[Minimally invasive fasciotomy in the treatment of chronic exertional anterior compartment syndrome of the leg: personal technique]. / La fasciotomia nella sindrome del compartimento anteriore di gamba con singola incisione cutanea minima: tecnica personale.

Numerous fasciotomy techniques have been proposed for the treatment of chronic exertional anterior compartment syndrome. In this work we evaluate the efficacy of a personal surgical technique whereby the fasciotomy is performed through a small cutaneous incision using endo mini-shears. From 2004 to 2006 19 patients, all professional skaters, were submitted to bilateral fasciotomy (38 legs). No complications were observed. Only two patients used pain-killers. In the follow-up (12 months), resumption of competitive activity was achieved by the fourth week in 63.2% of cases (12 patients), by the fifth week in 26.3% (5 patients), and by the sixth week in 10.5% (2 patients). All patients achieved sporting performance comparable to that present before the onset of symptoms. There were no recurrences. This technique is relatively simple to perform, is easily repeatable, does not require a long learning curve, is practically complication-free, and is characterised by a virtually painless postoperative course.

[Protruding isolated rectal and anal neoplastic polyps removed by local transanal excision: our experience with 16 cases]. / Polipi adenomatosi rettoanali protrudenti isolati asportati per via transanale. Nostra esperienza.

Local transanal excision as primary treatment of rectal and anal canal adenomas in selected patients is supported by the recent literature. Sixteen patients with low rectal or anal canal neoplastic polyps underwent transanal resection. Postoperatively, 5 patients (31.25%) had complications, consisting in 2 cases of bleeding (12.5%) and 3 of urine retention (18.75%). Histologically, 2 were tubular adenomas without atypia (12.5%), 3 were tubulo-villous adenomas with moderate atypia (18.75%), 8 were tubulo-villous adenomas (50%) with severe atypia, 2 were tubulo-villous adenomas with locally invasive foci of adenocarcinoma (12.5%), and 1 case was a pT1 cloacogenic carcinoma (6.25%). The mean follow-up was 21.7 months (range: 12-36 months). One patient had a double recurrence at 8 months and after a further 6 months. After the third surgical operation the patient had no further recurrence. The outcomes were similar to those reported in the recent literature, showing that the procedure, when correctly performed, is simple and effective, with a good risk/benefit ratio.

[Recurrent varicose veins due to neovascularisation: can they be prevented?]. / Varici recidive da "neocrosse"; è possibile prevenirle?

The authors analyse the problems of recurrent varicose veins on the basis of their own experience. The 5-year incidence of recurrent varicose veins ranges from 25 to 40% after internal saphenectomy. The recurrences should be classified in relation to the site and pathogenetic mechanism. The authors assess the effectiveness of a prevention method for sapheno-femoral stump recurrences. The study population consisted of 80 patients undergoing internal saphenectomy. In 34 (Group A) a traditional safenectomy was performed with short stripping, while in 46 (Group B) closure of the ostium with a flap of pectineal fascia was performed in order to prevent recurrences caused by neovascularisation. In Group A the recurrence rate was 27.1% as against 14.8% in Group B. Recurrences originating from the sapheno-femoral stump are mainly caused not only by an inadequate echo-colordoppler preoperative diagnosis and an inadequate or insufficient crossectomy, but also by neovascularisation. The pectineal flap method in our experience is a very simple, effective and complication-free technique to appreciably reduce recurrent varicose veins originating from the sapheno-femoral stump.

Superficial parotidectomy as first choice for parotid tumours.

Parotid neoplasms represent 3% of all head and neck tumours, and most are benign. Malignant tumours account for 14-25% of cases. Surgery is the treatment of choice, with options ranging from simple enucleation to radical parotidectomy. Sixteen patients presented with a history of a painless parotid lump. Diagnosis was achieved by ultrasound scan and MRI. Fifteen superficial parotidectomies and 1 nerve-sparing total parotidectomy were carried out. At histology, 10 pleomorphic adenomas, 4 Warthin's tumours, 1 lymphoepithelial cyst and 1 sebaceous adenocarcinoma were detected. In the single case of carcinoma, the 6 peri-glandular lymph nodes included in the specimen were metastasis-free. In 3 patients (20%) a transient paresis of the facial nerve was noted. The capsule appeared breached in only 1 case of pleomorphic adenoma. Four patients (26%) were diagnosed as suffering from Frey's syndrome. A salivary fistula was recorded in 2 patients (13%). During follow-up ranging from 3 to 96 months no tumour recurrence was recorded. Superficial parotidectomy seems to be the best choice of treatment for benign parotid tumours, since it allows complete excision of the tumour with sparing of the facial nerve. A radical procedure is, however, needed if malignancy is confirmed at frozen section.

[Ultrasound tissue modifications after polypropylene prosthesis apposition in inguinal hernia]. / Studio ecografico della risposta tissutale dopo ernioplastica inguinale con protesi in polipropilene.

Few studies have addressed the use of ultrasonography in the evaluation of abdominal hernia. In the present study ultrasonography was used to assess tissue modifications after apposition of a polypropylene prosthesis for inguinal hernia. Seventy-two patients submitted to calibrated inguinal hernioplasty (mesh and plugs) in local anaesthesia for inguinal hernia were studied by ultrasonography at 5 days, 1 and 3 months, and 1 year after the surgical intervention. The mesh presented as a small hyperechoic layer. In 50 patients (69.4%) a seroma was present above the mesh. The seroma was < 5 cc in 33 patients, between 5 and 10 cc in 6 patients, and > 10 cc in 11 patients. During the ultrasound examinations no recurrences were found and the mesh was not displaced. The seroma disappeared spontaneously between postoperative days 30 and 90 and was probably related to the size of the hernia and the number of plugs.

[Chest wall fibromatosis after mammary prosthesis implantation. A case report and review of the literature]. / Fibromatosi del torace dopo impianto di protesi mammaria. Caso clinico e revisione della letteratura.

Desmoid tumour of the breast is a rare lesion. Only 9 cases in which the origin of the tumour was linked to a breast implant had been published up to 2004. We report a case of aggressive fibromatosis which developed on the thoracic wall two years after implantation of a mammary prosthesis. This tumour was locally aggressive. Radical surgery is the treatment of choice and in this case required a wide surgical resection, including removal of the chest wall, to gain control. The application of adjuvant radiation therapy is controversial.

[Role of echo-colour Doppler in the diagnostic work-up and surgical timing of chronic venous insufficiency]. / Ruolo dell'ecocolordoppler nel timing diagnostico-chirurgico dell'insufficienza venosa cronica.

Chronic venous insufficiency affects about 10-12% to 35-50% of the population in industrialised countries. We analyse the role of echo-colour Doppler in the diagnostic-therapeutic work-up for this pathology in the light of their own experience. We report the results of the study of 158 legs in 79 patients, classifying the severity of chronic venous insufficiency using the Widmer classification, and private circulations using the Franceschi shunt classification. The mean duration of the examination was about 30 minutes (range: 22-46). A reflux time > 0.5 sec. was considered pathological. The patients with chronic venous insufficiency were divided into three groups on the basis of type of treatment: medical treatment and elastic compression (group 1,12 patients), sclerotherapy and elastic compression (group II, 20 patients), surgical treatment and sclerotherapy (group III, 36 patients). The echo-colour Doppler results were confirmed in the operating theatre in 34 patients. Echo-colour Doppler enabled us to identify patients who needed less invasive treatment than stripping; in group III, echo-colour Doppler allowed precise mapping and identification of communicant veins and collaterals, with 95% accuracy.

[Late cutaneous fistula after inguinal hernia repair. A case report]. / Insorgenza tardiva di fistola cutanea dopo ernioplastica inguinale protesica. Caso clinico.

A late inflammatory reaction and the formation of fistula after prostetic implant for primitive hernia of the abdominal wall are recent clinical events. The Authors describe a case of inguinal cutaneous fistula verified after 6 years from the execution of an prostetic hernioplasty with polypropylene. The possible etiology and the therapeutic options are discussed.

[Antibiotic prophylaxis in laparotomic and laparoscopic cholecystectomy]. / La profilassi antibiotica nella colecistectomia laparoscopica e laparotomica.

Antibiotic prophylaxis in biliary surgery, when correctly used, has led to the minimisation of postoperative infections. Conventional cholecystectomy, and particularly laparoscopic cholecystectomy give rise to a very complicated issue concerning the use of antimicrobial prophylaxis, especially in relation to low-risk patients. The authors describe their experience with the use of short-term prophylaxis in biliary surgery based on a hundred consecutive laparoscopic cholecystectomies. In addition, the literature on this topic strengthens the authors' conviction that antimicrobial prophylaxis may be indicated in all surgical cholecystectomy procedures, also in view of the difficult management of postoperative infection risk factors.

[Biologic tolerance of prolene prosthesis in inguinal hernia repair]. / Tolleranza biologica della protesi in prolene nella riparazione dell'ernia inguinale.

The aim of this study was to evaluate the efficacy, safety and durability of a calibrated inguinal hernioplasty polypropylene prosthesis, particularly in relation to the microbiological phenomena that may set in the vicinity of the polypropylene plugs and mesh employed. Over the period from January 1994 to December 2002, 1416 operations were carried out for inguinal hernia. In 5 of these patients we conducted an immunological study to assess serum cytokine concentrations. In addition, we incubated peripheral blood mononuclear cells for 24 or 72 hours in RPMI 1640 medium added with 10% FCS, with or without 0.5 cm2 of polypropylene. We then evaluated cytokine levels in the supernatant of these cultures. It proved impossible, either in vivo or in vitro, to detect appreciable levels of IL-10 or IP-10. Serum levels of IFN-gamma, TNF-alpha, IL-18 and IL-6 increased in the postoperative phases as compared to the preoperative period. In the study performed in vitro, in the presence of prosthetic material there was a remarkable increase in the production of TNF-alpha and INF-gamma both in basal conditions and after an appropriate mitogenic stimulus. The results of this study allow us to speculate that the use of polypropylene induces remarkable chemotactic activity in the tissues adjacent to the prosthesis. The in-vitro study data suggest that the presence of polypropylene may stimulate the immunocompetent cells of patients with prosthetic implants.

[Inguinal hernia recurrence after prosthetic repair: our experience]. / Le ernie inguinali recidive post-protesiche: nostra esperienza.

Inguinal hernia recurrence after prosthetic repair is a very rare clinical condition (1%), but it is probably underestimated and hard to resolve surgically. The authors reports their experience with 16 recurrent post-prosthetic inguinal hernias. A greater incidence of recurrence was noted in obese patients with concomitant chronic diseases (56%). Hernia recurrences following prosthetic repair are often asymptomatic. The use of Lichtenstein's plug technique yielded satisfactory results in terms of rehabilitation and incidence of recurrence and is also associated with a very low risk of complications.

[Organization of a day surgery unit for hernia]. / L'organizzazione di un servizio di chirurgia erniaria in day surgery.

The authors report their experience with the organisational aspects of minimal hospitalisation of patients undergoing surgical treatment for hernias of the abdominal wall. 1544 hernia repairs were carried out from January 1994 to March 2002; over 80% of these were performed on a day surgery basis. The organisation of a day surgery unit requires dedicated medical and nursing staff and also diagnostic imaging facilities that should be immediately available, though all this is not strictly necessary in a general surgery department. In conclusion, in addition to the organisational problems, inadequacy of the D.R.G. system in Italy is the primary obstacle to diffusion of the practice of ambulatory hernia repair.

[Laparoscopic treatment of benign ovarian cysts]. / Trattamento laparoscopico della patologia ovarica cistica benigna.

Laparoscopic surgery is the most frequent indication for the management of benign ovarian cysts in the obstetric and gynaecological field. On the basis of their experience the authors address the clinical classification of benign ovarian pathology and the surgical laparoscopic procedures utilised in the treatment of adnexal cysts. Forty-two patients underwent laparoscopic surgery after a preoperative clinical and biological evaluation and imaging in order to exclude the presence of ovarian malignancies. All surgical procedures were carried out laparoscopically, with a conversion index of 0%. The morbidity was 2.3% (one case of haematoma of the umbilical trocar site) and there was no mortality. No late complications were observed. In conclusion, laparoscopic surgery in the management of ovarian cysts is technically feasible. On the basis of these findings laparoscopic surgery is the treatment of choice for adnexal cystic tumours after careful exclusion of malignancy.

Poorly differentiated jejunal adenocarcinoma in a patient with coeliac disease: a case report.

It is well known that coeliac disease increases the risk of gastrointestinal lymphomas, whereas adenocarcinoma is a rare complication. The authors report a case of a poorly differentiated jejunal adenocarcinoma complicating coeliac disease in a 40-year-old female and discuss the clinical, diagnostic and therapeutic aspects.

[Role of nutritional support in the treatment of enteric fistulas]. / Ruolo del trattamento nutrizionale nelle fistole enteriche.

Enteric fistulas are nowadays considered an important therapeutic challenge. Artificial, total parenteral and enteral nutrition have allowed an improvement in the healing of these fistulas and a lower incidence of mortality. Fourteen patients with enteric fistulas (10 men, 4 women; mean age: 64.4 years; range: 20-80 years) were observed. The fistula was located in the large bowel in 11 patients, in the ileum in 2, and in the jejunum in 1. Thirteen patients received enteral nutrition. The patient with the jejunal fistula received total parenteral nutrition for 30 days and then enteral nutrition. The fistulas were successfully treated in 11 patients. One patients underwent surgery after 6 weeks of treatment with enteral nutrition because of lack of improvement of the symptomatology. In two patients, with advanced cancer of the colon and stomach, respectively, only a reduction of the fistula output was achieved. Nutritional support in the treatment of enteric fistulas is an effective procedure widely utilised to restore adequate nutritional status and bowel rest, which are two important targets for achieving fistula closure. Nutritional support is also useful in the management of patients undergoing surgery in order to reduce the postoperative complication rate.

[Extraperitoneal prosthesis repair in the surgical treatment of inguinal hernias]. / La protesizzazione extraperitoneale nel trattamento chirurgico dei laparoceli.

The authors analyse the current state of the art of the prosthetic repair of incisional hernia and the problems involved in positioning the prosthesis, comparing their own experience with the most recent literature. From January 1994 to June 2001, 50 patients were operated on for incisional hernia (28 males and 22 females); 12% had recurrent or re-recurrent incisional hernias. Defects smaller than 3 cm were repaired with a polypropylene plug; a double-layer polypropylene mesh placed in a preperitoneal position was used for defects measuring from 3 to 5 cm; in defects greater than 5 cm a double-layer mesh was placed behind the muscle layer. Fifteen patients were operated on under local anaesthesia. Only 22% required postoperative analgesia. The mean hospital stay was 3.95 days. Only 3 recurrences (6%) were recorded. On the basis of our experience it seems appropriate to repair incisional hernias when of small size, preferably under local anaesthesia, avoiding opening the hernia sac, using an extraperitoneal approach with an overlap technique that employs polypropylene.

[Robotic techniques in laparoscopic surgery]. / La robotica in chirurgia laparoscopica.

Robotic technology is being increasingly used in surgery. The authors assess the usefulness, effectiveness and safety of the AESOP 2000 robotic device (Automated Endoscopic System for Optimal Positioning) in videolaparoscopic surgery. Two laparoscopic cholecystectomies were performed with the aid of the AESOP 2000 robot. A short increase in operative time was observed and there were no complications. Voice understanding was accurate and flawless and no inadvertent smearing of the lens occurred. The use of the AESOP 2000 robotic device is safe, improves the quality of vision and reduces the number of surgeons needed in the team. Nevertheless, a learning curve and simultaneous training in the use of the device are required.

[Laparoscopic treatment in a case of torsion of ovarian benign mature teratoma. Clinical case and review of the literature]. / Trattamento laparoscopico in un caso di torsione di teratoma maturo benigno dell'ovaio. Caso clinico e revisione della letteratura.

Benign mature teratomas account for approximately 10-17% of all ovarian neoplasms and are the type of ovarian neoplasm most likely to occur during a woman's reproductive life. Bilateral localization is observed in some 10-15% of cases and the estimated incidence of malignant degeneration is 0.5-1.8%. The authors report a case of a 35-year-old woman admitted with discontinuous abdominal and pelvic pain. Imaging procedures showed an adnexal mass with the appearance of a dermoid cyst. The patient underwent laparoscopic ovarian cystectomy with preservation of the adnexal gland. After a review of the international literature and a description of the clinical features of the disease the authors go on to stress the advantages of laparoscopic management of benign ovarian teratomas.

Locally advanced breast cancer in the elderly: a major challenge requiring effective and appropriate treatment.

AIMS AND BACKGROUND: Breast cancer is the most common tumor in women. As the population above 65 years increases, breast cancer will be a more substantial problem for elderly patients. This work reports our experience in the management of stage III and IV locally advanced breast cancer. METHODS: Nineteen patients over 65 years of age (mean, 70.3 years) with stage III and IV breast cancers, treated between 1990 and 2000, are considered. The management and outcome are evaluated. RESULTS: Nine patients had stage IIIA breast cancer, 7 stage IIIB and 3 stage IV. Sixteen underwent Madden mastectomy and 3 simple mastectomy. Patients at stage IIIB and 1 patient at stage IV with T4 tumor received neo-adjuvant chemotherapy. There were no significant postoperative complications. Sixteen patients were given tamoxifen and 10 patients adjuvant chemotherapy. Patients were followed for a median of 36.7 months (range, 6-72 months). In 8 patients with stage IlIl disease, metastasis developed. Two patients had local recurrence of disease. Of the patients at stage IIIA, 6 were free from disease (one died from unrelated causes) and 3 had recurrent disease (2 died). Of the patients at stage IIIB, 2 are disease free and 5 had recurrent disease and died. Of the patients at stage IV, only one is alive. CONCLUSIONS: Stage and individual characteristics of elderly women influence management. Patients should be managed adequately since most of them are fit enough to undergo treatment.