Chirurgia italiana最新文献

Laparoscopic left hemicolectomy is still uncommon in surgical practice, because of both an unjustified fear of oncological inadequacy and technical difficulties with a steep learning curve. The aim of the present study was to analyse our 5-year experience with laparoscopic left hemicolectomy and its short- and long-term results. Thirty patients with non-metastatic non-infiltrating left colon cancer were treated laparoscopically and retrospectively compared to a group treated laparotomically and well matched for age, comorbidity and stage of disease in respect to the laparoscopic group. The duration of the laparoscopic procedures was longer, but intraoperative blood loss, passage of flatus and hospital stay were significantly less. Morbidity was similar and there was no 30 days mortality in either group. Specimen length and number of harvested lymph nodes were similar and 5-year cumulative survival curves showed no significant statistical difference (73.1% laparoscopic vs 70.8% open). Today, laparoscopic colon procedures are rarely performed, due both to fear of oncological inadequacy and to technical difficulties, yet several recent trials have presented evidence of safety, and oncological results comparable to those of the open counterpart. Our 5-year experience confirms these studies: our short- and long-term results show no statistical differences between the laparoscopic and "open" procedure. Laparoscopic left hemicolectomy is a safe, effective and oncologically adequate surgical procedure for non-metastatic non-infiltrating left colon cancer and is therefore a valid option for the surgical treatment of these neoplasms.

There are several classifications of appendicular epithelial cancer with a wide variety of nomenclature. Epithelial tumours of the appendix have been classified into four distinct types: carcinoids, mucinous adenocarcinoma (often called mucinous cystadenocarcinoma or malignant mucocele), colonic-type adenocarcinoma, and adenocarcinoids with a dual cell origin. We report a case of a woman who presented to our emergency unit with a history of acute appendicitis and who had undergone an appendectomy. The histopathological analysis showed the presence of a well differentiated mucinous adenocarcinoma, infiltrating the full thickness of the appendix wall.

Two types of covered self-expanding metal stents were compared in a consecutive series of 57 patients. Stent placement was successful in all patients. No procedure-related deaths were observed. The overall hospital morbidity was 7%. No significant differences in the efficacy of palliation of dysphagia, rate of complications, and survival rates were seen using the two types of stent. An endoscopic reintervention was required in 14% of the patients. Both stents proved to be safely removable in the short term follow-up, and the benefit of temporary insertion was documented in patients with primary oesophageal neoplasms prior to chemotherapy or chemoradiation therapy and in those with anastomotic strictures/leaks. A multidisciplinary strategy, guided by the concept that a stent should not represent the only, definitive treatment modality, may improve the quality of life of patients with advanced oesophageal carcinoma.

We report a case of rectus sheath haematoma (RSH) in a patient undergoing laparoscopic right hemicolectomy and anticoagulant prophylaxis of a pulmonary thromboembolism (PTE) with low molecular weight heparin. This pathological condition is rare and could be a cause of misdiagnosis in patients with acute abdominal pain. It can be a serious complication in the course of anticoagulant therapy. A rapid, correct diagnosis may lead to better treatment which must be timely, aggressive and ultimately curative. Our patient, with acute onset and swift worsening of his general condition, benefited from an immediate surgical procedure, with ligature of the epigastric artery stumps and drainage of the haematoma.

The authors describe a paradigmatic case of a large renal angiomyolipoma not associated with tuberous sclerosis. The lesion was discovered as an incidental finding during abdominal ultrasound for other pathology. Owing to the extent of the lesion and the appreciable risk of spontaneous rupture and bleeding, we opted for surgical treatment. The impossibility of dissecting the angiomyolipoma from the right kidney obliged us to perform a nephrectomy. The clinical interest of angiomyolipoma is in its rapid growth, the difficulty of distinguishing it from malignant lesions, the association with tuberous sclerosis, the presence of numerous aspecific symptoms and the difficulty of establishing the correct diagnosis and treatment strategy.

The aim of surgical treatment of fistula-in-ano is to eradicate the suppurative process permanently without compromising faecal continence. The appearance of a recurrence of fistula-in-ano is often due to non-identification of the internal opening by the surgeon, and to the presence of complex fistulae. We evaluated the clinical course of 214 patients in a randomised. controlled trial with respect to the recurrence rate of anal fistula with or without preoperative endoanal ultrasonography. In this study we demonstrate that endoanal ultrasonography was the most accurate diagnostic modality for detecting internal opening and complex fistulae. Therefore, endoanal ultrasonography is reliable and useful in the preoperative assessment of anal fistula, and particularly for decreasing the recurrence rate of this disease.

Rectal mucosal prolapse is characterised by protrusion of the rectal mucosa alone in the anal lumen. To correctly establish the intraoperative stage of rectal mucosal prolapse the authors performed a test based on the intrarectal introduction of a large-sized hydrophilic plug, to be extracted later from the anal canal. A total of 40 patients with proctological symptoms and with a diagnosis of rectal mucosal prolapse were submitted, in the outpatient setting, to a minimally invasive test with a small plug and later, in the preoperative stage, in patients under anaesthesia, using a plug entirely inserted into the rectal lumen and extracted via the anus. The same procedure was performed after surgery to verify the results of the excision. In all cases the plug test used in the preoperative stage permitted the perfect surgical evaluation of the extent of the prolapse. The plug test revealed a mucosal prolapse occupying 25% of the anal circumference in 10 patients, up to 50% in 20 patients and more than 50% in 10 patients. The first 30 patients were treated with the transfixed stitch technique, while for the others the Longo surgical technique was preferred. The plug test for the preoperative and postoperative evaluation of rectal mucosal prolapse is an effective tool for obtaining a more precise indication as to the optimal surgical intervention and for verifying the radicality of the surgical excision. The plug test, moreover, proved to be a minimally invasive and easily performed test for evaluating rectal mucosal prolapse.

The aim of this study was to assess the incidence and identify the risk factors associated with colorectal anastomotic leakage. A further objective was to investigate the therapeutic choices. We reviewed the clinical files of 124 patients who underwent mechanical end-to-end anastomosis after colorectal resection during the period 2000-2007. The mean age was 66.9 years and the male:female ratio was 1.2:1. Indications for surgery were malignant neoplasms in 109 cases (87.9%) and benign disease in 15 cases (12.1%). The anastomosis was always performed in an elective setting in the framework of a procedure of one or more stages (87.9% and 7.3% respectively). A pelvic drain was positioned in a routine manner and no protective ileostomies were constructed. Among the various risk factors, co-morbidities, ASA risk and low anastomotic level were the most important we examined. Student's t-test, the Chi-square test and Fisher's test were used for comparative univariate analysis, with significant results for p < or = 0.05. The incidence of anastomotic leak was 10.5% (13/124), but only 4.8% (6/124) required a second operation or failed to heal with simple conservative therapy. The pelvic drain was always effective in allowing the early diagnosis of leakages and limiting the spread of peritoneal inflammation. Mortality was 1.6% (2/124) overall, but, if leakages alone were considered, it increased to 15.4%. Among the risk factors examined, only low anastomotic level was confirmed by statistical analysis. In conclusion, the study confirms low anastomotic level as a negative prognostic factor for the healing of colorectal anastomosis. The pelvic drain proved to be effective in allowing early diagnosis and conservative management of leakages.

In 1991 Delaitre and Maignien described the first laparoscopic splenectomy, since when a rapid spread of this technique has been observed and the procedure has become the gold standard in the surgical management of benign and malignant haematological diseases. In the present study, the results of the first 30 laparoscopic splenectomies performed at the Division of General Surgery of the S. Eugenio Hospital of Rome are reported. The operations were performed in patients with benign (27 cases) and malignant (3 cases) haematological diseases, treated in the Regional Haematological Centre of the same hospital. The procedures were carried out according to criteria corresponding to those recently described in the guidelines of the European Association for Endoscopic Surgery. As regards the results, two procedures (6.7%) were converted to open surgery. One postoperative haemorrhage was observed, requiring a laparoscopic reoperation for haemostasis. No other major local or general complications were observed. Mortality was nil. The mean postoperative hospital stay was 4.2 days (range: 4-8 days). Medium-term surgical and haematological results were excellent. Laparoscopic splenectomy is the surgical gold standard, but should be performed in advanced centres in close cooperation with a haematology centre. The procedure is indicated in all patients who are candidates for splenectomy, with the sole exception of those affected by portal hypertension or with general contraindications to laparoscopy. In advanced centres, better early and late results can be achieved, in addition to the well-known benefits of the minimally invasive technique, particularly in aesthetic terms, which in younger patients affected by benign haematological pathologies are very important.

Biliary stent migration occurs in about 5% of patients. The most common complications secondary to stent migration are pancreatitis, small bowel perforation and peritonitis. We report the case of a patient presenting with an abdominal wall abscess secondary to migration of a biliary stent. Direct abdominal radiography, abdominal ultrasound and CT scan have proved very useful in the diagnosis, providing the correct localisation of the stent in the left rectus muscle of the abdominal wall that led to a surgical approach under local anaesthesia for the removal, and abscess formation surrounding the stent. The patient was discharged on the day after surgery. After reviewing the literature concerning this rare complication, the Authors conclude that closer monitoring of patients with biliary prostheses is needed to prevent the migration and the consequent serious complications.