The alterations of the sigmoid-rectal junction in diverticular disease of the colon revealed by MR-defecography.

PURPOSE: The sigmoidorectal junction (SRJ) has been defined as an anatomical sphincter with particular physiological behavior that regulates sigmoid and rectum evacuation. Its function in clinical conditions, such as diverticular disease has been advocated. The aim of our study is to identify the SRJ and to compare the morphometric and dynamic features of the SRJ between patients with diverticular disease and healthy subjects using MR-defecography. METHODS: Sixteen individuals, eight with uncomplicated diverticular disease and eight healthy subjects, were studied using MR-defecography to identify the SRJ and to compare the morphometric and dynamic features observed. RESULTS: In each subject studied, MR-defecography was able to identify the SRJ. This resulted in the identification of a discrete anatomical entity with a mean length of 31.23 mm, located in front of the first sacral vertebra (S1) and at a mean distance of 15.55 cm from the anal verge, with a mean wall thickness of 4.45 mm, significantly different from the sigmoid and rectal parietal thickness. The SRJ wall was significantly thicker in patients with diverticular disease than the controls (P = 0.005), showing a unique shape and behavior in dynamic sequences. CONCLUSION: Our findings support the hypothesis that SRJ plays a critical role in patients with symptomatic diverticular disease; further investigation may clarify whether specific SRJ analysis, such as MR-defecography, would predict inflammatory complications of this diffuse and heterogenic disease.

Laparoscopic colorectal surgery in urgent and emergent settings.

Laparoscopic colectomy (LC) is slowly becoming the standard of care for elective resections. The use of LC in the emergency setting is relatively unstudied. Authors describe their experience with a series of 34 emergent and urgent LC cases for a variety of benign and neoplastic colorectal diseases, admitted from 2007 to 2009 at Emergency Department of a tertiary level hospital, comparing laparoscopic group with matched control open group. Twenty-one LC was performed for benign complicated disease, 12 for malignant disease and 1 for iatrogenic perforation during colonoscopy. Two cases were converted to open procedure (5.8%), the average operative time was 188 minutes (SD 61.84). The average postoperative length of hospital stay was 6.57 days (SD 1.75), with no postoperative mortality and no major morbidity. Results of laparoscopic group compared with 61 patients treated with open colorectal procedure confirm the advantages of laparoscopic approach similar to those established in elective colorectal surgery. With increasing experience, LC would be a feasible and an effective option in nonelective situations lowering complication rate and length of hospital stay.

Gerota's fascia flap: a technique for autogenous packing in major liver injuries.

Hepatic trauma occurs in ∼ 5% of patients admitted to emergency rooms and nonoperative management has become the standard of care in hemodynamically stable patients with blunt trauma, for most of the injured solid organs. However, the staged surgery represents the first line of treatment in hemodynamically instable patients. The abdominal packing is considered the first step of this surgical policy. The authors describe a new surgical technique consisting of Gerota's fascia dissection that provide an autogenous pedunculated flap to obtain a definitive hemostasis of the injured liver with a permanent packing system.

[Emergency laparoscopic cholecystectomy in the treatment of acute cholecystitis: when and how?]. / Colecistectomia laparoscopica d'urgenza nel trattamento della colecistite acuta: "quando" e "come".

Optimal surgical timing and operative technique in the treatment of acute cholecystitis are of major importance and are still debatable issues. We report the results of our study on the timing of surgery in a consecutive series of 163 patients treated in the emergency setting for acute cholecystitis over the period from 1998 to 2008. Early surgery and the partially downwards laparoscopic cholecystectomy technique provide a safe and effective way of treating these patients and preventing major complications. The mean time period between onset of symptoms and surgery was 69.2 hrs, with a median value of 53 hrs. The mean operative time was 63.9 min, with a conversion rate of 0.6% and a specific complication rate of 1.22%. The mean postoperative hospital stay was 3.2 days. The timing of surgery (measured in hours) and operative time (measured in minutes) were recorded and analysed to verify whether or not there was a statistically significant relationship between these two variables and establish the best timing for surgery. Our results show a linear relationship between operative time and the timing of surgery. Moreover, at the cut-off point of 57 hrs, the later subgroup (over 57 hrs) had a two-fold increase in operative time compared to the earlier subgroup. At more than 60 hrs approximately from the onset of symptoms, the pathological changes in the surgical target begin, with increasing rapidity, to present a troublesome challenge to the surgeon, making laparoscopic cholecystectomy for acute cholecystitis more difficult and less safe than when performed earlier.

[Therapeutic and diagnostic protocol for mild acute biliary pancreatitis: our experience and review of the literature]. / Protocollo diagnostico terapeutico della pancreatite acuta biliare lieve: nostra esperienza e revisione critica della letteratura.

Through a critical review of the literature, the authors analyze and re-assess the current diagnostic and therapeutic algorithms used in the treatment of mild acute biliary pancreatitis, reporting their experience with 27 cases observed in the Policlinico Umberto I Emergency Department (Rome) over the period from March 2003 to May 2005. All patients were treated with the same diagnostic and therapeutic protocol: once the diagnosis of acute biliary pancreatitis had been made and the severity evaluated, patients presenting clinical or ultrasonographic signs of main biliary duct stones underwent ERCP within 72 hours of onset of symptoms. All patients then underwent a standard-technique laparoscopic cholecystectomy during the same hospital stay, and whenever ERCP had not been performed preoperatively, an intraoperative cholangiography was performed at the time of surgery. No intra- or postoperative complications were observed, with a mean hospital stay of 10.6 days (range: 5-25 days).

The best timing of surgery in laparoscopic cholecystectomy for acute cholecystitis: when and how is to be performed.

BACKGROUND/AIMS: In the treatment of acute cholecystitis the optimal timing of operation, regardless of whether performed laparoscopically or conventionally, is of major importance and not yet well defined feature among the different authors. We report our study on the timing of surgery in a consecutive series of 133 patients. METHODOLOGY: The surgical technique consists in a partially downwards cholecystectomy from the infundibulum to the cystic duct. The dissection never involves the Calot Triangle's structures; this provides a safe and effective way to prevent major complications procedure related. Length of time interval from the onset of symptoms to surgery (ST measured in hours) and operating time (OT measured in minutes) have been recorded and analyzed to find out how these two variables are each other linked and what is the best timing for surgery. We also split the series taking a progressively increasing of ST as a cut off point and analyzed the two derived subgroups to outline which was the time of surgery (period of ST) that provided the best result in term of worsening of laparoscopic procedure difficulty. RESULTS: 51.3 hrs of average time between the onset of symptoms and surgery has been reported, with minimum of 24 hrs and maximum of 90 hrs, and median value of 48 hrs. The curve fit analysis on the scatterplot of the variable ST (independent) and OT (dependent) shows that these two variables are directly each other linked. The best division of the series was at the cut off of 57 hrs; each subgroup reached a statistical correlation coefficient: the late subgroup (the one over the cut off time of 57 hrs) had a twofold operating time increasing respect to the early group. CONCLUSIONS: Our results outline that there is a linear relationship between the technical difficulties, expressed in term of operating time, and time intervals from the onset of symptoms to surgery. At the cut off time of 57 hrs of interval from the onset of symptoms to surgery, the linear regression coefficient that links the dependent variable OT to the independent variable ST changes increasing up to 1,92. Over 60 hrs from the onset of symptoms the pathological changes of the surgical target becomes more and more quickly a troublesome challenge to the surgeon, letting the laparoscopic cholecystectomy for AC more difficult and less safe than that performed early.

[New orientations in the management of advanced, metastatic gastrointestinal stromal tumors (GIST): combination of surgery and systemic therapy with imatinib in a case of primary gastric location]. / Nuovi orientamenti nella cura dei tumori stromali gastroenterici (GIST) avanzati e metastatici: trattamento combinato intervento chirurgico-terapia sistemica con imatinib in un caso a localizzazione primitiva gastrica.

Gastrointestinal stromal tumours (GIST) are rare neoplasms originating from connective tissue in the digestive tract with an incidence of less than 1% and account for most non-epithelial primitive digestive tumours. Metastasis diagnosed at the time of disease discovery confirms GIST malignancy. Kit protein, a trans-membrane tyrosine kinase receptor of staminal cells, is characteristically expressed by GIST. Most GIST have a mutation in the kit proto-oncogene. Resistance to conventional chemotherapy is commonly shown by malignant GIST. Most patients with advanced malignant GIST achieve clinical benefit with imatinib mesilate, an orally administered selective inhibitor of the tyrosine kinase receptor. We treated a 43-year-old male patient suffering from a gastric GIST diagnosed during a surgical emergency operation for peritonitis caused by gastric perforation. At the time of the first operation the patient had lost 10 kg body weight over the previous months and was seriously cachectic. During the emergency operation the perforation was sutured. The biopsy results showed the presence of CD1 17 (c-kit) and CD34 markers. A total body CT scan documented the substantial size of the gastric wall lesion, an increased volume of abdominal lymph nodes and compression of the splenic vein with alternative collateral circulation. The liver presented no less than 5 large metastases distributed in both the left and right lobes. There was also a pulmonary metastasis. Because of frequent spontaneous bleeding and starvation the patient was seriously anaemic. Considering the action mechanism of imatinib and the extent of the lesion we decided to perform a total gastrectomy procedure. At the time of the operation the stomach seemed to have a modified volume and shape: it appeared to be divided into two sacs, the larger and deeper of which was the original gastric cavity, while the superficial, smaller one seemed to be a protrusion of the organ. The stomach was indistinguishable from the spleen, the transverse colon and the distal pancreatic tract. The neoplasm was directly linked to the left liver and to the inferior diaphragmatic surface. We performed total gastrectomy and resection of the tail of the pancreas, the spleen, and the transverse colon all in one and the same session. The patient was discharged on postoperative day 8 and commenced imatinib therapy 30 days after the operation with 4 tablets per day. In the following months the patient repeated the CT scan to monitor the progressive volume reduction of the liver and lung lesions and a PET scan confirmed that the lesions were not active; the patient experienced a 13 kg body weight increase. One year after the operation the outcome appears to be lasting and the patient has tolerated the drug treatment well.

Is there a place for intraperitoneal onlay mesh repair (IPOM) of inguinal hernia among laparoscopic techniques?

BACKGROUND/AIMS: The Authors report their experience on laparoscopic hernioplasty using the intraperitoneal onlay mesh repair in 56 patients. METHODOLOGY: Thirty patients had a monolateral hernia, 9 of which were recurrent and 26 had a bilateral hernia, 6 of which were recurrent. Overall, a total of 90 hernias were treated. The hernia repair was performed by using "GORETEX Dual Mesh Plus biomaterial with holes" in the first 32 cases and the latest "Corduroy" type in the following 24 cases. The prostheses were fixed with titanium spiral tacks (Protack, Auto Suture, Tyco Healthcare). RESULTS: No intraoperative complications occurred and no conversion was necessary. Five minor postoperative complications (5.5%), 2 seromas and 3 transient paresthesias, were observed. Four patients (7.1%) needed analgesics after the first 24 hours. Mean hospital stay was 36 hours with a minimum of 24 and a maximum of 48. Mean resumption of normal activity was 8 days with return to work within two weeks. At an average 18 months follow-up, 3 recurrences were recorded (3.3%). CONCLUSIONS: The results of this study as well as the meta-analysis of the series presented in the literature, indicate that the intraperitoneal onlay mesh repair may be a feasible, safe and effective procedure in the treatment of recurrent and bilateral hernias or when a hernia repair is performed during other laparoscopic procedures. The intraperitoneal onlay mesh repair has in fact been shown to be faster and easier than the other more commonly performed laparoscopic hernioplasties (trans-abdominal preperitoneal repair and total extra-peritoneal repair). These data may also suggest utilizing this technique in particular cases of primitive hernia such as very active young males or heavy-duty workers. However the limited series and the short follow-up ask for randomized prospective long-term studies to definitely ascertain the true incidence of recurrence and therefore the effectiveness of this attractive procedure.

[Ergonomic and cosmetic aspects of laparoscopic appendectomy: personal technique]. / Ergonomia ed estetica nell'intervento di appendicectomia laparoscopica: tecnica personale.

We analyzed our case series in order to evaluate the evolution of our laparoscopic technique in ergonomic and cosmetic terms, leading to the right compromise between these aspects. We retrospectively analyzed 136 diagnostic laparoscopies for suspected appendicitis, using scheme A in the first 98 cases (one 10/12-mm umbilical trocar for the optics and two 5-mm operative trocars placed above the pubis on the right and left side) and scheme B in the other 38 cases (one 10/12-mm umbilical trocar for the optics and two 5-mm operative trocars, one placed over the pubis and the other one on the right hip, just on the umbilical line). The diagnosis of appendicitis was confirmed in 117 patients, while other diseases were present in 19 patients. There were no differences between the two groups in mean operative time (45 min), postoperative complications (0.7%) and clinical course (hospital stay: 36 hours on average). We believe that the right compromise between ergonomic and cosmetic considerations is the one shown in scheme B. In this way it is possible to perform all diagnostic and therapeutic manoeuvres such as pulling the appendix out through the umbilical trocar and using suprapubic trocars as an access route for a possible drainage.

["Low-pressure" laparoscopic cholecystectomy in high risk patients (ASA III and IV): our experience]. / La colecistectomia laparoscopica a "bassa pressione" nei pazienti ad alto rischio (ASA III ed ASA IV) nella nostra esperienza.

The insufflation pressure used for laparoscopic cholecystectomy is usually 12-15 mm Hg, and a pneumoperitoneum with carbon dioxide has a significant effect on both cardiovascular and respiratory function. These effects are transient in young, healthy patients, but may be dangerous in ASA III and IV patients with a poor cardiac reserve. This study was designed to assess the feasibility of performing laparoscopic cholecystectomy at 6.5-8 mm Hg insufflation pressure in "high-risk" patients. Thirteen patients, 10 ASA III and 3 ASA IV, with cholelithiasis, were included in this study The insufflation pressure was 6.5-8 mm Hg, with a 10 degrees anti-Trendelenburg position. The cardiovascular and blood gas variables studied were: mean arterial blood pressure, heart rate, respiratory rate, and end-tidal CO2 pressure. The authors reported no conversions and no intra- or postoperative complications. During insufflation heart rate and mean arterial blood pressure increased minimally if compared with laparoscopic cholecystectomy at 12-15 mm Hg. Pa CO2 increased after insufflation (+5 mm Hg), and the end-tidal CO2 pressure gradient was moderate (3.5 mm Hg) and unchanged during surgery. A low-pressure pneumoperitoneum is feasible for laparoscopic cholecystectomy and minimizes the adverse haemodynamic effects of peritoneal insufflation.

[Treatment of esophageal perforations. Considerations on a clinical case]. / Trattamento delle perforazioni esofagee. Considerazioni su un caso clinico.

The Authors describe a rare case of esophageal perforation occurred after Transoesophageal echocardiography in 68 years old patient and review the literature relating to the causes and management of this pathology. Transoesophageal echocardiography, which is a semi-invasive investigation increasingly used in cardiology and cardiac surgery and intensive care units, is a rare though extremely dangerous cause of such complications. Perforation of the esophagus continues to present a formidable diagnostic and therapeutic challenge. The diagnosis depends on a high degree of suspicion and on the recognition of clinical features and is confirmed by contrast esophagography. The outcome after esophageal perforation depends on the location of the injury, the presence or otherwise of concomitant esophageal disease and the time elapsing between the injury and inititian of treatment. Reinforced primary repair of the perforation is the procedure most frequently employed and preferred for the surgical management of the esophageal perforation. In the case reported here, early diagnosis and prompt surgical treatment consisting in primary repair of the esophageal perforation contributed to the successful management of this serious pathology.