Long-term results of abdominal salvage surgery following restorative proctocolectomy.

BACKGROUND: This study evaluated outcomes of patients who underwent abdominal salvage ileal pouch redo surgery and identified factors associated with pouch failure following restorative proctocolectomy. METHODS: Data on patients who underwent abdominal salvage surgery in a tertiary referral centre between 1985 and 2003 were collected. Outcomes studied included failure of salvage and bowel function of patients with an intact intestine. RESULTS: One hundred and twelve patients underwent 117 pouch salvage procedures for ulcerative colitis (86), indeterminate colitis/ulcerative colitis (eight), indeterminate colitis/Crohn's disease (three), familial adenomatous polyposis (ten) and other conditions (five). The most common indications for pouch salvage were intra-abdominal sepsis (45 patients), anastomotic stricture (13) and retained rectal stump (35). Median follow-up was 46 (range 1-147) months. Twenty-four patients (21.4 per cent) experienced pouch failure, the incidence of which increased with time. The pouch failed in all patients with Crohn's disease. Successful salvage at 5 years was significantly associated with non-septic (85 per cent) rather than septic (61 per cent) indications (P = 0.016). Frequency of night-time defaecation and faecal urgency improved after salvage surgery (P = 0.036 and P = 0.016 respectively at 5-year follow-up; n = 32). CONCLUSION: Abdominal salvage surgery was associated with a failure rate of 21.4 per cent. A successful outcome was less likely when the procedure was carried out for septic compared with non-septic indications. The rate of pouch failure increased with length of follow-up.

Case report: laparoscopic cholecystectomy in situs viscerum inversus.

Situs viscerum inversus is a rare condition, in which the organs are transposed from their normal location in the opposite side of the body. The inversion of L-R asymmetry may be complete (SVI totalis) or partial (SVI partialis), whereby transposition is confined to either the abdominal or thoracic viscera. The authors report a case of videolaparocholecystectomy for cholelithiasis successfully performed on a 41-year-old Caucasian woman with situs viscerum inversus totalis. The patient was discharged on the 2nd postoperative day. The symptomatology disappeared right after the intervention, and still now, after a follow-up of six months, is absent. The procedure was safely performed on the patient with no particular difficulties, except for the reverse position of the angle between the operating and exposing trocars, which led to a difficult approach to the Calot triangle when using the right hand of the surgeon.

[Clinical study on the pharmacological treatment of hemorrhoids with 0.25% oxethacaine chlorhydrate]. / Nota clinica sul trattamento farmacologico della malattia emorroidaria con "Oxetacaina Cloridrato" allo 0.25%.

In this clinical study, the authors refer to a thirty-six month treatment of Grades I and II haemorrhoids (pharmacological treatment) with a group of 75 patients (45 females and 30 males) and treatment for Grades III and IV haemorrhoids (Pharmacological and surgical treatment) on a second group of 23 patients for a total of 98 patients treated and observed. For the pharmacological treatment, a rectal cream containing 0.25% Oxethacaine chlorhydrate (Emoren, produced by Novasorel, srl) was used on all patients. The cream was applied intra-anally and on the external orifice twice a day, morning and evening, for ten days. In order to evaluate the therapeuctic effect, the following symptoms were monitored: pruritus, ematochezia, burning, tenesmus, and pain. The following results were demonstrated: a) in all patients: A reduction in pruritus, pain, blood and mucous loss, Elimination of tenesmus, Absence of peri-anal eczema, b) in 15 patients, haemorrhoids were reduced for 11 months. Therefore the results obtained reconfirm that local treatment with EMOREN demonstrated to be clinically efficient in the treatment of Grades I and II haemorrhoids as well as in post surgical treatment both for the attenuation and elimination of pain and the clinical objectives of the pathology in question.

Laparoscopic approach for treatment of a primary splenic cyst.

We present the case of a 24-year-old woman with a symptomatic primary splenic cyst, and we relate our first experience with laparoscopic resection of the extrasplenic wall of the cyst. The procedure was successful, and the patient was discharged asymptomatic two days following surgery. We describe the surgical technique used and comment on some pathologic and tactical aspects. We conclude by remarking on the association of the beneficial advantages of minimally invasive surgery with the demand for more conservative splenic surgical procedures. Therefore, laparoscopic partial cystectomy may be a useful alternative for patients who require an effective treatment for nonparasitic splenic cysts.

[The hemodynamics of oral nicardipine determined by radioisotope ventriculography in patients with ischemic cardiopathy]. / Hemodinámica de la nicardipina oral determinada por ventriculografía radioisotópica en pacientes con cardiopatía isquemica.

Hemodynamic effects of nicardipine (60 mg) were evaluated in 20 patients whose left ventricular ejection fraction was less than 55%. Nicardipine significantly reduced the mean arterial blood pressure by 28 mmHg (p less than 0.0005). Left ventricular ejection fraction and maximal rate of ventricular diastolic filling were increased in 12% and 84.0 VDF/s (p less than 0.0005) respectively. The end diastolic volume was reduced by 26 ml (p less than 0.001). The decrease in mean arterial blood pressure correlates with the increase in the left ventricular ejection fraction (r = 0.76, p less than 0.001) as well as with the reduced end diastolic volume (R = 0.43, p less than 0.05). The results obtained corroborate the beneficial effects of nicardipine on ventricular function of ischemic patients, whose cardiac reserve is reduced.

[Chronic obstructive bronchopneumopathy and ectodermal dysplasia]. / Broncopneumopatia cronica ostruttiva e displasia ectodermica.

A boy, 5 year aged, admitted in intensive therapy room because affected by respiratory insufficiency, is reported. Recurrent lower respiratory tract infections and three surgical operation in the lacrimal ducts were present in the anamnesis. Clinical and radiologic features of chronic obstructive pneumonia were present. Hypotrichosis, onychodystrophy, microdontia, associated with absence of muciparous glands and greatly reduced muciparous cells of respiratory tract, were other findings.

Assessment of a physical training program in patients with myocardial infarction in a tropical country.

Twenty-five myocardial infarction patients, included in a comprehensive cardiac rehabilitation programme, were studied in order to assess the physical training effects upon several physiological parameters in a country with a tropical climate. Training consisted of three-times weekly supervised sessions with running, under telemetric control, accomplished continuously, during thirty minutes at 120 m/min as mean speed. Symptom-limited exercise stress testing was initially performed and repeated after three months of training. 88% of patients showed an increase in physical working capacity, 84% in exercise time duration and 80% in the myocardial efficiency index at subsequent ergometries. A decrease of double product and submaximal heart rate was observed. Angina, ECG ischaemic alterations and arrhythmias during exercise in the first test disappeared or occurred with higher workload in the second ergometry. Mean resting acid concentration, 1.28 +/- 0.36 mmol/l, increased immediately after exercise to 2.03 +/- 0.58 mmol/l. The prescribed physical training programme showed satisfactory results and increased the patients' quality of life, even in a humid and moderately hot climate.

[Bronchiolitis. Our clinical experience in the 4 years from 1981 to 1984]. / La bronchiolite. La nostra esperienza clinica nel quadriennio 1981-1984.

The clinical experience of 661 children with bronchiolitis is reported in four-years period to gain a better understanding of diagnosis and pathogenesis of bronchiolitis. Upper airways infections, expiratory dyspnea, clear sound by chest percussion, vesicular rales and whistling by chest auscultation, air trapping on the chest radiography were considered as essential data of diagnosis. It was found in 595 patients: expiratory dyspnea, air trapping, vesicular r. and whistling in 85% and whistling only in 15%; hypoxemia in 20% combined with hypercapnic acidosis in 10%; normoxemia in 80% combined with hypocapnia in 54%; hyperlactemia in 64% combined with an increment in the serum of CPK in 50% and of GPT in 30%; virus were cultured in 27%, adenovirus and RSV were identified in 90%. Instead it was found in 66 patients: air trapping but no difficult breath, with normal chest auscultation; crisis of cyanosis or paleness-cyanosis chilly sweat in 80% were motive of admission. The clinical and/or radiological features of "air trapping" were considered as essential symptoms and signs of bronchiolitis. The insufficient systemic perfusion was considered as a frequent occurrence and as cause for sudden respiratory and circulatory emergency.

Spontaneous variability and detection of repetitive extrasystoles during simulated acute antiarrhythmic testing.

In order to estimate the reduction in ventricular premature contractions (VPCs) due to spontaneous variability during simulated acute antiarrhythmic testing, and also to determine the detection capacity for repetitive VPCs during short periods of ECG monitoring usually employed as baseline recordings, 2 groups of patients were studied A reduction by more than 50% of the baseline VPC-rate can be expected to occur as a result of an antiarrhythmic intervention, while approximately 40% of the patients with repetitive high risk VPCs escape detection during short periods of control recordings. It is suggested to use a 24 to 47-hour ambulatory monitoring for the diagnosis and classification of VPCs, while acute antiarrhythmic testing should be employed for assessing individual efficacy and tolerance.

Comparison of segmental and global ejection fraction in ischaemic heart disease.

In order to evaluate whether segmental ejection fraction (SEF) is a better index of left ventricular (LV) performance than global ejection fraction (EF), 25 patients with significant coronary stenosis and normal EF were studied. SEF was estimated from the LV cineangiogram after dividing the LV into eight segments by means of a long axis and three equally spaced chords perpendicular to it. The area of a given segment was measured in the end-diastole and the end-systole and SEF was calculated by determining the percent decrease in area for each segment. 12 out of the 25 patients presented hypokinesis, akinesis or dyskinesis of at least two segments; the inferior apical and both diaphragmatic segments were the regions most frequently affected. In 7 patients, these abnormalities were compensated by hyperkinesis of two or three other segments, whereas in the remaining 5 patients contraction abnormalities were not accompanied by hyperkinesis in spite of a normal EF. It is concluded that SEF is a more sensitive index of regional LV function than EF in patients with ischaemic heart disease.

Miocardipatía familiar. Laminario de electrocardiogramas / Familial myocardiopathy. File of electrocardiograms

Se hace un estudio en el Instituto de Cardiología y Cirugía Cardiovascular (ICCC) de la miocardiopatía familiar. Para esto se sigue la evolución de 13 integrantes de una familia y se estudian los trazados de cada uno de ellos. También se presenta un laminario de algunos de sus electrocardiogramas (AU)

Segmental ejection fraction in normal subjects.

Following a modification of the area method described by Gelberg et al., left ventricular regional wall motion was studied in 30 normal subject. The left ventricular cineangiograms were filmed in the right anterior oblique projection at 48 frames/s after injection of 76% sodium-meglumine diatrizoate. The end-diastolic and end-systolic frames were each divided into 8 regions using a grid formed by longitudinal axis, which was traced from the midpoint of the aortic valve to the apex, and three equally spaced perpendiculars to the long axis. Segmental ejection fraction was estimated by determining the percent decrease in each segment area in end-systole with respect to the end-diastolic area. The mean values +/- S. D. obtained for each segment were: anterobasal 58 +/- 14%; anterolateral-proximal 59 +/- 6%; anterolateral-distal 58 +/- 4%; apical-superior 59 +/- 8%; apical-inferior 58 +/- 7%; diaphragmatic-distal 58 +/- 9%; diaphragmatic-proximal 55 +/- 6%; and posterobasal 42 +/- 15%. The values obtained are useful for comparison when evaluating left ventricular performance in patients.

Modification of blood pressure and systolic time intervals by diuretics and beta-blockers in essential hypertension.

Heart rate (HR), blood pressure and systolic time intervals (STI), including total electromechanical systole (QS2), left ventricular ejection time (LVETc), pre-ejection period (PEPc), the PEP/LVET index and the time to the peak of carotid upstroke (Ut), were measured in 24 patients with moderate essential hypertension after 15 days of treatment with oral furosemide (F), hydrochlorothiazide (H), propranolol (P), atenolol (A), furosemide + propranolol (F + P) and hydrochlorothiazide + propranolol (H + P). Except F, all treatments significantly reduced blood pressure; maximal reductions were brought about by A and H + P. The heart rate was most reduced by A. THe QS2c interval was reduced only after F and H, LVETc was significantly reduced by H, A and H + P. Drug combinations prolonged PEPc, while the PEP/LVET index was increased only by H + P. Beta-blockers significantly prolonged the Ut. It is concluded that diuretics shorten QS2c mainly through reduction in blood volume. The H + P combination diminishes contractility and cardiac output and should not be employed in heart failure.

Oral amiodarone in high-risk ventricular arrhythmias.

Oral amiodarone was evaluated in 24 patients with complex forms of ventricular premature depolarizations (VPD) by means of ECG monitoring and measurement of systolic time intervals. The patients received 800 mg daily for 3 days, 600 mg daily for 7 days and 400 mg daily thereafter. Follow-up lasted from 6 to 17 months. Advanced forms of VPD were abolished and the VPD rate was reduced in 98% of patients. After 10 days repetitive VPD were absent in more than 80% and after 4 months more than 70% were completely free from arrhythmia. ECG changes revealed heart rate reduction and prolongation of PR, QRS and QTc intervals. Left ventricular performance was not influenced. After 6 months of treatment, 10 randomly selected patients received placebo instead of amiodarone in a single blind fashion until arrhythmia reappeared; the latter was again abolished by reinstituting amiodarone, The most frequent side effect were corneal microdeposits which were reversible and did not impair vision. It is concluded that amiodarone is effective and well tolerated in patients with high-risk VPD.

Effects of propranolol and atenolol on plasma renin activity and systolic time intervals in borderline hypertension.

Plasma renin activity (PRA) and systolic time intervals (STI), including total electromechanical systole (QS2), left ventricular ejection time (LVET), pre-ejection period (PEP) and isovolumetric contraction time (ICT), were measured in patients with borderline hypertension (n = 23) before and after oral treatment with atenolol and propranolol. Both beta blockers caused a similar fall in blood pressure and heart rate (P less than 0.001). QS2, PEPc and PEP/LVET values did not change after treatment. Propranolol prolonged ICT (p less than 0.001) and reduced LVET (p less than 0.001). No significant changes were detected in PRA after atenolol while a reduction was found after treatment with propranolol (p less than 0.001). No relationship was found between PRA and STI, however a linear correlation was recorded between systolic pressure and PRA (r = 0,91; p less than 0.01) before beta-blockade. These results suggest that: a) only beta 2-adrenoceptors are involved in the release of renin; and b) the effect of beta-blockers on STI follows a reduction of blood pressure and heart rate which in turn affect afterload.

Effects of oral atenolol and propranolol on blood pressure, heart rate and plasma cyclic adenosine 3':5'-monophosphate in borderline hypertensive patients.

The effects of oral treatment with atenolol and propranolol on blood pressure, heart rate and plasma cyclic adenosine 3':5'-monophosphate (cAMP) were studied in a group of young borderline hypertensives. Observations were accomplished after a period of recumbent relaxation and also following physiological stress testing. The latter significantly increased blood pressure, heart rate and plasma cAMP. A direct relationship was found between heart rate and plasma cAMP at rest and also following psychological stress. This relationship was lost following drug treatments. Both beta-blockers significantly reduced all measured variables in both conditions. However, plasma cAMP was most affected by propranolol.

Candidiasis en pacientes quirurgicos. / Candidiasis in surgical patients

Se analiza una seire de 15 pacientes quirurgicos que presentaron durante el postoperatorio inmediato severas complicaciones coronadas en 12 casos por una candidiasis profunda comprobada o probable. Se debe sospechar esta contingencia cuando una sepsis postoperatoria, que se supone correctamente tratada por medios medicos y/o quirurgicos, se agrava o no logra controlar. Practicamente no existen signos clinicos patognomonicos de esta forma de sepsis. Para diagnosticarla se debe recurrir al laboratorio que permite la observacion directa y el cultivo de las muestras, completamentando estos examenes con los estudios serologicos. Se comenta el plan de tratamiento y los resultados observados

Candidiasis en pacientes quirurgicos. / Candidiasis in surgical patients

Se analiza una seire de 15 pacientes quirurgicos que presentaron durante el postoperatorio inmediato severas complicaciones coronadas en 12 casos por una candidiasis profunda comprobada o probable. Se debe sospechar esta contingencia cuando una sepsis postoperatoria, que se supone correctamente tratada por medios medicos y/o quirurgicos, se agrava o no logra controlar. Practicamente no existen signos clinicos patognomonicos de esta forma de sepsis. Para diagnosticarla se debe recurrir al laboratorio que permite la observacion directa y el cultivo de las muestras, completamentando estos examenes con los estudios serologicos. Se comenta el plan de tratamiento y los resultados observados