Schwannomas of the cervical vagal nerve are rare neoplasms, usually occurring between the third and the sixth decade of life. They don't demonstrate any sex predilection, and they often present as slow-growing, palpable neck masses, leftright sided, without early neurological symptoms, and they are often confused with enlarged lymphnodes or lipomas. Several differential diagnosis should be considered. Imaging techniques are largely used to define their etiology. If they are considered primary to evaluate their relationship with surrounding structures (i.e. omolateral neck vessels and nerves, oesophagus, trachea), they don't always result decisive for a correct differential diagnosis. Surgical excision is the treatment of choice: when technically possible, nerve sparing technique has to be preferred to en-bloc resection, because of the possibility of neurological outcomes such as dysphonia, dysphagia, hoarseness, vocal cord paralysis after surgical therapy. We report our case about a 34 years-old male, evaluating differential diagnosis course, choosing the correct therapy in relation with literature cases, and including new techniques for post-operative outcomes, such as injectable soft-tissue bulking agent performed in the last years to ameliorate dysphonia after nerve trunk injury. KEY WORDS: Enucleation; Neurinoma; Schwannoma.

Although associated with certain advantages, laparoscopic repair of inguinal hernias implies longer operative times, increased intra-abdominal injuries, and a higher rate of urinary retention. To address these issues, we developed the transabdominal rivet technique (TART) for laparoscopic inguinal hernia repair.Three patients underwent bilateral inguinal hernia repair: two underwent TART only, and one underwent a standard transabdominal preperitoneal technique on one side and TART on the other for comparison. TART was performed using a round ring of mesh connected to two non absorbable polyethylene straps; the ring closed the gap in the abdominal wall, and the straps were passed through the defect and secured externally.The average operative time was 12 minutes per side, and the average hospital stay was 22.3 hours. No patients required analgesics. Urinary retention occurred in one patient with preexisting prostatitis and was not thought to have been the result of the procedure. Good mesh positioning was observed by computed tomography at 2 months, and no recurrence was seen 6 months after the operation.Based on the results of this preliminary study, TART is a safe, rapid, feasible procedure for treatment of inguinal hernia repair. This study serves as a foundation for further research using a larger sample size. KEY WORDS: Inguinal hernia, Laparoscopy, Rivet.

Abstract.

The lipoma is the most common tumor of the body and can be found in virtually every tissue or organ. However, a parosteal lipoma is a rare benign fatty neoplasm having an intimate relationship to the periosteum. The incidence of this tumor is 0.3% of all lipomas. Over 150 cases of parosteal lipoma have previously been described in the literature. Owing to the rarity of this condition and the difficulties encountered in its diagnosis and treatment, we wish to report fifteen new cases of parosteal lipoma. We reviewed the clinical records of 15 patients who underwent surgery to remove a parosteal lipoma between November 2003 and July 2009. The diagnosis of a parosteal lipoma was made by the histological findings, the confirmation of fat content at Magnetic Resonance or Computed Tomography. Surgery in all the cases entailed resecting the tumor with parosteal excrescence. In three cases with hyperostosis, a further exeresis of the bone was performed. Parosteal lipomas are rare entities associated with periosteal involvement depending on their location. Current management should include computed tomographic scanning and magnetic resonance. Surgery, which is mandatory treatment, requires particular attention to ensure that any periosteal involvement is removed completely. KEY WORDS: Computed Tomography, Diagnosis, Magnetic Resonance, Parosteal lipoma, Surgical treatment.

Neoplastic gastroduodenal inoperable stenosis require a palliative treatment to restore alimentary transit.Our purpose was to treat neoplastic gastroduodenal stenosis with self-expanding enteral stents.An endoscopic treatment with uncovered self-expanding metal stents has been performed in 45 patients: 37 duodenal stenosis (34 pancreatic neoplasia, 1 gallbladder neoplasia, 2 peritoneal carcinosis), 5 anthropyloric neoplastic stenosis and 3 gastro-jejunal anastomosis stenosis were treated. A total of 47 metal stent were positioned: in 43 patient 1 stent; in 2 patient, with a long stenosis, 2 stents. Main Outcome Measurement: Efficacy of endoscopic treatment to restore alimentary transit.The positioning was successfull in all cases without any complication. All patients had a rapid and satisfying recovery from symptoms connected to the obstruction. The hospitalization period was averagely 3 days (range 1-7). In one patient another stent was inserted 2 months later because of tunoral ingrowth. The median survival period was 4 months (range 1-5). In one patient with duodenal stenosis due to pancreatic neoplasia,in which were inserted 2 stents, distal one dislocated in the jejunum 3 months later. It was removed by surgery.The endoscopic stenting is a valid treatment of inoperable gastric duodenal stenosis and may become the preferable option for the palliative treatment of this pathology. KEY WORDS: Endoscopy, Gastroduodenal, Neoplasia, Obstruction, Stent.

The acute intrathoracic gastric volvulus is a rare condition, difficult to diagnose and treat. It consist in a abnormal organo-axial rotation over 180°, associated with gastric obstruction or strangulation. More uncommon condition is the gastric volvulus caused by a right sliding diaphragmatic hernia and dislocating the stomach, or part of it, on the right hemithorax. Gastric volvulus classic clinical presentation described by Borchardt, consist on a triad of severe epigastric pain, vomiting followed by retching without ability to vomit and difficulty or inability to pass a nasogastric tube. Imaging, beginning from a simple chest radiograph showing an elevated gastric air-fluid level in lower lung segments, can help to define diagnosis and to determine the immediate necessity to operate trying to avoid fatal complications as gastric ischemia, perforation or haemorrhage. We present the case of a 58 year-old man arrived at our Emergency Department with moderate acute epigastric pain and already vomiting from 4 hours. The patient underwent initially a chest radiograph, Computed Tomography, upper digestive endoscopy, upper digestive contrasted radiology and then was operated. Post operative situation of the patient on recovery and during the 3 months follow up didn't experience any pain or difficulty in feeding. KEY WORDS: Borchardt's triad, Diaphragmatic hernia, Gastric volvulus.

This study want to examine (a) whether neutrophils, the neutrophil-elastase, C-reactive protein and the Interleukin- 6 are modified and how, in patients after laparoscopic cholecystectomy open cholecy stectomy; (b) whether these findings are indicative of an increased risk to develop infectious complications. MATERIALS OF STUDY: Circulating Interleukin-6 level, C-reactive protein and neutrophil-elastase were measured in 71 patients (35 underwent open cholecystectomy and 36 laparoscopic cholecystectomy). The diagnosis was confirmed by ultrasound examination. During hospitalization the patients were not given antispastic drugs, steroids, or nonsteroidal antiinflammatory drugs (NSAID).The increase in the serum Interleukin-6 and neurtophil-elastase, during laparoscopic cholecystectomy, was found to be significantly smaller than that during open cholecystectomy and resulted in a smaller extent of postoperative elevations for C-reactive protein. We recorded three cases (8.5%) of postoperative infections in the "open'" group and neutrophil- elastase values normalized later in patient with complications.There were significant associations between the response areas of Interleukin-6, C-reactive protein and neutrophil- elastase levels. Neutrophils-elastase level is a more sensible inflammatory marker in comparison to the IL-6 and C-reactive protein. Excessive and prolonged post injury elevations of these mediators are associated with increased morbidity. KEY WORDS: Cholecistectomy, Inflammatory markers, Neutrophils response.

The number of short-stay surgery procedures has progressively increased since the concept of short-stay surgery was first introduced. Initially this type of surgery was reserved for patients undergoing inguinal hernia repair, proctological surgery, and various minor procedures. Careful patient selection makes it possible to apply one-day surgery to other surgical specialties including breast cancer surgery. Reducing the length of hospital stay lowers health care costs, and shortens waiting lists. The most important benefits for patients are a more rapid return to work and positive psychological effects. Exclusion criteria for one-day surgery are the lack of home care, excessive distance from place of treatment and the presence of any concomitant pathology that is a contraindication to this type of surgery. We report our experience in oncological surgery of the breast in one-day surgery. KEY WORDS: Breast cancer surgery; One-day surgery.

Skeletal muscle metastasis is a very rare event in patients with oesophageal cancer. We herein report and discuss a case of a 65 years old man with history of gastro-esophageal reflux disease referred to our department for pyrosis associated to persistent low back pain. Oesophageal endoscopy and transesophageal endo-sonography showed a tumour localized in the lower third of the esophagus, histologically proved to be adenocarcinoma. Clinical staging procedures detected a two centimetres vascularized nodular lesion placed into right para-vertebral muscles at the level of L4 as the only sign of potential distant disease (versus a differential diagnosis of primitive sarcoma). The muscle lesion was completely removed and confirmed as secondary adenocarcinoma. Due to this evidence a chemotherapy protocol was initiated. After nine months the patient underwent transhiatal oesophagectomy. To the best of our knowledge this is the first reported case of a soft tissue metastasis from oesophageal cancer resected with radical intent. KEY WORDS: Low back pain, Oesophageal adenocarcinoma, Skeletal muscle metastasis.

Several studies have now demonstrated that the lymph node ratio (LNR), as a superior indicator of axillary tumor burden to the number of excised nodes. While, about the prognostic value of LNR on the the survival of elderly patients is limited. The aim of this retrospective multicenter study is to evaluate the prognostic value of lymph node ratio in elderly patients with node positive breast cancer.Onehundredeightyfour patient with operable breast cancer, recruited from 17 institutions, were enrolled into the retrospectively study. Eleven potential prognostic variables were chosen for analysis in this study. Univariate and multivariate analyses were conducted to identify prognostic factors associated with survival.Among the eleven variables of univariate analysis, four variables were identified to have prognostic significance for Overall survival (OS): pathologic tumor size (T), No. of positive nodes (N), LNR and estrogen receptor-positive (ER). Among the eleven variables of univariate analysis, two variables were identified to have prognostic significance for Disease-free survival (DFS): N and LNR. Multivariate analysis by Cox proportional hazard model showed that T, LNR and ER were considered independent prognostic factors for OS. Furthermore, LNR was considered independent prognostic factors for DFS.In conclusion, the LNR was associated with the prognostic importance for DFS and OS in elderly patients who were administered adjuvant treatments. KEY WORDS: Breast cancer, Elderly patients, Lymph Node Ratio.