Colorectal medullary carcinoma: heterogeneous presentations of a rare clinico-pathological entity. Report of two cases.

Colorectal medullary carcinoma (CMC) is a rare subset of minimally differentiated carcinomas. CMC tend to be right-sided and present at an advanced stage. Despite this, distant metastases are rare at presentation. The liver and the regional lymph nodes represent the most common sites of metastases. Most of the time, CMCs exhibit mismatch repair deficiency and a strong association with high-level microsatellite instability. There is no conspicuous data regarding treatment strategies and short-term outcomes. CMC is supposed to be related to better prognosis compared to poorly-differentiated and undifferentiated colonic adenocarcinomas, but reports are controversial.This lesion, with heterogeneous presentations and unclear prognostic significance, may be unfamiliar to histopathologists and can lead to diagnostic uncertainty and overtreatments.Our aim is to renew the attention to this rare histological subtype through the report of two cases.

Awake Major Abdominal Surgeries in the COVID-19 Era.

Background: During the outbreak of coronavirus disease 2019 (COVID-19), allocating intensive care beds to patients needing acute care surgery became a very difficult task. Moreover, since general anesthesia is an aerosol-generating procedure, its use became controversial. This strongly restricted therapeutic strategies. Here, we report a series of undeferrable surgical cases treated with awake surgery under neuraxial anesthesia. Contextual benefits of this approach are deepened. Methods: During the first pandemic surge, thirteen patients (5 men and 8 women) with a mean age of 80 years, needing undelayable surgery due to abdominal emergencies, underwent awake open surgery at our Hospital. Prior to surgery, all patients underwent nasopharyngeal swab tests for COVID-19 diagnosis. In all cases, regional anesthesia (spinal, epidural, or combined spinal-epidural anesthesia) was performed. Intraoperative and postoperative pain intensities have been monitored and regularly assessed. A distinct pathway has been set up to keep patients of uncertain COVID-19 diagnosis separated from all other patients. Postoperative course has been examined. Results: The mean operative time was 87 minutes (minimum 60 minutes; maximum 165 minutes). In one case, conversion to general anesthesia was necessary. Postoperative pain was always well controlled. None of them required postoperative intensive care support. No perioperative major complications (Clavien-Dindo ≥3) occurred. Early readmission after surgery never occurred. All nasopharyngeal swabs resulted negative. Conclusions: In our experience, awake laparotomy under regional anesthesia resulted feasible, safe, painless, and, in specific cases, was the only viable option. This approach allowed prevention of the need of postoperative intensive monitoring during the COVID-19 era. In such a peculiar time, we believe it could become part of an ICU-preserving strategy and could limit viral transmission inside theatres.

The management of "fragile" and suspected COVID-19 surgical patients during pandemic: an Italian single-center experience.

BACKGROUND: During Coronavirus disease (COVID-19) pandemic entire countries rapidly ran out of intensive care beds, occupied by critically ill infected patients. Elective surgery was initially halted and acute non-deferrable surgical care drastically limited. The presence of COVID-19 patients into intensive care units (ICU) is currently decreasing but their congestion have restricted our therapeutic strategies during the last months. METHODS: In the COVID-19 era eighteen patients (8 men, 10 women) with a mean age of 80 years, needing undelayable abdominal surgery underwent awake open surgery at our Department. Prior to surgery, all patients underwent COVID-19 investigation. In all cases locoregional anesthesia (LA) was performed. Intraoperative and postoperative pain has been monitored and regularly assessed. A distinct pathway has been set up to keep patients of uncertain COVID-19 diagnosis separated from all other patients. RESULTS: Mean operative time was 104 minutes. In only one case conversion to general anesthesia was necessary. Postoperative pain was always well controlled. None of them required postoperative intensive care support. Only one perioperative complication occurred. Early readmissions after surgery were never observed. CONCLUSIONS: On the basis of our experience awake laparotomy under LA resulted feasible, safe, painless and, in specific cases, the only viable option. For patients presenting fragile cardiovascular and respiratory, reserves and in whom general anesthesia (GA) would presumably increase morbidity and mortality we encourage LA as an alternative to GA. In the COVID-19 era, it has become part of our ICU-preserving strategy allowing us to carry out undeferrable surgeries.

Relapsed metachronous pancreatic metastasis from renal cell carcinoma (RCC): report of a case and review of literature.

AIM: The pancreas is a preferred site of metastasis from renal cell carcinoma (RCC), that may occur even after many years from a radical nephrectomy. Surgical R0 resection remains the only potentially curative treatment for solitary tumor. The possibility of a multifocality of the lesions (20-45%) must be considered. MATERIAL OF STUDY: We report a case of metachronous pancreatic metastasis from RCC that occurred twice. After five years from a right polar inferior nephrectomy for a RCC, two nodular lesions were identified in the body-tail of the pancreas and were treated with distal pancreatectomy and splenectomy. After six months the CT imaging revealed a nodular lesion of few millimeters in the residual pancreatic body; we followed the slow growth and in October 2012, when the size reached 2 cm, the patient was operated to remove the residual portion of pancreatic body. After 16 months of follow-up the patient is well and there isn't relapse of disease. DISCUSSION: Patients with metachronous pancreatic lesions represent a particular group with a more indolent course of RCC, the appearance of metastases after a prolonged interval from nephrectomy is related to a more favorable prognosis. Radical lymph-node dissection is not necessary for the uncommon involvement of peripancreatic nodes, condition that explains the positive outcomes achieved with surgery. CONCLUSION: Patients with resected metastasis present an 88% survival rate at 5 years versus 47% observed in nonoperated patients; studies provide encouraging results in survival and quality of life of surgically treated patients.

Laparoscopic cyst fenestration in the treatment of polycystic liver disease.

INTRODUCTION: The PLD, included in the group of malformative lesions of ductal plate, is characterized by progressive development of multiple parenchymal cysts. Different surgical treatments have been proposed for symptomatic patients with PLD: percutaneus aspiration, fenestration, hepatic resection and liver transplantation. The aim of this report is to outline the treatment of polycystic liver disease with laparoscopic fenestration. MATERIALS AND METHODS: Of thirteen patients with PLD, in all cases associated with polycystic kidney disease, 7 patients underwent to laparoscopic treatment of cysts fenestration, and 6, asymptomatic and not amenable to surgical treatment, underwent to clinical follow-up. Of the 7 patients, 5 have symptoms related to "effect mass" 1-2-3 of hepatic cysts while in the 2 asymptomatics the fenestration of the cysts was performed during the procedure of laparoscopic cholecystectomy for cholelithiasis. DISCUSSION: The best indication for laparoscopic fenestration are those cases of PLD characterized by a relatively limited number of large cysts, preferably situated in the anterior segments of the liver and in the left lobe; in this patients, laparoscopic fenestration reduces significantly the volume of the liver and relieves symptoms. The laparoscopic fenestration of hepatic cyst, in carefully selected patients, is an effective technique in terms of morbidity, mortality, conversion rate and recurrence rates; while in patients with cyst diffuse in liver parenchyma is indicated the hepatic resection or liver transplantation. The optimal surgical approach is still evolving, the type of approach is related to extent and distribution of the cysts, and vascular anatomy of normal segment of the liver. KEY WORDS: Laparoscopic fenestration, Policystic liver.

Wall defects after abdominoperineal resection: a modified tension-free technique.

BACKGROUND: The treatment of wall defects after abdominoperineal resection has yet to be defined. In this study we report the outcome of a modified prosthetic technique for the treatment of combined large incisional and parastomal hernia performed after abdominoperineal resection. MATERIAL AND METHODS: Between January 2005 and July 2008, 21 consecutive patients who underwent abdominoperineal resection for low rectal cancer received surgical repair for large incisional hernias with a modified mesh technique consisting of a tension-free attachment of the prosthetic material to the posterior sheath of the rectus abdominis muscle. The surgical outcome was assessed mainly as the recurrence rate of abdominal hernia and postoperative complications. RESULTS: Among the 21 patients we reported two minor complications: partial necrosis of the skin flap (4.8%) and a seroma (4.8%). One major complication occurred: extensive necrosis of the skin flap (4.8%). We reported one death due to stroke 20 days after surgery. The mean postoperative hospital stay was 6.1 days (SD, 2.3). CONCLUSIONS: This study encourages the use of a tension-free modified prosthetic technique for the repair of combined wall defects after abdominoperineal resection. The technique does not lead to an increase in the incidence of complications, offering a considerable advantage to the patient.