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.

Incidence of incisional hernia following emergency abdominal surgery.

BACKGROUND: A retrospective study was conducted to determine incidence and predisposing factors of incisional hernia after an emergency midline laparotomy. PATIENTS AND METHODS: The study population consisted in 197 patients of whom 138 were followed-up for 2 years after surgery. RESULTS: An incisional hernia developed in 25 (18.1%) patients at a mean follow-up of 11.2 months. Multivariate analysis showed the importance of age (> 60 years, p < 0.004), obesity (p < 0.008) and occurrence of post-operative wound infection (p < 0.00001) for the development of an incisional hernia. Univariate analysis showed that intestinal occlusion (p < 0.02), peritonitis (p < 0.006), upper abdominal access (p < 0.04) and post-operative wound infection (p < 0.003) in older patients and obesity (p < 0.003) and the presence of a neoplasm (p < 0.006) in younger patients, played a significant role. The comparison between young and old patients showed that upper abdominal access (p < 0.007), interrupted and layered wound closure (p < 0.02 and p < 0.01, respectively) and contamination of the operative field (p < 0.004) played a statistically significant role in older patients. CONCLUSIONS: The rate of incisional hernia after an emergency midline laparotomy is higher than after elective procedures. However, it could be reduced with proper attention to the suture technique, i.e. mass and continuous suture, better preparation of the operative field and scrupulous sterility throughout the procedure in order to decrease the incidence of post-operative wound infection.

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.

Carotid endarterectomy in young adults: is it a worthwhile procedure?

PURPOSE: The aim of the study was to investigate surgical indication and long-term outcome of carotid endarterectomy (CE) in young adults. METHODS: Between 1973 and 1990, 1693 patients underwent CE. Forty-nine patients (group T) 35 to 45 years of age who had carotid artery stenosis greater than 70%, formed the basis for the analysis. They were compared with two additional groups of patients older than 45 years of age selected from the entire series. Group 2 was randomly chosen to determine differences in risk factors, associated diseases, operative indications, preoperative findings, and outcome. Group 3 was matched with patients in group 1 for sex, risk factors, associated diseases, preoperative findings, and operative indications to assess the importance of age in determining the short- and long-term outcome of CE. RESULTS: Postoperative mortality, cerebrovascular accidents, and cardiac complications in patients of group 1 (2%, 2%, and 2%, respectively) were similar to those of the other groups (p = NS). During the follow-up (76.7 +/- 3.6 months; range, 1 to 120 months) the incidence of strokes and transient ischemic attacks in group 1 was lower than in group 2 (p < 0.05) but similar to group 3 (p = NS). Ten-year disease-free intervals were 75.7%, 58.7%, and 77.6%, respectively, for groups 1, 2, and 3. Mortality rate unrelated to cerebrovascular disease was similar between group 1 and group 3 (p = NS) but was higher in group 1 than in group 2 (p < 0.02). Ten-year survival rates were 46.1%, 71.7%, and 55.5%, respectively, for groups 1, 2, and 3. CONCLUSIONS: CE in patients younger than 45 years of age is a safe procedure with low operative risks and good disease-free intervals. However, life expectancy is poor because of the high incidence of deaths resulting from complications of atherosclerosis.

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.

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.

Emergency transjugular intrahepatic portosystemic shunt in patients with active variceal bleeding and hepatocarcinoma.

Variceal hemorrhage is a leading cause of death in patients with hepatic cirrhosis. We report the case of two cirrhotic patients with hepatocarcinoma in whom oesophageal varices bled repeatedly. Because the bleeding was not controlled by sclerotherapy, vasopressin or Blakemore balloon, the patients were evaluated for emergency transjugular intrahepatic portosystemic shunt. After the procedure, portal vein pressure decreased from 45.5 mmHg to 18 mmHg and from 44 mmHg to 19 mmHg respectively and no filling of varices was evident at venogram or endoscopy. After 16 and 8 months respectively, bleeding had not recurred, and no episodes of encephalopathy were referred. Transjugular intrahepatic portosystemic shunt should always be considered an effective emergency therapeutic alternative to shunt surgery in patients with active variceal bleeding when traditional management fails.

Fatal bleeding after fine-needle aspiration biopsy of the liver.

Ultrasonographic-guided fine-needle aspiration (FNA) biopsy has become a routine diagnostic procedure in the histological evaluation of both focal and chronic liver diseases. It is a safe and low-cost procedure that may be quickly and easily performed by radiologists and gastroenterologists. Severe and unexpected complications, of FNA biopsy, are rarely observed, haemorrhage being the most frequent and often fatal (1,2). This report presents the case of a patient with chronic liver disease who died of massive hemorrhage due to a FNA biopsy complication.

[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.

[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.

[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.

[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.

[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.

[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.

[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.