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INTRODUCTION. During the last 30 years, the multidisciplinary treatments of colon and uterus neoplasm have yielded an increase in total survival rates, fostering therefore the increase of cases with regional relapse involving the urinary tract. In these cases the iterative surgery can be performed, if no disease secondary to pelvic pain, haemostatic or debulking procedure is present, and must be considered and discussed with the patient, according to his/her general status. MATERIALS AND METHODS. From 1997 to August 2007 we performed altogether 43 pelvic iterative surgeries, with simultaneous urologic surgical procedure because of pelvic tumor relapse in patients with uterus neoplasm and colon and rectal cancer. In 4 cases of anal cancer, the urological procedure were: one radical prostatectomy with continent vesicostomy in the first case, while in the other 3 cases radical pelvectomy with double-barrelled uretero-cutaneostomy. In 23 cases of colon cancer, the urologic procedures were: 9 cases of radical cystectomy with double-barrelled uretero-cutaneostomy, 4 cases of radical cystectomy with uretero-ileo-cutaneostomy according to Bricker- Wallace II procedure, and 9 cases of partial cystectomy with pelvic ureterectomy and ureterocystoneostomy according to Lich-Gregoire technique (7 cases) and Lembo-Boari (2 cases) procedure. In 16 cases of uterus cancer, the urological procedure were: 7 cases of partial cystectomy with pelvic ureterectomy and uretero-cystoneostomy according to Lich-Gregoire procedure; in 3 cases, a radical cystectomy with urinary continent cutaneous diversion according to the Ileal T-pouch procedure; 2 cases of total pelvectomy and double uretero-cutaneostomy, and 4 cases of bilateral uretero-cutaneostomy. RESULTS. No patients died in the perioperative time; early systemic complications were: 2 esophageal candidiasis, 1 case of venous thrombosis. CONCLUSIONS. The iterative pelvic surgery in the case of oncological relapse involving the urinary tract aims to achieve the best quality of life with the utmost oncological radicality. The equation: eradication of pelvic neoplasm and urinary tract reconstruction, with acceptable quality of life, will be the future target; nevertheless, it is not possible to establish guidelines beforehand, and the therapy must be adapted to each single case. [ABSTRACT FROM AUTHOR]

INTRODUCTION. During the last 30 years, the multidisciplinary treatments of colon and uterus neoplasm have yielded an increase in total survival rates, fostering therefore the increase of cases with regional relapse involving the urinary tract. In these cases the iterative surgery can be performed, if no disease secondary to pelvic pain, haemostatic or debulking procedure is present, and must be considered and discussed with the patient, according to his/her general status. MATERIALS AND METHODS. From 1997 to August 2007 we performed altogether 43 pelvic iterative surgeries, with simultaneous urologic surgical procedure because of pelvic tumor relapse in patients with uterus neoplasm and colon and rectal cancer. In 4 cases of anal cancer, the urological procedure were: one radical prostatectomy with continent vesicostomy in the first case, while in the other 3 cases radical pelvectomy with double-barrelled uretero-cutaneostomy. In 23 cases of colon cancer, the urologic procedures were: 9 cases of radical cystectomy with double-barrelled uretero-cutaneostomy, 4 cases of radical cystectomy with uretero-ileo-cutaneostomy according to Bricker- Wallace II procedure, and 9 cases of partial cystectomy with pelvic ureterectomy and ureterocystoneostomy according to Lich-Gregoire technique (7 cases) and Lembo-Boari (2 cases) procedure. In 16 cases of uterus cancer, the urological procedure were: 7 cases of partial cystectomy with pelvic ureterectomy and uretero-cystoneostomy according to Lich-Gregoire procedure; in 3 cases, a radical cystectomy with urinary continent cutaneous diversion according to the Ileal T-pouch procedure; 2 cases of total pelvectomy and double uretero-cutaneostomy, and 4 cases of bilateral uretero-cutaneostomy. RESULTS. No patients died in the perioperative time; early systemic complications were: 2 esophageal candidiasis, 1 case of venous thrombosis. CONCLUSIONS. The iterative pelvic surgery in the case of oncological relapse involving the urinary tract aims to achieve the best quality of life with the utmost oncological radicality. The equation: eradication of pelvic neoplasm and urinary tract reconstruction, with acceptable quality of life, will be the future target; nevertheless, it is not possible to establish guidelines beforehand, and the therapy must be adapted to each single case.

Liver surgery for colorectal metastasis has moved toward a parenchymal sparing strategy in order to reduce postoperative liver failure, to resect an higher number of metastases and to allow a future re-resection. Patients undergone hepatectomy in our Department before and after 1999 were retrospectively compared. In the recent years surgery became more aggressive: a higher number of patients with multiple and bilateral lesions were treated. Short-term results improved in the recent series. After 1999, the rate of wedge resections was significantly increased with the same oncological radicality and with improved long-term results. Moreover, parenchymal sparing strategy allowed a higher re-resection rate in patients with liver recurrence.

Extended cholecystectomy is the only chance of a cure for patients with locally advanced cancer of the gallbladder. The aim of the study was to evaluate the short- and long-term results of surgical treatment and to define the prognostic factors associated with better survival. We conducted a retrospective study in 81 patients with gallbladder cancer admitted to our surgical department from 1985 to 1999. Radical surgery was performed on 39 patients. The type of surgical treatment was based on the TNM stage of the disease: all but stage I patients underwent extended cholecystectomy (resection of segment IVa-V, N1-2 lymph-node dissection). The mortality and morbidity rates were 5.1% and 28.2%, respectively. In the patients undergoing curative resection, the 5-year survival was 31.5% (75% in T1 patients, 57.1% in T2, 25.9% in T3 and 0% in T4. Long-term survival of patients with T1-2 tumours was significantly better than that of T3 (P = 0.02) or T4 patients (P = 0.0003); 53.6% of N0 patients were still alive at 5 years as against only 14.5% of N+ patients (P = 0.06). Depth of infiltration is an important prognostic factor. The presence of lymph-node metastases should not be a contraindication to surgery since long-term survival is possible.

With the advent of laparoscopic techniques and other nonoperative techniques, the management of patients with common bile duct (CBD) stones became more complex. With low, medium or high preoperative suspicion of CBD stones, three factors influence the correct management: the degree of endoscopic, radiologic and laparoscopic expertise; the severity of symptoms; the presence or absence of the gallbladder. In patients with a low probability of having CBD stones routine ERCP pre-LC appears inappropriate. The management of patients with medium probability of CBD stones depends on the ability of the laparoscopist to remove CBD stones. A single laparoscopic procedure for cholelithiasis and CBD stones would be the best approach in the majority of patients. ERCP should be considered the procedure of choice in patients with severe gallstones pancreatitis, acute cholangitis and in those with a high probability of having CBS stones.

We studied antipyrine clearance (APC1) in 19 healthy controls, 10 cirrhotic patients, 20 patients undergoing partial hepatectomy for liver tumors (14 with cirrhosis and 6 without cirrhosis). The aim of the study was to evaluate if the test represents a measure of the residual hepatic function and a useful index of surgical risk in cirrhotic patients following partial hepatectomy. The APC1 was significantly reduced in cirrhotic patients ws healthy controls. It is reduced following partial hepatectomy in cirrhotic patients (p less than 0.001) and in non cirrhotic patients (n.s.). The APC1 was found to be related with the plasma level of albumin and pseudocholinesterase; it also was related with the Pugh's score for hepatic function. The APC1 is a satisfactory index of residual hepatic function. On the other hand it does not provide more useful information than the Pugh's score for surgical risk in liver resection.

Encephalopathy is the most common complication after total portal by-pass operation. 5-15% of patients have severe and intractable encephalopathy. Many medical and surgical procedures were proposed to prevent and treat this complication but none of these were effective. Two cases of patients with severe encephalopathy after side to side portal by-pass are presented. They were treated with the procedure proposed by Bismuth; it consists of a gradual suppression of the anastomosis associated with esophagogastric devascularization. In the first case we obtained the regression of encephalopathy while the second patient died portal thrombosis (probably due to this procedure) two months after surgery. Validity and efficacy of this procedure must be evaluated with a higher number of patients. This surgical technique should lead to choose the type of portal by-pass: side to side portal by-pass operation allows according to Bismuth's procedure to reestablish an hepatopetal flow.

Indications for and results of bilio-digestive shunt are discussed and basic stages described. The data refer to non-cancerous pathology of the bile ways. It is concluded that the operation should always be carried out in the first instance (comparatively high intracholedochic pressure values, moderate dilatation of the main bile way, calculosis of the papilla) and not just at reoperation. This convinction is backed up by the very low operative mortality, the good long-term results and the operation's comparatively easy performance.

Le Veen's peritoneal-jugular shunt was employed in the treatment of irreducible ascites in 16 patients with cirrhosis of the liver. Intraoperative mortality was 18%. It was due to disseminated intravascular coagulopathy in 2/3 cases. Regression of ascites and renal failure was noted in all survivors. Follow-up over 6-28 months (mean 10 months) showed that 2 patients had died from sepsis and two from liver failure. Recurrence of ascites (3 cases) had been brought about by malposition or thrombosis of the venous catheter; in one subject, thrombosis extending to the vena cava superior necessitated a portal shunt. There were no instances of digestive haemorrhage attributable to rupture of oesophageal varices. Good results free from complications were noted in 7 patients (43%) and easily treatable complications in 9 (56%). There was an evident improvement over the results obtainable with conventional management. The fact that mortality is generally confined to patients in Child's group C with marked hypoprothrombinaemia suggests that such candidates should be carefully selected. This, together with technical improvements designed to reduce the incidence of intravascular coagulopathy and haemodynamic overload following the operation, would seem capable of permitting better results in the future.

A case of Zollinger-Ellison syndrome with some peculiar aspects is described. The disease started with painless dyspepsia, watery diarrhea, relevant loss of body weight and absence of peptic ulcer. After a steroid treatment performed at home without any rationale, diarrhea stopped totally for 18 months and body weight returned to normal. Subsequently, the disease recurred with more typical clinical characters: juxtapyloric ulcer, increase in serum gastrin levels and positive secretin test, presence of gastrinomas at angiography. The monitoring of gastric pH showed a persistent hyperacidity during medical treatment with H2 and muscarinic antagonists. The localization of gastrinomas was extrapancreatic, at the root of jejunal mesentery. Excellent results were obtained by surgical treatment which consisted in resection of the principal neoplastic masses with total gastrectomy. The patient's general conditions after two years are good.