New biograft solution, growth factors and bone regenerative approaches in neurosurgery, dentistry, and orthopedics: a review.

Bone regeneration following surgery, trauma, or any other condition is an autologous process that can fail, necessitating the requirement of novel procedures and materials. Recently, significant progress has been made in the research related to regenerative medicine. At the same time, biomedical implants in spine surgery, orthopedics, and dentistry are facing many challenges and posing clinical concerns. A PubMed, MEDLINE, and Scopus review was carried out to identify all studies dealing with bone regenerative approaches in dentistry, orthopedics, and neurosurgery from database inception to December 2022. There has been an upsurge in the implication of a multitude of materials in the enhancement of bone regeneration and/or neo-bone formation, including blood-derived growth factors, new biografts, biosynthetic polymers, inorganic compounds, and sea corals, in the very recent years. Stem cells (SCs) have been found to be efficacious and safe modalities in osteogenesis. Furthermore, bone regeneration/formation depends on the host's immune system and metabolic condition. Epidermal growth factors (EGFs) and their receptors (EGFRs) are important in the mechanism of wound repairing and healing through the recruitment of stromal stem cells for epidermal and dermal regeneration. Similarly, biocomposite developed from Silica assembled with calcium and phosphorous has been utilized in the treatment of broken bones. In this review, we summarized the clinical and laboratory evidence of bone regenerative approaches in the field of spine surgery, orthopedics, and dentistry. An accurate pre-operative screening is the key to managing and carefully planning all surgical steps and achieving the final success.

Study on the use of focus harmonic scalpel in thyroidectomies: is it useful also in preserving voice function?

OBJECTIVE: The aim of this randomized study is to evaluate the real benefits of the FOCUS Harmonic Scalpel in total thyroidectomies compared with conventional ligation, regarding operative time, postoperative blood loss, length of stay and complications. Furthermore, as never seen in other studies, we studied the effects of using the FOCUS during thyroidectomy analyzing the vocal production of patients before and after surgery. PATIENTS AND METHODS: We enrolled 361 patients who underwent total thyroidectomy from 2008 to 2014. It was a randomized clinical trial in which all the surgical procedures were performed by the same surgeon. Patients were randomized into two groups according to the haemostatic technique: 187 patients were included in a "conventional" group (C) in whom dissection and haemostasis were performed using conventional materials (Vicryl, stitches, V titanium hemostatic clips and monopolar or bipolar electrocautery); 174 patients were included in a group in which the FOCUS was used (F group). RESULTS: Our data show that the FOCUS allows a one-third time-saving vs. classic haemostasis. Moreover, the use of the FOCUS would allow reduced traction and reduced manipulation of the thyroid during surgery. Our data demonstrate that the rate of complications in the Focus group might not be significantly reduced. In our series, we noticed that the quantitative acoustic assessment of voice quality show important alterations in several parameters (Shim, Jitt, sPPQ, sAPQ studied with the Multi Dimensional Voice Program evaluation) between the C group and F group. CONCLUSIONS: The FOCUS Harmonic Scalpel reduces the operative time, post-operative blood loss and length of hospital stay in thyroidectomy. Besides, important vocal alterations after thyroidectomy seem more severe using the conventional technique instead of FOCUS.

Evaluation of scientific production in oral surgery in Italy from 1998 to 2012.

AIM: Dental research, especially in the field of oral surgery, showed a strong and significant increase during the last years. This was probably determined by the introduction among the clinicians of different therapeutic protocols through biomaterials engineering, and by the large broadcasting of scientific knowledge due to new media such as the internet. The aim of this work was to analyze the scientific production of a sample of Italian Oral Surgeons from 1998 to 2012. METHODS: The scientific production of 252 Active Members belonging to three Italian associations of Oral Surgery (SIdCO, SIO, SICOI) was examined. The number of authors, the number of publications and the number of citation were quantified for three periods of 5 years each from the first year considered along 15 years. The overall sample was then divided into two groups, academics and not academics, in order to differently assess the scientific production conducted inside or outside the University. RESULTS: Over the years, scientific production increased considerably, with a progression not strictly proportional if compared to the number of authors, especially in the last 5 years. By spearately considering the academics and the not academics authors, the biggest contribution to the scientific production increasingly came from the last 5 years, both in terms of authors' and published papers number. CONCLUSION: The results reported in this bibliometric analysis show how scientific research increasingly pursued by clinicians in oral surgery in the last 15 years.

Preprosthetic interceptive orthodontics for missing lateral incisors in late mixed dentition.

BACKGROUND: Different treatment alternatives are possible in the preprosthetic orthodontic management of missing of lateral incisors. We describe an efficient approach in a 12.11-year-old girl with incisors agenesis. CASE REPORT: Treatment started with repositioning of the permanent canines in site 2 and the deciduous canines in site 3. After growth completion the deciduous canines will be extracted and replaced by dental implants. Permanent canines will then undergo reshaping in order to look like lateral incisors. The molar and cuspid relationships were finalised in Class I, with correct overjet and overbite. The mandibular and maxillary arch forms were acceptable without crowding and rotations. Opening the space offers different solutions for maintaining the alveolar bone for a future implant, with the advantage of a molar Class I relationship and a wider arch. It would also be possible to achieve distalisation of the permanent canine, following the Kokich's principle of alveolar development. CONCLUSION: The described treatment is a valid alternative in the management of missing lateral incisors. This solution can avoid an additional orthodontic treatment in adulthood and allow easy management of the retention phase prior to final rehabilitation with single tooth implants

Work stress and negative affectivity: a multi-method study.

BACKGROUND: In the literature negative affectivity (NA) is considered both a confounding variable as well as a predictive variable for work-related stress. However, a common limitation in this line of research relates to the use of self-report measures for determining NA, perceived stressors and psychophysical strain. AIMS: To test, using a multi-method study, a theoretical model that correlates NA, perceived interpersonal conflict (with co-workers and supervisors), psychophysical strain and medically certified sickness absences. METHODS: A multi-method prospective study was carried out on a sample of metalworkers. NA and interpersonal conflict were determined using self-report (Time 1), whereas psychophysical strain was determined by an occupational physician (Time 2). Data on medically certified sickness absences were collected from the company's database (Time 3). RESULTS: There were 326 participants. The results showed an association between NA and conflict with co-workers, as well as between NA and conflict with supervisors. Psychophysical strain could be predicted from NA and conflict with co-workers but not from conflict with supervisors. NA had a significant indirect effect on psychophysical strain through conflict with co-workers. Lastly, psychophysical strain predicted sickness absences from work. CONCLUSIONS: NA influenced psychophysical strain in the worker, both directly and indirectly, through perceived conflict with co-workers.

Primary cutaneous mucoepidermoid carcinoma infiltrating the parotid gland.

Mucoepidermoid carcinoma (MEC) of the skin is an extremely rare neoplasm but is common in the major and minor salivary glands accounting of approximately 30% of all malignant tumors arising from these glands. Cutaneous involvement should be carefully assessed to exclude the possibility of metastases from distant sites. We report an 81 year-old man presenting a primary cutaneous mucoepidermoid carcinoma infiltrating his left parotid gland. Excision of the affected skin and a total parotidectomy with supraomohyoid neck dissection (level I-III) was performed followed by radiotherapy. No relapse after 2 years follow up has been observed. Since the primary cutaneous mucoepidermoid carcinoma is an aggressive neoplasm that frequently develops metastases it is important to distinguish it from primary MEC originating from the salivary glands for better management and suitable therapeutic decisions.

Angioleiomyoma of the oral cavity extended to submandibular space; an unusual tumor in an unusual deep-seated space: a case report.

Angioleiomyoma (AL) is a benign neoplasia originating from smooth muscle and very uncommon in the oral cavity. The most frequent subtype in the oral cavity is the vascular one. AL usually occurs in the extremities: only around 12% are found in other areas such as head and neck. It presents as an asymptomatic, slow growing nodule lodging in the palate, tongue or lips. The diagnosis is essentially by histological exam and special specific stains are helpful to confirm the origin and to distinguish it from other tumors. We present a case of AL found in unusual site: attached to the submandibular region in a deep-seated space.

Completely laparoscopic versus open total gastrectomy in stage I-III/C gastric cancer: safety, efficacy and five-year oncologic outcome.

AIM: Laparoscopic gastrectomy is becoming a minimally invasive procedure widely accepted by laparoscopic surgeons; yet, many doubts remain about its oncologic efficacy in treating malignant neoplasia. Aim of this study was to analyze our experience comparing completely laparoscopic total gastrectomy to its laparotomic counterpart, about safety, efficacy and five-year oncologic outcome. METHODS: From January 2003 to October 2009, 25 patients with stage I-III/C gastric cancer (TNM Seventh Edition, 2010) were operated on and retrospectively compared to an homogeneous group of patients, stratified for age, stage of disease and comorbidities. Length of surgery, estimated blood loss, postoperative ileus, resumption of oral intake, morbidity, 30 days mortality, number of lymph nodes harvested, five years overall and disease free survival were analyzed, comparing the two groups. RESULTS: There was no conversion. Thirty days mortality was zero for both groups, while morbidity was 16% in the lap group, 32% in the open group (P<0.05). Length of operation was 211±23 min for the lap group, and 185±19 min for the open group (P>0.05); the estimated blood loss was 250±150 mL for the lap group, 495±190 mL for the open group (P<0.05). Number of lymph nodes harvested was 35±18 for the lap group, 40±16 for the open group (P>0.05). No port site metastatic implantation occurred in any patient treated laparoscopically; five years overall and disease free survival were 55.7% and 54.2% for the lap group, 52.9% and 52.1% for the open group, respectively, with no statistical difference (P>0.05). Completely laparoscopic total gastrectomy represents a new challenge for the laparoscopic surgeon. In spite of clear advantage for patients, some debate remains about its oncologic efficacy in the middle and long period, even if many authors report comparable results to open total gastrectomy. In our experience, it is a safe and valid alternative to its open counterpart, with no statistically different number of lymph nodes harvested, five years overall and disease free survival in respect to the open gastrectomy. Yet, it remains a complex procedure requiring high laparoscopic skill. CONCLUSION: In our opinion, completely laparoscopic total gastrectomy is a safe and effective procedure, with long term oncologic results not statistically different from the open procedure; yet, it requires high laparoscopic experience, especially to carry out an extended lymphadenectomy and to fashion the anastomosis. More randomized prospective trials are needed to state this procedure as a new gold-standard in treating stage I-III/C non metastatic gastric cancer.

Laparoscopic versus open radical nephrectomy in T1-T2 renal carcinoma: personal 5-year experience about the oncologic outcome.

AIM: Since 1990 when it was firstly performed, radical laparoscopic nephrectomy has gained wide popularity because of its less morbidity and adequate oncologic outcome. The aim of this study was to report our experience about oncologic 5-year outcome of laparoscopic radical nephrectomy. METHODS: Fifteen patients were treated laparoscopically and retrospectively compared to a group of patients treated laparotomically, omogeneous for age, stage of disease and comorbidities. RESULTS: There was no conversion in the laparoscopic group and duration of both procedure showed no statistical difference. Laparoscopic procedures showed less intraoperative blood loss, less postoperative ileus, shorter hospitalization and less morbidity, all with statistical significance. Overall 5 years survival showed no statistical significant difference in the two groups (88.9% laparoscopic group vs. 86.2% laparotomic group). CONCLUSION: Laparoscopic radical nephrectomy has clear advantages compared to the traditional surgery, especially about less morbidity, less blood loss, shorter hospitalization, with an oncologic outcome absolutely comparable to the laparotomic procedure. Laparoscopic radical nephrectomy is a safe and oncologically adequate surgical procedure with clear advantages compared to the its open counterpart, so it must be considered as a valid alternative to laparotomic surgery in case of non metastatic T1-T2 kidney cancer.

High-density data acquisition system and signal preprocessor for interfacing with microelectromechanical system-based biosensor arrays.

Microelectromechanical system (MEMS) development has become an active area for research in over the last decade. This area has advanced rapidly in recent years due to the potential ability of MEMS devices to perform complex functions in a smaller area. There is also the prospect to develop devices that can (1) be easily manufactured, (2) offer low power consumption, and (3) reduce waste. Especially in the BioMEMS area these advantages are important in terms of applied devices for biosensing, clinical diagnostics, physiological sensing, flow cytometry, and other lab-on-a-chip applications. However, one major obstacle that has been overlooked is the interface of these microdevices with the macroworld. This is critical to enable applications and development of the technology, as currently testing and analysis of data from these devices is mostly limited to generic microprobe stations. New advancements in BioMEMS have to occur in concert with the development of data acquisition systems and signal preprocessors to fully appreciate and test these developing technologies. In this work, we present the development of a cost effective, high throughput data acquisition system (Bio-HD DAQ) and a signal preprocessor for a MEMS-based cell electrophysiology lab-on-a-Chip (CEL-C) device. The signal preprocessor consists of a printed circuit board mounted with the CEL-C device and a 64-channel filter/amplifier circuit array. The data acquisition system includes a high-density crosspoint switching matrix that connects the signal preprocessor to a 16-channel, 18 bit, and 625 kSs DAQ card. Multimodule custom software designed on LABVIEW 7.0 is used to control the DAQ system. While this version of the Bio-HD DAQ system and accompanying software are designed keeping in view the specific requirements of the CEL-C device, it is highly adaptable and, with minor modifications, can become a generic data acquisition system for MEMS development, testing, and application.

Cognicion e impacto familiar en niños con epilepsias refractarias: Resultados preliminares en 100 casos / Cognition and familial impact of children with refractory epilepsy. Preliminary results in 100 cases

Objetivos: conocer el nivel cognitivo global y el impacto familiar en un grupo de niños con epilepsias de dificil control, posibles candidatos a tratamiento quirúrgico. Material y método: la muestra estuvo constituida por 100 niños (edad media 11.2 años). El nivel cognitivo global se evaluó con un test de inteligencia general (Stanford-Binet, Wechsler). El impacto sobre la familia se estimó a través de una encuesta donde se consideró la percepción subjetiva de los padres acerca del nivel de calidad de vida de sus hijos. Resultados. Nivel cognitivo: el 58 por ciento registra retraso mental de grado leve a grave (Organización Mundial de la Salud OMS) el 11 por ciento tiene un cociente intelectual promedio y el 31 por ciento restante se sitúa en la franja de normal bajo y limítrofe. Percepción subjetiva de calidad de vida: 12 por ciento mala o muy mala, 40 por ciento regular, 37 por ciento buena, y 11 por ciento muy buena. Conclusiones. coincidente con otras investigaciones los niños con epilepsias refractantes registran un nivel intelectual inferior al término medio, lo cual refleja un grado variable pero claramente significativo de afectación cognitiva. De acuerdo a la percepción de sus padres, la calidad de vida es mala o regular en el 52 por ciento de los casos. Estos datos confirman la importancia de buscar medidas terapéuticas más efectivas, incluyendo un eventual tratamiento quirúrgico con el objeto de evitar o detener el deterioro cognitivo y mejorar la calidad de vida (presente y futura)de estos niños

Cognicion e impacto familiar en niños con epilepsias refractarias: Resultados preliminares en 100 casos / Cognition and familial impact of children with refractory epilepsy. Preliminary results in 100 cases

Objetivos: conocer el nivel cognitivo global y el impacto familiar en un grupo de niños con epilepsias de dificil control, posibles candidatos a tratamiento quirúrgico. Material y método: la muestra estuvo constituida por 100 niños (edad media 11.2 años). El nivel cognitivo global se evaluó con un test de inteligencia general (Stanford-Binet, Wechsler). El impacto sobre la familia se estimó a través de una encuesta donde se consideró la percepción subjetiva de los padres acerca del nivel de calidad de vida de sus hijos. Resultados. Nivel cognitivo: el 58 por ciento registra retraso mental de grado leve a grave (Organización Mundial de la Salud OMS) el 11 por ciento tiene un cociente intelectual promedio y el 31 por ciento restante se sitúa en la franja de normal bajo y limítrofe. Percepción subjetiva de calidad de vida: 12 por ciento mala o muy mala, 40 por ciento regular, 37 por ciento buena, y 11 por ciento muy buena. Conclusiones. coincidente con otras investigaciones los niños con epilepsias refractantes registran un nivel intelectual inferior al término medio, lo cual refleja un grado variable pero claramente significativo de afectación cognitiva. De acuerdo a la percepción de sus padres, la calidad de vida es mala o regular en el 52 por ciento de los casos. Estos datos confirman la importancia de buscar medidas terapéuticas más efectivas, incluyendo un eventual tratamiento quirúrgico con el objeto de evitar o detener el deterioro cognitivo y mejorar la calidad de vida (presente y futura)de estos niños(AU)

[Experience of a peripheral center in the surgical treatment of hepatic metastasis from colorectal cancer]. / Esperienza di un centro periferico nel trattamento chirurgico delle metastasi epatiche da cancro colorettale.

Surgical resection is still the first therapeutic option in patients with resectable colorectal cancer metastatic to the liver. Application of radiofrequency energy has been used in patients who did not meet the criteria for resectability and yet were candidates for a liver-directed procedure based upon the presence of liver-only disease. Hepatic resection has evolved in the last two or three decades from a procedure with associated mortality rate of up to 20% in the early 80s to usually less than 5% in patients undergoing liver resection thereafter. This improvement in morbidity and mortality is multifactorial; despite the increased safety of liver operations, hepatic resection still remains a complex surgical procedure with serious potential morbidity. The experience with liver resections and/or radiofrequency ablations, for colorectal cancer metastatic to the liver, performed at a medium-volume center (15 cases in 4 years) is presented. Some features of the metastatic disease, including the number, size and location of metastases are identified. The perioperative mortality is 0, morbidity for non surgical complications is 40%. In this series the reported overall 1-yr survival is 80%, 2-yr is 67%. This paper reviews the experienced factors that have defined the morbidity and mortality associated with liver surgery.

Zygotic and nucellar embryo survival following dehydration and cryopreservation of citrus intact seeds.

A cryopreservation procedure by dehydration and direct immersion in liquid nitrogen was developed for seeds of four polyembryonic Citrus species, and the sexual or nucellar origin of the recovered seedlings was investigated. Seeds of three species could be desiccated in a sterile air flow to 16 percent (C. sinensis) or 10 percent (C. aurantium and C. limon) moisture content with a negligible reduction in germination levels. Differently, the germinability of C. deliciosa seeds dropped to 50 percent after drying to 15 percent moisture content. Following dehydration treatments, a reduction in the average number of seedlings per germinated seed was always observed. However, all four species benefited from desiccation in terms of protection during immersion in liquid nitrogen, with C. sinensis and C. aurantium showing the greatest survival (93 percent germination) after cryopreservation. The Inter-Simple Sequence Repeat analysis of seedlings recovered from cryopreserved seeds showed that the dehydration/cryopreservation procedure promotes the germination of zygotic embryos and reduces the number of apomictic seedlings per seed.

The Trabucco technique in the treatment of inguinal hernias; A six-year experience.

BACKGROUND: The introduction of both polypropylene prosthesis and the new tension-free methods for the treatment of inguinal hernias, induced us to choose the Trabucco technique since August 1994. METHODS: Up to April 2001 983 inguinal hernia repairs were carried out in 825 patients, 948 with the Trabucco technique. RESULTS: Minor complications (hematoma, seroma, inguino-crural pain) were 42 (5.1%) with no wound infections. There were 3 relapses (0.36%), one treated in an other hospital and the other two were surgically treated because of the small dimension of the hernia and they were not troublesome for the patients, although they were strictly controlled. CONCLUSIONS: In spite of the limited follow-up period, there is satisfaction for the short-term period outcomes which showed the superiority of the Trabucco method compared with the traditional techniques both as to hospitalization and good recovery and to the early relapse.

[Carcinoid of the appendix. Clinical report of 3 cases and diagnostic and therapeutic considerations]. / Il carcinoide dell'appendice. Osservazione clinica di 3 casi e considerazioni diagnostiche e terapeutiche.

The Authors report three cases of carcinoid of the appendix and discuss the difficult preoperative diagnosis and the different therapeutic options available. Over the period from January 1994 to December 1999, in the Surgery Unit of Penne Hospital, 424 appendicectomies were performed in 182 males and 242 females (age: 12-86 years; mean age: 39.9 years). In three cases the histological response was positive for carcinoid of the appendix. No postoperative mortality or morbility were reported. The authors analyze the biological peculiarities and the prognostic factors associated with appendiceal carcinoid tumours, such as tumour size and the lymphatic or vascular infiltration of the mesoappendix (and the corresponding more aggressive surgical treatments) and recommend an appropriate postoperative follow-up since synchronous or metachronous bowel carcinomas are likely to occur. Pharmacological therapy has also made important progress, with the possibility of administering compounds capable of interfering with tumour development and neoplastic growth.

[Current epidemiological and clinical features meningitis in a northern Italian area] / Attuali aspetti epidemiologici e clinici delle meningiti in un'area del nord Italia.

Objectives: To study etiological, epidemiological and clinical features of 97 cases of acute meningitis. Methods: Ninety-seven cases of acute meningitis were examined in adult HIV-negative patients admitted to the Infectious Diseases Unit of the Azienda Ospedale-Universita S. Anna in Ferrara. Demographic, etiological, epidemiological and clinical data were analyzed. Results: All cases were divided into two groups according to the macroscopic aspect of cerebrospinal fluid (CSF): purulent CSF (50 cases) or non-purulent CSF (47 cases). Purulent CSF meningitis more frequently affected male patients (64% vs 47%) and older patients (average 52 vs 44 years). The main epidemiological features in both groups were underlying bacterial diseases (i.e. otomastoiditis and/or sinusitis in 50% of pneumococcal meningitis) and iatrogenic immunodeficiency. From a clinical point of view the following alterations in the state of consciousness (stupor, confusion and coma) were most frequently found in purulent meningitis. The following non purulent forms of meningitis were diagnosed: 5 tubercular, 3 viral infections, 2 by Listeria monocytogenes, 1 by Entoameba histolytica, 1 by Cryptococcus neoformans and 35 (74,4%) unknown causes. Purulent meningitis were: 20 (40%) Streptococcus pneumoniae, 10 Neisseria meningitidis, 3 Staphylococcus aureus, 2 Escherichia coli, 1 Haemophilus influenzae and 1 Pseudomonas aeruginosa; 13 cases were unidentified. From 1989 to 1993 and from 1994-98 both groups of meningitis increased; respectively from 17 to 30 cases for non-purulent meningitis and from 18 to 32 cases for purulent meningitis. Meningitis due to Streptococcus pneumoniae increased from 27.7% to 46.8% during the period 1994-98. Conclusions: The study shows the high incidence of pneumococcal meningitis, during 1994-98, because a large number of patients with sinusitis and otomastoiditis were observed. The incidence of meningococcal meningitis appears stable. These data confirm the importance of timely diagnosis and correct therapy for such infections with reserved prognosis.

[The single-stage surgery of perforated colon carcinoma. Our experience of 46 cases]. / La chirurgia in un tempo del carcinoma colico perforato. Esperienza di 46 casi.

BACKGROUND: 46 cases of perforated colonic neoplasm (4.6% of the entire series): 11 (24%) of the right colon, 35 (76%) of the left colon; 19 males (41%) and 27 females (59%); mean age 67 years old, range 32-92 years. pTNM: stage II, 1 case (2%); stage III: 27 cases (59%); stage IV, 18 cases (39%). The aim of this study was to resolve the perforation and to treat the neoplasm in a single operation. METHODS: The various types of perforation included: 35/46 = 76% perforations in situ; 6/47 = 13% recent perforations upstream; and 5/46 = 11% at a distance from the neoplasia. The following types of peritonitis were observed: purulent localised 10/46 = 22%, purulent generalised 12/46 = 26%, fecaloid 18/46 = 39%, fecal 6/46 = 13%. In 24 cases/46 = 52% the perforation had occurred in an occluded colon. The preoperative finding of pneumoperitoneum in 12/46 = 26% indicated generalised fecaloid-fecal peritonitis. Surgery commenced by suturing the perforation followed wherever possible by standard colectomy: on the right in all 11 cases = 100%, on the left in 15/35 = 43%; only in the event of prohibitive local or in particular general conditions was Hartmann's segmentary colectomy used in 10 cases/35 = 29%, or a definitive preternatural anus in 10/35 = 29%. The following aspects are essential in this single-stage surgery: the emergency nature of the operation; massive dose antibiotic treatment limited to the pre- and perioperative stages and above all peritoneal cleansing using accurate, methodical, repeated and abundant lavage with 8-10-20 or more litres of polysaline isotonic solution at 37 degrees C, but only used 500 ml at a time. This lavage is essential to reduce bacterial load contributes to the rapid hydroelectrolytic re-equilibrium in severe conditions of peritonitis. When necessary, colonic preparation was carried out using direct colostomic perioperative lavage. The peritonisation of the retroperitoneum with the omentum is important, as is the protection of the anastomosis using omental wrapping and active lavage and aspiration of the colorectal anastomosis, even using the 3-way tube, in a transanal trans- or subanastomotic position. Total parenteral feeding is useful and almost indispensable for 6-8 days. RESULTS: Postoperative morbidity was negligible and mortality occurred in 14/46 cases = 30%, of whom 13/32 = 41% were over 60 and 1/14 = 7% under 60; if the cases are divided into two periods, pre-Gullino tube (1974-84) mortality was 8/22 = 36% and with Gullino's tube (1985-95) it was 6/24 = 25%; postoperative stay was 18 days in the first period and only 11 days in the second. The 11 cases at stage IV who survived the operation all died following the spread of neoplasms within 2-30 months, mean 10 months; the over-5-year survival rate for the only case at stage II and the 19 at stage III was 38% (Kaplan-Meier). CONCLUSIONS: By using this courageous single-stage surgery and operating patients at such a severe stage, both the immediate and long-term results appear to be more than satisfactory. It is important to underline, however, that not all neoplastic perforations appeared to be caused by endoluminal hypertension-ischemia; in those cases with non-occluded colon, about half might have been the consequence of biological problems of immune hyperreactivity of a rejection reaction type (Arthus, Snarelli-Shwartzman phenomenon and similar).

[The single-stage surgery of colorectal neoplastic occlusion. The experience of 133 cases]. / La chirurgia in un tempo dell'occlusione neoplastica colon-rettale. Esperienza di 133 case.

BACKGROUND AND AIM: 133 cases of occluded colorectal neoplasms (14% of the entire series): 30 (23%) of the right colon, 103 (77%) of the left colon-rectum; 69 males (52%) and 64 females (48%); mean age 67.5 years old, range 33-91 years. pTNM: stage II, 28 cases (21%); stage III: 43 cases (32%); stage IV, 62 cases (47%). The aim of this study was to resolve the occlusive symptoms and to treat the neoplasm in a single operation. METHODS: In the 62 cases at stage IV, surgery was solely palliative: 49 (79%) derivations, 13 (21%) entero-enterostomies and 36 (58%) preternatural anus; 11 (18%) standard hemicolectomies, extended in two cases to hepatic resection, and 2 (3%) Hartmann's operations. In the 71 cases at stages II and III, surgery took the form of standard colic exeresis with primary ligature of the colonic vessels at source and at the outlet; 15 (21%) right colectomies, 50 (70%) left colectomies, extended in 6 cases (8%) to abdomino-perineal amputation; 6 segmentary colectomies, 3 (4%) of the transverse colon and 3 (4%) Hartmann's operations. The following aspects are essential in this single-stage surgery: urgency; massive dose antibiotic treatment limited to the pre- and perioperative stages; peritoneal cleansing using accurate, methodical, repeated and abundant lavage; perioperative colonic preparation using direct colotomic perioperative lavage or using a trans-buccoenteric access (using Grosz-Dennis tube); the peritonisation of the retroperitoneum with the omentum and the protection of the anastomosis using omental wrapping and active lavage and, for colorectal anastomosis, even using the 3-way tube, lavage and active aspiration, in a transanal trans- or sub-anastomotic position. Total parenteral feeding is useful for 6-7 days. RESULTS: In the 62 cases at stage IV, postoperative morbidity was 3 cases (6%): 3 suppurations of laparotomy, and mortality occurred in 10 cases (16%): one case of anastomotic disunion (pre-Gullino's tube), 3 cases of septic shock and 6 cardiorespiratory failures. Mean postoperative hospitalisation was 14 days. All these patients died owing to the spread of neoplasms within 1-40 months, mean 13 months. The worst results were obtained in entero-enterostomies: 1-9 months, mean 5 months. In the 71 cases at stages II and III, postoperative morbidity was 3 cases (4%): a small anastomotic filtration after right colectomy and 2 suppurations of the laparotomic incision; mortality amounted to 10 cases (14%): one case of septic shock, one of acute hepatitis, one intestinal infarction and one cardiac infarction, 3 pulmonary embolisms and 3 cardiorespiratory failures. Mean postoperative hospitalisation was 13 days, only 10 in cases of left colectomy with anastomosis protected by Gullino's tube. The long-term results were very good in these 71 patients: over 5-year survival of 50% (Kaplan-Meier). CONCLUSIONS: Using this courageous single-stage surgery, the results are optimal even at a distance, together with reduced surgical trauma and a shorter hospital stay.

[Perforated diverticular disease of the left colon. Proposed single-stage left colectomy protected by a three-way lavage and active aspiration tube (di Gullino) positioned inside or below the anastomosis. Experience in 65 cases]. / Malattia diverticolare perforata del colon sinistro. Proposta di colectomia sinistra in un tempo, protetta dal tubo a tre vie (di Gullino) di lavaggio ed aspirazione attiva, trans- o sottoanastomotico. Esperienza di 65 casi.

BACKGROUND: The incidence of perforative diverticulitis of the left colon is steadily increasing. Today the decision is generally taken to perform two-stage surgery: segmentary resection without (Hartmann's operation) or with anastomosis, but protected by a colostomy ("limited intervention"). This study aimed to examine standard colectomy performed in a single operation ("ideal intervention"). METHODS: Left colectomy with primary ligature of the lower mesenteric artery and vein at the source and outlet, en bloc removal of the colon-mesocolon and immediate transverse colorectal anastomosis. Anastomosis protected by the omentum which is also used to peritonise the retroperitoneum and to wrap around the anastomosis, and anastomosis also protected by the author's three-way lavage and active aspiration tube in either a trans- or subanastomosis and transanal position. Urgency is essential for this single-stage operation, together with massive dose antibiotic treatment limited to the pre- and postoperative stages, but above all peritoneal cleansing using accurate, methodical, repeated and abundant lavage with 8-10-20 or more litres, but only used 500 ml at a time. Of these 65 cases, 40 (62%) were purulent localised peritonitis and 25 (38%) were generalised (14 purulent, 4 fecaloid and 7 fecal). 8 cases (12.3%) underwent surgery in three stages and 16 (24.6%) underwent sigmoidectomy in one or two stages ("limited intervention"), 41 cases (63%) (1985-95, when Gullino's three-way tube became available) underwent standard colectomy in a single stage. RESULTS: Morbidity in 10 cases/65 (15%) and septic mortality in 5 cases/65 (7.7%) (limited to generalised peritonitis alone) only affected patients undergoing "limited interventions", but none of the 41 patients undergoing "ideal intervention". Mortality was significantly influenced by age: 50% of over 80 year-olds, none below 60. Postoperative hospitalisation was 17.1 days (in the first stage) of "limited interventions" and 9.7 days for "ideal interventions". CONCLUSIONS: The results argue clearly in favour of the "courageous" ideal colectomy with peritoneal lavage and protection of the colorectal anastomosis using Gullino's three-way tube.