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Aim: The purpose of this retrospective review of the charts of 51 Jehovah's Witness patients, who underwent surgery without blood transfusions, was to compare two study groups (major surgery vs minor-medium surgery)., Methods: We compared the following variables: age, sex, length of stay, type of surgical operation, use of intraoperative red cell salvaging devices, hemodilution, number of drainages and their stay, postoperative blood loss, complications, need of reoperation and mortality rate. Between medical variables we focused on blood production therapy and nutritional support (administration of iron, folate, erythropoietin and albumin) and blood tests (at the first day of admission; intraoperative; at the first postoperative day; at the discharge)., Results: In the two study groups, we detected statistically significant differences in the following variables: total of postoperative blood loss (p < 0.00001), complications rate (p = 0.0122) and in Hgb values (intraoperative: p = 0.0197; at the first postoperative day: p = 0.0028; at the discharge: p = 0.0100)., Discussion: The aims of a bloodless surgery program are: 1) minimize blood loss, reducing iatrogenic anemia and intraoperative hemorrhage loss; 2) maximize blood production by administration of erythropoietin, iron and folate; 3) maximize cardiac output by alternatives to blood transfusions, as crystalloids, colloids and blood substitutes; 4) increase oxygen content; 5) decrease metabolic rate. We focused on advantages and disadvantages of the suggested procedures. Most interesting techniques are the normovolemic hemodilution and the intraoperative red cell salvaging devices, indispensable in emergency., Conclusions: A close team-work between surgeons, anesthesiologists and hematologists is determinant in a reference center that guarantees experience, organization, professionality, respect for the patients' will and, above all, low morbidity and mortality rates, as those reported by our series.

In this paper, the authors present a modified Rives' technique for the treatment of incisional hernias. This technique requires the use of a nonabsorbable prosthesis (Composix Mesh) made of a double-knit layer of monofilament polypropylene bonded with a single layer of low-porosity e-PTFE inserted behind the rectus muscles and fixed by metallic clips. The outer side (polypropylene) encourages complete host tissue incorporation to reduce recurrences, the inner side (e-PTFE) minimizes tissue attachment and, therefore, visceral complications.

The authors herein show their own experience in the treatment of acute biliary pancreatitis. Aim of this study is to evaluate the effectiveness and the safety of the "early" laparoscopic approach to the mild to moderate acute biliary pancreatitis. The authors studied sixty cases of laparoscopic cholecystectomy with intraoperative colangiography for acute biliary pancreatitis (M/F 1:1.2; mean age 59.6 yrs, range 29.79). The patients were divided in two groups on the basis of the severity of the pancreatitis, defined through Ranson's score and Balthazar classification. The mortality rate was nil. Intraoperative morbidity rate was 6.6% in the group I (3/45), and 13.3% in the group II (2/15). Postoperative morbidity rate was 6.7% (3/45) in the group I and 40% in the group II (6/15). The authors show an original diagnostic and therapeutic algorithm for the treatment of acute biliary pancreatitis. Early laparoscopic cholecystectomy with I.O.C. is proposed as the gold standard treatment for mild to moderate acute biliary pancreatitis. This approach appears to be effective and safe in their experience. In case of severe acute biliary pancreatitis, further investigations are mandatory to evaluate the role of laparoscopic approach.

At least two thirds of patients with pancreatic cancer are still unsuitable for resection, because of the extent of their disease or because of their high-risk conditions. In these cases, a palliative treatment is indicated to maximize the quality of life, in spite of the poor prognosis. During the years 1959-95, two-hundred-ninety-four patients, affected with pancreatic neoplasm, were observed. Resectability rate was 18%. One-hundred patients underwent surgical palliation (34%): 58 biliary-bypasses, 15 gastroenterostomies and 27 double-bypasses. Sixty-nine explorative laparotomies were performed (23.4%), of which thirty-six were carried out during the years 1959-70. Sixty-three patients did not undergo surgical treatment (21.6%), of which twenty-two underwent percutaneous biliary drainage, during the years 1981-95. Overall morbidity rate was 13% with decrease during the years of major postoperative complications. During the years 1959-70 operative mortality rate after surgical bypass was 13.6%, during 1971-80 was 10.5% and during 1981-95 decreased to 8.1%. Major percentages were reported after explorative laparotomies. During the years 1959-70 and 1971-80, operative mortality rate was 16.6%, compared with 9.5% during the years 1981-95. Patients with stage II tumours survived palliative surgery for about 12.8 months, compared with those with stage III and IV tumours, who survived for about 10.6 and 5 months, respectively. Patients who did not undergo surgical treatment survived 8.3, 4 and 1.3 months, respectively in II-III and IV stages. In this paper the authors examine advantages and disadvantages of palliative procedures, on the bases of their aims: relief of obstructive jaundice, duodenal obstruction and pain.

Authors report their own experience on the treatment of pancreatic neoplasms. Two-hundred-ninety-four patients were observed during the years 1959-95. Resectability rate was 18%. Fifty-three patients underwent pancreatic resection: 22 distal pancreatectomies (41.5%), 2 total pancreatectomies (3.7%) and 29 pancreaticoduodenectomies (54.7%) (7 PPPD). Overall morbidity rate was 15.6% with decrease during the years of major postoperative complications. More frequent complications were renal failure (4%), bleeding (1.7%) and acute pancreatitis (5.6%), which was absent during the 1981-95 period. Pancreatic fistula occurred in 5.6%, but in the years 1981-95 only one patient suffered from it (1.8%). During the years 1959-70 operative mortality rate after pancreatic resection was 22.7%, during 1971-80 was 12.5% and during 1981-95 decreased to 4.3%. Patients with stage I tumours survived curative pancreatic resection for about 18.2 months, compared with those with stage II and III tumours, who survived for about 15 and 13 months, respectively. Recent studies have demonstrated a reduction in the morbidity and mortality of pancreatic resections and improvement in the actuarial 5-year survival for patients with resected ductal adenocarcinoma. In the presence of lymphnode metastases, pancreaticoduodenectomy offers good palliation and meaningful survival. In the absence of lymphnode metastases, pancreaticoduodenectomy offers encouraging long-term survival rates and a chance for cure.

Near a century after the first successful total gastrectomy for gastric cancer, the authors review the various technical proposals for digestive tract reconstruction following total gastrectomy. Following a classification based on duodenal circuit, on the viscerum employed and on the creation of pouches and/or anti-reflux mechanisms, pros and cons of the various classes of reconstructions are clearly depicted, suggesting the reasons that made Roux-en-Y esophago-jejunostomy and jejunal interposition the most used reconstructive procedure in worldwide clinical practice.

Lesions of the colon are generally considered to be uncommon sequelae of pancreatitis. They include: localized paralytic ileus (colon cut-off sign), necrosis, fistulae, stenosis and varices. On the basis of an extensive review of the literature (432 cases), it is suggested indeed that the real incidence is significant. The anatomic relationship of the large bowel to the pancreas is an important factor in the genesis and localization of the lesions. Enzymatic-inflammatory and ischemic processes are involved in the most highly supported theories. Colon cut-off sign is almost always spontaneously reversible and may represent an "alarm" for more serious complications. Massive necrosis develops during the early stage of severe pancreatitis and its mortality rate has been reported to be high. Fistulae are late complications of the disease, associated with a protracted course and probably a consequence of pancreatic suppuration or pseudocysts. Stenoses are the most interesting colonic complications following pancreatitis and caused by either acute obstruction of the colon due to an inflammatory mass or progressive obstruction due to pericolic fibrosis. In this case, the clinical picture may mimic carcinoma.

Severe bleeding may complicate the course of either acute or chronic pancreatitis, the latter being more frequently involved. Pseudocysts, severe inflammation, regional necrosis and infection may cause major vessel erosion with or without pseudoaneurysm formation which eventually may result in severe bleeding into the gastrointestinal tract, retroperitoneum and peritoneal cavity. The AA report their experience on 8 cases and analyze the data of a comprehensive review of 389 cases of massive bleeding reported in the literature during the last 100 years until December 1993. Mortality rate seems to be related to the etiology of the bleeding along with its localization and the underlying anatomo-pathologic findings. In patients with chronic pancreatitis it is 22% while in patients with acute pancreatitis or chronic pancreatitis with acute exacerbation it is 60.4% and 57.1% respectively. Splenic, gastroduodenal and superior pancreaticoduodenal arteries are the most commonly involved vessels being associated respectively with a mortality rate of 20.5%, 27.9% and 46.1%. Massive haemorrhage complicating infected necrosis or abscesses implies a worse prognosis when compared to severe bleeding associated with pseudocyst with or without pseudoaneurysm. The increasing use of diagnostic and interventional radiology appears to be the way forward to improve survival rates. Awareness of high risk predisposing condition, activism in achieving an early identification of the bleeding sources, and eventually its angiographic control are essential guidelines for successful approach to the most unpredictable complication of pancreatitis. When embolization fails or is followed by recurrence of hemorrhage, definitive surgical procedures should be immediately instituted.