Laparoscopic ultrasound-guided resection of gastric submucosal tumors.

BACKGROUND: The laparoscopic resection of gastric stromal tumors is being performed with increased frequency. Wedge resection of anterior wall lesions is generally performed. The treatment of posterior wall lesions is still controversial. METHODS: We report three cases of gastric submucosal tumors treated by a laparoscopic wedge resection of the stomach. All lesions were localized anterior gastric wall by intraoperative ultrasound on the. In the first patient the resection was performed with an endoscopic stapler; in the other patients, ultrasonic coagulation in association with an intracorporeal suture has been used. RESULTS: All patients were successfully treated laparoscopically; there were no conversions to open surgery. In all cases the operative course was uneventful. The postoperative hospital stay ranged from 6 to 8 days. CONCLUSIONS: The results suggest that laparoscopic surgery is an adequate strategy for gastric submucosal neoplasms including gastrointestinal stromal tumors (GIST). Intraoperative ultrasound is very useful in the selection of the technical approach with or without the endoscopic stapler.

Factors predicting chronic hepatic encephalopathy after distal splenorenal shunt: a multivariate analysis of clinical and hemodynamic variables.

BACKGROUND: This study was aimed at evaluating several factors that promote chronic hepatic encephalopathy by multivariate analysis of data for patients with cirrhosis with good or moderate liver function submitted to distal splenorenal shunts. METHODS: The study group comprised 131 patients: 55 had alcoholic and 76 nonalcoholic cirrhosis. Seventy patients were in Child's class A and 61 in class B. Cerebral function was assessed by a complete neurologic examination. Angiography with venous phase was performed before and within 1 month after the shunt operation. In 84 cases the original Warren technique was used and in 20 cases a Britton's modified procedure was used. Twenty-seven patients had distal splenorenal shunts with a splenopancreatic disconnection. Statistical analysis was performed by two multivariate analyses based on stepwise selection. RESULTS: Thirty-nine patients died during a follow-up period of 51 +/- 32 months. Chronic encephalopathy occurred in 18 patients (14%). According to the multivariate analysis of the preoperative prognostic factors, only age (p = 0.0001) and albumin values (p = 0.0002) were independent predictive risk factors for chronic encephalopathy. In the multivariate analysis concerning the hemodynamic consequences of the selective shunts, independent risk factors promoting chronic encephalopathy were postoperative portal perfusion (p = 0.0001), postshunt portal pressure (p = 0.001), and surgical disconnection (p = 0.0064). CONCLUSIONS: Our study has shown that chronic encephalopathy after selective shunt surgery is promoted by both clinical and hemodynamic factors. A better selection of the candidates for shunt surgery and prevention of the development of portal malcirculation by accurate surgical disconnection should further decrease the risk of chronic encephalopathy.

The efficacy and safety of moguisteine in comparison with codeine phosphate in patients with chronic cough.

We conducted a multicentre, double-blind, parallel group study to compare the clinical efficacy of a new antitussive drug, moguisteine (100 mg t.i.d.), to that of a reference standard, codeine (15 and 30 mg, t.i.d.). Both drugs were given orally for a period of two days. A group of 119 patients (mean age 54 yrs; 61 females and 58 males) with chronic, dry or slightly productive cough, associated with various respiratory disorders (including chronic obstructive pulmonary disease, respiratory malignancies and pulmonary fibrosis) were enrolled at six participating centres. The percentage reduction in the number of morning coughs over a period of 6 h after the first administered dose compared to baseline assessment, was 21% with moguisteine (n = 39), 28% with codeine 15 mg (n = 38), and 29% with codeine 30 mg (n = 36). Differences between treatments were not significant. The percentage reduction in the number of nocturnal coughs per hour, after the last evening dose compared to baseline assessment, was 33, 46 and 52%, respectively. Subjective assessments (patients' visual analogue scale scores of cough frequency, cough intensity and sleep disturbance, and investigators' ranking of cough severity) indicated that there was a similar improvement in cough symptoms in all treatment groups. Adverse events were observed in two patients on moguisteine, three on codeine 15 mg, and five on codeine 30 mg. No event was serious, but discontinuation of treatment was required in two patients on codeine 30 mg. The results of our study suggest that moguisteine 100 mg t.i.d. is safe, and seems to have an antitussive activity similar to that of codeine 15-30 mg t.i.d.

[Surgery in the cirrhotic patient. Prognosis and risk factors]. / La chirurgia nel paziente cirrotico. Prognosi e fattori di rischio.

Patients with cirrhosis have reduced life expectancy. Surgery is often associated with clinical decompensation in this group of patients. The purpose of this paper is to study the surgical risk in cirrhotic patients undergoing nonderivative operations. Unfortunately, most of the studies in the literature about this problem are retrospective reviews with limitations. The conditions increasing surgical risk in cirrhotic patients are analysed. These include changes in the pharmacokinetics and pharmacodynamics of various drugs, altered hemostasis, poor resistance to infections, water retention, suture line insufficiency, chronic renal failure and congestive heart failure. Assessment of the disease stage in cirrhosis is very important, because the severity of hepatic abnormalities influences the prognosis. The Child-Pugh classification has been used extensively to risk-stratify patients with cirrhosis. However, the disregard for cardiorespiratory, renal, electrolyte balance and acid-base status limits its predictive accuracy. Recently a new scoring system, the Acute Physiology and Chronic Health Evaluation (APACHE III), has been introduced and seems to be superior to Child-Pugh for prognosticating short term survival of cirrhotic patients. In conclusion, surgery can be done safely only in cirrhotic patients with a good hepatic function. On the contrary, in patients with advanced cirrhosis, surgery causes a very high mortality. Finally, the patients with moderate hepatic failure can be operated only after a careful study of the disease and an adequate correction of the reversible risk factors.

[Surgical treatment of varicocele with inguinal microligation technique. 6-year experience]. / Il trattamento chirurgico del varicocele con tecnica di microlegatura inguinale. Sei anni di esperienza.

BACKGROUND: Varicocele is found approximately in 15% of the male population and is considered a major cause of infertility. Varicocele management include surgical (traditional or laparoscopic) or conservative techniques (sclerotherapy). The authors present their experience on microsurgical inguinal varicocelectomy. This technique has been adopted since 1992 to decrease the incidence of recidives of high spermatic vein ligation; it also permitted to use local or loco-regional anesthesia, reducing time of hospitalization and realizing a minimally invasive approach. METHODS: From 1992 to 1997, 433 microsurgical inguinal varicocelectomy with artery and lymphatic sparing have been performed at the Militar Hospital of Milan in 409 young men with idiopathic varicocele. All patients were discharged 24 hours after operation. Only those who lived particularly far from the hospital remained for 48 hours. RESULTS: Clinical controls were performed I, III, VI months after operation. At the third control (VI month), a new semen analysis was performed, and 65% of patients had an improvement of seminal characteristics. In 394 patients, a complete resolution of varicocele was observed; 4 patients had a recurrence of the pathology and 11 had a recidive. Seventy-three patients who presented a concomitant homolateral inguinal hernia were treated at the same time. CONCLUSIONS: The conclusion is drawn that microsurgical ligation of spermatic veins represents a good surgical option in the treatment of varicocele. It is a quite simple technique that guarantees a low risk of recidives, permits using local or loco-regional anesthesia and can be performed in day-surgery with good results, few complications and good short and long term results.

[Role of surgical therapy in the treatment of refractory ascites]. / Ruolo della terapia chirurgica nel trattamento dell'ascite refrattaria.

In 5-10% of cases ascites is not controlled by medical therapy and is defined refractory. These patients may be submitted to one of the four following surgical options: portal-systemic shunt, peritoneo-venous shunt, transjugular intrahepatic portal-systemic shunt, orthotopic liver transplantation. Although the portal-systemic shunt is efficient in clearing ascites, it does not improve the survival, which depends on liver function, and it is complicated by an important incidence of encephalopathy. Since the patients with refractory ascites and good hepatic risk are not usually many, it is possible to understand why derivative surgery has been disappointing with this indication. Although the peritoneo-venous shunt is associated with a significant rate of valve obstruction, it is an easy, effective and not expensive treatment. So, till now, it has been considered the first choice procedure of refractory ascites, if any situations, determinating the onset of postoperative complications, are not present. Recently a new method has been introduced in the therapy of portal hypertension, the transjugular intrahepatic portal-systemic shunt. This is a bloodless portal-systemic derivation and so it has caused great enthusiasm even if the available data are insufficient to give a definitive opinion on its role in management of ascites. Certainly the liver transplantation, which presents the great advantage to treat both the cirrhosis and its complications, seems to be the most rational therapy for these patients. However, at least for this moment, the well-known absence of organ donors makes still actual the palliative surgical measures.

Surgical and radiologic treatment of primary Budd-Chiari syndrome.

Budd-Chiari syndrome (BCS) is an uncommon form of portal hypertension caused by obstruction of the hepatic venous outflow. From 1969 to 1997 we treated 19 patients (7 men, 12 women; mean age 37.6 years) affected by primary BCS. In most of the cases no etiologic factors were identified; in the remaining cases the etiology was associated with polycythemia vera, use of oral contraceptives, presence of endoluminal membranes, and repeated episodes of sepsis. Three patients with membranous occlusion of the major hepatic veins were treated by percutaneous placement of a self-expanding metallic stent inserted via a transjugular or transhepatic approach. The remaining 16 patients underwent a side-to-side portacaval shunt, which required interposition of a graft in five cases. In two patients with a significant caval obstruction, a metallic vascular stent was placed in the narrowed tract of the inferior vena cava, before shunting, by means of a transfemoral venous approach. One patient died within the first 30 postoperative days. The 18 survivors were followed for a mean of 66.7 months. The 5-year survival was 83%. Primary BCS requires different therapies depending on the stage of the disease. The fulminant or chronic forms with irreversible hepatic damage require definitive treatment, such as orthotopic liver transplantation. For the acute or subacute forms, characterized by reversible hepatic injury, a portasystemic shunt represents the most effective treatment. The patients at poor hepatic risk can be treated by interventional radiology. In both cases preliminary caval stenting is necessary if the syndrome is complicated by significant obstruction of the inferior vena cava.

Gasless laparoscopic resection of hepatocellular carcinoma (HCC) in cirrhosis.

Liver resection by open surgery remains the method of choice for treatment of hepatocellular carcinoma (HCC) in cirrhotic patients with compensated liver function. Laparoscopy for surgical treatment of hepatic diseases is at an early stage. Laparoscopy has been often proposed for diagnosis, staging of hepatic malignancy, treatment of hepatic cyst or benign tumors, but very few laparoscopic treatments of hepatic malignancies have been reported at present and always using conventional CO2 laparoscopy. We describe herein the operative treatment of a single subglissonian HCC of segment III in a child, HCV (hepatitis C virus)-related cirrhosis. A nonanatomical wedge resection was performed by gasless laparoscopic technique using a mechanical retractor obviating the creation of the pneumoperitoneum and of the sealed environment. The technique, in selected cases, is a simple, safe, and effective surgical method. The gasless technique guarantees a clear vision, it makes possible the continuous suction of smoke and fluids, it allows the use of conventional instruments for classic maneuvers of the liver surgery (Pringle maneuver), and the easy management of suturing. The present case has proved to be another abdominal procedure that can be carried out with all the advantages of gasless minimally invasive surgery.

Complications of subcutaneous infusion port in the general oncology population.

Subcutaneous infusion ports (SIPs) represent a valid method for long-term chemotherapy. The SIPs have several advantages over other methods of venous access: they are easy to implant under local anaesthesia, have less discomfort for the patients, allow low costs, can be implanted in day hospital, and can be managed ambulatorily. However, SIPs have delayed complications, frequently related to clinical conditions of the neoplastic patients, and immediate complications, often due to the placement technique. From March 1992 to March 1997 we placed, under local anaesthesia and under fluoroscopic control, 102 SIPs in 99 general oncology patients for long-term chemotherapy (88% solid, 12% haematological tumours). The percutaneous venous access devices were in the subclavian vein in 96% of the cases and in the internal jugular vein in 4% of them. Immediate complications were: 1 haemopneumothorax, which required thoracic aspirations and two blood transfusions, 1 loop of the tunneled part of the catheter without alterations in SIP function, and 1 left jugular thrombosis in a patient with subclavian veins already thrombosed. The venous access was in the subclavian vein in the first 2 cases, and it was not necessary to suspend the therapeutic program. In the third instance, implanted in jugular vein, it was necessary to remove the SIP. Delayed complications were: 1 necrosis of the skin over the port, 1 infection of subcutaneous pocket, 2 infections of the system, 1 catheter deconnection, and 3 catheter ruptures with embolization of the catheter tip. The SIPs were removed in all cases but 1 in whom infection was successfully treated by appropriate antibiotic therapy. Embolization of the catheter required removal from the pulmonary artery under fluoroscopic guidance in the cardiac catheterization laboratory. In conclusion, infection and thrombosis are the two major complications of SIP in general oncology patients. In these cases it is not necessary to remove systematically the system, but a correct therapy (antibiotic, fibrinolytic agents) can be utilized with good results. The catheter rupture is often due to the wear over the costoclavicular angle. The interventional radiology is the method of choice in the treatment of the catheter embolization by rupture or dislocation. The experience of the surgical and nursing staff is probably the most important factor in decreasing the total rate of complications.