Sigmoid intramural hematoma and hemoperitoneum: an early severe complication after stapled hemorrhoidopexy.

Stapled hemorrhoidopexy is a widely used surgical technique for treating hemorrhoids, although severe complications have been reported. The authors report a rare case of extensive ascending intramural hematoma of the sigmoid colon complicating stapled hemorrhoidopexy, with perforation and hemoperitoneum. Diagnosis was established at CT scan and treatment consisted of drainage, suturing, and diverting colostomy. This reported case is the ninth described in the literature, but, so far, it is not known what preventive measures to use in order to avoid such a rare complication. Adoption of a correct surgical technique remains the step of utmost importance in order to prevent such a severe postoperative complication.

[Laparoscopic appendicectomy: an 8-year clinical experience]. / Appendicectomia laparoscopica: esperienza clinica di 8 anni.

BACKGROUND: For more than a century, open appendectomy through a laparotomy has been the golden standard for the surgical removal of the appendix. Nowadays, many surgeons question the utility of laparoscopic surgery to perform appendectomies because it is commonly stated that the appendix can be removed through a small surgical incision carrying a minimal surgical trauma to the patient. Although open appendectomy is really safe, on the other hand it carries a considerable risk of postoperative complications, is associated with postoperative pain and affects patient s normal activity. Laparoscopic appendectomy was first described in 1983 and, in many studies, it is described to be better than open standard technique for the treatment of appendiceal diseases. The aim of the present study is the retrospective analysis of laparoscopic appendectomies performed in a 8-year period. METHODS: The authors report on 129 patients who underwent laparoscopic appendectomy. RESULTS: Conversion rate was 0.7 %, while the laparoscopic procedure was completed in 96 female and 32 male patients. The position of the appendix was behind the cecum in 37 cases, associate diseases were found in 15 cases. Mean operative time was 51 minutes; kind of laparoscopic instrumentation affected the operation time. Histologically there were 71 (55.5 %) focal appendicitis, 22 (17.1 %) suppurative appendicitis, 11 (8.6 %) gangrenous appendicitis, 18 (14.1 %) chronic appendicitis showing signs of previous suppurative episodes and 6 (4.7 %) normal appendix. There were neither in-hospital morbidity nor mortality. Follow-up showed reduced postoperative pain, short hospital stay, fast return to complete social activity. CONCLUSIONS: The authors conclude that laparoscopic technique can be considered a safe and effective procedure for the removal of the appendix as it has the advantage of allowing faster postoperative recovery; moreover the author recommend a wider and routinely use for appendectomy.

[Intestinal infarction. Retrospective clinical study]. / L'infarto intestinale. Studio clinico retrospettivo.

Acute mesenteric ischaemia is the result of inadequate blood flow to all or part of the small intestine and the right half of the colon. Irrespective of the cause of the ischaemic insult, the end results are similar, namely, a spectrum of bowel injury ranging from completely reversible alterations of bowel function to transmural haemorrhagic necrosis of the intestinal wall. Depending on the degree of ischaemia and the length of bowel involved, a wide variety of clinical presentations are observed. Mesenteric infarction is a pathology which is encountered fairly often in elderly patients where the concomitance of other diseases make its prognosis more severe, especially since the diagnosis is usually late. The pessimism expressed more than 70 years ago concerning this disease is still shared by many physicians today. The authors report on their experience with 37 cases of mesenteric infarction. The median age of the patients was 77 years (range: 66-91). The mortality rate was 67.5% (25 deaths) which is in line with the results in the literature. The median hospital stay was 17 days (range: 10-71). The authors emphasise the difficulty of diagnosing and treating this entity, also in view of the fact that, in most centres, it is impossible to perform emergency selective angiography of the superior mesenteric artery. The need for an early specific diagnosis is stressed, because the therapeutic options may vary widely in relation to the different causes of acute intestinal ischaemia.

[An intramural hematoma of the duodenum]. / L'ematoma intramurale del duodeno.

Intramural hematoma of the duodenum is a rare event which is usually associated with trauma. Because of the rarity of this problem, there has been little conformity of opinions as to diagnosis and treatment of this disease. The authors report on a case of intramural hematoma of the duodenum post-traumatically occurred in a young woman. Etiopathogenesis, diagnosis and treatment of hematoma of the duodenum are thoroughly examined in the present study. Plain abdominal radiography, oral barium study, ultrasound examination, CT and RNM are diagnostic tools in this disease. It appears that most patients with intramural hematoma of the duodenum would respond well to conservative management; surgery should be reserved for those cases that remain obstructed over seven days or have evidence of peritonitis. However surgery is mandatory in cases of uncertain diagnosis. The evacuation of hematoma is considered the most effective and safest surgical treatment.

[Adenocarcinoma of the duodenojejunal flexure. A report of 2 clinical cases and a review of the literature]. / L'adenocarcinoma della giunzione duodeno-digiunale. Presentazione di due casi clinici e revisione della letteratura.

The authors report two cases of adenocarcinoma of the duodenojejunal angle and remark the rarity of this pathology, the difficulty of making diagnosis peculiar to neoplasm of the small intestine and the difficulty of treatment peculiar to tumours of the duodenum. According to the literature the diagnosis was determined through X-ray films, after traditional endoscopy was inadequate. Surgical treatment is radical, with extensive exeresis procedures (unless the mesenteric upper vessels are infiltrated) since the prognosis of this tumours is good.

[Therapeutic strategy in symptomatic diverticular disease of the colon]. / La strategia terapeutica nella malattia diverticolare conclamata del colon.

Diverticular disease of the colon has been recorded with increasing frequency and approximately 25-30% of symptomatic patients require surgery for complications. Controversy still surrounds the best operative approach for the management of diverticular disease, particularly when it presents with complications. The three-stage operation has, for the most part, been abandoned because of its unacceptably high morbidity and mortality rates. Today it is generally believed that performing two-stage surgery is a wise decision, namely segmentary resection either without (Hartmann's procedure) or with anastomosis, protected by a covering colostomy. However, the ideal intervention is a one-stage surgical procedure (segmentary resection and primary anastomosis without a covering colostomy), but this can only be performed in selected patients. The aim of this study was to analyse the clinical course and the medical and surgical therapy retrospectively in 79 patients with symptomatic diverticular disease in order to identify the best therapeutic procedure; specifically, the severity of septic complications was evaluated using Hinchey's classification. The authors conclude that most patients with symptomatic diverticular disease require specific medical therapy. If surgical treatment is necessary (complicated diverticular disease), Hartmann's procedure is still a valid surgical option, particularly in the presence of diffuse faecal peritonitis. Colonic resection and primary anastomosis are certainly a satisfactory treatment, because of their low morbidity and mortality rates, but this surgical approach is only feasible in selected patients. Finally, it is a matter for the individual surgeon's experience to select the best surgical procedure in any particular situation, depending on age and general state, local findings and the extent of peritonitis.

Pre-operative angiography in gastric cancer surgery with extended lymphadenectomy.

BACKGROUND/AIMS: The value of pre-operative angiographic evaluation in patients undergoing gastric cancer surgery with extended lymphadenectomy was assessed in a prospective study comparing exposed and unexposed groups of patients. METHODOLOGY: During the period from July 1991 to October 1997, 76 patients (Group A--exposed) were pre-operatively submitted to a digital subtraction angiography (DSA) after informed consent. Concurrently, 94 patients (Group B--unexposed) were included as an unexposed reference group. All patients underwent total or subtotal gastrectomy with D2 lymphadenectomy according to the guidelines proposed by the Japanese Research Society for Gastric Cancer (JRSGC). RESULTS: In 34 (45%) exposed patients (Group A), DSA detected an atypical vascular anatomy. Major anatomical variations of the celiac axis, its branches and the superior mesenteric artery were discovered in 4 subjects (5%). Vascular anomalies affecting the surgical tactics of lymphadenectomy were detected in less than 8% of patients. Five post-operative deaths (6.6%) were registered between patients of the Group A, exposed to pre-operative angiography, 8 in the unexposed Group B (8.5%). Post-operative morbidity was significantly higher (P = 0.038) in the Group B (34%) in comparison to Group A (20%) but no difference in risk of individual complications was detected. CONCLUSIONS: Although useful in the presence of major vascular anomalies, it appears that pre-operative angiography did not significantly reduce intra- and post-operative complications associated with radical gastrectomy combined with extended lymphadenectomy. Arteriography is therefore not routinely recommendable but its use is mandatory in specific operations for gastric cancer.

Juvenile polyposis: case report and assessment of the neoplastic risk in 271 patients reported in the literature.

A case of juvenile polyposis is reported and 271 cases are collected from the literature. The risk for neoplasia is analyzed and the endoscopic or surgical therapy is discussed. The authors conclude that juvenile polyposis should be considered as a challenge to the surgeon with regard to familial adenomatous syndromes, and strongly recommend a close follow-up of patients with juvenile polyposis.

[Biliary lithiasis in childhood. A spectrum of diseases with different clinical significance during fetal life, childhood and adolescence]. / La litiasi biliare in età pediatrica. Uno spettro di patologie con diverso significato clinico nella vita fetale nel lattante, nell'infanzia e nell'adolescenza.

On the basis of a research on fetal cholelithiasis, a review on the various form of cholelithiasis in pediatric age has been carried out. These include, in addition to fetal cholelithiasis, lithiasis in the first year of life and lithiasis in infancy and adolescence. These various expressions of the same pathology differ for incidence, predisposing factors, clinical situation, therapy and follow-up. The research conducted on fetal cholelithiasis showed an incidence of 0.39%, higher than expected. There isn't any maternal, obstetrical or fetal predisposing factor. The diagnosis is purely instrumental and is not correlated with known clinical or humoral data. The most frequent evolution is spontaneous resolution of the biliary echogenic images in absence of clinical manifestations; the complications are rare and not well documented. Cholelithiasis in the first years of life is correlated with malformative, pharmacologic or iatrogenic predisposing factors. The clinical situations include symptomless cases with spontaneous resolution and cases with serious complications. Therapy is to be chosen in each case in accordance with clinical features. Pediatric cholelithiasis beyond the first year of life, especially in the later childhood and adolescence, can be similar to cholelithiasis of adults for epidemiology, pathogenesis, symptomatology and therapy.

[Prospective research on fetal cholelithiasis: incidence, predisposing conditions, echographic diagnosis, and clinical features]. / Una ricerca prospettica sulla colelitiasi fetale: incidenza, condizioni predisponenti, diagnosi ecografica e quadro clinico.

The Authors report a prospective study on fetal cholelithiasis, analyzing its differences with the more widely known cholelithiasis of paediatric age. The study shows that the number of cases diagnosed by ultrasonography is higher than expected (0.39%, 3 cases on 764 pregnancies). The Authors could find no correlation between fetal cholelithiasis and any maternal, obstetrical and fetal factor. They have focused attention on sonographic imaging showing clinical-instrumental correlation between echogenic material, clinical features and their evolution. The study confirms that the most common evolution results in spontaneous resolution of fetal endocholecystic pathological images. Finally, wide review of the international literature is reported on the rare, but possible clinical manifestations and their complications.

[Juvenile polyposis coli associated with hereditary spherocytosis]. / Associazione morbosa tra poliposi giovanile del colon e sferocitosi ereditaria.

The first case of colorectal juvenile polyposis associated with hereditary spherocytosis is reported. Symptoms, diagnosis and therapy of juvenile polyposis are described along with the associated syndromes reported in the literature. The scientific and clinical consequences of this association are discussed.

[Fetal biliary lithiasis: ultrasonographic diagnosis and clinical interpretation. Report of 3 cases]. / La litiasi biliare fetale: diagnosi ecografica e interpretazione clinica. Descrizione di tre casi.

Fetal cholelithiasis was first diagnosed in 1983 and since then there have been only few reports about the presence of gallstones in the fetus. Maternal conditions, fetal or obstetrical predisposing risk factors have been proposed to have a causative role, but the pathogenesis of fetal gallstones remains unknown. Clinical sequelae of fetal gallstones are poorly understood as well as the role of fetal cholelithiasis in predisposing the adult to gallstones. We report on 3 patients whose cholelithiasis was diagnosed by obstetrical ultrasonography. Repeated ultrasound scans were performed in each patient until resolution of the US images. The goal of US was to correctly identify the number, size, and US features of the material within the gallbladder. The presence of distal shadowing or comet-tail artifact was assessed. Multiple, small echogenic foci without distal shadowing were recognized in the fetal gallbladder in our patients. Echogenic material was present at the US exams after birth in two patients and disappeared in the second month of life. In the third case echogenic foci disappeared during pregnancy. In all the cases, US showed no biliary tract abnormality, and neither the mothers nor the patients had clinical or laboratory findings consistent with liver or biliary diseases. The Authors discuss a diagnostic protocol to detect and follow-up gallstones in the perinatal period by ultrasonography. In our experience, fetal cholelithiasis confirmed to be a self-limiting disease without complications and did not require any form of therapy. However, a close follow-up is indicated in these patients until spontaneous resolution is demonstrated by US.

Juvenile polyposis coli and associated anomalies. Review of the literature and report of a case associated with hereditary spherocytosis.

A case of juvenile polyposis associated with hereditary spherocytosis is presented. All the anomalies associated with juvenile polyposis coli reported in the literature are reviewed. The clinical consequences of such a report are discussed along with the different forms of therapy for treating juvenile polyposis coli. To our knowledge, this is the first report in the literature of juvenile polyposis associated with hereditary spherocytosis.

[A case of gastric hemangiopericytoma]. / Un caso di emangiopericitoma dello stomaco.

The authors report a case of gastric hemangiopericytoma. This tumor, histogenetically derived from pericytes, has been detected in any tissue or structure. According to the review of the literature, the hemangiopericytoma of the stomach occurred very uncommonly, being published only 29 cases. Diagnosis is based on histological and immunohistochemical techniques. Surgery is the main therapy but the impredictable biological behaviour require different strategies.

[Original excluding cecostomy procedure for the prevention of colorectal anastomotic dehiscence]. / Un'originale procedura di ciecostomia escludente per la prevenzione delle deiscenze anastomotiche colo-rettali.

The authors report the results of an original technique of cecostomy performed on 30 patients as an alternative to temporary colostomy. Colorectal anastomotic leakage following surgery represents the main indication to this procedure. This original technique seems to be safer, simpler and more effective than a temporary colostomy.

Arterial vasculature of the stomach and oncologic gastrectomies.

Preoperative knowledge of the gastric arterial blood-supply with special regard to anatomic anomalies is desirable for a correct surgical approach to this viscus and for the reduction of intra- and postoperative complication rates. The authors report their experience with the use of preoperative digital angiography in the evaluation of 46 consecutive patients undergoing gastric cancer surgery. Twenty of these (43.5%) presented a vascular anatomy different from the normal pattern. In 6 (13%), a double arterial anomaly was detected. Some anatomic anomalies of the celiac axis and superior mesenteric artery are described in relation to operative procedures during oncologic gastrectomies.

The role and timing of surgery in the treatment of pseudomembranous colitis. A case complicated by toxic megacolon.

The authors describe a particularly serious case of pseudomembranous colitis due to Clostridium difficile that was complicated by toxic megacolon. It was resolved by surgical intervention, and the reasons why subtotal colectomy is preferable to simple ileostomy are discussed.

[Long-term results of surgical treatment of early cancers of the stomach]. / Résultats à long terme du traitement chirurgical des cancers précoces de l'estomac.

The postoperative course of 172 patients with early gastric cancer operated between 1974 and 1987 was reviewed with a median follow-up of 7 years. The survival probability at the end of 1989 was 0.916 (excluding operative mortality and other causes of death) or 0.876 when the operative mortality was included. Univariate analysis showed a significant survival difference according to the presence or absence of submucosal invasion (p = 0.02, Log-Rank test) and lymph node invasion (p = 0.04, age greater than or less than 50 years (p = 0.03) and according to the type of resection performed (total gastrectomy with gastric and perigastric lymph node dissection or subtotal gastrectomy with incomplete lymph node dissection (p = 0.05). Eleven patients died from cancer recurrence, one is still alive with a recurrence of the gastric stump. The other deaths were due to cancers of other organs (6), cardiovascular disease (2), pneumonia (3), septicaemia (1) and a car accident. Although the prognosis of early gastric cancer is relatively favourable in European countries, patients must be carefully followed for a long period because of recurrences and the high incidence of cancers in other organs.

[The surgical treatment of hepatic echinococcosis and of its biliary complications]. / Il trattamento chirurgico dell'echinococcosi epatica e delle sue complicanze biliari.

The authors report the experience of 47 patients submitted to surgery for hepatic hydatidosis. Results from different therapeutic procedures are then compared. Finally, possible biliary complications of the hepatic echinococcosis and their surgical treatment are discussed.