A novel robotic system for single-port laparoscopic surgery: preliminary experience.

BACKGROUND: The concept of single-access procedures has gained greater attention from general surgeons during the past 5 years. Despite this wide momentum, these procedures pose several changes for the surgeon, such as impaired eye-hand coordination and restricted manipulation. In this context, robotic-assisted surgery represents a promising technology to enhance the dexterity of laparoscopic surgeons. METHODS: A novel teleoperated robotic system for minimally invasive surgery (MIS) called SPRINT (Single-Port lapaRoscopy bImaNual roboT) has been developed. SPRINT is a master-slave robotic platform designed for bimanual interventions through a single-access port. The system is basically composed by two main arms having a maximum diameter of 18 mm and a stereoscopic-camera (Karl-Storz, Tuttlingen, Germany). The arms may be inserted into a cylindrical introducer that has a maximum diameter of 30 mm. The surgeon console is composed of two master manipulators, a foot-switch, and a 3D full-HD display. RESULTS: In an animal study, a small-bowel enteroenterostomy and the ligation of a mesenteric vessel bundle have been performed. As preliminary experience, the system has been placed within the peritoneal cavity through an incision of approximately 10 cm: the robot has been suspended in an open fashion, due to some mechanical constraints of the current prototype. The procedures have been performed in an authorized laboratory on a female pig of approximately 50 Kg. CONCLUSIONS: Two typical surgical maneuvers have been performed successfully with the SPRINT surgical platform: an intestinal anastomosis and a vessel ligation. Moreover, the speed, precision, and force with which the SPRINT robot executed the commands by the surgeon controlling the master console have been subjectively described as adequate to the tasks. Based on this preliminary demonstration, bimanual robot solutions, such as the SPRINT robot, may offer more dexterity and precision to single-port techniques in the next future.

Molecular characterisation of the small GTPase CDC42 in the ectomycorrhizal fungus Tuber borchii Vittad.

The small GTPase CDC42 is ubiquitously expressed in eukaryotes, where it participates in the regulation of the cytoskeleton and a wide range of cellular processes, including cytokinesis, gene expression, cell cycle progression, apoptosis, and tumorigenesis. As very little is known on the molecular level about mycorrhizal morphogenesis and development and these events depend on a tightly regulated reorganisation of the cytoskeleton network in filamentous fungi, we focused on the molecular characterisation of the cdc42 gene in Tuber borchii Vittad., an ascomycetous hypogeous fungus forming ectomycorrhizae. The entire gene was isolated from a T. borchii cDNA library and Southern blot analyses showed that only one copy of cdc42 is present in the T. borchii genome. The predicted amino acid sequence is very similar to those of other known small GTPases and the similar domain structures suggest a similar function. Real-time PCR analyses revealed an increased expression of Tbcdc42 during the phase preparative to the instauration of symbiosis, in particular after stimulation with root exudate extracts. Immunolocalisation experiments revealed an accumulation of CDC42 in the apical tips of the growing hyphae. When a constitutively active Tbcdc42 mutant was expressed in Saccharomyces cerevisiae, morphological changes typical of pseudohyphal growth were observed. Our results suggest a fundamental role of CDC42 in cell polarity development in T. borchii.

Gallstone ileus in patient with Crohn's disease: report of a clinical observation.

Gallstone ileus is an uncommon form of bowel obstruction, related in the majority of cases to a cholecystoenteric fistula. In patients with Crohn's disease the stone can obstruct the diseased bowel. We report a case of gallstone ileus in a patient with Crohn's disease. An explorative laparoscopy and a minimally-invasive laparotomy were achieved to resolve the obstruction. Cholecystectomy and closure of the cholecystoduodenal fistula were not performed. The association of gallstone ileus and Crohn's disease is very rare; only few cases are reported in the literature. Laparoscopic approach could identify the extension of the disease and the site of impaction, allowing the differential diagnosis in particular in patients with Crohn's disease. In the cases described, cholecystectomy and the closure of the fistula were not performed considering the absence of any residual stone in the gallbladder and the associated risk of treating the cholecysto-duodenal fistula in an emergency settings.

Specific features of differentiated thyroid carcinoma in patients over 70 years of age.

BACKGROUND AND OBJECTIVES: Among the geriatric population, there is a lower incidence of thyroid carcinoma (TC), but it accounts for 30% of all thyroid disorders compared to 6-8% in younger subjects. Prognosis, moreover, is worse in the elderly, as demonstrated by the fact that 81% of deaths related to these tumors occur in patients over 55. The aim of this retrospective study was to identify the characteristics of differentiated thyroid carcinoma (DTC) peculiar to the elderly. METHODS: Of 638 patients who underwent surgery for DTC over a period of 30 years, 46 were more than 70 years old. All the elderly patients had undergone radioioidine and TSH-suppression therapy following surgical resection. RESULTS AND CONCLUSIONS: Despite these measures, the rate of recurrence was 26.5% at 5 years and 63.6% at 10 years. The 5- and 10-year disease-specific survival rates were 87.8% and 63.6%, respectively. On an average, survival was 55.1 months when death was disease-related, and with regard to histological type, it was longer in papillary carcinoma than in the follicular variant, and longest of all in occult sclerosing carcinoma. Survival was greatest in patients with tumors less than 2 cm in diameter, characterized by the absence of extraglandular spread and by lymph node metastasis.

An overview of research on increasing indices of happiness of people with severe/profound intellectual and multiple disabilities.

PURPOSE: This paper was to provide an overview of research studies aimed at increasing indices of happiness of persons with severe/profound intellectual and multiple disabilities. METHODS: Computerized and manual searches were carried out to identify the studies published from 1990 to 2004 (i.e., the period during which the issues of quality fo life and happiness in people with disabilities have become more prominent). Twenty-four research studies were identified. They involved the use of six different procedures, that is, structured stimulation sessions, microswitch-based simulation sessions, leisure activities and favourite work tasks or conditions, positive environment or positive behaviour support programmes and mindful caregiving, favourite stimulation automatically delivered on exercise engagement, and snoezelen. RESULTS AND CONCLUSION: Data tended to be positive with increases in the participants' indices of happiness, but some failures also occurred. The outcomes were discussed in relation to (a) methodological issues, such as designs of the studies, length of the intervention, and number of participants, and (b) personal and practical implications of the procedures. Some suggestions for future research (particularly focused on extending evidence and overcoming present methodological weakness) were also examined.

Enabling a person with multiple disabilities and minimal motor behaviour to control environmental stimulation with chin movements.

PURPOSE: To assess whether a young man with multiple disabilities and minimal motor behaviour would learn to control environmental stimulation using chin movements and a mechanical microswitch. METHOD: The study was carried out according to an ABAB design in which A represented baseline and B intervention phases. The chin movements controlled the stimulation only during the intervention phases. A 2-month post-intervention check was conducted. RESULTS: The man increased the frequency of his chin movements, thus increasing the level of environmental stimulation, during the intervention phases. This performance was maintained at the post-intervention check. CONCLUSION: The use of chin movements is a practical strategy for enabling individuals with minimal motor movements to control environmental stimulation. Future research should examine whether similar types of movements may enable some individuals to control voice-output communication devices.

[Risk of recurrence following partial thyroidectomy for benign lesions. Report of 58 patients 15-25 years after surgery]. / Il rischio di recidiva dopo tiroidectomia parziale per lesione benigna. Indagine condotta su 58 pazienti 15-25 anni dopo l'intervento.

BACKGROUND: Since the 1980's, thanks to the introduction of new techniques and methods for the study of thyroid function, new light has been shed on certain aspects of thyroid disease that constitute the basis for surgical therapy. Multinodular goiter is a disorder affecting the entire gland, even when alterations mostly or exclusively involve a single lobe. The functional deficit resulting from partial or subtotal resection has a hypertophic/hyperplastic effect on the remaining parenchyma. Partial resections often lead to postoperative hypothyroidism, usually of a subclinical nature, which implies difficult management by means of replacement therapy. METHODS: The authors report a series of 58 patients who underwent partial thyroidectomy to treat benign thyroid disease at the 2nd Surgical Department of the University of Florence during the period 1975-1985. RESULTS: Of these patients, operated on more than 15 years ago, 36.2% - the majority of whom (87.5%) have constantly been on substitutive therapy using L-thyroxin - currently shows no alteration of the remaining parenchyma. Conversely, in 60.3% of the patients there was evidence of nodular/pseudonodular alterations; in this group, only 40% of the patients were on substitutive therapy. There seems to be no doubt that, with few exceptions, disease involving an apparently circumscribed area of the thyroid in reality affects the entire parenchyma. CONCLUSIONS: Total thyroidectomy, therefore, represents the most appropriate treatment for multinodular goiter, even when the disease is limited to one lobe, thereby providing a cure for the disease and at the same time a state of euthyroidism easily achieved with the proper therapy.

An overview of technological resources used in rehabilitation research with people with severe/profound and multiple disabilities.

PURPOSE: This paper provides an outline of technological resources used in rehabilitation research with persons with severe/profound and multiple disabilities, and discusses the practicality of such resources. METHOD: Research articles published during the last 8 years (1993-2000) are considered. With regard to each of the technological resources used in the articles (i.e. microswitches, speech output devices, computer-aided instruction systems, audio recording systems, orientation systems, mobile robot, and SIBIS), accessibility, cost and implementation issues are examined. RESULTS AND CONCLUSIONS: Some technological resources are easily accessible and affordable (i.e. microswitches, speech output devices, audio-recording systems and SIBIS). Other resources are still at the prototype level (i.e. computer-aided instruction systems, orientation systems and robot) and are much more complex and costly. In spite of this, the latter resources might still have an important role in daily contexts.

Use of microswitches and speech output systems with people with severe/profound intellectual or multiple disabilities: a literature review.

Microswitches and speech output systems are two forms of technology which have been used with people with severe/profound intellectual or multiple disabilities to help them reduce their isolation and interact with the surrounding world (i.e., thus obtaining environmental stimulation independently or requesting it efficiently). This paper reviews the studies which used microswitches and speech output systems with the aforementioned people during the 1986-1999 period, and discusses the research findings and the practicality of these two forms of technology. Some relevant issues for future research are also pointed out.

[Ischemic pathogenesis of acute pancreatitis. A case report]. / La patogenesi ischemica della pancreatite acuta. Una osservazione clinica.

An ischemic origin of acute pancreatitis has been considered for a long time, at least as an aiding factor: ischemia has a fundamental role in the development of necrotizing pancreatitis from an oedematous one. Shock, heart condition and celiac-mesenteric ischemia can determine the onset of an acute pancreatitis through local ischemic lesions. Personal experience with a case of acute pancreatitis following an intestinal ischemic failure is reported. The duration of ischemia and, in particular, the free radicals formation during the organ reperfusion have been considered as the main pathogenetic factors. In the observed case, the ischemic hypothesis seems to be supported from the lack of other known factors and from the intestinal ischemic failure episode.

[Massive thrombosis of the superior mesenteric artery following splenectomy. A coincidence?]. / Trombosi massiva dell'arteria mesenterica superiore dopo splenectomia. Una coincidenza?

Postsplenectomy thrombocytosis is a well recognised complication about which there is little published information. Therefore, postoperative complications of this effect have not been emphasised. An experience with a case of superior mesenteric artery thrombosis and small intestinal ischemia following splenectomy is reported. We reviewed the literature, but we wasn't able to find any case, whereas the association between splenectomy and mesenteric or portal vein thrombosis is well known. Pathogenesis of postsplenectomy thrombocytosis is poorly understood. Theories to explain it include removal of the splenic sequestration effect or removal of a regulatory humoral factor produced by the spleen. Both mechanisms could be operative at the same time, explaining the observation that some patients develop thrombocytosis related complications soon after surgery, while others after a longer time. The literature on the thromboembolic risk of postsplenectomy thrombocytosis is inconclusive and no studies have established whether patients with thrombocytosis following splenectomy should be treated with anticoagulants or antiplatelet medications in order to prevent thrombotic complications. Certainly, a recommendation for the routine use of these drugs cannot be made on the basis of one observation, but the need for controlled studies must be stressed.

Review of strategies for treating sleep problems in persons with severe or profound mental retardation or multiple handicaps.

During the last 15 years, researchers have shown that a large percentage of persons with severe or profound mental retardation or multiple handicaps have serious sleep problems. These problems can cause emotional and physical burdens for caretakers, interfere with the persons' daily learning and occupational performance, and/or exacerbate deviant behaviors. Several studies have been conducted to assess behavioral and pharmacological strategies (e.g., bedtime fading and response cost, extinction, chronotherapy, and the use of melatonin) for reducing sleep problems. Those studies are reviewed here and the effectiveness, suitability, practicality, and acceptability of the strategies are discussed. Relevant issues for future research are also examined.

[Hürthle cell carcinoma and "insular" carcinoma: uncommon varieties of thyroid carcinoma]. / Carcinoma a cellule di Hürthle e carcinoma "insulare", varietà non comuni del carcinoma tiroideo.

The Hürthle cell carcinoma and "insular" carcinoma are two uncommon types of thyroid carcinoma. These neoplasms do not present accurate characteristics as to incidence, natural history, pathophysiology and therapies. Two cases are presented: the first was submitted to near-total thyroidectomy for Hürthle cell carcinoma, the second to total thyroidectomy for "insular" carcinoma with bone and lung metastases. Some literature previous studies on pathophysiology and natural history of both tumors are discussed. At the end, personal trend on the surgical treatment of these two thyroid neoplasms is presented: total thyroidectomy for CCh and "insular" carcinoma, and near-total thyroidectomy for Hürthle cell adenoma.

[Colo-uterine fistula, a complication of sigma diverticulitis]. / Fistola colo-uterina, complicanza della diverticolite del sigma.

The colo-uterine fistula is a rare complication of diverticular disease of the colon; the literature review has shown only few well studied cases. The fistula, among the complications of the sigma diverticulitis, is 20% of the observed cases; generally, the bladder is the most involved organ, but also the skin or gut can be interested. If we consider the aetiology of the colo=uterine fistula of the observed case, the presence of the sigma locked stenosis with an endocolic pressure increase, associated with a peridiverticulitis condition, seems to have a relevant rule. The clinical symptomatology is represented by vague abdominal pain localized in particular in the left iliac cavity and by emission of blood, purulent material and stools from the vagina. The diagnosis of colo-uterine fistula is not easily reached: barium enema, Fallopian tube endoscopy and colon endoscopy not always allow to visualize in a right manner the fistula and only the oral administration of non-absorbable substances to be searched in the vaginal tampon, clear each doubt. Regarding the therapy to be carried out, we think that, colic resection en bloc with the uterus is the treatment of choice, while, in emergency, the Hartman operation is the most suitable to avoid the beginning of septic complications.

[The involvement of the urinary tract in inguinal hernias]. / L'impegno dell'apparato urinario nelle ernie inguinali.

The involvement of the organs of the urinary tract in an inguinal hernia represent a constant trap for the surgeon because the diagnosis of that pathology is very rare. The authors report two cases: 1) male, carrier of a voluminous bilateral inguinal hernia, that on the right, contains a diverticulum of the bladder. 2) male, with a bilateral inguinoscrotal hernia. Bilaterally the hernia contains the ureter. The hernias of the bladder properly called are very rare but the involvement of a small portion of the organ, often a diverticulum, in an inguinal hernia is more frequent and always associated with hypertrophy of the prostate. The relative symptoms to this interest seem to supply obvious indications but very rarely are interpreted in the right way. The hernias of ureter are rare too, some acquired, some, about a quarter, congenital. The case-history don't supply useful news for the diagnosis. In the most of the cases of involvement of the urinary tract organs in an inguinal hernia, we arrived at operative-room without knowing the hernia content. The structures of urinary tract usually are recognised by particular maneuvers but is not infrequent that, moreover unforeseen, they are accidentally damaged.

[Diagnostic problems, pathogenetic hypothesis and therapeutic proposals in Ogilvie's syndrome. Review of 470 observations from the literature and presentation of 5 new cases]. / Problemi diagnostici, ipotesi patogenetiche e proposte terapeutiche nella sindrome di Ogilvie. Revisione di 470 osservazioni della letteratura e presentazione di cinque nuovi casi.

The authors describe five cases of acute pseudo-obstruction of the colon: the first, alcoholic, treated with antidepressant drugs, with a long history of intestinal occlusions and explorative laparotomies, treated successfully by conservative therapy; the second, with meningitis, in which right colectomy for the presence of multiple perforations of the cecum was performed; the third with acute neurological problems of ischemic nature, died before any treatment was given; the fourth, with left hemicolectomy performed for cancer, in which transversostomy was performed after colonoscopy and medical treatment with prokynetic drugs had failed; the last one, in a young woman treated with anti-depressant and antipsychotic drugs, treated by conservative therapy. In reviewing 470 cases from the literature the most commonly associated disorders are found; 33 patients (7%) were diagnosed as idiopathic. Only 273 cases were available for detailed analysis of age, sex, mode of treatment, presence of perforation, mortality rate. The mortality rate was 17.6%. When comparing the different treatment procedures, surgery has a higher mortality rate (23.5%) than medical treatment or colonoscopy (12.1%) (p < 0.02). In this study the presence of perforation increased mortality from 15.1% to 29.9% (p < 0.03). The mortality rate for cecostomy is 15.3% vs 30.1% for other surgical procedures. Recently the syndrome pathogenesis is attributed to an autonomic imbalance, between the sympathetic and parasympathetic innervation of the colon: sympathetic prevalence due to sacral parasympathetic derangement, lead to inhibition of colonic peristalsis. The attention must be focused on early diagnosis and prompt treatment; for this purpose colonoscopy seams to be a safe method of establishing the diagnosis and carrying out treatment.

Childhood enteritis: a community study.

The population aged 0-12 years living in the area of an Italian Local Health Unit (about 8,800 children) was studied for one year in order to estimate the overall incidence rate of enteritis and the incidence rates of diarrheas from bacterial agents. All children complaining of acute diarrhea and seen by the pediatric practices of the study area were recorded by date, age, and sex; the microbiological study of stools was performed for a sample of patients. All hospitalized cases of childhood enteritis occurring in the same period in the study population were studied too. Campylobacter jejuni and Salmonella were cultured from 5 out of 71 examined out-patients (7.0%), with a projected annual consultation rate of 2.1 per 1000 population aged 0-12 years. Yersinia enterocolitica was cultured from 2 out-patients (2.8%), while no cases from Shigella and enterotoxigenic Escherichia coli were observed in this group. Data concerning hospitalized cases confirmed this pattern of results. Bacterial enteritis is an important public health problem in the study area and its occurrence is possibly related to animal reservoirs of infection, with particular regard to poultry and pets.