Abstract: In recent years it has seen an increase of incidental thyroid carcinomas (ICs), most of the ICs are any microcarcinoma (MC). The term refers to a CT, predominantly papillary, and smaller than or equal to 1 cm. The MC is characterized by a papillary heterogeneous clinical behavior ranging from small outbreak discovered accidentally after surgery than the cancer that manifests clinically with lymph node metastases in the neck or rarely systemic.
Abstract: Trauma is one of the leading causes of death in any age group. The 'lethal triad' of acidosis, hypothermia, and coagulopathy has been recognized as a significant cause of death in patients with traumatic injuries. In order to prevent the lethal triad two factors are essential, early control of bleeding and prevention of further heat loss. In patients with major abdominal trauma, damage control surgery (DCS) avoids extensive procedures on unstable patients, stabilizes potentially fatal problems at initial operation, and applies staged surgery after successful initial resuscitation. It is not currently known whether DCS is superior to immediate surgery for patients with major abdominal trauma.
Abstract: The Primary Breast Lymphomas (PBL) represent 0,38-0,70% of all non-Hodgkin lymphomas (NHL), 1,7-2,2% of all extranodal NHL and only 0,04-0,5% of all breast cancer. Most frequent PBLs are the diffuse large B cell lymphomas; in any case-reports MALT lymphomas lack or are a rare occurrence. Their incidence is growing. From 1880 (first breast resection for "lymphadenoid sarcoma" carried out by Gross) to the recent past the gold standard treatment for such diseases was surgery. At present such role has lost some of its importance, and it is matter of debate.
Abstract: Anastomotic leakage is one of the most important complications that occur after surgical low anterior resection for rectal cancer. There are indications that anastomotic leak is associated with increased morbidity, mortality, frequent re-operation or radiological drainage, and prolonged hospital stay. Defunctioning stoma can be useful for patients undergoing a rectal surgery.
Abstract: Acute intestinal obstruction is one of the most common surgical emergencies. The small bowel obstruction (SBO) is the site of obstruction in most patients (76%) and adhesions are the most common etiology (65%). Laparoscopy in SBO has no clear role yet as it may have a therapeutic and diagnostic function. In some settings laparoscopic or laparoscopy-assisted surgery is considered feasible and convenient more than conventional surgery for SBO; however little is known if laparoscopic or laparoscopy-assisted surgery is more suitable with respect to open surgery for patients with SBO.
Abstract: A 57-year-old male patient was admitted in our Department for a non-variceal upper gastrointestinal massive bleeding. In accordance with the clinical guidelines, the patient underwent an early endoscopy (within 24 hours from admission), which showed the source of bleeding in the second portion of the duodenum. An endoscopic haemostatic injection with dilute adrenalin (epinephrine, 1:10.000) was then performed. After 8 hours, severe recidive bleeding occurred with reduced haemoglobin levels, which led us to an emergency surgical treatment. A gastric resection was performed, followed by the application of high-viscous gel (Floseal) into the source of bleeding within the duodenal lumen. This technique allowed to obtain a definitive haemostasis without long-term complications. Our experience suggests that the intra-operative application of Floseal can be an effective alternative to traditional haemostatic techniques in the emergency surgical treatment of upper gastrointestinal bleeding. This also provides additional time to perform other haemostatic techniques techniques avoiding the precarious haemodynamic conditions of a patient in emergency.
Abstract: ABSTRACT: BACKGROUND: We conducted a systematic review to evaluate the role of Ultrasonic dissector (UAS) versus conventional clamp and tie in thyroidectomy. Materials and methods We searched for all published RCT in into electronic databases. To be included in the analysis, the studies had to compare thyroidectomy with UAS versus conventional vessel ligation and tight (conventional technique = CT). The following outcomes were used to compare the total thyroidectomy group with UAS versus CT group: operative duration, operative blood loss, overall drainage volume during the first 24 hours, transiet laryngeal nerve palsy, permanent laryngeal nerve palsy, transiet hypocalcaemia and permanent hypocalcaemia. RESULTS: There are currently 7 RCT on this issue to compare thyroidectomy with UAS versus CT. From the analysis of these studies it was possible to confront 608 cases: 303 undergoing to thyroidectomy with UAS versus 305 that were treated with CT. Actually, it was shown a relevant advantage of cost-effectiveness in patients treated with UAS; there is a statistically significant reduction of the operative duration (weighted mean difference [WMD], -18.74 minutes; 95% confidence interval [CI], (-26.97 to -10.52 minutes) (P=0.00001), intraoperative blood loss (WMD, -60.10 mL; 95% CI, -117.04 to 3.16 mL) (P=0.04) and overall drainage volume (WMD, -35.30 mL; 95% CI, -49.24 to 21.36 mL) (P=0.00001) in the patients underwent thyroidectomy with UAS. Although the analysis showed that the patients who were treated with USA presented more favourable results in incidence of post-operative complications (transient laryngeal nerve palsy: P=0.11; permanent laryngeal nerve palsy: not estimable; transient hypocalcaemia: P=0.24; permanent hypocalcaemia: P=0.45), these data didn't present statistical relevance. CONCLUSION: This meta-analysis shown a relevant advantage only in terms of cost-effectiveness in patients treated with UAS; it is subsequent to statistically significant reduction of operation duration, intraoperative blood loss and of overall drainage volume during the first 24 hours. Although the analysis showed that the patients who were treated with UAS presented more favourable results in incidence of post-operative complications (transiet laryngeal nerve palsy; transiet hypocalcaemia and permanent hypocalcaemia), these data didn't present statistical relevance.
Abstract: ABSTRACT: Synchronous colorectal neoplasias are defined as 2 or more primary tumors identified in the same patient and at the same time. The most voluminous synchronous cancer is called "first primitive" or "index" cancer. The aim of this work is to describe our experience of minimally invasive approach in patients with synchronous colorectal neoplasias.Since January 2001 till December 2009, 557 patients underwent colectomy for colorectal cancer at the Department of General and Emergency Surgery of the University of Perugia; 128 were right colon cancers, 195 were left colon cancers while 234 patients were affected by rectal cancers. We performed 224 laparoscopic colectomies (112 right, 67 left colectomies and 45 anterior resections of rectum), 91 Transanal Endoscopic Microsurgical Excisions (TEM) and 53 Trans Anal Excisions (TAE). In the same observation period 6 patients, 4 males and 2 females, were diagnosed with synchronous colorectal neoplasias. Minimal invasive treatment of colorectal cancer offers the opportunity to treat two different neoplastic lesions at the same time, with a shorter post-operative hospitalization and minor complications. According to our experience, laparoscopy and TEM may ease the treatment of synchronous diseases with a lower morbidity rate.
Abstract: In patients with localized gastrointestinal stromal tumors, surgery remains the elective treatment. Nowadays, imatinib therapy has been standardized in advanced gastrointestinal stromal tumors, showing continuous improvements in progression-free and overall survival. A combination of imatinib therapy and surgery may also be effective in a subset of patients with metastatic or unresectable gastrointestinal stromal tumors. In this review, the authors analyzed the role of imatinib mesylate associated to surgery in unresectable and/or metastatic gastrointestinal stromal tumors.
Abstract: Bronchogenic cyst is a rare clinical entity that occurs due to abnormal development of the foregut; the majority of bronchogenic cysts have been described in the mediastinum and they are rarely found in an extrathoracic location.
Abstract: Versione italiana Riassunto: Complicanze chirurgiche della tiroidectomia: le lesioni del dotto toracico. N. Avenia, A. Sanguinetti, S. Santoprete, M. Monacelli, R. Cirocchi, R. Lucchini, S. Galasse, F. Calzolari, M. Urbani, F. D'Ajello, F. Puma Le lesioni del dotto toracico rappresentano evento infrequente nella chirurgia del collo; relativamente più comuni dopo chirurgia laringea ed esofagea sono rare in chirurgia tiroidea. Dal gennaio 1986 al giugno 2009 sono stati trattati 14 pazienti con lesioni del dotto toracico cervicale sottoposti ad interventi per patologia tiroidea: 4 gozzi cervico-mediastinici e 10 tiroidectomie totali per cancro, 9 delle quali con linfoadenectomia laterocervicale sinistra. In 2 casi la rilevazione intraoperatoria ha consentito immediata legatura. In 12 casi ècomparsa nell'immediato post-operatorio fistola chilosa cervicale senza chilotorace consensuale: 5 fistole a bassa portata e 7 ad alta. Dei 5 casi di fistola a bassa portata, 4, sono guariti dopo circa 1 mese di trattamento conservativo, solamente 1 paziente ha necessitato di correzione chirurgica. I 7 pazienti con fistola ad alta portata sono stati sottoposti ad intervento chirurgico: 4 nella prima settimana post-operatoria e 3 dopo un periodo di oltre 30 giorni di terapia medica. Nei pazienti con fistola chilosa cervicale ad alta portata un trattamento medico prolungato non apporta vantaggi, anzi è caratterizzato da maggiore difficoltà chirurgica con possibile incremento di complicanze. English version Summary: Complications of thyroid surgery: cervical thoracic duct injuries. N. Avenia, A. Sanguinetti, S. Santoprete, M. Monacelli, R. Cirocchi, R. Lucchini, S. Galasse, F. Calzolari, M. Urbani, F. D'Ajello, F. Puma Thoracic duct injury is uncommon in surgery of the neck: relatively more common after laryngeal and esophageal surgery, rare in thyroid surgery. From January 1986 to June 2009 were treated 14 patients with lesions of the cervical thoracic duct undergo surgery for thyroid disease: 4 goitre cervico-mediastinal and 10 total thyroidectomy for cancer, 9 of which have laterocervical left lymphadenectomy. In 2 cases, the intraoperative detection has allowed immediate ligature. In 12 patients a cervical chylous fistula without chilothorax was found: 5 low-flow fistulas and 7 high-flow fistulas. Of the 5 cases of low-flow fistula, 4 were recovered after 1 month of conservative treatment, only 1 patient required surgical correction. The 7 patients with high-flow fistula were undergoing surgery: 4 in the first week post-operative and 3 after a period of more than 30 days of medical therapy. In patients with high-flow fistula prolonged medical treatment does not provide benefit and increase the risk of complications during and after surgery.
Abstract: Versione italiana Riassunto: Mielolipoma presacrale: case report. A. Spizzirri, V. Napolitano, F. La Mura, L Cattorini, E. Farinella, P. Del monaco, C. Migliaccio, E. Pressi, A. De Sol, M. Bravetti, M. Coccetta, R. Cirocchi, F. Sciannameo Obiettivi. I tumori presacrali sono più frequentemente benigni, occasionalmente maligni ed a crescita lenta. La loro incidenza è di 1:40.000; nel 26-50% dei casi risultano asintomatici. Quando presente, la sintomatologia è in relazione alle dimensioni, alla localizzazione e alla presenza di infezione. Caso clinico. Riportiamo il caso di una paziente di 69 anni con sintomatologia dolorosa addominale aspecifica localizzata ai quadranti addominali inferiori associata a parestesie e ipostenia dell'arto inferiore destro. L'esplorazione rettale faceva apprezzare formazioni rettale della parete postero-laterale destra, fissa, moderatamente dolorabile, duro-elastica. La TC, la RM e una biopsia TC-guidata, sequenzialmente eseguite, rivelavano una massa pelvica di circa 10 cm nel mesoretto, a struttura disomogenea e di origine verosimilmente connettivale, in assenza di linfoadenopatie del piccolo bacino. L'intervento chirurgico consentiva di asportare, a livello dello spazio presacrale, una tumefazione strettamente adesa al sacro. L'esame istologico deponeva per mielolipoma. Conclusioni. L'escissione en bloc di queste neoplasie con approccio chirurgico anteriore trans-addominale permette una diagnosi di natura e rappresenta la migliore cura nel caso di lesioni maligne, spesso chemio- o radioresistenti. English version Summary: Presacral myelolipoma: a case report. A. Spizzirri, V. Napolitano, F. La Mura, L Cattorini, E. Farinella, P. Del monaco, C. Migliaccio, E. Pressi, A. De Sol, M. Bravetti, M. Coccetta, R. Cirocchi, F. Sciannameo Background. Presacral tumors are more frequently benign, and only occasionally malignant, showing a slow growth and an incidence of 1:40.000. They are asymptomatic in the 26-50% of the cases. When symptoms occur, these are related to the dimensions of the tumor, to its location and to the presence of infection. Case report. We report the case of a 69-year old woman with a lower abdominal pain associated with paresthesia and ipostenia of the right inferior limb. Digital rectal examination showed a fixed, mild tender and hard tumor of the posterior rectal wall. CT, MR and CT-guided biopsy sequently performed revealed a solid, dishomogeneous mass, located in the presacral region, with a connective likely origin, without pelvic lymphoadenopathy. The operation allowed to esteem a mass which was tenaciously adherent to the sacrum. We performed a total excision. Final histological diagnosis was myelolipoma. Conclusions. The Authors' opinion is that the en-bloc resection of these tumors with an anterior surgical approach allows a histological diagnosis of the nature, representing the best treatment for potentially malignant lesions, which are frequently radio and chemo-resistant.
Abstract: We have conducted a clinical controlled trial (CCT) on patients who had undergone thyroidectomy for goitre or thyroid carcinoma. The endpoint of this study was to evaluate the benefits of ultrasonic dissector vs conventional technique (vessel ligation and tight) in patients undergoing thyroid surgery.
Abstract: In western countries intestinal obstruction caused by sigmoid volvulus is rare and its mortality remains significant in patients with late diagnosis. The aim of this work is to assess what is the correct surgical timing and how the prognosis changes for the different clinical types.
Abstract: Post-operatory wound infections are a very uncommon finding after thyroidectomy. For these reasons international guidelines do not routinely recommend systemic antibiotic prophylaxis. The benefits of this antibiotic prophylaxis is not supported by clinical evidence in the literature. We have conducted a multicentric randomized double-blind trial on 500 patients who had undergone thyroidectomy for goitre or thyroid carcinoma. The 500 patients enrolled in the study (mean age 47 years) were randomized in two subgroups of 250 patients. 250 patients were treated with standard antibiotic prophylaxis with sulbactam/ampicillin 1 fl (3 gr.) 30 min before surgery. No antibiotic prophylaxis was instituted in the remainder 250 patients. Our RCT showed that prophylactic antibiotic treatment is not beneficial in patients younger than eighty years old, with no concomitant metabolic, infective and hematologic disease, with no cardiac valvulopathies, not under steroidal or immunosuppressive treatment, and not severely obese. Our study should be regarded only as a preliminary RCT, and should be followed by a study in which a larger number of patients should be enrolled so that statistically significant data can be obtained.
Abstract: Primitive thyroid lymphoma, although rare, is becoming more frequent. Its incidence is increasing, from 0.5% in the sixties to 1-5% of all thyroid neoplasms today. The diagnosis of such neoplasms is not always straightforward. In fact, it is often the result of pathologic findings on a gland resected for an apparently benign disease. Surgical dissection may prove more complicated than in standard cases of thyroidectomy for the possible tight adhesions existing between the gland's capsule and the surrounding structures. In cases of capsular infiltration, postoperative external local radiotherapy is indicated.
Abstract: Between 5 and 10% of the patients undergoing a colonoscopy cannot have a complete procedure mainly due to stenosing neoplastic lesion of rectum or distal colon. Nevertheless the elective surgical treatment concerning the stenosis is to be performed after the pre-operative assessment of the colonic segments upstream the cancer. The aim of this study is to illustrate our experience with the Computed Tomographic Colonography (CTC) for the pre-operative assessment of the entire colon in the patients with stenosing colorectal cancers.
Abstract: Cholecystectomy has been the treatment of choice for symptomatic gallstones, but remains the greatest source of post-operative biliary injuries. Laparoscopic approach has been recently preferred because of short hospitalisation and low morbidity but has an higher incidence of biliary leakages and bile duct injuries than open one due to a technical error or misinterpretation of the anatomy. Even open cholecystectomy presents a small number of complications especially if it was performed in urgency. Hemobilia is one of the most common cause of upper gastrointestinal bleeding from the biliary ducts into the gastrointestinal tract due to trauma, advent of invasive procedures such as percutaneous liver biopsy, transhepatic cholangiography, and biliary drainage.
Abstract: In most cases Colovesical fistulae are complications of diverticular disease and representing the most common kind of colodigestive fistula; less common are colovaginal, colocutaneous, coloenteric and colouterine fistula. In this article we review the literature concerning colovesical fistulae in colorectal surgery for sigmoid diverticulitis and report on two cases that required a surgical treatment, one elective and the other in emergency. In both cases we performed a sigmoid resection with a primary anastomosis and small vesical window-ectomy placing a Foley catheter for about 10 days.
Abstract: Thoracic aortic aneurysm (TAA) is an uncommon disease with an incidence of 10.4 per 100,000 inhabitants. It occurs mainly in older individuals and is evenly distributed among both sexes. There are no signs or symptoms indicative of the presence of the disease. Progressive but unpredictable enlargement of the dilated aorta is the natural course of the disease and can lead to rupture. Open chest surgical repair using prosthetic graft interposition has been a conventional treatment for TAAs. Despite improvements in surgical procedures perioperative complications remain significant. The alternative option of thoracic endovascular aneurysm repair (TEVAR) is considered a less invasive and potentially safer technique, with lower morbidity and mortality compared with conventional treatment. Evidence is needed to support the use of TEVAR for these patients, rather than open surgery.
Abstract: Adherential pathology is the most common cause of small bowel obstruction. Laparoscopy in small bowel obstruction does not have a clear role yet; surely it doesn't always represent only a therapeutic act, but it is always a diagnostic act, which doesn't interfere with abdominal wall integrity.
Abstract: Skin metastasis from internal carcinoma rarely occurs. It has an incidence of 0.7 to 9% and it may be the first sign of an unknown malignancy. However, it can also occur during follow-up.
Abstract: Analyzing a complex case and referring to the literature, the authors describe abdominal compartmental syndrome as a complication of Fournier's gangrene, stressing out the importance of an early diagnosis to perform prompt and effective treatment. The characteristic of this case is not represented only by the Fournier's gangrene rarity, but also by the appearance of an abdominal compartmental syndrome due to the gangrene extension from the scrotum to the abdominal wall and cavity through the spermatic funiculus. The treatment of the abdominal compartmental syndrome was the surgical toilette of the necrotic regions (scrotum, abdominal wall and cavity) together with an orchiectomy.
Abstract: New sphincter-saving approaches have been applied in the treatment of perianal fistula in order to avoid the risk of fecal incontinence. Among them, the fibrin glue technique is popular because of its simplicity and repeatability. The aim of this review is to compare the fibrin glue application to surgery alone, considering the healing and complication rates.
Abstract: Breast surgery is classified among the procedures performed in clean surgery and is associated with a low incidence of wound infection (3-15%). The objective of this study was to evaluate the advantages antibiotic prophylaxis in patients undergoing breast surgery. A multicenter randomized controlled study was performed between January 2008 and November 2008. One thousand four hundred patients were enrolled in prospective randomized study; surgical wound infection was found in 41 patients (2.93%). In our RCT we have shown that in breast surgery antibiotic prophylaxis does not present significant advantages in patients with potential risk of infection (17 patients, 2.42%, subjected to antibiotic prophylaxis vs 24 patients, 3.43%, without antibiotic prophylaxis) (P = 0.27). In patients with drainage there is a significant minor incidence of wound infections in patients receiving antibiotic prophylaxis (5 patients, 0.92%, subjected to antibiotic prophylaxis vs 14 patients, 3.09%, without antibiotic prophylaxis) (P = 0.02). CONCLUSION: This study is only a preliminary RCT to be followed by a study which should be enrolled more patients in order to get the results as statistically significant.
Abstract: The emergency treatment of incisional hernias is infrequent but it can be complicated with strangulation or obstruction and in some cases the surgical approach may also include an intestinal resection with the possibility of peritoneal contamination. Our study aims at reporting our experience in the emergency treatment of complicated incisional hernias.
Abstract: The diagnosis-related group (DRG) system is a prospective hospital payment system used to categorize hospital patients expected to require similar hospital services. In Italy, hospital productivity is calculated from DRG-based data coded according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), which is a classification system for coding of diagnoses and operations for indexing medical records by diagnosis and operations. The aim of our survey was to determine the national incidence of appendectomies based on the coded summary of selected data in hospital discharge reports (HDR).
Abstract: The aim of this study is to evaluate the safety and feasibility of laparoscopic cholecystectomy for acute cholecystitis and to determine the optimal timing.
Abstract: In patients with colorectal cancers synchronous neoplastic lesions are an increasingly frequent finding at preoperative staging; 3% of the cases are other cancers while 33-35% of the synchronous lesions are villous adenomas. The treatment of most colorectal adenomas can be performed by endoscopic poplypectomy. In 5% of cases there are synchronous colorectal lesions also requiring surgical treatment. From January 1995 to June 2007 we treated 5 patients with rectal lesions by transanal endoscopic microsurgery (TEM) together with a laparoscopic colectomy for the presence of synchronous lesions at the "Clinica Chirurgica Generale e d'Urgenza" of the University of Perugia,. Surgical timing involved performing a sequential exeresis characterised by a cancer resection, followed by resection of the voluminous adenoma: TEM for rectal cancer followed by a laparoscopic right hemicolectomy with an extracorporeal anastomosis for a voluminous villous adenoma (1 patient) and laparoscopic right hemicolectomy with an extracorporeal anastomosis for cancer followed by TEM for a voluminous villous adenoma (2 patients). One patient with left colon cancer associated with a voluminous villous rectal adenoma first underwent TEM for the rectal adenoma and then a left laparoscopic hemicolectomy with an extracorporeal anastomosis in order to ease the transit of the circular mechanical stapler. Another patient with rectal and right colon adenomas first underwent TEM for a voluminous rectal sessile adenoma and later a right hemicolectomy. The use of this minimally invasive approach allowed rectum preservation and less invasive surgery.
Abstract: Gastric volvulus is an uncommon clinical entity, first described by Berti in 1866. It is a rotation of all or part of the stomach through more than 180 degrees . This rotation can occur on the longitudinal (organo-axial) or transverse (mesentero-axial) axis. This condition can lead to a closed-loop obstruction or strangulation. Traditional surgical therapy for gastric volvulus is based on an open approach. Here we report the case of a patient with chronic intermittent gastric volvulus who underwent a successful laparoscopic treatment.
Abstract: In 5-10% of patients it is not possible to achieve a complete endoscopic examination of the colon, because of obstructing cancer, excessive length of the colon, anatomical abnormalities or adhesions. Virtual colonoscopy is currently capable of investigating the colic lumen with a non-invasive technique, with high specificity and sensitivity. From January 2005 to July 2007 we treated 21 patients with obstructing neoplastic colorectal lesions, preventing a complete endoscopic examination. In all patients we performed a virtual colonoscopy, which revealed the presence of synchronous lesions (19%): a pedunculated polyp in two cases, a sessile polyp in one case and a right colonic vegetating lesion. In the 21 patients studied we performed a follow-up colonoscopy 3 months after the surgical treatment. No other endoluminal lesions were found, confirming the results of virtual colonoscopy. In our experience virtual colonoscopy presented 100% sensitivity and specificity. In this selected group of patients with obstructing lesions of the colon, virtual colonoscopy enables the surgeon to evaluate the entire colon, avoiding the execution of an intraoperative colonoscopy and possible surgical reintervention due to the finding of synchronous neoplastic lesions at postoperative follow-up endoscopy.
Abstract: The name ''carcinoid'' was invented by Oberndorfer in 1907, when the nature of those histological entities was little understood. Usually, they were found in various locations in the gastrointestinal (GI) apparatus (67%), most of them in the small intestine (25%), appendix (12%), and rectum (14%).The techniques used for their removal are various. The authors present here a case of rectal carcinoid removed using the transanal endoscopic microsurgery technique, and referred to the diagnosis and treatment of this uncommon tumor. A 37-year-old male was admitted to the Santa Maria Hospital of Terni (Italy) with a chief complaint of intermittent pain in the lower right quadrant, that began three years ago. Complete blood count (CBC) and laboratory data as tumor markers and urinary 5-hydroxyindoleacetic acid (5-HIAA) showed no abnormalities, while urinary vanilmandelic acid level was elevate (18 mg/24 h). The patient was submitted to a colonoscopy with magnifying endoscopy and biopsy. The histological finding demonstrated a nodule characterized by cellular proliferation, with few microscopical abnormalities, arranged in small cords with a glandular pattern, separated by dense connective tissue. Histochemically the tumor cells were cytocheratins +/-, chromogranin positive, synaptophysine positive, CD56 positive and Growth Index MIB1-Ki67 which was almost zero. The patient also underwent an endoscopic ultrasonography and an Octreoscan. He was operated using a transanal endoscopic microsurgery technique. The use of Transanal Endoscopic Microsurgery (TEM) as a safe and feasible technique for exciding rectal tumors can be easily understood, for the excellent view and precise dissection. The use of new surgical devices as Harmonic Scalpel has improved the precision of this kind of approach, increasing the appropriateness of this approach compared to other kind of resection. A full diagnostic course and an immunohistochemistry are mandatory for precise diagnosis of rectal carcinoid. Careful attention must be paid to these tumors because of their unexpected behaviour.
Abstract: Most laparoscopic procedures are performed on an elective basis. However, as general surgeons have gained more experience with laparoscopy, they are employing this procedure also for the evaluation and treatment of acute abdominal conditions such acute appendicitis, acute cholecystitis, perforated gastroduodenal ulcer and abdominal trauma, acute pancreatitis and intestinal obstruction. Although its advantages are still under debate, the laparoscopic approach has already been adopted by many centers in the emergency setting.
Abstract: At the beginning of the laparoscopic surgery, intestinal obstruction was considered an absolute contraindication for this approach, because of the high risk of injuring the bowel. Today laparoscopic surgery for small bowel obstruction is still under evaluation. Adhesions are the most common cause of obstruction; although an important proportion of these patients can be nonoperatively treated, some of these require immediate operation. The aim of this review was to evaluate the reliability and immediate results of laparoscopic management of small bowel obstruction by postoperative adhesions. Laparoscopic management of acute small bowel obstruction is feasible, but it is often difficult and may be hazardous. The patients with acute obstruction may be undergo laparoscopy after a careful selection. Morbidity is low if the operation is performed by skilled. The immediate benefit is rapid intestinal motility and shorter hospital stay. The long-term effect is the prevention of small bowel obstruction recurrences by new postoperative adhesions.
Abstract: Several studies have demonstrated the feasibility and safety of laparoscopic surgery for Crohn's disease. A trend towards less morbidity as compared to laparotomy has been suggested. However, problems noted early in the experience may have prevented the optimal benefit from having been conferred. Accordingly, the aim of this study was to evaluate perioperatively those patients.
Abstract: The Authors present a recent case of a medullary thyroid cancer arised in an ectopic accessory gland, whose definitive diagnosis was only set after the pathologist observation of the resected specimen. The Authors then review the causes of the anomaly and the literature classification of thyroid ectopies together with the commonest clinical, laboratory and imaging diagnostic features. In conclusion Authors indicate the importance of thinking about the possible ectopic thyroidal nature of an undiagnosed cervical mass, in order to recognize an unusual disease thus avoiding a delayed therapy.
Abstract: Interventional magnetic resonance (IMR) machines have produced unique opportunity for image-guided surgery. The open configuration design and fast pulse sequence allow virtual real time intraoperative scanning to monitor the progress of a procedure, with new images produced every 1.5 sec. This may give greater appreciation of anatomy, especially deep to the 2-dimensional laparoscopic image, and hence increase safety, reduce procedure magnitude and increase confidence in tumour resection surgery. The aim of this paper was to investigate the feasibility of performing IMR-image-guided general surgery, especially in neoplastic and laparoscopic field, reporting a single center -- St. Mary's Hospital (London, UK) -- experience. Procedures were carried out in a Signa 0.5 T General Elettric SP10 Interventional MR (General Electric Medical Systems, Milwaukee, WI, USA) with magnet-compatible instruments (titanium alloy instruments, plastic retractors and ultrasonic driven scalpel) and under general anesthesia. There were performed 10 excision biopsies of palpable benign breast tumors (on female patients), 3 excisions of skin sarcoma (dermatofibrosarcoma protuberans), 1 right hemicolectomy and 2 laparoscopic cholecystectomies. The breast lesions were localized with pre- and postcontrast (intravenous gadolinium DPTA) sagittal and axial fast multiplanar spoiled gradient recalled conventional Signa sequences; preoperative real time fast gradient recalled sequences were also obtained using the flashpoint tracking device. During right hemicolectomy intraoperative single shot fast spin echo (SSFSE) and fast spoiled gradient recalled (FSPGR) imaging of right colon were performed after installation of 150 cc of water or 1% gadolinium solution, respectively, through a Foley catheter; imaging was also obtained in an attempt to identify mesenteric lymph nodes intraoperatively. Concerning laparoscopic procedures, magnetic devices (insufflator, light source) were positioned outside scan room, the tubing and light head being passed through penetration panels. Intraoperative MR-cholangiography was performed using fast spin echo (SSFSE) techniques with minimal intensity projection 3-dimensional reconstruction. About skin sarcomas, 2 of them were skin recurrences of previously surgically treated sarcomas (all of them received preoperative biopsy) and the extent of the lesion was then determined using short tau inversion recovery (STIR) sequence. The skin was closed in each case without need for any plastic reconstruction. The breast lesions were visualized with both Signa and real-time imaging and all enhanced with contrast: 2 (20%) were visualized only after contrast enhancement; intraoperative real time imaging clearly demonstrated a resection margin in all cases. Maximum dimensions of breast specimens (range 8-50 mm, median 24.5 mm) were not significantly different from those measured by Signa (p>0.17, Student's paired t-test) or real time images (p>0.4): also there was no significant difference in lesion size between Signa and real time images (p>0.25). All postprocedure scans clearly demonstrated complete excision. The extent of the tumor at MR imaging was greater in each case than suggested by clinical examination. Adequate resection margins were planned using STIR sequences. Histological examination confirmed clear surgical margins of at least 1 cm in each case. During right hemicolectomy, both intraoperative SSFSE and FSPGR contrast imaging revealed the lesion and details of the colonic surface; imaging of the lymph node draining right colon was only partially successful, due to movement artifact. Concerning laparoscopic procedures, both FSE and SSFSE techniques produced reasonable images of the gallbladder and intrahepatic ducts, but the FSE imaging was of poor quality due to respiration artifact; however, SSFSE allowed visualization of the gallbladder and part of the common bile duct. About skin sarcomas, the extent of the tumor at MR imaging was greater in each case than suggested by clinical examination and in each case the complete tumor excision was confirmed. Histological examination confirmed clear surgical margins of at least 1 cm in each case. Intraoperative MR scanning reliably identifies palpable breast tumours and skin sarcomas and is sufficiently accurate to guide their surgical excision. Further work may be done to develop laparoscopic and open abdominal surgery as well.
Abstract: The role of nephron sparing surgery in patients with a solitary kidney, bilateral kidney tumors or an impaired renal function has been widely accepted. Partial nephrectomy in patients with a normal contralateral kidney is still under discussion.
Abstract: The vast majority of benign colorectal neoplasms can be safely removed by colonoscopic polypectomy; while peduncolated polyps can be easily endoscopically excised, the removal of sessile polyps may be more difficult.
Abstract: Laparoscopic surgery is used with increasing frequency to treat colorectal pathologies and some groups have also attempted to treat the complicated forms of diverticulitis (abscesses and/or fistulas). The results reported in the international literature are still controversial, especially in terms of the duration of surgery, the frequency of laparotomic conversions and postoperative morbidity. The aim of this study was to analyse the results of laparoscopic or laparotomic treatment of diverticular disease of the colon in patients admitted to the Department of Colorectal Surgery at the Cleveland Clinic in Florida over a three-year period.
Abstract: Nowadays the only indications to truncal vagotomy is recurrent ulceration after previous gastric surgery. Truncal vagotomy allows us to obtain a reduction in acid production and to promote ulcer healing, but this technique causes pylorospasm in about 20% of cases and this requires further synchronous or metachronous pyloric drainage procedure. For this reason, videothoracoscopic truncal vagotomy is reserved to patients with gastroresection.
Abstract: The authors reviewed the experience on the use of laparoscopy performed since January 1997 in malignant neoplasms at their institution. The aim of the study was to evaluate the real effectiveness of this procedure in the staging of abdominal neoplasms which were considered resectable at preoperative examinations and in particular in the detection of peritoneal metastases not evidenced with traditional imaging techniques.
Abstract: Anal fistulas are frequent events which often recur after an inadequate surgical treatment. Nevertheless their evolution into malignant diseases is infrequently observed. The authors report one case of mucinous adenocarcinoma arising out of a recurrent, long-lasting fistula-in-ano. As reported, abdomino-perineal resection combined with radiotherapy can be the choice treatment. The difficulty is to obtain a reliable differential diagnosis. No imaging technique nor histologic examination can establish a definitive reliable diagnosis; nevertheless, as the risk of adenocarcinoma developing from a long-lasting recurrent fistula-in-ano, although small, is real, authors believe that operative exploration and biopsy of recurrent abscesses and fistulas should be recommended.
Abstract: Hepatoid carcinoma of the stomach is a rare neoplasm (especially in western countries) characterized by high levels of serum alpha-fetoprotein (AFP), the presence of "hepatoid foci" inside the gastric tumor and poor prognosis, due to the earlier onset of liver metastases. We treated six patients for hepatoid carcinoma of the stomach between 1990 and 1997. The female to male ratio was 1:1, the average age was 71 (54-81) and the average AFP-level was 1160 ng/ml (603-1531). We performed 2 total gastrectomies, 2 subtotal gastrectomies and 2 gastro-jejunostomies (due to presence of liver metastases): in one case, the patient underwent a splenectomy as well. All the tumors showed the presence of "hepatoid foci" (the morphological feature is close to the hepatocellular carcinoma) and a positive immunoreactivity to AFP. The mean survival was 3 months: only one patient is still alive and disease-free (with a 52 months follow-up). After radical surgery, she underwent a chemotherapic treatment with cisplatin, epirubicin, 5-fluorouracil and l-leucovorin. We conclude that our series (the widest in Italy and one of most impressive in Europe) confirm the poor prognosis of this neoplasm, but we also want to underline that this tumor is not so "unusual" any more and it requires new types of treatment, like postoperative chemotherapy, besides surgery, to be fighted properly.
Abstract: The aim of this randomized study was to determine the effects of octreotide therapy on the growth and development of experimental liver metastases from a human colonic cancer cell line (HT 29) in nude mice model. No important and significant difference could be found between mice, lungs and liver weights of both groups as well as lung metastatization; indeed, significant was the difference between groups concerning liver, metastases (the majority of them were in treated group): in spite of the small number of data collected, which does not allow to draw any conclusion on the efficacy of this drug on liver metastases, we believe that octreotide therapy does not affect dramatically the growth and development of liver metastases from a human colon cancer.
Abstract: After the spleen the liver is the most exposed organ to injury in abdominal blunt trauma. The improvement in imaging techniques and in anesthesia and intensive care have contributed to a fallen in mortality rate and an enhanced possibility in non-operative management. In unstable patients the packing may be used to defer the definitive operation. The Authors report a case of liver injury of two lobes where the packing was followed by liver wrapping with an absorbable mesh. The patient, a female aged 67, resulted to have a bilobar liver injury of IV degree in the injury severity score. The delay of reoperation was 15 days. The procedure was complicated by a subphrenic abscess, successfully managed with non-operative procedures. Wrapping after liver packing may be considered a good option in unstable patient affected, by severe liver injuries after blunt abdominal traumas.
Abstract: Splenic artery pseudoaneurysms are the most common of visceral artery pseudoaneurysms. Splenic pseudoaneurysms appear to have developed as a consequence of inflammatory processes adjacent to the splenic artery, particularly acute pancreatitis and chronic pancreatitis with associated pseudocysts. They are often asymptomatic and picked up on abdominal examination for ultrasound or CT scanning for other conditions. Complications include rupture with retroperitoneal hemorrhage or intraperitoneal hemorrhage. Two cases of splenic pseudoaneurysms, following acute pancreatitis, are reported between the years 1987 and 1996.
Abstract: Considering that laparoscopic procedure is associated with increased resistance to lower-limb venous return and subsequent stasis, with possible implications in terms of thromboembolic complications, the aim of our study was to investigate prospectively the coagulative-fibrinolytic profile, in laparoscopic and open cholecystectomy, in patients randomly alloted to receive or not preoperative heparin.
Abstract: Authors performed the mechanical termino-lateral bilio-digestive anastomosis, adopting a circular 21 mm stapler device. The patient was affected by non neoplastic papillary stenosis producing a common biliary tract dilatation so large to allow the stapler's head introduction. A 12 month follow-up was performed using ultrasonography and MRI cholangiopancreatography, that obtained a good demonstration of both biliary tract and bilio-digestive anastomosis.
Abstract: The authors, after an examination of the literature on the subject, present the results of a retrospective study in which the incidence of varicocele among selected young soldiers population called up at SARVAM (Viterbo) from May 1993 until October 1995 is evaluated.
Abstract: Isolated traumatic laceration of the azygos vein is a rare condition that is mainly associated with violent deceleration traumas. Diagnosis is crucially based on radiologic evidence of massive right pleural bleeding and hemorrhagic shock. Surgical exploration needs to be early and concomitant with resuscitation, prognosis largely depending on timely intervention. Median sternotomy provides the most advantageous access because it can be quickly performed and allows for surgical exploration.
Abstract: The authors present their experience in the study of blood supply of flaps. The machine used to study both pre and postoperatively the myocutaneous flap is the echo-color Doppler, a brand new device which has recently been used in investigating the morphology and the blood supply. The use of such method has provided us with the following information: detailed ultrasound structure of the skin, subcutaneous and muscular tissues of the examined flap; localization of vessels within the flap; size of the vessel in its whole length; quality and speed of both the arterial and venous flow. Such information is very important for the surgeon to plan in detail the reconstruction by knowing the blood supply of myocutaneous flap.
Abstract: Improvements in the techniques of preoperative needle localization of nonpalpable breast lesions that have been detected at mammography, coupled with surgical biopsy of smaller volumes of breast tissue and the use of local anesthesia have produced a more aggressive attitude toward early biopsy of lesions that are suspected of malignancy. The authors report the follow-up in 92 cases, who underwent breast biopsy for microcalcifications with no palpable lesions. In 46 women the presence of microcalcifications was evaluated through a computerized instrument which allows digitalization of the image.
Abstract: At the Plastic and Reconstructive Surgery Department of Perugia, 52 patients were examined by color flow duplex scanning, in order to study rectus abdominis myocutaneous flap vascular supply before surgical procedures. This ultrasound technique permits a precise and accurate measurement of blood flow volume and velocity within the epigastric arteries (which represent the superior and inferior vascular pedicles of the flap) and makes it possible to detect the exact location of the perforating branches with their cutaneous distribution. This preoperative evaluation, pointing out vascular pathologies which contra-indicate the use of rectus abdominis flap, can be considered a great help for the reconstructive surgeon in the choice of the operative procedure and can surely lead to a significant decrease in postoperative complication rate.
Abstract: The Authors report two cases of ectopic gastric pancreas, one of them causing a massive upper gastrointestinal hemorrhage, representing an infrequent complication of the disease. A literature review on the subject was then performed, and the importance of a differential diagnosis of the ectopy versus gastric malignancies, with relevant prognostical and management implications was assessed.
Abstract: The aim of this paper is to evaluate the role of Doppler and echo color-Doppler in the microsurgical treatment of varicocele. Since December 1993, 87 consecutive patients underwent microsurgical treatment of varicocele. The study demonstrates that Doppler and Color-flow-Duplex scanning provide an accurate, non-invasive method to identify the position of accessory spermatic veins, evaluating at the same time the flow characteristics of the microsurgical anastomosis.
Abstract: In recent years pancreatic cancer has shown an increasing incidence. Preoperative staging represents a main problem for its surgical management. Recent behaviour in the treatment of the disease led to considerably more encouraging results. The Authors describe the cases treated at the Dept. of Surgery of the University of Perugia and review the most important international reports on preoperative staging of pancreatic cancer.
Abstract: In this study the Authors describe two cases of hepatoid adenocarcinoma of the stomach: one is characterized by the presence of alpha-fetoprotein (AFP) high levels of the serum both pre and post-operating and by the very positive response to the adjuvant chemotherapy (how the return to the normality of such values demonstrates). The other is instead characterized by the presence of post operating hepatic metastasis, event which is very frequent in this kind of neoplasm, but presents many problems concerning the differential histological diagnostics with the primitive hepatocarcinoma (problems which are nowadays not completely solved). Moreover the Authors relate to this study the revision of the international literature of the main characteristics and of prognosis of this particular and rare neoplasm.
Abstract: The local recurrence, after radical exeresis of a large intestinal cancer represents until now an extremely interesting question, taking into consideration that it represents the cause of death in 50% of operated patients. Frequency is higher after an exeresis of a rectal cancer, with a range of 2.6-83% in the different case histories, than after a surgical intervention on a colon cancer, whose incidence is lower than 5%. The early diagnosis of rectum cancer recurrence is the first step towards the favourable issue of treatment. Surgical treatment of loco-regional recurrences of rectum cancer can be curative when it is possible to perform a total resection of the recurrences and of the infiltrated structures, without microscopic residuals of disease, or palliative, aiming to reset the intestinal and urinary functions or to reduce pain. At the Department of Surgery of the University of Perugia, from January 1984 to December 1983, 153 patients with rectal cancer-79 males (52%) and 74 females (48%)-were treated. The operations, all involved total removal of the affected segment and were in 88 cases (58%) an anterior resection and in 65 cases (42%) an abdomino-perineal amputation. The analysis was made of 128 patients with a follow-up of at least five years; the local recurrence incidence was 12.5%. The authors adopted a follow-up protocol based on clinical examination, CEA antigen and routine Lab tests, chest X-rays, colonoscopy, abdominal ultrasonography, pelvic CT scan; these procedures are performed starting 3 months after operation.
Abstract: From January 1989 to December 1993 at the Department of Clinical Surgery at the University of Perugia, 7 patients were under observation for multiple costal fractures and flail chest. One of them died almost immediately after his admission and therefore received no more than the initial medical treatment. Another died 17 days after costal osteosynthesis of cerebral complications. Four others successfully underwent a costal osteosynthesis, while the 7th patient received medical therapy with a positive outcome. In the case of a critical flail chest with very serious physio-pathological consequences, if the fractures are in technically favourable places, we think it is better to stabilize immediately, since the operating trauma is minimum and in many cases the patient is already intubated and curarized.
Abstract: Although rarely, several conditions may cause malabsorption through lymphatic obstruction. Primary lymphangiectasia, a genetically determined disease characterized by diarrhoea, steatorrhoea and protein-losing enteropathy, is one of these conditions. The Authors report their experience in three cases of small bowel lymphangiectasia occurring in adults and discuss diagnostic and therapeutic problems of the disease.
Abstract: Acute appendicitis is a very common disease in western countries, affecting the entire population with higher prevalence in younger people. The diagnosis of the disease is still basically performed through the clinical evaluation of the patient, while peripheral White Cell Count or imaging techniques such as ultrasonography are poorly helpful. Therefore, a great number of patients is operated without finding a severe involvement of the appendix at intraoperative observation. To evaluate the rate of false acute appendicitis and to correlate the histological involvement with the clinical behavior of the disease the Authors carried a prospective study during a period of 28 months on 124 patients with a diagnosis of acute appendicitis treated on emergency basis.
Abstract: From January 1989 to December 1993 at the Institute of Clinical Surgery of the University of Perugia, 5 patients were under observation for penetrating chest injuries. Two of them had show-wounds, one a slash, one a stabbing and slash and one a cutting blow. One of the patients with shot-wounds died on the operating table from a haemorrhage while the other was saved by surgery. One patient successfully underwent surgery for loss of tissue in the thorax walls. Another had a mini-thoracotomy plus lung suture which were successful. Finally, in the patient with a slash in the front region of the thorax and a slight pneumothorax, we inserted a chest thorax tube and so obtained a complete re-expansion of the lung. Total mortality was 20%. Surgical exploration of the thorax we believe is necessary wherever there is a risk of haemorrhage or possible lung damage requiring only surgery. According to many authors, video-thoracoscopy has the advantage of a reliable diagnosis and above all, enable us to repair lung wounds without opening the thorax. In one of our patients we could have avoided the mini-thoracotomy and used thoracoscopy to repair the lung damage.
Abstract: The general surgical profile of octogenarians compared with that of younger patients, and risk factors predictive of operative mortality and morbidity, were determined retrospectively using a computer database for all patients admitted between 1989 and 1993. There were 934 admissions of octogenarians and surgery was performed in 447 cases (47.9 percent). The admission rate of patients over 80 years of age increased during the 5-year period from 4.6 to 9.0 per cent, and was significantly higher than that of geriatric patients aged 65-79 years (P < 0.01). Emergency admissions (63.6 percent) and operations (42.3 percent) were more frequent in patients aged over 80 years (P < 0.01); emergency operations increased during the 5 years from 38 to 59 percent. Altogether, 83 deaths and 171 complications were recorded. The mortality rate of octogenarians was greater than that of younger patients (P < 0.01). Postoperative mortality and morbidity rates were 10.1 and 32.2 percent respectively. After multiple logistic regression analysis with stepwise backward elimination, an American Society of Anesthesiologists score of II-V (P < 0.01), the presence of two associated diseases (P < 0.01) and laparotomy procedures (P < 0.03) appeared to be independent risk factors for postoperative mortality and morbidity.
Abstract: Primary choledocholithiasis represents a quite unusual sequela of biliary tract surgery. Primary stones originate in the common bile duct and are soft, smooth, with a yellowish or brown-reddish colour, reproducing the shape of the duct in which arise. The Authors report a review of the cases observed in the division of General and Vascular Surgery-Department of Surgery and Surgical Emergencies of the University of Perugia. From January 1988 to December 1993, 577 laparotomic biliary tract operations were performed, and in 8 cases a re-operation was needed. Among the latter, particularly interesting were 2 cases of primary choledocholithiasis occurred in two patients with bilio-digestive anastomosis previously performed, i.e. two side-to-side Roux-en-Y or Braun loop choledochojejunostomies, respectively. Therefore, primary lithiasis following a choledochojejunostomy occurred when the bilio-digestive anastomoses were performed with the indication of a curative re-operation on the biliary tract. On the contrary, most choledochojejunostomies are performed as a palliative procedure in patients presenting a low survival rate not allowing to develop a Sump Syndrome and a consequent choledocholithiasis, which are long-term complications.
Abstract: From January 1989 to December 1992, in the Institute of Clinical Surgery of the University of Perugia, 102 patients were admitted for thoracic trauma. Two patients with an open thoracic trauma, both presenting multiple shot-wounds, underwent an explorative thoracotomy. One of them died on the operating-table from hemorrhage, while the other was saved by a wedge-resection. A 3rd explorative thoracotomy was successfully performed on a patient with internal thoracic trauma and severe hemothorax. Among the 100 patients with an internal thoracic trauma, mortality was 6%, but only one of the 6 deceased, had no lesions other than a fail chest. As a matter of fact 38 patients presented lesions in other parts of the body. Simple and complicated multiple costal fractures, found in 84 cases, were the most frequent lesions observed. Seventeen of the 38 patients with pneumothorax and/or pleural effusion had a chest tube applied. Three patients were operated for a diaphragmatic hernia with a positive outcome. Only 75 patients received medical treatment without surgery. Six of the patients with multiple costal fractures presented flail chest. One of them (mentioned above) died almost immediately after his admission and therefore received no more than the initial medical treatment. Four others, aged over 65, successfully underwent a costal osteosyntesis, while the 6th patient received medical therapy with a positive outcome. In the case of a critical flail chest with severe patho-physiological consequences, if the fractures are in technically favourable sites, the Authors believe it is better to immediately stabilize the thorax, since the operating trauma is minimum and in many cases the patient is already intubated and curarized.
Abstract: The authors review their experience of 8 cases of primary carcinoma of the gastric stump during the period 1989-1992. During the same period, 164 gastric cancers were treated in the same department. Mean duration between primary gastric resection and diagnosis of gastric stump carcinoma was 30 years (6 to 42 years). All patients underwent a Billroth II primary gastric resection. Only 4 patients underwent radical surgical resection of their gastric stump carcinoma; 2 patients underwent only explorative laparotomy for very advanced and unresectable gastric stump carcinoma; 2 patients were inoperable because of their general status. This series of 8 cases of gastric stump carcinoma emphases the importance of endoscopic investigations during follow-up of patients with gastric resection, in order to diagnose and treat resectable gastric stump carcinoma.
Abstract: Colorectal cancer is the second most common malignancy of the adult population in the United States. It is exceeded only by lung cancer among males and breast cancer among females. Malignancies of the colon and rectum are responsible for approximately 12 per cent of all adult cancer deaths. These tumors appear as surgical urgency by intestinal obstruction for 15-20 per cent and by perforation for 3-8 per cent of all cases. It often occurs in elderly patients; in fact, urgent surgical operations are especially performed in patients older than seventy. The mortality rate for urgent surgical operation in elderly patients is about 32-54 per cent. This high mortality is even due to concurrent pathologies and particular locoregional and/or general alterations induced by tumor. The authors studied all patients older than 75 years affected by colorectal cancer and treated by choice or by urgency at Dept. of Surgery of the University of Perugia from January 1987 to February 1993 to individualize some clinical, anatomo-pathological and therapeutical significant characteristics about colorectal cancer in geriatric age.
Abstract: The authors present their diagnostic approach to acute intestinal ischemia. They underline the need for early specific diagnosis because the therapeutic options vary widely in relation to different types of acute intestinal ischemia. Selective arteriography preceded by an aortogram is considered the diagnostic "gold standard". Although at present mesenteric ischemia is a serious, and often lethal, disease, an aggressive therapeutic approach can improve the outcome of this group of patients.
Abstract: Inferior caval vein invasion not infrequently complicates advanced neoplastic lesions. Primitive caval neoplasms (leiomyosarcomas) or other tumors such as renal carcinomas, pheochromocytoma, as well as liver, testis, and retroperitoneal tumors most likely cause caval invasion. In the past, caval invasion was a clear index of non operability, while today, a modern multidisciplinary approach allows to treat successfully even so advanced diseases. In the present report the Authors analyze the cases treated at the Dept. of Surgery of the University of Perugia, and review the most important international reports on this subject illustrating the new possibilities offered by IVC substitution with biological or artificial grafts.
Abstract: Microcalcific clusters represent good indicators for breast cancer detection. The Authors evaluated 98 cases of breast microcalcifications in patients with no palpable lesions. The patients had undergone mammography, biopsy and excised specimen's radiography to confirm that the target lesion was adequately removed. The presence of microcalcifications was detected through a computerized instrument which allows the digitalization of the image.
Abstract: The authors report their experience of different imaging techniques (US, CT, MRI, and cavography) used to evaluate inferior vena cava involvement due to abdominal malignant neoplasms. The study is a retrospective analysis of preoperative data on 15 patients of both sexes in comparison with intraoperative and/or pathological findings. All patients underwent ultrasonography, with good results in all the venous segments studied, as for the CT scan; the limitation of both techniques is the unsafe evaluation of venous wall involvement when the neoplastic tissue is confined inside the vessel. The results obtained using MRI seem to be very encouraging, but we only studied three cases with this technique, and so cannot assess the real value of the method. In nine patients we performed inferior cava phlebography: we believe this to be a very reliable exam to demonstrate vessel wall invasion, even if it is a very invasive procedure, its limits being the inability to observe proximal thrombotic extension when the vein is completely obstructed by the tumor. On the basis of their experience the authors suggest a multi-technique imaging diagnostic procedure for preoperative staging with a view to obtaining as much information as possible to correctly program surgical procedure.
