Emergency totally laparoscopic surgery for appendicitis in right Amyand's hernia associated to symptomatic left inguinal hernia: A case report.

INTRODUCTION AND IMPORTANCE: Amyand's hernia is a rare type of inguinal hernia which contains vermiform appendix in the inguinal sac, seldom complicated by acute appendicitis. It is usually repaired by open inguinal approach, but laparoscopic technique has been increasingly described in literature; nevertheless, standard of care is far from being defined. Here we report the case of Amyand's hernia complicated by acute appendicitis and simultaneous symptomatic left inguinal hernia, both repaired by laparoscopic technique. CASE PRESENTATION: A 85-years-old man presented with acute appendicitis in Amyand's hernia and simultaneous incarcerated left inguinal hernia. CLINICAL DISCUSSION: After complete preoperative work-up, the patient underwent laparoscopic appendectomy and laparoscopic bilateral hernia repair with mesh. CONCLUSION: Laparoscopic approach may be safe and feasible for Amyand's hernia treatment in emergency setting when performed by expert hands, with minimized risk of surgical site infection (SSI), quick recovery and reduced hospital stay. Laparoscopic hernia repair with mesh can be a reasonable approach in selected cases of bilateral or recurrent hernia, and concomitant intrabdominal inflammation, especially when contamination is scarse and limited to a restricted area.

Robotic-assisted distal pancreatectomy with splenectomy in a paediatric patient for solid pseudopapillary tumour.

Solid pseudopapillary tumour is a rare low-grade malignant potential carcinoma of the pancreas that typically occurs in females in their third decade. It most commonly occurs in the tail of the pancreas, although any site can be affected. Surgical resection is the standard treatment and offers an excellent prognosis. We report a case of a 17-year-old female with an acute onset abdominal pain and a radiological diagnosis of a cystic lesion in the distal pancreas. A robotic-assisted distal pancreatectomy with splenectomy was performed. Robotic-assisted surgery is an emerging technique for the treatment of pancreatic neoplasms. This approach can be considered for younger patients, thanks to the potential advantages of the robotic Da Vinci Xi System.

Surgical treatment and management of syndromic paraganglioma. The experience of a referral center.

BACKGROUND: Paragangliomas (PGL) are neuroendocrine tumors arising from neural crest-derived chromaffin cells in the parasympathetic ganglia or in sympathetic ganglia located in the adrenal glands (Pheochromocytoma, PHEO), or extra-adrenal location and around 30-40% of PGL can be hereditary (MEN2, Von Hippel Lindau syndrome, von Reklingausen syndrome and Pheochromocytoma-Paraganglioma syndrome). METHODS: We retrospectively evaluate 127 patients with PHEO/PGL treated at our Institution from 1992 to 2018 and report our experience, focusing on different surgical treatment based on hereditary syndrome. Genetic analysis was performed in patients with features suspected for hereditary syndrome to search genetic mutations of RET, VHL, SDHD and SDHB. RESULTS: Hereditary syndrome was diagnosed in 30 patients (7 patients affected by MEN2A, 6 VHL, 9 NF1, 2 PGL- 1, and 6 PGL-4). 17 patients with monolateral PHEO underwent adrenalectomy (laparoscopic approach since 1998); 8 patients with bilateral adrenal lesions underwent bilateral adrenalectomy with cortical-sparing approach of almost one gland. CONCLUSIONS: Syndromic PGLs are rare conditions; surgery is the treatment of choice. Adrenal PGL requires laparoscopic adrenalectomy with transperitoneal lateral approach as gold standard. For genetic syndrome such as MEN2 and VHL, laparoscopic cortical sparing adrenalectomy of at least one gland should be considered. KEY WORDS: Adrenalectomy, Endocrine Surgery, Hereditary Syndromes, Paraganglioma, Pheochromocytoma.

Surgical Management of Adrenocortical Carcinoma: Current Highlights.

INTRODUCTION: Adrenocortical carcinoma (ACC) is a rare tumor, often discovered at an advanced stage and associated with poor prognosis. Treatment is guided by staging according to the European Network for the Study of Adrenal Tumors (ENSAT) classification. Surgery is the treatment of choice for ACC. The aim of this review is to provide a complete overview on surgical approaches and management of adrenocortical carcinoma. METHODS: This comprehensive review has been carried out according to the PRISMA statement. The literature sources were the databases PubMed, Scopus and Cochrane Library. The search thread was: ((surgery) OR (adrenalectomy)) AND (adrenocortical carcinoma). RESULTS: Among all studies identified, 17 were selected for the review. All of them were retrospective. A total of 2498 patients were included in the studies, of whom 734 were treated by mini-invasive approaches and 1764 patients were treated by open surgery. CONCLUSIONS: Surgery is the treatment of choice for ACC. Open adrenalectomy (OA) is defined as the gold standard. In recent years laparoscopic adrenalectomy (LA) has gained more popularity. No significant differences were reported for overall recurrence rate, time to recurrence, and cancer-specific mortality between LA and OA, in particular for Stage I-II. Robotic adrenalectomy (RA) has several advantages compared to LA, but there is still a lack of specific documentation on RA use in ACC.

Inadequate sunlight exposure in patients with inflammatory bowel disease.

OBJECTIVE: Inadequate sun exposure impairs vitamin D activity and favors low bone density, especially in patients at increased risk for osteoporosis, such as those affected by inflammatory bowel disease (IBD). In this study, sun exposure was investigated in a large series of patients with IBD in a Mediterranean country, Italy, where this risk is considered less likely to occur than in higher latitudes. METHODS: This is a case-control study of 292 patients with IBD [132 with Crohn's disease (CD) and 160 with ulcerative colitis (UC)], 80 diseased and 540 healthy controls, conducted via a validated questionnaire to quantify sunlight exposure. Data were also compared with controls matched by age and gender. RESULTS: In total 78 of the 292 patients with IBD had low, 169 had moderate and 45 had high exposure to sunlight, significantly differing from controls (P < 0.001). The 132 patients with CD were more likely to have abnormal levels of sunlight exposure (49 low, 72 moderate and 11 high) than those with UC (29 low, 97 moderate and 34 high) (P < 0.001). The controls were significantly more exposed to sunlight than both men and women with IBD (P < 0.001 and 0.004, respectively). CONCLUSIONS: IBD patients are significantly less exposed to sunlight than matched controls in Italy, often to an extent that may impair vitamin D activation. Increasing responsible sunlight exposure, thus promoting adequate vitamin D concentrations, may prove beneficial in IBD, in geographical areas in which this risk factor is not generally taken into consideration.

Dietary calcium intake in patients with inflammatory bowel disease.

BACKGROUND & AIMS: Osteopenia and increased risk for fractures in IBD result from several factors. AIM OF THE STUDY: To investigate the dietary intake of calcium in IBD patients. METHODS: A 22-item quantitative validated frequency food questionnaire was used for quantifying dietary calcium in relation to gender and age, in 187 IBD patients, 420 normal- and 276 diseased controls. STATISTICAL ANALYSIS: Mann-Whitney, chi-square- and T-tests. RESULTS: The mean calcium intake was 991.0 ± 536.0 (105.8% Recommended Daily Allowances) and 867.6 ± 562.7 SD mg/day (93.8% RDA) in healthy and diseased controls, and 837.8 ± 482.0 SD mg/day (92.7% RDA) in IBD, P<0.001. Calcium intake was high in celiac disease (1165.7 ± 798.8 SD mg/day, 120% RDA), and non-significantly lower in ulcerative colitis than in Crohn's disease (798.7 ± 544.1 SD mg/day vs 881.9 ± 433.0). CD and UC females, but not males, had a mean calcium intake well under RDA. In all study groups the intake was lower in patients believing that consumption of lactose-containing food induced symptoms, versus those who did not (105.8% vs 114.3% RDA in normal controls; 100.4% vs 87.6% RDA in IBD). CONCLUSIONS: Diet in IBD patients contained significantly less calcium than in healthy controls. Gender and age, more than diagnosis, are central in determining inadequate calcium intake, more so in IBD. Self-reported lactose intolerance, leading to dietary restrictions, is the single major determinant of low calcium intake. Inadequate calcium intake is present in one third of IBD patients and represents a reversible risk factor for osteoporosis, suggesting the need for tailored nutritional advice in IBD.