Novel Modality of Endoluminal Anastomotic Integrity Assessment with Fluoroangiography After Left-sided Colorectal Resections.

BACKGROUND: Several methods have been described for the intraoperative evaluation of colorectal anastomotic integrity. Technological evolution has allowed to progress from basic mechanical methods to the use of more sophisticated techniques. This study describes a novel endoluminal modality of colorectal anastomotic assessment through the use of a Disposable Rigid Scope Introducer (DRSI) also allowing for intraoperative endoluminal perfusion evaluation by indocyanine green (ICG) fluoroangiography in patients undergoing left-sided colorectal resection. METHODS: The DRSI consists of an endoluminal introducer device made up of an insertion tube and port connected to an insufflation bulb to manually insufflate the sigmoid and rectum and is compatible with any laparoscopic camera, also allowing for ICG fluoroangiography for perfusion purposes. RESULTS: The DRSI was successfully used to assess anastomotic integrity after left-sided colorectal resections performed in 16 consecutive patients. The DRSI allowed to visualize by fluoroangiography the quality of tissue perfusion at the anastomotic site in all cases, contributing to the decision of avoiding loop ileostomies in low rectal resections. In 2 cases, the DRSI showed the presence of significant anastomotic bleeding which was successfully controlled by laparoscopic suture placement. No adverse event resulted from the use of this device. CONCLUSIONS: The DRSI combines direct endoluminal visualization of the anastomosis together with real-time evaluation of its blood flow. This device holds great potential for prompt intraoperative detection of anastomotic alterations, possibly reducing the risk of postoperative anastomotic bleeding or leaks related to mechanical construction/perfusion issues. Potential advantages of this device warrant larger cohort studies and prospective randomized trials.

Lung Tumor Skin Metastasis: Case Report of a Solitary Cutaneous Ulcerated Lesion as Initial Manifestation of Lung Carcinoma.

Lung cancer has the highest cancer incidence, and it is the most common cause of cancer death worldwide. Cutaneous metastases are infrequent compared to hilar nodes, adrenal glands, liver, brain, and bones. However, unusual skin lesions in patients at high risk of lung cancer should be regarded carefully to rule out a metastatic manifestation of an occult primary site tumor. Surgical excision, or incisional biopsy when the former is deemed unfeasible, should be performed to allow histopathological examination in case of occult primary site. In patients affected by advanced lung tumors, surgical excision could be beneficial in terms of pain control and improvement of the quality of life. We report a case of a solitary large skin lesion as an early manifestation of a lung adenocarcinoma.

Simultaneous Laparoscopic Cholecystectomy and Endovascular Infrarenal Aortic Aneurysm Repair.

Background/Aim: With the increasing use of endovascular aneurysm repair (EVAR) and the availability of laparoscopic cholecystectomy (LC) for treating abdominal aortic aneurysms (AAA) and cholelithiasis, respectively, the association between these elective treatments is not yet well-defined. Thus, this study aimed to evaluate the results of elective and simultaneous EVAR and LC. Methods: Thirteen patients (mean age, 72 years) with concomitant large and asymptomatic AAA and asymptomatic cholelithiasis underwent simultaneous EVAR and LC. Results: Post-operative mortality was absent, and the morbidity rate was 7%. The mean total duration of the procedure was 142 min. The mean duration of fluoroscopy was 19 min, and the mean radiation dose was 65 mGy. The mean amount of iodinated contrast injected was 49 mL. The timing of oral fluid intake was 28 h (range, 24-48 h) and that of the oral low-fat diet was 53 h (range, 48-72 h). No patient presented with an aortic graft infection during the entire follow-up period (mean duration, 41 months). The mean length of post-operative hospital stay was 6 days (range, 5-8 days). Late survival was 85%, and the exclusion of AAA was 100%. Conclusion: Simultaneous EVAR and LC can be performed safely, allowing effective and durable treatment under both AAA and cholelithiasis conditions.

Standard versus eversion-modified double-staple technique for low colorectal anastomoses after resection of rectal cancer.

PURPOSE: The double-staple technique, performed as either the standard procedure or after eversion of the rectal stump, is a well-established method of performing low colorectal anastomoses following the resection of rectal cancer. Eversion of the tumor-bearing ano-rectal stump was proposed to allow the linear stapler to be fired at a safe distance of clearance from the tumor. We conducted this study to compare the results of the standard versus the eversion-modified double-staple technique. METHODS: The subjects of this retrospective study were 753 consecutive patients who underwent low stapled colorectal anastomosis after resection of rectal cancer. The patients were divided into two groups according to the method of anastomosis used: Group A comprised 165 patients (22%) treated with the modified eversion technique and group B comprised 588 patients (78%) treated with the standard technique. The primary endpoints of the study were postoperative mortality, surgery-related morbidity, the number of sampled lymph nodes in the mesorectum, and late disease-related survival. RESULTS: Postoperative mortality was 1.2% in group A and 1.7% in group B (p = 0.66). Postoperative morbidity was 12% in group A and 11% in group B (p = 0.75). The mean number of sampled lymph nodes in the mesorectum was 23 (range 17-27) in group A and 24 (range 19-29) in group B (p = 0.06). The 5-year disease-related survival was 73% in group A and 74% in group B (p = 0.75). CONCLUSION: The standard and eversion-modified double-staple techniques yield comparable results.

Laparoscopic lavage/drainage as a bridge treatment for perforated diverticulitis with purulent peritonitis associated with an abdominal aortic aneurysm A retrospective case-control study.

AIM: Laparoscopic lavage /drainage (LALA) or surgical resection are both methods of treatment for perforated diverticulitis with purulent peritonitis (Hinchey Stage III). In case of associated abdominal aortic aneurysm (AAA), laparoscopic lavage/drainage could be an interesting bridge option to treat sepsis before endovascular exclusion of the aneurysm and resection of the sigmoid. We performed LALA as a bridge treatment of peritonitis before elective, staged endovascular exclusion of the aneurysm (EE) and elective resection of the colon. MATERIAL AND METHODS: Seven patients presenting a perforated diverticulitis with purulent peritonitis (Hinchey III), associated with an uncomplicated AAA of a mean diameter of 6 cm, underwent LALA followed by staged EE and resection. They were retrospectively reviewed for a case-control study. The mean length of follow-up after completing all the procedures was 28 months. Primary endpoints were mortality and morbidity of each procedure, complications related to each procedure and to the untreated disease in the interval between each one of them, late outcome and complications related to each treatment method. As secondary endpoints, the mean length of surgery for resection, of stay in the hospital, of the interval between each procedure, and of time required for the treatment of both the diseases were considered. RESULTS: Postoperative mortality was absent. Morbidity consisted of a sigmoido-vescical fistula 18 days after resolution of peritonitis and sepsis, not hindering EE,and a delayed healing of the surgical wound for access to the common femoral artery (28.6%). No complications of untreated disease in the interval between each procedure were observed. No late complications of both diseases occurred. The mean interval between LALA and EE,and between EE and resection was, respectively, 19 days and 18 days. Both the diseases were treated within a mean delay of 37 days after LALA (range, 24-61 days). CONCLUSIONS: LALA, as a bridge treatment, before EE and resection, in patients presenting a perforated diverticulitis with purulent peritonitis, associated with an uncomplicated AAA, may be an effective treatment option. KEY WORDS: Perforated diverticulitis, Purulent peritonitis, Abdominal aortic aneurysm.

May predictors of difficulty in thyroid surgery increase the incidence of complications? Prospective study with the proposal of a preoperative score.

BACKGROUND: Although thyroidectomy is one of the most common surgical procedures performed worldwide, some permanent complications, despite the considerably reducing incidence, may affect dramatically the patients quality of life. The purpose of this study is to evaluate whether factors identified preoperatively and expressed in a score could be predictors of major surgical difficulty during total thyroidectomy and influence the incidence of complications. METHODS: A total of 164 patients who underwent total thyroidectomy were examined. For each patient we calculated a preoperative score, including seven parameters, which we evaluated to be predictors of difficulty in thyroid surgery, that is, sex, body mass index (BMI), neck length, neck extension, thyroid gland volume, thyroiditis, and increased parenchymal vascularization. The overall score was also compared with peri- and post-operative factors describing objectively the difficulty in thyroid surgery. These factors are the duration of the operation, the length of hospitalization, the incidence of complications such as hemorrhage, hypoparathyroidism, and recurrent laryngeal nerve injuries. RESULTS: There was no statistically significant association between our score and either the percentage of postoperative complications or the length of hospitalization. The operative time was the only variable remarkably associated with the score value (p < 0.00001). Comparing the duration of the operation with each of the preoperative predictive factors, we found that none of the factors reached the value of statistical significance, but a close association could be noted with the thyroid volume and the BMI. CONCLUSIONS: In our study, predictors of difficulty in thyroidectomy did not affect morbidity rates, as suggested by previous studies, but only operative times, which were significantly increased in patients with higher score. Although our results have limited statistical significance, they allow us to confirm the fundamental role of a systematic use of optical magnification and microsurgical technique in thyroidectomy. Further studies, with a larger cohort of patients, are needed to validate our results and to formulate a universally accepted predictive score of difficulty in thyroidectomy preoperatively.

Laparoscopic modified double stapling technique with transanal resection for low anterior resection of rectal cancer.

BACKGROUND AND AIM: Anterior resection of the rectum with a total mesorectal excision is the standard surgical technique for the treatment of rectal cancer. Laparoscopic low anterior resection (LALAR) is an alternative to open surgical approach and was validated in diverse randomized control trials to be as safe and oncologically effective. That said, confronting a low rectal tumor in an obese patient with a narrow pelvis can be technically challenging even for the most expert surgeon. METHODS: We propose a modified double stapling technique with transanal eversion and staple resection of the rectal stump. RESULTS: We applied the above technique in 3 patients with a dubious distal resection margin due to patient/tumor characteristics. The mean length of operation was 272 minutes and a R0 resection with a mean number of 16 nodes could be obtained in all the patients. No recurrence occurred during a follow-up of 28 months. CONCLUSIONS: We conclude that this technique is a feasible, safe and valid adjunct to the double staple technique whenever intraabdominal application of the linear staple is difficult or unsafe. KEY WORDS: Colorectal cancer, Laparoscopic anterior resection, Double, Low colorectal anastomosis, Stapling technique.

Death due to external compression of the trachea in a patient with multinodular hemorrhagic goiter.

In this paper we describe the case of an 81-year-old Caucasian female (142 cm tall, weighing 45 kg) who suffered from a multinodular goiter for approximately 40 years. Following the onset of a clinical condition characterized by acute respiratory failure, she was transported to the emergency room by ambulance, where she died within a few hours after admission. A recent cardiac examination showed the absence of risk factors for cardiovascular disease, sinus tachycardia with a heart rate of 131 bpm, negative objectivity for signs of cardiocirculatory failure, a blood pressure of 120/80 mmHg and modest exertional dyspnea. A recent hemochemical laboratory analysis showed a TSH value of 0.01microUI/mL, FT3 value of 4.76 pg/mL and FT4 value of 2.33 ng/mL, pointing to a pattern of hyperthyroidism, attributable to Basedow's goiter. Autopsy showed some peculiarities, and we came across two extremely rare findings; the thyroid gland had reached a very large size in relation to the patient's body mass (1510 g, in a patient of 142 cm and 45 kg), and the death of the patient was due to the development of a massive intra-thyroid hemorrhage that had caused acute external compression of the trachea. To the best of our knowledge this very rare event has not previously been reported in the international scientific literature.

Appendiceal abscess in a giant left-sided inguinoscrotal hernia: a rare case of Amyand hernia.

The hernia of Amyand is an inguinal hernia containing the appendix in the sac. It is a rare pathology often diagnosed only intra-operatively. We report a case even more rare of a giant left-sided inguinoscrotal Amyand hernia with appendiceal abscess without clinical findings of incarceration/strangulation, occlusion, perforation, or acute scrotum and with the presence in the sac of the caecum and other anatomical structures (last ileal loops, bladder and omentum). The 68-years-old man patient successfully underwent surgical treatment only through the hernia sac (meshless repair according to Postempski technique).

Primitive sarcoma of the breast: new insight on the proper surgical management.

BACKGROUND: Primitive sarcoma of the breast is a rare and challenging disease at high risk of recurrence and with poor prognosis. There are controversies in the diagnosis and management of such solid tumor due to its rarity and heterogeneity. This sarcoma is poorly responsive to both chemotherapy and radiotherapy, thus, surgery is the first and most important therapeutic approach. However, given the rarity of this type tumor it has not be possible to standardize unique guidelines for the proper surgical strategy to adopt. Here, we performed a retrospective study of new 10 cases of primitive sarcoma of the breast that underwent either mastectomy or a more conservative quadrantectomy, in the attempt to better standardize correct surgical indications. METHODS: Ten new cases of primitive sarcoma of the breast were registered between 2002 and 2012 and constituted the study group. They underwent either mastectomy or quadrantectomy and the clinical, prognostic and survival characteristics after surgery were analysed. RESULTS: Within the group of patients treated with mastectomy, two had metastasis and died because of that. Among the five patients treated with quadrantectomy four are alive and free of disease after 3 to 5 years follow-up, while the patient with sarcoma arising in pregnancy, although is still alive, developed lung metastases four years after surgery. CONCLUSIONS: The first and most important therapeutic approach to primary sarcomas of the breast is surgical which has the purpose to achieve radical tumor excision to prevent local recurrence and skip metastases. However, given the rarity of the condition and the consequent small number of cases in this, like in similar studies, it is not possible to draw any definitive conclusions and further studies with larger numbers are necessary. However it would appear that performing a larger procedure such as mastectomy rather than performing a more limited one such as a quadrantectomy, has no advantage in terms of overall prognosis.

Rare chondrosarcoma of the breast treated with quadrantectomy instead of mastectomy: A case report.

Breast chondrosarcoma is a rare sarcoma that mainly occurs in females >50 years old. To the best of our knowledge, only 16 cases were reported in the literature prior to 2013 and all patients were surgically treated by mastectomy, with or without lymphadenectomy, which was occasionally preceded by neoadjuvant chemotherapy. However, the literature does not report the benefit of mastectomy compared with a more conservative surgery. The present study reports a novel case of extraskeletal chondrosarcoma of the breast. A 63-year-old female patient presented with a neoplasm localized in the upper-outer quadrant of the right breast. The palpable lesion with sharp margins was a firm parenchymatous mass, which was confirmed by ultrasonography and mammography. The patient underwent conservative quadrantectomy instead of mastectomy, followed by post-surgical chemotherapy. A positron emission tomography scan performed five months subsequent to the surgery revealed no remnants of the disease. The patient underwent a strict clinical and instrumental follow-up, and two and half years after surgery, there are no signs of recurrent disease. In conclusion, the present case is currently one of the two cases in which a more conservative quadrantectomy was performed, instead of mastectomy. This surgical approach did not lead to metastasis and resulted in a good follow-up for the patient.

Microsurgical approach for unusual and unexpected malignant fibrous histiocytoma of the forearm: A case report.

Soft tissue sarcomas are rare tumors with a dismal prognosis. Among the most common histological types of sarcomas of the extremities, malignant fibrous histiocytoma (MFH) is the one with the highest incidence. Surgery is considered to be the first choice of treatment for MFH. To the best of our knowledge, this is the first case report in the literature of a patient with MFH within the abductor pollicis longus (APL) muscle. This unusual location was also unexpected by the treating surgeons, as the preoperative magnetic resonance imaging localized the tumor inside a different muscle. A 79-year-old Caucasian man presented with a swelling in the middle third of the dorsal aspect of the left forearm. MFH was diagnosed following biopsy and instrumental diagnostic examinations. Surgical excision and simultaneous reconstruction was performed by the same microsurgical team, achieving an excellent functional outcome. The present case highlights the significance of microsurgical approach for improving strategic planning in oncologic surgery. Accurate surgical dissection, performed by a team of microsurgeons, allowed for the identification of the unusual and unexpected tumor localization within the APL muscle. For this reason, a change of surgical strategy allowed for preservation of the extensor digitorum communis muscle, which would otherwise have to be resected, with tendon transfer and successful restoration of the thumb abduction function.

Breast Mondor's disease: Diagnosis and management of six new cases of this underestimated pathology.

Mondor's disease is an unusual and little-known pathology of the breast, characterized by superficial thrombophlebitis. The causes are still unresolved. Most of the patients do not fall under case studies of the scientific literature, given the reported incidence rate between 0.5% and 0.8%. The Mondor's disease patients are not always properly identified, and they are frequently treated as outpatients, even considering the benign course of the disease which often spontaneously resolves without any medical therapy. We report here six new cases of Mondor's disease, two of them were likely due to a trauma and were easily resolved with the use of non-steroidal anti-inflammatory drugs; the third one was apparently due to the stretching of the mammary veins in a patient with gigantomastia; the fourth one was subsequent to hormonal stimulation for in vivo fertilization and following gestation; and the last two cases (one was a man) were diagnosed after undergoing surgery for breast carcinoma.

Laparoscopic cholecystectomy in Steinert's myotonic dystrophy. About two clinical cases.

Myotonic dystrophy type 1, or Steinert's myotonic dystrophy, is a rare RNA-mediated autosomal dominant disease. Here we describe two clinical cases of patients with Steinert's disease who underwent laparoscopic cholecystectomy under general anaesthesia in conjunction with thoracic peridural anaesthesia, without muscle relaxants. Using such an anaesthesiological technique allowed for rapid recovery from anaesthesia, quick and complete recovery of autonomous breathing, and a significant haemodynamic and arterial blood gases stability, as well as an adequate and complete analgesic coverage over the entire perioperative period.

Contralateral axillary metastases from breast cancer. Personal experience and review of literature.

UNLABELLED: The contralateral axillary lymph node metastasis (CAM) from breast cancer are very rare, and pose a number of classification problems and therefore also on the surgery attitude to be adopted and the subsequent surgical oncological approach, making a distinction between synchronous and metachronous cases. You must always wait for a reasonable period of time to exclude the presence of an occult cancer in the contralateral breast. You make assumptions about the lymphatic pathways that determine this metastasis underlining that in the literature (rare) cases are reported in which the lymphoscintigraphic sentinel lymph node search has shown an uptake of contralateral axillary lymph nodes. KEY WORDS: Breast cancer, Controlateral axillary lymph node metastasis, Lymph node metastasis.

Laparoscopic retroperitoneal lymphadenectomy for stage I non-seminomatous testicular tumors.

Retroperitoneal lymph node dissection (RPLND) is the most accurate method to evaluate the presence and extent of retroperitoneal nodal metastases in clinical stage I non-seminomatous germ cell testicular carcinoma. In our Department the open "nerve sparing" RPLND is already the standard surgical treatment for these tumors and laparoscopic technique is employed in surgical treatment of digestive diseases as cholelithiasis, hiatal hernias and gastrointestinal tumors; we report our first experience with laparoscopic RPLND in patients with low stage non-seminomatous germ cell testicular tumors (NSGCTT). A laparoscopic modified template RPLND was performed in 5 high-risk patients with non-seminomatous germ cell clinical stage I tumors by a transperitoneal approach. In 4 of the 5 cases a template dissection was performed. In one pathological stage II tumor a limited lymph node dissection was performed and the patient underwent postoperative chemotherapy. Mean operative time was 190 minutes (range 160-210). No retrograde ejaculation occurred. The mean number of dissected nodes was 21 (range 16-25). At mean follow-up of 16.3 months (range 12-21) the 4 operated patients with pathological stage I NSGCTT are disease free without ejaculatory or urinary dysfunction. Our preliminary experience suggests that laparoscopic RPLND for stage I NSGCTT is feasible and safe for surgeons largely trained in either laparoscopic digestive surgery or open RPLND for whom the learning curve of that minimally invasive approach is lower than expected.

Choice of the surgical treatment in early gastric cancer.

BACKGROUND/AIMS: The authors report their experience in choosing the surgical treatment for early gastric cancer. METHODOLOGY: A retrospective study was conducted to examine the long-term outcome of 18 patients with early gastric cancer (10%) on a series of 180 patients treated for gastric carcinoma by the same surgical équipe from January 1986 to June 1997. Radical surgery with gastrectomy and extended lymphadenectomy ("regional" from 1986 to 1991; D2 from 1992 to 1997) was chosen as standard treatment for early gastric cancer except in elderly or high-risk patients and in cases of mucosal tumors diagnosed at definitive histology after surgery for benign diseases in which limited surgery was performed. RESULTS: All patients received curative (R0) surgery. One patient with mucosal-N1 tumor and another one with submucosal-N0 tumor died because of gastric cancer at 51 and 42 postoperative months respectively. The mean follow-up time was 99.8 (11-193) months. The overall 5-year and 10-year survival rates are 86.7% and 86.7% respectively. The 5- and 10-year survival rates for intramucosal tumors are 91% and 91% respectively and for submucosal cancer are 75% and 75% (P=0.39). CONCLUSIONS: According to the prognostic value of nodal involvement and the difficulty in achieving a preoperative accurate diagnosis of depth of invasion and of nodal involvement in early gastric cancer, a radical gastric resection with D2-lymphadenectomy should be performed.

[Thyroid anaplastic tumor: our experience]. / Il tumore anaplastico della tiroide: nostra esperienza.

We report our experience over the past 10 years in the treatment of thyroid anaplastic carcinoma analysing retrospectively 21 cases of surgical treatment (7 total thyroidectomies, 12 partial resection of the tumours and 2 biopsies). We consider the prognosis, which is invariably fatal, with no survival at 19 months and a mean survival of only 9 months, and assess the validity of a combined therapeutic approach (surgery + radiotherapy + chemotherapy) to increase survival and, above all, the patient's quality of life. The importance is stressed of through monitoring of risk factors consisting in concomitant or previous benign or malignant thyroid disease, considering total thyroidectomy to be necessary in principle for any variety of thyroid cancer. Lastly, we examine the survival trend in terms of residual disease and the presence or otherwise of remote metastases.