Global attitudes in the management of acute appendicitis during COVID-19 pandemic: ACIE Appy Study.

BACKGROUND: Surgical strategies are being adapted to face the COVID-19 pandemic. Recommendations on the management of acute appendicitis have been based on expert opinion, but very little evidence is available. This study addressed that dearth with a snapshot of worldwide approaches to appendicitis. METHODS: The Association of Italian Surgeons in Europe designed an online survey to assess the current attitude of surgeons globally regarding the management of patients with acute appendicitis during the pandemic. Questions were divided into baseline information, hospital organization and screening, personal protective equipment, management and surgical approach, and patient presentation before versus during the pandemic. RESULTS: Of 744 answers, 709 (from 66 countries) were complete and were included in the analysis. Most hospitals were treating both patients with and those without COVID. There was variation in screening indications and modality used, with chest X-ray plus molecular testing (PCR) being the commonest (19·8 per cent). Conservative management of complicated and uncomplicated appendicitis was used by 6·6 and 2·4 per cent respectively before, but 23·7 and 5·3 per cent, during the pandemic (both P < 0·001). One-third changed their approach from laparoscopic to open surgery owing to the popular (but evidence-lacking) advice from expert groups during the initial phase of the pandemic. No agreement on how to filter surgical smoke plume during laparoscopy was identified. There was an overall reduction in the number of patients admitted with appendicitis and one-third felt that patients who did present had more severe appendicitis than they usually observe. CONCLUSION: Conservative management of mild appendicitis has been possible during the pandemic. The fact that some surgeons switched to open appendicectomy may reflect the poor guidelines that emanated in the early phase of SARS-CoV-2.

ANTECEDENTES: Las estrategias quirúrgicas están siendo adaptadas en presencia de la pandemia de la COVID-19. Las recomendaciones del tratamiento de la apendicitis aguda se han basado en la opinión de expertos, pero hay muy poca evidencia disponible. Este estudio abordó este aspecto a través de una visión de los enfoques mundiales de la cirugía de la apendicitis. MÉTODOS: La Asociación de Cirujanos Italianos en Europa (ACIE) diseñó una encuesta electrónica en línea para evaluar la actitud actual de los cirujanos a nivel mundial con respecto al manejo de pacientes con apendicitis aguda durante la pandemia. Las preguntas se dividieron en información basal, organización del hospital y cribaje, equipo de protección personal, manejo y abordaje quirúrgico, así como las características de presentación del paciente antes y durante de la pandemia. Se utilizó una prueba de ji al cuadrado para las comparaciones. RESULTADOS: De 744 respuestas, se habían completado 709 (66 países) cuestionarios, los datos de los cuales se incluyeron en el estudio. La mayoría de los hospitales estaban tratando a pacientes con y sin COVID. Hubo variabilidad en las indicaciones de cribaje de la COVID-19 y en la modalidad utilizada, siendo la tomografía computarizada (CT) torácica y el análisis molecular (PCR) (18,1%) las pruebas utilizadas con más frecuencia. El tratamiento conservador de la apendicitis complicada y no complicada se utilizó en un 6,6% y un 2,4% antes de la pandemia frente a un 23,7% y un 5,3% durante la pandemia (P < 0.0001). Un tercio de los encuestados cambió la cirugía laparoscópica a cirugía abierta debido a las recomendaciones de los grupos de expertos (pero carente de evidencia científica) durante la fase inicial de la pandemia. No hubo acuerdo en cómo filtrar el humo generado por la laparoscopia. Hubo una reducción general del número de pacientes ingresados con apendicitis y un tercio consideró que los pacientes atendidos presentaban una apendicitis más grave que las comúnmente observadas. CONCLUSIÓN: La pandemia ha demostrado que ha sido posible el tratamiento conservador de la apendicitis leve. El hecho de que algunos cirujanos cambiaran a una apendicectomía abierta podría ser el reflejo de las pautas deficientes que se propusieron en la fase inicial del SARS-CoV2.

Totally minimally invasive two-stage esophagectomy with intrathoracic hand-sewn anastomosis: short-term clinical and oncological outcomes.

Several esophageal resection techniques have been reported in literature. The objective of this study is to assess postoperative and oncological outcomes of two-stage minimally invasive esophagectomy (MIE) in a prone position using thoracoscopic hand-sewn anastomosis. Consecutive patients who underwent two-stage MIE in 2016 performed by the senior author were included. This was compared with the preceding cohort of consecutive patients who underwent two-stage hybrid esophagectomy (HE). The primary outcome was 30-day morbidity and mortality. The secondary outcomes were operation duration, length of stay (LOS), total nodes examined (TNE), number of positive nodes (NPN), and resection margin. Overall, 15 patients underwent MIE and 11 patients underwent HE. Respiratory complications occurred in three (20.0%) patients in the MIE group and in five (45.5%) patients in the HE group (P = 0.218). Cardiac complications occurred in two (18.2%) patients, and two other patients (18.2%) experienced anastomotic leak in the HE group. Mean operative duration was 349 ± 41.6 min in MIE and 309 ± 47.8 min in HE (P = 0.040). Median LOS was 10 days (range: 7-70) in MIE and 13 days (range: 10-116) in HE (P = 0.045). Median TNE was 23 (range: 12-36) in MIE and 20 (range: 14-47) in HE (P = 0.775). Longitudinal margin was involved in one patient (9.1%) in HE and no longitudinal margin was involved in the MIE group. Circumferential resection margin was involved in seven patients (46.7%) in MIE and in four patients (36.4%) in HE (P = 0.391). Two-stage MIE using hand-sewn technique is safe and feasible without compromising surgical and oncological outcomes. A multicenter large trial is recommended to confirm these results.

A systematic review of the prognostic value of lymph node ratio, number of positive nodes and total nodes examined in pancreatic ductal adenocarcinoma.

BACKGROUND Pancreatic ductal adenocarcinoma is the most common pancreatic cancer. Five-year overall survival is currently 3.3-6.0%. The aim of this review was to evaluate the prognostic value of lymph node ratio, number of positive nodes and total nodes examined on overall survival rate following pancreatic resection. MATERIALS AND METHODS A literature search was conducted of MEDLINE, EMBASE, the Cochrane Library and Central Register of Controlled Trials and the Cochrane Database of Systematic Review databases, from January 1996 to January 2016. RESULTS Overall, 19 studies including 4,883 patients examined the relationship between lymph node ratio and overall survival. A high lymph node ratio was associated with decreased overall survival in 17 studies. A total of 12 studies examined the relationship between the number of positive nodes and overall survival, and 11 studies revealed that an increase in the number of positive nodes was associated with decreased overall survival. In 15 studies examining the relationship between the total nodes examined and overall survival, there was no association with overall survival in 12 studies. CONCLUSIONS Lymph node ratio and number of positive nodes are factors associated with overall survival in pancreatic ductal adenocarcinoma, but not total nodes examined.

Routes of early enteral nutrition following oesophagectomy.

Introduction Oesophagectomy for cancer is a challenging procedure with a five-year overall survival rate of 15-20%. Early enteral nutrition following oesophagectomy is a crucial component of the postoperative recovery and carries a significant impact on the outcome. Different methods of enteral feeding were conducted in our unit. The aim of this study was to examine the efficacy and safety of nasojejunal tube (NJT), jejunostomy tube (JT) and pharyngostomy tube (PT) feeding after oesophagectomy. Methods A retrospective review was carried out of prospectively collected data on patients with oesophageal cancer who underwent an oesophagectomy between 2011 and 2014. The primary outcome was feeding tube related complications such as occlusion, dislocation and leak. The secondary outcomes were length of stay and 30-day morbidity. Results A total of 90 oesophagectomies were included in the study. A NJT was inserted in 41 patients (45.6%), a JT was used in 14 patients (15.5%) and a PT was the route for enteral nutrition in 35 patients (38.9%). In total, five patients (5.5%) developed tube related complications. There were no tube related complications in the NJT group but one JT patient (7.1%) developed tube related cellulitis (p=0.189) and four PT patients (11.4%) developed tube related haemorrhage (p=0.544), tube dislocation (p=0.544) or cellulitis (p=0.189). The median length of stay and 30-day postoperative morbidity were similar between the groups. Conclusions NJT feeding is a less invasive, feasible route for early enteral nutrition following oesophagectomy. A randomised controlled trial is recommended to verify these findings.

Extended right hemicolectomy and left hemicolectomy for colorectal cancers between the distal transverse and proximal descending colon.

INTRODUCTION: We report our experience with extended right hemicolectomy (ERH) and left hemicolectomy (LH) for the treatment of cancers located between the distal transverse and the proximal descending colon, and compare postoperative morbidity, mortality, pathological results and survival for the two techniques. METHODS: A retrospective review was performed of a single institution series over ten years. Patients who underwent different operations, had benign disease or received palliative resections were excluded. Data collected were patient demographics, type and duration of surgery, tumour site, postoperative complications and histology results. RESULTS: Ninety-eight patients were analysed (64 ERHs, 34 LHs). ERH was conducted using an open approach in 93.8% of cases compared with 73.5% for LH. The anastomotic leak rate was similar for both groups (ERH: 6.3%, LH: 5.9%). This was also the case for other postoperative complications, mortality (ERH: 1.6%, LH: 2.9%) and overall survival (ERH: 50.4 months, LH: 51.8 months). All but one patient in the ERH cohort had clear surgical margins. Nodal evaluation for staging was adequate in 78.1% of ERH cases and 58.8% of LH cases. CONCLUSIONS: In our experience, both ERH and LH are adequate for tumours located between the distal transverse and the proximal descending colon.

Spontaneous splenic rupture four days after an open appendicectomy.

INTRODUCTION: Spontaneous splenic rupture is a rare but dangerous event that requires prompt diagnosis and frequently an emergency splenectomy. Previous case reports have described the occurrence in patients with medical conditions, anticoagulant treatments, endoscopic procedures, laparoscopic surgery or no particular predisposing factor. Our report is the first to describe the occurrence of spontaneous spleen rupture following a laparotomy conducted in the lower abdomen. CASE HISTORY: A 62-year-old woman presented with a 10-day history of right iliac fossa pain radiating to the right leg and associated vomiting. Following a routine blood check and computed tomography (CT), she underwent an open appendicectomy through a lower midline laparotomy for an appendicular abscess. Four days later, she experienced haemorrhagic shock and a second CT scan diagnosed a spontaneous splenic rupture that required a prompt splenectomy. CONCLUSIONS: Our case is the first that describes the spontaneous rupture of the spleen following an open procedure conducted in the lower quadrants. This entity must still be considered as a rare but potential cause for postoperative bleeding when no other obvious sources are identified.

"Left-sided" Chilaiditi sign? A large gastric perforation with secondary pancreatitis.

BACKGROUND: Although the Chilaiditi sign correctly underestimates the radiological presence of air-under-the-diaphragm, in few cases it has lead to delays in the diagnosis of underlying pneumoperitoneum. In this article we report the case of a young lady presenting with acute pancreatitis and radiographic findings of "left-sided" Chilaiditi sign with underlying a large gastric perforation. CASE REPORT: A 35 year old Caucasian female presented to the Emergency Department with a twenty-four hour history of severe epigastric pain radiating into her back. Stable observations, mildly raised white cell count, increased amylase and subdiaphragmatic radiolucency were interpreted as acute pancreatitis with Chilaiditi sign and treated accordingly. Twenty-four hours later the deterioration of the clinical conditions required a CT scan and an emergency laparotomy that lead to the diagnosis of a large gastric perforation. However, after several days she died of a disseminated intravascular coagulation in the Intensive Care Unit. CONCLUSIONS: In our case the young age of the patient and lack of underlying comorbidities initially compensated the severity of the perforation until it became evident from the absent resolution of the pancreatitis. Bearing this in mind, radiological appearances similar to Chilaiditi sign with significant symptoms or signs should be investigated with a CT scan in order to reach promptly a correct diagnosis.

Goblet cells carcinoid with mucinous adenocarcinoma of the vermiform appendix: a step towards the unitary intestinal stem cell theory?

Associations of various histotypes in appendiceal neoplasms may help elucidate the histogenesis of such uncommon tumors. We present the fourth published case of Goblet Cell Carcinoid (GCC) associated with mucinous adenocarcinoma of the appendix. This association has been described only for GCC and not for classic appendix carcinoids which are thought to originate from neuroendocrine-committed cells. The GCC-mucinous association adds more towards the theory of a pluripotent intestinal stem cell with amphicrine possibilities of differentiation.

Multicenter clinical trial on the performance and tolerability of the Hyaluronic acid-collagenase ointment for the treatment of chronic venous ulcers: a preliminary pilot study.

BACKGROUND: Bed debridement is important to treat chronic wounds. Effective agents should remove the necrosis but protect the granulation tissue. We evaluated the performance and tolerability of a new composite ointment containing collagenase and hyaluronic acid for chronic venous ulcers. PATIENTS AND METHODS: Subjects with class 6 venous ulcers (CEAP classification) of at least 6 months duration were prospectively recruited. The ointment was administered daily and follow-up visits were conducted on the fifth, 10th, 15th and 20th days. On each visit the necrotic area was measured with a grid. The moisture balance, odour, viability of non-necrotic areas and the presence of erythema were also assessed. Primary outcome was the percentage of subjects with complete debridement, secondary outcomes the time to complete healing, reduction of the lesion area, absence of necrotic tissue, presence of odor, erythema, hydration, any adverse events. RESULTS: One hundred subjects were enrolled in four centres. All patients achieved complete debridement of the necrotic area and a significant reduction of the total ulcer area by day 20, while other parameters improved significantly over time. Only two patients experienced a transient leg oedema. CONCLUSIONS: The combination of collagenase and hyaluronic acid is safe and effective for chronic venous ulcers.

A retrospective study on mesh repair alone vs. mesh repair plus pedicle flap for large incisional hernias.

OBJECTIVE: Our experience with the treatment of large incisional hernias (IH) was reviewed comparing mesh repair alone vs. mesh repair plus pedicle flaps. MATERIALS AND METHODS: A retrospective study was performed on patients treated between 2001 and 2005 that underwent component separation technique (CST) repair with polypropylene mesh alone or with polypropylene mesh and local "pedicle" dermal flaps. The primary outcome evaluated was the recurrence rate, secondary outcomes the complication rate, hospital stay and reoperation rate. RESULTS: Forty-eight patients were reviewed. Six patients (13%) developed an IH recurrence, two of them (4%) required secondary repair. CST combined with prosthetic mesh repair and pedicle flap was performed in 19 patients (39.6%) while CST combined with mesh repair alone in 29 patients (60.4%). The duration of surgery, hospitalization, postoperative complications as well as long-term results were similar. CONCLUSIONS: Dermal pedicled flaps obtained through deepithelization of redundant skin following corrections of large incisional hernias are a safe, relatively easy and effective technique that allows reliable soft tissue coverage of the abdominal submuscular mesh.

A case of psoriasis with secondary amyloidosis, associated symbrachydactyly of the hand and a transverse deficiency of the foot.

Secondary amyloidosis is associated with a variety of chronic inflammatory diseases such as rheumatoid arthritis, ankylosing spondylitis, familial Mediterranean fever, osteomyelitis, inflammatory bowel diseases and infective or neoplastic conditions. Few cases of secondary amyloidosis complicating psoriasis have been reported. We describe a 58-year-old patient with secondary amyloidosis, psoriasis, an associated symbrachydactyly of the hand and a transverse deficiency of the foot. To the best of our knowledge, no case of this association has been previously reported.

Laparoscopic vs. open appendicectomies: results obtained by junior surgeons at a British University Hospital.

BACKGROUND: The laparoscopic approach for appendicectomies remains a frequent topic of debate. In this study we report the experience with laparoscopic (LA) and open appendicectomies (OA) achieved in a British University Hospital over one year where most of these operations have been conducted by junior trainees. METHODS: Retrospective review of LA and OA performed at the Whipps Cross University Hospital of London (U.K.). Outcomes measured were the operating time, length of hospital stay and post-operative complications. RESULTS: Between January and December 2008 205 appendicectomies have been performed on adult patients. Eighty-eight per cent of the procedures were conducted by junior surgeons. The operating time was significantly shorter for the OA vs. LA patients (55 +/- 26.8 vs. 83 +/- 26.9 min, p < 0.01). The hospital stay confirmed a significant advantage for LA (2.2 vs. 3.7 days, p = 0.02). No significant differences were present among techniques for the overall morbidity, post-operative intra-abdominal abscesses and rate of readmissions. CONCLUSIONS: Under adequate supervision LA can be safely performed by junior surgeons and reduces the hospital stay.

The role of radiofrequency surgery in the treatment of hemorrhoidal disease.

BACKGROUND: In this article we reported results obtained in our previous studies concerning application of radiofrequency (RF) in proctology and in particular for hemorrhoids treatment. METHODS: We compared radiofrequency submucosal hemorrhoidectomy (RSH) and conventional Parks' hemorrhoidectomy (CPH) (group 1), radiofrequency open hemorrhoidectomy (ROH) and Milligan-Morgan hemorrhoidectomy (MMH) (group 2), radiofrequency closed hemorrhoidectomy (RCH) and Ferguson hemorrhoidectomy (FH) (group 3), combined hemorrhoidal radiocoagulation (CHR) and rubber band ligation (RBL) (group 4). In this work primary endpoints were determined as evaluation of the grade of pain felt immediately after the procedure and at the first evacuation, bleeding, operation time, readmission to work, incidence of failures and patient's satisfaction. RESULTS: Group 1 - In comparison to Parks' technique, use of radiofrequency scalpel reduced mean operation time (61.2 min, range 50-75, vs. 37.4 min, range 30-51; p < 0.05), first postoperative day pain score (5.9, range 3-10, vs. 4.0, range 1-10; p < 0.05), pain score at first evacuation (5.7, range 2-10, vs 4.2, range 1-8; p < 0.05) and pain score on postoperative days (3.6, range 1-9, vs. 2.8, range 1-8; p < 0.05). Group 2 - Results show a substantial similarity between these techniques, however the procedure lasted 7 minutes less with RF scalpel (18.6 min, range 16-21, vs. 25.55 min, range 20-30; p < 0.05). Group 3 - Patients treated with RF showed significant reduction in surgical time (23 min, range 21-31, vs. 33 min, range 24-35; p < 0.01), in pain at 1st post-operative day (VAS score 3.4 +/- 1.3 vs. 4.8 +/- 1.0; p < 0.05) and at the first evacuation (3.4 +/- 1.0 vs. 5.0 +/- 0.8; p < 0.05). Group 4 - The study confirmed validity of both the used techniques, however CHR seems to allow a reduction in incidence of failures. CONCLUSIONS: Results obtained from radiofrequency surgery compared with those achieved with classic surgery for hemorrhoidal disease show in the majority of cases that radiosurgery facilitates, accelerates and improves surgical procedures.

Microwave ablation of the liver: a description of lesion evolution over time and an investigation of the heat sink effect.

AIM: Microwave ablation has been successfully used to treat unresectable liver tumours for many years. However, despite its widespread use, there seems to be a relative paucity of experimental data regarding lesion evolution and the effects of any surrounding vasculature on ablation morphology. The aim of this study was to investigate the principal pathological changes in the liver following microwave ablation, in particular the heat sink effect. In addition we carefully reviewed the available literature to provide an overview of all relevant pathological studies. METHODS: Microwave ablation was carried out on male rats at various distances from the hilum. Histological (H&E) and immunocytochemical (caspase 3) analyses of the lesion were performed at various time points; 0, 4, 24, 48  hours, 2 weeks and 1 month. A literature review was carried out using Medline, Embase and the Cochrane database to identify all relevant histological studies. RESULTS: The lesion underwent complete coagulative necrosis and was extremely regular at the ablation edge with no evidence of any influence from surrounding blood vessels at all time points. H&E and caspase 3 results were consistent and microwave caused little collateral damage outside the intended ablation zone. CONCLUSION: This study suggests that microwave ablation is extremely concise and is minimally affected by the heat sink effect. Comparative investigations with other treatment modalities are required.

Prospective evaluation of stapled haemorrhoidopexy versus transanal haemorrhoidal dearterialisation for stage II and III haemorrhoids: three-year outcomes.

INTRODUCTION: The aim of the study was to compare short- and medium-term outcomes of transanal haemorrhoidal dearterialisation (THD) versus stapled haemorrhoidopexy (SH) for the treatment of second- and third-degree haemorrhoids. METHODS: Patients with second- or third-degree haemorrhoids who failed conservative treatment were randomly allocated to THD or SH. Preoperative and postoperative symptoms, postoperative pain, time until return to normal activities, complications, patient satisfaction and recurrence rates were all assessed prospectively. Patients were followed up at 2, 8 months and when the study was completed. RESULTS: Twenty-eight patients (43% third degree) underwent THD and 24 (38% third degree) underwent SH. There were no significant differences in terms of postoperative pain, expected pain and analgesia requirements, but more THD patients returned to work within 4 days (P < 0.05). One THD patient developed a sub-mucosal haematoma after surgery, one SH patient occlusion of the rectal lumen and two rectal bleeding. At 8-month follow-up, two SH patients complained of faecal urgency. At 38-month follow-up (range 33-48 months), all short-term complications resolved. Patient satisfaction ("excellent/good outcome", THD 89 vs. SH 87%) and recurrence rate (THD 14 vs. SH 13%) were similar in the two groups. CONCLUSIONS: Short-term results although similar seem to suggest SH may result in increased morbidity while return to work is quicker after THD. Medium-term results demonstrate that THD and SH have similar effectiveness.

Experimental application of electrolysis in the treatment of liver and pancreatic tumours: principles, preclinical and clinical observations and future perspectives.

BACKGROUND: Electrolytic ablation (EA) is a treatment that destroys tissues through electrochemical changes in the local microenvironment. This review examined studies using EA for the treatment of liver and pancreatic tumours, in order to define the characteristics that could endow the technique with specific advantages compared with other ablative modalities. METHODS: Literature search of all studies focusing on liver and pancreas EA. RESULTS: A specific advantage of EA is its safety even when conducted close to major vessels, while a disadvantage is the longer ablation times compared to more frequently employed techniques. Bimodal electric tissue ablation modality combines radiofrequency with EA and produced significant larger ablation zones compared to EA or radiofrequency alone, reducing the time required for ablation. Pancreatic EA has been investigated in experimental studies that confirmed similar advantages to those found with liver ablation, but has never been evaluated on patients. Furthermore, few clinical studies examined the results of liver EA in the short-term but there is no appropriate follow-up to confirm any survival advantage. CONCLUSIONS: EA is a safe technique with the potential to treat lesions close to major vessels. Specific clinical studies are required to confirm the technique's safety and eventually demonstrate a survival advantage.

The effects of radiofrequency ablation on the hepatic parenchyma: histological bases for tumor recurrences.

BACKGROUND: This review examines histological modifications obtained after liver radiofrequency ablation (RFA). METHODS: A literature search has been undertaken for all pre-clinical and clinical studies involving RFA and in which ablation zones have been excised for a complete histological examination. RESULTS: Two main histological areas are present, a central zone of coagulative necrosis and a peripheral rim of congestion and extravasation. Both corresponded to specific microscopic characteristics that evolved over time and that are influenced by the proximity of patent vessels and the liver perfusion status. Viable cells are not present in the central zone but have been described in the ischemic peripheral rim where they survive the ischemia and inflammation process. These correspond in clinical studies to residual viable tumor cells that lead to failure of the procedure. CONCLUSIONS: Histological changes following RFA are complex and interactions take place at both a cellular and tissue level. Changes in the peripheral zone must be considered in future studies in order to extend the volume of reliable tumor destruction and increase the effectiveness of the procedure.

Cryotherapy of the liver: a histological review.

INTRODUCTION: Cryotherapy has been largely used in the past for palliation of unresectable liver tumors, but high local recurrence rates and peculiar systemic complications have determined its progressive abandonment. This review analyzes the histological changes produced to provide the basis for the local recurrences. MATERIALS AND METHODS: A detailed literature search was performed on studies focusing on liver cryotherapy. Included were only those that described the histological characteristics in detail. RESULTS: A total of 22 studies were found, one clinical and the others in-vivo animal studies. Similar to other ablative techniques, cryotherapy produces a lesion which is composed by a central zone of coagulative necrosis surrounded with a transitional inflammatory zone. The lesion's dimensions and morphology are influenced by numerous factors including the probe temperature, diameter, the duration of freezing time, fast cooling rate, slow thawing rate, the number of freezing cycles and the inflow occlusion (Pringle maneuver). The temporal evolution is consistent across studies and leads to a progressive inflammatory invasion of the necrosis with definitive fibrotic substitution. CONCLUSIONS: Lesions obtained after cryotherapy seem similar and behave as those obtained after other techniques of liver ablation. However, controversial areas still exist and include the optimum number of freeze thaw cycles, the place of inflow occlusion, the potential corrupting effects of intra-lesional or proximal blood vessels on ablation morphology. The influence of these factors on the local recurrences are still not fully understood.

Management of spermatic cord liposarcoma in renal transplant recipients: case report.

Herein, we report the case of a 52-year-old man with a spermatic cord liposarcoma that developed 4 years after renal transplantation. The patient was admitted with a diagnosis of inguinal hernia. During surgical exploration, a solid mass was found arising from the spermatic cord. Histologic analysis demonstrated a well-differentiated sclerosing liposarcoma.