Retroperitoneal paraduodenal unicentric Castleman disease: case report and review of the literature.

Castleman disease is a rare and benign disorder, characterized by enlarged lymph nodes and angiofollicular lymphoid hyperplasia. We report a case of a 57-year-old male, who was admitted to our surgical department because of a retroperitoneal nodular mass measuring about 4 cm in maximum diameter, incidentally discovered on a radiologic exam performed for the onset of vague abdominal pain with posterior irradiation. The patient was subdue to laparoscopic removal of the mass and no intra- and post-operative complications were recorded. Histologic diagnosis of hyaline-vascular variant of the Castleman disease was confirmed. Only two cases have been found in the literature reporting the paraduodenal unicentric Castleman disease localization like our case. Although rare, the Castleman disease must be considered in the differential diagnosis among all the lymph nodes diseases, for avoiding improper therapies.

An unusual association between pancreatic cancer and Purtscher-like retinopathy: Presentation of a unique case.

INTRODUCTION: Purtscher's retinopathy causes sudden loss of vision of varying severity, secondary to head injury or chest compression. Its pathophysiology is unclear. Purtscher's-like retinopathy has more attenuated clinical and objective features and can be associated with many non-neoplastic pathologies. Otherwise, an association of this kind of retinopathy with malignancies has been described once in the Literature. We present a case report on a unique association between pancreatic cancer and Purtscher-type retinopathy. CASE PRESENTATION: A 79-year-old man with reduced central vision in both eyes required an ophthalmic evaluation. Visual acuity was 20/40 in the right eye and 20/50 in the left eye. Fundus examination showed yellow-white peripapillary spots and bilateral retinal hemorrhages in the superficial retina. The patient complained of abdominal pain and received a CT scan of the abdomen, which showed a pancreatic mass extending into the spleen. A percutaneous needle biopsy sample showed mucinous pancreatic adenocarcinoma. CLINICAL DISCUSSION: This case report should warn of a possible association between pancreatic adenocarcinoma and Purtscher's-like retinopathy. CONCLUSION: Patients with this kind of retinopathy should be evaluated to rule out not only benign associated disease, but also malignant tumors of the pancreas.

Appendicular schwannoma Review of the literature on a rare benign tumor often mistaken for hyperplasia.

INTRODUCTION: Appendicular schwannoma is a rare benign neoplastic proliferation of the appendicular Schwann cells. It is often asymptomatic until it occludes the appendicular lumen thus causing appendicitis-like symptoms. EVIDENCE ACQUISITION: The neoplastic proliferation of the Schwann cells, although benign, may rarely degenerate into a malignant neoplasm, thus denoting the importance of diagnosis. Some Authors in the Literature used the term "neuroma" or "neurinoma" to indicate either a hyperplastic proliferation of the Schwann cells or its neoplastic but benign proliferation, thus raising the important question of a probable mistaking of these two different histologic entities. The hyperplastic proliferation is usually subsequent to a chronic appendicular inflammation, and it is a more common finding in specimen of appendectomy. EVIDENCE SYNTHESIS: Aim of the study is to review the published scientific papers about the rare histologic entity of appendicular schwannoma and to define the not clear aspects of Schwann cell neoplasia versus hyperplasia. A review of the Literature from Medline/Pubmed has been accomplished. Forty-four studies from the Literature resulted suitable for our study. CONCLUSION: Appendicular schwannoma has to be considered in patients with recurrent right lower quadrant pain, and may affect the patient's prognosis if it remains undiagnosed, since it may degenerate in malignancy. There is a lack of clarity in the Literature about the distinction between the hyperplastic and the neoplastic benign Schwann cells proliferation, which must be clarified. The meaning of the terms "neuroma" and "neurinoma" should be standardized, the first referring to the hyperplastic proliferation, and the second to the neoplastic but benign proliferation of the Schwann cells. KEY WORDS: Appendiciis, Appendectomy, Appendicular neuroma, Appendicular neurinoma, Appendicular schwannoma.

Ergonomics in laparoscopic surgery.

BACKGROUND AND OBJECTIVES: Laparoscopic surgery is a widely used surgical technique, whose benefits either for patients or for surgeons are well-recognized. Despite the rise in the use of this technique, the ergonomics of the operating room is still very low. The consequence is that injuries and illness related to laparoscopic surgery are present. The aims of this study are to investigate how an increase in the surgeon' perception of the fatigue during the execution of the intervention influences the surgeon' health, and to evaluate if there is a correlation between the increase in fatigue and the operating field dimension. MATERIALS AND METHODS: The observation was conducted on a single laparoscopist working at our Institution and the Borg CR 0-10 scale was used to perform this study. Two groups of 20 surgical procedures each were analysed. Group A included laparoscopic procedures whose operating field comprehended only one abdominal quadrant. Group B included laparoscopic procedures where at least two abdominal quadrants were involved in the operative field. RESULTS: The results from both groups were statistically compared. There was a significant correlation between the increase in perception of the exertion and duration of the intervention in both groups and a significant difference in term of Borg scale value, which was higher in group B where the laparoscopic surgery was performed on more than one quadrant of the abdomen. CONCLUSION: We suggest an important improvement in the ergonomic aspects, especially in more complex laparoscopic procedures that require longer operating time and include more than one abdominal quadrant. KEY WORDS: Ergonomics, Laparoscopic surgery, Operating theatre.

Offending staple as an unusual but preventable cause of internal hernia with bowel obstruction Case report and review of the Literature.

In the laparoscopic era, the use of the stapler is a common practice and it adds to the possible causes of post-operative bowel adhesions with obstruction. In this study, we reviewed the Literature in order to study the pathogenesis and the incidence of bowel obstruction after using the laparoscopic stapler. Furthermore, we report a case of a woman who went to our observation for incoming bowel obstruction after laparoscopic ileal resection. In the emergency setting, the laparoscopic exploration revealed that a staple created adherence between an intestinal loop and its mesentery with consequent internal hernia and volvulus. The patient was treated by laparoscopy with removal of the offending staple and resection of the intestinal necrotic segment. Tips and tricks of the surgical technique for avoiding such rare but threatful complication, are discussed. KEY WORDS: Internal hernia, Mechanical bowel obstruction, Laparoscopic stapler, Volvulus.

Transmission ways of Echinococcus granulosus in rare muscular locations of hydatid disease.

The most common modality of transmission of the Echinococcus granulosus is through the alimentary tract. Other ways of infestation are questionable. Airborne penetration of bronchial venules to reach the heart and the systemic circulation has been advocated, but never demonstrated. Direct subcutaneous contamination through an injured skin has also been considered. Moreover, the hypothesis that a contamination different from eggs ingestion is not possible, is justified by the reason that eggs transform into larvae in the gastro-intestinal environment. Therefore, it is accepted the possibility that parasites might reach organs and tissues other than liver and lungs through a lymphatic or venous shunt that skip the portal filter. In cases of myocardial muscle or skeletal muscle involvement, it could be speculated that eggs of Echinococcus granulosus might hatch not only in the gastrointestinal tract, but also in soft tissues due to the lactic acid produced by the muscle. These unconventional ways of transmission suggest that the lifecycle of the Echinococcus is not at all known and must be revised. Issues that can help in ideating new therapies may emerge.

Management of a kidney stone in ectopic pelvic kidney with Extracorporeal Shockwave Litothripsy: Description of a case and revision of literature.

Urolithiasis is one of the most frequent disease in the population and it represents one of the most frequent causes of access to emergency department. In addition. congenital anomalies occur more often in the kidney than in any other organ and the association of both renal abnormalities and stones is of clinical relevance. In this report, we discuss a case of a women with pelvic ectopic kidney affected by a large pyelic stone treated with ESWL (Extracorporeal Shockwave Lithotripsy).

Hemocoagulative post-operative changes after laparoscopic surgery compared to open surgery: the role of lupus anticoagulant.

Although still debated, post-operative modification of hemostasis seems to be less pronounced after laparoscopy compared to open surgery. Antiphospholipid antibodies might play a role in the post-operative thromboembolic risk, although their evaluation in surgical patients has never been performed. Post-operative modification of antiphospholipid antibodies could be related to the surgical approach (laparoscopic or open). In this prospective study, the authors statistically compared the pre-operative values and post-operative modification of antiphospholipid antibodies in two homogeneous groups of patients operated on by laparoscopic and open surgery. No statistical differences within each group and between the two groups were shown comparing mean values of pre-operative and post-operative antiphospholipid antibodies. In the open group, there was a significant difference between pre-operative and post-operative LAC means (P < 0.01). In the laparoscopic group, on the contrary, no significant change in LAC values between pre- and post-operative tests (P = 0.55) was observed. Since LAC could be related to coagulation disorders, this study seems to support that laparoscopic surgery might induce a less risk of post-operative thromboembolic disease.

Benign adenomyoepitelioma of the breast: Presentation of two rare cases and review of literature.

INTRODUCTION: Adenomyoepithelioma of the breast is a rare benign breast neoplasm with a particular behaviour. PRESENTATION OF CASES: We report two cases of adenomyoepithelioma of the breast in two old female patients, diagnosed over a period of 5 years. The clinical presentation, the radiological and the histopathologic findings are discussed. DISCUSSION: Adenomyoepithelioma of the breast is characterized by the proliferation of both epithelial and myoepithelial cells belonging to the breast lobules and ducts. The imaging features are not pathognomonic and FNAB is usually not diagnostic. The morphologic appearance of this tumor varies, and it has to be considered in the differential diagnosis with other breast tumors. Although benign, adenomyoepithelioma has a potential for local recurrence, and malignant transformation is possible; therefore, wide excision is recommended to lower the recurrence rate. CONCLUSION: The rarity of this histological type and the finding of two cases in a relatively short period makes this case report unique.

Intragastric enucleation of stromal tumors through a combined laparoscopic and endoscopic approach.

Dear Editor, We read with great interest the paper entitled "Laparoscopic organ-preserving gastric resection improves the quality of life in stromal tumor patients: an observational study with 23 patients" written by Ozcan et al. in Ann Ital Chir. 2018 Oct 23;7 1. We agree with the Authors that preserving the stomach after excision of stromal tumors is essential to improve the patients' quality of life. We would like, however, to discuss some issues that the paper published by Ozcan et al. might raise. When feasible, laparoscopic surgery is the best procedure for removal of gastric stromal tumors, since it is associated with all the advantages already recognized to the mini-invasive approach 2,3. Furthermore, it allows reducing the entity of the resected stomach wall and, therefore, it may help maintain the stomach functions and a post-operative excellent quality of life. Besides the standard laparoscopic procedure with wedge resection of the stomach, we would like to draw the attention that other mini-invasive procedures might be performed. The standard surgical treatment of gastric stromal tumors typically involves full-thickness resection of the tumor site stomach wall. Surgical treatment could be technically challenging for proximal gastric lesions located near the gastro-esophageal junction. In the article by Ozcan et al. it is not well defined how they approached iuxta-cardial stromal tumors. A combined endoscopic/laparoscopic intraluminal enucleation technique has been proposed by some Authors, including us, in these cases 4-6. Our technique consisted in inserting two 5-mm radially expandable trocars through the abdominal and gastric walls. Through the 5-millimeter trocar, a laparoscope was introduced into the gastric cavity and with an endoscopic polipectomy snare introduced per mouth, the gastric iuxta-cardial lesion was grasped and tractioned. Through the other 5-mm laparoscopic trocar, the iuxtacardial gastric lesion was then removed with a complete submucosal resection. The excellent exposure of the site of excision allowed by the endoscopic traction was essential in this step. The specimen was then pulled away from the mouth after its introduction into a small plastic bag and the gastric holes were closed with monofilament non-absorbable sutures. In selected cases of submucosal iuxta-cardial gastric stromal tumors, as well as in every small stromal gastric lesions, the laparoscopic-endoscopic technique should be preferred since it allows a complete safe and oncologic resection of submucosal lesions, reducing risk of complications (e.g., perforation) and lowering morbidity when compared to other open or laparoscopic approaches.

Idiopathic intramural hematoma of the right colon. A case report and review of the literature.

INTRODUCTION: Intestinal hematoma is usually observed after an abdominal trauma or in patients treated with anticoagulant therapy. Conversely, idiopathic bowel hematoma is very rare, being colon involvement sporadic with few reports in the Literature. PRESENTATION OF CASE: The Authors report a case of idiopathic spontaneous large bowel hematoma. A 48-year-old man was admitted for a thoraco-abdominal pain and signs of acute abdomen and fever. After ruling out heart diseases, a CT scan revealed a marked thickening of the ascending colon wall, obstructing the bowel lumen. Leukocytosis was observed. In an emergency setting, an explorative laparotomy was performed. Hemoperitoneum and a large hematoma involving the caecum and the ascending colon were detected, together with intramesenteric and retroperitoneal blood effusion. A right hemicolectomy was accomplished. Histopathology confirmed the diagnosis of large bowel hematoma. Post-operative molecular diagnostic testing for coagulative disorders failed to demonstrate any genetic variation associate with hemorrhagic predisposition. In the post-operative course, the patient experienced a left basal bronco-pneumonia with increased unilateral pleural effusion, successfully treated by a thoracic drain and antibiotic therapy. DISCUSSION: The reported case and Literature data show that diagnosis of idiopathic colon intramural hematoma is challenging, especially in the emergency setting. Although conservative therapy is the first line treatment, surgery still has an important role when the diagnosis is uncertain, medical treatment fails or a complication, such untreatable bleeding, perforation or occlusion occur. CONCLUSION: The Authors report a very rare case of spontaneous intramural hematoma of the right colon. Surgery still has a role in selected cases.

Laparoscopic surgery with total mesocolic excision in colon cancer. A systematic review of the literature.

PURPOSE: Nowadays, there is no standardization in surgical procedures for treatment of colon cancer. Since its introduction, laparoscopic surgery has gained increasing interest in colorectal surgery and it is now performed worldwide for treatment of colon cancer. Following the concept of total mesocolic excision introduced by Heald in 1988 in order to reduce local recurrence after surgical treatment of mid/low rectal tumors, the idea of complete removal of the mesocolon mesocolic envelope has been developed also for colon cancer, has evolved longtime and complete mesocolic excision has been recently adopted as the optimal approach for colon cancer. However, complete mesocolic excision, whose purpose is to remove all lymphatics and lymph nodes draining the tumor, is still discussed as far as oncologic results are concerned. Moreover, the role of laparoscopic approach for complete removal of mesocolon has to be defined. METHODS: Selection of studies. A MEDLINE-PubMed database search of the current English Literature was performed using the terms: complete mesocolic excision; high vascular ligation; splenic flexure mobilization. INCLUSION CRITERIA: The inclusion criteria were report on CME for colonic cancer with high vascular ligation; minimum number of patients included (20 patients). Two independent reviewers (CRS, IE) extracted the data. RESULTS AND CONCLUSION: In this article, an update from the Literature on results of complete mesocolic excision was undertaken and data have been discussed. The role of laparoscopic complete mesocolic excision in colon cancer patients has been focused, and it seems to be safe and feasible, it should be standardized and hypothetical oncologic advantages should be expected. KEY WORDS: Colorectal-tumor, Complete mesocolic excision, High vascular ligation, Laparoscopic colorectal surgery, Splenic flexure mobilization, Total mesocolic excision.

A rare case of epithelioid hemangiothelioma of the quadriceps.

Hemangioendotelioma is a group of rare vascular tumors with border-line behavior. They may involve internal organs, limbs, bones and soft tissue. The histological variant epitheliod hemangiothelioma is locally aggressive and has metastatic potential. We present a case of a 41-years old woman affected by epitheliod hemangiothelioma of the right quadriceps. The patient complained of localized pain in the anterior region of the right thigh, which started about 3 months earlier during physical exercise. For the increasing size of the lesion, the patient was referred to our Department. On physical examination, the lesion appeared elastic, fixed to the surrounding tissues and painful under pressure. An ultrasound examination revealed a small avascular lesion and a MRI examination showed an oval formation measuring about 18 mm in diameter of nonspecific significance. A surgical removal of the lesion was performed and diagnosis of epithelioid hemangiothelioma was achieved. A complete removal of the quadriceps muscle was then accomplished. In this paper, clinical and oncologic aspects of this rare tumor are discussed KEY WORDS: Epithelioid hemangiothelioma, Lower limbs tumor, Rare tumors.