Chirurgia italiana最新文献

Surgery as a treatment modality for morbid obesity has shown impressive progress over the past decades because of a better understanding of the metabolic characteristics of obesity and the rationale for its surgical treatment. Biliopancreatic diversion was first performed in humans in 1976. Since then it has been an excellent operation for morbid obesity to achieve long-term weight reduction. We present our laparoscopic biliopancreatic diversion protocol, with or without distal gastrectomy (Resa's operation). From 1995 to October 2008 we operated on 201 patients; open biliopancreatic diversion was performed in 48 patients, while the remaining patients underwent laparoscopic biliopancreatic diversion (84 laparoscopic Scopinaro's operations, 69 laparoscopic Resa's operations). The mean operating time was 140 minutes for the open procedures, 180 minutes for Scopinaro's laparoscopic operation and 135 minutes for Resa's laparoscopic operation. The mean postoperative stay was 5.5 days. Our mortality rate consisted of two patients (0.99%) who had pulmonary embolisms. Other major complications were three cases of leakage from the jejuno-ileal anastomosis, 18 cases of incisional hernia, 6 cases of metabolic diseases; 1 case of acute hepatitis and 1 case of bronchopneumonia. Biliopancreatic diversion can be performed satisfactorily by laparoscopy. A factor that may reduce the technical difficulties and make the technique totally reversible is the gastric sparing. Thus an upper digestive endoscopy can determine preoperatively whether the patient will need a gastrectomy, depending on its results.

Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract. These tumours originate in Cajal interstitial cells and the majority are located in the stomach and small intestine. They frequently develop in males aged 50-60 years. The symptoms of GIST are non-specific and depend on the size and location of the lesion. Imaging difficulties impede an early diagnosis; sometimes these tumours represent an unexpected intraoperative finding or an emergency abdominal picture. GISTs are classified as tumours with low- and high-risk of malignancy, depending on tumour size and mitotic count. Tumour site and acute onset are also significant parameters for prognostic purposes. Fifteen patients with GIST - gastric in 7 cases, ileal in 6, jejunal in 1 and colonic in 1 - were treated surgically and, in 9 cases, with adjuvant therapy (chemotherapy in 4 patients and imatinib mesylate in 5). The mean follow-up was 38 months. No postoperative mortality was recorded, and the morbidity was 13.3%. Histological examinations documented 6 benign tumours and 9 malignancies. Two patients, one with gastric and one with colonic GIST, were lost to follow-up. One patient, with two synchronous gastric neoplasms (GIST + adenocarcinoma) died after 16 months, while the other 5 patients with gastric GIST are still alive; two patients with ileal GIST, treated with chemotherapy, died after 15 and 18 months, respectively. The mean survival of patients treated with imatinib mesylate was 36 months. Surgical management and the use of imatinib constitute the therapeutic gold standard for GIST. The use of imatinib mesylate is recommended today in the treatment of advanced GIST, especially in cases with liver and peritoneal metastases.

Castleman's disease is a very rare disease that causes many problems both in diagnosis and therapy. It is often associated with other diseases and can develop in any part of the body. Castleman's disease can be classified as uni-centric or multicentric based on clinical and radiological findings, as hyaline-vascular or plasma-cell based on the histological aspect, and as HIV-related or non-HIV-related, based on the HIV status of the patient. An inflammatory fibroid polyp is a very rare benign lesion that can develop anywhere in the gastrointestinal tract. Such polyps are most commonly found in the gastric antrum and usually occur in 50- to 60-year-old people. The authors report the unusual finding of mesenteric Castleman's disease and an inflammatory fibroid polyp of the stomach in a 41-year-old woman.

Gastrointestinal stromal tumours (GIST) constitute a heterogeneous group of neoplasms which, although rare (around 1% of the total number of malignant tumours), are the most common mesenchymal tumours of the gastrointestinal tract. In the past they were not very well known, whereas today, thanks to the remarkable progress made in the immunohistochemical and molecular fields, considerable knowledge has been acquired, offering new opportunities for classification and, above all, for a more adequate multidisciplinary treatment of this pathology. In this study, the authors report a case of a bleeding GIST of the stomach which they recently observed and discuss it in the light of recent reflections on the aetiopathogenesis, diagnosis and therapy of these tumours in the literature.

Although the gastrointestinal tract is a fairly frequent site of melanoma metastases, reports of small bowel intussusception caused by this condition are rare. The presence of intestinal metastases is an expression of what is already a disease at an advanced stage and, therefore, the prognosis of these patients is generally poor with only sporadic cases of long-term survival after resective surgery. We describe the case of a patient referred to our department with a clinical picture of frank occlusion. Ileo-ileal intussusception was diagnosed preoperatively thanks to ultrasound and abdominal CAT scans. The patient was unaware that he had a cutaneous melanoma and, moreover, the diagnosis of a metastasised melanoma was possible only after histological examination of the surgical specimen and the subsequent search for and identification of the primary lesion at the level of the dorsal skin. We performed an extensive ileal resection with an end-to-end entero-enteroanastomosis. Ten months after the operation the patient is still alive but in poor general condition due to the presence of diffuse liver metastases and ascites. We believe that radical resective surgery affords valid palliation for these patients, with disappearance of symptoms and minimal postoperative morbidity and mortality.

Nowadays neuroendocrine breast cancer is a rare entity, though the presence of neuroendocrine cells is often detected within breast cancers. Most of these tumours are associated with conventional ductal or globular breast cancers. We describe the case of neuroendocrine cancer of the breast and discuss its clinical, radiological and cytological aspects.

Adult intussusception is a rare condition. Most of the cases are due to an organic lesion and unlike the incidence in children idiopathic forms are really exceptional, occurring at a rate of 5% of all cases. Whereas in children a main cause is seldom found, adult intussusception is usually characterised by the presence of a leading intraluminal benign or malignant lesion. The authors report their experience with a clinical case of ileocolic intussusception occurring in an 28-year-old white male. In spite of the patient's age, the clinical presentation was very typical with the classic triad of abdominal pain, blood per rectum and a palpable mass. Diagnostic tools, namely US and TC scan, together with colonoscopy confirmed the physical examination, so that surgery was initiated with a definite diagnosis of intussusception. A large polyp or a lymphoma were considered the possible leading causes. After right hemicolectomy, pathology revealed that there was no organic lesion and the bulging mass was caused only by oedema and haemorrhagic infiltration of the invaginated loop. The patient had been on antipsychotic drugs for several months and the possible explanation of the pathology was linked to altered peristalsis induced by the pharmacological agents he was taking. The authors compare their experience with the data reported in the literature, evaluating in particular the incidence, pathology, clinical presentation, diagnosis and treatment of adult intussusception.

The authors report the preliminary results of a prospective study in 30 patients with gastro-oesophageal reflux disease. The aim was to assess the efficacy of an-original device designed to augment the lower oesophageal sphincter barrier using magnetic force. The device was placed laparoscopically around the oesophagogastric junction, at the level of the z line identified by intraoperative endoscopy. Transient dysphagia not requiring any treatment was recorded in 45% of patients. At 3 months postoperatively, the GORD-HRQL score was fond to be significantly decreased from 24.4 to 2.2 (p < 0.001) and the DeMeester score was normalised in 80% of patients. At one year follow-up, 100% of patients were off proton pump inhibitors, and 70% of them had a normal DeMeester score. All patients preserved the ability to belch.

Radiation-induced arteriopathy is a well-known disease whose incidence is not known and which usually arises chronically many years after radiation therapy. When it arises acutely, spontaneous rupture or, more rarely, thrombosis of the involved vessel may occur. Spontaneous rupture can occur within 4 to 32 weeks of radiotherapy, and usually affects the carotid artery involved in radiotherapy of the neck and head. Spontaneous rupture of the femoral artery is a very rare event and only a few cases have been reported in the literature. In this paper we report a case of spontaneous rupture of the left femoral superficial artery after adjuvant radiotherapy following surgery for a liposarcoma of the spermatic cord with multiple local recurrences, successfully treated with an extra-anatomic bypass through the obturator canal and rectal muscle flap.

The aim of the study was to evaluate the laparoscopic approach to reoperative bariatric surgery. From January 2003 to July 2007, 26 obesity surgery patients were referred to our Institution for revision. Nineteen patients previously had an open gastric banding, 3 an open vertical banded gastroplasty, 2 an open jejunoileal by-pass (J-l BP) and 2 an open gastric by-pass. Indications for re-operation were insufficient weight loss in 14 patients, band slippage in 7, band erosion in 3 and severe malabsorptive syndrome in 2. Mean preoperative BMI was 45 kg/m2. Twenty-six laparoscopic re-operative procedures were performed. Three patients required a third operation. Eleven gastric banding patients underwent band removal, 7 gastric banding patients were converted to an open gastric by-pass, 1 band was removed and simultaneously re-placed, the 2 jejuno-ileal by-pass patients underwent an intestinal restoration, 3 vertical banded gastroplasty patients were converted to laparoscopic gastric by-pass, 1 open gastric by-pass patient was converted to a laparoscopic long-limb gastric by-pass and in 1 patient with a gastro-gastric fistula after open gastric by-pass the fistula was resected. Further procedures included 1 laparoscopic gastric banding, 1 laparoscopic gastric bypass and 1 laparoscopic bilio-pancreatic diversion. Conversion to laparotomy was needed in 5 cases (5/29, 17.2%). Early complications included 1 case of pneumothorax and 6 cases of wound infection (24.1%). Mortality was zero. The mean follow-up was 36.2 months. Mean postoperative BMI was 34.3 kg/m2. Laparoscopic reoperative bariatric surgery is feasible, safe and effective after open bariatric surgery.