[Cystic dilatation of the choledochus associated with stenosis of the hepatic duct bifurcation. An analysis of a clinical case]. / Dilatazione cistica del coledoco associata a stenosi della biforcazione dei dotti epatici. Analisi di un caso clinico.

The authors report a case of cystic dilatation of the choledochus associated with narrow stenosis at the confluence of the left and right hepatic ducts which was found to be inflammatory on histological examination. This pathology is becoming an increasingly more commonplace clinical finding. The case reported here is particularly interesting owing to the onset of the disease and the way in which it was treated. An attempt was made to treat the patient using a simple operation which was to the least radical possible. The authors take this opportunity of reviewing the literature on the subject.

[Malignant tumors of the pancreas and periampullary area. Our experience]. / I tumori maligni del pancreas e dell'area periampollare.

The authors analyse and evaluate the clinical records of 45 patients treated in the last 4 years for pancreatic cancer and neoplasm of the bilioduodenapancreatic area, comparing the results with data available in the literature. In the group of patients treated with resection (12 cases), postoperative morbidity and mortality were respectively 28% and 6%, and three-years survival was 22%. The authors discuss particularly about reconstruction ways after duodenopancreatectomy, showing good results after reconstruction by Y loop sec. Roux and pancreato-jejunal anastomosis.

[Axillo-femoral bypass in the treatment of aorta prosthesis infection. A special case]. / Il by-pass axillo-femorale nel trattamento di protesi aortica infetta. Un caso particolare.

The authors report a case recently brought to their observation: T.A., a 77 year old patient, operated on in July 1990, for aortic aneurysm with axillo femoral by-pass. The patient was reoperated on the 5th day for ischaemic necrosis of the descending colon. In 1992 he was operated in another hospital for right iliac branch removal of the by-pass and performing of extra-anatomic bifemoral by-pass for right iliac branch infection of anatomic prosthesis. He was brought to our observation in March 1993, after the patient was refused in other Centres because of purulent abscess located near the aortic prosthesis and in the right iliac fossa, with a fistula to right superior anterior iliac crista. The patient was operated on in April 1993, with an explorative laparatomy to drain the abscess and to remove the aortic prosthesis. The aorta was sutured with closed bottom by means of delayed points. The postoperative course was regular and an arteriography performed three months after confirms the good running of the axillo-femoral by-pass and of the bifemoral one previously performed. The authors because of their experience and the bibliographical data underline the goodness of the axillo-femoral by-pass in serious infections of an aortic prosthesis.

Malignant tumors in the head of the pancreas and the periampullary region. Diagnostic and prognostic aspects.

This paper analyzes the value of ultrasonography (US), computerized tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP) to establish the location, nature and resectability of carcinomas of the pancreatic head and of the periampullary region. The prognostic importance of certain pathological factors in relation to survival was also evaluated. As regards the site of origin, 112 cases with carcinoma were classified as follows: 56 pancreatic, 32 ampullary, 10 common bile duct, and 14 undefined. Papillary tumors were more accurately defined by ERCP compared to CT+US (p = 0.033), whereas CT was less accurate than US+ERCP (p = 0.05). No significant differences were found in pancreatic and common bile duct tumors. Pathological confirmation was obtained with ERCP in 54 cases (46% pancreatic, 69% papillary and 50% common bile duct). In the remaining 58 patients (including 1 chronic pancreatitis) the diagnosis was confirmed with percutaneous or intraoperative biopsy. Tumor extent was better defined by US+CT. In 42 resected patients the final pathological examination revealed an error of preoperative staging in 79% pancreatic, 59% papillary, and 83% common bile duct tumors. Tumor size, nodal status, perivascular, capsular and portal vein infiltration proved to be significant prognostic factors for pancreatic tumors. Stepwise regression identified tumor size, capsular infiltration and perivascular invasion as the most important covariates for survival. Ulceration, papillary histotype, pancreas and Oddi muscle infiltration, grading, perineural, lymphatic and vascular involvement were found to be significant in papillary tumors. The Cox proportional hazard model showed that pancreatic, Oddi muscle, perineural infiltration, and histologic type respectively represent a relative risk of 5.93, 107.36, 21.31, 20.61. The limited number of cases of common bile duct primary did not allow us to carry out statistical analysis on these tumors.

[Clinical use of a totally implantable and programmable pump for the infusion of drugs]. / Impiego clinico di una pompa totalmente impiantabile e programmabile per l'infusione di farmaci.

Totally implantable programmable systems allow preordained complex continuous infusion of drugs. Sixteen totally programmable implantable pumps (Medtronic DAD) have been implanted in fifteen advanced colorectal and renal cancer patients for continuous ia and iv sinusoidal Fudr infusion. Median duration of pump function was 125 days (range 46-468), there was observed only one case of malfunction device which required the implant of a new device, and three complications of pump pocket (seroma, hematoma and infection) without interrumption of chemotherapy for clinical causes. The use of totally implantable programmable systems provides and important clinical improvement in controlled long-term drugs administration improving quality of life and duration of chemotherapy.

[Termino-terminal arteriovenous fistula at the anatomic snuffbox for chronic hemodialytic treatment]. / La fistola arterovenosa termino-terminale alla tabacchiera anatomica per il trattamento emodialitico cronico.

Between January 1979 and December 1989, an end-to-end arteriovenous fistula for chronic haemodialysis was performed at the anatomical snuffbox (AVF-AS) in 140 patients (49 females and 91 males) with mean age 51 years (range 14-81) referred to our Center from 12 different Hospitals. The choice of the site, on the non dominant arm, depends on the characteristics of the vessels and on the arterial blood pressure. No operative mortality no major complications occurred no distal symptoms related to venous hypertension or arterial steal syndrome or ischaemia. The median survival was 36 months with a patency rate of 77.3% at 1 year, 36.3% at 5 and 18.9% at 10 years. The high incidence of thromboses (52.9%) reflects an excessive compliance with this technique and a lack of expertise on the choice of the proper vessels or an inadequate management of the vascular access. Compared to the graft vascular access, the patency rate is superimposable but with higher rate of complications and lower cost-benefit rate for the grafts. In our experience, the AVF-AS should be, whenever possible, the first step as vascular access for chronic haemodialysis, but the surgical procedure should be reserved only to experienced surgeons. It is safe, cheap and allow to save and use for a longer period the patient's own vessels.

Pancreatic fistula and relative mortality in malignant disease after pancreaticoduodenectomy. Review and statistical meta-analysis regarding 15 years of literature.

This paper analysed the literature published in the last 15 years regarding the onset of pancreatic fistula after pancreaticoduodenectony carried out for tumours in the periampullary region, in the head of the pancreas and in the distal common bile duct. Out of 8370 pancreatic resections we were able to go by only 2684 cases, which showed the type of treatment used in the remaining stump, the rates of leakage and relative mortality. The data collected were analysed statistically using the Cochran test and or the chi 2, evaluating the possible significant difference relative to the various methods of reconstruction. The onset of pancreatic fistrula was found to be statistically more frequent after ligation of the stump than after pancreatico-jejunal anastomosis (p = 0.001). Comparing the pancreatico-jejunal end-to-side anastomosis, to pancreatico-jejunal end-to-end and wirsung-jejunal end-to-side anastomosis the first one had shown a significantly higher rate only for leakage (respectively p = 0.008 and p = 0.010). The occlusion of the wirsung duct with biological substances showed better results compared to ligation (p = 0.001) only as regards onset of the fistula, while the comparison between the occlusion and the three types of anastomosis did not show any statistically difference, except for the pancreatico-jejunal end-to-side anastomosis, in which it was significant only as regards leakage (p = 0.009). The statistical analysis between pancreatico-gastrostomy and pancreatico-jejunal anastomoses indicated that the first technique had a lower morbidity rate than pancreatico-jejunal end-to-side (p = 0.001), pancreatico-jejunal end-to-end (p = 0.010) and wirsung-jejunal end-to-side (p = 0.011). We analysed and compared the results obtained before and after 1975, in order to discover whether was an improvement in the prevnetion or in the treatment of such a complication and its consequences. Furthermore, we tried to establish whether the transanastomotic drainage, the site of the neoplasm, the texture of pancreatic parenchyma and the patient's age could in any way influence the onset and course of the fistula.

[Distal gastrectomy with Y gastroenteroanastomosis not associated with vagotomy in elective surgical treatment of gastroduodenal ulcer. Clinical and functional long-term results]. / La gastrectomia distale con gastroenteroanastomosi a Y non associata a vagotomia nel trattamento chirurgico di elezione dell'ulcera gastroduodenale. Risultati clinici e funzionali a lungo termine.

During the period 1977-1984, 53 patients with peptic ulcer resistant to H2-blockers (29 gastric and 24 duodenal ulcers) were submitted to distal gastrectomy with Roux-en-Y gastroenteroanastomosis not associated with vagotomy. The indication was used as an alternative to proximal vagotomy in cases with delayed gastric emptying, high acid output, perforation or bleeding. The study plan consisted of serial clinical and instrumental controls including determination of basal (BAO) or maximal (MAO) acid output. Operative mortality was nil. At various times after the operation, 4 patients died for unrelated reasons and 3 were lost to follow-up. Median follow-up was 84 months with an interval of from 4 to 137 months. Fifty-one patients were followed up for at least one year and 49 for at least two. Five patients (2 gastric and 3 duodenal ulcers) developed peptic recurrences (Visick IV, 9.8%) by the end of the first postoperative year and, in all cases but one, healed stably by the second year after medical (3 cases) or surgical (1 case) therapy. In the remaining patients, Visick was grade III in 6 cases (4 gastric and 2 duodenal ulcers), grade II in 6 and grade I in 34. Before operation, mean values (+/- SD) of BAO and MAO were respectively 5.84 +/- 5.03 and 29.6 +/- 18.6 mEq/h. In the immediate postoperative period there was a considerable reduction in BAO (p less than 0.02) and MAO (p less than 0.03) which continued up to the third postoperative year with a tendency to further progressive reduction in MAO. In spite of a considerable individual variability in dimensions and temporal evolution, the phenomenon occurred qualitatively in all cases. No significant difference was observed in the behaviour of BAO and MAO in gastric ulcers by comparison with duodenal ulcers and in cases with recurrence and Visick III compared to those with a favourable clinical result.