Gennaro Liguori

Gastric Wall Necrosis from Organo-axial Volvulus as a Late Complication of Laparoscopic Gastric Banding

We present a case of massive gastric wall necrosis associated with volvulus of the stomach occurring 17 months after laparoscopic gastric banding. The 19- year-old female was admitted to our hospital with acute abdominal pain with rapid deterioration from massive necrosis of a distended stomach which perforated distal to the gastric band, accompanied by splenic infarction. Total gastrectomy and spenectomy were required. We present this very rare complication which should be recognized and treated early, so that a less drastic operation is possible.

Sentinel lymph node mapping in the management of colorectal cancer: preliminary report.

Aim and background The problem of understaging the lymph node status in colorectal cancer because of missed micrometastases led authors to investigate the role of sentinel node (SN) mapping also in colorectal malignancies. The aim of this study was to evaluate the feasibility of the technique and to correlate the results with some characteristics of the primary tumor. Methods Sentinel lymph node mapping was performed in 23 patients who underwent a standard lymphadenectomy for colorectal cancer. The vital dye Patent Blue had been injected into the peritumoral subserosa in vivo in 17 cases and ex vivo in seven, including one case where the in vivo method did not allow to identify the sentinel node. The nodes that took up the dye were removed and analyzed with standard hematoxylin-eosin staining in serial sections. Immunohistochemistry (AE1-AE3 cytokeratin markers) was performed in hematoxylin-eosin-negative nodes. SN status was related to the status of the other lymph nodes in the surgical specimen analyzed with the standard technique and to the following characteristics of the primary tumor: stage, grade and diameter. Results The in vivo technique allowed to identify the SN in 16/17 cases (94.1%), the ex vivo technique in 7/7. A total of 336 lymph nodes dissected from the surgical specimens was analyzed, with an average of 14.6 nodes per patient (range, 7-35). Of these nodes 58 were SNs, with an average of 2.5 nodes per patient (range, 1-8). In the 19 cases where the SN was tumor negative, the non-SNs were also negative (specificity: 100%), whereas in the four cases where the non-SNs were positive, in two cases the SN was positive and in two cases of pT3 rectal carcinoma the SN was negative (sensitivity: 50%). Immunohistochemistry did not modify the negative results of the standard hematoxylin-eosin evaluation. Conclusions The method used to identify the SN using vital dye proved to be easy to use both in vivo and ex vivo and allowed to identify the SN in all cases. The preliminary results indicate that there is a risk of false negative findings and therefore further studies are required to improve the sensitivity and the specificity of the technique and to evaluate the role of SN mapping in colorectal cancer management.

Minimally invasive video-assisted parathyroidectomy. Initial experience in a General Surgery Department

Background: The aim of this study is to analyze our preliminary results from minimally invasive video-assisted parathyroidectomy (MIVAP) and demonstrate the feasibility of MIVAP also in non-referral centers. Material and methods: During a period from June 2005 to January 2008, in the General Surgery Department of University of Trieste, we operated on 39 patients with primary hyperparathyroidism (pHPT). MIVAP by an anterior approach was proposed for 23 (59%) patients with sporadic pHPT and one unequivocally enlarged parathyroid gland on pre-operative ultrasound and 99mTc-SestaMIBI scintigraphy without associated goiter and without previous neck surgery. Intra-operatively, a quick parathyroid assay was used during the last 11 surgical procedures. All patients underwent pre-operative and post-operative investigations of calcemia, phoshoremia and PTH levels and vocal cord function. Age, operative times, pathologic findings, post-operative pain, calcemia, length of hospital stay, cosmetic results, and complications were retrospectively analyzed. Results: MIVAP was successfully accomplished in 22 cases. Conversion to standard cervicotomy was required in one patient (4.34%). Mean operative time was 67 min. Post-operative complications included 1 (4.34%) transient hypocalcemia. No laryngeal nerve palsies, no definitive hypocalcemias, no persistent pHPT and no recurrent pHPT were observed. The cosmetic result was excellent in all cases. Conclusions: Our preliminary results demonstrate that MIVAP for localized single-gland adenoma, after adequate training, seems to be feasible with significant advantages, especially in terms of cosmetic results, post-operative pain, and post-operative recovery even in a General Surgery Department, if performed by a dedicated team, with a sufficient and specific activity volume.

Primary bilateral adrenal non-Hodgkin's Burkitt-like lymphoma: a rare cause of primary adrenal insufficiency. Case report and literature review.

Aims and background Primary bilateral adrenal non-Hodgkins lymphoma is an extremely rare entity. Only 44 cases have been reported in the literature. The most common presenting symptoms are abdominal pain, fever, asthenia, constipation, weight loss or typical symptoms of adrenal insufficiency, hypertension, darkening of skin, orthostatic hypotension or an addisonian crisis. Methods The case is presented of a 57-year-old man suffering from primary bilateral adrenal lymphoma with symptoms of adrenal insufficiency syndrome associated with bilateral, stabbing lumbar pain and a palpable mass on the left side. Laboratory tests revealed a considerable increase in lactate dehydrogenase levels, adrenal insufficiency, and high corticotropin levels. Results Abdominal CT scan showed two large adrenal masses. A CT-guided fine needle aspiration biopsy revealed a large B-cell non-Hodgkins lymphoma. Combination chemotherapy according to the CHOP protocol with cyclophosphamide, doxorubicin, vincristine and prednisolone was initiated, which caused a slight reduction in size of the two adrenal masses. The patient underwent a bilateral adrenalectomy with almost complete excision of the tumors. Replacement therapy with cortisone acetate was initiated postoperatively. Adjuvant combination chemotherapy according to the CHOP protocol was started but renal failure gradually emerged and the treatment could not be completed. The patient died seven months after surgery due to acute bronchial pneumonia and progression of disease. Conclusions Primary bilateral adrenal non-Hodgkins lymphoma mainly affects adult men. Diagnosis is based on histological examination. Whether associated or not with radiotherapy, chemotherapy is the most recommended treatment. Surgery, where possible, seems to lead to an increase in survival rates, but it is not possible to draw any definite conclusions on its effectiveness as yet.

Idiopathic mesenteric venous thrombosis: Report of a case ☆

INTRODUCTION Idiopathic mesenteric venous thrombosis is a rare entity. An early diagnosis and thrombolytic and anticoagulant therapy are very important. PATIENT AND METHODS We report a case of a patient, without any specific known risk factor, with small intestinal ischemia secondary to superior mesenteric vein thrombosis (SMVT). RESULTS In our case, only a computed tomography (CT) abdominal scan permitted the diagnosis of SMVT. The patient was successfully treated by resection of the infarcted bowel with primary anastomosis and immediate postoperative anticoagulation. CONCLUSIONS Diagnosis of intestinal ischemia from mesenteric venous thrombosis (MVT) is often delayed because the symptoms are nonspecific. Moreover, when there is not any known predisposing factor, the diagnosis may become even more difficult with significant morbidity and mortality. CT abdominal scan done early in case of nonspecific abdominal pain, since the patients had a previous history of venous thrombosis, may not require a surgical treatment of MVT.

Case Report: Pancreatic Injury Following Blunt Abdominal Trauma during a Soccer Game

Abstract This article reports a case of unusual pancreatic trauma, underestimated initially and treated surgically at a later stage. A 26-year-old man presented with an abdominal trauma sustained during a soccer game. The patient arrived 24 hours after the trauma with abdominal pain associated to vomiting and intestinal occlusion. Laboratory tests revealed elevated serum amylase levels. An abdominal computed tomography (CT) scan showed a pancreatic parenchymal dishomogeneity at the passage between body and tail, highly suspicious for pancreatic full thickness laceration. Magnetic resonance pancreatography (MRP) demonstrated possible duct involvement. The patient was urgently submitted to distal pancreatectomy with splenectomy. This case demonstrates a rare mechanism of injury and the potential importance of serial CT scans in the diagnosis, grading, and management of isolated pancreatic injury.

Does the routine histological examination of the inferior mesenteric artery lymph nodes have a prognostic value in elderly patients with sigmoid colon and rectum tumors

The purpose of our study is to estimate the frequency of the histopathological exam, analyze the prognostic/therapeutic value of central LN examination and determine their advantage in elderly patients.

The treatment of bleeding peptic ulcer in the elderly

Background In the last decades the incidence of peptic ulcer disease (PUD) has increased especially in the elderly. Haemorrhage is the most frequent PUD complication and its incidence is increasing in comparison to perforation and stenosis. Therapeutic endoscopy is considered the treatment of choice for bleeding ulcers, reducing the need for emergent surgical procedures to 10–20% of the cases.