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Secondary achalasia due to submucosal invasion of cardia by gastric cancer is a rare condition. We report a case of pseudoachalasia, secondary to the involvement of gastroesophageal junction by poorly differentiated gastric cancer, initially mistaken as idiopathic form. We focus on the difficulty to establish differential diagnosis only on the basis of routine exams and we stress the necessity of “second level” instrumental exams; EUS in routine workup in selected patients should be considered. We support that routine workup based on history, clinical presentation, radiological and endoscopic findings, and certainly manometry could be insufficient for a correct differential diagnosis between primary and secondary forms in some patients.

Introduction. The aim of this study is to evaluate the incidence of appendiceal and pelvic endometriosis in a population with diagnosis of acute appendicitis in an emergency setting. Materials and methods. We carried out a retrospective study in the period between January 2010 and October 2013. We performed 429 appendectomy including 233 in female subjects (54.3%). In all patients of childbearing age, we did β-hCG urine test to rule out the presence of an extra-uterine pregnancy. Results. 127 of 233 patients received a laparoscopic approach (54.5%). The median age was 29 years-old (range 17-68). The diagnosis of appendiceal and/or pelvic endometriosis was performed in 10 patients (4.3%): 9 treated in laparoscopy and only 1 treated in open. In only one case was required conversion to open surgery. We diagnosed appendiceal endometriosis in 3 patients, pelvic endometriosis with consensual acute appendicitis in 5 cases, pelvic endometriosis in the absence of macroscopic changes of the appendix in one case, sigmoid endometriosis in one case. There were no intraoperative complications, wound's complications or intra-abdominal abscesses. Conclusions. In general female population with clinical, laboratoristic and instrumental diagnosis of acute appendicitis and without anamnestic suspicion of gynecological pathology, it is always good to consider the hypothesis of pelvic and/or appendiceal endometriosis. The laparoscopic approach should be considered the treatment of choice for these patients in an emergency setting.

Objective: Cancers of the small intestine are rare pathologies. They occur with vague and unspecific symptoms and cause many problems in differential diagnosis. Methods: A 64-years-old man, smoker, suffered inappetence, nausea and vomit over about 20 days until the presence of melena led to his admission to our hospital. His history included diabetes mellitus and moderate alcohol intake. The objective examination showed a hard-inelastic swelling in epi-mesogastric region. Laboratory data showed an increase of leukocytes and elevated level of CA 19-9. Esophagogastroduodenoscopy showed a duodenal vegetans neoformation, subjected to examination biopsy and bacterial culture. Computed tomography scans showed a voluminous duodenal mass without safe plans of cleavage with the head of the pancreas. The biopsy results were not decisive for the presence of necrotic tissue. The microbiological culture was positive for Candida Glabrata mimicking an advanced mycotic abscess. Laparotomy revealed a palpable hard mass in duodenum. Cephalic duodenopancreatectomy was performed. Results: Postoperative period was regular. The patient resume eating during the sixth postoperative day and was discharged in good conditions. The final histological diagnosis was papillary moderately differentiated adenocarcinoma with expansive growth in duodenal wall. There was no lymph node involvement or distant organ metastasis. Conclusions: The duodenal tumors are rare pathologies. There is association with familial adenomatous polyposis, Cronh disease, alcohol abuse, smoking, peptic ulcer. Diagnosis is based on endoscopic and imaging techniques. The main prognostic factors are tumor stage, lymph node involvement and metastasis. When is possible we perform a radical approach reserving palliative treatment for advanced neoplasm.

Objective: Laparoscopic adrenalectomy is today considered the gold standard treatment for all benign adrenal tumors. The aim of this study is to evaluate the results of laparoscopic adrenalectomy in a single centre. Methods: We reviewed clinical data on 32 adrenalectomies performed at our istitution from 2009 to 2012. The average age of patients was 47 years (range 38-68); 18 were men and 14 women. For the clinical analysis, patients were divided into the nonfunctioning tumor group (n = 20) and the functioning tumor group (n = 12). All operations were performed via transperitoneal lateral access. Results: All laparoscopic adrenalectomy were finished successfully and no open surgery was necessary. The median operative time and blood loss in two group were similar. Only in a case of non-functioning left adrenal mass we had a significative intraoperative blood loss managed via laparoscopy with hemostatic matrix. 3 patients with aldosteronoma became normotensive and no longer required postoperative blood pressure medications. 9 patients with Cushing adenoma had resolution or improvement of clinical signs during follow-up periods. In a case at definitive histological analysis we found an adrenocortical carcinoma treated with no capsular disruption during dissection. Conclusions: The results of this retrospective review document that laparoscopic adrenalectomy is a safe and effective treatment for functioning as well as and non-functioning adrenal tumors. Pre-operative workup plays a fundamental role in these diseases. Mere size should not be considered as a contraindication to laparoscopic approach in adrenal masses without signs of local invasion.