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Background: Perforation of the esophagus still carries high morbidity and mortality rates, and there is no gold standard for the surgical treatment of choice., Materials and Methods: We reviewed the records of patients treated for esophageal perforation in the last decade at the General Surgery Unit of the University of Udine. Patients suffering from perforation secondary to surgical procedures or neoplastic disease were ruled out., Results: Eight males (66.7%) and four females (33.3%) met the inclusion criteria. The cause of perforation was iatrogenic in seven cases (58.3%) and spontaneous in five (41.7%). The perforation was in the cervical esophagus in five cases (41.7%) and at thoracic level in the other seven (58.3%). Two patients (16.7%) with cervical lesions were treated conservatively; two (16.7%) underwent primary closure and the insertion of a drainage tube; one patient with a distal cervical lesion underwent diversion esophagostomy; six patients had resection of the entire thoracic esophagus and terminal cervical esophagostomy; one had segmental resection of the distal thoracic esophagus and lateral diversion esophagostomy. In the five patients whose reconstruction was postponed, esophagogastroplasty surgery was performed with an anastomosis at cervical level in four cases and at thoracic level in one. The global mortality rate was 25%. Late diagnosis-more than 24 h after the perforation event-seems to be the only factor correlated with fatal outcome (p = 0.045)., Conclusions: The choice of treatment for perforation in a healthy esophagus depends mainly on the site and size of the lesion. Cervical lesions may be amenable to conservative treatment or require primary surgical repair, while thoracic lesions with associated sepsis or major loss of substance demand an aggressive approach, with esophageal resection and delayed reconstruction seeming to be the safest option.

Solid organ transplantation in HIV-infected individuals requires concomitant use of immunosuppressants and antiretrovirals that may cause significant drug interactions. Here we report on a peculiar pharmacokinetic interaction between tacrolimus and protease inhibitors (PIs) which occurred in four HIV-infected liver transplant patients who had to shift PI therapy from nelfinavir to fosamprenavir as a consequence of regulatory restrictions. After the switch, tacrolimus trough blood concentrations significantly dropped in all patients (mean +/- SD 6.9 +/- 2.6 versus 3.2 +/- 2.0 ng/ml before and after the switch, respectively; P=0.01), so that a marked dosage increase was needed (0.29 +/- 0.14 versus 0.88 +/- 0.48 mg/day, 1-3 days before and 3 weeks after the switch, respectively; P=0.046) to attain the desired target (8.7 +/- 2.3 ng/ml). Consistently, marked changes of the concentration/dose ratio of tacrolimus were observed in all cases (27.2 +/- 9.7 ng/ml per mg/kg/day versus 9.7 +/- 4.0 ng/ml per mg/kg/day before and after the switch, respectively; P<0.001). Our findings suggest that fosamprenavir may be less potent than nelfinavir in inhibiting tacrolimus clearance and support the need for higher tacrolimus dosage to avoid insufficient immunosuppression in HIV-infected liver transplant patients when switching from nelfinavir to fosamprenavir or even when directly starting antiretroviral therapy with fosamprenavir.

Aim: Regarding the surgical treatment of esophageal cancer, a question was raised by the introduction of minimally invasive surgery, because of the technical complexity of the techniques involved and its uncertain benefits. We evaluated the impact of laparoscopic esophagectomy on the surgical approach to esophageal cancer., Patients and Methods: From January 2002 to March 2006, 22 non-randomized patients were recruited to undergo esophagectomy for neoplastic disease. The esophagectomy and esophagogastroplasty were performed using the laparoscopic transhiatal technique (THE) in 9 cases, while a combined laparoscopic gastric mobilisation and right transthoracic incision (TT/LE) was performed in the other 13., Results: Mean follow up was 21+/-3.23 months, range 2-46 months. Overall cumulative survival was 84.0% at 12 months, 61.3% at 24 months, 51.0% at 36 months. THE achieved better results than TT/LE on the ground with regard to the time it took to complete the procedure (p=0.046) and the hospital stay times (p=0.039), and the time in ICU, postoperative oral feeding resumption, number of retrieved lymph nodes., Conclusion: The clinical benefits of minimally invasive techniques regard the time it takes to complete the procedure, the time in ICU, postoperative oral feeding resumption and the hospital stay times. Minimally invasive surgery might be not less curative and effective than open surgical procedures, as found in our small non-randomzed series of patients. Larger series should confirm these results.

We treated three cases of early portal vein thrombosis (PVT) by minimally invasive percutaneous transhepatic portography. All patients developed PVT within 30 days of major hepatic surgery (one case each of orthotopic liver transplantation, splenectomy in a previous liver transplant recipient, and right extended hepatectomy with resection and reconstruction of the left branch of the portal vein for tumor infiltration). In all cases minimally invasive percutaneous transhepatic portography was adopted to treat this complication by mechanical fragmentation and pharmacological lysis of the thrombus. A vascular stent was also positioned in the two cases in which the thrombosis was related to a surgical technical problem. Mechanical fragmentation of the thrombus with contemporaneous local urokinase administration resulted in complete removal of the clot and allowed restoration of normal blood flow to the liver after a median follow-up of 37 months. PVT is an uncommon but severe complication after major surgery or liver transplantation. Surgical thrombectomy, with or without reconstruction of the portal vein, and retransplantation are characterized by important surgical morbidity and mortality. Based on our experience, minimally invasive percutaneous transhepatic portography should be considered an option toward successful recanalization of early PVT after major liver surgery including transplantation. Balloon dilatation and placement of a vascular stent could help to decrease the risk of recurrent thrombosis when a defective surgical technique is the reason for the thrombosis.

Objectives: The incidence of lymphocele after kidney transplantation ranges from 0.6% to 16%. The management of lymphocele is still controversial. Percutaneous needle aspiration and external drainage, with or without the injection of sclerosing solutions, are associated with high recurrence and complication rates. Open or laparoscopic intraperitoneal marsupialization requires hospital admission, general anesthesia, and, sometimes, extensive surgical dissection., Methods: We report our experience treating recurrent symptomatic lymphocele with intraperitoneal drainage using a Tenckhoff catheter on an outpatient basis in 7 consecutive patients. In all cases, the lymphocele was diagnosed by abdominal ultrasonography 26 to 90 days after kidney transplantation. The mean diameter of the lymphocele was 14 +/- 6 cm. Percutaneous drainage was the initial approach, which was also used to differentiate between urinoma and lymphocele and to rule out infection. The lymphocele recurred within 1 month in all cases. The recurrent lymphoceles were treated on an outpatient basis using intraperitoneal drainage with a Tenckhoff catheter inserted into the lymphocele under ultrasound guidance. After administration of local anesthesia, two 1-cm vertical incisions were performed: one to access the lymphocele and the other to access the peritoneal cavity. A Tenckhoff catheter was inserted in the lymphocele and tunneled into the peritoneal cavity., Results: All procedures were completed on an outpatient basis without any complications. The catheter was removed 6 months later with no evidence of recurrent lymphocele at ultrasound follow-up in all cases., Conclusions: This outpatient surgical approach using ultrasound-guided intraperitoneal drainage with a Tenckhoff catheter appears to be a simple, effective, and safe method for treating unilobular recurrent symptomatic lymphocele after renal transplantation.

Aim: The most frequent urologic complications after renal transplantation involve the uretero-vescical anastomosis (leakage, stenosis, and reflux), with a frequency of 1% to 30% in different series., Methods: We present our results in a prospective randomized trial performed from October 2004 to September 2005, in a cohort of 36 patients, who underwent renal transplantation from cadaveric donor at our institution. A uretero-vescical anastomosis according to Lich-Gregoir was used in 18 cases (group A), whereas an anastomosis according to Knechtle was performed in other 18 patients (group B), respectively. The groups were comparable for donors and recipients characteristics. The mean donor age was 46.3 years vs 44.9 years, and the mean duration of cold ischemia was 1 086+/-296 min vs 1 100+/-381 min for group A and for group B respectively. The mean recipient age was 47.5 years vs 46.1 for group A and group B, respectively., Results: No differences were evidenced between the two uretero-vescical anastomosis in term of surgical complications, infections or patient and graft survival at one year of follow-up. Stenosis and leakage involved 2 patients for each group respectively. Numbers of infections, days of antibiotic therapy were similar between the two groups., Conclusion: Our early experience does not evidence differences between the two types of uretero-vescical anastomosis.

Biliary reconstruction continues to be a major source of morbidity following liver transplantation. The spectrum of biliary complications is evolving due to the increasing number of split-liver and living-donor liver transplantation, which are even associated with a higher incidence of biliary complications. Bile duct strictures are the most common cause of late biliary complications and account for up to 40% of all biliary complications. Optimal therapy for posttransplantation anastomotic biliary strictures remains uncertain and requires a multidisciplinary approach. We report the case of a 54-year-old Caucasian male affected by hepatocarcinoma and hepatitis C-related cirrhosis who underwent right-lobe living-donor liver transplantation from his son complicated by double anastomotic stenosis of the main right hepatic duct and of an accessory biliary duct draining segments 6 and 7 of the graft that was successfully treated by percutaneous transhepatic cholangiography with long-term subcutaneous placement of two internal Rüsch-type biliary stents.

Introduction: The object of neoadjuvant chemoradiotherapy regimens is a downstaging or downsizing of advanced rectal tumor to increase the rate of curative resection and reduce loco-regional failure. A reliable method of assessing response to adjuvant therapies is required to help standardize the assessments of new multimodality therapies. The purpose of this study was to evaluate the role played by tumor regression grading on the evaluation of pathological response to chemoradiotherapy, compared with both the predicting value of the clinical response to neoadjuvant therapy and pathologic response evaluation., Methods: From 1994 to 2003, 58 patients with a primary diagnosis of rectal cancer were studied at our department and enrolled in a single center, not randomized study based on 5-week sessions of radiotherapy associated with a 30-day 5-fluorouracil (FU) infusion, followed by surgical resection. Instrumental restaging and routine histological examination, including tumor regression grading, were performed to asses the response to neoadjuvant therapy., Results: The cCR rate corresponds to pCR rate, while a 3.5% of cPR and a 3.4% of cSD corresponded to a pPD. cPR and cSD show a PPV of 92.8% and 90.9% respectively, while cPD NPV is 20%. No case was found with no regression (grade 0). Tumor regression was defined grade 1 in 24.5% of cases, grade 2 was found in 58.5% of cases, 7.5% were grade 3, and 9.5% showed complete regression (grade 4). Pathologic response resulted to be associated with regression grade (p=0.006). Tumor regression grading is an independent variable for pT (p=0.0002), pN status (p=0.00004), pathologic staging (p=0.000001) and local recurrence (p=0.003)., Conclusion: Our results lead us to consider only pathologic evaluation to determine the response to neoadjuvant treatment: the application of tumor regression grading on the specimens obtained after combined neoadjuvant chemoradiotherapy and surgery is useful to plan a better therapeutic strategy on the ground of a quantitative evaluation of the response to neoadjuvant treatment; it shows it is an important comparable pathological feature, useful in comparing different protocols' results and differences between patient's response as well as prognostic factors.

The development of new and more effective immunosuppressive agents has provided long-term survival for transplant recipients, thereby increasing the risk of de novo malignancy in chronic immunocompromised hosts. While de novo post-transplant lymphoproliferative diseases and skin cancer has been shown to have an increased incidence in long-term surviving solid organ transplant recipients, the association with gastrointestinal (GI) cancer is controversial. Over 12 yr, 20 patients (5%) out of 395 renal transplant recipients developed 23 de novo tumours; 11 skin cancer and 12 non-skin cancer. Four patients (1%) developed de novo tumours of the GI tract (three colon, and one gastric cancer). Immediately after tumour's diagnosis, immunosuppressive therapy was reduced; all patients were shifted from cyclosporine to Rapamicine within 30 d. The tumour was surgically resected with curative intent in three cases, while one patient had only palliative surgery because of metastatic disease. The post-operative courses was uneventful. All patients maintained normal graft function. However, three out of four patients (75%) died of progression of the neoplasm, within a median time from the diagnosis of 12 months. Further, we investigated a possible correlations between de novo GI cancer and HCV, HBV status, infections, cytomegalovirus (CMV) and Epstein-Barr virus (EBV) reactivation, episodes of rejection, and blood transfusions. All cases with GI de novo cancers reported in this paper developed CMV and EBV reactivation within three months after transplantation. Thereafter we suggest a closer follow-up for de novo GI cancer in renal transplants with early CMV and EBV reactivation in order to avoid delayed diagnosis.

The stem cell factor (SCF), besides regulating hemopoietic stem cells homing and proliferation, has proliferative effects on hepatocytes and may be involved in liver regeneration. We investigate if liver transplantation (LT) and hepatic resection (HR) modify the concentration of soluble SCF (s-SCF) in peripheral blood of 15 LT and 7 HR. s-SCF was measured by ELISA as ng/ml. s-SCF basal levels were higher in LT that in HR (818 +/- 349 vs. 479 +/- 79, p = 0.005). A significant increase of s-SCF, peaking at postoperative day +3, was seen after LT (from 818 +/- 349 to 1212 +/- 461, p = 0.01) and HR (from 479 +/- 79 to 698 +/- 122, p = 0.004). s-SCF peak levels were higher after LT than HR (p = 0.0008). At day +7 s-SCF concentration returned to baseline values. LT have a higher basal s-SCF level than HR. These data show for the first time that liver injury affects s-SCF level and suggest that SCF may be involved also in clinical liver regeneration.

Aims: The development of new effective immunosuppressive agents has provided long-term survival for transplant recipients, thereby increasing the risk of de novo malignancy in chronic immunocompromised hosts. Although de novo post-transplant lymphoproliferative diseases and skin cancer have been shown to have an increased incidence in long-term surviving solid organ transplant recipients, the association with colon cancer is controversial., Patients and Methods: Over a 12-year period, 20 patients (5%) out of 400 renal transplant recipients (treated at the University Hospitals of Udine and Ancona) developed 24 de novo tumors; 11 skin cancers and 13 non-skin cancers. Three patients developed de novo colon cancer. Immunosuppressive therapy was reduced immediately after diagnosis, and all patients were shifted from cyclosporine to rapamycin within 30 days. The tumor was surgically resected with curative intent in 2 cases, and 1 patient had only palliative surgery due to metastatic disease. The postoperative course was uneventful, and all patients maintained normal graft function., Results: Two of 3 patients died of progression of the neoplasm, within a median time from the diagnosis of 12 months. We analyzed the possible correlations between de novo colon cancer and "serology (hepatitis C virus-hepatitis B virus, HCV-HBV) status" infections, cytomegalovirus and Epstein-Barr virus reactivation, episodes of rejection, and blood transfusions., Conclusions: Differently from other de novo skin and non-skin tumors, our cases developed cytomegalovirus and Epstein-Barr virus reactivation within 3 months of transplantation. Therefore, we suggest a closer follow-up for de novo colon cancer in renal transplants with early cytomegalovirus and Epstein-Barr virus reactivation in order to avoid a delay in diagnosis.

Aim: Rubber band ligation (RBL) is a widely performed and well established treatment for second degree haemorrhoids. The aim of our prospective study was to assess the satisfaction of patients treated by rubber band ligation, as well as the immediate and long-term results of this technique., Methods: From January 2001 to December 2004, 73 consecutive outpatients with second degree haemorrhoids underwent RBL. From 1 to 3 years from the initial treatment, 73 patients were contacted by phone call to have some news about their health condition and to collect their opinion about the satisfaction of RBL technique., Results: We didn't identify any major complication in our series, sometimes a temporary anal discomfort that could be controlled by low dose of NSAIDs. We report an excellent immediate benefit in 13.7% of cases, a good one in 58.9%. From 1 to 3 years after the initial procedure 82.2% of patients are either symptom free or improved and don't need any medical therapy., Conclusions: Immediate results are very good in particular for bleeding, anal pain and mucosal prolapse. Immediate and long-term results are invalidated by the concomitance of more symptoms and different results are recorded between sexes. We consider RBL a good ambulatory practice that could either get better or resolve haemorrhoidal disease or delay the invasive surgical treatment for second degree haemorrhoids.

Aim: The last 20 years have seen a systematic reappraisal of the physiopathology and diagnosis of gastroesophageal reflux disease (GERD) and its associated typical symptoms, while less attention has been paid to correlating GERD with certain extraesophageal symptoms and the value of surgery for their treatment. The aim of this study was to determine the clinical and physiopathological features and the outcome of surgery, in a group of patients who underwent laparoscopic fundoplication for GERD with atypical symptoms, and to compare the results with another group of patients operated for GERD with typical symptoms., Methods: Two hundred and forty-one patients were evaluated for GERD at our Digestive Physiopathology outpatients surgery from January 2001 to January 2003. Of the 36 patients who underwent laparoscopic fundoplication, 23 had the typical symptoms of GERD and 13 had atypical symptoms. Twelve months after surgery, these patients were compared in terms of 24-h pH monitoring, esophageal manometry, regression of symptoms and degree of satisfaction., Results: Postoperatively, patients with atypical symptoms had a smaller increase in effective peristalsis (P = 0.06) and a more limited improvement in symptoms (54% vs 91%, P = 0.001), and they expressed less satisfaction with the surgical treatment (5.9 vs 8.2, P = 0.003)., Conclusions: The results of surgery in GERD patients with atypical symptoms are worse than in those with typical symptoms. A careful preoperative work-up, based on 24-h pH monitoring, is fundamental for patients with atypical symptoms, who also need to be informed of the high likelihood of surgery proving clinically unsuccessful.

A surgical and oncological patient feel anguish, anxiety and fear when he know his health problems. Information is a very important factor for reducing anxiety level of patient and, at the same time, affects his perceived satisfaction. The aim of this study was to evaluate the impact of informations giving by one or more physicians on anxiety and satisfaction of patient. We have used the State Trait Anxiety Inventory (S.T.A.I.) and the Perceived Physician Communication Style Scale for evaluating anxiety and patient perceived satisfaction in medical encounter. We have involved 36 oncological and surgical patients admitted in General Surgery Department of University Hospital of Udine. The findings showed that patients post-consultation and post-information encounter anxiety level became lower when there were only one physician giving informations; instead there were no significant differences between perceived satisfaction inside groups of patients. Nevertheless case group patients perceived more disposition in listening of physician.

Liver retransplantation is considered to carry a higher risk than primary transplantation. The aim of this study was to analyse a single-center experience with late liver retransplantation. The overall rate of primary retransplantation was 11% (30 re-OLT out of 272 primary OLT). fiftten of these (50%) had retransplantation more than 3 months after the first transplant and were analyzed by reviewing their medical records. Causes of primary graft failure leading to retransplantation were chronic hepatic artery thrombosis in 6 cases (40%), HCV cirrhotic recurrence in 4 cases (28%), chronic rejection in 2 cases (14%), veno-occlusive disease, hepatic vein thrombosis and idiopathic graft failure in 1 case each (6%). UNOS status at re-OLT was 2A in all cases. All patients were hospitalised, and three of them were in intensive care. One- and two-year patient and graft survival rates were 80% and 66% and 66% and 59%, respectively. Death occurred in 5 patients, including 2 of the 3 admitted to the intensive care unit at the time of retransplantation, who died after a mean interval of 15 +/- 9 days from retransplantation. Retransplantation should be considered a very efficient way of saving lives, especially when the optimal timing for its execution is defined.

Development of lymphoceles after renal transplantation is a well-described complication that occurs in up to 40% of recipients. The gold standard approach for the treatment of symptomatic cases is not well defined yet. Management options include simple aspiration, marsupialization by a laparotomy or laparoscopy, and percutaneous sclerotherapy using different chemical agents. Those approaches can be associated, and they depend on type, dimension, and localization of the lymphocele. Percutaneous sclerotherapy is considered to be less invasive than the surgical approach; it can be used safely and effectively, with low morbidity, in huge, rapidly accumulating lymphoceles. Moreover, this approach is highly successful, and the complication rate is acceptable; the major drawback is a recurrence rate close to 20%. We herewith report a renal transplant case in which the patient developed a symptomatic lymphocele that was initially treated by ultrasound-guided percutaneous sclerotherapy with ethanol and thereafter using acetic acid for early recurrence. A few hours after injection of acetic acid in the lymphatic cavity, the patient started to complain of acute pain localized to the renal graft and fever. An ultrasound of the abdomen revealed thrombosis of the renal vein and artery. The patient was immediately taken to the operating room, where the diagnosis of vascular thrombosis was confirmed and the graft was urgently explanted. In conclusion, we strongly suggest avoiding the use of acetic acid as a slerosating agent for the percutaneous treatment of post-renal transplant lymphocele because, based on our experience, it could be complicated by vascular thrombosis of the kidney, ending in graft loss.

Introduction: Multimodality therapy has become the standard treatment for patients with locally advanced (T3 and T4) rectal carcinoma. Accurate preoperative staging of the patients with rectal cancer has increased in importance because the selection of patients with transmural rectal cancer (T3 or T4) or node-positive disease leads to a previous nonsurgical neoadjuvant treatment. The purpose of this study was to evaluate the predictive value of the clinical response to neoadjuvant therapy on the basis of pathological results obtained on rectal cancer patients treated by chemoradiotherapy and surgery., Methods: From 1994 to 2003, 58 patients with a primary diagnosis of rectal cancer were studied at our department and enrolled in a neoadjuvant protocol of chemoradiotherapy followed by surgery. All patients were treated by 30 days of chemoradiotherapy. At the end of the chemoradiotherapy, each patient underwent clinical examination, including digital rectal examination, proctoscopy and abdominal-pelvic computerized tomography to define the clinical response to the chemoradiotherapy. Surgical resection was performed in all patients three weeks after the end of chemoradiotherapy, and histological analysis was performed on all resected specimens., Results: The clinical complete response rate corresponded to the pathological complete response rate, whereas the clinical evaluation overestimated partial response and stable disease. The pathologic examination revealed that 3.5% of clinical partial responses and 3.4% of clinical stable disease were really pathological progressive disease. Clinical partial response and clinical stable disease positive predictive values were 92.8% and 90.9%, respectively, whereas the clinical progressive disease negative predictive value was 20%. Then, 6.9% of patients believed to have responded to the therapy, or not to have responded or worsened, actually had worsened by the end of the chemoradiotherapy., Conclusions: Positive and negative predictive values, in particular for partial response and stable disease, of clinical evaluation of the response to chemoradiotherapy were not high enough to consider clinical evaluation accurate enough to make treatment decisions.

Background: Quality-of-life (QoL) assessment includes health status, disability, psychological wellness, and social performance. We sought to evaluate the effect of liver transplantation (OLT) on the QoL of patients awaiting the procedure and its variations up to 8 years afterwards., Methods: LEIPAD-perceived QoL and BSI-psychological distress tests were used. Patients were divided in four groups (waiting list patients, 1 to 2 years after LT, 3 to 4 years after LT, 5 to 8 years after LT). Patients were also evaluated for type and severity of liver disease., Results: We evaluated 126 patients, 71% male, 29% female, median age 60.7 years (range 40 to 76 years), median follow-up 4 years (range 1 to 8). The patients on the waiting list scored worse both in global stress index (GSI) and total LEIPAD scores than transplanted patients. Upon univariate linear regression analysis, the only dimension associated with time groups was LEIPAD--physical functioning, showing a progressive improvement of perceived physical status with time from transplant. Severity of liver disease showed a protective effect, probably reflecting a better control of stressful events from patients transplanted at advanced stages of liver disease. Protective effects were found for male sex, retired, cohabitant patients, and the degree of education. Housewife and widow patients showed negative associations with BSI and LEIPAD dimensions. No independent predictors of QoL were found in this study., Conclusions: OLT improves most, but not all, QoL and psychological distress domains.

Day Surgery (DS) and prehospitalization emerged in Italy--as it had previously in the United States and other European countries--as able to improve healthcare and reduce costs. The purpose of this study was to evaluate the impact of the Nurse Case Manager (NCM) Model on patients undergoing DS procedures. The study assessed the intensity of pain, anxiety, and stress factors, and the level of discomfort experienced. The quasi-experimental study design involved two groups of patients (at two different DS hospital centers): one using the NCM model (Ward A) the other based on team nursing (Ward B). All patients undergoing DS for (a) varicose veins, (b) inguinal hernia, (c) breast biopsy, and (d) hemorrhoids were included. A valid questionnaire interview based on 22 questions was used (1) the morning before surgery, (2) the evening after surgery, and (3) 48 hr after the operation, by telephone. Of the 145 patients that were involved, 66 were from Ward A (45.5%) and 79 from Ward B (54.5%). When patient care was based on the NCM Model (Ward A), it seemed that (a) the pathway before DS was more efficient; (b) they perceived lower levels of perioperative anxiety and pain; and (c) they recognized the DS center as a unique point of reference for all postoperative problems.

Objective: As it is difficult to submit patients to instrumental follow-up after laparoscopic treatment of the gastroesophageal reflux disease (GERD), it is not easy to have a complete patients analysis after fundoplication. Telephone questionnaire can be a valid instrument to investigate clinical outcome and patients satisfaction to surgery., Methods: This study discusses the results acquired through a telephone questionnaire which has been administered to patients undergoing laparoscopic fundoplication to study postoperative clinical evolution of GERD and satisfaction to surgery through a numerical rating scale from 1 to 10., Results: Sixty three patients, who had a laparoscopic antireflux procedure at Department of General Surgery of the University of Udine (Italy), answered to telephone questionnaires. Fifty patients (74.9%) reported no symptoms. Patients satisfaction to surgery was 7.93 +/- 2.36. Fifty eight patients (92.1%) would have repeated the operation and 59 (93.6%) would have advised it to a friend suffering of GERD. A significant difference of patients satisfaction between preoperative typical and atypical symptoms has been found (8.43 +/- 2.04 vs. 6.95 +/- 2.71 p < 0.05)., Discussion and Conclusion: Telephone questionnaire is comparable with face to face consultation, allowing to do a correct clinical follow-up, to exclude patients accusing pathological acid reflux after fundoplication; however preoperative symptoms are not so accurate as postoperative symptoms. Their presence giustifies a postoperative oesophageal pH metry.

Several factors contribute to the ill defined concept of complexity: critical patients, emergency situations, severity, intensity of care, dependency. The aim of this work is to assess nurses' perception of surgical patients' complexity, to obtain bottom-up data to validate a new model (of the Federazione Nazionale Collegi IPASVI) that measures the patients complexity. Data were collected over two months, by interviewing 64 nurses caring for surgical patients in 8 wards of the Friuli Venezia Giulia region. Patients' complexity (Low, Medium and High) and the explicit criteria adopted for the process of qualification, are formulated according to a priority ranking. Nurses were interviewed in 8 index days over 2 months. Criteria were independently classified by 3 nurses and any discrepancies discussed. Data on 1287 patients collected. 729 patients (56.6%) were classified as low complexity; 393 (30.6%) medium and 165 (12.8%) highly complex. The judgement is influenced by patients' age (p<0.01) but not sex. An high complexity score was assigned to patients with abdominal, soft tissues and vascular and gastrointestinal oncological surgery. 1291 different criteria were reported (2.89 +/- 1.88--range 1-15--for patient). The more frequent criteria were dependency in ADLs, need of strict monitoring/surveillance; presence of devices (such as cvc, pumps etc), and type of illness. The criteria expressed, only partially fit in the reference model. The judgement of complexity is based more on clinical problems and patients' dependency than on patients' ability to adapt to the illness and participate to his/her care.

To assess the correlation between esophageal manometry and 24-h pH-metry and the clinical, endoscopic and radiological picture, we carried out a retrospective analysis of the data of 175 patients in 2001-2002 with symptoms of gastroesophageal reflux disease and/or the established presence of esophagitis. The data were analyzed on the basis of the mean, standard deviation (SD) and percentage (%). Student's "t"-test was used to calculate statistical significance (P < 0.05). pH-metry was positive in 112 cases (64% R+) and negative in 63 (36% R-). Manometry revealed a significant sphincter hypotonia and a greater involvement of peristalsis in R+ patients. There was no significant relationship between symptoms and response to medical treatment compared to a positive pH-metry. Ninety-three (53%) patients presented esophagitis, while 58 (33%) had a hiatal hernia. Esophagitis was more frequent in R+ patients, while hiatal hernia was equivalent in both groups. In the diagnosis and treatment of gastroesophageal reflux disease, the first step is empirical medical therapy. If symptoms persist, esophagogastroduodenoscopy and barium radiology are performed to evaluate the presence of esophagitis and/or gastroesophageal reflux and any related diseases. Manometry and pH-metry (the gold standard for the diagnosis of gastroesophageal reflux disease) are therefore always performed in patients with atypical symptoms of patients to be subjected to surgical treatment.

The simultaneous occurrence of hyperthyroidism and primary hyperparathyroidism is quite rare. A case is reported here of Graves' disease and primary hyperparathyroidism. Treatment of these concomitant diseases consists in combined thyroidectomy and parathyroidectomy. Histological examination confirmed Graves' disease and revealed the presence of a parathyroid adenoma in one gland and parathyroid hyperplasia in another one. After surgical treatment, secondary hyperparathyroidism due to 25-OH Vitamin D deficiency appeared. To our knowledge, this is the first case in which a Vitamin D absorption deficit was found in presence of hyperthyroidism and hyperparathyroidism without other intestinal absorption deficits. Diagnostic and follow-up difficulties related to these three concomitant pathological conditions are discussed.

Surgery with or without adjuvant radiotherapy (RT) is the standard treatment of esophageal cancer. Preoperative radio- and chemotherapy (CT) have been introduced to improve prognosis. We report a phase II prospective non-randomized trial of preoperative RT (42 Gy/25) plus CT (cisplatin 20 mg/mq/day plus 5-fluorouracil 600 mg/mq/day, 1-5 weeks) for the treatment of thoracic esophageal cancer. From 1993, 50 patients were enrolled (40 men and 10 women, mean age 57 years, range 30-75 years). Squamous cell carcinoma accounted for 90% of cases; 10% were adenocarcinoma. Downstaging of the disease was obtained in 77.3% of cases; there were 13 (29.5%) complete responses (CR) and 21 (47.7%) partial responses (PR). Median survival was 28 and 25 months, respectively, for CR and partial response (PR) plus stable disease (SD) and progressive disease (PD) (P = 0.05). Progressive-free median survival was 22 and 17 months, respectively, for CR and PR + SD + PD (P = 0.08). Multimodal treatment of esophageal cancer showed promising results, although not significant, in terms of survival and disease progression for patients achieving a complete pathologic response.

Midthoracic esophageal diverticula represent 15% of all esophageal diverticula. Gastrointestinal endoscopy, barium swallow, esophageal manometry (indispensable for detecting any motor alterations often at the root of the pathogenesis of the diverticulum and for selecting the best surgical option), and 24-h pHmetry are the correct examinations to perform. Simple diverticulectomy performed via thoracoscopy can be sufficient for small diverticula without associated motor alterations. In other cases, it is best to combine diverticulectomy with a longitudinal extramucous myotomy extending at least 3 or 4 cm above and below the neck of the diverticulum or to the entire esophageal body for diffuse esophageal spasm. We report the case of a 67-year-old male patient with a sacciform diverticulum at the mid-third on the anterior wall of the thoracic esophagus. Manometric examination showed peristaltic waves with an amplitude and duration that were above normal at the inferior third of the esophagus. Lower esophageal sphincter (LES) and upper esophageal sphincter (UES) were essentially normal. The diagnosis was pulsion-type midthoracic esophageal diverticulum. We performed a diverticulectomy with endoGIA via right thoracoscopy and extramucous myotomy extended from the upper margin of the diverticulum to the esophageal inlet in the hiatus, corresponding to the area showing motor alteration. After 3 months, the patient reported complete remission of symptoms and had gained 4 kg. Radiography of the digestive tube showed a normal transit at the distal esophagus. Manometric follow-up revealed the presence of peristaltic waves with a normal amplitude and duration along the entire esophagus.

Background: Enlarged spleens increase the technical difficulties associated with laparoscopic splenectomy (LS). The aim of this study was to analyze the impact of splenic weight on the results of LS., Methods: We performed a prospective analysis of 20 LS for splenomegaly and 40 LS for normal spleen in terms of intraoperative and early postoperative outcome., Results: Patients with splenomegaly had longer operative times and higher conversion and transfusion rates than those with normal spleens. Patients with spleens weighing < 2000 G experienced less blood loss, fewer conversions, and a shorter postoperative hospital stay than those with spleens > 2000 g. No differences-except for the longer operative time-were observed between normal-sized spleens and those weighing < 2000 G., Conclusions: LS for splenomegaly is feasible for experienced laparoscopic surgeons. For spleens weighing < 2000 G, the outcome was comparable to that of normal spleens, whereas LS for spleens >2000 g was associated with a higher conversion rate, greater blood loss, a longer hospital stay, and increased morbidity.

Background: The role of laparoscopic intraoperative cholangiography (IC) in the diagnosis of asymptomatic choledocholithiasis is still controversial. The aim of this study was to evaluate the diagnostic-therapeutic impact and the educational implications of this method for residents specializing in general surgery., Methods: We reviewed the records of 835 patients who underwent laparoscopic cholecystectomy for cholecystolithiasis without choledocholithiasis. IC was routinely performed by both expert surgeons and residents in general surgery., Results: The cholecystectomy was completed laparoscopically in 804 cases, but conversion to open surgery was required in 31 cases. IC was not completed in 140 cases (17.4%), and in 44 cases it revealed a suspected choledocholithiasis. The stones were treated via laparoscopy in 36 cases, laparotomy in six cases, and endoscopic retrograde cholangiopancreatography (ERCP) in two cases. Five patients were not diagnosed wit h choledocholithiasis. In one case, a lesion of the choledochus was discovered and treated laparoscopically. A total of 610 IC were done by expert surgeons and 225 by residents. The duration of the cholecystectomy with IC was significantly different between the two groups (76.9 +/- 12 vs 92.4 +/- 11), as was the feasibility index (88.6% vs 80.6%)., Conclusions: Laparoscopic IC is a safe and accurate procedure for the diagnosis of unrecognized choledocholithiasis. Teaching of this procedure as part of the specialization in general surgery would be opportune because it would provide surgical residents with an additional tool for the diagnosis and treatment of this pathology of the common bile duct.

Background: The aims of the study were to evaluate how the sliding hiatal hernia, in patients with gastroesophageal reflux disease (GERD), acts on the lower esophageal sphincter (LES) and esophageal clearance, and how surgical therapy corrects the physiopathological parameters., Methods: Records of 25 patients with only GERD and of 15 with GERD associated to hiatal hernia (> 3.5 cm) were reviewed. Ten subjects without symptoms and/or endoscopic and functional signs of GERD were considered as control group. The selection of the patients was done by reviewing radiographic examination, endoscopy and functional tests (esophageal manometry, pH-monitoring)., Results: Manometry showed a greater LES incompetence (pressure and length) and a worse peristalsis (distal amplitude) in the group with reflux and hiatal hernia against patients with reflux only. Also, patients with hiatal hernia had more acid exposure (total time pH < 4 in the distal esophagus) and a longer time of esophageal clearance, at pH-monitoring. The functional tests in 8 patients, before and after laparoscopic Toupet fundoplication with posterior closing of the crura, showed a normalised LES, esophageal clearance and acid exposure. Esophageal peristalsis did not show any statistically significance., Conclusions: The presence of hiatal hernia, in patients with GERD, causes worse LES, peristalsis and clearance with a greater acid exposure of the esophagus. Fundoplication, by reconstructing the sphincter-diaphragm unit, normalises the preoperative physiopathology situation but without an effective peristalsis improvement.

The authors report a case of anomalous implantation of the base of the appendix, observed in a 8-year-old boy, arising from the anterior wall of ascending colon at 15 cm from the ileo-cecal valve. After a brief review of the most frequent congenital anomalies of the appendix and the few cases of anomalous implantation described in international literature, the authors emphasize the importance of an accurate exploration and mobilization of the ascending colon to reduce the risk of diagnostic and therapeutic mistakes, also related to the small incision of McBurney, usually made for the routine laparotomic appendectomy.

Objective: Evaluation of saphenous vein sparing surgical procedures alternative to high ligation and distal stab avulsion, in terms of effectiveness and suitability for eventual bypass surgery., Experimental Design: Prospective evaluation of 421 operations for primary varicose veins, 64 external valve-plasties of the sapheno-femoral junction (EV-SFJ), (42 performed using the hand sewing technique and 22 using the Veno-cuff device), mean follow-up 52 months, and 357 hemodynamic correction of varicose veins (French acronymis CHIVA), mean follow-up 49 months. Moreover, a subgroup of 27 patients was operated on using the CHIVA technique in two steps, mean follow-up 18 months., Setting: Institute of General Surgery, University of Ferrara. Institutional practice, one-day surgery., Patients: Patients were selected using clinical and duplex scanning evaluations, and classified according to CEAP criteria. Patients with varicose veins due to sapheno-femoral reflux with duplex scanning evidence of mobile valve leaflets underwent EV-SFJ. The other patients were operated on using the hemodynamic correction technique., Interventions: EV-SFJ restores valve function correcting vein wall dilatation by applying an external prosthesis. CHIVA consists of selected ligatures of the superficial veins that allow superficial blood aspiration in the deep veins through the perforators as well as the preservation of saphenous drainage., Measures: The outcome was evaluated with independent clinical and ultrasonographic examinations; pre and postoperative AVP and LRR-RT measurements were assessed in 125 cases. Data from self-assessment of the functional and cosmetic result of the patients of the CHIVA group were also obtained using a scoring system. Moreover, scanning the preserved long saphenous vein the rate of long saphenous vein suitable as arterial conduit following sparing surgery was also evaluated., Results: Overall long saphenous vein patency registered after EV-SFJ and CHIVA was 94%. Varicose veins recurrence rate was 12% and 11%, respectively. Postoperative AVP and LRR-RT improvement was statistically significant (p<0.001)., Conclusions: These two alternative procedures seem to be effective in varices treatment following the proposed indications and techniques. In addition, they appear able to preserve a more significant rate of saphenous veins suitable for eventual bypass surgery than high ligation and multiple cosmetic avulsion.

Videolaparoscopic cholecystectomy is considered the treatment of choice for simple cholelithiasis. Now many surgeons consider the laparscopic procedure usable also in the complicated biliary lithiasis like acute cholecystitis and choledocholithiasis. The authors report their recent experience of the laparoscopic treatment of biliary lithiasis, regarding 221 non-selected patients (69% symptomatic cholelithiasis, 20% chronic cholecystitis, 4.5% acute cholecystitis, 4.5% coledocolithiasis, 2% hydrops). The diagnostic-therapeutic protocol and the results are described and compared with the beginning of their experience, when they treated only symptomatic gallbladder stone disease, and with the reports of the literature. The authors concluded that the laparoscopic procedure is a good chance for the surgeon in the treatment of all cases of benign biliary disease. But, in particular for patients with choledocholithiasis, he has be able to know all the diagnostic and therapeutic possibilities, to choose the best in every single case.

Objective: A prospective study was performed in order to compare results obtained in the treatment of early and/or limited primary varicose veins of the lower limbs using two different procedures: external valvuloplasty and high ligation or disconnection of the sapheno-femoral junction., Materials and Methods: 116 limbs (113 patients) were selected. 57 with normal cusps in dilated valves were subjected to external valvuloplasty with Silicone prosthesis under Doppler control (intraoperative angioscopy in 16 cases); 59 limbs were subjected to high ligation or disconnection of the junction; 57 limbs out of 116 were subjected to complementary procedures. Duplex and photoplethysmographic examinations were performed before and after the surgical procedures in all patients. Doppler venous pressures were measured in 36 limbs and invasive pressures in 40 limbs. Patients were postoperatively followed up every 4 months until the 12th month., Results: Indications for valvuloplasty were found in 8.2% of cases and in 66.3% of the early varices. Clinical results were slightly superior in the reparative surgery group. Thrombotic occlusion of the proximal long saphenous vein was significantly higher in the ligation-disconnection group. Results from photoplethysmography and venous pressure measurements indicated that both operations are equally effective in the elimination of reflux in the junction.

The pathophysiology of gastroesophageal reflux disease (GERD) is often multifactorial, as abnormal function of the lower esophageal sphincter (LES) may be associated to abnormalities of the esophageal peristalsis, the esophageal clearance, and the gastric reservoir. The preoperative evaluation of patients with GERD must include esophageal function tests (esophageal manometry and ambulatory pH monitoring) and evaluation of the gastric emptying in addition to UGI series and endoscopy. The information provided by these tests is essential to identify the pathophysiology of the disease in the individual patient, and tailor the operative treatment accordingly. For patients with an incompetent LES but normal esophageal peristalsis, the Nissen fundoplication is the procedure of choice. When abnormal peristalsis and delayed clearance are identified by preoperative esophageal function tests, a partial fundoplication must be chosen in order to avoid postoperative dysphagia and gas bloat syndrome. Too many eponyms have been used to describe antireflux surgery (Nissen, Rossetti, Toupet, Lind, Hill, Guarner). It is time to go beyond these eponyms, and focus on the technical details which contribute to the stability of the wrap, as this is the main determinant of long term outcome.

The authors report their experience on cervical anastomosis dehiscence in patients who had total esophagectomy and esophagogastroplasty for esophageal neoplasms. They describe, accurately and step by step, the plastic reconstructive technique (by using a vascularized transposed cutaneous flap), used to treat a symptomatic cervical fistula which occurred in 3 of the 24 patients who had esophagectomy and cervical-esophagogastroplasty. This kind of treatment led to complete healing of the fistulas, without clinical and radiological signs of fistula recurrence in all the patients treated.

The aim of the experimental study was to evaluate the possibility of performing an end-to-end anastomosis by using fibrin adhesive as the only means of suture. To this end, 24 Wistar rats were used, of which 16 underwent ilear resection and 8 underwent colotomy, and they were divided respectively into two groups. On the rats of the first group the anastomosis was performed by using only fibrin adhesive; on the rats of the second group operated the anastomosis was performed by using fibrin adhesive in association with non adsorbable suture material, while on those operated of colectomy the anastomosis was performed by fibrin adhesive and adsorbable suture material. The anatomo-phatological studies on the anastomosis have shown a similar healing process in the cases treated only with fibrin adhesive and by using absorbable material and has demonstrated the trange material from the suture, which are a possible causes of complication.

The aim of the paper is to give a contribution to the understanding of the role of surgery in patients with N3 lung cancer. The A. describe their results on 32 patients with N3 lung cancer operated on mediastinectomy; histological examination of the specimens showed 27 squamous cell carcinomas and 5 adenocarcinomas. The operation was performed through a median sternotomy to gain access to the left and right paratracheal nodes, pretracheal, precarinal and subcarinal nodes, subaortic and left and right hilar nodes that were removed together with the fat of the mediastinum. Left pneumonectomy was performed in 5 patients. There was no operative mortality; 12 patients were irradiated in the postoperative period with 5,000 Rads (50 Gy), while 18 or the 27 patients with squamous cell carcinoma are still alive.

Tracheal sleeve lobectomy is right upper lobectomy extended to include resection of the main bronchus, the carina and a segment of the trachea with end-to-end anastomosi of the trachea and end-to-side anstomosis of the intermediate bronchus on the main left bronchus, or the upper lobe on the trachea. This operation is possible with the aid of high frequency jet ventilation. The surgical indication of this operation is bronchoscopic and functional and guarantees a good oncological radicality in the presence of N0.

More than 60% of patients who are submitted to Hartmann's procedure refuse to undergo reversal. This procedure is in fact a major undertaking associated with significantly mortality and morbidity rates. The authors suggest a minimally invasive approach without pneumoperitoneum. A consecutive series of four male patients, average age 64 years, underwent laparoscopic assisted reversal of Hartmann's procedure in our department. The procedure was performed for intestinal malignant occlusion in two cases and for perforated diverticulitis in the other two. Mobilization was nearly immediate and incisional pain almost absent; peristalsis restarted after 36-48 h. Finally, the patients were discharged on day 6. Neither mortality nor morbidity occurred in the 8-month follow-up period. The authors conclude that this new laparoscopic procedure may lead to shorter hospital stays and increased acceptance by patients, while maintaining the same safety of the traditional open procedure.

The experience with video-assisted mediastinoscopy in 16 cases examined, is reported. Initially the classic mediastinoscopic device with the aid of an operative thoracoscopy was used. Starting from April 1994 the Authors used the video-assisted mediastinoscopy which, enlarging the surgical field, allows to improve the operative performance and may be a good aid for multiple teaching.

Since 1959, when mediastinoscopy was introduced by Carlens, the practice has been technically unchanged. The authors suggest how the new video technologies could be very helpful to this procedure leading to an ergonomic position for the operator and a faster performance. Initial experience is reported.

Up until now the problem of surgical infections has been one of the most important which surgeons must confront daily. In 1989 our Institute began programs for control and surveillance of surgical infections; these include, among others, the use of chemo-antibiotic prophylaxis protocols applied to all of the patients hospitalized for surgery. The authors report two years application of three protocols of chemo-antibiotic prophylaxis related to 1722 patients, in which we pointed out the passage from 27.6% of infected cases in the control group to 10.2% infected cases in one of the groups subject to prophylaxis. In these cases the antibiotic prophylaxis also acted reducing in a spectacular manner the incidence of clinically not significant infections.

In this paper the Authors report their experience on diagnostic and surgical procedures with respect to aneurysms of the visceral district. The clinical review during the last ten years of surgical activity in the Istituto di Clinica Chirurgica (Università di Ferrara) regards 13 patients with different visceral aneurysms. The study reports the different percentage of localization, the diagnostic approach, the surgical procedure performed and discussion of results obtained. Patients at risk for this disease are pointed out.

Modern technology has recently provided us with new resorbable suture material for use also in vascular surgery. Clinical use of these sutures has been impeded however by not little mistrust and by old dogmas without a rational experimental basis. We have therefore begun studies of two slowly resorbable materials, polyglactin 910 and polyglycolic acid, in comparison with two classic nonreabsorbable materials, nylon and polypropylene, used in experimental model of end-to-end anastomosis rats'infrarenal aorta, following up the healing process and its evolution after an interval. The results are discussed in relation to data collected from current literature.

Among the anomalies of internal carotid artery, agenesis and aplasia recur with a low rate: only about sixty cases are reported in literature. We observed a case of aplasia of the left internal carotid in a 49 year old male suffering from hypertension and showing cerebro-vascular symptoms due to TSA pathology: it was studied with arterial angiography and duplex scanner. The angiographic examination raised a suspicion of left internal carotid thrombosis; on the contrary the duplex scanner revealed a correct diagnosis of carotid aplasia.

The cost/benefit ratio of stapled anastomoses in colorectal surgery has been retrospectively evaluated on the basis of a 8 year experience taking into account the overall costs in surgery as well as short term and long term benefits. With this aim, our experience was divided in two periods: 1st period: November 1970-January 1981: 598 hand sutures; 2nd period: February 1981-December 1988: 787 stapled sutures. Mechanical suturing was found to be superior based on the following: a) the average postoperative hospital stay decreased from 20.2 days to 14.7 days; b) temporary stomas decreased from 62.2 to 25.1%; c) abdominoperineal resection for rectal cancer decreased from 60.7 to 41.6%.

The Authors report on the use of non-invasive techniques in the preliminary evaluation of revascularization of the femoral-popliteal axis. The study of this pathology, for which surgery has become less and less frequent, being limited to the more serious cases, has greatly benefited by the use of H/R echography and of Doppler. These techniques, which remain complementary to angiography, have proved very important and reliable for their capacity to visualize the arterial lumen, an important element for the pre- and post surgical evaluation of vascular recanalization and of the relationship of continuity and continuity with the nearby structures.