Minerva Chir

[Total gastrectomy and quality of life]

Year 1998
Calomino N. Malerba M. Tanzini G.
Istituto di Clinica Chirurgica e Terapia Chirurgica, Universita degli Studi, Siena.
We have evaluated quality of life after surgery in 24 patients (9 males and 15 females mean age 64.23 years, range 47-83 years) who underwent total gastrectomy for cancer (23 carcinomas and 1 lymphoma) in the last three years at the Department of Clinical Surgery, University of Siena. Intestinal continuity was re-established with Y jejunal loup according to Roux. All patients were studied prospectively: after the operation every six months they were interviewed using Korenaga's questionnaire. Group performance status scale was used to determine the level of activity of each patients. Comparing symptoms of patients after six months and 18 months there was a significant difference (p = 0.005) in terms of number of meals throughout the day, food tolerance and abdominal pain. Postoperative performance status revealed a complete recovery in 11 of 24 patients (45.8%) after 18 months. According to our experience patients who have undergone total gastrectomy enjoy a good quality of life and most of them return to the preoperative lifestyle in 18 months.

[Gastrointestinal hemorrhage]

Year 1998
Rossi R. Morelli M. Ruscalla L. Clemente A.
Chirurgia II Divisione, Ospedale Civile, Asti.
Acute digestive system haemorrhage is a recurrent cause of hospitalization. As to the upper segment of the digestive system, ulcerous peptic disease is often the cause of this pathology, above all in Western Countries. As to the lower segment, colic diverticula and angiodysplasy represent the most common cause. Bleeding usually clears up spontaneously or with hemodynamic pharmacological help. In some cases, the situation does not improve because of bleeding persistence, so more complex diagnostic and therapeutic techniques are necessary. Instrumental diagnostics is based on endoscopy (once with flexible optical fibre instruments, now with videoendoscopy) whose diagnostic effectiveness is inversely proportional to the latency since the haemorrhagic occurrence. Success is evident in 90-95% of the cases within the first twelve hours. Mesenteric angiography and scintigraphy with marked erythrocytes can solve difficult diagnosis and topographic location on some serious occasions. In every case the risk of complication and death is closely related to the haemorrhagic consistency, the flow of the bleeding, the basic disease, the age and the presence of chronic diseases. The authors examine a personal survey taken from the hospitalization in their own ward during a period of a year.

[Videolaparoscopic treatment of biliary lithiasis. Evolution of our experience]

Year 1998
Bresadola V. Pinna R. Loi V. Occhioni G. Padula G. De Anna D. Trignano M.
Istituto di Patologia Chirurgica, Universita degli Studi, Sassari.
Videolaparoscopic cholecystectomy is considered the treatment of choice for simple cholelithiasis. Now many surgeons consider the laparscopic procedure usable also in the complicated biliary lithiasis like acute cholecystitis and choledocholithiasis. The authors report their recent experience of the laparoscopic treatment of biliary lithiasis, regarding 221 non-selected patients (69% symptomatic cholelithiasis, 20% chronic cholecystitis, 4.5% acute cholecystitis, 4.5% coledocolithiasis, 2% hydrops). The diagnostic-therapeutic protocol and the results are described and compared with the beginning of their experience, when they treated only symptomatic gallbladder stone disease, and with the reports of the literature. The authors concluded that the laparoscopic procedure is a good chance for the surgeon in the treatment of all cases of benign biliary disease. But, in particular for patients with choledocholithiasis, he has be able to know all the diagnostic and therapeutic possibilities, to choose the best in every single case.

[Varicocele. Ligation of the internal spermatic vein using laparoscopic approach]

Year 1998
Casciola L. Ceccarelli G. Mazzoli W. Di Zitti L. Giulianelli F. Fedeli C. Flamini FO.
Unita Operativa, Azienda USL n. 3, Regione Umbria, Ospedale di Spoleto, Perugia.
It is now unquestionable that varicocele represents one of the main causes of male infertility, and thus requires appropriate surgical treatment. Inguinal and retroperitoneal methods have for some time been the most widely used. However, a significant postoperative morbidity and relatively long convalescence have prompted the search for alternative surgical techniques, such as percutaneous sclero-embolisation and microsurgery. Laparoscopic treatment of varicocele is a relatively recent surgical technique. The first studies by Sanchez de Badajoz date back to 1988 and to date a relatively small number of cases have been reported. The authors analyse the results in 54 patients treated over a period of two and a half years; 13 cases also presented inguinal hernia pathology which was treated during the same operation by applying a polypropylene graft again using a laparoscopic approach; the latter method has been routinely applied since 1992 in over 1000 cases with excellent results. The internal spermatic artery was always identified and preserved. No peri- or postoperative complications were observed. A follow-up was performed at 10 months after surgery and showed results which although referred to a relatively small series, were certainly better than those reported in the literature using traditional surgical techniques; in addition, this method also reveals interesting possibilities for the treatment of associated pathologies during the same operation, with obvious advantages in terms of costs and patient compliance.

[Surgical treatment of recurrent inguinal hernia using prosthetic materials]

Year 1998
Paino O. Rosato L. Cossavella D. Catania S. Coluccio G.
Divisione di Chirurgia Generale, Regione Piemonte, USL n. 9, Ospedale di Ivrea, Torino.
The authors affirm that plastic surgery using graft materials is a feasible technique also in case of recurrent inguinal hernia. They follow with interest the evolution of laparoscopic techniques which are still the cause of some perplexity. The paper reports a series of nine recurrent inguinal hernias out of 447 inguinal hernias operated during the period May 1994-May 1996.

[Dilatation versus surgery in the treatment of cardial achalasia]

Year 1998
Tosato F. Passaro U. Scocchera F. Vasapollo L. Giordani D. Paolini A.
Servizio Speciale di Chirurgia Esofagea, Policlinico Umberto I, Roma.
Both surgery and dilatation are useful for the treatment of cardial achalasia. The authors make a wide review of the literature with particular attention to reports comparing results of these procedures. This review evidences that surgery gives better results than dilatations (84.4% of good results with surgery against 71.4% with repeated dilatations) and is certainly more stable over the years. Mini-invasive surgery points out even more strongly that surgery is nowadays to be preferred. Laparoscopy makes it possible to avoid postoperative pain, to discharge the patient in a couple of days and finally to eliminate surgical scars. Complications, even more frequent after surgery (5.5% against 2.1% of dilatation) are still acceptable in number and not heavy in quality.

[Diverticulosis of the gallbladder. A case report and review of the literature]

Year 1998
Porzio S. Lombardi V. Buonomo O. Cervelli V. Chiusano R. Tisone G. Pisani F.
Ospedale S. Eugenio, Chirurgia d'Urgenza, Azienda USL Roma C.
We report a case of diffuse diverticulosis of the gallbladder in a 32 year old patient, who presents epigastric pains and decayed general conditions. With the suspicion of a primitive tumor of the gallbladder, we make a cholecystectomy and the intraoperative histological examination shows a "diffuse diverticulosis of the gallbladder wall"; it displays micro-stones inside diverticulums, too. The patient, after the surgical treatment, has no problem and he gets back to his normal weight. The literature shows the rarity of this disease; its etiopathogenesis is connected with congenital factors. In our opinion, the many terms used (cholecystitis glandularis proliferans, hypertrophic, adenomyomatosis) to define those conditions are not appropriate for our case but rather for the gallbladder's chronic inflammation characterized by the Rokitansky-Ashoff sinuses.

[Intestinal perforation caused by a toothpick]

Year 1998
Cossavella D. Clerico G. Paino O. Pozzo M. Trompetto M.
Divisione di Chirurgia Generale, Ospedale di Ivrea, Torino, Regione Piemonte, Azienda USL 9.
Intestinal injuries are pathologies frequently caused by toothpicks. In literature are reported serious damage to the cardiovascular system, lung and systemic fatal sepsis. In literature are also reported some deaths caused by delayed diagnosis. The authors report two cases of intestinal perforation by toothpick. Both patients had accidentally swallowed the toothpick. The clinical state was compatible with acute abdomen in a 59 year old psychopathic patient and acute appendicitis in a 27 year old patient. The aim of this paper is to emphasize the importance of a careful anamnesis for detecting the swallowing of a toothpick.

[Rectal endometriosis. Apropos of a clinical case]

Year 1998
Cudazzo E. Capelli P. Bianchi M. Sabag R. Rusconi A.
Divisione di Chirurgia, Ospedale di S. Secondo, Parma.
Regarding a case of rectal endometriosis, presenting with cyclic menstrual rectal bleeding, the authors discuss the clinical and treatment aspects of such a rare pathology. History was sufficient to indicate the diagnosis which was confirmed by the histological examination of the excised rectal tract. These observations underline the diagnostic difficulty; the surgical approach is the treatment of choice when medical treatment gives no success.

[Gastric cancer. Which resection?]

Year 1998
Rossi M. Dellagiacoma G. Dalle Ore G. Bovolato M. Pellini F. Cadamuro M. Moretto G. Santoro G.
Istituto di Patologia Chirurgica, Universita degli Studi, Verona.
BACKGROUND: The choice of surgical technique in antral gastric cancer is still debated. Some authors support total gastrectomy in all cases. In recent years there is a trend to use total gastrectomy only if strictly necessary. Total gastrectomy allows a large lymph node excision, with better oncological results. The mortality rate and post-operative complications are quite similar today after gastric resection. Anyway, if exact histological diagnosis is possible and at least 6 cm unaffected tissue is preserved, oncological cure is possible by gastric resection. METHODS: Personal experience in 224 patients operated on from 1975 to 1994 is reported. RESULTS AND CONCLUSIONS: 54.3% had antral gastric cancer, 16.5% body cancer and 8.7% fundus gastric cancer. Subtotal gastric resection should be the surgery of choice in antral gastric cancer. Early subtotal gastrectomy with R2, Advanced (III and IV-TNM) only resection with R2, and Advanced (II-TNM) total gastrectomy with R3.

[Video laparoscopy in patients with pain in the right iliac region]

Year 1998
Saviano M. Piccoli M. Menozzi M. Gelmini R. Heydari A.
Dipartimento di Chirurgia, Universita degli Studi, Modena.
The authors report on their experience of 235 laparotomy operations and 125 laparoscopic operations performed on patients with right lower abdominal pain. Concerning each of these different approaches, the authors analyzed and compared preoperative diagnosis, anatomo-pathological findings, intraoperative and early post operative morbidity and hospital stay. The ratio of negative open-appendectomies was 24.1% (56 cases out of 233). The laparoscopic approach, performed on 88 cases of suspected appendicitis, allowed to document and to treat other pathologies, real causes of the lower right abdominal pain, in 42 cases (47.7%). The rate of conversion from laparoscopic appendectomy to open appendectomy was only 2.19% (2 cases out of 91). The morbidity rate of laparoscopic appendectomy was estimated at 6.5% (4.4% major complications, 2.2% minor complications). The morbidity rate of open appendectomy was estimated at 8.9% (0.4% major complications, 8.5% minor complications). Though the median postoperative stay, after laparotomy approach, was slightly longer (2.6 days versus 2.4 days), the difference was not statistically significant. Based on these results, the authors conclude that the laparoscopic approach should be reserved for fertile female patients, especially when the diagnosis of appendicitis is uncertain.

[Technique of repair of acquired inguinal hernia by anterior reinforcement of the Fruchaud floor with polypropylene mesh]

Year 1998
Ferrari CA.
Divisione di Chirurgia Generale, Ospedale di Guastalla (Reggio Emilia), USL di Reggio Emilia.
The main cause of acquired inguinal hernia is weakness of Fruchaud's deep muscolofascial floor, following metabolically-determined collagen disorders. A technique for the anterior reinforcement of this structure with polypropylene mesh is described here. Following intermuscular decollement, the mesh is placed in direct contact with the surface formed by the transversalis fascia and the transversus abdominis muscle and stretched as extensively as possible. Because the posterior aspect of the inguinal canal is the true barrier to abdominal pressure, the author believe that its direct reinforcement, without interposition of the internal oblique muscle, constitutes the most correct anatomo-surgical approach to hernia repair. This is the case for both indirect hernias, in which the internal ring is reconstructed at a deeper level, and for direct hernias, in which the "tent effect" of the prosthesis is prevented. Ninety-two primary inguinal hernias (56 indirect, 29 direct and 7 direct and indirect) in 87 patients were repaired with this technique. Seventy-nine patients were followed up from 2 to 24 months. Early complications included: 7 ecchymosis, 3 seromas, 2 subcutaneous infections, 3 testicular swellings. Incision and testicular pain for longer than 6 months occurred in 2 cases. No prosthetic infections or recurrences have been detected up to the present.

[Intestinal occlusion caused by Morgagni-Larrey diaphragmatic hernia]

Year 1998
Fornero G. Rosato L. Coluccio G.
Divisione di Chirurgia Generale, Ospedale di Ivrea, Torino.
Morgagni-Larrey's hernias, which are both infrequent and generally asymptomatic, are often diagnosed by chance during routine diagnostic tests performed for other pathologies. Usually congenital in adults, they are often small or only take the form of a pre-hernia lipoma. Intestinal occlusion is rarely described and frequently entails diagnostic difficulties before hydroaerial levels are demonstrated in the thoracic region. In these cases, surgery using an abdominal approach should be preferred in order to treat compressed abdominal viscera at the same time and to exclude the bilateral nature of the lesion. The authors present two cases of an adult man and woman who were referred to their attention for occlusive pathologies. Both were operated using a laparotomy approach. The reduction of abdominal viscera did not present any difficulties. The hernial sac was only removed in the first patient. Plastic surgery was completed by attaching the diaphragmatic flap to the costal and sternal wall using separate non-reabsorbing suture stitches. No complications were reported.

[Complicated Spigelian hernia. A case report]

Year 1998
Di Lernia S. Armiraglio L. Branchini L. Massazza C. Salatino G. Scandroglio I. Pugliese R.
U.O. Chirurgia Generale, USSL n. 3, Ospedale di Busto Arsizio, Varese.
Prompted by the observation of a case of lateral ventral Spigelian hernia complicated by strangulation and manifested by symptoms of small intestine occlusion, the authors describe the anatomo-surgical characteristics of the abdominal site of this pathology. They analyse the various diagnostic and subsequently surgical options available to the surgeon when dealing with this pathology. This is achieved with reference to data reported in the current international literature on the subject. Lastly, the authors provide a series of evocative images obtained during the diagnosis of the patient treated and of the results achieved following surgery and a 1-year follow-up after the operation.

[Lithiasis of the vermiform appendix. Remarks on a clinical case]

Year 1998
Melis MV. Scintu F.
Chirurgia Generale II, Universita degli Studi, Cagliari.
The authors present a case of a 36 year old male, admitted with a 3 year history of cramping abdominal pain, fever, and transient finding of a right lower quadrant mass. The abdominal roentgenogram revealed a large opacity located on the right side of the fifth lumbar segment. The patient underwent laparotomy: an enlarged appendix was removed. The specimen had 4 calculi completely obstructing the lumen of the appendix. The diameter of calculi were 0.5 (in 3 instances) and 3 cm. The case herein described is rather uncommon, due to: 1) the rarity of multiple appendiceal calculi; 2) the size of the larger stone; 3) the inconstant finding of right lower quadrant mass; 4) the non development of acute appendicitis. Differential diagnosis involved several diseases presenting with palpable mass of the lower quadrant of the abdomen and/or laminated densities at the plain abdominal roentgenogram.

[Mucinous cystadenocarcinoma (malignant mucocele) of the cecal appendix]

Year 1998
Marzano T. Coluccio G. Coli P.
Divisione di Chirurgia Generale, Ospedale di Fossano (Cuneo), Regione Piemonte, ASL n. 17.
Mucinous cystadenocarcinoma of the cecal appendix is a very rare malignant neoplasia. The majority of these tumours are discovered during surgery performed for other pathologies or as a chance finding in the histological analysis of surgically removed inflamed appendix. There is no characteristic symptomatology of this neoplasia which requires oncologically correct surgery, such as right hemicolectomy. The authors report a case study o peritoneal recidivation of a mucinous cystadenocarcinoma of the appendix.

[Duodenal lipoma causing intestinal subocclusion. Case report]

Year 1998
Napolitano C. Evrard S. Mutter D. Tassetti V. Marescaux J.
Universite Louis Pasteur, Hopital Civil, Strasbourg, France.
Duodenum is a rare position for gastrointestinal lipoma which sometimes may lead to severe complications. Authors report the case of a 60-year old woman treated with a transduodenotomic excision through a midline laparotomy. At admission the patient presented epigastric pain for 1 month. Physical examination was negative except for a modest epigastric sensitivity. CT scan showed image with regular features and fat density, and permitted the exact preoperative diagnosis. Final histopathological examination confirmed the diagnosis.

[Ileal duplication in adults. A very rare nosological entity]

Year 1998
Lombardi P. Nincheri Kunz M. Giovane A. Renzi F. Borrelli A. Kroning KC. Prosperi P. Bencini L. Catarzi S.
Clinica Chirurgica (Direttore: Prof. G. Allegra), Universita degli Studi, Firenze.
The report presents a rare case of intestinal duplication in a 43-year old female. Intestinal duplication is a rare congenital malformation and is extremely exceptional in adults. A lot of etiopathogenic theories have been advanced to explain this malformation that can occur anywhere along the alimentary tract, even if the ileum remains the most common. It may be cystic or tubular. An important aspect of mucosal histology is the possibility of gastric heterotopy, conditioning a particular treatment. The literature shows 14 cases with clinical very different presentations and instrumental exams were rarely helpful for correct diagnosis. Treatment of choice is surgical complete resection of the duplication. When contiguous structures are involved intestinal bypass or Roux-on-Y anastomosis may be necessary with mandatory stripping of the mucosa when heterotopic gastric mucosa is present in order to prevent the risk of gastrointestinal haemorrhage or malignant transformation, an event possible in about 25% of the cases reported in the literature.

[Volvulus of the sigmoid colon]

Year 1998
Paino O. Trompetto M. Clerico G. Pozzo M. Coluccio G.
Divisione di Chirurgia Generale, Regione Piemonte, Azienda USL n. 9, Ospedale Civile, Ivrea, Torino.
Sigmoid colon is the most frequent side for a volvulus. We present four cases of sigmoid volvulus admitted to our department during the period July 1994-December 1995. Intestinal volvulus, despite its benignity, has a quite high morbidity and mortality. Important factors such as the patient's features and frequent late diagnosis can influence the complicated outcome of the disease. Plane X-ray of the abdomen is helpful while barium enema can be therapeutical because of the pressure of the inflated air. Sigmoid resection is the most effective treatment for the disease.