Laparoscopic adhesiolysis: consensus conference guidelines.

AIM: Laparoscopic adhesiolysis has been demonstrated to be technically feasible in small bowel obstruction and carries advantages in terms of post-surgical course. The increasing dissemination of laparoscopic surgery in the emergency setting and the lack of concrete evidence in the literature have called for a consensus conference to draw recommendations for clinical practice. METHODS: A literature search was used to outline the evidence, and a consensus conference was held between experts in the field. A survey of international experts added expertise to the debate. A public jury of surgeons discussed and validated the statements, and the entire process was reviewed by three external experts. RESULTS: Recommendations concern the diagnostic evaluation, the timing of the operation, the selection of patients, the induction of the pneumoperitoneum, the removal of the cause of obstructions, the criteria for conversion, the use of adhesion-preventing agents, the need for high-technology dissection instruments and behaviour in the case of misdiagnosed hernia or the need for bowel resection. CONCLUSION: Evidence of this kind of surgery is scanty because of the absence of randomized controlled trials. Nevertheless laparoscopic skills in emergency are widespread. The recommendations given with the consensus process might be a useful tool in the hands of surgeons.

[Massive endocardial thrombosis in a patient with a peritoneo-jugular shunt for refractory ascites: the therapeutic success of tissue plasminogen activator and defibrotide]. / Trombosi massiva endocardica in paziente portatrice di dotto peritoneo-giugulare per ascite refrattaria: successo terapeutico dell'attivatore tessutale del plasminogeno e del defibrotide.

The authors report a case of a patient with a refractory ascites due to extrahepatic portal thrombosis in course of idiopathic thrombocythemia. A peritoneovenous shunt was applied and as a late complication a massive thrombosis of the intracardiac portion of the duct developed. Thrombolysis was obtained with tissue plasminogen activator at doses usually administered for acute myocardial infarction. Prophylaxis of recurrence was pursued with pictomide and defibrotide.

[Gallbladder and common bile duct calculi: treatment with laparoscopy vs laparotomy. Costs and benefits]. / Litiasi colecisto-coledocica: trattamento laparoscopico vs. laparatomico. Costi-benefìci.

The cost-benefit ratio of laparoscopy vs laparotomy was evaluated comparing 2 groups of patients: 500 operated using traditional laparotomy and 500 operated via laparoscopy. The first parameter considered was the average hospital stay, which was 8.4 days (min. 3, max. 22 days) in group I (laparotomy) (Fig. 1) against 4 days (min. 2, max. 13 days) in group II (laparoscopy). Even more interesting were the results related to the average postoperative hospital stay: 5 days for laparotomy, 2 days for laparoscopy. Currently, 90% of patients submitted to laparoscopic cholecystectomy is discharged in the first postoperative day. The cost of the surgical procedure is 1,100,000 It. Lit. for laparotomic cholecystectomy and 2,130,000 It. Lit. for laparoscopic cholecystectomy. However, considering the cost of the daily hospital stay and adding the cost of the surgical procedure we already save 50% with the laparoscopic method. Furthermore, if we consider the time occurring between patients' discharge and return to work a 50% reduction of the postoperative recovery time is obtained. The conclusions of the Authors are the following: Laparoscopic cholecystectomy performed by skilled surgeons presents an incidence of complications comparable to traditional cholecystectomy. The operating time is almost the same for both methods. Operative costs are higher for the laparoscopic technique. Postoperative hospital stay is drastically reduced with the laparoscopic procedure. Return to work is assured in a shorter time after laparoscopy.

Primary gastrointestinal lymphoma: a clinicopathological study of 58 cases.

BACKGROUND: Primary non Hodgkin's lymphoma (NHL) of the gastrointestinal tract (GI) is the most frequent extranodal lymphoma accounting for approximately 40% of all extranodal primary NHL. The role of surgery and other treatment modalities in the management of these patients is still controversial. PATIENTS AND METHODS: We reviewed the records of 68 patients with primary GI-NHL. Ten patients had incomplete records and were excluded from further evaluation. The records of 58 patients were considered, and all were available for analysis and follow-up. RESULTS: The most frequent site of involvement was the stomach (47 patients), followed by ileum (7 patients), large bowel (3 patients) and duodenum (1 patient). Malignant lymphomas of follicular center cell origin represented the most prevalent histologic types, accounting for 58% (34 of 58) of all cases. Stage, evaluated according to the criteria of Musshoff, was Ie in 15 cases, IIe in 16, IIIe in 7, and IV in the remaining 20 cases. The median survival for the entire group of 58 patients was 54 months, with 46% of patients surviving at 5 years. The median survival was 71 months for patients in stage I-II, 60 for patients in stage III, and 25 for patients in stage IV (p = 0.016). Moreover, we found significantly improved survival in patients undergoing surgical tumor resection (p = 0.003). CONCLUSIONS: Even if at the present time the optimal management of primary GI-NHL is difficult to assess, our data suggest that it is prudent to advise resection followed by adjuvant CT in most patients, whereas CT alone should be considered only when surgery cannot be performed.

Laparoscopic surgery for colorectal cancer.

Despite the widespread use of laparoscopic techniques in many fields, in the realm of malignant diseases, a great concern has been raised regarding safety, efficacy, and long-term results. The authors report their experience of 163 patients operated on for colorectal malignancies by minimally invasive access. The conversion rate (20.4%), morbidity (15.1%), and null mortality compare well with other studies published worldwide. The postoperative outcome was characterized by a prompt return to activity (1.3 days) and of bowel movements (2.9 days), while length of stay and an adequate oral resumption were comparable to those of open surgery. Peritoneal lavage did not show tumor cells disseminated during the operative maneuvers. The distance of tumor from resection margins and the number of lymph nodes harvested with the operative specimen did not vary from those obtained in open surgery. Two patients (1.2%) recurred at the mini-laparotomy and port sites, but, in both cases, the traumatic manipulation of the cancer specimen was probably responsible for the event. After a mean follow-up of over 3 years, 34 patients died of neoplastic recurrence, and 17 are alive with disease relapse. The laparoscopic approach to colectomy has not yet gained an unquestioned place in the experience of the colorectal surgeon. However, if sound surgical method and judgement are used to minimize local recurrences, and if a better preservation of postoperative immune function proves to be of clinical significance in the long term, laparoscopic colectomy may prove to be a safe and less stressful approach to colon resection.

[Primary angiosarcoma of the right atrium invading the pericardial cavity. Description of a case diagnosed by exploratory thoracotomy and surgically treated with success]. / Angiosarcoma primitivo dell'atrio destro ad espansione in cavità pericardica. Descrizione di un caso diagnosticato con toracotomia esplorativa e trattato chirurgicamente con successo.

The AA. report the case of a 43-year-old woman with an angiosarcoma arising from the right atrial wall and growing into the pericardial cavity. The patient presented with recurrent pericardial effusion initially responsive to medical therapy. The diagnosis was made at the exploratory thoracotomy. Repeated 2D-Echocardiograms did not help for the diagnosis in this particular case. The patient underwent surgical resection of the tumor, chemo- and radiotherapy. After 30 months there are no signs of recurrence or metastasis. In our opinion the frequent recurrence of pericardial effusion in the same patient should be regarded with special suspicion.

Right colon adenocarcinoma presenting as Bacteroides fragilis liver abscesses.

Pyogenic abscesses of the liver occur in association with a variety of diseases. Sometimes they are caused by anaerobic infections of liver metastases. Uncommonly, however, multiple hepatic abscesses caused by anaerobic bacteria are the presenting signs of unsuspected colonic cancer in the absence of liver metastases. We report a 60-year-old man who presented with febrile cholestatic liver disease initially thought to be metastases. Repeated ultrasound-directed liver biopsies yielded a diagnosis of multiple abscesses. Bacteroides fragilis was grown from the liver specimen and the patient responded well to metronidazole treatment. Two months later, however, overt symptoms of large bowel disease led to the diagnosis of colonic adenocarcinoma. After a 6-month postoperative follow-up, the patient is free of liver metastases. Anaerobic liver abscesses should always alert the clinician to possible silent colonic cancer.