Timing of early laparoscopic cholecystectomy for acute calculous cholecystitis: a meta-analysis of randomized clinical trials.

BACKGROUND: Early cholecystectomy for acute cholecystitis has proved to reduce hospital length of stay but with no benefit in morbidity when compared to delayed surgery. However, in the literature, early timing refers to cholecystectomy performed up to 96 h of admission or up to 1 week of the onset of symptoms. Considering the natural history of acute cholecystitis, the analysis based on such a range of early timings may have missed a potential advantage that could be hypothesized with an early timing of cholecystectomy limited to the initial phase of the disease. The review aimed to explore the hypothesis that adopting immediate cholecystectomy performed within 24 h of admission as early timing could reduce post-operative complications when compared to delayed cholecystectomy. METHODS: The literature search was conducted based on the Patient Intervention Comparison Outcome Study (PICOS) strategy. Randomized trials comparing post-operative complication rate after early and delayed cholecystectomy for acute cholecystitis were included. Studies were grouped based on the timing of cholecystectomy. The hypothesis that immediate cholecystectomy performed within 24 h of admission could reduce post-operative complications was explored by comparing early timing of cholecystectomy performed within and 24 h of admission and early timing of cholecystectomy performed over 24 h of admission both to delayed timing of cholecystectomy within a sub-group analysis. The literature finding allowed the performance of a second analysis in which early timing of cholecystectomy did not refer to admission but to the onset of symptoms. RESULTS: Immediate cholecystectomy performed within 24 h of admission did not prove to reduce post-operative complications with relative risk (RR) of 1.89 and its 95% confidence interval (CI) [0.76; 4.71]. When the timing was based on the onset of symptoms, cholecystectomy performed within 72 h of symptoms was found to significantly reduce post-operative complications compared to delayed cholecystectomy with RR = 0.60 [95% CI 0.39;0.92]. CONCLUSION: The present study failed to confirm the hypothesis that immediate cholecystectomy performed within 24 h of admission may reduce post- operative complications unless surgery could be performed within 72 h of the onset of symptoms.

Isolated Type Immunoglobulin G4 Sclerosing Cholangitis: The Misdiagnosed Cholangiocarcinoma.

Immunoglobulin G4 sclerosing cholangitis (IgG4-SC), firstly described in 2004, is the biliary manifestation of a recently described multisystem immune-mediated disease known as IgG4-related disease. IgG4-SC is a unique and rare type of cholangitis of unknown etiology and its precise prevalence rate is still unclear. It is characterized by bile duct wall thickening and high levels of systemic serum IgG4 plasma cells. Differential diagnoses for IgG4-SC include benign (primary sclerosing cholangitis) as well as malignant (extra-hepatic cholangiocarcinoma) diseases. Discrimination between these entities is very important, due to the fact that they have different biological behaviors and different therapeutic strategies. The rare IgG4-SC subgroup with its puzzling manifestations carries a hefty diagnostic challenge for the treating physicians, and inaccurate diagnosis can lead to unnecessary morbid surgical procedures. With the paucity and relative weakness of available data in the current literature, one needs to carefully review all available parameters. A low threshold of suspicion is required to try and prevent missing IgG4-SC. IgG4-SC is highly responsive to steroid treatment, especially during the early inflammatory phase, while delay in management could lead to fibrosis and organ dysfunction. On the other hand, cholangiocarcinoma is treated by means of surgery and/or chemotherapeutic agents.

2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis.

BACKGROUND: Acute calculus cholecystitis (ACC) has a high incidence in the general population. The presence of several areas of uncertainty, along with the availability of new evidence, prompted the current update of the 2016 WSES (World Society of Emergency Surgery) Guidelines on ACC. MATERIALS AND METHODS: The WSES president appointed four members as a scientific secretariat, four members as an organization committee and four members as a scientific committee, choosing them from the expert affiliates of WSES. Relevant key questions were constructed, and the task force produced drafts of each section based on the best scientific evidence from PubMed and EMBASE Library; recommendations were developed in order to answer these key questions. The quality of evidence and strength of recommendations were reviewed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria (see https://www.gradeworkinggroup.org/ ). All the statements were presented, discussed and voted upon during the Consensus Conference at the 6th World Congress of the World Society of Emergency Surgery held in Nijmegen (NL) in May 2019. A revised version of the statements was voted upon via an online questionnaire until consensus was reached. RESULTS: The pivotal role of surgery is confirmed, including in high-risk patients. When compared with the WSES 2016 guidelines, the role of gallbladder drainage is reduced, despite the considerable technical improvements available. Early laparoscopic cholecystectomy (ELC) should be the standard of care whenever possible, even in subgroups of patients who are considered fragile, such as the elderly; those with cardiac disease, renal disease and cirrhosis; or those who are generally at high risk for surgery. Subtotal cholecystectomy is safe and represents a valuable option in cases of difficult gallbladder removal. CONCLUSIONS, KNOWLEDGE GAPS AND RESEARCH RECOMMENDATIONS: ELC has a central role in the management of patients with ACC. The value of surgical treatment for high-risk patients should lead to a distinction between high-risk patients and patients who are not suitable for surgery. Further evidence on the role of clinical judgement and the use of clinical scores as adjunctive tools to guide treatment of high-risk patients and patients who are not suitable for surgery is required. The development of local policies for safe laparoscopic cholecystectomy is recommended.

Unexpected Gastrointestinal Tract injury years following Laparoscopic Adjustable Gastric Banding.

INTRODUCTION: Band migration is a late complication of Laparoscopic Adjustable Gastric Banding insertion, although rare it could be life threatening presenting as peritonitis secondary to gastro-intestinal tract injuries. A case of an unexpected extension of severe gastro-intestinal tract injuries secondary to intra-gastric migration and distal band dislocation is reported. PRESENTATION OF CASE: A 53 years old male, with a history of laparoscopic gastric banding 15 years before and known erosion of the band into the gastric lumen was admitted for abdominal pain and raised serum amylase. Imaging revealed dislocation of the band down to the jejunum. Endoscopy and exploratory surgery showed severe decubitus pressure on the gastric antrum up to the duodenum as well as on the pancreas due to rod-like effect of the gastric band catheter and multiple sites of perforation on distal duodenum and small bowel proximal to the band, which migrated within the lumen until 90 cm distal to the Treitz ligament. Extended distal gastrectomy and resection of distal duodenum and small bowel extended to the proximal affected small bowel were necessary. Digestive tract was restored by a gastro-jejunostomy and duodeno-jejunostomy in a Roux-En-Y configuration with duodenal stump closure on tube duodenostomy. A post-operative leakage from the duodenal stump was treated conservatively and the patient was discharged on post-operative day 21. DISCUSSION: Erosion and migration of the band within the digestive lumen is one of the less frequent late complications occurring after LAGB, furthermore, the amount of extensive damage reported in this case presentation has yet to be reported in literature. CONCLUSION: Migration of the band should be considered in the differential diagnosis of abdominal complain in patients with adjustable gastric banding. Such a complication could be severe, and lesions may have unexpected extension requiring complex surgical approach.

Timing of early laparoscopic cholecystectomy for acute calculous cholecystitis revised: Protocol of a systematic review and meta-analysis of results.

Background: Early laparoscopic cholecystectomy has been adopted as the treatment of choice for acute cholecystitis due to a shorter hospital length of stay and no increased morbidity when compared to delayed cholecystectomy. However, randomised studies and meta-analysis report a wide array of timings of early cholecystectomy, most of them set at 72 h following admission. Setting early cholecystectomy at 72 h or even later may influence analysis due to a shift towards a more balanced comparison. At this time, the rate of resolving acute cholecystitis and the rate of ongoing acute process because of failed conservative treatment could be not so different when compared to those operated with a delayed timing of 6-12 weeks. As a result, randomised comparison with such timing for early cholecystectomy and meta-analysis including such studies may have missed a possible advantage of an early cholecystectomy performed within 24 h of the admission, when conservative treatment failure has less potential effects on morbidity. This review will explore pooled data focused on randomised studies with a set timing of early cholecystectomy as a maximum of 24 h following admission, with the aim of verifying the hypothesis that cholecystectomy within 24 h may report a lower post-operative complication rate compared to a delayed intervention. Methods: A systematic review of the literature will identify randomised clinical studies that compared early and delayed cholecystectomy. Pooled data from studies that settled the early intervention within 24 h from admission will be explored and compared in a sub-group analysis with pooled data of studies that settled early intervention as more than 24 h. Discussion: This paper will not provide evidence strong enough to change the clinical practice, but in case the hypothesis is verified, it will invite to re-consider the timing of early cholecystectomy and might promote future clinical research focusing on an accurate definition of timing for early cholecystectomy for acute cholecystitis.

2017 WSES and SICG guidelines on acute calcolous cholecystitis in elderly population.

BACKGROUND: Gallstone disease is very common afflicting 20 million people in the USA. In Europe, the overall incidence of gallstone disease is 18.8% in women and 9.5% in men. The frequency of gallstones related disease increases by age. The elderly population is increasing worldwide. AIM: The present guidelines aims to report the results of the World Society of Emergency Surgery (WSES) and Italian Surgical Society for Elderly (SICG) consensus conference on acute calcolous cholecystitis (ACC) focused on elderly population. MATERIAL AND METHODS: The 2016 WSES guidelines on ACC were used as baseline; six questions have been used to investigate the particularities in elderly population; the answers have been developed in terms of differences compared to the general population and to statements of the 2016 WSES Guidelines. The Consensus Conference discusses, voted, and modified the statements. International experts contributed in the elaboration of final statements and evaluation of the level of scientific evidences. RESULTS: The quality of the studies available decreases when we approach ACC in elderly. Same admission laparoscopic cholecystectomy should be suggested for elderly people with ACC; frailty scores as well as clinical and surgical risk scores could be adopted but no general consensus exist. The role of cholecystostomy is uncertain. DISCUSSION AND CONCLUSIONS: The evaluation of pro and cons for surgery or for alternative treatments in elderly suffering of ACC is more complex than in young people; also, the oldest old age is not a contraindication for surgery; however, a larger use of frailty and surgical risk scores could contribute to reach the best clinical judgment by the surgeon. The present guidelines offer the opportunity to share with the scientific community a baseline for future researches and discussion.

Role of Epidural Analgesia within an ERAS Program after Laparoscopic Colorectal Surgery: A Review and Meta-Analysis of Randomised Controlled Studies.

Introduction. Epidural analgesia has been a cornerstone of any ERAS program for open colorectal surgery. With the improvements in anesthetic and analgesic techniques as well as the introduction of the laparoscopy for colorectal resection, the role of epidural analgesia has been questioned. The aim of the review was to assess through a meta-analysis the impact of epidural analgesia compared to other analgesic techniques for colorectal laparoscopic surgery within an ERAS program. Methods. Literature research was performed on PubMed, Embase, and the Cochrane Library. All randomised clinical trials that reported data on hospital stay, postoperative complications, and readmissions rates within an ERAS program with and without an epidural analgesia after a colorectal laparoscopic resection were included. Results. Five randomised clinical trials were selected and a total of 168 patients submitted to epidural analgesia were compared to 163 patients treated by an alternative analgesic technique. Pooled data show a longer hospital stay in the epidural group with a mean difference of 1.07 (95% CI 0.06-2.08) without any significant differences in postoperative complications and readmissions rates. Conclusion. Epidural analgesia does not seem to offer any additional clinical benefits to patients undergoing laparoscopic colorectal surgery within an ERAS program.

Sonographic diagnosis of acute cholecystitis in patients with symptomatic gallstones.

PURPOSE: The aim of the retrospective study was to assess the diagnostic ultrasound (US) criteria for acute cholecystitis in patients admitted for symptomatic gallbladder stones. METHODS: The medical records of 186 patients who had undergone cholecystectomy within 24 hours after an US examination were reviewed. Acute cholecystitis was defined on the basis of pathology findings. The correlation between standardized US signs and final diagnosis of acute cholecystitis was assessed with univariate and multivariate analyses. The diagnostic values of US based on the correlated signs were then calculated. RESULTS: The prevalence of acute cholecystitis was 52.7% (95% confidence interval [CI], 42.8-64.2). Three US signs were found to be predictive of acute cholecystitis: gallbladder distension, wall edema, and pericholecystic fluid collection. When none of the US signs were registered, sonography proved to have a 72.4% (95% CI, 59.1-83.3) negative predictive value. When registering two or three signs, sonography had positive predictive values of 78% (95% CI, 56.3-92.5) and 100% (95% CI, 58.9-100), respectively. With just one sign, the positive predictive value was 57.6% (95% CI, 47.2-67.4), and such a finding was furthermore observed in only 53.2% of the cases. CONCLUSIONS: The sonografic diagnosis of acute cholecystitis may be achieved by registering only three standardized US signs. Nevertheless, in patients admitted for symptomatic gallstones, US is of some utility in less than half of those patients.

Predictive factors for the diagnosis of severe acute cholecystitis in an emergency setting.

BACKGROUND: The aim of this study was to assess predictive factors for the diagnosis of severe acute cholecystitis. METHODS: The medical records of 295 patients with pathologically confirmed acute cholecystitis were reviewed. Patients were divided, based on pathology findings, into a group with nonsevere acute cholecystitis and a group with severe acute cholecystitis. Preoperative data were compared by univariate and multivariate analyses. Therefore, diagnostic values were assessed based on the statistically significant predictive factors. The same approach was attempted for differential diagnosis between gangrenous and phlegmonous cholecystitis. RESULTS: Among ten variables found to be significantly different at univariate analysis, four were found to be independent predictive factors of severe acute cholecystitis: fever, distension of the gallbladder, wall edema, and preoperative adverse events. Common bile duct stones were confirmed as a protective factor. Leukocyte count, cardiovascular diseases, age, gender, and diabetes were not found to be significant predictive factors of severe acute cholecystitis. No differences were found in any of the preoperative data by comparing phlegmonous and gangrenous cholecystitis. CONCLUSION: Severe acute cholecystitis may be differentiated preoperatively from nonsevere acute cholecystitis based on clinical and US data, and predictive diagnostic values may be estimated according to the number of observed predictive factors. No differences were found when comparing phlegmonous and gangrenous cholecystitis.

Treatment for retained [corrected] common bile duct stones during laparoscopic cholecystectomy: the rendezvous technique.

OBJECTIVE: To determine the feasibility and efficacy of the laparoscopic intraoperative rendezvous technique for common bile duct stones (CBDS). DESIGN: Case series. SETTING: Verona University Hospital, Verona, Italy. PATIENTS: A total of 110 patients were enrolled in the study; 47 had biliary colic; 39, acute cholecystitis; 19, acute biliary pancreatitis; and 5, acute biliary pancreatitis with associated acute cholecystitis. INTERVENTIONS: In all patients, CBDS diagnosis was reached by intraoperative cholangiography. Intraoperative endoscopy with rendezvous performed during laparascopic cholecystectomy for confirmed CBDS; for such a procedure, a transcystic guide wire was positioned into the duodenum. Intraoperative endoscopy with rendezvous was performed for retrieved CBDS during a laparoscopic cholecystectomy. MAIN OUTCOME MEASURES: Laparoscopic rendezvous feasibility, morbidity, postprocedure pancreatitis, and mortality. RESULTS: The laparoscopic rendezvous proved to be feasible in 95.5% (105 of 110 patients). The rendezvous failed in 3 cases of successfully performed laparoscopic cholecystectomy, and a conversion of the laparoscopy was needed in 2 cases of successful rendezvous. Two major complications and 2 cases of bleeding were registered after sphincterotomy was successfully performed with rendezvous, and severe acute pancreatitis complicated a traditional sphincterotomy performed after a failed rendezvous. CONCLUSIONS: Rendezvous is a feasible option for treatment of CBDS; it allows one to perform only 1 stage of treatment, even in acute cases such as cholecystitis and pancreatitis. Positioning of the guide wire may allow reduced complications secondary to papilla cannulation but not those of the endoscopic sphincterotomy.

Minimally invasive treatment of portal hypertension, abdominal aortic aneurysm, and colon cancer: a case report.

Surgical therapy in cirrhotic patients has high morbidity and mortality. Hepatic function and complexity of surgical procedures strongly influence postoperative results. We report the case of a cirrhotic patient with portal hypertension, abdominal aortic aneurysm (AAA), and right colon cancer. After neoadjuvant transjugular intrahepatic portosystemic shunt, we performed 1-stage endovascular aneurysm repair and laparoscopic right colectomy. Minimally invasive surgery allows the effective treatment of high-risk patients with severe comorbidities that some years ago would not have been operated on.

Second surgery for recurrence of malignant pleural mesothelioma after extrapleural pneumonectomy.

BACKGROUND: Extrapleural pneumonectomy is a treatment option for malignant pleural mesothelioma (MPM), but disease recurrence is common. Among different therapeutic options for recurrence, we have found no reports for second surgical procedures. METHODS: We retrospectively evaluated the types and outcomes of surgical management of solid recurrences of MPM, in a series of 74 patients treated with extrapleural pneumonectomy over a 20-year period. RESULTS: Of 57 patients for whom follow-up data were available, 11 patients experienced recurrent disease in the form of a solid mass, 1.5 to 12 years after the initial treatment; 8 of these patients had sufficiently good clinical conditions to undergo a second surgery with curative intent. Chest wall resection was performed in 4 cases of parietal recurrence, radical retroperitoneal resection was done in 3 cases of retroperitoneal relapse, and segmental resection of the remaining lung was done in one case of pulmonary metastasis. In this latter case, although computed tomographic images showed a solid mass, at surgery the disease was found to have a serosal nature, precluding the possibility of a curative surgery. Median survival after the second surgery was 14.5 months (range, 6 to 29); no association between survival and site of recurrence, age or disease-free interval was found. CONCLUSIONS: In this series, the second surgery did not offer the expected survival benefit of curative treatment strategies and should therefore be considered palliative. Second surgery may be a treatment option in a subset of patients who experience a solid recurrence of MPM that is symptomatic or near vital organs and who cannot undergo additional radiotherapy.

Perianal Paget's disease: presentation of six cases and literature review.

PURPOSE: Extramammary Paget's disease (EMPD) is frequently associated with adnexal or visceral synchronous or metachronous malignancies. Our purpose was to evaluate, retrospectively, the results obtained in six cases of EMPD and to review the literature. METHODS: Six patients with the perianal Paget's disease had been treated in our division between March 1996 and December 2006. In three cases, the disease was confined in the epidermis; in one case, there was a microinvasion of the dermis, while in another one the dermis was infiltrated. The last case was associated to a low rectal adenocarcinoma. All patients underwent wide perianal excision and reconstruction with skin graft. We performed a transanal resection of the rectal adenocarcinoma. A review of the literature from 1990 to 2008 revealed 193 cases of perianal EMPD, 112 were intraepithelial/intradermal while 81 were associated with malignancies. Anorectal adenocarcinoma was already existing in two cases, synchronous in 48, and subsequent to diagnosis in 11. RESULTS: In three cases, the disease recurred locally, but no patient developed metastatic spread. Five patients survived and are free of disease. The review of the literature allows a clear identification of the primitive EMPD and the form associated to anorectal adenocarcinoma and little information about cases associated with synchronous adnexal adenocarcinoma. The Paget's disease can relapse after radical surgery and has a capacity of metastatic spread. CONCLUSIONS: Up to now, no clear guidelines have been established for the diagnosis of EMPD. The association with synchronous or metachronous carcinomas imposes a long-term follow-up with frequent clinical, radiological, and endoscopical controls.

[Treatment of the peritoneal carcinomatosis by cytoreductive surgery and intraperitoneal hyperthermic chemotherapy (IHPC): postoperative morbidity and mortality and short-term follow-up]. / Trattamento della carcinosi peritoneale con chirurgia citoriduttiva e chemioipertermia intraperitoneale (IHPC): morbilità e mortalità postoperatorie e risultati a breve termine.

BACKGROUND: In order to treat the peritoneal carcinomatosis from abdominal neoplasms has been recently proposed complete peritonectomy associated with IntraPeritoneal Hyperthermic Chemotherapy (IHPC). AIM OF THE STUDY: Estimate of postoperative morbidity and mortality and short-term outcome. METHODS: Twenty-four patients with peritoneal carcinomatosis or positive cytology at peritoneal washing were treated in our Department from January 2005 to October 2007. Primary tumor was ovarian carcinoma in ten patients: four cases presented peritoneal surface malignancies (PSM) after any time from hysteroadnexectomy related to primary tumor, six cases synchronous PSM. Primary tumor was gastric cancer in seven patients: the peritoneal washing was positive in four cases and, during follow-up period after gastrectomy, other two cases presented PSM. One patient was previously treated with ovariectomy for ovaric mass that resulted a Krukenberg's tumor of gastric cancer. Primary tumor was pseudomixoma peritonei in four patients; cytoreductive surgery and IHPC was carried as first line therapy in only one patient. Three patients were previously treated for colon carcinoma. IHPC was carried out through abdominopelvic cavity for 60 minutes using a closed abdomen technique. The drugs used were Mitomycin C (3.3 mg/m2/L) and Cisplatin (25 mg/m2/L). The intracavitary mean temperature was 41.8 degrees C. RESULTS: The mean Peritoneal Cancer Index (PCI) was 14. Postoperative major complications occurred in 7 cases (28%), postoperative minor complications occurred in 8 cases (32%). No patients died in the postoperative period. Mean hospital staying was 11.5 days ( 6-35 days). After a median follow-up of 8 months (range 2-34), 14 (58%) patients are alive and 13 are disease free. CONCLUSIONS: Our experience is consistent with other studies for the high rate of postoperative morbidity associated with treatment, but we achieved best results on mortality and post-operative staying. CRS associated with IHPC is a good therapeutic option especially in ovaric-related carcinosis and PMP. It' s still debated whether it could be useful or not in colorectal related carcinosis, whereas there is a general agreement in the un uselessness of this technique in gastric cancer.

Concomitant pulmonary carcinoma and abdominal aortic aneurysm: therapeutic strategies.

PURPOSE: A diagnosis of concomitant pulmonary carcinoma and abdominal aortic aneurysm is rare (<1% of treated cases). However, such an association makes the therapeutic decisions critical, especially regarding the priority and timing of treatment. This article reports on our experience of 14 cases of concomitant pulmonary carcinoma and abdominal aortic aneurysm. METHODS: From April 1987 to June 2006 we observed 14 cases of concomitant pulmonary carcinoma and abdominal aortic aneurysm. In patients for whom simultaneous treatment was not indicated due to a poor general condition, priority was given to lung cancer except for cases in which the aneurysm needed an urgent approach. Patients observed after 2000 and scheduled for a two-stage treatment were treated with endovascular procedures whenever possible. RESULTS: Only one patient was treated by a simultaneous aneurysmectomy and a left lower lobectomy, while in the other 13 patients two-stage treatment was performed. Lung carcinoma was operated on first in 7 cases but one patient underwent an urgent aneurysmectomy after chest surgery due to a rupture of the aneurysm. Priority was given to an aneurysmectomy in 2 patients. An endovascular approach was performed in 4 patients, thus allowing a pulmonary resection during the same period of hospitalization, 2 days after 2 uneventful endovascular procedures and on the 6th and 7th postoperative days in 2 cases due to an intraoperative rupture of right iliac artery and type I postoperative endoleak, respectively. CONCLUSION: An endovascular exclusion of the aneurysm may therefore be proposed in order to achieve a concomitant treatment of both diseases. Such an approach excludes complications due to a postoperative rupture of the aneurysm when a pulmonary resection would be first performed; moreover, it does not delay the performance of a pulmonary resection when treatment of the aneurysm is considered to have priority.

Laparoscopic cholecystectomy for severe acute cholecystitis. A meta-analysis of results.

OBJECTIVE: The aim of this review was to evaluate surgical outcomes of laparoscopic cholecystectomy for gangrenous and empyematous acute cholecystitis defined as severe acute cholecystitis. BACKGROUND: It is not known to what extent surgical outcomes of laparoscopic cholecystectomy for severe acute cholecystitis differ from those for the nonsevere acute form, making it questionable whether urgent laparoscopic cholecystectomy is the best approach even in severe acute cases. METHODS: Literature searches were conducted to identify: (1) comparative studies which reported laparoscopic surgical outcomes separately for severe acute and nonsevere acute cholecystitis; (2) studies comparing such an approach with open cholecystectomy, subtotal laparoscopic cholecystectomy or cholecystostomy in severe acute cholecystitis. Results were pooled by standard meta-analytic techniques. RESULTS: Seven studies with a total of 1,408 patients undergoing laparoscopic cholecystectomy were found. The risks of conversion (RR 3.2, 95% CI 2.5 to 4.2) and overall postoperative complications (RR 1.6, 95% CI 1.2-2.2) were significantly higher in severe acute cholecystitis with respect to the nonsevere acute forms. However, no difference was detected as regards to local postoperative complications. No studies comparing open cholecystectomy or cholecystostomy with urgent laparoscopy were found. CONCLUSION: A lower feasibility of laparoscopic cholecystectomy has been found for severe cholecystitis. A lower threshold of conversion is recommended since this may allow to reduce local postoperative complications. Literature data lack valuable comparative studies with other treatment modalities, which therefore need to be investigated.

Intra-thoracic desmoid tumour in a patient with a previous aortocoronary bypass.

BACKGROUND: Intra-thoracic desmoid tumours with mediastinal invasion are very rare. Although rare they have to be taken into account in the differential diagnosis of a thoracic mass and therapeutic options have to be weighted since surgical treatment may require wide excision. CASE PRESENTATION: A 48-year-old male diabetic, dyslipidaemic, former heavy smoker with psychiatric illness was operated by sternotomy for a triple aorto-coronary bypass 4 years before, presented with complains of recent onset such as constant and oppressive chest pain. At surgery a mass extending from the aortic arch into the entire anterior mediastinum and to most of the right pleural cavity was found. The mass was separated from sternal periosteum and vessels of aorto-coronary by pass were isolated starting from the aortic arch up to the pericardium. The histological examination revealed aggressive fibromatosis. CONCLUSION: Although technically demanding, radical surgical excision is actually the most indicated therapeutic approach for intra-thoracic desmoid tumours.

[Robotics in general surgery: personal experience, critical analysis and prospectives]. / La robotica in chirurgia generale: esperienze personali, analisi critica e prospettive.

Today mini invasive surgery has the chance to be enhanced with sophisticated informative systems (Computer Assisted Surgery, CAS) like robotics, tele-mentoring and tele-presence. ZEUS and da Vinci, present in more than 120 Centres in the world, have been used in many fields of surgery and have been tested in some general surgical procedures. Since the end of 2003, we have performed 70 experimental procedures and 24 operations of general surgery with ZEUS robotic system, after having properly trained 3 surgeons and the operating room staff. Apart from the robot set-up, the mean operative time of the robotic operations was similar to the laparoscopic ones; no complications due to robotic technique occurred. The Authors report benefits and disadvantages related to robots' utilization, problems still to be solved and the possibility to make use of them with tele-surgery, training and virtual surgery.

Liver abscess due to acute cholecystitis. Report of five cases.

Acute cholecystitis is one of the most frequent causes of admissions to surgical departments. The development of liver abscesses is an uncommon and underrated complication of acute cholecystitis. In this study we report on our experience with the treatment of 5 cases of liver abscesses secondary to acute cholecystitis. All 5 cases were characterised by a lengthy period between the onset of acute cholecystitis symptoms and the subsequent diagnosis of a secondary liver abscess. In 4 out of 5 patients, admission for liver abscess occurred 12, 30, 50 and 120 days, respectively, after the acute cholecystitis episode. The liver abscesses were successfully treated with percutaneous drainage under US guidance (4 cases) and 4 patients underwent percutaneous cholecystostomy to treat the acute cholecystitis. After resolution of the acute phase, an elective cholecystectomy was performed in 4 out of 5 cases. Failure to diagnose acute cholecystitis at onset or inappropriate treatment of the condition could lead to the development of liver abscesses.

Treatment of gallstone pancreatitis: six-year experience in a single center.

Acute pancreatitis (AP) is a complicated disease in 20% to 25% of cases and carries a mortality of 8% to 15%. Etiologically, the most frequent form is acute biliary pancreatitis. Treatment of such an entity is still controversial, but minimally invasive techniques undoubtedly play an important role. We retrospectively analyze our cases of AP observed from January 1992 to May 1998. Etiology was biliary in 95/125 (76%) cases. In 90 cases we evaluated the patient within a few hours of the onset of symptoms. According to the Ranson criteria, we observed a mild form in 74/90 (82.2%) cases and a severe form in 16/90 (17.8%) cases. Our standard policy was to perform urgent endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy followed by elective laparoscopic cholecystectomy. In particular clinical settings, other modalities of treatment were employed, such as percutaneous cholecystostomy and percutaneous drainage of fluid collections. Successful ERCP was performed in 86/90 cases (95.5%). The procedure was performed in an emergency setting (within 48 hours) in 62/90 cases (68.9%). Whenever the patient was a candidate for surgery, cholecystectomy was performed, laparoscopically in 67/90 cases (74.4%) and via laparotomy in 7/90 cases (7.8%). In only two cases was pancreatic necrosectomy necessary. Globally, we observed a low procedure-related morbidity (6.7%) and no mortality. In the setting of acute biliary pancreatitis, regardless of the severity of the attack, an urgent ERCP + endoscopic sphincterotomy followed by laparoscopic cholecystectomy is safe and could enable successful management of the patient. Associated morbidity and mortality were low. In addition, when indicated, it is possible to treat a great number of concomitant complications with percutaneous ultrasound-guided drainage.