Right-side fixation of the sigmoid colon causing internal herniation with closed-loop obstruction of both small and large bowel: a case report and review of the literature

Background

Right-side fixation of the sigmoid colon is a rare anatomical variant associated with intestinal malrotation (Choi et al. in J Korean Surg Soc. 84(4):256–60, 2013). Differently from other forms of malrotation, this variant has not been associated thus far with acute surgical conditions.

Case presentation

In this report, we present a 65-year-old Caucasian patient admitted for bowel obstruction symptoms. Computed tomography scan revealed right-side fixation of the sigmoid colon extended to the subhepatic recess complicated by obstructed internal herniation of the ileum. In this patient, the sigmoid colon occupied a recess posterior to the ascending colon and right Toldt’s fascia. Within this narrow anatomical space, an ileal loop was trapped causing internal herniation with resultant close-bowel obstruction of both ileum and sigmoid colon. The ileal loop was released surgically and the anatomical abnormality corrected.

Conclusions

To our knowledge, this is the first case of right-side fixation of the sigmoid colon causing acute obstruction secondary to internal herniation of the small intestine. Early recognition and precise anatomical definition of such anatomical variants are essential to optimize their surgical approach.

Multicentre evaluation of case volume in minimally invasive hepatectomy

Background

Surgical outcomes may be associated with hospital volume and the influence of volume on minimally invasive liver surgery (MILS) is not known.

Methods

Patients entered into the prospective registry of the Italian Group of MILS from 2014 to 2018 were considered. Only centres with an accrual period of at least 12 months and stable MILS activity during the enrolment period were included. Case volume was defined by the mean number of minimally invasive liver resections performed per month (MILS/month).

Results

A total of 2225 MILS operations were undertaken by 46 centres; nine centres performed more than two MILS/month (1376 patients) and 37 centres carried out two or fewer MILS/month (849 patients). The proportion of resections of anterolateral segments decreased with case volume, whereas that of major hepatectomies increased. Left lateral sectionectomies and resections of anterolateral segments had similar outcome in the two groups. Resections of posterosuperior segments and major hepatectomies had higher overall and severe morbidity rates in centres performing two or fewer MILS/month than in those undertaking a larger number (posterosuperior segments resections: overall morbidity 30·4 versus 18·7 per cent respectively, and severe morbidity 9·9 versus 4·0 per cent; left hepatectomy: 46 versus 22 per cent, and 19 versus 5 per cent; right hepatectomy: 42 versus 34 per cent, and 25 versus 15 per cent).

Conclusion

A volume–outcome association existed for minimally invasive hepatectomy. Complex and major resections may be best managed in high-volume centres.

SPan-1 and Exocrine Pancreatic Carcinoma. The Clinical Role of a New Tumor Marker

AIMS OF THE STUDY

Considerable progress has been made in imaging techniques over the past few years, yet this has not resulted in the ability to reach an earlier diagnosis of exocrine pancreatic cancer. The search for a noninvasive diagnostic tool capable of early diagnosis has led to the development of a series of serum tumor markers. This article discusses the clinical evaluation of SPan-1 and its comparison with established markers such as CA 19.9, CEA, TPA and CA 242.

METHODS

The markers were measured in preoperative serum samples collected from 46 patients who had undergone surgery for ductal carcinoma of the pancreas, 20 patients with chronic pancreatitis, and 23 patients with other digestive neoplasms.

RESULTS

The sensitivity, specificity and diagnostic accuracy for pancreatic cancer were as follows: [table: see text]

CONCLUSIONS

The antigenic determinant SPan-1, recognized by monoclonal antibodies, is elevated in sera of patients with exocrine pancreatic cancer. SPan-1 may be considered as an additional useful and reliable serum marker for the detection of this neoplasm, but it does not significantly improve the diagnostic accuracy obtained with CA 19.9.

[Radical surgery for gallbladder carcinoma]

The aims of the study were to evaluate the adequacy of the surgical treatment and results of curative extended resections for gallbladder cancer. To this end we carried out a retrospective analysis of 59 patients operated on at our institution from 1983 to 2000. Nineteen patients received a curative resection with a radical intent (4 stage I-II patients and 15 stage III-IV patients, according to the AJCC classification). Kaplan-Meyer survival was 100% after one year and 66.6% after five years for stage I-II patients; 44.4% after one year and 0% after 5 years for stage III patients; 75.0% after one year and 0% after 5 years for stage IV patients. Our analysis confirms the poor prognosis of gallbladder carcinoma. In stage I-II patients surgical treatment offers a good chance of survival. In stage III-IV patients surgery affords good palliation. "Curative" extended resection is, however, a safe surgical procedure and offers a real possibility of enhancing survival.

[Monoclonal antibody SPan-1 in the diagnosis of exocrine pancreatic adenocarcinoma]

The great progress made in imaging techniques over the past few years has not resulted in an improvement in terms of earlier diagnosis of exocrine pancreatic cancer. The search for a non-invasive diagnostic tool, capable of yielding an early diagnosis, has led to the development of a series of serum tumour markers. This article discusses the clinical evaluation of SPan-1 and its comparison with established markers such as CA 19.9, CEA, TPA and CA 242. The markers were tested in preoperative serum samples collected from 46 patients operated on for ductal carcinoma of the pancreas, 20 patients with chronic pancreatitis and 23 patients with other digestive neoplasms. Sensitivity, specificity and diagnostic accuracy for pancreatic cancer were as follows: [table: see text] The antigenic determinant recognised by monoclonal antibody SPan-1 is high in sera of patients with exocrine pancreatic cancer. SPan-1 may be another useful, reliable serum marker in detecting this neoplasm, but this study indicates that SPan-1 does not greatly improve the diagnostic accuracy achieved with CA19.9.

[Pancreatic fistula following duodenocephalopancreatectomy with Wirsung occlusion]

AIMS

The large number of operative procedures used to carry out an enteropancreatic anastomosis after pancreatoduodenectomy definitely mirror all difficulties and problems brought about by anastomosis. The aim of this study is to evaluate the clinical results and complications concerning the pancreatic remnant after pancreatoduodenectomy with Wirsung duct occlusion.

METHODS

From 1984 to 1999, 134 patients were treated by pancreatoduodenectomy with Wirsung duct occlusion using synthetic resins. A consecutive series of 95 patients without mortality operated in the last decade were regularly followed by ultrasound examination and CT-scan as well as by serial measurements of the volume and the amylase content of the drainage fluid.

RESULTS

No operative mortality occurred. Two events could be evidenced after this kind of operation: 1) the presence of an asymptomatic fluid collection at the side of the pancreatic section with spontaneous absorption (31 patients: 32.6%); 2) the occurrence of a pancreatic fistula (5 patients: 5.3%): in three cases (3.2%) a fistula jejunostomy was required.

CONCLUSIONS

The evidence of the mild clinical relevance of complications and the low percent rate of reoperations enables to state that this method can be highly reliable.

Liver resection without blood transfusion

A retrospective study was carried out of 522 elective liver resections to determine the impact of blood transfusion on the immediate postoperative outcome and on long-term survival. The number of liver resections without transfusion has increased in recent years, as a result of improvement in surgical technique with less blood loss during operation and more careful choice of the timing of transfusion. In resections carried out in the past 5 years, the indication for intraoperative transfusion was restricted and the decision was made jointly by the surgeon and anaesthetist, and in any case only if the haematocrit was below 25 per cent. Of resections carried out in the past 2 years, 59 per cent did not require intraoperative transfusion. Postoperative deaths and complications were related to blood transfusion, particularly in patients with cirrhosis, in whom stepwise logistic regression analysis showed that transfusion was the only factor that correlated significantly with complications. Transfusion also affected the long-term survival of patients operated on for hepatocellular carcinoma and colorectal carcinoma metastases in univariate analysis and was the only factor shown by multivariate analysis to correlate with survival for hepatocellular carcinoma in patients with cirrhosis.

Surgical experience with 168 primary liver cell carcinomas treated with hepatic resection

Liver resections were performed in 168 patients with hepatocellular carcinoma (HCC) over the past 10 years; 116 were cirrhotics. Operative mortality was 7.7% (8.6% in the cirrhotic group and 5.8% in non-cirrhotics). In the years 1987-1992 the operative mortality decreased from 15.6% to 4.9% (P < .05). A statistical analysis of survival was made with the data of 155 patients with a follow-up of more than 1 month after curative resection: 56 (36.1%) died, while 99 (63.8%) are currently alive, with a follow-up varying from 2 to 76 months. The actuarial survival rate is 56.7% after 3 years and 36.3% after 5 years (59% and 35.2% for cirrhotics; 52.2% and 37.7% for non-cirrhotics, respectively). Satisfactory results can be obtained after liver resections in HCC, even in the presence of cirrhosis. Further efforts are needed in the early diagnosis of HCC, to prevent the formation of satellite nodules and the intrahepatic tumoral spread, which represent the major cause of exclusion from surgical therapy.

An unusual case of hepatic tumor

A case is reported of a large hepatic tumor in a patient aged 71. Preoperative diagnostic techniques, including echography, CT and angiography, did not provide sufficient criteria for a precise diagnosis. The mass was removed with an extended right hepatectomy with no particular physiopathological consequences. Histological analysis revealed that this was a metastasis from a melonoma of the choroid, operated on 17 years previously.

Comparison of combined portal-arterial versus portal perfusion during liver procurement

PAP of harvested livers is routinely used to minimize parenchymal anoxia during storage. PP is compared with PAP to evaluate the relative reliability of PAP. Sixty female Landrace pigs were used for 30 OLTs. Group 1 livers underwent PP, whereas group 2 livers were treated with PAP. The cold ischemic time was less than 120 minutes for both groups, with no warm ischemia. Intraoperative and 24-hour postoperative biochemical, coagulation, and histocytological data were analyzed. Morphological studies of cellular damage were based on the percentage of CVD and KP and classified as light, moderate, and severe damage. Data, at closing, were compared by using Fisher's test (group 1 v group 2,P = 0.003 for light damage and P = .04 for severe damage; first postoperative day for group 1 v group 2, P = .133 for light damage and P = .25 for severe damage. Blood samples at closing and 24 hours postoperatively showed significant differences between groups 1 and 2: At closing for groups 1 and 2, respectively: AST, 968.9 +/- 742.7 and 327.4 +/- 174.7 IU/L (P less than .001); ALT, 63.1 +/- 40.3 and 20.3 +/- 5.3 IU/L (P less than .001); AP, 292.2 +/- 107.1 and 139.5 +/- 45.3 IU/L (P less than .001); and 24 hours postoperatively for groups 1 and 2, respectively: AST, 1,664.9 +/- 917.8 and 419.3 +/- 230.9 IU/L (P less than .001): ALT. 180.4 +/- 28.9 and 66.4 +/- 17.5 IU/L (P less than .001); AP, 602.1 +/- 153.3 and 255.7 +/- 116.3 IU/L (P less than .01). Comprehensively, the results reflect a better perfusate distribution of the PAP livers compared with PP ones: uniform organ preservation, faster metabolic recovery, and reduced postoperative mortality.