Management of groin hernias in emergency setting: differences in indications and outcomes between laparoscopic and open approach. A single-center retrospective experience

PURPOSE

The use of minimally invasive groin hernia repair techniques in an emergency setting is still debated and its widespread is limited. The aim of this study is to evaluate the safety and efficacy of the laparoscopic transabdominal preperitoneal (TAPP) technique in the treatment of inguinal and femoral hernias in emergency setting based on our experience, comparing indications and outcomes with the open technique.

METHODS

A retrospective analysis was performed including all patients with incarcerated and/or strangulated groin hernia who underwent emergency surgery from November 2019 to September 2022. Perioperative variables and short- and long-term outcomes were examined. Statistical analysis was performed using chi-square test for nominal variables and Student's t test for continuous ones. A p value < 0.05 was considered statistically significant.

RESULTS

Sixty-six patients were included: 29 patients were treated with TAPP technique (Tapp group) and 37 with open technique plus diagnostic laparoscopy (Open group). Patients in the TAPP group were younger, had less severe clinical scenarios, and had a trend for lower Charlson Comorbidity Index, whereas ASA score and BMI were similar. The small bowel was more frequently herniated in the open group. Bilateral hernia repair was performed in 20.69% of patients in the Tapp group versus 0% in the Open group (p = 0.004). Bowel resection was more frequent in the open group (48.65% vs 0% of the Tapp group, p < 0.001) length of surgery was comparable in the two groups. In the Tapp group, the length of hospitalization was significantly shorter (2.59 ± 2.28 days vs. 9.08 ± 14.48 days; p = 0.023). Postoperative complications, according to Clavien-Dindo, were more severe in Open group where there were two deaths. There were no differences in the number of readmission and re-operations at 30 days and in the recurrence rate.

CONCLUSIONS

Emergency repair of inguinal and femoral hernias using TAPP is a valuable option, safe and feasible in selected patients. In this series, indications for TAPP were reserved to younger patients with less comorbidities and less severe clinical scenario. Future randomized studies are needed to compare TAPP with open emergency hernia surgery in all settings. Potential advantages of TAPP are the reduction of postoperative complications, earlier recovery, and the possibility of bilateral treatment.

Is the social status a new prognostic factor in the Fournier's gangrene?

Fournier's gangrene is a life-threatening acute necrotizing fasciitis of perianal, genitourinary and perineal areas. Local symptoms are scrotal swelling, erythema of scrotal skin and pain with generalized constitutional symptoms. The gangrene may extends to abdominal wall, intra-abdominal structures, and even in the retroperitoneal tissues. Urgent surgical debridement is crucial to warrant a good outcome since delayed intervention carries a poor prognosis. We report the case of a not diabetic patient with Fournier's disease presented with severe sepsis and successfully treated with urgent deep debridement and reconstructive surgery. We propose the social status of the patient as a prognostic factor with high impact for survival rate.

MIVAT: the last 2 years experience, tips and techniques after more than 10 years

BACKGROUND

Minimally invasive video-assisted thyroidectomy (MIVAT) has been introduced into clinical practice by Miccoli in the late 1990s (Miccoli et al., Am J Surg 181(6):567-570, 2001) and it has become a widespread technique used and welcomed worldwide. In this paper, we present our experience of the last 2 years; we also describe tips and techniques derived from over 460 cases performed in the last 10 years by the same surgical team with the same single operator.

METHODS

In the last 10 years, we did about 460 MIVAT procedures. In the last 2 years, we performed MIVAT on 156 consecutive patients at Sant'Andrea University Hospital of Rome "Sapienza" University. of 156 cases performed, we were able to monitor the follow-up in 110 patients.

RESULTS

On 110 cases, the mean surgical time was 74 ± 7.2 min. In our data, we reported: transitory hypoparathyroidism 11 (10%), definitive hypoparathyroidism 4 (3.60%) (this value is inclusive of patients treated with central neck dissection. The value referred only to MIVAT is 1.05%), 2 (1.81%) transitory monolateral nerve palsy, 16 (14.50%) transitory, and 1 (0.9%) definitive nerve palsy. 4 (3.60%) cases of transitory dysphagia and 0 (0%) cases of definitive dysphagia (Table 4). We also had 1 (0.9%) case of surgical scar infection, 0 (0%) postoperative bleeding, and 2 (1.81%) cases of subcutaneous surgical adhesion. Cosmetic results were: 0 (0%) insufficient, 0 (0%) sufficient, 6 (6.30%) passable, 17 (15.50%) good. and 86 (78.20%) excellent. Conversion rate 0 (0%).

CONCLUSION

MIVAT is a good and safe technique, with similar short-term outcomes and similar costs compared to traditional total thyroidectomy. We hope that the tips and techniques reported in this paper as well as the advices in the use of instruments in MIVAT and open surgery will be useful to improve the skills of young surgeons and make thyroid surgery less invasive.

Post-incisional ventral hernia repair in patients undergoing chemotherapy: improving outcomes with biological mesh

Background

Patients requiring ventral hernia (VH) repair during perioperative chemotherapy have a higher risk for post-operative complications. The aim of the study was to perform a case-controlled analysis in patients undergoing chemotherapy who underwent VH repair using biological mesh or synthetic mesh.

Methods

From January 2013 to December 2015, 32 patients, within 8 weeks from chemotherapy administration, were treated electively for VH repair using a biological mesh (BIOMESH). A control group (CG) receiving chemotherapy within the same time interval and treated with synthetic meshes was selected. There were no differences regarding sex, age, American Society of Anesthesiologists (ASA) score III, BMI, and size of the defect. Morbidity, type of complications, and recurrence rate were investigated and compared between the two groups.

Results

In the BIOMESH group, eight patients (25 %) experienced complications. Wound dehiscence occurred in four (12.5 %) patients and was treated conservatively. Only three small seromas not requiring treatment were observed. The CG presented a higher mean Clavien-Dindo complication grade (1.94 ± 0.44 vs 1.63 ± 0.52; p = 0.13) and a higher incidence of wound dehiscence (n = 9/32, 28.1 % vs n = 4/32, 12.5 %; p = 0.11). Five patients developed seroma treated by wound drainage. One patient experienced an intra-abdominal collection treated by percutaneous drainage. At the univariate and multivariate analysis use of traditional mesh, BMI and the ASA III were predictive factors of post-operative complications. Two patients (6.3 %) developed a VH recurrence only in the CG.

Conclusions

Biological meshes could be considered a valid option to improve post-operative short-term outcomes in selected high-risk patients undergoing chemotherapy treated for VH repair.

Laparoscopic liver resection compared to open approach in patients with colorectal liver metastases improves further resectability: Oncological outcomes of a case-control matched-pairs analysis

AIMS

Liver resection is considered the standard treatment of colorectal metastases (CRLM). However, to date, no long term oncological results and data regarding repeat hepatectomy after laparoscopic approach are known. The aim of this study is to analyze single center long-term surgical and oncological outcomes after liver resection for CRLM.

METHODS

A total of 57 open resections (OR) were matched with 57 laparoscopic resections (LR) for CRLM. Matching was based mainly on number of metastases, tumor size, segmental position of lesions, type of hepatectomy and type of resection.

RESULTS

Morbidity rate was significantly less in the LR group (p = 0.002); the length of hospital stay was 6.5 ± 5 days for the LR group and 9.2 ± 4 days for the OR group (p = 0.005). After a median follow up of 53.7 months for the OR group and 40.9 months for the LR group, the 5-y overall survival rate was 65% and 60% respectively (p = 0.36) and the 5-y disease free survival rate was 38% and 29% respectively (p = 0.24). More patients in the LR group received a third hepatectomy for CRLM relapse than in the OR group (80% vs. 14.3% respectively; p = 0.015).

CONCLUSIONS

Laparoscopic resection for CRLM offers advantages in terms of reduced blood loss, morbidity rate and hospital stay. It provides comparable long-term oncological outcomes but can improve further resectability in patients with recurrent disease.

Laparoscopic liver resection compared to open approach in patients with colorectal liver metastases improves further resectability: Oncological outcomes of a case-control matched-pairs analysis

AIMS

Liver resection is considered the standard treatment of colorectal metastases (CRLM). However, to date, no long term oncological results and data regarding repeat hepatectomy after laparoscopic approach are known. The aim of this study is to analyze single center long-term surgical and oncological outcomes after liver resection for CRLM.

METHODS

A total of 57 open resections (OR) were matched with 57 laparoscopic resections (LR) for CRLM. Matching was based mainly on number of metastases, tumor size, segmental position of lesions, type of hepatectomy and type of resection.

RESULTS

Morbidity rate was significantly less in the LR group (p = 0.002); the length of hospital stay was 6.5 ± 5 days for the LR group and 9.2 ± 4 days for the OR group (p = 0.005). After a median follow up of 53.7 months for the OR group and 40.9 months for the LR group, the 5-y overall survival rate was 65% and 60% respectively (p = 0.36) and the 5-y disease free survival rate was 38% and 29% respectively (p = 0.24). More patients in the LR group received a third hepatectomy for CRLM relapse than in the OR group (80% vs. 14.3% respectively; p = 0.015).

CONCLUSIONS

Laparoscopic resection for CRLM offers advantages in terms of reduced blood loss, morbidity rate and hospital stay. It provides comparable long-term oncological outcomes but can improve further resectability in patients with recurrent disease.

Open tension-free Lichtenstein repair of inguinal hernia: use of fibrin glue versus sutures for mesh fixation

PURPOSE

To investigate pain and other complications following inguinal hernioplasty performed by the Lichtenstein technique with mesh fixation by fibrin glue or sutures.

METHODS

Five hundred and twenty patients were enrolled in this 12-month observational multicenter study and received either sutures or fibrin glue (Tissucol(®)/Tisseel(®)) based on the preference of the surgeon. Pain, numbness, discomfort, recurrence, and other complications were assessed postoperatively and at 1, 3, 6, and 12 months. Pain intensity was assessed by a visual analog scale (VAS; 0 [no pain] to 10 [worst pain]).

RESULTS

One hundred and seventy-one patients received sutures and 349 received fibrin glue. During the early postoperative phase, 87.4% of patients in the fibrin glue group and 76.6% of patients in the sutures group were complication-free (P = 0.001). Patients who received fibrin glue were also less likely to experience hematoma/ecchymosis than those in the suture group (both P = 0.001). The mean pain score was significantly lower in the fibrin group than the sutures group (2.5 vs. 3.2, P < 0.001). At 1 month, significantly fewer patients in the fibrin glue group reported pain, numbness, and discomfort compared with patients in the sutures group (all P < 0.05). Fibrin glue patients also experienced less intense pain (0.6 vs. 1.2; P = 0.001). By 3 months, the between-group differences had disappeared, except for numbness, which was more prevalent in the sutures group. By 12 months, very few patients reported complications.

CONCLUSIONS

Tissucol fibrin glue for mesh fixation in the Lichtenstein repair of inguinal hernia shows advantages over sutures, including lower incidence of complications such as pain, numbness, and discomfort, and should be considered as a first-line option for mesh fixation in hernioplasty.

Contrast Media in Urogenital Radiology

Background

Contrast media are widely used in urogenital radiology. The ideal contrast agent should be totally inert, causing no interactions with organism, and with a rapid and complete excretion. Adverse reactions could occur after using any type of contrast media. Contrast enhanced procedures are performed with increasing frequency and the patients population is progressively older and with multiple co-morbid conditions, thus contrast media toxicity is becoming a serious problem. Contrast media-induced nephropathy (CIN) is considered an important cause of hospital-acquired renal failure. The administration of gadolinium-based contrast agents has been recently associated with the development of a serious adverse reaction, potentially lethal in patients with renal insufficiency, named nephrogenic systemic fibrosis (NSF).

Methods

Literature review on contrast media in urogenital radiology, CIN, NSF.

Conclusions

Since 1996, the Contrast Media Safety Committee of the European Society of Urogenital Radiology (ESUR) has released its guidelines regarding safety about the use of contrast media. CIN, and the emerging NSF, are topics of increasing interest for urologists, radiologists, nephrologists, dermatologists and all the clinicians. Contrast media have progressively become safer in the last years. Even if rare, some adverse reactions still occurr up to now. CIN and its prevention remain an issue under debate. In the past, whenever a patient required a contrast-enhanced imaging study, the trend was to select magnetic resonance imaging with gadolinium-based contrast agents in order to avoid the well-known CIN of iodinated-based contrast agents. The awareness of NFS is changing the contrast–enhanced imaging in patients with renal failure. At present we have to investigate NSF etiopathogenesis, in order to prevent and eventually to cure it. The understanding of the risk factors for both CIN and NSF is an emerging need, the adoption of all preventive measures to reduce the risks remain a mandatory issue.

[Contrast media in urogenital radiology]

BACKGROUND. Contrast media are widely used in urogenital radiology. The ideal contrast agent should be totally inert, causing no interactions with organism, and with a rapid and complete excretion. Adverse reactions could occur after using any type of contrast media. Contrast enhanced procedures are performed with increasing frequency and the patients population is progressively older and with multiple co-morbid conditions, thus contrast media toxicity is becoming a serious problem. Contrast media-induced nephropathy (CIN) is considered an important cause of hospital-acquired renal failure. The administration of gadolinium-based contrast agents has been recently associated with the development of a serious adverse reaction, potentially lethal in patients with renal insufficiency, named nephrogenic systemic fibrosis (NSF). METHODS. Literature review on contrast media in urogenital radiology, CIN, NSF. CONCLUSIONS. Since 1996, the Contrast Media Safety Committee of the European Society of Urogenital Radiology (ESUR) has released its guidelines regarding safety about the use of contrast media. CIN, and the emerging NSF, are topics of increasing interest for urologists, radiologists, nephrologists, dermatologists and all the clinicians. Contrast media have progressively become safer in the last years. Even if rare, some adverse reactions still occurr up to now. CIN and its prevention remain an issue under debate. In the past, whenever a patient required a contrast-enhanced imaging study, the trend was to select magnetic resonance imaging with gadolinium-based contrast agents in order to avoid the well-known CIN of iodinated-based contrast agents. The awareness of NFS is changing the contrast-enhanced imaging in patients with renal failure. At present we have to investigate NSF etiopathogenesis, in order to prevent and eventually to cure it. The understanding of the risk factors for both CIN and NSF is an emerging need, the adoption of all preventive measures to reduce the risks remain a mandatory issue.

[Teaching in the operative room: the benefit of daysurgery on surgical trainees]

AIM

Aim of the study was to evaluate the operative time and the incidence of post-operative complications in a group of patients undergoing Lichtenstein inguinal hernia repair performed either by surgical residents or senior surgeons in a day-surgery setting.

PATIENTS AND METHODS

The study population consisted of 198 patients: group I (n=102), in which the operator was a senior surgeon, group II (n=96), in which the operator was a resident supervised by a senior surgeon. We recorded the duration of the operation and the complications following the procedure, and statistically compared them between group I and II.

RESULTS

Our analysis showed that there was a statistically significant difference between the two groups only for the mean operative time, being shorter in group I (62 vs 82 min, p>0.05), while no significant difference was found for the incidence of complications.

CONCLUSION

In conclusion, the day-surgery setting allows a high quality training of young surgeons, based on performing minor surgical procedures such has inguinal hernia repair. This training allows a step by step supervised learning process that does not jeopardize the efficacy of the treatment as well as the patient safety. The major cost due to the increase in operative time should be considered as an investment in young surgeons education.

Regenerative Medicine: Applications and Development in Urology

Purpose

Congenital abnormalities and acquired disorders can lead to organ damage and loss. Nowadays, transplantation represents the only effective treatment option. However, there is a marked decrease in the number of organ donors, which is even yearly worsening due to the population aging. The regenerative medicine represents a realistic option that allows to restore and maintain the normal functions of tissues and organs. This article reviews the principles of regenerative medicine and the recent advances with regard to its application to the genitourinary tract.

Recent findings

The field of regenerative medicine involves different areas of technology, such as tissue engineering, stem cells and cloning. Tissue engineering involves the field of cell transplantation, materials science and engineering in order to create functional replacement tissues. Stem cells and cloning permit the extraction of pluripotent, embryonic stem cells offering a potentially limitless source of cells for tissue engineering applications. Most current strategies for tissue engineering depend upon a sample of autologous cells from the patient's diseased organ. Biopsies from patients with extensive end-stage organ failure, however, may not yield enough normal cells. In these situations, stem cells are envisaged as being an alternative source. Stem cells can be derived from discarded human embryos (human embryonic stem cells), from fetal tissue or from adult sources (bone marrow, fat, skin). Therapeutic cloning offers a potentially limitless source of cells for tissue engineering applications. Regenerative medicine and tissue engineering scientists have increasingly applied the principles of cell transplantation, materials science and bioengineering to construct biological substitutes that will restore and maintain normal function in urological diseased and injured tissues such as kidney, ureter, bladder, urethra and penis.

Conclusions

Regenerative medicine offers several applications in acquired and congenital genitourinary diseases. Tissue engineering, stem cells and, mostly, cloning have been applied in experimental studies with excellent results. Few preliminary human applications have been developed with promising results.

Human Biobank in Uro-Oncological Research

Purpose

Uro-oncological translational research requires clinical data and human biological tissues collected within a biological tissue bank (BTB). We are hereby outlining ethic-legal, methodological and technical issues of a BTB establishment process, focusing particularly on prostate cancer and Italian setting.

Materials and Methods

Review of literature data, and national and international regulations and guidelines; direct field experience of urological BTB; counseling of the different professionals involved.

Results

Within a BTB establishment process, it is of utmost importance to protect the donors’ privacy and rights through the programmatic adoption of the following procedures: 1) informed consent; 2) confidentiality protection thanks to anonymity of biological specimens and use of an “honest broker” method; 3) identification of a single responsible researcher; 4) dedicated and protected location; 5) approval of the Ethical Committee. There are two main organizational models of BTB: “systematic”, i.e. collecting specimens from all patients and through the same methodology; “project-driven”, i.e. prospectively selecting patients for a specific study and using the specific methods required by researchers. In the preliminary step it is necessary to establish detailed protocols of sampling and crioconservation techniques, and methods of validation and quality control. For prostate tissue sampling, several techniques have been described such as specimens of alternate slices, macro dissection, Tru-Cut.

Conclusions

Today BTBs are necessary in order to support molecular and translational research in uro-oncology and to overcome the limits of the research based only on clinical-pathological data. Ethic-legal and methodological issues related to BTBs are still requiring specific legislation and standardization of techniques.

Locoregional IL-2 therapy in the treatment of colon cancer. Cell-induced lesions of a murine model

BACKGROUND

Local therapy with IL-2 may be very effective in the treatment of different forms of cancer. The aim of this study was to determine the effectiveness of IL-2 locoregional application in the treatment of colon cancer.

MATERIALS AND METHODS

Twenty eight syngenic BDIX rats were utilized in this study. The rats were divided into two groups of fourteen animals: group T (treatment) and group C (control). All rats of both groups were injected, under the splenic capsule, with T 10(7) DHD/K2/ TRb neoplastic cells. Then, within and around the site of the previous inoculation, the T group was injected with 1 ml of glucosate solutions + 0.1% albumin (BSA) containing 2.5 x 10(6) IU of IL-2 ( Proleukin-Chiron), whereas the C group was injected with 1 ml of BSA alone. After three weeks, rats were sacrificed and the liver and spleen were removed. The following parameters were considered: volume and weight, neoplastic-non neoplastic tissue index of the spleen, mitotic index and vascular density of splenic and hepatic lesions.

RESULTS

All the studied parameters showed statistically significant differences in treated and untreated animals.

CONCLUSION

This study of a murine model demonstrated that IL-2 locoregional therapy may be effective in the treatment of colon cancer.

Clinical and biological features of an intranodal palisaded myofibroblastoma

Intranodal palisaded myofibroblastoma (IPM) is a rare benign tumor of the lymph nodes probably arising from smooth muscle-like cells. The tumor is characterized by intranodal proliferation of spindle cells. Neoplastic spindle-cell proliferation is most often of metastatic repetition which is very important in the recognition of IPM, because it may be mistaken for metastasis or other tumors such as Kaposi's sarcoma. We report a novel case of IPM that confirms the myofibroblastic differentiation of the tumor. The onset of IPM has been associated with Epstein-Barr virus (EBV). In addition, recently reported cases of IPM have been seen with cyclin 1 overexpression and also with human herpes virus (HHV)-8 and EBV DNA sequences. In our case, there was no evidence of HHV-8 and EBV DNA sequences and we were not able to find cyclin 1 overexpression.

Abdominal aortic aneurysm in renal transplant recipients

BACKGROUND

Abdominal aortic aneurysms (AAA) requiring surgical management are encountered more frequently in renal transplant recipients, presenting an important technical problem during the repair. The aim of the present study was to analyze the epidemiology and natural evolution of AAA among renal allograft recipients.

METHODS

Three hundred ninety-four renal transplant recipients were periodically evaluated with abdominal aortic ultrasound tomography for AAA. The indication for surgery was a maximal diameter >5 cm. Renal function, graft, and patient survival were evaluated after a mean follow-up of 51 months.

RESULTS

Four AAA were detected in 394 renal transplant recipients, a prevalence of 1.01%. All of the AAA were found in male recipients of mean age 59.2 +/- 5.5 years and mean time posttransplantation of 82.7 +/- 77.3 months. The mean follow-up period between diagnosis and indication for surgery was 14.2 +/- 10.8 months. Two patients underwent open repair with aneurysmectomy and conventional tube graft positioning, and 2 patients refused surgical repair. To preserve renal graft function during the aortic cross-clamping phase, cold perfusion with 4 degrees C Ringer acetate and local hypothermia with sterile ice were used. Renal function did not change after the operation (preoperative serum creatinine levels were 1.2 and 1.3 mg/dL; postoperative 1.3 and 1.5 mg/dL respectively). The 2 patients who underwent surgery are alive with excellent graft functioning after a follow-up of 1.5 and 7 years, respectively. The 2 patients who refused surgical treatment are dead.

CONCLUSIONS

Yearly ultrasound screening for AAA must be recommended in renal transplant recipients as part of the routine posttransplantation follow-up. De novo AAA occurs in younger subject in the transplant population and shows a faster evolution.

Gonadal function and immunosuppressive therapy after renal transplantation

End-stage renal disease is associated with disorders in hypothalamic-pituitary-gonadal function. Immunosuppressive therapies may influence the restoration of normal levels of gonadal hormones after renal transplantation. The aim of the present study was to evaluate the hormonal status of successful renal transplant recipients who were treated with different immunosuppressive agents.

METHODS

Testosterone, luteinizing hormone (LH), and follicle stimulating hormone (FSH) were measured in 59 male renal transplant recipients with stable graft function with serum creatinine <2.5 mg/dL. Patients were treated with three different immunosuppressive regimens: group I, calcineurin inhibitors (CI; n = 15), group II, sirolimus without calcineurin inhibitors (SRL; n = 15), group III, sirolimus in combination with calcineurin inhibitors (SRL * CI; n = 29).

RESULTS

Testosterone was significantly lower in group II versus group I (3.12 +/- 1.23 versus 4.39 +/- 1.53 ng/mL; P < .0197). Group III had higher testosterone values than group II, but lower than group I. FSH and LH were also higher in the SRL group, but the differences were not statistically significant, perhaps because of the small number of patients. No relationship was found between testosterone blood levels and age, posttransplant follow-up, renal function, time on dialysis, body mass index, steroid use, or posttransplant diabetes.

CONCLUSION

Sirolimus seems to impair the improvement of gonadal function after renal transplantation. Further prospective studies are needed to confirm these data before patients are advised of this potential side effect.

A phase II study of gemcitabine and tamoxifen in advanced pancreatic cancer

BACKGROUND

Advanced pancreatic cancer (APC) constitutes a poor-prognosis disease with few and disappointing therapeutic options. In recent years chemotherapy has demonstrated a positive effect on disease-related symptoms with the introduction of a novel pyrimidine analogue, gemcitabine. Moreover there is experimental and clinical evidence that endocrine therapy may play a small but unexplored role in the management of APC. Therefore we performed a phase II study to assess whether the combination of gemcitabine and tamoxifen could be an active and safe schedule for the treatment of APC in terms of response rate and clinical benefits.

MATERIALS AND METHODS

Twenty-seven evaluable consecutive patients with locally advanced, unresectable or metastatic adenocarcinoma of the pancreas were treated with gemcitabine (1000 mg/mq given as a short infusion once weekly for 3 consecutive weeks out of every 4 weeks) and tamoxifen (20 mg daily starting the second day after gemcitabine). The treatment was continued until progression or unacceptable toxicity. Evaluation of efficacy included response rate, time to progression, survival and clinical benefit, an integrated measurement of pain parameters, weight and performance status.

RESULTS

A partial response was achieved in 11% of patients while 48% experienced stable disease, lasting at least 8 weeks; disease progression was documented in 41% of patients. The median time of progression was 4.5 months; the median survival-time was 8 months and one-year survival was 31%. Clinical benefit was documented in 59% of patients with a median duration of 13 weeks. No gastrointestinal or haematological grade 4 toxicity was observed. In general the treatment showed a satisfactory safety profile and tamoxifen-related toxicity was not documented.

CONCLUSION

The combination of gemcitabine and tamoxifen appears to be an innovative therapeutic approach in the management of APC with interesting clinical activity and a good profile of toxicity. This novel schedule of treatment deserves further investigation in large randomized trials to assess if the addition of tamoxifen could improve the therapeutic results of gemcitabine in APC, mostly in term of quality of lfe.

[Remote teaching in surgery: problem-based learning, telementoring, and evaluation tests]

The authors propose the use of distant learning in the surgical knowledge teaching. The problem based learning methodology can support this new didactic approach. Telementoring is an interactive experimental methodology that allows young surgeons education by distant learning tutoring of an expert surgeon. The problem about assessment of efficacy and quality of computer-assisted instruction is to day under evaluation.

[Endoscopic surgery of chronic venous insufficiency (CVI)]

The endoscopic technique in chronic venous insufficiency is simple and almost complication free. Our preliminary results due to a good postoperative course and to a quick return to social activity induce the Authors to indicate this type of procedure as the best treatment in chronic venous insufficiency.

[Primary sarcoma of the breast: criteria for radical surgery]

The experience in a case of primitive stromal sarcoma of the breast brought the Authors to study and to characterize the surgical interventions to prefer in these tumors. Criteria of radicality are considered in the light of the modern notion of "anatomical compartment" already applied to the sarcomas of the musculoskeletal or parenchymal location, from which breast sarcomas don't differ in order to the clinical behavior.

[Criteria of choice in prosthetic surgery of laparocele]

The employment of prosthesis in abdominal plastic surgery for incisional hernia has contributed to a remarkable improvement in the results of this surgery. The current use of PTFEe, according to the Authors experience, proves to be effective. Both satisfactory functional results and evident aesthetic advantages are obtained. The Authors report their experience in the treatment of the median incisional hernia also by means of a polypropylene mesh. The latter was shaped in a very original way thanks to a technique borrowed from plastic surgery. The complete mobilization of the ombilicus, by a circular incision, allowed the Authors to insert this prosthesis symmetrically under the rectus abdominis muscles for the entire extension of the incisional hernia.

[The Trabucco tension-free hernioplasty: our experience and technical considerations]

The Authors report their experience in the management of 30 patients undergone tension free hernioplasty according to Trabucco for inguinal hernia. Results and some modifications of the original technique are discussed.

[Peroperative endoscopic papillotomy in a patient with an abdominal aortic aneurysm and biliary calculi]

The authors report a case of abdominal aortic aneurysm associated with biliary tract lithiasis. The need to simultaneously treat both diseases is stressed. A technique which involves endoscopy during open surgery in order to prevent contamination is illustrated. The technique used together with other manoeuvres is part of a methodology aiming to broaden indications to the treatment of abdominal diseases associated with vascular diseases, limiting at the same time the risks of prosthetic infection.

[A case of ileocecocolic intussusception from cecal carcinoma]

The authors present a case of ileocecocolic intussusception by carcinoma of the caecum. They stress the most peculiar aspects of this condition: rare etiology; complete invagination of caecum appendix and ileum; typical clinical presentation characterized by variable dimensions of the mass and symptoms not ascribing to occlusion, no lesions at endoscopy; evidence of a typical "target mass" visualized at T.C.

[Extracorporeal lithotripsy and endoscopy in the treatment of pancreatic lithiasis]

The decompression of the pancreatic duct with the extraction of stones by endoscopy is now recognized as an effective method for the treatment of some forms of chronic pancreatitis. The limits of this methodology are strictly linked to the morphology of the pancreatic duct and/or to the size, morphology and number of stones. The association of endoscopy with the ESWL often allows to overcome these limits. A case of lithiasis of the Wirsung in a patient affected by C.P. successfully treated associating endoscopy to ESWL is reported.

[The colorectal adenoma-carcinoma sequence: the limits between polypectomy and intestinal resection]

According to a clinic case, the authors pointed out the role of histological diagnosis in the therapeutic approach of large intestinal adenomas. In order to identify those lesions which can metastasize, having exceeded the muscularis mucosae and having invaded the submucosa, rigorous histological standards must be performed. Intestinal resection versus polypectomy is determined only according to the involvement or not of the muscularis mucosae.

[Bilateral carcinoma of the breast: treatment and prevention, Review of the literature]

Authors analyze 256 patients admitted in III Clinica Chirurgica of University of Rome "La Sapienza" for breast cancer, from 1982 to 1992; 16 of them had later developed another neoplasm in the opposite breast. After a retrospective study of the clinical history of all patients they came to the conclusion that bilateral neoplasm frequency is similar to that reported in world literature (1-18%) (23, 9, 2). Moreover, are analyzed the primary risk factors for a bilateral carcinoma, and they consider the utility of the prophylactic surgical treatment of the opposite breast.

[Pathology and clinical course of pancreatic pseudocyst]

According to the literature and the personal experience of the authors there seem to exist many controversies on the treatment of pancreatic pseudocysts, partly due to the lack of definitions and to the fact that prognosis is different based upon the pathophysiology of the lesions. We report 4 cases of pancreatic pseudocysts successfully treated with a multidisciplinary approach, stressing the role of pharmacology and of artificial nutrition and endoscopy on the outcome of these lesions.

[Nutritional and defunctionalized jejunostomy in the chemotherapeutic treatment of gastric non-Hodgkin's lymphoma. Preliminary experience]

The authors propose a jejunostomy on an omega loop distal to the Treitz ligament as a treatment for unresectable gastric lymphomas. The rationale is to provide nutritional support during chemotherapy in a situation when the stomach is defunctionalised. As assessed by clinical, morphological and biological parameters, the association of chemotherapy and jejunostomy may represent a valid therapeutical strategy for patients considered unresectable.

[The use of scintigraphy with labelled leukocytes: our experience]

The authors describe various applications of scintigraphy with labeled leukocytes and its value in the diagnosis of gut diseases such as Crohn's disease, ulcerative colitis and related complications. Furthermore, the study of vascular prosthesis infection, cryptogenetic fever and abdominal sepsis, three cases of which are herein reported, is facilitated. The method, in conjunction with endoscopy and traditional radiology, revealed to be of great value in terms of sensitivity and specificity for the diagnosis of the aforementioned diseases. Therefore, the use of such method is encouraged in all those cases of abdominal sepsis of uncertain interpretation and in the evaluation of vascular prosthesis infection.

[Anterograde laparoscopic cholecystectomy: when and why]

Today largely diffused is the concept that laparoscopic cholecystectomy (LC) represents the treatment of choice for symptomatic gallstones. Nonetheless some questions have been raised on the real safety of this new method in terms of procedure-related complications. On the basis of our experience with traditional open cholecystectomy, we have recently performed a prograde LC in those cases with difficulties in identifying the anatomical structures of the so called Calot's triangle. This alternative route can be easily performed laparoscopically and has been useful in reducing the time of the intervention in the most difficult setting and to increase the safety of the procedure. The technical details and the results are compared with those of the laparoscopic retrograde route.

[Bilateral breast tumors]

From a retrospective analysis of 181 cases observed in a ten-year period (1980-1990), the authors registered a frequency of bilateral breast cancer comparable to that reported in the literature (1-12%). Early diagnosis is the only factor able to modify positively the prognosis, through an accurate follow up, based on blood and X-ray tests (low-density mammography).

[New trends in the diagnosis of Crohn's disease]

The Authors in reviewing the diagnostic techniques commonly used in Crohn's disease, focus their attention on Indium-111 scanning. The method seems useful, not only to point out the complications of the disease (stenosis, abscess, fistula) but especially for the follow up of patients after surgery with early diagnosis of a possible relapse.

[Colonic stenosis due to a "microcarcinoma" of the ovary: a clinical note]

The authors, on the basis of a case recently observed, suggest to take into account the presence of an ovarian "microcarcinoma" when a jejunal stenosis of uncertain origin is found in a female patient. In fact, ovarian carcinoma is often misdiagnosed. A complete surgical exploration is recommended even though diagnostic techniques such as endoscopy, CT scan, ultrasonography and X-ray barium enema are negative.

[Formation of calculi on a double J catheter]

A case of lithiasis due to indwelling double J ureteral stent is described. Pathogenesis and possibilities of prevention are discussed.

[Adjuvant chemotherapy in carcinoma of the bladder: current results and prospects]

Adjuvant chemotherapy is one of the latest and more promising modality of cancer treatment within the multidisciplinary approach to neoplasms. This paper illustrates the biological rationale as well as preliminary evaluation of its effectiveness for bladder carcinoma.