Small bowel obstruction caused by an unusual variant of paraduodenal hernia. The "middle congenital mesocolic hernia": case report.

Internal hernias account for 0.2-0.9 % of all small bowel obstructions and are associated with a mortality rate of 50 % when strangulation is present. Congenital mesocolic hernias, traditionally called paraduodenal hernias, caused by an abnormal rotation of the primitive midgut, are the most common type of internal hernia. They can be divided into three types: the right and the left congenital mesocolic hernias, accounting for the 25 and 75 % of all cases, respectively, and the extremely rare transverse congenital mesocolic hernia. A high preoperative misdiagnosis rate has been reported and a surgical exploration is recommended to identify strangulation. The present case report describes a case of small bowel obstruction due to an unusual variant of congenital mesocolic hernia never previously reported in the literature. We discuss the clinical appearance, pathogenesis, diagnosis, and treatment of the case, with a brief review of the literature focused on the pathogenesis and management of mesocolic congenital hernias.

Ultrasound-guided percutaneous treatment of abdominal collections.

Abdominal abscess is a very important problem nowadays, being responsible for prolonged hospitalisation, because these infections still cause substantial morbidity and mortality. For many years, surgical drainage has been considered the best therapeutic option in abdominal abscesses but several studies have subsequently shown that the percutaneous approach is as effective as surgical drainage. Starting from this background, the aim of this study was to evaluate whether or not percutaneous drainage is a valid treatment of choice. In the Department of Surgical Sciences, Organ Transplantation and Advanced Technologies of the University of Catania, 451 ultrasound guided percutaneous drainages of intra-abdominal abscesses were performed on 430 patients. Abscess drainage was successful in 322/403 (80%) of postoperative abscess, in 16/18 (90%) of primitive abscesses, in 10/12 cases (85%) of acute cholecystitis, in 3/6 cases (50%) of intrahepatic abscess and in 12/12 cases (100%) of pyelonephritis. US-guided drainage is currently the gold standard in the treatment of simple abdominal abscesses.

Anastomotic dehiscence after gastrectomy for cancer. Personal series.

BACKGROUND/AIMS: Nowadays the risk of anastomotic dehiscence after gastrectomy still exists. So the aim of this study was to analyze our experience regarding these anastomoses. METHODOLOGY: In our Surgical Unit, which is located in the Department of Surgical Sciences, Organ Transplantation and Advanced Technologies of the University of Catania, from January 1st 1985 to December 31st 2000, 249 patients underwent surgery for gastric cancer. RESULTS: We observed a statistically significant decrease of leaks in the third period of our study. CONCLUSIONS: These data demonstrate a significant decrease of anastomotic leaks with stapler in comparison to manual anastomoses.

Cancer of the sigmoid colon: left hemicolectomy or sigmoidectomy?

Left hemicolectomy is the ideal treatment of sigmoid cancer, but sometimes sigmoidectomy is a safe treatment. We radically treated 102 patients affected by sigmoid cancer: 83 were gross sigmoid cancer treated by left hemicolectomy, 19 were residual cancer after endoscopic polypectomy; of these, 4 underwent left hemicolectomy and 15 underwent sigmoidectomy. No recurrence was observed in the 15 patients treated by sigmoidectomy. In patients with sigmoid cancer accidentally associated with sigmoid diverticulitis, the surgeon should extend the resection up to a left hemicolectomy or follow-up with the patient, but sometimes sigmoidectomy could be safe. The sentinel lymph node technique in colorectal cancer could suggest indications to complementary treatments. However, in the presence of a negative node, sigmoidectomy could probably be planned as a rational treatment. In conclusion, even if more data are required, in some selected cases of sigmoid cancer, sigmoidectomy could be a safe treatment.

Ancient schwannoma of the facial nerve: a case report.

Ancient schwannomas are rare benign tumours, deriving from neural crest cells. Schwannomas of the head and neck are frequently misdiagnosed and preoperative investigations are often fruitless. We report a very rare case of a patient with a schwannoma of the seventh nerve. T.A., a 43-year-old male, was referred to our department in September 2003 with a 6-month history of a gradually enlarging asymptomatic right neck mass. Ultrasonography of the parotid gland demonstrated the presence of a nodule, with irregular borders, measuring about 2.90 x 2.00 x 1.70 cm. During surgery we found a mass apparently spreading from the parotid gland and therefore we decided to resect the mass together with the gland. The histological examination yielded a diagnosis of ancient schwannoma. Schwannomas are very rare and approximately 25-30% of all reported cases occur in the head and neck, mostly in the eighth nerve, while involvement of the seventh nerve is extremely rare.

Bilateral Morgagni-Larrey hernia: a rare cause of intestinal occlusion.

Morgagni-Larrey hernia is a rare pathologic finding, representing approximately 3% to 5% of diaphragmatic hernias. Its bilateral presentation is an absolute rarity, and its description is based only on isolated case reports. Two different theories exist about its origin: congenital vs acquired. Morgagni-Larrey hernia is asymptomatic in most cases, but it can also manifest with abdominal or thoracic symptoms. Diagnosis is based on findings from conventional radiography and computed tomography. The only treatment is closure of the herniary pass, even if the patient is asymptomatic. We describe this case because of the absolute rarity of bilateral localization in Morgagni-Larrey hernia and because of its subocclusive symptoms.

Thermic ablation with RF of liver metastases from colorectal cancer.

Aim of this study was to evaluate the role of radiofrequency ablation in the treatment of the hepatic metastasis of colorectal cancer. From November 1997 to July 2002 49 radiofrequency ablations have been performed in 19 patients (11 male and 8 female; mean age 65 years: range 50-78 years). The disease-free period was between 5 and 32 months. Nodules had a diameter <3 cm in 4 cases while in 3 cases a single lesion was present. One patient had a single lesion after 2 courses of intravenous systemic chemotherapy which had a reduced greater lesion (from 6 to 3 cm) while a 2 cm lesion had disappeared. In the remaining 12 patients the mean number of lesions is 3 (range 1-13) with a diameter between 3 and 12 cm. The radiofrequency ablation has been performed during laparotomy and vascular exclusion through clampage of the liver hilum in 4 cases and percutaneously under ultrasound guide in the remaining 15 cases. All patients underwent follow up by computed tomography, CEA level and ultrasound every 3 months. One patient only has completed a 4 year follow up and is alive without local recurrence but with a cerebral metastasis. The other 18 patients have a 32 months follow up with a survival of 50% (9 on 18). In conclusion in our experience the radiofrequency ablation is a valid alternative method in the treatment of the hepatic metastasis of colorectal cancer.

Gastric cancer: prognostic significance of the Goseki histological classification.

The aim of this study was to evaluate the prognostic significance of the Goseki factor in patients undergoing potentially curative resection for gastric cancer. From 1989 to 1999 202 patients with gastric cancer came in for observation to the Ist Surgical Clinic of Catania University. For the purposes of this study we examined 86 patients with a 5-year follow-up, from whom it was possible to obtain samples which were mounted in paraffin blocks and stained (haematoxylin-eosin and PAS-Alcian blue). The 5-year survival rates of patients with Goseki I and II tumours with good tubular differentiation were 90% and 30% as compared with 42% and 32% in patients with tumours that showed poor tubular differentiation (Goseki III and IV). In contrast, the 5-year survival rates in patients with mucin-poor tumours (Goseki I and III) were 90% and 42%, as against 30% and 32% in patients with mucin-rich tumours (P < 0.05). Our conclusion is that of the two components of the Goseki system, i.e. tubular differentiation and intracellular mucus, mucus production was found to be the more important determinant of clinical outcome. Mucus production has a greater impact on survival than the degree of tubular differentiation and is independent of it.

Lymphoma of the cecum: a case report.

Non-Hodgkin lymphomas present a wider systemic diffusion than Hodgkin lymphomas. Superficial and internal nodes, the tracheobronchial tree, and the digestive tract are almost always affected. The gastrointestinal tract is affected in 50% of the cases; the stomach is the first organ, followed by the small intestine and large intestine. The colon is affected in only approximately 0.4% of cases. The clinical picture of our patient showed abdominal pain, palpable mass, and anemia. Colonoscopy showed a tumor in the cecum (diameter, approximately 10 cm) and the biopsy indicated lymphoma. Through computed tomography, bone marrow biopsy, and measurement of beta2-microglobulin, complete staging was obtained. Right hemicolectomy was immediately performed because the large tumor could determine intestinal occlusion. Definitive diagnosis was non-Hodgkin lymphoma, type mucosa-associated lymphatic tissue B cells with a low grade of malignancy. After surgery the patient underwent six courses of chemotherapy according to the CHOP scheme (750 mg/m2 cyclophosphamide, 1.4 mg/m2 vincristine, 50 mg/m2 adriamicin, and 80 mg prednisone). Two years after surgery the patient shows no sign of the disease.