Trocar-related abdominal wall bleeding in 200 patients after laparoscopic cholecistectomy: Personal experience

AIM: To determine the complications and incidence of the first and second access-related vascular injuries induced by videolaparoscopic cholecistectomy. METHODS: We retrospectively reviewed vascular injuries in 200 consecutive patients who underwent videolaparoscopic cholecistectomy from 2003 to 2005. One hundred and one patients with placement of radial expanding trocars were assigned into group A and 99 patients with placement of pyramidal tipped trocars into group B. All the patients were submitted to open access according to Hasson for the first trocar. RESULTS: Bleeding did not occur at the intraoperative cannula-site in group A. However, it occurred at the intraoperative cannula-site of 7 patients (7.1%) in group B, with a statistically significant difference (P < 0.01). No mortality was registered. More vascular lesions were found in group B. CONCLUSION: The advantage of Hasson technique is that peritoneal cavity access is gained under direct vision, preventing most severe injuries. The open technique with radial expanding trocars is recommended for secure access to the abdominal cavity in videolaparoscopy. Great care should be taken to avoid major complications and understanding the abdominal wall anatomy is important for reducing bleeding during or after s placement of trocars

La gastrostomia percutanea endoscopica (PEG) metodo pull: nostra esperienza

Obiettivi: scopo del lavoro è valutare le indicazioni al posizionamento, i risultati e le eventuali complicanze della gastrostomia percutanea endoscopica (PEG), posizionata routinariamente in pazienti disfagici (per patologia neurologica, portatori di neoplasie del distretto cervico-faciale, esofagee o affetti da disturbi psicologici). Tipo di studio: valutazione retrospettiva dei pazienti sottoposti a PEG dal 2003 al 2005. Ambiente: Unità Operativa Semplice di Chirurgia Endoscopica (Responsabile: Prof. C. Sciumè) nell’ambito della Unità Operativa Complessa di Chirurgia Generale ad Indirizzo Toracico (Direttore: Prof. G. Modica) del Policlinico Universitario “Paolo Giaccone” di Palermo. Pazienti e metodi: 50 pazienti (11 donne e 39 uomini) sono stati sottoposti a posizionamento di PEG. Le indicazioni includevano disturbi neurologici di varia natura (82%), neoplasie esofagee inoperabili (6%), neoplasie del cardias inoperabili (4%), esiti di ictus cerebrale (2%), anoressia (2%), ostruzione faringo-esofagea (2%), neoplasia del distretto cervico-faciale (2%). Tutti i pazienti hanno ricevuto antibioticoprofilassi short-term. Risultati: sono state posizionate 51 PEG in 50 pazienti. Non si sono registrate complicanze maggiori; 45 pazienti (90%) sono vivi al follow-up ad 1 anno e non si è registrata mortalità procedura-correlata. La rimozione della PEG è stata eseguita in 2 pazienti (fine dell’utilità terapeutica) e quindi 43 pazienti in atto hanno ancora una PEG in situ. Conclusioni: il posizionamento di PEG in regime ambulatoriale in sedazione conscia è un metodo sicuro ed efficace per la nutrizione enterale, tanto da costituire il gold standard in caso di pazienti disfagici per patologie neurologiche o in previsione di interventi chirurgici demolitivi del distretto cervico-faciale. I pazienti devono essere seguiti e valutati attentamente da una equipe multidisciplinare per identificare candidati idonei. Riteniamo utile il ricorso all’antibioticoprofilassi short-term per la riduzione e la prevenzione delle infezioni della cute attorno alla gastrostomia

SELF-EXPANDABLE METAL STENT PLACEMENT FOR CLOSURE OF A LEAK AFTER TOTAL GASTRECTOMY FOR GASTRIC CANCER: REPORT ON THREE CASES AND REVIEW OF THE LITERATURE

consequently the management of this problem has become more critically focused than was previously possible. We report here three cases of placement of a partially silicone-coated SEMS (Evolution Controlled Release Esophageal Stent System, CookMedical, Winston-Salem, NC, USA) in patients who underwent total gastrectomy with Roux-en-Y end-to-side esophagojejunostomy for a gastric adenocarcinoma. The promising results of our report, despite the small number of patients, suggest that early stenting (through a partially silicone-coated SEMS) is a feasible alternative to surgical treatment in this subset of patients. In fact, in the treatment of leakage after total gastrectomy, plastic stents and totally covered metallic stents may not adhere sufficiently to the esophagojejunal walls and, as a result, migrate beyond the anastomosis. However, prospective studies with a larger number of patients might assess the real effectiveness and safety of this procedure

Rettorragia severa dopo biopsia prostatica transrettale ecoguidata. Case report

Caso clinico. Gli autori riportano un caso di rettorragia severa in seguito a biopsia prostatica transrettale ecoguidata (BPTE). Intervento. Dopo aver posto la diagnosi, il paziente è stato sottoposto a trattamento endoscopico risolutivo (fallimento delle manovre meccaniche di emostasi, colonscopia in urgenza, emostasi mediante soluzione adrenalinata, coagulazione bipolare e Argon Plasma Coagulation). Risultati. Guarigione completa. Follow-up ad 1 anno negativo. Conclusioni. Il sanguinamento emodinamicamente significativo post-BPTE costituisce una entità nosologica importante, che può mettere a rischio la vita del paziente. La maggiore conoscenza dei fattori di rischio e delle cause ne potrà in futuro limitare l?incidenza. La BPTE resta comunque senza dubbio la migliore procedura per lo screening del tumore della prostata nella popolazione generale, sempre in associazione al dosaggio del PSA

Il trattamento endoscopico delle pseudocisti pancreatiche

Obiettivo: gli Autori riportano la loro esperienza nel trattamento endoscopico delle pseudocisti pancreatiche (PP). Materiali e metodi: report di 10 casi; valutazione dell?efficacia, della morbilità e della mortalità del trattamento. Ambiente: Sezione di Chirurgia Generale ad Indirizzo Toracico della AOUP ?Paolo Giaccone?. Università degli Studi di Palermo. Intervento: tutti i pazienti sono stati sottoposti a drenaggio endoscopico delle PP: sono state eseguite 2 cisto-gastrostomie, 5 cisto-duodenostomie e 3 drenaggi cistici trans-papillari. Risultati: tasso di successo del 100%; si sono registrati un caso di emorragia intra-operatoria (10%), un caso di sepsi (10%) ed un caso di stenosi della ?stomia? tra la PP ed il duodeno (10%). Conclusioni: il trattamento endoscopico delle PP rappresenta una metodica semplice e sicura, con alte percentuali di successo e con bassi tassi di complicanze, complementare alla chirurgia

Juxtapapillary duodenal diverticular bezoar as an exceptional cause of biliary stent obstruction. Case report

Introduction: we describe the first case in literature of biliary stent obstruction by bezoar impaction in a iuxtapapillary duodenal diverticulum. Case report: this case illustrates an juxtapapillary duodenal diverticulum and bezoar in it causing obstructive jaundice in subject with two biliary stents for cholangiocarcinoma (Klatskin’s tumor) in the absence of bile duct stones. Result: successful treatment with endoscopic stent removal and diverticulum toilette. Obstructive jaundice was cured after endoscopic removal of the bezoar and stent substitution. Discussion: the presence of a bezoar and its possible contribution to the pathogenesis of pancreatitis in the presence of periampullaryextraluminal duodenal diverticula makes endoscopic intervention for removal of the bezoar necessary and effective. Conclusions: biliary bezoar is a very rare but treatable cause of stents obstruction in patients with juxtapapillary duodenal diverticula. Endoscopic retrograde cholangiopancreatografhy is helpful in making diagnosis and for resolutive treatmen

Unusual acute onset of pedunculated extragastric leiomyosarcoma. Case report

Introduction: a case report of 25 yrs-old man with pedunculated exogastric leiomyosarcoma (with acute onset) surgically treated is presented. Case report: the patient was operated after clinical, instrumental and blood sample tests. We performed a 5 cm wedge resection of the stomach in continuity with the omentum. Careful inspection revealed neither adenopathy nor metastases. Results: actual complete remission of pathology. Negative 1 year follow up by endoscopy and CT. Discussion: information on gastric leiomyosarcoma (LM), such as prognostic factors, patterns of disease recurrence, and optimal methods of treatment, are derived from limited clinical experience. Although about 25% of the gastric mesenchymal tumors present an exogastric growth, pedunculated exogastric leiomyosarcomas are extremely rare. Lymphatic spread of gastric LM is uncommon, therefore a formal lymph node dissection is not standard surgical management. At present, there is no evidence of intraperitoneal seeding from exogastric leiomyosarcomas. Consequently, a local resection with an adequate margin is sufficient when no invasion to the adjacent structures is observed. Neither the addition of lymphadenectomy nor the wider tumor-free margins of a radical gastrectomy seemed superior to the more conservative local excision Conclusions: further studies are called for to elucidate if exogastric tumours lead to peritoneal seeding and, thereby, affect tumour survival

Severe rectal bleeding after transrectal US-guided prostate biopsy. Case report

CASE: The Authors report their experience about a case of severe rectal bleeding after transrectal ultrasound-guided prostate biopsy. INTERVENTION: After correct and sure diagnosis, the patient was submitted to resolutive endoscopic haemostatic treatment (failure of haemostatic mechanical manoeuvres, emergency colonscopy, haemostasis with sclerotherapy, heat bipolar probe and Argon Plasma Coagulation). RESULTS: Complete recovery (immediate stop bleeding). Follow-up (1 year) negative. CONCLUSIONS: Rectal bleeding after prostate biopsy is a important but rare complication of prostate cancer screening, potentially lethal. Best knowledge of causes and risk factors may improve the diagnosis and standardize the treatment. The prostatic biopsy is surely the best procedure for the screening of prostate cancer in the population, associated with PSA dosag

Il nervo ricorrente che non ricorre. Esperienza personale

Damage to the recurrent laryngeal nerve (RLN) during thyroid or parathyroid surgery is the most common iatrogenic cause of vocal cord paralysis. Identification of the RLNs and meticulous surgical technique can significantly decrease the incidence of this complication. Nonrecurrent RLNs (NRRLNs) are exceedingly rare. Surgeons need to be aware of their position to avoid injuries. PATIENT AND METHODS: A retrospective review of 263 right RLN exposures (and 251 left RNL) over a 5-year period was performed. RESULTS: Two NRRLNs were encountered, for an incidence of 0.39% (0.76% only for right dissection), without anatomic anomalies on the left side. The nerve anomaly was never preoperatively diagnosed. CONCLUSION: NRRLNs are rare and is associated with a right subclavian artery arising from distal aortic arch. Awareness of their existence and correct surgical technique will prevent the surgeon from accidentally lesion of NRRLN one if it is encountered during thyroid or parathyroid surgery