1,720,989 research outputs found
Laparoscopic resection, splenic artery aneurysm, splenic function preservation
No full textL'aneurisma dell'arteria splenica (AAS) ha un'incidenza del 0,02%-10,4%, rappresenta il 60-71% di tutti gli aneurismi viscerali ed è il terzo come frequenza tra gli aneurismi intraaddominali. L'eziologia è sconosciuta, ma sono state ipotizzate diverse cause, le cui principali sono l'aterosclerosi e difetto congenito della parete arteriosa. Il 3-10% degli AAS va incontro a rottura, evenienza che comporta una mortalità compresa tra il 25% ed il 36%. La maggior parte di essi sono asintomatici e la diagnosi viene formulata occasionalmente dopo la rottura o durante riscontri autoptici (dal 0,1% al 10,4%) od in corso di indagini diagnostico-strumentali eseguite per altri motivi (0,78% vengono riscontrate casualmente durante arteriografia). L'indicazione al trattamento dell'AAS si pone sulla base di diversi parametri di valutazione, primo tra tutti la dimensione, in quanto un diametro di 1,5-2 cm presenta un'incidenza di rottura con range compreso tra il 3% ed il 9,6% seguito dall'incremento volumetrico nel tempo; altri criteri sono la sintomatologia, seppur aspecifica ed incostante, paziente candidato a chirurgia per ipertensione portale o al trapianto epatico, in quanto in quest'ultimo caso l'incidenza dell'AAS è maggiore, tra il 7% ed il 17%, dovuto allo stato di ipertensione portale che si può instaurare. Il rischio di rottura spontanea aumenta di circa 3% - 4% dopo trapianto epatico, soprattutto nell'immediato post-operatorio con un tasso di mortalità del 50%. Anche nella paziente in età fertile o gravida vi è indicazione al trattamento dell'AAS in quanto la rottura spontanea si verifica nel 20%-50% dei casi, più frequentemente nel terzo trimestre di gravidanza; qualora ciò si dovesse verificare la mortalità materna sale a circa il 75% e quella fetale a circa il 95%. Il trattamento dell'AAS necessità di una stretta collaborazione tra i membri di un team multidisciplinare composto dal chirurgo, medico radio-diagnosta, del radiologo interventista e comporta un complesso algoritmo gestazionale: - Follow-up: sorveglianza radiologica con cadenza semestrale - Trattamento endovascolare: Embolizzazione; Stenting - Trattamento chirurgico " Open " vs " VL ": Aneurismectomia +/- Splenectomia; Legatura/Resezione dell'arteria splenica +/- Splenectomia. Un approccio laparoscopico può permettere una selettiva resezione dell'aneurisma con accurata preservazione dei vasi collaterali e quindi della vascolarizzazione e funzionalità splenica
Primary gastrointestinal stromal tumour of the ileum pre-operatively diagnosed as an abdominal abscess
No full textThe present case report described the acute presentation, diagnosis and management of a primary gastrointestinal stromal tumour (GIST) of the ileum. A male patient (age, 51 years) was admitted to Maggiore Hospital (Parma, Italy) due to presenting with fever, dysuria and lower abdominal pain. Ultrasonography and computed tomography showed a 7,5×5,5-cm pelvic mass containing air and purulent fluid indicative of an intraperitoneal abscess. The patient was subjected to diagnostic laparoscopy, which revealed a huge, soft cystic mass arising from the small bowel. The procedure was then converted to an open exploration through a midline incision. Ileal resection including a Meckel's diverticulum was performed. Macroscopic examination revealed that the cystic mass was filled with a large amount of pus, probably due to communication between the tumour mass and the small bowel lumen. In fact, the surgical specimen showed enteric leakage from the ileal mucosal ulcer into the tumour mass. Histopathology and immunohistochemistry of the abscess wall identified a spindle-cell mesenchymal-type, c-KIT-positive neoplasm. The post-operative course was uneventful and adjuvant imatinib mesylate was administered for 1 year. Follow-up by computed tomography demonstrated no tumour recurrence at 72 months after surgery
Internal Hernias and Angina Abdominis After Laparoscopic Gastric Bypass: The Challenging Management of an Underestimated Problem
No full textIntroduction:. Internal hernia represents one of the most common late complications of Roux-en-Y gastric bypass (RYGBP), with an estimated incidence varying from 0.7% to 3.25%, reaching 6% considering only procedures with transmesocolic alimentary loop [1-2-3]. Such incidence only account for complicated hernias, while a greater part of internal hernias occur (si manifesta) as a recurrent episode of postprandial colic pain (angina abdominis). Those latter cases are probably the most challenging to diagnose, to treat and to prevent..
Case series: we present a video of four cases of laparoscopic exploration in patients with recurrent, not complicated, postprandial abdominal pain (angina abdominis) after RYGB. All the patients were mid age (mean age 39.5) females, previously submitted to an antecolic RYGB; mean EWL was 83%. Preoperative study revealed in all cases a partial or complete twist of the mesenteric axis at CT san. None presented with an acute syndrome (occlusion, leucocytosis, shock) and they were all operated on a not urgent setting.
A Petersen non complicated hernia was detected in three patients, and reduction with stitch fixation was performed, while an adhesion to an intraperitoneal mesh with loop rotation was detected in the last case, and treated by a laparoscopic adhesiolysis.
Postoperative course was uneventful for all the patients (mean hospital stay 2.5 days), and abdominal pain resolution was achieved at follow-up.
Conclusions: Laparoscopic exploration yields a sure diagnosis and a safe and effective treatment of non complicated internal hernias after RYGBP
Laparoscopic subtotal pancreatectomy: the right edge of the distal resection
No full textCase
We report a case of an obese (BMI 30.) 48 year-old male patient who presented with recurrent upper abdominal pain. He was found to have a symptomatic cystic mass in the neck of the pancreas.. US demonstrated a 5 cm hypoechoic cystic mass of the pancreatic isthmus. Serum CA 19-9 was slightly elevated. CT and MRI findings were consistent with a mucinous cystoadenoma/cystoadenocarcinoma. EUS-FNAB diagnostic of a cystic lesion with no evidence of malignant cells. A 6-month follow up MRI scan demonstrated the lesion had increased in size, strengthening the suspicion for mucinous cystoadenocarcinoma. The patient underwent a laparoscopic subtotal pancreatectomy and splenectomy. The pancreatic transection was extended to the left side of the gastroduodenal artery. The surgical procedure was technically demanding due to the patient’s visceral obesity and the anatomical location of the lesion. The postoperative course was complicated by a grade B pancreatic leak, managed conservatively. The pathology report demonstrated a pancreatic lympho-epithelial cyst which was resected with a clear surgical margin.
Conclusions
Laparoscopic distal pancreatectomy and splenectomy for a pancreatic neck lesion can be extended to the left side of the gastroduodenal artery in order to obtain a clear resection margin. Even if obesity increased the techinical difficulty, it should not be considered a contraindication to laparoscopic approach
Laparoscopic gastric bypass with remnant gastrectomy in a super-super obese patient with gastric metaplasia: a surgical hazard?
No full textThe endoscopic inaccessibility of the gastric remnant after Roux-en-Y gastric bypass (RYGBP) for morbid obesity represents an important issue for patients with familiar history of gastric cancer (GC) or affected by premalignant lesions, such as intestinal metaplasia. If a different bariatric procedure is contraindicated, RYGBP with remnant gastrectomy represents a reasonable alternative, significantly reducing the risk of GC but potentially increasing postoperative morbidity. For this reason, only few cases have been reported in the recent Literature and none regarding a super-super obese patient. We present the case of a 55-year-old super-super obese man with a family history of GC and antral gastritis with extensive intestinal metaplasia at preoperative upper endoscopy, who underwent laparoscopic RYGBP with remnant gastrectomy
Prognostic assessment of gastric cancer: Retrospective analysis of two decades
No full textBackground: Gastric cancer mortality rates have remained relatively unchanged over the past decades, in spite of progressive decrease in incidence. Nodal status represents a key factor for prognostic assessment, allowing a tailored-made adjuvant therapy for the patients. The aim of this study is to evaluate the prognostic influence of different nodal involvement indicators on the overall survival in a large series of patients submitted to gastrectomy at our Institution. Methods: we retrospectively collected data from 634 newly diagnosed patients with gastric cancer who underwent curative gastrectomy, with D1/D2 lymphadenectomy during the last 20 years. Prognostic values of age, histologic type, pN, nodal ratio (LNR) and log odds of positive lymph nodes (LODDS) of were analyzed. Results: The median overall survival was 40.2 +/-31 months. Multivariate analysis identified age at diagnosis, diffuse-type tumor, pN and LODDS as independent predictors of worse prognosis. Scatter plots of relationships between LODDS and LNR showed that LODDS seems to better assesses prognosis for patients at LNR stage 0 or 1. Conclusions: Nodal involvement confirmed to be a strong indicator of prognosis. LODDS demonstrated a theoretical advantage over pN and LNR system allowing more accurate patients stratification, but our results have to be confirmed by further trials. (www.actabiomedica.it
Abdominal Pain After Roux-en-Y Gastric Bypass: Semiotic Aspects Suggestive of Internal Hernias
No full textIntroduction: Abdominal pain is the most frequent cause of hospital admission after Roux en y gastric bypass (RYGB) Among numerous possible underlying causes, internal hernia represents one of the most peculiar and insidious circumstances, setting challenging diagnostic and therapeutic problems for the surgeon.
Objectives: The aim of this study is to analyze abdominal pain incidence and characteristics after RYGB, discriminating peculiar aspects suggestive of internal hernias.
Methods: 9 patients submitted to internal hernia repair after RYGB and a group of 49 controls (non complicated RYGB) were evaluated using 2 types of abdominal pain questionnaires (Roma III and Roma III modified). Overall abdominal pain incidence (controls) and specific characteristics of internal hernias (cases) were analyzed.
Results: 32% of controls presented aspecific (no diagnosed cause) abdominal pain after RYGB - mainly deep, remittent, colic, located in the upper left abdomen, postprandial.
78% of the cases presented prodromic algic episodes similar to those of the controls, differing from the acute episode only in pain intensity.
Excess weight loss, mainly at 3 months and after one year, showed the most significant correlation with internal hernia (p: 0.043 and p: 0,026, respectively).
Conclusion: Based on abdominal pain characteristics (angina abdominis-like) we can reasonably postulate the presence of remittent bowel torsions (remittent internal hernias) in many patients, occasionally complicating.
Therapeutic management of such cases remains controversial, laparoscopic exploration being a good option when symptomatology is suggestive
Laparoscopic subtotal gastrectomy for the treatment of advanced gastric cancer: A comparison with open procedure at the beginning of the learning curve
No full textBackground: In the last decades, after some initial concern, laparoscopic subtotal gastrectomy (LSG) is gaining popularity also for the treatment of advanced gastric cancer (AGC). The aim of this study is to compare a single surgeon initial experience on LSG and open subtotal gastrectomy in terms of surgical safety and radicality, postoperative recovery and midterm oncological outcomes. Methods: a case control study was conducted matching the first 13 LSG for AGC with 13 open procedures performed by the same surgeon. Operative and pathological data, postoperative parameters and midterm oncological outcomes were analyzed. Results: There was no significant difference in mortality (0%) and morbidity, while the laparoscopic approach allowed lower analgesic consumption and faster bowel movement recovery. Operation time was significantly higher in LSG patients (301.5 vs 232 min, p: 0.023), with an evident learning curve effect. Both groups had a high rate of adequate lymph node harvest, but the number was significantly higher in LSG group (p: 0.033). No significant difference in survival was registered. Multivariate analysis identified age at diagnosis, diffusetype tumor, pN and LODDS as independent predictors of worse prognosis. Conclusions: LSG can be safely performed for the treatment of AGC, allowing faster postoperative recovery. (www.actabiomedica.it)
CHOLECYSTO-CHOLEDOCHAL LITHIASIS: A CASE-CONTROL COMPARISON OF EARLY AND LONG-TERM OUTCOME OF A “LAPAROSCOPY-FIRST” ATTITUDE VS. SEQUENTIAL TREATMENT (SYSTEMATIC ENDOSCOPIC SPHINCTEROTOMY FOLLOWED BY LAPAROSCOPIC CHOLECYSTECTOMY).
No full textBACKGROUND: No unanimous consensus has been achieved regarding the ideal management of cholecystocholedocholithiasis. The treatment of gallbladder and common bile duct (CBD) stones may be achieved currently according to a two-step-protocol (endoscopic sphincterotomy associated with laparoscopic cholecystectomy) or by a one-step laparoscopic procedure, including exploration of the CBD and cholecystectomy. Endoscopic sphincterotomy is reported to have considerable morbidity/mortality and CBD stone recurrence rates, whereas laparoscopic CBD clearance is a demanding procedure, which to date has not spread beyond specialized environments.
METHODS: To evaluate our "laparoscopy first" (LF) approach for patients affected by gallbladder/CBD stones (laparoscopic exploration and intraoperative decision whether to proceed with laparoscopic CBD exploration or to postpone CBD stone treatment to a postoperative endoscopic retrograde cholangiopancreatography [ERCP]), we performed a retrospective, two-center case-control comparison of the postoperative outcome for 49 consecutive patients treated for gallbladder/CBD stones from January 2000 through December 2004. The results obtained with this LF approach were compared with those achieved with the traditional, "endoscopy-first" (EF) approach (ERCP plus endoscopic sphincterotomy, followed by laparoscopic cholecystectomy). The mean follow-up period was 6.4 years (range, 4-8 years).
RESULTS: No difference emerged concerning early and late complications, mortality, or laparotomies needed to accomplish cholecystectomy and CBD clearance. The postoperative hospital stay was shorter for the LF group. In the LF group, only 22 patients underwent choledochotomy (45%), and 15 patients underwent perioperative ERCP (30%). Conversions decreased with practice. After choledochotomy, an increasing number of patients underwent primary closure of the CBD (with no biliary drain), without complications.
CONCLUSIONS: An LF approach to gallbladder/CBD stones is safe and feasible. It may allow the majority of surgeons to avoid excessively difficult/dangerous surgical procedures as well as unnecessary ERCPs in most cases. A tendency toward a lower incidence of conversions and a rarer use of biliary drains may lead to an improved immediate outcome for patients undergoing an LF approach
Quality of life in post-bariatric surgery patients undergoing aesthetic abdomi-noplasty: Our experience
No full textBackground/aim of the study: Aesthetic post-bariatric surgery abdominoplasty aims to reshape the abdominal wall in order to improve the patient's appearance and self-image. Patients who have undergone this surgery report significant improvements in self-esteem and quality of life. Material and Methods: The authors evaluated the quality of life in 30 patients (22 women and 8 men) aged 24-79 years (mean age: 50.5 years) undergoing aesthetic post-bariatric surgery abdominoplasty between January 2012 and September 2015. Quality of life and body image were measured with two self-report questionnaires: a basic questionnaire (BQ) and the Body Image As-sessment-Obesity (BIA-O). Results: At the end of the study, 58% of patients reported complete satisfaction with the aesthetic results, while 23% of patients expressed dissatisfaction with the surgical scars. Analysis of the responses to the BIA-O, showed that patients had a better and slimmer body image perception after surgery than they had preoperatively. Conclusion:Although our study sample was small, we could demonstrate that most patients undergoing aesthetic post-bariatric surgery abdominoplasty experience improvement in body image perception and quality of life
- …
