[Ferguson hemorrhoidectomy, modified by using the Ligasure radiofrequency coagulator]. / L'emorroidectomia seco Ferguson, modificata mediante l'impiego del coagulatore a radiofrequenza Ligasure.

The aim of the study was the evaluation of results of modified Ferguson hemorrhoidectomy, with use of the Ligasure radiofrequency coagulator, compared to the Milligan-Morgan and Longo techniques. From January 1988 to December 2005, 3011 patients underwent Ferguson hemorrhoidectomy (1849 F, 1162 M; age range: 18 to 84 years). One thousand three hundred patients had previously been treated by medical therapy with poor results and in 225 patients (7.5%) the indication was recurrence after previous surgical treatment. All patients underwent a closed Ferguson hemorrhoidectomy (combined with anoplasty in 28 cases of post-hemorrhoidal stenosis). Eighty percent of patients were operated on with loco-regional assisted anaesthesia, and the remainder with narcosis (cases of recurrence). During the last two years we performed hemorrhoidal excision in 116 patients (4%) with the Ligasure radiofrequency coagulator, followed by continuous suturing with Vicryl 4/0. There was no intraoperative mortality. Mean operation time was 25 minutes. Postoperative complications were hemorrhage in 6 patients (0.2%) and acute urinary retention in 9 patients (0.3%). No important complications were observed in any of the patients treated with Ligasure. The hospital stay was 24 hours for 2852 patients, and 36-86 hours in the other 5%. Seventy-two percent of patients (2160) had moderate postoperative pain, while 14% (420) had severe postoperative pain necessitating repeated administration of analgesics. The 115 patients undergoing Ferguson haemorrhoidectomy plus Ligasure were discharged within 24 hours of surgery. No cases of major domiciliary haemorrhage were observed. There were 13 cases of suture dehiscence (none in the Ferguson plus Ligasure group). Five patients presented suture infection, not requiring surgical drainage, but only medical treatment with local antibiotics. These results, obtained with the modified Ferguson technique, as compared to the classical and even the most innovative hemorrhoidectomy, appear to confirm the feasibility and accuracy of this operation in almost all patients, with both a considerable reduction in costs and enhanced patient comfort and compliance.

[Haemorrhoidectomy according to Ferguson in day-surgery. Experience and results]. / Emorroidectomia secondo Ferguson in day-surger Esperienza e risultati.

AIM OF THE STUDY: To evaluate of results of 1511 surgical haemorrhoidectomies performed in day-surgery setting (7-24 hours hospital stay) with improvement of both cost effectiveness and patient comfort. MATERIAL AND METHODS: From January 1980 to December 2002, 1511 patients underwent haemorrhoidectomy according to Ferguson, 1011 patients for grade III-IV haemorrhoids 10% of them for recurrence and 5% previous treated by cryotherapy or elastic ligature, 500 patients for grade II haemorrhoids 25% of them previous treated by cryotherapy or elastic ligature and 7% for recurrence. 97.6% of patients were operated on with loco-regional anaesthesia; the others with narcosis and peripheral anaesthesia. The hospital-stay was 24 hours in 34% of patients, while the remaining 66% operated on under loco-regional anaesthesia were hospitalised for 7-10 hours. Twenty-seven patients (1.8%) have had postoperative haemorrhage, only three patients (0.2%) underwent reoperation under general anaesthesia with a hospital stay of 7 days. In 52% of patients clinical recovery was observed at first follow-up (7 days); 48% had recovered at the second follow-up (14 days). RESULTS: In 1286 patients (98% of patients came back to control) anatomical recovery was observed at the follow-up three months after surgery. Patients satisfaction 6 months after operation was high in 73%; good in 26%; low in 1%. CONCLUSIONS: These results seems confirm the feasibility of haemorrhoidectomy in day-surgery in almost all patients, with both a considerably cost reduction and enhanced patient comfort and compliance.

[Hypoparathyroid risk after total thyroidectomy]. / Il rischio ipoparatiroideo post tiroidectomia totale.

From January 1970 to December 1999, 881 patients with thyroid pathology underwent surgery consisting in 551 subtotal thyroidectomies and 330 total thyroidectomies. Permanent hypocalcaemia was present in 32 patients (3.6%). The importance of accurate isolation and ultraligature of the branches of the inferior thyroid artery in the prevention of parathyroid damage is stressed.

[Tubulo-villous rectal tumours. Results of surgical resection in relation to histotype (30 years' experience)]. / I tumori tubulo-villosi del retto. Risultati delle exeresi chirurgiche in funzione dell'istotipo. Esperienza di 30 anni.

Adenomas of the rectum are frequently found during endoscopic examination. We report on our 30 years of experience with the treatment of tubulo-villous adenomas based on histotype. Between 1971 and 2001, 104 villous tumours of the rectum were treated surgically. The patients' average age was 65 years. These were sessile tumours in 69% of cases, pedunculated in 17.5% and flowing tumours in 13.5%. The mean tumour size was 3 cm. They were associated with colon cancer in 15% of cases and with polyadenoma in 10%. They were located in the rectum within 0 to 6 cm of the anal margin in half the cases. These tumours were treated by local excision in 74 cases and by wide excision in 30 cases. The malignant potential of the tumours was 30%, including 10% invasive malignancy. There were no surgical fatalities, but a 6% medical fatality rate was registered. There was a 20% complication rate related to the surgical technique. Twenty patients were lost to follow-up. Out of 84 villous tumours, monitored over a mean survival period of 6.5 years, there were 24 recurrences: 18 underwent endoscopic excision and in 6 cases a wide resection. The various tumour resection techniques and the operative indications of variable difficulty are presented. It would seem, at present, that total resection of the rectum with a colo-anal anastomosis is the best treatment for large flowing villous tumours occupying almost the entire rectum. Thorough preoperative examination and the mastering of various surgical procedures should allow the most suitable choice of treatment for each individual case.

[Surgical treatment of rectal prolapse with transanal resection according to Altemeier. Experience and results]. / Terapia chirurgica del prolasso del retto mediante resezione transanale secondo Altemeier. Esperienza e risultati.

In recent years the number of patients with partial or total rectal prolapse has increased. Numerous techniques and surgical approaches have been described for its treatment. In this study we examine the main ones and stress the advantages of the transanal-perineal resection technique according to Altemeier and modified by Prasad, which we have used to treat the condition in the last 15 years. From 1988 to 2002, 269 patients with "haemorrhoidal prolapse" were referred to our department; 146 were females (54%), and the mean age was 58 years. Clinical examination and proctosigmoidoscopy revealed the presence of total rectal prolapse in 41 patients (15%, 32 F, 9 M), complicated in 4 cases by moderate incontinence and associated in 3 cases with post-haemorrhoidectomy stenosis. These 41 patients underwent transanal resection according to Altemeier. Thirty-four of them (83%) were operated on under local anaesthesia with sedation, 5 patients (12%) under peridural anaesthesia and 2 patients (5%) under narcosis. The mean hospital stay was 5 days and depended on the time of the first spontaneous evacuation. Check-ups were performed after 7 days, 1 months and every 3 months for 1 year. There was no postoperative mortality, and only 1 case of postoperative haemorrhage, which did not require reoperation, in a patient with a previous myocardial infarct who spontaneously continued to take salicylates up to 24 h before surgery. Thirty-three patients (80%) had their first postoperative evacuation within 48 h of surgery after taking sorbitol orally in the evening, 6 patients (15%) within 72 h, and 2 patients (5%) on postoperative day 4. No evacuative enemas were performed. We observed clinical healing in all patients 1 month after the operation, and regular, spontaneous evacuations without the use of oral laxatives. Stool or gas incontinence were never observed or reported. During the follow-up, only in 2% of cases did we observe partial recurrence of the prolapse. The choice between the numerous surgical techniques for correcting rectal prolapse, depends on the state of the disease, on the patient's general condition and on the surgeon's experience with the various techniques. The perineal approach proposed by Altemeier and modified by Prasad presents a low risk of mortality and immediate complications, as confirmed by our experience, even in high risk patients, and relatively easy execution. It would appear, moreover, to be the only technique capable of correcting the preoperative incontinence sometimes present.

[Mucin-secreting tumor of the appendix with large gelatinous effusion]. / Tumore mucosecernente dell'appendice con cospicuo versamento gelatinoso.

The authors report a case of a mucinous tumour of the appendix with a large muco-gelatinous effusion detected as a result of massive abdominal compression. The mucinous mass occupied the entire abdominal cavity and was compressing the abdominal vascular trunks. Increases in CEA, Ca 19.9 and Ca 50 were recorded. The abdominal CT scan was of fundamental importance for diagnosing the condition. Surgery was performed consisting in removal of the mucinous abdominal mass, the appendix and part of the caecum. The postoperative course was favourable with rapid restoration of abdominal organic functions and normalisation of CEA. The rarity of these tumours is stressed.

[Radiofrequency ablation in primary and secondary liver tumors]. / La termoablazione mediante radiofrequenza delle neoplasie primitive e secondarie del fegato.

The authors report the preliminary results of a new treatment for primary and secondary hepatic malignancies called radiofrequency ablation. Seven patients undergoing the new radiofrequency ablation procedure (4 M and 3 F; mean age 62 years) were studied. The 3 female patients were suffering from breast cancer metastases (1 case), left colon cancer metastases to the first hepatic segment with caval and portal compression (1 case), and metastases to the eighth hepatic segment from an operated left colon cancer (1 case). The 4 male patients were suffering from carcinoma of the first hepatic segment on a cirrhotic liver (1 case), two liver metastases from left a colon cancer (1 case), a single 3-cm diameter metastasis treated by laparotomic radiofrequency ablation after resection of a gastric cancer (1 case), and one metastasis to the eighth hepatic segment from an operated left colon cancer (1 case). Prior to treatment all patients were subjected to investigation of routine blood-chemistry parameters, hepatic enzymes, cancer markers (Ca 19.9, alphafetoprotein, cytokines), abdominal spiral CT or MRI or PET (18 FDG); and thorough ultrasonography. Four patients underwent percutaneous radiofrequency ablation; one patient with concomitant gastric cancer underwent laparotomic radiofrequency ablation and simultaneous removal of the tumour; one patient was treated by celioscopic radiofrequency ablation in the course of laparoscopic cholecystectomy; and one underwent transpleural-diaphragmatic radiofrequency ablation for metastases to the seventh and eighth hepatic segments. None of the patients undergoing ultrasonography and CT follow-up examinations after 6 months presented recurrence of hepatic metastases. This treatment, though its use has so far been limited to only a few cases with a short follow-up, opens up new prospects for the surgical treatment of primary and secondary malignancies, also in the light of experience based on a substantial number of patients, recently reported in the literature.

[Surgical treatment of acute respiratory failure caused by mediastinal goiter. Clinical experience and results]. / Il trattamento chirurgico della insufficienza respiratoria acuta da gozzo mediastinico. Esperienza clinica e risultati.

In the regions where goitre is endemic, onset of the disease with acute respiratory insufficiency caused by thyroid compression is an uncommon situation requiring a rapid diagnosis and urgent surgical treatment. From January 1997 to December 2000 we observed 81 patients with thyroid pathologies, (69 males and 12 females; mean age 64 years). We found colloid-cystic goitre in 39 cases, adenomatous goitre in 26, carcinoma in 12, Hürthle's cell tumours in 3 and inflammatory disease in 1. All patients underwent thyroidectomy. Nine patients (11%) presented acute respiratory insufficiency caused by thyroid compression, with various associated phonesis disorders; in these cases we performed emergency surgery with postoperative maintenance of tracheal intubation or tracheotomy or the possible positioning of a self-expanding tracheal stent. In these 9 patients there were 4 deaths (44%), 3 in the immediate postoperative period and one after 10 months. We also observed one hydropneumothorax. Functional recovery was achieved in the remaining 5 patients. The treatment of this clinical picture requires urgent tracheal intubation, before the use of diagnostic tools, and it is important to maintain it after the surgical procedure for as long as is necessary for the tracheal wall to be reconstituted. In the severest cases a temporary tracheotomy is needed or the positioning of a tracheal stent, which offers a valid and effective alternative.

[Surgical treatment of anal stenosis following hemorrhoid surgery. Results of 150 combined mucosal advancement and internal sphincterotomy]. / Il trattamento chirurgico delle stenosi anali post-emorroidectomia. Risultati di 150 interventi di anoplastica per scorrimento mucoso e sfinterotomia interna.

The aim of the study was to evaluate the efficacy of anoplasty by mucosal advancement combined with internal sphincterotomy for the treatment of iatrogenic anal stenosis. From January 1990 to December 2000, 149 patients with post-haemorrhoidectomy anal strictures underwent internal sphincterotomy and mucosal advancement flap anoplasty. Seventy-one percent of patients were operated on under local anaesthesia by perineal block according to Marti. In 90 percent of the patients, postoperative pain was mild. No significant complications were seen. The mean hospital stay was two days. Ninety-seven percent of patients were well satisfied with the surgical result one year after operation. Current surgical options for the treatment of post-haemorrhoidectomy anal stricture are reported and the advantages of mucosal advancement flap anoplasty outlined.