An Unusual Presentation of Crohn's Disease Diagnosed Following Accidental Ingestion of Fruit Pits: Report of Two Cases and Review of the Literature.

The clinical course of Crohn's disease (CD) is often complicated by intestinal strictures, which can be fibrotic, inflammatory, or mixed, therefore leading to stenosis and eventually symptomatic obstruction. We report two cases of subclinical CD diagnosed after fruit pit ingestion, causing bowel obstruction; additionally, we conducted a narrative review of the scientific literature on cases of intestinal obstruction secondary to impacted bezoars due to fruit pits. Symptoms of gastrointestinal bezoars in CD patients are not diagnostic; and the diagnosis should be based on a combined assessment of history, clinical presentation, imaging examination and endoscopy findings. This report corroborates the concept that CD patients are at a greater risk of bowel obstruction with bezoars generally and shows that accidental ingestion of fruit pits may lead to an unusual presentation of the disease. Therapeutic options in this group of patients differ from the usual approaches implemented in other patients with strictures secondary to CD.

Minimally invasive surgical approach for radicalization of incidental post-cholecystectomy gallbladder carcinoma: safety, feasibility and outcomes.

BACKGROUND AND AIMS: Gallbladder carcinoma is a rare but aggressive malignant neoplasm. The incidence of intra- or post-operative incidental gallbladder carcinoma diagnosis following laparoscopic cholecystectomy is estimated to be 1-2%. Aggressive re-resection is warranted as the majority of patients have residual disease either in the liver or the lymph nodes. However the use of a minimally invasive surgical approach (MISA) to perform a radicalization in these patients has not been investigated yet. We retrospectively analyzed surgical and oncologic outcome of a small selected cohort of patients with incidental gallbladder carcinoma whom underwent redo radicalization surgery by MISA. MATERIAL AND METHODS: From April 2012 to June 2014 at our department six patients (three females and three males) with incidental findings of gallbladder carcinoma pT1b (stage I) following laparoscopic cholecystectomy, and referred to our center from other secondary-level referral hospitals, underwent a redo surgery for radicalization by means of laparoscopic (n. 3) or robotic approach (n. 3). A retrospective analysis of prospective collected data was performed. RESULTS: The redo procedure consisted of a liver resection (segments IVb + V) and lymph nodes clearance of hepatoduodenal hilum and common hepatic artery. Conversion rate was zero. Median operative time was 290 (250-310) min. Estimate blood loss was 175 (100-350) ml. Total hospital stay was 6 (5-10) days. All liver resections were performed without inflow vascular clamping. One patient was re-operated for hemoperitoneum while peri-operative mortality was zero. Oncologically, an R0 resection was always achieved with a mean number of lymph nodes retrieved of 17,5 (14-22). The stage of the neoplasm was confirmed in all cases but one, who was found to have a pN1 status (stage IIIb). At 21 (6-32) months follow-up all patients are alive and no recurrence has been observed. CONCLUSIONS: Our data suggest that radicalization of patients with stage I incidental postoperative gallbladder carcinoma can be done by a MISA without compromising the oncologic outcome. Larger studies are needed to validate these results.

[Laparoscopic incisional hernia repair: our experience and review of the literature]. / La riparazione laparoscopica del laparocele. Revisione della letteratura e nostra esperienza.

Incisional hernia after laparotomy closure continues to be an important postoperative complication. Historically, the best results have been obtained with the open Rives-Stoppa technique. This approach is done by fixing a prosthetic mesh behind the posterior fascia of the rectus muscle. The laparoscopic approach allows similar mesh placement with minimal dissection. In this study, we review the scientific literature and report our experience, describing the clinical outcome of patients who have undergone laparoscopic repair of ventral hernias. After describing the standard technique of laparoscopic insertion of a prosthesis, we reviewed the records of all our patients who underwent such a procedure from March 2004 to January 2006. A laparoscopic approach was attempted in all patients. The patients' demographic characteristics, operative details and outcomes were recorded. Of 55 patients scheduled to undergo laparoscopic incisional herniorrhaphy, conversion to an open procedure was necessary in 2/55 (3.6%). All the remaining 53 patients (31 men and 22 women; mean age 51.8 years) underwent laparoscopic repair of ventral hernias. The mean fascial defect size was 98.3 cm (range: 5-200 cm). In 52/53 patients (98%) a dual mesh was used. 40% of patients (22/53) had multiple wall defects. The mean operative time was 90 minutes (range: 32-190 minutes). The average hospital stay was 2.6 days (range: 1-16 days). 50/53 patients (94.3%) tolerated an oral diet 24 hours after the operation. 49/53 (92.4%) returned to normal working activity within two weeks. The percentage of complications amounted to 13% (7/55), with 5.6% (5/53) minor and 3.7% (2/55) major complications. In one patient it was necessary to remove the mesh 6 months after surgery because of pain. The recurrence rate of 5.6% confirms the permanence of the repair. The follow-up was 12 months for 44/53 patients and 6 months for 9/53 patients. The procedure for incisional hernia repair used in our study may be performed safely with low complication and recurrence rates and should be considered for the majority of incisional hernia repairs requiring a mesh prosthesis.