Epigastrium: unusual site of incisional hernia from a 5 mm trocar

The observation of an unusual case of incisional hernia, found in the epigastric zone at the site of a 5 mm trocar incision for a cholecystectomy, has caused us to describe it and to review the literature. C.A. is a male aged 59 and He came to our attention in 2014, complaining about the presence, for about three months, a swelling in the epigastric area, without occlusive symptoms. An objective examination showed an epigastric mass at the scar of the insertion site of a 5mm trocar during the cholecystectomy operation. The patient was hospitalized and underwent traditional surgery: incision at the scar; isolation of the extruded fatty tissue, which had no sac, identified as part of the round ligament, herniated through the residual incision of the previous operation. Based on experience acquired it is useful to make careful sutures of 5 mm incisions repairing peritoneal laceration.

KEY WORDS

Epigastrium, General surgery, Incisional hernia, Laparoscopy, Trocar.

Post-thyroidectomy hypoparathyroidism, what should we keep in mind?

AIM

Hypoparathyroidism and the resulting hypocalcemia is a common iatrogenic complication following surgical procedures to the neck, and commonly, to the thyroid gland. The aim of this study was to review the available literature to summarize current data related to the development of hypoparathyroidism after thyroid surgery.

MATERIALS AND METHODS

An analysis of the surgical literature was performed using the search engine EMBASE and PubMed with particular reference to the principal risk factors related to the post-thyroid surgery hypoparathyroidism. Moreover the medical records of 345 patients, who underwent thyroid surgery at the Section of Endocrine Surgery - Department of Medical and Surgical Sciences, Advanced Technologies "G. Ingrassia" University of Catania, Italy, were also examined.

RESULTS

The definition of hypoparathyroidism varies widely in literature. There is a wide range of reported incidences of transient and permanent postoperative hypoparathyroidism in literature. Extensive surgery, malignant disease and concomitant central and/or lateral neck dissection, autoimmune or Grave's' disease and re-operation represent the most recognized risk factors. A wide consensus exists about transplanting a parathyroid gland when it seems to be nonviable.

DISCUSSION

Although many improvements have been done in surgical technique, hypoparathyroidism seems to be one of the most common complication after total thyroidectomy. In this study we discuss the diagnosis methods and the importance of its early prediction regardless it is transient or permanent. Recovery time is under discussion: some author consider a gland permanent injury if restoring functionality does not occur within 6 months other 12 months. To assess the parathyroid gland function some authors have been using postoperative PTH level as a useful tool for predicting hypocalcemia.

CONCLUSIONS

Many efforts are required to address the problem of a consensus on best define these complications. An early low PTH level after total thyroidectomy is associated with a high risk of permanent hypoparathyroidism and normal levels usually exclude long-term parathyroid glands dysfunction. However, the cost of the PTH assay may limit its widespread application. Despite the reassuring presence of new therapeutic strategies, intra-operative preservation of the parathyroid glands is the best prophylaxis to avoid postoperative hypocalcemia after total thyroidectomy.

KEY WORDS

Hypoparathyroidism, Thyroid surgery.

Non-mycotic anastomotic pseudoaneurysm of renal allograft artery. Case Report

Vascular complications after kidney transplantation are uncommon, and in most cases they present in the early post-transplant period. Anastomotic pseudo-aneurysms usually involve the renal transplant artery anastomosis and in most cases are the consequence of a mycotic contamination during organ recovery or handling of the graft. We report the case of a 61 year-old woman, who presented, eight months after successful kidney transplantation from a deceased donor, with mild pain in the right iliac fossa. Graft sonography and computed tomography scan demonstrated a 33-mm pseudo-aneurysm of the transplant renal artery at the anastomotic site with the external iliac artery. The patient underwent an emergent surgical intervention with resection of the pseudo-aneurysm. Renal transplant artery was re-perfused with a by-pass with the internal iliac artery, while the common iliac artery was revascularized through an autologous vein by-pass between the proximal external iliac artery and the common femoral artery. Postoperative course was complicated by inguinal lymphorrea, with complete resolution on postoperative day 22. Histopathologic examination of the pseudo-aneurysm wall did not reveal any sign of mycotic infection. At 6-month follow-up, graft function was stable and graft sonography demonstrated the patency of iliac-femoral by-pass and a normal renal graft perfusion. In conclusion, pseudo-aneurysm of the renal transplant artery is a rare but potentially life-threatening complication of kidney transplantation, occurring even in the late post-transplant period. Surgical resection of the pseudo-aneurysm, although challenging, may be a valuable option for definitive treatment of the pseudo-aneurysm, while preserving the renal graft function.

KEY WORDS

Aneurysm, Deceased donor, Kidney transplantation, Pseudo-aneurysm, Renal artery Surgery, Vascular complications.

Physiopathology and clinical considerations of laparoscopic surgery in the elderly

OBJECTIVE

The marked improvements in medical technology and healthcare, lead an increasing number of elderly patients to take advantage of even complex surgical. Recently, laparoscopic surgery has been accepted as a minimally invasive treatment to reduce the morbidity after conventional surgery, and a number of studies have demonstrated the feasibility of laparoscopy with significant advantages also in the elderly. On the other side, the laparoscopic procedure has some drawbacks, including prolonged operation time and impact of carbon dioxide pneumoperitoneum on circulatory and respiratory dynamics. This paper will review the physiopathological implications of laparoscopy, as well as the current literature concerning the most common laparoscopic procedures that are increasingly performed in elderly patients.

MATERIALS AND METHODS

A systematic review of the current literature was performed using the search engines EMBASE and PubMed to identify all studies reporting the physiopathological implications of laparoscopy in the elderly. The MeSH search terms used were "laparoscopy in the elderly", "physiopathology of laparoscopy", and "pneumoperitoneum". Multiple combinations of the keywords and MeSH terms were used with particular reference to elderly patients.

RESULTS

Although laparoscopy is minimally invasive in its dissection techniques, the increased physiologic demands present particular challenges among elderly patients.

CONCLUSIONS

Laparoscopy and its safety in the elderly patients remains a challenge and the evaluation of this approach is therefore mandatory. Although many studies have demonstrated the applicability and advantages of the laparoscopy also in the geriatric population, with low rates of morbidity and mortality, in elderly patients undergoing general surgical procedures the physiologic demands of laparoscopy should be carefully considered.

First Case Report of Acute Renal Failure After Mesh-Plug Inguinal Hernia Repair in a Kidney Transplant Recipient

Acute renal failure due to ureter compression after a mesh-plug inguinal repair in a kidney transplant recipient has not been previously reported to our knowledge. A 62-year-old man, who successfully underwent kidney transplantation from a deceased donor 6 years earlier, was admitted for elective repair of a direct inguinal hernia. The patient underwent an open mesh-plug repair of the inguinal hernia with placement of a plug in the preperitoneal space. We did not observe the transplanted ureter and bladder during dissection of the inguinal canal. Immediately after surgery, the patient became anuric, and a graft sonography demonstrated massive hydronephrosis. The serum creatinine level increased rapidly, and the patient underwent an emergency reoperation 8 hours later. During surgery, we did not identify the ureter but, immediately after plug removal, urine output increased progressively. We completed the hernia repair using the standard technique, without plug interposition, and the postoperative course was uneventful with complete resolution of graft dysfunction 3 days later. Furthermore, we reviewed the clinical features of complications related to inguinal hernia surgery. An increased risk of urological complications was reported recently in patients with a previous prosthetic hernia repair undergoing kidney transplantation, mainly due to the mesh adhesion to surrounding structures, making the extraperitoneal dissection during the transplant surgery very challenging. Moreover, older male kidney transplant recipients undergoing an inguinal hernia repair may be at higher risk of graft dysfunction due to inguinal herniation of a transplanted ureter. Mesh-plug inguinal hernia repair is a safe surgical technique, but this unique case suggests that kidney transplant recipients with inguinal hernia may be at higher risk of serious urological complications. Surgeons must be aware of the graft and ureter position before proceeding with hernia repair. A prompt diagnosis with graft sonography and abdominal computed tomography scan and emergency surgery may avoid the need for nephrostomy and may resolve graft dysfunction more rapidly.

Synchronous ileal neuroendocrine tumor: diagnosis and treatment. A case report and review of the literature

INTRODUCTION

The majority of neuroendocrine tumors (NET) are located in the gastrointestinal tract (67.5%) and in the bronchopulmonary (25.3%).

CASE REPORT

CA, female, 42 years old, profuse diarrhea about two months, cramping for increased peristalsis, vomiting and weight loss. The patient, diagnosed with ileal neuroendocrine tumor, by colonoscopy with biopsy of lesion, therefore came in our unit to be subjected to surgical therapy. Plasma assay Chromogranin A was performed: 160 ng / ml (nv: 15-100 ng / ml). The patient underwent surgery of right hemicolectomy.

DISCUSSION

Neuroendocrine tumors although are rare diseases, have an increasing impact, probably by virtue of improved diagnostic methods. In case of profuse diarrhea should be suspected a neuroendocrine tumor. Certainly the diagnosis of certainty is given by histological examination (biopsy or resected nodule).

CONCLUSION

After surgical excision is necessary to perform the follow-up of chromogranin A, and, if not executed, perform nuclear medicine examinations such as Octreoscan and PET.

KEY-WORDS

Chromogranin A, Neuroendocrine tumor, Octreoscan.

Laparoscopic cholecystectomy and concomitant diseases Effectiveness of the single step treatment

AIM

With the expanded use of laparoscopy, the options for combined surgical procedures have also increased and can be a modality of choice for coexisting pathologies in the abdomen. In our study we evaluate the safety and the efficacy of a number of surgical procedures combined with laparoscopic cholecystectomy and report our results.

MATERIAL OF STUDY

We conducted a retrospective study on 19 consecutive patients who underwent laparoscopic cholecystectomy simultaneously with other operations.

RESULTS

No conversion to open surgery was necessary. Postoperative complications occurred in three patients. The mean postoperative hospital stay was 3 days (range 2-4) and a few patients required more than 48 hours postoperative hospitalization. The perioperative mortality rate was 0%.

DISCUSSION

Concomitant surgical procedures result in longer operating time, but certainly the patient benefits from a single exposure to anesthesia, single hospital stay, and single period of absence from work.

CONCLUSIONS

Combining surgeries does not significantly alter the outcome of the procedure, proved to be a safe and feasible and present an interesting alternative to two separate operations. Prospective studies with long-term follow-up are required to better understand the implications of simultaneous operations.

KEY WORDS

Laparoscopic combined procedures, Minimally invasive surgery.

Appendix stump closure with endoloop in laparoscopic appendectomy

AIM

To address the question of the appendix stump closure in laparoscopic appendectomy and evaluate the incidence of intraoperative and postoperative complications after application of endoloops.

MATERIAL OF STUDY

Data included age and gender, ASA score, co-morbid illness, prior abdominal surgery, clinical presentation, operative time, conversion rate and reasons for conversion, postoperative morbidity and mortality rates, pathologic diagnosis, and length of hospital stay.

RESULTS

Laparoscopic appendectomy with stump closure using endoloops was performed in 35 consecutive patients. Postoperative complications occurred in three patients. The mean postoperative hospital stay was 2 days. The perioperative mortality rate was 0%.

DISCUSSION

The treatment of appendiceal stump closure in laparoscopic appendectomy represents the main technical aspect and it is an important step for its potentially serious postoperative complications due from an inappropriate management. Endostapling, hem-o-lok clips and intracorporeal knotting are the most commonly recommended methods. All alternatives have advantages and disadvantages against the different clinical stages of acute appendicitis, and it should be noted that the different forms of appendiceal stump closure have never been assessed in prospective randomized studies.

CONCLUSIONS

From our experience we can confirm that the endoloop can be safely used and should be the preferred modality in treating the appendiceal stump, especially for low-grade appendicitis. Alternative methods should be used in case of phlegmonous or gangrenous appendicitis, perityphlitic abscess or simultaneous operation for Meckel's diverticulum. Knowledge about and appropriate use of all of them are important for a safe and more cost-effective procedure.

KEY WORDS

Appendiceal stump closure, Laparoscopic appendectomy.

The role of obesity in kidney transplantation outcome

BACKGROUND

The number of obese kidney transplant candidates has been growing. However, there are conflicting results regarding to the effect of obesity on kidney transplantation outcome. The aim of this study was to investigate the association between the body mass index (BMI) and graft survival by using continuous versus categoric BMI values as an independent risk factor in renal transplantation.

METHODS

We retrospectively reviewed 376 kidney transplant recipients to evaluate graft and patient survivals between normal-weight, overweight, and obese patients at the time of transplantation, considering BMI as a categoric variable.

RESULTS

Obese patients were more likely to be male and older than normal-weight recipients (P = .021; P = .002; respectively). Graft loss was significantly higher among obese compared with nonobese recipients. Obese patients displayed significantly lower survival compared with nonobese subjects at 1 year (76.9% vs 35.3%; P = .024) and 3 years (46.2% vs 11.8%; P = .035).

CONCLUSIONS

Obesity may represent an independent risk factor for graft loss and patient death. Careful patient selection with pretransplantation weight reduction is mandatory to reduce the rate of early posttransplantation complications and to improve long-term outcomes.

Can laparoscopic cholecystectomy be safety performed in the elderly?

AIM

To assess the suitability of laparoscopic cholecystectomy in elderly patients, although early reports have questioned the efficacy of this procedure in that patient group.

MATERIAL OF STUDY

Retrospective study evaluating the medical records of the elderly patients who underwent laparoscopic cholecystectomy in our surgical unit. Data included age and gender, American Society of Anesthesiologists (ASA) score, comorbid illness, prior abdominal surgery, presentation, operative time, conversion rate, postoperative morbidity, and mortality rates and length of hospital stay.

RESULTS

Fifty consecutive patients age 70 or older who underwent laparoscopic cholecystectomy were studied Postoperative complications occurred in five patients.

DISCUSSION

Many Studies have shown that the incidence of complicated gallstone disease in the elderly is higher when compared with that of younger patients and gallbladder disease is particularly virulent in the elderly, with high rate of acute cholecystitis, biliary tract disease, increased morbidity, and prolonged hospital stay. This poor outcome has been attributed to the presence of severe co-morbid factors associated with the aging process. Compared to open cholecystectomy, laparoscopic cholecystectomy may cause less postoperative depression of respiratory function and cell-mediated immunity. In our study perioperative mortality rate was 0%.

CONCLUSIONS

Laparoscopic cholecystectomy in elderly patients is a relatively safe procedure that can be accomplished with acceptable low morbidity. In this series of geriatric patients, there was no evidence of any increased risk for conversion to an open cholecystectomy, delayed recovery, or prolonged hospitalization.

Contamination of preservation fluid in kidney transplantation: single-center analysis

INTRODUCTION

Contamination of preservation fluid is common, with a reported incidence of 2.2% to 28.0%, and may be a major cause of early morbidity after transplantation. Herein, we report our experience with routine examination of preservation fluid collected just before implantation, focusing on the rate of contamination and the clinical consequences to recipients.

MATERIALS AND METHODS

We analyzed 62 samples of preservation fluid for microbial and fungal contamination.

RESULTS

Twenty-four samples (38.7%) were contaminated with at least 1 organism. Bacterial contamination alone was observed in 18 samples; all patients received prophylactic treatment with intravenous piperacillin/tazobactam, 4.5 g/d for 10 days, without clinical sequelae. Six samples were contaminated with Candida species; all patients received prophylactic treatment with fluconazole, 100 mg/d for 3 months. One patient developed reversible acute renal failure due to ureteral obstruction by fungus balls at 30 days after transplantation.

CONCLUSION

Contamination of preservation fluid occurs frequently after kidney transplantation. Bacterial contamination evolved without symptoms in most patients treated with prophylactic antibiotic therapy. Fungal contamination may be potentially life-threatening. However, graft nephrectomy is not mandatory if the involved Candida species is identified correctly and appropriate antifungal therapy is rapidly prescribed.

Differentiated thyroid cancer: role of the lymph node dissection

Thyroid cancer is the most common endocrine malignancy with the highest mortality, so it has generated considerable debate and voluminous literature by endocrinologists, surgeons, and nuclear physicians. If total thyroidectomy is the primary treatment for patients with differentiated thyroid cancers (DTC) and it has proven to be effective and safe, the extent of lymph nodes dissection remains controversial among experts in the field. This controversy persists largely due to the lack of a prospective randomized controlled trial to define whether the addition of central lymph node dissection (CLND) to total thyroidectomy for papillary thyroid cancer (PTC) confers an increased risk of permanent hypoparathyroidism and permanent nerve injury. According to the Consensus Conference of the UEC's Club therapeutic modified radical neck dissection (MRND) should be performed only in the patients with evidence of neoplastic multiple lymph node involvement. Although central lymph node dissection may increase the risk of hypoparathyroidism and nerve injury when compared with total thyroidectomy without CLND, it may decrease recurrence of PTC and likely improves disease specific survival and offers a sufficient alternative to routine prophylactic modified radical neck dissection. Selective central lymph node dissection should be performed, under the care of experienced surgeons, in high risk patients (50 years or older aged, large tumor expansion within the thyroid, or with extrathyroid extension), with the extension to the station II-III-IV in case of single lymph node involvement.

Could a high resectability rate improve the long-term survival of patients with proximal bile duct cancer?

BACKGROUND AND OBJECTIVES

This retrospective study was undertaken to evaluate if high resectability rate could improve the long-term outcome of patients with proximal bile duct cancer.

METHODS

Between 1985 and 2001, 50 patients (34 male and 16 female) with proximal bile duct cancer were treated. Thirty-six patients (72%) were considered suitable for surgery, while 14 underwent nonsurgical palliative procedures. Twenty patients had bile duct resection only. Ten patients had Roux-en-Y cholangiojejunostomy with two or three divided segmental hepatic ducts; in 10 patients, the cholangiojejunostomy was performed with four or five divided segmental hepatic ducts. Three patients were treated by palliative transtumoral intubation with Kehr tube. Thirteen patients had bile duct resection plus hepatectomy. Despite the curative intention of the operation, only in 19 (52.7%) patients did the histopathological examination reveal tumor-free margins.

RESULTS

There was no operative mortality. Postoperative morbidity was 25%. Overall 1-, 3-, and 5-year survival of the entire surgical group was 61%, 22.5%, and 9%, respectively. In the 19 patients treated with curative intent the survival at 1, 3, and 5 years was 63.1%, 31.5%, and 15.8%, respectively, while in the group that had palliative treatment it was 45%, 15%, and 0%, respectively.

CONCLUSIONS

Only margins free from tumor can guarantee an improvement in long-term outcome. Increasing resectability improves survival and could offer a chance of better long-term survival.

[Antibiotic prophylaxis in laparotomic and laparoscopic cholecystectomy]

Antibiotic prophylaxis in biliary surgery, when correctly used, has led to the minimisation of postoperative infections. Conventional cholecystectomy, and particularly laparoscopic cholecystectomy give rise to a very complicated issue concerning the use of antimicrobial prophylaxis, especially in relation to low-risk patients. The authors describe their experience with the use of short-term prophylaxis in biliary surgery based on a hundred consecutive laparoscopic cholecystectomies. In addition, the literature on this topic strengthens the authors' conviction that antimicrobial prophylaxis may be indicated in all surgical cholecystectomy procedures, also in view of the difficult management of postoperative infection risk factors.

Living kidney transplantation: a starting experience

INTRODUCTION

We present our initial experience with living kidney transplantation.

PATIENTS AND METHODS

From January 2001 to December 2002, we performed 27 living kidney transplants using immunosuppression with induction basiliximab, cyclosporine (n = 10 patients), or tacrolimus (n = 17), mycophenolate mofetil, and steroids.

RESULTS

Nineteen (70.3%) donors were women and 8 (29.7%) were men of mean age 50.6 years. Four donors were over 65 years of age at the time of living donation. Donor morbidity was 5.5%: namely, one wound infection and one asymptomatic acute pancreatitis. There were no differences between the preoperative and the postoperative mean serum creatinines and systolic blood pressure values. All living donors are in good health with a mean serum creatinine of 0.80 mg/dL at a mean follow-up of 15.2 months. Nineteen (70.3%) recipients were men and 8 (29.7%) were women of mean age 36 years. Acute rejection occurred in 6 (22.2%) recipients. It was more common among spousal donors and among cyclosporine-treated recipients. Patient and graft survivals at a mean follow-up of 15.2 months was 100%.

CONCLUSIONS

Our early results showed that accurate selection and preoperative management of potential living donors lead to excellent results in kidney transplantation. The health of the living donors was not impaired by the donation. The rate of early postoperative complications was low. Living donor kidney transplantation, in our geographical area with a low-rate of cadaveric donor transplants, is an alternative to expand the donor pool, which offers better results in term of patient and graft survival.

Psoas abscess: a rare complication of Crohn's disease

Psoas abscess is a rare complication of Crohn's disease.

METHODS AND MATERIALS

We evaluated the incidence of psoas abscess on 312 patients with Crohn's disease, seen at our institution between 1992-2001.

RESULTS

We encountered three cases of psoas abscess (0.9%). One patient was managed with ileocolic resection and immediate anastomosis, while in two patients a percutaneous drainage was first performed and then, after 12 days of total parenteral nutrition, a resection of the diseased bowel with immediate reconstruction was carried out.

CONCLUSIONS

A correction of the nutritional deficiencies is mandatory. Percutaneous computed-tomography guided drainage of the abscess with intestinal resection with immediate anastomosis, performed after a parenteral hyperalimentation, should be the method of choice in the management of such patients.

Rare surgical complications of Crohn's disease. Clinical and therapeutic considerations

We present our clinical experience in the management of rare surgical complications in Crohn's disease. Two hundred and eight patients affected by Crohn's disease were treated surgically between January 1992 and September 2001, at the Department of Surgical and Gastroenterological Sciences of the University of Padua. Rare surgical complications were identified in 17 patients (6.2%): 4 with small intestine adenocarcinoma, 5 with massive gastrointestinal bleeding, 5 with free peritoneal perforation and 3 with psoas abscesses. The very substantial clinical variability of Crohn's disease is a constant challenge to researchers. In particular, the high incidence of associated pathologies and complications related to Crohn's disease makes this pathology extremely disabling. In addition, this disease quite often appears to occur together with a rare complication which, though in most cases its course tends to remain unknown, at times may be potentially life-threatening. For this reason, it is crucial to suspect the occurrence of these pathologies, especially in patients responding poorly to therapy or in those whose symptoms suddenly become acute. Early diagnosis and treatment are therefore fundamental for the most appropriate treatment to be administered.

[Is it possible to improve survival in patients with Klatskin tumors?]

BACKGROUND

This retrospective study was undertaken to evaluate if a high resectability rate could improve the long-term outcome of patients with proximal bile duct cancer.

METHODS

Between 1985 and 2001, 50 patients (34 males and 16 females) with proximal bile duct cancer were treated. The tumor site were classified according to Bismuth-Corlette's classification: 9 lesions (18%) were Bismuth type I, 23 lesions (46%) type II, 12 lesions (24%) Type IIIa, 5 lesions (10%) type IIIb and only 1 resected tumor (2%) was type IV. Thirty-six patients (72%) were considered suitable for surgery, while 14 underwent non surgical palliative procedures. Twenty patients had bile duct resection only. Ten patients had Roux-enY cholangiojejunostomy with two or three divided segmental hepatic ducts; in ten, the cholangiojejunostomy was performed with 4 or 5 divided segmental hepatic ducts. Thirteen patients had bile duct resection plus hepatectomy. Despite the curative intention of the operation, only in 19 (52.7%) patients did the histopathological examination reveal tumor-free margins.

RESULTS

There was no operative mortality. Overall 1-year, 3-year and 5-year survival of the entire surgical group was 61%, 22.5% and 9% respectively. In the 19 patients treated with curative intent the survival at 1,3, and 5 years was 66%, 30% and 15%, respectively, while in the palliative group it was 45%, 15% and 0%, respectively.

CONCLUSION

Only margins free from tumor may guarantee an improvement in long-term outcome. Increasing resectability improves survival and could offer a chance of better 5-year survival.

[Bilateral breast cancer]

Bilateral breast cancer has a cumulative incidence of 3-13% in patients with primary breast cancer, and the majority of these lesions are metachronous. The synchronous and metachronous bilateral breast cancer have at greater risk for distant metastasis than unilateral breast cancer. There was no difference in overall survival when comparing metachronous and synchronous bilateral patients to those with unilateral disease.

[Surgical tactics in abdominal wall neoplasia]

Abdominal wall neoplasms represent more or less 1% of human neoplasms in the adult. The authors reports their own experience based on 9 cases during over 20 years. The prognosis of these tumors is almost influenced from a lot of factors such as: histology, localization, staging, grading, sex, surgical margins, number of local recurrences. Abdominal wall neoplasm are less aggressive for compartmentalization of muscle layer and with a better prognosis because of their localization, and surgical opportunities of extensive resection (not less of 2 cm from tumor's macroscopic limits) allowed by modern prosthetic reconstruction techniques. Polipropilene seems to be the ideal material for such kind of reconstruction even if also mersilene, PTFEe and others were employed. PTFEe and Dual-meshes could be useful in those malignant tumors in which peritoneum resection is necessary.

[Early de novo neoplasia after renal transplantation]

INTRODUCTION

The chronic use of immunosuppressive therapy in transplant recipients to prevent acute rejection increases the long-term risk of cancer. The overall incidence of de novo malignancies (DNM) after kidney transplantation ranges from 6% to 11%.

PATIENTS AND METHODS

Between January 2000 and December 2002, 135 renal and 3 combined kidney-pancreas transplantations were performed.

RESULTS

Of 138 solid organ transplant recipients, a total of 16 (11.6%) cancers were diagnosed in 10 renal transplant recipients (7.2%). Six patients were male and three female, with a mean age of 47 years (range, 19-63, years). Tumor presented at a mean time of 14 months (range, 2-24, months) after transplantation. There were three patients with skin cancers, three with Kaposis's sarcoma, one with renal cell cancer, one with bladder carcinoma and one with breast cancer.

CONCLUSIONS

Although the DNM occurs more frequently many years after a kidney transplantation, our experience demonstrated that they can occur early in the follow-up. Skin malignancies had the best prognosis, probably because of early detection and treatment. Kaposi's sarcoma benefits from reduction or cessation of immuno-suppression, but there is a higher risk of graft loss. Solid organ de novo malignancies are often more aggressive than in normal population, and the life expectancy of these recipients is very low. Careful long-term screening protocols are needed for detection of such malignancies in an early stage.

[Breast cancer screening in the elderly]

The incidence and mortality of breast cancer increase with increasing age, and almost half of all breast cancer cases are diagnosed in women aged 65 years and older. Moreover many studies have indicated that the elderly are less screened, and have lesser and frequently inferior treatment. In contrast, clinical trials focusing on the elderly suggest that they do as well with surgery, radiation, and standard chemotherapy regimens as their younger counterparts. Our study suggest that in women aged 65 years, and older, breast cancer can be detected at an earlier stage by mammographic screening.

[Undifferentiated carcinoma of the thyroid]

Anaplastic thyroid carcinoma is a rare and highly lethal cancer. Between 1969 and 2002, 9 cases with anaplastic carcinoma were reviewed. Surgical treatment with radiotherapy and chemotherapy were performed in all cases. All patients died of their disease within 5 years. The mean survival was 10 months. There is still controversy as to what constitutes adequate treatment for anaplastic thyroid carcinoma, and combined multimodal therapy seems to be the most common management strategy for this aggressive disease.

[Gastrointestinal metastasis of melanoma: a case study]

The Authors report on a case of multiple metastases located in the jejunum (where it caused intussusception), the omentum, and retroperitoneum having originated from a malignant melanoma with subungual primary site on first finger of left hand. After thoroughly surveying the specific literature, the Authors deal in more detail with current treatments and therapeutic prospects for this kind of neoplastic disease.

Severe gastrointestinal bleeding in Crohn's disease

INTRODUCTION

Acute gastrointestinal bleeding is rare in Crohn's disease.

METHODS

We characterized the clinical features and course of such hemorrhage in patients seen at our institution from 1992 to 2000.

RESULTS

Five patients had gastrointestinal bleeding during Crohn's disease. All patients had a known Crohn's disease, with a mean duration of the disease of 6 years. The source of bleeding was identified in four patients (80%). Endoscopy was, in all patients, the first diagnostic procedure. An Hartmann total colectomy with closure of the rectal stump and ileostomy was performed in three patients, while two patients with ileal massive bleeding were treated conservatively. One patient had a recurrence of bleeding from the small bowel one week later but he didn't required surgical treatment. One patient with pancolic Crohn's disease died on 10th postoperative day because of multiorgan failure and septic complications.

CONCLUSIONS

Gastrointestinal bleeding is rare in Crohn's disease, with a predilection for site of involvement. The preoperative diagnosis of the site of bleeding is not easy, and enteroscopy should be mandatory in such patients. Surgery is required for half of cases and recurrent haemorrhage should be an appropriate indication for surgery.

[Laparoscopic treatment in a case of torsion of ovarian benign mature teratoma. Clinical case and review of the literature]

Benign mature teratomas account for approximately 10-17% of all ovarian neoplasms and are the type of ovarian neoplasm most likely to occur during a woman's reproductive life. Bilateral localization is observed in some 10-15% of cases and the estimated incidence of malignant degeneration is 0.5-1.8%. The authors report a case of a 35-year-old woman admitted with discontinuous abdominal and pelvic pain. Imaging procedures showed an adnexal mass with the appearance of a dermoid cyst. The patient underwent laparoscopic ovarian cystectomy with preservation of the adnexal gland. After a review of the international literature and a description of the clinical features of the disease the authors go on to stress the advantages of laparoscopic management of benign ovarian teratomas.

[Breast carcinoma in the elderly]

Breast cancer represents 40% of all carcinomas and is responsible for the 20% of deads due to a cancer in female population. Patients in more of 50% age over 65 years. 150 patients with breast cancer older then 65 years underwent surgery. T1 and T2 < 2 cm patients were treated with quadrantectomy and radiotherapy. T2 > 2 cm and T3 patients underwent radical mastectomy. T4 patients were treated with neoadjuvant chemotherapy before surgery. Mean follow up was 48 (range 12-78) months. 43 patients (28.6%) had a progression of the neoplasia. Five years mortality rate was 18.6%. Surgery nowadays represents the treatment of choice for breast cancer even in elderly woman. Associated diseases in these patients shouldn't always considered an absolute contraindication for surgery.

[Laparoscopic treatment of benign ovarian cysts]

Laparoscopic surgery is the most frequent indication for the management of benign ovarian cysts in the obstetric and gynaecological field. On the basis of their experience the authors address the clinical classification of benign ovarian pathology and the surgical laparoscopic procedures utilised in the treatment of adnexal cysts. Forty-two patients underwent laparoscopic surgery after a preoperative clinical and biological evaluation and imaging in order to exclude the presence of ovarian malignancies. All surgical procedures were carried out laparoscopically, with a conversion index of 0%. The morbidity was 2.3% (one case of haematoma of the umbilical trocar site) and there was no mortality. No late complications were observed. In conclusion, laparoscopic surgery in the management of ovarian cysts is technically feasible. On the basis of these findings laparoscopic surgery is the treatment of choice for adnexal cystic tumours after careful exclusion of malignancy.

Poorly differentiated jejunal adenocarcinoma in a patient with coeliac disease: a case report

It is well known that coeliac disease increases the risk of gastrointestinal lymphomas, whereas adenocarcinoma is a rare complication. The authors report a case of a poorly differentiated jejunal adenocarcinoma complicating coeliac disease in a 40-year-old female and discuss the clinical, diagnostic and therapeutic aspects.

[Role of nutritional support in the treatment of enteric fistulas]

Enteric fistulas are nowadays considered an important therapeutic challenge. Artificial, total parenteral and enteral nutrition have allowed an improvement in the healing of these fistulas and a lower incidence of mortality. Fourteen patients with enteric fistulas (10 men, 4 women; mean age: 64.4 years; range: 20-80 years) were observed. The fistula was located in the large bowel in 11 patients, in the ileum in 2, and in the jejunum in 1. Thirteen patients received enteral nutrition. The patient with the jejunal fistula received total parenteral nutrition for 30 days and then enteral nutrition. The fistulas were successfully treated in 11 patients. One patients underwent surgery after 6 weeks of treatment with enteral nutrition because of lack of improvement of the symptomatology. In two patients, with advanced cancer of the colon and stomach, respectively, only a reduction of the fistula output was achieved. Nutritional support in the treatment of enteric fistulas is an effective procedure widely utilised to restore adequate nutritional status and bowel rest, which are two important targets for achieving fistula closure. Nutritional support is also useful in the management of patients undergoing surgery in order to reduce the postoperative complication rate.

[Plug-technique for umbilical hernia repair in the adult]

BACKGROUND

Umbilical hernia represents 6% of all abdominal wall hernias in the adult. Surgical repair should always be carried out due to possible occurrence of complications. Aim of this paper is to evaluate the efficacy of the plug-technique.

METHODS

From October 1995 to April 2000, the authors performed 21 operations for acquired umbilical hernia with a defect smaller than 4 cm. Local anesthesia was used and a light intravenous sedation added in particularly anxious patients. The repair was achieved by insertion of a polypropylene dart plug sutured to the margins of the hernial defect.

RESULTS

All patients were up and about straightaway and were discharged within 24 hours of surgery. Postoperative pain was mild and required hospital analgesia in only 19% of cases and domiciliary analgesia in 24%. During a follow-up ranging from 6 to 60 months (mean 30), only one recurrence has been recorded.

CONCLUSIONS

This tension-free technique allows immediate rehabilitation, with few complications and a low recurrence rate.

[Robotic techniques in laparoscopic surgery]

Robotic technology is being increasingly used in surgery. The authors assess the usefulness, effectiveness and safety of the AESOP 2000 robotic device (Automated Endoscopic System for Optimal Positioning) in videolaparoscopic surgery. Two laparoscopic cholecystectomies were performed with the aid of the AESOP 2000 robot. A short increase in operative time was observed and there were no complications. Voice understanding was accurate and flawless and no inadvertent smearing of the lens occurred. The use of the AESOP 2000 robotic device is safe, improves the quality of vision and reduces the number of surgeons needed in the team. Nevertheless, a learning curve and simultaneous training in the use of the device are required.

Enteral nutrition in patients with chronic neurological diseases

BACKGROUND

Malnutrition is commonly considered an important risk factor that can produce a negative influence on the prognosis of patients with chronic neurological diseases. The reduced caloric or proteic intake due to the motor or cognitive dysfunction, the hypercatabolic state due to infections, the abnormal gastrointestinal motility are the main mechanisms responsible for a state of malnutrition.

METHODS

Between January and December 1999 fourteen patients with chronic neurological diseases were treated. Ten of them had had a stroke, four due to Amyotrophic Lateral Sclerosis (ALS). After the evaluation of nutritional status the patients received enteral nutrition (EN) by placement of a nasointestinal feeding tube or a Bengmark tube. Glycaemia, blood urea nitrogen, serum creatinine, electrolytes, glycosuria, glutamic-oxalacetic and glutamic pyruvic transaminase were monitored in all patients. Polymeric enteral feeding was administered by an infusion pump. Standard nourished patients (7/14) received a 30 Kcal/kg/day support, the undernourished ones (6 low, 1 moderate malnutrition) received a 35-40 Kcal/kg/day support.

RESULTS

The complete caloric supply was reached in three-four days. Both of the groups received continuous feeding infusion during hospitalization. For the patients who continued the nutritional support at home (3/14) refeeding was performed only during night-time. In the patients with stroke the optimal/standard weight was reached within one month. In these patients oral nutrition was started within 45 days of treatment taking into account the restored swallowing function. In the patients with ALS the improvement of nutritional standards was reached within the first month and complete restoration within the second/third month.

CONCLUSIONS

On the basis of our experience enteral nutrition represents an effective refeeding procedure in patients with chronic neurological diseases.

[Repair of large vesical wall defects with lyophilized dura mater. Experimental research (author's transl)]

In order to evaluate whether and how far a fuller case documentation can contribute to a better knowledge of the real possibilities of the lyophilised human dura mater in the field of vesical alloplastic surgery, the Authors present and discuss the results they obtained during the course of experimental research. In the light of personal histological documents, they stress the absence of reject phenomena, a property which, together with the absence of precipitates, the complete re-epithelialisation of the transition epithelium and the possibility of ensuring good vesical capacity, evidence that lyophilised human dura mater has full rights to a place in repair surgery of large vesical wall defects.