Pasquale Cianci

A recurrent epidermoid cyst of the spleen: report of a case and literature review

BackgroundSplenic cysts are rare disease. Epidermoid cysts of the spleen belong to the primary nonparasitic splenic cysts group. They are an unusual event in surgical practice. Usually, epidermoid cysts occur in children and young female. Most often, they are asymptomatic, but they may present with abdominal discomfort.Case presentationWe are reporting a rare case of a 23-year-old female came to our attention with history of intermittent pain and previously undergone two times to laparoscopic decapsulation of the cyst in others institutions. During hospitalization, serum and intracystic levels of tumor marker CA19-9 increased. Enhanced CT of the abdomen showed recurrent large cyst in the upper pole of the spleen with satellite nodules. Laparotomic total splenectomy was performed. Histopathological and immunoreactive examinations were executed, and they revealed stratified squamous epithelium on the inner surface of cystic wall, which was positive for EMA, CEA, and CA19-9. The diagnosis of epidermoid cyst was confirmed.ConclusionsRecently, the surgical approach is changing towards conservative treatments in order to save the spleen in young patients for immunological reasons. Sometimes, this target is not achievable. In such circumstances, like recurrent large cyst, anomalous anatomical relationship to the surrounding tissues, total splenectomy is safe and necessary.

Voluminous Omental Inflammatory Myofibroblastic Tumor in an Elderly Man: A Case Report and Literature Review

Inflammatory myofibroblastic tumor (IMT) is a rare neoplasm of intermediate biologic potential, with uncertain etiology. This tumor occurs primarily in the lung, but the tumor may affect any organ system. A 75-year-old male was evaluated for voluminous palpable high abdominal mass with continuous and moderately abdominal pain, associated with abdominal distension for the last two months. Abdominal computed tomography showed a large (32 × 29 × 15 cm) heterogeneously enhanced mass with well-defined margins. At surgery, the mass originated from the greater omentum was completely excised. Histologically the tumor was a mesenchymal neoplasm in smooth muscle differentiation and was characterized by spindle-cell proliferation with lymphocytes, plasma cells, and rare eosinophils. Immunohistochemically, the tumor cells were positive for vimentin and smooth muscle actin and negative for anaplastic lymphoma kinase. Complete surgical resection of IMTs remains the mainstay of treatment associated with a low rate of recurrence. Final diagnosis should be based on histopathological and immunohistochemical findings. Appropriate awareness should be exercised by surgeons to abdominal IMTs in combination with constitutional symptoms, abnormal hematologic findings, and radiological definition, to avoid misdiagnosed.

Cholecystoduodenocolic Fistula by Gallbladder Carcinoma that Presenting as Bouveret's Syndrome: Case Report and Review of the Literature

We describe the first case in the literature of Bouveret’s syndrome as the result of a cholecystoduodenocolic fistula secondary to gallbladder carcinoma. A 67-years-old woman was admitted to our department presenting with complaints of severe cramping abdominal pain, localized predominantly in the right hypochondrium and epigastrium, with infrequent alimentary and biliary vomiting for about three months. Based on the radiological and endoscopic findings, the provisional diagnosis of Bouveret’s syndrome in a patient with cholecystoduodenal fistula and history of cholelithiasis was made. The laparotomy showed the presence of the stone in the duodenal bulb, already seen at endoscopy, and adhesions between gallbladder, superior duodenal flexure and hepatic flexure of the colon, and this inflammatory gangue strethed up to the hepatic hilum. During dissection in addition to the communication between the gallbladder and the duodenum, another fistula was found that led from the gallbladder to the colon. The suspicion of malignancy of this multiple biliary enteric fistula was confirmed by intraoperative frozen sections that revealed the precence of a poorly differentiated carcinoma of biliary-pancreatic origin, but the ultimate diagnosis of gallbladder carcinoma was made exclusively after the definitive histopathological examination. For these reasons the surgical procedure involved cholecystectomy with resection of the regional lymph nodes, gastrotomy with extraction of gallstone, trans-mesocolic Roux-en-Y gastro-jejunal mechanical anastomosis, resection of the hepatic flexure of the colon with termino-lateral colo-colic mechanical anastomosis. It’s important to remember that rarely the Bouveret’s syndrome can hide multiple biliary enteric fistulas or even a malignancy. We believe, in the light of our experience, that the surgical approach represents the first choice in the treatment of this serious disease.

Haemostasis in Thyroid Surgery: Collagen-Fibrinogen-Thrombin Patch versus Cellulose Gauze—Our Experience

Purpose. Postoperative hemorrhage is fortunately uncommon but potentially life-threatening complication of thyroid surgery that increases the postoperative morbidity and the hospital stay. In this study we compare the efficacy of collagen patch coated with human fibrinogen and human thrombin (CFTP) (group C) and oxidized regenerated cellulose gauze (group B) versus traditional hemostatic procedures (group A) in thyroid surgery. Methods. From January 2011 to December 2013, 226 were eligible for our prospective, nonrandomized, comparative study. Patients requiring a video-assisted thyroidectomy without drain, “near total,” or hemithyroidectomy were excluded. Other exclusion criteria were a diagnosis of malignancy, substernal goiter, disorders of hemostasis or coagulation, and Graves or hyperfunctioning thyroid diseases. Outcomes included duration of operation, drainage volume, and postoperative complications. Results. Our results show a significant reduction in drainage volume in group C in comparison with the other two groups. In group C there was no bleeding but the limited numbers do not make this result significant. There were no differences in terms of other complications, except for the incidence of seroma in group B. Conclusion. The use of CFTP reduces the drainage volume, potentially the bleeding complications, and the hospital stay. These findings confirm the efficacy of CFTP, encouraging its use in thyroid surgery.

Laparoscopic antegrade cholecystectomy: a standard procedure?

Abstract Retrograde approach (“fundus first”) is often used in open surgery, while in laparoscopic cholecystectomy (LC) is less frequent. LC, with antegrade access, is done by putting in traction the infundibulum and going up to the fundus before to clip the cystic. Our study analyzes a number of surgical procedures performed by experienced surgeons in laparoscopy. From 2002 to 2015, 1740 laparoscopic cholecystectomies were performed at our Institution. The operative procedure performed since 2002 consists of the incision of the visceral peritoneum from the infundibulum away from Calot’s triangle along the gallbladder bed up to the fundus. Then it continues from the fundus up to the infundibulum. Results: There were no bile duct injuries. Average operative time was 40 min. 22 conversions to an open procedure (1.3%) occurred, in cases of acute cholecystitis and cirrhotic patient. Postoperative stay was mean 2 days with no delayed sequelae on follow up. Conclusions: gallbladder antegrade dissection for laparoscopic cholecystectomy can reduce the time of surgery and is an easier technique to perform. Therefore, it can be proposed as the standard procedure and not only be used for difficult cholecystectomies.

A Rare Case of Functioning Adrenocortical Oncocytoma Presenting as Cushing Syndrome

Functioning adrenocortical oncocytoma is very rare neoplasm. It is usually nonfunctional and benign and incidentally detected. Generally, these tumors originate in the kidneys, thyroid, parathyroid, and salivary or pituitary glands; they have also been reported in other sites including choroid plexus, respiratory tract, and larynx. Histologically, they are characterized by cells with eosinophilic granular cytoplasm and numerous packed mitochondria. We reported a case of a 44-year-old female who presented with Cushing syndrome for hypersecretion of cortisol due to adrenocortical oncocytoma. Magnetic resonance of abdomen revealed a right adrenal mass. Laparoscopic adrenalectomy was performed and the tumor was pathologically confirmed as benign adrenocortical oncocytoma. After surgical treatment, Cushings syndrome resolved.

Bladder Metastases from Breast Cancer: Managing the Unexpected. A Systematic Review

Breast cancer (BrC) has the highest incidence among females world over and it is one of the most common causes of death from cancer overall. Its high mortality is mostly due to its propensity to rapidly spread to other organs through lymphatic and blood vessels in spite of proper treatment. Bladder metastases from BrC are rare, with 50 cases having been reported in the last 60 years. This review aims to discuss some critical points regarding this uncommon condition. First, we performed a systematic review of the literature in order to draw a clinical and pathological profile of this entity. On this basis, its features in terms of diagnostic issues, imaging techniques, and survival are critically examined. Most bladder metastases from BrC are secondary lobular carcinoma, which mimic very closely the rare variant of urothelial cancer with lobular carcinoma-like features (uniform cells with an uncohesive single-cell, diffusely invasive growth pattern); thus, immunohistochemistry is mandatory to arrive at a correct diagnosis. This article summarizes the current knowledge regarding the incidence, clinical presentation, diagnosis, prognosis, and treatment of bladder metastases in patients with BrC.

Cervical Esophagotomy for Foreign Body Extraction: A Case Report and Extensive Literature Review of the Last 20 Years

Patient: Male, 64 Final Diagnosis: Meat bolus retention in cervical esophagus Symptoms: Meat bolus impacted Medication: — Clinical Procedure: Cervical esophagotomy Specialty: Surgery Objective: Rare disease Background: Voluntary and involuntary ingestion of foreign bodies is a common condition; in most cases they pass through the digestive tract, but sometimes they stop, creating emergency situations for the patient. We report a case of meat bolus with cartilaginous component impacted in the cervical esophagus, with a brief literature review. Case Report: A 64-year-old man came to our attention for retention in the cervical esophagus of a piece of meat accidentally swallowed during lunch. After a few attempts of endoscopic removal carried out previously in other hospitals, the patient has been treated by us with a cervical esophagotomy and removal of the foreign body, without any complications. We checked the database of PubMed, Scopus, and the Cochrane Library from January 2007 to January 2017 in order to verify the presence of randomized controlled trials, clinical trials, retrospective studies, and case series regarding the use of the cervical esophagotomy for the extraction of foreign bodies impacted in the esophagus. Conclusions: The crucial point is to differentiate the cases that must be immediately treated from those requiring simple observation. Endoscopic treatment is definitely the first therapeutic option, but in case of failure of this approach, in our opinion, cervical esophagotomy could be a safe, easy, viable, durable approach for the extraction of foreign bodies impacted in the cervical esophagus. Our review does not have the purpose of providing definitive conclusions but is intended to represent a starting point for subsequent studies.

Acute Cholecystitis: Diagnostic Pitfall and Timing of Treatment

Objective: Cholelithiasis represents a very frequent health problem with higher prevalence in developed countries. The aim of this chapter is to underline, also by submitting our surgical experience, some diagnostic deceptions and the timing of treatment. Methods: The presentation of 42 patients admitted in our institution (September 2012/ September 2014) with the diagnosis of acute pancreatitis allows to identify two different clinical forms of acute biliary pancreatitis: the pancreatic pattern and biliary pattern. Moreover, the evaluation of another 42 patients observed in our institution (September 2014/September 2016) with acute cholecystitis should show our treatment program. Also, we added the analysis of our previous research, regarding acute cholecystitis, already published: difficult cholecystectomy, antegrade dissection in laparoscopic cholecystectomy, postoperative morbidity, laparoscopic approach in cirrhotics, finally the robotic experience. Results: Clinical features, laboratory, and imaging exams should identify, into acute biliary pancreatitis, two clinical forms as biliary pattern and pancreatic pattern for different therapeutic approach. The treatment chosen for acute cholecystitis is early laparoscopic cholecystectomy within 24–72 hours. Severe, complicated acute cholecystitis can require urgent surgical intervention. Conclusion: Acute cholecystitis encompasses clinical forms with various degree of severity and several clinical courses. The treatment is focused on early cholecystectomy with various and different management strategies, suitable to the specific pathological conditions.