Multidimensional analysis of the learning curve for laparoscopic colorectal surgery in a regional hospital: the implementation of a standardized surgical procedure counterbalances the lack of experience.

BACKGROUND: Although a larger proportion of colorectal surgeries have been performed laparoscopically in the last few years, a steep learning curve prevents us from considering laparoscopic colorectal surgery as the gold standard technique for treating disease entities in the colon and rectum. The purpose of this single centre study was to determine, using various parameters and following a well-structured and standardized surgical procedure, the adequate number of cases after which a single surgeon qualified in open surgery but with no previous experience in laparoscopic colorectal surgery and without supervision, can acquire proficiency in this technique. METHODS: From 2012 to 2019, 112 patients with pathology in the rectum and colon underwent laparoscopic colorectal resection by a team led by the same surgeon. The patients were divided into two groups (group A:50 - group B:62) and their case records and histopathology reports were examined for predefined parameters, statistically analysed and compared between groups. RESULTS: There was no significant difference between groups in the distribution of conversions (p = 0.635) and complications (p = 0.637). Patients in both groups underwent surgery for the same median number of lymph nodes (p = 0.145) and stayed the same number of days in the hospital (p = 0.109). A statistically important difference was found in operation duration both for the total (p = 0.006) and for each different type of colectomy (sigmoidectomy: p = 0.026, right colectomy: p = 0.013, extralevator abdominoperineal resection: p = 0.050, low anterior resection: p = 0.083). CONCLUSIONS: Taking into consideration all the parameters, it is our belief that a surgeon acquires proficiency in laparoscopic colorectal surgery after performing at least 50 diverse cases with a well structured and standardized surgical procedure.

An unusual case of mechanical bowel obstruction due to cholecysto-intestinal fistula and impacted gallstone: A case report and literature review.

Gallstone ileus is a rare entity and constitutes an uncommon complication of gallstone disease. It is caused by the impaction of a gallstone in the gastrointestinal tract and may cause serious symptoms or even life-threatening complications. It should be part of the differential diagnosis of acute abdomen especially in patients presenting with signs and symptoms of bowel obstruction and known gallstone disease. An early diagnosis is essential, and surgical treatment is the gold standard in order to relieve the obstruction. We present the case of an 84-year-old male patient with gallstone ileus due to cholecysto-intestinal fistula and impacted gallstone at jejunum. He was treated via urgent enterolithotomy, and his post-operative period was uneventful. This report aims to further educate clinical doctors on this rare medical condition which may pose a potentially serious health risk.

A Rare Case of Extended Retroperitoneal Biloma Due to Spontaneous Perforation of Common Bile Duct, Mimicking a Strangulated Right Inguinal Hernia: A Case Report and Literature Review.

BACKGROUND Biloma is the collection of bile outside the biliary tree as a result of visceral perforation. The most common site of disruption is the gallbladder, whereas common bile duct lesions usually occur following medical procedures or trauma. Spontaneous perforation of the common bile duct has been previously reported in the literature. Retroperitoneal biloma secondary to spontaneous perforation of the common bile duct is an extremely rare pathological entity. The purpose of this report is to inform clinical doctors of this rare entity, which can have fatal consequences for the patient. CASE REPORT We present the case of an 89-year-old man who was hospitalized with symptoms of vomiting, nausea, fatigue, and diffuse abdominal pain. The clinical examination and blood tests revealed peritonitis, a finding which was confirmed by the computed tomography of the abdomen as a retroperitoneal fluid collection, extending from the region posterior to the duodenum and head of the pancreas to the right inguinal fossa. As the patient's clinical status deteriorated, an urgent laparotomy was performed, revealing the presence of retroperitoneal biloma secondary to spontaneous perforation of the common bile duct. The operation was never completed as the patient died during the operation. CONCLUSIONS The diagnosis of this entity is difficult and is made during surgery. A large spectrum of treatment approaches has been used, but, regardless of the method, the goal is to halt the spreading abdominal contamination with bile and to treat the associated biliary pathology.

Right-sided strangulating diaphragmatic hernia in an adult without history of trauma: a case report.

BACKGROUND: Diaphragmatic hernia involves protrusion of abdominal contents into the thorax through a defect in the diaphragm. This defect can be caused either by developmental failure of the posterolateral foramina to fuse properly, or by traumatic injury of the diaphragm. Left-sided diaphragmatic hernias are more common (80-90%) because the right pleuroperitoneal canal closes earlier and the liver protects the right diaphragm. Diaphragmatic hernias in adults are relatively asymptomatic, but in some cases may lead to incarcerated bowel, intraabdominal organ dysfunction, or severe pulmonary disease. The aim of this report is to enlighten clinical doctors about this rare entity that can have fatal consequences for the patient. CASE PRESENTATION: We present a rare case of a right-sided strangulating diaphragmatic hernia in an adult Caucasian patient without history of trauma. Clinical examination revealed bowel sounds in the right hemithorax, which were confirmed by the presence of loops of small intestine into the right part of the thorax through the right diaphragm, as was shown on chest X-ray and computerized tomography. Deterioration of the clinical status of the patient led to an operation, which revealed strangulated necrotic small bowel. Approximately 1 m of bowel was removed, and laterolateral anastomosis was performed. The patient had an uneventful postoperative recovery and was discharged 8 days later. CONCLUSIONS: Surgery is required to replace emerged organs into the abdomen and to repair diaphragmatic lesion. A delayed approach can have catastrophic complications for a patient.

A rare giant gastric trichobezoar in a young female patient: Case report and review of the literature.

A bezoar is an aggregate of undigested foreign materials that accumulate in the gastrointestinal tract and may cause serious symptoms or even life-threatening complications. Trichobezoars, a subtype of bezoars, are a rare condition usually occurring in females with psychiatric disorders, with Rapunzel syndrome being an uncommon form of trichobezoar.

Ileocolic Intussusception in a Woman: A Case Report and Literature Review.

BACKGROUND Intussusception is a rare pathological entity in adults and remains a diagnostic challenge for clinicians, as it shares many clinical signs and symptoms with other morbid conditions (including appendicitis, abdominal hernias, colic, volvulus, and Meckel diverticulum). High clinical suspicion and use of appropriate imaging techniques are essential for early diagnosis and treatment of intussusception. Surgical intervention is the treatment of choice in cases of sustained and persistent invagination. CASE REPORT We present the case of a 65-year-old woman with a medical history of Crohn's disease, diabetes mellitus type II, hypertension, and rheumatoid arthritis. She was hospitalized for diarrhea, fatigue, and anemia. Computerized tomography of the abdomen and a colonoscopy revealed telescoping of the ileum, ileocecal valve, and part of the ascending colon inside the terminal segment of the ascending colon. The antegrade ileocolic intussusception was treated by performing a right hemicolectomy. The pathologic examination of the excised intestine showed mucosal lesions compatible with Crohn's disease, an inflammatory fibroid polyp at the terminal section of the ileum, and a low-grade appendiceal mucinous neoplasm. CONCLUSIONS Regardless of the etiology, when the normal motility of the intestine is altered, it can lead to invagination. Although intussusception is rare, it must always be part of the differential diagnosis for a patient presenting with constant abdominal pain.

Gastric glomus tumor: a case report and review of the literature.

INTRODUCTION: Gastric glomus tumor is a rare mesenchymal neoplasm. There are only a few cases of the tumor showing malignancy, and there are no specific guidelines for the management of this entity. CASE PRESENTATION: We present the case of a 53-year-old Caucasian male who was hospitalized for anemia. Computerized tomography of the abdomen depicted a mass between the pylorus of the stomach and the first part of the duodenum. Preoperative diagnosis was achieved with pathology examination of the biopsies taken via endoscopic ultrasound and upper gastrointestinal endoscopy. An antrectomy with Roux-en-Y anastomosis and appendicectomy, due to suspicion of appendiceal mucocele, were performed. The patient had an uneventful postoperative recovery and was discharged 5 days later. DISCUSSION: Preoperative diagnosis of a gastric glomus tumor is difficult owing to the location of the tumor and the lack of specific clinical and endoscopic characteristics. Furthermore, it is exceptional to establish diagnosis with biopsies taken through endoscopic ultrasound or upper gastrointestinal endoscopy, prior to surgical resection. Although most glomus tumors are benign and are not known to metastasize, there are rare examples of glomus tumors exhibiting malignancy. Treatment of choice is considered wide local excision with negative margins. However, long-term follow-up is required as there is the possibility of malignancy. CONCLUSION: The aim of this report is to enlighten doctors about this uncommon pathologic entity. Surgical resection is considered the golden standard therapy to establish a diagnosis and evaluate the malignant potential.