A Narrative Review on Non-Cirrohotic Portal Hypertension: Not All Portal Hypertensions Mean Cirrhosis.

Non-cirrhotic portal hypertension (NCPH), also known as idiopathic non-cirrhotic portal hypertension (INCPH) and porto-sinusoidal vascular disorder (PSVD), is a rare disease characterized by intrahepatic portal hypertension (IPH) in the absence of cirrhosis. The precise etiopathogenesis of IPH is an area of ongoing research. NCPH diagnosis is challenging, as there are no specific tests available to confirm the disease, and a high-quality liver biopsy, detailed clinical information, and an expert pathologist are necessary for diagnosis. Currently, the treatment of NCPH relies on the prevention of complications related to portal hypertension, following current guidelines of cirrhotic portal hypertension. No treatment has been studied that aimed to modify the natural history of the disease; however, transjugular intrahepatic porto-systemic shunt (TIPS) placement, shunt and liver transplantation are considerable symptomatic options. In this review, we discuss the heterogeneity of NCPH as well as its etiopathogenesis, clinical presentation and management issues. Starting from the assumption that portal hypertension does not always mean cirrhosis, cooperative studies are probably needed to clarify the issues of etiology and the possible genetic background of this rare disease. This knowledge might lead to better treatment and perhaps better prevention.

Non traumatic right Bochdalek hernia with loss of Domain in adults. Our experience and review of literature.

INTRODUCTION: Right-sided Bochdalek hernia (BH) is a rare developmental defect in the posterolateral diaphragm, allowing herniation of abdominal contents into the thorax. To date only 44 reported cases of right-sided BH have been surgically managed in adults in literature. We report one additional case of right-sided BH with loss of Domain. "Loss of domain" (LOD) is a term used commonly in the hernia literature to describe the distribution of abdominal content between the hernia and residual abdominopelvic cavity. After repairing hernias with significant LOD, serious physiological complications can arise. METHODS: PubMed and Cochrane bibliographical databases were searched (last search: February 2022) for studies concerning BH. CASE PRESENTATION: We report the case of a 50-year-old woman whose right-sided diaphragmatic hernia strangulated loops of small bowel and who was thus treated via urgent laparoscopy. After reduction of the intrathoracic contents we were unable to primarily close the midline fascia.We performed a staged abdominal wall reconstruction as the chronicity of the hernia led to loss of intra-abdominal domain. DISCUSSION: Bochdalek hernia (BH) is the most common type of congenital diaphragmatic hernia and is usually leftsided. It typically presents in neonates and diagnosis in adults is a rarity. Various surgical repair options include open surgery, laparoscopic repair, thoracoscopic approach and robotic transthoracic approaches. CONCLUSION: BH should be managed timely regardless of its symptoms to avoid future complications. The closure of the defect can be done by different methods. When, after diaphragmatic hernia repair, it is suspected that the herniated viscera have lost their domain, it is preferable to use a Temporary Abdominal Closure to prevent compartment syndrome. KEY WORDS: Bochdalek hernia with loss of Domain, Bochdalek hernia in adults, Non traumatic Bochdalek hernia, Right-sided diaphragmatic hernia.

Treatment of haemorrhoids in pregnancy: A retrospective review.

AIM: Haemorrhoids are varicose veins of the rectum covered by mucosa at or near the anal canal. They are normally asymptomatic, can occur at any age and affect both males and females. Haemorrhoids are common in young women and commoner during pregnancy and the puerperium. In this review, we address the issue of the approach of the obstetrician and surgeons to haemorrhoids and their management. This is significant because there are currently no recommendations for pregnant patients with hemorrhoids. METHODS: The literature search comprised all the inherent published original papers; also abstract were included. No language selection was done. Search terms used were: "hemorrhoid", "hemorrhoid therapy", "hemorrhoid in pregnancy", "hemorrhoid complication". Data research was conducted using MEDLINE, EMBASE, Web of Sciences, Scopus, Clinical Trial. gov, OVID and Cochrane Library querying for all articles related to treatment of hemorrhoidis in pregnancy. RESULTS: Fiber supplement, stool softener and mild laxatives are generally safe for pregnant women. Topical medication or oral phlebotonics may be used with special caution because the strong evidence of their safety and efficacy in pregnancy is lacking. In case of massive bleeding, anal packing could be a simple and useful maneuver. Hemorrhoidectomy is reserved in strangulated or extensively thrombosed hemorrhoids, and hemorrhoids with intractable bleeding. KEY WORDS: Hemorrhoid, Hemorrhoid Therapy, Hemorrhoid in Pregnancy, Hemorrhoid Complication.

Adenocarcinoma of the sigmoid colon causing sigmoido-rectal intussusception: A rare entity in adults.

INTRODUCTION: Intussusception occurs when a more proximal portion of the bowel (intussusceptum) invaginates into the more distal bowel (intussuscipiens). The pathomechanism is thought to involve altered bowel peristalsis at the intraluminal lesion, which is then a lead point for the intussusceptum. Intestinal intussusception is rare in adults, accounting for approximately 1 % of all bowel obstructions. We report a unique case in which a partially obstructing sigmoid cancer caused full thickness rectal prolapse requiring surgical intervention. PRESENTATION OF CASE: A 75-year-old male presented in the emergency department due to anal haemorrhage for 5 days. On clinical examination his abdomen was distended with signs of peritoneal irritation in the right quadrants. The CT scan showed sigmoid-rectal intussusception with an sigmoid colonic tumour. The patient underwent emergency anterior resection of the rectum without reduction of the intussusception. Histological examination revealed a sigmoid adenocarcinoma. DISCUSSION: Intussusception is the most common urgent situation among the pediatric population but its incidence in adults is very rare. The diagnosis is difficult to establish with history and physical exam findings alone. Since in adults, unlike children, in most cases a malignant pathology acts as a lead point, the treatment of this pathology still reserves doubts. Recognizing and understanding pertinent signs, symptoms, and imaging findings is essential to the early diagnosis and appropriate management of adult intussusception. CONCLUSION: The appropriate management of adult intussusception is not always clear cut. There is controversy about the reduction before resection in cases of sigmoidorectal intussusception.

Strangulated richter's hernia with caecum necrosis. Case report.

AIM: Describe a rare case of Richter's hernia with caecum incarceration into a right femoral hernia and provide a narrative literature review about its surgical management. MATERIAL AND METHODS: A 46-year-old woman presented to the Emergency Department and to our surgical unit with a two-days history of worsening abdominal pain in the right lower quadrant without nausea or vomiting, associated with an irreducible lump. Computed tomography of the abdomen described a right inguinal hernia containing small bowel with perivisceral fluid in it without signs of small bowel occlusion nor perforation. RESULTS: A Richter 's femoral hernia with necrotic caecum wall was found but the appendix was not involved. Through a mini-laparotomy, tangential caecal resection and appendectomy were performed. The femoral defect was repaired with a polypropylene mesh-plug placed in the pre-peritoneal space. Postoperative period was uneventful and the patient was discharged on the fifth post-operative day. DISCUSSION: Femoral hernias account for only 2-4% of all groin hernias and occur through a small fascial defect in the femoral canal. Due to its narrowness, it leads to a high risk of incarceration and strangulation thus explaining the increased mortality in the emergency setting (up to 10 fold compared with the elective repair). In some cases, symptoms are no specific and uncommon findings have been reported. Surgical exploration is mandatory in the presence of signs of bowel strangulation or perforation and different approaches (either open or laparoscopically) have been described in literature. CONCLUSIONS: Caecum wall necrosis secondary to an incarcerated Richter's femoral hernia is a rare but dangerous event. Surgical approach is selected on surgeon's expertise. The use of prosthetic mesh is always recommended. KEY WORDS: Bowel necrosis, Emergency surgery, Hernia repair, Richter's hernia.

Comparison between children and adults intussusception. Description of two cases and review of literature.

INTRODUCTION: Intussusception is a common condition in children, it is rare in adults. Adult intussusception differs from pediatric intussusception in various respects, including etiology clinical characteristics and therapy. METHODS: We present and discuss a new case of intussusception in children and adults. RESULTS: In child the Barium Enema x-ray examination is identified an endoluminal filling defect to refer to the apex of the invaginated loop at the rectal level, with slow ascent during the progressive injection of the radiopaque contrast medium. At the end of the procedure, incomplete reduction of the picture is documented. The patient undergoes emergency surgery where the presence of an ileo-ceco-colic invagination is documented. Intussusception is reduced by taxis. In the adult laparoscopic right hemicolectomy was performed. High-grade B-cell Burkitt's lymphoma was confirmed by immunohistochemistry. DISCUSSION: In contrast to intussusceptions in children, in the adult population, a demonstrable etiology is found in most of the cases. In adults surgery is always indicated. The non-invasive resolutive intervention most commonly used in the child and best known consists in the rectal introduction of a radiopaque contrast medium (air or barium) at controlled pressure until. CONCLUSIONS: Although intussusceptions occur at all ages, there are major differences in the clinical presentation, diagnostic approach, and management between pediatric and adult populations. Intussusception is remarkably different in these two age groups and it must be approached from a different clinical perspective. KEY WORDS: Intussusception in children, Intussusception in adults, Intussusception symptoms, Radiology and treatment.

A case report of incarcerated inguinal hernia: Amyand's hernia with adenocarcinoma tumor.

INTRODUCTION: Inguinal hernia is one of the most common surgical problems, often posing technical challenges even to expert surgeons. Amyand's hernia (AH) is an inguinal hernia whose sac contains the vermiform appendix. Primary appendiceal neoplasms are rare. We report the case of an appendiceal adenocarcinoma within an Amyand's hernia, presenting as an incarcerated right inguinal hernia. PRESENTATION OF CASE: A 87-year-old male presented in the emergency department due to a persistent right inguinal pain. Clinical examination revealed a tender right groin mass. Under the diagnosis of an right inguinal hernia, an operation was taken. Intraoperatively, an inflamed appendix and a part of the cecum were found in the hernia sac. The operation was completed with an ileocecal resection and a modified Bassini hernia repair. Histological examination revealed a adenocarcinoma of the appendix. DISCUSSION: Amyand's hernia is an inguinal hernia that contains vermiform appendix in its sac. It consists 1% of all inguinal hernias while appendicitis in an Amyand's hernia accounts for 0.1% of all appendicitis cases. Adenocarcinomas of the appendix are even rarer, accounting for 0.2% to 0.5% of all intestinal malignancies, and 4%-6% of primary appendiceal neoplasms. Diagnosis is usually established intraoperatively. CONCLUSION: A malignancy of the appendix should always be in the differential diagnosis of a right inguinal mass, in order to provide optimum surgical treatment.

Viscero-visceral hyperalgesia in dysmenorrhoea plus previous urinary calculosis: Role of myofascial trigger points and their injection treatment in the referred area.

BACKGROUND: Women with dysmenorrhoea plus symptomatic urinary calculosis experience enhanced pain and referred muscle hyperalgesia from both conditions than women with one condition only (viscero-visceral hyperalgesia). The study aimed at verifying if enhanced dysmenorrhoea persists after urinary stone elimination in comorbid women and if local anaesthetic inactivation of myofascial trigger points (TrPs) in the lumbar area (of urinary pain referral) also relieves dysmenorrhoea. METHODS: Thirty-one women with dysmenorrhoea plus previous urinary calculosis (Dys+PrCal) and lumbar TrPs, and 33 women with dysmenorrhoea without calculosis (Dys) underwent a 1-year assessment of menstrual pain and muscle hyperalgesia in the uterus-referred area (electrical pain threshold measurement in rectus abdominis, compared with thresholds of 33 healthy controls). At the end of the year, 16 comorbid patients underwent inactivation of TrPs through anaesthetic injections, whereas the remaining 12 received no TrP treatment. Both groups were monitored for another year at the end of which thresholds were re-measured. RESULTS: In year1, Dys+PrCal presented significantly more painful menstrual cycles and lower abdominal thresholds than Dys, thresholds of both groups being significantly lower than normal (p < .001). Anaesthetic treatment versus no treatment of the lumbar TrP significantly reduced the number of painful cycles during year2 and significantly increased the abdominal thresholds (p < .0001). CONCLUSION: Viscero-visceral hyperalgesia between uterus and urinary tract may persist after stone elimination due to nociceptive inputs from TrPs in the referred urinary area, since TrPs treatment effectively reverses the enhanced menstrual symptoms. The procedure could represent an integral part of the management protocol in these conditions. SIGNIFICANCE: A past pain process from an internal organ can continue enhancing pain expression from a painful disease in another neuromerically connected organ (viscero-visceral hyperalgesia) if secondary myofascial trigger points (TrPs) developed in the referred area at the time of the previous visceral disease. Inactivation of these TrPs reverts the enhancement. Assessment and treatment of TrPs in referred areas from past visceral pain conditions should be systematically carried out to better control pain from current diseases in other viscera.

A case of Type 2 appendiceal diverticulum perforated and a review of the literature.

BACKGROUND: Appendiceal diverticulosis disease is a rare entity. An perforated appendiceal diverticulosis mimicking acute appendicitis is a extremely unusual surgical finding and the reported prevalence is between 0.014 and 3.7%. CASE REPORT: We report the case of an elderly man, who presented with a typical clinical image of acute appendicitis and underwent laparoscopic surgery. Intraoperative an acute appendicitis with localized peritonitis was identified and a laparoscopic appendectomy was performed, but pathologic analysis demonstrated a type 2 appendiceal diverticulitis. CONCLUSION: Appendiceal diverticulosis disease should be included in differential diagnosis of patients presenting with clinical signs of an acute appendicitis and prompt surgical treatment is essential in order to avoid severe complications.

Minimally Invasive Treatment of Sporadic Burkitt's Lymphoma Causing Ileocaecal Invagination.

INTRODUCTION: Primary NHL (non-Hodgkin lymphoma) of the colon represents only 0.2% to 1.2% of all colonic malignancies. Burkitt's lymphoma (BL) is usually a disease reported in children and young people, most of them associated with EBV or HIV infection. We describe a rare case of intestinal obstruction due to sporadic Burkitt's lymphoma causing ileocaecal invagination explaining our experience Methods. A 31-year-old man presented with diffuse colic pain and weight loss. Clinical examination revealed an abdominal distension with pain in the right iliac fossa. Colonoscopy documented a caecal large lesion with ulcerated mucosa. Computed tomography (CT) have shown a 60 × 50 mm right colic parietal lesion with signs of ileocolic intussusception. RESULTS: Laparoscopic right hemicolectomy was performed. Postoperative period was uneventful. CD20+ high-grade B-cell Burkitt's lymphoma was confirmed by immunohistochemistry (CD20+, CD79+, and CD10+) and FISH test (t (8;14) (q24; q32). The patient was subsequently treated with adjuvant combination chemotherapy (Hyper-CVAD) and is alive and disease-free at 8 months follow-up. DISCUSSION: Adult sporadic Burkitt's lymphoma (BL) causing intestinal obstruction due to ileocaecal intussusception is an extremely rare occurrence and a diagnostic dilemma. Despite the surgical approach is selected based on patient's conditions and surgeon's expertise, minimally invasive method could be preferred.

Left colon obstruction due to non-reducible Spigelian hernia of the right side. Report of a case and literature review.

AIM: Describe a rare case of intestinal obstruction due to sigmoid colon incarceration into a right Spigelian hernia and provide a literature review about its surgical management. MATERIAL OF STUDY: An 88 year-old man presented with a 3-day history of right lower quadrant pain and abdominal distension. Clinical examination revealed a not reducible palpable mass on right side of the anterior abdominal wall. Computed tomography shown signs of intestinal obstruction and a Spigelian hernia of about 3 cm. RESULTS: Sigmoid colon was incarcerated in the defect but no signs of intestinal ischemia was found during the surgical exploration. The hernia content was reduced and the defect was repaired with a polypropylene mesh placed in the pre-peritoneal space. Postoperative period was uneventful and the patient was discharged on the fourth postoperative day. DISCUSSION: Spigelian hernia occurs through congenital or acquired defects in the Spigelian fascia at the level of the semicircular line. Clinical presentation depends on the size and the pattern of the hernia defect. In some cases, symptoms are no specific and uncommon findings have been reported so far. Preoperative establishment of the hernia content and the location of the sac is mandatory to plan a correct surgical strategy. Intestinal incarceration often occurs and suggests a prompt surgical exploration. CONCLUSIONS: Colonic obstruction secondary to an incarcerated Spigelian hernia is a rare but dangerous occurrence. Surgical approach is selected based on patient's conditions and surgeon's expertise. In a non-contaminated surgical field, the use of prosthesis is recommended. KEY WORDS: Intestinal obstruction, Mesh repair, Spigelian hernia.

[A possible late complication of Mason's vertical gastroplasty: the erosion of the vertical band]. / Possibile complicanza tardiva della gastroplastica verticale secondo Mason: il decubito della benderella.

AIM: To evaluate possible adverse consequences and complications following the procedure of Mason-McLeans Vertical Banded Gastroplasty (VBG), and in those cases the possibility to be related to a surgical mistake. PERSONAL EXPERIENCE: It is based on a casuistic of more than 180 patients, submitted to this restrictive bariatric surgery in the same institution since 2001. Controls of the prescribed postop follow up revealed a very low rate of complications, as only in three cases, all of them with spontaneous presentation, there was a complication related to the banding. RESULTS: All the observed complications were related to a late postoperative inadequate alimentation for excess of meals, after the immediate orthodox behaviour of the first months. DISCUSSION: From the comparative evaluation of all the patients submitted to the Mason-McLean procedure it seems of the utmost evidence the importance of a correct alimentation, mainly to the low bulk of the single meal, to avoid complications and obtain the best EWL%. CONCLUSIONS: Adherence to the guidelines for the post op alimentation in such patients is the key to obtain the best results from the operation avoiding the side effects and complications here described.