Chirurgia italiana最新文献

Intraductal papillary mucinous neoplasms are a well-recognized pathologic entity of the pancreas that is being reported with increasing frequency. These tumours carry a relatively favourable prognosis and are frequently associated with extrapancreatic malignancies. The combination of advanced age and co-existence of two neoplasms challenges the planning of the best treatment option. A 78-year-old man presented with rectal bleeding which led to the diagnosis of a stenosing adenocarcinoma of the sigmoid colon. No metastatic lesions were present but a 30 mm intraductal papillary mucinous neoplasm with mural nodules was detected in the uncinate process of the pancreas. Small diffused dilations of the side branches were present in the body and tail of the gland. A two-stage procedure was planned: an R0 sigmoid resection was undertaken first with an uneventful postoperative course. Forty-five days later a pancreaticoduodenectomy was performed and the postoperative course was again uneventful apart from delayed gastric emptying. Histology showed a combined-type intraductal papillary mucinous neoplasm with foci of non-invasive carcinoma. The patient is still alive without evidence of cancer recurrence 33 month after the pancreatico-duodenectomy. The co-existence of a potentially malignant pancreatic tumour with an extra-pancreatic overt malignancy in elderly patients poses difficulties in the attempt to cure the patient with minimal morbidity. In the present case we considered a staged surgical procedure with the aim of reducing the perioperative risk, since the excision of the pancreatic neoplasm required a pancreaticoduodenectomy in an elderly patient.

Cystic neoplasms of the pancreas account for only a small percentage of pancreatic tumours. They include mucinous cystic tumours, which have a higher incidence in females in their forties or fifties. Cystic neoplasms of the pancreas can present in a benign, borderline or malignant form. These tumours have a natural evolution from a benign (mucinous cystadenoma) to a malignant form (cystadenocarcinoma). It is not always easy to diagnose cystic tumours, including mucinous cystic tumours of the pancreas, and the final diagnosis is often reached only after the surgical procedure, which is the gold standard treatment of this disease. We present the case of a 56-year-old woman affected by a mucinous cystic tumour of the body-tail of the pancreas, who underwent distal splenopancreasectomy. She was discharged on postoperative day 12. After an 18-month followup, she is in good general condition and disease-free.

Morgagni hernia is a rare cause of diaphragmatic hernia. There are few reports of laparoscopic repair in the literature. Tension-free hernia closure with synthetic mesh reduces recurrence but occasionally results in complications, such as visceral stricture, erosion or perforation. We report a case of successful laparoscopic repair of a very large symptomatic Morgagni hernia in a 78-year-old patient, treated by positioning a gradually resorbable mesh made from porcine SIS (Surgisis Soft Tissue Graft device--Cook Inc, Bloomington, Ind). After surgery, the patient reported an immediate, marked improvement in clinical symptoms. During the postoperative course, pleural and pericardial leakage occurred. The pleural leakage was immediately drained with thoracentesis, and the pericardial leakage was treated conservatively. No other complications occurred after patient discharge. One year later, the patient was in very good general condition. No recurrence was documented with abdominal CT scan, which also demonstrated connective tissue proliferation that was progressively replacing the prosthesis. Laparoscopic repair is a safe, efficacious procedure for the treatment of diaphragmatic hernia, and presents all the advantages of minimally invasive surgery. The use of new types of material featuring marked biocompatibility and gradual reabsorbability characteristics offers considerable benefits.

The aim of this study was to review a series of patients submitted to hepatectomy for primary intrahepatic lithiasis to evaluate early and late results with an assessment of indications, methods and long-term outcomes. From January 1992 to December 2007, 40 patients (25 males and 15 females with a mean age of 51 years) underwent surgery for primary intrahepatic lithiasis in our Hepato-biliary Surgery Unit. Left hepatectomy (20 patients) and left lateral segmentectomy (12 patients) were the most common procedures performed. A cholangiocarcinoma was found in 4 patients (10%) and only two of these underwent liver resection, while an exploratory laparotomy was performed in the remaining two patients for an unresectable tumour, unexpected before surgery. There was no postoperative mortality. The morbidity rate was 22.5% with a prevalence of infectious complications related to bile leakage. Long-term results, assessed in 30 patients with a follow-up longer than 12 months, were good or fair in 28 patients (93.3%). Primary intrahepatic lithiasis is diagnosed increasingly in Western countries as a result of the improvement in imaging techniques. The stones originate inside the liver at the level of dilatations of the bile ducts above congenital strictures of the main hilar ducts. Biliary pain and cholangitis are the most common presenting symptoms, whereas cholangiocarcinoma represents the unfavourable complication of the disease. In the majority of cases, a single liver lobe or segment is involved and liver resection allows definitive treatment of the disease and prevention of cancer.

Biofeedback is an important therapeutic option in patients with outlet dysfunction. A total of 75 patients referred to our proctological division from March 2004 to June 2008 and complaining of chronic constipation were studied by history, physical examination, anorectal functional tests and a structured questionnaire. Patients were treated with biofeedback plus electrical stimulation or both biofeedback plus electrical stimulation and surgery. Sixty of the 75 patients were treated with biofeedback only; and 15 with both treatments. All patients underwent, on average, twice weekly 15-minute EMG-biofeedback training sessions followed by 5 minutes of electrical stimulation. At 6 months' follow-up all physiological parameters with the exception of anal squeeze pressure showed a significant improvement (p < 0.05); there were reductions in sensation of incomplete evacuation (from 72 to 29.3 percent), in difficult stool passage (from 76 to 18.7 percent), and in the use of laxatives, enemas or digital manoeuvres (from 88 to 40 percent). At a telephone follow-up at 1 year, an improvement in satisfaction was reported by 77.3% of patients (58/75). The results of this study confirm that biofeedback plus electrical stimulation produces an improvement in bowel symptoms in patients with outlet dysfunction, as well as underlining the importance of anorectal functional tests as a guide to the most appropriate treatment.

Perforation of peptic ulcer is a surgical emergency which still carries a risk of mortality. The main risk factors are delayed diagnosis > 24 hours, ASA-III or ASA-IV, age over 70 years, and associated cardiorespiratory pathologies. There is no unanimous consensus regarding the gold standard treatment of such complications. In this study we report our experience and analyse the literature with the aim of assessing the possible advantages of laparoscopic treatment of perforated duodenal ulcers versus open surgery. From April 2003 to December 2008, 39 patients underwent laparoscopic repair and 7 patients open repair of perforated duodenal ulcer. The following parameters were evaluated in all patients: operative time, duration of hospital stay, time to intestinal canalisation, morbidity and mortality. The conversion rate, in laparoscopic treated patients, was 0%. The mean operative time was longer in the laparoscopic group than in the open group (76.15 +/- 9.49 vs. 63.57 +/- 15.19 minutes; Mann Whitney test p < 0.05). The laparoscopic cases had a shorter mean hospital stay than the open cases (5.8 +/- 1.02 vs. 7.8 +/-1.34 days; Mann Whitney test p < 0.001). The time to canalisation in the two groups of patients was similar. One patient (2.56%) in the laparoscopic group and two (28.57%) in the open repair group presented morbidity in the postoperative period. One patient (ASA IV) in the open group died. Laparoscopic treatment in the emergency setting is a safe, reliable procedure, affording all the advantages of the minimally invasive approach.

Splenic artery aneurysms, although rare, are the most common visceral artery aneurysms with a high risk of rupture. The purpose of this retrospective study was to analyse our experience with such aneurysms. Eight patients (6 women, 2 men; mean age: 60.2 years; range: 33-76 years) with a diagnoses of splenic artery aneurysm were reviewed. Six patients were asymptomatic and two had chronic pancreatitis with left flank pain. The condition was diagnosed by ultrasonography and computed tomography. Five patients underwent surgery, two requiring splenectomy, and three patients were treated by embolisation. There were no postoperative deaths. Follow-up data were available for 7 patients, the mean follow-up period being 60 months (range: 2-72 months). Although open surgical repair remains the gold standard, endovascular techniques may, in selected cases, offer a viable alternative in high-risk patients with significant co-morbid conditions.

The aim of this study was to describe the feasibility and efficacy of a new operative technique using biological material as an adjuvant for the repair of inguinal hernia according to the original Bassini technique in an attempt to achieve complete restoration not only of the anatomical integrity but also of the physiological elasticity and flexibility of the inguinal canal. Between February and July 2008 a total of 12 patients underwent the original Bassini repair of primary and recurrent inguinal hernia. The biological material was used as an adjuvant to create a quadruple layer in the restoration of the posterior wall of the inguinal canal in order to further strengthen it. Fourteen procedures were performed on 12 adult male, unselected patients. Inguinal hernias were unilateral in 10 patients, bilateral in 2 patients, and recurrent in 3 patients. Mean operation time was 45 minutes (range: 30-70). No general or local intraoperative complications were registered. Mean postoperative pain was rated with the VAS pain score was 2.8 (range: 2-4) in the first 48 hours. No postoperative complications occurred. After a mean follow-up of 5 months (range: 3-6), there were no early recurrences nor persisting inguinal pain. The use of biological material as an adjunct to the Bassini procedure achieves four main objectives: two mechanical and two biological. The two mechanical aims include: further decrease of the tension of the suture line when anchored to the isolated posterior border of Poupart's ligament. The second mechanical objective is that the biological material acts as a binder that protects the suture line when the intra-abdominal pressure increases. The two biological objectives are regrowth of the fascia over the transversalis fascia, and increased production and deposition of collagen on the suture line ten times greater than that of the native fascia, thus improving the healing process.

According to the WHO about 300 million people in the world are affected by obesity with an increasing trend. The aim of the present study was to assess our preliminary results with sleeve gastrectomy. Over the period from June 2006 to March 2008, 25 laparoscopic sleeve gastrectomy were performed at our Department of Surgery for morbid obesity by the same surgeon. The operation consists in resection of approximately three quarters of the stomach with the creation of a long slender gastric tube, dividing the stomach vertically in two parts and removing all the left side with the greater curvature and gastric fundus. The mean age of the patients was 38 +/- 9 years, and the mean BMI 48 +/- 3. The mean operative time was 110 minutes, and the mean hospital stay 6 days. Mean intraoperative bleeding was negligible (20 cc). In our study we observed just one case of gastric leakage from the staple line, treated by surgical drainage and by placement of an endoscopic stent. There were no cases of bleeding of the resection margin and no long-term stenosis; there was no mortality. The mean follow-up was 18 months. BMI showed a mean reduction of about 17 points. During postoperative visits all the patients reported marked reduction of hunger sensation, together with a sense of early satiety. On the basis of these preliminary results we can consider laparoscopic sleeve gastrectomy as a safe, functional and definitive procedure that constitutes a valid alternative in bariatric surgery, though it is as yet not completely standardised and requires a longer follow-up.

Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumours of the GI tract, deriving from interstitial Cajal cell degeneration. Over 95% of GISTs express CD-117 and CD-34, thus differing from other mesenchymal-derived tumours. The aim of this study was to evaluate our experience with a multifocal GIST, treated by laparoscopic total gastrectomy, and review the literature. A 74-year-old man with a preoperative diagnosis of sub-cardial GIST, obtained by endoscopy, CT scan and endoscopic ultrasound, was submitted to laparoscopic total gastrectomy with an end-to-side oesophago-jejunal anastomosis, using the Or-Vil system. GISTs account for only 1% of all GI tumours, with a variable behaviour, from indolent forms to aggressive tumours with potential for hepatic and peritoneal metastasis. Surgery is the cornerstone of therapy, the aim being to obtain an R0 resection, so as to minimise the risk of recurrence. Laparoscopic total gastrectomy is an excellent solution for their treatment, with possible adjuvant therapy based on imatinib-mesylate, for high-risk GIST.