Bone heterograft for chest wall reconstruction after sternal resection.

BACKGROUND: Experimental and clinical results of chest-wall reconstruction with bone heterograft after sternectomy are reported. METHODS: Seven dogs underwent subtotal or total sternectomy and reconstruction by implantation of a cortico-spongy bone heterograft sandwiched between two layers of a reabsorbable mesh. RESULTS: No major postoperative complications were observed. The implant has shown favorable mechanical and biological properties. Six and 9 months after operation all animals were sacrificed and pathologic examination showed good incorporation of the implanted bone with only partial resorption of its spongiosa. Subsequently, 2 patients underwent sternal resection with different indications and reconstruction was achieved by the technique developed experimentally. No complications were observed. Excellent immediate chest-wall stabilization was obtained, persisting for a follow-up period longer than 6 months. CONCLUSIONS: In comparison with autologous bone, sterile bone heterograft seems to offer the same mechanical properties with a significantly reduced surgical trauma.

Vascular endostapler as aid to hepatic vein control during hepatic resections.

Significant hemorrhage during hepatic resections for malignancies can result in increased mortality due to liver failure or acute blood loss. Massive hemorrhage is often related to loss of control or injury to the hepatic veins or inferior vena cava. Prevention or reduction of intraoperative blood loss, through improved surgical techniques and increased operator experience, can significantly reduce postoperative morbidity and mortality. Although the use of continuous or intermittent clamping of the portal triad structures (Pringle maneuver) has reduced the incidence of bleeding during hepatic transections, the hepatic vein ligation step of liver resections continues to be a possible source of major blood loss. Because of its safety, rapidity, and ease of application, the EndoGIA 30V vascular stapler is presented as an efficient means for controlling and dividing the major hepatic veins. In skilled hands, this stapling device can contribute to a reduction in incidence and risk of major intraoperative bleeding during hepatectomy. The critical factor to ensuring postoperative morbidity reduction, however, is the surgeon's experience in major hepatic resection procedures.

Preservation of the inferior mesenteric artery in colorectal resection for complicated diverticular disease.

BACKGROUND: Preservation of the inferior mesenteric artery (IMA) and consequential blood flow to the rectum would reduce the risk of leakage of a colorectal anastomosis. METHODS: One hundred and sixty-three patients undergoing left colectomy for complicated diverticular disease of the colon were randomly placed into two groups: A, n = 86; and B, n = 77. In group A, the integrity of the IMA was preserved by artery skeletization (IMAS); in group B, the IMA was divided at its origin. Variables recorded included duration of the surgical procedure, need for blood transfusion, length of hospital stay, operative mortality and morbidity, staple-ring disruption, and radiologic and clinical leakage. Anastomotic stenosis and recurrence of diverticular disease were noted. RESULTS: Surgical time was superior in the IMAS group. Radiologic and clinical leakages were significantly higher in group B (P = 0.02, P = 0.03, respectively). In group A a significant lower number of staple-ring disruptions was observed, evolving into clinical dehiscence. CONCLUSION: Preserving the natural blood supply to the rectum and the ensuing use of a healthy well-nourished rectal stump are suggested as the main aspects of IMAS in preventing and healing leakage of colorectal anastomosis.

Synthetic prostheses in repair of chest wall defects after exeresis of malignancies.

Five cases of chest wall repair with synthetic prostheses following thoracectomy for malignant tumours are reported. Two patients were submitted to partial sternal resection (manubrium); in the first case Marlex mesh alone and in the second a composite graft with Methyl-methacrylate were used. The remaining cases underwent extended thoracectomy and reconstructive procedure based upon Marlex prosthetic replacement and myoplasty. No postoperative complications were observed and satisfactory stabilization of the chest wall with good cosmetic results were obtained.

Effective vascular endostapler techniques in hepatic resection.

The purpose of this report is to describe the technique of liver resection using an endovascular stapling device. A total of 31 patients underwent major hepatic resections with stapling techniques. The authors have used various approaches to portal structures and hepatic veins with the application of a vascular endostapler device. The specific techniques of different hepatectomies are described and illustrated. There were no deaths. A minor complication (biliary fistula) occurred in one patient, related to binary leak from parenchymal transection. No complications directly attributable to stapler ligations of portal pedicle or hepatic veins were observed. Stapling techniques can be helpful in major hepatic resection procedures. The vascular endostapler can significantly reduce both portal vein and hepatic vein closure time and may expedite the transection of the liver, eliminating the risk of slipped ligature following simple ligation.

Subtotal parathyroidectomy for secondary hyperparathyroidism in chronic renal failure.

Twenty-seven patients on chronic haemodialysis and with secondary hyperparathyroidism underwent subtotal parathyroidectomy during the period 1985-1989. The operation was indicated by severe clinical symptoms and evidence of radiological abnormalities not responsive to conservative treatment (low phosphorus diet, phosphate binding substances, oral calcium and vitamin D). If despite intensive medical management, inadequate control of parathyroid hyperplasia continues surgical intervention becomes necessary. Ultra-sonography was performed pre-operatively in all 27 cases and detected 42 of 99 glands (42.5 per cent). Also scintigraphy was carried out in every patient but it gave a relatively low detection rate (24.5 per cent). Surgery was followed by improvement in 20 patients and progression of hyperparathyroidism in seven cases. Three of the seven patients failed to improve after subtotal parathyroidectomy, necessitating a re-intervention; the remaining four responded sufficiently to medical therapy. From our experience we conclude that subtotal parathyroidectomy for renal hyperparathyroidism is recommended.

[Embryologic and anatomo-surgical presuppositions in intraoperative injuries of the spleen. A clinical study]. / Presupposti embriologici ed anatomo-chirurgici delle lesioni intraoperatorie della milza. Studio clinico.

Records related to 2559 patients submitted to main abdominal surgery have been reviewed. Accidental splenic injury and subsequent splenectomy occurred in 4.5% of cases. A study of the embryological development and anatomical patterns of the splenic peritoneum has been carried out as well as an analysis of the site and the shape of the capsular damage in order to assess the mechanism of injury. Avulsion of splenic capsule occurring from traction on the peritoneal attachment of the spleen appears to be the most common mechanism of injury. Previous surgery and geriatric age seem to be factors predisposing to splenic injury.

[The Ogilvie syndrome. Review of literature and report of 2 cases]. / La sindrome di Ogilvie. Revisione della letteratura e presentazione di due casi.

Two cases of pseudo-obstruction of the colon (Ogilvie's syndrome) are presented. Increasing abdominal distension and the pain suggested surgical treatment for both patients. The operation showed in the first case a marked dilatation of the transverse colon and sigmoid, in the second the dilatation of the ascending and transverse colon, without any distal obstruction. Enterotomy was performed only in the first case, as the diameter of the colon was more then 10 cm. The authors, by review of the literature and their own experience, propose a critical revision of the syndrome, discussing the physiopathology of the rising disease.

[Use of vascular endostapler in surgery of the lower rectum]. / Impiego dell'endostapler vascolare nella chirurgia del retto basso.

A practical and effective method for rapid and bloodless preparation of the rectum using endovascular stapler devices during low anterior resection, or abdominal-perineal excision, is described. This method is presented as an effective means for easily dividing the anterior and lateral attachment of the rectum. The application of this technique is the absence of intraoperative bleeding related to injury of middle hemorrhoidal vessels, with minimal risk of autonomic pelvic nerve damage. An additional factor relevant in the choice of this technique, is the easier possibility to perform rectal dissection of an oncologically adequate tumor clearance from the margin of rectal tumor and with complete radical transection of the lateral ligaments fastly proceeding with the downward mobilization of the rectum close to the pelvic side walls, between the parietal and visceral layer of the pelvic fascia.

Parietal sierosa for protecting colonic suture lines. Technical note.

Suture line leakage is a frequent, serious problem in colon surgery. We propose the use of a flap of the parietal peritoneum from the paracolic gutter, adjacent to the operative site, to protect right and left colon suture lines. The advantage of this method is that it permits complete exclusion of the sutured intestine from the peritoneal cavity and avoids the risks of leakage from an intestinal suture line within the peritoneal cavity.

[The study of the modification of the natural resonance of the external ear following tympanoplasty]. / Studio delle modificazioni della risonanza naturale del C.U.EST. a seguito di interventi di timpanoplastica.

The shape, position and amplitude of the natural resonance curve of external ear is related to sensation evoked in a subject by sound coming from the external environment. The involution of this curve varies from individual and is the sum of the effects provoked on the incident sound by the head, auricle and the conformation of canal (EEE = External Ear Effect). Natural amplification supplied by the system allows the individual to distinguish natural sound, whose being natural make them pleasant to hear. Any interventions that modifies the anatomy of the auricle and/or the canal activity alternates the REUR (Real Ear Unaided Response) to some degree. Restoration of basic anatomical conditions are choice of interventions which displace the curve only slightly allows a physiological sensation of sound to be maintained. Surgeon often neglect this little studied aspect preferring to evaluate this work in terms of quantity thus rather ignoring the quality of sound achieved.

Delayed bilateral ureteral fistula following abdominoperineal resection: a case report.

A case of delayed bilateral ischemic necrosis of the pelvic ureter in a 66-year-old woman submitted to abdominal perineal resection and hysterectomy for advanced rectal cancer, is reported. Five days after the operation urine was observed in the perineal cavity. External urine diversion was carried out by catheterizing the ureteral stumps through the perineal cavity. The reconstructive procedure was performed at a later date by bilateral ureteroileocystoplasty with a defunctionalized loop. The vascular anatomy of the ureter is discussed to highlight the essential technical details useful for prevention of ischemic injury.