Maurizio Zizzo

Subcapsular Hepatic Hematoma After Endoscopic Retrograde Cholangiopancreatography: A Case Report and Review of Literature.

AbstractEndoscopic retrograde cholangiopancreatography (ERCP) is one of the most frequently performed procedures for the diagnosis and treatment of biliary-pancreatic diseases. ERCP-related complications total around 2.5% to 8%, with a mortality rate ranging from 0.5% to 1%. An exceptional ERCP complication is subcapsular hepatic hematoma, and few cases are reported worldwide.We present the case of a 52-year-old woman with a history of recurring upper abdominal pain and a clinical and ultrasonographic diagnosis of obstructive jaundice due to common bile duct stones. After 2 difficult endoscopic biliary procedures, common bile duct stones clearance was obtained. Post-ERCP course was symptomatic with upper abdominal pain and anemization with hemodynamic instability.CT scan demonstrated a 15 cm × 11 cm subcapsular hepatic hematoma filled with air and liquid on the surface of the right hepatic lobe. The patient was successfully treated with the embolization of a small branch of right hepatic artery angiographically identified as the cause of bleeding.Subcapsular hepatic hematoma after ERCP is a rare complication that must be taken into account in the differential diagnosis of symptomatic cases after ERCP. Its diagnosis is based on clinical and laboratory data and especially on imaging (ultrasound, CT, or MRI). Treatment is often conservative but, in some cases, embolization or percutaneous drainage or surgery may be necessary.

Laparoscopic treatment of acute small bowel obstruction due to left paraduodenal hernia: A case report and literature review.

Highlights • Left paraduodenal hernia is a potentially severe cause of small bowel obstruction.• Abdominal computed tomography scan is the standard for a correct diagnosis.• Laparoscopy is feasible and effective, also in emergency situation.

The “Hepatic Core”: How to Reach It

We read with interest the article by Hoshikawa and colleagues regarding a transhepatic approach to deeply located liver tumors, focused on minimal sacrifice of the hepatic parenchyma. Based on our anatomic observations of liver casts, we would like to underline some details. The “hepatic core,” as appropriately defined, cannot be considered a proper anatomic structure, because it lacks distinct arterial, portal, biliary, and lymphatic apparatus. Rather, it has to be considered a zone inside the hepatic parenchyma where different liver segments converge. It covers a space behind the hilar plate, above segment I and the portal horizontal plane, extending to the dome of the liver. No important vascular or biliary structures are encountered inside, but only small branches of the hepatic veins. Its anatomic variability, according to the liver configuration or pathology, must be ascertained for each patient by cross-sectional imaging, and intraoperatively by ultrasound. At operation, this region of the liver parenchyma can be reached, under ultrasound guidance, through 1 of the 3 intersegmental planes, already adopted for major hepatic resection, and after having localized the neoplastic nodule to be resected. The middle plane, traced on Cantlie’s line, leads toward its central part; the other 2 run parallel and in front of the corresponding right or left hepatic veins. Notably, the distal parts of the hepatic veins project onto the inferior liver surface in front of segment I. In particular, the left hepatic vein corresponds to its anterior left part, the middle to its paracaval portion, and the right to the caudate process. In practice, operation begins with dissection of the hepatic vein, corresponding to the selected intersegmental plane, at its confluence into the vena cava; it is extended until a good exposure of the hepatic nodule is achieved, but not necessarily up to the hepatic edge. This helps to reduce the surgical trauma. The limited dissection of the intersegmental plane can be facilitated by a “hanging maneuvre”; with the aid of bimanual palpation, a single or double tape is passed from the inferior to the superior liver surface, and used for downward and lateral traction.

Pancreaticojejunostomy with or without reinforcement after pancreaticoduodenectomy: surgical technique of ligamentum teres hepatis wrap around pancreaticojejunostomy

In a previous issue of the Journal, Zhong et al. reported a retrospective study that compared the perioperative outcomes of the mesh-reinforced pancreaticojejunostomy with conventional pancreaticojejunostomy. They concluded that mesh-reinforced pancreaticojejunostomy was a safe and effective technique, as it provided a safe anchor site for suture, thus reducing the risk of pancreatic leakage. Considering these encouraging results, we present a further simple technique using ligamentum teres hepatis wrap around pancreatojejunostomy for prevention of postoperative pancreatic fistula after pancreaticoduodenectomy.

Primary classic Hodgkin lymphoma of the ileum and Epstein-Barr virus mucocutaneous ulcer of the colon: two entities compared

Primary classic Hodgkin lymphoma of the gastrointestinal tract represents a rare occurrence. A full patient’s work-up is essential in order to exclude a secondary intestinal involvement. Histologically Epstein-Barr virus mucocutaneous ulcer closely resembles Hodgkin lymphoma. The differential diagnosis between these two entities is relevant, since both the therapeutic approach and the clinical behavior are different. Herein, we describe a case of primary classic Hodgkin lymphoma arising in the ileum and a case of Epstein-Barr virus mucocutaneous ulcer of the colon, focusing on the main clinicopathological differences.

Radiation therapy damages external anal sphincter and perineal muscle floor: DOMATI et al.

To the Editor, We were very impressed by Ihnát et al, whose analysis examined both anorectal dysfunction after radiotherapy and damages related to internal anal sphincter. Nevertheless, we believe it is important to introduce our histological observations on this topic. We analyzed 25 surgical specimens of patients who underwent abdominoperineal resections 5 weeks after long‐term radiotherapy with 55 Gy and concurrent Folfox treatment. While rectal wall and internal anal sphincter displayed just minor edema and hyperemia, both external anal sphincter and muscles of the perineal floor showed more visible lesions. They mainly affected the striated muscle myofibrils through nuclear swelling and more serious pycnosis, karyolysis, and karyorrhexis. Corresponding cytoplasmatic lesions involved a widespread hyalinosis, showing disappearance of striated bands and reduced immune‐histochemical staining with anti‐ Sarcomeric actin antibodies. Newly generated fibroblasts and collagen fibrils were detected in the interstitial spaces between muscle fibers. Arterioles showed partially disrupted endothelium and media layer edema. Lymphatic capillaries appeared mildly dilated. Peripheral nervous fibers exhibited edema, and new collagen fibrils wrapped the single axons. As surgical specimens of patients who had received short‐term radiation therapy of only 25 Gy did not show similar lesions, we can assume that detected radiation toxicity is dose dependent, not ruling out chemotherapy as an aggravating factor. We estimate that detected lesions evolve following a series of events: direct radiation damage produces a local cytokines release that depresses cells replication and increases capillary permeability, leading to erythrocytes diapedesis, extravasation of serum proteins, and local edema. In the middle‐term, we did not record any proper remodeling of the striated muscles; we recorded just their partial repair, mainly provided by fibroblasts, which generate new collagen fibrils. This process involved also peripheral nervous fibers, with an induced functional damage. Therefore, we are allowed to suppose a real “vascular‐nervous myopathy” for perineal floor muscles and external anal sphincter. This justifies both hard perineal wound healing, which follows abdominoperineal resection and dysfunction of anal sphincter apparatus in the case of restorative rectal resection. In our opinion, improved radiation therapy protocols might lead to reduced secondary perineal damages, particularly in scheduled reconstructive surgery of upper or middle rectal cancers.

Dramatic progression of a chest wall desmoid-like fibromatosis: Images for surgeons

An 87-year-old woman presented with parasternal mass referred as rapidly growing in the previous 2 months. Medical history was completely unremarkable (no previous surgery, trauma and haemostasis disorders). At clinical presentation, a painless, fixed and hard lesion was identified at the lower third of the sternum, in the absence of alterations of the overlying skin. Lab tests and tumour markers were within the normal ranges. A chest–abdomen computed tomography scan (Fig. 1a,b) showed a bulky, hyperdense parasternal mass with measurements of 81 mm × 54 mm × 100 mm. An excisional biopsy was indicative of desmoid fibromatosis; thereafter, a dramatic progression of the mass occurred among with a large ulceration of the overlying skin in about 3 weeks (Fig. 2a,b); a control chest–abdomen computed tomography scan (Fig. 1c,d) confirmed the rapid growth of the mass (measurements of 110 mm × 120 mm × 155 mm) now extending up to the left pectoral muscle. Surgical en bloc resection was performed by complete removal of the mass (Fig. 2c) and reconstruction of the chest–abdominal wall with polypropylene mesh. At pathological evaluation, the surgical specimen consisted of a whitish bossolated huge mass (Fig. 2d). Microscopically, the lesion was characterized by a proliferation of bland, uniform spindled cells (Fig. 2e), with low mitotic activity, and no atypical mitotic figure. The lesional cells were set within a collagenous to myxoid stroma, sometimes with keloid-like features. At immunohistochemistry, the cells were positive for β-catenin (Fig. 2f) and focally positive for calretinin and smooth muscle actin. The final diagnosis of desmoid-type fibromatosis was then rendered. The post-operative course was uneventful and the patient was discharged on the fourth post-operative day. No sign of recurrence was observed at 6-month radiological follow-up. Desmoid-type fibromatosis is a locally invasive tumour with no metastatic potentiality, characterized by monoclonal proliferation of myofibroblasts occurring in deep tendon membrane tissues. The tumour seems to originate from totipotent mesenchymal cells and the WNT pathway (mutation in the β-catenin gene and adenomatous polyposis coli gene) is strongly implicated in its pathogenesis. Although 50% of desmoid-type fibromatosis patients have an indolent course, the natural history of the disease is extremely variable, this complicating the identification of the best strategy of care. Treatment options may include surgery, non-steroidal anti-inflammatory drugs, hormone manipulation, chemotherapy, radiation therapy and other forms of local therapy. Patients with stable disease for more than 1 year do not seem to need active treatment but only clinical surveillance. Even after surgery, the risk of local recurrences is estimated from 25% to 60% at 5 years. This is dependent on the

Contemporary Thoracic Aortic and Abdominal Injuries: An Emergency Strategy

Topcu and colleagues [1] interestingly bring attention to the management of contemporary injury of the thoracic aorta and spleen. On the basis of our experience, we would like to consider some basic points. In each case of severe thoracoabdominal trauma, it is essential to perform a hemodynamic monitoring and contrast-enhanced computed tomography (CT) angiography to detect a condition of circulatory instability, and to obtain a complete imaging of the thorax, abdomen, and vessels. The most common injuries of the thoracic aorta involve isthmus. In addition, high-grade lesions (III and IV) are preferentially treated with an endovascular technique [2]. Usually, treatment priority is given to the aortic isthmus injuries, possibly considering an endovascular procedure [3]. Subsequently, the other concomitant injuries, especially abdominal ones, must be treated adequately. This strategy was applied successfully in our last consecutive 5 cases of injuries of the aortic isthmus of grade IV, with an associated spleen rupture (3 cases) and a liver laceration (2 cases), obtaining a complete recovery without important complications. On the contrary, a prompt emergency laparotomy becomes necessary when an endovascular treatment is not possible, and the subsequent cardiovascular surgery requires a cardiopulmonary bypass and a prolonged full heparinization, with the risk of increased or recurrent abdominal hemorrhage [1]. Interestingly, we applied an equivalent strategy in three cases of injuries of the left subclavian artery, with secondary hemothorax and associated blunt abdominal trauma [4]. CT allowed a precise diagnosis of the vascular injury. A prompt endovascular treatment was successful, and the subsequent laparotomy for spleen rupture followed without difficulties. When this strategy is not possible, direct surgery of the injured supraaortic branch is indicated. In cases of polytrauma involving contemporaneously the thoracic aorta or its supraaortic branches and the abdomen, and an associated massive hemoperitoneum and hemodynamic instability, a prompt laparotomy becomes necessary. It must be performed under careful hemodynamic control, avoiding increase or recurrence of the thoracic hemorrhage after resolution of the circulatory hypotension. We believe that these challenging clinical situations merit further study and contributions.

Rectal cancer restaging after neoadjuvant chemoradiation: towards a down-staging score system

We have read with great interest the article of Singhal et al . (1) and we agree with their conclusions. It is our policy to submit the patients affected by rectal cancer, T3 and T4, independently from N, to a neoadjuvant treatment with 50 Grays and FOLFOX chemotherapy. Surgery follows after 4–5 weeks, and it is preceded by a restaging procedure. In order to classify the down-staging of rectal tumors, we have adopted a score system ( Table 1 ), inspired to the current TNM classification and based on imaging criteria, usually acquired with the common contrast-enhanced radiological tools, such as computed tomography (CT) and magnetic resonance (MR). We have also considered that tumor regression follows a preferential centripetal way, starting from its most peripheral zones toward the centre of the mass and to the site of deeper penetration.

Glomus Tumor of the Stomach: GI Image

A 70-year-old female presented to our attention with an incidental finding, of a gastric mass, during videolaparoscopic cholecystectomy; the surgeon described a mass forming lesion within the gastric wall that did not erose the serosa. The patient underwent different gastroscopies, and during the last gastroscopic control, the endoscopist found a significant increasement of the well-known mass (2 cm in diameter), located in the gastric antrum nearby the pylorum laying in the greater curvature. According to the macroscopic findings, our first diagnostic hypothesis was of GIST. Then, an EUSFNA (Fig. 1) was performed with on-site cytopathology assistance to evaluate the adequacy of material. The cytopathology smear showed a population of uniform, round epithelioid cells, with relatively small nucleoli and variable eosinophilic cytoplasm, which stained for smooth muscle actin but were negative for desmin, chromogranin, synapthophisin, and keratin (Fig. 2). A final cytological diagnosis of glomus tumor (GT) of the stomach was obtained. The patient underwent a CT scan (Fig. 3) that confirmed the presence of a hyperdense lesion of about 14 mm, in the absence of lymphadenomegaly or metastatic disease. There weren’t any contraindications for surgery, so we decided to perform a gastric laparoscopic wedge resection of the lesion (Fig. 4). Laparoscopy is a good minimally invasive technique in case of small and benign tumors, which allowed us to discharge the patient in the fourth