[Gastrointestinal stromal tumors (GIST). Update and indications for treatment: our experience]. / Tumori gastrointestinali stromali (gist). Attualità e indicazioni al trattamento: nostra esperienza.

The gastrointestinal stromal tumors (GISTs) represent 1% among bowel diseases. Their clinical history is unknown, and it seems to develop from muscolar or nervous tissue in the bowel wall. The grade of malignancy is directly correlate to the dimension of tumor and the number of mythosis for field. We report our experience in diagnosis and treatment.

[Mirizzi's syndrome. Evaluation of 3 cases]. / Sindrome di Mirizzi. Analisi di 3 casi.

OBJECTIVE: Evaluation of three cases of Mirizzi's syndrome (MS), a rare condition of non neoplastic biliary tree obstruction. MATERIALS AND METHODS: We reviewed three cases of MS, operated from July 1998 to December 2000 in our institution. All patients were preoperatively evaluated by clinical examination, Ultrasound (US) and Endoscopic retrograde colangiopancreatography (CPRE) for jaundice. Computed Tomography (TC) was also performed in two. RESULTS: Abdominal pain was the main symptom in two patients, jaundice in one (17 mg/dl); Courvoisier-Terrier sign, suggestive for a biliopancreatic neoplasm, was present in two patients. US was sensitive for gallbladder stones and biliary tree dilatation but not specific for MS; TC only excluded a malignancy in the biliopancreatic area but wasn't useful for diagnosis. CPRE visualized a gallbladder stone obstructing the biliary tree in two cases, but failed to show the fistula between gallbladder and hepatic duct in one. Operations were performed with an "open" approach; in two patients colecystectomy was sufficient to relieve the obstruction, in one patient the biliary fistula was closed with a gallbladder tissue flap over a T tube. DISCUSSION: Mirizzi's syndrome is a rare condition, but surgeons must be aware of it, particularly in the laparoscopic era were dissection of the Calot triangle may lead to a damage of the hepatic duct. Suspect of MS is mandatory in all cases of jaundice with non neoplastic biliary obstruction. Preoperative diagnosis of MS is not easy; US is sensitive for gallbladder stone and biliary tree dilatation, but not specific for choledochal stone compression and biliobiliary fistula. TC is useful for exclusion of pancreatic or liver neoplasms but is non specific for MS. CPRE represents the "gold" standard for MS, showing the hepatic duct compression caused by the stone impacted in gallbladder neck. CPRE is not only diagnostic but also operative; sphyncterotomy and stones extraction give a temporary relief of hyerbilirubinemia waiting for operation. When only a gallbladder stone causing the biliary tree obstruction is found simple cholecystectomy is curative, but a large colecysto-choledocal fistula needs a biliary tree reconstruction, also with a bilio-digestive anastomosis. CONCLUSIONS: Mirizzi syndrome is a rare condition, but surgeons must be aware of it. Surgical approach to MS in the "laparoscopic era" may be complicated by the presence of a colecysto-biliary fistula; in these cases dissection of the Calot triangle may difficult or impossible. When a MS is suspected the "open" approach is preferable, also for the reconstruction of biliary tree. CPRE is the most important diagnostic tool, showing the stone compressing the biliary tree.

[Inguinal hernia in the elderly. Indications, techniques, results]. / L'ernia inguinale nell'anziano. Indicazioni, tecniche, risultati.

AIM: Inguinal hernia in the elderly is a quite common problem in general surgery. Surgical treatment must be aware of the cardiovascular and respiratory pathology these patients are often affected by and, on the other side, the goal of surgery is a quick functional recovery after the operation using the "tension free" technique and, whenever possible, local anesthesia. In this paper personal experience on inguinal hernioplasty in elderly patients (>65 years) is presented; the aim is a better definition of the indications to surgery and anesthesia and verify the results of surgical treatment. METHODS: From January 1999 to December 2002 our group operated 317 patients with inguinal hernia; 123 patients were over 65 (119 male, 4 female, age from 65 to 101 years, mean 74); in this group 111 Lichtenstein and 12 Trabucco HPL were performed. There were 89 primitive hernias, 17 recurrences and 17 emergency operation. Local anesthesia was the method of choice except for obese patients, obstruction or strangulation, or patient's preference. In giant hernia, or when a large sac was found, the Wantz technique was performed (13 patients); a suction drainage was used if a large space in the inguinoscrotal area remained after hernia reduction (9 patients). RESULTS: Local anesthesia was used in 87 patients, spinal in 31 and 5 in general; there were no postoperative deaths. Local complications were: 4 inguinal hematomas, 2 hematomas and 2 transient edemas of the scrotum, 1 wound infection, 1 sieroma of the wound and 1 scrotal sieroma (9%); all patients recovered after few days of medical therapy. No cases of ischemic orchitis occurred. CONCLUSION: Inguinal herniorraphy can be safely performed, in elderly patients; according to personal experience local anesthesia proved to be a safe technique, also in patients with cardiocirculatory problems. Local complications were mild and more frequent in patients "over" 65 years (13% vs 6%, in "under" 65), but recurrent hernias make the difference; a suction drainage can reduce the problems caused by a fluid collection in the inguinoscrotal area. Wantz technique reduces the operative time and, according to personal opinion, contributed to lower ischemic testicular complications to zero.

Bile duct injuries during laparoscopic cholecystectomy: a 1994-2001 audit on 13,718 operations in the area of Rome.

BACKGROUND: Bile duct injuries (BDIs) during laparoscopic cholecystectomy (LC) still are reported with greater frequency than during open cholecystectomy (OC). METHODS: In 1999, a retrospective study evaluating the incidence of BDIs during LC in the area of Rome from 1994 to 1998 (group A) was performed. In addition, a prospective audit was started, ending in December 2001 (group B). RESULTS: In group A, 6,419 LCs were performed (222 were converted to OC; 3.4%). In group B, 7,299 LCs were performed (225 were converted to OC; 3.1%). Seventeen BDIs (0.26%) occurred in group A and 16 (0.22%) in group B. Overall, mortality and major morbidity rates were 12.1% and 30.3%, respectively, without significant differences between the two groups. CONCLUSIONS: The incidence and clinical relevance of BDIs during LC in the area of Rome appeared to be stable over the past 8 years and were not influenced by the use of a prospective audit, as compared with a retrospective survey.

[Recurrent inguinal hernia after mesh hernioplasty. An emerging problem?]. / Ernie inguinali recidive ad ernioplastica con protesi. Un problema emergente?

BACKGROUND: In spite of the successful results of tension free hernioplasties, recurrent inguinal hernias are not an uncommon finding in the clinical practice. METHODS: The authors report their experience in 24 patients observed from January 1994 to December 2000 (23 men, 1 women, min. age 28 yrs, max 78 yrs, mean 58 yrs) who had recurrent inguinal hernia after a tension free hernioplasty. In 22 patients a tension free hernioplasty (Lichtenstein technique 5 patients, Trabucco 7 patients, unclassifiable 10 patients) through an anterior approach was performed while in two, respectively, a Stoppa procedure and a laparoscopic hernioplasty were the first operations; mean recurrence time was 17 months. RESULTS: Mesh and/or plug dislocation was the most frequent cause of recurrence (15 patients), followed by a failure of the internal ring reconstruction (6 patients) and loss of the pubic stitch (2 patients); in 1 patient the mesh was of reabsorbable type. CONCLUSIONS: Mesh hernioplasties represent a valuable progress in inguinal hernia therapy, but increasing clinical experience shows that, together with the experience of the surgeon in the surgical technique, suture of a wide mesh to the surrounding tissues and a adequate inguinal ring reconstruction are critical condition for good results.

[Postoperative pain in prosthetic inguinal hernioplasty. Predictive factors and effects on patient recovery]. / Il dolore postoperatorio nell'ernioplastica inguinale protesica. Fattori predittivi e impatto sulla convalescenza.

BACKGROUND: Tension free hernioplasty under local anaesthesia in day care basis is now the gold standard for inguinal hernia surgery, but a severe postoperative pain may affect convalescence and return to work, so minimizing economic benefits of day hospital. METHODS: To evaluate the incidence and predisposing factors of severe postoperative pain the authors examined 100 patients (96 men and 4 women, min. age 16 yrs, max 91 yrs, median age 53 yrs) operated from January 1999 to January 2000; in all cases a tension free hernioplasty under local anesthesia was performed. RESULTS: Good results were obtained in 83% of patients for intraoperative comfort, in 91% for postoperative pain, in 86% for immediate postoperative walking and in 93% for walking in the first week. Postoperative pain (first 24 hours) was strictly correlated to intraoperative pain, while a difficult postoperative walking was predictive for a difficult walking in the first week. CONCLUSIONS: Tension free hernioplasty allows a good functional recovery to daily activities since the first postoperative week; with an even more accurate patients selection and aggressive postoperative analgesia in pain risk patients better results will be achievable.

[Postoperative pain in inguinal hernioplasty: does it exist?]. / Il domani doloroso dell'ernioplastica inguinale: esiste?

Tension-free hernioplasty in the Day Hospital or Short Stay Surgery setting is now considered the gold standard for hernia treatment, but early discharge is not synonymous with a rapid recovery, and pain in the inguinal region may persist for months after the operation. The authors examined 100 tension-free hernioplasties, performed in 1999. 72 Lichtenstein and 28 Trabucco hernioplasties were performed in 97 men and 3 women (min age 18 yrs., max. 90 yrs., mean 55 yrs.). Three months after hernioplasty residual inguinal pain was present in 10 patients (mild in 9, moderate in 1). Hypo-dysaesthesia in the inguino-crural region was also present in 8 patients (mild in 7, moderate in 1). Operative technique, emergency surgery and the surgeon himself were not correlated with results; occupational status was significantly associated with residual pain, which affected active workers more than retired patients.

[Recurrent inguinal hernia. Intraoperative findings and cause of failure]. / L'ernia inguinale recidiva. Reperti intraoperatori e cause di insuccesso.

BACKGROUND: Recurrent inguinal hernia is still frequently observed today. METHODS: In order to evaluate factors causing failure of hernia repair 64 recurrent hernias are examined (63 men, 1 woman; age: min 32 years, max 88, median 60 years), 54 previously operated with "traditional" Italian surgical school techniques (Bassini and Postempskij) and 10 with "tension free" operations. For every patient previous surgical procedures, complications occurred, timing of recurrence and intraoperative findings at reoperation were recorded. RESULTS: In the "traditional" hernioplasty group, 31 indirect and 23 direct hernias occurred; median relapse time was 11 years. In "tension free" techniques, 4 mesh suture failures (Lichtenstein), 2 mesh or plug dislocations (Trabucco) and 4 indirect hernias (mesh ring failures) were found at reoperation; median relapse time in this group was 2 years. The findings of a so long relapse time for traditional techniques was surprising, it is obvious now that every new "tension free" technique must have (at least) a such success rate. In the first group, inadequate technique of operation and physiologic weakening of the abdominal wall were responsible for the relapse, while in the second a technical failure was the main reason. CONCLUSIONS: "Traditional" hernia surgery is now progressively abandoned in favour of "tension free" techniques, in which recurrences are due to the "physiologic" training period of the surgeon; mesh itself doesn't warrant success, but anatomical knowledge and an adequate dissection of musculo-fascial planes are mandatory.

[Tension free hernioplasty in the treatment of recurrent inguinal hernia. Our experience]. / L'ernioplastica "tension free" nel trattamento dell'ernia inguinale recidiva. Nostra esperienza.

BACKGROUND: Despite the new surgical approach with "tension free" techniques, recurrent inguinal hernia repair remains a difficult surgical problem. METHODS: Personal experience in 61 cases of recurrent inguinal hernia is reported; in all patients a new hernioplasty with a "tension free" technique was performed. Medium follow-up of the study was 27 months (min 6 mm, max 56 mm); 3 recurrences were observed, 2 in Lichtenstein "plug" hernioplasty and 1 with the Trabucco technique. RESULTS: No recurrences were observed in Lichtenstein "mesh" hernioplasty group. CONCLUSIONS: Lichtenstein "mesh" hernioplasty can solve every anatomical situation in hernia recurrence and good results, with little or any complications, are achievable; "plug" technique is easier but recurrences in other sites of a weak inguinal wall are possible.

[Reoperations in surgical oncology: recurrence of colon carcinoma after surgery]. / Reinterventi in chirurgia oncologica: le recidive dopo interventi per carcinoma del colon.

Colon cancer is the second leading cause of death for cancer disease, after lung cancer, with nearly 18,000 deaths per year in Italy. In spite of the progress that have taken place over the past 30 years, little improvement has been gained in this dismal outcome, and the 5-year survival remains around 50%. Over one half of the patients will suffer from recurrence after a potentially curative resection. A major challenge lies in better detection of recurrences in order to diagnose those patients still amenable to curative resection. Locoregional recurrence is of particular interest and its frequency, diagnostic limitations and surgical treatment are herein discussed.

[Biodegradable compression ring in intestinal anastomosis]. / L'anello bioframmentabile a compressione nelle anastomosi intestinali.

The Authors report their experience with the use of biofragmentable anastomosis ring ("Bowel Anastomosis Ring" B.A.R.--Valtrac): 34 patients underwent colic resection and bowel anastomosis by B.A.R. No complications related to the anastomosis were recorded. The ring was always discharged in the third postoperative week and the endoscopic follow up showed no late complications. It is concluded that B.A.R. is a safe technique and represents a good alternative to hand or mechanical anastomosis with a favorable cost/benefit ratio.

[The elective use of protective colostomy in rectal resection surgery]. / Impiego in elezione della colostomia di protezione nella chirurgia resettiva del retto.

To clarify the indications and clinical value of "protective colostomy" in cases of low colorectal anastomoses, some recent series are analyzed and compared to the experience of the authors, which includes 65 low anterior resections of the rectum for cancer, with colorectal anastomosis at less than 10 cm from the anus. "Protective colostomy" seems not to prevent the onset of anastomotic fistulae, but appears effective in reducing its clinical effects. "Protective colostomy" seems convenient when there is an increased risk of fistulization, as indicated by a series of factors defined by the authors. In doubtful cases "protective colostomy" may be performed but not opened. So the patient will be given the maximum safety, and not submitted to the uneasiness of an open colostomy unless needed.

The effect of treatment with coenzyme Q10 on the mitochondrial function and superoxide radical formation in cardiac muscle hypertrophied by mild aortic stenosis.

A 40% reduction of the diameter of the ascending aorta maintained for 60 days induced the formation of a compensate cardiac hypertrophy in rabbits without changing the value of the azide insensitive Ca2+-ATPase activity in comparison to control hearts. The cardiac mitochondria isolated from constricted animals assayed in presence of glutamate and succinate did not show a change in the R.C.I. and ADP/O values in comparison to the controls, whilst the QO2 value enhanced or decreased respectively when determined with glutamate or succinate. The intramuscular injections of CoQ10 (12 mg/kg body weight/48 h) enhanced the mitochondrial CoQ10 concentrations both in the control and in the constricted animals and further increased the QO2 value determined in both groups of animals when glutamate was used as the substrate. The production of O2.- radicals by the level of the complexes I and III of the respiratory chain, did not change in the constricted animals, nor in the animals administered with CoQ10 in comparison to the control. CoQ10 augmented the rate of oxygen consumption by the submitochondrial particles only in the constricted animals. Moreover, the treatment with the coenzyme or the constriction of the aorta, did not modify the cardiac superoxide dismutase activity, but increased the glutathione peroxidase activity only in the banded animals. In addition, in the CoQ10 treated animals there was a reduction of NADH-diaphorase activity both in the control and constricted animals, while the malondialdehyde, generated during the thiobarbituric acid test, and the cardiac content of lipofuscin were decreased.