Spontaneous rupture of a giant hepatic hemangioma. Sequential treatment with preoperative transcatheter arterial embolization and conservative hepatectomy

Hemangioma is the most common benign tumor of the liver and it is often asymptomatic. Spontaneous rupture of liver hemangiomas is a rare but potentially lethal complication. Emergent hepatic resection has been the treatment of choice but carries high operative morbidity and mortality. Recently, preoperative transcatheter arterial embolization (TAE) has been used successfully for the management of bleeding ruptured liver tumors and non-operative treatment of symptomatic giant liver hemangiomas. We report a case of spontaneous rupture of a giant hepatic hemangioma that presented with thoracic and abdominal pain and shock due to hemoperitoneum. Once proper diagnosis was made the patient was successfully managed by TAE, followed by conservative hepatic resection.

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. .

Subfascial endoscopic perforator surgery (SEPS) in chronic venous insufficiency. A 14 years experience

Introduction. Subfascial Endoscopic Perforator Surgery (SEPS) enables the direct visualization and section of perforating veins. Morbidity and duration of hospitalization are both less than with conventional open surgery (Linton’s or Felder’s techniques). Patients and methods. A total of 322 legs from 285 patients with a mean age of 56 years (range 23-90) were treated at our Department from May 1996 to January 2010. In 309 cases, an endoscope (ETM Endoskopische Technik GmbH, Berlin, Germany) was introduced through a transverse incision approximately 1.5 cm in length and 10 cm from the tibial tuberosity, as with Linton’s technique. A spacemaker balloon dissector for SEPS, involving a second incision 6 cm from the first, was used in only 13 cases. Results. The procedure used in each case was decided on the basis of preoperative evaluation. SEPS and stripping were performed in 238 limbs (73.91%), SEPS and short stripping in 7 limbs (2.17%), SEPS and crossectomy in 51 limbs (15.84%), and SEPS alone in 26 limbs (8.07%). 103 patients presented a total of 158 trophic ulcers; the healing time was between 1 and 3 months, with a healing rate of 82.91% after 1 month and 98.73% after 3 months. Conclusion. Subfascial ligature of perforating veins is superior to sclerotherapy and minimally invasive suprafascial treatment for the treatment of CVI. It is easy to execute, minimally invasive and has few complications.

Ulnar artery aneurysm: case report and review of the literature

Aim. We report a case of ulnar and palmar arch artery aneurysm in a 77 years old man without history of any occupational or recreational trauma, vasculitis, infections or congenital anatomic abnormalities. We also performed a computed search of literature in PUBMED using the keywords “ulnar artery aneurysm” and “palmar arch aneurysm”. Case report. A 77 years old male patient was admitted to hospital with a pulsing mass at distal right ulnar artery and deep palmar arch; at ultrasound and CT examination a saccular aneurysm of 35 millimeters at right ulnar artery and a 15 millimeters dilatation at deep palmar arch were detected. He was asymptomatic for distal embolization and pain. In local anesthesia ulnar artery and deep palmar arch dilatations were resected. Reconstruction of vessels was performed through an end-to-end microvascular repair. Histological examination confirmed the absence of vasculitis and collagenopaties. In postoperative period there were no clinical signs of peripheral ischemia, Allen’s test and ultrasound examination were normal. At follow-up of six months, the patient was still asymptomatic with a normal Allen test, no signs of distal digital ischemia and patency of treated vessel with normal flow at duplex ultrasound. Conclusion. True spontaneous aneurysms of ulnar artery and palmar arch are rare and can be successfully treated with resection and microvascular reconstruction.

Squamous cell carcinoma of the renal pelvis with stones and inferior vena cava infiltration. Case report

We report a rare case of a 50 year old man with renal squamous cell carcinoma (SCC) who first came to our attention with renal colic and fever not responding to antibiotic or analgesic treatment. He had a long history of kidney stones, but had not undergone any imaging in the last 5 years. Physical examination revealed tenderness and a palpable mass in the right flank and lumbar region. A whole body CT scan was performed, revealing an 11 cm mass in the right kidney infiltrating the inferior vena cava. There were areas of calcification within the mass and multiple stones within the renal pelvis. The tumor was considered unsuitable for resection according to radiological and clinical criteria. The mass was biopsied percutaneously under CT guidance and histological examination revealed squamous cell carcinoma of the renal pelvis. The patient was treated with neoadjuvant chemotherapy and embolization of the renal artery. He died one month after diagnosis. To our knowledge this is the second reported case in the world of renal SCC infiltrating the inferior vena cava and with kidney stones.

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.

Endovascular treatment of multiple anomalous splenic artery aneurysms in a Jehovah witness

Purpose. The present report describes a full endovascular treatment of a multiple anomalous (Splenic artery aneurysms) SAA with combination of coils embolization and proximal occlusion of the splenic artery with the Amplatzer vascular plug. Case report. A 53-year-old Jehovah witness woman presented with multiple aneurysms arising from an anomalous splenic artery. An endovascular treatment was performed by implantation of multiple coils and an Amplatzer Vascular Plug. A CT scan 2 months after the procedure showed complete thrombosis of the aneurysms. Discussion. Aneurysms involving an anomalous or aberrant splenic artery are rarely reported in the literature. Their surgical treatment involves potential difficulties as a consequence of anatomical position and vascular anomalies. A fully endovascular technique can be much more attractive compared to any surgical management, providing an effective and minimally invasive option. Splenic artery - Aberrant splenic artery - Aneurysm - Endovascular treatment - Jehovah witness.

Behind Recurrent Thromboembolic Events

We describe the case of a 68-year-old man, who presented with an ischemic stroke due to cardiac embolization related to mitral valve endocarditis. Blood cultures were always negative and post-operative valve histology did not show microorganisms. The patient also presented further recurrent peripheral embolic events. These clinical aspects were the first sign of a pancreas adenocarcinoma, which was only diagnosed in the clinical autopsy. In conclusion, these clinical findings of recurrent thromboembolic events with no microorganisms isolated suggests the diagnostic of a marantic endocarditis.