Ileal endometriosis and Crohn's disease: an unusual association causing acute bowel obstruction.

AIM: Endometriosis is a commun health disorder in women, which is defined as the presence of bowel endometrial-like tissue outside the uterus. Bowel endometriosis occurs in approximately10% pf all cases, with ileal localization as a very rare clinical intestinal occlusion:acute intestinal obstruction is possible presentation of this disease. We report a case of a patient with known history of Crohn's treated with ileal resection for acute intestinal occlusion;histology showed the coexistence of IBD and endometriosis in the intestinal wall. CASE REPORT: A 35 years old female patient, with previous diagnosis of Crohn's disease confirmed by endoscopic biopsies, was admitted to our Institutions because oc acute intestinal obstruction. She previously suffered of dysmenorrhea and pelvic pain during menstration. A contrast enhanced CT abdominal scan was performed with evidence of diffuse small bowel fluid distension and thickening of terminal iileum wall, compatible with ilea stenosis in acute Crohn disease. RESULTS: The patient underwent laparoscopic resection of distal ileus. Definitive histological examination showed ileal wall with multiple endometriosis foci and chronic follicular flogosis. CONCLUSION: The case that we have described shows a rare co-existence of the two clinical entitle (Crohn's disease and ileal deep endometriosis), histologically demonstrated, with acute presentation as intestinal obstruction, susseflully treated with laparoscopic ileal resection KEY WORDS Bowel obstruction, Crohn's disease, Endometriosis.

Voluminous oesophageal bronchogenic cyst treated with thoracoscopic approach.

AIM: Bronchogenic cysts are congenital lesions deriving from the primitive foregut, and are usually located in close relation to tracheobronchial tree or oesophagus. We report a case of an oesophageal bronchogenic cyst appearing at preoperative examinations as a benign fibromuscular tumour (leiomyoma). CASE REPORT: A 62 years old male patient in good general conditions, was admitted to our Institution because of moderate dysphagia and upper post-prandial abdominal pain. Conventional imaging, endoscopy and echo endoscopy detected a parietal oesophageal wall mass looking like a solid formation, determining extrinsic compression and narrowing of the lumen. RESULTS: The mass has been radically removed with thoracoscopic approach. Postoperative stay was uneventful and the patient was discharged three days after the operation. At histological examination the mass appeared as a cystic formation with fibromuscular wall and ciliated epithelium (so-called disembriogenetic bronchogenic cyst). CONCLUSION: The case we have reported describes a very unusual case of a voluminous symptomatic intramural oesophageal disembriogenetic cyst whose characteristics had not been defined at preoperative examinations. Surgical removal of the mass has been achieved with a minimally invasive approach.

A typical behaviour of thymic carcinoma.

AIM: To describe the case of a thymic carcinoma with atypical clinical behavior that has arisen with a voluminous metastasis at the right hemidiaphragm while the primitive thymic neoplasm was initially occult. CASE REPORT: A 42 years female patient came to clinical observation for a voluminous thoraco-abdominal mass located in right side, infiltrating the diaphragm. The patient was submitted to surgical excision of the mass; definitive histological examination: non-keratinizing spinocellular carcinoma suggestive for neoplasia on ectopic thymic tissue or metastasis from carcinoma of the thymus. Three 3 months after surgery MR and CT-scan restaging identified the presence of anterior mediastinal mass of about 3 cm of diameter, compatible with thymical origin; thymectomy was performed (histology: Lymphoepithelial thymoma). Eight months after the first surgical procedure a restaging by CT, MR and PET CT showed the presence of disease recurrence at the right diaphragmatic level. The patient underwent surgical exploration, with right thoracotomic approach: a metastasis in the hepatic segment VII was found and radically removed. Six months after liver metastasis resection, CT scan showed disease progression in mediastinum, with involvement of pericardium and aorta; the patient died for disease recurrence five months later, 22 months after the first surgical procedure. CONCLUSION: Thymic neoplasms are the most common tumors of the mediastinum; a small percentage of these tumors are however extremely aggressive carcinomas. Rare but not exceptional findings are also cancers arising from ectopic thymic tissue.

Metachronous solitary left adrenal gland metastasis of right colon cancer treated with laparoscopic approach.

AIM: Adrenal gland metastasis are the second most common type of adrenal mass lesions after adenomas and they could be related to numerous malignancies; Literature shows that adrenal metastasis deriving from colorectal cancer are very rare. MATERIAL OF THE STUDY: A 71-year old - male patient, treated two years before with right colectomy and adjuvant chemotherapy for right colon cancer, came to our attention after the diagnosis at follow up, of a left adrenal gland mass; CT scan and CT - PET did not show other pathological findings. RESULTS: The patient underwent left adrenalectomy with trans-peritoneal laparoscopic approach: the definitive histological examination diagnosed metastatic tissue of colonic cancer in left adrenal gland. CONCLUSIONS: Adrenal gland metastases are common clinical entities, but which of them arise starting from colonic cancer are very rare and they are generally discovered about 1 year after the first diagnosis of cancer. Early diagnosis, laparoscopic radical excision when feasible and eventual adjuvant radio-chemotherapy are actually the proper clinical management of adrenal gland metastases finalized to better outcomes in terms of longer survival rate and quality of life. KEY WORDS: Adrenal gland, Colorectal cancer, Laparoscopic, Metastasis.

A short course of granulocyte-colony-stimulating factor to accelerate wound repair in patients undergoing surgery for sacrococcygeal pilonidal cyst: proof of concept.

BACKGROUND AIMS: Stem cells, namely easily accessible bone marrow-derived cells (BMC), are reportedly capable of tissue repair in different damaged organs and might favor wound healing. The present study was undertaken to evaluate the feasibility and safety of BMC mobilization induced by granulocyte-colony-stimulating factor (G-CSF) in patients undergoing surgery for sacrococcygeal pilonidal cysts (SPC). To evaluate the possible clinical benefit of G-CSF in reducing the time to complete resolution, a comparison with a control group receiving surgery without G-CSF was performed. METHODS: Eight patients with complex SPC were included in this prospective trial. Patients were treated with G-CSF (5 µg/kg b.i.d.) for 3 consecutive days; standard surgical exeresis of the pilonidal cyst was scheduled on day 2 of mobilization. Mobilization was assessed in terms of circulating CD34(+) cells and granulocyte-macrophage colony-forming unit (CFU-GM) progenitors. RESULTS: Mobilization of CD34(+) cells and CFU-GM occurred in all patients, along with a marked increase in white blood cells (median peak value 28 435/µL, day 3). G-CSF was well tolerated and no adverse events occurred. All patients received the planned surgical treatment without any complications. Interestingly, the G-CSF group patients had a median time to resolution (117 days, range 110-130) significantly shorter than control patients (145 days, range 118-168) (P = 0.034). CONCLUSIONS: G-CSF administration, along with BMC mobilization, is feasible and well tolerated in patients undergoing surgery for SPC; clinical results compare favorably with those observed in controls not receiving G-CSF; the results suggest the potential use of G-CSF as an additional treatment to accelerate wound healing in patients undergoing surgery.

Ramirez's abdominoplasty technique combined with intraperitoneal chemohyperthermia after surgical cytoreductive procedures for the treatment of advanced intraperitoneal cancer in patients with ventral hernia.

Patients affected by peritoneal carcinomatosis are frequently submitted to repeated laparotomies to reduce intra-abdominal bulky lesions and to enhance the systemic chemotherapeutic action. Aim of our study is to evaluate feasibility and results of cytoreductive surgery and intraperitoneal chemohypertermic (IPCH) perfusion combined with Ramirez's abdominoplastic technique in selected patients with voluminous ventral hernias.At the same time, we support the hypothesis that Ramirez' technique would allow a normal intra-abdominal pressure leading to an optimal capability of penetration of chemotherapeutic agents in IPCH.From January 1998 to December 2003, 30 patients were submitted to a surgical debulking and IPCH through a laparotomic approach involving a ventral hernia. After extensive cytoreductive surgery, we closed the large abdominal wall damage with Ramirez's abdominoplasty technique, followed by IPCH. The technique described by Ramirez uses bilateral muscle flap complexes transposed medially to reconstruct the central abdominal wall without using meshes to supply or reinforce the abdominal reconstruction.A total of 23 patients (76.7%) were completely cytoreducted and subjected to IPCH. Postoperative mortality was 1/30 (3.3%). Major morbidity was 5/30 (16.7%). After a mean follow-up of 3 years, no sign of recurrent ventral hernia was noted in the survivors.This study suggests that surgical debulking combined with IPCH is feasible in patients with a previously large abdominal wall defect using the functional Ramirez's abdominoplasty technique. The reconstructive technique allows a regular IPCH procedure without recurrence of the ventral hernia confirmed by clinical examination and abdominal computed tomography.