[The role of the intraoperative manometry in the esophageal achalasia surgical treatment]. / Il ruolo della manometria intraoperatoria nel trattamento chirurgico dell'acalasia esofagea.

INTRODUCTION: The authors report their experience about the intraoperative manometry in the achalasia surgical treatment. PATIENTS AND METHODS: We have considered 239 patients with achalasia observed from 1994 to 2006; only 79 continued the path diagnostic therapeutic and 31 underwent Heller longitudinal miotomy, with Dor anti-reflux plastic in 25 patients and in 6 Nissen anti-reflux plastic. In 24 we performed the intraoperative manometry (MI) recording the high pressure areas. RESULTS: The patients underwent Heller's procedure with manometric check of the gastric muscular fibre sectioned areas reported the disappearance of the dysphagia. Three of the operated ones without using the MI complained about the persistence of mild dysphagia and it did not depend from the antireflux surgical procedure used. CONCLUSIONS: Our findings confirm that the extramucosal miotomy is the treatment of choice for the achalasia and suggest that by MI a complete miotomy is allowed mostly on the gastric side where the muscular fibres get an important role in the maintenance of the high pressure areas.

[Infected pancreatic pseudocysts: technical notes]. / Pseudocisti pancreatiche infette: note di tecnica.

INTRODUCTION: Starting from the observation of 9 cases of giant infected pancreatic cysts, which occurred from 1994 to 2004 at the Department of Oncological and Surgical Studies, the Authors' aim has been to evaluate whether a more thorough necrosectomy, carried-out under video-endoscopic control, associated with a nose-gastro-cavity tube, which ensures a continuous cleansing of the newly-formed cavity, and an appropriate positioning of the drainages, could reduce the morbidity and allow a shorter recovery of the infected pseudocysts. PATIENTS AND METHODS: Of 73 cases of acute pancreatitis, observed from 1994 to 2004, 9 showed severe and acute pancreatitis, which included giant pseudocysts, as revealed by the abdomen angio-TC. Our nine septic patients underwent cysto-gastro-anastomosis, necrosectomy, intraoperative cleansing of the cavity with an antibiotic solution and positioning of multiple drainages. Three of these patients also underwent a thorough and targeted necrosectomy, assisted by a trans-anastomotic video-endoscopy. A nose-gastro-cavity tube has been placed in all the patients. RESULTS: The disappearance of the septic state in our three patients who underwent a targeted video-assisted necrosectomy occurred after three days of treatment; moreover, the abdomen angio-TC on the 5th postoperative day showed the disappearance of the necrotic areas. The recovery of these three patients was significantly shorter, compared to those undergoing traditional treatment (cysto-gastro-anastomosis, standard necrosectomy and positioning of abdominal drainages). CONCLUSIONS: Our surgical video-assisted technique demonstrated that, with a slight increase in the operative time, a better control over sepsis may be accomplished, as well as a reduction of the post-operative morbidity, which leads to shorter hospitalisation of patients with infected pancreatic pseudocysts.

[Gallstone ileus: diagnosis and treatment. Case report]. / Ileo biliare: diagnosi e trattamento. Case report.

The authors present a case of gallstone intermittent ileus caused by the passage of a big gallstone (about 4 cm in diameter) in the intestinal lumen, through a cholecystoduodenal fistula. They emphasize the peculiarity of the case for the characteristics of symptoms and for casual diagnostic check-up with a ultrasonography. The disease is not frequently diagnosed; today it has a safe recognition by modern imaging. The symptoms can be intermittent and, even when there are the classic signs of intestinal occlusion, the site of the occlusion is various. With a timely endoscopical or surgical approach (open or laparoscopic) it is possible to reduce mortality of patients treated in emergency.

[A gastric polypoid signet ring cell carcinoma]. / Carcinoma con cellule ad anello con castone insorto in polipo gastrico.

AIM: The authors signal a case of gastric polypoid signet ring cell carcinoma, of particular interest for its rarity like show from the review of the literature, which is the first to have been described after Tabaru's citation. METHODS: The study has been carried out at the Department of Surgical and Oncological Sciences of the University of Palermo. It has been based on 2000 cases analysed from June 2001 to December 2003. RESULTS: The authors advance some and emphasizes the diagnostic flow chart and therapeutic choices adopted. CONCLUSIONS: We agree that the endoscopic polypectomy is surgical procedure of first approach, but modifying the therapeutic guideline in relation to histologic examination, like happened in the case in issue.

[Observations about a case of giant splenic cyst]. / Osservazione a proposito di un caso di cisti gigante della milza.

The Authors, on the basis of a case of giant spleen cyst with positive tumoral markers, analyse some epidemiological and clinical aspects related to splenic non parasitic cysts. They affirm the priority of the conservative surgery, whenever possible, followed by an appropriate follow-up, although in this case their therapeutic choice was radical, due to the lack of residual parenchyma. In accordance with the data of several publications, as well as on the basis of the results obtained, the conservative approaches have been reevaluated, above all in view of the modern findings related to the function of the spleen. The conservative approach cannot be carried out in the following cases: neoplastic diseases, increase of the tumoral markers serum levels, total involvement of the splenic parenchyma by cysts.

[Ultrasonic dissector for total thyroidectomy: results of prospective randomized study]. / Tiroidectomia totale con impiego del dissettore ad ultrasuoni: risultati di uno studio prospettico randomizzato.

In the last years, the introduction and employment in surgery of the dissectors of last generation (ultrasounds, radiofrequency, etc.) have contributed to a remarkable improvement and simplification of the performances and the surgical techniques. The present study has the aim to verify, on the basis of the experience made in the last two years and through a careful comparisons with operations performed in the usual way, the advantages of employment of ultrasonic dissector in thyroid surgery and if besides such advantages it is possible to obtain real and substantial reductions of the complications. To such aim a randomized perspective study has been lead, confronting two groups of 60 patients, submitted to total thyroidectomy in Chair of General Surgery and Surgical Physiopathology of the University of Palermo-Complex Operating Unit of General Surgery. In all patients have been considered age, sex, histological diagnosis, length of the incision, time (from the incision until suture of skin), entity of the bleeding, hospital stay, post-operative consequences and total costs of thyroidectomy. The elaboration of the obtained data shows the advantages following to the use of the dissectors of last generation: reduction of the times, reduction of the complications, better tolerance of the operation by patients, better rationalization of the resources.

Inguinal hernia surgery performed on elderly cardiopath patients.

Old age cannot be considered as an absolute risk factor in the surgical treatment of inguinal hernia, which can also be stated for the majority of elderly people pathologies. The opportunity of surgically treating a wider range of individuals has been made possible thanks to the use of both modern, less invasive surgical techniques and easy-to-handle anaesthetic medicines, as well as a new concept of elderly-customer-friendly sanitary planning. The evaluation of the risks is multifactorial; consequently, in the case of elderly cardiopath individuals, suffering from inguinal hernia, one has to reconsider both the type of anaesthetic and the surgical technique to be performed, in view of the increased risks, as against the case of non cardiopath, elderly patients. The modern tension-free techniques have demonstrated in cardiopath patients the same advantages which have been observed in elderly non cardiopath patients, such as a faster functional recuperation as well as no significant percentage difference related to the early and late complications following the operation.

Prognostic factors of cirrhotic patients in extra-hepatic surgery.

BACKGROUND: The surgical approach to a cirrhotic patient is conditioned by a number of variables depending on the emergency and kind of the intervention. It is also related to the evolutionary stage of the liver pathology (evaluated following Child-Pugh score). The present study will explore the physiopathologic mechanisms which should be correlated with the preoperative risk factors responsible for the variation of morbidity and mortality of the hepatopathic patient addressed to an extrahepatic surgical intervention. METHODS: This study includes a retrospective analysis (from 1992 to 1999) of 40 patients with cirrhosis (80% HCV correlated cirrhosis, 15.5% alcoholic cirrhosis, 2.5% cryptogenic cirrhosis), who underwent such procedures as: colon resection (5), gastrectomy (4), hernioplasty (11), cholecystectomy (14), ulcorraphy (3), laparotomy (3). Patients with hepatic resection and portal shunt are excluded from this study. A pre- and postoperative evaluation of ascites, PT, APTT, albumin, bilirubin and protein value, number of leukocytes and Child-Pugh score was performed on all patients. Their follow-up was 30 days. RESULTS: The presence of tensive ascites, low albumin value, PT, APTT, together with the emergency of the operation, proved to be significant (p<0.001), in correlation with a mortality of 7.1% in Child's class A, of 23% in class B, and of 84% in class C. CONCLUSIONS: Cirrhotic patients undergoing elective or emergency surgery can incur significant preoperative risks and postoperative complications, increasing their mortality rate. An accurate preoperative predictive factor is Child's class.

Artificial nutrition for the treatment of short bowel syndrome.

BACKGROUND: In the short bowel syndromes (SBS) it is often difficult to grant a correct and sufficient alimentary supply only by ordinary natural nutrition. In the present research, we will study the prospective possibilities of integrating the nutritional supply making resort to artificial nutrition techniques in patients with SBS. METHODS: We have treated 7 patients with SBS, 6 males and 1 female, whose age was ranging from 29 and 70 years. They all underwent wide intestinal resection, 2 of them for massive infarct, 4 for Crohn's disease, 1 for bowel volvolus. An evaluation of nutritional and immunological conditions was performed on all of them, determining: albumin, transferrin, C-reactive protein, prealbumin, leukocyte count, skin test. In a second time, a protocol was implemented, based on total parenteral nutrition for the first 5 days, with scalar calorie supply up to a total of 35 kcal/kg/die; on day 6 after the operation, the parenteral caloric supply was reduced of 500 kcal/die, being compensated by the introduction of an equal caloric ration by nasointestinal tube with peristaltic pump having a flow of 20 mL/h. In the following days, the parenteral caloric supply was reduced of 500 cal each 48 hours, being substituted with an equal enteral supply in order to progressively reach a complete abandonment of parenteral nutrition. RESULTS: All the patients have a follow-up of 2 to 5 years; today they follow a high-calorie hyperglycidic, hypolipidic diet; no signs of malnutrition are shown by clinical and laboratory analysis. CONCLUSIONS: In the light of the data in our possession, it can be understood that nutritional therapy is the main treatment for SBS; parenteral subministration has to be abandoned during the postoperatory course to give way to enteral nutrition, in order to create a physiological stimulus able to make the digestive system rapidly adapt to the new situation.

Severe obstructive jaundice in a 90-year-old man caused by an annular pancreas. Report of a case.

Although the annular pancreas is a rare congenital malformation of the pancreatic glandular parenchyma, this pathology often remains asymptomatic until the adult or old age and can represent an incidental finding during an ERCP or an abdominal Computed Tomography, because the clinical appearance of this condition can be of very various kinds. We present a case of an extra-hepatic jaundice in a 90-year-old man, caused by an annular pancreas constricting coledochus. Description of this case results very interesting and particular for two reasons: the very old age of the patient, probably the oldest recorded, and the unusual clinical appearance: obstructive jaundice as beginning one symptom of this malformation.

Ultra short-term antimicrobial prophylaxis in patients undergoing surgery for gynecologic cancer.

OBJECTIVE: To evaluate the efficacy of ultra short-term antimicrobial prophylaxis with ceftazidime in patients undergoing radical gynecologic surgery. PATIENTS AND METHODS: Two hundred patients undergoing surgery for a malignant disease of the female genital tract were enrolled in a prospective trial to receive 2.0 g ceftazidime as a single dose, 30 minutes before induction of anaesthesia. After surgery, each patient was assessed to confirm febrile status and the presence of infections at the surgical site, urinary tract and respiratory tract. RESULTS: Postoperative morbidity occurred in 23 patients (11, 5%). Ten patients (5%) developed febrile morbidity, five (2, 5%) vaginal cuff infections, four asymptomatic bacteriuria and two each wound infiltration and urinary tract infection. Twelve patients had microbiological evidence of infection and Staphylococccus aureus was the most common pathogen isolated. Univariate analysis demonstrated that pre-existing systemic disease, extensive blood loss (more than 500 ml) and long duration of surgery (more than 150 minutes) were the only factors associated with a significant increase in postoperative febrile morbidity. CONCLUSIONS: Ultra short-term antimicrobial prophylaxis with ceftazidime is safe and effective in patients undergoing surgery for gynecologic cancer.

High levels of exogenous C2-ceramide promote morphological and biochemical evidences of necrotic features in thyroid follicular cells.

CD95 and ceramide are known to be involved in the apoptotic mechanism. The triggering of CD95 induces a cascade of metabolic events that progressively and dramatically modifies the cell shape by intense membrane blebbing, leading to apoptotic bodies production. Although the CD95 pathway has been abundantly described in normal thyrocytes, the effects of cell permeable synthetic ceramide at morphological and biochemical levels are not fully known. In the present study, we show that thyroid follicular cells (TFC) exposed to 20 microM of C(2)-ceramide for 4 h are characterized by morphological features of necrosis, such as electron-lucent cytoplasm, mitochondrial swelling, and loss of plasma membrane integrity without drastic morphological changes in the nuclei. By contrast, TFC treated with 2 microM of C(2)-ceramide for 4 h are able to accumulate GD3, activate caspases cascade, and induce apoptosis. Furthermore, we provide evidence that 20 microM of C(2)-ceramide determine the destruction of mitochondria and are not able to induce PARP cleavage and internucleosomal DNA fragmentation, suggesting that the apoptotic program is not activated during the death process and nuclear DNA is randomly cleaved as the consequence of cellular degeneration. Pretreatment with 30 microM of zVAD-fmk rescued TFC from 2 microM of C(2)-ceramide-induced apoptosis, whereas, 20 microM of C(2)-ceramide exposure induced necrotic features. Deltapsi(m) was obviously altered in cells treated with 20 microM of C(2)-ceramide for 4 h (75% +/- 3.5%) compared with the low percentage (12.5% +/- 0.4%) of cells with altered Deltapsi(m) exposed to 2 microM of C(2)-ceramide. Whereas, only 20% +/- 1.1% of cells treated with anti-CD95 for 1 h showed altered Deltapsi(m). Additionally, Bax and Bak, two pro-apoptotic members, seem to be not oligomerized in the mitochondrial membrane following ceramide exposure. These results imply that high levels of exogenous ceramide contribute to the necrotic process in TFC, and may provide key molecular basis to the understanding of thyroid signaling pathways that might promote the apoptotic mechanism in thyroid tumoral cells.

Role of color flow Doppler sonography in pre-operative diagnostics of the thyroid pathology.

BACKGROUND: The aim of this work is to demonstrate the high effectiveness of preoperative diagnosis by echotomographic study of thyroid nodules through color-Doppler sonography integrated by B-mode. The authors performed both B-mode ultrasonography and color-Doppler sonography on 125 patients expecting total thyroidectomy surgical intervention, without a previous evaluation of a number of other already performed clinical and instrumental tests. After the intervention, we compared the histologic test with the data drawn from the ultrasound scan, in order to demonstrate that color-Doppler sonography is able to provide for additional diagnostic information in the preoperative period. METHODS: One hundred and twenty five patients with thyroid pathologies were examined by both B-mode and color-Doppler sonography. Two diagnoses were made for each clinical case: the first supported by B-mode data, the second based on vascularity. Our aim was to check color-Doppler's ability to provide new information in the ultrasound diagnosis. All patients underwent a total thyroidectomy surgical intervention. The data were examined by K concordance test. RESULTS: Ultrasound data were compared with the histologic test, which showed 118 (97.4%) benign and 7 (5.6%) malignant lesions. B-mode ultrasound test gave a correct diagnosis in 115 (97%) out of 118 benign lesions and in 4 (57%) out of 7 malignant lesions, while 3 (2.5%) out of 118 cases were false positive and 3 (42.8%) out of 7 were false negative. In those cases showing a wrong conventional ultrasound diagnosis, after the integration of B-mode with color-Doppler results, a decrease was recorded in both false negative and false positive. CONCLUSIONS: Even if no correspondence was found between the different aspects of blood flow and the histologic types of lesions, this experience proves that the color-Doppler test has a high predictive value of benignity in cases with pattern I II and IV, while lesions with pattern III should be more carefully examined, since both malignant and benign lesions belong to this group. From the data drawn from this study, we are able to infer that color-Doppler sonography is undoubtedly an advantage not only in terms of cutting the false negatives, but also in the aim of obtaining a higher effectiveness in the screening of goitrogenic pathology.

Antimicrobial prophylaxis in laparotomic gynecologic surgery: a prospective randomized study comparing amoxicillin-clavulanic acid with cefazolin.

A prospective randomized study was conducted at the Department of Obstetrics and Gynecology, University of Bari to compare two antimicrobial regimens, amoxicillin-clavulanic acid with cefazolin as ultra-short term prophylaxis in laparotomic gynecologic surgery. Patients were randomly allocated to receive a single dose of amoxicillin-clavulanic acid (2.2 g) [Group A] or cefazolin (2 g) [Group B] 30 minutes before surgery. Each patient was assessed daily until discharge for fever and the presence of infection of the surgical wound, urinary tract and respiratory tract. In the amoxicillin-clavulanic acid (Group A) and cefazolin (Group B) groups, overall 258 and 253 patients, respectively were evaluable for prophylactic efficacy at hospital discharge. Infectious complications were infrequent in both arms. Febrile morbidity occurred in 16 (6.3%) and 21 (8.1%) patients respectively in the amoxicillin-clavulanic acid and cefazolin groups. Wound infection and urinary tract infection were also higher but not significantly in the cefazolin group (0.8% versus 0% and 2.7% versus 2.0% respectively). There was no respiratory tract infection or septic death in either group. It is concluded that ultra-short term prophylaxis with both amoxicillin-clavulanic acid and cefazolin is safe and effective in elective laparotomic gynecologic surgery.

Calyceal rupture and perirenal urinoma as a presenting sign of recurrent ovarian cancer.

BACKGROUND: Rupture of the urinary collecting system with peripelvic extravasation of urine is an uncommon pathologic condition usually associated with ureteral obstruction from calculi. CASE: We report a patient with calyceal rupture and peripelvic extravasation of urine secondary to distal ureteral obstruction by recurrent ovarian carcinoma. Diagnosis was established with computed tomography and renal scans. Placement of an indwelling ureteral stent via a nephrostomy resolved the urinoma. CONCLUSION: Gynecologic oncologists should be aware that calyceal rupture is a potential complication of gynecologic malignancy. Causes of perirenal urinary extravasation and approaches to diagnosis and management are reviewed.

Socio-demographic factors and indications in second trimester voluntary abortion.

BACKGROUND: According to Italian Law, second trimester termination of pregnancy is allowed for life threatening conditions or for severe psychological distress, linked or not to prenatal diagnosis of foetal abnormalities. Socio-demographic factors related to this condition have been analysed. METHODS: Clinical records of 330 patients admitted during the years 1988-1997 to the Obstetrics and Gynaecology Department, University of Bari, Italy, for voluntary second trimester abortion, were examined. Maternal psychiatric indications have been given in nearly all of the cases. In 123 cases the indications were secondary to the women suffering a psychiatric disorder due to foetal pathologies. In 205 cases--where poor social conditions were more frequent--the indication was given on the ground of a psychiatric disorder linked to the pregnancy itself. RESULTS: Significantly higher incidence of teenagers (23.3%) and singles (50%) in women who underwent a late abortion. Students were 16.4% in this group. In primary psychiatric indication singles prevail (74.4%) and students represent 23.6% while in secondary psychiatric indication the married were 84.7%, students only 4.8%. In primary psychiatric indication 32.5% of women aged nineteen or less, while in secondary psychiatric indication this percentage was 8%. CONCLUSIONS: Among patients who have a late abortion, teenagers students and singles are prevalent, these patients have significantly more primary psychiatric indications, not linked to foetal abnormalities. The high percentage of teenagers with primary psychiatric indication could depend on inadequate information and social service. Reduction of mid-trimester terminations of pregnancy can be significantly achieved intervening in this group of young women. On the other hand, in secondary indications earlier diagnosis of foetal abnormalities must be encouraged (villocentesis instead of amniocentesis) and abortion discouraged when the foetal pathology is minor, treatable or unlikely to significantly impair the future quality of life.

Primary peritoneal carcinoma: a report of twelve cases and a review of the literature.

Primary peritoneal carcinoma (PPC) is rare tumor histologically identical to epithelial ovarian carcinoma (EOC); it is differentiated from EOC based on the extent of gross ovarian involvement and microscopic invasion of the cortex. We report 12 cases of PPC which were diagnosed in our Department during a 9-year period. Total abdominal hysterectomy, bilateral salpingo-oophorectomy and omentectomy were performed in 9 patients, while 3 underwent only explorative laparotomy with bilateral salpingo-oophorectomy. All patients were treated with postoperative platinum-based chemotherapy. After a median follow-up of 42 months, only 5 patients are alive without disease. PPC is a rare tumor currently managed in the same way as ovarian cancer. Primary debulking surgery and chemotherapy represent the cornerstones of treatment. Considering the limited number of patients with PPC, no definitive conclusion can be drawn concerning the prognostic factors for survival.

Prognostic factors and selective use of vaginal hysterectomy in early stage endometrial carcinoma.

INTRODUCTION: Endometrial cancer represents the fourth most frequent malignancy in women of any age, tending to become the most common gynaecological tumor in developed Countries. A retrospective analysis has been conducted on the prognostic factors of endometrial neoplasm during 15-years experience (1977-1991). MATERIAL AND METHODS: 321 patients affected by stage I and II endometrial carcinoma have been treated surgically first hand. Surgical-pathological staging and prognostic factors were reviewed and related to follow-up and 5-year survival rate. RESULTS: The age-peak of patients was 50-70 years; prevalent histologic type was adenocarcinoma (95.6%); 269 patients were in stage I and 52 in stage II. In stage I disease overall 5-year survival rate resulted to be 81.4%, while in stage II it fell to 59.6%. DISCUSSION: Myometrial involvement by adenocarcinomatous cells is probably the most important prognostic factor, considering its reliability and non-contradictory evaluation. Our data confirm there is no difference in impact on 5-year survival between abdominal and vaginal routes in clinical stage I and occult stage II endometrial carcinoma.

Surgical treatment of recurrent ovarian cancer: report of 21 cases and a review of the literature.

AIM: To evaluate the role of secondary cytoreductive surgery in patients with recurrent ovarian cancer. PATIENTS AND METHODS: A retrospective chart review was conducted on 21 patients submitted to secondary cytoreductive surgery for apparently isolated and resectable recurrence of ovarian cancer, after a disease-free interval of at least 12 months. RESULTS: Fifteen patients (71%) had complete surgical debulking with no macroscopic tumor at the completion of the surgical procedure. Eight patients (38%) required an intestinal resection but no colostomy was performed. Eleven complications were recorded in nine patients, but no operative death occurred. The median survival time for all patients after diagnosis of recurrent disease was 29 months (range 6-96 months). Survival time after diagnosis of recurrence was not significantly related either to known prognostic factors of ovarian cancer or to the length of the clinical remission time. The absence of residual disease after salvage surgery was the only factory associated with prolonged survival. CONCLUSION: Secondary cytoreductive surgery is a safe procedure which should be offered to recurrent ovarian cancer patients with apparently isolated and resectable disease, and without ascitis.

Hypersensitivity reactions in ovarian cancer patients receiving paclitaxel.

OBJECTIVE: The aim of this study was to describe a rapid retreatment strategy in patients with paclitaxel hypersensitivity reactions. METHODS: A retrospective review of all patients receiving standard 3-hour infusion paclitaxel-based chemotherapy after proper premedication at the Department of Gynecologic Oncology, University of Bari between 1995 and 1998, was performed. All patients who developed hypersensitivity reactions to paclitaxel were identified and their treatment course and outcome were reviewed. A review of the literature on this subject is also presented. RESULTS: Eighty-six women were treated with 461 cycles of paclitaxel-based chemotherapy at our Unit. Twelve patients (14%) developed hypersensitivity reactions. All had received standard premedication consisting of corticosteroids and hystamine blockers. Hypersensitivity reactions consisted of isolated face flushes (3 patients), dyspnea and chest tightness (4 patients) or bronchospasm (5 patients). Eleven patients were rechallenged with the original paclitaxel solution starting at a slower rate after a second premedication with a double dosage of steroids. None of these patients had reactions in subsequent courses. Only one patient (the first of this series treated in February 1995), was retreated 5 days later under strict monitoring in intensive care unit. CONCLUSIONS: Retreatment with the original paclitaxel solution is safe in almost all patients with hypersensitivity reactions. The drug should be administered within the next 24 hours with a new premedication protocol.