An extremely rare case of an oversized accessory spleen: case report and review of the literature.

BACKGROUND: The accessory spleen is a congenital defect characterized by a separated ectopic splenic parenchyma. The size is rarely more than 4 cm. The preoperative diagnosis is prohibitive preoperatively. The aims of the present manuscript were to present the case of a patient with a rare oversize accessory spleen and a review of the literature. CASE PRESENTATION: A 15-year-old boy was admitted to the emergency department following blunt abdominal trauma. The computed tomographic scan showed a traumatic rupture of the spleen and a 7-cm mass at the left side of the retroperitoneal space. Conservative treatment started and aborted after 4 h due to the onset of haemodynamic instability. Splenectomy was performed. An accessory spleen was discovered. A second large mass in the retroperitoneum was diagnosed as a second large accessory spleen that was also left in place. The postoperative course was uneventful, and the patient was discharged on the 7th postoperative day. Seven months later, the CT scan showed viability of both accessory spleens. CONCLUSION: An accessory spleen can be variously located and the retroperitoneal position is extremely uncommon. Preoperative diagnosis is still difficult, especially in emergency and as in our case, the literature shows the difficulty of reaching a diagnosis before surgery. The main misdiagnosis is neoplastic disease and for this reason accessory spleen can be wrongly removed. An undiagnosed pre or intra operative retroperitoneal mass, closely to the spleen, have to be managed carefully. The diagnosis of accessory spleen needs to be ever considered as if found, represents a great possibility to conduct a normal life after splenectomy (of main spleen) for trauma.

Open conversion for laparoscopically difficult cholecystectomy is still a valid solution with unsolved aspects.

The difficult laparoscopic cholecystectomy remains a surgical challenge for surgeons who must decide between laparoscopic continuation and open conversion. The balance between the lack of open surgery training of young surgeons and the risk of maintaining the laparoscopic approach in difficult laparoscopic cholecystectomy is still an unresolved problem. Furthermore, the time that must be spent in an attempt to complete laparoscopic surgery before conversion is still controversial. The authors in this letter discuss about these and other questions that still require an answer.

Effective of laparoscopy for post-operative small bowel adhesion in children.

AIM: The aim of this paper is to report a case of a child with adhesive small bowel obstruction treated by laparoscopic ap-proach. CASE REPORT: A 13-year old patient developed a small bowel obstruction caused by adhesion. He was successfully treated by laparoscopic adhesiolysis and was discharged from the hospital on the 7th post-operative day in satisfacto-ry condition. DISCUSSION: this disease is treated by laparoscopy very rarely, especially in children. In patients without comorbidities, such as pulmonary or cardiovascular diseases, laparoscopic approach could be considered as the first approach in children because the patient has the advantage of less pain and short hospitalization. CONCLUSION: Until clinical trials will address guidelines, when possible, laparoscopic approach should be attempted.

A new modified Mayo technique: should the surgeons need a new open technique for hernia repair in their armamentarium?

INTRODUCTION: The Mayo technique is one of the most common techniques used to repair incisional, umbilical, and epigastric hernias. A high percentage of recurrences, together with the use of particular expensive types of meshes, are some of the most relevant problems in this surgical field. PATIENTS AND METHODS: This study is a clinical prospective observational and involves all the patients who underwent procedures using a new modified Mayo technique from 2006 through 2013. The general criteria analyzed were age, sex, obesity, smoke abuse, diabetes, chronic diseases, type of hernia, operative time, morbidity and mortality. All the patients involved in this study were followed-up from 6 to 120 months. RESULTS: The types of hernia were 5 epigastic hernia (20,8%), 8 umbilical hernia (33,3%), 11 midline incision hernia (45,9%). Ten patients (41,7%) presented non-complicated hernias; 8 patients (33,3%) presented strangulated hernias and 6 patients (25,0%) presented obstructed hernias. No intestinal resection was necessary in any of the patients. The mean operative time was 55 minutes (range 30-180). The mean hospital stay of the patients' after-post operative procedure was 4.5 days (range, 2 to 8 days). No major complications have been reported. Only one patient present a recurrence. CONCLUSION: These preliminary results suggest that this modified Mayo technique could be useful in the armamentarium of surgeon to repair incisional, umbilical, and epigastric hernias. More studies are needed to validate the technique.

Modified Mayo Technique for Ventral Hernia Repair: An Experimental Study.

BACKGROUND: To reduce the rate of recurrence of incisional hernia repair associated with open anatomic techniques, we present an experimental study, focusing on two different sutures, with the aim to apply clinically in a revised version of the Mayo technique. METHODS: Thirteen biological tissue samples from adult pig central brawn and upper and lower fasciae were measured using two techniques defined as "œunbroken suture thread" and "œseparated suture stitches" to test the breaking resistance of the two types of suture. RESULTS: The t test results show that the two sets can be considered as different populations. The mean tensile stress ƒmax is greater (with reduced deviation) for the specimens of the set sutured with unbroken thread technique. Student'™s t-test performed on values obtained for each set of samples indicated that the unbroken thread suture technique corresponds to higher ultimate failure strength. CONCLUSION: Considering these results, a modified Mayo technique with continuous closure could be suggested. Of course a valid clinical study is required to better clarify this experimental hypothesis.

Anemia as One of Presenting Symptoms in an Adult with Cyst and Torsion of the Omentum - A Case Report.

BACKGROUND: Torsion is an uncommon disorder of the omentum and cysts are one of the rarest causes of omental torsion. To our knowledge, this is the first report of a case of an omental cyst presenting with both omental torsion and anemia. CASE PRESENTATION: We herein present a case report of a 41 year old indian female patient who presented with anemia (hemoglobin concentration 6.5 g/dL) and intermittent abdominal pain caused by torsion of a hemorrhagic omental cyst. A computed tomography scan, showed an omental cyst with free fluid in the abdominal cavity. At abdominal exploration, 1.5 L of hemorrhagic fluid was confirmed in the abdominal cavity. The cyst and twisted omentum were removed en bloc. The patient had an uneventful postoperative course and was discharged on day 8. At her 2-month follow-up, she was no longer anemic (hemoglobin concentration 10.7 g/dL). CONCLUSION: Cases of anemia associated with omental torsion have been reported in children; however, to the best of our knowledge, this is the first reported case of such a presentation in an adult. In such patients, surgical removal is the treatment of choice. Persons with recurrent abdominal pain and anemia must be assessed carefully and their differential diagnosis should include omental torsion. Appropriate diagnosis and treatment help avoid complications.

Could the complications of megacolon be avoided by monitoring the risk patients? cases report.

We report 2 cases of megacolon associated with cerebrovascular accident and neuropsychiatric drug consumption. Case report 1: a 75-year-old woman with diabetes mellitus, hypertension, tachycardia with atrial fibrillation, bilateral pleural effusions and previous cerebral hemorrhage was admitted in our hospital. She presented clouded sensorium and abdominal distension, with closed alvus. The CT scan showed a distension of the colon, with severe fecal impaction. A volvulus of the sigma was found at surgical intervention.Case report 2: a 59-year-old man with a medical history of oligophrenia was admitted to our hospital for acute abdomen.He presented stupor and closed alvus with abdominal distension. The abdominal CT scan showed a dolichosigma, with fecal impaction. The patient was submitted to a laparotomy and a two millimetres perforation of the sigma was found.The sigma had a diameter of 28 cm and a length of 75 cm.Even if a clear correlation has not been found yet, anomalies of the regulation of the gastro-intestinal motility can occur at different levels in patients with psychiatric or cerebrovascular diseases and drug consumption with anticholinergic properties,and they should be carefully monitored. The purpose is an early diagnosis of colon function anomalies in order to avoid potentially fatal complications.

Role of laparoscopic peritoneal biopsy in the diagnosis of peritoneal tuberculosis. A seven-year experience.

The diagnosis of asymptomatic abdominal tuberculosis,without characteristic laboratory and radiologic findings, is difficult. We therefore investigated the role of diagnostic laparoscopy in patients with suspected peritoneal tuberculosis(PTB). Patients admitted to Hamad General Hospital, Qatar,who underwent laparoscopic peritoneal biopsy for suspected PTB from January 2004 to December 2010 were retrospectively analysed. Factors assessed included patient age, sex, symptoms,clinical signs, CT scan findings, laparoscopic findings andhistopathological diagnosis. A total of 41 patients, 33 males(80.5%) and 8 females (19.5%), of mean age 31 years, underwent laparoscopic peritoneal biopsy for suspected PTB duringthe study period. Abdominal pain was the most common presenting symptom, observed in 33 (80.5%) patients.Computerized tomography (CT) of the abdomen showed as citesin 37 patients (90%), bowel nodules in 22 (54%), peritoneal thickening and nodules in 37 (90%) and enlarged mesenteric lymph nodes in 11 (27%). The classical gross laparoscopic appearance of peritoneal tuberculosis was observed in 38 patients (93%), whereas laparoscopic findings were normal in 3 patients (7%). Histopathological results confirmed granulomatous inflammation in 38 patients (93%). The sensitivity and specificity of gross laparoscopic appearance in diagnosing peritoneal TB were both 100%. Two patients experienced complications from laparoscopy (5%), but there were nolaparoscopy-related deaths. Laparoscopic peritoneal biopsy isa rapid and safe method of accurately diagnosing PTB.

Combined duodenal and pancreatic major trauma in high risk patients: can a partial reconstruction be safe?

Pancreatic trauma is an uncommon injury, occurring in only about 0.2% of blunt abdominal injuries, while duodenal injuries represent approximately 4% of all blunt abdominal injuries. When trauma of the pancreas and duodenum do not permit reparation, pancreatoduodenectomy (PD) is mandatory. In the reconstructive phase, the use of ductal ligation as an alternative to standard pancreaticojejunostomy has been reported by some authors. We report a case of polytrauma with pancreatic and duodenal injury in which the initial diagnosis failed to recognize the catastrophic duodenal and pancreatic situation. The patient was submitted for PD and the pancreatic stump was abandoned in the abdominal cavity after main pancreatic ductal ligation. This technique can minimize the morbidity and mortality of PD in patients with other organs or apparatus involved severely and extensively in trauma.

Thigh emphysema as a first sign of abdominal disease.

Thigh infection is a rare complication of intra-abdominal sepsis that can present with emphysema. We report a case of infection in the thigh resulting from colonic perforation. A 61-year-old woman with cirrhosis, grade Child B6 and diabetes treated with oral hypoglycemic drugs was referred to the emergency department because of a persistent pain in her left thigh and also for some abdominal discomforts during the preceding few days. Ultrasonography identified the presence of gas and fluid in the thigh. The patient received fluids and antibiotics but on the day after she reported an increase in pain. For this reason the patient was submitted to a CT scan that showed a thigh emphysema due to intestinal perforation. The patient was submitted to laparotomy. A Hartmann's procedure was performed, with resection of about 15 cm of affected sigmoid colon. The left thigh wound did not require any treatment.

Primary anastomosis vs Hartmann procedure in acute complicated diverticulitis. Evolution over the last twenty years.

BACKGROUND/AIMS: Aim of this review is to assess the role and indications for primary sigmoidectomy with direct anastomosis for diverticulitis comparing it with the Hartmann's procedures. METHODS: A literature search was performed using MEDLINE (PubMed), Google Scholar and The Cochrane Library and the articles from January 1990 until June 2011 were analyzed. All patients were divided into three groups: primary anastomosis (PA), primary anastomosis and stoma protection (SP) and Hartmann's procedure (HP). Number of patients, overall mortality and morbidity, the rate of fistulization, the rate of reversal after SP (RSP) and after HP (RHP) and the Hinchey classification have been considered. RESULTS: The mortality was of 38/1010 patients (3.8%) for PA, 11/153 patients (7.2%) for SP and 139/800 patients (17.4%) for HP. The morbidity was reported in 103/325 patients (31.7%) in PA, in 23/97 patients (23.7%) in SP and in 290/586 patients (49.5%) in HP. Fistula formation was recorded in 35/625 patients (5.6%) for PA, in 10/149 patients (16.4%) for RSP and 11/426 patients (6.4%) for RHP. The intestinal continuity was restored in 82/628 patients (56.9%) who underwent SP and in 315/581 patients (54.2%) undergoing HP. A total of 790 patients (54.5%) were classified in class I-II Hinchey and total of 659 patients (45.5%) was classified in class III-IV Hinchey. CONCLUSION: The PA has a lower morbidity and mortality in relation to the HP and except some limited indications, should be used as treatment of choice in the case of diverticulitis.

Telbivudine on-treatment HBsAg loss in naive HBeAg negative chronic hepatitis B: a case report and brief review of the literature.

The authors describe the clinical case of a naive patient with chronic hepatitis HBV-related (CHB) HBeAg negative, treated with Telbivudine (LdT) 600mg/day. After six months of treatment, as well as it determines rapid, profound and sustained suppression of HBV replication, LdT induced a progressive decline of HBsAg serum level and HBsAg loss, probably through an immune modulator effect. Recent studies have indicated the possible action of LdT on the immune system and specifically it would be able to stimulate Th1 lymphocyte subpopulation by increasing their cytokines production, thus playing a major role in cleaning the HBV infection. This aspect appears to be of much interest in clinical practice, because on-treatment HBsAg rapid decline >1 log10 IU/mL during the first year of treatment is highly predictive for future HBsAg clearance and CHB resolution.

Diagnostic and prognostic value of alpha-fetoprotein, des-γ-carboxy prothrombin and squamous cell carcinoma antigen immunoglobulin M complexes in hepatocellular carcinoma.

The hepatocellular carcinoma (HCC) is one of the most common malignant tumors. It carries a poor survival rate and has an increasing incidence worldwide. In most cases, HCC is diagnosed at a late stage. Therefore, the prognosis of patients with HCC is generally poor and has a less than 5% 5-year survival rate. The aim of this study was compare the accuracy of α-fetoprotein (AFP), des-γ- carboxy prothrombin (DCP), squamous cell carcinoma antigen-immunoglobulin M complexes (SCCA-IgM Cs) in the early diagnosis and in the prognosis of HCC. A literature search identified the markers for hepatocellular carcinoma. A search of the literature was made using cancer literature and the PubMed database for the following keywords: "markers and HCC", "α-fetoprotein (AFP) and HCC", "Des-γ-carboxy prothrombin"(DCP) and HCC, "squamous cell carcinoma antigen-immunoglobulin M complexes" (SCCA-IgM Cs). Despite the large number of studies devoted to the immunohistochemistry of HCC, at the present time, the absolute positive and negative markers for HCC are still lacking, and even those characterized by very high sensitivity and specificity do not have an universal diagnostic usefulness. In conclusion none of the three biomarkers (AFP, DCP, SCCA-IgM Cs) is optimal. According to recent reviews, these biomarkers should be measured simultaneously and in combination with imaging techniques to increase the sensitivity, specificity, diagnostic accuracy and to make a reliable prognosis. Currently the recommended screening strategy for patients with cirrhosis includes the determination of serum AFP levels and an abdominal ultrasound every six months to detect HCC at an earlier stage.

[Complex partial seizure in patient with insulinoma: importance of early diagnosis]. / Crisi parziali complesse in un paziente affetto da insulinoma: l'importanza di una diagnosi precoce.

Insulinoma, usually benign (90%), is clinically characterized by symptoms as tremulousness, tachycardia, weakness, sweating, fatigue, hunger, headache, dizziness, disorientation and unconsciousness. However rarely it has an unusual presentation. We present a case of insulinoma misdiagnosed as neurologic disease. A 48-year-old man was admitted to our Emergency Division because of car accident caused by loss of consciousness. A diagnosis of complex partial seizure was made one year before. The patient appeared pale, tachycardic, BP 130/85 mmHg. Laboratory tests showed a severe hypoglycemia (30 mg/dl). He was treated with hypertonic glucose solution and the resolution of symptoms was obtained. Dosages of insulin and C-peptide, CT-scan and RMN confirmed a diagnosis of insulinoma. Seizure disappeared after surgical excision. The diagnosis of insulinoma is sometimes delayed up to more than 20 years. Neurologic or psychiatric presentation like disorientation, personality changes, amnesia, irritability, seizures, bizarre behavior, visual difficulties, neuropathy in patients affected by insulinoma could be cause of misdiagnosis. Diagnosis of insulinoma should always be considered whenever these symptoms occur, especially if unresponsive to specific therapy. Insulinoma is curable in most cases and an early diagnosis can avoid adverse consequences including neurologic damage.

A right diaphragmatic eventration incidentally diagnosed and successfully repaired through an abdominal approach. A case report.

We report a case of an elderly woman with a large eventration of the right hemidiaphragm, discovered during an episode of acute cholecystitis, with abdominal and pleural effusion, successfully treated by a laparotomic approach.

Surgery of the aortoduodenal fistula: two cases with survival.

We report on two cases of aortoduodenal fistula. The patients underwent the positioning of an aortic stent 1.9 and 5 yearly before, respectively. They complained of fever and abdominal pain and were admitted to the hospital. A stent infection was suspected and an angio-CT confirmed the suspicion. Each patient was brought immediately to the operating room, where the fistula was individuated and resected, with closure of the aortic wall and excision of a part of the ulcerated intestinal loop involved. The infected stent was removed and an extra-anatomic bypass was performed. The patients survived and were discharged from hospital 38 and 29 days after the surgery, respectively, with no postsurgical sequelae and in good health. These patients are alive and in good health respectively 18 and 19 months (mo) after the procedure. If performed immediately upon diagnosis, this technique permits achievement of an optimal result.