Treatment of renal angiomyolipoma: surgery versus angioembolization

Renal angiomyolipoma (AML) is a benign mesenchymal tumour. AML often leads to haemorrhagic complications such as retroperitoneal haematoma. Treatment varies from case to case, ranging from minimally invasive approaches such as selective embolization of the renal artery to invasive wedge resection, partial nephrectomy or, in more severe cases, radical nephrectomy. Here we report a case of retroperitoneal haematoma secondary to AML, treated with conservative approach by super-selective embolization of the lower-pole segmental renal artery.

Single Stapler Parachute Technique (SSPT): a new procedure for large hemorroidal prolapse

Procedure for Prolapse and Hemorrhoids (PPH or Longo procedure), a stapled circumferential anal mucosectomy, has proven to be very popular as it is considered safe and successful. However, a high haemorrhoid recurrence rate is reported, specially due to insufficient mucosal resection. The authors have come up with a technical modification to the mucoprolapsectomy, notably the Single Stapler Parachute Technique (SSPT), in order to obtain more abundant mucosal resection. In this study they will present the results obtained in 80 patients treated for muco-haemorrhoidal prolapse, 40 of whom underwent traditional PPH, while the remaining 40 patients underwent SSPT, both performed in two different specialised centres located in Rome, Italy.

Human muscle-derived stem cells. Effectiveness in animal models of faecal incontinence. Research scheduling

Researchers believe that human muscle-derived cells are able to restore leak-point pressure to normal levels by differentiating into new muscle fibres that prevent anal sphincter muscle atrophy. Laboratory data are needed to identify exactly how these cells work to regenerate muscle. The objective of this study is to test whether stem cells can be employed to treat internal anal sphincter (IAS) injuries in humans; to this end, this work will use a two-step process to study: first, the effectiveness of the treatment in a sample of animals with artificial injuries to the IAS and then to verify the results in a population of selected humans affected by pathology.

[Treatment of obstructive defecation syndrome related to hedrocele. Our experience]

Hedrocele represents an unusual variant of the rare posterior perineal hernia and results from a defect in the rectogenital septum. We report two cases of obstructive defecation syndrome (ODS) related to presence of hedrocele successfully treated by laparoscopy-assisted transanal surgery.

[Low rectovaginal fistula treated with platelet-rich plasma (PRP)]

Rectovaginal fistula (RVF) is an abnormal communication between vagina and anorectum. Most frequent causes are iatrogenic. Often surgery is the therapy of choice. The suggested treatments include trans-anal access or combined trans-anal and vaginal access. We present the case of a woman with complicated iatrogenic fistula treated by a combined trans-anal and vaginal access, interposition of buccal mucosa and opposition of PRP (platelet rich plasma).

[Gastric lipoma presenting as intestinal obstruction]

Gastric lipoma is a rare benign tumor. The symptoms are correlated with the size and the dimensions of neoplasm. It can be the cause of bleeding, gastroduodenal intussusception and intestinal obstruction, as in case reported and surgically treated. The Authors make a literature review to define the better diagnostic and surgical approach.

[Gangrene of Meckel's diverticulum in strangulated left inguinal hernia]

We report a case of a 57-year-old woman admitted for abdominal pain and a not reducible mass in left inguino-abdominal region. With a diagnosis of strangulated inguinal hernia, the patient underwent urgent surgery. The surgical exploration showed a gangrenous intestinal loop with a Meckel's necrotic diverticulum. A small bowel resection (20 cm) was performed. The post-operative course was uneventful. This seems the first case reported in the literature of woman with a Meckel's diverticulum involved in a strangulated left inguinal hernia.

[Adhesion ileus in patient with previous diagnosis of Ogilvie's syndrome]

A case of a 72-year-old man with abdominal pain and ileus is reported. Previous surgery for Ogilvie's syndrome had been performed. Despite conservative therapy, the occlusive symptoms worsen. Therefore the patient was submitted to surgery. At laparotomy two abdominal adhesions were found and sectioned. The differential diagnosis between mechanical ileus and pseudoobstruction for neuro-mechanics dissociation (Ogilvie's syndrome) is difficult, particularly in patients with neurodegenerative diseases.

[Rectal stenosis after stapler hemorrhoidopexy]

We report a case of a 52-year-old woman with hemorrhoids submitted to Procedure for Prolapse and Hemorrhoids (PPH), i.e. stapled hemorrhoidopexy, using a modified Longo's technique (double purse string) to treat an associated rectocele and rectal prolapse; the STARR technique (Stapled Trans Anal Rectal Resection) was not yet codified. The post-operative course was uneventful and the patient is discharged in II p.o. day. In fifth post-operative day the patient came back with an unusual rectal stenosis due to the superior purse string. The stricture was easily resolved by 'opening' the purse string with a transanal approach in outpatient setting.

Intestinal anisakiasis in Italy: a case treated by emergency surgery

Anisakiasis is a fish-borne zoonotic disease. A case of intestinal anisakiasis in a woman who had consumed raw marinated anchovies was reported. The intestinal localization resulted in occlusive acute abdomen which required an emergency surgical treatment. The histological examination of the eosinophilic granuloma removed from the resected colon revealed the presence of larval nematodes of the genus Anisakis as causative agents.

[Strangulated abdominal herniation by Ladd's band]

A case of a 64-year-old man with abdominal pain since three days, with vomiting and ileus and without previous surgery is reported. Faecal material was aspirated by a nasogastric tube; TC showed dilatation of the small bowel with the walls of the loops thickened. The patient was submitted to emergency surgery with diagnosis of intestinal infarction. At laparotomy an extensive necrosis (two meters) of small bowel was present, caused by visceral herniation by a Ladd's band. Intestinal resection was performed with latero-lateral stapled anastomosis. The postoperative course was uneventful and the patient was transferred in VII p.o. day to an hospital of his Country.

[Prevention of post-operative pain and haemorrhage in PPH (Procedure for Prolapse and Hemorrhoids) and STARR (Stapled Trans-Anal Rectal Resection). Preliminary results in 261 cases]

Intra- and early (first week) post-operative haemorrhages are the most common complications in stapled hemorrhoidectomy PPH (Procedure for Prolapse and Hemorrhoids) and in circumferential resection of the rectal prolapse STARR (Stapled Trans Anal Rectal Resection). Performing PPH and STARR we employed a gelatin based haemostatic sealant with thrombin component (FloSeal) to control intra-operative bleeding and to reduce post-operative bleeding avoiding haemostatic stitches on suture line. We report the preliminary results on 197 PPH and 64 STARR; 44 PPH (22.4%) and 27 STARR (42.2%) were treated by FloSeal. No major post-operative bleeding was observed in all patients treated by FloSeal, compared to 1.3% and 2.7% of hemorrhage respectively in PPH and STARR patients treated without sealant. Post-operative pain was less severe in patients treated by FloSeal, without a difference statistically significant. The data are preliminary and must be confirmed in prospective randomized trials in larger series.

[Desmoid tumor of rectus muscle of abdomen in a woman of childbearing age: what can we do?]

The desmoid tumor (DT) is a soft tissue neoplasm most frequently localized in the anterior abdominal wall typically in females of childbearing age. Because its particular incidence in women who had recently been pregnant, it was correlated with delivery's trauma stimulating proliferation of muscolo-aponeurotic tissues. Complete surgical resection is the recommended treatment approach to prevent recurrence. Many authors emphasize the role of radiotherapy in regression of DT and in controlling local recurrence in patient who had incomplete resection. Many others emphasize the role of chemotherapy or antiestrogenic compounds, even though tumour does not express estrogen receptors. DT, otherwise, is neoplasm with high rates of recurrence after surgery but it never develops distant metastases, so that function and structure-sparing surgery may be a reasonable choice in young women when possible without leaving macroscopic residual disease. Furthermore literature data suggest that the presence of incomplete histological surgical resection does not correlate with local recurrence and that pregnancy does not represent a risk factor. In women of childbearing age, even after non radical histological DT primary resection, adjunctive radiotherapy, chemotherapy or antiestrogen therapy could be avoided and clinical observation alone may be considered.

[The use of Floseal in the prevention and treatment of intra- and post-operative hemorrhage in the surgical treatment of hemorrhoids and colporectocele. Preliminary results]

Stapled hemorrhoidectomy (PPH) is a modern approach to the treatment of hemorrhoids removing a circumferential strip of mucosa. In the same way the circumferential resection of the rectal prolapse (STARR) is successfully used for effective treatment of colporectocele and obstructed defecation syndrome. These surgical procedures offer several advantages over conventional techniques including reduced postoperative pain, stenosis and recurrences, an earlier recovery time and return to work. Furthermore, bleeding is one of the most common immediate complication (first week) and one of the possible late complication in these procedures. Our results with this surgery (153 PPH and 37 STARR) confirmed the data of many other Authors regarding the incidence of intra and early post-operative haemorrhages (1.3% in PPH and 2.7% in STARR). With the aim to reduce this complications, which represents the only negative side-effect of these procedures, we employed the FloSeal, a gelatine based haemostatic sealant with thrombin component, to control intraoperative bleeding. The preliminary results obtained in 10 PPH and in 7 STARR confirmed the theoretical usefulness of FloSeal in reducing this hemorrhagic complications.

[Packing: current concepts of "life-saving" surgery]

Abdominal packing is a lifesaving technique for temporary control of severe injury and it is used in Damage Control Surgery schedule. Technically bleeding from abdominal cavity can generally be achieved by applying pressure with several large abdominal packs. It's possible too applying packs in organ-specific techniques (early abdominal packing). A wide review of the literature has allowed to emphasize the most common problem of this technique, the adequacy of the particular indications, their evolution, timing, the results in general and particular which multiple critical situations and not always predictable when an intensive diagnostic and methodological approach is necessary in. The principal indications are when complex anatomic lesions are diagnosed with not ruleable hemorrhages, in presence of metabolic failure--like hypothermia < 35 degrees C, acidosis > 7.2, coagulopathy PTT > 16 seconds: these three derangements become established quickly in the exsanguinating trauma patient and, once established, form a vicious circle which may be impossible to overcome. The results are encouraging and we can evaluate a median survival of the 60%, certainly superior to the obtainable survival with immediate surgical repair. Immediate failures are substantially due to bleeding, especially in "underpacking" case, and remote: these last can be premises, fundamentally septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions; in these situations is possible a MOF syndrome due to excessive intraabdominal pressure (overpacking) or to an abdominal compartment syndrome.

[Glomus tumor and neovascular syndrome of the arm: a clinical case]

Glomus tumour represents a benign tumor which originates from myoepithelial cells of arteriovenous anastomosis that has a preference for subungual localization with painful and multiform symptomatology. A fifty-year-old female presented a vasospastic symptom with hyperalgesia and cold hypersensitivity in the fourth finger of the right hand. There was a little palpable tumefaction and after an echography, we decided for surgical revision. Differential diagnosis with Raynaud's phenomenon is very important but not simple. The diagnosis is often late. MRI and angio-MR with its typical symptomatology could give the accurate diagnosis. The therapy is only surgical. The excision must be very careful making sure to spare the nervous structures.

[Small intestine tumors: our experience in emergencies]

Small bowel tumours are relatively rare neoplasms; unusual occurrence associated with nonspecific symptoms, and low-sensitivity tests availability, are responsible for diagnostic delay. A retrospective study was performed on 42 cases with acute presentation, from 1972 to 2001; median age was 52 years (range 14-79) and there was a slight female prevalence (57.1% vs 42.9%). The most common acute presentation was occlusion (57.1%), followed by gastrointestinal (GI) bleeding (23.8%), perforation (14.3%) and occlusion/perforation (4.8%). Benign neoplasia were 38.1% (16 cases) and adenoma is was the most common type; malignant forms were 61.9 (26 cases) and adenocarcinoma and lymphomas were the most common histotype. Radical surgical procedures were possible only in 57% of malignant forms (24 patients); morbility was 4.8% (2 cases: 1 anastomotic dehiscence and 1 subphrenic abscess); mortality was 14.3%. From our retrospective study, we can state that survival for malignant lesions is strictly dependent of early TNM staging and possibility of radical surgical procedure. An extremely high index of suspicion in evaluating mild and often misleading symptoms, integrated with specific diagnostic studies, should be the proper approach. Prognosis for benign from is excellent in all cases.

[Peritoneal papillary serous carcinoma: clinical report]

Peritoneal papillary serous carcinoma (PPSC) is a rare tumour that involves the surface of the peritoneum, with prevalence in female patients and can originate from a single or multicentric focus is here described. A primary peritoneal serous carcinoma is here described. The patient has been treated with paclitaxel 175 mg/m2 and carboplatinum AUC 6.

[Superior vena cava syndrome]

Superior vena cava syndrome is due to an intrinsic or extrinsic caval obstruction that evolves in acute or subacute way with distinctive clinical feature such as respiratory symptoms and venous stasis. Since 1998 we have treated three cases of spontaneous superior vena cava thrombosis in neoplastic patients who underwent several infusion of chemotherapy, respectively for a breast, uterine and rectum cancer. All patients was female, 52, 58 and 70 years old. The first two cases was treated with locoregional thrombolysis by infusing Urokinase 50,000 UI/h during 24 hours and Urokinase 50,000 UI/h during 12 h the third one. After that, we have positioned a 16/9 wallstent: in the first two cases directly into the superior vena cava, in the third case in the subclavian-anonyma truncus. We had in all cases the complete opening of the stent within the first 48 hours without complications, enabling us to reach a free caval diameter of about 2 cm with resolution of the clinical signs. In patients with high surgical risk, the caval wall-stent is the first choice to solve the vein recanalization.

[Cutaneous Merkel cell carcinoma: case report]

Merkel cell carcinoma is an unusual cutaneous malignancy with a propensity for spreading to regional lymph nodes, with recurrence at original site or/and in lymph node. Occurring most often on the head and neck of the elderly patients. Complete surgical resection is the mainstay of treatment of the primary tumor. A case is here described of an old patient with more than one local relapse and in regional lymph nodes too, complete surgical resected, actually in good state of health, treated with radiotherapy.

[Difficult endoscopic extraction: pneumomediastinum and bilateral pneumothorax after attempted endoscopic extraction of needle incarcerated in hiatal hernia]

From June 1987 to April 2000, 167 (74%) of 223 patients suspected of swallowing foreign bodies were treated. Hundred-sixty-three were successfully treated endoscopically. The surgery rate was 2.4%. There was failure to remove a tablespoon, a tooth-brush, a dental prostheses with metallic hook, a knitting-needle. The sharp and pointed foreign bodies were 35 (20.9%). Endoscopic removal of sharp and pointed foreign bodies in the upper gastrointestinal tract can be very difficult to manage. The Authors report iatrogenic perforation of esophagus-gastric-fundus in a patient with hiatus hernia who ingested a big knitting-needle in order to suicide. They think that it is absolutely necessary to use special endoscopic equipment during the taking out of foreign-body procedure, especially when pointed and sharp-edge shaped bodies are involved and when there is high risk of iatrogenic lesions.

[Damage control surgery: the technique]

Abdominal packing and planned reoperation is a lifesaving technique for temporary control of haemorrhage in severely injured patients. Morbidity and mortality, however, remain significant. The purpose of this study is to evaluate all surgical technique and our results during 31 years of trauma surgery. In the last 12 years the Authors have performed 11 packing. They stressed fully "damage control technique" in trauma surgery in the last four years. Overall mortality was 45.5%.

[Use of adhesives in emergency surgery]

In a prospective study, the Authors present an analysis on the use of surgical adhesives in the wounds treatment. In sixteen months we have treated 157 patients exclusively with a surgical tissue adhesive 2-octylcianoacrylate to repair traumatic wounds and surgical ones. In the Emergency Department were treated 110 patients (70%) with 2-octylcianoacrylate for skin incisions, lacerations and the length of lesion. We have paid attention to prepare regular wound edges, irrigation and debridement when appropriate to reduce skin tension at the site of laceration. Forty-seven patients (30%) whit surgical skin incisions for thyroidectomy, appendicectomy, hernio-plastic and safenectomy were treated with 2-octyl-cianoacrylate. In both groups of patients, the surgical adhesive has made possible a simple and quick wounds repair as well as good aesthetic results. No relevant complications have been arisen. The writers recommend the surgical adhesive in Emergency Department to abridge waiting time and to avoid the psychological impact caused by local anaesthesia, suture and medications especially in the treatment of all wounds types in children.

[Unusual case of kidney rupture]

The Authors report a case of renal rupture in a patient 36 years with acute abdominal pain and progressive anaemia. The history of the patient shows no past signs and symptoms of either renal pathology or traumatic event. Radiological examinations demonstrates dislocation of the kidney through presence of large retroperitoneal formation interpretable as haematoma. Progressing bloodless, they proceeded to embolization of renal artery and successive nephrectomy. Only histological examination of the removed kidney demonstrates the presence of a renal clear cells adenocarcinoma.

[Spontaneous biliodigestive fistulae. The clinical considerations, surgical treatment and complications]

To reevaluate the current feature of spontaneous bilioenteric fistula we reviewed 81 cases who had been treated for biliary fistula between 1948 and 1998. After a review of the literature on this subject, the multiple problems relate to pathological anatomy, pathogenesis and physiopathology are discussed. Of 81 patients, 55 were women and 26 were men with the average age of 54.5 years. The most common type of fistula was cholecysto-duodenal (55 cases--68%), followed by cholecysto-colonic (11 cases--13.6%), choledocho-duodenal (7 cases--8.6%), cholecysto-gastric (4 cases--4.9%) and duodeno-left hepatic duct fistula (4 cases). The authors have found in 41 cases the gallstone ileus complications, in 12 cases inflammatory disease of biliary three, in 8 cases hemobilia, gallstone ileus with perforation and digestive hemorrhage compliances respectively. All the patients were treated with surgery. A first procedure consists of enterolithotomy, in gallstone ileus cases, followed by biliary surgery. In 14 patient the general or local conditions argued against one-stage procedure and two-stage procedure had been considered. In 63 patients a cholecystectomy was done, 15 were treated with enterolithotomy and 8 with intestinal resection. Seven patients with gastroduodenal ulcer based fistula have required a gastroduodenal resection. The mortality was 13.6% (11 cases).

[Inhaled foreign bodies: first aid]

In the last 30 years 1,484,576 patients with traumatic lesions of different kind of seriousness were observed and managed. By mean of retrospective investigation, the authors selected and statistically analysed a sample of 95 patients treated for accidental tracheobronchial foreign bodies inhalation: authors' aim was to punctually determinate--step by step--diagnosis and treatment procedure in a "time-saving" frame. Inhalation of foreign bodies is a very dangerous event, particularly in children. In authors' experience, in 60% of cases they were children under 3 years; in 25% of cases children under 10; in 10% patients from 10 to 60 and in 4.5% over 60. As regards the gender of the patients, the male/female ratio has been 2 to 1 in favour of male. Since 85% of the study population was represented by children under 10, its clear that male children in this range of age has a greater statistical risk for accidental tracheobronchial foreign bodies inhalation.

[Deep venous thrombosis and neoplastic pathology: our experience in emergencies]

Deep vein thrombosis incidence is 1/1000 per year; it is associated with many risk factors which is considered as "thrombophilic states". Its pathogenesis is complex, caused by alterations of hemostasis system. Many studies have established the relation between cancer and subsequent venous thromboembolism, confirming the relationship of neoplastic cell interaction with coagulation system. Forty-seven patients admitted to the hospital from 1987 to 1996 with symptomatic clinically proved deep vein thrombosis were included in a retrospective study. Routine examination at the time of diagnosis of deep vein thrombosis revealed an occult cancer in 8 out of 47 patients; 9 out of 47 patients were admitted in hospital with vein thrombosis and known cancer. The aim of this study is to suggest the best, first treatment of vein thromboembolism in emergency to avoid the dangerous pulmonary embolism complication. The patients affected with deep vein thrombosis and cancer were elderly (over 70 years old, in mean); the neoplasia was of digestive system (8/17) in advanced metastatic stage there was cancer familiarity in 7 out of 47 patients. The high risk of pulmonary embolism associated to deep vein thrombosis suggests the importance of early starting the anticoagulant therapy and placing caval filter.

[Primary "small-cell" lymphoma of the lung. A clinical case report]

Primary lymphoma of the lung is a rare pathological condition arising from mucosa-associated lymphoid tissue (MALT). The lack of specific symptoms and the related diagnostic problems induced the authors to report a clinical case recently observed. Therefore, some histopathologic characteristics useful for a correct differential diagnosis with the pseudolymphoma of the lung and the interstitial lymphocyte pneumonia are analysed.

[An unusual case of spontaneous idiopathic hemothorax]

Spontaneous haemothorax is an extremely rare pathology. Up to date, only 3 cases have been described in literature. The authors report the fourth case personally observed.

[Free microvascularized flaps in head and neck lesions: the technics of microsurgical reconstruction]

The authors report their experience of microsurgical reconstructive techniques using musculo-cutaneous free flaps after radical operations for head and neck neoplasms.

[A case of carcinoma of the cervical esophagus treated with interposition of an intestinal loop revascularized using a microsurgical technique]

The Authors present a case of hypopharyngeal tumor in which digestive continuity was assured by a jejunal autotransplant. Tumoral exeresis and jejunal preparation were carried out at the same time by two surgical teams. The use of microsurgical techniques assures the revascularization of the neck transplant by implementing the superior thyroid artery and the internal jugular vein. Digestive anastomoses complete the operation.

[Venous replacement surgery: history, update and perspectives]

The impulse given to vascular surgery by new technologies has facilitated the use of the bypass technique in a number of arterial pathologies with better and better results over time. At the moment, however, we haven't a "sure prosthesis" in venous surgery. Our intention has been to examine the most significant developments, studying all the available material dating from the beginnings of the art up to the present. After a careful examination of the venous pathophysiology as well as the most valid surgical approaches, we tried to evaluate on laboratory animals the results of experimental graft replacement of the inferior vena cava. In this study we analysed prostheses in PTFE, biological prostheses, spiral composite vein grafts, arterial autologous grafts. For the experimental study we used 55 rabbits (New Zealand and Fiandra). Results have been rather successful with respect to biological prostheses (62.5% patency) and PTFE (66.6%). As for spiral composite vein graft prosthesis patency over time was very low (16.6%); this was affected by the different venous graft (heterologous graft) and caval wall thicknesses. Arterial autologous graft was carried out only once because rabbit experimented on did not stand up to surgical stress.

[Mesorectal resection in oncologic surgery]

A surgical technique to "en bloc" resect the mesorectum while performing an anterior resection is here described. The procedure aims at preserving those nerves whose injury is responsible for a series of neurological sequalae, which affect the patient's quality of life. Fifteen dissections were carried out in order to demonstrate the possibility to perform an accurate mesorectal lymphadenectomy while preserving, in most cases, the nervi erigentes and, in some cases, the hypogastric plexus.