Attilio Maria Farinon

Systemic acute-phase response after laparoscopic and open cholecystectomy.

Background: Cytokines are the main mediators of inflammation and the response to trauma. The purpose of this study was to compare variations in cytokine levels following laparoscopic cholecystectomy (LC) and minilaparotomy cholecystectomy (OC), since these two types of operations were considered to be a unique model for examining the role of local tissue injury in postoperative inflammatory reactions. Methods: A total of 40 patients were studied. Eighteen of them underwent LC; the remaining 22 were operated on using the open technique. Systemic concentrations of interleukin- 6 (IL-6), interleukin-1 (IL-1), tumor necrosis factor (TNF), and C-reactive protein (CRP) were measured before and after the operation. In addition, we compared pre- and postoperative white blood cell (WBC) counts, postoperative body temperature, and length of postoperative hospitalization. Results: There was no difference between the two groups in IL-1 and TNF response. The rise in plasma IL-6 levels (18.86 ± 9.61 vs 5.00 ± 0.0 pg/ml, p < 0.0001) and CRP (8.40 ± 5.81 vs 1.43 ± 1.30 mg/dl, p < 0.001) were more marked after open cholecystectomy than after the laparoscopic procedure. There was no correlation between serum CRP concentrations and the other postoperative parameters. Conclusion: The magnitude of the acute-phase response was less pronounced following laparoscopic cholecystectomy, consistent with a reduction in tissue trauma.

Randomized comparison of Limberg flap versus modified primary closure for the treatment of pilonidal disease

BACKGROUND The best surgical technique for sacrococcygeal pilonidal disease is still controversial. The aim of this randomized prospective trial was to compare both the results of Limberg flap procedure and primary closure. METHODS A total of 260 patients with sacrococcygeal pilonidal disease were assigned randomly to undergo Limberg flap procedure or tension-free primary closure. RESULTS Success of surgery was achieved in 84.62% of Limberg flap patients versus 77.69% of primary closure (P = .0793). Surgical time for primary closure was shorter. Wound infection was more frequent in the primary closure group (P = .0254), which experienced less postoperative pain (P < .0001). No significant difference was found in time off from work (P = .672) and wound dehiscence. Recurrence was observed in 3.84% versus 0% in the primary closure versus Limberg flap group (P = .153). CONCLUSIONS Our results do not show a clear benefit for surgical management by Limberg flap or primary closure. Limberg flap showed less convalescence and wound infection; our technique of tension-free primary closure was a day case procedure, less painful, and shorter than Limberg flap.

Dermoid cyst of the pancreas: presentation and management

BackgroundDermoid cyst of the pancreas is a benign, well-differentiated, extremely rare germ cell neoplasm. Published data indicate that differential diagnosis of cystic lesions of the pancreas is challenging and although ultrasonography, computed tomography and magnetic resonance may be useful, radiological findings are often inconclusive and the diagnosis is intraoperative. We report a case of a dermoid cyst of the tail of the pancreas intraoperatively diagnosed and successfully treated with left pancreatectomy. Further, characteristics, preoperative detection and differential diagnosis of this rare pathology are also discussed.Case presentationThis report documents the findings of a 64-year-old male presenting with a well defined echogenic pancreatic mass on ultrasonography. Computerized Tomography (CT) showed a 5 cm cystic tumor arising from pancreatic tail and Magnetic Resonance Imaging (MRI) suggested a tumor extension to the middle side of the stomach without defined margins. A left pancreatectomy was performed. On surgical specimen, histological evaluation revealed a dermoid cyst of the tail of the pancreas measuring 8.5 × 3.0 cm.ConclusionGiven the benign nature of the dermoid cyst, surgical resection most likely represents the definitive treatment and cure. In addition, resection is indicated in consideration of the difficulty in diagnosing dermoid cyst preoperatively. However, endoscopic ultrasound and fine needle aspiration cytology have recently been shown to be effective, safe, reliable and cost-saving preoperative diagnostic tools. Therefore, until more cases of dermoid cyst are identified to further elucidate its natural history and improve the reliability of the preoperative diagnostic tools, surgical resection should be considered the standard therapy in order to exclude malignancy.

Helicobacter pylori and gastroesophageal reflux disease

BackgroundThe nature of the relationship between Helicobacter pylori and reflux oesophagitis is still not clear. To investigate the correlation between Helicobacter pylori infection and GERD taking into account endoscopic, pH-metric and histopathological data.MethodsBetween January 2001 and January 2003 a prospective study was performed in 146 patients with GERD in order to determine the prevalence of Helicobacter pylori infection at gastric mucosa; further the value of the De Meester score endoscopic, manometric and pH-metric parameters, i.e. reflux episodes, pathological reflux episodes and extent of oesophageal acid exposure, of the patients with and without Helicobacter pylori infection were studied and statistically compared. Finally, univariate analysis of the above mentioned data were performed in order to evaluate the statistical correlation with reflux esophagitis.ResultsThere were no statistically significant differences between the two groups, HP infected and HP negative patients, regarding age, gender and type of symptoms. There was no statistical difference between the two groups regarding severity of symptoms and manometric parameters. The value of the De Meester score and the ph-metric parameters were similar in both groups. On univariate analysis, we observed that hiatal hernia (p = 0,01), LES size (p = 0,05), oesophageal wave length (p = 0,01) and pathological reflux number (p = 0,05) were significantly related to the presence of reflux oesophagitis.ConclusionBased on these findings, it seems that there is no significant evidence for an important role for H. pylori infection in the development of GERD and erosive esophagitis. Nevertheless, current data do not provide sufficient evidence to define the relationship between HP and GERD. Further assessments in prospective large studies are warranted.

Long saphenous vein stripping reduces local level of reactive oxygen metabolites in patients with varicose disease of the lower limbs.

Long saphenous vein (LSV) stripping is the most common surgical procedure in patients affected by varicose disease of the lower limbs. Reactive oxygen metabolites (ROM) generation plays a crucial role in chronic venous insufficiency (CVI). The aim of this study was to investigate whether ROM generation is increased in patients affected by varicose disease versus healthy controls and whether LSV stripping has a positive effect on the local production of ROM. The local production of ROM was assessed measuring hydroperoxides in the blood collected from the leg of 30 patients consecutively undergoing LSV stripping and 30 controls. In both the patient group and the control group, the test was repeated 30 days later. We found that ROM levels before surgery are higher in varicose vein patients than in controls (p < .0001) and that ROM are significantly reduced 30 days after LSV stripping (p < .0001). At that time point, no significant differences between patients and controls was found. We also found that sex and age do not affect ROM concentration in patients and controls, either before or after surgery. In conclusion, our data indicate that CVI is characterized by significant oxidative stress and that LSV stripping is able to normalize local production of ROM in patients with varicose disease of the lower limbs. We suggest that measurement of ROM might be useful to test the positive effects of LSV stripping in these patients.

Primary Malignant Fibrous Histiocytoma of the Duodenum

Background/Aim: We report on a case of primary malignant fibrous histiocytoma of the duodenum. Methods: Report of a case and review of the literature on the occurrence of this tumor in the alimentary tract. Results: The neoplasm was detected incidentally at the time of diagnostic workup for upper gastrointestinal bleeding. Curative surgery using the Whipple procedure was carried out with uneventful postoperative course; no evidence of liver metastases was detected during intraoperative ultrasonography. The patient died of diffuse metastatic liver disease 2 months after surgical resection. Up-to-date review of the literature has added only 3 cases to those previously reported, including that reported by us. Conclusions: The biological behavior of malignat fibrous histiocytomas is extremely aggressive and mainly conditioned by size and histological grading. The treatment of choice, whenever possible, is based on early and complete surgical excision of the tumor.

Technetium-99m HIDA hepatobiliary scanning in evaluation of afferent loop syndrome.

A study of 118 patients, operated on with Billroth II gastrectomy for peptic disease and affected by postgastrectomy syndromes, was carried out. Fifty patients were investigated by means of technetium-99m HIDA hepatobiliary scanning. In 18 patients, in whom an afferent loop syndrome was clinically suspected, hepatobiliary scanning demonstrated an altered afferent loop emptying in 8 and atonic distension of the gallbladder without afferent loop motility changes in 10. Among the patients in the first group, four were treated with a biliary diversion surgical procedure and in the second group, two patients underwent cholecystectomy. Our findings indicate that biliary vomiting, right upper abdominal pain pyrosis, and biliary diarrhea in Billroth II gastrectomized patients are not always pathognomonic symptoms of afferent loop syndrome. Technetium-99m HIDA hepatobiliary scanning represents the only diagnostic means of afferent loop syndrome definition. A differential diagnosis of abnormal afferent loop emptying and gallbladder dyskinesia is necessary for the management planning of these patients, and furthermore, when a surgical treatment is required, biliary diversion with Roux-Y anastomosis or Brauns biliary diversion seems the treatment of choice for afferent loop syndrome, whereas cholecystectomy represents the best procedure for atonic distension of the gallbladder.

Advances in treatment of obstructed defecation: Biomesh transperineal repair.

To the Editor—We read with interest the article on the successful treatment of enterorectocele and rectal intussusceptions with use of a combined abdominal and transperineal approach by Pescatori. According to the author, we believe that the combined abdominal and transperineal treatment of all the anatomic abnormalities of both bowel and rectum has a key role in allowing satisfactory results. Moreover, a combined laparoscopic and transperineal approach seems less invasive. D’Hoore and colleagues reported excellent results with obstructed defecation symptom improvement in 14 of 18 patients with enterorectocele and rectal intussusception treated both laparoscopically and transperineally. Besides, according to several authors and in our experience, transperineal repair of rectocele with mesh seems to be the standard procedure to repair rectocele, especially using biomeshes. Actually, both transanal and transvaginal repairs have shown several limitations: resting and squeeze pressure reduction after transanal repair, and dyspareunia and persistence of obstructed defecation after transvaginal repair. Porcine acellular collagen matrix (Pelvicol®, C. R. Bard, Cranston, RI) seems to reduce postoperative complications. Recently, we successfully treated both a 48year-old woman and a 45-year-old woman, who had third degree symptomatic rectocele, with use of Pelvicol® Biomeshes placed transperineally in the rectovaginal space and anchored to the levator plate on each side. Synthetic meshes have been associated with poor wound healing, infection, and mesh erosion. Pelvicol® is an acellular sheet of porcine dermal collagen in which the collagen fibers have been cross-linked by use of diisocyanate to avoid graft biodegradation. It is not cytotoxic, hemolytic, pyrogenic, or allergenic, and it was used in inguinal, incisional, and parastomal hernia repairs. It seems especially helpful in the perineal repairs, which are at high risk of wound contamination. Actually, given the immediate contact between vaginal, rectal wall, and underlying host tissues through fenestrations in the mesh graft material, delayed healing and infective complications seem less frequent.

Evaluation of clinical, laboratory and morphologic prognostic factors in colon cancer

BackgroundThe long-term prognosis of patients with colon cancer is dependent on many factors. To investigate the influence of a series of clinical, laboratory and morphological variables on prognosis of colon carcinoma we conducted a retrospective analysis of our data.MethodsNinety-two patients with colon cancer, who underwent surgical resection between January 1999 and December 2001, were analyzed. On survival analysis, demographics, clinical, laboratory and pathomorphological parameters were tested for their potential prognostic value. Furthermore, univariate and multivariate analysis of the above mentioned data were performed considering the depth of tumour invasion into the bowel wall as independent variable.ResultsOn survival analysis we found that depth of tumour invasion (P < 0.001; F-ratio 2.11), type of operation (P < 0.001; F-ratio 3.51) and CT scanning (P < 0.001; F-ratio 5.21) were predictors of survival. Considering the degree of mural invasion as independent variable, on univariate analysis, we observed that mucorrhea, anismus, hematocrit, WBC count, fibrinogen value and CT scanning were significantly related to the degree of mural invasion of the cancer. On the multivariate analysis, fibrinogen value was the most statistically significant variable (P < 0.001) with the highest F-ratio (F-ratio 5.86). Finally, in the present study, the tumour site was significantly related neither to the survival nor to the mural invasion of the tumour.ConclusionThe various clinical, laboratory and patho-morphological parameters showed different prognostic value for colon carcinoma. In the future, preoperative prognostic markers will probably gain relevance in order to make a proper choice between surgery, chemotherapy and radiotherapy. Nevertheless, current data do not provide sufficient evidence for preoperative stratification of high and low risk patients. Further assessments in prospective large studies are warranted.

Teaching subfascial perforator veins surgery: survey on a 2-day hands-on course

Background : The present paper describes a training method with objective evaluation to enhance video‐assisted surgical skills in subfascial endoscopic perforator veins surgery (SEPS). Training was scheduled during a 2‐day intensive course.