Stefano D’Ugo

Solitary metachronous gastric metastasis from pulmonary adenocarcinoma: Report of a case

INTRODUCTION Gastric metastases from lung adenocarcinoma are rare and usually associated with disseminated disease. The great majority is asymptomatic and in few cases discovered during autopsy studies. Reports of single metachronous metastases during the lifetime are anecdotal. We describe a case of solitary gastric metastasis 5 years after lung surgery. PRESENTATION OF CASE A 68-year-old male submitted in 2006 to right lobectomy for lung adenocarcinoma was referred at Emergency Room department in 01/2011 because of chronic epigastric pain. Radiologic and endoscopic evaluation showed a bulky lesion inside the stomach, originating from the muscular layer, suspected for GIST. He underwent a subtotal gastrectomy and the pathologic examination revealed an undifferentiated adenocarcinoma, positive for Thyroid Transcriptional Factor-1, Cytokeratin 7, AE 1/3 and CEA, confirming the pulmonary origin. DISCUSSION At the time of diagnosis about 50% of lung cancer are metastatic, with survival rates of 1% at 5-year. Gastric metastasis is very rare; autopsy studies report an incidence of 0.2-0.5%. They develop in the submucosa, usually without any symptom and the diagnosis is incidental during the staging of primary cancer or the follow-up. There are no guidelines about surgical treatment; however few cases of long-term survival following the operation were reported. Pathologic diagnosis is difficult, but the immunohistochemical staining helps to recognize the primary origin. CONCLUSION Solitary metachronous gastric metastasis from pulmonary adenocarcinoma is an exceptional event, but it could happen during the follow-up. It seems that a radical resection, in absence of systemic implants, might provide survival benefits in selected patients.

Combined liver transplantation and sleeve gastrectomy for end-stage liver disease in a bariatric patient: First European case-report

Highlights • Non-alcoholic Steatohepatitis is the 3rd indication for liver transplantation.• Obese transplanted patients have higher morbidity and mortality rates.• Bariatric surgery decreases morbidity and mortality in obese patients.• Combined liver transplant and sleeve gastrectomy can be safely performed.

Modified Stapled Transanal Rectal Resection (Starr) for Full Thickness Excision of Rectal Tumour

IntroductionTraditionally, adenomatous rectal lesions and unexpected malignant polyps that could not be removed endoscopically are referred to surgery. Local excision is the treatment of choice, and several techniques have been proposed. The choice of the approach requires that the tumour is excised intact, with a low recurrence rate and limited morbidity. Local excision can be a straight forward or conversely a demanding procedure due to the restricted space in which the surgeon must work and the difficulty of achieving a satisfactory exposure.MethodsWe describe a modified stapled transanal rectal resection for the excision of flat lesions with a diameter up to 2 cm and located between 5 and 12 cm from the anal verge.Discussion and ConclusionIn our experience, it is quick, simple, and easy to teach but it has not previously been reported. It provides full thickness resection with adequate lateral margins. It overcomes some of the limits of the incomplete surgical field exposure and difficult manipulation, since after the confectioning of double half purse-string suture, the suture and sectioning is made by the stapler device.

Tu1800 Effect of Bariatric Surgery on Comorbidities vs Medical Treatment in a Cohort of Morbidly Obese Patients: A Prospective Study

As it is being common in Japan to perform surgery in patients over 85 years old, postoperative complications such as pneumonia, heart failure, dementia, and bedridden status become big problems for patients and their family. Although some prognostic scoring systems such as POSSUM score are available, these scoring systems do not precisely predict the postoperative complications. Aim of the present study was to evaluate mortality and morbidity after the surgery and consider surgical indication in super-old patients. Methods: We retrospectively reviewed 222 patients who underwent surgery from 2003 to 2010 at the age over 85 years and analyzed postoperative mortality and morbidity rate. In our hospital, indications of surgery in super-old patients were, 1) informed consent from patient and his/her family and 2) good pulmonary and cardiac function to tolerate operation. We evaluated POSSUM score for information, and poor POSSUM score was not considered as an absolute contraindication. Results: Among 222 operations, emergent operations were 114, while elective operations were 108. Diseases for operation were gastric cancer in 24, colorectal cancer in 49, cholecystolithiasis in 9, inguinal hernia in 19 patients. Emergent operations included perforation of GI tract for 26, acute cholecystitis for 22, intestinal obstruction for 21, inguinal hernia for 20, acute appendicitis for 10, and colorectal cancer for 7 patients. Mortality and morbidity rates in elective surgery were 1.9% (2 patients) and 31.5% (34 patients), respectively, while those in emergent operation increased to 14.9% (17 patients) and 58.4% (66 patients) (p<0.01 vs. elective operation), respectively. Pulmonary complications were observed in 5 (1.9%) and 24 (21.1%) patients in elective and emergent surgeries, respectively. In 19 patients with postoperative deaths, 15 (79.4%) suffered from pulmonary diseases including aspiration pneumonia. Mortality rate in patients with pulmonary complications increased to 51.7% in elective and emergent operations. In patients undergoing operations for upper GI tract, pulmonary complications were observed in 8.3% in elective operations and 42.9% (3/7) in emergent operations, and all 3 patients died of pulmonary complications. Conclusions: In super-old patients, mortality and morbidity rates in emergent operations were high compared to those in elective operations. These results indicate importance of preoperative estimation in super-old patients, and indication of the operation should be carefully considered in patients with poor pulmonary function.

449 Medical and Surgical Treatment of Chronic Anal Fissure: Prospective Longer-Term Results

In this video presentation we are presenting a patient with a submucosal mass at the gastroesophageal junction (GEJ). At time of laparoscopic surgery, the mass was adherent to the GEJ and extended into the distal left esophagus. Resection of the mass included a portion of the lower esophageal sphincter and distal left esophagus. This area was then reconstructed primarily over a 42 Fr tapered Bougie with running 3.0 and 2.0 Vicryl® suture in two layer fashion. The patient did well post-operatively and was discharged home on day six.