Malignant colonic obstruction managed by endoscopic stent decompression followed by laparoscopic resections.

BACKGROUND: Acute left-side colonic obstruction is a surgical emergency whose management is controversial. Recently metallic expandable stents have been used to relieve obstruction either to palliate the condition or to prepare for an elective surgical resection. METHODS: We propose a new minimally invasive therapeutic strategy for the management of malignant colonic obstructions: emergency endoscopic stenting followed by elective laparoscopic one-stage resection. The first four cases are presented. RESULTS: The stents were positioned successfully in all cases, and all the patients had an immediate restoration of bowel functions. After a period that varied from 4 to 5 days, they underwent a one-stage laparoscopic resection and were discharged 5 to 7 days after the operation. There were no postoperative complications. CONCLUSIONS: Malignant colonic obstruction can be managed by a sequential minimally invasive endolaparoscopic approach with an excellent postoperative outcome, good patient comfort, and a short hospital stay without the need for diverting stomas. A study involving a larger number of patients is needed to determine whether this approach is superior to traditional open surgery in terms of morbidity, mortality, quality of life, and recurrences.

[Gastric carcinoma. Our experience]. / Il carcinoma gastrico. Nostra esperienza.

This study analysed 66 cases of gastric cancer from 1985 to 1992. Twenty-seven patients (41%) has been treated with anti-H2 drug, either medical care or Jerkily "a la demande": 12 patients have been treated several years. Of the 66 patients: 52 (89%) were operated on while the other 16 received medical treatment because of the extension disease and their precarious condition. Long-term 35 (67%) patients (of the 52 operated) died four years later, independently of the stage and PKT of the first and the second level. The 27 patients treated with anti-H2 drug showed the most undifferentiated grading and 88% belong to the third and the fourth stage; moreover 81% underwent first diagnostic endoscopy notwithstanding a clinical and surgical history of gastric ulcer. Is it possible, therefore, that anti-H2 drug delay the diagnosis.

[Palliative endoscopic treatment of esophageal neoplastic stenosis]. / Considerazioni sul trattamento palliativo endoscopico delle stenosi tumorali dell'esofago.

The authors examined a series of 231 patients suffering from unoperable neoplastic dysphagia of the esophagus and treated using prevalently palliative endoscopic methods (photocoagulation and/or intubation) during the period 1980-1991. They draw the following conclusions: a) endoscopic methods are better than surgical techniques; b) there are a greater number of indications for endoscopic intubation than for photocoagulation (approximately 2 to 1); c) some situation which are indicated for photocoagulation are not contraindicated for intubation; d) the sole contraindication for intubation is stenosis in which the proximal limit is less than 2 cm from the upper esophageal sphincter; e) contraindications for photocoagulation are long stenoses and/or those of the infiltrating type, and/or involving the upper third of the esophagus; f) sometimes the two methods may be complementary in the sense that intubation may be preceded by a few photocoagulation sessions in order to necrotize the vegetating portion of an infiltrating tumour; g) it is best to choose intubation wherever possible since this technique is less expensive and the quality of remaining life better, even if the percentage of severe and generally fatal complications (perforation) is still too high; h) the possible introduction of expandable metal prostheses might increase indications for intubation and reduce the number of severe complication.

[Surgical treatment of perforation of colonic diverticula]. / Trattamento chirurgico della perforazione dei diverticoli colici.

Personal experience of 32 cases of colon diverticula observed between 1972 and 1989 is reported. Nine conservative operations and 23 resections of the perforated segment of the colon, followed 20 times by primary anastomosis, were performed. The importance of removing the sector of the colon involved is reiterated. It is concluded that a sectorial type primary resection-anastomosis is advisable in the case of generalised peritonitis, preceding the operation with an abundant peritoneal wash-out. Protective colostomy can be avoided by using an endoluminal active aspiration tube. In a series of 11 primary resection-anastomosis operations carried out in the presence of general peritonitis, anastomotic dehiscence was never observed.

[Traumatic perforation of the duodenum: report of 5 cases]. / Perforazioni traumatiche del duodeno: a proposito di 5 casi.

The results of surgery in 5 cases of traumatic rupture of the duodenum are presented. The site of the laceration, the time between trauma and operation, associated lesions, diagnostic routine and type of operation are specified. The mortality encountered (40%) should be related to the seriousness of the lesions.

[Endoscopy or surgery in the treatment of obstructive jaundice]. / Endoscopia o chirurgia nel trattamento dell'ittero ostruttivo.

The role of operative endoscopy as opposed to surgery in the treatment of obstructive jaundice is in continuous positive evolution due to the rapid technical progress made in the use of this method. Of a total of 93 patients treated over the course of 3 years, some received surgical treatment alone, others endoscopic treatment alone, and a third group received endoscopic therapy followed by surgery. Various parameters were taken into consideration for the three groups studied: the pathological cause of jaundice, age, sex, success of the method used, early and late complications, hospital deaths. Results were then compared.

[Biliary ileus. Our experience]. / Ileo biliare. La nostra esperienza.

Personal surgical experience of 7 cases of typical gallstone ileus and 2 cases of Bouveret's syndrome secondary to spontaneous bilio-digestive fistula of lithiasic aetiology are reported. After analysing the problems inherent in the clinical picture and the diagnostic protocol, stress is laid on the therapeutic strategies employable in the event of typical gallstone ileus. It is concluded that single stage correction of the bilio-digestive occlusion and fistula is always preferable except in patients whose general condition is very poor. Patients should initially be submitted to treatment of intestinal occlusion alone.

[Retrospective analysis of 1354 autopsies in cases of death caused by trauma]. / Analisi retrospettiva di 1354 autopsie in casi di decesso per trauma.

1,354 deaths due to traumatic causes arising in 1976-1985 among patients admitted to the Molinette Hospital, Turin were analysed. The causes were divided into 5 major groups with to monitoring the course of the pathologies concerned over time. The results confirm an increase in deaths from septic shock that reflects increased recourse to surgery and the application of resuscitation manoeuvres and equipment, but a decrease in death due to haemorrhagic shock. These two pathologies represent the major lines for future research aimed at improving the prognosis in traumatic lesions.