Background: Gastrointestinal stromal tumors (GIST) are the most frequent mesenchymal tumours in the digestive tract. The duodenal GIST (dGIST) is the rarest subtype, representing only 4-5% of all GIST, but up to 21% of the resected ones. The diagnostic and therapeutic management of dGIST may be difficult due to the rarity of this tumor, its anatomical location, and the clinical behavior that often mimic a variety of conditions; moreover, there is lack of consent for their treatment. This study has evaluated the scientific literature to provide consensus on the diagnosis of dGIST and to outline possible options for surgical treatment.Methods: An extensive research has been carried out on the electronic databases MEDLINE, Scopus, EMBASE and Cochrane to identify all clinical trials that report an event or case series of dGIST.Results: Eighty-six studies that met the inclusion criteria were identified with five hundred forty-nine patients with dGIST: twenty-seven patients were treated with pancreatoduodenectomy and ninety-six with only local resection (segmental/wedge resections); in four hundred twenty-six patients it is not possible identify the type of treatment performed (pancreatoduodenectomy or segmental/wedge resections).Conclusions: dGISTs are a very rare subset of GISTs. They may be asymptomatic or may involve symptoms of upper GI bleeding and abdominal pain at presentation. Because of the misleading clinical presentation the differential diagnosis may be difficult. Tumours smaller than 2 cm have a low biological aggressiveness and can be followed annually by endoscopic ultrasound. The biggest ones should undergo radical surgical resection (R0). In dGIST there is no uniformly adopted surgical strategy because of the low incidence, lack of experience, and the complex anatomy of the duodenum. Therefore, individually tailored surgical approach is recommended. R0 resection with 1-2 cm clear margin is required. Lymph node dissection is not recommended due to the low incidence of lymphatic metastases. Tumor rupture should be avoided.

Introduction In obese patients with hiatal hernia (HH), laparoscopic sleeve gastrectomy (LSG) with cruroplasty is an option but use of prosthetic mesh crura reinforcement is debated. The aim was to compare the results of hiatal closure with or without mesh buttressing during LSG. Methods Gastroesophageal reflux disease (GERD) was assessed by the Health-Related Quality of Life (GERD-HRQL) questionnaire before and after surgery in two consecutive series of patients with esophageal hiatus ≤ 4 cm2. After LSG, patients in group A (12) underwent simple cruroplasty, whereas in group B patients (17), absorbable mesh crura buttressing was added. Results At mean follow-up of 33.2 and 18.1 months for groups A and B, respectively (p = 0.006), the mean preoperative GERD-HRQL scores of 16.5 and 17.7 (p = 0.837) postoperatively became 9.5 and 2.4 (p = 0.071). In group A, there was no difference between pre- and postoperative scores (p = 0.279), whereas in group B, a highly significant difference was observed (p = 0.002). The difference (Δ) comparing pre- and postoperative mean scores between the two groups was significantly in favor of mesh placement (p = 0.0058). Conclusions In obese patients with HH and mild-moderate GERD, reflux symptoms are significantly improved at medium term follow-up after cruroplasty with versus without crura buttressing during LSG.

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AbstractFournier’s gangrene is a potentially fatal emergency condition characterized by necrotizing fasciitis and supported by an infection of the external genital, perineal and perianal region, with a rapid and progressive spread from subcutaneous fat tissue to fascial planes.In this case report, a 52-year-old man, with a history of hepatitis C-virus (HCV)-related chronic liver disease and cocaine use disorder for which he was receiving methadone maintenance therapy, was admitted to the Emergency Department with necrotic tissue involving the external genitalia.Fournier’s gangrene is usually due to compromised host immunity, without a precise cause of bacterial infection; here it is linked to a loco-regional intravenous injection of cocaine. A multimodal approach, including a wide surgical debridement and a postponed skin graft, was needed. Here we report this case, with a narrative review of the literature.

Background The aim of this case-control study is to compare the surgical outcomes of laparoscopic adrenalectomy (LA) for lesions measuring C6 cm versus B5.9 cm in diameter. Methods Eighty-one patients with adrenal gland lesions C6 cm in diameter (intervention group) were identified. Patients were matched to 81 patients with adrenal gland B5.9 cm in diameter (control group) based on disease (Conn-Cushing syndrome, pheochromocytoma, primary or secondary adrenal cancer or other disease), lesion side (right, left), surgical technique (anterior transperitoneal approach for right and left LA or anterior transperitoneal submesocolic for left LA) and body mass index class (18-24.9, 25-29.9, 30-34.9, 35-39.9, C40 kg/m 2 ). Surgical outcomes were compared between the intervention and control groups. Results Mean operative time was statistically significantly longer in the interventional arm (101.4 ± 52.4 vs. and 85 ± 31.6 min, p = 0.0174). Eight conversions were observed in the intervention group (9.8%) compared to four in the control group (4.9%) (p = 0.3690). Five (6.1%) and three (3.7%) postoperative complications were observed in the intervention and control groups, respectively (p = 0.7196). Mean postoperative hospital stay was 4.6 ± 2.4 and 4.1 ± 2.3 days in the intervention and control groups, respectively (p = 0.1957). Conclusions Operative time was statistically significantly longer in adrenal gland lesions C6 cm in diameter (vs. B5.9 cm). Conversion and complication rates were also higher, but the difference was not statistically significant. Based on the present data, adrenal gland lesions C6 cm in diameter are not an absolute contraindication to the laparoscopic approach.

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The use of NGME during ELRR by TEM increases the lymph node harvest and may improve staging accuracy after transanal surgery.