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Pancreaticoduodenal resection yields poor results, mainly because of cancer spread into retropancreatic nervous tissue. The aim of this study was to evaluate the feasibility of dissection capable of sparing a portion of retropancreatic nervous tissue in order to lessen, if not prevent, postoperative diarrhoea and severe malabsorption. From April 2000 to June 2001 20 dissections were carried out on 18 fresh cadavers (15 male) within 24 hours of death and on 2 frozen trunks. In all dissections the splanchnic nerves, coeliac plexuses, capital pancreatic plexus and superior mesenteric plexus were identified and traced. The capital pancreatic plexus is composed of two bundles, the first originating in the right coeliac plexus, the second in the superior mesenteric plexus. These two bundles join together just behind the head of the pancreas. The superior mesenteric plexus is composed of two preganglionic bundles, one ganglion, and another two postganglionic bundles. These latter two bundles receive fibres from both the right and left coeliac plexuses. In pancreaticoduodenal resection for cancer, the capital pancreatic plexus has to be completely removed, like the superior mesenteric plexus, as they are very often infiltrated and constitute a route for cancer spread. In small cancers, a thin layer of nervous tissue around the superior mesenteric artery might be spared in order to avoid diarrhoea due to intestinal denervation. The results of this study show that there is anatomical evidence that a thin layer of superior mesenteric plexus receiving fibres from both the left and right coeliac plexuses maintains adequate intestinal innervation.

The modern approach to rectal surgery aims at preserving the nerves to the urogenital system. The relationships between the lateral aspects of the rectum and the surrounding structures represent one of the most controversial points in the surgical anatomy of this area. This study was conducted on 27 fresh cadavers and 5 frozen pelvises. All dissections were performed with a technique similar to that used for the surgical mobilisation of the rectum. The lateral ligaments can be considered extensions of the mesorectum; they originate laterally to the middle portion of the rectum and descend posterolaterally to anchor to the endopelvic fascia. The lateral neurovascular pedicle of the rectum, comprising the middle rectal artery and the transverse autonomic nervous fibres, courses partially beneath the lateral ligament. The urogenital nervous bundle runs close to the point of insertion of the lateral ligaments in the endopelvic fascia, but is not covered with the same layer that forms the ligament itself. Anatomical dissection of cadavers is of invaluable help to the surgeon as it represents the basis for easy recognition of all the various structures in the rectal area.

The key concepts regarding nutrition of elderly patients prior to surgery are outlined. The main metabolic changes that occur during surgical stress, paying special attention to the characteristics of elderly patients, are described. Lastly, the caloric-energy intake required by postoperative geriatric patients is evaluated and the methods of food intake compared to the benefits obtained are analysed.

Background/aims: The investigators studied the surgical anatomy of the main structures involved in the mobilization of the rectum (Denonvilliers' fascia, mesorectum, middle rectal artery, superior and inferior hypogastric plexuses)., Methodology: The study was carried out on 20 cadavers (17 unembalmed and 3 embalmed). To study Denonvilliers' fascia, ten embryos and fetuses (11 mm to 80 mm CRL) were also examined., Results: Denonvilliers' fascia originates from the fusion of the primary pouch of Douglas. The two leaves making up this structure are easily separated. The mesorectum surrounds the rectum on three sides; it is easily separated from the presacral fascia and its connective tissue is bordered by a thin membrane. The middle rectal artery varies in appearance rate, origin, size, distribution and anastomosis. It runs under the lateral ligament and also sends branches to the genital apparatus. Of the two hypogastric plexuses, the inferior is the most difficult one to identify. Its superior branches extend to the rectum, and the inferior ones to the genital apparatus. Because the anterior part contains the parasympathetic nerves and the middle rectal artery, this region is at major risk during surgical dissection., Conclusions: A sound understanding of the surgical anatomy of the rectum enables the surgeon to perform a more correct and reasonable procedure in terms of both the extent of surgical treatment and the preservation of important anatomical structures.

Background: There are many causes of ulcer of the lower limb. In the elderly, venous ulcers and arteriosclerosis often coexist; for this reason pressure bandages might be contraindicated for the risk of precipitating a potentially critical arterial flow. In this work, the conditions which allow a safely treatment with pressure bandage in the elderly are evaluated., Material and Method: Eleven self-sufficient elderly, with venous ulcerations to one leg only, and ankle pressure/omeral pressure between 0.92 and 0.86 were treated with elastic bandaging of the leg., Results: All patients completed the treatment, with healing of the ulcer obtained in 3-8 months time. So far none of them relapsed., Conclusions: In the elderly, in selected cases, when Pc/Po > 0.86, pressure bandages can be safely applied to heal the ulcer, without running the risk of endangering arterial circulation.

The aim of this work is to evaluate the differences in lymphocytic sub-classes between elderly patients with gastroenteric cancer and elderly patients with a non neoplastic disease. A group of 88 patients over 60, consecutively admitted to the III Division General Surgery for gastro-enteric cancer has been collected for the study, the control group consisted of 74 patients also over 60, consecutively admitted over the same period for benign abdominal diseases. In all patients the following data were measured: body mass index (BMI), white blood cells (WBC), total lymphocytes, total T lymphocytes (CD3+), helper T lymphocytes (CD4+), suppressor T lymphocytes (CD8+), CD4+/CD8+ ratio, B lymphocytes, CD5+ B lymphocytes, activated T lymphocytes (CD3+ HLA-DR+), CD4+ "naive" lymphocytes (CD4+ CD45 RA+), CD4+ "memory" lymphocytes (CD4+ CD45 RO+), NK lymphocytes (CD16+ 56+), red blood cells (RBC), total serum cholesterol, albumin, total serum proteins. The main lymphocytic subsets were on an average lower in the cancerous elderly group with respect to the non cancerous. As the tumour progressively increases in size (T), total lymphocytes significantly decrease, while CD4+ progressively decreases with nodal involvement (N). In the cancerous elderly, we found a lower immune response. The immune system appears to be less efficient also in association with tumor growth, especially when T and N get worse. The response of effector cells to the tumour seems not specific.

The authors present a case of acute suppurative thyroiditis complicated by acute dyspnoea with asphyxia in a patient of geriatric age. In this patient there were present possible infectious focuses like multiple dental abscesses and contamination of the urinary tract. Histological examination highlighted a focus of papillifer carcinoma in the context of the gland. We have a review of the literature on this observation and description. Acute suppurative thyroiditis is currently a pathology of rare observation. This rarity is due, apart from the availability of antibiotic therapy, to an intrinsic resistance of the thyroid gland to contamination. In most cases we are talking of bacterial infections, but in immunodepressed subjects fungal etiology is noteworthy. The infection could arise from primitive focuses present in any bodily district with propagation to the thyroid across different ways. Expressive is the anamnestic observation of preexisting thyroid dysfunction. After an attentive evaluation of the clinical findings, usually characteristic, it is important to complete the diagnostic course with some instrumental investigations. In particular cervical sonography, possibly associated with agobiopsy is fundamental. Initially therapy is medical (basically antibiotic). The surgical resolution foresees the drainage of the purulent abscess or the thyroidectomy if it is associated with a struma.

The authors report the case of correction of a large laparocele after lung transplant. Paradoxical respiration interfered with patient breathing. Three overlapping meshes were used to surgically correct the wound. Excellent results were achieved. Cortisone and immunosuppression therapy was not discontinued; infection risk was minimized by implementing rigorous asepsis and a wide spectrum antibiotic therapy.

Background: Gastroesophageal reflux disease (GERD) is a common intestinal disorder. Although fundoplication immediately achieves good results, some problems arise about duration., Methods: From 1990 to 1992, thirty-seven patients underwent operation for GERD, the indications for surgery being: persistence of reflux symptoms after at least 6 months of medical therapy, esophagitis, manometric evidence of LES incompetence, augmented esophageal exposure to gastric juice documented by 24 hours pH monitoring. Nissen-Rossetti was the technique used; intraoperative calibration was 29.8 mmHg., Results: Twenty-five patients were studied 12 months after the operation. They were submitted to clinical examination, gastroscopy, manometry, 24 hours pH monitoring. Clinically 2 patients were unable to belch. All of them showed LESP and intra-abdominal HPZ length decreased (32.3% and 13.5% respectively). The factors influencing LESP 12 months after surgery are age and intraoperative calibration. Pressure decrease is related to age and calibration. An older patient will show a smaller decrement, to a higher intraoperative pressure corresponds a higher pressure decrease with time., Conclusions: For these reasons we do not recommend hypercalibration especially in the elderly.

The case of a giant diverticulum of the sigmoid colon in a 74 year-old woman is reported. The diverticulum had perforated into the urinary bladder and required a 3-phase operation with resection of the sigmoid colon and urinary bladder. Giant diverticulum is considered a rare complication of diverticulosis. Generally, it is a pseudo-diverticulum that grows due to a valve mechanism working in the neck of the diverticulum. The differential diagnosis lies mainly between intestinal duplication and pneumatosis cystoides. Surgical therapy yields favorable results.

In elderly males, and in particular in very old men, the anatomical changes produced by senility encourage the formation of large inguino-scrotal hernias. Their repair may be achieved using Gilbert's technique to which the authors have proposed a number of variants. The good results show that the "tension-free" technique may be correctly applied in elderly patients with inguino-scrotal hernias, thus allowing a straightforward postoperative recovery with no complications.

The paper reports a study which was carried out to assess immunological function by assaying IL2 in cancer-operated patients treated with thymostimulin. The results of the study show that, used in normally fed, immunodepressed patients, this immunomodulator is able to normalise levels of lymphocyte subpopulations and to bring serum concentrations of IL2-RS to the levels of normoergic patients.

Constipation is a very frequent symptom. It affects 7-10% of people. Otherwise a severe constipation exists which is rare, but extremely serious with evacuations every 15 days to 2 months. We expose the classification of constipation in its types: colonic, rectal and anal. We analyse the diagnostic trial which has to be started with a careful anamnesis and well directed physical examination. Laboratory tests and instrumental investigations will be essential means to define exactly the type of constipation and its pathogenetic mechanism. We go deep into physical involvement of constipation and into the problem of constipation in the elderly: except for particular groups (women suffering from colonic hypokinetic constipation) the age of patient is usually old. Medical treatment is described especially regarding the type of constipation. At last we review the surgical techniques proposed for every form of constipation, with exposure and interpretation of their results.

In this second note, some technical details used during amputation are described, leaving out the systematic description of interventions. The analysis of the postoperative period shows that the more distal the amputation, the higher the incidence of local complication, while about postoperative mortality our data show an opposite trend. The Authors conclude by pointing out that an early indication and an accurate evaluation often allow a more distal amputation, that must be as conservative as possible anyway.

The problem relating to leg amputation following ischemia are analysed in the first part of this study, bearing in mind that amputation must be as conservative as possible in order to ensure the best quality of life. Following a short review of the topic and the introduction of recent trends, the case for amputation, which must be early in order to be conservative, is studied. The first part of this article concludes with a discussion of Doppler and clinical evaluations as techniques used to determine the level of amputation.

The authors carried out a prospective study to ascertain whether cholecystectomy itself might be the cause of duodenogastric reflux. Patients with cholelithiasis were examined and underwent the following tests: hemanalysis, gastroscopy with biopsy, 24 hour pH-metry and acetaminophen test. Twelve patients were selected. Six months after the operation the tests were repeated. All patients were asymptomatic. Hemanalysis was normal in all 12 patients and no difference was seen in the tests of 5 of the patients; however in the other 7 differences were observed in all the tests. The authors conclude that cholecystectomy helps to provoke duodenogastric reflux in predisposed patients, and that this reflux may be asymptomatic.

The correlation between the immunological status of surgical patients and cancer is examined. 52 patients with gastric and colonic cancer were studied. On the basis of the immunological results of skin tests these were subdivided into non-reactive and reactive. The two groups were statistically compared in relation to cancer stage and blood concentrations of 4 markers: CEA, Ca 19-9, Ca-50, T.A.T.I. The first data show that anergic patients are older to a statistically significant degree; the second that there are no significant differences between the two groups as regards cancer stage. The third data show a difference between the two groups in relation to two of the four markers; anergic patients have a statistically significant higher blood concentration of CEA and T.A.T.I. This is rather interesting, since the literature offers no specific studies on the correlation between the patient's immunological status and tumour marker concentration. Therefore, in clinical practice, the high concentrations of these markers, could reveal, as well as the presence of cancer an endangered immunologic status.

Some relevant data on 290 patients (151 under 65 and 139 over 65 years of age) operated on for gastric carcinoma, have been analysed. The age, the stage and location of the neoplasm, the type of surgery and the post-operative mortality have been studied. The mortality in the 113 patients (64 under and 49 over the age of 65 years) who had had total or partial gastrectomies performed, was evaluated at one year, from one to three years and from three to five years. The survival was evaluated according to the age of the patients, the stage and site of the tumour and the type of operation performed. The most frequent location in the elderly patient is the distal third or two-thirds of the stomach. There is no difference between the mortality in elderly or younger patients except following partial gastrectomy. The survival analysed on the basis of the absolute value, the relationship to the stage, the site of the tumour and the type of operation, is longer in the elderly.

The results of superior polar resection carried out for benign and malignant lesions of the lower 3rd of the oesophagus and cardias were controlled endoscopically. Cure time, elasticity, suture function and the onset of complications were assessed in relation to the technique employed. It is known that the most important late complications in this surgery are, apart from recurrences, cicatricial stenosis, perianastomotic granulomas and, particularly, serious oesophagitis secondary to reflux. It is concluded that Lortat-Jacob valvular anastomosis gives the best immediate and long-term results because of its good elasticity and anastomosis function; there are almost never any problems connected with the presence of reflux, which is so important and invalidating for patients operated on with other techniques.

A case of neurinoma of the vagus nerve localized in the cervical, intertracheo-oesophageal region is described. After a survey of the literature on the subject, the differential diagnosis and operative technique are discussed.

A new technique to study esophageal reflux by means of hepatobiliary photoscintigraphy using TC-99m DISIDA was examined. The study was undertaken on 19 patients undergoing total gastrectomy without esophageal recurrence or hepatic or pulmonary metastases. The results of hepatobiliary photoscintigraphy were compared with the clinical, endoscopic and radiologic data. From this comparison it was demonstrated that photoscintigraphy is a non-invasive procedure which permits the study of the intestinal loops excluded from the transit of food but not of bile. Hepatobiliary scintigraphy was shown to be a reliable examination and the only one which demonstrates the reflux under physiological conditions, since the 24h. pH test in the absence of the stomach does not clearly prove the presence of alkaline reflux (bile) in an alkaline environment (esophagus). The disadvantages of photoscintigraphy are that the reflux is demonstrated only during the period of examination and in the patients undergoing total gastrectomy it is difficult to identify with accuracy the esophageal anastomosis. In these cases however, the radioactive bolus was used to localize the anastomosis and therefore to assess the esophageal reflux.

In a series of 70 patients suffering from biliary lithiasis, the roentgenologic findings of fissures in the calculi was observed in 5 cases examined by means of cholecystography and in 7 cases who underwent cholangiocholecystography. Fissures were demonstrated 11 times in calculi after surgery. The "Mercedes-Benz" sign was never observed at the abdominal examination without contrast medium. The presence of fissures may be an additional sign in the radiologic diagnosis of biliary calculi, but its value is not determinant.

In every serious thoracic or abdominal injury, or both, a hernia of the diaphragm should be suspected and always sought clinically and roentgenologically. If a hernia is present, compatible with the condition of the patient, it should be operated upon immediately. The choice of surgical access depends upon the associated lesions. We prefer thoracotomy as the surgical approach if important submesocolic lesions are not present. In instances of a late diagnosis, the approach should always be through the chest. The late results, in patients diagnosed and operated upon early, are good and are comparable with those obtained in operations of the thorax for nonneoplastic conditions. The surgical approach of choice for the treatment of such hernias is a thoracotomy both in the early as well as in the late stages, provided that no important submesocolic lesions are present.

Sliding hiatal hernia occurs in the elderly with a symptom complex which differs from that seen in younger persons. A comparison of the symptoms of this disease in 66 older patients with the symptoms in 154 younger patients revealed four categories in the elderly: digestive, anemic, anginal, and pseudoneoplastic. Of these, the digestive-tract abnormality, even though the most common, was the least characteristic and was caused by the associated pathologic lesions rather than by the hiatal hernia itself.

The effect of segmentary sectioning of the proximal jejunal tunica muscularis on intestinal propulsion was studied in the rat. Care was taken to avoid damage to the mucosa. In no instance was perforation or occlusion of the intestine observed. Myotomy was followed by a significant slackening of the passage of a test meal during the first 15 min after feeding, while the total transit time was virtually unchanged. Sectioning the musculature of the intestinal wall is shown to be responsible for retardation of bowel passage.

6 cases of suprarenal phaeochromocytoma were operated on at the Department of Special Surgical Pathology and Clinical Propaedeutics of the University of Turin between 1954 and 1975. The age of the patients was between 32 and 53, 5 cases being male and 1 female. Personal data are compared with larger series and mention is made of the importance of certain pharmacological tests and new radiological techniques for the diagnosis of tumour nature and localization. An atypical case in which exact clinical classification was only possible histologically a posteriori is discussed. Immediate and long-term results were good. Although not all patients presented normalised pressure values, the disappearance of hypertensive crises and normalization of glycaemia and urinary catecholamines were constant observations.

A technique for the repair of inguinal hernias in elderly patients with weak abdominal muscles has been presented. It consists of the overlapping of the flaps of the aponeurosis of the external oblique muscle according to the method previously proposed by Andrews. To date, the technique has given good results, even in very old patients, with almost completely atrophied muscles.