[Therapeutic Plasma Exchange in a Patient with Chronic Hemodialysis and a New Diagnosis of Myasthenia Gravis].

Case ReportC.S.T. (♂, 71 years old) is a patient with multiple and severe comorbidities, undergoing thrice-weekly chronic hemodialysis since 2008 due to the progression of post-lithiasic uropathy. Over the past 2 months, the patient had been experiencing progressive ptosis of the eyelids, muscle weakness, and ultimately dysphagia and dysarthria that emerged in the last few days. Urgently admitted to the Neurology department, electromyography (EMG) was performed, leading to a diagnosis of predominant cranial myasthenia gravis (with borderline anti-acetylcholine receptor antibody serology). Prompt treatment with pyridostigmine and steroids was initiated. Considering the high risk of acute myasthenic decompensation, therapeutic plasma exchange (TPE) with centrifugation technique was promptly undertaken after femoral CVC placement. TPE sessions were alternated with hemodialysis. The patient's condition complicated after the third TPE session, with septic shock caused by Methicillin-Sensitive Staphylococcus Aureus (MSSA). The patient was transferred to the Intensive Care Unit (ICU). Due to hemodynamic instability, continuous veno-venous hemodiafiltration (CVVHDF) with citrate anticoagulation was administered for 72 hours. After resolving the septic condition, intermittent treatment with Acetate-Free Biofiltration (AFB) technique was resumed. The patient completed the remaining three TPE sessions and, once the acute condition was resolved, was transferred back to Neurology. Here, the patient continued the treatment and underwent a rehabilitation program, showing significant motor and functional recovery until discharge. Conclusions. The multidisciplinary interaction among Nephrologists, Neurologists, Anesthesiologists, and experts from the Immunohematology and Transfusion Medicine Service enabled the management and treatment of a rare condition (MG) in a high-risk chronic hemodialysis patient.

Laparoscopic transabdominal preperitoneal (TAPP) hernia repair: surgical phases and complications.

BACKGROUND: This study aimed to determine the nature of complications after transabdominal preperitoneal (TAPP) hernia repair, and to evaluate possible links to intraoperative factors in an effort to reduce the incidence of complications. METHODS: The TAPP procedures for inguinal/femoral hernias performed between 1992 and 2004 at a single center were analyzed retrospectively. Complications were categorized according to severity and stage of the surgical procedure at which they occurred. Individual surgeon performances were examined to determine whether the rates of complications were related to surgeon experience. RESULTS: A total of 1,973 TAPP procedures were reviewed, and 81% of the patients completed 5 years of follow-up evaluation. The 74 complications (3.7%) reported were categorized as follows: 33 major (1.7%) versus 41 minor (2.0%), 66 hernia-related (3.4%) versus 8 laparoscopy-related (0.5%) complications, and 12 recurrences (0.6%). Risk factors for complications included inguinoscrotal hernia (p < or = 0.001), dissection/reduction of the sac (p = 0.02), and surgeon experience (< 50 TAPP procedures; odds ratio, 7.1; 95% confidence interval, 4.2-11.9). CONCLUSIONS: Accuracy in dissection/reduction of the sac improves the outcome of TAPP hernia repair. This effect is related to the experience of the surgeon. Experience performing more than 75 procedures is required for optimal results.

[Laparoscopic harvest of the jejunal free flap for cervical esophageal reconstruction]. / Il prelievo laparoscopico di un lembo libero di digiuno per la ricostruzione dell' esofago cervicale.

The jejunal free flap is a standard technique in the reconstruction of hypopharyngeal and cervical esophageal defects. Conventional harvesting of the jejunal segment is performed with midline open laparotomy, which is associated with complications including prolonged ileus, abdominal pain, wound infection or dehiscence. Laparoscopic resection of the small intestine is a well documented surgical technique. Two different methods of laparoscopic harvest of a jejunal autografts for their cervical implantation have been already described. In both cases, low complication rate and better postoperative course have been observed in the patients treated. During the last 10 years, we have performed 43 circumferential pharyngoesophageal resection for advanced hypo-pharyngeal cancer followed by reconstruction with a free flap of jejunum. All but one the jejunal segments have been harvested with conventional open laparotomy. In the last patient of this group, laparoscopic harvest of the jejunal segment has been successfully performed. In this paper, we describe the laparoscopic technique used and we compare the postoperative course of this patient with those of the patients treated with conventional technique.

[Mini-invasive surgical treatment of gallstones and common bile duct calculi]. / Trattamento chirurgico mini-invasivo della calcolosi colecisto-coledocica.

Between June 1st 1990 and December 31st 1991, 449 patients with cholelithiasis were operated on. All patients with isolated cholecystolithiasis (400) were offered video-laparoscopic (VLC) treatment. Forty-nine patients had both cholecystolithiasis and choledocholithiasis. They all underwent further evaluation by ERCP, on the basis of which 30 patients were selected for sequential endoscopic and laparoscopic treatment with endoscopic papillosphincterotomy (EPST) followed by VLC. Three patients were selected for VLC and ideal laparoscopic choledocholithotomy. No complications were observed. At present, sequential ERCP-PST and VLC treatment seems to be the ideal approach to combined cholecystic and choledochal lithiasis in terms of safety, efficacy and tolerability. The increasing surgical skill in the field of minimally invasive surgery and the availability of sophisticated laparoscopic instrumentation allow to consider VLC and laparoscopic choledocholithotomy a valid alternative in terms of reduced surgical trauma and patient discomfort.