The role of HIPEC in the treatment of peritoneal carcinomatosis from gastric cancer: between lights and shadows.

Gastric cancer is one of the most dreadful neoplastic diseases and remains the second cause of cancer death worldwide. Patients who develop peritoneal metastasis have a poor prognosis, with a median survival of less than 6 months. Despite being the cause of 60% of deaths from gastric cancer, peritoneal metastasis can still be considered a local disease and a local multidisciplinary approach can improve the prognosis even in this end-stage disease. At present, hyperthermic intraperitoneal chemotherapy (HIPEC) is the most widely accepted treatment for peritoneal surface diseases and can be performed in patients with different stages of cancer and with various antitumoral drugs. We performed a systematic review of the current status of HIPEC in the treatment of gastric peritoneal metastasis in an attempt to obtain answers to the questions that still remain: do results differ with these different methods? Does HIPEC exert a significant effect on the intracavitary delivery of drugs? Which patients should be treated and which should not? What can we expect from this approach in terms of survival, morbidity, and mortality? On reviewing the literature, despite the lack of trials comparing the different methods, we found that HIPEC has been shown to be an effective tool whenever a complete or an almost complete resection of the peritoneal implants can be performed. Therefore, it is advisable to refer all at-risk patients to specialized centers to be enrolled in randomized trials to achieve truly reliable results.

Recurrent gastric antral vascular ectasia: a single center experience.

Introduction: Gastric antral vascular ectasia (GAVE) is a rare cause of chronic or acute gastrointestinal bleeding. This condition accounts for ∼4% of upper gastrointestinal bleeding cases. This disease is often associated with systemic diseases, such as liver cirrhosis, chronic kidney failure, autoimmune conditions, diabetes mellitus, hypothyroidism, and cardiovascular diseases. However, its etiopathogenesis remains controversial. Materials and method: We retrospectively reviewed the cases of GAVE treated at our digestive surgery unit. A total of nine patients were identified with a male/female ratio of 1.25:1 and an average age of 75.51 years (SD ± 9.85). All patients underwent endoscopic argon plasma coagulation (APC) treatment. At the time of the review, data on eight patients were available after 36 months of follow-up. Results: APC appears to be safe and effective for hemostasis of bleeding vascular ectasia. Only one (11.1%) patient required surgical intervention due to hemodynamic instability after multiple unsuccessful endoscopic treatments. No intraoperative and postoperative complication or bleeding relapse was experienced. Discussion: Based on our findings, we concluded that endoscopic APC is technically simple, but requires multiple re-interventions due to the incidence of relapses. Furthermore, larger randomized studies should be conducted to assess the role of elective surgery as the first intervention in stable patients with severe pathology and the timing of surgery after failed endoscopic treatment.

Vestibular approach for thyroid surgery: a comprehensive review.

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is an innovative technique in thyroid surgery. This review compiles current research on TOETVA, covering its development, anatomical challenges, techniques, selection of suitable patients, results, complications, and future advancements. We performed a comprehensive literature review on PubMed, EMBASE, and Cochrane databases for articles published up to 15th March 2024. The search strategy included a combination of terms focused on "vestibular approach" and "thyroidectomy". The review underscores the necessity for preoperative planning and careful patient selection to reduce risks and enhance outcomes. It discusses the unique anatomical challenges of TOETVA, such as avoiding mental nerve damage and the complexities involved in creating a subplatysmal space. Outcomes of TOETVA, including surgical duration, complication rates, and recovery times, are compared favorably to traditional methods. The approach is particularly noted for high patient satisfaction and superior cosmetic results. Complications specific to TOETVA, like infection, bleeding, and potential harm to the recurrent laryngeal nerve, are recognized. Future research directions are discussed as well. In summary, TOETVA is a promising alternative for thyroidectomy with excellent cosmetic outcomes and patient satisfaction. Success relies on selective patient criteria, surgical expertise, and continuous research to refine the approach.

Giant gastrointestinal stromal tumor (GIST) of the stomach cause of high bowel obstruction: surgical management.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) represent 85% of all mesenchymal neoplasms that affect the gastrointestinal (GI) tract. These GISTs range in size from small lesions to large masses. Often they are clinically silent until they reach a significant size, so their discovery is usually incidental. CASE PRESENTATION: A 67-year-old man was admitted at our general surgery department with a persistent abdominal pain in the left hypochondrium, associated with nausea and vomiting. Clinical examination revealed a palpable mass in the epigastrium and in the left hypochondrium, which was approximately 40 cm long. Ultrasonography and computed tomography of the abdomen showed a large mass of 40 × 25 cm, which extended from the posterior wall of the stomach to the spleen, involving the body and the tail of the pancreas. The patient underwent en-block resection of the mass, sleeve resection of the stomach, and distal pancreatectomy-splenectomy. The histopathology of the resected specimen was consistent with a gastrointestinal stromal tumor of the stomach (positive for CD 117) with a high risk of malignancy (mitotic count >5/50 high-power fieldand Ki67/Mib1 >10%). The postoperative course was uneventful and treatment with imatinib mesylate began immediately. The patient appears to be disease free after four years. CONCLUSIONS: Giant GISTs of the stomach are rare. Surgical resection with curative intent is feasible. The combination of surgical resection and imatinib can provide long-termdisease-free survival. An R0 resection is the best achievable treatment, therefore the patient should be evaluated over time for potential resectability.

Localized and systemic bacterial infections in necrotizing pancreatitis submitted to surgical necrosectomy or percutaneous drainage of necrotic secretions.

BACKGROUND: Infectious complications are observed in 40-70% of all patients with severe acute pancreatitis. Infections are associated with a significant increase in mortality rates. METHODS: We evaluated the prevalence and characteristics of pancreatic and systemic infections in 46 patients with necrotizing pancreatitis submitted to surgical procedures during their hospital stay as well as the impact of such infectious complications on patient clinical outcome. Samples for microbiological cultures were taken at hospital admission from blood and bile and 2 days after invasive procedure from blood, drainage fluid, bile and necrotic tissues. RESULTS: 74% patients with necrotizing pancreatitis had a localized or systemic infection. At admission, 15% of subjects had positive blood cultures whereas 13% had evidence of bacterial growth from bile cultures. Two days after the invasive procedures for removal of necrotic materials and fluids, blood cultures became positive in 30% of patients in spite of antibiotic prophylaxis and bile cultures resulted positive in 22% of cases. Furthermore, bacterial growth from drainage fluids was found in 30% and from homogenized necrotic material in 44% of cases. As refers to bacterial isolates, all patients had a monomicrobial infection. Carbapenems were the drugs with the best sensitivity profile. CONCLUSIONS: Infectious complications significantly increase mortality in patients with necrotizing pancreatitis. In addition, subjects with systemic infections developed more complications and demonstrated a higher mortality rate in comparison with those having a localized infection. In our study, the sensitivity pattern of the isolated microorganisms suggests to consider carbapenems as the best option for empirical treatment in patients with necrotizing pancreatitis who develop a clear-cut evidence of systemic or localized bacterial infection.

Prognostic factors in elderly patients with breast cancer.

BACKGROUND: Breast cancer (BC) remains principally a disease of old ages; with 35-50% of cases occurring in women older than 65 years. Even mortality for cancer increases with aging: 19.7% between 65 and 74 years; 22.6% between 75 and 84 years; and 15.1% in 85 years or more. METHODS: A search was performed on Medline, Embase, Scopus using the following Key words: Breast cancer, Breast neoplasms, Aged, Elder, Elderly, Eldest, Older, Survival analysis, Prognosis, Prognostic factors, Tumor markers, Biomarkers, Comorbidity, Geriatric assessment, Axilla, Axillary surgery. 3029 studies have been retrieved. Paper in which overall or disease free survival were not end points, or age class was not well defined, or the sample was too small, were excluded. At last 42 papers fulfilled the criteria. RESULTS AND DISCUSSION: Lack of screening and delay in diagnosis may be responsible for the minor improvement in survival observed in elderly respect to younger breast cancer patients. Predictive factors are the same and must be assessed with the same attention reserved to younger women. CONCLUSIONS: Most of elderly patient are fit to undergo standard treatment and can get the same benefits of younger women. Nevertheless it is possible that some older women with early breast cancer can be spared too aggressive treatments. Geriatric assessment and co-morbidities can affect the prognosis modifying surveillance, life expectancy and compliance to therapies. They can thus be useful to select the better treatment, either surgical or radio or hormone - or chemo-therapy.

Gallbladder hemorrhage-An uncommon surgical emergency: A case report.

BACKGROUND: Gallbladder hemorrhage is a life-threatening disorder. Trauma (accidental or iatrogenic such as a percutaneous biopsy or cholecystectomy surgery), cholelithiasis, biliary tract parasitosis, vasculitis, vascular malformations, autoimmune and neoplastic diseases and coagulopathies have been described as causes of hemorrhage within the lumen of the gallbladder. The use of non-steroidal anti-inflammatory drugs and anticoagulants may represent a risk factor. CASE SUMMARY: We report the case of a 76-year-old male patient. An urgent contrast computed tomography scan demonstrated relevant distension of the gallbladder filled with hyperdense non-homogeneous content. The gallbladder walls were of regular thickness. Near the anterior wall a focus of suspected active bleeding was observed. Due to the progressive decrease in hemoglobin despite three blood transfusions, this was an indication for urgent surgery. CONCLUSION: Early diagnosis of this potentially fatal pathology is essential in order to plan a strategy and eventually proceed with urgent surgical treatment.

Cystic peritoneal mesothelioma: report of a case.

Benign multicystic peritoneal mesothelioma (BMPM) is a rare disease with good short-term prognosis and rare malignant transformation. However, its biological significance remains unexplained. A neoplastic origin is considered by many authors to require a surgical excision, based on the high recurrence and progressive growth rate of the tumors. However, alternative or integrative treatment options have also been proposed. A 45-year-old woman presented to our unit with a history of occasional discomfort and pain in the left hip. On physical examination, we noticed a tough-elastic, fixed mass located in the iliac fossa. Computed tomography scan detected a mass with multiseptated cystic-like areas. Due to the similarity of these findings to a primitive sarcomatous tumor of the retroperitoneum, an arteriographic study was also performed. The patient underwent en bloc resection of the mass, including a segment of the sigmoid colon. The final pathologic diagnosis was cystic mesothelioma. Further studies are needed to better understand the etiology and pathogenesis of this rare disease, and to define a more tailored treatment plan.

Muscular metastasis from mesocolic and duodenal leiomyosarcoma. A case report and a review of the literature.

BACKGROUND: Mesenteric and duodenal leiomyosarcomas are very rare malignancies. Muscular metastases from leiomyosarcoma are even more rare. Surgery is the only chance of cure and should be attempted whenever possible. The relief of symptoms and the prevention of recurrences are ultimately the aims of surgery. We present a unique case of mesocolic and duodenal leiomyosarcoma with muscular metastases. CASE REPORT: A 61 year old woman was treated by radical resection including left neftectomy and left hemicolectomy for a leiomyosarcoma of the left mesocolon. Three years after the first surgery a leiomyosarcoma of the duodenal wall was diagnosed. Following a careful evaluation that ruled out the presence of other secondary locations, she underwent pancreatoduodenectomy. Three months later she observed a small, mildly painful swelling in the left thigh, rapidly growing to a diameter of 4 cm over a month period. The MRI showed a low-signal intensity malignancy in T2-weighted images whereas the lesion was homogeneously enhanced by Gadolinium on T1-weighted imaging. The histological examination after excision confirmed the clinical suspicion of a metastasis from high grade leiomyosarcoma. Successively the patient underwent a palliative chemotherapy treatment with epirubicin and ifosfamide for three cycles. The patient experienced a progression of disease with multiple pulmonary and encephalic metastases five months later. CONCLUSION: Muscular metastases from leiomyosarcoma are occasionally described in the literature. The apparition of muscular metastases is considered a negative prognostic factor and shortly precedes massive distant diffusion of the malignancy. Denervation syndrome can be a risk factor for muscular metastases. To our knowledge, this is the first report of a skeletal-muscle metastasis following mesenteric and duodenal leiomyosarcoma.

Multicentric evaluation by Verbal Rate Scale and EuroQoL-5D of early and late post-operative pain after TAPP and TEP procedures with mechanical fixation for bilateral inguinal hernias.

Aimed to evaluate the postoperative pain and other complications among two cohorts of patients undergone transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) laparoscopic hernia repairs with mechanical fixation, the chart of 305 TAPP and 134 TEP for bilateral not recurrent inguinal hernias were reviewed. The postoperative pain was assessed by using the Verbal Rating Scale (VRS) at one week, one month, 3 months ad six months postoperatively. A subgroup of 60 patients was also administered the QoL EQ-5D questionnaire and follow up for at least 6 months. We found a statistically significant difference in the first day (p = 0.001), in the 7th day (p = 0.002), 30th, and 90th day (p = 0.008) between patients perception of pain in TAPP group and TEP group, but after the 180th day there was not any considerable distinction. On the short term the postoperative pain seems slightly lesser in TEP group.

Is there a relationship between length of resection and lymph-node ratio in colorectal cancer?

BACKGROUND: The prognosis of colorectal cancer depends on the number of positive lymph nodes (LN+) and the total number of lymph nodes resected (rLN). This represents the lymph-node ratio (LNR). The aim of our study is to assess how the length of the resected specimen (RL) influences the prognostic values of the LNR. METHODS: We conducted a retrospective study of all the patients operated on for colorectal cancer from 2000 to 2015 at our institution. Pathology details were analysed. The total number of rLN, the number of LN+, and the LNR were calculated and measured against the RL. The receiver-operating characteristic (ROC) curve of patients with LN+ was calculated. RESULTS: Of the 670 patients included in our study, 337 were men (50.3%) and the mean age was 69.2 years. The correlation with prognosis of the LNR is greater than that of the LNR adjusted to RL (LNR/RL), both in subjects with positive nodes (n = 312) and in all cases (n = 670). The LNR presents a higher prognostic value than LNR/RL and RL in patients with LN+ except for metastatic recurrence, for which the predictive value appears slightly higher for LNR/RL. The statistical significance of the maximal divergence in Kaplan-Meier survival plots was demonstrated for the LNR (P = 0.043), not for LNR/RL (P = 0.373) and RL alone (P = 0.314). CONCLUSION: An increase in RL causes an increase in the number of harvested lymph nodes without affecting the number of LN+, thus representing a confounding factor that could alter the prognostic value of the LNR. Prospective larger-scale studies are needed to confirm these findings.

The role of E-cadherin expression in the treatment of western undifferentiated early gastric cancer: Can a biological factor predict lymph node metastasis?

The use of endoscopic techniques to cure small sized, well differentiated early gastric cancer has been adopted worldwide. In the Eastern world, endoscopic resection is being increasingly utilized to treat small undifferentiated early gastric cancer according to the extended criteria proposed by the Japanese Gastric Cancer Associations. However, studies in the Western world reported in these tumors a rate of nodal metastasis ranging between 5% and 20%, that is higher of those observed in Eastern counterparts. A tool to predict the risk of nodal dissemination would be of great use to guide treatment toward endoscopic resection. In our study, we propose E-cadherin expression as a biological factor to predict lymph node involvement. We retrospectively reviewed the E-cadherin (E-cad) expression profile of all histological specimens of undifferentiated early gastric cancer from two Oncologic Departments and compared it with several tumor characteristics. A total of 39 patients with early gastric cancer met the inclusion criteria, of which 16 (41%) pT1a, and 23 (58.9%) pT1b SM1. Thirty-two patients (82%) underwent subtotal gastrectomy, whereas total gastrectomy was performed in only seven cases (17.9%). Patients were divided into two groups: low E-cad expression (E-cad 0/1+, 10 patients) and high E-cad expression (E-cad 2+/3+, 29 patients) according to the immunohistochemical assay (ICH). On univariate analysis, we found an association between low E-cad expression and low grading tumor (p = 0.019), pure undifferentiated histotype (PU-type) (p = 0.014), and lymph node involvement (N+) (p < 0.001). The association between low E-cad expression and lymph node metastasis was confirmed by multivariate analysis (OR = 14.5, 95% CI 3.46-60.76, p < 0.001). The loss of expression of E-cad may be a simple biological factor to predict lymph nodes metastasis in patients with undifferentiated early gastric cancer. Additional larger prospective studies are necessary to confirm these findings.

Main bile duct carcinoma management. Our experience on 38 cases.

BACKGROUND: Cholangiocarcinoma (CC) is rare malignant tumors arising from cells of the biliary tract. It presents some difficulties to diagnose, and is associated with a high mortality. Traditionally extrahepatic CC is divided into klatskin tumors, intermediate tract and distal or iuxtapapillar tumors according to its location within the biliary tree. CT RM, PET may provide useful diagnostic information in those patients. Surgical resection is the only chance for cure, with results depending on selected patients and careful surgical technique. Liver transplantation could offer long-term survival in selected patients when combined with chemotherapy. Chemotherapy, radiation therapy, and external drainage remain as the only treatment for inoperable patients. MATERIAL AND METHODS: The authors report their experience since 1997 inherent to 38 cases of extrahepatic CC, 21 of which were treated by surgery: their outcome has been evaluated. RESULTS: Surprisingly four of them (2 with intermediate tract tumor and 2 with distal tract tumors) are still alive and apparently disease-free after 5 years since surgery. Moreover another one patient with papillar tumor has reached 5 years survival despite has undergone surgery two times. CONCLUSION: Surgery remains the best chance for long-term survival, and lymph node status is the most important prognostic factor following R0 resection.

Gastric GIST and prognostic models. Which is the best to predict survival after surgery?

BACKGROUND: Gastrointestinal Stromal Tumours (GIST) are the most frequent mesenchymal tumour of the alimentary tract. Their prognosis is largely variable as are their size, mitotic rate and site, the stomach being mostly affected. Several risk classifications have been proposed: two developed by the NIH, one proposed by the AFIP and one presented by the AJCC in 2010. The objective of this study is to compare the accuracy of the three prognostic models (AJCC, NIH and AFIP) with regard to survival after surgery, also based on the different surgical approaches. METHODS: A retrospective review of all cases of gastric GIST's performed at the General and Breast Surgery Unit of the Department of General Surgery the University of Catania and at the "Gemelli" General Surgery Unit of Taormina Hospital, Italy between 2001 and 2016 was conducted. The cases were reviewed and re- classified according to the three prognostic models. Analysis of data, including Kaplan-Meyer survival curves, was performed using SPSS version 21.0. RESULTS: Among a total of 1,625 gastrectomies and gastric resections were found 25 primary GIST's patients, 13 females, and 12 males, with a mean age 63 years. Cancer size varied between 1.5 cm and 37 cm and number of mitosis between 2 and 50/50 HPF. A total of 12 (48%) underwent sub-total gastrectomy (STG), seven (28%) underwent a wedge resection (WR), and 6 (12%) total Gastrectomy (TG). Twenty-three patients (92%) are currently alive at a follow up of 18 months to 17 years, and only two patients died during the long term follow-up. Both patients were AFIP high risk (6b), AJCC stage IV, already metastatic at the time of surgery. Both patients underwent total extended gastrectomy and therapy with imatinib, but died 8 and 9 years after surgery. Recurrences have been observed in 2 patients (8%), with high risk according to AFIP (6a) with AJCC stage IIIa disease. CONCLUSIONS: In localized GISTs R0 surgical resection is the standard therapy as it leads to excellent outcomes. Our findings suggest that all the three classifications considered are adequate to achieve a correct prognostic evaluation. KEY WORDS: GIST, Prognostic factors, Prognostic models.

The unique simultaneous occurrence of a squamous cell carcinoma and a granular cell tumor of the tongue at the same site: a histological and immunohistochemical study.

We report a case of a 47-year-old man with a granular cell tumor (GCT) of the tongue colocalized with a squamous cell carcinoma. To our knowledge, this is the first case to be reported in the literature with such an association. Furthermore, we performed an immunohistochemical analysis with p63 to distinguish pseudoepitheliomatous hyperplasia from invasive squamous cell carcinoma. Clinicians and pathologists must be made aware of this potential diagnostic pitfall so that the workup of a tongue lesion does not end prematurely with a benign diagnosis of granular cell tumor with overlying pseudoepitheliomatous hyperplasia.

The recurrent goiter: prevention and management.

AIM OF THE STUDY: Conservative surgery of thyroid is followed by recurrence in 2 to 70% of cases in an 8-20 years period. The surgical treatment of such recurrence is affected by higher morbidity than a primary total thyroidectomy. We wanted verify in our series this difference and discuss motivations for conservative or radical surgery of goiter. MATERIALS AND METHODS: We compared a series of 91 primary total thyroidectomy (A) with 11 cases of total thyroidectomy for recurrence (B) performed between 2001 and 2005. RESULTS: Postoperative complications were: Transient hypocalcemia 7 (7.69%) in A and 3 (27%) in B, Permanent hypocalcemia only 1 (9%) in B, Transient RLN deficit 2 (2.1%) in A and 2 (18.1%) in B. CONCLUSIONS: Due to the need of a lifelong therapy with LT4 no utility is observed in conservative surgery of thyroid. Further, in primary surgery, differences in incidence of perioperative complications cannot be advocated to justify a conservative approach. Sophisticated technologies are not able to prevent all damages to parathyroid or to recurrent nerves when operating on recurrent goiter. Our experience confirms the results of a review of literature on this topic: the best management of recurrent goiter is its prevention by primary total thyroidectomy.

Laparoscopic repair of incisional hernia. Risk factors for the conversion.

INTRODUCTION: Some factors may affect the conversion to open of the laparoscopic treatment of incisional hernia. Their presence can help to choose the most appropriate technique identifying patients at high risk conversion. METHODS: A retrospective study has been performed on a cohort of 306 patients, selected among those undergone to elective laparoscopic surgery for post incisional hernia between 2005 and 2015. Only symptomatic patients with single site wall defect, diameter between 5 and 10 cm, ASA ≤3, have been included. Patients were divided in 2 groups, Laparoscopic (L) and Converted (C) and preoperatory data were evaluated and statistically analyzed. RESULTS: The L group accounted for 228 patients and C group for 78 patients. The univariate analysis showed that risk factor for conversion included BMI ≥ 30, Smoking, Diabetes mellitus, Prior emergency surgery. Age > 60 years was associate with lower risk of conversion. CONCLUSIONS: The result of this retrospective study allows us to say that the choice of the technique, in the presence of multiple risk factors, should be carefully assessed and discussed with the patient. A prospective study with a larger number of patients would allow a better definition of the risk determined by individual factors and the development of a score that could be used in practice to simplify the risk assessment KEY WORDS: Conversion to open surgery, Incisional hernia, Laparoscopy, Risk factors.

Acellular dermal matrix for breast reconstruction after surgery for giant dermatofibrosarcoma protuberans.

INTRODUCTION: Dermatofibrosarcoma protuberans (DFSP) is a rare neoplasm that exceptionally can affect the breast, always originating from skin and dermis, so imposing large sacrifice of skin. Only few cases have been reported of intraparenchymal DFS. We describe a unique case of giant intraparenchymal DFS that required removal of all the gland and reconstructive surgery. CASE REPORT: A 34 years old woman presents with a quickly growing breast mass, about 12 cm, with radiological features suggestive for giant fibroadenoma or mesenchymal neoplasm. The histology showed a Dermatofibrosarcoma protuberans infiltrating the surrounding parenchyma. The need for radicalization imposed, due to the size of the tumour, a nipple sparing mastectomy. The reconstruction has been performed using a new type of Acellular Dermal Matrix (ADM) mesh to wrap the prosthesis that has been placed and fixed over the great pectoral muscle. RESULTS: The final histologic report showed that the residual parenchyma and the skin removed were free from neoplastic infiltration. The patient is free from recurrence at 24 months from the surgery and the cosmetic result is excellent. DISCUSSION AND CONCLUSIONS: The treatment of DFSP should be aimed to prevent local recurrence, that are usually located in the scar or very close to it. Large size DFS can impose even mastectomy. If skin is not compromised like in this case, a nipple sparing mastectomy is suitable and the one time reconstruction with ADM wrapping of the prosthesis and fixation over the muscle can help to spare time, avoid complications and pain medication and reach excellent cosmetic resu. KEY WORDS: Acellular Dermal Matrix (ADM) mesh, Protuberans, Breast neoplasms, Dermatofibrosarcoma, Mastectomy, Nipple sparing, reconstructive surgery.

Very atypical presentation of a retroperitoneal "atypical lipoma". A well differentiated liposarcoma presenting as sciatic hernia.

Unlike hernias and neoplasms of any other body site, the sciatic hernia is uncommon and the finding of an atypical lipoma in it is probably unique. In such instance making the correct diagnosis is paramount in order to perform a procedure with a radical intent. A CT scan must be considered any time a rare form of hernia is observed and the surgical treatment of a retroperitoneal lipoma has to be radical, to prevent a recurrence. This is the strategy followed by the authors in a case of a 53 year old lady presenting with a large retroperitoneal lipomatous neoplasm within a sciatic hernia.

Presentation and management of splenic injury after colonoscopy: a systematic review.

This study reviewed all single experience of splenic injuries after colonoscopy in the last 40 years to define the possible risk factors and the management of this complication. A MEDLINE and a PubMed search was undertaken to identify articles in English, French, Spanish, and Italian from 1974 to 2012 using the key words: "splenic injury," "splenic rupture," and "colonoscopy." Data were analyzed using descriptive statistic. A total of 103 cases have been described in 75 reports. The majority of the patients were women (71.56%) and 6.85% underwent previous pelvic surgery. The mean age was 63 years (range, 29 to 90 y). About 61 of the 103 studies (59.2%) reported the presence or the absence of previous abdominal surgery and within these, only 31 of 61 patients (50.82%) underwent previous abdominal surgery. In this review, over half of the patients with splenic injury underwent colonoscopy for routine surveillance (62.75%), and only one third of the splenic injures were associated with biopsy or polypectomy. The majority of patients (78.57%) developed symptoms within the first 24 hours after colonoscopy and in a minority of cases (21.43%), there was a delayed presentation 24 hours after colonoscopy. Computed tomography was used as the primary modality to make the diagnosis in 69 of 98 cases (70.41%) and as a confirmatory test in many additional cases. Twenty-six of 102 patients (25.49%) were treated by conservative methods, whereas the majority of patients (69.61%) underwent splenectomy as a definitive treatment. Because of possible medicolegal implications, the endoscopists should consider mentioning splenic injury on the consent form of colonoscopy after bowel perforation and bleeding, particularly in higher risk patients.