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Laparoscopic colorectal surgery for cancer is nowadays performed in several referral centers and has been gaining increasing interest for treatment of colo-rectal cancer. After the introduction of complete mesorectal excision for rectal cancer, complete mesocolic excision has been advocated as an essential surgical step to improve oncologic results for patients with colon cancer. Complete mesocolic excision is a crucial step of hemicolectomy, and consists in the total removal of the mesocolon and its lymph nodes with high ligation of main mesenteric arteries and veins. In laparoscopic surgery, magnification of the images and gas dissection might probably improve the precision and safety of this surgical step. In this paper, the Authors reviewed the Literature and discussed on the feasibility and accuracy of complete mesocolic excision performed during laparoscopic left colectomy for cancer in a preliminary series.Colic lymph nodes, Laparoscopic left hemicolectomy, Mesocolon excision.La chirurgia colorettale laparoscopica per cancro è al giorno d’oggi eseguita in numerosi centri di riferimento e sta guadagnando crescente interesse per il trattamento del cancro del colon-retto. Dopo l’introduzione del concetto dell’escissione completa del mesoretto per cancro del retto, l’escissione completa mesocolica è stata proposta come un passo chirurgico essenziale per migliorare i risultati oncologici nei pazienti affetti da tumore del colon. L’escissione completa del mesocolon è un passo cruciale dell’emicolectomia, e consiste nella rimozione totale del mesocolon e dei suoi linfonodi con legatura alta delle principali arterie e vene mesenteriche. In chirurgia laparoscopica, l’ingrandimento delle immagini e la dissezione facilitata dallo pneumoperitoneo potrebbero probabilmente migliorare la precisione e la sicurezza di questa fase chirurgica. In questo lavoro, gli Autori hanno esaminato la Letteratura e hanno discusso sulla fattibilità e l’accuratezza dell’escissione mesocolica completa eseguita durante la colectomia sinistra laparoscopica per cancro in una serie preliminare.

Pressure ulcers are frequent complications for long term hospitalized bed-ridden patients which are not able to move or move very little. In fact, the lesion forms in a skin and muscle region which undergoes a constant pressure between an underlying bone protrusion and a support structure such as a bed or a wheelchair. Initially only the outer layers are involved but in time, the ulcer can spread to the deeper structures and reach the bone.In our work we described the anatomical areas that are most often subject to developing a pressure ulcer and we considered the surgical treatment and reconstructive procedures which are applied using a logical and rigorous sequence.We considered 4 clinical cases (2 ischiatic sores, 1 sacral sore and 1 gluteal-trochanteric sore) which demonstrate the surgical treatment and the reconstructive procedures.It is crucial to cover the defects with a thick flap to give more support and protection to the areas which undergo pressure and to lower the incidence of recurrences.

The educational-political activity of AIPO in the past 15 years has captured the interest of Pulmonologists for intensive care and achieved the institutional recognition of the Respiratory Intensive Care Units (RICUs) as care units for acute (ARF) or acute-on-chronic respiratory failure (ACRF). Aim of this study is to analyze the organizational evolution of Italian RICUs in the management of ARF/ACRF in the light of the second national AIPO survey data. Despite RICUs have increased from 26 to 44 units over the past 10 years, the number of beds surveyed is still below the estimated national demand. The geographical distribution of RICUs has been heterogeneous with a greater concentration in the North. The organizational model and the level of care turn out to be different with a greater development of the Monitoring Units within a pneumological ward compared to the Intermediate and Intensive Care Units, mostly functioning as autonomous units. The majority of RICUs have treated patients with ARF/ACRF in hospitals for acute, while a minority of them has dealt with weaning in Rehabilitation Centres. Consistent with the prevalent implementation of lower intensity of care models, average medical and nursing resources of RICUs have decreased. In contrast, their "efficiency" has increased with the reduction of admissions for only monitoring in favour to those for mechanical ventilation, weaning and decannulation. The pattern of disease has changed with a decrease in hospitalizations for COPD exacerbations in favour to those for neuro-myopathies decompensations and de novo hypoxemia. In conclusion, the Italian landscape photographed by this second survey - increasing number of RICUs and of complexity of interventions and disease treated - strengthens the role of Pulmonologist in the clinical governance of ARF/ACRF where these units are well structured. Further efforts are needed to expand the network of Italian RICUs and improve the training of Pulmonologists in intensive care.

Summary Background Tracheostomy is increasingly performed in intensive care units (ICU), with many patients transferred to respiratory ICU (RICU). Indications/timing for closing tracheostomy are discussed. Aim and Method We report results of a one-year survey evaluating: 1) clinical characteristics, types of tracheostomy, complications in patients admitted to Italian RICU in 2006; 2) clinical criteria and systems for performing decannulation, and outcome of patients undergoing tracheostomy (number decannulated; number non-decannulated/non-ventilated; number non-decannulated/ventilated; dead/lost patients). Results 22/32 RICUs replied. There were 846 admissions of 719 patients (Mean age 64,3 (±14.2) years, 489 (68%) males). Causes of admission were: acute respiratory failure with underlying chronic co-morbidities 176 (24.4%); exacerbation of Chronic Obstructive Pulmonary Disease 222 (34.4%); neuromuscular diseases 200 (27.8%); surgical patients 77 (10.7%); thoracic dysmorphism 28 (3.8%); obstructive sleep apnea syndrome 16 (2.2%). Percutaneous tracheostomies were 65.9%. Major complications after tracheostomy were 2%. 427 tracheostomies were evaluated for decannulation: 96 (22.5%) were closed; 175 patients (41%) were discharged with home mechanical ventilation; 114 patients (26.5%) maintained the tracheostomy despite weaning from mechanical ventilation and 42 patients (10%) died or lost. The clinical criteria chosen for decannulation were: stability of respiratory conditions, effective cough, underlying diseases and ability to swallow. The systems for evaluating feasibility of decannulation were: closure of tracheostomy tube; laryngo-tracheoscopy; use of tracheal button and down-sizing. Conclusions There were few major complications of tracheostomy. A substantial proportion of patients maintain the tracheostomy despite not requiring mechanical ventilation. There was no agreement on indications and systems for closing tracheostomy.

Ventral incisional hernia rate is decreasing due to the introduction of new clinical and surgery method. As a result, the complex incisional hernias, are less often described and rarely treated. We describe our experience in emergency case. We present the case of permagna incisional hernia with skin necrosis, subcutaneous abscess and bowel perforation which cause a long-lasting bedding. The successful management includes an emergency surgery applying hernia reduction, bowel resection and abdominal wall reconstruction through a biological mesh and positioning of VAC System. There is not a gold standard treatment that obtained an unanimous consensus, however we recommend the following procedure in that, in our patient, it shows no recurrences, infections and other post-operative complications.

Knowing the likelihood of failure of noninvasive positive pressure ventilation (NPPV) in patients with exacerbation of chronic obstructive pulmonary disease (COPD) could indicate the best choice between NPPV and endotracheal intubation instituted earlier. For this purpose, two risk charts were designed (at admission and after 2 h of NPPV) that included all relevant measurable clinical prognostic indicators derived from a population representing the patients seen routinely in clinical practice. Risk stratification of NPPV failure was assessed in 1,033 consecutive patients admitted to experienced hospital units, including two intensive care units, six respiratory intermediate care units, and five general wards. NPPV was successful in 797 patients. Patients with a Glasgow Coma Score or =29, respiratory rate > or =30 breaths x min(-1) and pH at admission 70%. A pH 90%). The risk charts were validated on an independent group of 145 consecutive COPD patients treated with NPPV due to an acute ventilatory failure episode. To identify patients with a probability of failure >50%, the sensitivity and specificity were 33% and 96.7% on admission and 52.9% and 94.1% after 2 h of NPPV, respectively. The prediction chart, based on data from the current study, can function as a simple tool to predict the risk of failure of noninvasive positive pressure ventilation and thus improve clinical management of patients tailoring medical intervention.

Bowel obstruction resulting from colorectal and ovarian cancer is a serious and distressing complication of these malignancies. This may be caused by diffuse peritoneal carcinomatosis, bulky masses filling the pelvis and abdomen or postoperative adhesions, and should be carefully worked out by pre-operative imaging. We report the case of a small bowel obstruction and intestinal ischemia caused by a bulky (20x40 cm in diameter) cystic ovarian neoplasm that was found to be a stage IA G2 cystadenocarcinoma, successfully managed by uterus-sparing surgery.

Mucinous adenocarcinoma of the small bowel is very rare, and only few cases have been described in the literature. Association of this tumor with celiac disease has never been published. The authors report a unique case of jejunal mucinous adenocarcinoma in which a concomitant celiac disease has been histologically recognized. The difficult diagnosis, the role of laparoscopic surgery and the relationship between small bowel tumors and celiac disease are discussed. A 49-year-old man presented with recurrent melena, nausea, vomiting and anemia. A stenosis of the jejunum was documented by means of CT scan and video capsule enteroscopy. A laparoscopy was scheduled. A tumor, found in the first jejunal loop, was removed by laparoscopic surgery. Histopathology revealed a rare mucinous adenocarcinoma associated with epithelial changes secondary to celiac disease. Although small bowel tumors are rare entity, in patients with celiac disease complaining of symptoms related to altered intestinal transit or occult bleeding, an appropriate work-up should be planned for diagnosis. Mucinous type intestinal adenocarcinoma, even if never published before, could be observed. Laparoscopic surgery is often essential for the diagnosis and treatment.

Pediatric surgery is now in the forefront of minimal access procedures. Although pediatric surgeons have been skeptic about laparoscopic splenectomy, recently minimally invasive approach for spleen removal has been revaluated also in young patients. Purpose of this study was to report Authors' personal experience in patients under eighteen who underwent laparoscopic splenectomy. Results of the procedure were evaluated.A retrospective review was undertaken in 18 splenectomised patients under the age of eighteen. Indications were hereditary spherocytosis in 10 patients, β-thalassemia in 4, idiopathic thrombocytopenic purpura in 3 and a splenic cyst in 1 child.No intra-operative complications occurred. No conversion to open surgery was reported. During the follow-up one case of portal vein thrombosis, treated by medical therapy, was encountered and no other postoperative complications were observed.Laparoscopic approach has to be preferable for all those children undergoing spleen surgery. In experienced hands, it is of beneficial effects with a very reasonable rate of complications.