Intracorporeal versus extracorporeal anastomosis. Results from a multicentre comparative study on 512 right-sided colorectal cancers.

BACKGROUND: Although nowadays considered as feasible and effective surgery in terms of short- and long-term results and oncological radicality, laparoscopic right colectomy is performed by a small number of surgeons, and in the vast majority of cases, this technique was performed with an extracorporeal anastomosis. Current literature failed to solve the controversies between intracorporeal and extracorporeal anastomosis after laparoscopic right colectomy. METHODS: A multicenter case-controlled study has been designed, including 286 patients who underwent laparoscopic right hemicolectomy with intracorporeal anastomosis (IA) compared with 226 matched patients who underwent laparoscopic right hemicolectomy with extracorporeal anastomosis (EA). RESULTS: There was no significant difference in terms of age, sex, BMI, and ASA score between the two groups. Surgical post history, tumor localization, and stage of disease according to AJCC/UICC TNM were similar too. Although similar oncologic radicality in term of number of lymph nodes harvested (25.7 ± 10.7 of IA group vs. 24.8 ± 8.7 of EA group; p = 0.3), as well as similar operative time (166 ± 43.7 min. in IA group vs. 157.5 ± 67.2 min in EA group) have been registered, time to flatus was statistically lower after intracorporeal anastomosis (40.8 ± 24.3 h in TLRC group vs. 55.2 ± 19.2 h in LARC group; p < 0.001) Laparoscopic colectomy with intracorporeal anastomosis was associated with a lower rate of post-operative complications (OR 0.65, 95 % CI 0.44, 0.95, p = 0.027). However, when stratifying according to clavien classification, the difference was consistently confirmed for less severe (class I and II) complications (OR 0.63, 95 % CI 0.42, 0.94, p = 0.025), but not for class III, IV, and V complications (OR 1.015, 95 % CI 0.64, 1.6, p = 0.95). CONCLUSION: Our results are encouraging to consider the intracorporeally approach the better way to fashion the anastomosis after laparoscopic right colectomy. This study clearly provides the rationale for a randomized clinical trial, which would be useful to give definitive conclusion.

Perforated duodenal ulcer presenting with a subphrenic abscess revealed by plain abdominal X-ray films and confirmed by multi-detector computed tomography: a case report.

INTRODUCTION: Peptic ulcer disease is still the major cause of gastrointestinal perforation despite major improvements in both diagnostic and therapeutic strategies. While the diagnosis of a perforated ulcer is straightforward in typical cases, its clinical onset may be subtle because of comorbidities and/or concurrent therapies. CASE PRESENTATION: We report the case of a 53-year-old Caucasian man with a history of chronic myeloid leukemia on maintenance therapy (100mg/day) with imatinib who was found to have a subphrenic abscess resulting from a perforated duodenal ulcer that had been clinically overlooked. Our patient was febrile (38.5°C) with abdominal tenderness and hypoactive bowel sounds. On the abdominal plain X-ray films, a right subphrenic abscess could be seen. On contrast-enhanced multi-detector computed tomography, a huge air-fluid collection extending from the subphrenic to the subhepatic anterior space was observed. After oral administration of 500cm3 of 3 percent diluted diatrizoate meglumine, an extraluminal leakage of the water-soluble iodinated contrast media could then be appreciated as a result of a perforated duodenal ulcer. During surgery, the abscess was drained and extensive adhesiolysis had to be performed to expose the duodenal bulb where the ulcer was first identified by methylene blue administration and then sutured. CONCLUSIONS: While subphrenic abscesses are well known complications of perforated gastric or duodenal ulcers, they have nowadays become rare thanks to advances in both diagnostic and therapeutic strategies for peptic ulcer disease. However, when peptic ulcer disease is not clinically suspected, the contribution of imaging may be substantial.

Penetrating cardiac injuries. Two case reports.

INTRODUCTION: Penetrating cardiac injuries is still a diagnostic problem at this time. Their management requires immediate surgical intervention and excellent surgical critical care postoperatively. PRESENTATION OF CASES: A 15-year old male patient was stabbed with a knife to the right chest. The chest radiograph showed an haemothorax and the angiography showed an intercostals artery and a right auricle injury. After an emergency operation the patient was released home in good condition after the toracotomy had healed. A 19-year old male patient was stabbed with a knife to the chest more than once. By a left toracotomy we sutured the lesion of the left ventricle with multiple single stitch in non-absorbable suture, we covered the suture with a sealant. The patient released home in 24 days. DISCUSSION: Penetrating cardiac injuries is one of the leading cause of death from urban violence. To evaluate a thoracic trauma with cardiac injury it's clear the use of thorax X-ray and multislice angio-Tc scan. Echocardiography has clearly emerged for the diagnosis in patients haemodynamically stable. When the patient is haemodynamically unstable the emergency thoracotomy is mandatory. CONCLUSION: Despite the high mortality of penetrating cardiac injuries new surgical and radiological tecniques may help surgeon to save this patients.

Use of biological prostheses in transplant patients with incisional hernias. Preliminary experience.

AIM: The use of synthetic mesh in transplant patients is still under debate. In this paper the authors report their preliminary experience on biological prosthesis for surgical treatment of incisional hernias in transplant patients. MATERIAL OF STUDY: Between 2009-2010, 10 patients with incisional hernia underwent surgery using a biological prosthesis (porcine dermis collagen). All patients were transplanted: 9 kidney transplants and 1 liver transplant. RESULTS: In all patients postoperative course was uneventful and were not observed complications related to surgery, kind of prosthesis or transplanted organs. At follow up, laparoplasty was associated with good functional outcome. DISCUSSION: Transplant patients are at risk for use of synthetic prostheses, as immunosuppressed. In our preliminary experience biological prostheses compared to synthetic ones showed a greater ability to integrate into tissues, to resist bacterial colonization and to reduce cytotoxic or allergenic reactions, providing similar functional results. Moreover it must be added that biological prostheses did not require reductions/suspensions of immunosuppressive therapy and resulted to be versatile. All these features are particularly sought in incisional hernias surgery of transplanted patients. CONCLUSIONS: Surgery of incisional hernias in transplanted patients requires a prosthesis with characteristics as close as possible to the ideal one and, in this sense, biological prostheses would seem to outweigh synthetic ones. In our experience, biological prostheses have shown to be safe, effective and reliable; therefore they seem to be able to open new horizons in the treatment of wall defects in this group of patients.

Intravascular lipoma from iliofemoral tract.

Lipoma is a benign tumour composed of well-differentiated adipocytes and is the most common soft tissue mass. We present a case of an intraluminal lipoma of the iliofemoral axis presenting as lower limb venous obstruction. In our case, definite diagnosis is impossible as there is aspecific symptomatology and radiologic imaging methods are not able to provide diriment data, considering rarity of the disease. Therefore, we could make correct diagnosis only intraoperatively. We preferred a direct reconstruction of the wall of vein. At 12-month follow-up, we have had complete disappearance of symptoms and functional diseases.

Easy closure of anterior palatal fistula with local flaps.

BACKGROUND: Anterior palatal fistula is often observed in the treatment of the cleft palate with a push-back palatoplasty. High rate of incomplete closure is reported. We describe a reliable new technique with reverse local flaps to close an anterior palatal fistula. MATERIALS AND METHODS: One hundred seventeen cleft patients, treated with push-back palatoplasty, underwent repair of an anterior palatal fistula by our group. Fistulas were located in the anterior hard palate, with a variable size between 0.1 cm to more than 0.5 cm. Two reverse local flaps from the nasal mucosa of the lateral palatal edges are used to close the fistula. A third flap is elevated from the premaxilla in bilateral clefts. The flaps are elevated toward the center of the fistula. The closure is made in 2 layers for unilateral cleft and in 3 layers for bilateral cleft, using absorbable sutures. RESULTS: Complete closure of the anterior palatal fistula was achieved in 77 patients (65%) after the first surgery, 27 patients (23%) required a second attempt to close the fistula, and 10 patients (8.5%) required a third surgery. Three patients (2.5%) continued to have a fistula after 5 surgeries. CONCLUSIONS: We believe that our method is reliable and easy to perform, and it has a high success rate. The technique is indicated to correct small- to medium-size defects.

[Mesenteric Castleman's disease and inflammatory fibroid polyp of the stomach: a case report and review of the literature]. / Malattia di Castelman mesenterica e polipo fibroide infiammatorio dello stomaco: associazione in un caso clinico e revisione della letteratura.

Castleman's disease is a very rare disease that causes many problems both in diagnosis and therapy. It is often associated with other diseases and can develop in any part of the body. Castleman's disease can be classified as uni-centric or multicentric based on clinical and radiological findings, as hyaline-vascular or plasma-cell based on the histological aspect, and as HIV-related or non-HIV-related, based on the HIV status of the patient. An inflammatory fibroid polyp is a very rare benign lesion that can develop anywhere in the gastrointestinal tract. Such polyps are most commonly found in the gastric antrum and usually occur in 50- to 60-year-old people. The authors report the unusual finding of mesenteric Castleman's disease and an inflammatory fibroid polyp of the stomach in a 41-year-old woman.