[Intestinal intussusception due to metastatic melanoma: a case report]. / Intussuscezione ileo-ileale da melanoma metastatico: caso clinico.

Although the gastrointestinal tract is a fairly frequent site of melanoma metastases, reports of small bowel intussusception caused by this condition are rare. The presence of intestinal metastases is an expression of what is already a disease at an advanced stage and, therefore, the prognosis of these patients is generally poor with only sporadic cases of long-term survival after resective surgery. We describe the case of a patient referred to our department with a clinical picture of frank occlusion. Ileo-ileal intussusception was diagnosed preoperatively thanks to ultrasound and abdominal CAT scans. The patient was unaware that he had a cutaneous melanoma and, moreover, the diagnosis of a metastasised melanoma was possible only after histological examination of the surgical specimen and the subsequent search for and identification of the primary lesion at the level of the dorsal skin. We performed an extensive ileal resection with an end-to-end entero-enteroanastomosis. Ten months after the operation the patient is still alive but in poor general condition due to the presence of diffuse liver metastases and ascites. We believe that radical resective surgery affords valid palliation for these patients, with disappearance of symptoms and minimal postoperative morbidity and mortality.

Short and long term results of the laparoscopic Heller-Dor myotomy. The influence of age and previous conservative therapies.

AIMS: To evaluate the long-term outcome and quality of life (QoL) data, and to assess the potential influence of age and different conservative procedures on laparoscopic surgery. BACKGROUND: Current therapies for achalasia can palliate dysphagia, but other symptoms may persist, making it difficult to quantify and compare. To understand if they could influence results, we analyzed short- and long-term results and correlated them to age and previous conservative treatments using a specific QoL test. METHODS: Functional examinations (endoscopy, 24-hr pH manometry, upper GI X-rays) and the gastrointestinal quality of life index (GIQLI) were used before and after a laparoscopic Heller-Dor myotomy. Data were analyzed by the Mann-Whitney U test, Wilcoxon signed rank test, and Spearman's rho coefficient for bivariate correlations (p < 0.05). RESULTS: From January 1996 to January 2004, 31 consecutive patients out of 35 diagnosed with achalasia, in clinical stages I-III, were operated on by laparoscopy . Two groups were identified using the break point of 70 years of age, (20 younger and 15 older) and two subgroups according to the conservative therapy performed (20, none; 15, some). Patients underwent a clinical manometry evaluation at six and 12 months, and then yearly, and pH-metry at six, 24, and 60 months. In 78% of patients dysphagia disappeared and the incidence of reflux was 13%. Age and previous treatments did not influence surgical outcome. Patients completed a GIQLI questionnaire before surgery, six months after surgery, and then yearly (for five years). The median preoperative GIQLI score was 78 (range 38-109) out of a theoretical maximum score of 144. At a median follow-up of 49 months (range 24-72 months), the score had significantly improved to 115 (range 71-140). There was no significant statistical difference between the groups. CONCLUSIONS: Laparoscopic Heller-Dor myotomy is an effective palliation for achalasia; the long-term outcome is not significantly affected by preoperative conservative treatments or by the age of the patients. The GIQLI questionnaire is a reliable instrument to compare the impact of achalasia symptoms on health-related QoL before and after surgery.

[Timing and results of the surgical treatment of the diverticular disease of the colon]. / Timing e risultati della terapia chirurgica della malattia diverticolare del colon.

AIMS: To evaluate retrospectively the outcome of the curative open and laparoscopic surgical approach to the diverticular disease according to timed steps based on the pathologic stage. PATIENT AND MATERIAL: From 1989 83 out of 242 outpatients underwent surgery in emergency or after medical failure and at least two acute attacks requiring hospital admittance, or complicated diverticulitis. Modified Hinchey classification staged the disease. Clinic and instrumental criteria, surgical procedures, early and late complications were statistically evaluated (Students t-test and exact Fischer test, p < 0.05) in comparison with the different steps of therapeutic strategy. RESULTS: Twenty nine patients were classified as Hinchey 0, 26 as I, 14 as II, 11 as III, 3 as IV. Clinical characteristics of the lap and open groups overlapped, with higher rate of earlier age in first and advanced stages in the second group. 16 patients (19.3%) underwent surgery at the first attack in emergency or in delayed emergency (5 TC-guided drainages). 30 open and 53 lap procedures were done: 21 two-stage: 18 primary resections + ileostomy and 3 Hartmann; 61 single stage: 49 sigmoidectomy, 12 left colectomy. 4 conversions (7.5%), 12 early (14.5%) and 10 late (12.1%) complications were observed. DISCUSSION: Complications rate was higher in the open group including more advanced stages. Elective surgery performed following conservative therapy, 4 weeks from the first acute attack in younger people (age < 55yrs.) and after two attacks in elder (age > 55yrs.) showed a significant lower complications' incidence (p < 0.05) compared to the 8 weeks delayed operations. CONCLUSION: Surgery of diverticulitis must follow standardized criteria. The laparoscopic approach could be performed in more severe stages, provided that conditions of delayed emergency were achieved.