Giornale di Chirurgia最新文献

Aim: We present a novel approach to a Littré hernia case.

Case report: A 62-year old male presented at our department with a painless mass in the inguinal area and was successfully treated for an inguinal Littré hernia. A Lichtenstein tension-free mesh repair was used without performing simultaneous diverticulectomy.

Discussion: Resection of an asymptomatic Meckel's diverticulum remains a controversial issue. In adult population, leaving an accidentally found silent Meckel's diverticula in situ could reduce the risk of postoperative complications without increasing late complications. Mesh-based techniques provide lower recurrence rates compared to non-mesh techniques.

Conclusions: Management of asymptomatic Littré hernias presents a challenge for the operating surgeon. Treatment guidelines should be developed for the optimal management of these patients.

Introduction: Intraductal papillary mucinous neoplasms (IPMN) are a rare group of pancreatic neoplasms. Often are asymptomatic and, when are symptomatic, patients complain sensation of weight in the abdomen or compression at the neighboring structures. In many cases the diagnosis is incidental, during a CT or MR performed for other raisons.

Case report: We report a case of a 59-year-old woman with diagnosis of post-pancreatitis pseudocyst who, instead, was affected by an intraductal papillary mucinous neoplasm (IPMN), treated by us with pancreatoduodenectomy.

Discussion: The diagnosis of IPMN has increased in recent years thanks to an improvement in radiological investigation. The study of pancreatic lesions must be very careful and it is absolutely necessary that diagnostic imaging be accompanied by a correct clinical evaluation of the patient.

Conclusion: A thorough anamnesis is required in patient with history of acute pancreatitis to avoid the mistake of exchanging an IPMN for a pseudocyst.

Introduction: Colon cancer is one of the most common neoplastic diseases, with onset in old age; the benefits of the ERAS protocol were evaluated in the peri-operative treatment of patients affected by this neoplasm.

Methods: We studied 90 cases of colorectal neoplasia observed at the General Surgery UOC of the San Camillo de Lellis Hospital between September 2014 and April 2016, undergoing laparoscopic surgery and to which the ERAS protocol was applied; key points were the preoperative oral feeding, the epidural anesthesia, the reduced or failed hydro-electrolytic overload, the early mobilization and recovery of the feeding, the non-use of drainage. The most important parameers considered were the reduced duration of the operating hospital stay, the lower occurrence of early and distant complications.

Results: 85 surgical procedures were performed with laparoscopic technique (94.4%) and 5 with traditional open technique (5.6%). The conversion rate was 5.8% (5/85). 29 surgical procedures of right hemicolectomy (32.2%) and 26 of anterior resection of the rectum (28.9%) were performed; in another 29 patients (32.2%) an intervention with an open traditional technique was performed. A balanced anesthesia was performed in 41 patients (45.6%); epidural anesthesia in 32 cases (35.6%); the Tap Block in 17 subjects (18.9%). The average volume of liquid infusion was 1664cc ± 714; the average post-operative hospital stay of 4.3 ± 0.9 days.

Conclusions: The ERAS protocol reduces the duration of the post-operative hospitalization, involves a lower incidence of precocious and remote complications, in particular if associated with a minimally invasive surgical method; it is easily applicable and reproducible in a hospital environment, with a marked reduction in healthcare management costs.

Background: Groin hernioplasty is the most performed intervention in the adults worldwide. Small bowel occlusion after hernioplasty with anterior approach is an unusual complication because the peritoneum is not opened during this procedure. However during TAPP the closure of the peritoneal flap is mandatory. In literature some cases of small bowel occlusion related to the barbed suture for the closure the peritoneum are reported.

Methods: Here we describe a case of a 64-year old male with small bowel obstruction after TAPP caused by the barbed suture used for peritoneal closure.

Results: Intrabdominal use of self-anchoring suture is controversial. Some studies reported good results by using this device, while others from gynecologists describe bowel occlusion and volvulus caused by barbed suture.

Conclusions: Self-anchoring device is innovative and reduces operation time. It is most important to know the correct use of this device to reduce some possible troubles.

Merkel cell carcinoma (MCC) of the skin is a rare but aggressive cutaneous neuroendocrine-derived malignancy that predominantly affects elderly white males. The presence of distant nodal metastases significantly impacts survival. Typical metastatic sites of MCC are liver, bone, brain and skin. Gastrointestinal metastases are uncommon and small bowel is the most common site followed by stomach. We report a case of symptomatic MCC jejunal metastasis.

Esophageal reconstruction with colonic or jejunal segment is a second choice treatment when the stomach is injured or not adequate for use. These reconstructions, whether pedicled or as free jejunal graft, are technically demanding and they are associated with high rate of morbidity and mortality. Complications are mainly due to insufficient blood supply and therefore anastomotic leak or stricture and graft necrosis. We describe the case of a 51-year-old psychiatric man with diagnosis of esophageal perforation after ingestion of metallic razor blades for suicide intent. The patient was treated at an outside hospital with endoscopic removal of the blades and apposition of endoscopic clips, be cause of esophageal mucosal perforation. Nevertheless, he developed a septic status caused by mediastinitis. The patient underwent several interventions to solve the sepsis and after complete recovery he was referred to our Department for esophageal reconstruction. During surgery we found that the stomach was unavailable for reconstruction, therefore a left colonic interposition pedicled on the left colic vessels was performed through the retrosternal route. During the postoperative course the patient developed acute respiratory failure and suppuration of the cervical wound. The postoperative course was complicated because of the poor compliance of the patient due to his psychiatric disorder. He was discharged in postoperative day (POD) 42 in good clinical conditions, on oral-only diet. Colonic interposition through the retrosternal route after esophagectomy is a technically demanding procedure, associated with high morbidity and mortality, but it is a feasible option when the stomach is not available for reconstruction.

Introduction: Chronic venous insufficiency (CVI) has an important impact on the public health system in particular due to the occurrence of chronic venous ulcers (UCV) and infections.

Objective: To evaluate cultures of biopsies of chronic venous ulcers of patients who suffered an acute change in the intensity of pain of the lesion.

Method: Antibiograms of the cultures of chronic venous ulcer biopsies of patients who suffered an acute change in the lesion with significant pain for 24 hours were evaluated. All patients were treated between 2011 and 2015 in the Vascular Surgery Outpatient Clinic of the Medical School in São José do Rio Preto. Other causes of pain such as chronic arterial insufficiency and problems with the dressings were ruled out.

Results: Positive cultures were detected in 34 of the 35 patients whose pain was resolved by antibiotic therapy.

Conclusion: Acute changes in the intensity of pain associated with chronic venous ulcers seem to be related to local infectious disease.

Background: The impact of diabetes and cardiovascular comorbidity on laparoscopic cholecystectomy has been long debated, evaluating them as risk factors for conversion to an open procedure especially in patients with acute cholecystitis: an "early" procedure, as suggested by 2013 Tokyo guidelines, has been compared to a "very delayed" one in patients under anticoagulant/antiplatelet therapy or treated for diabetes and referred by medical wards to surgery after the acute period.

Methods: We selected 240 patients operated for acute cholecystitis by laparoscopy over the last 4 years at St. Orsola University Hospital-Bologna and Umberto I University Hospital-Rome, comparing 98 diabetic/cardiovascular patients versus 142 subjects as control group: the selection was based on operative timing, "early" (73 patients treated within 3 days) and "very delayed" (167 patients operated after 6 weeks).

Results: In the "early" subgroup there was no difference comparing diabetic/cardiovascular patients (31 pts) versus control group (42 pts) while in the "very delayed" subgroup among diabetic/cardiovascular patients (67 pts) there was significantly male predominance, ASA III/IV prevalence and less positive imaging findings versus control group (100 pts). In both subgroups, the conversion rate was significantly higher for diabetic/cardiovascular patients ("early"=25.8% and "very delayed"=8.95%) compared to control groups ("early"=4.76% and "very delayed"=1%), showing a trend (p=0.058) towards an increased conversion rate in the early approach among diabetic/cardiovascular group.

Conclusions: Our study showed a significantly increased conversion rate to an open cholecystectomy for diabetic/cardiovascular patients affected by cholecystitis, especially within 3 days by the acute episode.

Aim: Typhoid perforation is the most fatal complication of typhoid fever in developing countries and is most often caused by the bacteria Salmonella Typhi. There are conflicting views as to which type of surgical intervention gives the best outcome. The aim of this study was to determine the mortality associated with the different types of surgical interventions employed in patients with typhoid perforation.

Method: This was a retrospective review of the medical records of adult and paediatric surgical patients treated in the general and paediatric surgical units of the Korle Bu Teaching Hospital. Information was obtained from medical records at the Korle Bu Teaching Hospital in Accra, Ghana, between January 2009 and April 2012. The data was analysed using IBM SPSS Statistics version 20 and 22.

Results: 133 patients (median age of 21 years, 72.2% males) with typhoid perforation were included in the study. The typhoid perforation specific mortality rate was 12.8%. Males had a significantly lower mortality rate (7.3%) compared to females (27%). Simple bowel closure (85.7% of total) was the most common surgical intervention performed and patients operated upon with this method had a significantly lower mortality rate (9.6%) compared to patients with bowel resection (31.6%).

Conclusions: In this study, patients treated with intestinal resection were more likely to die from typhoid perforation and female gender was a risk factor for death. Simple bowel closure was the predominant surgical procedure.

Aim: Thoracoscopic lobectomy is superior to thoracotomy, but the evidence for this assumption is low. We present a comparison between thoracotomy and thoracoscopy in term of postoperative complications, mortality, postoperative pain, hospital stay and quality of life.

Patients and methods: This is a retrospective analysis of 224 lobectomies in 24-months. 128 patients (57.1%) were operated by thoracotomy; 96 patients (42.9%) by videothoracoscopy.

Results: Major complications were observed in 4/128 (3.1%) in thoracotomy group and in 1/96 (1%) in thoracoscopy. Minor complications were observed in 38/128 patients (29.7%) in the thoracotomy, and in 16/96 (16.7%) thoracoscopy. Thoracoscopy patients had a shorter hospital stay.

Conclusion: Our study shows an advantage of thoracoscopy over thoracotomy but further studies are needed.