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We describe a case of a 30-year-old man who complained intermitted pain in right abdominal flank; a large cavernoumatos hemangioma - up to 6 cm in size - was revealed in the fifth hepatic segment using Ultrasonography and MRI (Magnetic Resonance Imaging). Indications for treatment - based on imaging features and clinical data - are briefly discussed in our report, providing also a review of existing literature.

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BACKGROUND: Neuroendocrine tumors are a group of rare neoplasms, and the pancreatic neuroendocrine tumors (PNETs) represent only 1-2% of all pancreatic malignant tumors. The most common sites of these tumors include the gastrointestinal tract, lung, adrenal gland, and thyroid gland. Moreover, the most common sites of PNET metastases are the lymph nodes, liver, spleen, and bone. A 40-year-old woman with pT3N1 PNET underwent surgical excision of the lesion (12 cm, at the level of the pancreatic body and tail). Postsurgical treatment included chemotherapy and radiation, both of which the patient showed a good tolerance for. After a 12-month disease-free interval, however, the patient reported the development of a lesion in her left breast and a small lesion in the left posterior region of her neck. The lesions were surgically excised, and the histological findings characterized both as pancreatic neuroendocrine metastatic poorly differentiated neoplasms (G3). A re-staging CT scan showed multiple metastases in the left axillary, clavicular, and latero-cervical lymph nodes, as well as diffuse osteolytic-osteoblastic bone metastases, almost mimicking the behavior of a primitive breast tumor. CONCLUSION: This case of breast and subcutaneous metastases from PNET should prompt awareness of potential metastatic lesions in unusual locations.

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Hepatic ischemia/reperfusion injury (IRI) is a clinical condition that may lead to cellular injury and organ dysfunction that can be observed in different conditions, such as trauma, shock, liver resection, and transplantation. Moderate levels of nitric oxide (NO) produced by the endothelial isoform of the NO synthase protect against liver IRI. GIT-27NO is a NO-derivative of the toll-like receptor 4 antagonist VGX-1027 that has been shown to possess both antineoplastic and immunomodulatory properties in vitro and in vivo. In this study, we have investigated the effects of this compound in vitro, in a model of oxidative stress induced in HepG2 cells by hydrogen peroxide (H2O2), and in vivo, in a rat model of IRI of the liver. GIT-27NO significantly counteracted the toxic effects induced by the H2O2 on the HepG2 cells and in vivo, GIT-27NO reduced the transaminase levels and the histological liver injury by reducing necrotic areas with preservation of viable tissue. These effects were almost similar to that of the positive control drug dimethyl fumarate. These data suggest that the beneficial effect of GIT-27NO in the hepatic IRI can be secondary to anti-oxidative effects and hepatocyte necrosis reduction probably mediated by NO release.

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INTRODUCTION: Inguinal hernia may contain vermiform appendix in very rare cases. This particular condition is known as Amyand's hernia and it has an incidence of 1%. Diagnosis is very difficult preoperatively, so it is usually an incidental finding. PRESENTATION OF CASE: We report a case of a 80 year old man with an irreducible mass in right inguinal region. During surgical procedure an Amyand's hernia was identified and we performed hernioplasty sec Trabucco and appendectomy. DISCUSSION: According to Losanoff and Basson classification, our case was type 1 and its management is very controversial. CONCLUSION: Surgical treatment depends on surgeon's experience and on clinical evaluation because there are many factors that may increase morbidity and mortality.

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To evaluate whether, in a sample of patients radically treated for colorectal carcinoma, the preoperative determination of the carcinoembryonic antigen (p-CEA) may have a prognostic value and constitute an independent risk factor in relation to disease-free survival. The preoperative CEA seems to be related both to the staging of colorectal neoplasia and to the patient's prognosis, although this-to date-has not been conclusively demonstrated and is still a matter of intense debate in the scientific community. This is a retrospective analysis of prospectively collected data. A total of 395 patients were radically treated for colorectal carcinoma. The preoperative CEA was statistically compared with the 2010 American Joint Committee on Cancer (AJCC) staging, the T and N parameters, and grading. All parameters recorded in our database were tested for an association with disease-free survival (DFS). Only factors significantly associated (P < 0.05) with the DFS were used to build multivariate stepwise forward logistic regression models to establish their independent predictors. A statistically significant relationship was found between p-CEA and tumor staging (P < 0.001), T (P < 0.001) and N parameters (P = 0.006). In a multivariate analysis, the independent prognostic factors found were: p-CEA, stages N1 and N2 according to AJCC, and G3 grading (grade). A statistically significant difference (P < 0.001) was evident between the DFS of patients with normal and high p-CEA levels. Preoperative CEA makes a pre-operative selection possible of those patients for whom it is likely to be able to predict a more advanced staging.

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The aims of the present study were to: (1) assess surgical site infection (SSI) incidence in a cohort of surgical patients and (2) estimate the compliance with national guidelines for perioperative antibiotic prophylaxis (PAP). SSIs, among the most common health care-associated infections, are an important target for surveillance and an official priority in several European countries. SSI commonly complicates surgical procedures in older people and is associated with substantial attributable mortality and costs. The implementation of PAP guidelines is difficult among surgeons, and failure to comply with the standard of care has been widely reported. A 12-month prospective survey was performed in accordance with the methods, protocols, and definitions of the Hospital in Europe Link for Infection Control through Surveillance (HELICS) protocol. The compliance of the current PAP practices with the published national guidelines was assessed. A total of 249 patients were enrolled. The cumulative SSI incidence was 3.2 per 100 operative procedures. Cumulative compliance for PAP was 12.4%. Overall, only infection risk index ≥ 1 was confirmed as a significant risk factor for SSI (odds ratio, 6.65; 95% confidence interval, 1.04-42.59; P = 0.045). When only older patients (age >65 years) were considered, no significant risk factors for SSI were identified. Our study indicates an overall inadequate compliance with PAP recommendations, thus highlighting the need to develop multimodal and targeted intervention programs to improve compliance with PAP guidelines.

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Intraductal papillary mucinous neoplasms (IPMNs) represent a group of cystic pancreatic neoplasms with large range of clinical behaviours, ranging from low-grade dysplasia or borderline lesions to invasive carcinomas. They can be grouped into lesions originating from the main pancreatic duct, main duct IPMNs (MD-IPMNs), and lesions which arise from secondary branches of parenchyma, denominated branch-duct IPMNs (BD-IPMNs). Management of these cystic lesions is essentially based on clinical and radiological features. The latter have been very well described in the last fifteen years, with many studies published in literature showing the main radiological features of IPMNs. Currently, the goal of imaging modalities is to identify "high-risk stigmata" or "worrisome feature" in the evaluation of pancreatic cysts. Marked dilatation of the main duct (>1 cm), large size (3-5 cm), and intramural nodules have been associated with increased risk of degeneration. BD-IPMNs could be observed as microcystic or macrocystic in appearance, with or without communication with main duct. Their imaging features are frequently overlapped with cystic neoplasms. The risk of progression for secondary IPMNs is lower, and subsequently an imaging based follow-up is very often proposed for these lesions.

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MATERIAL OF STUDY: We report a case of a 66-year-old man with a gastric schwannoma incidentally discovered during the treatment of a colon cancer. At the pre-operative computed tomography performed for the stadiation of the colonic tumor was incidentally noted the presence of a nodular tumor between the liver and the gastric wall. RESULT: A wedge resection of this gastic tumor and the surgical resection of the left colon were performed all at once. The pathological examination of the gastric neoplasia revealed a picture consistent with gastric schwannoma. DISCUSSION: Gastrointestinal schwannomas are difficult but not impossible to diagnose preoperatively although they are often asymptomatic and radiologic findings are often nonspecific. Radiological features of Gastrointestinal schwannomas described in literature are reviewed. CONCLUSIONS: The treatment of choice is complete surgical excision with free margins because of diagnostic uncertainty, and the long-term outcome is excellent as these lesions are uniformly benign.

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BACKGROUND: The persistent patency of the urachus after birth is a rare anomaly, especially because most of the cases are asymptomatic. The guiding symptom for urachal-umbilical sinus and urachal cyst is the presence of umbilical discharge. Even if today we tend to laparoscopic treatment, in scientific literature there is still no evidence, because the reports are rare and often they are clinical cases. METHODS: Thirteen patients with a symptomatic urachal pathology were evaluated; 12 of these were affected by umbilical discharge and 1 by periumbilical discomfort. Five of 13 were prospectively treated by laparoscopy and the remaining 8 patients, who had been previously treated with conventional surgery, formed the control group. The authors report the laparoscopic technique used, which allowed the complete excision of the urachus. RESULTS: The operation time was lower for the patients treated by conventional surgery (71.9 minutes versus 101 minutes; P=.002), whereas the control pain (P=.05) and, above all, the excised urachus length (11.6 versus 8.7 cm; P=.03) were in favor of the patients treated by laparoscopic surgery. We registered only one recurrence in a patient treated by conventional surgery. CONCLUSION: In the rare international scientific literature, only one study report comparative data, as our study. The results that we obtained seem to be in favor of the laparoscopic procedure, although prospective, randomized trials are needed to get stronger evidence.

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AIM: Haemorrhoids are the most common surgically-treated gastrointestinal disorder. Complications of this surgery are generally non-neoplastic. Because rectal tumours usually present demonstratively during endoscopic examination, it is perhaps tempting to omit histopathologic examination after haemorrhoidectomy, especially in younger patients. METHODS: The AA present a case of an early rectal carcinoid discovered after surgical treatment of haemorrhoids in a 27 years old man as an example of why it is essential to send all such specimens in the pathologist. RESULTS: The detection of early lesions permits the adequate follow-up necessary to preclude more extensive surgery and eventually to prevent recurrence of tumour. CONCLUSION: All tissue resected by haemorrhoidopexy must be sent to the pathology laboratory to protect the life and health of the patient .

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Deep endometriosis is a subserosal growth (for more than 5 mm) of funzional endometrial tissue outside the uterine cavity. Authors report two clinical cases of intestinal endometriosis localized in the anterior wall of the rectum and in the last ileal loop. Both cases were characterized by sub-occlusive symptoms, diagnosis performed by laparoscopy and surgical resection. Authors focus the various pathogenetic theories and dwell itself on the symptomatology often characterized by nonspecific abdominal symptoms such as chronic abdominal pain, sometimes in relation to the menstrual cycle, and intestinal disorders. If rectal bleeding is rare, more frequent are dysmenorrhea, dyspareunia and infertility may occur in up to 50% of patients. The diagnosis of intestinal endometriosis is very difficult and can be made by radiological methods (CT or MRI) or by endoscopic ultrasound only for the rectal localization but nowadays often the diagnosis is due to laparoscopic techniques. In the absence of guidelines the surgical therapy is not well defined. When is not necessary surgical emergency, according to the depth of endometriotic infiltration, elective surgery includes several surgical techniques both conservative and extensive such as segmental intestinal resection with hysterectomy and ovariectomy. In the most recent literature, finally, are reported over 50% of pregnancies after surgery

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Echinococcosis is a cyclozoonosis characterized by cystic lesions usually situated inside or outside the liver. We discuss the case of a 77-year-old woman with a recurrent hydatidosis with a cyst arising from the liver, growing through the lateral right abdomen wall, and reaching the subcutaneous tissue of the lumbar region. In the literature, rare subcutaneous or muscular localizations of hydatid cysts are described, however, there is no mention of a cyst growing over the abdominal wall muscles, shaped like an hourglass, partially in the liver and partially in the subcutaneous tissue, as in our case. We have not found any pathogenetic explanation for this growth pattern which is not typical of the biological behaviour of a hydatid cyst.

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Over the past 2 decades the surgeon and the hospital where he or she works have been considered to play an important role in the prognosis of the rectal cancer patients. The rate of sphincter-sparing rectal resection, local recurrence and survival are the factors more frequently utilized in the literature to evaluate if surgeons are able to affect the natural history of the rectal cancer. The quantitative aspect, high volume of the surgeon, is not enough but in order to achieve better results in the treatment of rectal cancer a specific interest in colorectal surgery is more important. While retrospective studies show a positive influence of the surgeon on the prognosis of these patients, prospective studies are very few so that we need to get more data to reach valid conclusions. The high number of rectal cancer patients does not allow a centralization of these patients into specialist Units, but we should get up everywhere colorectal programmes so that every department can reach a high standard of efficiency.

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