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Aim: Retrospective multicenter analysis of the results of two different approaches for band positioning: perigastric and pars flaccida., Methods: Data were collected from the database of the Italian Group for LapBand (GILB). Patients operated from January 2001 to December 2004 were selected according to criteria of case-control studies to compare two different band positioning techniques: perigastric (PG group) and pars flaccida (PF group). Demographics, laparotomic conversion, postoperative complications, and weight loss parameters were considered. Data are expressed as mean +/- standard deviation., Results: 2,549 patients underwent the LapBand System procedure [age: 40 +/- 11.7 years; sex: 2,130 female, 419 male; body mass index (BMI): 46.4 +/- 6.9 kg/m(2); excess weight (EW): 60.1 +/- 23.6 kg; %EW: 90.1 +/- 32.4]. During this period 1,343/2,549 (52.7%) were operated via the pars flaccida (PF group) and 1,206/2,549 (47.3%) via the perigastric approach (PG group). Demographics for both groups were similar. Thirty-day mortality was absent in both groups. Operative time was significantly longer in the PG group (80 +/- 20 min versus 60 +/- 40 min; p < 0.05). Hospital stay was similar in the two groups (2 +/- 2 days). Laparotomic conversion was significantly higher in the PG group (6 versus 2 patients; p < 0.001). Overall postoperative complication rate was 172/2,549 (6.7%) and was linked to gastric pouch dilation/slippage (67/172), intragastric migration/erosion (17/172), and tube/port failure (88/172). Gastric pouch dilation and intragastric migration were significantly more frequent in the PG group: 47 versus 20 (p < 0.001) and 12 versus 5 (p < 0.001), respectively. Patients eligible for minimum 3-year follow-up were 1,118/1,206 (PG group) and 1,079/1,343 (PF group). Mean BMI was 33.8 +/- 12.1 kg/m(2) (PG group) and 32.4 +/- 11.7 kg/m(2) (PF group) (p = ns), and mean percentage excess weight loss (%EWL) was 47.2 +/- 25.4 and 48.9 +/- 13.2 in PG and PF groups, respectively (p = ns)., Conclusions: Significant improvement in LapBand System results with regard to laparotomic conversion and postoperative complication rate, with similar weight loss results, was observed in the pars flaccida group.

There is no uniform consensus on the utility of routine intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC). In this paper, we present a 10-year retrospective audit of our cases of LC without IOC, performed by a search of readmission cases through our electronic database. Data regarding all patients subjected to LC at our unit in the period January 1996-December 2006 were obtained through our hospital database system. Subsequently, a query was made to ascertain if there were any readmissions to any of our city hospitals, up to December 2006. A total of 1321 patients underwent LC at our unit in the period January 1, 1996-December 31, 2006. The median operating time for LC without IOC was 58 minutes (range, 15-370). The median hospital stay was 2 days (range, 1-30). Postoperative outcome was uneventful in 1250 patients (94.7%). There was no mortality. Grade I and II complications occurred in the remaining 71 patients. Patients were stratified by risk of common bile duct stones (BDSs) according to clinical, ultrasonographic, and serum chemistry data. Patients with suspected BDS underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP) and BDS clearance (142 patients). No patient in our series of LC was readmitted to any of the city hospitals for biliary desease up to 10 years after the operation. Our retrospective audit confirms the safety of LC without routine IOC and the rarity of readmissions for retained BDS and supports the policy of selective IOC.

According to the WHO about 300 million people in the world are affected by obesity with an increasing trend. The aim of the present study was to assess our preliminary results with sleeve gastrectomy. Over the period from June 2006 to March 2008, 25 laparoscopic sleeve gastrectomy were performed at our Department of Surgery for morbid obesity by the same surgeon. The operation consists in resection of approximately three quarters of the stomach with the creation of a long slender gastric tube, dividing the stomach vertically in two parts and removing all the left side with the greater curvature and gastric fundus. The mean age of the patients was 38 +/- 9 years, and the mean BMI 48 +/- 3. The mean operative time was 110 minutes, and the mean hospital stay 6 days. Mean intraoperative bleeding was negligible (20 cc). In our study we observed just one case of gastric leakage from the staple line, treated by surgical drainage and by placement of an endoscopic stent. There were no cases of bleeding of the resection margin and no long-term stenosis; there was no mortality. The mean follow-up was 18 months. BMI showed a mean reduction of about 17 points. During postoperative visits all the patients reported marked reduction of hunger sensation, together with a sense of early satiety. On the basis of these preliminary results we can consider laparoscopic sleeve gastrectomy as a safe, functional and definitive procedure that constitutes a valid alternative in bariatric surgery, though it is as yet not completely standardised and requires a longer follow-up.

The preoperative diagnosis of polycystic liver is easily obtainable by ultrasound, while computed tomography is more sensitive for making the differential diagnosis versus other hepatic lesions. This report describes a case of polycystic liver with mass-related symptoms. A laparoscopic fenestration of the larger and superficial cysts was performed. At a three-years follow-up neither postoperative complications nor recurrent episodes were observed. A number of studies have shown that the rates of cyst and symptom recurrence are 9% and 4.5%, respectively, and that the reduction of liver volume is 12.5%. in our opinion the choice of adequate treatment must be based on an accurate evaluation of the patient's clinical aspects and on tthe characteristics of cystic lesions, such as number, size and location. In conclusion, laparoscopic fenestration of liver cysts is a safe, effective procedure for obtaining excellent outcomes in terms of absence of recurrence, as well as being a more sparing approach.

The aim of the study was to consider all the factors associated with the development of postoperative dysphagia which, in its transitory form, can be present in as many as 40 to 70% of cases. From 1996 to 2007, 302 Nissen fundoplications were performed at our department of surgery. We divided this series into two groups, the first consisting of 149 cases (from March 1996 to March 2004) where short gastric vessels were not dissected (nl-VGB) and the second of 153 cases (from April 2004 to December 2007) where short gastric vessels were dissected (I-VGB).The incidence of postoperative dysphagia was distinctly lower in I-VGB than in nl-VGB (4.5% vs 19.5%). One month after operation, the incidence of postoperative dysphagia in I-VGB and nl-VGB was 12% and 1,5%, respectively, while 3 months after surgery the percentages were 2% and 0.5%. Exclusion of cases performed during the learning curve period yielded similar results. At postoperative examinations we noticed a substantial reduction in gastro-oesophageal reflux disease symptoms in both groups, with no significant difference between the two. L-VGB patients appeared clearly more satisfied after operation than nl-VGB patients (97% vs 88%), even if the results were similar after 3 months. Our experience confirms the good results obtained with Nissen fundoplication with a distinct, rapid reduction in postoperative dysphagia.

The demand for shorter admissions and quicker recoveries prompted us to adopt a new approach, favouring day surgery as the preferred organisational modality. Since 2004, 312 Milligan-Morgan haemorrhoidectomies have been performed at our department of surgery. The operations were performed at our proctological outpatient unit by means of LigasureTM with immediate discharge. In our study we observed postoperative bleeding in 3 cases (0.96%), while 4 patients (1.28%) required an ordinary admission. There were no cases of acute urinary retention in our experience. Operating time is about 12-16 minutes; and recovery time around 60-70 minutes. Over the period 1992-2003, 978 Milligan-Morgan haemorrhoidectomies were performed at our department of surgery using diathermy. Historical comparison of the results of the two groups shows a reduction in complications, operating times and recovery times. On the basis of our experience, radiofrequency ablation causes less postoperative pain and makes for shorter recovery times compared with diathermy, because of its lower tissue damage. The aim of the present study was to verify the safety and effectiveness of day surgery haemorroidectomy in selected cases.

Background: Among bariatric operations, laparoscopic adjustable gastric banding (LAGB) has been the preferred one in Europe and Australia, and has become recently popular in the USA. Like every surgical procedure, however, it is not devoid of specific complications, like slippage, band erosion, outlet obstruction and port problems. Assuming that the absence of the pouch may avoid postoperative slippage, we introduced the technique of esophago-gastric placement, instead of the original gastric banding technique. A further technical variant, introduced in June 2002, consists of suturing the gastric fundus to the left hemidiaphragm, using two non-resorbable sutures and pledgets., Methods: Between January 1999 and July 2005, 400 LAGBs have been placed in 90 males and 310 females, with the technical variants above. Mean age was 42 (range 17-69 years), and mean BMI was 44.8 kg/m(2) (range 33-67)., Results: Mean hospital stay was 2.5 days (range 1-17). Mortality has been zero. Major complications included: 16 slippages (after a range of 6-45 months), 5 outlet obstructions (immediately after the operation), and one intragastric migration (after 2 years). Minor complications included 18 port problems. Since the introduction of gastric fundus fixation to the diaphragm in 2002, gastric slippage has decreased from 8% to 0.9%. BMI has decreased from 44.8 to 32 kg/m(2) at 60 months., Conclusions: The technique herein presented is effective and useful to prevent postoperative gastric slippage. It does not induce pseudo-achalasia, if strictly controlled. In fact, it is avoided by the patient due to the immediate appearance of dysphagia, in the case of wrong food ingestion. Long-term clinico-radiological follow-up confirms that the technique is safe and effective in motivated patients with good compliance and willing to undergo periodic studies.

Background: Little is known about obesity surgery in young and adolescent patients. The aim of this study is to evaluate results of laparoscopic adjustable gastric banding in obese teenagers., Methods: Patients < or = 19 years old selected from the database of the Italian Collaborative Study Group for Lap-Band were analyzed according to mortality, comorbidities, laparotomic conversion, intra- and postoperative complications, body mass index (BMI), and % excess weight loss (EWL) at different times of follow-up. Data were expressed as mean +/- SD., Results: Fifty-eight (1.5%) of 3813 patients who underwent operation with the Lap-Band System were < or = 19 years old: 47F/11M; mean age, 17.96 +/- 0.99 years (range, 15-19); mean BMI, 46.1 +/- 6.31 Kg/m2 (range, 34.9 - 69.25); mean % excess weight, 86.4 +/- 27.1 (range, 34 - 226.53). Sixteen (27.5%) of the 58 patients were superobese (BMI > or = 50). In 27/58 (46.5%) patients, 1 or more comorbidities were diagnosed. Mortality was absent. Laparotomic conversion was necessary in 1 patient with gastric perforation on the anterior wall. Overall postoperative complications occurred in 6/58 (10.3%). The band was removed in 6/58 (10.3%) patients for gastric erosion (3 patients), psychologic, intolerance (2 patients), and in the remaining patient was converted 2 years after surgery (BMI 31) to gastric bypass or gastric pouch dilatation. Patient follow-up at 1, 3, 5, and 7 years was 48/52 (92.3%), 37/42 (88.1%), 25/33 (75.7%), and 10/10, respectively. At these times, mean BMI was 35.9 +/- 8.4, 37.8 +/- 11.27, 34.9 +/- 12.2, and 29.7 +/- 5.2 Kg/m2. Mean %EWL at the same time was 45.6 +/- 29.6, 39.7 +/- 29.8, 43.7 +/- 38.1, and 55.6 +/- 29.2. Five/25 (20%) patients had < or = 25% EWL at 5 years follow-up, while none of the 10 patients subject to follow-up at 7 years had < or = 25% EWL., Conclusions: Lap-Band System is an interesting option for teenagers suffering obesity and its related comorbidities, which deserves further investigation.

Background: Laparoscopic of the LAP-BAND System placement stage of obesity is a safe operation, but its indication in terms of stage of obesity is controversial. The aim of this study was to evaluate the 5 years stage of obesity results for weight loss in patients with varying preoperative ranges of body mass index (BMI)., Methods: Data were obtained from the Italian Collaborative Study Group for LAP-BAND System (GILB) registry. Detailed information was collected on a specifically created database (MS Access 2000) for patients operated on in Italy from January 1996 to 2003. Patients operated on between January 1996 and December 1997 were allocated to four groups according to preoperative BMI range: 30-39.9 kg/m(2) (group A), 40-49.9 kg/m(2) (group B), 50-59.9 kg/m(2) (group C), and =60 kg/m(2) (group D) percent estimated weight loss respectively. Postoperative complications, mortality, BMI, BMI loss, and (%EWL) were considered in each group. Data are expressed as mean +/- SD, except as otherwise indicated. Statistical analysis was done by means of Fisher's exact test, and p < 0.05 was considered significant., Results: After 5 years from LAP-BAND System surgery, 573 of 3,562 patients were eligible for the study. One hundred fifty-five of 573 (27.0%) were lost to follow-up, 24 of 418 (5.7%) underwent band removal due to complications (gastric pouch dilation, band erosion), eight of 418 (1.9%) were converted to other bariatric procedures, five of 418 (1.2%) died of causes not related to the operation or the band, and 381 of 573 (66.5%) were available for follow-up. Based on 96, 214, 64, and seven patients their preoperative BMI, Were allocated to groups A, B, C, and D, respectively. At time of follow-up mean BMI was 27.5 +/- 5.2 in group A, 31.6 +/- 4.7 in group B, 37.6 +/- 17.3 in group C, and 41.4 +/- 6.9 kg/m(2) in group D. Mean BMI loss was 9.8 +/- 5.4, 12.9 +/- 5.2, 15.8 +/- 8.1, and 23.2 +/- 4.9 kg/m(2), respectively, in groups A, B, C, and D. Mean %EWL at the same time was 54.6 +/- 32.3 in group A, 54.1 +/- 17.2 in group B, 51.6 +/- 35 in group C, and 59.l +/- 17.1 in group D., Conclusion: Initial BMI in this series did not correlate with %EWL 5 years after the operation. In fact %EWL was almost the same in each group, independent of preoperative weight. Initial BMI was an accurate indicator of the results obtained 5 years after LAP-BAND in group C (50-59.9 kg/m(2)) and D (=60 kg/m(2)) patients, who remained morbidly obese despite their %EWL.

Background: The Lap-Band System is the most common bariatric operation world-wide. Current selection criteria do not include patients with BMI < or = 35. We report the Italian multicentre experience with BMI < or = 35 kg/m(2) over the last 5 years., Patients and Methods: Data were obtained from 27 centres involved in the Italian Collaborative Study Group for Lap-Band System. Detailed information was collected on a specially created electronic data sheet (MS Access 2000) on patients operated in Italy since January 1996. Items regarding patients with BMI < or = 35 were selected. Data were expressed as mean +/- SD except as otherwise indicated., Results: 225 (6.8%) out of 3,319 Lap-Band patients were recruited from the data-base. 15 patients, previously submitted to another bariatric procedure (BIB =14; VBG= 1) were excluded. 210 patients were eligible for study (34M/176F, mean age 38.19+/-11.8, range 17-66 years, mean BMI 33.9+/-1.1, range 25.1-35 kg/m(2), mean excess weight 29.5+/-7.1, range 8-41). 199 comorbidities were diagnosed preoperatively in 55/210 patients (26.2%). 1 patient (0.4%) (35 F) died 20 months postoperatively from sepsis following perforation of dilated gastric pouch. There were no conversions to laparotomy. Postoperative complications presented in 17/210 patients (8.1%). Follow-up was obtained at 6, 12, 24, 36, 48 and 60 months. At these time periods, mean BMI was 31.1+/-2.15, 29.7+/-2.19, 28.7+/-3.8, 26.7+/-4.3, 27.9+/-3.2, and 28.2+/-0.9 kg/m(2) respectively. Co-morbidities completely resolved 1 year postoperatively in 49/55 patients (89.1%). At 60 months follow-up, only 1 patient (0.4%) has a BMI >30., Conclusions: Although surgical indications for BMI < or = 35 remain questionable, the Lap-Band in this study demonstrated that all but 1 patient achieved normal weight, and most lost their co-morbidities with a very low mortality rate.

The definition of difficult laparoscopic cholecystectomy (LC) is inconsistent. The aim of this study was to analyze the factors that make LC difficult to perform and determine ways to avoid conversion, based on our series. All patients who underwent LC or open cholecystectomy (OC) between January 1993 and December 2001 in our division of general surgery were the subject matter of this study. Preliminary decisions regarding LC or OC were avoided. Our experience (1993-2001) was based on 1360 consecutive elective LC procedures in 381 male and 979 female patients. The mean age of the patients at operation was 53 years (range, 17-84). The median operating time was 55 minutes (range, 35-180). The overall conversion rate was 1.8%. Indications for conversion included surgical difficulty during the laparoscopic procedure and anesthesia issues. The conversion rate has decreased to less than 1% in recent years. There were no mortalities, and the postoperative complication rates were low. The mean hospital stay of the patients was 2.6 days. In conclusion, based on our experience, we suggest limiting OC to patients with proven contraindications to LC (i.e., Mirizzi syndrome or systemic illness incompatible with pneumoperitoneum), attempting LC in all other cases, and considering cholecystostomy and delayed LC as an alternative to conversion during difficult LC.

Background: The Lap Band system procedure is currently the most common bariatric surgical procedure worldwide. This is an interim report of the experience of the 27 Italian centers participating in the national collaborative study group for Lap Band (GILB)., Methods: An electronic database was specifically created. It was mailed and e-mailed to all of the surgeons now performing the laparoscopic gastric banding operation in Italy., Results: Beginning in January 1996, 1893 patients were recruited for the study. There were 1534 women and 359 men with a mean body mass index (BMI) of (range 30.4-83.6) and a mean age of 37.8 +/- 10.9 years (range; 17-74). The mortality rate has been 0.53% (n = 10), mainly due to cardiovascular complications (myocardial infarction, pulmonary embolism). The laparotomic conversion rate has been 3.1% (59/1893) and was higher in superobese patients (BMI>50) than in to morbidly obese patients (BMI <50) (p <0.05). Postoperative complications occurred in 193 patients (10.2%), including tube port failure (n = 79; 40.9%), gastric pouch dilation (GPD) (n = 93; 48.9%), and gastric erosion (n = 21, 10.8%). Most GPD (65.5%) occurred during the first 50 patients treated at each center. The incidence of GPD decreased as the surgeons acquired more experience. Surgery for complications was often performed by laparoscopic access, rarely via laparotomy. No death was recorded as a consequence of surgery to treat complications. Weight loss has been evaluated at the following intervals: 6, 12, 24, 36, 48, 60, and 72 months, with BMI 37.9, 33.7, 34.8, 34.1, 32.7, 34.8, and 32., Conclusions: The Lap Band system procedure has a very low mortality rate and a low morbidity rate and it yields satisfactory weight loss. Surgery for complications can be performed safely via laparoscopic access.

Background: Laparoscopic adjustable gastric banding (LAGB) is the most common bariatric operation. This study is a retrospective analysis of the multicenter Italian experience in patients with BMI > 50 over the last 4 years., Methods: An electronic data sheet made for LAGB-operated patients since January 1996, was mailed and e-mailed to all surgeons involved in this kind of procedure in Italy. Items regarding patients with BMI > 50 were selected. Analysis used Fisher's exact test and logarithmic regression analysis (P < 0.05 significant). Data were expressed as mean +/- SD., Results: 239 patients (13.3%), out of 1,797 Lap-Band operated patients entered the study (179F / 60M), with mean age 37.6 +/- 11.3 years (19-69) and mean BMI 54.6 +/- 4.8 (50.1-83.6). Laparotomic conversion rate was 5.4% (44/239). Postoperative complications occurred in 24 / 239 patients (9.0%). Follow-up was obtained in 218 / 218, 198 / 198, 121 /147, 75 / 93, 30 / 38 LAGB patients at 6,12, 24, 36, and 48 months respectively. At these time periods, mean BMI was 46.7, 43.9, 42.2, 41.9, and 39.3 kg/m2. At the same intervals, mean %EWL was 24.1, 34.1, 38.8, 38.9, and 52.9%. The number of patients with < 25% EWL at 12, 24, 36, and 48 months follow-up were 34, 10, 4, and 0. Serious co-morbidities (189 in 124 of 239, 57%) had completely resolved 1 year postoperatively in 74 / 124 of the patients (59.6%)., Conclusion: Although super-obese patients following the LAGB remain obese with BMI > 35, in the short-term most lose their co-morbidities, with a very low morbidity and mortality rate.

Background: Laparoscopic gastric banding is effective in surgical treatment of morbid obesity, but has had the drawback of specific complications, like slippage and gastric erosion. To prevent such complications, modifications have been used, including high retrogastric positioning above the bursa omentalis, complete anterior fixation by gastro-gastric stitches over the band, and reduction of the pouch volume to < or = 15 ml. These technical variants may induce dysphagia., Methods: We adopted a different technique, consisting of placement of the band (9.75 cm BioEnterics Lap-Band) around the esophagus just above the cardia, to induce an amplification of the dysphagic mechanism. No fixation stitches were used., Results: From January 1999 to March 2001, 80 consecutive patients (16 males, 64 females, mean age 41 years, average BMI 45) were operated this way. All operations were completed laparoscopically. However, in 1 patient the procedure had to be interrupted for bleeding from a large fatty liver injury by the retractor. Complications included 2 cases of slippage: an early one after 24 h, requiring surgical removal, and a late one after 9 months, treated by laparoscopic repositioning. The third complication, a reactive esophageal stenosis, occurred in a transsexual male on estrogen treatment, that needed replacement with a wider Swedish band. Band adjustment was required in 28 patients, one time in 22 cases and twice in the other 6. Mean BMI decreased from 45 to 38 after 6 months, remaining at 37 after 24 months, while excess weight was reduced by 50% at 24 months., Conclusions: The technique has a re-educational function, in that patients are induced to chew thoroughly, to introduce small morsels of food and to prolong the mastication time, in order to avoid dysphagia. Laparoscopic adjustable esophagogastric banding gave no problem if well positioned, and promoted new alimentary habits through a dysphagic mechanisms, inducing significant excess weight loss.

Background and Purpose: Twenty years after the first report of laparoscopic appendectomy (LA), its role in the treatment of appendicitis is still under debate. We report herein a retrospective analysis of our cases of LA in the last 5 years, during which we adopted a policy of an almost uniform laparoscopic approach on a rather selected population composed mainly of women with acute or recurrent lower quadrant abdominal pain., Patients and Methods: Laparoscopic appendectomy was performed on 33 male and 98 female patients. The mean age at operation was 25.7+/-11.4 years (range 11-59 years). Acute appendicitis with localized or diffuse peritonitis was present in 34 cases. In the remaining 97 patients, the operation was performed for acute or recurring symptoms of lower quadrant abdominal pain., Results: There were no conversions to open surgery. The operating time was 45+/-17 minutes (range 30-110 minutes). The pathology examination of the removed appendices showed acute appendicitis in 34 cases and chronic inflammation in the remaining 97 patients. In one case, histology revealed a coexisting mucinous carcinoid that extended to the perivisceral fat, and a completion right hemicolectomy was performed. Complications were minor in most cases. Reoperation for deep abdominal abscess or hematoma was required in three cases. The mean hospital stay was 2.59+/-1.58 days (range 24 hours-11 days)., Conclusion: In our hands, LA has proven to be safe and effective. The laparoscopic operation has significant advantages in terms of lower invasiveness and better diagnostic capability. It is especially useful in women of child-bearing age, in whom it may be considered the procedure of choice.

Background: An increasing number of surgeons with different levels of experience with laparoscopic surgery and open obesity surgery have started to perform laparoscopic implantation of the Lap-Band., Methods: An electronic patient data sheet was created and was mailed and e-mailed to all surgeons performing laparoscopic adjustable silicone gastric banding (LASGB) in Italy. Patients were recruited since January 1996. Data on 1,265 Lap-Band System operated patients (258 M/1,007 F; mean BMI 44.1, range 27.0-78.1; mean age 38, range 17-74 years) were collected from 23 surgeons performing this operation., Results: Intra-operative mortality was absent. Post-operative mortality was 0.55% (7 patients) for causes not specifically related to LASGB implantation. The laparotomic conversion rate was 1.7% (22 patients). LASGB related complications occurred in 143 patients (11.3%). Pouch dilatation was diagnosed in 65 (5.2%), and 28 (2.2%) of these underwent re-operation. Band erosion was observed in 24 patients (1.9%). Port or connecting tube-port complications occurred in 54 patients (4.2%), 12 of whom required revision under general anesthesia. Follow-up was obtained at 6, 12, 18, 24, 36 and 48 months, and mean BMI was respectively 38.4, 35.1, 33.1, 30.2, 32.1 and 31.5. The percentage of patients observed at each follow-up was > 60%. There was no intra-operative mortality and no complication-related mortality, with acceptable weight loss., Conclusion: The LASGB operation is safe and effective, and deserves wider use for treatment of morbid obesity.

The authors of this article describe two cases of post-traumatic pneumomediastinum, without pneumothorax and oesophageal or bronchial mucosal lesions. Both cases had a benign evolution. General considerations are discussed and the authors concluded that when pneumomediastinum is not associated with lesions of mediastinical organs no surgical treatment is usually required.

A review of 2,092 patients who had sustained closed thoracic trauma or undergone mechanical ventilation was made in order to clarify the incidence, clinical picture, pathogenesis and prognosis of pneumomediastinum without pneumothorax or lesion of mediastinal organs. Air in the mediastinal space was observed in ten patients (0.5% of cases). Bronchial and esophageal lesions were excluded at bronchoscopy and esophagoscopy. The clinical presentation included subcutaneous emphysema of the neck, without signs of mediastinitis. No patient had pain or dyspnoea. Trauma or barotrauma were assumed to have caused sudden rise in the intrapulmonary pressure, leading to passage of air from the parahilar alveoli into the mediastinum along the peribronchial and perivascular spaces. Management was conservative and the prognosis good, with normalization of the chest radiogram usually within a week.

Splenectomized subjects show a higher incidence of myocardial ischemia and of Overwhelming Post-Splenectomy Infection (OPSI). It is doubtful that implanted splenic tissue guarantees an adequate protection from OPSI. The histological characteristics and the capacity of protection from OPSI of two models of omental autoimplantation of splenic tissue in rats were examined. The implanted splenic tissue offers a significant protection from pneumococcal sepsis, even though there is no relation between implant architecture and survival rate.

In the last 5 years the authors have treated 30 cases of external intestinal fistulas with total parenteral nutrition. These cases are described and the results analyzed in relation to fistular secretion, age of patients and the early timing of treatment.

The authors propose a model of hepatic transplantation in the inbred rat which may be used for an immunological study. The whole liver is transplanted. It is orthofunctional, heterotopic and auxiliary. The technic is described in detail. Various improvements are proposed to give better results.