Hybrid transanal endoscopic microsurgery: a novel approach to rectal neoplasm excision.

AIM: Rectal neoplasm excision is a challenging issue in gastrointestinal endoscopy and surgery. This technical note describes a hybrid method for the excision of challenging rectal neoplasms. METHOD: The procedure consists of the combined use of classic endoscopy and transanal endoscopic microsurgical instrumentation for full-thickness removal of a recurrent rectal polyp in a patient who had previously undergone endoscopic excision of a Tis rectal adenocarcinoma, located behind the valve of Houston and 9 cm from the anal verge. RESULTS: The lesion was removed completely in 50 min with no operative complication. The patient's postoperative course was uneventful, and she was discharged after 5 days. Pathological examination of the specimen confirmed complete resection of the lesion with adequate disease-free margins. CONCLUSION: Hybrid transanal endoscopic microsurgery successfully combines the precision and flexibility of classic endoscopy with the radicality and safety of transanal endoscopic microsurgery for the treatment of demanding benign or early-stage malignant rectal tumours.

[Indications, techniques, complications and results of sleeve lobectomy]. / Indicazioni, tecniche, complicanze e risultati della sleeve lobectomy.

AIM: The authors analyse their personal series and compare it with reported data in order to assess the functional results sleeve lobectomy offers with respect to traditional techniques. METHODS: Sixty-six sleeve lobectomies were carried out from 1986 to 2000. In 49 cases the operation was carried out on the basis of criteria of choice and in 17 of functional necessity. Three vascular sleeves and 5 tangential vascular plastic operations were associated. The disparity of lumen was corrected with oblique sections on the intermediate bronchus according to Merendino. In the case of reimplantation of the intermediate on the left main bronchus high frequency jet ventilation was necessary. The anatomoses were covered with broad pedunculated pleural strips. In 3 cases extramucosal myectomy of the medio-thoracic esophagus was carried out associated in 1 case with mucous resection and subsequent direct suture. RESULTS: Morbility was 34.5% (21% atrial fibrillation, 7.5% parenchymal complications, 4.5% anastomotic complications and 1.5% mediastinitis). Mortality at 30 days was 6% (massive hemoptysis in 3 cases and respiratory failure in 1 case). The pTNM of the 57 survivors was IB in 35 cases, IIB in 6 and IIIA in 16. Follow-up showed 5-year survival of 62% for stage IB and 24% for stage IIIA. CONCLUSIONS: On the basis of their experience, with a postoperative mortality and a rate of complications comparable to literature data, the authors consider that sleeve lobectomy, although it presents postoperative problems requiring more prolonged clinical control, is preferable to traditional operations because of the functional advantages it offers patients with lung cancer.

[Crossectomy combined with sclerosis in the ambulatory treatment of varicose veins]. / Crossectomia associata a sclerosi nel trattamento ambulatoriale delle varici.

This paper focuses on the advantages of an outpatient technique in the treatment of the 1st various syndrome based on crossectomy and complementary sclerotherapy to eliminate the proximal reflux. In addition to the speed, low costs and total absence of discomfort for the patient, this method results in a low percentage of easily correctable failures provided the patients to be treated are carefully chosen. Selection involves a preoperative screening phase based on anamnesis, semeiological tests, Doppler and evaluation of tibial venous pressure, as well as careful topographical mapping of proximal refluxes which allow a correct postoperative follow-up in the event of possible recidivation (14.3% based on the authors' experience). The surgical technique used entails an accurate crossectomy with full exposure of the SF crosse (??) and its affluent branches, and subsequent sclerotherapy with atoxysclerol in a variable quantity and % as required. Of a total of 91 cases treated with a 3-year follow-up, 5 cases of recidivation were observed during the first year and 8 during the third. In both cases postoperative pressure values in the tibial veins were considerably higher than in other patients and recidivation occurred through perforating sclerosed recanalised vessels.

[Lipiodol chemoembolization in the treatment of hepatic carcinoma. Our experience]. / La chemioembolizzazione con Lipiodol nel trattamento del carcinoma epatico. Nostra esperienza.

Of the alternative methods of treatment to surgery in the treatment of liver cancer, chemoembolization with Lipiodol appears to have obtained encouraging results. After a preoperative study to confirm the diagnosis and staging of the tumour, lipiodolisation is performed: a mix of Adriamycin, Iopamidol and Lipiodol is injected using selective catheterism of the hepatic artery; gelfoam is then added. Lipiodol selectively localises in the hepatocarcinoma and has a distal embolising effect on the vessels of the tumour, thus necrotising it, acting as a carrier for chemotherapy. Since july 1990 a total of 15 hepatocarcinoma have been observed: 6 in healthy livers and 9 in cirrhotic livers; 3 patients recovered after radical surgery, 1 patient underwent associated surgery and chemoembolization, whereas in 11 the only therapy was chemoembolization, at six monthly intervals. Lipiodolisation enabled a better diagnosis to be made and was found to be a valuable therapeutic aid both when used alone in Inoperable patients and in association with non-radical surgery.

[Video-thoracoscopic sympathectomy in the treatment of Raynaud's disease and palmar hyperhidrosis]. / La simpaticectomia videotoracoscopica nel trattamento del morbo di Raynaud e dell'iperidrosi palmare.

BACKGROUND AND AIM: Raynaud's syndrome is a clinical entity characterised by episodic vascular spasm, digital ischemia in response to cold or emotional stimuli and hyperhidrosis. Many patients suffering from Raynaud's syndrome are successfully treated using medical therapy alone. Those patients who do not respond to medical treatment undergo surgery but the indications continue to be a source of controversy. A modern approach to thoracic sympathectomy requires a video-assisted technique. The aim of this study is to attempt to use mini-invasive type surgery to treat Raynaud's disease and hyperhidrosis in order to evaluate the real efficacy of thoracic sympathectomy in a large number of patients. The results of this method were compared for the two different pathologies in question. METHODS: The methodology used by this study is based on instrumental and clinical tests performed before and after surgery on treated patients using a comparative criterion and with a minimum 5-year follow-up. The pre- and postoperative diagnostic tests were performed by the vascular surgery laboratory and using a C.W. Doppler and a reflected light photoplethysmograph. Capillaroscopy and laboratory evaluations relating to secondary Raynaud's disease were carried out by internist type structures. The patients enrolled in the study responded to the following criteria: primary Raynaud's disease, palmar hyperhidrosis and associated syndromes. The population came from a mixed sociodemographic background, albeit within a strictly regional zone (Sardinia). A total of 42 patients were studied. The surgical technique used consisted of the ablation of thoracic ganglia from the 2nd to the 4th. RESULTS: The results showed a resolution of symptoms in 95% of patients treated for hyperhidrosis, whereas a 50% recidivation rate was observed in patients with Raynaud's disease alone, although symptoms were less intense. The results for Raynaud's disease were more disappointing, but it is important to remember that surgery is the ultimate choice for cases with advanced lesions which do not respond to medical treatment. Under these circumstances, the possibility of halting the evolution of the pathology represents an auspicious achievement. CONCLUSIONS: The authors affirm that mini-invasive surgical treatment of hyperhidrosis was resolutive during a mean follow-up of 3 years. It therefore represents a valid method which causes minimum esthetic damage to the patient and the greatest functional benefit. The postoperative period is short (about 3 days) and free of major complications. There is virtually no post-surgical pain.

[Pleuro-pneumo-phreno-pericardiectomy with pericardial and diaphragmatic plasty]. / Le pleuro-pneumo-freno-pericardiectomie con plastica pericardica e diaframmatica.

Aim of the paper is to evaluate 43 extrapleural pneumonectomy performed from 1988 to May 2000. Criteria for extrapleural pneumonectomy were pleural biopsy by thoracoscopy, potentially completely resectable unilateral disease by computed tomography and predicted postresection forced expiratory volume >1,3 L/sec. The resections regarded 33 pleural mesothelioma, 9 pleural lung-carcinosis and 1 pleural melanoma effusion. The perioperative mortality rate was 2,2% (1 death) and morbidity 21,4%.

[Videolaparoscopic treatment of biliary lithiasis. Evolution of our experience]. / Trattamento videolaparoscopico della litiasi biliare. Evoluzione della nostra esperienza.

Videolaparoscopic cholecystectomy is considered the treatment of choice for simple cholelithiasis. Now many surgeons consider the laparscopic procedure usable also in the complicated biliary lithiasis like acute cholecystitis and choledocholithiasis. The authors report their recent experience of the laparoscopic treatment of biliary lithiasis, regarding 221 non-selected patients (69% symptomatic cholelithiasis, 20% chronic cholecystitis, 4.5% acute cholecystitis, 4.5% coledocolithiasis, 2% hydrops). The diagnostic-therapeutic protocol and the results are described and compared with the beginning of their experience, when they treated only symptomatic gallbladder stone disease, and with the reports of the literature. The authors concluded that the laparoscopic procedure is a good chance for the surgeon in the treatment of all cases of benign biliary disease. But, in particular for patients with choledocholithiasis, he has be able to know all the diagnostic and therapeutic possibilities, to choose the best in every single case.

[Laparoscopic cholecystectomy. Our experience]. / La colecistectomia laparoscopica. Nostra esperienza.

This study analysed 90 cases of symptomatic cholelithiasis treated with laparoscopic cholecystectomy. 27% of the cases studied suffered from microlithiasis, 44% from multiple calculosis with calculi measuring 1 to 2 cm in diameter, 25% from single calculi measuring up to 4 cm in diameter, and 4% from a benign proliferative pathology of the cholecystic wall. Calculosis of the main biliary tract was also found in 3 patients and was treated by preoperative endoscopic papillosphincterotomy. In addition to routine tests and ultrasonography, endovenous cholangiography, or retrograde cholangiography (ERCP) in cases of suspected calculosis of the biliary tract, was always performed prior to surgery. Mean operating time was 60 min. Two procedures were converted into laparotomy due to laceration of the cystic artery. In one case laparotomy was performed on day two due to choleperitoneum following a lesion of the cystic duct. Pneumoperitoneum could not be performed in three cases. Mean hospital stay was 48 hours. No other intra- or postoperative complications were reported. These results support the opinion that laparoscopic cholecystectomy is a safe method, with few limitations and represents the treatment of choice in the therapy of symptomatic cholelithiasis.

[Current criteria of treatment of angiomas]. / Criteri attuali di trattamento degli angiomi.

The authors set out their therapeutic trend in the treatment of angioma and the criteria governing the use of the various therapies according to the type of dysplasia and its clinical course; they then report on the results obtained in a series of 400 cases. Only 22 cases with unfavourable trend (evolution of lesion) were observed, whereas the others exhibited spontaneous regression (85 cases), arrest of evolution (50 cases) or regression or cure (243 cases).

[Agenesis of the gallbladder and cystic duct (author's transl)]. / L'agenesia della colecisti e del dotto cistico.

The authors describe a case of agenesis of the gallbladder and cystic duct diagnosed at operative cholangiography; they discuss the embryological, etiopathogenetic and clinical aspects of this abnormality, and pertinent treatment policies. They stress the need for operative teleradiocholangiomanometry for the correct diagnosis and treatment of the disorder.

[Proximal selective vagotomy in treatment of duodenal ulcer (author's transl)]. / La vagotomia selettiva prossimale nel trattamento dell'ulcera duodenale.

Thirty duodenal ulcer patients were subjected to proximal selective vagotomy (p.s.v.) and modified Dor antireflux plastic surgery. Accurate clinical, radiological, endoscopic, gastrosecretory, radioimmunological and PH-manometric tests were made before and 7 and 30 days after surgery. The results confirm the effectiveness of p.s.v. in treatment of ulcerous disease, and the usefulness of combining modified Dor plastic surgery in order to prevent postoperative feedback.

[Intraoperative evaluation of the high pressure zone in anti-reflux plastic operations]. / Valutazione intraoperatoria della H.P.Z. nelle plastiche antireflusso.

It has been done a manometric intraoperating study on 18 patients (7 acalasical megaoesophagi, 6 herniae of hiatus, 5 duodenal ulcers) who had undergone an operation of modified Dor's anti-reflux plastics. After Haller H.P.Z. pressure has gone down of 13 mmHg, and has gone up again of 5,5 mmHg after modified Dor; after plastics H.P.Z. average intraoperating pressure has been of 18 mmHg. The posterior plastics of hiatus and the reconstruction of His' angle for hernia of hiatus modify scarcely H.P.Z. pressure. During a superselective vagotomy we have recorded a modest reduction of H.P.Z. pressure, of which average intraoperating values after vagotomy and anti-reflux plastics have been of 16,5 mmHg. At a distance of 30 months from the operation it has been done a follow up on 70% of patients that had undergone an operation of anti-reflux plastics and also 18 patients that had had en intraoperating inspection. However it has been, a degradation of manometric values, the results have been satisfactory over 90% of cases. The authors insist on the utility of intraoperating manometry for a valuation of the completenes and the efficacy of the operation.

[The role of the Billroth I operation peptic ulcer surgery]. / Il ruolo della Billroth-I nella chirurgia dell'ulcera peptica.

The conviction is expressed that none of the operations today available for treatment of peptic ulcer is always effective for all types of patient; the surgeon must in fact be able to select and perform the operation most suitable for each case. In this connection the advantages and disadvantages of gastric resection according to Billroth's first method are considered. The fundamental stages of this operation are described in detail, with a critical analysis of the various pathological conditions in which its performance is indicated or, on the contrary, there is a precise contraindication. On the basis of the main parameters of judgment (follow-up, operating mortality, relapse rate, dumping syndromes and Visick's scale) obtained from personal experience and wide research on literature, a comparative evaluation is then made between Billroth I and other operations commonly used in treatment of gastroduodenal ulcer. In conclusion it is asserted that Billroth I is a technically good, physiological operation capable of ensuring immediate and long-term results not inferior to those of Billroth II and other operations; it therefore deserves to be considered among the methods of choice and more widely used.

[Raynaud's phenomenon: diagnostic and therapeutic aspects]. / Il fenomeno di Raynaud: aspetti diagnostico-terapeutici.

The Authors report their experience concerning 120 patients with Raynaud's Disease (50 pats.) or Syndrome (70 pats.). All patients were studied before and after treatment, by clinical, thermometric, oscillographic and photoplethysmographic observation and by the Doppler examination, in order to evaluate the functional and organic component of the disease. Surgical treatment was reserved to 45 patients with secondary or primitive Raynaud's phenomenon refractory to medical therapy. The treatment of choice was thoracic sympathectomy. The result was excellent in 64% of cases, fair in 26%, and nil in 8%. 75 patients were treated with various drugs for a period of 6 months or 1 year. In 54% of cases the result was excellent, fair in 29%, and nil in 16%. The Authors conclude that diagnosis of Raynaud's Syndrome is above all clinical, that a leading part is played by photoplethysmography and the Doppler examination, and that medical therapy is indicated in the first instance, since it is capable of preventing the rise of those distal trophic disorders that constitute one of the main indications of surgical treatment.

[Colonic and rectal cancer screening using fecal occult blood analysis (our experience)]. / Screening per il cancro colo-rettale mediante la ricerca del sangue occulto fecale (nostra esperienza).

The authors describe their experience with colorectal cancer screening by means of the Hemoccult test for the detection of occult fecal blood according to Gregor's method. In particular, the decentralized aspect of the screening is examined, and the results discussed are in agreement with those observed in larger study populations. The authors go on to stress the effective possibility of conducting this type of screening also on the basis of collaboration with general practitioners.

[The interposed jejunal loop after resection for gastric ulcer (endoscopic study)]. / L'ansa digiunale interposta dopo resezione per ulcera gastrica (studio endoscopico).

Authors refer about an endoscopic study concerning twenty patients who have been previously operated for gastric ulcer. In these patients it was performed a reconstruction of the alimentary canal by means of a gastro-duodenal interposition of an isoperistaltic jejunal loop. Authors show that this method has been proved valid to prevent duodeno pancreatic reflux in the residual gastric sac.

[Monofilaments in digestive system surgery]. / Il monofilamento in chirurgia digestiva.

The most important physical and chemical properties of the new synthetic absorbable suture materials are shown. Particularly this paper make a comparison between multifilament and monofilament suture wire from the point of view of tensile strength, "in vivo" tensile strength retention, reabsorbability, foreseeability of the reabsorption time of the capillarity. On these theoretical basis the AA. think that actually the best suture wire for the gastrointestinal surgery must be a synthetic absorbable monofilament suture material. Clinical and experimental experience of the AA. utilizing in the surgery of the gastrointestinal tract a copolymer monofilament of the glycolic acid and of the trimethylene carbonate (polyglyconate-Maxon), resorbable by not-enzymatic hydrolysis in about 180 days are described. The clinical experience was acquired performing 43 manual gastroenteric anastomosis by polyglyconate suture material and making an endoscopic follow-up in 19 cases (12 oesophago-jejunal anastomoses and 7 colo-rectal anastomoses). The experimental study consist of 30 enteric anastomosis performed on rats. The results evaluation was made from three points of views: bacteriological, optical diffuse light microscopy and electronic transmission microscopy. The conclusions of the clinical and experimental studies are favourable for the use the polyglyconate suture wire in digestive surgery, and confirm also "in vivo" its theoretical properties.

[Sutures without sutures in digestive surgery. Experimental study of the rat intestine]. / Suture senza suture in chirurgia digestiva. Studio sperimentale sull'intestino del ratto.

The aim of the experimental study was to evaluate the possibility of performing an end-to-end anastomosis by using fibrin adhesive as the only means of suture. To this end, 24 Wistar rats were used, of which 16 underwent ilear resection and 8 underwent colotomy, and they were divided respectively into two groups. On the rats of the first group the anastomosis was performed by using only fibrin adhesive; on the rats of the second group operated the anastomosis was performed by using fibrin adhesive in association with non adsorbable suture material, while on those operated of colectomy the anastomosis was performed by fibrin adhesive and adsorbable suture material. The anatomo-phatological studies on the anastomosis have shown a similar healing process in the cases treated only with fibrin adhesive and by using absorbable material and has demonstrated the trange material from the suture, which are a possible causes of complication.

[Rationale for the use of bile salts after cholecystectomy: results of a controlled clinical study using tauroursodeoxycholic acid (TUDCA)]. / Razionale all'utilizzo dei sali biliari nel paziente colecistectomizzato: risultati di uno studio clinico controllato con l'impiego dell'acido tauroursodesossicolico (TUDCA).

Cholecystectomy causes alterations in bile composition. In particular it rises the proportion of highly detergent bile acids with the possible consequence of the manifestation of dyspepsia in a high percentage of patients: this is the well-known post-cholecystectomy syndrome. In this clinical trial we studied the activity and safety of tauroursodeoxycholic acid--TUDCA--(500 mg/die) in the prevention of dyspepsia in cholecystectomized patients, in comparison with no treated group. We enrolled 203 patients (101 TUDCA--group A--and 102 control-group B). The two groups were comparable for age (47.1 years in group A and 50.7 years in group B), sex (m/f: 28/73 and 37/65 in the two groups) and for other characteristics connected to surgical procedures. After operation all patients suffered from dyspepsia symptoms. In patients treated with TUDCA we registered a prompt regression in severity of symptoms when compared with no treated group: in fact we noted a significant difference only at the first control planned after one month from operation. No difference were registered at the other controls (two and three months after operation). Two patients in A and 3 in group B manifested adverse events. In conclusion, the treatment with TUDCA, a new hydrophilic bile acid, seems to contribute to the improvement of clinical course in cholecystectomized patients.