Laparoscopic treated so-called reformed gallbladder in patient with postcholecystectomy chronic pain.

INTRODUCTION: Inadequate calculi removal, bile stasis, inflammation and strictures are causes of postcholecystectomy biliary syndrome. A cystic duct remnant is defined as a residual duct greater than 1 cm; it may predispose to chronic postcholecystectomy symptoms. CASE REPORT: We describe a case of a 33-years-old woman with recurrent epigastric pain radiating to right back. In the past medical history, an uncomplicated cholecystectomy was reported 11 years earlier. Imaging demonstrated a 2 cm impacted calculus within a cystic duct remnant, mimicking a so-called reformed gallbladder. At the magnetic resonance imaging the biliary tract was regular without dilatation. The patient was scheduled to laparoscopic exploration. Intraoperatively, the cystic duct stump containing the impacted calculus was easily found and meticulously dissected from extrahepatic bile structures. CONCLUSION: In our experience the laparoscopic removal was safely performed with complete cystic duct remnant excision and definitive cure of chronic painful symptoms. Therefore we think that, in selected cases, the reoperation is feasible by means of mininasive surgical procedures.

Endoscopic therapy for type B surgical biliary injury in a patient with short cystic duct.

Anatomical variations of the cystic duct are well-defined. The presence of short or absent cystic duct is unusual and represents a co-factor of biliary injury especially during laparoscopic cholecystectomy. Thus, its knowledge is important to avoid ductal injury in hepato-biliary surgery. We experienced the case of a 40-year-old woman with symptomatic cholelitiasis, who underwent to laparoscopic cholecystectomy. At surgery, an accidental bile duct lesion was carried, during Calot's triangle dissection, due the particular difficulties in dissecting an extremely short cystic duct found at the junction of the common hepatic duct and common bile duct. No vascular anomalies were present. The biliary leakage from the common bile duct was intraoperative identified and subsequentially treated by the endoscopic method. Laparoscopic cholecystectomy with sequential biliary endoprosthesis insertion was completed without conversion to open surgery. The endoscopic stenting was the definitive treatment for the leakage. No evidence of biliary stent complication was observed during the follow-up. This report documents a case of short cystic duct with particular emphasis to the biliary injury risk during the laparoscopic dissection of "unusual" Calot's triangle, and examines our mini-invasive therapeutic strategies in the management of bile leakage after laparoscopic cholecystectomy.

Laparoscopic colectomy in colon cancer. A single-center clinical experience.

INTRODUCTION: Aim of our study was to compare the results of the laparoscopic technique to those obtained by traditional open approach in patients with colon cancer. The advantages, disadvantages, and the contraindications (real and presumptive) of this mini-invasive approach are described, by comparing the data obtained from the international literature with our clinical experience. PATIENTS AND METHODS: From February 2000 to May 2006, we performed 73 laparoscopic colectomies for cancer in the Operative Unit of General and Laparoscopic Surgery, Department of Surgical Sciences of the University of Chieti, Italy. The data of these patients were compared with the data obtained from 141 other patients who underwent open procedure for the same pathology in the same period and in the same Unit. Factors such as obesity, previous major abdominal surgery, T4 cancers, perforation and obstruction of the colon, tumor located in the transverse colon or in the left flexure of the colon were considered contraindications to laparoscopic approach. RESULTS: The length of surgical specimens and the number of lymph nodes removed did not show significant differences in the two groups. Two patients in the open procedure group died in the postoperative period. No postoperative death was noted in the group of patients operated by laparoscopic method. Postoperative complications requiring re-operation were observed in 9 patients in the open group and in 3 patients of laparoscopic group. Postoperative complications not requiring re-operation were observed in 16 patients in the open group and in 4 patients in laparoscopic group. Hospital stay was shorter for laparoscopic right or left colectomy compared to corresponding open procedures. At the follow-up (a mean 30 months), the overall survival was 78% for open colectomies and 82.1% for laparoscopic colectomies. Disease-free survival, excluding patients with stage IV tumor and patients died in the postoperative period, was 77.6% for open colectomies and 82.5% for laparoscopic colectomies. In the group of laparoscopic patients, we observed 1 case of port-site recurrence. CONCLUSIONS: Our clinical experience, even if limited by the number of patients and by the duration of follow-up period, contributes in confirming the reliability of laparoscopic procedures in the treatment of tumours of the colon and the safety of oncological results.

[Anisakiasis presenting as perforated ulcer of the cecum]. / Su di un caso di anisachiasi con perforazione del cieco.

A case of cecal anisakiasis is presented. Symptoms were compatible with appendicitis. The patient was operated and a perforated ulcer of the cecum was found. Ileocolic resection was performed. The histologic result showed the presence of Anisakis simplex larva in the muscle of the cecum. The patient was discharged the fifth day without complications. At present he is asymptomatic. He had eaten uncooked anchovies some days before the onset of the disease.

[A case of perforated small bowel adenocarcinoma as first symptom of Crohn's disease]. / Adenocarcinoma perforato del piccolo intestino come prima evidente manifestazione del morbo di Crohn: case report.

A case of perforated small bowel adenocarcinoma presenting as first symptom of Crohn's disease is reported in a 53 years old male patient with abdominal pain and alteration of bowel habits. Endoscopic bioptical sampling demonstrated a Crohn's disease in active stage. The patient underwent medical therapy with resolution of the complained symptomatology; 20 days after discharge the patients is rehospitalized for acute abdomen. A narrowing perforated neoplasia in terminal ileum was discovered at laparotomy. Diffuse peritonitis and metastatic peritoneal implantations were also revealed. An ileocolic resection is performed with ileo-transverse colon anastomosis. The patient dies 4 months later for advanced disease.

[Pelvic recurrence of rectal cancer: our experience]. / Recidiva pelvica da cancro del retto: nostra esperienza.

Isolated recurrence of rectal carcinoma have been reported from 7% to 33% with a median of 15. Increasing recurrence is associated with increasing Dukes's stage. Patient who have recurrence after a low-anterior resection are more likely to present with non fixed, surgically correctable lesion versus recurrences after abdominoperineal resection. The most common symptom related to pelvic recurrence is pain, which may be perineal or radiate to the lower extremities. The diagnosis of a locally recurrent rectal cancer was obtained with CT; imaging is the first step to estimate the extent and location of the local tumor growth and the presence or absence of distant metastases. The most common location is at or around the anastomosis and the presacral region. Apart from distant metastases locoregional recurrence is the most important factor determining prognosis and survival. If an R0 resection can be performed, a 5-year survival rate of 20-30% can be achieved. Local or locoregional recurrence implies the reappearance of carcinoma after an intended complete removal of the tumor. For rectal cancer, the adjacent organs include the perineum, bladder and vagina, and LR failure includes perineal or pelvic lesions. Total pelvic exenteration is performed in patients with local recurrence of rectal cancer and a 5-year suvival rate of 30-40% was achieved. For patient with unresectable recurrence, chemotherapy and radiation contribute to a better quality of life and prolong survival. While radiotherapy may reduce recurrence, it is now apparent that total mesorectal excision is the most effective modality, with rates as low as 5%. The anastomotic recurrence that can be locally resected, the best approach for long-term survival is an extensive surgical procedure requiring en bloc removal of adjacent organs and pelvic structures so called composite resection. Intraoperative radiotherapy and brachytherapy, and/or preoperative chemoradiation may provide better results in future. While radioterapy remains the most common antineoplastic modality used for palliation of symptoms, surgical resection remains the mainstay of curative treatment for carcinoma of colon and rectum.

[Neoadjuvant radiochemotherapy of rectal cancer: our experience]. / Radiochemioterapia neoadiuvante nel cancro del retto nostra esperienza.

Postoperative chemoradiotherapy is the recommended standard therapy for patients with locally advanced rectal cancer. In recent years, encouraging results with preoperative radiotherapy have been reported. From 2000 at January 2005 we treated 11 patient and our results suggest that preoperative radiotherapy combined with chemotherapy increases the chances of tumor downstaging and downsizing and facilitates sphincter-sparing surgical procedures.

Segmental resection of the third and fourth portions of the duodenum after intestinal derotation for a GIST: a case report.

We describe a case in which segmental resection of the third and fourth portion of the duodenum was performed for a very rare duodenal gastrointestinal tumor (GIST). A 58-year old man presented with melena. Capsule endoscopy revealed a pathological bleeding of the duodenum and oral contrast-CT enema confirmed a lesion of the duodenum inferior knee, measuring 3.5 cm in diameter. Such an image suggested a duodenal leiomyoma. Segmental resection of the third and fourth portion of the duodenum after intestinal derotation (Valdoni-Strong's procedure) was carried out and there were no post-operative complications. Pancreas sparing duodenal resection is at the present time indicated only in selected cases. The duodenal resection associated with bowel and right colon derotation has proved to be a safe and adequate procedure and could be preferred to other procedures.

[Surgical laparoscopic therapy of small bowel tumors: review of the literature and report of two cases]. / Terapia chirurgica laparoscopica dei tumori del tenue: revisione della letteratura e report di due casi.

The Authors, after a short review of small bowel tumors, point out that recently a laparoscopic approach for these tumors has been suggested and some cases have been reported. The Authors present two cases of patients operated for small bowel tumor using a laparoscopic technique: the first case for a stromal tumor (GIST), the second case for an adenocarcinoma in advanced stage with multilobar lung metastases. The first patient is alive and disease free after one year, the second died after six months for tumor progression. The Authors believe that laparoscopic technique can be employed with satisfying results also in the treatment of small bowel tumors with moderate trauma and invasiveness.

[Clinical study on laparoscopic approach to cholelithiasis in the elderly]. / Studio clinico sull'approccio laparoscopico alla colelitiasi nei pazienti geriatrici.

The Authors report 66 cases of patients aged 75 years or older who underwent laparoscopic cholecystectomy: 28 cases presented a clinical picture of acute cholecystitis, 3 cases had associated common bile duct stones. A high percentage of patients had cardiovascular disease: 29 patients presented with cardiopaties, of these 9 cases had a history of myocardial infarction, 31 patients had artheriosclerotic hypertension, associated, in 7 patients with signs of brain ischemia. Five patients were suffering from Parkinson's disease, 7 were carriers of diabetes, 2 had liver cirrosis. Three patients were converted due to extensive presence of adhesions from previous surgery. Morbidity and mortality rates were respectively 12% and 1.5%. The Authors think that laparoscopic technique widens indications and reduces risks of cholecystectomy also in elderly patients.

[Use of prosthetic materials in incisional hernias: our clinical experience]. / Utilizzo dei materiali protesici nei laparoceli: la nostra esperienza clinica.

Incisional hernias are fairly frequent complications of surgery. Such complications are presented by variable percentages ranging from 1% to 8% for non complicated laparotomies and from 10% to 15% in case of infection. The therapeutic possibilities are abdomino-plastic with direct suture and the use of prosthesis. The percentage of recurrency varies from 30% to 50% and from 0% to 19% respectively. From May 2000 to September 2003, the Authors operated 64 patients. In 30 cases they opted for a direct suture approach, in 34 cases a prosthesis was used. Of the 34 patients, 18 were treated using polypropylene mesh placed below the rectus muscles and above the peritoneum (Rives technique); 10 with PTFEe (Polytetrafluoroethylene expanded) prosthesis placed in intraperitoneal site and 6 were treated with SIS prosthesis (Small Intestine Submucosa), 3 placed using the Rives technique and 3 in intraperitoneal site. Nine patients had associated operations. The use of prosthesis in the management of incisional hernias has brought a considerable reduction in the percentages of recurrency, especially in cases of associated pathologies. The availability of SIS in the market has permitted the use of this prosthesis even in case of contaminated and/or infected fields. In a follow-up ranging from 3 years to 3 months (mean 18 months) the Authors observed 2 cases of recurrence in the group of direct suture. Despite the advantages offered by the use of prosthesis, we can affirm that there is no "universal" prosthesis. Their selection should be evaluated on the bases of the site and the dimensions of the incisional hernia, the possibility of infection, the surgical technique and the site of prosthetic placement in the abdominal wall.

[Duodenal obstruction: unusual complication of acute pancreatitis]. / Ostruzione duodenale: una complicazione rara della pancreatite acuta.

The authors notice that, though the duodenal involvement in patients with acute pancreatitis is very common, the duodenal obstruction is quite exceptional and the reported cases are very few. The Authors describe; then, the case of a patient with duodenal obstruction caused by a peri-duodenal phlegmon due to an acute pancreatitis treated with a gastro-jejunostomy and a drainage of the abscess.

[Urologic complications of diverticulosis of the colon]. / Complicanze urologiche nella diverticolosi del colon.

In this paper the complications of colonic diverticulosis are reported, on the basis of two clinical cases personally observed. In the first case, a 68 year-old man, the typical symptomatology with pneumaturia, cloudy urine and watery diarrhea suggested a uro-colonic fistula, therefore a fistula between sigma and bladder, caused by a perforate diverticulum, has been diagnosed by means of cystography and barium enema. In the second case, a 64 year-old woman, the irritative symptomatology, hematuria and endoscopic picture suggested a vesical neoplasia. An accurate examination with abdominal TAC and barium enema, showed a perforate diverticulum between uterus and bladder, without affecting the bladder lumen. The surgical treatment required, in both cases, a left hemicolectomy, a minimal bladder resection in the first case, and a greater one in the second case. During the discussion, the main etiopathogenetic causes of uro-colonic fistulae together with the variants in the onset symptomatology, have been stressed.

[Laparoscopic management in acute cholecystitis]. / Il management laparoscopico della colecistite acuta.

The authors discuss the possibility of changing out laparoscopic cholecystectomy during the first clinical manifestation of acute cholecystitis. The international published series report similar results to those found with the laparotomic operation. There is no common operating conduct either or regards surgical technique or the diagnosis of possible pathologies of biliary ducts. It is shown the effective improvement of the pain, the lowest complications and the duration of the postoperative course which, especially in old patients, results considerably diminished with consequent advantage for them.

[Large inguino-scrotal bladder herniation]. / Voluminosa ernia inguino-scrotale vesicicale.

The authors describe a case of voluminous inguinoscrotal bladder erniation. They write about the subjet with the help of the literature and above all they show the possible dangers of a vesical underestimated injury.

[Rupture of the upper urinary tract during renal colic. Two cases]. / Rottura dell'alta via escretrice in corso di colica renale.

The rupture of the upper urinary tract is an uncommon event. The authors describe 2 cases during renal colic and they write, particularly, about the diagnostic and therapeutic aspects of this pathology.

[Peritoneal mesothelioma]. / Il mesotelioma peritoneale.

Peritoneal mesothelioma is a quite rare tumor with an incidence of one or two cases per million inhabitants; approximately in the 30-45% of the cases diagnosed it is associated with the corresponding pleural mesothelioma. A predisposing factor is a previous occupational exposure to materials containing asbestos. Clinical symptomatology and instrumental findings may be confusing. Diagnosis is often possible only after direct vision and histologic examination during laparoscopy or laparotomy but it is always tardy, whereas therapy is still unsuccessful. Surgical excision and radiotherapy are less effective than intraperitoneal chemotherapy which seems to lengthen the average survival rate.