Usefulness of ultrasounds in the management of breast phyllodes tumors

Introduction. Breast phyllodes tumors (PT) are uncommon fibroepithelial lesions having potential malignant features. These tumors have characteristic features, like phleomorphism, mitoses and overgrowth of the stroma with possible infiltrative margins. The clinical behaviour could be unpredictable, since the relatively high recurrence rate despite correct surgical strategy. Conventional diagnostic examinations show high sensitivity and specificity, but cannot demonstrate the differences between benign and malignant PT. MRI is not more effective. Patients and methods. Sixteen patients affected by PT have been surgically treated at our Institution. All patients received mammography and ultrasonography (US) as preoperative diagnostic work-up. Results. in 13 patients, US was effective in preoperative diagnosis of PT. Mammography was uneffective in detecting breast lesions in 5 cases, while in 11 cases mammographic findings presented benign features, with a round opacity with moderate tissue density and well-defined wall. Conclusion. US remains the most useful diagnostic test in detecting PT. However, there is no test effective in identifying malignat PT. In case of suspicion, fine needle biopsy should be performed.

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.

Factors affecting the prognosis of Albanian adult patients with generalized tetanus

Background. Despite systematic vaccination of the population, tetanus continues to be a health problem in Albania, as in some other developing countries. In this study, our intent was to evaluate prognostic factors relating to death in adult patients with generalized tetanus. Methodology and patients. All the patients (60) included in the study were hospitalized at the regional hospitals of Shkodra and Korça, and the University Hospital Centre “Mother Theresa” of Tirana, Albania, during the period of 1984-2004. They had a mean age of 49.1+14.4 years, 43 (71.7%) were males and 40 (66.6%) of them lived in rural areas. The mean incubation period was 12 days and the case-fatality rate (CFR) was 38.3%. Results. The CFR in patients with an onset period ≥2 days was 21.7% and in those with <2 days was 48.6%, OR=0.29 (p<0.05). Patients >50 years old had a CFR=60.87% (OR=7, p<0.05). We found the high CFR to be significantly associated with urban residency, male gender, complicated wound, head localization, fever ≥ 38.4 °C, tachycardia > 120 beats/min, and hypertension. Discussion. The main prognostic factor of those analyzed in our study appeared to be the onset period and the age of the patients. We didn’t find significant differences in CFR in patients with different incubation periods. Clinicians must take into account that wound complication and localization, tachycardia and hypertension, high fever, male gender and urban residency significantly influence the prognoses of adults with generalized tetanus.

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.

Modified patch repair of femoral hernia after inguinal herniorrhaphy

Background and aim. It has been reported that femoral hernias are rather common after a previous repair of inguinal hernia. We herein present a modified patch repair technique for large femoral hernias that develop after a Lichtenstein operation for ipsilateral inguinal hernia. Patients and methods. The modified technique for femoral hernia was applied to three patients who had a Lichtenstein repair for inguinal hernia. All patients were male. Hernia sac is dissected completely and sent back into to the preperitoneal space. Special attention should be given to the prevascular component of the sac. It is dissected as deep as possible into the preperitoneal space over the femoral vein. The defect is quite wide in this particular type of femoral hernia following Lichtenstein repair. A prosthetic patch that matches the defect is prepared. The medial edge of the mesh is configured to correspond to the pubic corner and lacunar ligament. The lateral margin of the patch is cut to create several petals for inverting the mesh above and medial to the femoral vein to prevent prevascular herniation. The mesh is secured to inguinal ligament, ilioinguinal tract, lacunar ligament, and Cooper ligament. Few sutures are put on the pubic corner and lacunar ligament. Results. One patient was discharged after two hours, other two stayed overnight. Readmission because of seroma development was recorded in two cases where standard polypropylene meshes were used. No complication was observed in the other patient who received lightweight meshes. No early recurrences were recorded after 4, 9, and 30 months. Conclusion. Femoral recurrence after previous inguinal hernia repair seems to be a specific entity. It has a prevascular component and the hernia defect can be much larger than that of a primary femoral hernia. A patch repair with infra-inguinal approach can be a valuable alternative with low complication rate.

Delayed and occult splenic rupture: a diagnostic puzzle

Splenic rupture is a common complaint encountered in emergency surgery. Trauma is the most common cause of splenic rupture, while non-traumatic or occult splenic rupture (OSR) is a rare condition. The differential diagnosis weighs on treatment that ranges between close monitoring, splenorrhaphy, splenic conservation and splenectomy. We report a case of an 63-year-old man presenting with acute atraumatic left upper quadrant pain. Preliminary diagnosis was subsequently determined to be a hematoma secondary to OSR. More accurate detailed history revealed a previous trauma, which occurred more than one year before and mimicked an OSR. Delayed and occult splenic rupture are as different diagnosis as different treatment. Even in emergency surgery, the key for a target therapeutic strategy should consider an accurate diagnostic time.

Pancreatic large mucinous cystoadenoma with invasive ductal carcinoma in pregnancy. Case report

Background. Cystic tumour of the pancreas are infrequent and malignancy of the pancreas during pregnancy is extremely rare. Mucinous cystoadenomas is the most frequent cystic pancreatic neoplasm and it is seen mainly in women suggesting a sex hormone influence. Its presentation during pregnancy is extremely rare and entails difficulties in diagnosis and therapy. Case report. A 28 year old woman was referred to our service for abdominal mass. She had given birth to her second child two weeks previously. Ultrasound and CT scan showed a large cystic lesion, with sepitation and inner solid growth portions, involved mainly the left sovramesocolic space. An ultrasound-guided aspiration of the cystic fluid showed high level of CEA and CA. 19-9. The patient underwent laparotomic body-tail pancreatectomy and splenectomy. The histological examination showed mucinous cystoadenoma with associated invasive ductal carcinoma, with ovarian-like stroma and a well delimited fibrous capsule. Hystochemical study revealed a strong positivity for progesterone receptors. Conclusions. To our knowledge this is the eighth case of mucinous cystoadenoma reported in English literature and the forth with an invasive adenocarcinoma associated. This pathological entity should always be kept in mind in case of patient with an hepigastric mass during or soon after pregnancy. Aggressive approach is mandatory.

Lipofilling in skin affected by radiodermatitis: clinical and ultrasound aspects. Case report

In recent years, lipofilling has established itself as one of the most effective and least invasive techniques to treat connective dystrophy subsequent to radiotherapy. We report the case of a patient diagnosed with intraductal carcinoma of the right breast in 1996, at the age of 41. The patient underwent quadrantectomy with ipsilateral axillary lymph node dissection and adjuvant chemotherapy and radiotherapy. Four years later, a recurrence led the patient to undergo a subcutaneous mastectomy and immediate reconstruction, involving the submuscular insertion of a permanent implant. In 2007 the patient suffered both radiodermatitis and capsular contracture around the implant, causing constant pain and significant functional limitation. She first took a leukotriene inhibitor (Zafirlukast, 20 mg daily for 8 months) to reduce the capsular contracture. She then underwent lipofilling (Coleman’s technique) of the area affected by radiodermatitis, in which the skin was considerably thinned and visibly ischemic. A second session followed four months later. Clinical, photographic and ultrasound examination revealed clear and lasting thickening of the superficial tissues, increased coverage of the implant, and reduced skin discoloration and tension.

Endoscopic treatment of difficult choledocholithiasis

Common bile duct stones can be treated with normal endoscopic techniques. Where stones cannot be removed due to their size or number or due to stenosis of the common bile duct, a plastic stent can be inserted, enabling rapid drainage of bile. At the three-month check-up complete removal of the stones was found in 41 (85.4%) of the 48 patients with difficult choledocholithiasis. In the remaining 7 patients (14.6%), the stent in any case resulted in clinical improvement. A permanent stent was necessary in 4 patients, enabling safe drainage with no complications. The use of endoscopy for stent placement was effective in all our cases of difficult coledocholithiasis without any complications.

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.

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.