Abstract: INTRODUCTION: The aim of this study is to retrospectively analyze the incidence of complications after two-stage laparoscopic biliopancreatic diversion with duodenal switch (Lap BPD-DS) in high-risk super-obese patients and explore the possible predictive factors of specific complications after laparoscopic sleeve gastrectomy (SG). METHODS: High-risk patients--body mass index (BMI) > 50 kg/m(2) with at least two major comorbidities: type 2 diabetes, obstructive sleep apnea syndrome (OSAS), hypertension--undergoing two-stage laparoscopic BPD-DS were retrospectively analysed. The SG pouch volume was 100-150 ml; in the second stage, the common channel and the alimentary loop were 100 cm and 150 cm, respectively. RESULTS: Eighty-seven patients (50 female, 57.5%) underwent SG (two open). The mean age was 41.8 +/- 10.22 years with BMI of 55.2 +/- 6.69 kg/m(2). Four patients had Prader-Willy syndrome. Fourteen (16.46%) patients (6 female, 42.8%) had postoperative complications such as bleeding, fistula, pulmonary embolism, transitory acute renal failure, and abdominal abscess. One patient died at postoperative day 5 of pulmonary embolism. One patient was reoperated for hemoperitoneum by laparoscopy. The risk of complications after SG was lower in patients where reinforcement of the suture line was used (0.492), while it was higher in men (1.780). Neither difference was statistically significant [p = not significant (NS)]. After 9-24 months, 27 patients (BMI 43 +/- 8 kg/m(2)) underwent a second stage of BPD-DS (two open). Major postoperative complications were registered in eight patients (29.6%): three bleeding, four duodeno-ileal stenosis and one rhabdomyolysis. Two cases of internal hernia required laparoscopic reoperation. The reoperation rate was 1/85 (1.2%) after SG and 2/27 (7.4%) after second stage. CONCLUSIONS: Complications after SG greatly decrease after the learning curve period and can be successfully managed without need of reoperation. Suture-line reinforcement, at least selectively in the middle-upper portion of the staple line and in super-super-obese patients, is recommended to decrease the incidence of specific complications.

Abstract: BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is gaining popularity as a "per se" bariatric procedure due to its effectiveness on weight loss and comorbidity resolution. The most feared and life-threatening complication after LSG is the staple line leak and its management is still a debated issue. Aim of this paper is to analyze the incidence of leak and the treatment solutions adopted in a consecutive series of 200 LSG. METHODS: From October 2002 to November 2008, 200 patients underwent LSG. Nineteen patients (9.5%) had a body mass index (BMI) of >60 kg/m(2). A 48-Fr bougie is used to obtain an 80-120-ml gastric pouch. An oversewing running suture to reinforce the staple line was performed in the last 100 cases. The technique adopted to reinforce the staple line is a running suture taken through and through the complete stomach wall. RESULTS: Staple line leaks occurred in six patients (mean BMI 52.5; mean age 41.6 years). Leak presentation was early in three cases (first, second, and third postoperative (PO) day), late in the remaining three cases (11th, 22nd, and 30th PO day). The most common leak location was at the esophagogastric junction (five cases). Mortality was nihil. Nonoperative management (total parenteral nutrition, proton pump inhibitor, and antibiotics) was adopted in all cases. Percutaneous abdominal drainage was placed in five patients. In one case, a small fistula was successfully treated by endoscopic injection of fibrin glue only. Self-expandable covered stent was used in three cases. Complete healing of leaks was obtained in all patients (mean healing time 71 days). CONCLUSION: Nonoperative treatment (percutaneous drainage, endoscopy, stent) is feasible, safe, and effective for staple line leaks in patients undergoing LSG; furthermore, it may avoid more mutilating procedures such as total gastrectomy.

Abstract: BACKGROUND: To assess the rates and causes of reoperations in a long-term follow-up of a cohort of morbidly obese patients treated by laparoscopic adjustable gastric banding. METHODS: A retrospective study was performed to evaluate a cohort of 498 consecutive patients who had undergone laparoscopic adjustable gastric banding since 1996. The first 50 patients were excluded to avoid the learning curve bias. A perigastric technique was used until 2002 (37% of patients) and was then rapidly replaced by a pars flaccida approach. The patients who underwent band removal or port reposition/removal were considered, respectively, as having required a major or minor reoperation. RESULTS: Of the 448 patients (83% women) followed up for an average of 3.2 +/- 2.2 years, 79 (mean age 37.7 years, mean body mass index 44.0 kg/m(2)) underwent repeat surgery between 1997 and 2006. Of these procedures, 29 were minor and 59 were major reoperations. Ten patients underwent band removal after a port complication developed. The main causes were pouch dilation (37%), insufficient weight loss (20%), erosion (20%), and psychological (15%). Ten patients underwent revisional surgery. A 13% incidence of major reoperations was observed for the entire group; the rate of major and minor reoperations was 4.1 and 2.1 interventions per 100 persons-years, respectively. In patients with follow-up >5 years (perigastric technique), the cumulative incidence reached 24%. CONCLUSION: The need for a major reoperation appears to be substantial in patients who have undergone laparoscopic adjustable gastric banding, particularly when the long-term follow-up data are considered, and can occur at any point after surgery. More severe obesity (body mass index >50 kg/m(2)) seems to carry a greater risk of reoperation. These findings highlight the need for lifelong multidisciplinary management and surveillance for these patients.

Abstract: BACKGROUND: Epiphrenic diverticulum is an uncommon disorder of the distal third of the esophagus. We report the case of a 73-year-old woman with a large symptomatic esophageal epiphrenic diverticulum, diffuse nonspecific esophageal dysmotility, and a hiatal hernia. METHODS: Surgery was indicated by the patient's symptoms, the size of the diverticulum (maximum diameter 10 cm), and the associated esophageal motor disorder. Preoperative study included barium swallow, upper gastrointestinal endoscopy, and esophageal manometry. A laparoscopic transhiatal diverticulectomy associated with a Heller myotomy, hiatoplasty, and a Dor's fundoplication was carried out. The overall operative time was 230 minutes. RESULTS: No intraoperative complications occurred. Gastrografin swallow performed on postoperative day 4 did not show any signs of leakage from the staple line. The postoperative hospital stay was 5 days. The patient was readmitted 10 days after discharge complaining of fever and chest pain. A new Gastrografin swallow demonstrated a small leak from the staple line successfully treated with 3 weeks of total enteral nutrition. CONCLUSION: The laparoscopic approach to epiphrenic diverticulum is feasible. Postoperative Gastrografin swallow is not 100% sensitive in detecting small suture-line leaks if a preexisting esophageal motility disorder is present. In case of late postoperative fever and pleural effusion, a suture-line leak should be suspected. Conservative management of the small suture-line leak should be considered as an effective therapeutic option.

Abstract: BACKGROUND: Breast cancer in patients under 40 years is uncommon. Surveillance, Epidemiology and End Results (SEER) program reveals that 75% of breast tumors occur in women age > 50 years, only 6.5% in women age < 40 years, and a mere 0.6% in women age < 30 years. Breast-conserving surgery with subsequent chemo-radiotherapy has become the treatment of choice in women with breast neoplasm. CASE REPORT: Two young patients, 30 and 28 years respectively, with breast cancer. One patient with an atypical medullary breast carcinoma diagnosis, pT2 pN1 bipMx, Grade 3 Stage IIB, negative for receptors, Ki 67: 47%, cERB-2 negative; the other with an intraductal breast carcinoma, pT1c pN0 pMx, Grade 2 Stage I, negative for receptors, Ki 67: 85%, cERB-2 negative, p53 negative, Bcl-2 negative. The first patient underwent right radical mastectomy sec. Madden and axillary lymphoadenectomy in October 2001, started six cycles of adjuvant chemotherapy and radiotherapy on the right side of the chest and on axillary and supraclavicular lymph nodes area. After 2 years an ecotomography revealed small hypoechogenic nodules in the left breast. In December the patient underwent left radical mastectomy with positioning of an expander device. The histological exam revealed a not much differentiated intraductal carcinoma, pT1a N0 Mx, Stage I. After the surgical therapy, she follows another adjuvant chemotherapy. The second patient underwent left quadrantectomy with axillary limphoadenectomy in November 2004. Like the first-will follow several cycles of adjuvant chemotherapy and radiotherapy. DISCUSSION: Breast cancer in women under 40 years of age differ from breast cancer in older women in numerous clinical, pathological and biological features. The studies demonstrate that breast cancer arising in women under 40 years have a more aggressive profile than those of older patients. In both our patients family history of breast cancer was reported. That suggests a possible genetic susceptibility of these patients through BRCA1 and BRCA2 germ-line mutations. Breast conservative surgery with chemio-radiotherapy is the most commonly used treatment breast cancer, expecially in consideration of the aggressiveness of the lesions.

Abstract: BACKGROUND: We evaluated laparoscopic sleeve gastrectomy (LSG) on major co-morbidities (hypertension, type 2 diabetes / impaired glucose tolerance, obstructive sleep apnea syndrome (OSAS) and on American Society of Anesthesiologists (ASA) operative risk score in high-risk super-obese patients undergoing two-stage laparoscopic biliopancreatic diversion with duodenal switch (LBPD-DS). METHODS: 41 super-obese high-risk patients (mean BMI 57.3+/-6.5 kg/m(2), age 44.6+/-9.7 years) were entered into a prospective study (BMI > or = 60, or BMI > or = 50 with at least two severe co-morbidities, no Prader-Willi syndrome, no conversion, minimum follow-up 12 months). 9 patients had BMI > or = 60. 17 patients (41.4%) had OSAS on C-PAP therapy. In 10 patients, at least one intragastric balloon had been positioned and 4 had undergone laparoscopic adjustable gastric banding, all with unsatisfactory results. At surgery, 41.5% were classified ASA 4 and 58.5% as ASA 3 (mean ASA score 3.4+/-0.5). Patients underwent evaluation every 3 months postoperatively and were restaged at 12 months and/or before the second step. RESULTS: 60% of major co-morbidities were cured and 24% improved. Average BMI after 6 and 12 months was 44.5+/-8.1 and 40.8+/-8.5 respectively (mean follow-up 22.2+/-7.1 months). After 12 months, 57.8% of the patients were co-morbidity-free and 31.5% had only one major co-morbid condition. At restaging, 20% of patients were still classified as ASA score 4 (OSAS on C-PAP therapy). 3 patients showed BMI <30 and were co-morbidity-free 12 months after LSG. CONCLUSIONS: LSG represents a safe and effective procedure to achieve marked weight loss as well as significant reduction of major obesity-related co-morbidities. The procedure reduced the operative risk (ASA score) in super-obese patients undergoing two-stage LBPD-DS.

Abstract: BACKGROUND: Substernal goiter, also said cervico-mediastinic goiter, is a thyroid formation with cervical departure that goes beyond, with stretched neck, the superior thoracic strait for at least 3 cm and that preserves, generally, the parenchimal or fibrous connections between the cervical and thoracic portion, maintaining a direct vascularization supplied by the thyroid arteries. The prevalence of this pathology is very variable and fluctuates between 1.7% and 30% of all thyroid damages. The actual classification is provided by the radiologic examination of the chest and, above all, by the new techniques of imaging. METHODS: In the period between January 1998 and December 2003, 332 patients with thyroid pathology have been treated surgically. Forthy-five (13.5%) of these were afflicted with a cervico-mediastinic goiter. In 32/45 (71.1%) cases a total thyroidectomy has been performed by collar carving in accordance with Kocher; in 11/45 (24.5%) cases an hemithyroidectomy has been performed by collar incision; in 2/45 (4.4%) cases, already submitted to surgical intervention of isthmus-lobectomy a totalization has been performed. RESULTS: The surgical technique foresees always an anterior collar neck incision. This way of access is to prefer in the substernal goiters, both for the presence of a cervical vascularization easy to control and for the possibility, nearly always realizable, to dislocate the goiter by that way. As for what concerns the results of the histological examination, in 2/45 (4.5%) cases it has been set a diagnosis of follicular carcinoma (one of them surely invading and the other, leastly invading), in 3/45 (6.6%) cases papillary carcinoma, in 4/45 (8.8%) cases colloido-cystic goiter, in 33/45 (73.5%) cases micro-macrofollicular hyperplasia (in one of which contemporarily compromise from lymphoma of Hodgkin); in 3/45 (6.6%) cases of adenomatous hyperplasia of the thyroid. DISCUSSION: The surgical approach has been in all cases the collar neck incision in accordance to Kocher, and it has never been necessary to associate a sternotomy or thoracotomy. After the intervention, in all the patients the symptomatology tied to the mediastinal compression has disappeared. The goiter showed signs of neoplastic degeneration in 11.1% of the cases, with prevalence of the papillary carcinoma in the 6.6% and, in the remaining 4.5%, of follicular carcinoma. These data are superimposable to the data gathered in other surveys. All the patients passed the post-operating hospitalization in optimal conditions and have been discharged during the fourth post-operating day with the prescription of increasing levothyroxine doses according to the body weigh.

Abstract: BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) has become the most popular bariatric intervention in Europe. International guidelines recommended age limits for bariatric surgery of 18-60 years. The aim of this study was to evaluate the immediate results in morbidly obese patients >55 years old, treated with LAGB. METHODS: Between January 1996 and January 2004, 350 patients underwent LAGB. 24 (6.8%) were >55 years old (Group A), mean age 58.6+/-3.3 years, mean preoperative BMI 42.3+/-4.5 kg/m2. A comparative randomized analysis with 24 patients younger than age 55 years was performed (Group B: mean age 41.2+/-9.6 years, mean BMI 42.1+/-3.6 kg/m2). Baseline clinical features, operative parameters and postoperative results were evaluated. RESULTS: No perioperative complications were recorded. Conversion rate and mortality were nil. Major postoperative complications occurred in 2 patients (8.3%) from Group A (1 intragastric prosthesis migration, 1 pouch dilatation) and 2 patients (8.3%) from Group B (intragastric migrations). Reoperation was needed in 3 cases, and one erosion (Group B) is on the waiting list for removal. Minor complications: 1 port infection in each group required ambulatory port substitution; 1 intraperitoneal portcatheter disconnection (Group B) was successfully treated laparoscopically. Mean follow-up was 31.7 months (Group A) and 33.0 months (Group B). Mean postoperative BMI at 12 and 24 months was 35.9+/-4.2 and 33.8+/-4.9 for Group A, and 33.8+/-4.6 and 33.2+/-6.0 for Group B. CONCLUSION: There have been no significant differences in results between the 2 groups. LAGB has been safe and effective in patients >55 years old.

Abstract: Mesenteric fibromatosis is a proliferative fibroblastic neoplasia of the small intestine mesentery which may occur as a unique or multiple formation. Mesenteric fibromatosis represents the 8% of all desmoid neoplasm. Giant mesenteric fibromatosis is uncommon by itself (2-4 case/milion/year). Since the rarity of this tumor and the difficulties in diagnostic and therapeutic ambit, we believe it justified to describe a case of giant mesenteric fibromatosis which came to our observation.

Abstract: At present, laparoscopic splenectomy (LS) is mostly indicated in hematologic benign diseases, and in case of normal size spleen it is considered the gold standard. The technique is under a continuous evolution and several studies have demonstrated feasibility and safety of laparoscopic approach also in case of massive splenomegaly, malignant diseases and even in the treatment of selected cases traumatic lesions. LS is an advanced surgical procedure that requires a management of a full trained team involved in the preoperative preparation, surgical strategy and postoperative care. A fully comprehension of the impact of the surgical strategy is needed to plan the treatment of diseases that often are managed in a multidisciplinary setting. Indications and contraindications to surgery does not differ significantly from open traditional splenectomy, but the nature of the disease and the volume of the spleen can greatly influence the operation. A preoperative study with definition of these parameters along with a standard preparation to surgery is required. Over the years the technique has been developed and adapted to respond to emergent necessities related to those parameters. Anterior, semilateral, later and hand assisted approaches offer advantages and drawbacks that should be weighed in each case. They depend on surgeons preferences but most of the time are related to the preoperative studies, even when new surgical tools (i.e. harmonic scalpel and radiofrequency). No randomized, prospective trials have been conducted, however several studies with strong evidence have shown that less surgical trauma, intraoperative blood loss, early hospital discharge, rapid return to normal activities and better cosmesis can be obtained with a laparoscopic approach.

Abstract: Sialolithiasis of the salivary glands is a relatively rare occurrence. It is the most common cause of acute and chronic infections. Sialoliths occurs in the submandibular gland in 80% of the cases and its etiology is associated with some anatomical factors proper of it. In many cases the diagnosis is easy due to obvious clinical features but, for treatment, imaging studies are always necessary. The most of the sialoliths are usually of 5 mm in maximum diameter and all the stones over 10 mm should be reported as a sialolith of unusual size. For these reason we considered useful to report our case in the managing of a stone 13 mm placed in the submandibular gland context and its treatment by surgical resection of the entire gland.