Domenico Russello

Catheter fracture and cardiac migration: a rare complication of totally implantable venous devices.

Totally implantable venous device (TIVD) are widely used for the treatment of patients requiring long‐term chemotherapy, total parenteral nutrition and fluid replacement. Until today, many kinds of complications have been reported in the literature. We report an unusual case of catheter fracture as a consequence of pinchoff syndrome, and discuss the potential methods to avoid this complication and its evolution. J. Surg. Oncol. 2000;73:172–173.

Simultaneous laparoendoscopic rendezvous for the treatment of cholecystocholedocholithiasis

BackgroundDifferent approaches are available for the treatment of combined cholecystocholedocholithiasis including totally laparoscopic (TL) treatment, simultaneous laparoendoscopic treatment, and sequential treatments (ST) combining endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) with cholecystectomy. This review aimed to clarify the issue of the simultaneous laparoendoscopic rendezvous (RV).MethodsA careful analysis of papers was performed to determine the results, technical differences, limits, disadvantages, and advantages of RV compared with other options.ResultsData were collected from 27 papers concerning 795 patients. The overall effectiveness of RV was 92.3%. The morbidity rate was 5.1%, and the mortality rate was 0.37%. Almost all the authors were satisfied with the procedure. The authors’ comparison to ST and TL showed that the advantages outweigh the disadvantages mostly related to logistical problems.ConclusionsThere is confusion concerning the definitions and techniques of RV due to differences in combining surgical and endoscopic steps of the procedure. The results are at least comparable with those of the other available approaches. The effectiveness of RV is greater with reciprocal implementation of surgical and endoscopic procedures. The morbidity and the risk of iatrogenic damage seem lower than with ERCP-ES and the risk of residual stones lower than with TL treatment. The RV procedure is safe and can sometimes be the preferable option, but collaboration between surgeon and endoscopist is mandatory.

Simultaneous occurrence of adenoma, focal nodular hyperplasia, and hemangioma of the liver: Are they derived from a common origin?

Abstract  The association between hepatic hemangioma (HH) and focal nodular hyperplasia (FNH) or the association between FNH and hepatic adenoma (HA) has been reported. The authors report a case in which FNH, HH, and HA simultaneously appear in the liver. A 25‐year‐old woman was admitted to the Department of Surgery of the University of Catania (Italy), after presenting pain in the right hypocondrium. No therapy with oral contraceptives, no pregnancy and no abnormalities of the laboratory tests were found. Ultrasonography and computed tomography scans revealed four masses with the characteristics of HH, HA, FNH, and a hydatid cyst located, respectively, in segments II, IV, IV, and V of the liver. The surgical procedures performed were hemangioma and adenoma enucleation and en bloc resection of the FNH, hydatid cyst and gallbladder. No complications were recorded in the postoperative period and the patient was discharged from the hospital after 1 week. A pathological examination confirmed the preoperative diagnosis. To the best of our knowledge, the association of HH, FNH, and HA has never been reported. A common pathogenesis has clearly been demonstrated for hepatocytes and other cell types. The simultaneous presence of these three different kinds of tumor suggest that HH, FNH and HA could be the different expression of the same malformative anomaly.

A new simple laparoscopic-extracorporeal technique for the repair of a Morgagni diaphragmatic hernia.

We used a new technique to treat a right-sided Morgagni hernia in a symptomatic adult with a transverse colon that was herniated in the chest. Three trocars were required. The herniated viscera were easily reduced in the abdomen, and the diaphragmatic border that was mobilized from the liver showed the elliptical diaphragmatic defect (9 x 5 cm); however, the hernial sac was not resected. Four transversal 1-cm cutaneous incisions were made just below the costal arch. Using a Reverdin needle holder, we introduced eight ligatures under laparoscopic control through the abdominal wall and through the free diaphragmatic border. Each suture was then held by the grasper and freed from the Reverdin. After the Reverdin was extracted and reintroduced more caudally, the intraabdominal suture was placed into it and finally extracted again. Before knotting, all the sutures were pulled together to achieve perfect closure of the defect. A suction drain was placed in the hernial sac. The duration of the procedure was 12 min. The patient was discharged on the 5th postoperative day. A review of 20 other patients treated via a video-assisted approach is also included here. We found this original technique to be extremely simple, rapid, and effective. It can also be performed by surgeons who are not specially trained in intracorporeal suturing and knotting and can probably also be used for the repair of other types of diaphragmatic defects. The use of laparoscopy and magnification allows the surgeon to achieve a better point of control for simpler solutions.

Adjusting CA19-9 values to predict malignancy in obstructive jaundice: Influence of bilirubin and C-reactive protein

AIM To find a possible relationship between inflammation and CA19-9 tumor marker by analyzing data from patients with benign jaundice (BJ) and malignant jaundice (MJ). METHODS All patients admitted for obstructive jaundice, in the period 2005-2009, were prospectively enrolled in the study, obtaining a total of 102 patients. On admission, all patients underwent complete standard blood test examinations including C-reactive protein (CRP), bilirubin, CA19-9. Patients were considered eligible for the study when they presented obstructive jaundice confirmed by instrumental examinations and increased serum bilirubin levels (total bilirubin > 2.0 mg/dL). The standard cut-off level for CA19-9 was 32 U/mL, whereas for CRP this was 1.5 mg/L. The CA19-9 level was adjusted by dividing it by the value of serum bilirubin or by the CRP value. The patients were divided into 2 groups, MJ and BJ, and after the adjustment a comparison between the 2 groups of patients was performed. Sensitivity, specificity and positive predictive values were calculated before and after the adjustment. RESULTS Of the 102 patients, 51 were affected by BJ and 51 by MJ. Pathologic CA19-9 levels were found in 71.7% of the patients. In the group of 51 BJ patients there were 29 (56.9%) males and 22 (43.1%) females with a median age of 66 years (range 24-96 years), whereas in the MJ group there were 24 (47%) males and 27 (53%) females, with a mean age of 70 years (range 30-92 years). Pathologic CA19-9 serum level was found in 82.3% of MJ. CRP levels were pathologic in 66.6% of the patients with BJ and in 49% with MJ. Bilirubin and CA19-9 average levels were significantly higher in MJ compared with BJ (P = 0.000 and P = 0.02), while the CRP level was significantly higher in BJ (P = 0.000). Considering a CA19-9 cut-off level of 32 U/mL, 82.3% in the MJ group and 54.9% in the BJ group were positive for CA19-9 (P = 0.002). A CA19-9 cut-off of 100 U/mL increases the difference between the two groups: 35.3% in BJ and 68.6% in MJ (P = 0.0007). Adjusting the CA19-9 value by dividing it by serum bilirubin level meant that 21.5% in the BJ and 49% in the MJ group remained with a positive CA19-9 value (P = 0.003), while adjusting the CA19-9 value by dividing it by serum CRP value meant that 31.4% in the BJ group and 76.5% in the MJ group still had a positive CA19-9 value (P = 0.000004). Sensitivity, specificity, positive predictive values of CA19-9 > 32 U/mL were 82.3%, 45% and 59.1%; when the cut-off was CA19-9 > 100 U/mL they were, respectively, 68.6%, 64.7% and 66%. When the CA19-9 value was adjusted by dividing it by the bilirubin or CRP values, these became 49%, 78.4%, 69.4% and 76.5%, 68.6%, 70.9%, respectively. CONCLUSION The present study proposes CRP as a new and useful correction factor to improve the diagnostic value of the CA19-9 tumor marker in patients with cholestatic jaundice.

Liver metastases from lung cancer: is surgical resection justified?

Resection of the liver for metastatic lesions has largely been done for secondary colorectal or neuroendocrine tumors, and there is little information of its value for other lesions. Recent improvements in hepatic surgery have made resection of metastases a safe procedure and it should certainly be considered whenever there is an isolated lesion. We report the case of a successful resection of an isolated secondary hepatic lesion from a lung primary tumor, which was resected approximately 4 years beforehand. A review of the literature demonstrates that although early reports of similar procedures were not favorable, more recent reports reinforce the value of an aggressive approach in favorable cases.

Isolated agenesis of the gallbladder: report of a case.

Abstract We report the rare case of an isolated gallbladder with cystic duct agenesis that was misdiagnosed as acute alithiasic cholecystitis. We underline the inaccuracy of currently used diagnostic tests and the importance of making a correct preoperative diagnosis to avoid a needless surgical procedure. Based on the rare and incidental nature of this congenital anomaly, we discourage an extensive routine diagnostic workup, but rather, suggest a careful clinical and diagnostic evaluation of the patient who has symptoms suggestive of biliary tract disease. We conclude that in patients with gallbladder and cystic duct agenesis surgery might be useless and risky when performed by the laparoscopic approach. On the other hand, the awareness of the laparoscopic surgeon of the problems posed by this anomaly and a careful review of currently available diagnostic tests can prevent unnecessary laparotomy and minimize the risk of complications.

Recurrent Aortoduodenal Fistula

Aortoenteric fistula is defined as a communication between the aorta and an adjacent loop of the bowel and is often the cause of devastating upper gastrointestinal tract bleeding with only few survivors. According to the etiology, the aortoenteric fistulas are classified as primary aortoenteric fistula or secondary aortoenteric fistula (SAEF) after previous aortic surgery. The recurrence of a fistula on a previous SAEF is defined as recurrent aortoenteric fistula and is reported only in a few rare cases occurring within an unpredictable period from the previous surgical treatment. We describe a unique case of recurrent aortoenteric fistula, in which the relationship with recurrence consisted of the presence of the metallic clips of a stapled suture to close the duodenal wall during the previous SAEF repair. A review of the published data on this subject was performed to analyze the clinical features, the overall results, the risk factors of recurrence, and the main technical points of surgical treatment to prevent it.

Laparoscopic implementation of the Altemeier procedure for recurrent rectal prolapse. Technical note

INTRODUCTION Many surgical options exist to treat rectal prolapse with different indications, feasibility and results in urgent and complicated cases. These include perineal or abdominal approaches including rectopexy with or without resection. Perineal approaches have reduced surgical invasivity and hospital stay if compared to transabdominal approaches by open surgery or laparoscopy. Up to now there was still a clear dividing line for surgical treatment between the perineal approach, used more for complicated emergency case while the transabdominal open, or laparoscopic approach more common in elective surgery, but more complex to perform. PRESENTATION OF CASE A 37 year old female patient affected by psychiatric disease presented with an unreducible second recurrence of a complicated rectal prolapse. The patient was treated with a third Altemeier procedure but now performed under laparoscopic control. The patient recovered promptly without any complication or recurrence up to the 24 months follow-up. DISCUSSION To the best of our knowledge, this is the first case report describing the combined laparoscopic-perineal approach for the treatment of a complicated recurrence of rectal prolapse. The technical feasibility, the rapidity, the optimal outcome and the rationale behind this option all suggest that this laparoscopic assistance certainly allows an implementation of the effectiveness, safety and results of an established effective perineal approach. CONCLUSION This combined approach has the advantage of maintaining the simplicity and rapidity of conventional perineal surgery, adding the advantages of abdominal control and avoiding the risks, the invasivity, and the longer duration of more complex laparoscopic procedures.

Laparoscopic resection of an abdominal wall desmoid using a modified suture traction technique: the "marionette trick".

Desmoids are rare mesenchimal tumors that may originate also inside the abdomen or in the abdominal wall. These tumors are biologically characterized by a tendency to local growth, and only rarely are they able to develop distant metastases. Surgical excision usually is the best treatment with a chance of a cure. In the few reports on intraabdominal or abdominal wall desmoids, open surgery always was performed. The first case of successful laparoscopic resection of a symptomatic anterior wall desmoid tumor with intraabdominal growth is reported. During the procedure, it was difficult to mobilize and grasp the mass using the common laparoscopic instruments, but with the help of the “marionette trick,” modified suture traction technique, the tumor could be removed easily using only three trocars. With four traction sutures minimizing the wall trauma, the trick made it possible to mobilize the mass in at least, seven directions, according to the principles of physical forces and vectors. This simple trick can be helpful for other common laparoscopic procedures, avoiding the insertion of sometimes ineffective instruments through more traumatic trocars.