INTRODUCTION:The objective of this study was to evaluate the feasibility of outpatient breast definitive surgery.CASE AND METHODS:Between January 2001 and September 2003 181 definitive breast cancer surgical approaches were performed at Surgical Department of Genoa University on 173 patients. Mean age was 60 years (28-92). All the patients were discharged the day of surgery or the day after in the morning.RESULTS:There were no major complications or deaths. The specific complication rate was similar to inpatient setting and there was no readmission. The patients' quality of life and satisfaction were satisfactory or good.DISCUSSION:In conclusion, holding in due consideration some philosophical and technical changes, breast cancer surgery can be safely and comfortably performed on an outpatient basis.

The aim of this study was to analyse radiological findings in patients surgically treated for adjustable silicone gastric banding (ASGB) for morbid obesity complicated by band penetration into the gastric lumen. We reviewed the records of four patients with surgically confirmed penetration of gastric band into the gastric lumen; three had preoperative opaque meal, one only a plain abdominal film. Vomiting was the presenting symptom in two cases, whereas others had new weight gain and loss of early satiety. Two patients had normally closed bands: radiography showed that their position had changed from previous controls and the barium meal had passed out of their lumen. Two patients had an open band. One patient had the band at the duodeno-jejunal junction, and the tube connecting the band to the subcutaneous port presented a winding course suggesting the duodenum. In the other case, both plain film and barium studies failed to demonstrate with certainty the intragastric position of the band. As ASGB is becoming widely used, radiologists need to be familiar with its appearances and its complications. Band penetration into the stomach is a serious complication which needs band removal. Patients with this problem, often with non-specific symptoms and even those who are asymptomatic, are encountered during radiographic examinations requested either for gastric problems or follow-up purposes, and have to be properly diagnosed.

OBJECTIVE To describe a 7-year experience with recurrent inguinal hernia repair performed mainly with tension-free mesh or plug technique under local anesthesia through the anterior approach, and to evaluate the safety and effectiveness of this method of treatment. METHODS One hundred forty-five elective and 1 emergency herniorrhaphies for recurrent groin hernia were performed in 141 subjects (134 men and 7 women) with a mean age of 65 years (range 30-89). Concomitant medical and surgical problems were present in 73% and 8% of subjects, respectively. In 28 instances, the relapsed hernia had already been operated on once or twice for recurrence. A traditional hernioplasty had been previously performed in the vast majority of cases (136). Tension-free mesh or plug techniques through an anterior approach under local anesthesia were performed in 144 reoperations. Preperitoneal mesh repair and general or spinal anesthesia were used in all but one case when herniorrhaphy was performed during simultaneous operations. RESULTS Mean hospital stay after surgery was 1.5 days (range 3 hours-14 days). No perioperative deaths occurred in this series. General complications were one case of acute intestinal bleeding and two cases of urinary retention. Local complications consisted of eight (5.5%) minor complications and one case of orchitis (0.7%) followed by testicular atrophy. In no instance was postoperative neuralgia or chronic pain reported. Two re-recurrences occurred. CONCLUSIONS Given the low complication rate in this and other reported series and the absence of surgical or general complications described after preperitoneal open or laparoscopic repair and after general and spinal anesthesia, anterior mesh repair under local anesthesia seems to be a low-cost surgical technique that can be safely and effectively used even in a teaching hospital for the treatment of the majority of patients with recurrent groin hernias.

BACKGROUND:This study evaluates a 5-year experience of the management of the most frequent abdominal wall hernias in an elderly population.METHODS:From April 1990 to December 1995, 231 inguinal, 12 femoral and seven umbilical hernias were repaired in 221 patients (mean age 74 (range 66-93) years). Concomitant diseases were present in 157 patients. A mesh repair was performed with 'tension-free' or 'plug' techniques in all but 23 inguinal and two femoral hernia repairs, in which the Bassini or Shouldice procedures were adopted. Ten emergency hernia repairs were performed for strangulation. A total of 232 operations, including four emergency hernia repairs, were carried out under local anaesthesia.RESULTS:There was no perioperative mortality. Acute intestinal bleeding occurred 2 days after surgery in a patient with colonic diverticular disease. Urinary retention occurred once following emergency hernia repair under general anaesthesia and twice after elective hernia repair under local anaesthesia. Local complications included four scrotal haematomas (2 per cent), three wound infections (1 per cent) and one case of orchitis with atrophy after repair of a recurrent hernia. There was one recurrence after a Bassini repair and one after Shouldice inguinal herniorrhaphy. No recurrence was observed after mesh repair.CONCLUSION:Local anaesthetic mesh hernia repair is safe and effective in elderly patients. Age should be no bar to elective hernia repair. This policy should avoid the complications of emergency operation.

From April 1990 to November 1996, 313 inguinal and 14 femoral hernias were repaired in 295 subjects with a mean age of 74 years (66 to 97). Concomitant diseases increasing the operative risk were present in 206 subjects (70 per cent). A mesh repair was performed with "tension-free" or "plug" techniques in all but 23 inguinal and 2 femoral herniorrhaphies where the Bassini or the Shouldice procedures were adopted. Fifty-two inguinal hernias were recurrent, 11 emergency herniorrhaphies were performed for strangulation. Almost all operations (305), including 9 emergency herniorrhaphies, were carried out under local anaesthesia. There was no perioperative mortality. Acute intestinal bleeding occurred after surgery in a subject with colon diverticulosis. One urinary retention following emergency hernia repair under general anaesthesia and 2 following elective hernia repair under local anaesthesia in 2 subjects with hypertrophy of the prostate were observed. Some episodes of hypotension and/or bradycardia were observed either during or after surgery. Local complications following inguinal hernioplasty were 5 (1.5%) scrotal hematomas, 3 (0.9%) wound infections and 1 case (0.4%) of orchitis with atrophy after repair of a recurrent hernia. There were 1 recurrence after Bassini, 1 after Shouldice, and 1 (0.4%) after mesh inguinal hernioplasty. Using local anaesthesia and a mesh repair elective surgery of inguinal and femoral hernias can be safely and effectively performed in elderly patients. Consequently, early elective surgery should be recommended to avoid the risk of an emergency operation.

Between January, 1991 and December, 1993, 208 subjects with monolateral and 19 with bilateral inguinal hernia were submitted to herniorrhaphy. Thirty-four were recurrent hernias. All but one bilateral hernias were treated at the same time. Eight cases were operated in emergency condition for acute strangulated hernia. Two-hundred and ten operations were performed under local, 17 under general and 1 under spinal anesthesia. Herniorrhaphy was performed in 14 cases with the Bassini and in 38 with the Shouldice technique. In 191 instances the "tension-free" and in 3 the "plug" techniques were adopted utilizing a polypropylene mesh. Following local anesthesia 13 episodes of bradycardia with hypotension were recorded during the operation and 4 in the early postop period. There were no general complications. Two elderly patients developed urinary retention following general anesthesia. Local complications included 6 (2.4%) cases of infection and 4 (1.6%) cases of hematoma of the wound, and 5 (2.0%) cases of edema with infiltration of the cord. Percentage of follow-up at 1, 2 and 3 years was 96, 95, and 93 percent respectively. Five recurrences were recorded: in 1 case following Bassini repair (7.6%), in 2 following Shouldice (5.6%), and in 2 following tension-free (1.5%). Local anesthesia has been confirmed to be well accepted by the patients, effective an safe, especially in the elderly patients with high operative risk. Similarly, the tension-free hernioplasty has been confirmed as a simple, easily reproducible technique, followed by less pain and disability as compared with other types of herniorrhaphies, and more effective mainly in the treatment of recurrent hernia.

Pancreaticobiliary diversion is a surgical procedure undertaken for obesity. It consists of a distal gastrectomy with a long Roux-en-Y reconstruction, the enteroenterostomy being placed 200 cm distal to the gastroenterostomy and 50 cm proximal to the ileocaecal valve. Three intestinal limbs are recognized: (a) the alimentary loop from the gastroenterostomy to the enteroenterostomy; (b) common loop from the enteroenterostomy to the ileocaecal valve and (c) pancreaticobiliary loop from the duodenum to the enteroenterostomy. The radiological findings in 15 pancreaticobiliary diversion patients with small bowel obstruction were reviewed (15 plain abdominal radiographs, 13 ultrasound (US), 8 CT) and compared with 20 plain abdominal radiographs, 10 US, and 10 CT studies performed for other causes in patients with pancreaticobiliary diversion and 15 CT scans from non-operated patients. After pancreaticobiliary diversion the pancreaticobiliary loop was completely air-free. In the patients operated on more than 1 year previously, alimentary and common loops were significantly larger than the pancreaticobiliary loop and small bowel loops of non-operated subjects. Obstruction of the pancreaticobiliary loop arrests only the flow of pancreaticobiliary Secretions with non-specific clinical findings. Plain abdominal radiographs were not diagnostic in all but two cases with radiographically detectable dilated fluid filled loops. Air-fluid levels were never apparent. US and CT showed markedly dilatated intestinal loops and duodenum. Obstruction of the alimentary and common loops presented with symptoms, clinical signs, and radiological findings more typical for bowel obstruction in intact subjects.

Background. Surgical attempts to treat obesity began because of the discouraging results of conservative medical treatment, which successfully achieved initial weight loss but failed to maintain it. Gastric restrictive procedures, currently the most popular surgical methods for obesity therapy, have proved to be effective in initiating weight loss, but some concerns regarding their? long-term efficacy in weight maintenance have arisen.Methods. Of a total of 1968 obese patients who underwent biliopancreatic diversion since 1976, the Last consecutive 1217 underwent the ''ad hoc stomach'' type of diversion with a 200 cm alimentary limb, a 50 cm common limb and a gastric volume varying between 200 and 500 mi. Mean age was 37 years old (11 to 69 years), and mean excess weight was 117%. Maximum follow-up was 115 months with nearly 100% participation.Results. In the last half of the series, operative mortality was 0.4% with no general complications and with early surgical complications of wound dehiscence and infection (total, 1.2%) and late complications of incisional hernia (8.7%) and intestinal obstruction (1.2%). Mean percent loss of initial excess weight (IEW) at 2, 4, 6, and 8 years was 78 +/- 16, 75 +/- 16, 78 +/- 18, and 77 +/- 16 in the patients with IEW up to 120% and 74 +/- 12, 73 +/- 13, 73 +/- 12, and 72 +/- 10 in those with IEW more than 120%. A group of 40 patients who underwent the original ''half-half'' biliopancreatic diversion maintained a mean 70% reduction of IEW during a 15-year follow-up, period. Specific late complications included anemia (less than 5%), stomal ulcer (2.8%), protein malnutrition (7% with 1.7% requiring surgical revision by common limb elongation or by restoration). Clinical problems from bone demineralization were minimal in the short term and almost absent in the long term.Conclusions. Biliopancreatic diversion is a very effective procedure but is potentially dangerous if used incorrectly.

Wernicke-Korsakoff disease with sensory-motor neuropathy was diagnosed in three out of a series of 1663 patients (0.18%), with onset 2, 3 and 5 months after biliopancreatic diversion. Precipitating factors were vomiting, minimal food intake, anorexia, rapid weight loss, and glucose-containing intravenous feeding. Recovery was partial in two and complete in one of the patients. In the early postop, prophylactic thiamine should be given to the patients with excessively limited eating capacity. Larger doses of thiamine should be instituted parenterally either in the case of suspected Wernicke-Korsakoff encephalopathy or before starting feeding for protein malnutrition.

Small bowel obstruction occurred in nine of 880 patients undergoing biliopancreatic diversion. This complication has different features depending on the site of the obstruction. Obstruction of the alimentary limb is mainly characterized by vomiting, is easy to diagnose, and is not catastrophic. When the common limb is affected, the pattern is similar to that of a low small bowel obstruction in an intact intestine. The most dangerous event is obstruction of the biliopancreatic limb because symptoms are unclear and often misleading, and standard radiology is useless. The possibility of the ensuing diagnosis being wrong or delayed can contribute to potentially lethal complications, namely perforation and acute pancreatitis. Serum amylase level determination and an abdominal ultrasound scan are essential for prompt diagnosis.

Following gastric surgery for obesity, a satisfactory weight loss and, above all, long-term weight maintenance can only be achieved in patients who have succeeded in radically changing their preoperative eating habits. In this preliminary study gastric banding is associated with rehabilitative training which was carried out using similar methods to the programs used for eating disorders. One year after surgery the results were substantially the same as those reported in the literature, with an overall weight loss of approximately 50%. The lack of correlation between weight loss and the degree of gastric banding underlines, even after a short interval, the efficacy and importance of postoperative re-educational training. The utility of this integrated approach will only be more fully evaluated after a longer period.

The body composition of lean control subjects was compared with that of subjects following biliopancreatic diversion for morbid obesity, when their excess weight had been stabilized at under 40 per cent of the ideal body weight value for over two years. Lean body mass, body cell mass and fat were indirectly calculated from total body water and total body sodium, measured by isotope dilution technique. The body composition in the two groups of subjects was essentially normal, as was indicated by the percentage values of the body composition parameters and by the linear correlations between body weight and the lean body compartments size.