Maria Sofia

External Jugular Vein Cutdown Approach, as a Useful Alternative, Supports the Choice of the Cephalic Vein for Totally Implantable Access Device Placement

BackgroundCephalic vein (CV) cut down for totally implantable venous access device (TIVAD) placement has been accepted as an alternative to the percutaneous subclavian vein approach. The aim of this retrospective study was to validate the external jugular vein (EJV) cut-down approach when the CV is not feasible.MethodsPatients receiving a TIVAD from January 1995 to December 2003 were included in this study. Age, sex, surgical technique, disease, device used, length of the procedure, and morbidity were considered.ResultsA total of 427 TIVADs were placed in 425 patients: 253 men (59.5%) and 172 women (40.5%) aged 31 to 79 years. Of 425 patients, 5 were excluded; 420 underwent a CV cut down on the first attempt, and 391 (93.1%) procedures were successful. Among the final 29 patients, 20 (68.96%) underwent a TIVAD placement through the ipsilateral EJV cut-down approach. In the remaining nine patients (31.04%), TIVAD placement was performed through the ipsilateral internal jugular vein in four cases, via the ipsilateral axillary vein in three cases, and through the ipsilateral coracobrachial vein in the other cases. No immediate postoperative complications were detected in any of the patients.ConclusionsTIVAD placement by the CV cut-down approach is safe and fast, and its success rate is very high. By avoiding the immediate complications associated with the percutaneous approach, the EJV cut down has to be considered a valid, safe, and suitable alternative when the CV is not feasible.

Hepatic resections using a water-cooled, high-density, monopolar device: a new technology for safer surgery.

Several techniques and devices have recently been developed in an effort to allow safer liver resections and avoid intraoperative blood loss. The aim of this study was to analyze our initial experience with hepatic resections using a new water-cooled, high-density, monopolar device—the Tissuelink Monopolar Floating Ball (Tissuelink Medical, Inc., Dover, NH)—in order to avoid bleeding during hepatic surgery. We analyzed patients who underwent hepatic surgery between January and June 2003. Sex, age, type of disease, and type of surgical procedure, in association with the duration of the surgical procedure, blood loss, use of vascular clamping of the liver, length of hospital stay, morbidity, and mortality were analyzed. Seven minor liver resections, two major liver resections, and one total cystopericystectomy were performed with the use of this new device. Average blood loss was 150 ml (range 50 to 300 ml). No vascular clamping was used with the exception of one patient. No deaths were recorded. Morbidity included ascites in one case and pleural effusion in another. In conclusion, the Tissuelink Monopolar Floating Ball permitted excellent coagulation of the cut liver surface, thus avoiding bleeding and vascular clamping. As a result, postoperative morbidity and mortality were low.

Simultaneous laparoendoscopic rendezvous for the treatment of cholecystocholedocholithiasis

BackgroundDifferent approaches are available for the treatment of combined cholecystocholedocholithiasis including totally laparoscopic (TL) treatment, simultaneous laparoendoscopic treatment, and sequential treatments (ST) combining endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) with cholecystectomy. This review aimed to clarify the issue of the simultaneous laparoendoscopic rendezvous (RV).MethodsA careful analysis of papers was performed to determine the results, technical differences, limits, disadvantages, and advantages of RV compared with other options.ResultsData were collected from 27 papers concerning 795 patients. The overall effectiveness of RV was 92.3%. The morbidity rate was 5.1%, and the mortality rate was 0.37%. Almost all the authors were satisfied with the procedure. The authors’ comparison to ST and TL showed that the advantages outweigh the disadvantages mostly related to logistical problems.ConclusionsThere is confusion concerning the definitions and techniques of RV due to differences in combining surgical and endoscopic steps of the procedure. The results are at least comparable with those of the other available approaches. The effectiveness of RV is greater with reciprocal implementation of surgical and endoscopic procedures. The morbidity and the risk of iatrogenic damage seem lower than with ERCP-ES and the risk of residual stones lower than with TL treatment. The RV procedure is safe and can sometimes be the preferable option, but collaboration between surgeon and endoscopist is mandatory.

Adjusting CA19-9 values to predict malignancy in obstructive jaundice: Influence of bilirubin and C-reactive protein

AIM To find a possible relationship between inflammation and CA19-9 tumor marker by analyzing data from patients with benign jaundice (BJ) and malignant jaundice (MJ). METHODS All patients admitted for obstructive jaundice, in the period 2005-2009, were prospectively enrolled in the study, obtaining a total of 102 patients. On admission, all patients underwent complete standard blood test examinations including C-reactive protein (CRP), bilirubin, CA19-9. Patients were considered eligible for the study when they presented obstructive jaundice confirmed by instrumental examinations and increased serum bilirubin levels (total bilirubin > 2.0 mg/dL). The standard cut-off level for CA19-9 was 32 U/mL, whereas for CRP this was 1.5 mg/L. The CA19-9 level was adjusted by dividing it by the value of serum bilirubin or by the CRP value. The patients were divided into 2 groups, MJ and BJ, and after the adjustment a comparison between the 2 groups of patients was performed. Sensitivity, specificity and positive predictive values were calculated before and after the adjustment. RESULTS Of the 102 patients, 51 were affected by BJ and 51 by MJ. Pathologic CA19-9 levels were found in 71.7% of the patients. In the group of 51 BJ patients there were 29 (56.9%) males and 22 (43.1%) females with a median age of 66 years (range 24-96 years), whereas in the MJ group there were 24 (47%) males and 27 (53%) females, with a mean age of 70 years (range 30-92 years). Pathologic CA19-9 serum level was found in 82.3% of MJ. CRP levels were pathologic in 66.6% of the patients with BJ and in 49% with MJ. Bilirubin and CA19-9 average levels were significantly higher in MJ compared with BJ (P = 0.000 and P = 0.02), while the CRP level was significantly higher in BJ (P = 0.000). Considering a CA19-9 cut-off level of 32 U/mL, 82.3% in the MJ group and 54.9% in the BJ group were positive for CA19-9 (P = 0.002). A CA19-9 cut-off of 100 U/mL increases the difference between the two groups: 35.3% in BJ and 68.6% in MJ (P = 0.0007). Adjusting the CA19-9 value by dividing it by serum bilirubin level meant that 21.5% in the BJ and 49% in the MJ group remained with a positive CA19-9 value (P = 0.003), while adjusting the CA19-9 value by dividing it by serum CRP value meant that 31.4% in the BJ group and 76.5% in the MJ group still had a positive CA19-9 value (P = 0.000004). Sensitivity, specificity, positive predictive values of CA19-9 > 32 U/mL were 82.3%, 45% and 59.1%; when the cut-off was CA19-9 > 100 U/mL they were, respectively, 68.6%, 64.7% and 66%. When the CA19-9 value was adjusted by dividing it by the bilirubin or CRP values, these became 49%, 78.4%, 69.4% and 76.5%, 68.6%, 70.9%, respectively. CONCLUSION The present study proposes CRP as a new and useful correction factor to improve the diagnostic value of the CA19-9 tumor marker in patients with cholestatic jaundice.

Liver resection for hepatic metastases from adrenocortical carcinoma

Liver metastases from adrenocortical carcinoma are very rare and no clear indications for surgery exist. The aim of the present work was to define surgical indications for these neoplasms. All the patients submitted to hepatic resection for liver metastases from adrenal carcinoma reported in the literature (PubMed source) from 1978 to 2005 were considered for the present study. Forty-eight patients were found in the period of study, but it was only possible to obtain certain data for nine patients (18.7%). The data investigated suggest that metachronous metastases, developed after a minimum of 1 year from the primary tumor, and completely removable, may represent an indication for surgery - although this still needs to be proved.

Recurrent Aortoduodenal Fistula

Aortoenteric fistula is defined as a communication between the aorta and an adjacent loop of the bowel and is often the cause of devastating upper gastrointestinal tract bleeding with only few survivors. According to the etiology, the aortoenteric fistulas are classified as primary aortoenteric fistula or secondary aortoenteric fistula (SAEF) after previous aortic surgery. The recurrence of a fistula on a previous SAEF is defined as recurrent aortoenteric fistula and is reported only in a few rare cases occurring within an unpredictable period from the previous surgical treatment. We describe a unique case of recurrent aortoenteric fistula, in which the relationship with recurrence consisted of the presence of the metallic clips of a stapled suture to close the duodenal wall during the previous SAEF repair. A review of the published data on this subject was performed to analyze the clinical features, the overall results, the risk factors of recurrence, and the main technical points of surgical treatment to prevent it.

Laparoscopic implementation of the Altemeier procedure for recurrent rectal prolapse. Technical note

INTRODUCTION Many surgical options exist to treat rectal prolapse with different indications, feasibility and results in urgent and complicated cases. These include perineal or abdominal approaches including rectopexy with or without resection. Perineal approaches have reduced surgical invasivity and hospital stay if compared to transabdominal approaches by open surgery or laparoscopy. Up to now there was still a clear dividing line for surgical treatment between the perineal approach, used more for complicated emergency case while the transabdominal open, or laparoscopic approach more common in elective surgery, but more complex to perform. PRESENTATION OF CASE A 37 year old female patient affected by psychiatric disease presented with an unreducible second recurrence of a complicated rectal prolapse. The patient was treated with a third Altemeier procedure but now performed under laparoscopic control. The patient recovered promptly without any complication or recurrence up to the 24 months follow-up. DISCUSSION To the best of our knowledge, this is the first case report describing the combined laparoscopic-perineal approach for the treatment of a complicated recurrence of rectal prolapse. The technical feasibility, the rapidity, the optimal outcome and the rationale behind this option all suggest that this laparoscopic assistance certainly allows an implementation of the effectiveness, safety and results of an established effective perineal approach. CONCLUSION This combined approach has the advantage of maintaining the simplicity and rapidity of conventional perineal surgery, adding the advantages of abdominal control and avoiding the risks, the invasivity, and the longer duration of more complex laparoscopic procedures.

Treatment of cholecysto-choledocolithiasis in elderly patients: personal experience

Background Biliary stones are a common disease in western countries, and its management has changed dramatically over the past decade. Due to the increase of the middle-aged people, a larger number of elderly patients are affected by this disease. Laparoscopic cholecystectomy (LC) represents the gold standard for the treatment of gallbladder stones, and in cholecystectomized patients, the treatment of CBD stones remains the exclusive work of the endoscopist. But if the patient still has the gallbladder with stones, the ideal management of CBD stones remains controversial. There are two treatment options: the two time (LC and pre or postoperative ERCP), and the one time procedures (trans cystic approach and CBD exploration and laparoendoscopic procedure called “rendezvous”:RV). The aim of the work is to analyse our results of the mininvasive treatment of the cholecysto-choledocolithiasis in elderly patients.

Muscle-Sparing Approach for Recurrent Hydatidosis of the Thigh and Psoas: Report of a Rare Case

A 46-year-old male shepherd presentedwith a mildly painful mass 4.5 cm indiameter localized at the right groin andthigh, diffuse edema involving the right leglasting for 2 weeks, and fever. The patienthad had eight previous operations fordiffuse hydatidosis with reported intraper-itoneal seeding, but further informationwas unavailable.Laboratory tests are shown in Table 1.An abdominal ultrasound (US) and aDoppler US of the right leg detected thepresence of multiple and partially confluentcysts localized up to the Scarpa’s triangle. Acomputed tomography (CT) scan detecteda multi-cystic 18-cm mass originating fromthe psoas muscle (Figure 1, I and II). Othercysts were localized deeply and behind themuscular aponeurotic plane of the femoralquadriceps and abductor muscles (Figure 1,III and IV). All these findings were sug-gestive of diffuse hydatidosis and the patientwas promptly operated on with a muscle-sparing approach, for which a writtenconsent was obtained.Piperacillin/tazobactam was adminis-tered from the date of admission to theday of surgery. Preoperative prophylaxiswith benzimidazole derivatives was notperformed due to the extent of the disease,the history of recurrences, and the need toperform the operation promptly to reducethe symptoms.At surgery, the retroperitoneum wasaccessed and tissues surrounding the cystswere covered with sponges soaked withhypertonic saline. The cystic content wasevacuated and the interior of the cyst wasrepeatedly washed with protoscolicides.Due to the tight adhesions with the peri-toneal sac, only the lateral-lower portionof the cystic wall could be resected. Nodaughter cyst was found. Subsequently,the right thigh was anteriorly incised andthe cysts were evacuated. The washingtreatment was repeated but extensive resec-tion was avoided to prevent any risk ofunnecessary damage.Histopathological examination did notdetect viable protoscolices and routinecultures performed to individuate otherpathogens were negative.A CT scan performed before dischargeshowed the integrity of the psoas muscle(Figure 2, I and II) and the lack of residualcysts in the thigh with conservation of themuscular structures (Figure 2, III and IV).The patient was discharged after 11 dayswith 6 months of administration ofmebendazole. Further investigations couldnot be performed because the patientmissed the planned follow-up.