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Background: Pancreaticoduodenectomy is still associated to high morbility, especially due to pancreatic surgery related and infectious complications: many risk factors have already been advocated. Aim of this study is to evaluate the role of preoperative oral immunonutrition in well nourished patients scheduled for pancreaticoduodenectomy., Methods: From February 2014 to June 2015, 54 well nourished patients undergoing pancreaticoduodenectomy were enrolled for 5 days preoperative oral immunonutrition. A series of consecutive patients submitted to the same intervention in the same department, with preoperative standard oral diet, was matched 1:1. For analysis demographic, pathological and surgical variables were considered. Mortality rate, overall postoperative morbility, pancreatic fistula, post pancreatectomy haemorrhage, delayed gastric emptying, infectious complications and length of hospital stay were described for each groups. Chi squared test, Fisher's Exact test and Student's T test were used for comparison. Differences were considered statistically significant at p < 0.05. Statistics was performed using a freeware Microsoft Excel (®) based program and SPSS v 10.00., Results: No statistical differences in term of mortality (2.1% in each groups) and overall morbility rate (41.6% vs 47.9%) occurred between the groups as well as for pancreatic surgery related complications. Conversely, statistical differences were found for infectious complications (22.9% vs 43.7%, p = 0.034) and length of hospital stay (18.3 ± 6.8 days vs 21.7 ± 8.3, p = 0.035) in immunonutrition group., Conclusion: Preoperative oral immunonutrition is effective for well nourished patients scheduled for pancreaticoduodenectomy; it helps to reduce the risk of postoperative infectious complications and length of hospital stays., (Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Aim: Distal pancreatectomies (DP) are associated with high risk of postoperative complications, and in many series higher morbidity rate than duodenopancreatectomies has been reported. To evaluate the role of a collagen sponge with human fibrinogen and thrombin film (TachoSil®) in limiting the incidence of complications after DP., Methods: From 1996 to 2013, 221 patients have been submitted to distal pancreatectomy (± splenectomy) in our Division. A retrospective analysis has been conducted in a group of 36 consecutive and prospectively collected DP treated with intraoperative placement of TachoSil® on pancreatic stump from 2010 to 2013 (group 1). A control series of 36 consecutive patients (group 2) was matched 1:1 from hystorical database. The variables considered in the analysis were: age, gender, ASA score, pancreatic texture (hard vs. soft), histology, operative time, postoperative mortality, morbility (postoperative pancreatic fistula - POPF, postoperative hemorrage - PPH, delayed gastric emptying - DGE) and hospital stay. Differences between POPF, PPH, DGE and hospital stays between grops were investigated with χ² and t-Student test. Univariate analysis was conducted to determine factors related to POPF development. Statistical analysis was performed using freeware Microsoft Excel based program., Results: Post operative mortality was 0% in both groups. POPF were registered in 36.1% (13/36) and 41.6 % (15/36) in groups 1 and 2, respectively (P=n.s.); in group 1 we didn't observe grade C POPF, while 4 patients in control group developed grade C POPF (P<0,05). No differences were found between two groups in terms of incidence of PPH and DGE. The median duration of postoperative hospital stay in group 1 was 21.8 (7-189) days compared with 31.13 (9-249) days in group 2 (P<0.001)., Conclusion: The use of TachoSil® seems to be associated with lower incidence of grade C POPF but larger controlled trials are needed to surely assess the usefulness of TachoSil® in pancreatic surgery in order to reduce pancreatic specific complications and their severity.

Objective: To evaluate Peng's binding pancreaticojejunostomy as a safe technique which avoids anastomotic leakage after a pancreaticoduodenectomy., Methods: Prospective, observational, dual-institutional study, of patients who underwent a Peng's binding pancreaticojejunostomy was conducted. It was compared with an historical control group of patients who underwent duct to mucosa pancreaticojejunostomy. Overall postoperative mortality, morbidity, postoperative pancreatic fistulas, postpancreatectomy hemorrhage, reoperation, length and costs of hospital stay were collected. Factors related with pancreatic fistula were: sex, age, co-morbidities, body mass index, American Society of Anesthesiologists score, type of resection, extension of resection, characteristics of the pancreatic remnant, pathological diagnosis and surgeons. Univariate and multivariate analyzes were carried out., Results: Sixty-nine patients who underwent binding pancreaticojejunostomy were reported. The control group consisted of 52 patients. The mean length of hospital stay was significantly shorter in the control group than in binding group (p = 0.003). Multivariate analyzes showed that soft pancreatic remnant was significantly related to an increasing rate of postoperative pancreatic fistula (OR 3.7-CI 1.1-12.8-P = 0.034) while the type of pancreatic anastomosis was not significantly related with the occurrence of postoperative pancreatic fistula., Conclusions: In the European population, the binding pancreaticojejunostomy according to Peng did not preclude or reduce the postoperative pancreatic fistula rate., (Copyright © 2013 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

The role of the proinflammatory interleukin (IL)-18 in cancer progression remains controversial; we thus examined the hypothesis that impaired antitumor immune response in pancreatic carcinoma patients is related to elevated levels of its natural inhibitor IL-18 binding protein (BP) and/or to alteration in the IL-18 receptor complex expression and function. IL-18 and IL-18 binding protein isoform a (BPa) was assessed in pancreatic carcinoma patients at various disease stages, and after surgery/chemotherapy; free bioactive IL-18 concentrations were calculated. IL-18 receptor complex expression in lymphocyte subsets was analyzed and signaling function was assessed versus healthy donors. Carcinoma cells exhibited below normal IL-18BPa expression and above normal IL-18 expression. Circulating IL-18BPa and IL-18 were above controls. Unexpectedly, free unbound IL-18 serum levels were correlated with disease severity and poor survival. IL-18BPa levels were unchanged by surgery but free IL-18 levels were elevated. Gemcitabine with 5-fluorouracil or oxaliplatin, but not alone, increased IL-18 and free IL-18 levels statistically significantly, without affecting IL-18BPa. Spontaneous/induced IL-18 receptor alpha and receptor beta expression in peripheral blood lymphocyte subsets from patients with advanced disease were near-normal, although CD4+ and CD8+ cells were fewer in percentage, and fully functional in inducing interferon-gamma. IL-18 is proposed as novel adjuvant cancer therapy, but free IL-18 levels are increased in the blood of pancreatic carcinoma patients, despite elevated IL-18BP levels, and are associated with poor survival; this highlights recent experimental insights into the prometastatic and proangiogenic effects of IL-18, and suggests that careful preclinical studies are needed to determine the proper application of IL-18 in cancer therapy.

As surgery and chemotherapy may act as adjuvants providing antitumor immunity benefits, we ran phenotypical and functional immunomonitoring in patients with resectable pancreatic adenocarcinoma and advanced metastatic disease receiving combined treatment (cisplatin, gemcitabine, 5-FU). Blood was taken before/one month after resection; before/during chemotherapy. Controls were age- and gender-matched. Circulating lymphocyte, myeloid and plasmacytoid dendritic cell (MDC and PDC) subsets were examined by flow cytometry; functional activity by mixed lymphocyte reaction (MLR) for DC allostimulation, through 4-h 51Cr-release assay for Natural Killer (NK) and lymphokine-activated-killer (LAK) cell cytotoxicity; ELISA for spontaneous/activated cytokine release by PBMC and T cells. Significant differences occurred in several parameters between pretreatment patient and control values: fewer CD8+ cells and increased apoptosis-prone CD3+/CD95+ lymphocytes, higher frequency of MDC, reduced allostimulatory activity by ex vivo-generated DC, depressed LAK activity, elevated IL-10 and IL-12p40 production; impaired IL-12p70 and IFN-gamma production by stimulated PBMC and T cells. Only IL-12p70 level was correlated with survival. One month after radical, but not palliative surgery, the percentage of T-lymphocytes coexpressing CD3/CD95 decreased significantly, the stimulatory capacity of DC increased, and LPS-induced IL-12p70 release by PBMC rose concomitantly with the anti-CD3 stimulated-IFN-gamma production by T cells. In patients with locally advanced or metastatic disease, one and/or two combined drug cycles increased percentage of CD4+ cells and LAK cell cytotoxicity and decreased PDC frequency and spontaneous/LPS-stimulated IL-10 by PBMC. Results suggest immunological changes induced by surgical resection/combined chemotherapy indicate specific precisely-timed windows of opportunity for introducing immunotherapy in pancreatic cancer, possibly improving survival in this highly lethal disease.

Survival of pancreatic cancer is improved by surgery and is related to R0 resection. An accurate diagnosis and a careful staging are mandatory. Differential diagnosis must be estabilished between the different pancreatic lesions as carcinoma, chronic pancreatitis, cystic or endocrine neoplasms. Endoscopic ultrasound (EUS) is the best technique for diagnosis and allows cytological examination by fine needle aspiration (FNA). Preoperative resectability is defined by EUS in borderline tumors. EUS is a useful procedure for the surgical strategy of pancreatic cancer.

Morgagni-Larrey hernia (MH) is an unusual diaphragmatic hernia of the retrosternal region. Few cases of MH, treated laparoscopically, associated with Down's syndrome (DS) have been reported in literature. On October 2004, a DS 40-year-old male was admitted to our Department with mild abdominal pain and nausea. Hematochemical tests were within the normal range. Ultrasonography showed biliary sludge and multiple gallstones. Chest X-ray revealed a right-sided paracardiac mass that appeared as MH after a thoraco-abdominal computed tomography (CT). Four trocars were placed as a routinary cholecystectomy. Abdominal exploration confirmed the presence of a voluminous hernia through a wide diaphragmatic defect (12 cm) on the left side of the falciform ligament, containing the last 20 cm ileal loops and right colon with the third lateral of transverse. After retrograde cholecystectomy and reduction of the herniated ileo-colonic tract from multiple adherences, the defect was repaired with an interrupted 2/0 silk suture and then a running 2/0 polypropylene suture. Postoperative course was complicated by pulmonary edema but subsequently the patient was discharged without further complications and has no recurrence after 2 years. In conclusion, surgery is necessary for symptomatic MH and to prevent possible severe complications. We preferred laparoscopy for the reduced morbidity compared to laparotomy, even if in our case the postoperative course was not uneventful. There are still few comparative data about the modality of closure of the defect between primary repair with nonabsorbable suture material, in case of small defects, or continuous monofilament suture or prosthesis in case of large defects.

Aim: To investigate the seroprevalence of Helicobacter pylori (H pylori) infection and its more virulent strains as well as the correlation with the histologic features among patients who had undergone surgery for gastric cancer (GC)., Methods: Samples from 317 (184 males, 133 females, mean age 69+/-3.4 years) consecutive patients who had undergone surgery for gastric non-cardia adenocarcinoma were included in the study. Five hundred and fifty-five (294 males, 261 females, mean age 57.3+/-4.1 years) patients consecutively admitted to the Emergency Care Unit served as control. Histological examination of tumor, lymph nodes and other tissues obtained at the time of surgery represented the diagnostic "gold standard". An enzyme immunosorbent assay was used to detect serum anti-H pylori (IgG) antibodies and Western blotting technique was utilized to search for anti-CagA protein (IgG)., Results: Two hundred and sixty-one of three hundred and seventeen (82.3%) GC patients and 314/555 (56.5%) controls were seropositive for anti-H pylori (P<0.0001; OR, 3.58; 95%CI, 2.53-5.07). Out of the 317 cases, 267 (84.2%) were seropositive for anti-CagA antibody vs 100 out of 555 (18%) controls (P<0.0001; OR, 24.30; 95%CI, 16.5-35.9). There was no difference between the frequency of H pylori in intestinal type carcinoma (76.2%) and diffuse type cancer (78.8%). Intestinal metaplasia (IM) was more frequent but not significant in the intestinal type cancer (83.4% vs 75.2% in diffuse type and 72.5% in mixed type). Among the patients examined for IM, 39.8% had IM type I, 8.3% type II and 51.9% type III(type III vs others, P = 0.4)., Conclusion: This study confirms a high seroprevalence of H pylori infection in patients suffering from gastric adenocarcinoma and provides further evidence that searching for CagA status over H pylori infection might confer additional benefit in identifying populations at greater risk for this tumor.

Purpose: Anastomotic configuration may influence anastomotic leak rates. The aim of this study was to determine whether a side-to-side stapled ileocolonic anastomosis produces lower anastomotic leak rates than those with a handsewn end-to-end ileocolonic anastomosis after ileocecal or ileocolonic resection for Crohn's disease., Methods: A series of 122 consecutive patients underwent elective ileocecal or ileocolonic resection with ileocolonic anastomosis for Crohn's disease from January 1998 to June 2003: 71 had handsewn end-to-end anastomosis and 51 had side-to-side stapled anastomosis. The choice between the two anastomoses was left to the surgeon's preference. A retrospective analysis was performed to assess if there was any difference in anastomotic leak rates., Results: The two groups were comparable in terms of age, gender, preoperative presence of abscess or fistula, history of smoking, and albumin levels. More patients were taking steroids in the handsewn group than in the stapled group. In the handsewn group there were 10 anastomotic leaks (14.1 percent) and in the stapled group there was 1 anastomotic leak (2.0 percent) (risk difference, +12.1 percent; 95 percent confidence interval, 1.7-22.2; P = 0.02). Anastomotic configuration was the sole variable that influenced anastomotic leak rates at univariate analysis. Mortality was 1.4 percent in the handsewn group and 0 percent in the stapled group. Complications other than anastomotic leak developed in 11 patients in the hand-sewn group and in 6 patients in the stapled group. Mean postoperative hospital stay was 12.3 days in the handsewn group and 9.7 days in the stapled group (P = 0.03). Excluding those patients who had an anastomotic leak, the difference was still present (handsewn group, 10.1 days; stapled group, 9.1 days; P = 0.04)., Conclusion: Although confirmation from randomized, controlled trials is required, side-to-side stapled anastomosis seems to substantially decrease anastomotic leak rates in surgical patients with Crohn's disease, compared with handsewn end-to-end anastomosis. Postoperative hospital stay decreased in the stapled anastomosis group, and this was not entirely a result of decreased anastomotic leak rates.

Hepatocellular carcinoma (HCC) may arise in ectopic livers, which are autonomous islands of normal liver parenchyma located in the abdomen or thorax. The majority of HCCs in ectopic livers are reported in oriental patients. We describe here three new cases of HCC in Caucasian patients. The clinical presentation varied from dull epigastric pain in one patient, to abrupt onset with signs and symptoms of acute abdomen caused by intra-abdominal bleeding in another patient, to an unexplained progressive increase of alpha-fetoprotein serum levels in a third patient. None had risk factors for HCC or liver disease. One of the patients developed HCC at age 34 years; she is the youngest patient ever described to develop HCC in ectopic liver. Our data further strengthen the hypothesis that ectopic livers are particularly predisposed to developing HCC. The patients were followed up for 4 years after surgery: two remain free of disease, suggesting that the unique localisation and growth pattern may render these tumours particularly susceptible to curative resection.

Background: Carcinoma of the gallbladder is a gastrointestinal malignancy with a very poor prognosis. The 5-year survival rate amounts to less than 5% in most series. In this study we reviewed the results of surgical treatment for gallbladder carcinoma with special reference to extended radical procedures., Methods: Between 1995 and 2000 we enrolled 36 patients (17 males and 19 females), 24 of whom were treated with simple cholecystectomy and 12 with radical resection (partial hepatectomy, regional lymphadenectomy, and common bile duct resection). The tumours were classified by stage using the criteria of the American Joint Committee on Cancer (AJCC). Stages, operative procedures, results of pathologic examinations and the outcome of the resected cases were reviewed., Results: There were 2 postoperative deaths (0.55%). The mean follow-up period was 19.1 months (range 1-60). For stage I and II disease extended cholecystectomy had a better result than simple cholecystectomy: the 5-year survival rates were 38.4 versus 19%, respectively. For the patients with advanced stage III or IV gallbladder carcinoma, a significant advantage of survival resulted in case of liver resection as compared to surgical treatment without liver resection: the 5-year survival rates were 20 and 0%, respectively., Conclusions: The survival of stage I-II patients was good. For the patients in higher stages the prognosis was significantly worse. In these cases more aggressive surgery may be needed.

The authors compare their experience in the surgical treatment of gastric carcinoma with the literature and point out that therapeutic value of a wide gastric resection and adequate lymphadenectomy can improve a 5-year survival without increasing mortality and morbidity. In an 8-year experience in 258 patients with gastric carcinoma, 249 underwent operation, 139 with curative intention. Wide gastric resection proved to be effective and safer than elective total gastrectomy, and D2-lymphadenectomy showed the same morbidity of D1 and seems to offer a better 5-year survival. Extended resections for gastric cancer, that result in simultaneous pancreatectomy, splenectomy, hesophagectomy, resection of the colon and hepatectomy, do not show significant improvement of the survival.

Sepsis of the biliary tract is a severe disease, due to its course and its significant association with relevant diseases, either benign or malignant, of the biliary tract, pancreas, hepatic hilus. In many cases it remains difficult to set the limit between medical therapy, percutaneous or endoscopic therapy and surgical treatment. Through a thorough review of the last 20 years' literature, we have studied this topic and classified cholangitis according to its etiology: Iithiasis, benign stenosis or Klatskin tumor as malignant diseases. The sequential approach, endoscopy-surgery, seems to provide the best results in lithiasic cholangitis. In patients with benign stenosis of the biliary tract, a percutaneous drainage is indicated as a first choice, meanwhile surgery is limited to unsuccessful bilioplasty and to segmental extrahepatic localization of sclerosing cholangitis. On the contrary, in Klatskin tumours preoperative percutaneous drainages are useful to obtain an accurate map, which is indispensable to perform an aggressive radical hepatic resection.

Background/aims: Laparoscopic cholecystectomy has become the procedure of choice for symptomatic cholelithiasis. A study to evaluate the benefits and risks of laparoscopic cholecystectomy in cirrhotic patients was performed., Methods: Between January 1994 and December 2000, 1,100 laparoscopic cholecystectomies for symptomatic gallbladder diseases were performed. There were 24 cirrhotic patients (group A) and 72 age- and sex-matched controls (group B). All patients had well-compensated cirrhosis (Child's class A or B)., Results: There was no operative mortality in either group and the postoperative complication rates were 20.8 and 9.72% in groups A and B, respectively (p < 0.000001). Operative time in group A was 89.16 vs. 68.41 min in group B (p < 0.000001). The estimated intraoperative blood loss in group A was 106.25 vs. 37.08 ml in group B (p < 0.000001). The average transfusion requirement was 0.155 and 0.0 units in groups A and B, respectively (p < 0.025). The hospital stay in groups A and B was 4.7 and 3.61 days, respectively (p < 0.0500)., Conclusion: Laparoscopic cholecystectomy in patients with compensated cirrhosis is safe and should be the treatment of choice for these patients. Laparotomy should be applied only if the surgeon considers the operation inadequate to be continued laparoscopically., (Copyright 2001 S. Karger AG, Basel)

The resectability rate of hilar bile duct carcinoma is reported to be variable and to inversely correlate with the size of the associated liver resection. In an attempt to reduce the risk of postoperative liver failure, the induction of a hypertrophy of remnant liver by preoperative portal vein embolization (PVE) has been proposed. We hereby analyse the results and the technical aspects of this procedure along with our personal experience.

Hepatocellular carcinoma (HCC) is closely associated with cirrhosis, but it also develops, although much less frequently, in a non-cirrhotic liver. It is suspected that hepatocellular carcinoma has a different etiology when associated and not associated with chronic liver disease. We report two cases of patients with hepatocellular carcinoma that developed in a non-cirrhotic liver. In the first case we describe an incidental liver nodular lesion containing multiple foci of HCC including pseudogland or trabecular formation and areas of sclerosis. The non-cancerous parenchyma of the liver was histologically unremarkable except for mild fatty changes of hepatocytes and minimal dysplasia. The second case describes a combined hepatocellular carcinoma and cholangiocellular carcinoma (CCC) (mixed carcinoma) in a patient who was serologically negative for both hepatitis B and C viruses. The adjacent liver parenchyma showed mild piecemeal necrosis and mild lobular activity compatible with chronic viral hepatitis, but cirrhosis was not established. This case appears to indicate that mixed type carcinoma can develop in a non-cirrhotic liver, with CCC being far more dominant than HCC; such a finding is extremely unusual, based on previously published reports.

Background: Only a part of patients suffering from Crohn's disease has enteric fistulae and a different behaviour of Crohn's disease with fistulae is reported in the literature. Aim of this paper is to evaluate if enteric fistulae are a factor conditioning mortality, morbidity and overall postoperative course, in patients with Crohn's disease., Methods: Data on the postoperative course of 126 laparotomies for Crohn's disease, performed between November 1993 and July 1998, have been prospectively examined. Moreover, the presence of enteric fistula has been evaluated during surgery., Results: Out of 126 interventions, in 58 (46%) enteric fistulae were present. Mortality (5.2% vs 0), morbidity (14.5% vs 7.3%), necessity for a temporary ostomy (20.4% vs 3.5%) were greater in those patients with fistula, as compared as those without fistula., Conclusions: In conclusion, it is suggested that Crohn's disease with fistulae is a different type of disease, with higher mortality and morbidity rates.

Objective: Selected mechanisms of the immune system participate in the development of inflammatory bowel disease. Recently, overexpression of the ligand for CD40 (CD40L), a lymphocyte costimulatory molecule, was shown to induce severe inflammatory bowel disease in transgenic mice. In the present study, we examined the expression of CD40 and CD40L on surgical specimens of ileum from 12 patients with Crohn's disease and 10 patients with diverticulitis., Methods: Several CD40L+ cells were present in the affected tissue of patients with Crohn's disease, whereas few scattered CD40L+ cells were detected in sections of histologically normal ileum, resected distantly from the affected tissue, in patients with diverticulitis and in normal ileum portions obtained from colorectal cancer undergoing extensive surgery. The phenotype of CD40L+ cells was mainly CD4+., Results: In patients with Crohn's disease, several CD40+ cells were detectable in the same areas of lymphocytes expressing CD40L, whereas in patients with diverticulitis, the number of CD40+ cells was significantly lower. Most of the CD40+ cells costained with CD20, thus showing to be B-lymphocytes, and only a few were CD14+ macrophages. Several von Willebrand-positive vessels were also positive for CD40. In addition, several infiltrating macrophages were found to express B7-1 and B7-2 molecules, the ligands of CD28 and CTLA-4, which cooperate with the CD40-CD40L pathway in lymphocyte activation. Staining of ileal lesions with anti-CTLA-4 antibodies resulted in detection of none or very few positive cells. In contrast, in patients with diverticulitis, an enhanced number of B7-1 and B7-2 and CTLA-4 was observed., Conclusion: The local accumulation of CD40L+ together with CD40+ cells within intestinal lesions of Crohn's disease suggests the involvement of this co-stimulatory pathway.

Lipohyperplasia or intestinal lipomatosis is an infrequent disease characterised by anomalous infiltration of adipose tissue in the intestinal submucosa. Localised forms are generally asymptomatic, whereas diffuse forms may lead to intestinal subocclusion, digestive hemorrhage or diarrhoea. Although benign, the differential diagnosis of intestinal lipomatosis with malignant pathologies of the colon or appendix often prompts the need for surgical exploration and the histological analysis of biopsy material. Surgical exeresis of the lesion is generally associated with the normalisation of clinical symptoms. The authors report the onset and clinical evolution of two cases of intestinal lipomatosis referred to their attention.

The "groove pancreatitis" is a special form of segmental chronic pancreatitis affecting the "groove" between pancreatic head, duodenum and common bile duct. This type of chronic pancreatitis was first described in 1973 and only few cases have been reported in literature. Unlike other forms of chronic pancreatitis, this is often preceded by peptic ulcers, gastric resections or biliary tract diseases; it could be associated with cysts of the duodenal wall and pancreatic cysts. Abdominal pain, vomiting due to duodenal stenosis, obstructive jaundice and weight loss are the most common presenting symptoms. The radiological features show a pancreatic mass similar to a pancreatic head carcinoma and the discrimination of groove pancreatitis from pancreatic carcinoma is often difficult or even impossible in some patients. We describe a case of groove pancreatitis treated with pancreatoduodenectomy, reviewing the clinical and radiological features. We remark that the groove pancreatitis is a disease that must be known and should be considered in the differential diagnosis of pancreatic carcinoma.

The authors consider the various causes of ascites and they also develop the concept of refractory ascites. They consider the various possibilities of medical and dietary therapy whose failure constitutes the basis for a surgical approach. In the latter case it is being considered the Peritoneo Venous Shunt (PVS) that employs different types of valves. In the light of their personal experience, matured over a period of 15 years, in which 75 valves were positioned in 64 patients and precisely: 55 valves of Le Veen, 15 Hakim and 5 Denver, it is emphasized that the best results, as for as mortality and morbidity goes, were obtained through careful attention in the preoperative stage and during surgery itself with the privileged use of a Le Veen's valve. For such motives, since in a high percentage of these patients there persists a poor prognosis a year away from the onset of refractory ascites, a PVS seems proposable anyway and even though this will not alter the pathological outcome, there's a clear improvement in the quality of life without precluding any other surgical approach. Finally, the authors outline the possibilities offered by the Transjugular Intrahepatic Portosystemic Shunt (TIPS), as a new original approach for the resolution of refractory ascites.

Since 1983 we have percutaneously treated 150 cases of bile duct lithiasis in which previous endoscopic maneuvers had been incomplete or unfeasible. Complete resolution of lithiasis was obtained in 139 of 150 patients. In 6 cases only partial success was obtained but symptoms subsided. In 2 cases the treatment failed and the patients underwent surgery. Minor complications were observed in 12.6% of patients and resolved either spontaneously or by percutaneous maneuvers. Mortality rate was 2%. After a follow-up period of 6-12 months, 9 patients had a recurrence, completely resolved with further percutaneous treatment. These cases never required surgery. We obtained the best results in patients with stones residual after cholecystectomy or a iatrogenic stricture of the biliary tree. We obtained good results in massive lithiasis with combined endoscopic, surgical and radiological procedures. Morbidity and mortality rates were lower than in surgical series and similar to the endoscopic ones. The short hospitalization, the low cost and the possibility of treatment on an outpatient basis should promote the spreading of percutaneous techniques in the treatment of bile duct lithiasis.

The Authors report a case of rhabdomyosarcoma observed in a 17-year-old boy. They emphasize that this rare form has an extremely rapid evolution, and in this case was also in an unusual site and of abnormal size. The difficulty of an early diagnosis and the impossibility of radical surgery are also underlined.