Management of critically ill surgical patients Case reports

The acute abdomen (AA) still remains a challenging situation for surgeons. New pathological conditions have been imposed to our attention in this field in recent years. The definition of abdominal compartmental syndrome (ACS) in surgical practice and the introduction of new biological matrices, with the concepts of tension-free (TS) repair of incisional hernias, prompted us to set up new therapeutic strategies for the treatment of patients with AA. Thus we reviewed the cases of AA that we observed in recent years in which we performed a laparostomy in order to prevent or to treat an ACS. They are all cases of acute abdomen (AA), but from different origin, including chronic diseases, as in the course of inflammatory bowel disease (IBD), and acute pancreatitis. In all the cases, the open abdominal cavity was covered with a polyethylene sheet. The edges of the wound were sutured to the plastic sheet, and a traction exerted by a device that causes a negative pressure was added. This method was adopted in several cases without randomization, and resulted in excellent patient's outcomes.

KEY WORDS

Abdominal compartmental syndrome, Acute abdomen, Laparostomy.

Association of severe myoclonic epilepsy of infancy (SMEI) with probable autoimmune lymphoproliferative syndrome-variant

The paper reported on a case of severe myoclonic epilepsy of infancy (SMEI) associated with a probable autoimmune lymphoproliferative syndrome variant (Dianzani autoimmune lymphoproliferative disease) (DALD). A male patient with typical features of SMEI and a SCN1A gene variant presented in the first year of life with multiple lymph nodes, palpable liver at 2 cm from the costal margin, neutropenia, dysgammaglobulinemia, relative and sometimes absolute lymphocytosis. Subsequently the patient presented with constantly raised IgA in serum and positive antinuclear and thyroid antimicrosomal antibodies. The diagnosis of probable autoimmune lymphoproliferative syndrome was made; arthritis, skin and throat blisters, which appeared subsequently led to the diagnosis of linear IgA disease. On the basis of these unique associations, the Authors hypothesized that autoimmunity may be partly responsible of the severe epileptic symptomatology, perhaps mediated by autoantibodies against sodium channels or by accompanying cytotoxic T-lymphocytes. Corticosteroid treatment ameliorated the epilepsy and laboratory tests. Future studies will be necessary to evaluate the relevance of autoimmunity in SMEI.

Severe necrotic and septic pancreatitis. Indications to endoscopic, surgical, and nutritional therapy

Severe acute pancreatitis (SAP) management has changed over the last fifteen years, and from too aggressive behaviour, we moved to a cautious one. In every case, we can appreciate defect of extremist conceptual position. We reviewed our strategy on disease treatment, and we analyzed treatment of single cases. We collected 4 SAP cases from January 2009 to January 2010. All patients were septic, and we adopted the same approach for all of them, avoiding surgery without peritoneal infection. In all patients we placed jejumostomy and, after cleaning of septic site, we started immediate enteral nutrition (EN). Antibiotic therapy against Gram+, Gram- and antifugal drug had been started. No one died and all patients were back to an active life even if social costs are considerably high especially due to very long hospital stay.

Anti-tissue transglutaminase antibodies and EEG pattern in celiac patients on prolonged gluten-free diet

The Authors investigate the relationship between serum anti-tTG antibodies and EEG pattern in 12 celiac patients of various age on gluten-free diet for 1-10 years. In a group of 6 patients with good compliance with the diet, anti-tTG antibodies were normal in all and EEG in 5; in another group of 6 patients with poor compliance with the diet, serum anti-tTG antibodies were raised in all; EEG abnormalities of various gravity were reported in 5 patients. The concomitance of raised anti-tTG antibodies and EEG abnormalities is stressed, as possible expression of an immune-inflammatory reaction persistent in Central Nervous System.

[Acute abdomen in antiphospholipid antibodies syndrome (PAPS)]

Intestinal ischemia in antiphospholipid antibody syndrome (PAPS) could be due to arterial thrombosis from hypercoagulability. A male patient, 45 years old, was admitted to the hospital with symptoms of acute abdomen and after laparotomy he developed sepsis, right kidney infarction, jejunal ischemia, aortic thrombosis, wide necrosis of both gluteus muscles, left subclavian vein thrombosis. Our therapeutic and diagnostic strategy was delineated after demonstration of antiphospholipid antibodies. The patient was treated with total parenteral nutrition in the presence of 5 enteric fistulas with very high outflow, arterial stent insertion and daily changes of medicated dressings. Outcome was excellent with small residual deficit in walking. Continuous nutritional status monitoring and very high nitrogen supply allowed excellent healing of huge wounds and closure of enteral fistulas.

[Artificial nutrition in severe acute pancreatitis: an evolving concept]

We reviewed our series of consecutive cases of severe pancreatitis observed from 2002 to 2004, in order to verify how our actual therapeutic strategy improved prognosis. Seventeen patients with diagnosis of severe pancreatitis (SP) were admitted. On presumption of SP we inserted a naso-jejunal self-propelling feeding tube (SPT) in all but one patients, and an early enteral nutrition ( EEN ) was started. Severity of pancreatitis has been scored by APACHE II (> 8), IMRIE (> or = 3), and Balthazar Computed Tomography findings (> 30% necrosis). We always used a polymeric diet added with glutamine and fibres at initial rate of 20-30 ml/h until achievement of a full regimen of EEN, based on Harris-Benedict formula but no more than 30 kcal/kg/day. Only one patient has been submitted to surgical removal of infected necrosis. A patient died (5.8%) by dis-metabolic and septic state. From our experience we can state EEN is safe and useful to determine a favourable outcome on this dismal pathology, preserving the patient from infection, without significative alterations of nutritional index.

[Perioperative enteral nutrition]

Enteral nutrition, as demonstrated by the many published papers, is not only safer and cheaper than parenteral supply of nutrients, but modulates an exaggerated cytokine response related to surgical trauma that leads to an increase in intestinal permeability, bacterial translocation and infection. The aim of enteral nutrition is to reduce the impact of cytokines on surgical patients and the related infectious complications. Via the enteral route the nutrients can reach the bowel lumen where enterocytes draw upon their fuel, preserving the barrier effect and modulating the cytokine response. Parenteral supply does not achieve this target since the blood supply of nutrients is not as important as the luminal supply. It is only via the enteral supply route that we can preserve the barrier effect. Since the cytokine response sets in immediately after a trauma such as surgery, we implement uninterrupted enteral nutrition, which means before, during and after surgery, plus parenteral support till the full calorie intake is achieved. In a hepatic resection study, we have demonstrated that enteral nutrition modulates the interleukin-6 immunological response and shortens both the period to bowel movement resumption and the duration of hospital stay. Aggressive enteral nutrition has also been implemented in severe pancreatitis, allowing control of the disease without the onset of septic complications. The most important target is not to achieve full calorie intake rapidly, but to supply the enteric mucosa continuously with useful immuno-nutrients, such as glutamine and fibres, to preserve the barrier effect, the mucus layer, and immunological status of the mucosa. In this way we have obtained significant results in the surgical treatment of these patients, reducing the infection rate and hospital stay. New prospects may be,possible in the fight against surgical infections by adding probiotics to enteral nutrition in order to improve the microenvironment of the colon.

Surgical treatment for liver metastases from colorectal carcinoma: results of 228 patients

BACKGROUND/AIMS

Liver metastases are a very common event. Multiple choices of therapies can be used. The aim of this paper is to analyze results and methods of a single institution series of 228 consecutive patients with colorectal liver metastases.

METHODOLOGY

228 consecutive patients underwent hepatic resection for colorectal liver metastases. From different periods intraoperative ultrasound, intraoperative histological examination, locoregional intra-arterial chemotherapy, and radiofrequency thermal ablation were introduced.

RESULTS

Operative mortality was 0.9%. Mean follow-up was 29.5 months. Overall survival was 16% and 9% at 5 and 10 years. 5-year survival was 23% and 6% for patients with single and multiple metastases respectively. For patients with extrahepatic metastatic single lesion 5-year survival was 15%. From the start of intraoperative ultrasound use, 5-year survival was 9% and 27% for patients with multiple and single metastases. Five-year survival for re-resected patients was 13%. Overall survival at 1 and 3 years was 90% and 58% in patients treated with HAI and systemic chemotherapy (disease-free 70% and 47%) and 94% and 12% in patients treated with systemic chemotherapy alone after radical resection (disease-free 53% and 0%).

CONCLUSIONS

Aggressive approach, re-resections, intraoperative ultrasound staging, intra-arterial chemotherapy and radiofrequency thermal ablation are justified in multimodal therapeutic strategy of colorectal metastases and seem to improve patients' survival.

Using the Angio-Seal to Achieve Hemostasis in Prosthetic Endovascular Surgery: Report of Three Cases

At least 10% of patients who undergo bilateral aortofemoral bypass are at risk of needing a reoperation for late prosthetic thrombosis because of reduced outflow as the disease progresses. To prevent occlusion of the prostheses, we performed endovascular surgery with transprosthetic access for distal stenosis. We report our experience of using the Angio-Seal with transprosthetic access after angioplasty in three patients who had undergone bilateral aortofemoral bypass. Hemostasis was achieved in all three patients. There were no complications, such as hemorrhage, hematoma, or prosthetic infection, and all three patients were discharged within 24 h. At the 12-, 15-, and 24-month follow-up, none of the patients had any sign of recurrent claudication. Using the Angio-Seal in bilateral aortofemoral bypass provided the means of treating distal stenosis by endovascular surgery with transprosthetic access. This method is both rapid and safe, and may broaden the indications for the endovascular treatment of distal arteriopathies in patients with vascular prostheses.

A case of rapid intrahepatic dissemination of hepatocellular carcinoma after radiofrequency thermal ablation

BACKGROUND

Radiofrequency ablation (RFA) is a novel technique for the treatment of liver malignancies that is becoming increasingly more popular because of its feasibility, effectivity, repeatability, and safety. However, an increased number of complications after RFA has been reported in literature. The aim of this paper is to discuss the possible role of RFA in rapid intrahepatic spreading of hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

We treated a 66-year-old woman who had a 3.5-cm HCC with two courses of percutaneous RFA using a modified needle with seven hooks. The effectiveness of the treatment was assessed 1 month later by enhanced computed tomography.

RESULTS

Two courses of treatment were needed owing to the nodule position (close to the inferior vena cava). Computed tomography scan performed 1 month after the second RFA showed an intrahepatic arteriovenous fistula. Angiography performed after 1 month showed a rapid intrahepatic spreading of HCC.

CONCLUSIONS

Radiofrequency ablation can create an arteriovenous fistula that can facilitate migration of tumoral cells from the nodule to the hepatic portal system and rapid intrahepatic dissemination of HCC.

[What is new in fasting guidelines of surgical patients? Review of the literature]

The concept of perioperative starvation requires an update on a more balanced physiological bias. The old British dictum "nil by mouth from midnight" is a thing of the past. We need to administer food and fluids as early as possible both before both before and after surgery and to avoid or reduce hospital infections. Resumption of bowel movements is very rapid, and the patients are fed and experience no thirst and thus have better compliance during their hospital stay. Moreover, the social cost is reduced. A short review of the rules of various Associations of Anaesthetists both in Europe and the US shows that today the starvation time is reduced, and re-feeding after surgery is implemented early. For clear fluids a 2-h period before surgery without ingestion of clear fluids is enough, whilst in most countries a 6-h period of starvation for solid foods is the rule, but if proper distinctions are made between the various nutrients given to the patients, this time could be reduced to 2-3 hours.

[Current trends of artificial enteral nutrition in acute pancreatitis]

During recent years, there has been considerable debate as to the nutritional supply that needs to be established for a patient with acute pancreatitis. The main problem is still infection of the pancreatic necrosis, which has a decisive bearing on the indication for surgery and is the main cause of mortality. Infection stems from bacterial translocation from the patient's gut. Enteral nutrition with its known potential for reducing this type of infection constitutes an attempt to prevent it by preserving the enteric mucosal barrier. Today, the concept of pancreatic rest is no longer considered mandatory in the guidelines of many Surgical and Nutritional Societies, whilst enteral nutrition is the gold standard for acute pancreatitis. Assuring an integrated parenteral and enteral supply before reaching the full regimen of enteral nutrition is the most reliable policy during the early days of the disease. Moreover, outcomes being equal, enteral nutrition is cheaper than parenteral nutrition, as has been extensively demonstrated in many clinical trials in severe acute pancreatitis.

[Influence of enteral nutrition on cytokine response in resective liver surgery]

Postoperative infectious complications are nowadays a major problem in liver surgery. Better surgical outcomes with a consequent reduction in treatment and hospitalisation costs are a primary objective. The aim of this prospective, randomised study was to evaluate the cytokine response during and after portal clamping in patients undergoing liver resection and continuously fed with enteral nutrition as compared to patients receiving parenteral nutritional support. Forty patients with liver tumours were divided into two groups of 20 on the basis of the presence or absence of chronic liver disease. Furthermore, the latter group of 20 were randomised to two subgroups A and B of 10 patients on the basis of the different perioperative nutrition modalities. Group A patients were fed by so-called uninterrupted enteral nutrition, which means without interruption from the day before surgery with a nutritional solution delivered via a nasojejunal tube. The patients in group B were submitted to hepatic resection with parenteral nutritional support. Liver resection had to consist in resection of at least 30% of the parenchyma in non-cirrhotic patients or in segmental resection in cirrhotic ones. Ten milliliter blood samples were harvested before operation, and 10, 30 and 60 min after declamping and at 24 h. Interleukin 6 and a-tumour necrosis factor values were detected in blood samples. The values of C reactive protein and of prealbumin were recorded at 72 h postoperatively. We also evaluated postoperative complications, resumption of bowel movements, oral intake of nourishment, and patient discharge. Values in blood samples in the two groups showed a statistically significant difference in interleukin 6 values only after 24 h (10 min: group A 121 +/- 25.3, group B 156 +/- 31.4; after 24 h: group A 31.5 +/- 12, group B 105.1 +/- 24.1), while the a-tumour necrosis factor assay showed no significant difference between the two groups. However, there was an appreciably longer hospital stay (group A 10.9 +/- 3.1 days (range: 7-21 days), group B 13.2 +/- 2.7 days (range: 8-19 days) (P < 0.02) and a quicker resumption of bowel movements in group A. The data available show that uninterrupted enteral nutrition produces a modulation of the cytokine response following portal clamping. A lower cytokine activation cascade reduces the impact of the action of cytokines on the hepatic parenchyma with consequent enhancement of the hepatic Kupffer cell component. These factors thus substantially reduce the length of the patient's hospital stay and consequently the cost of medical care.

Treatment of recurrent hepatocellular carcinoma by radiofrequency thermal ablation

BACKGROUND AND AIMS

The treatment of choice for hepatocellular carcinoma is surgical resection. Recurrence occurs in most patients. Aggressive treatment of liver recurrence increases patients' survival, but most frequently, these patients are not suitable for surgery. The aim of this study was to analyze the indications for and results of radiofrequency thermal ablation (RFTA) in the treatment of intrahepatic recurrences of hepatocellular carcinoma after surgical resection or after RFTA.

PATIENTS AND METHODS

Seventy-nine patients with HCC were treated by RFTA (17 during laparotomy, 1 in video-laparoscopic surgery, and 61 percutaneously). Five (5/79) of these patients had recurrences after surgical resection and 1 patient had a recurrence (new lesion) after percutaneous RFTA. Fifteen of the 79 patients were treated for recurrence after transarterial chemoembolization (TACE) and, for the remaining 58 patients, RFTA was the first treatment. We used a radiofrequency generator with an expandable needle with four, seven, or nine hooks at its end. We followed up all patients with enhanced computed tomography (CT) scans and alpha-fetoprotein sampling 1 month after RFTA, and then every 4 months.

RESULTS

All 5 patients treated for recurrence after resection are alive, after a mean period of 43 months from liver resection. One patient is disease-free, 1 patient has controlled disease, and 3 patients are in progression. The patient treated for recurrence after RFTA is disease-free after 4 months.

CONCLUSIONS

We treated all our patients with intrahepatic recurrence after surgical resection by a multimodal approach. We regard RFTA as the treatment of first choice in the management of intrahepatic recurrence. For superficial tumors, surgical resection is still the best treatment. For multifocal recurrence, TACE is needed. RFTA can be useful as a complementary technique for lesions not completely treated by TACE.

Prophylaxis for septic complications in acute necrotizing pancreatitis

Because the mortality of severe pancreatitis is higher when infected necrosis supervenes, prevention of infections has become a relevant endpoint for management. The "ideal" drug should be characterized by specific activity against the bacteria known to be responsible for infection and should be able to penetrate the gland in a sufficient concentration. To date there have been eight prospective trials with antibiotics, one on selective digestive decontamination, and others with enteral nutrition. A meta-analysis regarding experiences with antimicrobial drugs reports a significant reduction in the incidence of infected necrosis and pancreatic abscesses during severe pancreatitis. In conclusion, among the several options aimed at reducing infections during necrotizing pancreatitis, the prophylactic use of antibacterial drugs is the only one to have been tested to date in several randomized studies. Strong consideration should be given to treating patients with severe pancreatitis with broadspectrum antibiotics, selective digestive decontamination, and enteral nutrition.

Lactobacillus plantarum reduces infection of pancreatic necrosis in experimental acute pancreatitis

BACKGROUND

Infection is the commonest cause of death in acute pancreatitis. Early reduction of commensal flora (particularly Lactobacillus species) and, at the same time, overgrowth of Enterobacteriaceae, especially Escherichia coli, have recently been described during acute pancreatitis. Lactobacillus plantarum has been shown to be effective in reducing the egress of endotoxin and microbial translocation in several experimental models such as chemically induced hepatitis and ulcerative colitis.

AIM

The aim of the study was to determine whether L. plantarum 299v (Lp 299v) is capable of effectively reducing microbial translocation in experimental pancreatitis.

METHODS

Acute pancreatitis was induced by isolation and ligation of the biliopancreatic duct in Lewis rats weighing 250-350 g. The animals were divided into 3 groups: group A, sham operation; group B, induction of pancreatitis and no further treatment, and group C, induction of pancreatitis + daily administration by gavage of a 5-ml/day suspension of Lp 299v at 0.5-1.0 x 10(9) bacteria/ml for 8 days, 4 days before and 4 days after induction of pancreatitis. All animals were sacrificed after 96 h. Histological studies and microbiological analyses were performed.

RESULTS

At sacrifice, 40/55 animals showed signs of severe pancreatitis. Since acute pancreatitis was the specific disease investigated, only these animals were subjected to further study. In group B, we found pathogenic micro-organisms in the mesenteric lymph nodes in 14/20 animals and in the pancreatic tissue in 10/20. The bacterial flora consisted predominantly of E. coli, Enterococcus faecalis, Pseudomonas and Proteus species. In contrast, when the animals were kept under an 'umbrella' of Lp 299v, growth of E. faecalis or E. coli were detected only in 4/20 mesenteric lymph node cultures and in 3/20 pancreatic tissue cultures.

CONCLUSIONS

Lp 299v is effective in reducing microbial translocation in experimental pancreatitis. Treatment with probiotic bacteria seems to be a promising alternative to antibiotic therapy.

[Effect of probiotic administration on colic anastomosis healing]

Colic anastomoses are still affected by a high incidence of leakage. We speculate that a supply of fibres and probiotic bacteria improves the healing of colic anastomoses due to a higher production of short-chain fatty acids. These are known to improve the anastomotic healing of colic sutures. Sixty Lewis rats, weighing from 250 g to 350 g, were divided into 6 groups. Groups A + A1 were fed with a low-fibre diet (less than 0.1%), Groups B + B1 with normal rat chow and groups C + C1 with normal rat chow + Lactobacillus plantarum 299v. Transections and re-anastomosis of the distal colon were performed. Groups A1, B1 and C1 were sacrificed after 3 days, and groups A, B, and C after 7 days. The bursting pressure of colic anastomoses was measured. All data are expressed as mean (+/- S.D.). The pH of the colon contents was evaluated by means of a fine needle plastic electrode only in groups A1, B1 and C1. The results were studied by analysis of variance followed by the Student Newman Keuls test for multiple comparisons (significance level P < 0.05). Three days postoperatively, the pH of the colic lumen was lower in animals fed with a normal diet (pH 7.1 +/- 0.3 without Lp supplementation, 6.5 +/- 0.2 with Lp supplementation) than in animals fed with a low-fibre diet (pH 8.0 +/- 0.3). Bursting pressures were significantly higher in the groups fed with fibre and fibre + Lactobacilli than in animals on a low-fibre diet, both on day 3 and day 7. On the basis of these data there seems to be no support for the belief that a supply of fibre-rich food might impair healing and promote development of anastomotic leakage. On the contrary, short-chain fatty acids and fibres would seem to facilitate the healing of colic anastomoses.

[The Bengmark tube in surgical practice and in the critically ill patient]

Enteral nutrition (EN) is increasingly used to minimize the rate of septic complications related to bacterial translocation, due to its effectiveness and low cost. Bengmark's self-propelling auto-positioning feeding tube (SPT) absorbs and uses gut motility for rapid transport to the upper small intestine, thereby allowing uninterrupted EN both in surgical and critically ill patients. We report on our experience with 175 SPTs applied over the period from December 1996 to February 2000, and analyse the safety, compliance, and indications of SPT in surgical and ICU practice. Open study: feasibility of insertion, time and rate of placement, compliance and complications related to the tube or to EN were studied. SPTs were successfully placed in 40 patients before liver resection, in 32 patients before extensive maxillo-facial surgery MFS and prior to colon resections in 10 cases. SPTs were also applied in 56 patients with acute vascular neurological diseases, 22 in pancreatic diseases and in another 15 critically ill patients. 92.5% of SPT's crossed the pylorus, while only 7.5% stopped in the stomach and 3.4% in the duodenum; 89.14% reached the first jejunal loop. The tip of the tube reached its final position within a mean period of 5.2 hours, 8% instantly and all within 24 hours. Enteral nutrition was started immediately after introduction of the tube into the stomach. The compliance was excellent, even in maxillo-facial surgery patients: only 2/76 patients (2.6%) showed poor compliance. There were no cases of aspiration pneumonia or other complications related to SPT. Polymeric nutrition was usually supplied at a starting flow rate of 45 ml/hour and rapidly increasing over the following 48 h. Eleven patients experienced diarrhoea and 6 abdominal distension, leading to a temporary reduction of the EN flow rate. Clogging of the SPT occurred in 13 patients: 7/13 were cleansed with pancreatic enzymes, but 6 had to be replaced. SPT is ideal for intensive EN and is characterised by minimal complications and excellent patient compliance.

Intraoperative and percutaneous radiofrequency thermal ablation in the treatment of hepatocellular carcinoma

AIMS AND BACKGROUND

The aim of the study was to evaluate feasibility, survival rate, complications and length of hospital stay in 47 patients with hepatocellular carcinoma (HCC) treated by radiofrequency thermal ablation (RFTA). Though the treatment of choice for HCC is surgical resection, the strong association of this disease with cirrhosis often rules out this procedure. Many investigations have been conducted in order to identify alternative therapies. Preliminary studies of radiofrequency thermal ablation have shown that the technique is effective and safe, achieving a predictable area of tumor tissue coagulative necrosis and sparing the surrounding cirrhotic parenchyma, without any significant side effects. In addition, this technique, which can be performed percutaneously, allows very short hospital stays.

PATIENTS AND METHODS

We report the results of a series of 47 cirrhotic patients with 52 HCC nodules (mean diameter 2.9 cm, range 1-6 cm) treated in our Institute between May 1997 and June 1999 by RFTA using an expandable needle with four hooks at its tip. All patients had hepatic cirrhosis (32 Child A, 13 Child B and two Child C). We treated patients with both unifocal (35 patients) and multifocal HCC (12 patients); 33 patients underwent percutaneous RFTA (54 passes), while in 14 cases RFTA was performed during laparotomy (22 passes).

RESULTS

The mean number of passes to achieve complete necrosis was 1.43 in 28 patients with unifocal HCC treated by percutaneous RFTA, 1.7 in 7 patients with unifocal HCC treated by intraoperative RFTA, 2.8 in 5 patients with multifocal HCC treated by percutaneous RFTA and 1.43 in 7 patients with multifocal HCC treated by intraoperative RFTA. No deaths related to the procedure or major complications occurred. Post-treatment dynamic CT was performed in all patients. All patients but one were followed-up for a mean period of 11.8 months (1-25 months). Six patients died during the follow-up (three Child A, two Child B and one Child C. The actuarial survival, computed by the Kaplan-Meier method, was 83% at 24 months. The mean hospital stay was 3.4 days in patients treated by percutaneous RFTA and 11.2 days in those treated by intraoperative RFTA.

CONCLUSIONS

In our opinion RFTA is an effective, safe technique capable of achieving good results in the conservative therapy of small HCC. We believe that curative ablation is possible for HCC nodules measuring up to 3 cm in diameter. Further studies of longer duration are necessary.

[Butterfly mesh for the treatment of hernia]

Incisional hernias (IH) occur with an incidence of 2 to 11% after laparotomy and represent a huge social and economical problem. Polypropylene meshes remarkably decreased the incidence of recurrence after first repair. This paper reports a personal method that allows a strong, safe and quick replacement of the abdominal wall with a double layer of polypropylene mesh. This method is reliable for IHs bigger than 4 cm. The sac and the surrounding fascia are cleaned from fat and scarred tissue: peritoneum is dissected up to at least 3 cm all around the edges of the hernial sac and under the fascia, as far as possible. Two sheets of PM, 3 cm larger than the defect, are sutured together with non-absorbable running suture (polypropylene 2-0) from the center to 2 cm from the extremities at the bank. The inferior mesh is extended and fixed under the fascia with polypropylene mattress stitches. When the peritoneum is not present, the edges of the mesh are refolded and sutured to the fascia in order to avoid trauma to the loops. The superior mesh is sutured directly onto the fascia. Closed aspiration drainage is positioned. We performed this method on 20 IHs (from 5 to 25 cm long). At 24 months follow-up we never observed recurrence. This method is similar to abdominal wall suture, and permits tension free repair.

[A probiotic as an antagonist of bacterial translocation in experimental pancreatitis]

Infection is the most common cause of death in acute pancreatitis. Earlier studies have demonstrated that early enteral nutrition decreases microbial translocation, upregulates the immune function and reduces septic complications and mortality. Lactobacillus plantarum (Lp) has been shown to be effective in reducing egress of endotoxin and microbial strain that showed very high adherence power to gut mucosa. We adopted a model of acute pancreatitis induced by isolation and ligation of biliopancreatic duct in adult Lewis rats. Three groups were studied: A. control group (sham operation); B. induced pancreatitis, no further treatment; C. Induced pancreatitis + gavage with 5 ml/day of a suspension of Lp 299 v in a dose of 0.5-1.0 x 10(9)/ml during 4 days before and 4 days after induction of pancreatitis. All animals were sacrificed after 96 hours. Histological studies and microbiological analyses were performed. Forty out of 55 animals showed signs of severe pancreatitis on sacrifice after 96 hours. Only these animals were further studied. In group A, we found only 1/20 bacteria in mesenteric nodes (MN). Pathogenic microrganisms were found in the non-treated group in MN in 14/20 and in the pancreatic tissue in 10/20. In contrast, when kept on an umbrella of Lp 299 v, only 4/20 animals demonstrated growth of enteric bacteria in MN and 3/20 in pancreatic tissue. All of these results showed a significant reduction of infection in the treated groups. In our model, Lp 299 v is effective in preventing microbial translocation in experimental pancreatitis. Treatment with probiotic bacteria, such as Lactobacillus spp, seems to be a promising alternative as problems with antibiotic-resistant bacteria seem to accumulate.

[Perforation of the esophagus during pneumatic dilatation in achalasia]

Esophageal perforation is a serious complication of pneumatic dilatation. We studied the cases of 4 patients (2 men and 2 women, mean age 58 years, range 56-62) who had surgical treatment for achalasia, two of which had had previous dilatation. The main symptoms were pain and dyspnea. Pneumomediastinum was present in all patients, pleural effusion in 2 and cervical emphysema in 1. Esophagographic results showed evidence of perforation in all four cases and gastric patches were surgically placed on the esophageal tear within 12 hours. Three patients received enteral nutrition for an average of 13 days. Mean hospital stay was 14 days. No post-operative complications were exhibited although one patient did develop gastroesophageal reflux 3 months later and underwent surgery to repair a hernia in the thorax 5 years later. Early and aggressive treatment is considered the best therapy and the gastric patch, in our opinion, is an effective and reliable technique for esophageal perforation repair in achalasia patients.

[Reconstruction technique after pancreaticoduodenectomy]

The many techniques proposed for the reconstruction of the digestive path after pancreaticoduodenectomy show the continuous research of the most anatomical and safest way to achieve the best results. Most of the technical variations concern the treatment of the pancreatic stump and are directed to prevent the pancreatic fistula that is the most frequent cause of postoperative mortality and morbidity. None of the pancreatico-digestive reconstruction ways is absolutely better than the others and we think neither the total obstruction of the Wirsung duct is the solution of the problem of the pancreatic fistula. The accuracy and technical precision, the availability to modify the technique in relationship to different anatomy and functional conditions of the pancreatic stump are essential to improve the results. To achieve this goal is decisive the experience and patients volume of the surgeon and of the institutional team.

Does extended pancreaticoduodenectomy increase operative morbidity and mortality vs. standard pancreaticoduodenectomy?

The poor prognosis of pancreatic carcinoma after resection is related to distant metastases and local recurrence that is characterized by a strong tendency to infiltrate the retroperitoneal tissue and spread along the neural plexuses and lymph nodes. Thorough clearance of these tissues around the celiac and mesenteric axes, aorta, and inferior vena cava from the diaphragm to the inferior mesenteric artery (extended pancreaticoduodenectomy may lower the rate of local recurrence, but the procedure has been criticized for its higher morbidity and mortality. Our aim was to compare extended pancreaticoduodenectomy (EPD) with standard pancreaticoduodenectomy (SPD) in terms of postoperative morbidity and mortality. Data from 47 patients who underwent either EPD (n=24) or SPD (n=23) between November 1992 and October 1995 were retrospectively analyzed. Preoperative laboratory findings, operative risk (according to the American Society of Anesthesiologists classification), type of operation (classic Whipple vs. pylorus-preserving Whipple), operative time, intraoperative blood and plasma transfusion, postoperative morbidity and mortality, and postoperative hospital stay were scrutinized. The results showed that all of the parameters considered were similar in the EPD and SPD groups (intraoperative blood transfusion 800+/-490 ml vs. 700+/-586 ml, postoperative mortality 0% vs. 4.3%, overall morbidity 45.8% vs. 47.8%, surgical morbidity 37.5% vs. 34.7%, and postoperative hospital stay 16+/-8.1 days vs. 17+/-13.1 days. These two groups differed only in the operative time, which was significantly longer for EPD than for SPD (360+/-68.9 minutes vs. 330=66.9 minutes, P=0.02). Although the operative time is increased with EPD, there does not appear to be an increase in intraoperative complications, postoperative morbidity and mortality, or postoperative hospital stay with this procedure. However, definitive confirmation of these results can only be provided by a prospective randomized study.

[Diagnosis and treatment of traumatic diaphragmatic hernia with delayed presentation]

AIM

To evaluate the clinical picture, diagnostic techniques and most appropriate treatment in traumatic diaphragmatic hernia with delayed presentation on the basis of personal experience and in the light of other published studies.

EXPERIMENTAL DESIGN

Review of cases treated.

SETTING

Patients treated in University General Surgery wards.

PATIENTS

Those patients in whom diagnosis was made some time after trauma and after the acute event were selected from a group of patients with traumatic diaphragmatic hernia.

SURGERY

All patients underwent surgery to reduce hernia and repair the diaphragmatic lesion.

MEASUREMENTS

All clinical findings were examined together with the tests performed and the type of treatment carried out.

RESULTS

The diagnosis was made between 3 months and 3 years after the injury. Three patients presented manifest symptoms of high intestinal occlusion on entry. Radiological alterations were present in standard chest X-rays in all patients and digestive tract contrast radiography was positive for the diagnosis of hernia in 3 out of 4 cases in which it was performed; a preoperative diagnosis of hernia was obtained in 4 cases. Patients were operated using a thoracotomy (3 cases) or combined laparothoracotomy access (2 cases); the diaphragmatic lesion, localised in all cases in the cupula of the left hemidiaphragm, was repaired using separate sutures in non-reabsorbable material without the use of grafts. One patient died postoperatively owing to septic complications.

CONCLUSIONS

traumatic diaphragmatic hernia with delayed presentation involves severe complications that increase morbidity and operating mortality.

[Rupture of the diaphragm caused by closed trauma. Case contributions and review of the literature]

AIM

Retrospective evaluation of 19 diaphragmatic ruptures due to blunt trauma.

MATERIALS AND METHODS

We collected all patients with thoracic and/or abdominal blunt trauma who were admitted to the department of surgery (Clinica Chirurgica and Chirurgia generale C) from 1970 to 1995. We selected patients with ascertained diaphragmatic rupture.

RESULTS

We considered 17 cases of TDR (15 males and 4 females). Mean age was 38 years (range 16-67). Radiologic findings were consistent with TDR in 10 cases out of 17 (58.8%). Right hemidiaphragm was injured in 6 cases (31.6%). 10 patients (52.6%) presented at operation with intrathoracic visceral herniation. 8 patients underwent laparotomy, 7 both laparotomy and thoracotomy, 4 thoracotomy alone. Perioperative mortality was 15.7% (3 patients).

DISCUSSION AND CONCLUSIONS

The clinical features were complicated by a large number of associated lesions; radiologic diagnosis is comparatively easy if visceral herniation into the thorax is present, repeated radiologic examinations facilitate diagnosis. The surgical access is determined by concomitant associated injuries which may require urgent operation.

Delayed traumatic hernia of the diaphragm presenting with hypertensive pneumothorax. Case report and review of the literature

The diagnosis of traumatic hernia of the diaphragm can be obtained at the time of injury or months-years after the trauma. The Authors report a case of traumatic hernia of the diaphragm, diagnosed 3 years after a blunt thoracic trauma in a 47-year-old man. The patient was admitted to the hospital for a pneumothorax caused by perforation of the herniated colon. He underwent colonic resection and reduction of the herniated viscera but unfortunately he died of septic shock on the 40th postoperative day. Pneumothorax is a very rare complication of traumatic diaphragmatic hernia and few cases are reported in literature. The diagnosis in the delayed phase is not easy since the correlation with the trauma is not always clear.

[Postoperative ischemic ileocolitis in the elderly. Suggested therapy with intraluminal administration of oxygen and glutamine]

Ischaemic ileocolitis in postoperative course of major abdominal surgery is a great challenge for the surgeon: the mortality rate is very high, and therapeutic choices are poor. In the elderly patients ischaemic bleeding ileocolitis is often determined by low flow: sepsis and cytologic damage are primed by activation of endotoxins and chemical mediators, and bacterial translocation could develop across intestinal wall. In our case the patient (male, caucasian, 68 years old) underwent bilio-hepatic resection for hilar cholangiocarcinoma. In the postoperative period continuous enteric haemorrhage was determined by an ischaemic ileocolitis demonstrated by colonoscopy. Abdominal angiography did not show stenosis or occlusion of mesenteric vessels. We administered dopamine and dobutamine as vasodilator drugs for splanchnic circulation without any positive response. Surgical removal of the colon was unsuccessful to stop bleeding. ileostomy and sigmostomy were performed. Histologic samples of the specimen showed ischaemic ileocolitis. After a few days the patient bled again. As last therapeutic choice, we bubbled oxygen in a solution of L-glutamin 500 mml (3 liters/min for 5 min). We administered 500 mml of this solution three times a day by enteral sond, and 100 mml twice a day by sigmoidostomy and endoluminal oxygenation was performed twice a day (1l/min for 1-2 minutes) under continuous control. Bleeding was reducing during the next five days, until stopping. If glutamine and O2 can be considered the fuel of enterocytes, we hypothesized endoluminal oxygenation and glutamine enteral supply of the small intestine could feeding enterocytes, until a complete restoration of enteral mucosa and stopping of the haemorrhage.

[Terminal ballistics. 1]

We have chosen to conceive of terminal ballistics as a violent and extremely rapid confrontation between two forms of resistance before the final state of rest is reached. This definition, which cannot help but don the admittedly loud and outlandish garb of physics, is the most promising for the purposes of biological interpretation. The main characters on this stage are two, but only one of these really plays the lead, namely the human target, which acts out the basic roles inherent in its physical make-up; the other, the bullet, remains a background figure, frozen in its walk-on part, and ready for the next performance. This modus operandi, which is no simplification, but rather an academic necessity, enables us to focus on images which stand out more clearly as a result of an intensive macroscopic spotlight which brings out the features of the individual phenomena, broken down into a succession of close-ups, and subtracts them from the cold physical nature of this or that form of inert matter, which here is merely an occasional, disagreeable witness, or even more, a standing from time to time for but one of the infinite facets of the biological composite being. Here, then, faced with a kind of exploded macrophotograph of a complex kaleidoscope, we see the animal universe, of which we capture so far the plasticity, the subdivisibility, the anisotropy and the cavitation.

[Biomechanical-clinical interpretation of firearm wounds. General problems. VIII. Propedeutic ABC of terminal ballistics]

The Authors, consistent with their aim to compare and contrast the two protagonists of bullet wounds, namely the bullet and its soft human target, delineating their respective profiles, strengths and weaknesses, feel obliged to dwell at some length on the most frequently pathogenetic regulation firearms. Up until the early twentieth century bullet wounds could be generically classified among the forms of open traumatism, but with the advent of high-speed bullets they have come to take on a unique profile of their own, setting against the old permanent cavity due to mechanical insult a new type of transitory ghost, the definition of which as a cavity would merely be an oversimplification in theoretical terms. Can we really attribute this somewhat privileged dimension to bullet wounds today or must we relegate them once again to the sphere of mechanical traumatisms, albeit with a new inflammatory key to their interpretation, making the most in this sense of the contribution provided by the speed of the bullet? The literature is abundant, but uncertain; we intend to attempt an answer to this tricky question in the following pages, devoted more properly to terminal ballistics. Undoubtedly, the new speeds have had a substantial impact on the wounds inflicted upon the soft target, but the streamlining of the jacket has modified and even offset the results, giving rise to the unexpectedly humanitarian bullet, later subject to reappraisal in military quarters as tactically more efficient, because it obliges the enemy to employ greater resources for recovering, assisting and healing the wounded. We can safely claim that ballistic science in the field of light or portable firearms is experiencing a contradiction between the speed of the bullet and the streamlining of the jacket which makes this speed possible, but which undermines the efficacy of the often unconfessable results. Short-barrelled firearms, which on account of their defensive role, the alibi of their problematic access to speed, and their characteristic use as "last-chance" weapons, are less subject to international constraints and enjoy an extensive civilian market with specific claims to stopping power, thus become the true witnesses to a reality no different to the one Dum-Dum interpreted: the field of modern regulation firearms is shrouded in similar doubts, strengthened by the increasingly short barrels of the weapons, remedies and temptations, with, in addition, the increasingly precarious nature of the human element behind the firearm.(ABSTRACT TRUNCATED AT 400 WORDS)

[Biomechanical-clinical interpretation of firearm wounds. General problems. IX. Propedeutic ABC of terminal ballistics]

In this chapter, the leading role is played by the mechanical-thermal-ballistic device, issued as a long-barrelled regulation firearm to modern armies. The most accurate description of this type of firearm and its present and possible future development seeks to be in line with the objective comparison between the biological matter and the mechanical material, which constitutes the essential basis for any optimal nosological, aetiological, or pathogenetic classification of bullet wounds. We should not forget that the advent of the M 16 A 1 has aroused great technical interest, particularly--though not only--as regards the hydroshock aspect, and that the technological developments in future can hardly fail to increasingly confirm the singular nature of bullet wounds, which refuse to be encompassed merely within the somewhat limited sphere of their strictly local effects, but carry a broader significance in a critical context open to further verification in the future. There can be no denying that this unique nature of modern bullet wounds makes them ideal candidates bearing witness to a new interpretation of traumatism, which at present is only in its infancy.

[Biomechanical and clinical interpretation of firearm wounds. General problems. VII. Propedeutic ABC of terminal ballistics]

The parallelism breaks down, and the bullet, which is now the subject, speeds towards the object, the body, its target. The ideal vantage point for capturing the moment of impact is the nose. We set up our station here, imaging that were are a kind of TV camera recording with cold objectivity, in slow motion, instant by instant, the marks and the impact made by the hard body on its soft target.

[Terminal ballistics. 2. (The skin)]

It goes without saying that, at first glance, it is the velocity with which the fired bullet pierces the solid target and perhaps even penetrates it that bears witness to the efficiency of a firearm. Prior to the advent of ceramic and composite materials, iron and its clone, steel, provided the most satisfactory and most coveted evidence as a test material in both the positive and negative senses. It the biological field, wood and deal in particular were for decades the only witnesses, alongside tests in cadavers, which, despite obvious reservations, provided us with a wealth of data, much of which is still regarded today as among the mainstays of forensic didactics. Prominent among these, in terms of clinical importance, in that they mark the start of the bullet wound, are the velocity and energy thresholds per presentation area. The bullet, after overcoming the barrier of the skin, continues on its course through the soft tissues, and there leaves its most authentic and singular mark as a bullet wound.

[Biomechanical-clinical interpretation of firearm wounds. General problems. XI. Propedeutic ABC of terminal ballistics]

The pathogenetic potentiality of firearms differs in relation to whether we are dealing with rifled long-barrelled weapons, handguns, or smooth-bore long-barrelled guns. Up until a few years ago, the tissue-damaging effect, at least in the modern warfare context, of short-barrelled or smooth-bore long-barrelled firearms, was thoroughly negligible; today, however, their impact, as causes of wounds and death, is steadily increasing, and for the first time small bullets designed for low-cost military training are also coming to play a primary role on the battlefield. At the same time short-gun bullets are appearing which, which in the name of "stopping power" seem to contradict the very definition of a handgun. The smooth-bore long-barrelled gun, in turn, is casting off the anti-humanitarian image of the trench gun to play the more suggestive ordinance role of the grenadiercumhunter.

[Terminal ballistics. 3]

This brief chapter, focusing essentially on a single topic, has been written in homage to Emile Theodor Kocker, a masterful exponent of the art of surgery and founder of the culture of terminal ballistics. For most of the literature we are indebted to Fackler and Dougherty, who, with the particular grasp, and fair of historians, act as guides on a trial which is only apparently retrograde, but which actually bears eloquent witness to the fact that even in the most physically tangible of arts, namely the art of surgery, inspired curiosity may help us to go well beyond the limits of our day and age. This chapter is also dedicated to the memory of another great surgeon, Vittorio Pettinari, who for one of the authors was an incomparable mentor and past-master of such curiosity.

[Biomechanical-clinical interpretation of firearm wounds. General problems. X. Propedeutic ABC of terminal ballistics]

Any discussion of firearms which failed to take due account of the complex interaction between the weapon and its user would be missing the point. This interaction takes on a major role, particularly in the case of military ordinance weapons; their "optimal" use demands the maximum control of this interaction, which is of the utmost importance for the tactical role of the soldier-weapon system. The use of the latest long-barrelled ordinance firearms is more acceptable precisely because of their smaller calibre (which also means reduced interaction with the user). Today the traditional primacy of the long-barrelled weapon (now getting progressively shorter) is threatened by the short-barrelled gun cartridge, which we have seen used on an extensively scale in recent militia warfare. Paradoxically, it is precisely this cartridge, whose main shortcoming is its low propellant content (and thus reduced kinetic energy) which is expected to provide the kind of killing performance capable of snuffing out even "the dead man's last five seconds".

[Propedeutic to general problems of the hypothesis of a new "open" interpretation of firearm wounds of soft tissues]

On the basis of a review of the literature and their own personal knowledge and experience, the authors define the state of the art regarding a point of considerable importance, namely the leaky gut hypothesis. Taking gunshot wounds in soft tissues as their starting point, they believe that such lesions are among the most suitable for illustrating the chain of events which translates an entirely local pathology--admittedly serious--into a systemic pathology carrying a very severe prognosis, if the physician is unable to interrupt this clinical course.

[Treatment of pain in advanced-stage intra-abdominal neoplasms]

Different types of pain are present in far advanced intra-abdominal cancer, sometimes in the same site too. An accurate semeiological analysis of pain is important because different types of pain often differently respond to the available therapeutical tools. In this paper the results and the complications of the most important methods of pain management in far advanced intra-abdominal cancer are examined. Analysis of the data reveals that the association of more methods, pharmacological and non, should be a rule rather than the exception.

[Biomechanical and clinical interpretation of firearm wounds. General problems. VI. Propedeutic ABC of terminal ballistics]

Any lengthy and properly structured propedeutic ABC of terminal ballistics must necessarily embrace a comparison between the two main protagonists of gunshot wounds. It is almost a specular, yet distorted image of the ritual act consumed by the larger mammals, not proud of their mutual aggression, but the conformation between mechanics and biology, or between kilogram-metres and life. The two types of physical entity brought together through the unique agency of a new language--both biological and mechanical, but necessarily halting and inadequate--stand out like two parallel lines opposite one another, displaying their respective profiles and most intimate structures. One can take this as far as the biological paradox of the clash between the dimension of power and the chance quality of life.

Contribution of CT to characterization of focal nodular hyperplasia of the liver

Our personal series of 20 cases of focal nodular hyperplasia (FNH) of the liver is presented. All lesions were studied with computed tomography (CT), 16 of which with surgical control. Retrospective evaluation of the CT features of the identified FNH, along with those of five hepatocellular adenomas (HCA) and 30 hepatocellular carcinomas (HCC), allowed the definition of specific patterns leading to a correct characterization of FNH in 78% of cases. This greatly reduced the diagnostic errors, with the sole exception of patients with fatty liver in whom nuclear medicine may eventually provide a correct characterization. Fine-needle biopsy is thus only necessary in the dubious cases. A precise diagnostic workup of FNH is necessary, since it may avoid the surgical intervention.

[Anti-gliadin antibodies in the diagnosis and follow-up of celiac disease]

The study assessed the value of anti-gliadin antibodies (AGA) as a diagnostic test for celiac disease (CD) by examining 219 children: 57 were affected by malabsorption syndrome and underwent the first duodenojejunal biopsy; 83 underwent a secondary diagnostic phase for CD; 44 underwent a challenge test; 35 controls. Duodenojejunal biopsy was performed in all subjects in the three stages of diagnosis for CD. By comparing AGA levels and on the basis of histological tests of duodenojejunal mucosa it is possible to confirm the reliability of the method as a screening test for use in subjects whose clinical symptoms suggest CD. AGA are however less reliable in the second and third stages, that is to say in the follow-up of CD, since they do not always reflect the conditions of intestinal mucosa.