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Handlebar hernia is a rare entity, mainly resulting from blunt abdominal trauma with a sudden deceleration mechanism. Diagnosis of handlebar at admission may be difficult because the rupture of abdominal wall layers often is not clinically recognized in the emergency department, which requires a high degree of suspicion to identify theses lesions. It is very important to rule out the presence of intra-abdominal injuries, and in adults, surgical repair is needed. Herein, the case of an adult man who presented to the emergency department with blunt abdominal trauma caused by a motorcycle handlebar is described.

The primary cutaneous B-cell lymphoma (PCBCL) is a rare neoplasm. It is believed that antigenic stimulation and chronic inflammation can be the basis of pathogenesis. Here, we report a case that to our knowledge is the first patient with a presentation of a PCBCL arising from a surgical scar, in particular, an inguinal hernioplasty. The case reminds us of the importance of raising clinical suspicion for malignant neoplasms in surgical scars, in particular, after mesh placement. MeSH terms: ‘lymphoma, large b-cell, diffuse’, ‘skin’ and ‘cicatrix’.

Ingestion of foreign bodies (FBs) is common and rarely has consequences for the patient, but sometimes it can originate gastrointestinal perforation and lead to devastating consequences if unrecognized. Therefore, whenever present, bowel perforation demands immediate surgical treatment. An 89-year-old woman with an incarcerated incisional hernia, whose imaging study was consistent with intestinal occlusion and perforation within the hernia sac was treated at our hospital. A segmental enterectomy and direct correction of the hernial defect were performed. A perforation in the mesenteric border due to a FB, which seemed to be a toothpick, was identified in the surgical specimen. Nine months after surgery, the patient was without complaints, with adequate healing, and without evidence of hernial recurrence. To the best of our knowledge, this is the first case of intestinal perforation on an incarcerated incisional hernia, due to an ingested FB, reported in the literature.

Meckel’s diverticulitis is an unusual cause of acute abdomen condition in adults requiring prompt surgical treatment. We report a case of a 53-year-old male with coronavirus disease 19 (COVID-19), admitted to the emergency department with an acute abdominal pain. A computed tomography scan with intravenous contrast performed on the patient confirmed an inflamed short segment of the small bowel and the presence of a localized free peritoneal fluid. The definitive diagnosis was made intraoperatively, by means of an emergent ileal resection with primary anastomosis, which confirmed Meckel’s diverticulitis. Postoperative evolution was ordinary. The association of COVID-19 with the acute abdomen is found to be weak, therefore surgical consultation is advised to minimize delayed treatment.

During laparoscopic cholecystectomy, gallbladder perforation may occur leading to gallstone spillage and despite being rare, early or late complications may therefore develop. We report a case of a 79-year-old female, with a past medical history of a laparoscopic cholecystectomy 3 years earlier for symptomatic gallstones, admitted in the emergency department with a subcutaneous right lumbar abscess confirmed by computed tomography. Emergent abscess surgical drainage was performed and a gallstone was identified during saline lavage. Postoperative evolution was unremarkable and follow-up within a year was uneventful. Split gallstones due to gallbladder perforation during laparoscopic cholecystectomy should be retrieved in order to reduce future complications.

Highlights • Inflammatory pseudotumor is a very rare benign neoplasm. • Definitive diagnosis is usually made only after surgery. • Mesenteric location is rare. • Surgical resection can cure the disease. • Close follow-up is advised to identify recurrences., Introduction Inflammatory pseudotumor (IP) is an uncommon benign neoplasm. It was first described in the lung but it has been recognized in several somatic and visceral locations. Mesenteric presentation is rare and its clinical presentation is variable but patients can be completely asymptomatic. Complete surgical resection is the only curable treatment. Rational follow-up protocols have not been established yet. Presentation of case A 57 years-old man, with no relevant comorbidities and completely asymptomatic, apart from a lump on the right hypochondrium, was submitted to surgical resection of a large mesenteric mass. The preoperative Computed Tomography suggested gastrointestinal stromal tumor as the most probable diagnosis. Definitive histological examination of the completely resected surgical specimen confirmed the diagnosis of IP. The patient has been on follow-up for four years, without no evidence of recurrence. Discussion The preoperative diagnosis of IP may be difficult to establish mainly due to the lack of a typical clinical presentation. It is a rare entity, particularly in the adult population. These two aspects make it easier to neglect this entity in the differential diagnosis of an abdominal mass on asymptomatic adults. Although there are no formal guidelines on follow-up, close follow-up seems to be advisable in these patients as recurrence is frequent. Conclusion IP should be present as a possible differential diagnosis in an abdominal mass. Complete excision of the lesion can be curable but close follow-up seems to be required.

Existen pocas publicaciones sobre el uso de terapia de presión negativa en heridas de cabeza y cuello, probablemente por la compleja configuración anatómica de estas áreas, que dificulta el lograr un correcto sellado. Presentamos el caso de un paciente con úlcera extensa de región frontal, con afectación ciliar y exposición ósea. Optamos por una estrategia de estimulación del crecimiento del tejido de granulación con terapia de presión negativa sobre la superficie ósea y posterior cobertura con un injerto cutáneo, logrando excelentes resultados. La utilización de adyuvantes a la terapia de presión negativa posibilitó un cierre eficaz en un área de dificil abordaje. El conocimiento previo de las complicaciones potenciales nos permitió llevar a cabo su profilaxis.

Abdominal actinomycosis is a rare infection and the non-recognition of this particular microorganism may led to a prolonged septic process and recurrent disease. We hereby present a case report of 53 years-old woman with a secondary peritonitis due to this microorganism and our option to perform a long course of penicillin derived antibiotics, after suture of a perforated gastric ulcer caused by a foreign body.

Highlights • This is a case report of an association of a c-Kit positive gastrointestinal stromal tumor and a hepatocellular carcinoma in a non-cirrhotic patient. • Attending to this unusual association and the relevance for clinical diagnosis and treatment, the authors decided to publish this case report., Introduction Gastrointestinal stromal tumors (GIST) are uncommon, potentially malignant tumors, that arise in the wall of the gastrointestinal tract. Up to 50% can develop metastasis, mainly in the liver, but the occurrence of synchronous primary liver tumors is a rare event in these patients. Presentation of case The authors report a case of the association of gastric GIST and hepatocellular carcinoma (HCC) in a non-cirrhotic liver in a 76 year-old patient. Discussion The appearance of an hepatic lesion in a GIST patient does not necessarily imply its secondary nature. Conclusion In diagnosed GIST patients, all efforts should be pursued to characterize synchronous hepatic lesions, in order to plan a correct and tailored treatment of the patients.

Nos países ocidentais tem-se observado um aumento alarmante da incidência do adenocarcinoma da junção esófago-gástrica. Com base em dados epidemiológicos e histopatológicos, estas neoplasias são classificadas em adenocarcinoma do esófago distal, adenocarcinoma juncional, ou verdadeiro carcinoma do cárdia, e adenocarcinoma subcárdico. Geralmente, a sua apresentação clínica ocorre em estádios avançados, logo, uma intervenção terapêutica precoce e ajustada apenas será possível através de um diagnóstico precoce, uma classificação uniformizada e um estadiamento rigoroso. A estratégia com intenção curativa deve ser multidisciplinar, mas a cirurgia permanece como tratamento de eleição, apesar da percentagem de resseção R0 estar longe da ideal. Estudos recentes parecem sugerir que um regime peri-operatório de quimioterapia, com ou sem radioterapia, diminui a recorrência loco-regional, melhorando a sobrevida dos doentes com carcinoma da junção esófago-gástrica ressecável. No entanto, perante adenocarcinomas irressecáveis ou com metástases à distância, a quimioterapia sistémica poderá ser a única opção terapêutica possível. Novos agentes quimioterapêuticos estão sob investigação com o intuito de aumentar a eficácia e reduzir a toxicidade destas combinações. Este trabalho de revisão tem como objetivo ajudar a clarificar algumas das controvérsias existentes na classificação, estadiamento e tratamento destes carcinomas, com especial destaque para as diferentes opções terapêuticas. In Western countries there has been an alarming rise in the incidence of gastroesophageal junction adenocarcinoma. Based on epidemiological and histopathological data, these tumors are classified as adenocarcinoma of the distal esophagus, junctional adenocarcinoma, or true carcinoma of the cardia, and subcardial adenocarcinoma. Commonly, his clinical presentation occurs in advanced stages, thus, an early and adjusted therapeutic intervention is only possible through an early diagnosis, a standardized classification and an accurate staging. The strategy with curative intent is most often multidisciplinary, but surgical resection remains the treatment of choice, despite the percentage of R0 resection being far from ideal. Recent evidence suggests that a perioperative regimen with chemotherapy, with or without radiotherapy, can reduce locoregional recurrence, improving survival of patients with resectable gastroesophageal junction carcinoma. However, in unresectable adenocarcinomas or with distant metastases, systemic chemotherapy may be the only acceptable treatment option. New chemotherapeutic agents are under investigation in order to increase the efficacy and to reduce the toxicity of these combinations. This review paper aims to help clarify some of the controversies in the classification, staging and treatment of these carcinomas, with special emphasis on the different therapeutic options.

Background/Aims: The putative influence of tumor location on the biologic behavior of gastric carcinomas remains controversial. The aim of this study was to investigate if carcinomas arising in the three types of gastric mucosa (cardia, fundus/body and antrum) have different clinical and pathologic profiles and carry a different prognosis. Methods: Three hundred and two patients with cardia or gastric carcinoma resected between 1984 and 1996 were retrospectively studied. Cases were divided in three groups according to tumor location: cardia (n = 80); fundus/body (n = 60); antrum (n = 162). The three groups were crosstabulated with clinic and pathologic parameters, such as age, sex, macroscopy, histology, desmoplasia, tumor size, depth of tumor wall penetration, nodal status, venous invasion and stage. Survival rates were calculated for the three locations according to the aforementioned parameters. Univariate survival analysis and Cox regression were performed for each location. Results: Cases from the cardia and fundus/body were similar and distinct from antrum cases according to macroscopy, tumor size, depth of wall penetration, venous invasion, nodal status and stage. Cases from fundus/body were similar to antrum cases and distinct from cardia cases according to gender and Laurén’s classification. An overall difference in survival between the three locations was observed (p = 0.006). Cumulative survival was better for patients with carcinomas in the antrum than in the cardia (p = 0.04) and in the fundus/body (p = 0.003); no significant differences were observed in survival between cardia and fundus/body carcinoma cases. Cox regression identified stage and venous invasion as prognostic factors for patients with carcinomas in the three locations. In the group of cardia tumors, older patients had a worse outcome and in the group of fundus/body carcinomas, large tumors were associated with a poorer survival. Conclusions: Our results show that cardia carcinoma and antrum carcinoma are distinct gastric carcinoma entities whereas fundus/body carcinoma shares some characteristics from both entities.

Background. Considerable controversy persists about the biological behavior of gastric stump cancer (GSC). The aim of this study is to clarify if this cancer is just another proximal gastric cancer or if it emerges as a distinctive clinicopathologic entity.Methods. This review of a prospectively collected gastric cancer database identified 73 patients with GSC in a single institution between January 1980 and June 2012 and compared them with 328 patients with proximal gastric cancer (PGC) and 291 patients with esophagogastric junction cancer (EGJC).Results. Patients with GSC were predominantly males. Eighty-three percent of GSC penetrated the subserosal or the serosal layers. The median number of lymph nodes retrieved in GSC patients was significantly lower than in PGC patients or in EGJC patients. Cumulative survival curves were not different between GSC, PGC, or EGJC patients. Unlike that observed in PGC and in EGJC, no significant differences in cumulative survival according to the TNM staging system were observed in GSC cases.Conclusions. The outcome of patients with GSC displayed significant differences when compared to those with other proximal gastric cancers concerning the lack of survival association with the TNM staging system. Therefore a more suitable staging system should be designed for these unique cancers.

Background: This study aimed to characterize the clinicopathological features and prognosis of early onset gastric carcinomas (EOGCs) in a sample of young Portuguese adults. Material and Methods: A subset of 415 patients submitted to gastric resection was divided into 2 groups: A – patients aged 45 years or less (n = 108), and B – patients older than 45 years (n = 307). The groups were compared for several clinicopathological features and the survival of the patients was analyzed by uni- and multivariate analysis. Results: The surgical resection rate was higher in young patients, in whom tumors more frequently displayed an ulcerative shape (p < 0.001) and diffuse/isolated cell-type histology (p < 0.001). In the elderly, the rate of vascular invasion was significantly higher (p = 0.002). Overall, the survival of young patients was higher than in the elderly (p < 0.001). Survival curves were higher in young patients, except for pT4 and pM1 cases. In the multivariate survival analysis, age (p < 0.001), depth of tumor invasion (p < 0.001), nodal status (p < 0.001), vascular invasion (p = 0.011) and distant metastases (p = 0.007) emerged as independent prognostic factors for gastric carcinoma. Conclusion: Young gastric cancer patients no longer present with more advanced disease than the elderly and, overall, survival is better in young patients.

Gastric necrosis is a rare entity mainly due to the rich collateral blood flow the stomach is supplied by. Acute gastric dilation is one of the described underlying causes, and although not fully understood, many potential alterations, such as vascular compression, herniation, volvulus, acute necrotizing gastritis, complications after abdominal surgery, anorexia, bulimia nervosa, trauma, exposure to caustic materials, diabetes, medications, infections, debilitating chronic illness, gastric outlet obstruction, aerophagia and acute pancreatitis have been described. In this report, we present a case of partial gastric ischemia with necrosis and consequent perforation of the lesser curvature of the stomach, as a result of gastric outlet obstruction due to pyloric stenosis. The patient underwent an emergency laparotomy. An atypical gastrectomy and a Heineke–Mikulicz pyloroplasty were performed. We emphasize the need for the quick recognition of this condition and for the urgent management because of the high mortality rate associated with undiagnosed gastric necrosis.

141 Background: Optimized survival in oesophageal squamous cell carcinoma (OSCC) depends on complete surgical resection: prognostic impact of well-standardized techniques and per operative management in experienced groups has proven to be a key aspect. Multimodal treatment (MT) options are still controversial but particularly important in locally advanced disease apparently allowing better resectability. We perform an early evaluation of a MT protocol in locally advanced OSCC. Methods: Survival and clinical response analysis of a cohort of pts selected between 01/01/2002 and 31/12/2007. Criteria: Locally advanced OSCC (T3/4); No distant metastases; Negative bronchoscopy; Age under 76y; No other known cancer; Surgical feasibility. Pts underwent a 5 week MT: Chemo – taxotere 20 mg/m2 IV, cysplatin 20 mg/m2 IV, 5-FU 425 mg/m2 iv (days 1,8,14,22 and 29); Radio- 40 Gy (days 1-5, 8-12, 14-19, 22-26 and 29-34) followed by surgery within 4 weeks. Results: 57 pts (38% of all admitted) 8 fem and 49 male, aged < 50y = 11, 51-65y = 30 and > 65y = 16. Response: Complete pathological remission = 13; Partial clinical response with downstaging = 15; Minimal / no clinical response = 14; Disease progression / no surgery: 15. From the 42 pts operated, an “en bloc” osophagectomy with extended lymphadenectomy was possible in 36. The overall mean follow-up for resected pts was 16.9 months (CI 95%: 10.9-22.8). The median survival was 18 months for resected patients (CI 95%: 8.7-27.3) in contrast with 7 for all candidates to MT. There was a statistically significant difference in the survival of the 4 groups divided according to their response to MT, with clear advantage of the complete pathological remission achievers. Conclusions: Short follow-up and series size does not allow definite conclusions. It seems nevertheless that only the group of full pathological remission and probably those that obtain a downstaging of their disease benefit from MT. Histopathological or molecular markers are required to identify target pts for neoadjuvant radio chemotherapy. No significant financial relationships to disclose.

To compare the natural history and course of acute diverticulitis in a younger age group with an older population and to evaluate whether younger patients should be managed differently.This study was a retrospective review of 157 patients treated with acute diverticulitis between January 1, 2004 and December 31, 2007. Diverticulitis was stratified according to the Hinchey classification. Patients were divided into 2 populations: group A ≤ 50 years (n = 31); group B50 years (n = 126). Mean patient follow-up was 15 mo.The median age was 60 years. A significantly higher proportion of patients in group B presented with complicated diverticulitis (36.5% vs 12.9%, P = 0.01). Recurrence was more frequent in group A (25.8% vs 11.1%, P = 0.03) and the mean time-to-recurrence was shorter (12 mo vs 28 mo, P = 0.26). The most severe recurrent episodes of acute diverticulitis were classified as Hinchey stage I and none of the patients required emergency surgery. In multivariate analysis, only age (P = 0.024) was identified as an independent prognostic factor for recurrence.Based on the results of this study, the authors recommend that diverticulitis management should be based on the severity of the disease and not on the age of the patient.

Introduction Gastric cancer is a heterogeneous disease, whose pathological and clinical patterns have changed in the last decades. In most western countries, decreases in incidence and mortality and a proximal migration have been reported. The clinical and pathological trends in an European country with high prevalence of gastric cancer were reviewed, based on the patients treated at a University Hospital. Methods Analysis of a prospective database with 1618 patients who underwent surgery for gastric cancer in the last 3 decades. The patients were divided in 3 groups according to decades and the cohorts were analyzed according to demographic, surgical and pathological factors. Results The mean age increased from 59.8 to 65.6 years. Antral tumors and intestinal cancer were the most frequent. The rate of complete resection increased as well as the percentage of total gastrectomies and D2-type lymphadenectomies. There was an increase both in early stage carcinomas and in surgically treated Stage-IV carcinomas. The median overall crude survival almost doubled from 14 to 22 months ( p = 0.003), but once stratified for stage, only in stage II patients could we observe a significant increase in survival time. (29–47 months; p = 0.047). Conclusion The proximal migration described for Western Europe was not observed and the intestinal-type carcinoma is still the most frequent. We are treating older patients, often with more advanced disease. In spite of an increasing surgical aggressiveness, the prognosis has only been significantly improved in Stage-II cancers. The prognosis for advanced cancer is still dismal, hence the need for effective adjuvant treatments.

Background C-reactive protein (CRP) has been used as an indicator of postoperative complications in abdominal surgery. Its short half-life makes it a reliable marker of the systemic inflammatory response secondary to a surgical procedure or to the appearance of complications, rapidly returning to normal values with the recovery of the patient. Aim To demonstrate the value of sequential serum determinations of postoperative C-reactive protein (CRP) and white blood cell counts (WBC) in the identification of increased risk of anastomotic leakage after colorectal surgery. Methods We reviewed the daily postoperative serum CRP and white blood cell counts in 173 patients who underwent surgery for colorectal disease with anastomosis, between January 2008 and October 2009. Patients with anastomotic leakage (Group A, n = 24) were compared to patients without leakage (Group B, n = 149). Patients with ongoing infections before surgery or with acquired postoperative infections other than leakage were excluded. Mean pre- and postoperative values of CRP and WBC were compared. Results The diagnosis of anastomotic leakage was made between the 4th and 11th postoperative day (POD; mean 7th POD). The daily average values of serum CRP were significantly higher in group A starting at the 2nd POD and remained significantly elevated until the diagnosis of leakage ( p = 0.003). The cut-off value of 140 mg/L on the 3rd POD maximized the sensitivity (78%) and specificity (86%) of serum CRP in assessing the risk of leakage. Comparison of postoperative serum WBC values did not show any significant differences between the two groups until the 6th POD. Conclusion According to these results, an early and persistent elevation of CRP after colorectal surgery with anastomosis, is a marker of anastomotic leakage. A cut-off value > 140 mg/L on POD3 maximizes sensitivity and specificity.

Brunner's gland hyperplasia is a very rare lesion of the duodenum, which is usually asymptomatic and diagnosed incidentally during upper gastrointestinal endoscopy. It can cause gastrointestinal bleeding but hemorrhagic shock is a rare clinical presentation of Brunner's gland hyperplasia. The authors present a case of a patient with hemorrhagic shock due to a bleeding Brunner's gland hyperplasia, treated by urgent laparotomy and polypectomy.

The HER-2/neu gene or c-erb B-2, localized on chromosome 17q, belongs to a family of tyrosine kinase receptors and shares extensive homology with the epidermal growth factor receptor. c-erb B-2 gene amplification and protein overexpression have been reported in several human cancers. The prognostic value of this genetic alteration in gastric carcinoma is far from being established. In the present study, formalin-fixed, paraffin-embedded gastric carcinoma tissues from 157 patients were evaluated for c-erb B-2 overexpression, by immunohistochemistry using a polyclonal antibody. c-erb B-2 expression was evaluated according to clinical and pathological parameters, and to the survival of the patients. Our results show that: (1) c-erb B-2 was overexpressed in 15.3% of gastric carcinoma cases; (2) c-erb B-2 overexpression was significantly more frequent in cardia (23.8%) and fundus/body (25.0%) carcinomas than in antrum (7.2%) carcinomas; (3) c-erb B-2 overexpression was significantly associated with venous invasion; (4) c-erb B-2 is a prognostic factor for gastric carcinoma.