Foot soft tissue myopericytoma: Case-report and review.

INTRODUCTION: Myopericytoma is a rare tumor of deep soft tissues, originating from pericytes and characterized by numerous thin walled blood vessels. CASE REPORT: We report a case of myopericytoma found at the level of the second toe of the right foot.A patient came to the Endocrinology Surgery Department of Catania Polyclinic because of a presence of a small swelling in the plantar region, between the 2nd and 3rd toe of the right foot. At the anatomopathological examination, the escalated lesion showed a neoformation of 0.6 cm in diameter, well circumscribed, capsulated, with myopericytoma diagnosis. DISCUSSION: Its histopathological appearance is similar to myofibromatic lesions from glomic and angiomyoma tumors. It is a rare tumor that affects all ages with a peak after 50 years 3. The most frequent localization is at the lower extremities, particularly in soft subcutaneous tissues, but can rarely occur in other sites. CONCLUSION: At the anatomopathological evaluation, the immunohistochemical examination for the correct formulation of the diagnosis is essential and an adequate surgical excision is important.

[Benign tumors and pseudotumors of temporo-mandibular joint: radiologic aspects]. / Tumori benigni e pseudotumori dell'articolazione temporo-mandibolare: aspetti radiologici.

Benign tumors and tumor-like lesions that involve temporo mandibular joint are very rare. Those more frequent are osteochondroma, chondroma, osteoma, pigmented villonodular synovitis and synovial chondromatosis. The Authors report six cases of patients affected by these pathologies in which imaging, such as TC, MRI and/or ortopantomography have been useful to have a diagnosis.

[Surgical treatment of abdominal trauma in pediatric age]. / Traumi chirurgici addominali in età pediatrica.

AIM OF THE STUDY: to value the appropriateness and the efficacy of non-operative treatment in children with blunt abdominal trauma. PATIENTS AND METHODS: in this research 14 children with abdominal trauma, secondary mostly to road accidents, were studied; 9 of these had single organ injury while 5 had multiple organ injuries. Spleen has been the most injured organ (9 children), followed by liver (5 cases) and kidney (2 cases). Five children were admitted at emergency department in hypovolemic conditions, promptly corrected by resuscitative measures. All patients underwent abdominal ultrasound and/or C.T. scans in order to detect any intraperitoneal free fluid or organic injuries. Six children (43%) were followed by non-operative treatment, while other eight underwent surgery. RESULTS: all children, those treated conservatively as well as those operated, were cured, without any important complication. DISCUSSION AND CONCLUSIONS: nowadays, with the great help of ultrasound and C.T. scans, is possible to treat 40-50% of children affected by abdominal trauma with non-operative measures, with return to normal functions by the injured organs. The surgical approach is today accomplished only in presence of severe injuries or haemodynamic instability resistant to resuscitative treatment. The majority of Authors in the literature agree on the usefulness of non-operative treatment, especially for children. Regarding surgical treatment, in the near future probably we'll see a larger application of laparoscopic techniques also in the field of abdominal traumatology.

Cystadenoma and laparoscopic surgery for hepatic cystic disease: a need for laparotomy?

BACKGROUND: This study aimed to evaluate the incidence of cystadenoma diagnosis in a series of laparoscopic treatments for nonparasitic liver cysts, as well as its management. METHODS: From 1996 to 2004, 26 patients with a nonparasitic cyst of the liver were selected for laparoscopic liver surgery. Solitary nonparasitic liver cysts were, whenever feasible, completely enucleated. RESULTS: In four patients, the histopathologic examination showed a cystadenoma. Three patients with 13, 9, and 12-cm cysts, respectively, had undergone complete enucleation of the lesion, with no evidence of recurrence in the follow-up visit. One patient with multicystic liver experienced a recurrence and required an open hepatic resection. CONCLUSIONS: When a complete laparoscopic enucleation of the cyst can be ensured, a strict follow-up assessment should be considered as the definitive treatment, with surgical intervention demanded only in the case of recurrence or high suspicion for malignancy.

[Magnetic resonance and traditional radiology in the spine localizations of alkaptonuric ochronotic arthropathy]. / Risonanza magnetica e radiologia tradizionale nelle localizzazioni vertebrali dell'artropatia ocronotica alcaptonurica.

AIM: To study the spine alterations in alcaptonuria with traditional radiology and magnetic resonance (MR), comparing the results of the two techniques. PATIENTS AND METHODS: Five patients (4 males, 1 female, mean age 51 years) underwent the examinations. For the study with X-rays we performed anteroposterior and lateral scan and the images have been studied making reference to a radiographic score; it examines the alterations of the joint space and the presence of calcifications. MR scan, oriented in the three spatial planes, were performed using spin echo T1-weighted and spin echo T2-weighted sequences. RESULTS: Both MR and X-rays pointed out, in the cases with known diagnosis, the typical alterations of the ochronosis: narrowing of the articular spaces, even osseous ankylosis, calcifications of the discs, osteophytosis, multiple disc protrusions and reactive sclerosis of the articular surfaces, evident above all to dorso-lumbar tract; nevertheless MR has been more accurate than X-rays for individualizing the lesions and recognizing alterations, such as the thickness of the anterior longitudinal ligament. In the case of new diagnosis, the MR is fundamental to recognize typical signs of the ochronotic arthropathy not well detected by X-rays. CONCLUSIONS: Imaging techniques, first of all the MR, are essential in the differential diagnosis of ochronosis vertebral lesions with other articular diseases.

[Valuation on prognostic factors about secondary acute peritonitis: review of 255 cases]. / Considerazioni sui fattori prognostici della peritonite acuta secondaria su di una revisione di 255 casi.

Despite advances in diagnosis, surgical treatment, antimicrobial therapy and intensive care support, severe secondary peritonitis remains a potentially fatal affliction. The purpose of this study is to present our experience of postoperative mortality in 255 patients with secondary acute peritonitis between 1998 to 2002. The Mannhein Peritonitis Index score (MPI) was calculated for each patient to predict the peritonitis related in-hospital death. Both literature reviews and our results show a strong correlation between some etiopathogenetic elements (age, origin of sepsis, organ failure, ...) and prognosis. Our patients were classified in three groups according to MPI, one with a score less than 21, another with a score between 21 and 29 and the third one with a score greater than 29. There was no mortality in the first group and there was significantly less mortality in the second group than the third one (P<0.001). While prognosis is influenced by many factors, the intervention time was the same, greater than 24 hours, for all the patients regardless of MPI score. This study suggests that intervention time may be considered the main determinant of mortality in patients with peritonitis. This observation is especially relevant since intervention time is a modifiable prognostic factor whilst many other factors are not.

[Hemorrhagic adrenal pseudocyst: case report]. / Pseudocisti emorragica del surrene: caso clinico.

INTRODUCTION: Adrenal cysts are usually asymptomatic; they are usually identified occasionally during ultrasound or C.T. scans (incidentaloma). Among adrenal cysts the most common types are epithelial cysts and pseudocysts. Intracystic haemorrhage is one of the possible complications of adrenal pseudocysts. CASE REPORT: We report a case of a young woman with right superior abdominal pain, fever and acute anemia. A C.T. scan showed a 10 cm. mass between the liver and the right kidney. To be sure of the nature of this mass also M.R., urography and C.T.-guided biopsy were carried out. This latter only let us make the final diagnosis of hemorrhagic adrenal pseudocyst. Thereafter, a laparotomic right adrenalectomy was performed, with full recovery of the patient. DISCUSSION: Adrenal cysts may cause differential diagnostic problems with masses of contiguous organs like kidney, liver and gallbladder. For this reason, ultrasound and C.T. scans may not be sufficient and must be completed by M.R., urography and/or C.T.-guided biopsy. Intracystic hamorrhage, spontaneous or post-traumatic, may cause to the patient acute anemia which, as soon as the diagnosis is confirmed, indicates surgery. The operation usually is a laparotomic adrenalectomy, since the laparoscopic approach is not sufficient to control large masses with active bleeding inside.

[Metachronous carcinoma of the colon: report of a clinical case]. / Carcinoma 'meta-metacrono' del colon: descrizione di un caso clinico.

The Authors deal with a rare case of 'meta-metachronous' carcinoma of the colon. A seventy years old man was admitted to ward after being diagnosed an adenocarcinoma of the transverse colon. The anamnestic data pointed out that the patient had already been operated twice for the colon carcinoma, which had been diagnosed in the left colon and in the cecum respectively seven and two years before. A colonoscopy performed sixteen months before did not show any lesion of the residual colon. It is likely that tiny lesions, which were still in the adenoma phase, were not diagnosed by the endoscopy; it is also possible that the adenoma-carcinoma sequence was extremely fast. On the basis of this experience the Authors recommend that patients with metachronus carcinoma undergo either frequent controls or a preventive subtotal colectomy.

Severe gastrointestinal bleeding in Crohn's disease.

INTRODUCTION: Acute gastrointestinal bleeding is rare in Crohn's disease. METHODS: We characterized the clinical features and course of such hemorrhage in patients seen at our institution from 1992 to 2000. RESULTS: Five patients had gastrointestinal bleeding during Crohn's disease. All patients had a known Crohn's disease, with a mean duration of the disease of 6 years. The source of bleeding was identified in four patients (80%). Endoscopy was, in all patients, the first diagnostic procedure. An Hartmann total colectomy with closure of the rectal stump and ileostomy was performed in three patients, while two patients with ileal massive bleeding were treated conservatively. One patient had a recurrence of bleeding from the small bowel one week later but he didn't required surgical treatment. One patient with pancolic Crohn's disease died on 10th postoperative day because of multiorgan failure and septic complications. CONCLUSIONS: Gastrointestinal bleeding is rare in Crohn's disease, with a predilection for site of involvement. The preoperative diagnosis of the site of bleeding is not easy, and enteroscopy should be mandatory in such patients. Surgery is required for half of cases and recurrent haemorrhage should be an appropriate indication for surgery.

[Pancreatic pseudocysts. Clinical contribution]. / Le pseudocisti del pancreas. Contributo clinico.

Aim of this study was to compare, taking into consideration data from the literature, the various diagnostic examinations and therapeutic modalities nowadays available to manage patients affected by pancreatic pseudocysts. Personal experience regarding three patients with post-necrotic pancreatic pseudocysts is reported; these patients complained of epigastric pain with nausea and tenderness in the upper abdominal quadrants. Diagnosis was made by CT. In one case a progressive decrease of the pseudocyst was observed; the second patient was treated by a pseudocyst-jejunostomy; the last patient initially underwent a trans-gastric percutaneous drainage for infection of the pseudocyst and afterwards an open pseudocyst-gastrostomy. All patients were cured, even if the second patient during the postoperative course developed a pleuric effusion, which was treated by thoracentesis. Pancreatic pseudocysts in 20% of cases resolve spontaneously, as observed in one of our patients. In other cases, a surgical operation is needed, now feasible through an endoscopic, percutaneous, laparotomic or laparoscopic approach. The endoscopic and percutaneous approach are indicated only in selected cases, so that the "gold standard" treatment is still the laparotomic one, especially by a pseudocyst-jejunostomy, which also in our experience has given the best result. Very promising also, according to the latest data from the literature, seems the laparoscopic approach, by which a wide communication between the stomach and the pseudocyst is obtained.

Blunt liver injury: from non-operative management to liver transplantation.

Therapeutic options for blunt hepatic trauma include both non-operative and operative management. We have reviewed our experience of the management of blunt hepatic trauma, from non-operative to liver transplantation. A total of 72 patients with blunt hepatic injury observed at the first surgical unit of Padua in a 3-year period (1998-2000) were analysed; we also included a patient who had a liver transplant in 1993 for severe liver trauma. Twenty-nine patients (39.7%) were treated conservatively, with a 93% success rate; 60.3% were treated surgically. Suture hepatorraphy was the most common procedure performed (52.3%). Advantages of non-operative management in our experience were the reduced need for transfusion (1.1U versus 4.3U) with 92% of patients not needing transfusion, and a reduced stay in the intensive care unit; there was no liver-related mortality. The overall morbidity in surgical patients was 30%, with 16% liver-related complications. Twelve surgical patients (27.2%) died, with a liver-related mortality of 18.2%. A large number of patients may present with an associated endo-abdominal injury, even in low-grade liver trauma, requiring rapid laparotomy. In high-grade hepatic trauma, the evolution toward liver failure is an indication for liver transplantation.

[Blunt trauma of hepatic ducts: a difficult diagnostic-therapeutic approach]. / I traumi chiusi dei dotti epatici: un difficile inquadramento diagnostico-terapeutico.

Traumatic injuries of left and right hepatic ducts are rare, with about 40 cases reported in literature. Preoperative diagnosis is difficult, so that up to 40% of lesions may be undetected at laparotomy. Prompt diagnosis could preserve by high morbidity rate of such injuries. The extremely widespread and routine use of ERCP as well as intraoperative cholangiography may allow reducing dramatically the diagnostic time lag and the percentage of lesions formerly undetected by laparotomy. Therapeutic options are extremely variable. On the basis of the experiences reported for the treatment of iatrogenic lesions of the biliary tract, reconstruction by jejunal Roux-en-Y loop biliodigestive anastomosis is preferred, whenever lacerations of an hepatic duct appear to be complete or nearly so, on account of the high incidence of stenosis and late complications, detected in case of termino-terminal direct biliary anastomosis. However, in selected cases, when the transection appear neat and simple, an end-to-end anastomosis could be performed with low risk. Mortality after blunt biliary duct injury represents nowadays a rare event at least in patients presenting without severe associated traumatic lesions, so that the clinical attention has been progressively focused on the relatively high rate of postoperative complications. These adverse events are often extremely demanding in terms of prolongation of hospital stay, need for multiple invasive procedures and overall costs of patient's management.

[Recent concepts regarding the treatment of traumatic hemopneumothorax]. / Recenti acquisuzioni sul trattamento dell'emopneumotorace traumatico.

BACKGROUND: The aim of the study was to examine the different therapeutic options for traumatic hemopneumothorax and in particular the latest concepts (videothoracoscopy). METHODS: A retrospective study was performed on a group of 20 patients with post-traumatic hemothorax and/or pneumothorax attending the emergency department at Ospedale Vittorio Emanuele in Catania over the past 10 years where 2500 patients with abdominal and/or thoracic trauma were treated during the same period. The patients included 18 males and 2 females with a mean age of 35 years (range 13-70). The cause of injury was a gunshot wound in 8 patients, a blunt trauma following a road accident in 9 and a stab wound in 3 patients. A drainage tube was inserted in 15 patients (a videothoracoscopic approach was used in 2 cases); 3 patients required a diaphragmatic suture and 2 thoracotomy (inferior lobectomy and repair of the main left bronchus). RESULTS: Three out of 20 patients died with an overall mortality rate of 15%. Two patients died respectively from severe brain and abdominal injuries associated with thoracic trauma, while the third patient died from septic complications. CONCLUSIONS: In the past few years videothoracoscopy has allowed a different approach to be used in patients affected by hemo-pneumothorax since it allows a more accurate diagnosis (extent and origin of bleeding, identification of associated diaphragmatic lesion) and the possibility of treating pleuro-pulmonary injuries without performing extensive thoracotomies.

Malignant schwannoma of the rectum: a clinical and pathological contribution.

Schwannomas of the rectum are uncommon and incompletely characterized tumours, and only a limited number of cases have been reported. On the basis of a case of rectal schwannoma and a review of the literature on this rare condition, we stress the importance of the clinical features, diagnostic difficulties and surgical indications for the various therapeutic approaches. The basis for radical operation, due to the tendency of such tumours to recur locally and the real possibility of malignant degeneration, is discussed. We also emphasize the difficulty of making a benign diagnosis with histological certainty.

[The use of Dacron prostheses in laparoceles]. / L'impiego di protesi in Dacron nei laparoceli.

BACKGROUND: Purpose of the study was to evaluate indications and efficacy of Dacron prostheses in the treatment of incisional hernias. METHODS: The study has been carried out in a retrospective way; mean follow-up has been 20 months. Surgical setting has been the Institute of Emergency Surgery at the University of Catania, where about 500 abdominal operations are performed every year. Thirty patients affected by incisional hernias have been considered (mean age 66.8 years). In 12 patients the Mayo technique was performed, whereas a Dacron prosthesis was placed in 18 patients. Other than early postoperative complications, patients have been followed by periodical clinical exams in order to find out possible recurrences as well as other late complications. RESULTS: Among 18 patients treated with insertion of Dacron prosthesis no infection, recurrence, bowel fistula, haematoma or dislocation have been observed. Only in one case an intestinal occlusion secondary to adhesions between prosthesis and bowel has occurred; in this patient a new operation has been necessary to remove the prosthesis. CONCLUSIONS: Considering that prostheses have been used in large incisional hernias or in patients with a weak abdominal wall, the high successful percentage (94%) obtained suggests the use of Dacron prostheses which guarantee long stability and minimum risk of recurrences.

[An update in the diagnosis and treatment of tumors of the hepatic portal]. / Attualità nella diagnosi e nel trattamento dei tumori della placca ilare.

BACKGROUND: Cholangiocarcinoma affecting the cross of the bile ducts is a tumour which has, although treatments, a high rate of mortality. METHODS: Between January 1986 and January 1996 six patients affected by Klatskin's tumor were studied; three of them underwent operation and were treated with insertion of a T tube (Kerr), whereas the other three were managed endoscopically with trans-tumoral stenting. RESULTS: The survival rate was about seven months for patients who underwent operation and fifteen months for patients managed with endoscopic stenting. CONCLUSIONS: After a review of the literature and according to personal experience, it is underlined that only an early diagnosis can achieve best results, since the latest knowledge about hepatic anatomy derived from transplants allows more extensive resections.

[Treatment of stage IV breast carcinoma]. / Il trattamento del carcinoma della mammella al IV stadio.

The authors report a study carried out in 4 patients with stage 4 breast cancer. The treatment protocol was selected according to age and the general conditions of patients. Two out of four patients were treated with adjuvant chemotherapy associated with cyclophosphamide, adriblastin, 5-fluorouracil and folic acid; one patient received neoadjuvant chemotherapy with the same treatment protocol, while the fourth patient was treated with hormone and immunotherapy. Results were satisfying given that survival was considerably increased in 3 patients together with an improvement in general conditions.

[The diabetic foot]. / Il piede diabetico.

The rise in the mean age and the increase in diabetes have frawn the surgeon's attention to gangrene of the lower limb which requires a multidisciplinary approach (doctor, surgeon, prosthesis specialist). Contrary to the concept of high thigh amputation, the possibility of carrying out a lumbar sympathectomy has encouraged the idea of a more distal amputation with conservation of physiological joints and an early recovery of function thus enabling patients who would otherwise have been condemned to permanent invalidity to return to social life.

[Acute thyroiditis]. / La tiroidite acuta.

Acute suppurating thyroiditis is now an uncommon pathology which is rarely found, although it was frequent before the introduction of antibiotics. Having observed a case, the Authors were prompted to study the subject in greater depth, in particular to assess whether the disease is easier to diagnose using modern techniques diagnosis, and whether there are changes in the therapy. In conclusion, the paper affirms that in spite of the fact that the diagnostic evolution has thrown further light on the clinical aspects of the disease, biopsy still remains the most reliable instrument of diagnosis, whereas surgery is the most effective form of therapy.