[Retroperitoneal giant schwannoma: a case report and review of the literature]. / Schwannoma gigante retroperitoneale: presentazione di un caso clinico e revisione della letteratura.

Schwannomas are rare tumours that originate in the neural sheath and account for only a small percentage of all retroperitoneal tumours. They are usually solitary, circumscribed and encapsulated lesions eccentrically located on proximal nerves or spinal nerve roots. Presentation is typically varied and non-specific, ranging from abdominal pain, an abdominal mass or an incidental finding. The preoperative diagnosis is difficult and laboratory tests are usually unremarkable. We report the case of a 66-year-old female presenting with abdominal pain in her left flank and with an ultrasonographic diagnosis of a left kidney mass. She was diagnosed as suffering from a giant retroperitoneal schwannoma after surgical exploration and complete excision. The role of CT scan and CT-guided needle biopsy is emphasised, in that ultrasonography and fine needle aspiration alone do not provide sufficient information regarding aetiology and malignancy. Radical surgical excision is curative but recurrences may occur. Careful follow-up is needed.

[Laparoscopy in traumatic abdominal emergencies]. / La videolaparoscopia nelle urgenze addominali non traumatiche.

Over the past few years the laparoscopic technique has changed most of the concepts of traditional surgery and is today the standard approach in elective surgery for many pathologies requiring surgery. Unfortunately the same cannot be said for emergency surgery, though much progress has been made in this field, too. The Authors examine the most important abdominal diseases that can be diagnosed and, possibly, treated by the laparoscopic approach in the emergency setting, concluding that laparoscopic management of such conditions is a feasible proposition in many cases. Technological improvements and the development of new, more versatile surgical instruments will undoubtedly contribute to the increasingly widespread use of the laparoscopic approach also in emergency procedures.

Gallstone ileus: report of a case successfully treated by a laparoscopically-assisted enterolithotomy.

Gallstone ileus is an unusual cause of small bowel obstruction that occurs more frequently in elderly patients. The diagnosis is always very challenging and in most of cases this rare complication is misdiagnosed before surgery. The Authors report on a 81-year-old woman with small bowel obstruction who was laparoscopically diagnosed with gallstone ileus and successfully treated by a laparoscopically-assisted enterolithotomy.

[Role of ultrasonography in the non-operative management of liver traumas]. / iI ruolo dell'ultrasonografia nel trattamento non operatorio dei traumi epatici.

The technical progress in imaging methodology and intensive care over recent years has allowed a reduction in surgical operations for hepatic trauma. In the past, surgeons based their evaluations on clinical findings and patients in critical condition were submitted to surgery. The percentage of negative laparotomies was high (6% to 25%) due to non-haemorrhagic hepatic lesions at surgery. The introduction of ultrasonography and computed tomography offered two important tools for determining the origin and extent of traumatic lesions of the liver and other abdominal organs. These modern imaging techniques enable us to diagnose and monitor patients with hepatic trauma with a reduction in negative laparotomies and allow conservative treatment of numerous traumatic lesions of the liver. Despite the diagnostic superiority of computed tomography in the evaluation of patients with hepatic trauma, the risk of exposure to ionising radiation in several, consecutive examinations in patients undergoing conservative treatment has aroused considerable interest with regard to the use of ultrasonography for both the initial and later evaluation of such patients. We report on our experience with 28 patients with liver traumas, focusing on the role of ultrasonography in their non-operative management.

Duodenal perforation secondary to biliary stent dislocation: a case report and review of the literature.

Gut perforation secondary to the insertion of a biliary stent is an uncommon but potentially life-threatening complication. Duodenal perforation has to be taken into consideration whenever the patient starts to suffer severe abdominal pain after the stenting procedure. An early diagnosis is fundamental in order to avoid further complications. Timely conservative treatment with nasogastric suction, nothing by mouth, antibiotics and stent replacement could prevent infection and consequent development of an abscess. We report a case of duodenal perforation secondary to biliary endoprosthesis dislocation in which, in spite of prompt diagnosis and treatment, a large retroperitoneal abscess developed and a CT-guided drainage proved necessary followed later by a surgical operation.

Incidental gall bladder carcinoma: does the surgical approach influence the outcome?

BACKGROUND: The aim of the study was to evaluate the outcome in patients with unsuspected gall bladder carcinoma diagnosed after cholecystectomy, comparing the laparoscopic approach with open surgery. METHODS: A retrospective study was done of 16 patients who were diagnosed with unsuspected gall bladder carcinoma out of the 2850 who had undergone cholecystectomy for symptomatic cholelithiasis at our institution between 1990 and 2004. Eight cases (seven women and one man, mean age 63 (range 49-75 years) ) were diagnosed after laparoscopic cholecystectomy (group A) and eight cases (six women and two men, mean age 63 (range 50-79 years) ) after open cholecystectomy (group B). We evaluated the outcome in the two groups correlating the cumulative survival rates with tumour stage and surgical technique. RESULTS: In group A, three patients had port-site recurrence (1 pT1a and 2 pT1b tumours) after 6, 7 and 9 months, one had intraperitoneal dissemination (pT2) after 3 months, and four had no recurrence (1 pTis, 2 pT1a and 1 pT1b). In group B, five patients had recurrences (4 pT1b and 1 pT2) after an average of 8 months (range 5-11) and three had no recurrence (1 pTis and 2 pT1a). Survival rate was statistically correlated with tumour stage but not with the surgical approach used to perform cholecystectomy. CONCLUSIONS: The surgical approach used for cholecystectomy would seem not to influence the outcome in patients with unsuspected gall bladder carcinoma. The tumour stage is the most important prognostic factor.

Laparoscopic cholecystectomy in Child-Pugh class C cirrhotic patients.

OBJECTIVES: This study aimed to determine whether laparoscopic cholecystectomy is a safe and advisable procedure in Child-Pugh C cirrhotic patients with symptomatic cholelithiasis. METHODS: The records of 42 laparoscopic cholecystectomies performed between January 1995 and February 2004 in patients with Child-Pugh A, B, and C cirrhosis were retrospectively reviewed, focusing on the 4 patients with Child-Pugh C cirrhosis. RESULTS: Among the 38 Child-Pugh A and B patients, no deaths occurred. In this group, only 1 Child-Pugh B cirrhotic patient required blood transfusion, and postoperative morbidity occurred in 10 patients including hemorrhage, wound infection, intraabdominal collection, and cardiopulmonary complications (morbidity rate 26%). The mean postoperative stay was 5 days (range, 3 to 13). The indication for surgery in the 4 Child-Pugh C patients was acute cholecystitis. In this group, 2 deaths occurred for severe liver failure in 1 case and for sepsis in the other. One patient developed heavy gallbladder bed bleeding, and a second operation was necessary to control the hemorrhage. The morbidity rate was 75%. Only 1 patient had no complications. The mean postoperative stay was 10 days (range, 4 to 17). CONCLUSIONS: Laparoscopic cholecystectomy is a safe procedure in well-selected Child-Pugh A and B cirrhotic patients indicated for surgery, but it is a very high-risk procedure in Child-Pugh C patients. Indications for surgery in Child-Pugh C patients should be evaluated very carefully and surgery should be avoided unless the patient needs an emergency cholecystectomy for acute cholecystitis. Child-Pugh C cirrhotic patients might better benefit from percutaneous drainage of the gallbladder.