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Introduction to qualitative research: the main approaches and designs. The main methods (phenomenology, ethnography, Grounded, narrative enquiry and case studies) and sampling technique of qualitative research are briefly outlined. A practical example is presented for each method.

Introduction: The main purpose of our study was to determine, through the introduction of a checklist in the operating room, the incidence rate of adverse events and their predictability in a representative sample of patients admitted to our Urology unit and undergoing surgery., Methods: The study includes 324 patients. The checklist includes 3 phases (Sign In, Time Out, Sign Out), 20 items with checks to be performed during surgery and the marking of boxes after a successful check. All the staff in the operating room has been specifically trained with a theoretical and practical 20-hour course., Results: The overall average incidence of adverse events reported was determined by 4.8%, is consistent with the expectations of the study protocol, and is at a lower level than the average median rate of international studies (8.9%). The overall complication rate fell from 11% to 7.9%, the rate of intra-hospital mortality from 1.7% to 0.9%, the rate of surgical site infection decreased from 8.2% to 4.7%., Conclusions: The results were consistent with the results of other international studies similar in scope in terms of study (definition of the rate of adverse events) and epidemiological study (retrospective study). The variability of the results obtained in our inquiry is likely attributable to varied factors occurred during the study.

Aim: To evaluate feasibility, tolerability and cosmetic outcome of intra-operative radiation therapy (IORT) as an exclusive post-surgery treatment of early stage breast cancer., Patients and Methods: From October 2008 to October 2009 30 patients underwent wide breast cancer excision or quadrantectomy followed by IORT on tumor bed with accelerated electrons at the dose of 21Gy. The characteristics of the patients were: ductal breast cancer or invasive lobular cT1, cT2 ≤ 2,5 cm, cN0, G1-2, age over 35 years, M0., Results: The average age was 51.7 (range 38 - 75) with an average follow up of 11.7 months (range 6 - 18). The pathologic stage of the lesions resulted pT1 in 29 cases (96,6%), in particular: one case pT1a (3,3%), 21 cases pT1b (70,0%) and 7 cases pT1c (23,3%). One case (3,3%) was pT2 with a diameter of 2.5 cm. The grading was G2 in 20 cases (66,6%) and G1 in 10 cases (33,3%). The toxicity, evaluated according to the EORTC-RTOG criteria, was G0 (33.3%) in 10 cases, G1 (63,3%) in 19 cases, G2 in one case (3,4%); there was no G3 toxicity. The time needed for a complete healing of the wound was less than 10 days in 96,7% of the cases, with one case of limphocele (3,3%). There were no infections of the surgical wound nor any mastitis, neither in the treated quadrant nor in the other ones. We observed a light fibrosis in 5 cases (16,6%), moderate in 2 cases (6,6%) but never severe. Cosmetics, evaluated in four levels, according to Danoff et al., was excellent in 3 cases (43,3%), good in 15 cases (50%), sufficient in 2 cases (6,7%), never insufficient. As regards local control, there was no local relapse. The global survival was 100%., Conclusions: The IORT in early breast cancer, at the doses used in this study, proved itself as a secure technique, repeatable, with limited complications. The advantages of its use are the possibility of a direct control, by the surgeon and the radiotherapist, of the structures to treat and those to protect; the absence of time needed for cellular repopulation between surgery and radiotherapy; a good cosmetic outcome; and logistic advantages. It is necessary to have a long term follow up to evaluate the efficacy in terms of long term cosmetic and local control.

Mesenteric and retroperitoneal cysts are rare intra-abdominal tumours with an incidence of 1/140.000 in surgery departments and 1/20.000 in paediatric departments. There are no pathognomonic signs or symptoms for the cysts. In the differential diagnosis lymphangiomas, sarcomas, adenocarcinomas and intestinal duplications should be considered. Diagnostic includes abdominal computed tomography, ultrasound and MRI. Barium enema examination or intravenous pyelogram may be used in special cases. Surgical treatment is indicated also in asymptomatic patients; laparoscopic approach is the "gold standard". Laparotomic approach should be used in the cases of impossibility of total enucleation or in the cases of malignant degeneration. Complete enucleation is the treatment of choice for retroperitoneal and mesenteric cysts. If this cannot be accomplished, the alternative should be the excision of the cyst or the marsupialization. In this paper we present a case of young man with a mesenteric cyst mimicking acute appendicitis.

Rectal mucosal prolapse is characterised by protrusion of the rectal mucosa alone in the anal lumen. To correctly establish the intraoperative stage of rectal mucosal prolapse the authors performed a test based on the intrarectal introduction of a large-sized hydrophilic plug, to be extracted later from the anal canal. A total of 40 patients with proctological symptoms and with a diagnosis of rectal mucosal prolapse were submitted, in the outpatient setting, to a minimally invasive test with a small plug and later, in the preoperative stage, in patients under anaesthesia, using a plug entirely inserted into the rectal lumen and extracted via the anus. The same procedure was performed after surgery to verify the results of the excision. In all cases the plug test used in the preoperative stage permitted the perfect surgical evaluation of the extent of the prolapse. The plug test revealed a mucosal prolapse occupying 25% of the anal circumference in 10 patients, up to 50% in 20 patients and more than 50% in 10 patients. The first 30 patients were treated with the transfixed stitch technique, while for the others the Longo surgical technique was preferred. The plug test for the preoperative and postoperative evaluation of rectal mucosal prolapse is an effective tool for obtaining a more precise indication as to the optimal surgical intervention and for verifying the radicality of the surgical excision. The plug test, moreover, proved to be a minimally invasive and easily performed test for evaluating rectal mucosal prolapse.

The aim of the paper is to discuss possible urological complications related to laparoscopic hysterectomy and to focus on the most effective strategies to get their occurrence reduced. A review of the literature concerning the safety of the procedure was conducted, comparing laparoscopic hysterectomy (LH) with abdominal hysterectomy (AH) and vaginal hysterectomy (VH) in terms of urological complications during surgery. The possible effect of the "learning curve" on the frequency of this kind of complications was evaluated. The effect of the "learning curve" has been shown by large observational studies where the number of urological complications occurring during LH seems to diminish as the ability in performing this surgical procedure increases. Also the great variability existing between different centres was highlighted showing that the spreading in case of urological complications varies between 0.4% and 4%. The lesions of the bladder roof are not specific for LH while they are commonly associated with AH, although their rate of occurrence is far higher in the LH group when compared with AH (2% vs 0.8%). Little difference seems to exist between VH and LH regarding this specific lesion (1.6 vs 1.2). Ureteral lesions occur with a frequency of 1.2% in the LH and 0.2% in case of an hysterectomy performed by the abdominal route whereas current data show that these lesions are very rare in those women undergoing VH. The present study stresses the importance of intraoperative diagnosis of urological lesions and gives some practical tips to avoid them providing also a brief description of some procedural aspects of LH as performed at our institution.

Intraoperative fluid administration is considered an important factor in the management of metabolic acidosis following surgical procedures. The aim of this study was to compare three types of intraoperative infusional models in order to evaluate their effect on acid-base changes in the immediate postoperative period as calculated by both the Henderson-Hasselbach equation and the Stewart approach. Forty-seven patients undergoing left hemicolectomy were enrolled in the study and assigned randomly to receiving 0.9% saline alone (Group A, n=16), lactated Ringer's solution alone (Group B, n=16) or 0.9% saline and Ringer's solution, 1:1 ratio (Group C, n=15). Arterial blood samples were taken before operation (t0) and 30 min after extubation (t1) in order to measure the acid-base balance. The results showed a metabolic acidosis status in Group A patients, whereas Group B exhibited metabolic alkalosis only by means of the Stewart method. No difference was found in Group C between the time points t0 and t1 when using either the Henderson-Hasselbach equation or using the Stewart model. We conclude that saline solution in association with Ringer's solution (1:1 ratio) appears to be the most suitable form of intraoperative fluid management in order to guarantee a stable acid-base balance in selected surgical patients during the immediate postoperative period.

Surgical resection is the only curative treatment option for local recurrence of well differentiated thyroid cancer. In our experience, we found that intraoperative ultrasonography can be of significant help in facilitating the localisation and complete resection of lesions. From 2005 to 2006, 12 patients with well differentiated thyroid tumour recurrences underwent intraoperative ultrasonography. Recurrences were easily identified and resected in all patients. Postoperative thyreoglobulin was not detected. Intraoperative ulrasonography can be of significant help in the identification of well differeniated thyroid tumour recurrences, particularly when the cancer is smaller than 10 mm in diameter, and can facilitate a more radical excision of the tumour.

Aim: The aim of the study was to evaluate the clinical role or [(99m)Tc]MIBI SPECT in selecting primary hyperparathyroid (PHPT) patients for minimally invasive radioguided surgery (MIRS)., Methods: One hundred and forty-one consecutive PHPT patients were studied by a single-session [(99m)Tc]Percethnetate/[(99m)Tc]MIBI subtraction scintigraphy, followed by [(99m)Tc]MIBI SPECT in order to localize hyperfunctioning parathyroid adenoma (PA) and plan the surgical approach., Results: A solitary PA was depicted at preoperative scintigraphy in 135 of 141 patients (95.7%), two or more PA in 5 patients, and was negative in 6 patients (4.3%). In 27 patients, the PA was located deep in the paraesophageal/paratracheal space. One hundred and twenty-four patients (in 18 of them the PA was located deeply in the neck) underwent successful MIRS using the low 37 MBq (1 mCi) [(99m)Tc]MIBI dose protocol. Intraoperative quick parathyroid hormone (QPTH) assay demonstrated a fall >50% in respect to the baseline value in all patients, confirming successful parathyroidectomy. After a follow-up of 6 to 37 months (median 18 months), no case of persistent/recurrent PHPT was recorded. When comparing the parathyroid to background (P/B) ratio measured at planar and SPECT preoperative scintigraphy with that measured intraoperatively with the gamma probe, a significant linear correlation was found between the SPECT and intraoperative gamma probe measurements (r = 0.91; P <0.01) while no correlation was found with planar scintigraphic data., Conclusions: Our data suggest that the P/B ratio calculated by means of [(99m)Tc]MIBI SPECT is more accurate in predicting the intraoperative measurements with the intraoperative gamma probe. Thus, a preoperative [(99m)Tc]MIBI SPECT acquisition should be recommended for a better selection of PHPT patients to offer MIRS.

Background: Intraoperative parathyroid hormone (iPTH) assay (QPTH) in combination with preoperative localization, permits a less invasive operative approach in the treatment of hyperparathyroidism. A 50% reduction of the intraoperative PTH level, mesured within 15 minutes with an immunochemestry system of III generation (ICMA), shows the completeness of the hypersecretive tissues surgical removal., Patients and Methods: From June 2003 to December 2005 a series of 39 patients underwent target parathyroidectomy with intraoperative parathyroid hormone assay for parathyroid disease. Intraoperative PTH was measured before, 5-10 and 20 minutes after parathyroidectomy. 79.5% of patients had secondary hyperparathyroidism, 29.5% had primary disease. In 38 patients (97,4%) the intraoperative PTH levels declined more than 70% and in only one patient (2,6%) intraoperative PTH levels declined less than 50%., Results and Conclusions: QPTH has deeply modified the surgical approach to the treatment of hyperparathyroidism. Intraoperative measurement of iPTH is useful in prediction the complete removal of all parathyroid tissue after surgery for parathyroid disease, thus avoiding persistence or recurrence of disease and surgical failures. In well-studied cases QPTH can be considered a valid alternative to the intraoperative hystological examination.

Introduction: The routine use of intraoperative cholangiography during laparoscopic cholecystectomy remains controversial. Mirizzi was the first to recommend the use of intraoperative cholangiography in 1931 based on the high incidence of unsuspected common bile duct stones. The use of intraoperative cholangiography before common bile duct exploration reduced the incidence of unnecessary common bile duct explorations from 66% to less than 5%. With the introduction of laparoscopic cholecystectomy, an increase of incidence of bile duct injury two to four times that seen in open cholecystectomy was witnessed. The vast majority of the injuries were a direct result of the surgeon misidentifying the anatomy. The Authors report their experience in the use of intraoperative cholangiography to prevent bile duct injuries and to discover common bile duct unknown lithiasis., Methods: From December 2002 to January 2004 in 169 patients affected to cholecystolithiasis were undergone cholecystectomy. During this operation intraoperative cholangiography was performed routinely. The patients were divided in two groups. In the Group A the patient with high risk according to a score system. and the others in the group B., Results: The cholangiography was performed with success in the 97% of patients. It were discover common bile duct in the 17%, biliary anatomy anomalies in the 3.5%, bile duct injuries in the 0.5% and false positive in the 2.9%., Conclusion: The Authors recommended the routinely use of intraoperative cholangiography owing to its a feasible and safe technique with a success rater greater than 90%. If a bile duct injury is going to occur because of misidentification, cholangiography will not prevent the injury, but a properly performed cholangiogram will minimize the extent of the injury. Finally, the intraoperative cholangiography can discover a common unknown bile duct lithiasis and can reduce incidence of unnecessary ERCP with subsequent complication

The intraoperative localization of residual parathyroid tissue during re-operations for persistent or recurrent secondary hyperparathyroidism (HPT) could have difficult due to cicatricial phenomena, anatomic modifications, ectopic or super-numerous glands. The use of intraoperative localisatin methods, as ultrasonographic and gamm-camera, permits a great level of success in identifying residual gland tissue. The Authors report their experience in the treatment of 5 cases of persisten HPT and 3 cases of recurrent HPT using gamma-camera and ultrasonography intraoperatively. Gamma-camera presented a sensitivity of 88% while ultrasonography did 100%. According to the experience, even numerically limited, of the Authors, intraoperative ultrasonography offers better results than gamma-camera, with less technical complexity.

The diagnosis of well differentiated carcinoma (i.e papillary carcinoma and follicular carcinoma) represents one of the most challenging issue in thyroid pathology. Aim of the present review is to discuss new perspective and old problems in this topic. Three main subjects are developed, corresponding to: 1) the role of fine needle aspiration versus frozen section examination in pre- or peri- operative diagnosis; 2) the management of small papillary tumour; 3) pathological classification of those tumours indeterminate for papillary or follicular nature. There is general agreement that fine needle aspiration represent the best pre-operative diagnostic tool for thyroid nodules; foremost limits are represented by "not diagnostic" and 'follicular lesion, NOS". The former should be repeated or, if suspicious for papillary lesion, improved with intra-operative apposition cytology; the latter should be deferred to histology with frozen section evaluation reserved to those institution with daily practice on this issue. The management of papillary micro-carcinoma (i.e. papillary carcinoma smaller than 1 cm.) in the setting of an otherwise benign thyroid disease is a matter of debate, since several clinicians suggest to consider these as incidental findings thus avoiding additional treatment. Recently this attitude has been supported by the proposal to regard these lesion as "tumour" and not carcinoma: available data on follow up seems to sustain and favour this approach. There exist a group of well differentiated tumours of the thyroid lacking the criteria to be diagnosed either as papillary (i.e. nuclear grooves, nuclear pseudo-inclusion and nuclear clearing) or follicular (i.e. capsular or vascular invasion) carcinoma; for these lesion, whose behaviour (nodal or blood metastasis) can not be predicted, it has been suggested the term of well differentiated tumour of uncertain malignant potential. Finally it has to be mentioned the possible role of molecular biology in the diagnosis of well differentiated thyroid carcinoma; indeed markers such as RET/PTC or PAX8/PPARgamma, which to date have been employed mainly in basic research, might represent useful diagnostic (and therapeutic) tools in the future.

Aim: Endovascular surgery is an efficacious alternative to conventional surgery in the treatment of descending thoracic aorta aneurysms. However, primary and delayed endoleaks are some endovascular technology's weak points. They are usually detected by angiography or angio CT, but many information may be obtained by transesophageal echocardiography (TEE) both as to endoleaks and to endograft's correct placement. Our purpose is to confirm, on the basis of our experience, the validity of this technique chosen both by us and by other groups with a wider casuistry., Methods: We positioned endografts for the treatment of degenerative or post-traumatic aneurysms of the descending thoracic aorta using TEE, together with angiography, during surgery in 8 out of 9 patients. TEE was carried out on the same 8 patients also before surgery, and for some patients even in the follow-up together with angio CT, after 6 and 12 months., Results: In the situations where TEE was used we found 5 cases of endoleaks and 1 of these was not detected by angiography because of its small dimensions. All of these endoleaks were immediately corrected with more angioplasty or graft extensions; in a case, where we could not utilize the TEE, the problem solved spontaneously after 30 days as it was confirmed both by angiography and angio TC. The statistical analysis with the Student t test is significant for P < 0.005., Conclusions: We think that using TEE during the placement of an endograft on the descending thoracic aorta may help to obtain useful information in addition to those that we can obtain with angiography. Therefore, this may lead to improve the technique and to reduce possible both immediate or delayed complications.

Mitral valve prolapse (MVP) is still a clinical challenging problem. In this report, we review the main characteristics of this entity. Epidemiology of MVP, which relies on the diagnostic criteria adopted, and the incidence of complications, both arrhythmic and structural, are influenced by the characteristics of the population studied, which may lead to bias in data interpretation. Even the definition of MVP may differ according to the cardiologist's or cardiac surgeon's point of view. Usually, cardiologists define MVP as the protrusion of all or part of the mitral leaflets into the left atrium, independent of maintenance of coaptation. Therefore, using this definition, mitral regurgitation is considered as a complication rather than a diagnostic criterion. Arrhythmias, either supraventricular or ventricular, are other possible complications, mostly not life-threatening and associated with myxomatous degeneration of the valve. Diagnosis of MVP is based on echocardiography, which provides detailed anatomic and functional evaluation of the affected valve. Leaflet thickness and motion as well as presence and severity of mitral regurgitation can be assessed, with important diagnostic and prognostic implications. Echocardiographic evaluation of the mitral valve requires a systematic approach in order to define the leaflet/scallop involved and the mechanisms of mitral regurgitation. To this aim, three-dimensional reconstruction may add further insights into objective rendering of mitral valve pathology. Finally, surgical timing in mitral regurgitation due to MVP is an evolving issue and the likelihood of surgical repair is a crucial factor in the optimal timing of surgical intervention, especially in asymptomatic patients with severe mitral regurgitation.

Total hip replacement surgery carries the risk of thromboembolic complications, which could be fatal. Over the last three decades however, the risk has decreased considerably thanks to progress made in the understanding of the physiopathogenetic mechanism of thromboembolic disease and perioperative prophylaxis. It is the purpose of this study to discuss the main medical and surgical preventive measures that must be carried out before, during and immediately after surgery. The old concept of deciding thromboembolic prophylaxis after surgery is now obsolete.

Belghiti's liver hanging maneuver is now widely used for right hemihepatectomy or donor operation in living-related liver transplantation. This technique allows parenchymal transection to be performed without liver mobilization and avoiding tumour spread. On the basis of the first few years of world-wide experience we can now assess the advantages and limitations of this technique.

New approach in treatment of peritoneal carcinomatosis combining cytoreductive surgery and intraperitoneal chemotherapy suggests improved survival when it is possible to achieve a complete cytoreduction. In this study we consider the carcinomatosis from colorectal and appendiceal adenocarcinoma. In all cases, patients in whom cytoreductive surgery was complete had a median survival much longer compared with patients in whom was not possible and, as perfusion works on minimal residual disease, peritonectomy is the only surgical technique that aim at total removal of parietal and visceral peritoneal lesions.

Local recurrence (LR) is a major problem following curative resection of rectal cancer. Intraoperative radiation therapy (IORT) is considered an ideal boost technique for increasing the dose of radiation therapy within a restricted area without introducing a significant toxicity. The aim of this study is to present the results of a multimodality treatment containing external beam irradiation, chemotherapy, surgical resection, and IORT delivered by a movable linear accelerator (NOVAC7, Hitesys SpA, Italia), employed in a "traditional" operating room.

Introduction: In the neuropathological intraoperative diagnostic is extremely important having guide lines to obtain a lot of information about the slide. In our study we have considered only the intraoperative the cases diagnosed within a month comparing the histological evaluation using the cryostat and the cytological examination of touch or smear preparation., Materials and Methods: Our study includes 7 meningiomas, 2 metastatic carcinomas, 1 anaplastic astrocitoma, 1 mieloplaxis tumor, 1 anaplastic chordoma. For the cytological examination we have got ready 8 touch or smear preparations and we have executed 4 proceedings: stainings with Giemsa, toluidine blue and haematoxylin and eosin, after fixation with 95% alcohol and staining with haematoxylin and eosin after fixation with alcohol and a small quantity of acetic acid. For the histological examination we have got ready 8 preparations, using the cryostat. We have fixed the slides with 95% alcohol or 10% formalin and stained them with haematoxylin and eosin. In the 50% of the cases we have treated the sections with microwave at 400W., Results: Two pathologists have examinated the 192 sections prepared, judging each slide considering the legibility: unsatisfactory, quite good, good and excellent., Conclusions: Considering the cytological examination, Giemsa and toluidine blue permit the best legibility of nuclear and cytoplasmatic morphological details. Legibility is worse in staining with haematoxylin and eosin. Addition of acetic acid makes variable results. In the histological slides the best result are obtained using 95% alcohol for fixing. Microwave use doesn't determine improvement.

The literature considers hyperthermic intraoperative intraperitoneal chemotherapy a safe and effective procedure for peritoneal carcinomatosis, but a technical improvement is necessary. Regional chemotherapy anticipates the "downfall" of tumoral cells in the peritoneum. The Authors considered 5 patients--female, age 27-45 years, ASA 2--operated of peritonectomy in ovaric neoplasia with peritoneal metastasis. The hyperthermic intraoperative intraperitoneal chemotherapy has been made at the end of the surgery with a hot solution (43 degrees C): 3000 ml of dextrose 1.5% with mytomicina C 25 mg e cysplatino 75 mg/m2. We considered variation of emodinamic parametres (blood pressure, central venous pressure, stroke volume, etc.) and biochemical parametres (Na, K, CI-, CO2, etc.). These parametres have been correlated with some complications: fistula, anastomotic leakage, pancreatitis and postoperative bleeding.

Surgical management of primary hyperparathyroidism has undergone several chances in recent years and historically has required bilateral neck exploration with identification of the parathyroid adenoma together with three normal glands. The intraoperative hormone assay allows a more limited procedure by confirming complete removal of hypersecreting tissue. The Authors report surgical treatment of 24 consecutive hyperparathyroidism and conclude that evaluation of intraoperative hormone assay accurately predicts the determination of adequacy of resection and the correct outcome of surgery in patients with parathyroid adenomas.

Drugs administrable in oral surgery for adult patients are antiseptics-antibiotics, antiinflammatory-analgesics and sedative-hypnotics. Such drugs can be administered before, during or after oral surgery. Sedative-hypnotics can be administered before or during oral surgery in order to control the patient's anxiety. Anti-inflammatory-analgesics, on the other hand, can be administered before or after oral surgery to lower edema and pain. For this purpose, FANS are the most commonly used drugs but, in more traumatic oral surgery, the administration of a single pre-surgery dose of corticosteroids is suitable. As regards, antibiotics have to be given from 15 min to 1 h before oral surgery and continued or otherwise for 24-48 h depending on the dosage. post-surgery infection onset, in fact, is higher within 3 h after oral surgery.

Background: The aim of this study was to validate the preliminary surgical results of the integrated approach to pulmonary atresia, ventricular septal defect (VSD), and multiple aortopulmonary collateral arteries by retrospective analysis of our center experience., Methods: Between January 1994 and January 2003, 40 patients aged 22 days to 13 years underwent surgery for pulmonary atresia, VSD, and multiple aortopulmonary collaterals. Case selection was based on preoperative calculation of total neopulmonary arterial index (TNPAI), pulmonary arterial index (PAI), and pulmonary arteries-to-collateral arteries lung segment perfusion ratio (Spa:Sca). The decision for a possible VSD closure during one-stage procedures was based on an intraoperative pulmonary flow study. Twenty-seven patients with a TNPAI > or = 150 mm2/m2 underwent primary unifocalization, irrespective of PAI and Spa:Sca. Conversely, 13 patients with a TNPAI < 150 mm2/m2 and hypoplastic (PAI < 100 mm2/m2) dominant (Spa:Sca > 1) pulmonary arteries received a first-stage right ventricular outflow tract reconstruction, followed by unifocalization and repair (i.e., VSD closure) in 11 cases., Results: Among 38 patients who received total unifocalization, the overall repairability rate was 84% (first instance repairs: n = 29; delayed VSD closure: n = 3; 95% confidence interval 72-96%), with a survival rate at 7.8 years of 83%. Repaired survivors (n = 29) are asymptomatic (n = 25) or mildly symptomatic (n = 4) at a follow-up interval of 43 +/- 30 months, with a 0.48 +/- 0.2 mean hemodynamic right ventricular/left ventricular pressure ratio., Conclusions: Increasing experience with the integrated approach to pulmonary atresia, VSD, and multiple aortopulmonaty collaterals has confirmed the preliminary results of our surgical series. The pulmonary flow study remains the most accurate intraoperative test for successful management of VSD during unifocalization procedures.

More than 10 years after its appearance in clinical practice, laparoscopic cholecystectomy can now be considered the standard operation for gallstone disease. However, some aspects of this operation are still debated. The need to perform routine antibiotic prophylaxis in order to reduce the incidence of infectious complications is still a matter of controversy. International guidelines do not recommend its routine use. The evidence for this, however, is rather limited, because there are no randomized trials with a sufficient number of cases to avoid a type II error. The authors, on behalf of the Lap Group Roma, introduce the protocol of a multicenter prospective randomized controlled clinical trial designed to find a definitive answer to this problem.

Lymphatic mapping and sentinel lymph node (SLN) biopsy for breast cancer is rapidly becoming the standard of care. This is mainly due to the accuracy of the procedure, with a significant decrease in morbidity compared with the standard level III node dissection. We present our experience with SLN biopsy and a small series in which we performed an immediate histologic evaluation of the SLN: in case of positive SLN, a complete lymph node dissection was carried out in the same operative time, thus reducing the need of a second operation. In our experience, we had a 100% accordance between immediate and definitive results: we had neither false positive, which could lead to overtreat the patients with an unnecessary lymph node dissection, nor false negative.

A multicentric prospective study has been carried on 69 patients affected by peritoneal carcinomatosis from colorectal cancer. Patients have been treated by cytoreductive surgery and intraoperative hyperthermic chemoperfusion. CC 0-1 has been achieved in 82%. Major morbidity and mortality was respectively 21.7% and 2.9%. Three years overall survival was 26.7% for all series. Difference in survival evaluating CC 0-1 vs CC 2 patients and PCI < or = 10 vs > 10 was statistically significant. Evaluating only patients CC 0-1 and PCI < or = 10 overall survival rised up to 44.7% at 4 years. A smaller subgroup of patients with a disease-free interval to peritoneal carcinomatosis > or = 2-year showed a 50% disease-free survival at 5 years. In conclusion PCI < or = 10, complete or optimal cytoreduction feasibility and disease-free interval have to be considered for the patients selection to the integrate treatment.

Intra-operative examination of sentinel LN is controversial. Concordance with definitive exam of SLN in this series was 81%, though only 54% of positive cases were diagnosed. Micrometastases and ITC were usually lost intraoperatively, accounting for 14% of cases. Frozen section and touch prep of the SLN were approximately equivalent. The latter has the advantage of preserving tissue for step-analysis of SLN. The ultimate method of intraoperative analysis of SLN which can combine cost-effectiveness and accuracy needs to be determined.

Sentinel lymph node biopsy and intraoperatory radiolocalization (RLI) are fast becoming the standard surgical treatment for invasive breast cancer. Actually, it seems, they have the same rule in "high risk" DCIS of the breast.

Extraction of third molars is the operation most frequently performed by oral and maxillofacial surgeons. The American National Institute of Health (1979) and the American Association of Oral and Maxillofacial Surgeons (1993) have organised consensus conferences to systematically analyse the scientific evidence and provide official guidelines for the management of third molars. However, some clinical aspects are still controversial: indications for preventive extraction, early extraction, prognosis of impacted teeth, continuous follow-up, relationship with anterior crowding and temporo-mandibular disorders. This article reviews the conclusions from the consensus conferences and integrates them with more recent data. The actual trend seems to justify a more conservative clinical approach rather than an aggressive extraction policy.

Consensus doesn't exist about the intraoperative cholangiography specially if is need in every one laparoscopic cholecystectomy either exclusively in case of anatomical doubts or suspect of injures or stones of the common duct. We have considered 450 patient subjected to laparoscopic cholecystectomy during 1992-2000. Patients suspicious to be affected by common duct lithiasis (28 cases) are subjected to ERCP with cleaning of the biliary tree. In 18 patients (4%) it has been necessary the laparotomic conversion; 176 patients (39%) have been subjected to intraoperative cholangiography, selected on anatomical regional disposition or anamnesis and biochemical and instrumental results (history of jaundice or gallstones pancreatitis, abnormal serum level of the biliary stasis biochemistry, common bile duct major of 8 mm, michrolitiasis of the gallbladder). In 7 cases (4%) we have discovered common bile duct stones. We don't attempt intraoperative cholangiography in every one laparoscopic cholecystectomy, but only in cases where we suspect presence of common bile duct stones either iatrogenic injuries or when we retain it necessary to clarify the regional anatomy. Unlikely just in patients where would be more useful, causes major risk of intra- and post-operative complications, it is very difficult, often impossible, to attempt the intraoperative cholangiography. Routinary employing of the intraoperative cholangiography could be useful just for a little number of patients, while selective employing reduce 60% the X-ray. Collaboration with the radiologist is able to reduce the mistaken on the interpretation of the radiograms.

Background: Local recurrence remains one of the most complex problem in the management of rectal carcinoma. Often, surgery alone is not able to prevent local recurrence development, particularly in locally advanced cancer. A better local control is obtained using the association with radiotherapy and chemotherapy. Intraoperative Radiation Therapy (IORT) represents an innovative therapeutic modality., Patients and Methods: 141 patients, 97 with "high risk" cancer (T2N1-2 or T3N0-2) and 44 with "locally advanced" tumor (T3N3, T4N0-3 or local recurrence). 64 patients with extraperitoneal "high risk" rectal cancer have been treated with preoperative radiotherapy (38 Gy), surgical excision and IORT (10 Gy). In other 33 "high risk" cases, preoperative radio- (50.4 Gy) chemotherapy (Tomudex 2-3 mg), surgery and IORT (10 Gy) have been given. Fourty four patients with "locally advanced" rectal tumor have had external radiotherapy (48 Gy) + chemotherapy (5FU + Mitomicin C) preoperatively, surgery, IORT (10-15 Gy) and chemotherapy (5FU + Levamisolo) postoperatively., Results: Among "high risk" patients, 52-83% of cases have had a sphincter-saving surgical procedure, 5-year local control is 93%, 5-year overall survival 80%, and 5-year disease free survival 77%. In 50-60% of "high risk" tumors treated with preoperative chemo-radiotherapy the pathologic staging have found a T0-1 tumor. Among "locally advanced" primary tumors, 5-year local control is 90.9%, 5-year disease free survival 47.1%, 5-year overall survival 60.7%. Among patients treated for local recurrence, in 60% a complete tumor resection has been performed; 5-year local control is 79.5%, 5-year disease free survival 19.4%, 5-year overall survival 41.4%., Conclusions: Integrated treatment with radiotherapy, chemotherapy, surgery and IORT has allowed a good local control and seems prolong survival also.

Background: An innovative approach to peritoneal neoplasm therapy is based on the surgical exeresis of visceral neoplasms, peritonectomy and lastly perfusion of the abdominal cavity with cytostatic drugs in hypothermia (1PCH). Cisplatin (CDDP) is one of the most frequently used drugs for peritoneal perfusion owing to its excellent synergy with hypothermia, reduced ability to penetrate the peritoneal- plasma barrier and its demonstrated efficacy against the majority of neoplasms causing peritoneal carcinosis. A major restriction is that CDDP causes renal toxicity. In order to minimise the risk of renal damage, the authors studied the use of amifostin to protect the renal system. A phase-1 study was performed to find the dose of amifostin that guarantees effective renal protection without causing hypotension., Methods: A total of 67 cytoreductions were performed at our centre associated with abdominal cavity perfusion using cytostatic compounds in hyperthermia (1PCH) with CDDP for peritoneal carcinosis. Among the first 9 patients undergoing IPCH without nephroprotection, Grade 2 (WHO) renal toxicity was observed in 4 cases (44%) and Grade IV-WHO toxicity in one patient (11%) leading to hemodialysis and death. Arnifastin was then administered to 18 patients. The administration protocol was as follows: cytoreduction, im. administration of amifostin 910 mg/m2 in 15 minutes, execution of IPCH. All patients treated using this dose presented hypotension with systolic arterial pressure <70 mmHg and amifostin administration was consequently suspended. Amifostin was then administered to a further 18 patients divided into groups of three. The dose used for the first triplet was 400 mg/m2; we then increased the dose by 50 mg/m2 in each subsequent triplet. The maximum dose tolerated was 50 mg/m2 less than the initial dose that caused systolic pressure to fall below 70 mmHg., Results: Patients treated with doses = or <500 mg/m2 did not present hypotension and it was therefore possible to administer the entire dose. Patients treated with 600 mg/m2 of amifostin all presented hypotension <70 mg Hg, leading to the suspension of the drug. A new triplet of patients was treated at a dose of 550 mg/m2 and none showed hypotension. Taking 550 mg/m2 as the maximum tolerable dose, a further 22 patients then received amifostin infusion with 550 mg/m2 prior to IPCH. Creatinemia was assayed daily for two weeks and creatinine clearance was measured twice a week to evaluate the efficacy of nephroprotection. None of the patients treated with amifostin during the study died from causes correlated to renal failure: 1 patient died from TEP and 1 from septic shock. No patient treated with a dose of 550 mg/m2 developed arterial hypotension. None of the 18 patients in the dose-finding study presented postoperative creatinemia >1.6 (WHO grade 1 toxicity). In the group of 22 patients treated later, 2 cases (9%) presented creatinemia >1.6 (1.8 and 2.1) for a few days; both had undergone severe debulking and one of the patients subsequently underwent resection and anastomosis of the left renal artery invaded by the neoplasm., Conclusions: Some patients undergoing cytoreduction+IPCH without the use of amifostin developed severe renal toxicity; acute renal failure occurred in 1 patient requiring hemodialysis and was the main cause of death. None of the 28 patients treated with amifostin 550 mg/m2 developed hypotension or renal insufficiency; only 2 cases showed a slight transient increase in renal function markers. Amifostin appears to be an effective drug for protecting renal emunctory from the toxic effects of CDDP used in cytoreduction+IPCH in patients with peritoneal carcinosis. The dose of 550 mg/m2 used in this study does not cause hypotension and is recommended for this type of clinical use.

Coronary angiography remains the standard technique for the assessment and therapy of coronary artery disease. Recently, intravascular ultrasound (IVUS) has emerged as a new adjunctive invasive tool which allows the acquisition of direct images of the atherosclerotic plaque in the cardiac catheterization laboratory; however it cannot be considered as an alternative to angiography. The aim of this article was to describe the indications, technique, and interpretation of IVUS imaging and its diagnostic and therapeutic applications, to review the pertaining literature and report the experience from our catheterization lab group. Ultrasound provides a unique method to study the regression or progression of atherosclerotic lesions in vivo. Lipid-laden lesions appear hypoechoic, fibromuscular lesions generate low-intensity or "soft echos" while the fibrous and calcified tissue impedes ultrasound penetration, obscuring the underlying vessel wall (acoustic shadowing). IVUS has been used to evaluate arterial remodeling: positive remodeling is the increase in arterial size to compensate for plaque accumulation and represents a compensatory mechanism to preserve lumen size; negative remodeling is vessel shrinkage and has been implicated in restenosis after balloon angioplasty. Positive remodeling seems to be significantly more frequent in myocardial infarction and unstable angina, negative remodeling occurs more often in stable coronary syndromes and is the main mechanism of restenosis after balloon angioplasty. In ostial and bifurcation lesion, the stenosis may be obscured by overlapping contrast-filled structures. Intermediate stenoses are particularly problematic in patients whose symptomatic status is difficult to assess. In these ambiguous situations, ultrasound provides a tomographic perspective, independent of the radiographic projection, which often allows precise lesion quantification. IVUS has emerged as the optimal method for the detection of diffuse post-transplant vasculopathy. Rapidly progressive intimal thickening (> 0.5 mm increase) in the first year after transplantation has major negative prognostic significance. The safety of IVUS is well documented, with studies reporting complication rates varying from 1 to 3%; the complications most frequently reported is transient spasm. Ultrasound allows us to evaluate plaque morphology, plaque eccentricity and lesion length, often helping in procedural decision-making. IVUS demonstrates plaque fracture and arterial wall dissection more often than angiography. Coronary angiograms frequently underestimate disease burden, whereas IVUS identifies residual plaque burden and minimal lumen diameter as the most powerful predictor of clinical outcome (restenosis). Several IVUS studies of directional atherectomy have addressed the issue of more aggressive plaque removal possibly resulting in decreased angiographic restenosis rate. IVUS imaging has played a pivotal role in the optimization of stent therapy. The concept of high-pressure stent implantation disseminated quickly, and larger trials demonstrated the safety of stent implantation using high pressures. IVUS has shown that in-stent restenosis is determined by the degree of intimal hyperplasia within the stent or in the stent border. In conclusion, the use of IVUS in the world is slowly increasing. Ultrasound commonly detects occult disease in patients with coronary artery disease. However, no short- or long-term studies have determined whether disease detected exclusively by ultrasound portends a worse prognosis as compared with "true normal" angiography.