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The complexity of cancer patients and the use of advanced and demolitive surgical techniques frequently need post-operatory ICU hospitalization. To increase safety and to select the best medical strategies for the patient, a multidisciplinary team has performed a new peri-operatory assessment, arising from evidence-based literature data. Verifying that most of the cancer patients, admitted to the intensive care unit, undergo major surgery with localizations in the supramesocolic thoraco-abdominal area, the team focused the attention on supramesocolic peridiaphragmatic cancer surgery. Some scores already in use in clinical practice were selected for the peri-operatory evaluation process. None of them evaluate parameters relating to the entire peri-operative period. In detail, only a few study models were found that concern the assessment of the intra-operative period. Therefore, we wanted to see if using a mix of validated scores, it was possible to build a single evaluation score (named PERIDIAphragmatic surgery score or PERIDIA-score) for the entire peri-operative period that could be obtained at the end of the patient’s hospitalization period in post-operative ICU. The main property sought with the creation of the PERIDIA-score is the proportionality between the score and the incidence of injuries, deaths, and the length of stay in the ward. This property could organize a tailor-made therapeutic path for the patient based on pre-rehabilitation, physiotherapy, activation of social assistance services, targeted counseling, collaborations with the continuity of care network. Furthermore, if the pre-operative score is particularly high, it could suggest different or less invasive therapeutic options, and if the intra-operative score is particularly high, it could suggest a prolongation of hospitalization in ICU. The retrospective prospective study conducted on 83 patients is still ongoing. The first data would seem to prove an increase of clinical complications in patients who were assigned a one-third score with respect to the maximum (16/48) of PERIDIA-score. Moreover, patients with a 10/16 score within each phase of the evaluation (pre, peri, and post) more frequently develop injuries. In the light of these evidence, the 29-point score assigned to our patient can be considered as predictive for the subsequent critical and fatal complications the patient faced up.

Although the second most common site of the accessory spleen is the tail of the pancreas, intrapancreatic accessory spleens (IPAS) are rarely recognized radiologically. When an accessory spleen is located in the pancreas, it may mimic a hypervascular pancreatic tumor. We report a case of intrapancreatic accessory spleen which radiologically (on TC) mimicked a neuroendocrine pancreatic tumor (PNET). It was not possible to be sure that the pancreatic nodule had no malignant potential; because of the close proximity to splenic vessel we performed en bloc resection of the spleen and distal pancreas. Postoperative course was uneventful. IPAS must be considered in the differential diagnosis of pancreatic tail tumors, particulary an asymptomatic small PNET; new and adequate diagnostic studies have demonstrated utility in defining these lesions. We review pertinent literature. KEY WORD: Intrapancreatic accessory spleen, Pancreatic neuroendocrine tumor.Sebbene il secondo sito più comune della milza accessoria sia la coda del pancreas, la milza accessoria intrapancreatica è raramente riconosciuta radiologicamente. Quando una milza accessoria si trova nel pancreas, può simulare un tumore pancreatico ipervascolare; riportiamo un caso che alla TC era diagnosticato come un tumore pancreatico neuroendocrino. Non potendo escludere la potenzialità maligna del nodulo pancreatico, è stata eseguita una spleno-pancreasectomia distale. Il decorso postoperatorio è stato regolare. La milza accessoria intrapancreatica deve essere considerata nella diagnosi differenziale dei tumori della coda del pancreas, in particolare un piccolo tumore neuroendocrino asintomatico; nuovi e adeguati mezzi diagnostici hanno dimostrato utilità nel definire queste lesioni; esaminiamo la letteratura pertinente.

Schwannoma is a benign neurogenic tumor originating from Schwann cells. These produce the myelin sheath that covers peripheral nerves that are often affected. This latter localization is extremely rare, and only a few case reports can be found in the medical literature. Studies have shown that approximately 0.5% to 5% of schwannomas are retroperitoneal, constituting 0.2% of adrenal incidental tumors. These usually present as incidental findings, nonsecreting adrenal masses in asymptomatic patients. Diagnosis of a schwannoma is based on detection of spindle cells with Antoni A and Antoni B regions in histological sections and positive staining for S-100 protein by immunohistochemical analysis. We report a case of an incidentally identified during an abdominal ultrasound examination with schwannoma localized in the left adrenal gland.

Background: TA-TMA is a life-threatening complication of hematopoietic cell transplantation (HCT), usually manifested as a combination of non-immune mediated hemolytic anemia, thrombocytopenia and end-organ dysfunction (renal, neurologic and/or hypertension). Reported mortality rates following TA-TMA are high (50-75%; Gavriilaki et al, Bone Marrow Transplantation 2017). It is more commonly associated with allogeneic HCT, however, may infrequently occur with autologous HCT. Traditionally, treatment for TA-TMA consisted in removing possible offending agents (calcineurin inhibitors, sirolimus) and/or instituting total plasma exchange (PLEX). These approaches have not resulted in significant improvement in the natural history of TA-TMA, with complete resolution in 12-20% of pts (Mulay et al, J Clin Apher 2015). Recent evidence of alternate complement pathway activation has been implicated in the pathophysiology of TA-TMA (Jodele et al, Blood 2013). Eculizumab (ECU) is an anti-C5 monoclonal antibody, approved for treatment of PNH and aHUS, which has been used anecdotally as treatment for TA-TMA. Most reports consist of pediatric patients. In this analysis, we evaluated consecutive cases of adult recipients of HCT who developed TA-TMA and have received ECU therapy at our institution. Methods: We reviewed electronic records of consecutive patients who presented with a diagnosis of TA-TMA (non-immune hemolytic anemia plus worsening thrombocytopenia and end-organ dysfunction) and were treated with ECU between 2015 and 2017 at our institution. Univariate and bivariate statistics were calculated for the sample; Fisher's exact tests and Wilcoxon rank sum tests were utilized to test for differences across groups. Results: Table 1 shows the baseline characteristics of these pts. A total of 15 pts were included in the analysis; 2/3 were female and the median age was 62. ECU was given according to the usual schedule for aHUS (900 mg IV weekly x 4, 1200 mg every other week starting on week 5). Median time from TA-TMA diagnosis to initiation of ECU was 2 days. All patients received prophylaxis for Neisseria meningitides with ciprofloxacin and antifungal prophylaxis at initiation of ECU. Three (20%) pts received PLEX prior to ECU. Seven (47%) patients were receiving tacrolimus at diagnosis, however, levels were not within toxic range (3.7-7.9 ng/mL). Median time post-HCT for development of TA-TMA was 135 days. Median LDH, hemoglobin, platelet count and creatinine at TA-TMA diagnosis were 1724 U/L, 7.3 g/dL, 33,000/mcL and 1.7 mg/dL, respectively. Ten (66.6%) patients had acute kidney injury and 7 (46.6%) pts had neurologic manifestations. Eight (53.3%) pts had evidence of GVHD concurrent with TA-TMA diagnosis. Ten (63.3%) pts developed systemic infections during their TA-TMA treatment. No pts developed meningitis or fungal infections. Median follow-up was 4.5 months after initiation of ECU. Eight (53.3%) patients had complete resolution of TA-TMA (i.e. resolution of hemolytic anemia, thrombocytopenia and end-organ damage), 4 of these 8 pts were recipients of autologous HCT. Median time to resolution was 98 days and median cumulative ECU dose was 10,200 mg (range 4800-36400mg). An additional 2 pts (13%) presented clinical improvement without complete resolution of TA-TMA. Mortality secondary to TA-TMA or its complications was 33%. Median time to death was 31 days. The most common cause of mortality were infectious complications. Median survival for the entire cohort was 130 days (range 6-833 days, Figure). LDH >1300 U/L; more than one organ involvement, allogeneic HCT, use of tacrolimus and early ( Conclusion: To our knowledge, this is the largest reported series of adult pts with TA-TMA who were treated with ECU. Treatment with ECU for TA-TMA is associated with higher rates of resolution and lower rates of cause-specific mortality than what has been previously reported with other approaches. We hypothesize that higher cumulative doses of ECU are warranted to achieve resolution of TA-TMA. A prospective study utilizing a more intensive schedule of ECU infusions is required to confirm such hypothesis. Based on our analysis, we conclude that ECU is an appropriate - and potentially better - option in the treatment of TA-TMA. Disclosures Skarbnik: Seattle Genetics: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Jazz Pharmaceuticals: Honoraria, Speakers Bureau; Genentech: Honoraria, Speakers Bureau; Abbvie: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Pharmacyclics: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Novartis: Honoraria, Speakers Bureau; Gilead Sciences: Honoraria, Speakers Bureau.

Ankle syndesmosis injuries are relatively frequent in sports, especially skiing, ice hockey, and soccer, accounting for 1 %-18 % of all ankle sprains. The evolution is unpredictable: When missed, repeated episodes of ankle instability may predispose to early degenerative changes, and frank osteoarthritis may ensue. Diagnosis is clinical and radiological, but arthroscopy may provide a definitive response, allowing one to address secondary injuries to bone and cartilage. Obvious diastasis needs to be reduced and fixed operatively, whereas less severe injuries are controversial. Nonoperative treatment may be beneficial, but it entails long rehabilitation. In professional athletes, more aggressive surgical treatment is warranted.

The new means and modalities of communication and information technologies have significantly revolutionized access to surgical education. The introduction of the Internet information highway into mainstream clinical practice as an information sharing medium offers a wide range of opportunities to healthcare professionals. High-speed Internet broadcasting allows the display of high-quality full-screen videos. Access to surgical procedures through the Internet already plays a major role in continuing medical education nowadays and will undoubtedly be gaining grounds in the future. WebSurg.com, the World Virtual University, a web-based surgical university, is dedicated to minimally invasive laparoscopic surgery. Using brand-new multimedia data, the electronic university provides thorough descriptions of over 150 procedures in minimal access surgery and 265 videos of surgical interventions. Such a teaching tool recreates all the prerequisites and requirements of a traditional School of Medicine, incorporating the manifold standpoints of world-renowned experts about specific topics and hands-on hints in various surgical specialities. Following the evolution of technologies, recent advances have made it possible to display items of Websurg.com on handheld devices (personal data/digital assistance also known as PDAs, Pocket PCs, and smart phones). Integrating all these elements into a unique World Virtual University, Websurg.com epitomizes the concept of a unified academic center providing teaching and tutorials administered by international experts. The Internet assuredly contributes to the worldwide diffusion of scientific information in an easy and user-friendly way.

Retroperitoneal sarcomas are rare neoplasms that account for only 1%-2% of all solid tumors and liposarcomas represent the most frequent histological type. We describe the case of a 44-year-old female with a retroperitoneal myxoid liposarcoma of 22 × 19 × 8 cm in size. The only symptoms were persistent pain and progressive tenderness of the abdomen lasting for two months. The mass was radically excised during laparotomy. CT and MRI were useful to clarify the site of origin of the tumor, relationships with other organs, and planning surgery but final diagnosis was based on histological findings. Here we review the literature about the challenging diagnosis, treatment, and prognostic factors of this disease.

Background: Surgical hemorrhoidectomy has a reputation for being a painful procedure. The aim of this study was to determine the efficacy and safety of a new procedure for surgical treatment of hemorrhoid disease. Study Design: From April 1998 to August 1998, 140 patients (83 men and 57 women) with an average age of 43.8 years (range 19 to 83 years) underwent hemorrhoidectomy using a circular stapler. Operative times, peri- and postoperative complications, mean hospital stay, assessment of the postoperative pain, period of incapacity for work, and functional results were collected. All patients were evaluated at 2 weeks, 2 months, and 18 months after operation. Results: The average length of the operation was 18 minutes (range 8 to 60 minutes). There were no perioperative complications. The postoperative complication rate was 6.4% (n = 9). Mean hospital stay was 36 hours (range 8 to 72 hours). Paracetamol was the only analgesic used. Eighty-three patients (59.3%) required analgesic for less than 2 days, 45 patients (32.1%) between 2 and 7 days, and 12 patients (8.6%) more than 7 days. No patients had anal wound care. One hundred four patients had professions. The period of incapacity for work was less than 3 days for 22 patients (21.1%), between 3 and 7 days for 13 patients (12.5%), between 7 and 14 days for 62 patients (59.6%), and more than 14 days for 7 patients (6.8%). At 18 months, 95.7% of patients were fully satisfied with the results, 3.6% were somewhat satisfied (n = 4), and 0.7% were unsatisfied. Conclusions: Treatment of hemorrhoids with a circular stapler appears to be safe, effective, and rapid, causing few postoperative complications and minimal postoperative pain. At 18 months, 95.7% of the patients were fully satisfied with the results.