[Recent concepts regarding the treatment of traumatic hemopneumothorax]. / Recenti acquisuzioni sul trattamento dell'emopneumotorace traumatico.

BACKGROUND: The aim of the study was to examine the different therapeutic options for traumatic hemopneumothorax and in particular the latest concepts (videothoracoscopy). METHODS: A retrospective study was performed on a group of 20 patients with post-traumatic hemothorax and/or pneumothorax attending the emergency department at Ospedale Vittorio Emanuele in Catania over the past 10 years where 2500 patients with abdominal and/or thoracic trauma were treated during the same period. The patients included 18 males and 2 females with a mean age of 35 years (range 13-70). The cause of injury was a gunshot wound in 8 patients, a blunt trauma following a road accident in 9 and a stab wound in 3 patients. A drainage tube was inserted in 15 patients (a videothoracoscopic approach was used in 2 cases); 3 patients required a diaphragmatic suture and 2 thoracotomy (inferior lobectomy and repair of the main left bronchus). RESULTS: Three out of 20 patients died with an overall mortality rate of 15%. Two patients died respectively from severe brain and abdominal injuries associated with thoracic trauma, while the third patient died from septic complications. CONCLUSIONS: In the past few years videothoracoscopy has allowed a different approach to be used in patients affected by hemo-pneumothorax since it allows a more accurate diagnosis (extent and origin of bleeding, identification of associated diaphragmatic lesion) and the possibility of treating pleuro-pulmonary injuries without performing extensive thoracotomies.

Pheochromocytoma: inherited associations, bilaterality, and cortex preservation.

BACKGROUND: Hereditary pheochromocytoma (HP) is characterized by early onset, bilateral adrenal involvement, low malignancy rate, and genetic linkage with certain familial syndromes. This retrospective review is intended to show the high yield of surveillance, predictable bilaterality, and the challenge of cortex-sparing adrenalectomy. METHODS: From 1964 to 1999, 32 patients with HP were treated at a single institution and followed for a mean of 7 years. There were 15 cases of multiple endocrine neoplasia type 2A (MEN 2A), 12 cases of von Hippel-Lindau (VHL) disease, 3 cases of von Recklinghausen's disease (VRD), and 2 cases of familial pheochromocytoma. Twenty-four of 32 patients underwent bilateral adrenalectomy (9 metachronous). Subtotal resection with orthotopic cortex preservation was performed in 5 patients, and heterotopic autografting was performed in 14 patients. RESULTS: Pheochromocytoma was the first manifestation in 50% of patients with VHL disease and in 27% of patients with MEN 2A. Surveillance uncovered medullary thyroid cancer in 5 of 15 patients with MEN 2A and hemangioblastomas, renal cell carcinoma, and islet cell tumors in 7 of 15 patients with VHL disease and VRD. HP was bilateral in 24 of 32 patients (14/15 in patients with MEN 2A, 7/12 in patients with VHL disease, 2/3 in patients with VRD, and 1/2 in patients with familial pheochromocytoma). In 9 cases of metachronous adrenalectomy, the mean interval was 67 months (range, 9-156 months). Three of 5 patients who underwent orthotopic preservation of the adrenal cortex experienced recurrence compared with 0 of 14 patients with heterotopic autotransplantation of cortical tissue. CONCLUSIONS: Pheochromocytoma frequently heralds coexisting silent VHL disease or MEN-2, mandating surveillance for inherited associations. The long interval of metachronous pheochromocytoma argues against prophylactic removal of the contralateral "normal" adrenal gland. Total adrenalectomy and heterotopic autotransplantation of medulla-free cortex may diminish the need for lifelong steroid substitution and eliminates recurrence.

[Laparoscopic surgery of perforated duodenal ulcer]. / Trattamento laparoscopico dell'ulcera duodenale perforata.

BACKGROUND AND AIM: Endoscopic diagnostic and therapeutic possibilities have been increased by videolaparoscopy. The method enables an immediate reliable diagnosis to be made, associated with possible surgical treatment. METHODS: The authors report their laparoscopic experience relating to the treatment of perforated duodenal ulcer from 1972 to 1995 in 8 patients divided into two groups. Jacob Palmer's laparoscopic operator was used in the first group together with Menghini's needle for the aspiration of peritoneal effusion; the operation was performed under local anesthesia with nitrogen monoxide insufflation using Taylor's technique number I. The second group underwent ulcorrhaphy with omentopexy, again using a laparoscopic route, together with abundant lavage and accurate aspiration of fibrin. RESULTS: The patients in the first group made a prompt recovery in terms of their general conditions following the remission of fever, pain, diminished leukocytes and an early renewal of canalisation; cicatrisation of the ulcer was confirmed by the endoscopic control on day 15. Patients in the second group showed early deambulation approximately 4 hours after surgery; canalisation occurred after about 6 hours and all patients were discharged on day 3. The eradication of Helicobacter pylori led to complete resolution, as was confirmed by subsequent follow-ups. CONCLUSIONS: Laparoscopy was found to be extremely useful both in the immediate diagnosis of acute abdomen following perforated ulcer and in its surgical treatment as a result of the introduction of operating laparoscopes and in particular videolaparoscopes, together with surgical instruments that allow careful abdominal cleansing and ulcorrhaphy. In the authors' opinion, the latter procedure is the most suitable for managing this pathology.

[Cholecystic-choledochal calculi. Endolaparoscopic treatment]. / Calcolosi colecisto-coledocica. Trattamento endolaparoscopico.

BACKGROUND AND AIM: Common bile duct calculosis is a pathology which has always been treated using traditional laparotomic surgery. The introduction of endoscopic papillosphincterotomy and mini-invasive and videolaparoscopic methods has drawn attention to the fact that these methods may be able to replace conventional surgery. METHODS: The authors examine the epidemiological and clinical aspects of common bile duct calculosis, reporting their experience in ten female patients treated during the period from 1992 to 1997, all of whom presented jaundice, pain and fever. Of these, eight underwent papillosphincterotomy using an endoscopic approach, followed by laparoscopic removal of common bile duct calculi within 24 hours. In two cases it was necessary to resort to conventional methods owing to difficulty in cannulating the papilla caused by a diverticulum in one patient and stenosis in the other, and the tenacious synechiae between the common bile duct and the gallbladder. RESULTS: The postoperative period was free of complications. CONCLUSIONS: The associated treatment, namely endoscopic papillosphincterotomy and endoscopic cholecystectomy proved a valid alternative to traditional laparotomic treatment, demonstrating a good level of reliability and safety for patients and reductions in terms of resources and hospitalisation time.

[Use of surgical staplers in emergency surgery]. / L'utilizzo delle suturatrici meccaniche in chirurgia d'urgenza.

BACKGROUND AND AIM: Over the past decade the use of surgical staplers has resulted in a substantial change in both elective and emergency surgery for gastrointestinal pathologies. A large number of studies have now affirmed the safety, reliability, simplicity, rapidity and usefulness of these instruments. They offer many advantages, above all the possibility of shortening operating times and thus reducing morbidity and mortality, especially in emergency surgery. METHODS: The authors describe their experience in treating 68 cases of emergency intestinal resection from 1980 to 1997 which were treated with the help of automatic staplers. Twenty-three cases of hemicolectomy (right and left) were performed; 17 sigmoid resections for diverticulitis; 15 gastric sections using Billroth II; 7 Meckel's diverticuli; 6 total gastrectomies. GEA 50 and 75 staplers were used for the intestine, TA 50, 90, 90 Plus and Roticulator, Circular staplers for esophagus, stomach and rectum. Patients were predominantly male: 40 males and 25 females with a ratio of 2:1. RESULTS: Complications included a fistula caused by dehiscence of the esophagojejunal anastomosis which lead to death in 30 days; 3 cases of hemorrhage of the gastroenteric anastomosis which regressed with medical therapy. CONCLUSIONS: In conclusion, mechanical staplers have led to considerable savings in time and a reduced number of postoperative complications.

[Update on the treatment of choledocholithiasis]. / Attualità nel trattamento della calcolosi coledocica.

Primitive or residual common bile duct calculi following common bile duct surgery can now be treated with minimum surgery using an endoscopic or X-ray guided approach. Having examined the etiopathogenetic theories, the authors analyse the treatment, in particular the possibility of endoscopic papillosphincterotomy and X-ray guided dilatation of the papilla, affirming that the latter can be extremely valuable in cases where it is difficult to canalize the latter.

[The hemorrhagic complication of peptic ulcer]. / Complicanza emorragica dell'ulcera peptica.

The hemorrhagic complication of peptic ulcer is a pathology which is still responsible for a high mortality. After reviewing the etiopathogenesis and physiopathology of hemorrhagic complications in the light of the recent discoveries regarding H. pylori, the authors report their experience and confirm the important role of surgery in the treatment of this pathology. Resolution is improved by the use of surgical staplers which are regarded as particularly valuable in emergency surgery where the need to cut operating times has undoubted advantages in terms of patient survival.

[An update in the treatment of intra-abdominal abscesses]. / Attualità nel trattamento degli ascessi intraddominali.

BACKGROUND AND AIMS: Intra-abdominal abscesses represent a relatively severe complication in gastroenterological surgery owing to their association with high levels of morbidity and mortality. METHODS: The authors report their experience between January 1990 and January 1996 in 11 patients with intra-abdominal abscesses secondary to emergency surgery for gastroenterology in 10 cases and gynecology in 1 case. After the lesion had been identified using ultrasonography and CT, it was emptied, washed with antibiotic and drained using Seldinger's ultrasonographic and CT-guided technique. Small abscesses (less than 5 mm) were completed removed. RESULTS: The following results were obtained: the immediate disappearance of pain and fever, accompanied by improved general conditions, restoration of canalisation and closure of the abscess cavity (on average between 10 and 15 days). CONCLUSIONS: In conclusion, ultrasonographic-CT guided drainage of postoperative intra-abdominal abscesses, which were previously managed using surgical methods, appears to be the best treatment, relying on the use of imaging techniques and thereby allowing both morbidity and mortality to be reduced.

[Splenic metastases]. / Le metastasi spleniche.

Splenic metastases are found with a frequency varying from 2.4 to 7.1%. The primary tumours most often followed by metastases are breast, lung, pancreas and melanoma. They may also be the direct extension of retroperitoneal tumours and carcinoma of the pancreas. The authors report a case which came to their attention; by examining the literature, they discover the rarity of this pathology which confirms the possibility of this localisation for both intra-abdominal and extra-abdominal tumours.

Laparoscopic robot-assisted right adrenalectomy and left ovariectomy (case reports).

BACKGROUND: Laparoscopic robot-assisted surgery has been created to reduce the patient risk of inappropriate scope movements by an assistant and to perform operations quicker and with greater ease. The Authors report their experience in laparoscopic robot-assisted right adrenalectomy for Conn's syndrome and right ovariectomy for benign ovarian mass. MATERIAL AND METHODS: Case 1. CT scan: solid right adrenal mass (diam. 2 cm). An anterior transperitoneal approach was used to perform the right adrenalectomy. The surgeon was placed at the ventral side of the patient and robotic-device was placed at the backside. HISTOLOGY: adrenocortical adenoma (diam. 3 x 2.5 x 1.5 cm). Case 2. CT scan: left iliac mass (diam. 3.5 cm) with origin in the left ovary. The patient was positioned in the gynecological position. The surgeon was positioned on right side of the patient and robot-device on left side. Left ovariectomy was performed. HISTOLOGY: ovarian serous cyst. RESULTS: Operating time was 180 min. for the adrenalectomy and 25 min. for the ovariectomy. No blood loss or complications for both operations were encountered. Image was steady and lens cleaning was unnecessary. CONCLUSIONS: The robot device (AESOP 2000) facilitated the procedures by enhancing stability of the image and reducing the need for lens cleaning. We believe that this method is feasible and could be advantageous especially for cholecystectomy, Nissen funduplication or ovariectomy but at the moment there are no comparative studies to establish the real value of this device.

[Ogilvie's syndrome]. / La sindrome di Ogilvie.

"Ogilvie's syndrome" or the idiopathic dilatation of the colon is an infrequent pathology whose underlying physiopathology is not yet well known. On the basis of their experience and having reviewed the literature, the authors affirm that this syndrome is caused by the inhibition of gastrointestinal hormones which, under the control of the neurohypophysis, contribute to colon motility. This supposition is backed up by the fact that medical treatment with somatostatin or octreotide leads to the resolution of the disorder.

[Treatment of stage IV breast carcinoma]. / Il trattamento del carcinoma della mammella al IV stadio.

The authors report a study carried out in 4 patients with stage 4 breast cancer. The treatment protocol was selected according to age and the general conditions of patients. Two out of four patients were treated with adjuvant chemotherapy associated with cyclophosphamide, adriblastin, 5-fluorouracil and folic acid; one patient received neoadjuvant chemotherapy with the same treatment protocol, while the fourth patient was treated with hormone and immunotherapy. Results were satisfying given that survival was considerably increased in 3 patients together with an improvement in general conditions.

[Intestinal invagination caused by colonic lipoma]. / Invaginazione intestinale da lipoma del colon.

The observation of a case of intestinal intussusception caused by lipoma of the colon prompted the authors to review the literature on the subject and to examine the main characteristics of lipoma of the colon which represent the most frequent benign neoplasia of the large intestine after adenomatous polyps. Lipomas of the colon are localised in 90% of cases at the submucous level, are usually solitary, of varying size and may be sessile or pedunculated. They are almost always asymptomatic; only when they are of a reasonable size do they become manifest following alterations of the alveus, rectorrhagia, abdominal pain or the occupation of the colic lumen by the mass, or intestinal intussusception caused by the progression of the pedunculated lipoma. This difficult diagnosis may be aided by colonscopy with biopsy and dual contrast opaque enema. The prognosis of the disease depends on the presence or absence of complications and, in the case of the former, on early diagnosis and treatment. Lipoma of the colon of less than 2 cm may be electively removed endoscopically, those greater than 2 cm by laparotomy or laparoscopy. In emergency cases, it is advisable to perform a more or less extensive resection of the colon depending on the size of the tumour. In the case reported by the authors, an intussusception manouevre was first performed followed by left segmentary colectomy.

[Complications of ileal lymphoma]. / Le complicanze del linfoma dell'ileo.

Non-Hodgkin lymphoma of the ileum accounts for some 3% of all extranodal onset lymphoma and 20% of gastrointestinal lymphoma given that the ileum is more frequently affected than the jejunum and duodenum. The large majority of primary extranodal lymphomas present a diffuse histological structure and in particular involve the cervico-fascial and gastrointestinal regions. Moreover, it is not uncommon to find an association between gastroenteric involvement and Waldeyer's ring (cervico-fascial region). Primary intestinal involvement may not present specific symptoms and remain silent for some time. It is manifested by the onset of complications caused by occlusion and perforation. Two cases of ileal lymphoma were treated at the Institute of Emergency Surgery of Catania University between 1992 and 1993. They were complicated by intestinal perforation and occlusion respectively. Both patients underwent emergency intestinal resection. Surgery represents the elective treatment for primary forms, followed by polychemotherapy and radiotherapy. Prognosis depends on the spread of disease and the hystotype. The administration of NTP and somatopstatin resulted in a shorter postoperative period with fewer surgical complications.