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Patients undergoing colon resection are often concerned about their functional outcomes after surgery. The primary aim of this prospective, multicentric study was to assess the intestinal activity and health-related quality-of-life (HRQL) after ileocecal valve removal. The secondary aim was to evaluate any vitamin B12 deficiency. The study included patients undergoing right colectomy, extended right colectomy and ileocecal resection for either neoplastic or benign disease. Selected items of GIQLI and EORTC QLQ-CR29 questionnaires were used to investigate intestinal activity and HRQL before and after surgery. Blood samples for vitamin B12 level were collected before and during the follow-up period. The empirical rule effect size (ERES) method was used to explain the clinical effect of statistical results. Linear mixed effect (LME) model for longitudinal data was applied to detect the most important parameters affecting the total score. A total of 158 patients were considered. Applying the ERES method, the analysis of both questionnaires showed clinically and statistically significant improvement of HRQL at the end of the follow-up period. Applying the LME model, worsening of HRQL was correlated with female gender and ileum length when using GIQLI questionnaire, and with female gender, open approach, and advanced cancer stage when using the EORTC QLQ-CR29 questionnaire. No significant deficiency in vitamin B12 levels was observed regardless of the length of surgical specimen. In our series, no deterioration of HRQL and no vitamin B12 deficiency were found during the follow-up period. Nevertheless, warning patients about potential changes in bowel habits is mandatory. In our series, no deterioration of HRQL and no vitamin B12 deficiency were found during the follow-up period. Nevertheless, warning patients about potential changes in bowel habits is mandatory.

Resume La duodenopancreatectomie cephalique (DPC) est le traitement de choix pour les tumeurs malignes periampullaires, et aujourd’hui, les indications se sont elargies aux maladies benignes, telles la pancreatite chronique symptomatique, la dystrophie kystique sur pancreas aberrant de la paroi duodenale et les tumeurs papillaires benignes qui ne relevent pas de la chirurgie conservatrice. En depit d’une baisse significative de la mortalite dans les centres a gros volume pendant les trois dernieres decennies (de > 20 % dans les annees 1980 a

INTRODUCTION The use of robotic surgery in liver resection is still limited. Our aim is to present our early experience of robotic liver resection. MATERIALS AND METHODS It is a retrospective review of Sanchinarro University hospital experience of robotic liver resection performed from 2011 to 2014. Clinicopathologic characteristics, and perioperative and postoperative outcomes were recorded and analyzed. RESULTS Twenty-one procedures have been performed and 13 (65%) of them were for malignancy. There were 2 left hepatectomies, 1 right hepatectomy, 1 associated liver partition and portal vein ligation staged procedure (both steps by robotic approach), 1 bisegmentectomy and 3 segmentectomies, 9 wedge resections, and 3 pericystectomies. The mean operating time was 282 minutes (range, 90 to 540 min). Overall conversion rate and postoperative complication rate were 4.7% and 19%, respectively. The mean length of hospital stay was 13.4 days (range, 4 to 64 d). CONCLUSION From our early experience, robotic liver surgery is a safe and feasible procedure, especially for major hepatectomies.

Patients undergoing colon resection are often concerned about their functional outcomes after surgery. The primary aim of this prospective, multicentric study was to assess the intestinal activity and health-related quality-of-life (HRQL) after ileocecal valve removal. The secondary aim was to evaluate any vitamin B12 deficiency. The study included patients undergoing right colectomy, extended right colectomy and ileocecal resection for either neoplastic or benign disease. Selected items of GIQLI and EORTC QLQ-CR29 questionnaires were used to investigate intestinal activity and HRQL before and after surgery. Blood samples for vitamin B12 level were collected before and during the follow-up period. The empirical rule effect size (ERES) method was used to explain the clinical effect of statistical results. Linear mixed effect (LME) model for longitudinal data was applied to detect the most important parameters affecting the total score. A total of 158 patients were considered. Applying the ERES method, the analysis of both questionnaires showed clinically and statistically significant improvement of HRQL at the end of the follow-up period. Applying the LME model, worsening of HRQL was correlated with female gender and ileum length when using GIQLI questionnaire, and with female gender, open approach, and advanced cancer stage when using the EORTC QLQ-CR29 questionnaire. No significant deficiency in vitamin B12 levels was observed regardless of the length of surgical specimen. In our series, no deterioration of HRQL and no vitamin B12 deficiency were found during the follow-up period. Nevertheless, warning patients about potential changes in bowel habits is mandatory. In our series, no deterioration of HRQL and no vitamin B12 deficiency were found during the follow-up period. Nevertheless, warning patients about potential changes in bowel habits is mandatory.

Mirizzi syndrome (MS) is a rare complication of cholelithiasis. Despite the success of laparoscopic cholecystectomy as a minimally invasive approach to gallstone disease, MS remains a challenge, also for open and robotic approaches, due to the subverted anatomy of the hepatocystic triangle. Moreover, when emergency surgery is needed, the optimal preoperative diagnostic assessment could not be always achievable. We aim to analyze our experience of MS treated in emergency and to assess the feasibility of a diagnostic and therapeutic decisional algorithm.From March 2006 to February 2016, all patients with a preoperative diagnosis, or an intraoperative evidence of MS, were retrospectively analyzed at our Academic Hospital, including patients operated on in emergency or in deferred urgency. Eighteen patients were included in the study using exclusion criteria and were treated in elective surgery.The patients were distributed according to modified Csendes' classification: type I in 15 cases, type II in 2, type III in 0, type IV in 1, and type V in 0. In the type I group, diagnosis was intraoperatively performed. Laparoscopic approach was performed with cholecystectomy or subtotal cholecystectomy, when the hepatocystic triangle dissection was hazardous. Patients with preoperative diagnosis of acute abdomen and MS type IV were directly managed by open approach.Diagnosis of MS and the therapeutic management of MS are still a challenge, mostly in an emergency setting. Waiting for standardized guidelines, we propose a decisional algorithm in emergency, especially in nonspecialized centeres of hepatobiliary surgery.

Mirizzi’s syndrome (MS) is a rare complication of the inveterate biliary lithiasis. Diagnostic and therapeutic standardization is still missing, especially since laparoscopic cholecystectomy has become the gold standard approach for symptomatic cholelithiasis. Our study is a retrospective analysis based on a case-series. It considered 370 cholecystectomies performed from 2006 to 2011. We selected 11 patients affected by MS (2.97%). We divided them according to Csendes’ classification. Endoscopic Retrograde Cholangio-Pancreatography (ERCP) was used for biliary drainage when the patient suffered jaundice and/or cholangitis and, preoperatively, to confirm the suspicion of MS obtained through Magnetic Resonance Cholangio-Pancreatography (MRCP). We found it useful to exploit nasobiliary drainage (NBD) for intra-operative check of the biliary tree. In all 5 patients of the type 1 group MS was discovered intraoperatively and treated with Laparoscopic Sub-total Cholecystectomy (LSC). One patient suffered from biliary leakage, solved with NBD positioning. The type 2 group was made up of 2 women and 1 man. All of them were preoperatively submitted to ERCP and NBD positioning. Two underwent LSC and one was converted to laparotomy. The type 3 was represented by a 63-year-old woman suffering from recurrent cholangitis. She was submitted to MRCP, ERCP and then underwent LSC. The 2 patients affected by type 4 underwent open biliary reconstruction. In conclusion, every attempt should be made to identify MS prior to LCS since it will allow NBD insertion by ERCP. Once LCS is initiated, if MS is identified intra-operatively, we can provide the most practical surgical options.

Resume L’objectif de cette etude etait d’evaluer l’extension mediastinale du goitre en tant que facteur de risque de paralysie recurrentielle apres thyroidectomie. Une thyroidectomie totale etait realisee chez 14 993 patients entre 1999 et 2008. Trois groupes de patients etaient identifies : le groupe A (temoins ; n = 14 200 ; 94,7 %), goitre cervical traite par incision horizontale ; le groupe B ( n = 743 ; 5,0 %) goitre sous-sternal traite par voie cervicale ; le groupe C ( n = 50 ; 0,3 %) avec manubriotomie. L’incidence des formes transitoire et permanente de paralysie recurrentielle unilaterale etait augmentee dans les groupes B + C compares au groupe A ( p p p p

The aim of this retrospective multicenter study was to verify whether the substernal goiter and the type of surgical access could be risk factors for recurrent laryngeal nerve palsy during total thyroidectomy. Between 1999-2008, 14,993 patients underwent total thyroidectomy. Patients were divided into three groups: group A (control; n=14.200, 94.7%), cervical goiters treated through collar incision; group B (n=743, 5.0%) substernal goiters treated by cervical approach; group C (n=50, 0.3%) in which a manubriotomy was performed. Transient and permanent unilateral palsy occurred significantly more frequently in B+C vs. A (P≤.001) and in B vs. A (P≤.001). Transient bilateral palsy was significantly more frequent in B+C vs. A (P≤.043) and in C vs. A (P≤.016). Permanent bilateral palsy was significantly more frequent in B+C vs. A (P≤.041), and in B vs. A (P≤.037). Extension of the goiter into the mediastinum was associated to increased risk of recurrent nerve palsy during total thyroidectomy.

Objectives Primary tumors of the inferior vena cava are rare, with leiomyosarcoma representing the vast majority. Method A 60-year-old man was admitted in emergency for fainting and mild anemia. A whole-body computed tomography revealed a retroperitoneal mass of approximately 8 cm in diameter, invading the lumen of the inferior vena cava, extending to the renal vein confluence. An en bloc resection of the solid mass was performed. Macroscopically the tumor did not seem to insist on the resection margin. Results Histopathological examination confirmed the diagnosis of leiomyosarcoma of the inferior vena cava. Postoperative recovery was uneventful and the patient was discharged after eight days, starting adjuvant chemotherapy. During the follow-up, the patient did not show other fainting episode, and at 24 months he is disease free. Conclusions: Unusually, fainting could even be the isolated sign of a large leiomyosarcoma of the inferior vena cava, also when it affects its middle portion.

I really appreciated the Editor’s kind invitation to write a comment about the papers of Ielpo and colleagues. Laparoscopic surgery is nowadays widespread all over the world and we have witnessed a frenetic race for the introduction of new instruments and devices that are able to help surgeons to perform laparoscopic operations. Consequently, this race has increased the costs of a single operation in a geometrical progression pushed by industries.

Introduction : Barbed sutures are routinely used for laparotomy, peritoneal and mesenteric closure, but few studies have reported their use for intestinal anastomosis. We proposed their use for totally hand-sewn anastomosis during laparoscopic gastric bypass secured at the end of the suture with an absorbable clip. Materials and Method : Two totally hand-sewn single-layer extramucosal running sutures were performed for side-to-side gastrojejunal and jejuno-jejunal anastomosis during laparoscopic gastric bypass. Each run (anterior and posterior layer) was locked at the end by an absorbable poly-p-dioxanone suture clip. Results : A total of 96 hand-sewn anastomoses were performed. A total of two leaks occurred originating from the jejunaljejunal anastomosis. No cases of leakage from gastrojejunostomy were recorded. Two stenoses of the gastrojejunal anastomosis were recorded. They were successfully treated with three sessions of endoscopic balloon dilatation. No bleeding occurred. Conclusion : In our experience, the suture-related complication rate is comparable with the data reported in the literature. Further studies are needed to address the safety and efficacy of the self-maintained suture in digestive surgery.

Background Creating the pneumoperitoneum is the first surgical procedure in laparoscopic abdominal surgery. Morbid obesity is a risk factor for iatrogenic injuries because of the considerable thickness of the abdominal wall. The aim of this study was to assess the feasibility and the incidence of complications when using Veress needles (VN) in obese patients undergoing bariatric surgery. Methods Between March 2004 and December 2010, a retrospective analysis was performed on 139 obese patients (mean body mass index=45.94 kg/m). Blind VN insertion followed by optical trocar insertion was the most widely used technique. Results Of the 139 patients, VN was successfully used in 138 cases (99.28%), and in 1 patient the procedure failed and an open laparoscopy was performed (0.72%). During the study period, there were 63 gastric bypasses, 18 sleeve gastrectomies, 50 gastric bandings, and 8 reoperations. The VN was inserted in the left upper quadrant in 46 cases and in the midline above the umbilicus in 93 cases. A colonic perforation after VN insertion at the left upper quadrant occurred. The overall rate of complications was 0.72%. There were no access-related complications when VN was inserted above the umbilicus; complication rate was 2.17% at upper left quadrant VN placement. No cases of subcutaneous emphysema or extraperitoneal insufflation were observed. Conclusions In our experience, the success rate was 98.28% and the overall rate of complications was 0.72%. The VN technique can be considered feasible and safe even when used in obese population.

A proximal diverting stoma is recommended in “high-risk” conditions after total mesorectal excision. The aim of the study is to assess whether, after checking the anastomosis by using a water-soluble contrast enema (WCE), the closure of the ileostomy is feasible and safe, even in the presence of a persistent radiological leak. From 2003 to 2010, 210 colorectal anastomoses were performed. Ileostomy was carried out in “high-risk” anastomosis. A radiological control was performed 2 weeks later. If a leakage was present, conservative therapy controlled by serial WCEs was prescribed. Ileostomy closure was performed in the absence of leakage or with persistent leakage without clinical signs of pelvic infections. Seventy patients (33.3%) had a protective ileostomy. Fifty-eight of these (82.9%) had an uneventful course, whereas 12 (17.1%) had clinical leakage. All 70 patients were submitted to WCE after 2 weeks. Nine of 58 patients (15.5%) and eight of 12 patients with clinical anastomotic leakage showed a leakage at radiology. All these patients were scheduled another WCE 2 months later. It showed that the anastomosis had been healed in seven patients, whereas the 10 patients with leaks remained with ostomy until the third enema 1 month later. For all these patients, closure of the ileostomy was planned despite persistent radiological and subclinical leakage. A radiological study using WCE before closure of the stoma is essential and stoma closure, in the presence of a persistent leakage, is possible in selected patients.

Background The prevalence of thyroid disease in patients with cardiac disease can be as high as 11.2%. Combined thyroid and cardiovascular surgery has rarely been reported. Methods Ten patients (6 female, 4 male, age range 51-73 years) had total thyroidectomy and cardiac surgery in the same procedure in our surgical department. Six patients had coronary artery disease; four patients had valvulopathy. The thyroid goiter was retrosternal in 6 patients. Results Mean stay in the intensive care unit was 46.4 hours; the postoperative course was complicated by transient right laryngeal nerve palsy in one case and by transient hypocalcemia in the patients in whom a parathyroid autotransplantation was performed (n = 3). There was one case of hemodynamic compromise needing vasoactive drug support; the mean hospital stay was 8.4 days. Conclusions Our experience and our review of the literature suggest that a single-stage procedure is safe and feasible and must be preferred to different operations as it has an acceptable peri-operative and anesthesiological risk.

Appendicitis is one of the most common causes of acute abdomen in adults and appendectomy is the most common emergency abdominal procedure. Laparoscopic appendectomy has gained popularity only in recent years and the optimal approach for the treatment of acute appendicitis is still under debate. This retrospective study aimed at examining the current indications for laparoscopic appendectomy. 1024 patients undergoing laparoscopic appendectomy between February 1992 and December 2007 were retrospectively reviewed. 39.9% of patients (n=408) underwent emergency surgery. In 616 cases (60.1%) conservative management was performed in vain and these patients underwent an elective operation. In the 36 patients with an intraoperative normal appendix, other pathological findings were laparoscopically detected and treated. Conversion to an open procedure was required for 13 (1.3%) cases. The mean operative time was 38 min and the average length of postoperative hospitalization was 2.5 days. The overall morbidity rate was 2.6%. Laparoscopic appendectomy should be considered a procedure of choice for the treatment of non-complicated appendicitis. We stress the possibility to laparoscopically treat even complicated appendicitis in the surgical setting with substantial experience in minimally invasive surgery.

First access in laparoscopy still causes trouble and a small percentage of visceral and vascular injuries. Residents and surgeons-in-training often have doubts about which technique is safer and "friendlier." Semiopen technique (SO) for the first umbilical trocar access was originally described in 2002. We report our retrospective analysis using SO that shows its safety and easiness.In the period from January 2003 to November 2007, 300 unselected patients, including obese patients (body mass index30) were treated with laparoscopy beginning with a periumbilical approach using SO. We usually prefer to enter the cavity with a STEP cannula stiffened by an unarmed Veress needle of 1.9 mm. There were 112 men and 188 women with ages ranging from 16 to 82 years. The procedure was performed by an expert laparoscopic surgeon in 260 cases and by residents or surgeons without expertise in laparoscopy in 40 cases.We experienced no injuries of the viscera or vessels (0%). The mean time to enter the abdomen was 180 seconds, including obese patients.After our limited experience with the SO, we believe that every surgeon who tries it will experience safety of the Hasson and the comfort of the Veress.

Aim: To report our experience of managing patients affected by descending duodenal injuries secondary to laparoscopic cholecystectomy and to review the literature. Methods: Analysis of 5 cases of descending duodenal injury as a consequence of laparoscopic cholecystectomy managed between June 1992 and September 2006. Results: The median age was 59 (range 49–67) years.In all cases an emergency laparotomy showed an injury to the descending duodenum. Two patients underwent direct suture of the duodenum and external biliary drainage through a T-tube, 1 case underwent a duodenojejunostomy and in another a duodenopancreatectomy. The latter patient underwent drainage of the duodenum with a Petzer tube, followed 5 days later by gastric resection, closure of the duodenal stump and repair of the duodenal wound by suture. The median postoperative stay was 45 days and 1 patient died. Conclusion: Descending duodenal injuries are extremely rare complications of laparoscopic cholecystectomy with potentially fatal consequences if not promptly recognized and treated. The site of the descending duodenal injury is important for determining the surgical approach.

Groin hernia repair by using the laparoscopic transabdominal preperitoneal (TAPP) repair approach presents lower post-operative pain with a quicker return to normal patient activity compared to the open technique. Nevertheless, the long learning curve, general anaesthesia, and increased costs due to devices are the arguments against TAPP. Currently, the only mesh fixation techniques are those using glue or tacks. We report the audit of two years follow-up about our experience using a self-gripping lightweight mesh Parietex ProGrip™ (Covidien, Trevoux, France). The records of 39 patients for the first 50 procedures were reported. We registered wound infection, hematoma, seroma, neuralgia, numbness, and recurrence. In our opinion, TAPP procedure with ProGrip™ mesh is a feasible procedure without using fixation devices; costs, chronic pain and recovery are improved. Moreover, in the medium-term follow-up, we are able to reduce foreign body sensation and numbness.

Introduction Emergency pancreaticoduodenectomy (EPD) has been very rarely reported in literature as a lifesaving procedure for complex pancreatic injury, uncontrollable hemorrhage from ulcers and tumors, descending duodenal perforations, and severe infection. The aim of this study was to analyze the experience of two non-trauma centers and to review the literature concerning emergency pancreaticoduodenectomy. Methods From January 2005 to December 2014, from a population of 169 PD (92 females and 77 males; mean age: 61.3, range 23–81) 5 patients (3%; 2 females and 3 males; mean age: 57.8, range: 42–74) underwent EPD for non-traumatic disease performed at two Academic Units of the University of Bari. Results The emergency pancreaticoduodenectomy subgroup of patients showed an overall morbidity of 80%, and mortality of 40%. In 80% (4/5) of patients treated by emergency pancreaticoduodenectomy, the pancreatic remnant was not reconstructed, and in 20% (1/5) a pancreaticojejunostomy was performed. Conclusion Emergency pancreaticoduodenectomy is an effective life-saving operation reservable to pancreatoduodenal trauma, perforations, and bleeding, unmanageable by a less invasive approach. It should be preferentially approached by surgeons with a high level of experience in hepatobiliary and pancreatic surgery and in trauma centers too, but it should also be in the armamentarium of general surgeons performing hepato-pancreato-biliary surgery.

Autoimmune pancreatitis is now a defined entity and it could mimic a pancreatic malignancy. True oncological emergencies in pregnant patients are rare.A 39 years-old pregnant woman was admitted to our emergency unit due to right upper quadrant abdominal pain and evidence of obstructive jaundice. Since computed tomography-scan and endoscopic retrograde cholangiopancreatography are contraindicated in pregnant woman, a cholangio-Nuclear Magnetic Resonance was performed, confirming the biliary tract dilatation with stenosis of the intrapancreatic portion of the common bile duct and a shaded image of a mass in the pancreatic head. An endoscopic ultrasound with fine needle aspiration biopsy were performed. US-guided external percutaneous trans-hepatic biliary drainage was successfully performed. The cytological examination showed the presence of erythrocytes, granulocytes, histiocytes and rare lymphocytes; a diagnosis of AIP was supposed, and steroid therapy with metilprednisolone was started. Laboratory tests and jaundice were normalized within 15 days, and the fetus was born in very good health, 22 weeks after. The follow-up was uneventful and a CT-scan confirmed the complete normalization of the pancreatic gland, 12 months after hospital discharge.Autoimmune pancreatitis should be taken into account in the differential diagnosis of a not well defined pancreatic mass; in the event of pancreatic mass-forming disease in pregnancy, the differential diagnosis should be early and accurate, because destructive surgery involves an high rate of morbidity and may interrupt pregnancy. A US-guided FNAB and the response to the corticosteroid therapy should lead to a correct diagnosis.La pancreatite autoimmune è attualmente considerata una patologia ben definita ma che può mimare un carcinoma pancreatico. Le reali emergenze oncologiche nella gravida sono però rare.Una donna di 39 anni gravida giunge alla nostra osservazione per un dolore all’ipocondrio destro associato ad ittero ostruttivo franco. Stante la controindicazione ad eseguire una TAC ed una Colangio Pancreatografia Retrograda Endoscopica nella gravida, la paziente fu avviata all’esecuzione di una colangio- Risonanza Magnetica che confermò la dilatazione delle vie biliari intra ed extra-epatiche per effetto di una stenosi della Via Biliare Principale nel tratto intra-pancreatico associata ad un ispessimento parenchimale della testa del pancreas simulante una massa neoformata. La paziente fu sottoposta all’esecuzione di una eco-endoscopia pancreatica trans-duodenale con agobiopsia e le fu posizionato un drenaggio biliare percutaneo transepatico. L’esame citologico dimostrò la presenza di eritrociti, granulociti, istiociti e rari linfociti; pertanto fu posto il sospetto diagnostico di pancreatite acuta autoimmune ed iniziata una terapia con metilprednisolone. Gli esami sierologici e l’ittero si normalizzarono entro 15 giorni e la paziente partorì 22 settimane dopo un neonato in buone condizioni di salute. Nel follow-up non sono stati registrati eventi ed una TAC eseguita 12 mesi dopo la dimissione ha dimostrato il recupero completo della ghiandola pancreatica.La pancreatite autoimmune deve essere tenuta in conto nella diagnosi differenziale delle lesioni pancreatiche non ben definite: nell’eventualità della comparsa di una massa pancreatica in corso di gravidanza, la diagnosi differenziale deve essere precoce ed accurata in quanto la chirurgia demolitiva potrebbe rivelarsi fatale per il feto e con un alto tasso di morbilità. La biopsia con ago sottile in corso di eco-endoscopia e la terapia con steroidi possono aiutare la diagnosi differenziale.

Malignant chronic bowel obstruction (MCBO) is a syndrome caused by abdomen-pelvic diffusion of neoplastic diseases of any origin. It generally occurs in an advanced disease, affecting 3-15% of patients recently operated, untreated, or submitted to radiotherapy. Patients complain of chronic pain and vomitus. The approach to this problem is multidisciplinary, involving the surgeon, the endoscopist, the oncologist, and the pain-therapy expert. Direct percutaneous jejunostomy (DPEJ) using a percutaneous endoscopic gastrostomy (PEG) tube is a jejunal percutaneous access procedure indicated for nutrition in those patients whose stomach cannot be used, as in cases of partially or totally gastrectomized ones. A venting PEG or percutaneous endoscopic jejunostomy (PEJ) is a solution to drain the gastrointestinal tract for MCBO even in difficult cases represented by patients with previous abdominal surgery, those with partial or total gastrectomies, ascites, or peritoneal carcinosis. We report our five-case experience of draining an MCBO in patients previously operated on for gastric cancer, using a DPEJ technique that we believe is the best technique for this purpose.

Leakage of a large bowel anastomosis remains the most serious postoperative complication in gastrointestinal surgery. In a recent experimental study we found that surgically induced hypoxia resulted in more derangement of a variety of biochemical markers in the large bowel (LB) than in the small bowel (SB). We explored the question of whether spontaneous and agonist-induced contractility of SB and LB muscle strips was influenced by surgical procedures and how contractility was related to energetic oxidative metabolism capacity in smooth muscle mitochondria. Sixty male New Zealand rabbits were operated on under general anesthesia. Segments of ileum and colon were resected from each rabbit, and an end-to-end anastomosis was constructed. A representative subset of segments from SB (n = 14) and LB (n = 14) at time 0 was used as controls. Tracts containing an anastomosis were resected at days 2, 7, and 14 after operation. At each time point, 20 segments adjacent to the anastomosis of both SB and LB were used for tensiometric and biochemical studies. Tensiometric studies demonstrated modifications in the smooth muscle function at both the acute and chronic stages with intestinal inflammation that may contribute to surgical stress-associated abnormal motility. Biochemical data showed that the respiratory capacity of the resected LB was more impaired than that of the SB. In both SB and LB, changes in respiratory activity preceded tensiometric changes. Thus abnormalities of contractility after surgical stress are more evident in LB than SB in segments adjacent to the anastomoses. This could be the consequence of abnormal biochemical changes, as adenosine triphosphate (ATP) is required for membrane potential maintenance, calcium homeostasis, and actin-myosin interactions.

A 61-year old man with coeliac disease and chronic lack of appetite, malabsorption and weight loss, despite the gluten-free diet, was operated because of a sub-diaphragmatic free air due to a small-bowel pneumatosis cystoides intestinalis (PCI). The jejunum showed granulomatous lesions with a honeycombed appearance of air cysts in the submucosa/subserosa. We found overexpression of peptide YY (PYY) into only the jejunum with PCI, while the expression was very weak or absent in the tissue without cysts. One year after surgery, he had no abdominal pain or PCI recurrence. The above chronic symptoms were plausibly attributable to the PYY.

Objective To compare open with closed treatment ofchronic pilonidal sinus.Patients and methods From 1993 to 1996, 100patients were submitted to excision of chronic pilonidalsinus, with local anaesthesia and were randomized in twogroups: group A in which open treatment and group B inwhich direct suture were performed. The follow-up,ranging from 37 to 89 months, was performed byoutpatient visits or by phone.Results Short-term results showed 6 (12.0%) post-operative complications in group A vs 10 (20.0%) ingroup B. Long-term results showed 9 (18.0%) compli-cations in group A vs 7 (14.0%) in group B. Mean woundhealing was 58 days (range: 29–93) in group A vs 12(range: 9–61) in group B. The return to normal activitywas 25.7 (range: 11–77) vs 10.4 (range: 5–32). Woundhealing and the return to normal activity were the onlystatistically significant differences.Conclusions Regarding morbidity neither technique hasparticular advantages over the other. The closed tech-nique produced quicker wound healing and a quickerreturn to normal activity.Keywords Pilonidal sinus, randomization, primaryclosure, open packing

Pancreatoduodenectomy is an exceptional procedure that requires an extensive dissection of the supramesocolic region extended to the first jejunal limb. Lymphadenectomy, required for cancer, increases the dissection surface. The extensive preparation of the area is traditionally conducted with bipolar ormonopolar instruments, while clips, ligatures, and sutures are used for haemostasis. LigaSure™ vessel sealing(LSVS; Valleylab, Boulder, CO) is a technology that obtains vessel closure by using the body's own collagen and elastin to create a permanent fusion zone. This is obtained by a combination of forceps pressure and radio frequency. This effect has been improved by the introduction of the Force Triad™ (Valleylab, Boulder,CO) energy platform, controlled by TissueFect™ (Valleylab, Boulder, CO) sensing technology. With this device, the surgeon is able to fuse vessels up to 7 mm, lymphatics, tissue bundles, and pulmonary vasculature in a fast-seal cycle of almost 4 seconds. In our daily practice of open surgery we observe a rapid improvement of abdominal drainage output with a drastic reduction of protein loss. Its practical significance is, in our opinion, that we obtain a rapid recovery of normal serum protein levels with a low number of blood/plasmasac transfusions and a real improvement of anastomosis healing. Moreover, the efficacy and the speed of work of the device allow us to reduce the operating time significantly but safely. We performed a retrospective analysis of the data of 20 pancreatic resections conducted both with traditional dissection and with the Liga-Sure Impact device with Force Triad platform in order to verify whether observed data were real. Our clinical results show that the use of the LigaSure Impact device with Force Triad energy platform is really useful in open surgery to save operating time, number of postoperative days, and hemoderivate administration.

Portal hypertensive duodenopathy is a rare condition related to liver cirrhosis; there is little in the literature about its clinical significance and management. It seems to be endoscopically and histologically similar to portal hypertensive gastropathy, which is well defined. We report the case of a patient, initially treated for acute bleeding resulting from the rupture of esophageal varices, who developed an atypical endoscopic picture of portal hypertensive duodenopathy over a 6-month period. After microscopic definition of the disease we found chronic bleeding which required blood transfusions. Medical treatment did not solve the problem. We describe an approach using the argon plasma coagulator.

Hypercalcaemic crisis is an uncommon and potentially life-threatening manifestation of primary hyperparathyroidism, and it is associated with rapid deterioration of the central nervous system, and cardiac, gastrointestinal, and renal function. We present the case of a 76 year-old man in a sudden coma due to hypercalcaemic crisis as a first manifestation of primary hyperparathyroidism. At first, the patient was treated conservatively, his mental status gradually improved in the next three days. On the ninth day after the initiation of therapy, a minimally invasive radio-guided parathyroidectomy was performed. Histologically, the tumour consisted of densely arranged chief cells immunohistochemically positive for PTH antigens, suggesting adenoma. Calcaemia level and PTH were normalised in the immediate postoperative period. A systematic review was performed by consulting PubMed MEDLINE for publications from 1958 to 2011. This review found a total of 499 reported cases of hypercalcaemic crisis due to primary hyperparathyroidism. Manifestations are neurological alterations, and cardiac, renal and gastrointestinal dysfunctions associated with markedly elevated serum calcium and parathyroid hormone levels. The most frequent histology is the parathyroid adenoma. In untreated cases, mortality is 100%. Despite advances in its management, the mortality rate is still 93.5% in patients treated only conservatively. Medical therapy followed by expeditious parathyroidectomy should be considered as the treatment of choice for patients affected by hypercalcaemic crisis due to a primary hyperparathyroidism.

Background Acute respiratory failure due to thyroid compression or invasion of the tracheal lumen is a surgical emergency requiring urgent management. The aim of this paper is to describe a series of six patients treated successfully in the emergency setting with total thyroidectomy due to ingravescent dyspnoea and asphyxia, as well as review related data reported in literature. Methods During 2005-2010, of 919 patients treated by total thyroidectomy at our Academic Hospital, 6 (0.7%; 4 females and 2 men, mean age: 68.7 years, range 42-81 years) were treated in emergency. All the emergency operations were performed for life-threatening respiratory distress. The clinical picture at admission, clinical features, type of surgery, outcomes and complications are described. Mean duration of surgery was 146 minutes (range: 53-260). Results In 3/6 (50%) a manubriotomy was necessary due to the extension of the mass into the upper mediastinum. In all cases total thyroidectomy was performed. In one case (16.7%) a parathyroid gland transplantation and in another one (16.7%) a tracheotomy was necessary due to a condition of tracheomalacia. Mean post-operative hospital stay was 6.5 days (range: 2-10 days). Histology revealed malignancy in 4/6 cases (66.7%), showing 3 primitive, and 1 secondary tumors. Morbidity consisted of 1 transient recurrent laryngeal palsy, 3 transient postoperative hypoparathyroidism, and 4 pleural effusions, treated by medical therapy in 3 and by drains in one. There was no mortality. Conclusion On the basis of our experience and of literature review, we strongly advocate elective surgery for patients with thyroid disease at the first signs of tracheal compression. When an acute airway distress appears, an emergency life-threatening total thyroidectomy is recommended in a high-volume centre.

A proximal diverting stoma is recommended in "high-risk" conditions after total mesorectal excision. The aim of the study is to assess whether, after checking the anastomosis by using a water-soluble contrast enema (WCE), the closure of the ileostomy is feasible and safe, even in the presence of a persistent radiological leak. From 2003 to 2010, 210 colorectal anastomoses were performed. Ileostomy was carried out in "high-risk" anastomosis. A radiological control was performed 2 weeks later. If a leakage was present, conservative therapy controlled by serial WCEs was prescribed. Ileostomy closure was performed in the absence of leakage or with persistent leakage without clinical signs of pelvic infections. Seventy patients (33.3%) had a protective ileostomy. Fifty-eight of these (82.9%) had an uneventful course, whereas 12 (17.1%) had clinical leakage. All 70 patients were submitted to WCE after 2 weeks. Nine of 58 patients (15.5%) and eight of 12 patients with clinical anastomotic leakage showed a leakage at radiology. All these patients were scheduled another WCE 2 months later. It showed that the anastomosis had been healed in seven patients, whereas the 10 patients with leaks remained with ostomy until the third enema 1 month later. For all these patients, closure of the ileostomy was planned despite persistent radiological and subclinical leakage. A radiological study using WCE before closure of the stoma is essential and stoma closure, in the presence of a persistent leakage, is possible in selected patients.

Pancreatoduodenectomy currently represents the treatment of choice for resectable pancreatic and periampullary malignant tumours, symptomatic chronic pancreatitis, duodenal cystic dystrophy, large adenomas, diverticula and benign periampullary tumours. Pancreato-jejunostomy failure remains the main complication following pancreatoduodenectomy, even leading to death. To improve the safety of this anastomosis, a modified technique of pancreato-jejunal anastomosis with posterior double-layer suture and Wirsung duct evagination is proposed. We report our experience in eight consecutive patients (4 females, 4 males; average age 66, range 57-74) undergoing Traverso-Longmire pylorus-preserving pancreatoduodenectomy using Wirsung duct evagination and posterior double-layer suture technique. There was no mortality; the post-operative recovery was uneventful with no pancreatic anastomotic leakage. The mean post-operative stay was 15 days (range 12-19). This proposed procedure could be considered an additional opportunity in the performance of a pancreato-enteric anastomosis, yielding good results and preserving from post-operative pancreatic ductal obstruction.

The purpose of this study was to investigate the actual management of mucinous cystic neoplasm (MCN) of the pancreas. A systematic review was performed in December 2009 by consulting PubMed MEDLINE for publications and matching the key words "pancreatic mucinous cystic neoplasm", "pancreatic mucinous cystic tumour", "pancreatic mucinous cystic mass", "pancreatic cyst", and "pancreatic cystic neoplasm" to identify English language articles describing the diagnosis and treatment of the mucinous cystic neoplasm of the pancreas. In total, 16 322 references ranging from January 1969 to December 2009 were analysed and 77 articles were identified. No articles published before 1996 were selected because MCNs were not previously considered to be a completely autonomous disease. Definition, epidemiology, anatomopathological findings, clinical presentation, preoperative evaluation, treatment and prognosis were reviewed. MCNs are pancreatic mucin-producing cysts with a distinctive ovarian-type stroma localized in the body-tail of the gland and occurring in middle-aged females. The majority of MCNs are slow growing and asymptomatic. The prevalence of invasive carcinoma varies between 6% and 55%. Preoperative diagnosis depends on a combination of clinical features, tumor markers, computed tomography (CT), magnetic resonance imaging, endoscopic ultrasound with cyst fluid analysis, and positron emission tomography-CT. Surgery is indicated for all MCNs.

Sphincterotomy has been the most commonly used treatment for chronic anal fissures. Although effective it is associated with incontinence (0-20%). Intrasphincteric Botulinum Toxin A injection seems to be a reliable option. The aim of this clinical report is to verify the effectiveness of this treatment in relieving symptoms and healing fissures without relapse.The study design was an open label non-comparative prospective trial to evaluate the efficacy ofbotulinum toxin injection in anal sphincters. In the period 2003-2005 sixty patients were enrolled in our Unit of Coloproctology. After inoculation hygiene measures (sitz baths, Vaseline oil and water intake) were recommended. After the first 4 weeks without improvement we administered a second injection (30 U.I). After failure of the second administration the patient was addressed to surgery. Mean follow-up was 24 months; patients were re-evaluated at the 6th, 12th and 24th month.In 29 pts the fissure was healed (48.33%) after the first injection; 31 patients (51.6%) were re-treated; 20 pts presented a complete healing of the fissure in a period ranging between 4-5 weeks from the second injection and 11 patients were introduced to surgery. In 3 cases we observed haemorrhoidal thrombosis. Gas incontinence was reported in two patients and solved spontaneously.Our clinical experience suggests that botulinum toxin therapy can be considered effective and safe. It can be proposed to the patient as first line therapy before surgery.

We sought to determine the efficacy of sutures, human fibrin glue and N-butyl-2-cyanoacrylate for mesh fixation in patients undergoing the plug and mesh procedure for groin hernia.A total of 156 patients with 167 inguinal hernias (11 bilateral) underwent a plug and mesh procedure and were randomly assigned to received either sutures (n = 59 hernias), human fibrin glue (n = 52) or N-butyl-2-cyanoacrylate (n = 56) for mesh fixation.The overall morbidity rate was 38.98% in the suture group, 9.62% in the fibrin glue group and 10.71% in the N-butyl-2-cyanoacrylate group (suture v. fibrin glue, p0.001; suture v. N-butyl-2-cyanoacrylate, p0.001). There was no significant difference in morbidity between the fibrin glue and N-butyl-2-cyanoacrylate groups. Overall, short-term morbidity was significantly higher in the suture group (27.12%) than in the fibrin glue (9.62%, p = 0.01) or N-butyl-2-cyanoacrylate (8.93%, p = 0.004) groups, but there was no significant difference between the fibrin glue and N-butyl-2-cyanoacrylate groups. There was no significant difference between the groups in terms of mean postoperative stay (32.6 h in the suture group v. 30.8 h in the fibrin glue group v. 32.0 h in the N-butyl-2-cyanoacrylate group) or mean time to return to work (20.4 d in the suture group v. 20.3 d in the fibrin glue group v. 19.8 d in the N-butyl-2-cyanoacrylate group). Overall, long-term morbidity was significantly higher in the suture group (11.86%) than in the fibrin glue (0%, p = 0.001) or N-butyl-2-cyanoacrylate (1.78%, p = 0.03) groups. There was no recurrence in any of the groups. Two cases (3.39%) of chronic groin pain were reported in patients in the suture group. A sensation of extraneous body was reported in 5 (8.47%) patients who received sutures and in 1 (1.78%) patient in the N-butyl-2-cyanoacrylate group; there were no reported cases in the fibrin glue group (suture v. fibrin glue, p = 0.01; suture v. N-butyl-2-cyanoacrylate, p = 0.03; fibrin glue v. N-butyl-2-cyanoacrylate, p = 0.30).The use of human fibrin glue or N-butyl-2-cyanoacrylate is better tolerated than sutures in tension-free inguinal open repair using the plug and mesh technique in terms of overall immediate results, and there is a better trend in the long-term data.

To compare the outcome in patients with cervical goiters and cervicomediastinal goiters (CMGs) undergoing total thyroidectomy using the cervical or extracervical approach. This was a retrospective study conducted at six academic departments of general surgery and one endocrine-surgical unit in Italy. The study population consisted of 19,662 patients undergoing total thyroidectomy between 1999 and 2008, of whom 18,607 had cervical goiter (group A) and 1055 had CMG treated using a cervical approach (group B, n = 986) or manubriotomy (group C, n = 69). The main parameters of interest were symptoms, gender, age, operative time, duration of drain, length of hospital stay, malignancy and outcome. A split-sternal approach was required in 6.5% of cases of CMG. Malignancy was significantly more frequent in group B (22.4%) and group C (36.2%) versus group A (10.4%; both P

The parathyroid hormone-related peptide (PTHrP) has been shown to be the major pathogenic factor to humoral hypercalcemia of malignancy (HHM). The presence of PTHrP in many normal tissues and in normal or abnormal parathyroids has been described in literature and its role has been investigated. PTHrP release from parathyroid cells into the extracellular space has been demonstrated to depend on the extracellular calcium concentration. The hormone binds to PTH type 1 Receptor (PTH1R) with a high affinity, as well as parathyroid hormone (PTH). These hormones' amino-terminal (1-34) peptide fragments are considered sufficient to achieve efficient receptor activation and action on mineral ion homeostasis. Generally, diagnosis of primary hyperparathyroidism (PHPT) is based on hypercalcaemia and elevated levels of PTH. The advent of intact-PTH immunoradiometric assay allowed us to distinguish PHPT from non-parathyroid-dependent hypercalcaemia, but the presentation of normal PTH level and hypercalcaemia due to a parathyroid adenoma is possible. The aim of the study is to identify the relationship between the production of PTHrP without malignancy and the diagnosis of PHPT by a systematic review.

To study in the rat whether oxidative stress appears early in a model of short-term cholestasis induced by bile duct ligation.Adult male rats underwent proximal bile duct ligation; controls underwent a sham operation. Animals were sacrificed at days 0, 1, 3, 7 and 10. Livers were removed for histological studies and biochemical analysis.GSH and PSH levels declined earlier in mitochondria than cytosol. Data were analyzed for statistical significance by ANOVA analysis.This study represents an experimental model which helps in the interpretation of the damage induced by bile duct injury in humans emphasizing an early detection of bile duct injury after surgery to ensure appropriate treatment and optimal patient outcome.

Shotgun injuries are the cause of increasing surgical problems related to the proliferation of firearms. Gunshot pancreaticoduodenal traumas are unusual in urban trauma units. Their management remains complex because of the absence of standardized, universal guidelines for treatment and the high incidence of associated lesions of major vessels as well as of other gastrointestinal structures. Surgical treatment is still controversial, and the possibilities offered by the safe and effective mini-invasive techniques seem to open new, articulated perspectives for the treatment of pancreaticoduodenal injury complications.We present the case of a 27-year-old man with multiple penetrating gunshot trauma evolving into acute necrotizing pancreatitis, treated by combining a surgical with a mini-invasive approach. At admission, he presented a Glasgow Coma Score of 4 due to severe hemorrhagic shock. First, surgical hemostasis, duodenogastric resection, multiple intestinal resections, peripancreatic and thoracic drainage were carried out as emergency procedures. On the 12th postoperative day, the patient underwent re-surgery with toilette, external duodenal drainage with Foley tube and peripancreatic drainage repositioning as a result of a duodenal perforation due to acute necrotizing pancreatitis. Eight days later, following the accidental removal of the peripancreatic drains, a CT scan was done showing a considerable collection of fluid in the epiploon retrocavity. Percutaneous CT-guided drainage was performed by inserting an 8.5 Fr pigtail catheter, thus avoiding further re-operation. The patient was successfully discharged on the 80th postoperative day.The treatment of multiple pancreaticoduodenal penetrating gunshot traumas should focus on multidisciplinary surgical and minimally invasive treatment to optimize organ recovery.

Hernia repair is the most commonly practiced operation in the departments of surgery in developed countries. Huge abdominal hernias are uncommon in western civilization. We present a rare case of a 73-year-old woman with a diagnosis at admission of intestinal obstruction caused by a giant strangulated umbilical hernia. At the clinical and radiological examination, the patient showed an enormous strangulated umbilical hernia with acute abdomen, atrial fibrillation, and pulmonary subedema. Emergency laparotomy showed a huge peritoneal umbilical sac containing massive mesenteric ischemia starting from 40 cm after the Treitz ligament and extended to the right colonic flexure. A near-total resection of the small bowel, a right colectomy with double terminal stomas, and a direct hernia repair without prosthetic mesh were performed. Twenty days after the operation, the patient was discharged and begun domiciliary total parenteral nutrition, and 24 months after surgical treatment she is still alive.