Spontaneous abdominal wall endometriosis: a case report.

Endometriosis is the presence of endometrial glands and stroma outside the uterus. Spontaneous abdominal wall endometriosis (AWE) is any ectopic endometrium found superficial to the peritoneum without the presence of any previous scar. Rarely, endometriosis represents a disease of specific interest to the general surgeon, on account of its extrapelvic localisations. We describe a case with spontaneous AWE presenting as a painful mass with cyclic symptoms. A 28-year-old woman presented to the day-surgery division of our department, suffering from a painful mass in the left lower abdominal quadrant. A mobile mass of 5 x 4 cm was identified. The initial diagnosis was lipoma and excision was planned. During the operation two masses were spotted, very close to one another, and were excised within healthy limits. Pathology revealed endometrial glands surrounded by a disintegrating mantle of endometrial stroma and fibrous scar tissue in which there was a scattering of leucocytes. The woman had no scars. She was discharged from hospital after 2 hours. Two years after the excision she is free of disease and no recurrence has been observed. Spontaneous AWE is rare, accounting for 20% of all AWEs. The triad ; mass, pain and cyclic symptomatology helps in the diagnosis, but unfortunately it is not present in all cases. Spontaneous endometriomas are usually diagnosed by pathology and the treatment of choice is surgical excision.

Gigantic hepatic amebic abscess presenting as acute abdomen: a case report.

INTRODUCTION: Amebiasis is a parasitic disease caused by Entamoeba histolytica. It most commonly results in asymptomatic colonization of the gastrointestinal tract, but some patients develop intestinal invasive or extra-intestinal diseases. Liver abscess is the most common extra-intestinal manifestation. The large number of clinical presentations of amebic liver abscess makes the diagnosis very challenging in non-endemic countries. Late diagnosis of the amebic abscess may lead to perforation and amebic peritonitis, resulting in high mortality rates. CASE PRESENTATION: This report describes a 37-year-old white man, suffering from hepatitis B, with a gigantic amebic liver abscess presenting as an acute abdomen due to its rupture. Rapid deterioration of the patient's condition and acute abdomen led to an emergency operation. A large volume of free fluid together with debris was found at the moment of entry into the peritoneal cavity because of a rupture of the hepatic abscess at the position of the segment VIII. Surgical drainage of the hepatic abscess was performed; two wide drains were placed in the remaining hepatic cavities and one on the right hemithorax. The patient was hospitalized in the ICU for 14 days and for another 14 days in our department. The diagnosis of amebic abscess was made by the pathologists who identified E. histolytica in the debris. CONCLUSION: Acute abdomen due to a ruptured amebic liver abscess is extremely rare in western countries where the parasite is not endemic. Prompt diagnosis and treatment are fundamental to preserving the patient's life since the mortality rates remain extremely high when untreated, even nowadays.

Primary pancreatic anaplastic large cell lymphoma, ALK negative: a case report.

We present the fourth case of a primary pancreatic anaplastic large cell lymphoma (ALCL), ALK-. An 80-year-old man was admitted to our clinic for further investigation of a fever of unknown origin. He noted anorexia, weight loss and fatigue. His laboratory tests showed anemia and a great elevation of ESR, LDH, and beta (2) microglobulin. In CT and MRI scan, a soft tissue mass in the pancreas was observed. A repeated endoscopy after his admission revealed an ulcerated mass-like deformity of the duodenal bulb. Explorative laparotomy confirmed a diffuse spread of an unresectable malignant pancreatic mass extending to the adjacent organs. Duodenal and surgical biopsies identified an ALCL of T-cell lineage, ALK-. The patient died in the Intensive Care Unit due to hemodynamic instability. Our case is the first one indicating that primary pancreatic lymphoma should be suspected in a patient with pancreatic mass and elevated serum LDH and beta(2) microglobulin.

Endoscopic fibrin sealing of high-output non-healing gastrocutaneous fistulas after vertical gastroplasty in morbidly obese patients.

BACKGROUND: Fibrin glue was used in a various fields of surgery during the last 15 years, but its use has not been reported in bariatric surgery yet. METHODS: In 2 out of 215 morbidly obese patients who underwent vertical banded gastroplasty, a non-healing gastrocutaneus fistula (GCF) developed. In both patients sepsis occurred, caused by a leak of the posterior gastric wall, which was managed by means of an unsuccessful reoperation. After that, sepsis recurred, and a non-healing GCF developed. These GCF were managed endoscopically by the use of a fibrin sealant (Beriplast P 2 ml set, Behring) as a tissue adhesive. RESULTS: One injection was needed for the first case and six for the second in achieving full healing of the fistulas. No evidence of fistula was observed at gastroscopy 3 and 24 months after the end of therapy. CONCLUSIONS: Endoscopic use of human fibrin sealant is simple, safe, effective and in some cases life-saving. This is a therapeutic option in high output GCF in morbidly obese patients.

Complications after vertical gastroplasty with artificial pseudopylorus in the treatment of morbid obesity: a 7-year experience.

BACKGROUND: Vertical gastroplasty with artificial pseudopylorus (VGAP) was designed to reduce the complication rate of other forms of gastroplasty. The purpose of this study was to analyze the complications of this approach for 7 years of surgical practice. METHODS: A total of 156 morbidly obese patients (BMI 41-81 kg/m2) who underwent VGAP were analyzed retrospectively in terms of early and late complications and gastroplasty failure. RESULTS: The early complication rate, operative and systemic, was 6.40% (10 patients) and the late complication rate was 12.16% (19 patients). Early complications: We observed two gastric leaks and subphrenic abscess formation with one gastrocutaneous fistula, one severe intraabdominal hemorrhage, one evisceration, two serious wound hematomas, one lobar pneumonia, one massive pulmonary embolism and two nodular erythemas. Late complications: There were two prepyloric ulcers, one pseudopyloric ulcer with stoma stenosis, seven wound hernias, four pseudopyloric dilatations with suture rejection and gastroplasty failure, and five staple-line dehiscences with endostomach channel formation and gastroplasty failure. One patient (0.64%) died from massive pulmonary embolism. CONCLUSIONS: The early and late complication rate was acceptable in this series. The applied technique of VGAP is simple, safe, and helps avoid many complications caused by the other forms of gastroplasty.

Upper gastrointestinal endoscopic and histologic findings before and after vertical banded gastroplasty.

BACKGROUND: A total of 30 consecutive morbidly obese patients, six males and 24 females, who underwent vertical banded gastroplasty (VBG) between January 1992 and December 1994 and were followed up by endoscopy and biopsy were included in this study with the aim to determine the short- and mid-term complications and to investigate alterations in esophageal, gastric, and duodenal mucosa after surgery. METHODS: All patients underwent endoscopy before operation. Postoperatively, 28 patients were reendoscoped at 6 months, 26 at 12 months, and 22 at 18 months. Biopsies were taken from the lower part of esophagus, just below the esophagogastric junction (vertical part of the partitioned stomach), corpus, antrum, and duodenal bulb. RESULTS: Before operation 5 patients (16.6%) had a hiatus hernia and four of them (13.3%) had esophagitis. Endoscopic gastritis was diagnosed in nine patients (30%) and endoscopic duodenitis in two (6. 6%). Histologically, in 15 patients (50%) esophagitis was recognized; in 24 patients (80%) corpus gastritis; in 27 patients (90%) antral gastritis; and in 23 (76.6%) duodenitis. Helicobacter pylori was found in 20 (66.6%) patients. Postoperatively, three patients developed a mild stoma stenosis and were treated only by passing the endoscope 6 months after operation; one patient, with a severe stoma stenosis, was treated by Eder-Puestow dilatations and surgery. Gastric ulcer was found in two patients 6 and 12 months after surgery. One patient developed an endostomach channel because of staple line dehiscence 18 months after VBG. An increasing incidence of esophagitis and gastritis of the vertical part of the stomach was found at 6 and 12 months. Endoscopic and histologic gastritis of the corpus and antrum, as well as endoscopic and histologic duodenitis decreased gradually after surgery. CONCLUSIONS: Our findings suggest that postoperative complications of VBG can be diagnosed by endoscopy, and some of them can easily be managed. Vertical banded gastroplasty causes not only no harm to the esophageal, gastric, and duodenal mucosa but also influences them favorably.

Splenorrhaphy for splenic damage in patients with multiple injuries.

OBJECTIVE: To evaluate the results of splenorrhaphy by a 'figure of eight' suture in patients with multiple injuries. DESIGN: Open clinical study. SETTING: University hospital, Greece. SUBJECTS: 25 patients with multiple injuries after blunt abdominal trauma, 11 of whom were children. There were 2 grade II, 20 grade III, and 3 grade IV injuries. INTERVENTIONS: Diagnostic peritoneal lavage resulted in blood-stained effluent in all cases. A 'figure of eight' suture technique with size 0 chromic catgut mounted on a hepatic needle was used. A thin layer of sterile oxidised cellulose (Surgical) was placed over the laceration and round each knot. MAIN OUTCOME MEASURES: Mortality, morbidity, incidence of reoperation, measurements of splenic function, and adequacy of repair as judged by scintigraphy, ultrasonography, and computed tomography. RESULTS: There were no deaths as a result of splenic injury. Haemorrhage from the spleen was controlled in 23 patients. The remaining two, both of whom had grade IV injuries, required ligation of the vessels of the lower pole and hemisplenectomy combined with suture. Two patients with grade III injuries bled subsequently and required splenectomy. Splenic function was good in all patients. Examination by imaging techniques showed intact and functioning splenic parenchyma. CONCLUSION: The 'figure of eight' suture technique is a safe and reasonably successful way of controlling bleeding from a damaged spleen in a patient with multiple injuries.

A simple and safe method for preservation of the injured spleen.

A total of 29 patients sustaining closed injuries of the spleen was evaluated after repair of the organ; 11 were children. The injuries were classified as grade II, 5; grade III, 22; and grade IV, 2. The spleens were repaired with figure-of-eight, 0 chromic catgut stitches placed at right-angles to the rupture using a liver needle. A thin layer of Surgicel was placed over the tear and each free side of the stitch. Haemorrhage from the spleen was controlled with this technique in 27 patients. Two patients with grade IV injury underwent ligation of the lower pole vessels and hemisplenectomy combined with patching and suture. Postoperative bleeding occurred in two patients with grade III injury, who then underwent splenectomy. The splenic function after splenorrhaphy was established to be perfect and there were no deaths. This modified technique of repair is a simple and safe method for preservation of the injured spleen.

Pedicle grafts of peritoneum and transversalis muscle for the repair of large defects in the duodenal wall.

OBJECTIVE: To find out if pedicle grafts of peritoneum and transversalis muscle could be used to repair large defects in the wall of the duodenum. DESIGN: Experimental study. MATERIAL: 18 healthy mongrel dogs. INTERVENTIONS: Defects were created in the second part of duodenum and repaired with pedicle grafts of peritoneum and transversalis muscle from the anterior wall of the right side of the abdomen. MAIN OUTCOME MEASURES: Postoperative complications, appearances on upper gastrointestinal radiography two and four months after operation, and histological examination of necropsy specimens. RESULTS: There were no postoperative deaths or complications. Radiographs of the duodenum showed no abnormalities and in particular no signs of obstruction. Animals were killed at intervals from one week to eight months after operation, and the only abnormality was 20-30% stenosis found in five dogs killed within two months of operation, which did not affect gastric emptying. Histological examination showed that by four months after operation the patch was completely covered by neomucosa that was similar to normal duodenal mucosa. By six months the site of the defect was well healed and the histological appearance was the same as at four months. CONCLUSION: Pedicle grafts of peritoneum and transversalis muscle may be useful in the treatment of patients with large defects in the wall of the duodenum.