The influence of residents in the outcome of elective laparoscopic surgery: a prospective study comparing a teaching hospital and a private community hospital in Italy.

OBJECTIVES: We compared the outcome of elective laparoscopic cholecystectomy (LC) in a teaching hospital and a private communityhospital to assess the impact of the involvement of residents. MATERIALS AND METHODS: The following parameters were studied prospectively in patients who underwent elective LC during the period from September 2014 to February 2016 in a teaching university hospital (group A) and in a private community hospital (group B): age, sex, body mass index (BMI), comorbidities, American Society of Anaesthesiologists (ASA) score, length of surgery from skin incision to skin closure, use of drain, 30-day perioperative morbidity and mortality, and length of postoperative hospital stay. RESULTS: The group A consisted of 93 elective LC and the group B of 167 elective LC. Operative time was significantly longer in group A. Intraoperative complications were similar and no conversion was necessary in both groups. An increased rate of postoperative complications was observed in group A. All postoperative complications were managed with conservative therapy. No mortality occurred. At logistic regression analysis, the only factor favouring the occurrence of complications was the hospital type. CONCLUSIONS: Our study shows that elective LC can be performed in a teaching hospital with comparable intraoperative morbidity and increased postoperative complications. The greater rate of morbidity found in the teaching hospital may be due to an increased vigilance linked to the presence of residents and not to the lack of expertise.

Biliodigestive fistulae and gallstone ileus: diagnostic and therapeutic considerations. Our experience.

The biliodigestive fistula is not a rare affection in the context of acute pathology of the gastrointestinal tract. It often affects patients between 63 and 85 years old , particularly the female sex, and the most common cause is acute or chronic cholecystolithiasis. Open issues are the delayed in the pre-operative diagnosis, and controversies exist regarding the best surgical approach. The choice of treatment options is influenced by the age of the patients and their clinical conditions and also by the presence of comorbidities and of a delayed right diagnosis. In the 1 to 3% of cases, the biliodigestive fistula presents a gallstone ileus as complication, whose diagnosis is particularly difficult for the lack of specific signs and symptoms. The contrast-enhanced CT is considered the gold standard for a specific pre-operative diagnosis, as it directly shows the fistula. Surgical treatments include one-stage procedure or two-stage procedure. Many studies seem to favor a deferred definitive procedure. The Authors describe 4 cases: in 3 cases, women between 70 and 80 years old presenting an history of recurrent cholecystitis, in 2 cases, and in 1 case presenting a bowel obstruction; in 1 case a 50-years-old man, with no significant past medical history, presenting a bowel obstruction. The Authors have performed in the 2 cases of gallstone ileus an enterolithotomy with cholecysto-duodenal fistula repair and cholecystectomy, in one-stage, and this has been possible because of the good clinical conditions of the patients and their low operative risk. In the case of fistula without the complication of gallstone ileus, the treatment approach has been cholecysto-gastric fistula closure with a gastroplastic using separate stitches and cholecystectomy, in one-stage. We are in agreement with data in the literature regarding the delay into the diagnosis of biliodigestive fistula and with the importance to suspect it or gallstone ileus presence, although the clinical presentation is extremely non-specific. In our experience, cholangiopancreatography-CT and CECT have made easier the pre-operative diagnosis and so reducing the delay of the treatment.

Small bowel intussussception due to metastatic melanoma of unknown primary site. Case report.

Malignant melanoma is characterized by metastases also to the gastrointestinal tract, especially in the small bowel. The diagnosis is often delayed because unspecific clinical presentation (frequently as chronic iron deficiency anemia, rectal bleeding or intestinal obstruction). We present a case of melanoma of unknown primary site, with clinical presentation of intestinal obstruction. A segmental resection of the ileum was performed including mesentery with lymph nodes. Histology revealed metastatic melanoma from unknown primary. PET and MRI confirmed disseminated disease without brain metastasis.

Single-incision laparoscopic appendectomy is comparable to conventional laparoscopic and laparotomic appendectomy: our single center single surgeon experience.

Several studies have demonstrated the clinical and technical benefits of the laparoscopic surgery for complicated and uncomplicated appendicitis. Our retrospective study included 12 patient who underwent SILS appendectomy (SILS-A), 14 who received conventional laparoscopic surgery (VL-A), and 12 who received laparotomic appendectomy (OA); performed in all cases by the same surgeon (C.F.). The aim of this study was the comparison between this three different surgical techniques on same features: post operative leukocytosis, post operative pain, need abdominal drainage, esthetic viewpoint, incidence of complication, hospital stay. The results showed no significant differences between SILS-A and VLS-A, while an evident improvement shows versus O-A, even though not statistically significative. SILS was more effective in decreasing the risk of postoperative wound infection.

Quantitative and functional study of breast cancer axillary lymph nodes and those draining other human malignant tumors.

Lymphocyte functional activity from lymph nodes draining human malignancies reflects the host immune response against tumour. Breast cancer is the neoplasia with the greatest amount of identified antigens but a weak inducer of a host efficient immune response. In our study we compared the mitogen stimulated-proliferative response of cells isolated from metastases-free lymph nodes draining breast cancer (Group 1), other malignant tumours (Group 2), and those obtained from patients without malignancies (Control group). A significant decrease of the proliferative response in cells isolated from lymph nodes draining breast cancer was observed comparing it to the other groups. Quantitative analysis of B and T cells showed a higher number of B cells than T cells in Groups 1 and 2. Moreover, Group 1 presented a two fold increase of T cells compared with Group 2. Our results suggest that the immunosuppression observed in lymph nodes draining breast cancer is higher than the inmunosuppression presented in other malignant tumours and that impaired function is not correlated with the increased number of T cells.

[Identification of a tumor antigen associated to the estrogen receptor in axillary lymph nodes of breast cancer patients]. / Identificación de un antigeno tumoral asociado al receptor estrogénico en ganglios linfáticos axilares de pacientes con cáncer mamario.

Sixteen axillary lymph nodes were incubated with sera from patients with mammary carcinoma. Using immunofluorescence staining sera recognized antigenic determinants on follicular dendritic cells (FDC) within the follicle centers. These results were confirmed with isolated and cultured FDC that were incubated with the same sera. All the results were negative with normal sera. We also found a cell population positively reacting with a monoclonal antibody against an estrogen receptor associated protein (ERAP) in subcapsular and cortical sinusae and germinal centers. Phenotype identification of ERAP+ cells indicated that they presented characteristics of macrophages and FDC respectively. Lymph nodes from other malignancies were negative for ERAP. These findings suggest that the tumoral antigen could be either the protein associated with the estrogen receptor or the receptor itself. The ERAP could be transported by the macrophages from the tumor to the regional lymph nodes where it could be processed and maintained during a long time by FDC, since it is known that these are the most efficient antigen presenting cells.

Detubularized sigmoid colon for bladder replacement after radical cystectomy.

During the last 6 years 24 sigmoid colon neobladders were constructed at our institute according to a surgical technique that provides for an optimal spherical configuration of the orthotopic reservoir. All patients underwent radical cystectomy for locally advanced or superficial recurrent bladder cancer. The surgical complication rate was minimal. Mean followup was 38.3 months (range 7 to 70). Patients were evaluated at 9 and 18 months with urodynamic tests. Daytime continence was achieved in 20 of 21 (95.2%) and in 16 of 17 (94.1%) patients, respectively. Nocturnal incontinence was noted in 9 of 21 (42.8%) and 5 of 17 (29.4%) patients. The mean neobladder capacity was 414 cc and 492 cc, respectively. Endoluminal pressure at the maximum reservoir capacity was 31 cm. water (range 23 to 54) and this did not change significantly at 18 months. Minimal post-voiding residual volume was evidenced in all but 1 patient and was maintained at 18 months. Our modified sigmoid colon neobladder is an easy surgical procedure that provides satisfactory total bladder replacement in select patients.

Multimodal therapy for stones in pelvic kidneys.

Stones located in pelvic kidneys can be successfully treated by extracorporeal lithotripsy, either alone or in combination with endourology and open surgery. A multimodal approach was used in 16 patients with pelvic kidney stone disease and a 87.5% stone-free rate was achieved. The proper positioning of the patient on the lithotripter apparatus and the correct integration of the different therapeutic procedures were the real clues for obtaining a remarkable success rate with a minimally invasive approach.

Long term experience with the prostatic spiral for urinary retention due to benign prostatic hyperplasia.

Twenty high risk patients with benign prostatic hyperplasia and urinary retention were treated by insertion of an intraprostatic spiral. The device was positioned under fluoroscopic guidance using a technique developed by us. The procedure required only local anaesthesia and successfully relieved the obstruction in all patients. At the six-month follow-up full continence had been achieved in 15 patients (75%). Three patients (15%) complained of mild stress incontinence but this was not severe enough to require removal and repositioning of the spiral. A 92-year-old patient reported severe incontinence despite correct positioning of the spiral. Removal of the spiral was necessary in one of the continent patients who was receiving anti-coagulant drugs because of sudden, severe macrohaematuria with subsequent acute urinary retention. The spiral became displaced and required repositioning in one patient. Median residual urine volume was constantly lower than 50 ml and the median maximal flow rate at six-month follow-up was 13.2 ml/s. Our long term follow-up study shows the effectiveness and safety of the prostatic spiral as an alternative treatment for selected patients with urinary retention caused by benign prostatic hyperplasia.

[Local prostatic hyperthermia in the therapy of urinary obstruction caused by prostatic adenoma. Experimental, clinico histologic and structural findings]. / L'ipertermia locale prostatica nella terapia dell'ostruzione urinaria da adenoma prostatico. Acquisizioni sperimentali, cliniche istologiche ed ultrastrutturali.

A specifically designed system of selective prostate heating was used to treat 197 patients with prostatic diseases: 164 benign prostatic hypertrophy cases, 14 prostatic adenocarcinoma cases, 19 chronic abacterial prostatitis cases. Ninety-one benign prostatic hypertrophy patients could be evaluated at the three month follow-up date. Sixty-eight patients complained of severe obstructive symptoms and 23 had an indwelling catheter. Prostates were heated up to 42 +/- 0.5 degrees C during 60 minute long sessions, once or twice a week for five weeks. Local prostatic hyperthermia determined a marked amelioration of the clinical picture in 67% of patients who presented without an indwelling catheter. Sixteen patients (70%) were weaned off the catheter. Major complications were not encountered.

Local bacillus Calmette-Guerin therapy for superficial bladder cancer: clinical, histological and ultrastructural patterns.

The effectiveness of intravesical administration of bacillus Calmette-Guerin as a prophylaxis of superficial bladder cancer has been definitely demonstrated. On the other hand, therapeutic regimens, duration effects, efficacy of either maintenance cycles or repeated courses of therapy in case of failures are still controversial. We report the results achieved in 15 cases of carcinoma in situ of the bladder and in 48 cases of superficial bladder cancer (Ta-T1 stage of disease) with bacillus Calmette-Guerin immunotherapy. Our patients underwent an initial six week cycle and a following maintenance cycle with monthly administrations for one year. Median follow-up was 19 months (range 18-21 months). Patients with carcinoma in situ are now free of disease; on the contrary, patients with Ta-T1 tumors experienced 18 recurrences (28%). There was a marked decrease of recurrence rate when compared to previous local chemotherapy. We report in detail the adverse effects encountered and both histologic and ultrastructural findings observed after immunotherapy. Bacillus Calmette-Guerin therapy can influence positively the natural history of the disease but possible adverse effects should always be considered before starting the treatment.

Extracorporeal lithotripsy and combined surgical procedures in the treatment of renoureteral stone disease: our experience with 2,955 patients.

From May, 1985 to August, 1987, a total of 2,955 patients with renoureteral stone disease presented at our institution and were treated either by extracorporeal lithotripsy alone or combined with percutaneous nephrolithotomy, ureteroscopy, or open surgery. Seventy-three percent of patients were stone-free at the 3 month follow-up date while 22% presented with negative urine culture and small (less than 5 mm) asymptomatic fragments deemed susceptible to spontaneous discharge. The rate of major complications was extremely low (sepsis, 0.03% and major renal bleeding, 1.55%). The application of this multimodal therapeutic strategy allowed successful treatment in almost every case of renoureteral lithiasis with minor iatrogenic damage to the renal parenchyma.

Histological and ultrastructural evaluation of extracorporeal shock wave lithotripsy-induced acute renal lesions: preliminary report.

Biopsy material taken from kidneys of 14 patients with renal stones before performing extracorporeal shock wave lithotripsy (ESWL) and an average of 15 days after was examined histologically and ultrastructurally. In the post-ESWL specimens, light microscopy revealed edema and extravasation of urine and blood into the interstitial spaces, blocking of cortical tubules by hemorrhagic streaks and widespread dilatation of the veins, with signs of endothelial destruction and partial organization of thrombi. By using the electron microscope, abnormalities of the endothelium and glomerular epithelium, hemosiderin accumulations in the tubular cells and small linear patches of fibrosis at the corticomedullary junction and in the cortical interstitial spaces were seen. This preliminary report indicates that renal damage can be shown soon after ESWL on histological and ultrastructural studies and that the lesions observed can be either reversible or permanent.

[A new intrauterine device with progesterone for control of reproduction]. / Osservazioni sul nuovo dispositivo intrauterino al progesterone per il controllo della riproduzione.

PIP: The article reports on 33 insertions of the progesterone-releasing IUD, Progestasert, in patients aged 17-45 with an average age of 31; most patients had 2 children. Insertion of the device was easy, and the device itself was extremely well tolerated; 12 of the original 33 patients carried the device for more than 24 months, and 5 carried it for more than 36 months. There were no pregnancies, 2 cases of spontaneous expulsion, 2 removals for pelvic pain, and 2 for desire of pregnancy. Not only were there no side effects, but a positive action of the device was noted against genital inflammation, together with marked improvement of mammary tension and intramenstrual occurrence of headache. Vaginal cytology remained normal or it improved.^ieng