The tip of the iceberg of colorectal perforation from enema: a systematic review and meta-analysis.

BACKGROUND: Although rare, perforation following an enema used to treat constipation is a dangerous complication. However, no recommendations or guidelines for enema use are available. So, in common clinical practice, the diagnostic approach and the treatment are not standardized. In an attempt to resolve this clinical dilemma associated with high mortality and potential medicolegal claims for malpractice, we have performed a systematic review and meta-analysis of studies reporting on colorectal perforation secondary to enema use for adult patients with constipation. METHODS: A systematic search of PubMed, Web of Science and Scopus was performed according to the PRISMA statement up until February 2020. Studies that reported on colorectal perforation from enema use in adult patients with constipation were included. The primary outcomes were the rate of hospital mortality and pooled prevalence estimates of mortality from perforation secondary to enema use. The secondary outcomes were the administration of rectal enemas, site of visceral perforation, signs, symptoms, radiological evaluation, and type of treatment RESULTS: A total of 15 studies were included in the final analysis (49 patients). Across all studies, the pooled prevalence estimate of mortality for patients with perforation secondary to enema use was 38.5%, (95% CI [22.7%, 55.5%]). This rate was lower in patients who had surgery (35%) than in patients treated conservatively (57.1%). The sites of perforation were intraoperatively reported in 84% of cases, but in 16% of patients the rectal perforation was undiagnosed, and surgical decision making was problematic. The primary location of the perforation was the rectum in 80.9% of the patients. The enema was administered by a nurse in 90% of the cases, self-administered in 7.5% and a family doctor in 2.5%. The main objective of emergency surgery in this setting is resection of the perforation caused by the enema; when it is not possible to resect the perforated rectum, faecal diversion is needed. Hartmann's procedure was most commonly performed by the surgeons in this review (60.7%), with other reported treatments included a diverting proximal loop colostomy and sigmoid segment exteriorization CONCLUSIONS: Considering the studies available, it is not possible to undertake a thorough evaluation of enema use, including the associated complications and their management. Further data are required to allow the development of guidelines to advice on safe enema use and management of complications.

Non cross-linked equine collagen (Salvecoll-E gel) for treatment of complex ano-rectal fistula.

BACKGROUND: Fistula-in-ano is one of the most commonly presenting anorectal diseases. Sphincter sparing treatment options should be considered in patients with complex fistulas. Salvecoll-E gel is a native collagen deantigenated and purified, non-cross-linked equine dermal extract, with an amino acid composition identical to human collagen. METHODS: The multicentric trial study was a prospective, single-arm observational clinical study with the objective to assess the efficacy of Salvecoll-E gel for anal fistula repair in 70 patients. All patients had undergone preliminary surgical treatment consisting of positioning of a draining loosing seton that was maintained for a period of 4-6 weeks. After seton removal, a gentle debridement and washing of the fistula track was performed. The scar tissue was removed from the internal orifice. Internal opening was covered by a side-to side mucosal suture. Salvecoll-E was injected through the external opening into the fistula track, the external opening it has been opened. RESULTS: Twelve months after surgery, 55 patients demonstrated a clinically healed fistula (78,5%), 15 patients have a recurrence (21,5%). Most of the recurrences were observed in the first 6 months of treatment (13/15, 86.6%). We don't observe any worsening in CCF score. The results obtained at 1 year certainly seem satisfactory and in line with the best results published in literature using mini-invasive techniques. CONCLUSION: Salvecoll-E gel is a promising non-invasive technique for conservative treatment of anal fistulas, it's well tolerated by the patients and, in case of recurrence, reinjection or all other known techniques are feasible.

Colocutaneous fistula through ulcerative colitis and cancer to the pyoderma gangrenosum: a never-ending story for a single patient. Case report.

BACKGROUND: Inflammatory bowel diseases may be associated with many extraintestinal complications, that in some cases can represent the first onset of these disorders. In particular during the course of the disease, Ulcerative Colitis develops extraintestinal manifestations very frequently. One of the rarest is pyoderma gangrenosum, a noninfectious neuthrophilic dermatosis, that can involve most commonly legs but also other parts of the skin or mucosas. It can be idiopathic or associated with gammopathies, vasculitis, chronic arthritis or, like in our case, with inflammatory bowel disease and malignancies. CASE PRESENTATION: A 38-year-old man was referred to our Department with a colo-cutaneous fistula in the left quadrant of abdominal wall. In the anamnesis he reported a trauma during a soccer match three weeks before. Through a CT scan and endoscopy with biopsy an inflammatory bowel disease with a segmental colitis and stenosis was diagnosed. After medical therapy, an initial radiological drainage and a period of parenteral nutrition, he underwent a left hemicolectomy. Despite the previous endoscopic biopsy the histopathological examination put in evidence not only inflammatory disease (in particular Ulcerative Colitis) but also a colorectal tumor pT4pN0. After the full recovery before chemotherapy he has developed on the chest and on the abdomen some painful nodules, with central necrosis, one of those in contact with one of the ribs. Through TC and RM it was impossible to understand the precise nature of these skin lesions. With biopsy a pyoderma gangrenosum was diagnosed and treated until complete resolution. DISCUSSION AND CONCLUSION: Management of inflammatory bowel diseases can be a true challenge, not only for the intestinal manifestations, but also for all the other features not related to gut. In some cases the same patient can develop many complications, such as malignancies or rare cutaneous diseases. Despite the initial surprise for such a weird evolution in a same patient, from fistula to inflammatory disease to cancer and finally to pyoderma gangrenosum, to face every single complication following consolidated diagnostic and pathological paths has been the correct strategy for controlling the disease.

Transperineal rectocele repair with biomesh: updating of a tertiary refer center prospective study.

PURPOSE: Symptomatic rectocele results in obstructed defecation and constipation. Surgical repair may provide symptomatic relief. A variety of surgical procedures have been used in the rectocele repair to enhance anatomical and functional results and to improve long-term outcomes. METHODS: In this prospective study, we treated 25 selected women suffering from simple symptomatic rectocele with transperineal repair using porcine dermal acellular collagen matrix Biomesh (Permacol®). Watson score and SF-36 questionnaire were used to evaluate postoperative outcomes and quality of life. RESULTS: Follow-up ranged from 12 to 24 months, the mean total Watson score was significantly lower than the preoperative score (P < 0.001), and every patient has improved functional outcomes. There were no major intraoperative or postoperative complications. Two cases of urinary infection and 4 patients delayed wound healing were reported. Those patients who were sexually active prior to surgery have not experienced problems with sexual function or dyspareunia. CONCLUSIONS: Despite lack of comparative study in literature, rectocele repair with Permacol® by the transperineal approach seems an effective and safe procedure that avoids some of the complications associated with synthetic mesh use.

Treatment of obstructed defecation syndrome due to rectocele and rectal intussusception with a high volume stapler (TST STARR-plus).

BACKGROUND: In recent years, stapled transanal resection (STARR) has been adopted worldwide with convincing short-term results. However, due to the high recurrence rate and some major complications after STARR, there is still controversy about when the procedure is indicated. The aim of this study was to assess the safety, efficacy and feasibility of STARR performed with a new dedicated device for tailored transanal stapled surgery. METHODS: All the consecutive patients affected by obstructed defecation syndrome (ODS) due to rectocele or/and rectal intussusception, who underwent STARR with the TST STARR-Plus stapler, were included in a prospective study. Pain, Cleveland Clinic Score for Constipation (CCCS) and incontinence, patient satisfaction, number of hemostatic stitches, operative time, hospital stay and perioperative complications were recorded. Postoperative complications and recurrence were also reported. RESULTS: Forty-five consecutive patients (median age 50; range 24-79) were included in the study. Median resected volume was 15 cm3 (range 12-19 cm3) with a median height of surgical specimen of 5.6 cm (range 4.5-10 cm). The mean CCCS decreased from 17.26 (± 3.77) to 5.42 (± 2.78) postoperatively (p < 0.001). Patient satisfaction grade was excellent in 14 patients (31.1%), good in 25 (55.5%), sufficient in three (6.7%) and poor in three patients (6.7%). No major complications occurred. Five patients (11%) reported urgency after 30 days and two patients (4%) after 12 months. The Cleveland Clinic Incontinence score did not significantly change. At a median follow-up of 23 months (range 12-30 months), only three patients (6.7%) reported recurrent symptoms of obstructed defecation comparable to those reported at baseline. CONCLUSIONS: TST STARR-Plus seems to be safe and effective for the treatment of ODS due to rectocele and rectal intussusception, and technical improvement could reduce the risk of some complications. However, careful patient selection is still the best means of preventing complications.

Pilonidal disease mimicking anterior anal fistula and associated with posterior anal fistula: a two-step surgery. Case report.

AIM: Anal fistula is a common disease originated from abscess according the cryptoglandular theory. A rare etiology is the pilonidal disease. In our case we observed a pilonidal disease mimicking an anterior perianal fistula, associated with another posterior anal fistula. CASE PRESENTATION: A 36-year old man was referred to our department with an anal fistula with an anterior opening. Despite the clinical examination and the endoanal ultrasound, only during the surgery we discovered the origin of the anterior fistula from a misdiagnosed pilonidal sinus. There was also a posterior anal fistula in communication with the same abscess of the anterior one. We performed a two-step surgery with a first fistulectomy of the anterior tract, a drainage of abscess and the positioning of a seton for the posterior fistula. After about one month and the fall of the seton we evaluate the good healing of posterior anal fistula and excised the residual pilonidal sinus. CONCLUSION: This misdiagnosed pilonidal disease created in our clinical report a true challenge. Our goal was to eliminate as much disease as possible, but also to avoid major complications or recurrences. We refused an aggressive approach and chose a two-step surgery, with in the first approach not only a demolitive time but also a reconstruction to facilitate healing, and in the second time the complete eradication of the pathology.

Selective inhibitors of aurora kinases inhibit proliferation, reduce cell viability and impair cell cycle progression in papillary thyroid carcinoma cells.

The three members of the Aurora kinase family, Aurora-A, -B and -C, regulate several aspects of the mitotic process, and their aberrant expression and/or function causes mitotic abnormalities leading either to cell death or aneuploidy. They are found overexpressed in several human malignancies, including the papillary thyroid carcinoma (PTC). In the present study, we sought to establish whether Aurora kinase inhibition could be of any therapeutic value in the treatment of aggressive forms of PTC, enduring to radioactive iodide (RAI) ablation. To this end, the effects of selective inhibitors of Aurora-A (MLN8237) and Aurora-B (AZD1152) were analyzed on 3 human PTC cell lines expressing either wild-type (K1 and TPC1) or mutant p53 (BCPAP). The two inhibitors were capable of reducing cell proliferation in a time- and dose-dependent manner, with IC50 comprised between 65.4 and 114.9 nM for MLN8237, and between 26.6 and 484.6 nM for AZD1152. Immunofluorescence experiments confirmed that AZD1152 inhibited Aurora-B phosphorylation of histone H3 on Ser10, however, it did not affect Aurora-A autophosphorylation. MLN8237 inhibited Aurora-A autophosphorylation as expected, but at concentrations required to achieve the maximum antiproliferative effects it also abolished H3 (Ser10) phosphorylation. Time-lapse videomicroscopy evidenced that both inhibitors prevented the completion of cytokinesis, and cytofluorimetric analysis showed accumulation of cells in G2/M phase and/or polyploidy. Apoptosis was induced in all the cells by both inhibitors independently from the p53 status. In conclusion, in the present preclinical study MLN8237 and AZD1152 have emerged as promising drug candidates for RAI-insensitive PTC.

Prevention of complications during reoperative thyroid surgery.

BACKGROUND: Thyroidectomy performed by an experienced surgeon is associated with a low incidence of recurrent laryngeal nerve injury and permanent hypoparathyroidism. During reoperative thyroid surgery there is a higher technical risk because detection and preservation of the recurrent laryngeal nerves and parathyroid glands are more difficult than in the primary surgery. AIM: Our retrospective cohort study was to assess short- and long-term complications associated with reoperative thyroid surgery in order to suggest a technical approach to lower the morbidity rate. MATERIALS AND METHODS: From January 2005 to September 2013, 745 patients underwent surgery for thyroid disease. Before surgery all patients underwent clinical examination, laboratory blood tests, hormonal assays, neck ultrasound, chest radiography and indirect laryngoscopy. Patients were followed up at 1, 3, 6 months and then annually after operation with hormonal assays, blood tests and neck ultrasound. RESULTS: Eighty (10.7%) out of 745 patients (mean-age= 52.5 years; age-range 18-80) underwent reoperative surgery for recurrent thyroid disease. The primary treatments were enucleoresection (11.2%), thyroid lobectomy(56,3%), thyroid lobectomy with isthmectomy(10%) and subtotal thyroidectomy (22,5%). In the reoperative surgery group (Group Re) the transient RLN complications were 1.3% compared to 0.2% in the primary surgery group (Group P) (p= 0.51). The incidence of temporary hypocalcemia was 45% in the reoperative surgery group vs. 42.7% in the primary surgery group (p=0.72). CONCLUSIONS: Reoperative surgery should be reserved to experienced surgeons. However, even in this case, when surgical maneuvers reserved for primary surgery are applied, then this surgery is associated with a low complications rate.

[Adenocarcinoma following restorative proctocolectomy for ulcerative colitis: a case report and review of the literature]. / Adenocarcinoma insorto dopo proctocolectomia restaurativa per rettocolite ulcerosa: presentazione di un caso clinico e revisione della letteratura.

Restorative proctocolectomy with ileal pouch-anal anastomosis has been accepted as the surgical treatment of choice for most patients with ulcerative colitis. The occurrence of adenocarcinoma arising near or into the ileal pouch is rare. Only 19 such cases have been reported so far. The authors report a case of a 67-year old male who developed an adenocarcinoma in the small rectal stump 12 years after a restorative proctocolectomy with double stapled ileal pouch-low rectal anastomosis for ulcerative colitis unresponsive to medical treatment. They, after a literature review, examine same steps of the procedure and emphasize the importance of regular and prolonged follow-up for all patients having restorative proctocolectomy for ulcerative colitis.

[Mininvasive treatment of strangulated paraesophageal hiatal hernia in emergency. Case report]. / Trattamento chirurgico minivasivo d'urgenza di ernia gastrica iatale paraesofagea strozzata. Caso clinico.

The Authors report a case of strangulated paraesophageal hiatal hernia occurred in a elderly woman and treated with laparoscopic approach. After review of the literature regard on this uncommon pathology that present about 5% of the hiatal hernias, they emphasize that the laparoscopic approach is appropriated even in emergency and comprises complete reduction of the stomach in abdomen, control of suitable position of the distal esophagus and cardias and making of effective hiatus-plasty.

Stapled haemorrhoidopexy: a consensus position paper by an international working party - indications, contra-indications and technique.

An international working party with experience in the performance of an alternative haemorrhoid operation through the use of the circular stapler was convened for the purpose of developing a consensus as to the criteria for undertaking this procedure. The agenda consisted of first, naming the operation; second, the indications and contra-indications for its performance; and third, the preferred surgical technique. Among the recommendations for individuals who plan to embark on this surgery are that experience with anorectal surgery and an understanding of anorectal anatomy are requisites; experience with circular stapling devices is essential; and the surgeon must attend a formal course which should include lectures, videos, the application of the instrument in models, and observation of the operation as performed by a surgeon recognized by his or her peers-leading ultimately to undertaking the procedure while being observed by an experienced surgeon. Following satisfactory completion of the above, independent responsibility should be determined by an individual's department of surgery.

Peritoneal mesothelioma in a case of inguinal hernia. A review of the literature.

The peritoneal mesothelioma (PM) is a rare, benign or malignant, primary tumour, arising from the peritoneal membrane. The most frequent histological form is the malignant one with an incidence of 2-2.6 new cases per million per year. The symptomatology is insidious and poses difficult problems in the diagnosis and the treatment. Instrumental diagnostic investigations are useful only in the diagnostic orientation. Only the pathologic examination allows to distinguish a peritoneal carcinomatosis from PM. The prognosis of MPM is pour. An intense multimodal therapy, combining surgery with CT and RT, increases the survival rates in the patients with MPM. It has been proposed that hernia of abdominal wall play a role in the pathogenesis of this tumor. We believe that hypothesis seems unlikely considering the enormous discrepancy between the incidence of hernial pathology and PM.

Lateral pelvic lymphadenectomy and total nerve sparing for locally advanced rectal cancer in Western patients.

BACKGROUND: In an attempt to improve the results of locally advanced rectal cancer treatment, we performed an extended surgical technique consisting of total mesorectal excision (TME), lateral pelvic lymphadenectomy (LPL) and total nerve sparing (NS). Resection of the autonomic nerves was realized only when these fibres were involved by the tumour. METHODS: Nine cases (9.2%) of a personal series of 98 western patients with rectal carcinoma operated on between January 1992 and December 1997 at Third Department of Surgery, University La Sapienza, Rome, underwent TME, LPL and NS procedures for locally advanced extraperitoneal disease. RESULTS: Two out of seven patients in stage II/III suffered postoperatively from urinary retention with mild irregular flow as tested on urodynamics, but no long-term urinary disturbances persisted. Retrograde ejaculation occurred postoperatively in one of two patients who experienced urinary disturbances. Another patient had erection dysfunctions. These sexual dysfunctions did not improve during the long-term follow-up. Seven patients with stage II or stage III disease achieved a 5-year survival rate of 80.0% and a 5-year disease-free survival rate of 68.6% after a mean follow-up period of 64.7 months. None of them experienced local recurrence, but one patient died of diffuse metastatic disease 50 months after surgery. Two patients with stage IV rectal carcinoma died of local and distant disease 13 months and 35 months after operation. One patient underwent liver resection for solitary metastasis 25 months after primary operation. CONCLUSIONS: TME, LPL, and NS with resection of autonomic nerves only when these fibres are involved by the disease can achieve satisfactory results in terms of survival and functional outcome in selected western patients with locally advanced rectal cancer.

[Compatibility, indications, and limits of nerve sparing technique in lateral pelvic lymphadenectomy for advanced rectal carcinoma]. / Compatibilità, indicazioni e limiti della nerve sparing technique nella linfadenectomia pelvica laterale per carcinoma del retto avanzato.

The aim of radical surgical treatment of rectal cancer is to control the spread and prevent recurrence of the disease. In an attempt to improve the results of treatment of locally advanced rectal cancer, we advocate an extended surgical approach consisting of total mesorectal excision, lateral pelvic lymphadenectomy and the nerve sparing technique with resection of autonomic nerves whenever these fibers are affected by locally advanced tumor. Nine cases (9.2%) in a personal series of 98 patients with rectal carcinoma, operated on over the period from January 1992 to December 1997, underwent total mesorectal excision, lateral pelvic lymphadenectomy and the nerve sparing technique procedures for locally advanced extraperitoneal disease. In 7 patients with stage II or III disease, the 5-year survival rate was 80% and the 5-year disease-free survival rate 66.7% after a mean follow-up of 55 months. None of them experienced local recurrence, but one patient died of diffuse metastatic disease 50 months after surgery. One patient with stage IV rectal cancer died of disease 13 months postoperatively, while another patient with the same stage of disease is still alive with disease 26 months after surgery. One patient underwent liver resection for a solitary metastasis 25 months after the primary operation. Two patients suffered postoperatively from urinary retention with mild irregular flow at urodynamic testing, but no long-term urinary disturbances persisted. Retrograde ejaculation occurred postoperatively in one of the two patients who experienced urinary disorders, and another patient had erection disturbances. These sexual dysfunctions did not improve during long-term follow-up. Total mesorectal excision, lateral pelvic lymphadenectomy, and the nerve sparing technique, with resection of the autonomic nerves whenever these fibers are involved, allow satisfactory results to be achieved in terms of survival and functional outcome in patients with locally advanced rectal cancer. In western subjects, however, this procedure is safe only after careful patient selection.

Evaluation of anal function after surgery for rectal cancer.

BACKGROUND AND OBJECTIVES: Sphincter-saving surgical procedures for rectal cancer have been legitimized if executed respecting the criteria of oncological radicalness. Our objective was to evaluate anal sphincteric continence after rectal cancer surgery. METHODS: A detailed questionnaire regarding continence was administered to 3 groups of patients. Group 1 was composed of 9 patients treated with a higher (>4 cm), stapled colorectal anastomosis; the 9 group 2 patients were treated with a low (< or =4 cm), stapled colorectal anastomosis; the 9 group 3 patients underwent coloanal anastomosis. RESULTS: The results were evaluated about 3 years after surgery. Continence was excellent in group 1 and very good in group 2. However, in group 3, we observed diminished gas/feces discrimination, reduced ability to postpone evacuation, and increased soiling and perianal rash. CONCLUSIONS: Anal sphincteric continence was better after surgery with a high or low colorectal anastomosis than after coloanal anastomosis.

Nerve-sparing surgery in rectal cancer: feasibility and functional results.

Traditional rectal cancer surgery has been burdened with a high rate of sexual and urinary dysfunctions due to intraoperative injury or the cutting of the sympathetic and/or parasympathetic nerves. The experience acquired in the last ten years with total mesorectal excisions has permitted the use of the "nerve-sparing" technique. The present study regards 239 patients from two surgical centres, most of whom underwent sphincter-saving radical surgery between 1994 and 1998 with the above mentioned technique for resectable colon cancer. Details regarding the technique were recorded in the last 58 patients, in order to examine the severity of the surgical damage. The subgroup with the longest follow-up, which included 36 patients, was diagnostically evaluated by a surgeon, psychologist, urologist and neurologist to analyze the risk of sexual and urinary dysfunctions. A complete nerve-sparing was performed in 86.3% of the cases. The parasympathetic nerve trunks were those most often damaged because of perineural tumor spreading. Partial to complete sexual impotence was observed in 44% of the patients and surprisingly, preoperative dysfunctions were detected by means of the multidisciplinary approach in one third of these patients. Therefore, only 30.5% of the patients presented with strictly postoperative sexual impotency, above all, those who had undergone high-dose preoperative chemoradiation for T3 or T4 middle to low rectal cancer. A prospective study was initiated to evaluate the genitourinary dysfunctions after rectal cancer surgery in all of the clinical phases by means of a multidisciplinary approach aimed at functional recovery and improved quality of life.

Local recurrences and primary surgery in rectal carcinoma.

BACKGROUND: The authors analyze retrospectively a consecutive series of rectal carcinomas operated on with different surgical strategies at Third Surgical Department of "La Sapienza" University of Rome, between January 1985 and December 1997, by one expert surgeon (GDM), and report the incidence of the local recurrence correlated to the surgical technique development. METHODS: In most recent groups of patients treated for extraperitoneal neoplasm from January 1992 with curative (R0) total mesorectal excision (TME) and nerve sparing technique (NST) (Group C, n = 47) and with curative TME plus lateral pelvic lymphadenectomy (LPL) and NST (Group D, n = 7), sacrificing the pelvic autonomic nervous system only in case of neoplastic infiltration, the local recurrence was 8.5% (4 cases, with mean interval of 30.5 months) and 0 respectively at mean follow-up of 44.9 and 55 months. RESULTS: In none of the local recurrences of the Group C a re-resection (neither curative nor palliative) was possible and the survival was 50% at 14 months from the diagnosis of relapse. Instead, in local recurrences of rectal carcinoma in patients who underwent a first anterior resection with less extended dissection in other Department (Group E), a re-resection was possible for 3 cases out of 4 (R0, R1 and R2 operations); re-resected patients are now alive at mean follow-up of 33.6 months (82, 12 and 7 months, respectively). In Group A patients, treated between January 1985 and December 1988 with partial mesorectal excision (R0) also for extraperitoneal localization, the incidence of local relapses is 21.9% (9/41 cases) vs 11.2% (11/98 cases) in Group B patients, treated from January 1989 with curative TME for extraperitoneal tumors. CONCLUSIONS: The incidence of local recurrences of extraperitoneal rectal cancer can be reduced by total mesorectal excision. The total sparing of pelvic autonomic nervous system in advanced rectal carcinoma doesn't increase the incidence of local recurrences.

Giant abdominopelvic epithelioid angiomyolipoma associated with tuberous sclerosis: report of a case.

Tuberous sclerosis is a hereditary autosomal-dominant disease characterized by hamartomas that can develop in any organ. We report herein the case of a 34-year-old female with tuberous sclerosis and a huge abdominopelvic mass that started growing quickly 2 years after its diagnosis. The patient had undergone several previous operations for hydrocephalus and cerebral tubers, and a nephrectomy for right renal angiomyolipoma. On admission, she was in poor general health with renal failure, severe anemia, and weight loss. A laparotomy revealed that the tumor occupied the pelvis, the lower and part of the upper abdomen, and was hypervascularized, with an extremely irregular surface covered in nodules, vegetations, and areas of hemorrhagic necrosis. The development of the mass and the impossibility of recognizing the internal genital organs led us to assume that the formation had originated from these. Frozen-section examination indicated an undifferentiated tumor that had not been completely resected. Her postoperative course was complicated by bronchopneumonia and progressive renal failure. The patient died 10 days after surgery due to cardiorespiratory failure. A histological diagnosis of epithelioid angiomyolipoma was confirmed. Although it is presently impossible to determine whether angiomyolipoma with predominant epithelioid cells is more aggressive than typical angiomyolipoma, it definitively demonstrated local aggressive behavior in this patient.

[Traditional cholecystectomy in a patient with situs viscerum inversus partialis]. / Colecistectomia per via tradizionale in paziente con situs viscerum inversus partialis.

The authors discuss the etiology of situs viscerum inversus partialis (SVIP), the associated anomalies and the malformations and the relative clinical problems, reviewing the international literature. The present a case of a 51 years old female with a diagnosis of umbilical hernia and cystocele. During hospitalization the patient complained a typical acute cholecystitis pain. The patient underwent ultrasonography, CT scan, and MNR that allowed us to diagnosis a calculous cholecystitis with SVIP and was elected for an open cholecystectomy. The Authors describe the surgical technique in relation to the anatomic anomalies, in particular vascular ones, that were discovered with the imaging studies and confirmed at laparotomy.