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Background The accessory spleen is a congenital defect characterized by a separated ectopic splenic parenchyma. The size is rarely more than 4 cm. The preoperative diagnosis is prohibitive preoperatively. The aims of the present manuscript were to present the case of a patient with a rare oversize accessory spleen and a review of the literature. Case presentation A 15-year-old boy was admitted to the emergency department following blunt abdominal trauma. The computed tomographic scan showed a traumatic rupture of the spleen and a 7-cm mass at the left side of the retroperitoneal space. Conservative treatment started and aborted after 4 h due to the onset of haemodynamic instability. Splenectomy was performed. An accessory spleen was discovered. A second large mass in the retroperitoneum was diagnosed as a second large accessory spleen that was also left in place. The postoperative course was uneventful, and the patient was discharged on the 7th postoperative day. Seven months later, the CT scan showed viability of both accessory spleens. Conclusion An accessory spleen can be variously located and the retroperitoneal position is extremely uncommon. Preoperative diagnosis is still difficult, especially in emergency and as in our case, the literature shows the difficulty of reaching a diagnosis before surgery. The main misdiagnosis is neoplastic disease and for this reason accessory spleen can be wrongly removed. An undiagnosed pre or intra operative retroperitoneal mass, closely to the spleen, have to be managed carefully. The diagnosis of accessory spleen needs to be ever considered as if found, represents a great possibility to conduct a normal life after splenectomy (of main spleen) for trauma.

Contains fulltext : 215819.pdf (Publisher’s version ) (Open Access) Renal and urogenital injuries occur in approximately 10-20% of abdominal trauma in adults and children. Optimal management should take into consideration the anatomic injury, the hemodynamic status, and the associated injuries. The management of urogenital trauma aims to restore homeostasis and normal physiology especially in pediatric patients where non-operative management is considered the gold standard. As with all traumatic conditions, the management of urogenital trauma should be multidisciplinary including urologists, interventional radiologists, and trauma surgeons, as well as emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) kidney and urogenital trauma management guidelines.

The aim of this paper is to report a case of a child with adhesive small bowel obstruction treated by laparoscopic ap-proach.A 13-year old patient developed a small bowel obstruction caused by adhesion. He was successfully treated by laparoscopic adhesiolysis and was discharged from the hospital on the 7th post-operative day in satisfacto-ry condition.this disease is treated by laparoscopy very rarely, especially in children. In patients without comorbidities, such as pulmonary or cardiovascular diseases, laparoscopic approach could be considered as the first approach in children because the patient has the advantage of less pain and short hospitalization.Until clinical trials will address guidelines, when possible, laparoscopic approach should be attempted.

The Mayo technique is one of the most common techniques used to repair incisional, umbilical, and epigastric hernias. A high percentage of recurrences, together with the use of particular expensive types of meshes, are some of the most relevant problems in this surgical field.This study is a clinical prospective observational and involves all the patients who underwent procedures using a new modified Mayo technique from 2006 through 2013. The general criteria analyzed were age, sex, obesity, smoke abuse, diabetes, chronic diseases, type of hernia, operative time, morbidity and mortality. All the patients involved in this study were followed-up from 6 to 120 months.The types of hernia were 5 epigastic hernia (20,8%), 8 umbilical hernia (33,3%), 11 midline incision hernia (45,9%). Ten patients (41,7%) presented non-complicated hernias; 8 patients (33,3%) presented strangulated hernias and 6 patients (25,0%) presented obstructed hernias. No intestinal resection was necessary in any of the patients. The mean operative time was 55 minutes (range 30-180). The mean hospital stay of the patients' after-post operative procedure was 4.5 days (range, 2 to 8 days). No major complications have been reported. Only one patient present a recurrence.These preliminary results suggest that this modified Mayo technique could be useful in the armamentarium of surgeon to repair incisional, umbilical, and epigastric hernias. More studies are needed to validate the technique.

Sustainability, while being definitely a new form of humanity, as it has been proposed and dealt with in many urban and landscape projects, lacks often of an essential characteristic of the anthropic space: seduction. The authors believe that sustainability has to find its own power of seduction if it is to compete successfully with the ambiguous but established charms of the unsustainable city. From all the above it is clear that the importance of the ‘aesthetic of sustainability’ is fundamental for the success of a new model of green planning not just from an environmental and economic point of view, but, perhaps and most importantly, from a social and mental one. This paper will investigate the possibility to look at sustainability and aesthetics through the lens of evolutive processes and the complexity theory to inform a new Bottom-Up/Self-Organized approach as a possible morphogenetic process for sustainable city design. Often criticized as the theory of ‘out of control’ the complexity theory applied to the urban could instead be the enabler of a new paradigm where the notion of single authorship with intellectual ownership and his aesthetic language is substituted by the concept of a collective and a new aesthetics of choice where aesthetics might recover, according to the evolutionary theory, their essence of an ‘adaptive system’ and an ecological category.

We report 2 cases of megacolon associated with cerebrovascular accident and neuropsychiatric drug consumption. Case report 1: a 75-year-old woman with diabetes mellitus, hypertension, tachycardia with atrial fibrillation, bilateral pleural effusions and previous cerebral hemorrhage was admitted in our hospital. She presented clouded sensorium and abdominal distension, with closed alvus. The CT scan showed a distension of the colon, with severe fecal impaction. A volvulus of the sigma was found at surgical intervention.Case report 2: a 59-year-old man with a medical history of oligophrenia was admitted to our hospital for acute abdomen.He presented stupor and closed alvus with abdominal distension. The abdominal CT scan showed a dolichosigma, with fecal impaction. The patient was submitted to a laparotomy and a two millimetres perforation of the sigma was found.The sigma had a diameter of 28 cm and a length of 75 cm.Even if a clear correlation has not been found yet, anomalies of the regulation of the gastro-intestinal motility can occur at different levels in patients with psychiatric or cerebrovascular diseases and drug consumption with anticholinergic properties,and they should be carefully monitored. The purpose is an early diagnosis of colon function anomalies in order to avoid potentially fatal complications.

The diagnosis of asymptomatic abdominal tuberculosis,without characteristic laboratory and radiologic findings, is difficult. We therefore investigated the role of diagnostic laparoscopy in patients with suspected peritoneal tuberculosis(PTB). Patients admitted to Hamad General Hospital, Qatar,who underwent laparoscopic peritoneal biopsy for suspected PTB from January 2004 to December 2010 were retrospectively analysed. Factors assessed included patient age, sex, symptoms,clinical signs, CT scan findings, laparoscopic findings andhistopathological diagnosis. A total of 41 patients, 33 males(80.5%) and 8 females (19.5%), of mean age 31 years, underwent laparoscopic peritoneal biopsy for suspected PTB duringthe study period. Abdominal pain was the most common presenting symptom, observed in 33 (80.5%) patients.Computerized tomography (CT) of the abdomen showed as citesin 37 patients (90%), bowel nodules in 22 (54%), peritoneal thickening and nodules in 37 (90%) and enlarged mesenteric lymph nodes in 11 (27%). The classical gross laparoscopic appearance of peritoneal tuberculosis was observed in 38 patients (93%), whereas laparoscopic findings were normal in 3 patients (7%). Histopathological results confirmed granulomatous inflammation in 38 patients (93%). The sensitivity and specificity of gross laparoscopic appearance in diagnosing peritoneal TB were both 100%. Two patients experienced complications from laparoscopy (5%), but there were nolaparoscopy-related deaths. Laparoscopic peritoneal biopsy isa rapid and safe method of accurately diagnosing PTB.

Thigh infection is a rare complication of intra-abdominal sepsis that can present with emphysema. We report a case of infection in the thigh resulting from colonic perforation. A 61-year-old woman with cirrhosis, grade Child B6 and diabetes treated with oral hypoglycemic drugs was referred to the emergency department because of a persistent pain in her left thigh and also for some abdominal discomforts during the preceding few days. Ultrasonography identified the presence of gas and fluid in the thigh. The patient received fluids and antibiotics but on the day after she reported an increase in pain. For this reason the patient was submitted to a CT scan that showed a thigh emphysema due to intestinal perforation. The patient was submitted to laparotomy. A Hartmann's procedure was performed, with resection of about 15 cm of affected sigmoid colon. The left thigh wound did not require any treatment.

Intraabdominal cystic lymphangioma occurs rarely, and lymphangioma of the diaphragm has not been previously reported in the literature. The authors herein report the clinical features, radiographic findings, and treatment of one encountered case of lymphangioma of the diaphragm.

The authors describe the clinical case of a naive patient with chronic hepatitis HBV-related (CHB) HBeAg negative, treated with Telbivudine (LdT) 600mg/day. After six months of treatment, as well as it determines rapid, profound and sustained suppression of HBV replication, LdT induced a progressive decline of HBsAg serum level and HBsAg loss, probably through an immune modulator effect. Recent studies have indicated the possible action of LdT on the immune system and specifically it would be able to stimulate Th1 lymphocyte subpopulation by increasing their cytokines production, thus playing a major role in cleaning the HBV infection. This aspect appears to be of much interest in clinical practice, because on-treatment HBsAg rapid decline1 log10 IU/mL during the first year of treatment is highly predictive for future HBsAg clearance and CHB resolution.

Insulinoma, usually benign (90%), is clinically characterized by symptoms as tremulousness, tachycardia, weakness, sweating, fatigue, hunger, headache, dizziness, disorientation and unconsciousness. However rarely it has an unusual presentation. We present a case of insulinoma misdiagnosed as neurologic disease. A 48-year-old man was admitted to our Emergency Division because of car accident caused by loss of consciousness. A diagnosis of complex partial seizure was made one year before. The patient appeared pale, tachycardic, BP 130/85 mmHg. Laboratory tests showed a severe hypoglycemia (30 mg/dl). He was treated with hypertonic glucose solution and the resolution of symptoms was obtained. Dosages of insulin and C-peptide, CT-scan and RMN confirmed a diagnosis of insulinoma. Seizure disappeared after surgical excision. The diagnosis of insulinoma is sometimes delayed up to more than 20 years. Neurologic or psychiatric presentation like disorientation, personality changes, amnesia, irritability, seizures, bizarre behavior, visual difficulties, neuropathy in patients affected by insulinoma could be cause of misdiagnosis. Diagnosis of insulinoma should always be considered whenever these symptoms occur, especially if unresponsive to specific therapy. Insulinoma is curable in most cases and an early diagnosis can avoid adverse consequences including neurologic damage.

In a polycentric study, the influence of some of the most common variables capable of influencing the reliability of prekeratotomy pachymetry has been evaluated. The fluctuation in a sequence of measurements from the same point on the cornea, with the patient in different positions (orthostatic and clinostatic), during progressive drying of the lacrimal film and before and after corneal marking have been evaluated. Three operators, working randomized, used the same computerized pachymeter (DGH 1000) to make the measurements. The data obtained in this way were statistically analyzed by the Statgraphics personal computer program. Some interesting and useful considerations about the more correct methods to run the test and its real accuracy have emerged.

Background. Many technological devices have been used to avoid intraoperative bleeding during hepatic parenchymal transection and to avoid morbidity and mortality, but until now none is complete. The aim of this work is to prospectively analyze hepatic resection patients treated with a water-cooled high frequency monopolar device in order to evaluate its effectiveness. Patients and methods. All consecutive patients who underwent liver resection by use of this device, between January 2003 until December 2007, were analyzed prospectively. The following variables were considered: age, sex, kind of disease, kind of liver resection, number of major/minor resections, total operative time and transection time, number and time of clamping, blood loss, time of hospitalization, morbidity, and mortality. Results. Between January 2003 and December 2007, 26 patients were analyzed prospectively (69% women, 31% men). Ages ranged from 18 to 84 years. Sixty-five percent of patients had a malignant disease; 35%, a benign disease. The procedures performed were two major hepatectomies (7.6%) and 24 minor hepatectomies (92.4%). Hepatic transection was performed in 35 to 150min. Total operative time range was 120–480min. The average blood loss was 325ml (range 50–600 ml). The mean postoperative stays were nine days for all the patient and six days for non-cirrhotic patients. Conclusion. The water-cooled high frequency monopolar device is useful for reducing ischemia–reperfusion damage due to the Pringle maneuver and for reducing the risk of morbidity. However, the Kelly forceps remains the only inexpensive instrument really essential for liver surgery.

The most common targets of the echinococcus are the liver and the lung, but several organs can be affected by this disease. The isolated diaphragmatic location of the cyst, not associated with liver or lung, is very rare. The aim of this work is to report a case of hydatid cyst located in the abdominal side of the diaphragm and to review the literature. The diagnosis was fortuitous and at CT scan the cyst was apparently located on segment VII of the liver. During surgery, after dissection of the adherences with the liver, the cyst remained attached to the diaphragm. Thirty months after the resection, the patient is free of symptoms without any recurrence.

Minimally invasive laparoscopic surgery is the method of choice for the surgical treatment of gallbladder disease. However, surgery of the biliary tract in the elderly is often associated with high morbidity and mortality.To evaluate the efficacy and safety of the laparoscopic cholecystectomy in the elderly with symptomatic, uncomplicated gallbladder disease, we retrospectively compared the records of 24 consecutive patients over 70 years of age with symptomatic uncomplicated gallbladder disease, who underwent elective laparoscopic cholecystectomy, with a similar cohort of patients who underwent elective open cholecystectomy for the same indications.In the laparoscopic group we found a significantly low incidence of postoperative complications, low analgesics and antibiotics administration, rapid recovery, short length of stay and considerable cost savings.We conclude that elective laparoscopic cholecystectomy in elderly with uncomplicated gallbladder disease is safe and effective and we suggest that it may become the surgical procedure of choice.

We read with interest Impact of Surgery on Quality of Life in Patients with Hepatocellular Carcinoma by Mise et al. [1]. In Fig. 1 of the article, the authors well demonstrate that with regard to quality of life (QOL), patients’ physical component summary (PCS) 12 months after surgery can be impaired compared with their preoperative status, but the mental component summary (MCS) is higher than the initial value. The subgroup analysis shows debatable results. In Fig. 3, patients with multiple nodules have poorer MCSrelated QOL, probably because these patients continue to think that nodules will remain in the liver or can regenerate easier after the resection. This is a concern of patients who undergo radiofrequency ablation (RFA). In fact, as reported in our work [2], although patients have an excellent QOL in the first period (up to 12 months) after the RFA, surgeryrelated QOL worsens in the second period (12–24 months), as the tumor’s presence in their body presents a continual emotional stressor. In Fig. 4, the authors show that PCS-related QOL does not differ between patients who undergo resections of up to two segments and those who undergo resections of more than two sections. Although Mise et al. [1] are among the finest hepatic surgery groups in the world, this result was surprising, as it implies that an enucleation or a simple segmentectomy has the same effect on PCS-related QOL as does a right hepatectomy. Slow regeneration after a large hepatic resection is the main cause of impaired post-operative physical condition; however, when the resected tissue is very limited, as in cirrhotic patients, recovery is generally easier. Our investigation [2] has shown this to be a major predictor of QOL in patients who undergo RFA and surgery, especially in the first 6 months after the procedures.

A review of the experience with laparoscopic cholecystectomy to evaluate the impact of the efficacy, safety, and complications on the learning curve.Retrospective study.Between 1993 and 1998, 415 patients, 123 males and 292 females, median age 52.1 years (range 23-96 years), with symptomatic cholelithiasis, underwent laparoscopic cholecystectomy. On the basis of different selection criteria and surgical techniques adopted, our experience was divided into two periods (93-95 and 96-98).The success rate was 89.4% (371 patients) with a conversion rate of 10.6% (44 patients). Overall complications rate was 2.9% (12 patients): 7 major complications (2 biliary tract injuries, 2 hemorrhages, 1 sub-phrenic abscess, 1 gastric perforation and 1 choleperitoneum) and 3 minor complications (1 biliary leakage and 2 wound infections) with 2 long-term sequela (umbilical site eventration). Median hospital stay was 3.3 days, 2.2 days for uncomplicated cases and 5.6 in those converted or complicated. Comparison between the two groups showed a conversion rate of 10.6 vs 10.4% (23 vs 21 patients), with a complication rate of 4.2% vs 2.2%.Laparoscopic cholecystectomy can be considered a safe and effective procedure for the treatment of simple or complicated cholelithiasis. French surgical technique seems to be easier in the management of acute cholecystitis or lithiasis occurring after acute pancreatitis. Specific training in laparoscopy surgery is mandatory to avoid major complications.

Catheter migration, represents a rare, mechanical complication following the use of totally implantable venous devices. A case, in which the catheter was inserted into the right internal jugular vein by percutaneous route, without radiological control, is described. Following the chemotherapy infusion drugs, the patient developed a catheter displacement and subcutaneous extravasation. Etiological hypotheses and modalities of prevention are discussed.

Ileal localization of intestinal endometriosis is not extremely rare, but there are always problems related to the preoperative diagnosis. Symptoms of intestinal endometriosis offer often problems to the surgeon in the differential diagnosis with many more pregnant illnesses like appendicitis, diverticulitis, inflammatory bowel diseases and abdominal neoplasms. The authors report a case of endometriosis of the ileum clinically mimicking Crohn's disease. Crohn's disease of the ileum is the most frequently reported illness that is considered in the differential diagnosis. The review of the literature shows that a correct preoperative diagnosis of endometriosis of the ileum is very seldom done. All common diagnostic tools are not able to resolve diagnostic doubts. Also during explorative surgery the diagnosis of endometriosis is not easy. The authors conclude that endometriosis of the ileum has to be more often considered as possible cause of common intestinal symptoms mimicking inflammatory bowel disease and that this illness induces to reevaluate the importance for a correct diagnosis of an accurate clinical history.

We report a case of an elderly woman with a large eventration of the right hemidiaphragm, discovered during an episode of acute cholecystitis, with abdominal and pleural effusion, successfully treated by a laparotomic approach.

A new alternative technique for regional perfusion chemotherapy in the presence of a right hepatic artery arising from the superior mesenteric artery is described. The cystic artery branch of the right hepatic artery and the gastroduodenal artery can be used to place two catheters and thus apply two implantable systems. This risk-free, straightforward technique preserves native flow and achieves homogeneous distribution of the chemotherapeutic agent.

Meckel's diverticulum (MD) is the most frequent congenital abnormality of the small bowel and it is often difficult to diagnose. The authors report a case of a patient with long-term symptoms erroneously not related with MD disease and developing a diverticulum perforation.

Since the first report of TIVD implantation, many authors have published immediate and post-operative complications. The Authors report the first case in which the catheter, implanted via the cephalic vein by cutdown technique, has migrated completely out of the vein. In order to avoid extravascular migration, during the surgical procedure, the catheter should be fixed at the vein with nonabsorbable sutures, taking care to avoid narrowing the catheter lumen. This case report discusses the possibility of catheter migration when a TIVD fails to function properly and considers how to avoid more disastrous effects.

Diagnostic and therapeutic findings of benign hepatic tumors are analysed. In particularly the authors describe the more frequent tumors such as angioma, adenoma and FNH, but also give a guidelines on how to approach less frequent lesions.

A percentage ranging from 60 to 80% of hepatocarcinomas are associated with increased levels of alphafetoprotein (AFP). In the three years following surgical resection there was a 80% possibility of recidivation. The aims of the present study were: a) to evaluate the significance of preoperative AFP assay as a prognostic index of recidivation; b) to evaluate the importance of repeated assays during the postoperative period in order to ensure an early diagnosis of recidivation. Between 1982 and 1989, 62 patients underwent surgery for hepatocarcinoma. Thirty-one patients who had undergone so-called curative surgery were periodically controlled for a period varying between 6 and 55 months, and were included in the present study. The remaining 32 patients were excluded for the following reasons: palliative surgery, postoperative death, postoperative complications unrelated to tumoral recidivation. In all cases AFP assay was carried out preoperatively, one month after surgery, and then every six months. Recidivation was always confirmed on the basis of tomodensitometric and arteriographic data. Before surgery out of a group of 30 patients, 11 showed normal AFP levels (below 20 mg/ml), while 19 had levels between 49 and 7350 mg/ml. Twenty-three patients (74%) reported one case of recidivation during the period between 6 and 40 months. Among the 11 patients who had showed normal preoperative AFP levels, 5 had a recidivation between 12 and 36 months, and 3 of these showed high AFP levels. In 18 out of the 19 patients (90%) with high preoperative AFP levels recidivation was diagnosed between 4 and 40 months following surgery; 4 of these were not associated with a rise in AFP.(ABSTRACT TRUNCATED AT 250 WORDS)

A sample population of 517 subjects was screened in order to evaluate the incidence of idiopathic varicocele. Subjects were examined clinically and underwent tests using a Doppler flow-meter. Following a brief introduction to the didymoepididymal disease, the findings of the study are reported. In conclusion, the important role of orthostasis as a causal factor leading to the onset of disease in subjects with a predisposition to diathesis is underlined.

The Authors, after a brief review of the most important epidemiologic, etiologic, diagnostic and therapeutic problems related to male breast cancer, report their personal experience. They point out the importance of an early diagnosis in order to obtain satisfactory results, comparable to those achieved in female breast cancer treatment.