Gastric schwannoma: a case report and literature review.

Schwannomas are generally benign, slow growing tumors, which can originate from any nerve that has a Schwann cell sheath. Digestive tract schwannomas are rare and are usually asymptomatic. We present the case of a 48-year-old woman with a symptomatic submucosal tumour of the gastric antrum. The patient underwent partial gastrectomy and the histological and immunohistochemical findings of the resected specimen established the diagnosis of schwannoma.

Repair of a giant inguinoscrotal hernia.

Giant inguinoscrotal herniae are infrequent in developed countries nowadays, nonetheless they may still typically present after years of neglect. The morbidity associated with them can be significant. Surgical management, although challenging even for the experienced surgeon, enables the patient to return to a reasonable level of function and quality of life. We present a case of a giant right inguinoscrotal hernia, which was treated with a multi-stage extensive operation, following adequate pre-operative respiratory preparation. The operation included reduction of the hernial contents in the abdominal cavity following omentectomy, right hemicolectomy and splenectomy, hernioplasty and reconstruction of the abdominal wall with the preperitoneal use of a Composix mesh and finally reductive reconstruction of the scrotum. The technique described represents a successful combination of various techniques described for the management of these patients.

Effect of time on risk of perforation in acute appendicitis.

INTRODUCTION: The aim of this study was to quantify the role of time between symptom onset and surgery on the changing risk of perforation, and to evaluate the possible factors leading to delay to the operation. PATIENTS AND METHODS: The files of 169 patients who underwent appendectomy in our clinic over a two-year period (May 2004-June 2006) were reviewed. The relative risk of perforation was calculated according to the "time-table" method. Time was divided into intervals, initially of 12 hours and, later on, of 24 hours. RESULTS: 18 patients were found to have perforated appendicitis. The time from symptom-onset to first examination ("symptom onset to presentation" time, "SOP" time) was longer for patients with perforation than for those without (p = 0.047). On the other hand, the time from initial examination in the emergency department to the operating room ("ER to OR" time) was shorter for patients with perforation than for those without (p = 0.027). Overall time from symptom onset to operating room, showed no statistical difference between patients with rupture and those without. The risk of perforation was negligible within the first twelve hours of untreated symptoms, but then increased to 8% within the first twenty-four hours. It then decreased to approximately 1.3% to 2% during 36 to 48 hours, and subsequently rose again to approximately 6% (7.6% to 5.8%) for each ensuing 24-hour period. In multivariate analysis, neither the "SOP" nor the "ER to OR" time remained significant contributors to the probability of an individual to suffer from appendiceal perforation. CONCLUSION: When time matters and the risk of adverse outcomes can be reduced, we should change our current approach to care. Surgeons should be mindful of delaying surgery beyond 24 hours of symptom onset in patients with assumed appendicitis.

Hyperhomocysteinemia and hypercoagulable state in carotid plaque evolution. Novel risk factors or coincidental risk predictors?

AIM: The majority of patients with carotid occlusive disease (COD) have one or more of the conventional risk factors of atherosclerosis. In addition, hyperhomocysteinemia (HHCY) and hypercoagulable state (HCGS) are increasingly recognized as potentially ''novel'' risk factors. The aim of this study was to determine the role of these factors in carotid plaque evolution and clinical manifestation of COD. METHODS: Between September 2003 and 2005, 153 patients were admitted in our Department with clinical and duplex ultrasound evidence of severe (>70%) COD as operative candidates and 33 patients with evidence of moderate (50-69%) stenosis included in the protocol of conservative treatment and lifelong observation. Conventional risk factors of atherosclerotic disease and plasma levels of homocysteine (HCY), fibrinogen (FBG), protein C (PC), protein S, antithrombin III and activated protein C resistance were recorded in all patients. The degree of carotid stenosis was measured in a carotid angiogram following North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria for all operative candidates. Angiographic workup revealed 147 carotid stenoses >70% and 16 internal carotid occlusions in 82 symptomatic and 52 asymptomatic patients, while in 19 patients the carotid stenosis was moderate (50-69%) and these patients included in the conservative treatment group. The study of the ''novel'' and conventional risk factors was performed with univariate and multivariate statistical analysis as well as with correlational analysis of HCY and the other risk factors between patients with severe or moderate COD and between symptomatic and asymptomatic patients with carotid stenosis >70%. RESULTS: Our data showed that HHCY was a strong independent risk factor of symptomatic carotid disease >70%. In addition, the coexistence of high FBG levels and thrombophilia factor deficiency with HHCY was significantly related with the clinical manifestation of COD. CONCLUSION: HHCY and HCGS are often detected among patients with severe and symptomatic carotid stenosis. The early diagnosis and treatment of these deficiencies might be helpful for the management of COD, but their role in future clinical practice is yet to be determined.

Primary torsion of the greater omentum. An obscure and unusual cause of acute abdomen.

A 36-year-old man was admitted with a 3-day history of severe abdominal pain in the right upper abdomen and was initially diagnosed with acute cholecystitis or acute retrocecal appendicitis. The patient was transferred to the department of surgery for close surgical observation. CT of the entire abdomen was performed just before the operation, which demonstrated inflammation in the omental fat. Surgery revealed primary omental torsion and subsequent resection of the infarcted segment offered a rapid recovery. We report a case of primary segmental omental torsion and discuss the diagnostic and therapeutic implications of this unusual entity.

Appendiceal mucocele. a retrospective analysis of 19 cases.

BACKGROUND: Appendiceal mucocele is an infrequent well-recognized entity that can present in a variety of clinical syndromes or can be asymptomatic and discovered incidentally. PATIENTS AND METHODS: Nineteen patients with a diagnosis of primary appendiceal mucocele treated in our institution between January 1, 1987 and December 31, 2006 were included in this retrospective analysis. RESULTS: The histological examination of the specimens revealed simple and hyperplastic appendiceal mucocele in nine cases (47%), mucinous appendiceal cystadenoma in eight cases (42%), and mucinous appendiceal cystadenocarcinoma in two cases (11%). Thirteen patients (68%) underwent appendectomy, five patients (26%) right colectomy, and two patients (6%) underwent right colectomy for invasive appendiceal cystadenocarcinoma and at the same time right nephrectomy and sigmoidectomy, respectively, for concomitant malignancy. CONCLUSION: Mucocele of the appendix may be related to a benign or malignant appendiceal process, leading to individualized diagnosis and treatment.

Primary hydatid cyst of the thigh.

Echinococcosis of the musculoskeletal system is found in 0,5-4% of the patients suffering from hydatid disease. We describe a case of primary hydatid cyst of the posterior thigh in a 73 year-old woman, who presented with a painless mass. The diagnosis was set intraoperatively after biopsy of the cyst wall. A wide excision of the cyst with part of the attached muscles was performed. The postoperative course of the patient was uneventful. A postoperative CT-scan of the thorax and abdomen revealed no signs of other echinococcal cysts. Thus, the case was considered as a primary hydatid cyst of the thigh. The patient received adjuvant oral treatment with albendazole for six months. The patient remains in good general condition and without any signs of recurrence, one year after the operation. Hydatid disease should be considered in the differential diagnosis of any cystic mass detected in the thigh, especially if occurs in regions where the disease in endemic.