title: A rare case of Wunderlich syndrome five days after left hemicolectomy for colorectal cancer.
abstract: BACKGROUND
  Wunderlich syndrome (WS) is a surgical emergency characterized by spontaneous, non-traumatic retroperitoneal hemorrhage. Angiomyolipoma (AML), a benign mesenchymal tumor, is the most frequent cause of WS. We present a case of WS, appearance five days after a left hemicolectomy for cancer.
  
  
  METHODS
  A 66 years-old man with a sigmoid adenocarcinoma and a small left AML (3.4cm) was undergone to left hemicolectomy. He was subjected to bridging therapy with high doses of low-molecular-weight heparin for prosthetic replacement of heart valve secondary to endocarditis and atrial fibrillation. Five days after surgery he presents retroperitoneal hemorrhage due to rupture of AML diagnosed by a CT scan and scintigraphy with labeled red blood cells. Total left nephrectomy was performed as the patient became unstable.
  
  
  CONCLUSIONS
  Rupture of a renal AML is the main cause of WS. This risk increases with the size of the tumor (>4cm) and during pregnancy. CT scan is the best imaging modalities for diagnosis. The bridging therapy increases the perioperative bleeding risk. These patients are conservative treated with selective transarterial embolization. Nephrectomy is limited for the patients hemodynamically unstable or in case of failed embolization.
  
  
  CONCLUSIONS
  This is a unusual case of WS after surgery in patients with small AML and treated with high dose of anticoagulant for cardiac disease. There are no other similar cases in literature.
authors.affiliation: Department of General Surgery, Second University of Naples, Italy. Electronic address: michelegrassia@live.it.
authors.forename: Michele
authors.initials: M
authors.lastname: Grassia
authors.affiliation: Department of General Surgery, Second University of Naples, Italy. Electronic address: angelaromano_ar@libero.it.
authors.forename: Angela
authors.initials: A
authors.lastname: Romano
authors.affiliation: Department of General Surgery, Second University of Naples, Italy. Electronic address: g-expo@libero.it.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Esposito
authors.affiliation: Department of General Surgery, Second University of Naples, Italy. Electronic address: braccio.bartolomeo@email.it.
authors.forename: Bartolomeo
authors.initials: B
authors.lastname: Braccio
authors.affiliation: Department of General Surgery, Second University of Naples, Italy. Electronic address: ninopezze@gmail.com.
authors.forename: Modestino
authors.initials: M
authors.lastname: Pezzella
authors.affiliation: Department of General Surgery, Second University of Naples, Italy. Electronic address: amaliarosariarita.rossetti@gmail.com.
authors.forename: Amalia Rosaria Rita
authors.initials: AR
authors.lastname: Rossetti
authors.affiliation: Department of General Surgery, Second University of Naples, Italy. Electronic address: francesco.torelli@unina2.it.
authors.forename: Francesco
authors.initials: F
authors.lastname: Torelli
authors.affiliation: Department of General Surgery, Second University of Naples, Italy. Electronic address: giuseppe.izzo@unina2.it.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Izzo
authors.affiliation: Department of General Surgery, Second University of Naples, Italy. Electronic address: roberto.alfano@unina2.it.
authors.forename: Roberto
authors.initials: R
authors.lastname: Alfano
authors.affiliation: Department of General Surgery, Second University of Naples, Italy. Electronic address: natale.dimartino@unina2.it.
authors.forename: Natale
authors.initials: N
authors.lastname: Di Martino
keywords: Angiomyolipoma (AML); Bridging therapy; Hemicolectomy; Nephrectomy; Wunderlich syndrome (WS)