Salvatore Caterino

Hemoperitoneum from a Spontaneous Rupture of a Giant Hemangioma of the Liver: Report of a Case

Hemangioma is the most common benign tumor of the liver and it is often asymptomatic. Spontaneous or traumatic rupture, intratumoral bleeding, consumption coagulopathy, and rapid growth are mandatory surgical indications. We report a case of giant hemangioma of hepatic segments II and III, which presented as hemoperitoneum, and were treated successfully with preoperative transcatheter arterial embolization (TAE) and hepatic bisegmentectomy. A PubMed Medline search has identified up to now 32 cases of spontaneous rupture of hepatic hemangioma in adults (age >14 years) without a history of trauma, including the present case. Twenty-seven out of these were reviewed. Sixteen (84.2%) of 19 tumors of known size were giant hemangiomas (mean diameter 14.8 cm; range 6–25). Twenty-two (95.7%) patients underwent surgery. Thirteen patients (59.1%) had a resection, 5 (22.8%) were sutured, and 4 (18.1%) underwent tamponade. Three (23%) out of the 13 resected patients died. Four patients (30.8%) underwent TAE prior to elective hepatic resection without any operative mortality. Among the 5 sutured patients, 2 (40%) died as well as 3 (75%) out of 4 patients who underwent tamponade. The mortality rate of all surgery patients was 36.4% (8/22).

Small periampullary duodenal gastrointestinal stromal tumor treated by local excision: Report of a case

Gastrointestinal stromal tumors (GIST) are mainly located in the stomach and the small bowel, with the duodenum accounting for about 4%. We report the case of a 66-year-old woman with a periampullary GIST of the duodenum that was treated by local excision and direct duodenal wall defect repair. Since no definitive clinical criteria have been established to differentiate malignant from benign mesenchymal tumors, preoperative cytology was not available and surgical removal of the 3.5 cm tumor was feasible, the patient was treated conservatively. The morbidity and mortality rates of the more radical and invasive duodenopancreatectomy, in particular when dealing with a soft pancreatic stump with a narrow pancreatic duct, are, in our opinion, too high for a potentially benign disease when the more conservative procedure is feasible. Four years after surgery the patient is doing well and control CT scan showed the absence of local recurrence.

Solitary left axillary metastasis after curative surgery for right colon cancer

mouth. GFPO is postulated to arise at the pharyngo-oesophageal junction in the muscle deficient Laimer-Haeckermann triangle when a flap of mobile, redundant submucosa prolapses distally, slowly enlarging over time. Endoscopic differentiation of bulky GFPO lesions from oesophageal sarcoma or leiomyoma may be difficult. Misguided attempts at radical longitudinal resection of the oesophagus should be avoided. Endoscopic resection is appropriate in selected, generally smaller lesions though care must be taken with potentially large feeding vessels. An open left cervical approach provides access to larger lesions with minimal morbidity.

Epididymal‐testicular fusion anomalies in cryptorchidism are associated with proximal location of the undescended testis and with a widely patent processus vaginalis

Past studies documented the presence of epididymal/testicular fusion anomalies and persistence of a patent processus vaginalis in a small case‐series of cryptorchid and/or hydrocele patients. The primary aim of this study was to determine the prevalence of the epididymal/testicular anomalies in a series of more than 1000 cryptorchid patients compared with controls. Secondary aims were: (i) to investigate the association between the cryptorchidism and the patency of p. vaginalis; and (ii) to correlate the epididymal/testicular fusion anomalies with the position of the testis and with the patency of the p. vaginalis. The clinical and surgical data of 1002 cryptorchid patients and 230 controls were retrospectively retrieved and analysed. Epididymal/testicular fusion anomalies were classified as: (i) normal anatomy; (ii) minor anomalies; and (iii) major anomalies. Statistical analysis was performed using the Students t‐test and Chi‐square tests. The prevalence of the epididymal/testicular fusion anomalies was higher in the cryptorchid group compared with that of the control group (minor and major anomalies in cryptorchids vs. controls, respectively: 42.2 vs. 5.6% and 9.3 vs. 1.6%, P < 0.0001). Moreover, we documented a correlation of these anomalies with a more proximal localization of the testis (minor and major anomalies in proximal vs. distal location of the testis, respectively: 62.5 vs. 34.8% and 19.1 vs. 6.3%, P < 0.0001) and with the persistence of a widely patent p. vaginalis (minor and major anomalies in widely patent p. vaginalis vs. narrow duct, respectively: 51.7 vs. 42.2 and 11.9% vs. 7.8%, P < 0.001). In conclusion, the epididymal/testicular fusion anomalies were strongly associated with cryptorchidism and the persistence of a widely patent peritoneal vaginal duct. Although it remains unclear whether these anomalies cause non‐descent of the testis or, conversely, result from the cryptorchidism or from the persistence of a widely patent duct, our data re‐enforce this association.

Imaging of leiomyosarcoma of the inferior vena cava: comparison of 2 cases and review of the literature

Abstract Leiomyosarcoma of the inferior vena cava is a rare tumour arising from the smooth muscle fibres of the media with a mean size at diagnosis generally around 12 cm (range 2–38 cm). This study compares a 4-cm leiomyosarcoma of the inferior vena cava discovered incidentally with a symptomatic late stage leiomyosarcoma.

Staged orchidopexy: simplifying the second stage

In some cases high undescended testes cannot be brought into the scrotum by means of a standard orchidopexy, but require different procedures such as autotransplantation, Fowler-Stephens orchidopexy, or staged orchidopexy. Over a period of 3 years 9 months the authors employed staged orchidopexy in 15 cases; 14 of these have already undergone the second stage. In 6 cases a modified Corkery operation was performed: after anchoring the gonad to the tuberculum pubis (first stage), a Silastic sheet is placed to cover the testis and cord, suturing it beneath the internal oblique muscle and external oblique fascia. This sheet of Silastic is not placed around the whole testis, as originally described by Corkery, but lies on the gonad and cord separating them from the overlying layers. As the purpose of this modification is to create a solid plane against vas/vessel injury during the second stage, the sheet of Silastic used is much thicker than the one originally described. In the 5 children who have undergone the modified second stage so far, isolation of the testis during the second procedure has proved easier and safer with respect to possible cord injuries. Our data indicate better results using this technique, compared to a standard staged procedure, with regard to secondary testicular atrophy.

Fibrous hamartoma of infancy in the scrotum

Fibrous hamartomas of infancy and childhood are rare benign tumors. The clinical and morphological features of these lesions can be different according to the age at onset. Although the most common localizations are the shoulders, axillas, and upper arms, these lesions may develop in unusual sites such as the scrotum. The authors report a 13-month-old child with a fibrous hamartoma in the scrotum, which was excised. At 1-year follow-up there was no sign of local recurrence or distant disease. The clinical and histological features of the disease are described in order to facilitate correct diagnosis and avoid inadequate therapy.

Zoosexuality: an unusual cause of colorectal injury

Abstract Zoosexuality (the sexual intercourse between humans and animals) represents an extremely rare but potentially fatal cause of colorectal trauma and sepsis. A case of penetrating rectal injury associated with a rapidly progressive sepsis following sexual intercourse with a Maremma Sheepdog is presented.

Abdominoscrotal hydrocele: when one sac becomes bissac.

A 5-month-old male infant was referred to our department with a history of left scrotal hydrocele since birth. His parents related a progressive enlargement of the hydrocele accompanied by the development of a mass in the ipsilateral lower quadrant of the abdomen over the month before admission. On bimanual palpation, both abdominal and scrotal swellings showed cross-fluctuation. A sonography was arranged revealing a dumbbell-shaped hypoechoic lesion continuing from the left scrotum to the abdomen suggesting the provisional diagnosis of abdominoscrotal hydrocele (ASH) (Fig. 1). Additionally, a right scrotal hydrocele and an undescended testis within the left inguinal canal were noticed. Surgical treatment consisted of left inguinal skin crease incision, resection of ASH after its complete exteriorization from the abdominoscrotal cavity, identification with ligation of the processus vaginalis and left orchiopexy (Fig. 2). The patient did well post-operatively and no recurrent hydrocele developed after 7 years of follow-up. Hydrocele en bissac, as coined by Dupuytren in 1834 and later renamed abdominoscrotal, bilocular or hourglass hydrocele (ASH) by Bickle in 1919, is a rare congenital condition in which a hydrocele of the tunica vaginalis develops two large components, one in the scrotum and one in the abdomen, communicating in an hourglass fashion through the inguinal canal. Unique in its kind, this pathological entity can manifest in the newborns and children (only 130 cases so far) as well as in the adults (some 100 cases) with a predilection for male sex. The aetiopathogenesis is under debate and several interesting hypotheses have been proposed. The most accepted speculation is the cephalad extension of ASH espoused by Dupuytren: when the intracystic pressure within the scrotal hydrocele exceeds the intraperitoneal one, the tunica vaginalis becomes overdistended and, protruding into a locus minoris resistentiae, the inguinal canal ascends to the abdomen forming a new sac. Other theories implicate the herniation of a peritoneal diverticulum into the inguinoscrotal space (caudad extension of ASH) or the existence of a one-way valve-like mechanism within a patent processus vaginalis (PPV) at the internal inguinal ring. Regarding the last topic, however, most authors deem ASH a non-communicating hydrocele explaining that a PPV is practically impossible to find in such a condition. Usually, the abdominal component is unilateral and larger than the scrotal counterpart. The abdominal component has been described properitoneal, retroperitoneal and also between the two layers of the broad ligament; in our patient, it was mainly properitoneal but also expanded into the left retroperitoneum. Basically, the diagnosis of ASH is clinically obtained through the ‘springing back ball’ sign: the manual reduction of the scrotal hydrocele implicates an initial enlargement of the abdominal lesion which is followed by the subsequent restoration of the scrotal component. Generally asymptomatic, ASH can manifest with exquisite abdominal or scrotal pain and has also been described in association with acute appendicitis, malignant mesothelioma of the tunica vaginalis, cryptorchidism and abnormal testicular findings. Abdominal ultrasound examination is the most practical, informative, innocuous and inexpensive imaging study corroborating the provisional diagnosis of ASH: characteristically, it shows an hourglass-shaped cystic collection extending from the scrotal to the abdominal region with the narrowest portion passing through the inguinal canal. In 1991, Sasidharan et al. reported the first and so far only the case of ASH was detected antenatally during a maternal ultrasonography performed at 22 weeks of gestation. Computed tomography and

Surgical strategies for duodenal GISTs: Benefits and limitations of minimal resections

Sex e n (%) M 5 (62.5%) F 3 (37.5%) M/F 1.66 Age years Mean; SD 57.3; 14.3 Range 28e76 Location e n (%) D1 2 (25.0%) D2 1 (12.5%) D3 2 (25.0%) D4 3 (37.5%) Symptoms e n (%) Gastrointestinal bleeding/anemia 4 (50.0%) Abdominal pain 1 (12.5%) Diarrhea 1 (12.5%) Incidental diagnosis 2 (25.0%) Resection e n (%) Duodenal resection þ end to end anastomosis 2 (25.0%) Wedge resection 6 (75.0%) Tumor’s diameter e cm Mean; SD 3.7; 2.0 Range 1.5e8 Mitosis e n/50HPF Mean; SD 9.75; 17,3 Range 0e52 Risk Classification e n (%) Very low risk 1 (12.5%) Low risk 4 (50.0%) High risk 3 (37.5%) Dear Editor,