Preoperative diagnosis and surgical treatment for giant retroperitoneal liposarcoma: A case report.

INTRODUCTION: The purpose of this article is to present the diagnostic and surgical approach for a giant retroperitoneal sarcoma and to highlight the difficulty of a precise preoperative diagnosis and the extention of surgical resection. PRESENTATION OF CASE: A 63-year-old female patient was admitted at our department with light diffuse abdominal pain, fever and gradual increase of abdominal girth. A CT scan showed a giant fatty tumor occupying left hemiabdomen and indirect findings of renal damage, probably sustained by ureter stretching and urine stasis. At surgical exploration, no cleavage plane was discovered between the mass and the surrounding organs. The severe pielonephritis and the apparent intraoperatively involvement of surrounding tumour structures lead to an aggressive surgery. An "en-bloc" resection of tumor mass, left colon, spleen, pancreatic tail, left annex, left kidney and adrenal gland was performed. Histology revealed a well differentiated liposarcoma with large areas of high grade of dedifferentiation. DISCUSSION: Liposarcoma is an histologic subtype of soft tissue sarcoma and the most common type of sarcoma arising in retroperitoneum. It is difficult to make an accurate preoperative diagnosis through a percutaneous biopsy. Although it is required to obtain negative resection margins, literature shows that surgical radicality is not a primary endpoint if noble structures are strictly close. In some cases surgery must be more aggressive because of the apparent organ involvement or damage. CONCLUSION: This is a rare case of a giant liposarcoma involging many organs. Surgery should be tailored according to intraoperative findings and organ damage.

The effectiveness of Hemopatch™ in preventing postoperative distal pancreatectomy fistulas.

OBJECTIVES: Postoperative fistula after distal pancreatectomy (DP) is still a significant complication, although many tools and tips have been utilized to try to reduce its elevated frequency. This paper focuses on the role of a sealing hemostatic device, Hemopatch™, to prevent postoperative pancreatic fistula (POPF) after DP. METHODS: Retrospectively we divided our sampling of 57 patients submitted to DP into two groups according to the availability of the device: 18 patients without Hemopatch™ and 39 patients using Hemopatch™. RESULTS: Significant difference was observed in leak occurrence (p < 0.05). No significant association was observed between the number of blood transfusions, the frequency of postoperative complications, associated splenectomy and POPF. CONCLUSION: This is a preliminary study and the first focused on the prevention of POPF after DP using Hemopatch™. Thanks to its double function of hemostasis and sealant, Hemopatch™ can be taken into consideration as an efficacy tool to prevent pancreatic POPF.

Correction to: Acute acalculous cholecystitis determining Mirizzi syndrome: case report and literature review.

Following publication of the original article [1], the authors reported that one of the authors' names is spelled incorrectly.

Acute acalculous cholecystitis determining Mirizzi syndrome: case report and literature review.

BACKGROUND: Although Mirizzi syndrome is widely reported in literature, little is known about acute acalcholous cholecystitis determinig the findings of a Mirizzi syndrome. CASE PRESENTATION: We report a case of MRCP-confirmed Mirizzi syndrome in acute acalculous cholecystitis resolved by surgery. CONCLUSION: Acute acalcholosus cholecystitis determinig a Mirizzi Syndrome should be included in the Mirizzi classification as a type 1. Thus it could be useful to divide the type 1 in two entity (compression by stone and compression by enlarged gallbladder). Magnetic Resonance should be considered the preferred diagnostic tool in any case of Mirizzi syndrome suspicious.

Bariatric surgery is not contraindicated in obese patients suffering from glycogen storage disease type IXa. A case report with follow-up at three years.

INTRODUCTION: Glucose storage disease type IXa (GSD IXa) is an uncommon condition presenting with childhood onset hepatomegaly, growth retardation, and often, fasting ketosis and hypoglycemia. Despite its benign course, the lack of dietary counseling may favor uncontrolled weight gain. We investigated the efficacy of bariatric surgery in one 17 years old female suffering from GSD IXa and morbid obesity. PRESENTATION OF CASE: The diagnosis was GSD type IXa in a patient with a body mass index (BMI) of 45.5kg/m(2). Onset of hypoglycemia was reported twice each month. She was treated her implanting an adjustable gastric banding through laparoscopy. Three years after surgery the patient presents a BMI of 30.1kg/m(2) and an excess of weight loss (EWL) of 71.1%. Only once, following surgery, she had to deflate her band to allow a faster transit of food through her stomach, thus reaching a prompt euglycemic condition, due to an incoming hypoglycemic crisis. DISCUSSION: Laparoscopic adjustable gastric banding (LAGB) is one of the most used approaches to treat morbid obesity. It is a restrictive procedure unable to affect the absorption of any nutrient, presenting a very low intra and perioperative complication rate. In our GSD IXa patient, it offered a prompt modification of food intake restriction whenever requested, thus avoiding hypoglycemia. CONCLUSION: LAGB is effective in determining weight loss without inducing significant side effects or worsening hypoglycemia, in this morbid obese patient, suffering from GSD type IXa.

Bariatric surgery in elderly patients. A comparison between gastric banding and sleeve gastrectomy with five years of follow up.

INTRODUCTION: The prevalence of obesity is rising progressively, even among elderly patients. Many studies investigated about safety and efficacy of bariatric surgery among aged obese patients. The objective of this review is to assess the benefits relative to risks of weight loss that may be obtained by performing two common bariatric procedures in obese elderly patient. MATERIALS AND METHODS: We retrospectively evaluated 10 morbid obese patients older than 60 years reaching 5 years of follow up who respectively underwent Laparoscopic Sleeve Gastrectomy (LSG) or Laparoscopic Adjustable Gastric Banding (LAGB). Eventual changes in comorbidities, weight loss, EWL% were investigated. RESULTS: Although LSG patients required a longer postoperative hospital stay than LAGB patients (p < 0.001), both procedures have shown to be safe and equally effective for weight loss achievement in elderly patients. Whereas all patients showed comorbidities resolution, no significant difference in weight loss between LAGB group and LSG group was found at 1 year (EWL% p = 0.87; BMI p = 0.32), 3 years (EWL% p = 0.62; BMI p = 0.79) and 5 years (EWL% p = 0.52; BMI p = 0.46) of follow up. CONCLUSIONS: Bariatric surgery is safe and effective to reach obesity related comorbidities resolution among elderly obese patients. Both LAGB and LSG determine a weight loss lesser than observed in a standard bariatric population. In this study LSG is significantly less cost effective than LAGB. Larger studies with longer follow up are however needed to evaluate the real impact of bariatric surgery on weight loss, resolution of comorbidities and improvement of quality of life in elderly obese patients.

Laparoscopic sleeve gastrectomy: efficacy of fibrin sealant in reducing postoperative bleeding. A randomized controlled trial.

Staple line leakage and bleeding are worrisome complications of laparoscopic sleeve gastrectomy (LSG). Solutions such as buttressing, oversewing or roofing the staple line with gelatin matrix have been proposed with controversial results. Because the use of fibrin sealant has shown a possible benefit in reducing the reoperation rate due to early complication in patients (pts) undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP), this solution has been tested in 100 consecutive pts undergoing LSG. A clinical trial has been performed on 100 consecutive pts. Exclusion criteria from the study were considered ASA IV pts, treated or untreated malignancies at any stage, steroids or FANS assumption, previous sovramesocolic surgery and conversion to open surgery. All pts were randomized to receive (group A, 50 pts) or to not receive (group B, 50 pts) 4 ml of human fibrin sealant (Tisseel™, Baxter(®) Deerfield, IL, USA) sprayed along the suture line. Primary endpoint was the incidence of postoperative complications: leaks, bleeding of the staple line or stenosis of the gastric remnant. Significance was assigned at a p level <0.05. By considering pts in group A vs. pts in group B our results shown no significant difference in fistulas or strictures occurrence (p = 0.2). Bleeding was significantly higher in patients not sprayed with sealant (group A vs. group B, 1/7, p = 0.03). This randomized trial has so far shown the use of fibrin sealant in LSG to significantly reduce postoperative bleeding. Although a trend in reducing leak occurrence emerges, it does not reach statistical significance.

Wernicke encephalopathy in subjects undergoing restrictive weight loss surgery: a systematic review of literature data.

The use of weight loss surgery is progressively increasing, and in recent years, restrictive bariatric surgery procedures have been more often used. Although thought to be associated with a lower incidence of post-operative side effects than malabsorpitive surgery, some cases of micronutrients deficiency have been reported because of an acquired thiamine deficiency; in this clinical setting, some cases of Wernicke encephalopathy (WE) have been described. Major determinants and predictors of this major neurological complication are currently unknown. The aim of this systematic review was to analyse literature data in order to address this issue. The main result of our systematic review was that persistent vomiting is the major determinant of WE in patients undergoing restrictive weight loss surgery. In addition, early thiamine supplementation can rapidly improve the clinical conditions, avoiding permanent deficiencies. On the other hand, given the wide variability of clinical and demographic characteristics, definite prognostic factors of WE occurrence and of clinical outcome cannot be identified. In conclusion, although our results are suggestive, further ad hoc prospective studies evaluating changes in micronutrients levels according to different types of surgery are needed.

The mini-gastric bypass in the management of morbid obesity in Prader-Willi syndrome: a viable option?

AIMS: To test the efficacy of the mini-gastric bypass (MGB) in the treatment of morbid obesity related to the Prader-Willi Syndrome (PWS). PATIENTS AND METHODS: Three young male patients (mean age 15.6 years) complaining with PWS were treated by MGB with the aim to improve morbid obesity associated with the syndrome. Preoperative body mass index was 51 ± 4.13 kg/m(2). Two patients suffered from both hypertension and frequent sleep apnea crises. The mean preoperative level of fasting plasma acyl ghrelin was 1417.26 ± 289.37 pg/ml. All patients underwent a laparoscopic MGB. RESULTS: The postoperative period was uneventful and all patients were discharged on the fifth postoperative day. The patients suffering from both hypertension and respiratory crises are now free from receiving any therapeutic support. When measured, the postoperative level of fasting plasma acyl ghrelin decreased to 675.5, 524.6, and 353.1 pg/ml, respectively. An excess weight loss of 79% has been recorded at two years so far. To date, no nutritional impairment, weight regain, or need for revision surgery has been recorded. CONCLUSION: MGB appears to provide an effective weight reduction in patients suffering from PWS without determining significant nutritional impairment or weight regain. Larger studies are however required.

[Spontaneous rectus sheath hematoma: a rare condition with uneasy diagnosis and multidisciplinary treatment. Report of 5 cases and review of literature]. / Ematoma spontaneo del muscolo retto addominale: evenienza rara, diagnosi difficile e trattamento multidisciplinare. Presentazione di 5 casi clinici e revisione della letteratura.

Spontaneous rectus sheath hematoma is a rare condition. It encompasses a wide spectrum of severity (self-limiting to fatal) depending of its size, etiology, and the development of complications. It enters into the differential diagnosis of abdominal pain but it's frequently difficult to diagnose and often radiologic imaging is required. Authors report a series of five patients admitted at emergency room within a 2-year period. Patient were between 63 to 78 years old. One of them was in therapy with warfarin, one was in therapy with acetilsalicililate and clopidogrel and in an another patient a coagulation disorder was detected. Diagnosis was suspected in all cases by clinical exam and ultrasonography, but CT-scan was necessary in three cases. All patients underwent conservative treatment, mainly pain relief and rest. In two cases blood transfusion was performed and in two cases clotting abnormalities were corrected with vitamin K and fresh frozen plasma. Average ospedalization was 10 days (range 5-17). One patient developed late seroma and was treated with ultrasound-guided aspiration. Rectus sheath hematoma is a rare but important entity in the differential diagnosis of abdominal pain. The difficulties in the correct diagnosis frequently lead to delay in treatment or unneeded surgery. CT-scan is the gold-standard investigation. Treatment options are variable and include conservative treatment, intravascular embolization and surgery Frequently an interdisciplinary team approach is needed.

[Squamous-cell carcinoma and pilonidal sinus disease. Case report and review of literature]. / Epitelioma a cellule squamose e malattia del seno pilonidale. Presentazione di un caso clinico e revisione della letteratura.

Squamous-cell carcinoma arising in a pilonidal sinus is a rare occasion. Authors report the case of a 60 years old male, with a 15 years history of recurrent pilonidal sinus disease. The patient underwent incisional biopsy, staging with total body CT, and finally radical surgery. The large wound healed by secondary intention, with a complete formation of the scar in three months. After six months, no complications or signs of recurrence were observed. Authors recommend careful inspection of the pilonidal area in all chronic and longstanding inflammatory lesions to identify promptly malignant transformation.