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Background: The diffusion of minimally invasive surgery in emergency surgery still represents a developing challenge. Evidence about the use of minimally invasive surgery shows its feasibility and safety; however, the diffusion of these techniques is still poor. The aims of the present survey were to explore the diffusion and variations in the use of minimally invasive surgery among surgeons in the emergency setting. Methods: This is a web-based survey administered to all the WSES members investigating the diffusion of minimally invasive surgery in emergency. The survey investigated personal characteristics of participants, hospital characteristics, personal confidence in the use of minimally invasive surgery in emergency, limitations in the use of it and limitations to prosecute minimally invasive surgery in emergency surgery. Characteristics related to the use of minimally invasive surgery were studied with a multivariate ordinal regression. Results: The survey collected a total of 415 answers; 42.2% of participants declared a working experience > 15 years and 69.4% of responders worked in tertiary level center or academic hospital. In primary emergencies, only 28,7% of participants declared the use of laparoscopy in more than 50% of times. Personal confidence with minimally invasive techniques was the highest for appendectomy and cholecystectomy. At multivariate ordinal regression, a longer professional experience, the use of laparoscopy in major elective surgery and bariatric surgery expertise were related to a higher use of laparoscopy in emergency surgery. Conclusions: The survey shows that minimally invasive techniques in emergency surgery are still underutilized. Greater focus should be placed on the development of dedicated training in laparoscopy among emergency surgeons. © 2022, The Author(s).

Low-pressure silica polymorphs, e.g. quartz (Qtz), tridymite (Trd), and cristobalite (Crs), are common in silicic magmas, but the conditions of their formation are still unclear. The stability fields of these polymorphs have been determined in the SiO2, SiO2–H2O, and haplogranite systems, but these simple systems are not directly applicable to silica polymorph crystallization in natural silicic magmas. The present study compiles an experimental database of new and previously-published data documenting the crystallization of silica phases in natural silicic magmas and simple synthetic systems. Silica polymorphs are identified using Raman spectroscopy and their pressure-temperature domains of occurrence and chemical compositions are determined at pressures between 0·1 and 200 MPa, temperatures between 685 to 1200° C, and under H2O-saturated and H2O-undersaturated conditions. Qtz is the stable silica polymorph at pressures higher than 25–30 MPa, temperatures between ∼700 and 950° C, and occurs for a narrow range of melt SiO2 contents (∼79–81 wt %). Constraints on Qtz stability derived from simple systems are mutually compatible with, and thus applicable to natural compositions. This is consistent with Qtz compositions being close to ‘pure’ SiO2, both in experiments and nature. In volcanic systems, Qtz crystallization may occur in magmatic reservoirs and deep volcanic conduits. Trd did not crystallize in the experiments conducted as part of this study despite several experiments having been performed in the Trd stability field. This is consistent with results from the literature which show that Trd crystallization is kinetically inhibited in particular relative to Crs. Natural Trd have compositions deviating substantially from ‘pure’ SiO2, so that stability limits determined in simple systems should not be applied directly to natural cases. Crs was encountered at pressures below 20–30 MPa (or H2O contents < ∼1·5 wt %), from sub-solidus (∼800° C) to near-liquidus (up to 1040° C), and coexisting with melts having a large range of SiO2 contents (70–81 wt %). The Crs stability field is much larger in natural magmas compared to pure SiO2 systems. Crs is a metastable phase stabilized by components (Al, Na, K; about 3 wt %) present in the silicic melt. In volcanic systems, Crs crystallization may thus be restricted to subsurface manifestations such as lava domes.

Technique, indications and outcomes of laparoscopic splenectomy in stable trauma patients have not been well described yet. All hemodynamically non-compromised abdominal trauma patients who underwent splenectomy from 1/2013 to 12/2017 at our Level 1 trauma center were included. Demographic and clinical data were collected and analysed with per-protocol and an intention-to-treat comparison between open vs laparoscopic groups. 49 splenectomies were performed (16 laparoscopic, 33 open). Among the laparoscopic group, 81% were successfully completed laparoscopically. Laparoscopy was associated with a higher incidence of concomitant surgical procedures (p 0.016), longer operative times, but a significantly faster return of bowel function and oral diet without reoperations. No significant differences were demonstrated in morbidity, mortality, length of stay, or long-term complications, although laparoscopic had lower surgical site infection (0 vs 21%).The isolated splenic injury sub-analysis included 25 splenectomies,76% (19) open and 24% (6) laparoscopic and confirmed reduction in post-operative morbidity (40 vs 57%), blood transfusion (0 vs 48%), ICU admission (20 vs 57%) and overall LOS (7 vs 9 days) in the laparoscopic group. Laparoscopic splenectomy is a safe and effective technique for hemodynamically stable patients with splenic trauma and may represent an advantageous alternative to open splenectomy in terms of post-operative recovery and morbidity. Supplementary Information The online version contains supplementary material available at 10.1007/s13304-021-01045-z.

Background The accessory spleen is a congenital defect characterized by a separated ectopic splenic parenchyma. The size is rarely more than 4 cm. The preoperative diagnosis is prohibitive preoperatively. The aims of the present manuscript were to present the case of a patient with a rare oversize accessory spleen and a review of the literature. Case presentation A 15-year-old boy was admitted to the emergency department following blunt abdominal trauma. The computed tomographic scan showed a traumatic rupture of the spleen and a 7-cm mass at the left side of the retroperitoneal space. Conservative treatment started and aborted after 4 h due to the onset of haemodynamic instability. Splenectomy was performed. An accessory spleen was discovered. A second large mass in the retroperitoneum was diagnosed as a second large accessory spleen that was also left in place. The postoperative course was uneventful, and the patient was discharged on the 7th postoperative day. Seven months later, the CT scan showed viability of both accessory spleens. Conclusion An accessory spleen can be variously located and the retroperitoneal position is extremely uncommon. Preoperative diagnosis is still difficult, especially in emergency and as in our case, the literature shows the difficulty of reaching a diagnosis before surgery. The main misdiagnosis is neoplastic disease and for this reason accessory spleen can be wrongly removed. An undiagnosed pre or intra operative retroperitoneal mass, closely to the spleen, have to be managed carefully. The diagnosis of accessory spleen needs to be ever considered as if found, represents a great possibility to conduct a normal life after splenectomy (of main spleen) for trauma.

Contains fulltext : 215819.pdf (Publisher’s version ) (Open Access) Renal and urogenital injuries occur in approximately 10-20% of abdominal trauma in adults and children. Optimal management should take into consideration the anatomic injury, the hemodynamic status, and the associated injuries. The management of urogenital trauma aims to restore homeostasis and normal physiology especially in pediatric patients where non-operative management is considered the gold standard. As with all traumatic conditions, the management of urogenital trauma should be multidisciplinary including urologists, interventional radiologists, and trauma surgeons, as well as emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) kidney and urogenital trauma management guidelines.

The aim of this paper is to report a case of a child with adhesive small bowel obstruction treated by laparoscopic ap-proach.A 13-year old patient developed a small bowel obstruction caused by adhesion. He was successfully treated by laparoscopic adhesiolysis and was discharged from the hospital on the 7th post-operative day in satisfacto-ry condition.this disease is treated by laparoscopy very rarely, especially in children. In patients without comorbidities, such as pulmonary or cardiovascular diseases, laparoscopic approach could be considered as the first approach in children because the patient has the advantage of less pain and short hospitalization.Until clinical trials will address guidelines, when possible, laparoscopic approach should be attempted.

The Mayo technique is one of the most common techniques used to repair incisional, umbilical, and epigastric hernias. A high percentage of recurrences, together with the use of particular expensive types of meshes, are some of the most relevant problems in this surgical field.This study is a clinical prospective observational and involves all the patients who underwent procedures using a new modified Mayo technique from 2006 through 2013. The general criteria analyzed were age, sex, obesity, smoke abuse, diabetes, chronic diseases, type of hernia, operative time, morbidity and mortality. All the patients involved in this study were followed-up from 6 to 120 months.The types of hernia were 5 epigastic hernia (20,8%), 8 umbilical hernia (33,3%), 11 midline incision hernia (45,9%). Ten patients (41,7%) presented non-complicated hernias; 8 patients (33,3%) presented strangulated hernias and 6 patients (25,0%) presented obstructed hernias. No intestinal resection was necessary in any of the patients. The mean operative time was 55 minutes (range 30-180). The mean hospital stay of the patients' after-post operative procedure was 4.5 days (range, 2 to 8 days). No major complications have been reported. Only one patient present a recurrence.These preliminary results suggest that this modified Mayo technique could be useful in the armamentarium of surgeon to repair incisional, umbilical, and epigastric hernias. More studies are needed to validate the technique.

Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs.

The effect of sulfur dissolved in anorthite-diopside eutectic (AD) glasses on the glass transition temperature (Tg) has been investigated via Differential Scanning Calorimetric measurements (DSC) and Thermogravimetric Analysis (TGA) under moderately reducing to oxidizing conditions. In a series of AD glasses, we have measured the change in Tg as a function of S content present as SO4 2- (HS- is also identified to a lesser extent) and H2O content. The AD glasses investigated have S contents ranging from 0 to 7519 ppm and H2O contents ranging from 0 to 5.3 wt.%. In agreement with previous studies, increasing H2O content induces a strong exponential decrease in Tg: volatile free AD glass has a Tg at 758±13C and AD glass with 5.18±0.48 wt.% H2O has a Tg at 450±11C. The change in Tg as a function of H2O is wellreproduced with a third-order polynomial function and has been used to constrain Tg at any H2O content. The effect of S on Tg is almost inexistent or towards a decrease in Tg with increasing S content. For instance, at ~2.4 wt.% H2O, the addition of S induces a change in Tg from 585±10°C with 0 ppm S to 523±3C with 2365±138 ppm S; a further increase in S up to 7239±90 ppm S does not induce a dramatic change in Tg measured at 529±2C. The limited effect of S on the glass transition temperature contrasts with recent spectroscopic measurements suggesting that S dissolution as SO4 2- groups provokes an increase in the polymerization degree. We propose an alternative view which reconciles the spectroscopic evidence with the Tg measurements. The dissolution of S as SO4 2- does not induce the formation of Si-O-Si molecular bonding through consumption of available non-bridging oxygens (NBO) but instead we suggest that Si-O-S molecular bonds are formed which are not detectable by DSC measurements but mimic the increase in glass polymerization. Therefore, spectroscopic measurements must be used with caution in order to extract melt physical properties.

Sustainability, while being definitely a new form of humanity, as it has been proposed and dealt with in many urban and landscape projects, lacks often of an essential characteristic of the anthropic space: seduction. The authors believe that sustainability has to find its own power of seduction if it is to compete successfully with the ambiguous but established charms of the unsustainable city. From all the above it is clear that the importance of the ‘aesthetic of sustainability’ is fundamental for the success of a new model of green planning not just from an environmental and economic point of view, but, perhaps and most importantly, from a social and mental one. This paper will investigate the possibility to look at sustainability and aesthetics through the lens of evolutive processes and the complexity theory to inform a new Bottom-Up/Self-Organized approach as a possible morphogenetic process for sustainable city design. Often criticized as the theory of ‘out of control’ the complexity theory applied to the urban could instead be the enabler of a new paradigm where the notion of single authorship with intellectual ownership and his aesthetic language is substituted by the concept of a collective and a new aesthetics of choice where aesthetics might recover, according to the evolutionary theory, their essence of an ‘adaptive system’ and an ecological category.

We report 2 cases of megacolon associated with cerebrovascular accident and neuropsychiatric drug consumption. Case report 1: a 75-year-old woman with diabetes mellitus, hypertension, tachycardia with atrial fibrillation, bilateral pleural effusions and previous cerebral hemorrhage was admitted in our hospital. She presented clouded sensorium and abdominal distension, with closed alvus. The CT scan showed a distension of the colon, with severe fecal impaction. A volvulus of the sigma was found at surgical intervention.Case report 2: a 59-year-old man with a medical history of oligophrenia was admitted to our hospital for acute abdomen.He presented stupor and closed alvus with abdominal distension. The abdominal CT scan showed a dolichosigma, with fecal impaction. The patient was submitted to a laparotomy and a two millimetres perforation of the sigma was found.The sigma had a diameter of 28 cm and a length of 75 cm.Even if a clear correlation has not been found yet, anomalies of the regulation of the gastro-intestinal motility can occur at different levels in patients with psychiatric or cerebrovascular diseases and drug consumption with anticholinergic properties,and they should be carefully monitored. The purpose is an early diagnosis of colon function anomalies in order to avoid potentially fatal complications.

The diagnosis of asymptomatic abdominal tuberculosis,without characteristic laboratory and radiologic findings, is difficult. We therefore investigated the role of diagnostic laparoscopy in patients with suspected peritoneal tuberculosis(PTB). Patients admitted to Hamad General Hospital, Qatar,who underwent laparoscopic peritoneal biopsy for suspected PTB from January 2004 to December 2010 were retrospectively analysed. Factors assessed included patient age, sex, symptoms,clinical signs, CT scan findings, laparoscopic findings andhistopathological diagnosis. A total of 41 patients, 33 males(80.5%) and 8 females (19.5%), of mean age 31 years, underwent laparoscopic peritoneal biopsy for suspected PTB duringthe study period. Abdominal pain was the most common presenting symptom, observed in 33 (80.5%) patients.Computerized tomography (CT) of the abdomen showed as citesin 37 patients (90%), bowel nodules in 22 (54%), peritoneal thickening and nodules in 37 (90%) and enlarged mesenteric lymph nodes in 11 (27%). The classical gross laparoscopic appearance of peritoneal tuberculosis was observed in 38 patients (93%), whereas laparoscopic findings were normal in 3 patients (7%). Histopathological results confirmed granulomatous inflammation in 38 patients (93%). The sensitivity and specificity of gross laparoscopic appearance in diagnosing peritoneal TB were both 100%. Two patients experienced complications from laparoscopy (5%), but there were nolaparoscopy-related deaths. Laparoscopic peritoneal biopsy isa rapid and safe method of accurately diagnosing PTB.

Thigh infection is a rare complication of intra-abdominal sepsis that can present with emphysema. We report a case of infection in the thigh resulting from colonic perforation. A 61-year-old woman with cirrhosis, grade Child B6 and diabetes treated with oral hypoglycemic drugs was referred to the emergency department because of a persistent pain in her left thigh and also for some abdominal discomforts during the preceding few days. Ultrasonography identified the presence of gas and fluid in the thigh. The patient received fluids and antibiotics but on the day after she reported an increase in pain. For this reason the patient was submitted to a CT scan that showed a thigh emphysema due to intestinal perforation. The patient was submitted to laparotomy. A Hartmann's procedure was performed, with resection of about 15 cm of affected sigmoid colon. The left thigh wound did not require any treatment.

Intraabdominal cystic lymphangioma occurs rarely, and lymphangioma of the diaphragm has not been previously reported in the literature. The authors herein report the clinical features, radiographic findings, and treatment of one encountered case of lymphangioma of the diaphragm.

The authors describe the clinical case of a naive patient with chronic hepatitis HBV-related (CHB) HBeAg negative, treated with Telbivudine (LdT) 600mg/day. After six months of treatment, as well as it determines rapid, profound and sustained suppression of HBV replication, LdT induced a progressive decline of HBsAg serum level and HBsAg loss, probably through an immune modulator effect. Recent studies have indicated the possible action of LdT on the immune system and specifically it would be able to stimulate Th1 lymphocyte subpopulation by increasing their cytokines production, thus playing a major role in cleaning the HBV infection. This aspect appears to be of much interest in clinical practice, because on-treatment HBsAg rapid decline1 log10 IU/mL during the first year of treatment is highly predictive for future HBsAg clearance and CHB resolution.

Aim of this review is to assess the role and indications for primary sigmoidectomy with direct anastomosis for diverticulitis comparing it with the Hartmann's procedures.A literature search was performed using MEDLINE (PubMed), Google Scholar and The Cochrane Library and the articles from January 1990 until June 2011 were analyzed. All patients were divided into three groups: primary anastomosis (PA), primary anastomosis and stoma protection (SP) and Hartmann's procedure (HP). Number of patients, overall mortality and morbidity, the rate of fistulization, the rate of reversal after SP (RSP) and after HP (RHP) and the Hinchey classification have been considered.The mortality was of 38/1010 patients (3.8%) for PA, 11/153 patients (7.2%) for SP and 139/800 patients (17.4%) for HP. The morbidity was reported in 103/325 patients (31.7%) in PA, in 23/97 patients (23.7%) in SP and in 290/586 patients (49.5%) in HP. Fistula formation was recorded in 35/625 patients (5.6%) for PA, in 10/149 patients (16.4%) for RSP and 11/426 patients (6.4%) for RHP. The intestinal continuity was restored in 82/628 patients (56.9%) who underwent SP and in 315/581 patients (54.2%) undergoing HP. A total of 790 patients (54.5%) were classified in class I-II Hinchey and total of 659 patients (45.5%) was classified in class III-IV Hinchey.The PA has a lower morbidity and mortality in relation to the HP and except some limited indications, should be used as treatment of choice in the case of diverticulitis.

Insulinoma, usually benign (90%), is clinically characterized by symptoms as tremulousness, tachycardia, weakness, sweating, fatigue, hunger, headache, dizziness, disorientation and unconsciousness. However rarely it has an unusual presentation. We present a case of insulinoma misdiagnosed as neurologic disease. A 48-year-old man was admitted to our Emergency Division because of car accident caused by loss of consciousness. A diagnosis of complex partial seizure was made one year before. The patient appeared pale, tachycardic, BP 130/85 mmHg. Laboratory tests showed a severe hypoglycemia (30 mg/dl). He was treated with hypertonic glucose solution and the resolution of symptoms was obtained. Dosages of insulin and C-peptide, CT-scan and RMN confirmed a diagnosis of insulinoma. Seizure disappeared after surgical excision. The diagnosis of insulinoma is sometimes delayed up to more than 20 years. Neurologic or psychiatric presentation like disorientation, personality changes, amnesia, irritability, seizures, bizarre behavior, visual difficulties, neuropathy in patients affected by insulinoma could be cause of misdiagnosis. Diagnosis of insulinoma should always be considered whenever these symptoms occur, especially if unresponsive to specific therapy. Insulinoma is curable in most cases and an early diagnosis can avoid adverse consequences including neurologic damage.

In a polycentric study, the influence of some of the most common variables capable of influencing the reliability of prekeratotomy pachymetry has been evaluated. The fluctuation in a sequence of measurements from the same point on the cornea, with the patient in different positions (orthostatic and clinostatic), during progressive drying of the lacrimal film and before and after corneal marking have been evaluated. Three operators, working randomized, used the same computerized pachymeter (DGH 1000) to make the measurements. The data obtained in this way were statistically analyzed by the Statgraphics personal computer program. Some interesting and useful considerations about the more correct methods to run the test and its real accuracy have emerged.

Background. Many technological devices have been used to avoid intraoperative bleeding during hepatic parenchymal transection and to avoid morbidity and mortality, but until now none is complete. The aim of this work is to prospectively analyze hepatic resection patients treated with a water-cooled high frequency monopolar device in order to evaluate its effectiveness. Patients and methods. All consecutive patients who underwent liver resection by use of this device, between January 2003 until December 2007, were analyzed prospectively. The following variables were considered: age, sex, kind of disease, kind of liver resection, number of major/minor resections, total operative time and transection time, number and time of clamping, blood loss, time of hospitalization, morbidity, and mortality. Results. Between January 2003 and December 2007, 26 patients were analyzed prospectively (69% women, 31% men). Ages ranged from 18 to 84 years. Sixty-five percent of patients had a malignant disease; 35%, a benign disease. The procedures performed were two major hepatectomies (7.6%) and 24 minor hepatectomies (92.4%). Hepatic transection was performed in 35 to 150min. Total operative time range was 120–480min. The average blood loss was 325ml (range 50–600 ml). The mean postoperative stays were nine days for all the patient and six days for non-cirrhotic patients. Conclusion. The water-cooled high frequency monopolar device is useful for reducing ischemia–reperfusion damage due to the Pringle maneuver and for reducing the risk of morbidity. However, the Kelly forceps remains the only inexpensive instrument really essential for liver surgery.

Cholecystoduodenal fistula, a rare complication of biliary lithiasis, occurs in 0.5% to 3% of patients affected by cholelithiasis. Diagnosis is not easy and is usually incidental at surgery. The literature guidelines call for a laparoscopic approach to treating these patients; here, however, we report a case of a very elderly patient in which, among other reasons, open surgery was the treatment of choice to decrease morbidity and mortality.

The most common targets of the echinococcus are the liver and the lung, but several organs can be affected by this disease. The isolated diaphragmatic location of the cyst, not associated with liver or lung, is very rare. The aim of this work is to report a case of hydatid cyst located in the abdominal side of the diaphragm and to review the literature. The diagnosis was fortuitous and at CT scan the cyst was apparently located on segment VII of the liver. During surgery, after dissection of the adherences with the liver, the cyst remained attached to the diaphragm. Thirty months after the resection, the patient is free of symptoms without any recurrence.

Done to the improvement of knowledges in hepatic surgery and postoperative care, hepatocellular carcinoma (HCC) have been treated more and more frequently by hepatic resection. Aim of this study is to report an initial series of patients affected by HCC treated by hepatic resection utilizing a new water-cooled, high-density, monopolar device, the Tissuelink Monopolar Floating Ball (Tissuelink Medical Inc., Dover, NH, U.S.A.), in order to avoid bleeding during hepatic surgery. Sex, age, kind of disease, viral and Child status, type of surgical procedure, in association to lenght of surgical procedure, blood loss, utilization of the vascular clamping of the liver, hospital stay, morbidity and mortality have been analized. Six liver resections have been performed utilizing this new device. No vascular clamping was established except one. No mortality was recorded. Morbidity was ascites in one case and pleural effusion in a second one. In conclusion the Floating Ball reduces the intraoperative bleeding during hepatic resection in patients with HCC.

When venous system of superior vena cava is not useful or when chest wall is not utilizable to place a reservoir, saphenous vein can be utilized for totally implantable venous access device (TIVAD) placement. Aim of this work is to establish the best location of the reservoir for the function and the comfort of the patient.All the patients submitted to TIVAD placement from January 1995 to October 2004 at the Department of Surgical Science, Organs Transplantations and Advanced Technologies of University of Catania have been considered to the present study. Age, sex, kind of disease, surgical procedure, early and late complications, function of the system and comfort to the patients in relation to the different site of reservoir placement have been studied.447 TIVAD have been implanted in 258 males and 189 females aged from 31 to 79 years in the period considered for the study. Solid tumors represent the majority of the indications and all the TIVAD have been implanted by surgical cutdown to avoid all the early complications related to the percutaneous approach. Two patients received their TIVAD using saphenous vein by surgical cut-down, and no early complications have been recorded. The reservoirs have been placed respectively: in the chest wall in the first patient; and in the anterior wall of the abdomen, close to the anterosuperior iliac crest, firstly and later in the anterolateral face of the thigh in the second one. The first patient had non complications instead the second one referred discomfort with both reservoir locations.For the comfort of the patient related to the reservoir position in case of saphenous vein utilization chest wall should represent the best studies are required to validate the appropriate reservoir location.

Peritoneal carcinomatosis can be actually treated by new surgical and oncological techniques. Aim of this work is to report preliminary results of a group of patients with peritoneal carcinomatosis, submitted to peritonectomy and intraperitoneal hypertermic chemoperfusion (IPHC).Age, sex, type of neoplasm, peritoneal carcinomatosis index (PCI), completeness of cytoreduction (CC), operative time, morbidity and mortality of patients submitted to IPHC have been considered.From May 2001 to December 2004, 10 patients were submitted to peritonectomy and IPHC: 9 (90%) females and 1 (10%) male, aged from 49 to 72 years. Seven patients (70%) were affected of peritoneal carcinomatosis from ovarian tumor, three patients (30%) from colon cancer. The PCI was ranged from 8 to 25. The operative time was ranged from 6 to 14 hours. Two patients with a CC of 2 developed relaps and died respectively after 2 and 4 months. The remaining patients had a CC between 0 and 1. Of these last patients, 1 affected by ovarian cancer died 24 months after, 1 patient died 3 days after surgery for septic shock; the other patients are still alive with a period ranged from 1 to 30 months.Our preliminary results suggest that the peritonectomy and IPHC can be effective only in patients with CC of 0 or 1, in the remaining cases these therapeutical methods should be avoided.

The sigmoid colon is the most frequent site for a volvulus due to anatomical and pathological reasons. When the rotation of the loop occurs slowly, the sigma can greatly blow up and stretch. We report the clinical case of an 80-year-old woman admitted to our Department for an enormous volvulus of sigmoid colon. Physical examination, abdominal X-ray and CT-scan were performed to diagnose the disease. At the surgical procedure the sigma was about 50 centimetres in length and 15 centimetres in diameter, with a gangrenous necrosis of the loop; the treatment was a sigmoidectomy by Hartmann procedure. Surgical resection is the only therapeutical option for volvulus in advanced stage due to a late diagnosis.

During the last years operators implanting totally implantable venous access devices (TIVADs), type of access, and kind of complications are changed. Aim of this work is to evaluate the incidence of early complications during the learning curve of residents in surgery or inexperienced surgeons, besides considering the tutoring to evaluate its rule to prevent early complications. TIVADs, implanted by residents in surgery or by inexperienced surgeons in the Department of Surgical Science Organ Transplantation and Advanced Technologies of University of Catania from January 1995 to October 2003, have been considered for the present study. Age and sex of the patients, indication, type of surgical access and early complications of the TIVADs have been considered. Early complications are those complications that occur within 30 day after the implant. Ninety-five TIVADs were implanted by surgical approach in 95 patients: 58 males (61%) and 37 females (39%), with a mean age of 55 years (range 31-79). Inexperienced surgeons performed 40 implants (42%) instead resident in surgery implanted 55 TIVADs (58%). The migration out of the vein of a catheter 20 days after the operation was the only complication recorded. TIVADs implant by cut-down technique represent the way to avoid early complications. The learning curve is short and the tutoring is limited at the first phase.

The Authors report a case of a patient submitted to chemotherapy that has a complication of its totally implantable venous access device (TIVAD) due to incorrect nursing. The symptoms related to the extravasation of drugs were due to the lateral lesions of the catheter with Huber needle. After X-ray examination the therapy was ablation of the non-functioning device and implant of a new TIVAD. The Authors conclude about careful nursing of the TIVAD in order to avoid further psychological problems in cancer patients.

The Authors report the case of a patient with intrahepatic colangiocarcinoma, operated on for totally implantable arterial device (TIAD) implant in view of hepatic chemotherapy. The postoperative course was characterized by cutaneous drainage of ascites fluid from the wound of the TIAD implant. Its aetiology and therapy are discussed.

Minimally invasive laparoscopic surgery is the method of choice for the surgical treatment of gallbladder disease. However, surgery of the biliary tract in the elderly is often associated with high morbidity and mortality.To evaluate the efficacy and safety of the laparoscopic cholecystectomy in the elderly with symptomatic, uncomplicated gallbladder disease, we retrospectively compared the records of 24 consecutive patients over 70 years of age with symptomatic uncomplicated gallbladder disease, who underwent elective laparoscopic cholecystectomy, with a similar cohort of patients who underwent elective open cholecystectomy for the same indications.In the laparoscopic group we found a significantly low incidence of postoperative complications, low analgesics and antibiotics administration, rapid recovery, short length of stay and considerable cost savings.We conclude that elective laparoscopic cholecystectomy in elderly with uncomplicated gallbladder disease is safe and effective and we suggest that it may become the surgical procedure of choice.

We read with interest Impact of Surgery on Quality of Life in Patients with Hepatocellular Carcinoma by Mise et al. [1]. In Fig. 1 of the article, the authors well demonstrate that with regard to quality of life (QOL), patients’ physical component summary (PCS) 12 months after surgery can be impaired compared with their preoperative status, but the mental component summary (MCS) is higher than the initial value. The subgroup analysis shows debatable results. In Fig. 3, patients with multiple nodules have poorer MCSrelated QOL, probably because these patients continue to think that nodules will remain in the liver or can regenerate easier after the resection. This is a concern of patients who undergo radiofrequency ablation (RFA). In fact, as reported in our work [2], although patients have an excellent QOL in the first period (up to 12 months) after the RFA, surgeryrelated QOL worsens in the second period (12–24 months), as the tumor’s presence in their body presents a continual emotional stressor. In Fig. 4, the authors show that PCS-related QOL does not differ between patients who undergo resections of up to two segments and those who undergo resections of more than two sections. Although Mise et al. [1] are among the finest hepatic surgery groups in the world, this result was surprising, as it implies that an enucleation or a simple segmentectomy has the same effect on PCS-related QOL as does a right hepatectomy. Slow regeneration after a large hepatic resection is the main cause of impaired post-operative physical condition; however, when the resected tissue is very limited, as in cirrhotic patients, recovery is generally easier. Our investigation [2] has shown this to be a major predictor of QOL in patients who undergo RFA and surgery, especially in the first 6 months after the procedures.

A review of the experience with laparoscopic cholecystectomy to evaluate the impact of the efficacy, safety, and complications on the learning curve.Retrospective study.Between 1993 and 1998, 415 patients, 123 males and 292 females, median age 52.1 years (range 23-96 years), with symptomatic cholelithiasis, underwent laparoscopic cholecystectomy. On the basis of different selection criteria and surgical techniques adopted, our experience was divided into two periods (93-95 and 96-98).The success rate was 89.4% (371 patients) with a conversion rate of 10.6% (44 patients). Overall complications rate was 2.9% (12 patients): 7 major complications (2 biliary tract injuries, 2 hemorrhages, 1 sub-phrenic abscess, 1 gastric perforation and 1 choleperitoneum) and 3 minor complications (1 biliary leakage and 2 wound infections) with 2 long-term sequela (umbilical site eventration). Median hospital stay was 3.3 days, 2.2 days for uncomplicated cases and 5.6 in those converted or complicated. Comparison between the two groups showed a conversion rate of 10.6 vs 10.4% (23 vs 21 patients), with a complication rate of 4.2% vs 2.2%.Laparoscopic cholecystectomy can be considered a safe and effective procedure for the treatment of simple or complicated cholelithiasis. French surgical technique seems to be easier in the management of acute cholecystitis or lithiasis occurring after acute pancreatitis. Specific training in laparoscopy surgery is mandatory to avoid major complications.

Catheter migration, represents a rare, mechanical complication following the use of totally implantable venous devices. A case, in which the catheter was inserted into the right internal jugular vein by percutaneous route, without radiological control, is described. Following the chemotherapy infusion drugs, the patient developed a catheter displacement and subcutaneous extravasation. Etiological hypotheses and modalities of prevention are discussed.

Ileal localization of intestinal endometriosis is not extremely rare, but there are always problems related to the preoperative diagnosis. Symptoms of intestinal endometriosis offer often problems to the surgeon in the differential diagnosis with many more pregnant illnesses like appendicitis, diverticulitis, inflammatory bowel diseases and abdominal neoplasms. The authors report a case of endometriosis of the ileum clinically mimicking Crohn's disease. Crohn's disease of the ileum is the most frequently reported illness that is considered in the differential diagnosis. The review of the literature shows that a correct preoperative diagnosis of endometriosis of the ileum is very seldom done. All common diagnostic tools are not able to resolve diagnostic doubts. Also during explorative surgery the diagnosis of endometriosis is not easy. The authors conclude that endometriosis of the ileum has to be more often considered as possible cause of common intestinal symptoms mimicking inflammatory bowel disease and that this illness induces to reevaluate the importance for a correct diagnosis of an accurate clinical history.

Totally implantable venous access devices are usually implanted by surgical cut-down technique or by percutaneous approach, after a first surgical procedure. The authors describe a new surgical approach utilizing the right gonadal vein or the vena cava for totally implantable venous access device placement in patients submitted to major digestive surgical procedures for tumors. This new surgical approach allows one to avoid a second operative procedure.

Today, it is difficult to set a correct definition and diagnosis of gastroesophageal reflux disease. The attempt to define it on the basis of "typical" symptoms, like heartburn and regurgitation, or "atypical" symptoms, like chronic cough, asthma, hoarseness and thoracic pain, or on the basis of endoscopic esophagitis presents notable difficulties. Moreover, the problem of a correct definition is tightly tied up to the ability to set a correct and early diagnosis. There are many diagnostics tools, but none of them is the golden standard. Today, the trend is to emphasize the role of the 24-hour pH-monitoring in diagnosing the reflux in those symptomatic patients with no visible esophagitis. However, its limit is to underline only the acid, not the duodenogastric alkaline reflux, which is also very important in the genesis of the inflammatory esophageal lesions. The esophageal manometry, however, evaluates only the mechanical state of the lower esophageal sphincter and the peristaltic function of the esophageal body but does not provide any direct information about the exposure of the esophagus to the gastric juice. The aim of this study is to analyze the problems concerning the definition and the diagnosis of the gastroesophageal reflux disease with particular attention to the practical implications on the common surgical practice, and to review some solutions reported in the literature for the difficult clinical approach to the patient with this pathology.

We report a case of an elderly woman with a large eventration of the right hemidiaphragm, discovered during an episode of acute cholecystitis, with abdominal and pleural effusion, successfully treated by a laparotomic approach.

A new alternative technique for regional perfusion chemotherapy in the presence of a right hepatic artery arising from the superior mesenteric artery is described. The cystic artery branch of the right hepatic artery and the gastroduodenal artery can be used to place two catheters and thus apply two implantable systems. This risk-free, straightforward technique preserves native flow and achieves homogeneous distribution of the chemotherapeutic agent.

Portal vein thrombosis is a rare pathology. The etiopathogenetic causes that most frequently lead to this pathology are myeloproliferative syndromes. The authors present a case of acute pre-hepatic portal vein thrombosis and discuss its etiopathogenesis, diagnosis and therapy.

Meckel's diverticulum (MD) is the most frequent congenital abnormality of the small bowel and it is often difficult to diagnose. The authors report a case of a patient with long-term symptoms erroneously not related with MD disease and developing a diverticulum perforation.

Since the first report of TIVD implantation, many authors have published immediate and post-operative complications. The Authors report the first case in which the catheter, implanted via the cephalic vein by cutdown technique, has migrated completely out of the vein. In order to avoid extravascular migration, during the surgical procedure, the catheter should be fixed at the vein with nonabsorbable sutures, taking care to avoid narrowing the catheter lumen. This case report discusses the possibility of catheter migration when a TIVD fails to function properly and considers how to avoid more disastrous effects.

Diagnostic and therapeutic findings of benign hepatic tumors are analysed. In particularly the authors describe the more frequent tumors such as angioma, adenoma and FNH, but also give a guidelines on how to approach less frequent lesions.

A percentage ranging from 60 to 80% of hepatocarcinomas are associated with increased levels of alphafetoprotein (AFP). In the three years following surgical resection there was a 80% possibility of recidivation. The aims of the present study were: a) to evaluate the significance of preoperative AFP assay as a prognostic index of recidivation; b) to evaluate the importance of repeated assays during the postoperative period in order to ensure an early diagnosis of recidivation. Between 1982 and 1989, 62 patients underwent surgery for hepatocarcinoma. Thirty-one patients who had undergone so-called curative surgery were periodically controlled for a period varying between 6 and 55 months, and were included in the present study. The remaining 32 patients were excluded for the following reasons: palliative surgery, postoperative death, postoperative complications unrelated to tumoral recidivation. In all cases AFP assay was carried out preoperatively, one month after surgery, and then every six months. Recidivation was always confirmed on the basis of tomodensitometric and arteriographic data. Before surgery out of a group of 30 patients, 11 showed normal AFP levels (below 20 mg/ml), while 19 had levels between 49 and 7350 mg/ml. Twenty-three patients (74%) reported one case of recidivation during the period between 6 and 40 months. Among the 11 patients who had showed normal preoperative AFP levels, 5 had a recidivation between 12 and 36 months, and 3 of these showed high AFP levels. In 18 out of the 19 patients (90%) with high preoperative AFP levels recidivation was diagnosed between 4 and 40 months following surgery; 4 of these were not associated with a rise in AFP.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors report their experience of one case of Budd-Chiari syndrome with total thrombosis of the portal vein. The patient was undergoing hepatico-atrial anastomosis with Senning's procedure. The original technique utilised extracorporeal circulation with hypothermia; the authors utilised venovenous bypass from femoral vein to axillary vein. Anastomosis function is proved with nuclear magnetic resonance and echo-Doppler on year after operation. Senning's procedure is feasible in the case of Budd-Chiari syndrome with total portal thrombosis with venovenous bypass without extracorporeal circulation with hypothermia.