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It is known that prosthetic infection, graft-duodenal fistula, and erosion are possible late complications after aortic reconstruction, and that all these reported complications are accompanied generally by variable bleeding with different presentations. We report the case of a 63-year-old man who underwent a diagnostic upper gastrointestinal endoscopy for investigation of nausea, anorexia, asthenia, fever, and mild leukocytosis. The patient's medical history included a gastric resection for ulcer, with Billroth II gastrojejunostomy reconstruction and implantation of a Dacron vascular graft for abdominal aortic aneurysm 20 years and 3 years earlier, respectively. Abdomen ultrasonography showed hypoechoic area around an aortic prosthesis. Endoscopy found a foreign body corresponding to the vascular graft at the jejunum. No signs of bleeding were recorded. The patient was hospitalized and submitted to surgery that involved extra-anatomic axillofemoral bypass, bowel resection with a gastrojejunum Roux anastomosis, and prosthesis removal.

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PURPOSE: Colonoscopic polypectomy is the preferred technique to remove the majority of polyps. The authors evaluate feasibility, safety, and the effectiveness of endoscopic treatment of colorectal benign-appearing polyps equal to or larger than 3 cm. METHODS: Ninety-seven patients with 104 giant polyps underwent polypectomy within a nine-year period. The majority of these procedures were performed on an outpatient basis, all on unsedated patients. Gross appearance, size, location, histologic characteristics, synchronous lesions, modality, and adequacy of removal of giant polyps were analyzed. The follow-up was achieved in 89 percent of patients during a period ranging from 6 to 96 months (median, 38). RESULTS: Of the 104 removed polyps, 75 (72 percent) were adenomatous, 2 (2 percent) were hyperplastic, and 27 (26 percent) were malignant polyps. Six patients had more than one giant polyp. Several additional smaller polyps were found in 52 patients and a synchronous cancer in 4. Twenty-one (20 percent) giant polyps were equal to or larger than 4 cm. Forty-nine were pedunculated, 20 were short-stalked, and 35 were sessile. Sixty-one polyps were excised in one piece, and forty-three were excised using a piecemeal technique. Only four complications (3.8 percent) were recorded; all cases were treated endoscopically. Fifty-eight (75 percent) adenomas and eighteen (67 percent) malignant polyps were completely excised. Surgery was performed in 7 of 27 patients (27 percent) with malignant polyps, where there was a doubtful, infiltrated margin or poorly differentiated cancer. Postpolypectomy surveillance permitted the detection and treatment of 25 metachronous or recurrent polyps and a metachronous cancer. CONCLUSIONS: This study shows that polypectomy of giant colorectal polyps, performed by an expert endoscopist, is feasible, effective, and safe, even on an outpatient basis. The authors confirm that malignant polyps with incomplete excision, lymphovascular invasion, and poor differentiation require bowel resection. Postpolypectomy surveillance is useful for all patients who have undergone colonoscopic resection of giant adenomatous or malignant polyps.

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We report a case of gallbladder agenesis in a 30-year-old woman affected by a cardiac congenital malformation who had been operated on at the age of 12. The patient was sent for laparoscopic cholecystectomy due to a preoperative diagnosis of cholelithiasis using clinical and instrumental examinations such as ultrasonography and cholangiography. During laparoscopy, the gallbladder was not found, and laparotomy with intraoperative cholangiography and ultrasonography was performed which also resulted negative. The preoperative possibility of a diagnosis of gallbladder agenesis, the association with other malformations and the steps to be taken to discover agenesis of the gallbladder are discussed.

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Hyperplastic polyps are the most frequent nonneoplastic lesions of the colon. Typically, they are small sessile polyps (5 mm) located in the rectosigmoid area. Recently, they have been identified as markers of neoplastic polyps. Herein we describe four cases of large (20 mm in size) hyperplastic polyps found at our institution over a 9-year period. All four polyps were excised by endoscopic polypectomy on an outpatient basis without complications. Two polyps were in the right colon; one was pedunculated, none of them was associated with synchronous neoplastic polyps or polyposis. Up to now, follow-up in three patients has been negative for metachronous polyps. We conclude that a large hyperplastic polyp is an unexpected and rare finding, difficult to distinguish, and not related to particular colonic sites or synchronous adenomatous lesions. These polyps should be removed with a standard technique, and patients need to be followed with successive endoscopies.

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Endoscopic colonic tattooing is the simplest and most economic technique for identifying small lesions or polypectomy sites during open and laparoscopic surgery. Moreover, it is useful for the endoscopic follow-up of polypectomy sites. India ink is the agent of choice because of its long-lasting stain and the low risk of adverse reaction and toxicity. Very few cases of complications have been reported. We report here the case of a patient in whom colonic tattooing in preparation for surgical resection was followed by clinical complications such as fever and abdominal pain. An abscess-type inflamed pseudotumor was found at laparotomy. Histological examination revealed chronic granulomatous inflammation.

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The portal venous thrombosis is an infrequent disease that accounts from 0.25 to 1%. The etiopathogenesis is unknown in about one half of cases. Sometimes the thrombosis of mesenterico-portal venous axis is a complication following splenectomy, especially when the operation is performed for hematologic disease. The authors report a clinical case of chronic portal venous thrombosis widespread to superior mesenteric and splenic vein, in man 38 years old after splenectomy, in pediatric age, manifesting with gastrointestinal bleeding due to rupture of esophagogastric varices. On the basis of literature, the following were taken into consideration the incidence, the epidemiology, the aetiopathogenesis, the clinical characteristics, the diagnosis as well as the therapy of portal venous thrombosis.

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The aim of this work is to describe the three years experience in hepatic resections for primitive and metastatic liver tumors. Of the 90 patients considered initially only 33% was admitted to radical surgical treatment, after a complete clinical and instrumental evaluation. Twenty of them was affected by liver metastases, most of which from colo-rectal cancer; ten had hepatocellular carcinoma developed on hepatic cirrhosis. All the patients affected by HCC underwent pre-operative chemoembolisation (TACE). Regional chemotherapy (TACI) was performed in synchronous metastatic tumors before surgical treatment. Surgical resection in HCC was extremely limited, removing at most 35% of total liver volume. For metastatic tumors 12 major resections and 8 minor resections was carried out. Postoperative complications occurred in 13.3%, including one death for digestive bleeding. A relationship between intraoperative risk factors, such as blood loss and transfusions was registered. The actuarial surviving rate was 47.5% for HCC and 48.3% for colo-rectal metastases at three years. Finally, preoperative CEA levels was the only factor significantly related to long term prognosis of patients affected by liver colo-rectal metastases.

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PURPOSE: To evaluate the efficacy of early enteral nutrition in management of patients operated by major urologic surgery and to demonstrate her advantages versus total parenteral nutrition. MATERIALS AND METHODS: 20 patients, operated by radical cystectomy and urinary diversion by ureteroileocutaneostomy, Padua ileal bladder or ureterosigmoidostomy are inserted in our study: 12 were treated by early enteral nutrition for 8 days and eight by total parenteral nutrition for the same period: in each group nutritional and immunological parameters at day -1, +3 and +7, the length of postoperatory stay, the incidence of complications, with particular respect for infections have been evaluated and correlated one to each other. RESULTS: We have no death in each group; in the first group no gastroenteric allergy to the nutrient, less incidence of venous catheter and surgical wound infections (respectively p < 0.01 and p < 0.005); we have no significant decrease of postoperatory stay length; the effective problem in this group was the incidence of diarrhea, that in one case have made necessary the suspension of enteral nutrition. Enteral nutrition costs were about half of those of total parenteral nutrition. CONCLUSIONS: We believe that early enteral nutrition is an effective and safe nutrition method in patients operated by major urologic surgery: with this is possible a better nutrition, that reduce the incidence of postoperative complications, mainly infections, and maybe the length of postoperatory stay (our champion is too small for statistical evaluation), that may lead to a decrease in management costs of these patients.

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We present our experience in the treatment of middle-lower rectal cancer particularly in reference to the use of those operative techniques which permit to save the sphincteric system. From 1990 to April 1995 seventy-two patients were operated on for middle-lower rectal cancer applying the Knight-Griffen technique. Such a method has already demonstrated the characteristics of a valid anastomosis, being simple, fast and safe. The introduction of stapler devices in the rectal surgery, particularly in its middle-lower tract has significantly modified the quality of life of such patients, reducing drastically the number of colostomies. The possibility to extend the rectal resection towards the anus with colo-anal anastomosis has showed a loco-regional recurrence rate not different from abdominal-perineal resection, even though with some sphincteric troubles due to incontinence. The satisfying surgical results obtained with low and ultra-low recta resections, by now widewordly accepted, should not anyway mask the importance of an early diagnosis as the main factor governing the prognosis (i.e. the overall mortality).

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The Authors report their experience in the endoscopic treatment using pneumatic dilatation for 18 patients with achalasia, seen in the period January 1992 August 1995 at the Laboratory of Digestive Endoscopy of the Institute of General Thoracic and Vascular Surgery of the University of Parma. Ten were males and 8 females, age range 23-79 years (average age 48 yrs.). The most common symptoms was dysphagia, all patients were radiologically and manometrically studied confirming the clinical and endoscopic diagnosis. All underwent pneumatic dilatation under endoscopic control. In all, 36 dilations were carried out without registering complications related to the method. A maximum follow-up of 30 months confirmed a good-excellent outcome in 89% of cases. In 3 cases a gastroesophageal reflux symptomatology was registered, but successfully treated medically. The Authors conclude that the pneumatic dilation for achalasia is to be considered the treatment of choice, leaving the surgical approach only for cases resistant to such treatment.

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Obturator hernias are relatively rare. Elderly women with chronic diseases are most frequently affected. Mechanical small bowel obstruction is the most common presenting symptom. Cause the Howship-Romberg sign is found in only 20% of cases, a correct preoperative diagnosis is uncommon. Midline abdominal incision is thought to be the better approach, allowing an easy reduction of the incarcerated ileum and a direct repair of the defect. Contralateral side exploration is recommended, being bilateral hernias quite common. The prognosis, despite our own results, remains severe for the compromised general conditions of the great majority of the patients.

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To perform ambulatorial surgery with local anaesthetics, it is important to carry out a correct postsurgical NSAID therapy avoiding the risks induced by these drugs. Two groups of patients submitted to ambulatorial hemorrhoidectomy were enrolled in a randomized study to evaluate the safety of NSAID therapy with or without the coadministration of misoprostol, a PGE1 analogue with gastroprotective action. Aim of this study was to evaluate if misoprostol in coadministration with NSAID could permit a correct domiciliary postsurgical NSAID therapy without gastric symptoms related to the NSAID therapy. From January 1990 to December 1991, 95 patients underwent hemorrhoidectomy and were discharged with analgesic therapy: the first group (n = 45) without gastroprotective therapy, the second group (n = 50) with the coadministration of misoprostol 200 mcg bid. After 7 and 14 days of treatment patients showed the following symptoms: in the first group 13.3% of the cases showed mild epigastric pain, 8.8% moderate epigastric pain and 4.4% severe epigastric pain with heartburn; in the second group (NSAID + misoprostol) only 4% of the cases showed moderate epigastric pain. The incidence of epigastric pain was statistically higher (p < 0.05) in patients treated with NSAID alone in comparison with the group treated with NSAID + misoprostol. The results, according to international literature, show that correct gastro-protective therapy with synthetic prostaglandins (misoprostol) is necessary for patients in treatment with NSAIDs.

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Between the prognostic indices in the colorectal cancer the ploidy has determined a great interest. To study the value of ploidy in the prognosis of the colorectal cancer, as a sign of the aggressiveness of the tumor for a therapeutic help, we have examined, in a retrospective study, 150 patients who had a colorectal cancer resected from 1980 to 1986. We have compared ploidy of specimens of paraffin-embedded tumors and Dukes' stage, Grading, the over-all, distal and local recurrence and the survival at 5 years. The statistics were performed by the chi-square test, the Fisher exact-test and the Wilcoxon test. The aneuploids are 126 (84%) and the diploids 24 (16%). The correlations of ploidy and the Duke's stages, the Grading, and the over-all and local recurrence are not statistical significant. The distal recurrence of the aneuploids and the better survival of the diploids are significant. In conclusion the ploidy is only a generic indicator of the aggressiveness of the tumor, not useful for a more complete therapeutic choice.

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The spastic pelvic floor syndrome, caused by a paradox contraction of the sphincteric apparatus at defaecation instead of relaxing, leads to constipation with difficult evacuation. Forty patients (15 males and 25 females, average age 49 years, age range 15-78) affected by serious chronic idiopathic constipation, underwent, at our Institute, from June 1989 to September 1990, the following instrumental examinations: anal manometry; electromyography of the pelvic floor; proctogram; intestinal transit time; anorectal endoscopy; in addition, in 6 cases at risk for colorectal cancer, left colonoscopy. Fifteen patients showed dyskinetic functioning of the voluntary sphincteric apparatus. The following diagnostic methods proved to be of fundamental importance: proctogram, which revealed failure to open of the anorectal angle at defaecation (mean values: at rest 88.93 degrees +/- 6.62; at defaecation 88.93 degrees +/- 9.44); electromyography of the pelvic floor, which showed the anomalous contraction of the external anal sphincter. These patients were treated by means of an air inflated endoampullary balloon to evoke the sensation of a stool and its subsequent expulsion. The correct evacuating function was resumed definitely in 9 patients (60%); for the remaining 6 patients, regular sessions of re-education are still necessary. The spastic pelvic floor syndrome is a major cause of constipation and requires an accurate diagnostic method of investigating the correct functioning of the recto-pelvic region by means of the above-mentioned methods.(ABSTRACT TRUNCATED AT 250 WORDS)

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The Authors present a case of post traumatic pseudocyst of the pancreas added to their observations and treated with an endoscopic cytogastric deviation. The incidence of such pathology has increased during the last few years thanks also to the improvement of the diagnostic techniques (TAC, U/S, Rm and eco-endoscopy) on hard today; in the second place the technological evolution has allowed, improving the diagnostic definition, the ability to heat pseudocysts, in selected patients, with minor surgery techniques with result equal to those of conventional surgery, but with complications and mortality decisively reduced. The morbidity and mortality rates of internal deviation surgery has respectively worsened varying between 21% and 50% and from 5% to 12%. The results of endoscopic deviations, even if the cases are less, report positive results from 80% to 100%, with complications and mortality greatly reduced. To be able to propose an endoscopic indication certain requirement are necessary of which one is indispensable: the distance between the two adjacent lumen must not be more than one centimeter. The Authors are of the opinion that such methods, in expert hand an on selected patients, should be the first surgical choice for the treatment of pancreatic pseudocysts.

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The Authors report their experience in the treatment of bleeding gastric and duodenal ulcers by means of endoscopic sclerotherapy. From August 1988 to December 1989, 104 patients with haematemesis and/or melena were observed at the Clinica Chirurgica Generale, Toracica e Vascolare-Università di Parma. Endoscopy, carried out in the first 24 hours, led to the diagnosis of a bleeding gastric or duodenal ulcer in 73 cases; 22 of these patients underwent emergency sclerotherapy using 1:10,000 Adrenaline in association with 1% Polydocanol. Results obtained are the following: absolute haemostasis in 20 patients (91%), and surgical intervention in the other 2 cases for renewed haemorrhage. Among patients endoscopically treated, one death (5%) was recorded. Further complications were not encountered. The Authors believe sclerotherapy is reliable and quick thus representing a considerable therapeutic advance in the treatment of gastroduodenal haemorrhage, notoriously at high death rate (8-10%).

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The authors report their experience about the esophageal manometry in patients with Progressive Systemic Sclerosis (PSS). From January 1987 to December 1991, 32 patients (27 females and 5 males, in the ratio of 5.4 to 1; mean age of 56.6 years, range 18-84) were send to our Department with the diagnosis of PSS. The patients were divided in two group according to the presence or absence of esophageal symptoms. The first group (A) of 12 patients without symptoms, was examined only with manometry, while the second (B) was studied with the 24-hour pH-monitoring and esophagoscopy. In the group A the manometry noticed in 9 cases (75%) various degrees of esophageal motility disorders; in B the 90% of cases had a more or less severe disorder of the peristalsis. Moreover the grade of esophagitis and the importance of the gastroesophageal reflux were proportioned to the motility disorders. The conclusion is that also the subjects with PSS, but without esophageal symptoms, have in a high percentage motility disorders of the viscera. The alterations of the peristalsis increases in the group of symptomatic patients associated with esophagitis and severe reflux. On account of the fact that the esophageal lesions involve not only the LES but also the esophageal body, it is clear that the anti-reflux surgical procedures fail and an early medical therapy is the more adequate treatment.

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The authors present a report of their study on a group of patients affected by serious chronic constipation undergoing multidisciplinary evaluation by a radiologist, a neurologist and, if necessary, also a psychiatrist. From June 1989 to October 1990, 40 patients were examined using anal manometry, intestinal transit time, proctogram and electromyography of the pelvic floor. The examinations carried out by the different specialists led to the following results: 10 patients were found to be affected by slowed transit due to right colon constipation; in 16 cases, spastic pelvic floor syndrome (S.P.F.S.) was diagnosed; 5 subjects showed a rectocele which in 3 was associated with S.P.F.S.; 3 patients presented with an anterior rectal prolapse; in 6 cases the diagnosis was perineal descent syndrome, associated in 3 cases with S.P.F.S.; the remaining 6 subjects manifested a diminished ampullary sensitivity. This experience reveals the complexity of the alterations that, alone or in association, cause chronic idiopathic constipation. The authors' conclusion is that a correct diagnostic approach requires close collaboration between various specialists, who, by careful examination of different aspects of the colo-recto-anal region, arrive at an accurate physiopathological diagnosis leading to the most suitable therapy.

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