Laparoscopic treatment of Meckel's diverticulum perforation caused by a chicken bone. A case report.

We describe an uncommon case of a Meckel's diverticulum perforation by a chicken bone in a patient with symptoms of acute appendicitis. Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract. The incidence is approximately 2% of the population. Most patients are asymptomatic, only 4-16% presenting complications, including bleeding, obstruction, and diverticulitis. The perforation due to a foreign body is a very infrequent complication and may have a bad prognosis in case of a delayed diagnosis. Only in a few cases, a careful evaluation of the CT scan leads to correct preoperative diagnosis. Definitive treatment is surgical intervention and should not be delayed in patients with peritonitis. Laparoscopy is a safe diagnostic and therapeutic tool to treat complicated Meckel's diverticulum. In our case, a stapled laparoscopic diverticulectomy has been performed with an excellent outcome. KEY WORDS: Laparoscopy, Meckel's diverticulum, Perforation.

Primary laparoscopic approach to repair perforated peptic ulcer. A retrospective cohort study.

BACKGROUND: Perforated peptic ulcer is a serious complication of peptic ulcer disease and carries high risk for morbidity and mortality. Although the incidence of peptic ulcer disease has decreased in recent decades, the percentage of patients with perforated peptic ulcer requiring emergency surgery remains constant. The use of laparoscopic management as a first choice for the treatment of the perforation is growing but is not routine in many centers. METHODS: Clinical and surgical data on 42 patients underwent surgical treatment for perforated peptic ulcer from January 2012 to December 2016 were collected. Laparoscopic repair of the perforation with a three-port technique was made in all cases. The Boey scoring system was used to predict the prognosis. RESULTS: All patients underwent suture-closure of the ulcer, and omental patch through laparoscopy without conversion to open surgery. Duodenal leakages occurred in 3 patients (7.1%), then treated with a conservative approach and resolved on the 10th postoperative day. Two patients (4.7%) had deep space infections in the first week after surgery, therefore subdiaphragmatic and pelvic abscess were drained by ultrasound guidance. Four patients (9.5%) died up to 30-day post-surgery due to progression of multisystem organ failure in absence of leakages or infections. All these patients were American Society of Anesthesiologists Classification >III and Boey Score 3. CONCLUSIONS: Our data show that a primary laparoscopic approach in patients with peptic ulcer perforation is associated with postoperative advantages and acceptable rates of morbidity and mortality, essentially related to high Boey Score. Therefore, we suggest that the surgical repair of PPU could be always started laparoscopically.

Malignant transformation of a tailgut cyst.

INTRODUCTION: Tailgut cyst are congenital cystic lesion arising from remnant of the embryological postnatal gut. Tailgut cyst are multinodular, uncapsulated and usually well-circumscribed. Presacral cysts are rare in adult and most of the lesions are benign. Malignant degeneration can occur, however is extremely rare. CASE REPORT: We present the case of a 74 years old woman with slow increase in size and malignant degeneration of a tailgut cyst. Five years before, during the follow up after mastectomy for cancer, she manifested rise of CA 19-9 tumor marker and a presacral cystic collection on thoraco-abdominal CT. She was followed with CT and MRI that showed that the cyst, with a solid component of the wall, was growing larger. After a five-year evolution, the cyst was resected. The histological examination on the solid component demonstrated intestinal adenocarcinoma. CONCLUSION: MRI ant TC can play essential role in the preoperative detection and characterization for the differential diagnosis, treatment strategies and evaluate neoplastic degeneration. Due to the risk of malignancy surgical resection must be performed after the diagnosis. Surgical therapy is mandatory when the cyst grow larger and a solid component is present. KEY WORDS: Presacral cyst, Retrorectal tumors, Tailgut cyst.

A comparative analysis between laparoscopy and open colectomy: assessment of perioperative and oncological outcomes.

AIM: Aim of the study was to compare two groups of patients affected by colorectal adenocarcinoma that underwent to open colectomy and laparoscopic colectomy respectively, highlighting the advantage and problems. MATERIAL OF STUDY: This is a retrospective analysis. Between January 2003 and December 2006, 54 patients who underwent colectomy were recruited. Of these, 26 patients underwent open colectomy, and 28 laparoscopy. RESULTS: For open colectomy the average duration of surgery was 177.9 minutes (surgical time) and 280.4 minutes (time of operating room) with a minimum of 110 and a maximum of 360 minutes, with significant differences according to type of surgery performed and the patient's clinical history. For laparoscopy the average duration was 293 minutes, (range 135 - 520), with significant differences depending on the portion of the intestinal tract removed. DISCUSSION: The comparison of two different surgical techniques, laparoscopic and open colectomy revealed some differences. The duration of the resection was greater for laparoscopy when compared to the traditional technique. CONCLUSIONS: Both approaches are technically feasible, safe and oncologically correct. Laparoscopic technique shows a much more favorable outcome in terms of pain, absence of extensive scarring, the incidence of incisional hernias and hospital stay -surgery compared with surgery laparotomy.

Randomized trial of a robotic assistive device for the upper extremity during early inpatient stroke rehabilitation.

BACKGROUND: A recent Cochrane Review showed that early robotic training of the upper limb in stroke survivors can be more effective than other interventions when improving activities of daily living involving the arm function is the aim of therapy. OBJECTIVE: We tested for efficacy of the study a protocol which involved the use of the NeReBot therapy in partial substitution of standard upper limb rehabilitation in post-acute stroke patients. METHODS: In this dose-matched, randomized controlled clinical trial, 34 hemiparetic participants with movement against gravity in shoulder, elbow, and wrist muscle groups were enrolled within 15 days of the onset of stroke. All participants received a total daily rehabilitation treatment for 120 minutes, 5 days per week for 5 weeks. The control group received standard therapy for the upper limb. The experimental group received standard therapy (65% of exercise time) associated with robotic training (35% of exercise time). Muscle tone (Modified Ashworth Scale), strength (Medical Research Council), and synergism (Fugl-Meyer motor scores) were measured at impairment level, whereas dexterity (Box and Block Test and Frenchay Arm Test) and activities of daily living (Functional Independence Measure) were measured at activity level. All assessments were performed at baseline, at the end of therapy (time T1), at 3 months (time T2), and at 7 months (time T3) after entry. All between-group analyses were tested using nonparametric test with Bonferroni's adjustments for multiple testing. RESULTS: No significant between-group differences were found with respect to demographic characteristics, motor, dexterity, and ADLs at baseline, postintervention (T1) and at follow-up (T2 and T3). CONCLUSIONS: The robot therapy by NeReBot did not lead to better outcomes compared with conventional inpatient rehabilitation.

Granular cell tumor of the appendix: a new case and review of the literature.

Granular cell tumor (GCT) is a rare and usually benign lesion of neural / schwannian origin, most frequently found in middle-age women. The appendicular involvement is extremely rare: in over half a century only twelve cases have been reported in the literature, the patients living in America and Europe. Hitherto, no cases are documented from Africa, Asia and Oceania and no cases of malignant GCTs of the appendix have been reported. Most patients were diagnosed preoperatively as having acute appendicitis, whereas in three patients the tumor was incidentally detected during major abdominal surgery. The GCTs were equally distributed between mid-appendix and tip, where lymphoid tissue is more abundant and the anatomical nerve supply is progressively reduced. Moreover, the appendix surrounding the GCTs is characterized by the presence of chronic inflammatory cells (histiocytes, plasmocytes, eosinophils, mastocytes) and, therefore, a chronic inflammation of the appendix may be an antecedent condition favouring the appearance of GCTs. The GCT of the appendix appears so to be a lesion that reflects local reactive changes in the neural / schwannian cells, rather than being a genuine neoplasm. We describe the smallest GCT of the appendix ever reported, with a detailed literature review supporting its reactive origin in the lymphatic tissue-rich sites, such as ileo cecal appendix.

Primary adrenal gland carcinosarcoma associated with metastatic rectal cancer: a hitherto unreported collision tumor.

In this report we describe the case of a young woman with familial adenomatous polyposis who developed metastatic rectal cancer during pregnancy. At diagnosis, we decided to perform a transabdominal laparoscopic adrenalectomy, because of the high risk of bowel obstruction, and to define the origin of the adrenal gland lesion, suspected to be primary on the basis of imaging results. The histological specimen showed a collision tumor between an adrenal metastasis of a rectal tumor and a primary adrenal gland carcinosarcoma. The peculiarity of the case is due not only to its clinical presentation during pregnancy, but also to the presence of this uncommon adrenal collision tumor. A particular challenge for the clinician is to define the priority between these two tumors: the presence of two distinct and colliding aggressive neoplasms poses a problem in the choice of the best therapeutic approach, also given the impossibility to biopsy all metastatic sites. However, we decided to treat the patient as having a metastatic rectal cancer, because we had a solid histological confirmation of metastases.

Upper limb rehabilitation robotics after stroke: a perspective from the University of Padua, Italy.

Rehabilitation robotics is an emerging research field that aims to employ leading-edge robotic technology and virtual reality systems in the rehabilitation treatment of neuro-logical patients. In post-stroke patients with upper limb impairment, clinical trials have so far shown positive results in terms of motor recovery, but poor efficacy in terms of functional outcome. Much work is needed to develop a new generation of rehabilitation robots and clinical protocols that will be more effective in helping patients to regain their abilities in activities of daily living. This paper presents some key issues in the future perspective of upper limb robotic rehabilitation after stroke.

[Haemoperitoneum secondary to avulsed short gastric arteries after vomiting]. / Emoperitoneo per rottura dei vasi gastrici brevi da conati di vomito.

We present the case of a rare and serious complication of vomiting. A 25-year-old man presented to the emergency room with acute abdomen secondary to haemoperitoneum. There was no evidence or history of trauma in the previous 30 days. The only antecedent was a history of violent vomiting in the afternoon. Laparoscopy showed a massive haemoperitoneum secondary to avulsed short gastric arteries.

Post-stroke robotic training of the upper limb in the early rehabilitation phase.

The successful motor rehabilitation of the upper limb of post-stroke patients requires early, intensive and task-specific therapy. The literature, albeit on the basis of a limited number of randomised controlled trials, shows that the use of robotics in upper limb neurorehabilitation has the potential to increase motor and functional recovery with respect to traditional therapy, especially if applied in the acute and sub-acute phases. This paper presents an overview of the literature on early robotic training of the upper limb after acute stroke.

Small bowel obstruction by a congenital band. Report of two cases.

The authors report two cases of acute small bowel obstruction, the first in an adult patient, and the second in a three-month-old baby due to a congenital fibrous band. The second case was retrospectively detected from a pool of at least 50 cases of secondary fibrous band obstructions over the period from 1970 to 2008. Surgery was performed early, and simple resection of this very rare malformative bundle (usually affecting very young people) was required.

Voluntary self-amputation of the colon.

We describe an unusual case of self-amputation of a transanal prolapsed colorectal segment by a 48-year-old mentally impaired woman. The surgical procedure and favourable outcome are reported.

Neoadjuvant treatment with single-agent cetuximab followed by 5-FU, cetuximab, and pelvic radiotherapy: a phase II study in locally advanced rectal cancer.

PURPOSE: Preoperative chemoradiotherapy followed by surgery represents the standard of care for locally advanced rectal cancer (LARC). Cetuximab has proved activity in advanced colorectal cancer, and its incorporation in preoperative treatment may increase tumor downstaging. METHODS AND MATERIALS: After biopsy and staging, uT3/uT4 N0/+ LARC received single-agent cetuximab in three doses, followed by weekly cetuximab plus 5-fluorouracil (5-FU), concomitantly with RT. Sample size was calculated according to Bryant and Day test, a two-stage design with at least 10 pathologic complete remissions observed in 60 patients (pts) able to complete the treatment plan. RESULTS: Forty pts with LARC were entered: male/female = 34/6; median age: 61 (range, 28-77); 12 uT3N0 Ed(30%); 25 uT3N1 (62%); 3 uT4N1 (8%); all Eastern Cooperative Oncology Group = 0. Thirty-five pts completed neoadjuvant treatment; 5 (12%) withdrew therapy after one cetuximab administration: three for hypersensitivity reactions, one for rapid progression, and one for purulent arthritis. They continued 5-FU in continuous infusion in association with RT. Thirty-one pts (77%) presented with acnelike rash; dose reduction/interruption of treatment was necessary in six pts (15%): two for Grade 3 acnelike rash, two for Grade 3 gastrointestinal toxicity, and two for refusal. Thirty-eight pts were evaluable for pathological response (one patient refused surgery, and one was progressed during neoadjuvant treatment). Pathological staging was: pT0N0 three pts (8%), pT1N0 1 pt (3%); pT2N0 13 pts (34%), and pT3 19 pts (50%) (N0:9, N1:5; N2:5); pT4 2 pts (5%). CONCLUSIONS: Preoperative treatment with 5-FU, cetuximab, and pelvic RT is feasible with acceptable toxicities; however, the rate of pathologic responses is disappointingly low.

Autologous great saphenous vein tailored graft to replace an infected prosthetic graft in the groin.

The authors propose a technique using the autologous great saphenous vein to replace an infected prosthetic limb graft at the groin. The whole great saphenous vein is incised longitudinally and divided into 2 approximately equal segments, which are sewn side to side. The longitudinal edges of the resulting great saphenous vein are then joined and anastomosed side to side to form a conduit, whose caliber is twice the original vein's diameter. The authors have used this technique to replace 1 limb of a prosthetic aortofemoral bypass infected at the groin. After 5 years, the new venous conduit is patent, with no recurrent infection, dilation, or aneurysmal degeneration. If validated by further experiences, this might be an attractive alternative to restoring flow through clean tissue planes using extra-anatomic bypass or the femoral vein in the infected fields.

High-grade symptomatic and asymptomatic carotid stenosis in the very elderly. A challenge for proponents of carotid angioplasty and stenting.

BACKGROUND: Carotid angioplasty and stenting (CAS) is often considered as the preferred treatment for severe carotid occlusive disease in patients labelled as "high risk", including those aged 80 or more. We analyzed 30-day stroke risk and death rates after carotid endarterectomy (CEA) for severe symptomatic or asymptomatic carotid disease in patients aged 80 or more, by comparison with the outcome of CAS reported in the recently- published literature. METHODS: A retrospective review was conducted on a prospectively compiled computerized database of all primary CEAs performed by a single surgeon at our institution from 1990 to 2003. Descriptive demographic data, risk factors, surgical details, perioperative strokes and deaths, and other complications were recorded. RESULTS: In all, 1260 CEAs were performed in 1099 patients; 1145 were performed in 987 patients less than 80 years old, and 115 were performed in 112 patients aged 80 or more. There were 11 perioperative strokes in the 1145 procedures in the younger group, for a stroke rate of 0.8%, and no strokes in the 115 procedures in the older group. The death rates were 0% for the octogenarians and 0.3% for the younger group. CONCLUSION: The conviction that older age means higher risk needs to be revised. Patients aged 80 or more can undergo CEA with no more perioperative risks than younger patients. Proponents of CAS should bear this in mind before recommending CAS as the best therapeutic option for such patients.

Implementation of a water compensator for total body irradiation.

This paper presents the design, implementation, and testing of an integrated system for improving dose homogeneity in total body irradiation (TBI). TBI is a radiation therapy technique that consists in delivering a uniform X-ray dose to the entire body of the patient. Because of variations in patient's tissues thickness and density, achieving a uniform dose over the entire body is one of the major challenges in TBI. The system proposed in this paper, whose main goal is to compensate for tissues heterogeneities, is made up of a translating bed, a linear accelerator, a vision system for body thickness assessment, a dynamically controlled water filter, and a main control unit. The water filter, placed between the X-ray source and the patient, is made up of an array of 70 small water containers (cells). The water level in each cell is controlled in real time, so as to modify the dose distribution both in the transverse direction and in the longitudinal direction. A prototype of the water filter system was implemented and tested, achieving good results in terms of dose uniformity.

Prospective randomized study on asymptomatic severe carotid stenosis and perioperative stroke risk in patients undergoing major vascular surgery: prophylactic or deferred carotid endarterectomy?

We compared the perioperative (30-day) stroke risk in asymptomatic patients with severe carotid stenosis who underwent carotid endarterectomy (CEA) before or after major vascular surgery. Seventy-nine patients with asymptomatic severe carotid lesion were randomly assigned to group I (n = 40) or group II (n = 39) to receive prophylactic CEA (within 1 week before major surgery) or deferred CEA (between 30 days and 6 months after major surgery), respectively. All procedures were eversion CEAs performed under deep general anesthesia and cerebral protection involving continuous electroencephalographic monitoring for selective shunting. There were no perioperative deaths or strokes relating to the major surgical procedure in either group. All group II patients underwent deferred CEA as planned (median 47 days, range 38-94) with no subsequent perioperative deaths or strokes. Two of these patients (5.1%) suffered a minor stroke, however, 65 and 78 days after their major surgical procedure, while awaiting carotid revascularization. Although data emerging from this analysis indicate that severe asymptomatic carotid disease may be safely postponed in patients undergoing major noncarotid vascular surgery, only a multicenter prospective study could determine the most appropriate management of this subset of patients.

Prospective randomized study on reversed saphenous vein infrapopliteal bypass to treat limb-threatening ischemia: common femoral artery versus superficial femoral or popliteal and tibial arteries as inflow.

PURPOSE: Use of inflow sources distal to the common femoral artery (CFA) for bypass to infrapopliteal arteries is a compromise measure when the length of the vein is not adequate. The purpose of this study was to compare the clinical outcome of vein infrapopliteal bypass arising from the CFA and from the distal superficial femoral or popliteal and tibial arteries in patients with limb-threatening ischemia. METHODS: Over 13 years, 160 vein infrapopliteal vein bypass procedures (160 patients) were randomized into 2 groups, 80 with inflow arising from the CFA (group 1) and 80 with inflow from below the CFA (group 2). Patency and limb salvage rates were assessed with the Kaplan-Meier method. All patients underwent graft surveillance at discharge and at 30 days and 6 months after surgery, then every 6 months thereafter. Follow-up ranged from 30 days to 127 months (mean, 49 months). RESULTS: Groups were similar with regard to age, sex, and most atherosclerotic risk factors. Gangrene as an indication for surgery was statistically more frequent in group 1 (73.7% vs 48.7%; P = .002), whereas nonhealing ulcer and rest pain were statistically more frequent in group 2 (respectively, 51.2% vs 25%; P = .001 and 46.2% vs 28.7%; P = .03). No patients died during the perioperative (30 days) period. At 1, 3, and 5 years patency and limb salvage rates were comparable between groups, tending toward significance for the 5-year primary patency rate (73% vs 57%; P = .08). CONCLUSIONS: In the absence of significant proximal disease, infrapopliteal revascularization arising distal to the CFA can ensure patency and limb salvage rates statistically similar to those with use of the CFA. Moreover, procedures arising distal to the CFA required fewer graft revisions to maintain patency of failing grafts.

Immunocytochemical increased evidence of inducible nitric oxide synthase, tumor necrosis factor-alpha, and adrenocorticotropic hormone in human peritumoral lymph nodes.

In the current study, mesenteric and peritumoral lymph nodes surgically removed from patients with colon-rectum cancer were studied. Morphologic and immunocytochemical investigations demonstrated that mesenteric (control) and peritumoral lymph nodes of a same patient showed the same morphologic structure, but a different immunocytochemical pattern. Indeed, an increased immunoreactivity to anti-inducible nitric oxide synthase, anti-tumor necrosis factor-alpha, and anti-adrenocorticotropic hormone antibodies in the lymphatic tissue of peritumoral lymph nodes compared with mesenteric lymph nodes was observed. These findings suggest that in colon-rectum cancer, the pathologic event induces an increased expression of the molecules involved in the processes of inflammation and carcinogenesis that occurs earlier than the appearance of morphologic modifications.