Bile leaks after videolaparoscopic cholecystectomy: duct of Luschka. Endoscopic treatment in a single centre and brief literature review on current management.

BACKGROUND: Laparoscopic cholecystectomy (LC) for gallstone disease is the most common surgical procedures performed in Western countries and bile leaks remain a significant cause of morbidity (0.2-2%). The bile ducts of Luschka (DL)are small ducts which originate from the right hepatic lobe, course along the gallbladder bed, and usually drain in the extrahepatic bile ducts. Injuries to these ducts are the second most frequent cause of bile leaks after cholecystectomy. Aim of our study is build a literature review starting from our experience. PERSONAL EXPERIENCE: Forty four patients with abdominal bile collections post-cholecystectomy by suspected bile leak under-went endoscopic retrograde cholagio-pancreatography (ERCP). A complete cholangiogram was obtained in 42 patients(95.5%). In according to the magnitude of bile leak daily, we subdivided the patients in two groups: a) < 180 ml/daily,and b) > 180 ml/daily. The most common site of the leak was the cystic duct stump (94.5%), followed by DL (2 patient = 5.5%). 10 Fr stent insertion after endoscopic sphincterotomy (ES) was the most common intervention. In 6 patients (14%) a 7 Fr naso-biliary drainage was inserted. On an intention-to-treat basis, endoscopic intervention at ERCP had 100% success rate for resolution of the leak. The median time for resolution of the leak was 8 and 12 days in the first and second group respectively. No mortality ERCP-related were recorded. Early minor complications occurred in 7/42 (16.5%) patients. METHODS: A literature search using MEDLINE's Medical Subject Heading terms was used to identify recent articles.Cross-references from these articles were also used. RESULTS: ERCP is the most common diagnostic and therapeutic method used in bile leaks post-cholecystectomy. Most patients with DL leaks are symptomatic, and most leaks are detected postoperatively during the first postoperative week. Reduction of intra-ductal pressure with ES and stent or naso-biliary tube insertion will lead to preferential flow of bile through the papilla, thus permitting DL injuries to heal. This is the most common treatment modality used. In a minority of patients,re-laparoscopy is performed. In such cases, the leaking DL is visualized directly and ligation usually is sufficient treatment.Simple drainage is adequate treatment for a small number of asymptomatic patients with low-volume leaks. CONCLUSIONS: DL leaks occur after cholecystectomy regardless of gallbladder pathology or urgency of operation. They have been encountered more frequently in the era of LC Intraoperative cholangiography does not detect all such leaks. ERCP with ES and stent placement are the most common effective diagnostic and therapeutic methods used. Intraoperative and perioperative adjunctive measures, such as fibrin glue instillation and pharmacologic relaxation of the sphincter of Oddi,can potentially be used in lowering the incidence and in the treatment of DL leaks.

Secondary aortoduodenal fistula.

Aorto-duodenal fistulae (ADF) are the most frequent aorto-enteric fistulae (80%), presenting with upper gastrointestinal bleeding. We report the first case of a man with a secondary aorto-duodenal fistula presenting with a history of persistent occlusive syndrome. A 59-year old man who underwent an aortic-bi-femoral bypass 5 years ago, presented with dyspepsia and biliary vomiting. Computed tomography scan showed in the third duodenal segment the presence of inflammatory tissue with air bubbles between the duodenum and prosthesis, adherent to the duodenum. The patient was submitted to surgery, during which the prosthesis was detached from the duodenum, the intestine failed to close and a gastro-jejunal anastomosis was performed. The post-operative course was simple, secondary ADF was a complication (0.3%-2%) of aortic surgery. Mechanical erosion of the prosthetic material into the bowel was due to the lack of interposed retroperitoneal tissue or the excessive pulsation of redundantly placed grafts or septic procedures. The third or fourth duodenal segment was most frequently involved. Diagnosis of ADF was difficult. Surgical treatment is always recommended by explorative laparotomy. ADF must be suspected whenever a patient with aortic prosthesis has digestive bleeding or unexplained obstructive syndrome. Rarely the clinical picture of ADF is subtle presenting as an obstructive syndrome and in these cases the principal goal is to effectively relieve the mechanical bowel obstruction.

Permanent stenting in "unextractable" common bile duct stones in high risk patients. A prospective randomized study comparing two different stents.

BACKGROUND: Endoscopic sphincterotomy (ES) and stone extraction is the treatment of choice for bile duct stones. Therefore, if ES and conventional stone extraction fail, further treatment is mandatory. Insertion of a biliary endoprosthesis is an effective option. MATERIALS AND METHODS: We treated 30 high-risk patients (17 women and 13 men, mean age 82 years) affected by difficult common bile duct stones. The patients were randomly assigned preoperatively using closed envelopes (blind randomization) into two groups to receive insertion of polyethylene or hydrophilic hydromer-coated polyurethane stent, respectively. Follow-up was achieved by contacting referring physicians and patient's relatives. RESULTS: Biliary drainage was established in all patients. Early minor complications occurred in 28%. In all these patients, the stent was a definitive measure. Median follow-up was 38 months. Late complications occurred in 34%. Cholangitis was the most frequent. During follow up, 11 patients died, two as result of a biliary-related cause. No statistically significant difference was observed on different stents patency. CONCLUSION: Endoprosthesis insertion as a permanent therapy is an effective alternative to surgery or dissolution therapy. Therefore, biliary stenting should preferably be restricted to high-risk patients unfit for operative treatment and with a short life expectancy.

[Complication of flexible fiberoptic bronchoscopy. Literature review]. / Le complicanze della fibrobroncoscopia. Revisione della letteratura.

INTRODUCTION: Fiberoptic bronchoscopy is the gold standard to study and eventually treat tracheo-bronchial pathology. Performance of fiberoptic bronchoscopy enhances diagnostic precision and has not well documentated risks for the patients. This review examines the international literature of the last 30 yrs about the indication, complications and their prevention during bronchoscopy. MATERIALS AND METHODS: We reviewed by Internet 50 scientific articles, 23 of those were reporting or citing other experiences. We included as metasearch criteria "flexible", "fiberoptic", "bronchoscopy" and "complications" from 1974 to 2006, and as exclusions terms "pediatry", "pregnancy" and "urgency/emergency". Thus, we reported for every complication the incidence range, the characteristics and the indications for the bronchoscopy. DISCUSSION: On 107969 bronchoscopies, the incidence of complication of local anaesthesia was 0.3-0.5%; hypoxiaemia 0.2-21%; arrhythmia 1-10%; post-biopsy bleeding 0.12-7.5%; pneumothorax or pneumomediastinum 1-6%; fever 0.9-2.5%; death 0.1-0.2%. The majority of these complications were not life threatening. CONCLUSIONS: Flexible bronchoscopy is an extremely safe procedure as long as some basic precautions are taken: complications incidence may be reduced by accurate patient selection, correct indication to bronchoscopy with an adequate anaesthesia or analgosedation and the correct endoscope. Is safe and useful virtual bronchoscopy in selected cases. Equipe cooperation and the responsibility of performing endoscopes are basilar. The gain of informed consensus is imperative before the bronchoscopy.

Trocar-related abdominal wall bleeding in 200 patients after laparoscopic cholecistectomy: Personal experience.

AIM: To determine the complications and incidence of the first and second access-related vascular injuries induced by videolaparoscopic cholecistectomy. METHODS: We retrospectively reviewed vascular injuries in 200 consecutive patients who underwent videolaparoscopic cholecistectomy from 2003 to 2005. One hundred and one patients with placement of radial expanding trocars were assigned into group A and 99 patients with placement of pyramidal tipped trocars into group B. All the patients were submitted to open access according to Hasson for the first trocar. RESULTS: Bleeding did not occur at the intraoperative cannula-site in group A. However, it occurred at the intraoperative cannula-site of 7 patients (7.1%) in group B, with a statistically significant difference (P < 0.01). No mortality was registered. More vascular lesions were found in group B. CONCLUSION: The advantage of Hasson technique is that peritoneal cavity access is gained under direct vision, preventing most severe injuries. The open technique with radial expanding trocars is recommended for secure access to the abdominal cavity in videolaparoscopy. Great care should be taken to avoid major complications and understanding the abdominal wall anatomy is important for reducing bleeding during or after s placement of trocars.

[Biliary stent placement for postoperative benign bile duct stenosis: personal experience]. / Il posizionamento di protesi biliari per stenosi biliari benigne post-operatorie. Nostra esperienza.

OBJECTIVE: To describe the management and outcome after endoscopic treatment of 23 patients with post-operative benign bile duct stricture (BBDS) managed in Authors' Department from 1991 to 2000. BACKGROUND DATA: The management of the postoperative bile duct strictures remains a challenge for even the most skilled biliary tract surgeon and endoscopist. The 1990s saw a dramatic increase in the incidence of bile duct strictures from the introduction and widespread use of laparoscopic cholecystectomy. The management of these injuries, short-term outcome and follow-up have been reported. METHODS: Data were collected retrospectively on 23 patients treated in the Service of Diagnostic and Operative Endoscopy of the Operative Unit of General and Thoracic Surgery (Policlinico Paolo Giaccone, Palermo, Italy) with BBDS between 1991 and 2000. All patients underwent ERCP (endoscopic retrograde cholangiopancreatography). Follow-up and pharmacological therapy post-ERCP were conducted by scheduled medical audit. RESULTS: Of the 23 initial patients, 20 undergoing endoscopic stenting (3 with complete transaction were invited to surgery), 16 had completed treatment with symptoms resolution (mean follow-up of 70 months). One patient died of reason unrelated to biliary tract disease before the completion of treatment. Seven had not completed treatment. Of 16 patient who had completed treatment, 13 were considered to have a successful outcome without the need of follow-up invasive, diagnostic or therapeutic interventional procedures. Overall, a successful outcome, was obtained in 65% of patients, including those requiring a secondary procedure for recurrent strictures. CONCLUSIONS: Postoperative bile duct strictures remain a considerable surgical challenge. Management with endoscopic cholangiography to delineate the postoperative anatomy and to place biliary stents, to solve the symptoms, is associated with a successful outcome in up of 65% of patients, in well experienced team. Endoscopic treatment should be the initial management of choice for postoperative bile duct stenosis, as a real alternative to surgical reconstruction: because his failure will not compromised the following surgical treatment prior endoscopic treatment does not preclude surgery), whereas endoscopic treatment is impossible one a Roux-en-Y loop has been constructed

[Complications in thyroid surgery: symptomatic post-operative hypoparathyroidism incidence, surgical technique, and treatment]. / Complicanze in chirurgia tiroidea: ipoparatiroidismo sintomatico post-operatorio. Incidenza, note di tecnica chirurgica, prevenzione e trattamento.

INTRODUCTION: Total thyroidectomy has a definite role in the management of malignant and benign thyroid disorders, with minimal complications and rare postoperative mortality. Even though thyroid surgery is quite safe, mechanical damage, devascularization or inadvertent removal of the parathyroid glands are possible. The aim of this study is to report report the personal surgical experience and to define some of the pathologic and clinical characteristics of unintentional parathyroidectomy and post-thyroidectomy hypocalcemia. MATERIALS AND METHODS: A retrospective-observational study was carried on 313 thyroidectomies from January 2000 to January 2004 (60 males and 253 females), mean age 41 years (range 17-86 yrs). The positions of at least 3 parathyroid glands are defined, and are left within their fat envelope. Parathyroid glands and their vascular supply are preserved by individual ligation of the branches of the inferior thyroid artery on the surface of thyroid lobe. RESULTS: Over 313 thyroidectomy, in 3 cases (0.95%) the AA. accidentally removed parathyroid glands (1 superior and 2 inferior), transplanted in sternocleidomastoideus pouch. The overall incidence of temporary hypocalcemia was 5.4% and no cases of permanent hypocalcemia were registred, regressed after medical therapy. DISCUSSION: Prevention of complications in thyroid surgery is based on knowledge of embryology and anatomy of cervical district, to visualize and respect the glands and their vascular pedicle: the patients must be appropriately and preoperatively counselled regarding potential complications and they must be well aware of the surgical risk they are undertaken. It is possible by the identifications of risk factors. CONCLUSIONS: Postoperative hypocalcemia is the most immediate surgical complication of total thyroidectomy; it is a multifactorial phenomenon, where surgical technique has a greater phisiopatologic impact. However, hypoparatyroidism does not appeared to be the main reason for hypocalcemia after thyroidectomy, and other causes (surgical stress, "hungry bone syndrome", release of calcitonin during surgical manipulation) may be important contributory factors. In conclusion, as we exposed, extent of resection, surgical technique and thyroid pathologic condition had a greater impact on the rates of postoperative hypoparathyroidism. By developing understanding of the anatomy and the ways to prevent each complication, the surgeon can minimize each patient's risk and can handle complications expediently and avoid worse consequence.

[Infrequent early complication of mechanical digestive anastomosis: bleeding. Personal experience]. / Una rara complicanza precoce delle anastomosi digestive meccaniche: l'emorragia. Esperienza personale.

INTRODUCTION: Bleeding from mechanical digestive anastomosis is an uncommon complication (0.9-3.2%) often self-limiting but potentially lethal if not evidenced intraoperatively or in the immediate postoperative. MATERIAL AND METHODS: The Authors retrospectively report incidence of anastomotic bleeding after stapled anastomosis (11/163 = 6.7%) and analyse probable causes. In 6 of 11 patients (54%) intraoperative bleeding was stopped after manual reinforce of anastomosis (3/6) or stopped spontaneously (3/6). In 5 patients (45%), 1 with gastro-jejunal anastomosis, 2 with ileo-colonic anastomosis and 2 with colo-rectal anastomosis, they used endoscopy and endoscopic treatment in emergency. RESULTS: All 5 patients were treated with endoscopic clerotherapy (NaCl 0.9% plus epinephrine 1:10000): in 4 (80%) the Authors obtained hemostasis after the first treatment but in one of 2 cases ol ileo-colonic anastomosis (20%) the bleeding relapsed and the patient was re-operated. In 1 patient with the self-limiting lower anastomotic bleeding was associated to a Dieulafoy's gastric ulcer, perendoscopic treated successfully. In summary 2 patients were resubmitted to laparotomy, without evidence of source of bleeding. CONCLUSIONS: In accord with literature, bleeding from mechanical digestive anastomosis is a rare complication, often self-limiting (50-76%), that may be evidenced and treated early in intraoperative phase. Endoscopic examination may have diagnostic (source and type) and therapeutic valence, is effective, with low intrinsic risk and can reach endoscopic hemostasis without relaparotomy, except in case of rebleeding.

[Videolaparoscopic cholecystectomy: personal experience]. / Colecistectomia videolaparoscopica. Esperienza personale.

AIM: Laparoscopic cholecystecomy (LC) is now the gold standard for the treatment of gallstones. In this report were analyzed 153 LC performed by a single surgical team and, according to results, elaborated any technical recommendation. MATERIALS AND METHODS: 153 LC has been performed in Section of General and Thoracic Surgery of University of Palermo, Sicily, by a single surgical team, since 2000. Indications for LC were all forms of calculous cholecystitis (biliary colic in 73.2%, acute cholecystitis in 4.5%, gallbladder polyps in 5.8%) or colecystocoledochal lithiasis (9.8%). The mean age of patients was 49.46 years (range 18-78) and 62.7% were female. The patients were studied in our Section with hematochemical routine, plane chest roentgram, ECG, abdominal ultrasound (the day before the operation) and ASA classification (ASA I: 9.8%, ASA II: 67.3%, ASA III: 22.9%). RESULTS: All cases (153) were uneventful in terms of either serious intraoperative complications or necessity in relaparoscopy. In operatory room we adopted the French position, with mean operatory time of 65.03 minutes (range 30-180 minutes) and we also used the French technique of exposure of the cystic pedicle. The grade of difficulty of LC was analysed according 4 variables (approach to peritoneum, approach to gallbladder, pedicle dissection, cholecystectomy). There were 10 cases (6.5%) of convertions in total. Subhepatic space drainage was performed in 60.1% of cases. No postoperative biloma or subhepatic infiltration were observed. No port site infections were diagnosed, no port site hernias observed and no mortality observed. The mean postoperative bedstay was 2.21 days. CONCLUSIONS: LC is the treatment of choice for symptomatic gallstone disease. When performed by experienced surgeons, it is safe and effective.

[Surgical treatment of liver hydatidosis: our experience with diagnostic and therapeutic consideration]. / Il trattamento chirurgico dell'idatidosi epatica: nostra esperienza e considerazioni diagnostico-terapeutiche.

OBJECTIVE: The Authors report on their experience in diagnosis and treatment of liver hydatidosis (LH). MATERIALS AND METHODS: From January 2000 to December 2003, we observed 24 patients (10 male = 42% and 14 female = 58%, male/female ratio 1:1.4, range of age 23 - 80 years, mean age 45.25 years). The most frequent initial symptom was hepigastric and hypocondriac pain (82.6%), meanwhile acute abdominal pain was only in 26.1%. In one half of cases performed radical surgery (total pericistectomy), in 35% of cases the AA subtotal pericistectomy and only in 17% the AA partial pericistectomy. Only one left hepatectomy during total pericistectomy we performed. Major complications were registered, except a post-operative bleeding treated with 3 blood transfusion. The mean time of bedridden was 68 days (range 4 - 35, mode 7 days, median 7 days). All patients are actually in clinical, instrumental and serological follow-up as outpatients (3 months - 2 years): we not encountered any relapse. CONCLUSIONS: The surgical treatment of liver hydatidosis must to be radical (as in total pericistectomy), free from severe and disabling complications and without risks and relapses. The choice of type of surgery (radical or conservative) must came from attempt examination of anatomo-clinical tools and experience and agreement of surgical team.

[Substernal goitre. Personal experience]. / Il gozzo cervico-mediastinico. Esperienza personale.

INTRODUCTION: Aim of the study is to discuss the diagnostic and therapeutic problems of substernal goiter (SG). MATERIALS AND METHODS: The Authors retrospectively analyzed 12 patients (3.1%) with substernal goiters among 379 patients undergoing surgical treatment for thyroid diseases from January 2000 to 2005, and evaluated the clinical data, preoperative diagnostic findings, surgical treatments, histopathological results, and postoperative complications. RESULTS: The most common symptoms were a cervical mass (100%) and dyspnea (16%), but 50% of the patients were asymptomatic. Chest radiography provided the first evidence of a substernal goiter in 100% of the patients. The AA performed total thyroidectomy and operated through a cervical incision in all the patients. There was operative mortality (1 case: = 8%), 2 (16%) patients suffered temporary hypoparathyroidism; no patients suffered transient vocal cord paralysis. Malignancy was diagnosed by histopathological examination in 2 patients (16%). CONCLUSIONS: The presence of a substernal goiter is considerd as a sole indication for surgery. Surgical treatment of SG requires a diagnosis that exactly defines the extent of the lesion. A correct choice of surgical access and scrupulous operating technique are likewise of paramount importance to reduce the risk of severe compressive complications. Most retrosternal goiters can be resected through an entirely cervical approach with a low complication rate. On rare occasions a median sternotomy or a sternal split will be required to permit a safe and complete thyroidectomy.

[Treatment of gastrointestinal stromal tumor (GIST)--review of the literature and a case report]. / Il trattamento dei tumori stromali gastrici (GIST). Revisione della letteratura e descrizione di caso clinico.

BACKGROUND: Gastrointestinal stromal tumors (GIST) are rare mesenchimal tumors that are characterized by constitutive overexpression of the tyrosin-kinase receptor KIT (CD117). The authors analyse the basis of the treatment of gastric GIS, starting form the study of a recent observed case. EXPERIMENTAL DESIGN: Report of one case treated with endoscopic resection. Evaluation of treatment and 2-years follow-up. RESULTS: The treatment of gastric GIST must be modulated on prognostic, genetic and molecular factors. These factors are the basis of the formation and growth of GIST. CONCLUSIONS: Complete surgical extirpation without rupture remains the only curative treatment of localized favourable prognosis. Endoscopic treatment, as in our case, reflect the modulation of therapy on prognostic factors. Selective targeted therapy of metastatic disease yields encouraging clinical responses.

[Endoscopic palliation of obstructive jaundice caused by inoperable pancreatic cancer: personal experience]. / La palliazione endoscopica dell'ittero ostruttivo da carcinoma inoperabile del pancreas. Nostra esperienza.

AIM OF THE STUDY: Few patients with pancreatic cancer are eligible for resection. In the remainder, estimation of prognosis is important to optimise various aspects of care, including palliation of biliary obstruction and trial of chemotherapy. The aim is to refer our personal experience about the palliation with endoscopic stenting in patients with unresectable pancreatic cancer. METHODS: The Authors reviewed retrospectively 132 patients affected by unresectable pancreatic cancer who underwent palliative interventions with endoscopic stenting from 2000 to 2004. RESULTS: Jaundice dramatically decreased in 86% of patients within 36 hours, in 12% within 48 hours and in 2% after two days. As complication were registered 3% of bleeding after endoscopic sphincterotomy, 2% mild acute post-ERCP pancreatitis and in 7% of patients transitory hyperamylasemia. The most frequent late complication was relapse of jaundice or cholangitis for stent clogging (51%) in a variable range fom 72.3 to 120.7 days, treated with stent substitution. No mortality ERCP-related was registered. CONCLUSION: Resection offers the only potentially curative approach to pancreatic cancer. The majority of patients are either too old, too ill with coexistent disease, or have a tumour that is undoubtedly inappropriate to resect. Thus for the vast majority an endoprosthesis to relieve the jaundice, is the preferred management, after a multidisciplinary approach.

[A rare complication of ERCP: Mallory-Weiss syndrome]. / Una rara complicanza dell'ERCP: la sindrome di Mallory-Weiss.

OBJECTIVE: To describe the management and outcome after endoscopic treatment of hematemesis by Mallory-Weiss Syndrome (MWS) occurred after CPRE (suspected choledocolithiasis). BACKGROUND DATA: Although cough and retching is common during EGD or CPRE, MWS resulting from endoscopy seems to be uncommon (0.0001-0.04%) and always self-limiting. CASE REPORT: The patient was submitted to CPRE with the suspicion of choledocholithiasis. Eight hours after CPRE the patient presented with hematemesis and hypotension. With emergency EGD, the AA identified a small bleeding mucosal tear (visible vessel with spurting) just proximal to the esophagogastric junction. The patient was safely treated with endoscopic hemoclipping after the failure of sclerotherapy. CONCLUSIONS: The usefulness of hemoclipping in MWS is emphasized: although always self-limiting, endoscopic hemostasis is mandatory in high risk patients. The hemoclips are effective and safe in hemostasis in the case of bleeding visible vessel (spurting or oozing), even with or after sclerotherapy. The hemoclips not obstacles the healing.

[Prevention of clogging of biliary stents by administration of levofloxacin and ursodeoxycholic acid]. / Prevenzione dell'occlusione delle protesi biliari mediante somministrazione di levofloxacina e acido ursodesossicolico.

One of the main advances in biliopancreatic endoscopic therapy has been the ability to palliate patients with biliary obstruction by placement of a stent during ERCP, but this is often complicated by clogging of the stent with subsequent jaundice and/or cholangitis. Stent clogging may be caused by microbiological adhesion and biliary stasis. Therefore, the use of antibiotics and choleretic agents such as levofloxacin and ursodeoxycholic acid has been investigated to see whether they prolong stent patency. Ninety patients with strictures of the biliary tract and untreatable macrolithiasis with endoscopically inserted stents were randomized into two groups: 49 subjects in group 1 (levofloxacin + ursodeoxycholic acid) and 41 in group 2 (ursodeoxycholic acid alone). In the patients in group 1 "stent patency in situ" was 50% longer than in group 2, with a lower incidence of cholangitis and hospital admittance. No adverse pharmacological effects were registered. Treatment with ursodeoxycholic acid and levofloxacin to prevent clogging of biliary stents is recommended as routine practice on the basis of our brief experience. Further trials are needed with rigorous methodology and adequate statistical power, because the perfect biliary stent (inexpensive, easy to insert, and with prolonged patency) does not exist. Prophylactic stent replacement is probably the most prudent strategy to avoid cholangitis, but the optimal time interval is unknown.

A Strange Case of Left Bowel Ischemia after Right Hernioplasty.

We report the first observed case of a young man who suffered of large and unsuspected left bowel ischemia following an elective right open hernioplasty. A 54-year-old man had a 2-year history of right inguinal reducible mass and was admitted to hospital for an elective day case open inguinal hernioplasty for a direct right inguinal hernia. Apart from mild hypertension controlled with ACE inhibitor, he was medically fit and well. The patient was submitted to open tension-free mesh repair with polypropylene preshaped mesh with local infiltration anesthesia and additive sedation with midazolam. The local anesthesia and surgery were uneventful and he was discharged home on the same day as per day case protocol. He was readmitted about 12 h after discharge with a history of central and left lower abdominal pain with palpable mass, and distension and fever (38°C). After imaging and laboratory studies the patient was submitted to explorative surgery with the suspicion of left colonic ischemia. After intraoperative confirmation we performed standard left hemicolectomy. The postoperative course was uneventful; the patient was discharged in good general condition on the 7th postoperative day. Actually, the patient is in follow-up, with normal coagulation and hemochromocytometric pattern, asymptomatic for hypercholesterolemia and atrial flutter/fibrillation. Complications relating to bowel during open techniques of hernia repair are limited to two situations: the freeing of an incarcerated or strangulated segment of bowel and inadvertent laceration of large bowel in the presence of a sliding hernia. Following this strange case of colonic ischemia, a boolean Medline search (terms: hernia, complication, repair, groin, herniorrhaphy, hernioplasty, all major MESH subjects without language restriction) revealed no previous similar cases reported. However, to our knowledge, there is another trouble hypothesis: not causality but casualty. In conclusion, to our knowledge this is the first reported case of large left bowel ischemia following right open hernioplasty. We can conclude that the presence of a dolichocolon is an added risk factor for this rare and uneventful complication, but further investigations and case reports are necessary to estabilish the real causality.

Duodenal Signet Ring Cell Carcinoma in a Celiac Patient.

Celiac disease results from damage to the small intestinal mucosa due to an inappropriate immune response to a cereal protein. Long-standing or 'refractory' celiac disease is associated with an increased risk of autoimmunity and malignancy. We produced a brief literature review starting from a case of duodenal cancer in a celiac patient. The patient with an history of celiac disease since six months presented with acute manifestation of gastric outlet syndrome. A duodenal stricture was diagnosed at upper gastrointestinal endoscopy and confirmed by abdominal computed tomography. He was successfully treated by segmental duodenal resection. In the resected specimens, the diagnosis was duodenal signet cell adenocarcinoma. 6-month follow-up is uneventful. Primary carcinoma of the duodenum is rare (duodenal adenocarcinoma accounts for less than 0.5% of all gastrointestinal cancers and 30-45% of small intestinal cancers). Some patients with duodenal carcinoma are potentially curable by surgery, but conflicting opinions exist on the factors influencing the survival rate and on surgical treatment as the gold standard. Nevertheless, the goal in surgical treatment is to achieve clear margins. At present, surgical resection (pancreaticoduodenectomy or pancreas-sparing duodenal segmental resection) is the only available option for cure of this disease.

Presence of white bile in malignant biliary obstruction is associated with poor prognosis: personal preliminary observations.

OBJECTIVE: The chemical composition and clinical significance of white bile in patients with malignant obstructive jaundice were evaluated in a prospective study. MATERIALS AND METHODS: 115 consecutive patients with inoperable malignant biliary obstruction underwent endoscopic placement of 10 Fr straight, plastic biliary stents, Amsterdam-type. Bile was aspirated during the endoscopic procedure and a blood sample was taken. Patients were divided into two groups: those with white bile and those with yellow bile. The groups were compared for decremental fall in bilirubin, cholangitis after stent insertion, and survival. RESULTS: Thirty-five patients (15 men, 20 women; mean age 54 years) underwent endoscopic drainage for malignant obstruction (29 hilar, 6 distal bile duct). Eighteen patients had white bile. Refractory jaundice (p > -0.025) was seen in nine (50%) patients with white bile compared with three (17.6%) patients with yellow bile; mean difference -42.2 (95% CI [-62.4, -22.0]) and -45.7 (95% CI [-72.0, -19.4]), respectively. The bilirubin (0.49 mg/L) and bile acid (14.6 mmol/L) concentrations in white bile were significantly less than bilirubin (41.9 mg/L) and bile acid (62.2 mmol/L) concentrations in yellow/black bile. Cholangitis developed in 66.6% of patients with white bile compared with 35% of those with yellow/black bile (OR 3.67: 95% CI [0.74, 19.25]). Kaplan-Meier curves showed that median survival was shorter in patients with white bile (36 [23-60] vs 75 [35-220] days) (p = 0.004, log rank test), which was significant even after adjusting for potential confounders with Cox proportional hazards regression. CONCLUSION: White bile is largely devoid of bilirubin and bile acids. The presence of white bile was associated with significantly worse survival in patients with malignant biliary obstruction.