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The Authors report two cases of ectopic gastric pancreas, one of them causing a massive upper gastrointestinal hemorrhage, representing an infrequent complication of the disease. A literature review on the subject was then performed, and the importance of a differential diagnosis of the ectopy versus gastric malignancies, with relevant prognostical and management implications was assessed.

Acute appendicitis is a very common disease in western countries, affecting the entire population with higher prevalence in younger people. The diagnosis of the disease is still basically performed through the clinical evaluation of the patient, while peripheral White Cell Count or imaging techniques such as ultrasonography are poorly helpful. Therefore, a great number of patients is operated without finding a severe involvement of the appendix at intraoperative observation. To evaluate the rate of false acute appendicitis and to correlate the histological involvement with the clinical behavior of the disease the Authors carried a prospective study during a period of 28 months on 124 patients with a diagnosis of acute appendicitis treated on emergency basis.

Although rarely, several conditions may cause malabsorption through lymphatic obstruction. Primary lymphangiectasia, a genetically determined disease characterized by diarrhoea, steatorrhoea and protein-losing enteropathy, is one of these conditions. The Authors report their experience in three cases of small bowel lymphangiectasia occurring in adults and discuss diagnostic and therapeutic problems of the disease.

Primary choledocholithiasis represents a quite unusual sequela of biliary tract surgery. Primary stones originate in the common bile duct and are soft, smooth, with a yellowish or brown-reddish colour, reproducing the shape of the duct in which arise. The Authors report a review of the cases observed in the division of General and Vascular Surgery-Department of Surgery and Surgical Emergencies of the University of Perugia. From January 1988 to December 1993, 577 laparotomic biliary tract operations were performed, and in 8 cases a re-operation was needed. Among the latter, particularly interesting were 2 cases of primary choledocholithiasis occurred in two patients with bilio-digestive anastomosis previously performed, i.e. two side-to-side Roux-en-Y or Braun loop choledochojejunostomies, respectively. Therefore, primary lithiasis following a choledochojejunostomy occurred when the bilio-digestive anastomoses were performed with the indication of a curative re-operation on the biliary tract. On the contrary, most choledochojejunostomies are performed as a palliative procedure in patients presenting a low survival rate not allowing to develop a Sump Syndrome and a consequent choledocholithiasis, which are long-term complications.

From January 1989 to December 1992, in the Institute of Clinical Surgery of the University of Perugia, 102 patients were admitted for thoracic trauma. Two patients with an open thoracic trauma, both presenting multiple shot-wounds, underwent an explorative thoracotomy. One of them died on the operating-table from hemorrhage, while the other was saved by a wedge-resection. A 3rd explorative thoracotomy was successfully performed on a patient with internal thoracic trauma and severe hemothorax. Among the 100 patients with an internal thoracic trauma, mortality was 6%, but only one of the 6 deceased, had no lesions other than a fail chest. As a matter of fact 38 patients presented lesions in other parts of the body. Simple and complicated multiple costal fractures, found in 84 cases, were the most frequent lesions observed. Seventeen of the 38 patients with pneumothorax and/or pleural effusion had a chest tube applied. Three patients were operated for a diaphragmatic hernia with a positive outcome. Only 75 patients received medical treatment without surgery. Six of the patients with multiple costal fractures presented flail chest. One of them (mentioned above) died almost immediately after his admission and therefore received no more than the initial medical treatment. Four others, aged over 65, successfully underwent a costal osteosyntesis, while the 6th patient received medical therapy with a positive outcome. In the case of a critical flail chest with severe patho-physiological consequences, if the fractures are in technically favourable sites, the Authors believe it is better to immediately stabilize the thorax, since the operating trauma is minimum and in many cases the patient is already intubated and curarized.

Inferior caval vein invasion not infrequently complicates advanced neoplastic lesions. Primitive caval neoplasms (leiomyosarcomas) or other tumors such as renal carcinomas, pheochromocytoma, as well as liver, testis, and retroperitoneal tumors most likely cause caval invasion. In the past, caval invasion was a clear index of non operability, while today, a modern multidisciplinary approach allows to treat successfully even so advanced diseases. In the present report the Authors analyze the cases treated at the Dept. of Surgery of the University of Perugia, and review the most important international reports on this subject illustrating the new possibilities offered by IVC substitution with biological or artificial grafts.