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The authors report their views on the treatment of unoperable neoplastic esophago-gastric stenoses with Nitinol prostheses. Despite a number of advantages (reduced trauma, greater tolerability) in relation to plastic prostheses, the paper highlights some problems (difficulty of unfastening, incomplete opening) which may be eliminated by improved materials.

The authors examined a series of 231 patients suffering from unoperable neoplastic dysphagia of the esophagus and treated using prevalently palliative endoscopic methods (photocoagulation and/or intubation) during the period 1980-1991. They draw the following conclusions: a) endoscopic methods are better than surgical techniques; b) there are a greater number of indications for endoscopic intubation than for photocoagulation (approximately 2 to 1); c) some situation which are indicated for photocoagulation are not contraindicated for intubation; d) the sole contraindication for intubation is stenosis in which the proximal limit is less than 2 cm from the upper esophageal sphincter; e) contraindications for photocoagulation are long stenoses and/or those of the infiltrating type, and/or involving the upper third of the esophagus; f) sometimes the two methods may be complementary in the sense that intubation may be preceded by a few photocoagulation sessions in order to necrotize the vegetating portion of an infiltrating tumour; g) it is best to choose intubation wherever possible since this technique is less expensive and the quality of remaining life better, even if the percentage of severe and generally fatal complications (perforation) is still too high; h) the possible introduction of expandable metal prostheses might increase indications for intubation and reduce the number of severe complication.

Personal experience in the non-surgical treatment of postoperative biliary fistulas observed between July 1987 and October 1990 is reported. Leakage were treated with an endoscopic technique (papillosphincterotomy+nasobiliary drain) in 11 of 12 patients in an average time of 2 weeks. The 12 patient, who presented a lesion of an intrahepatic duct, needed 2 months to heal following combined endoscopic-percutaneous manoeuvres. On the basis, then, of the good results obtained, it is recommended that in these cases, non-surgical treatment should be carried out on principle, choosing endoscopy as the initial access route.

The role of operative endoscopy as opposed to surgery in the treatment of obstructive jaundice is in continuous positive evolution due to the rapid technical progress made in the use of this method. Of a total of 93 patients treated over the course of 3 years, some received surgical treatment alone, others endoscopic treatment alone, and a third group received endoscopic therapy followed by surgery. Various parameters were taken into consideration for the three groups studied: the pathological cause of jaundice, age, sex, success of the method used, early and late complications, hospital deaths. Results were then compared.

Three typical cases of segmental portal hypertension due to occlusion of the splenic vein are reported. This syndrome may be asymptomatic for a very long time and then present suddenly in the form of a serious picture of high digestive haemorrhage due to rupture of the varices of the fundus of the stomach as a result of hypertrophized submucous collateral drainage circulation. Useful for diagnosis are oesophagogastroduodenoscopy, which points to stomach varices, and splenoportography or superselective arteriography of the splenic artery with venous phase, which highlight pathognomonic dilatation and tortuosity of the gastroepiploic veins. Surgical exploration typically shows: presence of large epipolic vessels, splenomegaly, absence of changes in the liver and in the portal and mesenteric circulation. Resolutive treatment of choice is splenectomy.

A case of villous polyps of the duodenum is reported, world-wide series also being considered. The various symptomatologies and percentages of malignant transformation and localization are described and stress laid on the superiority of endoscopy to radiography owing to the fact that it gave: 1) exact site and nature diagnosis of the lesion during the haemorrhagic phase; 2) exact histological and topographical diagnosis, following the haemorrhage, paving the way to the subsequent surgery.

Clinical, radiological and endoscopic results at follow-up about 1-5 yr after surgery in a series of 62 patients subjected to Billroth I resection are compared with those in the literature. Recurrence of ulcers was observed in 8% (as opposed to 5% with the Billroth II). In addition, there was a marked reduction in the incidence of post-resection diseases, with less serious forms of dumping, sounder digestion, and smaller weight losses.

Twenty-one cases of acute mesenteric occlusion are presented. Stress is laid on the difficulty of reaching a diagnosis in time to enable disobstruction to be carried out. In the reported series, diagnosis was established 1-8 days after the onset of symptoms. When radical surgery was performed (extensive resection occasionally coupled with right hemicolectomy), postoperative mortality was high and transit and nutritional problems brought about by the shortness of the residual gut were encountered.

Leiomyosarcoma of rectum is a rather rare malignant tumour. Generally, it manifests late when pain, tenderness, rectal bleeding and obstruction occur or ulceration through the rectal mucose with bleeding or discharge occur. Rectal examination leads to the diagnosis of malignancy. The histological report confirms the type of tumor. A case of leiomyosarcoma of the rectum has been reported. Radical resection (Miles) is the treatment of choice at present. The prognosis is poor.

Three cases of intestinal occlusion due to endometriosis, presenting as surgical emergencies, are reported. After a review of the literature on the incidence of endometriosis, the mechanisms underlying the occlusive process and the various anatomopathological pictures are presented. The reasons why no correct preoperative diagnosis was possible and the problems encountered in differential diagnosis, particularly with respect to carcinoma of the colon and the sigma-rectum, are discussed. It is considered that correct preoperative diagnosis is very important to avoid subjecting the non-cancer patient to destructive surgery. The therapy recommended for intestinal occlusion due to suspected endometriosis is presented.

Six cases of delayed rupture of the spleen in two stages are described. One case of occult rupture is also presented. A picture of acute anaemia was observed in the five two-stage cases, whereas the occult rupture was diagnosed as organised splenic haematoma following computerised scintiscanning, arteriography and tomography. Splenectomy was performed in all cases, under emergency conditions in the first five, and of choice in the sixth. No post-operative complications were noted.

Somatostatin was compared with intensive antacid and thrombin in a randomised controlled study on 15 patients with severe haemorrhages of the upper digestive tract deriving from peptic ulcers and identified endoscopically in order to assess the efficacy of the two drugs. The results in both groups were similar but somatostatin appeared more effective than antacids and thrombin in terms of blood transfusions required and the average time it took to stop the bleeding. The insignificance of these results is in contrast with the data from similar studies using other drugs (anti-H2) and reported by others. This shows the need for controlled polycentric studies conducted on large groups of homogeneous patients.

The technique used to carry out pancreaticogastrostomy after duodenocephalopancreatectomy in 4 cases is described. The technique is better than pancreaticojejunostomy, which is associated with a high incidence of postoperative complications, such as abscesses, fistulae, haemorrhage, and autodigestion at the site of anastomosis.

Oesophagogastroplasty has been performed in 4 patients in the Turin Department of Emergency Surgery. Three of them presented high neoplastic lesion of the oesophagus, while the fourth was suffering from mediastinic compression due to sclerosing mediastinitis. The technique and results are reported in detail. Indications for surgery for both malignant and benign lesions are presented. The real advantages of the operation with respect to stomach to chest transposition and oesophagocolonplasty which have in the personal series created considerable inconvenience, are discussed. The reasons making it necessary to carry out the operation in two stages, with different modalities, are also discussed. Complications are indicated and postoperative treatment discussed. This plays a notable part in the success of the operation, as does correct technique.

Multivaried and trend analyses were applied to a set of 27 periodic haematochemical checks on 37 patients given surgery for biliopancreatic pathology. Preoperative and postoperative data were separately analysed. The software employed was specially designed for the purpose. The discriminating function was used in the preoperative period to establish the best moment for diagnosis, which turns out to be 5 days after admission to hospital. Variance and regression analyses were used for short term prognosis by calculating survival chances. In one case the prognosis turned out to be distinctly inaccurate.

An examination is made of a series of emergency operations carried out in the period 1974-78 to arrest haemorrhage due to the rupture of oesophageal varices. An account is given of the personal criteria employed in the choice of candidates and the type of surgical management. Stress is laid on the need for greater aggressivity. In addition, support is expressed for the porto-systemic shunts, especially shunts of the porto-cava and meso-cava type. These are superior to other forms on account of their easy and rapid execution.

9 cases of caustic ingestion are reported and the diagnostic and therapeutic problems of the consequent gastritis and oesophagitis conditions discussed. In the case of small quantities of acids at low concentrations, the immediate steps are largely medical and conservative, their purpose being to monitor complications. In cases of massive ingestion, surgery should be as early as possible to avoid secondary lesions to the surrounding viscera and serious electrolytic imbalances; the limit for action with a relatively favourable prognosis is within 5 hours and removal of the damaged segments must be radical and extensive.