A rare case of pneumatosis cystoides intestinalis with bowel perforation and secondary sepsis.

MATERIALS AND METHODS: We present here the case of an 83 y.o. male with intestinal perforation from pneumatosis cystoides intestinalis and consequent sepsis. RESULTS: The patient underwent urgency intestinal resection in our institute, with complete restitution ad integrum Discussion: Pneumatosis cystoides intestinalis is a rare affection, which can be categorized as primary (15%) or idiopathic( 85%). The clinical appearance can be very variable from patient to patient, since it can be completely asymptomatic or start with life-threatening clinical presentation of bowel perforation and sepsis. There are various theories about the formation of the gas bubbles trough the intestinal wall. The mechanical theory assumes that the gas, tearing trough the intestinal wall seeps trough it. The bacterial theory assumes that antibiotic treatment, such as with metronidazole, allows the creation of gas by microbiological elements like Clostridium Perfringens or Clostridium Difficile. The pulmonary theory, instead, assumes that air released from ruptured alveoli gets into the mediastinum and retro peritoneum, reaching the intestinal tract. The treatment is conservative most of the times, except for the cases of intestinal perforation and sepsis. CONCLUSIONS: Despite of the long history of the disease, with the first description in 1783, little is known nowadays about PCI, due to the rarity of symptomatic disease. Further studies are needed to better evaluate the aetiology of the condition, and the prognostic criteria, which may be very important for clinical decisions about conservative or surgical treatment. KEY WORDS: Diagnosis, Pneumatosis cystoides intestinalis, Peritonitis, Therapy.

The "Watch and wait" approach following chemoradiotherapy for rectal cancer: a case series and review of literature.

Neoadjuvant chemoradiotherapy (NCRT) combined with total mesorectal excision (TME) is currently the gold standard for locally advanced low-lying rectal cancer (LACR). Around 20-30% of patients after NCRT can achieve clinical complete response (cCR); 5-44% of the patients who underwent TME achieve pathological complete response (pCR) on postoperative histopathologic studies. In the present study we perform a review of current Literature and retrospectively analyze our personal experience on "watch and wait" approach after cCR. Further studies are needed to establish an internationally accepted definition of clinical complete response, to delineate the real role of MRI in the post-treatment staging and to determine more precise predictors of sustained clinical complete response. The eventual presence of long-term morbidity and adverse effects after chemoradiation needs as well to be better evaluated. Evidence suggests that watch and wait approach is associated with substantially better quality of life and functional outcomes compared with standard surgical resection. KEY WORDS: Chemoradiation, Neoadjuvant therapy, Rectal cancer, Remission induction.

Cholecystogastric fistula. A case report and literature review.

Cholecystogastric fistulas is a rare complication of gallstone. Even if well described in the literature, this condition still poses a debate on diagnosis and surgical treatment. We present a case of a 35 year's old female which unexpectedly presented a cholecystogastric fistula during a laparoscopic cholecystectomy, treated successfully with fistula transection and repair and cholecystectomy through an open access. The open access remains the preferable option in this cases but laparoscopic techniques are being used worldwide with increasing success. The preoperative diagnosis remains difficult for the unspecific symptoms. KEY WORDS: Biliodigestive Fistula, Gallstone Ileus, Gastric Fistula, Biliary Fistula, Cholecystitis.

High ligation of sapheno-femoral junction and thermal ablation for lower limb primary varicosity in day hospital setting.

AIM: The traditional surgical treatment for lower limb primary varicosity has been for a long time high ligation of sapheno-femoral junction and stripping of great saphenous vein. Surgery, however, has been frustrated by postoperative pains and discomfort and recurrences so that it has been challenged by minimally invasive endovenous techniques such as laser treatment and radiofrequency ablation. The aim of the article is to assess the feasibility, in a day hospital setting, of a combined approach to greater saphenous vein reflux: high ligation of sapheno-femoral junction and thermal treatment of the great sapenous vein. METHODS: A retrospective analysis on 95 patients treated with high ligation and thermal ablation at our institution from January 2009 to July 2017 was performed, assessing duration of surgery, post-operative pain and analgesics requirements, early complications and resumption of activities. RESULTS: Two patients (2.74%), in the laser group experienced skin burns in the course of the GSV. Moderate ecchymosis, by laser fibre-induced perforation of the vein wall, were observed in another two patients (2.74%). Four limbs (5.48%) in the EVLT group developed transient paraesthesias. Analgesic requirement on POD 3 was nil for RFA group; conversely half of the EVLT patients did take analgesics, either 2 or 3 tabs were required. On POD 7, the patients of RFA group continued to not ask for any analgesics, but the same half of the patients in EVLT group still needed 1-2 tabs to carry out their normal activities smoothly. On POD 15, no patient did require analgesics. Resumption of routine activities was earlier for RFA group patients than for those in the EVLT group. The RFA group resumed their activities within 3 days, whereas EVLT group in 8-9 days. High ligation of the SFJ didn't add too much time or morbidities. CONCLUSION: Catheter delivery of thermal energies for saphenous ablation, even when combined with high ligation of saphenous femoral arc, demonstrated to be minimally invasive, easy to learn and easy to perform in day hospital setting, with early return to normal activity. EVLT achieved similar results to RFA and both techniques were considered equally effective and safe; the results we obtained were not statistically significant but RFA showed less pain, ecchymosis and haematomas, as well as provided better short-term quality of life. KEY WORDS: Day Hospital setting, Endovenous laser treatment, High ligation ablation of the saphenous vein, Radiofrequency ablation.

Extragenital malignant mixed mesodermal tumor: A case report.

INTRODUCTION: Primary malignant mixed mesodermal tumor (MMMt, also called malignant mixed Mullerian tumor and designated in the WHO classification of female genital tract neoplasms as carcinosarcoma) is an infrequent tumor that develops usually in the uterus and more rarely in the ovary. Extragenital tumor, including primary peritoneal MMMt, is an extremely rare and aggressive neoplasm with only few case reported in the literature. PRESENTATION OF CASE: We report a case of a 70-year's old female who presented with nausea and abdominal discomfort for 6 months. Workup revealed an abdominal mass. Patient was treated with surgical removal in a general hospital. DISCUSSION: Most peritoneal carcinosarcomas originate in the pelvic peritoneum, followed by decreasing frequency in the serosal surface of the colon, retroperitoneum, anterolateral abdominal peritoneum, and omentum. Surgical excision is the most effective treatment in carcinosarcomas. A complete cytoreduction, with resection of cancer to a status of no evidence of disease by the surgeon's unaided eye should be attempted. CONCLUSION: Owing to the rarity of the disease, limited data regarding the management of peritoneal MMMT exists. Recommendations for the treatment of MMMT are based on individual cases only. In our case, the patient is alive with a follow-up of 15 months and she did not receive any cycle of chemotherapy.

Totally implantable central venous access devices in adult oncological patients.

Totally implantable vascular access devices (ports) were introduced into clinical practice to replace external catheters in patients undergoing prolonged intravenous therapy. Today, they are also designed to provide repeated access to the vascular system for the delivery of blood products and are also used for the withdrawal of blood samples. As regards cancer patients, the availability of these continuous reliable intravenous catheterisation devices has provided an opportunity to deliver more complex, multi-drug regimens, in safety and with a good quality of life. One hundred and eight patients underwent the subcutaneous positioning of a totally implanted reservoir (via the right subclavian vein) for aggressive combination chemotherapy in an operating room suite, using local anaesthesia. No patients suffered from air embolism, severe bleeding, brachial plexus injury, cardiac tamponade, haemothorax or hydrothorax. No patients experienced catheter occlusion or catheter-related venous thrombosis. One patient suffered from a pocket infection. Two patients experienced pneumothorax, but neither of them required catheter removal or required chest drainage. Indications, contraindications and complications are discussed. With careful routine care, totally subcutaneously implanted ports are very safe and provide reliable access to the venous system.

Endovenous laser therapy combined with a surgical approach for primary varicose veins of the lower limbs.

In recent years, the minimal invasive alternatives to surgical ligation and stripping for the treatment of an incompetent greater saphenous vein have been explored. Endovenous laser therapy (EVLT) is one of these therapeutic options. We report on our initial experience with endovenus laser therapy combined with a surgical approach. Over the period from September 2006 to September 2007, in the Colleferro City Hospital General Surgery Department, 19 patients were submitted to endovenous laser therapy combined with a surgical approach. We opted for a combined technique in which the use of the laser was preceded by high ligation of the saphenous vein ("crossectomy") together with complete sectioning of the venous collaterals. We observed no severe complications and endovenous laser therapy proved safe and easy to perform. However, this study is too limited and too short in terms of follow-up and number of patients to establish the superiority of the procedure over stripping in terms of recurrences. Endovenous laser therapy seems promising, but larger numbers and longer follow-up are needed to suggest this technique as the best approach to the management of varicose vein disease.

Pancreatic pseudocyst caused by extracorporeal shock wave lithotripsy for right renal pelvic calculi.

A 39-year-old white man with a history of right renal pelvic stones treated 1 year before by extracorporeal shock wave lithotripsy, but with no history of major surgery, alcoholism, pancreatitis, hyperparathyroidism or trauma, was admitted, suffering from an abdominal mass. Abdominal and pelvic computed tomography revealed an enlarged pancreatic head (9 cm in transverse diameter) with, inside it, a heterogeneous, cyst-like structure, measuring 7 cm in diameter. It was suspected that this lesion was a cystic neoplasm and the patient underwent a proximal pancreaticoduodenectomy and a cholecystectomy. After the operation, the microscopic findings ruled out the presence of a neoplasm and we were obliged to reconsider the case. Speculating as to the possible role of past extracorporeal shock wave lithotripsy in determining the pancreatic pseudocyst, it was found that damage to the intra-abdominal organs during extracorporeal shock wave lithotripsy has been mentioned in published series, but it was also noted that this case seemed to differ from the other published cases, where cirrhosis and thrombocytopenia, gallbladder stones, or adhesions between the pancreas and surrounding tissue caused by laparotomy were considered the causes of the lithotripsy complications. We suggest a direct traumatic disruption of the pancreas as a result of the extracorporeal shock wave lithotripsy and conclude that the post-lithotripsy follow-up should include periodic ultrasonographic investigation of the pancreas and serum amylase level determinations in order to diagnose pancreatic complications, if any, and plan the correct treatment.