[Laparoscopic surgery of varicocele. Role of total endovenous anesthesia in same-day discharge]. / Chirurgia laparoscopica del varicocele. Ruolo dell'anestesia totalmente endovenosa nella dimissione in giornata.

The success of out-patients laparoscopic surgery depends on a careful selection of patients and the ability of anesthetic technique to ensure a rapid emergence from anesthesia, with a satisfactory control of postoperative pain and the absence of side effects. This study was undertaken to investigate the influence of a total intravenous anesthetic management on the recovery process after laparoscopic varicocelectomy. Fifty-three ASA 1 patients aged 12-41 yrs (mean 26.02) scheduled to undergo laparoscopic varicocelectomy as day surgery procedure were included in this study. Propofol was used as inductor agent and in variable-rate infusion (170-100 mcg/Kg/min) to maintain anesthesia supplemented with Fentanyl (FNT) before endotracheal intubation, incision surgery and if the patient manifested clinical signs of inadequate analgesia. Local anesthesia was infiltrated into the skin before incision. Tramadol 100 mg and Ketorolac 30 mg were administered before the end of surgery to delay the onset of the postoperative pain. Pain was evaluated using a self-rating visual analoque scale (VAS) ranging from 0 to 10 at 0-0.5 hrs postoperatively and every 2 hrs until discharge. At the same time nausea was clinically evaluated using a scale ranging from 0 to 3. Postoperative pain and nausea (PONV) treatment were standardized. Patients were discharged by Post-Anesthesia Discharge Scoring System (PADS). Mean operating time was 34.2 min and mean estubation time was 11.6 min. At time 0 all patients had VAS pain score < 3, on the same time 2 of patients was treated for mild PONV; mean time to first request for postoperative analgesia treatment in 89% of patients was more than 6 hrs, 5 patients required pain treatment before discharge in a mean time 216' +/- 156'. Using the PADS system, 64% of patients were discharged at 4 hrs and 89% at 6 hrs after surgery. One patient was admitted to hospital for an overnight stay for walking dizziness; another was readmitted for surgical complications. This results suggest that the proposed anesthetic management provided adequate pain control with minimun postoperative nausea and a good recovery rate. This permitted a short postoperative hospital stay without compromising in safety, efficacy, or patient satisfaction.

[Cholecysto-colic fistula: laparoscopic treatment]. / Fistola colecisto-colica: trattamento laparoscopico.

Cholecystocolic fistula is an unusual complication of biliary tract disease and it may defeat laparoscopic treatment. We recently was a patient who, while undergoing laparoscopic cholecystectomy, was found to have a fistula between the gallbladder and the transverse colon. The fistula was transected with a 3 cm endoscopic linear stapling device and uneventful laparoscopic cholecystectomy was performed. This report shows that, with increasing experience, no absolute contraindications exist to starting laparoscopic cholecystectomy by introducing the laparoscope.

Sequential intraluminal endoscopic and laparoscopic treatment for bile duct stones associated with gallstones.

BACKGROUND: On the basis of a flowchart including prior or current jaundice or pancreatitis, abnormal liver function, ultrasound or IV cholangiography, bile duct (BD) stones were suspected in 71/593 patients referred for gallstones. METHODS: When endoscopic retrograde cholangiography detected BD stones, endoscopic sphincterotomy (ES) and endoscopic BD clearance were attempted, followed by laparoscopic cholecystectomy (LC). BD stones were found in 44/71 patients. The sensitivity values of preoperative conditions were: 92% for IV cholangiography, 88% for abnormal liver function, 50% for ultrasound, and 37% for jaundice at admission. RESULTS: Endoscopic clearance succeeded in 37 patients and LC was completed in 33 patients. Conversion to open surgery (9%) was comparable with the rate in patients without BD stones. The median hospital stay for the sequential endoscopic and laparoscopic treatments was 13 days (range 4-54) or 22 days if open surgery was used. CONCLUSIONS: In conclusion, BD stones can be endoscopically cleared preoperatively in most patients without interfering with LC.

[Laparoscopic cholecystectomy in pregnancy]. / Colecistectomia laparoscopica in gravidanza.

After appendicectomy, cholecystectomy is the most frequently nongynecological operation performed in pregnant women. Pregnancy has been stated to be a contraindication to laparoscopic cholecystectomy (LC) because of the unknown effects of a prolonged CO2 pneumoperitoneum on the fetus. Between September 1990 and December 1993 451 patients underwent LC at the 2nd Surgical Department of the University of Padova-Italy. Two patients were operated during the second trimester of pregnancy. LC without cholangiograms was successful in both patients and uncomplicated term delivery occurred. The Authors conclude that pregnancy is not a contraindication to LC; it can be performed safely during pregnancy and should be scheduled during the second trimester.

Laparoscopic versus conventional surgery for suspected appendicitis in women.

The diagnosis of appendicitis remains uncertain in female patients and laparoscopy has been suggested as a valid diagnostic tool. The laparoscopic approach has recently also been proposed for the treatment of acute appendicitis, though its real value is still under debate. A clinical and economic prospective evaluation of laparoscopic surgery over a 1-year period in female patients is reported. The study involved 38 patients presenting with signs of appendicitis and assigned to open (18) or laparoscopic surgery (20). The two groups were comparable as regards age and clinical presentation of the disease. The duration of the procedures was similar (60 min). Morbidity was comparable (3 vs 2). The ratio of negative appendectomy (50% vs 44%) was also similar, but the laparoscopic approach enabled a higher number of certain diagnoses (9/10 vs 3/8 p > 0.05). No significant differences were observed in the median postoperative stay (3 days for laparoscopy and 4 for surgery) or in the days needed to return to normal activity (15 vs 18). The cosmetic satisfaction was higher for the laparoscopic patients. The cost of the laparoscopic approach, however, was much higher than for conventional surgery. Our results suggest that laparoscopy is a useful diagnostic tool in female patients, but that laparoscopic appendectomy should be considered with some caution in times of restricted financial resources.

[Limited surgery in cancer of the hypopharynx and cervical esophagus: role of autotransplants of the intestinal loop and skin flaps]. / Chirurgia limite nel cancro dell'ipofaringe e dell'esofago cervicale: ruolo dell'autotrapianto di ansa intestinale e dei lembi cutanei.

The cervical esophageal region can be involved by several cancer types as primary malignancies of the hypopharynx and cervical esophagus, locally advanced tumors of the larynx and thyroid, and neoplastic recurrence after laryngectomy for cancer. These situations often require complex surgical procedures, and the integrated use of multiple surgical techniques or multistage operations. It is often a limit-type surgery that requires free loop intestinal autotransplants, local and regional skin flaps, and peduncle myocutaneous flaps, and therefore requires specific skill not only in general and thoracic surgery but also in head and neck surgery, plastic surgery and microsurgery. This paper summarizes the experience in the field of cervical esophagus replacement with jejunal free loop autotransplant (23 cases) and cutaneous or myocutaneous flaps (23 cases) at the "Centro Regionale Veneto per le Malattie dell'Esofago" from 1980 to 1993.

[The use of totally implantable systems (TIS) for long-term endovenous therapy]. / Utilizzo dei sistemi totalmente impiantabili (STI) per la terapia endovenosa prolungata.

The availability of a long-term central venous access for the management of neoplastic and chronic patients is extremely important in order to achieve an easy and safe infusion of chemotherapeutic drugs, blood components, and parenteral nutrition. The authors evaluated 26 adult patients (25 with malignant tumors and 1 with severe asthma) in whom implantable catheter systems were placed subcutaneously between February 1989 and March 1992. Catheters were inserted through the cephalic vein in 13 cases, the subclavia vein in 8 cases and jugular vein in 5 cases. The mean function time was 262 days in deceased patients and 155 in alive ones. There were no infective or thromboembolic complications. The authors, in agreement with the literature, confirm that TIS represent a safe and easy access for a long term i.v. therapy, with a very low complication rate. Furthermore, comfort of the patients is substantially improved and nursing care is greatly facilitated.

Esophageal strictures following nasogastric intubation.

Esophageal stricture is not reported to be a common complication of nasogastric intubation. Two patients who had a Levin tube inserted in the stomach for nutrition during a prolonged coma, and finally presented with a severe esophageal stricture were observed and treated. The clinical history of the patients suggests that the pathogenesis of this lesion is probably multifactorial, secondary to induced gastroesophageal reflux, impaired esophageal clearance, high gastric acid output, and use of steroids. Jejunostomy feeding, rather than nasogastric feeding, is probably a better means to provide nutritional support in comatose patients, thus averting the risk of such a serious complication. Esophageal replacement with left colon interposition appears the treatment of choice for these severe esophageal strictures.

[Presentation of a new instrument for the prolonged monitoring (24 hrs.) of endoesophageal pH, based on microprocessor technologies]. / Presentazione di un nuovo strumento per il monitoraggio prolungato (24 ore) del pH endoesofageo, basato su tecnologie a microprocessori.

Prolonged monitoring of oesophageal pH is the most sensitive test for GOR. An ideal instrument for this test should be simple, reliable and inexpensive. It should enable the patient to live a normal life, even at home, allows rapid analysis of the data, and monitors other parameters at the same time (intragastric pH). An instrument with these features has been devised at Padua University Surgical Clinic. It uses NSC 800 microprocessor technology and has a 32 K C-MOS memory. The examination can be programmed (patient code, date, start and end times, sampling duration and time). Postural changes are automatically recorded. Subjective symptoms are signalled by the patient through an alphanumeric keyboard. ROM software at the end of the test is employed for automatic processing according to Johnson and De Meester's parameters. Proxima is also made for a serial output to a larger-capacity computer and an analogue output compatible with a Beckman paper printer.