Treatment of abdominal aortic aneurysms associated with pancreatic tumors: personal experience and review of the literature (1967-2006).

The aim of the present study was to discuss the approach to a rare, but challenging, clinical situation: the coexistence of an abdominal aortic aneurysm (AAA) and a pancreatic tumor. The authors present their experience and a review of the literature of the last 40 years. From January 1988 to December 2006 the authors faced 3 cases of associated AAA and pancreatic neoplasia. Through a Medline search the authors found 15 cases of this comorbidity reported in the literature from 1967 to 2006, obtaining a total number of 18 cases. The treatment of the two diseases was in a single stage in 4 cases (22%) and in two stages in 5 cases (28%), while only one pathology was treated in 7 cases (39%) and no treatment at all was attempted in 2 cases (11%). Mortality was 0%, while morbidity was 22%, i.e. in 4 cases out of 18, although no aortic prosthesis infection was recorded. From literature analysis and their experience the authors concluded that the surgical strategy in cases of AAA and a pancreatic tumor is to be chosen depending on the pancreatic tumor prognosis, the AAA dimensions and the schedule of chemotherapy. According to the authors, AAA surgical repair is recommended in case of pancreatic cystic adenoma and neuroendocrine neoplasia, in view of their good prognosis, while endovascular repair (EVAR), when feasible, is better in patients with pancreatic adenocarcinoma.

Cystadenoma and laparoscopic surgery for hepatic cystic disease: a need for laparotomy?

BACKGROUND: This study aimed to evaluate the incidence of cystadenoma diagnosis in a series of laparoscopic treatments for nonparasitic liver cysts, as well as its management. METHODS: From 1996 to 2004, 26 patients with a nonparasitic cyst of the liver were selected for laparoscopic liver surgery. Solitary nonparasitic liver cysts were, whenever feasible, completely enucleated. RESULTS: In four patients, the histopathologic examination showed a cystadenoma. Three patients with 13, 9, and 12-cm cysts, respectively, had undergone complete enucleation of the lesion, with no evidence of recurrence in the follow-up visit. One patient with multicystic liver experienced a recurrence and required an open hepatic resection. CONCLUSIONS: When a complete laparoscopic enucleation of the cyst can be ensured, a strict follow-up assessment should be considered as the definitive treatment, with surgical intervention demanded only in the case of recurrence or high suspicion for malignancy.

Laparoscopic treatment of simple hepatic cysts and polycystic liver disease.

BACKGROUND: The authors present their experience in the laparoscopic management of hepatic cysts and polycystic liver disease (PLD). METHODS: Between January 1996 and January 2002, 16 patients underwent laparoscopic liver surgery. Indications were solitary giant cysts (n = 10) and PLD (n = 6). Data were collected retrospectively. RESULTS: Laparoscopic fenestration was completed in 15 patients. Median operative time was 80 min. There was no deaths. Complications occurred in four patients: one patient with a solitary liver cyst experienced diarrhea, while a pleural effusion, a bleeding from the trocar-insertion site, and ascites occurred in three patients with PLD. Median follow-up was 34 months. There was one asymptomatic recurrence (11%) in one patient with a solitary cyst. Two patients with PLD had a symptomatic recurrence of a liver cyst. CONCLUSION: Laparoscopic fenestration could be the preferred treatment of solitary liver cysts and PLD. Adequate selection of patients and type of cystic liver together with a meticulous surgical technique are recommended.

[Timing in disorders associated to tracheo-pulmonary pathology]. / Timing nelle affezioni in associazione a patologie tracheo-polmonari.

Although a wide variety of extrathoracic pathologies may be associated to tracheo-pulmonary lesions, this paper draws attention to tumour pathologies due to their frequency and the difficulties involved in their treatment in relation to the question of "whether to carry out treatment" as well as the importance of timing. This dual nature is particular true of malignant conditions, since the lung may be the site of primary tumours and metastasis. The most frequent associations reported in the literature are tumours of the upper airways-digestive tract and colon carcinoma. Although tumours of the upper airways-digestive tract and lung cancer are both primary and primary tumour must be given priority treatment and only when oncologically satisfactory results have been obtained and there is no evidence of metastasis in other sites, are lung metastases. As far as concerns tracheal pathologies, this often takes the form of a locoregional extension of tumours from nearby organs such as the thyroid gland. In these cases, it is preferable to carry out total thyroidectomy and tracheal resection using T-T anastomosis.

[Stomach rupture due to barotrauma (a report of the 13th case since 1969)]. / Rottura dello stomaco da barotraumatismo (descrizione del tredicesimo caso dal 1969).

The thirteenth case of rupture of the stomach after a diving accident since 1969 is reported. This rare event was caused by equipment failure and panic reaction, which induced swallowing air during diving and consequential gas expansion in gastric cavity meanwhile the rapid ascent. Peritoneal decompression by paracentesis quickly improved the patient's condition and the following surgical laparotomy revealed a gastric tear along the lesser curvature, which was closed by suturing. The patient presented a postoperative splenic abscess two months later; literature demonstrated that rupture of a filled stomach may lead to septic complications.

[Emergency surgery in inflammatory bowel disease. Experience in 26 cases]. / La chirurgia in urgenza delle malattie infiammatorie croniche intestinali. Esperienza su 26 casi.

BACKGROUND: The emergency surgical treatment of inflammatory chronic bowel diseases is closely related to the classification of patients according to their symptoms and clinical conditions, as well as possible surgical options. In our study, an actual set of criteria is proposed for the classification of the degree of seriousness of symptoms, related to patient conditions, and applicable surgical strategies. METHODS: Retrospectively evaluation of the outcome of the disease has been performed over 26 patients undergoing emergency treatment in our Hospital, and with at least 5 years of follow-up. Fourteen patients were affected by ulcerative rectocolitis and 11 underwent subtotal colectomy with ileostomy; the remaining 12 were affected by Crohn's disease and were treated with colic or ileal local resection. RESULTS: Among 11 operated patients with RCU, 6 toxic megacolon, 4 severe colitis and one perforation (postoperative death) have been diagnosed. Recanalization was possible in 8 patients. On the other hand proctectomy was necessary in the remaining 3 patients as final operation. In MC patients 6 occlusions, 4 severe colitis, one multiple perineal fistulization and one perforation of occult right colon tumor have been diagnosed. We performed 5 right colectomy, 4 jejuno-ileal resections, one Hartmann's operation, one colostomy in emergency and one multiple bypass. Because of recurrence, one right colectomy needed following total colectomy and two jejuno-ileal resections needed right colectomy soon after. Three jejuno-ileal resections were performed with a conservative purpose in patients treated by right colectomy. CONCLUSIONS: It has resulted that in ulcerative rectocolitis total colectomy actually permits an adequate control of the disease, as well as a satisfactory therapy of the rectal stump, with subsequent recanalization in the majority of cases, whereas in Crohn's disease the frequency of recidive is higher and it seems more advisable to opt for a radical resection treatment (chiefly right colectomy), but with a conservative purpose.

Liver transplantation. A summary of our surgical practice.

At the turn of the new century, liver transplant procedures can finally be considered an efficient treatment option. Technology has helped transplant intervention become a preferred treatment for patients with progressive and irreversible liver failure. New immuno-suppressive drugs have been introduced which reduce the patient's immunological reaction to the implanted organ, entail minimal side effects and improve practical applications of liver transplantation. As a result of these technological advanced and proper disease management, liver transplant procedures are no longer thought of as an elite therapy, reserved for selected patients with end stage liver disease. In our opinion, it is now a sound and valid surgical option with strictly defined characteristics, indications and well-understood limits. Throughout the past decade, we have studied and applied this type of intervention and have come to terms with its rapid expansion at both the theoretical and practical levels. The most significant obstacle remaining today is the discrepancy between the ever increasing demand and limited supply of organs. The future of liver transplant lies in overcoming this obstacle. Liver transplant practice began at our Institute on 23 November 1990 with the first surgical intervention to replace an organ. In the past 10 years, we have exceeded 200 liver transplant procedures.

[Lithiasic, congenital, choledochal dilatation: problems of diagnosis and therapy]. / Dilatazione coledocica congenita litiasica: problemi di diagnosi e di terapia.

We report a case of a 30-year old female with congenital lithiasic choledochal dilatation which was not diagnosed at the ultrasonographic examination. Congenital biliary dilatation abnormalities are rare and may clinically present with episodic biliary colics or more rarely with recurrent pancreatis. Ultrasound, CT-scanning and ERCP usually make these anatomic alterations evident but in some cases there may be some doubt despite the vast range of radiological techniques available (PTC, Tc99m-Isida scinti-scan). The best results from a diagnostic point of view are obtained from the ERCP that may in fact visualize an anomalous pancreatico-biliary junction, rule out carcinoma, accurately define the cyst dimensions or show the intrahepatic ductal radicals. Furthermore, the extraction of intracystic stones or the treatment of choledochocele through a papillostomy may be performed. However the ERCP may cause traumatic pancreatitis, above all in youngster as was verified in our patient. During surgical exploration, the definitive diagnosis can be achieved via intraoperative cholangiography. We emphasize that in patients with congenital choledochal dilatation, the dilated choledochus should be excised even in young children to avoid the risk of malignancy which may occur also following cyso-duodeno- or cystojejunostomy treatment. In our patient an hepatiocojejunostomy on a Roux-en-Y limb was performed. This single case has been oresented along with a review of the literature to recall such anomalies in differential diagnosis of biliary colics and to stress that the choice treatment is surgical resection.

Importance of the mode of intravenous administration on cephotaxime concentration in bile. A comparison of bolus, drip infusion and bolus plus drip infusion.

Success of antibacterial therapy depends on many factors, among which the level reached at the site of infection is important. Drug concentration in tissues and body fluids can be related to the mode of administration. The aim of the present work was to study the levels of cephotaxime (CFX) in bile, after intravenous administration of 1 g by bolus, drip infusion and bolus plus drip infusion. The drug was detected by a microbiological method. The results indicate that passage of CFX from blood into bile is a carrier-mediated process, and bolus, in the case of CFX, is the best mode of administration.

Surgical management of tracheal stenoses: personal experience with 105 cases.

A 10-year experience with 105 tracheal lesions is reported. Of these, 61 were inflammatory stenoses (27 post-tracheotomy, 26 post-intubation, 6 mixed and 2 post-irradiation), 30 neoplastic stenoses, 12 traumatic lesions and 2 degenerative lesions. The therapeutic approach should consider the type, site, extension and multifocality of the lesion. In inflammatory stenoses resection followed by end-to-end anastomosis was performed: resection with Montgomery T-tube in 16, and laryngeal release in 3 since the resected portion was extensive. In neoplastic forms it is necessary to utilize techniques (Montgomery or laser) which permit the respiratory lumen to remain open since surgery is not always possible. As for traumatic lesions in 4 cases resection followed by end-to-end anastomosis, in 5 a simple suture of a lesion and in 3 intubation, was performed. This experience showed that the treatment of choice for tracheal stenoses is resection with primary anastomosis. The Montgomery T-tube prosthesis and laser therapy were also effective.