Robotic colectomy: is it necessary?

More than 20 years ago the introduction of laparoscopic surgery represented a paradigm shift in the management of colorectal cancer. In most recent years robotic surgery is becoming a viable alternative to laparoscopic and traditional open surgery. The major clear advantages of robotic surgery in comparison with laparoscopy are the lower conversion to open surgery rates and the shorter learning curve. However, the role of robotics in colorectal surgery is still largely undefined and different with respect to its application in abdominal versus pelvic surgery. As for colon cancer there are emerging data that laparoscopic and robotic surgery have the same advantages in terms of faster recovery, although robotic-assisted colectomy is associated with costs increase of care without providing clear reduction in overall morbidity or length of stay. Long-term outcomes for laparoscopic versus robotic colonic resections remain still largely undetermined and randomized controlled clinical trials are required to establish a possible difference in outcomes. Interesting issues for the educational aspects are associated with robotic surgery, as the double console allows the resident to take part actively at the surgical procedure since the beginning of his surgical experience.

Role of robotic surgery in colorectal resections for cancer.

In recent years, robotic surgery is becoming a valid alternative in colorectal diseases treatment to laparoscopic and traditional open surgery. The most relevant reported technical advantages of the robotic surgery are 3D-view, tremor-filtering, seven degree-free motion and a higher comfortable setting for the surgeon. Both case series and comparative studies available in Literature report only short and mid-term outcomes. These studies are able to demonstrate that robotic surgery is as safe and feasible as laparoscopic surgery regarding perioperative outcomes. Trials with long term follow up are needed to establish the real safety and effectiveness of the robotic surgery especially concerning resections for cancer. The robotic surgery could be considered a promising surgical field. The high costs represent one of the most relevant drawbacks.

Infections in lung transplanted patients: A review.

Lung transplantation can improve the survival of patients with severe chronic pulmonary disorders. However, the short- and long-term risk of infections can increase morbidity and mortality rates. A non-systematic review was performed to provide the most updated information on pathogen, host, and environment-related factors associated with the occurrence of bacterial, fungal, and viral infections as well as the most appropriate therapeutic options. Bacterial infections account for about 50% of all infectious diseases in lung transplanted patients, while viruses represent the second cause of infection accounting for one third of all infections. Almost 10% of patients develop invasive fungal infections during the first year after lung transplant. Pre-transplantation comorbidities, disruption of physical barriers during the surgery, and exposure to nosocomial pathogens during the hospital stay are directly associated with the occurrence of life-threatening infections. Empiric antimicrobial treatment after the assessment of individual risk factors, local epidemiology of drug-resistant pathogens and possible drug-drug interactions can improve the clinical outcomes.

Conservative approach to Hepatic Portal Venous Gas: A case report.

INTRODUCTION: Hepatic Portal Venous Gas (HPVG), a rare condition in which gas accumulates in the portal venous circulation, is often associated with a significant underlying pathology, such as Crohn's disease, ulcerative colitis, diverticulitis, pancreatitis, sepsis, intra-abdominal abscess, endoscopic procedures, mesenteric ischemia, abdominal trauma. PRESENTATION OF CASE: Here we report a case of HPVG in an 82-year-old patient who underwent a left colectomy for stenosing tumor of the descending colon. The patient was treated conservatively, and his symptoms resolved. Follow-up computed tomography (CT) scan showed complete resolution of HPVG. DISCUSSION: The mechanism underlying the passage of the gas from the intestine into the mesenteric, then portal, venous system is not fully understood. Historically, this condition has been related to acute intestinal ischemia, as a consequence of a bacterial translocation through a wall defect. CONCLUSION: This case underscores the role of conservative management, highlighting how the severity of the prognosis of HPVG should be related to the underlying pathology, and not influenced by the presence of HPVG itself.

Abdominal Wall Schwannoma.

Neurilemmomas-or schwannomas-are rare soft tissue tumours involving peripheral nerve sheaths, usually found in the head and neck regions. They can infrequently originate within the tissues of the abdominal wall. Here, we present a case of symptomatic schwannoma of the abdominal wall in a 62-year-old woman referred for abdominal pain in the right iliac fossa. On physical examination, a 5-7-cm oval-shaped area of consolidation with regular borders and elastic consistence was palpable. Ultrasound examination of the abdomen revealed a hypoechogenic mass measuring 80-33-42 mm; subsequently, a CT scan confirmed the presence of a well-circumscribed mass, with small calcifications inside. Radical excision of the lesion under general anaesthesia was performed, and the histological examination was consistent with the diagnosis of "ancient" schwannoma. The patient was discharged on the second postoperative day, and, at a clinical check 1 month postoperation, she reported no recurrence of abdominal pain and had an improved quality of life. Schwannomas have a good prognosis overall, with malignant degeneration being very rare. Local recurrence is plausible only if non-radical resection of the primitive tumour occurs. This is the second case ever reported, to our knowledge, of symptomatic schwannoma of the abdominal wall. We advocate surgical removal of the tumour when it presents as a cause of abdominal pain, ensuring that a radical excision is performed due to the possibility-though rare-of malignant transformation or recurrence. This offers the possibility of total regression of symptoms through surgical therapy.

Nonfunctional paraganglioma of the head of the pancreas: A rare case report.

BACKGROUND: Paragangliomas are rare neoplasms that originate from the neural crest. They are malignant in approximately 10% of cases, with a 50% survival rate at 5 years from diagnosis. In most cases, manifestations of malignancy (such as metastasis) are lacking, and paragangliomas are considered benign lesions. Pancreatic paragangliomas are extremely rare, with only 31 cases described in the scientific literature to date. CASE SUMMARY: Here we describe a case of a 55-year-old Caucasian male patient referred to our institution in September 2013 for lumbar pain lasting five months. The ultrasound and the CT scan revealed a 2.5cm solid nodule located in the uncinate process of the pancreas. On the basis of this evidence, the preoperative diagnosis was a pancreatic neuroendocrine tumor (NET), which was further confirmed by a subsequent In-Pentetreotide Scan examination. A pylorus-preserving duodenocephalopancreasectomy was performed. Pancreatic paraganglioma was the final pathological diagnosis. Rare localizations of paraganglioma are often discovered casually, during imaging examinations for other clinical reasons, as happened in the case of our patient. It appears evident that the preoperative diagnosis of pancreatic paragangliomas is extremely challenging. Surgery represents the cornerstone of the clinical management of these neoplasms, primarily for the need of a definitive diagnosis, which is difficult to assess preoperatively in most cases. CONCLUSIONS: Our strategy is the same as that adopted for the management of pancreatic NETs; the dimensional limit for a conservative resection is 2cm, while major resections (Whipple's approach or distal pancreatectomy) should be employed in larger tumors, which are generally associated with a worse prognosis.

Bowel obstruction after biliopancreatic diversion: a deceptive complication.

BACKGROUND: Although obesity surgery is now practiced in most of the world, many general surgeons, faced with an emergency, are not experienced in the diagnostic problems associated with these techniques, or about the most suitable treatment to resolve the acute pathology while preserving the weight loss. The biliopancreatic diversion (BPD), because of its complexity, could cause a delay in the diagnosis and therapy, with possible catastrophic consequences for the patient. METHODS: We report 3 patients with bowel obstruction after BPD. In the first patient intestinal occlusion was due to an adhesion obstructing the alimentary tract; in the other two patients the occlusion was localized to the biliopancreatic tract, due to a serrate stenosis of the entero-entero anastomosis in one patient and due to volvulus of the biliopancreatic loop in the other patient. RESULTS: Signs and symptoms were different according to whether the obstruction was in the alimentary tract or the biliopancreatic tract. In all cases a prompt gastrointestinal x-ray with barium and ultrasound scan and/or CT scan induced us to a mandatory laparotomy with resolution of the obstruction. CONCLUSIONS: After BPD, diagnosis of an intestinal obstruction must be made promptly. Even colleagues who express doubts must be persuaded to perform immediately an upper gastrointestinal tract x-ray and an U/S or CT scan. In this way, it may be possible to avoid intestinal resection and catastrophic complications.

Biliopancreatic diversion for treatment of morbid obesity: experience in 50 cases.

BACKGROUND: Biliopancreatic diversion (BPD) by Scopinaro's method is an operation advocated by some surgeons as an effective treatment for morbid obesity. METHODS: Between February 1995 and April 1997 we performed BPD by Scopinaro's method on 50 patients with morbid obesity (23 males), average age 41.4 years (range 20-63 years), average body weight 135.08 kg (range 89-256 kg), mean body mass index (BMI) 50.65 kg/m2 (range 37.01-81.56 kg/m2). RESULTS: In all cases a gradual decrease in weight was obtained [mean BMI at 1 month: 44.8 kg/m2, at 6 months (31 patients): 35.09 kg/m2, at 1 year (23 patients): 31.36 kg/m2, at 18 months (14 patients): 29.89 kg/m2 and at 2 years (5 patients): 29.27 kg/m2]. At the same time a significant improvement in the pathological conditions associated with morbid obesity was observed. The patients were able to suspend oral antihypertensive and antidiabetic therapy as these parameters spontaneously returned to normal values by the sixth postoperative month; all cases showed a marked reduction in hypercholesterolemia and hypertriglyceridemia. Postoperative complications were: one death (2%) on the third day due to heart failure; two late intestinal occlusions (4%); one acute dilatation of the stomach (2%); one peritonitis caused by early dehiscence of the anastomosis (2%); five anastomotic ulcers (10%); two cases of protein malnutrition (4%). CONCLUSIONS: BPD by Scopinaro's method is a bariatric procedure which is technically complex. However is it safe and reproducible and it induces a substantial weight loss.

Biliopancreatic diversion preserving the stomach and pylorus in the treatment of hypercholesterolemia and diabetes type II: results in the first 10 cases.

BACKGROUND: Besides weight loss Scopinaro's operation produces correction of hypercholesterolemia and noninsulin dependent diabetes mellitus in all patients who suffer from these conditions. These results encouraged us to perform biliopancreatic diversion (BPD) without gastric resection, thus preserving the functions of the stomach and pylorus in moderately overweight patients with hypercholesterolemia associated with diabetes type II and hypertriglyceridemia. METHODS: Between March 1996 and July 1997 we performed BPD without gastric resection on 10 moderately overweight patients [mean body mass index (BMI) = 33.2 kg/m2]. All patients had suffered from hypercholesterolemia and hypertriglyceridemia for more than 5 years. Ten patients suffered from diabetes type 11; four of them had had insulin treatment or oral anti-diabetic agents; the other patients all had hyperglycaemia in the fasted state and diabetes confirmed by preoperative oral glucose tolerance test (OGTT). Five patients suffered from hypertension. RESULTS: In all patients, cholesterol and triglyceride levels returned to normal within the first postoperative month. Glycemia also stabilized at normal values in nine patients within the early weeks after surgery. One patient who took 70 U of insulin reduced his daily intake to 35 U 2 months postoperatively. In all patients blood pressure returned to normal. Weight loss was predictably slight (10-15 kg). CONCLUSIONS: Our experience with the procedure found that this new method seems to be as effective in controlling lipidic metabolism and diabetes II as the original version of BPD. As expected, weight loss is only moderate, so that the modified BPD is not suitable for very obese patients.

Orally administered ranitidine plasma concentrations before and after biliopancreatic diversion in morbidly obese patients.

BACKGROUND: Patients undergoing biliopancreatic diversion (BPD) may develop gastric ulcers, particularly within the first postoperative year. The prophylactic use of antisecretory compounds at the usual therapeutic doses, mainly conventional H2-receptor antagonists such as ranitidine, may reduce the incidence of this complication, which occurs in approximately 5% of patients after BPD. METHODS: The authors measured the plasma concentrations of ranitidine (300 mg orally) in obese patients, before and 8 months after BPD, and in control subjects of normal weight. The study included 11 obese patients undergoing BPD (age 45+/-14 years; preoperative and postoperative weights 124+/-21 and 92+/-11 kg) and 10 normal-weight subjects (age 37+/-13 years, weight 67+/-9 kg). RESULTS: Postoperative ranitidine plasma concentrations showed only minor differences from preoperative levels, with slightly higher maximum concentrations occurring sooner. The mean area under the curve was on the average 30% higher than preoperatively. All parameters, however, were similar to those in control subjects. CONCLUSIONS: BPD per se does not greatly affect the pharmacokinetic behavior of ranitidine, and therefore a conventional dosage regimen appears adequate for the prophylaxis and therapy of gastric ulcers associated with this operation.

Biliopancreatic diversion with pylorus-preserving technique: a new method for the surgical control of hypercholesterolaemia and diabetes II?

OBJECTIVE: The aim of this study was to evaluate the efficacy of biliopancreatic diversion by Scopinaro's method, with a pylorus-preserving modification, in correcting hypercholesterolaemia and diabetes II not controllable by diet or medical treatment. DESIGN: Besides weight loss, Scopinaro's operation produces a correction of hypercholesterolaemia and diabetes. These results encouraged us to perform BPD without gastric resection, thus preserving the functions of the stomach and pylorus in moderately overweight patients with hypercholesterolaemia and diabetes. SETTING AND PATIENTS: The pylorus-preserving technique has been performed on two patients suffering from severe hypercholesterolaemia and hyperglycaemia and who were not more than 30% overweight, at Clinica Chirurgica and Chirurgia d'Urgenza Department, University of Sassari, Italy. Both patients had a six-month follow-up assessment. MAIN OUTCOME MEASURES. Examination of cholesterol and glycaemia levels after the operation, and the moderate weight loss. INTERVENTION: The operation is the same as Scopinaro's with regard to the length of intestine forming the alimentary loop and the common tract. The difference lies in the fact that instead of resecting the stomach and creating a gastroileostomy, we resect the duodenum, and perform a duodenoileostomy. RESULTS. In both patients the cholesterol and glycaemia levels had returned to normal 1 month after the operation and are stable after six months. Weight loss was only moderate. CONCLUSION: By the preliminary data on two patients treated with our modified technique this method seems to be as effective in controlling lipidic metabolism and diabetes II as the original version of biliopancreatic diversion.

Simultaneous ileal intussusception and volvulus after jejunoileal bypass for morbid obesity.

OBJECTIVE: The aim of this work is to consider the mechanical complications of jejunoileal bypass for morbid obesity which can have a serious outcome because of the occult nature of the symptoms. DESIGN: The mechanical complications of jejunoileal bypass are mainly intussusception of the bypassed ileal segment, internal herniation of the ileal loops through the mesenteric defects and laparocele. SETTING AND PATIENTS: A recent case is reported in which, most unusually, intussusception and volvulus were both present, with ischaemia and necrosis of the bypassed segment. Moreover, the general health of the patient remains normal despite the severity of the complication. MAIN OUTCOME MEASURES: Examination of blind loop with CT scan which showed an abdominal mass of uncertain interpretation. INTERVENTION: A laparotomy revealed a volvulus of bypassed ileal loops, probably caused by a simultaneous ileal intussusception and an adhesion. On account of the extensive nature of the process and the degree of advanced ischaemia and gangrene patches in the folds of the ileum, resection of the entire bypassed segment as far as the previous jejunoileal anastomosis was necessary. CONCLUSION: The authors point out the occult nature of the manifestations of this type of complication: aspecific abdominal pains in all quadrants, fever, non vomiting, normal passing of faeces and gas and suggested that simultaneous diverticulitis of the colon (frequently found in the obese) can further complicate and delay diagnosis.

A case of relapsing polychondritis presenting as mediastinal syndrome, diagnosed by CT scans of the trachea and head.

OBJECTIVE: The aim of this study is to evaluate the significance of CT scans of the trachea and head in the diagnosis of Relapsing Polychondritis (RP). DESIGN: Relapsing polychondritis is a disease involving cartilaginous structures, particularly those of the ears, nose and trachea. Diagnosis is based on specific clinical features and immuno-histopathological evaluation of the cartilages involved. SETTING AND PATIENTS: We describe a case of RP in which the most evident clinical signs (cough, dyspnoea, vertigo, tinnitus, headache, oedema of the face and shoulders and fever), led us first to suspect a mediastinal compression syndrome. INTERVENTION: A CT scan of the trachea and head revealed details which established the correct diagnosis, supported by other typical RP symptoms and by histopathological examination of the cartilage. MAIN OUTCOME MEASURES: Evaluation by CT scan of the chest, the mediastinum, the head and the pinnae. RESULTS: CT scanning revealed thickening and calcification of the anterolateral tracheal wall and main bronchi besides marked narrowing of the trachea. CT of the head showed calcification also of the external auditory meatus and part of the pinnae. CONCLUSION: We consider that CT scan of the trachea and head is helpful in evaluating the bronchial tree, the auditory meatus and pinnae as well as being a valid tool for the final diagnosis and in following the course of the disease.

A case of primary hydatidosis of the thyroid gland.

A 54-year-old woman presented with an expansive mass in the anterior cervical region (front of the neck) with abscess. Laboratory tests and thyroid profile proved normal. Surgical exploration revealed a hydatid cyst in the left lobe of the thyroid gland with parasitic metastasis of the left lateral cervical lymph node chain. Postoperative examination of the nodule showed it to be a solitary primary thyroid hydatid cyst.

A case of primary hydatidosis of the thyroid gland.

A 54-year-old woman presented with an expansive mass in the anterior cervical region (front of the neck) with abscess. Laboratory tests and thyroid profile proved normal. Surgical exploration revealed a hydatid cyst in the left lobe of the thyroid gland with parasitic metastasis of the left lateral cervical lymph node chain. Postoperative examination of the nodule showed it to be a solitary primary thyroid hydatid cyst.

The use of the Valtrac ring in the upper and lower gastrointestinal tract, for single, double, and triple anastomoses: a report of 50 cases.

The Valtrac biofragmentable anastomotic ring (V-BAR) technique has been widely used in clinical practice, particularly in anastomoses of the colon. The success of this method encouraged some surgeons to use it also in anastomosis of the small intestine. We are convinced that the method can be used successfully also in anastomosis of the small intestine and the upper gastrointestinal tract, particularly in cases of technically difficult and high-risk anastomoses. Between 1995 and 1998, we used the V-BAR in 35 patients, performing a total of 50 anastomoses. In 13 patients a double anastomosis was created in the same operation, and in one patient a triple anastomosis was created. In all we performed one end-to-end esophagojejunostomy, one gastrojejunostomy, six gastroileostomies, two duodenojejunal anastomoses, 13 end-to-end duodenoileostomies, one jejuno-jejunal anastomosis, 18 end-to-side ileoileal anastomoses, one ileocolic anastomosis, and seven colocolic anastomoses. Follow-up at between 2 and 36 months showed good overall results with regard to resumption of intestinal transit and canalization, even in those cases in which a double and triple suture was performed using the Valtrac ring. In our experience, the V-BAR can be used in upper gastrointestinal surgery with excellent results. Compared with manual sutures, the ring allows better and faster resumption of transit and canalization.

[Botallo's duct with pulmonary hypertension in the adult]. / Il dotto di Botallo con ipertensione polmonare nell'adulto.

A patent ductus arteriosus in adults is a rare eventuality. After correct diagnosis, an accurate evaluation of pulmonary vascular resistances is necessary with, in case of normality, a straightforward indication to surgery, because the evolution of the disease cannot be predicted. In case of pulmonary hypertension irreversible pulmonary vascular damage must be excluded. Haemodynamic data such as pressures, flows and resistance ratios are not reliable. According to the majority of Authors the value of pulmonary resistances seems to be more accurate, and when more then 8 u/m2 an histological specimen must be obtained. In our experience a comparative study between the Health and Edwards method and the Yamaki et al., one shows, confirmed by postoperative follow-up, a greater reliability of the second one.

[Preliminary results of biliopancreatic diversion in the treatment of morbid obesity. Clinical considerations on 69 patients with a 3-year follow-up]. / Risultati preliminari della diversione biliopancreatica nel trattamento della grande obesità. Considerazioni cliniche su 69 pazienti con follow-up a 3 anni.

BACKGROUND AND AIMS: The aim of this study was to evaluate the results obtained using Scopinaro's biliopancreatic diversion technique (AHS-BPD) in the surgical treatment of morbid obesity. METHODS: A retrospective study was carried out in 69 patients with a follow-up ranging between 6-44 months. All patients were operated and monitored by the Obesity Surgery Centre operating in Sardinia since february 1995 at the Department of Emergency Surgery of Sassari University. All the patients were severely obese with a mean BMI of 51.58 and, in the majority of cases, presented associated metabolic diseases with the following incidence: type 2 diabetes in 40.57%, arterial hypertension in 36.23%, severe alteration of lipid status in 52.17%; in overall terms, a plurimetabolic syndrome was present in 24.63% of cases. All patients underwent biliopancreatic diversion using Scopinaro's classic technique (AHS-BPD). Controls were carried out at set intervals (1-3-6-12-18 and 24 months) to evaluate weight loss and the metabolic effects of surgery in terms of the lipid, glucose and protein status. RESULTS: Results were good, as confirmed by the marked weight loss (BMI after 24 months: 30) and the normalisation of cholesterol and glycemia. No major reductions were observed in proteinemia and albuminemia levels. CONCLUSIONS: In the light of these results, the authors affirm that Scopinaro's technique is a valid solution for the treatment of morbid obesity. Its relatively invasive nature is justified by the results obtained in terms of weight control and its effect on associated metabolic diseases.

[Congenital anomalies of the inferior vena cava]. / Le anomalie congenite della vena cava inferiore.

Congenital anomalies of the inferior vena cava are a relatively rare pathology, usually with an asymptomatic iter. They are usually diagnosed by chance during surgery on the aorta or retroperitoneal structures. From bioptic material their incidence is estimated to be 2-3% and the percentage of intraoperative findings varies in different series between 0.2 and 0.6%. Of the various kinds of anomaly, caval duplication and a left-positioned vena cava are those most commonly found. The recent report of a case of a malpositioned vena cava and iliac veins prompted us to re-examine the literature and revise our series of cases.

[Treatment of early colorectal carcinoma: surgery or endoscopy?]. / La terapia del carcinoma iniziale del colon-retto: chirurgia o endoscopia?

This retrospective study analyses the value of endoscopic polypectomy as the operation of choice in cases of early invasive colorectal carcinoma located on the adenomatous polyp. Under these conditions the authors outline their therapeutic strategy, based not only on the histological characteristics of lesions, but also on the evaluation of the risk/benefit ratio established in relation to the characteristics of each individual patient.