Chirurgia italiana最新文献

Videoassisted surgery has recently led to a new era, aimed mainly at minimising surgical trauma and improving the cosmetic result. Natural Transluminal Endoscopic Surgery (NOTES) and Single Incision Laparoscopic Surgery (SILS) are emerging as effective techniques whose advantages and possible applications have been widely explored in the most recent literature. Twenty-two consecutive patients, mean age 51.5 years (range: 24-86 years), were subjected to a laparoscopic cholecystectomy through a single, trans-umbilical, incision (SILS). We utilised standard laparoscopic instruments, placing one 10 mm trocar for the camera and two 5 mm trocars for the operative instruments. Mean operative time was 69 min (range: 40 - 120 min). There were no major complications during surgery, and the postoperative recovery was uneventful. All patients referred complete satisfaction with the surgical and cosmetic result obtained 1 and 3 weeks postoperatively.

Splenic artery aneurysms account for the majority of splanchnic artery aneurysms. These constitute a uncommon pathology, but with a mortality rate greater 70%. We report a case of a double symptomatic aneurysm of the splenic artery with a proximal and distal localization. The patient was a 65-year-old woman with chronic abdominal pain of the left hypochondrium, irradiating to the ipsilateral iliac fossa. In this case, the particular anatomical characteristics, which prevented a conservative endovascular treatment, were well suited to surgical treatment, performed successfully. In conclusion, in the case of a low-risk patient, in the presence of aneurysms with favourable anatomical characteristics one should prefer surgical rather than endovascular treatment, despite the widespread use of the latter.

Rectocele and haemorrhoidal prolapse are two pathologies that in all cases entail partial excision of anorectal tissue possibly with less invasive surgical procedures. For these pathologies, the authors have recently improved their treatment procedures, introducing the sequential transfixed stitch technique (STST) for rectocele and the transfixed stitch technique (TST) for haemorrhoidal prolapse, and thereby obtaining a significant technical and clinical improvement in terms of both outcomes (complete correction of rectal prolapse and haemorrhoidal prolapse) and discomfort and quality of life in the postoperative period. Moreover, in the present study the authors propose a subsequent innovation of the technique developed recently for the treatment of rectocele and haemorrhoidal disease using a new curved siliconate needle, thinner than the traditional lanceolate needles, with a longer, more rigid needle-thread junction in order to achieve less invasiveness and mucosal trauma, enabling the surgeon to perform sutures in a simple, easy manner. Ten consecutive patients with a clinical and instrumental diagnosis of rectocele--6 type II and 4 type III--were treated with TSTS and 20 patients with third (12 patients) and fourth degree (8 patients) haemorrhoidal disease were treated with TST. The surgical procedures were the same for all patients, although patients were divided into two groups. To the first group (A) were allocated patients treated with traditional stitches with a cylindrical, half circle needle, (Hr 25.9 mm). To the second group (B) were allocated, for the same objective, patients treated with the new siliconate needle, with an ultrafine tip, manufactured by Assut Europe S.p.A. The mean duration of the TST surgical procedures was 16 minutes using the new siliconate needle, whereas the mean duration using the traditional lanceolate needle was 17 minutes (p = ns). The surgical team judged the TST performed with the siliconate needle to be easier in 90% of cases in comparison to 70% of cases treated with the traditional lanceolate needle (p < 0,05). In patients treated with TSTS using the traditional lanceolate needle the mean duration of the surgical procedures was 20 minutes as against 18 minutes in the cases treated with the siliconate needle (p = ns). The surgical team judged the TSTS performed with the siliconate needle to be easier in all cases, while in two cases treated with the traditional lanceolate needle there were technical difficulties related to the use of the needle. The use of the ultrafine siliconate siliconate needle is more effective for the treatment of rectocele with TSTS and for haemorrhoidectomy with TST, particularly with a view to improving the surgical procedures and limiting the extent of mucosal damage related to suture oedema.

The RET gene codes for a tyrosine kinase receptor, expressed in neural crest derived cells playing a central role during embryogenesis. The RET proto-oncogene is responsible for medullary thyroid cancer and multiple endocrine neoplasia type 2. To date, more than 50 germline point mutations have been described. A specific correlation between genotype and phenotype is well recognized. Genetic testing is predictive of cancer onset, age at onset and biological aggressiveness. In recent years, the concept of codon-oriented prophylactic surgery has been introduced and three levels of risk have been identified on the basis of specific mutations. A review of the literature shows the excellent results of laboratory, genetic and clinical research that have made it possible to reduce medullary thyroid cancer-related mortality.

Papillary and follicular thyroid carcinoma are still characterised by unclear biological and clinical behaviour with an autoptic incidence higher than the clinical incidence. Lymph-node involvement represents a prognostic factor that may increase the rate of local relapse, reducing long-term survival only in high risk patients--age > 45 years, M+, T > 3 cm, extra thyroidal extension, follicular histotype. The authors analyse the role of lymph-node cervical dissection. Routine or selective, extended or conservative lymphectomy are described in the literature. Prognostic factors are useful to determine the most appropriate surgical procedure. An elective cervical central dissection may be indicated in patients at high risk, while in cases of monolateral lymph-node metastases, in patients at low risk, a selective lymph node dissection of levels VI-III-IV is associated with lower morbidity. Modified radical neck dissection is reserved for patients at high risk or in cases of multiple lymph-node metastases (> 5) to reduce the incidence of local relapse. In the treatment of differentiated thyroid carcinoma an elective total thyroidectomy must be performed in combination with adjuvant radioiodine ablation.

Internal hernias are a rare form of dislocation of the abdominal viscera, usually in the small intestine, in the peritoneal sacs or cavities, resulting from the defective coalescence of the peritoneal flaps due to abnormal rotation of the medium intestine in the second stage of embryogenesis. In this paper the authors describe three cases observed during the last twelve months: two cases were ascribable to left paraduodenal hernia and one to a transepiploic hernia. Special attention needs to be paid to knowledge of the rotation process of the primitive medium intestine and to understanding whether an internal hernia underlies the clinical picture, when occlusive patients have not previously undergone surgery and show no signs of external hernias. In the surgical treatment of paraduodenal hernias, special attention must be paid to incarcerated loops, in order to prevent severe vascular complications caused by potential lesions to the mesenteric vessels.

The aim of the study was to elucidate the problem of visual disorders after heart surgery, focusing on aetiology, modes of prevention and treatment. Information from a literature search and the authors' personal experience are provide clues as to the modes of development and the means of avoidance and therapy of this category of postoperative, neurosensory complications. Multiple morbid situations, such as preoperative augmented ocular pressure, perioperative bleeding and hypotension, are shown to be predisposing and precipitating factors. Medical treatment seems to be less important than minimisation of risk factors. Prevention rather than treatment is more helpful for heart-operated patients, as far as postoperative visual disorders are concerned.

The authors report two cases of acute small bowel obstruction, the first in an adult patient, and the second in a three-month-old baby due to a congenital fibrous band. The second case was retrospectively detected from a pool of at least 50 cases of secondary fibrous band obstructions over the period from 1970 to 2008. Surgery was performed early, and simple resection of this very rare malformative bundle (usually affecting very young people) was required.

Fibromuscular dysplasia or fibromuscular hyperplasia is a rare non-atherosclerotic and non-inflammatory vascular disease that primarily involves medium-size and small arteries, most commonly the renal and carotid arteries, and less frequently the vertebral, iliac, subclavian or visceral arteries (mesenteric, hepatic, splenic). Antiphospholipid syndrome is one of the most commonly acquired hypercoagulable states, defined by the association of laboratory evidence of anti-phospholipid antibodies with arterial or venous thrombosis or recurrent pregnancy losses. The presence of these antibodies is associated with an increased risk of thromboembolic phenomena, including peripheral thrombophlebitis, pulmonary thromboembolism, stroke, retinal artery occlusion, myocardial infarction, placental thrombosis and Budd-Chiari syndrome. In this report we discuss the uncommon case of a young male patient with both antiphospholipid syndrome and fibromuscular dysplasia that came to our attention for pulmonary embolism and "angina abdominis" due to occlusion of three mesenteric vessels. The possible relationship between antiphospholipid syndrome and fibromuscular dysplasia encountered in our patient still remains unclear. We treated the patient as if he had the two different diseases. After partial failure of endovascular surgery, the patient underwent surgery with reimplantation of three visceral arteries to the aorta. Subsequently he was treated with stent placement after development of a re-stenosis of one of the three reimplanted visceral arteries. The patient was treated conservatively for antiphospholipid syndrome with anticoagulant oral therapy for life.

The aim of the present study was to identify risk factors for morbidity and mortality in patients submitted to emergency colonic surgery. Between 1997 and 2008 157 patients, 106 of whom affected by colon cancer (67.5%) and 51 by benign disease (32.5%), were treated. The risk factors for morbidity and mortality were evaluated by univariate and multivariate analysis considering clinical and demographic data. The overall 30-day morbidity and mortality rates were 19.1% (30 patients) and 12.7% (20 patients), respectively. Among patients affected by cancer the mortality rate was 15% (16 patients) and the morbidity rate 23.6% (25 patients), while among the patients with benign disease the mortality rate was 7.8% (4 patients) and the morbidity rate 9.8% (5 patients). No postoperative surgical complications were noted. The strongest risk factors for early death were postoperative medical complications such as cardiopulmonary, renal, thrombo-embolic and infectious complications. The results of the univariate analysis showed that advanced age, neoplastic disease, advanced stage of cancer and associated medical disease prior to surgery play a role as risk factors for morbidity and mortality. In the multivariate analysis only the presence of associated medical disease proved to be a significant independent predictor of outcome. Emergency surgery for both neoplastic and benign colonic disease is still associated with an increased risk of death. Although restorative colectomy should be regarded as the first choice procedure in the emergency setting, Hartmann's procedure is still widely used in high-risk patients.