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Voluntary self-amputation of the colon. 自愿自我切除结肠。
Pub Date : 2009-09-01
Aldo Rossi, Beniamino Palmieri, Marzio Malagoli, Nicola Sforza, Marco Giacometti, Stefania Capone

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.

我们描述了一个不寻常的情况下,自我截肢经肛门脱垂结肠直肠段由一个48岁的智障妇女。手术过程和良好的结果报告。
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引用次数: 0
[Recurrent goitre: our experience]. 复发性甲状腺肿:我们的经验。
Pub Date : 2009-09-01
Pietro Giorgio Calò, Massimiliano Tuveri, Giuseppe Pisano, Alberto Tatti, Fabio Medas, Marcello Donati, Angelo Nicolosi

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.

保守甲状腺手术后复发率为7 - 40%。复发的危险因素为女性、切除肺叶内多发结节和术后缺乏LT4治疗。再次手术指征为疑似恶性肿瘤、复发性甲状腺毒症及复发性单结节性或多结节性甲状腺肿。从2002年到2008年,进行了2149例甲状腺全切除术。92例患者完成了甲状腺切除术。81例甲状腺结节复发,3例甲状腺毒症复发,8例疑似恶性肿瘤。双侧完全甲状腺切除术63例,肺叶切除术27例,纵隔复发切除1例,锥体残余切除1例。组织学检查显示乳头状癌18例,滤泡癌1例。平均手术时间140分钟(范围:60-260分钟)。所有患者均接受至少6个月的随访。暂时性甲状旁腺功能减退36例(39.1%),终末期甲状旁腺功能减退7例(7.6%)。短暂性喉返神经麻痹3例(3.2%),永久性神经麻痹1例(1.1%)。3例(3.2%)术后出血需要手术止血。甲状腺全切除术是多结节性甲状腺肿的首选治疗方法。在需要再手术的情况下,必须由经验丰富的外科医生进行干预。
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引用次数: 0
Gastrointestinal stromal tumours. Is aggressive surgical treatment reasonable in locally advanced cases? 胃肠道间质瘤。局部晚期患者积极手术治疗是否合理?
Pub Date : 2009-09-01
Pasquale Ascenzi, Luca Orienti, Uche Okoro, Andrea Raspanti, Giampiero Ucchino

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.

胃肠道间质瘤(gist)是胃肠道最常见的间质肿瘤,直到最近才根据其特异性免疫组织化学和特定试剂盒相关突变的存在进行描述,这些突变可能使其成为酪氨酸激酶抑制的靶标。大多数gist是值得尊敬的,生存主要取决于有丝分裂计数和切除的完整性。我们自己和其他研究表明,在局部晚期病例中,完全手术切除(R0切除)和伊马替尼辅助分子治疗在12个月和18个月的生存和无病状态方面取得了良好的结果。这种方法,结合手术-分子综合疗法和目前正在研究的新药,意味着我们现在可以为晚期疾病或局部复发的患者提供真正的康复机会和更长的生存期。
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引用次数: 0
Laparoscopic appendectomy for acute appendicitis. 腹腔镜阑尾切除术治疗急性阑尾炎。
Pub Date : 2009-09-01
Vincenzo Minutolo, Giuseppe Gagliano, Orazio Minutolo, Maurizio Carnazza, Salvatore La Terra, Alessandro Buttafuoco, Salvatore Dipietro, Raffaele Lanteri

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.

腹腔镜技术(VL)相对于开放手术治疗急性和复杂阑尾炎的优势和应用尚不明确。本研究的目的是确定两种方法中哪一种更合适。该研究检查了124例患者,其中73例女性(57.5%),51例男性(42.5%)。我们比较了62例腹腔镜组患者和62例开放手术患者。我们分析了两组(VL、open)的年龄、性别、手术时间、住院时间、并发症和费用。患者平均年龄为24.1岁(范围:4-70岁)。转化率为1.6%(1例/62)。腹腔镜组患者以女性为主(p < 0.0001)。VL患者的平均年龄较开放手术明显增高(p < 0.01)。两组平均手术时间差异无统计学意义。腹腔镜组住院时间短(4.77天vs. 6.39天,p < 0.01)。VL组并发症发生率为0%,开放组为4.81%。开放组VL的平均手术费用为8070.00欧元(+/- 4267欧元),6818.00欧元(+/- 1446欧元)(p < 0.05)。腹腔镜阑尾切除术与传统开放手术相比有明显优势,应作为急性但无并发症的阑尾炎的首选。
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引用次数: 0
Small bowel metastasis from primary neuroendocrine small cell lung carcinoma. 原发性神经内分泌小细胞肺癌的小肠转移。
Pub Date : 2009-09-01
Stefano Scabini, Edoardo Rimini, Emanuele Romairone, Renato Scordamaglia, Maurizio Boggio, Yuri Musizzano, Valter Ferrando

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.

原发性肺癌的小肠转移是罕见的。我们报告一例76岁男性原发性神经内分泌小细胞癌,经化疗治疗,出现发烧和肠道症状(亚闭合和疼痛)。CT检查发现他的小肠有肿瘤。病人随后接受了腹部手术。在手术中,我们发现小肠肿瘤阻塞,因此我们切除了15厘米的回肠,并进行了侧对侧吻合。早期发现这种罕见的疾病是很重要的,因为肺癌的复杂肠道转移可导致高死亡率和较差的短期预后。随着化疗和姑息治疗的进步,转移性肺癌患者有时可以在合理的生活质量下存活一年以上。
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引用次数: 0
[Modulation of the extent of lymphadenectomy in early gastric cancer. Review of the literature and role of laparoscopy]. 早期胃癌淋巴结切除范围的调节。文献综述及腹腔镜的作用[j]。
Pub Date : 2009-09-01
Luca Maria Siani, Fabrizio Ferranti, Antonio De Carlo, Marco Marzano, Alberto Quintiliani

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.

早期胃癌是一种局限于胃粘膜或粘膜下层的胃癌,与有无淋巴结累及无关,在任何情况下仅在约20%的患者中出现。这种不常见的淋巴结受累是一个明显的临床问题,因为标准D2淋巴结切除术在80%以上的患者中构成过度治疗。文献回顾表明,对于不符合后田氏标准(即不适合内镜下粘膜或粘膜下解剖)的患者,目前的手术倾向是根据肿瘤的特点调整淋巴结切除术的范围:对于位于胃上三分之一的粘膜早期胃癌,胃切除术加D1淋巴结切除术就足够了;如果位于中间三分之一,则应选择D1 + α (D1 + n. 7),而如果位于远三分之一,则D1 + β (D1 + n. 7,8a,9)是最佳选择。在所有这些情况下,微创手术是一种有效的选择,其结果与开放手术相当,但具有腹腔镜方法的所有优点。对于粘膜下早期胃癌,D1 + β淋巴结切除术适用于瘤变> 20mm和隆起型,而对于所有其他粘膜下早期胃癌(> 20mm和凹陷型,穿透粘膜下层超过500微米,未分化,伴淋巴血管浸润),标准D2淋巴结切除术是最安全的肿瘤学手术。在这些情况下,腹腔镜方法也是一个安全的选择,即使它需要更高的腹腔镜技术。
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引用次数: 0
[So-called "dense-vascularised" peritoneal adhesions: clinical and aetiopathogenetic considerations]. 【所谓的“密集血管化”腹膜粘连:临床和病因学考虑】。
Pub Date : 2009-09-01
Stefano Scuderi, Michele Giaccone, Ezio Falletto, Carlo Maria Fronticelli, Marcela Alejandra Maorenzic, Raffaele Seghesio, Alessandro Maria Gaetini

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.

在外科医生选择性手术的日常临床实践中,或者更常见的是在急诊情况下,在腹腔和骨盆内进行手术,经常发现肠道粘连障碍,并可能引起许多并发症和随后的再干预。我们报告三例女性患者提到我们的观察肠亚闭由于粘连综合征。剖腹手术后,发现存在单一的顽固纤维血管粘连,患者接受免疫组织化学和受体分析,诊断为弥漫性腹膜平滑肌瘤病。高水平的外源性女性激素(激素替代疗法或长期服用口服避孕药)或内源性激素(如怀孕期间发生的),遗传易感性(包括遗传畸形)和既往手术(腹膜创伤)的同时结合,正如我们的患者所证明的那样,似乎都在所谓的“血管密集化”的发病机制中起着关键作用。特别是顽强的粘连负责激活多能间充质间皮下腹膜细胞。当与解剖病理描述相关时,这张引人注目的宏观图片是弥散性腹膜平滑肌瘤病的病理实体的基础。
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引用次数: 0
[Echo-guided spleen-preserving resection of the pancreas tail for pancreatic intraductal papillary mucinous neoplasms]. 超声引导下保脾胰尾切除术治疗胰腺导管内乳头状黏液性肿瘤。
Pub Date : 2009-09-01
Emilio De Raffele, Mariateresa Mirarchi, Samuele Vaccari, Donatella Santini, Lucia Calculli, Gaspare Maria Pendino, Bruno Cola

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.

胰腺导管内乳头状粘液瘤(IPMNs)是一种独特的具有恶性潜能的肿瘤,可能在手术切除后复发。有限的胰腺切除术最近被建议用于非侵入性肿瘤。我们报告术中us引导下切除位于胰腺尾部的无创IPMNs的技术,并保留脾脏和脾血管。在充分暴露胰腺远端后,完成对实质的彻底超声检查,以确定肿瘤的特征,其与主要胰管和脾血管的关系,并用电刀标记横切线。剥离从胰尾的下边缘开始,沿外侧至内侧方向直至横切线。确定主胰管并缝合,然后闭合实质,并用纤维蛋白原/凝血酶包被的胶原补片加固缝合线。患者1为63岁男性,术中us引导行胰尾切除术,胰尾IPMN大小为28mm,组织学表现为中度发育不良,术后9天出院。患者2为60岁男性,术中行us引导胰尾切除术,胰尾IPMN尺寸为30 mm,组织学上为原位癌,术后9天出院。保留脾脏和脾血管的有限远端胰腺切除术是治疗胰腺尾部非侵入性IPMN的一种合适的手术技术。术中超声检查对计划“根治性但保守性”胰腺切除术至关重要。
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引用次数: 0
[Isoperistaltic endoluminal drainage (IED) in the surgical treatment of upper digestive tract dehiscence]. [等肠腔内引流术在上消化道裂孔手术治疗中的应用]。
Pub Date : 2009-09-01
Fernando Prete, Alda Montanaro, Leonardo Vincenti, Paolo Nitti, Francesco Paolo Prete

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.

上消化道缝合线破裂仍然是一个严重的临床问题,通常需要复杂的手术修复。尽管它是多因素的病因,但腔内压似乎在这种并发症的发生和维持中起着重要作用。回顾性评价等肠腔内引流术(IED)在手术治疗或预防上消化道手术裂孔中的疗效。IED手术是通过一根双向鼻胃管通过腹部插入空肠近端并推进到泄漏部位,以实现低内脏内压,正常肠道自由流动病变下游和监测愈合过程。在过去十年中,31例患者(平均年龄62岁;52.9%男性)术后胸腹段食管、胃或十二指肠裂开的患者接受了再介入治疗。在手术修复过程中,17例置入了IED, 14例未置入IED (NOIED):两组在年龄、性别、原发病理、部位和泄漏类型上匹配良好。总手术死亡率(30天)为16% (12.5% IED vs 20% NOIED),发病率为45% (37.5% IED vs 53.3% NOIED)。漏气复发率有显著差异:漏气复发率为6%,漏气复发率为20%。在过去的5年中,IED手术也被预防性地用于另外16例其他高风险上胃肠道缝合患者,并取得了良好的效果。这项回顾性研究的结果似乎支持使用IED手术来最大限度地减少上消化道手术中缝合/吻合失败的风险。需要其他的研究来验证这种补充手术治疗的有效性。
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引用次数: 0
Blunt abdominal trauma: current management. 钝性腹部创伤:当前处理。
Pub Date : 2009-09-01
Emanuele D'Errico, Beatrice Goffre, Davide Mazza

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.

钝性腹部创伤的治疗在过去十年中不断发展,非手术治疗(NOM)最初被认为是怀疑的,现在已被广泛使用。这项回顾性研究的目的是检查在钝性腹部创伤中自由使用NOM的结果。为此,我们检查了从1998年1月到2006年7月我们外科收治的119例钝性腹部创伤患者的病历。在血流动力学稳定的情况下,选择NOM。当手术是强制性的,它包括探查性剖腹手术或腹腔镜检查。6例NOM患者(7%)在创伤后24小时内需要手术探查。因此,NOM的成功率为93%。平均住院时间12.5天(范围:2-78天);急诊手术患者为17天(范围:2-78),NOM患者为14.5天(范围:2-45)。总之,在钝性腹部创伤的病例中,NOM可以安全使用。血流动力学不稳定,怀疑空心内脏穿孔和多次输血是该入路的禁忌症。
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引用次数: 0
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Chirurgia italiana
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