[The use of the biofragmentable ring (BAR-Valtrac) in colon surgery]. / Utilizzo dell'anello bioframmentabile (BAR-Valtrac) nella chirurgia colica.

BACKGROUND: Clinical results of colic anastomosis using biofragmentable anastomosis ring (BAR-Valtrac) are presented. Such a method showed to be a real alternative technique to the usual ones. METHODS: Eighty-six colic anastomosis using BAR are collected, 76 of which performed as elective surgery and 10 in emergency. The patients were 47 males and 39 females, with a mean age of 64 years. In 63 cases the patients were affected by colic neoplastic disease, in 16 by complicated diverticular disease (stenosis or perforation) and 7 patients had neoplastic disease of other organs involving the colon BAR device was used in 48 colic reconstructions after segmentary resection and in 38 colic reconstructions after left hemicolectomy. In each case 31-34 mm BAR were used. RESULTS: No perioperative death occurred in our series. Only one case (2%) of anastomotic leak was observed, while in 3 cases (4%) intestinal canalization disorders occurred. No problems for ring expulsion occurred in any patient. Three late complications were observed, as three cases of asymptomatic substenosis discovered during instrumental follow-up and spontaneously cleared up. CONCLUSIONS: On the basis of clinical results, and according to those reported in literature BAR anastomosis is considered a safe, feasible and easy technique to perform colic anastomosis, even in emergency, limited to the intraperitoneal tract of the colon.

Combined laparoscopic splenectomy and cholecystectomy for the treatment of hereditary spherocytosis: is it safe and effective?

Hereditary spherocytosis is the most common red blood cell membrane disorder and often is associated with hemolytic crisis and premature cholelithiasis. Splenectomy is the only effective therapy for this disorder and often it is performed in combination with cholecystectomy. Conventional surgery requires a wide upper abdominal incision for correct exposure of the gallbladder and spleen. Laparoscopic cholecystectomy and splenectomy have been performed safely worldwide. We report our experience with seven patients (one male and six female, average age 12 years) who underwent combined laparoscopic splenectomy and cholecystectomy for hereditary spherocytosis. The patient was placed in supine position and the procedure performed with a five-trocar technique. Cholecystectomy was performed first, then splenectomy was achieved and the spleen removed by morcellation into a retrieval bag (five cases) or via a 4- to 5-cm left subcostal incision (two cases). No patient required conversion to open technique or blood transfusion. The mean blood loss was 162 mL, mean operative time 207 minutes, mean spleen size 14.5 cm, and median postoperative hospital stay 4 days. No perioperative mortality or major complications occurred in our series. After a median follow-up of 18 months all patients showed sharp hematologic improvement. Despite the small number of cases, we consider the combined laparoscopic approach safe and effective for the treatment of hereditary spherocytosis.

Laparoscopic splenectomy for hematological disorders. Our experience in adult and pediatric patients.

Laparoscopic splenectomy has gained increasing acceptance in the surgical management of a variety of splenic disorders, in particular hematological diseases. In this series, we report our experience with 20 patients (male:female ratio of 4:16 with median age of 16 years, range 5-49 years) who underwent this procedure because of ITP in 9 cases, spherocytosis in 7 and Cooley disease, sickle cell anemia, dyserythropoietic and hemolytic anemia in one case each. The patient was placed in a supine position using a fourtrocars technique. We did not perform pre-operative splenic artery embolization in any case. Spleen lower pole and its posterolateral attachments were dissected first, using electrocautery and endoclips. Vascular hilar isolation was achieved with an EndoGIA stapler and the spleen was removed by morcelation within a retrieval bag (16 cases) or via a 4-5 cm left subcostal incision (4 cases). One patient required conversion to open technique (conversion rate 5 %), because of uncontrolled bleeding from splenic hilum. Mean operative time was 165 min (range 100-240 min), mean splenic size was 13.5 cm (range 11-20 cm), with weight ranging between 140 and 1060 g and estimated blood loss was 151 ml (75-280 ml). No patient required a blood transfusion. Median postoperative hospital stay was 4 days (range 3-8 days). Postoperative complications occurred in 2 patients (10%), with no mortality rate in this series. Regarding the low complication rate and the advantages of a small abdominal trauma in the postoperative period, such as less postoperative pain, faster hospital discharge and better cosmetic results, the laparoscopic approach for elective splenectomy in hematological disorders has a substantial benefit for the patient.

Central venous catheter-related infections in pediatric hematology-oncology patients: role of home and hospital management.

In a 61-month period, 135 single-lumen central venous catheters (CVCs) were positioned in 125 children with mainly hematological malignancies. We retrospectively investigated the different role of home and hospital CVC management in development of CVC-related infections (CI) during different hematological conditions (presence or absence of neutropenia). Forty-nine percent of the children presented at least one CI, for a total of 109 episodes, during the 20,558 days a CVC remained in situ. CVC hospital management was safer and more reliable than CVC home management in both neutropenic and nonneutropenic patients. None of the CI was life threatening and only in 11% of the cases was it necessary to remove the catheter. Analysis of the microorganisms involved showed that they were mainly gram-positive with CVC home management and gram-negative with CVC hospital management. Careful evaluation of our retrospective survey study suggests that a better training of parents in the care of the CVC and more careful measures of asepsis in hospital could further decrease the incidence of CI, thus improving patients' quality of life.

Central venous catheter-related complications after bone marrow transplantation in children with hematological malignancies.

We studied infectious and mechanical complications occurring with 55 central venous catheters (CVCs) managed in hospital and at home, in 53 children with hematological malignancies who underwent bone marrow transplantation (BMT). The total catheter life span was 6906 days (median 111), 2359 days (median 40) in hospital and 4547 days (median 78.5) at home. Duration of neutropenia was 1241 days (median 20), mostly in hospital. We observed 21 CVC-related infections from 17/55 CVCs (31%): 0.30 episodes/100 days of CVC use with 0.55/100 days in hospital vs 0.17/100 days at home. Antibiotic treatment resolved 72% of infections without CVC removal, which was required in six instances. There were 14 mechanical complications (0.20 episodes/100 days of CVC use) in 6/55 CVCs (11%), with three removals. Interventions to resolve mechanical problems included catheter declotting by urokinase, repair and replacement. We conclude that CVC is an essential component of care of children with cancer undergoing BMT and that it has a relatively low complication rate. Most complications can be resolved by an appropriate CVC handling and by a multidisciplinary intervention in the critical post-BMT phase.

[Intestinal hemorrhage in a milk-fed infant: a case of laryngo-tracheo-gastric duplication]. / Emorragia intestinale in un lattante: un caso di duplicazione laringo-tracheo-gastrica.

An important gut hemorrhage in a breast fed child is not a usual event. If, in addition, the etiology represents a real rarity, even the most sophisticated diagnostic trials can't give any aid and this constitutes a hard diagnostic and therapeutic problem. In this report, the authors describe how, after a long sequence of analysis and exams, no certain diagnosis was possible, till serious anaemia gave indication to an explorative laparatomy. Laparatomy became both diagnostic and therapeutic and allowed to discover a rare malformation: a tracheal-gastric duplication.