A single-trocar technique for minimally-invasive surgery of the chest.

BACKGROUND: In thoracic surgery, the classic thoracoscope is used to perform simple maneuvers in the chest. We have devised a minimally invasive technique that requires only a single trocar. This technique is used in our department to diagnose and treat a wide range of thoracic pathologies. METHODS: Between October 1998 and August 1999, 37 patients underwent surgery prospectively for a thoracic disease through a single trocar. There were 19 men and 18 women with a mean age of 60 years (range, 40-85). The trocar was flexible or soft and had a diameter of 15-20 mm. A 2-cm skin incision was made in the planned intercostal space. The chest drain was always inserted under video control. RESULTS: The mean operative time was 53 +/- 5 min. One patient developed intraoperative bleeding that required intubation and a 5-cm mini-thoracotomy. In one patient with stage II empyema, it was necessary to insert another trocar. Chest tubes were removed after 77.7 +/- 7 h. Hospital stay was 4 +/- 1 days (range, 2-14). Histologic examination revealed malignant disease in 26 cases and benign disease in 11. Two patients (5.4%) developed wound infections. None of the patients had port site metastasis. There were no hospital deaths. CONCLUSION: Because of its simplicity, we recommend the use of this mini-invasive technique in place of the classic thoracoscope or video-mediastinoscope.

Clinical features and oesophageal motility in patients with tight fundoplication.

OBJECTIVE: Tight fundoplication is a well known complication of surgery for gastroesophageal reflux. We have noted, in clinical experience, that some patients operated for gastro-oesophageal reflux develop pharyngo-oesophageal dysphagia. This study was undertaken to elucidate, by comparing motility data in patients with and without tight fundoplication, the pathophysiologic characteristics of the swallowing mechanism and to clarify the cause of dysphagia in these patients. METHODS: Sixteen patients with postoperative persistent dysphagia following a fundoplication have been studied, of those 10 presented a lower oesophageal sphincter resting pressure above or equal to 30 mmHg (group A). Clinical work-up included a questionnaire, oendoscopy, manometry and barium meal or video-roentgenography. Oesophageal manometry was performed using a slow pull through technique while the stationary pull through technique was used for the pharyngo-oesophageal segment. The following parameters were evaluated: (a) amplitude of pharyngeal contraction; (b) upper oesophageal sphincter resting pressure; (c) amplitude of upper oesophageal sphincter contraction; (d) amplitude of oesophageal contraction; (e) lower oesophageal sphincter resting pressure. The results were compared to those of 21 patients who had a fundoplication with normal lower oesophageal sphincter pressure (group B). RESULTS: in group A there were three males and seven females, with a mean age of 51 years (ranging from 28 to 60 years). Previous operations were Nissen in two and Nissen Rossetti in eight patients. Three out of 10 patients of group A presented pharyngo-oesophageal dysphagia. Mean lower oesophageal sphincter 36 versus 21 mmHg and upper oesophageal sphincter 86 versus 42 mmHg resting pressure, pharyngeal 147 versus 76 mmHg and oesophageal amplitude, upper oesophageal contraction 251 versus 103 mmHg were significantly higher in patients of group A versus group B. An increased number of repetitive contractions was also found in group A. The presence of a strong correlation was demonstrated between the pharyngeal amplitude and the closing tone of the upper oesophageal sphincter (R2 0.742 and R2 0.739) in both groups. CONCLUSION: Tight fundoplication is, in our experience, always associated with total fundoplication. The appearance of pharyngo-oesophageal dysphagia in the postoperative period in patients operated on to correct gastroesophageal reflux using a total fundoplication, should not be under-estimated because it suggests an obstruction of the distal oesophagus.

The place of Belsey Mark IV fundoplication in the era of laparoscopic surgery.

OBJECTIVES: Laparoscopic fundoplication to correct or avoid gastroesophageal reflux decreased Belsey Mark IV fundoplication (BMIV) dramatically worldwide. The purpose of this paper was to determine the role of BMIV and its current indications. METHODS: We reviewed all patients who underwent fundoplication between April 1997 and December 2001. All patients underwent a complete work-up included barium meal, endoscopy, 24-h pH-metry and manometry preoperatively. RESULTS: Sixty-two consecutive fundoplications were performed. There were 23 males and 39 females. Forty-six patients were treated by laparoscopic approach (37 patients with total and nine patients with partial fundoplication). BMIV was preferred in 16 patients with the following indications: reoperations for failed oesophageal surgery (5), hiatal hernia fixed in the chest (4), epiphrenic oesophageal diverticula (3), diffuse oesophageal spam (2), hiatal hernia associated with bullous emphysema (1), leiomyoma of the oesophago-gastric junction (1). Excellent to good results were reported in 14 patients and poor in two. Follow-up was completed in all patients. CONCLUSIONS: BMIV remains a valid fundoplication although the current indications are now limited. The technique is to be considered an additional, but necessary, weapon for thoracic surgeons with interest in oesophageal disease.

[CT-guided FNA in the diagnosis of lung opacities. Our experience]. / La FNA-CT guidata nella diagnosi delle opacità polmonari. Nostra esperienza.

Between January 1989 and December 1994 we accomplished 130 CT-guided transthoracic fine needle aspirations (FNA) in 120 patients. Ten patients underwent a second FNA because of the negativity and doubts of the first. Diagnosis was targeted in 114 (95%) patients and 89% showed cytological evidence of malignancy. FNA-CT guided is reliable in the diagnosis of lung cancer, but less accurate in excluding diagnosis of malignancy. In our experience FNA had an accuracy with regard to lung cancer, of 92%. Sensitivity and specificity were respectively 93.8% and 100%. There were 6 false negative and 9 very negative. All patients should have bronchoscopy rather than FNA as the initial diagnostic procedure and perform it only in the absence of endobronchial lesions and malignant cells obtained with cytologic sputum or fiber bronchoscopy. In our experience 91 patients have lung cancer and thoracotomy was performed in 21% with confirm of diagnosis. FNA offers several advantages over other diagnostic procedures used in the evaluation of patients with intra-thoracic nodules and masses. The uses of small needles (20-22 gauge) and CT-guide has practically eliminated the risk of major haemorrhage. Deep and superficial lesions of the lung may be approached safely with FNA-CT guided and complications are no fatalities. Pneumothorax occurred in our experience in 5 cases and no occurred a chest drainage.

[A carcinoid with cecal localization. Apropos a case]. / Il carcinoide a localizzazione cecale. A proposito di un caso.

An observed case of carcinoid tumor of the large-bowel in a 68-year-old woman leads to an analysis of the clinical-diagnostic and therapeutic aspects of this rare gastrointestinal tumour. Carcinoid tumour represents 0.8-1.5% of malignant digestive tumours, in 6% of cases it is localized in large-bowel and in 2-3% in cecal-bowel. In our experience there is no specific symptoms and diagnosis was based on postoperative histopathologic analysis. Right hemicolectomy with lymphadenectomy performed and the operative specimen included a 7 cm diameter tumour, which had narrowed the lumen by 80% and infiltrated ileocecal valve. Carcinoid tumour presents considerable problems of diagnosis because symptoms are aspecific. Diagnosis is possible only in patients with high urinary levels of 5-HIAA, in presence of carcinoid syndrome and by endoscopic biopsy when tumour infiltrated gastrointestinal mucosa. False negative cases are frequent in small carcinoids ( < 2 cm) because the tumour tissues are covered by integral mucosa. C.T., ultrasonography and angiography play a primary role in the diagnosis of this tumour but octreotide scintigraphy is very important for tumour and metastases localization in consequence of its ability to demonstrate somatostatin receptor positive tumours. Radical surgery is the only treatment in very little carcinoids to prevent metastases risk. Determinant risk factors are: primary size, localization, serosal penetration. In patients with any of these risk factors, resection with regional lymphadenectomy is recommended. Other prognostic factors include histologic differentiation, the presence of macroscopic residual disease after initial surgery and level of 5-HIAA in urine. We think that neither adjuvant chemotherapy, or radiotherapy may play a significant role in this neoplasm. Many authors report considerable unsuccessful with this treatment and it is used mainly for palliation. At present, the medical treatment of inoperable gastrointestinal carcinoid consist in association with interferon alpha and octreotide. During this treatment the size of the tumour is stable: reduction of symptoms and 5-HIAA urinary levels are noted.

[Intrathoracic hemangiopericytoma localized in the mediastinum]. / L'emangiopericitoma intratoracico a localizzazione mediastinica.

The paper reports a case of intrathoracic hemangiopericytoma localised in mediastinum which was brought to the authors attention and treated surgically. Having analysed the tumour's macro- and microscopic histological and biological features and the most suitable methods of diagnosis, the authors stress that, in line with international literature, radical surgery extended to the surrounding tissues is the elective surgical treatment for hemangiopericytoma in a mediastinal site.

[Stomach leiomyosarcoma. Clinico-diagnostic considerations and therapeutic criteria]. / Il leiomiosarcoma dello stomaco. Considerazioni clinico-diagnostiche e criteri di terapia.

An observed case of leiomyosarcoma of the stomach in a 67 year old man leads to an analysis of the diagnostic, clinical and therapeutical aspects of this myoid tumour in the digestive tract representing 50-60% of cases. Symptoms are aspecific and gastric bleeding is the most common sign (50%). leiomyosarcoma always presents considerable problems of diagnosis and represents the most important among the various examined diagnostic investigations but it is maintained that surgery many times plays a primary role in the diagnosis of this tumour. The accuracy of gastrofiberoscopic biopsy is limited by frequent false-negative cases. False negative cases are obtained because the tumour tissues are usually covered by gastric mucosa and so the biopsy with standard forceps is too small and too superficial. The ultrasonographic finding of a gastric leiomyosarcoma is variegated, in fact it can be hyperechoic or hypoechoic. Frequently we can see echo-free spaces due to liquefactive necrosis and in such a case, an echogenic rim is demonstrable. According to our experience ultrasonography is very important in post-operative follow-up. The TC study can be considered superior to the other diagnostic investigations, in fact with it, detailed characteristics and location of the tumour, invasivity, metastatic dissemination, are recognized. It is still controversial the criterium concerning the diagnosis of malignant smooth muscle tumour of the gastrointestinal tract. We believe that number of mitoses (having five or more mitotic figures x 10 high-power fields), cellularity, pleomorphism, atypicality, together with macroscopic aspects (size, bleeding, ulcerations, necrosis, invasivity) are the most reliable indicators of malignancy.(ABSTRACT TRUNCATED AT 250 WORDS)

[Thoracic neurinoma: a case of a giant neurinoma]. / Il neurinoma endotoracico: a proposito di un caso di neurinoma gigante.

Having observed 6 cases of benign tumours deriving from nerve sheaths, one of which was of exceptional size (19 x 11 x 10 cm), with an endothoracic localization over the past 5 years, the Authors analyse the etiopathogenetic problems, anatomo-clinical symptoms and the possible methods of treating these endothoracic tumours. Neurinomas represent between 60 and 70% of mediastinal neurogenic tumours which account for 20% of all cancers of the mediastinum. Their typical localization is the posterior mediastinum, along the paravertebral grooves, and the dimensions of these tumours vary between 3 and 8 cm, although on rare occasions they reach 15 cm. In all cases except that of the giant neurinoma, surgery took the form of straightforward enucleation. Follow-up has not revealed recidivation in any of the cases operated.

[Pleuro-pericardial cysts. Case reports and clinical-diagnostic as well as therapeutic considerations]. / Le cisti pleuro-pericardiche. Contributo casistico e considerazioni clinico-diagnostiche e terapeutiche.

Three patients with pleuropericardial cysts are reported. The authors accoding to what exists in literature confirm the congenital origin of this relatively rare pathology. It is benign and rapresents 6-19% of all mediastinal neoplasms. This lesion is more common in adults and prefer IV-VI decade of life. Usually this cyst constitute a casual radiological report because most of these tumours are asymptomatic. In our experience only one case was characterized by dyspnea. The authors, besides, consider CT of great help in diagnosis of pleuropericadial cyst in view of its high specificity. Thoracoscopy, result very important to diagnosis and exeresis of this neoplasm when doubts no persist as to the true nature of the lesion. Surgical treatment of pleuropericadial cyst is the only therapy. In our experience thoracotomy was preferred with excellent results and no postoperative complications or recurrences.

[Spigelian hernia: apropos of two cases]. / L'ernia di Spigelio: a proposito di due casi.

Two observed cases of spigelian hernias in 54 years and 62 years old men leads to an analysis of the diagnostic clinical and therapeutic aspects of this rare abdominal pathology. It represents 1-2% of all abdominal hernias and can occur anywhere along the semicircular line of Douglas, but in 90% of cases its most frequent localization is from the level of the umbilicus to the inguinal area. Diagnosis can be difficult because of non-specificity of symptoms. Many times Spigelian hernia is masked by abdominal fat and the only symptom is pain. TAC plays a primary role in the diagnosis of spigelian hernia, infact with it, detailed characteristiques and location of the hernia, hernial content, other intra-abdominal pathology, are recognized. The only treatment of spigelian hernia is surgical; many times it is diagnostic and therapeutic. A pararectal skin incision permits an accurate exploration of the abdominal cavity and an cautious choice of aponeurosis to the plastic repair.

[Efficacy of continuous intercostal analgesia versus epidural analgesia on post-thoracotomy pain]. / Efficacia del blocco analgesico intercostale continuo versus l'analgesia epidurale nel dolore post-toracotomico.

The authors compare the efficacy of epidural morphine analgesia with continuous intercostal extrapleural block using bupivacaine 0.5% after thoracotomy. They affirm that antalgic treatment in thoracotomised patients is the most important factor in preventing the onset of major complications that may negatively influence the results of surgery. The efficacy of the analgesic techniques examined was evaluated using El-Baz's visual analogic scale of pain, through the analysis of spirometric values and on the incidence of postoperative complications. The authors demonstrate that the extrapleural continuous nerve block is a reliable method of post-thoracotomic analgesia.

[Hamartochondroma of the lung. Apropos 11 cases]. / L'amartocondroma del polmone. A proposito di 11 osservazioni.

The authors take the opportunity of 11 cases of pulmonary hamartomas observed during the last 10 years, to specify the clinical and diagnostic problems and the therapeutic possibilities of this rare pulmonary neoplasm. The hamartochondroma is found mainly in the male sex, between the age of the fifth and sixth decades of life; the size of the neoplasm varies from 2 to 4 cm, rarely exceeding 10 cm. In 8 cases the operation was the simple enucleation of the hamartochondroma or its removal by atypical resection: in only one case, become of the conspicuous dimensions of the neoplasm, was it necessary to perform a typical lobectomy. The follow-up did not demonstrate any relapse, or the appearance of carcinoma of the lung in any of the cases under observation and surgically treated.

[Criteria of choice and long-term results of surgery for plain goiter (author's transl)]. / Criteri di scelta e risultati a distanza della terapia chirurgica del gozzo semplice.

The Authors review their criteria of choice in 95 operations for plain goiter. The explain the parameters used in the evaluation of the various surgical procedures represented in this series, and give an account of long-term results in patients completing the followup period.

[Nipple discharge]. / La mammella secernente.

The Authors examine the various types of breast discharge concentrating in particular on the secretions due to inherent pathology. After having studied origin, they concentrate on the diagnostic significance and the limits of exfoliative cytology and contrast mammography. The Authors conclude by presenting an original protocol of treatment of the afflicted breast illustrating in addition, the various surgical techniques proposed for the cure of the sicknesses of intramammary origin that cause abnormal discharge.

[The automatic stapling devices: a real progress in the resections of pulmonary tissue (author's transl)]. / Le suturatrici meccaniche: un reale progresso nelle exeresi polmonari parenchimali.

The Authors describe their experience in the resections of pulmonary tissue performed with the use of American automatic staples TA and GIA after having illustrated the surgical techniques allowed by them, and in most use, the Authors conclude by reviewing the numerous advantages, both operatory and clinical, of the metallic suture applied by the staplers, which confirm the validity of their use in pulmonary resections.

[Indications and limitations of bronchography in surgery of carcinoma of the lung]. / Indicazione e limiti della broncografia nella chirurgia del carcinoma del polmone.

Starting from a consecutive series of 53 bronchographies performed under local anesthesia, in subjects with carcinoma of the lung ascertained by operation, the Authors analyse both the bronchographical aspects which most frequently come under the surgeon's observation, and the usefulness of this investigation in formulating the operating plan. As regards carcinomas of the large and medium bronchi, the bronchographic aspects they found most frequently are occlusion (82%) both in the form of sudden arrest and in the form of a cone image and stenosis (18%). In peripheral carcinomas, on the other hand, most characteristic bronchographic signs are identified as occlusion (58%) (amputation and stenosis) and dislocation (38%) with rigidity of one or more small calibre bronchi (rigid impairment). On the basis of their experience the Authors conclude that bronchography constitutes an almost indispensable examination for diagnostic purposes in malignant neoplasias, especially in the initial stage, when located outside the field of action of bronchoscopy, and can supply elements indispensable in the preoperative operatability judgement. In fact it not only gives very reliable information on the anatomical situation of the bronchus, as well as on the site and presumed starting-point of the neoplasia, but also supplies more approximate elements with regard to the extent of the neoplasia and any presence of lymphoglandular metastases.

[Clinical and therapeutic considerations on bochdalek's congenital posterolateral diaphragmatic hernia (author's transl)]. / Considerazioni clinico-terapeutiche sulle ernie congenite postero-laterali diaframmatiche di Bochdalek.

The Authors describe 5 cases of Bochdalek's posterolateral diaphragmatic hernia in terms of their clinical, diagnostic, and therapeutic aspects. They also explain their criteria in the choice of surgical approaches and describe reconstruction methods used in the repair of large hernias. Finally, they propose a special schedule of postoperative management to be used in connection with neonatal surgery, where surgical mortality is still high.

[Gastric diverticula]. / Contributo allo studio dei diverticoli gastrici.

The Authors, on the basis of two recently observed cases of gastric diverticula, emphasize its relative rarity and set out the various aetiopathogenetic theories of the disease. In this connection they point out that, apart from congenital alterations, particular importance may attach to gastric dyskinetic factors. The Authors conclude by discussing the diagnostic difficulties posed by gastric diverticula and setting out the modern possibilities of study and therapy of the disease.