Long-term outcome of consecutive case series of congenital isolated agenesis of corpus callosum.

OBJECTIVE: To describe the long-term outcome of children with prenatally diagnosed isolated complete agenesis of the corpus callosum (cACC). METHODS: In this single-center case series, we reviewed retrospectively the charts of fetuses referred to our fetal therapy unit from January 2004 to July 2020 for a suspected anomaly of the corpus callosum (CC). Cases with prenatally diagnosed isolated cACC were included. Fetal karyotype and comparative genomic hybridization microarray of amniotic fluid, in addition to fetal magnetic resonance imaging, were offered to all pregnant women with a diagnosis of fetal CC malformation. The surviving children were enrolled in the neurodevelopmental follow-up program at our institution, which included postnatal magnetic resonance imaging, serial neurological examinations and neurodevelopmental evaluations with standardized tests according to age. Families living in remote areas or far from our institution were offered a structured ad-hoc phone interview. RESULTS: A total of 128 pregnancies with fetal CC malformation were identified (mean gestational age at diagnosis, 24.5 (range, 21-34) weeks), of which 53 cases were diagnosed prenatally with apparently isolated cACC. Of these, 12 cases underwent termination of pregnancy, one resulted in intrauterine demise at 24 weeks of gestation and 13 cases were lost to follow-up. Of the remaining 27 children, one was excluded due to an associated chromosomal anomaly (8p21.3q11.21 mosaic duplication) diagnosed after birth, which could have been detected prenatally if the parents had consented to amniocentesis. In the 26 children included in the analysis, neurodevelopmental follow-up was available for a median of 3 (range, 1-16) years. Three (11.5%) infants had severe neurodevelopmental impairment, two of which were diagnosed postnatally with a genetic syndrome (Mowat-Wilson syndrome and Vici syndrome) that would not have been diagnosed prenatally. Seven (26.9%) children had mild neurodevelopmental impairment and 16 (61.5%) had normal neurodevelopmental outcome. The Full-Scale Intelligence Quotients of the three children with severe neurodevelopmental impairment were 50, 64 and 63, respectively, while that of the remaining children was in the normal range (median, 101; range, 89-119). CONCLUSIONS: In 88% of the children with cACC included in this study, neurodevelopment was not severely impaired. However, long-term follow-up is recommended in all cases of congenital isolated cACC to recognize subtle neurodevelopmental disorders as early as possible. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Rare cases reports of gastrointestinal stromal tumour (GIST).

The GISTs are rare tumours but even rarer is the localization in some districts. We reported two GISTs of the duodenum, two of the omentum and peritoneum, one of the rectum and one of a Meckel's diverticulum. These exceptional locations are confirmed by the relative difficult diagnosis, obtained in some cases only by the surgical treatment despite the CT and MR. The endoscopy is useful in hemorrhagic and duodenum forms, only for the diagnosis and for the control of blood loss. Surgical treatment in all cases was decisive without the need to make use of adjuvant therapy, with positive long-term results, which excluded the disappearance of relapses or secondary lesions.

Whipple's disease infection surgical treatment: presentation of a rare case and literature review.

The Whipple' Disease (W.D.) is a very rare disease with an incidence of 1 per 1.000.000 inhabitants; it is a systemic infection that may mimic a wide spectrum of clinical disorders, which may have a fatal outcome and affects mainly male 40-50 years old. The infective agent is an actinomycete, Tropheryma Whipplei (T.W.) that was isolated 100 years after first description by Wipple, and identified in macrophages of mucosa of the small intestine by biopsy which is characterized by periodic acid-Schiff-positive, products of the inner membrane of his polysaccharide bacterial cell wall. The multisystemic clinical manifestations evolve rapidly towards an organic decay characterized by weight loss, malabsorption, diarrhea, polyathralgia, opthalmoplegia, neuro-psychiatric disorders and sometimes associated to endocarditis. Early antibiotic treatment with trimethoprim and sulfometathaxazole reduces the fatal evolution of the disease. The authors present a rare experience about a female subject in which the clinical gastrointestinal signs were preceded by neuro-psychiatric disorders, and evolved into obstruction and intestinal perforation which required an emergency surgery with temporary ileostomy, recanalized only after adequate medical treatment with a full dose of antibiotic and resolution of clinical disease for the high risks of fistulae for the edema and lymphadenopathy of mucosa. The diagnosis was histologically examined by intestinal biopsy performed during surgery, which showed PAS-positive histiocytes, while PRC polymerase RNA was negative, which confirms the high sensibility of PAS positive and low specificity of RNA polymerase for T.W.

Surgical management of symptomatic simple hepatic cysts.

The authors present three cases of symptomatic, large, benign, nonparasitic hepatic cysts. The diagnosis was determined by US and CT scan, the latter enabling differential diagnosis with neoplastic or hydatid cysts. All patients were treated with open hepatic resection. In 2 cases, laparoscopy was performed to enable complete diagnosis. The authors used LigaSure™ (Covidien, USA) instrument, avoiding bleeding complications and reducing surgery time. Histological examination confirmed the diagnosis of benign cysts. CT follow-up at 6 months and 1 year demonstrated the efficacy of the surgery, with no recurrences.

Delayed decline of gamma-globin expression in infant age associated with the presence of Ggamma-158 (C-->T) polymorphism.

Persistent production of fetal hemoglobin (HbF) in adult has ameliorative effects on hemoglobinopathies and great efforts are currently made to achieve an exhaustive understanding of the molecular mechanisms of the switching in globin gene expression. One of the factors reported to be associated with the expression of fetal globin genes is the Xmn I Ggamma-158 polymorphism, although it is still unclear if it is involved in this mechanism either by itself or in strong linkage disequilibrium with other loci. Here, we report a novel effect of the Xmn I Ggamma-158 site that was found associated with a significant delayed decline of HbF production in infant age. The prolonged decay trend was enhanced when the Ggamma-158 C-->T substitution was co-inherited with a beta-thalassemic trait. Our observations reinforce the hypothesis that this region plays an important role in the expression of the gamma-globin genes and give new insights on the intriguing and still poorly understood mechanisms of globin gene expression switching.

[Giant and bilateral adrenal myelolipoma. Case report]. / Mielolipoma surrenalico bilaterale gigante. Caso clinico.

The adrenal myelolipoma is a relatively rare benign tumour of adipose cell and bone marrow elements, non functioning and asymptomatic. Giant and bilateral adrenal myelolipoma is quite rare. The Authors report a case of bilateral adrenal myelolipoma, a giant one (> 15 cm) on the left side and a small one (> 4 cm) on the right with constant pain in a 57-year-old man, shown by computerized tomography. The hormonal blood tests were normal. Surgical excision was performed for large left symptomatic mass, by open laparotomy, and biopsy for right minor adrenal lesion. Histology confirmed diagnosis of myelolipoma for both masses. Follow-up to 6-12 months did'nt show any change of the right myelolipoma. The authors agree with the need to remove the giant adrenal myelolipoma, because the lesion > 10 cm have a high risk of cancer and hemorrhagic complication, while for small myelolipoma (< 6 cm) 6-12 months follow-up is the appropriate choice.

[Two cases of small bowel ischemia due to unusual cause]. / Ischemia intestinale da cause inusuali. Presentazione di due casi.

The authors report 2 cases of small bowel ischemia due to unusual cause. In both cases, vasculopathy was the cause of ischemia, but with a different etiology. In the first case, a mesenteric inflammatory veno-occlusive disease, with striking features of extensive phlebitis and venulitis affecting the veins of the small intestine and mesentery, without arterial involvement of this district was observed and histological examination showed inflammatory lymphocytic infiltrates and myointimal hyperplasia of the veins. The second case affected by intestinal ischemia from secondary and multiple cholesterol embolism, the histological examination showed inflammatory infiltrates with (lymphocytes and granulocytes) in the vessels of submucosal mesenteric area, by loose intimal fibrosis incorporating cholesterol clefts. Both patients required surgical exploration with resection of ischemic bowel. In the second case laparoscopy was the initial approach which allowed to identify the extension of ischemia with special regard to the perforation. The ultimate diagnosis is possible only with histological examination. Clinically, patients show the general signs of intestinal ischemia with pain, vomiting and bloody diarrhea. Prognosis depends on the extension of the lesions and the early surgical treatment.

[The surgical needs of elderly patients in day-surgery]. / I fabbisogni di chirurgia in Day Surgery nell'anziano.

AIM: The possibility of carrying out surgery in day-surgery (DS) conditions is gradually becoming reality in most branches of surgery; in recent years, DS has also found a place in general surgery, with unquestionable advantages for the management of patients, particularly the elderly. The purpose of the present study is to investigate general surgery needs in DS conditions in elderly patients in order to analyse the clinical-administrative feasibility of DS procedure and the level of its acceptability in this group of patients. METHODS: A specially drafted questionnaire was submitted to patients admitted over a period of 18 months to the General Surgery Division of the University of L'Aquila. The details investigated in the questionnaire were: age, sex, educational qualification, working activity (independent or employee), presence in the patient's relational entourage of health workers willing to serve the patient at home, the patient's willingness to undergo the surgery for which he was admitted to the DS. The questionnaires of the over-64s were examined and the percentage of patients willing to undertake DS intervention instead of normal hospitalisation was evaluated; this willingness was then compared with the parameters sex, educational qualification, working activity and presence in the patient's relational entourage of health workers willing to assist the patient at home. RESULTS: 317 questionnaires were compiled. In 78 cases (24.6%) the patient was older than 64; the data for these patients were extrapolated. Willingness to undergo surgery in DS conditions was expressed by 23 patients (29%), whereas 55 patients (71%) stated that they were not available. In relation to sex, willingness to use the DS was 29.7% in the 37 male patients and 29.2% in the 41 females. With reference to the qualification, willingness was expressed by 71.4% of patients with a degree, 26.9% of patients with a high school leaving certificate and 15.7% of patients with a lower qualification. DS-willingness was 28% in the 75 pensioners and 66.6% in the 3 patients who worked for themselves. As regards the presence in the relational entourage of the patient of health workers ready to assist at home, DS-willingness was 23.9% in the 71 patients who did not have anyone in their relational entourage and 85.7% in the 7 patients who had such a health worker in their entourage. CONCLUSIONS: Willingness to undergo DS by elderly patients is mainly influenced by three factors: educational qualification, working activity and possibility to have home assistance from someone in the relational entourage; these parameters can be considered veritable selection criteria for DS in the elderly. The quality improvement in assistance levels and the introduction in the near future of telematic communication system could lead to an extension of DS indications to the elderly.

[Surgical treatment in acute cholecystitis emergencies]. / Trattamento chirurgico in urgenza della colecistite acuta.

The aim of the study was to demonstrate the importance of early laparoscopic cholecystectomy for acute cholecystitis, without "conservative" treatment (intravenous fluids and antibiotics for 48-72 hours) to reduce inflammation. Early laparoscopic cholecystectomy reduces bile duct injury and the percentage of conversion to open cholecystectomy. Thirty-five patients with acute cholecystitis were submitted to early laparoscopic cholecystectomy, equally divided according to sex. All patients were submitted to US scans preoperatively and operated on by surgeons skilled in emergency laparoscopic operative techniques. Laparoscopic cholecystectomy was always performed with 4 trochars and the use of a 30 degrees laparoscope. Technical modifications during early laparoscopic cholecystectomy were drainage and decompression with subsequent de-tension and distention of the gallbladder. These manoeuvres entailed the use of Babcock, Endopatch (Ethicon) atraumatic forceps. In the presence of acute gallbladder inflammation we dissect the gall-blader well with a suction-irrigation tube. In patients suspected of having common bile duct stones, biliary duct injuries and/or anatomical changes due to inflammation, we perform intraoperative cholangiography. Five patients had conversion to open cholecystectomy (14.2%), in two cases (5.7%) for concomitant choledochal stones, in two cases (5.7%) for biliary peritonitis and in the fifth case (2.8%) for severe empyema of the gallbladder. Laparoscopic cholecystectomy was performed in 20 patients for acute cholecystitis (57.1%), in 9 patients for empyema (25.7%) and in 6 patients for gangrenous cholecystitis. Four cases presented postoperative complications owing to bile leakage from the liver bed, treated with antibiotic therapy. One patient presented jaundice on day 30 after laparoscopy owing to inadequate positioning of the clips on the cystic duct, near the common bile duct; ERCP was performed with application of a prosthesis, which was removed after two months. Our experience and results support the validity of early laparoscopic cholecystectomy in the treatment of acute cholecystitis, because it reduces the postoperative length of hospital stay and hospital costs. Early treatment is always helpful for inflamed and oedematous tissue which favours dissection, while dense, fibrotic adhesions hinder regular dissection with a greater risk of injury to the biliary duct and and a higher conversion rate to open cholecystectomy.

[Laparoscopic appendicectomy: an 8-year clinical experience]. / Appendicectomia laparoscopica: esperienza clinica di 8 anni.

BACKGROUND: For more than a century, open appendectomy through a laparotomy has been the golden standard for the surgical removal of the appendix. Nowadays, many surgeons question the utility of laparoscopic surgery to perform appendectomies because it is commonly stated that the appendix can be removed through a small surgical incision carrying a minimal surgical trauma to the patient. Although open appendectomy is really safe, on the other hand it carries a considerable risk of postoperative complications, is associated with postoperative pain and affects patient s normal activity. Laparoscopic appendectomy was first described in 1983 and, in many studies, it is described to be better than open standard technique for the treatment of appendiceal diseases. The aim of the present study is the retrospective analysis of laparoscopic appendectomies performed in a 8-year period. METHODS: The authors report on 129 patients who underwent laparoscopic appendectomy. RESULTS: Conversion rate was 0.7 %, while the laparoscopic procedure was completed in 96 female and 32 male patients. The position of the appendix was behind the cecum in 37 cases, associate diseases were found in 15 cases. Mean operative time was 51 minutes; kind of laparoscopic instrumentation affected the operation time. Histologically there were 71 (55.5 %) focal appendicitis, 22 (17.1 %) suppurative appendicitis, 11 (8.6 %) gangrenous appendicitis, 18 (14.1 %) chronic appendicitis showing signs of previous suppurative episodes and 6 (4.7 %) normal appendix. There were neither in-hospital morbidity nor mortality. Follow-up showed reduced postoperative pain, short hospital stay, fast return to complete social activity. CONCLUSIONS: The authors conclude that laparoscopic technique can be considered a safe and effective procedure for the removal of the appendix as it has the advantage of allowing faster postoperative recovery; moreover the author recommend a wider and routinely use for appendectomy.

[Intestinal infarction. Retrospective clinical study]. / L'infarto intestinale. Studio clinico retrospettivo.

Acute mesenteric ischaemia is the result of inadequate blood flow to all or part of the small intestine and the right half of the colon. Irrespective of the cause of the ischaemic insult, the end results are similar, namely, a spectrum of bowel injury ranging from completely reversible alterations of bowel function to transmural haemorrhagic necrosis of the intestinal wall. Depending on the degree of ischaemia and the length of bowel involved, a wide variety of clinical presentations are observed. Mesenteric infarction is a pathology which is encountered fairly often in elderly patients where the concomitance of other diseases make its prognosis more severe, especially since the diagnosis is usually late. The pessimism expressed more than 70 years ago concerning this disease is still shared by many physicians today. The authors report on their experience with 37 cases of mesenteric infarction. The median age of the patients was 77 years (range: 66-91). The mortality rate was 67.5% (25 deaths) which is in line with the results in the literature. The median hospital stay was 17 days (range: 10-71). The authors emphasise the difficulty of diagnosing and treating this entity, also in view of the fact that, in most centres, it is impossible to perform emergency selective angiography of the superior mesenteric artery. The need for an early specific diagnosis is stressed, because the therapeutic options may vary widely in relation to the different causes of acute intestinal ischaemia.

[Sigmoid occlusion due to endometriosis. A case report]. / Occlusione del sigma da endometriosi. Presentazione di un caso.

The Authors report a case of sigmoid obstruction due to endometriosis and review the literature about. Unusual localisation and difficult preoperative differential diagnosis with IBD and bowel carcinoma are stressed. A 45-years old woman with previous history of oophorectomy was admitted at the hospital with symptomatic bowel obstruction. A barium enema showed a sigmoid stenosis thought to a carcinoma of bowel. A laparoscopic approach confirmed the diagnosis and a laparotomy was performed with a subsequent anterior resection (end-to-end anastomosis with stapler) plus myomectomy. The Authors do believed, during surgery, to be treating a carcinoma which disappeared with opening the specimen. The mucosa were intact and muscular layers so think to form a strong ring to be able to invaginate the upper colon for 3-4 cm. A stromal tumor was supposed and the definite diagnosis of endometriosis was very surprisingly. Intestinal resection to be necessary, with associated salpingo-oophorectomy and hysterectomy in older patients and treatment with oral contraceptive in younger female. Laparoscopy may be helpful in the diagnosis showing pelvic endometriosis with bowel wall involvement. Laparoscopic treatment in our opinion must be confirmed to particular situation and to well experience of surgeons.

[Aortic dissection: role of the general surgeon in diagnostic-therapeutic procedure]. / Dissecazione aortica: ruolo del chirurgo generale nell'iter diagnostico-terapeutico.

Aortic dissection occurs when there is a tear or separation of the aortic intima from the media; flow of blood into the intima-media space allows the tear to develop into a dissecting hematoma. Aortic dissection is a rare condition which represents an acute cardiovascular emergency for which the appropriate therapy is immediate surgical correction. Patients with aortic dissection show a heterogeneous constellation of symptoms; hence, clinical suspicion is often difficult. Only a minority of patients has "classic" symptomatology, the electrocardiogram is often misleading and the chest radiogram is almost always non-specific. In Italy, the usual "hospital routine practice" assigns the key-role in the emergency diagnostic procedure for these patients to the general surgeon. In view of the necessity of immediate cardiac surgery and the overwhelming likelihood of adverse events when surgery is delayed, techniques for diagnosis must be accurate, widely available and easily and quickly used. The present study consists of four case-reports of aortic dissection thoroughly examined and confronted with the literature. Management strategy based on emergency echocardiography is a reliable, feasible and successful technique for evaluating patients with aortic dissection. It allows a rapid accurate diagnosis with a single examination that can also be performed in the emergency room and provides information of sufficient diagnostic value to allow immediate cardiovascular surgery. CT scan and/or MRI are also valid tools for the emergency diagnosis of aortic dissection. However, a major problem still exists: the range of symptoms is sufficiently broad that a high index of "personal suspicion" of aortic dissection is required on the part of the general surgeon when he performs the role of "emergency-team leader".

[Laparoscopic treatment of varicocele]. / Il trattamento laparoscopico del varicocele.

The Authors present their experience on the treatment of the varicocele; they performed laparoscopic clamping of the internal spermatic vein in 12 subfertile patients, utilizing only the bipolar coagulation without the use of clips. All patients were available for follow-up, which ranged from 6 to 12 months, including physical examination, Doppler C.W. and study of semen quality. Recurrence of varicocele was not observed, the semen quality demonstrated improvement in semen motility in 9 patients (75%) and normal on 3 patients (25%). The use of bipolar coagulation with smaller ports (phi 5 mm) resulted in less postoperative pain and shorter convalescence than when larger ports were used (phi 10 mm). The Authors conclude that the laparoscopic procedure, used as they do, is safe and costs less than classic ligation with clips as well as radiological occlusion procedures.

Videolaparoscopic treatment of Spigelian hernias.

Because treatment for Spigelian hernia is rarely discussed in the literature, this report presents two cases observed in a recent 6-month period by the U.O.A. Independent General Surgery Department, Hospital of Este. Both patients had laparoscopic treatment using a polypropylene prosthesis, which confirms the technological validity of the surgical method. The described cases are emblematic, because the intervention permitted a resolution of associated pathologies (gallbladder gallstones and umbilical hernia), which confirms both the efficacy of the surgical technique and of the high diagnostic precision of laparoscopy, as it is described by several sources. The validity of the technique is also confirmed by the quick recovery of patients and by the reduced hospitalization time, especially in elderly patients and in precarious general conditions.

[Role of laparoscopy in abdominal traumas: a case report]. / Ruolo della laparoscopia nei traumi addominali: presentazione di un caso clinico.

The Authors report a case of abdominal traumatism by gunshot wound, presenting with retroperitoneal hematoma and hematoma of the mesocolon, treated in emergency laparoscopy. After a literature review and their case report analysis, they confirm the importance of emergency laparoscopy in hemodynamically stable patients, as well as the diagnostic value of peritoneal lavage, positive for minimal and moderate hemoperitoneum. Laparoscopy allows, as the same time in most cases, the diagnosis and the management of the lesion, while surgery is reserved to the cases of severe hemoperitoneum and perforating injuries. The use of laparoscopy in abdominal blunt injuries, has reduced the number of unnecessary laparotomies with related higher incidence of morbidity. The Authors conclude confirming the importance of this technique for its diagnostic efficacy, lower costs, minimal traumatism, and good aesthetic results as observed in the case report for the modality of the injuries, the young age and the previous sternotomy of the patient.

[Inguinal hernioplasty: current trends]. / L'ernioplastica inguinale: attuali orientamenti.

The Authors report their experience in the surgical management of 282 inguinal hernias classified according to Gilbert's classification. The different techniques used were compared analysing the results obtained in 104 patients operated with the Bassini hernioplasty, while in 120 cases the Lichteinstein tension-free repair and in 58 cases the Shouldice hernioplasty were performed. In the patients operated according to the Lichteinstein tension-free technique an Autosuture mesh was used. The Authors conclude that the Lichteinstein tension-free repair is preferable, not simply for the incidence, although low in this series, of recurrence observed with the Bassini hernioplasty, but particularly for the reduced postoperative pain, the fast return to full activities, the low cost, and the possibility to be performed in Day-Hospital.

[The current controversies over video laparoscopic cholecystectomy as the treatment of choice for cholelithiasis]. / Attuali controversie sulla colecistectomia per via videolaparoscopica come trattamento di scelta per la calcolosi della colecisti.

Recently, the widespread use of laparoscopic cholecystectomy allowed to reach several goals such as a minimal invasive approach, a minimal operative trauma, the absence of aesthetic or functional damage of the abdominal wall, and a quick return to full activities. On the other hand, as all innovations, laparoscopic cholecystectomy is matter of debate and a number of controversies have recently appeared in the Scientific Literature. On the basis of their experience and through a critical review of the Literature, the Authors have therefore analyzed possible solutions to such controversies. Particularly, current indications and contraindications of this approach, surgical technique and relative sites of insertion of the trocars, the need to drain or not, the pre- and intra-operative study of the bile duct and the approach in case of bile duct stones pre- or intra-operatively demonstrated, have been evaluated as possible answers. The Authors conclude that indications to laparoscopic cholecystectomy are the same of those for laparotomy, contraindications are represented by coagulopathies, liver cirrhosis and plastic peritonitis. At present it is still impossible to affirm which is the best surgical technique, the best position for the surgeon, and the best site for the insertion of the trocars, while drainage must be used only in those cases in which further manoeuvres on the bile duct are required. At last the Authors underline there is no need for a routine intraoperative cholangiography during laparoscopic cholecystectomy, however such technique must be known by laparoscopic surgeons since it may be mandatory in some selected cases. ERCP, on the contrary, is a valid support to laparoscopic cholecystectomy in the treatment of gallbladder stones associated with bile duct stones.

[Ambulatory treatment of postphlebitic ulcers of lower limbs. Physiopathological bases and clinical results]. / Il trattamento ambulatoriale delle ulcere postflebitiche degli arti inferiori. Basi fisiopatologiche e risultati clinici.

Venous ulceration is a troublesome and disabling complication, representing one of the most difficult problems to be treated by the vascular surgeon. Venous insufficiency is a widespread condition, the prevalence of venous ulceration being 0.5 - 1 per cent in European populations. Although all venous ulcers will heal if the limb is elevated above heart level for an extended period of time, patients need a safe, effective, not disabling and quick therapy. Hence, the competent vascular surgeon must be familiar with venous pathophysiology and possess a thorough understanding of the treatment options available for a discouraged patient in need of an acceptable and effective approach. The aim of the present study was to assess the efficacy and the speed of healing of venous ulcer using an outpatient ambulatory treatment protocol. This protocol consisted of elastic compression bandage allowing deambulation, local dressing using lyophilized heterologous collagen (Condress, Gentili) and systemic profibrinolytic drugs. Exclusion criteria were coexisting arterial insufficiency, ulcer area greater than 25 cm2, coexisting disabling diseases (congestive cardiac failure, hepatic insufficiency, malignancy). From December 1990 to June 1993, 37 patients affected by venous ulcer were treated, according to the aforementioned protocol, at the Surgical Department of Montecchio Maggiore Hospital (VI). There were 16 male and 21 female patients, mean age was 66 years (range 59-91). Results show the complete healing of the venous ulcer in 94.5% of patients; mean time for ulcer healing was 128 days (range 45-91). The Authors conclude that the outpatient ambulatory treatment protocol is safe, quick, and effective for the therapy of chronic venous ulcer; once obtained the healing of the ulcer, elastic compressive bandage with elastic stockings is mandatory to prevent recurrences.

[A rare case of accessory choledochus associated with diverticulum of the common bile duct]. / Un raro caso di coledoco accessorio associato a diverticolo della via biliare principale.

The Authors report on a rare congenital anomaly of the biliary tract characterized by an accessory choledochus, which drained the inferior paramedian segments of the liver. Such anomalous duct emerged from the hepatic hilum right behind the cystic artery, the cystic duct and the gallbladder to join the primary choledochus few millimeters from the papilla of Vater. At the point of junction, in the posterior aspect of the II duodenal portion, a choledochal diverticulum containing cholesterin and bilirubin stones was also present. Surgery was indicated by the onset of a pseudo-obstructive syndrome followed by jaundice. At laparotomy the exact diagnosis was possible. The intervention consisted in a choledochotomy and duodenotomy with tube drainage and exeresis of the choledochal cyst containing the stones.