Complications of percutaneous endoscopic gastrostomy: a surgical experience

AIM

Percutaneous endoscopic gastrostomy (PEG) is a practical and safe option to place an alimentary gastrostomy. We observed that a relevant rate of complications are related to management of PEG.

PATIENTS AND METHODS

We registered the patients treated in our Unit from September 1994 to December 2005. We placed 293 PEG (243 pts). Preferably using a tube 16 Fr, in 7 cases 18 Fr, in 21 cases 20 Fr and only in 3 cases 9 Fr. The median age was 69.8 years; ratio female:male 3:1. In 67 cases the treatment was carried out in not hospitalized patients.

RESULTS

The incidence of late and early complications is statistically higher in hospitalized patients than at home.

CONCLUSION

We think that a correct management of PEG (nurses correct information) and the experience of endoscopist and a dietician can significantly reduce the rate of complications.

Standardized laparoscopic right hemicolectomy technique for colon cancer

AIM

We analysed our experience of laparoscopic surgical treatment vs traditional surgery of right colon cancer.

METHODS

A series of 27 patients was treated from January 2001 to December 2005 out of a total of 927 surgical colorectal operations in the same period (147 with the laparoscopic approach). Inclusion and exclusion criteria are reported. We compared this group with 25 patients treated by the same surgical group with open surgery. The mean operative time, the distance from the distal margin of resection, the number of lymphnodes, the mean period of canalization and the mean hospital stay are reported.

RESULTS

In the laparoscopic group, the mean operative time was 124.8+/-36.3 min vs open surgery group of 94+/-23.6 min; the distance from the distal margin was 6.7+/-3.1 cm vs 6.4+/-2.1 cm; number of lymphnodes was 15.2+/-4.3 vs 18.7+/-2.9 nodes; and canalization 1.7+/-0.9 vs 2.7+/-0.7 days. The hospital stay was 6.8+/-1.7 vs 7.2+/-0.8 days.

CONCLUSIONS

We consider laparoscopic right colon resection a safe procedure but it needs good laparoscopic practice and the observance of inclusion criteria.

[Longo hemorrhoidopexy vs Milligan-Morgan hemorrhoidectomy: perspective analysis]

The authors analyzed their experience from January 2001 to February 2005 on 117 patients treated with Longo hemorrhoidopexy (46 cases) and Milligan-Morgan hemorroidectomy (71 cases). All the patients were observed after a week and one month after surgical procedure; at 6 months the Authors controlled 70 patients treated with Milligan-Morgan and 33 treated with Longo technique. The pain after 24 hours was the same in two groups but after a week a significative difference between two groups (p<0.05) was registered with a better quality of life for hemorrhoidopexy group. At 6 months pain during defecation was present in two cases of Longo group and in 6 cases of Milligan-Morgan group. In author's experience the Longo technique is a safe treatment with lower postsurgical pain and lower complications.

Laparoscopic technique in enlarged cystic duct

The risk of dislodgment of endoclips placed during laparoscopic cholecystectomy in enlarged cystic duct is higher with minor bile leak. From January 2000 to April 2004, we performed 1013 procedures; in 12 patients we have showed a enlarged duct ligated with 4 laparoscopic cholecystectomy endoclips after a 180 degrees rotation of the gallbladder during a retrograde cholecystectomy. We haven't registered complications and all the cases were discharged the first postoperative day. The method is safe and economically sound.

[Laparoscopic colectomy in the treatment of colon cancer: prospective study]

The Authors report their experience on laparoscopic colectomy in 38 patients treated between June 2001-September 2003 in General Surgery and Organ Transplantation Department of University of Parma, Italy. The patients were 23 male and 15 female, with average age 58.4 years. All patients were studied with TC and colonoscopy performed by the surgeon. The conversion rate was 15.8% and the average hospital stay 6.9 days (range 6-15 days). The patient's general clinical conditions and the results showed that the laparoscopic colectomy is a safe surgical option.

The size of pancreatic pseudocyst does not influence the outcome of invasive treatments

BACKGROUND

Authors generally agree that Giant Pancreatic Pseudocysts (> 10 cm) have a lower spontaneous resolution and are more difficult to treat than smaller pancreatic pseudocysts. This study was carried out on two groups of patients with larger and smaller pancreatic pseudocysts (pancreatic pseudocysts > 10 cm versus pancreatic pseudocysts < 10 cm), and aims to establish whether the size of pancreatic pseudocysts is a factor influencing treatment outcomes.

PATIENTS AND METHODS

In a retrospective study, we examined 71 patients with pancreatic pseudocysts following an episode of acute pancreatitis, which were treated in our hospital from 1980 to 2000. Forty-one (57.5%) patients had a large pancreatic pseudocyst. Most patients underwent invasive treatments: 9 (12.6%) had percutaneous drainage, 37 (52.1%) open surgery and 13 (18.3%) endoscopic cyst gastrostomy. 12 patients (16.9%) of the 71 were cured with medical therapy alone.

RESULTS

As far as the aetiology of the pancreatitis, location and number of the cysts were concerned, no major differences emerged between the two groups, although large pancreatic pseudocysts followed more severe pancreatitis (P = 0.0005). All giant pancreatic pseudocysts required invasive treatments; 40% of the pancreatic pseudocysts < 10 cm were successfully treated with medical therapy alone. No statistical differences were found regarding hospital mortality, morbidity, recurrence rate and hospital stay among the patients treated invasively.

CONCLUSIONS

Giant pancreatic pseudocysts more often require invasive therapy due to persistent symptoms or complications. Treatment outcomes do not seem to be influenced by the size of the pancreatic pseudocysts.

[Endoscopic polypectomy with the use of endoloop in giant gastric polyp: a case report]

The gastric polyps are lesions found in 2-3% of endoscopic procedures. We point out the hystologic nature of these lesions to a correct therapeutic evaluation. The endoscopic polypectomy is today safe; we report our experience in an endoscopic polypectomy with use of endoloop for a giant gastric polyp.

[Early enteral nutrition in patients treated with major surgery of the abdomen and the pelvis]

Hypercatabolism after operations has a negative influence on nutritional status, the healing process, infective complications and hospital stay. Moreover, the immune status of the patient has been shown to be equally important for septic morbidity and mortality. It is extensively accepted that in critical situations, an adequate nutritional support (enteral or parenteral) is absolutely necessary, but subjects such as the best way of feeding, the kind of nutrients to be used and the administration time are still debatable issues. Our aim was to evaluate the effectiveness (nutritional and immunological features) and clinical outcomes (septic morbidity and mortality) of total parenteral nutrition (TPN), early enteral nutrition and early enteral immunonutrition (EEN, EEIN) in 171 patients undergoing major abdominal and urological surgery for neoplastic pathology. Our prospective, randomised study showed no significant differences among the 3 nutritional supports (TPN, EEN, EEIN) with regard to restoration of normal nitrogen balance during the acute phase of surgical stress. No correlations were found in the 3 groups with immunoglobulin percentage, lymphocyte subpopulations and their functional patterns as studied by specific immunological tests. The skin test, on the other hand, seems to be more representative of the immune condition of the patients, demonstrating a faster improvement in immunological status in the EEIN group as compared to the control group. A smaller percentage of septic morbidity and mortality was found in both enteral nutritional groups (EEN and EEIN), although there was a statistically significant difference only between the TPN and EEIN groups. The hospital stay was 3.5 days shorter in enteral feeding patients (EEN, EEIN). Finally, EEN was less expensive than the other nutritional conditions, this result depending on the cost of the different materials used (infusion sets, linear filters, prepacked diets, etc.).

Endoscopic treatment of colorectal benign-appearing lesions 3 cm or larger: techniques and outcome

PURPOSE

Colonoscopic polypectomy is the preferred technique to remove the majority of polyps. The authors evaluate feasibility, safety, and the effectiveness of endoscopic treatment of colorectal benign-appearing polyps equal to or larger than 3 cm.

METHODS

Ninety-seven patients with 104 giant polyps underwent polypectomy within a nine-year period. The majority of these procedures were performed on an outpatient basis, all on unsedated patients. Gross appearance, size, location, histologic characteristics, synchronous lesions, modality, and adequacy of removal of giant polyps were analyzed. The follow-up was achieved in 89 percent of patients during a period ranging from 6 to 96 months (median, 38).

RESULTS

Of the 104 removed polyps, 75 (72 percent) were adenomatous, 2 (2 percent) were hyperplastic, and 27 (26 percent) were malignant polyps. Six patients had more than one giant polyp. Several additional smaller polyps were found in 52 patients and a synchronous cancer in 4. Twenty-one (20 percent) giant polyps were equal to or larger than 4 cm. Forty-nine were pedunculated, 20 were short-stalked, and 35 were sessile. Sixty-one polyps were excised in one piece, and forty-three were excised using a piecemeal technique. Only four complications (3.8 percent) were recorded; all cases were treated endoscopically. Fifty-eight (75 percent) adenomas and eighteen (67 percent) malignant polyps were completely excised. Surgery was performed in 7 of 27 patients (27 percent) with malignant polyps, where there was a doubtful, infiltrated margin or poorly differentiated cancer. Postpolypectomy surveillance permitted the detection and treatment of 25 metachronous or recurrent polyps and a metachronous cancer.

CONCLUSIONS

This study shows that polypectomy of giant colorectal polyps, performed by an expert endoscopist, is feasible, effective, and safe, even on an outpatient basis. The authors confirm that malignant polyps with incomplete excision, lymphovascular invasion, and poor differentiation require bowel resection. Postpolypectomy surveillance is useful for all patients who have undergone colonoscopic resection of giant adenomatous or malignant polyps.

Large hyperplastic polyps of the colon

Hyperplastic polyps are the most frequent nonneoplastic lesions of the colon. Typically, they are small sessile polyps (5 mm) located in the rectosigmoid area. Recently, they have been identified as markers of neoplastic polyps. Herein we describe four cases of large (20 mm in size) hyperplastic polyps found at our institution over a 9-year period. All four polyps were excised by endoscopic polypectomy on an outpatient basis without complications. Two polyps were in the right colon; one was pedunculated, none of them was associated with synchronous neoplastic polyps or polyposis. Up to now, follow-up in three patients has been negative for metachronous polyps. We conclude that a large hyperplastic polyp is an unexpected and rare finding, difficult to distinguish, and not related to particular colonic sites or synchronous adenomatous lesions. These polyps should be removed with a standard technique, and patients need to be followed with successive endoscopies.

Agenesis of the gallbladder found at laparoscopy in an adult patient with cardiac congenital malformation

We report a case of gallbladder agenesis in a 30-year-old woman affected by a cardiac congenital malformation who had been operated on at the age of 12. The patient was sent for laparoscopic cholecystectomy due to a preoperative diagnosis of cholelithiasis using clinical and instrumental examinations such as ultrasonography and cholangiography. During laparoscopy, the gallbladder was not found, and laparotomy with intraoperative cholangiography and ultrasonography was performed which also resulted negative. The preoperative possibility of a diagnosis of gallbladder agenesis, the association with other malformations and the steps to be taken to discover agenesis of the gallbladder are discussed.

Endoscopic preoperative colonic tattooing: a clinical and surgical complication

Endoscopic colonic tattooing is the simplest and most economic technique for identifying small lesions or polypectomy sites during open and laparoscopic surgery. Moreover, it is useful for the endoscopic follow-up of polypectomy sites. India ink is the agent of choice because of its long-lasting stain and the low risk of adverse reaction and toxicity. Very few cases of complications have been reported. We report here the case of a patient in whom colonic tattooing in preparation for surgical resection was followed by clinical complications such as fever and abdominal pain. An abscess-type inflamed pseudotumor was found at laparotomy. Histological examination revealed chronic granulomatous inflammation.

[Thrombosis of the portal vein]

The portal venous thrombosis is an infrequent disease that accounts from 0.25 to 1%. The etiopathogenesis is unknown in about one half of cases. Sometimes the thrombosis of mesenterico-portal venous axis is a complication following splenectomy, especially when the operation is performed for hematologic disease. The authors report a clinical case of chronic portal venous thrombosis widespread to superior mesenteric and splenic vein, in man 38 years old after splenectomy, in pediatric age, manifesting with gastrointestinal bleeding due to rupture of esophagogastric varices. On the basis of literature, the following were taken into consideration the incidence, the epidemiology, the aetiopathogenesis, the clinical characteristics, the diagnosis as well as the therapy of portal venous thrombosis.

[The use of early enteral nutrition (EEN) after major urologic surgery]

PURPOSE

To evaluate the efficacy of early enteral nutrition in management of patients operated by major urologic surgery and to demonstrate her advantages versus total parenteral nutrition.

MATERIALS AND METHODS

20 patients, operated by radical cystectomy and urinary diversion by ureteroileocutaneostomy, Padua ileal bladder or ureterosigmoidostomy are inserted in our study: 12 were treated by early enteral nutrition for 8 days and eight by total parenteral nutrition for the same period: in each group nutritional and immunological parameters at day -1, +3 and +7, the length of postoperatory stay, the incidence of complications, with particular respect for infections have been evaluated and correlated one to each other.

RESULTS

We have no death in each group; in the first group no gastroenteric allergy to the nutrient, less incidence of venous catheter and surgical wound infections (respectively p < 0.01 and p < 0.005); we have no significant decrease of postoperatory stay length; the effective problem in this group was the incidence of diarrhea, that in one case have made necessary the suspension of enteral nutrition. Enteral nutrition costs were about half of those of total parenteral nutrition.

CONCLUSIONS

We believe that early enteral nutrition is an effective and safe nutrition method in patients operated by major urologic surgery: with this is possible a better nutrition, that reduce the incidence of postoperative complications, mainly infections, and maybe the length of postoperatory stay (our champion is too small for statistical evaluation), that may lead to a decrease in management costs of these patients.

[Hepatic resections for primary and secondary malignant pathology of the liver: our experience]

The aim of this work is to describe the three years experience in hepatic resections for primitive and metastatic liver tumors. Of the 90 patients considered initially only 33% was admitted to radical surgical treatment, after a complete clinical and instrumental evaluation. Twenty of them was affected by liver metastases, most of which from colo-rectal cancer; ten had hepatocellular carcinoma developed on hepatic cirrhosis. All the patients affected by HCC underwent pre-operative chemoembolisation (TACE). Regional chemotherapy (TACI) was performed in synchronous metastatic tumors before surgical treatment. Surgical resection in HCC was extremely limited, removing at most 35% of total liver volume. For metastatic tumors 12 major resections and 8 minor resections was carried out. Postoperative complications occurred in 13.3%, including one death for digestive bleeding. A relationship between intraoperative risk factors, such as blood loss and transfusions was registered. The actuarial surviving rate was 47.5% for HCC and 48.3% for colo-rectal metastases at three years. Finally, preoperative CEA levels was the only factor significantly related to long term prognosis of patients affected by liver colo-rectal metastases.

Low and ultra-low rectal resection: results and prospectives

We present our experience in the treatment of middle-lower rectal cancer particularly in reference to the use of those operative techniques which permit to save the sphincteric system. From 1990 to April 1995 seventy-two patients were operated on for middle-lower rectal cancer applying the Knight-Griffen technique. Such a method has already demonstrated the characteristics of a valid anastomosis, being simple, fast and safe. The introduction of stapler devices in the rectal surgery, particularly in its middle-lower tract has significantly modified the quality of life of such patients, reducing drastically the number of colostomies. The possibility to extend the rectal resection towards the anus with colo-anal anastomosis has showed a loco-regional recurrence rate not different from abdominal-perineal resection, even though with some sphincteric troubles due to incontinence. The satisfying surgical results obtained with low and ultra-low recta resections, by now widewordly accepted, should not anyway mask the importance of an early diagnosis as the main factor governing the prognosis (i.e. the overall mortality).

Ultrastructural damage of the pulmonary endothelial cell after storage in lung preservation solutions. Comparison between Belzer and Euro-Collins solutions

The preservation of the lung for transplantation for a long period is still a problem not solved. Euro-Collins (EC) and Belzer (UW) solution are the most widely used. The aim of this work is to analyse the direct influence of both EC and UW solutions on endothelial cells of human pulmonary artery by means of an ultrastructural analysis. The arteries were obtained from 3 patients that underwent pneumonectomy and prepared with the no touch technique. The arteries were divided in 15 specimens and preserved in EC and UW solution at 4 degrees C for 6 and 10 hours. The specimens were fixed in osmic acid veronal buffer 1% and embedded in Durcupan. Ultrastructural examination was done with transmission electron microscopy (TEM) and the influence of the solutions was evaluated using a grading scale with scores ranging from 0 to 4 that express the damages of the cellular wall, mitochondria and nuclei. The data are expressed as mean +/- standard deviation (n = 5). Student's t-test was used for statistical comparison between the solutions.

RESULTS

after 6 hours of preservation in EC and UW the scores were 5.2 +/- 0.45 and 4.8 +/- 0.84 (p = 0.373) while after 10 hours were respectively 8.2 +/- 0.84 and 6.8 +/- 0.84 (p = 0.029). In conclusion our experimental model suggests that there are no significant differences between EC and UW after hypothermic 6 hours preservation while endothelial cells are better preserved after 10 hours in UW solution.

[Evaluation of the clinical efficacy of misoprostol for gastric cytoprotection in patients under treatment with NSAID after proctologic intervention]

To perform ambulatorial surgery with local anaesthetics, it is important to carry out a correct postsurgical NSAID therapy avoiding the risks induced by these drugs. Two groups of patients submitted to ambulatorial hemorrhoidectomy were enrolled in a randomized study to evaluate the safety of NSAID therapy with or without the coadministration of misoprostol, a PGE1 analogue with gastroprotective action. Aim of this study was to evaluate if misoprostol in coadministration with NSAID could permit a correct domiciliary postsurgical NSAID therapy without gastric symptoms related to the NSAID therapy. From January 1990 to December 1991, 95 patients underwent hemorrhoidectomy and were discharged with analgesic therapy: the first group (n = 45) without gastroprotective therapy, the second group (n = 50) with the coadministration of misoprostol 200 mcg bid. After 7 and 14 days of treatment patients showed the following symptoms: in the first group 13.3% of the cases showed mild epigastric pain, 8.8% moderate epigastric pain and 4.4% severe epigastric pain with heartburn; in the second group (NSAID + misoprostol) only 4% of the cases showed moderate epigastric pain. The incidence of epigastric pain was statistically higher (p < 0.05) in patients treated with NSAID alone in comparison with the group treated with NSAID + misoprostol. The results, according to international literature, show that correct gastro-protective therapy with synthetic prostaglandins (misoprostol) is necessary for patients in treatment with NSAIDs.

Colostomy plug devices: a possible new approach to the problem of incontinence

The authors report their experience in the use of the Conseal (Coloplast S.p.A., Bologna, Italy) Colostomy Plug, a new device for the regulation of continence in patients with colostomies. The devices were tested on 57 patients divided into two groups: Group A (36 patients) fit with a two-piece Conseal system and Group B (21 patients) fit with a one-piece Conseal system. All patients had the same colostomy type, and all were trained for self-irrigation. The objectives of this randomized, prospective study were to determine compliance with the different systems, to identify the advantages, and to verify the possible different applications among the population of irrigated patients. The following results were obtained. Regarding compliance: Group A's results were excellent in 22.2 percent and good in 52.7 percent of patients. Group B had better compliance than Group A (excellent in 66.6 percent and good in 19 percent of patients). Regarding controlled evacuation, continence time, and silent gas emission: in Group A, the device permitted controlled evacuations (23.8 percent of patients practicing daily washouts) with silent and odorless gas emission (100 percent of cases). In Group B, the results concerning improvement in continence were good (33.3 percent of patients) and excellent concerning the emission of flatus. Regarding the potential use of both systems in different groups of self-irrigated patients: the study has revealed the Conseal Uni-system as being ideal for patients with a well-constructed stoma, slight gas distention, and a better psychologic adaptability to larger-sized systems. In all other cases, the alternative two-piece system is more suitable, owing to the better safety it offers.

[The spastic pelvic floor syndrome: its diagnosis and treatment]

The spastic pelvic floor syndrome, caused by a paradox contraction of the sphincteric apparatus at defaecation instead of relaxing, leads to constipation with difficult evacuation. Forty patients (15 males and 25 females, average age 49 years, age range 15-78) affected by serious chronic idiopathic constipation, underwent, at our Institute, from June 1989 to September 1990, the following instrumental examinations: anal manometry; electromyography of the pelvic floor; proctogram; intestinal transit time; anorectal endoscopy; in addition, in 6 cases at risk for colorectal cancer, left colonoscopy. Fifteen patients showed dyskinetic functioning of the voluntary sphincteric apparatus. The following diagnostic methods proved to be of fundamental importance: proctogram, which revealed failure to open of the anorectal angle at defaecation (mean values: at rest 88.93 degrees +/- 6.62; at defaecation 88.93 degrees +/- 9.44); electromyography of the pelvic floor, which showed the anomalous contraction of the external anal sphincter. These patients were treated by means of an air inflated endoampullary balloon to evoke the sensation of a stool and its subsequent expulsion. The correct evacuating function was resumed definitely in 9 patients (60%); for the remaining 6 patients, regular sessions of re-education are still necessary. The spastic pelvic floor syndrome is a major cause of constipation and requires an accurate diagnostic method of investigating the correct functioning of the recto-pelvic region by means of the above-mentioned methods.(ABSTRACT TRUNCATED AT 250 WORDS)

[A subclavian vein lesion due to the positioning of a chest tube via thoracostomy]

The authors describe an unusual complication of chest tube placement: subclavian vein lesion. After a literature review concerning complications of chest tube placement, the authors conclude that associated risks may be best minimized with a strict adherence to standardized technique and management protocol.

[Endoscopic sclerotherapy of bleeding gastroduodenal ulcer. Our experience]

The Authors report their experience in the treatment of bleeding gastric and duodenal ulcers by means of endoscopic sclerotherapy. From August 1988 to December 1989, 104 patients with haematemesis and/or melena were observed at the Clinica Chirurgica Generale, Toracica e Vascolare-Università di Parma. Endoscopy, carried out in the first 24 hours, led to the diagnosis of a bleeding gastric or duodenal ulcer in 73 cases; 22 of these patients underwent emergency sclerotherapy using 1:10,000 Adrenaline in association with 1% Polydocanol. Results obtained are the following: absolute haemostasis in 20 patients (91%), and surgical intervention in the other 2 cases for renewed haemorrhage. Among patients endoscopically treated, one death (5%) was recorded. Further complications were not encountered. The Authors believe sclerotherapy is reliable and quick thus representing a considerable therapeutic advance in the treatment of gastroduodenal haemorrhage, notoriously at high death rate (8-10%).