Acute cholecystitis: the golden 72-h period is not a strict limit to perform early cholecystectomy. Results from 316 consecutive patients.

PURPOSE: Early laparoscopic cholecystectomy (ELC) is the treatment of choice for acute cholecystitis (AC), but the optimal surgical timing is controversial. The aim of this study was to retrospectively verify the outcome of patients with AC according to different timing of cholecystectomy. METHODS: Patients undergoing cholecystectomy for AC from 2006 to 2012 were stratified into two groups: initial admission cholecystectomy (IAC) and delayed cholecystectomy (DC, after at least 4 weeks). Among IAC, a subgroup undergoing immediate cholecystectomy (IC, within 72 h of symptom onset) was further analyzed. RESULTS: Three-hundred and sixteen consecutive patients were studied. IAC group included 262 patients (82.9 %) and DC group included 54 patients (17.1 %). The two groups were similar in conversion rate, operation length, and overall complication rate. The total length of hospitalization was longer in DC patients (p = 0.005). Among DC patients, 25.9 % required re-hospitalization while waiting an elective procedure. In the group undergoing IC (66 patients), conversion rate, length of operation, and postoperative morbidity were similar to that of the IAC group. Length of stay was shorter in IC group (p < 0.001). Multivariate analysis identified moderate-severe AC grading and ASA score ≥ 3 as predictors of postoperative complications. CONCLUSIONS: The timing of cholecystectomy for AC does not seem to affect conversion rate and postoperative morbidity. Therefore the 72-h period should not be considered a strict limit to perform LC, provided that the operation is carried out during the initial hospital admission.

Mature cystic teratoma of the pancreas. Case report and review of the literature of a rare pancreatic cystic lesion.

CONTEXT: Pancreatic cystic lesions are increasingly recognized and comprise different pathological entities. The management of these lesions is challenging, because of inadequate preoperative histological diagnosis. Among this family of lesions, mature cystic teratomas are an extremely rare finding. CASE REPORT: We present the case of a 61-year-old man with a mature cystic teratoma of the pancreas' uncinate process, incidentally discovered at diagnostic imaging. CONCLUSIONS: This case highlights the difficulty to obtain a preoperative diagnosis of this pathological entity and the need of increased awareness about mature cystic teratoma when examining a pancreatic cystic lesion.

Surgical treatment of liver metastases of gastric cancer: state of the art.

BACKGROUND: The prognosis of patients with liver metastases from gastric cancer (LMGC) is dismal, and little is known about prognostic factors in these patients; so justification for surgical resection is still controversial. Furthermore the results of chemotherapy for these patients are disappointing. The purpose of this study was to review recent outcomes of hepatectomy for LMGC and to determine the suitable candidates for surgery, assessing the surgical results and clinicopathologic features. Moreover we compare these results with those obtained with alternative treatments.

Extramedullary hemopoiesis and littoral cell angioma of the spleen: our experience and review.

Littoral cell angioma (LCA) is a rare primary vascular neoplasm of the spleen. A 54-year-old man was referred to our emergency department for abdominal pain. A CT scan showed multiple round hypodense lesions of various sizes throughout the spleen. The spleen was increased in volume. An MRI confirmed the lesion with a suspect of multiple angiomas vs. amartomas. The haematologists excluded any haematological disease. After a collegial discussion, we decided to perform laparotomic splenectomy. Histologically, the multiple lesions consisted in anastomosing vascular channels lined by plump cells. There was an increased number of dysmorphic megakaryocites inside the splenic parenchyma and along the tumour's border, known signs of extramedullary hemopoiesis, whose etiology in our patient was unexplained. To the best of our knowledge this is the third description of the association between littoral cell angioma and extramedullary hemopoiesis. LCA is a rare primary splenic vascular tumour that originates from the splenic littoral cells. The diagnosis of littoral cell angioma is confirmed histologically and on immunohistochemistry. This case report underlines the rarity of this type of benign splenic neoplams, but since the malignant potential of LCA, we recommend close clinical follow- up of patients with LCA of the spleen.

Surgical treatment of liver metastases of gastric cancer: is local treatment in a systemic disease worthwhile?

OBJECTIVES: The prognosis of patients with liver metastases of gastric cancer (LMGC) is dismal, but little is known about prognostic factors in these patients; thus justification for surgical resection is still controversial. The purpose of this study was to review recent outcomes of hepatectomy for LMGC and to determine which patients represent suitable candidates for surgery by assessing surgical results and clinicopathologic features. METHODS: Outcomes in 21 patients with LMGC who underwent hepatectomy between 1998 and 2007 were assessed. Isolated metastases and potential to perform a curative resection were requisite indi-cations for surgery. Surgical outcome and clinicopathologic features of the hepatic metastases were analysed. RESULTS: Overall 1-, 3- and 5-year survival rates after hepatic resection were 68%, 31% and 19%, respectively; three patients survived for >5 years without recurrence. Univariate analysis revealed a solitary metastasis, negative margin (R0) resection and the presence of a peritumoral fibrous capsule as significant favourable prognostic factors. These characteristics were present in all of the three patients who survived for >5 years. CONCLUSIONS: Solitary metastases from gastric cancer should be treated surgically and confer a better prognosis. Surgical resection should provide microscopically negative margins (R0). A new prognostic factor, the presence of a pseudocapsule, may be associated with improved prognosis.

Right colon, left colon, and rectal surgeries are not similar for surgical site infection development. Analysis of 277 elective and urgent colorectal resections.

PURPOSE: Surgical site infections (SSIs) are the most common infections in colorectal surgery. Although some studies suggest that rectal surgery differs from colon surgery for SSI incidence and risk factors, the National Nosocomial Infection Surveillance system categorizes all colorectal surgeries into only one group. The aim of this study was to determine incidence, characteristics, and risk factors of SSIs according to the subclassification of colorectal surgery into right colon surgery (RCS), left colon surgery (LCS), and rectum surgery (RS). METHODS: From November 2005 to July 2009, all patients requiring colorectal resectioning were enrolled into our program. The outcome of interest was an SSI diagnosis. Univariate and multivariate analyses were performed to determine SSI predictors in each group. RESULTS: Two hundred seventy-seven consecutive colorectal resections were analyzed. SSI rates were 8% in RCS, 18.4% in LCS, and 17.6% in RS. LCS and RS showed significantly higher SSI incidences (p = 0.022) and greater rates of organ/space infections compared to RCS (p = 0.029). Predictors of SSI were steroid use among RCS, age greater than 70 years, multiple comorbidities, steroid use, non-neoplastic colonic disease, urgent operation, ostomy creation, postoperative intensive care among LCS, preoperative chemoradiation, heart disease, and prolonged operation among RS patients. On multivariate analysis, the coupled LCS and RS groups showed an increased risk for SSI compared to RCS (OR, 2.57). CONCLUSIONS: SSI incidences, characteristics, and risk factors seem to be different among RCS, LCS, and RS. A tailored SSI surveillance program should be applied for each of the three groups, leading to a more competent SSI recognition and reduction of SSI incidence and related costs.

Bipolar vessel sealing system vs. clamp crushing technique for liver parenchyma transection.

BACKGROUND/AIMS: To evaluate the impact of the traditional clamp-crush technique and a radiofrequency bipolar vessel sealing device (BVSD) for liver resection on operative blood loss, transfusion rate, duration of operation, length of hospitalization and morbidity. METHODOLOGY: From a database, 100 patients who underwent elective liver resection were retrospectively selected. In 40 patients parenchyma transection was performed by BSVD (LigaSure system) and 60 patients were operated using traditional clamp-crush technique (CC group). RESULTS: The two groups were well-matched for baseline and surgical characteristics. Peak of transaminases was significantly higher in the BSVD on postoperative days 1, 3 and 5 (minimum p = 0.02 vs. CC). There was no significant difference between CC group and BVSD group in median operation time (180 vs. 190 min), blood loss (600 vs. 700 mL), transfusion rate (48.0% vs. 60.5%), hepatic failure (3.2% vs. 2.5%), morbidity rate (26.6% vs. 27.5%), and hospital stay (13 vs. 12 days). CONCLUSIONS: Increased tissue damage in the BSVD group did not seem to correlate with organ dysfunction or postoperative morbidity. The two techniques appear equivalent in term of outcome and thus the choice of transection strategy remains according to the surgeon preference and experience.

Energy-based hemostatic devices in laparoscopic adrenalectomy.

PURPOSE: In literature, few papers compare different hemostatic devices in laparoscopic adrenalectomy. This sequential cohort study analyzes the outcomes of laparoscopic adrenalectomy performed by different hemostatic instruments, to evaluate if any of them has any advantage over the other and as secondary endpoints, the impact of body mass index (BMI) and tumor size on the indication, and the outcome of laparoscopic adrenalectomy. METHODS: Forty-six patients, aged 54.6 +/- 46 years, underwent laparoscopic adrenalectomy over 5 years. Mean BMI was 27 +/- 4.8 kg/m(2). Twenty-four patients had a left tumor, and 22 had a right one. Patients were divided into two groups according to the hemostatic device: Ultracision was used in 26 patients, and Ligasure was used in 20. Groups were well matched for histology, tumor size and site, BMI, gender, and age. RESULTS: Mean operating time was 126.5 +/- 52 min, blood losses were 101 +/- 169 mm, conversion rate was 6.5%, morbidity was 26%, and hospitalization was 5.3 +/- 2.5 days. Groups did not differ for surgical time, blood losses, complications, and conversion rate; BMI and length of surgery were not related. Tumor side and size did not affect surgical time, regardless of the hemostatic tool. Patients submitted to left adrenalectomy bled more (p = 0.007) and had more complications (p = 0.016) than those undergone operation on the right side. CONCLUSIONS: Obesity (BMI > 30) and large masses do not contraindicate laparoscopic adrenalectomy. Left adrenalectomies bleed more and have a higher morbidity. Hemostatic device choice is up to surgeon's preference.

Interleukin-2 immunotherapy action on innate immunity cells in peripheral blood and tumoral tissue of pancreatic adenocarcinoma patients.

BACKGROUND AND AIMS: Innate immunity cells play a crucial role in host anticancer defense: cancer patients with high levels of natural killer (NK) cells and eosinophils have a better prognosis. Recombinant interleukin-2 (rIL-2) immunotherapy stimulates innate immunity cells. This study aims to evaluate the toxicity of pre- and postoperative rIL-2 treatment and the effects on innate immunity both in peripheral blood and in cancer tissue of patients with resectable pancreatic adenocarcinoma. MATERIALS AND METHODS: Seventeen patients received high dose rIL-2 preoperative subcutaneous administration and two low dose postoperative cycles. We evaluated NK cell and eosinophil count in blood and in pancreatic surgical specimens. RESULTS: Toxicity was moderate. In the early postoperative period, blood NK cells and eosinophils significantly increased compared to basal values (p < 0.02). Histopathological analysis did not find significant intratumoral infiltration of NK cells nor of eosinophils. CONCLUSIONS: Preoperative high dose rIL-2 administration is able to counteract surgery-induced deficiency of NK cells and eosinophils in peripheral blood in the early postoperative period, although it cannot overcome local mechanisms of immune tumor escape in cancer tissue. The amplification of innate immunity, induced by immunotherapy, may improve the control of metastatic cells spreading in the perioperative period.

Short-term preoperative IL-2 immunotherapy in operable pancreatic cancer: a randomized study.

BACKGROUND/AIMS: A cell-mediated immunodeficiency is demonstrated to occur in advanced cancer patients. Lymphocytopenia predicts a poor prognosis, moreover, the surgical trauma can worsen the impaired immune surveillance and favor disease recurrence. This study investigates the effectiveness of preoperative interleukin-2 administration to improve lymphocyte counts' postoperative recovery in pancreatic cancer. METHODOLOGY: 31 patients with pancreatic cancer who underwent radical surgery were randomized according to 3 different groups. Group A: 9 patients treated with human recombinant IL-2 subcutaneously at 9 million IU/day for 3 days before surgery; group B: 9 patients treated with IL-2 at 12 million IU/day for 3 days before surgery; group C: 13 patients treated with surgery alone. Assessment of total and T helper lymphocyte counts were studied at hospital admission and in 7th and 14th postoperative day. RESULTS: Toxicity of IL-2 treatment was mild in all groups. Postoperative lymphocytopenia was observed in group A and C, without statistical differences, whereas group B had mean lymphocyte levels within the normal values in the postoperative period. CONCLUSIONS: This preliminary result suggests that preoperative subcutaneously IL-2 immunotherapy at 12 million IU for 3 consecutive days before surgery is able to abrogate the effects of the surgical trauma and recover a normal immunofunction in pancreatic cancer patients.

Challenging diagnosis of ileal gastrointestinal stromal tumor presenting with obscure digestive bleeding.

We report a case of a patient observed in emergency condition for recurrent episodes of massive obscure gastrointestinal bleeding that required surgical control. At laparotomy we found an ileal mass with the characteristics of a gastrointestinal stromal tumor (GIST) at histopathological analysis. GISTs should always be considered as a possible cause of obscure gastrointestinal bleeding, although they are often difficult to diagnose preoperatively. Laparotomy is sometimes the only way to obtain a diagnosis. Starting from this case, we reviewed the literature about GISTs, focusing our attention on their diagnosis and the possible surgical and nonsurgical therapies.

Surgical treatment of intrathyroid metastases: preliminary results of a multicentric study.

BACKGROUND: Intrathyroid metastases (ITM) are rare and usually have a dismal prognosis. The aim of this study was to detect which neoplasms metastasize most often to the thyroid gland, their clinical features and treatment options. MATERIALS AND METHODS: Retrospective analysis of clinical files of 17,122 patients submitted to surgery for thyroid disease between 1995 and 2005. Twenty-five patients (median age 61 years) were affected by ITM. RESULTS: The site of the primary tumor was: kidney (15), lung (4), colon (3), breast (1), melanoma (1), and unknown in 1 patient. Ten patients (40%) complained of preoperative symptoms, in the others, thyroid involvement was incidentally discovered during the follow-up for the primary cancer. Twenty patients (80%) underwent total thyroidectomy, 3 received thyroid lobectomy and 2 palliative procedures. Morbidity was 16%, mortality was nil. The median follow-up was 24 months. CONCLUSION: ITM should always be suspected in any patient with a previous history of malignancy. Fine-needle agobiopsy (FNAB) with immunohistochemical stains may help in preoperative workup. A long delay between the primary tumor and the recurrence warrants surgery and total thyroidectomy seems to be the treatment of choice because of the multifocality of metastasis to the thyroid gland.

Ligasure versus Ultracision in thyroid surgery: a prospective randomized study.

PURPOSE: New hemostatic technologies (NT) are often employed in thyroid surgery in the effort to reduce operating time and complications. The aim of this study is to compare three different hemostatic techniques. METHODS: This is a prospective randomized study. There were 150 patients, aged 56 +/- 14 years, randomized for total thyroidectomy with conventional technique (CT), Ligasure vessel sealing system (LI) or Harmonic Scalpel (HS) at the university surgical department. One hundred thirty-five patients had benign diseases; 15 had malignancies. RESULTS: Mean postoperative hospital stay was 2.6 days. Mean operation time was 113 +/- 31 min; in HS patients, it was significantly shorter (p < 0.001). Morbidity was 43.3%; mortality was nil. Morbidity was significantly different between CT and NT groups (p = 0.0002); HS and LI groups had a higher morbidity (p = 0.0001 and p = 0.02, respectively). Mean postoperative calcemia was 1.12 +/- 0.1 mmol/l with a significant difference between groups; NT patients had a significantly lower calcemia (p < 0.05). There was no difference in recurrent laryngeal nerve palsies and in intraoperative blood losses (p = ns). CONCLUSIONS: According to our experience, the only real advantage of new hemostatic technologies was a shorter operation time with HS.

Prolonged survival of a patient affected by pancreatic adenocarcinoma with massive lymphocyte and dendritic cell infiltration after interleukin-2 immunotherapy. Report of a case.

Several studies have shown that there is a paucity of immune cells within the stroma of pancreatic adenocarcinoma, a very aggressive cancer with a median survival of about 18 months. A 65-year-old man presented with jaundice. Abdominal ultrasound revealed intra- and extrahepatic bile duct dilatation and a 45-mm diameter hypoechoic solid mass within the pancreatic head; a computed tomography scan excluded vascular infiltration and metastatic lesions. The patient received immunotherapy consisting of 6,000,000 IU human recombinant interleukin-2 administered subcutaneously twice a day for 3 consecutive days. Thirty-six hours after the last dose, he underwent a pylorus-preserving pancreatoduodenectomy. Because of the presence of high-grade dysplasia detected by intraoperative histological examination of a distal section, a spleen preserving total pancreatectomy was performed. The postoperative course was uneventful. The patient died 32 months after surgery because of local recurrence. Histopathology showed G3 pancreatic ductal adenocarcinoma infiltrating the anterior and posterior peripancreatic tissue, duodenal wall and intrapancreatic common bile duct, with sarcoma-like foci and a component of intraductal tumor involving the common bile duct. In the distal pancreas, widespread foci of pancreatic intraepithelial neoplasia (PanI2-3) were found. The Ki-67 proliferation index was 16%. TNM staging was pT3 pN1 R1. Sections were immunostained for the T-lymphocyte marker CD3 and for the dendritic cell marker CD1a. Intratumoral infiltration was high for CD1a+ cells and mild for CD3+ cells. Preoperative immunotherapy with interleukin-2 may contribute to massive stromal infiltration of immune cells in pancreatic adenocarcinoma. This may prolong the survival even in the presence of negative prognostic factors (age >65 years, tumor diameter >20 mm, R1, tumor grade G3).

Laparoscopic splenectomy: ligasure versus EndoGIA: a comparative study.

BACKGROUND: Laparoscopic splenectomy (LS) is considered the gold standard for the treatment of hematologic disease of the spleen. Intraoperative bleeding is the main complication and main cause of conversion during LS. In this paper, we present our experience with 112 LS procedures, comparing two different techniques and instruments for spleen dissection and hilar vascular control. METHODS: We have performed a total of 112 LS procedures in 9 years in two affiliated university hospitals. There were 48 males and 64 females (median age, 32.8 years). Indications were as follows: idiopathic thrombocytopenic purpura (ITP) in 42 patients, hereditary spherocitosis in 28, 6 with beta-talassemia, 1 with hemolitic anemia, 27 with lymphoma, 2 with leukemia, 3 with splenic cysts, and 3 PPT cases. Associated procedures were present in 25 cases (17 cholecystectomy and 4 liver/lymphnodal biopsies + lysis of adhesions). Patients were divided in two groups according to the method of dissection and hilar section (group 1, endostapler + monopolar coagulation with 38 patients; group 2, the Ligasure Vessel Sealing System (Valleylab, Boulder, CO) with 74 patients). RESULTS: Groups were well matched according to age, indications, spleen sizes, and procedures associated. Conversion rates (10 cases, 9%; 5 in each group), postoperative hospital stay (median 4 days in each group), and intra- and postoperative complications were similar in the 2 groups without any mortality in each group, while intraoperative blood loss (loss of 100 mL in 55 patients in group 2, 78%; and in 21 patients in group 1, 52%), transfusion rates (8 patients in group 1 versus 4 patients in group 2), and operative mean time (150 minutes in group 1 versus 125 minutes in group 2) were minor in the Ligasure Vessel Sealing System group, with a statistical significance. CONCLUSIONS: The approach to spleen dissection and hilum section was safe and efficacy in each case, otherwise the use of Ligasure results in a gain of time. Furthermore the average intraoperative bleeding and average transfusion rates of this series were lower in group 2.

Carcinoma of the neck showing thymic-like elements (CASTLE): report of a case and review of the literature.

Carcinoma showing thymic-like elements (CASTLE) is a rare tumor affecting thyroid and neck soft tissues, which has to be distinguished from squamous cell and anaplastic thyroid carcinoma, because it has a better prognosis. We report a new case of CASTLE which occurred in a patient submitted to total thyroidectomy with central neck dissection. The tumor stained positively for CD5, which seems to be the most useful marker in the differential diagnosis. By the analysis of the 18 cases reported in literature, total thyroidectomy with selective modified neck dissection should be the treatment of choice and radiotherapy should be considered for patients with positive nodal status.

Preoperative interleukin-2 immunotherapy in pancreatic cancer: preliminary results.

BACKGROUND/AIMS: Cancer patients' immunodeficiency, made worse by surgery, represents a poor prognostic factor for postoperative complications and long-term survival. Interleukin-2 has been shown to contrast the immunodeficiency related to the tumor and surgical treatment. The aim of this study is to evaluate the effectiveness of preoperative immunotherapy with interleukin-2 in pancreatic cancer patients. METHODOLOGY: 19 patients with pancreatic cancer undergoing radical surgery were divided in 2 different groups. Group 1: 9 patients treated with preoperative Interleukin-2 (9 million IU of IL-2 s.c. for 3 consecutive days) followed by pancreaticoduodenectomy after 36 hours; group 2: 10 patients who underwent pancreaticoduodenectomy without any neoadjuvant treatment. Two groups were well matched for age, sex, stage of disease, preoperative tumor markers and preoperative hematological assessment. Inflammatory cells' infiltration on the resected specimens, pre- and postoperative blood lymphocyte counts were evaluated as well as postoperative complications and survival and compared between the groups. RESULTS: Hematological and histological findings showed no significant difference between the 2 groups. Postoperative complications were more frequent in the control than in the treated group (p<0.05). Two-year survival was 33% in the treated group compared with 10% in the control (p<0.05). CONCLUSIONS: Preoperative Interleukin-2 administration seems to achieve a positive effect on postoperative complications and survival in pancreatic adenocarcinoma.

Preoperative IL-2 immunotherapy enhances tumor infiltrating lymphocytes (TILs) in gastric cancer patients.

BACKGROUND/AIMS: Tumor infiltrating lymphocytes (TILs), recognized as a tumor-host reaction, have been linked to prognosis in various tumors, with a clear positive correlation between the density of the lymphoid infiltrate at the advancing margin of the tumor and the prognosis of the patients. TILs are somewhat activated by tumor associated antigens and by IL-2 endogenous release. The aim of this study is to verify if subcutaneously administered IL-2 is able to enhance TILs in gastric cancer patients and is able to influence the prognosis of the patients. METHODOLOGY: We enrolled 39 consecutive patients with gastric adenocarcinoma. Patients were randomized to be treated with surgery alone (control group, 20 patients) or with surgery plus preoperative IL-2 (Interleukin-2) administration (treated group, 19 patients). Total lymphocytes, CD4 and CD4/CD8 were evaluated pre- and postoperatively. Peritumoral stromal reaction, neutrophils, lymphocytes and eosinophils infiltration in tumor histology were evaluated as well as survival curves and compared between the groups. RESULTS: IL-2 treatment was safe and well tolerated, and in the IL-2 treated group a significant increase over the baseline pretreatment values of the total lymphocyte, CD4 and CD4/CD8 on both the 14th and 50th postoperative days was observed (p < 0.05). Peritumoral stromal reaction, neutrophils and eosinophils infiltration did not shown any statistical difference between the two groups. Otherwise we observed a statistically significant difference in the peri- and intratumoral lymphocytes infiltration between IL-2 treated and control patients (p = 0.000026). Median overall and disease-free survivals were longer, even if not significantly, in the IL-2 group than in the control arm (p = 0.089 and p = 0.09 respectively). CONCLUSIONS: Our data shows that IL-2 seems to be able to induce substantial changes in the inflammatory infiltration of the neoplasm, improving the host activity toward the tumor and enhancing the TILs phenomenon in gastric cancer patients. This feature seems to improve the prognosis of the patients.

A case of pancreatic heterotopy of duodenal wall, intraductal papillary mucinous tumor and intraepithelial neoplasm of pancreas, papillary carcinoma of kidney in a single patient.

We report a case of the contemporaneous presence of two histologically different pancreatic neoplasms, one renal cancer and one embryogenic duodenal anomaly in a single patient. A 66-year-old man underwent ultrasound examination because of urinary disorders; a solid neoformation within the inferior pole of the left kidney was observed. Computed tomography confirmed the renal lesion, but also a heterogeneous mass within the pancreatic head appeared without bile ducts dilatation. Abdominal magnetic resonance revealed a multiloculated cystic component of the pancreatic mass. A second CT scan confirmed the renal and biliary findings, but it revealed a modest enlargement of the pancreatic asymptomatic mass. A resection of the left kidney inferior pole and a pylorus-preserving pancreaticoduodenectomy were performed. Histopathologic analysis of the surgical specimen revealed mild differentiated papillary renal carcinoma, intraductal papillary mucinous adenoma of the pancreatic head, foci of intraepithelial pancreatic neoplasm and pancreatic heterotopy of duodenal muscular and submucosal layers. The coexistence of several primaries and anomalies in one patient led us to suppose a genetic predisposition to different lesions, even in the absence of known familial genetic syndromes. The study of such cases may help to improve the investigation of molecular correlations and etiological factors of different solid tumors. Nowadays, surgery is the only effective cure.

Elective laparoscopic splenectomy and thrombosis of the spleno-portal axis: a prospective study with ecocolordoppler ultrasound.

Thrombosis of the portal system is a potentially life-threatening but otherwise underappreciated complication after splenectomy. Nonspecific and mild onset symptoms are the cause of delay in diagnosis, and the short hospital stay after laparoscopic approach could even contribute to the difficulty of early detection of this condition. The aim of this study was to verify if planned imaging controls are able to discover this complication leading to a prompt treatment. Thirty-eight patients (19 males and 19 females with a mean age of 24 years) who underwent laparoscopic splenectomy at our institution were studied to identify clinical signs of thrombosis of the portal venous system and eventually associated factors. All the patients were enrolled in a protocol of imaging surveillance using a doppler ultrasound method. Postoperative thrombosis of the spleno-portal axis occurred in 7 patients (18.9%) of the series. In 3 cases (8.1%) the thrombus extended from the splenic vein to occlude the portal axis. The complication was symptomatic in 4 cases (10.8%), whereas in 3 cases, the thrombosis was an ultrasonographic surprise in totally asymptomatic patients. Thrombosis occurred even as late as 2 months after splenectomy. Splenomegaly was the only significant factor predictive of thrombosis. Only those patients who had an early detection of portal or splenic vein thrombosis had a recanalization of the veins with anticoagulant therapy. Patients with splenomegaly who underwent laparoscopic splenectomy are at risk of thrombosis of the portal system and should undergo strict imaging surveillance and aggressive anticoagulation therapy.