Laparoscopic treatment of pancreatic insulinoma.

Laparoscopy and laparoscopic ultrasonography (LUS) have been proposed for the diagnosis and treatment of pancreatic insulinoma. We present for cases of pancreatic insulinoma approached by laparoscopy guided by LUS. In three cases, insulinomas were in the pancreatic body and in one case in the pancreatic head. All lesions were detected preoperatively by abdominal US and confirmed by computed tomography. Laparoscopy was performed under general anesthesia. LUS was performed using a 10-mm flexible probe. In two cases the adenoma was enucleated using scissors and electrocoagulation, major vessels were controlled using clips, and enucleation was completed using a 30-mm endo-GIA. In one case a laparoscopic distal pancreatectomy with spleen preservation was performed. In one case the adenoma was deep in the pancreatic head; minilaparotomy was performed and the adenoma enucleated. Patients were discharged in good health 5-7 days after surgery. The postoperative course was complicated in one case of enucleation by peripancreatic fluid collection that was treated percutaneously. Our experience confirms that accurate localization followed by excision of tumors via the laparoscopic approach constitute a significant advance in the management of insulinoma.

TIMTEM project: our experience in a remote area.

We report our experience, begun in 1998 on a small island in the Dodecanese area of Greece, which has been called TIMTEM. The aim of this project was to improve care for people living on islands, creating a model exportable to other rural areas. The operative setting of the TIMTEM project is the island of Tilos (Greece); local authorities take part in it under the guidance of the only physician available on the island. The University of Pisa-Italy (Department of Surgery, Post-graduate School of Emergency Surgery) manages the scientific and organizational part of the project. Tilos is a rocky Mediterranean island with a surface of 64 km(2) and a population of about 500 inhabitants (with a peak of 2,000 tourists in July and August). A physician and a nurse are responsible for the only medical care on the island, and they also dispense drugs. The project was implemented on three phases. During the first phase, a campaign was held to encourage the population to cooperate with clinical data collection; a temporary telemedicine station was established, and a complete screening of the population was performed. The second phase was focused on the application of telesonography. During the third phase, a telematic and/or direct participation for reference hospital physicians (Regional Medical Society-Dodecanese) and for Greek physicians was planned. As well, a fully equipped central telemedicine station in the reference hospital was established under the local jurisdiction. The results of the third phase are still incomplete; the data presented here are preliminary. But all indicators show that the project is exportable to remote areas elsewhere.

Laparoscopic left hemicolectomy in a patient with cirrhosis scheduled for liver transplantation.

Hepatic cirrhosis is a negative prognostic factor for major abdominal surgery, with a greater risk of bleeding, infection, and ascites. The case of a 54-year-man with adenocarcinoma of the sigma affected by hepatitis B virus and hepatitis C virus hepatopathy as well as micro- and macrconodular cirrhosis (Child's B7 stage) waiting for liver transplantation is reported. After a consultation with the liver transplantation our hospital, and considering the the patient's age laparoscopy was determined to be the procedure of choice because it would give him the possibility of a transplantation in the future. A typical left hemicolectomy with left flexure mobilization and mechanic colorectal T-T-anastomosis was therefore performed. All surgical maneuvers in the right hypochondrium were avoided. Mobilization was performed using an ultrasonic scalpel to reduce the risk of bleeding, and the anatomic stump was pulled out by means of a midline minilaparotomy, sparing the anastomotic circles of the abdominal wall. Follow-up evaluation was uneventful. At an 8-month follow-up visit, the patient was in good general condition. In this case, laparoscopic surgery allowed an oncologically suitable colonic resection without complication and poor surgical stress. Moreover, open surgery would have reduced the possibility of a transplantation in the future.

Percutaneous management of multiple bilateral liver abscesses complicating Crohn disease.

Liver abscess is a rare complication of Crohn disease. A case of multiple, bilateral, pyogenic liver abscesses appearing as a recurrent manifestation of Crohn disease in a 34-year-old man is reported. Conservative management with antibiotics, double-catheter drainage, and multiple aspirations was successful. The liver abscesses disappeared with no recurrence during a 5-year follow-up period.

"What you see is not what you get". A plea to remove a 'normal' appendix during diagnostic laparoscopy.

BACKGROUND: Diagnostic laparoscopy (DL) is a well established alternative option to coeliotomy for suspected appendicitis. When a 'normal' appendix is found, appendectomy is often believe unnecessary. Little is known however about how normal a normal appearing appendix is. In this study we postulated that a normal appendix seen at DL, may show pathological indications at microscopy, and thus, to leave the appendix untouched may be unsafe. METHODS: A retrospective review of data from 48 patients which, in a five year period (1995-1999), had virtually normal appendices removed as completion of DL for lower abdominal pain. RESULTS: No procedure-related drawback and no subsequent complications were recorded. Symptoms subsided in all the patients. Mean hospital stay was 2.1 days. When receiving specimens, incidence of pathologic changes of the appendix were observed in 58 percent of the cases (n = 28). The negative predictive value of DL was 41 percent. CONCLUSIONS: Due to the consistently false negative rate of DL, and the low morbidity rate for laparoscopic appendectomy, we support incidental appendectomy in patients with lower abdominal pain.

Laparoscopic radiofrequency thermal ablation of hepatocarcinoma: preliminary experience.

The objective was to evaluate the feasibility, safety, and effectiveness of radiofrequency thermal ablation (RFT), performed during laparoscopy with a cooled-tip electrode needle, in the treatment of neoplastic hepatic focal lesions. Seven patients with hepatocarcinoma (10 hepatic lesions) were treated during laparoscopy with RFT using a 100-watt RF generator and 17-gauge, dual-lumen, cooled-tip electrode needles with a 3-cm exposed tip. The mean exposure time was 12 minutes for each needle insertion. Spiral computed tomography scanning detected complete tumor necrosis in nine lesions; in one lesion, peripheral neoplastic tissue was detected, and percutaneous RFT was performed. Two patients during follow-up developed two new neoplastic lesions, treated with percutaneous ethanol injection. No recurrences of the treated lesions were seen after 6 months of follow up. Intraoperative RFT with a cooled-tip electrode needle is a safe and effective local treatment of hepatic focal lesions during laparoscopic surgery. Possible indications are large hepatocarcinoma (>5 cm), superficial lesions, multiple lesions, or tumor located near vascular or biliary structures.

Effect of blood transfusions on disease-free interval after rectal cancer surgery.

BACKGROUND/AIMS: To assess retrospectively the impact of perioperative blood transfusions on disease-free interval after curative surgery of rectal cancer. METHODOLOGY: One hundred and seven (107) subjects (65 men and 42 women, median age: 67) underwent anterior resection of the rectum for rectal cancer between 1990 and 1996. Thirty-six (37%) were transfused perioperatively. Outcome variables measured were: age, sex, distance of the tumor from the anal verge, type of stapled anastomosis, protective colostomy, cancer-free margin in the specimen, grading and staging, leak of the suture line, transfusion, number of blood units given, and adjuvant therapy. RESULTS: Transfusion, nodes involvement and adjuvant therapy had a significant impact on disease-free interval at the univariate analysis. The estimated probability of cancer-free survival at 5 years was 81% for the not transfused, and 63% for the transfused patients (P < 0.05). At multivariate analysis, nodes involvement resulted significantly and independently related to time to recurrence (P < 0.05) but also perioperative blood transfusion showed an important role as independent risk factor for rectal cancer relapse (P = 0.05). CONCLUSIONS: This study suggests that blood transfusion is likely to have a detrimental effect on disease-free interval after resective surgery of rectal cancer.

Quality of life after total anorectal reconstruction: long-term results.

The aim of the study was to assess the long-term quality of life (minimum 8 years after surgery) of patients undergoing total anorectal reconstruction for low rectal cancer. The quality of life of 27 patients undergoing total anorectal reconstruction (mean age: 73.07 years) and 27 healthy subjects (mean age: 73.50 years) randomly chosen from the population was analysed and compared using general standardized questionnaires and specific fecal continence scales. Twenty-one out of 27 patients were clinically evaluated and personally interviewed by the same surgeon who had performed the reconstruction some years before. Quality of life analysis yielded good global results, also in the light of the mean age of the patients. Fecal continence was obtained in 81% of patients. All of them report a good physical, psychological and social situation. There was no statistically significant difference (P = ns) in quality of life between these 27 total anorectal reconstruction patients and the control population. In adequately selected patients, total anorectal reconstruction is proposed as a technique capable of guaranteeing good quality of life as well as being a safe technique for the treatment of low rectal cancer.

Telemedicine on a small island.

Information on the health status of the population of a small Greek island was collected. The information consisted of personal data, clinical history, physical examination, blood pressure evaluation, electrocardiography, and ultrasound scans of neck, breast and abdomen. Ninety-six per cent of the entire island population (280 inhabitants) participated in the study. Two per cent were at risk of serious complications of pathological disease and were immediately referred to a regional hospital for adequate care while 25% had minor pathological problems. Our experience suggests that health-care workers on small islands should be trained in the use of technology as a means of communication with mainland hospitals.

[Echography in the surgical emergency]. / L'ecografia nell'urgenza chirurgica.

Abdominal sonography represents the diagnostic method of choice in case of acute abdomen. On the bases of their experience on more than 1200 consecutive examinations performed in case of acute abdomen the author evaluate the fields of application of sonography in acute patients. A decisional algorithm in trauma patients based on sonographic results is presented. The actual indications of sonography abdominal non traumatic pathology are presented: paying particular attention to acute gastro-intestinal diseases. The therapeutic role of interventional sonography in the acute abdomen is also discussed.

Safety and efficacy of dynamic muscle plasty for anal incontinence: lessons from a prospective, multicenter trial.

BACKGROUND & AIMS: Dynamic muscle plasty has been advocated as therapy for refractory fecal incontinence and for anorectal reconstruction to avoid colostomy after abdominoperineal resection. This study evaluates the results of a multicenter experience with dynamic muscle plasty in the treatment of fecal incontinence and total anal reconstruction. METHODS: One hundred thirty-nine patients were enrolled at 12 centers between June 1992 and November 1994 and followed up through June 1996. Intramuscular leads and neurostimulators were implanted to stimulate transposed gracilis or gluteus muscle. Success was defined as 70% reduction in solid stool incontinence for patients with baseline incontinence and zero incontinence to solid stool for patients with baseline stomas and for patients undergoing total anal reconstruction. RESULTS: Overall, 85 of 128 graciloplasty patients (66%) achieved and maintained a successful outcome over the follow-up period. By etiology, these proportions were 71%, 50%, and 66% for patients with acquired fecal incontinence, congenital incontinence, and total anal reconstruction, respectively. One third of graciloplasty patients experienced a major wound complication, with therapy failing in 41%. Experienced centers had better outcomes and lower complication rates than inexperienced centers. Of the 11 gluteoplasty patients, 5 (45%) achieved and maintained a successful outcome. CONCLUSIONS: Dynamic graciloplasty may be an effective procedure for patients with refractory, end-stage fecal incontinence as well as for patients who require anorectal excision for low-lying malignancy. However, the procedure has significant morbidity that can lead to functional failure. Outcome after dynamic graciloplasty appears to correlate with surgical experience. In contrast to graciloplasty, the use of dynamic gluteoplasty should be limited to investigational purposes.

Laparoendoscopic treatment of gastric ectopic pancreas.

A case of ectopic pancreas located on the anterior gastric wall treated with a combined gastroscopic and laparoscopic approach, which permitted isolation and complete resection of the lesion, is reported. The patient was discharged without complication.

Laparoscopic treatment of appendico-cecal intussusception.

Laparoscopy is a therapeutic possibility in pediatric surgery. A case of appendiceal intussusception treated laparoscopically in a 27-month-old girl is presented. The postoperative course was normal.

Laparo-endoscopic "rendezvous": a new technique in the choledocholithiasis treatment.

BACKGROUND/AIMS: Endoscopic sphincterotomy for common bile duct stone clearance during laparoscopic cholecystectomy may fail due to difficulties in cannulating the papilla major. In this study we propose a new technique that facilitates the cannulation of the papilla and the common bile duct stone clearance during a standard laparoscopic cholecystectomy. Its clearance percentage, complication rate and post-operative stay have been evaluated and compared with standardized procedures such as open surgery and endoscopic sphincterotomy before laparoscopic cholecystectomy. METHODOLOGY: In a group of 16 patients presenting with cholelithiasis and common bile duct stones or papillitis, the sphincterotome was driven across the papilla into the choledochus by a Dormia basket passed in the duodenum through the cystic duct during laparoscopic cholecystectomy. Measures of outcome were clearance rate, mortality, morbidity and hospital stay. Furthermore, data obtained from this sample of patients were compared with those from another two groups of 16 patients in which choledocholithiasis was managed either by endoscopic sphincterotomy performed before laparoscopic cholecystectomy or by open cholecystectomy and trans-duodenal sphincterotomy. RESULTS: The rate of cannulation of the papilla and of the common bile duct stone clearance was 100% when the combined endo-laparoscopic approach was used in 15 patients with endoscopic sphincterotomy (93,7%) and in 15 patients with open sphincterotomy (93,7%), cholecystectomy was successful in every case. The groups were statistically similar with regard to complications; none of the patients required blood transfusion. The mean post operative stay was 95.2 hours (range 48-240) for the first group, 350.1 hours (range 192-1680) for the second and 69.7 hours (range 24-132) for the third. CONCLUSION: The laparo-endoscopic rendezvous, though still in evolution, is an efficacious method which can be used during the laparoscopic strategy of common bile duct clearance.

Treatment of hyperfunctioning thyroid nodules with percutaneous ethanol injection: Eight years' experience.

The aim of our study was to define the long-term efficacy and safety of percutaneous ethanol injection (PEI) for the treatment of autonomous thyroid nodule (ATN), and to optimise the clinical usefulness of such a therapy. We treated 132 patients with ATN (30 M and 102 F, aged 47.5+/-12.9 years; mean+/-SD), in case other established treatments were refused or contraindicated. Eighty-five patients were affected by toxic adenoma and 47 suffered from pre-toxic nodules. Ethanol was administered weekly under sonographic control, in 7 sessions (range 2-16). During PEI treatment, 26 toxic elderly patients were treated with methimazole and propranolol. Three possible outcomes were identified for statistical analysis: failure (persistent suppression of extra nodular tissue uptake, along with elevated free thyroid hormone and undetectable TSH levels); partial cure (normal free thyroid hormone and low/undetectable TSH levels); complete cure (normal thyroid hormone and TSH levels; restored extra nodular uptake). The patients were followed for up to 8.5 years (median 76 months). PEI therapy was well tolerated by all patients though a mild to moderate local pain occurred in about 30% of sessions. Complete cure was achieved in all pre-toxic patients and in 60 (70.6%) patients with toxic adenoma, while partial cure was observed in 11 cases (12.9%) and failure in 14 (16.5%). A significant shrinkage of nodule volume was observed in all patients (p = 0.0001), while those with toxic nodules larger than 30 mL showed a significantly lower response rate to PEI (p < 0.05). At controls, only one patient developed subclinical hypothyroidism while, among partially cured patients, five relapsed. The administration of methimazole and/or propranolol did not modify PEI outcome. In conclusion, we suggest that PEI therapy may be the treatment of choice in patients with pre-toxic thyroid adenoma where therapy is least necessary- despite the nodule volume. Though ethanol injection therapy of toxic thyroid nodules may be troublesome for the need of multiple sessions, it appears an effective alternative procedure in patients at poor surgical risk, and in younger patients in whom radioiodine is contraindicated. Since a special technical skill in intervention procedures is required, PEI therapy may be suitable only for patients living nearby a trained centre.

Trocar site tumor recurrences. May pneumoperitoneum be responsible?

BACKGROUND: Port site metastasis following laparoscopy for cancer is reported with increasing frequency and represents one of the most important limitations of the technique. METHODS: A scintigraphic model was utilized to evaluate a possible role of pneumoperitoneum in tumor cell dissemination. Labeled red blood cells (RBC) were injected at the level of the gallbladder bed during laparoscopic cholecystectomy (LC) performed for symptomatic cholecystolithiasis. LC was performed in two groups with standard CO2 pneumoperitoneum: in one group an endobag for retrieval of the specimen was utilized. In one group a gasless LC with endobag was performed. RESULTS: Radioactivity in the area of the trocar introduction was observed in almost all the patients who underwent standard (CO2) LC but represented a rare event in patients treated with the gasless method. The utilization of a protective bag for the extraction of the surgical specimen did not modify significantly the results. Moreover all patients treated with pneumoperitoneum demonstrated a wide intraperitoneal diffusion of the tracer not observed in gasless patients. CONCLUSIONS: The results of this study confirm that pneumoperitoneum may play an important role in the evolution of port site metastasis after laparoscopy for gastrointestinal cancer.