Duodenal metastasis from male breast cancer: a case report and review of the literature

<p>Abstract</p> <p>Introduction</p> <p>Breast cancer is the most frequent type of tumor and the second leading cause of death in women. Metastases are present in nearly 60% of cases at the time of diagnosis with the lymph nodes, skeleton, lungs, brain and liver as the most frequent sites of metastases. Gastrointestinal involvement is rare, present in only 10% of all the cases. There is a very low risk of developing breast cancer in men.</p> <p>Case presentation</p> <p>A 68-year-old man, with a past history of ductal breast cancer, presented with duodenal obstruction. Medical treatment was attempted without success, so he underwent surgery with subtotal gastrectomy and resection of the first portion of the duodenum. Histological examination showed a duodenal metastasis originating from the previous carcinoma of the breast. Five months after surgery, the patient is alive and well.</p> <p>Conclusion</p> <p>Gastrointestinal metastases should be considered in patients with a past history of breast cancer. Surgical treatment should be performed in patients who are symptomatic and in good general condition. To our knowledge this is the only case of a gastrointestinal metastasis from breast carcinoma in a man.</p

Upper limb artery segmental occlusions due to chronic use of ergotamine combined with itraconazole, treated by thrombolysis

<p>Abstract</p> <p>Background</p> <p>The ergotamine tartrate associated with certain categories of drugs can lead to critical ischemia of the extremities. Discontinuation of taking ergotamine is usually sufficient for the total regression of ischemia, but in some cases it could be necessary thrombolytic and anticoagulant therapy to avoid amputation.</p> <p>Case report</p> <p>A woman of 62 years presented with a severe pain left forearm appeared 10 days ago, with a worsening trend. The same symptoms appeared after 5 days also in the right forearm. Physical examination showed the right arm slightly hypothermic, with radial reduced pulse in presence of reduced sensitivity. The left arm was frankly hypothermic, pulse less on radial and with an ulnar humeral reduced pulse, associated to a decreased sensitivity and motility.</p> <p>Clinical history shows a chronic headache for which the patient took a daily basis for years Cafergot suppository (equivalent to 3.2 mg of ergotamine).</p> <p>From about ten days had begun therapy with itraconazole for vaginal candidiasis. The Color-Doppler ultrasound shown arterial thrombosis of the upper limbs (humeral and radial bilateral), with minimal residual flow to the right and no signal on the humeral and radial left artery.</p> <p>Results</p> <p>Angiography revealed progressive reduction in size of the axillary artery and right humeral artery stenosis with right segmental occlusions and multiple hypertrophic collateral circulations at the elbow joint. At the level of the right forearm was recognizable only the radial artery, decreased in size. Does not recognize the ulnar, interosseous artery was thin. To the left showed progressive reduction in size of the distal subclavian and humeral artery, determined by multiple segmental steno-occlusion with collateral vessels serving only a thin hypotrophic interosseous artery.</p> <p>Arteriographic findings were compatible with systemic drug-induced disease. The immediate implementation of thrombolysis, continued for 26 hours, with heparin in continuous intravenous infusion and subsequent anticoagulant therapy allowed the gradual disappearance of the symptoms with the reappearance of peripheral pulses.</p> <p>Conclusion</p> <p>Angiography showed regression of vasospasm and the resumption of flow in distal vessels. The patient had regained sensitivity and motility in the upper limbs and bilaterally radial and ulnar were present.</p

A drastic complex atheromatous aorta A case report

Aortic atherosclerosis is the most common disease of the aorta. More than 50% of the plaques thicker than 4 mm are located along the descending aorta. The complex morphology of the plaque, such as ulceration or the presence of thrombi, is associated with increased embolic risk. The increasing use of transesophageal echocardiogram has enhanced the recognition of aortic atheromas. We describe a case of a male patient with complex atherosclerotic disease involving the coronary vessels and descending aortic tract with some embolic complications

A drastic complex atheromatous aorta. A case report

Aortic atherosclerosis is the most common disease of the aorta. More than 50% of the plaques thicker than 4 mm are located along the descending aorta. The complex morphology of the plaque, such as ulceration or the presence of thrombi, is associated with increased embolic risk. The increasing use of transesophageal echocardiogram has enhanced the recognition of aortic atheromas. We describe a case of a male patient with complex atherosclerotic disease involving the coronary vessels and descending aortic tract with some embolic complications

Prospective randomized comparison of open versus laparoscopic management of splenic artery aneurysms: a 10-year study

Abstract BACKGROUND: The literature does not support the choice between open and laparoscopic management of splenic artery aneurysms (SAA). METHODS: We designed a prospective, randomized comparison between open and laparoscopic surgery for SAA. Primary end points were types of surgical procedures performed and clinical outcomes. Analysis was developed on an intention-to-treat basis. RESULTS: Fourteen patients were allocated to laparotomy (group A) and 15 to laparoscopy (group B). Groups displayed similar patient- and aneurysm-related characteristics. The conversion rate to open surgery was 13.3 %. The type of surgical procedure performed on the splenic artery was similar in the two groups: aneurysmectomy with splenic artery ligature or direct anastomosis was performed in 51 % and 21 % of patients in group A and in 60 % and 20 % in group B, respectively. The splenectomy rate was similar (14 % vs. 20 %). Postoperative splenic infarction was observed in one case in each group. Laparoscopy was associated with shorter procedures (p = 0.0003) and lower morbidity (25 % vs. 64 %, p = 0.045). Major morbidity requiring interventional procedures and blood transfusion was observed only in group A. Laparoscopy was associated with quicker resumption of oral diet (p < 0.001), earlier drain removal (p = 0.046), and shorter hospital stay (p < 0.01). During a mean follow-up of 50 months, two patients in group A required hospital readmission. In group B, two patients developed a late thrombosis of arterial anastomoses. CONCLUSIONS: Our study demonstrates that laparoscopy permits multiple technical options, does not increase the splenectomy rate, and reduces postoperative complications. It confirms the supposed clinical benefits of laparoscopy when ablative procedures are required but laparoscopic anastomoses show poor long-term results

Trattamento chirurgico dei GIST gastrici non metastatici: due casi significativi e revisione della letteratura

I tumori stromali del tratto gastrointestinale (GIST) rappresentano un capitolo della chirurgia oncologica ancora in evoluzione e devono essere affrontati secondo criteri prognostici e terapeutici specifici. Nel sospetto di GIST il chirurgo deve vagliare tutte le opzioni terapeutiche, considerando tuttavia l’impossibilità frequente di predirne il comportamento biologico e quindi l’aggressività. La presenza di un GIST deve essere sempre sospettata nel caso di pazienti con emorragia del tratto gastroenterico, nei quali non emerga una diversa patologia causale. La strategia chirurgica deve considerare che, rispetto ai più comuni adenocarcinomi, una resezione conservativa in queste neoplasie ha un suo razionale anche per quanto riguarda la radicalità. L’estensione della resezione può variare, in relazione alle caratteristiche volumetriche e di sede, da interventi estremamente demolitivi condotti per via “aperta” tradizionale all’asportazione con accesso video-laparoscopico e demolizioni settoriali. La linfoadenectomia non è indicata di principio per la bassissima probabilità di diffusione linfatica di queste neoplasie. Vengono discussi di seguito due casi clinici giunti alla nostra osservazione per emorragia gastrointestinale. Nel sospetto di GIST gastrico le pazienti sono state sottoposte ad asportazione chirurgica della neoplasia: nel primo caso si è proceduto a una gastrectomia polare superiore, indicata per la contiguità della massa con il cardias; nel secondo caso è stata eseguita una resezione parziale del fondo gastrico a comprendere la neoformazion

A proposito di un caso di neuroma d'amputazione della via biliare dopo colecistectomia laparoscopica

Presentiamo un caso di neuroma del dotto epatico comune insorto 5 anni dopo colecistectomia (laparoscopica, convertita in laparotomica). Il paziente, di 73 anni, è stato ricoverato per ittero ostruttivo e sottoposto ad ecografia, TC e colangiografia retrograda endoscopica che evidenziavano una massa di 1 cm a livello del dotto epatico comune determinante una stenosi dello stesso. L?esame istologico sul pezzo operatorio ha dimostrato trattarsi di neuroma del dotto epatico comune. Basandoci sull?analisi di questo e di altri 42 casi descritti in letteratura, abbiamo potuto delineare le seguenti caratteristiche del neuroma delle vie biliari: 1) esiste un intervallo di tempo variabile tra la colecistectomia e l?insorgenza dell?ittero (da 2 mesi fino a 40 anni); 2) l?incidenza è simile dopo colecistectomia laparoscopica o laparotomica; 3) generalmente il decorso post-operatorio dell?intervento primitivo non è esente da complicanze; 4) la possibilità di variazioni nella localizzazione a livello dell?albero biliare (dotto cistico, via biliare principale, vie biliari intraepatiche); 5) l?ittero come primo segno di presentazione clinica; 6) la necessità di una diagnosi istologica; e 7) il trattamento di scelta è la resezione del tratto della via biliare interessata e la ricostruzione mediante epaticodigiunostomia. English version We report a case of neuroma of the common hepatic duct arising five years after cholecystectomy (laparoscopic then converted in laparotomic). A 73-years-old patient was admitted for obstructive jaundice. Ultrasonography, TC and cholangiography showed a nodular lesion of the common hepatic of 1 cm in diameter, causing a regular and important stenosis of the main bile duct. Histologic examination demonstrated neuroma. By the analysis of this and 42 other previously published cases, the following features of bile duct neuroma were outlined: 1) variable interval between cholecystectomy and the onset of jaundice (2 months to 40 years); 2) the same incidence after laparoscopic or laparotomic cholecystectomy; 3) the generally complicated postoperative course after first surgical approach; 4) the various localizations on the biliary tree (cystic, main bile duct, intrahepatic ducts); 5) the circumstances of onset are almost the same (obstructive jaundice); 6) the histologic examination is mandatory for a correct diagnosis; and 7) the best treatment is resection of the bile duct tract involved in neuroma and reconstruction of biliary tree with hepaticojejunostomy

Appearance and rapid evolution of thoraco-abdominal intramural hematoma after TEVAR

Some studies consider the different physical properties of the stent graft when compared with the blood vessel on the basis of vascular lesions that may require further intervention. We present a case in which a patient developed an intramural hematoma at the distal landing of previous thoracic endovascular aortic repair (TEVAR) that required the relining with a flared prosthesis. During follow-up, we observed the appearance of more caudal hematoma. We decided to observe this lesion with close radiological controls. In order to prevent serious complication after the induction of TEVAR, accurate planning of the procedure is very important to study the impact of the prosthesis implanted in the cardiovascular system. In particular, oversize, radial forces and length of coverage have been taken into account. The adherence to follow-up is very important to precociously detect the lesions to avoid the onset of complication

Late open conversion after endovascular repair of abdominal aneurysm failure: Better and easier option than complex endovascular treatment

Aim: Conversion to open repair becomes the last option in case of endovascular repair of abdominal aneurysm failure, when radiological interventional procedures are unfeasible. While early conversion to open repair generally derives from technical errors, aetiopathogenesis and results of late conversion to open repair often remain unclear. Methods: We report data from our Institute’s experience on late conversion to open repair. Twenty-two late conversion to open repairs out of 435 consecutive patients treated during a 18 years period, plus two endovascular repair of abdominal aneurysms performed in other centres, are analysed. The indication for conversion to open repair was aneurysm enlargement because of type I, type III, type II endoleak and endotension. Even if seven cases (23%) had shown an initial aneurysmal shrinkage, in a later phase, the sac began to enlarge again. In 12 patients, conversion to open repair was the last chance after unsuccessful secondary endovascular procedures. Results: Three cases (12.5%) were treated in emergency. Aortic cross-clamping was only infrarenal in 10 cases, only or temporarily suprarenal in 14 and temporarily supraceliac in 9 cases, for 19 total and 5 partial endograft excisions. Two patients died for Multiple Organ Failure (MOF), on 42nd (endovascular repair of abdominal aneurysm infection) and 66th postoperative day. No other conversion to open repair-related deaths or major complications were revealed by followup post-conversion to open repair (mean: 68 months ranging from 24 to 180 months). Conclusion: Late conversion to open repair is often an unpredictable event. It represents a technical challenge: specifically, the most critical point is the proximal aortic clamping that often temporarily excludes the renal circulation. In our series, conversion to open repair can be performed with a low rate of complications. In response to an endovascular repair of abdominal aneurysm failure, before applying complex procedures of endovascular treatment, conversion to open repair should be taken into account