Chirurgia italiana
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Review Case Reports
[Intestinal occlusion caused by persistent omphalomesenteric duct and Meckel's diverticulum: report of 2 cases].
Two rare cases of mechanical intestinal obstruction due to an omphalomesenteric duct remnant and/or to a Meckel's diverticulum, respectively, are reported. The first case was a 20-year-old man and the second an 87-year-old woman. ⋯ A complete diagnosis was possible only at operation and early surgery was important to prevent strangulation and gangrene of the bowel. The authors conclude that prompt and appropriate surgical treatment reduces the mortality risk in all patients with intestinal obstruction, including even resected cases.
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The term acute mediastinitis describes a number of clinical conditions, usually secondary to diseases of other aetiology with which they tend to share the severity of the clinical picture. In these situations even a timely diagnosis and adequate therapeutic management are not always enough to ensure healing. Over the period 1987-2002 15 patients with acute mediastinitis were observed (8 male, 7 female), aged from 22 to 90 years (mean age: 57.9), distributed as follows: descending necrotising mediastinitis, 4 cases; iatrogenic oesophageal rupture, 2 cases; iatrogenic tracheal rupture, 3 cases; oesophageal perforation (foreign body), 4 cases; Boerhaave's syndrome, 1 case; oesophageal perforation (lye ingestion), 1 case. ⋯ In 4 cases (2 descending necrotising mediastinitis, 2 acute mediastinitis secondary to oesophageal perforation) repeated interventions were necessary in order to drain pleural or mediastinal effusions. Acute mediastinitis remains a serious clinical entity, the outlook of which is often poor. Factors influencing outcome are the patient's age and general condition (adequate immune response), a timely diagnosis, preoperative localisation of effusions, an aggressive therapeutic approach including drainage of infection sites in the mediastinum, neck and/or pleural cavities, alimentary tract diversion in cases of oesophageal lesions observed late, adequate antibiotic therapy, and nutritional support (total parenteral/enteral nutrition).
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During recent years, there has been considerable debate as to the nutritional supply that needs to be established for a patient with acute pancreatitis. The main problem is still infection of the pancreatic necrosis, which has a decisive bearing on the indication for surgery and is the main cause of mortality. Infection stems from bacterial translocation from the patient's gut. ⋯ Today, the concept of pancreatic rest is no longer considered mandatory in the guidelines of many Surgical and Nutritional Societies, whilst enteral nutrition is the gold standard for acute pancreatitis. Assuring an integrated parenteral and enteral supply before reaching the full regimen of enteral nutrition is the most reliable policy during the early days of the disease. Moreover, outcomes being equal, enteral nutrition is cheaper than parenteral nutrition, as has been extensively demonstrated in many clinical trials in severe acute pancreatitis.
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Review Case Reports
[Pancreatic metastasis from clear cell renal carcinoma: a clinical case].
Renal cell carcinoma rarely metastasizes to the pancreas. In this report we describe a case of late pancreatic metastases in a seventy-year-old woman, surgically treated 21 years before for renal clear-cell carcinoma. Preoperative staging revealed the presence of four pancreatic lesions. ⋯ This case shows that in patients operated on for renal clear-cell carcinoma we have to consider the possibility of late metastases to the pancreas. Therefore, these patients should be submitted to long-term follow-up. In keeping with the current literature, we advocate aggressive surgical treatment in pancreatic metastases from renal clear-cell carcinoma.
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Laparoscopic cholecystectomy has become the treatment of choice for patients with symptomatic cholelithiasis. About 10-20% of patients with gallbladder stones may also present associated common bile duct stones. The management of the latter remains controversial because many different surgical strategies are available: laparoscopic treatment (laparoscopic common bile duct exploration), sequential endoscopic and laparoscopic treatment (endoscopic retrograde cholangiopancreatography/endoscopic sphincterotomy [ERCP/ES] prior to laparoscopic cholecystectomy), inverted sequential endoscopic-laparoscopic treatment (laparoscopic cholecystectomy followed by ERCP/ES), and combined endoscopic-laparoscopic treatment (laparoscopic cholecystectomy with intraoperative ERCP/ES). ⋯ In the group of patients with no suspicion of common bile duct stones, the conversion rate was 4.9%. Sequential treatment cannot be considered the best approach for patients with cholecystocholedocholithiasis because of its morbidity rate and the high rate of negative preoperative ERCP findings. Combined endoscopic-laparoscopic treatment seems to present more advantages, especially in term of morbidity, hospital stay and patient compliance and may, in future, be considered the treatment of choice for patients with cholecystocholedocholithiasis.