Role of TachoSil® in distal pancreatectomy: a single center experience.

AIM: Distal pancreatectomies (DP) are associated with high risk of postoperative complications, and in many series higher morbidity rate than duodenopancreatectomies has been reported. To evaluate the role of a collagen sponge with human fibrinogen and thrombin film (TachoSil®) in limiting the incidence of complications after DP. METHODS: From 1996 to 2013, 221 patients have been submitted to distal pancreatectomy (± splenectomy) in our Division. A retrospective analysis has been conducted in a group of 36 consecutive and prospectively collected DP treated with intraoperative placement of TachoSil® on pancreatic stump from 2010 to 2013 (group 1). A control series of 36 consecutive patients (group 2) was matched 1:1 from hystorical database. The variables considered in the analysis were: age, gender, ASA score, pancreatic texture (hard vs. soft), histology, operative time, postoperative mortality, morbility (postoperative pancreatic fistula - POPF, postoperative hemorrage - PPH, delayed gastric emptying - DGE) and hospital stay. Differences between POPF, PPH, DGE and hospital stays between grops were investigated with χ² and t-Student test. Univariate analysis was conducted to determine factors related to POPF development. Statistical analysis was performed using freeware Microsoft Excel based program. RESULTS: Post operative mortality was 0% in both groups. POPF were registered in 36.1% (13/36) and 41.6 % (15/36) in groups 1 and 2, respectively (P=n.s.); in group 1 we didn't observe grade C POPF, while 4 patients in control group developed grade C POPF (P<0,05). No differences were found between two groups in terms of incidence of PPH and DGE. The median duration of postoperative hospital stay in group 1 was 21.8 (7-189) days compared with 31.13 (9-249) days in group 2 (P<0.001). CONCLUSION: The use of TachoSil® seems to be associated with lower incidence of grade C POPF but larger controlled trials are needed to surely assess the usefulness of TachoSil® in pancreatic surgery in order to reduce pancreatic specific complications and their severity.

Anal transitional zone adenocarcinoma following restorative proctocolectomy for ulcerative colitis: case report and review of literature.

Conservative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become the intervention of choice for severe ulcerative colitis (UC) requiring surgery. Sporadically, the occurrence of carcinoma arising in or near the ileo-anal pouch after IPAA for UC has been reported. This issue is of utmost importance as an endoscopic follow-up is mandatory also after the operation. The present paper reports a case of cancer which developed four years after proctocolectomy with IPAA in a young man suffering from UC. Moreover, the authors provide update (PubMed research) by literature review on this issue.

A double Meckel's diverticulum as obscure gastrointestinal bleeding cause. Report of a case.

Meckel's diverticulum is the most common developmental anomaly of the gastrointestinal tract, affecting 1-4% of the general population. It is usually an incidental finding during laparotomy for other causes; occasional complications are bleeding, obstruction, diverticulitis and perforation. Up to 60% of Meckel's diverticula harbor heterotopic mucosa (mostly gastric or pancreatic), neoplastic degeneration occurs in 1-5% of cases. We report herein a case of obscure gastrointestinal bleeding in a 25-years-old man, due to a double Meckel's diverticulum, both located into jejunum and ileum, harboring ectopic gastric mucosa, diagnosed by a small bowel double contrast enema and managed laparoscopically with a tangential resection. To the best of our knowledge this is an unfrequent case of such a variant of Meckel's diverticulum with ectopic gastric mucosa diagnosed by double contrast enema.

Morbidity and mortality after D1 and D2 gastrectomy for cancer: interim analysis of the Italian Gastric Cancer Study Group (IGCSG) randomised surgical trial.

BACKGROUND: The disadvantages of D2 gastrectomy have been mostly related to splenopancreatectomy. Unlike two large European trials, we have recently showed the safety of D2 dissection with pancreas preservation in a one-arm phase I-II trial. This new randomised trial was set up to compare post-operative morbidity and mortality and survival after D1 and D2 gastrectomy among the same experienced centres that participated into the previous trial. METHODS: In a prospective multicenter randomised trial, D1 gastrectomy was compared to D2 gastrectomy. Central randomisation was performed following a staging laparotomy in 162 patients with potentially curable gastric cancer. FINDINGS: Of 162 patients randomised, 76 were allocated to D1 and 86 to D2 gastrectomy. The two groups were comparable for age, sex, site, TNM stage of tumours, and type of resection performed. The overall post-operative morbidity rate was 13.6%. Complications developed in 10.5% of patients after D1 and in 16.3% of patients after D2 gastrectomy. This difference was not statistically significant (p<0.29). Reoperation rate was 3.4% after D2 and 2.6% after D1 resection. Post-operative mortality rate was 0.6% (one death); it was 1.3% after D1 and 0% after D2 gastrectomy. INTERPRETATION: Our preliminary data confirm that in very experienced centres morbidity and mortality after extended gastrectomy can be as low as those showed by Japanese authors. They also suggest that D2 gastrectomies with pancreas preservation are not followed by significantly higher morbidity and mortality than D1 resections.

Surgery for carcinoma of the gallbladder. Our experience.

BACKGROUND: Carcinoma of the gallbladder is a gastrointestinal malignancy with a very poor prognosis. The 5-year survival rate amounts to less than 5% in most series. In this study we reviewed the results of surgical treatment for gallbladder carcinoma with special reference to extended radical procedures. METHODS: Between 1995 and 2000 we enrolled 36 patients (17 males and 19 females), 24 of whom were treated with simple cholecystectomy and 12 with radical resection (partial hepatectomy, regional lymphadenectomy, and common bile duct resection). The tumours were classified by stage using the criteria of the American Joint Committee on Cancer (AJCC). Stages, operative procedures, results of pathologic examinations and the outcome of the resected cases were reviewed. RESULTS: There were 2 postoperative deaths (0.55%). The mean follow-up period was 19.1 months (range 1-60). For stage I and II disease extended cholecystectomy had a better result than simple cholecystectomy: the 5-year survival rates were 38.4 versus 19%, respectively. For the patients with advanced stage III or IV gallbladder carcinoma, a significant advantage of survival resulted in case of liver resection as compared to surgical treatment without liver resection: the 5-year survival rates were 20 and 0%, respectively. CONCLUSIONS: The survival of stage I-II patients was good. For the patients in higher stages the prognosis was significantly worse. In these cases more aggressive surgery may be needed.

[Gastric cancer. New frontiers in surgical therapy]. / Il carcinoma gastrico. Le nuove frontiere della terapia chirurgica.

The authors compare their experience in the surgical treatment of gastric carcinoma with the literature and point out that therapeutic value of a wide gastric resection and adequate lymphadenectomy can improve a 5-year survival without increasing mortality and morbidity. In an 8-year experience in 258 patients with gastric carcinoma, 249 underwent operation, 139 with curative intention. Wide gastric resection proved to be effective and safer than elective total gastrectomy, and D2-lymphadenectomy showed the same morbidity of D1 and seems to offer a better 5-year survival. Extended resections for gastric cancer, that result in simultaneous pancreatectomy, splenectomy, hesophagectomy, resection of the colon and hepatectomy, do not show significant improvement of the survival.

Laparoscopic cholecystectomy in cirrhotic patients.

BACKGROUND/AIMS: Laparoscopic cholecystectomy has become the procedure of choice for symptomatic cholelithiasis. A study to evaluate the benefits and risks of laparoscopic cholecystectomy in cirrhotic patients was performed. METHODS: Between January 1994 and December 2000, 1,100 laparoscopic cholecystectomies for symptomatic gallbladder diseases were performed. There were 24 cirrhotic patients (group A) and 72 age- and sex-matched controls (group B). All patients had well-compensated cirrhosis (Child's class A or B). RESULTS: There was no operative mortality in either group and the postoperative complication rates were 20.8 and 9.72% in groups A and B, respectively (p < 0.000001). Operative time in group A was 89.16 vs. 68.41 min in group B (p < 0.000001). The estimated intraoperative blood loss in group A was 106.25 vs. 37.08 ml in group B (p < 0.000001). The average transfusion requirement was 0.155 and 0.0 units in groups A and B, respectively (p < 0.025). The hospital stay in groups A and B was 4.7 and 3.61 days, respectively (p < 0.0500). CONCLUSION: Laparoscopic cholecystectomy in patients with compensated cirrhosis is safe and should be the treatment of choice for these patients. Laparotomy should be applied only if the surgeon considers the operation inadequate to be continued laparoscopically.

[Stricture plasty in Crohn's disease. Indications and results]. / La stritturoplastica nel morbo di Crohn. Indicazioni e risultati.

BACKGROUND: Aim of the paper is to evaluate the indications and results of stricture plasty in the treatment of intestinal obstruction due to Crohn's disease. It is hypothesized that, as far as fibrotic strictures are treated, operative morbidity will be reduced to a minimum. METHODS: Data regarding 147 interventions for Crohn's disease performed in a 4.5 year-period have been prospectively collected. Eight interventions including stricture plasty have been identified and indication, morbidity and end results analyzed. RESULTS: In 8 interventions 20 stricture plasties have been performed. As a rule, a stricture plasty is performed only when a resection would have sacrificed a too long bowel tract or it was inappropriate, in relation to stricture site. Three patients had fistulae, but those fistulae were not in the same site of stricture plasty and only one patient was malnourished and with active disease. There was no operative mortality or major morbidity, but there was only a short episode of hyperthermia. No relapses were observed after a 26-month mean follow-up. CONCLUSIONS: Stricture plasty is a useful tool in order to avoid extensive intestinal resections. If it is performed only on fibrotic strictures with inactive disease and only if a resection is deemed inappropriate, minimal morbidity and very good results can be anticipated.

[Surgical treatment of internal duodenal diverticulum. Report of 2 clinical cases]. / Terapia chirurgica del diverticolo duodenale interno. Presentazione di due casi clinici.

Internal duodenal diverticulum is a rare disease. Nowadays, less than 100 cases are reported in Western literature. Even if it is a pathology of malformative origin, the first clinical manifestations occur quite always during the III decade. Main symptom is a violent, suddenly arisen, abdominal colic, often associated with meals and with spontaneous remission. Frequency of accesses is variable in time; in most serious cases, colics are so close to cause a considerable reduction of nutrition. Among diagnostical means, very useful are Rx enema (that offers pathognomonical images) and endoscopy, by which the formation can be visualized directly and its connection with papilla can be delineated. In some rare cases, differential diagnosis has to be made with cystic dilatations of bile duct, and particularly with type III according to Alonso-Lej classification or choledochocele. When such a distinction is not possible, differential diagnosis will be made on the basis of histological examination of the type of mucosa present in the internal aspect of the diverticulum. Therapy of symptomatic forms is surgery. The technique of choice is transduodenal diverticulectomy. Cannulation of bile duct is a useful means to found the papilla during intervention, to protect duodenal suture in the postoperative period and to control it radiologically. Two cases of internal duodenal diverticulum operated on in the last 2 years are described and diagnostical and therapeutical items are discussed.

[Repair of large laparoceles]. / La riparazione dei grandi laparoceli.

The authors report a series of 100 incisional hernias operated on and consider general and local problems in repair of wide hernias. They underline some rules in order to obtain a strong reconstruction, with minimal relapse risk and to avoid adverse systemic effects produced by the intervention itself. Now they consider synthetic meshes to be apt for the treatment of the largest hernias, in order to reinforce or to repair the fascial defect, as meshes are strong, easy to use and are well tolerated by tissues and have a good resistance to infection.

[Palliative treatment of pancreatic carcinoma. Comparison between 2 successive observation periods]. / Il trattamento palliativo del carcinoma pancreatico. Confronto fra due successivi periodi di osservazione.

Explorative laparotomies and palliative surgery for pancreatic carcinoma have been reduced due to improved diagnostic tools, the spread of laparoscopic techniques and the growing use of external biliary drainage and endoprostheses. By comparing two successive observation periods the authors point out that, owing to the good results obtained, mini-invasive surgery is more frequently used in the management of obstructive jaundice than biliodigestive surgical derivations. Of these, hepatico-jejunostomy is preferable to duodenal anastomosis due to the latter's frequent involvement by the primary tumour. The authors also consider it inappropriate to increase operative morbidity through the systematic association of gastroenteric with biliodigestive derivation, except in cases of symptomatic or radiologically or endoscopically ascertained duodenal stenosis and when the objective finding of visceral involvement leads to the supposition of its imminent obliteration. The indications for surgical splannicectomy have also been reduced with the spread of percutaneous alcoholization of the celiac plexy in cases which resist analgesic treatment using a parenteral route.

[Abdominal desmoid tumor]. / I desmoidi addominali.

Two cases of desmoid tumor of the abdominal wall are reported, together with some considerations and a review of the literature; desmoid tumor is an unusual neoplasm which affects women in prevalence. This is an histologically benign neoplasm with no metastatic capacity; however it is highly invasive in the site where it arose, so its treatment can become very difficult. The treatment is by surgical excision that must be as wide as possible, in order to obviate the great incidence of recurrence. The role of radiotherapy, hormone and chemotherapy has not been completely assessed so far.

[Endoscopic and intraoperative ultrasonography in staging of stomach neoplasms]. / Ecografia perendoscopica ed intraoperatoria nella stadiazione delle neoplasie gastriche.

In Japan a better prognosis of gastric cancer has been achieved by early diagnosis and wide, careful lymphectomy. This is not true in western countries. Thus the Authors believe that rational surgical strategy and the careful use of advanced diagnostic tools would produce a better outcome. The Authors report the new diagnostic methods that they adopt in every case of gastric neoplasm: endoscopic ultrasonography, which also proved useful in submucosal tumors, like lymphomas; parenteral nutrition, immune status assessment for a possible use of immune response modulators, single-dose antimicrobial prophylaxis, antithrombotic prophylaxis, autologous blood storage, in order to reduce transfusion-linked risks. Surgical strategy is also reported, which includes wide resection with adequate margins, R2 lymphectomy and intraoperative assessment of disease extension by ultrasonography.

[Lipoid hyperplasia of the ileocecal valve. A report of 2 cases operated on in the occlusive phase]. / La lipoiperplasia della valvola ileo-ciecale. Osservazione di due casi operati in fase occlusiva.

Two cases of lipomatosis of the ileocaecal valve, causing intestinal obstruction are reported. Surgery was performed on an emergency basis. A careful assessment of clinical and radiological findings is important, in order to distinguish such as a disease from caecal carcinoma. In fact this is a benign disease, for which conservative surgery is indicated.

[Adrenal neuroblastoma in adults: a rare neoplasm of difficult diagnostic interpretation. A case report]. / Il neuroblastoma del surrene nell'adulto: una rara neoplasia di difficile interpretazione diagnostica. Contributo casistico.

A case of a 25-year old girl, affected by an adrenal neoplasia with bone marrow and splenic metastases, is reported. The site of the neoplasm, that was highly undifferentiated, the presence of rosette-forming cells along with the clinical picture and the rapidity of the final outcome, could suggest the diagnosis of neuroblastoma. However we stress that the diagnosis is very difficult and can only be stated on probability bases in such undifferentiated neoplasms.

[Laparocele: a review of the literature and analysis of case histories]. / Il laparocele: revisione della letteratura e analisi di una casistica.

We analyze a group of 64 laparoceles from which it emerges a per cent distribution in the different regions and a correlation between the dimensions of the lesion and the relative regions in agreement with the data usually given in the literature. Furthermore we point out a clear dependence on pathogenetic factors of general and local order. Is therefore recognized the necessity of preventing their insurgence and reducing the risk of relapses through appropriate laparotomy incisions, with adoption of a suitable surgical technique and the correction of systemic diseases. The voluminous laparoceles are responsible of cardiac, respiratory, coagulative diseases, that must be scrupulously judged for an appropriate therapeutical approach. The surgical treatment, as well as for the cases of bigger dimensions, has mostly availed itself of an elementary technique (simple approach, apposition "en paletot" splitting of the fasciae). In the necessity of strengthening weak parietal tissues or of replacing vast losses of matter, we have limitedly resorted to autologous grafts, while good results have been observed with the lyophilized dura mater.

[Actinic lesions of the small intestine requiring surgery. Case reports]. / Le lesioni attiniche del tenue di pertinenza chirurgica. Contributo casistico.

Radiation enteropathy is a disease that seldom requires surgical treatment, in the chronic variety. We report the findings of four cases we operated in an attempt to identify the weak points of surgery involving a high percentage and morbidity of mortality. NPT (total parenteral nutrition) can favour a positive evolution with total rest of the bowel and with reinstatement of normal nutrition.