Iatrogenic rectal diverticulum in patients treated with transanal stapled techniques.

PURPOSE: The aim of this study was to demonstrate the possibility of rectal diverticula developing in patients treated with endoanal circular staplers for haemorrhoids (Longo's stapled haemorrhoidectomy) or obstructed defaecation syndrome [stapled transanal rectal resection (STARR)]. MATERIALS AND METHODS: Between January 2005 and December 2006, we carried out 634 defaecographic examinations. Of these, 45 were postoperative follow-up studies of patients who had been treated with the Longo technique (n = 13) or STARR technique (n = 32). RESULTS: Seven out of 45 patients, five of whom were women treated with the Longo technique and two men with the STARR technique, developed rectal diverticula. One diverticulum was located on the left lateral rectal wall, four on the posterior wall and two on the anterior wall. All diverticula had arisen from the surgical suture point. In one case, the diverticulum was discovered incidentally during a double-contrast barium enema. One of the male patients, who had been treated with the Longo procedure 5 years earlier, developed acute pain due to faecal stasis in a widenecked diverticulum abutting the posterior rectal wall. CONCLUSIONS: The use of endorectal stapling devices can lead to focal weakness at the point of surgical suture on the rectal wall and predispose to the development of rectal diverticula.

Shunt-related abdominal metastases in an infant with medulloblastoma: long-term remission by systemic chemotherapy and surgery.

This is the first reported case of long remission of abdominal metastases spread through a ventriculo-peritoneal shunt in an infant diagnosed, four years ago, at age 1 year and 10 months, to have cerebral medulloblastoma. Two years later, while in second complete remission of his cerebral tumor, he showed abdominal metastases, successfully treated by platinum based chemotherapy and surgery. One year later, a second abdominal relapse and hepatic metastases were treated by doxorubicin administration and surgery. Since then the child remained in continuous complete remission. This unusual favorable outcome can be explained by an extreme responsiveness of the tumor, unprotected by the blood brain barrier, to systemic chemotherapy, particularly to doxorubicin administration. The need for careful surveillance of patients with ventriculo-peritoneal shunts is emphasized. Searching for new tools, such as entrapment of doxorubicin in liposomes, able to overcome the blood-brain barrier and to expose brain tumors to effective drugs, probably represents the best choice for future treatment strategies of CNS tumors.

Hepatic resection for primary giant leiomyoma of the liver.

BACKGROUND: Smooth muscle tumours are common in the genito-urinary and gastro-intestinal tracts, but primary leiomyoma of the liver is extremely rare. Only a few cases have been reported to date. CASE OUTLINE: We report a case of giant leiomyoma of the liver in a 67-year-old woman that was treated by an extended right hepatectomy. There was no evidence of leiomyoma elsewhere in the abdomen (including the uterus). DISCUSSION: This appears to be the largest hepatic leiomyoma reported in the literature.

Morphological imaging of thymic disorders.

The thymus is a bilobed lymphoid organ the morphology of which varies considerably with age as a result of a process of fatty infiltration occurring after puberty. Although several diseases can arise in the thymic parenchyma, including germ cell and neuroendocrine tumours, primitive epithelial neoplasms (thymomas) are the most common neoplasms and account for almost 10% of mediastinal masses. Thymomas are usually benign but can be locally invasive. Up to 30% of patients with a thymoma have myasthenia gravis, which is more commonly associated with thymic hyperplasia. The latter results in a symmetric diffuse enlargement of the thymus. However, thymic hyperplasia can be histologically found in up to 50% of normal-sized thymuses on computed tomography (CT). CT is much more accurate in detecting thymomas than it is in detecting thymic hyperplasia, although CT findings may be unspecific. CT can be exhaustive in the case of an encapsulated thymoma (65% of all thymomas), which appear as a solid homogeneous mass with a slight contrast enhancement and a well-defined surrounding fat plane. These tumours rarely recur after surgery. CT can also accurately detect a spread through the capsule into the adjacent mediastinal fat, which characterizes invasive thymomas (35%). These, however, are best evaluated by magnetic resonance imaging (MRI). On T1-weighted MR scans the thymus is well delineated against the mediastinal fat, whereas marked inhomogeneity of the signal may appear on T2-weighted images as a result of areas of cystic degeneration in the tumour mass. The superior contrast resolution of MRI and the multiplanar images that can be produced with it are well suited for documenting the mediastinal spread of invasive thymomas. MRI depicts accurately pleural and/or pericardial implants as well as the involvement of great vessels, offering considerable aid in the planning of surgery.

Hepatic resection and percutaneous ethanol injection for the treatment of selected patients with more than one hepatocellular carcinoma.

OBJECTIVE: To report our results in a selected series of patients who had two separate hepatocellular carcinomas that were not suitable for treatment by resection alone or percutaneous injection of ethanol alone, whom we treated by a combination of the two. DESIGN: Open study. SETTING: Teaching hospital, Italy. SUBJECTS: 11 patients with Child's grade A or B cirrhosis who had two hepatocellular carcinomas in distant segments of the liver. INTERVENTIONS: Percutaneous injection of ethanol into the smaller of the two nodules before, during, or after resection. MAIN OUTCOME MEASURES: Morbidity, mortality, and recurrence. RESULTS: No patient died and there was one postoperative complication (atelectasis). During a median follow-up period of 24 months (range 8-48) two patients have developed recurrences (at 10 and 18 months). CONCLUSION: Although we have studied only a few patients for a relatively short time this double approach may be an important treatment option for suitable patients with two hepatocellular carcinomas.

[Abdominal mass in childhood: characterization with fine needle percutaneous biopsy guided with computerized tomography]. / Masse addominali nell'età pediatrica: caratterizzazione mediante biopsia percutanea con ago sottile guidata con Tomografia Computerizzata.

INTRODUCTION: CT-guided fine needle aspiration biopsy (FNAB) is known to improve diagnosis of expansile abdominal lesions, especially relative to more invasive procedures like explorative laparotomy. FNAB is not commonly used in pediatric patients because of their poor collaboration and of associated risks. We investigated the feasibility of FNAB in the pediatric age. MATERIAL AND METHODS: Over a 2-year period, we performed CT-guided FNAB of 21 abdominal lesions in a series of pediatric patients ranging in age 10 days to 14 years. Thirteen lesions were in intraperitoneal and 8 in retroperitoneal sites. CT had been performed in all patients but had failed to make a diagnosis. Cytologic samples were obtained with 22-23 G needles; the cytologist was always present to ensure adequate sampling. Follow-up CT was performed to assess the possible onset of complications. RESULTS: First-pass diagnosis was made in 14 of 21 biopsies and second-pass diagnosis in 5; histology was needed in three cases. Cytologic findings were compared with postoperative histologic results in 13 cases; clinical follow-up and further instrumental studies confirmed the diagnosis in nonsurgical patients. CONCLUSIONS: CT-guided FNAB can be performed in pediatric patients with accuracy and confidence. These patients' age calls for great skills of the operator and possible contraindications must be accurately evaluated; complications must not be neglected. FNAB should be performed during CT examination because young patients often require anesthesia. The pathologist's presence during biopsy permits to repeat sampling, if necessary, without repeating the anesthesia. CT-guided FNAB is a valid alternative to explorative laparotomy in the workup of expansile abdominal masses also in pediatric patients.

[Computerized tomography-guided drainage of postoperative abdominal fluid collections]. / Drenaggio guidato con tomografia computerizzata delle raccolte addominali post-operatorie.

INTRODUCTION: We report our personal technique and the results of CT-guided percutaneous drainage of postoperative abdominal fluid collections. MATERIAL AND METHODS: January 1990 to March 1998, eighty-three patients were treated for postoperative abdominal fluid collections. Forty-eight patients had undergone bowel resection, 11 laparoscopic cholecystectomy, 3 cholecystectomy, 5 splenectomy, 3 cephalopancreasectomy, 6 hepaticojejunal anastomosis, 4 hepatic resection, 2 laparocele, 1 hysterectomy. The complications had developed few days to about one year postoperatively. The suspicion of abdominal fluid collection was supported by clinical and laboratory findings. All patients were submitted to a preliminary CT scan to locate the fluid collection, assess its morphology and relationships with surrounding structures, and plan the safest access route. After local anesthesia, a trial fine needle (Chiba 20-22 G) aspiration was performed and then the draining tube was inserted into the collection under CT guidance; the tube caliber depended on the fluid amount and viscosity. After drainage, the tube was removed if CT showed complete resolution of the fluid collection; otherwise it was left in place for subsequent washing of the cavity. Based on clinical, laboratory and CT findings, another CT-guided percutaneous drainage was judged necessary in 30 patients, 2-9 days after the first one. Drainage was considered successful when sepsis resolved and no further percutaneous/surgical drainages were needed. RESULTS: CT-guided percutaneous drainage was successful in 61 of 83 patients (73.5%); the fluid collection resolved after one drainage in 26/61 patients, in 2-9 days in 18/61, and after a second CT-guided drainage in 17/61. Drainage was not resolutive in 22 of 83 patients, because major postoperative complications required laparotomic surgery; these complications were fistulas (anastomotic in 12 cases; pancreatic in 5 and biliary in 3) and segmentary bowel necrosis in 2 cases. Intracavitary bleeding as a catheter-related complication occurred only in one patient with an anterior abdominal wall abscess. CONCLUSIONS: CT-guided percutaneous drainage offers many advantages over surgery: it is less invasive, can be repeated and requires no anesthesia; there are no surgery-related risks and lower morbidity and mortality rates. Moreover, subsequent hospitalization is shorter and costs are consequently reduced. We conclude that CT-guided percutaneous drainage is the method of choice in the treatment of postoperative abdominal fluid collections.

Neurological deficit following spinal anaesthesia: MRI and CT evidence of spinal cord gas embolism.

A 62-year-old diabetic woman developed permanent neurological deficits in the legs following spinal anaesthesia. MRI showed oedema in the spinal cord and a small intramedullary focus of signal void at the T10 level, with negative density at CT. Intramedullary gas bubbles have not been reported previously among the possible neurological complications of spinal anaesthesia; a combined ischaemic/embolic mechanism is hypothesised.

[Computerized tomography and magnetic resonance in the study of retroperitoneal sarcomas]. / Tomografia Computerizzata e Risonanza Magnetica nello studio dei sarcomi retroperitoneali.

PURPOSE: We investigated the yield of CT and MRI in the diagnosis and staging of 15 patients with retroperitoneal sarcomas; these lesions are often asymptomatic and need radical surgery to avoid local recurrences. MATERIAL AND METHODS: April 1993, to September 1997, fifteen patients with retroperitoneal sarcomas were examined and then operated on. CT and CT-guided FNAB were always performed, while MRI was performed in 8 patients only. Because of the high risk of sampling errors, the bioptic specimens were immediately evaluated by a pathologist: a second sampling was required in 10 cases and a third sampling in 6 cases. MRI was performed with a .5 T system (GE Vectra); T1- and T2-weighted transverse images of the abdomen were acquired in all patients and additional coronal and sagittal images were acquired for each abnormal region. All patients underwent surgery and the pathologic diagnosis was compared with CT and MR findings. RESULTS: CT always allowed accurate location of the lesions and identification of their components, especially fat deposits. The cytologic examination of FNAB samples allowed the diagnosis of sarcoma in 12 of 15 cases. CT results were compared with MR findings in 8 patients and the latter method had better spatial definition of the abdominal masses, particularly of vascular structures, which is important for surgical planning. DISCUSSION: The present-day imaging techniques are very important to plan the surgical treatment of retroperitoneal sarcomas. In particular, CT has the advantage of high spatial resolution and excellent tissue contrast from abundant retroperitoneal fat tissue; it also permits the cytologic sampling of viable tumor tissue. However the bulk of such lesions often prevents CT from determining the tumor origin, in which case MRI provides better spatial resolution and vascular detailing, which helps surgical planning. CONCLUSIONS: Both CT and MRI are major tools in the diagnosis and staging of retroperitoneal sarcomas because they can accurately define the borders of large tumors and their relationships with surrounding organs. MRI has the advantage of characterizing the blood supply to the mass, but CT is better to guide FNAB.

Cystic dilation of extrahepatic bile ducts in adulthood: diagnosis, surgical treatment and long-term results.

To evaluate the long-term results of surgery for choledohal cyst in adulthood, a series of 13 patients over the age of 16 operated on for choledochal cyst during a period of six years and followed-up for a minimum of 3 years was analyzed. Patients with type I and IVa cysts underwent extrahepatic cyst resection and Roux-en-Y hepatico-jejunostomy. Choledochoceles (type III) were managed endoscopically. No operative mortality or morbidity occurred. Type I and III cysts showed almost ideal follow-up with no sign of stricture on HIDA scan. One type IVa cyst patients developed recurrent cholangitis due to anastomotic stricture, managed percutaneously. Whenever possible, complete cyst resection and Roux-en-Y reconstruction is the treatment of choice for all extrahepatic biliary cysts. Intra- and extrahepatic dilatations are adequately treated by extrahepatic resection and careful endoscopic or radiologic surveillance. Small choledochoceles can be safely managed by endoscopic sphincterotomy.

CT and anal endosonography in the evaluation of electrically stimulated neoanal sphincter: a preliminary report.

We report a preliminary experience concerning the postoperative assessment of three patients who underwent gracilis neosphincter operation for severe fecal incontinence and were studied by computed tomography and anal endosonography soon after gracilis transposition and later after 6-8 weeks of neuromuscular training. Morphologic assessment was correlated with physiologic testing (manometry). Continence was satisfactorily improved in all patients. Both imaging techniques demonstrated the anatomy of the transposed muscle. Computed tomography also assessed lead placement onto the gracilis nerve root and the completeness of muscle transposition around the anal canal. Anal endosonography provided a more accurate assessment of the relation between the neosphincter and residual external sphincter.

Hepatic incidentaloma. Retrospective analysis of 35 cases.

At present imaging techniques and laboratory tests are employed very extensively to investigate obscure visceral symptoms. During these investigations it can happen that a liver lesion is discovered. This lesion, solid or cystic, when discovered in the liver of a healthy person, is called hepatic incidentaloma. This study analyzes retrospectively the diagnostic and therapeutic management of a series of 35 patients, with an asymptomatic lesion of the liver discovered incidentally. These patients had been observed over a period of five years (1988-1993). There were 22 benign lesions and 13 hepatic cell carcinomas (HCCs), three of which discovered in patients with non diagnosed cirrhosis. The presence of a risk factor for HCC in the past history of the patient with a hepatic incidentaloma strongly suggests that the lesion is malignant (p < 0.05). The average age of patients with malignant lesions was significantly higher than that of patients with benign lesions (65 vs 45 years; p < 0.01). Symptoms and/or signs did not help to distinguish between patients with benign and malignant lesions. Serum alkaline phosphatase (SAP) and alpha-fetoprotein levels were significantly higher in patients with malignancies (p < 0.01). A certain diagnosis was achieved preoperatively in 85% of the cases. In the remaining 15%, a definitive diagnosis was reached only after surgery. Surgical or percutaneous treatment was required in 80% of the cases. In conclusion, although in a minority of cases, surgery is still required for definitive diagnosis of a hepatic incidentaloma.

Primary extrahepatic bile duct carcinoids.

Biliary tact carcinoids are extremely rare: only ten cases have been reported up to now. The Authors describe a successfully treated carcinoid tumour of the proximal bile duct and review the literature about these rare malignancies. Despite extensive preoperative work-up, including ultrasound, CT scan and ERCP, a definite diagnosis is hardly possible prior to histologic examination of the operative or necropsy specimen. Due to the slow-growing nature and the non-aggressive behaviour of these malignancies, surgical resection followed by biliodigestive anastomosis should be the treatment of choice.

[Sacrococcygeal chordoma: clinico-radiologic and histologic characteristics]. / Cordoma sacrococcigeo: aspetti clinico-radiologici e istologici.

Chordoma is a rare, slow-growing, malignant tumor which usually localizes in the sacrococcygeal area. The authors report the case of a 36-year-old woman treated by sacral resection by a posterior approach. At admission, the patient reported a 5-month history of sacral pain. Digital rectal examination revealed a presacral mass. CT and above all MR revealed the presence and the precise extent of the mass which involved the last sacral vertebra and the coccyx. Diagnosis was confirmed histologically. Bilateral S-3 nerve roots were preserved. No radiotherapy was given. After 4 years the patients is free of disease.

[The use of computed tomography guided needle biopsy in thoracic lesions in childhood]. / Impiego dell'agobiopsia con Tomografia Computerizzata guidata nelle lesioni toraciche nell'età pediatrica.

Percutaneous fine-needle aspiration biopsy (FNAB) is widely used in adult but not in pediatric patients, probably because young patients cooperate little. Twenty-six CT-guided FNABs were performed in children aged 40 days to 15 years (mean: 11.6 years) from January through December, 1993. The lesions were found in anterior mediastinum (17 cases), posterior mediastinum (5 cases) and lung (4 cases). Some specimens were fixed for cytology and some were cultured. Twenty-five of 26 biopsies (96.1%) provided adequate material for the cytologic assay, while in one case the result was poor because of much necrotic material. Cytologic findings were compared with postoperative biopsy results in 9 cases and confirmed by follow-up in 17 non-surgical lesions.

[Non-surgical treatment of pseudoaneurysm of the hepatic artery and its branches]. / Trattamento non chirurgico degli pseudoaneurismi dell' arteria epatica e dei suoi rami.

The transcatheter embolization of hepatic artery pseudoaneurysms and of its branches is now considered the most effective tool for their treatment. These lesions are caused by abdominal traumas or inappropriate surgical treatment. These pseudoaneurysms must be treated promptly because they are at high risk for rupture, with subsequent complications such as hematemesis, hemobilia and hemoperitoneum. We treated 7 patients with pseudoaneurysms: 4 of them were in the right hepatic artery, 1 in a right hepatic artery branch, 1 in the common hepatic artery and 1 in the suprahilar hepatic artery. Two pseudoaneurysms were treated with Gianturco coils, 2 with Ivalon particles, 1 with Contour particles, 1 with fibrin particles and 1 with transcatheter occlusion with Bucrylat. Six of 7 patients recovered completely after embolization and in 1 patient only subsequent surgery was required. The success rate of transcatheter embolization was 85%. In our personal experience and from international literature reports, percutaneous embolization emerges as the safest therapeutic approach to hepatic artery pseudoaneurysms, yielding optimal results. In particular, percutaneous embolization is indicated for intrahepatic pseudoaneurysms and extraparenchymal saccular pseudoaneurysms of the common hepatic artery. Moreover, this technique exhibits a lower complication rate than surgery, whose mortality rate ranges 15-20%.