An unusual case of gastric volvulus through Bochdalek hernia A case report and review of the recent literature.

INTRODUCTION: Bochdalek Hernias are one of the most common types of diaphragmatic hernia, a congenital pathology diagnosed during the neonatal period. In adulthood, diagnosis of a Bochdalek hernia is rare and its complications may be fatal. CASE REPORT: We report an unusual case of a 60-year-old woman who presented with upper gastrointestinal bleeding due to a Bochdalek hernia with herniation of stomach and spleen into the chest with a gastric volvulus. Endoscopy showed a strong suspicion of ischemic suffering of the stomach walls, therefore the patient was subjected to urgent laparotomy. The content was reduced, the stomach was congested but viable and the diaphragmatic hernia defect was closed with interrupted sutures. DISCUSSION: Bochdalek hernia in an adult may present with a myriad of abdominal symptoms, such as recurrent abdominal pain, postprandial fullness, and vomiting. The hernia size varies and the content of the hernial sac may differ in each case. The sac may contain multiple viscera including the small bowel, colon, stomach and spleen. As in our case, strangulation of the herniated stomach can occur and this condition can lead to gastric perforation, sepsis and even DEATH. CONCLUSIONS: Considering the severity of this condition, accurate diagnosis and timely surgical treatment is mandatory to reducing morbidity and mortality. KEY WORDS: Bochdalek hernia, Gastric volvulus.

Gastric inflammatory fibroid polyp tumor with acute intestinal obstruction-Vanek's tumor can mimick a giant gastrointestinal stromal tumor or a gastric lymphoma.

An inflammatory fibroid polyp (IFP) is a solitary rare benign neoplasm of the gastrointestinal tract, frequently located in the gastric antrum. IFPs account for about 0.1% of all gastric polyps. We report a case of a giant gastric inflammatory polyp of 2.5 cm × 7 cm that determines a gastric outlet obstruction called "ball valve syndrome" mimicking a gastrointestinal stromal tumor (GIST) and a gastric lymphoma, with an intestinal obstruction of high origin. Therefore, due to acute presentation we have decided to submit the patient to a subtotal gastrectomy. The patient was discharged two weeks later, asymptomatic. At 14 months of follow-up, patient is disease free at abdominal CT and OGDS. Depending on their size and location, IFPs can be associated with unspecific symptoms. Giant IFPs of the gastric antrum or the duodenum can determine an intermittent gastric outlet obstruction called "ball valve syndrome". Endoscopic biopsies are unhelpful and right diagnosis can be reached only with resection. In fact, only about 10% of the gastric lesions are diagnosed correctly prior to resection. Surgical treatment with complete resection with safe margins is curative. Giant IFPs are rare benign lesions whose atypical presentation can mimic GISTs, lymphomas or carcinomas. Clinical and radiological findings may not clarify the right diagnosis until histopathological evaluation aided with immunohistochemical analysis. The resection of IFPs with negative margins is curative with a good clinical outcome. In acute presentation, like in our case, surgery is the mainstay of treatment.

Wernicke encephalopathy as rare complication of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

BACKGROUND: Peritoneal carcinomatosis of gastric origin is a frequent event with poor survival. A new promising approach is the association of the Cytoreductive Surgery (CRS) with the Hyperthermic Intraperitoneal Chemotherapy (HIPEC), which yet is characterized by high morbidity and mortality. We report, to our knowledge, the first case of Wernicke Encephalopathy (WE) complicating CRS plus HIPEC. WE, caused by a deficiency of thiamine, is characterized by ataxia, ocular motor cranial neuropathies and changes in consciousness. METHODS: A patient affected by gastric cancer with peritoneal seeding, submitted to CRS plus HIPEC, in 4th post-operative day had manifested the appearance of flapping tremors, with positive manoeuvre of Mingazzini, impaired vision and mental confusion. The brain Magnetic Resonance Imaging (MRI) confirmed the clinical suspicion of WE. Even though the appropriate therapy was promptly applied, the patient died in 10th post-operative day. CONCLUSION: WE is an uncommon neurological disorder. Only 16% of these patients inadequately treated recover fully, with a mortality rate of 10-20%. We consider useful to report this case, because it is the first time that WE is correlated to CRS plus HIPEC.

The role of prophylactic hyperthermic intraperitoneal chemotherapy in the management of serosal involved gastric cancer.

BACKGROUND: Peritoneal carcinomatosis of gastric origin is associated with poor survival. The use of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) did not significantly improve the survival of patients with this disease. A promising approach can be based on the use of HIPEC as prophylaxis of peritoneal dissemination. PATIENTS AND METHODS: From our database, we have sampled 12 patients with advanced gastric cancer. In all cases, a D2 total gastrectomy was performed, associated with splenectomy in four cases. All patients were submitted to HIPEC. RESULTS: Morbidity and mortality were 33.3% and 8.3%, respectively. The median survival was 24 months, with only one case (8.3%) of peritoneal recurrence. CONCLUSION: In light of our experience and supported by literature data, we can affirm that HIPEC has a potential role in the prevention of gastric carcinomatosis. Certainly further studies are required on a larger scale to validate this new but promising approach.

Metastasis of the gallbladder from the breast cancer.

AIM: Metastatic lesions of the gallbladder are an infrequent clinical condition. The metastatic lesions of gallbladder from primary breast tumors are rarely described in literature. MATERIAL OF STUDY: We report a case of an 83-year-old woman who underwent cholecystectomy for cholelithiasis by video laparoscopy (VL), and in whom a metastatic lesion was detected at the histological examination of surgical specimen. For this reason, the patient was subjected to diagnostic-instrumental investigation with the aim of detecting the primary tumor, which showed the presence of infiltrating lobular carcinoma, pleomorphic variety, in the upper outer quadrant of the right breast. DISCUSSION: Breast cancer and in particular the histological type "ductal infiltrating" is frequently associated with locoregional and distant metastases, the latter especially to bones, liver, lungs and central nervous system. An analysis of literature was conducted on secondary lesions of the gallbladder from breast cancer that has allowed us to confirm the rarity of this disease only described in 18 patients: 12 from infiltrating lobular, 1 ductal origin and 2 mixed ductal and lobular infiltrating. CONCLUSIONS: The most frequent tumor histology associated with the above-mentioned metastatic localization is the metastatic infiltrating lobular carcinoma. Clinically speaking, it is difficult to suspect a metastatic localization from primary breast cancer in the gallbladder, but it is necessary to be well aware of the possibility of metastasis and to bear this in mind during the follow-up of patients with breast cancer. Although cholecystectomy is regarded as a palliative treatment in patients with metastasis in the gallbladder from breast cancer, it is intead recommended in symptomatic cases.

Vulvar endometriosis and Nuck canal.

AIM: Endometriosis is not a well-known disease and sometimes its rare onset is a pathogenetic, diagnostic and therapeutic problem. The Canal of Nuck is an embryonal rest of the parietal peritoneum that accompanies the round ligament through the inguinal canal. The perviousness of the canal of Nuck could explain the pathogenesis of vulvar endometriosis. MATERIAL OF STUDY: We reported a case of vulvar endometriosis localization, which is rather uncommon, in a patient previously operated on with cyst of Nuck. DISCUSSION: One of the most helpful instrumental exams in defining the nature of vulvar swallows is magnetic resonance, but it remains difficult to diagnose vulvar endometriosis in spite of the instrumental exam in our possession. The hypothesis of retrograde menstruation is supported by the fact that ovarian localization is the most common in this disease. Extra-pelvic localization as well as vulvar one are less common. The Canal of Nuck is an embryonal rest of the parietal peritoneum that accompanies the round ligament through the inguinal canal. CONCLUSIONS: Endometriosis could be taken into consideration in differential diagnosis of vulvar swellings, and for this reason it is necessary to carry out a histological exam in every operated vulvar neoformation. We suggest vaginalis-peritonei duct contamination as a possible pathogenesis mechanism of this disease.

Gastric paraganglioma: a case report and a review of the literature.

AIM: Paragangliomas are neural crest-derived neuroendocrine tumors, originating from paraganglia, which are dispersed neuroendocrine organs characterized by catecholamine and peptide-producing cells. With an annual incidence estimated at 1/100,000, paragangliomas represent 10% of catecholamine secreting tumors. MATERIAL OF STUDY: We report a case of a 76-year-old man who was submitted to a subtotal gastrectomy with omentectomy and gastrojejunal anastomosis. The Hystologic exam has revealed an ulcerative polypoid gastric carcinoma with cell poorly cohesive and infiltration of the muscular gastric wall and an incidental parietal gastric lesion which was a paraganglioma with immunocytochemical investigations positive for NSE and negative for CD117, S100, CD34 e SMA. DISCUSSION: Pheochromocytoma indicates exclusively tumors arising from the adrenal medulla, while the extra-adrenal paraganglioma suggests tumors of the chromaffin cells with other locations. Gastric or paragastric localization, as in our case, is very rare for these neoplasms, and in literature there are only isolated case reports. Genetical predisposition is observed in 30% of these tumors and can be responsible of hereditary disease characterized for differences in tumor distribution, catecholamine production, risk of metastasis, and association with others types of tumors. CONCLUSION: In asymptomatic patients and when biochemical and clinical suspicion of neuroendocrine tumor is strong, you have to perform anatomical and functional investigations to detect these neoplasms. The first line treatment for resectable tumors is complete surgical resection, that can be performed with open surgery or laparoscopic technique. Surgical therapy is also indicated to palliative intent when a complete eradication of disease is not achievable for metastatic status of malignancies.

Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy in elderly patients.

BACKGROUND: The treatment of peritoneal malignancies in elderly patients with cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) is an ongoing question due to the high associated surgical risk. PATIENTS AND METHODS: Thirty patients, 11 (36.7%) older than 65 years, were submitted to CRS plus HIPEC. Criteria of patient eligibility were: peritoneal carcinomatosis of different origin, T3-4 gastric cancer, ECOG performance status ≤2, no extra-abdominal extension and no evidence of bowel obstruction. The median follow-up was 21.5 months (range: 1-63). The purpose of this retrospective study, was to evaluate the feasibility of this approach in elderly patients, with special reference to postoperative morbidity, mortality and survival. RESULTS: We have recorded, in elderly patients, higher grade 3 and 4 morbidity and mortality, similar mean duration of cytoreductive surgery, of postoperative hospital stay, of median survival and of overall survival rates. CONCLUSION: Since there no statistical differences, in terms of morbidity and mortality, CRS with HIPEC may also be suitable for elderly patients.

[The role of the incidence of genetic abnormalities on the onset and on the results of the surgical repair of varicocele]. / Ruolo dei fattori genetici sull'insorgenza e sui risultati del trattamento chirurgico del varicocele.

AIM OF THE STUDY: The purpose of this study is to identify possible implications of the presence of genetic abnormalities of male infertility evaluating the suitable response to surgical repair of varicocele, comparing the clinical characteristics of infertile men with the presence or absence of genetic abnormalities. MATERIALS AND METHODS: It has been evaluated the incidence of chromosomal abnormalities and microdeletions of the Y chromosome, through the use of techniques of cytogenetics and molecular biology in patients with varicocele of grade III, preoperatively submitted to physical examination and U.S. Doppler examination, and in which the seminal and hormonal parameters for the diagnosis of oligospermia didn't have meaningful differences. Six months after the surgical correction of the varicocele a comparison has been performed between the response to surgical repair between patients of group A (free of genetic defects) and patients of group B (with genetic defects) through the reevaluation of semen parameters and of the U.S. Doppler. RESULTS: 26.6% of patients had genetic defects suggesting a significant association of genetic alterations in varicocele. Moreover in the group without genetic abnormality a better response to varicocelectomia has been observed. CONCLUSIONS: We found that a high percentage of examined patients showed genetic defects such as chromosomal aberrations (insertions, deletions, inversions or translocations) or Y chromosome microdeletions. As these genetic alterations are associated with infertility, genetic screening in patients with varicocele may represent a useful tool for diagnosis and prognosis of some cases of male infertility.

[Post-operative analgesia in case of ano-rectal diseases]. / L'analgesia post-operatoria nel trattamento delle patologie ano-rettali.

BACKGROUND: The aim of the study was that to evaluate the post-operative pain in case of ano-rectal diseases wether treated by ketorolac, or buprenorphine or tramadol. MATERIALS AND METHODS: The intensity of post-operative pain was evaluated in 60 patients with hemorrhoidal diseases, fistulae, abscesses and anal neoplasms, divided into three homogenous groups and treated with intramuscular ketorolac (Group I), transdermal buprenorphine (Group II) and tramadol in elastomeric pump (Group III). RESULTS: The average index of the visual analogue scale, as mean to evaluate the intensity of the post-operative pain, was 1,85 in the first group, 1,20 in the second one and 1,40 in the third group. DISCUSSION: In patients treated with transdermal buprenorphine or with tramadol in elastomeric pump there has been a more quick psycho-physical recovery than in those treated with ketorolac; the management of elastomeric pump represents however for patients cause of concern while the transdermal system is a kind of rational and comfortable way of treatment of the pain, with the advantage of being non-invasive. CONCLUSIONS: Better compliance and lower operating costs have given the preference to the use of transdermal buprenorphine for the treatment of diseases of the post-operative pain in the diseases of the anal canal.

[Skin neuroendocrine carcinoma metastasis: a case report]. / Metastasi da carcinoma neuroendocrino della cute. Caso clinico.

BACKGROUND: Merkel cell carcinoma (MCC) is a rare and aggressive skin tumour with a highly malignant nature whose appropriate treatment is still debated. The Authors report a case of cutaneous metastasis from neuroendocrine carcinoma and analyse new diagnostic and therapeutic options of neoplasms that occurs in sun-exposed areas. METHODS: The authors present the clinical, immunocytochemical characteristic of primary and secondary skin localization of a neuroendocrine tumor that affected a woman. RESULTS: Histological and immunocytochemical analysis demonstrated that the secondary cutaneous localization appeared to be compared to the primary tumour. CONCLUSIONS: The case confirm the high incidence of regional metastasis; a wide surgical excision of tumor and regional lymphadenectomy is therefore recommended for primary treatment of MCC; the radiation treatment minimized the local recidives with long time survival.