[Traumatic lesions of the pancreas: diagnosis and treatment]. / Le lesioni traumatiche del pancreas: diagnosi e trattamento.

The diagnosis and treatment of traumatic lesions of the pancreas are difficult. The deep anatomical location of the organ, the lack of truly accurate non-invasive diagnostic investigations and the frequent initial scarcity or absence of specific symptoms, often mean that a clinical assumption based on the dynamics of the trauma is fundamental for a rapid, correct diagnosis. The state of the main pancreatic duct is the most important element in establishing the prognosis and guiding the treatment, and should therefore be accurately defined before or during surgery. If the Wirsung duct is intact, even when radiological, clinical and laboratory signs indicate a pancreatic lesion, conservative treatment can be attempted. On the contrary, if there is evidence of a lesion of the duct, surgery is mandatory, bearing in mind that pancreatic resections involving removal of the portion of the gland distal to the lesion have a lower incidence of complications than do reconstructive and/or anastomotic procedures and are therefore to be preferred. Nevertheless, in selected cases, especially in young patients, Roux-en-Y pancreaticojejunostomy can avoid the risk of functional insufficiency, sparing large tracts of otherwise sacrificed glandular tissue. Only the more serious complex lesions of the head of the pancreas also affecting the duodenum require pancreaticoduodenectomy.

Gastrointestinal sutureless anastomosis using fibrin glue: reinforcement of the sliding absorbable intraluminal nontoxic stent and development of a stent placement device.

Sutureless anastomosis of the gastrointestinal tract using fibrin glue and sliding absorbable intraluminal nontoxic stents (SAINTs) has two shortcomings, stent shaft breakage and the lack of a transanal insertion device (TID) for low anterior resection. Reinforcement of the sucrose base SAINT (R-SAINT) is described. Sutureless anastomosis is attempted using a stapleless mechanical stapler (SS) and used as preprototype to screen histologically and mechanically for TID anastomoses in the small intestine. Finally, a prototype absorbable head SAINT placement device (SAINT-PD) intended for TID, similar to the SS, is utilized on the small intestine. Fifty-seven Landrace pigs weighing 25-35 kg were used to perform 58 anastomoses, including the small intestine (15 manual, 19 SAINT, 11 SS, 5 R-SAINT, 6 SAINT-PD) and large intestine (2 R-SAINT). All anastomoses performed with the R-SAINT succeeded on the first attempt even if the shaft cracked. The SS technique proved impractical, but the histological screen results from 7 to 60 days did approximate those of corresponding SAINT anastomoses. The SAINT-PD demonstrated operational improvement over the SS, but the histological results were similar to both the SS and SAINT. The advantages of the R-SAINT and SAINT-PD are that they leave no foreign bodies or pressure clamping devices at the anastomostic site. Larger studies may show the R-SAINT and the SAINT-PD to be practical, new surgical tools in sutureless fibrin glue anastomosis.

[Venereal perihepatitis: Fitz-Hugh-Curtis syndrome]. / La periepatite venerea: sindrome di Fitz-Hugh-Curtis.

A case of Fitz-Hugh-Curtis syndrome (venereal perihepatitis) is reported. This syndrome is observed almost exclusively in women as a complication of genital gonococcal or chlamydial infections. A sudden, acute biliary-type pain generally characterizes the disease; only a few cases present symptoms related to associated genital infection. The real clinical incidence of venereal perihepatitis is quite high; in fact, a lot of the emergency admitted patients diagnosed with biliary colic or acute cholecystitis as a matter of fact suffer from this syndrome. If haematological investigations, ultrasonography and cholangiography do not confirm a suspected biliary lithiasis, it will be needed to investigate the genital tract. After clinical and ultrasound examinations, neisseria gonorrhoeae and chlamydia trachomatis must be sought in vaginal and cervical secretions and serum antichlamydial antibodies level is to be sought too. Through these examinations, the venereal perihepatitis can usually be diagnosed. In uncertain cases laparoscopy can be useful: in fact, it can reveal the typical violin-string-like adhesions between the anterior liver capsule and the anterior abdominal wall, and, in the same session, it allow to resect them. Tetracycline, doxycycline and, more recently, ofloxacine gave good results in the syndrome's treatment.

Sutureless anastomosis of the small intestine and the colon in pigs using an absorbable intraluminal stent and fibrin glue.

A new sutureless anastomosis technique employing a sliding absorbable intraluminal nontoxic stent (SAINT) and fibrin glue with limited (minutes) stump margin pressure is described. Fifty-one (27 small intestine, 24 colon) SAINT anastomoses were performed in 31 Landrace pigs (25-35 kg). Controls consisted of 48 (26 small intestine, 22 colon) continuous single-layer submucosal anastomoses in 26 pigs. SAINTs, which dissolve in about 30-60 min, were formed from heated sucrose and water poured into handcrafted aluminum molds. Follow-up from 7 to 540 days showed no stenosis or anastomotic imperfections in the latter part of the experiment after the SAINT production and surgical techniques were improved. The SAINT group had fewer site adhesions, faster healing, less foreign body reaction, and fewer lymphocytes than the control group. Initial results indicate that the SAINT-fibrin glue procedure may be an effective sutureless anastomotic method from the duodenum to the sigmoid colon.

Value of ERCP in the diagnosis and management of pre- and postoperative biliary complications in hydatid disease of the liver.

Twenty-nine patients with symptomatic hydatid disease of the liver were evaluated preoperatively by endoscopic retrograde cholangiopancreatography (ERCP) in the years 1982-1987. In the same period, 6 patients who previously underwent surgery for the parasitic disease also underwent ERCP because of postoperative symptoms of biliary obstruction. Findings at ERCP excluded biliary tract involvement in 11 cases. Positive findings were shown in 24 patients, including compression of the bile ducts in 4, small cysto-biliary communications in 5, intrabiliary rupture in 9, residual hydatid material in the common bile duct, and sclerosing cholangitis in 3. Endoscopic removal of migrated hydatid debris was achieved in 8 patients, avoiding reoperation in 4.

Double stapling technique for low colorectal anastomoses after anterior resection for rectal cancer.

A group of 26 patients submitted to anterior colorectal resections for carcinoma is reported: all of the anastomoses were performed using the so-called "Double Stapling Technique" (DST), first introduced by Knight and Griffen in 1980. The technical results are discussed, in the light of recent reports. "DST" offers clear advantages, over both traditional hand-stitched and end-to-end stapled anastomosis. This procedure is considered cost-effective and time-saving and offers lower intra-operative risks. It permits optimal sterility of the operative field and lower risk of neoplastic spreading. Furthermore it eliminates some technical problems such as the preparation of the distal purse-string suture and the inequality between the two intestinal stumps to be anastomosed.

[Leiomyosarcoma of the inferior vena cava]. / Léiomyosarcome de la veine cave inférieure.

Leiomyosarcoma is a rare tumor of soft tissues. The inferior vena cava is affected infrequently, a literature review showing only 66 cases reported previously, 29 of these patients undergoing radical surgery. The case described was diagnosed during operation for gallstones, and the lesion was excised radically using an original technique. Experience of this case and opinions of various authors who have treated similar cases suggest that the factors determining choice of therapy are: the caval segment involved, an effective collateral circulation, longitudinal or circumferential extension of the affected vascular wall, the presence or absence of neoplastic or hepatic thromboses.