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Persistent production of fetal hemoglobin (HbF) in adult has ameliorative effects on hemoglobinopathies and great efforts are currently made to achieve an exhaustive understanding of the molecular mechanisms of the switching in globin gene expression. One of the factors reported to be associated with the expression of fetal globin genes is the Xmn I Ggamma-158 polymorphism, although it is still unclear if it is involved in this mechanism either by itself or in strong linkage disequilibrium with other loci. Here, we report a novel effect of the Xmn I Ggamma-158 site that was found associated with a significant delayed decline of HbF production in infant age. The prolonged decay trend was enhanced when the Ggamma-158 C-->T substitution was co-inherited with a beta-thalassemic trait. Our observations reinforce the hypothesis that this region plays an important role in the expression of the gamma-globin genes and give new insights on the intriguing and still poorly understood mechanisms of globin gene expression switching. [ABSTRACT FROM AUTHOR]

Persistent production of fetal hemoglobin (HbF) in adult has ameliorative effects on hemoglobinopathies and great efforts are currently made to achieve an exhaustive understanding of the molecular mechanisms of the switching in globin gene expression. One of the factors reported to be associated with the expression of fetal globin genes is the Xmn I G γ−158 polymorphism, although it is still unclear if it is involved in this mechanism either by itself or in strong linkage disequilibrium with other loci. Here, we report a novel effect of the Xmn I G γ−158 site that was found associated with a significant delayed decline of HbF production in infant age. The prolonged decay trend was enhanced when the G γ−158 C→T substitution was co-inherited with a β-thalassemic trait. Our observations reinforce the hypothesis that this region plays an important role in the expression of the γ-globin genes and give new insights on the intriguing and still poorly understood mechanisms of globin gene expression switching. [ABSTRACT FROM AUTHOR]

Galectins are a group of β-galactoside-binding proteins with several roles in immune response, cellular adhesion, and inflammation development. Current evidence suggest that these proteins could play a crucial role in many respiratory diseases such as pulmonary fibrosis, lung cancer, and respiratory infections. From this standpoint, an increasing body of evidence have recognized galectins as potential biomarkers involved in several aspects of asthma pathophysiology. Among them, galectin-3 (Gal-3), galectin-9 (Gal-9), and galectin-10 (Gal-10) are the most extensively studied in human and animal asthma models. These galectins can affect T helper 2 (Th2) and non-Th2 inflammation, mucus production, airway responsiveness, and bronchial remodeling. Nevertheless, while higher Gal-3 and Gal-9 concentrations are associated with a stronger degree of Th-2 phlogosis, Gal-10, which forms Charcot-Leyden Crystals (CLCs), correlates with sputum eosinophilic count, interleukin-5 (IL-5) production, and immunoglobulin E (IgE) secretion. Finally, several galectins have shown potential in clinical response monitoring after inhaled corticosteroids (ICS) and biologic therapies, confirming their potential role as reliable biomarkers in patients with asthma.

Background and Objectives: Reliable biomarkers able to predict post-COVID syndrome development are still lacking. The aim of the study was to evaluate the relationship between Galectin-3 blood concentrations and the development of post-COVID syndrome., Methods: We performed a single-center, prospective, observational study, enrolling 437 consecutive patients attending our outpatient clinic for the post-COVID assessment. For each patient, we recorded the main clinical, functional and radiological findings. We also dosed several blood biomarkers which have been related to COVID-19 disease, including Galectin-3. We performed Receiver Operating Characteristic (ROC) and multivariate regression analysis to evaluate the predictive performance of Galectin-3 for post-COVID syndrome development., Results: Among the blood biomarkers tested, Galectin-3 resulted the only one correlated with the outcome, although the insufficient performance of the Cox regression model from a statistical standpoint. Correlation coefficients and ROC curves analysis revealed the close relationship between Galectin-3 levels and the time passed from the acute phase of COVID-19 disease, suggesting a possible predictive role for this biomarker when dosed from 60 to 120 days after the infection., Conclusions: Galectin-3 could play an important role as predictive biomarker for COVID-19 sequelae, but its evaluation must be carefully planned along the follow up to avoid misinterpretations., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Andrea Portacci: Payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Astrazeneca, GSK, Sanofi, Vitalaire, Chiesi, Zambon. Monica Amendolara: no conflict of interest to disclose. Vitaliano Nicola Quaranta: no conflict of interest to disclose. Ilaria Iorillo: no conflict of interest to disclose. Enrico Buonamico: no conflict of interest to disclose. Fabrizio Diaferia: no conflict of interest to disclose. Sara Quaranta: no conflict of interest to disclose. Cristian Locorotondo: no conflict of interest to disclose. Annalisa Schirinzi: no conflict of interest to disclose. Esterina Boniello: Payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Boehringer. Silvano Dragonieri: no conflict of interest to disclose. Giovanna Elisiana Carpagnano: Payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Astrazeneca, GSK, Sanofi. Grants or contracts from any entity from Astrazeneca, GSK, Sanofi, Chiesi, Grifols. Support for attending meetings and/or travel from Astrazeneca, Menarini, Chiesi., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objectives: Right ventricular outflow tract abnormalities (RVOTA) have been mostly reported in recipient twins (RT) of monochorionic/diamniotic (MC/DA) twin pregnancies with twin-to-twin transfusion syndrome (TTTS). Aim of the study was to describe RVOTA detected in MC/DA pregnancies without TTTS., Methods: Cases of RVOTA were retrieved from our database among all MC/DA pregnancies without TTTS from 2009 to 2018., Results: Out of 891 MC/DA twin pregnancies without TTTS, 14 (1.6%) were associated with RVOTA: 10 pulmonary stenosis (PS), one steno-insufficiency, one insufficiency and two atresia (PA). In 93% of cases (13/14), pregnancy was complicated either by amniotic fluid discrepancy (AFD) or by TAPS or mostly by selective fetal growth restriction (sFGR) (11/13: 85%), involving predominantly (10/11: 91%) the large twin, with high incidence (9/11: 82%) of sFGR and AFD coexistence. Eight out of 14 (57%) survived after the perinatal period (7 PS, 1 PA). Five (62%) underwent pulmonary balloon valvuloplasty, whereas 3 children still showed persistent mild PS at cardiac follow up after 1 year of life., Conclusions: RVOTA can occur in MC/DA pregnancies without TTTS, particularly when other complications coexist. In complicated cases specialized fetal echocardiographic evaluation is recommended during pregnancy; RVOTA cases should be delivered in a tertiary level center, where cardiologists are available., (© 2021 John Wiley & Sons Ltd.)

Objective: The aim of this study was to propose a classification in order to stratify the probability of an acute Toxoplasma infection in pregnancy and to estimate the risk of vertical transmission. Study design: We evaluated the likelihood of a primary maternal infection according to the Lebech classification and to the modified-Lebech classification proposed for our group of 375 patients referred for a suspected primary maternal infection. Fetal diagnosis included the examination of amniotic fluid by PCR to detect Toxoplasma DNA as a confirmation test. Results: Differences between the old and new classification resulted statistically significant for old classes defined as probable and unlikely with a clear shift of cases from the unlikely to the probable class in the new classification. Transmission rate showed a significant ( p  < .05) increase of the transmission rate in the probable class in our new classification as compared with the Lebech one. Conclusions: Results obtained in the present study suggest that the new IgG avidity-based classification herein proposed could estimate more precisely the likelihood of a primary maternal Toxoplasma infection as well as the risk of fetal infection, when compared with the historical Lebech Classification.

The GISTs are rare tumours but even rarer is the localization in some districts. We reported two GISTs of the duodenum, two of the omentum and peritoneum, one of the rectum and one of a Meckel's diverticulum. These exceptional locations are confirmed by the relative difficult diagnosis, obtained in some cases only by the surgical treatment despite the CT and MR. The endoscopy is useful in hemorrhagic and duodenum forms, only for the diagnosis and for the control of blood loss. Surgical treatment in all cases was decisive without the need to make use of adjuvant therapy, with positive long-term results, which excluded the disappearance of relapses or secondary lesions.

The Whipple' Disease (W.D.) is a very rare disease with an incidence of 1 per 1.000.000 inhabitants; it is a systemic infection that may mimic a wide spectrum of clinical disorders, which may have a fatal outcome and affects mainly male 40-50 years old. The infective agent is an actinomycete, Tropheryma Whipplei (T.W.) that was isolated 100 years after first description by Wipple, and identified in macrophages of mucosa of the small intestine by biopsy which is characterized by periodic acid-Schiff-positive, products of the inner membrane of his polysaccharide bacterial cell wall. The multisystemic clinical manifestations evolve rapidly towards an organic decay characterized by weight loss, malabsorption, diarrhea, polyathralgia, opthalmoplegia, neuro-psychiatric disorders and sometimes associated to endocarditis. Early antibiotic treatment with trimethoprim and sulfometathaxazole reduces the fatal evolution of the disease. The authors present a rare experience about a female subject in which the clinical gastrointestinal signs were preceded by neuro-psychiatric disorders, and evolved into obstruction and intestinal perforation which required an emergency surgery with temporary ileostomy, recanalized only after adequate medical treatment with a full dose of antibiotic and resolution of clinical disease for the high risks of fistulae for the edema and lymphadenopathy of mucosa. The diagnosis was histologically examined by intestinal biopsy performed during surgery, which showed PAS-positive histiocytes, while PRC polymerase RNA was negative, which confirms the high sensibility of PAS positive and low specificity of RNA polymerase for T.W.

The authors present three cases of symptomatic, large, benign, nonparasitic hepatic cysts. The diagnosis was determined by US and CT scan, the latter enabling differential diagnosis with neoplastic or hydatid cysts. All patients were treated with open hepatic resection. In 2 cases, laparoscopy was performed to enable complete diagnosis. The authors used LigaSure™ (Covidien, USA) instrument, avoiding bleeding complications and reducing surgery time. Histological examination confirmed the diagnosis of benign cysts. CT follow-up at 6 months and 1 year demonstrated the efficacy of the surgery, with no recurrences.

Impaired switching from fetal haemoglobin (HbF) to adult globin gene expression leads to hereditary persistence of fetal haemoglobin (HPFH) in adult life. This is of prime interest because elevated HbF levels ameliorate β-thalassaemia and sickle cell anaemia. Fetal haemoglobin levels are regulated by complex mechanisms involving factors linked or not to the β-globin gene (HBB) locus. To search for factors putatively involved in the expression of the γ-globin genes (HBG1, HBG2), we examined the reticulocyte transcriptome of three siblings who had different HbF levels and different degrees of β-thalassaemia severity although they had the same ΗBA- and ΗΒB cluster genotypes. By mRNA differential display we isolated the cDNA coding for the cold shock domain protein A (CSDA), also known as dbpA, previously reported to interact in vitro with the HBG2 promoter. Expression studies performed in K562 and in primary erythroid cells showed an inverse relationship between HBG and CSDA expression levels. Functional studies performed by Chromatin Immunoprecipitation and reporter gene assays in K562 cells demonstrated that CSDA is able to bind the HBG2 promoter and suppress its expression. Therefore, our study demonstrated that CSDA is a trans-acting repressor factor of HBG expression and modulates the HPFH phenotype., (© 2010 Blackwell Publishing Ltd.)

The adrenal myelolipoma is a relatively rare benign tumour of adipose cell and bone marrow elements, non functioning and asymptomatic. Giant and bilateral adrenal myelolipoma is quite rare. The Authors report a case of bilateral adrenal myelolipoma, a giant one (> 15 cm) on the left side and a small one (> 4 cm) on the right with constant pain in a 57-year-old man, shown by computerized tomography. The hormonal blood tests were normal. Surgical excision was performed for large left symptomatic mass, by open laparotomy, and biopsy for right minor adrenal lesion. Histology confirmed diagnosis of myelolipoma for both masses. Follow-up to 6-12 months did'nt show any change of the right myelolipoma. The authors agree with the need to remove the giant adrenal myelolipoma, because the lesion > 10 cm have a high risk of cancer and hemorrhagic complication, while for small myelolipoma (< 6 cm) 6-12 months follow-up is the appropriate choice.

The authors report on their experience with two cases of Krukenberg's tumour treated at Chioggia Hospital in patients admitted for pelvic tumours. The clinical manifestation of Krukenberg's tumour is mainly related to the presence of the pelvic mass even in advanced forms of gastrointestinal cancers. The authors stress the importance of an adequate follow-up of premenopausal patients with a previous gastrectomy for adenocarcinoma because the incidence of ovarian metastases is quite frequent and influences the prognosis. The Authors do not consider a bilateral preventive ovariectomy associated with gastrectomy as advisable in premenopausal patients, because the studies to date are inadequate for the purposes of drawing conclusions regarding the benefit of these procedures. They consider a more valid policy to be a thorough follow-up in women with a previous gastrectomy for adenocarcinoma because the priority must be accorded to diagnosing secondary lesions so as to be able to perform an ovariectomy which may improve the prognosis. With this in mind it is important to assess Ca 19.9 and perform radiological procedures, such as CT and MRI. The prognosis may be distinctly unfavourable as in one of the cases reported by the Authors involving a very rare form of secondary lesion of the bone marrow and consequent medullary aplasia, with the onset of severe haemorrhages in several areas leading to the patient's death. They consider that surgical treatment should be preceded by a diagnostic laparoscopy. When there are other concomitant negative prognostic factors such as neoplastic ascites and perineal carcinosis, ovariectomy will prove ineffective from the prognostic point of view.

The authors report 2 cases of small bowel ischemia due to unusual cause. In both cases, vasculopathy was the cause of ischemia, but with a different etiology. In the first case, a mesenteric inflammatory veno-occlusive disease, with striking features of extensive phlebitis and venulitis affecting the veins of the small intestine and mesentery, without arterial involvement of this district was observed and histological examination showed inflammatory lymphocytic infiltrates and myointimal hyperplasia of the veins. The second case affected by intestinal ischemia from secondary and multiple cholesterol embolism, the histological examination showed inflammatory infiltrates with (lymphocytes and granulocytes) in the vessels of submucosal mesenteric area, by loose intimal fibrosis incorporating cholesterol clefts. Both patients required surgical exploration with resection of ischemic bowel. In the second case laparoscopy was the initial approach which allowed to identify the extension of ischemia with special regard to the perforation. The ultimate diagnosis is possible only with histological examination. Clinically, patients show the general signs of intestinal ischemia with pain, vomiting and bloody diarrhea. Prognosis depends on the extension of the lesions and the early surgical treatment.

Aim: The possibility of carrying out surgery in day-surgery (DS) conditions is gradually becoming reality in most branches of surgery; in recent years, DS has also found a place in general surgery, with unquestionable advantages for the management of patients, particularly the elderly. The purpose of the present study is to investigate general surgery needs in DS conditions in elderly patients in order to analyse the clinical-administrative feasibility of DS procedure and the level of its acceptability in this group of patients., Methods: A specially drafted questionnaire was submitted to patients admitted over a period of 18 months to the General Surgery Division of the University of L'Aquila. The details investigated in the questionnaire were: age, sex, educational qualification, working activity (independent or employee), presence in the patient's relational entourage of health workers willing to serve the patient at home, the patient's willingness to undergo the surgery for which he was admitted to the DS. The questionnaires of the over-64s were examined and the percentage of patients willing to undertake DS intervention instead of normal hospitalisation was evaluated; this willingness was then compared with the parameters sex, educational qualification, working activity and presence in the patient's relational entourage of health workers willing to assist the patient at home., Results: 317 questionnaires were compiled. In 78 cases (24.6%) the patient was older than 64; the data for these patients were extrapolated. Willingness to undergo surgery in DS conditions was expressed by 23 patients (29%), whereas 55 patients (71%) stated that they were not available. In relation to sex, willingness to use the DS was 29.7% in the 37 male patients and 29.2% in the 41 females. With reference to the qualification, willingness was expressed by 71.4% of patients with a degree, 26.9% of patients with a high school leaving certificate and 15.7% of patients with a lower qualification. DS-willingness was 28% in the 75 pensioners and 66.6% in the 3 patients who worked for themselves. As regards the presence in the relational entourage of the patient of health workers ready to assist at home, DS-willingness was 23.9% in the 71 patients who did not have anyone in their relational entourage and 85.7% in the 7 patients who had such a health worker in their entourage., Conclusions: Willingness to undergo DS by elderly patients is mainly influenced by three factors: educational qualification, working activity and possibility to have home assistance from someone in the relational entourage; these parameters can be considered veritable selection criteria for DS in the elderly. The quality improvement in assistance levels and the introduction in the near future of telematic communication system could lead to an extension of DS indications to the elderly.

Two rare cases of mechanical intestinal obstruction due to an omphalomesenteric duct remnant and/or to a Meckel's diverticulum, respectively, are reported. The first case was a 20-year-old man and the second an 87-year-old woman. In contrast with various reports in the literature, our experience demonstrates that this kind of obstruction may also affect elderly female patients in western countries. Both patients showed signs and symptoms of intestinal obstruction and were operated on as emergencies. A complete diagnosis was possible only at operation and early surgery was important to prevent strangulation and gangrene of the bowel. The authors conclude that prompt and appropriate surgical treatment reduces the mortality risk in all patients with intestinal obstruction, including even resected cases.

Laparoscopic cholecystectomy has become the treatment of choice for patients with symptomatic cholelithiasis. About 10-20% of patients with gallbladder stones may also present associated common bile duct stones. The management of the latter remains controversial because many different surgical strategies are available: laparoscopic treatment (laparoscopic common bile duct exploration), sequential endoscopic and laparoscopic treatment (endoscopic retrograde cholangiopancreatography/endoscopic sphincterotomy [ERCP/ES] prior to laparoscopic cholecystectomy), inverted sequential endoscopic-laparoscopic treatment (laparoscopic cholecystectomy followed by ERCP/ES), and combined endoscopic-laparoscopic treatment (laparoscopic cholecystectomy with intraoperative ERCP/ES). The aim of this study was to evaluate the efficacy and safety of sequential endoscopic-laparoscopic treatment in patients with cholecystocholedocholithiasis. We retrospectively analyzed the clinical, biochemical and radiological features of 552 patients operated on for cholelithiasis from 1991 to 2001. Common bile duct stones were suspected on the basis of increased serum levels of bilirubin, GOT, GPT, GGT, alkaline phosphatase; presence of jaundice; history of pancreatitis or cholangitis; dilated common bile duct (diameter > 8 mm) or common bile duct stones at hepatobiliary ultrasonography; presence of common bile duct stones at MR-cholangiography or at i.v. cholangiography. In patients with suspected common bile duct stones, preoperative ERCP was performed; if common bile duct stones were confirmed, ES was performed. When common bile duct stones were not suspected preoperatively, laparoscopic cholecystectomy was performed directly. Overall morbidity, mortality and conversion rates in the two groups were evaluated. Of 552 patients admitted for cholelithiasis, 62 (11.3%) underwent preoperative ERCP for suspected common bile duct stones. In 41 patients (66.1%) common bile duct stones were identified and ES with common bile duct stone extraction was performed in 40 patients (clearance: 97.5%). The overall morbidity was 16% (10 cases of post-ERCP acute pancreatitis); no mortality occurred. The conversion rate during subsequent laparoscopic cholecystectomy was 4.8%. In the group of patients with no suspicion of common bile duct stones, the conversion rate was 4.9%. Sequential treatment cannot be considered the best approach for patients with cholecystocholedocholithiasis because of its morbidity rate and the high rate of negative preoperative ERCP findings. Combined endoscopic-laparoscopic treatment seems to present more advantages, especially in term of morbidity, hospital stay and patient compliance and may, in future, be considered the treatment of choice for patients with cholecystocholedocholithiasis.

Laparoscopy, which has been well known as a diagnostic procedure for more than a century, has recently established itself as an important therapeutic procedure in several branches of surgery. In the present study the authors report on 221 patients over a 10-year period (1991-2001), admitted to hospital with a diagnosis of acute abdomen or abdominal trauma. All patients were submitted to emergency laparoscopic surgery; 128 patients (57%) presented acute appendicitis, 40 (18%) acute cholecystitis, 13 (6%) occlusive ileus, 10 (5%) adnexal pathologies, 9 (4%) perforation of abdominal viscera, 3 (1.4%) acute diverticulitis, 3 (1.4%) subdiaphragmatic abscesses, 3 (1.4%) intestinal infarction, 2 (0.8%) other diseases and 10 (5%) abdominal trauma. The operation was completed laparoscopically in 192 cases (87%), while conversion to laparotomy proved necessary in 29 cases (13%). The morbidity of the cases completed laparoscopically was 3%, the mortality 0.5%, and the mean hospital stay 4 days. Advantages of laparoscopy (shorter hospital stay, rapid postoperative recovery and faster return to social activities) emerge from the present study and are confirmed by the literature. The possibility of combining a diagnostic procedure with curative therapy suggests that laparoscopy may have an important role in emergency surgery, demonstrating its efficacy also in acute abdominal syndromes. Nevertheless, emergency laparoscopic surgery is still a technically difficult procedure that needs to be performed by an expert surgical team.

The Authors report a case of sigmoid obstruction due to endometriosis and review the literature about. Unusual localisation and difficult preoperative differential diagnosis with IBD and bowel carcinoma are stressed. A 45-years old woman with previous history of oophorectomy was admitted at the hospital with symptomatic bowel obstruction. A barium enema showed a sigmoid stenosis thought to a carcinoma of bowel. A laparoscopic approach confirmed the diagnosis and a laparotomy was performed with a subsequent anterior resection (end-to-end anastomosis with stapler) plus myomectomy. The Authors do believed, during surgery, to be treating a carcinoma which disappeared with opening the specimen. The mucosa were intact and muscular layers so think to form a strong ring to be able to invaginate the upper colon for 3-4 cm. A stromal tumor was supposed and the definite diagnosis of endometriosis was very surprisingly. Intestinal resection to be necessary, with associated salpingo-oophorectomy and hysterectomy in older patients and treatment with oral contraceptive in younger female. Laparoscopy may be helpful in the diagnosis showing pelvic endometriosis with bowel wall involvement. Laparoscopic treatment in our opinion must be confirmed to particular situation and to well experience of surgeons.

The aim of the study was to demonstrate the importance of early laparoscopic cholecystectomy for acute cholecystitis, without "conservative" treatment (intravenous fluids and antibiotics for 48-72 hours) to reduce inflammation. Early laparoscopic cholecystectomy reduces bile duct injury and the percentage of conversion to open cholecystectomy. Thirty-five patients with acute cholecystitis were submitted to early laparoscopic cholecystectomy, equally divided according to sex. All patients were submitted to US scans preoperatively and operated on by surgeons skilled in emergency laparoscopic operative techniques. Laparoscopic cholecystectomy was always performed with 4 trochars and the use of a 30 degrees laparoscope. Technical modifications during early laparoscopic cholecystectomy were drainage and decompression with subsequent de-tension and distention of the gallbladder. These manoeuvres entailed the use of Babcock, Endopatch (Ethicon) atraumatic forceps. In the presence of acute gallbladder inflammation we dissect the gall-blader well with a suction-irrigation tube. In patients suspected of having common bile duct stones, biliary duct injuries and/or anatomical changes due to inflammation, we perform intraoperative cholangiography. Five patients had conversion to open cholecystectomy (14.2%), in two cases (5.7%) for concomitant choledochal stones, in two cases (5.7%) for biliary peritonitis and in the fifth case (2.8%) for severe empyema of the gallbladder. Laparoscopic cholecystectomy was performed in 20 patients for acute cholecystitis (57.1%), in 9 patients for empyema (25.7%) and in 6 patients for gangrenous cholecystitis. Four cases presented postoperative complications owing to bile leakage from the liver bed, treated with antibiotic therapy. One patient presented jaundice on day 30 after laparoscopy owing to inadequate positioning of the clips on the cystic duct, near the common bile duct; ERCP was performed with application of a prosthesis, which was removed after two months. Our experience and results support the validity of early laparoscopic cholecystectomy in the treatment of acute cholecystitis, because it reduces the postoperative length of hospital stay and hospital costs. Early treatment is always helpful for inflamed and oedematous tissue which favours dissection, while dense, fibrotic adhesions hinder regular dissection with a greater risk of injury to the biliary duct and and a higher conversion rate to open cholecystectomy.

Background: For more than a century, open appendectomy through a laparotomy has been the golden standard for the surgical removal of the appendix. Nowadays, many surgeons question the utility of laparoscopic surgery to perform appendectomies because it is commonly stated that the appendix can be removed through a small surgical incision carrying a minimal surgical trauma to the patient. Although open appendectomy is really safe, on the other hand it carries a considerable risk of postoperative complications, is associated with postoperative pain and affects patient s normal activity. Laparoscopic appendectomy was first described in 1983 and, in many studies, it is described to be better than open standard technique for the treatment of appendiceal diseases. The aim of the present study is the retrospective analysis of laparoscopic appendectomies performed in a 8-year period., Methods: The authors report on 129 patients who underwent laparoscopic appendectomy., Results: Conversion rate was 0.7 %, while the laparoscopic procedure was completed in 96 female and 32 male patients. The position of the appendix was behind the cecum in 37 cases, associate diseases were found in 15 cases. Mean operative time was 51 minutes; kind of laparoscopic instrumentation affected the operation time. Histologically there were 71 (55.5 %) focal appendicitis, 22 (17.1 %) suppurative appendicitis, 11 (8.6 %) gangrenous appendicitis, 18 (14.1 %) chronic appendicitis showing signs of previous suppurative episodes and 6 (4.7 %) normal appendix. There were neither in-hospital morbidity nor mortality. Follow-up showed reduced postoperative pain, short hospital stay, fast return to complete social activity., Conclusions: The authors conclude that laparoscopic technique can be considered a safe and effective procedure for the removal of the appendix as it has the advantage of allowing faster postoperative recovery; moreover the author recommend a wider and routinely use for appendectomy.

Acute mesenteric ischaemia is the result of inadequate blood flow to all or part of the small intestine and the right half of the colon. Irrespective of the cause of the ischaemic insult, the end results are similar, namely, a spectrum of bowel injury ranging from completely reversible alterations of bowel function to transmural haemorrhagic necrosis of the intestinal wall. Depending on the degree of ischaemia and the length of bowel involved, a wide variety of clinical presentations are observed. Mesenteric infarction is a pathology which is encountered fairly often in elderly patients where the concomitance of other diseases make its prognosis more severe, especially since the diagnosis is usually late. The pessimism expressed more than 70 years ago concerning this disease is still shared by many physicians today. The authors report on their experience with 37 cases of mesenteric infarction. The median age of the patients was 77 years (range: 66-91). The mortality rate was 67.5% (25 deaths) which is in line with the results in the literature. The median hospital stay was 17 days (range: 10-71). The authors emphasise the difficulty of diagnosing and treating this entity, also in view of the fact that, in most centres, it is impossible to perform emergency selective angiography of the superior mesenteric artery. The need for an early specific diagnosis is stressed, because the therapeutic options may vary widely in relation to the different causes of acute intestinal ischaemia.

The Authors present their experience on the treatment of the varicocele; they performed laparoscopic clamping of the internal spermatic vein in 12 subfertile patients, utilizing only the bipolar coagulation without the use of clips. All patients were available for follow-up, which ranged from 6 to 12 months, including physical examination, Doppler C.W. and study of semen quality. Recurrence of varicocele was not observed, the semen quality demonstrated improvement in semen motility in 9 patients (75%) and normal on 3 patients (25%). The use of bipolar coagulation with smaller ports (phi 5 mm) resulted in less postoperative pain and shorter convalescence than when larger ports were used (phi 10 mm). The Authors conclude that the laparoscopic procedure, used as they do, is safe and costs less than classic ligation with clips as well as radiological occlusion procedures.

Aortic dissection occurs when there is a tear or separation of the aortic intima from the media; flow of blood into the intima-media space allows the tear to develop into a dissecting hematoma. Aortic dissection is a rare condition which represents an acute cardiovascular emergency for which the appropriate therapy is immediate surgical correction. Patients with aortic dissection show a heterogeneous constellation of symptoms; hence, clinical suspicion is often difficult. Only a minority of patients has "classic" symptomatology, the electrocardiogram is often misleading and the chest radiogram is almost always non-specific. In Italy, the usual "hospital routine practice" assigns the key-role in the emergency diagnostic procedure for these patients to the general surgeon. In view of the necessity of immediate cardiac surgery and the overwhelming likelihood of adverse events when surgery is delayed, techniques for diagnosis must be accurate, widely available and easily and quickly used. The present study consists of four case-reports of aortic dissection thoroughly examined and confronted with the literature. Management strategy based on emergency echocardiography is a reliable, feasible and successful technique for evaluating patients with aortic dissection. It allows a rapid accurate diagnosis with a single examination that can also be performed in the emergency room and provides information of sufficient diagnostic value to allow immediate cardiovascular surgery. CT scan and/or MRI are also valid tools for the emergency diagnosis of aortic dissection. However, a major problem still exists: the range of symptoms is sufficiently broad that a high index of "personal suspicion" of aortic dissection is required on the part of the general surgeon when he performs the role of "emergency-team leader".

Because treatment for Spigelian hernia is rarely discussed in the literature, this report presents two cases observed in a recent 6-month period by the U.O.A. Independent General Surgery Department, Hospital of Este. Both patients had laparoscopic treatment using a polypropylene prosthesis, which confirms the technological validity of the surgical method. The described cases are emblematic, because the intervention permitted a resolution of associated pathologies (gallbladder gallstones and umbilical hernia), which confirms both the efficacy of the surgical technique and of the high diagnostic precision of laparoscopy, as it is described by several sources. The validity of the technique is also confirmed by the quick recovery of patients and by the reduced hospitalization time, especially in elderly patients and in precarious general conditions.

The Authors report a case of abdominal traumatism by gunshot wound, presenting with retroperitoneal hematoma and hematoma of the mesocolon, treated in emergency laparoscopy. After a literature review and their case report analysis, they confirm the importance of emergency laparoscopy in hemodynamically stable patients, as well as the diagnostic value of peritoneal lavage, positive for minimal and moderate hemoperitoneum. Laparoscopy allows, as the same time in most cases, the diagnosis and the management of the lesion, while surgery is reserved to the cases of severe hemoperitoneum and perforating injuries. The use of laparoscopy in abdominal blunt injuries, has reduced the number of unnecessary laparotomies with related higher incidence of morbidity. The Authors conclude confirming the importance of this technique for its diagnostic efficacy, lower costs, minimal traumatism, and good aesthetic results as observed in the case report for the modality of the injuries, the young age and the previous sternotomy of the patient.

The Authors report their experience in the surgical management of 282 inguinal hernias classified according to Gilbert's classification. The different techniques used were compared analysing the results obtained in 104 patients operated with the Bassini hernioplasty, while in 120 cases the Lichteinstein tension-free repair and in 58 cases the Shouldice hernioplasty were performed. In the patients operated according to the Lichteinstein tension-free technique an Autosuture mesh was used. The Authors conclude that the Lichteinstein tension-free repair is preferable, not simply for the incidence, although low in this series, of recurrence observed with the Bassini hernioplasty, but particularly for the reduced postoperative pain, the fast return to full activities, the low cost, and the possibility to be performed in Day-Hospital.

Recently, the widespread use of laparoscopic cholecystectomy allowed to reach several goals such as a minimal invasive approach, a minimal operative trauma, the absence of aesthetic or functional damage of the abdominal wall, and a quick return to full activities. On the other hand, as all innovations, laparoscopic cholecystectomy is matter of debate and a number of controversies have recently appeared in the Scientific Literature. On the basis of their experience and through a critical review of the Literature, the Authors have therefore analyzed possible solutions to such controversies. Particularly, current indications and contraindications of this approach, surgical technique and relative sites of insertion of the trocars, the need to drain or not, the pre- and intra-operative study of the bile duct and the approach in case of bile duct stones pre- or intra-operatively demonstrated, have been evaluated as possible answers. The Authors conclude that indications to laparoscopic cholecystectomy are the same of those for laparotomy, contraindications are represented by coagulopathies, liver cirrhosis and plastic peritonitis. At present it is still impossible to affirm which is the best surgical technique, the best position for the surgeon, and the best site for the insertion of the trocars, while drainage must be used only in those cases in which further manoeuvres on the bile duct are required. At last the Authors underline there is no need for a routine intraoperative cholangiography during laparoscopic cholecystectomy, however such technique must be known by laparoscopic surgeons since it may be mandatory in some selected cases. ERCP, on the contrary, is a valid support to laparoscopic cholecystectomy in the treatment of gallbladder stones associated with bile duct stones.

Venous ulceration is a troublesome and disabling complication, representing one of the most difficult problems to be treated by the vascular surgeon. Venous insufficiency is a widespread condition, the prevalence of venous ulceration being 0.5 - 1 per cent in European populations. Although all venous ulcers will heal if the limb is elevated above heart level for an extended period of time, patients need a safe, effective, not disabling and quick therapy. Hence, the competent vascular surgeon must be familiar with venous pathophysiology and possess a thorough understanding of the treatment options available for a discouraged patient in need of an acceptable and effective approach. The aim of the present study was to assess the efficacy and the speed of healing of venous ulcer using an outpatient ambulatory treatment protocol. This protocol consisted of elastic compression bandage allowing deambulation, local dressing using lyophilized heterologous collagen (Condress, Gentili) and systemic profibrinolytic drugs. Exclusion criteria were coexisting arterial insufficiency, ulcer area greater than 25 cm2, coexisting disabling diseases (congestive cardiac failure, hepatic insufficiency, malignancy). From December 1990 to June 1993, 37 patients affected by venous ulcer were treated, according to the aforementioned protocol, at the Surgical Department of Montecchio Maggiore Hospital (VI). There were 16 male and 21 female patients, mean age was 66 years (range 59-91). Results show the complete healing of the venous ulcer in 94.5% of patients; mean time for ulcer healing was 128 days (range 45-91). The Authors conclude that the outpatient ambulatory treatment protocol is safe, quick, and effective for the therapy of chronic venous ulcer; once obtained the healing of the ulcer, elastic compressive bandage with elastic stockings is mandatory to prevent recurrences.

The Authors report on a rare congenital anomaly of the biliary tract characterized by an accessory choledochus, which drained the inferior paramedian segments of the liver. Such anomalous duct emerged from the hepatic hilum right behind the cystic artery, the cystic duct and the gallbladder to join the primary choledochus few millimeters from the papilla of Vater. At the point of junction, in the posterior aspect of the II duodenal portion, a choledochal diverticulum containing cholesterin and bilirubin stones was also present. Surgery was indicated by the onset of a pseudo-obstructive syndrome followed by jaundice. At laparotomy the exact diagnosis was possible. The intervention consisted in a choledochotomy and duodenotomy with tube drainage and exeresis of the choledochal cyst containing the stones.

The mortality rate following traditional (open) surgical appendectomy has declined over the past 60 years to almost zero. Many surgeons question the utility of laparoscopic surgery for appendicitis as the appendix can often be removed through a small incision and the degree of trauma to the patient may be minimal. However, some patients suffer wound infection, prolonged hospitalization and delay in returning to full normal activity. Moreover, postoperative adhesions have been recorded in as many as 63 per cent of cases. Although recent studies have shown that laparoscopic appendectomy is safe and feasible, controversies still exist concerning indications and limits of the procedure. The aim of the present study is to clarify the advantages of the laparoscopic technique in performing appendectomy for both acute and chronic appendicitis. The Authors report on their experience of laparoscopic appendectomy performed at the Surgical Department of Montecchio Maggiore Hospital (VI) from July 1992 to December 1992. Ten laparoscopic appendectomies were performed in 8 female and 2 male patients with a mean age of 19 years (range 14-31). There were no conversions to laparotomy; mean operative time was 57 minutes (range 28-92). As far as the position of trocars is concerned, the Authors utilize a particular technique which presents an aesthetic advantage but requires the use of an endolaparoscopic stapler (Multifire Endo GIA 30 Autosuture). There was no mortality; the postoperative course was uneventful in all cases. Patients were discharged from the hospital the day after laparoscopic intervention. Follow up showed no postoperative pain, short bed stay at home and fast return to full activity; functional and aesthetic results were most satisfactory.(ABSTRACT TRUNCATED AT 250 WORDS)

Cerebrovascular disease is a leading cause of morbidity and mortality in Italy. Although atherosclerotic involvement of the carotid artery is more prevalent, some patients suffer from stenosis of the subclavian artery, usually proximal to the origin of the vertebral artery. Neurological symptoms result from reversed flow in the vertebral artery, so-called "subclavian-steal". This collateral pathway may rob the posterior circulation of perfusion to the degree of producing episodes of vertebrobasilar insufficiency. The authors have therefore reviewed their experience with this disease and present their findings, therapeutic procedures and short-term results. During 1990 four patients affected by "subclavian-steal syndrome" were observed at the Surgical Department of Montecchio Maggiore Hospital (VI). Two patients were operated on and axillo-axillary bypass operations were performed (with a 5 mm Gore-tex graft). The goal of surgical treatment is to alleviate cerebrovascular symptomatology by restoring flow to the subclavian artery distal to the occlusion. Axillo-axillary bypass offers distinct advantages over the alternative methods such as transthoracic procedures or carotid-subclavian bypass. Axillo-axillary bypass is a technically simple procedure with very good results and minimal complications. It avoids sternotomy, thoracotomy and clavicular resections: the carotid artery is not involved in the procedure. The authors conclude that axillo-axillary bypass is a cheap, safe and effective treatment for symptomatic subclavian artery insufficiency.

The management of calculous disease of the gallbladder has undergone significant change during the last decade. Recent years have seen the development of alternative methods for the treatment of biliary stones including dissolution therapy, endoscopic and percutaneous extraction, extracorporeal shock wave lithotripsy. Yet, despite these technologic advances, most surgeons have continued to consider cholecystectomy the safest, most effective and the only curative procedure. Open cholecystectomy, performed in the same fashion for more than a century has demonstrated low morbidity and minimal mortality rates. However, the operation does incur sizable expense in terms of hospitalization, cosmetic appearance and time lost from work. Laparoscopic cholecystectomy quickly emerged as an alternative to open cholecystectomy. The authors report their experience of laparoscopic cholecystectomy performed at the Surgical Department of Montecchio Maggiore Hospital (VI). Twenty-eight patients were operated on: in all but one laparoscopic cholecystectomy was successfully completed; in one case a fistula between gallbladder and the common bile duct led to T-tube drainage insertion via a laparotomy. In one patient laparoscopic cholecystectomy was performed after an endoscopic retrograde cholangio-sphincterotomy for associated stones of the common bile duct. Mean operative time was 69 minutes (range 46-210). Morbidity and mortality were 0%; maximal hospital stay was 48 hours. These data confirm that laparoscopic cholecystectomy may be considered the treatment of choice for stone disease of the gallbladder and it should enter into the cultural and technical background of a general surgeon.

This retrospective study was undertaken to determine if the advent of H2-blockers has altered the surgical treatment and the outcome of patients with peptic ulcer disease. The records of patients undergoing surgery for peptic ulcer disease at Montecchio Maggiore Hospital, Vicenza (Italy), from 1968 to 1977 (group A) and from 1979 to 1989 (group B) were reviewed. Data recorded included, ulcer location, surgical procedures (emergency or elective), indications for emergency surgery (perforation, bleeding). Statistical analysis was performed by means of the chi-square test. From 1968 to 1989, 15.810 surgical operations were performed: the indication was peptic ulcer disease in 398 cases (2.51%). The percentage of surgical operations performed for peptic ulcer was 3.54% in group A and 1.55% in group B. A marked decline in surgery for peptic ulcer was noted in group B, concerning both elective and emergency surgery; surgical interventions strongly decreased for both duodenal and gastric ulcer. This study demonstrates that H2-blockers have definitely altered the surgical treatment for peptic ulcer disease.