[Dysplastic cysts of the liver: our experience]. / Le cisti displastiche del fegato. Nostra esperienza.

AIM: Systematic surveys with advanced non-invasive imaging techniques have revealed that hepatic cysts are quite common in the general population. Therefore, we retrospectively examined our case series and compared it with the literature. METHODS: Between January 1990 and December 2000, 228 patients with non-parasitic liver cysts were referred to the outpatients section of the Department of Surgery of the University of Cagliari and 23 were submitted to treatment: 14 patients (60.8%) for solitary cyst and 9 (39.2%) for multiple simple cysts of the liver. One patient (4.5%) had right upper quadrant pain. Eleven (47.8%) patients were asymptomatic: 7 (63.7%) required treatment for other pathologies, 3 (27.3%) for a progressive enlargement of the cyst and 1 (9%) for a suspected hydatid disease. Mean diameter of the treated cysts measured by preoperative CT or US was 8.8 cm (range 7-14). Percutaneous aspiration-injection reaspiration (PAIR) was performed in 5 patients (21.7%), US-guided in 2 cases (40%) and CT-guided in 3 (60%). Twenty patients (86.9%) underwent cysts unroofing, 18 (78.2%) with open surgical fenestration and the latest 2 cases with a laparoscopic approach. Two patients had PAIR as second treatment for recurrence: CT-guided in one and US-guided in the other case. RESULTS: Four (25%) out of 16 patients treated exclusively for cystic liver disease, had fever in 3 cases and nausea and vomiting in 1 case; 8 patients (50%) had an intraperitoneal drainage for a mean of 6-7 days (range 4-11) and of 116 cc of serum-hematic liquid. CONCLUSIONS: In our opinion the choice of an adequate treatment must be based on an accurate evaluation of the clinical aspects of the patients and on the characteristics of cystic lesions such as number, size and location. These data let us to choose a surgical treatment rather than a strict US follow-up and to get the best outcome in terms of absence of recurrence, and less biological and economic costs.

[Tumoral calcinosis in a Sardinian patient mimicking hydatid disease: a case report]. / Calcinosi tumorale in una paziente Sarda: caso clinico-patologico simulante la malattia idatidea.

The aim of this study is to report on a case of tumoral calcinosis (TC) mimicking hydatid cyst, which was diagnosed in a 51-year-old Caucasian woman of Sardinian origin. This lady presented with two symmetrical enlarging masses of soft tissue in the hips. The CT findings were suggestive of hydatid cysts. Grossly the two lesions appeared as unencapsulated firm, rubbery masses extending into the surrounding muscles. On cut surface the two specimens were multiloculated and contained either calcareous material or milky fluid. At histology the main findings were represented by multiple foci of amorphous calcified material bordered by proliferating macrophages, fibroblasts and multinucleated giant cells, separated by fibrous septa. The following characteristics are worth of note: the presentation in adulthood (late onset); the Caucasian race of the patient; the radiological appearances indicative of hydatid cyst; the aggressive clinicopathologic course, with multifocal involvement, rapid growth, infiltrative pattern. Histologically the TC exhibited the typical pattern of stage II according to Slavin's classification of disease.

[Biliary complications of laparoscopic cholecystectomy: our experience compared with laparotomic cholecystectomy]. / Complicanze biliari della colecistectomia laparoscopica: nostra esperienza a confronto con la colecistectomia laparotomica.

Major bile ducts injuries during cholecystectomy were one of the most common complications, but they were becoming rare. With the introduction and the fast diffusion of laparoscopy their incidence has increased. For this reason we have reviewed our experience about open and laparoscopic cholecystectomy. We report 18 patients, 8 male and 10 female with age ranged from 27 to 73 years, with common bile duct injuries. Only three patients (20%) underwent surgery in our Department of Surgery of the University of Cagliari. Of these patients, two were operated on open and one laparoscopic cholecystectomy. They represent 0.08% and 0.36% of the respective groups. The most common cause of this complication is peritonitis (94.5%), followed by bleeding and congenital anomalies of the biliary tree, that were present in 5.5% respectively. The conversion to laparotomy was necessary in 3.9% of our patients, while residual choledocholithiasis in one patient was treated by laparotomic reexploration because of the unsuccessful ERCP. In summary in our opinion the prevention of this complication depends on appropriate indication and choice of the patients, as well as an adequate training. The ERCP, if indicated, must be done before laparoscopic cholecystectomy.

[Human fibrin glue in the treatment of residual parenchymal surface after total pericystectomy for hepatic echinococcus]. / La colla di fibrina umana nel trattamento della superficie parenchimale residua a pericistectomia totale per echinococco epatico.

The aim of this study was to evaluate the presumed efficacy of fibrin sealant in limiting bleeding and biliary leakage from liver residual surface after total pericystectomy for hydatid disease. Forty-five patients (group A) who underwent total pericystectomy in our Institution from 1986 to 1995 and liver residual surface treated with conventional techniques and fibrin sealant for control of haemorrhage and bile leakage were selected. A control group (B) was carefully selected, matching the main characteristics of patients in group A: it consisted of 44 patients, who underwent total pericystectomy from 1981 to 1993 and in which fibrin sealant was not used. Postoperative hospital stay, morbidity, mortality, abdominal drainage discharge, perioperative variations of hemoglobin and hematocrit readings and the need for postoperative blood transfusion were evaluated in the two groups. A statistical analysis was performed. We found no statistical significance for the considered parameters in the two groups. Markedly no significative difference was found in morbidity, abdominal drainage discharge and need for postoperative blood transfusion. Our results do not allow a definite assessment of the actual role of fibrin sealant in rising efficacy on control of bleeding and biliary leakage from residual liver surface to total pericystectomy obtained with conventional haemostatic techniques. We believe that a previously planned controlled prospective trial could give the needed further elements to precisely evaluate the role of fibrin sealant in the surgical treatment of hydatid disease of the liver.

[Stomach cancer in the elderly patient]. / Il cancro dello stomaco nell'anziano.

Gastric cancer is a typical disease of old age, in fact about one half of the patients affect by it are aged over 65. Elderly patients imply a problematical choice of surgical treatment due to the general and specific risk and to life expectancy. In order to evaluate the specific features of gastric cancer in aged people and to share their experience in choosing the surgical treatment, a series of 50 patients with gastric cancer selected on the age > or = 75 years and observed from 1970 to 1993, was reviewed by the authors. Some features have been settled such as sex ratio approaching the unity, a prevalence of tumors located in the distal third of the stomach, the higher incidence of intestinal type and a wide incidence of intestinal type and a wide incidence of patients in III or IV stage. No surgical procedure was undertaken in eleven patients. The remaining 39 patients (78%) underwent a surgical procedure. In 22 patients (56.4) a resection was performed: 17 (77.3%) underwent a subtotal gastric resection, 11 curative and 6 palliative, and 5 (22.7%) a total gastrectomy out of necessity for tumor localization. In 17 patients (43.6%) a bypass procedure was carried out, while in 7 (17.9%) the surgical procedure was a simple laparatomy. Postoperative morbidity incidence was 17.9%, mortality rate 10.2%. Actuarial 5 years survival rate for curative resection was 41.5%. Median survival time was 13 months for patients who underwent a palliative resection and 6 months after bypass procedures. The data suggest that subtotal gastrectomy, also as palliative procedure, fits better to geriatric patients' requirements and is able to offer a satisfactory quality of life, to prevent cancer complications and to determine a longer survival.

Thoracic extension of hydatid cysts of the liver.

Of a total of 77 patients affected by hydatid cysts of the liver observed between 1983 and 1988, we examined a group of 25 patients with cysts that had migrated into the thorax. The main characteristic of these patients was the hydatid hepatic cyst, which was situated in the right hepatic lobe in every patient, involving one or more right hemithoracic structures. In 24 patients, there were different combinations of symptoms, but only ten were thoracic. In those with advanced intrathoracic evolution of the hydatid cyst, we not only found a destruction of the hemidiaphragm, but also the presence of pleural effusion, empyema, atelectasis and multiple pleural hydatidosis caused by the development of a cystic fistula in the pleural cavity. Analysis of these instances allowed us to see that ultrasonograms of the liver and roentgenograms of the thorax are often the most sensitive and reliable diagnostic procedures for showing the intrathoracic evolution of the cyst. We believe that the surgical treatment must be carried out with simultaneous right thoracoabdominal access, which, besides exposing the thoracic lesions, also permits adequate treatment of the hepatic hydatid cyst and the possible associated biliary complications.