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.

The urokinase plasminogen activating system in thyroid cancer: clinical implications

The urokinase plasminogen activator (uPA) system (uPAS) comprises the uPA, its cell membrane receptor (uPAR) and two specific inhibitors, the plasminogen activator inhibitor 1 (PAI-1) and 2 (PAI-2). The uPA converts the plasminogen in the serine protease plasmin, involved in a number of physiopathological processes requiring basement membrane (BM) or extracellular matrix (ECM) remodelling, including tumor progression and metastasis. The tumor-promoting role of PAS is not limited to the degradation of ECM and BM required for local diffusion and spread to distant sites of malignant cells, but widens to tumor cell proliferation, adhesion and migration, intravasation, growth at the metastatic site and neoangiogenesis. The relevance of uPAS in cancer progression has been confirmed by several studies which documented an increased expression of uPA, uPAR and PAI-1 in different human malignancies, and a positive correlation between the levels of one or more of them and a poor prognosis. For these reasons, the uPAS components have aroused considerable interest as suitable targets for anticancer therapy, and several pharmacological approaches aimed at inhibiting the uPA and/or uPAR expression or function in preclinical and clinical settings have been described. In the present manuscript, we will first glance at uPAS biological functions in human cancer progression and its clinical significance in terms of prognosis and therapy. We will then review the main findings regarding expression and function of uPAS components in thyroid cancer tissues along with the experimental and clinical evidence suggesting its potential value as molecular prognostic marker and therapeutic target in thyroid cancer patients.

Aortic valve replacement through the upper ministernotomy. Preliminary experience with modified technique

Minimally invasive approach for aortic valve surgery has been developed since 1995, reducing the complications related to the full sternotomy. We have introduced a new method for central cannulation that reduces the length of surgical incision for the aortic valve replacement through upper mini-sternotomy. To improve the surgical view without enlargement of the incision, two small additional incisions are performed for both arterial and atrial cannulation. We have used the modified technique in 60 patients without sternal infection or other surgical complications and with good cosmetic results. Cardiac surgery - Aortic valve replacement - Minimally invasive approach.

Simultaneous volvulus of the transverse and sigmoid colon. Case report

Introduction. Volvulus of transverse colon is rare when compared to cecal and sigmoid volvulus. Cases involving simultaneous volvulus of the transverse colon and another colonic segment are extremely rare. Case report. We report a rare case of simultaneous sigmoid and transverse colon volvulus in a 82-year-old Caucasian female Conclusion. Volvulus is a well recognized cause of large bowel obstruction. The development of transverse and sigmoid volvulus in the same patient is extremely rare. Though rare this possibility must always be considered in the differential diagnosis, when dealing with recurrent intermittent abdominal pain or acute intestinal obstruction.

Giant condyloma acuminatum quickly growing. Case report

Background. Giant Condyloma Acuminatum (GCA) is a rare, slow growing, large cauliflower tumor of the penile foreskin and perianal region with benign histologic appearance but high propensity for local invasion and recurrences. GCA is associated with Human Papilloma Virus (HPV) types 6 and 11 and it also has considerable risk of neoplastic transformation into fully invasive squamous cell carcinoma into about 5 years. Objective. Because of the rarity of perianal GCA, to date there is no general agreement on the best method for treatment. We wanted to know if surgical approach only was a good method to treat our case. Case report. A 28 years old man, HIV-negative, with a 4 years history of perianal GCA quickly growing underwent full tickness local excision at least 0,7 cm margin of normal tissue with skin grafting taken from the thighs. Fecal contamination was avoided by diet and loperamide per os. At two years follow-up no recurrence was detected. Conclusion. Surgical approach with full tickness excision and immediate skin-grafting and regular follow-up demonstrated effective to treat GCA and to minimize disease recurrence.

Risk factors in reoperative thyroid surgery for recurrent goitre. Our experience

Aim. Reoperative thyroid surgery is an uncommon operation associated with a higher complication rate; we reviewed our series of patients on whom reoperative thyroid surgery was performed.Method. 106 patients had a thyroid reoperation for recurrent multinodular goiter (93 patients), recurrent thyrotoxicosis (3) or suspected malignancy (10); bilateral completion thyroidectomy was performed in 68 cases, lobectomy in 36, removal of a mediastinal recurrence and of a pyramidal remnant in 1 patient respectively. Results. Temporary hypoparathyroidism occurred in 41 patients (38.67%), definitive in 7 (6.6%), transient recurrent laryngeal nerve palsy in 5 (4.71%), permanent nerve palsy in 1 (0.94%); in 3 cases (2.83%) surgical revision of haemostasis was necessary for postoperative haemorrhage. After monolateral surgery we had 13 cases of transient hypoparathyroidism (34.21%), 2 of definitive (5.26%) and 1 transient recurrent laryngeal nerve palsy (2.63%); after bilateral surgery we had 29 cases of transient hypoparathyroidism (42.64%), 5 of definitive (7.35%), 4 of transient recurrent laryngeal nerve palsy (5.88%), 1 of definitive (1.47%) and 3 of postoperative bleeding (4.41%). Conclusions. Reoperative thyroid surgery is a technical challenge with a high incidence of complications. Scarring, edema and friability of the tissues together with distortion of the landmarks make reoperative surgery azardous. A higher risk of complications is described when previous surgery has been performed on both sides. Total thyroidectomy should be considered the procedure of choice for benign multinodular goiter eliminating the potential of a reoperation. Whenever necessary, reoperative hyroidectomy may be performed safely with little morbidity in experienced hands.

Role of pre and post-operative oral calcium and vitamin D supplements in prevention of hypocalcemia after total thyroidectomy

Aim. to evaluate the role of pre and post-operative oral calcium and vitamin D supplements in prevention of hypocalcemia after total thyroidectomy. Patients and methods. 50 consecutive patients, undergoing total thyroidectomy, were enrolled. Oral calcium and vitamin D were administered in the pre and post-operative time. The data concerning symptomatic and laboratoristic hypocalcemia were collected. Results. Incidence of symptomatic hypocalcemia was very low (6%); incidence of laboratoristic hypocalcemia was 10%. No permanent hypocalcemia developed. Conclusions. Implementing oral calcium and vitamin D both before and after total thyroidectomy can reduce the incidence of hypocalcemia related to surgery.

Long-term outcomes following “presumed” total parathyroidectomy for secondary hyperparathyroidism of chronic kidney disease

Aim. The most efficacious surgical treatment for renal hyperparathyroidism is still subject of research. Considering its low incidence rate of long-term relapse, “presumed” total parathyroidectomy without autotrasplantation (TP) may be indicated for secondary hyperparathyroidism (2HPT) in patients with chronic kidney disease (CKD), not eligible for kidney transplantation. The aim of this study was to analyse the TP long-term results in 2HPT haemodialysis (HD) patients. Method. Between January 2004 and October 2009, 25 2HPT HD patients, not eligible for kidney transplantation, underwent TP of at least four parathyroid glands. Clinical status and intact parathyroid hormone (iPTH) serum levels were assessed intraoperatively and during a 36-month follow-up. Results. TP improved the typical clinical symptoms and a significant reduction of iPTH serum levels was achieved in each patient. Aparathyroidism was never observed; in case of severe postoperative hypocalcemia, hypocalcemic seizures were never reported and the long-term recurrence rate was 8%. Only one patient received a kidney transplantation. Postoperative cardiovascular events (hypertension, peripheral artery disease, arrhythmia, coronary or cerebrovascular disease) were observed in 32% of cases and mortality rate was 16%. Conclusions. Considering its low long-term relapse rate and the absence of postoperative aparathyroidism, TP may still be considered the treatment of choice in patients with aggressive forms of 2HPT or of advanced dialytic vintage, with no access to renal transplantation. In case of postoperative hypoparathyroidism, hypocalcaemia can be effectively managed by medical treatment.

Colorectal retained foreign bodies per anum introduced. Three years retrospective study at Emergency Surgery Unit

Colorectal foreign bodies per anum introduced are not exceptional. They can be classified as high-lying or low-lying, depending on their location relative to the recto-sigmoid junction. High-lying rectal foreign bodies sometimes require surgery; low-lying ones are often palpable by digital examination and can removed at bedside. No reliable data exist regarding the frequency of inserted rectal foreign bodies and the literature is largely anecdotal. We review our experience on patients almost all males and heterosexual with retained colorectal foreign bodies and their outcome in Surgical Emergency Unit of a Southern Italy University hospital.

Pancreatic pseudocyst: case report and short literature review

We report a case of pancreatic pseudocyst secondary to acute necrotizing pancreatitis treated with open cystogastrostomy. Following a literature review, we stress the enormous benefits offered by modern diagnostic techniques, and especially imaging techniques, for the diagnosis and monitoring of this disease. Treatment should be delayed for at least six weeks, following which the drainage by open surgery offers the best results and lowest morbidity and mortality, followed by laparoscopy and endoscopy, indicated in particular cases and in patients where open surgery is contraindicated.