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The authors report a case of operative injury of the hepatic artery during a total spleno-pancreasectomy procedure for a mixed-type intraductal papillary mucinous neoplasm. During the preparation of the structures of the hepatic pedicle, a "true" hepatic artery was not identified, but only a small arterial vessel measuring about 2 mm in diameter, just in front of the portal vein, apparently emerging from the parenchyma of the pancreatic head. To obtain complete mobilisation of the duodeno-pancreatic block from the portal vein, it was necessary to cut this small arterial vessel. In the postoperative period, the patient developed extensive liver ischaemia, which was gradually resolved, but resulted in multiple stenosis of the intra- and extra-hepatic biliary tree. At follow-up at three years, the patient was in fairly good condition, with a permanent percutaneous biliary drainage, but with no clinical or radiological signs of local or distant disease. Although interruption of hepatic arterial flow is usually well tolerated, this is not always the case. It is important to predict in what circumstances complications are likely to occur. The main determinants that should guide the surgeon faced with this problem are whether the portal circulation is normal, whether structures carrying collateral blood supply have been interrupted, and whether some form of biliary reconstruction is needed.

Pancreatic cystic tumours are rare and less frequent than other pancreatic tumours. In recent decades, these tumours are being diagnosed with increasing frequency due to the extensive availability of, and improvement in, modern imaging techniques and it is often possible not only to differentiate them preoperatively from other cystic pancreatic disorders but also from one another. Pancreatic cystic tumours comprise a variety of neoplasms with a wide range of malignant potential: serous cystic tumours are benign, whereas mucinous cystic tumours, and intraductal papillary mucinous tumours are considered premalignant, while solid pseudopapillary tumours have a non-aggressive behaviour in the vast majority of cases. Most patients have no symptoms; and when clinical signs are present, they never help us to identify the type of pathology. Serous cystic neoplasms usually do not mandate resection unless the lesion is symptomatic. Mucinous cystic neoplasms and intraductal papillary mucinous neoplasms have a premalignant or malignant tendency, and therefore need to be managed aggressively by pancreatic resection. Their prognosis is excellent in the absence of invasive disease, but the presence of invasive malignancy is associated with a poor prognosis. This review addresses the symptoms, diagnosis, management and prognosis of this group of tumours.

Gastrointestinal stromal tumours, though rare, are the most common mesenchymal neoplasms affecting the gastrointestinal tract. The most frequent sites of origin are the stomach and the small bowel, but they can occur anywhere in the gastrointestinal tract. Mesenteric and retroperitoneal forms have been described. The Authors present their personal experience with the treatment of gastrointestinal stromal tumours, with particular reference to the broad spectrum of clinical presentations and to the consequent therapeutic implications. We report on a retrospective analysis of the clinical presentations and courses, surgical management and pathological features of 27 patients with such tumours treated in our institution from 1993 to 2005. The variables analysed were the morphological and clinical characteristics of the tumours, demographic data, type of surgical treatment and postoperative course. Long-term survival was evaluated on the basis of clinical and/or telephonic follow-up in all patients. One tumour was located in the oesophagus, 14 in the gastric area, 7 in the small bowel, 2 in the colon-rectum, and 3 in the peritoneum. All patients studied received radical surgical treatment. In 7 patients surgical resection was extended to other organs. No postoperative mortality or major postoperative complications were observed. Twenty-two patients are still alive at follow-up. Three patients died as a result of neoplastic relapse and 2 of other causes. The median survival was 36 months. The actuarial 3- and 5-year survival rates were 89.7% and 67.8%, respectively. Our experience indicates that the site of origin of gastrointestinal stromal tumours with their broad spectrum of clinical presentations may influence both the therapeutic choice (neoadjuvant utilisation of imatinib mesylate) and the surgical treatment (wedge resection vs enlarged operations).

Castleman's disease is a rare disorder of the lymphoid tissue with three possible histological variants--the hyalin-vascular type, with a good prognosis, the plasma-cellular type and the mixed type; the latter two are both more aggressive than the hyalin-vascular type. Two clinical types of this disease have already been described: the localized or unifocal type and the multicentric or multifocal type. The aetiology of Castleman's disease remains unclear due to polymorphic clinical features that give rise to many diagnostic and treatment problems. Its diagnosis, therefore, can only be confirmed by histological examination. Surgical treatment is the treatment of choice in patients with Castleman's disease, but radical removal of the tumour mass, especially in the multicentric type, is not always possible. We are still in no position to draw definitive conclusions as to treatment, because there are only a few reports with different regimens regarding patients with multicentric Castleman's disease. A better understanding of the pathogenesis of this rare disorder may help in deciding the best treatment approach. In this study, we report two cases of Castleman's disease, one hyalin-vascular and the other plasma-cellular, both of which were unifocal and located in a retroperitoneal-pararenal site. We also analyse the main clinical, diagnostic and treatment problems associated with this rare condition, with an overview of the literature.

Gastrointestinal stromal tumours are a relatively new nosological entity with an increasing incidence. CD117 positivity at immunohistochemical analysis is mandatory to distinguish them from other mesenchymal tumours. A gastric localisation is observed in more than 70% of cases. In the present paper 11 primary gastrointestinal stromal tumours of the stomach operated during the last decade at our institution were retrospectively reviewed. Hospital files and histological slides of 11 patients with gastrointestinal stromal tumours of the stomach undergoing surgical resection at our institution over the period from 1993 to 2003 were reviewed retrospectively. The variables analysed were: morphological and immuno-histochemical characteristics of the tumours, demographic data, type of surgical treatment and postoperative course. Long-term survival was evaluated on the basis of clinical and/or telephone follow-up in all patients. Immunohistochemical analysis for CD11 7 proved positive in all patients. The size of the tumours ranged from 3 to 23 cm: tumour size was > 5 cm and > 10 cm in 8 and 3 patients, respectively. Nodal involvement was detected in one patient and another had liver metastases. Surgical treatment consisted of wedge resection in 3 cases, distal subtotal gastrectomy in 4 and total gastrectomy in 4. In 2 patients surgical excision was extended to other organs. No postoperative mortality or major postoperative complications were observed. Nine patients were still alive at follow-up; 1 patient died as a result of a neoplastic relapse (38 months) and 1 died of other causes (48 months). The median survival was 42 months. Gastrointestinal stromal tumours are characterised by slow growth and therefore clinical signs are delayed. For that reason large tumours are often observed at the time of diagnosis. Surgical resection is the only potential curative treatment; but the risk of recurrence (local or at distance) remains high.

Dehiscence of the Roux-en-Y oesophagojejunostomy after total gastrectomy is an infrequent complication that may lead to severe morbidity and even death when it occurs. A prospective multicentre randomised trial was designed to assess the need for routine nasojejunal decompression after total gastrectomy with Roux-en-Y oesophagojejunostomy in patients with gastric cancer. Two hundred and thirty-seven patients undergoing total gastrectomy for gastric cancer were randomly assigned to placement of a nasojejunal tube (NJT group) or not (no-NJT group). The patients were monitored for postoperative complications, mortality and postoperative course. The rates of anastomotic leaks were similar in both groups (NJT group, 6.9%; no-NJT group 5.8%) as were the rates of major postoperative complications (25.9% and 21.5%, respectively) and the overall postoperative mortality rates (0.9% and 0.8%, respectively). There were no differences between the two groups in mean time +/- SD to passage of flatus (4.6 +/- 1.3 and 4.5 +/- 1.7 days, respectively) and to starting a liquid diet (7.8 +/- 2.6 and 7.7 +/- 1.6 days, respectively), or in mean +/- SD postoperative hospital stay (13.5 +/- 7.3 and 13.9 +/- 10.9 days, respectively), mean postoperative pain and postoperative abdominal distension. The results of this study suggest that routine placement of an NJT after Roux-en-Y oesophagojejunostomy is unnecessary in elective total gastrectomy for gastric cancer.

Duodenal perforations occur in 0.4-1% of endoscopic manoeuvres. In cases of periampullary injury, the best therapeutic approach is still controversial. Generally, the first treatment will be conservative, but in some patients large retroperitoneal infections requiring surgical treatment develop. Six patients, referred to our unit for extensive retroperitoneal collections and unstable septic conditions as a consequence of periampullary duodenal perforation during ERCP, were treated by right posterior laparostomy with twelfth rib resection. The septic process was treated efficaciously by the open posterior approach that favoured the spontaneous closure of the duodenal leak after a mean period of 14.5 +/- 5.2 days. No hospital deaths or major complications were recorded. Late incisional hernia developed in one case. The technique of posterior laparostomy with twelfth rib resection permits adequate debridement and drainage of both the upper and lower parts of the retroperitoneal space involved in infection after periampullary duodenal perforations. The good control of both the retroperitoneal septic process and the duodenal secretions facilitates the spontaneous closure of the duodenal leak, thus avoiding the risk of more complex and dangerous procedures.

The review of the literature shows the improvement of outcome of patients with gastric cancer after resection and extended lymphadenectomy. Lymphadenectomy D2/D3 was performed in 206 out of 639 patients with gastric cancer: 5-year survival was 66.3% versus 41.5% of the 121 patients that underwent D1 resection (p < 0.0001). Univariate and multivariate analyses show that proximal location of the cancer, advanced stage and lymphadenectomy limited to perigastric stations are negative prognostic factors. Although there are still different opinions regarding D2 or D3 lymphadenectomies for the operative risks, pancreatic resection (preferring pancreas sparing techniques) and splenectomy is subtotal gastrectomy for antral carcinoma, extended lymphadenectomy remains an important point to improve survival.

The EEA Stapler is widely employed in the rectal cancer surgery, particularly allowing a more frequent sphincteric preservation after low anterior resection. The authors rather employ the manual suture whenever possible and report their own experience on EEA Stapler employment in the surgical management of rectal cancer located 12 to 6 cm. from the anal verge. They emphasize this technique pointing out the necessity of further investigations which may confirm the possibility of obtaining a curative complete surgical removal as well as by abdomino-perineal resection.