A multicenter retrospective study on 4480 implanted PICC-ports: A GAVeCeLT project.

BACKGROUND: PICC-ports may be defined as totally implantable central venous devices inserted in the upper limb using the current state-of-the-art techniques of PICC insertion (ultrasound-guided venipuncture of deep veins of the arm, micro-puncture kits, proper location of the tip preferably by intracavitary ECG), with placement of the reservoir at the middle third of the arm. A previous report on breast cancer patients demonstrated the safety and efficacy of these devices, with a very low failure rate. METHODS: This retrospective multicenter cohort study-developed by GAVeCeLT (the Italian Group of Long-Term Venous Access Devices)-investigated the outcomes of PICC-ports in a large cohort of unselected patients. The study included 4480 adult patients who underwent PICC-port insertion in five Italian centers, during a period of 60 months. The primary outcome was device failure, defined as any serious adverse event (SAE) requiring removal. The secondary outcome was the incidence of temporary adverse events (TAE) not requiring removal. RESULTS: The median follow-up was 15.5 months. Device failure occurred in 52 cases (1.2%), the main causes being local infection (n = 7; 0.16%) and CRBSI (n = 19; 0.42%). Symptomatic catheter-related thrombosis occurred in 93 cases (2.1%), but removal was required only in one case (0.02%). Early/immediate and late TAE occurred in 904 cases (20.2%) and in 176 cases (3.9%), respectively. CONCLUSIONS: PICC-ports are safe venous access devices that should be considered as an alternative option to traditional arm-ports and chest-ports when planning chemotherapy or other long-term intermittent intravenous treatments.

Abdominal compartment syndrome due to a giant multilobulated ovarian serous cystadenoma. Case report and review of the literature.

The Authors report a case of abdominal compartment syndrome due to a giant ovarian serous cystadenoma. Despite of the relief of intra-abdominal hypertension (IAP: 16 mmHg), mild symptomatology (clinostatic dyspnea) lead to defer the emergency surgical treatment; after CT scan of abdomen and pelvis was performed a resection en bloc of the cystic mass, oophorectomy and cholecystectomy. However it seems advisable to perform an emergency laparotomy in patients with abdominal compartment syndrome (ACS) grade II when presenting as an acute abdomen.

[Conservative treatment of chyle fistula of the neck following a reintervention of cervical bilateral lymphectomy for medullary carcinoma of the thyroid. Case report]. / Trattamento conservativo di fistola chilosa del collo in paziente sottoposta a reintervento chirurgico di linfectomia bilaterale per carcinoma midollare della tiroide. Case report.

Chyle fistula is an uncommon serious complication of neck surgery, occurring in 1-3% of radical neck dissections. An untreated chyle leak is a potentially dangerous condition that may rarely lead to hypovolemia, hyponatremia, hypochloremia, hypoproteinemia and lymphopenia. Anatomic variants of the terminal portion of the thoracic duct and suction drainage in the neck wound play a primary role in causing this kind of lesion. Poor is the literature concerning chyle fistula, due to its rarity, and mostly case reports; still debated--prevalently empiric--is the management of this disease. The Authors report a case of chyle fistula following a reintervention of cervical bilateral lymphectomy for medullary carcinoma of the thyroid in a 75 years old female. In the reported case the chyle fistula was successfully treated conservatively, in early post-operative period with a low-fat diet and total parenteral nutrition, definitely followed by sclerosant therapy. The injection of a sclerosant agent (4 g of sterile medical talc diluted in isotonic sodium chloride solution) into the supraclavicular wound bed, through the drainage tube (clamped for 2 hours), determined rapid decline in fistula output, hence obviating surgical intervention.

[Diagnosis, surgical treatment and follow-up of the hyalizing trabecular adenoma of the thyroid]. / Diagnosi, trattamento chirurgico e follow-up dell'adenoma trabecolare ialinizzante della tiroide.

In the last twenty years, we submitted 853 patients to thyroid surgery. We found only in ten patients a hyalinizing trabecular adenoma at the (histological control), as a confirmation of the rarity of this tumour. The authors report a retrospective analysis of this cases to document the clinical features and the evolution through a long term follow-up that has showed no recurrent disease. In conclusion the hyalinizing trabecular adenoma represents a low malignant potential tumour. However, the uncertain clinical behaviour doesn't be undervalued and patients must be subjected to accurate follow-up.

[Diagnosis, surgical treatment and follow-up of the hyalizing trabecular adenoma of the thyroid]. / Diagnosi, trattamento chirurgico e follow-up dell'adenoma trabecolare ialinizzante della tiroide.

In the last twenty years, we submitted 853 patients to thyroid surgery. We found only in ten patients a hyalinizing trabecular adenoma at the (histological control), as a confirmation of the rarity of this tumour. The authors report a retrospective analysis of this cases to document the clinical features and the evolution through a long-term follow-up that has showed no recurrent disease. In conclusion the hyalinizing trabecular adenoma represents a low malignant potential tumour. However, the uncertain clinical behaviour doesn't be undervalued and patients must be subjected to accurate follow-up.

The semiopen first umbilical trocar access technique in laparoscopic surgery: easy and safe.

BACKGROUND: First access in laparoscopy still causes trouble and a small percentage of visceral and vascular injuries. Residents and surgeons-in-training often have doubts about which technique is safer and "friendlier." Semiopen technique (SO) for the first umbilical trocar access was originally described in 2002. We report our retrospective analysis using SO that shows its safety and easiness. METHODS: In the period from January 2003 to November 2007, 300 unselected patients, including obese patients (body mass index > 30) were treated with laparoscopy beginning with a periumbilical approach using SO. We usually prefer to enter the cavity with a STEP cannula stiffened by an unarmed Veress needle of 1.9 mm. There were 112 men and 188 women with ages ranging from 16 to 82 years. The procedure was performed by an expert laparoscopic surgeon in 260 cases and by residents or surgeons without expertise in laparoscopy in 40 cases. RESULTS: We experienced no injuries of the viscera or vessels (0%). The mean time to enter the abdomen was 180 seconds, including obese patients. CONCLUSIONS: After our limited experience with the SO, we believe that every surgeon who tries it will experience safety of the Hasson and the comfort of the Veress.

[Chronic abdominal pain and peritoneal mesothelioma: case report]. / Dolore addominale cronico e mesotelioma peritoneale: caso clinico.

Chronic abdominal pain syndrome is becoming increasingly important. The main symptom is persistent abdominal pain, which may vary intensely and be associated with constipation and episodes of vomiting, evolving towards sub- or total occlusion of the bowel. A 65-year old man presented with malignant peritoneal mesothelioma, with environmental asbestos exposure and chronic abdominal pain for more than one year. Due to his poor general condition, only palliative surgery was performed to resolve small and large bowel obstruction.

Venting direct percutaneous jejunostomy (DPEJ) for drainage of malignant bowel obstruction in patients operated on for gastric cancer.

Malignant chronic bowel obstruction (MCBO) is a syndrome caused by abdomen-pelvic diffusion of neoplastic diseases of any origin. It generally occurs in an advanced disease, affecting 3-15% of patients recently operated, untreated, or submitted to radiotherapy. Patients complain of chronic pain and vomitus. The approach to this problem is multidisciplinary, involving the surgeon, the endoscopist, the oncologist, and the pain-therapy expert. Direct percutaneous jejunostomy (DPEJ) using a percutaneous endoscopic gastrostomy (PEG) tube is a jejunal percutaneous access procedure indicated for nutrition in those patients whose stomach cannot be used, as in cases of partially or totally gastrectomized ones. A venting PEG or percutaneous endoscopic jejunostomy (PEJ) is a solution to drain the gastrointestinal tract for MCBO even in difficult cases represented by patients with previous abdominal surgery, those with partial or total gastrectomies, ascites, or peritoneal carcinosis. We report our five-case experience of draining an MCBO in patients previously operated on for gastric cancer, using a DPEJ technique that we believe is the best technique for this purpose.

[Subtotal colectomy in the treatment of neoplastic left colon obstruction]. / La colectomia subtotale nel trattamento dell'occlusione meccanica da carcinoma del colon.

INTRODUCTION: Subtotal colectomy and ileo-sigmoid or ileo-rectal anastomosis is a treatment wort of considering in patients affected by colonic neoplastic obstruction, as it shows low morbidity and mortality, and good results. CASE REPORT: A case of bowel obstruction due to a stenotizing neoplasm of sigmoid colon is reported. The obstruction causes severe dilation before the stricture), particularly accentuated in the cecum, which showed very reduced wall thickness and initial signs of ischaemia. Staplers (GIA 75 and EEA 31) were employed to perform a quick and aseptic (removal of a closed specimen) surgical procedure, subtotal colectomy and L-T ileo-rectal anastomosis. CONCLUSIONS: According to personal experience, benefits and disadvantages related to its surgical options are considered by the Authors.

[Complications in the treatment of cholangiolithiasis. Personal experience]. / Complicanze nel trattamento della colangiolitiasi. Esperienza personale.

Bile ducts lithiasis is a very common disease all over the world. In Italy prevalence is about 5 millions cases: 11% of the population. Choledocholithiasis concurrent with gallbladder stones frequency is estimated from 4 to 20%. Incidence is even higher in the elderly and in patients affected by chronic liver disease. The treatment of bile ducts lithiasis is still debated; several surgical strategies may be performed: (1) fully laparoscopic procedure; (2) endo-laparoscopic sequential treatment; (3) sequential inverse treatment (endoscopy following video laparoscopic cholecystectomy); (4) combined endo-laparoscopic treatment simultaneously performed; (5) 'open" treatment. The authors refer their experience concerning a series of 172 patients who underwent endo-laparoscopic sequential treatment to amend bile duct and gallbladder lithiasis. Complications are pointed out, pending to demonstrate safeness and effectiveness of this strategy.

[Evaluation of operative risk in emergency treatment of neoplastic left colon obstruction: personal experience]. / Valutazione del rischio operatorio nel trattamento d'urgenza dell'occlusione meccanica da carcinoma del colon sinistro. Esperienza personale.

AIM OF THE STUDY: To analyse the risk factors in the treatment of intestinal obstruction due to colorectal carcinoma. The treatment of neoplastic obstruction of the right colon until the splenic flexure is well defined: right hemicolectomy, enlarged right hemicolectomy. Otherwise the treatment of the obstruction due to left colon carcinoma beyond left flexure is not standardized. MATERIAL AND METHODS: The Authors report on a consecutive series of 15 patients, classified according to Colorectal Tumours Emergencies Score (CTES), based on the analysis of 4 risks factors: colic, perforation, serum albumin, concurrent cardiovascular disease, chronic renal insufficiency. Each patient has been ranked in three classes of risk: low (CTES < 4), moderate (CTES 4-12), and high (CTES > 12). CONCLUSIONS: Referring to this classification the Authors consider the choice of surgical treatment. When general conditions of the patient permit, it seems preferable to perform primary anastomosis.

Acute onset of non-Hodgkin's lymphoma with serious gastrointestinal haemorrhage: diagnosis and surgical treatment (case report).

The authors report a rare case of acute onset of gastrointestinal non-Hodgkin's lymphoma with acute gastrointestinal haemorrhage. The patient, a man aged 49 years, was admitted to the surgical department for the evaluation of an increased anemia and weakness. Physical examination disclosed mild epigastric tenderness in response to palpation but no palpable mass. Few hours after hospital admission, he underwent a serious gastrointestinal haemorrhage with shock. Laparotomy revealed that the malignant lesions were in the upper and in the middle of the stomach and multiple white lesions were found in the small bowel. A standard radical gastrectomy with D2 lymphadenectomy and bowel resection (about 120 cm) was performed; bowel canalization was restored by esophago-jejunal end-to-side anastomosis Roux-en-Y. The main problems of surgical treatment are discussed.

[Reoperation on the femoral arterial bifurcation: technical notes and surgical strategy]. / I reinterventi sulla biforcazione arteriosa femorale. Note di tecnica e di strategia chirurgica.

Femoral bifurcation reoperation is a stern test for skilfull surgeons, owing to the presence of thick scar tissue from the previous operations, especially when prosthetic grafts are used. In cases of aorto-femoral graft thrombosis, if thrombectomy of the entire graft is possible, one could isolate the anastomotic tract with all the afferent vessels and construct a new anastomosis downstream in tissue which allows a better run-off. Often in our experience we executed a by-pass, with a vein or short tract of new graft, from the previous prosthetic branch to a distal part of the deep femoral artery. In this way the reoperation is faster and safer, limiting dangerous dissection times. In infected inguinal pseudo-aneurysms we prefer an axillo-femoral by-pass, with isolation of the deep femoral artery by lateral incision, outside the infected field. In the non-infected ones, the reconstruction involves the use of a new small-sized graft between the previous structures. In cases of femoro-femoral occlusion we think it is better, first of all, to evaluate the possibility of an orthotopic graft from the aorta or iliac artery.