[Synchronous gastric and oesophageal cancer: a case report]. / Neoplasia sincrona dello stomaco e dell'esofago: caso clinico.

We describe the case of a male patient, aged 50, affected by an undifferentiated cancer of the gastric stump of a Billroth II gastric resection associated with a well-differentiated squamous-cell cancer of the oesophagus. The patient was submitted to gastrectomy and removal of the oesophagus together with reconstruction trough colon interposition. The association of the two synchronous neoplasms of the stomach and oesophagus is a very uncommon event, as the evidence in the medical literature demonstrates. Nevertheless, for the purposes of achieving in the right surgical planning, it is important to take this possibility into consideration in the preoperative management of oesophageal cancer, through the study of the organs which could be used to reconstruct the transit (stomach, colon). The association with a gastric neoplasm implies the use of the other organs (colon, ileum). However, for a number of selected cases of association with early gastric cancer, Japanese authors have suggested using the stomach in place of the oesophagus.

Objective follow-up after laparoscopic repair of large type III hiatal hernia. Assessment of safety and durability.

BACKGROUND: Symptomatic results of laparoscopic repair of large type III hiatal hernias, with/without prosthetic mesh, are often excellent; however, a high recurrence rate is detected when objective radiological/endoscopic follow-up is performed. The use of mesh may reduce the incidence of postoperative hernia recurrence or wrap migration in the chest. METHODS: We retrospectively studied 54 patients (10 men, 44 women; median: age 64.5 years) with a diagnosis of large type III hiatal hernia (>1/3 stomach in the chest on x-ray) who underwent laparoscopic repair at our department from January 1992 to June 2005. Complications, recurrences, and symptomatic and objective (radiological/endoscopic) long-term outcome were evaluated. RESULTS: Nineteen patients had laparoscopic Nissen/Toupet fundoplication with simple suture; in 35 patients a double mesh was added. The median radiological/endoscopic follow-up was 64 months (interquartile range (IQR): 6-104) for the non-mesh group and 33 (IQR:12-61) for the mesh group (p = 0.26). Recurrences occurred in 11/54 (20%) patients: 8/19 (42.1%) without mesh and 3/35 (8.6%) with mesh (p = 0.01). The 3 recurrences in the mesh group all occurred < or =12 months postoperatively; 4/8 recurrences in the non-mesh group occurred > or =5 years after operation. On multivariate logistic regression analysis, only mesh absence significantly predicted hernia recurrence or wrap migration. DISCUSSION: Laparoscopic repair of large type III hiatal hernias is safe and effective. Short-term symptomatic results are excellent, but mid-term objective radiological/endoscopic evaluation reveals a high recurrence rate. Possible reasons for failure of a laparoscopic hiatal repair are tension or poor muscle tissue characteristics in the hiatus. The use of a mesh, either by reducing tension or reinforcing muscle at the hiatus, might be associated with a lower recurrence rate. Longer-term follow-up will be needed before definitive conclusions can be drawn, however.

Could a high resectability rate improve the long-term survival of patients with proximal bile duct cancer?

BACKGROUND AND OBJECTIVES: This retrospective study was undertaken to evaluate if high resectability rate could improve the long-term outcome of patients with proximal bile duct cancer. METHODS: Between 1985 and 2001, 50 patients (34 male and 16 female) with proximal bile duct cancer were treated. Thirty-six patients (72%) were considered suitable for surgery, while 14 underwent nonsurgical palliative procedures. Twenty patients had bile duct resection only. Ten patients had Roux-en-Y cholangiojejunostomy with two or three divided segmental hepatic ducts; in 10 patients, the cholangiojejunostomy was performed with four or five divided segmental hepatic ducts. Three patients were treated by palliative transtumoral intubation with Kehr tube. Thirteen patients had bile duct resection plus hepatectomy. Despite the curative intention of the operation, only in 19 (52.7%) patients did the histopathological examination reveal tumor-free margins. RESULTS: There was no operative mortality. Postoperative morbidity was 25%. Overall 1-, 3-, and 5-year survival of the entire surgical group was 61%, 22.5%, and 9%, respectively. In the 19 patients treated with curative intent the survival at 1, 3, and 5 years was 63.1%, 31.5%, and 15.8%, respectively, while in the group that had palliative treatment it was 45%, 15%, and 0%, respectively. CONCLUSIONS: Only margins free from tumor can guarantee an improvement in long-term outcome. Increasing resectability improves survival and could offer a chance of better long-term survival.

True solitary pancreatic cyst in an adult: report of a case.

The differential diagnosis of cystic neoformations in the pancreas is challenging. We report a case of a true solitary cyst of the pancreas in a 26-year old woman. Abdominal magnetic resonance imaging and computed tomography showed a unilocular neoformation in the head of the pancreas, without obstruction of Wirsung's duct. We excised the cyst and performed Roux-en-Y loop pancreaticojejunostomy, but the patient suffered recurrent acute pancreatitis from Wirsung's duct stenosis. Thus, a new Roux-en-Y loop pancreaticojejunostomy was successfully done 6 months later. Histologically, the cyst was lined by cuboidal epithelium, immunohistochemically positive to anti-carbohydrate antigen 19-9 antibodies. To our knowledge, only 11 cases of solitary true cyst of the pancreas in adults have been reported, so the characteristics of this unusual entity are not well known. We propose a scheme for the differential diagnosis of cystic neoformations of the pancreas, starting from the histopathological definition of a true solitary cyst.

[Blunt liver trauma: therapeutic options]. / I traumi chiusi del fegato: opzioni terapeutiche.

Therapeutic options for management of blunt hepatic trauma include both non-operative and operative management, until liver transplantation. The presence of associated intraabdominal lesions increases mobility and mortality. A total of 58 patients with blunt hepatic injury, observed at the 2nd Surgical Unit of the "Santa Chiara Hospital" of Trento over a four-year period (1999-2003), were analyzed. Thirty-eight patients (65.5%) were treated conservatively with a 94.7% success rate. Twenty (34.5%) patients were surgically treated. Suture hepatorraphy was the most common procedure performed. The overall morbidity in surgical patients was 25%, with 20% of liver related complications. Four patients (20%) died with a liver related mortality of 10%. Advantages of non-operative management included a reduced need for transfusion (1.1 vs. 4.3 U), with 81.5% of patients not requiring transfusion, a reduced stay in the ICU and a reduced rate of morbidity and mortality (2.6% vs. 20%). Hemodynamic instability and the presence of an associated lesion in blunt hepatic trauma patients require emergency laparotomy. The widespread application of non-operative management has reduced the rate of morbidity and mortality related to unnecessary surgical approaches.

A rare diagnosis for a pancreatic mass: splenosis.

Splenosis, the autotransplantation of splenic tissue, has been designed to preserve organ functions after splenectomy. We present the first case of laparoscopic resection of a pancreatic splenosis, in a patient who had undergone a splenectomy 31 years before, complaining of abdominal pain and diarrhea. Abdominal computed tomography (CT) scan showed an enhancing hypervascular 3-cm solid mass in the body of the pancreas, mimicking a pancreatic cancer or a neuroendocrine tumor. A diagnostic laparoscopy was planned, and a 3-cm peripancreatic nodule with a long pedicle was visualized, with many nodules close to the tail of the pancreas and in the greater omentum. They were all resected, and the specimens obtained were immediately sent for frozen-section examination, which confirmed the diagnosis of heterotopic splenic tissue. Splenosis should be included in the differential diagnosis of the pancreatic masses in patients with previous splenic surgery. A hypervascular mass on CT scan should be regarded as an adenocarcinoma of the pancreas until proven otherwise. The possibility of a neuroendocrine tumor mandates an octreotide scan and gastrointestinal hormones dosage. In the unlikely event that all tests may produce equivocal results, a diagnostic laparoscopy is mandatory, in order to obtain an accurate histopathologic diagnosis.

Incidental cystadenoma after laparoscopic treatment of hepatic cysts: which strategy?

Biliary cystadenoma is a very rare hepatic neoplasm, accounting for fewer than 5% of cystic neoplasms of the liver; regardless of the various diagnostic modalities, such a lesion may be difficult to distinguish preoperatively from a cystadenocarcinoma. Although a diagnosis of cystadenoma during open hepatic surgery demands a complete surgical resection, there are few reports describing the correct approach to such lesions after a laparoscopic approach. This article presents the first case series of incidental cystadenoma after laparoscopic surgery for hepatic cystic lesions. One patient with a polycystic liver disease treated with a laparoscopic enucleation of the larger cyst declined the reintervention after the diagnosis of cystadenoma; she had no recurrence at follow-up. One patient with a large simple hepatic cyst laparoscopically enucleated had no recurrence at the 18-month follow-up. In one patient, there was a high suspicion of recurrence of cystadenoma after the laparoscopic fenestration of a large cyst, but a histopathological specimen obtained after the open surgical resection could not confirm any signs of cystadenoma. The incidental finding of biliary cystadenoma after laparoscopic fenestration of a cystic hepatic lesion requires an open hepatic resection. When a complete laparoscopic enucleation of the cyst may be assured, a strict clinical, biochemical, and radiologic follow-up could be considered as the definitive treatment, demanding the surgical intervention only in case of recurrence or high suspicion for malignancy.

Rare surgical complications of Crohn's disease. Clinical and therapeutic considerations.

We present our clinical experience in the management of rare surgical complications in Crohn's disease. Two hundred and eight patients affected by Crohn's disease were treated surgically between January 1992 and September 2001, at the Department of Surgical and Gastroenterological Sciences of the University of Padua. Rare surgical complications were identified in 17 patients (6.2%): 4 with small intestine adenocarcinoma, 5 with massive gastrointestinal bleeding, 5 with free peritoneal perforation and 3 with psoas abscesses. The very substantial clinical variability of Crohn's disease is a constant challenge to researchers. In particular, the high incidence of associated pathologies and complications related to Crohn's disease makes this pathology extremely disabling. In addition, this disease quite often appears to occur together with a rare complication which, though in most cases its course tends to remain unknown, at times may be potentially life-threatening. For this reason, it is crucial to suspect the occurrence of these pathologies, especially in patients responding poorly to therapy or in those whose symptoms suddenly become acute. Early diagnosis and treatment are therefore fundamental for the most appropriate treatment to be administered.

Laparoscopic colorrhaphy, irrigation and drainage in the treatment of complicated acute diverticulitis: initial experience.

The natural history of diverticulosis is worthy of note for its acute, sometimes recurrent, attacks of diverticulitis and the significant risk of serious complications, such as abscess, fistula and peritonitis. Most mild attacks of diverticulitis respond well to medical therapy while surgical treatment is indicated in the complicated forms of the disease. We evaluate the results of treatment of complicated acute diverticulitis by laparoscopic colorrhaphy, irrigation and drainage as a minimal surgical approach in 7 selected patients. We retrospectively analyzed all patients admitted to our institute for acute diverticulitis from 1996 to 2001. One hundred and thirty-five patients were admitted for acute sigmoid diverticulitis. Ninety-eight patients (72%) had their diverticular disease completely resolved after medical therapy, while 37 (28%) required a surgical approach. Seven patients underwent a laparoscopic colorrhaphy with irrigation and drainage. Laparoscopic procedures were completed in 6 patients. No perioperative morbidity or mortality was observed. All patients were discharged with no further re-operation. The technique could be considered a valid alternative for the management of complicated and perforated diverticulitis in selected patients.

Renal allograft rupture caused by acute tubular necrosis.

Renal allograft rupture is a rare but potentially lethal complication of kidney transplantation. A renal allograft recipient receiving quadruple immunosuppressive therapy developed a spontaneous allograft rupture 13 days after kidney transplantation. Warm ischaemia time during the transplant was 80 minutes. The ruptured kidney graft could not be salvaged because of the patient's haemodynamic instability. The histopathological examination showed interstitial oedema with severe acute tubular necrosis with no signs of acute rejection. The most common causes of renal graft rupture are acute rejection and vein thrombosis, while acute tubular necrosis may only rarely be responsible for this complication. Renal graft rupture may be the result of interstitial damage attributed both to the prolonged warm ischaemia time during the transplant and to post-transplant acute tubular necrosis in the absence of graft rejection. In those patients whose haemodynamic status cannot be stabilized by appropriate aggressive haemodynamic support therapy, graft nephrectomy should be considered the only definitive treatment.

Giant splenic epithelial cyst with elevated serum markers CEA and CA 19-9 levels: an incidental association?

True spleen cysts are uncommon and rarely associated with elevated serum and intracystic tumor markers CA 19-9 and CEA levels. A 19-year-old woman with a left subcostal mass was observed. Echinococcus granulosus serology was negative, and serum tumor markers CA 19-9 and CEA levels were 273 kU/L and 33 ng/mL, respectively. CT-scanning showed a splenic cyst of 18 cm in greatest diameter. The patient underwent total laparoscopic splenectomy and the serum tumor markers progressively decreased and became normal three months after surgery. Splenic cysts derive from an invagination of the splenic capsule in the splenic pulp with a subsequent squamous metaplasia. This last evidence could be confirmed from the variable cellular differentiation lines of the mesothelial squamous cells in the cyst wall. We should not exclude a higher degenerative potential of cystic epithelium that produces de-differentiation proteins. The lowering of the serum levels of the two markers after the cyst removal is witness of the direct relationship between the increment of the serum tumor markers and the presence of the epidermoid cyst.