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PubMed2002

Management of spontaneous bleeding due to hepatocellular carcinoma.

BACKGROUND: Spontaneous rupture is a life-threatening complication of HCC, occurring in 4.8-26% of cases. Liver failure is the main cause of death. Debates still remain on the most appropriate treatment in such patients because of the high operative mortality of emergency surgery and the high risk of rebleeding and less satisfying mid- and long-term results of nonoperative procedures like angiographic embolization. Early and long-term results of a surgically oriented treatment, based on prompt evaluation of the functional liver reserve and tumor resectability was retrospectively review-ed. METHODS: From January 1994 to December 2000, 11 patients (7 males and 4 female, mean age 66.2 (11.86 years) were treated for ruptured HCC, in 10 cases involving a cirrhotic liver. Seven patients underwent emergency surgery and 4 patients transcutaneous arterial embolization (TAE). Liver resection was performed in patients with preserved liver function, after ultrasonography and/or CT scan demonstrated hemoperitoneum and a single resectable liver tumour (5 cases). In one patient with cirrhosis, ultrasonography showed only hemoperitoneum. A bleeding nodule was discovered intraoperatively and resected in a liver with a multinodular HCC. Another patient under-went emergency resection after referral at our Unit with a surgical packing. In 4 cases with poor liver function and/or unresectable tumour TAE of the neoplasm was performed, in one case after surgical packing. Mortality, morbidity and patients survival after treatment were analyzed. All patients had at least 1 year follow-up. RESULTS: All patients underwent minor resection; 2 left lobectomies, 1 segmentectomy (VII), 1 bisegmentectomy (VII-VIII), and 3 wedge resections. Postoperative course was complicated by ascites in 5 cases and subphrenic abscess in one case. Four patients died 3, 4, 6 and 62 months after surgery; 3 patients are actually alive 22, 25, and 89 months after surgery. Four patients were submitted to TAE: all patients died within 6 months. CONCLUSIONS: When ruptured HCC is suspected, preserved liver function (Child A-B7) and a resectable hepatic tumour are considered clear indications to surgery. Emergency liver resection achieved good early and long-term results. In cases of advanced liver disease or multinodular HCC a non-operative approach, like TAE, must be attempted. Surgical direct hemostasis or hepatic artery ligation must be reserved for patients with uncontrollable o recurrent bleeding after TAE.

Aged↗
PubMed2002

[Radiologic pneumoperitoneum without perforation of a hollow viscus].

About 10% of the radiological pneumoperitoneums occur without hollow viscus perforation. Pseudopneumoperitoneum is defined when the subphrenic lucency does not correspond to free intraperitoneal air: subphrenic fat pad, linear lung atelectasis, abnormal subphrenic shape, Chilaïditi syndrome or subphrenic abscess. True pneumoperitoneum without hollow viscus perforation may result from diffusion of thorax-derived air through a phrenic defect or along sheaths of mediastinal blood vessels. The female genital tract represents another route for intraperitoneal air penetration. Other etiologies include iatrogenic pneumoperitoneum (after abdominal surgery and digestive endoscopy) and pneumatosis cystoides intestinalis, when the subserous intraparietal gaseous bubbles rupture into the peritoneal cavity.

Diagnosis, Differential↗
PubMedDate not supplied

New insight for management of blunt splenic trauma: significant differences between young and elderly.

BACKGROUND/AIMS: Although highly successful in children and young patients, the non-operative management of blunt splenic injury in the elderly has yet to be clearly studied. The purpose of this study was to determine whether or not a relationship exists among the mechanism of injury, the grade of splenic injury, the associated injuries, and whether patterns of injury differ between the young group (younger than 60 years old) and the elderly group (60 years and older than 60 years). METHODOLOGY: One hundred and sixty-seven patients (116 young patients including 30 early deaths and 51 elderly patients including 20 early deaths) with blunt splenic injury were admitted to our clinic from 1983 to 1997. Computed tomography scans were interpreted in a blind fashion. In addition, the Injury Severity Score, Glasgow Coma Scale, blunt splenic injury grade, length of hospital stay, length of intensive care unit stay, survival, number of abdominal injuries and number of total diagnoses were investigated in both the young and elderly groups. The different types of management for blunt splenic injury were also studied. RESULTS: Higher injury severity scores, lower Glasgow Coma Scales, and higher mortality all indicated that the elderly were more severely injured than the young patients. The rate of non-operative treatment was also significantly greater for young patients than for elderly patients (62.8 vs. 32.3%, P < 0.05) and the rate of a splenectomy was significantly less for the young patients than for the elderly patients (29.1 vs. 51.6%, P < 0.05). Regarding infectious complications, the rates of pneumonia (14.0 vs. 23.1%, P < 0.05), subphrenic abscess (9.3 vs. 23.1%, P < 0.05), and urosepsis (7.0 vs. 23.1%, P < 0.05) was significantly greater for the elderly patients than for the young patients. The overall failure of non-operative management was 5.2% in the young patients and 9.8% in the elderly patients. CONCLUSIONS: The final selection of splenic management decision was individualized for each patient and based on multiple variables. For persistent hemodynamic instability or unresolved concerns for other individual pathologic conditions, aggressive management is recommended. In the absence of these two important conditions, the variables that predicted a need for operative intervention include an Injury Severity Score above 20 in younger and elderly patients; an American Association for the Surgery of Trauma splenic grade above III in elderly; a large hemoperitoneum on an initial computed tomography scan; the presence of active extravasation on an initial computed tomography scan; and high-energy mechanisms. In conclusion, selecting the optimal non-operative management of blunt splenic injury in elderly patients remains difficult. An aggressive initial operation is thus recommended because the specific fragility of the spleen and the decreased physiologic reserve in elderly patients is difficult to estimate, especially at small hospitals where performing emergency splenic angiography and treating embolisms is difficult.

Adult↗
PubMedDate not supplied

Liver metastases from breast cancer. Results of surgical resection.

BACKGROUND/AIMS: Purpose of this study is to define the effectiveness of surgical resection of liver metastases from operated breast cancer. METHODOLOGY: Nineteen patients underwent surgical exploration to resect liver metastases from previously operated breast carcinoma. Seventeen patients were resected: 15 patients had unique metastases and were submitted to a wedge liver resection while 2 had multiple lesions; in these cases a V-VI segmentectomy and a right hepatectomy was required. After liver resection 11 patients received chemotherapy, 2 chemotherapy plus hormone therapy, 2 hormone therapy alone and in the remaining 2 no adjuvant treatment was done. RESULTS: Postoperative mortality was nil and morbidity consisted of 1 subphrenic abscess and 1 pleural effusion. Actuarial 5-year survival rate was 46%. Eight patients are still alive, 7 of whom are disease-free. Nine patients died for neoplastic progression. CONCLUSIONS: Surgical resection of liver metastases from breast cancer seems to be able to improve long-term survival in selected patients with unique and isolated lesions especially in association to systemic chemotherapy and hormone therapy.

Adult↗
PubMed2002

[Radical surgical treatment of gastric cancer. Personal experience].

After surgical therapy the survival outcome of gastric cancer is still poor. Early diagnosis and radical surgery are the two most important means to improve the prognosis. Radical surgery must include all lymph nodes embryologically related to stomach. The aim of this study was to verify whether an aggressive surgical strategy can increase postoperative survival rate. In the period 1990-1994 eighty two patients with gastric cancer were operated on. The M:F ratio was 1.6:1 and the mean age was 65.3 years (range 23-89). Palliative operations (6 gastroenterostomy) were performed in 7.3% of cases. In the other patients, 36 total gastrectomies (43.9%), 8 total gastrectomies extended to spleen, pancreas and colon (9.7%), 32 distal subtotal gastrectomies (39.1%) were performed. Gastric exeresis was always associated with lymph node dissection extended to level I and II (R2). In some cases level III and IV lymphadenectomy (R3) was performed according to Maruyama-Mishima technique. There were no intraoperative deaths. The operative mortality was 13.6% for total gastrectomies and 3.1% for subtotal gastrectomies. Postoperative complications occurred in 15.9% of total gastrectomies (3 anastomotic fistula, 2 wound infection, 1 subphrenic abscess, 1 melena) and in 3.1% of subtotal gastrectomies (1 sepsis). Stage III and IV cancers represented 74.4% of all cases (stage IIIA 19.6%, IIIB 21.9%, IV 32.9%). Metastatic lymph node involvement (N2+) affected 53.1% of T3 and 88.2% of T4 cancers. The mean survival rate of patients subjected to gastroenterostomy was 6 months. The 2-year survival for total gastrectomies was 42%, for subtotal gastrectomies 28.1%. In our experience, wide removal of lymph nodes and total or extended gastrectomies were performed without any increase of mortality and morbidity. In advanced stages, a wider exeresis increased survival and prevented local recurrence.

Adenocarcinoma↗
PubMedDate not supplied

[Surgical treatment of hepatic hydatidosis. Analysis of results of conservative and radical surgery in our experience].

The authors review a series of 194 cases of hepatic hydatidosis submitted to surgery over the period from July 1973 to December 2001, comparing the results of conservative and radical operatins. In this period we performed 164 conservative operations (140 indirect marsupialisations, 5 delaminations with capitonnage of the residual cavity and 19 partial pericystectomies), 26 total pericystectomies and 4 liver resections. The main outcome measures analysed were postoperative hospital stay, mortality, morbidity and recurrence rates. The median postoperative hospital stay was 17.5 days for conservative operations and 12.5 days for radical surgical procedures. No deaths occurred in either group. The morbidity was 26.8% after conservative treatment (34 biliary fistulas, 3 cases of jaundice, 5 residual cavity infections and 2 subphrenic abscesses) and 13.3% after total pericystectomy and liver resection (3 wound infections and 1 pleural effusion). Recurrences occurred only in the group treated by marsupialisation (12/140 = 8.5%) and were managed by total pericystectomy in 5 cases and by a second drainage procedure in 7. The surgical procedure for the treatment of hepatic hydatidosis should be tailored to the needs of each patient, depending on the size, location and complications of the cyst and high surgical risk should be avoided in view of the benign nature of the disease. No deaths occurred in either of our patient groups, but postoperative hospital stay, morbidity and recurrence rates were better in those undergoing radical treatment.

Adolescent↗
PubMed2003

[An unusual case of traumatic hemoperitoneum].

The authors describe the case-history of an uncommon traumatic haemoperitoneum which developed during sexual intercourse in a 49-year-old woman. She was admitted to the department of surgery of the Kromĕríz Hospital on account of pain in the epigastrium. Previously the patient was free from complaints and collapsed on the way to the toilet. On admission she lacked sign of cardiopulmonary failure, on examination of the abdomen only deep painfulness on palpation in the epigastrium was found, on laboratory examination leukocytosis, the sonographic finding was negative. Two hours after admission signs of haemorrhagic shock developed, on abdomen symptoms of diffuse peritoneal irritation and on repeated sonographic examination accumulation of fluid in the abdominal cavity. The patient was subjected to an urgent operation with finding of rupture of a lienal aneurysm. Resection of the aneurysm and splenectomy were performed. During the subsequent course the patient was twice revised on account of a left-sided subphrenic abscess, now (six month after the first operation) she is free from complaints. The authors analyze incidence, etiology, clinical picture and treatment of aneurysm of the lienal artery. As to the clinical picture they emphasize the typical picture of two-stage rupture.

Abdominal Injuries↗
PubMed2003

Effect of the learning curve on the early outcomes of laparoscopic Roux-en-Y gastric bypass.

Open gastric bypass has been demonstrated to provide durable weight loss in morbidly obese patients. As laparoscopic techniques have evolved surgeons are offering patients such an approach for performance of gastric bypass. The purpose of this study was to evaluate the relationship between increasing experience and outcome for this technically challenging operation. A retrospective analysis was performed on the initial 160 consecutive patients undergoing laparoscopic gastric bypass by a single surgeon over a 24-month period. Patients were divided into quartiles for data analysis. Duration of surgery decreased significantly between quartiles: 324 +/- 124, 225 +/- 70, 190 +/- 47, and 168 +/- 40 minutes, respectively (P < 0.01). However, the conversion rate (3.1%) and mean hospital length of stay (2.1 +/- 2.4 days) were unaffected by surgeon experience. The early and late postoperative complication rates were 9.4 and 3.1 per cent, respectively. Early complications included: leak (1.3%), bleeding (3.8%), obstruction (1.9%), acute gastric distention (0.6%), subphrenic abscess (0.6%), and wound infection (0.6%). Late complications include: obstruction (1.3%), anastomotic stricture (1.3%), and marginal ulcer (0.6%). The complication rates did not change statistically between quartiles. The excess weight loss at one year was 77.4 +/- 16.7 per cent. These data suggest that throughout the learning curve laparoscopic gastric bypass can be accomplished with acceptable complication rates, conversion rates, and hospital length of stay. Duration of surgery improves with experience. Early weight loss results compare favorably with those of open gastric bypass.

Adult↗
PubMedDate not supplied

[Small intestine tumors: our experience in emergencies].

Small bowel tumours are relatively rare neoplasms; unusual occurrence associated with nonspecific symptoms, and low-sensitivity tests availability, are responsible for diagnostic delay. A retrospective study was performed on 42 cases with acute presentation, from 1972 to 2001; median age was 52 years (range 14-79) and there was a slight female prevalence (57.1% vs 42.9%). The most common acute presentation was occlusion (57.1%), followed by gastrointestinal (GI) bleeding (23.8%), perforation (14.3%) and occlusion/perforation (4.8%). Benign neoplasia were 38.1% (16 cases) and adenoma is was the most common type; malignant forms were 61.9 (26 cases) and adenocarcinoma and lymphomas were the most common histotype. Radical surgical procedures were possible only in 57% of malignant forms (24 patients); morbility was 4.8% (2 cases: 1 anastomotic dehiscence and 1 subphrenic abscess); mortality was 14.3%. From our retrospective study, we can state that survival for malignant lesions is strictly dependent of early TNM staging and possibility of radical surgical procedure. An extremely high index of suspicion in evaluating mild and often misleading symptoms, integrated with specific diagnostic studies, should be the proper approach. Prognosis for benign from is excellent in all cases.

Abdomen, Acute↗
PubMedDate not supplied

Role of surgery in the patients with stage I and II primary gastric lymphoma.

BACKGROUND/AIMS: Primary gastric lymphoma is a relatively rare disease. As the concept of MALT (mucosa-associated lymphoid tissue) lymphoma has been acknowledged, a relation between primary gastric lymphoma and Helicobacter pylori infection seems apparent, appropriate treatment, including surgical resection, and/or chemotherapy, and/or radiotherapy has remained controversial. METHODOLOGY: Between 1974 and 1996, we treated 85 Japanese patients with histologically proven primary gastric lymphomas (stage I and II according to modified Ann Arbor staging) with surgery, and/or adjuvant chemotherapy. The clinicopathological factors, especially regarding surgical curability and survival were evaluated retrospectively. RESULTS: Of the 85 patients (44 men, and 41 women), average age was 60.5 years. The lesion was frequently located at the middle third of the stomach, and multiple lesions were noted in 19 patients. Microscopic lymph node metastasis was positive in 37.6% (32/85), and the rate of positive metastasis increased in proportion to depth of invasion. There was a discrepancy between macro- and microscopic findings regarding lymph node metastasis. Total gastrectomy was done for 50 patients, distal gastrectomy for 31, pancreatoduodenectomy for 3, and gastrojejunostomy for 1 patient. Lymph node dissection was done at the D1,2 level for 73, and at the D3 level for 12 patients. There were no major complications except in 3 cases (subphrenic abscess), and there was 1 operative death. The overall 5-year survival and 10-year survival was 82.3% and 74.0%, respectively. In the stage I patients, the 5-year and 10-year survival rate was 97.5%, respectively. All cases of surgery were curative, and surgery alone resulted in the same survival time as the surgery plus chemotherapy group (10-year survival; 100% vs. 96.6%, no statistical difference). In the stage II patients, 5-year and 10-year survival rates were 58.6% and 44.2%, respectively. Surgery was curative in 59.3% (19/32), and palliative in 40.7% (13/32). Palliative surgery was done because of extensive lymph node metastasis in 6 patients, invasion to adjacent organ in 6, and both in 1 patient. Chemotherapy was prescribed in 71.9% of the patients (23/32), and when compared with the patients who were on chemotherapy, the survival rate showed no statistical difference regardless of palliative or curative surgery. CONCLUSIONS: Surgery for primary gastric lymphoma had low complication rate, and led to good survival rate in stage I disease. In stage II disease, surgical curability did not affect the survival, implying the necessity of the evaluation about the treatment strategy by randomized study. However, considering the stage migration before and after and possible inaccuracy of preoperative staging, the application of non-surgical treatment must be prudent.

Adult↗
PubMed2003

Implications of anastomotic leakage after total gastrectomy for gastric carcinoma.

BACKGROUND/OBJECTIVES: Oesophagojejunal anastomotic leakage is a serious complication following total gastrectomy, and is reported to be decreasing in frequency. This study was an audit of the radiological and clinical frequency of such leakage and its consequences. METHODS: A retrospective (1983-2000) cohort study was undertaken in a tertiary institution where 175 patients had undergone a total gastrectomy for gastric carcinoma with oesophagojejunal reconstruction using a stapling device and a 50 cm J-loop. Anastomotic leakage was sought 3-9 days postoperatively using a Gastrograffin (diatrizoate meglumine) swallow. RESULTS: Leakage was demonstrated in 7 patients (4%), being subclinical in 2, minor in 4, and fatal in 1. There was no correlation between leakage and patient factors (age, medical risk, haemoglobin, albumin), surgical factors (surgical seniority, approach, reconstruction, splenectomy, lymph node dissection) or tumour factors (stage, nodes examined, and margin positivity). However, intraoperative difficulties or mishaps were recorded in most cases of leakage. Subclinical leakage was marked by an uneventful postoperative course, and low-volume enterocutaneous fistulas were self-limiting. One patient developed a subphrenic abscess that required drainage. One patient suffered an intrathoracic leak which proved fatal. CONCLUSIONS: Anastomotic leakage was an infrequent complication of total gastrectomy when using a stapling device and a 50 cm J-loop. It was related to intraoperative surgical difficulty and mishap rather than conventional patient and tumour factors. It was subclinical or self-limiting, if occurring in the abdomen, but fatal if in the chest.

Adult↗
PubMed1992

[Sulbactam-ampicillin in surgery. Our experience].

The bacterial infections constitute a serious problem for the surgeon: the choice of antibiotic drugs is really important and, as often as possible, should be guided by antibiotic sensitivity tests. In this study we used sulbactam-ampicillin (Unasyn) who is an antibiotic combination between sulbactam, inhibitor of beta lactam and ampicillin. The preliminary results were as follows: Unasyn was administered to 21 hospitalized selected patients, 16 women and 5 man, who had clinical signs of intraabdominal infection, wound infection and subphrenic abscess after digestive surgery. In these patients were isolated the following organisms: Staphylococcus epidermidis (8), Staphylococcus aureus (11), serratia (1), streptococcus (3), E. coli (3). The daily dosage of Unasyn was 3-12 g/die administered in three to four divided doses, and was determined by the severity of infection, the antibiotic susceptibility of the causative organism(s) and the condition of the patient. Each dose was given by slow i.v. infusion in 15-30 minutes. Our success rate was 100%, and neither systemic nor local side effects were recorded.

Adult↗
PubMedDate not supplied

The role of extended total gastrectomy in advanced gastric cancer.

BACKGROUND/AIMS: Extended total gastrectomy represents, in our experience, 52 out of 443 (11.7%) surgical resections for gastric cancer (1976-1998, 269 total gastrectomies). METHODOLOGY: Enlarged resections were performed on left liver lobe (5 cases), transverse colon (8 cases), pancreas body-tail (35 cases), mesocolon (4 cases), diaphragm (6 cases), jejunum (1 case), and adrenal gland (1 case). RESULTS: Morbidity rate was 18 out of 52 cases (34.60%); 1 esophagus-jejunum anastomosis leakage, 6 cases of pneumonia, 1 pancreatic fistula, 1 p.o. pancreatitis, 3 subphrenic abscesses, 4 cardiocirculatory complications, successfully resolved with conservative therapy. There was one case of postoperative death (1.9% due to cardiac failure). There was a 5-year survival rate for 36.5% of the patients, with follow-ups from 6 months to 11 years. The authors, based on their data, international literature (Roder 1993, Cordiano 1996, Shchepotin 1998) and taking into account mortality and morbidity rates estimate a 5-year survival rate in 30-52% of the cases. CONCLUSIONS: In conclusion, we believe that major surgical procedures for gastric cancer are indicated for every case of suspected neoplastic infiltration of contiguous organs.

Adult↗
PubMedDate not supplied

[The treatment of laparoscopic cholecystectomy for acute cholecystitis].

The aim of the study is to evaluate the results of early laparoscopic cholecystectomy for acute cholecystitis and to analyse the problems related to patients' selection and surgical timing. The authors report their personal experience of 45 laparoscopic cholecystectomies for acute cholecystitis. The diagnosis was based on clinical, blood test and US scan analyse findings. Technical surgical details were decompression of the gallbladder, use of endobag and abdominal dranage. We didn't perform and intraoperative cholangiography in absence of predictive factor for common bile duct stones. The mean time required for surgery was 120 minutes, conversion rate was 15% in early operations and 23.8% in operations delaied more than 72 h. Dissection difficulty is the main cause of conversion. Four patients underwent postoperative complications: one subphrenic abscess, one bile leakage (both recovered with nonsurgical therapy and two wound infections). In conclusion laparoscopic cholecystectomy is safe and effective as early treatment of acute cholecystitis in the first 72 hours due to easier dissection of the inflammed and oedematous tissue. This approach allows a reduction of the operative risk and the conversion rate with medical and economic advantages. Presence of bile duct stones is still now indication to conversion in open surgery.

Acute Disease↗
PubMedDate not supplied

[Uncommon abdominal sites of hydatid disease. Our experience with the surgical treatment of 15 cases].

The aim of this retrospective study is to report on a series of 15 patients with abdominal hydatid disease in uncommon sites submitted to surgery in our unit over the period 1974-2003. Eight women and 7 men (mean age: 48.4 years) were included in the study. The hydatid cysts were located in the peritoneum in 8 patients, in the spleen in 5, in the kidney in 1 and in the retroperitoneum in 1. In 4 cases the peritoneal cysts were solitary, while 4 patients in this subgroup presented multiple cysts and 2 had concomitant liver hydatidosis. The splenic cysts were solitary in 2 cases, associated with a hepatic cyst in 2 and with a lung cyst in 1. The renal and retroperitoneal cysts were both solitary. The diagnosis was made at operation in 3 cases, while in 12 patients it was made by serological tests, ultrasonography and/or CT. All patients were operated on: we performed a total cystectomy in 7 patients with peritoneal cysts and in the patient with a retroperitoneal location, splenectomy in the 5 splenic cysts and a partial cystectomy with external drainage of the residual cavity in 1 peritoneal cyst and in the renal location. The postoperative course was regular with no mortality and no major morbidity in 14 patients, while 1 patient submitted to splenectomy developed a subphrenic abscess that required surgical drainage. Two recurrences occurred in patients with peritoneal cysts 71 and 20 months, respectively, after the first operation and these were managed by total cystectomy. The diagnosis of uncommon abdominal sites of hydatid disease is more accurate today because of the new imaging techniques, which are often able to show specific radiological signs of hydatid disease. The treatment of choice is surgical and complete removal of the cyst is the gold standard, but its feasibility is related to the location of the cyst.

Adult↗