Chirurgia italiana最新文献

Appendicitis is an acute disease requiring urgent surgical treatment. Acute appendicitis is the most common surgical emergency in children and young adults, with an incidence of about 100-140 cases per 100,000 people. In our study we analyse 501 consecutive appendectomies performed in our department. From June 2003 to December 2008 we performed 501 appendectomies, 287 in male and 214 in female patients. The average age was 27.99 years (range: from 4 to 94 years). We routinely perform a laparoscopic approach with a standard protocol for patient selection. Following a standard protocol, 429 patients were selected for the laparoscopic approach and 72 for an open appendectomy. In 411 patients (95.8%) the surgical procedure was completed in laparoscopy with a conversion rate of about 4.2% (18/429). The conversion rate in the simple appendectomy subgroup was 0.98%, as against about 12.1% in the complex appendectomy subgroup. The open appendectomy group comprised 72 patients, 27 patients treated with an open approach by choice, 26 for necessity and 19 for protocol violation. There were 9 post-appendectomy complications (2.1%) and 3 re-operations (0.5%); the mortality rate was nil. Although 20 years have passed since the first laparoscopic appendectomy, today it is still debated whether or not the laparoscopic approach is the correct surgical procedure for the treatment of acute appendicitis. Several studies have shown that laparoscopic appendectomy presents a number of advantages in terms of a shorter hospital stay, less postoperative pain and fewer wound infections. Some authors, however, have demonstrated that the laparoscopic approach for acute appendicitis is associated with increased operative times and risk of intra-abdominal abscesses (above all if the appendix is perforated). Our experience confirms that the routinely performed laparoscopic approach to treat acute appendicitis is associated with a low rate of abscess complications: in our series some of the complications could be attributed to the surgical learning curve.

Abdominal abscess is a very important problem nowadays, being responsible for prolonged hospitalisation, because these infections still cause substantial morbidity and mortality. For many years, surgical drainage has been considered the best therapeutic option in abdominal abscesses but several studies have subsequently shown that the percutaneous approach is as effective as surgical drainage. Starting from this background, the aim of this study was to evaluate whether or not percutaneous drainage is a valid treatment of choice. In the Department of Surgical Sciences, Organ Transplantation and Advanced Technologies of the University of Catania, 451 ultrasound guided percutaneous drainages of intra-abdominal abscesses were performed on 430 patients. Abscess drainage was successful in 322/403 (80%) of postoperative abscess, in 16/18 (90%) of primitive abscesses, in 10/12 cases (85%) of acute cholecystitis, in 3/6 cases (50%) of intrahepatic abscess and in 12/12 cases (100%) of pyelonephritis. US-guided drainage is currently the gold standard in the treatment of simple abdominal abscesses.

The incidence of tuberculosis in Italy steadily decreased until two decades ago, but the infection is now frequently diagnosed in common clinical practice. The Authors describe a rare acute abdominal presentation of the disease featuring a double intestinal perforation in a subject affected by pulmonary, renal and gastrointestinal miliary tuberculosis. A review of the literature is also presented. Intestinal resection is the treatment of choice in such cases, even if it leads to frequent, major complications, but the authors stress that there may be a possibility for a less radical form of management of these patients.

Cutaneous sebaceous carcinoma (SC) is a rare malignancy deriving from the adnexal epithelium of the sebaceous glands. Periorbital SC is approximately three times more common than extraorbital cutaneous SC. Extraocular SC is reported to be less aggressive than orbital sebaceous carcinoma and rarely metastasizes. We report a case of sebaceous carcinoma of the scalp, characterised by highly aggressive behaviour and huge invasion of the intracranial space. The patient was a 79-year-old woman who developed an infiltrating sebaceous carcinoma followed by lymph-node metastases shortly after excision of the primary lesion, resulting in death. In this case, aggressive biological behaviour was observed in a carcinoma arising in an extraorbital area, although it has traditionally been considered a less aggressive neoplasm.

Pericardial effusion may lead to cardiac tamponade sometimes requiring surgical treatment. The aim of the study was to retrospectively analyse a group of patients with cardiac tamponade treated with a modified video-assisted thoracoscopy technique. We treated 15 patients (8 males and 7 females; mean age 63 years; range 24-80 years) with cardiac tamponade. All patients were treated by a modified video-assisted thorascopic approach on the right hemithorax, with the use of two trocars: a 15-mm trocar on the 4th right intercostal space on the anterior axillary, and a 10-mm trocar on the 7th right intercostal space on the median axillary line. We used a 5-mm optic, the size of which permitted the simultaneous use of two instruments through a single trocar (both for the optic and the endoscopic forceps), leaving the second trocar for the dissecting scissors. In all patients we obtained a pericardial resection equivalent to the one obtainable in an anterolateral thoracotomy. There was no intraoperative mortality or perioperative morbidity. Drainage of the pericardial effusion was effective in all cases. The modified video-assisted thoracoscopic technique on the right chest using two trocars seems a feasible surgical technique for patients suffering from cardiac tamponade.

Here we report a case of a 60 years old woman who came to the Emergency Department of San Martino Hospital suffering from abdominal pain for about a week with high fever in the last 24 hours. The final histological examination led to the diagnosis of ileal diverticulosis associated with perforation and peritonitis with a fibrotic reaction involving the last ileal loop, the caecum and the appendix.

Adenocarcinoma of the gastro-oesophageal junction is progressively rising in western countries and, because of its poor prognosis, presents a real clinical challenge for the oncological surgeon. We evaluate our initial experience with wholly laparoscopic trans-hiatal extended total gastrectomy with the Or-Vil device for treating Siewert type II and III tumours of the gastro-oesophageal junction. Ten patients were enrolled in the present study; ASA score, stage of disease, length of surgery, estimated blood loss, number of lymph nodes harvested, length of proximal margin clearance, morbidity and mortality were analysed. Mortality was nil and morbidity 20%; the average proximal clearance margin was 5.7 cm and all margins were tumour-free (RO). The number of lymph nodes harvested was 38 +/- 19. Neither anastomotic fistulas nor major dehiscence were observed. In our initial experience, wholly laparoscopic trans-hiatal extended total gastrectomy for treating Siewert type II and III tumours of the gastro-oesophageal junction is safe, effective and, according to our preliminary results, oncologically correct, but it remains a complex, advanced laparoscopic procedure, requiring major skills and adequate experience. Prospective, randomised trials--possibly multicentric--are required to establish its efficacy in terms of long-term oncological outcomes.

We present the case report of a male patient with a diagnosis of synchronous kidney, bladder and prostate tumours with different histologies: renal oncocytoma, urothelial carcinoma of the bladder, and adenocarcinoma of the prostate. This is the first case report described in the literature in which a complete surgical resection of triple tumours has been performed with surgery in a single session. Recent advances in the field of genetics enable the surgeon to hypothesise new strategies in the early treatment of synchronous tumours, particularly when a number of common tumour markers are positive. One such marker recently identified is the prostate-specific membrane antigen (PSMA), present with high expression in carcinoma of the prostate and in the vascular endothelium of solid tumours; only overexpression of PSMA is to be regarded as diagnostic, inasmuch as this antigen is normally expressed in the renal tubular epithelium. Recent knowledge in the field of genetics has led to new strategies for the early treatment of synchronous tumours, but clinical data and instrumental diagnostics are still of fundamental importance, in that they may enable the surgeon to diagnose the presence of synchronous tumours at an early stage. The execution of prompt surgical treatment remains of basic importance for the purposes of guaranteeing oncological radicality also of synchronous tumours, in association with more sensitive and accurate instrumental diagnostics.

Arteriovenous malformations of the gastrointestinal tract are a known but rare cause of bleeding. Those of the stomach are the rarest if compared with other causes of gastric bleeding. The aetiology is still unknown, but senile age is considered an important cause, as are the degenerative processes connected with old age. These lesions are diagnosed by endoscopy which, with a haematostatic intent, often is not sufficient to stop the bleeding. Angiography is necessary for patients with massive bleeding whose endoscopy results are negative. The surgical treatment of gastric arteriovenous malformations requires excision of the lesion and part or all of the stomach. We report the case of a 57-year-old patient admitted to the Casualty Department with haematemesis and anaemia caused by acute gastric bleeding.

Radiation proctitis, is a relatively frequent complication resulting from the direct or collateral irradiation of the rectum in radiotherapy treatment for genito-urinary or anorectal malignancies. The main symptoms are diarrhoea, tenesmus, proctorrhagia, anal pain, mucorrhoea and faecal incontinence. The evolution of chronic radiation proctitis requires treatment for related anaemia, anal incontinence and micturition disorders. The approach and type of treatment depend on the severity of the symptoms and on the endoscopic aspect, in relation to the response to previous medical therapy performed. In our experience, endoscopic treatment is the best choice in the presence of ongoing bleeding and the possible development of severe anaemia. The surgical option is mandatory in patients at high risk of sepsis, requiring a faecal diversion constructed using the Hartmann technique. We report two cases, observed during the last two years, one treated with endoscopic bipolar coagulation and the other with a double urinary and faecal diversion.