Double-stapling technique for transhiatal distal esophageal resection: feasibility test in a cadaver model.

OBJECTIVES: To assess the feasibility of a new surgical technique for the resection of the distal third of the esophagus and/or cardias for neoplasm. METHODS: This surgical technique consists of two steps: For this purpose we built a stainless steel support bar for the anvil that is thinner than the freespace of a standard linear suturing stapler (TATM). The support bar holds up a push rod that can be adapted to the hooking-unhooking of the anvil. RESULTS: We performed our new technique on five cadavers. We did not encounter any difficulty during the procedures. We tested the anastomosis with hydropneumatic assessment without recording any leaks. The esophago-enteric anastomosis was then opened without finding any mechanical defects related to the procedure. CONCLUSION: It can often be very difficult to fashion a safe hand-sewn pouch or a purse string around the anvil of an EEATM during the resection of the distal third of the esophagus or the cardias by a trans-hiatal approach. Moreover, there is no standardized procedure to minimize anastomotic leak. To avoid these mechanical problems we designed this innovative procedure, which is considered to be reproducible without significant training.

Percutaneous radiofrequency ablation versus surgical radiofrequency-assisted nodulectomy in treatment of small single nodes of hepatocellular carcinoma: our experience.

AIM: Surgical resection usually represents the treatment of choice for solitary hepatocellular carcinoma (HCC) in cirrhotic patients, with well preserved liver function; local ablative strategies are the best treatment option for patients with small tumors who are not candidates for surgical resection or liver transplantation. Several studies showed that percutaneous radiofrequency ablation (RFA) has similar efficacy to surgical nodulectomy in the treatment of early-stage HCC, and is associated with lower complication rates and costs than resection. The aim of this study was to compare the effectiveness of these treatments, in terms of morbidity, overall survival, tumor recurrence and causes of death. METHODS: Between January 2006 and January 2012 we observed 176 patients affected by HCC, 84 underwent curative treatment. The 40 patients presenting single HCC nodes smaller than 3 cm in diameter have been treated with radiofrequency-assisted surgical nodulectomy (N.=20) or with percutaneous radiofrequency (N.=20). RESULTS: No perioperative mortality occurred in the two groups. Perioperative morbidity was 5% in group A (1 case of peritoneal bleeding) and 5% in group B (1 case of hepatic abscess). Disease-free survival was slightly higher in surgically treated patients, but not statistically significative differences have been demonstrated (P<0.06); no local recurrences were observed in surgically treated patients. CONCLUSION: RF and surgical nodulectomy can be either used in treatment of early stage hepatocellular carcinoma; no differences in terms of morbidity, overall and disease free survival were observed; nodulectomy seems to prevent from tumor local recurrence.

Ultrastructural analysis of different-made staplers' staples.

AIM: Recently, Chinese-made mechanical staplers with lower price respect to American-made ones have been introduced in clinical practice. In literature, small case series compare the clinical outcomes of different staplers concluding that the new stapler devices perform as well as the American ones. The aim of this study is to compare with an ultrastructural analysis the staples of different staplers in order to verify the existence of differences that might explain significant price disparity and condition clinical outcomes. METHODS: Each stapler was subjected to morphological analysis, energy dispersive X-Ray spectroscopy, metal release assessment followed by inductively coupled plasma mass spectroscopy. P-values were considered statistically significant when <0.05. RESULTS: Autosuture staples have square section whereas the other American one and Chinese made staples have round sections. Roughness index and chips presence before and after ageing tests were comparable for all samples except for Ethicon Endo-Surgery stapler. Energy dispersive X-Ray spectroscopy showed that all staplers are made of pure Titanium but Ethicon Endo-Surgery staples are made with an alloy. Metal release analysis release statistically significant differences between samples in simulated body fluid 20 days solution (P=0.002) and in Aquaregia at 14 days solution. Discussion. Stapling devices have became routinely used in gastrointestinal surgery mainly because of operative time reduction. Recently, new Chinese-made mechanical staplers, with significantly lower prices, have been introduced in clinical practice. In literature, there are some studies that compare clinical outcomes of American-made and Chinese-made staplers on small groups of patients but doesn't exist any work which consider structural differences between traditional and new devices. In our study, for the first time, we propose a comparison between two American-made staplers and three Chinese-made staplers which evaluate morphology, metal composition and chemical staples release. CONCLUSION: Our study suggest that there are some ultrastructural differences between commercially available staplers with no correlation to price disparity. More studies are needed to confirm our results and to verify if our findings could condition clinical outcomes.

Idiopathic ileo-colonic varices in a young patient.

Colonic varices are an infrequent cause of rectal bleeding and haematochezia and they are often related to portal hypertension due to either haepatopathy or any other cause of obstruction of the portal circulation. A 20-year-old patient was studied after she suffered a serious episode of rectal bleeding, followed by syncope. In view of her clinical picture of serious rectal bleeding, which could not be kept under control by means of medical therapy or endoscopy, the patient underwent total video laparoscopic colectomy surgery with ileum-rectum anastomosis. The histological examination revealed prominent ectasia presence of venous vessels under the mucosa. Colonic varices are one of the most common causes of low gastroenteric bleeding and in most cases they are caused by portal hypertension or intestinal occlusion. In less common cases, they are caused by thrombosis of the splenic vein, cardiac insufficiency, venous mesenteric thrombosis, extrinsic compression on tumoral invasion. Idiopathic colonic varices are described in the literature as the cause of low gastroenteric bleeding in not more than 20 patients. Therapeutic options are conservative follow-up or surgery. As it happened in our case, surgery is generally the chosen treatment, in view of the risk of recurring bleeding, the young age of patients and the low degree of co-morbidity of patients. The prognosis for surgery of idiopathic colonic varices is very good at any age when compared with the one for the treatment of varices caused by cirrhosis of the liver, thus confirming the importance of diagnosing idiopathic varices, only after having ruled out the presence of other basic pathologies.

Eyelid eosinophilic granuloma in a Siberian husky.

Canine eosinophilic granuloma (CEG) is a rare skin disease of unknown origin. It has been reported in Siberian huskies, Cavalier King Charles spaniels and occasionally in other breeds. The lesions comprise nodules or plaques, mostly localised in the oral cavity. A case of a single cutaneous nodular lesion of CEG on the eyelid of a Siberian husky is described. Complete remission was achieved with oral glucocorticoid treatment.