Duodenal leiomyosarcoma.

Malignant stromal tumours of the duodenum are rare. The efficacy of surgical resection for duodenal leiomyosarcoma was assessed in 5 patients treated over an 11-year period, probably the largest series treated by a single surgeon. There were 3 women and 2 men with an age range of 27-52 years. Tumours were large (8.5-21 cm diameter) and partly cystic (4 cases). They arose from the second (2), third (2) and fourth parts of the duodenum. Resection was a major undertaking and comprised either partial duodenectomy (n = 4) or Whipple resection. Two patients required a right hemicolectomy in addition. Two patients with positive resection margins had adjuvant radiotherapy. Operative time ranged from 4.0 to 6.25 h and blood loss from 1.8 to 4.5 litres. Two patients developed complications: a transient low-output biliary fistula and an infected haematoma requiring percutaneous drainage. The 2 patients with incomplete resection died of recurrent disease at 3 and 15 months. The 3 survivors are free of disease at 24, 60 and 66 months. The results support a policy of aggressive resection despite the technical difficulties posed by these large and vascular tumours.

[Biliary surgery in the aged]. / La chirurgia biliare nell'anziano.

Between 1980 and 1995 in the Section of General and Oncological Surgery of the Department of Surgery of the University of Catania, on a total of 1715 biliary surgical procedures, 926 were performed on the elderly patients, 287 of which in emergency. Cholelithiasis (469 cases) morbidity 4.5%, mortality 0.4%; acute colecystitis, (247 cases) morbidity 21%, mortality 12%. Choledocholithiasis (122 cases) surgical treatment (51 cases) morbidity 21.6%, mortality 3.9%; endoscopic treatment (71 cases) morbidity 9.4%, mortality 0%. Neoplasms of the biliary tract (48 cases) diagnostic laparotomises 9, surgery (27 cases) morbidity 37%, mortality 11%; endoscopy (12 cases) morbidity 33%, mortality 0%. Acute obstructive cholangitis (34 cases), surgical drainage (9 cases) morbidity 55%, mortality 33%; endoscopic drainage (22 cases) morbidity 14%, mortality 4.8%; transhepatic drainage (3 cases) morbidity 66%, mortality 33%. Acute biliary pancreatitis (6 cases) surgery (2 cases) morbidity 100%, mortality 50%; endoscopy (4 cases) morbidity 25%, mortality 0%. This experience confirms that in elderly patients the treatment of choice for cholelithiasis is cholecystectomy and for acute colecystitis is early cholecistectomy. The preferred treatment of choledocholithiasis and severe acute biliary pancreatitis is endoscopic sphincterectomy. Endoscopic or radiologic drainages are the choice for acute biliary pancreatitis. In conclusion elderly patients with surgical biliary problems should be treated by a surgical, endoscopic and radiological team, taking in account all the available procedures.

[Treatment of the residual pancreatic stump after pancreatoduodenectomy: pancreatogastrostomy]. / Trattamento del moncone pancreatico residuo dopo duodenocefalopancreatectomia: la pancreatogastrostomia.

In the last few years more and more often the use of pancreaticogastrostomy (PG) for reconstruction after pancreatoduodenectomy (PD) has been reported. Aim of this paper is to review pertinent Literature and to try to define, on the basis of Authors' experience, the role this technique may have in reducing morbidity and mortality of PD. From January 1993 to June 1995 nine pancreaticogastrostomies were performed. Five patients had an adenocarcinoma of the papilla, two had a carcinoma of the distal choledochus and two had a carcinoma of the head of the pancreas. Major complications in this series were one operative death unrelated to PG and a massive bleeding from the gastric site of the anastomosis occurred 3 days after the operation, associated to a partial dehiscence of the anastomosis, treated surgically. Reported results after pancreaticogastrostomy seem to demonstrate a dramatic decrease in morbidity and mortality after PD, however, the real value of this technique will be established only after a greater clinical experience and, when possible, wider randomized prospective studies.

[Abdominal wall metastasis of pancreatic adenocarcinoma following laparoscopy]. / Metastasi della parete addominale da adenocarcinoma del pancreas in seguito a laparoscopia.

Wound recurrence after oncologic surgery is known since 1885, but nowadays we deal with a new problem after the rapid diffusion of laparoscopically assisted surgery and the 22 cases of trocar site metastases already reported in literature. Aim of this paper is to present a case of cutaneous seeding of adenocarcinoma of the pancreas, in two trocar sites, after laparoscopy for lithiasis of the gallbladder. Diagnosis of neoplasia was made intraoperatively for the presence of peritoneal and omental carcinomatosis; no cholecystectomy was performed and after biopsy and postoperative TC-scan a chemotherapeutic treatment was started. Five months after the operation parietal seeding was evident and treated with local radiotherapy; the patient died one month later for further dissemination of the disease. The etiopathogenesis of tumor recurrence in the abdominal scar tissue is still unknown, local (trauma) and general (decreased immunologic defences) factors could be responsible. The apparent higher incidence after laparoscopic surgery could presuppose the presence of further specific risks: more tissue manipulation (increased cellular exfoliation), contact between trocar and abdominal wall for the whole operative period (malignant cell carrier), pneumoperitoneum. In conclusion, as 50% of the patients with cutaneous metastases die within 6 months after the operation and almost nobody is still alive after 4 years, it is necessary to establish if a real additional risk, due to the laparoscopic procedure, exists to contrast eventual benefits of the mini-invasive procedure.

Diffuse colonic lipomatosis with giant hypertrophy of the epiploic appendices and diverticulosis of the colon. Report of a case and review of the literature.

PURPOSE: A case of diffuse colonic lipomatosis, dolichosigmoid, hypertrophy of the epiploic appendices and diverticulosis of the colon producing constipation, recurrent sub-occlusive episodes with diarrhea and vomiting, and weight loss is reported. METHODS: Careful preoperative assessment of clinical, radiologic, and endoscopic findings suggested the diagnosis. RESULTS: A total colectomy, followed by a lateroterminal ileoproctostomy, gave complete relief from symptoms. CONCLUSIONS: Of the 12 cases of colonic lipomatosis previously reported, only 2 have isolated involvement of the entire organ, but they do not present lipomatosis of the epiploic appendices.