Drop in trough blood concentrations of tacrolimus after switching from nelfinavir to fosamprenavir in four HIV-infected liver transplant patients

Solid organ transplantation in HIV-infected individuals requires concomitant use of immunosuppressants and antiretrovirals that may cause significant drug interactions. Here we report on a peculiar pharmacokinetic interaction between tacrolimus and protease inhibitors (PIs) which occurred in four HIV-infected liver transplant patients who had to shift PI therapy from nelfinavir to fosamprenavir as a consequence of regulatory restrictions. After the switch, tacrolimus trough blood concentrations significantly dropped in all patients (mean +/- SD 6.9 +/- 2.6 versus 3.2 +/- 2.0 ng/ml before and after the switch, respectively; P=0.01), so that a marked dosage increase was needed (0.29 +/- 0.14 versus 0.88 +/- 0.48 mg/day, 1-3 days before and 3 weeks after the switch, respectively; P=0.046) to attain the desired target (8.7 +/- 2.3 ng/ml). Consistently, marked changes of the concentration/dose ratio of tacrolimus were observed in all cases (27.2 +/- 9.7 ng/ml per mg/kg/day versus 9.7 +/- 4.0 ng/ml per mg/kg/day before and after the switch, respectively; P<0.001). Our findings suggest that fosamprenavir may be less potent than nelfinavir in inhibiting tacrolimus clearance and support the need for higher tacrolimus dosage to avoid insufficient immunosuppression in HIV-infected liver transplant patients when switching from nelfinavir to fosamprenavir or even when directly starting antiretroviral therapy with fosamprenavir.

A comparative study of the transhiatal laparoscopic approach versus laparoscopic gastric mobilisation and right open transthoracic esophagectomy for esophageal cancer management

AIM

Regarding the surgical treatment of esophageal cancer, a question was raised by the introduction of minimally invasive surgery, because of the technical complexity of the techniques involved and its uncertain benefits. We evaluated the impact of laparoscopic esophagectomy on the surgical approach to esophageal cancer.

PATIENTS AND METHODS

From January 2002 to March 2006, 22 non-randomized patients were recruited to undergo esophagectomy for neoplastic disease. The esophagectomy and esophagogastroplasty were performed using the laparoscopic transhiatal technique (THE) in 9 cases, while a combined laparoscopic gastric mobilisation and right transthoracic incision (TT/LE) was performed in the other 13.

RESULTS

Mean follow up was 21+/-3.23 months, range 2-46 months. Overall cumulative survival was 84.0% at 12 months, 61.3% at 24 months, 51.0% at 36 months. THE achieved better results than TT/LE on the ground with regard to the time it took to complete the procedure (p=0.046) and the hospital stay times (p=0.039), and the time in ICU, postoperative oral feeding resumption, number of retrieved lymph nodes.

CONCLUSION

The clinical benefits of minimally invasive techniques regard the time it takes to complete the procedure, the time in ICU, postoperative oral feeding resumption and the hospital stay times. Minimally invasive surgery might be not less curative and effective than open surgical procedures, as found in our small non-randomzed series of patients. Larger series should confirm these results.

Treatment of perforation in the healthy esophagus: analysis of 12 cases

BACKGROUND

Perforation of the esophagus still carries high morbidity and mortality rates, and there is no gold standard for the surgical treatment of choice.

MATERIALS AND METHODS

We reviewed the records of patients treated for esophageal perforation in the last decade at the General Surgery Unit of the University of Udine. Patients suffering from perforation secondary to surgical procedures or neoplastic disease were ruled out.

RESULTS

Eight males (66.7%) and four females (33.3%) met the inclusion criteria. The cause of perforation was iatrogenic in seven cases (58.3%) and spontaneous in five (41.7%). The perforation was in the cervical esophagus in five cases (41.7%) and at thoracic level in the other seven (58.3%). Two patients (16.7%) with cervical lesions were treated conservatively; two (16.7%) underwent primary closure and the insertion of a drainage tube; one patient with a distal cervical lesion underwent diversion esophagostomy; six patients had resection of the entire thoracic esophagus and terminal cervical esophagostomy; one had segmental resection of the distal thoracic esophagus and lateral diversion esophagostomy. In the five patients whose reconstruction was postponed, esophagogastroplasty surgery was performed with an anastomosis at cervical level in four cases and at thoracic level in one. The global mortality rate was 25%. Late diagnosis-more than 24 h after the perforation event-seems to be the only factor correlated with fatal outcome (p = 0.045).

CONCLUSIONS

The choice of treatment for perforation in a healthy esophagus depends mainly on the site and size of the lesion. Cervical lesions may be amenable to conservative treatment or require primary surgical repair, while thoracic lesions with associated sepsis or major loss of substance demand an aggressive approach, with esophageal resection and delayed reconstruction seeming to be the safest option.

[Uretero-vescical anastomosis during kidney transplantation. Preliminary results of two surgical techniques]

AIM

The most frequent urologic complications after renal transplantation involve the uretero-vescical anastomosis (leakage, stenosis, and reflux), with a frequency of 1% to 30% in different series.

METHODS

We present our results in a prospective randomized trial performed from October 2004 to September 2005, in a cohort of 36 patients, who underwent renal transplantation from cadaveric donor at our institution. A uretero-vescical anastomosis according to Lich-Gregoir was used in 18 cases (group A), whereas an anastomosis according to Knechtle was performed in other 18 patients (group B), respectively. The groups were comparable for donors and recipients characteristics. The mean donor age was 46.3 years vs 44.9 years, and the mean duration of cold ischemia was 1 086+/-296 min vs 1 100+/-381 min for group A and for group B respectively. The mean recipient age was 47.5 years vs 46.1 for group A and group B, respectively.

RESULTS

No differences were evidenced between the two uretero-vescical anastomosis in term of surgical complications, infections or patient and graft survival at one year of follow-up. Stenosis and leakage involved 2 patients for each group respectively. Numbers of infections, days of antibiotic therapy were similar between the two groups.

CONCLUSION

Our early experience does not evidence differences between the two types of uretero-vescical anastomosis.

Intraperitoneal Tenckhoff catheter for the treatment of recurrent lymphoceles after kidney transplantation: our early experience

Lymphoceles may occur as frequently as 16% of the time after kidney transplantation, becoming clinically evident between 18 and 180 days after surgery. The management of lymphoceles is unclear. Percutaneous needle aspiration and external drainage are associated with high recurrence and complications. Surgical intraperitoneal marsupialization of lymphocele is considered the treatment of choice, but requires hospital admission, general anesthesia, and sometimes extensive surgical dissection. We discuss our experience in the treatment of recurrent symptomatic lymphocele intraperitoneally drained using a Tenckhoff catheter in 7 consecutive patients. Clinical manifestations became evident between 26 and 90 days after transplantation. The diagnosis was obtained with abdominal ultrasound in all cases; mean lymphocele diameter was 14 +/- 6 cm. After percutaneous drainage, performed to differentiate urinoma/lymphocele and to rule out infections, the lymphocele recurred within 1 month. Thereafter, we decided to treat recurrent lymphatic collection using a Tenckhoff catheter. The lymphocele was located during the operative procedure using a sterile 3.5-MHz ultrasound probe. With the patient under local anesthesia, we performed 2 vertical 1-cm incisions to the lymphocele and peritoneum, respectively. The Tenckoff catheter was first positioned into the lymphocele and the tunneled inside the peritoneal cavity. One cuff of the Tenckhoff was fixed to the fascia to avoid possible delocalization. The patients were discharged the same day. The catheter was removed 6 months later with no evidence of lymphocele recurrence.

Comparison of Two Techniques of Arterial Anastomosis During Adult Cadaveric Liver Transplantation

Arterial complications are a major source of morbidity and mortality after orthotopic liver transplantation (OLT). The incidence of hepatic artery thrombosis (HAT) ranges from 1.6% to 8%, with a mortality rate that ranges from 11% to 35%. We have described herein a technique of arterial anastomosis aiming to perform the anastomosis as straight as possible to avoid any kinking, redundancy, or malposition of the artery when the liver is released in its final position. We compared this technique with the traditional technique of arterial anastomosis using an aortic Carrel patch, namely, 198 OLT (group A) with the traditional technique and 117 OLT (group B) with the modified technique. An aorto-hepatic bypass was necessary in 25% of the cases in group A and in 21% of the cases in group B (P = .33). Vascular anomalies were present in 20% of cases in group A and in 27.5% in group B (P = .14). Fourteen cases (7%) of HAT developed in group A versus 0 cases in group B (P = .003). In group B, we experienced 2 (1.7%) late arterial stenoses that were successfully treated using percutaneous transluminal angioplasty. The 14 cases of HAT occurring in group A were successfully managed using immediate surgical revascularization with graft salvage in 6 cases (43%), whereas the remaining 8 cases needed urgent retransplantation. We suggest that a technique of arterial anastomosis aimed at avoiding kinking, redundancy, or malposition of the artery may be a viable option to reduce the risk of HAT after OLT.

Superiority of Transplantation Versus Resection for the Treatment of Small Hepatocellular Carcinoma

The best therapy for hepatocellular carcinoma (HCC) is still debated. Hepatic resection (HR) is the treatment of choice for single HCC in Child A patients, whereas liver transplantation (OLT) is usually reserved for Child B and C patients with multiple nodules. The aim of this study was to compare HR and OLT for HCC within the Milan criteria on an intention-to-treat basis. Forty-eight patients were treated by OLT and 38 by HR. Three- and 5-year patient survival rates were significantly higher (P = .0057) in the OLT group (79% and 74%) than after HR (61% and 26%). The 3- and 5-year disease-free survival rate was better (P = .0005) for OLT (74% and 74%) versus HR (41% and 11%). The probability of HCC recurrences after resection was greater (P = .0002) than after transplantation, achieving 31% and 76% for HR and 2% and 2% for OLT at 3 and 5 years after surgery. The median waiting list time was 118 days; two patients dropped out for HCC progression. We concluded that OLT is superior to HR for small HCC in cirrhotic patients assuming that OLT can be performed within 6 to 10 months after listing to reduce dropouts due to tumor progression.

Selective Bilirubin Removal by Plasma Treatment With Plasorba BR-350 for Early Cholestatic Graft Dysfunction

Early cholestatic graft dysfunction is a frequent cause of morbidity after orthotopic liver transplantation (OLT). We analyze the role of selective bilirubin plasma absorption (PAP) using Plasorba BR-350 in 4 OLT patients who had experienced early severe cholestatic graft dysfunction within 15 days after transplantation. Patients were treated with 3 consecutive cycles of PAP with Plasorba BR-350. The median amount of plasma treated was 7500 mL. Median treatment duration was 231 minutes. The average plasma bilirubin level was 37 +/- 1 mg/dL before PAP and decreased to 15 +/- 0.2 mg/dL at the end of the third cycle of PAP; 3 of 4 cases had progressive bilirubin normalization after PAP. The average amount of bilirubin removed from the plasma of the patients during each PAP treatment was 143 +/- 24 mg. At the beginning of each cycle of PAP, the Plasorba BR-350 was able to remove >90% of the total plasma bilirubin, a percentage that decreased to 60%, 50%, and 40% after 2 L, 4 L, and 7 L of plasma were treated, respectively. Liver biopsies performed after the third treatment showed reduced cholestasis when compared with the pretreatment biopsy specimen. The preliminary data suggested that PAP selective for bilirubin removal may not only reduce the bilirubin level, but may also improve the histological pattern of the graft in terms of reduced cholestatic signs.

Percutaneous Transhepatic Portography for the Treatment of Early Portal Vein Thrombosis After Surgery

We treated three cases of early portal vein thrombosis (PVT) by minimally invasive percutaneous transhepatic portography. All patients developed PVT within 30 days of major hepatic surgery (one case each of orthotopic liver transplantation, splenectomy in a previous liver transplant recipient, and right extended hepatectomy with resection and reconstruction of the left branch of the portal vein for tumor infiltration). In all cases minimally invasive percutaneous transhepatic portography was adopted to treat this complication by mechanical fragmentation and pharmacological lysis of the thrombus. A vascular stent was also positioned in the two cases in which the thrombosis was related to a surgical technical problem. Mechanical fragmentation of the thrombus with contemporaneous local urokinase administration resulted in complete removal of the clot and allowed restoration of normal blood flow to the liver after a median follow-up of 37 months. PVT is an uncommon but severe complication after major surgery or liver transplantation. Surgical thrombectomy, with or without reconstruction of the portal vein, and retransplantation are characterized by important surgical morbidity and mortality. Based on our experience, minimally invasive percutaneous transhepatic portography should be considered an option toward successful recanalization of early PVT after major liver surgery including transplantation. Balloon dilatation and placement of a vascular stent could help to decrease the risk of recurrent thrombosis when a defective surgical technique is the reason for the thrombosis.

Analysis of clinical outcomes and prognostic factors of neoadjuvant chemoradiotherapy combined with surgery: intraperitoneal versus extraperitoneal rectal cancer

Neoadjuvant chemoradiotherapy (CRT) is a widely purposed and performed treatment for rectal cancer. Downstaging effects possibly enhance the rate of curative surgery and may enable sphincter preservation in low-lying tumours. The current study examines the clinical outcomes in patients enrolled in a neoadjuvant CRT-surgery protocol for rectal cancer, distinguishing between intraperitoneal and extraperitoneal cancer. From 1994 to 2003, 58 patients with a primary diagnosis of rectal cancer were enrolled in a single-centre, not randomized study based on 5-week sessions of radiotherapy associated with a 30-day protracted venous 5-FU infusion followed by surgical resection. The study population was divided into two groups according to the localization of the tumour: 18 intraperitoneal and 40 extraperitoneal (EPt). Fifty-eight patients were treated with neoadjuvant CRT and surgery. Overall mortality rate was 25.9%, no deaths were recorded during hospitalization; 10 patients (all EPt) died because of recurrence. Significant differences in disease-free survival and overall survival rates were found between intraperitoneal vs. extraperitoneal tumours (P = 0.006), both intraperitoneal vs. extraperitoneal tumours N(0) (P = 0.04 and P < 0.05) and intraperitoneal vs. extraperitoneal tumours N(+) (P < 0.05). We diagnosed all local recurrence and liver metastasis in extraperitoneal tumours (t = 0.02 and t = 0.04), and only one case of lung metastasis arose from intraperitoneal cancer. Extraperitoneal tumours could be more aggressive than intraperitoneal ones, spreading more precociously, and/or less responsive to the neoadjuvant CRT because of their localization rather than biological differences. Aside from lymph node status, the location of the tumour with respect to the peritoneum border, is also a prognostic factor of survival in rectal cancer treated by neoadjuvant CRT and surgery.

De novo gastrointestinal tumours after renal transplantation: role of CMV and EBV viruses

The development of new and more effective immunosuppressive agents has provided long-term survival for transplant recipients, thereby increasing the risk of de novo malignancy in chronic immunocompromised hosts. While de novo post-transplant lymphoproliferative diseases and skin cancer has been shown to have an increased incidence in long-term surviving solid organ transplant recipients, the association with gastrointestinal (GI) cancer is controversial. Over 12 yr, 20 patients (5%) out of 395 renal transplant recipients developed 23 de novo tumours; 11 skin cancer and 12 non-skin cancer. Four patients (1%) developed de novo tumours of the GI tract (three colon, and one gastric cancer). Immediately after tumour's diagnosis, immunosuppressive therapy was reduced; all patients were shifted from cyclosporine to Rapamicine within 30 d. The tumour was surgically resected with curative intent in three cases, while one patient had only palliative surgery because of metastatic disease. The post-operative courses was uneventful. All patients maintained normal graft function. However, three out of four patients (75%) died of progression of the neoplasm, within a median time from the diagnosis of 12 months. Further, we investigated a possible correlations between de novo GI cancer and HCV, HBV status, infections, cytomegalovirus (CMV) and Epstein-Barr virus (EBV) reactivation, episodes of rejection, and blood transfusions. All cases with GI de novo cancers reported in this paper developed CMV and EBV reactivation within three months after transplantation. Thereafter we suggest a closer follow-up for de novo GI cancer in renal transplants with early CMV and EBV reactivation in order to avoid delayed diagnosis.

Instrumental clinical restaging, pathological evaluation, and tumor regression grading: how to assess the response to neoadjuvant chemoradiotherapy for rectal cancer

INTRODUCTION

The object of neoadjuvant chemoradiotherapy regimens is a downstaging or downsizing of advanced rectal tumor to increase the rate of curative resection and reduce loco-regional failure. A reliable method of assessing response to adjuvant therapies is required to help standardize the assessments of new multimodality therapies. The purpose of this study was to evaluate the role played by tumor regression grading on the evaluation of pathological response to chemoradiotherapy, compared with both the predicting value of the clinical response to neoadjuvant therapy and pathologic response evaluation.

METHODS

From 1994 to 2003, 58 patients with a primary diagnosis of rectal cancer were studied at our department and enrolled in a single center, not randomized study based on 5-week sessions of radiotherapy associated with a 30-day 5-fluorouracil (FU) infusion, followed by surgical resection. Instrumental restaging and routine histological examination, including tumor regression grading, were performed to asses the response to neoadjuvant therapy.

RESULTS

The cCR rate corresponds to pCR rate, while a 3.5% of cPR and a 3.4% of cSD corresponded to a pPD. cPR and cSD show a PPV of 92.8% and 90.9% respectively, while cPD NPV is 20%. No case was found with no regression (grade 0). Tumor regression was defined grade 1 in 24.5% of cases, grade 2 was found in 58.5% of cases, 7.5% were grade 3, and 9.5% showed complete regression (grade 4). Pathologic response resulted to be associated with regression grade (p=0.006). Tumor regression grading is an independent variable for pT (p=0.0002), pN status (p=0.00004), pathologic staging (p=0.000001) and local recurrence (p=0.003).

CONCLUSION

Our results lead us to consider only pathologic evaluation to determine the response to neoadjuvant treatment: the application of tumor regression grading on the specimens obtained after combined neoadjuvant chemoradiotherapy and surgery is useful to plan a better therapeutic strategy on the ground of a quantitative evaluation of the response to neoadjuvant treatment; it shows it is an important comparable pathological feature, useful in comparing different protocols' results and differences between patient's response as well as prognostic factors.

Laparoscopic versus open gastroplasty in esophagectomy for esophageal cancer: a comparative study

How best to approach esophagectomy is a controversial issue. In the last decade, the opportunity to use minimally invasive surgical methods for esophagectomy has been documented, but their real advantages over conventional surgery have yet to be clearly established. The aim of this study was to compare a series of patients who underwent laparoscopic esophagectomy with those who underwent open surgery to ascertain the feasibility, safety, and clinical advantages of the former surgical techniques. Between January 2002 and May 2004, 14 patients with cancer of the esophagus underwent laparoscopic esophagectomy and another 14 had conventional open esophagectomy. Their demographic features, and intraoperative and postoperative data were compared. The 2 groups were comparable in terms of age, American Society of Anesthesiologists score, and site of the neoplasm. The operating times were the same for transhiatal laparoscopic esophagectomy and conventional surgery, although using the thoraco-laparoscopic access took longer than the thoraco-laparotomic procedure (P<0.05). The hospital stay was shorter after laparoscopy (P<0.05). No differences emerged in terms of morbidity, mortality, number of transfusions, and time in the intensive care. The numbers of lymph nodes removed were comparable. In conclusion, it is feasible and safe to use a laparoscopic approach instead of open surgery for esophagectomy, but the former does not offer very significant clinical advantages in the postoperative stage. A shorter hospital stay seems to be the most significant finding. The minimally invasive procedure would seem to assure oncological radicality because it enables lymphadenectomy to be as thorough as in the conventional surgical approach.

Comparison of clinical and pathological staging and long-term results of liver transplantation for hepatocellular carcinoma in a single transplant center

Liver transplantation (OLT) is a treatment for hepatocellular carcinoma (HCC) superimposed on cirrhosis provided that the disease meets defined criteria. The aim of the study was to evaluate our experience with respect to clinical and pathological staging and long-term results. From 1996 to 2005, 50 patients underwent OLT for HCC including 43 men (86%) and seven women (14%) of median age 57 years (range 37 to 67). All patients fulfilled the Milan criteria. The HCC diagnosis was based on preoperative imaging and alpha-fetoprotein levels; no tumor biopsy was performed. Upon histological examination of the resected specimens, we discovered 6 (12%) incidentalomas and 8 (16%) cases of no HCC. Finally we had 42 "true" HCC. Twenty-six patients (52%) have been downstaged and 10 (20%) upstaged by preoperative imaging; 15% were pT1, 45% were pT2, 27% pT3, and 13% pT4a. Twenty-six percent of cases exceeded the Milan criteria. One patient (pT4a) with microvascular invasion died of pulmonary metastases at 14 months after transplantation. No HCC recurrences within the liver have been encountered at a median follow-up of 20 months (range 0 to 80 months). Overall the estimated 1-, 3-, and 5-year survival rates were 83%, 77%, and 72%, respectively. One-, 3-, and 5-year estimated survival rates were 87%, 75%, and 75% for pT1, and pT2, and 75%, 67%, and 67% for pT3 and pT4a, respectively (P = .99). Based on our experience OLT for HCC has long-term results comparable to those without HCC despite the presence of a significant number of cases exceeding the Milan criteria upon pathological staging.

Long-Term Placement of Subcutaneous Rüsch-Type Stents for Double Biliary Stenosis in a Living-Donor Liver Transplant Recipient

Biliary reconstruction continues to be a major source of morbidity following liver transplantation. The spectrum of biliary complications is evolving due to the increasing number of split-liver and living-donor liver transplantation, which are even associated with a higher incidence of biliary complications. Bile duct strictures are the most common cause of late biliary complications and account for up to 40% of all biliary complications. Optimal therapy for posttransplantation anastomotic biliary strictures remains uncertain and requires a multidisciplinary approach. We report the case of a 54-year-old Caucasian male affected by hepatocarcinoma and hepatitis C-related cirrhosis who underwent right-lobe living-donor liver transplantation from his son complicated by double anastomotic stenosis of the main right hepatic duct and of an accessory biliary duct draining segments 6 and 7 of the graft that was successfully treated by percutaneous transhepatic cholangiography with long-term subcutaneous placement of two internal Rüsch-type biliary stents.

Implication of stem cell factor in human liver regeneration after transplantation and resection

The stem cell factor (SCF), besides regulating hemopoietic stem cells homing and proliferation, has proliferative effects on hepatocytes and may be involved in liver regeneration. We investigate if liver transplantation (LT) and hepatic resection (HR) modify the concentration of soluble SCF (s-SCF) in peripheral blood of 15 LT and 7 HR. s-SCF was measured by ELISA as ng/ml. s-SCF basal levels were higher in LT that in HR (818 +/- 349 vs. 479 +/- 79, p = 0.005). A significant increase of s-SCF, peaking at postoperative day +3, was seen after LT (from 818 +/- 349 to 1212 +/- 461, p = 0.01) and HR (from 479 +/- 79 to 698 +/- 122, p = 0.004). s-SCF peak levels were higher after LT than HR (p = 0.0008). At day +7 s-SCF concentration returned to baseline values. LT have a higher basal s-SCF level than HR. These data show for the first time that liver injury affects s-SCF level and suggest that SCF may be involved also in clinical liver regeneration.

The Role of Hepatic Biopsy to Detect Macrovacuolar Steatosis During Liver Procurement

The ability to predict graft function before transplantation has proven to be a difficult task, especially for macrovacuolar steatosis that is considered a major cause of posttransplant dysfunction. It is well known that macrovacuolar steatosis greater than 25% influences the short- and long-term outcomes of liver transplantation. We retrospectively analyzed frozen sections from 43 donor livers comparing preoperative laboratory/clinical values, and liver ultrasound of a cohort of donors without (group A, n=21) versus with steatosis of 25% to 35% (group B, n=22) upon liver biopsy performed during harvesting. We analyzed the possible correlations between preoperative donor data and the degree of macrovacuolar steatosis. None of the biochemical and clinical parameters were related to the degree of hepatic steatosis. The only difference between the two groups was the echographic pattern, with evidence of 27% fatty liver by ultrasound in group B and 5% in group A (p=.04). The specificity of hepatic ultrasound for macrovacuolar steatosis was 95% and the sensitivity was only 27%, while the positive and negative predictive value were 86% and 55%, respectively. In conclusion, liver biopsy during donor harvesting remains the gold standard to identify macrovacuolar steatosis greater than 25%. Hepatic ultrasound has a role to exclude the presence of steatosis in normal livers due to its high specificity, but it is not useful to make the diagnosis of a fatty liver since it has a low sensitivity and negative predictive value. Thereafter a liver ultrasound positive for hepatic steatosis alone should not be considered a valuable tool to discard an organ from transplantation.

De Novo Malignancies After Kidney and Liver Transplantations: Experience on 582 Consecutive Cases

De novo malignancies after transplantation are a growing problem of solid organ transplant recipients, due to longer survival follow-up under chronic immunosuppression. The aim of this study was to analyze a population of 582 consecutive kidney (n = 382) and liver (n = 202) transplant recipients, who survived at least 12 months after transplantation, at a single transplant center for the development of de novo cancers. The incidence of de novo malignancies was 7% after both renal and liver transplantation. The median elapsed time from transplant to the diagnosis of de novo malignancy was 45 months (range 3 to 220) months for kidney and 37 months (range 12 to 101 months) for liver transplants. Skin cancers were the most common within renal recipients, while gastroenteric cancers were more frequently encountered in liver transplants. Oropharyngeal and upper digestive tract tumors were always associated with a history of chronic alcohol consumption in liver recipients. Liver transplant recipients treated for acute rejection had a worse cancer prognosis than patients without rejection 1- and 2-year survivals 83% and 63% versus 36% and 17% (P = .026). The estimated 1- and 2-year survival rates for all types of de novo malignancies were 79% and 66%, including 64% and 51% for solid organ tumors versus 89% and 89% for skin cancers and posttransplant lymphoproliferative disorder (PTLD) (P = .17) in renal transplants and 70% and 42%, including 57% and 28% for solid organ tumors versus 85% and 64% for skin cancers and PTLD (P = .43) in liver transplants respectively.

Prevention of postoperative recurrence of Crohn's disease by infliximab

The prevention of the recurrence of Crohn's disease after surgery remains difficult. The monoclonal antibody anti-TNF-alpha, infliximab, is very effective in inducing and maintaining the remission of uncomplicated, active Crohn's disease. We present here the case of a 23-year-old white woman who underwent resection for a sigmoid stricture caused by Crohn's disease. Surgery removed the involved colon, and pathology confirmed the stricture to be fibrotic. Two weeks after the operation she was given infliximab at the dose of 5 mg/kg body weight and followed in time. Since then, she has been disease free for approximately 4 years after surgery on clinical, radiological and endoscopic/histological grounds (Crohn's Disease Activity Index < or = 110 on all occasions). Up to now, she has had no increase in inflammatory indices, no anaemia and no abnormal blood tests. In contrast, all of five control patients operated in the same period with colonic or ileocolonic resection for symptomatic strictures and treated with mesalamine or no medication developed endoscopic or clinical recurrence (abdominal pain or diarrhoea) by year 3. This is the first case, to our knowledge, in which infliximab has been successfully used to prevent the postsurgical recurrence of Crohn's disease, an event so far considered to be inescapable. We believe that, with this aim in mind, clinical trials with this drug are warranted.

Second degree haemorrhoids: patient's satisfaction, immediate and long-term results of rubber band ligation treatment

AIM

Rubber band ligation (RBL) is a widely performed and well established treatment for second degree haemorrhoids. The aim of our prospective study was to assess the satisfaction of patients treated by rubber band ligation, as well as the immediate and long-term results of this technique.

METHODS

From January 2001 to December 2004, 73 consecutive outpatients with second degree haemorrhoids underwent RBL. From 1 to 3 years from the initial treatment, 73 patients were contacted by phone call to have some news about their health condition and to collect their opinion about the satisfaction of RBL technique.

RESULTS

We didn't identify any major complication in our series, sometimes a temporary anal discomfort that could be controlled by low dose of NSAIDs. We report an excellent immediate benefit in 13.7% of cases, a good one in 58.9%. From 1 to 3 years after the initial procedure 82.2% of patients are either symptom free or improved and don't need any medical therapy.

CONCLUSIONS

Immediate results are very good in particular for bleeding, anal pain and mucosal prolapse. Immediate and long-term results are invalidated by the concomitance of more symptoms and different results are recorded between sexes. We consider RBL a good ambulatory practice that could either get better or resolve haemorrhoidal disease or delay the invasive surgical treatment for second degree haemorrhoids.

Graft loss due to percutaneous sclerotherapy of a lymphocele using acetic acid after renal transplantation

Development of lymphoceles after renal transplantation is a well-described complication that occurs in up to 40% of recipients. The gold standard approach for the treatment of symptomatic cases is not well defined yet. Management options include simple aspiration, marsupialization by a laparotomy or laparoscopy, and percutaneous sclerotherapy using different chemical agents. Those approaches can be associated, and they depend on type, dimension, and localization of the lymphocele. Percutaneous sclerotherapy is considered to be less invasive than the surgical approach; it can be used safely and effectively, with low morbidity, in huge, rapidly accumulating lymphoceles. Moreover, this approach is highly successful, and the complication rate is acceptable; the major drawback is a recurrence rate close to 20%. We herewith report a renal transplant case in which the patient developed a symptomatic lymphocele that was initially treated by ultrasound-guided percutaneous sclerotherapy with ethanol and thereafter using acetic acid for early recurrence. A few hours after injection of acetic acid in the lymphatic cavity, the patient started to complain of acute pain localized to the renal graft and fever. An ultrasound of the abdomen revealed thrombosis of the renal vein and artery. The patient was immediately taken to the operating room, where the diagnosis of vascular thrombosis was confirmed and the graft was urgently explanted. In conclusion, we strongly suggest avoiding the use of acetic acid as a slerosating agent for the percutaneous treatment of post-renal transplant lymphocele because, based on our experience, it could be complicated by vascular thrombosis of the kidney, ending in graft loss.

Prognostic value of tumour regression grading and depth of neoplastic infiltration within the perirectal fat after combined neoadjuvant chemo-radiotherapy and surgery for rectal cancer

OBJECTIVE

To evaluate histological variables correlated with pathological response to chemo-radiotherapy protocols for rectal cancer and with local recurrence and survival.

METHODS

From 1994 to 2003, 58 patients with rectal cancer were enrolled in a non-randomised study based on standardised treatment with radiotherapy, 5-fluorouracil, and surgical resection, followed by histological examination, including tumour regression grading and depth of neoplastic infiltration within the perirectal fat. All patients were followed up. Mean (SD) length of follow up was 55.3 (28.1) months, range 5 to 108.

RESULTS

No case was found with no regression (grade 0). Tumour regression was defined as grade 1 in 24.5% of cases, grade 2 in 58.5%, grade 3 in 7.5%, and grade 4 (complete regression) in 9.5%. Neoplastic infiltration of >4 mm within the perirectal fat was found in 25.6% of cases in grade 1, 55.8% in grade, 2.7% in grade 3, and 11.6% in grade 4. In 80% cases of pT4 depth of neoplastic infiltration within the perirectal fat was >4 mm (100% were pN+), and the same spread was also found in 53.4% of pT2 and 86.2% of pT3. Pathological response was associated with regression grade (p = 0.006) and depth of neoplastic infiltration within the perirectal fat (p = 0.04). Tumour regression grading was an independent variable for pT (p = 0.0002), pN status (p = 0.00004), pathological staging (p = 0.000001), and local recurrence (p = 0.003).

CONCLUSIONS

Involvement of the lateral resection margins correlates with a poor prognosis and indicates the likelihood of local recurrence of rectal cancer. Tumour regression grading and the depth of neoplastic infiltration within the perirectal fat are important prognostic factors that need to be evaluated routinely.

Surgical therapy for patients with extraesophageal symptoms of gastroesophageal reflux disease

AIM

The last 20 years have seen a systematic reappraisal of the physiopathology and diagnosis of gastroesophageal reflux disease (GERD) and its associated typical symptoms, while less attention has been paid to correlating GERD with certain extraesophageal symptoms and the value of surgery for their treatment. The aim of this study was to determine the clinical and physiopathological features and the outcome of surgery, in a group of patients who underwent laparoscopic fundoplication for GERD with atypical symptoms, and to compare the results with another group of patients operated for GERD with typical symptoms.

METHODS

Two hundred and forty-one patients were evaluated for GERD at our Digestive Physiopathology outpatients surgery from January 2001 to January 2003. Of the 36 patients who underwent laparoscopic fundoplication, 23 had the typical symptoms of GERD and 13 had atypical symptoms. Twelve months after surgery, these patients were compared in terms of 24-h pH monitoring, esophageal manometry, regression of symptoms and degree of satisfaction.

RESULTS

Postoperatively, patients with atypical symptoms had a smaller increase in effective peristalsis (P = 0.06) and a more limited improvement in symptoms (54% vs 91%, P = 0.001), and they expressed less satisfaction with the surgical treatment (5.9 vs 8.2, P = 0.003).

CONCLUSIONS

The results of surgery in GERD patients with atypical symptoms are worse than in those with typical symptoms. A careful preoperative work-up, based on 24-h pH monitoring, is fundamental for patients with atypical symptoms, who also need to be informed of the high likelihood of surgery proving clinically unsuccessful.

Quality-of-life assessment before and after liver transplantation

BACKGROUND

Quality-of-life (QoL) assessment includes health status, disability, psychological wellness, and social performance. We sought to evaluate the effect of liver transplantation (OLT) on the QoL of patients awaiting the procedure and its variations up to 8 years afterwards.

METHODS

LEIPAD-perceived QoL and BSI-psychological distress tests were used. Patients were divided in four groups (waiting list patients, 1 to 2 years after LT, 3 to 4 years after LT, 5 to 8 years after LT). Patients were also evaluated for type and severity of liver disease.

RESULTS

We evaluated 126 patients, 71% male, 29% female, median age 60.7 years (range 40 to 76 years), median follow-up 4 years (range 1 to 8). The patients on the waiting list scored worse both in global stress index (GSI) and total LEIPAD scores than transplanted patients. Upon univariate linear regression analysis, the only dimension associated with time groups was LEIPAD--physical functioning, showing a progressive improvement of perceived physical status with time from transplant. Severity of liver disease showed a protective effect, probably reflecting a better control of stressful events from patients transplanted at advanced stages of liver disease. Protective effects were found for male sex, retired, cohabitant patients, and the degree of education. Housewife and widow patients showed negative associations with BSI and LEIPAD dimensions. No independent predictors of QoL were found in this study.

CONCLUSIONS

OLT improves most, but not all, QoL and psychological distress domains.

[Relation between information, anxiety and satisfaction in oncological and surgical patients]

A surgical and oncological patient feel anguish, anxiety and fear when he know his health problems. Information is a very important factor for reducing anxiety level of patient and, at the same time, affects his perceived satisfaction. The aim of this study was to evaluate the impact of informations giving by one or more physicians on anxiety and satisfaction of patient. We have used the State Trait Anxiety Inventory (S.T.A.I.) and the Perceived Physician Communication Style Scale for evaluating anxiety and patient perceived satisfaction in medical encounter. We have involved 36 oncological and surgical patients admitted in General Surgery Department of University Hospital of Udine. The findings showed that patients post-consultation and post-information encounter anxiety level became lower when there were only one physician giving informations; instead there were no significant differences between perceived satisfaction inside groups of patients. Nevertheless case group patients perceived more disposition in listening of physician.

Late retransplantation of the liver: a single-centre experience

Liver retransplantation is considered to carry a higher risk than primary transplantation. The aim of this study was to analyse a single-center experience with late liver retransplantation. The overall rate of primary retransplantation was 11% (30 re-OLT out of 272 primary OLT). fiftten of these (50%) had retransplantation more than 3 months after the first transplant and were analyzed by reviewing their medical records. Causes of primary graft failure leading to retransplantation were chronic hepatic artery thrombosis in 6 cases (40%), HCV cirrhotic recurrence in 4 cases (28%), chronic rejection in 2 cases (14%), veno-occlusive disease, hepatic vein thrombosis and idiopathic graft failure in 1 case each (6%). UNOS status at re-OLT was 2A in all cases. All patients were hospitalised, and three of them were in intensive care. One- and two-year patient and graft survival rates were 80% and 66% and 66% and 59%, respectively. Death occurred in 5 patients, including 2 of the 3 admitted to the intensive care unit at the time of retransplantation, who died after a mean interval of 15 +/- 9 days from retransplantation. Retransplantation should be considered a very efficient way of saving lives, especially when the optimal timing for its execution is defined.

Global Case Management

Day Surgery (DS) and prehospitalization emerged in Italy--as it had previously in the United States and other European countries--as able to improve healthcare and reduce costs. The purpose of this study was to evaluate the impact of the Nurse Case Manager (NCM) Model on patients undergoing DS procedures. The study assessed the intensity of pain, anxiety, and stress factors, and the level of discomfort experienced. The quasi-experimental study design involved two groups of patients (at two different DS hospital centers): one using the NCM model (Ward A) the other based on team nursing (Ward B). All patients undergoing DS for (a) varicose veins, (b) inguinal hernia, (c) breast biopsy, and (d) hemorrhoids were included. A valid questionnaire interview based on 22 questions was used (1) the morning before surgery, (2) the evening after surgery, and (3) 48 hr after the operation, by telephone. Of the 145 patients that were involved, 66 were from Ward A (45.5%) and 79 from Ward B (54.5%). When patient care was based on the NCM Model (Ward A), it seemed that (a) the pathway before DS was more efficient; (b) they perceived lower levels of perioperative anxiety and pain; and (c) they recognized the DS center as a unique point of reference for all postoperative problems.

[Follow-up of patients submitted to antireflux laparoscopic treatment. A study by a telephone questionnaire]

OBJECTIVE

As it is difficult to submit patients to instrumental follow-up after laparoscopic treatment of the gastroesophageal reflux disease (GERD), it is not easy to have a complete patients analysis after fundoplication. Telephone questionnaire can be a valid instrument to investigate clinical outcome and patients satisfaction to surgery.

METHODS

This study discusses the results acquired through a telephone questionnaire which has been administered to patients undergoing laparoscopic fundoplication to study postoperative clinical evolution of GERD and satisfaction to surgery through a numerical rating scale from 1 to 10.

RESULTS

Sixty three patients, who had a laparoscopic antireflux procedure at Department of General Surgery of the University of Udine (Italy), answered to telephone questionnaires. Fifty patients (74.9%) reported no symptoms. Patients satisfaction to surgery was 7.93 +/- 2.36. Fifty eight patients (92.1%) would have repeated the operation and 59 (93.6%) would have advised it to a friend suffering of GERD. A significant difference of patients satisfaction between preoperative typical and atypical symptoms has been found (8.43 +/- 2.04 vs. 6.95 +/- 2.71 p < 0.05).

DISCUSSION AND CONCLUSION

Telephone questionnaire is comparable with face to face consultation, allowing to do a correct clinical follow-up, to exclude patients accusing pathological acid reflux after fundoplication; however preoperative symptoms are not so accurate as postoperative symptoms. Their presence giustifies a postoperative oesophageal pH metry.

[Indicators that affect the complexity of surgical patients care. The nurses' view]

Several factors contribute to the ill defined concept of complexity: critical patients, emergency situations, severity, intensity of care, dependency. The aim of this work is to assess nurses' perception of surgical patients' complexity, to obtain bottom-up data to validate a new model (of the Federazione Nazionale Collegi IPASVI) that measures the patients complexity. Data were collected over two months, by interviewing 64 nurses caring for surgical patients in 8 wards of the Friuli Venezia Giulia region. Patients' complexity (Low, Medium and High) and the explicit criteria adopted for the process of qualification, are formulated according to a priority ranking. Nurses were interviewed in 8 index days over 2 months. Criteria were independently classified by 3 nurses and any discrepancies discussed. Data on 1287 patients collected. 729 patients (56.6%) were classified as low complexity; 393 (30.6%) medium and 165 (12.8%) highly complex. The judgement is influenced by patients' age (p<0.01) but not sex. An high complexity score was assigned to patients with abdominal, soft tissues and vascular and gastrointestinal oncological surgery. 1291 different criteria were reported (2.89 +/- 1.88--range 1-15--for patient). The more frequent criteria were dependency in ADLs, need of strict monitoring/surveillance; presence of devices (such as cvc, pumps etc), and type of illness. The criteria expressed, only partially fit in the reference model. The judgement of complexity is based more on clinical problems and patients' dependency than on patients' ability to adapt to the illness and participate to his/her care.

Role of manometry and pH-metry in patients with symptoms and signs of gastroesophageal reflux disease

To assess the correlation between esophageal manometry and 24-h pH-metry and the clinical, endoscopic and radiological picture, we carried out a retrospective analysis of the data of 175 patients in 2001-2002 with symptoms of gastroesophageal reflux disease and/or the established presence of esophagitis. The data were analyzed on the basis of the mean, standard deviation (SD) and percentage (%). Student's "t"-test was used to calculate statistical significance (P < 0.05). pH-metry was positive in 112 cases (64% R+) and negative in 63 (36% R-). Manometry revealed a significant sphincter hypotonia and a greater involvement of peristalsis in R+ patients. There was no significant relationship between symptoms and response to medical treatment compared to a positive pH-metry. Ninety-three (53%) patients presented esophagitis, while 58 (33%) had a hiatal hernia. Esophagitis was more frequent in R+ patients, while hiatal hernia was equivalent in both groups. In the diagnosis and treatment of gastroesophageal reflux disease, the first step is empirical medical therapy. If symptoms persist, esophagogastroduodenoscopy and barium radiology are performed to evaluate the presence of esophagitis and/or gastroesophageal reflux and any related diseases. Manometry and pH-metry (the gold standard for the diagnosis of gastroesophageal reflux disease) are therefore always performed in patients with atypical symptoms of patients to be subjected to surgical treatment.

Preoperative chemoradiotherapy in cancer of the thoracic esophagus

Surgery with or without adjuvant radiotherapy (RT) is the standard treatment of esophageal cancer. Preoperative radio- and chemotherapy (CT) have been introduced to improve prognosis. We report a phase II prospective non-randomized trial of preoperative RT (42 Gy/25) plus CT (cisplatin 20 mg/mq/day plus 5-fluorouracil 600 mg/mq/day, 1-5 weeks) for the treatment of thoracic esophageal cancer. From 1993, 50 patients were enrolled (40 men and 10 women, mean age 57 years, range 30-75 years). Squamous cell carcinoma accounted for 90% of cases; 10% were adenocarcinoma. Downstaging of the disease was obtained in 77.3% of cases; there were 13 (29.5%) complete responses (CR) and 21 (47.7%) partial responses (PR). Median survival was 28 and 25 months, respectively, for CR and partial response (PR) plus stable disease (SD) and progressive disease (PD) (P = 0.05). Progressive-free median survival was 22 and 17 months, respectively, for CR and PR + SD + PD (P = 0.08). Multimodal treatment of esophageal cancer showed promising results, although not significant, in terms of survival and disease progression for patients achieving a complete pathologic response.

Concomitant primary hyperparathyroidism, Graves' disease and vitamin D deficiency

The simultaneous occurrence of hyperthyroidism and primary hyperparathyroidism is quite rare. A case is reported here of Graves' disease and primary hyperparathyroidism. Treatment of these concomitant diseases consists in combined thyroidectomy and parathyroidectomy. Histological examination confirmed Graves' disease and revealed the presence of a parathyroid adenoma in one gland and parathyroid hyperplasia in another one. After surgical treatment, secondary hyperparathyroidism due to 25-OH Vitamin D deficiency appeared. To our knowledge, this is the first case in which a Vitamin D absorption deficit was found in presence of hyperthyroidism and hyperparathyroidism without other intestinal absorption deficits. Diagnostic and follow-up difficulties related to these three concomitant pathological conditions are discussed.

Diverticulum of the midthoracic esophagus: pathogenesis and surgical treatment

Midthoracic esophageal diverticula represent 15% of all esophageal diverticula. Gastrointestinal endoscopy, barium swallow, esophageal manometry (indispensable for detecting any motor alterations often at the root of the pathogenesis of the diverticulum and for selecting the best surgical option), and 24-h pHmetry are the correct examinations to perform. Simple diverticulectomy performed via thoracoscopy can be sufficient for small diverticula without associated motor alterations. In other cases, it is best to combine diverticulectomy with a longitudinal extramucous myotomy extending at least 3 or 4 cm above and below the neck of the diverticulum or to the entire esophageal body for diffuse esophageal spasm. We report the case of a 67-year-old male patient with a sacciform diverticulum at the mid-third on the anterior wall of the thoracic esophagus. Manometric examination showed peristaltic waves with an amplitude and duration that were above normal at the inferior third of the esophagus. Lower esophageal sphincter (LES) and upper esophageal sphincter (UES) were essentially normal. The diagnosis was pulsion-type midthoracic esophageal diverticulum. We performed a diverticulectomy with endoGIA via right thoracoscopy and extramucous myotomy extended from the upper margin of the diverticulum to the esophageal inlet in the hiatus, corresponding to the area showing motor alteration. After 3 months, the patient reported complete remission of symptoms and had gained 4 kg. Radiography of the digestive tube showed a normal transit at the distal esophagus. Manometric follow-up revealed the presence of peristaltic waves with a normal amplitude and duration along the entire esophagus.

The impact of splenic weight on laparoscopic splenectomy for splenomegaly

BACKGROUND

Enlarged spleens increase the technical difficulties associated with laparoscopic splenectomy (LS). The aim of this study was to analyze the impact of splenic weight on the results of LS.

METHODS

We performed a prospective analysis of 20 LS for splenomegaly and 40 LS for normal spleen in terms of intraoperative and early postoperative outcome.

RESULTS

Patients with splenomegaly had longer operative times and higher conversion and transfusion rates than those with normal spleens. Patients with spleens weighing < 2000 G experienced less blood loss, fewer conversions, and a shorter postoperative hospital stay than those with spleens > 2000 g. No differences-except for the longer operative time-were observed between normal-sized spleens and those weighing < 2000 G.

CONCLUSIONS

LS for splenomegaly is feasible for experienced laparoscopic surgeons. For spleens weighing < 2000 G, the outcome was comparable to that of normal spleens, whereas LS for spleens >2000 g was associated with a higher conversion rate, greater blood loss, a longer hospital stay, and increased morbidity.

Intraoperative cholangiography in laparoscopic cholecystectomy during residency in general surgery

BACKGROUND

The role of laparoscopic intraoperative cholangiography (IC) in the diagnosis of asymptomatic choledocholithiasis is still controversial. The aim of this study was to evaluate the diagnostic-therapeutic impact and the educational implications of this method for residents specializing in general surgery.

METHODS

We reviewed the records of 835 patients who underwent laparoscopic cholecystectomy for cholecystolithiasis without choledocholithiasis. IC was routinely performed by both expert surgeons and residents in general surgery.

RESULTS

The cholecystectomy was completed laparoscopically in 804 cases, but conversion to open surgery was required in 31 cases. IC was not completed in 140 cases (17.4%), and in 44 cases it revealed a suspected choledocholithiasis. The stones were treated via laparoscopy in 36 cases, laparotomy in six cases, and endoscopic retrograde cholangiopancreatography (ERCP) in two cases. Five patients were not diagnosed wit h choledocholithiasis. In one case, a lesion of the choledochus was discovered and treated laparoscopically. A total of 610 IC were done by expert surgeons and 225 by residents. The duration of the cholecystectomy with IC was significantly different between the two groups (76.9 +/- 12 vs 92.4 +/- 11), as was the feasibility index (88.6% vs 80.6%).

CONCLUSIONS

Laparoscopic IC is a safe and accurate procedure for the diagnosis of unrecognized choledocholithiasis. Teaching of this procedure as part of the specialization in general surgery would be opportune because it would provide surgical residents with an additional tool for the diagnosis and treatment of this pathology of the common bile duct.

Distant metastases from cervical esophagus cancer

Cancer of the cervical esophagus has a poor prognosis in relation to stage. Correct staging is thus essential in order to establish the prognosis and the treatment program. Distant metastases can involve the lymph nodes (mediastinal and celiac lymph nodes) or they can be extranodal visceral types. Correct lymph node staging can be performed with esophageal endoscopic ultrasonography, computed tomography (CT) scan and, currently, with positron emission tomography (PET) and minimally invasive surgery. For hematogenous metastases, CT scan and PET are mainly used, as well as minimally invasive surgery, with the eventual aid of intraoperative ultrasonography.

[Sliding hiatal hernia in patients with gastroesophageal reflux: physiopathology and surgical treatment]

BACKGROUND

The aims of the study were to evaluate how the sliding hiatal hernia, in patients with gastroesophageal reflux disease (GERD), acts on the lower esophageal sphincter (LES) and esophageal clearance, and how surgical therapy corrects the physiopathological parameters.

METHODS

Records of 25 patients with only GERD and of 15 with GERD associated to hiatal hernia (> 3.5 cm) were reviewed. Ten subjects without symptoms and/or endoscopic and functional signs of GERD were considered as control group. The selection of the patients was done by reviewing radiographic examination, endoscopy and functional tests (esophageal manometry, pH-monitoring).

RESULTS

Manometry showed a greater LES incompetence (pressure and length) and a worse peristalsis (distal amplitude) in the group with reflux and hiatal hernia against patients with reflux only. Also, patients with hiatal hernia had more acid exposure (total time pH < 4 in the distal esophagus) and a longer time of esophageal clearance, at pH-monitoring. The functional tests in 8 patients, before and after laparoscopic Toupet fundoplication with posterior closing of the crura, showed a normalised LES, esophageal clearance and acid exposure. Esophageal peristalsis did not show any statistically significance.

CONCLUSIONS

The presence of hiatal hernia, in patients with GERD, causes worse LES, peristalsis and clearance with a greater acid exposure of the esophagus. Fundoplication, by reconstructing the sphincter-diaphragm unit, normalises the preoperative physiopathology situation but without an effective peristalsis improvement.

[Anomalous implantation of the appendiceal base: a clinical case]

The authors report a case of anomalous implantation of the base of the appendix, observed in a 8-year-old boy, arising from the anterior wall of ascending colon at 15 cm from the ileo-cecal valve. After a brief review of the most frequent congenital anomalies of the appendix and the few cases of anomalous implantation described in international literature, the authors emphasize the importance of an accurate exploration and mobilization of the ascending colon to reduce the risk of diagnostic and therapeutic mistakes, also related to the small incision of McBurney, usually made for the routine laparotomic appendectomy.

Saphenous vein sparing surgery: principles, techniques and results

OBJECTIVE

Evaluation of saphenous vein sparing surgical procedures alternative to high ligation and distal stab avulsion, in terms of effectiveness and suitability for eventual bypass surgery.

EXPERIMENTAL DESIGN

Prospective evaluation of 421 operations for primary varicose veins, 64 external valve-plasties of the sapheno-femoral junction (EV-SFJ), (42 performed using the hand sewing technique and 22 using the Veno-cuff device), mean follow-up 52 months, and 357 hemodynamic correction of varicose veins (French acronymis CHIVA), mean follow-up 49 months. Moreover, a subgroup of 27 patients was operated on using the CHIVA technique in two steps, mean follow-up 18 months.

SETTING

Institute of General Surgery, University of Ferrara. Institutional practice, one-day surgery.

PATIENTS

Patients were selected using clinical and duplex scanning evaluations, and classified according to CEAP criteria. Patients with varicose veins due to sapheno-femoral reflux with duplex scanning evidence of mobile valve leaflets underwent EV-SFJ. The other patients were operated on using the hemodynamic correction technique.

INTERVENTIONS

EV-SFJ restores valve function correcting vein wall dilatation by applying an external prosthesis. CHIVA consists of selected ligatures of the superficial veins that allow superficial blood aspiration in the deep veins through the perforators as well as the preservation of saphenous drainage.

MEASURES

The outcome was evaluated with independent clinical and ultrasonographic examinations; pre and postoperative AVP and LRR-RT measurements were assessed in 125 cases. Data from self-assessment of the functional and cosmetic result of the patients of the CHIVA group were also obtained using a scoring system. Moreover, scanning the preserved long saphenous vein the rate of long saphenous vein suitable as arterial conduit following sparing surgery was also evaluated.

RESULTS

Overall long saphenous vein patency registered after EV-SFJ and CHIVA was 94%. Varicose veins recurrence rate was 12% and 11%, respectively. Postoperative AVP and LRR-RT improvement was statistically significant (p<0.001).

CONCLUSIONS

These two alternative procedures seem to be effective in varices treatment following the proposed indications and techniques. In addition, they appear able to preserve a more significant rate of saphenous veins suitable for eventual bypass surgery than high ligation and multiple cosmetic avulsion.

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

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.

Reparative surgery of valves in the treatment of superficial venous insufficiency. External banding valvuloplasty versus high ligation or disconnection. A prospective multicentric trial

OBJECTIVE

A prospective study was performed in order to compare results obtained in the treatment of early and/or limited primary varicose veins of the lower limbs using two different procedures: external valvuloplasty and high ligation or disconnection of the sapheno-femoral junction.

MATERIALS AND METHODS

116 limbs (113 patients) were selected. 57 with normal cusps in dilated valves were subjected to external valvuloplasty with Silicone prosthesis under Doppler control (intraoperative angioscopy in 16 cases); 59 limbs were subjected to high ligation or disconnection of the junction; 57 limbs out of 116 were subjected to complementary procedures. Duplex and photoplethysmographic examinations were performed before and after the surgical procedures in all patients. Doppler venous pressures were measured in 36 limbs and invasive pressures in 40 limbs. Patients were postoperatively followed up every 4 months until the 12th month.

RESULTS

Indications for valvuloplasty were found in 8.2% of cases and in 66.3% of the early varices. Clinical results were slightly superior in the reparative surgery group. Thrombotic occlusion of the proximal long saphenous vein was significantly higher in the ligation-disconnection group. Results from photoplethysmography and venous pressure measurements indicated that both operations are equally effective in the elimination of reflux in the junction.

[New directions in the surgical treatment of gastroesophageal reflux. Review of the literature]

The pathophysiology of gastroesophageal reflux disease (GERD) is often multifactorial, as abnormal function of the lower esophageal sphincter (LES) may be associated to abnormalities of the esophageal peristalsis, the esophageal clearance, and the gastric reservoir. The preoperative evaluation of patients with GERD must include esophageal function tests (esophageal manometry and ambulatory pH monitoring) and evaluation of the gastric emptying in addition to UGI series and endoscopy. The information provided by these tests is essential to identify the pathophysiology of the disease in the individual patient, and tailor the operative treatment accordingly. For patients with an incompetent LES but normal esophageal peristalsis, the Nissen fundoplication is the procedure of choice. When abnormal peristalsis and delayed clearance are identified by preoperative esophageal function tests, a partial fundoplication must be chosen in order to avoid postoperative dysphagia and gas bloat syndrome. Too many eponyms have been used to describe antireflux surgery (Nissen, Rossetti, Toupet, Lind, Hill, Guarner). It is time to go beyond these eponyms, and focus on the technical details which contribute to the stability of the wrap, as this is the main determinant of long term outcome.

[Surgical treatment of cervical fistula after esophagogastroplasty (EGP)]

The authors report their experience on cervical anastomosis dehiscence in patients who had total esophagectomy and esophagogastroplasty for esophageal neoplasms. They describe, accurately and step by step, the plastic reconstructive technique (by using a vascularized transposed cutaneous flap), used to treat a symptomatic cervical fistula which occurred in 3 of the 24 patients who had esophagectomy and cervical-esophagogastroplasty. This kind of treatment led to complete healing of the fistulas, without clinical and radiological signs of fistula recurrence in all the patients treated.

[Sutures without sutures in digestive surgery. Experimental study of the rat intestine]

The aim of the experimental study was to evaluate the possibility of performing an end-to-end anastomosis by using fibrin adhesive as the only means of suture. To this end, 24 Wistar rats were used, of which 16 underwent ilear resection and 8 underwent colotomy, and they were divided respectively into two groups. On the rats of the first group the anastomosis was performed by using only fibrin adhesive; on the rats of the second group operated the anastomosis was performed by using fibrin adhesive in association with non adsorbable suture material, while on those operated of colectomy the anastomosis was performed by fibrin adhesive and adsorbable suture material. The anatomo-phatological studies on the anastomosis have shown a similar healing process in the cases treated only with fibrin adhesive and by using absorbable material and has demonstrated the trange material from the suture, which are a possible causes of complication.

[The role of surgery in the management of diffuse (N3) lung cancer]

The aim of the paper is to give a contribution to the understanding of the role of surgery in patients with N3 lung cancer. The A. describe their results on 32 patients with N3 lung cancer operated on mediastinectomy; histological examination of the specimens showed 27 squamous cell carcinomas and 5 adenocarcinomas. The operation was performed through a median sternotomy to gain access to the left and right paratracheal nodes, pretracheal, precarinal and subcarinal nodes, subaortic and left and right hilar nodes that were removed together with the fat of the mediastinum. Left pneumonectomy was performed in 5 patients. There was no operative mortality; 12 patients were irradiated in the postoperative period with 5,000 Rads (50 Gy), while 18 or the 27 patients with squamous cell carcinoma are still alive.

[Tracheal sleeve lobectomy in the radical surgery for lung cancer]

Tracheal sleeve lobectomy is right upper lobectomy extended to include resection of the main bronchus, the carina and a segment of the trachea with end-to-end anastomosi of the trachea and end-to-side anstomosis of the intermediate bronchus on the main left bronchus, or the upper lobe on the trachea. This operation is possible with the aid of high frequency jet ventilation. The surgical indication of this operation is bronchoscopic and functional and guarantees a good oncological radicality in the presence of N0.