Detachable snare versus epinephrine injection in the prevention of postpolypectomy bleeding: a randomized and controlled study.

BACKGROUND AND STUDY AIMS: Several endoscopic techniques have been developed to prevent bleeding after the removal of large pedunculated polyps. PATIENTS AND METHODS: From January 1995 to December 2002, 488 consecutive patients with pedunculated colorectal polyps, the heads of which were larger than 10 mm in diameter, were randomly assigned to three groups. In group A (163 patients), detachable snares were placed at the base of the stalk and standard snares were then used for polypectomy. In group B (161 patients), the polyp stalk was injected with a 0.01 % epinephrine solution before conventional snare polypectomy. Group C (a control group including 164 patients) underwent conventional snare polypectomy without preventive measures. Early (< 24 h) and late (> 24 h - 30 days) bleeding complications were assessed. Each group was divided into two subgroups relative to the polyp size (polyps 1.0 - 1.9 cm and polyps > or = 2 cm). RESULTS: Overall bleeding complications occurred after 4.3 % of the polypectomies. Bleeding was successfully controlled in all patients, and no blood transfusions were required. There were three cases of bleeding in group A (1.8 %), five in group B (3.1 %), and 13 in group C (7.9 %). Early bleeding was more frequent than late bleeding (15 vs. six patients). In polyps > or = 2 cm (207 patients), postpolypectomy bleeding occurred in 14 patients (6.7 %): two (2.7 %) in the detachable snare group, two (2.9 %) in the epinephrine injection group, and 10 (15.1 %) in the control group. CONCLUSIONS: These results show that polypectomy of large pedunculated polyps is associated with a higher incidence of bleeding. Particularly in polyps larger than 2 cm, preventive measures can significantly reduce bleeding complications after polypectomy. This can be achieved with similar efficacy either by placing Endoloops or by injecting epinephrine.

[Intestinal occlusion caused by malignant neoplasia of the colon: surgical strategy]. / Occlusione intestinale da neoplasia maligna del colon: strategia chirurgica.

Malignant tumors of the large bowel become often clinically evident as an obstruction in 8-29% cases, specially the neoplasms at the splenic flexure (50%) or descending colon (25%). Different factors (urgency, age, colonic distension and lack of adequate bowel preparation) influence therapeutic choice, specially about the bowel resection and one stage anastomosis. Twenty-six patient with neoplastic stenosis of the large bowel (8 of ascending colon and proximal transverse, 5 of splenic flexure or descending colon, 12 of the sigma, 1 of the rectum) have been surgically treated. 4 patient have been subjected to right emicolectomy and ileo-transverse anastomosis; 2 to Hartman's operation; 1 to anterior resection of the rectum; 3 to left hemicolectomy and 2 to resection of the sigma with colic on table irrigation and one-stage anastomosis; 13 to colostomy; 1 to palliative ileo-colic bypass. Two patients (7.5%) died in post-operative period. In patients subjected to one-stage procedures for left colic stenosis, the Authors haven't observed major complications, but one patient developed an anastomic leakage (4%), conservative treated. In stenosis localized to ascending colon or hepatic flexure standard surgical operation is right emicolectomy. In patients affected by cancer of descending colon, the Hartmann's operation is considered the more rational procedure, even if 50% of the patients aren't reoperated on for reconstruction. The one-stage anastomosis is indicated only in selected cases, specially subjected to TPN before surgery or balancing of the metabolic parameters and to antibiotic prophylaxis. The subtotal or total colectomy is indicated when signs of colic perforation are found or when the colon is massively dilatated or there are signs of colonic necrosis or in case of other lesions of the large bowel preoperatively known.

Laparoscopic procedures in patients who have previously undergone laparotomic operations.

BACKGROUND: Patients who have undergone laparotomy can undergo laparoscopic procedures and thus benefit from the advantages that the technique offers without significantly increasing the risk of the operation. METHODS: We present the results of 240 patients, chosen at random who underwent laparoscopic procedures and who had already had 1 or more laparotomic abdominal operations. We carried out 180 cholecystectomies, 12 of which for acute inflammation of the gall bladder, 10 for acute biliary pancreatitis, 3 with exploration of the common bile duct, 45 Nissen fundoplication procedures, of which 16 with removal of the gall bladder, 4 subtotal gastrectomies, 2 GEAs, 2 left colectomies, 4 adhesiolyses. RESULTS: The duration of the procedure varied from 40 to 300 minutes, and hospitalization time after the operation from 1 to 15 days, depending on the previous operation and on the laparoscopic procedure used. A traditional operation (conversion) became necessary in 1.35% of patients. Complica-tions arose in 4% of cases: 4 hematomas, 1 infected wound, 2 bile leaks and 2 bowel fistulas at low flow. CONCLUSIONS: Laparoscopic surgery in pa-tients who have previously undergone abdominal operations is difficult. The extent of conversions and complications can be contained within acceptable limits by choosing carefully the insertion point of the first trocar and dissecting the bowel with great precision.

[Management of the neoplastic stenosis of the left colon with self-expandable endoprosthesis]. / Il trattamento delle stenosi neoplastiche del colon sinistro mediante endoprotesi autoespandibili.

Malignant tumors of the large bowel develop colonic obstruction in 10-30% cases. Recently many authors have employed self-expandable stents to resolve the colonic obstruction. During 2002, seven patients affected by neoplastic malignant stenosis of the left colon underwent endoscopic placement of self-expandable enteral stent. The technique succeeded in relieving the obstruction in 6 patients, while in a woman affected by malignant tumor of the splenic flexure, colonic stenting was unsuccessful. The Authors didn't observe any procedure related complications; sign and symptoms of intestinal obstruction resolved within 24-72 hours from placement. Four patients needed hydro-electrolitemic correction, intestinal cleaning and R0 resection with one stage anastomosis within 5 and 9 days. Bowel decompression of the neoplastic stenosis relieved by self expandable metallic stents is useful to avoid emergency surgery and provide time for a complete preoperative staging, a metabolic correction and a mechanical bowel preparation. Complications of stent placement are common in many reports and include minor rectal bleeding (2%) and perforations (4%). Stenting is contraindicated in cases of enlarged colon with diameter superior to 8 cm or in flogistic lesions.

[Sarcoma of the breast. Two clinical cases and review of the literature]. / I sarcomi della mammella. Due casi clinici e revisione della letteratura.

BACKGROUND: Sarcomas of the breast are rare neoplasm. Wide discordances exist about prognostic factors, therapy and life expectancy. METHODS: Two women affected by sarcoma of the breast; prognostic aspects and therapy are analyzed. RESULTS: After radical mastectomy one patient, with neoplasm of 4.5 cm in diameter, is still alive one year after the surgical procedure. CONCLUSIONS: Diagnosis of the sarcomas of the breast is very difficult with the common radiological imaging, specially in the early phases when the sarcomas often can simulate absolutely benign lesions. Prognostic factors are histological type and degree, mytosis number for field and, probably, dimensions of the neoplasm. Sarcomas less than 3 cm in diameter can be admitted to conservative surgical procedure, but radical mastectomy is unavoidable when dimensions exceed this limit.

[Intraoperative cholangiography in videolaparoscopic cholecystectomy: indications, advantages, and limitations]. / Colangiografia intraoperatoria in corso di colecistectomia videolaparoscopica: indicazioni, vantaggi, limiti.

Consensus doesn't exist about the intraoperative cholangiography specially if is need in every one laparoscopic cholecystectomy either exclusively in case of anatomical doubts or suspect of injures or stones of the common duct. We have considered 450 patient subjected to laparoscopic cholecystectomy during 1992-2000. Patients suspicious to be affected by common duct lithiasis (28 cases) are subjected to ERCP with cleaning of the biliary tree. In 18 patients (4%) it has been necessary the laparotomic conversion; 176 patients (39%) have been subjected to intraoperative cholangiography, selected on anatomical regional disposition or anamnesis and biochemical and instrumental results (history of jaundice or gallstones pancreatitis, abnormal serum level of the biliary stasis biochemistry, common bile duct major of 8 mm, michrolitiasis of the gallbladder). In 7 cases (4%) we have discovered common bile duct stones. We don't attempt intraoperative cholangiography in every one laparoscopic cholecystectomy, but only in cases where we suspect presence of common bile duct stones either iatrogenic injuries or when we retain it necessary to clarify the regional anatomy. Unlikely just in patients where would be more useful, causes major risk of intra- and post-operative complications, it is very difficult, often impossible, to attempt the intraoperative cholangiography. Routinary employing of the intraoperative cholangiography could be useful just for a little number of patients, while selective employing reduce 60% the X-ray. Collaboration with the radiologist is able to reduce the mistaken on the interpretation of the radiograms.

[Septic complications of gallbladder lacerations during laparoscopic cholecystectomy]. / Complicanze settiche da lacerazione della colecisti in corso di colecistectomia laparoscopica.

The iatrogenic gallbladder perforation with bile and, eventually, gallstones loss in the peritoneal cavity happens in the laparoscopic cholecystectomies more frequently than in the laparotomic ones. The authors have reviewed their experience and recent bibliography with the aim to clarify factors that increase risks for this adverse effect; 579 patients subjected to laparoscopic cholecistectomy: in 81 cases (13.98%) the intra-peritoneal perforation of the gallbladder wall has happened, in 26 associated to gallstones loss; 12 of these last have developed abdominal wall infections. No case of intra-peritoneal abscess was observed. The Authors believe to be proper to select patients with the clinical and instrumental evaluation. They identify emergency and flogosis as risk factors for the perforations, as well the systemic illnesses for sepsis. They emphasize the role of antibiotic prophylaxis in the high risk subjects.

[Role of the subfascial endoscopic perforator vein surgery in the treatment of venous ulcers]. / Ruolo della interuzione sottofasciale delle vene perforanti per via endoscopica nella terapia delle ulcere flebostatiche.

BACKGROUND: Limbs phlebostatic ulcers are in many cases associated with perforator reflux veins often caused by post-thromboflebitis syndrome. The origin operation consisting in perforating vein interruption, described by Linton in 1938, allowed high quality exposition of these vessels and gave successful therapeutic results only affected by complications which prolonged hospitalisation. The most unfavorable prognostic factor was the need of performing an incision in skin sites affected by dermo-hypodermic degeneration induced by phlebopathy which inhibits post-surgery cicatrization. The therapeutic importance of reflux perforator vein interruption induced vascular surgeons to improve various procedures not affected by post-surgery complications and able to excise as much incontinent vessels as possible. METHODS: By video-surgery and new surgery tools nowadays available, the Subfascial Endoscopic Perforating Veins Surgery (SEPS) was established as a feasible and valuable method. At present, there are many surgical techniques differing from each other for the tools and the subneurotic compartement from which the perforating veins start. The results obtained from 45 SEPS procedures performed on 45 patients presenting lymphodermatosclerosis or venous ulcers caused by chronic venous insufficiency have been retrospectively evaluated. RESULTS: Thirty-six patients reached ulcer healing within 4 weeks after the operation; 7 ulcers healed over a 2 month time, while for 2 patients no clinical improvement has been recorded yet. CONCLUSIONS: SEPS is a valid alternative to the Linton procedure and provides remarkable advantages both in economic and clinical terms since it yields a more rapid lesions healing of small incisions which makes it one of the most minimally invasive surgical technique.

The effects of increasing heel height on forefoot peak pressure.

The purpose of this study was to determine the effect of increasing heel height on peak forefoot pressure. Thirty-five women were examined while wearing sneakers and shoes with 2-inch and 3-inch heels. An in-shoe pressure-measurement system was used to document the magnitude and location of plantar peak pressures. Pressure under the forefoot was found to increase significantly with increasing heel height. As the heel height increased, the peak pressure shifted toward the first metatarsal and the hallux. The reproducibility of data obtained with the in-shoe pressure-measurement system was tested in five subjects; the data were found to be reproducible to within approximately 3% of measured pressures.