An extremely rare case of an oversized accessory spleen: case report and review of the literature.

BACKGROUND: The accessory spleen is a congenital defect characterized by a separated ectopic splenic parenchyma. The size is rarely more than 4 cm. The preoperative diagnosis is prohibitive preoperatively. The aims of the present manuscript were to present the case of a patient with a rare oversize accessory spleen and a review of the literature. CASE PRESENTATION: A 15-year-old boy was admitted to the emergency department following blunt abdominal trauma. The computed tomographic scan showed a traumatic rupture of the spleen and a 7-cm mass at the left side of the retroperitoneal space. Conservative treatment started and aborted after 4 h due to the onset of haemodynamic instability. Splenectomy was performed. An accessory spleen was discovered. A second large mass in the retroperitoneum was diagnosed as a second large accessory spleen that was also left in place. The postoperative course was uneventful, and the patient was discharged on the 7th postoperative day. Seven months later, the CT scan showed viability of both accessory spleens. CONCLUSION: An accessory spleen can be variously located and the retroperitoneal position is extremely uncommon. Preoperative diagnosis is still difficult, especially in emergency and as in our case, the literature shows the difficulty of reaching a diagnosis before surgery. The main misdiagnosis is neoplastic disease and for this reason accessory spleen can be wrongly removed. An undiagnosed pre or intra operative retroperitoneal mass, closely to the spleen, have to be managed carefully. The diagnosis of accessory spleen needs to be ever considered as if found, represents a great possibility to conduct a normal life after splenectomy (of main spleen) for trauma.

Open conversion for laparoscopically difficult cholecystectomy is still a valid solution with unsolved aspects.

The difficult laparoscopic cholecystectomy remains a surgical challenge for surgeons who must decide between laparoscopic continuation and open conversion. The balance between the lack of open surgery training of young surgeons and the risk of maintaining the laparoscopic approach in difficult laparoscopic cholecystectomy is still an unresolved problem. Furthermore, the time that must be spent in an attempt to complete laparoscopic surgery before conversion is still controversial. The authors in this letter discuss about these and other questions that still require an answer.

A new modified Mayo technique: should the surgeons need a new open technique for hernia repair in their armamentarium?

INTRODUCTION: The Mayo technique is one of the most common techniques used to repair incisional, umbilical, and epigastric hernias. A high percentage of recurrences, together with the use of particular expensive types of meshes, are some of the most relevant problems in this surgical field. PATIENTS AND METHODS: This study is a clinical prospective observational and involves all the patients who underwent procedures using a new modified Mayo technique from 2006 through 2013. The general criteria analyzed were age, sex, obesity, smoke abuse, diabetes, chronic diseases, type of hernia, operative time, morbidity and mortality. All the patients involved in this study were followed-up from 6 to 120 months. RESULTS: The types of hernia were 5 epigastic hernia (20,8%), 8 umbilical hernia (33,3%), 11 midline incision hernia (45,9%). Ten patients (41,7%) presented non-complicated hernias; 8 patients (33,3%) presented strangulated hernias and 6 patients (25,0%) presented obstructed hernias. No intestinal resection was necessary in any of the patients. The mean operative time was 55 minutes (range 30-180). The mean hospital stay of the patients' after-post operative procedure was 4.5 days (range, 2 to 8 days). No major complications have been reported. Only one patient present a recurrence. CONCLUSION: These preliminary results suggest that this modified Mayo technique could be useful in the armamentarium of surgeon to repair incisional, umbilical, and epigastric hernias. More studies are needed to validate the technique.

Genetic diversity of Burkholderia contaminans isolates from cystic fibrosis patients in Argentina.

A total of 120 Burkholderia cepacia complex isolates collected during 2004-2010 from 66 patients in two cystic fibrosis reference centers in Argentina were analyzed. Burkholderia contaminans was the species most frequently recovered (57.6%), followed by Burkholderia cenocepacia (15%), a species distribution not reported so far. The recA-PCR-based techniques applied to the B. contaminans isolates revealed that 85% of the population carried the recA-ST-71 allele. Our results showed the utility of BOX-PCR genotyping in analyzing B. contaminans diversity. This approach allowed us to address clonal transmission during an outbreak and the genetic changes occurring in infecting bacteria over the course of chronic infection.

Acute toxicity and 2-year adverse effects of 30 Gy in five fractions over 15 days to whole breast after local excision of early breast cancer.

AIMS: A pilot study was undertaken with the aim of documenting acute skin reactions and 2-year late adverse effects of a five-fraction course of adjuvant whole breast radiotherapy delivered over 15 days after local tumour excision of early breast cancer. MATERIALS AND METHODS: Thirty women with early invasive breast cancer aged>or=50 years with a pathological tumour size<3 cm, complete microscopic resection, negative axillary node status and no requirement for cytotoxic therapy were prescribed 30 Gy in five fractions over 15 days to the whole breast using tangential 6-10 MV X-ray beams and three-dimensional dose compensation with written informed consent. Post-surgical baseline photographs of the breasts were taken, and acute skin erythema and moist desquamation were each scored weekly for 7 weeks using four-point graded scales (grade 0=none, 1=mild, 2=moderate, 3=severe). This was followed by an annual clinical assessment, including repeat photographs at 2 years. RESULTS: Nine patients (30%, 95% confidence interval 14.7-49.4%) developed grade 2 erythema, with the remaining 21 patients developing milder degrees of reaction. Four (13.3%, 95% confidence interval 3.7-30.7) patients developed moist desquamation, grade 1 in three women and grade 2 in the fourth. At 2 years after treatment, 23/30 (77%) patients scored no change in photographic breast appearance compared with the pre-treatment baseline; seven (23%, 95% confidence interval 9.9-42.3) scored a mild change in breast appearance, and none developed a marked change. After a mean follow-up of 3.1 years (standard deviation 0.37, range 2.1-3.9 years) there have been no ipsilateral local tumour relapses. CONCLUSIONS: Further evaluation of a five-fraction regimen of adjuvant whole breast radiotherapy in a phase III randomised trial is justified, including a regimen delivered in a total of 5 days.

Carcinoma of the tongue and bulbar-onset amyotrophic lateral sclerosis: unusual differential diagnosis.

We present a 72-year-old woman with progressive dysphagia, dysarthria and tongue palsy who was initially diagnosed with bulbar-onset amyotrophic lateral sclerosis (ALS). However, the absence of atrophy or fasciculations in the tongue, as in other voluntary muscles, and the lack of reproducible neurophysiological evidence of denervation, prompted a revision of the diagnostic work-up, which eventually led to the discovery of a carcinoma of the tongue. This case report describes a relatively rare type of oropharyngeal carcinoma that, in its early stage, resembled a bulbar-onset ALS. This differential diagnosis is unusual, and it was fostered by the persistent lack of atrophy of the tongue and the absence of spreading of signs and symptoms of motor neuron degeneration.

Setting up an office anesthesia practice.

The number of office surgery suites have drastically increased over the past several years. As a result, the quantity of anesthesia practice opportunities has also increased. It is the purpose of this report to assist the nurse anesthetist in the process of finding, developing, and maintaining an office anesthesia practice.

Anesthesia for male aesthetic surgery.

The male patient for aesthetic plastic surgery should expect to have a good experience, with few, if any complications from anesthesia. Proper planning is essential to the process, from setting up the surgical facility to selection and preparation of patients. Anesthetic techniques should be adapted to the needs of each patient, with his safety and comfort the most important consideration. Anesthesia for plastic surgery has progressed from simple injection of local anesthetics to sophisticated sedation and general endotracheal techniques. Better anesthetic drugs, monitors, and procedures for dealing with complications have made anesthesia a major factor in the advances of the plastic surgery specialty. Male patients frequently have different medical problems than their female counterparts have, including cardiovascular disease, hypertension, and smoking history. Other problems include back discomfort and prostate enlargement, both factors that must be taken into consideration with local sedation anesthesia techniques. The use of basic monitoring equipment has made ambulatory surgery safer for patients and has been instrumental in reduction of medication-related complications. Monitoring standards changed in anesthesia in the late 1980s to include electrocardiogram (EKG), precordial or pretracheal continuous monitoring, blood pressure, and pulse oximetry. In addition, if general anesthesia is used, end-tidal carbon dioxide and temperature monitoring and oxygen analysis of the anesthesia gases are also recommended. General anesthesia is being utilized more frequently in cosmetic surgery procedures and offers many advantages over local and conscious sedation techniques. The modern agents and techniques permit the patient to recover quickly, with minimum postoperative sequelae, and provide obvious comfort during the operative procedure. The traditional anesthesia technique for facial plastic surgery has been local anesthesia supplemented by sedation. This technique requires a combination of skillful local administration, selection of appropriate sedation drugs in proper doses, and a cooperative patient. Ideally, the selection and administration of drugs and monitoring of the patient should be by an anesthetist, who understands drug interactions and synergistic and additive effects of sedation drugs. Facility set-up, professional personnel, and recovery and discharge criteria are essential to good anesthesia care for the male aesthetic patient.

Ruptured pyogenic Baker's cyst.

The authors present the case of a patient who developed a ruptured Baker's cyst. Methods of diagnosis and treatment are discussed.