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Les auteurs rapportent leur experience de la gastrostomie percutanee endoscopique (GPE), chez 193 patients porteurs de neoplasie, traumatisme, et d'affection neurologique, de septembre 1994 a mai 2001.

PURPOSE: Colonoscopic polypectomy is the preferred technique to remove the majority of polyps. The authors evaluate feasibility, safety, and the effectiveness of endoscopic treatment of colorectal benign-appearing polyps equal to or larger than 3 cm. METHODS: Ninety-seven patients with 104 giant polyps underwent polypectomy within a nine-year period. The majority of these procedures were performed on an outpatient basis, all on unsedated patients. Gross appearance, size, location, histologic characteristics, synchronous lesions, modality, and adequacy of removal of giant polyps were analyzed. The follow-up was achieved in 89 percent of patients during a period ranging from 6 to 96 months (median, 38). RESULTS: Of the 104 removed polyps, 75 (72 percent) were adenomatous, 2 (2 percent) were hyperplastic, and 27 (26 percent) were malignant polyps. Six patients had more than one giant polyp. Several additional smaller polyps were found in 52 patients and a synchronous cancer in 4. Twenty-one (20 percent) giant polyps were equal to or larger than 4 cm. Forty-nine were pedunculated, 20 were short-stalked, and 35 were sessile. Sixty-one polyps were excised in one piece, and forty-three were excised using a piecemeal technique. Only four complications (3.8 percent) were recorded; all cases were treated endoscopically. Fifty-eight (75 percent) adenomas and eighteen (67 percent) malignant polyps were completely excised. Surgery was performed in 7 of 27 patients (27 percent) with malignant polyps, where there was a doubtful, infiltrated margin or poorly differentiated cancer. Post-polypectomy surveillance permitted the detection and treatment of 25 metachronous or recurrent polyps and a metachronous cancer. CONCLUSIONS: This study shows that polypectomy of giant colorectal polyps, performed by an expert endoscopist, is feasible, effective, and safe, even on an outpatient basis. The authors confirm that malignant polyps with incomplete excision, lymphovascular invasion, and poor differentiation require bowel resection. Post-polypectomy surveillance is useful for all patients who have undergone colonoscopic resection of giant adenomatous or malignant polyps.

Les auteurs rapportent leur experience concernant la survenue et le traitement d’une complication rare de la gastrostomie percutanee: le syndrome du «bumper enfoui».

Les auteurs rapportent une methode de traitement endoscopique d’un cas de duplication kystique duodenale. La lesion fut revelee par des symptomes correspondant a de frequents episodes de subocclusion intestinale haute. Les auteurs ont analyse la litterature relative au traitement chirurgical de cette malformation. Se referant a l’operation chirurgicale dite « de porte ouverte » proposee par Anderson en 1935, les auteurs ont realise par voie endoscopique, une communication entre la paroi kystique et le duodenum.

It is known that prosthetic infection, graft-duodenal fistula, and erosion are possible late complications after aortic reconstruction, and that all these reported complications are accompanied generally by variable bleeding with different presentations. We report the case of a 63-year-old man who underwent a diagnostic upper gastrointestinal endoscopy for investigation of nausea, anorexia, asthenia, fever, and mild leukocytosis. The patient's medical history included a gastric resection for ulcer, with Billroth II gastrojejunostomy reconstruction and implantation of a Dacron vascular graft for abdominal aortic aneurysm 20 years and 3 years earlier, respectively. Abdomen ultrasonography showed hypoechoic area around an aortic prosthesis. Endoscopy found a foreign body corresponding to the vascular graft at the jejunum. No signs of bleeding were recorded. The patient was hospitalized and submitted to surgery that involved extra-anatomic axillofemoral bypass, bowel resection with a gastrojejunum Roux anastomosis, and prosthesis removal.

We report a case of gallbladder agenesis in a 30-year-old woman affected by a cardiac congenital malformation who had been operated on at the age of 12. The patient was sent for laparoscopic cholecystectomy due to a preoperative diagnosis of cholelithiasis using clinical and instrumental examinations such as ultrasonography and cholangiography. During laparoscopy, the gallbladder was not found, and laparotomy with intraoperative cholangiography and ultrasonography was performed which also resulted negative. The preoperative possibility of a diagnosis of gallbladder agenesis, the association with other malformations and the steps to be taken to discover agenesis of the gallbladder are discussed.

Hyperplastic polyps are the most frequent nonneoplastic lesions of the colon. Typically, they are small sessile polyps (5 mm) located in the rectosigmoid area. Recently, they have been identified as markers of neoplastic polyps. Herein we describe four cases of large (20 mm in size) hyperplastic polyps found at our institution over a 9-year period. All four polyps were excised by endoscopic polypectomy on an outpatient basis without complications. Two polyps were in the right colon; one was pedunculated, none of them was associated with synchronous neoplastic polyps or polyposis. Up to now, follow-up in three patients has been negative for metachronous polyps. We conclude that a large hyperplastic polyp is an unexpected and rare finding, difficult to distinguish, and not related to particular colonic sites or synchronous adenomatous lesions. These polyps should be removed with a standard technique, and patients need to be followed with successive endoscopies.

Endoscopic colonic tattooing is the simplest and most economic technique for identifying small lesions or polypectomy sites during open and laparoscopic surgery. Moreover, it is useful for the endoscopic follow-up of polypectomy sites. India ink is the agent of choice because of its long-lasting stain and the low risk of adverse reaction and toxicity. Very few cases of complications have been reported. We report here the case of a patient in whom colonic tattooing in preparation for surgical resection was followed by clinical complications such as fever and abdominal pain. An abscess-type inflamed pseudotumor was found at laparotomy. Histological examination revealed chronic granulomatous inflammation.

To evaluate the efficacy of early enteral nutrition in management of patients operated by major urologic surgery and to demonstrate her advantages versus total parenteral nutrition.20 patients, operated by radical cystectomy and urinary diversion by ureteroileocutaneostomy, Padua ileal bladder or ureterosigmoidostomy are inserted in our study: 12 were treated by early enteral nutrition for 8 days and eight by total parenteral nutrition for the same period: in each group nutritional and immunological parameters at day -1, +3 and +7, the length of postoperatory stay, the incidence of complications, with particular respect for infections have been evaluated and correlated one to each other.We have no death in each group; in the first group no gastroenteric allergy to the nutrient, less incidence of venous catheter and surgical wound infections (respectively p0.01 and p0.005); we have no significant decrease of postoperatory stay length; the effective problem in this group was the incidence of diarrhea, that in one case have made necessary the suspension of enteral nutrition. Enteral nutrition costs were about half of those of total parenteral nutrition.We believe that early enteral nutrition is an effective and safe nutrition method in patients operated by major urologic surgery: with this is possible a better nutrition, that reduce the incidence of postoperative complications, mainly infections, and maybe the length of postoperatory stay (our champion is too small for statistical evaluation), that may lead to a decrease in management costs of these patients.

The aim of this work is to describe the three years experience in hepatic resections for primitive and metastatic liver tumors. Of the 90 patients considered initially only 33% was admitted to radical surgical treatment, after a complete clinical and instrumental evaluation. Twenty of them was affected by liver metastases, most of which from colo-rectal cancer; ten had hepatocellular carcinoma developed on hepatic cirrhosis. All the patients affected by HCC underwent pre-operative chemoembolisation (TACE). Regional chemotherapy (TACI) was performed in synchronous metastatic tumors before surgical treatment. Surgical resection in HCC was extremely limited, removing at most 35% of total liver volume. For metastatic tumors 12 major resections and 8 minor resections was carried out. Postoperative complications occurred in 13.3%, including one death for digestive bleeding. A relationship between intraoperative risk factors, such as blood loss and transfusions was registered. The actuarial surviving rate was 47.5% for HCC and 48.3% for colo-rectal metastases at three years. Finally, preoperative CEA levels was the only factor significantly related to long term prognosis of patients affected by liver colo-rectal metastases.

The portal venous thrombosis is an infrequent disease that accounts from 0.25 to 1%. The etiopathogenesis is unknown in about one half of cases. Sometimes the thrombosis of mesenterico-portal venous axis is a complication following splenectomy, especially when the operation is performed for hematologic disease. The authors report a clinical case of chronic portal venous thrombosis widespread to superior mesenteric and splenic vein, in man 38 years old after splenectomy, in pediatric age, manifesting with gastrointestinal bleeding due to rupture of esophagogastric varices. On the basis of literature, the following were taken into consideration the incidence, the epidemiology, the aetiopathogenesis, the clinical characteristics, the diagnosis as well as the therapy of portal venous thrombosis.

We present our experience in the treatment of middle-lower rectal cancer particularly in reference to the use of those operative techniques which permit to save the sphincteric system. From 1990 to April 1995 seventy-two patients were operated on for middle-lower rectal cancer applying the Knight-Griffen technique. Such a method has already demonstrated the characteristics of a valid anastomosis, being simple, fast and safe. The introduction of stapler devices in the rectal surgery, particularly in its middle-lower tract has significantly modified the quality of life of such patients, reducing drastically the number of colostomies. The possibility to extend the rectal resection towards the anus with colo-anal anastomosis has showed a loco-regional recurrence rate not different from abdominal-perineal resection, even though with some sphincteric troubles due to incontinence. The satisfying surgical results obtained with low and ultra-low recta resections, by now widewordly accepted, should not anyway mask the importance of an early diagnosis as the main factor governing the prognosis (i.e. the overall mortality).

The Authors report their experience in the endoscopic treatment using pneumatic dilatation for 18 patients with achalasia, seen in the period January 1992 August 1995 at the Laboratory of Digestive Endoscopy of the Institute of General Thoracic and Vascular Surgery of the University of Parma. Ten were males and 8 females, age range 23-79 years (average age 48 yrs.). The most common symptoms was dysphagia, all patients were radiologically and manometrically studied confirming the clinical and endoscopic diagnosis. All underwent pneumatic dilatation under endoscopic control. In all, 36 dilations were carried out without registering complications related to the method. A maximum follow-up of 30 months confirmed a good-excellent outcome in 89% of cases. In 3 cases a gastroesophageal reflux symptomatology was registered, but successfully treated medically. The Authors conclude that the pneumatic dilation for achalasia is to be considered the treatment of choice, leaving the surgical approach only for cases resistant to such treatment.

Obturator hernias are relatively rare. Elderly women with chronic diseases are most frequently affected. Mechanical small bowel obstruction is the most common presenting symptom. Cause the Howship-Romberg sign is found in only 20% of cases, a correct preoperative diagnosis is uncommon. Midline abdominal incision is thought to be the better approach, allowing an easy reduction of the incarcerated ileum and a direct repair of the defect. Contralateral side exploration is recommended, being bilateral hernias quite common. The prognosis, despite our own results, remains severe for the compromised general conditions of the great majority of the patients.

To perform ambulatorial surgery with local anaesthetics, it is important to carry out a correct postsurgical NSAID therapy avoiding the risks induced by these drugs. Two groups of patients submitted to ambulatorial hemorrhoidectomy were enrolled in a randomized study to evaluate the safety of NSAID therapy with or without the coadministration of misoprostol, a PGE1 analogue with gastroprotective action. Aim of this study was to evaluate if misoprostol in coadministration with NSAID could permit a correct domiciliary postsurgical NSAID therapy without gastric symptoms related to the NSAID therapy. From January 1990 to December 1991, 95 patients underwent hemorrhoidectomy and were discharged with analgesic therapy: the first group (n = 45) without gastroprotective therapy, the second group (n = 50) with the coadministration of misoprostol 200 mcg bid. After 7 and 14 days of treatment patients showed the following symptoms: in the first group 13.3% of the cases showed mild epigastric pain, 8.8% moderate epigastric pain and 4.4% severe epigastric pain with heartburn; in the second group (NSAID + misoprostol) only 4% of the cases showed moderate epigastric pain. The incidence of epigastric pain was statistically higher (p0.05) in patients treated with NSAID alone in comparison with the group treated with NSAID + misoprostol. The results, according to international literature, show that correct gastro-protective therapy with synthetic prostaglandins (misoprostol) is necessary for patients in treatment with NSAIDs.

Between the prognostic indices in the colorectal cancer the ploidy has determined a great interest. To study the value of ploidy in the prognosis of the colorectal cancer, as a sign of the aggressiveness of the tumor for a therapeutic help, we have examined, in a retrospective study, 150 patients who had a colorectal cancer resected from 1980 to 1986. We have compared ploidy of specimens of paraffin-embedded tumors and Dukes' stage, Grading, the over-all, distal and local recurrence and the survival at 5 years. The statistics were performed by the chi-square test, the Fisher exact-test and the Wilcoxon test. The aneuploids are 126 (84%) and the diploids 24 (16%). The correlations of ploidy and the Duke's stages, the Grading, and the over-all and local recurrence are not statistical significant. The distal recurrence of the aneuploids and the better survival of the diploids are significant. In conclusion the ploidy is only a generic indicator of the aggressiveness of the tumor, not useful for a more complete therapeutic choice.

The Authors present a case of post traumatic pseudocyst of the pancreas added to their observations and treated with an endoscopic cytogastric deviation. The incidence of such pathology has increased during the last few years thanks also to the improvement of the diagnostic techniques (TAC, U/S, Rm and eco-endoscopy) on hard today; in the second place the technological evolution has allowed, improving the diagnostic definition, the ability to heat pseudocysts, in selected patients, with minor surgery techniques with result equal to those of conventional surgery, but with complications and mortality decisively reduced. The morbidity and mortality rates of internal deviation surgery has respectively worsened varying between 21% and 50% and from 5% to 12%. The results of endoscopic deviations, even if the cases are less, report positive results from 80% to 100%, with complications and mortality greatly reduced. To be able to propose an endoscopic indication certain requirement are necessary of which one is indispensable: the distance between the two adjacent lumen must not be more than one centimeter. The Authors are of the opinion that such methods, in expert hand an on selected patients, should be the first surgical choice for the treatment of pancreatic pseudocysts.

The spastic pelvic floor syndrome, caused by a paradox contraction of the sphincteric apparatus at defaecation instead of relaxing, leads to constipation with difficult evacuation. Forty patients (15 males and 25 females, average age 49 years, age range 15-78) affected by serious chronic idiopathic constipation, underwent, at our Institute, from June 1989 to September 1990, the following instrumental examinations: anal manometry; electromyography of the pelvic floor; proctogram; intestinal transit time; anorectal endoscopy; in addition, in 6 cases at risk for colorectal cancer, left colonoscopy. Fifteen patients showed dyskinetic functioning of the voluntary sphincteric apparatus. The following diagnostic methods proved to be of fundamental importance: proctogram, which revealed failure to open of the anorectal angle at defaecation (mean values: at rest 88.93 degrees +/- 6.62; at defaecation 88.93 degrees +/- 9.44); electromyography of the pelvic floor, which showed the anomalous contraction of the external anal sphincter. These patients were treated by means of an air inflated endoampullary balloon to evoke the sensation of a stool and its subsequent expulsion. The correct evacuating function was resumed definitely in 9 patients (60%); for the remaining 6 patients, regular sessions of re-education are still necessary. The spastic pelvic floor syndrome is a major cause of constipation and requires an accurate diagnostic method of investigating the correct functioning of the recto-pelvic region by means of the above-mentioned methods.(ABSTRACT TRUNCATED AT 250 WORDS)

The Authors report their experience in the treatment of bleeding gastric and duodenal ulcers by means of endoscopic sclerotherapy. From August 1988 to December 1989, 104 patients with haematemesis and/or melena were observed at the Clinica Chirurgica Generale, Toracica e Vascolare-Università di Parma. Endoscopy, carried out in the first 24 hours, led to the diagnosis of a bleeding gastric or duodenal ulcer in 73 cases; 22 of these patients underwent emergency sclerotherapy using 1:10,000 Adrenaline in association with 1% Polydocanol. Results obtained are the following: absolute haemostasis in 20 patients (91%), and surgical intervention in the other 2 cases for renewed haemorrhage. Among patients endoscopically treated, one death (5%) was recorded. Further complications were not encountered. The Authors believe sclerotherapy is reliable and quick thus representing a considerable therapeutic advance in the treatment of gastroduodenal haemorrhage, notoriously at high death rate (8-10%).

The authors report their experience about the esophageal manometry in patients with Progressive Systemic Sclerosis (PSS). From January 1987 to December 1991, 32 patients (27 females and 5 males, in the ratio of 5.4 to 1; mean age of 56.6 years, range 18-84) were send to our Department with the diagnosis of PSS. The patients were divided in two group according to the presence or absence of esophageal symptoms. The first group (A) of 12 patients without symptoms, was examined only with manometry, while the second (B) was studied with the 24-hour pH-monitoring and esophagoscopy. In the group A the manometry noticed in 9 cases (75%) various degrees of esophageal motility disorders; in B the 90% of cases had a more or less severe disorder of the peristalsis. Moreover the grade of esophagitis and the importance of the gastroesophageal reflux were proportioned to the motility disorders. The conclusion is that also the subjects with PSS, but without esophageal symptoms, have in a high percentage motility disorders of the viscera. The alterations of the peristalsis increases in the group of symptomatic patients associated with esophagitis and severe reflux. On account of the fact that the esophageal lesions involve not only the LES but also the esophageal body, it is clear that the anti-reflux surgical procedures fail and an early medical therapy is the more adequate treatment.

The authors present a report of their study on a group of patients affected by serious chronic constipation undergoing multidisciplinary evaluation by a radiologist, a neurologist and, if necessary, also a psychiatrist. From June 1989 to October 1990, 40 patients were examined using anal manometry, intestinal transit time, proctogram and electromyography of the pelvic floor. The examinations carried out by the different specialists led to the following results: 10 patients were found to be affected by slowed transit due to right colon constipation; in 16 cases, spastic pelvic floor syndrome (S.P.F.S.) was diagnosed; 5 subjects showed a rectocele which in 3 was associated with S.P.F.S.; 3 patients presented with an anterior rectal prolapse; in 6 cases the diagnosis was perineal descent syndrome, associated in 3 cases with S.P.F.S.; the remaining 6 subjects manifested a diminished ampullary sensitivity. This experience reveals the complexity of the alterations that, alone or in association, cause chronic idiopathic constipation. The authors' conclusion is that a correct diagnostic approach requires close collaboration between various specialists, who, by careful examination of different aspects of the colo-recto-anal region, arrive at an accurate physiopathological diagnosis leading to the most suitable therapy.

Thirty-seven patients with thyroid cancer were treated at 1a Clinica Chirurgica of Parma between 1962 and 1970. Fourty-five per cent of tumors were papillary, 24 per cent follicular, 2 per cent medullary, 9 per cent anaplastic. Surgery combined with ormonal therapy formed the commonest treatment. Eighty-five per cent of the patients with papillary carcinoma 70 per cent with follicular and 33,3 per cent with anaplastic carcinoma survived for 10 years. This present series indicates that total thiroidectomy combined with ormonal therapy influences the survival time, confirms the prognostic value of histology and shows that papillary node metastases do not prejudice survival.

Cecal diverticulitis, is not a common disease, frequently congenital, becoming clinically evident between the second and the fourth decade. The diagnosis of cecal diverticulitis is often controversial since the signs and symptoms simulate an acute appendicitis or an appendicular abscess. Moreover, during surgery, sometimes it appears like carcinoma of the cecum. Barium enema is the only clinical test useful for a correct diagnosis before surgical procedure, but in the case of an acute appendicitis this test is normally not performed. The surgical treatment is, when possible, diverticular resection associated with cecal appendix resection. In doubtable or technically hazardous cases it is sometimes necessary a right hemicolectomy. Mortality and morbidity for minor procedures are negligible, whereas for right hemicolectomy they range between 3,7% and 11% according to different Authors.

The Authors describe 6 patients with esophageal jatrogenic of foreign body perforation treatment during the last 5 years. The early recognition and immediate direct suture of the lesion proved a simple and efficient treatment. At the contrary a delayed diagnosis represent the cause of morbidity and mortality (one case on the six described) being impossible a direct suture of the lesion as consequence of local and general infective complication leading to very long postoperative causes with possible iterative surgery. The use of T.P.N. and of antibiotic therapy gascromatografich testing guides for anaerobic infection provide today a much improved prognosis for these patients.

The Authors described their experience in 41 patients operated on because of gallbladder cancer. The overall mortality was 20%. Four cases suitables for a "radical" wide resection showed an average survival of 8 months, while 2 on 3 patients with in "situ" carcinoma treated by simple cholecystectomy are still alive at more than 3 years, the other dying after five years because of disease not related to the gallbladder cancer. The bad general prognosis of the disease is mainly related to the delayed diagnosis together with the anatomical relations of the gallbladder as demonstrated by the discouraging survival in the "radically" widely resected patients. It must be considered consequently categorical to realize an early cholecystectomy, the only possible preventive procedure, in the height risk patients.

The Authors review 86 cases, aged over 70, needing surgical treatment because of atherosclerotic obstructive disease of the lower limb, stage III-IV. 35 patients underwent thigh amputation with 14% mortality in the early post-operative period (30 days) and 32% in the late post-operative period, considered up to 6 months. For 38 patients who underwent a revascularisation procedure mortality resulted 8% in the 30 post-operative days and 10% at 6 months. Escluding the aorto-iliac reconstructions through a trans-peritoneal approach, the overall mortality is limited to 3,2%. A major amputation was avoided in 76% of patients who underwent a revascularisation. On the base of their results the Authors discuss the indications of direct surgery in treatment of advanced ischemic lesions in elderly patients concluding that a surgical correction should be always considered in the aim of avoiding or limiting the amputation. In these high-risk elderly patients the extra-peritoneal aorto-iliac reconstructive technique must be preferred together with extraanatomical femoro-femoral or axillo-femoral by-passes.

A series of 145 patients with cancer of the pancreas is presented. Radical surgery was performed in 23 cases. An assessment is made of anatomical and clinical factors likely to interfere with the results of surgery, particularly radical surgery. The mean survival after palliative operations was 5.5 months and after duodenocephalopancreatectomy 16.1 months. After resection, operative mortality as a whole was 21.6%, though in the last 5 years it had fallen to 8.8%. Actuarial survival after 1 yr was 56.3% and after 2 yr 18.8%. The average duration of the symptom picture was long due to the difficulty of making an early diagnosis. This has an adverse influence on the operability of cancer of the pancreas. On average, survival after resection was less in cases with infiltration of the lymph nodes, but not in those with extension of the neoplasia to neighbouring organs, such as the duodenum. The results of radical management were much the same as those reported in the literature and are regarded as unsatisfactory, even though better than those achieved with palliative surgery. Their improvement is discussed in the light of the technical features of duodenocephalopancreatectomy. It is felt that extensive lymphadenectomy is required and that this should be planned and performed in accordance with strict anatomical and surgical criteria.

The Authors report 180 cases of transdudenal papillosphincterotomy. Medium follow-up at 5 years revealed a complete recovery in 87 of 100 controlled patients. Nine cases revealed persistence of some degree of dyspepsia, while a second operation was necessary for the remaining patients to remove recurrent calculi in 2 cases and because of Oddi's stenosis in other two cases. A 4,4% mortality operative was observed, following postoperative pancreatitis in 1,1%, duodenal fistula or haemorrhage in 1,6%, and 1,6% from other causes. On the basis of their results the Authors conclude that transduodenal papillosphincterotomy is an effective procedure in treating complicated lithiasic biliary disease when respecting the reported indications.