Spontaneous bladder rupture mimicking a jejuno-ileal perforation.

Spontaneous urinary bladder perforation is a very rare disease. The main cause of urinary perforation, indeed, is a damage to the urinary bladder wall by blunt or penetrating trauma. There are only few idiopathic spontaneous rupture of urinary bladder (ISRUB) cases reported in the literature. Pre-operative diagnosis is very difficult due to similar symptoms, laboratory and imaging findings of a gastrointestinal perforation that is usually excluded intraoperatively. Herein we report a case of a 91-year-old man presented to the emergency department with a spontaneous bladder perforation mimicking an ileal perforation.

Prognostic factors and oncologic outcome in 146 patients with colorectal peritoneal carcinomatosis treated with cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy: Italian multicenter study S.I.T.I.L.O.

AIM: The present study was specifically designed to assess the major clinical and pathological variables of patients with colorectal peritoneal carcinomatosis in order to investigate whether currently used criteria appropriately select candidates for peritonectomy procedures (cytoreductive surgery) combined with hyperthermic intraperitoneal chemotherapy (HIPEC). PATIENTS AND METHODS: Preoperative, operative and follow-up data on 146 consecutive patients presenting with peritoneal carcinomatosis of colorectal origin and treated by surgical cytoreduction combined with HIPEC in 5 Italian Hospital and University Centers were prospectively entered in a common database. Univariate and multivariate analyses were used to assess the prognostic value of clinical and pathologic factors. RESULTS: Over a minimum 24-month follow-up, the overall morbidity rate was 27.4% (mortality rate: 2.7%) and was directly related to the extent of surgery. Peritoneal cancer index (PCI), unfavorable peritoneal sites, synchronous or previously resected liver metastasis and the completeness of cytoreduction, all emerged as independent prognostic factors correlated with survival. CONCLUSIONS: Until research provides more effective criteria for selecting patients based upon the biomolecular features of carcinomatosis, patients should be selected according to the existing independent prognostic variables.

[Laparoscopic combined Nissen-Rossetti fundoplication and cholecystectomy: our experience]. / Plastica Nissen-Rossetti e colecistectomia in un unico tempo laparoscopico: esperienza personale.

OBJECT: The aim of this study is to valuate the opportunity to associate both laparoscopic Nissen-Rossetti fundoplication and cholecystectomy in patients with gallbladder cholelithiasis and gastro-oesophageal acid reflux (endoscopically and pHmetrically assessed), considerating that the gallbladder removal makes duodenal-gastric reflux worse. PATIENTS AND METHODS: From 2005 until 2007 we associated laparoscopic Nissen-Rossetti fundoplication and cholecystectomy in 10 patiens, who presented surgical indications for gallbladder cholelithiasis and gastro-oesophageal reflux. Clinical data, surgical procedures and post-operative complications were compared to our esperiency on the singular procedure (laparoscopic Nissen-Rossetti fundoplication and cholecystectomy). Results were valuated at 3, 6 and 12 months after surgical interventions by clinical and instrumental follow up (24-pH-metry and oesophagus-gastro-duodenoscopy). RESULTS: The analysis of instrumental data of these associated procedures doesn't present significative differences between the singular surgical approach. In all the patients treated by combined procedure, the follow-up shows a normal pHmetric exam, a good control on the acid reflux by fundosplication, absence of distal oesophagitis and gastric reflux symptoms. CONCLUSIONS: The association of laparoscopic Nissen-Rossetti fundoplication and laparoscopic cholecystectomy is indicated in patients who present both pathologies and needs to be considerating in relations to the good results and the low postoperatoric morbidity.

[Retroperitoneal mass: a clinical case]. / Formazione retroperitonale: caso clinico.

The Authors discuss about a case of retroperitoneal mass, recently observed in their Institution. About the nature of the mass, by the imaging and clinical evolution, the Authors suppose a traumatic genesis: subcapsular renal hematoma, occurred 2 years before, broken and expanded in retroperitoneal space and then superficialized in the left lumbar region.

[Intragastric balloon in bariatric surgery]. / Ruolo del palloncino intragastrico in chirurgia bariatrica.

Intragastric balloon (BIB) is a mechanical restrictive device formed by a silicone wrapper inserted endoscopically in the stomach, filled with 500 cc of physiological blue methyl solution and kept in situ for 6 months. In two years 98 intragastric balloon have been set in 88 patients at the average age of 37.1 years, of 41.9 of BMI and 47.6 kg of weight. Complications were intolerance, gastro-oesophageal reflux, break and/or deflation and meteorism. BIB is an effective procedure in the temporary treatment of obesity leading to satisfactory weight loss and to short-term improvement of comorbidities.

[Predisposing factors for development of cardial adenocarcinoma]. / Fattori predisponenti l'adenocarcinoma del cardias.

After a careful revision of the various papers and on the basis of their personal experience, the persons responsible for this project analyse the factors that, today, influence the development of an adenocarcinoma in the region of the gastro-esophageal junction. They also study therapeutic strategies on the basis of new findings in anatomic-physiological matters of this region. From this analysis, specialists notice an increase in adenocarcinomas which affect the gastric region of the cardia, in comparison with carcinomas which affects the gastric region in toto. By considering Barrett, Hayward, Riedel and Ruol's studies, they maintain that the fundamental factor which causes the development of cardial adenocarcinoma is the gastroesophageal reflux. This reflux acts as a chronic irritative stimulus on the esophageal wall and therefore it provokes an increase in mucous secretion and the formation of metaplasia. This metaplasia is initially mucosecreting, acid-secreting and in the end it becomes intestinal. This also leads to the appearance of absorbent calciform cells; the absorption of toxic or mutagenic substance for the cell itself, will be the next step for the development of an adenocarcinoma. Nowadays the therapy of intestinal metaplasia provides for different therapeutic levels: from the endoscopic monitoring (which is used for the most serious cases of dysplasia), to the PPI medical treatment(today in disuse), to the surgical laparoscopic treatment with non-refluxing plasty (Nissen, Toupet). This last treatment is today associated with endoscopic esophageal mucosectomy in order to achieve a better effectiveness. This happens through the use of various methodologies, for example the multipolar electrocoagulation.

[Lung surgery in the elderly]. / La chirurgia polmonare dell'anziano.

Lung surgery in the elderly, once considered a major risk, to be avoided if possible has become more popular in recent years as a result of many factors. First: lung cancer incidence has increased significantly in every age group but mostly in the elderly. Second: diagnosis at an early stage of the disease is higher in patients over 70 due to more frequent medical control in old subjects. Third: we now have more and more humans over 80 and a life expectancy increasing over the years. Fourth: preoperative, operative and postoperative medical supports are now safer and more reliable than previously. Operability criteria in the elderly are substantially the same as in younger group of patients for lung cancer. There are no reasons to refuse surgery in a subject over 80 because he is old. Lobectomy is the procedure of choice for lung cancer even in the elderly. Pneumonectomy must be avoided preferring a less radical procedure (wedge resection) so avoiding the risk of a postoperative respiratory failure that is often fatal for a patient with in border line functional respiratory tests, as often happens in the elderly. Thoracoscopic atypical resections must be considered in patients when a wedge resection is indicated preoperatively and almost always metastatic pulmonary lesion.

[Simultaneous bilateral pneumothorax. Case report]. / Presentazione di un caso di pneumotorace a contemporanea insorgenza bilaterale.

A case report of a 44 year-old white man admitted to the surgical unit for a bilateral simultaneous pneumothorax is presented. The pneumothorax occurred on day one after a surgical operation for discal hernia; in the past the patient already presented a right spontaneous pneumothorax at 32 years of age and a left pneumothorax at 37 years of age, both treated with a pleural drainage. A thoracic drain was bilaterally positioned with a good result only in the right side. The persistence of the left pneumothorax induced the authors to perform a postero-lateral thoracotomy bullae excision and pleurectomy with a good postoperative course. After a few months a new right pneumothorax occurred and the patient was treated with a right postero-lateral thoracotomy, bullae resection and pleurectomy. On the basis of the case reported, the authors consider the different opportunities in the treatment of spontaneous pneumothorax in relation to the present knowledges and technologies. Surgical procedure is to be preferred in case of persistence of pneumothorax despite a pleural drain and in case of pneumothorax in high risk subjects. Even if thoracoscopy seems to give better results regarding postoperative pain, it is not always possible with such a method to perform a careful pleurectomy neither to obtain it in all cases (above all in secondary pneumothorax). Every case must then be carefully studied to choose the best treatment at present available.