[Reoperation in necrotizing acute pancreatitis: evaluation of physiopathology and surgical treatment]. / I reinterventi per pancreatite acuta necrotizzante: valutazioni di fisiopatologia e di trattamento chirurgico.

We reviewed our experience of PAN cases operated for complications after a first laparotomy over the period 1992-1994. Over 29 PAN cases, 7 (24%) had been submitted to a second laparotomy or more. Total mortality rate of PAN was 10.3%, while mortality rate of relaparotomy was 14.2%. Haemorrhage and intra-abdominal sepsis were the main cause of relaparotomy (42.8% of the re-operations in both cases). Abdominal wall abscesses (14%) were treated locally; enteric or pancreatic fistulas (34%) were successful treated by drugs, such as somatostatin and octreotide, and / or by total parenteral nutrition. The main diagnostic tools to evaluate clinical course of the patients were computed tomography scan, that seems to gain serial staging of the necrosis and the septic collections. Arteriography is necessary to identify the bleeding source and to perform temporary embolization in the massive arterial haemorrhage before surgical treatment. Moreover, we need radiological exploration to explain fistulas pathways. According to circumstances, we can perform surgically the definitive hemostasis, the pancreatojejunostomy in pancreatic fistulas, and the digestive reconstruction in enteric fistulas. At all events the debridement of necrosis and septic collection is necessary. Up to date, there are not prognostic differences between "closed laparotomy" and "open laparotomy", and we think that the choice is determined only by individual believing of the surgeon.

[Role of surgical splanchnicectomy in the treatment of pancreatic carcinoma]. / Il ruolo della splancnicectomia chirurgica nel trattamento del carcinoma pancreatico.

Palliative surgical procedures offer considerable benefit for the patients with unresectable pancreatic cancer: surgical splanchnicectomy performed in conjunction with biliary-enteric by-pass offers good results as regard pain relief without increased morbidity and mortality. We treated 25 patients with unresectable pancreatic cancer by mean of biliary-enteric by-pass plus bilateral splanchnicectomy performed through different surgical approaches. In this series of patients postoperative mortality was nil, mean survival time was 7.2 months (range 3-14 months). Preoperatively, we assessed all patients as affected by visceral pain: Scott-Huskisson 10 mark-scale value in quantitative assessment of pain was equal or above the 7th mark in 87.5% of patients. One month later in the postoperative follow-up, 96% of the patients had a significant reduction in pain intensity from a preoperative median of 7 mark to a postoperative median of 1.5 mark (p = 0.0001). The mean period free of pain recurrence was 4.8 months. However, after 6 months only 46% of survivors were pain-free with such rate decreasing further to a 10% of survivors after 8 months. Nevertheless, the patients had around 70% of their survival span free of pain. We strongly believe that failure in relief of pain is due to a mistake in preoperative evaluation of the type of pain (somatic and not visceral, or both) and to the onset of somatic pain in the course of the disease rather than to surgical technical errors. Recurrence of pain has been considered inevitable in the biological progression of unresected cancer, and would be treated by combination of therapies, such as non steroidal anti-inflammatory drugs, transaortic coeliac plexus block, narcotics and cervical cordotomy.

[Repeated liver resections for metastases from colorectal carcinoma: the experience of 23 cases]. / Resezioni epatiche reiterate per metastasi da carcinoma colo-rettale: esperienza su 23 casi.

One hundred and thirteen patients with metastases from colorectal carcinoma underwent liver resection. The authors report their experience with respect to 23 repeated hepatic resections (or metastases from colorectal carcinoma). The calculated actuarial survival from the first operations is 100% at 12 months, 67% at 24 months, 48% at 36 months and 26% at 60 months. In 90 patients who underwent a single liver resection during the same period, 76% were alive at 12 months, 40% at 24 months, 27% at 36 months and 14% at 60 months (p = 0.03). Survivals calculated from the second operation were 67% at 12 months, 41% at 24 months and 11% at 35 months. There was no operative mortality with morbidity added to that of the first operation. None patients had extrahepatic disease at the second operation: this was resected. Seven patients were treated with neo adjuvant chemotherapy; six with systemic adjuvant chemotherapy; in one this was associated with loco-regional chemotherapy. The number of lesions (single versus multiple), the presence or absence of extrahepatic disease, neo-adjuvant chemotherapy and adjuvant chemotherapy did not seem to influence the prognosis. Average survival calculated from the appearance of the first metastasis in the liver is better in patients with a synchronous lesion compared to the patients with a metachronous lesion (48.1 months versus 29.3). The authors claim that surgery is indicated, when technically possible, in the hepatic recurrence of disease. The results are not as good as those obtained following the first liver resection, with a probability of earlier recurrence of disease.(ABSTRACT TRUNCATED AT 250 WORDS)

[The therapeutic strategy in benign liver tumors: a 20-year experience]. / La strategia terapeutica dei tumori epatici benigni: esperienza di 20 anni.

Therapeutic choices for benign liver tumours have changed over the last 20 years. From 1975 to December 1993, we observed 145 hemangiomas (HMG) (57.2% females-mean age 47.3 years, 42.8% males-mean age 50.4 years): we resected 42 symptomatic hemangiomas: mortality rate was 2.3%. 93 HMG without symptoms were only followed-up: 5 of these increased in size and were resected. 27 symptomatic cases over 50 focal nodular hyperplasia (FNH) were resected, 7 cases were resected and 3 biopsied during laparotomy performed for other pathology. Postoperative mortality was nil. 13 cases were only followed-up after diagnosis by imaging techniques and fine needle biopsy: over a mean period of 23 months. No variations have been recorded. Increases in GGT and ALP were present respectively in 34% and 22% of FNH-cases. Scintigraphic techniques were the most diagnostically accurate (96.2%). All 16 hepatocellular adenomas (HCA) were removed (11 females, 5 males), postoperative mortality was nil: oestrogen administration was present in 36.4% of female cases, histological diagnosis v/s well differentiated hepatocellular carcinoma was difficult in 2 cases, whilst 3 cases had spontaneous rupture. We resected also 8 cases of biliary adenomas in order to determine a precise diagnosis v/s liver metastases, and 4 biliary cystadenomas for their malignant potential. Asymptomatic HMG and FNH for their low tendency to increase, can be only observed, whilst HCA must be fully resected for risk of bleeding and misdiagnosis v/s well differentiated hepatocellular carcinoma.