[Renal stone ileus in xanthogranulomatous pyelonephritis. A case report]. / Occlusione intestinale da calcolo renale in pielonefrite xantogranulomatosa. Descrizione di un caso.

A peculiar case of intestinal occlusion caused by a renal stone in a patient with nephroduodenal fistula due to previous xanthogranulomatous pyelonephritis is reported. Only few cases of nephroduodenal fistula are described in the literature, generally as a single case report or in small series. A nephroduodenal fistula as a result of chronic renal inflammatory disease such as xanthogranulomatous pyelonephritis, is usually associated with renal stones, recurrent urinary tract infections or endocrine disorders. Finally, renal stone as a cause of ileus is an event rarely described in the literature. In the case described, a correct preoperative diagnosis was possible with computerized tomography. During the operation a big renal stone was found and removed from the small bowel, but a limited resection was necessary because of the vascular impairment of the tract. At 8-month follow-up from operation, the patient was in good health, and no symptoms of renal or intestinal diseases were found.

[Gasless laparoscopic cholecystectomy. Our experience with 130 cases compared with 450 cases treated with the CO2 technique]. / Colecistectomia laparoscopica gasless. La nostra esperienza su 130 casi confrontati con 450 casi trattati con la tecnica con CO2.

Alongside the technique based on the creation of an abdominal cavity for surgery following the introduction of gas (usually CO2) into the peritoneal cavity, a new method has been developed. This involves the use of an atraumatic mechanical lifting device connected to the same abdominal wall (gasless laparoscopy). The authors report a technique that uses an inflatable cushion inserted into the abdomen through a periumbilical incision. The cushion is connected to an external motorized hydraulic jack fixed to the operating table, fitted with an electric motor and friction gear. Between May 1991 and June 1998, 580 patients underwent laparoscopic cholecystectomy. Since December 1995 a total of 130 patients have undergone surgery using gasless laparoscopy. Shoulder pain and pain in the upper abdominal quadrant were no longer reported; pain was present in 70% of the patients operated using the CO2 technique. There was also a marked reduction in the anesthesiological risks, above all in elderly patients with cardiopulmonary insufficiency. Surgical manoeuvres are made easier owing to the possibility of using traditional surgical instruments. Washing and continuous aspiration allow a good control of intraoperative hemostasis, and reduce the phenomenon of lens misting without the risk of losing pneumoperitoneum. Less visibility of the surgical field was reported, particularly in obese patients, above all because of the reduced diaphragmatic distension and the lack of displacement of the intestinal loops. In the authors' opinion the gasless technique is suitable above all in patients affected by cardiopulmonary disorders in whom hypercapnia might represent a significant operating risk.

Severe steroid-unresponsive ulcerative colitis: outcomes of restorative proctocolectomy in patients undergoing cyclosporin treatment.

PURPOSE: The recent introduction of the immune suppressor cyclosporin for treatment of steroid-refractory ulcerative colitis has required surgeons to perform a colectomy in those patients who eventually fail this rescue treatment, thus raising questions as to the safety of surgery as performed in patients with a heavily manipulated immune system. To assess the rates of mortality and morbidity in this setting, we studied a cohort of consecutive patients who had surgery after failing cyclosporin for refractory ulcerative colitis at our center. METHODS: Between January 1991 and December 1996, 25 patients with ulcerative colitis underwent restorative proctocolectomy performed in three steps (21 patients) and in two steps (4 patients). Seventeen of the 25 patients (68 percent) were initial nonresponders to a dose of 2 mg/kg/day of intravenous cyclosporin and underwent surgery immediately, the remaining 8 (32 percent) relapsed as outpatients on oral cyclosporin and were readmitted for surgery. RESULTS: There was no operative mortality. Nine patients of the 25 developed postoperative (early) complications (36 percent). The three-step operation subset had a 28 percent complication rate, the two-step 75 percent. Three patients needed reoperation. A total of 11 patients (44 percent) reported with late complications: two patients required surgical treatment, one for obstruction and one for pouch-perianal fistula. Three cases of pouchitis were recorded. No patient required pouch removal. CONCLUSION: Given the absence of postoperative mortality and a low overall complication rate, restorative proctocolectomy can safely be performed in patients who fail rescue treatment with a dose of 2 mg/kg of cyclosporin for steroid-refractory ulcerative colitis. Corollary evidence in this article hints but does not prove that the three-step procedure is safer than the two-step operation.

[Superior mesenteric artery syndrome after surgical correction of severe dorso-lumbar deformities. Authors' experience]. / La sindrome da compasso aorto-mesenterico dopo correzione chirurgica delle gravi deformità del rachide dorso-lombare. Nostra esperienza.

The authors report two cases of superior mesenteric artery syndrome observed in 22 operations for severe spinal deformities. Medical, dietary and postural treatment enabled the situation to be resolved in one case; whereas an intestinal derotation according to Strong-Valdoni was successfully performed in the other. The various surgical alternatives are discussed.

Role of serum alpha-fetoprotein in pre- and post-orthotopic liver transplantation (OLT) for malignant disease.

We have examined serum alpha-fetoprotein (AFP) concentrations in the pre- and post-orthotopic liver transplantation (OLT) period of a population of 19 adult patients. (Five with secondary hepatic malignancy and fourteen with primary hepatic cancer). In pre-OLT, rises in serum AFP levels are indicatives for hepatocellular carcinoma (HCC): six of our nine cases of HCC were associated with the increase in serum AFP concentration, but none of the non-hepatocellular primary cancers and only one of the five secondary malignancy (hepatic metastasis of breast carcinoma with serum AFP values around 20 ng/ml). In pre-OLT, AFP values correlated with viable tumor mass rather than tumor:volume. In post-OLT, rises in AFP concentrations may be explained either by recurrent hepatic cancer or by hepatic post-necrotic regeneration. In this case, the increase in serum transaminasis is an important help for differential diagnosis.

[Our experience in 6 cases of leiomyoma of the esophagus]. / La nostra esperienza su 6 casi di leiomiomi dell'esofago.

The Authors present 6 cases of oesophageal leiomyomas operated on during the past 15 years at the Institute of Surgical Pathology of the University of Turin and compare the results with those in the literature. The pre-operative diagnosis was not always possible and often difficult: it was however, helped by many clinical and instrumental examinations. The treatment of choice was surgery, usually by enucleation or occasionally by gastroesophageal resection. There was no operative mortality and no recurrences have been observed.

[Unusual congenital diaphragmatic hernias. Report of 2 cases of aplasia of the phrenic center]. / Le ernie congenite rare del diaframma. Presentazione di due casi di aplasia del centro frenico.

Two cases of congenital diaphragmatic hernia affecting the central tendon are described. The anatomic, etiologic, pathogenic and clinic characteristics of this uncommon disease are then discussed. Finally some considerations about indications on how to operate on these congenital hernias and different repairing surgical techniques are made.