[Laparoscopic cholecystectomy. An analysis of the reasons for a conversion to conventional surgery in an elective surgery department]. / La colecistectomia laparoscopica. Analisi delle cause di conversione in chirurgia tradizionale in un reparto di chirurgia di elezione.

BACKGROUND: To assess which factors determined conversion to laparotomy in patients undergoing laparoscopic elective cholecystectomy. SETTING: department of General Surgery. University of Genoa. Italy. METHODS: Two hundred sixty-four consecutive laparoscopic cholecystectomies were performed in our Department. INTERVENTIONS: laparoscopic cholecystectomy was performed according to Dubois's technique. Duration of the procedure was not considered a reason for conversion. RESULTS: 121 patients showed "difficult intraoperative situations" with further conversion risk factor. Conversion to laparotomy was necessary in 11 patients (4.16%). Five patients underwent conversion in the first 50 cases (10%), while six in the last 214 (2.8%). We had to convert to open cholecystectomy only in eleven patients, despite the high rate of technical difficulties and anatomic anomalies even in cases which, in the past, represented a contraindication to this kind of technique. The use of new instruments and new surgical techniques has reduced to only factors of increased risk in those situations that in the past were considered as contraindications to laparoscopic cholecystectomy. CONCLUSIONS: Conversion to open cholecystectomy is based on the surgeon's decision and the safety should be the main consideration in performing laparoscopic cholecystectomy. The use of a careful dissection could avoid the conversion in many patients.

Pseudotumor of the liver: a challenging diagnosis.

Inflammatory pseudotumors of the liver are rare, and their natural history is mostly unknown. Making the diagnosis is often difficult, and these masses are often confused with other lesions, generally either primary or secondary neoplasms. The case of a patient who had an exhaustive preoperative work-up, including ultrasonography, CT scan and MRI, is herein presented. The characteristics of each exam, particularly those of the MRI, in which the pattern is poorly described in the literature, are reported. A fine needle biopsy was not contributive, as it was performed too centrally within the nodule. Only a high degree of suspicion and the existence of this tumor might lead to a preoperative diagnosis, thus avoiding major surgery. However, as is evident from the experiences of most authors and from our own, doubt may persist even after an exhaustive work-up. Since the morbidity and mortality of liver resection of noncirrhotic livers is low, surgery should be considered the treatment of choice.

[Connection between the type of drainage and sepsis in thyroid surgery]. / Rapporto fra tipo di drenaggio e sepsi nella chirurgia tiroidea.

Drainage in thyroid surgery, although still controversial, is used at our service routinely, as it guarantees the output of serum, sometimes abundant after thyroidectomy, and allows the immediate check of hemorrhage. It is nevertheless known that the presence of drainage can favour the occurrence of infection of the surgical bed. Through a randomized trial, we tested the incidence of sepsis after thyroidectomy, using in one group a double open Silastic drain and in another group a double aspirative drain. We registered 3 cases of wound infection and 4 cases of seroma in the group treated with open drainage versus one case of wound infection and 2 cases of seroma in the group treated with aspirative drainage. Such difference, although evident, did not result significant. Nevertheless, it is our opinion to conclude that the aspirative draining system guarantees a better sterility of the surgical wound, and therefore a lower incidence of wound complications.

[The role of drainage and antibiotic prophylaxis in thyroid surgery]. / Il ruolo del drenaggio e della profilassi antibiotica in chirurgia tiroidea.

BACKGROUND: It is our habit to employ an open drainage after thyroid surgery in our department. We have also found a large number of surgical infections in these patients (5.8% vs 2.5). Aim of the study is to evaluate prospectively if contamination happens during surgical procedure or in a later time according to the presence of the open drainage. METHODS: From October 1995 to November 1996, 113 patients who underwent a subtotal thyroidectomy were randomized into two groups: group A with antibiotic prophylaxis (57 patients) and group B without it (56 patients). RESULTS: One case (1.7%) of sepsis among 57 patients of group A and 2 cases (3.4%) among 56 patients of group B were observed. CONCLUSIONS: No statistical difference was found between the two groups despite antibiotic prophylaxis covering surgical procedure. It is personal opinion that sepsis arose after surgical procedure, due to the presence of the open drainage.

[Comparison of colorectal mechanical suture techniques]. / Tecniche di sutura meccanica colo-rettale a confronto.

UNLABELLED: Objective of this study is to establish which kind of stapled anastomosis is the most reliable in rectal surgery. 67 patients randomly assigned to three groups underwent low anterior resection of the rectum with end-to-end, side-to-end or double stapling anastomosis. Main outcome measures were incidence of leakage at the intraoperative check of the suture, postoperative leakage, stenosis, mortality, mean post-operative stay. Side-to-end anastomosis were followed by 4 intra-operative (19%) and one post-operative (4.7%) leakages with one case of mortality (4.7%). Four intra-operative (18.2%) and 5 post-operative (22.7%) leakages, 3 stenosis (13.6%) and one case of mortality (4.5%) were observed after double-stapling procedures. No intra- or post-operative anastomotic complications were seen after end-to-end anastomosis. Mean post-operative stay was 20, 31 and 13 days for the three methods respectively. CONCLUSIONS: In this series of colo-rectal anastomoses, the end-to-end stapling technique appears to be safer and more reliable than others.

Laparoscopic cholecystectomy and gallbladder cancer: a diagnostic and therapeutic dilemma.

The correct treatment strategy of patients with unsuspected gallbladder cancer undergoing laparoscopy, and the prevention of delayed diagnosis are current issues. We report a case of late diagnosis with umbilical metastasis and poor survival. A policy of careful inspection of the gallbladder and a cautious strategy in the case of gross alteration of its external morphology seems advisable during laparoscopic cholecystectomy. Although no agreement exists concerning the best treatment in the event of delayed diagnosis, the adopted strategy is contingent on patient status, disease stage and the possibility of performing appropriate follow-up.

Giant hemangiomas of the liver: surgical treatment by liver resection.

BACKGROUND: The correct therapeutic strategy of giant hemangiomas of the liver is debated and based on two main techniques: resection and enucleation. MATERIALS AND METHODS: We report seven consecutive typical hepatic resections for giant cavernous hemangiomas in symptomatic patients. Most frequent symptom was pain at the right hypochondrium, associated with epigastric discomfort. Hepatectomy was carried out after extraparenchymal ligation of the hilary structures and parenchymal resection was performed with kellyclasia and ligation of the intraparenchymal vessels with clips. In all cases the resection was performed after intermittent clamping of the hepatic pedicle. RESULTS: Three right hepatectomies, 1 right extended hepatectomy, 1 left hepatectomy and 2 left lobectomies (segments 2 and 3) were performed. Estimated blood loss ranged from 350 to 1000 ml with a mean loss of 550 ml. No major postoperative complication and no long term sequela occurred. Two episodes of cholangitis in an old patient after emergency operation regressed under medical treatment. CONCLUSIONS: Enucleation is an option when a lesion is small and superficial. In the case of large and deep hemangiomas in proximity of vascular structures, typical liver resection is a safe operation entailing lower morbidity and blood loss.

Surveillance after colorectal cancer surgery.

Early diagnosis of local and distant recurrences of colorectal cancer remains difficult and there is no agreement on the effectiveness of follow-up in these patients. The aim of this study is to assess the value of our method of follow-up. We consider 239 patients with colorectal cancer and at least 2 years follow-up following radical resection. A local recurrence appeared in 26 patients (10.9%), a distant metastasis in 41 (17.1%), while in seven (2.9%) local and distant recurrences appeared simultaneously. Local recurrence was detected because of an increase in carcinoembryonic antigen (CEA) level in 15 patients (57.7%), during a scheduled endoscopy in four (15.4%) and because of symptoms in seven (26.9%). In seven patients (26.9%) a radical resection was possible. Distant metastases were detected by CEA levels in 20 patients (48.8%), by ultrasonography (U.S.) in 12 (29.3%) and by chest X-ray in five (12.2%). In 13 of 26 patients with liver metastases a resection was performed. This study shows that few patients benefit from follow-up and only CEA levels and liver U.S. performed intensively between 15 and 36 months after surgery are useful in early detection of recurrences. A modification of the follow-up to the single patient, according to the stage, location and grading of cancer, could improve the results, so lowering the costs of this expensive practice.

A new technique for intraoperative blood recovery in the cancer patient.

Homologous blood transfusion in the cancer patient is dangerous because of an apparent immunodepressive action. Even a program of pre-deposit and isovolemic hemodilution, for reasons of immediacy and patient conditions, is often not feasible. Likewise, the intraoperative recovery of blood, although used by some, does not prevent the possible reinfusion of suspended neoplastic cells. A system that eliminates tumor cells could enable the recovery of blood in cancer patients in non-septic operative sites. A system that seems to correspond to these requisites has been set up by inserting two filters for the elimination of leucocytes from erythrocyte concentrates into a cell separator that is normally used in clinical practice. Laboratory studies, using immunohistochemical identification of tumor cells cultivated in vitro, have demonstrated the absence of contaminating cells in blood available for reinfusion.

[Gastroduodenal surgery using mechanical staplers: our experience]. / Chirurgia gastroduodenale con suturatrici meccaniche: nostra esperienza.

Results of 71 operations of the gastroduodenal tract performed with stapling devices are reported (51 for malignant diseases and 20 for benign diseases). 20 total gastrectomies, 21 Billroth II gastrectomies, 17 Roux en-Y-gastrojejunoplasty, 6 Billroth II to Roux-ex-Y-conversion and 7 palliative gastroenteroanastomosis were performed, using TA, GIA and EEA stapling instruments. The analysis of the reported data brought us to some considerations regarding the safety and versatility of mechanical viscerosynthesis, also in relation to some technical aspects.