Chirurgia italiana最新文献

We describe an unusual case of self-amputation of a transanal prolapsed colorectal segment by a 48-year-old mentally impaired woman. The surgical procedure and favourable outcome are reported.

Recurrence after conservative thyroid surgery ranges from 7 to 40%. Risk factors for recurrence are female sex, multiple nodules in the resected lobe and lack of postoperative LT4 therapy. Indications for reoperation are suspected malignancy, recurrent thyrotoxicosis and recurrent uninodular or multinodulare goitre. From 2002 to 2008, 2149 total thyroidectomies were performed. Ninety-two patients had a completion thyroidectomy. The indication was recurrent multinodular goitre in 81, recurrent thyrotoxicosis in 3, and suspected malignancy in 8. Bilateral completion thyroidectomy was performed in 63 cases, lobectomy in 27 cases, removal of a mediastinal recurrence in 1 case and removal of a pyramidal remnant in 1 case. Histological examination revealed papillary cancer in 18 patients and follicular cancer in 1. Mean operative time was 140 minutes (range: 60-260). All patients were submitted to a minimum follow-up of 6 months. Temporary hypoparathyroidism occurred in 36 patients (39.1%) and definitive hypoparathyroidism in 7 patients (7.6%). Transient recurrent laryngeal nerve palsy occurred in 3 cases (3.2%) and permanent nerve palsy in 1 (1.1%). In 3 cases (3.2%) surgical revision of haemostasis was necessary for postoperative haemorrhage. Total thyroidectomy is the treatment of choice in multinodular goitre. In the cases in which reoperation is necessary, the intervention must be performed by an experienced surgeon.

Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract and have only recently been described based on their specific immunohistochemistry and the presence of particular kit-related mutations which potentially make them targets for tyrosine kinase inhibition. Most GISTs are respectable, with survival mainly depending upon mitotic count and completeness of resection. Our own and other studies suggest that, in locally advanced cases, complete surgical resection (R0 resection) and adjuvant molecular therapy with imatinib yield good outcomes in terms of survival and disease-free status at 12 and 18 months. This approach, in the light of such integrated surgical-molecular therapy and of the new pharmaceuticals currently under research, means that we can now offer a real chance of recovery and a longer survival period to patients even with advanced-stage illness or local recurrence.

The advantages and applications of the videolaparoscopic technique (VL) versus open surgery in the treatment of acute and complicated appendicitis are not well defined. The aim of this study was to identify which of the two procedures is more suitable. The study examined 124 patients, 73 females (57.5%) and 51 males (42.5%). We compared 62 patients in the laparoscopic group with 62 open surgery patients. We analysed the results of the two groups (VL, open) for age, gender, operative time, hospital stay, complications and costs. The mean patient age was 24.1 years (range: 4-70). The conversion rate was 1.6% (1 case/62). The patients in the laparoscopic group were predominantly female (p < 0.0001). The average age of VL patients compared to open surgery was significantly higher (p < 0.01). The mean operative time was not significantly different between the two groups. The hospitalisation time was shorter for the laparoscopic group (4.77 vs. 6.39 days, p < 0.01). Complications were 0% for VL and 4.81% for the open group. The average operation cost in the open group was 8070.00 euros (+/- 4267) and 6818.00 euros (+/- 1446,00) for VL (p < 0.05). Laparoscopic appendectomy has significant advantages over traditional open surgery and should be the first choice in cases of acute but uncomplicated appendicitis.

Small bowel metastases from a primary lung carcinoma are rare. We report a case of a 76-year-old male with a primary neuroendocrine small cell carcinoma of the lung, treated by chemotherapy, who developed fever and bowel symptoms (subocclusion and pain). On CT examination, he was found to have a tumour in the small bowel. The patient then underwent abdominal surgery. At operation we found small bowel occlusion by neoplasia and we therefore resected 15 cm of ileum with a side-to-side anastomosis. Early recognition of this rare condition is important due to the fact that complicated intestinal metastases from lung carcinoma can lead to high mortality rates and poor short-term outcomes. With advances in chemotherapy and palliative care, patients with metastatic lung carcinoma can sometimes survive more than a year with a reasonable quality of life.

Early gastric cancer is a gastric carcinoma confined to the mucosa or submucosa of the stomach, regardless of the presence of nodal involvement, which in any event is present only in about 20% of patients. This uncommon nodal involvement is a distinct clinical problem, because standard D2 lymphadenectomy constitutes overtreatment in more than 80% of patients. A review of the literature shows that the present surgical tendency for those patients who do not fulfill the Gotoda criteria (i.e. not amenable to an endoscopic mucosal or submucosal dissection) is to modulate the extent of the lymphadenectomy on the basis of the characteristics of the cancer: for mucosal early gastric cancers located in the upper third of the stomach, gastrectomy with D1 lymphadenectomy is sufficient; if located in the middle third the extent should be D1 +alpha (D1 + n. 7), while if located in the distal third, D1 +beta (D1 + n. 7,8a,9) is the best option. In all these cases, minimally invasive surgery can be a valid option, with results which are comparable to those of open surgery, but with all the advantages of the laparoscopic approach. For submucosal early gastric cancers, D1 +beta lymphadenectomy is indicated for neoplasia > 20 mm and of the protuberance type, while, for all other submucosal early gastric cancers (> 20 mm and of the depressed type, penetrating more than 500 micron into the submucosal layer, not differentiated, with lymphovascular invasion), standard D2 lymphadenectomy is the safest oncological procedure. In these cases, too, the laparoscopic approach can be a safe option, even if it requires greater laparoscopic skill.

In the daily clinical practice of surgeons operating electively or, more frequently, in the emergency setting, within the abdominal cavity and pelvis, the detection of an intestinal adhesive disorder is frequent and is capable of causing numerous complications and subsequent reintervention. We report three cases of female patients referred to our observation for bowel subocclusion due to adhesive syndrome. After laparotomy, which revealed the presence of singular tenacious fibrovascular adhesions, the patients were subjected to immunohistochemical and receptor analysis yielding a diagnosis of leiomyomatosis peritonealis disseminata. The simultaneous combination of high levels of exogenous female hormones (hormone replacement therapy or prolonged exposure to oral contraceptives) or endogenous hormones (as happens during pregnancy), a genetic predisposition (including genetic malformations) and previous surgery (peritoneal trauma), as evidenced in our patients, all seem to play a key role in the pathogenesis of so-called "dense-vascularised", particularly tenacious adhesions responsible for the activation of multipotent mesenchymal submesothelial peritoneal cells. This striking macroscopic picture, when related to the anatomico-pathological description, is the basis of the pathological entity known as leiomyomatosis peritonealis disseminata.

Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are a distinct entity with malignant potential, which may recur after surgical excision. Limited pancreatectomies have been recently proposed for non-invasive tumours. We report our technique of intraoperative US-guided resection of non-invasive IPMNs located in the tail of the pancreas with spleen and splenic vessel preservation. Following adequate exposure of the distal pancreas, a thorough ultrasonographic examination of the parenchyma is accomplished to define the features of the neoplasia, its relationship with the main pancreatic duct and splenic vessels and to mark the transection line with electrocautery. Dissection begins at the inferior edge of the pancreatic tail and proceeds in a lateral to medial direction up to the transection line. The main pancreatic duct is identified and sutured, the parenchyma is then closed and the suture line is reinforced with a fibrinogen/thrombin-coated collagen patch. Patient 1 was a 63-year-old male who underwent intraoperative US-guided resection of the pancreatic tail for an IPMN of the pancreatic tail measuring 28 mm with moderate dysplasia at histology, and was discharged 9 days after surgery. Patient 2 was a 60-year-old male who underwent intraoperative US-guided resection of the pancreatic tail for an IPMN of the pancreatic tail measuring 30 mm with carcinoma in situ at histology, and was discharged 9 days after surgery. Limited distal pancreatic resection with spleen and splenic vessel preservation is an adequate surgical technique for non-invasive IPMN of the tail of the pancreas. Intraoperative ultrasonography is crucial in planning "radical but conservative" pancreatic resection.

Dehiscence of upper gastrointestinal sutures still remains a severe clinical problem and often requires complex surgical repair. Despite its multifactorial aetiopathogenesis, endoluminal pressure seems to play an important role in the onset and maintenance of this complication. The efficacy of isoperistaltic endoluminal drainage (IED) in the operative treatment or prevention of upper gastrointestinal surgical dehiscence was assessed in a retrospective study. The IED procedure is obtained by means of a two-way nasogastric tube inserted in the proximal jejunum through the abdominal and advanced to the site of the leak in order to achieve low endovisceral pressure, normal intestinal free flow downstream of the lesion and monitoring of the healing process. Over the past decade 31 patients (mean age 62 years; 52.9% male) with postoperative dehiscences of the thoraco-abdominal oesophagus, stomach or duodenum underwent reintervention. During the surgical repair an IED was inserted in 17, while no IED was inserted in 14 (NOIED): the two groups were well matched for age, gender, primary pathology, site and type of leak. The overall operative mortality (30 days) was 16% (12.5% IED vs. 20% NOIED), and morbidity was 45% (37.5% IED vs. 53.3% NOIED). The rate of leak relapse was significantly different: 6% IED vs. 20% NOIED. In the last 5 years the IED procedure has also been used preventively with promising outcomes in another 16 other high-risk upper gastrointestinal suture patients. The results of this retrospective study appear to support the use of the IED procedure to minimize the risk of failure of the suture/anastomosis in upper gastrointestinal surgery. Other studies are needed to validate the efficacy of this supplementation of surgical treatment.

Management of blunt abdominal trauma has evolved over the last decade and non-operative management (NOM), initially viewed with scepticism, has now become widely used. The aim of this retrospective study was to examine the results of liberal utilisation of NOM of blunt abdominal trauma. For that purpose we examined the charts of 119 patients admitted to our Department of Surgery from January 1998 to July 2006 for blunt abdominal trauma. NOM was opted for in cases of haemodynamic stability. When surgery was mandatory, it consisted in exploratory laparotomy or laparoscopy. Six of the NOM patients (7%) needed surgical exploration during the 24 hours following the trauma. Thus, the success rate for NOM was 93%. Mean length of hospital stay was 12.5 days (range: 2-78); for emergency surgery patients it was 17 days (range: 2-78), and for NOM patients 14.5 days (range: 2-45). In conclusion, NOM may be safely used in cases of blunt abdominal trauma. Haemodynamic instability, suspicion of hollow viscus perforation and multiple transfusions are contraindications to this approach.