Large gastrointestinal stromal tumours of the stomach: Is laparoscopy reasonable?

BACKGROUND: Laparoscopic resection (LR) offers significant advantages compared to open resections for gastric gastrointestinal stromal tumours (GISTs). We aimed to evaluate whether LR outcomes jeopardised short and long-term outcomes of patients with large GISTs. PATIENTS AND METHODS: Among 50 patients undergoing surgery for gastric GISTs, 12 underwent LR for large GISTs (>5 cm). Their characteristics, perioperative results and survival were retrospectively compared to those of 22 patients who underwent LR for 'small GIST'. RESULTS: The two groups were similar regarding demographics, rate of wedge resection and mean blood loss. No patient required transfusion or conversion. Operative time was significantly increased in the 'large GIST' group (160 min vs 112 min, P = 0.001). Mean tumour size was significantly lower in the 'small GIST' group (8.4 cm vs 2.4 cm, P = 0.0001). Resection margins were negative. The mortality rate was nil and the overall morbidity rates was similar in both groups. Median length of hospital stay was significantly increased in the 'large GIST' group (7 days vs 5 days, P = 0.004). Median follow-up was 47 months and one patient in the 'small GIST' group developed recurrence and died during follow-up 11 years after surgery. No patient died during follow-up. CONCLUSIONS: LR for large GISTs is safe and technically feasible and does not negatively influence the oncologic course. Prospective randomised trials should be performed before using this approach in routine surgical care.

Acute symptomatic Meckel diverticulum management. Our experience on seven consecutive cases.

Meckel's diverticulum (MD ) is the most common congenital anomaly of the gastrointestinal tract. We revalued clinical records of patients discharged from Unit of Urgent and General Surgery of Highly Specialized Hospital "A.O.R.N. Antonio Cardarelli" of Naples with diagnosis of acute pathology associated to complicated MD from 1(st) January 2011 to 30(th) November 2012. Seven consecutive cases have been chosen: five males (71,4%) and two females (28,6%). The age ranges over from 13 to 50 years with a 28 years average. Four of them were submitted to emergency surgical intervention for hemorrhage from gastro-enteric tract (57%), two for bowel obstruction (29%) and one for acute appendicitis (14%). In all cases sample was send to histological examination. Two samples showed normal epithelial mucosa. Four of them showed ectopic mucosa inside the diverticulum: three gastric and one pancreatic ectopic mucosa focal areas. The last case showed normal epithelial cells but with ulcerated and hemorrhagic areas. Four samples of patients with hemorrhage from gastroenteric tract showed at histological examination: a case of normal mucosa, a case of gastric mucosa areas, one of pancreatic ectopic tissue and the last with normal mucosa but ulcerated and with bleeding areas.In our experience we never speculated that acute symptomatology depended on complicated MD and diagnosis was always done during laparotomy. We think that MD removal is always the correct choice, so that future complications such as neoplasm can be avoided. MD simple resection by Stapler at the base of diverticulum is the correct choice.

Penetrating cardiac injuries. Two case reports.

INTRODUCTION: Penetrating cardiac injuries is still a diagnostic problem at this time. Their management requires immediate surgical intervention and excellent surgical critical care postoperatively. PRESENTATION OF CASES: A 15-year old male patient was stabbed with a knife to the right chest. The chest radiograph showed an haemothorax and the angiography showed an intercostals artery and a right auricle injury. After an emergency operation the patient was released home in good condition after the toracotomy had healed. A 19-year old male patient was stabbed with a knife to the chest more than once. By a left toracotomy we sutured the lesion of the left ventricle with multiple single stitch in non-absorbable suture, we covered the suture with a sealant. The patient released home in 24 days. DISCUSSION: Penetrating cardiac injuries is one of the leading cause of death from urban violence. To evaluate a thoracic trauma with cardiac injury it's clear the use of thorax X-ray and multislice angio-Tc scan. Echocardiography has clearly emerged for the diagnosis in patients haemodynamically stable. When the patient is haemodynamically unstable the emergency thoracotomy is mandatory. CONCLUSION: Despite the high mortality of penetrating cardiac injuries new surgical and radiological tecniques may help surgeon to save this patients.

[Intestinal reconstruction after dehiscence of a jejunal suture in a patient submitted to aorto-enteric fistula repair: a case report]. / Ricostruzione intestinale dopo deiscenza di sutura digiunale in paziente sottoposto a riparazione di fistola aorto-enterica: case report.

Aorto-enteric fistulas are serious complications of aortic surgery that require swift, effective surgical intervention. We report a case of a secondary aortoenteric fistula treated with prosthesis replacement and an intestinal suture subsequently complicated by the dehiscence of the previously constructed anastomosis. We opted for reconstruction re-intervention, closing the intestinal lesion by means of a mechanical suture above the jejunal dehiscence, making a side-to-end jejuno-jejunal Roux anastomosis and an end-to-side anastomosis at the base of the loop. The operation was completed by performing a gastrostomy and transforming the fistula into a jejunostomy. This intervention enabled us to discharge the patient in good general condition after 30 days.

Clinical symptoms of intestinal vascular disorders.

Despite advances made in the diagnostic and therapeutic field, acute intestinal ischemia remains a highly lethal condition. This is related to the variability of symptoms and the absence of typical laboratory alterations in early stage.

Giant basal cell carcinoma.

A 72-year-old white man presented with a large cutaneous tumor on his back. The patient said the lesion, mostly asymptomatic, had increased in size for about 7 years. Physical examination revealed a vegetating mass (Figure 1), partially ulcerated, measuring 30 x 20 cm, which easily dripped serum and blood, with small necrotic areas and a sclerotic border. Perilesional skin appeared edematous, probably owing to inflammation and impaired lymphatic flow. Clinically, there was no evidence of lymph node involvement. His family history was noncontributory. Hematologic examination revealed hypochromic microcytic anemia. Laboratory test results showed hyperuricemia and hypercholesterolemia. The patient's history revealed mild hypertension, ischemic cardiopathy treated with percutaneous transluminal coronary angioplasty and anticoagulant drugs, and moderate chronic renal insufficiency. Histologic examination of a biopsy specimen taken from the margin of the lesion displayed a superficial area of ulceration and invasion of the deeper dermis and subcutaneous tissue (Figure 2A and Figure 2B). The tumor mostly showed an adenoid pattern: gland-like structures and cystic spaces sometimes containing amorphous or granular material, surrounded by strands of basaloid cells devoid of any peripheral palisading (Figure 2C). In some areas, the adenoid pattern coexisted with infiltrated areas characterized by thin and elongated strands or cords of basaloid cells with irregular and jagged peripheral contours within a fibrous or edematous stroma (Figure 2D). Basaloid cells often revealed nuclear atypia, marked pleomorphism and hyperchromatism (Figure 2C and Figure 2D). Therefore, a diagnosis of basal cell carcinoma, adenoid subtype, was made. Magnetic resonance imaging showed a 10-cm wide thickening of the subcutaneous layer on the lumbar region, with a partial neoplastic infiltration of the muscle fascia. No evidence of metastases was found with a total body computed tomography scan. Because the patient was taking anticoagulant drugs and had unstable renal and cardiac function, surgical treatment was at least temporarily excluded, and the patient was referred for radiation therapy.