Diagnosis and Treatment of Biliary Fistulas in the Laparoscopic Era.

Biliary fistulas are rare complications of gallstone. They can affect either the biliary or the gastrointestinal tract and are usually classified as primary or secondary. The primary fistulas are related to the biliary lithiasis, while the secondary ones are related to surgical complications. Laparoscopic surgery is a therapeutic option for the treatment of primary biliary fistulas. However, it could be the first responsible for the development of secondary biliary fistulas. An accurate preoperative diagnosis together with an experienced surgeon on the hepatobiliary surgery is necessary to deal with biliary fistulas. Cholecystectomy with a choledocoplasty is the most frequent treatment of primary fistulas, whereas the bile duct drainage or the endoscopic stenting is the best choice in case of minor iatrogenic bile duct injuries. Roux-en-Y hepaticojejunostomy is the extreme therapeutic option for both conditions. The sepsis, the level of the bile duct damage, and the involvement of the gastrointestinal tract increase the complexity of the operation and affect early and late results.

Incarcerated massive incisional hernia: extensive necrosis of the colon in a very obese patient. Surgical treatment and vacuum-assisted closure therapy: a case report.

We discuss a diabetic obese patient with an extensive necrosis of the ascending and transverse colon plus segmental necrosis of the small bowel incarcerated in a massive median incisional hernia below the umbilicus. After a blood test and an abdominal CT scan (without contrast dial), the patient underwent an urgent operation. We performed an extended right hemicolectomy, multiple segmental small bowel resections and a terminal ileostomy. The defect of the abdominal wall was treated with vacuum-assisted closure (VAC) therapy with good results.

[Surgical treatment of ulcerative rectocolitis: technical aspects of total restorative proctocolitis with S pouch]. / Il trattamento chirurgico della rettocolite ulcerosa: aspetti tecnici della proctocolectomia totale restaurativa con pouch a S.

Restorative proctocolectomy with an ileal-pouch-anal anastomosis seems to be the treatment of choice for ulcerative colitis. The aim of this study was to discuss a number of technical and functional aspects of the procedure that still appear to be controversial such as the shape of the pouch, the mucosectomy and the type of anastomosis. The authors report on their experience with the surgical treatment of ulcerative colitis with an "S" pouch. The technique reported, however, differs from the original method proposed by Parks and Nicholls in 1978 and the reasons for this surgical choice are discussed. A six-year experience (1993-1999) regarding 35 patients undergoing this approach is reported. No perioperative deaths were observed. The early and long-term complication rates were 8.5% and 11.4%, respectively. The average number of daily evacuations was 4. Mucosectomy affords complete resolution of the disease, while the particular shape of the pouch guarantees good functional results.

Early perioperative results and surgical recurrence after strictureplasty and miniresection for complicated Crohn's disease.

BACKGROUND/AIMS: Strictureplasty (SP) or miniresective 'bowel-sparing' techniques (MR) can prevent the risk of intestinal stomia and short bowel syndrome in patients affected by Crohn's disease (CD). The aim of this study was to analyze the perioperative morbidity and mortality in 104 of 138 consecutive patients treated for CD complications using bowel-sparing techniques. We also considered the factors that may be related to the risk of perioperative complications and the long-term outcome. METHODS: One hundred and four patients were treated with SP and/or MR and then included in a prospectively maintained database. The factors claimed to influence perioperative complications were analyzed using Fisher's exact test for categorical observations and the Mann-Whitney U test for continuous variables. A multivariate analysis, using logistic regression, and a long-term time-to-event analysis using the Kaplan-Meier function, were also performed. RESULTS: Perioperative mortality was nil. In relation to the 6 postoperative complications (5.8%), 4 patients underwent minimal bowel resection (MR), 1 a MR with SP, and 1 SP alone. Three of these patients (2.9%) needed reoperation for septic complications, and 3 (2.9%) were treated as outpatients for enterocutaneous fistulas. A correlation (p < 0.05) was found between low serum hemoglobin levels and postoperative complications at univariate and multivariate analyses. The 5-year surgical recurrence-free rate was 75% overall, 73% for patients treated with SP, 78% with MR, and 77% with MR + SP. CONCLUSIONS: Postoperative complications are not related to conservative or miniresective surgery even when active disease is present at the resection margins or the site of SP. The higher risk reported for patients with low serum hemoglobin and hematocrit levels suggests that surgeons should consider using preoperative iron and vitamin support, parenteral nutrition and erythropoietin therapy, when necessary, in those cases. Our postoperative morbidity, mortality and long-term surgical recurrence rate results support the efficacy and safety of SP and MR surgery in the treatment of complicated CD.

Transcatheter arterial chemoembolization in cytoreduction of inoperable hepatocarcinomas.

Transcatheter arterial chemoembolization (TAE) is often considered a mean of palliation for inoperable liver carcinomas. A few centers use a sequential treatment (TAE followed by surgery). However the role of TAE in bringing to surgery patients with hepatocarcinomas (HCC) considered inoperable at first diagnosis is debated. We report on the case of a 57 y.o. male diagnosed as having HCC, inoperable because of bilateral location and size. The patient was treated with repeated TAEs and the results were monitored with CT scans. After three TAEs, the main tumor mass volume was reduced 2.2 fold and the patient could undergo surgery; the postoperative period was uneventful, with no clinical signs of liver failure. Our experience leads us to suggest that TAE, further to being an option for palliation, can be a valuable tool to lead to surgery otherwise inoperable HCC patients.

[Validity, limitations and indications of intraoperative dosage of parathyroid hormone (I-PTH) in the surgical treatment of primary hyperparathyroidism]. / Validità, limiti ed indicazioni del dosaggio intraoperatorio del paratormone (I-PTH) nel trattamento chirurgico dell'iperparatiroidismo primario.

INTRODUCTION: Recently new methods have been experienced to achieve the best surgical results in complete removal of pathological parathyroid tissue; serum I-PTH (1-84) rapid dosage is the most interesting and reliable method. MATERIAL AND METHODS: In a group of 11 patients with IPP, diagnosed by high levels of I-PTH, total and ionized serum calcium, 7 were paucisymptomatic, 3 presented nephrolityasis, 1 acute pancreatitis and severe hypercalcemic crisis. No MEN were found. A systemic research of all parathyroid glands was always performed, then 10, 20, 30 and any 30 minutes after each parathyroidectomy serum I-PTH rapid dosage was made (rapid IRMA method) until the end of surgical treatment. RESULTS: Eight single adenomas parathyroid were diagnosed, 1 double adenoma and 2 hyperplasia. All patients had high levels of serum I-PTH during pathologic parathyroid removal. The decrement of I-PTH level to 40% 10 min after parathyroidectomy, and 50% after 20 minutes confirmed the efficacy of surgery. DISCUSSION: Intraoperative rapid dosage of I-PTH associated with anatomopathologic results leads to a successful diagnosis and therapy. Sometimes in multiglandular disease serum level of PTH decreases after first parathyroidectomy as in a single adenoma: this underlines the importance of systematic surgical research of all glands in any case. CONCLUSION: In our experience serum I-PTH rapid dosage in IPP would be applied by specialized surgical equipments only in selected patients, such as reoperation or those few cases of first surgical treatment when ectopy is suspected.

Carcinoma of the head of the pancreas: review of 67 cases and comparison with 27 additional periampullary carcinomas.

BACKGROUND/AIMS: Carcinoma of the head of the pancreas is reported with increasing incidence. The classical Whipple procedure, modified by Traverso and Longmire, is a major surgical undertaking and there is question on its indication in the case of lesions which, although technically resectable, are not susceptible to cure. PATIENTS AND METHODS: We review 67 cases of carcinoma of the head of the pancreas comparing the results of radical vs. palliative surgery. The results were then compared with 27 additional cases of periampullary carcinomas. RESULTS: Long term survival was obviously higher after resection, due to the more advanced tumor stage in the palliation group. However, perioperative mortality, supposedly high in extensive resective surgery, was 8.7% (vs 11.9% in the palliation group). CONCLUSIONS: At present, extensive resective surgery carries unacceptable incidence of perioperative mortality. Therefore we suggest that indication for resection should be widened, as it may offer better chances of cure in resectable periampullary carcinomas and, even in non curable cases, it offers better quality of life and the advantages of tumor debulking.

Third segment cholangio-jejunostomy in the treatment of unresectable klatskin tumors.

BACKGROUND/AIMS: Cholangiocarcinoma of the hepatic hilum is a seldom curable lesion when detected and several methods of palliation have been suggested. Bismuth has proposed an intrahepatic cholangiojejunostomy on the third segment of the liver, which in his experience obtains effective biliary drainage with better quality of life compared with other forms of palliation. PATIENTS AND MATERIALS: We have used this technique in nine cases. We evaluate results, mortality and morbidity, in comparison with other authors' reported series. RESULTS: In the early postoperative period one patient died, two patients suffered from immediate postoperative complications, and jaundice resolved completely in six patients. Long term survival was influenced by the underlying disease. CONCLUSION: Our findings support Bismuth preference for this technique of surgical palliation for non resectable tumors of the biliary tract.

Improvement of colo-rectal cancer surgery following introduction of endoscopical approach.

In the period 1968-1993, we treated 399 patients for colo-rectal cancer. Up to 1980, preceding large scale use of endoscopy, 217 patients, out of the group of 399, were submitted to surgery; at time of diagnosis all patients had symptoms of advanced colonic tumor (intestinal obstruction; palpable mass; significant rectal bleeding); none of the lesions detected was in Dukes A or B1 groups; 56 patients were in Dukes B2 and stages C1 + C2 + D were detected in 161 cases. In period 1981-1993 we treated 182 patients; in all cases the diagnosis consisted of endoscopical examinations. Out of this group 69 patients underwent endoscopic resection of polyps with focal neoplastic degeneration: 44 did not require surgery according to Haggitt criteria. In the group of 138 patients who underwent surgery, 89 were in Dukes A + B1 + B2 groups and 49 were in Dukes C1 + C2 + D groups. In our experience endoscopy is not essential in the clear cut colonic neoplasms, however it is an invaluable screening test in early stages, in poor symptomatic population, in elderly patients (> 50 y.o.) and in patients with non specific symptoms. We wish to emphasize how endoscopy has improved the results of colonic cancer surgery.

[Echographic evaluation of goiter recurrence]. / Valutazione ecografica della recidiva di gozzo.

Ultrasound is mandatory in the follow up of patients surgically treated for benign thyroid diseases. In this study the Authors have examined 87 patients who underwent different surgical treatments for goiter over 40 years. Ultrasound allowed a more accurate study of residual thyroid, particularly evaluating thyroid tissue morphology in symptomatic patients (43.6%) and detecting many recurrences in asymptomatic patients (37.3%). This study also confirms the advantage of a more extensive surgery to reduce recurrences without increasing complications.

[Total versus partial pancreatectomy in the surgical treatment of carcinoma of the pancreatic head]. / Pancreasectomia totale vs pancrasectomia parziale nel trattamento chirurgico del carcinoma della testa del pancreas.

This is a review of the recent advances in total pancreatectomy versus regional pancreatectomy for adenocarcinoma of the head of the pancreas. The rationale for total pancreatectomy comes from a tendency for pancreatic cancer to be multicentric, the absence of the pancreatico-enterostomy and the argument that total pancreatectomy is a better cancer procedure (wider lymphadenectomy and soft tissue resection). In spite of these theoretical advantages, any important impact on morbidity, mortality and ultimately on survival has not been realised. We analyse the principal metabolic and functional sequelae of total pancreatectomy, particularly highlighting the importance of glucagone hormone in maintaining correct blood glucose levels. The data suggest, a tendency to use total pancreatectomy in selected patients on the basis of pre- and intraoperative cytodiagnosis to prevent occult neoplasms in the pancreatic remnant.