Minimally invasive management of rare giant Bochdalek hernia in adults.

Bochdaleck hernia (BH) is a congenital diaphragmatic hernia that presents after birth with respiratory symptoms and needs surgical treatment in the neonatal period. However, there are some rare cases of adult presentation, which require surgery to avoid complications. BHs can be treated through several approaches, including laparoscopy. Laparoscopic treatment of a giant BH was successfully attempted on a woman affected by multiple myeloma, with severe dyspnoea and dysphagia. Preoperative work-up included chest X ray, CT-scan and MRI. The whole stomach, duodenum, the small bowel, the right and transverse colon, most descending colon and the pancreas were herniated into the thorax. The herniated viscera were totally reduced into the abdominal cavity and the large defect of the left diaphragm repaired with a biosynthetic web scaffold especially designed for diaphragmatic reconstruction. Finally, to avoid a compartment syndrome in an abdomen with not enough room for the reduced viscera, an extended right colectomy with extracorporeal anastomosis was carried out through a mini-laparotomy. At seven-month follow-up, the patient is symptomless and control CT scan showed no hernia recurrence. Laparoscopic repair of large symptomatic adult BHs can be performed successfully with significant clinical improvement, even in difficult cases and fragile patients.

A case of arrhythmogenic right ventricular cardiomyopathy with biventricular involvement.

We reported a case of a young adult male aged 18 years admitted in our institution for syncope during a basketball match. No previous symptoms were reported. Electrocardiogram (ECG) showed T-wave inversion in the anterior leads and an incomplete right bundle branch block. Surprisingly, a complete echocardiographic evaluation demonstrated the presence of severe right ventricular enlargement with significant wall motion abnormalities, apical aneurysm and reduced systolic function. Cardiac Magnetic Resonance was pathognomonic for a fibro-fatty replacement of both ventricles. We decided for a subcutaneous defibrillator implantation and, after inducing a ventricular fibrillation to test the device status, epsilon wave appeared on the ECG. This clinical scenario depicted an advanced arrhythmogenic right ventricular cardiomyopathy at its first clinical manifestation.