Giovanni Colombo

Laparoscopic splenectomy using ligasure

Abstracts Background: Intraoperative bleeding is the main complication and main cause of conversion during laparoscopic splenectomy (LS). We present the advantages of the use of the Ligasure Vessel Sealing System added to lateral approach for achieving a safe vascular control. Methods: Ligasure is an energy-based device which works applying a precise amount of bipolar energy and pressure to the tissue, achieving a permanent seal. We have performed a total of 35 LS in a 5-year period using different approaches and methods of dissection, including the anterior approach, monopolar coagulation, clips, endostaplers, and ultrasonic shears. In the last 10 patients (4 males and 6 females, mean age 24 yr) we employed a technique with 4 trocars, right semilateral position associated with the entire dissection of the spleen and vessels sealing (lower pole vessels, main vascular pedicles, short gastric vessels) performed with Ligasure. Six had thrombocytopenic idiopatic purpura (ITP), 2 hereditary spherocytosis and one each b-thalassemia and hemolytic anemia. Results: Nine LS were completed with one (10%) conversion because of hilar bleeding due to accidental injury with Ligasure. The average splenic weight was 485 g (range 265–1800), with an average diameter of 16 cm (range 12–25). In all but one patients (the converted one) the intraoperative blood loss was less than 100 mL (range 50–100 mL, average 80 mL). No blood transfusion were needed. The average operative time was 120 min (range 90–165), including 2 patients undergoing combined laparoscopic cholecystectomy. There was no mortality, with one (10%) postoperative complication (thrombosis of the spleno-portal axis), treated with a conservative approach. The average postoperative hospital stay was 3.5 days (range 3–6). Conclusions: The use of Ligasure, associated with the lateral position, results in a gain of time and safety. Furthermore, the average intraoperative bleeding of this series is very low.

Laparoscopic versus open splenectomy: a comparative study.

Laparoscopic splenectomy (LS) is gaining wide acceptance as a safe, effective alternative to open splenectomy (OS) in the treatment of hematologic disorders in adult and pediatric patients, with low conversion rates and complications. The aim of this retrospective case-control study was to compare two cohorts of patients, with similar characteristics, who underwent OS or LS in a single institution. The medical records of the initial 20 consecutive patients who underwent LS were reviewed and compared with a control group of 28 patients undergoing OS, matched for age, gender, diagnosis, splenic size and weight, and American Society of Anesthesiologists score. Data were collected regarding operative time, blood loss, blood tranfusions, pathologic findings, accessory spleen detection, complications, ileus duration, and postoperative hospital stay. Nineteen patients underwent attempted LS. One procedure (5%) was converted to OS for uncontrolled hilar bleeding. Accessory spleens were detected in two cases in the LS group compared with four cases in the OS group (14%). Mean operative time was 165 minutes (range: 100–240 minutes) for LS and 114 minutes (75–180 minutes) for OS (P < 0.001). In the LS group a regular diet was tolerated 36 hours (range: 24–48 hours) after surgery compared with 72 hours (range: 48–96 hours) for the OS group (P < 0.001), and mean postoperative hospital stay was 4.1 days (range: 3–8 days) for LS, compared with 8.1 days (range: 5–12 days) for OS (P < 0.001). No differences were observed in blood loss, complication rates, or transfusion requirements. Compared with OS, LS requires more operative time (showing a learning curve), is comparable in blood loss, transfusion requirements, complication rates, and detection of accessory spleens and appears to be superior in terms of return of bowel function and hospital stay.

Monolateral severe eyelid erythema and edema as unique manifestation of lupus tumidus

A 38-year-old Caucasian otherwise healthy man was referred to the Department of Dermatology and the Department of Otorhinolaryngology during Spring for evaluation of a 3month history of persistent erythema and swelling of the lower and upper right eyelid (Fig. 1). The erythema worsened after sun exposure. The edema was soft and the skin, although erythematous, was of normal appearance. The conjunctiva was not inflamed and no limitation of ocular movements was present. Other skin findings were unremarkable. The patient was previously treated with topical and systemic antibiotics because a cellulite was suspected, without any improvement. Magnetic resonance imaging of the orbit showed edema of periorbital soft tissues. The results of laboratory studies, including antinuclear antibody titers, extractable nuclear antigen (SSA, SSB), complement levels, erythrocyte sedimentation rate, urinalysis, complete blood cell count and blood chemistry, were all in the normal range. Patch tests proved negative. Total IgE antibodies as well as specific IgE antibodies against the most common antigens were all in the normal range. Borrelia burgdorferi serology proved negative. A biopsy from the right lower eyelid was obtained. The histopathologic findings were characterized by a dermal perivascular and periadnexal infiltrate composed of lymphocytes (Fig. 2). Edema of the dermis was revealed by the enlargement of the spaces among collagen bundles. Deposits of mucin were present in the reticular and mid dermis. The epidermis and hypodermis were uninvolved. A diagnosis of lupus erythematosus, tumidus variant, was made. Direct immunofluorescence revealed granular deposits of fibrinogen and C3 at the basement membrane zone. The patient was treated with hydroxychloroquine 400 mg/day and metilprednisolone was added at the initial dose of 50 mg/day. After 1 month of treatment, an edema was improved and there was discoloration of the erythema. However, after tapering both antimalarial and steroid, the patient relapsed. Treatment with talidomide 100 mg/day for 10 days, then 200 mg/day for 20 days, and finally 100 mg/ day for 2 months was made. In 3 months the lesion healed completely. Up to now (July 2003) the patient has been free from lupus tumidus, and only photoprotection treatment with sunscreens has been given.

Case report of a hepatic angiomyolipoma.

Angiomyolipoma (AML) is a benign mesenchymal tumor that has been frequently reported in the kidney but rarely in the liver. Hepatic AML may be clinically, radiologically and morphologically difficult to distinguish from hepatocellular carcinoma or other hepatic lesions, even though the number of cases has been increasing recently due to improved imaging techniques. Histologically it consists of smooth muscle cells, adipose cells and abnormal blood vessels. It is commonly diagnosed following abdominal pain but may also be asymptomatic, has a predominant female predilection, highly variable size and occurs in subjects with a wide age range. The right lobe is the most common site, and multicentricity has been reported. Here we report a case of the myomatous variant of AML, accidentally discovered in a young woman with no clear features on radiographic examination, which was diagnosed by means of fine needle aspiration biopsy (FNAB) and then surgically removed. Although careful observation with serial radiological follow-up is an option in these cases, we chose the surgical approach because of the risk of rupture due to the large size of the lesion and the risk of malignant behavior or transformation. In case of the myomatous variant composed of irregular cells with epithelioid appearance, hepatocellular carcinoma with fatty changes or the possibility of other malignant tumors must be ruled out by immunohistochemistry (HMB-45), even in biopsy specimens.

A case of carcinoid of Meckel's diverticulum associated with gastric adenocarcinoma.

Meckels diverticulum is an uncommon gastrointestinal congenital anomaly that occurs in 1-3% of the population. It is sometimes associated with complications related to the presence of ectopic tissue (obstruction, ulceration, hemmorhage, inflammation, perforation, fistula and tumors). Neoplastic degeneration of Meckels diverticulum mucosa is rare, developing in only 1-5% of all diverticula, usually asymptomatic and occasionally discovered. Disease is metastatic, usually to the liver, in 25% of cases. We report a case of asymptomatic unsuspected carcinoid of Meckels diverticulum with ileal, hepatic and mesenteric metastasis discovered during a gastrectomy performed for gastric adenocarcinoma. The patient underwent ileal and Meckel diverticulum resection, excision of mesenterial metastasis and liver bisegmentectomy. Furthermore, total gastrectomy with esophago-jejunal anastomosis was performed. After an 18-month follow-up period, the patient is alive and disease free. Owing to possible neoplastic degeneration, Meckels diverticulum should be resected when occasionally discovered. In the presence of a carcinoid tumor, even if associated with metastatic disease, extended resection is recommended.

Treatment of endolymphatic sac tumour (Papillary adenocarcinoma) of the temporal bone.

AIM To define a better treatment of sporadic endolymphatic sac tumours (ELST) analysing our experience and literature available data. BACKGROUND ELST can arise as sporadic case (rare) or as a part of von Hippel-Lindau (VHL) disease. It is a low grade malignancy with local spread by continuity. MATERIALS AND METHODS we described our experience with 7 cases with up to date follow up. RESULTS Five cases were free of disease after first surgical procedure. One case had recurrence in the temporal lobe after 12 years. One case had two surgical procedures followed by irradiation and died five years after radiotherapy with a slow disease progression. CONCLUSION With increasing expertise in the skull base surgery, complete tumour excisions are achieved in majority of the more recent cases and appear to be the treatment of choice. External irradiation is also used as palliative measures with doubtful effectiveness. Some recent reports showed encouraging results with gamma knife radiosurgery.

Cerebellopontine Angle Mixed Tumor in Type 2 Neurofibromatosis

Copyright

Reply to G. Dionigi’s letter: energy based devices and recurrent laryngeal nerve injury: the need for safer instruments

1. Professor Dionigi’s comments are undoubtfully remarkable; as he pointed out, both Harmonic Scalpel (HCS) and Ligasure® (electrothermal bipolar vessel-sealing systems) are gaining popularity since they significantly reduce operating time in open as well as in videoassisted thyroid surgery [1–3]. 2. Up to now, studies about heat dispersion of energybased devices in thyroid surgery are lacking, and those which use a nerve model do not clarify the safety distance to prevent nerve injury [4, 5]. 3. Proper training of the surgical team before these devices are used is essential because it is of paramount importance to maintain an adequate safety distance not only from recurrent laryngeal nerve (RLN) but also from other vital structures as the trachea. However, as reported by Bergenfelz [6], even with a distance exceeding the one recommended by the maker, the rate of transient RLN palsies was higher in patients submitted to surgery with HCS. 4. In literature, there are no data about the new Harmonic Focus® device, which has a smaller tip than the traditional HCS scissor and an aluminum coating which, as reported in product leaflet, should further reduce heat dispersion. Moreover, results of the Ethicon® (Ethicon Endo Surgery INC, Cincinnati, OH, USA) study about safety margins close to the nerves are not available yet. 5. Chan [7] in 2006 reported intraoperative neurophysiological monitoring (IONM) as not effective in preventing RLN injury, and Delbridge [8], the following year, added it is unuseful in resident training and considered it as a “technological toy” which can be harmful if viewed as a substitute of training by an experienced thyroid surgeon. Moreover, it is very expensive and not cost effective. 6. The German study, the largest ever published about IONM, demonstrated that visual identification of the RLN is the gold standard for nerve protection in all types of thyroid surgery [9]; IONM may be useful only in special cases. The same group in 2008 reviewed world literature on this topic, trying to detect some evidence-based guidelines; they concluded the additional use of IONM did not result in significantly decreased rates of postoperative RLN palsies when compared to visual dissection [10]. 7. Probably, at least as long as new and hopefully safer devices are developed, near by the nerve, the safest hemostatic method is still represented by tiny stitches or vascular clips which, as pointed out by Prof. Dionigi, can even be removed.

Orbital exenteration: our experience

Introduction We reviewed our experience of the multidisciplinary collaboration between ophthalmologists, head and neck surgeons, neurosurgeons, radiologists and oncologists in the management of extensive tumors treated by orbital exenteration at the Humanitas Research Institute, Milan, Italy, over the past 10 years. Methods This is a retrospective cohort study of all patients who underwent orbital exenteration between March 2005 and August 2014 at the Humanitas Research Institute. The 10-year cohort of exenterated patients was identified through operating room notes using the clinical code set of the International Classification of Diseases, 10th revision (ICD-10). Results A total of 26 patients were identified, including 19 (73.1%) males. The median age was 65.5 years (range 37-87). Eighteen (69.2%) patients had major skin cancers extending to the orbit. Patients were divided into 2 cohorts: cohort 1 comprising patients with sinus or craniofacial cancers requiring orbital exenteration, and cohort 2 comprising patients with advanced periorbital skin cancers. The two cohorts were well matched for sex, age at surgery, degree of invasion, extension of surgical removal, necessity of adjuvant radiotherapy, reconstruction processes, and rehabilitation. Conclusions In our experience patients never died of the primary lesion but because of the occurrence of other problems. So we encourage local surgical radicality.