Dario Tartaglia

Acute abdomen caused by greater omentum torsion: A case report and review of the literature. Omentum majus torsiyonunun neden olduğu akut batın: Olgu raporu ve literatürün gözden geçirilmesi

Torsion of the greater omentum is a rare cause of acute abdomen. Based on etiopathogenesis, it can be classified as primary or secondary. However, regardless of the cause, segmentary or diffuse omental necrosis will follow. Preoperative diagnosis is not easy, though abdominal ultrasound and computed tomography (CT) scans may show peculiar features suggestive of omental torsion. Laparoscopic resection of the affected omentum is the treatment of choice. Presently reported was a case of primary omental torsion, in addition to a comprehensive literature review.

Adenocarcinoma on j-pouch after proctocolectomy for ulcerative colitis-case report and review of literature.

Dear Editor: Pouch adenocarcinoma following restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) has been reported and reviewed [1]. Ileal pouchanal reconstruction was introduced for the first time in 1978 by Parks and Nicholls; it is accepted as a standard surgical procedure following total proctocolectomy for ulcerative colitis (UC). With very low mortality and acceptable morbidity, it has largely replaced the permanent ileostomy in these patients. IPAAmay be performed either with a mucosectomy and handsewn anastomosis or with an entirely stapled anastomosis. The onset of an adenocarcinoma in the small residual rectal stump or in the ileal pouch after surgery for UC is a rare occurrence, being that there has been only a few cases reported in the literature. An association of backwash ileitis and chronic pouchitis with pouch cancer has been described [2]. We are presenting here a case of a poorly differentiated mucinous adenocarcinoma of the pouch following 13 years after IPAA for UC with entirely stapled anastomosis, and we have reviewed all the previous experiences in the published literature searching online databases PubMed and Medline. Only indexed published articles were included. The following search terms were used: adenocarcinoma, ileal pouch, restorative proctocolectomy, ulcerative rectocolitis. The patient was a 75-year-old male with a history of ulcerative colitis, diagnosed at age 52, who presented with change in bowel habits with alternating diarrhea and constipation. Because of chronic disease activity and inability to taper high-dose corticosteroids, the patient, at the age of 61 (1999 at our department), underwent total proctocolectomy with ileal pouch-anal anastomosis. This operation consisted of abdominal colectomy, proctectomy in blockwith the meso-rectum up to the plane of the elevators, formation of a j-pouch ileoanal reservoir with stapler, and circumferential ileoanal anastomosis with stapler. The pathology revealed pancolitis, in the absence of other pathological findings. A proximal diverting loop ileostomy was constructed, which was closed 20 weeks later. This patient was evaluated by a gastroenterologist every 3 months for the first year and then every 6 months for the second year. The patient underwent yearly pouchoscopy with no documented episodes of pouchitis, and no biopsies were taken during the first 6 year of follow-up. From 2005, the patient presented with anal pain and diarrhea, and therefore has performed several colonoscopies documenting pouchitis, and the biopsies always proved positive for “inflammation compatible with IBD in phase of activity.” Despite treatment with local and oral antiinflammatory therapy, the patient reported frequent emissions of liquid stools and anal pain. Subsequently, he was treated also with monoclonal antibodies therapy (infliximab), without good response. Endoscopic control in September 2012 showed pouchitis and two perianastomotic pseudopolyps, and the biopsy performed on one of these polyps showed “inflammation and low-grade dysplasia.” The patient underwent a new endoscopic control with biopsies in December 2012 documenting regular anastomosis and persistence of hyperemic and friable mucosa with numerous erosion upstream of the anastomosis and on the side walls with the presence of two pseudopolyps. The biopsy performed M. Luca : P. Matteo : T. Dario (*) :G. Simone :D. C. Giulio : M. Franco General Surgery Unit, Department of Oncology Transplantation and New Technologies, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy e-mail: dario261184@gmail.comDear Editor: Pouch adenocarcinoma following restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) has been reported and reviewed [1]. Ileal pouchanal reconstruction was introduced for the first time in 1978 by Parks and Nicholls; it is accepted as a standard surgical procedure following total proctocolectomy for ulcerative colitis (UC). With very low mortality and acceptable morbidity, it has largely replaced the permanent ileostomy in these patients. IPAAmay be performed either with a mucosectomy and handsewn anastomosis or with an entirely stapled anastomosis. The onset of an adenocarcinoma in the small residual rectal stump or in the ileal pouch after surgery for UC is a rare occurrence, being that there has been only a few cases reported in the literature. An association of backwash ileitis and chronic pouchitis with pouch cancer has been described [2]. We are presenting here a case of a poorly differentiated mucinous adenocarcinoma of the pouch following 13 years after IPAA for UC with entirely stapled anastomosis, and we have reviewed all the previous experiences in the published literature searching online databases PubMed and Medline. Only indexed published articles were included. The following search terms were used: adenocarcinoma, ileal pouch, restorative proctocolectomy, ulcerative rectocolitis. The patient was a 75-year-old male with a history of ulcerative colitis, diagnosed at age 52, who presented with change in bowel habits with alternating diarrhea and constipation. Because of chronic disease activity and inability to taper high-dose corticosteroids, the patient, at the age of 61 (1999 at our department), underwent total proctocolectomy with ileal pouch-anal anastomosis. This operation consisted of abdominal colectomy, proctectomy in blockwith the meso-rectum up to the plane of the elevators, formation of a j-pouch ileoanal reservoir with stapler, and circumferential ileoanal anastomosis with stapler. The pathology revealed pancolitis, in the absence of other pathological findings. A proximal diverting loop ileostomy was constructed, which was closed 20 weeks later. This patient was evaluated by a gastroenterologist every 3 months for the first year and then every 6 months for the second year. The patient underwent yearly pouchoscopy with no documented episodes of pouchitis, and no biopsies were taken during the first 6 year of follow-up. From 2005, the patient presented with anal pain and diarrhea, and therefore has performed several colonoscopies documenting pouchitis, and the biopsies always proved positive for “inflammation compatible with IBD in phase of activity.” Despite treatment with local and oral antiinflammatory therapy, the patient reported frequent emissions of liquid stools and anal pain. Subsequently, he was treated also with monoclonal antibodies therapy (infliximab), without good response. Endoscopic control in September 2012 showed pouchitis and two perianastomotic pseudopolyps, and the biopsy performed on one of these polyps showed “inflammation and low-grade dysplasia.” The patient underwent a new endoscopic control with biopsies in December 2012 documenting regular anastomosis and persistence of hyperemic and friable mucosa with numerous erosion upstream of the anastomosis and on the side walls with the presence of two pseudopolyps. The biopsy performed M. Luca : P. Matteo : T. Dario (*) :G. Simone :D. C. Giulio : M. Franco General Surgery Unit, Department of Oncology Transplantation and New Technologies, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy e-mail: dario261184@gmail.com

Primary retroperitoneal müllerian adenocarcinoma: a case report and literature review.

Primary retroperitoneal müllerian adenocarcinoma (PRMA) is an extremely rare clinical entity. We report the case of a 54-year-old woman who presented with a mass in the right lower retroperitoneum, identified during an ultrasound exam. Computed tomography confirmed a retroperitoneal mass measuring 11 cm. The patient underwent laparotomy and the mass was completely excised. The histopathological exam revealed PRMA.

Less is more: an outcome assessment of patients operated for gallstone ileus without fistula treatment

Highlights • In this study, 1.9% patients were diagnosed with gallstone ileus among those admitted for small bowel obstruction.• 85% of them underwent a conservative surgical approach mainly consisting in the enterolithotomy.• Only one complication exceeded grade II in each group and no deaths were reported.• Mean follow-up was 50 months and only one patient without fistula treatment had recurrent disease; no gallbladder cancer were identified.• Enterolithotomy without fistula closure proved to be safe and effective for the management of gallstone ileus both on a short and long-term basis.

Perfore apandisitte pulmoner sekestrasyonun neden olduğu hemoptizi: Seyrek görülen bir olgunun raporu

Pulmonary sequestration is a rare and usually asymptomatic congenital anomaly. Optimal management of this condition is still a subject of debate, including superiority of surgical resection or angiographic embolization of the aberrant arterial vessel. Presently described is rare case of a 51-year-old male who presented with hemoptysis related to pulmonary sequestration associated with acute right lower quadrant abdominal pain caused by perforated appendicitis.

Long-term, low-dose tigecycline to treat relapsing bloodstream infection due to KPC-producing Klebsiella pneumoniae after major hepatic surgery

A 68-year-old male underwent a right hepatectomy, resection of the biliary convergence, and a left hepatic jejunostomy for a Klatskin tumour. The postoperative course was complicated by biliary abscesses with relapsing bloodstream infections due to Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae (KPC-Kp). A 2-week course of combination antibiotic therapy failed to provide source control and the bacteraemia relapsed. Success was obtained with a regimen of tigecycline 100mg daily for 2 months, followed by tigecycline 50mg daily for 6 months, then 50mg every 48h for 3 months. No side effects were reported.

Ninety-Percent Distal Pancreatectomy

Context Brittle diabetes typically plagues the quality of life of patients after total pancreatectomy. Sparing even a small amount of endocrine tissue avoids extreme glycemic fluctuations, by maintaining a source of servo-regulated endogenous production of all pancreatic hormones (insulin, glucagon, somatostatin and pancreatic polypeptide). Objective We report on the outcome of a selected group of patients undergoing ninety-percent distal pancreatectomy (90% DP). Methods From April 2000 to May 2012, 90% DP was performed in 26 patients: 7 males (27%) and 19 females (73%), with a mean age of 68 years (range 40-79 years). Twenty-three patients underwent conventional open resection while 3 had a laparoscopic operation (robot-assisted in 2 of them). Splenectomy was associated in 24 patients (92%), while 2 had a multivisceral resection. Segmental resection of peripancreatic vessels was associated in 4 patients (1 celiac trunk-hepatic artery, and 3 superior mesenteric/portal vein). Results Seventeen patients were diagnosed with ductal adenocarcinoma (65%), 3 with well-differentiated endocrine tumor (12%), 3 with a serous cystadenoma, 1 with a mucinous cystadenocarcinoma (4%), 1 with carcinoma on IPMN, and 1 patient with chronic pancreatitis. Mean operative-time was 330 minutes (range 180-535 minutes). There was no post-operative mortality with a morbidity of 40%. Pancreatic fistula was recorded in 8 patients (32%) and was always managed conservatively. Thirteen patients developed insulin dependent diabetes mellitus (50%) and 16 developed exocrine insufficiency (61%) requiring enzyme supplementation. Conclusions 90% DP may be considered in patients with centrally located pancreatic lesions to avoid the complications due to pancreatic exocrine and endocrine insufficiency. In selected patients 90% DP may be performed laparoscopically, especially if robotic assistance is available. Careful patient selection and extended experience in pancreatic surgery are crucial to achieve the best results.