Retroperitoneal paraduodenal unicentric Castleman disease: case report and review of the literature.

Castleman disease is a rare and benign disorder, characterized by enlarged lymph nodes and angiofollicular lymphoid hyperplasia. We report a case of a 57-year-old male, who was admitted to our surgical department because of a retroperitoneal nodular mass measuring about 4 cm in maximum diameter, incidentally discovered on a radiologic exam performed for the onset of vague abdominal pain with posterior irradiation. The patient was subdue to laparoscopic removal of the mass and no intra- and post-operative complications were recorded. Histologic diagnosis of hyaline-vascular variant of the Castleman disease was confirmed. Only two cases have been found in the literature reporting the paraduodenal unicentric Castleman disease localization like our case. Although rare, the Castleman disease must be considered in the differential diagnosis among all the lymph nodes diseases, for avoiding improper therapies.

Ergonomics in laparoscopic surgery.

BACKGROUND AND OBJECTIVES: Laparoscopic surgery is a widely used surgical technique, whose benefits either for patients or for surgeons are well-recognized. Despite the rise in the use of this technique, the ergonomics of the operating room is still very low. The consequence is that injuries and illness related to laparoscopic surgery are present. The aims of this study are to investigate how an increase in the surgeon' perception of the fatigue during the execution of the intervention influences the surgeon' health, and to evaluate if there is a correlation between the increase in fatigue and the operating field dimension. MATERIALS AND METHODS: The observation was conducted on a single laparoscopist working at our Institution and the Borg CR 0-10 scale was used to perform this study. Two groups of 20 surgical procedures each were analysed. Group A included laparoscopic procedures whose operating field comprehended only one abdominal quadrant. Group B included laparoscopic procedures where at least two abdominal quadrants were involved in the operative field. RESULTS: The results from both groups were statistically compared. There was a significant correlation between the increase in perception of the exertion and duration of the intervention in both groups and a significant difference in term of Borg scale value, which was higher in group B where the laparoscopic surgery was performed on more than one quadrant of the abdomen. CONCLUSION: We suggest an important improvement in the ergonomic aspects, especially in more complex laparoscopic procedures that require longer operating time and include more than one abdominal quadrant. KEY WORDS: Ergonomics, Laparoscopic surgery, Operating theatre.

An unusual association between pancreatic cancer and Purtscher-like retinopathy: Presentation of a unique case.

INTRODUCTION: Purtscher's retinopathy causes sudden loss of vision of varying severity, secondary to head injury or chest compression. Its pathophysiology is unclear. Purtscher's-like retinopathy has more attenuated clinical and objective features and can be associated with many non-neoplastic pathologies. Otherwise, an association of this kind of retinopathy with malignancies has been described once in the Literature. We present a case report on a unique association between pancreatic cancer and Purtscher-type retinopathy. CASE PRESENTATION: A 79-year-old man with reduced central vision in both eyes required an ophthalmic evaluation. Visual acuity was 20/40 in the right eye and 20/50 in the left eye. Fundus examination showed yellow-white peripapillary spots and bilateral retinal hemorrhages in the superficial retina. The patient complained of abdominal pain and received a CT scan of the abdomen, which showed a pancreatic mass extending into the spleen. A percutaneous needle biopsy sample showed mucinous pancreatic adenocarcinoma. CLINICAL DISCUSSION: This case report should warn of a possible association between pancreatic adenocarcinoma and Purtscher's-like retinopathy. CONCLUSION: Patients with this kind of retinopathy should be evaluated to rule out not only benign associated disease, but also malignant tumors of the pancreas.

Offending staple as an unusual but preventable cause of internal hernia with bowel obstruction Case report and review of the Literature.

In the laparoscopic era, the use of the stapler is a common practice and it adds to the possible causes of post-operative bowel adhesions with obstruction. In this study, we reviewed the Literature in order to study the pathogenesis and the incidence of bowel obstruction after using the laparoscopic stapler. Furthermore, we report a case of a woman who went to our observation for incoming bowel obstruction after laparoscopic ileal resection. In the emergency setting, the laparoscopic exploration revealed that a staple created adherence between an intestinal loop and its mesentery with consequent internal hernia and volvulus. The patient was treated by laparoscopy with removal of the offending staple and resection of the intestinal necrotic segment. Tips and tricks of the surgical technique for avoiding such rare but threatful complication, are discussed. KEY WORDS: Internal hernia, Mechanical bowel obstruction, Laparoscopic stapler, Volvulus.

Prospective randomized comparison of clinical results between hand-assisted laparoscopic and open splenectomies.

BACKGROUND: Although some studies have compared laparoscopic and hand-assisted laparoscopic splenectomy (HALS) in splenomegaly cases, no study has analyzed the differences between HALS and open splenectomy (OS). This study aimed to compare the HALS and OS techniques in splenomegaly cases. METHODS: This prospective study included 27 patients undergoing splenectomy for splenic disorders at the Department of General Surgery, Istanbul Medical Faculty between February and October 2007. Open splenectomy was performed for 14 patients and HALS for the remaining 13 patients. RESULTS: The end points compared included incision length, operative time, intraoperative blood loss, postoperative drain output and duration, postoperative pain scores, length of postoperative hospitalization, and perioperative complications. The authors found benefits of HALS over OS for incision length, postoperative pain score, postoperative drain output and duration, and hospital stay. The main advantages of the HALS technique over OS were less postoperative pain (p = 0.0002), shorter hospital stay (p = 0.004), and shorter abdominal incision (p = 0.012). CONCLUSIONS: For splenomegaly, HALS significantly facilitates the surgical procedure and reduces the hospital stay while maintaining the advantages of OS such as tactile sense as well as easy and atraumatic manipulation of enlarged spleens.

Transmission ways of Echinococcus granulosus in rare muscular locations of hydatid disease.

The most common modality of transmission of the Echinococcus granulosus is through the alimentary tract. Other ways of infestation are questionable. Airborne penetration of bronchial venules to reach the heart and the systemic circulation has been advocated, but never demonstrated. Direct subcutaneous contamination through an injured skin has also been considered. Moreover, the hypothesis that a contamination different from eggs ingestion is not possible, is justified by the reason that eggs transform into larvae in the gastro-intestinal environment. Therefore, it is accepted the possibility that parasites might reach organs and tissues other than liver and lungs through a lymphatic or venous shunt that skip the portal filter. In cases of myocardial muscle or skeletal muscle involvement, it could be speculated that eggs of Echinococcus granulosus might hatch not only in the gastrointestinal tract, but also in soft tissues due to the lactic acid produced by the muscle. These unconventional ways of transmission suggest that the lifecycle of the Echinococcus is not at all known and must be revised. Issues that can help in ideating new therapies may emerge.

Benign adenomyoepitelioma of the breast: Presentation of two rare cases and review of literature.

INTRODUCTION: Adenomyoepithelioma of the breast is a rare benign breast neoplasm with a particular behaviour. PRESENTATION OF CASES: We report two cases of adenomyoepithelioma of the breast in two old female patients, diagnosed over a period of 5 years. The clinical presentation, the radiological and the histopathologic findings are discussed. DISCUSSION: Adenomyoepithelioma of the breast is characterized by the proliferation of both epithelial and myoepithelial cells belonging to the breast lobules and ducts. The imaging features are not pathognomonic and FNAB is usually not diagnostic. The morphologic appearance of this tumor varies, and it has to be considered in the differential diagnosis with other breast tumors. Although benign, adenomyoepithelioma has a potential for local recurrence, and malignant transformation is possible; therefore, wide excision is recommended to lower the recurrence rate. CONCLUSION: The rarity of this histological type and the finding of two cases in a relatively short period makes this case report unique.

Hemocoagulative post-operative changes after laparoscopic surgery compared to open surgery: the role of lupus anticoagulant.

Although still debated, post-operative modification of hemostasis seems to be less pronounced after laparoscopy compared to open surgery. Antiphospholipid antibodies might play a role in the post-operative thromboembolic risk, although their evaluation in surgical patients has never been performed. Post-operative modification of antiphospholipid antibodies could be related to the surgical approach (laparoscopic or open). In this prospective study, the authors statistically compared the pre-operative values and post-operative modification of antiphospholipid antibodies in two homogeneous groups of patients operated on by laparoscopic and open surgery. No statistical differences within each group and between the two groups were shown comparing mean values of pre-operative and post-operative antiphospholipid antibodies. In the open group, there was a significant difference between pre-operative and post-operative LAC means (P < 0.01). In the laparoscopic group, on the contrary, no significant change in LAC values between pre- and post-operative tests (P = 0.55) was observed. Since LAC could be related to coagulation disorders, this study seems to support that laparoscopic surgery might induce a less risk of post-operative thromboembolic disease.

Drug rash with eosinophilia and systemic signs syndrome in a patient with multiple sclerosis.

INTRODUCTION: Drug rash with eosinophilia and systemic signs (DRESS) syndrome is defined by the triad of fever, dermatitis, and internal organ involvement, characteristically occurring with a delay of 3 to 8 weeks after the initiation of treatment with the associated drug. We describe a case of DRESS syndrome in a patient with multiple sclerosis (MS), characterized by a very high eosinophilia and cholestatic hepatitis. CASE SUMMARY: A 44-year-old white woman with primary progressive MS receiving a multidrug of PO baclofen 75 mg/d, PO piracetam 3 g/d, and IV mitoxantrone 10 mg administered once a month presented to the Multiple Sclerosis Center, University of Catania, Catania, Italy. Eight weeks after the introduction of the latter 2 drugs, the patient had clinical and histological signs of severe cholestatic syndrome followed by hypereosinophilia. All treatments were stopped on admission. Laboratory tests (serologic viral markers, autoantibody pattern antinuclear autoantibodies, antismooth muscle autoantibodies, antimitochondrial autoantibodies, antineutrophil-cytoplasmic autoantibodies, antiliver-kidney-microsomes), abdomen ultrasound, and magnetic resonance cholangiopancreatography did not reveal a cause of the cholestatic syndrome. A liver biopsy was performed because of the persistence of the clinical signs. A Naranjo rating of 4 suggested that mitoxantrone was possibly associated with the occurrence of DRESS. Six months after the first symptoms of DRESS appeared, laboratory tests were normal. Although there are few diagnostic methods for confirming an adverse drug hypersensitivity reaction, a skin prick test suggested a marked positivity for mitoxantrone at all concentrations (100%, 50%, 10%). During the first 72 hours, reaction was characterized by skin edema, erythema, and itchiness in the site of inoculation of the drug. The local reaction started to regress after 72 hours, with a complete restitution ad integrum in 6 days. A blue discoloration of skin remained for an additional 13 days. CONCLUSION: We report a case of DRESS syndrome possibly associated with mitoxantrone in a patient with MS.

Intragastric enucleation of stromal tumors through a combined laparoscopic and endoscopic approach.

Dear Editor, We read with great interest the paper entitled "Laparoscopic organ-preserving gastric resection improves the quality of life in stromal tumor patients: an observational study with 23 patients" written by Ozcan et al. in Ann Ital Chir. 2018 Oct 23;7 1. We agree with the Authors that preserving the stomach after excision of stromal tumors is essential to improve the patients' quality of life. We would like, however, to discuss some issues that the paper published by Ozcan et al. might raise. When feasible, laparoscopic surgery is the best procedure for removal of gastric stromal tumors, since it is associated with all the advantages already recognized to the mini-invasive approach 2,3. Furthermore, it allows reducing the entity of the resected stomach wall and, therefore, it may help maintain the stomach functions and a post-operative excellent quality of life. Besides the standard laparoscopic procedure with wedge resection of the stomach, we would like to draw the attention that other mini-invasive procedures might be performed. The standard surgical treatment of gastric stromal tumors typically involves full-thickness resection of the tumor site stomach wall. Surgical treatment could be technically challenging for proximal gastric lesions located near the gastro-esophageal junction. In the article by Ozcan et al. it is not well defined how they approached iuxta-cardial stromal tumors. A combined endoscopic/laparoscopic intraluminal enucleation technique has been proposed by some Authors, including us, in these cases 4-6. Our technique consisted in inserting two 5-mm radially expandable trocars through the abdominal and gastric walls. Through the 5-millimeter trocar, a laparoscope was introduced into the gastric cavity and with an endoscopic polipectomy snare introduced per mouth, the gastric iuxta-cardial lesion was grasped and tractioned. Through the other 5-mm laparoscopic trocar, the iuxtacardial gastric lesion was then removed with a complete submucosal resection. The excellent exposure of the site of excision allowed by the endoscopic traction was essential in this step. The specimen was then pulled away from the mouth after its introduction into a small plastic bag and the gastric holes were closed with monofilament non-absorbable sutures. In selected cases of submucosal iuxta-cardial gastric stromal tumors, as well as in every small stromal gastric lesions, the laparoscopic-endoscopic technique should be preferred since it allows a complete safe and oncologic resection of submucosal lesions, reducing risk of complications (e.g., perforation) and lowering morbidity when compared to other open or laparoscopic approaches.

Idiopathic intramural hematoma of the right colon. A case report and review of the literature.

INTRODUCTION: Intestinal hematoma is usually observed after an abdominal trauma or in patients treated with anticoagulant therapy. Conversely, idiopathic bowel hematoma is very rare, being colon involvement sporadic with few reports in the Literature. PRESENTATION OF CASE: The Authors report a case of idiopathic spontaneous large bowel hematoma. A 48-year-old man was admitted for a thoraco-abdominal pain and signs of acute abdomen and fever. After ruling out heart diseases, a CT scan revealed a marked thickening of the ascending colon wall, obstructing the bowel lumen. Leukocytosis was observed. In an emergency setting, an explorative laparotomy was performed. Hemoperitoneum and a large hematoma involving the caecum and the ascending colon were detected, together with intramesenteric and retroperitoneal blood effusion. A right hemicolectomy was accomplished. Histopathology confirmed the diagnosis of large bowel hematoma. Post-operative molecular diagnostic testing for coagulative disorders failed to demonstrate any genetic variation associate with hemorrhagic predisposition. In the post-operative course, the patient experienced a left basal bronco-pneumonia with increased unilateral pleural effusion, successfully treated by a thoracic drain and antibiotic therapy. DISCUSSION: The reported case and Literature data show that diagnosis of idiopathic colon intramural hematoma is challenging, especially in the emergency setting. Although conservative therapy is the first line treatment, surgery still has an important role when the diagnosis is uncertain, medical treatment fails or a complication, such untreatable bleeding, perforation or occlusion occur. CONCLUSION: The Authors report a very rare case of spontaneous intramural hematoma of the right colon. Surgery still has a role in selected cases.

Laparoscopic surgery with total mesocolic excision in colon cancer. A systematic review of the literature.

PURPOSE: Nowadays, there is no standardization in surgical procedures for treatment of colon cancer. Since its introduction, laparoscopic surgery has gained increasing interest in colorectal surgery and it is now performed worldwide for treatment of colon cancer. Following the concept of total mesocolic excision introduced by Heald in 1988 in order to reduce local recurrence after surgical treatment of mid/low rectal tumors, the idea of complete removal of the mesocolon mesocolic envelope has been developed also for colon cancer, has evolved longtime and complete mesocolic excision has been recently adopted as the optimal approach for colon cancer. However, complete mesocolic excision, whose purpose is to remove all lymphatics and lymph nodes draining the tumor, is still discussed as far as oncologic results are concerned. Moreover, the role of laparoscopic approach for complete removal of mesocolon has to be defined. METHODS: Selection of studies. A MEDLINE-PubMed database search of the current English Literature was performed using the terms: complete mesocolic excision; high vascular ligation; splenic flexure mobilization. INCLUSION CRITERIA: The inclusion criteria were report on CME for colonic cancer with high vascular ligation; minimum number of patients included (20 patients). Two independent reviewers (CRS, IE) extracted the data. RESULTS AND CONCLUSION: In this article, an update from the Literature on results of complete mesocolic excision was undertaken and data have been discussed. The role of laparoscopic complete mesocolic excision in colon cancer patients has been focused, and it seems to be safe and feasible, it should be standardized and hypothetical oncologic advantages should be expected. KEY WORDS: Colorectal-tumor, Complete mesocolic excision, High vascular ligation, Laparoscopic colorectal surgery, Splenic flexure mobilization, Total mesocolic excision.

Surgical management of hereditary spherocytosis Current strategies.

BACKGROUND: Hereditary spherocytosis is a benign hematologic disease, which needs surgical treatment when medical therapy fails. Currently, the surgical strategies consist mainly in total or partial splenectomy, which can be performed either in open or in laparoscopic fashion. In this study, we analyzed our series of splenectomies for hereditary spherocytosis and we discuss about the surgical management, reviewing the Literature. MATERIAL AND METHODS: Twenty-seven patients (mean age 16.5 years, range 8 - 30 years) affected by hereditary spherocytosis were retrospectively evaluated. Indication to surgery was based on hemolysis severity. Thirteen patients were submitted to laparoscopic splenectomy and 14 to open splenectomy, after preventive specific vaccinations. Cholecystectomy for associated cholelithiasis was performed during the same operation in 4 laparoscopic patients and in 6 open patients. RESULTS: Main reasons for performing splenectomy were anemia unresponsive to iron supplementation in 7 patients (42%), splenomegaly in 6 patients (37%), and jaundice in 4 cases (21%). All the patients had a severe disease with hemoglobin level below 80 g/L, median reticulocytes count 6,5%, median value of indirect bilirubin concentration 2,0 mg/dL. Indications to splenectomy were increased need for red cell transfusions in 11 patients (66%) and symptoms related to cholelithiasis in 6 patients (34%). A post-operative early complication was observed after open splenectomy, consisting in a pancreatic fistula, which was treated conservatively. No post-operative complications were observed after laparoscopic splenectomy. Neither intra-operative complications nor conversions to open surgery were recorded during the laparoscopic approach. In a long-term follow- up, no infective complications were recorded. CONCLUSIONS: According to our results, total splenectomy is associated with good results and few complications. In our opinion, it remains the best therapeutic option in selected adult patients non-responder to the medical treatment. KEY WORDS: Hereditary spherocytosis, Laparoscopic splenectomy, Partial splenectomy.

A rare case of epithelioid hemangiothelioma of the quadriceps.

Hemangioendotelioma is a group of rare vascular tumors with border-line behavior. They may involve internal organs, limbs, bones and soft tissue. The histological variant epitheliod hemangiothelioma is locally aggressive and has metastatic potential. We present a case of a 41-years old woman affected by epitheliod hemangiothelioma of the right quadriceps. The patient complained of localized pain in the anterior region of the right thigh, which started about 3 months earlier during physical exercise. For the increasing size of the lesion, the patient was referred to our Department. On physical examination, the lesion appeared elastic, fixed to the surrounding tissues and painful under pressure. An ultrasound examination revealed a small avascular lesion and a MRI examination showed an oval formation measuring about 18 mm in diameter of nonspecific significance. A surgical removal of the lesion was performed and diagnosis of epithelioid hemangiothelioma was achieved. A complete removal of the quadriceps muscle was then accomplished. In this paper, clinical and oncologic aspects of this rare tumor are discussed KEY WORDS: Epithelioid hemangiothelioma, Lower limbs tumor, Rare tumors.

Preoperative Predictive Factors of Conversions in Laparoscopic Splenectomies.

PURPOSE: Presently, laparoscopic splenectomy (LS) is being performed for several indications in clinical practice. However, conversion to open surgery is occasionally required in some patients. We analyzed the intraoperative indications and potential preoperative predictors associated with conversion to open surgery in those presenting for LS. METHODS: We reviewed 107 patients who underwent LS. We analyzed the surgical indications, spleen size, surgical procedure performed, operative time, rate of and indications for conversions, as well as postoperative complications. RESULTS: Among the 15 patients (14.0%) who underwent conversion, the conversion was related to the occurrence of a splenic lymphoma in 10, severe bleeding in 3, a lack of anatomic definition in 1, and splenic candidiasis in 1 patient. A comparison between the results obtained in the initial 30 patients (LS performed during the learning curve) and those obtained in the remaining 77 patients, showed that conversions appeared to be related to the experience/expertise of the surgical team excluding patients with splenic malignancies. Conversion was not associated with a higher morbidity-mortality rate, but only a longer length of hospitalization. CONCLUSIONS: LS is a gold standard procedure when performed by experienced and competent surgeons. However, careful patient selection is recommended before using the laparoscopic approach in those presenting with splenic malignancies.

Laparoscopic Colorectal Surgery for Cancer: What Is the Role of Complete Mesocolic Excision and Splenic Flexure Mobilization?

Laparoscopic colorectal surgery for cancer is nowadays routinely performed worldwide. After the introduction by Heald of total mesorectal excision for rectal cancer, also a complete mesocolic excision has been advocated as an essential surgical step to improve oncologic results in patients with colon cancer. The complete removal of mesocolon with high ligation of the main mesenteric arteries and veins and the mobilization of splenic flexure are well-known but still debated in western surgical society. The authors reviewed the literature and outlined the rationale and the results of splenic flexure mobilization and complete mesocolic excision in laparoscopic surgery for colorectal cancer.

The use of surgical drains in laparoscopic splenectomies Consideration on a large series of 117 consecutive cases.

BACKGROUND DATA: The use of surgical drains after traditional splenectomy has been largely debated and several Authors have been unfavorable to their use. With the advent of laparoscopic splenectomy, their role has been re-discussed. The increased risk of undetectable pancreatic, gastric or colon injury in challenging laparoscopic removal of the spleen have induced some surgeons to reconsider the advantages related to their use. METHODS: One hundred seventeen consecutive cases of laparoscopic splenectomy with routine use of surgical drains have been reviewed. Indications for surgery, length of operations, post-operative day of drain removal, post-operative complications were retrospectively analyzed. RESULTS: Laparoscopic splenectomy was performed for idiopathic thrombocytopenic purpura in 77 patients (65,8%), splenic lymphoma in 11 (9,4%), hereditary spherocytosis in 12 (10,2%), ß-thalassemia in 6 (5.1%), other diseases in 11 (9,4%) cases. Conversion to open surgery was necessary in 11,1% of cases. Drains were removed 2-3 days after surgery in 95,8%, within 10 days in 3.4%, within 2 months in 0,8% of cases. In 2 cases a post-operative bleeding, detected through the drainage, required re-operation. One patient with myelofibrosis and massive splenomegaly developed a late post-operative subphrenic abscess, successfully treated by a percutaneous drainage. CONCLUSIONS: In Authors' experience, the use of drains after laparoscopic splenectomy helped detect early post-operative bleeding. Surgical drains could reduce the incidence of fluid intra-abdominal collections and infections. Their use should be recommended in the laparoscopic approach, especially in technically demanding surgical procedures. KEY WORDS: Laparoscopy, Surgical drainage, Splenectomy.