A prospective non-randomized controlled, multicenter trial comparing Appendectomy and Conservative Treatment for Patients with Uncomplicated Acute Appendicitis (the ACTUAA study).

PURPOSE: Acute appendicitis (AA) is among the most common causes of lower abdominal pain and admissions to the emergency department. Over the past 20 years, there has been a renewed interest in the conservative management of uncomplicated AA, and several studies demonstrated that an antibiotic-first strategy is a viable treatment option for uncomplicated AA. The aim of this prospective non-randomized controlled, multicenter trial is to compare antibiotic therapy and emergency appendectomy as treatment for patients with uncomplicated AA confirmed by US and/or CT or MRI scan. METHODS: All adult patients in the age range 18 to 65 years with suspected AA, consecutively admitted to the Surgical Department of the 13 participating Italian Hospitals, will be invited to take part in the study. A multicenter prospective collected registry developed by surgeons, radiologists, and pathologists with expertise in the diagnosis and treatment of uncomplicated acute appendicitis represents the best research method to assess the long-term role of antibiotics in the management of the disease. Comparison will be made between surgical and antibiotic-first approaches to uncomplicated AA through the analysis of the primary outcome measure of complication-free treatment success rate based on 1-year follow-up. Quality of life, length of hospital stay, pain evaluation, and time to return to normal activity will be evaluated as secondary outcome measures. TRIAL REGISTRATION: Clinicaltrials.gov ID: NCT03080103.

T2-T4 sympathectomy versus T3-T4 sympathicotomy for palmar and axillary hyperhidrosis.

OBJECTIVE: To evaluate and compare the immediate and long-term outcomes of videothoracoscopic T2-T4 sympathectomy and T3-T4 sympathicotomy for the treatment of palmar and axillary hyperhidrosis. METHODS: Between October 1993 and September 2007, we treated a total of 88 patients affected by palmar and axillary hyperhidrosis. Twenty-four patients underwent T2-T4 sympathectomy with 5-10 mm trocars (Group A), 43 T2-T4 sympathectomy with 2-5 mm trocars (Group B), 15 T3-T4 sympathicotomy with 5-10 mm trocars and 6 T3-T4 ganglion block with 2-5 mm trocars (Group C). The mean operative time, for each side, was 15 min for sympathicotomy and 28 min for sympathectomy. In September 2008, we recontacted 98% of patients (total 86), by telephone, to establish long-term results (follow-up range 1-15 years). RESULTS: In this series, we did not find any significant difference between T2-T4 sympathectomy and T3-T4 sympathicotomy in terms of postsurgical palmar anhidrosis or onset of compensatory hyperhidrosis, while both methods show high efficacy for remission of palmar hyperhidrosis. The slightly higher recurrence rate in our early experience (Group A) can be attributed to the learning curve. Using smaller trocars (2-5 mm), we reduced postsurgical intercostal pain and obtained better aesthetic results and a higher grade of patient's satisfaction. INTERPRETATION: Thoracoscopic approach to hyperhidrosis has evolved in the last few decades with a consequent decrease in side effects. In this series, all patients experienced an improvement in quality of life even in case of recurrence or onset of compensatory hyperhidrosis. Due to these results, the shorter operative time and easier performance of sympathicotomy, we prefer this method.

[Surgical management of a voluminous abdominal paraganglioma and review of the literature]. / Management chirurgico di voluminoso paraganglioma dell'addome. Case report e revisione della letteratura.

UNLABELLED: The Authors report a case of a voluminous abdominal paraganglioma and a review of the literature on the surgical management of paragangliomas. CASE REPORT: A 58 years old woman was admitted to our Institution with acute endocrine impairment and simultaneous intestinal necrosis resulting from the mass effect of the tumor on the mesenteric vessels. Clinical and biochemical preoperative work up posed the suspect of paraganglioma. Previous intensive care treatment, the patient, underwent surgical resection of the tumor and left hemicolectomy, with immediate remission of both endocrine and abdominal syndromes. Histological examination confirm the preoperative clinical hypothesis. Paragangliomas are rare tumors of the extra-adrenal chromaffin tissue. A paraganglioma may be discovered in the absence of any symptom. When symptomatic, the clinical findings are related to the hypersecretion of catecholamines or to the compression of several anatomical structures from a growing mass. Combined acute syndromes of hormonal impairment and contemporaneous mass effect, as in our case, are exceptional. The diagnosis of the secreting forms may be obtained on the basis of biochemical dosage of serum and urinary catecholamines and metanephrines. The assessment of malignancy for paragangliomas is not always feasible. Several imaging, cytological and histological parameters have been proposed as predictors of malignancy, but the only element widely accepted is the existence of distant metastasis. Surgery represents the treatment of choice for paragangliomas. Benign forms, catecholamine secreting forms and tumors compressing neighbouring anatomical structures can be treated surgically with success. In general, an accurate follow-up after complete resection must be considered.

Multimodality approach to malignant pleural mesothelioma. A case report.

INTRODUCTION: We report a case of diffuse malignant pleural mesothelioma (DMPM) in a 68-years-old male patient who was admitted for right sited pleural effusion. The patient was treated by multimodality approach consisting in surgical treatment with Extrapleural Pleuropneumonectomy followed by chemotherapy with Cisplatin and Pemetrexed. He had a disease free period of one year and survived for 31 months. CASE REPORT: The patient was admitted to our Institute for a right sited pleural effusion diagnosed on chest X ray. Anamnesis revealed professional asbestos exposure and the patient presented dyspnea, dry cough, right sited chest pain, low fever and loss of weight. As thoracentesis and CT scan did not reveal pathological findings except of the effusion, we performed videothoracoscopy. Several grey nodular lesions involving the costal, diaphragmatic and mediastinic parietal pleural sheets were found. Histological examination of the specimens extracted revealed the presence of epithelial malignant pleural mesothelioma with sarcomatoid areas. Further examinations staged the lesion as Butchart I. Extrapleural pleuropneumonectomy was performed followed by a chemiotherapic treatment with Cisplatin and Pemetrexed. The patient underwent a follow up program with CT scan every four months. The disease free period was of about one year and the patient died after 31 months from diagnosis for septic complications related to chronic effusion. DISCUSSION: Single treatments do not demonstrate an acceptable efficacy on the treatment of DMPM. Multimodality therapy provides good survival improvement and acceptable quality of life for the patients.

[The role of cervical mediastinoscopy and video assisted thoracoscopy in the diagnosis and staging of thoraco-mediastinal neoplastic diseases]. / Ruolo della mediastinoscopia e della video toracoscopia per la diagnosi e la stadiazione delle patologie neoplastiche toraco-mediastiniche.

INTRODUCTION: In this work we evaluate the role of mediastinoscopy and video-assisted thoracoscopy in the diagnosis and staging of coin lesion of the lung and of mediastinal masses. MATERIALS AND METHODS: 72 patients, 55 males and 17 females, affected by lung coin lesion without any previous histological diagnosis have been admitted to our Institution from 1997 to 2007. Mean age was 59.4 for males (range 29-82) and 57.2 for females (range 14-79). RESULTS: Mediastinoscopy resulted to be diagnostic in 95% of cases. In just one case mediastinoscopy failed and video assisted thoracoscopy was performed, which permitted to obtain diagnosis. Video assisted thoracoscopy was able to lead to diagnosis in 98.1% of cases, as we observed only one failure. In this single case we converted the thoracoscopic approach to open, but although the conversion it was not possible to make diagnosis. DISCUSSION: In these ten years, thanks to adequate indication for mediastinoscopy and video assisted thoracoscopy, the use of thoracotomy for diagnosis and staging of pulmonary neoplastic diseases has been reduced: thus we avoided 80% of unnecessary thoracotomies in patients affected by not resectable lung cancer, metastases (treated by atypical thoracoscopic resection) or benign diseases. CONCLUSION: The minimally invasive surgical exploration of mediastinum and thoracic cavity allows to obtain all necessary informations (in terms of histology and staging) to programme an adequate therapeutic protocol, reducing postoperative pain and hospital stay, in comparison to thoracotomy.

[Functional sequelae after low anterior rectal surgery]. / Le sequele funzionali dopo chirurgia del retto basso.

INTRODUCTION: The treatment of colorectal cancer has changed radically in the last decades. Due to the great advances it is now often possible to subject patients to oncological radical treatments without applying to highly aggressive surgery, such as the Miles abdomino perineal resection, which requires a definitive colostomy. So nowadays we more and more apply to anterior resection of the rectum. Some recent studies about quality of life in patients who underwent anterior resection of the rectum focalized their attention on postoperative functional sequels. In particular incontinence, constipation, obstructed defecation and urgency are some of the symptoms which define the anterior resection syndrome, which can be efficiently treated by electrostimulation and biofeedback. MATERIALS AND METHODS: A prospective study on 61 patients who underwent between 2002 and 2007 anterior resection of the rectum with total mesorectal excision for adenocarcinoma, has shown symptoms of anterior resection syndrome in 14 patients. Succeeding treatment with sphincter electrostimulation and biofeedback has shown improvement in all patients and complete resolution of the anterior resection syndrome in 10 patients who showed a great compliance and a steady improvement on quality of life. DISCUSSION AND CONCLUSIONS: Rehabilitative treatment with electrostimulation and biofeedback can sensibly reduce symptoms of anterior resection syndrome. An accurate manometric functional assessment is necessary before starting treatment with electrostimulation and biofeedback.

[Cystic pancreatic tumor treated by distal spleno-pancreatectomy with occasional diagnosis of neuroendocrine tumor: case report]. / Tumore cistico pancreatico trattato mediante splenopancreasectomia distale con riscontro occasionale di neoplasia neuroendocrina. Case report.

INTRODUCTION: Cystic and neuroendocrine pancreatic neoplasms are quite rare tumors which diagnosis is often difficult due to their non specific symptomatology and limited diagnostic accuracy of conventional diagnostic instruments. Their treatment is still controversial. CASE REPORT: A young woman is admitted with abdominal pain and dyspepsia. Instrumental diagnosis reveals a cystic pancreatic lesion which seems to be malignant as CEA of pancreatic liquid is increased. The patient undergoes distal spleno-pancreatectomy and postoperative histological examination found IPMN associated with MCN and furthermore there was occasional diagnosis of a small neuroendocrine tumor in the pancreatic tail. DISCUSSION: A correct diagnostic approach is indispensable for a correct therapeutic approach. Radical surgical treatment is indicated in all cases of main- and branch duct IPMN and in case of MCN with signs of malignant transformation. Surgical treatment is also the gold standard for pancreatic neuroendocrine tumors if they are singular and in M0 stage. CONCLUSIONS: In case of cystic and neuroendocrine neoplasms of the pancreas the preoperative diagnostic approach is often not enough to obtain a definite diagnosis. Review of literature and this case report show that a definite diagnosis can only be done after postoperative histological examination. Recent prospective studies suggest the possibility for a follow up instead of surgical treatment for some neuroendocrine tumors.