[Laparoscopic appendectomy. Our experience]. / Appendicectomia laparoscopica. Esperienza personale.

The advantages and applications of the videolaparoscopic technique (VL) versus open surgery in the treatment of acute and complicated appendicitis are not well defined. Our study examined 150 patients, 67 males and 83 females. They underwent surgery for acute appendicitis in emergency. The choice between open or laparoscopic tecnique was due to patient's clinical conditions and surgeon's experience. Two of these patients had no infiammatory process. Eleven patients were affected by gynaecological diseases. The last 137 patients underwent surgery for acute appendicitis and the diagnosis was confirmed. Among them, 35 (25%) were affected by a complicated appendicitis with diffuse or clearly defined peritonitis. In 134 patients the surgery was completed laparoscopically. The conversion rate was 2%. Morbility rate was 3%, due to intra abdominal abscesses secondary to acute complicated appendicitis. The mean operative time was 76 min and the mean hospital stay was 4.8 days. The death rate was 0%. In our experience, laparoscopic appendectomy has significant advantages over traditional open surgery in both acute and complicated appendicitis, especially in young women. In this way, we can diagnose pelvic disease that could be characterized by the same symptoms of acute appendicitis, then we suggest laparoscopic appendectomy even just to complete the diagnostic iter. Laparoscopy is useful in terms of convalescence, postoperative pain, hospital stay, aesthetic outcome and an easier exploration of the peritoneal cavity.

[Incidental carcinoma in thyroid pathology: our experience and review of the literature]. / Il carcinoma incidentale nella patologia tiroidea. La nostra esperienza e revisione della letteratura.

The diagnosis of incidental thyroid carcinoma in patients submitted to thyroidectomy for a benign disease is quite frequent. A retrospective analysis was performed on 240 patients submitted to surgical intervention in order to establish the incidence of the carcinoma. One hundred sixty five patients (68.75%) were affected by benign disease (132 multinodular goiter, 30 uninodular goiter, 2 Plummer and 1 Basedow) and 75 (31.25%) by carcinoma. In 30 of 165 patients (18.2 %), affected by benign disease, occurred a histological diagnosis of thyroid carcinoma, (18 papillary carcinoma, 6 follicular carcinoma, 5 papillary carcinoma follicular variant and 1 oncocytic carcinoma). In this study it's considered incidental thyroid carcinoma the one occurred in patients who never underwent FNA and there were no suspicious features in all exams that may suggest the presence of carcinoma. Fifteen of the 30 incidental carcinoma (50%) were microcarcinomas; in the other 13, dimensions were more than 1 cm, but less than 2 cm in 9 cases. Two patients had a synchronous carcinoma. Actually these patients are still in a follow up program and no recurrency of disease is occasionally observed. This study shows that the only way to put doubts on the real benignity of the disease is the fine needle aspiration; there are no other instruments that could let think about the occurrence of the carcinoma. Moreover in the majority of cases the incidental carcinoma is a microcarcinoma, it doesn't reach significant volume, may be not centered by a FNAB, but in must cases it's not really biologically aggressive.

Outcomes of bariatric surgery in human immunodeficiency virus positive individuals: a single center experience.

BACKGROUND: Obesity is a global pandemic that is also affecting HIV-positive individuals receiving combined anti-retroviral therapy. We present the outcomes of a cohort of HIV-positive individuals who underwent bariatric surgery in a single centre. The primary outcome was weight loss including secondary end points such as the use of hypoglycaemic and/or anti-hypertensive medication. METHODS: An electronic hospital database was used to retrospectively identify individuals that were HIV-positive and had bariatric surgery between 2003 and 2013. Detailed morphometric, immunological and virological data including post-operative follow-up information were obtained from the database. RESULTS: Twelve HIV-positive individuals (male =8, female =4) underwent bariatric surgery following multi-disciplinary team meetings and engagement in the pre-operative bariatric surgery care pathway. Their mean age was 46 years (range 33-66) with a median BMI of 43 kg/m2 (range 37-55). The mean duration of HIV prior to surgery was six years (range 3-24). All procedures were performed laparoscopically and included gastric banding (N.=8), sleeve gastrectomy (N.=1), gastric ileo-bypass (N.=1) and a Roux -en -Y gastric bypass (N.=2). Two patients had wound infections related to their gastric bands. Nine patients achieved weight loss and all but one patient remained without anti-hypertensives or anti-diabetic medication. CONCLUSIONS: Bariatric surgery is safe in stable HIV-positive individuals receiving multiple drug therapies with no detrimental effect on viral suppression. It should therefore be offered as a management strategy for obesity in HIV-positive individuals as per the general population.

Laparoscopic management of pancreatic cancer. Our experience.

AIM: Minimally invasive techniques have a definite role in the surgical treatment of several gastrointestinal tract cancers but there is still no widespread use of the laparoscopic approach for cancers of the head of the pancreas. The aim of this retrospective study is to review our experience from 2003 to 2013 in the management of pancreatic cancer with particular emphasis on the clinical application of minimally invasive techniques. METHODS: One hundred fifty-eight pancreatic cancer patients (median age 69,7±12,6 years) with obstructive jaundice were enrolled in our study. One hundred eighteen (74,7%) had an endoscopic biliary stent, 68 patients (43,03%) were eligible for surgery. Only 22 of the patients eligible for surgical intervention underwent pancreaticoduodenectomy (PD): 14 had open PD and 8 had laparoscopic PD (LPD). Thirteen of the PD patients had a pylorus-preserving procedure (8 open and 5 laparoscopic procedures) whereas in 9 the pylorus was not preserved (6 open and 3 laparoscopic procedures). The other 46 patients had un-resectable tumors and 34 of them underwent palliative surgery consisting of gastrojejunal and hepatojejunal anastomosis (18 open and 6 laparoscopic procedures), and gastrojejunal anastomosis in 10 patients (4 open and 6 laparoscopic procedures). Ten patients had only explorative laparoscopy and 2 only explorative laparotomy. RESULTS: The resectability rate was 13,9%. The median age in patients treated with an endoscopic biliary stent was significantly higher than in those who underwent surgery (73,2±13,3 years vs 64,4±9,6 years; p < 0,05). Operative time in LPD patients was significantly longer than in PD patients (521±68 minutes vs 381±88 minutes; p<0.05). The hospital stay of patients who underwent PD was significantly longer than that of those who underwent palliative surgery (27±4 days vs 10±5 days; p < 0.05). in PD patients the morbidity rate was 22,72 % and the mortality rate 4.5%. CONCLUSIONS: In recent years laparoscopic surgery has become very important in oncologic surgery because it is minimally invasive and reduces postoperative complications and because there is sufficient evidence based data showing that results in terms of complications and survival are as good as the results of conventional surgery. However the learning curve for laparoscopic cancer surgery of the head of the pancreas is steep and our results indicate that in LPD operative time is significantly longer than in PD, and moreover the laparoscopic approach is not associated with a shorter hospital stay. Therefore LPD should be performed only in well-established laparoscopic and oncological centers with a multidisciplinary team. KEY WORDS: Laparoscopy, Pancreatic cancer, Pancreaticoduodenectomy.

Percutaneous transhepatic cholangiography for choledocholithiasis after laparoscopic gastric bypass surgery.

INTRODUCTION: Gallstones are a common condition in bariatric patients after a laparoscopic Roux-en-Y gastric bypass (LRYGB). The management of ductal stones is challenging due to the altered gastrointestinal anatomy. Various techniques have been reported to manage bile duct stones. PRESENTATION OF CASE: We present the successful percutaneous trans hepatic management of common bile duct stones after LRYGB. One year after a LRYGB for morbid obesity, a 59-year-old female presented with acute cholecystitis. One month after laparoscopic cholecystectomy a 1cm calculus was found within the distal CBD and patient underwent a percutaneous trans hepatic cholangiography under local anesthetic. This involved a right sided anterior segmental duct puncture. With the sphincter dilated to 10mm, a balloon catheter was used to push the stone into the duodenum leaving an internal- external drain. Patient recovered completely at follow up. DISCUSSION: Patients with morbid obesity have a higher incidence of gallstones. After LRYGB, the altered anatomy does not allow the conventional endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis. Various techniques have been reported as means of managing bile duct stones in LRYGB patients. These include a double balloon enteroscope-assisted ERCP, laparoscopic transgastric ERCP, laparoscopic or open biliary surgery and interventional radiology. We report a non-surgical approach using percutaneous transhepatic technique under local anesthetic that resulted effective and could be applied more extensively. CONCLUSION: Due to the increase of global obesity, bariatric centers need to strategically plan resources such as interventional radiology in order to manage post LRYGB choledocholithiasis safely, efficiently and in a cost effective manner.