Search

Aim: Intestinal obstruction is a frequent event in patients affected by ovarian carcinoma. Little data on repeat palliative surgery for recurrent bowel obstruction are available. The aim of this study was to analyze postoperative and long term outcomes of ovarian cancer patients who underwent reoperation for recurrent intestinal obstruction., Methods: We retrospectively evaluated the records of these patients treated at our Department between 1992 and 2002., Results: Nine women with a mean age of 56 years (range 37-72) were identified. All patients had undergone previous abdominal surgery for bowel obstruction from ovarian cancer. All patients underwent exploratory laparotomy. In 4 patients (Group A) because of advanced disease, only exploratory surgery was carried out. A surgical correction was achieved in the other 5 patients (Group B), but only 3 patients had a successful palliation, defined as the ability to tolerate an oral intake for at least 60 days postoperatively. Postoperative mortality was nil, morbidity was 44.4%; particularly 2 patients developed an enterocutaneous fistula. Mean survival of Group A and B patients were 36.7 and 96.2 days respectively. The 3 successful palliated patients died of disease after 3.5, 4 and 5 months, in 2 cases for recurrent bowel obstruction., Conclusions: Repeat surgery for recurrent bowel obstruction in advanced ovarian carcinoma may achieve successful palliation in few cases and is associated with high postoperative morbidity and limited survival. In these patients non surgical approaches based on medical treatment, percutaneous endoscopic gastrostomy and stent placement should be considered.

Background: Gastrointestinal carcinoid tumors are rare and little is known about factors related to prognosis in patients with carcinoid disease. Aim of this study is to determine the impact of clinical presentation variables on the management and survival., Methods: We have evaluated 31 consecutive patients with gastrointestinal carcinoid tu-mours who underwent surgical intervention at the I Department of Surgery of Milano-Bicocca University over 15 years (1985-1999). Tumor distribution, hormone production, prognostic factors and survival were analysed., Results: Carcinoid syndrome was the only clinical pattern diagnostic of carcinoid tumour. Most common symptoms were abdominal pain (64%), nausea and vomiting (48%). High levels of urinary 5-hydroxyindolacetic acid were significantly associated with carcinoid syndrome and metastatic disease. Tumor size, depth and gender were significant predictors of metastases. Age, gender, tumor size, metastatic spread and location were statistically significant predictors of death., Conclusions: Clinical presentation was non specific except for those patients affected by carcinoid syndrome. Ten years overall survival was 43%, with 52% metastatic spread incidence. The extent of surgical resection should be modulated on patient related risk factors. Poor prognostic factors affecting survival were: age, gender, metastatic disease, depth of invasion and tumour size.

Vertical banded gastroplasty, reported by Mason in 1982, is an effective method to control pathologic obesity (BMI>40 kg/m2). With the widespread of this procedure and the introduction of laparoscopic approach several complications are described in literature: gastroesophageal reflux, esophagitis, gastritis, gastric bleeding and perforations, prolonged vomit, dislocation of gastric ring, cholelithiasis, gastric fistulas, gastric stomal stenosis, dehiscence of vertical stomach staple line. From 2 to 10% of patients are reoperated because of inefficacy of treatment or short and long-term complications. Morbidity and mortality associated to reoperations are still high and it is difficult to identify criteria for an appropriate revision procedure. This can occur through endoscopy, laparotomy or laparoscopy, depending on clinical and radiologic feature. Dehiscence of vertical stomach staple line, observed in 10-20% of cases, even if asymptomatic, can lead to bad complications such as fistulas, peritonitis and sepsis. The case of a young woman, who underwent a vertical banded gastroplasty for pathologic obesity (117 kg, h 167 cm, BMI 42/m2) and subsequent laparotomies in the attempt to correct vertical staple line dehiscence, is reported. The patient came to our observation in a septic shock caused by peritonitis and ARDS and a total gastrectomy with Roux-en-Y esophago-jejunostomy was performed.

Background: Primitive gastric lymphoma (PGL) is a rare tumour, and although its incidence is rising it is difficult to state the role of the various therapeutic methods in treating this disease. Aim of this study is to point out what sequence of treatment is more effective trying to find out some guidelines which can be useful in clinical practice., Methods: Retrospective analysis of clinical data of 54 patients with PGL admitted at a University surgical department during 10 years. All the patients underwent neoadjuvant or adjuvant chemotherapy and D2 gastrectomy. Follow-up ranged from 6 to 120 months. Survival was related to: Mushoff's stage of disease, the grade according to the Working Formulation and the sequence of treatment. Statistical analysis was performed by Kaplan-Maier method and the difference between survival curves was compared by log-rank test., Results: Mean postoperative hospital stay was 12 days and morbidity was 18%. Five and 10 years overall survival rates were 70 and 85%. There was a significant difference in survival between patients with high grade PGL and those with intermediate grade (p=0.0188) as well as in those with low grade (p=0.0435). Patients in stages IE-II1E had a significantly longer survival than those in stages IIIE-IVE (p=0.0123). Patients in stages IE-II1E underwent neadjuvant chemotherapy and surgery and survived longer than those in whom surgery preceded chemotherapy (p=0.0293) instead for patients in stages IIIE-IVE neoadjuvant chemotherapy shortened survival (p=0.0403)., Conclusions: In personal opinion, in patients in stages IE-II1E chemotherapy should be carried out before surgery, while in those in stages IIIE-IVE the reverse scheme is more effective in achieving longer survival rates.

Background: Gallbladder cancer (GC) is reported in 1.5-3% of cholecystectomies. Since the introduction of laparoscopic surgery, cholecystectomies have increased and occult GC may therefore be more frequent., Methods: Here we conduct a retrospective study on a series of 1200 LC performed between January 1991 and December 1998 at our Institution, to determine whether there was an increase in GC. We also evaluated the risk factors for this outcome and the possibilities of treatment, in case of unsuspected GC discovered after LC at histological examination. Seven cases of GC undiagnosed before surgery (0.6% of the study population) were submitted to LC (against 0.3% GC discovered after open surgery). The clinical course depended on the histopathologic stage of the cancer., Results: After a median follow-up of 18 months (range 12-48), 2 pT1 patients were alive and well, 2 pT2 patients were alive and disease free (in 1 case after a surgical removal of a trocar site metastasis appeared 6 months after LC). The other 3 patients died, 2 (1 pT2 and 1 pT3) after an additional resection of the liver bed with lymph node dissection, due to peritoneal dissemination of the disease. In 2 cases we found a gallbladder polyp pre and intraoperatively, which proved to be a carcinoma., Conclusions: Undiagnosed GC is on the increase with the introduction of LC. Polypoid lesions of the gallbladder, age > 70 years: a long history of stones and a thickened gallbladder wall all represent significant risk factors. If one or more is present, examination of the gallbladder and a frozen section are recommended.

Background: Laparoscopic treatment of common bile duct (CBD) stones is gaining great acceptance worldwide, but actually it requires skills and technologies too expensive for a great part of general surgeons. So endoscopic removal of CBD stones before cholecystectomy is usually performed. Since 1991 in our department we started a policy of selective preoperative cholangiopancreatography (ERCP) in patients suspected for choledocholithiasis and waiting for laparoscopic cholecystectomy., Methods: A retrospective study has been made on a population of 1100 patients who underwent elective laparoscopic cholecystectomy in the period between January 1991 and December 1997. They were 391 male and 719 female with a mean age of 52 years, 126 of whom (11.5%) were selected to have ERCP preoperatively because they had clinical, biochemical and ultrasound signs of the presence of common bile duct stones (CBDS)., Results: Successful cannulation of the CBD was achieved in 124 cases (98.4%), with failures due to ampullary diverticula. In 7 cases (5.5%) a precut was necessary to obtain cannulation. Sphincterotomy was performed in 113 patients (89.7%). In 93 patients (73.8%) stones were found (87 macrolithiasis and 6 microlithiasis); in 91 (97.8%) stones were removed in one (87) or two (4) endoscopic session. There were 2 major complications (one bleeding and one severe pancreatitis) due to ERCP or a sphincterotomy. Two patients developed symptoms from unsuspected common bile duct stones after LC and were removed endoscopically. No complications during LC were due to ERCP or ES., Conclusions: Selective preoperative ERCP is an effective way of clearing the CBD stones before laparoscopic cholecystectomy, with low rate of complications related to endoscopic and laparoscopic procedures, and short mean hospital stay (5.5 days), according to the concept of minimally invasive treatment.

Background: Inguinal hernia repair with prolene mesh according to Lichtenstein "tension free" technique has gained great acceptance worldwide, showing efficacy to consolidate the posterior wall of the inguinal canal and to reduce recurrence risk because of tension on suture lines and postoperative pain. Personal experience of 692 hernias treated with this technique is reported., Methods: From January 1989 to December 1997, 692 patients were treated according to Lichtenstein at the General Surgery Department of the San Gerardo Hospital. Mean age was 60 years (range 18-88) with a male: female ratio of 13:1. Surgery was performed under local anesthesia in 185 cases, under epidural anesthesia in 317 and under general anesthesia in 190. Hernia was primitive in 647 cases (411 obliquo-external and 236 direct), while in 45 patients it was a recurrent hernia. In this series, 619 patients had monolateral inguinal hernia, while 73 had a bilateral one. In 40 cases hernia was incarcerated and in 8 strangulated., Results: Mean hospital stay was 2.3 days (range 1-8). Eleven (1.6%) early complications, were observed, with one periprosthetic infection which resolved after patch removal, 3 hematomas, 2 seromas and 2 wound infections. Furthermore, there were 32 (4.6%) late complications with only one recurrence (0.14%) in this series and 25 cases of persistent nerve irritation., Conclusions: The results obtained with Lichtenstein "tension free" repairs of inguinal hernias confirmed this technique as easy to perform, also under local anesthesia, and associated with low rates of complications and without recurrences.

Background: Laparoscopic cholecystectomy is now worldwide considered the elective therapy for biliary lithiasis. Morbidity, mortality and conversion rates reported in the literature are assessed between 1 and 6%, 0 and 0.9%, 3.6 and 7.2% respectively. Data on personal experience with 1019 attempted laparoscopic cholecystectomy are reported., Methods: In the period between 1991 and 1997 1019 laparoscopic cholecystectomy were performed. Patients were 361 males and 658 females (ratio M:F 1:2), with an average age of 51 years (range 5-85). Indications were: 647 symptomatic cholelithiasis, 28 hydrops, 121 empyemas, 76 cholecystocholedocolithiasis and 13 alithiasic cholecystopathy., Results: Conversion was necessary in 61 cases, with a conversion rate of 6%. Mean duration of surgery was 65 minutes (range 30-240) with a mean hospital stay of 2.1 days (range 1-10). No deaths occurred in our series, with a morbidity rate of 1.8% (18 cases, 7 major and 11 minor). Only 1 case of bile duct injury (0.1%) is reported., Conclusions: In consideration of low conversion rate, low early and late morbidity, absence of bile duct injury, advantages for the patient and the opportunity of evolution of this surgery, laparoscopic cholecystectomy can be considered the standard treatment for biliary lithiasis.

Background: Clinical results of colic anastomosis using biofragmentable anastomosis ring (BAR-Valtrac) are presented. Such a method showed to be a real alternative technique to the usual ones., Methods: Eighty-six colic anastomosis using BAR are collected, 76 of which performed as elective surgery and 10 in emergency. The patients were 47 males and 39 females, with a mean age of 64 years. In 63 cases the patients were affected by colic neoplastic disease, in 16 by complicated diverticular disease (stenosis or perforation) and 7 patients had neoplastic disease of other organs involving the colon BAR device was used in 48 colic reconstructions after segmentary resection and in 38 colic reconstructions after left hemicolectomy. In each case 31-34 mm BAR were used., Results: No perioperative death occurred in our series. Only one case (2%) of anastomotic leak was observed, while in 3 cases (4%) intestinal canalization disorders occurred. No problems for ring expulsion occurred in any patient. Three late complications were observed, as three cases of asymptomatic substenosis discovered during instrumental follow-up and spontaneously cleared up., Conclusions: On the basis of clinical results, and according to those reported in literature BAR anastomosis is considered a safe, feasible and easy technique to perform colic anastomosis, even in emergency, limited to the intraperitoneal tract of the colon.

"Tension free" technique with prosthetic mesh for inguinal hernia repair was introduced since 1988 in Authors' Institution. In a review of 98 hernioplasties performed, only one relapse was observed (around 1%), while prosthetic infection cases were never observed. The disorder most frequently complained by the patients is a pain in the pubic area, persisting even months after the operation. Therefore this technique seems to be reliable, safe, and easy. While waiting for a long-term follow up to confirm these results, the Authors however suggest to limit the indications for this technique avoiding the use of prosthetic material in young patients since Shouldice's hernioplasty assures a low percentage of relapse for them.

A case of repeated, exsanguinating gastrointestinal haemorrhage in a 36-yr-old man, due to rupture in the duoedenum of an arteriosclerotic aneurysm of the coeliac artery, is described. Selective arteriography enabled the cause of bleeding to be established. The pictures for the coeliac and superior mesenteric arteries showed good hepatic arterial vascularisation via the vessels issuing from the right hand side of the superior mesenteric, immediately after its point of origin. Successful aneurysmectomy was not performed until the fifth operation, when the cause of bleeding had thus been made clear.