Age at onset of mental disorders worldwide: large-scale meta-analysis of 192 epidemiological studies.

Promotion of good mental health, prevention, and early intervention before/at the onset of mental disorders improve outcomes. However, the range and peak ages at onset for mental disorders are not fully established. To provide robust, global epidemiological estimates of age at onset for mental disorders, we conducted a PRISMA/MOOSE-compliant systematic review with meta-analysis of birth cohort/cross-sectional/cohort studies, representative of the general population, reporting age at onset for any ICD/DSM-mental disorders, identified in PubMed/Web of Science (up to 16/05/2020) (PROSPERO:CRD42019143015). Co-primary outcomes were the proportion of individuals with onset of mental disorders before age 14, 18, 25, and peak age at onset, for any mental disorder and across International Classification of Diseases 11 diagnostic blocks. Median age at onset of specific disorders was additionally investigated. Across 192 studies (n = 708,561) included, the proportion of individuals with onset of any mental disorders before the ages of 14, 18, 25 were 34.6%, 48.4%, 62.5%, and peak age was 14.5 years (k = 14, median = 18, interquartile range (IQR) = 11-34). For diagnostic blocks, the proportion of individuals with onset of disorder before the age of 14, 18, 25 and peak age were as follows: neurodevelopmental disorders: 61.5%, 83.2%, 95.8%, 5.5 years (k = 21, median=12, IQR = 7-16), anxiety/fear-related disorders: 38.1%, 51.8%, 73.3%, 5.5 years (k = 73, median = 17, IQR = 9-25), obsessive-compulsive/related disorders: 24.6%, 45.1%, 64.0%, 14.5 years (k = 20, median = 19, IQR = 14-29), feeding/eating disorders/problems: 15.8%, 48.1%, 82.4%, 15.5 years (k = 11, median = 18, IQR = 15-23), conditions specifically associated with stress disorders: 16.9%, 27.6%, 43.1%, 15.5 years (k = 16, median = 30, IQR = 17-48), substance use disorders/addictive behaviours: 2.9%, 15.2%, 48.8%, 19.5 years (k = 58, median = 25, IQR = 20-41), schizophrenia-spectrum disorders/primary psychotic states: 3%, 12.3%, 47.8%, 20.5 years (k = 36, median = 25, IQR = 20-34), personality disorders/related traits: 1.9%, 9.6%, 47.7%, 20.5 years (k = 6, median = 25, IQR = 20-33), and mood disorders: 2.5%, 11.5%, 34.5%, 20.5 years (k = 79, median = 31, IQR = 21-46). No significant difference emerged by sex, or definition of age of onset. Median age at onset for specific mental disorders mapped on a time continuum, from phobias/separation anxiety/autism spectrum disorder/attention deficit hyperactivity disorder/social anxiety (8-13 years) to anorexia nervosa/bulimia nervosa/obsessive-compulsive/binge eating/cannabis use disorders (17-22 years), followed by schizophrenia, personality, panic and alcohol use disorders (25-27 years), and finally post-traumatic/depressive/generalized anxiety/bipolar/acute and transient psychotic disorders (30-35 years), with overlap among groups and no significant clustering. These results inform the timing of good mental health promotion/preventive/early intervention, updating the current mental health system structured around a child/adult service schism at age 18.

Effectiveness of Cerebellar Circuitry Modulation in Schizophrenia: A Systematic Review.

Structural and functional abnormalities of the cerebellum have been observed in schizophrenia since the first neuroimaging studies. More recently, the functions of the cerebellum have been extended beyond sensorimotor control to include participation in higher-level cognition and affective regulation. Consistently, the "cognitive dysmetria" theory posits that dysfunctions of cortical-subcortical-cerebellar circuitry may be crucial for the pathogenesis of different clinical features of schizophrenia. This conceptual framework offers a set of testable hypotheses, now that various tools to exert direct modulation of cerebellar activity are available. We conducted a systematic review of studies examining the effects of cerebellar modulation in schizophrenia. Two independent authors conducted a search within PubMed for articles published up to April 2019 and identified 10 studies (three randomized controlled trials, two open-label studies, two case reports, one preclinical study) describing the effects of cerebellar circuitry modulation in patients with schizophrenia or animal models. The majority of interventions were uncontrolled and used stimulation of the cerebellar vermis, using transcranial magnetic stimulation or transcranial direct-current stimulation. Most studies detected improvements after cerebellar modulation. Clinical changes mostly pertained the domains of negative symptoms, depressive symptoms and cognitive functions. In conclusion, few studies examined the effects of cerebellar modulation in schizophrenia but yielded promising results. This approach may hold therapeutic potential, pending further methodologically robust replication.

Action prediction in psychosis.

Aberrant motor-sensory predictive functions have been linked to symptoms of psychosis, particularly reduced attenuation of self-generated sensations and misattribution of self-generated actions. Building on the parallels between prediction of self- and other-generated actions, this study aims to investigate whether individuals with psychosis also demonstrate abnormal perceptions and predictions of others' actions. Patients with psychosis and matched controls completed a two-alternative object size discrimination task. In each trial, they observed reaching actions towards a small and a large object, with varying levels of temporal occlusion ranging from 10% to 80% of movement duration. Their task was to predict the size of the object that would be grasped. We employed a novel analytic approach to examine how object size information was encoded and read out across progressive levels of occlusion with single-trial resolution. Patients with psychosis exhibited an overall pattern of reduced and discontinuous evidence integration relative to controls, characterized by a period of null integration up to 20% of movement duration, during which they did not read any size information. Surprisingly, this drop in accuracy in the initial integration period was not accompanied by a reduction in confidence. Difficulties in action prediction were correlated with the severity of negative symptoms and impaired functioning in social relationships.

First-episode psychosis in the Ferrara Mental Health Department: Incidence and clinical course within the first 2 years.

AIM: To examine the incidence of with first-episode psychosis (FEP) in the Integrated Department of Mental Health and Pathological Addictions in Ferrara, Italy, and to examine the association between the Duration of Untreated Psychosis (DUP) and the clinical course. METHODS: Participants recruited in 2013-2019 were assessed with the Health of the Nation Outcome Scale (HoNOS) every 6 months for 24 months. Hierarchical growth models analysed changes of global severity (HoNOS total scores) and symptom dimensions. Regression modelled factors associated with remission (HoNOS < 8) and clinical improvement (<12). RESULTS: The incidence of FEP was 21.5 (95%CI: 21.2-21.9) cases per 100 000 person year. Among participants (n = 86, mean age 23, 76% males), baseline HoNOS scores were higher for those with a longer DUP. More than half subjects reached clinical remission (61.6%) or improvement (82.6%), while very few (2.3%) were re-hospitalized. HoNOS total scores decayed with a mixed linear/quadratic trend, with a slower decay among migrants. A longer DUP was associated with reduced improvements of positive symptoms and lower likelihood of clinical improvement (OR: 0.84; 95%CI: 0.73-0.96). CONCLUSIONS: Patients from the FEP program of Ferrara reached good clinical outcomes. Nonetheless, individuals with a longer DUP may need additional clinical attention. Systematic monitoring of clinical outcomes may be an optimal strategy to improve the outcomes of FEP in the real world.

Laparoscopic incisional hernia repair with fibrin glue in select patients.

BACKGROUND AND OBJECTIVE: Laparoscopic treatment of incisional hernias can be performed using different types of fixation devices and prosthesis. We present a case series of 19 patients with incisional hernias with a diameter of < 6 cm, who underwent laparoscopic repair using Hi-tex dual-side mesh, positioned intraperitoneally, fixed to the abdominal wall by fibrin glue (Tissucol). METHODS: Nineteen patients with incisional hernias < 6 cm in diameter were enrolled in this study and treated laparoscopically with Hi-tex and Tissucol. Surgical complications and patient outcomes were assessed with a clinical follow-up. RESULTS: Laparoscopic repair of incisional hernias by using Hi-tex mesh affixed to the parietal wall with fibrin glue was feasible and easy in patients with parietal defects < 6 cm in diameter. Mean operating time was 30 minutes. Mean hospital stay was 1.5 days. Almost no postoperative pain, major surgical complications, seroma formation, relapses, or prosthesis infection occurred during a mean follow-up of 20 months. CONCLUSIONS: In select patients, Hi-tex mesh affixed using fibrin glue allows laparoscopic repair of incisional hernias with very good patient outcomes, especially in terms of postoperative pain and seroma formation.

Beyond pain: can antidepressants improve depressive symptoms and quality of life in patients with neuropathic pain? A systematic review and meta-analysis.

Neuropathic pain can be a predictor of severe emotional distress, up to full-blown depressive states. In these patients, it is important to move beyond the sole treatment of pain, to recognize depressive symptoms, and to ultimately improve the quality of life. We systematically searched for published and unpublished clinical trials assessing the efficacy and tolerability of antidepressants vs placebo on depression, anxiety and quality of life in patients with neuropathic pain, and pooled data in a meta-analysis. A total of 37 studies fulfilled eligibility criteria and 32 provided data for meta-analysis. Antidepressants were more effective than placebo in improving depressive symptoms (standardized mean difference -0.11; 95% confidence interval -0.20 to -0.02), although the magnitude of effect was small, with a number needed to treat of 24. No significant difference emerged between antidepressants and placebo in reducing anxiety. Quality of life seemed improved in patients on antidepressants, as did pain. Acceptability and tolerability were higher in patients on placebo. To the best of our knowledge, this is the first meta-analysis specifically focusing on the effect of antidepressants on psychiatric symptoms and quality of life in patients with neuropathic pain. Our findings suggest that despite their potential benefit in patients with neuropathic pain, antidepressants should be prescribed with particular care because they might be less tolerable in such a fragile population. However, our findings warrant further research to explore how a correct use of antidepressants can help patients to cope with the consequences of neuropathic pain on their psychosocial health and quality of life.

Quantification of pain in laparoscopic transabdominal preperitoneal (TAPP) inguinal hernioplasty identifies marked differences between prosthesis fixation systems.

BACKGROUND: Various systems exist for prosthesis fixation in hernia repair. These techniques vary in terms of postoperative complications and pain. This study compares prosthesis fixation techniques employed in laparoscopic transabdominal preperitoneal (TAPP) hernioplasty using a visual analog scale (VAS) to quantify postoperative pain. METHODS: Patients (n = 600) underwent TAPP inguinal hernia repair in a randomized prospective study. Prostheses were fixed with Protak (Tyco, Norwalk, Conn), (Group A; n = 150), EndoANCHOR (Ethicon Endo-Surgery, Inc., Cincinnati, Ohio) (Group B; n = 150), EMS (Ethicon Endo-Surgery, Inc.) (Group C; n = 150), or Tissucol (Baxter Healthcare, Milan, Italy) (Group D; n = 150). Patients were interviewed up to 1 month post-intervention. Post-operative pain was evaluated on a 0- to 10-point VAS (0 = no pain, 10 = maximum pain). Morbidity, length of stay, return to work and recurrence were also assessed. RESULTS: Overall, 803 hernias were treated: 397 patients (66.2%) had unilateral hernias and 203 (33.8%) had bilateral hernias. In total, 96 (12%) hernias were recurrences and 707 (88%) were primary. Postoperative pain ranged from VAS1 to VAS2 (mild pain) between 12 hours and 72 hours with Tissucol (Group D), and it was higher in Groups A-C: Maxima ranged from VAS4 (moderate pain) with EMS to VAS7 (severe pain) with Protak at 48-hour follow-up. Significant differences in length of stay occurred, no recurrence or conversion rates were observed among groups, and morbidity was generally lower with Tissucol. Patients in Group D (Tissucol) also returned to work sooner than did Groups A-C (Protak, EndoANCHOR, and EMS). CONCLUSIONS: We found differences in postoperative pain among different laparoscopic TAPP prosthesis fixation methods. The use of the biocompatible fibrin sealant Tissucol seems to reduce significantly postoperative pain, complications, and resumption to work times compared with other systems.

Laparoscopic repair of inguinal hernias using an intraperitoneal onlay mesh technique and a Parietex composite mesh fixed with fibrin glue (Tissucol). Personal technique and preliminary results.

INTRODUCTION: Laparoscopic repair of inguinal hernias is usually achieved by totally extraperitoneal (TEP) or transabdominal preperitoneal (TAPP) techniques. The intraperitoneal onlay mesh (IPOM) could be an interesting alternative as it is much easier to perform and faster to execute. This technique is subject to correct selection of indications and to demonstration of its safety. MATERIALS AND METHODS: From January 2003 to January 2006 we performed 61 laparoscopic hernia procedures on 60 selected patients (60 males with a mean age of 60 and mean weight of 76 kg) with an IPOM technique combining the Parietex composite mesh (12 cm circular model) and a fibrin glue (Tissucol) for its fixation. The glue was diluted to increase fixation time and applied to the mesh prior to positioning on the hernia defect. RESULTS: Mean operative time was 10 minutes. Mean hernia diameter was 2.5 cm (+/- 0.8 cm). 10 hernias were direct, 51 were indirect and 10 out of 61 were recurrent. We did not convert any of the laparoscopic procedures. Mean hospital stay was one day; mean recovery time for working and general physical activities was five days. Patients were checked after one week, 1-3-6 months and 1-2 years. Average follow up time was 23.7 months. 1.6 % of patients showed short-term complications: one trocar site haematoma. No additional complications were reported; particularly, we had no recurrence, no seroma, no mesh migration, and no bowel obstruction or fistula. CONCLUSION: Results of this study show intraperitoneal (IP) tolerance to this kind of mesh and the safety of its fixation with Tissucol. The absence of recurrence and complications could be a good reason to extend the indication of IPOM hernia repair. However, these preliminary results should be confirmed by longer follow-up.

Acute colonic obstruction: endoscopic stenting and laparoscopic resection.

INTRODUCTION: Acute colonic obstruction is a frequent emergency condition in a general surgical setting. The use of an endoscopic self-expanding stent can relieve obstruction and eventually prepare the patient for elective laparoscopic or open surgery. MATERIALS AND METHODS: From September 2001 to March 2006 we treated 25 patients with acute left or transverse colonic obstruction. In 23 patients stents were positioned planning an elective procedure to be performed. In two patients with multiple liver metastases and malignant ascites only a palliation was intended (2 of 25 patients). RESULTS: Mean age was 66.6 years. The 23 patients who underwent resection, 14 females and nine males, had a mean age of 65.5 years. Obstructions were located in the rectum (five), in the sigmoid (16) and in the transverse colon (two). In one patient stricture was due to radiotherapy, in twenty four cases it was due to primary cancer. Stents were successfully placed in 24 patients. In one of them two stents had to be placed due to the slippage of the first one beyond the stricture. Excellent resumption of colonic transit was achieved in all the patients. No complications were observed. In 23 patients resection was performed (19 laparoscopy; four open). Complications occurred in one patient in open group (pancreatic fistula after splenectomy) and was treated conservatively. Mean postoperative stay was 18.5 (range 9-35) days for the open group and 12 (range 9-20) for the laparoscopic group. Mean follow-up was 36 months. CONCLUSIONS: Use of self expanding endoscopic colonic stents can provide excellent palliation in acute obstruction, aiming both to prepare the colon to elective surgery after adequate preparation or to palliate the stricture in case of unresectable advanced tumors.

Experimental comparison of type of Tissucol dilution and composite mesh (Parietex) for laparoscopic repair of groin and abdominal hernia: observational study conducted in a university laboratory.

PURPOSE: The primary objective of this observational study was to determine the best possible dilution of fibrin glue (Tissucol) to employ for prosthesis fixing in laparoscopic treatment of abdominal wall defects and, secondly, to assess its feasibility and safety. MATERIALS AND METHODS: This study was carried out in a university experimental animal laboratory in accordance with all international laws, ethics regulations and quality criteria associated with animal experiments. The tests were carried out on two pigs, using four samples of mesh (Parietex). All meshes were fixed using two different Tissucol dilutions (standard with distilled water and that with calcium chloride). Follow-up evaluations were at 15 days after 30 days, with the latter consisting of traction tests and a biopsy for histological analysis. RESULTS: No post-operative complications were observed. The collagen-coated polyester meshes showed 0% adhesions, and reperitonealization had ensued after 15 days. We saw no shrinkage or migration of any of the meshes. Histopathological analyses confirmed a greater stability, greater tissue integration and the largest number of fibroblasts in meshes fixed with a 1/10 Tissucol dilution without calcium chloride. CONCLUSIONS: This observational study using animals showed that the 1/10 standard dilution - not that with calcium chloride - provided the best fixation and integration and prevented the formation of intraperitoneal adhesions, provided a hydrophilic collagen film-covered mesh was used.

Laparoscopic surgery of pancreatic cancer: state of the art.

The use of laparoscopy in pancreatic cancer offers a significant contribution to the diagnosis and treatment of this disease. Both laparoscopic staging and treatment of pancreatic cancer have proved feasible and effective. This paper reviews the literature on this topic, by a Medline search using the words laparoscopy and pancreas. Various aspects are considered: staging, treatment and palliation. Cross-references from the articles retrieved were reviewed. The efficacy and safety of diagnostic laparoscopy and ultrasonography, lowering the rate of useless laparotomies, is evident in most studies. Moreover laparoscopic resection of the body and tail of the pancreas, as well as palliation of digestive obstruction has been demonstrated as feasible. Controversy exists on feasibility of pancreatoduodenectomy. Laparoscopic gastric outlet obstruction bypass and laparoscopic biliary decompression have been reported with good results compared to open surgical procedures. Randomized controlled trials are required to validate promising results coming from the reported series, mainly retrospective.

Results of laparoscopic versus open abdominal and incisional hernia repair.

BACKGROUND: Incisional hernia is a frequent complication of abdominal surgery. The object of this study was to confirm the safety, efficacy, and feasibility of laparoscopic treatment of abdominal wall defects. METHODS: Fifty consecutive laparoscopic abdominal and incisional hernia repairs from September 2001 to May 2003 were compared with 50 open anterior repairs. RESULTS: The 2 groups were not different for age, body mass index, or American Society of Anaesthesiologists scores. Mean operative time was 59 minutes for the laparoscopic group, 164.5 minutes for the open group. Mean hernia diameter was 10.6 cm for the laparoscopic group, 10.5 cm for the open group. Mean length of stay was 2.1 days for the laparoscopic group, 8.1 days for the open group. Complications occurred in 16% of the laparoscopic and 50% of open group. Median follow-up was 9.0 months for the laparoscopic group, 24.5 months for the open group. Recurrence rates were 2% for laparoscopic group and 0% for the open group. CONCLUSION: Results for laparoscopic abdominal and incisional hernia repair seem to be superior to results for open repair in terms of operative time, length of stay, wound infection, major complications, and overall hospital reimbursement.

[Use of fibrin glue (Tissucol) for mesh fixation in laparoscopic transabdominal hernia repair]. / Utilizzo della colla di fibrina (Tissucol) per il fissaggio protesico nell'ernioalloplastica laparoscopica transaddominale (TAPP): indicazioni, tecnica e risultati iniziali.

The aim of this study was to demonstrate the efficacy and safety and report the results of prosthesis fixation by means of fibrin glue during laparoscopic treatment of inguinal and femoral hernias. From September 2001 to December 2004 we employed fibrin glue (Tissucol, Baxter, Maurepas) as a means of fixation during a transabdominal preperitoneal procedure in 230 patients (225 M, 5 F) with an average age of 45 years (range: 20-75) presenting a total of 320 hernias: 140/230 (60.8%) were monolateral and 90 (39.2%) bilateral; 267/320 hernias (83.6%) were primary and 53 (16.4%) recurrent. We had no perioperative complications. After an average follow-up of 26 months (range: 1-40) the only postoperative complications we encountered were 6 seromas (1.8%) and 1 trocar-site haematoma (0.3%). None of the patients developed scrotal haematomas. None of the patients complained of immediate or subsequent paraesthesia or cruralgia. No recurrences have occurred to date. The mean operative time was 30 minutes for monolateral hernias (range: 15-45) and about 50 minutes for bilateral hernias (range: 30-75). This was true of both primary and recurrent hernias. Patients are usually discharged on day 1 postoperatively. In the absence of pain, working activities are resumed after 5 days and sports can be practiced after 10 days. In our experience, fibrin glue (Tissucol) is the best way of fixing the mesh during a transabdominal preperitoneal procedure. It is better than mechanical devices because, though guaranteeing prosthetic stability, it is completely non-traumatic and presents none of the problems of metal clips.

[Prospective study of laparoscopic treatment of incisional hernia by means of the use of composite mesh: indications, complications, mesh fixation materials and results]. / Studio prospettico sul trattamento laparoscopico del laparocele con mesh composita: indicazioni, complicanze, sistemi di fissaggio e risultati.

The aim of this study was to establish the indications, safety, efficacy, feasibility and reproducibility of laparoscopic techniques in the treatment of abdominal wall defects, even of the larger kind, in order to standardise procedures and confirm the performance of the composite mesh used (Parietex, Sofradim, Trevoux, France). From January 2001 to December 2004, 185 non-selected patients (109 females, 76 males), with a mean age of 56 years (range: 26-77) and a mean BMI of 30 (range: 26-40) were included in the study; 162 patients (87.5%) had incisional hernias and 23 patients (12.5%) primary wall defects. The size of the defects treated ranged from 4 cm to 26 cm (mean: 12.1 cm). All patients underwent laparoscopic repair and all meshes were placed intraperitoneally. Over a mean follow-up period of 29 months (range: 1-48), we observed 11 postoperative complications (6.7%): 7 seromas (4.3%) which were still present after 4 weeks, one of which turned septic after several attempts at percutaneous evacuation and in which the prosthesis had to be removed laparoscopically; 3 (1.8%) experienced persistent neuralgia which disappeared after 2 months' treatment with NSAIDs, and also one case of trocar-induced haematoma. We had 4 recurrences (2.4%), all within 1 to 3 months of surgery; 1 in the size group measuring less than 9 cm and 3 in the larger defect group. Adhesiolysis was performed in 98% of all incisional hernia cases and in 7 cases (4.3%) we had to repair iatrogenic lesions of the small bowel. In 4 patients (2.5%), because of thick adhesions (1 patient) or bowel loop fixation to the previous surgical scar (3 patients), we caused complete bowel perforation repaired by laparoscopic suture. Mean operative time was 65.6 minutes (range: 28-130) and the mean hospital stay was 2.1 days (range: 1-5). We had no conversions and no mortality. We also reviewed the main methods of mesh fixation and believe that the best system at the moment is the EndoAnchor (Ethicon Endo-Surgery, Cincinnati, Ohio) device, although in future the best option is likely to be fixation with non-traumatic biological glue (Tissucol, Baxter, Maurepas), which we have already used in a series of 16 patients with optimal results and no recurrences. The results emerging from this clinical trial confirm the safety and efficacy of laparoscopic repair techniques, of this kind of mesh and of the anchoring devices used as well as the reproducibility of this technique for the intraperitoneal repair of primary and incisional abdominal wall defects, including even those of large size.

Scissor-knot-pusher: an instrument for simplified laparoscopic extracorporeal knotting.

This paper describes the "scissor-knot-pusher," an instrument that greatly facilitates the execution of knot tying during laparoscopic operations. The instrument acts in essence as an extension of the surgeon's hand and, given its rigid structure, allows the surgeon full control of the process of knot tying. Additionally, after the knot has been tightened, it is possible to cut the suture without using a different instrument. As a result, this technical device simplifies knot tying and may help to reduce the frustration and the time often associated with intracorporeal suturing during laparoscopic surgery.

[Laparoscopic surgery of the stomach: state of the art]. / Chirurgia laparoscopica dello stomaco: stato dell'arte.

Over the past 10 years laparoscopy has been used for the staging of gastric cancer. It has also been used over the past decade for cancer resections, mainly stage I. In addition, it can be used for palliation in advanced stages. We have reviewed the main papers published in the English literature with a view to assessing the validity of laparoscopy in the staging of gastric cancer and in curative resections for cancer. Several studies published in the last 5 years have demonstrated the utility of laparoscopy in the staging of gastric cancer--mainly T3 and T4--and of cancer of the oesophagogastric junction. Laparoscopy can reduce the numbers of useless laparotomies performed and may be useful in selecting patients for neoadjuvant therapy. A number of studies have demonstrated the feasibility of laparoscopic gastric resections, mainly in stage I cancer. The advantages it affords consist above all in less postoperative pain and a quicker recovery. Laparoscopy, then, is useful in the staging of gastric cancer and in cancer of the oesophagogastric junction, mainly because it brings down the number of pointless laparotomies. More debatable is the issue of gastric resection for cancer, because of the low prevalence of early gastric cancer in Western countries.

Laparoscopic stoma creation.

Laparoscopic creation of an intestinal stoma may be preferable to an open operation. We report here our experience with faecal diversions. From April 1992 to April 2003 we performed 55 procedures (23 end colostomies for Miles operations; 21 end colostomies for Hartman procedures; 9 loop colostomies and 3 loop ileostomies). In 45 cases the procedure was completed laparoscopically. Ten (18%) of the cases required conversion due to bulky tumours (6 pts), obesity (2 pts) and adhesions (2 pts). The indications for diversions were rectovaginal fistula (1 pt), anastomosis leakage (1 pt), unresectable rectal cancer (21), rectal cancer resectable by Miles operation (20 pts). The two ileostomies were constructed to protect colo-anal anastomoses. The average duration of surgery was 50 minutes (range: 20-100) and 200 minutes in the case of Miles operations. The average postoperative hospital stay was 3 days (range: 2-5) and 7 days (range: 6-9) after a Miles operation. The demand for analgesics was far lower than with traditional surgery and did not continue after postoperative day two. We had no intraoperative complications. There was no mortality. During the follow-up period all the stomas have functioned well but a prolapse occurred in one case (2.6%). The laparoscopic creation of intestinal stomas is safe, feasible and effective and can be performed with a low morbidity rate. Stoma construction is the simplest of all laparoscopic procedures because it requires little dissection and only minimal mesenteric handling. The length of the procedure is longer in patients who have had prior surgery, but prior surgery is not a contraindication and a laparotomy can be avoided in the majority of patients. Patients who are obstructed or have significant bowel dilation are less prone to damage with laparoscopic procedures. In addition to the benefits of laparoscopic techniques for the patients, a laparoscopic colostomy may be ideal for the surgeon as a basic, initial step in the performance of laparoscopic colorectal procedures.

[Laparoscopic surgery of the liver: state of the art]. / Chirurgia laparoscopica del fegato: stato dell'arte.

Laparoscopic hepatic surgery has recently claimed its place among the minimally invasive techniques. Adequate technologies and experience both in laparoscopy and liver surgery are essential for its correct use. A review of the English literature on this subject is presented and the present state of the art discussed. Various topics are considered: staging, treatment of cystic lesions and treatment of benign and malignant primary and secondary tumours. Over the past five years various groups have published papers regarding case series, mainly concerning hepatic resection. More correct indications for the use of laparoscopy in liver surgery have been defined. In particular, laparoscopy is of great importance in the staging of primary and secondary liver cancer and in the treatment of cystic and benign lesions, mainly of the anterior segments. Less univocal are surgeons' attitudes towards the treatment of primary and secondary liver cancers. Laparoscopic liver surgery is gradually gaining wider and clearer acceptance in the treatment of hepatic lesions, while it has now virtually consolidated its role in the treatment of cystic lesions and in the staging of primary and secondary liver cancer.

[Laparoscopic liver resection using a radiofrequency dissector. Initial experience]. / Resezioni epatiche laparoscopiche mediante dissettore a radiofrequenza. Esperienza iniziale.

Laparoscopic liver surgery, especially when resective, requires both the skill of an expert laparoscopist and the experience of a liver surgeon. The aims of the study were to assess the feasibility of minor laparoscopic liver resection by means of a radiofrequency dissector and to evaluate the laparoscopic approach. From January 1993 to November 2002 we carried out 7 laparoscopic liver resections (3 men, 4 women), 5 of which for benign diseases and 2 for metastases from colorectal cancer. In 4 of the above resections we used an argon coagulator, while the last 3 were performed using a radiofrequency instrument. We had no perioperative or postoperative complications in this small series of patients. The mean perioperative blood loss was 120 ml (range: 80-200) and the procedure took about 90 minutes on average (range: 80-110). The mean hospital stay was 4 days and pain was adequately controlled by administering 2 ml of Toradol twice daily. We believe that the advantages of the laparoscopic technique together with the efficacy of the radiofrequency instrument in liver surgery will lead to a more widespread use of this procedure and extension of its use to include the safe execution of both minor and major resections.