[Sequential endoscopic and laparoscopic and one-step treatment of cholecysto-choledochal calculosis. New perspectives for the surgeon]. / Il trattamento sequenziale endoscopico e laparoscopico ed in tempo unico della calcolosi colecisto-coledocica. Nuove prospettive per il chirurgo.

The Authors describe 132 cases of sequential treatment of cholecysto-choledochal lithiasis by videolaparoscopic cholecystectomy after endoscopic Common Bile Duct (CBD) clearance and 3 endoscopic sphincterectomy and CBD stone extraction during laparoscopic cholecystectomy. No complications occurred during the procedure. Even though the second one is not a routine method undoubtedly represents the best solution when the surgeon meets an unexpected choledocholithiasis. However, laparoscopic CBD exploration requires a good experience of the surgeon and currently there are not sufficient data to support this procedure.

[Resection surgery in malignant neoplasms of the exocrine pancreas: our experience, 1987-1994]. / La chirurgia resettiva nelle neoplasie maligne del pancreas esocrino: nostra esperienza 1987-1994.

From 1987 to 1994, 24 patients underwent resection for pancreatic cancer; they represented 24% of all patients observed in that period. Surgical procedures were a pancreatoduodenectomy (PD) in 20 cases, a distal pancreatectomy in 4 cases, a palliative intervention in 61 cases, an exploratory laparotomy in 13 cases and a video laparoscopy in 2 cases. Adjuvant treatments were given in addition to resection in 20 patients. In the 20 patients undergoing PD, mortality was 20% and morbidity 20%. There was no mortality and no morbidity in distal pancreatectomy. The 1-year survival in pancreatoduodenectomy was 50% and 0% for distal pancreatectomy. Pancreatic resection, radical and palliative, whenever technically possible, represents the treatment of choice for pancreatic cancer.

Surgical strategy in primary retroperitoneal tumours.

Sixty-nine patients with primary retroperitoneal tumours (17 benign, 52 malignant including 4 malignant tumours of uncertain origin) were reviewed to determine the best form of surgical strategy. Total resection was performed in 88 per cent of benign cases and in 65 per cent of malignant cases. In 62 per cent of the total resections for malignant tumours, en bloc excision included adjacent organs or anatomical structures. Operative mortality rate (in terms of the total number of operations performed) was 5 per cent. Postoperative complications occurred in 14 per cent and recurrences in 35 per cent. The overall 5-year survival rate was 67 per cent in patients with totally resected tumours and zero in patients whose tumours were treated by partial resection or biopsy. An aggressive surgical approach aimed at total excision of the tumour is the best form of therapy currently available. In the totally resected retroperitoneal tumour, the use of adjuvant radiotherapy and/or chemotherapy depends on the grade of the malignancy and clearance as assessed histologically. Careful follow-up based on the use of computerized axial tomography and ultrasound allows early identification of recurrence at a stage when the recurrence is amenable to total resection.

[Reinterpretation of the hepatic abscess, a new dimension in abdominal digestive surgery]. / Dalla rilettura dell'ascesso epatico, una nuova dimensione dell'addome chirurgico digestivo.

Pyogenic abscess of the liver is viewed here as a surgical disease, which appears to raise doubts as to its actual identity. Though located in a given abdominal organ, such abscesses find it hard to recognize this as their exclusive setting and attempt to shrug off these traditional confines. They aspire, rightly or wrongly perhaps, to symbolize a splanchnic context, though, in actual fact, the latter--at least for contingent, doctrinal reasons--is confined to the bipolar liver-bowel system. This context presents its candidacy as playing a leading role in a disease of such importance as to be regarded almost as the "Caudine Forks" of the very process of "surgical" dying. Liver abscess and multiorganic or multisystemic organ failure (MOF or MSOF) might thus be viewed as the two opposite poles (taxonomically definable) of a single clinical condition, which fans out over a broad area and for the most part is only barely known to us. Though is characterized by its abdominal location, it would be all too simple to define the condition as abdominal. In this case, in fact, the abdomen speaks an unusual language, not the habitual, traditional, "spatial" language of location, but the as yet uncertainly articulated "biological" or, why not, even "biosurgical" language of mediation. Is this then a turning point in the pathological field? No, if by that we mean a new concept of the problem. In effect, the concept dates back several centuries and, moreover, darries a heavy burden of responsibility, such as, for instance, having induced the Nobel Prize-winner Elie Metcknicoff (Metcknicoff E., The prolongation of life. London, Heinemann, 1907) to come up with theories appropriated and implemented surgically by Sir William Arbutnot Lane, gaining him nothing but sad notoriety (Gordon R., Great Medical Disasters, Hutchinson, London-Melbourne, 1983). "Concept" is a euphenism, and a more appropriate term might be simply "intuition". The real innovation lies in reviving this old intuition, reinterpreting it now, in fact, as a "concept". The code for this modern interpretation has barely been sketched out in its essentials, but is daily going from strength to strength.(ABSTRACT TRUNCATED AT 400 WORDS)

[Biomechanico-clinical interpretation of firearm wounds. General problems (III). A propedeutic ABC on terminal ballistics]. / Lettura biomeccanico-clinica della ferita d'arma da fuoco. Problematica Generale (Parte III). Abbecedario di propedeutica alla balistica terminale.

The surgeon should have a comprehensive knowledge of firearms as thermochemico-ballistic machines in order to come to grips in an adequate manner with the wounds they inflict on the human body. The traces left on the body to all intents and purposes embrace a cultural "cul de sac" which risks being defrauded of most of its content by a lack of those propedeutics elements which painstaking reflection is capable of affording us. Only the interpretation of each individual ballistic phase, both as a complete phenomenon in itself and as a component in a single articulated complex, can offer such elements: credit is due at least for a wholehearted commitment in this direction, while never losing sight at any time of the clinical perspective of such wounds.

Emergency surgical management of retrosternal goiter causing tracheal compression.

Acute tracheal compression caused by mediastinal masses is a rare event. Dyspnea is the most frequent symptom and the treatment of choice is intubation followed by surgical operation. Four cases of acute tracheal compression due to retrosternal goiter are described. All of them underwent emergency surgical treatment. Clinical findings and problems of surgical technique are discussed.

[Biomechanico-clinical study of gunshot wounds (general problems--II)]. / Lettura biomeccanico-clinica della ferita d'arma da fuoco (problematica generale--Parte II).

Whenever the surgeon finds himself face to face with a wound (probably this is the only opportunity for a meeting between physician and pathology which seems to be able to leave the "illness" on one side, almost forgotten, as it were), even when immersed in routine, he can hardly help making a number of considerations of a general nature, to which the sentence above in brackets is not entirely extraneous. In practice, we cannot help asking ourselves an apparently simple, almost banal, question: what exactly is trauma? This triggers off a whole series of secondary queries, such as, for instance, what the relationship is between trauma and classical pathology? In the first place, it should be pointed out that "traumatic" pathology is undoubtedly the only instance of pathology in which, as a rule, at least at the outset, one can justifiably talk about the "isolated" role of what can certainly be regarded as an out-of-body factor. If, then, we consider the specifically morphological and pathophysiological aspects of the period subsequent to the traumatic insult, we find ourselves in an even more embarrassing position: we are faced with irreparably devastated organ and body structures, or with a situation which is already on the way to convalescence. One last alternative is that the traumatic insult is merely a memory, a key finding in the case history, a past reality which to all intent and purposes has ceased to exist, and we are faced with extremely complex clinical pictures which we tend to label as complications. A few examples by way of explanation: shock, adult respiratory distress syndrome (ARDS), stress ulcer, acute post-traumatic cholecystitis, haemorrhagic pancreatitis, and problems caused by resolving the hypovolaemia-ischaemia situation and by implementing reperfusion (oxygen radicals). Trauma favours - and surgeons concerned with organ transplants are well aware of this - the only possibility of death which, perhaps with a grain of excessive optimism, we may even accept as fruitful, in that it occurs without all the destructive deterioration involved in the process of dying. The above consideration probably plays a major role in our attitudes of almost fatalistic resignation towards the youthful victims of trauma.(ABSTRACT TRUNCATED AT 400 WORDS)

[Biomechanical and clinical study of gunshot wounds (general problems). I]. / Lettura biomeccanico-clinica della ferita d'arma da fuoco (problematica generale--Parte I).

Above and beyond their effective epidemiological incidence, which is perhaps somewhat greater than is commonly imagined even outside the war context, gunshot wounds constitute a unique cultural opportunity for the traumatologist and for surgeons in general. The actual morphological and clinical features of such wounds, which bear precise, localized witness to, and reflect in a virtually mathematical manner, a programmed, and thus readily quantifiable, dimension of kinetic energy (rich in experimental implications), stand out against the backcloth of an extremely extensive involvement of the body in which, amongst other things, the intervention of a whole host of mediators may be seen to play a decisive role. Lastly, it should not be forgotten that it is precisely in field hospitals or their equivalents that surgery has found a precious opportunity to escape the environmental or "cultural" conditioning of the moment and play a leading role not only in terms of technological solutions but also in terms of reflection on the main leitmotive of pathophysiology, from shock to ARDS.

[Treatment of perineal breach in radical surgery of the rectum: notes on the surgical technic]. / Il trattamento della breccia perineale nella chirurgia demolitiva del retto: note di tecnica chirurgica.

The Authors review the various techniques used in closing and draining the pelvic basin after total resection of the rectum due to neoplastic and/or inflammatory disease. The examine their experience with 248 cases of total resection of the rectum and propose closure of the perineal breach as the first step in through closure of the pelvic peritoneum.

[Hypothesis of mediation pathology in surgery (4)]. / L'ipotesi della patologia da mediazione in chirurgia (4a Parte).

The mediation pathology concept takes account to a large extent, though by no means exhaustively, of that horizontal language between peripheral cells, based on locally produced hormone-like substances and aimed at covering extremely short distances. This brings us well and truly into the paracrine domain of intercellular communication, whereby an exchange of messages takes place between adjacent cells via the interstitial spaces. Alongside this short-range communication network, there also exists a long-range network, involving above all the blood stream both as an intermediary and as mediation terrain. To the mediatory processes partakes the neuro-endocrine system, albeit it is not the predominant one as it was classically thought. There are other actors on the mediation stage: oxygen radical plays an important role.

[Hypothesis of the pathology of mediation in surgery (2)]. / L'ipotesi della patologia da mediazione in chirurgia (2a parte).

There are clearly numerous examples of mediation pathology in surgery. They go far beyond what may be defined as severe forms, in which the entire body is involved in the precipitating disease process and in which the mediation appears more easily recognizable, in that it evokes a resonance which wipes out all specificity and becomes the true protagonist of the critical situation. Forms which can be traced to a well defined pathogenesis, and others to a more debatable pathogenesis, afford great scope for mediation. May one, for instance, be justified in suggesting a mediation hypothesis for a classic surgical disease such as duodenal ulcer?

[Hypothesis of the pathology of mediation in surgery (3)]. / L'ipotesi della patologia da mediazione in chirurgia (3 parte).

There are three aspects to mediation: the first of these is purely physiological, or rather is concerned with performance of service functions such as ovulation, sexual activity, sleep, etc.; the second, strictly speaking, may be defined as pathophysiological, as its starting point is considered to be an aggressive event, even when a routine occurrence (in the stomach, for instance, aggression is a constant feature, even when of only slight intensity, as produced by the physical characteristics of the enormous quantities of food transiting the stomach and by particular environmental conditions; the third aspect is distinctly pathological, in that it constitutes the basis for the aggravation of a pathological situation already in progress, sometimes according to the logic of plain addition, but more often according to a more catastrophic process of multiplication (less frequently it takes the form of induction of a prevalent or independent disease condition). This break-down of mediation into distinct types, though necessary from the point of view of academic classification, proves extremely difficult to apply in practice. The validity of this latter consideration obviously depends on the specific area we are tackling. As regards the sex glands and male genital organ, the service role is unquestionable; elsewhere, we can be equally sure that we faced with pathophysiological aspects. In the stomach, for example, the difference between "normality" and "disease" does not lie so much in the absence, as opposed to the presence, of lesions, but rather in their extent and duration. This makes it extremely difficult to draw the line between physiology and pathology, and at the same time suggests that the state of health may be an unstable equilibrium phase somewhere midway between divergent forces belonging to the same mechanism. This latter mechanism may therefore be the key factor both in vital performance and in disease processes, whereas the "classic" aetiological factor may actually be relegated to a secondary role, at least in most cases.

[Hypothesis of the pathology of mediation in surgery (1)]. / Ipotesi della patologia da mediazione in chirurgia (1 Parte).

The mediation pathology hypothesis is not new. As early as 1955, Laborit hinted at something of the kind in his phrase "N'est malade que l'organisme qui le vent bien". Today, however, in the light of free oxygen radicals, which together with other mediators may possibly represent only the tip of an enormous iceberg, we may venture a number of admittedly cautious theoretical considerations. This would appear to be particularly relevant today, in that surgery at this precise moment, I would venture to say, is at a turning point. On the one hand, surgery is pushing to extremes its classic restrictive morpho-mechanistic approach to disease, while on the other, together with cardiology, it is quick to perceive new biological horizons, which until very recently were unimaginable and, as such, constitute its elective target of interest. Paradoxically, to all intent and purposes at least, the biological rite appears to have found the most natural place for its celebration precisely on the site where the morpho-mechanistic ritual seems to have reached its zenith and, at the same time, its moment of glory.

[Biology and surgery: a bound pair or merely a couple of disciplines? (3)]. / Biologia e chirurgia: una cordata o una coppia di discipline? (3a Parte).

In the following reports two main problems are questioned by the Authors. To start with, a sharp distinction is made between the so-called "theoretical physiology" and the "actual" use of the physiological functions adopted by the single man and woman. The second question is concerned with the biological consistency of the different surgical approaches. In the neoplastic treatments, surgeon can draw a conclusion that goes behind the single therapeutic event casting over other different areas of the surgery itself. To answer this second question by no means represents the solution of the aimed goal, on the contrary it is the starting-line towards a surgery, which, having left behind his old, obsolete, but pompous garments, does wear those, which, apparently shabby, are, on the other hand, enriched of many lapels, such as those naturally offered by the self-healing behaviour.

[Biology and surgery: a bound pair or merely a couple of disciplines? (2)]. / Biologia e chirurgia: una cordata o una coppia di discipline? (2a Parte).

Carcinoma of the breast, to our way of thinking, appears to be capable of providing what is virtually a master key to the interpretation of surgical oncological pathology. In the wake of the acquisitions made in this field--not always as a result of the initiative of the surgeon - a definite process of revision of the age-old concept of surgical radicality is underway, albeit in a somewhat surreptitious manner. Oncological surgery is clearly passing through a difficult phase, almost a crisis of identity, and, in the authors' opinion, may to some extent come back into its own, albeit only after a great deal of painstaking effort, by adopting a "biological" approach with greater respect for the morpho-functional integrity of the patient, who must no longer be viewed as merely the victim of disease, but rather as the prime mover of the disease itself.

[Nd-YAG laser disobstruction of esophageal endoprostheses occluded by neoplastic development in the palliative treatment of esophageal cancer]. / La disostruzione tramite Nd. YAG laser di endoprotesi esofagee occluse dalla evoluzione neoplastica nel trattamento palliativo del cancro esofageo.

Since August 1984 18 patients suffering from inoperable esophageal cancer have been treated by Nd. Yag Laser therapy under endoscopic control in the Verona University Institute of Clinical Surgery. Three patients, all males ranging in age from 68 to 80 years, had endo-esophageal prostheses which were occluded as a result of the neoplasms. Occlusion of the prostheses had been ascertained by both x-rays and endoscopy. The symptoms consisted of severe dysphagia of solid foods in 2 cases and of solids and liquids in 1 case. The original sites of the tumors were the lower 3rd in two cases and the mid 3rd in 1 case. Histologically, the tumors were identified as 2 squamous-cell carcinomas and 1 adenocarcinoma. Laser treatment was given on average once every 7 days. Patients were admitted to the day hospital, thus avoiding negative repercussions in terms of quality of life or length of hospital stay. In 2 cases there was an improvement in symptoms with the possibility of semi-solid nutrition after a single treatment with 6000-5032 Joules. In the third case, to obtain the same result, 2 treatments were necessary at an interval of 7 days with a total of 9396 J. One patient died of cardiorespiratory failure 24 days after the first treatment. A second patient was treated a further 3 times with a total of 12356 J and is now on a liquid and solid diet 5 months after the first treatment. The third patient was treated 4 times with a total of 15769 J; this patient was on a liquid and solid diet, but died of cardiorespiratory failure 3 months after the first treatment. In the light of our experience, Nd. Yag Laser disocclusion of endo-esophageal prostheses occluded by neoplasms presented no complications and was an appropriate indication in these cases with satisfactory long-term results.

Leiomyomata of the oesophagus: report of four surgically-treated cases.

Four patients with leiomyoma of the upper or middle third of the oesophagus treated by surgical excision are reported. All operations were performed through a right thoracotomy with simple enucleation of the lesion. Two patients were asymptomatic. In one the tumour had a spiral configuration almost completely surrounding the lumen. No complications occurred. Early surgical treatment is advised although the tumour grows slowly.