Appendiceal mucinous neoplasms: an uncertain nosological entity. Report of a case.

INTRODUCTION: Appendiceal mucocele is a relatively rare condition characterized by progressive dilation of the appendix caused by intraluminal accumulation of mucoid substance. Its incidence is 0.07 - 0,63% of all appendectomies performed. CASE REPORT: We report the case of a 70-year-old man who came to our observation with gravative pain in right lower abdominal region. A computed tomography abdominal scan revealed a cystic/tubular structure like an appendicular mass with wall enhancement but without calcifications suggestive of a mucocele. Into peritoneal cavity we found profuse mucinous material with a 1,5 cm size parietal nodule. We also identified a free perforation of the cecum with consensual spillage of gelatinous material mimicking a pseudomyxoma peritonei. We decided to perform a right hemicolectomy with excision of peritoneal lesion. DISCUSSION: The controversy in the pathologic terminology can give rise to a clinical dilemma in terms of the management and follow-up plans. For mucosal hyperplasia and cystadenoma simple appendectomy is curative. Only in case of large base of implantation it may be necessary the resection of the ileum and caecum or right hemicolectomy. In case of mucinous cystoadenocarcinoma authors perform a right hemicolectomy. CONCLUSION: Appendiceal mucinous neoplasms are different pathological entities. The correct surgical management depends on size and location of lesion. A preoperative diagnosis is obviously needed in order to perform the correct treatment. CT abdominal scan is the better diagnostic tool, but different authors show their inability to reach a preoperative diagnosis in the larger majority of cases.

Terminal or truncal ligation of the inferior thyroid artery during thyroidectomy? A prospective randomized trial.

INTRODUCTION: Thyroidectomy is a common procedure in general and endocrine surgery. The technique of ligation of inferior thyroid artery (ITA) has been invoked as a possible cause of appearance of postoperative hypocalcemia. METHODS: We performed a prospective randomized study involving 184 patients undergoing total thyroidectomy to evaluate the differences of truncal ligation versus distal ligation of ITA in terms of postoperative hypocalcemia, vocal fold palsy, voice and swallowing impairment. The patients were divided into group A (trunk ligation of ITA) and group B (terminal branches ligation of ITA). RESULTS: We evaluated postoperative PTH and calcemia (immediate, 6 and 12 months after thyroidectomy), postoperative day of discontinuation of calcium and vitamin D supplementation, voice and swallowing complaints, evaluated by mean of two specific tests available in literature, day of hospital discharge. CONCLUSION: The only significant differences between the two groups were a higher immediate postoperative calcemia and a greater number of patients discharged without calcium and vitamin-D supplementation in the group B. In conclusion, no substantial differences were found between the two groups. The choice depends on the experience of the surgeon.

Large cavernous hemangioma of the adrenal gland: Laparoscopic treatment. Report of a case.

INTRODUCTION: Cavernous hemangioma of the adrenal gland is a rare benign tumor. The diagnosis is often postoperative on histological exam with the presence of blood-filled, dilated vascular spaces. PRESENTATION OF CASE: We report the clinical case of a 49 years-old woman who came to our observation with aspecific abdominal pain. A computed tomography (CT) abdominal scan revealed a 11cm right adrenal mass. This lesion was well circumscribed, round, encapsulated. After iodinated-contrast we observed a progressive, inhomogeneous enhancement without evidence of active bleeding and with pre-operative diagnosis of adrenal hemangioma. Laparoscopic adrenalectomy was performed by a transperitoneal flank approach. Pathological examination revealed a 11cm adrenal mass with extensive central necrotic areas mixed to sinusoidal dilation and fibrotic septa. Postoperative diagnosis was adrenal hemangioma. DISCUSSION: Adrenal hemangiomas occur infrequently. Generally these adrenal masses are non-functioning and there is no specific symptoms. Recent records demonstrate that laparoscopic adrenalectomy is technically safe and feasible for large adrenal tumors, but controversy exists in cases of suspected malignancy. We choose laparoscopic approach to adrenal gland on the basis of preoperative CT abdominal scan that excludes radiological signs of adrenocortical carcinoma (ACC) such as peri-adrenal infiltration and vascular invasion. CONCLUSION: Laparoscopic adrenalectomy is considered the standard treatment in case of diagnosis of benign lesions. In this case report we discussed a large adrenal cavernous hemangioma treated with laparoscopic approach. Fundamental is the study of preoperative endocrine disorders and radiologic findings to exclude signs of malignancy.

Laparoscopic adrenalectomy for large adrenal masses: single team experience.

INTRODUCTION: Laparoscopic adrenalectomy is today considered the standard treatment for benign small adrenal tumors. An open question is the use of laparoscopy for large adrenal masses because of technical limitations and increased risk of malignancy. In this study we report our experience in laparoscopic adrenalectomy for adrenal masses larger than 6 cm. METHODS: Between January 2010 and December 2013 we performed 41 laparoscopic adrenalectomy. Fourteen of 41 patients (34,1%) were submitted to laparoscopic adrenalectomy for lesion >6 cm in size. All patients were submitted routinely to radiological and hormonal tests to indentify tumors characteristics. RESULTS: The patients treated were 9 male and 5 female, the mean age was 55.6 years (range 38-74). The mean tumor size was 8.2 cm (range 6-14 cm) and the lesion were localized on right side in 8 patients and on the left side in 6 patients. The mean operative time was 181 min (range 145-240 min). Mean blood loss was 90 ml. No conversion to open surgery was required. CONCLUSION: Laparoscopic adrenalectomy offers better surgical outcomes than open adrenalectomy. Size criteria are, at the moment, the main subject discussed for the laparoscopic approach to adrenal tumors. In fact, size is an important variable in predicting malignancy. This experience and the results of literature suggest that laparoscopic approach is safe and feasible for adrenal masses larger than 6 cm with a longer operative time. In presence of local invasion or vascular infiltration laparoscopy is contraindicated.

Endoscopic sclerotherapy for hemostasis of acute esophageal variceal bleeding.

INTRODUCTION: Currently the most widely used methods for endoscopic control of esophageal varices bleeding are sclerotherapy and rubber band ligation. Although the superiority of band ligation (BL) over endoscopic sclerotherapy (SCL) for the secondary prophylaxis of variceal hemorrhage has been proven, the best approach for acute bleeding remains controversial. PATIENTS AND METHODS: We performed a retrospective study between January 2005 and May 2013. We selected 104 patients with gastrointestinal hemorrhage from rupture of esophageal varices treated with endoscopic sclerotherapy. The sclerosing agent used was 1% polidocanol in 89 cases, butyl-cyanoacrylate in 8 cases and sodium tetradecylsulfate in 4 cases. In 3 cases had not been carried sclerosis because it was not possible to identify the bleeding site. RESULTS: Among the 101 patients who underwent endoscopic sclerotherapy 4 presented re-bleeding within 12 hours from first treatment. Other 10 patients (9.9%) presented re-bleeding within a 5-days period. The most frequent complication was ulceration, observed in 4 cases (3.8%). There was only one case of perforation treated conservatively. CONCLUSIONS: The general improvement in the results of the treatment of variceal acute bleeding might be attributed to better clinical management of these patients. In literature no consensus exists regarding the preferred endoscopic treatment. To date, there is no single method applicable to all patients with bleeding esophageal varices, but sclerotherapy is considered effective, safe and repeatable in experienced hands.

Laparoscopic, three-port and SILS cholecystectomy: a retrospective study.

INTRODUCTION: The aim of this study was to compare the results of classic laparoscopic, three-port and SILS cholecystectomy. MATERIALS AND METHODS: We conducted a retrospective study of data collected between January 2010 and December 2012 pertaining to 159 selected patients with symptomatic gallstones. 57 underwent laparoscopic cholecystectomy, 51 three-port cholecystectomy and 48 SILS cholecystectomy. We then compared the groups with respect to mean operating time, intraoperative complications, postoperative pain, duration of hospitalization and final aesthetic result. RESULTS: The mean operating time was significantly higher in the SILS cholecystectomy group (93 minutes) than in the other two groups. There were no intraoperative complications. There were no significant differences in the duration of hospitalization among the three groups. Patients in the SILS cholecystectomy group reported significantly less pain 3, 6 and 12 hours after surgery. The aesthetic results at 1 and 6 months' follow-up were also decidedly better. CONCLUSIONS: On the basis of this study, SILS cholecystectomy is a feasible, safe procedure. In any case, it should be used in selected patients only and carried out by a dedicated team with strong experience in laparoscopy. The main advantages of this technique are a reduction in post-operative pain and improved aesthetic result, at the price, however, of its greater technical difficulty and longer operating times. Future studies are in any case necessary to evaluate any other benefits of this method.