Acute Cholecystitis: Diagnostic Pitfall and Timing of Treatment

Objective: Cholelithiasis represents a very frequent health problem with higher prevalence in developed countries. The aim of this chapter is to underline, also by submitting our surgical experience, some diagnostic deceptions and the timing of treatment

Current Approaches in the Minimally Invasive Surgical Treatment of Adrenal Tumors

The use of imaging modalities and minimally invasive surgery plays an important role in the current management of adrenal tumors. Ultrasonography frequently allows for the incidental diagnosis of adrenal masses. The most frequent adrenal pathologies encountered are hypercortisolism (Cushing’s syndrome), primary hyperaldosteronism (Conn’s syndrome), and pheochromocytomas. Clinical presentation of these adrenal tumors can often be non-specific, or such lesions may present as “incidentalomas” in patients who undergo imaging for clinical reasons unrelated to the adrenal glands. Adrenal malignancy is suggested by morphologic characteristics found on imaging studies: increased size, irregular borders, local invasion, and large necrotic areas. The risk of malignancy increases for larger adrenal masses. Minimally invasive surgery has become the initial choice for the treatment of adrenal tumors with retroperitoneal and transperitoneal approaches. This chapter describes the surgical indications and compares the various minimally invasive surgical approaches for the therapeutic management of adrenal masses

Defining a Therapeutic Program for Recurrent Acute Pancreatitis Patients with Unknown Etiology

Aim To define a therapeutic program for mild-moderate acute pancreatitis (AP), often recurrent, which at the end of the diagnostic process remains of undefined etiology. Material and Methods In the period 2011-2012, we observed 64 cases of AP: 52 mild-moderate, 12 severe; biliary 39, biliary in alcoholic chronic pancreatitis 5, unexplained recurrent 20. The clinical and instrumental evaluation of the 20 cases of unexplained AP showed 6 patients with biliary sludge, 4 microlithiasis, 4 sphincter of Oddi dysfunction, and 6 cases that remained undefined. Results Among 20 patients with recurrent, unexplained AP at initial etiological assessment, we performed 10 video laparo cholecystectomies (VLCs), 2 open cholecystectomies and 4 endoscopic retrograde cholangiopancreatography/endoscopic sphincterotomies (ERCP/ES) in patients who had undergone previous cholecystectomy; 4 patients refused surgery. Among these 20 patients, 6 had AP that remained unexplained after second-level imaging investigations. For these patients, 4 VLCs and 2 ERCP/ES were performed. Follow-up after six months was negative for further recurrence. Conclusion The recurrence of unexplained acute pancreatitis could be treated with empirical cholecystectomy and/or ERCP/ES in cases of previous cholecystectomy

Acute Mild Moderate Unexplained Pancreatitis: Which Treatment?

Context Unexplained pancreatitis actually remain a diagnostic and therapeutic challenge. Objective The aim of this study is to define a possible therapeutic program for mild-moderate acute pancreatitis, most often recurrent, which at the end of the diagnostic process remain with an undefined etiology. Methods In the period 2011-2012 we observed 64 acute pancreatitis (AP): 52 mild-moderate and 12 severe AP. Etiological data: 39 biliary AP; 5 biliary AP in alcoholic chronic pancreatitis; 20 unexplained recurrent AP. At the end of the clinical and instrumental evaluation of the 20 unexplained AP, we had 6 patients with biliary sludge, 4 microlithiasis, 4 sphincter of Oddi dysfunction, 6 AP remain undefined. Results Among 20 patients with recurrent AP unexplained at the admission, we performed 10 videolaparocholecystectomies (VLC), 2 open cholecystectomies, 4 ERCP/ES in patients undergone to previous cholecystectomy, and 4 patients refused surgery. In particular in 6 patients with unexplained acute pancreatitis, 4 VLC and 2 ERCP/ES were performed. Follow up after 6 months was negative for further recurrence in all patients. Conclusion The recurrence of unexplained acute pancreatitis with a non predictable severity evolution is due to the persistence of the bilio-pancreatic flux obstacle, in most cases (80%) related to microlithiasis. After the complete diagnostic process which may exclude other causes, it is proposable to perform a cholecystectomy and/or ERCP/ES to define empirical in few cases