Complications after laparoscopic Roux-en-Y gastric bypass: a diagnostic challenge. Report of three cases and review of the literature

The number of Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) procedures for morbid obesity and type 2 diabetes mellitus will increase worldwide, and therefore, an increase in perioperative morbidity can be anticipated. The authors present three cases based on different complications after LRYGB to demonstrate the diagnostic challenge that clinicians face in this particular group of patients. Also, a review of the literature covering the value of different imaging in these particular cases is provided by the authors. The role of imaging in the diagnostic process is discussed.

Incisional hernia in Day Surgery: our personal experience

Incisional hernia is one of the most common complications of laparotomy. Its repair with prosthesis has enabled a considerable improvement in the outcome, significantly reducing recurrences. This study analyses the results of open hernioplasty with mesh performed as a Day Surgery procedure in 42 patients between November 2008 and October 2010. The results were good, with low postoperative morbidity and recurrences (2.4%).

Liver resection for hemoperitoneum caused by spontaneous rupture of unrecognized hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is an increasingly common form of cancer. Although its spontaneous rupture is rare in Western countries, it constitutes a surgical emergency and is associated with high mortality. There is a lack of consensus as to the best approach and what parameters to use in choosing it. The three main approaches are conservative, endovascular and resection - the treatment of choice for acute abdominal bleeding. We report a case of hemoperitoneum following the spontaneous rupture of an unrecognized HCV-related HCC in a patient with no history of liver disease. The patient was successfully treated by emergency surgery, with resection of two segments of the left liver.

Small bowel adenocarcinoma. Two case reports

Introduction. Small bowel adenocarcinoma is a rare tumor, with a still not well studied tumorigenesis process, and non-specific symptoms that cause a delay in the diagnosis and consequently a worst outcome for the patient. Videocapsule endoscopy (VCE) and double-balloon enteroscopy (DBE) have revolutionized the diagnosis and management of patients with small bowel diseases. Surgery is the treatment of choice when feasible, while the chemotherapeutic approach is still not well standardized. Case reports. Two cases in 2 months (two women 52 and 72-yr-old) of primary bowel adenocarcinoma is reported. The site of the tumor was in jejunum, instead of the most common site in duodenum. The patients underwent DBE with biopsy and ink mark. Laparoscopic-assisted bowel segmental resection was performed. The pathologic diagnosis was primary jejunum adenocarcinoma. No post-operative mortality or significant morbidities were noted. Conclusion. The combination of DBE and laparocopic-assisted bowel surgery represents an ideal diagnostic and therapeutic method.

Bilateral lung and liver hydatid cysts. Case report

Introduction. Synchronous occurrence of pulmonary and hepatic hydatid cysts is an uncommon manifestation of hydatid disease that is observed in less than 10% of cases. We report a rare case of bilateral lung (with bronchial fistula) and liver cyst, surgically treated after medical therapy. Case report. A 44-year-old housewife reporting fever, anorexia and fatigue that had been present for the previous 20 days received diagnosis of bilateral lung and liver hydatid cyst. Because of the dimensions of right lung cyst and the successive bronchial fistolization, we proceeded to three-stage operation of two thoracotomies and a laparotomy to control the risk of further rupture. After surgery, all post-operatives were uneventful. Complete resolution of the therapy with no evidence of recurrence at 2 years follow-up. Conclusion. We emphasize the need to search for additional hydatids in patients who present with either pulmonary or liver hydatids. The simultaneous treatment of liver and lung should be reserved to patients in good conditions; in all other cases, especially when one cyst is more symptomatic than the others or has more risk of rupture, we prefer to treat single cyst.

Vacuum-assisted closure treatment of leg skin necrosis after angiographic embolization of a giant plexiform neurofibroma

Type 1 neurofibromatosis is a relatively common inherited disease of the nervous system, with a frequency of almost 1 in 3000. It is associated with neurofibromas of various sites. Our case report is about the surgical management of a giant neurofibroma of the right gluteal fold in a 46-year-old male with NF1. The patient presented with increasing edema and accelerated growth of the mass; he underwent percutaneous embolization of lesion vessels that induced necrosis of the neurofibroma. The patient was taken to the operating room, where surgical resection of the bulk of the lesion was undertaken. The postoperative course was complicated by delayed wound closure managed with antibiotics and vacuum-assisted wound closure. Giant neurofibromas similar to this tumor require complex preoperative, intraoperative and postoperative management strategies. Surgical debulk is best managed with preoperative percutaneous embolization that help to avoid surgical bleeding. Postoperative delayed wound closure was managed with the application of negative pressure in a closed environment that triggers granulation and tissue formation.

Anastomotic strictures in colorectal surgery: treatment with endoscopic balloon dilation

The incidence of anastomotic stricture following colorectal surgery has increased in recent years. This complication is observed in 2-5% of all operated patients and is probably due to the greater number of low anastomoses performed with surgical staplers. We observed 31 patients with postoperative stricture, arising from one to nine months post-surgery. All patients had been treated for colorectal cancer and underwent endoscopy either during routine follow-up or for symptoms of stenosis. In 16 patients (group A) the stricture diameter was less than 4 mm and the patients had symptoms attributable to partial bowel obstruction. In the remaining 15 patients (group B), who had difficult bowel movements, the stricture diameter ranged from 4 to 8 mm. All patients were treated with endoscopic dilation using achalasia balloons. The results were considered good when the post-dilation anastomosis diameter achieved was at least 13 mm, fair when it was 9-12 mm and poor when it was less than 9 mm. The short term results (3 weeks) were good in 27 patients (87.2%), fair in 3 patients (9.6%), and poor in 1 patient (3.2%). After several unsuccessful dilations, the latter was treated by surgery. Follow-up at 3-4 months of the remaining 30 patients revealed good results in 20 (66.6%), fair in 6 (20%), and poor in 4 (13.3%). In 1 of these 4 patients, cancer recurrence was observed and a new surgical resection was performed. In 2 patients a self–expandable metal stent was inserted for 4-6 weeks, with satisfactory results. In 1 patient a biodegradable polydioxanone stent was inserted with good results after 6 months. Follow-up at 3-4 months showed good results in 25 patients. After 38 months, cancer recurrence in the area of the anastomosis was observed in 1 patient, who was treated surgically. Endoscopic dilatation should be considered the first therapeutic approach in case of anastomotic strictures, as it is immediately effective, repeatable, and does not preclude surgery if this should become necessary. .

On the need of standards for reporting on esophageal perforation

Esophageal perforation is associated with significant mortality and morbidity. Its etiology is as heterogenous as modalities currently employed for its treatment. There is no clear evidence which is the treatment of choice for esophageal perforation. This is partly due to the suboptimal quality of available studies and failure to accurately report on the characteristics, treatment and outcome of these patients. Indeed, baseline, operative and outcome data are important for a better evaluation of published data and possibly for including them in meta-analyses of aggregate or individual patient data. We propose a checklist for reporting data on esophageal perforation in order to standardize reporting of data of studies on this severe condition.

Laparoscopic colorectal resections performed over a seven-years period in a single Italian Centre

Introduction. Laparoscopic approach for treatment of colorectal lesion is gaining acceptance gradually. Evidence from numerous randomised controlled trials has shown the short-term benefits of laparoscopic colon resection over open surgery, and its long-term outcomes also does not differ considerably from those of open surgery. This study aims at a retrospective analysis of operative and short term outcomes of patients. Patients and methods. All laparoscopic colon and rectal resections performed between September 2004 and September 2011 were included. The clinical parameters, operative parameters and short-term outcome details of laparoscopic colorectal surgery patients were collected from the retrospectively reviewed database. Results. A total of 347 patients, median age 71 years (range 32 to 96), underwent laparoscopic resection of the colon and rectum. The median Body Mass Index (BMI) was 26.5. The majority of the procedures were performed for malignant disease (97,1%) and the most common procedure was right colectomy (41%). The median duration of surgery was 202,3 minutes, with conversion to open surgery in 40 patients (11.5%). Complications occurred in 23 patients (6.6%). The median length of hospital stay was 8.9 days. In patients with malignant disease, the median number of lymph nodes removed was 14.9. Conclusion. Our results show that laparoscopic approach for colon-rectal lesions is safe, feasible and produces favourable results. The most important aspect of surgery for malignant disease is the ability to remove radically the disease. However all data are still related to the experience of the operator.

Laparoscopic versus open appendectomy for the treatment of complicated appendicitis

Aim. Laparoscopic Appendectomy (LA) is widely performed for the treatment of acute appendicitis. However the use of laparoscopic approach for complicated appendicitis is controversial, in particular because it has been reported an increased risk of postoperative IntraAbdominal Abscess (IAA). The aim of this study was to compare the outcomes of LA versus Open Appendectomy (OA) in the treatment of complicated appendicitis, especially with regard to the incidence of postoperative IAA. Patients and Methods. A retrospective study of all patients treated at our institution for complicated appendicitis, from May 2004 to June 2009, was performed. Data collection included demographic characteristics, postoperative complications, conversion rate, and length of hospital stay. Results. Thirty-eight patients with complicated appendicitis were analysed. Among these, 18 (47,3%) had LA and 20 (52,7%) had OA. There were no statistical differences in characteristics between the two groups. The incidence of postoperative IAA was higher (16,6%), although not statistically significant, in the LA compared with OA group (5%). On the other hand the rate of wound infection was lower (5%) in the LA versus OA (20%). Conclusion. Our study indicated that LA should be utilised with caution in case of perforated appendicitis, because it is associated with an increased risk of postoperative IAA compared with OA.

A rare case of postpartum thrombocytosis. Differential diagnosis and management

This is a case of a 43-year-old primigravida primipara woman who presented in our Department in 36 weeks gestational age and underwent caesarean section due to preeclampsia. From her history, it was known that her pregnancy was an in vitro fertilization (IVF) result. She also received low molecular weight heparin because of thrombophilia (protein S insufficiency). We present this case of postpartum thrombocytosis and discuss the differential diagnosis of this condition through the presentation of its management.

Small bowel mesentery solitary fibrous tumor. A rare neoplasia in a young male

Extrapleural Solitary Fibrous Tumors (SFT), in particular small bowel mesentery SFTs, are extremely rare neoplasms. We describe the case of a young male hospitalized for unspecific abdominal symptoms and evidence of a well-circumscribed mass arising from the small bowel mesentery. Histopathological and immunohistochemical analysis on the surgical specimen confirmed the diagnosis of SFT. A Pubmed search revealed only another case of small bowel mesentery SFT, confirming the extremely rarity of this tumor.