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Abstract Background Distant spread from breast cancer is commonly found in bones, lungs, liver and central nervous system. Metastatic involvement of peritoneum and retroperitoneum is unusual and unexpected. Case presentation We report the case of a 67 year-old-woman who presented with gastrointestinal symptoms which revealed to be the clinical manifestations of peritoneal and retroperitoneal metastatic spread of an invasive lobular breast cancer diagnosed 15 years before. Conclusion To the best of our knowledge, the case presented is the third one reported in literature showing a wide peritoneal and extraperitoneal diffusion of an invasive lobular breast cancer. The long and complex diagnostic work up which led us to the diagnosis is illustrated, with particular emphasis on the multidisciplinary approach, which is mandatory to obtain such a result in these cases. Awareness of such a condition by clinicians is mandatory in order to make an early diagnosis and start a prompt and correct therapeutic approach.

The advent of laparoscopic surgery has created a set of peculiar morbidities. As the laparoscopic devices, also the type of retained foreign bodies has changed. We present a case of unusual, apparently isolated and recurrent lung abscess, pleural effusion and poorly evident subphrenic abscess after laparoscopic gastric bypass, due to a retained Endo-Catch bag. A 27-year-old obese female underwent an uneventful laparoscopic Roux-en-Y gastric bypass. After sugery she developed a left basal lung abscess, that resolved in two weeks with heavy antibiotic therapy, while radiological abdominal imaging was apparently normal. Patient was discharged on p.o. day 30. After two months, she presented with fever and dyspnoea and no gastrointestinal complaints. Chest and abdominal computer tomography showed a left recurrent abscess with effusion but this time a 3 cm subphrenic mass with metallic clips inside was demonstrated on CT scan. Patient was treated with an explorative laparoscopy that identified an Endo-Catch bag with the jejunal blind loop inside. Postoperative left lung abscess can be a warning of a suphrenic surgical complication. Laparoscopic surgery requires even more attention to retained foreign bodies due to the reduced visibility of the surgical field. The recommendation to enforce recording of laparoscopic maneuvers is mandatory. [ABSTRACT FROM AUTHOR]

Background: Distant spread from breast cancer is commonly found in bones, lungs, liver and central nervous system. Metastatic involvement of peritoneum and retroperitoneum is unusual and unexpected. Case presentation: We report the case of a 67 year-old-woman who presented with gastrointestinal symptoms which revealed to be the clinical manifestations of peritoneal and retroperitoneal metastatic spread of an invasive lobular breast cancer diagnosed 15 years before. Conclusion: To the best of our knowledge, the case presented is the third one reported in literature showing a wide peritoneal and extraperitoneal diffusion of an invasive lobular breast cancer. The long and complex diagnostic work up which led us to the diagnosis is illustrated, with particular emphasis on the multidisciplinary approach, which is mandatory to obtain such a result in these cases. Awareness of such a condition by clinicians is mandatory in order to make an early diagnosis and start a prompt and correct therapeutic approach. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Venous thromboembolism (VTE) is a severe preventable disease; HIV-infection represents a prothrombotic condition, because of specific factors due to the virus itself, the host response and the antiretroviral therapy. Our aim is to raise awareness of thromboembolic risk when dealing with HIV-positive patients presenting to the Emergency Department for treatment of injuries, even though small. CASE REPORT: We present a case of a 33-year-old woman suffering from HIV-infection who presented to the Emergency Department with two small stab wounds. Laboratory tests and radiologic examinations were normal. About 8 hours after admission the patient developed a syncopal attack: a CT scan performed after he-modynamic stabilization revealed a massive pulmonary embolism (PE); the patient was then transferred to the Intensive Care Unit and treated with systemic thrombolysis. CONCLUSIONS: This case confirms that HIV-positive patients carry a higher risk for VTE and PE compared to general population, similarly to patients suffering from cancer: emergency physicians must be aware even in case of minor wounds. [ABSTRACT FROM AUTHOR]

Aim: The management of open abdomen with enteroatmospheric fistula is a real nightmare for surgeons; negative pressure with fluid instillation is affordable and effective. After improvement of general conditions, a good strategy for promoting tissue granulation around the fistula could be the application of a matrix wound dressing., Materials and Methods: A 45-year-old man was admitted to our Emergency Department for abdominal compartment syndrome following a previous intervention for bowel occlusion; at exploration we found a frozen abdomen that was managed by negative pressure wound therapy with fluid instillation (AbThera  device, VAC Instill , 3M+KCI). The condition was complicated by an enteroatmospheric fistula that we managed by negative pressure and fistula diversion according to "Baby Bottle Nipple VAC technique". After improvement of general and local conditions, in order to obtain a faster reepithalization around the stoma, we decided to apply a dermal substitute (Integra  Bilayer Wound Matrix, LifeSciences Corporation)., Results: We obtained a good reeepithalization and five months after admittance the patient was dismissed in a good health with a stoma bag applied on the fistula. Six month lather bowel continuity was restored., Conclusions: The role of negative pressure with instillation in the management of open abdomen is defined; it allows to preserve healthy bowel integrity and to improve septic environment control. If an enteroatmospheric fistula is present, the application of a dermal substitute can be a good strategy for promoting tissue granulation around the fistula, thus allowing the application of a stoma bag and a faster regain of the upright position., Key Words: Dermal Substitute, Enteroatmospheric fistula, Negative pressure Wound therapy, Open abdomen.

Background: Postoperative parotitis is a well known entity which can develop in patients who undergo major abdominal surgery., Methods: We present a case of postoperative parotitis which occurred after a laparotomy for incisional hernia repair., Results: After establishing diagnosis by ultrasonography assessment and blood chemical tests, patient was successfully treated by morphine discontinuing and antibiotics therapy., Conclusion: Beside sialolithiasis, sitting position or dehydratation we suggest that morphine could play a substantial role in the development of postoperative parotitis.

Aims and Background: To describe and discuss, on the basis of the authors' experience and a review of the literature, the main aspects regarding the etiology, diagnosis, treatment and prognosis of congenital tumors of the retrorectal space., Methods: We present 2 cases of congenital retrorectal tumors, a sacrococcygeal teratoma and a dermoid cyst, which represent, from the pathogenetic point of view, the most frequent presentation of the rare tumors of the retrorectal space., Results: The reported cases are typical. The teratoma presented as an encapsulated, mixed mass located in the pelvic cavity behind the rectum and the vaginal canal, without signs of sacral involvement. The dermoid cyst appeared as a unilocular lesion filled with sebum and hair, which extended laterally to the iliopubic branch, medially to the urethra and anal canal, and posteriorly to the adipose tissue of the right buttock. Pelvic MRI produced a precise picture of the extension of the lesion and of the relationship between the mass and the pelvic organs and surrounding bony structures. Both lesions were completely removed via the perineal approach without coccygectomy. No recurrences were observed at 2 years of follow-up., Conclusions: Congenital retrorectal tumors are rare. MRI is crucial for diagnosis and preoperative planning. Complete surgical removal is the treatment of choice. Resection of the coccyx is necessary only in case of its involvement by the neoplastic mass or suspected malignant transformation.

Purpose: The long-term results after stapled hemorrhoidopexy compared with Milligan-Morgan procedure are discussed., Methods: The clinical data of 100 patients treated by Milligan-Morgan procedure or stapled hemorrhoidopexy for fourth-degree hemorrhoids have been reviewed. All patients were visited and submitted to a questionnaire to evaluate resumption of symptoms, functional results, and recurrence rate., Results: The mean follow-up was 54 months for stapled hemorrhoidopexy and 92 months for the Milligan-Morgan procedure. Postoperative pain and return to normal activity were worse in the Milligan-Morgan procedure (Visual Analog Scale 8.56 vs. 5.46, P < 0.001; and 2.4 vs. 2 weeks, P value = 0.018). Eight percent of patients who had stapled hemorrhoidopexy complained of spontaneous pain or pain during defecation vs. 0 percent of patients who underwent the Milligan-Morgan procedure. We noted that there was bleeding in 14 percent of stapled hemorrhoidopexy vs. 0 percent of Milligan-Morgan procedure (P < 0.006), tenesmus in 32 percent of stapled hemorrhoidopexy vs. 0 percent of Milligan-Morgan procedure (P < 0.001), and pruritus in 4 percent of stapled hemorrhoidopexy vs. 0 percent of Milligan-Morgan procedure. Minor leakage was similar in the two groups. Flatus impaired control was less frequent in Milligan-Morgan. The relative risk of recurrence for stapled hemorrhoidopexy compared with Milligan-Morgan procedure was 1.18 (95 percent confidence interval 1< relative risk < 1.4). No statistical difference was noted in patients' satisfaction after the procedures., Conclusions: Long follow-up seems to indicate more favorable results in Milligan-Morgan procedure in terms of resumption of symptoms and risk of recurrence.

Background: Incisional hernias are one of the most frequent complications of open abdominal surgery. The incidence of relapses after a conventional repair procedure is higher in recurrent than in primary cases (30%-50% vs. 11%-20%). The laparoscopic approach can prevent the complications associated with the conventional approach when dealing with recurrent incisional hernias. The aim of this study was to evaluate the efficacy of laparoscopic treatment in such cases., Materials and Methods: We prospectively analyzed data from 41 consecutive patients with recurrent incisional hernias, who submitted to a laparoscopic repair procedure with an expanded polytetrafluoroethylene Dual Mesh (Gore-Tex Dual Mesh Plus Biomaterial; W.L. Gore 8 Associates) from December 2001 to December 2004. All of the patients underwent clinical follow-up at 1, 6, and 12 months and then yearly. An ultrasound scan of the abdominal wall was performed at 6 and 12 months after the procedure. The parameters considered for the analysis were: mesh size, operating time, hospital stay, postoperative complications, and recurrences., Results: The defects were usually localized along midline laparotomies. The mean mesh size was 400 cm2, the mean operating time was 68 minutes, and the mean length of hospital stay was 2.7 days. Complications were encountered in 17% of patients. The mean follow-up was 38 months (range, 18-54). Recurrence was reported in 1 case only (2.4%), which occurred within the first 6 months after the operation., Conclusions: The laparoscopic repair of recurrent incisional hernia seems to be an effective alternative to the conventional approach, as it can give lower recurrence and complication rates.

Background: Infection of polytetrafluoroethylene (ePTFE) prostheses for abdominal incisional hernia is a rare but serious complication that often makes meshes removal necessary. Instead serous collections (seromas) without signs of infection don't require surgical removal. Differential diagnosis between infected and non-infected fluid collections is difficult and sometimes impossible before surgical exploration., Methods: We describe a new sign observed in two patients who underwent abdominal computed tomography for evaluation of a fluid collection without clear signs of prosthesis infection, complicating abdominal wall repair for incisional hernia in which an ePTFE mesh was used. In both patients an alteration of the mesh profile was demonstrated on imaging, and in both patients prostheses resulted infected at surgical exploration and at microbiological examination after removal. The sign we observed is not evident in computed tomography images performed in cases of seromas., Conclusions: We discuss the possible mechanism of this finding and propose that this sign may be due to a "rejection" of the infected prosthesis from the surrounding neo-formed fibrous and inflammatory tissue.

Background and Objectives: Neoadjuvant chemotherapy is increasingly considered an effective treatment option for patients with gastric carcinoma. Aim of the study is to evaluate the prognostic significance of the pathological response and of known prognostic factors in a group of accurately staged locally advanced gastric cancer (LAGC) patients., Methods: Thirty-three patients with LAGC, staged by laparoscopy, underwent D2-gastrectomy after preoperative chemotherapy. Survival was calculated by Kaplan-Meier method and differences were assessed by the Log-rank and Breslow test. Multivariate analysis was performed using the Cox proportional hazard model in backward stepwise regression., Results: Curative resection (R0) was achieved in 81.8% of patients. A complete or subtotal pathological response was documented in 3 and 6%, respectively. Nineteen out of thirty-three (57.6%) patients were alive and 16 of them were free of relapse at last follow-up. Survival rates were 81, 67, and 59% at 12, 24, and 36 months, respectively. At univariate and multivariate analysis, only R0 resection was found to be an independent prognostic factor., Conclusions: In the current study, R0 resection is the most important prognostic factor for resectable LAGC; according to our results we feel encouraged to consider neoadjuvant chemotherapy a promising modality for increasing the R0-percentage of gastric carcinoma patients who could benefit from a curative surgery.

Introduction: Detensive laparotomy is the first choice treatment for abdominal compartment syndrome (ACS). Tension free closure of the abdominal wall with the use of prosthesis is a broadly diffused technique; the polypropylene and the ePTFE (expanded polytetrafluoroethylene--Goretex Dual Mesh) are the most commonly used materials., Materials and Methods: We report our experience on five patients affected by ACS submitted to detensive laparotomy and positioning of a wide Goretex Dual Mesh prosthesis., Results: In our initial experience ACS has been treated with success through detensive laparotomy and there were no complications related to the use of Goretex., Discussion: Even though limited, our initial clinical experience is favorable to the use of Goretex Dual Mesh as first choice material for reconstruction of the abdominal wall after detensive laparotomy for ACS.