Ileal schwannoma causing intussusception in an adult.

Ileal schwannomas are extremely rare tumours. Very few cases have been previously reported. Most cases present with abdominal pain and gastrointestinal bleeding; intussusception is a rare presentation. Due to limitations in imaging modalities, arriving at a diagnosis preoperatively can be challenging. The only reliable method of diagnosis, and treatment, is resection of the tumour, followed by histological and immunohistochemical testing. This report details the rare case of intussusception as the presenting feature of an ileal schwannoma.

Intragastric balloon followed by biliopancreatic diversion in a liver transplant recipient: a case report.

Liver transplantation is a life-saving procedure for end-stage liver disease. In liver transplant recipients, morbid obesity influences post-operative survival and graft function. In 1996, our patient underwent a successful liver transplantation because of a HCV-related liver failure (body mass index (BMI) 31). Follow-up showed a functional graft and the development of severe obesity up to a BMI of 61 in January 2006. In January 2007, he was submitted to intragastric balloon therapy for 6 months, reaching a BMI of 54. In September 2007, he underwent a biliopancreatic diversion. During follow-up to March 2008, he reached a BMI of 42 with ameliorations of comorbidities. In May 2008, during a hospital admission, he suddenly died of a heart attack. Post mortem study revealed a myocardial infarction. This is the first world case report for this approach. According to our opinion, patient's death was not related to bariatric surgery.

Laparoscopic reoperative approach after open bariatric surgery.

The aim of the study was to evaluate the laparoscopic approach to reoperative bariatric surgery. From January 2003 to July 2007, 26 obesity surgery patients were referred to our Institution for revision. Nineteen patients previously had an open gastric banding, 3 an open vertical banded gastroplasty, 2 an open jejunoileal by-pass (J-l BP) and 2 an open gastric by-pass. Indications for re-operation were insufficient weight loss in 14 patients, band slippage in 7, band erosion in 3 and severe malabsorptive syndrome in 2. Mean preoperative BMI was 45 kg/m2. Twenty-six laparoscopic re-operative procedures were performed. Three patients required a third operation. Eleven gastric banding patients underwent band removal, 7 gastric banding patients were converted to an open gastric by-pass, 1 band was removed and simultaneously re-placed, the 2 jejuno-ileal by-pass patients underwent an intestinal restoration, 3 vertical banded gastroplasty patients were converted to laparoscopic gastric by-pass, 1 open gastric by-pass patient was converted to a laparoscopic long-limb gastric by-pass and in 1 patient with a gastro-gastric fistula after open gastric by-pass the fistula was resected. Further procedures included 1 laparoscopic gastric banding, 1 laparoscopic gastric bypass and 1 laparoscopic bilio-pancreatic diversion. Conversion to laparotomy was needed in 5 cases (5/29, 17.2%). Early complications included 1 case of pneumothorax and 6 cases of wound infection (24.1%). Mortality was zero. The mean follow-up was 36.2 months. Mean postoperative BMI was 34.3 kg/m2. Laparoscopic reoperative bariatric surgery is feasible, safe and effective after open bariatric surgery.

Early (1 hour) post-operative parathyroid hormone (PTH) measurement predicts hypocalcaemia after thyroidectomy: a prospective case-control single-institution study.

The aim of the study was to evaluate the efficacy of parathyroid hormone 1-hour assay for the early prediction of hypoparathyroidism after thyroidectomy. Candidates for total, subtotal, completion thyroidectomy or lobectomy were entered into the study. Pre- and postoperative calcium and parathyroid hormone (1 hour and postoperative day 1 after thyroidectomy) levels and clinical hypocalcaemia were recorded. Patients were divided into 3 groups and 2 subgroups: 1. patients who underwent lobectomy (control group); 2. patients who underwent total thyroidectomy with postoperative hypocalcaemia (2A: asymptomatic patients, 2B: symptomatic patients); 3. asymptomatic patients with normal calcium levels after total thyroidectomy. Of 119 patients, 109 underwent total thyroidectomy and 10 lobectomy. Of the 109 patients submitted to total thyroidectomy, 35 (32.11%) developed postoperative transient hypocalcaemia. Twenty-one patients (19.27%) were asymptomatic and 14 (12.84%) were symptomatic. Parathyroid hormone levels decreased after 1 hour in group 3 (32.98 pg/dl), 2A (9.84 pg/dl) and 2B (7.46 pg/dl). There was no significant difference in parathyroid hormone levels at 1 hour between group 2A and 2B (p = 0.06), but were significantly lower compared to groups 3 and 1 (p < 0.05). Parathyroid hormone levels at 1 hour after total thyroidectomy is a good predictor of early hypocalcaemia. It might be more useful than serum calcium monitoring for the early identification of patients requiring postoperative calcium supplementation.

[Trocars and hernias: a simple, cheap remedy]. / Trocar ed ernie: un rimedio semplice ed economico.

Trocar-site incisional hernias and their complications are reported in 1% to 6% of patients. Such hernias are attributed to the difficulty of applying standard suturing techniques to wound closure. We report our experience with a simple device, the Deschamps ligature needle.

Laparoscopic suture repair of a perforated gastric ulcer in a severely cirrhotic patient with portal hypertension: first case report.

BACKGROUND: Open digestive surgery in cirrhotic patients is associated with high morbidity and mortality. Laparoscopy in this setting has the potential to reduce postoperative complications. Laparoscopic treatment of a perforated gastric ulcer in a severely cirrhotic patient with portal hypertension is herein described. METHODS: A 75-year-old woman affected by cirrhosis of the liver (Child class C) and chronic gastric ulcer presented with acute abdominal pain. The diagnosis of perforation was made with plain films of the abdomen and computed tomography. Diagnostic laparoscopy showed intense peritonitis due to a perforated ulcer of the anterior gastric wall, 2 cm proximal to the pylorus. Suture closure and placement of an omental patch were performed laparoscopically. RESULTS: Postoperative recovery was complicated by a minor leak of the gastric suture, managed by total parenteral nutrition. Closure of the gastric wound was demonstrated by Gastrografin studies on the 10th postoperative day. The patient was discharged on the 16th postoperative day. At 3-months follow-up, the patient is alive and free of gastric disease.

[Impact of laparoscopic surgery in the treatment of chronic abdominal pain syndrome]. / L'impatto della chirurgia laparoscopica nel trattamento della sindrome del dolore addominale cronico.

Chronic abdominal pain syndrome is becoming increasingly important with regard to the quality of life of the patients and its social and economic impact, in terms of cost of hospitalization, income loss due to sick leave, and pharmaceutical costs for treatments which fail to offer either significant clinical improvement or resolution of the pain symptoms. The main symptom is chronic abdominal pain, which may vary in intensity and may be associated with constipation and episodes of vomiting, when the clinical picture evolves toward one of subocclusion or total occlusion of the bowel. We considered the following criteria in our selection of patients for this study: 1) quality of life, 2) constant use of antispastic and analgesic medications, 3) absence of any other diagnosticable pathology prior to the operation. From August 1992 to April 2000 we operated on 105 patients with this syndrome (16 males and 89 females). Among these 8 patients had never been subjected to a laparotomy, while 97 had previously undergone surgical procedures (126 laparotomies). In the first 85 patients in the series (81%) we used a 10 mm laparoscope (0-30 degrees) to evaluate the presence of abdominal-visceral adhesions based on the type of surgery the patient had undergone previously, as well as the location of the pain reported by the patient. In 41 cases (48.2%) the pneumoperitoneum was obtained with the Veress needle. In another 44 cases (51.8%) the Hasson technique was used. Since June 1999, we have carried out the exploration of the abdominal cavity in 20 patients (19%) using a trocar and 2.2 mm laparoscope in the left hypochondrium along with a mini-trocar placed either in the right or left flank. (The positioning of the trocars depended on the previous surgical procedures performed). The exploration included inspection of the abdominal cavity. In 8 of the patients the procedure was carried out under local anaesthesia We performed laparoscopic adhesiolysis in 93 cases; in 7 cases no signs of adhesions were seen, while in another 5 cases it was necessary to convert the original laparoscopic procedure to a laparotomy. The types of adhesions found were fine-filmy (46%), dense-vascularised (46%), and cohesive (16%). In 6 cases during lysis of the adhesions complications of serous-muscular lesions occurred, which required laparotomic repair. In 5 cases we diagnosed a pathological condition which was not suspected. The average postoperative hospital stay was 2 days (range: 1-7); no major postoperative complications were noted. In the course of the follow-up of 78 patients over an average of 37 months (range: 6-72) the results obtained were as follows; 47 patients (60.2%) had complete pain relief, 18 patients (23.1%) had partial pain relief, and the remaining 13 patients (16.7%) had no significant pain relief. Laparoscopic exploration in patients with chronic abdominal pain is technically feasible in a simple manner in most patients. By means of careful and accurate preoperative selection of the patients partial if not complete pain relief can be achieved in a high percentage of cases (83.3% in our series).

Port-site closure: a new problem, an old device.

OBJECTIVE: Trocar-site incisional hernias and their complications are reported in 1% to 6% of patients. Such hernias are attributed to the difficulty of applying standard suturing techniques to wound closure. We report our experience with a simple device, the Deschamps ligature needle. METHODS: The Deschamps needle has a handle and a tip (sharp or blunt), with an opening to pass suture. The blunt tip is very effective for closing trocar sites. Disposable needles are obviously sharp, but can bend on the needle holder and break in a deep small incision. The Deschamps needle is a rigid, noncutting instrument that can be forced through fascia and peritoneum (around the surgeon's fingertip) avoiding loss of pneumoperitoneum. A full-thickness closure is accomplished. We perform closure under direct vision through the scope. Tactile sense is provided by the surgeon's finger. The last trocar site is closed in the same manner without the scope. RESULTS: We have used the Deschamps needle since 1992 in all (1400) laparoscopic procedures. We close 10-mm and 5-mm trocar sites and have not observed wound dehiscence or hernias at these sites. CONCLUSION: The Deschamps needle is effective in preventing incisional hernias and wound dehiscence. It is cost-effective. Disposable, single-use devices vary in price from $30 to $75 each. The Deschamps needle is sold in Italy at approximately $35 each. Considering that it may have been in the trays of most operating rooms for years (as in our case), and the number of procedures performed, we conclude that the real cost of this instrument is almost negligible.