Pneumothorax: a rare complication of colonoscopy. A systematic review of literature.

AIM: The purpose of this study is to determine the anatomica! aspects, mechanisms, risk factors and appropriate management of development of pneumothorax during a routine colonoscopy. MATERIAL OF STUDY: The review has been carried out according to PRISMA statement. The literature search included PubMed and Scopus database. The search string was "pneumothorax AND colonscopy". RESULTS: A total of 36 papers met the inclusion criteria out of 57 non duplicate citations. Papers describing the clinical course of 36 patients with pneumothorax alter colonoscopy plus one case (our personal report), achieving a total of 37 patients available for analysis have been investigated. The review revealed a female predominance. 16 procedures were just diagnostic without biopsies, whereas in 21 cases procedures were performed with interventional maneuvers. The most common clinical feature of extraperitoneal colonic perforation was dyspnea in 31 patients (84%). Treatment included unilateral or bilateral chest drain, chest drain and laparotomy, only laparotomy or laparoscopìc approach, endoscopic treatment and conservative management was also reported. DISCUSSION: Rarely, colonic perforation during colonoscopy can occur into the extraperitoneal space, thus leading to the passage and diffusion of air along the fasciai planes and large vessels, possibly causing pneumoretroperitoneum, pneumomediastinum, pneumopericardium, pneumothorax, and subcutaneous emphysema. The combination of intraperitoneal and extraperitoneal perforation has also been reported. CONCLUSION: Pneumothorax and tension pneumothorax following a colonoscopy is an extremely rare but severe and often lifethreatening complication. If the patient develops dyspnea and pneumoderma during or alter this procedure, a chest radiogram or thoracoabdominal CT should be taken for diagnostic purposes. Urgent treatment, starting with chest tube insertion(s) and laparotomy or laparoscopy could be lifesaving. KEY WORDS: Colonic perforation, Colonoscopy, Pneumothorax.

Parathyroid Autotransplantation During thyroid Surgery. Where we are? A Systematic Review on Indications and Results.

Introduction: Hypoparathyroidism still represents an important concern in thyroid surgery. Careful dissection with identification and preservation of parathyroid glands in situ remains the best way to maintain gland vitality and avoid post-operative failure. Nevertheless, parathyroid glands are still inadvertently removed in up to 11% of cases. Parathyroid autotransplantation may represent the only way to restore parathyroid gland functionality in case of inadvertent removal or devascularization during thyroid surgery. Despite this, there is still no agreement on the effectiveness of this procedure. The present systematic review is focused on the mainly debated matters regarding the procedure, indications, technique and results. Methods: This review has been carried out according to PRISMA statement and checklist. The research item was: (((parathyroid autotransplantation[Title]) OR parathyroid reimplantation[Title]) NOT hyperparathyroidism[Title]) AND english[Language]. Results: A total of 31 studies have been found according to limitations already described, reporting from 4 to 890 procedures, with a total amount of 4088 PA. Among these studies, there are only 7 prospective case-series evaluations, 2 prospective randomized trials, while the other 22 studies are retrospective evaluations. The main concerns are: when and how to perform autotransplantation; in which anatomical site; which result to be expected, and how to manage and control the graft. Conslusions: Parathyroid autotransplantatin is an important tool to avoid or minimize the risk for hypoparathyroidism following thyroid surgery in selected cases. Parathormone assay can help the surgeon to determine when reimplantation is indicated or not. Further studies could theoretically give definitive results.

Epidermal inclusion cyst of the breast: A literature review.

An epidermal inclusion cyst (EIC) of the breast is a rare, benign condition that may potentially be malignant. The present study conducted a systematic review of the literature in order to identify pathological hypotheses, clinical characteristics, and diagnostic and treatment options. A search for relevant studies was conducted through the Scopus, Embase and Medline databases during September 2014. The search term employed was ῾epidermal inclusion cyst breast᾽. Studies were selected if they contained adequate information regarding symptoms at presentation, diagnostic tools, pathology, characteristics, type of procedure performed and follow-up routines. A total of 35 papers describing 91 patients affected by EIC of the breast were identified. Following this, a total of 82 patients, including an additional case supplied from the present study, were selected for further analysis. EIC of the breast typically occurs during the fifth decade of life. A palpable mass of the breast was present in 65 (79%) patients. Ultrasonographic imaging was consistently utilized as a diagnostic tool in all the cases analyzed, whereas fine-needle aspiration cytology was used in 70% of the cases and mammography in 65%. No tumor recurrence was reported at a mean follow-up time of 53 months. The present study demonstrated that elliptical excision is the preferred treatment for EIC of the breast, with pathological analysis required to exclude malignancy.

Cystic adrenal lesions: clinical and surgical management. The experience of a referral centre.

BACKGROUND: Cystic adrenal lesions (CALs) represent a rare entity having heterogeneity in etiology and clinical manifestations. Due to their very low incidence and heterogeneity in clinical aspects, many controversials still exist about their management. METHODS: From 1984 to 2012, 21 patients (7 M, 14 F, mean age 48.2 years) underwent adrenalectomy for CALs. 9 patients suffered from hypertension, and 7 were affected by thyroid disorders. RESULTS: 4 patients presented with vague abdominal pain, while in 17 patients the CAL was incidentally identified during imaging examinations. All patients underwent evaluation of adrenal functionality and imaging study. We found 1 case of cystic pheochromocytoma (confirmed by urinary and blood sampling, and MIBG-scan). All patients underwent adrenalectomy (open approach in the first 10 patients treated from 1984 to 1996, laparoscopic lateral transabdominal approach in the other 11 cases). Indication to surgery included: size over 4.5 cm in 16 cases, suspected malignancy at imaging evaluation (not confirmed by histology) in 4 cases, cystic pheochromocytoma in 1 case. Histology revealed 11 endothelial cysts, 3 pseudocysts, 6 epithelial cysts and 1 cystic pheochromocytoma. CONCLUSIONS: The presence of CAL, even asymptomatic, requires complete endocrinological evaluation and imaging study. In the presence of large size, endocrine activity or any suspicion of malignancy, patients must be referred to surgery.

Surgery for symptomatic colon lipoma: a systematic review of the literature.

AIM: Isolated colon lipomas are rare benign tumors. We herein conducted a systematic review of the literature to identify clinical characteristic, diagnostic and treatment options. MATERIALS AND METHODS: A search for relevant studies was conducted in Scopus, Embase and Medline databases until the end of May 2014. The search terms were "colonic lipoma and colon lipoma". Articles were included if they had information on symptoms, lipoma characteristics and type of procedure performed. RESULTS: 88 articles describing 184 patients affected with colonic lipomas were found. One hundred and twenty-seven patients were selected for further analysis. The most common signs included abdominal pain, rectal bleeding and alteration in bowel habits. Colonic lipomas were frequently localized in the right colon (50%). The majority of patients had open surgery, whereas current treatment is laparoscopic resection. CONCLUSIONS: Laparoscopic surgery is the current standard-of-treatment of symptomatic colonic lipomas greater than 2 cm in diameter or when malignancy can not be preoperatively excluded.

Recurrence of paratesticular liposarcoma: a case report and review of the literature.

Paratesticular liposarcomas are rare tumors that typically affect adult. Diagnosis is very difficult and inadequate surgical excision leads to a high rate of recurrence.We report a case of local recurrence of paratesticular liposarcoma diagnosed six months following surgery.Since there is low response to adjuvant treatments, extensive surgery remains the only curative approach, as shown by the case described here and the following review of the literature.

Surgical treatment of pheochromocytoma in MEN 2.

Multiple endocrine neoplasia type 2 (MEN 2) is a rare autosomal dominant cancer syndrome. Forty to fifty percent of patients with MEN 2A develops pheochromocytoma. Surgeons treating these patients with pheochromocytoma have always been faced with question of whether to perform mono-or bilateral adrenalectomy and the timing of surgical intervention. Over the past 20 years, thanks to the development of ever more sophisticated techniques of diagnostic imaging (TC, MRI, Scintigraphy, PET), which make it possible to identify small lesions, and to ever more rapid laboratory tests, there has been a change in the surgical management of this condition. Surgeons moved from bilateral open adrenalectomy (6- 9) to laparoscopic partial adrenalectomy and cortical sparing (10-13). After partial adrenalectomy one third of the patients require replacement therapy because the function of the residual parenchyma was compromised by excessive devascularization during surgery. In patients with bilateral pheochromocytoma it is advisable to perform only partial adrenalectomy of at least one gland, i.e. to completely remove the gland with the larger lesion and remove part of the gland with the smaller lesion to reduce the risk of recurrence. The authors report 4 cases of MEN 2, including 2 first-degree relatives, which illustrate the progress made in surgical treatment for pheochromocytoma.

A rare case of malignant epithelioid angiomyolipoma in multiple locations: multifocal disease or metastases?

BACKGROUND: Perivascular epithelioid cell tumors (PEComas), make up a family of extremely rare mesenchymal neoplasms, with characteristic morphological, immunohistochemical and molecular findings. Malignant PEComas and gastrointestinal epithelioid angiomyolipoma (E-AML) are especially rare. To the best of our knowledge E-AML have not been found in the breast. The difficulty in determining what constitutes optimal therapy for PEComas, owing to the sparse literature available, led us to report this rare case. METHODS: We report a case of a 44-year-old woman, with a family history of multiple endocrine neoplasia syndrome (MEN) (gastrinoma, medullary thyroid cancer and parathyroid hyperplasia), affected by PEComa located in the kidney, stomach, ileum, liver and breast. RESULTS: The renal, gastric, ileal and mammarian tumors were completely resected, with no evidence of local disease. Liver lesions were biopsied. The morphological and immunohistochemical findings confirm the diagnosis of PEComa. CONCLUSION: On this basis it is difficult to determine if some E-AML are multifocal tumors or metastatic disease.