Digestive hemorrhages of obscure origin.

BACKGROUND: The diagnosis of digestive bleeding in some cases can require a diagnostic laparotomy when other methods have been ineffective. Video-laparoscopy can provide such cases with a certain diagnosis and the possibility of performing a simultaneous surgical treatment. METHODS: Our experience using video-laparoscopic to treat digestive hemorrhages of obscure origin involved 16 patients. The examined patients presented with the following diseases: Meckel's diverticulum (8 cases), gastric leiomyoma (1 case), small bowel leiomyoma (4 cases), jejunum leiomyosarcoma (1 case), small bowel melanoma (1 case), and Peutz-Jeghers syndrome (1 case). RESULTS: In all these patients the laparoscopic approach allowed us to identify the origin and site of the hemorrhages, and subsequently to treat the identified lesions. In one patient, an intraperitoneal resection of the diverticulum was performed using Endo-Gia (TM30NIF; Tyco Auto-Suture). In the remaining cases, a minilaparatomy was performed for resection of the disordered loop. CONCLUSIONS: Video-laparoscopy is very useful for avoiding explorative laparatomies on patients affected by digestive hemorrhages of obscure origin. In these cases, the video-laparoscopic approach allows full and meticulous explorations of the small bowel to be performed, and seems to be useful for diagnosis through direct observation of the lesions. Moreover, if necessary, video-laparoscopy can be used for the effective treatment of the diseases.

Endolaparoscopic rendezvous treatment: a satisfying therapeutic choice for cholecystocholedocolithiasis.

BACKGROUND: There are many different strategies for the treatment of the main bile duct lithiasis. When lithiasis of the biliary tract is suspected at a preoperative stage, we can treat patients with sequential treatment: endoscopic netrograde cholangiopancreatography followed by laparoscopic cholecystectomy. If common bile duct-lithiasis is recognized at an intraoperative stage, many options for treatment exist, one of which is intraoperative retrograde endoscopic sphincterotomy (ES) (laparoendorendezvous). METHODS: We report our experience using the aforementioned technique with 58 patients affected by cholelithiasis and complex Common bile duct disease who underwent laparoscopic cholecystectomy and intraoperative ES consecutively from March 1996 to May 2000. Of the 58 patients, 43 were affected by cholecystocholedocolithiasis: 12 by previously described lithiasis plus stenosant papillitis, 2 also by a pancreas head cancer, and 1 by cancer of the papilla. RESULTS: The combined technique was performed in 86% of the cases. Six patients required conversion to open surgery. In two other patients, laparoscopic choledocotomy was performed with positioning of a Kehr-tube for an ampulla-impacted lithiasis. CONCLUSIONS: Intraoperative ES offers a valid approach to the treatment of cholecystocholedocolithiasis in one session. Furthermore, it represents a valid alternative to transcholedocical laparoscopic treatment of cholelithiasis and complex common bite duct pathology.

Cholecystoenteric fistula (CF) is not a contraindication for laparoscopic surgery.

BACKGROUND: Cholecystoenteric fistula (CF) is a rare complication of cholelithiasis. The aim of this study was to evaluate the safety and risk of complications when the laparoscopic approach is applied in patients with CF. METHODS: A questionnaire was mailed to all surgeons with experience of >100 cholecystectomies working in Naples, Italy, and the neighboring area. RESULTS: Between February 1990 and May 1999, 34 patients presented with cholecystoenteric fistula (0.2% of >15,000 laparoscopic cholecystectomies performed in the same period). These patients were allocated into two groups: the LT group (those who underwent laparotomic conversion after the diagnosis of CF), which consisted of 20 patients, four men and 16 women, with a mean age of 66.5 +/- 9.3 years (range, 46-85) and the LS group (laparoscopically treated patients), which consisted of 14 patients, three men and 11 women, with a mean age of 65.6 +/- 8.8 years (range, 51-74). They types of CF observed were as follows: in the former group of patients, cholecystoduodenal fistulas (n = 11, 55%), cholecystocolic fistulas (n = 5, 25%), cholecystojejunal fistulas (n = 3, 15%), and cholecystogastric fistulas (n = 1, 5%); in the latter group, cholecystoduodenal fistulas (n = 8, 5.1%), and cholecystocolic fistulas (n = 4, 28.6) and cholecystojejunal fistulas (n = 2, 14.3%). Stapler closure of CF was done in four LT patients and three LS patients with cholecystoduodenal fistula; it was also done in three LT patients and three LS patients with cholecystocolic fistula. Hand-sutured fistulectomy was performed in six LT patients and three LS patients with cholecystoduodenal fistula, in two LT patients with cholecystocolic fistula, and in all patients with cholecystojejunal or cholecystogastric fistula. There were no deaths or intraoperative complications in either group. One patient in the LT group developed a bronchopneumonia postoperatively. Postoperative hospital stay was significantly longer in LT patients-17 +/- 4 vs 3+/-1 days (p < 0.001). CONCLUSION: Cholecystoenteric fistula is an occasional intraoperative finding during laparoscopic cholecystectomy. The results of this study, which are based on the collective experiences of 19 surgeons, illustrate the growing success of the laparoscopic approach to this condition, including a decreasing rate of conversion to open surgery over the last 3 years.

[Repair of splenic lesions with video-laparoscopy]. / Riparazione di lesioni spleniche in videolaparoscopia.

Conservative therapy of spleen injuries (non-operative treatment, partial splenectomy, autotransplantation, etc.) makes it possible to avoid the risk related to post-splenectomy hyposplenism. The videolaparoscopic approach makes the performance of such treatment possible achieving a clear reduction in surgical stress. The authors report two multiple injured patients showing spleen lesions, treated conservatively through videocoelioscopic procedure. Both patients (a 42-year-old woman and a 26-year-old man) presented hemorrhagic shock in hemodynamic compensation and hemoperitoneum. Abdominal ultrasonographic scanning proved the presence of spleen injuries. Both patients underwent a conservative surgical videolaparoscopic treatment using fibrin glue and omentoplasty. The resolution of the hemorrhagic shock and the restoration of the spleen lesions were achieved in both cases. The authors have already used the videocoelioparoscopic approach both in elective (biliary lithiasis, inguinal hernia, appendicitis, etc.) and in emergency surgery (acute cholecistitis, perforated ulcer, intestinal obstruction, etc.). They note the effectiveness of the method, also in the field of the mini-invasive conservative treatment of parenchymatous organ lesions (mainly in the case of spleen injuries, when the splenic function has to be preserved). So, it's possible to add the advantages of a conservative treatment to those of the minimal invasivity, provided by the videolaparoscopic procedure.

[Hydatid cyst of the pancreas responsible for chronic recurrent pancreatitis]. / Kyste hydatique du pancréas responsable d'une pancréatite chronique récidivante.

Hydatid cyst of the pancreas is a rare localization of hydatidosis. It raises diagnostic problems which can only be solved by section of the surgical specimen. An exceptional case of hydatid cyst of the pancreatic tail which resulted in chronic recurrent pancreatitis, and a review of the literature, enable to put hydatidosis on the list of causes of pancreatitis.

[Auto- and homoplastic grafts in the treatment of osteolytic lesions]. / Innesti auto ed omoplastici nel trattamento delle lesioni osteolitiche scheletriche.

Based on 32 cases of neoplastic and degenerative lesions, the indications and limits of auto- and alloplastic grafts are discussed. Grafting was successful in all of the cases, obtaining excellent clinical and radiographic results. An auto graft may be used to more rapidly fill cavities which remain after curettage has been performed, but the limited availability of grafts, the need for a second operation, and the weakening of the donor site encourage us to develop more practical methods of removal and preservation of the allograft.

Different effect of Intralipid and triacylglycerol rich lipoproteins on the Kodak Ektachem serum cholesterol determination.

We documented the quantitative effects of lipaemia on cholesterol recovery on a Kodak Ektachem 700 XRC analyser (Rochester, NY, USA) in comparison with a Hitachi 717 analyser (Boehringer, Mannheim, Germany). Using the linear ranges of the analysers, we compared the effects of adding Intralipid and of adding high concentrations of native Very-Low-Density-Lipoproteins and/or chylomicrons. Our data demonstrate less than 10% bias for the Kodak cholesterol determination in an Intralipid dilution series prepared according to M. R. Glick and coworkers (e.g. Clin. Chem. 33 (1987) 1453-1458). However, in a hypertriglyceridaemic dilution series (theoretical cholesterol concentrations ranged from 5.2 to 15.5 mmol/l) the Kodak cholesterol recovery fraction decreased from 0.88 to 0.58 when the triacylglycerol concentration increased from 5.64 mmol/l to 38.35 mmol/l. In contrast, the cholesterol recoveries on the Hitachi analyser were complete for both approaches. We conclude that the lipaemia effect on the Kodak cholesterol determination is not adequately reflected by addition of Intralipid, because the Kodak cholesterol determination is more prone to interference by turbidity when triacylglycerols are presented as native serum lipoproteins, especially as chylomicrons.

The importance of the acetabular rim in the genesis of congenital hip dysplasia. Experimental research.

The posterior aspect of the cartilaginous acetabular rim was surgically removed in very young rabbits in order to study its effect on the further development of the acetabular cavity. A dysplasic change was produced which led to posterior hip dislocation. Through an analysis of the morphological, radiographic and histological findings, and comparison with human congenital hip dislocation, the acetabular rim is considered to be physiologically responsible for the development of the retaining properties of the acetabular cavity. Moreover, a genetic abnormality altering the physiological development of the cartilaginous acetabular rim, is responsible for the non-retaining power of the acetabulum which leads to congenital hip dislocation.

Echotomographic imaging in a case of plexiform von Recklinghausen neurofibromatosis.

The authors present a case of plexiform von Recklinghausen neurofibromatosis with lumbosacral localisation and extension along the femoral nerve. The usefulness of echotomographic imaging is illustrated in clarifying the diagnosis, and excluding other pathological conditions which may present a similar clinical picture.

Conservative treatment in splenic trauma.

Conservative management of splenic injuries following blunt abdominal trauma is receiving increasing support following delineation of the role of the spleen in preventing infections. This report describes experience with the treatment of 215 consecutive cases treated between 1982 and 1989. A total of 38 patients underwent non-operative management (NOM), 16 splenorrhaphy, 16 partial splenectomy, 60 splenectomy with autotransplantation and 85 splenectomy alone. All patients, regardless of the treatment received, were assessed before discharge and periodically with a maximum follow-up of 5 years. During the follow-up period immunohaematological studies were performed that demonstrated an almost normal activity in the autotransplantation group when compared with the simple splenectomy group. No major complications were observed in the autotransplantation group; a good function and morphology of the re-implanted splenic tissue was always evident by radioisotopic, echographic and histological studies. A conservative approach should always be considered in splenic trauma. In cases where NOM, splenorrhaphy and partial resection are unsafe, splenectomy with autotransplantation should be considered as this simple and reliable technique allows preservation of splenic function.

Videolaparoscopic treatment of spleen injuries. Report of two cases.

Splenectomy is very frequently used to manage splenic lesions. Nevertheless, spleen-injured patients who have undergone splenectomy are exposed to hyposplenism. Authors report two patients with splenic lesions treated by conservative surgery (with fibrin glue) using the videolaparoscopic method. In both cases the preservation of the spleen was achieved. The conservative treatment allows one to avoid the risk of hyposplenism and the videolaparoscopy provides the possibility to treat the patient with minimal surgical stress.