Behaviour of the bowel wall during the first year after surgery is a strong predictor of symptomatic recurrence of Crohn's disease: a prospective study.

BACKGROUND: Recurrences after surgery for Crohn's disease are frequent and unpredictable. To date, there is little agreement as to which factors increase a patient risk of early recurrence. AIM: To assess whether the post-operative behaviour of diseased bowel walls, as determined by ultrasound, may be a useful predictor of relapse. METHODS: A total of 127 Crohn's disease patients were monitored after surgery by means of bowel ultrasound as well as by clinical and laboratory evaluations for a median follow-up of 41.0 months. Bowel wall thickness of diseased loops measured at ultrasound during follow-up was compared with the presurgery values. Multivariable survival analysis was performed to elucidate predictors of early post-operative recurrence. Receiver operating characteristic curves were also constructed taking into account bowel wall thickness for selecting Crohn's disease patients with high risk of clinical/surgical recurrence. RESULTS: The estimated 5 years survival probability of symptomatic Crohn's disease recurrence were 90% and 33%, respectively for unchanged/worsened bowel wall thickness vs. improved bowel wall thickness at 12 months from surgery. The hazard ratio for unchanged/worsened bowel wall thickness at 12 months was 8.9 (95% CI: 3.4-23.2). Receiver operating characteristic curve identified a bowel wall thickness > 6.0 mm at 12 months from surgery as directly associated with the risk of having a Crohn's disease recurrence (hazard ratio was 6.5, 95% CI: 2.8-15.4). CONCLUSIONS: Systematic ultrasound follow-up of diseased bowel walls after conservative surgery allows the early identification of patients at high risk of clinical/surgical recurrence.

Small bowel stenosis in Crohn's disease: clinical, biochemical and ultrasonographic evaluation of histological features.

AIM: To establish whether intestinal ultrasound, clinical or biochemical indices of activity can assess histological features of ileal stenosis in Crohn's disease. METHODS: In 43 patients undergoing surgery for a single ileal stenosis, clinical and biochemical parameters, as well as intestinal ultrasound, were assessed prior to surgery. The echo pattern of thickened bowel segments at the site of stenosis was classified as hypoechoic, stratified or mixed (segments with/without stratification). During surgery, stenoses were identified, resected and then histologically examined using standardized criteria. RESULTS: Clinical and biochemical indices of activity showed an overall weak positive correlation with histological inflammatory parameters and a negative correlation with fibrosis. The intestinal ultrasound echo pattern at the stenosis site was stratified in 25 patients, hypoechoic in 14 and mixed in four. Stenoses characterized by a stratified echo pattern showed a significantly higher degree of fibrosis, those characterized by hypoechoic echo pattern showed a higher degree of inflammation, while stenoses with a mixed echo pattern showed high degrees of both fibrosis and inflammation. CONCLUSION: Ultrasound and, to a lesser degree, clinical and laboratory indices discriminate between inflammatory and fibrotic ileal stenoses complicating Crohn's disease, thus allowing appropriate medical and/or surgical treatment to be defined.

[Surgical options in the treatment of perianal Crohn's disease]. / Opzioni chirurgiche nel trattamento della malattia di Crohn a localizzazione perianale.

INTRODUCTION: About 40% of patients with Crohns disease (CD) have a perianal involvement. Despite the recent introduction of anti-TNF antibody, this therapy has uncertain long-term results and surgery still remains a major treatment option. AIMS & METHODS: This study relates our experience in surgical management of perianal CD without anti-TNF treatment. From July 92 to February 02, 37 patients with perianal Crohns disease were treated, 43 underwent local operations or faecal diversion for fistulas and/or abscesses. Patients not requiring surgery or in therapy with anti-TNF. were excluded from the study. We analysed the outcome of surgical treatment for perianal CD. RESULTS: Male to female ratio was 1:0.6, median age was 36,9 years (range 17-62). Perianal disease included 32 fistulas (16 trans-sphincteric, 2 superficial, 2 ano-vaginal, 10 multiple and complex, 2 horseshoe) and 7 abscesses (5 perianal, 2 ischio-rectal). Local surgery included 1 abscess drainage, 5 abscess drainage and fistula incision with seton insertion, 2 fistulotomy, 9 partial fistulectomy and seton insertion. At surgery, 40% of patients were ongoing a medical treatment with 5-ASA and/or antibiotics, 40% with steroids and/or immunosoppressors, 15% only with 5-ASA and 5% no ongoing treatment. The horseshoe fistulas were managed with a fistulotomy and seton insertion. One patient with ano-vaginal fistula required proctectomy and the other one total proctocolectomy. Patients treated by diverting colonostomy (3) had fistula recurrence after its closure in 100%. 20% of patients required total proctocolectomy and ileostomy for extensive intestinal disease. Of the 27 patients undergoing seton insertion or fistulotomy none had faecal incontinence due to the operation and 38% had a 1 year recurrence. CONCLUSIONS: Perianal CD is a heterogeneous entity, therefore its management is still controversial. Moreover, a high percentage of patients (18% in our series) requires a major surgery due to the extension and seriousness of rectal involvement. In our survey only 12 patients (39%), with trans-sphincteric fistula, could have been theoretically treated with anti-TNF. We wonder if the cost-and-benefit of this medical treatment justifies its application on patients that could undergo a surgical treatment with good long-term results.

[Strictureplasty in the surgical treatment of complicated Crohn's disease]. / Le stricturoplastiche nel trattamento chirurgico della malattia di Crohn complicata.

INTRODUCTION: Crohns disease is a panintestinal chronic inflammatory condition. Its remitting-relapsing behaviour may require in the single patient repeated surgeries, with the aim of resolving the complications of the disease. The awereness that surgery cannot resolve the disease has led, in the last years, to the development of new "conservative surgical techniques", which preserve as much of the intestinal tissue as possible. These techniques are minimal resection and strictureplasty (SP). Aim of the study was to perform a prospective analysis of the long-term outcome of SP in a consecutive series of patients undergoing surgery for complicated Crohns Disease at the Division of general surgery, L. Sacco University Hospital, Milano, Italia. METHODS AND RESULTS: During the period of October 1992 to June 2002, 286 patients underwent surgical procedures for jejunoileal Crohns disease. 116 of them underwent SP resulting in a total of 217 procedures, of which: 111 Heineke-Mikulicz SP (51.2%), 36 ileoileal side-to-side SP (16.6%), 40 ileoceacal SP (18.4%) and the remaining 30 ileocolic SP (13.8%), as previously described by A.M. Taschieri. Fiftyone of the patients (23.5%) had concomitantly a minimal bowel resection. Postoperative mortality was nil, while in 3 cases (2.59%) repeated surgery was necessary due to postsurgical complications. Time-to-event estimates were performed using the Kaplan-Meier function. CONCLUSIONS: mortality, morbidity, and long-term results in this population of patients who underwent SP are encouraging and in line with reports in the international literature. It is suggested that SP together with minimal bowel resections, may be considered as first line surgical therapy in patients with Crohns Disease.

Gastric cancer in young patients with no alarm symptoms: focus on delay in diagnosis, stage of neoplasm and survival.

BACKGROUND: The test and treat strategy for Helicobacter pylori infection has raised some concern since young gastric cancer patients may have no alarm symptoms. In this study the frequency of alarm symptoms was assessed in a series of young gastric cancer patients, as well as the impact of absence of alarm symptoms on delay in diagnosis and stage of gastric cancer at diagnosis and survival. METHODS: A retrospective study was carried out on 92 gastric cancer patients < or = 45 years of age identified from databases in four hospitals between January 1985 and December 2001. Characteristics analysed included duration and features of dyspeptic symptoms, presence of alarm symptoms, time interval from the onset of symptoms to diagnosis, pTNM stage and survival. RESULTS: Of the 92 patients, 54 (58.7%) presented uncomplicated dyspepsia and 38 (41.3%) alarm symptoms. In those with uncomplicated dyspepsia, epigastric pain was the most common complaint (64.1%) followed by vomiting (30.4%), heartburn and nausea. Weight loss was the most common alarm symptom (30.4%), followed by anorexia (10.9%), dysphagia or anaemia (7.6%). The mean delay from first symptoms to final diagnosis was 16.8 +/- 13.9 weeks in patients with alarm symptoms and 29.3 +/- 39.9 weeks in patients without alarm symptoms (P:ns). Patients without alarm symptoms showed significantly less aggressive gastric cancer compared to patients with alarm symptoms in relation to TNM stage and survival (cumulative 5-year survival rate: 76% versus 49% P: 0.01). The survival rate, at 5 years, of patients without alarm symptoms, and with a history of dyspepsia of more than 24 weeks, was higher than that in patients with early diagnosis (93.4% versus 66.5%: P: 0.05). CONCLUSIONS: A large proportion of young gastric cancer patients present without alarm symptoms. Despite the delay in diagnosis, these patients have a better outcome than those with alarm symptoms. Thus the delay in diagnosis of patients without alarm symptoms does not affect survival.

Oxidative stress, vitamin A and vitamin E behaviour in patients submitted to conservative surgery for complicated Crohn's disease.

AIMS: To assess whether plasma peroxidation and plasma levels of antioxidant compounds are correlated with clinical and biochemical activity in complicated Crohn's disease patients, and to evaluate whether the relief of obstructive complication by conservative surgery has any effect on the oxidative stress. PATIENTS AND METHODS: From May 1998 to May 2000, 20 Crohn's disease patients were studied. Basal peroxidative state (basal thiobarbituric acid reactive substances), peroxidative state after stimulation with copper sulfate (stimulated thiobarbituric acid reactive substances], lag time of plasma peroxidation susceptibility, plasma levels of vitamin E and A, C reactive protein, erythrocyte sedimentation rate and Crohn's disease activity index, were determined, before surgery, then 2 months and 1 year after surgery. A group of 134 healthy volunteers were used as controls. All patients were treated by conservative surgical procedures (i.e., strictureplasty and/or minimal resections). Student t test for paired and unpaired data and Spearman R correlation coefficient were calculated. RESULTS: Peroxidative plasma levels, as well as inflammatory indices, are significantly reduced 2 months and 1 year after surgery (p < 0.005), but basal levels of peroxidation and antioxidant scavengers seem to be disregulated in Crohn's disease patients compared to those in controls (p < 0.005). A correlation was found between basal thiobarbituric acid reactive substances, lag-time and erythrocyte sedimentation rate (R:0.51; p < 0.05. R:0.56; p < 0.05) and C reactive protein (R:0. 6; p < 0.005. R:0. 65; p < 0.005). CONCLUSIONS: An imbalance between pro- and antioxidant mechanisms, due to chronic gut inflammation, is present in complicated Crohn's disease, and an excess of lipid peroxidation is probably an important pathogenetic factor Conservative surgery can reduce the oxidative stress avoiding repeated or extended resections that could lead to intestinal malabsorption and short bowel syndrome.

Cathamenial pneumothorax.

Cathamenial pneumothorax is a relatively low-frequency pathology (approximately 100 cases cited in the literature) characterized by recurrent pneumothorax episodes during the menstruation period. We report on a 34-year-old female patient who had recurrent pneumothorax that did not respond to chest drainage and whose presentation was directly related to the menstruation period. Our patient also had a significant clinical record for pelvic endometriosis. She underwent video-assisted thoracoscopic exploration (VATS) of the pleural cavity and dystrophic parenchymal blebs of the middle lobe were found. An atypical resection of the bollous tissue was performed and pleurodesis completed the intervention. During VATS no ectopic endometriosis foci or diaphragmatic fenestrations (widely considered as a possible cause of this clinical picture) were evidenced.

Bowel ultrasound in assessment of Crohn's disease and detection of related small bowel strictures: a prospective comparative study versus x ray and intraoperative findings.

BACKGROUND AND AIM: Despite the fact that bowel ultrasound (US) has recently been proved to be useful in the assessment of bowel diseases, uncertainty persists as to its diagnostic role in patients with complicated Crohn's disease (CD). Therefore, we have prospectively investigated the accuracy of US compared with x ray procedures and intraoperative findings in detecting small bowel strictures complicating CD as well as its reliability in assessing disease extent and location within the bowel. METHODS: A series of 296 consecutive patients with proven CD admitted to L Sacco University Hospital between 1997 and 1999, having undergone complete radiographic evaluation (including small bowel x ray, colonoscopy, or double contrast barium enema), were enrolled in the study. Bowel US was performed in each patient by two experienced operators unaware of the results of other diagnostic procedures. The accuracy of US in detecting strictures compared with x ray studies was determined separately in two different groups of patients: 211 patients treated conservatively (non-operative CD) and 85 patients who were candidates for surgery for CD complications or unresponsiveness to medical therapy (operative CD). RESULTS: Overall sensitivity and specificity of US in assessing the anatomical distribution of CD were 93% and 97%, respectively. The extent of ileal disease measured at US correlated well with that determined by x ray (r=0.52, p<0.001) in medically treated patients as well as with that measured intraoperatively in surgical patients (r=0.64, p<0.001). One or more stenoses were detected in 75 patients (35.5%) at small bowel enteroclysis in the non-operative CD group compared with 70 (82%) in the operative CD series. Sensitivity, specificity, and positive predictive values of bowel US in the detection of strictures were 79%, 98%, and 95% in non-operative CD patients and 90%, 100%, and 100% in operative CD cases, respectively. CONCLUSIONS: In experienced hands, bowel US is an accurate technique for assessing CD extent and location and is very helpful in detecting small bowel strictures, especially in very severe cases that are candidates for surgery. The use of bowel US is therefore justified as a primary investigation in CD patients in whom complications are suspected.

Impact of the introduction of laparoscopic cholecystectomy on the population aged 70 and over.

BACKGROUND/AIMS: Laparoscopic cholecystectomy is reported to be better tolerated than open cholecystectomy by patients aged 70 and over. We evaluate its impact on patients aged 70 and over, from one single center. METHODOLOGY: We review 427 cholecystectomies performed in one single centre, from November 1992 through November 1999. We consider 23 patients, 70 years old or older at the time of surgery. The following objective parameters were considered and compared with the younger population: length of stay in the hospital; mean preoperative stay; mean postoperative stay; incidence of risk factors; postoperative complications. A questionnaire was also mailed to all individual 427 patients. RESULTS: Length of stay in the hospital declined in both population, during the time interval considered. The incidence of risk factors, both major and minor, increases consistently with age from less than 1% below the age of 30 to about 62% in the eighth decade and over. Major postoperative complications were 4.34% in patients > or = 70 vs. 2.8% in patients < 70 years of age. Mortality was nil in both groups. Ninety percent reported complete disappearance of preoperative symptoms. CONCLUSIONS: Laparoscopic cholecystectomy in geriatric patients is safe and risks are reasonably low. Selection of patients must be done on strict indications.

[Surgical treatment of ulcerative rectocolitis: technical aspects of total restorative proctocolitis with S pouch]. / Il trattamento chirurgico della rettocolite ulcerosa: aspetti tecnici della proctocolectomia totale restaurativa con pouch a S.

Restorative proctocolectomy with an ileal-pouch-anal anastomosis seems to be the treatment of choice for ulcerative colitis. The aim of this study was to discuss a number of technical and functional aspects of the procedure that still appear to be controversial such as the shape of the pouch, the mucosectomy and the type of anastomosis. The authors report on their experience with the surgical treatment of ulcerative colitis with an "S" pouch. The technique reported, however, differs from the original method proposed by Parks and Nicholls in 1978 and the reasons for this surgical choice are discussed. A six-year experience (1993-1999) regarding 35 patients undergoing this approach is reported. No perioperative deaths were observed. The early and long-term complication rates were 8.5% and 11.4%, respectively. The average number of daily evacuations was 4. Mucosectomy affords complete resolution of the disease, while the particular shape of the pouch guarantees good functional results.

Preoperative characteristics and postoperative behavior of bowel wall on risk of recurrence after conservative surgery in Crohn's disease: a prospective study.

OBJECTIVE: To evaluate in patients with Crohn's disease, using transabdominal ultrasound, the morphologic characteristics of the diseased bowel wall before and after conservative surgery and to assess whether these characteristics and their behavior in the postoperative follow-up are useful and reliable prognostic factors of clinical and surgical recurrence. SUMMARY BACKGROUND DATA: Ultrasound is effective for evaluating the thickness of bowel wall, the most typical and constant finding of Crohn's disease. No data are currently available concerning the behavior of the diseased intestinal wall after conservative surgery and whether the preoperative characteristics of bowel wall or its behavior after conservative surgery may predict recurrence. METHODS: In 85 consecutive patients treated with strictureplasty and miniresections for Crohn's disease, clinical and ultrasonographic evaluations were performed before and 6 months after surgery. Assessed before surgery were the maximum bowel wall thickness, the length of bowel wall thickening, the bowel wall echo pattern (homogeneous, stratified, and mixed), and the postoperative bowel wall behavior, classified as normalized, improved, unchanged, or worsened. RESULTS: A significant correlation was found between a long preoperative bowel wall thickening and surgical recurrence. Bowel wall thickness after surgery was unchanged or worsened in 43.3% of patients; in these patients, there was a high frequency of previous surgery. Patients with unchanged or worsened bowel wall thickness had a higher risk of clinical and surgical recurrence compared with those with normalized or improved bowel wall thickness. CONCLUSION: With the use of abdominal ultrasound, the authors found that the thickening of diseased bowel wall may unexpectedly improve after conservative surgery, and this is associated with a favorable outcome in terms of clinical and surgical recurrence. In addition to its diagnostic usefulness, ultrasound also provides reliable prognostic information concerning clinical and surgical recurrence in patients with Crohn's disease in the postoperative follow-up.

Long-term results and multivariate analysis of prognostic factors in 138 consecutive patients operated on for Crohn's disease using "bowel-sparing" techniques.

BACKGROUND: Conservative surgery has become accepted as a useful option for the surgical treatment of complicated Crohn's disease (CD). METHODS: One hundred thirty-eight consecutive patients treated with strictureplasty or miniresections for complicated CD have been observed prospectively. The possible influence of a number of variables on the risk of recurrence was investigated using the Cox proportional hazard model, and a time-to-event analysis was made using the Kaplan-Meier function. RESULTS: There was no perioperative mortality; the morbidity rate was 5.7%. A close correlation was found between the risk of recurrence and the time between diagnosis and first surgery. The overall 5-year recurrence rate was 24%, being 36% in the patients requiring surgery within 1 year of diagnosis and 14% in those operated on more than 1 year after diagnosis. CONCLUSIONS: Risk factor analysis highlighted a group of patients at high risk of surgical recurrence. Given that our results are similar to those reported in other series, we consider strictureplasty and miniresections safe and effective procedures for the treatment of complicated CD.

Early perioperative results and surgical recurrence after strictureplasty and miniresection for complicated Crohn's disease.

BACKGROUND/AIMS: Strictureplasty (SP) or miniresective 'bowel-sparing' techniques (MR) can prevent the risk of intestinal stomia and short bowel syndrome in patients affected by Crohn's disease (CD). The aim of this study was to analyze the perioperative morbidity and mortality in 104 of 138 consecutive patients treated for CD complications using bowel-sparing techniques. We also considered the factors that may be related to the risk of perioperative complications and the long-term outcome. METHODS: One hundred and four patients were treated with SP and/or MR and then included in a prospectively maintained database. The factors claimed to influence perioperative complications were analyzed using Fisher's exact test for categorical observations and the Mann-Whitney U test for continuous variables. A multivariate analysis, using logistic regression, and a long-term time-to-event analysis using the Kaplan-Meier function, were also performed. RESULTS: Perioperative mortality was nil. In relation to the 6 postoperative complications (5.8%), 4 patients underwent minimal bowel resection (MR), 1 a MR with SP, and 1 SP alone. Three of these patients (2.9%) needed reoperation for septic complications, and 3 (2.9%) were treated as outpatients for enterocutaneous fistulas. A correlation (p < 0.05) was found between low serum hemoglobin levels and postoperative complications at univariate and multivariate analyses. The 5-year surgical recurrence-free rate was 75% overall, 73% for patients treated with SP, 78% with MR, and 77% with MR + SP. CONCLUSIONS: Postoperative complications are not related to conservative or miniresective surgery even when active disease is present at the resection margins or the site of SP. The higher risk reported for patients with low serum hemoglobin and hematocrit levels suggests that surgeons should consider using preoperative iron and vitamin support, parenteral nutrition and erythropoietin therapy, when necessary, in those cases. Our postoperative morbidity, mortality and long-term surgical recurrence rate results support the efficacy and safety of SP and MR surgery in the treatment of complicated CD.

Is the loss of gallstones during laparoscopic cholecystectomy an underestimated complication?

Laparoscopic cholecystectomy entails an increased risk of gallbladder rupture and consequent loss of stones in the abdominal cavity. Herein we report the case of a 51-year-old male patient, who underwent laparoscopic cholecystectomy 2 years before presentation to our hospital. He had experienced tension sensation and epigastric pain since 4 months postoperatively. A well-defined epigastric mass, which was hard and painful on palpation, was detected and later confirmed by ultrasonography and CT scan. Explorative laparotomy revealed a mass in the area of the gastrocolic ligament,resulting from biliary gallstones in conjunction with a perimetral inflammatory reaction. A review of the literature showed that the incidence of gallbladder lesions during laparoscopy is 13-40%. In order to prevent this complication, meticulous isolation of the gallbladder, proper dissection of the cystic duct and artery, and careful extraction through the umbilical access are required. Ligation after the rupture or use of an endo-bag may be helpful. The loss of gallstones and their retention in the abdominal cavity should be noted in the description of the surgical procedure.

[2 cases of choledochal calculosis associated with juxtapapillary diverticulum in patients with gastric resection: submesocolon approach]. / Su due casi di calcolosi coledocica associata a diverticolo juxtapapillare, in resecati gastrici: accesso sottomesocolico.

Although laparoscopy and endoscopy have reduced the need for laparotomies in biliary tract surgery, open surgery is sometimes still needed. One case in particular is when previous operations have significantly distorted normal upper abdomen anatomy. We chose an inframesocolic entrance to the posterior peritoneum in two patients with bile duct stones, juxtapapillary duodenal diverticulum and a history of cholecystectomy and partial gastric resectioning. The duodenum was reached at the junction between the second and third section by entering the posterior peritoneum through the inferior sheet of the mesocolon, a relatively avascular area. The diverticulum was incised, the sphincter and papilla operation was performed and the bile duct stones removed. The diverticulum was then resected. Our conclusion is that in certain cases, an inframesocolic entrance can significantly reduce technical difficulties involved in re-operating through dense adhesions, minimize surgical time and blood loss and, when operating through the open diverticulum, spare an unnecessary duodenotomy.

Hepatocarcinoma: considerations on surgical treatment in a personal series of 23 patients.

BACKGROUND/AIMS: Surgical treatment of primary liver tumors has undergone significant changes in recent years because of improved surgical and anesthesiological techniques and better pre- and post-operative care. We review our personal series from 1987-1995. METHODOLOGY: Of 31 cases of hepatocellular carcinoma (HCC) observed in the years 1987-1995, 23 underwent curative resective surgery for a total of 24 liver resections: 6 hepatectomies; 10 segmentectomies; 4 atypical subsegmentectomies; 2 extended resections, with excision of neoplastic thrombi within the portal vein; 1 orthotopic liver transplantation in another institution, and 1 limited segmental resection for tumor recurrence. In 7 recent cases, pre-operative transcatheter arterial chemoembolization (TAE) was used. RESULTS: The mean survival of the 13 patients that are known to be deceased is 27 months (range: 7-114 months). Perioperative mortality was nil. Actuarial 5-year survival rate is 27%. Pre-operative TAE was used in 7 patients: 4 out of 7 lesions were significantly reduced at computed tomography (CT) scan control 21 days following TAE, while in 3 the tumor size was unchanged. CONCLUSIONS: Liver surgery, even major resections, has become safe with no perioperative mortality in our series. In our experience, pre-operative TAE has often produced significant reduction of the mass, but its real efficacy is still the subject of debate. TAE and percutaneous ethanol injection (PET) should be evaluated as part of combined multimodality treatment in the therapy of large lesions previously considered inoperable.

Surgical treatment of pancreatic tumors invading the spleno-mesenteric-portal vessels. An Italian Multicenter Survey.

BACKGROUND/AIMS: The authors are interested in determining the diagnostic and surgical approach followed in different Italian institutions in the treatment of adenocarcinoma of the head of the pancreas, whenever the spleno-mesenteric-portal confluence is invaded. METHODOLOGY: A 10-item questionnaire was sent to 21 Italian Centers of Surgical Oncology and a total of 1185 patients treated with pancreaticoduodenectomy were collected from 15 centers. Among them, 164 spleno-mesenteric-portal vein (SMPV) resections were performed. RESULTS: In all collaborative centers, the diagnostic work-up is comparable with what is reported in the literature. An accurate pre- and intra-operative staging and a differential diagnosis between inflammatory and neoplastic involvement of the vessel walls is universally considered essential for its surgical and oncological implications. If vessel involvement is ruled out, 7 centers proceed to pancreasectomy anyway. Direct end-to-end vein reconstruction is used as the primary procedure, but interposition of PTFE and autologous vein grafting may be used. An overall 4.8% post-operative complications only have been reported. Mean perioperative mortality reported is 3.8% (0-11.5%) and morbidity is 22.8% (4.7-57%). Survival rate is 10 months overall. The mean actuarial 5-year survival is 12%. CONCLUSIONS: The attitude of the collaborative centers in cases of SMPV involvement varies, with a slight majority favoring a conservative behavior. Surgical resection extended to the vessels is still uncommon, even in centers mostly experienced in surgery of the pancreas. We believe that vascular resections can be safely performed in both of the different conditions: localized tumors locally invading the vessels and neoplasms with massive invasion of the peripancreatic structures. We share with others the opinion that, in experienced centers, extensive resections should have a role for palliation of carcinoma of the pancreas whenever they offer a better quality of life, although life expectancy may not be positively influenced.

[The conservative surgery of Crohn's disease: the long-term results]. / La chirurgia conservativa della malattia di Crohn: risultati a lungo termine.

INTRODUCTION: Patients with Crohn's disease (CD) receive one or more surgical interventions throughout their clinical history. Conservative surgery has recently been proposed as a safe and effective option for the treatment of complicated CD and for the prevention of short bowel syndrome and stoma. PATIENTS AND METHODS: One hundred nineteen patients affected by CD were treated with stricture plasty and mini-resection in our Department between January 1993 and January 1998. At admission, the prior complete clinical and surgical history of each patient was collected and then inserted in a prospectively maintained data base. Analysis of recurrence was made using the Kaplan-Meier function and the influence of certain variables on the risk of recurrence was analyzed using a Cox proportional hazard model. RESULTS: Perioperative mortality was nil, postoperative complications occurred in 8 patients (6.7%). Overall long term surgical recurrence at 5 years was 28%, 35% in patients operated on within one year and 15% in those treated after one year from the diagnosis (p < .05). CONCLUSIONS: Stricture plasty and minimal resections show lower perioperative mortality and postoperative complications similar to resective surgery. From risk factor analysis, a group of patients with high risk of surgical recurrence emerged. In this group and whenever technically possible, we consider stricture plasty and minimal resection the gold standard in the treatment of complicated CD.