Subtotal cholecystectomy for Mirizzi syndrome: Should we ever remove the stone? A case report.

INTRODUCTION AND IMPORTANCE: Mirizzi Syndrome is a rare complication of cholelithiasis.In this case report the Authors present an original surgical approach for the treatment of complicated gallbladders, based on open subtotal cholecystectomy, leaving in situ the stone. This is the first case showing safety and reliability of the present strategy at a four-year follow-up. CASE PRESENTATION: A 68-year-old patient came to our emergency room with abdominal pain, leukocytosis and fever. At surgical exploration he presented a sclerotic retraction of the gallbladder together with an intrahepatic abscess, that forced us first to perform an open subtotal cholecystectomy, resecting the gallbladder cranially and leaving in situ the stone. CLINICAL DISCUSSION: The post-operative course was uneventful. The four-year clinical, US and CT scan follow-up was negative and the patient referred a normal quality of life. The present strategy could be considered an intraoperative rescue option in such a complex operative scenario in which is impossible to safely remove the stone. CONCLUSION: This case report demonstrates how in selected cases, when absolutely necessary and unavoidable without high risks, the stone can be left in situ as an eventual stone resection would be extremely risky.

Nodular Sclerosing Mesenteritis: An Occasional Finding Mimicking a Spindle Cell Tumor.

BACKGROUND The term "sclerosing mesenteritis" includes a spectrum of rare idiopathic diseases involving the small and/or large bowel. It appears as a diffuse, localized, or multinodular thickening of the mesentery, with a variable degree of chronic non-specific inflammation, fat necrosis, and fibrosis. CASE REPORT Here, we report a case of 83-year-old woman with symptoms of intestinal occlusion, vomiting, and abdominal pain. Radiographic examinations showed air fluid levels in right and left quadrants and in the mesogastric site, while computed tomography (CT) documented a strangulated inguinal hernia with ileal obstruction. Based on clinical examination and radiologic findings, the patient underwent surgery for inguinal hernia reduction. The examination of viscera revealed 2 tracts of ileum with ischemic signs and covered by fibrin; thus, the 2 intestinal loops were resected. Histological examination revealed chronic non-specific inflammation of the whole intestinal wall, including the subserosa in the resected tract of proximal ileum, while the distal ileal loop (not herniated tract) showed a subserosal fibrous nodule of 2 cm in greatest diameter, composed of a proliferation of spindle cells haphazardly arranged in a collagenized stroma. The diagnosis of sclerosing mesenteritis was rendered. CONCLUSIONS The present case shows the possibility of an incidental diagnosis during another intervention such as hernia surgery. Pathologists should be aware of this disease to avoid confusion with aggressive tumors such as intra-abdominal desmoid-type fibromatosis and gastrointestinal stromal tumor.

Clinical pictures mimicking acute hernia complications: are we really daring to violate a traditional abdominal wall surgery dogma?

BACKGROUND: Acute abdominal wall hernia complications usually require a prompt surgical treatment. The aim of this case series is to report our experience with some unusual cases of apparent acute and subacute hernia complications not requiring surgical treatment, changing the classical paradigm of immediate surgical approach into a "wait and see" situation. CASE PRESENTATION: We shortly report here four cases of abdominal wall hernia complications in which surgical treatment could have been unsafe for the patients considering their clinical condition. Two cases were fistulated and two were apparently strangulated. After clinical evaluation and CT-scan, we opted for a conservative treatment weighting the risk-benefit balance in order to give the best quality of life to the patient. CONCLUSIONS: In selected cases and under well-defined situations, an accurate evaluation should convince every surgeon to opt for a conservative approach refraining from a promptly operative treatment of the patient. This may be particularly relevant among very old or high-risk patients affected by long-standing abdominal wall hernias.

Hemorrhagic shock from post-traumatic rupture of microcystic splenic lymphangioma: A case report and review of the literature.

INTRODUCTION: Lymphangioma is an abnormal proliferation of lymphatic vessels. Isolated splenic lymphangioma (SL) is rare; in the last 30 years only 22 cases were reported in the literature. Diagnosis is difficult by the absence of typical symptoms and signs. SL is often asymptomatic and occasionally detected through radiological exams or, after the onset of a life-threatening complication, at surgery or pathological examination. Surgery represents the treatment of choice. PRESENTATION OF CASE: A 22-year-old Caucasian male was admitted to the Emergency Department after a car accident, complaining of sudden onset, severe, left upper quadrant abdominal pain. Abdominal examination revealed mild abdominal distention and a severe abdominal pain on superficial and deep palpation of left upper abdominal quadrant with obvious muscle guarding and rebound tenderness. Abdominal computed tomography scan showed splenic rupture with hemoperitoneum. Laboratory tests reported severe anemia. The patient received blood transfusions and was taken emergently to the operating room for exploratory laparotomy, evacuation of hemoperitoneum and splenectomy. The postoperative course was uneventful, the patient was discharged on the 7th post-operative day. Diagnosis of microcystic SL was made at pathological examination. DISCUSSION: Post-traumatic splenic rupture may be favored by the presence of a unknown and asymptomatic isolated SL. Although different types of treatment of SL are reported in the literature, splenectomy represents the treatment of choice to avoid complications. CONCLUSION: Isolated SL is difficult to diagnose and suspect because of lack of pathognomonic symptoms and specific diagnostic signs. It can be diagnosed after the onset of a life-threatening complication. Splenectomy is the preferable definitive treatment.

Immunological reaction and oxidative stress after light or heavy polypropylene mesh implantation in inguinal hernioplasty: A CONSORT-prospective, randomized, clinical trial.

UNLABELLED: The relationship between mesh weight and host tissue reaction has, so far, not been fully investigated. Lightweight meshes (LWM) are thought to give less inflammatory response compared with heavyweight meshes (HWM). The present study is a randomized, controlled, double-blind clinical trial performed in 61 patients who underwent an elective inguinal hernioplasty. The primary outcome of the study was to investigate the relationship between total amount of prosthetic material (polypropylene), immunological reaction, and oxidative stress. The study was double-blinded. Sixty-one patients were recruited for the study and randomly assigned to 2 groups (groups A and B). Levels of inflammation markers (interleukin-6 [IL-6] and tumor necrosis factor-α [TNF-α]) and oxidative stress markers (reduced glutathione [GSH] and lipid hydroperoxides [LOOH]) were determined preoperatively and after undergoing inguinal hernioplasty (after 6, 72, and 288 hours), respectively, with LWM and HWM. There was no significant difference in IL-6 levels between HWM and LWM (P = 0.3, 0.7, 0.8 after 6, 72, and 288 hours, respectively). A statistically significant difference was found after 72 hours for TNF-α (P = 0.01), for GSH after 6 hours (P < 0.01), and after 6 and 72 hours for LOOH (P = 0.05, 0.01, respectively). Oxidative stress occurred at earlier time points and was pore accentuated HWM versus LWM and prodromal to TNF-α increase.Also, in randomized clinical trial, the use of LWM gives advantages in terms of less inflammatory response when compared with HWM. Moreover, there is a significant higher oxidative stress after implantation of HWM. The intensity of oxidative stress seems to be strongly related to the amount of implanted polypropylene. ( TRIAL REGISTRATION NUMBER: NCT01090284).

Incidence of pain after inguinal hernia repair in the elderly. A retrospective historical cohort evaluation of 18-years' experience with a mesh & plug inguinal hernia repair method on about 3000 patients.

BACKGROUND: Chronic pain after prosthetic inguinal hernioplasty is one of the most important current issues in the current literature debate. Mechanisms related to pain development are only partially known. Influence of age as well as other factors is still unclear. The aim of this work was to evaluate whether development of chronic pain after open prosthetic plug and mesh inguinal hernioplasty is influenced by age. METHODS: Analysis was retrospectively conducted, dividing our cohort of patients (2,902) who had undergone prosthetic open plug&mesh inguinal hernioplasty from Jannuary 1994 to May 2012, following only the age criterion (cut-off 65 yrs.), into two groups (Gr.A<65 yrs, Gr.B>65 yrs.). All patients were routinely submitted to a postoperative questionnaire. Complications such as analgesic assumption were registered in both groups. Pain intensity was classified following the Visual Analogic Scale (VAS). Incidence of chronic pain, discomfort, and numbness, was assessed in both groups. Statistical significance was assessed by X2-test. RESULTS: Only 0.2% of patients suffered from a recurrence in our cohort. Postoperative chronic pain was observed in Gr. A in 0.12% of patients vs Gr.B 0.09% (p>0.05). Incidence of other postoperative symptoms such as discomfort or numbness were slightly prevalent on young patients (respectively p = 0.0286 and p = 0.01), while for hyperesthesia and sensation of foreign body no statistically significant difference of incidence between groups was observed. CONCLUSIONS: Real chronic pain after inguinal hernioplasty is a rare clinical entity. Other causes of chronic pain should be accurately researched and excluded. In young patients psychological factors seem to show a slight influence. There was no influence of age on chronic postoperative pain incidence after inguinal hernioplasty.

The surgical treatment of a rare complication: gallstone ileus.

The authors describe 3 cases of gallstone ileus observed in two different hospitals and evaluate the current rarity of this complication of the biliary lithiasis and/or of cholangiocarcinomas. There were two cases of stones at the ileal level and one case in the left colon. In one case a single surgical intervention was carried out while in the other a two-step strategy was adopted. Notwithstanding the fact that the correct strategy to adopt is still controversial in literature, the authors discuss the single and double step strategies and propose that the second intervention of the 2-step strategy should not be performed in high risk surgical patients.

Clinical biomarkers in hepatocellular carcinoma (HCC).

The Authors make a review of the most important molecules used today for detecting and screening hepatocellular carcinoma, analyzing their known biological features, advantages and limits especially concerning differential diagnosis from cirrhosis and others diseases. AFP, AFP-L3, DCP, Alpha-1-fucosidase are analyzed and all the current knowledge reviewed, as well as focusing on possible future applications and results of combined determination (what about another word here: evaluation etc) in HCC. Additionally other more recent molecules showing promising future clinical application are cited.

[Recurrent varicose veins due to neovascularisation: can they be prevented?]. / Varici recidive da "neocrosse"; è possibile prevenirle?

The authors analyse the problems of recurrent varicose veins on the basis of their own experience. The 5-year incidence of recurrent varicose veins ranges from 25 to 40% after internal saphenectomy. The recurrences should be classified in relation to the site and pathogenetic mechanism. The authors assess the effectiveness of a prevention method for sapheno-femoral stump recurrences. The study population consisted of 80 patients undergoing internal saphenectomy. In 34 (Group A) a traditional safenectomy was performed with short stripping, while in 46 (Group B) closure of the ostium with a flap of pectineal fascia was performed in order to prevent recurrences caused by neovascularisation. In Group A the recurrence rate was 27.1% as against 14.8% in Group B. Recurrences originating from the sapheno-femoral stump are mainly caused not only by an inadequate echo-colordoppler preoperative diagnosis and an inadequate or insufficient crossectomy, but also by neovascularisation. The pectineal flap method in our experience is a very simple, effective and complication-free technique to appreciably reduce recurrent varicose veins originating from the sapheno-femoral stump.

Superficial parotidectomy as first choice for parotid tumours.

Parotid neoplasms represent 3% of all head and neck tumours, and most are benign. Malignant tumours account for 14-25% of cases. Surgery is the treatment of choice, with options ranging from simple enucleation to radical parotidectomy. Sixteen patients presented with a history of a painless parotid lump. Diagnosis was achieved by ultrasound scan and MRI. Fifteen superficial parotidectomies and 1 nerve-sparing total parotidectomy were carried out. At histology, 10 pleomorphic adenomas, 4 Warthin's tumours, 1 lymphoepithelial cyst and 1 sebaceous adenocarcinoma were detected. In the single case of carcinoma, the 6 peri-glandular lymph nodes included in the specimen were metastasis-free. In 3 patients (20%) a transient paresis of the facial nerve was noted. The capsule appeared breached in only 1 case of pleomorphic adenoma. Four patients (26%) were diagnosed as suffering from Frey's syndrome. A salivary fistula was recorded in 2 patients (13%). During follow-up ranging from 3 to 96 months no tumour recurrence was recorded. Superficial parotidectomy seems to be the best choice of treatment for benign parotid tumours, since it allows complete excision of the tumour with sparing of the facial nerve. A radical procedure is, however, needed if malignancy is confirmed at frozen section.

[Ultrasound tissue modifications after polypropylene prosthesis apposition in inguinal hernia]. / Studio ecografico della risposta tissutale dopo ernioplastica inguinale con protesi in polipropilene.

Few studies have addressed the use of ultrasonography in the evaluation of abdominal hernia. In the present study ultrasonography was used to assess tissue modifications after apposition of a polypropylene prosthesis for inguinal hernia. Seventy-two patients submitted to calibrated inguinal hernioplasty (mesh and plugs) in local anaesthesia for inguinal hernia were studied by ultrasonography at 5 days, 1 and 3 months, and 1 year after the surgical intervention. The mesh presented as a small hyperechoic layer. In 50 patients (69.4%) a seroma was present above the mesh. The seroma was < 5 cc in 33 patients, between 5 and 10 cc in 6 patients, and > 10 cc in 11 patients. During the ultrasound examinations no recurrences were found and the mesh was not displaced. The seroma disappeared spontaneously between postoperative days 30 and 90 and was probably related to the size of the hernia and the number of plugs.

[Role of echo-colour Doppler in the diagnostic work-up and surgical timing of chronic venous insufficiency]. / Ruolo dell'ecocolordoppler nel timing diagnostico-chirurgico dell'insufficienza venosa cronica.

Chronic venous insufficiency affects about 10-12% to 35-50% of the population in industrialised countries. We analyse the role of echo-colour Doppler in the diagnostic-therapeutic work-up for this pathology in the light of their own experience. We report the results of the study of 158 legs in 79 patients, classifying the severity of chronic venous insufficiency using the Widmer classification, and private circulations using the Franceschi shunt classification. The mean duration of the examination was about 30 minutes (range: 22-46). A reflux time > 0.5 sec. was considered pathological. The patients with chronic venous insufficiency were divided into three groups on the basis of type of treatment: medical treatment and elastic compression (group 1,12 patients), sclerotherapy and elastic compression (group II, 20 patients), surgical treatment and sclerotherapy (group III, 36 patients). The echo-colour Doppler results were confirmed in the operating theatre in 34 patients. Echo-colour Doppler enabled us to identify patients who needed less invasive treatment than stripping; in group III, echo-colour Doppler allowed precise mapping and identification of communicant veins and collaterals, with 95% accuracy.

[Late cutaneous fistula after inguinal hernia repair. A case report]. / Insorgenza tardiva di fistola cutanea dopo ernioplastica inguinale protesica. Caso clinico.

A late inflammatory reaction and the formation of fistula after prostetic implant for primitive hernia of the abdominal wall are recent clinical events. The Authors describe a case of inguinal cutaneous fistula verified after 6 years from the execution of an prostetic hernioplasty with polypropylene. The possible etiology and the therapeutic options are discussed.

[Femoral hernioplasty with a mesh plug]. / L'ernioplastica crurale con plug protesico.

Prosthetic repair of femoral hernias is now standard practice. The aim of the study was to evaluate the results obtained using different types of polypropylene plugs in relation to the different anatomic-surgical aspects of the hernia. Twenty-five femoral hernioplasties were performed, 3 with Gilbert's conical plug, 18 with a dart plug, and 4 with Lichtenstein's cylindrical plug. The functional rehabilitation was rapid, and there were no postoperative complications; over follow-up periods of 3-132 months no recurrences have been reported. The correct choice of plug in femoral hernioplasty makes for efficacy, safety and simplicity. The possibility of choosing among different types of plug in relation to the anatomical characteristics of the hernia provides the surgeon with the right degree of flexibility for achieving the best possible result.

[Biologic tolerance of prolene prosthesis in inguinal hernia repair]. / Tolleranza biologica della protesi in prolene nella riparazione dell'ernia inguinale.

The aim of this study was to evaluate the efficacy, safety and durability of a calibrated inguinal hernioplasty polypropylene prosthesis, particularly in relation to the microbiological phenomena that may set in the vicinity of the polypropylene plugs and mesh employed. Over the period from January 1994 to December 2002, 1416 operations were carried out for inguinal hernia. In 5 of these patients we conducted an immunological study to assess serum cytokine concentrations. In addition, we incubated peripheral blood mononuclear cells for 24 or 72 hours in RPMI 1640 medium added with 10% FCS, with or without 0.5 cm2 of polypropylene. We then evaluated cytokine levels in the supernatant of these cultures. It proved impossible, either in vivo or in vitro, to detect appreciable levels of IL-10 or IP-10. Serum levels of IFN-gamma, TNF-alpha, IL-18 and IL-6 increased in the postoperative phases as compared to the preoperative period. In the study performed in vitro, in the presence of prosthetic material there was a remarkable increase in the production of TNF-alpha and INF-gamma both in basal conditions and after an appropriate mitogenic stimulus. The results of this study allow us to speculate that the use of polypropylene induces remarkable chemotactic activity in the tissues adjacent to the prosthesis. The in-vitro study data suggest that the presence of polypropylene may stimulate the immunocompetent cells of patients with prosthetic implants.

[Inguinal hernia recurrence after prosthetic repair: our experience]. / Le ernie inguinali recidive post-protesiche: nostra esperienza.

Inguinal hernia recurrence after prosthetic repair is a very rare clinical condition (1%), but it is probably underestimated and hard to resolve surgically. The authors reports their experience with 16 recurrent post-prosthetic inguinal hernias. A greater incidence of recurrence was noted in obese patients with concomitant chronic diseases (56%). Hernia recurrences following prosthetic repair are often asymptomatic. The use of Lichtenstein's plug technique yielded satisfactory results in terms of rehabilitation and incidence of recurrence and is also associated with a very low risk of complications.

[Organization of a day surgery unit for hernia]. / L'organizzazione di un servizio di chirurgia erniaria in day surgery.

The authors report their experience with the organisational aspects of minimal hospitalisation of patients undergoing surgical treatment for hernias of the abdominal wall. 1544 hernia repairs were carried out from January 1994 to March 2002; over 80% of these were performed on a day surgery basis. The organisation of a day surgery unit requires dedicated medical and nursing staff and also diagnostic imaging facilities that should be immediately available, though all this is not strictly necessary in a general surgery department. In conclusion, in addition to the organisational problems, inadequacy of the D.R.G. system in Italy is the primary obstacle to diffusion of the practice of ambulatory hernia repair.

[Role of nutritional support in the treatment of enteric fistulas]. / Ruolo del trattamento nutrizionale nelle fistole enteriche.

Enteric fistulas are nowadays considered an important therapeutic challenge. Artificial, total parenteral and enteral nutrition have allowed an improvement in the healing of these fistulas and a lower incidence of mortality. Fourteen patients with enteric fistulas (10 men, 4 women; mean age: 64.4 years; range: 20-80 years) were observed. The fistula was located in the large bowel in 11 patients, in the ileum in 2, and in the jejunum in 1. Thirteen patients received enteral nutrition. The patient with the jejunal fistula received total parenteral nutrition for 30 days and then enteral nutrition. The fistulas were successfully treated in 11 patients. One patients underwent surgery after 6 weeks of treatment with enteral nutrition because of lack of improvement of the symptomatology. In two patients, with advanced cancer of the colon and stomach, respectively, only a reduction of the fistula output was achieved. Nutritional support in the treatment of enteric fistulas is an effective procedure widely utilised to restore adequate nutritional status and bowel rest, which are two important targets for achieving fistula closure. Nutritional support is also useful in the management of patients undergoing surgery in order to reduce the postoperative complication rate.