Improvement in the fertility rate after placement of microsurgical shunts in men with recurrent varicocele.

OBJECTIVE: To evaluate the effectiveness of microsurgical shunts for secondary varicocele repair after ligation-like procedures, focusing on long-term functional outcomes. DESIGN: Long-term survey (mean follow-up, 8.5 years) of infertile men after secondary microsurgical reconstructive varicocelectomy. SETTING: University-based medical center. PATIENT(S): Thirty-four infertile men (group A, <30 years of age; and group B, >30 years) with recurrent palpable varicocele after varicocelectomy, according to Ivanissevich (n = 28), or after angiographic vein occlusion (n = 6). Ten patients presented bilateral recurrence. INTERVENTION(S): Microsurgical shunts between spermatic vein and inferior epigastric vein. MAIN OUTCOME MEASURE(S): Sperm count, pregnancy rate, and ultrasound evaluation of varicosity. RESULT(S): Complete disappearance of varicosity was achieved in 97.06% of patients, while in 2.94%, a consistent reduction in size was observed. In patients with severe infertility, a significant postoperative increase in seminal parameters was observed. Pregnancy rates were 43.75% in group A and 22.22% in group B. CONCLUSION(S): Microsurgical drainage in patients with recurrent varicocele after ligation-like procedures was shown to be an effective minimally invasive treatment, with immediate hemodynamic recovery of testicular venous outflow and excellent long-term results in patients with left or bilateral recurrences.

[Transfixed stitches for the treatment of haemorrhoids]. / La tecnica dei punti transfissi per il trattamento della malattia emorroidaria.

Nowadays the proctologist has the opportunity to perform various different surgical techniques for the treatment of hemorrhoids. Circumferential mucosectomy with a stapler, diathermic hemorrhoidectomy with high frequency devices, and the HLA doppler II system have significantly modified the classical indications for the treatment of the disease. There is, however, still no general consensus as to the indications for the use of each of these techniques in clinical practice, giving rise to confusion among specialists and an inappropriate use of health care resources. For these reasons the authors propose a new technique for the treatment of haemorrhoids based upon a new classification system, named PATE 2000 Sorrento. The transfixed correction of haemorrhoids makes it possible to treat third degree internal piles in association with the Milligan-Morgan procedure for fourth degree piles in a simple, definitive and safe session. This technique seems to offer a valid alternative to stapled hemorrhoidectomy, on the one hand, and classical open or closed hemorrhoidectomy combined with rubber band ligation, on the other. The authors describe the technical feasibility of their technique and underline the good clinical results obtained in their initial experience with 20 consecutive patients.

Potentially fatal bleeding in acute pancreatitis: pathophysiology, prevention, and treatment.

INTRODUCTION: Massive bleeding may complicate the course of either acute or chronic pancreatitis. Although the latter is more frequently involved when bleeding occurs in the acute form, a poorer prognosis is to be expected. Abscess, severe inflammation, regional necrosis, and pseudocysts may cause major vessel erosion, with or without pseudoaneurysm formation, whose eventual rupture may result in massive bleeding into the gastrointestinal tract, retroperitoneum, and peritoneal cavity. AIMS: To define the most important pathophysiologic mechanisms and factors that might contribute to a better understanding, better prevention, and more efficient treatment of severe hemorrhage complicating acute necrotizing pancreatitis. Awareness of high-risk conditions occurring during the natural evolution of the disease (from extensive local severe enzymatic damage to late septic sequelae), avoidance of a too early and too aggressive approach to sterile pancreatic necrosis, and providing prompt and effective treatment of local septic complications, when they occur, are crucial steps for bleeding prevention. METHODOLOGY: Forty-four cases of severe bleeding following acute pancreatitis that were reported during the last decade since 1992 (including the six cases reported here) are reviewed, analyzed, and summarized. RESULTS: The overall mortality rate was 34.1%. Splenic artery, portal vein, spleen, and unspecified peripancreatic vessels were the most commonly involved sources of bleeding, with associated mortality rates of 33.3%, 50.0%, 30%, and 28.5%, respectively. Massive hemorrhage was more frequently associated with severe necrosis, with a mortality rate of 37.9%. CONCLUSION: The increased use of diagnostic and interventional radiology, in association with prompt surgical treatment, appears to be the way to improve survival rates in cases of arterial bleeding. Venous bleeding due to lesion of major peripancreatic veins or diffuse bleeding represents a therapeutic challenge, and treatment of these conditions should be tailored to the individual case, as no general rule can be suggested. In extreme cases, open packing or salvage emergency pancreatectomy may represent the only chances for survival.

Wirsung and Santorini: the men behind the ducts.

During the 16th and 17th centuries, several important discoveries were accomplished by anatomists whose contribution has enlightened the most important anatomic structures of the pancreas. Following the earliest discoveries, researchers of several medical specialities further investigated the ductal pancreatic system. The accessory pancreatic duct with its minor papilla, the main pancreatic duct and the papilla major along with the confluence of the main pancreatic duct with the bile duct and pancreas divisum, have been the objects of interest of several personalities of the medical history. Eponyms in pancreatic anatomy were given to remember some of them, although anatomical misattributions are frequent and controversial. The aim of the authors was to dedicate a small tribute to the researchers who have written, during the last 500 years, important chapters of the medical history and who dedicated their lives to study the pancreatic ducts and their duodenal endings. Furthermore, a brief outlook was dedicated to the impact of anatomic variations and of embryologic anomalies of the pancreatic ducts in our clinical practice and in our actual understanding of duct-related diseases. The authors are confident that the genial curiosity of few extraordinary personalities of the past and the opportunities provided by modern technology continue to play a major role that may finally add wisdom to decision-making in dealing with duct-related biliopancreatic diseases and safety to diagnostic and therapeutic procedures employed.