Laparoscopic management of adrenal tumors: a four-year experience in a single center

AIM: Today laparoscopy is considered the first choice treatment of many adrenal tumors, although its use is still controversial for large adrenal masses and incidentally found adrenal cortical carcinoma. METHODS: From January 2009 to February 2014 we performed 42 lateral transperitoneal laparoscopic adrenalectomies. The indications for surgery were non-functioning adenoma larger than 4 cm or rapid growth and hormone-secreting tumor. The diagnosis was confirmed in all cases with computed tomography and magnetic resonance imaging and also metaiodobenzylguanidine scintigraphy if pheochromocytoma was suspected. In all cases we realized a complete preoperative hormonal study. We describe and analyzed retrospectively: age, side, indication for surgery, tumor size, length of hospital stay, complication and conversion rate. RESULTS: Twenty-two patients with functional tumors and 20 with non functional tumor were subjected to laparoscopic adrenalectomy. There was no conversion to open surgery. Mean operative time was 120 min and estimated blood loss was 80 mL (range 50-350). There was no mortality or major complications. The average length of hospital stay was 3.5 day. During pheocromocitoma removal hypertension occurred in 2 cases. Patient with aldosteroma became normotensive and no required postoperative antihypertensive therapy. CONCLUSION: Laparoscopic adrenalectomy is a standard safe procedure for adrenal surgery. The risk of encountering incidental adrenal cortical cancer increases for large lesions and additional attention is required in these cases to observe oncologic surgical principles. Pre-operative work –up has a primary role in adrenal surgery. An accurate management of adrenal tumors requires an agreement among radiologist, endocrinologist, oncologist and surgeon. Previus abdominal surgery does not constituite a contraindication to laparoscopic transperitoneal adrenalectomy

Role and outcomes of laparoscopic cholecystectomy in the elderly.

Introduction: Laparoscopic cholecystectomy is the standard of treatment for gallstones disease and acute colecystitis. The prevalence of this disease increases with age and the population is aging in industrialized countries. So, in this study we report our experience in the treatment of gallstone disease in elderly patients, particularly analyzing the outcomes of laparoscopic approach. Methods: Between January 2010 and May 2014 we performed a total of 1227 cholecystectomies. In this retrospective study age group was the primary independent variable: 351 patients were 65-79 years of age and 65 were 80 years of age or older. Results: Only 65 patients (5.3%) of all population had primary open cholecystectomy, but the rate in young group was 3.7% respect the highest frequency (9.2%) in the elderly group. The conversion rate was higher (1.2%) in the older group but there was no significant difference with younger group. LC in emergency setting was performed in 10.3% of young patients and in 13.8% of elderly group. Conclusion: Laparoscopic cholecystectomy is a feasible and safe procedure in elderly patients and might be performed during the same hospitalization like definitive treatment of gallstone disease. The old age and subsequent comorbidity are the fundamental predictor of surgical outcomes. Elective treatment should be recommended when repeated gallstone symptoms have occurred in the elderly patient before the development of acute cholecystitis and related complications

Whipple's pancreaticoduodenectomy: Surgical technique and perioperative clinical outcomes in a single center

Introduction: Pancreatic cancer is the fourth cause of death from cancer in Western countries. The radical surgical resection is the only curative option for this pathology. The prevalence of this disease increases with age in population. The causes of pancreatic cancer are unknown, but we consider risk factors like smoke and tobacco usage, alcohol consumption coffee, history of diabetes or chronic pancreatitis. In this study we report our experience in the treatment of resectable pancreatic cancer and periampullary neoplasms with particular attention to evaluate the evolution of surgical technique and the clinical postoperative outcomes. Methods: In our Department between January 2010 and December 2014 we performed a total of 97 pancreaticoduodenectomy. We considered only resectable pancreatic cancer and periampullary neoplasms defined by absence of distant metastases, absence of local tumor extension to the celiac axis and hepatic artery as the lack of involvement of the superior mesenteric vasculature. None of these patients received neoadjuvant chemotherapy. Results: The mean age of these patients was 64.5 years. Jaundice was the commonest presenting symptom associated to anorexia and weight loss. The mean operative time was 295min (±55min). The mean blood loss was 450ml and median blood transfusion was 1 units. 12.1% of patients had an intra-abdominal complication. The commonest complication was Delayed Gastric Emptying responsable of increased length of hospital stay and readmission rate. Postoperative pancreatic fistula of grade C occurred in 4 patients. 2 patients developed a postpancreatectomy hemorrhage. Perioperative mortality was 4.1%. Conclusion: Pancreaticoduodenectomy is a complex surgical technique and the associated high morbidity and mortality resulted in initial reluctance to adopt this surgery for the management of pancreatic and periampullary tumors. Surgical outcomes of pancreatic surgery are better at high-volume experienced center reporting mortality rates below 5%. We perform an end-to-side duct-to-mucosa pancreaticojejunostomy with routinely use of internal pancreatic stent. However no one technique has been shown to definitely be the solution to the problem of postoperative pancreatic fistula. At our center we have a reasonable volume and our data are comparable to literature data

Primary umbilical endometrioma: Analyzing the pathogenesis of endometriosis from an unusual localization

Objective: This report presents a rare case of symptomatic primary umbilical endometriosis and reviews the literature on the topic with the aim to clarify some questions on the origin of endometriosis. Case Report: A 33-year-old woman with cyclic umbilical bleeding was found to have umbilical endometriosis. She had no history of pelvic or abdominal surgery. There was no past history of endometriosis or endometriosis-associated symptoms. An omphalectomy was performed after explorative laparoscopy to carefully inspect the abdominopelvic cavity and assess any coexisting pelvic endometriotic lesions. Histological examination confirmed the diagnosis of umbilical endometriosis. Conclusion: Umbilical endometriosis is a rare but under-recognized phenomenon. Primary lesions are difficult to recognize, but probably represent an independent nosological entity. The possibility of endometriosis must be considered during the evaluation of an umbilical mass despite the absence of previous surgery. Complete excision and successive histology are highly recommended

Right diaphragmatic injury and lacerated liver during a penetrating abdominal trauma: case report and brief literature review.

INTRODUCTION: Diaphragmatic injuries are rare consequences of thoracoabdominal trauma and they often occur in association with multiorgan injuries. The diaphragm is a difficult anatomical structure to study with common imaging instruments due to its physiological movement. Thus, diaphragmatic injuries can often be misunderstood and diagnosed only during surgical procedures. Diagnostic delay results in a high rate of mortality. METHODS: We report the management of a clinical case of a 45-old man who came to our observation with a stab wound in the right upper abdomen. The type or length of the knife used as it was extracted from the victim after the fight. CT imaging demonstrated a right hemothorax without pulmonary lesions and parenchymal laceration of the liver with active bleeding. It is observed hemoperitoneum and subdiaphragmatic air in the abdomen, as a bowel perforation. A complete blood count check revealed a decrease in hemoglobin (7 mg/dl), and therefore it was decided to perform surgery in midline laparotomy. CONCLUSION: In countries with a low incidence of inter-personal violence, stab wound diaphragmatic injury is particularly rare, in particular involving the right hemidiaphragm. Diaphragmatic injury may be underestimated due to the presence of concomitant lesions of other organs, to a state of shock and respiratory failure, and to the difficulty of identifying diaphragmatic injuries in the absence of high sensitivity and specific diagnostic instruments. Diagnostic delay causes high mortality with these traumas with insidious symptoms. A diaphragmatic injury should be suspected in the presence of a clinical picture which includes hemothorax, hemoperitoneum, anemia and the presence of subdiaphragmatic air in the abdomen

Three-dimensional (3D) versus two-dimensional (2D) laparoscopic adrenalectomy: A case-control study

Laparoscopic adrenalectomy is today considered the gold standard of treatment for adrenal tumors. The development of high definition cameras does not eliminate the major limitation of two-dimensional (2D) laparoscopy: lack of depth perception and loss of spatial orientation. Tree-dimensional (3D) HD laparoscopy was developed as an alternative to conventional 2D laparoscopy

Laparoscopic, three-port and SILS cholecystectomy: a retrospective study.

Introduction. The aim of this study was to compare the results of classic laparoscopic, three-port and SILS cholecystectomy. Materials and methods. We conducted a retrospective study of da- ta collected between January 2010 and December 2012 pertaining to 159 selected patients with symptomatic gallstones. 57 underwent lapa- roscopic cholecystectomy, 51 three-port cholecystectomy and 48 SILS cholecystectomy. We then compared the groups with respect to mean ope- rating time, intraoperative complications, postoperative pain, duration of hospitalization and final aesthetic result. Introduction The first laparoscopic cholecystectomy was carried out in 1987 in France by Philippe Mouret (1). The progressive evolution of the technique has led this procedure to be- come the gold standard in the treatment of symptoma- tic gallstones (2). As the technology improved, many sur- geons began to reduce the number and size of the ports with the aim of achieving ever lower invasiveness, con- sequently reducing trauma and postoperative pain and improving the cosmetic results. There was thus a pro- Results. The mean operating time was significantly higher in the SILS cholecystectomy group (93 minutes) than in the other two groups. There were no intraoperative complications. There were no significant differences in the duration of hospitalization among the three groups. Patients in the SILS cholecystectomy group reported significantly less pain 3, 6 and 12 hours after surgery. The aesthetic results at 1 and 6 months’ follow-up were also decidedly better. Conclusions. On the basis of this study, SILS cholecystectomy is a feasible, safe procedure. In any case, it should be used in selected patients only and carried out by a dedicated team with strong experience in laparoscopy. The main advantages of this technique are a reduction in post-operative pain and improved aesthetic result, at the price, howe- ver, of its greater technical difficulty and longer operating times. Future studies are in any case necessary to evaluate any other benefits of this method

Adrenal gunshot wound: Laparoscopic approach. Report of a case.

introduction: Although there is no debate that patients with peritonitis or hemodynamic instability should undergo urgent laparotomy after penetrating abdominal injury, it is also clear that certain stable patients may be managed without operation. Controversy persists regarding use of laparoscopy. PRESENTATION OF CASE: We report a case of gunshot wounds with bullet in left adrenal gland and perirenal subcapsular hematoma. The patients had no signs of peritonitis but in the observation period we noted a significative blood loss, so we performed an exploratory laparoscopy. DISCUSSION: We found the bullet in adrenal parenchyma. The postoperative period was regular and the patient was discharged without any local or general complication. CONCLUSION: Although the data are still controversial, the importance of the laparoscopic approach is rapidly increasing also in case of penetrating trauma of the abdomen. This technique assumes both a diagnostic and therapeutic role by reducing the number of negative laparotomie

DUODENAL ADENOCARCINOMA: A CASE REPORT

Objective: Cancers of the small intestine are rare pathologies. They occur with vague and unspecific symptoms and cause many problems in differential diagnosis. Methods: A 64-years-old man, smoker, suffered inappetence, nausea and vomit over about 20 days until the presence of melena led to his admission to our hospital. His history included diabetes mellitus and moderate alcohol intake. The objective examination showed a hard-inelastic swelling in epi-mesogastric region. Laboratory data showed an increase of leukocytes and elevated level of CA 19-9. Esophagogastroduodenoscopy showed a duodenal vegetans neoformation, subjected to examination biopsy and bacterial culture. Computed tomography scans showed a voluminous duodenal mass without safe plans of cleavage with the head of the pancreas. The biopsy results were not decisive for the presence of necrotic tissue. The microbiological culture was positive for Candida Glabrata mimicking an advanced mycotic abscess. Laparotomy revealed a palpable hard mass in duodenum. Cephalic duodenopancreatectomy was performed. Results: Postoperative period was regular. The patient resume eating during the sixth postoperative day and was discharged in good conditions. The final histological diagnosis was papillary moderately differentiated adenocarcinoma with expansive growth in duodenal wall. There was no lymph node involvement or distant organ metastasis. Conclusions: The duodenal tumors are rare pathologies. There is association with familial adenomatous polyposis, Cronh disease, alcohol abuse, smoking, peptic ulcer. Diagnosis is based on endoscopic and imaging techniques. The main prognostic factors are tumor stage, lymph node involvement and metastasis. When is possible we perform a radical approach reserving palliative treatment for advanced neoplasm