Morgagni hernia: technical variation in the laparoscopic treatment.

INTRODUCTION: Morgagni hernia is a rare entity that accounts for 3-5% of diaphragmatic hernias. They are mostly asymptomatic and discovered incidentally. Surgical treatment is indicated once diagnosis is made. Abdominal or thoracic accesses are possible using open or minimally invasive technique. METHODS: We report two cases of laparoscopic assisted repair of Morgagni hernia conducted by primary closure of the diaphragmatic defect with extracorporeal nonabsorbable sutures anchoring the diaphragmatic edge at the muscular fascia of the abdominal wall. RESULTS: Both patients had an uneventful postoperative recovery. The operative time was 90 and 60 minutes and the postoperative hospitalization was 4 and 2 days respectively. CONCLUSIONS: Laparoscopic intervention for Morgagni hernia repair is easy, safe and less invasive compared to the open one, with reduced hospitalization time. Primary closure of the diaphragmatic defect with extracorporeal nonabsorbable sutures is an effective technique for Morgagni hernia; defects larger than 20-30 cm2 should be repaired using a prosthetic patch.

Endovenous 808-nm diode laser occlusion of perforating veins and varicose collaterals: a prospective study of 482 limbs.

BACKGROUND: Endovenous laser ablation (EVLA) was performed in the treatment of great and small saphenous veins (GSVs, SSVs), perforating veins (PVs), and varicose collaterals (VCs). OBJECTIVE To verify the outcome in PVs and VCs. MATERIALS AND METHODS: Four hundred eighty-two limbs of 306 patients were studied. EVLA was performed on 167 GSVs, 52 SSVs, and 534 PVs of 303 limbs and on VCs of 467 limbs; 133 GSVs were stripped, 300 of saphenofemoral junctions (SFJs) and 45 saphenopopliteal junctions (SPJs) were interrupted. Limbs were selected using duplex ultrasound examination and photographs; PVs-VCs diameter (<4 mm) and VC length were measured. EVLA was performed using a 808-nm diode laser, 0.6-mm fibers, continuous emission, 4 to 10 W, and 10 to 20 J/cm. Follow-up on 467 limbs occurred over a mean 27.5 months (range 3 months to 6 years); 98 limbs were followed up for longer than 4 years. RESULTS: Operating time range from 10 to 30 minutes per limb. Blood vaporization, thrombosis, fibrosis, and atrophy prevailed in PVs and in the large VCs (>4 mm) and massive coagulation in the smaller (<4 mm). High rate of occlusion was seen, with different rates of patent PV-VC mainly in diameter >6 mm. Thirty-nine out of 511 patent PVs (7.6%) and 96 out of 778 VCs (12-13%) were re-treated using EVLA or foam sclerotherapy. Minor complications occurred in 88 of the 778 (11%). CONCLUSIONS: EVLA of PVs and VCs is effective and faster than surgery in 2- to 6-mm PVs and VCs using an 808-nm diode laser.

The length of peritoneal surgical manipulation correlates with serum CA 125 levels.

BACKGROUND: Peritoneal recovery after uncomplicated serum manipulation usually lasts 7 days and high values of serical CA 125 are measured following abdominal surgery. The aim of this study was to assess a possible correlation between peritoneal manipulation and serical CA 125 levels following abdominal surgery for benign diseases. PATIENTS AND METHODS: Twenty-eight patients with abdominal benign disease were operated on. They were pooled into three groups of low, intermediate and high peritoneal manipulation, according to the extent of laparotomy and length of surgical peritoneal manipulation. Venous blood samples (5 ml) were taken from each patient 24-48 hours before surgery, 12-24 hours after surgery and on the 4th and 7th postoperative day. CA 125 levels were quantified by microparticle enzyme immunoassay. RESULTS: After surgery, patients having high peritoneal manipulation showed significantly higher levels of CA 125 compared to the preoperative levels. In particular, the length of peritoneal manipulation was correlated with increasing levels of the marker (p<0.0001). CONCLUSION: Peritoneal manipulation was significantly correlated to serum CA 125 levels; therefore its role as marker of peritoneal surgical injury should be considered.

Steatosis of the hepatic graft as a risk factor for post-transplant biliary complications.

BACKGROUND: Despite recent advances in organ preservation, immunosuppression, and surgical techniques, the biliary tree is still considered the Achilles' heel of liver transplantation. The aim of this study is to retrospectively analyze the incidence of biliary complications and identify risk factors that might predispose to the development of biliary problems. METHODS: From January 2004 to December 2007, 117 consecutive liver transplantations were retrospectively analyzed for the development of biliary complications by the review of medical records. Patients were divided into group 1 with biliary complications (n = 43) and group 2 without biliary complications (n = 74). RESULTS: The overall biliary complication rate was 36.8% (leakage 6% and stricture 30.8%). Univariate analysis indicated that significant predictors of biliary complications were the time interval between portal and arterial reperfusion (p = 0.037) and macrovacuolar steatosis of the graft > 25% (p = 0.004). Stepwise logistic regression model demonstrated that a macrosteatosis of the graft > 25% (OR = 5.21 CI 95% [1.79-15.15], p = 0.002) was the only independent risk factor predicting biliary complications after liver transplantation. No differences in patient's and graft's survival were noted between the two groups. CONCLUSION: According to our experience, transplanting a liver with > 25% of steatosis is a risk factor for the development of biliary complication.

[Lack of prognostic predictive value of hepatic agobiopsy in a group of patients operated of hepatic resection for hepatocellular carcinoma]. / Mancanza di valore prognostico predittivo dell'agobiopsia epatica sull'outcome di una serie consecutiva di pazienti resecati per epatocarcinoma.

AIM: To determine prior to surgery whether a fine needle biopsy is able to define a hepatocellular carcinoma grading, or not. MATERIAL OF STUDY: Thirty patients, who all underwent liver resection for HCC. In every case a fine needle biopsy of the neoplasm was taken prior to surgery, and after the operation a complete microscopic assessment of tumor grade according to Edmondson and Steiner classification was taken. RESULTS: We found no correlation between fine needle biopsy grading and post surgical one. We also found no correlation between fine needle grading and other relevant elements, alpha-fetoprotein levels and number of neoplastic nodules. DISCUSSION: Considering the small number of patients in the study, fine needle biopsy seems to be unfit to determine HCC grading before surgery, this is probably due to the different levels of neoplastic differentiation present into every single nodule and to the characteristics of Edmondson and Steiner classification. In Literature there is at least one study, similar to ours, showing problems in the correct attribution of grading level using this classification. Other authors consider the possibility to modify the scale from a 4-levels one to a 3-levels one. CONCLUSIONS: In spite of these discouraging results, and with a strict follow up monitoring any tumor seeding, we think fine needle biopsy is still fundamental for controversial cases, and for new studies on hepatocellular carcinoma, like those over vascular invasion or the molecular profile of the neoplasm.

Laparoscopic reconstruction after esophageal resection for perforation: a new surgical approach.

The authors present 2 cases of esophageal perforation treated using a new 2-step approach, consisting of esophageal resection and delayed reconstruction of the digestive tract after laparoscopic preparation and transposition of the stomach. The method is characterized by the minimally invasive insertion of a gastric tube through the precardial esophageal stump for postoperative enteral nutrition, and by the use of a laparoscopic method in the reconstruction step for gastrolysis and transposition of the stomach. The benefits lie in the opportunity for enteral feeding preparatory to the reconstruction, with no need for any gastrostomy or jejunostomy, and with fewer complications and a better recovery after reconstruction surgery thanks to the use of a laparoscopic method instead of a laparotomy.

Duplex ultrasound changes in the great saphenous vein after endosaphenous laser occlusion with 808-nm wavelength.

BACKGROUND: Endosaphenous laser ablation is used in the treatment of great saphenous vein insufficiency with various methods, with and without surgical interruption. However, its mode of action and indications are not yet clear. METHODS: To verify the mode of action of endosaphenous laser ablation by duplex ultrasound (DUS) follow-up, with the support of histologic observations of eight cases, 44 of 182 affected limbs (CEAP C2 to C6) were selected for intravenous laser ablation of the great saphenous vein. Saphenofemoral junction incompetence was treated by surgical interruption. An 808-nm diode laser (Eufoton, Trieste, Italy) was used (variable pull-back velocity, 1 to 3 mm/s; power, 12 to 15 W; energy, 30 to 40 J/cm). In eight limbs the venous fragments were studied under light microscopy at 5 minutes and after 1 and 2 months. In 44 limbs DUS and clinical examinations were performed from 7 days to 1, 2, 6, and 12 months. RESULTS: Variously organized thrombi containing necrotic inclusions and patent areas were observed in the vein lumen. Neither neovascularization nor thrombus extension were detected at the groin by DUS examination. Progressive venous diameter decrease and thrombus fibrotic transformation up to the hypotrophic venous disappearance at 12 months were followed up (P < .00001). Not occluded (18.8%), recanalized short segments (22.7%), two entirely recanalized saphenous veins with varicose recurrence (4.5%), and postoperative phlebitis (13.6%) were observed. Nonocclusions and phlebitis prevailed in the larger veins (P < .05). CONCLUSION: The healing process is based on vein thrombosis, fibrosis, and venous atrophy. Saphenofemoral interruption makes venous occlusion easier and prevents potential thrombotic complications and recurrence by recanalization. DUS monitoring makes possible to follow-up the thrombus involution and perform early retreatment. The 808-nm endosaphenous laser should be mainly applied to veins of <10 mm in diameter.

Treatment of perforation in the healthy esophagus: analysis of 12 cases.

BACKGROUND: Perforation of the esophagus still carries high morbidity and mortality rates, and there is no gold standard for the surgical treatment of choice. MATERIALS AND METHODS: We reviewed the records of patients treated for esophageal perforation in the last decade at the General Surgery Unit of the University of Udine. Patients suffering from perforation secondary to surgical procedures or neoplastic disease were ruled out. RESULTS: Eight males (66.7%) and four females (33.3%) met the inclusion criteria. The cause of perforation was iatrogenic in seven cases (58.3%) and spontaneous in five (41.7%). The perforation was in the cervical esophagus in five cases (41.7%) and at thoracic level in the other seven (58.3%). Two patients (16.7%) with cervical lesions were treated conservatively; two (16.7%) underwent primary closure and the insertion of a drainage tube; one patient with a distal cervical lesion underwent diversion esophagostomy; six patients had resection of the entire thoracic esophagus and terminal cervical esophagostomy; one had segmental resection of the distal thoracic esophagus and lateral diversion esophagostomy. In the five patients whose reconstruction was postponed, esophagogastroplasty surgery was performed with an anastomosis at cervical level in four cases and at thoracic level in one. The global mortality rate was 25%. Late diagnosis-more than 24 h after the perforation event-seems to be the only factor correlated with fatal outcome (p = 0.045). CONCLUSIONS: The choice of treatment for perforation in a healthy esophagus depends mainly on the site and size of the lesion. Cervical lesions may be amenable to conservative treatment or require primary surgical repair, while thoracic lesions with associated sepsis or major loss of substance demand an aggressive approach, with esophageal resection and delayed reconstruction seeming to be the safest option.

The role of pancreatic leakage on rising of postoperative complications following pancreatic surgery.

INTRODUCTION: The variations in methods of pancreatic stump management and the volume of literature available on both main pancreatic duct and pancreaticoenetric anastomosis leak indicates the concern associated with the leak and the continuing efforts to prevent it. Herein we analyzed the role of pancreatic leakage followed by pancreatic surgery on the incidence of postoperative morbidity. PATIENTS AND METHODS: From 1989 to 2005, we performed 76 pancreaticoduodenectomy (PD) and 26 distal pancreatectomy (DP), assumed as control case). During DP the parenchymal transection was performed with a linear stapler. The surgical reconstruction after PD was as follows: 11 manual nonabsorbable stitch closure of the main duct, 24 closure of the main duct with linear stapler, 17 temporary occlusion of the main duct with neoprene glue, and 24 duct-to-mucosa anastomosis. RESULTS: In the PD group, morbidity rate was 60%, caused by pancreatic leakage, with an incidence of 48%, hemorrhagic complication, occurred in 10% of patients following surgical procedure and infectious complication, with an incidence of 15%. After distal pancreatectomy we recorded 80, 7% no complications, 3, 9% leakage, 15, 4% hemoperitoneum. By multivariate analysis bleeding complications, biliary anastomosis leakage, and infectious complications were consequences of pancreatic leakage (P = 0.025, P = 0.025, and P = 0.025, respectively). A significant statistical difference was recorded analyzing re-operation rates between closure of the main duct with linear stapler versus temporary occlusion of the main duct with neoprene glue (t = 0.049) and closure of the main duct with linear stapler versus duct-to-mucosa anastomosis (t = 0.003). CONCLUSIONS: On the ground of our results of bleeding complication, biliary anastomosis leakage and infectious complication were consequences of pancreatic leakage: failure of a surgical anastomosis has serious consequences, particularly in case of anastomosis of the pancreas to the small bowel, because of the digestive capacities of activated pancreatic secretions.

Superiority of transplantation versus resection for the treatment of small hepatocellular carcinoma.

The best therapy for hepatocellular carcinoma (HCC) is still debated. Hepatic resection (HR) is the treatment of choice for single HCC in Child A patients, whereas liver transplantation (LT) is usually reserved for Child B and C patients with single or multiple nodules. The aim of this study was to compare HR and LT for HCC within the Milan criteria on an intention-to-treat basis. Forty-eight patients were treated by LT and 38 by HR. The median time on the waiting list for transplantation was 118 days. The estimated overall survival was significantly higher (P = 0.005) in the LT group than in the HR one. The estimated freedom from recurrence was also significantly higher (P < 0.0001) for LT patients than for HR ones. Indeed, the probability of HCC recurrence after resection was higher than after transplantation achieving 31% and 76% for HR and 2% and 2% for LT at 3 and 5 years after surgery. Multivariate analysis confirmed that transplantation was superior to resection in terms of patient's survival and risk of HCC recurrence. We conclude that LT is superior to HR for small HCC in cirrhotic patients assuming that LT should be performed within 6-10 months after listing to reduce the dropouts for reasons of tumor progression.

Treatment of recurrent symptomatic lymphocele after kidney transplantation with intraperitoneal Tenckhoff catheter.

OBJECTIVES: The incidence of lymphocele after kidney transplantation ranges from 0.6% to 16%. The management of lymphocele is still controversial. Percutaneous needle aspiration and external drainage, with or without the injection of sclerosing solutions, are associated with high recurrence and complication rates. Open or laparoscopic intraperitoneal marsupialization requires hospital admission, general anesthesia, and, sometimes, extensive surgical dissection. METHODS: We report our experience treating recurrent symptomatic lymphocele with intraperitoneal drainage using a Tenckhoff catheter on an outpatient basis in 7 consecutive patients. In all cases, the lymphocele was diagnosed by abdominal ultrasonography 26 to 90 days after kidney transplantation. The mean diameter of the lymphocele was 14 +/- 6 cm. Percutaneous drainage was the initial approach, which was also used to differentiate between urinoma and lymphocele and to rule out infection. The lymphocele recurred within 1 month in all cases. The recurrent lymphoceles were treated on an outpatient basis using intraperitoneal drainage with a Tenckhoff catheter inserted into the lymphocele under ultrasound guidance. After administration of local anesthesia, two 1-cm vertical incisions were performed: one to access the lymphocele and the other to access the peritoneal cavity. A Tenckhoff catheter was inserted in the lymphocele and tunneled into the peritoneal cavity. RESULTS: All procedures were completed on an outpatient basis without any complications. The catheter was removed 6 months later with no evidence of recurrent lymphocele at ultrasound follow-up in all cases. CONCLUSIONS: This outpatient surgical approach using ultrasound-guided intraperitoneal drainage with a Tenckhoff catheter appears to be a simple, effective, and safe method for treating unilobular recurrent symptomatic lymphocele after renal transplantation.

Percutaneous transhepatic portography for the treatment of early portal vein thrombosis after surgery.

We treated three cases of early portal vein thrombosis (PVT) by minimally invasive percutaneous transhepatic portography. All patients developed PVT within 30 days of major hepatic surgery (one case each of orthotopic liver transplantation, splenectomy in a previous liver transplant recipient, and right extended hepatectomy with resection and reconstruction of the left branch of the portal vein for tumor infiltration). In all cases minimally invasive percutaneous transhepatic portography was adopted to treat this complication by mechanical fragmentation and pharmacological lysis of the thrombus. A vascular stent was also positioned in the two cases in which the thrombosis was related to a surgical technical problem. Mechanical fragmentation of the thrombus with contemporaneous local urokinase administration resulted in complete removal of the clot and allowed restoration of normal blood flow to the liver after a median follow-up of 37 months. PVT is an uncommon but severe complication after major surgery or liver transplantation. Surgical thrombectomy, with or without reconstruction of the portal vein, and retransplantation are characterized by important surgical morbidity and mortality. Based on our experience, minimally invasive percutaneous transhepatic portography should be considered an option toward successful recanalization of early PVT after major liver surgery including transplantation. Balloon dilatation and placement of a vascular stent could help to decrease the risk of recurrent thrombosis when a defective surgical technique is the reason for the thrombosis.

A comparative study of the transhiatal laparoscopic approach versus laparoscopic gastric mobilisation and right open transthoracic esophagectomy for esophageal cancer management.

AIM: Regarding the surgical treatment of esophageal cancer, a question was raised by the introduction of minimally invasive surgery, because of the technical complexity of the techniques involved and its uncertain benefits. We evaluated the impact of laparoscopic esophagectomy on the surgical approach to esophageal cancer. PATIENTS AND METHODS: From January 2002 to March 2006, 22 non-randomized patients were recruited to undergo esophagectomy for neoplastic disease. The esophagectomy and esophagogastroplasty were performed using the laparoscopic transhiatal technique (THE) in 9 cases, while a combined laparoscopic gastric mobilisation and right transthoracic incision (TT/LE) was performed in the other 13. RESULTS: Mean follow up was 21+/-3.23 months, range 2-46 months. Overall cumulative survival was 84.0% at 12 months, 61.3% at 24 months, 51.0% at 36 months. THE achieved better results than TT/LE on the ground with regard to the time it took to complete the procedure (p=0.046) and the hospital stay times (p=0.039), and the time in ICU, postoperative oral feeding resumption, number of retrieved lymph nodes. CONCLUSION: The clinical benefits of minimally invasive techniques regard the time it takes to complete the procedure, the time in ICU, postoperative oral feeding resumption and the hospital stay times. Minimally invasive surgery might be not less curative and effective than open surgical procedures, as found in our small non-randomzed series of patients. Larger series should confirm these results.

The immediate effects of endovenous diode 808-nm laser in the greater saphenous vein: morphologic study and clinical implications.

BACKGROUND: We conducted this study to evaluate the immediate venous morphologic alterations produced in the great saphenous veins by the endovenous diode 808-nm laser used for the treatment of superficial venous insufficiency and varicose veins of the lower limbs and to clarify the clinical implications of the histologic findings. METHODS: Chosen for the study were 24 limbs of 16 patients with CEAP classification 3 to 6, ultrasound-documented greater saphenous insufficiency, and venous diameters between 3.9 mm and 17 mm (mean, 8.04 mm) without phlebitis, saphenous aneurysms, congenital malformations, or deep venous insufficiency. All limbs underwent surgical saphenofemoral disconnection, and the greater saphenous vein was treated with an endovenous diode 808-nm laser by continuous emission at 8 to 12 W and variable retraction speed (1 mm/s). Spinal or local, but not tumescent, anesthesia was used. Twenty-nine specimens (3 to 5 cm long) of 24 proximal greater saphenous and five anterior accessory saphenous veins were excised and studied by light microscopy for diameter and thickness of the venous wall, extent of injury into the intima, media, and adventitia, as well as penetration of thermal damage. RESULTS: The histologic evaluation showed thermal injury to the intima in all specimens and full-thickness intimal injury in 22 specimens (75%); the average penetration of thermal injury in 29 specimens was 194.40 microm (range, 10 to 900 microm; 14.61% of the mean wall thickness); complete intimal circumference injury occurred in 8 specimen veins <10 mm in diameter (27.5%), full thickness damage in 6 (20.7%), and perforation in 2 (6.9%). CONCLUSIONS: Saphenous ablation using 808-nm laser by variable retraction speed, combined with saphenofemoral interruption, leads to sufficient vein wall injury to assure venous occlusion. Full thickness thermal injury or perforation is infrequent. Optimal results can be obtained in veins <10 mm in diameter.

[New abdominal wall reconstruction technique with a plastic-rehabilitative intent (back pain improvement)]. / Nuova tecnica di ricostruzione della parete addominale con intento plastico-riabilitativo.

Many abdominal wall reconstruction techniques have generally failed to pay attention to a number of anatomical considerations concerning the continuity of the thoraco-lumboabdominal fascia that envelops the dorsal and ventral muscles. We have introduced a new surgical technique (round mesh) developed to improve the abdominal wall weakness or pathology (hernia, laparocele) with the aim of restoring the muscular synergy between the anterior and posterior trunk compartments, thus improving sacroiliac stability, posture, and standing effort endurance. One hundred patients of both sexes were enrolled in this investigation. All were affected by abdominal wall impairment, frank hernia or laparocele, and had been complaining of lumbar and sciatic pain for long periods without any definite intervertebral disk pathology. They underwent pre- and postoperative subjective and objective evaluation and insertion of a prefascial polypropylene mesh with a posterior martingale that passes across the spine and paravertebral muscles, ending in two wider rectangles that are criss-crossed ventrally and finally sutured to the iliopubic brim. All the patients improved either subjectively or objectively with the round mesh procedure. This new technique is particularly useful in cases of reduction or impairment of the recti abdominis, transverse and oblique muscles, because simple suture and plication of these muscles is no guarantee of long-term functional restoration.