G Tucci

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.

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.

Fournier’s gangrene wound therapy: our experience using VAC device

We read with interest the article by Czymek et al. [1] about Fournier’s gangrene in women [1]. Since Fournier first described in 1883, young men’s disease affecting scrotal region, different authors outlined that although male genitalia are usually involved, the condition has also been recognized ten times less frequently in females. Nevertheless, female gender can be considered a negative prognostic factor, as recently underlined by Czymek [1]. Accordingly, other authors found that different anatomy could explain both the lower incidence and the fatal outcome in women. In the modern era, Fournier gangrene (FG) can still be considered a potentially fatal disease; first line treatment consists of an aggressive surgical debridement and antibiotics. Besides, different protocols have been proposed for postoperative wound care: unprocessed honey, hyperbaric oxigenation, grown hormones, growing agents, and vacuum-dressing technologies. Recently, we successfully treated with the vacuum assisted closure device (V.A.C.®) an 88and a 66 yearold women who had presented with an extensive ischiorectal and perineal abscesses and had previously submitted to surgical debridement and abscess drainage. Clinical examination showed in both cases acute infection involving mons pubis, labia majora, right groin, and at the back, the gluteal fold. Computed tomography imaging revealed an inflammatory process of the superficial fascia and the subcutaneous fat with necrosis and soft tissue gas collection, involving the pubic region and the lateral abdominal walls. Postoperatively, they were both treated using VAC therapy from sixth postoperative day. Large sponge cut into several pieces were used for the wounds. The drape was cut and placed over the sponge, and suction was applied. Dressings were initially changed every 72 h. Marked improvements were observed in successive wound assessments and a repeat MRI performed on days61 and 73 demonstrated wounds healed. Following initial debridement, FG’s wound healing by secondary intention may be time spending. Conventional dressings require painful daily and additional changes due to blood and fluids from the wound, with quality-of-life impairment. Vacuum-assisted closure device is a wound care system that promotes healing providing continous negative pression by a portable pump connected to the foam sponge placed in the wound. VAC therapy can be reapplied every 48–72 and results less painful and more comfortable for patients [1]. VAC devices increase fibroblast migration and cell proliferation improving clinical outcome [5]. Accordingly, other authors reported improved wound healing using VAC compared with conventional gauze therapy. Rosser et al [2] reported a faster discharge using VAC in the management of perineal large soft-tissue defects. Differently, Czymek [1] found no difference in wound healing time comparing VAC with conventional dressing. Besides this, VAC therapy was useful in different situations: by acting as a barrier to fecal soilage in Langenbecks Arch Surg (2009) 394:759–760 DOI 10.1007/s00423-009-0486-8

Endoscopic single-port "components separation technique" for postoperative abdominal reconstruction.

BACKGROUND: In 1990, Ramirez introduced a new procedure to close abdominal wall hernia (AWH), called “components separation technique (CST)”. Thanks to endoscopy, surgical repair possibilities have risen, reducing the operative trauma and preserving vascular and neuronal anatomical structures. This report aims to describe a single port endoscopic approach for CST to repair the abdominal wall of a patient undergoing surgery for abdominal aneurysm and already subject to placement of a mesh for AWH. METHODS: We performed endoscopic-assisted CST, using a single-port access with a gasless technique. CONCLUSION: CST is a useful procedure to close large abdominal wall incisional hernia avoiding the use of mesh, notably under contamination, when prosthetic material use is contraindicated. The endoscopic-assisted CST produces same results than the conventional open separation technique and also minimised tissue trauma that ensures blood supply and prevents postoperative wounds complications. The described single port method was found to be safe and effective to close large midline abdominal hernias when a primary open or laparoscopic closure is not feasible or when patients have been previously treated with abdominal meshes.