Evaluation of Intraoperative End-Tidal Carbon Dioxide Change Relates to Length Hospitalisation in Peridiaphragmatic Surgery: A Pilot Study.

Intraoperative evaluation is deeply changed using many new tools, both invasive and non-invasive. Peripheral oxygen saturation percentage (SpO2) is the more reliable method for a non-invasive monitoring of patient's blood oxygen concentration. Capnography (using end-tidal CO2 (EtCO2)) evaluation is an immediate and continuous non-invasive monitoring of carbon dioxide (CO2) in the breathing that provides important information on circulatory status and ventilation.Aim of this study is to perform a preliminary analysis of oxygen change during surgery exploring its possible influence on post-operative evolution. METHODS AND RESULTS: Intraoperative evaluation of SpO2 and EtCO2 was performed. Change in each parameter was categorised as 1 point for each five-point variation from baseline value (∆SpO2 as 1 point for each 5%, ∆EtCO2 as 1 point for each 5 mmHg). For each patient, the length of stay (LOS) in the intensive care unit (ICU), total hospitalisation, duration of intervention, surgical risk and complications were recorded. RESULTS: We analysed 93 consecutive patients (43 males and 40 females, aged 66.35 ± 9.79 years) that underwent peridiaphragmatic surgery. Forty patients (48.19%) presented complications after surgery. There was no statistically significant difference in age, duration of intervention and length of stay in ICU between complicated and non-complicated patients. As expected, patients with complications present an increased hospitalisation time compared to uncomplicated cases (14.69 ± 11.41 days vs 10.70 ± 6.28 days; p < 0.05). ∆EtCO2 was significantly increased (p < 0.05) in complicated compared to non-complicated. No differences were found in ∆SpO2 between the two groups. Considering the whole population, ∆EtCO2 presents a significant direct correlation to surgical risk, hospitalisation and duration of intervention. CONCLUSION: ∆EtCO2 may be related to possible complications after surgery and hospitalisation. An important comparison between SpO2 and EtCO2 and strict monitoring with an intraoperative arterial blood gas (ABG) sample during the main steps of surgery could bring some essential information to understand oxygen changes in intra- and post-operative evolution. However, a further validation analysis is needed before the approach can be used extensively in daily clinical settings.

[Bacterial endocarditis. Unusual complications of acute diverticulitis]. / L'endocardite batterica. Complicanza rara della diverticolite acuta.

BACKGROUND: Colon diverticular disease represents an affection with high prevalence in the western countries. It appears particularly insidious in the elderly population for the presence of concomitant illnesses. CLINICAL CASE: A patient (> 80 years old) is submitted to surgical intervention in emergency sec. Hartman for acute diverticulitis and pelvic abscess. The post-operating time has been complicated for the arising of a fever resistant to the common antibiotic therapy, in absence of abdominal and respiratory objectivity. An accurate clinical examination has set the suspect of bacterial endocarditis, confirmed to the echocardiographic examination. DISCUSSION: The acute complicated diverticulitis therapy variates in according to the clinical presentation, the complications and the experience of the different Authors. A first conservative approach foresees the Total Parenteral Nutrition (TPN) and the wide spectrum antibiotic therapy and the eventual percutaneous drainage. The surgical treatment, realized with "open" or laparoscopic method, foresees the resection of the sick intestinal tract and the packing of a temporary preternatural anus. However, some Authors prefer an intestinal anastomosis performed in single time with the resection. Among all the complications, the most frequent are those affecting the respiratory and cardiovascular apparatus, as well as the sepsis. The bacterial endocarditis is not signalled in most recent international Literature. CONCLUSION: The bacterial endocarditis must be suspected in case of common antibiotic therapy resistant fever, with negative abdominal and pulmonary objectivity, arising after a septic surgical intervention.

[Endoscopic treatment of a calculous choledochocele. Report of a case]. / Trattamento per via endoscopica di un coledococele contenente un calcolo. Report di un caso.

OBJECTIVE: The authors report their experience about the treatment of choledochocele. DESIGN: Case report and 6-months follow up. SETTING: Operative Unit of General and Thoracic Surgery, Department of Surgical and Anatomical Disciplines. Policlinico, University of Palermo. INTERVENTIONS: ERCP + ES with complete resolution of pathology. RESULT: Complete resolution of symptoms; 6-months follow up negative. CONCLUSIONS: ERCP is choice treatment of choledochocele, only in well experienced teams.

Surgical treatment of morbid obesity with biliopancreatic diversion and gastric banding: report on an 8-year experience involving 235 cases.

STUDY AIM: Developments have recently been made in bariatric surgery outside the USA. The aim of this retrospective non-randomized study was to report on our experience regarding biliopancreatic diversion (BPD) and non-adjustable gastric banding (GB) in a population of 235 obese patients. PATIENTS AND METHODS: From March 1990 to March 1998, 235 obese patients were operated on, 142 by BDP and 93 by GB, via laparotomy after rigourous selection of the patient population. RESULTS: The mean duration of surgery was 2 h 50 minutes for BPD and 1 h for GB. One postoperative death occurred due to massive pulmonary embolism. Early major complications were frequent in the BPD group (n = 21) but rare in the GB group (n = 1). Mean duration of hospitalization was 16 days in the BPD group versus 9 days in the GB group. Mean percentage excess weight loss was 48% for the GB group and 60% for the BPD group after two years. Late mortality was limited to the BPD group (3.5%). Late complications were evenly distributed between the two groups, with a prevalence of malnutrition in the BPD group and outlet stenosis in the GB group. A high incidence of band removal was recorded related to this complication (17.2%). Incisional hernias were present in both groups. CONCLUSIONS: GB and BPD are techniques which can induce weight loss and bring about subsequent health benefits. Nevertheless, in a few patients further intervention or adaptation of the approach due to clinical failure or to a high complication rate is required. Additional research is needed regarding determination of the surgical treatment that is best adapted to the case in question, i.e., taking into consideration both the restrictive and malabsorbative aspects.

[Intestinal cystic pneumatosis and gastric banding. Etiopathogenic considerations on a clinical case]. / Pneumatosi cistica intestinale e "gastric banding". Considerazioni etiopatogenetiche su un caso clinico.

The authors describe a case of intestinal cystic pneumatosis in a patient submitted to gastric banding and then proceed with a critical review of the literature on the subject, examining the state of the art with regard to the pathogenetic hypotheses and the clinical manifestations of the disease and outlining the advantages of the instrumental investigations employed. On the basis of clinical considerations, an integrated pathogenetic hypothesis is advanced which takes account of the various indications expressed in the literature. In particular, recurrent vomiting is believed to bring about epithelial microlesions which, in the presence of severe respiratory impairment, the execution of endoscopic examinations and a mainly carbohydrate-based diet, are thought to cause onset of cystic pneumatosis.

Hydatid cyst of the liver communicating with the left colon.

Rupture and secondary infection are common complications of hydatid cyst in the liver. Ultrasound and CT findings are reported in a case of hydatid cyst which has ruptured directly into the left colon. Rupture of hydatid cyst into a hollow viscus is extremely rare. CT demonstrated partial drainage of the cyst contents with the creation of an air-fluid level.

[Intestinal carcinoid. A propos of a case]. / Il carcinoide intestinale. A proposito di un caso.

In this paper the authors report a case of carcinoid neoplasm in a rare localization like sigmoid colon. They describe the clinical and biological aspects of this kind of tumors, with particular regard to the tumor site and its biochemical products. A rational and prompt clinical approach to this neoplasm is considered important for the good chance of long survivals, achievable in the case of early diagnosis.

Subcutaneous low-dose interleukin-2 and intravenous 5-fluorouracil plus high-dose levofolinic acid as salvage treatment for metastatic colorectal carcinoma.

Thirty-three consecutive patients with recurrent and/or metastatic colorectal carcinoma (CRC) refractory to previous chemotherapy have been treated with levofolinic acid (I-FA) 100 mg/m2 i.v. over 1 h infusion followed by 5-fluorouracil (5-FU) 600 mg/m2 i.v. bolus every week for 6 weeks followed by a 2 week interval. Patients also received rIL-2 s.c. at 3 MU daily from day 1 to day 5 of each week for at least four consecutive weeks per cycle. Enrolled patients were divided in two groups: (i) group 1 including patients with progressive tumor refractory to chemotherapy with I-FA + 5-FU given for metastatic disease and (ii) group 2 consisting of patients with diagnosis of metastatic disease within 3 months from the completion of adjuvant chemotherapy with 5-FU + levamisole (LEV) after primary surgery. No objective response was observed in the group of 11 patients with CRC resistant to previous I-FA + 5-FU, thus no further patient with progressive disease after I-FA + 5-FU was included in the trial. In the group of patients pretreated with 5-FU + LEV, four patients experienced a PR with a mean duration of 7.3 months (range > or = 4.0-8.6) for an overall response rate of 18% (95% CI 12-26%). A stabilization of disease was observed in five cases (23%) with a mean duration of > or = 5.6 months (range > or = 2.0-7.0). The remaining 13 patients progressed. No complete responses were achieved. The mean overall survival was > or = 9.5 months (range > or = 2.0-14.0). Toxicity was generally mild. This study demonstrates that the combination of s.c. rIL-2 and intravenous 5-FU + I-FA on a weekly schedule may be safely given to patients with metastatic CRC on an outpatients basis. The addition of low-dose rIL-2 does not modify the toxicity profile of 5-FU + I-FA, even if IL-2-related side-effects such as systemic symptoms or cardiac abnormalities are to be expected. The clinical activity of the combination is not good, at least in terms of response rate, even if the duration of partial responses may suggest to test rIL-2 in a prospective study with response duration and overall survival as the final end-points.

Gastric Banding for Treatment of Morbid Obesity: Preliminary Results.

BACKGROUND: gastric banding (GB) has been used for treatment of morbid obesity. METHODS: a banding device, introduced by Broadbent and consisting of a self-blocking nylon strip covered with a silicone tube, was used in 13 patients who have completed 1-year follow-up. This device was used for its mechanical properties, biocompatibility, ease of insertion and low cost. RESULTS: at 1 year, mean excess weight loss was 51.6%, with all but one patient losing more than 25% of excess weight. Associated illnesses resolved. There were two complications (15%): one patient required band removal for self-induced vomiting and one patient required repair of an incisional hernia. CONCLUSIONS: GB has had good results thus far. Reported differences depend on materials, stoma diameter, pouch size, and developing techniques.

[Organization of a center for prevention and treatment of obesity]. / Organizzazione di un Centro per la prevenzione e cura dell'obesità.

Obesity, a pathology with a multifactorial etiopathogenesis currently has an incidence of around 6% in the adult population in Italy. Considering that this disease provokes a statistically significant reduction of life expectancy, there is an evidence need to create structures which can deal with this problem. For this purpose, the Centre for the prevention and cure of obesity was set up by the Department of Surgery and Anatomy at the University of Palermo in 1990. It makes use of the specialist skills of experts in internal medicine, dieticians, cardiologists, psychologists and surgeons. In particular the authors give a detailed description of the diagnostic iter used and the methods of follow-up adopted for patients undergoing biliopancreatic diversion (BPD) surgery. In conclusion, the authors emphasize the need for a multidisciplinary approach to this pathology since this is the only way of minimizing complications arising during BPD surgery and obtaining the best results.

Combination chemotherapy of 5-fluorouracil, epidoxorubicin and mitomycin C in the palliative treatment of locally advanced and/or metastatic adenocarcinoma of the stomach.

Thirty-seven consecutive patients with advanced and/or metastatic gastric adenocarcinoma received a combination of 5-fluorouracil 600 mg/m2 on days 1, 8, 29, 36; epidoxorubicin 75 mg/m2 i.v. on days 1, 29; mitomycin C 10 mg/m2 i.v. on day 1. This cycle was repeated every 8 weeks. Out of a total of 34 evaluable patients, 2 (5.8%) had a complete response and 7 (20.6%) had a partial response with an overall median duration of 40 weeks (range 20-128). The median survival of responding patients was not reached after a mean follow-up of 76 weeks, while that of patients with no change and progressive disease was reached at 36 and 13 weeks respectively. Treatment was generally well tolerated with hematological and gastrointestinal toxicities being the major side-effects. Despite the use of epidoxorubicin 75 mg/m2, the 26.4% (95% confidence limits 16-36%) objective response rate is not satisfactory. Evaluation of more aggressive protocols is strongly recommended within the limits of controlled trials.

[Postoperative venous thromboembolism in bariatric surgery]. / Le tromboembolie venose post-chirurgiche in chirurgia bariatrica.

The authors discuss the problem of venous thromboembolism as a complication of bariatric surgery. They consider obese patients at risk for these complications, even if different opinions exist about this topic in the literature. They report their experience in bariatric surgery consisting of 53 patients submitted to biliopancreatic diversion. Antithrombotic prophylaxis consisted for every patient in elastic bandaging of the lower limbs, preoperative hemodilution, early post-operative mobilization, and subcutaneous heparin. Complications consisted in one popliteo-femoral deep venous thrombosis (DVT) (1.6%), and two pulmonary embolisms (PE) (3.2%) of which one caused patient's death; total morbidity for venous thromboembolism. These results compared with literature are similar with other series of bariatriac surgery and slightly higher than general surgery series. This difference is not however significant. Even in the absence of this significance, thromboembolism, as desumed from more than 2900 cases considered in the literature, remains the main cause of morbidity and mortality in the post-operative course of bariatric surgery patients, deserving particular attention in terms of prevention, also because of difficulty existing in early clinical diagnosis of DVT in obese people. Further studies intended to identify pathogenesis and risk factors of venous thromboembolism in obese people will allow a more correct prophylactic and therapeutic approach.

[Laparocele. A late complication of bariatric surgery]. / Il laparocele. Complicanza tardiva della chirurgia bariatrica.

In this paper the authors consider the problem of incisional hernias as late complications of bariatric surgery. After a description of relationships between obesity and incisional hernias they report their experience on this topic, consisting of 56 patients submitted to bilio-pancreatic diversion between March 1989 and September 1991, for surgical treatment of morbid obesity. Incisional hernias developed in 28% of cases. Analysis of some risk factors like infections, epidemiological patterns, materials and techniques used to suture the abdominal wall, has not allowed identification of significant associations with incisional hernias occurrence. Only early reinterventions (3 cases) have always determined a subsequent development of incisional hernias. The authors confirm the close relationship existing between obesity and incisional hernias. They suggest incisional hernia repair to be undertaken once weight loss has terminated and stabilized, and in the absence of other specific or aspecific morbid obesity surgery complications.

[Prophylactic cholecystectomy in bariatric surgery]. / Opportunità della colecistectomia profilattica in chirurgia bariatrica.

In this paper the authors discuss about prophylactic cholecystectomy in bariatric surgery. Having analyzed the mechanisms that increase bile lithogenicity after bariatric surgery, they evaluate advantages and disadvantages of prophylactic cholecystectomy. They present 53 obese patients submitted to biliopancreatic diversion and prophylactic cholecystectomy for surgical treatment of morbid obesity, because of the high incidence of pathological findings in the specimens and the absence of surgical complications related to cholecystectomy, the authors, in agreement with the literature, suggest routine cholecystectomy as an obvious adjunct to bariatric surgery. This attitude protects against the higher risk of subsequent cholecystectomy and against the misinterpretation of non-invasive diagnostic tests too, because of known limits of echography in obese people.

[Comparison of echo-Doppler and splenoportography in the hemodynamic evaluation of the portal system]. / Confronto tra eco-Doppler e splenoportografia nella valutazione emodinamica del circolo portale.

The Authors discuss the instrumental diagnosis of portal hypertension, comparing echo-Doppler and splenoportography by celiac artery catheterization, performed on 42 patients with cirrhosis. From the data obtained, there may be observed a clear correlation between angiographic and echographic criteria, correlated to the degree of illness. In particular echo-Doppler whether it possible, in a non-invasive way, to control the evolution of progressive haemodynamic resistance, and hepatic and splenic parenchyma, leaving to splenoportography the role to depict anatomic characteristics of portal circulation for a correct surgical program.

[Diagnostic "gold standard" in cerebrovascular insufficiency. Comparison of angiographic and ultrasonic imaging]. / "Gold standard" diagnostico nella ICV. Imaging angiografico e ultrasonico a confronto.

The Authors consider the complex diagnostic problems of cerebrovascular disorders, with particular concern to angiography and echography. After a complete analysis of different aspects of angiographic and echographic lesions, considering their experience, they identify chances and limits of the two methods, they draw the conclusion that each of the two techniques has a proper role, and only a correct correlation between them can depict correctly the pathologic lesions.

Biliopancreatic Diversion: early complications.

The experience and early complications in 66 morbidly obese patients who underwent biliopancreatic diversion are presented. There was one death, due to a pulmonary embolus (PE) at home on the 15th postoperative day. Postoperative complications occurred in nine patients, consisting of gastric hemorrhage (2), gastric outlet obstruction (2), non-lethal PE (1), deep vein thrombosis (1), wound dehiscence (1), and asymptomatic gastric leak (1). In addition, there were 12 superficial wound infections. Four patients required urgent reoperation for gastric hemorrhage (2), gastric outlet obstruction (1), and wound dehiscence (1). The high complication rate is believed to represent the early part of the learning curve. Some reports of the early complications following other bariatric operations are discussed.

Fibrosclerotic lymphedema: pathophysiology and therapy.

We describe our experience with 12 patients with severe fibrotic lymphedema treated between 1979 and 1987. Each patient initially underwent nonoperative treatment (postural drainage and pneumatic compression) and in 10 patients who required operation, these measures were continued postoperatively. Operation included excision of subcutaneous tissue (debulking), which was extensive in 8 and limited in 2 patients. Only 2 patients were satisfactorily managed by nonoperative treatment alone. Based on the extensive pathophysiologic changes that occur in the tissue microenvironment with lymph stasis, it is unlikely that at this advanced stage of lymphedema that nonoperative treatment alone or "physiologic" operations such as lymphatic-venous shunt or lymphatic collector reconstruction is satisfactory. Rather, nearly all such patients require limited or extensive excision of the fibrotic-edematous subcutaneous tissue.

[Femoral anastomotic pseudoaneurysms]. / Gli pseudoaneurismi anastomotici a sede femorale.

In this paper the Authors discuss about femoral anastomotic pseudoaneurysms. They throughly consider the etiopathogenesis of this late complication of arterial prothesic surgery, pointing out the different hypothesis currently discussed. Particularly from this analysis it can be concluded that the choice of appropriate prothesic grafts and the weakness of an eventually endarterectomized arterial wall are the principal determinants in causing pseudoaneurysms. Between the different therapeutic choices the opportunity of an interposition graft is underlined, except for (rare) cases when an extra-anatomic bypass must be preferred.