Laparoscopic treatment of blunt splenic injuries: initial experience with 11 patients.

BACKGROUND: Nonoperative treatment of splenic injuries is the current standard of care for hemodynamically stable patients. However, uncertainty exists about its efficacy for patients with major polytrauma, a high Injury Severity Score (ISS), a high grade of splenic injury, a low Glasgow Coma Score (GCS), and important hemoperitoneum. In these cases, the videolaparoscopic approach could allow full abdominal cavity investigation, hemoperitoneum evacuation with autotransfusion, and spleen removal or repair. METHODS: This study investigated 11 hemodynamically stable patients with severe polytrauma who underwent emergency laparoscopy. The mean ISS was 29.0 +/- 3.9, and the mean GCS was 12.1 +/- 1.6. A laparoscopic splenectomy was performed for six patients, whereas splenic hemostasis was achieved for five patients, involving one electrocoagulation, one polar resection, and three polyglycolic mesh wrappings. RESULTS: The average length of the operation was 121.4 +/- 41.6 min. There were two complications (18.2%), with one conversion to open surgery (9.1%), and no mortality. CONCLUSIONS: Laparoscopy is a safe, feasible, and effective procedure for evaluation and treatment of hemodynamically stable patients with splenic injuries for whom nonoperative treatment is controversial.

Inferior vena cava involvement by a left side adrenocortical carcinoma: operative and prognostic considerations.

We report the fifth case of neoplastic involvement of the infrahepatic portion of the inferior vena cava, observed in a young woman affected by a left adrenal cortical carcinoma. The intracaval extension of a neoplastic thrombus from an adrenal tumor is a rare complication that should not be considered a dismal prognostic factor and does not contraindicate tumor resection with curative intent. Caval invasion must be preoperatively investigated to plan the correct surgical access and avoid the risk of neoplastic embolization.

Influence of acute cholecystitis on surgical strategy and outcome of inapparent carcinoma of the gallbladder: a report on two cases.

Unsuspected microscopic adenocarcinoma (T1) of the gallbladder was identified after surgery in two patients who underwent urgent open cholecystectomy for acute cholecystitis. In spite of the tumor being at an early stage both patients died after few months for local and disseminated tumor recurrence. The influence of the associated inflammatory disease of the gallbladder on the outcome of patients with inapparent gallbladder carcinoma is discussed and a more aggressive surgical strategy is suggested.

Influence of blunt needles on surgical glove perforation and safety for the surgeon.

BACKGROUND: Round-tipped blunt needle (BN) may decrease the risk of needlestick injuries and hand contamination. We prospectively determined the incidence of glove perforations in emergency abdominal procedures and the efficacy of BN in increasing the safety for surgeons. METHODS: Two hundred patients were randomized to undergo closure of the abdominal fascia using sharp needle (SN) or BN. Gloves were tested at the end of the procedure. RESULTS: Surgeons had 14 needlestick injuries and 76 perforations recorded in 69 pair of gloves. Sharp needles were responsible for all injuries and 58 (76%) perforations (P < 0.00004 and P < 0.00001, respectively). This difference was still higher when considering the perforations related to the abdominal fascia closure (BN 7% versus SN 50%; P < 0.0006). CONCLUSION: The risk of glove perforation is sevenfold greater if SN are used. Blunt needles reduce sharp injuries and improve safety for surgeons.

Management of abdominal aortic prosthetic graft infection requiring emergent treatment.

The purpose of this study was to investigate mortality and morbidity rates and long-term outcome of patients who underwent emergency treatment of abdominal aortic prosthetic graft infection. Between January 1984 and December 1993, 18 men aged fifty-nine +/- sixteen years were operated on as an emergency for an acute life-threatening complication of aortic prosthetic graft infection. The grafts had been implanted for abdominal aortic aneurysm in 9 patients and aortoiliac occlusive disease in 9, from one to one hundred seventy months previously. Five (28%) patients presented with a hemorrhagic shock due to a fistula between the vascular reconstruction and the small bowel (4 patients) or the right ureter (1 patient) and 13 (72%) had generalized sepsis. The grafts were always radically explanted. Extraanatomic revascularization procedures included 6 axillopopliteal and 12 axillofemoral bypass grafts. Operative mortality was 39% (7 patients), and 3 (9%) limbs were amputated within thirty days. Two (11%) patients died after seven and twelve months, respectively, of septic complications, and 1 (5%) patient died after six months from an unrelated cause. Eight (73%) patients are still alive at a mean follow-up of fifty +/- thirty-four months, but in 3 the extraanatomic bypass was removed for infection and 5 major amputations were performed. Two-year survival and limb salvage rates were 44% and 50%, respectively. Aortic prosthetic graft infections that require emergent treatment continue to demonstrate high early and late mortality and limb loss rates despite aggressive intervention and limb salvage procedures. Newer methods of managing these complications should continue to be investigated.

[Identification and preservation of the parathyroid glands in thyroidectomy using methylene blue]. / La identificazione e conservazione delle ghiandole paratiroidi in corso di tiroidectomia mediante l'uso del blu di metilene.

The risk to the parathyroids in thyroid surgery is widely known. Postoperative parathyroid insufficiency occurs because of accidental devascularization of one or several glands, or infarction due to manipulation, or resection within the thyroid lobe. The prevention of this complication requires a careful surgical technique which limits any injury of the parathyroids. A simple, safe and cheap method to improve the identification of these glands is the preoperative intravenous infusion of methylene blue, that results in a distinct staining of the parathyroids. The authors describe their experience with this useful procedure which helps to reduce the incidence of hypoparathyroidism after total and near total thyroidectomy.

[Palliative treatments in inoperable pancreatic tumors. Technics compared]. / I trattamenti palliativi nei tumori del pancreas inoperabili. Tecniche a confronto.

The authors experience of palliative treatment of advanced pancreatic cancer is reported. 32 patients underwent palliative surgical procedures of biliary decompression (20 choledochoduodenostomy and 12 cholecystoenteric bypass). In 26 patients a gastroenteric anastomosis was also performed. 8 patients underwent non surgical procedure because of their very poor conditions or short term survival. The authors point out the advantages offered by surgical treatment. Nevertheless a careful selection of patients submitted to this procedure is recommended.

[Drainage in surgery on the thyroid]. / Il drenaggio nella chirurgia della tiroide.

The authors report their experience of 534 thyroid operations and underline the importance of neck drainage in this type of surgery. Drainage positioning is very important for the prevention and immediate indication of hemorrhaging complications. Some correct indications, like large goiters, hyperthyroidism, reoperation and the lack of vascular ligature, are considered and discussed.

[Leiomyosarcoma of the small intestine. A rare case of abdominal emergency]. / Leiomiosarcoma dell'intestino tenue. Un raro caso di emergenza addominale.

Small bowel leiomyosarcomas are uncommon potentially curable tumors, unfortunately diagnosed at an advanced stage. The Authors report one case of leiomyosarcoma of the small bowel, with an eight-day history of severe abdominal pain, operated on, in emergency, for perforation with peritonitis. A review of English literature on this subject is reported.

[Primary lymphoma of the rectum: diagnosis and treatment]. / Il linfoma primitivo del retto: diagnosi e trattamento.

The authors report a rare case of primary rectal lymphoma non Hodgkin in a young non HIV infected man. Preoperative diagnostic problems, the standards for classification and staging and the proper treatment are briefly discussed. The importance of an accurate histological and immunohistochemical study on preoperative multiple biopsies for a correct diagnosis, staging and treatment, are emphasised in this report.

[Parathyroid cysts]. / Le cisti paratiroidee.

The Authors review the world literature on parathyroid cysts and report a case of this uncommon disease. The importance of an early pre-operative diagnosis by ultrasound, blood calcium level and parathyroid hormone assay with fine needle aspiration biopsy is pointed out. According to several surgeons, only the functioning parathyroid cysts require operation; needle aspiration may be appropriate therapy for the nonfunctioning ones.

[Role of surgery in the treatment of primary gastric lymphoma]. / Il ruolo della chirurgia nel trattamento del linfoma gastrico primitivo.

Recently the role of surgery in the LGP treatment is reviewed. 30 cases of LGP are reported; GT was in 9 cases performed, GST in 21 cases. All the patients were included in a therapeutical protocol as chemo and/or radio-therapy as adjuvant treatment. Two patients treated with GT died; the medial survival ranged was 30.5 months for the patients in stadium Ie, 52 months for the patients in stadium IIe and 15 months for the patients in stadium IV. The central role of surgery for treatment of this lesion is underlined; finally the role of adjuvant therapy is emphasized in the improvement of long-term survival.

[The treatment of recurrent inguinal hernias by using Marlex mesh preperitoneally]. / Il trattamento delle ernie inguinali recidive mediante l'uso delle reti di Marlex per via preperitoneale.

Several techniques are utilized in the treatment of inguinal hernia: each type of repair offers advantages, but a variable number of recurrences occurs regardless of the hernioplasty technique used. Treatment of hernial recurrence is a troublesome goal for surgeons. Nowadays, the use of prosthetic materials with a posterior surgical approach simplifies and resolves most of the problems encountered in the past. The authors report their experience with the use of Marlex mesh for hernia repair through a preperitoneal approach pointing out the advantages of such prosthetic material and of the surgical access as well. Finally, the importance of patients selection is stressed.

[Hürthle cell tumors: personal experience]. / Tumori a cellule di Hürthle: esperienza personale.

Hürthle cell tumors of the thyroid gland are uncommon lesions (3% of all well differentiated tumors). Histological diagnosis is often difficult: according to recent criteria only those tumors with almost 75% of oxyphil cells are well recognized as Hürthle cell neoplasms. Extracapsular and blood-vessels invasion, capsular penetration, DNA patterns and tumoral necrosis are indicative for malignancy. The Authors report their experience in the management of 46 patients who underwent thyroid surgery for Hürthle cell neoplasms. Histological findings, surgical approach and post-operative follow up are discussed.

[Neurogenic tumors of the brachial plexus]. / I tumori neurogeni del plesso brachiale.

The Authors report two cases of solitary neurogenic tumors of the brachial plexus not associated with Von Recklinghausen's disease. Peripheral nerve tumors are relatively rare and only 25% occur above the clavicles. The mass, usually asymptomatic, may cause sensory radicular symptoms or rarely motor deficits in the involved arm. Wide radical excision of a benign neurogenic tumor is the treatment of choice; for malignant tumors, associated with a particularly poor prognosis, a more aggressive surgical approach may be necessary. Adjuvant radiation therapy and chemotherapy do not seem to have any effect on survival rates.

[Respiratory complications in compressive goiters]. / Complicanze respiratorie nei gozzi compressivi.

Authors' experience in respiratory complications of compressive goiter is reviewed. Three cases with typical symptoms, relative therapy and outcome are reported. Appearance of respiratory distress should urge to avoid delay in elective surgery performing. In case of acute respiratory failure, immediate emergency tracheostomy is mandatory, subsequently followed by elective intervention. In case of malignancy, if radical surgery is not possible, tracheostomy is the short and medium-term palliative surgical treatment of choice.

[Carcinoma of the splenic flexure]. / Il carcinoma della flessura splenica.

The Authors report their experience in the management of 25 cancers of the splenic flexure corresponding to 4.8% of large bowel cancers overall observed. Twelve patients underwent elective surgery consisting in a left hemicolectomy, which in 1 of the 12 cases required an associated distal splenopancreatectomy. Operative mortality was null, whereas morbidity involved 1 case of anastomotic dehiscence. Thirteen patients presenting with complete obstruction underwent emergency surgery: a two-stage resection with primary colostomy was performed in 5 cases, a sub-total colectomy with one-stage ileo-rectal anastomosis or ileo-sigmoid anastomosis was performed in 8 cases. In this last group of 8 patients mortality rate was 12.5% (1 pt.) and diarrhoea was the most important sequela. On this regard the Authors point out the opportunity to perform an ileo-sigmoidostomy, which reduces the incidence of such complication.

[Varicose veins of the lower limbs caused by incompetence of the saphenous-femoral ostium: standard or complete stripping?]. / Le varici degli arti inferiori da incompetenza dell'ostio safeno-femorale: stripping corto o completo?

The Authors report their experience of 256 stripping operations performed during the last 3 years for varicose veins of the lower extremities. Preoperative Doppler examination was used to detect reverse flow in the saphenous veins. Removal of the entire saphenous trunk was performed in 158 limbs with segmental or total reverse flow; in the remaining 98 cases with reflux only in the proximal tract of the saphenous vein a selective stripping operation and, five weeks later, phlebectomy of remaining varicosities were performed. The results were assessed by follow-up examination from 6 months to 3 years. When there is a specified indication, the selective stripping operation appears to be an excellent and aesthetic solution with a very low incidence of saphenous nerve's injuries. Useful advice to obtain the best results with the traditional stripping operation are also pointed out.