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INTRODUCTION: thyroid cancer recurs most commonly in one or more cervical lymph nodes. Surgical treatment for differentiated or medullary thyroid carcinoma consists of total thyroidectomy (TT). The aim is to elucidate the potential benefits and drawbacks of neck dissection TT related. MATERIALS AND METHODS: differences between therapeutic and prophylactic neck dissection were analysed to prevent post-operative morbidity, neck recurrences and improve survival. DISCUSSION: there is considerable controversy regarding the treatment of patients with cervical node metastases specially in differentiated thyroid cancer. Considering that a neck dissection might help to reduce local recurrence, especially in medullary carcinoma, controversial remains regarding the modality and extension of cervical dissection. There are several surgical strategies to cervical lymphadenectomy as a prophylactic node dissection or a dissection only in symptomatic patients or the "node-picking" technique for selective lymphadenectomy or sentinel node biopsy. So it is possible to employ several kind of neck-node compartment related dissection. The risk of iatrogenic lesion during neck dissection is relatively high specially for nerve structures (i.e.: recurrent laryngeal nerve or spinal accessory nerve), so an experienced surgeon must mind the risk is higher during a re-operation in an anatomical subverted region. CONCLUSIONS: the extent of dissection and the experience of the surgeon both play important roles in determining the risk of surgical complications and recurrence. The decision to add neck dissection to total thyroidectomy weighed against documented benefits and risks. Injuries may also occur as a result of inadequate technique or as a result of poor expertise of the surgeon. We believe that deep knowledge of the thyroid region's surgical anatomy is necessary to realize a skilled and careful surgery of the neck.
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Carcinoma/cirurgia , Esvaziamento Cervical/métodos , Neoplasias da Glândula Tireoide/cirurgia , Tireoidectomia/métodos , Carcinoma/patologia , Carcinoma Medular/cirurgia , Carcinoma Papilar/cirurgia , Humanos , Metástase Linfática , Neoplasias da Glândula Tireoide/patologia , Resultado do TratamentoRESUMO
INTRODUCTION: In subjects operated by videolaparoscopic cholecystectomy (VLC) incidence of synchronous cholecysto-choledochal stones is 7-20%. Aim of the study is to report our experience in endoscopic treatment of common bile duct (CBD) stones before VLC (sequential treatment). PATIENTS AND METHODS: From January 2001 to May 2007, 189 ERCP for synchronous cholecysto-choledochal stones were performed with analgo-sedation. In selected cases antibiotics and protease inhibitors were used. RESULTS: CBD clearance was 100%. The incidence of complications (mild, moderate and severe) was 8.2%, mortality 0.53% (1 patient). We observed 31 cases of transient asymptomatic hyperamilasemia (16.4%). A total of 186 subjects were operated by VLC, with only 3 conversion, without procedure-related mortality. CONCLUSIONS: In our opinion, the best treatment of syncronous cholecisto-choledochal stones is related to available tools and human experience, but for an experienced surgical and endoscopic team the sequential approach is feasible, safe and effective.
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Colangiopancreatografia Retrógrada Endoscópica , Colecistectomia Laparoscópica/métodos , Colelitíase/diagnóstico por imagem , Colelitíase/cirurgia , Adulto , Colelitíase/diagnóstico , Colelitíase/mortalidade , Feminino , Cálculos Biliares/diagnóstico por imagem , Cálculos Biliares/cirurgia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Sicília/epidemiologia , Taxa de Sobrevida , Resultado do TratamentoRESUMO
BACKGROUND AND AIMS: Colonoscopic surveillance is an established method of colorectal cancer (CRC) screening that reduces death rates, but has an adenoma miss rate of 10-20%. Narrow band imaging (NBI), a novel endoscopic technology, highlights superficial mucosal capillaries and improves contrast for small adenomas. This study evaluated the role of NBI in the improving colon adenoma detection. PATIENTS AND METHODS: White light colonoscope was compared with NBI for adenoma detection during colonoscopy. 120 patients presenting for diagnostic colonoscopy were randomly assigned to undergo colonoscopy using either conventional white light or NBI colonscope during instrument withdrawal. The outcome parameter was the difference in the adenoma detection rate between the two techniques. All polyps detected were removed for histopathological analysis. RESULTS: Adenomas were detected more frequently in the NBI group (51) than in the control group (49); however, the difference was not statistically significant (p = 0.128). The extubation time was significatively longer in the NBI group (p = 0.003). CONCLUSIONS: In our experience, the NBI did not increased the adenomas detection rate compared to white light by an endoscopist with a known high detection rate using white light.
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Adenoma/diagnóstico , Colonoscopia/métodos , Neoplasias Colorretais/diagnóstico , Adulto , Idoso , Feminino , Humanos , Luz , Masculino , Pessoa de Meia-Idade , Vigilância da PopulaçãoRESUMO
Introduction. Herpes simplex esophagitis is well recognized in immunosuppressed subjects, but it is infrequent in immunocompetent patients. We present a case of HSE in a 53-year-old healthy man. Materials and Methods. The patient was admitted with dysphagia, odynophagia, and retrosternal chest pain. An esophagogastroduodenoscopy revealed minute erosive area in distal esophagus and biopsies confirmed esophagitis and findings characteristic of Herpes Simplex Virus infection. Results. The patients was treated with high dose of protonpump inhibitor, sucralfate, and acyclovir, orally, with rapid resolution of symptoms. Discussion. HSV type I is the second most common cause of infectious esophagitis. The majority of symptomatic immunocompetent patients with HSE will present with an acute onset of esophagitis. Endoscopic biopsies from the ulcer edges should be obtained for both histopathology and viral culture. In immunocompetent host, HSE is generally a self-limited condition. Conclusions. HSE should be suspected in case of esophagitis without evident cause, even if the patient is immunocompetent. When the diagnosis of HSE is confirmed, careful history and assessment for an immune disorder such as HIV infection is crucial, to look for underlying immune deficiency.
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INTRODUCTION: Esophageal duplication (ED) cyst is unusual congenital disorder of the foregut, accounting for 10% to 15% of duplications of all foregut cysts. We report a case of esophageal duplication with acute clinical presentation, treated successfully with surgical resection. CASE REPORT: 46-year-old man with acute dysphagia and gastroesophageal reflux of 2 weeks duration, showed submucosal bulging mass in the posterior wall of the middle third of oesophagus, fluid-filled cystic structure, dyshomogeneous, low-attenuation mass with smooth borders compatible with an hemorrhagic esophageal duplication cyst. With the suspect of acute presentation of a complicated esophageal cyst, the patient underwent surgery by right posterolateral thoracotomy. A gastrografin esophagogram was performed on third postoperative day and showed no leaks. DISCUSSION: Up to 80% of the esophageal duplication cysts are diagnosed in childhood and the majority of young patients develop symptoms, while symptomatic cyst into adult life is very rare (<7%). Acute onset is generally due to complications, i.e. intracystic hemorrhage, perforation, and infection, especially of the cyst with esophageal communication. Complete surgical excision by thoracotomy or thoracoscopy is the therapy of choice even if the patient is asymptomatic because of the risk of complications such as aspiration and bleeding. CONCLUSIONS: The diagnosis and treatment of esophageal cysts is still evolving. The pathological diagnosis of oesophageal duplication requires the presence of the Ladd and Gross criteria. The infrequent acute onset doesn't modify the management and the surgical resection is the procedure of choice. The future of the treatment of esophageal cysts lies in the advancement of minimally invasive operative techniques.
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Cisto Esofágico/congênito , Esôfago/anormalidades , Doença Aguda , Idade de Início , Transtornos de Deglutição/etiologia , Cisto Esofágico/complicações , Cisto Esofágico/diagnóstico por imagem , Cisto Esofágico/cirurgia , Doenças do Esôfago/etiologia , Esofagoplastia , Refluxo Gastroesofágico/etiologia , Hemorragia Gastrointestinal/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Radiografia , ToracotomiaRESUMO
INTRODUCTION: Although upper gastrointestinal (GI) endoscopy is reasonably safe, it is not perfectly so. The complication rate is about 0.1% for EGDS. Aim of this study is to schedule and evaluate all possible complications, starting from personal experience in Operative Unit of Surgical Endoscopy. PATIENTS AND METHODS: We evaluated all EGDS performed at the Operative Unit of Surgical Endoscopy of Policlinico in Palermo between January 2000 and January 2008. A single staff of endoscopists performed diagnostic and therapeutic exam. All complications were tabulated and scheduled to identify possible risk factors or indicators procedure- or patient-related. RESULTS: 5.258 patients (43.6 %) experienced temporary and self-limiting hypoxia (SaO2 < 85%); we report totally 18 complications (0.15%), according to literature data: 2 hypopharinx perforations (0.016%), 2 middle esophagus perforation (either with death of patients = 0.016%), 3 post-biopsy hematomas of the gastric wall (0.02%) and 2 duodenal wall (0.016%) 6 (0.04%) post-polypectomy bleeding, 1 abscess post-percutaneous endoscopic gastrostomy (PEG) (0.008%) and 1 accidentally PEG remove (0.008%). DISCUSSION: EGDS-related complications may occur and cannot be prevented completely even in expert hands however, early recognition and proper management will lead to better outcome. Because of the complexity of endoscopic procedures has increased, endoscopists need to be aware of all possible procedure-related complications and should use strategies to minimize it. CONCLUSIONS: Endoscopic complications will inevitably occur if an endoscopist does many procedures. The knowledge of potential complications and their expected frequency can lead to improved risk-benefit analysis by physicians and patients as well as true informed consent by patients. Early recognition of complications and prompt intervention may minimize patient morbidity.
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Endoscopia do Sistema Digestório/efeitos adversos , Complicações Intraoperatórias/etiologia , Abscesso/etiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Bacteriemia/epidemiologia , Bacteriemia/etiologia , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Endoscopia do Sistema Digestório/métodos , Nutrição Enteral , Perfuração Esofágica/etiologia , Perfuração Esofágica/mortalidade , Estenose Esofágica/cirurgia , Feminino , Hematoma/etiologia , Humanos , Hipnóticos e Sedativos/efeitos adversos , Hipofaringe/lesões , Hipóxia/induzido quimicamente , Perfuração Intestinal/epidemiologia , Perfuração Intestinal/etiologia , Complicações Intraoperatórias/epidemiologia , Masculino , Pessoa de Meia-Idade , Stents , Estômago/lesões , Gastropatias/etiologia , Adulto JovemRESUMO
BACKGROUND: The diffusion in the years '80 of the stapler has modified the habits of the surgeons, determining the reduction of the operative time in colorectal surgery and the possibility to operate cancer of lower rectum, but leaving unchanged the rates of postoperative complications and bringing to the footlights some new complications. Aim of paper is to report our experience about of mechanical sutures in the colorectal anastomoses, with particular attention to the risk factors and complications procedure-related. PATIENTS AND METHOD: From January 2000 to January 2006 in the Section of General and Thoracic Surgery of the University in Palermo, 26 stapled colorectal anastomosis and 11 mechanical terminal colostomies after Miles' amputation have been performed; 12 patients have been submitted to low colorectal termino-terminal anastomosis, 6 to termino-terminal ultralow anastomosis, 1 to coloanal anastomosis and 7 to Knight-Griffen technique. RESULTS: We registered 2 anastomotic dehiscences (8%), 3 (12%) anastomotic bleeding and one anastomotic stenosis (4%) 12 months after surgery. No mortality procedure-related took place. DISCUSSION: From the literature review emerges the absence of statistically differences between manual and mechanical suture in the colorectal anastomosis in terms of mortality, morbidity (clinical and radiological incidence of the anastomotic gaps, anastomotic stenosis, redo, bleeding, infection of the wound) of employed time to make the anastomosis and of staying in hospital. These data are from American Schools, while greater incidence of radiological leakage is recorded in the European schools is for the manual suture. CONCLUSIONS: At present does not exist clinical trial that shows the superiority of mechanical stapling versus manual suture in the colorectal anastomosis. Stapler makes possible the lower colo-rectal anastomosis often avoiding abdomino-perineal amputation of the rectum, with better quality of life and oncological radicality, but increasing however the incidence of complications as anastomotic dehiscence and stenosis, even if not statistically significant.
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Colo/cirurgia , Neoplasias Retais/cirurgia , Reto/cirurgia , Técnicas de Sutura , Idoso , Anastomose Cirúrgica/métodos , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
INTRODUCTION: Pyramidal lobe (PL) is an embryological remnant of the thyro-glossal duct; its incidence varies from 15% to 75% but data concerning its size are lacking and limited to autoptic and radiologic evidences. Aim of our study is to elucidate the intraoperative frequency, location and surgical management of the PL. PATIENTS AND METHODS: 604 total thyroidectomy were performed between 1999 and 2007 in Unit of General and Thoracic Surgery of the University Policlinico of Palermo. The intraoperative incidence of PL was 12% (57% male, 43% female, mean age 42.5 years), but only about 50% were identified preoperatively with ultrasonography (US) (4% false positive) or with Tc-99m pertechnetate scintigraphy (8% false positive). RESULTS: In 77% of cases the lobe was affected by nodular pathology in multinodular goiter, in 1.3% by papillary cancer; in the rest of cases was normal. PL branched off more frequently from the left part of the isthmus (96%) than from the right part (4%) and in 25% of cases was associated with delphian lymph node. No PL exceeded 2 cm in length in pathologic specimen. There was no difference in thyroidectomy operative time with or without PL. At US, scintigraphic and laboratory follow-up (2 months-8 years), no incomplete resection of the gland due to the presence of PL were recorded. DISCUSSION: In anatomical studies the frequency of the PL is between 15% and 75%; PL is in 10-17% of normal subject and in 43% of patients with multinodular goiter. The PL is of great importance to the thyroid surgeon during thyroidectomy: it is crucial to look for, identify, and remove the PL, as this can be a cause of incomplete resection of the gland. If left behind in a patient who will require postoperative radioactive iodine, its presence will virtually nullify the anticipated benefit of I131 by absorbing most of the radioactive material; may exist relapse of cancer from PL left in situ. CONCLUSIONS: The intraoperative frequence of PL is 12%, and it is considered a normal component of the thyroid. Scintigraphic visualization of the PL depends on the kind of thyroid disorder and on the experience of radiologist, so the PL can often not be diagnosed by scintigraphic imaging. Finally, the whole anterior cervical region has to be investigated very carefully during thyropidectomy not to overlook a long or thin pyramidal lobe or other ectopic thyroid tissue because actually doesn't exist the goldstandard preoperative method to diagnoses PL.
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Cisto Tireoglosso , Tireoidectomia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cisto Tireoglosso/epidemiologia , Cisto Tireoglosso/patologia , Cisto Tireoglosso/cirurgia , Tireoidectomia/métodos , Adulto JovemRESUMO
INTRODUCTION: The differential diagnosis between malignant and benign biliary strictures is the cornerstone of the management of jaundiced patients. The aim of our study is to define the role of cytology of the bile withdrawn during endoscopic retrograde cholangiopancreatography (ERCP), to reach a diagnosis of the nature of biliary stricture. PATIENTS AND METHODS: This retrospective study was conducted on 67 consecutive patients affected of ingravescent obstructive jaundice who underwent ERCP+/-PTE (percutaneous transhepatic endoscopic)+bile withdrawn+stenting. We founded hilar stricture in 21 patients (31.3%), middle third the common duct stricture in 17 (25.3%), and lower third stricture in 28 patients (41.4%). In one patient (2%) the cholangiography did not show any stricture, but we continued with the withdrawn of bile after positioning a naso-biliary drainage. RESULTS: Diagnosis was made in only 40 of 65 patients (61.5%) and no epithelial lining cells of the biliary tree was found in the remaining 25 patients (38.5%). The presence of neoplasm in the pancreato-biliary tract was excluded (absence of malignant cells) in 25 of 40 diagnostic exams (62.5%). During follow-up only 7 of these 25 patients resulted in having a benign disease (true negatives 28%) while the remaining 18 cases were diagnosed with malignant neoplasm of the pancreato-biliary tract (false negatives 72%). Nine of 14 with positive cytology for carcinoma were diagnosed with cholangiocarcinoma (65%), 4 with pancreatic (28%) and 1 with ampullary carcinoma. Of 25 non-diagnostic samples, 5 (20%) resulted as benign, 20 (80%) as malignant. The statistical analysis by chi-square test allowed us to conclude that bile cytology, if diagnostic, is significantly valid in identifying carcinoma of the pancreato-biliary tract (p<0.05) instead, considering the high rate of non diagnostic samples, its meaning is limited (p=0.09). DISCUSSION: Exfoliative cytology of bile samples obtained during ERCP is easier and less invasive method to determine the diagnosis of biliary strictures, but due to its low sensibility, varying from 6 to 63%, it doesn't appear accurate to establish a definite diagnosis; the stricture dilatation before the withdrawal increases the diagnostic sensibility and accuracy of the cytological exam. CONCLUSION: Bile withdrawn for cytology during ERCP is a safe method with no increasing in patient's morbidity. It allows a diagnostic orientation in 75% of the patients. Bile withdrawn after dilatation of stricture allows improves sensibility and accuracy. Negative results does not exclude malignant disease, however, if positive, it is considered diagnostic (positive predictive value 100%).
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Neoplasias dos Ductos Biliares/patologia , Bile/citologia , Colangiocarcinoma/patologia , Colangiopancreatografia Retrógrada Endoscópica , Icterícia Obstrutiva/patologia , Neoplasias Pancreáticas/patologia , Idoso , Idoso de 80 Anos ou mais , Doenças dos Ductos Biliares/patologia , Neoplasias dos Ductos Biliares/diagnóstico por imagem , Biópsia por Agulha , Distribuição de Qui-Quadrado , Colangiocarcinoma/diagnóstico por imagem , Constrição Patológica/diagnóstico , Diagnóstico Diferencial , Drenagem/instrumentação , Drenagem/métodos , Feminino , Seguimentos , Humanos , Icterícia Obstrutiva/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Neoplasias Pancreáticas/diagnóstico por imagem , Valor Preditivo dos Testes , Estudos Retrospectivos , Sensibilidade e Especificidade , Stents , Resultado do TratamentoRESUMO
AIM: The pleural effusion is a sign of pulmonary, pleural or extrapulmonary, benign or malignant pathology. Our aim is to bring our experience on the treatment of the malignant pleural effusion through thoracentesis and successive pleurodesis. PATIENTS AND METHODS: From January 2000 to January 2007 we performed 217 thoracentesis of which 123 (57%) in subjects with malignant pleural effusion. In 92 of 123 subjects (75%) we performed a drainage with small size thoracic tube to realize directly the pleurodesis with sterile des-asbestos talc. RESULTS: None complication was registered during and after thoracentesis and pleurodesis and no mortality was recorded. We usually used talc slurry technique. Relapse rate after first treatment was of 12.2%. CONCLUSIONS: The pleural effusion is a pathological condition that usually needs repeated operative procedures with serious danger for the patient, however without definitive results. On the basis of our experience and considering the characteristics of sclerosing agents, we conclude that the sure, effective and economic agent for the pleurodesis is the des-asbestos talc.
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Paracentese , Derrame Pleural Maligno/terapia , Pleurodese , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Paracentese/métodos , Derrame Pleural Maligno/diagnóstico , Pleurodese/métodos , Estudos Retrospectivos , Soluções Esclerosantes/administração & dosagem , Talco/administração & dosagem , Resultado do TratamentoRESUMO
BACKGROUND: Endoscopic retrograde cholangio pancreatography failure is a rare and some dramatic reality too for the management of bilio-pancreatic tract disorders and in these cases it needs to utilize others operative technique. PATIENTS AND METHODS: Over a 6-year period, a total of 757 ERCPs were performed. In seventeen of these ERCPs the standard endoscopic technique failed and we employed alternative techniques such as interventional radiology or surgical management or double endoscopic approach. RESULTS: In all 17 failed ERCPs the alternative procedures allowed us to success in bilio-pancreatic disease. CONCLUSION: ERCP is an operator-dependent procedure. Even in expert hands failure occurs in 3% to 10% of cases. ERCP failure doesn't be considerated a dramatic situation in the management of the bilio-pancreatic disease for a multidisciplinary team (endoscopist, surgeon and interventional radiologist) whose cooperation allows to success.
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Doenças Biliares/cirurgia , Colangiopancreatografia Retrógrada Endoscópica , Pancreatopatias/cirurgia , Esfinterotomia Endoscópica , Idoso , Idoso de 80 Anos ou mais , Doenças Biliares/diagnóstico por imagem , Colangiografia , Duodenoscopia , Feminino , Gastroscopia , Humanos , Masculino , Pessoa de Meia-Idade , Pancreatopatias/diagnóstico por imagem , Radiologia IntervencionistaRESUMO
INTRODUCTION: Medullary Thyroid Carcinoma (MTC) is a rare malignancy of the parafollicular C cells of the thyroid gland. Aim of our study is reporting retrospective analysis of our experience about the surgical treatment of MTC, especially pointing on lymphadenectomy. PATIENTS AND METHODS: from January 2000 to March 2006, were performed 546 thyroidectomy, 6 of them for MTC (1.09%): 5 sporadic and 1 familiar. All the patients were operated with standard technique (total thyroidectomy) and submitted to endocrinologic and instrumental follow-up. RESULTS: in our experience, we do not registered early or late complications as bleeding, laryngeal nerves lesions and parathyroid lesions or intra-postoperative deaths. DISCUSSION: MTC occurs sporadically or as part of the multiple endocrine neoplasia type 2 (MEN 2 a/b) syndromes in patients who have inherited a mutation in the RET proto-oncogene. The diagnosis is made by fine needle aspiration biopsy (FNAB) and by measuring calcitonin levels in the blood. Primary treatment consists of surgical resection including a total thyroidectomy, central neck nodal dissection and functional lateral neck nodal dissections. Most patients with a palpable primary tumour have nodal disease at the time of operation, and nodal involvement is often bilateral. CONCLUSIONS: adequate resection of the primary tumour and cervical lymph nodes is important to optimize outcome and minimize the risk of recurrent disease. Following primary surgical resection, more than 50% of the patients will have recurrent disease with persistent elevation of calcitonin levels. Currently, there is no adequate systemic therapy for recurrent disease. Surgical reoperation or conservative observation are the best available options.
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Carcinoma Medular/cirurgia , Neoplasias da Glândula Tireoide/cirurgia , Tireoidectomia , Adolescente , Adulto , Biópsia por Agulha , Carcinoma Medular/diagnóstico , Carcinoma Medular/genética , Carcinoma Medular/patologia , Feminino , Humanos , Excisão de Linfonodo , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Pescoço , Prognóstico , Proto-Oncogene Mas , Estudos Retrospectivos , Fatores de Risco , Neoplasias da Glândula Tireoide/diagnóstico , Neoplasias da Glândula Tireoide/genética , Neoplasias da Glândula Tireoide/patologia , Tireoidectomia/métodosRESUMO
INTRODUCTION: we describe the first case in literature of biliary stent obstruction by bezoar impaction in a iuxtapapillary duodenal diverticulum. CASE REPORT: this case illustrates an juxtapapillary duodenal diverticulum and bezoar in it causing obstructive jaundice in subject with two biliary stents for cholangiocarcinoma (Klatskin's tumor) in the absence of bile duct stones. RESULT: successful treatment with endoscopic stent removal and diverticulum toilette. Obstructive jaundice was cured after endoscopic removal of the bezoar and stent substitution. DISCUSSION: the presence of a bezoar and its possible contribution to the pathogenesis of pancreatitis in the presence of periampullary extraluminal duodenal diverticula makes endoscopic intervention for removal of the bezoar necessary and effective. CONCLUSIONS: biliary bezoar is a very rare but treatable cause of stents obstruction in patients with juxtapapillary duodenal diverticula. Endoscopic retrograde cholangiopancreatografhy is helpful in making diagnosis and for resolutive treatment.
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Bezoares/complicações , Divertículo/complicações , Duodenopatias/complicações , Icterícia Obstrutiva/etiologia , Stents , Idoso , Humanos , Masculino , Falha de PróteseRESUMO
INTRODUCTION: the clavicle is one of the most commonly fractured bones, accounting for up to 4-10% of all adult's fractures. These fractures are comparatively easy to manage and typically heal with routine immobilisation. CASE REPORT: a 28 year old man had direct driving trauma to the left shoulder and reported a displaced fracture of the third lateral of left clavicle and an apical pneumothorax. The pneumothorax was treated by the insertion of a chest drain under local anaesthesia. The chest drain was removed 12 days after the injury and the patient was transferred in Traumatology for specific therapy. RESULT: 6 months after the accident, the clavicular fracture had united and the chest radiograph and CT were normal. DISCUSSION: most clavicular fractures result from a fall or a trauma on ipsilateral shoulder. However, the incidence of complications associated with isolated clavicle fracture, including vascular, brachial plexus, and penumothorax, are low but potentially serious. CONCLUSION: careful history and physical examination with particular attention to the neurovascular and chest examination are vital. Close inspection of the radiographs for such potential complication are mandatory in all clavicular fractures and cannot be overstated. From the analysis of international literature, we can affirm that thoracostomy and immobilization are effective to heal pneumothorax and clavicle fracture.
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Clavícula/lesões , Fraturas Ósseas/complicações , Pneumotórax/etiologia , Adulto , Humanos , Masculino , Pneumotórax/diagnóstico por imagem , RadiografiaRESUMO
INTRODUCTION: A case report of 25 yrs-old man with pedunculated exogastric leiomyosarcoma (with acute onset) surgically treated is presented. CASE REPORT: The patient was operated after clinical, instrumental and blood sample tests. We performed a 5 cm wedge resection of the stomach in continuity with the omentum. Careful inspection revealed neither adenopathy nor metastases. RESULTS: Actual complete remission of pathology. Negative 1 year follow up by endoscopy and CT. DISCUSSION: Information on gastric leiomyosarcoma (LM), such as prognostic factors, patterns of disease recurrence, and optimal methods of treatment, are derived from limited clinical experience. Although about 25% of the gastric mesenchymal tumors present an exogastric growth, pedunculated exogastric leiomyosarcomas are extremely rare. Lymphatic spread of gastric LM is uncommon, therefore a formal lymph node dissection is not standard surgical management. At present, there is no evidence of intraperitoneal seeding from exogastric leiomyosarcomas. Consequently, a local resection with an adequate margin is sufficient when no invasion to the adjacent structures is observed. Neither the addition of lymphadenectomy nor the wider tumor-free margins of a radical gastrectomy seemed superior to the more conservative local excision. CONCLUSIONS: Further studies are called for to elucidate if exogastric tumours lead to peritoneal seeding and, thereby, affect tumour survival.
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Leiomiossarcoma/cirurgia , Neoplasias Gástricas/secundário , Neoplasias Gástricas/cirurgia , Doença Aguda , Adulto , Humanos , Leiomiossarcoma/patologia , Masculino , Neoplasias Gástricas/patologiaRESUMO
INTRODUCTION: Colonoscopy is the most commonly used technique for inspection of the colonic mucosa. The safety and effectiveness of colonoscopy in identifying important colonic pathology is directly impacted by the operator experience and by the quality of the bowel preparation performed in anticipation of the procedure. PATIENTS AND METHODS: From December 2000 to June 2006, we performed 8328 total colonoscopy (M:F ratio =1:1.8, mean age 54.7 years, range 16-93). All the patients were submitted to routinary bowel preparation with polyethylenglycol (PEG) the evening before the exam, with fibres diet restriction 5 days before the exam. RESULTS: On 8328 colonoscopy, 1243 were not actable for worst/absent intestinal toilette. 423 colonoscopy were completed after visceral washing with saline solution during the exam. On 1243 colonoscopy repeated, 852 were in subjects affected by diabetes (p < 0.05); in these patients we prescribed 5 litres solution of PEG one day before the endoscopy, diet without fibers 7 days before the exam and the use of 250 ml solution of PEG (bid): with these method, all the patients were submitted successfully to colonoscopy and retrograde ileoscopy. DISCUSSION: Physicians favor preparations associated with the best patient compliance to achieve the best results. Patients favour preparations that are low in volume, palatable, have easy to complete regimens, and are reimbursed by health insurance or are inexpensive. Both patients and physicians favor preparations that are safe to administer in light of existing comorbid conditions and those that will not interact with previously prescribed medications. CONCLUSIONS: Today doesn't exist the "gold standard" for bowel preparation before colonoscopy. Basing on our experience, the 4 litres PEG solution mentioned above is well tolerated and effective. In patients with severe comorbidity (diabetes, renal failure, high blood pressure) only little modifications are required to optimize the colon cleansing.
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Colonoscopia/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios/métodos , Inquéritos e QuestionáriosRESUMO
OBJECTIVE: To review the indications, complications, and outcomes of percutaneous endoscopic gastrostomy (PEG), that are placed routinely in patients unable to obtain adequate nutrition from oral feeding for swallowing disorders (neurological diseases, head and neck cancer, oesophageal cancer, psychological disorders). DESIGN: Retrospective review of patients referred for PEG placement from 2003 to 2005. SETTING: Endoscopic Surgery in Section of General and Thoracic Surgery, Faculty of Medicine and Surgery, Palermo, Italy. PATIENTS AND METHODS: A total of 50 patients, 11 women and 39 men, referred our Section for PEG placement. Indications for PEG placement included various neurologic impairment (82%), oesophageal non-operable cancer (6%), cardia non-operable cancer (4%), cerebrovascular accident (2%), anorexia (2%), pharyngeal esophageal obstruction (2%), head and neck cancer (2%). All patients received preoperative antibiotics as short-term profilaxis. RESULTS: 51 PEGs were positioned in 50 patients. No major complications were registered; 45 patients (90%) were alive at 1 year follow-up and no mortality procedure-related was registered. Percutaneous endoscopic gastrotomy removal had been performed on 2 patients as end-point of treatment, and 43 patients continued to have PEGs in use at 2006. CONCLUSIONS: Outpatients PEG placement using conscious sedation is a safe and effective method for providing enteral nutrition. This technique constitutes the gold standard treatment for enteral nutrition in patients with neurologic impairment or as prophylactic in patients affected by head and neck cancer who needs demolitive surgery. Patients should be carefully assessed, and discussion with the patient and their families should be held to determine that the patient is an appropriate candidate. The Authors feel prophylactic antibiotics lessened the incidence of cutaneous perigastrostomy infection.
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Gastroscopia , Gastrostomia/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
INTRODUCTION: Today, the "gold standard" of surgical management of benign thyroid disease is still controversy. There are different surgical approaches to the thyroid gland, from a radical, total thyroidectomy to a conservative treatment, lobectomy with or not isthmectomy. In consideration of the more frequent incidence of small carcinomas accidentally founded in the context of the thyroid parenchyma removed for another pathology, the aim of this study is to bring a contribute to resolve the debate on the therapeutic choice in the surgical management of the thyroid benign disease. PATIENTS AND METHODS: From January 2000 to January 2006 502 thyroidectomy were performed in the Section of General and Thoracic Surgery of University of Palermo: 458 total thyroidectomy (91.3%), 2 partial thyroidectomy (0.3%), 24 (4.8%) lobectomy with isthmectomy and 18 (3.6%) reinterventions for relapse; 34 patients (6.8%) were preoperative suspected (cytological or ultrasonography) for thyroid cancer. RESULTS: After total thyroidectomy in 17 patients (3.4%) we founded a papillary incidental "microcarcinoma", diameter range 2-10 mm (mean 6.9 mm). In 2 cases (11.7%) we found infiltrative and multifocal tendency. Histologically, were 11 cases of classical papillary (64.7%), 4 cases (23.6%) of follicular and 2 (11.7%) sclerosing, in 9 cases of multinodular goiter, 3 of follicular adenoma, 3 cases of follicular carcinoma, 1 case of Graves disease and 1 case of Hashimoto thyroiditis. DISCUSSION: Papillary microcarcinoma is a "thyroid papillary cancer with a diameter < or = 1 cm?". From the analysis of literature, we observed a progressive increasing of papillary microcarcinoma from 12% (1980) to 25% (1990), with a prevalence of diameters < or = 5. Actually, there are no univocal data on natural history, nodal metastasis, biological and clinical behaviour, morbidity and mortality of these neoplasms; the certain data is that only the radical surgery can prevent relapse and incidentalomas that modify surgical approach. CONCLUSIONS: In our opinion, the surgical management of the all thyroid disease must be the more radical since the first time, because we think other approaches not correct to improve the complete health from the benign thyroid disease and to prevent (secondary prevention) papillary microcarcinoma not pre-operative diagnosed, because there are no preoperative pattern to make a correct diagnosis of this tumour.
Assuntos
Carcinoma Papilar/cirurgia , Neoplasias da Glândula Tireoide/cirurgia , Tireoidectomia/métodos , Adulto , Idoso , Carcinoma Papilar/epidemiologia , Carcinoma Papilar/patologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Sicília/epidemiologia , Neoplasias da Glândula Tireoide/epidemiologia , Neoplasias da Glândula Tireoide/patologia , Resultado do TratamentoRESUMO
AIM: the Authors report their experience about the endoscopic treatment of pancreatic pseudocysts (PP). PATIENTS AND METHODS: report of 10 cases; evaluation of effectiveness, morbidity and mortality of treatment. SETTING: Section of General and Thoracic Surgery, AOUP ?Paolo Giaccone?, University of Palermo. PROCEDURE: endoscopic drainage was performed in all 10 patients, with 2 cysto-gastrostomy, 5 cysto-duodenostomy and 3 trans-papillary cystic drainage. RESULTS: 100% successful; one case of bleeding post-procedure (10%), one case of sepsis (10%) and one case of stricture of fistula between PP and duodenum. CONCLUSION: endoscopic drainage of PP is a safe and simple treatment, with high rates of success and low rate of complication procedure-related, complementary to surgery.
Assuntos
Endoscopia , Pseudocisto Pancreático/cirurgia , Adulto , Idoso , Drenagem , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Pseudocisto Pancreático/diagnóstico , Fatores de Tempo , Resultado do TratamentoRESUMO
CASE: The Authors report their experience about a case of severe rectal bleeding after transrectal ultrasound-guided prostate biopsy. INTERVENTION: After correct and sure diagnosis, the patient was submitted to resolutive endoscopic haemostatic treatment (failure of haemostatic mechanical manoeuvres, emergency colonscopy, haemostasis with sclerotherapy, heat bipolar probe and Argon Plasma Coagulation). RESULTS: Complete recovery (immediate stop bleeding). Follow-up (1 year) negative. CONCLUSIONS: Rectal bleeding after prostate biopsy is a important but rare complication of prostate cancer screening, potentially lethal. Best knowledge of causes and risk factors may improve the diagnosis and standardize the treatment. The prostatic biopsy is surely the best procedure for the screening of prostate cancer in the population, associated with PSA dosage.