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Background and Objectives: The oncologic efficacy of laparoscopic total mesorectal excision (TME) for middle-low rectal cancer is still under discussion because of the few long-term data. This study reports the results arising from a single-institution experience during a 18-year period., Methods: Data about 132 consecutive laparoscopic TME performed between January 1994 and January 2012 were analysed with Kaplan-Meier method and a uni- and multi-variate analysis was conducted to define independent survival predictors., Results: A total of 116 sphincter-preserving operations and 16 abdominoperineal resections were performed. Postoperative mortality and morbidity were 0.8 and 18.2%, with a rate of anastomotic leakage of 13.8%. Average follow-up was 85.9 months (range 13-210). Actuarial local recurrence rate was 4.13% at 5 years (any pelvic recurrence developed after 3 years from surgery). Overall and disease-free survival was respectively 83 and 79.8% at 5 years, 71 and 73% at 10 years and then remained constant until 18 years. Survival was correlated only to tumour stage and the type of surgery., Conclusions: Laparoscopic TME for extraperitoneal rectal cancer shows long-term oncologic outcomes similar to open rectal resections.

Aim: In the last 20 years the laparoscopic surgery rapidly and successfully diffused for the treatment of benign diseases and recently also for the treatment of malignancy; newerteless, the laparoscopic gastrectomy for gastric cancer is still controversial, in relation to extreme difficulty of a radical surgical resection performing with an accurate lymphadectomy. The authors present a surgical experience of patients affected by advanced gastric cancer who underwent total or subtotal gastrectomy with videoassisted or entirely laparoscopic technique in order to evaluate the safety, feasibility, advantages and limits of this surgical approach., Methods: between January 2002 and August 2007 we performed 40 laparoscopic procedure for advanced gastric cancer; of these, 38 (95%) patients underwent a laparoscopic gastric resection and 2 (5%) patients underwent a palliative surgical treatment (laparoscopic gastro-entero-anastomosis). In the 38 patients which underwent laparoscopic gastrectomy, the anatomical localization of cancer, ASA score, pTNM classification, type of surgical laparoscopic technique (videoassisted or entirey laparoscopic technique), mean number of lymph nodes harvested, mean operative time, rate of conversion, postoperative morbidity and mortality and rate of local recurrence at 24 mounths follow-up were retrospectively analyzed., Results: Thirty-eight laparoscopic gastrectomies for gastric cancer were performed: in relation to surgical technique, 4 (10.5%) of these were video-assisted gastric resection (left subcostal minilaparotomy and extracorporeal anastomosis) and 34 (89.5%) were entirely laparoscopic gastrectomy; regarding to extension of surgical resection, there were 16 (42%) total D2 gastrectomies and 22 (58%) subtotal gastrectomies, of which 19 D2 gastrectomy and 3 D1 gastrectomy. Regarding the ASA score, 23% of patients were in ASA I, 52% in ASA II, 25% in ASA III. The mean operative time was 225 minutes (range 160-285) for total gastrectomy and 183 minutes (range 70-270) for subtotal gastrectomy. Overall, on 38 laparoscopic gastric resection, the conversion rate was 7.8% (3 patients). The number of lymph nodes harvested was 28 (range 5-53). No major intraoperative complications were observed. Overall morbidity was 31.5% (12 patients); the rate of postoperative surgical complications was 8% (3 patients). One patient (2.6%) dead for a sepsis subsequent to leak of esophagojejunal anastomosis. Mean hospital stay was 16 days for total gastrectomies and 12 days for subtotal gastrectomies. Three cases (7.9%) of cancer recurrence were observed in 3 patients (2 patiens UICC IIIa, one patient UICC IIIb) at 20th, 23th, 24th postoperative month and one case (2.6%) of peritoneal carcinosis at 18th month. No port-site metastasis were observed at 24-month follow-up., Conclusions: On the basis of this surgical preliminary experience, laparoscopic gastrectomy for malignancy resulted a technically safe surgical procedure if performed by an advanced laparoscopic surgical team, with additional benefits, time to resumption of oral intake, morbidity rate, and acceptance from patients. A radical laparoscopic gastrectomy via laparoscopic approach is advisable until UICC stage II, in patients with ASA score I-III and minimal endoabdominal adhesion. The safe and efficacy of laparoscopic treatment in locoregional limph nodes dissection is still controversial. However, long-term results of prospective and comparative trials will be necessary to show the real oncologically benefits of laparoscopic approach.

Background: Urinary and sexual dysfunction are potential complications of rectal surgery for cancer. This study retrospectively evaluated the frequency of such complications after laparoscopic total mesorectal excision (LTME) with autonomic nerve preservation., Methods: For this study, 50 men younger than 75 years who underwent radical LTME for mid and low rectal cancer were followed up for at least 12 months, interviewed, and administered a standardized questionnaire about postoperative functional outcomes and quality of life., Results: Sexual desire was maintained by 55.6%, ability to engage in intercourse by 57.8%, and ability to achieve orgasm and ejaculation by 37.8% of the patients. Distance of the tumor from the anal verge and adjuvant or neoadjuvant treatments were the significant predictors of poor postoperative sexual function. Seven patients (14%) presented transitory postoperative urinary dysfunction, all of whom were medically treated. Tumor stage and distance from the anal verge were independently associated with the postoperative global International Prostatic Symptom Score (IPSS). No differences were observed in urinary quality of life., Conclusions: In this series, LTME did not reproduce or improve on sexual and urinary dysfunction outcomes obtained in the best open TME series. Further trials are needed to evaluate functional outcome in rectal cancer patients.

Paraganglioma is an exceedingly rare tumour of the duodenum that arises in close proximity to the ampulla of Vater. To date a total of 133 cases of duodenal paraganglioma have been reported in the literature; of these, 27 (20%) were histologically gangliocytic paragangliomas. This neoplasm generally behaves in a benign fashion, although instances of recurrence and/or lymph node metastasis have been described. The treatment consists in endoscopic polypectomy or surgical resection in relation to the histological features and the macroscopic extent of the neoplasm. We present a case of a benign duodenal gangliocytic paraganglioma treated by a laparo-endoscopic approach. We report a case of gangliocytic paraganglioma in a 75-year-old woman admitted to the General Surgery Division of Aosta Regional Hospital (Aosta-Italy), complaining of melaena and anaemia. Upper gastrointestinal endoscopy followed by enteroscopy with a video-capsula, revealed a pedunculated neoplasm in the second portion of the duodenum, with ulceration of the overlying mucosa. Multiple biopsies were performed during the endoscopic examination and showed the cellular pattern of benign paraganglioma. After stabilisation of the patient's clinical status, we performed a resection of the neoplasm via a laparoscopic transduodenal approach and a concomitant intraoperative duodenoscopy. The histological features showed a gangliocytic paraganglioma without a malignant cell pattern. The size of the neoplasm was 4 cm. The resection margins were free of neoplastic infiltration. The postoperative stay was 9 days and there were no intraoperative or postoperative complications. The patient is currently in good health without any tumour recurrence. Transduodenal laparoscopic resection with intraoperative duodenoscopy is a valuable treatment for benign gangliocytic paraganglioma of the duodenum which is unresectable by upper gastrointestinal endoscopy. This approach affords the advantages of the minimally invasive technique and fulfils the surgical tenets of the open transduodenal approach, if en bloc resection of the neoplasm with the adjacent duodenal wall is performed.

Aim: Severe obesity is a major health problem affecting more than 1,000,000 people in Italy, with a 95% failure rate of nonsurgical treatments. We report our over five-years experience with laparoscopic Roux-en-Y gastric bypass (LRYGBP), evaluating the postoperative course of the patients undergoing 3 different gastro-esophageal anastomosis technique: Gagner procedure (87 cases) (34.8%), the purse-string approach (93 cases) (37.2%), robotic-assisted gastric bypass (68 cases) (27.2%) and by laparoscopic hand sewn anastomosis (2 cases) (0.8%)., Methods: Between October 2000 and February 2006, we performed LRYGBP on 250 patients (77 male and 173 female aged from 16 to 65 years [mean age 43.1 years] and with an average body mass index of 51.1 kg/m(2) [35-99]). Comorbidities were: hypertension, type II diabetes, hyperlipemia, osteoarthritis, chronic restrictive pulmonary insufficiency, sleep apnea, deep venous thrombosis., Results: The mean operative time was 142.3 min (80-420) with a mean hospitalization of 9.8 days (5-44). Eighteen major complications were recorded. There were no deaths. The mean percent excess body weight loss was 47.2+/-18.2% after 1 year (212 patients), 66.2+/- 19.4% after 2 years (178 patients), 78.2+/-12.4% after 3 years (139 patients), 80.6+/-11.7% after 4 years (101 patients), and 82.5+/-10.2% after 5 years (67 patients). Nearly all of the comorbidities were solved or improved. Bariatric analysis and reporting outcome system results after 5 years were excellent, good or fair in 100% of the subject evaluated., Conclusions: Although requiring the skill of an expert surgeon, LRYGBP is one of the most effective procedure available today to induce long-term weight loss, with limited nutritional risks and better prospects for improved quality of life.

Objective: To analyze total mesorectal excision (TME) for rectal cancer by the laparoscopic approach during a prospective nonrandomized trial., Summary Background Data: Improved local control and survival rates in the treatment of rectal cancer have been reported after TME., Methods: The authors conducted a prospective consecutive series of 100 laparoscopic TMEs for low and mid-rectal tumors. All patients had a sphincter-saving procedure. Case selection, surgical technique, and clinical and oncologic results were reviewed., Results: The distal limit of rectal neoplasm was on average 6.1 (range 3-12) cm from the anal verge. The mean operative time was 250 (range 110-540) minutes. The conversion rate was 12%. Excluding the patient who stayed 104 days after a severe fistula and reoperation, the mean postoperative stay was 12.05 (range 5-53) days. The 30-day mortality was 2% and the overall postoperative morbidity was 36%, including 17 anastomotic leaks. Of 87 malignant cases, 70 (80.4%) had a minimum follow-up of 12 months, with a median follow-up of 45.7 (range 12-72) months. During this period 18.5% (13/70) died of cancer and 8.5% (6/70) are alive with metastatic disease. The port-site metastasis rate was 1.4% (1/70): a rectal cancer stage IV presented with a parietal recurrence at 17 months after surgery. The locoregional pelvic recurrence rate was 4.2% (3/70): three rectal cancers stage III at 19, 13, and 7 postoperative months., Conclusions: Laparoscopic TME is a feasible but technically demanding procedure (12% conversion rate). This series confirms the safety of the procedure, while oncologic results are at present comparable to the open published series with the limitation of a short follow-up period. Further studies and possibly randomized series will be necessary to evaluate long-term clinical outcome in cancer patients.

Gastroesophageal reflux disease (GERD) is a frequent illness, sometimes causing disabling symptoms and/or permanent oesophageal lesions. Etiology is multifactorial and not completely defined. Therapy is medical at first step, surgical indication is reserved to those patients with less compliance for medical therapy, unsuccessful medical therapy or reflux related complications. Different surgical techniques have been suggested for treatment of GERD, like Nissen, Rossetti or Toupet fundoplication. During the last decade laparoscopy has been proposed as a less invasive approach when surgery is indicated. From 1995 to the first months of 1999, 42 pts (28 females, 14 males, mean age 53.7 years), were operated on. Diagnosis and surgical indication were confirmed preoperatively by barium X-rays, endoscopy and 24 hrs-Ph-manometry. Hiatal hernia was demonstrated in 37 cases (88%), I or II grade esophagitis in 16 and III grade in 2; 1 patient had Barrett oesophagus. 37 pts were operated on by laparoscopic Nissen fundoplication, 5 patients had a Toupet operation. Mortality and conversion rate were 0. Complications occurred in 3 patients: 1 intraoperative pneumothorax, 1 acute cardiac ischemia in a patient with known hypertension, 1 permanent dysphagia successfully treated by endoscopic dilatation. Mean postoperative hospital stay was 6.1 days. Mean follow up was 9 months (3-48) in 100% of cases. Despite the fact that few patients were operated on by using this new less invasive approach, results are encouraging with no mortality, less morbidity and great advantages for patients.

The authors have reviewed the literature particularly of the last decade, about surgical indications and timing in chronic ulcerative proctocolitis, also regarding the difficulties and the hazards the surgeon has to face depending on which type of chronic disease is considered. The various solutions for intestinal transit restoration have been reviewed, especially after the indications for terminal and continent ileostomy and for ileo-rectal anastomosis have been put aside, and total proctocolectomy with mucosectomy was advocated, with a special concern for assets and drawbacks of every type of ileal pouch. It is herein discussed the difference between the attitudes towards chronic active and recurrent ulcerative proctocolitis. The active form can't be cured with steroids and shows a greater risk of malignant transformation after 10-15 years of illness, insofar most cases (82%) in the long run need operation with this form that just often permits a one-stage surgery with mucosectomy, though. The commoner recurrent form is quite sensitive to steroids until these prove to be ineffective and surgery becomes mandatory (28% of cases). A two or three-stage surgery is advocated in this form with conservation of the rectum (mucosal fistula) as long as the acute phase is present, permitting only after its remission a restorative procedure with mucosectomy, which would be likely to be jeopardizing during the acute phase. The many designs of ileal reservoir do not differ indeed between each other as much in compliance as in maximum tolerable volume. The quadruple loop reservoir affords a volume approaching highly the original rectal volume, with better compliance and lesser frequency of bowel evacuations compared to other pouch designs. Some authors maintain that the functional outcome is independent of the reservoir shape. The anal continence basically depends upon the integrity of the internal sphincter, on the conservation of the anal inhibitory reflex and on the resting pressure. Muscular cuff is also mentioned with reference to anal function. Circular staplers have been employed for pouch-anal anastomosis 1-2 cm above the dentate line without mucosectomy. The stapled pouch-anal anastomosis entails a damage to the internal sphincter by some authors on the contrary a better sphincter function by others, compared to hand-sewn anastomosis with mucosectomy. Trials are needed to compare the risk of rectocolitis recurrence or malignancy after hand-sewn pouch-anal anastomosis with mucosectomy and after stapled anastomosis without mucosectomy. Postoperative complications are also herein discussed, with a special regard to pouchitis and its various aetiologic factors in early and late postoperative course.

The incidence of intestinal adenocarcinoma in Crohn's ileal disease is reported in the literature to be higher than in the normal population. The authors report two cases of adenocarcinoma observed during the course of Crohn's ileitis and, by comparing these findings with earlier published data, highlight their characteristics. Two patients, a 53-year-old woman and a 62-year-old man, are reported as suffering from Crohn's ileitis. The woman underwent resection of the right colon with ileo-transversostomy due to stenosis twenty years earlier, whereas diagnosis in the male patient dates back to an appendicectomy 11 years earlier. Surgery, which was performed in both due to subocclusion which failed to respond to steroid therapy, showed the typical alterations of Crohn's disease. An adenocarcinoma was also found in both patients in the stenotic zone with highly dysplasic foci. The man presented a monoclonal gammopathy of an IgA-type with light lambda chains and Bence-Jones' proteinuria. Both patients are living and enjoy apparently good health respectively 2 and 6 years after surgery. The authors emphasize that the association between Crohn's ileal disease and intestinal adenocarcinoma cannot be considered casual. In the literature the relative risk is reported to be between 6 and 320 times higher, with approximately 1 out of 350 patients suffering from both diseases contemporaneously. In the series reported earlier, 2 cases of carcinoma were diagnosed in 38 Crohn's patients studied over a period of 12 years out of a total population of 114000 inhabitants, with a frequency of carcinoma of 5.13% compared to 0.3% reported in the literature. The incidence of Crohn's disease was 2.84/100000 per year.(ABSTRACT TRUNCATED AT 250 WORDS)

The frequency of alithiasic cholecystitis is considered and the various forms are subdivided into diffuse and localized dyskinesia. Symptomatology is described and the former are indicated as being electively medical and the latter surgical forms whether the condition is congenital or acquired. The various forms of cholecystosis are also distinguished with full documentation. Symptomatological techniques and diagnostic conclusions are illustrated for all forms and personal experience with their therapy reported.