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The thoracic paravertebral block (PVB), a technique of post-thoracotomy analgesia of similar effectiveness as continuous epidural analgesia (CEA) but with a better safety profile, is underutilized in current practice. This study compares the outcome of post-lobectomy patients in relation to the analgesic method used: parenteral analgesia (PA) vs. PVB + PA, and provides justification for the routine use of PVB in all patients where CEA is contraindicated.We randomized 213 consecutive patients undergoing open lobectomy to benefit from two different protocols of postoperative analgesia: PA vs. PVB +PA. We compared the frequency of cardiac hemodynamic, respiratory, pleural or surgical-related complications.After lobectomy, the PVB patients (72/213) were found to have a significantly lower frequency of congestive heart failure (7.1%vs.0.0%)(p=0.049), ischemic cardiomyopathy (10.6%vs.0.0%)(p=0.010), pulmonary atelectasis (35%vs.1.1%)(p0.001), residual pleural space (29.8%vs.15.3%)(p=0.032) and residual intrapleural blood clots (14.9%vs.1.4%)(p=0.005). Other postoperative complications, Intensive Care stay, total hospital stay and mortality rate were less frequent in the PVB group but without reaching statistical significance.The use of SPVB is associated with significant less postoperative complications than PA only. This study suggests that the SPVB might be the ideal choice in post-thoracotomy pain management when CEA cannot be used.Open lobectomy, Post-lobectomy, Thoracic paravertebral block.Il blocco toracico paravertebrale (PVB), pur essendo una tecnica di analgesia post-toracotomia di efficacia simile a quella di analgesia epidurale continua (CEA) ma con un profilo di sicurezza migliore, è sottoutilizzato nella pratica corrente. Questo studio confronta l’esito dei pazienti post-lobectomia in relazione al metodo analgesico utilizzato: analgesia parenterale (PA) vs PVB + PA e fornisce una giustificazione per l’uso di routine del PVB in tutti i pazienti in cui il CEA è controindicato. Lo studio è stato condotto su 213 pazienti consecutivi sottoposti a lobectomia aperta, e randomizzati rispetto a due diversi protocolli di analgesia postoperatoria: PA vs PVB + PA. Abbiamo confrontato la frequenza delle complicanze emodinamiche cardiache, respiratorie, pleuriche o chirurgiche. RISULTATI: Dopo la lobectomia, i pazienti PVB (72/213) hanno mostrato una incidenza significativamente più bassa di insufficienza cardiaca congestizia (7,1% vs.0,0%) (p = 0,049), di cardiomiopatia ischemica (10,6% vs.0,0%) ( p = 0.010), di atelettasia polmonare (35% vs.1.1%) (p0.001), di spazio pleurico residuo (29.8% vs.15.3%) (p = 0.032) e di coaguli ematici intrapleurici residui (14.9% vs.1.4%) (p = 0,005). Altre complicanze postoperatorie, degenza intensiva, degenza ospedaliera totale e mortalità sono state meno frequenti nel gruppo PVB ma senza raggiungere un significato statistico. CONCLUSIONE: L’uso di SPVB è associato a complicanze postoperatorie importanti significativamente inferiori alla sola PA. Questo studio suggerisce che l’SPVB potrebbe essere la scelta ideale nella gestione del dolore post-toracotomia quando non è possibile utilizzare il CEA.

Reviewing the cases and evaluate the efficacity of the trans-tumoral drilling in the Klatskin tumours which were operated in Colentina Surgical Department.This is a clinical retrospective study on 109 cases of Klatskin tumours operated between 1998-2004. in 80 cases of them we could practice a biliary drainage using a trans-tumoral drilling. SURGICAL INDICATION: Malignant tumours of the main biliary duct developed at the level and above the junction of the two hepatic ducts , extended to the liver in many cases.Through the choledochostomy, we performed with a special instrument the trans-tumoral drilling with the setting of a biliary axial drainage (40 cases), external biliary drainage through a semirigid trans-choledochal tube (25 cases), Kehr tube (9 cases), U tube (3 cases), internal drainage with intra-choledochal stent (2 cases), lost tube (1 case).In all cases we observed the early decrease of the jaundice. In the cases in which we used internal drainage, we had to perform a replacement of the closed tubes in 1-2 months after the first operation. Instead, the external biliary drainage, less expensive and periodically washed to preserve his permeability, proved his high efficiency. The average survival time was 8,9 months (between 5-20 months).The external biliary drainage through trans-tumoral drilling remains in many cases the only one available therapeutical solution for the Klatskin tumours.

Pancreatic cancer remains a disease with high mortality. The unspecific symptoms for a long time make the diagnostic difficult. Between 1995-2004, only 85 from 465 patients with this diagnosis, had pancreatic resection. To them, we performed Whipple pancreaticoduodenectomy (60), pylorus preserving pancreaticoduodenectomy (15), pancreatico-duodenectomy with preserving of duodenum (2), pancreaticoduodenectomy with associated resections (5), subtotal pancreatico-duodenectomy (30). The reconstruction after pancreatic resection was pancreatico-jejuno anastomosis (26) and pancreatico-gastro-anastomosis (59). Morbidity was about 34% and the mortality was about 9%.

Gallstone ileus is a rare, serious condition, requiring emergency surgery, specific to elderly age. The present study deals with 16 cases operated in 25 years period, with median age about 64 years old. The patients had clinical evidence of intestinal obstruction, confirmed by radiological examination and ultrasonography. Emergency operations were performed. In 7 cases had been treated radically both the obstruction (entero-lithotomy) and the bilio-digestive fistula (cholecystectomy, duodenal closure, enteral closure, colon-suture) with good results (only one death). In 9 cases, it had been treated only the intestinal obstruction, with only 2 cases of persistent cholangitis. Generally, we have used biliary drainage with Kehr tube in the presence of biliary stones and cholangitis. The biliodigestive fistula may close in evolution or become a harmless secondary route for internal biliary drainage.

It is presented the case of a 45 years old female patient transferred in our clinic from Parasitology Clinic with the diagnosis of hepato-splenic hydatidosis. Preoperative echography presented 3 abdominal hydatid cysts (hepatic, splenic and free in the peritoneal cavity--greater omentum). Intraoperative exam confirmed the preoperative evaluation. The operation consisted in two ideal cystectomies associated with one partial cystectomy with evacuation and drainage. Postoperative evolution was simple.