Stefano Gussago | Hopitaux Universitaires de Genève (original) (raw)

Papers by Stefano Gussago

HPB, 2024

Background: Recent metanalysis reported a higher risk of postoperative bleeding from pancreaticog... more Background: Recent metanalysis reported a higher risk of postoperative bleeding from pancreaticogastrostomy (PG) reconstruction following pancreaticoduodenectomy (PD). We aimed to evaluate incidence, risk factors and outcomes of hemorrhage from PG in a large single center experience.
Methods: We retrospectively evaluated all consecutive PDs performed over 11 years. PG reconstruction was performed according the double pursestring invaginated technique. Multivariate logistic regression analysis was performed to identify risk factors for PG bleeding.
Results: During the study period, 695 consecutive patients underwent PD with PG. The majority were performed for ductal pancreatic adenocarcinomas (410, 59%). Simultaneous venous resection was performed in 321 patients (46.1%) while arterial resection was performed in 111 patients. Postoperative 90 days mortality was 4.75% (n=33). Bleeding form PG occurred in 33 patients (4.7%) at a median interval of 5 days from surgery (0-14) leading to reoperation in 22 patients (66.6%). PG bleeding-related mortality was 9.0% (3/33). Multivariate analyses identified soft pancreatic consistency and wirsung duct > or > 3 mm (Class C and D of the ISGPS (HR=3.92, CI 95%,1.01-4.83 ;p=0.01) and the wrapping of the invaginated pancreas by haemostatic material (HR=0.37, CI 95%,0.15-0.87 ;p=0.04) as independent risk factors for PG bleeding.
Conclusions: In a large volume setting, postoperative bleeding from PG reconstruction occurred in about 5% of patients. Related mortality and reoperation remain high indicating the need for intensive postoperative surveillance mainly in patients with soft pancreatic parenchyma undergoing PG. Wrapping of the invaginated pancreatic stump might reduce the incidence of hemorrhagic complications.

Background: High acinar pancreatic contents are associated with a higher rate of postpancreatecto... more Background: High acinar pancreatic contents are associated with a higher rate of postpancreatectomy acute pancreatitis and pancreatic fistula formation (POPF). Predicting acinar contents preoperatively might identify those at high risk of developing postoperative complications.

Methods: A multivariable analysis was performed to identify radiological factors associated with high pancreatic acinar content at histology in patients undergoing pancreaticoduodenectomy. Clinical and radiological variables identified were used to build a composite score predicting low, moderate, and high acinar pancreatic contents.

Results: Pancreatic density, wirsung caliber, and pancreatic thickness on preoperative CT-scan predicted acinar contents. These three variables predicted low, moderate, and high acinar content in 94 (26%), 122 (33.6%), and 147 (40.5%) patients, respectively. Patients with high radiological acinar scores compared with patients with intermediate-low risk scores were more frequently male (73.4% vs. 54.1%; p = 0.0003), obese (14% vs. 6%; p = 0.01), and had a statistically significant higher rate of pancreatic-specific complications (23.8% vs. 8.33%; p = 0.01), POPF (12.9% vs. 4.63%; p = 0.005) and pancreaticogastrostomy bleeding (10.8% vs. 4.17%; p = 0.01).

Conclusion: A simple radiological score combining pancreatic thickness, density, and wirsung caliber at CT scan preoperatively predicts patients with pancreatic parenchyma that are at higher risk of postoperative pancreatic-specific complications.

e-ISSN 1941-5923, 2023

Objective: Rare disease Background: Hepatic portal venous gas (HPVG) is a rare radiologic finding... more Objective: Rare disease Background: Hepatic portal venous gas (HPVG) is a rare radiologic finding mostly associated with life-threatening diseases like bowel necrosis, but can also be benign; its overall mortality rate is 39-75%. In rare cases HPVG is associated with endoscopic procedures such as percutaneous endoscopic gastrostomy (PEG) placement. However, due to the rarity of this condition, there is no recommendation about its management. The aim of this case report was to describe a successful conservative management of HPVG without antibiotic administration based on the clinical presentation. Case Report: A 78-year-old male patient known for a history of esophageal cancer treated with radio-and chemotherapy, complicated by a post-radiation esophageal stenosis requiring a PEG tube placement 1 month prior was admitted to our Emergency Department for vomiting and abdominal pain. A contrast-enhanced abdominal CT scan showed small-bowel dilatation without obstruction, as well as gastric wall pneumatosis and HPVG. We opted for a conservative approach. The PEG was put to suction for 2 days. The clinical evolution was favorable, with resolution of abdominal pain and a restored transit on day 2. A follow-up CT scan at day 5 showed resolution of HPVG. Nutrition through the PEG was restored at day 6 without complication. Conclusions: HPVG can be a benign finding after a PEG tube placement. Conservative management without antibiotics can be used in oligosymptomatic and hemodynamically stable patients after life-threatening associated diseases like bowel necrosis have been ruled out.

BMJ Case Rep, 2023

Bronchogenic cysts (BCs) are congenital foregut malformations and usually asymptomatic, thin-wall... more Bronchogenic cysts (BCs) are congenital foregut malformations and usually asymptomatic, thin-walled, incidentally diagnosed cysts which can be easily resected by a minimal invasive approach at this time point. However, they may develop symptoms such as infection, bleeding or compression of adjacent structures. There is no consensus about the risk of developing complications during a lifetime; however, recent reports suggest a higher incidence than initially believed. Here, we report a case of severe life-threatening mediastinitis emerging from an infected BC requiring complex surgery, which could have been avoided if surgery had been performed at an early, asymptomatic stage.

Cureus, Oct 31, 2022

Metronidazole is an antibiotic commonly prescribed for anaerobic and protozoan infections. Despit... more Metronidazole is an antibiotic commonly prescribed for anaerobic and protozoan infections. Despite its good safety profile, this drug frequently causes a series of well-known side effects (nausea and intestinal transit disorders, dysgeusia, headaches, and alcohol intolerance). However, there are few data in the literature, mainly case reports and case series, about the onset of peripheral neuropathy with a generally self-limiting course after drug withdrawal. Thus, we herein describe two cases of peripheral neuropathy due to treatment with metronidazole. A 69-year-old woman treated with a total of 55 g of metronidazole for diverticular disease and a 52-year-old male patient on a long course of antibiotic therapy for hepatic abscesses (a cumulative dose of 168 g) developed peripheral neuropathy. The suspicion of metronidazole side effects was raised after the exclusion of other causes. After the suspension of the drug, different degrees of improvement were observed. Metronidazole is an effective antibiotic for treating infections caused by anaerobic or protozoan pathogens, and it has a good pharmacological and economic safety profile. However, in the existing literature, prolonged therapy regimens (>4 weeks of treatment and/or 42 g cumulative dose) may increase the risk of developing neurological complications, in particular peripheral polyneuropathy.

Journal of Surgical Case Reports, 2019

Benign Multicystic Peritoneal Mesothelioma (BMPM) is a rare benign cystic neoplasm that arise fro... more Benign Multicystic Peritoneal Mesothelioma (BMPM) is a rare benign cystic neoplasm that arise from the peritoneum, typically found in young females (83%), with a high incidence of local recurrence after resection (almost 50% of cases). Fewer than 200 cases have been reported worldwide in 2017. Due to its rarity and the lack of a classical clinical presentation, the diagnosis pre-operatively is challenging; moreover a great part of the literature is composed of case reports and small group studies. Nowadays, guidelines are still not available, and treatment is en bloc resection of the lesion. Some authors suggest the use of Hyperthermic Intraperitoneal Chemotherapy (HIPEC) associated with the surgical approach, even if comparative data on recurrence and complications are lacking. We report a case of BMPM diagnosed in a 40-year-old male who underwent an exploratory laparoscopy and complete excision of the neoformation. Pathology confirmed the presence of a BMPM.

Cureus, 2021

Prosthetic hip joint replacement is considered the operation of the 20th century because of its w... more Prosthetic hip joint replacement is considered the operation of the 20th century because of its wide diffusion and good outcome. More than 1 million prostheses are implanted worldwide annually. Although hip arthroplasty is considered a safe procedure, different complications can occur in relation with surgery. Periprosthesic joint infection is the most feared for its morbidity for the patients, and for the economic costs it generates. Most surgical site infections after hip arthroplasty are related to frequent germs as Staphylococci or Enterobacteriaceae, while Propionibacterium infections are more rare and often challenging in diagnosis and therapy. We report a case of a 77-year-old diabetic overweight male patient who developed a periprosthetic hip infection due to P. avidum and P. acnes after a mini-invasive direct anterior approach. To our knowledge, this represents the first case of chronic periprosthetic hip joint co-infection.

Hepatology International, 2022

Background: Optimal treatment of spontaneous portosystemic shunts (SPSS) during liver transplanta... more Background: Optimal treatment of spontaneous portosystemic shunts (SPSS) during liver transplantation (LT) remains debated. We systematically reviewed the literature on definitions, treatment and outcomes of patients presenting SPSS undergoing LT.

Methods: According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we used PubMed to retrieve all studies dealing with SPSS and LT between January 1987 and January 2020. The primary endpoints were definitions and outcomes according to the management of SPSS (treatment vs observation).

Results: Thirteen studies detailing the management of 962 SPSS were retrieved. Hemodynamically significant SPSS were defined as those having diameter ≥ 10 mm in 41% (n = 395) of patients. SPSS were splenorenal (42%), cavo-gastric (15.2%), umbilical (7.4%), mesenterico-caval (n = 31; 3.2%), mesenterico-renal (0.1%) and unreported (31.9%), respectively. At the time of LT 372 shunts (38.7%) were treated while 590 were observed (61.3%). During a follow-up time ranging from 4 months to 5 years, the reported overall survival (OS) at 1 year was not significantly different except for one study. Portal vein anastomosis complications (i.e. reduced flow, stenosis or thrombosis) were similarly reported in observed [n = 26 (4%)] and ligated SPSS [n = 10 (2%)] (p = 0.22) but the rate of relaparotomy was significantly higher in observed SPPS (16 vs 2; p = 0.01) to rescue post LT portal vein thrombosis (n = 6) and reduced portal flow and graft dysfunction (n = 10).

Conclusions: There was a heterogeneous management of SPSS during LT in the literature. Ligation of SPPS did not reduce vascular complications neither improved survival. A randomized prospective study might contribute to identify best management of SPSS at time of LT.

Cureus , 2022

Perforated diverticulitis is a rare but serious complication associated with a significant mortal... more Perforated diverticulitis is a rare but serious complication associated with a significant mortality rate. Although many cases of conservative treatment have been reported, surgery remains the mainstay for perforated duodenal diverticulitis.

We report a rare case of a 55-year-old female who presented with epigastric pain without fever. Computed tomography revealed a 3 cm perforated duodenal diverticulum of the D2 part of the duodenum with a localized abscess. After the failure of conservative treatment, we performed a deriving intestinal patch completed by cholecystectomy and biliary decompression via a transcystic drain, as well as feeding jejunostomy. The patient was discharged on day 32. Removal of the transcystic drainage at eight weeks postoperatively was complicated by the appearance of an iatrogenic bilioperitoneum, which was effectively treated with percutaneous drainage.

Surgery remains challenging; our experience suggests that perforation covering with a deriving jejunal patch offers an alternative to direct beach suturing when the latter is deemed precarious. Part of the treatment success lies in local drainage and duodenal exclusion that can be achieved by various surgical approaches.

HPB, 2022

Since Zein's work in 2013, interest in patient-based 3D printed liver models has been gradually d... more Since Zein's work in 2013, interest in patient-based 3D printed liver models has been gradually developing, as confirmed by the increase in dedicated scientific articles over the years.1
However, despite the fact that Witowski had already demonstrated the possibility of producing accurate and cost-effective 3D printed liver models,2,3 the application of this technology in the context of liver preoperative planning is not yet applied on a large scale.
In this context, the result of this work is commendable: in addition to confirming the reliable correlation between the 3D model, radiological imaging and the surgical specimen, it demonstrated that this technique to be useful for education, understanding, and surgical planning, with a proven benefit of 3D printed models over 3D visualisation.4
Interestingly, a paper by the same author has recently shown that the adoption of next-generation 3D modelling software in perihilar cholangiocarcinoma has also allowed a better understanding of anatomical features that could potentially influence preoperative planning.5
Nevertheless, none of the questionnaires administered in the two studies reported a similarly positive response with regard to intraoperative outcomes, reflecting the current expectations of the hepatobiliary surgeons involved.4,5
Despite the difficulty associated with the need for large and specifically designed studies, only the demonstration of an impact on the clinical outcome would be the key point for the adoption of 3D printing into current clinical practice.

Tribuna Medica Ticinese, 2018

Dolore in fossa iliaca destra, peritonismo, leucocitosi neutrofila e febbre in un paziente non pr... more Dolore in fossa iliaca destra, peritonismo, leucocitosi neutrofila e febbre in un paziente non precedentemente operato ed il primo sospetto che balena nella mente è un’appendicite acuta. Una diagnosi “clinica” secondo quanto imparato all’università, con tanto di score (Alvarado) per avere un indice di probabilità pre-operatoria. Ma non sempre la “storia” è così semplice e lineare, specialmente nel paziente anziano, dove il quadro clinico spesso ha una presentazione più sfumata con conseguente aumento di mortalità e morbilità. Tra le complicanze dell’appendicite acuta possiamo riscontrare la perforazione con peritonite generalizzata, la formazione di ascessi intraddominali, ma per trovare alcuni quadri decisamente meno frequenti è necessario spulciare la letteratura alla ricerca di “case reports” del passato o di realtà sanitarie molto lontane dalla nostra, dove l’accesso alle cure mediche è tutt’altro che immediato.

Conference Presentations by Stefano Gussago

SCS Annual Meeting 2024, 2024

Background: Spontaneous rupture of urinary bladder (SRUB) is a rare condition with no standard o... more Background:
Spontaneous rupture of urinary bladder (SRUB) is a rare condition with no standard of care and significant related morbidity and mortality. Although multiple causes (tumors, cystitis, excessive alcohol consumption, bladder outlet obstruction) including connective tissue disorders have been described, we report the rare association of SRUB and Osler-Weber-Rendu disease.

Aims:
A 60-year-old woman, known for Osler-Weber-Rendu disease, 3 previous C-sections and a hystero-annexectomy for benign disease, complains of lower abdominal pain for 4 hours earlier associated with mild dysuria. Blood tests detect no inflammation. Urinalysis shows moderate leukocyturia (24 M/l) without clear erythrocyturia. Free intra-peritoneal fluid is detected on the contrast enhanced CT scan. Exploratory laparoscopy is therefore deemed.

Methods:
Exploration reveals moderate clear ascites. A fluid sample found elevated creatinine (1101 µmol/l). After minimal adhesiolysis a perforation of about 1.5 cm of the bladder dome was found. After margin resection, defect was closed using 3.0 interrupted absorbable suture. Pathology report describes partially abraded squamous mucosa with fibrous changes in the chorion and underlying musculature. A Foley catheter and a surgical drain were left, the latter removed on the third postoperative day, and the patient discharged the same day.

Results:
Foley's catheter was removed at day 12, after cystography control. A six-week later cystoscopy found an inflammatory lesion of the bladder dome, compatible with the healing process, associated with 3 other inflammatory lesions.

Conclusion:
SRUB is a rare disease asssociated with morbidiy and mortality. Diagnosis is often challenging because signs and symptoms are non specific, particulary at urinary tract. To our knowledge, although association with connective tissue disorders has been described, this represents the first report of an association of spontaneous bladder perforation and Osler-Weber-Rendu disease.

XVIII Congresso Nazionale SICE, 2017

XXIXème Symposium de l'ASRCC, 2022

Swiss College of Surgeons annual meeting, 2023

Background vNOTES (vaginal natural orifice transluminal endoscopic surgery) is a minimally invasi... more Background
vNOTES (vaginal natural orifice transluminal endoscopic surgery) is a minimally invasive technique that combines the benefits of laparoscopy and a scar less vaginal approach. This technique is common in gynecologic surgery but is rarely used in visceral surgery, due to lack of familiarity with the technique. In the literature, vNOTES sigmoidectomy is described as safe and feasible for benign disease. For oncological diseases however, some series exist but no clear evidence exists.

Aims
We report a case of pure vNOTES sigmoidectomy for benign sigmoid disease.

Material and Methods
A 77 year- old female with chronic constipation and abdominal pain was diagnosed with transitory sigmoid volvulus in the context of dolichocolon. From a gynecologic point of view, hysterectomy and bilateral adnexectomy was considered due to benign disease. After a posterior endovaginal access, the gynecologist performed the adnexectomy and the hysterectomy. Following hemostasis, we performed a laparoscopic vNOTES sigmoidectomy. The rectosigmoid junction was sectioned following dissection of the mesorectum. The mesocolon was then dissected followed by vascular control. After partial mobilization of the left colon, a near infrared ICG perfusion test was performed. A hand assisted transrectal end-to-end circular stapler anastomosis was then carried out. Due to concern about the integrity of the anastomosis, even if rectoscopy and an air-leak test did not show any defect, an intracorporal suture was performed with the final air-leak test without any leak.

Results
Post-op recovery was uneventful, with bowel passage occurring 2 days post-operatively. The patient was discharged at Day 4.

Conclusions
vNOTES sigmoidectomy for benign disease is safe and feasible in selected patient. The literature is unclear regarding the benefits and risks of vNOTES versus a conventional sigmoidectomy. Ongoing research will clarify long term outcome for oncological disease.

Standardization and technological development of vNOTES will allow to perform more complex procedures and will become an interesting alternative for patient.

Swiss Knife, 2022

Objective: Amyand's hernia owes its eponym to the French surgeon who first described it in 1735 i... more Objective: Amyand's hernia owes its eponym to the French surgeon who first described it in 1735 in a young male patient who presented an incarcerated inguinal hernia containing a perforated appendix. Defined as an inguinal hernia containing the caecal appendix, this rare entity (0.28-0.37% of all inguinal hernia cases) for anatomical reasons predominantly affects the right side (92.5%), although a presence on the left is not excluded. A recent paper by Papaconstantinou reports that in the majority of cases it has an acute onset (62.3%) and since in the 77.3% the clinical presentation corresponds to an incarcerated hernia, a pre-operative diagnosis is only possible in less than a quarter of cases (23.1%). Consequently, the anterior laparotomic approach is predominant (87.2%).

Methods: a 53 years old male patient, with no particular medical history, has been suffering from right groin pain for a couple of weeks. A clinical evaluation found a reducible right inguinal hernia, which was subjected to radiological evaluation by abdominal CT scan that found the presence of a non-flogosated appendix inside the hernia sac. The indication for a laparoscopic exploration in a semi-urgent regime was recommended: after induction of the peritoneum, reduction of the vermiform appendix in the abdomen was observed. On direct observation there were no signs of local inflammation. We therefore opted for a trans-peritoneal approach (TAPP) to treat the hernia. A onflex mesh was placed and the peritoneum closed with a 3.0 V-Loc running suture. In the absence of a clear acute pathology of the appendix we opted not to resect it.

Results: as this is a rare condition, most of the available literature is based on case reports and small case series. In the absence of prospective studies and universally shared guidelines, the approach is mainly based on expert opinion. In cases where there is no clear appendicular inflammation, removal of the appendix is generally avoided in order not to contaminate the operation field. Laparoscopy could offer a better intraperitoneal assessment and to avoid to manipulate the appendicular stump in the inguinal canal.

Conclusions: the state of the art does not at this time allow a clear strategy to be defined in the case of a normal caecal appendix in the context of Amyand's hernia. It is therefore still up to the surgeon's experience to decide whether or not to proceed with appendicular resection.

11th Swiss Trauma & Acute Care Surgery Days , 2022

Background: Traumatic diaphragmatic hernia (TDH) is a rare entity, occurring in less than 1% of a... more Background: Traumatic diaphragmatic hernia (TDH) is a rare entity, occurring in less than 1% of all blunt traumatic injuries and are frequently associated with other thoraco-abdominal, cerebral, or musculoskeletal injuries. The prevalence of TDH is higher in penetrating compared to blunt trauma and is most frequently found on the left side (about 75 %). Due to its rarity, it remains a challenging disease, as no guidelines are available

Methods: A 51 year-old female, in good health, presented to our emergency department with an isolated blunt thoracic trauma after a minor ski accident a day earlier. She developed abdominal pain associated with multiple episodes of vomiting. A CT scan showed a right-sided intrathoracic translocation of intestinal loops with signs of strangulation

Results: We performed an emergency laparoscopy via an ombilical optical trocart (10mm). Two 5mm and one 10 mm trocars were placed in the left and right hypochondrium, and the subxiphoid region. The exploration confirmed the presence of about 100cm of small bowel as well as the apex of segment VIII that had herniated within the thoracic cavity. Following reduction into the abdominal cavity, no ischemic or necrotic lesion of the small bowel was observed. The diaphragmatic lesion measured 6 x 3 cm and was sutured with non-absorbable stitches (2-0 V-loc™ PBT). The remaining hydropneumothorax was suctioned prior to tight closure of the diaphragmatic tear. A resorbable mesh (VICRYL® 13.5 x 11 cm) was placed over the diaphragmatic suture and fixed with absorbable tackers (SorbaFix™). The exploration of the abdominal cavity did not show any further injuries. No thoracic drain was left in place. A post-operative chest X-ray showed a minimal residual pneumothorax (<1cm apical). The patient was discharged on post-operative day 3.

Conclusions: We describe a safe and effective minimally invasive approach for an acute TDH. Early diagnosis and treatment are essential in avoiding complications related to visceral strangulation. Even in the absence of a thoracic drainage, the postoperative clinical course and control radiography presented no complications. A transabdominal laparoscopic approach is preferable over a transthoracic approach, as any associated intraabdominal lesions can be diagnosed and repaired

Swiss Knife, 2018

Objectives: Peritoneal Mesothelioma is a known malignant entity, but much less described in liter... more Objectives: Peritoneal Mesothelioma is a known malignant entity, but much less described in literature is the existence of an extremely rare benign form. Benign Multicystic Peritoneal Mesothelioma (BMPM) is a benign cystic neoplasm that arise from the peritoneum, typically found in young females (83%), with a high incidence of local recurrence after surgical resection (almost 50% of cases). Fewer than 200 cases have been reported worldwide in 2017. Due to its rarity and the lack of a classical clinical presentation the diagnosis pre-operatively is challenging. Clear guidelines are nowadays still not avaible, and the treatment is based upon the resection en bloc of the lesion. Some authors suggest the use of hyperthermic intraperitoneal chemotherapy (HIPEC) associated with a surgical approach, even if comparative data on recurrence and complications are lacking.

Methods: A healthy 40 year old male who complained from 5 years of occasional abdominal discomfort was investigated with an echography, which identify a 9 cm polycystic lesion in the right flank. A contrast enhanced CT scan was performed revealing a polylobate hypodense formation, with multiple thin internal septa which are enriched after contrast (dimension 83 x 43 x 61 mm) (Fig.1).

Results: The patient underwent an exploratory laparoscopy that confirmed the presence of multiple cystic lesions of the peritoneum. We performed a complete excision of the neoformation, keeping a sufficient resection margin (Fig. 2,3). A small lesion of the colonic serum was treated with a prophylactic continuous. The post-operative course was uneventful and the patient was discharged after 2 days without complications. Pathology revealed a BMPM (Fig.4). After discussion with our Referral Center was suggested an annual follow-up with MRI, and in case of relapse an approach with cytoreductive surgery and subsequent HIPEC.

Conclusions: There is a benign form of peritoneal mesothelioma. The rarity of BMPM is for sure a prominent limitation to a better knowledge of this pathology. The most part of current literature is based upon small group studies and case reports, with an evident limit to the understanding of the causes, the biological behavior and the possible therapies. The institution of nation based registry for this pathology may help to rise the number of reported cases, helping to increase the possibility to understand this still almost unknown neoplasm.

Swiss Knife, 2018

Objectives: Acute appendicitis is one of the most common cause of admission at the emergency depa... more Objectives: Acute appendicitis is one of the most common cause of admission at the emergency department for abdominal pain. The typical signs and symptoms allow to make a strong diagnostic suspicion with clinical evaluation only, confirmed in most of the cases with an abdominal echography. In elderly the clinical pattern may not be so evident, leading to delayed diagnosis and increasingrisk of perforation, mortality and morbidity. But some complications of acute appendicitis appears mostly in case reports from developing countries, where the access to healthcare is strongly limited.

Methods: A 68 year old male, with a moderate kidney dysfunction, in therapy with Acenocoumarol for an hereditary thrombophilia was admitted for a spontaneous hematoma of the rectus abdominis, confirmed by an abdominal sonography. After one month he developed a new swelling in right iliac fossa. He was investigated again with an abdominal echography and a CT scan that were interpreted as an abscessualization of another spontaneous hematoma without relation with the abdominal cavity. It was started a broad spectrum antibiotic therapy but since there was not a clinical improvement, a new CT scan was performed.

Results: The patient was then transferred to our Hospital. In the strong suspect of an intra-abdominal source of the infection we performed a colonoscopy, that found a purulent secretion from the appendiceal foramen. The patient underwent a laparoscopic cecal resection and an open wedge resection of the abdominal wall interested by the abscess. The defect was closed with a Vycril mesh and omental patch, a V.A.C.® dressing was placed. The post-operative course was complicated by an extended DVT of the right leg, treated with unfractionated heparin. The patient was then dismissed in day 15.

Conclusions: In elderly patient acute appendicitis the urgency of the clinical presentation is often blurred, with consequent diagnostic delay and increased morbidity and mortality. Even if not frequently, an advanced acute appendicitis can present as a parietal abscess or much more rarely through an enteric fistulisation. It is necessary to consider in case of appearance of a swelling of the abdominal wall without trauma a possible endoperitoneal origin of the problem and proceed to adequate sonographic or tomographic imaging, deepening in case of persistence of doubt through a targeted endoscopic examination

Swiss Knife, 2018

Objectives: Laparoscopic approach for ventral hernias is nowadays a well-established technique. T... more Objectives: Laparoscopic approach for ventral hernias is nowadays a well-established technique. The most common procedure consists inthe placement of an intraperitoneal onlay mesh (IPOM) although this may lead to adhesions, fistulisation and migration inhollow organs. Some authors described a preperitoneal approach for the mesh placement but as described in the 2014 Guidelines of the International Endohernia Society (IEHS) the most important disadvantage is the technical difficulty and the longer operating time. In our experience a possible solution to these limitations is the adoption of a 3D laparoscopic system.

Methods: An obese 45 year old male (BMI 31 kg/m²), with a past history of laparoscopic resection of a strangulated epiploic appendix, complained of a symptomatic, reducible, supra-umbilical swelling. An abdominal wall echography identified the presence of 2 midline incisional hernias (1.9 x1.3 cm; 1 x 1,3 cm) containing only preperitoneal fat.

Results: The patient underwent a 3D laparoscopic approach (AESCULAP® 3D EinsteinVision). 3 Trocars (12, 10 and 5 mm) were placed on the left side of the abdomen. We proceeded with a longitudinal incision of the peritoneum on the left of the midline with opening of the preperitoneal space and exposure of the posterior rectus sheath. Intraoperatively we founded a third little defect (5 mm) of the fascia. The hernias were then closed with Polyester Suture knots and then covered with Monocryl and Prolene mesh (ULTRAPRO® 11x 6 cm) on the posterior rectus sheet. We fixed the mesh with absorbable fixation device (AbsorbaTack™) and then closed the peritoneum with a barbed suture (V-Loc™ 4-0).The course was uneventful and the patient was dismissed on the first post-operative day.

Conclusions: Laparoscopic IPOM hernia repair is nowadays a routinely approach for ventral and incisional abdominal wall hernias. Even if progress in technology of mesh composition is leading to better tolerate devices, two-thirds of the patients will develop adhesions. The placement of the mesh in the preperitoneal space could be a solution, but this requires advanced surgical skills and a longer operating time. The adoption of a 3D laparoscopic system could lead to an easier and faster approach, making the TAPP approach feasible and safer for small and medium ventral hernias. Further studies are needed to confirm if the third dimension could provide an effective surgical advantage.

HPB, 2024

Background: Recent metanalysis reported a higher risk of postoperative bleeding from pancreaticog... more Background: Recent metanalysis reported a higher risk of postoperative bleeding from pancreaticogastrostomy (PG) reconstruction following pancreaticoduodenectomy (PD). We aimed to evaluate incidence, risk factors and outcomes of hemorrhage from PG in a large single center experience.
Methods: We retrospectively evaluated all consecutive PDs performed over 11 years. PG reconstruction was performed according the double pursestring invaginated technique. Multivariate logistic regression analysis was performed to identify risk factors for PG bleeding.
Results: During the study period, 695 consecutive patients underwent PD with PG. The majority were performed for ductal pancreatic adenocarcinomas (410, 59%). Simultaneous venous resection was performed in 321 patients (46.1%) while arterial resection was performed in 111 patients. Postoperative 90 days mortality was 4.75% (n=33). Bleeding form PG occurred in 33 patients (4.7%) at a median interval of 5 days from surgery (0-14) leading to reoperation in 22 patients (66.6%). PG bleeding-related mortality was 9.0% (3/33). Multivariate analyses identified soft pancreatic consistency and wirsung duct > or > 3 mm (Class C and D of the ISGPS (HR=3.92, CI 95%,1.01-4.83 ;p=0.01) and the wrapping of the invaginated pancreas by haemostatic material (HR=0.37, CI 95%,0.15-0.87 ;p=0.04) as independent risk factors for PG bleeding.
Conclusions: In a large volume setting, postoperative bleeding from PG reconstruction occurred in about 5% of patients. Related mortality and reoperation remain high indicating the need for intensive postoperative surveillance mainly in patients with soft pancreatic parenchyma undergoing PG. Wrapping of the invaginated pancreatic stump might reduce the incidence of hemorrhagic complications.

Background: High acinar pancreatic contents are associated with a higher rate of postpancreatecto... more Background: High acinar pancreatic contents are associated with a higher rate of postpancreatectomy acute pancreatitis and pancreatic fistula formation (POPF). Predicting acinar contents preoperatively might identify those at high risk of developing postoperative complications.

Methods: A multivariable analysis was performed to identify radiological factors associated with high pancreatic acinar content at histology in patients undergoing pancreaticoduodenectomy. Clinical and radiological variables identified were used to build a composite score predicting low, moderate, and high acinar pancreatic contents.

Results: Pancreatic density, wirsung caliber, and pancreatic thickness on preoperative CT-scan predicted acinar contents. These three variables predicted low, moderate, and high acinar content in 94 (26%), 122 (33.6%), and 147 (40.5%) patients, respectively. Patients with high radiological acinar scores compared with patients with intermediate-low risk scores were more frequently male (73.4% vs. 54.1%; p = 0.0003), obese (14% vs. 6%; p = 0.01), and had a statistically significant higher rate of pancreatic-specific complications (23.8% vs. 8.33%; p = 0.01), POPF (12.9% vs. 4.63%; p = 0.005) and pancreaticogastrostomy bleeding (10.8% vs. 4.17%; p = 0.01).

Conclusion: A simple radiological score combining pancreatic thickness, density, and wirsung caliber at CT scan preoperatively predicts patients with pancreatic parenchyma that are at higher risk of postoperative pancreatic-specific complications.

e-ISSN 1941-5923, 2023

Objective: Rare disease Background: Hepatic portal venous gas (HPVG) is a rare radiologic finding... more Objective: Rare disease Background: Hepatic portal venous gas (HPVG) is a rare radiologic finding mostly associated with life-threatening diseases like bowel necrosis, but can also be benign; its overall mortality rate is 39-75%. In rare cases HPVG is associated with endoscopic procedures such as percutaneous endoscopic gastrostomy (PEG) placement. However, due to the rarity of this condition, there is no recommendation about its management. The aim of this case report was to describe a successful conservative management of HPVG without antibiotic administration based on the clinical presentation. Case Report: A 78-year-old male patient known for a history of esophageal cancer treated with radio-and chemotherapy, complicated by a post-radiation esophageal stenosis requiring a PEG tube placement 1 month prior was admitted to our Emergency Department for vomiting and abdominal pain. A contrast-enhanced abdominal CT scan showed small-bowel dilatation without obstruction, as well as gastric wall pneumatosis and HPVG. We opted for a conservative approach. The PEG was put to suction for 2 days. The clinical evolution was favorable, with resolution of abdominal pain and a restored transit on day 2. A follow-up CT scan at day 5 showed resolution of HPVG. Nutrition through the PEG was restored at day 6 without complication. Conclusions: HPVG can be a benign finding after a PEG tube placement. Conservative management without antibiotics can be used in oligosymptomatic and hemodynamically stable patients after life-threatening associated diseases like bowel necrosis have been ruled out.

BMJ Case Rep, 2023

Bronchogenic cysts (BCs) are congenital foregut malformations and usually asymptomatic, thin-wall... more Bronchogenic cysts (BCs) are congenital foregut malformations and usually asymptomatic, thin-walled, incidentally diagnosed cysts which can be easily resected by a minimal invasive approach at this time point. However, they may develop symptoms such as infection, bleeding or compression of adjacent structures. There is no consensus about the risk of developing complications during a lifetime; however, recent reports suggest a higher incidence than initially believed. Here, we report a case of severe life-threatening mediastinitis emerging from an infected BC requiring complex surgery, which could have been avoided if surgery had been performed at an early, asymptomatic stage.

Cureus, Oct 31, 2022

Metronidazole is an antibiotic commonly prescribed for anaerobic and protozoan infections. Despit... more Metronidazole is an antibiotic commonly prescribed for anaerobic and protozoan infections. Despite its good safety profile, this drug frequently causes a series of well-known side effects (nausea and intestinal transit disorders, dysgeusia, headaches, and alcohol intolerance). However, there are few data in the literature, mainly case reports and case series, about the onset of peripheral neuropathy with a generally self-limiting course after drug withdrawal. Thus, we herein describe two cases of peripheral neuropathy due to treatment with metronidazole. A 69-year-old woman treated with a total of 55 g of metronidazole for diverticular disease and a 52-year-old male patient on a long course of antibiotic therapy for hepatic abscesses (a cumulative dose of 168 g) developed peripheral neuropathy. The suspicion of metronidazole side effects was raised after the exclusion of other causes. After the suspension of the drug, different degrees of improvement were observed. Metronidazole is an effective antibiotic for treating infections caused by anaerobic or protozoan pathogens, and it has a good pharmacological and economic safety profile. However, in the existing literature, prolonged therapy regimens (>4 weeks of treatment and/or 42 g cumulative dose) may increase the risk of developing neurological complications, in particular peripheral polyneuropathy.

Journal of Surgical Case Reports, 2019

Benign Multicystic Peritoneal Mesothelioma (BMPM) is a rare benign cystic neoplasm that arise fro... more Benign Multicystic Peritoneal Mesothelioma (BMPM) is a rare benign cystic neoplasm that arise from the peritoneum, typically found in young females (83%), with a high incidence of local recurrence after resection (almost 50% of cases). Fewer than 200 cases have been reported worldwide in 2017. Due to its rarity and the lack of a classical clinical presentation, the diagnosis pre-operatively is challenging; moreover a great part of the literature is composed of case reports and small group studies. Nowadays, guidelines are still not available, and treatment is en bloc resection of the lesion. Some authors suggest the use of Hyperthermic Intraperitoneal Chemotherapy (HIPEC) associated with the surgical approach, even if comparative data on recurrence and complications are lacking. We report a case of BMPM diagnosed in a 40-year-old male who underwent an exploratory laparoscopy and complete excision of the neoformation. Pathology confirmed the presence of a BMPM.

Cureus, 2021

Prosthetic hip joint replacement is considered the operation of the 20th century because of its w... more Prosthetic hip joint replacement is considered the operation of the 20th century because of its wide diffusion and good outcome. More than 1 million prostheses are implanted worldwide annually. Although hip arthroplasty is considered a safe procedure, different complications can occur in relation with surgery. Periprosthesic joint infection is the most feared for its morbidity for the patients, and for the economic costs it generates. Most surgical site infections after hip arthroplasty are related to frequent germs as Staphylococci or Enterobacteriaceae, while Propionibacterium infections are more rare and often challenging in diagnosis and therapy. We report a case of a 77-year-old diabetic overweight male patient who developed a periprosthetic hip infection due to P. avidum and P. acnes after a mini-invasive direct anterior approach. To our knowledge, this represents the first case of chronic periprosthetic hip joint co-infection.

Hepatology International, 2022

Background: Optimal treatment of spontaneous portosystemic shunts (SPSS) during liver transplanta... more Background: Optimal treatment of spontaneous portosystemic shunts (SPSS) during liver transplantation (LT) remains debated. We systematically reviewed the literature on definitions, treatment and outcomes of patients presenting SPSS undergoing LT.

Methods: According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we used PubMed to retrieve all studies dealing with SPSS and LT between January 1987 and January 2020. The primary endpoints were definitions and outcomes according to the management of SPSS (treatment vs observation).

Results: Thirteen studies detailing the management of 962 SPSS were retrieved. Hemodynamically significant SPSS were defined as those having diameter ≥ 10 mm in 41% (n = 395) of patients. SPSS were splenorenal (42%), cavo-gastric (15.2%), umbilical (7.4%), mesenterico-caval (n = 31; 3.2%), mesenterico-renal (0.1%) and unreported (31.9%), respectively. At the time of LT 372 shunts (38.7%) were treated while 590 were observed (61.3%). During a follow-up time ranging from 4 months to 5 years, the reported overall survival (OS) at 1 year was not significantly different except for one study. Portal vein anastomosis complications (i.e. reduced flow, stenosis or thrombosis) were similarly reported in observed [n = 26 (4%)] and ligated SPSS [n = 10 (2%)] (p = 0.22) but the rate of relaparotomy was significantly higher in observed SPPS (16 vs 2; p = 0.01) to rescue post LT portal vein thrombosis (n = 6) and reduced portal flow and graft dysfunction (n = 10).

Conclusions: There was a heterogeneous management of SPSS during LT in the literature. Ligation of SPPS did not reduce vascular complications neither improved survival. A randomized prospective study might contribute to identify best management of SPSS at time of LT.

Cureus , 2022

Perforated diverticulitis is a rare but serious complication associated with a significant mortal... more Perforated diverticulitis is a rare but serious complication associated with a significant mortality rate. Although many cases of conservative treatment have been reported, surgery remains the mainstay for perforated duodenal diverticulitis.

We report a rare case of a 55-year-old female who presented with epigastric pain without fever. Computed tomography revealed a 3 cm perforated duodenal diverticulum of the D2 part of the duodenum with a localized abscess. After the failure of conservative treatment, we performed a deriving intestinal patch completed by cholecystectomy and biliary decompression via a transcystic drain, as well as feeding jejunostomy. The patient was discharged on day 32. Removal of the transcystic drainage at eight weeks postoperatively was complicated by the appearance of an iatrogenic bilioperitoneum, which was effectively treated with percutaneous drainage.

Surgery remains challenging; our experience suggests that perforation covering with a deriving jejunal patch offers an alternative to direct beach suturing when the latter is deemed precarious. Part of the treatment success lies in local drainage and duodenal exclusion that can be achieved by various surgical approaches.

HPB, 2022

Since Zein's work in 2013, interest in patient-based 3D printed liver models has been gradually d... more Since Zein's work in 2013, interest in patient-based 3D printed liver models has been gradually developing, as confirmed by the increase in dedicated scientific articles over the years.1
However, despite the fact that Witowski had already demonstrated the possibility of producing accurate and cost-effective 3D printed liver models,2,3 the application of this technology in the context of liver preoperative planning is not yet applied on a large scale.
In this context, the result of this work is commendable: in addition to confirming the reliable correlation between the 3D model, radiological imaging and the surgical specimen, it demonstrated that this technique to be useful for education, understanding, and surgical planning, with a proven benefit of 3D printed models over 3D visualisation.4
Interestingly, a paper by the same author has recently shown that the adoption of next-generation 3D modelling software in perihilar cholangiocarcinoma has also allowed a better understanding of anatomical features that could potentially influence preoperative planning.5
Nevertheless, none of the questionnaires administered in the two studies reported a similarly positive response with regard to intraoperative outcomes, reflecting the current expectations of the hepatobiliary surgeons involved.4,5
Despite the difficulty associated with the need for large and specifically designed studies, only the demonstration of an impact on the clinical outcome would be the key point for the adoption of 3D printing into current clinical practice.

Tribuna Medica Ticinese, 2018

Dolore in fossa iliaca destra, peritonismo, leucocitosi neutrofila e febbre in un paziente non pr... more Dolore in fossa iliaca destra, peritonismo, leucocitosi neutrofila e febbre in un paziente non precedentemente operato ed il primo sospetto che balena nella mente è un’appendicite acuta. Una diagnosi “clinica” secondo quanto imparato all’università, con tanto di score (Alvarado) per avere un indice di probabilità pre-operatoria. Ma non sempre la “storia” è così semplice e lineare, specialmente nel paziente anziano, dove il quadro clinico spesso ha una presentazione più sfumata con conseguente aumento di mortalità e morbilità. Tra le complicanze dell’appendicite acuta possiamo riscontrare la perforazione con peritonite generalizzata, la formazione di ascessi intraddominali, ma per trovare alcuni quadri decisamente meno frequenti è necessario spulciare la letteratura alla ricerca di “case reports” del passato o di realtà sanitarie molto lontane dalla nostra, dove l’accesso alle cure mediche è tutt’altro che immediato.

SCS Annual Meeting 2024, 2024

Background: Spontaneous rupture of urinary bladder (SRUB) is a rare condition with no standard o... more Background:
Spontaneous rupture of urinary bladder (SRUB) is a rare condition with no standard of care and significant related morbidity and mortality. Although multiple causes (tumors, cystitis, excessive alcohol consumption, bladder outlet obstruction) including connective tissue disorders have been described, we report the rare association of SRUB and Osler-Weber-Rendu disease.

Aims:
A 60-year-old woman, known for Osler-Weber-Rendu disease, 3 previous C-sections and a hystero-annexectomy for benign disease, complains of lower abdominal pain for 4 hours earlier associated with mild dysuria. Blood tests detect no inflammation. Urinalysis shows moderate leukocyturia (24 M/l) without clear erythrocyturia. Free intra-peritoneal fluid is detected on the contrast enhanced CT scan. Exploratory laparoscopy is therefore deemed.

Methods:
Exploration reveals moderate clear ascites. A fluid sample found elevated creatinine (1101 µmol/l). After minimal adhesiolysis a perforation of about 1.5 cm of the bladder dome was found. After margin resection, defect was closed using 3.0 interrupted absorbable suture. Pathology report describes partially abraded squamous mucosa with fibrous changes in the chorion and underlying musculature. A Foley catheter and a surgical drain were left, the latter removed on the third postoperative day, and the patient discharged the same day.

Results:
Foley's catheter was removed at day 12, after cystography control. A six-week later cystoscopy found an inflammatory lesion of the bladder dome, compatible with the healing process, associated with 3 other inflammatory lesions.

Conclusion:
SRUB is a rare disease asssociated with morbidiy and mortality. Diagnosis is often challenging because signs and symptoms are non specific, particulary at urinary tract. To our knowledge, although association with connective tissue disorders has been described, this represents the first report of an association of spontaneous bladder perforation and Osler-Weber-Rendu disease.

XVIII Congresso Nazionale SICE, 2017

XXIXème Symposium de l'ASRCC, 2022

Swiss College of Surgeons annual meeting, 2023

Background vNOTES (vaginal natural orifice transluminal endoscopic surgery) is a minimally invasi... more Background
vNOTES (vaginal natural orifice transluminal endoscopic surgery) is a minimally invasive technique that combines the benefits of laparoscopy and a scar less vaginal approach. This technique is common in gynecologic surgery but is rarely used in visceral surgery, due to lack of familiarity with the technique. In the literature, vNOTES sigmoidectomy is described as safe and feasible for benign disease. For oncological diseases however, some series exist but no clear evidence exists.

Aims
We report a case of pure vNOTES sigmoidectomy for benign sigmoid disease.

Material and Methods
A 77 year- old female with chronic constipation and abdominal pain was diagnosed with transitory sigmoid volvulus in the context of dolichocolon. From a gynecologic point of view, hysterectomy and bilateral adnexectomy was considered due to benign disease. After a posterior endovaginal access, the gynecologist performed the adnexectomy and the hysterectomy. Following hemostasis, we performed a laparoscopic vNOTES sigmoidectomy. The rectosigmoid junction was sectioned following dissection of the mesorectum. The mesocolon was then dissected followed by vascular control. After partial mobilization of the left colon, a near infrared ICG perfusion test was performed. A hand assisted transrectal end-to-end circular stapler anastomosis was then carried out. Due to concern about the integrity of the anastomosis, even if rectoscopy and an air-leak test did not show any defect, an intracorporal suture was performed with the final air-leak test without any leak.

Results
Post-op recovery was uneventful, with bowel passage occurring 2 days post-operatively. The patient was discharged at Day 4.

Conclusions
vNOTES sigmoidectomy for benign disease is safe and feasible in selected patient. The literature is unclear regarding the benefits and risks of vNOTES versus a conventional sigmoidectomy. Ongoing research will clarify long term outcome for oncological disease.

Standardization and technological development of vNOTES will allow to perform more complex procedures and will become an interesting alternative for patient.

Swiss Knife, 2022

Objective: Amyand's hernia owes its eponym to the French surgeon who first described it in 1735 i... more Objective: Amyand's hernia owes its eponym to the French surgeon who first described it in 1735 in a young male patient who presented an incarcerated inguinal hernia containing a perforated appendix. Defined as an inguinal hernia containing the caecal appendix, this rare entity (0.28-0.37% of all inguinal hernia cases) for anatomical reasons predominantly affects the right side (92.5%), although a presence on the left is not excluded. A recent paper by Papaconstantinou reports that in the majority of cases it has an acute onset (62.3%) and since in the 77.3% the clinical presentation corresponds to an incarcerated hernia, a pre-operative diagnosis is only possible in less than a quarter of cases (23.1%). Consequently, the anterior laparotomic approach is predominant (87.2%).

Methods: a 53 years old male patient, with no particular medical history, has been suffering from right groin pain for a couple of weeks. A clinical evaluation found a reducible right inguinal hernia, which was subjected to radiological evaluation by abdominal CT scan that found the presence of a non-flogosated appendix inside the hernia sac. The indication for a laparoscopic exploration in a semi-urgent regime was recommended: after induction of the peritoneum, reduction of the vermiform appendix in the abdomen was observed. On direct observation there were no signs of local inflammation. We therefore opted for a trans-peritoneal approach (TAPP) to treat the hernia. A onflex mesh was placed and the peritoneum closed with a 3.0 V-Loc running suture. In the absence of a clear acute pathology of the appendix we opted not to resect it.

Results: as this is a rare condition, most of the available literature is based on case reports and small case series. In the absence of prospective studies and universally shared guidelines, the approach is mainly based on expert opinion. In cases where there is no clear appendicular inflammation, removal of the appendix is generally avoided in order not to contaminate the operation field. Laparoscopy could offer a better intraperitoneal assessment and to avoid to manipulate the appendicular stump in the inguinal canal.

Conclusions: the state of the art does not at this time allow a clear strategy to be defined in the case of a normal caecal appendix in the context of Amyand's hernia. It is therefore still up to the surgeon's experience to decide whether or not to proceed with appendicular resection.

11th Swiss Trauma & Acute Care Surgery Days , 2022

Background: Traumatic diaphragmatic hernia (TDH) is a rare entity, occurring in less than 1% of a... more Background: Traumatic diaphragmatic hernia (TDH) is a rare entity, occurring in less than 1% of all blunt traumatic injuries and are frequently associated with other thoraco-abdominal, cerebral, or musculoskeletal injuries. The prevalence of TDH is higher in penetrating compared to blunt trauma and is most frequently found on the left side (about 75 %). Due to its rarity, it remains a challenging disease, as no guidelines are available

Methods: A 51 year-old female, in good health, presented to our emergency department with an isolated blunt thoracic trauma after a minor ski accident a day earlier. She developed abdominal pain associated with multiple episodes of vomiting. A CT scan showed a right-sided intrathoracic translocation of intestinal loops with signs of strangulation

Results: We performed an emergency laparoscopy via an ombilical optical trocart (10mm). Two 5mm and one 10 mm trocars were placed in the left and right hypochondrium, and the subxiphoid region. The exploration confirmed the presence of about 100cm of small bowel as well as the apex of segment VIII that had herniated within the thoracic cavity. Following reduction into the abdominal cavity, no ischemic or necrotic lesion of the small bowel was observed. The diaphragmatic lesion measured 6 x 3 cm and was sutured with non-absorbable stitches (2-0 V-loc™ PBT). The remaining hydropneumothorax was suctioned prior to tight closure of the diaphragmatic tear. A resorbable mesh (VICRYL® 13.5 x 11 cm) was placed over the diaphragmatic suture and fixed with absorbable tackers (SorbaFix™). The exploration of the abdominal cavity did not show any further injuries. No thoracic drain was left in place. A post-operative chest X-ray showed a minimal residual pneumothorax (<1cm apical). The patient was discharged on post-operative day 3.

Conclusions: We describe a safe and effective minimally invasive approach for an acute TDH. Early diagnosis and treatment are essential in avoiding complications related to visceral strangulation. Even in the absence of a thoracic drainage, the postoperative clinical course and control radiography presented no complications. A transabdominal laparoscopic approach is preferable over a transthoracic approach, as any associated intraabdominal lesions can be diagnosed and repaired

Swiss Knife, 2018

Objectives: Peritoneal Mesothelioma is a known malignant entity, but much less described in liter... more Objectives: Peritoneal Mesothelioma is a known malignant entity, but much less described in literature is the existence of an extremely rare benign form. Benign Multicystic Peritoneal Mesothelioma (BMPM) is a benign cystic neoplasm that arise from the peritoneum, typically found in young females (83%), with a high incidence of local recurrence after surgical resection (almost 50% of cases). Fewer than 200 cases have been reported worldwide in 2017. Due to its rarity and the lack of a classical clinical presentation the diagnosis pre-operatively is challenging. Clear guidelines are nowadays still not avaible, and the treatment is based upon the resection en bloc of the lesion. Some authors suggest the use of hyperthermic intraperitoneal chemotherapy (HIPEC) associated with a surgical approach, even if comparative data on recurrence and complications are lacking.

Methods: A healthy 40 year old male who complained from 5 years of occasional abdominal discomfort was investigated with an echography, which identify a 9 cm polycystic lesion in the right flank. A contrast enhanced CT scan was performed revealing a polylobate hypodense formation, with multiple thin internal septa which are enriched after contrast (dimension 83 x 43 x 61 mm) (Fig.1).

Results: The patient underwent an exploratory laparoscopy that confirmed the presence of multiple cystic lesions of the peritoneum. We performed a complete excision of the neoformation, keeping a sufficient resection margin (Fig. 2,3). A small lesion of the colonic serum was treated with a prophylactic continuous. The post-operative course was uneventful and the patient was discharged after 2 days without complications. Pathology revealed a BMPM (Fig.4). After discussion with our Referral Center was suggested an annual follow-up with MRI, and in case of relapse an approach with cytoreductive surgery and subsequent HIPEC.

Conclusions: There is a benign form of peritoneal mesothelioma. The rarity of BMPM is for sure a prominent limitation to a better knowledge of this pathology. The most part of current literature is based upon small group studies and case reports, with an evident limit to the understanding of the causes, the biological behavior and the possible therapies. The institution of nation based registry for this pathology may help to rise the number of reported cases, helping to increase the possibility to understand this still almost unknown neoplasm.

Swiss Knife, 2018

Objectives: Acute appendicitis is one of the most common cause of admission at the emergency depa... more Objectives: Acute appendicitis is one of the most common cause of admission at the emergency department for abdominal pain. The typical signs and symptoms allow to make a strong diagnostic suspicion with clinical evaluation only, confirmed in most of the cases with an abdominal echography. In elderly the clinical pattern may not be so evident, leading to delayed diagnosis and increasingrisk of perforation, mortality and morbidity. But some complications of acute appendicitis appears mostly in case reports from developing countries, where the access to healthcare is strongly limited.

Methods: A 68 year old male, with a moderate kidney dysfunction, in therapy with Acenocoumarol for an hereditary thrombophilia was admitted for a spontaneous hematoma of the rectus abdominis, confirmed by an abdominal sonography. After one month he developed a new swelling in right iliac fossa. He was investigated again with an abdominal echography and a CT scan that were interpreted as an abscessualization of another spontaneous hematoma without relation with the abdominal cavity. It was started a broad spectrum antibiotic therapy but since there was not a clinical improvement, a new CT scan was performed.

Results: The patient was then transferred to our Hospital. In the strong suspect of an intra-abdominal source of the infection we performed a colonoscopy, that found a purulent secretion from the appendiceal foramen. The patient underwent a laparoscopic cecal resection and an open wedge resection of the abdominal wall interested by the abscess. The defect was closed with a Vycril mesh and omental patch, a V.A.C.® dressing was placed. The post-operative course was complicated by an extended DVT of the right leg, treated with unfractionated heparin. The patient was then dismissed in day 15.

Conclusions: In elderly patient acute appendicitis the urgency of the clinical presentation is often blurred, with consequent diagnostic delay and increased morbidity and mortality. Even if not frequently, an advanced acute appendicitis can present as a parietal abscess or much more rarely through an enteric fistulisation. It is necessary to consider in case of appearance of a swelling of the abdominal wall without trauma a possible endoperitoneal origin of the problem and proceed to adequate sonographic or tomographic imaging, deepening in case of persistence of doubt through a targeted endoscopic examination

Swiss Knife, 2018

Objectives: Laparoscopic approach for ventral hernias is nowadays a well-established technique. T... more Objectives: Laparoscopic approach for ventral hernias is nowadays a well-established technique. The most common procedure consists inthe placement of an intraperitoneal onlay mesh (IPOM) although this may lead to adhesions, fistulisation and migration inhollow organs. Some authors described a preperitoneal approach for the mesh placement but as described in the 2014 Guidelines of the International Endohernia Society (IEHS) the most important disadvantage is the technical difficulty and the longer operating time. In our experience a possible solution to these limitations is the adoption of a 3D laparoscopic system.

Methods: An obese 45 year old male (BMI 31 kg/m²), with a past history of laparoscopic resection of a strangulated epiploic appendix, complained of a symptomatic, reducible, supra-umbilical swelling. An abdominal wall echography identified the presence of 2 midline incisional hernias (1.9 x1.3 cm; 1 x 1,3 cm) containing only preperitoneal fat.

Results: The patient underwent a 3D laparoscopic approach (AESCULAP® 3D EinsteinVision). 3 Trocars (12, 10 and 5 mm) were placed on the left side of the abdomen. We proceeded with a longitudinal incision of the peritoneum on the left of the midline with opening of the preperitoneal space and exposure of the posterior rectus sheath. Intraoperatively we founded a third little defect (5 mm) of the fascia. The hernias were then closed with Polyester Suture knots and then covered with Monocryl and Prolene mesh (ULTRAPRO® 11x 6 cm) on the posterior rectus sheet. We fixed the mesh with absorbable fixation device (AbsorbaTack™) and then closed the peritoneum with a barbed suture (V-Loc™ 4-0).The course was uneventful and the patient was dismissed on the first post-operative day.

Conclusions: Laparoscopic IPOM hernia repair is nowadays a routinely approach for ventral and incisional abdominal wall hernias. Even if progress in technology of mesh composition is leading to better tolerate devices, two-thirds of the patients will develop adhesions. The placement of the mesh in the preperitoneal space could be a solution, but this requires advanced surgical skills and a longer operating time. The adoption of a 3D laparoscopic system could lead to an easier and faster approach, making the TAPP approach feasible and safer for small and medium ventral hernias. Further studies are needed to confirm if the third dimension could provide an effective surgical advantage.

Swiss Knife, 2017

Objectives: Small bowel bleeds are rare compared to other gastrointestinal sources of haemorrhage... more Objectives: Small bowel bleeds are rare compared to other gastrointestinal sources of haemorrhage. Hemorragic Meckel Diverticulum is one of the most frequent causes of an "obscure" bleed, more typical of the juvenile population, often recurrent and in most cases not requiring blood transfusion. Classically the literature proposes the use of aMeckel's scan (Technetium-99 m) for accurate diagnosis of MD, but use of this exam is impractical in thediagnostic process when searching for other causes of small bowel bleeding. In this study we present a case of MD bleeding identified with another diagnostic tool.

Methods: A healthy 50 year old female who complained of melena was investigated in the outpatient setting with a EGDS, which did not identify any source of haemorrhage up until the Trietz ligament. Although haemodynamically stable, she presented to our emergency department (ED) for progressive anemia requiring blood transfusion.

Results: A contrast enhanced CT scan did not show active bleeding. The presence of melena and dark-red stools, without a hemorrhagic source was seen on emergent colonoscopy. After interdisciplinary discussion, it was decided to proceed with capsule enteroscopy with subsequent identification of a MD. The patient underwent a laparoscopic diverticulectomy and was discharged after 4 days without complications. Pathology revealed a diverticulum with ectopic gastric mucosa

Conclusions: Due to the presence of ectopic gastric mucosa, current literature suggests the use of a Technetium-99m scan for the diagnosis of Meckel diverticulum. However the specificity of this exam does not allow for the identification of other sources of bleeding. The practical use of capsule enteroscopy may allow for the inclusion of a greater spectrum of identifiable differential diagnoses. A recent increase in the number of published case reports of "obscure" gastrointestinal bleeds due to MD, found with capsule enteroscopy, may suggest a future diagnostic role for this exam. Further studies are needed to investigate the sensitivity, specificity, pros and cons of this diagnostic tool compared to the classic Meckel's scan.