[Identification of an objective reference parameter for the reconstruction of a large incisional hernia following physiological principles]

Repairing a parietal defect of a large incisional hernia should not be limited to the closure of the breach by means of the modern biocompatible prosthetic sheets, but must also be able to restore a correct intra abdominal pressure, otherwise the derangement from the normal respiratory dynamics and the circulatory stasis in the abdominal veins and in those of the lower limbs remain unaltered. Over-correcting the parietal abdominal tension on the contrary can cause a dangerous compartmental syndrome. The attempts of an intraoperative measurement of the correct intra abdominal pressure restoration has been generally hampered from the condition of curarization of the patient during the operation. Using the automatic mechanical ventilator fixed at volume and not at pressure priority, as usual, can offer the possibility to calibrate, following objective parameters, the propriety of the surgical repair still during the final phases of the reparative operation. The simplicity and ingenuity of the here proposed method and the normal availability in every operative theatre of the necessary means for this measurements described, requires attention among the surgeons and a large diffusions of its simple use.

A new surgical tool facilitating the low colo-rectal anastomosis. The original "grasping tie"

A new surgical tool is here proposed to be used together with a circular stapler to help performing a mechanical anastomosis of the low rectum after a sigma or rectum resection. Its name, grasping tie, indicates its main function to fix from outside the rectal stump to the axle of the stapler anvil by means of a nylon ribbon slipping knot before the connection of the two parts of the stapler. The small dimensions of the operative end of the tool make easy to operate in the narrow space of the deep pelvis.

[Experimental study of the effect of the Argon Beam Coagulator on organic tissues from the viewpoint of surgical utilization]

The Argon Beam Coagulator has gained his space in surgery thanks to its operative characteristics, that are very useful in sealing the bleeding parenchymal tissue with minimal injury to the surroundings. The aim of the present study is that of evaluate the physical properties of the instrument in its coagulation action. The experimental study with the Birtcher 6000 Argon Beam Coagulator has been designed to measure the top temperature that develops right where the Argon beam meets the tissue, while operating. Using a laser guided telethermometer, the searching of that temperature was uneasy right on the operatory field because of the unwilling movements of the operator hand and those of the patient himself. Therefore a similar protocol was made on a piece of meat coming from the butcher. At the longest application of the beam coagulation on the same point the developed temperature was never higher than 100 degrees C whilst a complete coagulation effects. The advantage of the Argon Beam coagulation are therefore to seal the diffuse bleeding without injury to this adjacent tissues, never exposed to a temperature higher than that of boiling water. The advantages are also evident in comparison with the more usual spray electrosurgery that is instead characterized by a wide carbonisation also with this spray option.

[Critical update on the no-touch technique in colonic cancer using the grasping tie]

The time honoured strategy of "no-touch" in the surgery of colon cancer does not stand an anatomical and patho-physiological criticism, also on the basis of some results of the literature. The personal experience of the problem leads to the proposal of an alternative realization of the procedure, that is an up-to-date of the classic method, and is really worth and easy to be overall adopted. The suggestion is to seal bipolarly the colon tract with the tumour by mean of the original grasping tie from the very beginning of the operation, and then to temporarily clamp the mesocolon close to the gut, before going on with the surgical dissection, lymphectomy and exeresis as usual. This procedure is able to completely isolate from the first steps of the operation the affected tract of the colon, so opposing the possible spreading of tumour cells in the portal and in the systemic venous stream during the following surgical manipulations. The rationale of the proposal is that of a more efficacy of the "no-touch" strategy based on strict anatomical and patho-physiological considerations.

[Complicated colon cancer: the experience at an Operative Surgery Unit]

INTRODUCTION

Prognosis of colon cancer is worse if complications are present at the moment of diagnosis. The high mortality rate with surgery in emergency in such cases needs a careful reflection about the best suitable operation to perform.

MATERIALS AND METHODS

107 consecutive patients observed along a 9 year-period for colon-rectal cancer are retrospectively analysed. 27 of them were complicated at the presentation for obstruction (19 patients), colon perforation (6 patients) or rectal hemorrhage (2 patients). In the whole experience 5 patients underwent primary resection of the tumour and direct anastomosis; 5 only a decompressive colostomy; 6 were primarily resected and anastomized under the protection of a cecostomy; 6 other patients underwent a Hartmann procedure; 2 were treated with only an intestinal by-pass; 1 was treated with Miles procedure; 1 with an anterior rectal section and the last one was resected-anastomosed in two steps, after a temporary decompressive colostomy.

RESULTS

Intraoperative mortality was of 11.1% (3 patients) and morbidity 18.5% (5 patients). General 5 years survival was 62.1% among the cases complicated at presentation. The recurrence rate was 8.45%. Both these figures are below a statistical significance (p = 0.57).

CONCLUSIONS

The necessity to treat in emergency the colon cancers reduces the possibility to adopt the best rules of modern programmed oncologic surgery giving up the chemotherapy w/o neoadjuvant radiotherapy with which a preoperative down-staging of the tumour were possible. For these reasons in emergency not only mortality and morbidity are higher than in case of elective surgery, but also metastasization and recurrence are worse because of a more difficult radicality in surgery.

[The treatment of inguinal hernia: experience of a Operative Surgery Unit]

INTRODUCTION

550 patients submitted to surgical hernia reparation are reviewed for a retrospective analysis.

PERSONAL EXPERIENCE

The case report shows a predominance of prosthesis reconstruction according to Trabucco (254 patients) and of the surgical technique of Shouldice (191 patients). Other procedures of the experience refer to the surgical techniques of Bassini (46 patients), Lichtenstein (46 patients), Mugnai/Ferrari (7 patients), Postenski (3 patients), Rives (2 patients), and Stoppa (1 patient).

RESULTS

The reconstruction procedure was performed from a number of surgeons, all let free to choice the kind of operation following his personal skill and preference, but always in the most correct technique way. The results were satisfying in terms of short hospital stay, both precocious and late low complications, and always without failure.

DISCUSSION

A first consideration is that there is no data from the literature that any prosthesis procedure offers a lower postoperative complication incidence than the Shouldice's technique, and our experience confirms this option.

CONCLUSIONS

A surgeon can nowadays freely cultivate his preference for any of the possible procedures in reconstructing an inguinal hernia, but it is highly advisable that all the possibilities, also the pure surgical ones, remain in the surgeon's possibility of choice not to waste a precious previous surgical culture.

[Monitoring sheet for the management of the diabetic patient in preparation for elective surgery]

Diabetes represents a risk factor for patients undergoing surgery, not only in emergency but also in elective situations. All efforts in such patients are addressed to the restoration of the most physiologic conditions in respect for glucose balance and glucose metabolism since the preoperative phase, and during all the perioperative period. As these patients have to observe a more or less long period of preoperative and perioperative fasting since the day preceding the operation, any oral anti-diabetic regimen has to be timely discontinued, and the use of insulin is necessary. The doses of insulin have to be defined preoperatively with respect of the metabolic needs of the patients in the days preceding the operation, and must be able meanwhile to reduce blood glucose among the physiologic values, in absence on any urinary glucose, to restore a correct metabolism. The simple management form introduced in the paper for this purpose, and in use in our department through many years, makes easier getting and keeping all this aim and is extremely useful not only for the residents but also for the nurse staff. Its main characteristic is to offer daily, and for the single meal, a direct visual comparison of insulin dose and blood glucose level, in respect of a correct and constant caloric alimentation.

Simulated use of the "grasping tie" as for colo-rectostomy after low rectal resection

Simulated test of effectiveness of the original tool grasping tie, technically already illustrated in two previous papers listed in bibliography, for fixing a spongy rubber tube, simulating a rectal stump on the anvil's axle of a circular stapler, by tightening over it a nylon ribbon slip-knot (the tie). After connecting the anvil to the stapler head through an other spongy rubber tube simulating a colonic loop, and the firing of the stapler, it is demonstrated the correct circular anastomosis achievable.

[The "grasping tie". I. Introduction to and technical notes of an innovative mechanical tool aimed at formation of "purse string" in digestive surgery]

The grasping tie is an original and mechanical tool, conceived and planned to be used in digestive surgery, to temporary grasp and fasten at the axis of the head or the anvil of a circular stapler the tract of the gut chosen for anastomosis. Its use permit to fix the lower oesophageal stump in total gastrectomy, or that of the rectal stump in the lower rectal resection, respectively to the axis of the circular stapler component for the time necessary to perform the mechanical anastomosis. That is performed by the employment of a thin nylon ribbon, which will be progressively tightened as requested like a one way running knot about the tract of the gut and at the axis of the part of the stapler. The device will be repeatedly activated by an handle located at one of its ends, tightening progressively at the other end a thin nylon ribbon preventively put and laced around the chosen point of the digestive tract to grasp firmly and irreversibly the gut to the axis of the stapler, and then cut away by a trigger of the device in the same end of the handle. The nylon ring will be extracted together with the muscle-mucosal rings once completed the stapler suture, so that nothing of the ribbon remains in the patient. Its function is alternative to the classical tool used to prepare a purse-string suture on a segment of the digestive tract. Its advantages in front of that tool is the minimal space it requires for its use, therefore with operative advantages in fixing the head of the circular stapler in the oesophagus during the reconstructive steps after a total gastrectomy, and in fixing the lower rectum to the axis of anvil of a circular stapler preventively introduced in the anus and extruded. Moreover its employment is advantageous in closing from the outside the two ends of a tract of the gut where a tumour is located, so allowing a safe subsequent manipulation of the gut without oncologic prejudice.

Study of the antireflux function of the Roux-en-y jejunal loop in reconstruction following gastrectomy

Persistence of global orthograde peristaltic propulsion in the Y jejunal loop according to Roux makes this latter adequate for reconstruction of digestive transit after gastric resection or total gastrectomy, simultaneously avoiding reflux. Ectopic pacemakers can set in its proximal tract and favor intestinal and bile juice reflux in the gastric stump or esophagus, especially if the loop is too short and the new pacemaker is far from its superior margin. Moreover, the slower peristaltic waves can favor a relative stasis and, thus, a containing function, which could represent an element of morbidity over a certain limit. If the Y loop is not too long, but long enough to include the higher frequency ectopic pacemaker, which overcomes the lower frequency ones located distally, the positive aspects of both these characteristics can be exploited for satisfying and free of morbidity results. We believe that the best length is 35-40 cm, with positive clinical results. 99Tc-HIDA sequential scintigraphy clearly shows the absence of bile material reflux in the digestive tract proximal to the anastomosis.

Surgical conservative treatment for Bauhin's syndrome

BACKGROUND AND STUDY AIMS

Hypertrophy of ileocaecal sphincter seems to be the basic etiological factor of Bauhin's valve syndrome (BVS). In the rare literature all cases are treated by means of an hemicolectomy. A patient with Bauhin's valve syndrome is described, whose pathologic characteristics were hypertrophy of ileocaecal sphincter and a circular submucosal lipoma on the caecal side of the valve. Lipomata, although uncommon, may arise throughout the whole gastrointestinal tract, mostly asymptomatic, and submucosal layer is most frequently involved than subserosal one. More than two-thirds of gut lipoma are found in the large bowel, where they represent the most common benign lesion after adenoma.

PATIENTS AND METHODS

A 36 year old woman suffering from periodic upper abdominal pain, nausea and diarrhea, was submitted to an explorative surgical procedure, after imaging study of the bowel showed only an indistict mass in the caecum. Though a caecotomy a dissection of an hypertrophic and swollen portion of the ileocaecal valve was performed, saving the ileo-caecal sphincter. The residual mucosal margins were sutured, the last tract of the ileum was fixed to the caecum, completing with a caecorrhaphy and appendectomy.

RESULTS

Normal post-operative period, discharging the patient after few days. Since the operation all symptoms disappeared, and after four years there is a total well-being of the patient with complete disappearance of the former symptoms.

CONCLUSIONS

If the BVS is only due to a lipomatous hypertrophy of the mucosa and submucosa of ileo-caecal valve, hemicholectomy seems to be not justified: it is an exceedingly invasive procedure for a non-malignant disease. It is important a throughout radiological diagnosis and a caecotomy direct control during an operative exploration for a correct surgical choice.

[Contribution to the knowledge on natural history of giant hepatic angioma]

Hepatic haemangiomas are mostly discovered by chance because of their limited dimensions. Their treatment is optional and very often an observing conservative strategy is adopted whilst a danger is foreseeing from different facts. Very different is the case of giant haemangiomas discovered because their bulk and discomfort coming from the compression exerted on near structures. In this cases a surgical treatment, segmentectomy or hemiepatectomy, are the current demanding choices. But if the volume of haemangioma is too bulky and occupies most hepatic parenchyma the necessary resection may be too extended and possibly dangerous. The two observations of the paper refer to two patients followed conservatively for over 20 years. In fact the volume of the haemangiomas in both patients was too large, the symptoms were only related to the weight of the mass and therefore a surgical solution was deferred to a possible worsening of the symptomatology. Such worsening didn't happen in the time for both the patients, demonstrating that the natural history of such lesion can also be very benign over many years.

[Digestive system neoplasms originating from the autonomic nervous system. Diagnostic, therapeutic and prognostic issues]

The gastrointestinal autonomic nerve tumors (GAN tumor) are uncommon stromal tumors of the intestinal tract and retroperitoneum. The distinction of GAN tumors from other gastrointestinal stromal tumors is based on electron microscopic findings. However further study of additional cases is needed to fully characterize both their gross and microscopic features and to further characterize the natural history of such tumors. In the present study we report two cases of GAN tumor that arose from the stomach and small intestinal with different prognostic evolution in two patients of 73 and 65 years old. They were both treated by surgery, but only one case was successful. In addition patient 1 aged 73, died 11 months after surgical treatment with liver metastases on CT. scan. Patient 2, is clinically well five years after surgical treatment.

[Transclavicular approach for delivery of intrathoracic giant goiter. An alternative surgical option]

To remove the immerse portion of a cervical goitre it is necessary to treat preventively the cervical thyroid arteries. In most cases it is afterwards it is easy the blunt finger dissection of the mediastinal bulk following the correct cleavage plane and its dislodging in the cervical area. But in very rare instances, according also to the personal experience, remains some difficulty for the passage of a too bulky and hard mediastinal mass through the rigid limits of the upper thoracic outlet, or the immerse struma is too fragile for pulling it by transfixion threads. Therefore, traditionally arises the opportunity of an additional surgical access, through the breastbone or through the thoracic wall, according to the circumstances. Our experience, completely occasional but extremely positive of two of such cases, induces us to advance a proved alternative surgical proposal. When the difficulty of the removal of the immerse portion of the goitre comes only from the incongruence of the immerse volume and the rigid limits of the upper thoracic outlet, our proposal is that to obtain an amplification of the narrow passage breaking the continuity of the clavicle, by its section beneath the periostium near the breastbone and removing this sternal stump from the joint. The result is that of an widening of the upper thoracic outlet, no more rigid, and making easy the transit of the immerse portion from anterior mediastinum so dislodged in the neck. The rationale of this choice is that all is requested in such cases is only to overcome the obstacle of the incongruence among volume and bulk of the immerse portion and the bone limits fixed from the narrow upper thoracic outlet. Both the traditional sternotomy and the thoracotomy seems disproportional for this purpose, moreover with additional problems during the operation. The true advantage of these classical solutions is in treating under direct vision the anomalous arteries of the mediastinal goitre in cases of ectopic localization. But this is not the case of an immerse cervical goitre. It is therefore essential to note that this proposal applies only to the migrated goitre and not to the ectopic ones. The recovery is extremely simple, and both the aesthetics and the static of the scapular joint are not substantially compromised.

[The radical treatment of hepatic hydatidosis with deep and multiple locations. The role of new technologies particularly in the case of multiple locations]

Advanced technologies (intraoperative ultrasonography, CT scan, argon coagulator ...) have changed the surgical approach of liver hydatid disease, allowing even multiple or deeply located cysts to be detected and treated successfully. Authors report a series of 4 patients with single (3) or multiple (1) unilocular hepatic cysts; and 1 patient with thoraco-pulmonary hydatid recurrent disease. Treatments of choice and surgical techniques are described. No infective compliances occurred. The mean period of hospitalization was 19 days (ranging between 10 days and 4 weeks). The longest hospitalization was observed in a patient with a post-operative biliary fistula at low out put. Total cysto-pericystectomy is emphasized as the gold standard procedure in the treatment of non complicated unilocular hydatid cysts of the liver. Modern means of investigation and technical equipment make it feasible and safe even in unfavorable localizations, allowing radical removal of the cysts preserving in the meantime all the surrounding liver parenchyma.

[The scientific videotape with digital processing in surgery. The new opportunities offered surgery for videotape recording and postprocessing with the use of information and digital technologies]

The facility of the tape recording of a surgical operation, by means of simple manageable apparatuses and at low costs, especially in comparison with the former cinematography, makes it possible for all surgeons to record their own operative activity. Therefore at present the demonstration in video of surgical interventions is very common, but very often the video-tapes show surgical events only in straight chronological succession, as for facts of chronicle news. The simplification of the otherwise sophisticated digital technology of informatics elaboration of images makes more convenient and advisable to assemble the more meaningful sequences for a final product of higher scientific value. The digital technology gives at the best its contribution during the phase of post-production of the video-tape, where the surgeon himself can assemble an end product of more value because aimed to a scientific and rational communication. Thanks to such an elaboration the video-tape can aim not simply to become a good documentary, but also to achieve an educational purpose or becomes a truly scientific film. The initial video will be recorded following a specific project, the script, foreseeing and programming what has to be demonstrated of the surgical operation, establishing therefore in advance the most important steps of the intervention. The sequences recorded will then be assembled not necessarily in a chronological succession but integrating the moving images with static pictures, as drawings, schemes, tables, aside the picture-in picture technique, and besides the vocal descriptive comment. The cinema language has accustomed us to a series of passages among the different sequences as fading, cross-over, "flash-back", aiming to stimulate the psychological associative powers and encourage those critical. The video-tape can be opportunely shortened, paying attention to show only the essential phases of the operation for demonstrate only the core of the problem and utilize at the best the physiological period of active attention of the observer. The informatic digital elaboration has become so easy that the surgeon himself can be able to elaborate personally on his personal computer, with professional and scientific attitude, the sequences of his surgical activity in a product of more general value. His personal engagement also in the phase of post-production gives him the possibility to demonstrate uprightly with images the complex surgical experience of science, skill and ability to communicate, perhaps better than he is able to do with words.

[Guideline concepts of the present-day surgery in breast cancer]

The more important trends of nowadays surgery for breast cancer are those of an advanced rationalization of combined strategies in a multidisciplinary view. Moreover it takes advantages from the availability of an extremely modern diagnostic instrumentation used in search of a truly early diagnosis, based on scheduled screening and surveillance criteria both for general population and particularly for that at risk. In this way it is easier and possible to adopt less radical and more conservative surgical techniques, whose effectiveness is well demonstrated in association with adjuvant treatment thanks to the convergence of multiple competences. The better results of the last years are certainly related to the collaboration of surgeons with oncologists, thanks to the ever more effectiveness of adjuvant chemo- and radiotherapy, that make more acceptable the attitude for the reconstructive and the conservative surgery whenever possible. This interpretation of the actual positive results of breast cancer surgery point the way to follow, and are the basis for hoping further improvement in the treatment of this disease, ever more efficacious whilst that diagnosis precocious be more and more.

Perspectives of scientific publications of surgery in Italy. Perspectives on the article of M. Rubino and Al. "Types of surgical articles. Comparative analysis of three Italian and three foreign journals"

The globalization of the information and the wide use of the English language in the scientific world impose a not avoidable comparison to the scientific Italian journals, but with value indicators that if accepted without criticism could humble the undeniable internal values. In fact such comparison is based certainly on the quality of the contents, but it has already as background parameter the language of publication if the aim is that of an adequate diffusion. The questions that rise from the analysis of the problem are essentially two: if there is still room nowadays for surgical scientific publications in Italian language and if it is correct to accept in a closed box the indicator of international comparison conditioned by the English language, with the consequence that the definite value judgement is entrusted to external opinions. Certainly the Italian journals of surgery must aim both to quality and to their diffusion for reaffirm and validate their cultural rights. The quality depends on the authors and on the surgical environment in which they operate, beyond the engagement of the scientific direction of the journal; the diffusion on the correct employment of the English language, at last of the abstracts, and on the general editorial strategy pointing to encourage and promote the widest coverage of critique. It remains but to bravely loose the knot represented from the proposal of a uncritical acceptance of the indicator of the IMPACT FACTOR with the consequent absolute judge of quality, that fatally depends from an egemonic Anglo-Saxon filter, not exempt from an unavoidable lobbystic imprint.

[Adrenal incidentaloma: a dopamine-secreting pheochromocytoma with an atypical clinical picture. A case report and review of the literature]

INTRODUCTION

The increasing and consolidated uses of US and CT scan in the diagnosis of abdominal diseases has improved the detection of adrenal asymptomatic masses. Current literature points out that these nodules are identified by 1:100 abdominal CT every year. On the other hand, about 50% of the adrenal tumors are discovered by autopsy. The diagnostic difficulties may be due both to clinical silence and to atypical clinical expressions of the neoplasm--as in the case report--where a pheochromocytoma shows non-specific abdominal symptoms rather than the typical signs of catecholamine overproduction.

CASE REPORT

Author,s report a suprarenal right pheochromocytoma, secreting dopamine prevalently. The tumor showed abdominal symptoms without history of hypertensive paroxysms, or better still in normotension regimen.

DISCUSSION AND CONCLUSIONS

According to current literature, abdominal symptoms occur in about 7% of all suprarenal pheochromocytomas. Most of these tumors prevalently secrete dopamine, that seems to make the prognosis worse. US, CT scan and CT-guided fine needle biopsy weren't able to characterize the real nature of the adrenal incidentaloma. On the contrary, the hormonal screening--by monitoring the urinary VMA and fractioned catecholamines through 24 hours--was decisive for the diagnosis of pheochromocytoma. The adrenal incidentalomas diagnostic significance is tied to the concept that adrenalectomy can change their prognosis, especially in case of pheochromocytoma, where a recovery rate about 90% can be achieved. Authors agree that adrenalectomy my must be performed in all case of "functioning" adrenal tumors and "nonfunctioning" ones with > 6 cm size. Of last years the laparoscopic approach has extended the adrenalectomy's indications to mass with size ranging between 3 and 6 cm., while lesions < 3 cm. size require only a follow up by means of imaging techniques and hormonal monitoring.

[Diagnostic and oncologic updating on gallbladder papilloma. Personal experience and review of the literature]

After a correct definition of the pathologic meaning of "papilloma of gallbladder" and the considerations about the main epidemiologic, pathogenetic and diagnostic guidelines, the authors discuss the meaning of the apparent higher frequency of this pathology in the biliary tract than in the gallbladder localization. This condition probably derives from the precocious appearance of pain or jaundice during choledocal pathology respects to the asymptomatic gallbladder localization. Moreover, using morphological indicators of intracholecistic ultrasonography, the gallbladder's polypoid lesions are divided in group s and for each of the m are indicate d most/actual curative criteria. Currently tendency is to check periodically gallbladder polypoid lesions, and to recure to surgery when the lesion result large more than 1 cm, single, associated with stones, when the patient is older than 50 years and when there is a clear clinical symptomatology. Finally, the authors discuss the malignance evolution of these lesions attaching importance as prognostic role to the study of the K-ras and p-53 proto-oncogenes, because they consider the carcinogenesis like a "multi-step" evolution.

[Epidermoid carcinoma of the thyroid]

About thyroid neoplasms the epidermoidal carcinoma represents an ingrown minority (0.3-0.74%). Several etiopathological hypotheses are considered and this testifies the notable uncertainty that still winds the origin of the neoplasm. In the actual case, the more accredited hypothesis foresees the origin of the neoplasm from a histopathological of Hashimotos' tyhroiditis. The objectivity of the case in examination constitutes the clinical picture of reference of the malignant neoplasms of the thyroid: oligosintomatic low cervical mass of increased consistence, adherent to the imminent pianos strictly following laryngeal movements, dysfagia and dysfonia. Additionally they were present pulmonary and right cervical lymphonodal metastases. After an adjuvant treatment with Paraplatin and 5-FU, to some months from the intervention of total thyroidectomy, local relapse in form of a festered mass is highlighted in sovrajugular region with result in cutaneous-esophagustracheal fistula. The diagnosis of certainty of the neoplasm, despite the rarity, it doesn't constitute a problem, albeit the percents of survival, anyway substantially more favorable respect to anaplastic neoplasms, concerning to as numerical as chronological aspects, result to be hardly discouraging.

[Deep parotidectomy with conservation of pre-neural tissue in the surgery for Warthin tumor]

The perfect acquaintance of the surgical anatomy of the parotid region associated to the rigid execution of the operative times by now standardized for the interventions on the parotid gland, they constitute a solid base of certainty on which found the own surgical choices. In some cases it's possible going away from the established rules to follow the impulses that the personal instinct suggests in the attempt of overcome unusual technical difficulty. The case in examination constitutes the tangible example to this enunciated, in which the technical difficulty of a neoplastic subneural bulk--the comfort on whose benignity arose from a preoperative FNAB (often but not always secure on the real histological nature)--that it could not be enucleated without dissect the trunk of the facial nerve, it imposed the adoption of technical extemporaneous solutions which, since dictate from the necessity of the moment, must not be recommended like rules to follow in all the situations, neither judged as rash surgical choices.

Modern surgical technique for thyroidectomy

Extracapsular lobectomy or total thyroidectomy are the surgical techniques normally used to deal with either benign or malignant thyroid diseases needing surgery. Both the well-known pathogenesis of benign surgical pathology and the positive role of post-operative radiometabolic treatment for differentiated carcinomas justify this surgical approach. Of course a complete understanding of anatomic structures and skilled operative techniques are necessary. The thyroid's parenchyma preventive extracapsular devascularization allows a strictly bloodless operative field, which makes it easier to preserve both the superior and inferior laryngeal nerves and the parathyroid glands of both sides. Therefore this procedure can be primarily considered a "vascular" technique. Our surgical technique is thoroughly described here, stressing anatomical landmarks and surgical steps, and maintaining awareness of pathophysiological implications and related operative choices.

[Oncologic "second-look" today]

The Wangensteen's proposal of the SLL is far from us, not only chronologically but, what is more meaningful, technologically. Radiology, with its digestive tract barium meal or enema, was at his time the only mean entrusted for the instrumental study of the patient, and the medical oncology was at its very dawn. The Wangensteen's purpose was to discover with a SLL the recurrence (metastasis or relapse) of the neoplastic disease after a first demolitive surgical approach, not waiting its late clinical evidence. And this on the conviction that also the recurrent neoplastic disease can be again successfully treated by surgery when early detected. Many facts have happened since the 50's, and if it is by now demonstrated true that also the neoplastic recurrence can be successfully treated by surgery--naturally for particular neoplasms and in particular localization--it is equally true that diagnostic possibilities have widely evolved permitting the non invasive detection and localization of neoplastic recurrences with remarkable accuracy. Thence the renewed possibility of a reinterventional surgery.

[Bilateral aneurysms of the popliteal artery]

INTRODUCTION

Popliteal artery aneurysms are the most common of peripheral arterial aneurysms. Popliteal aneurysms are bilateral in 42% of patients. Atherosclerosis and bacterial invasion of the arterial wall are the predominant etiologic factors of popliteal artery aneurysms.

CLINICAL CASE

A male of 67 years old was referred to our institution for bilateral claudication and 150 m. free interval. The angiogram showed a partial occluded aneurysm of the right popliteal artery and a complete thrombosis of the left popliteal artery aneurysms. The left aneurysm was resected and a femoral popliteal by-pass was performed, using the inverted saphenous vein graft, associated with left lumbar sympathectomy. Six months later the contralateral aneurysm was excised and a Dacron femoro-popliteal by-pass graft was performed. Two years later Arteriographic and Doppler examination showed patent by-pass bilaterally.

CONCLUSION

Popliteal artery aneurysms can be a threaten for the lower limbs, because of thromboembolic phenomena and occasional rupture. Surgery is the best treatment before the appearance of an acute complication and a by-pass with an autogenous vein graft or a Dacron graft are the most common surgical procedures performed. Thrombolytic therapy offers good results where an acute complication appears.

[Injury of the popliteal artery & the popliteal branches: analysis of 31 consecutive cases]

In complex traumas of lower limbs it is fundamental the reducing of the time of ischemia to reduce the number of failures in repairing surgery and the percentage of the demolishing of necessity surgery. The experience of the authors is based on 31 complex traumas of lower limbs with distal vascular injuries to Hunter's canal, which were associated to bone, nervous and muscular lesions. In total we are treated 37 vascular injuries by interposition of venous autografts in 37 cases, lateral pacth in one case ant suture T-T in two cases. The protection of the reconstructed vases, in case of a concomitant loss of substance, was entrused to microvascular flaps for 7 times latissimus dorsi, iliac crest and fascio-cutaneous for 5 times posterior reversed with distal baset and for three times antero-lateral, which in three cases of them needed successively a dermoepidermic grafts. The bone injuries, which were treated by external fixation, intramedullary nailing, plate and screws, just in two cases became worse in pseudoarthroses and just in one in osteomyelitis. The reparation of nervous injuries had bad results just in two cases. The percentage of saving of the limb it was about 83.9%.

[Renal angiomyolipoma causing an acute abdomen]

Herewith referred a case of renal angiomyolipoma relieved on a patient of 62. The new involvement has been found following an evidence of a keen syntomathology related by a steep abdominal ache centred above all on the right hypocondrium followed by a general light ache. The ecography and the "TAC" on the bely have showed a new enlarged involvement, centred on the hypocondrium and on the right oval side of a diameter of nearly 35 cm, that moved anteriorly the right renal, with an involvement of a perirenal hematoma. The surgery has ended with a nephrectomy with the drop of the involvement on the renal tissue and the emorragical enlargement which has allowed a local nephrectomy and therefore to resume the organon as a new growth not dangerous. The histological diagnosis separated on the renal carcinoma han been possible with certainty only examining cruently the area after a tumorectomia, but the general clinical course and the evidence of the angioTAC had been realized towards the exact diagnosis.

[Significance of antibiotic prophylaxis in infection prevention in biliary surgery. Personal experience]

Postoperative infections are one of the most frequent causes of morbidity in surgical patients. In biliary tract surgery the risk of septic complications is essentially increased by opening the bile ducts. Aim of this paper is to evaluate indications and effectiveness of short-term prophylaxis in preventing infective complications of biliary surgery. Authors report a personal six years review regarding 530 patients operated for biliary tract diseases. The patients were divided into two groups: the first one (n. 245) operated under short-term prophylaxis; the second one (n. 285) treated only postoperativelly with antibiotics. The results obtained show a significatively higher rate of infective complications in the second group of patients. There is a little difference between the groups in the case of elective cholecystectomy, whereas there is a great difference in case of non-elective surgery, bile ducts opening, external biliary drainages placement or sphincteropapillotomy. Authors furthermore emphasize how surgical results are conditioned by individual risk factors, especially obesity and diabetes.

[The distal pedicle fasciocutaneous flaps of the leg. Analysis of 21 cases of lower limb reconstruction]

The fascio-cutaneous flaps with distal pedicle, with the new discoveries on fascial and septal circulation of the lower limbs, are a valid reconstructing method for the loss of substance localized on the third inferior of the leg and in the heel's region. In 21 patients, 18 men and 3 women, fascio-cutaneous flaps were employed for the traumatic loss of substance, just in two cases consequentially to removal of maligns lesions, all of them were omolaterals except in three cases in which cross-leg were used. The results are satisfying if we remember that just in two cases we had partial necrosis and in other two cases we had to reinstate the flap which had survived just in his deep position. The advantages of using this technique are supported by his good results and simple execution, realising anyhow that complicated or contaminated trumas need more complex plastic reconstruction.

[Acute non-calculous cholecystitis: rationale for absolute emergency cholecystectomy]

The authors report a case of biliary peritonitis in acute perforated alithiasic cholecystitis and they highlight the opportunity to consider the acute alithiasic cholecystitis as an absolute emergency, both for the pathogenetic prenits and the coon association with other pathologies that represent adjunctive risk factors.

[Surgical choices and approaches in treating tumor metastases]

In oncology metastatization modifies the prognosis and the quality of life of patients. Otherwise metastases are apt to make the surgeon to modify in many cases his operative decisions, and moreover means and times of the demolitive surgical procedures for curative purpose. Namely the presence of metastases at the diagnosis is not necessarily the cause of a refusal for potentially curative operations, both for sincrone or methacrone metastases, because there are still possible, also if less frequently, the hopes of success, especially if they are localized in particular target organs. Actual knowledge about pathogenesis of metastases during surgical procedures, induces us to adopt particular caution in demolitive operations, to avoid the risk that surgery facilitate their insurgence or dissemination. Finally the clinically primitive metastases pose diagnostic problems minimally different from what was the current strategy previously. The study consider these various facets of the problem, on the basis of personal experience and of literature data, and proposes operative protocols that are actually generally accepted.

[Localization of preclinical nonpalpable lesions of the breast]

The discovery of mammary neoplastic node in a preclinical stage, most of all not yet palpable, represents the best chance for the surgeon to obtain a real curative exeresis therapy retaining also gland's aesthetics. This kind of situation is more frequent today, because the increased utilization of mammography, ultrasonography and their matched use with the aim to investigate into a population of women with a specific risk. In fact, their sequential use offers the best possibilities of a real earlier diagnosis. In this event the conservative surgical treatment ranks its best curative and aesthetic result. The author's target, based on their own experience, outcomes the comparison between mammography and ultrasonography, pointing out a reliability of the latter similar to the mammography's one upon a specific target at least. The other aspect considered is the possibility of a preoperative localization of the neoplasm using different kind of marks to get the radical tumour exeresis centred on the suspect mass and conservative at its best. The experience suggests more usefulness of metallic marks strung down mammography control, even without using radio-stereotaxic that permits a higher precision but needs adequate facilities with unavoidable more elevated costs. It is finally layed emphasis on the importance of identifying a population at risk to logically utilize, and not indiscriminately, the most modern diagnostic resources.

[Scleronodular retrosternal Hodgkin's disease with cervical protrusion]

The case of a retrosternal localization of Hodgkin disease is a very infrequent one, and its presentation as an inflammatory tumor is exceptional indeed. This case report of a young woman affected by a cervical tumour projecting in front of the sternal bone, both with fever and tenderness, gave a mistaken address toward a diagnosis of suppurative thyroiditis. But the rare evenience of this thyroidal affection made the diagnosis very improbable and the patient was treated by partial exeresis of the cervical mass and drainage of its apparently suppurative content. At the pathologic study the mass revealed its true nature, also if very unusual: the appearance of the specimen, studied also with immuno-chemical methods, revealed its true nature of scleronodular Hodgkin disease probably born on a thymic cyst remnant. Also the possibility of a suppurative evolution from a pyriform laryngeal sinus is discussed, but simply on a differential diagnostic basis for the original hypothesis of an inflammatory mass. The correct diagnosis instead offered the patient the possibility of the correct chemo-radio-therapeutic treatment and of final cure.

[The role of endoscopy in managing esophageal lesions caused by caustic fluids]

In the paper is described the chronological outline adopted from the authors about the endoscopic treatment in case of oesophageal caustications, both in the emergency and, respectively, after one week and after one month. It is emphasized the importance of an endoscopic recognition within 6/12 hours after the caustic ingestion, to prevent the immediate acute complications, the later acute complications and the scarring evolutions of the healing. Important parameter for a clinical evaluation is represented by the volontariety of ingestion to which is connected the quantity of ingested caustic and than the extension of oesophageal lesions.

[The epidemiology of gallbladder cancer in Italy. ISTAT data 1970-1987]

The Italian surgeon needs to know the real situation about gallbladder carcinoma in Italy, his professional field of action: real incidence, sex and age characteristics and regional distribution with useful correlations to define the risk population. We can use nowadays the ISTAT data (since 1969 also in magnetic tape) about such neoplasia, based on death denunces. These differentiate gallbladder carcinoma from others hepatobiliary neoplasms and are referred to the whole national territory and allow and analyze for the various regions a period of 18 years (from 1970 to 1987). We have therefore the facility of a statistical index which give us the possibility to compare directly the specific mortality taxes between very different regions of residence from the point of view of population density, sex and age distribution on each year of the period considered. Also in Italy incidence of gallbladder carcinoma shows an absolute and relative increasing with age in both sexes, reaching the peak in the seventy's, with a M/F rate between 1/3 to 1/2, and with global incidence that is increasing in the last years. Risk factors could be in the age older than 50 years, in the females, in the long standing gallbladder lithiasis with wide cholesterinic stones on the basis of a chronic inflammation and consequent dysplasia, in the diet more far from the mediterranean's, and finally in papillomas and papillomatosis of gallbladder.

[Reconstructive treatment with multiple tissue expanders after an extensive skin burn of the lower extremity]

The paper refers to an experience of skin reconstruction of a widely damaged lower limb as result of a hot water burn injury in a young girl. Evidence is given to adopted reconstruction times, and to the decision not to recur to flap transposition by skin innests, but to the tissue expansion technique, also to avoid new aesthetic damages. The peculiarity of the experience is in the employment of a multiple number of tissues expander, to meet characteristic problems of the limbs related to this reconstructive technique, particularly in presence of heavy burn scars. It is also widely illustrated the operatory phases and times which are necessary to obtain an optimal functional result, with very satisfying aesthetic final appearance.

[Nutritional treatment in the therapeutic strategy in benign esophageal stenosis]

Oesophageal strictures prevent a normal alimentation, and in chronic and more prolonged cases are the cause of severe denutrition. Many organs then undergo changes reflected on ultrastructural morphology, that in most severe and lasting cases can demonstrate irreversible. The functional aspect of such changes correspond to a hindered performance of the damaged organs with possible sudden cardiovascular accidents, which are particularly meaningful in the surgical steps of reconstruction, that is heavy for the patient not only in the perioperative period but also during the recovery when higher are the caloric energetic requirements. For the positive outcome of the surgical therapy of these strictures it is therefore necessary to preventively restore an acceptable nutritional status of the patient by the use of one or more of the nowadays available techniques of artificial nutrition. A particular topic of the need of a efficacious nutritional treatment can be pointed in the cases of oesophageal caustic burns, where the caloric requirements is high since the beginning to meet the catabolic effects of the traumatic condition, while malnutrition represents one of the negative factors in prolonging connettival and fibroblastic proliferation, cause of most severe strictures and recurrences. After a general survey of the whole problem, the characteristics of the various artificial nutrition techniques are discussed, with the identification of an optimal scheme of global and nutritional treatment in oesophageal caustic burns.

[Clinical research on the possibility that renal cysts may be responsible for the appearance of hematuria]

New techniques of study, namely echography, urography, TC, give evidence of a great number of asymptomatic renal cysts in the everyday experience. Then also if haematuria was classically considered one of the symptoms of renal cysts, there are now many reasons to consider such evidence very infrequent, and downright there are some valid doubts that renal cysts may cause haematuria at all. So the authors have analysed 113 patients, most of them coming from Institute of Radiology of Chieti University Faculty of Medicine; all of them had renal cysts diagnosed by echographs and/or urography but only a minority were just from the beginning studied for haematuria, whereas the majority for many different symptoms. Total cases was then divided into two groups: one of 102 patients, all without haematuria; 78 of them had been studied only with echography, whereas other 24 patients had been examined both with echography and urography. The second group, of 11 cases, included all the patients who had both renal cysts and haematuria. Only in two cases of this second group was lacking evidence of any associated pathology which must be responsible for haematuria, whereas in all the other 9 cases a different aetiology of the haematuria was demonstrated, for simultaneous presence of various pathologies (cystopyelitis with associated prostatis, haemorrhagic cystitis, bladder diverticula and renal papillomas and upper urinary ways tumours), all much easier responsible by themselves of haematuria, also if with different features from case to case.(ABSTRACT TRUNCATED AT 250 WORDS)

[Direct exeresis of adenoma of the parathyroid glands]

The only therapy for primary hyperparathyroidism (PHPT) is total surgical removal of all parathyroid tissue responsible for hypersecretion. The biggest difficulty for such treatment is the preoperative differential diagnosis between simple parathyroid adenoma (incidence up to 85-90% of PHPT) and diffuse gland hyperplasia (incidence up to 50% of PHPT). Total removal of all parathyroid tissue is not only needless if the aetiology of the syndrome is a simple adenoma, but moreover it is responsible of a completely unnecessary and deeply disabling hypoparathyroidism. It is therefore of the utmost importance to make any preoperative effort for an accurate aetiological diagnosis, and to try the exact localization of the eventually responsible adenoma with all modern diagnostic tools. In spite of any preoperative effort very often the resolution of such problem must be relied to the surgical exploration of all sites of possible hyperplastic gland, with intraoperative hystological study of multiple biopsies. But only a relative help comes from peroperative biopsy, because it is not so easy to reach intraoperatively an hystological certainty in discriminating between hyperplastic and adenomatous tissue on fresh specimens. In the case report a single adenoma of the right lower parathyroid was localized preoperatively with combined researches, mainly with echography, and its surgical removal demonstrated curative at all. The massive lithiasis of left residual kidney was then successfully treated by shock waves. Echography can give therefore a relevant help in preoperative diagnostics of a parathyroid adenoma; is foreseeable its useful employment also intraoperatively, avoiding so an extensive bilateral dissection of all parathyroid sites, responsible of postoperative scarring that hinders any postoperative morphological control and makes dangerous any neck reintervention.

[Rare malformation of the bile ducts of surgical interest]

Variations from normal anatomy of extrahepatic biliary tract, especially if on the basis of a congenital defect, are often dangerous for the surgeon, as hidden cause of a possible injury during surgery. During a cholecystectomy performed for lithiasis in non functioning gallbladder, whose preoperative cholangiogram revealed nothing of suspect, the dissection of cystic duct was regular at its normal junction with the Common Bile Duct (CBD). Because of the scheduled intraoperative cholangiogram, it was however not severed but only dissected free. The gallbladder was therefore detached from the liver in anterograde progression, after hemostasis and section of a normal cystic artery. During the detaching of gallbladder from the liver what seemed a very large "hepato-cystic" duct coming to the infundibulum was met: for caution the cholangiogram was then made proximally to such "hepato-cystic" duct that instead revealed to be the main right hepatic duct coming to the infundibulum of gallbladder without confluence with the left hepatic duct. The biliary tract going from the gallbladder to the supposed CBD was in fact the cystic duct, as the Heister's valvulae clearly show on the cholangiograms. Cholecystectomy was therefore performed proximally to the confluence of right hepatic duct, and the postoperative course was uneventful. Such kind of extrahepatic tract derangement must be very rare, because of the apparent lacking in literature of any similar case, also if the possibility is mentioned.(ABSTRACT TRUNCATED AT 250 WORDS)

[Correlation between post-cholecystectomy syndrome and biliary reflux gastritis. Endoscopic study]

Experimental reports have proved that bile acids damage the gastric mucosa. Moreover it is now accepted that duodenogastric reflux occurs in 20-30% of cholecystectomized persons. The Authors, with the purpose of defining a correlation between gastric mucosa damage by duodeno-gastric reflux and postcholecystectomy syndrome have taken into consideration two groups of 14 patients each. To the first group belonged cholecystectomized patients, who had episodic, often postprandial pain, constant heart burn, with associated vomiting and Hypochromic anemia. To the second group belonged asymptomatic patients with previous cholecystectomy. All these patients were endoscoped (EGDS), and their endoscopic biopsy specimens were surveyed. 99Tc HIDA cholescintigraphy was performed in all the groups of patients, after endoscopy. In 85% of symptomatic patients we found, during endoscopy, reflux of bile into the stomach with associated reddish and inflammatory change of antral mucosa vs. 7.14% of the control group. Atrophic chronic gastritis was found in 71.43% of endoscopic biopsy specimens of Symptomatic vs. 14.28% of asymptomatic patients. Superficial chronic gastritis was found in 28.57% of symptomatic vs. 50% of asymptomatic patients. At last we found active atrophic or superficial antral gastritis (Whitehead) in 90% of symptomatic patients vs. 0% of asymptomatic people. The Authors conclude that there is a positive correlation between duodenogastric reflux and postcholecystectomy syndrome when biliary reflux is correlated with an histological finding of antral active chronic gastritis.

[Diagnostic, prognostic and therapeutic problems of cystic pneumatosis of the colon]

Two cases of cystic pneumatosis of the colon raised clinical problems that were mainly concerned with the diagnostic difficulties posed by this disease. These can only be solved by correct employment of radiology and endoscopy. Reference is made to the proper therapeutic approach, which must be moderate and conservative in all cases. An account is given of the pathogenesis of this form and support is expressed for the most commonly held theory, namely that mechanical factors are responsible for the penetration of air into the wall of the intestine.

[Arteriovenous fistulas]

Three cases of arteriovenous fistulae observed in recent years at the University of Rome's 3rd Surgical Clinic, and of different site, entity are aetiology, are presented. The recent international literature is reviewed and the more outstanding clinical and therapeutical features of this form are discussed.

[Criteria of surgical treatment in 148 cases of recto-sigmoid cancer]

The clinical aspects of cancer of the rectum and sigmoid colon are discussed, and stress is laid on the importance of symptomatological, radiological and endoscopical examination, including biopsy. A description is given of the surgical criteria employed in 148 cases, with particular attention to the indications for anterior resection of the rectum and abdominoperineal amputation of the rectum according to Miles.