We describe an unusual case of self-amputation of a transanal prolapsed colorectal segment by a 48-year-old mentally impaired woman. The surgical procedure and favourable outcome are reported.

Self-expanding biliary drains seem to allow long-term patency and prevent stent migration in peri-ampullary neoplastic lesions. We report two cases of duodenal occlusions due to the stent advancing towards the intestinal lumen in patients with tumours of the pancreatic head. The stents had been percutaneously positioned after an endoscopic papillotomy or palliative choledocho-jejunostomy and were impacted by alimentary debris, blocking the passage of food. Dislodgement of the metallic mesh, in conjunction with duodenal wall stiffness and reduced absorption ability due to the pancreatic cancer, can give rise to progressive intestinal occlusion.

Splenic artery aneurysms account for the majority of splanchnic artery aneurysms. These constitute a uncommon pathology, but with a mortality rate greater 70%. We report a case of a double symptomatic aneurysm of the splenic artery with a proximal and distal localization. The patient was a 65-year-old woman with chronic abdominal pain of the left hypochondrium, irradiating to the ipsilateral iliac fossa. In this case, the particular anatomical characteristics, which prevented a conservative endovascular treatment, were well suited to surgical treatment, performed successfully. In conclusion, in the case of a low-risk patient, in the presence of aneurysms with favourable anatomical characteristics one should prefer surgical rather than endovascular treatment, despite the widespread use of the latter.

Small bowel metastases from a primary lung carcinoma are rare. We report a case of a 76-year-old male with a primary neuroendocrine small cell carcinoma of the lung, treated by chemotherapy, who developed fever and bowel symptoms (subocclusion and pain). On CT examination, he was found to have a tumour in the small bowel. The patient then underwent abdominal surgery. At operation we found small bowel occlusion by neoplasia and we therefore resected 15 cm of ileum with a side-to-side anastomosis. Early recognition of this rare condition is important due to the fact that complicated intestinal metastases from lung carcinoma can lead to high mortality rates and poor short-term outcomes. With advances in chemotherapy and palliative care, patients with metastatic lung carcinoma can sometimes survive more than a year with a reasonable quality of life.

Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are a distinct entity with malignant potential, which may recur after surgical excision. Limited pancreatectomies have been recently proposed for non-invasive tumours. We report our technique of intraoperative US-guided resection of non-invasive IPMNs located in the tail of the pancreas with spleen and splenic vessel preservation. Following adequate exposure of the distal pancreas, a thorough ultrasonographic examination of the parenchyma is accomplished to define the features of the neoplasia, its relationship with the main pancreatic duct and splenic vessels and to mark the transection line with electrocautery. Dissection begins at the inferior edge of the pancreatic tail and proceeds in a lateral to medial direction up to the transection line. The main pancreatic duct is identified and sutured, the parenchyma is then closed and the suture line is reinforced with a fibrinogen/thrombin-coated collagen patch. Patient 1 was a 63-year-old male who underwent intraoperative US-guided resection of the pancreatic tail for an IPMN of the pancreatic tail measuring 28 mm with moderate dysplasia at histology, and was discharged 9 days after surgery. Patient 2 was a 60-year-old male who underwent intraoperative US-guided resection of the pancreatic tail for an IPMN of the pancreatic tail measuring 30 mm with carcinoma in situ at histology, and was discharged 9 days after surgery. Limited distal pancreatic resection with spleen and splenic vessel preservation is an adequate surgical technique for non-invasive IPMN of the tail of the pancreas. Intraoperative ultrasonography is crucial in planning "radical but conservative" pancreatic resection.

Fibromuscular dysplasia or fibromuscular hyperplasia is a rare non-atherosclerotic and non-inflammatory vascular disease that primarily involves medium-size and small arteries, most commonly the renal and carotid arteries, and less frequently the vertebral, iliac, subclavian or visceral arteries (mesenteric, hepatic, splenic). Antiphospholipid syndrome is one of the most commonly acquired hypercoagulable states, defined by the association of laboratory evidence of anti-phospholipid antibodies with arterial or venous thrombosis or recurrent pregnancy losses. The presence of these antibodies is associated with an increased risk of thromboembolic phenomena, including peripheral thrombophlebitis, pulmonary thromboembolism, stroke, retinal artery occlusion, myocardial infarction, placental thrombosis and Budd-Chiari syndrome. In this report we discuss the uncommon case of a young male patient with both antiphospholipid syndrome and fibromuscular dysplasia that came to our attention for pulmonary embolism and "angina abdominis" due to occlusion of three mesenteric vessels. The possible relationship between antiphospholipid syndrome and fibromuscular dysplasia encountered in our patient still remains unclear. We treated the patient as if he had the two different diseases. After partial failure of endovascular surgery, the patient underwent surgery with reimplantation of three visceral arteries to the aorta. Subsequently he was treated with stent placement after development of a re-stenosis of one of the three reimplanted visceral arteries. The patient was treated conservatively for antiphospholipid syndrome with anticoagulant oral therapy for life.

Rectocele and haemorrhoidal prolapse are two pathologies that in all cases entail partial excision of anorectal tissue possibly with less invasive surgical procedures. For these pathologies, the authors have recently improved their treatment procedures, introducing the sequential transfixed stitch technique (STST) for rectocele and the transfixed stitch technique (TST) for haemorrhoidal prolapse, and thereby obtaining a significant technical and clinical improvement in terms of both outcomes (complete correction of rectal prolapse and haemorrhoidal prolapse) and discomfort and quality of life in the postoperative period. Moreover, in the present study the authors propose a subsequent innovation of the technique developed recently for the treatment of rectocele and haemorrhoidal disease using a new curved siliconate needle, thinner than the traditional lanceolate needles, with a longer, more rigid needle-thread junction in order to achieve less invasiveness and mucosal trauma, enabling the surgeon to perform sutures in a simple, easy manner. Ten consecutive patients with a clinical and instrumental diagnosis of rectocele--6 type II and 4 type III--were treated with TSTS and 20 patients with third (12 patients) and fourth degree (8 patients) haemorrhoidal disease were treated with TST. The surgical procedures were the same for all patients, although patients were divided into two groups. To the first group (A) were allocated patients treated with traditional stitches with a cylindrical, half circle needle, (Hr 25.9 mm). To the second group (B) were allocated, for the same objective, patients treated with the new siliconate needle, with an ultrafine tip, manufactured by Assut Europe S.p.A. The mean duration of the TST surgical procedures was 16 minutes using the new siliconate needle, whereas the mean duration using the traditional lanceolate needle was 17 minutes (p = ns). The surgical team judged the TST performed with the siliconate needle to be easier in 90% of cases in comparison to 70% of cases treated with the traditional lanceolate needle (p < 0,05). In patients treated with TSTS using the traditional lanceolate needle the mean duration of the surgical procedures was 20 minutes as against 18 minutes in the cases treated with the siliconate needle (p = ns). The surgical team judged the TSTS performed with the siliconate needle to be easier in all cases, while in two cases treated with the traditional lanceolate needle there were technical difficulties related to the use of the needle. The use of the ultrafine siliconate siliconate needle is more effective for the treatment of rectocele with TSTS and for haemorrhoidectomy with TST, particularly with a view to improving the surgical procedures and limiting the extent of mucosal damage related to suture oedema.

The Authors describe the reconstruction of an eyebrow, in a case of complete traumatic avulsion, using a scalp island flap based on the superficial temporal artery, in a young person aged 32 years. The lesion represented a serious aesthetic disablement capable of causing disturbed psychic equilibrium and individual relationships, in view of the fact that the eyebrows play a decisive role in the characterisation of the face and expressive gestures. The strategy of using a scalp island flap with a limited amplitude only slightly larger than that of the site in which it was inserted enabled optimal projection of the newly constructed eyebrow to be achieved during suturing.

Two types of covered self-expanding metal stents were compared in a consecutive series of 57 patients. Stent placement was successful in all patients. No procedure-related deaths were observed. The overall hospital morbidity was 7%. No significant differences in the efficacy of palliation of dysphagia, rate of complications, and survival rates were seen using the two types of stent. An endoscopic reintervention was required in 14% of the patients. Both stents proved to be safely removable in the short term follow-up, and the benefit of temporary insertion was documented in patients with primary oesophageal neoplasms prior to chemotherapy or chemoradiation therapy and in those with anastomotic strictures/leaks. A multidisciplinary strategy, guided by the concept that a stent should not represent the only, definitive treatment modality, may improve the quality of life of patients with advanced oesophageal carcinoma.

The authors report two cases of acute small bowel obstruction, the first in an adult patient, and the second in a three-month-old baby due to a congenital fibrous band. The second case was retrospectively detected from a pool of at least 50 cases of secondary fibrous band obstructions over the period from 1970 to 2008. Surgery was performed early, and simple resection of this very rare malformative bundle (usually affecting very young people) was required.

In the daily clinical practice of surgeons operating electively or, more frequently, in the emergency setting, within the abdominal cavity and pelvis, the detection of an intestinal adhesive disorder is frequent and is capable of causing numerous complications and subsequent reintervention. We report three cases of female patients referred to our observation for bowel subocclusion due to adhesive syndrome. After laparotomy, which revealed the presence of singular tenacious fibrovascular adhesions, the patients were subjected to immunohistochemical and receptor analysis yielding a diagnosis of leiomyomatosis peritonealis disseminata. The simultaneous combination of high levels of exogenous female hormones (hormone replacement therapy or prolonged exposure to oral contraceptives) or endogenous hormones (as happens during pregnancy), a genetic predisposition (including genetic malformations) and previous surgery (peritoneal trauma), as evidenced in our patients, all seem to play a key role in the pathogenesis of so-called "dense-vascularised", particularly tenacious adhesions responsible for the activation of multipotent mesenchymal submesothelial peritoneal cells. This striking macroscopic picture, when related to the anatomico-pathological description, is the basis of the pathological entity known as leiomyomatosis peritonealis disseminata.

The aim of the study was to elucidate the problem of visual disorders after heart surgery, focusing on aetiology, modes of prevention and treatment. Information from a literature search and the authors' personal experience are provide clues as to the modes of development and the means of avoidance and therapy of this category of postoperative, neurosensory complications. Multiple morbid situations, such as preoperative augmented ocular pressure, perioperative bleeding and hypotension, are shown to be predisposing and precipitating factors. Medical treatment seems to be less important than minimisation of risk factors. Prevention rather than treatment is more helpful for heart-operated patients, as far as postoperative visual disorders are concerned.

Internal hernias are a rare form of dislocation of the abdominal viscera, usually in the small intestine, in the peritoneal sacs or cavities, resulting from the defective coalescence of the peritoneal flaps due to abnormal rotation of the medium intestine in the second stage of embryogenesis. In this paper the authors describe three cases observed during the last twelve months: two cases were ascribable to left paraduodenal hernia and one to a transepiploic hernia. Special attention needs to be paid to knowledge of the rotation process of the primitive medium intestine and to understanding whether an internal hernia underlies the clinical picture, when occlusive patients have not previously undergone surgery and show no signs of external hernias. In the surgical treatment of paraduodenal hernias, special attention must be paid to incarcerated loops, in order to prevent severe vascular complications caused by potential lesions to the mesenteric vessels.

Reducing the number of ports used to perform laparoscopic cholecystectomy (LC) is indicated as means of further minimising postoperative pain, allowing a rapid return to activity and work, and obtaining patient satisfaction and better cosmetic results. It is still debatable whether the three-port technique is comparably safe. Since 2001, 374 consecutive patients underwent laparoscopic cholecystectomy in elective and emergency surgery. Three ports were routinely positioned and the need for a fourth cannula was evaluated during the surgical procedure. Of the 374 consecutive cholecystectomies performed, 204 were completed with three ports and 161 needed a fourth port to be completed, while 9 required conversion to laparotomy. Patients who were operated on with just three ports were significantly younger and mostly female. Complications of procedures completed with three ports were negligible and those of procedures completed with four ports were in line with the recent literature. Our experience shows that the three-port technique is always a good initial option when performing laparoscopic cholecystectomy. It is safe and requires conversion to four-port placement in only a minority of cases overall.

Videoassisted surgery has recently led to a new era, aimed mainly at minimising surgical trauma and improving the cosmetic result. Natural Transluminal Endoscopic Surgery (NOTES) and Single Incision Laparoscopic Surgery (SILS) are emerging as effective techniques whose advantages and possible applications have been widely explored in the most recent literature. Twenty-two consecutive patients, mean age 51.5 years (range: 24-86 years), were subjected to a laparoscopic cholecystectomy through a single, trans-umbilical, incision (SILS). We utilised standard laparoscopic instruments, placing one 10 mm trocar for the camera and two 5 mm trocars for the operative instruments. Mean operative time was 69 min (range: 40 - 120 min). There were no major complications during surgery, and the postoperative recovery was uneventful. All patients referred complete satisfaction with the surgical and cosmetic result obtained 1 and 3 weeks postoperatively.