameter located in superior splenic pole that can be firstly referred to cyst". Considered patient's frequency to thoraco-abdominal traumas, we decided to perform a total laparoscopic splenectomy. Surgical treatment was performed with a three trocar technique and lasted 150 minutes. Post-operative follow-up was regular and abdominal drain was removed in 4th POD (Post Operative Day). Patient was discharged in 5th POD. Pathological examination revealed epidermoid cyst. CONCLUSIONS: Total splenectomy needs to be performed in cases of giant cyst and in our limited experience it is a safe approach.

Study of the role of telomerase in colorectal cancer: preliminary report and literature review.

AIM: The aim of our study is to focus on hTERT (human Telomerase Reverse Transcriptase) expression to identify tumoral tissue after a comparison to TP53 and KRAS. More than 85% of cancer cells contain genetic aberrations and also overexpression of hTERT, and, in fact, the promoter of hTERT characterizes all malignant cells. PATIENTS AND METHODS: Our sample is composed of 18 patients, including 10 with CRC that underwent surgical procedure and 8 patients without CRC, which represent the control group. The hTERT gene expression, KRAS and p53 were evaluated by methodical Real Time - PCR on RNA extracted from tumor tissues, peritumoral tissue and control cases. RESULTS: Within the CRC group the evaluation of the tumor tissue showed an increase of hTERT expression with a statistical significance (> 0.1) in 5 of these, also associated with substantial increase of KRAS (> 0.2). The peritumoral tissue assessment showed important increase in KRAS in 4 patients (> 0.2), while hTERT is not found to be particularly increased. The value of p53 did not show any particular significance (<0.1). DISCUSSION: The analysis of our data leads us to consider that the increase of hTERT is evident in patients suffering from CRC and that some of them will become significant in relation to the increase of KRAS and independent of p53. In peritumoral tissues, however, KRAS increases considerably, instead hTERT maintains a low concentration and this is compatible with the cellular evolution of the neoplastic tissue adjacent to the tumor. CONCLUSIONS: hTERT could be used for diagnosis and prognosis in the future, to be able to identify the risk of tumor progression and to set up an adequate therapy.

Gallstone ileus in a ninety-two years old colecistectomized patient after endoscopic biliary sphincterotomy: a case report.

INTRODUCTION: Gallstone ileus is an uncommon condition of mechanical bowel obstruction caused by the passage of a gallstone into the bowel. It occurs more frequently in female patients older than 65 years and often for a biliary-enteric fistula. The pathognomonic features of gallstone ileus - the Rigler's triad - are pneumobilia, ectopic gallstone and bowel obstruction. Less commonly, a gallstone may enter the intestinal lumen through the common bile duct, after endoscopic retrograde cholangiopancreatography, and very rarely in colecistectomized patient. CASE REPORT: A 92-year old colecistectomized male patient was admitted to our unit for the clinical suspicion of bowel obstruction. He was also submitted to ERCP seven months before. Physical examination revealed tenderness in the lower abdomen and CT showed intrahepatic and extrahepatic biliary dilatation and small bowel obstruction with a hyperdense formation in right iliac fossa as gallstone ileus. It was performed an emergency laparotomy with enterotomy and a 5x3 cm gallstone removal. There were no post-operative complications and the patient was discharged 8 days after surgery. DISCUSSION: Cholecysto-duodenal fistulas are most frequently described in worldwide-reports. There are only few cases in literature of gallstone which enter the gastrointestinal tract following endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy through papilla of Vater, without a biliary-enteric fistula, causing gallstone ileus. If the patient is cholecistectomized, gallstone removal alone is required. CONCLUSION: The differential diagnosis in case of small bowel obstruction should always include gallstone ileus, even if the patient previously underwent a cholecystectomy.

Primitive squamous cell carcinoma of the breast (SCCB): case report of an uncommon variant of metaplastic carcinoma.

INTRODUCTION: Metaplastic carcinoma of the breast includes a heterogeneous group of neoplasms characterized by admixture of adenocarcinoma with area of squamous, chondroid and osseous differentiation. If the tumor shows pure squamous differentiation, it is designated as squamous carcinoma. SCCB accounts for less than 1% of all invasive breast carcinoma. It can present as cystic lesions and simulate a breast abscess. CASE REPORT: A 75-year old woman was visited at our General Surgery Unit for a palpable lump, about 5 cm in size, at the lower inner quadrant of right breast. Mammography revealed 3cm oval opacity with micro calcifications and US appearance as isoechogenic lump with lesion solid-cystic appearance; cytology deposes for cystic inflammatory lesion(C2) to be monitored. A subsequent ultrasound check one year later confirmed an increase of volume, so micro histology sampling was made with suspect malignancy(B4). After biopsy, the patient underwent excision of cyst. Final histological examination showed SCCB with diffuse positivity for Cytokeratin 34beta-E12 and p63; negative reactions to ER and PR; monoclonal antibody Ki67 > 40%; HER2/neu with score 2+ and FISH examination negative. Subsequently, the patient underwent radical Madden mastectomy which confirmed the histological diagnosis and the negativity of the lymph nodes. DISCUSSION: In literature, prognosis and therapy are still discussed; SCCB has shown very little responsiveness to common chemotherapy. CONCLUSION: A quadrantectomy or a radical mastectomy with lymph node dissection must be considered the best treatment for this rare neoplasia.

Lymph node assessment in colorectal cancer surgery: laparoscopic versus open techniques.

AIM: The aim of our study is to compare the outcomes of laparoscopic resection (LR) and open resection (OR) for colorectal cancer surgery evaluating lymph node assessment. It may be important to remove and examine an adequate number of lymph nodes because a more extensive nodal resection has been associated to higher survival rate and lower recurrences. PATIENTS AND METHODS: 150 patients (74 females and 76 males) with colorectal cancer were enrolled and analyzed from January 2006 to March 2010 in our Unit. 100 procedures were performed with traditional laparotomy and 50 procedures laparoscopically. A strict follow-up was scheduled every 1-3-6 months after surgery and, therefore, every year. RESULTS: Laparoscopic techniques require a longer operating time. 2484 total lymph nodes examined with a mean of 16,56 removed per resection in all procedures. 1632 lymph nodes were removed during open procedures and 852 removed during laparoscopy. The scheduled follow-up demonstrated that local recurrence and distant metastasis presented with no significant differences between two groups and overall survival and disease-free survival were assessed over 5 year in 80% of patients. CONCLUSIONS: According to our experience, laparoscopic colorectal surgery is safe and feasible, with better short-term outcomes and oncological adequacy comparable to open approach.

Effective management of extensive tissue loss after abdominoperineal resection for Buschke-Loewenstein tumor.

The giant condyloma acuminatum or Buschke-Loewenstein tumor is a rare, sexually transmitted disease. It is an epithelial tumor characterized by its high potential of malignancy towards developing into a highly invasive squamous cell carcinoma. The present case concerns a drug addicted 40-year-old man who smuggled drugs using his rectum. He had a partially ulcerated mass in the perianal area of about 20 x 10 cm. He reported a progressive growth of this neoplasm during the last 3 years associated with perianal pain, obstructed defecation, bad sitting posture, no fever and weight loss. Our first approach was a left laparoscopic loop colostomy for a fecal diversion and antalgic purpose, and biopsy of the perineal mass. Then, he underwent a complete excision of the perianal neoplasm. The pathologist's positive diagnosis of a well differentiated squamous cell carcinoma, evidently necessitated the radicalization of the surgical procedure of abdominal perineal resection. In consideration of the surgical wound depth and size, a VAC Therapy with Negative Pressure Wound Therapy was applied. The BLT incidence rate has been steadily increasing over the last decade especially among male patients. An aggressive surgical approach is usually to get the best oncologic outcome but the difficult management of the perianal wound is challenging. In our experience VAC therapy has been shown to be an effective tool in promoting the healing of the perineal wound after abdominoperineal resection.

Ingestion of foreign bodies among prisoners: a ten years retrospective study at University Hospital of Southern Italy.

INTRODUCTION: We studied 21 episodes of ingestion of foreign bodies (IFO) among 15 prisoners. PATIENTS AND METHODS: Rectrospective research in pts admitted to emergency from June 2005 to May 2105. Ingestion, management and pts outcome were analyzed. Prisoners with previous esophagogastroduodenal disease were excluded. RESULTS: All pts were males and ingestions were intentional. Esophagogastroduoduenoscopy (EGDS) was performed in 10pts (8 cases with successful removal, 1 case we did not find anything e 1 of unsuccessful EGDS, that required emergency surgey. 9 pts rejected EGDS: in 2 pts were not necessary.Among the 9 pts that rejected EGDS, 5 discharged voluntary. No mortality neither morbidity. Only 1 pt required surgery.The IFO were 34 (23 sharp, 6 flat,5 indefined). We did not observe any food bolus impaction. Multiple ingestion was found in 11 pts. Recurrent episodes were found in 4 pts. DISCUSSION: Almost all episodes can be treated conservatively with observation and endoscopy but the management of this pts has a financial impact on healthcare cost and on security costs. Prevention strategies are important to predict patient group at high risk for recurrent IFO.

Small bowel obstruction caused by Anisakis and Meckel's diverticulum: a rare case.

INTRODUCTION: Anisakiasis is a parasitic infection caused by the ingestion of raw fish contaminated by larval nematodes of Anisakis species. Intestinal or extraintestinal manifestations are rated to > 4% and >1% respectively. PRESENTATION OF CASE: A 61-year old patient was admitted to our General Surgical and Emergency Unit because of sudden abdominal pain, vomit and constipation. He had eaten raw fish 3 days before admission. Laboratory data showed high levels of WBC and PCR. CT scanning showed "dilation of jejunum and ileum loops, thickening of the terminal ileum and cecum and signs of inflammation of the intestinal wall and mesentery". The following emergency surgical procedure was performed: laparotomy with evidence of obstruction of the small bowels, a giant Meckel's diverticulum, resection of terminal ileum and cecum and ileocolonic anastomosis. At the microscopic examination, the intestinal wall appeared occupied by a transmural inflammatory infiltrate, mainly eosinophilic, edema and nematode larvae, referable to Anisakis, surrounded by necrotic-inflammatory material. Moreover, there was evidence of giant a Meckel's diverticulum. DISCUSSION: Normally, enteric anisakiasis exhibits leukocytosis with eosinophilia and high CRP levels. There are cases of successful medical treatment and other cases of endoscopic treatment avoiding surgical procedure. In our case, enteric Anisakias had not been taken into consideration at the moment of the operation and only histopathology could reveal Anisakis larvae inside the intestinal wall. CONCLUSION: Our surgical approach is considered in literature as the best one for this clinical presentation. Those patients need to be better studied and more attention should be paid to their history.

Preoperative fasting - "nihil per os" a difficult myth to break down: a randomized controlled study.

INTRODUCTION: For several years the scientific anaesthesia societies declared a preoperative fast of 6 hours for solid foods and 2 hours for clear liquids before elective surgical interventions to be sufficient. The aim of this study is to identify the extent of the gap that exists between the preoperative fasting time required and that actually encountered in operating rooms. PATIENTS AND METHODS: The safety and clinical applicability of a reduction of the preoperative fasting time was investigated through the use of oral solutions enriched with maltodextrin and their effects on the pre- and postoperative well-being that this may have on patients who are candidates for elective abdominal surgery. The study was conducted in two successive phases (I and II) and patients divided into two groups (A and B). DISCUSSION: Clinical practice is slow to change, in fact, in our study the duration of fasting was an average of 19 hours for solids and 13 hours for liquids. The duration of the fasting did not show differences in the various surgical departments, demonstrating that it is a transversal practice and is not only limited to abdominal surgery in which the utility of fasting would theoretically be greater. Among Group patients A, the fasting time for liquids was about 9 hours. This shows that the time is certainly shorter but not much different when compared to the fasting time for liquids in group B which was on average 14 hours. It is important how difficult it is to achieve good compliance from patients when trying to reduce the time of preoperative fasting based on scientific evidence that is now well established. CONCLUSION: The use of carbohydrate-enriched drinks up to 2 hours after induction of anaesthesia appears to be a safe procedure. The use of these solutions reduces the catabolic response to surgery and contributes to maintaining a pre-operative state of well-being by reducing feelings of hunger and thirst and the state of preoperative anxiety.

Occasionally report of sacral chordoma; treatment and review of literature.

INTRODUCTION: Brain notochordal cell tumors (BTCN) are lesions arising from notochordal differentiation which affect the axial skeleton. PRESENTATION OF CASE: We report a case of a patient treated in our General Surgery Unit of the University Hospital of Bari, Italy, with occasional finding of sacral chordoma at the histological examination. DISCUSSION: Because of their location, sacral chordomas can affect bowel and bladder with organ specific symptoms. Radiotherapy may be used as a palliative treatment or for recurrence in those patients who cannot be submitted to surgery. CONCLUSIONS: Due to the high local recurrence rate radiation therapy should be considered mandatory after any type of chordoma resection. Multidisciplinary management of the disease is mandatory and improve patient outcomes. Patients should have maximal tumor debulking with adjuvant radiotherapy when possible.