Laparoscopic left hemicolectomy in a patient with cirrhosis scheduled for liver transplantation.

Hepatic cirrhosis is a negative prognostic factor for major abdominal surgery, with a greater risk of bleeding, infection, and ascites. The case of a 54-year-man with adenocarcinoma of the sigma affected by hepatitis B virus and hepatitis C virus hepatopathy as well as micro- and macrconodular cirrhosis (Child's B7 stage) waiting for liver transplantation is reported. After a consultation with the liver transplantation our hospital, and considering the the patient's age laparoscopy was determined to be the procedure of choice because it would give him the possibility of a transplantation in the future. A typical left hemicolectomy with left flexure mobilization and mechanic colorectal T-T-anastomosis was therefore performed. All surgical maneuvers in the right hypochondrium were avoided. Mobilization was performed using an ultrasonic scalpel to reduce the risk of bleeding, and the anatomic stump was pulled out by means of a midline minilaparotomy, sparing the anastomotic circles of the abdominal wall. Follow-up evaluation was uneventful. At an 8-month follow-up visit, the patient was in good general condition. In this case, laparoscopic surgery allowed an oncologically suitable colonic resection without complication and poor surgical stress. Moreover, open surgery would have reduced the possibility of a transplantation in the future.

Laparoscopic treatment of pancreatic insulinoma.

Laparoscopy and laparoscopic ultrasonography (LUS) have been proposed for the diagnosis and treatment of pancreatic insulinoma. We present for cases of pancreatic insulinoma approached by laparoscopy guided by LUS. In three cases, insulinomas were in the pancreatic body and in one case in the pancreatic head. All lesions were detected preoperatively by abdominal US and confirmed by computed tomography. Laparoscopy was performed under general anesthesia. LUS was performed using a 10-mm flexible probe. In two cases the adenoma was enucleated using scissors and electrocoagulation, major vessels were controlled using clips, and enucleation was completed using a 30-mm endo-GIA. In one case a laparoscopic distal pancreatectomy with spleen preservation was performed. In one case the adenoma was deep in the pancreatic head; minilaparotomy was performed and the adenoma enucleated. Patients were discharged in good health 5-7 days after surgery. The postoperative course was complicated in one case of enucleation by peripancreatic fluid collection that was treated percutaneously. Our experience confirms that accurate localization followed by excision of tumors via the laparoscopic approach constitute a significant advance in the management of insulinoma.

Percutaneous management of multiple bilateral liver abscesses complicating Crohn disease.

Liver abscess is a rare complication of Crohn disease. A case of multiple, bilateral, pyogenic liver abscesses appearing as a recurrent manifestation of Crohn disease in a 34-year-old man is reported. Conservative management with antibiotics, double-catheter drainage, and multiple aspirations was successful. The liver abscesses disappeared with no recurrence during a 5-year follow-up period.

Telemedicine on a small island.

Information on the health status of the population of a small Greek island was collected. The information consisted of personal data, clinical history, physical examination, blood pressure evaluation, electrocardiography, and ultrasound scans of neck, breast and abdomen. Ninety-six per cent of the entire island population (280 inhabitants) participated in the study. Two per cent were at risk of serious complications of pathological disease and were immediately referred to a regional hospital for adequate care while 25% had minor pathological problems. Our experience suggests that health-care workers on small islands should be trained in the use of technology as a means of communication with mainland hospitals.

Quality of life after total anorectal reconstruction: long-term results.

The aim of the study was to assess the long-term quality of life (minimum 8 years after surgery) of patients undergoing total anorectal reconstruction for low rectal cancer. The quality of life of 27 patients undergoing total anorectal reconstruction (mean age: 73.07 years) and 27 healthy subjects (mean age: 73.50 years) randomly chosen from the population was analysed and compared using general standardized questionnaires and specific fecal continence scales. Twenty-one out of 27 patients were clinically evaluated and personally interviewed by the same surgeon who had performed the reconstruction some years before. Quality of life analysis yielded good global results, also in the light of the mean age of the patients. Fecal continence was obtained in 81% of patients. All of them report a good physical, psychological and social situation. There was no statistically significant difference (P = ns) in quality of life between these 27 total anorectal reconstruction patients and the control population. In adequately selected patients, total anorectal reconstruction is proposed as a technique capable of guaranteeing good quality of life as well as being a safe technique for the treatment of low rectal cancer.

[Is it possible to use "Medline" for assuring the quality of the scientific and research production of a medical school?]. / E possibile applicare "Medline" per la verifica di qualità (VRQ) sulla produzione scientifica e di "ricerca" di una facoltà?

Object of our Faculty investigation is a research made in the attempt to carry out an evaluation of efficiency and to offer a tool that might be useful to the future allocation of resources, structures and attribution of responsibility. The need of Faculty inspections in the fields of Didactics, Research, Attendance is becoming more and more important in the current phase of renewal. This work offers an example of inspection by means of Medline, performed on a given number of individuals and Institutions. The inspection of qualified scientific production has been thus performed on a sample of 808 individuals and 58 Institutions: the samples have been grouped according to their roles and to their university/hospital allocation within the "Azienda Ospedale di Pisa", Azienda c.d., which is conventionally headed by the Faculty of Medicine of the University of Pisa. As already suggested, the tool used for the inspection has been Medline. The collected data produce an x-ray which is in the whole very indicative, either in quantitative and in qualitative terms. The results are listed in tables (in anonymous). The criteria of application and the analysis of the results align themselves to the indications of the Conference of University Chancellors. The attempt to develop a method of inspection which shows as objective as possible might give heart to those who very often feel left out from the evaluation and determination of university initiatives. All this is therefore meant to satisfy the needs of the many who are currently seeking steadier values of support in order to obtain a sound renewal.

Restoration of fecal continence with chronic electrostimulation of gracilis muscle 17 years after a Pickrell's operation.

A 27-year-old woman who had undergone a Pickrell's operation at the age of 10 years, was observed for severe incontinence to solid and liquid stools. Physical examination and physiological tests revealed poor resting anal tone but a very good response of the transposed gracilis to percutaneous electrostimulation, which showed that the gracilis ability to contract was maintained in spite of 17 years of only occasional and unplanned muscular activity. Examination also demonstrated that the muscle had followed body growth during the patient's development. Restoration of continence by continuous electrostimulation of the gracilis muscle was then planned. To allow muscular resistance to this stimulation a fast-to-slow twitch fiber conversion was first obtained by low-frequency electrostimulation. A subcutaneous abdominal implant of a pulse generator connected to the gracilis by intramuscular platinum-iridium electrodes was carried out. After a period of muscular training, fiber conversion was achieved, and continuous electrostimulation led to complete restoration of continence with stable results at the 36 month follow-up evaluation. This case demonstrates that even such a long period of muscular inactivity does not affect the possibility of recovering a failed Pickrell's operation using electrostimulation. This easy and safe procedure can be applied to all previously failed graciloplasties provided that muscle contractility is maintained.

Anorectal reconstruction after abdominoperineal resection. Experience with double-wrap graciloplasty supported by low-frequency electrostimulation.

PURPOSE: The aims of the study contained herein were to analyze the efficacy and safety of a chronically electrostimulated double-wrap graciloplasty for restoration of continence after a curative abdominoperineal resection for rectal carcinoma and to evaluate late results of a stimulation protocol that was begun early. METHODS: During the last six years, 31 consecutive patients underwent this procedure: in 24 patients, electrostimulated double-wrap graciloplasty was performed simultaneously with abdominoperineal resection for lower rectal cancer, 7 strictly selected patients underwent conversion to an abdominal stoma following previous abdominoperineal resection (mean length of time from stoma creation, 71.4 months) Anorectal reconstruction was performed following a surgical scheme already standarized since 1985 in 102 patients: after abdominoperineal resection, the distal colon was pulled through to the perineum and surrounded by both gracilis muscles following an "alfa and new-sling" configuration; using platinumiridium electrodes, both muscles were then connected to pulse generator, which was implanted subcutaneously in the abdomen. All surgical steps were performed during the same surgical session to allow early postoperative stimulation of the transposed muscles. A contemporary covering stoma was abandoned as a standard procedure; the distal colon was left closed for a few postoperative days, then it was resected and sutured to the perineum under local anesthesia. Eighteen patients underwent preoperative or postoperative radiotherapy or both, without any significant adverse outcome. To increase gracilis resistance to prolonged "tonic" contraction, patients underwent a chronic, low-frequency stimulation protocol. In the last 11 patients, a new "over-the-nerve and intramuscular" implant was adopted to optimize fiber recruitment and to reduce electrostimulation thresholds. At regular intervals, all patients were evaluated using continence scores and questionnaires, electromanometry, endoluminal ultrasound study, and defecography. RESULTS: Twenty-six of 31 patients were evaluated for continence, with a mean length of follow-up of 37.8 (range, 4-68) months; 3 patients died because of cancer recurrence, 1 underwent conversion to an abdominal stoma, and 1 is waiting for stoma closure. Continence to liquid and solid stools was achieved in 22 patients (85 percent), and electromanometry findings confirmed a good muscular contraction postoperatively and during follow-up intervals. No postoperative mortality (40 days) was observed; the postoperative complication rate was high 22-percent), but early treatment (drainage and temporary diversion in 7 patients) led to favorable outcomes (4 resolutions, 3 partial muscular impairments). Four stimulators had to be temporarily explanted because of late complications, and two stimulators had to be replaced because of battery exhaustion after three years of use with high stimulation parameters. A significant difference was observed comparing full-contracting threshold after intramuscular (14 patients) and the new over-the-nerve and intramuscular implant technique. CONCLUSIONS: The study contained herein confirms the efficacy of the surgical scheme we have adopted since 1985 to reconstruct sphincteric apparatus after abdominoperineal resection of the rectum. The "one-step" timing of surgical and electrostimulation-related procedures and the early start of stimulation did not show a significant increase in the complication rate and did not produce noticeable muscular or nerve damage. Adoption of chronic electrostimulation protocols using implantable devices increased the rate of fully continent patients; nevertheless, the overall cost for devices and medical staff duties was high, and a small increase of late morbidity was observed. Finally, the preliminary experience with our new technique of electrode implants encourages further application.

Laparoscopically assisted abdominoperineal resection and simultaneous total anorectal reconstruction with electrostimulated static-dynamic graciloplasty.

Bilateral electrostimulated graciloplasty, performed in a "static-dynamic" configuration around a perineal colostomy (total anorectal reconstruction-TAR), has been proven a reliable way to restore continence in patients who undergo to abdomino perineal resection (A.Pe.R.) of the anorectum for lower rectal cancer. In selected cases, laparoscopically assisted TAR can significantly improve body-image preservation and aesthetic results. A 33-year-old woman affected by lower rectal cancer was submitted to laparoscopic-assisted A.Pe.R and TAR with simultaneous bilateral graciloplasty; a suprapubic median mini-access was adopted to fully mobilize the mesorectum in absence of pneumoperitoneum. A subcutaneous pulse generator and special electrodes were also implanted to chronically electrostimulate the graciloplasty. In spite of postoperative bleeding which required a blood transfusion, postoperative outcome was satisfactory; electrostimulation was started on the 10th postoperative (p.o.) day and the patient was discharged on the 17th p.o. day. Two months after TAR, level II continence (N.S. Williams Scale) was achieved. In selected cases, laparoscopically assisted A.Pe.R. and TAR can be safely adopted to preserve body image and quality of life, avoiding at the same time a large abdominal approach and a "permanent" abdominal colostomy.

TIMTEM project: our experience in a remote area.

We report our experience, begun in 1998 on a small island in the Dodecanese area of Greece, which has been called TIMTEM. The aim of this project was to improve care for people living on islands, creating a model exportable to other rural areas. The operative setting of the TIMTEM project is the island of Tilos (Greece); local authorities take part in it under the guidance of the only physician available on the island. The University of Pisa-Italy (Department of Surgery, Post-graduate School of Emergency Surgery) manages the scientific and organizational part of the project. Tilos is a rocky Mediterranean island with a surface of 64 km(2) and a population of about 500 inhabitants (with a peak of 2,000 tourists in July and August). A physician and a nurse are responsible for the only medical care on the island, and they also dispense drugs. The project was implemented on three phases. During the first phase, a campaign was held to encourage the population to cooperate with clinical data collection; a temporary telemedicine station was established, and a complete screening of the population was performed. The second phase was focused on the application of telesonography. During the third phase, a telematic and/or direct participation for reference hospital physicians (Regional Medical Society-Dodecanese) and for Greek physicians was planned. As well, a fully equipped central telemedicine station in the reference hospital was established under the local jurisdiction. The results of the third phase are still incomplete; the data presented here are preliminary. But all indicators show that the project is exportable to remote areas elsewhere.