Gasless laparoscopic treatment of perforated duodenal ulcer: a case report.

Ruptured duodenal peptic ulcer is a serious complication of ulcer disease that occurs in approximately 5% of cases. Its emergency treatment is based on surgery, namely, simple closure or more definitive ulcer surgery. Laparoscopic repair of perforated duodenal ulcer with classic insufflation of CO2 is quick, simple, and technically feasible in most patients. We describe herein the operative treatment of a perforated duodenal ulcer in a 33-year-old man who presented to our Hospital with acute onset of severe abdominal pain. Wide peritoneal lavage and suture of the perforation was performed by gasless laparoscopic technique using a mechanical retractor obviating the creation of the pneumoperitoneum and of the sealed environment. This new approach enables the use of conventional instruments and provides a clear field of vision in the abdomen equal to that created by the traditional CO2 technique. Because there is not a pneumoperitoneum to maintain, the gasless technique permits a constant irrigation and suction of the abdominal cavity, a wide peritoneal lavage, and the continuous suction of fluid, blood, smoke, and humidity without losing the camera set. If indicated, it permits the laparoscopic repair of the perforation combined with the laparoscopic vagotomy in the same emergency setting. The present case proved it to be another abdominal procedure that can be carried out with all the technical and anesthesiological advantages of gasless minimally invasive surgery.

Re-exploration of the saphenofemoral junction in the treatment of recurrent varicose veins.

A retrospective study of 61 patients (61 legs) with recurrent varicose veins (RVV) and saphenofemoral junction (SFJ) incompetence was set up to assess the efficacy of re-exploration of the SFJ through a lateral approach. All the patients underwent re-exploration of the SFJ by a single surgeon (MPV) through a lateral approach. Thirty-one patients (50.8%) presented an intact SFJ. Twenty-seven patients (44.2%) presented intact major tributaries emerging from the stump of SFJ. In 2 patients (3.2%) the recurrence was related to neovascularization and in 1 case (1.6%) to cross groin venous connection. Follow-up averaged 2.81 years. Three (4.9%) patients were lost, 56 out of 58 patients (96.55%) were asymptomatic, 2 out of 58 (3.4%) presented a new recurrence in the groin. Complete isolation of the FV to identify every tributary and ligation of the SFJ flush with the FV are essential to avoid further recurrences.

Gasless laparoscopic removal of retroperitoneal leiomyosarcoma.

Leiomyosarcoma is a rare malignant tumor originating from the smooth muscular tissue in any part of the organism. The only therapy is its complete removal. We describe herein the operative treatment of a retroperitoneal leiomyosarcoma with gasless laparoscopic complete removal. The procedure was successfully performed in a consenting woman with an abdominal mass. Gasless laparoscopic removal was performed with a mechanical retractor (Laparolift, Origin Medsystem Inc.), obviating the creation of the pneumoperitoneum and of the sealed environment. The technique is a simple, safe, and effective surgical method. Gasless technique guarantees a clear vision, makes possible continuous suction of smoke and fluids, and allows the use of conventional instruments and easy management of suturing. The present case has proved to be another abdominal procedure that can be carried out with all the advantages of gasless miniinvasive surgery.

Surgical treatment of substernal goiters.

Fifty-one patients (4.6%) underwent resection of a substernal goiter in a fifteen-year period during the course of 1103 thyroidectomies. Forty-eight (94.2%) goiters were benign and three (5.8%) malignant. Mean age was 55 years. Female:male ratio was 2:1. Four patients (7.8%) had undergone prior thyroid surgery. Most had long-standing goiters (mean duration: 15 years). The most common symptoms included airway compression (56.8%), hoarseness (13.7%), dysphagia (11.7%), superior vena cava syndrome (9.8%). Twelve patients (23.5%) were asymptomatic. Chest X-rays showed a tracheal deviation and/or a mediastinal mass in 43 patients (84.3%). Goiter extended into the right mediastinum in 28 patients (54.9%), into the left in 19 (37.2%), and bilaterally in three (5.8%). A cervical collar incision provided adequate exposure in 42 cases (82.3%). Five patients (9.8%) required a cervical incision plus partial median sternotomy and one (1.9%) a cervical incision plus a right postero-lateral thoracotomy. In three asymptomatic patients (5.8%) thoracotomy was followed by cervical incision due to a preoperative incorrect diagnosis. Major postoperative complications included two cervico-mediastinal hematoma with one subsequent death and four (7.8%) recurrent laryngeal nerve palsy. This series showed that: (1) Standard chest roetgenogram with esophagogram is still the most useful investigation, although CAT scan can help in planning the operation. (2) Cervical collar incision provides adequate exposure in nearly all cases. (3) When goiter enucleation is difficult or at risk, a complementary median sternotomy is indicated in right retrovascular goiters. (4) Operation should be recommended in all but the highest-risk patients. (5) Tracheal intubation with small caliber tubes is nearly always possible in patients with acute tracheal compression.

Surgical treatment of malignant tumors of the Oddian region.

From 1974 through 1984, 24 patients with malignancies of the Oddian region underwent surgery. Four ampullectomies were carried out with one more than 10-year survivor. Nineteen duodenopancreatectomies were performed with no operative mortality, a 21% complication rate and a 4% reoperation rate; mean survival was 42 months; 1-, 3- and 5-year survival was 95%, 53%, and 37% respectively. Nodal metastasis was the major determinant of long-term survival. Duodenopancreatectomy should be considered the operation of choice for malignancies of the Oddian region.

Venous grafting in femoropopliteal obstructions: a 16-year experience.

Over 15 years, 172 femoropopliteal saphenous vein bypasses were performed on 151 patients with chronic obstructive arterial disease. Follow-up varied from a minimum of six months to a maximum of 12 years. The operative mortality was 1.32%, the survival rates at five and ten years were 66.54% and 33.91% respectively, and the patency at five and ten years was 52.02% and 37.55%. The good results obtained, even in the majority of patients with trophic lesions and/or rest pain, indicate that direct arterial reconstruction should be considered the only effective treatment for saving a limb which would otherwise have to be amputated.

[Minimal jejunostomy for early postoperative enteral feeding: technic and results]. / Digiunostomia minima per nutrizione enterale post-operatoria precoce: tecnica e risultati.

From March 1980 to December 1982, at the 2nd Surgical Clinic of the University of Milan, 47 jejunostomies were performed at the conclusion of a major gastrointestinal surgery to provide immediate post-operative enteral nutrition. A fine needle catheter jejunostomy technique according to Delaney (10) was employed in all cases, using a polythene catheter with an internal diameter of 2.5 mm. inserted into the proximal jejunum using a stainless-steel needle. An elemental diet (13) was adopted and fed through a volumetric infusion pump. Enteral nutrition was usually initiated on the second postoperative day and on average lasted 12 days. No complications connected to positioning, permanence or removal of the catheter were observed. The only inconvenience was represented by obstruction of the catheter with food concretion thus feeding was discontinued in 3 patients. Collateral effects were observed in 9 patients: diarrhoea (5 cases), hyperperistaltis (2 cases), abdominal distension and nausea (1 case). This method of nutritional intake allowed us to: maintain body weight at pre-operative values; obtain a positive nitrogen balance on average the sixth postoperative day; reduce the volume of parenteral support, early suspension and a significant reduction in complications connected with this method.

A microcomputer based interactive system for the recording and automatic analysis of esophageal pH-studies.

A microcomputer based system for the recording and automatic analysis of esophageal pH-studies has been developed. It consists of a microcomputer interfaced with a pH-meter, one video display, two disk-drives for five inch diskettes, one printer and a fully interactive program written in BASIC. Every second, the microcomputer records the values of pH measured by the pH-meter. The options available in the program are: 1) Creation of medical records; 2) pH probe calibration; 3) pH-basal value acquisition; 4) Standard Acid Reflux Test (SART); 5) Acid Clearing Test (ACT); 6) 24-hour pH-monitoring test; 7) Summary of patient's current results; 8) Printing and data file management. Each one of these options provides access to other related functions. This system and its software has the following advantages: 1) it achieves a high standard in the execution of esophageal pH-study tests; 2) it provides an objective real-time analysis of the results; 3) it reduces the total cost of the investigation.

A morphometric and ultrastructural study of the long term effect of portacaval anastomosis on the liver of normal male rats.

A morphometric analysis of the lobular components of the liver of normal male rats up to 6 months from portacaval anastomosis revealed that the mean volume of each hepatocyte decreased about 30-40% in normally fed rats and this was associated with a shrinkage of the lobular tissue. A 10% reduction of the total hepatocyte volume density in the lobule and a net increase in time of the fat storing cell volume density could be measured, whereas the intralobular collagen decreased. Within the hepatocytes a persistent significant increase of fat globules was observed; an increase in the first period, followed by a decrease of the lysosomal component. The Golgi complex tended to decrease in the first period, then exhibited a volume density even higher than in the controls. A small reduction of the rough endoplasmic reticulum and a conspicuous reduction of the smooth endoplasmic reticulum and, in fed animals, of the glycogen content were also observed. These alterations were persistent with periods of up to 6 months from the anastomosis and were present in all the functionally distinct lobular zones. From the ultrastructural point of view, apart from variations due to the quantitative changes described above, both lobular and hepatocytic components were identical to those of age matched controls at all times from the intervention. The ultrastructural damages described by others could not be observed.

[A case of cancer arising on a multi-operated achalasic megaesophagus]. / Analisi di un caso di cancro insorto su megaesofago acalasico plurioperato.

The Authors report a case of acalasic megaoesophagus operated through extramucous myotomy according to Heller 20 years before coming to their observation and with relapse of disphagic symptoms due to serious oesophagitis during the subsequent years, in spite of an interposition of jejunal ansa according to Merendino and an oesophago-gastrostomy after removal of the interposed ansa. As the patient showed a further relapse of the disphagic symptoms, he, at last, underwent a subtotal oesophagectomy with intrathoracic oesophago-colon-plasty. At examination of the operative specimen, as a report added and not evidenced through the preoperative ascertainments, a limited oesophageal neoplastic degeneration at level of the oesophagogastro-stomy was found. The patient died one year and eight months after operation for neoplastic cachexia. The Authors analyse the causes determining the disphagic syndrome after surgical treatment of acalasic megaoesophagus, the therapeutical solutions suggested and the relations between megaoesophagus and oesophageal cancer.