Endoscopic treatment of bilateral pheochromocytoma in MEN 2A syndrome: case report and review of the literature.

The benefits of laparoscopic adrenalectomy for single adrenal lesion have been well documented in literature; less experience though has been reported with simultaneous bilateral laparoscopic adrenalectomy. This operation is indicated in case of primary hypercortisolism caused by bilateral adrenocortical hyperfunction, Cushing's disease after failure of pituitary surgery, ectopic adrenocorticotropic hormone (ACTH) production by a tumour inaccessible for surgical intervention, and pheochromocytoma when it occurs bilaterally in case of multiple endocrine neoplasia type 2A and 2B. Different laparoscopic approaches have been described to perform this operation, such as the "anterior" approach (transperitoneal), the "lateral" approach (transperitoneal and retroperitoneal), and the "posterior" approach (retroperitoneal). We report a case of bilateral laparoscopic adrenalectomy in a 33 years old female affected with bilateral pheochromocytoma due to multiple endocrine neoplasia type 2A treated with a bilateral transperitoneal laparoscopic adrenalectomy and disease free after 18 months follow-up.

Routine laparoscopic cholecystectomy after endoscopic sphincterotomy for choledocholithiasis in octogenarians: is it worth the risk?

BACKGROUND: No unanimous consensus has been reached as to the need for routine laparoscopic cholecystectomy (LC) after endoscopic sphincterotomy (ES) for choledocholithiasis in very elderly patients, who are considered as high-risk subjects for surgery. METHODS: From 1991 through 1997, 170 patients were referred to undergo preoperative ES and routine LC for common bile duct (CBD) stones. The results for 27 patients (age 80 years or older) were compared with those achieved for younger patients. Successively, in a retrospective case-control study, the results for the selected patients were compared with those for 27 very elderly patients who underwent endoscopic retrograde cholangiopancreatography (ERCP), but did not receive LC. The mean follow-up period was 126 months. RESULTS: Octogenarians showed longer surgery time (79 vs 51 min) and postoperative hospital stay (2.8 vs 1.2 days), as well as more early low-grade complications (15% vs 3%), whereas there were no differences in conversion rate or serious complications. Recurrent symptoms or complications developed in 48% of octogenarians not undergoing routine LC, and 30% finally needed surgery. One patient in the control group died after emergency cholecystectomy for acute cholecystitis. The results of surgery were significantly poorer for the control group. CONCLUSIONS: Although a "wait-and-see" policy allowed two-thirds of LCs to be avoided in octogenarians, biliary-related events developed for every second patient, often requiring delayed surgery, with poorer results. Sequential treatment (ES followed by elective LC) is a safe procedure for octogenarians, and should be considered as a standard, definitive treatment for cholecystocholedocholithiasis even after the age of 80 years.

Anorectal reconstruction by electrostimulated graciloplasty as part of abdominoperineal resection.

AIMS: To report the outcomes of anorectal reconstruction by electrostimulated graciloplasty as part of abdominoperineal resection, on data prospectively collected over 10 years. PATIENTS AND METHODS: Twenty-three abdominoperineal resections were associated to coloperineal pull through, double graciloplasty and loop abdominal stoma. Fifteen patients also received an implantable pulse generator, either for unsatisfactory result after external-source intermittent electrostimulation and biofeedback (five cases) or during graciloplasty (10 cases). Follow-up was to a maximum of 10 years. Functional outcome was followed up in sixteen patients who underwent stoma takedown. RESULTS: Mean actuarial survival at 5 years was 72.3%. Satisfactory results (score < or =8) occurred in 75% of patients (three without and 13 with stimulator) in the early stages, decreasing to 57% at 1 year and gradually increasing up to 100% at 5 years and over. CONCLUSIONS: Total anorectal reconstruction yields a good functional outcome over time. Thus, despite, and because of, a high complication rate and a great drain on resources, it should be considered a suitable procedure only for selected, strongly motivated patients.

Quality of life assessment in geriatric surgery.

An excessive number of studies on health-related quality of life (HRQOL) has rendered results often contradictory and difficult to interpret. HRQOL evaluation in the aged is even more difficult, due to intrinsic conceptual and methodological problems. Since no structured instruments are available for use in geriatric surgery, it would be necessary either to work out a new specific instrument or to adapt/adopt an already existing method. Properties and methodological steps for development and validation are set forth. The Functional Assessment for Cancer Therapy (FACT) scale was developed for patients with cancer and has been recently validated also in the elderly. The Multidimensional Assessment for Cancer in the Elderly (MACE) was originally developed for elderly cancer patients. Since both methods are irrespective of subjects undergoing surgery, its use requires further validation. The MACE gives a broad information spectrum, but in geriatric surgery it seems too complex. The FACT-G is a simple core item questionnaire which can be integrated by disease-specific items and seems more compliant. A disease-specific and treatment-specific application of FACT questionnaires by multicenter studies might be useful in evaluating surgical procedures in patients in whom significant advantages in survival cannot be expected, but QOL can still significantly improve.

Subtotal colectomy with antiperistaltic cecorectal anastomosis.

We assessed the functional results achieved with an antiperistaltic end-to-end cecorectal anastomosis (CRA) after subtotal colectomy. A total of 34 patients with colonic cancer, inflammatory bowel disease or chronic constipation were treated with subtotal colectomy and cecorectal anastomosis. The postoperative mortality was nil; no major postoperative complication was registered. At a mean 60-month follow-up (range, 12-92), 32 patients were alive, showed no diarrhea nor incontinence, were completely relieved from previous symptoms and abdominal discomfort, and had a normal diet. In conclusion, subtotal colectomy with end-to-end antiperistaltic CRA seems to have a role in selected cases for the treatment of inflammatory bowel diseases, colon tumors and slow-transit constipation.

Ampullary adenocarcinoma in neurofibromatosis type 1. Case report and literature review.

Periampullary tumors in patients affected by Neurofibromatosis Type 1 (NF-1) are usually carcinoids or stromal tumors and, rarely, adenocarcinomas. We report a case of an adenocarcinoma of the ampulla of Vater in a 54-year-old woman with NF-1 admitted to the hospital with jaundice and undergoing pancreato-duodenectomy. Histologically, the resected specimen showed an adenocarcinoma of the ampulla as being a part of a complex atypical epithelial proliferation extended from the papilla to the mucosa of the duodenum and distal choledochus, islet-cell adenomatosis of the pancreas and multiple gastric, duodenal, jejunal stromal tumors. The ampullary and periampullary adenocarcinomas in NF-1 patients have peculiar features, suggesting a widespread predisposition to cancer development in periampullary tissues and requiring widely demolitive surgery. Moreover, they occur at a younger age than those occurring in non-NF-1 patients, may be associated with additional periampullary epithelial tumors, are often operable and may present long survival.

Endometriosis on laparotomy scar. A three-case report.

Endometriosis of surgical scar is a rare late complication of cesarean section. 3 cases of endometriosis after Pfannenstiel-type laparotomy are reported. The typical surgical presentation, present in all 3 cases, is a nodule on laparotomy scar after cesaren section, spontanously painful during the menstrual period. Ultrasound, performed in two cases, and cytological examination, performed in one, proved to be ineffective in establishing the diagnosis. The histopathological analysis of surgical specimens revealed in all cases multiple foci of well developed endometrial tissue scattered in a sclerotic stroma. Both stromal and glandular components of the endometrial mucosa were present showing the typical changes of the various phases of the menstrual cycle. In our opinion, an accurate clinical history should directly lead the surgeon to the excision with inclusion of the needle tract, whenever biopsy is performed. Surgical excision is at present the most appropriate diagnostic and therapeutic procedure.

Rectal cancer in anorectal malformation with rectovestibular fistula: sphincter-restoring surgery by anterior resection and dynamic vaginoanograciloplasty.

PURPOSE: The aim of this study was to describe and discuss the anosphincter-restoring procedure adopted in an adult patient with rectal cancer, affected by anorectal atresia and rectovestibular fistula not previously treated. METHODS: After anterior resection and transverse dissection of the rectovaginal septum, a straight double-staple low colorectal anastomosis was performed. A subcutaneous tunnel was extended from the inter-rectovaginal space, surrounding the pseudoanal orifice. The tunnel housed a left gracilis muscle arranged counter-clockwise and connected to an implanted stimulator. The vaginal and anorectal flaps were sutured longitudinally, thereby spacing out the two orifices and creating an anorectal angle. A temporary loop right colostomy was performed. RESULTS: The postoperative course was uneventful. After continuous electrostimulation training and colostomy takedown, the patient had improved continence (stimulator on) and normal defecation (stimulator off). CONCLUSIONS: The solution described seemed a suitable alternative to a pull-through procedure, which would have involved a colocutaneous anastomosis and the loss of the anorectal sensory function. Any previous anal transposition or pull-through procedures would have prevented the saving of the pre-existing "anus," because of the interruption of the residual mesenteric vascular supply to the anorectal remnant secondary to mesorectal excision.

Laparoscopic diagnosis of gallbladder agenesis.

In this article, we report two cases of gallbladder agenesis that were incorrectly diagnosed as cholelithiasis on preoperative sonography. In the first case, the diagnosis was made by laparoscopic surgery and confirmed by postoperative CT scan. The second case was confirmed by laparoscopic abdominal examination and by laparoscopic sonography. Both patients had undergone preoperative IV cholangiography. Preoperative cholangiography and laparoscopic exploration completed by laparoscopic sonography should be considered adequate modalities for the diagnosis of gallbladder agenesis, without the need for laparotomy and thorough postoperative workup.

Diverticulitis of the caecum and ascending colon: an unavoidable diagnostic pitfall?

PURPOSE: The infrequency of right-sided colonic diverticulitis prompted this presentation of our experiences, with emphasis on the diagnostic aspects. PATIENTS AND METHODS: Charts and documentation regarding 20 patients who underwent surgery for diverticulitis of the caecum and/or ascending colon over 22 years were reviewed. RESULTS: Eleven patients underwent pre-operative instrumental examinations: right-sided diverticulitis was recognized in five patients (two by barium enema, two by both ultrasonography and computerized tomography, one by all three examinations) and was suspected in another four. All diagnoses on merely clinical grounds--acute appendicitis in 10 patients and perforated peptic ulcer in one--were erroneous. Surgery consisted of 13 right standard or limited hemicolectomies, six conservative procedures and one Mickulicz' operation and subsequent right hemicolectomy. No operative deaths or long-term failures were reported. CONCLUSIONS: In the presence of clinical features atypical of acute appendicitis, right-sided colonic diverticulitis should be taken into account; pre-operative instrumental examinations might increase diagnostic accuracy, thereby leading to a more correct therapeutic approach.

Laparoscopically assisted treatment of acute abdomen in systemic lupus erythematosus.

The incidence of abdominal pain in patients with systemic lupus erythematosus (SLE) is very high. Most patients do not require surgical treatment (serositis). Some cases such as appendicitis, perforated ulcer, cholecystitis or, rarely, intestinal infarction are surgical. Differential diagnosis is difficult, partly because noninvasive examinations do not provide enough evidence to rule out a diagnosis. On the other hand, in patients with SLE who have acute abdomen, it is dangerous to delay surgery by attempting conservative therapy. In fact, a better survival rate has been associated with early laparotomy. We report a case of acute abdomen in a patient affected by SLE, in which the diagnostic problem was solved by means of laparoscopy and the treatment was laparoscopically assisted. A 45-year-old woman with a 25-year history of SLE was admitted with abdominal pain and fever. Her physical examination revealed a painful right iliac fossa with rebound tenderness. Her WBC count was normal. Abdominal x-ray, ultrasonography, paracentesis, and peritoneal lavage did not provide a diagnosis. A diagnostic laparoscopy was performed, showing segmentary small bowel necrosis. The incision of the umbilical port site was enlarged to allow a small laparatomy, and a small bowel resection was performed. The histopathologic finding was "leucocytoclasic vasculitis, with infarction of the intestinal wall." The patient recovered uneventfully. In conclusion, this case report shows that emergency diagnostic laparoscopy is feasible and useful for acute abdomen in SLE. Currently, this diagnostic possibility could be considered the technique of choice in these cases, partly because, when necessary, it also can allow for mini-invasive treatment therapy.

[Caecal-rectal antiperistaltic anastomosis without torsion of the vascular pedicle]. / Anastomose caecorectale antipéristaltique sans torsion du pédicule vasculaire.

Caecorectal anastomosis by Deloyers' procedure has the disadvantage of creating torsion of the vascular pedicle. The technique reported here is a simple mechanical anti-peristaltic anastomosis without inversion of the caecum. This technique was performed successfully in 26 patients after subtotal colectomy for multiple colonic carcinomas or severe constipation.

Discriminant power and information content of Ranson's prognostic signs in acute pancreatitis: a meta-analytic study.

OBJECTIVE: To determine a meta-analytical definition of the discriminant power of Ranson's signs in the prediction of acute pancreatitis severity and outcome, and of their information content, also compared with clinical judgment. DATA SOURCES: Two hundred eleven studies since 1974, reporting any predictive system for acute pancreatitis (MEDLINE by various Medical Subject Headings in MEDLARS, Current Contents, Medscape, Virtual Hospital, and other on-line medical services). STUDY SELECTION: One hundred ten studies reporting clinical use of Ranson's signs were retained. A quality index was calculated for each study. A selection was made according to inclusion criteria, separately for prediction of severity (19 studies; group S) and prognosis (10 studies; group P). Six other studies reporting clinical judgment results were also selected (group C). DATA EXTRACTION: Sensitivity and specificity values were extracted. Effect sizes were calculated and summarized by the inverse variance-weighted method. Categorical models were studied by analysis of variance. Publication bias was sought by correlation test and analysis of variance. Summary receiver operating characteristic curves were drawn, and the corresponding false-positive rate (FPR) and true-positive rate were calculated for each group. From the total true-positive rate and FPRs, the probabilities of illness for positive and negative results were calculated, for severe pancreatitis prevalence from 0 to 1. Last, the area below the curve and the ratio between this and that of the "perfect test" were calculated as a measurement of information content. DATA SYNTHESIS: Ranson's signs demonstrated poor discriminant power in both predictions: "d" values were 1.200 (95% confidence interval, 1.083-1.318) and 1.302 (95% confidence interval, 1.046-1.559), respectively. The lack of homogeneity in group S (Q = 58.737; p = .0000032) can be explained by the presence of three outliers. The summary curves showed, for low FPRs, a higher sensitivity of clinical judgment; Ranson's signs reached useful sensitivity only for high FPRs. No differences between groups in the area below the information content curves were found. CONCLUSIONS: Ranson's signs showed a poor predictive power. The information content did not differ from that of clinical judgment.

Total anorectal reconstruction by double graciloplasty: experience with delayed, selective use of implantable pulse generators.

This study reports our experience with total anorectal reconstruction (TAR), supported at a later phase, whenever necessary, by an implantable pulse generator. Thirteen patients underwent total anorectal reconstruction by double graciloplasty, diverting loop colostomy, and implantation of temporary electrodes. External-source, short-term, intermittent electrostimulation and biofeedback were used for neosphincter voluntary control training. After abdominal stoma closure, 6 months after initial surgery in disease-free patients, functional results were evaluated by a scoring system and anomanometry. A pulse generator was implanted whenever continence was judged unsatisfactory. After continuous electrostimulation training, neosphincter function was reassessed. Major graciloplasty complications (partial muscle necrosis and perineal colostomy necrosis) were treated successfully by surgery. One death of myocardial infarction occurred after discharge. Three patients refused further surgery. One patient did not undergo abdominal stoma closure because of early hepatic metastases. Functional evaluation after closure (eight patients) showed the following results: two "excellent" (no pulse generator implanted), three "good" (two stimulator implantations, with an "excellent" result), two "fair", and one "poor" (3 implantations, with a "good" result). In addition to improving clinical results (P=0.042), resting anal pressures were also increased significantly by active an implantable pulse generator (P=0.043). Although stimulators, whenever implanted, improved the neosphincter function, delayed, selective use of these in some cases rendered an implantable pulse generator either unnecessary from a functional viewpoint or redundant because of cancer recurrence or infectious complications. Drawbacks to the procedure were poor patient compliance to neosphincter training and to multiple surgical procedures, and excessive wasting of human resources during training for intermittent electrostimulation and biofeedback.

Delay in the diagnosis and outcome of colorectal cancer: a prospective study.

AIMS: The aim of this study was to examine the incidence of the delay in the diagnosis of colorectal carcinoma, possible causes of this delay and its effects on outcome. METHODS: A prospective study was performed on 100 patients affected by colorectal cancer. Duration of symptoms was calculated from the date of onset of symptoms to the date of surgery. RESULTS: Sixty-nine patients suffered delays in treatment of more than 12 weeks from the onset of symptoms. In patients with symptoms of less than 12 weeks' duration there was a higher incidence of radical surgery and none of these patients presented, at the time of surgery, a neoplastic dissemination. Multivariate analysis, however, showed that the only factors with an independent effect on 5-year survival and disease-free survival were Dukes' stage and the presence of pre-operative complications. CONCLUSIONS: The results of this study suggest that, independent of the diagnostic delay, the outcome of the colorectal cancer is only conditioned by tumour stage and by complicated cancer.

Intrahepatic subcapsular hematoma. A rare postoperative complication of laparoscopic cholecystectomy.

Two cases of intrahepatic subcapsular hematoma as an early complication of laparoscopic cholecystectomy are described. The clinical course of these two patients is described, and possible causes of, and treatment modalities for, this unusual complication are discussed.

Double-gracilis anorectal neosphincter: technique of reconstruction after necrosis of the distal part of the muscles.

PURPOSE: The aim of the present study is to demonstrate further reconstruction of a double-gracilis anorectal neosphincter that had been destroyed because of a severe postoperative perineal infection, with necrosis of the distal part of the muscles. METHOD: Each residual gracilis muscle was split longitudinally into two branches, which surrounded the neorectum, one posteriorly and the other one anteriorly, so as to perform a perineorectal double sling. RESULT: Owing to a poor functional result, continence was achieved only by the support of an implantable pulse generator. CONCLUSION: This technique seemed to permit the optimum use of the contractile potential of the residual gracilis muscles, which did not show evidence of defunction-related or ischemia-related fibrosis.