[The role of the surgeon in a domiciliary peritoneal dialysis program]. / Il ruolo del chirurgo in un programma di peritoneo-dialisi domiciliare.

The Authors report their surgical experience with 54 ESRD patients treated with peritoneal dialysis (PD). Guidelines on videolaparoscopic surgical treatment have been described and in 13 patients peritoneal catheter (PC) was inserted by videolaparoscopy (VL). They performed five VL cholecystectomies, in four cases combined with the PC insertion, in one PD patient without PD interruption. In three cases VL was useful in diagnosis and treatment of PC malfunction. A protocol has been done to treat hernias or laparocele before starting PD or during the course of PD and to prevent their recurrence. Two patients were operated for hernia or laparocele before PC insertion, seven patients during PC insertion. Seven patients were operated for hernia or laparocele developed during PD treatment, one of them in emergency for intestinal strangulation. One patient was operated for epigastric laparocele after an hypogastric laparocele correction. Prosthetic mesh repair was performed in every patient.

[Intra- and postoperative complications in the surgical treatment of cholelithiasis]. / Complicanze intra e postoperatorie nel trattamento chirurgico della colelitiasi.

The authors report their experience in biliary tract surgery. From 1974 throughout 1988, 1.186 patients underwent surgery and the commonest operation was cholecystectomy. The most significant complications and the causes of death are reported. Mortality rate was 0.82%.

[Benign epithelial neoplasms of Vater's ampulla. Usefulness of the "epithelial dysplasia" concept in prognosis and surgical strategy]. / Neoplasie epiteliali benigne della papilla di Vater. Utilità del concetto di "displasia epiteliale" nella prognosi e nella tattica chirurgica.

The surgical behaviour in front of the benign epithelial tumors (adenomas) of Vater's ampulla is object of discrepancies due to the possible malignant evolution of such neoplasms. The authors stress the basic importance of a careful examination of histological bioptic material before and/or during operation, which, through the identification of the degree of epithelial dysplasia, may lead to the choice of the tecnique to be adopted. In 2 of the 3 cases reported by the authors, showing a low degree dysplasia of the papillary tumor, a submucous papillectomy was performed; in the third case, where histology showed severe dysplasia and some other elements of risk were present (patient's age and macroscopic features of the tumors), the surgeons performed a duodenopancreatectomy. Semiseriated histological sections of the surgical specimen revealed the presence of carcinomatous areas. The authors think simple papillectomy to be the surgical procedure to follow when low grade dysplasia of ampulla is documented, and duodenopancreatectomy to be performed in high risk conditions as high grade dysplasia and macroscopic features suggestive of malignancy. In addition, the authors deal with epidemiology, clinics and instrumental diagnostics of such benign neoplasms of ampulla, on the basis of their own experience and the review of the few cases reported in literature.

[Cystic neoformations of the retroperitoneal space (4 case reports)]. / Neoformazioni cistiche dello spazio retroperitoneale (contributo di 4 casi).

Based on the study of four cases of retroperitoneal cysts, the complex histopathogenesis of these neoplasms - the clinical diagnosis of which has recorded substantial progress thanks to the use of the computed tomography - has been analyzed. The practice of exeresis, though comparatively simple and radical in most cases (as recorded in 3 out of the 4 cases reported) owing to the little adhesions of these neoplasms to the contiguous anatomical formations and also to their histological benignity, may, in some instances, present such unexpected difficulties due to the expansion in volume and the complex and delicate anatomical connections, that palliative operations have to be opted for.

[Retroperitoneal tumors. Tactics, technics and surgical results]. / I tumori retroperitoneali. Tattica, tecniche e risultati chirurgici.

Out of 33 cases of retroperitoneal tumours (TRP), collected throughout 11 years (1970-1981), 8 (24%) resulted benign, 25 (76%) malignant. Liposarcoma resulted the most frequent tumour. In 11 of the 25 cases of malignant TRP (44%), a radical removal of the tumour was performed; in 8 (32%), a palliative demolition, and in the remaining 6 (24%) a simple diagnostic laparotomy. In 10 of the 19 demolitive operations (53%) the removal was extended to contiguous organs: kidney, adrenal glands, colon, pancreas, spleen, bladder, stomach. The postoperative mortality was 6%. The cases of recurrence after operations considered radical were 5 (45%). Out of the 8 patients suffering from benign neoformations, 7 underwent simple removal, and result recovered. The global survival for malignant TRP was 20% after 5 years and 8% after 10 years; as related to the cases subjected to radical removal, it results 45% and 18% respectively. The Authors maintain the essential function of computerized axial tomography (TAC) in the preoperative anatomo-topographic outlining of the retroperitoneal mass and in the early recognition of the remote recurrences. An aggressive surgical behaviour seems to be presently the primary therapeutical solution; nevertheless, the encouraging results obtained through the complementary treatment (radiotherapy and chemotherapy) command the necessity of a pluridisciplinary management of the treatment of TRP as an essential condition for the improvement of the remote results.

[Insular tumours of the pancreas (author's transl)]. / Tumori insulari del pancreas.

The use of immunohistochemistry and radioimmunological assay of the pancreatic polypeptides in the plasma has contributed substantial advances to the histophysiopathology and preoperative diagnosis of tumours of the endocrine pancreas and the related functional syndromes. Consequently, in addition to furthering knowledge on clinical pictures already known for some time, it has been possible to define new categories of the disease which were previously misunderstood or confused with others. The physiopathology and diagnostic methodology (clinical, biohumoral and instrumental) of each main known syndrome (insulinoma, Zollinger-Ellison Syndrome, Verner-Morrison disease and glucagonoma) are described in detail; there are notes on hormonal syndromes that are not fully known and which constitute a field of research in evolution (pluriendocrine and carcinoid syndromes, polypeptidoma, somatostatinoma, nesidioblastosis). The problems of preoperative preparation, intraoperative diagnostic tactics and surgical technique are illustrated. Lastly the possibilities of alternative therapeutic treatment are outlined.

[Syndrome caused by extrinsic compression of the celiac trunk (apropos of 4 cases)]. / Sindrome da compressione estrinseca del tronco celiaco.

On the basis of angiographic documentations the Authors report on 4 observations (3 men and 1 woman) of extrinsic compression of the coeliac trunk symptomatologically evidenced through abdominal pain attacks. All the patients were treated surgically by resection of the median arcuate ligament of the diaphragm. In one case distal pancreatic resection was also performed on account of accompanying chronic pancreatitis. The long-term results were excellent in 3 cases, and good in 1. The diagnosis and surgical indication were made possible after repeated biochemical and instrumental investigations in order to exclude different pathologies (vascular, biliary, pancreatic, gastrointestinal) which might account for the reported symptoms. There is still discussion on the unresolved problem of the pathogenesis of the pain, as well as on surgical tactic and the advisability of completing resection of the arcuate ligament by sympathicectomy or coeliac ganglionectomy.

[Pseudocystic pleural fistula documented by retrograde cholangiopancreatography]. / Fistola pseudocisto-pleurica documentata mediante colangiopancreatografia retrograda.

The use of recently introduced methods such as computerised axial tomography (CAT), in addition to endoscopic retrograde cholangiopancreatography (ERCP), has in recent years led to attainment of new targets in the diagnosis of pancreatic diseases. The Authors present a clinical case of massive and recurring left pleural effusion in a patient with a pseudocyst at the level of the cauda pancreatis. They report the clinico-diagnostico-instrumental factors leading to pre-operative diagnosis of pseudocystic-pleural fistula.

[Cystadenocarcinoma of the pancreas. Considerations on a clinical case]. / Cistoadenocarcinoma del pancreas. Considerazioni su un caso clinico.

A case of pancreatic cystoadenocarcinoma treated surgically four years earlier as a pancreatic pseudocyst is reported. The problems of differential diagnosis between cystic tumours (cystoadenoma and cystoadenocarcinoma) and the more common pseudocystic lesions are analysed. Stress is laid on the importance of correct intra-operative diagnosis, mainly based on multiple biopsy of the cyst wall, and the need for radical exeresis.

[Exocrine pancreas cancers: our experience (author's transl)]. / Le neoplasie del pancreas esocrino: la nostra esperienza.

The AA. report 136 cases of exocrine pancreas carcinomata that they have observed in 8 years in Surgical Hospital in Verona and they tackle diagnostic problems and surgical therapy. They confirmed the utility for the diagnosis of echotomography (ECO), computerizing axial tomography (T.A.C.), retrograde-endoscopic-cholangio-pancreatography (PTC). Considering the survival, at a distance of the cases that had an operation and life quality, the AA. incline, if possible, for a destroying surgical operation.

[Cavitary lesions and carcinoma of the pancreas. Diagnostic difficulties and errors]. / Lesioni cavitarie e carcinoma del pancreas. Difficoltà ed errori diagnostici.

Among 197 pancreatic and periampullar tumours operated between 1970 and 1979, an associated cystic of pseudocystic lesion was found on 15 occasions (a rate of 16%). In 10 cases it was a question of pseudocysts located at the bodytail, while the tumour occupied a distinct site (periampullar tumour or carcinoma of the head); in 5 cases the cavitary lesion coincided with the tumour (2 endocrine tumours of the head, 2 cystoadenocarcinomas and one adenocarcinoma of the body-tail). In 6 cases (of which 5 operated) the error in diagnosis led to misappreciation of the tumour: only 3 of these cases could be treated with radical surgery. In the other 9, correct diagnosis was possible from the start and in 6 radical surgery was performed. Stress is placed on the need for prompt and early diagnosis, in order to allow adequate treatment of the tumour in line with the canons of radical action.

The cancer of the papilla of Vater. Diagnosis, treatment and long term results.

Survey of 18 cases of cancer in the Papilla of Vater, which were observed during the years between 1971 and 1979 at the Surgical Clinic of Padua University - Seat of Verona - with particular regard to the diagnostic means and their reliability. The histological investigations gave the following results: All lesions were found to be adenocarcinomas; 6 cases well differentiated, 4 cases fairly well differentiated, 2 cases little differentiated, 3 cases indifferentiated. The following operations were carried out: 15 Duodenopancreatectomies, 3 Internal derivations of the biliary flow, one of which associated with gastroenteroanastomy. Of all the patients who underwent to the radical operation, 1 survived 3 years after the operation, and then was lost to the follow-up, 2 were surviving 19 months after the operation, 2 were surviving 12 months after the operation, 1 was surviving 10 months after the operation, 1 died 18 months after the operation, 7 died between the 2nd and the 12th month after the operation, 1 died in the postoperative period. Of those patients who underwent the palliative operation, none survived longer than one year.

[The biological results of duodenocephalopancreatectomy. Clinical evaluations based on a long-term follow-up]. / Le conseguenze biologiche della duodenocefalopancreatectomia. Valutazioni cliniche sulla base di un follow-up a distanza.

The authors discuss the main features of the complex pathophysiology of patients subjected to duodenocephalopancreatectomy, and particularly the difficulties inherent in clinical assessment of the digestive and metabolic impairment consequent upon the duodeno-gastro-pancreatic mutilation. Out of a total of 57 cases of this description, they singled out for recheck 23 patients who had undergone duodenocephalopancreatectomy not less than six months and not more than seven years before (chronic pancreatitis, 11 cases; various malignancies of the periampullar area, 10 cases; Zollinger-Ellison syndrome, 1 case; retroperitoneal lymphoma, 1 case). Seventy-six per cent of patients who had been gainfully employed were able to resume their jobs after surgery. Steatorrhea, assessed in terms of fecal fats, was present in all cases; notwithstanding, 70% of the patients gained weight (average increase 7 kg). All patients were on enzyme replacement therapy. Only 4% developed diabetes, and none developed postoperative peptic ulcers. Conversely there was a high incidence (65%) of bone structure reshuffling, signally osteoporosis, probably imputable to steatorrhea and vitamin D malabsorption, plus the often associated increase of serum alkaline phosphatase activity.

[Alteratiions of calcium and phosphorus metabolism in patients treated with duodenoencephalopancreatectomy]. / Alterazioni del metabolismo del calcio-fosforo negli operati di duodenocefalopancreatectomia.

In a followup study of 14 patients treated by duodeno-cephalo-pancreatectomy at least one year before, the authors detected radiological evidence of bone tissue reshuffling in 64 per cent of the cases. Of these, 70 per cent showed high serum alkaline phosphatase content not attributable to cholestasis, liver metastasis, or specific bone disease. The authors call attention to the significance of this biochemical parameter for diagnostic purposes and therapeutic guidance.