[Adrenal incidentaloma: case report and synthesis of indication and thresholds of surgery therapy]

With the term of incidental mass, any mass is identified, occasionally discovered with imaging techniques, in the absence of specific symptoms. In 1982, the term "incidentaloma" was introduced to indicate lesions detected on adrenal regions, found unexpectedly. The incidence percentages vary from 0.6%-3% in CT followed by other indications , to 10% and 25% in all patients who underwent an ultrasound, CT or MRI. An appropriate diagnostic protocol is mandatory to identify and to choose the proper treatment for the functioning lesions, as well as the malignant or potentially malignant lesions (1, 2). Incidentalomas with diameters under 1 cm seem to not have a pathologic significance, and are considered like manifestation of the gland involution in advanced-age subjects, and can remain unseen for a long time. The use of diagnostic imaging techniques has made it possible to identify these masses, even those of small size, in the course of diagnostic surveys done under various guidelines. The mass dimensions are a fundamental parameter used to distinguish benign lesions from malign ones (2, 3). Most Authors suspect malignity in masses above 5-6 cm, while considering those with a diameter under 3 cm to be benign. Whereas the rest remain undefined, thereby valued and treated according to criteria not perfectly established.

Gastric polypoid lesions. Our experience

BACKGROUND AND AIM

The Authors report the results of their experience on polypoids lesions of the stomach and on endoscopic polypectomies.

PATIENTS AND METHODS

A study on 2000 OGD (oesophagogastroduodenoscopy) has been carried out on 95 patients with polypoid lesions. The authors have analysed the associations existing between histological type and symptomatology and localisation of the lesion and the status of the Helicobacter pylori and the risk of cancerization. The data were confronted with the ones already available.

RESULTS

In the majority of the cases, the polypoid lesions were asymptomatic, the localization changed according to the histological type, with the antrum as the most affected area. The presence of Helicobacter pylori does not seem to be correlated to the lesion, except in the case of hyperplastic polyps. The percentage of risks of cancerization increased in case of adenomatous polyps. In one patient signet ring cell carcinoma within a gastric polyp was found. Gastric signet ring cell carcinomas are peculiar for their rarity as well as for the growth in polypoid lesions.

CONCLUSION

We confirm the higher frequency of hyperplastic polyps and the correlation between histological type and localization. Endoscopic polipectomy is the first approach in gastric polyps, with lower risk of developing cancer. Only in selected cases, as in one in ours, it is advisable the surgery.

[The role of the intraoperative manometry in the esophageal achalasia surgical treatment]

INTRODUCTION

The authors report their experience about the intraoperative manometry in the achalasia surgical treatment.

PATIENTS AND METHODS

We have considered 239 patients with achalasia observed from 1994 to 2006; only 79 continued the path diagnostic therapeutic and 31 underwent Heller longitudinal miotomy, with Dor anti-reflux plastic in 25 patients and in 6 Nissen anti-reflux plastic. In 24 we performed the intraoperative manometry (MI) recording the high pressure areas.

RESULTS

The patients underwent Heller's procedure with manometric check of the gastric muscular fibre sectioned areas reported the disappearance of the dysphagia. Three of the operated ones without using the MI complained about the persistence of mild dysphagia and it did not depend from the antireflux surgical procedure used.

CONCLUSIONS

Our findings confirm that the extramucosal miotomy is the treatment of choice for the achalasia and suggest that by MI a complete miotomy is allowed mostly on the gastric side where the muscular fibres get an important role in the maintenance of the high pressure areas.

[Infected pancreatic pseudocysts: technical notes]

INTRODUCTION

Starting from the observation of 9 cases of giant infected pancreatic cysts, which occurred from 1994 to 2004 at the Department of Oncological and Surgical Studies, the Authors' aim has been to evaluate whether a more thorough necrosectomy, carried-out under video-endoscopic control, associated with a nose-gastro-cavity tube, which ensures a continuous cleansing of the newly-formed cavity, and an appropriate positioning of the drainages, could reduce the morbidity and allow a shorter recovery of the infected pseudocysts.

PATIENTS AND METHODS

Of 73 cases of acute pancreatitis, observed from 1994 to 2004, 9 showed severe and acute pancreatitis, which included giant pseudocysts, as revealed by the abdomen angio-TC. Our nine septic patients underwent cysto-gastro-anastomosis, necrosectomy, intraoperative cleansing of the cavity with an antibiotic solution and positioning of multiple drainages. Three of these patients also underwent a thorough and targeted necrosectomy, assisted by a trans-anastomotic video-endoscopy. A nose-gastro-cavity tube has been placed in all the patients.

RESULTS

The disappearance of the septic state in our three patients who underwent a targeted video-assisted necrosectomy occurred after three days of treatment; moreover, the abdomen angio-TC on the 5th postoperative day showed the disappearance of the necrotic areas. The recovery of these three patients was significantly shorter, compared to those undergoing traditional treatment (cysto-gastro-anastomosis, standard necrosectomy and positioning of abdominal drainages).

CONCLUSIONS

Our surgical video-assisted technique demonstrated that, with a slight increase in the operative time, a better control over sepsis may be accomplished, as well as a reduction of the post-operative morbidity, which leads to shorter hospitalisation of patients with infected pancreatic pseudocysts.

[A gastric polypoid signet ring cell carcinoma]

AIM

The authors signal a case of gastric polypoid signet ring cell carcinoma, of particular interest for its rarity like show from the review of the literature, which is the first to have been described after Tabaru's citation.

METHODS

The study has been carried out at the Department of Surgical and Oncological Sciences of the University of Palermo. It has been based on 2000 cases analysed from June 2001 to December 2003.

RESULTS

The authors advance some and emphasizes the diagnostic flow chart and therapeutic choices adopted.

CONCLUSIONS

We agree that the endoscopic polypectomy is surgical procedure of first approach, but modifying the therapeutic guideline in relation to histologic examination, like happened in the case in issue.

[Gallstone ileus: diagnosis and treatment. Case report]

The authors present a case of gallstone intermittent ileus caused by the passage of a big gallstone (about 4 cm in diameter) in the intestinal lumen, through a cholecystoduodenal fistula. They emphasize the peculiarity of the case for the characteristics of symptoms and for casual diagnostic check-up with a ultrasonography. The disease is not frequently diagnosed; today it has a safe recognition by modern imaging. The symptoms can be intermittent and, even when there are the classic signs of intestinal occlusion, the site of the occlusion is various. With a timely endoscopical or surgical approach (open or laparoscopic) it is possible to reduce mortality of patients treated in emergency.

[Observations about a case of giant splenic cyst]

The Authors, on the basis of a case of giant spleen cyst with positive tumoral markers, analyse some epidemiological and clinical aspects related to splenic non parasitic cysts. They affirm the priority of the conservative surgery, whenever possible, followed by an appropriate follow-up, although in this case their therapeutic choice was radical, due to the lack of residual parenchyma. In accordance with the data of several publications, as well as on the basis of the results obtained, the conservative approaches have been reevaluated, above all in view of the modern findings related to the function of the spleen. The conservative approach cannot be carried out in the following cases: neoplastic diseases, increase of the tumoral markers serum levels, total involvement of the splenic parenchyma by cysts.

[Ultrasonic dissector for total thyroidectomy: results of prospective randomized study]

In the last years, the introduction and employment in surgery of the dissectors of last generation (ultrasounds, radiofrequency, etc.) have contributed to a remarkable improvement and simplification of the performances and the surgical techniques. The present study has the aim to verify, on the basis of the experience made in the last two years and through a careful comparisons with operations performed in the usual way, the advantages of employment of ultrasonic dissector in thyroid surgery and if besides such advantages it is possible to obtain real and substantial reductions of the complications. To such aim a randomized perspective study has been lead, confronting two groups of 60 patients, submitted to total thyroidectomy in Chair of General Surgery and Surgical Physiopathology of the University of Palermo-Complex Operating Unit of General Surgery. In all patients have been considered age, sex, histological diagnosis, length of the incision, time (from the incision until suture of skin), entity of the bleeding, hospital stay, post-operative consequences and total costs of thyroidectomy. The elaboration of the obtained data shows the advantages following to the use of the dissectors of last generation: reduction of the times, reduction of the complications, better tolerance of the operation by patients, better rationalization of the resources.

Inguinal hernia surgery performed on elderly cardiopath patients

Old age cannot be considered as an absolute risk factor in the surgical treatment of inguinal hernia, which can also be stated for the majority of elderly people pathologies. The opportunity of surgically treating a wider range of individuals has been made possible thanks to the use of both modern, less invasive surgical techniques and easy-to-handle anaesthetic medicines, as well as a new concept of elderly-customer-friendly sanitary planning. The evaluation of the risks is multifactorial; consequently, in the case of elderly cardiopath individuals, suffering from inguinal hernia, one has to reconsider both the type of anaesthetic and the surgical technique to be performed, in view of the increased risks, as against the case of non cardiopath, elderly patients. The modern tension-free techniques have demonstrated in cardiopath patients the same advantages which have been observed in elderly non cardiopath patients, such as a faster functional recuperation as well as no significant percentage difference related to the early and late complications following the operation.

Artificial nutrition for the treatment of short bowel syndrome

BACKGROUND

In the short bowel syndromes (SBS) it is often difficult to grant a correct and sufficient alimentary supply only by ordinary natural nutrition. In the present research, we will study the prospective possibilities of integrating the nutritional supply making resort to artificial nutrition techniques in patients with SBS.

METHODS

We have treated 7 patients with SBS, 6 males and 1 female, whose age was ranging from 29 and 70 years. They all underwent wide intestinal resection, 2 of them for massive infarct, 4 for Crohn's disease, 1 for bowel volvolus. An evaluation of nutritional and immunological conditions was performed on all of them, determining: albumin, transferrin, C-reactive protein, prealbumin, leukocyte count, skin test. In a second time, a protocol was implemented, based on total parenteral nutrition for the first 5 days, with scalar calorie supply up to a total of 35 kcal/kg/die; on day 6 after the operation, the parenteral caloric supply was reduced of 500 kcal/die, being compensated by the introduction of an equal caloric ration by nasointestinal tube with peristaltic pump having a flow of 20 mL/h. In the following days, the parenteral caloric supply was reduced of 500 cal each 48 hours, being substituted with an equal enteral supply in order to progressively reach a complete abandonment of parenteral nutrition.

RESULTS

All the patients have a follow-up of 2 to 5 years; today they follow a high-calorie hyperglycidic, hypolipidic diet; no signs of malnutrition are shown by clinical and laboratory analysis.

CONCLUSIONS

In the light of the data in our possession, it can be understood that nutritional therapy is the main treatment for SBS; parenteral subministration has to be abandoned during the postoperatory course to give way to enteral nutrition, in order to create a physiological stimulus able to make the digestive system rapidly adapt to the new situation.

Th1-like and Th2-like cytokines in patients undergoing open versus laparascopic cholecystectomy

The advantages of laparoscopic (LC versus, open cholecystectomy (OC) seems to be related to minimal invasive procedure and to the moderate inflammatory response. The aim of this study is to define the involvement of Th1 (IFN-gamma) and Th2 (IL-4, IL-6, IL-10, IL-13) cytokines production in vivo and in vitro in patients undergoing OC or LC. In 42 patients undergoing LC (n = 22) and OC (n = 20) Th1-like and Th2-like was evaluated before operation and at 6, 24 and 48 hours after operation for white blood cell counting and cytokines (IL-4, IL-6, IL-10, IL-13, IFN-gamma, TNF-alpha) in the sera and in the supernatants from circulating mononuclear cells stimulated with phytohemagglutinin or lipopolysaccharide. The acute phase response cytokine, IL-6, appeared significantly increased following OC than after LC. All other cytokines did not very significantly. In vitro data shows a reduction of IFN-gamma and increase in Th2-like cytokines in OC patients compared with the basal value. In LC subjects we observed an high production of IFN-gamma associated to an increase of Th2-like cytokines, like IL-10 and IL-13, even though IL-4 and IL-6 were unmodified. In contrast to OC, LC did not significantly affect immunocompetence, maintaining a moderate inflammatory response and an adequate balance between Th1 and Th2 cytokine. Furthermore, the strong activation of cells producing Th1-like cytokines in LC patients following mitogen activation indicated a consistent anti-microbial activity, that was not detectable in OC patients, that showed after activation only a Th2 response.

Tension-free hernia repair is associated with an increase in inflammatory response markers against the mesh

BACKGROUND

The purpose of this study was to evaluate the involvement of inflammatory mediators in patients undergoing Lichtenstein tension-free hernioplasty (LH) using polypropylene prosthetic materials or conventional Bassini hernia repair (BH).

METHODS

Thirty patients male with unilateral inguinal hernia without complications or recurrence were included in this study. Randomly, patients underwent LH or BH. Peripheral venous bloods samples were collected 24 hours prior to surgery and then 6, 24, 48 and 168 hours postoperatively.

RESULTS

We present evidences that LH patients showed a higher increased serum level of fibrinogen, C-reactive protein, alpha-1-antitrypsin, and interleukin-6 than BH patients. Postoperative visual analogue scales for pain were reduced on mobilization for patients undergoing LH compared with BH. Neutrophils were significantly increased only in LH compared with baseline. Ceruloplasmin, transferrin, and albumin levels were unmodified after BH or LH.

CONCLUSIONS

In conclusion our data show that although LH induces less pain and more rapid postoperative recovery, it is associated with an higher inflammatory response compared with BH, likely due to polypropylene mesh.

[Cell-mediated immunity after laparoscopic cholecystectomy]

Cell-mediated immunity (CMI) is temporarily decreased after major surgical procedures in relation to type of anaesthesia, length and severity of an intervention. In this study it has been evaluated CMI response in vivo, after laparoscopic (LC) and open cholecystectomy (OC). 5 healthy persons and 16 patients with symptomatic and uncomplicated gallstones were studied. They were subdivided in two groups: 8 were treated by OC, 8 by LC. A skin test system (Multitest, IMC-Institute Merieux, Lyon, France) consisting of a plastic disposable multiple-puncture device capable of simultaneous application of seven delayed-type hypersensitivity antigens and a glycerin and saline diluent (negative control) was used. The test was performed 48 hours before and 24 hours after the surgical procedure. A diameter of 2 mm or more of the induration was considered as a positive response. A score expressed, as the sum in millimeters of all the mean diameters (DM) of positive reactions and as numbers of antigens (NA) positive was calculated. Statistics was assessed by Student's t test for comparison of averages. There was no difference of age, sex, anesthesiologic risk, length of the operation between the two groups. We observed a significative reduction of DM (P < 0.05) and of NA (P < 0.05) in patients in which OC was performed while there were no significant in the group treated by LC. Results show a significant suppression of the CMI after OC, no particular changes after LC according to other studies in vitro.

[Changes in the hemostatic system after laparoscopic cholecystectomy]

A 30 degrees reverse Trendelenburg position and the pneumoperitoneum performed in patients undergoing at Laparoscopic Cholecystectomy (LC) cause haemodynamic modifications in inferior cava vein and in femoral veins producing a venous stasis in lower limbs. So that activation of coagulation with hypercoagulability occurs. The aim of this study is to value the modification of the haemocoagulative and fibrinolytic factors during LC and OC. 18 patients with symptomatic and non complicated lithiasis were examined. They were divided in two groups, nine patients for each group. LC was performed in first group and OC in the other group. Prothrombin time (PT), plasma-activated partial thromboplastin time (PTT), Antithrombin III (AT III) fibrinogen degradation products (FDP) were valued before and at 6, 12, 24, 48 hours after operation. For the statistical analysis Student "t" for average comparison was used. There were no relevant alterations of PT, PTT and ATIII after operation in the two groups. FP was increased after surgery, especially at 24th-48th hours in the group in which OC (p < 0.05) was performed. FDP were increased in both groups but only at 24 and 48 hour after OC (p < 0.05) the result was significant. Earlier mobilization and reduced invasivity of laparoscopy could contrast thrombotic effects of the blood stasis in the lower limbs when 30 degrees-45 degrees reverse Trendelenburg and pneumoperitoneum are performed.

[The intersigmoid hernia]

A case of intersigmoid hernia, personally observed is described, The various aspects of this pathology are examined and the imprecise clinical picture as well as the anatomical and diagnostic aspects and surgical techniques are underlined. The conclusion is drawn that a preoperative diagnosis is not easy and the importance of enteroclysma and TAC to prove the presence of hernia is underlined.

[Laparocele after laparoscopic surgery]

The authors have reported two laparocele cases in the place of insertion of the umbilical trocar, on 156 laparoscopic accesses made by them. Both cases took place at the beginning of their experience when the navel fascial breach had not yet been stitched. The authors made an extensive review of the medical literature and have found out that such complication is rare and to prevent it, it is right to stitch the navel fascial defect, being careful for not englobing the epiploon or an intestinal loop in the suture.

[Warthin's tumor of the parotid gland]

The Authors report 6 cases of Warthin's tumor of the parotid gland recently observed. In all cases the tumor was intraglandular, single, and no noteworthy disorders or symptoms except for a 2 to 5 cms tumefaction were present. At surgery all lesions appeared well-capsulated and the exeresis followed a cleavage plane easily identifiable which enabled the preservation of the residual glandular tissue as well as the surrounding nervous and vascular structures. All the patients, up to now, are free from relapse.

[Ulcerated carcinoma of the breast in an elderly woman. An unusual clinical case report]

The authors analyze the most current methods for the treatment of ulcerated breast cancer in the elderly. They describe a peculiar case recently observed, characterized by an ulcerative lesion spreading from the hemiclavicle to the foreaxilla including the axillary cavity, causing a large phlebo-lymphaedema, anaesthesia and paresis of the homoteral upper limb. After an initial treatment with tamoxifen a scapulo-humeral disarticulation and a suture of the cutaneous wide defect were performed using a myo-skin graft which included the deltoid muscle. A radiotherapeutic treatment followed by tamoxifen therapy was carried out. No distant metastases and no local relapses were registered in the one year follow up. The Authors on the basis of their experience and according to the review of the Literature suggest that age itself is not a limiting factor to the therapeutic approach of ulcerated breast cancer.

[Hypoxemia and pulmonary atelectasis after laparoscopic cholecystectomy]

The aim of this study is to evaluate, after laparoscopic (CL) or open (CO) cholecystectomy, the incidence of pulmonary atelectasis and hypoxaemia which are strictly related to the onset of pulmonary complications. Two groups of 20 consecutive patients affected by symptomatic and not complicated gallstone disease were cholecystectomized either using CO or CL. Hypoxaemia was assessed preoperatively and after operation. Postoperative determination was performed at the 4th, 8th, 12th and 24th hour and then every 12 hours until discharge from hospital. A not informed radiologist evaluated atelectasis through two X-rays, preoperatively and postoperatively at the 3rd day. Atelectasis cases were divided in micro, focal, segmental, lobar and of the entire lung. Statistic analysis was performed using the "t" Student test. No mortality or intraoperative complications occurred. The two groups were similar for age, sex, smoker percentage, obesity, preexisting pulmonary dysfunctions and anaesthesiological risk (ASA). Operative time resulted in longer in CL compared to CO patients although in an insignificant way. PO2 value resulted significatively reduced (P < 0.05) at 4th, 8th, 12th and 24th postoperative hour after CO, while subsequent measurements did not show significant differences. There was no evidence of PO2 significative reduction after CL. After operation atelectasis was found in 11 patients (55%) of CL group (P < 0.05) and in 17 patients (85%) of CO group (P < 0.001). Atelectasis observed in the group of 11 CL patients was represented by 7 micro and 4 focal types, while in the CO group 7 micro, 8 focal and 2 segmental types were found. This study suggests that CL alters the pulmonary function less than CO.

[The laparoscopic approach: a technical note]

The authors report their laparoscopic access technique. It has to be considered a variation of the classical closed technique, with the introduction of the Veress needle and the first trocar directly at the level of the fascia which is kept in traction by two Kochers.

[Complications of the laparoscopic access]

The Authors analysed the complications observed during 156 laparoscopic accesses. In 38 cases following the classic closed technique, two pneumoderma, one pneumoscrotum, one pneumoepiploon and two laparoceles were observed in the umbilical area. In 30 patients the laparascopic access was performed according to the open technique, registering a significant loss of gas during the operation though not compromising it in 4 patients, and two infections of the umbilical incision. In 88 cases the modified closed technique was used and only one infection in the umbilical trocar insertion area was observed. After discussing the incidence, the etiopathogenesis, the diagnosis and the treatment of complications related to the laparoscopic access, the Authors emphasize the fact that in patients with surgical scars near the naval or patients who have already undergone laparascopy, or those with a positive history of affections causing abdominal adherence, the laparoscopic access must be performed using the open technique.

[Persistent sciatic artery aneurysm. Case report]

Persistent sciatic artery is a rare vascular anomaly particularly interesting for possible complications as buttock aneurysm and ischemic or embolic. Authors describes a case of buttock aneurysm of persistent sciatic artery personally observed analyse its anatomic and clinical features, and lay stress on the importance of angiography as essential examination in order to an exact surgical treatment.

[Short-term and long-term surgical prophylaxis with pefloxacin]

In the present study the efficacy and safety of pefloxacin (400 mg/5 ml vial) intravenously administrated for surgical prophylaxis was assessed. Nine hundred and fifty-two patients were treated (599 M, 343 F), with a mean age of 57.9 years +/- 18.6 SD, and in all cases surgical prophylaxis was carried out according to the following scheme: short-term with 2 vials (800 mg) 1 h before the operation, repeated at 12 and 24 hours after the operation; long-term 2 vials (800 mg) 1 h before the operation repeated at 12 and 24 hours after the operation and followed by 1 vial every 12 h for other 2 days. The choice between the two schemes was conditioned by the type of operation and by the basic conditions of the patient. Pefloxacin was seen to be effective in preventing the onset of post-surgical infections (97%), also maintaining the clinical parameters considered within normal limits. Safety was also highly satisfactory, since only 22 (2.3%) cases of side effects occurred, particularly involving the gastro-intestinal system. Thus, in conclusion, the validity of pefloxacin in surgical prophylaxis, with special emphasis on its efficacy in elderly and compromised patients is asserted.

[Carcinomas of the small intestine]

Cancer of the small bowel observed at the 1st Surgical Clinic of Palermo University between 1964 and 1985 have been examined. In the light of reported data, the various factors that might explain the low frequency are analysed, stress being laid on the fact that non-pathognomonic clinical features present considerable diagnostic problems for an early diagnosis. The primary role of surgery in the treatment of such cancers is emphasised.

[Crohn disease and carcinoma of the small intestine]

A case of cancer of the small bowel associated with Crohn's disease with onset 21 years after the first clinical signs of the latter is reported. The patient survived for 20 months after cancer diagnosis. After noting the rare association between the two conditions, the aetiopathogenetic relations that can be called on to explain relations of causality are analysed and it is emphasised that it is impossible to distinguish symptoms from those of cancer due to the renewed inflammatory activity. Finally it is considered that to clarify unequivocably the relations between the two conditions further studies are required.

[Calcitonin inhibition of insulin-stimulated gastric secretion. A possibility of selective evaluation of gastric secretory function]

There is both clinical and experimental evidence for the antigastric effect of calcitonin. A study was therefore made of gastric secretion after maximum insulin stimulation, and during its inhibition by calcitonin. Evaluation of basal acid flow and the maximum acidity peak in these two tests showed that the difference between the two peaks was related to the increase in gastrin. This was not the case during inhibition. The results show that selective evaluation of gastric secretion enables selective surgical techniques to be employed in the treatment of duodenal ulcer.

[Chlorhydropeptic inhibition with atropine during stimulation with pentagastrin. A possibility of selective evaluation of gastric secretive function]

Basal secretion and the acidity peak have been evaluated in ulcerous patients during pentagastrinic stimulation and during atropinic inhibition, on the basis of the observations of Schofield et al. and in relation to the need to achieve correct identification and quantification of hydrochloric acid gastric secretive function. The results obtained with this technique suggest the possibility of a selective evaluation of the secretive function of oxyntic cells. This is extremely interesting because it opens the way to the most suitable surgical techniques for the treatment of ulcers.