Colour Doppler-guided Haemorrhoidal Artery Ligation: a possible evolution of Transanal Haemorrhoidal Dearterialisation.

INTRODUCTION: Haemorrhoids are a very common disease, with a great economic burden. Many treatments have been developed for trying to solve the problem, being the standard not yet found. In 1995, Doppler-guided haemorrhoidal artery ligation was introduced, aiming to reduce postoperative pain and complications. In this work, an evolu-tion of the aforementioned surgical technique was described. MATERIALS AND METHODS: 183 patients treated with standard Doppler-Guided Haemorrhoidal Artery Ligation were statistically compared with 225 patients dealt with Colour Doppler-Guided Haemorrhoidal Artery Ligation. The procedures were performed under local anaes-thesia with patients in lithotomy position. A special proctoscope and a dedicated Colourdoppler US probe were employed in the second group. Superior haemorrhoidal artery terminal branches were con-secutively ligated according to provided technique in the first group and under vision in the second. In all cases, each ligation was followed by mucopexy. RESULTS: No significant differences between the two groups, in terms of post-operative pain, early complications (bleeding, urinary retention, incontinence) or patient satisfaction, were demonstrated. Recurrence rate was significantly higher in patients treated with stan-dard DG-HAL. No late complications (after one-year follow-up) were registered in both groups. CONCLUSIONS: Colour Doppler-Guided Haemorrhoidal Artery Li-gation represents an ideal management for 1-day surgery, and fulfils the requirements of minimally invasive surgery in patients with III-IV grade haemorrhoids. The absence of complications and the evidence of significant wellness of patients are the best advantages. Colour Doppler-Guided Haemorrhoidal Artery Ligation is a safe and easy procedure with good results and a very short-time training. It could be considered an easy and reliable method to treat symptomatic haemorrhoids.

Diagnostic and therapeutic iter in paediatric OSAS: personal experience.

Obstructive sleep apnoea syndrome in a child is characterized by prolonged episodes of obstructive hypopnoea and/or apnoea of upper airway leading to morbidity. The most common risk factor is adeno-tonsillar hypertrophy. Obstructive sleep apnoea syndrome diagnosis is based on clinical ENT evaluation and an instrumental approach, such as pulse oximetry or the gold standard overnight polysomnography. The aim is to establish, in a population of children with suspected obstructive sleep apnoea syndrome, the frequency of this disorder, the effect of adenotonsillectomy and the risk of post-operative complications. A total of 481 patients (297 male, 184 female) with suspected obstructive sleep apnoea syndrome (aged 2-14 years) were evaluated between March 2007 and April 2010 and divided into 3 morphological phenotypes: classic, adult and congenital. All patients underwent ENT assessment and a pulse oximetry with 4 channels cardiopulmonary monitoring. The examination following the Brouillette criteria was defined as negative, positive or inconclusive; when positive, adenotonsillectomy was the first therapeutic approach. At 6 months after surgery, all patients underwent check-up pulse oximetry. Of the overall sample, 96% of the patients had a classical phenotype, 3% an adult type and 1% a congenital type. The monitoring resulted pathological in 19% (17% of them were at increased post-operative risk), negative in 61% and inconclusive in 20%. All 5 patients with congenital phenotype were positive. Of the positive patients, 86% underwent adenotonsillectomy and a control pulse oximetry 6 months thereafter, 96% resulted negative. Pulse oximetry was efficient in order to avoid incorrect surgery indications, improving appropriateness and safety of adenotonsillectomy in children with obstructive sleep apnoea syndrome. Adenotonsillectomy showed a success rate of 96% and there were no episodes of post-surgery complications in particular in those patients at increased risk.

Gastric polypoid lesions. Our experience.

BACKGROUND AND AIM: The Authors report the results of their experience on polypoids lesions of the stomach and on endoscopic polypectomies. PATIENTS AND METHODS: A study on 2000 OGD (oesophagogastroduodenoscopy) has been carried out on 95 patients with polypoid lesions. The authors have analysed the associations existing between histological type and symptomatology and localisation of the lesion and the status of the Helicobacter pylori and the risk of cancerization. The data were confronted with the ones already available. RESULTS: In the majority of the cases, the polypoid lesions were asymptomatic, the localization changed according to the histological type, with the antrum as the most affected area. The presence of Helicobacter pylori does not seem to be correlated to the lesion, except in the case of hyperplastic polyps. The percentage of risks of cancerization increased in case of adenomatous polyps. In one patient signet ring cell carcinoma within a gastric polyp was found. Gastric signet ring cell carcinomas are peculiar for their rarity as well as for the growth in polypoid lesions. CONCLUSION: We confirm the higher frequency of hyperplastic polyps and the correlation between histological type and localization. Endoscopic polipectomy is the first approach in gastric polyps, with lower risk of developing cancer. Only in selected cases, as in one in ours, it is advisable the surgery.

[Adrenal incidentaloma: case report and synthesis of indication and thresholds of surgery therapy]. / Un caso di incidentaloma surrenalico: sintesi delle indicazioni e limiti della terapia chirurgica.

With the term of incidental mass, any mass is identified, occasionally discovered with imaging techniques, in the absence of specific symptoms. In 1982, the term "incidentaloma" was introduced to indicate lesions detected on adrenal regions, found unexpectedly. The incidence percentages vary from 0.6%-3% in CT followed by other indications , to 10% and 25% in all patients who underwent an ultrasound, CT or MRI. An appropriate diagnostic protocol is mandatory to identify and to choose the proper treatment for the functioning lesions, as well as the malignant or potentially malignant lesions (1, 2). Incidentalomas with diameters under 1 cm seem to not have a pathologic significance, and are considered like manifestation of the gland involution in advanced-age subjects, and can remain unseen for a long time. The use of diagnostic imaging techniques has made it possible to identify these masses, even those of small size, in the course of diagnostic surveys done under various guidelines. The mass dimensions are a fundamental parameter used to distinguish benign lesions from malign ones (2, 3). Most Authors suspect malignity in masses above 5-6 cm, while considering those with a diameter under 3 cm to be benign. Whereas the rest remain undefined, thereby valued and treated according to criteria not perfectly established.

[Bilateral testicular lymphoma. Case report]. / Linfoma primitivo testicolare bilaterale: a proposito di un caso clinico.

A case of bilateral testicular lymphoma with involvement of skin and oropharynx was described. After a review of literature, the Authors underline the clinical features focusing the diagnostic approaches and the therapeutics options.

[Infected pancreatic pseudocysts: technical notes]. / Pseudocisti pancreatiche infette: note di tecnica.

INTRODUCTION: Starting from the observation of 9 cases of giant infected pancreatic cysts, which occurred from 1994 to 2004 at the Department of Oncological and Surgical Studies, the Authors' aim has been to evaluate whether a more thorough necrosectomy, carried-out under video-endoscopic control, associated with a nose-gastro-cavity tube, which ensures a continuous cleansing of the newly-formed cavity, and an appropriate positioning of the drainages, could reduce the morbidity and allow a shorter recovery of the infected pseudocysts. PATIENTS AND METHODS: Of 73 cases of acute pancreatitis, observed from 1994 to 2004, 9 showed severe and acute pancreatitis, which included giant pseudocysts, as revealed by the abdomen angio-TC. Our nine septic patients underwent cysto-gastro-anastomosis, necrosectomy, intraoperative cleansing of the cavity with an antibiotic solution and positioning of multiple drainages. Three of these patients also underwent a thorough and targeted necrosectomy, assisted by a trans-anastomotic video-endoscopy. A nose-gastro-cavity tube has been placed in all the patients. RESULTS: The disappearance of the septic state in our three patients who underwent a targeted video-assisted necrosectomy occurred after three days of treatment; moreover, the abdomen angio-TC on the 5th postoperative day showed the disappearance of the necrotic areas. The recovery of these three patients was significantly shorter, compared to those undergoing traditional treatment (cysto-gastro-anastomosis, standard necrosectomy and positioning of abdominal drainages). CONCLUSIONS: Our surgical video-assisted technique demonstrated that, with a slight increase in the operative time, a better control over sepsis may be accomplished, as well as a reduction of the post-operative morbidity, which leads to shorter hospitalisation of patients with infected pancreatic pseudocysts.

[Gallstone ileus: diagnosis and treatment. Case report]. / Ileo biliare: diagnosi e trattamento. Case report.

The authors present a case of gallstone intermittent ileus caused by the passage of a big gallstone (about 4 cm in diameter) in the intestinal lumen, through a cholecystoduodenal fistula. They emphasize the peculiarity of the case for the characteristics of symptoms and for casual diagnostic check-up with a ultrasonography. The disease is not frequently diagnosed; today it has a safe recognition by modern imaging. The symptoms can be intermittent and, even when there are the classic signs of intestinal occlusion, the site of the occlusion is various. With a timely endoscopical or surgical approach (open or laparoscopic) it is possible to reduce mortality of patients treated in emergency.

[Ultrasonic dissector for total thyroidectomy: results of prospective randomized study]. / Tiroidectomia totale con impiego del dissettore ad ultrasuoni: risultati di uno studio prospettico randomizzato.

In the last years, the introduction and employment in surgery of the dissectors of last generation (ultrasounds, radiofrequency, etc.) have contributed to a remarkable improvement and simplification of the performances and the surgical techniques. The present study has the aim to verify, on the basis of the experience made in the last two years and through a careful comparisons with operations performed in the usual way, the advantages of employment of ultrasonic dissector in thyroid surgery and if besides such advantages it is possible to obtain real and substantial reductions of the complications. To such aim a randomized perspective study has been lead, confronting two groups of 60 patients, submitted to total thyroidectomy in Chair of General Surgery and Surgical Physiopathology of the University of Palermo-Complex Operating Unit of General Surgery. In all patients have been considered age, sex, histological diagnosis, length of the incision, time (from the incision until suture of skin), entity of the bleeding, hospital stay, post-operative consequences and total costs of thyroidectomy. The elaboration of the obtained data shows the advantages following to the use of the dissectors of last generation: reduction of the times, reduction of the complications, better tolerance of the operation by patients, better rationalization of the resources.

Prognostic factors of cirrhotic patients in extra-hepatic surgery.

BACKGROUND: The surgical approach to a cirrhotic patient is conditioned by a number of variables depending on the emergency and kind of the intervention. It is also related to the evolutionary stage of the liver pathology (evaluated following Child-Pugh score). The present study will explore the physiopathologic mechanisms which should be correlated with the preoperative risk factors responsible for the variation of morbidity and mortality of the hepatopathic patient addressed to an extrahepatic surgical intervention. METHODS: This study includes a retrospective analysis (from 1992 to 1999) of 40 patients with cirrhosis (80% HCV correlated cirrhosis, 15.5% alcoholic cirrhosis, 2.5% cryptogenic cirrhosis), who underwent such procedures as: colon resection (5), gastrectomy (4), hernioplasty (11), cholecystectomy (14), ulcorraphy (3), laparotomy (3). Patients with hepatic resection and portal shunt are excluded from this study. A pre- and postoperative evaluation of ascites, PT, APTT, albumin, bilirubin and protein value, number of leukocytes and Child-Pugh score was performed on all patients. Their follow-up was 30 days. RESULTS: The presence of tensive ascites, low albumin value, PT, APTT, together with the emergency of the operation, proved to be significant (p<0.001), in correlation with a mortality of 7.1% in Child's class A, of 23% in class B, and of 84% in class C. CONCLUSIONS: Cirrhotic patients undergoing elective or emergency surgery can incur significant preoperative risks and postoperative complications, increasing their mortality rate. An accurate preoperative predictive factor is Child's class.

Artificial nutrition for the treatment of short bowel syndrome.

BACKGROUND: In the short bowel syndromes (SBS) it is often difficult to grant a correct and sufficient alimentary supply only by ordinary natural nutrition. In the present research, we will study the prospective possibilities of integrating the nutritional supply making resort to artificial nutrition techniques in patients with SBS. METHODS: We have treated 7 patients with SBS, 6 males and 1 female, whose age was ranging from 29 and 70 years. They all underwent wide intestinal resection, 2 of them for massive infarct, 4 for Crohn's disease, 1 for bowel volvolus. An evaluation of nutritional and immunological conditions was performed on all of them, determining: albumin, transferrin, C-reactive protein, prealbumin, leukocyte count, skin test. In a second time, a protocol was implemented, based on total parenteral nutrition for the first 5 days, with scalar calorie supply up to a total of 35 kcal/kg/die; on day 6 after the operation, the parenteral caloric supply was reduced of 500 kcal/die, being compensated by the introduction of an equal caloric ration by nasointestinal tube with peristaltic pump having a flow of 20 mL/h. In the following days, the parenteral caloric supply was reduced of 500 cal each 48 hours, being substituted with an equal enteral supply in order to progressively reach a complete abandonment of parenteral nutrition. RESULTS: All the patients have a follow-up of 2 to 5 years; today they follow a high-calorie hyperglycidic, hypolipidic diet; no signs of malnutrition are shown by clinical and laboratory analysis. CONCLUSIONS: In the light of the data in our possession, it can be understood that nutritional therapy is the main treatment for SBS; parenteral subministration has to be abandoned during the postoperatory course to give way to enteral nutrition, in order to create a physiological stimulus able to make the digestive system rapidly adapt to the new situation.