Laparoscopic adrenalectomy for a giant adrenal myelolipoma: A case report.

CASE PRESENTATION: We describe a case of a patient who presented with a mildly symptomatic, giant myelolipoma which was excised by laparoscopic approach without complications. INTRODUCTION AND IMPORTANCE: Adrenal myelolipoma (AML) is a rare tumour composed by fat and myeloid tissues. Usually it is asymptomatic, so the diagnosis is mostly incidental. It is generally located in the right adrenal gland, but it can also be found bilaterally. If its size exceeds 10 cm it is defined as a "giant myelolipoma"; in this case its treatment of choice would be adrenalectomy with an open surgical approach. CLINICAL DISCUSSION: Patient's signs and symptoms were mild pain in the right hypochondrium and a positive right Giordano's sign. The mass was detected by a contrast-enhanced CT scan. Once excised it measured 16 cm. CONCLUSION: Laparoscopic adrenalectomy for giant myelolipoma is a safe approach if performed by an expert surgeon, with low risk of bleeding and a better outcome for the patient.

Percutaneous and surgical treatment of pyogenic liver abscesses: observation over a 21-year period in 148 patients.

BACKGROUND: Percutaneous drainage of pyogenic liver abscess has become first-line treatment. In the past surgical drainage was preferred in some centres. AIM: The aim of this retrospective study was to assess the effectiveness of percutaneous treatments and surgical drainage, in terms of treatment success, hospital stay and costs. PATIENTS: Data of 148 patients (90 males; 58 females; mean age, 61 yrs; range, 30-86 yrs) were retrospectively analysed. METHODS: Patients' outcomes, including the length of hospital stay, procedure-related complications, treatment failure and death, were recorded. Multiple logistic regression model was used for statistical analysis. RESULTS: One hundred and four patients (83 with solitary and 21 with multiple abscesses) were treated percutaneously, either by needle aspiration (91 patients) or catheter drainage (13 patients) depending on the abscess's size, and 44 patients (30 with solitary and 14 with multiple abscesses) were treated surgically. There was no statistically significant difference in patients' demographics or abscess characteristics between groups. Hospital stay was longer, and costs were higher in patients treated surgically (p<0.001). There was statistically significant difference in morbidity rate between groups (p<0.001). No death occurred in both groups. CONCLUSIONS: Percutaneous and surgical treatment of pyogenic liver abscesses are both effective, nevertheless percutaneous drainage carries lower morbidity and is cheaper.

Bilateral inguinal hernia with dislocation of great saphenous vein as complication of long-standing granulomatous slack skin: a case report.

Granulomatous slack skin (GSS) represents a rare variant of mycosis fungoides, histologically characterized by a variably deep T helper lymphocytes infiltrate with alteration of the dermal elastic tissue and consequent elastolysis, elastophagocytosis and numerous giant cells. Clinically, a development of unelastic, slack skin, especially on flexural areas, is observed. Hereby, we describe a man with a 12-year history of GSS. In 2002, for practical (limitation of movement, deambulation) and cosmetic reasons, he underwent the surgical excision of loose and sagging skinfold over inguinal area, and, afterwards, of the opposite affected inguinal skin. The surgical treatment of bilateral inguinal hernia with reposition of inguinal dislocated vasculature is also reported. In both cases the excised material confirmed the former diagnosis of GSS and revealed a very deep, muscular infiltrate of neoplastic lymphocytes. One year later, a new excision of GSS on the axillae was made. Now, after 2 years, deambulation keeps improving, although an initial relapse of the inguinal slack skin has been observed.

Oral butyrate for mildly to moderately active Crohn's disease.

BACKGROUND: Butyrate exerts anti-inflammatory effects in experimental colitis and on Crohn's disease lamina propria mononuclear cells in vitro. AIM: To explore the efficacy and safety of oral butyrate in Crohn's disease. METHODS: Thirteen patients with mild-moderate ileocolonic Crohn's disease received 4 g/day butyrate as enteric-coated tablets for 8 weeks. Full colonoscopy and ileoscopy were performed before and after treatment. Endoscopical and histological score, laboratory data, Crohn's disease activity index and mucosal interleukin (IL)-1beta, IL-6, IL-12, interferon-gamma, tumour necrosis factor-alpha and nuclear factor-kappa B (NF-kappaB) were assessed before and after treatment. RESULTS: One patient withdrew from the study, and three patients did not experience clinical improvement. Among the nine patients (69%) who responded to treatment, seven (53%) achieved remission and two had a partial response. Endoscopical and histological score significantly improved after treatment at ileocaecal level (P < 0.05). Leucocyte blood count, erythrocyte sedimentation rate and mucosal levels of NF-kappaB and IL-1beta significantly decreased after treatment (P < 0.05). CONCLUSIONS: Oral butyrate is safe and well tolerated, and may be effective in inducing clinical improvement/remission in Crohn's disease. These data indicate the need for a large investigation to extend the present findings, and suggest that butyrate may exert its action through downregulation of NF-kappaB and IL-1beta.

Intestinal perforation as a long-term complication of plug and mesh inguinal hernioplasty: case report.

Tension-free and sutureless hernioplasty by plug and mesh of nonreabsorbable material is one of the most common techniques for inguinal hernia repair. It's a simple and quick procedure with a low cost and allows for a short hospital stay. It shows a low reoccurrence rate, but it can result, in very few cases, in complications strictly related to prosthetic material. The literature describes some cases of plug migration from its proper position, for example, to the scrotum, preperitoneal adipose tissue, and abdominal cavity. We report on a case of sigmoid colon perforation due to a plug of Trabucco hernioplasty performed 2 years previously.

Immunoglobulin M memory B cell decrease in inflammatory bowel disease.

BACKGROUND & OBJECTIVES: Memory B cells represent 30-60% of the B cell pool and can be subdivided in IgM memory and switched memory. IgM memory B cells differ from switched because they express IgM and their frequency may vary from 20-50% of the total memory pool. Switched memory express IgG, IgA or IgE and lack surface expression of IgM and IgD. Switched memory B cells derive from the germinal centres, whereas IgM memory B cells, which require the spleen for their survival and/or generation, are involved in the immune response to encapsulated bacteria. Since infections are one of the most frequent comorbid conditions in inflammatory bowel disease, we aimed to verify whether IgM memory B cell pool was decreased in Crohn's disease and ulcerative colitis patients. PATIENTS & METHODS: Peripheral blood samples were obtained from 22 Crohn's disease patients, 20 ulcerative colitis patients, 22 healthy controls and 18 splenectomized patients. To analyse peripheral blood lymphocytes, flow cytometry was performed using anti-CD19, anti-CD22, anti-CD27, anti-IgM, anti-IgD and anti-CD38 monoclonal antibodies. RESULTS: Circulating IgM memory B cells were significantly lower in Crohn's disease (median 7.1%, range 1.8-20.7) and ulcerative colitis patients (median 8.1%, range 2.1-18.8) in comparison to control subjects (median 14.0%, range 6.8-31.1). As expected, there was a highly significant difference in the proportion of IgM memory B cells between splenectomized patients (median 2.4%, range 0.9-6.9) and healthy controls. Crohn's disease patients with abscesses showed the lowest frequency of IgM memory B cells. DISCUSSION: Our findings show that peripheral IgM memory B cells are reduced in inflammatory bowel disease patients. Further studies are necessary to answer the question of whether high risk of infection (abscess development) is promoted by the reduction/depletion of IgM memory B-cell pool in inflammatory bowel disease.

Radioguided surgery for gastrinoma: a case report.

AIMS AND BACKGROUND: Gastrinomas are the most common neuroendocrine tumors of the duodenopancreatic region. Surgical resection is the primary type of radical treatment. METHODS AND STUDY DESIGN: At the Institute of General, Gastrointestinal and Breast Surgery we treated a patient with a duodenal gastrinoma that was diagnosed and localized by means of selective celiac-mesenteric angiography and labelled octreotide scintigraphy. Surgery was performed using a radioguided technique; in this way we easily detected the small tumor and discovered another tracer-uptaking lesion that turned out to be a metastatic lymph node. RESULTS: Surgical resection is the ideal treatment for sporadic gastrinoma: it improves quality of life, prolongs survival, and reduces the incidence of metastases, with a modest percentage of complications and practically zero mortality. Meanwhile, medical treatment is being reevaluated, particularly in the case of metastatic disease or polyendocrine MEN1 syndrome. A fundamental aspect in the management of gastrinomas is tumor localization. Endoscopic ultrasonography and labeled octreotide scintigraphy (Ostreoscan) proved to be more effective than the usual imaging modalities. Intraoperative ultrasonography gastroscopy for duodenal transillumination and repeated measurement of blood gastrin levels should be performed intraoperatively in the surgical treatment of gastrinomas. CONCLUSIONS: The clinical application of radioguided surgery for tracer-uptaking endocrine tumors is still controversial. In our case the decision to use this method was influenced by the fear that the patient's obesity and the effects of previous surgery could hamper the identification of the small tumor.

[Clinical and functional results after restorative proctocolectomy with ileal J reservoir in the treatment of ulcerative colitis]. / Risultati clinici e funzionali dopo proctocolectomia restaurativa con serbatoio ileale a J nel trattamento della colite ulcerosa.

PURPOSE: Restorative proctocolectomy is the procedure of choice in the treatment of ulcerative colitis. The operation is successful in removing all diseased mucosa while preserving a normal bowel function and a good quality of life for the patient. In this article are presented the clinical and functional results obtained in 28 patients, 19 males (68%) and 9 females (32%) after stapled restorative proctocolectomy with ileal J pouch-anal anastomosis. RESULTS: There were no perioperative deaths. The overall morbidity rate was 31%. Six patients (21%) presented pelvic abscess; 2 (7%) pelvic hematoma, 4 patients (14%) ileo-anal anastomotic stricture, 1 patient (3.6%) pouch-vagina fistula, three patients (11%) intestinal obstruction and 7 (25%) pouchitis. All patients were able to evacuate their pouches spontaneously. The mean bowel movements were 6-9/24 hours at the first postoperative month and 3-5/24 hours at the sixth month. Infrequent nocturnal seepage occurred in 6 patients (21%). Stool consistency returned to normal within 3-6 months. The mean pouch capacity was 210 cc. The mean resting pressure was diminished in 11 patients (39%), the men and maximal squeeze pressures were improved in 9 (32%); the ileo-rectal-anal inhibitory reflex was normal in 5 patients (18%), not defined in 12 (43%). Impotence or impaired bladder function was not present. CONCLUSION: The use of staplers in the surgical technique of restorative proctocolectomy with J shaped ileo-anal pouch is associated with low morbidity and better long-term results. The procedure requires a good selection of patients, a correct surgical timing, a very carefully technique and a low pre and postoperative treatment with steroids.

[Aspects of the complications after restorative proctocolectomy in the treatment of ulcerative colitis. Review of the literature and personal experience]. / Aspetti delle complicanze dopo proctocolectomia restaurativa nel trattamento della colite ulcerosa. Revisione della letteratura ed esperienza personale.

PURPOSE: Analysis of complications and causes of failure after stapled restorative proctocolectomy with ileal J pouchanal anastomosis in patients with ulcerative colitis is presented. PATIENTS AND METHODS: The procedure was performed in 28 patients, 19 males (68%) and 9 females (32%); diverting ileostomy was always performed. RESULTS: There was no perioperative mortality. The overall morbidity rate was 31%. Six patients (21%) had pelvic abscess, 2 (7%) pelvic hematoma, 4 patients (14%) presented ileo-anal anastomotic stricture, 1 patient (3.6%) had pouch-vaginal fistula, three patients (11%) presented intestinal obstruction and 7 (25%) pouchitis. Reoperation was necessary in patients with small bowel obstruction and with pouch-vaginal fistula. Septic complications and pouchitis were resolved with medical treatment. Stenosis of the anastomosis required anal dilation. No patient underwent pouch excision for pouch failure. CONCLUSION: The main significant complications of ileal pouch-anal anastomosis for ulcerative colitis were pelvic sepsis, intestinal obstruction and pouchitis. Our results suggest that the use of stapling technique is safer and has fewer early septic complications and sepsis-related pouch removals. Success in ileo-anal construction increases with experience. The selection of patients with exclusion of Crohn disease, a correct surgical timing, a carefully technique, a delayed ileostomy closure and a low pre and postoperative regimen of steroids are important factors of success.

[Aneurysms of the visceral arteries: report of 5 cases]. / Gli aneurismi delle arterie viscerali: presentazione di cinque casi.

Visceral artery aneurysms are uncommon and usually result from atherosclerosis, periarteritis nodosa and fibromuscular dysplasia. Hepatic artery aneurysms were detected in two patient, splenic artery aneurysms in three. In four patients rupture occurred. In the two patients with hepatic artery aneurysm hemobilia from arterial rupture into the common bile duct and intraperitoneal bleeding in lesser sac was assessed. Ruptured aneurysms of the splenic artery with free intraperitoneal bleeding occurred in two patients, one patient had an asymptomatic splenic artery aneurysm. In four patients the diagnosis was made by contrast-TC and/or celiac and mesenteric angiography. In four patients excision of the aneurysm was successfully performed. One patient with ruptured hepatic artery aneurysm and in which resection and revascularization was made died.

[Short bowel syndrome: etiologic, pathogenetic aspects and principles of treatment]. / La sindrome da intestino corto: considerazioni etio-patogenetiche e principi di trattamento.

A significant problem in surgery following massive intestinal resection is the short bowel syndrome characterized by severe fluid and electrolyte loss, watery diarrhoea and malnutrition. Total parenteral nutrition and enteral nutrition are essential in the clinical course of the syndrome; their use for prolonged periods results in the gradual intestinal adaptation and greater absorptive and reservoir capacities of the intestinal remnant. Adjunctive surgery can slow rapid intestinal transit and induce growth of neo-small-bowel mucosa but is not recommended for routine use. The early results of intestinal transplantation in the treatment of short bowel syndrome are encouraging. Furthermore chronic rejection and systemic sepsis with failure of the graft must be considered and indicate that at present this procedure cannot be offered to every patient but will be a potential form of therapy in future.