Primary pulmonary glomangioma: a coin lesion negative on PET study. Case report and literature review.

Glomus tumor is an uncommon perivascular lesion usually located in the dermis of the extremities. It rarely involves the respiratory tract or the lungs. We present the clinical and pathological features of a 39-year-old man who was evaluated for an incidental radiological finding of a pulmonary nodule. A chest computed tomography (CT) confirmed the presence of an upper left lobe coin lesion. Bronchoscopy and 18F-fluoro-2-deoxyglucose positron emission tomography (FDG-PET) were negative. An intraoperative frozen section examination was interpreted as a neuroendocrine tumor; therefore a left upper lobectomy with lymphadenectomy was performed. An immunohistochemical examination supported the diagnosis of a primary pulmonary glomangioma. The patient was free of disease at the 51-month follow-up. Due to its uncertain behavior we stress the usefulness of typical lung resection, lymph node dissection, and accurate follow-up.

Crohn's disease and Takayasu's arteritis: is this association difficult to find out?

Takayasu's arteritis is rarely reported associated with Crohn's disease in the English world literature. A case of Takayasu's arteritis type V in a young female affected by Crohn's disease is presented and the pathophysiology mechanism, and the clinical and diagnostic aspects are underlined. Surgical strategy is discussed.

Extended bilateral mediastinal dissection via a limited thoracotomy for right-lung cancer.

In non small cell lung cancer (NSCLC) patients undergoing surgery after induction chemotherapy, all mediastinal lymphnodes potentially involved by tumor should be resected whenever possible. Paratracheal bilateral lymphadenectomy for left sided tumors can be disabling, i.e. median sternotomy plus a thoracotomy to reach the subcarinal region. From the right side, an extensive ipsilateral dissection is feasible through a standard thoracotomy, but contralateral lymphnodes, especially in the left hilum and aortopulmonary window are considered inaccessible. A technical tip is shown to reach and dissect the left paratracheal and aortopulmonary window nodes through a simple right thoracotomy in right-lung cancer. The procedure has been carried out in 3 cases and proved to be technically feasible. The value of such a procedure as to staging accuracy, local disease control and survival should be evaluated in a clinical trial setting.

Presentation and surgical management of bronchogenic and esophageal duplication cysts in adults.

OBJECTIVE: Bronchogenic and esophageal duplication cysts are congenital anomalies of the tracheobronchial tree and foregut that are often asymptomatic at initial presentation in adults. Surgery is always recommended, even for patients with asymptomatic disease, because of the possible development of symptoms and complications during the natural course of the disease and because definitive diagnosis can be established only on surgical specimen. METHODS: Twenty-seven patients with bronchogenic and esophageal duplication cysts were treated in our institution over the last 2 decades. Ten patients (37%) were asymptomatic at initial presentation. Chest pain and dysphagia were the most common complaints in symptomatic patients affected by bronchogenic and duplication cysts, respectively. RESULTS: A complete excision of the cyst was performed in 26 cases, whereas one patient with intrapulmonary cyst underwent a right upper pulmonary lobectomy. A posterolateral thoracotomy was performed in 23 patients, and a video-assisted thoracoscopy using a three-port technique was performed in the last 4 patients. No postoperative morbidity was recorded. All patients, except one, were asymptomatic at a median follow-up time of 4 years. CONCLUSIONS: Surgery is the treatment of choice for bronchogenic and esophageal duplication cysts. Video-assisted thoracoscopy should represent the first-line approach in these patients.

Cervicomediastinal hibernoma.

Hibernoma is a benign soft-tissue tumor, derived from the brown fat, that often presents as a painless, slow-growing mass. About 100 cases of hibernomas have been reported in the world literature. Seven cases of intrathoracic hibernoma are reported, of which only 1 was located in the mediastinal region. That tumor was an intramediastinal hibernoma with a cervicomediastinal location, which was excised through an extended left supraclavicular incision without the necessity to perform a sternotomy. No recurrence was evident after 18 months.

Randomised controlled trial between stapled circumferential mucosectomy and conventional circular hemorrhoidectomy in advanced hemorrhoids with external mucosal prolapse.

BACKGROUND: This randomized prospective study compared the outcome of circular hemorrhoidectomy according to the Hospital Leopold Bellan (HLB) technique (Paris) with Longo stapled circumferential mucosectomy (LSCM) in two homogeneous groups of patients affected by circular fourth-degree hemorrhoids with external mucosal prolapse. METHODS: From December 1996 to December 1999, 80 consecutive patients with fourth-degree hemorrhoids and external mucosal prolapse were randomly assigned to two groups. Forty patients (group A: 18 men, 22 women, mean age 50.5 years, range 21 to 82) underwent HLB hemorrhoidectomy, and 40 patients (group B: 15 men, 25 women, mean age 51.0 years, range 29 to 92) underwent LSCM. Before surgery, all patients were selected with a standard questionnaire for symptom evaluation, full proctological examination, flexible rectosigmoidoscopy, dynamic defecography, and anorectal manometry. No significant differences among the two groups were found. All patients were controlled with follow-up questionnaire and with clinical examination at 1, 2, 4, 12, and 54 weeks after the operation. A postoperative manometry was performed 3 months after surgery. RESULTS: The length of the operation was significantly lower in group B (25 +/- 3.1 SD versus 50 +/- 5.3 minutes, P <0.001). Mean hospital stay was 3 +/- 0.4 days in group A and 2 +/- 0.5 days in group B (P <0.01). Mean duration of inability to work was 8 +/- 0.9 days in group B and 15 +/- 1.4 days in group A (P <0.001). Postoperative pain was significantly lower in group B (P <0.001). Mean length of follow-up was 20 +/- 8.0 months in group A and 20 +/- 7.8 months in group B. Late complications were similar in the two groups, with 0%, at present, recurrence rate. CONCLUSIONS: Our results confirm that both operations are safe, easy to perform, and effective in the treatment of advanced hemorrhoids with external mucosal prolapse. However, the LSCM seems to be preferable owing to the fewer postoperative complications, easier postoperative management, and shorter time to return to work. A longer follow-up is required to confirm the true efficacy of this surgical method.

Therapeutic options in the management of gastroesophageal reflux disease.

The treatment of gastroesophageal reflux disease requires an individualized approach, and aims to remove the symptoms, to heal the esophagitis, and to prevent the recurrence or complications. These objectives are obtained reducing the incidence of the damaging reflux into the esophagus by improving the anti-reflux barrier, decreasing the gastric acid component, enhancing the esophageal clearance. Depending on the severity of the disease, gastroesophageal reflux disease may be managed through a combination of lifestyle modifications, antacid-anti-refluxant drugs, prokinetic drugs, receptor-H2-antagonists, proton pump inhibitors or surgery. Antireflux surgery should be considered in several situations. All patients, especially at a young age, who have an insufficient response to medical management, presenting with a mechanically defective lower esophageal sphincter or with various grades of complications are candidates for surgery. Although a surgery is rarely used as treatment option in patients affected by gastroesophageal reflux disease, the percentage of success is upper to 80-90%, especially after the introduction of minimally invasive procedures, with significantly ad vitam reduced costs.

Gastroesophageal reflux disease. Pathogenesis, symptoms and complications.

The onset of GERD depends on several factors leading to a prolonged exposition of the esophageal mucosa to inflammatory agents. Various mechanisms play a role in different patients, but generally, decreased LES tone and delayed esophageal clearance are the major causes. Although pyrosis and regurgitation are the most frequent complaints, the patient may have different symptoms or can be asymptomatic. The symptoms are not necessarily correlated with damaged mucosa. Recognized complications caused by reflux include esophagitis, stricture, hemorrhage, Barrett's epithelium and ulceration, aspiration and respiratory implications. The severity of complications may be an important element in predicting whether the patient can be successfully treated medically or surgically. The exact knowledge of the pathogenesis is mandatory for carrying out the most effective treatment.

Isolated splenic metastasis from gastric carcinoma: value of CEA and CA 19-9 in early diagnosis: report of two cases.

We report two cases of an isolated splenic metastasis, occurring 5 and 3 years, respectively, after gastrectomy for gastric carcinoma. Serum carcinoembryonic antigen and CA 19-9 levels were evaluated preoperatively, postoperatively, and during the oncologic follow-up. The patients underwent splenectomy for solitary splenic metastasis. We conclude that the use of serum carcinoembryonic and CA 19-9 values may help in the early diagnosis of these recurrences and splenectomy allows radical treatment in patients with no evidence of disseminated disease.

Synchronous isolated splenic metastasis from colon carcinoma.

We report the first case known to us of a synchronous isolated splenic metastasis from colon carcinoma in a 52-year-old woman operated on splenectomy, left colectomy, and ileal resection. The patient died of diffuse carcinomatosis 1 year after the operation. Splenectomy for isolated splenic metastasis from colon carcinoma is justified, and serum tumor markers are useful to detect metastases early during the follow-up, as in our report.

Laparoscopic Lin operation for the treatment of polycystic liver disease.

Non parasitic hepatic cysts are a clinical entity that is often associated with polycystic kidney disease. We report the case of a 75 year-old woman who presented with symptomatic but non complicated polycystic liver disease. The treatment consisted of laparoscopic fenestration of a large simple cyst located in the left hepatic lobe. The postoperative course was uneventful and the patient remains free of symptoms at 18-months follow-up. Selected patients with symptomatic but uncomplicated polycystic liver disease and favourable anatomy benefit from laparoscopic fenestration of the cysts with low morbidity and hospital stay.

Primary multiple epithelioid leiomyosarcoma of the liver.

Sarcomas represent only 1-2% of primary malignant tumors of the liver. We report the twenty first case of primary hepatic leiomyosarcoma in the literature. Metastases from gastrointestinal tract, female genital system and lung have to be excluded before confirming diagnosis of a primary neoplasm. Extensive involvement of the liver parenchyma contraindicated surgery, the treatment of choice when the tumor is solitary or multiple but located in one lobe. Chemotherapy, as employed in our patient, is the alternative therapeutic option in inoperable cases, but its role has to be clarified.

Endoscopic ultrasonography in the evaluation of leiomyoma and extramucosal cysts of the esophagus.

BACKGROUND/AIMS: Leiomyoma is the most common type of benign esophageal tumor, whereas extramucosal cysts of the esophagus are congenital anomalies frequently asymptomatic in the adult and in most cases detected incidentally on chest x-ray. It is worthwhile considering these conditions together, because they present similar diagnostic and surgical problems. Conventional imaging tests do not lead to a precise diagnosis. The purpose of this study was to evaluate the use of endoscopic ultrasonography in the diagnosis of, and planning of treatment modalities for, these conditions. METHODOLOGY: Fifteen patients with esophageal leiomyoma and seven patients with extramucosal esophageal cysts were studied with endoscopic ultrasonography using an Olympus GF- EU-M3 instrument with a 7.5-12 MHz echoprobe. In all patients, the results of endoscopic ultrasonography were compared with the histology of the resected specimens. RESULTS: The histology of the resected specimens confirmed the endosonographic diagnosis in all patients. No malignancy was found in any specimen. CONCLUSIONS: Endoscopic ultrasonography is very accurate in visualizing these lesions and differentiating cystic from solid submucosal esophageal masses; in addition, the test can establish the exact location of the mass in relation to the esophageal wall and mediastinum. Therefore, endoscopic ultrasonography has a great impact in confirming the diagnosis of leiomyoma and extramucosal cysts of the esophagus and facilitates therapeutic decision-making because of its capacity to clearly define the size, layer of the origin, and pattern of the mass.

Ultrasonographic imaging of neoplasms of the cervical esophagus.

BACKGROUND/AIMS: We studied the effectiveness of ultrasonography in evaluating the cervical esophagus for the presence of large masses arising from the esophageal wall and consequently, the modifications of the visceral lumen. MATERIALS AND METHODS: The cervical esophagus can be evaluated by ultrasound with longitudinal and axial scans, using the left thyroid lobe as an acoustic window. The cervical esophagus can be visualized from the C5 to D2 vertebrae. From November 1992 to July 1996, 220 patients with esophageal cancer and 120 subjects without esophageal disease (control group) were examined with ultrasonography. Examination of the cervical esophagus was performed with a linear high definition small parts probe with a frequency of 7.5-10 Mhz. RESULTS: In all 31 patients with cancer of the cervical esophagus, ultrasonography of the cervical region showed the presence of an expanding mass from the esophageal wall as well as the modifications in the visceral lumen. The neoplasm of the cervical esophagus was visualized when its diameter exceeded 5 mm. CONCLUSIONS: The experience of the authors shows that, during ultrasound examination of the cervical region, it is possible to accurately evaluate the cervical esophagus, either morphologically or functionally.

Can laparoscopic cholecystectomy be a day surgery procedure?

BACKGROUND/AIMS: Gallbladder surgery by videolaparoscopy (VL) is now able to obtain the same goals as traditional surgery, and is associated with comparable or better results both in terms of positive surgical outcome and patient satisfaction. With public health spending under growing social and administrative pressure, and continuous efforts focusing on enhancing the efficiency of both surgical instruments and operating procedures, it is a most attractive, albeit initially challenging, prospect to regard video-laparoscopic surgery as day-case surgery. Herein, the authors assess the outpatient treatment option, due to recent technical developments and relevant major organizational and professional implications, and consider the feasibility of day-case surgery projects which should soon be implemented. METHODOLOGY: From January 1994 to December 1996, 1,334 patients underwent videolaparoscopic cholecystectomy. Of these, 898 were women and 436 men. In 1,034 of the laparoscopies gas was used and 300 were performed without gas. Out of the total 1,334 patients who were submitted to the videolaparoscopic cholecystectomy procedure with or without the use of gas, 72 (5.4%) were treated on an outpatient basis. RESULTS: In our series, 93.5% of patients reported normal post-operative functions within 24 hours; 90.2% of patients were able to take oral fluid on the same day of the operation and had normal bowel peristalsis within the first post-operative day. CONCLUSIONS: The authors assess the outpatient option treatment, due to recent technical developments and relevant major organizational and professional implications, and consider the feasibility of a day-case surgery project which should soon be implemented.

Circular hemorrhoidectomy in advanced hemorrhoidal disease.

BACKGROUND/AIMS: Milligan-Morgan's hemorrhoidectomy has a high recurrence rate (> 10%) in patients with circular IV grade hemorrhoids. In such cases a circular hemorrhoidectomy with complete elimination of residual piles, and anoplasty might be more successful. The aim of this retrospective study was to compare the results of circular hemorrhoidectomy using the Hopital Leopold Bellan (HLB) technique (Paris) with the reported results of other techniques in patients with advanced hemorrhoidal disease. METHODOLOGY: From January 87 to December 96, 100 consecutive patients with circular IV grade hemorrhoids underwent radical hemorrhoidectomy. Mean hospital stay was 4 days (range 3-7). Patients were strictly controlled in the postoperative period and in cases of early fibrosis anal dilators were used. RESULTS: Eighty one percent of patients had a complete recovery. The recurrence rate was 4%. The cumulative rate of early and late complications was 34%. Early and late hemorrhages were more frequent than in traditional hemorrhoidectomy, while the incidence of anal stenosis was the same. CONCLUSIONS: The HLB operation is the best choice for patients with advanced circular hemorrhoids because of its radicality and good results. The postoperative morbidity of HLB hemorrhoidectomy is higher than traditional hemorrhoidectomy; nevertheless, all complications are tractable without extension of hospital stay.

Evaluation of leiomyoma of the esophagus with endoscopic ultrasonography.

Fourteen patients with suspected leiomyoma of the esophagus were studied by endoscopic ultrasonography, computed tomography, endoscopy and barium swallow. The results were correlated with the histology of the resected specimens: in 2 patients with a peduncolated leiomyoma originating from the second echographic layer, endoscopic resection was performed. Endoscopic ultrasonography was superior to other imaging techniques in detection and staging of leiomyoma because it can determine the layer of origin, the direction of the growth and the consistency of the tumor.

Endoscopic ultrasonography for preoperative staging of gastric carcinoma.

BACKGROUND/AIMS: To assess the accuracy and limitation of endoscopic ultrasonography in preoperative staging of gastric cancer, we performed a prospective study on 99 patients. MATERIAL AND METHODS: Ninety-nine patients with gastric cancer had preoperative staging with endoscopic ultrasound (EUS) and CT. RESULTS: The depth of infiltration (T parameter) was correctly defined by EUS in 58/65 patients (89%). The lymph node involvement (N parameter) was correctly classified in 44/65 patients (68%), the sensitivity was 74% and the specificity was 54%. The most frequent cause of understaging T parameter was microscopic tumor invasion, whereas overstaging was due to peri-tumor inflammation. CONCLUSIONS: We believe that EUS is a reliable method, superior to all diagnostic tools, in the evaluation of locoregional extension of gastric cancer.

Surgical treatment of complete rectal prolapse: results of abdominal and perineal approaches.

This retrospective study reports the results of our 5-year experience in the diagnosis and treatment of rectal prolapse with fecal incontinence by the abdominal (laparotomy or laparoscopy) and perineal approaches. Twenty-five patients (group A; 22 women and 3 men; mean age 57.3 years; range 22-76 years) were operated on by the abdominal approach and ten (group B; 8 women and 2 men; mean age 68.9 years; range 58-84 years) by the perineal approach. All patients were evaluated by clinical examination, proctosigmoidoscopy, pancolonic transit time, dynamic defecography, anorectal manometry, and anal electromyography preparatory to surgery. In patients of group A, we performed an abdominal rectopexy in 19 cases (7 by laparoscopy) and in the remaining 6 cases, a sigmoid resection-rectopexy (3 of which were by laparoscopy). All patients of group B were treated by a perineal operation using Delorme's mucosectomy in 4 cases and Altemeier's rectosigmoidectomy with total perineoplasty in 6 cases. The mean follow-up was 38.8 months in group A and 25.7 months in group B. The postoperative complication rate was 8% (two cases) in group A, whereas no significant complications occurred in group B. Dyschezia and fecal incontinence improved significantly in both groups (P < 0.05 in group A and P < 0.005 in group B), whereas anoperineal pain was not significantly reduced. At 1-year follow-up, the recurrences rates were 8% in group A and 30% in group B. Rectopexy or resection-rectopexy proved to be a safe and effective procedure for external prolapse, without a discernible difference between the laparotomic and laparoscopic techniques. In selected cases, the perineal approach gives good results regarding fecal incontinence without complications, even if in these patients, the likelihood of recurrence is high.