[Multilevel atherosclerotic lesions of the lower limbs. Simultaneous surgical and endovascular approach. A case report]. / Lesioni aterosclerotiche "multi-level" dell'arto inferiore. Approccio terapeutico simultaneo, chirurgico ed endovascolare. Caso clinico.

Surgical treatment of femoro-popliteal atherosclerotic occlusion usually consists in a femoro-distal bypass. However, the associated presence of proximal lesions that reduce prosthesis inflow, or of distal lesions that increase resistances may be decisive factors in determining the outcome of the revascularisation. Frequently, an iliac or common femoral artery stenosis can be treated with an endovascular technique prior to surgery, thus increasing the bypass inflow that is going to be created. On the contrary, in the case described here, the stenosis was distal to the femoropopliteal bypass and was treated with PTA + stenting, thus increasing the run-off and the theoretical long-term patency. Therapeutic indications and technical options are discussed in the light of the recent international literature and the new achievements in terms of endovascular technique.

Blind pouch syndrome secondary to gastrojejunostomy. Report of a case.

A case of blind pouch syndrome following a Roux-en-Y reconstruction after gastrectomy is presented. The patient had a history of pain, anaemia and weight loss and the diagnosis was made on the basis of upper gastrointestinal barium contrast radiography. The surgical procedure was an entero-entero anastomosis between the blind loop and the efferent loop. The postoperative course was uneventful. No symptomatic recurrence was found at one-year follow-up. We advocate this procedure as a valid alternative to resection in cases where the blind loop is not damaged by chronic dilatation. The aim of this operation is to maintain the preferential gastric emptying route via the blind loop in order to prevent recurrence on the stump, and reduce loop isolation in order to minimise ischemic or stenotic damage to the anastomosis.

Introduction of laparoscopic appendectomy: a retrospective comparison with the open technique.

Laparoscopic appendectomy (LA) is gaining favour as an alternative to the traditional laparotomic technique (OA) despite the persistence of controversy regarding indications, morbidity, hospital stay, costs and surgical time. We present a retrospective analysis of our first three years of experience with the procedure. During this period we performed 235 appendectomies (102 laparoscopic and 133 laparotomic). The conversion rate was 9.7%, due to severe peritonitis, high-grade inflammation and an unfavorable position of the appendix; we found a significantly higher percentage of difficulty due to these factors in the laparotomic procedures. Operating time was similar in the two groups. The rate of associated pathology was higher (22.5% vs 6%) after laparoscopy, but conversion to laparotomy was never necessary for treatment. Early morbidity was limited to 2 patients who underwent laparoscopic appendectomy (1 re-operation for a micro-abscess and 1 conservatively treated haemorrhage), while wound infections (13.5% vs 1.9%) and incisional hernias (0% vs 2.3%) were more frequent in the open procedures. Hospital stay was slightly less in the laparoscopic group (4.0 vs 4.7 days). In our initial experience, laparoscopic appendectomy has shown significant advantages in terms of intraoperative diagnosis of associated diseases and diminished morbidity. We advocate a laparoscopic approach to appendicular disease, reserving conversion to laparotomy for selected cases after exploration.