Functional outcomes of transmetatarsal amputation in the diabetic foot: timing of revascularization, wound healing and ambulatory status.

Transmetatarsal amputation (TMA) is an effective surgical approach to treat forefoot infection and gangrene in diabetic patients. However, a high rate of complications and failure to heal require reamputation in a large number of cases. We analysed the outcomes of TMA to define the role of revascularization, wound healing and ambulatory status. From January 2008 to January 2013, 218 diabetic patients with foot infection and gangrene, submitted to TMA associated to revascularization were followed until healing, amputation or death. Revascularization was done in 202 (92 %) cases. In 16 (7 %) no revascularization was required. The TMA was closed in 135 (62 %) and left open in 83 (38 %) cases. The reamputation rate was 34 % and major amputation 12.6 % at 1-year follow-up. Patient following ranged 2-30 months with a mean of 15 months. The functional outcomes, living at home and ambulation outdoors, were 60 and 36 % at hospital discharge after TMA, 81 and 77 % at 1-year follow-up. TMA associated to revascularization can provide an effective limb salvage and functional results in diabetic patients with forefoot tissue loss and infection.

[Use of monofilament prosthesis in inguinal hernia treatment: cost-benefit ratio]. / L'impiego delle protesi in monofilamento nella terapia dell'ernia inguinale: rapporto costo-beneficio.

BACKGROUND: The authors aimed to demonstrate the real advantages in terms of cost and patient comfort of inguinal hernia surgery using monofilament prostheses. METHODS: A retrospective survey was carried out on two groups of patients: the first group, consisting of 1032 patients who underwent inguinal hernia surgery under general anesthetic between 1985 and 1995 at the Institute of General Surgery at the University Polyclinic of Messina, included cases of both emergency and elective surgery that did not use monofilament prosthesis. The second group, consisting of 348 patients operated under local anesthesia between 1996 and 1999 at the IV Division of General Surgery at the University Polyclinic of Messina, included cases of both emergency and elective surgery using tension-free techniques and polypropylene mesh. The numbers of recidivations and complications were compared, together with the relative costs of the methods used in both groups. CONCLUSIONS: In the light of these experimental results, it is clear that the use of biocompatible alloplastic materials in monofilament considerably reduces the risks of recidivation, without no significant increase in the number of dehiscences, infections or postoperative complications. Moreover, there was a striking reduction in costs linked not only to the shorter hospitalisation of patients and the reduced use of painkillers, but also a fall in the number of future hospital admissions owing to recidivation.

[Trans-anal resection of low rectal neoplasms]. / Exeresi transanale delle neoplasie del retto basso.

BACKGROUND: The rising incidence of colorectal neoplasms, and in particular those localised in the lower rectum is stressed and the therapeutic opportunities offered by the trans-anal resection technique are underlined. METHODS: The indispensable conditions for adopting a surgical approach are pointed out. These are identified as the size of the neoplasm, which should not exceed 4 cm, the fixity, site, the polypoid and non-ulcerated nature of the lesion, and the involvement of not more than 1/4 of the circumference of the bowel. Using these inclusion criteria, the authors operated on five patients in the 4th Division of General Surgery at G. Martino Polyclinic in Messina, using trans-anal resection of low rectal neoplasm. RESULTS: No hemorrhagic complications or lesions in the visceral wall occurred. All patients underwent a follow-up of up to 36 months and to date no patient has presented long-term metastasis; local recidivation was observed in one patient after 14 months and this was treated using the trans-anal method. CONCLUSIONS: The authors affirm that trans-anal resection may be regarded as the elective treatment of patients with neoplasms confined to the visceral wall and without dissemination; it is palliative in cases where the tumour is larger than 4 cm, with lymph node involvement. But even in this case, and in more advanced situations, this method allows mortality due to occlusive complications to be reduced and ensures a better quality of residual life.

[Anal carcinoma]. / Il carcinoma anale.

The authors, want to demonstrate the operation of abdominal perianal rectum amputation, and it is considered absolute, even 80 years, in the treatment of the anal neoplasia, it is superseded by alternative methods represented by protocols radio-chemo-therapeutic associated or less to the surgery treatment. They make then a retrospective valuation since 1963 till our days on 54 patients. In the 6 patients (stadium I-II) treated after 1982 with protocols of freemall, it is was obtained disappearance of the neoplasia about 50% the cases. On overcoming of the results there was in a second group of 8 patients (1987) treated always with protocol of Greenall, in 5 of these (62.5%) could observe absence of remaining of disease. In the third group (1993) on 8 patients treated with therapy fixed radio-chemo, it was registered the absence of the residual of illness in 6 patients(75.5%). Finally, from the analysis of patients observed in the last seven years, 5 of which suffered by Ca squamous in different evolutive stadium (one I stadium, three II stadium and one stadium III-B), the stadium I and II were treated with the protocol radio-chemotherapeutic obtaining total remission of the disease in the 100% of the cases. In the follow-up of 45 patients, 12 of whose were treated with the therapy combined radio-chemo and of these 10 were valuable for survival to 5 years which was about 70% superior to patients treated with only surgery therapy.

[Carcinoma of the gastric stump]. / Il carcinoma del monocone gastrico.

After having emphasized that carcinoma of the gastric stump represents a "major" risk in patients undergoing gastric resection, the authors describe the physiopathology of the new anatomical and functional status of the gastroenteric apparatus and underline the probable etiopathogenetic stages attributable to carcinogenesis. They then describe the treatment of this neoplasia with a marked aggressive character and conclude with the affirmation that the surgeon's efforts must be focused on the correct execution of gastroresection and the follow-up of gastro-resected patients in order to allow the early identification of precancerous conditions and therefore the commencement rational oncological prophylaxis.

[Laparoscopic cholecystectomy: the complications]. / La colecistectomia per via laparoscopica: le complicanze.

The authors report their experience of 48 consecutive cases of colecystectomy performed using a videolaparoscopic technique. Laparoscopic surgery was not successful in only two patients in whom it was necessary to resort to laparotomy; bile duct injury occurred in one patient. On the basis of their experience the authors conclude by affirming that this videolaparoscopic technique may be applied to almost all patients requiring cholecystectomy since it offers considerable advantages over traditional techniques.

[Barrett esophagus. The diagnostic and therapeutic aspects]. / Esofago di Barrett. Aspetti diagnostici e terapeutici.

The authors, after a dissertation on the aetiopathogenesis of "Barrett's oesophagus", dwell on the precancerous nature of this pathology involving the oesophageal-gastric junction. Its frequent association with cancer explains the necessity for an accurate follow-up in these patients: many investigations can be useful, the radiological study of oesophagus and stomach, manometry, pH-metry, but an irrefutable diagnosis can only be achieved through endoscopy, which makes possible a histological examination of the bioptic fragments. The authors also deal with the ideal therapeutic strategy and differentiate the cases in which the pharmacological therapy is more appropriate from those that need a surgical approach.

[Inguinal hernia repair with the Shouldice method. Our experience]. / Ernia inguinale: riparazione secondo Shouldice. Nostre esperienze.

From 1982 to 1990, in our Surgical General Department, we have replaced the traditional technique of inguinal hernia with Shouldice's method. This choice was treatment of the following considerations: few relapses happen compared to traditional operations.

[Clinical considerations of jejunal carcinoma]. / Considerazioni cliniche sul carcinoma del digiuno.

The carcinoma of the jejunum represents 3-6.5% of gastric intestinal tumors and 33-50% of small intestine carcinomas. The observation of a case of jejunum carcinoma has offered the authors the idea for a critical revision on the subject. After an examination on the diagnostic, anatomopathological, clinical and therapeutic problems, the authors underline the importance of the precocious diagnosis of neoplasia; in fact the jejunum carcinoma is characterized by a hidden and aspecific symptomatology and by dangerous evolution; besides the site is difficult for an organic study with the common methods of investigation. Therefore, in all patients in whom the suspicion of a jejunum pathology exists, it is indispensable to carry out a precise diagnostic iter which is based on radiological endoscopic and tomographic investigation: in fact the small intestine and the jejunum in particular are intestinal tracts that are explored with difficult and therefore at times only an accurate effecting of the radiological study can permit a precocious diagnosis the only valid supposition for the carrying out of a truly radical surgical therapy and for the acquiring of a batter prognosis.

[Care and rehabilitation of colostomized patients]. / L'assistenza e la riabilitazione del colostomizzato.

The enterostomies represent the result of a surgical operation that we have been carrying out more frequently in the last few years both on account of the neoplastic and inflammatory pathology of the large bowel; in fact about 40,000 colostomies are effectuated in Italy every year. On the basis of what has been said, the problem of assistance and of rehabilitation of the patients with colostomy assumes great importance. Therefore the authors have examined the various phases of the assistance (pre, intra and post-operatory) and they have underlined the rehabilitation of such patients. They conclude by affirming that it is indispensable to have a multidisciplinary collaboration to insure a correct assistance and rehabilitation, which involves the surgeon, the radiotherapist, the enterostomist, the psychologist and the oncologist; only in this way will they be able to restore to society these patients capable of living the rest of their lives if not happy at least serenely.

[Diagnostic and therapeutic considerations in early gastric cancer]. / Considerazioni diagnostiche e terapeutiche sull'early gastric cancer.

A ten-year series of early gastric cancer is reported, stress being laid on the diagnostic and therapeutic problems associated with the condition. The importance of intensified mass screening programmes, particularly in populations at risk, is underlined to enable these potentially dangerous conditions to be treated in time.

[Prostaglandins and gastric cancer: a preliminary study]. / Prostaglandine e cancro gastrico: studio preliminare.

As high levels of Prostaglandins E2 were observed in several gastric diseases, the Authors determined the PGE2 levels in gastric cancer patients without recurrences, in pre and post-operative period. PGE levels were correlated with cancer progression and their significance as tumoral markers was also assessed.

[The inguinal hernia today. Technical notes]. / L'ernia inguinale oggi. Note di tecnica.

Following a short introduction on Bassini's operation, alternative surgical techniques are discussed: Postempski, Halsted, Mugnai-Ferrari, Anson-McVay, Marcy, Ferguson, Shouldice with their indications, advantages and disadvantages. Personal experience in the surgical treatment of 516 patients suffering from inguinal hernia is then reported and stress is laid on the need for precise anatomic knowledge of the inguinal region and skill in one technique in particular to limit the risk of recurrences.

[Clinico-therapeutic considerations on primary gastric lymphoma]. / Considerazioni clinico-terapeutiche sul linfoma gastrico primitivo.

The Authors report four cases of primary gastric lymphomas. They stress the anatomopathological, clinical and therapeutic problems related to this disease because, at present, they are still discussed.