Primary Subcutaneous Umbilical Endometriosis: Case Report and Review of the Literature.

We report the case of a patient diagnosed with primary umbilical endometriosis intending to discuss the diagnostic and therapeutic management of this rare disease. A 45-year-old woman suffering from a painful swelling located in the umbilical region, with intact and normal cutaneous aspect, came to our attention. Ultrasonography of the umbilical region showed a nodule with a nonhomogeneous echotexture pattern. Partial omphalectomy was performed under local anesthesia in day care setting surgery. Histology confirmed the diagnosis of umbilical endometriosis. Pre- and postoperative clinical controls showed no evidence for other endometriosis localization. No medical treatment was administered. No signs of recurrence were observed after 5 years from surgery. A review of the literature of the last 10 years was generated based on MEDLINE research, selecting some specific keywords. Several lesions can occur in the umbilical region, and endometriosis has to be ruled out even in patients without any surgery in their medical history. Surgery is the gold standard treatment for this condition: partial and radical omphalectomy are the two treatment options. We believe that given the significant psychological and aesthetical value of the umbilicus, surgical treatment has to be tailored and in case of a small endometrial umbilical nodule, partial omphalectomy (local excision of the umbilical endometrial nodule) with a 3 mm free border, even without adjuvant hormonal treatment, could ensure adequate and effective treatment.

Natural history, diagnosis, treatment and outcome of thyroid microcarcinoma (TMC) A mono-institutional 5 year experience.

Thyroid microcarcinoma (TMC) it's a rare type of differentiated thyroid cancer, which according to the World Health Organization measures 10 mm or less. Accounting 7-16 % of all thyroid carcinomas, it occurs at any age, more frequently in men, with a female to male ratio of 1:3. More frequently histotype is the papillary subset, PTCM. Aim of this study is to retrospectively evaluate the patients diagnosed with TMC in terms of their clinical and histopathological features. In our institution we collected 23 cases of TMC sampled on 338 plongeant being operated. All the tumors, in our study, were found incidentally during the treatment of benign thyroid diseases. All the sample were analyzed and prepared using the same frozen section technique. Surgical pathology identified 11 papillary microcarcinomas, 10 follicular microcarinomas, 1 oncocytary microcarcinomas and in 1 patient was found only a focal tireocitary transformation. TMC's prognosis and treatment is still a subject of controversy We propose our approch consisting in total thyroidectomy (less than 5 gr residual thyroid tissue), being considered the low rate of post-operative complications, and recurrences: all patients are disease-free at the median follow-up of 78 months (range 96 to 30 months). We have considered either the less malignancy habit of this neoplasia either its well prognosis.

Conservative management and parenchyma-sparing resections of pancreatic neuroendocrine tumors: Literature review.

BACKGROUND: Pancreatic neuroendocrine tumors (pNETs) are uncommon entities. pNETs are often small, slow growing, clinically silent neoplasms. However, they have an almost unpredictable biological behaviour with a not negligible malignant potential. Surgery still represents the treatment of choice, but the high morbidity associated to the enucleation or the formal pancreatectomy should be considered in the decision of the proper treatment. Management of these neoplasms is still debated, and indications for a conservative observational approach and for parenchyma sparing resections are not yet standardized. METHOD: We review the state of art on the indications for the conservative management of pNETs. Searches on MEDLINE database were performed to identify articles reporting prognostic systems, biochemical screening, observational management, medical treatment and surgical strategies for pNETs. DISCUSSION: Currently, an accurate 'wait-and-see' policy is recommended by the European Neuroendocrine Tumor Society (ENETS) only for non-functioning pNETs (NF-pNETs) <2 cm. A biochemical screening, based on sampling of serum levels of pancreatic polypeptide (PP) and chromogranin A, can address to early conservative surgery for MEN-1 associated NF-pNETs <2 cm to prevent their malignant transformation. The subtotal (80%) distal pancreatectomy first proposed by Thompson, often with the enucleation of possible pancreatic head tumors, still represents a good compromise between oncological radicality and prevention of pancreatic endocrine/exocrine insufficiency caused by standard radical resections for the treatment of inherited syndromes associated with NF-pNETs >2 cm and symptomatic F-pNETs of any size. CONCLUSION: More studies are needed to further clarify and predict the biologic behaviour of pNETs and increase the indications for conservative observational management and parenchyma sparing pancreas resections.

Radiofrequency-assisted partial nephrectomy for metanephric adenoma: a case report and literature review.

Metanephric adenoma (MA) is a rare benign tumor, diagnosis of which is often carried out after surgical treatment. In case of peripheral lesions, a partial nephrectomy (PN)--either open or laparoscopic may be preferred--and, furthermore, a radiofrequency (RF)-assisted procedure may facilitate adequate hemostasis. In November 2010, the authors performed a RF-assisted PN, according to Habib's technique, using a 4-needle bipolar device, on a woman affected by a small exophytic MA of the right kidney. Fibrin glue was applied on the cut surface. Postoperative course was uneventful, and discharge was on postoperative day 4. MA is an extremely rare benign tumor with a favorable prognosis. In case of a preoperative cytological diagnosis, a careful follow-up has to be considered. PN represents the standard of care for small exophytic MA, and RF-assisted procedures allow an excellent hemostasis and a rapid conservative resection, with very low morbidity.

Role of parathyroidectomy on anemia control and erythropoiesis-stimulating agent need in secondary hyperparathyroidism of chronic kidney disease. A retrospective study in 30 hemodialysis patients.

BACKGROUND: Parathyroidectomy (Ptx) ameliorates anemia (A) and reduces postoperative erythropoiesis-stimulating agent (ESA) requirement. The authors retrospectively evaluated the effects of successful Ptx on chronic A and ESA need in 30 2HPT patients. METHODS: From 2004 to 2009,30 anemic hemodialysis (HD) patients, affected by severe 2HPT, underwent Ptx -15 total parathyroidectomy (TP) and 15 TP + subcutaneous autoimplantation (TPai). Patients were evaluated for iPTH, hemoglobin (Hb) levels, erythrocyte count, hematocrit and erythropoietin dosing before and at 6, and 12 months after surgery. RESULTS: In every case, Ptx achieved a dramatic reduction of iPTH levels. In 26/30 cases(86.6%) an improvement of Hb levels was observed,and 27/30 (90%) patients did not need postoperative ESA treatment,irrespective of the type of surgical procedure carried out (TP or TPai). CONCLUSIONS: Successful Ptx for 2HPT of CKD determined a considerable improvement of A,reducing exogenous ESA need.In 2HPT of HD patients A is a secondary indication to surgical treatment,but we propose that this condition should be taken into more careful account, given the high costs of ESA therapy.

Cytologically undetermined thyroid's follicular lesions: surgical procedures and histological outcome in 472 cases.

BACKGROUND: Fine needle cytology (FNC) of thyroid nodules is not always diagnostic. Most of FNCs undeterminated for malignancy belong to the cytological class of "follicular neoplasm/suspicious for follicular neoplasm" lesions (FN). In this group only 10-30% of cases are malignant and the most appropriate surgical management is still controversial. Here, this issue was addressed and the more reliable predictive criteria of malignancy were also evaluated. METHODS: We retrospectively evaluated 472 patients, surgically treated after a FN diagnosis in a tertiary care referral center. In patients affected by bilateral thyroid disease with a cytological diagnosis of FN, or when high-risk clinical features and familiarity for thyroid cancer were present, total thyroidectomy (TT) was performed. Conversely, hemithyroidectomy (HT) was preferred when the nodule was single and when the age was ≤ 45 years. Frozen section examination was not used, and if cancer was diagnosed by definitive pathology of the HT specimen, the remnant thyroid lobe was removed. Histological features, surgical complications, and long-term outcomes of the remnant lobe were reported. Clinical features predictivity was also evaluated. RESULTS: TT was performed in 154/472 pts (32.62%), while HT was carried out in 318/472 cases (67.37%). The overall malignancy rate (MR) was 18.85% (89/472 pts), respectively 16% (51/318pts) following HT, and 24.6% (38/154pts) following TT, with a statistically significant difference. Similarly, the rates of transient and definitive hypoparathyroidism and the mean hospital stay following TT were higher than after HT (and statistically significant). Age < 45years and female gender were more frequently associated to malignancy. The rate of complications following second surgery was comparable to that of primary HT. In the HT group incidence of unexpected contralateral papillary thyroid cancer (PTC) was 9.8% and, after 88.2 ± 30.42 months mean follow-up, completion surgery for benign pathology was carried out in 6.7% of cases. CONCLUSIONS: Our data show that histology following a cytological FN diagnosis is malignant only in a low percentage of cases (89/472, 18.85%). Following TT, a MR higher than in HT was observed. Even if some clinical features are cancer associated, malignancy cannot be reliably predicted before surgery. Thus, in solitary low-risk lesions, HT is still the standard of care. Its lower complication rates makes HT the safest procedure. In case of multiglandular disease TT may be recommended. Further investigation is warranted to achieve a better preoperative diagnostic accuracy in order to reduce the amount of surgical operations with diagnostic aim.

Early outcomes of colon laparoscopic resection in the elderly patients compared with the younger.

BACKGROUND: The aim of this study was to define any benefits in terms of early outcome for laparoscopic colectomy in patients over 75 years old (OP) compared with the outcomes of a younger populations (YP). METHODS: Forty elderly patients undergoing laparoscopic colectomy for colorectal cancer between 2007-2011 were studied, the patients are divided for gender, age, year of surgery, site of cancer, and comorbidity on admission and compared with 40 younger patients. RESULTS AND DISCUSSION: Mean (standard deviation) age was 81.3 in OP and 68.3 YP Conversion rate was the same between the two groups. There was no difference in operative mean time . The overall mortality rate was 0% percent. The surgical morbidity rate was the same but there was an increased in cardiologic e bronchopneumonia complications in older population. Patients treated with laparoscopic approach had a faster recovery of bowel function and a significant reduction of the mean length of hospital stay not age related. Laparoscopy allowed a better preservation of postoperative independence status. CONCLUSIONS: Laparoscopic colectomy for cancer in elderly patients is safe and beneficial including preservation of postoperative independence and a reduction of length of hospital stay.

The role of percutaneous US-guided drainage in the treatment of splenic abscess. Case report and review of the literature.

Splenic abscess is an uncommon but potentially life-threatening disease that generally occurs in patients with neoplasia, immunodeficiency, hemoglobinopathies, trauma, metastatic infection, splenic infarction and diabetes. Splenic abscess should be considered in a patient with fever, left upper abdominal pain, and leukocytosis. Splenectomy has been the gold standard treatment for splenic abscess, however, burdened by high morbidity rate related clinical conditions of the patient. With the recent development of minimally invasive techniques and percutaneous US- or CT-guided procedures, the placement of a drainage has achieved excellent results with resolution of the disease in a high percentage of cases with low morbidity and negligible mortality. Percutaneous drainage is indicated for uniloculated or biloculated abscesses and for high risk surgical patients. It is a reliable technique with a high rate of therapeutical success and low costs compared to surgery. Other advantages include avoiding risks of intra-abdominal spillage and perioperative complications and saving time, along with a better patient compliance and an easier nursing care. The authors describe a case of splenic abscess treated by percutaneous US-guided drainage. Our results suggest that ultrasound-guided percutaneous drainage is a safe and feasible alternative to surgery in the treatment of splenic abscesses. In addition, it allows spleen preservation.

Surgical treatment of metastases from cutaneous melanoma to the small intestine and the spleen. Case reports and review of the literature.

Cutaneous melanoma is found in the head and neck in 15% of patients, in the limbs in 22%, in the trunk in 40% and in occult sites in 16%. There is usually an interval of at least 3 years between the diagnosis of primary melanoma and the identification of metastases. Primary melanoma metastasizes most frequently to the lymph nodes (73.6% cases) and the lungs (71.3% cases). The small intestine and the spleen are the sites of 36.5% and 30.6% respectively of the gastrointestinal metastases from melanoma. The cases reported provide evidence of the effect radical resection in patients with gastrointestinal metastases can have on survival. The cases and a review of the literature suggest that a careful and multidisciplinary follow-up is of crucial importance since it is the only means of identifying metastases when they can be still cured with surgical treatment.

[Prognostic and curative value of sentinel node in breast cancer. A 377 patients experience]. / Valore prognostico e curativo del linfonodo sentinella nel trattamento chirurgico del cancro della mammella. Analisi di 377 pazienti.

Sentinel node is defined as the first lymphnode receiving limphatic drain from the breast. Several studies show a very low recurrence rate to axillary and locoregional nodes in sentinel node negative patients who did not undergo axillary dissection. Our study aims to verify if complete axillary dissection could be replaced by sentinel node biopsy (SNB) in the staging and treatment of breast cancer. From January 2005 to December 2008, 377 patients (mean age 57.63) underwent SNB in the General Surgery unit of "San Giuseppe Moscati" Hospital in Avellino (Italy). All the patients underwent SNB with local anesthesia. Histologic studies were performed using GIVOM protocol (Veneto Breast cancer interdisciplinary group). Sixty five patients (17.2%) underwent a radical mastectomy with SNB and 312 (82.6%) patients underwent a quadrantectomy with SNB. Of this last group, 178 (47.2%) underwent a superior quadrant excision with SNB, 77 (20.4%) an inferior quadrant excision with SNB and 57 (15.1%) a central quadrant excision with SNB. Ductal carcinoma represented 57.3% of the tumous detected, lobular carcinoma was diagnosed in 16.4% of the cases, intraductal microinvasive carcinoma in 10.3%, ductal carcinoma in situ in 5.8% while the other histotypes were diagnosed in 10% of the tumours. All SNB+ patients (34.5%) underwent a radical axillary dissection in general anesthesia. Sixty nine (53%) patients were diagnosed with axillary node metastasis, after axillary dissection Micrometastasis resulted in 19.6% of the excised patients. The prevalence of axillary node metastasis was 26.4% (581/2198), while the incidence was 34.5% (130/377). The first axillary lymphnodes level was metastasized in 65.8% patients who had undergone an axillary dissection, level I and II in 268% and all the levels in 7.4%. Only one case (0.4%) of nodal metastatic recurrence has been diagnosed in patients who had undergone SNB alone, after a mean follow-up of 28.5 month. Apart from showing a very high diagnostic and staging accuracy, the high level of SN detection associated with a high predictive rate underline a lower complications rate if compared to complete nodal dissection.

Hemoperitoneum caused by the rupture of a giant ovarian teratoma in a 9-year-old female. Case report and literature review.

The Authors report the case of a 9-year-old girl suffering from acute abdominal pain, combined with mild anaemia (Hb 10.9 g/dL), leukocytosis (24.3 x 10(3) cells/dL), and a large palpable mass in the upper left quadrant. The child underwent an appendectomy 20 days before the admission to our Department. The operation performed in urgency, as well as the removal of a bulky mass situated in the left flank and the right ovary whence it arose, made it clear that abdominal signs and symptoms were caused by the twisting and rupturing of a neoformation, that would hence cause an impressive hemoperitoneum. The histopathologic examination showed a three-germ layer mature mixed teratoma. Clinical, radiologic and biochemical test (alpha-FP, beta-hcG) performed in a postoperative 2 months follow-up revealed no residual disease.

[Coleman lipofilling: experience of an Italian group and review of the literature]. / Lipomodellamento secondo Coleman: esperienza di un gruppo italiano e revisione della letteratura.

Although the first operation of reconstructive breast surgery dates back to the end of the nineteenth century, it was only in the last decade of the twentieth century that lipofilling became widely adopted in the management of diseases of the breast. The Coleman technique involves taking a sample of fat from the regions of the body where it is largely present (abdomen, trochanter region, groin, knee), followed by centrifugation and the grafting of the fat cells thus purified. In 1987 the American Society of Plastic and Reconstructive Surgery banned the diffusion of this procedure because it was considered of little benefit for both aesthetic and oncological purposes. From January 2005 to May 2007, 17 patients underwent lipofilling according to the Coleman technique at the Operative Unit of General Surgery of the "San Giuseppe Moscati" Hospital in Avellino. Previously, 15 (88%) of the 17 women had received reconstructive breast surgery with a prosthesis after a Madden total mastectomy. As regards the other 2 patients, when admitted to hospital, one (5.9%) presented a pectum excavatum and the other (5.9%) a congenital depression of the temporal bone. No important complications were observed in the postoperative course. At a distance of 6 and 12 months after the injection, follow-up monitoring revealed that the loss of substance in the grafted adipose tissue was about 53%. In conclusion, reconstructive breast surgery should always be attempted after radical surgery. The multidisciplinary cooperation of radiologists, surgeons, anatomical pathologists and psychologists, in our opinion, avoids the danger of poor aesthetic results and the risk of underestimating a possible tumour relapse.

[Prognostic and therapeutic value of D2 lymphadenectomy in the treatment of gastric cancer: experience of an Italian team]. / Valore prognostico e terapeutico della linfoadenectomia D2 nel trattamento chirurgico del cancro gastrico: considerazioni di un gruppo Italiano.

Recently, the incidence of gastric cancer and the related percentage of mortality have been decreasing world-wide, especially in the industrialised countries. Surgery has commonly been opted for as primary treatment of this disease. However, the optimal extent of surgical intervention is still debated. Japanese surgeons have been the pioneers of perigastric and celiac tripod lymphadenectomies in an attempt to improve long-term survival and the postoperative disease-free period. In recent years, D2 resection has been compared with D1 resection, which consists in excision of the stomach along with its locoregional nodes. From March 2002 to January 2007, 70 interventions for gastric cancer were performed at the VII Division of General Surgery of the Second University of Naples. All patients underwent excision of the lymph nodes from stations 1 to 6 (D1) combined with excision of stations 7 to 12 (D2). In 32 cases (45.7%) there were no metastatic lymph nodes (NO), in 28 patients (40%) 1 to 6 nodes proved metastatic (N1), and in 10 cases (14.3%) from 7 to 15 nodes were metastasised (N2). The incidence of metastatic lymph nodes was 54.3% and the prevalence 13.6%. Metastatic lymph nodes were found mostly in T3 (15/24) and T4 (14/20) stage tumours rather than in T1 (3/12) and T2 (6/14) neoplasms. Two patients (2.86%) died within 60 days of the intervention. The overall postoperative morbidity and mortality rates were 21.43% and 2.86%, respectively. D2 gastrectomies without pancreatic resections present distinct advantages in terms of long-term survival and are associated with postoperative morbidity and mortality rates which are similar to those obtained after D1 node resection.

Effects of high and low ligation on survival in patients operated for colorectal cancer.

In spite of numerous studies on the subject, it is still unclear whether or not high ligation of the inferior mesenteric artery (at about 1 cm from its origin) improves the 5-year survival rate in patients operated on for colorectal cancer in comparison to low ligation (ligation below the origin of the left colic artery). From February 2000 to November 2001 40 patients with cancer of the colic segment between the descending sigmoid junction and the low rectum underwent surgical colorectal resection and low ligation of the inferior mesenteric artery. At the end of 5 years of observation we report a survival rate of 70% which is not very far from the value reported in the literature. In our study, the incidence of lymph-node metastases, inexistent in patients with T1 grading increases with the increase in the TNM T grading but does not depend on the location of the cancer. In our patients age below 65 years was a negative prognostic indicator because colorectal tumours in patients of that age are associated with a higher incidence of lymph-node metastases. On the basis of the data we obtained, it is also evident that the 5-year survival rate decreases in proportion to the increase in the distance of the lymph-node metastases from the mesenteric margin of the colon. In conclusion, in the treatment of cancers located between the descending sigmoid junction and the low rectum, we prefer to execute a low ligation of the inferior mesenteric artery because it exposes the patient to a lower risk of intra- and postoperative complications and also because several authors have demonstrated that high ligation with removal of lymph nodes at the origin of the artery for colorectal cancer does not improve the 5-year survival rate.

Surgical therapy of goiter plunged in the mediastinum. Considerations regarding our experience with 165 patients.

Thyroid goiter is called plunged when, starting from the cervical region, it grows in the anterior-superior mediastinum to a depth of more than 2 cm. The highest frequency (48.44%) is evident in the age range from 60 to 70. From February 2002 to August 2005, performed 133 (80.6%) near total thyroidectomies, 26 total thyroidectomies (15.7%), 4 lobectomies (2.4%) and 2 (1.2%) totalisations of recurrences for plunged goiter in the 7th Division of General Surgery of the Second University of Naples. The goiters were classified using Lamke and Ferrante's topographical classification, which distinguishes between prevascular and retrovascular cervico-mediastinal goiters depending on the position assumed by the part plunged in the mediastinum in relation to the vascular layer of the epiaortic trunks. Retrovascular goiters are further subdivided into: pre-tracheal, laterovisceral and retrovisceral goiters depending on the relation to the trachea, oesophagus and epiaortic trunks. Among the patients who underwent near total thyroidectomy, there were 3 cases of permanent hypocalcaemia, 7 (7.2%) of temporary hypocalcaemia and only 1 (0.6%) monolateral temporary recurrent nerve lesion. Among those who underwent total thyroidectomy there was 1 case (0.6%) of temporary hypocalcaemia, and 1 (0.6%) of permanent hypocalcaemia. Postoperatively we also observed 3 cases (1.8%) of haemorrhage and 3 (1.8%) transfers to intensive care for respiratory insufficiency; 1 of these patients died 25 days after the operation. Ligature of the inferior and superior thyroid artery near the thyroid capsule protects the vascularisation of the parathyroid glands as well as the recurrent nerve and its division branches.