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Background: Splenic rupture is an uncommon but potentially fatal complication of colonoscopy. Objectives: A case of splenic rupture during colonoscopy is reported and a review of literature is presented focusing the attention on evaluation of potential risk factors. Case Report: We report the case of a 77 years old man who developed splenic rupture during colonoscopy diagnosed with CT scan and treated with splenectomy. Results: More than 70 articles and more than 90 cases were found in the world literature; the review revealed that splenic rupture occurred more frequently in female, CT scan was the treatment was the referring diagnostic procedure in the large part of cases, splenectomywas the treatment of choice. On the other side none of the analyzed factor appeared as meaningful risk factors. Conclusion: The knowledge of this complication is the best tool to aid in early diagnosis. Evaluation of hemodinamic status and CT scan play remarkable roles to resolve to the correct management and splenectomy remains the option chosen in the most part of cases.

Background/Aims: Littoral cell angioma (LCA) is a rare primary vascular neoplasm of the spleen. A 54-year-old man was referred to our emergency department for abdominal pain. A CT scan showed multiple round hypodense lesions of various sizes throughout the spleen. The spleen was increased in volume. An MRI confirmed the lesion with a suspect of multiple angiomas vs. amartomas. The haematologists excluded any haematological disease. After a collegial discussion, we decided to perform laparotomic splenectomy. Histologically, the multiple lesions consisted in anastomosing vascular channels lined by plump cells. There was an increased number of dysmorphic megakaryocites inside the splenic parenchyma and along the tumour's border, known signs of extramedullary hemopoiesis, whose etiology in our patient was unexplained. To the best of our knowledge this is the third description of the association between littoral cell angioma and extramedullary hemopoiesis. LCA is a rare primary splenic vascular tumour that originates from the splenic littoral cells. The diagnosis of littoral cell angioma is confirmed histologically and on immunohistochemistry. This case report underlines the rarity of this type of benign splenic neoplams, but since the malignant potential of LCA, we recommend close clinical follow- up of patients with LCA of the spleen.

Liver resections are demanding operations which can have life threatening complications although they are performed by experienced liver surgeons. The parameter “Blood Loss” has a central role in liver surgery, and different strategies to minimize it are a key to improve results. Moreover, recently, new technologies are applied in the field of liver surgery, having one goal: safer and easier liver operations. The aim of this paper is to review the different principal solutions to the problem of blood loss in hepatic surgery, focusing on technical aspects of new devices.

Several studies have shown that there is a paucity of immune cells within the stroma of pancreatic adenocarcinoma, a very aggressive cancer with a median survival of about 18 months. A 65-year-old man presented with jaundice. Abdominal ultrasound revealed intra- and extrahepatic bile duct dilatation and a 45-mm diameter hypoechoic solid mass within the pancreatic head; a computed tomography scan excluded vascular infiltration and metastatic lesions. The patient received immunotherapy consisting of 6,000,000 IU human recombinant interleukin-2 administered subcutaneously twice a day for 3 consecutive days. Thirty-six hours after the last dose, he underwent a pylorus-preserving pancreatoduodenectomy. Because of the presence of high-grade dysplasia detected by intraoperative histological examination of a distal section, a spleen preserving total pancreatectomy was performed. The postoperative course was uneventful. The patient died 32 months after surgery because of local recurrence. Histopathology showed G3 pancreatic ductal adenocarcinoma infiltrating the anterior and posterior peripancreatic tissue, duodenal wall and intrapancreatic common bile duct, with sarcoma-like foci and a component of intraductal tumor involving the common bile duct. In the distal pancreas, widespread foci of pancreatic intraepithelial neoplasia (PanIN2-3) were found. The Ki-67 proliferation index was 16%. TNM staging was pT3 pN1 R1. Sections were immunostained for the T-lymphocyte marker CD3 and for the dendritic cell marker CD 1a. Intratumoral infiltration was high for CD1a+ cells and mild for CD3+ cells. Preoperative immunotherapy with interleukin-2 may contribute to massive stromal infiltration of immune cells in pancreatic adenocarcinoma. This may prolong the survival even in the presence of negative prognostic factors (age >65 years, tumor diameter >20 mm, Rl, tumor grade G3).

Hemangioma is a common benign tumor of the liver that is usually asymptomatic. If >4 cm (giant hemangioma), it could present symptoms related to bleeding, thrombosis, comsumptive coagulopathy, or adjacent abdominal organ compression. If symptomatic surgical treatment should be considered, liver resection as well as enucleation are considered. Recurrences after surgical resection are rare. We herein present a case of woman admitted to the emergency room for acute severe respiratory distress. She had undergone 2 surgical resections of liver hemangiomas. The respiratory syndrome, as showed by chest x-ray, computed tomography scan, and nuclear magnetic resonance imaging, was related to a recurrent giant multiple hemangioma, creating a prominent compression of right lung with left mediastinal shift and left heart dislocation. It resulted in pulmonary parenchymal compression associated with reduced chest wall compliance and increased pulmonary pressure. The patient was not eligible for surgical treatment because of the disease extension and her clinical conditions. She died 6 months later from respiratory insufficiency and hypercapnic coma. © 2006 Springer Science+Business Media, Inc.

Introduction. Blood loss and bile leakage are well-known risk factors for morbidity and mortality during liver resection. Bleeding usually occurs during parenchymal transection, and surgical technique should be considered an important factor in preventing intraoperative and postoperative complications. Objective. Many approaches and devices have been developed to limit bleeding and bile leakage. The aim of the present study was to determine whether a bipolar vessel sealing device allows a safe and careful liver transection without routine inflow occlusion, achieving a satisfactory hemostasis and bile stasis, thus reducing blood loss and bile leak and related complications. Patients and methods. A total of 50 consecutive patients (24 males, 26 females, with a mean age of 57 years) underwent major and minor hepatic resections using a bipolar vessel sealing device. A clamp crushing technique followed by energy application was used to perform the parenchymal transection. Inflow occlusion was used when necessary to control blood loss but not as a routine. No other devices were applied to achieve hemostasis. Results. The instrument was effective in 45 patients and failed to achieve hemostasis in 5 cases, all of whom had a cirrhotic liver. Median blood loss was 490 ml (range 100-2500 ml) and intraoperative blood transfusions were required in eight cases (16%). Mean operative time was 178 min (range 50-315 min). Inflow occlusion was necessary in 16 (32%) patients. The postoperative complication rate was 24%, with a postoperative hemorrhage in a cirrhotic patient. There was no clinical evidence of bile leak or procedure-related abdominal abscess. Conclusion. We conclude that the device is a useful tool in standard liver resection, achieving good hemostasis and bile stasis in patients with normal liver parenchyma, but its use should be avoided in cirrhotic patients.

Background: Bleeding is the main complication and cause of conversion during laparoscopic splenectomy (LS). We present the advantages of the LigaSure vessel sealing system added to the lateral approach for achieving safe vascular control. Methods: We performed 63 consecutive LS in a 3-year period using LigaSure in two affiliated university hospitals. We employed a right semilateral position technique with dissection of the spleen and vessel sealing using LigaSure. Forty-two patients had benign hematological disease, 19 had malignant disease, and two had splenic cysts. Results: A total of 58 LS were completed with five conversions due to hilar bleeding (three cases), difficult dissection (one), and massive splenomegaly (one). In all but five patients, blood loss was less than 100 ml. No transfusions were needed. There were five postoperative complications: portal thrombosis (one case), hemoperitoneum (two), surgical wound infection (one), and pleural effusion (one). Conclusions: The use of LigaSure, and the semilateral position, results in a gain of time and safety. Furthermore, average intraoperative bleeding is very low. © Springer Science+Business Media, Inc. 2006.

Morgagni-Larrey hernia is a congenital type of diaphragmatic hernia. It is quite uncommon, particularly when it occurs on the left side of the diaphragm. This is a report of a case of a large left-side diaphragmatic hernia through the foramen of Morgagni treated by laparoscopy. The hernia was repaired by incorporating and fixing a polypropylene double-filament mesh into the defect, leaving the sac in mediastinum. The patient recovered promptly after the hernia repair, and there was no recurrence or complaints 30 months after surgery. Our conclusion is that laparoscopically repairs of Morgagni hernias with a prosthetic material are a safe and effective treatment. A literature review also shows that laparoscopic techniques are the gold standard in diaphragmatic hernias repairs.

Gallbladder cancer is a relatively uncommon malignancy. Its presentation is similar to that of gallstone disease and sometimes with non-specific symptoms. Laparoscopic cholecystectomy has become the method of choice for removing the gallbladder in most benign conditions. Occasionally, unsuspected gallbladder carcinoma is encountered in association with laparoscopic cholecystectomy. Overall gallbladder cancers have a poor prognosis, despite surgery or adjuvant therapies. However, in selected cases, a favourable outcome can be expected and the less favourable predicted outcome can be improved. Management of patients with gallbladder cancer in different situations is discussed: gallbladder cancer noted post-operatively on final pathology, gallbladder cancer noted after removal of the gallbladder and opening of the specimen at the time of surgery, difficulty encountered at the time of dissection and resultant suspicion of gallbladder cancer, and diagnosis of extensive disease at initial placement of the laparoscope. (C) 2001 Harcourt Publishers Ltd.

Laparoscopic treatment of common bile duct (CBD) stones is gaining great acceptance worldwide, but actually it requires skills and technologies too expensive for a great part of general surgeons. So endoscopic removal of CBD stones before cholecystectomy is usually performed. Since 1991 in our department we started a policy of selective preoperative cholangiopancreatography (ERCP) in patients suspected for choledocholithiasis and waiting for laparoscopic cholecystectomy.