Combined pancreatojejunal and hepatojejunal anastomotic stent placement in total laparoscopic pancreaticoduodenectomy

INTRODUCTION

Laparoscopic pancreaticoduodenectomy (LPD) is a technically demanding procedure that is considered safe and feasible if performed in a high-volume institution, where surgeons and medical staff is appropriately trained. For this advanced abdominal procedure only few studies described a reproducible stepwise technique and a standard approach is still lacking.

METHODS

The attached video reports all steps of our standardized LPD with pancreatojejunal and hepatojejunal anastomotic stent placement performed with a double approach. The laparoscopic demolitive phase, exactly as the laparotomic one, begins with the surgeon placed on the patient's right side, while for the reconstructive one he moves between the patient's legs. The main characteristic of this technique is an easy realization of the end-to-side biliary anastomosis with a Kehr's "T" tube segment placement as internal biliary stent. This easy technical tip can facilitate the anastomosis realization that remains the most challenging step of this laparoscopic technique, especially in case of small common bile duct.

RESULTS

We consider that our standardized technique can be safely performed and it can facilitate the anastomosis execution, especially the hepatic-jejunal.

DISCUSSION

Despite our reproducible stepwise technique could help to minimize the learning curve for LPD, further randomized controlled trials are needed to validate the superiority of minimally invasive approach.

Systematic review of the influence of chemotherapy-associated liver injury on outcome after partial hepatectomy for colorectal liver metastases

BACKGROUND

The impact of chemotherapy-associated liver injury (CALI) on postoperative outcome in patients undergoing partial hepatectomy for colorectal liver metastases (CRLM) remains controversial. The objective of this study was to clarify the effect of CALI (sinusoidal dilatation (SD), steatosis and steatohepatitis) on postoperative morbidity and mortality by investigating a large data set from multiple international centres.

METHODS

PubMed and Embase were searched for studies published between 1 January 2004 and 31 December 2013 with keywords 'chemotherapy', 'liver resection', 'outcome' and 'colorectal metastases' to identify potential collaborating centres. Univariable and multivariable analyses were performed using binary logistic regression models, with results presented as odds ratios (ORs) with 95 per cent confidence intervals.

RESULTS

A consolidated database comprising 788 patients who underwent hepatectomy for CRLM in eight centres was obtained. In multivariable analyses, severe SD was associated with increased major morbidity (Dindo-Clavien grade III-V; OR 1·73, 95 per cent c.i. 1·02 to 2·95; P = 0·043). Severe steatosis was associated with decreased liver surgery-specific complications (OR 0·52, 95 per cent c.i. 0·27 to 1·00; P = 0·049), whereas steatohepatitis was linked to an increase in these complications (OR 2·08, 1·18 to 3·66; P = 0·012). Subgroup analysis showed that lobular inflammation was the sole component associated with increased overall morbidity (OR 2·22, 1·48 to 3·34; P = 0·001) and liver surgery-specific complications (OR 3·35, 2·11 to 5·32; P < 0·001). Finally, oxaliplatin treatment was linked to severe SD (OR 2·74, 1·67 to 4·49; P < 0·001).

CONCLUSION

An increase in postoperative major morbidity and liver surgery-specific complications was observed after partial hepatectomy in patients with severe SD and steatohepatitis. Postoperative liver failure occurred more often in patients with severe SD.

Does arterialisation time influence biliary tract complications after orthotopic liver transplantation?

BACKGROUND

In the cardiac death donor era, many reports deal with biliary tract complications and concerns about ischemic reperfusion injury owing to the exclusive arterial vascularization of the biliary tree, the warm ischemia time has been implicated as responsible for biliary lesions during organ procurement. We defined the arterialization time as the second warm ischemia time. Our purpose was to study the correlation between the arterialization time during liver implantation and the appearance of biliary lesions.

METHODS

We retrospectively collected data from the last 5-years of orthotopic liver transplantation: namely, indications, cold perfusion fluid, cold ischemia time, operative procedure times, and acute rejection events. We excluded split-liver transplantations, retransplantations, pediatric patients, transplantations for cholestatic disease, cases where hepatic artery thrombosis happened before biliary complications, or patients with posttransplant cytomegalovirus infection. We defined 2 groups: A) without biliary complications; and B) with biliary complications. We compared the mean arterialization time using Student t test to define whether the warm ischemic time during implantation was responsible for biliary tract complications. A P value of <.05 was considered to be significant.

RESULTS

Between 2004 and the end of 2008, we grafted 402 patients among whom 243 met the inclusion criteria: 198 in group A and 45 in group B. Only the cold ischemia time was significantly different between the 2 groups (P = .039).

CONCLUSION

After the anhepatic time, the surgeon may take time for the arterial anastomosis without fearing increased biliary damage.

Laparoscopic ultrasound-guided radiofrequency ablation as a bridge to liver transplantation for hepatocellular carcinoma: preliminary results

INTRODUCTION

The aim of this study was to assess the impact of laparoscopic thermoablation (LTA) as a neoadjuvant therapy prior to orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC).

METHODS

Between January 2008 and January 2009, 12 consecutive patients, including 10 males and 2 females with unresectable HCC within liver cirrhosis, were treated with LTA under ultrasound (US) guidance. Most patients were in Child-Pugh class B (54.1%) with a mean age of 60.7 +/- 7.74 years (range, 45-69; median, 60).

RESULTS

The LTA procedure was completed in all patients with thermoablation of 23 HCC nodules. LTA identified 4 new malignant lesions (20%) undetected by preoperative imaging (<0.5 cm). The mean length of surgery was 96 minutes (range, 45-118). Six procedures were performed in 4 patients. No postoperative hepatic insufficiency was reported. The mean hospital stay was 4.5 days; no postoperative morbidity was reported. Complete tumor necrosis was achieved in 19/23 thermoablated nodules (82.6%) as evidenced computed tomography (CT) scan by at 3 weeks after the treatment. All patients underwent OLT without complications. The histology of the native liver showed complete necrosis in 17/23 (74%) treated nodules.

DISCUSSION

There is currently no convincing evidence that LTA allows one to expand the current selection criteria for OLT, nor that LTA decreases dropout rates on the waiting list. However, LTA does not increase the risk of postoperative complications. There is insufficient evidence that LTA offers any benefit when used prior to OLT either for early or for advanced HCC.

Incisional hernia repair after liver transplantation: role of the mesh

BACKGROUND

Patients undergoing orthotopic liver transplantation (OLT) show a high risk of developing an incisional hernia. The aim of this retrospective study was to establish the incidence and the factors influencing the outcomes of this complication.

METHODS

We reviewed 450 consecutive OLT performed in 422 adult recipient between January 2000 and December 2005. Herniae were analysed with aspect to localization, classification, repair technique, and recurrence. All treated herniae were followed for a median of 50.5 months.

RESULTS

Incisional herniae occurred in 36 patients (8.5%, Group 1). Their mean age OLT was 51.4 years with 94.4% male subjects. No significant difference was observed between affects and unaffected individuals for age, OLT indication, Child-Pugh score, albumin, comorbidities, operative time, transfusions, immunosuppressant regimen, and graft rejection episodes as well as for the incisional approach and hospital stay. Gender, body mass index (BMI), preoperative ascites, and pulmonary complications after OLT were significantly different (P < .01). Herniae were small (<5 cm; n = 12), medium (5-10 cm; n = 28), or large (> 10 cm; n = 2). Herniorrhaphy techniques included primary suture repair in 5 (13.9%) and mesh repair in 31 (86.1%) cases. In 3 patients with a primary repair and 1 patient with a mesh repair there were recurrences.

CONCLUSIONS

Preoperative ascites, gender, BMI, and pulmonary complications after OLT seemed to have significant influences on the formation of incisional herniae. Polypropylene mesh may be a first choice for the surgical treatment of there transplant recipients.

Liver transplantation exceeding UCSF criteria: case report of a late recurrence treated by surgery and review of the literature

INTRODUCTION

Treatment of a recurrence of hepatocellular carcinoma (HCC) after liver transplantation. Surgery has seldom been considered in such a situation because HCC recurrences are generally considered as a systemic disease.

PATIENT AND METHODS

We describe a 47-year-old male patient who underwent liver transplantation in October 1999 for HCC exceeding the Milan and University of California, San Francisco (UCSF), criteria.

RESULTS

In 2007 (8 years after liver transplantation), the patient developed a cervical bone metastasis treated by surgery. In April 2008, HCC had disseminated to hepatic pedicle lymph nodes. An extended hepatic pedicle lymphadenectomy was then performed. Today, our patient is doing well, without signs of recurrence.

DISCUSSION

The risk of developing a tumor recurrence is the main argument against expanding the UCSF criteria. In case of an HCC recurrence, various treatments ranging from a change in the immunosuppression regimen to chemotherapy have been proposed. Surgical treatment has rarely been envisaged in the treatment of HCC recurrences because of the technical difficulties and the frequent dissemination of cancer.

Preliminary experience with the hanging maneuver for pancreaticoduodenectomy

BACKGROUND

Malignant periampullary tumours often invade retroperitoneal peripancreatic tissues and a positive resection margin following pancreaticoduodenectomy (PD) is associated with a poor survival. The margin most frequently invaded is the retroperitoneal margin (RM). Among the different steps of PD one of the most difficult and less codified is the resection of the RM with high risk of bleeding. We have developed a surgical technique - "hanging maneuver" - which allows at the same time a standardization of this step, a complete resection of the RM, and an optimal control of bleeding.

PATIENTS/METHODS

We described the surgical technique, and we reported our preliminary experience. Surgical data, postoperative outcome and pathological results of patients submitted to PD for pancreatic carcinoma using "hanging maneuver" technique between January 2007 and December 2007 were reviewed.

RESULTS

The hanging maneuver was performed in 20 patients without any intraoperative complication and massive bleeding. No patient required blood transfusion. After had inked the surgical margins, retroperitoneal peripancreatic tissue was invaded in 12 out of 17 patients with malignant diseases (70.5%). In only one case (6%), the retroperitoneal margin was involved by the tumour (R1 resection).

CONCLUSION

The "hanging maneuver" is a useful and safe technical variant and should be considered in the armamentarium of the pancreatic surgeons in order to achieve negative retroperitoneal margins.

Split liver transplantation for acute Wilson's disease: new option for urgent recipient?

Wilson's disease is a rare metabolic disorder that may lead to fulminant hepatitis and subsequent liver failure. Herein, we present a case of split liver transplantation performed on a patient with acute Wilson's disease. A 27-year-old female with acute presentation of Wilson's disease and advanced neurological impairment, received a Right Split liver Graft (Segments: IV, V, VI, VII and VIII) transplant. The graft was obtained by an in situ splitting technique. The graft implantation was performed in a standard fashion. No acute rejection episodes of the organ occurred. The postoperative course was uneventful. The graft function, ceruloplasmine level and copper levels progressively normalized. The patient totally recovered from neurological symptoms and the Kayser-Fleischer rings disappeared within one month. At 13 months of follow-up, the patient presented with no symptoms and in good condition. The current literature reports high preoperative mortality rate in patients that underwent partial liver graft for acute hepatic failure. However, our experience indicates that in situ split technique of liver may be a feasible and effective alternative to whole graft transplantation in urgent cases. Moreover, to our knowledge, this is the first successfully case of in situ split liver transplantation for acute Wilson's disease described in literature.

Impact of ischemia/reperfusion on transplanted livers procured from elderly cadaveric donors

The increasing number of clinical indications for liver transplantation has forced physicians to use livers procured from elderly cadaveric donors to expand the graft pool. However, the degree of ischemia/reperfusion damage in elderly livers remains poorly investigated. In this study, the outcomes of livers procured from a group (I) of young donors (n=12; 38 +/- 12 years; range: 21-58) were compared with a group (II) from elderly donors (n=7; 68 +/- 7 years; range: 62-84) for changes in reduced glutathione, the main hepatic free radical scavenger. Reduced and oxidized glutathione were assayed by high performance liquid chromatography in liver biopsies performed just before cold ischemia and during early reperfusion. A significant decrease in reduced glutathione was observed at the time of reperfusion in both groups I (P=.0195) and II (P=.002). Before cold ischemia and during early reperfusion, no differences between young versus elderly donors were noted in the oxidized/reduced glutathione ratio, in conventional graft function markers or in liver-related hemostatic parameters. Comparable glutathione contents were measured at the time of early reperfusion in livers obtained from young and elderly cadaveric donors, suggesting that livers procured from elderly donors might be adequately protected against ischemia/reperfusion damage.

Simultaneous liver-kidney transplantation for glycogen storage disease type IA (von Gierke's disease)

INTRODUCTION

Glycogen storage disease type Ia (GSDIa) is due to the deficiency of glucose-6-phosphatase activity in the liver, kidney, and intestine. Although significant progress has been achieved in the management of patients with GSDIa, complications still emerge. The potential for development of liver adenomatosis and kidney failure makes these patients candidates for simultaneous liver-kidney transplantation (SLKT). Herein, we describe such a transplantation in a patient affected by this rare storage disease.

METHODS

A 25-year-old female patient with GSDIa developed hepatic adenoma and kidney failure despite dietary therapy. The patient underwent an SLKT from a cadaveric donor.

RESULTS

The operative time was 8 hours without hemotransfusion. Only a transitory lactic acidosis was observed. Laboratory results normalized on postoperative day 7. The patient was discharged on postoperative day 9. After 4 months, the patient is in good condition with well-functioning kidney and liver allografts.

CONCLUSION

Patients with end-stage renal disease secondary to GSDIa should be considered for SLKT, especially when the disease is in an early stage.

Different reconstitution of peripheral blood lymphocytes and dendritic cells in liver and kidney transplant patients

T cells and dendritic cells are responsible for immune alloreactivity or tolerance after transplantation. In this study, we compared the levels of circulating T, B, and NK lymphocytes, as well as monocytes, plasmacytoid dendritic cells, and myeloid dendritic cells, in adult patients undergoing a liver transplant or kidney transplant. Our findings show that candidates for liver transplant had significantly lower levels of circulating T, B, and dendritic cells than candidates for kidney transplant. Nevertheless, liver transplant patients showed a greater T-cell recovery, despite the use of thymoglobulin, as compared with kidney transplant patients who were induced with Daclizumab. In four kidney transplant patients with allograft rejection we observed a dramatic drop of circulating T and dendritic cells at the time of rejection, and while myeloid dendritic cells and CD4(+) and CD8(+) cells rapidly recovered after 1 month, plasmacytoid dendritic cells and CD4(+)CD25(+) T-cell numbers remained significantly lower than in patients without rejection. Future studies will evaluate the monitoring of circulating CD4(+)CD25(+) T cells and myeloid dendritic cell:plasmacytoid dendritic cell ratio as potential biomarkers for rejection or, alternatively, for withdrawal of immune suppression.

Cerebral hemodynamic and metabolic changes in patients with fulminant hepatic failure during liver transplantation

BACKGROUND

Cerebral autoregulation and metabolism may be seriously compromised in patients with fulminant hepatic failure (FHF). The mechanism responsible for the alteration in cerebral blood flow (CBF) has not been yet clearly defined; however, it is known that it does correlate with liver function. Orthotopic liver transplant (OLT) rapidly restores normal liver function, but little is known about the restoration of cerebral metabolism and hemodynamics. To investigate the relationship between liver function and CBF, we evaluated autoregulation and metabolic changes during OLT in six patients comatose due to FHF.

METHODS

We evaluated autoregulation based on a linear regression analysis between mean arterial blood pressure and parallel CBF velocity (CBFV) changes using transcranial Doppler ultrasound. Cerebral metabolism rate was estimated by the arterial-jugular venous oxygen content difference (a-jDO2), while the percentile variation in cerebral metabolic rate for oxygen (CMRO2) was estimated using CBFV percentile variation rather than CBF percentile variation (eCMRO2).

RESULTS

Prior to transplant autoregulation was impaired in all patients. However it markedly improved at the end of surgery (P <.05). The eCMRO2 improved as well, particularly among subjects who displayed prompt neurological recovery. In all patients the a-jDO2 was low before transplantation increasing to normal values at the end of surgery.

CONCLUSIONS

A hallmark of FHF seems to be failure of autoregulation, which is linked to uncoupling between CBF and CMRO2 as attested by an a-jDO2 lower than normal in all patients (luxury perfusion). The recovery of liver function rapidly improves cerebral hemodynamics and metabolic stability. The study of autoregulation and eCMRO2 recovery using Doppler monitoring proffers the possibility to predict early graft function after liver reperfusion. In our patients eCMRO2 seemed to be associated with improved neurological outcomes.

Potential predictive value of the MELD score for short-term mortality after liver transplantation

In the last years, a model for end-stage liver disease (MELD) was suggested as a disease severity score for patients with end-stage liver disease awaiting liver transplantation. In the early 2002, United Network for Organ Sharing (UNOS) has proposed to replace the current status 2A, 2B, and 3 by a modified version of the original MELD score based upon patient risk for 3-month mortality on the waiting list. In this study UNOS status and MELD score were evaluated retrospectively for postoperative 3-month mortality in patients who underwent liver transplantation from 2000 to 2001. Liver recipients were stratified for UNOS status 2A, 2B, and 3, and the corresponding MELD score was calculated for each patient. A receiver operating characteristic (ROC) analysis was performed for both conventional UNOS status and MELD score by fitting patient deaths within 3 months after liver transplantation. The MELD score revealed a better prediction rate for 3-month mortality after the first LT than conventional UNOS status, although no statistical significance was evident by ROC curve comparison. This preliminary study seems to suggest a potentially better predictive rate for the MELD score than conventional UNOS status concerning short-term mortality after liver transplantation.

[Total splenectomy for a recurrent giant splenic cyst]

Primary splenic cysts are a rare finding. Some are large and require surgical removal. The Authors report a case of a recurrent huge splenic cyst in a 41-year-old female patient. A marsupialization was performed at another hospital 6 years before. Ultrasonography and computed tomography imaging revealed a cystic lesion in the spleen measuring approximately 20 cm in diameter. A total open splenectomy was performed. Postoperative course was uneventful. The histologic diagnosis was an epithelial cyst of the spleen with no atypical cells in the cyst wall, as previously found at the first operation. The epidermoid cysts have an epidermal lining, and prevention of recurrence is dependent on complete resection of the cyst wall preserving, whenever possible, the splenic tissue. Recurrence can be avoided with partial splenectomy in polar localization of the cyst, or complete removal of the cyst by "peeling" it off the splenic parenchyma. Marsupialization of the cyst, either via a laparoscopic or an open approach, is often ineffective.

[Cystic lymphangioma of the adult: our experience and review of literature]

Cystic lymphangioma is an uncommon benign pathology, usually reported in children, rarely in adult. Its embryopathogenesis is still controversial: it seems to arise from the lymphatic vessels, mainly in the cervico-cranial district. It is macroscopically characterised by multiple cystic non-communicating concamerations. Definitive diagnosis used to be intraoperative and was usually an unexpected finding. Nowadays, with modern imaging technologies, CT and MRI, diagnosis can be assumed before intervention even though certain diagnosis can still be reached only with histological examination. Imaging techniques can help for a precise mapping of the lesion and definition of its limits with the other structures, improving therapeutic success. Various therapeutical options are reported in literature, but complete surgical excision is still considered the best approach and the most successful. The Authors report their experience and review the literature on cystic lymphangioma in adult.

Severe hemolytic anemia due to passenger lymphocytes after living-related bowel transplant

BACKGROUND

Hemolytic anemia following solid organ transplant may be caused by 'passenger' lymphocytes producing antibodies against erythrocytes. This phenomenon has never been described after intestinal transplant.

MATERIALS AND METHODS

We report a case of severe, immune-mediated hemolysis due to symptomatic passenger lymphocyte syndrome (PLS) in a 4-yr-old recipient of living donor small bowel transplant. The Coombs'-positive hemolysis was caused by anti-A,B antibodies derived from donor lymphocytes in an ABO-compatible donor-recipient pair (O into A).

RESULTS

This complication was successfully and efficiently treated by the novel combined use of group O RBC transfusion, plasmapheresis and rituximab (anti-CD20).

CONCLUSIONS

A severe hemolytic anemia due to PLS can occur in bowel transplantation. This complication should be considered when performing ABO-incompatible bowel transplant with a blood group O donor and an A or B recipient. Treatment with plasmapheresis, blood group O transfusion and rituximab has proved successful in our case.

Modifications of cerebral vascular resistance and autoregulation after graft reperfusion during human orthotopic liver transplantation

We have studied cerebral blood flow velocity (CBFV) and cerebral autoregulation (CA) in 23 orthotopic liver transplantation (OLT) patients using transcranial doppler. CBFV was continuously recorded using a fixed (helmet) 2-Mz probe through the trans-temporal window. CA changes were studied using a linear regression analysis of percentile changes in CBFV and mean arterial blood pressure (MABP) after phenylephrine infusion compared with baseline. Pearson's "r" coefficient was considered an index of CA. In case of autoregulation is lost "r" tends to 1, thus representing complete dependence of CBFV on MABP. We regarded the slope coefficient parameter "S" as an index of cerebral vascular resistance (CVR), namely, the ratio of the corresponding variations of CBFV to MABP. Wilcoxon test showed a significant increase in both "r" and "S" between the anhepatic versus postreperfusion phases (within the first hour) and versus recovery in the neohepatic phase (end of surgery). A decreased CVR was observed within the first hour after graft reperfusion producing a loss of CA. These phenomena lead to an increase of CBFV and exposed the brain to hyperperfusion.

Portal vein pressure and graft oxygen consumption monitoring during liver transplantation

Abnormal splanchnic circulation (ASC) is often detected too late, when hepatic circulation is already irreversibly compromised. If we could detect surgical or metabolic problems early after graft reperfusion, we might be able to correct them immediately before the damage becomes irreversible. The aim of this study was to determine if ASC can be predicted early after liver transplantation (LT) using portal vein pressure measurements and graft oxygen consumption monitoring.

PATIENTS AND METHODS

Twenty-patients (13 men, 7 women of mean age 46 years) undergoing LT with the piggyback technique for hepatitis C virus (HCV)/hepatitis B virus (HBV)-related cirrhosis were retrospectively divided in two groups. Group A (16 patients), in which LT was successful, and group B (4 patients) in which LT was unsuccessful because of primary nonfunction (2 patients), infrahepatic portal vein thrombosis (1 patient), or hepatic vein kinking (1 patient). We then compared the portal blood pressure values and the prehepatic and posthepatic oxygen content difference (p-pDO(2)) before portal clamping; at the end of anhepatic phase; 5, 15, and 25 minutes after portal vein (PV) reperfusion; and 5, 20, 40, and 100 minutes after hepatic artery anastomosis.

RESULTS

Early after graft reperfusion; portal pressure decreased to levels lower than that at baseline in group A, but remained high until the end of surgery in group B. At the end of surgery, p-pDO(2) increased more among group B than group A.

CONCLUSION

ASC, specifically an increased PV resistance, can be predicted early after LT by portal vein pressure measurements and graft oxygen consumption monitoring.

Laparoscopic colon resection with intraoperative polyp localisation with high resolution ultrasonography coupled with colour power Doppler

A 40-year-old woman with a 3 cm sigmoid polyp lesion who underwent a laparoscopic colon resection after intraoperative localisation of the lesion using laparoscopic ultrasonography coupled with colour power Doppler is described. She has successful intraoperative detection of the polyp followed by radical laparoscopic removal of the lesion. The advantage of using laparoscopic high resolution ultrasonography coupled with colour power Doppler to locate colonic polyp lesions during a laparoscopic colon resection is that intraoperative colonoscopy can be avoided. Intraoperative ultrasonography of the colon can accurately localise colonic polyp lesions that are not detectable during laparoscopy and represents a quick and effective alternative to other imaging techniques.

Laparoscopic physiological hiatoplasty for hiatal hernia: new composite "A"-shaped mesh. Physical and geometrical analysis and preliminary clinical results

BACKGROUND

We analyzed, using a theoretical model, the modality of recurrence after a simple cruroplasty for large hiatal hernias, and on the basis of physical and geometrical principles, we conceived a new shaped mesh for a "tension-free" repair.

METHODS

We performed a physical and geometrical analysis of the hiatal region on a theoretical model. We also performed an anatomic study on 20 fresh cadavers to verify the reproducibility of the theoretical model and to study the most suitable shape for mesh and its adaptability to the hiatal region. Between September 2000 and October 2001, eight patients received laparoscopic reparation of large (type II or III) hiatal hernias by means of a composite "A"-shaped polytetrafluoroethylene (PTFE)-polypropylene mesh. There were two men and six women; mean age was 65 years (range, 35-78 years). Concomitant esophagitis was found in five patients and impaired esophageal peristalsis in two patients. A total or a partial fundoplication was associated in these cases.

RESULTS

The physical and geometrical analysis of the hiatal region explained the reasons for the recurrence after hiatoplasty. The anatomical study on fresh cadavers resulted in a mesh tailored in an "A" shape and permitted to verify the adaptability of such a shaped mesh composed of two layers, polypropylene and PTFE. In the clinical series no conversions occurred; the mortality rate was null. Persistent dysphagia was present in two patients and disappeared after 3 months of treatment. No recurrence was observed at an 8-month average follow-up.

CONCLUSION

The preliminary clinical study confirms the feasibility of this tension-free repair and the effectiveness of this composite A-shaped mesh.

Laparoscopic splenectomy for hematological diseases

BACKGROUND

We reviewed retrospectively the records of all patients who underwent laparoscopic splenectomy (LS) at our institution for a wide range of hematological disorders. We compared our experience to those reported in the literature and analyzed various aspects of the treatment that are still under discussion and in need of confirmation, such as the treatment of malignant blood diseases, the indication in case of splenomegaly, and the adequacy of the detection of accessory spleens.

METHODS

Between June 1997 and June 2001, we performed 43 LS. The patients were classified into three groups according to clinical diagnosis: idiopathic thrombocytopenic purpura (ITP) (n = 23), hemolytic anemia (HA) (n = 5), and hematological malignancy (HM) (n = 15). Statistical analyses were done to compare the three groups.

RESULTS

LS was completed in 41 patients, with a conversion rate of 5%. Splenomegaly was present in 37% of all patients (73% of HM). Mean operative time was 128 min. The incidence of accessory spleens was 20%. A concomitant laparoscopic procedure was done in three cases (cholecystectomy). Postoperative complications occurred in eight patients (18%). Duration of surgery, length of hospital stay, transfusions rate, and some demographics features, such as age and spleen weight and length, were significantly different in each group. No deaths were attributed to the procedure.

CONCLUSIONS

The statistical analysis of our series shows that, the laparoscopic approach reliable even in the management of malignant and nonmalignant blood diseases.

[Angioneurosis due to vibrating tools with special reference to plethysmographic and Doppler vascular diagnosis]

Angioneurosis, together with bones and joints disorders, represents the most frequent clinical syndrome due to vibrating instruments. The authors report a general presentation of the disease, particularly focused on indications, usefulness and methods of plethysmography and Doppler C.W., as noninvasive diagnostic procedures.

[Jejunal adenocarcinoma: case report and review of the literature]

Adenocarcinoma of the jejunum is a rare tumor. The diagnosis is often difficult and not early. The Authors report a case recently observed in their clinical practice and successfully operated, reporting also what's in the literature about.