Neck node dissection in thyroid cancer. A review

INTRODUCTION

thyroid cancer recurs most commonly in one or more cervical lymph nodes. Surgical treatment for differentiated or medullary thyroid carcinoma consists of total thyroidectomy (TT). The aim is to elucidate the potential benefits and drawbacks of neck dissection TT related.

MATERIALS AND METHODS

differences between therapeutic and prophylactic neck dissection were analysed to prevent post-operative morbidity, neck recurrences and improve survival.

DISCUSSION

there is considerable controversy regarding the treatment of patients with cervical node metastases specially in differentiated thyroid cancer. Considering that a neck dissection might help to reduce local recurrence, especially in medullary carcinoma, controversial remains regarding the modality and extension of cervical dissection. There are several surgical strategies to cervical lymphadenectomy as a prophylactic node dissection or a dissection only in symptomatic patients or the "node-picking" technique for selective lymphadenectomy or sentinel node biopsy. So it is possible to employ several kind of neck-node compartment related dissection. The risk of iatrogenic lesion during neck dissection is relatively high specially for nerve structures (i.e.: recurrent laryngeal nerve or spinal accessory nerve), so an experienced surgeon must mind the risk is higher during a re-operation in an anatomical subverted region.

CONCLUSIONS

the extent of dissection and the experience of the surgeon both play important roles in determining the risk of surgical complications and recurrence. The decision to add neck dissection to total thyroidectomy weighed against documented benefits and risks. Injuries may also occur as a result of inadequate technique or as a result of poor expertise of the surgeon. We believe that deep knowledge of the thyroid region's surgical anatomy is necessary to realize a skilled and careful surgery of the neck.

[Role of ERCP in the era of videolaparoscopic cholecystectomy. Personal experience]

INTRODUCTION

In subjects operated by videolaparoscopic cholecystectomy (VLC) incidence of synchronous cholecysto-choledochal stones is 7-20%. Aim of the study is to report our experience in endoscopic treatment of common bile duct (CBD) stones before VLC (sequential treatment).

PATIENTS AND METHODS

From January 2001 to May 2007, 189 ERCP for synchronous cholecysto-choledochal stones were performed with analgo-sedation. In selected cases antibiotics and protease inhibitors were used.

RESULTS

CBD clearance was 100%. The incidence of complications (mild, moderate and severe) was 8.2%, mortality 0.53% (1 patient). We observed 31 cases of transient asymptomatic hyperamilasemia (16.4%). A total of 186 subjects were operated by VLC, with only 3 conversion, without procedure-related mortality.

CONCLUSIONS

In our opinion, the best treatment of syncronous cholecisto-choledochal stones is related to available tools and human experience, but for an experienced surgical and endoscopic team the sequential approach is feasible, safe and effective.

[Complications of elective esophago-gastro-duodenoscopy (EGDS). Personal experience and literature review]

INTRODUCTION

Although upper gastrointestinal (GI) endoscopy is reasonably safe, it is not perfectly so. The complication rate is about 0.1% for EGDS. Aim of this study is to schedule and evaluate all possible complications, starting from personal experience in Operative Unit of Surgical Endoscopy.

PATIENTS AND METHODS

We evaluated all EGDS performed at the Operative Unit of Surgical Endoscopy of Policlinico in Palermo between January 2000 and January 2008. A single staff of endoscopists performed diagnostic and therapeutic exam. All complications were tabulated and scheduled to identify possible risk factors or indicators procedure- or patient-related.

RESULTS

5.258 patients (43.6 %) experienced temporary and self-limiting hypoxia (SaO2 < 85%); we report totally 18 complications (0.15%), according to literature data: 2 hypopharinx perforations (0.016%), 2 middle esophagus perforation (either with death of patients = 0.016%), 3 post-biopsy hematomas of the gastric wall (0.02%) and 2 duodenal wall (0.016%) 6 (0.04%) post-polypectomy bleeding, 1 abscess post-percutaneous endoscopic gastrostomy (PEG) (0.008%) and 1 accidentally PEG remove (0.008%).

DISCUSSION

EGDS-related complications may occur and cannot be prevented completely even in expert hands however, early recognition and proper management will lead to better outcome. Because of the complexity of endoscopic procedures has increased, endoscopists need to be aware of all possible procedure-related complications and should use strategies to minimize it.

CONCLUSIONS

Endoscopic complications will inevitably occur if an endoscopist does many procedures. The knowledge of potential complications and their expected frequency can lead to improved risk-benefit analysis by physicians and patients as well as true informed consent by patients. Early recognition of complications and prompt intervention may minimize patient morbidity.

[Endoscopic surveillance of colon-rectum in the narrow band imaging era]

BACKGROUND AND AIMS

Colonoscopic surveillance is an established method of colorectal cancer (CRC) screening that reduces death rates, but has an adenoma miss rate of 10-20%. Narrow band imaging (NBI), a novel endoscopic technology, highlights superficial mucosal capillaries and improves contrast for small adenomas. This study evaluated the role of NBI in the improving colon adenoma detection.

PATIENTS AND METHODS

White light colonoscope was compared with NBI for adenoma detection during colonoscopy. 120 patients presenting for diagnostic colonoscopy were randomly assigned to undergo colonoscopy using either conventional white light or NBI colonscope during instrument withdrawal. The outcome parameter was the difference in the adenoma detection rate between the two techniques. All polyps detected were removed for histopathological analysis.

RESULTS

Adenomas were detected more frequently in the NBI group (51) than in the control group (49); however, the difference was not statistically significant (p = 0.128). The extubation time was significatively longer in the NBI group (p = 0.003).

CONCLUSIONS

In our experience, the NBI did not increased the adenomas detection rate compared to white light by an endoscopist with a known high detection rate using white light.

Acute onset of esophageal duplication cyst in adult. Case report

INTRODUCTION

Esophageal duplication (ED) cyst is unusual congenital disorder of the foregut, accounting for 10% to 15% of duplications of all foregut cysts. We report a case of esophageal duplication with acute clinical presentation, treated successfully with surgical resection.

CASE REPORT

46-year-old man with acute dysphagia and gastroesophageal reflux of 2 weeks duration, showed submucosal bulging mass in the posterior wall of the middle third of oesophagus, fluid-filled cystic structure, dyshomogeneous, low-attenuation mass with smooth borders compatible with an hemorrhagic esophageal duplication cyst. With the suspect of acute presentation of a complicated esophageal cyst, the patient underwent surgery by right posterolateral thoracotomy. A gastrografin esophagogram was performed on third postoperative day and showed no leaks.

DISCUSSION

Up to 80% of the esophageal duplication cysts are diagnosed in childhood and the majority of young patients develop symptoms, while symptomatic cyst into adult life is very rare (<7%). Acute onset is generally due to complications, i.e. intracystic hemorrhage, perforation, and infection, especially of the cyst with esophageal communication. Complete surgical excision by thoracotomy or thoracoscopy is the therapy of choice even if the patient is asymptomatic because of the risk of complications such as aspiration and bleeding.

CONCLUSIONS

The diagnosis and treatment of esophageal cysts is still evolving. The pathological diagnosis of oesophageal duplication requires the presence of the Ladd and Gross criteria. The infrequent acute onset doesn't modify the management and the surgical resection is the procedure of choice. The future of the treatment of esophageal cysts lies in the advancement of minimally invasive operative techniques.

[Mechanical versus manual anastomoses in colorectal surgery. Personal experience]

BACKGROUND

The diffusion in the years '80 of the stapler has modified the habits of the surgeons, determining the reduction of the operative time in colorectal surgery and the possibility to operate cancer of lower rectum, but leaving unchanged the rates of postoperative complications and bringing to the footlights some new complications. Aim of paper is to report our experience about of mechanical sutures in the colorectal anastomoses, with particular attention to the risk factors and complications procedure-related.

PATIENTS AND METHOD

From January 2000 to January 2006 in the Section of General and Thoracic Surgery of the University in Palermo, 26 stapled colorectal anastomosis and 11 mechanical terminal colostomies after Miles' amputation have been performed; 12 patients have been submitted to low colorectal termino-terminal anastomosis, 6 to termino-terminal ultralow anastomosis, 1 to coloanal anastomosis and 7 to Knight-Griffen technique.

RESULTS

We registered 2 anastomotic dehiscences (8%), 3 (12%) anastomotic bleeding and one anastomotic stenosis (4%) 12 months after surgery. No mortality procedure-related took place.

DISCUSSION

From the literature review emerges the absence of statistically differences between manual and mechanical suture in the colorectal anastomosis in terms of mortality, morbidity (clinical and radiological incidence of the anastomotic gaps, anastomotic stenosis, redo, bleeding, infection of the wound) of employed time to make the anastomosis and of staying in hospital. These data are from American Schools, while greater incidence of radiological leakage is recorded in the European schools is for the manual suture.

CONCLUSIONS

At present does not exist clinical trial that shows the superiority of mechanical stapling versus manual suture in the colorectal anastomosis. Stapler makes possible the lower colo-rectal anastomosis often avoiding abdomino-perineal amputation of the rectum, with better quality of life and oncological radicality, but increasing however the incidence of complications as anastomotic dehiscence and stenosis, even if not statistically significant.

The importance of pyramidal lobe in thyroid surgery

INTRODUCTION

Pyramidal lobe (PL) is an embryological remnant of the thyro-glossal duct; its incidence varies from 15% to 75% but data concerning its size are lacking and limited to autoptic and radiologic evidences. Aim of our study is to elucidate the intraoperative frequency, location and surgical management of the PL.

PATIENTS AND METHODS

604 total thyroidectomy were performed between 1999 and 2007 in Unit of General and Thoracic Surgery of the University Policlinico of Palermo. The intraoperative incidence of PL was 12% (57% male, 43% female, mean age 42.5 years), but only about 50% were identified preoperatively with ultrasonography (US) (4% false positive) or with Tc-99m pertechnetate scintigraphy (8% false positive).

RESULTS

In 77% of cases the lobe was affected by nodular pathology in multinodular goiter, in 1.3% by papillary cancer; in the rest of cases was normal. PL branched off more frequently from the left part of the isthmus (96%) than from the right part (4%) and in 25% of cases was associated with delphian lymph node. No PL exceeded 2 cm in length in pathologic specimen. There was no difference in thyroidectomy operative time with or without PL. At US, scintigraphic and laboratory follow-up (2 months-8 years), no incomplete resection of the gland due to the presence of PL were recorded.

DISCUSSION

In anatomical studies the frequency of the PL is between 15% and 75%; PL is in 10-17% of normal subject and in 43% of patients with multinodular goiter. The PL is of great importance to the thyroid surgeon during thyroidectomy: it is crucial to look for, identify, and remove the PL, as this can be a cause of incomplete resection of the gland. If left behind in a patient who will require postoperative radioactive iodine, its presence will virtually nullify the anticipated benefit of I131 by absorbing most of the radioactive material; may exist relapse of cancer from PL left in situ.

CONCLUSIONS

The intraoperative frequence of PL is 12%, and it is considered a normal component of the thyroid. Scintigraphic visualization of the PL depends on the kind of thyroid disorder and on the experience of radiologist, so the PL can often not be diagnosed by scintigraphic imaging. Finally, the whole anterior cervical region has to be investigated very carefully during thyropidectomy not to overlook a long or thin pyramidal lobe or other ectopic thyroid tissue because actually doesn't exist the goldstandard preoperative method to diagnoses PL.

Endoscopic cytology in biliary strictures. Personal experience

INTRODUCTION

The differential diagnosis between malignant and benign biliary strictures is the cornerstone of the management of jaundiced patients. The aim of our study is to define the role of cytology of the bile withdrawn during endoscopic retrograde cholangiopancreatography (ERCP), to reach a diagnosis of the nature of biliary stricture.

PATIENTS AND METHODS

This retrospective study was conducted on 67 consecutive patients affected of ingravescent obstructive jaundice who underwent ERCP+/-PTE (percutaneous transhepatic endoscopic)+bile withdrawn+stenting. We founded hilar stricture in 21 patients (31.3%), middle third the common duct stricture in 17 (25.3%), and lower third stricture in 28 patients (41.4%). In one patient (2%) the cholangiography did not show any stricture, but we continued with the withdrawn of bile after positioning a naso-biliary drainage.

RESULTS

Diagnosis was made in only 40 of 65 patients (61.5%) and no epithelial lining cells of the biliary tree was found in the remaining 25 patients (38.5%). The presence of neoplasm in the pancreato-biliary tract was excluded (absence of malignant cells) in 25 of 40 diagnostic exams (62.5%). During follow-up only 7 of these 25 patients resulted in having a benign disease (true negatives 28%) while the remaining 18 cases were diagnosed with malignant neoplasm of the pancreato-biliary tract (false negatives 72%). Nine of 14 with positive cytology for carcinoma were diagnosed with cholangiocarcinoma (65%), 4 with pancreatic (28%) and 1 with ampullary carcinoma. Of 25 non-diagnostic samples, 5 (20%) resulted as benign, 20 (80%) as malignant. The statistical analysis by chi-square test allowed us to conclude that bile cytology, if diagnostic, is significantly valid in identifying carcinoma of the pancreato-biliary tract (p<0.05) instead, considering the high rate of non diagnostic samples, its meaning is limited (p=0.09).

DISCUSSION

Exfoliative cytology of bile samples obtained during ERCP is easier and less invasive method to determine the diagnosis of biliary strictures, but due to its low sensibility, varying from 6 to 63%, it doesn't appear accurate to establish a definite diagnosis; the stricture dilatation before the withdrawal increases the diagnostic sensibility and accuracy of the cytological exam.

CONCLUSION

Bile withdrawn for cytology during ERCP is a safe method with no increasing in patient's morbidity. It allows a diagnostic orientation in 75% of the patients. Bile withdrawn after dilatation of stricture allows improves sensibility and accuracy. Negative results does not exclude malignant disease, however, if positive, it is considered diagnostic (positive predictive value 100%).

[Thoracentesis and pleurodesis in the treatment of pleural effusion. Personal experience]

AIM

The pleural effusion is a sign of pulmonary, pleural or extrapulmonary, benign or malignant pathology. Our aim is to bring our experience on the treatment of the malignant pleural effusion through thoracentesis and successive pleurodesis.

PATIENTS AND METHODS

From January 2000 to January 2007 we performed 217 thoracentesis of which 123 (57%) in subjects with malignant pleural effusion. In 92 of 123 subjects (75%) we performed a drainage with small size thoracic tube to realize directly the pleurodesis with sterile des-asbestos talc.

RESULTS

None complication was registered during and after thoracentesis and pleurodesis and no mortality was recorded. We usually used talc slurry technique. Relapse rate after first treatment was of 12.2%.

CONCLUSIONS

The pleural effusion is a pathological condition that usually needs repeated operative procedures with serious danger for the patient, however without definitive results. On the basis of our experience and considering the characteristics of sclerosing agents, we conclude that the sure, effective and economic agent for the pleurodesis is the des-asbestos talc.

What to do when endoscopic retrograde cholangio-pancreatography fails? Personal experience

BACKGROUND

Endoscopic retrograde cholangio pancreatography failure is a rare and some dramatic reality too for the management of bilio-pancreatic tract disorders and in these cases it needs to utilize others operative technique.

PATIENTS AND METHODS

Over a 6-year period, a total of 757 ERCPs were performed. In seventeen of these ERCPs the standard endoscopic technique failed and we employed alternative techniques such as interventional radiology or surgical management or double endoscopic approach.

RESULTS

In all 17 failed ERCPs the alternative procedures allowed us to success in bilio-pancreatic disease.

CONCLUSION

ERCP is an operator-dependent procedure. Even in expert hands failure occurs in 3% to 10% of cases. ERCP failure doesn't be considerated a dramatic situation in the management of the bilio-pancreatic disease for a multidisciplinary team (endoscopist, surgeon and interventional radiologist) whose cooperation allows to success.

[Surgical management of medullary thyroid carcinoma. Personal experience]

INTRODUCTION

Medullary Thyroid Carcinoma (MTC) is a rare malignancy of the parafollicular C cells of the thyroid gland. Aim of our study is reporting retrospective analysis of our experience about the surgical treatment of MTC, especially pointing on lymphadenectomy.

PATIENTS AND METHODS

from January 2000 to March 2006, were performed 546 thyroidectomy, 6 of them for MTC (1.09%): 5 sporadic and 1 familiar. All the patients were operated with standard technique (total thyroidectomy) and submitted to endocrinologic and instrumental follow-up.

RESULTS

in our experience, we do not registered early or late complications as bleeding, laryngeal nerves lesions and parathyroid lesions or intra-postoperative deaths.

DISCUSSION

MTC occurs sporadically or as part of the multiple endocrine neoplasia type 2 (MEN 2 a/b) syndromes in patients who have inherited a mutation in the RET proto-oncogene. The diagnosis is made by fine needle aspiration biopsy (FNAB) and by measuring calcitonin levels in the blood. Primary treatment consists of surgical resection including a total thyroidectomy, central neck nodal dissection and functional lateral neck nodal dissections. Most patients with a palpable primary tumour have nodal disease at the time of operation, and nodal involvement is often bilateral.

CONCLUSIONS

adequate resection of the primary tumour and cervical lymph nodes is important to optimize outcome and minimize the risk of recurrent disease. Following primary surgical resection, more than 50% of the patients will have recurrent disease with persistent elevation of calcitonin levels. Currently, there is no adequate systemic therapy for recurrent disease. Surgical reoperation or conservative observation are the best available options.

[Clavicle fracture complicated by pneumothorax. Case report and literature review]

INTRODUCTION

the clavicle is one of the most commonly fractured bones, accounting for up to 4-10% of all adult's fractures. These fractures are comparatively easy to manage and typically heal with routine immobilisation.

CASE REPORT

a 28 year old man had direct driving trauma to the left shoulder and reported a displaced fracture of the third lateral of left clavicle and an apical pneumothorax. The pneumothorax was treated by the insertion of a chest drain under local anaesthesia. The chest drain was removed 12 days after the injury and the patient was transferred in Traumatology for specific therapy.

RESULT

6 months after the accident, the clavicular fracture had united and the chest radiograph and CT were normal.

DISCUSSION

most clavicular fractures result from a fall or a trauma on ipsilateral shoulder. However, the incidence of complications associated with isolated clavicle fracture, including vascular, brachial plexus, and penumothorax, are low but potentially serious.

CONCLUSION

careful history and physical examination with particular attention to the neurovascular and chest examination are vital. Close inspection of the radiographs for such potential complication are mandatory in all clavicular fractures and cannot be overstated. From the analysis of international literature, we can affirm that thoracostomy and immobilization are effective to heal pneumothorax and clavicle fracture.

Juxtapapillary duodenal diverticular bezor as an exceptional cause of biliary stent obstruction. Case report

INTRODUCTION

we describe the first case in literature of biliary stent obstruction by bezoar impaction in a iuxtapapillary duodenal diverticulum.

CASE REPORT

this case illustrates an juxtapapillary duodenal diverticulum and bezoar in it causing obstructive jaundice in subject with two biliary stents for cholangiocarcinoma (Klatskin's tumor) in the absence of bile duct stones.

RESULT

successful treatment with endoscopic stent removal and diverticulum toilette. Obstructive jaundice was cured after endoscopic removal of the bezoar and stent substitution.

DISCUSSION

the presence of a bezoar and its possible contribution to the pathogenesis of pancreatitis in the presence of periampullary extraluminal duodenal diverticula makes endoscopic intervention for removal of the bezoar necessary and effective.

CONCLUSIONS

biliary bezoar is a very rare but treatable cause of stents obstruction in patients with juxtapapillary duodenal diverticula. Endoscopic retrograde cholangiopancreatografhy is helpful in making diagnosis and for resolutive treatment.

Unusual acute onset of pedunculated extragastric leiomyosarcoma. Case report

INTRODUCTION

A case report of 25 yrs-old man with pedunculated exogastric leiomyosarcoma (with acute onset) surgically treated is presented.

CASE REPORT

The patient was operated after clinical, instrumental and blood sample tests. We performed a 5 cm wedge resection of the stomach in continuity with the omentum. Careful inspection revealed neither adenopathy nor metastases.

RESULTS

Actual complete remission of pathology. Negative 1 year follow up by endoscopy and CT.

DISCUSSION

Information on gastric leiomyosarcoma (LM), such as prognostic factors, patterns of disease recurrence, and optimal methods of treatment, are derived from limited clinical experience. Although about 25% of the gastric mesenchymal tumors present an exogastric growth, pedunculated exogastric leiomyosarcomas are extremely rare. Lymphatic spread of gastric LM is uncommon, therefore a formal lymph node dissection is not standard surgical management. At present, there is no evidence of intraperitoneal seeding from exogastric leiomyosarcomas. Consequently, a local resection with an adequate margin is sufficient when no invasion to the adjacent structures is observed. Neither the addition of lymphadenectomy nor the wider tumor-free margins of a radical gastrectomy seemed superior to the more conservative local excision.

CONCLUSIONS

Further studies are called for to elucidate if exogastric tumours lead to peritoneal seeding and, thereby, affect tumour survival.

[Bowel preparation before colonoscopy: personal experience and brief literature review]

INTRODUCTION

Colonoscopy is the most commonly used technique for inspection of the colonic mucosa. The safety and effectiveness of colonoscopy in identifying important colonic pathology is directly impacted by the operator experience and by the quality of the bowel preparation performed in anticipation of the procedure.

PATIENTS AND METHODS

From December 2000 to June 2006, we performed 8328 total colonoscopy (M:F ratio =1:1.8, mean age 54.7 years, range 16-93). All the patients were submitted to routinary bowel preparation with polyethylenglycol (PEG) the evening before the exam, with fibres diet restriction 5 days before the exam.

RESULTS

On 8328 colonoscopy, 1243 were not actable for worst/absent intestinal toilette. 423 colonoscopy were completed after visceral washing with saline solution during the exam. On 1243 colonoscopy repeated, 852 were in subjects affected by diabetes (p < 0.05); in these patients we prescribed 5 litres solution of PEG one day before the endoscopy, diet without fibers 7 days before the exam and the use of 250 ml solution of PEG (bid): with these method, all the patients were submitted successfully to colonoscopy and retrograde ileoscopy.

DISCUSSION

Physicians favor preparations associated with the best patient compliance to achieve the best results. Patients favour preparations that are low in volume, palatable, have easy to complete regimens, and are reimbursed by health insurance or are inexpensive. Both patients and physicians favor preparations that are safe to administer in light of existing comorbid conditions and those that will not interact with previously prescribed medications.

CONCLUSIONS

Today doesn't exist the "gold standard" for bowel preparation before colonoscopy. Basing on our experience, the 4 litres PEG solution mentioned above is well tolerated and effective. In patients with severe comorbidity (diabetes, renal failure, high blood pressure) only little modifications are required to optimize the colon cleansing.

[Pull percutaneous endoscopic gastrostomy: personal experience]

OBJECTIVE

To review the indications, complications, and outcomes of percutaneous endoscopic gastrostomy (PEG), that are placed routinely in patients unable to obtain adequate nutrition from oral feeding for swallowing disorders (neurological diseases, head and neck cancer, oesophageal cancer, psychological disorders).

DESIGN

Retrospective review of patients referred for PEG placement from 2003 to 2005.

SETTING

Endoscopic Surgery in Section of General and Thoracic Surgery, Faculty of Medicine and Surgery, Palermo, Italy.

PATIENTS AND METHODS

A total of 50 patients, 11 women and 39 men, referred our Section for PEG placement. Indications for PEG placement included various neurologic impairment (82%), oesophageal non-operable cancer (6%), cardia non-operable cancer (4%), cerebrovascular accident (2%), anorexia (2%), pharyngeal esophageal obstruction (2%), head and neck cancer (2%). All patients received preoperative antibiotics as short-term profilaxis.

RESULTS

51 PEGs were positioned in 50 patients. No major complications were registered; 45 patients (90%) were alive at 1 year follow-up and no mortality procedure-related was registered. Percutaneous endoscopic gastrotomy removal had been performed on 2 patients as end-point of treatment, and 43 patients continued to have PEGs in use at 2006.

CONCLUSIONS

Outpatients PEG placement using conscious sedation is a safe and effective method for providing enteral nutrition. This technique constitutes the gold standard treatment for enteral nutrition in patients with neurologic impairment or as prophylactic in patients affected by head and neck cancer who needs demolitive surgery. Patients should be carefully assessed, and discussion with the patient and their families should be held to determine that the patient is an appropriate candidate. The Authors feel prophylactic antibiotics lessened the incidence of cutaneous perigastrostomy infection.

[Total thyroidectomy of choice in papillary microcarcinoma]

INTRODUCTION

Today, the "gold standard" of surgical management of benign thyroid disease is still controversy. There are different surgical approaches to the thyroid gland, from a radical, total thyroidectomy to a conservative treatment, lobectomy with or not isthmectomy. In consideration of the more frequent incidence of small carcinomas accidentally founded in the context of the thyroid parenchyma removed for another pathology, the aim of this study is to bring a contribute to resolve the debate on the therapeutic choice in the surgical management of the thyroid benign disease.

PATIENTS AND METHODS

From January 2000 to January 2006 502 thyroidectomy were performed in the Section of General and Thoracic Surgery of University of Palermo: 458 total thyroidectomy (91.3%), 2 partial thyroidectomy (0.3%), 24 (4.8%) lobectomy with isthmectomy and 18 (3.6%) reinterventions for relapse; 34 patients (6.8%) were preoperative suspected (cytological or ultrasonography) for thyroid cancer.

RESULTS

After total thyroidectomy in 17 patients (3.4%) we founded a papillary incidental "microcarcinoma", diameter range 2-10 mm (mean 6.9 mm). In 2 cases (11.7%) we found infiltrative and multifocal tendency. Histologically, were 11 cases of classical papillary (64.7%), 4 cases (23.6%) of follicular and 2 (11.7%) sclerosing, in 9 cases of multinodular goiter, 3 of follicular adenoma, 3 cases of follicular carcinoma, 1 case of Graves disease and 1 case of Hashimoto thyroiditis.

DISCUSSION

Papillary microcarcinoma is a "thyroid papillary cancer with a diameter < or = 1 cm?". From the analysis of literature, we observed a progressive increasing of papillary microcarcinoma from 12% (1980) to 25% (1990), with a prevalence of diameters < or = 5. Actually, there are no univocal data on natural history, nodal metastasis, biological and clinical behaviour, morbidity and mortality of these neoplasms; the certain data is that only the radical surgery can prevent relapse and incidentalomas that modify surgical approach.

CONCLUSIONS

In our opinion, the surgical management of the all thyroid disease must be the more radical since the first time, because we think other approaches not correct to improve the complete health from the benign thyroid disease and to prevent (secondary prevention) papillary microcarcinoma not pre-operative diagnosed, because there are no preoperative pattern to make a correct diagnosis of this tumour.

[Severe rectal bleeding after transrectal US-guided prostate biopsy. Case report]

CASE

The Authors report their experience about a case of severe rectal bleeding after transrectal ultrasound-guided prostate biopsy.

INTERVENTION

After correct and sure diagnosis, the patient was submitted to resolutive endoscopic haemostatic treatment (failure of haemostatic mechanical manoeuvres, emergency colonscopy, haemostasis with sclerotherapy, heat bipolar probe and Argon Plasma Coagulation).

RESULTS

Complete recovery (immediate stop bleeding). Follow-up (1 year) negative.

CONCLUSIONS

Rectal bleeding after prostate biopsy is a important but rare complication of prostate cancer screening, potentially lethal. Best knowledge of causes and risk factors may improve the diagnosis and standardize the treatment. The prostatic biopsy is surely the best procedure for the screening of prostate cancer in the population, associated with PSA dosage.

[Endoscopic treatment of pancreatic pseudocysts]

AIM

the Authors report their experience about the endoscopic treatment of pancreatic pseudocysts (PP).

PATIENTS AND METHODS

report of 10 cases; evaluation of effectiveness, morbidity and mortality of treatment.

SETTING

Section of General and Thoracic Surgery, AOUP ?Paolo Giaccone?, University of Palermo.

PROCEDURE

endoscopic drainage was performed in all 10 patients, with 2 cysto-gastrostomy, 5 cysto-duodenostomy and 3 trans-papillary cystic drainage.

RESULTS

100% successful; one case of bleeding post-procedure (10%), one case of sepsis (10%) and one case of stricture of fistula between PP and duodenum.

CONCLUSION

endoscopic drainage of PP is a safe and simple treatment, with high rates of success and low rate of complication procedure-related, complementary to surgery.

[Non recurrent laryngeal nerve. Personal experience]

PURPOSE

Damage to the recurrent laryngeal nerve (RLN) during thyroid or parathyroid surgery is the most common iatrogenic cause of vocal cord paralysis. Identification of the RLNs and meticulous surgical technique can significantly decrease the incidence of this complication. Nonrecurrent RLNs (NRRLNs) are exceedingly rare. Surgeons need to be aware of their position to avoid injuries.

PATIENT AND METHODS

A retrospective review of 263 right RLN exposures (and 251 left RNL) over a 5-year period was performed.

RESULTS

Two NRRLNs were encountered, for an incidence of 0.39% (0.76% only for right dissection), without anatomic anomalies on the left side. The nerve anomaly was never preoperatively diagnosed.

CONCLUSION

NRRLNs are rare and is associated with a right subclavian artery arising from distal aortic arch. Awareness of their existence and correct surgical technique will prevent the surgeon from accidentally lesion of NRRLN one if it is encountered during thyroid or parathyroid surgery.

[Prevention of complications in thyroid surgery recurrent laryngeal nerve injury personal experience on 313 cases]

INTRODUCTION

Thyroidectomy poses many challenges for the surgeon who undertakes endocrine surgery and iatrogenic injury of inferior laryngeal nerve (ILN) is one of the most serious (0-20%). We report our personal experience of a series of 313 thyroidectomy with intraoperative identification of ILN.

METHODS

313 patients (253 females, 60 males, whose age was between 17 and 86 years, mean 41 years) had undergone thyroidectomy in our Operative Unit from January 2000 to January 2004. Among them, 259 patients underwent total extracapsular thyroidectomy, 38 subtotal thyroidectomy, 5 isthmo-lobectomy and 11 were completions of thyroidectomy in patients who had previously undergone a first thyroid surgical intervention.

RESULTS

We identified 588 ILN (in all cases), in the left or in the right side only in case of isthmo-lobectomy or completion of thyroidectomy. In two cases (0.63%) we noticed on the right side a non recurrent laryngeal nerve. Concerning the postoperative results we noticed only one case (0.38%) of ILN injury with monolateral vocal cord hypomotility and temporary dysphonia, actually on phoniatric therapy at follow-up.

CONCLUSION

A strong knowledge of the anatomy and embryology of the thyroid region, a commitment to meticulous attention to detail, the awareness of the extremely varying course of the ILN and the inferior thyroid artery and their relations, and adequate experience are all required to maintain a level of expertise and avoid ILN. Thyroid carcinoma, recurrent goitre, total thyroidectomy operation, duration of the operation are factors which increase the risk of postoperative ILN injury.

["Rendez-vous" technique for palliation of neoplastic jaundice: personal experience]

INTRODUCTION

"Rendez-vous" technique (RV) assume contemporaneous percutaneous transhepatic choledochal drainage (PTCD) and endoscopic (ERCP) approach to make easier biliary cannulation when it fails for anatomic, neoplastic or iatrogenic causes, in subject unresectable at presentation ("not fit for surgery").

MATERIALS AND METHODS

Over a 3 years period 618 ERCP were performed in the Service of Digestive Endoscopy in Section of General and Thoracic Surgery, 59 of whom (9%) failed for non-visualization of ampulla of Vater (25%), intradiverticular ampulla (54%) or anatomic defects (21%). Were attempted 44 pre-cut: 14 failed (close biliary stricture), and we proceed to RV.

RESULTS

11/14 (79%) RV were successful (successful stent insertion was defined as passage of the stent across the stricture) and 3 failure (21%) occurred in close biliary malignant obstruction even to percutaneous transhepatic approach. Only in 28% were registered minor complications (2 post-procedure fever, 1 papillary bleeding post PTE, 1 case mild acute pancreatitis). No mortality procedure related was registered and was not necessary to recur to surgery.

CONCLUSIONS

RV is very useful in case of difficult cannulation of biliary tree and after failure of pre-cut. US-guided PTC is easy to perform, with low incidence of complications. Every well experienced team who works on bilio-pancreatic pathologies may recurs to this technique: even if not much utilized, RV can solves complex cases of biliary stricture.

Treatment of complications of hepatic hydatid disease by ERCP: our experience

BACKGROUND

The aim of this study was to evaluate the effectiveness of endoscopic sphincterotomy and positioning of naso-biliary drain or biliary endoprosthesis for preoperative and postoperative complications of hepatic hydatid disease (fistuias, compressioni cholestasis, rupture in biliary tree).

METHODS

During the period 1994-2003, 22 patients (12 male and 10 female, mean age 55.4 years, range 16-65 yrs) underwent endoscopic treatment for complications of hepatic hydatid disease. Indications for ERCP in 5 patients treated before surgery (Group A) were obstructive jaundice in ali, associated with acute cholangitis in 4 (80%) and acute pancreatitis in 1 (20%). In 17 patients treated after surgery (Group B), the indication was acute cholangitis in 6 (36%), obstructive jaundice 3 (17%), and persistent external drainage in 8 patients (47%).

OBSERVATIONS

In group A, ERCP detected hydatid vesicies within the bile duct in all patients. Ali patients underwent endoscopic sphincterotomy and clearance of the duct with no complications. The 8 patients in Group B with persistent external drainage had biliary fistulas that resolved after endoscopic treatment within 10 to 25 days (in 4 patients with low-flow fistula was positioned nasobiliary drain to repeat cholangiogram) or in 4-6 weeks (in 4 patients with high-flow fistula was positioned biliary endoprosthesis). In 2 of 8 patients (25%) with postoperative external biliary fistulas was observed choledocholitiasis (resolution with ERCP). Ali the 9 patients with postoperative obstructive jaundice or acute cholangitis, had cyst remnants obstructing the bile duct. Surgical reintervention was avoided in all patients in group B: all underwent endoscopic sphincterotomy and clearance of the bile duct without complications. After treatment, all patients remained asymptomatic.

CONCLUSION

Endoscopic sphincterotomy with positioning of naso-biliary drain or biliary endoprosthesis is a safe and effective treatment for preoperative and postoperative biliary complications of hepatic hydatid disease.

[Gastric foreign body: bezoars. Apropos of two cases]

OBJECTIVE

The authors report their experience about the treatment of two cases of gastric bezoar, treated in curative mode, the first endoscopically and the second with surgical intervention.

SETTING

Operative Unit of General and Thoracic Surgery, Department of General and Emergency Surgery, Organ Transplantation, Policlinico, University of Palermo.

INTERVENTION

The patients were submitted to curative treatment, one with endoscopic treatment (mechanical fragmentation of phytobezoar and fragments extraction via-overtube), the second with surgical gastrotomy (stamp trichobezoar). There were no procedure-related complications.

RESULTS

The two patients were curative and radically treated. Negative 2 years follow-up.

CONCLUSIONS

There is no standardized method for the treatment of gastric bezoars. Endoscopic removal of gastric bezoars after fragmentation and using overtube is effective and safe. Surgical intervention, equally safe, is reserved to huge, stamp, impacted or complicated bezoars.

[Aberrant pancreas: a rare cause of epigastralgia]

OBJECTIVE

The Authors report their experience about a case of aberrant pancreas that lead epigastralgia.

DESIGN

Report of 1 case and endoscopic treatment (upper endoscopy + EUS + endoscopic polypectomy + endoscopic biopsy of the base. Surgical effectiveness evaluation.

SETTING

Section of General and Thoracic Surgery, Department of General Surgery, Emergency and Organ Transplantation, Policlinico "Paolo Giaccone", Palermo.

INTERVENTION

After correct and sure diagnosis, the patient was submitted to endoscopic polypectomy with radical and curative intention.

RESULTS

Complete recovery. Hematochemical and endoscopic follow-up (1 months) negative.

CONCLUSIONS

Diagnosis of aberrant pancreas is very hard and always post-resection. Symptoms are poor and makes the clinical diagnosis extremely difficult, except when the mass attains big dimension (>5 cm). The best treatment of aberrant pancreas is based on correct diagnosis (upper endoscopy + EUS + FNAB) and on a radical treatment that, if the lesion is mucosal, is totally endoscopic (endoscopic polipectomy), without specific risk.

[Intestinal endometriosis: an obscure cause of cyclic rectal bleeding]

OBJECTIVE

Authors report their experience about a case of intestinal endometriosis that lead cyclic and recurrent rectal bleeding in a fertile-age woman.

DESIGN

Report of 1 case with multidisciplinary approach and surgical treatment. Surgical effectiveness evaluation and 2 years follow-up. Brief review on the recent literature and the diagnostic and therapeutic implications.

SETTING

Section of General and Thoracic Surgery, Department of General Surgery, Emergency and Organ Transplantation, Policlinico "Paolo Giaccone", Palermo.

INTERVENTION

After correct and sure diagnosis, the patient was submitted to sigmoid segmental resection with radical and curative intention.

RESULTS

Complete recovery. Follow-up (24 months) negative.

CONCLUSIONS

Diagnosis of endometriosis should be considered in women with recurrent monthly abdominal pain and bowel symptoms, especially if accompanied by gynaecologic complaints, even because the significant symptoms overlap with the irritable bowel syndrome (IBS) and makes the differentiation extremely difficult. Treatment of GI endometriosis is best approached in collaboration between gynaecologist experienced and intestinal surgeon. The high accuracy and low complications suggested that EUS-FNA was effective for the correct histologic diagnosis of intestinal endometriosis.

[Fournier's gangrene: case report and review of recent literature]

OBJECTIVE

The authors report their experience in diagnosis and treatment of one case of Fournier's gangrene; recent international literature review.

EXPERIMENTAL DESIGN

Complete clinical report. Diagnostic, clinical and prognostic indication, evaluation of effectiveness of surgical treatment (debridement and necrosectomy) and follow-up; comparison between indications and multidisciplinary approach proposed by international literature.

SETTING

Operative Unit of General and Thoracic Surgery. University "Paolo Giaccone" of Palermo.

INTERVENTION

Repeated surgical treatment previous multimodal approach, according to international guide-lines.

RESULTS

Complete recovery with "restitutio ad integrum". No relapse were recorded at follow up.

CONCLUSIONS

Fournier's gangrene is an uncommon and aggressive synergistic fasciitis of the perineum and genital organs, which may bring the patient to death; it is a true surgical emergency. The disease can no longer be considered to be idiopathic; in most cases a urologic, colorectal or cutaneous source can be identified. Despite antibiotics and aggressive debridement, the mortality rate remains high, particularly in the elderly, in patients with renal failure, and in patients with extensive disease. The presentation is highly variable, necessitating a high index of suspicion. High risk patients include diabetics, alcoholics and debilitated and immunosuppressed individuals. As the AIDS population increases, the incidence of Fournier's gangrene may increase as well. In questionable cases, imaging modalities should be performed to allow early diagnosis and to reduce misses diagnosis. Broad spectrum antibiotics (while waiting for the results of culture and antibiogram effectuated on tissue specimens obtained during necrosectomy) and aggressive debridement remain the hallmarks of treatment. Hyperbaric oxygen therapy and improved local wound care may decrease the extent of tissue destruction. The surgical operation has to be performed in emergency to avoid a rapid spread of tissue necrosis and a possible development towards septic shock. Reconstructive techniques afford better cosmetic results. With early recognition, prompt treatment, improved wound care and reconstructive efforts, the mortality rates and cosmetic results should continue to improve.

[Regression of primary low-grade gastric mucosa-associated lymphoma by eradication of Helicobacter pylori infection: case report]

OBJECTIVE

The Authors report their experience in diagnosis and treatment of one case of primary low-grade gastric lymphoma of mucosa associated lymphoid tissue (MALT); recent international literature review.

EXPERIMENTAL DESIGN

Complete clinical report. Diagnostic, clinical and prognostic indication, evaluation of effectiveness of eradication therapy and short follow-up.

SETTING

Operative Unit of General and Thoracic Surgery. University "Paolo Giaccone" of Palermo.

INTERVENTION

Treatment of H. Pylori infection (lansoprazole, amoxicillin and metronidazole twice a day for 14 days; after that, lansoprazole for another 4 weeks), according to international guide-lines.

RESULTS

H. Pylori was completed eradicated. Disappearance and total regression of the lymphomatous tissue was observed. No relapse were recorded at short follow-up.

CONCLUSIONS

Our reports confirm the recent anecdotal reports on regression of gastric MALT lymphoma after eradication of H. Pylori and indicates that the growth of these extranodal lymphomas may depend on H. Pylori.

[Gastric antral vascular ectasia (GAVE) or watermelon stomach syndrome: report of 3 cases and clinical and therapeutic indications]

OBJECTIVE

The authors report their experience in diagnosis, treatment and ambulatorial follow up of 3 cases of obscure upper gastrointestinal bleeding by gastric antral vascular ectasia (GAVE).

EXPERIMENTAL DESIGN

Complete clinical report of 3 cases. Clinical and endoscopic indication, evaluation of effectiveness of endoscopic treatment with bipolar electrocoagulation and follow-up.

SETTING

Operative Unit of General and Thoracic Surgery. University "Paolo Giaccone" of Palermo.

INTERVENTION

Endoscopic treatment by multiple session with bipolar electrocoagulation. No complications were registered.

RESULTS

Complete recovery with "restitutio ad integrum". No relapse were recorded at follow up.

CONCLUSIONS

The objective of the treatment is to recognize the site of obscure bleeding and then stop it. The choice between pharmacological, endoscopic and surgical treatment is individual for each patient. According to us, the endoscopic treatment is the first step in a gradual clinical approach, to detect the site of the lesion, to treat with bipolar electrocoagulation or with Argon Plasma Coagulator (lower wall penetration and minimal risk of perforation).

[Paraesophageal hiatal hernia. Clinical considerations and report of a case]

OBJECTIVE

The authors report their experience about the treatment about a case of paraesophageal hernia and they redefine nosography.

DESIGN

Report of 1 case; evaluation of effectiveness of surgical treatment. 1-year follow up. Review of its clinical presentation.

SETTING

Operative Unit of General and Thoracic Surgery. Department of General Surgery, Emergency and Transplantation. Polyclinc, University of Palermo.

INTERVENTION

The patient was submitted to surgery with radical and curative intention.

RESULTS

Complete resolution of the pathology. Follow-up (1 year) negative.

CONCLUSION

Management of patients affected by paraesophageal hernia is difficult, because the physiopathology, anatomic basis and clinical presentation are not yet clear. The aim of surgical treatment is to reduce the hernia, to repair the hiatal gap and to make a correct antireflux procedure. According to us, the open surgical approach is very safe and useful because allows more safe surgical dissection, even if there is a big scar on the abdomen, the postoperative staying in hospital is longer. Finally, we emphasise the role of follow-up in these patients: it's the only way to prevent complications.

[Endoscopic removal of a Dormia basket impacted in the biliary tract during treatment of a difficult residual choledocholithiasis. Report of a case]

OBJECTIVE

The authors report their experience about the treatment of a broken Dormia in CBD in elder with "difficult" residual choledocholithiasis, with T tube.

DESIGN

Report of case. Evaluation of effectiveness of endoscopic treatment with 2-years follow-up.

SETTING

Operative Unit of General and Thoracic Surgery, Department of Surgical, Anatomical and Oncological Disciplines. Policlinico "Paolo Giaccone"--Palermo.

INTERVENTION

Endoscopic removal of Dormia broken and impacted in CBD after 2 session of extracorporeal shock wave lithotripsy (ESWL).

RESULTS

Resolution of the pathology with 2 session of ERCP and cholangiographic control.

CONCLUSIONS

ERCP and ES are the gold standard in the treatment of choledocholithiasis. Rare complication of this method is the rupture of Dormia Basket in CBD: this occurrence can be solved by endoscopy, but only in well experienced endoscopic teams.

[Atypical presentation of a case of Mirizzi syndrome simulating cholangiocarcinoma]

OBJECTIVE

The authors report their experience in the treatment of a case of Syndrome of Mirizzi (SM) that it simulates a cholangiocarcinoma.

EXPERIMENTAL DESIGN

Report of 1 case. Evaluation of the effectiveness of the treatment and 2 years follow-up.

SETTING

Operative Unit of General and Thoracic Surgery, Department of Surgical, Anatomical and Oncological Disciplines. Policlinico, University of Palermo.

INTERVENTION

Surgical treatment of the suspicious neoplastic lesion.

RESULTS

Complete recovery with "restitutio ad integrum".

CONCLUSIONS

The SM constitutes one important challenge from the diagnostic and therapeutic point of view, since it is not infrequent that the correct definition of this pathology is only intraoperative. The role of the videolaparoscopic cholecistectomy is not still well defined. To reduce the risks of lesion of the biliary tree during surgical intervention, also in case of diagnostic doubt, we propose an integrated approach of sequential type, with the exploration preoperative through ERCP and following surgical intervention.

[Unusual case of intestinal obstruction at the ileal level: strangulated obturator hernia. A case report]

OBJECTIVE

The authors report their experience about treatment of a rare case of intestinal (ileal) obstruction by strangulated obturator hernia.

DESIGN

Report of 1 case; evaluation of effectiveness of surgical treatment, 2-years follow-up and revision of literature about its clinical presentation and treatment.

SETTING

Operative Unit of General and Thoracic Surgery, Department of Surgical, Anatomical and Oncological Disciplines. Policlinico, University of Palermo.

INTERVENTIONS

The patient was submitted to curative and radical surgery.

RESULTS

Resolution of the pathology. Follow up (2 years) negative.

CONCLUSIONS

Obturator hernia is a rare pathology, with difficult and delayed diagnosis: all these character make dangerous this hernia, with a risk of high morbidity and mortality (delayed diagnosis and treatment). The only useful treatment is surgery, especially in front of intestinal obstruction, with a wide median laparotomy.

[Integration of operative endoscopy and laparoscopic surgery in the treatment of cholecysto-choledocholithiasis]

Laparoscopic cholecystectomy has become first choice for symptomatic gallstones, but there are not agreement about therapy of supposed synchronous choledocholithiasis. We report our experience about the sequential treatment (endoscopic-laparoscopic) of the gallstone and the associated common bile duct stones.

METHODS

During the period Jan. 1992 Dec. 1997 we have evaluated 128 patients that were submitted to ERCP for suspicion CBDS and gallstone. All patients undertook a systematic assessment: Patient age, sex, history of jaundice, history of pancreatitis, levels of serum alanine aminotransferase, alkaline phosphatase, amylase, total and direct bilirubin and CBD diameter on ultrasonography.

RESULTS

In the 96 (75%) cases of choledocholithiasis endoscopic sphincterotomy has been performed and combined with laparoscopic cholecystectomy. Thirty-two patients (25%) submitted to ERCP have been negative for stones. Only 4 patients have needed surgery because of big stones inside the CBD after ESWL failure. The incidence of complications of ERCP-ES has been, in our experience, 7.1% and mortality 0.8%. All the complications have been treated conservatively and did not need surgery.

CONCLUSIONS

The sequential treatment (endoscopic-laparoscopic) of synchronous CBDS and gallstone, in hands of expertise, is efficient with high rate of success and low rate of complications in order to morbidity and mortality. Finally we believe that it is very important to discover CBDS preoperatively with the non invasive methods as the MRI-Colangiography and to assay the liver tests in order to avoid negative ERCP for choledocholithiasis.

[Endoscopic treatment of pancreatic pseudocysts. Our experience in 8 cases]

OBJECTIVE

The authors report their experience about the endoscopic treatment of pancreatic pseudocysts (PP).

DESIGN

Report of 8 cases; evaluation of effectiveness, morbidity and mortality.

SETTING

Operative Unit of General and Thoracic Surgery, Department of Surgical, Anatomical and Oncological Disciplines. Policlinico, University of Palermo.

INTERVENTIONS

endoscopic drainage in all 8 patients.

RESULT

88% successful (7/8).

CONCLUSION

Endoscopic drainage of PP is a safe and simple treatment, with high rates of success and low rate of morbility.

[Multiple choledocholithiasis]

OBJECTIVE

The authors report their experience about the endoscopic (ERCP) treatment of multiple choledocholithiasis.

DESIGN

Report of 5 cases; evaluation of mortality and effectiveness of the treatment.

SETTING

Operative Unit of General and Thoracic Surgery, Department of Surgical, Anatomical and Oncological Disciplines. Policlinico, University of Palermo.

INTERVENTIONS

ERCP + ES + clearance of bile duct stones in all 5 patients.

RESULTS

100% successful.

CONCLUSION

ERCP is choice treatment of multiple choledocholithiasis, only in well experienced teams.

[Scrotal angiomyofibroblastoma. Report of a case]

OBJECTIVE

The authors report their experience about the treatment of a rare case of scrotal angiomyofibroblastoma (AMF).

DESIGN

Report of 1 cases; evaluation of effectiveness of surgical treatment.

SETTING

Operative Unit of General and Thoracic Surgery, Department of Surgical, Anatomical and Oncological Disciplines. Policlinico, University of Palermo.

INTERVENTIONS

The patient was submitted to curative and radical surgery.

RESULTS

Resolution of the pathology. Follow up (6 months) negative.

CONCLUSIONS

The AMF's treatment is surgical and localized. Is important the complete preoperative evaluation.

[Endoscopic treatment of a calculous choledochocele. Report of a case]

OBJECTIVE

The authors report their experience about the treatment of choledochocele.

DESIGN

Case report and 6-months follow up.

SETTING

Operative Unit of General and Thoracic Surgery, Department of Surgical and Anatomical Disciplines. Policlinico, University of Palermo.

INTERVENTIONS

ERCP + ES with complete resolution of pathology.

RESULT

Complete resolution of symptoms; 6-months follow up negative.

CONCLUSIONS

ERCP is choice treatment of choledochocele, only in well experienced teams.

[Surgical treatment of varicocele in day hospital. Our experience]

OBJECTIVE

The authors report their experience about surgical treatment of varicocele in Day Hospital (DH).

DESIGN

Report of 10 cases; evaluation of effectiveness of the surgical treatment.

SETTING

Operative Unit of General and Thoracic Surgery, Department of Surgical, Anatomical and Oncological Disciplines. Policlinico, University of Palermo.

INTERVENTIONS

Surgical procedure according to Ivanissevich in all 8 patients.

RESULT

100% successful.

CONCLUSION

Surgery in DH is a valid treatment option in varicocele, by the technical and economic point.

[Dieulafoy's ulcer: unusual cause of upper gastrointestinal tract. Our experience]

OBJECTIVE

The authors report their experience about the endoscopic treatment of upper gastrointestinal bleeding from Dieulatoy's ulcer (non variceal bleeding).

DESIGN

Report of 5 cases; evaluation of mortality and effectiveness of the treatment.

SETTING

Operative Unit of General and Thoracic Surgery, Department of Surgical, Anatomical and Oncological Disciplines. Policlinico, University of Palermo.

INTERVENTIONS

EGDS + sclerotherapy (emergency room) in all 5 patients.

RESULTS

80% successful (stop bleeding).

CONCLUSIONS

Endoscopic sclerotherapy is choice treatment of upper gastrointestinal bleeding from Dieulafoy's ulcer, only in well experienced teams and rapidly.