Toxic megacolon in ulcerative rectocolitis. Current trends in clinical evaluation, diagnosis and treatment.

Toxic megacolon is a clinical condition associated to high risk of colonic perforation, that significantly increases--even triplicates--the megacolon-related mortality when causing diffuse peritonitis. Abdominal and pelvic helical CT scan proved to be a fundamental diagnostic tool, in defining the colic dilatation and perforation. Conservative treatment is initially indicated in the event of toxic megacolon arising at the onset of a severe or toxic colitis. However it should be avoided when the toxic megacolon appears on corticosteroid therapy. Non operative management must not exceed 48 hours. The rationale of this strategy lies on the fact that early surgery is burdened by a mortality rate that, although moderate, is still higher than medical treatment. Nevertheless, successful conservative management does not exempt from surgery, which must be performed as soon as possible, in an elective setting, to prevent the recurrence of toxic megacolon. In emergency total colectomy and end ileostomy is the gold standard procedure. Bowel continuity will be restored, evaluating case by case, by performing an ileorectal anastomosis or proctectomy and ileoanal pouch anastomosis. Primary ileorectal anastomosis should be reserved to selected cases. In the elective setting, after proper therapy and regression of toxic megacolon, proctocolectomy and ileoanal pouch anastomosis is indicated.

An unusual tumor in a rare localization: intravascular leiomyosarcoma of the cephalic vein. Case report.

Vascular leiomyosarcoma is a very rare soft tissue neoplasma, with a poor prognosis. We report a vascular leiomyosarcoma arising from an unusual site: the media-vascular wall of the cephalic vein. A 71-year-old man with a subcutaneous node on the volar side of right forearm, came to our attention with signs of vascular obstruction and venous stases, without functional or sensory loss of the right upper extremity. We successfully performed a surgical excision of the cancer with a wide margin resection. During surgery no ascellar lympnodes metastes were found. 4 months after surgery the wound had fully healed, and he suffered no effects by surgery, but he became lost to long-term follow-up and refused adjuvant radiotherapy or chemiotherapy. This case report shows that, in presence of venous stases or thrombosis signs of the upper extremity, leiomyosarcoma of the cephalic vein must be considered in the differential diagnosis among lung cancer, lymphoma or mesenchymal tumours.

Abdominal compartment syndrome due to a giant multilobulated ovarian serous cystadenoma. Case report and review of the literature.

The Authors report a case of abdominal compartment syndrome due to a giant ovarian serous cystadenoma. Despite of the relief of intra-abdominal hypertension (IAP: 16 mmHg), mild symptomatology (clinostatic dyspnea) lead to defer the emergency surgical treatment; after CT scan of abdomen and pelvis was performed a resection en bloc of the cystic mass, oophorectomy and cholecystectomy. However it seems advisable to perform an emergency laparotomy in patients with abdominal compartment syndrome (ACS) grade II when presenting as an acute abdomen.

[Diagnosis, surgical treatment and follow-up of the hyalizing trabecular adenoma of the thyroid]. / Diagnosi, trattamento chirurgico e follow-up dell'adenoma trabecolare ialinizzante della tiroide.

In the last twenty years, we submitted 853 patients to thyroid surgery. We found only in ten patients a hyalinizing trabecular adenoma at the (histological control), as a confirmation of the rarity of this tumour. The authors report a retrospective analysis of this cases to document the clinical features and the evolution through a long term follow-up that has showed no recurrent disease. In conclusion the hyalinizing trabecular adenoma represents a low malignant potential tumour. However, the uncertain clinical behaviour doesn't be undervalued and patients must be subjected to accurate follow-up.

The semiopen first umbilical trocar access technique in laparoscopic surgery: easy and safe.

BACKGROUND: First access in laparoscopy still causes trouble and a small percentage of visceral and vascular injuries. Residents and surgeons-in-training often have doubts about which technique is safer and "friendlier." Semiopen technique (SO) for the first umbilical trocar access was originally described in 2002. We report our retrospective analysis using SO that shows its safety and easiness. METHODS: In the period from January 2003 to November 2007, 300 unselected patients, including obese patients (body mass index > 30) were treated with laparoscopy beginning with a periumbilical approach using SO. We usually prefer to enter the cavity with a STEP cannula stiffened by an unarmed Veress needle of 1.9 mm. There were 112 men and 188 women with ages ranging from 16 to 82 years. The procedure was performed by an expert laparoscopic surgeon in 260 cases and by residents or surgeons without expertise in laparoscopy in 40 cases. RESULTS: We experienced no injuries of the viscera or vessels (0%). The mean time to enter the abdomen was 180 seconds, including obese patients. CONCLUSIONS: After our limited experience with the SO, we believe that every surgeon who tries it will experience safety of the Hasson and the comfort of the Veress.

Management of descending duodenal injuries secondary to laparoscopic cholecystectomy.

AIM: To report our experience of managing patients affected by descending duodenal injuries secondary to laparoscopic cholecystectomy and to review the literature. METHODS: Analysis of 5 cases of descending duodenal injury as a consequence of laparoscopic cholecystectomy managed between June 1992 and September 2006. RESULTS: The median age was 59 (range 49-67) years. In all cases an emergency laparotomy showed an injury to the descending duodenum. Two patients underwent direct suture of the duodenum and external biliary drainage through a T-tube, 1 case underwent a duodenojejunostomy and in another a duodenopancreatectomy. The latter patient underwent drainage of the duodenum with a Petzer tube, followed 5 days later by gastric resection, closure of the duodenal stump and repair of the duodenal wound by suture. The median postoperative stay was 45 days and 1 patient died. CONCLUSION: Descending duodenal injuries are extremely rare complications of laparoscopic cholecystectomy with potentially fatal consequences if not promptly recognized and treated. The site of the descending duodenal injury is important for determining the surgical approach.

Postsplenectomy type-1 hypersensitivity response: a correlation between IL-4 and IgE serum levels.

Authors demonstrated the presence of allergic manifestations in splenectomized patients following traumatic rupture of this organ. In particular, allergic diathesis, as supported by serum IgE increase, was exclusively found in patients with preserved T helper (h)-2 lymphocyte function. Th-2 function was monitored by measuring serum levels of interleukin (IL)-4, a cytokine involved in IgE synthesis. On the opposite, in splenectomized individuals with a reduced Th-2 function as supported by lower IL-4 serum levels, no IgE increase and allergic manifestations were detectable. On these grounds, authors hypothesize that allergic manifestations may be correlated to splenectomy since its exeresis may favor the persistence of antigens in the blood. Consequentially, in patients with a preserved Th-2 function, antigenic overload may lead to IgE increase and allergy onset.

Endoscopic resection of benign very low-risk gastric gastrointestinal stromal tumors. Is it enough?

Great ongoing debate still exists over the definition, diagnosis and treatment of gastrointestinal stromal tumour especially for small gastric submucosal tumours. Simple endoscopic biopsy is not sufficient to determine their biological behaviour and their complete excision is necessary. We report the case of a 65-year-old woman, who was kept under observation after previously operated breast cancer, with a casual computed tomography-diagnosed submucosal gastric lesion. Endoscopy and endoscopic ultrasound confirmed a submucosal mass of 2-3 cm in diameter. An endoscopic resection was performed and the mass was integral at pathologic examination. It confirmed the stromal origin with a mitotic index of 1 (5/50 high power field). No more treatment was carried out because it was classified as a very low risk gastrointestinal stromal tumour according to Fletcher's classification. After 34 months follow-up, the patient is disease free and we believe that endoscopic treatment is sufficient and recommended for mainly intragastric growing gastrointestinal stromal tumour with a diameter of less than 3 cm.

[Correlations between splenectomy and allergic symptoms. Preliminary results of a study concerning IL-4 and IgE serum level]. / Correlazioni tra splenectomia e insorgenza di manifestazioni allergiche. Risultati preliminari di uno studio previo dosaggio sierico di IL-4 e IgE.

The Authors, studying the condition of immunodepression observed in patients who underwent splenectomy for traumatic lesion, noticed that a significant part of them complained of allergic symptoms. These seemed to appear only in subjects whose Th2 lymphocytes functionality was preserved--as witnessed by normal or increased IL-4 serum level--showing an increased level of IgE too, thus confirming the role of Th2 lymphocytes in stimulating IgE synthesis. On the contrary splenectomized patients with functional harm of the Th2 lymphocytes--proved by low IL-4 serum level--did not show increase of haematic IgE level nor allergic manifestations. The Authors stress that, despite the small numerical of the series not allowing definitive judgment, preliminary data are suggestive for an hypothesis--reported below--that needs further confirmation. The ablation of the spleen, organ devoted to remove from the blood antigens--many of these potentially allergic factors--, allows the prolonged persistence of such sensitizing agents, thus promoting the onset of allergic manifestations in splenectomized patients whose Th2 lymphocytes function is preserved.

Diagnosing and treating bleeding portal hypertensive duodenopathy.

Portal hypertensive duodenopathy is a rare condition related to liver cirrhosis; there is little in the literature about its clinical significance and management. It seems to be endoscopically and histologically similar to portal hypertensive gastropathy, which is well defined. We report the case of a patient, initially treated for acute bleeding resulting from the rupture of esophageal varices, who developed an atypical endoscopic picture of portal hypertensive duodenopathy over a 6-month period. After microscopic definition of the disease we found chronic bleeding which required blood transfusions. Medical treatment did not solve the problem. We describe an approach using the argon plasma coagulator.

[Reintervention in abdominal surgery. Personal experience in emergency]. / Reinterventi a distanza in chirurgia addominale. Esperienza personale nell'urgenza.

The Authors, regarding their emergency surgical experience, examine the need of reintervention in abdominal surgery at a distance (operations carried out not less than 30 days after previous procedure), a controversial situation, usually dealt with empirical approach. Such a feature is not rare in the experience of a surgeon; nevertheless still few are the studies concerning the severity of the disease and related complications requiring surgery. Occasionally it is really difficult--quite impossible- in these often complex clinical conditions, to identify the aetiology and even to perform a pre-operative diagnosis. Sometimes other factors may inhibit an exhaustive evaluation (acute onset of the symptoms, time spent from the former procedure, choice of the patient to refer to another surgeon) thus conditioning an adequate review of the first surgical act. The Authors study the more frequently observed clinical features, post-surgical abdominal adhesive syndrome, cancer recurrence, incisional hernia. Former surgical diseases and the latter one may be the same, but not necessarily. Surgery is only a feature of the treatment (multimodal treatment) in case of neoplastic recurrence. Morbidity and mortality concerning the latter surgical procedure are higher than the mere sum of those related to both the former and last operation performed (pre-operative disease understaging). Finally it must be stressed the need for early and accurate diagnosis to clearly steer the choice and course of surgical action.

Management of retrosternal goiters: experience of a surgical unit.

The aim of this study was to retrospectively analyze 5 years' experience of cervico-mediastinal goiters (CMG) management. Twenty-five patients with cervico-mediastinal goiters underwent surgery between January 1998 and December 2002. The group consisted of 16 females and 9 males (mean age, 48.2 years; range, 42-74 years). A total thyroidectomy under general anesthesia was always performed. A no. 7 Fogarty catheter with a 5-ml balloon was employed in the seven last cases to lift the retrosternal portion of the goiter into the neck. The mean postoperative stay was 3 days (range, 1-7 days), and the mean follow-up time was 29 months (range, 1-58 months). There were no postoperative deaths; overall morbidity rate was 28.0%. One patient with a severe life-threatening hematoma required surgical re-exploration. Surgery for CMGs shows a low morbidity rate; total thyroidectomy is the treatment of choice to prevent recurrences or re-surgery for malignancy.

[Chronic abdominal pain and peritoneal mesothelioma: case report]. / Dolore addominale cronico e mesotelioma peritoneale: caso clinico.

Chronic abdominal pain syndrome is becoming increasingly important. The main symptom is persistent abdominal pain, which may vary intensely and be associated with constipation and episodes of vomiting, evolving towards sub- or total occlusion of the bowel. A 65-year old man presented with malignant peritoneal mesothelioma, with environmental asbestos exposure and chronic abdominal pain for more than one year. Due to his poor general condition, only palliative surgery was performed to resolve small and large bowel obstruction.

Venting direct percutaneous jejunostomy (DPEJ) for drainage of malignant bowel obstruction in patients operated on for gastric cancer.

Malignant chronic bowel obstruction (MCBO) is a syndrome caused by abdomen-pelvic diffusion of neoplastic diseases of any origin. It generally occurs in an advanced disease, affecting 3-15% of patients recently operated, untreated, or submitted to radiotherapy. Patients complain of chronic pain and vomitus. The approach to this problem is multidisciplinary, involving the surgeon, the endoscopist, the oncologist, and the pain-therapy expert. Direct percutaneous jejunostomy (DPEJ) using a percutaneous endoscopic gastrostomy (PEG) tube is a jejunal percutaneous access procedure indicated for nutrition in those patients whose stomach cannot be used, as in cases of partially or totally gastrectomized ones. A venting PEG or percutaneous endoscopic jejunostomy (PEJ) is a solution to drain the gastrointestinal tract for MCBO even in difficult cases represented by patients with previous abdominal surgery, those with partial or total gastrectomies, ascites, or peritoneal carcinosis. We report our five-case experience of draining an MCBO in patients previously operated on for gastric cancer, using a DPEJ technique that we believe is the best technique for this purpose.

[Conservative treatment of the splenic traumas]. / Trattamenti conservativi dei traumi splenici.

Authors hope for a growing diffusion of conservative treatments for lien's lesions, to avoid the asplenia syndrome, and the unfavourable implications derive from, above all immunodepression that increases septic risk. They report their experience about conservative choices for spleens traumatic injures and emphasize the absolute need of select the appropriate patients for those procedure, that must require: haemodynamics stability; not geriatric age; type I and II, according to Buntain's classifications, ien's lesions, and attentive selection of the patients carriers of type III lesions; absence of preceding spleens injures, opportunity of monitor patients, in immediate postoperative, in intensive care units. Authors suggest that one of the essential condition for the correct selection and achievement of conservative treatments of traumatic lien's injures, is the team work of the surgeon, of the anesthesiologist, of the radiologist. Conclude maintain that, conservative procedure for lien's lesions, must find a growing diffusion, but mention that is appropriate to not extend those treatments indications over the encoded ones.

[Subtotal colectomy in the treatment of neoplastic left colon obstruction]. / La colectomia subtotale nel trattamento dell'occlusione meccanica da carcinoma del colon.

INTRODUCTION: Subtotal colectomy and ileo-sigmoid or ileo-rectal anastomosis is a treatment wort of considering in patients affected by colonic neoplastic obstruction, as it shows low morbidity and mortality, and good results. CASE REPORT: A case of bowel obstruction due to a stenotizing neoplasm of sigmoid colon is reported. The obstruction causes severe dilation before the stricture), particularly accentuated in the cecum, which showed very reduced wall thickness and initial signs of ischaemia. Staplers (GIA 75 and EEA 31) were employed to perform a quick and aseptic (removal of a closed specimen) surgical procedure, subtotal colectomy and L-T ileo-rectal anastomosis. CONCLUSIONS: According to personal experience, benefits and disadvantages related to its surgical options are considered by the Authors.

[Complications in the treatment of cholangiolithiasis. Personal experience]. / Complicanze nel trattamento della colangiolitiasi. Esperienza personale.

Bile ducts lithiasis is a very common disease all over the world. In Italy prevalence is about 5 millions cases: 11% of the population. Choledocholithiasis concurrent with gallbladder stones frequency is estimated from 4 to 20%. Incidence is even higher in the elderly and in patients affected by chronic liver disease. The treatment of bile ducts lithiasis is still debated; several surgical strategies may be performed: (1) fully laparoscopic procedure; (2) endo-laparoscopic sequential treatment; (3) sequential inverse treatment (endoscopy following video laparoscopic cholecystectomy); (4) combined endo-laparoscopic treatment simultaneously performed; (5) 'open" treatment. The authors refer their experience concerning a series of 172 patients who underwent endo-laparoscopic sequential treatment to amend bile duct and gallbladder lithiasis. Complications are pointed out, pending to demonstrate safeness and effectiveness of this strategy.

Risk factors of morbidity in thyroid surgery: analysis of the last 5 years of experience in a general surgery unit.

The aim of this retrospective study is to analyze the risk factors of morbidity in thyroid surgery. From January 1997 to December 2001, 343 patients (69 males and 280 females, mean age 46.1) who underwent surgery under general anesthesia for thyroid disease were analyzed. In 22 (6.4%) cases the operation was a second thyroidectomy. The mean post-operative stay was 2 days (range: 1-7) and the mean follow-up was 21 months (range: 1-60 months). Statistical analysis of our data was performed by chi-square test and confirmed by Fisher exact test. The statistical analysis showed the significance of malignancy and re-surgery as risk factors of hypoparathyroidism and recurrent laryngeal nerve palsy. Sex, age, and type of operation had no influence on the medical records. The completion of thyroidectomy and histological malignancy increase the morbidity of thyroid surgery.

Total thyroidectomy is improved by loupe magnification.

With this study, we verified if a microsurgical approach with magnification could improve the outcome of total thyroidectomy. Ninety-seven patients were consecutively randomized into group A (surgery with x 2.5 magnification and microsurgical instruments, n = 47) or group B (surgery with no magnification, n = 50). The mean operative time was 125 +/- 4.0 min in group A, and 150 +/- 4.0 min in group B (P = 0.00012). The recurrent laryngeal nerve was identified in all patients of group A, and in 96.8% of group B. The overall morbidity rate was 4.0% in group A and 25.5% in group B (P = 0.0038). This study indicates that a microsurgical approach with magnification is feasible, reduces surgical time, and improves the outcome in total thyroidectomy.