VITOM® 3D in Arterio-Venous Fistulas: Single Centre Preliminary Surgical Experience

BACKGROUND

Arteriovenous fistula (AVF) is the vascular access of choice for hemodialysis patients. A correct microsurgical vascular anastomoses is essential to the optimal care of patients. Loupes can help surgeons perform such procedures, but often cause neck or back pain and fatigue.

AIM

This study aimed to evaluate whether a video telescopic operating microscope (VITOM®; Karl Storz Endoscopy GmbH, Tuttlingen, Germany) could be used as a substitute for loupes to create microsurgical vascular anastomoses.

METHODS

We evaluated microsurgical anastomoses with VITOM® in 10 patients (6 male, 4 female) from January 2019 to December 2019. The created anastomoses were 7 side-to-side, 2 side-to-end and 1 end-to-end.

RESULTS

A valid thrill was always present on palpation. Surgical procedures had an average time of 87.6 min, ranging from 49 to 110 min. Eight patients had AVF maturation; in the remaining 2, one had a thrombosis after 25 days and one couldn't be dialyzed due to low flow in AVF.

CONCLUSIONS

The VITOM® system makes it possible to carry out anastomosis in difficult cases. It is both safe and useful for the training of young surgeons.

Secondary Carina and Lobar Bronchi Stenting in Patients with Advanced Lung Cancer: Is It Worth the Effort? A Clinical Experience

Background: The lobar airway stenting remains an endoscopic procedure not well standardized in patients with locally advanced lung cancer disease. The goal of this study was to evaluate technical feasibility, clinical outcome, and complications of different stents in patients with malignant lesions involving lobar bronchi, primary and secondary carina.

Methods: Between November 2008 and October 2013, we retrospectively analyzed 146 patients with benign and malignant tracheobronchial stenosis who underwent airway stent insertion below main carina and main bronchi.

Results: In all, 170 airway stenting procedures were performed on 146 patients. In all, 51 of them with malignant peripheral airway stenosis underwent stents placement below main carina. In all but one patient, the deployment of stents was successful with improvement of symptoms. The chest radiograph after the procedure detected the lung re-expansion in 29 of 51 patients. The mean follow-up duration was 123 days ± 157. Complications observed included stent migration, tumor overgrowth, infections, granulation tissue formation, and obstruction due to tenacious secretions. Longer survival was observed in patients who received additional treatment after airway stenting compared to those who did not (p <0.01).

Conclusions: Stenting of lobar bronchi and primary or secondary carina is technically feasible, effective, and acceptably safe.

Laparoscopic adrenalectomy: preoperative data, surgical technique and clinical outcomes

Background

laparoscopic adrenalectomy has become the standard treatment for adrenal lesions. The better clinical outcoms of laparoscopic technique are valid for treatment of small benign masses (< 5–6 cm), instead there are still open questions in literature regarding the correct management of larger lesions (> 6 cm) or in case of potentially malignant adrenal tumors. The aim of this study is to evaluate the outcomes of laparoscopic adrenalectomy in a referral surgical department for endocrine surgery.

Methods

at the University Hospital Policlinico “P. Giaccone” of Palermo between January 2010 and December 2017 we performed a total of 81 laparoscopic adrenalectomy. We created a retrospective database with analysis of patients data, morphologic and hormonal characteristics of adrenal lesions, surgical procedures and postoperative results with histological diagnosis and complications.

Results

Mean size of adrenal neoplasm was 7,5 cm (range 1.5 to 18 cm). The mean operative time was 145 min (range 75–240). In statistical analysis lenght of surgery was correlated to the lesion diameter (p < 0.05) but not with pre-operative features or histological results. 5 intraoperative complications occurred. Among these patients 4 presented bleeding and 1 a diaphagmatic lesion. No conversion to open surgery was necessary and no intraoperative blood transfusion were required. Mean estimated blood loss was 95 ml (range 50–350). There was no capsular disruption during adrenal dissection. Mean length of hospital stay was 3.7 days (range 3–6 days).

Conclusions

Laparoscopic adrenalectomy is a safe procedure with low rate of morbidity. An accurate preoperative radiological examination is fundamental to obtain a stringent patients selection. The lesion diameter is related to longer operative time and appeares as the main predictive parameter of intraoperative complications but these results are not statistically significant. On the other side secreting adrenal tumors require more attention in operative management without increased rate of postoperative complications.

Skip metastases to lateral cervical lymph nodes in differentiated thyroid cancer: a systematic review

Papillary thyroid carcinoma is a slow-growing cancer with a generally good prognosis that sometimes have an aggressive behaviour. Metastases to neck lymph nodes is the first step of the diffusion. The central neck compartment is involved most commonly. The ipsilateral lateral neck compartments are usually involved afterwards, and the involvement of the contralateral one is considered a quite rare occurrence. In more rare cases, metastases to lateral neck compartment without central lymph node metastasis (so called “skip metastases”) could be observed. Aim of this literature review study is to analyse the average incidence, pattern and risk factors of this occurrence.

This study was performed according to PRISMA criteria. A final selection of 13 articles published in English language from 1997 to 2017 was performed. Any research article, review or meta-analysis was taken into consideration. Research was expanded considering the related references of articles.

The incidence of skip metastases ranged from 1.6 to 21.8%. Risk factors such as age > 45 years, size < 5 mm and tumor located in the upper pole or isthmus of thyroid gland were found.

Due to the frequency of skip metastases in thyroid cancer, a careful preoperative examination of lateral lymph nodes should be necessary.

Recurrent retroperitoneal abscess after biliary tract surgery in an elderly patient: a minimally invasive nonsurgical approach and its consequences: a case report

Introduction

Hepatic abscess can be defined as an encapsulated collection of suppurative material within the liver parenchyma. Hepatic abscess can be distinguished as pyogenic, amebic, or fungal. Biliary tract disease remains the most common cause of hepatic abscess today, and the most common complications range from pleural effusion, empyema, and bronchohepatic fistula to subphrenic abscess and rupture into the peritoneal cavity, stomach, colon, vena cava, or kidney. A large abscess compressing the inferior vena cava and the hepatic veins may result in Budd-Chiari syndrome. In this report, we present a rare case of hepatic abscess with an unusual evolution that was treated with a noninvasive approach.

Case presentation

A 79-year-old Caucasian woman underwent endoscopic bile stone extraction and laparoscopic cholecystectomy. Six months later, a hepatic abscess in association with bilateral effusion was diagnosed. The prompt imaging-guided drainage solved the case. Three years later, she came to our attention complaining of dull, diffuse abdominal pain and high body temperature (38 °C). A retroperitoneal abscess was diagnosed that was spreading to the right lateral wall of the abdomen and extending across the muscular wall to the subcutaneous layer. The fluid collection also involved the right pleural cavity, forming an empyema. Also in this case, an imaging-guided drainage was performed, and the patient’s clinical picture resolved in a few days. The retroperitoneal abscess recurred 14 months later, and it was dealt with using the same treatment. Three months from the last follow-up, the patient came back to our attention with an evident swelling of her right lumbar region. Computed tomography revealed a right inferior lumbar hernia comprising adipose tissue and the right kidney. A surgical intervention was recommended to the patient, but, owing to her poor general health, she refused any invasive approach.

Conclusions

Retroperitoneal abscess is an uncommon complication of biliary tract surgery and represents a potential cause of death, especially in those patients with multiple diseases. Prompt drainage is crucial to the treatment. Failure in eliminating the primary infective focus could bring complications and, in general, a weakness of lumbar muscular wall, even resulting in a rare case of lumbar hernia.

Diagnostic techniques and multidisciplinary approach in idiopathic granulomatous mastitis: a revision of the literature

Idiopathic granulomatous mastitis (IGM) is a chronic benign inflammatory disease of the breast that may mimic breast cancer. It is most common in parous young fertile women, although it can occur in nulliparous women and in men. IGM is an idiopathic disease due to the influence of some environmental factors in genetically predisposed subjects. Several pathogenic hypothesis have been proposed in the last years (autoimmune, hormonal, infective genesis). IGM presents as a painful palpable mass located in one of the two udders. The skin is usually normal but could present signs of inflammation with or without lymph nodes involvement. Ultrasonography, mammography, magnetic resonance can be diagnosed an IGM, but pathognomonic radiological signs has not yet reported in literature. Biopsy findings show granulomatous lesion centered on the breast lobule, as in granulomatous mastitis induced by tuberculosis or sarcoidosis. The aim of this review of literature is to verify the development of new advanced diagnostic techniques and multidisciplinary approach for this condition. In the last years innovative approaches have modified IGM diagnosis and therapy, avoiding surgery in most of cases, introducing a more conservative medical approach based on recent etiopathological hypothesis. (www.actabiomedica.it)

Transanal hemorrhoidal dearterialization versus Milligan-Morgan hemorrhoidectomy in grade III/IV hemorrhoids

BACKGROUND

Grade III-IV hemorrhoids require surgical treatment. The Milligan Morgan hemorrhoidectomy (MM) - still considered the gold standard - is now flanked by less invasive surgical methods such as Procedure for Prolapse and Hemorroids (PPH) and Transanal Hemorroidal Dearterialization (THD). The authors wanted to compare in a prospective, randomized trial the MM hemorrhoidectomy and the THD in the treatment of grade III-IV hemorrhoids.

MATERIALS AND METHODS

Between January 2010 and March 2013 they were recruited 87 patients with grade III-IV hemorrhoids. All patients did not previously undergo surgical treatment. From the time of recruitment, for a period of six months the patients evaluated the extent of the symptoms of which were suffering expressing in simple and subjective questionare how hemorrhoidal disease accounted on their social life and wellness. After six months of the 52 patients with grade III hemorrhoids 27 were randomly treated with THD and 25 with Milligan Morgan; of 37 grade IV 18 they were treated with THD and 19 with MM. It was evaluated in particular the post-operative pain recovery, the reaching the feeling of wellness (evaluated with a modified VAS scale), the presence of bleeding and soiling. The patients then underwent follow-up to at three months, one year and three years.

RESULTS

Grade III-IV hemorrhoids treated with THD showed a more rapid achievement of the wellness with a lower incidence of post-operative pain and faster recovery and return to work activities and social life compared to MM cases. In grade IV hemorrhoids treated with THD or MM these objectives have been reached later compared to grade III. However in cases of grade IV hemorrhoids THD procedure resulted more difficult respect to cases of grade III and there has been an incidence of recurrence at 3 years equal to 15% of cases. In grade IV hemorrhoids treated with MM no recurrence occurred during the three-year follow-up.

CONCLUSIONS

For grade III hemorrhoids THD technique provides the same results of MM, while for grade IV hemorrhoids we believe that better result can be achieved with MM technique. However, we deem that in cases of grade IV hemorrhoids the choice between THD and MM can be more rationally made on the basis of objective examination with the patient in the operating position and already anesthetized and therefore in complete relaxation.

KEY WORDS

Transanal Hemorrhoidal Dearterialization THD, Milligan-Morgan Hemorrhoidectomy, Post-operative Pain, Hemorrhoids.

Anesthesia protocols in laboratory animals used for scientific purposes

Background: A suitable, effective and free of complications anesthetic protocol is very important in experimental studies on animal models since it could bias the outcome of a trial. To date there is no universally accepted protocol for induction, maintenance and recovery from anesthesia. The endotracheal intubation with the use of inhalation anesthesia is used very especially in the from of large size laboratory animals, because it is a secure and easy control mode. However, it is not common for small laboratory animals because of the high technical skills required. Aim: The aim of this paper is a review of the main methods of induction of anesthesia in laboratory animals. Materials and methods:We performed an electronic search of MEDLINE (PubMed interface), ISI Web of Science and Scopus using the keywords “anesthesia” and “animal (s)” or “protocol (s)” or “surgery”, without the data or the language restriction. We consider only the most common laboratory animals (rats, mice, rabbits, pigs). We identify all the scientific articles that refer to the use of anesthetics for studies on laboratory animals in all areas: experimental surgery, CT, MRI, PET. All documents identified the search criteria are subject to review only by identifying relevant studies. Conclusions:There is a strong need for application of existing guidelines for research on experimental animals; specific guidelines for anesthesia and euthanasia should be considered and reported in future studies to ensure comparability and quality of animal experiments. (www.actabiomedica.it)

OneShot-M: A New Device for Close Laparoscopy Pneumoperitoneum

INTRODUCTION

The induction of pneumoperitoneum is the first and most critical phase of laparoscopy, due to the significant risk of serious vascular and visceral complications. The closed technique for the creation of pneumoperitoneum could lead to several surgical complications. The present study aimed to overcome the complications associated with the insertion of Veress needle, improving its use, and facilitating the rapid creation of pneumoperitoneum.

METHODS

Thirty large white female pigs were enrolled in our study. A common plunger was modified in order to allow the passage of a 15-cm long Veress needle. This method was applied to 26 laparoscopic procedures (26 pigs) of several specialist branches.

RESULTS

OneShot-M close laparoscopy pneumoperitoneum creation device allowed us to obtain pneumoperitoneum quickly in all attempts, without any intraoperative and postoperative complications related to the use of the Veress needle.

CONCLUSION

The use of the proposed device showed an induction time as quick as the standard laparoscopic closed abdominal entry. The patented device is cheap and allows a safe abdominal entry. In addition, abdominal entry is much faster than the classic open technique.

Resection of esophageal diverticulum through uniportal video-assisted thoracoscopic surgery

Open surgery remains the standard strategy for management of esophageal diverticulum in symptomatic patients. However, in the last years an increasing number of minimally invasive approaches have been proposed for this issue in order to reduce the surgical trauma and favor a fast return to daily activity. Herein, we describe a novel technique as uniportal video-assisted thoracoscopic surgery (VATS) for performing resection of esophageal diverticulum. This procedure was successfully carried out in three consecutive patients with giant mid-esophageal diverticulum (mean size: 6.5±0.5 cm). The mean post-operative time was 121±10 minutes. The chest drain was removed 48 hours later in all cases and the mean length of hospital stay was 9±1 days. No intraoperative neither postoperative complications were found in all patients but one. He had a small fistula 15 days later that was successfully treated with stent insertion. No recurrence of diverticulum was seen in all cases. Uniportal VATS is a feasible procedure that in theory could reduce the surgical trauma compared to standard open approach. However, future prospective studies should corroborate our impression before it can be recommended as acceptable therapy.

Uniportal thoracoscopy combined with laparoscopy as minimally invasive treatment of esophageal cancer

A 67-year-old man was referred to our attention for management of esophageal adenocarcinoma, localized at the level of the esophagogastric junction and obstructed the 1/3 of the esophageal lumen. Due to the extension of the disease (T3N1M0-Stage IIIA), the patient underwent neo-adjuvant chemo-radiation therapy and he was then scheduled for a minimally invasive surgical procedure including laparoscopic gastroplasty, uniportal thoracoscopic esophageal dissection and intrathoracic end-to-end esophago-gastric anastomosis. No intraoperative and post-operative complications were seen. The patient was discharged in post-operative day 9. Pathological study confirmed the diagnosis of adenocarcinoma (T2N1M0-Stage IIB) and he underwent adjuvant chemotherapy. At the time of present paper, patient is alive and well without signs of recurrence or metastasis. Our minimally approach compared to standard open procedure would help reduce post-operative pain and favours early return to normal activity. However, future experiences with a control group are required before our strategy can be widely used.

Uniportal bilateral video-assisted sequential thoracoscopic extended thymectomy

Standard video-assisted thoracoscopic surgery has been reported as a minimally invasive approach alternative to sternotomy for management of myasthenia gravis (MG) associated with thymoma or thymic hyperplasia. Uniportal video-thoracoscopy is an evolution of standard multi-portal video-thoracoscopy for management of several thoracic diseases but its role for resecting mediastinal tumor remains under-evaluated. Herein, we describe our experience with bilateral uniportal thoracoscopic sequential extended thymectomy with case and video illustrations.

Reoperation for persistent or recurrent secondary hyperparathyroidism

BACKGROUND

Secondary hyperparathyroidism is a common acquired disorder seen in chronic renal failure. Its pathophysiology is mainly due to hyperphosphatemia and vitamin D deficiency and resistance. When medical treatment fails, subtotal and total parathyroidectomy with autotransplantation are the standard procedures, although both are associated with high recurrence rates.

METHODS AND RESULTS

4 patients experienced persistence and 9 relapse. The first 4 were subjected to reoperation after 6 months for the persistence of symptoms due to the finding of a supernumerary adenomatous gland while the remaining patients at the reoperation showed in 5 cases 2 more glands in over thymic position, and 4 an hyperplasia of the residual glandular tissue. A classic cervicotomy was sufficient to remove the residual parathyroid in patients with persistent hyperparathyroidism. For cases of recurrent hyperparathyroidism it was enough a medial approach and sometimes lateral for the complete excision of the hyperplastic tissue. The advent of the intraoperative technique of parathyroid hormone dosage allowed a better performance of the surgical technique for the last 3 patients undergoing reoperation. After reoperation all patients had immediate regression of clinical symptoms with normalization of serum calcium and PTH levels.

CONCLUSIONS

On the basis of these considerations, diagnostic imaging has a not negligible role because during the first intervention helps to have an idea of the possible location of the glands and thus to avoid the risk of recurrence and relapse due to ectopic or supernumerary tissue.

Uniportal Video-Assisted Thoracoscopic Surgery Resection of a Giant Midesophageal Diverticulum

We describe a new video-assisted technique for the management of a giant midesophageal diverticulum using a single 5-cm port. It maintained the same principles of the traditional open technique as diverticulectomy, myotomy, and fundoplication. The better visualization of the main esophageal body, diverticulum, and esophagogastric junction and the better alignment of the stapler cartridge to the longitudinal axis of the esophagus are all technical factors supporting our procedure. Heavily calcified mediastinal lymph nodes and diffuse pleural adhesions are the main contraindications. However, future experiences are needed before this technique can be recommended as acceptable treatment.

Mediastinal syndrome from plasmablastic lymphoma in human immunodeficiency virus and human herpes virus 8 negative patient with polycythemia vera: a case report

Background

Plasmoblastic lymphoma is a rare and aggressive subtype of diffuse large B cell lymphoma, which occurs usually in the jaw of immunocompromised subjects.

Case presentation

We describe the occurrence of plasmoblastic lymphoma in the mediastinum and chest wall skin of an human immunodeficiency virus-negative 63-year-old Caucasian man who had had polycytemia vera 7 years before. At admission, the patient showed a superior vena cava syndrome, with persistent dyspnoea, cough, and distension of the jugular veins. Imaging findings showed a 9.7 × 8 × 5.7 cm mediastinal mass. A chest wall neoformation biopsy and ultrasound-guided fine-needle aspiration biopsy of the mediastinal mass allowed diagnosis of plasmoblastic lymphoma and establishment of an immediate chemotherapeutic regimen, with rapid remission of compression symptoms.

Conclusions

Plasmoblastic lymphoma is a very uncommon, difficult to diagnose, and aggressive disease. The presented case represents the first rare mediastinal plasmoblastic lymphoma in a human immunodeficiency virus-/human herpesvirus-8-negative patient. Pathologists should be aware that this tumor does appear in sites other than the oral cavity. Fine-needle aspiration biopsy is a low-cost, repeatable, easy-to-perform technique, with a high diagnostic accuracy and with very low complication and mortality rates. Fine-needle aspiration biopsy could represent the right alternative to surgery in those patients affected by plasmoblastic lymphoma, being rapid and minimally invasive. It allowed establishment of prompt medical treatment with subsequent considerable reduction of the neoplastic tissue and resolution of the mediastinal syndrome.

Reoperation for persistent or recurrent secondary hyperparathyroidism

BACKGROUND

Secondary hyperparathyroidism is a common acquired disorder seen in chronic renal failure. Its pathophysiology is mainly due to hyperphosphatemia and vitamin D deficiency and resistance. When medical treatment fails, subtotal and total parathyroidectomy with autotransplantation are the standard procedures, although both are associated with high recurrence rates.

METHODS AND RESULTS

4 patients experienced persistence and 9 relapse. The first 4 were subjected to reoperation after 6 months for the persistence of symptoms due to the finding of a supernumerary adenomatous gland while the remaining patients at the reoperation showed in 5 cases 2 more glands in over thymic position, and 4 an hyperplasia of the residual glandular tissue. A classic cervicotomy was sufficient to remove the residual parathyroid in patients with persistent hyperparathyroidism. For cases of recurrent hyperparathyroidism it was enough a medial approach and sometimes lateral for the complete excision of the hyperplastic tissue. The advent of the intraoperative technique of parathyroid hormone dosage allowed a better performance of the surgical technique for the last 3 patients undergoing reoperation. After reoperation all patients had immediate regression of clinical symptoms with normalization of serum calcium and PTH levels.

CONCLUSIONS

On the basis of these considerations, diagnostic imaging has a not negligible role because during the first intervention helps to have an idea of the possible location of the glands and thus to avoid the risk of recurrence and relapse due to ectopic or supernumerary tissue.

Bilateral single-port thoracoscopic extended thymectomy for management of thymoma and myasthenia gravis: case report

Background

Video-assisted thoracoscopy is become a widely accepted approach for the resection of anterior mediastinal masses, including thymoma. The current trend is to reduce the number of ports and minimize the length of incisions to further decrease postoperative pain, chest wall paresthesia, and length of hospitalization. Herein, we reported an extended resection of thymoma in a patient with myasthenia gravis through an uniportal bilateral thoracoscopic approach.

Case presentation

A 74 years old woman with myasthenia gravis was referred to our attention for management of a 3.5 cm, well capsulate, thymoma. All laboratory and cardio-pulmonary tests were within normal; thus, she was scheduled for thymoma resection through an uniportal bilateral thoracoscopic approach. Under general anaesthesia and selective intubation, the patient was placed in a 60° right lateral decubitus. A 3 cm skin incision was performed in the fourth right intercostal space and, through that a 30° video-camera and working instruments were inserted without rib spreading. After complete dissection of the thymus and mediastinal fat, the contralateral pleura was opened, and, through that the specimen was pushed into the left pleural cavity. Then, the patient was placed in the left lateral decubitus. Similarly to the right side procedure, a 3-cm incision was performed in the fourth left intercostal space to complete thymic dissection and retrieve the specimen. No intraoperative and post-operative complications were found. The patient was discharged four days later. Pathological examination revealed a type A thymoma (Masaoka stage I). No recurrence was found at 18 months of follow-up

Conclusions

Bilateral single-port thoracoscopy is an available procedure for management of thymoma associated with myasthenia gravis. The less post-operative pain, the reduction of hospital stay and the better esthetic results are all potential advantages of this approach over traditional technique. Obviously, our impression should be validated by larger studies in terms of long-term oncological outcomes.

Electronic supplementary material

The online version of this article (doi:10.1186/s13019-016-0547-3) contains supplementary material, which is available to authorized users.

Simple and fast orotracheal intubation procedure in rats

INTRODUCTION

Endotracheal intubation in the rat is difficult because of the extremely small size of anatomical structures (oral cavity, epiglottis and vocal cords), small inlet for an endotracheal tube and the lack of proper technical instruments.

MATERIAL AND METHODS

In this study we used seventy rats weighting 400-500 g. The equipment needed for the intubation was an operating table, a longish of cotton, a cotton tip, orotracheal tube, neonatal laryngoscope blades, KTR4 small animal ventilator and isoflurane for inhalation anaesthesia. Premedication was carried out by medetomidine hydrochloride 1 mg/mL; then, thanks to a closed glass chamber, a mixture of oxygen and isoflurane was administered. By means of a neonatal laryngoscope the orotracheal tube was advanced into the oral cavity until the wire guide was visualized trough the vocal cords; then it was passed through them. The tube was introduced directly into the larynx over the wire guide; successively, the guide was removed and the tube placed into the trachea. Breathing was confirmed using a glove, cut at the end of a finger, simulating a small balloon.

RESULTS

We achieved a fast and simple orotracheal intubation in all animals employed.

CONCLUSIONS

We believe that our procedure is easier and faster than those previously reported in scientific literature.

Inflammation in irritable bowel syndrome: Myth or new treatment target?

Low-grade intestinal inflammation plays a key role in the pathophysiology of irritable bowel syndrome (IBS), and this role is likely to be multifactorial. The aim of this review was to summarize the evidence on the spectrum of mucosal inflammation in IBS, highlighting the relationship of this inflammation to the pathophysiology of IBS and its connection to clinical practice. We carried out a bibliographic search in Medline and the Cochrane Library for the period of January 1966 to December 2014, focusing on publications describing an interaction between inflammation and IBS. Several evidences demonstrate microscopic and molecular abnormalities in IBS patients. Understanding the mechanisms underlying low-grade inflammation in IBS may help to design clinical trials to test the efficacy and safety of drugs that target this pathophysiologic mechanism.

Laparotomic vs laparoscopic ovariectomy: comparing the two methods. The ovariectomy in the bitch in laparoscopic era

BACKGROUND AND AIM

The aim of the present work is to evaluate the effectiveness of the use of ultrasound scalpel during laparoscopic ovariectomy in the bitch.

METHODS

Two groups of 10 subjects each, of different races and ages, were compared. In the first group, ovariectomy was performed laparoscopically, using harmonic scalpel to remove ovary. In the second group surgery was performed by means of classical laparotomy.

RESULTS

Pre-operative time was similar in both groups. Total operative time, from incision to skin suture, showed significant difference between the two groups, being laparoscopy faster than laparotomy. Partial operative time for bilateral oophorectomy resulted lower using open technique, but, considering each ovary, there was no significant difference in both groups.

CONCLUSIONS

The use of harmonic scalpel to perform ovariectomy during laparoscopy is an effective time-sparing surgical approach compared to the already great practicality of laparotomy.

"Pure" large cell neuroendocrine carcinoma of the gallbladder. Report of a case and review of the literature

Primary Neuroendocrine Tumours (NETs) of the gallbladder are rare. Among all NETs of the gallbladder, large cell neuroendocrine carcinoma (LCNEC) is exceedingly rare. In most of the cases LCNECs are combined with other histological components. We reviewed clinical presentation and management of all patients with "pure" LCNEC from published literature since the first case was published in 2000, as well as one patient from our experience. Only 7 cases of "pure" LCNEC has been described in the last 15 years, our case is the eighth. The diagnosis of gallbladder NETs is rarely made preoperatively since the presentation generally consists of non-specific symptoms including upper abdominal pain, discomfort, jaundice, weight loss. The majority of patients are identified incidentally at the time of cholecystectomy for cholelithiasis. It is not possible to differentiate preoperatively between gallbladder adenocarcinoma and gallbladder neuroendocrine carcinoma (NEC) with imaging techniques. The only curative therapeutic modality for LCNECs is a complete en bloc surgical resection, including regional lymph node clearances and hepatic lobectomy, but only in patients without multiple metastasis. LCNECs benefit from an aggressive surgical resection in combination with chemotherapy, if resectability is possible. If the tumour is non-resectable, the primary management is therefore medical and not surgical. All patients with LCNEC presented a poor prognosis with a median survival of 10 months after the initial diagnosis. Only in five patients (62.5%) a wide surgical excision was performed, while in the other cases the tumour was non-resectable or multiple liver metastases were present at diagnosis.

Validation of a modified model of TNBS-induced colitis in rats. How to induce a chemical colitis in rats

BACKGROUND

There is no standard practice in the induction of colitis by 2,4,6-trinitrobenzene sulfonic (TNBS) acid. Usually, the repeated administration of TNBS is preferred, because it will result in a local Th1 response that has the characteristics of Crohn`s disease.

MATERIALS AND METHODS

A total of 30 rats were randomized into two groups, consisting of a saline control group of ten rats and a TNBS groups of 20 rats. After the animals were anesthetized, 0.5 ml of either 0.9% saline (controls) or TNBS 50 mg/kg dissolved in 50% ethanol were instilled into the colon through a rubber catheter. The experiment was repeated weekly for four weeks, then, the rats were killed at day 40, and the distal colon removed.

RESULTS

At day 40, the bowel wall was basically normal in the control group. In the TNBS group, the bowel lumen became narrow with thickened wall, and the mucosal surface presented adherent membrane with brown black, linear ulcers, proliferous lymphocyte tissue, inflammatory granulomas and submucosal neutrophil infiltration. The median score of the severity of the colonic damage was 0 in the control group, and 4,75 (range 4-5) in the TNBS group; the mean weight of the rats was 180+35 g in the TNBS group, while it was 215+25 in the control group.

CONCLUSIONS

The presented experiment is a cost-effective and safe method to induce Crohn-like colonic damage using a lower dose of TNBS, thus avoiding the risk of a massive loss of rats. This model is rather suitable for the assessment of the effects of potential therapeutic agents. (www.actabiomedica.it).

Renal Transplantation by Automatic Anastomotic Device in a Porcine Model

Automatic vascular staplers for vascular anastomoses in kidney transplantation may dramatically reduce the operative time and, in particular, warm ischemia time, thus increasing the outcome of transplantation. Ten pigs underwent kidney auto-transplantation by automatic anastomotic device. Kidneys were collected by laparotomy with selective ligations at the renal hilum and perfused with cold storage solution. To overcome the shortage in length of renal hilum, a tract of the internal jugular vein was harvested to increase the length of the vessels. The anastomoses were totally performed by the use of the anastomotic device. On 10 kidney transplants, nine were successful and no complications occurred. Renal resistive indexes showed a slight increase in the immediate postoperative period returning normal at 10 days of follow-up. We demonstrated the possibility to perform renal vascular anastomoses by means of an automatic anastomotic device. This instrument developed for coronary bypass surgery by virtue of the small caliber of the vessels could be adopted on a larger scale for renal transplantation. The reduced warm ischemia time needed for anastomosis may help to achieve a better outcome for the graft and expand the pool of marginal donors in renal transplantation.

Enteral nutrition support to treat malnutrition in inflammatory bowel disease

Malnutrition is a common consequence of inflammatory bowel disease (IBD). Diet has an important role in the management of IBD, as it prevents and corrects malnutrition. It is well known that diet may be implicated in the aetiology of IBD and that it plays a central role in the pathogenesis of gastrointestinal-tract disease. Often oral nutrition alone is not sufficient in the management of IBD patients, especially in children or the elderly, and must be combined with oral supplementation or replaced with tube enteral nutrition. In this review, we describe several different approaches to enteral nutrition—total parenteral, oral supplementation and enteral tube feeding—in terms of results, patients compliance, risks and and benefits. We also focus on the home entaral nutrition strategy as the future goal for treating IBD while focusing on patient wellness.

Somatic loss of an EXT2 gene mutation during malignant progression in a patient with hereditary multiple osteochondromas

Multiple osteochondromas (MO) is an autosomal-dominant skeletal disorder caused by mutations in the exostosin-1 (EXT1) or exostosin-2 (EXT2) genes. In this study, we report the analysis of the mutational status of the EXT2 gene in tumor samples derived from a patient affected by hereditary MO, documenting the somatic loss of the germline mutation in a giant chondrosarcoma and in a rapidly growing osteochondroma. The sequencing of all exons and exon-intron junctions of the EXT1 and EXT2 genes from blood DNA of the proband did not reveal any mutation in the EXT1 gene but did demonstrate the presence of the transition point mutation c.67C > T in the EXT2 gene, determining the introduction of a stop codon in the coding sequence (p.Arg23*). A mutational analysis of other members of the family and the presence of osteochondromas in the metaphysis of long bones confirmed the diagnosis of hereditary multiple osteochondromas. Direct sequencing from DNA extracted from different sites of two tumor samples (a small rapidly growing osteochondroma and a giant peripheral secondary chondrosarcoma, each located at different chondrocostal junctions) revealed the loss of the germline EXT2 mutation. Analysis of microsatellite polymorphic markers in the 11p region harboring the EXT2 gene did not reveal any loss of heterozygosity. This observation supports a recent model of sarcomagenesis in which osteochondroma cells bear EXT homozygous inactivation, whereas chondrosarcoma-initiating cells are EXT-expressing cells.

Could JC virus provoke metastasis in colon cancer?

AIM: To evaluate the prevalence of John Cunningham virus (JC virus) in a small cohort of patients with colon cancer and to assess its presence in hepatic metastasis.

METHODS: Nineteen consecutive patients with histologically diagnosed colon cancer were included in our study, together with ten subjects affected by histologically and serologically diagnosed hepatitis C virus infection. In the patients included in the colon cancer group, JC virus was searched for in the surgical specimen; in the control group, JC virus was searched for in the hepatic biopsy. The difference in the prevalence of JC virus in the hepatic biopsy between the two groups was assessed through the χ² test.

RESULTS: Four out of 19 patients with colon cancer had a positive polymerase chain reaction (PCR) test for JC virus, and four had liver metastasis. Among the patients with liver metastasis, three out of four had a positive PCR test for JC virus in the surgical specimen and in the liver biopsy; the only patient with liver metastasis with a negative test for JC virus also presented a negative test for JC virus in the surgical specimen. In the control group of patients with hepatitis C infection, none of the ten patients presented JC virus infection in the hepatic biopsy. The difference between the two groups regarding JC virus infection was statistically significant (χ² = 9.55, P = 0.002).

CONCLUSION: JC virus may play a broader role than previously thought, and may be mechanistically involved in the late stages of these tumors.

Intraperitoneal coated polypropylene hernia meshes: the dark side of the moon

BACKGROUND

To date, the use of meshes in repairing abdominal wall defects has brought many advantages, especially in terms of recurrence prevention, but it is not exempt from complications, such as chronic pain, entero-cutaneous fistulas and intestinal obstruction. Here we report a case of intestinal obstruction in a patient with a large umbilical hernia treated laparoscopically by means of a composite polypropylene mesh, six year before.

CASE REPORT

A 49-year-old man came to our care with a 3-day history of central and right lower abdominal quadrant pain and a clinical picture of intestinal obstruction. Six years before the patient underwent a laparoscopic intervention to repair his umbilical hernia, with the positioning of a polypropylene coated mesh. Abdominal ultrasonography (US) confirmed the obstruction and demonstrated adhesions between an intestinal loop and the mesh. Intraoperatively, obstruction was confirmed and an intestinal segment had to be resected.

CONCLUSIONS

Small bowel obstruction is an uncommon but possible late complication after laparoscopic hernia repair with coated polypropylene mesh.

Reconstruction with a pectoralis major myocutaneous flap after left first rib and clavicular chest wall resection for a metastasis from laryngeal cancer

We presented a case of recurrent metastasis from epidermoid cancer that occurred in the left clavicle of a patient with a history of laryngeal cancer treated on April 2005 with extended hemilaryngectomy, neck dissection and chemoradiation therapy. On September 2008, he developed a left clavicular metastasis. The disease was initially well controlled by chemoradiotherapy but it recurred 17 months later. The optimal treatment plan was established by several multidisciplinary meetings and the patient subsequently underwent an en bloc resection of the left clavicle, first rib and all the other involved structures. Coverage of the thoracic defect was achieved using pectoralis major myocutaneous flap. The patient had a successful surgical outcome. At 1-year follow-up, he had no evidence of disease, a good cosmetic result and returned to normal daily activity. He died for bone metastasis with an overall 21 months post-surgical survival.

Localization of sentinel lymph node in breast cancer. A prospective study

INTRODUCTION

Sentinel Lymph Node Biopsy (SLNB) is the standard of care for staging axillary lymph nodes in women with breast cancer and clinically negative nodes. It is associated with reduced arm morbidity, moderated or severe lymphoedema, and a better quality of life in comparison with standard axillary treatment. Unfortunately, skip metastases makes all minimally invasive approaches, such as axillary sampling, unreliable. The aim of the present clinical prospective study is to evaluate the position of SLN in an important number of cases and establish the real incidence of skip metastases in clinically node-negative patients.

PATIENTS AND METHODS

A cohort of 898 female patients with breast carcinoma was considered, from 2001 to 2008. Once SLN was localized, by means of radio-colloid or blue dye staining, and isolated, a biopsy was performed. Only those positive for metastases were submitted to axillary dissection.

RESULTS

Only in nine cases a SLN was not isolated. We had 819 cases of first level SLN (group A) and 69 cases of second level SLN (group B). Considering all of 889 cases, SLN was localized in the second level in 69 patients (7.8%); but if we consider metastatic SLN alone (340 cases), it was in the second level in 23 subjects (6.8%). In total, we had a positive second level SLN in 2.3% of cases (23/889).

CONCLUSION

Second level SLN could be considered only an anomalous lymphatic axillary drainage and it does not linked to particular histological variants of the primitive tumour. In our study, skip metastases were recognized in only 2.6% of cases, therefore, whenever a SLN is not isolated for any reason, the first level sampling represent a viable operative choice.

Mesh or no mesh: a hamletic dilemma to prevent Renal Allograft Compartment Syndrome (RACS)

Tension-free muscle closure is essential in kidney transplantation, both in adult and pediatric patients. Tight muscle closure may lead to renal allograft compartment syndrome either due to compression of the renal parenchyma or due to kinking of the renal vessels. It may also cause kinking of the transplant kidney ureter, wound dehiscence and incisional hernia. Many techniques have been proposed in an attempt to achieve tension-free closure. There is a wrong belief among surgeons that using prosthetic mesh may increase the incidence of infective complications in these immunosuppressed patients. Also, there is fear that one is not able to monitor the renal graft by ultrasound and perform biopsy in the presence of a mesh. Other alternative techniques to mesh closure include subcutaneous placement and intraperitonealization of the kidney transplant. These techniques however, are valuable when mesh closure is unfavorable or contraindicated as in case of a potential source of infection, like a stoma. Abdominal wall fasciotomy can be adjunctive to the various techniques of muscle closure.

KEY WORDS

Abdominal mesh closure, Post transplant incisional hernia, Renal transplantation, Renal Allograft Compartment syndrome (RACS).

Granulomatous Mastitis during Chronic Antidepressant Therapy: Is It Possible a Conservative Therapeutic Approach?

Granulomatous mastitis is a rare benign inflammatory disease of the breast with multiple etiologies such as tuberculosis, sarcoidosis, foreign body reaction, and mycotic and parasitic infections. In contrast, idiopathic granulomatous mastitis (IGM) is characterized by the presence of chronic granulomatous lobulitis in the absence of an obvious etiology. Clinically and radiologically it may mimic breast carcinoma and so awareness of surgeons, pathologists, and radiologists is essential to avoid unnecessary mastectomies. Cases of IGM are reported during antidepressant therapy in patients also showing high levels of prolactinemia. In these cases, we believe that surgical excision must be avoided being replaced with a conservative management of the pathological condition based on a corticosteroid treatment.

Dissecting the different biological effects of oncogenic Ras isoforms in cancer cell lines: could stimulation of oxidative stress be the one more weapon of H-Ras? Regulation of oxidative stress and Ras biological effects

Ras proteins are small GTPase functioning as molecular switches that, in response to particular extracellular signalling, as growth factors, activate a diverse array of intracellular effector cascades regulating cell proliferation, differentiation and apoptosis. Human tumours frequently express Ras proteins (Ha-, Ki-, N-Ras) activated by point mutations which contribute to malignant phenotype, including invasiveness and angiogenesis. Despite the common signalling pathways leading to similar cellular responses, studies clearly demonstrate unique roles of the Ras family members in normal and pathological conditions and the lack of functional redundancy seems to be explainable, at least in part, by the ability of Ras isoforms to localize in different microdomains to plasma membrane and intracellular organelles. This different intracellular compartmentalization could help Ras isoforms to contact different downstream effectors finally leading to different biological outcomes. Interestingly, it has also been shown that Ha- and Ki-Ras exert an opposite role in regulating intracellular redox status. In this regard we suggest that H-Ras specific induction of ROS (reactive oxygen species) production could be one of the main determinants of the invasive phenotype which characterize cancer cells harbouring H-Ras mutations. In our hypothesis then, while K-Ras (not able to promote oxidative stress) could mainly contribute to cancer progression and invasiveness through activation of MAPK and PI3K, H-Ras-mediated oxidative stress could play a unique role in modulation of intercellular contacts leading to a loss of cell adhesion and eventually also to a metastatic spread.

Ileus following spontaneous jejunum intramural hematoma: case report and review of the literature

Anticoagulant therapy may cause the onset of a spontaneous intramural hematoma of the small bowel, in the jejunum, ileum or duodenum. A 53-year-old woman on therapy with heparin for previous pulmonary embolism was admitted for abdominal pain and vomit. Computed tomography scan visualized an intramural hematoma of the jejunum causing subtotal obstruction of the intestinal lumen. The patient underwent resection of a part of the jejunum, securing intestinal continuity by a mechanical side-to-side anastomosis. The postoperative course was regular, but the initial anticoagulant therapy was reduced to prevent recurrence. In conclusion, spontaneous hematoma of small bowel can occur as a complication of anticoagulant therapy. The clinical picture and rapid diagnosis indicate medical or surgical therapy.

Post-transplantation tertiary hyperparathyroidism

Tertiary hyperparathyroidism is intended as a state of excessive autonomous excretion of parathyroid hormone after longstanding secondary hyperparathyroidism. It is a condition of a severe hyperparathyroidism that persists in the renal recipient despite a successful transplantation. The high levels of parathyroid hormone lead to a worsening of graft function accompanied by systemic symptoms. This article reviews the main aspects related to tertiary hyperparathyroidism from mechanism of pathogenesis to prevention and treatment, suggesting some indications about the best management of patients on a waiting list for kidney transplant.

An unexpected surprise at the end of a "quiet" cholecystectomy. A case report and review of the literature

BACKGROUND

Anatomic unexpected variations in biliary tree may be discovered during laparoscopic cholecystectomy.

CASE REPORT

A 57-year-old man was admitted for abdominal pain, vomiting and mild jaundice. Abdominal ultrasonography revealed a gallbladder containing multiple stones and biliary sludge. All pre-operative investigations showed no anatomical variations in extrahepatic biliary tree. During surgical intervention an accessory extrahepatic duct, connecting the IV segment of the liver to the fundus of gallbladder, was discovered.

CONCLUSIONS

Pre-operative routine investigations for gall stones diseases may not reveal anatomic variations of biliary tree.

Sistemic calciphylaxis and thrombotic microangiopathy in a kidney transplant patient: two mixing fatal syndromes?

Abnormalities in calcium and phosphorus metabolism are common and metabolic bone diseases develop often in patients with chronic renal failure (CRF). Effective clinical management includes measures to control phosphorus retention and prevent hyperphosphataemia, to maintain serum calcium concentrations within the normal range and to prevent excess parathyroid hormone (PTH) secretion by the judicious use of vitamin D sterols. Certain of these interventions, however, appear to increase the risk of soft tissue and vascular calcification in patients with End Stage Renal Disease (ESRD), so current therapeutic approaches are thus being re-evaluated in an effort to limit these risks. Patients with calciphylaxis have an extremely high mortality rate, diagnosis requires a high degree of clinical suspicion and the role and extent of parathyroidectomy in the management of this condition remain controversial. In some cases renal transplant patients could suffer from a comorbidity in which vascular function is compromised not only by secondary hyperparathyroidism-related calcification but also by other pathological condition as haemolytic uremic syndrome (HUS), leading to a fatal clinical outcome. We postulate that in these cases a secondary hyperparathyroidism not properly diagnosed in an early phase of the renal disease (probably before the kidney transplant) could cause a vascular calcification which, adding to the pre-existing HUS-related vascular compromission, gave rise to catastrophic clinical consequences. In the management of ESRD patients, in particular in the cases of pre-existing angiopathies, could be therefore crucial the early and proper diagnosis of an alteration of calcium-posphorus metabolism and effort of medicine could be oriented in these cases also towards identification of screening methodologies to undoubtedly assess such a diagnosis.

From gut microflora imbalance to mycobacteria infection: is there a relationship with chronic intestinal inflammatory diseases?

The gut of a healthy adult harbours a myriad of different microbial species. It is estimated that approximately 10 14 are present in total bacterial colony forming units (CFU). Each colony colonizes a specific intestinal tract. In healthy adult, the main control of intestinal bacterial colonization occurs through gastric acidity but also other factors can influence the intestinal microenvironment such as pH, temperature, competition among different bacterial strains, peristalsis, drugs, radiotherapy and much more. Impaired microbial homeostasis leads to an alteration of the permeability of tissue, together with the activation of the intestinal immune system MALT (mucosal associated lymphoid tissue). In this regard we discuss the increasing experimental evidences of the role of commensal microbiota in the activation of specific intestinal immunocompetent cells. The aforementioned micro-environmental changes provide the substrate for the etiopathogenetic outbreak of numerous pathologies of gastro-intestinal tract, such as intestinal chronic inflammation (Crohn's disease and Ulcerative Colitis), together with a miscellany of extra intestinal disorders. This article is an overview of the latest scientific findings about the close causal relationship between intestinal microbial flora and inflammatory bowel diseases or other extra-intestinal diseases; it is also mentioned the possible relationship between mycobacteria and Chron's disease. Finally we analyse the beneficial role of probiotics.