[Annular pancreas in adults: diagnostic considerations on a case]. / Il pancreas anulare nell'adulto: considerazioni diagnostiche su di un caso.

Annular Pancreas (AP) is a rare congenital anomaly that usually presents in childhood with symptoms referable to duodenal obstruction; nonetheless, this condition can manifest in adulthood with abdominal pain, pancreatitis, duodenal ulcer, pancreatic head mass. The Authors hereby discuss a case of AP observed in a 63 year-old patient in which EUS played a decisive role in achieving a certain diagnosis.

[Totally implantable venous access systems. Analysis of complications]. / Sistemi di accesso venoso totalmente impiantabili. Analisi delle complicanze.

UNLABELLED: Totally implantable central venous access devices (Port-a-Cath, PaC) allow better treatment of cancer patients, with safe administration of chemotherapeutic agents, and are well accepted by the patients. The aim of the present paper is to analyze the complications of the different implant techniques on the basis of a personal experience of 92 central venous access devices. MATERIAL AND METHODS: A total of 92 PaC (Port-a-Cath, Pharmacia: Celsite Braun) have been implanted in 88 patients between August 1992 and June 1995 for cancer treatment. Age ranged between 19 and 79 years (median 52 years), 56 were male and 32 women. PaC have been implanted by percutaneous cannulation of the subclavian vein, with Seldinger technique, in 34 cases; by venous cutdown respectively on the cephalic vein in 46 cases, the jugular vein in 7 cases, the basilar vein in 4 and the saphenous vein in 1 case. Four patients experienced a double implant. In 84 cases the implant was done under local anesthesia, while in 8 required general anesthesia, during operation for the primary neoplasm. RESULTS: A total of 7 complications were experienced (7.6%, 7/92): 4 sepsis and 3 mechanical. No cases of pnx were observed. Sepsis occurred after 29, 45, 64, 401 days of implantation respectively, and culture demonstrated S. aureus in 2 cases, and E. coli and Klebsiella oxytoca in 1 case each. Mechanical complication comprehends 2 cases of catheter dislodgement and 1 case of port rotation. No complications were noticed in case of implant during surgery for primary cancer (8 cases). In 7 cases the procedure has been converted from cephalic vein cutdown to percutaneous cannulation of the subclavian vein due to anatomic reasons (13.2%, 7/53). Five PaC have been explanted for complications. DISCUSSION: On the basis of the personal experience we think that PaC are of easy implant, with few complications and of good acceptance from the patients. We prefer venous cutdown on cephalic vein as implant technique because of avoidance of pnx or bleeding complications. Percutaneous puncture of subclavian vein is useful for implantation during major surgery, because less time consuming, and in case of anatomical anomalies fo the cephalic vein. Basilic vein cutdown has been utilized exclusively for esthetic reason in young people, to avoid the scar in the upper thoracic region. Alternative implant techniques has been employed in special conditions, such as catheter position in the inferior v.cava, or early in our experience (internal jugular vein). A total of 7 complication have been reported (7.6%), 4 sepsis and 3 mechanical (2 dislodgement, 1 rotation). Sepsis were not related to implant technique, presenting on day 29, 45, 64 and 401 respectively; all required the explant of the PaC as a treatment. Mechanical complications are related to surgical technique; all required re-exploration with 1 explant and 2 reposition of the PaC. In PaC positioning during surgery for primary cancer (8 cases) no morbidity has been reported. All but the 5 PaC explanted were functioning until patient's need; maximum length reported is 42 months.

[Esophago-jejuno-gastroplasty in the treatment of peptic stenosis of the esophagus]. / L'esofago-digiuno-gastroplastica nel trattamento delle stenosi peptiche dell'esofago.

From 1973 to 1994, 21 patients with esophageal peptic stenosis were submitted to esophago-jejuno-gastroplasty with Merendino's technique. In 14 cases peptic stenosis developed after Heller's myotomy for achalasia, associated in 3 cases with fundoplication. In 3 patients the stenosis was secondary to fundoplication. Other 3 subjects presented a primary stenosis. One patient showed Barrett's esophagus with in situ carcinoma. Endoscopic esophageal dilatation was attempted in every patient with no satisfactory results. One patient died for a postoperative cardiopulmonary failure (4.7%). One patient developed a fistula of the esophago-jejunal anastomosis treated with enteral nutrition successfully (4.7%). In another subject splenectomy was performed following a iatrogenic injury (4.7%). Minor complications developed in 5 patients (23.7%). After one year from operation in 1 patient a severe stricture of esophago-jejunal anastomosis appeared; it was treated with anastomotic resection and reconstruction. After 8 years one patient was submitted to a partial resection of interposed jejunal loop, that was redundant. In 18 patients long term follow-up showed good results in 14 patients (78%), discrete in 2 (11%), unsatisfactory in 2 (11%). Our results show that Merendino's esophago-jejunal gastroplasty allows to achieve good results with acceptable rate of mortality and morbidity.

Jejunal interposition for peptic stenosis of the esophagus following esophagomyotomy for achalasia.

Retrospective analysis of the results of esophagojejunogastrostomy in 21 patients with peptic stenosis after esophagomyotomy for achalasia is reported. All patients complained of severe dysphagia. The esophagogram showed the presence of a 2 to 3 cm long stenosis in the lower esophagus with a diameter < 10 mm. Endoscopic dilatation was possible in 18 cases and it was pursued until the passage of the endoscope was possible. Manometry confirmed the presence of an aperistaltic esophagus with incompetent LES in all cases examined. GERD was detected by 24 hour pH-metry in 15/21 patients (71.4%). One patient died because of postoperative cardiopulmonary failure. Other minor complications occurred in 6 patients. During an 11 year mean follow-up good results were achieved in 17 patients (85%), fair in 2 (10%) and poor in 1 (5%), in whom redundant jejunal loop was resected after 8 years. Resective surgery in peptic strictures after esophagomyotomy is the treatment that guarantees the best long-term results. Esophagojejunogastroplasty represents a valid technique. Careful selection of patients and an accurate surgical technique are fundamental to reduce mortality and morbidity.

[Non-parasitic splenic cysts]. / Le cisti non parassitarie della milza.

Nonparasitic cysts of the spleen are uncommon and often result from blunt abdominal trauma. Nonsurgical management of blunt splenic injuries increases the number of observations of the post-traumatic cysts. Complications (infection, rupture and hemorrhage) are lifethreatening, difficult to diagnose and require urgent surgical management. Until recently, splenectomy has been the primary choice of treatment of these cysts. Small (< 4 cm) asymptomatic post-traumatic pseudocysts stand a reasonable chance of involution with time (3-36 months) and so may be initially observed. Splenic preservation by partial splenectomy, enucleation or by marsupialization is actually recommended in children when technically feasible. Splenectomy is required for voluminous, central, multifocal cysts, in the presence of complications and in the adults with low immunologic risk. The Authors report 5 cases of large cysts successfully treated by splenectomy with one 12-year-old girl treated in emergency for infection by Salmonella.

[Biliary tract surgery in patients of 70 and older: an assessment of our experience with 100 consecutive cases]. / La chirurgia delle vie biliari nei pazienti di 70 anni ed oltre: bilancio di una esperienza su 100 casi consecutivi.

A series of 100 consecutive patients aged 70 years and older having biliary tract lithiasis observed over a 19-year period (1970-1989) at the 1st Surgical Department of the University of Rome was analyzed in an effort to define morbidity and mortality. Eighty-eight patients underwent surgical treatment. Three patients died postoperatively (3.4%); 12 patients had local and 13 general complications. The highest incidence of complications occurred in patients with associated diseases and bacteriobilia. A long-lasting symptomatology involved a more frequent exploration of the common bile duct. Morbidity and mortality were not significantly related to the type of surgical procedure performed. Elective biliary tract surgery is a safe procedure even in aged patients.

[Use of fibrin glue in the treatment of entero-cutaneous fistulas]. / L'uso della colla di fibrina nel trattamento delle fistole entero-cutanee.

The Authors present methods and results of the treatment of chronic fistulas complicating abdominal surgery in 5 patients. The use of human fibrin glue is described and its therapeutical usefulness is pointed out.

[Surgical treatment of hydatid cysts of the hepatic dome ruptured into the thoracic cavity]. / Trattamento chirurgico delle cisti idatidee della cupola epatica rotte in cavo toracico.

Two cases of hydatid cyst of the hepatic dome, complicated by rupture in the thoracic cavity, are reported. The Authors stress the frequency of human hydatidosis, still high in Italy, and the severity of the above mentioned complication. Surgical treatment is also discussed.

Delayed bilateral ureteral fistula following abdominoperineal resection: a case report.

A case of delayed bilateral ischemic necrosis of the pelvic ureter in a 66-year-old woman submitted to abdominal perineal resection and hysterectomy for advanced rectal cancer, is reported. Five days after the operation urine was observed in the perineal cavity. External urine diversion was carried out by catheterizing the ureteral stumps through the perineal cavity. The reconstructive procedure was performed at a later date by bilateral ureteroileocystoplasty with a defunctionalized loop. The vascular anatomy of the ureter is discussed to highlight the essential technical details useful for prevention of ischemic injury.

Hydatid hepatothoracic fistulas. A report of 30 cases.

A retrospective study was carried out on 30 patients with hepatothoracic transdiaphragmatic fistulas, classified as hepatopleural (5 cases), hepatopulmonary (11 cases), biliopleural (1 case) and biliobronchial (13 cases). Investigations included chest X-rays, bronchography, plain abdominal films, cholecystocholangiography, liver scanning, ultrasonography and CT scanning. Twenty-nine patients were submitted to 32 operations: two were performed in 1 case and three in another. Thoracotomy was performed in 20 cases, laparotomy in 7 and thoracophrenolaparotomy in 5. Surgical procedures for the treatment of endothoracic lesions included pleurectomy, middle lobectomy, lower lobectomy and wedge resections. Liver cysts were treated by cystectomy and pericystectomy. The postoperative course was uneventful in 21 patients. Complications developed in 3 patients. Operative mortality was 10.3%.