Treatment of iatrogenic and traumatic tracheal disruptions.

BACKGROUND AND AIM: The optimal management of tracheal disruptions is still controversial. It is usually postulated that lesions wider than 1 or 2 centimetres and/or lesions of full-thickness should be treated by surgery at an early stage. Such a statement is not supported by any proven evidence. On the contrary, the conservative management of such injuries has also produced very good results according to recent reports. The aim of this study is to investigate whether conservative treatment can be safely used for wide tracheal lacerations and to assess any possible association between clinical features and modality of treatment. METHODS: Records of all patients with iatrogenic and traumatic tracheal disruptions observed between January 1992 and December 2006 were collected and retrospectively reviewed. Data regarding mechanism of injury, clinical and morphological features and modalities of treatment were registered. All possible associations between clinical features and modalities of treatment were investigated. RESULTS: 23 patients were observed overall. There were 6 males and 17 females with a median age of 58 years (range 20-84 yrs). 15 patients had undergone single tube intubation. One patient had his trachea injured during an esophagectomy. Ruptures were secondary to blunt (n = 5) and open (n = 2) trauma in 7 patients. Lesions varied in length between 1 and 7 centimetres (median length 3 centimetres) and all were full-thickness. The time interval until diagnosis varied between 0 and 72 hours (median 6 hours). Respiratory failure was evident in 7 patients. 16 patients (69.5%) with lacerations ranging in length between 1 and 5.5 centimetres (median length 2.75 cm) underwent conservative treatment. Seven patients (30.5%) underwent surgery. The follow up was completed for 16 patients and varied between 15 and 105 months (median 22.5). One patient died after surgical treatment. No mortality or late major sequelae were registered after conservative treatment. Female sex, absence of respiratory failure and delayed diagnosis was associated with the conservative treatment. CONCLUSIONS: Conservative treatment can play a major role even in cases of wide tracheal lacerations. Clinical rather than morphological features should be regarded as main criteria for treatment. The conservative treatment is particularly indicated in the case of stable respiratory parameters independent of the size and the depth of the lesion.

[Complications of Barrett's esophagus: indications for esophageal resection with special reference to high-grade dysplasia]. / Complicanze dell'esofago di Barrett: indicazioni alla resezione esofagea. Con particolare riferimento alla displasia di alto grado.

BACKGROUND: Columnar lined oesophagus (Barrett's oesophagus) can sometimes be associated with complications such as stricture, ulcer and dysplasia. In some selected cases there is an indication for oesophageal resection. METHODS: From 1983 to 1997, 12 patients underwent oesophagectomy for "complicated" Barrett's oesophagus. All patients had gastroesophageal reflux and Barrett metaplasia for many years. Ten of them were symptomatic, and pH-manometric alterations as well as alterations were noted at biliary scintigraphy. Ten patients had intestinal metaplasia. Two patients had previous antireflux operations. Four had a long (3-5 cm) and undilatable stricture. One was affected by a perforating ulcer. One patient had an indefinite grade dysplasia but endosonography revealed high suspicion of cancer. Six patients had a high-grade dysplasia. Operative technique consisted of a transhiatal oesophagectomy in nine cases and a laparotomic and right thoracotomic oesophagectomy (Ivor-Lewis) in two. RESULTS: There was no 30-day mortality; three post operative complications were observed. One of the four patients suffering from stricture died four years after intervention due to non-related causes; the other three are still living and regularly feed per os after 12, 9 and 7 years. The patient with ulcer is still living after 6 years and regularly feeding per os. The patient suffering from an indefinite grade dysplasia had an adenocarcinoma (stage IIa) on the operative specimen. The patient is still living after 2 years. Three patients operated for high-grade dysplasia had an adenocarcinoma on the specimen. Two patients (stage I) are living after 3 and 5 years. One patient (stage IIa) died after 19 months with recurrence. CONCLUSIONS: In case of non neoplastic "complicated" Barrett's oesophagus the indication for the oesophageal resection can be considered as the extreme useful therapy only after an accurate selection of patients. Especially in case of high-grade dysplasia, the great incidence of unexpected adenocarcinoma indicates oesophagectomy for patients who are suitable for surgery.

[Etiopathogenetic hypothesis on the course of esophageal dyskinesias regarding particularly the transitional forms between esophageal spasm, vigorous achalasia and decompensated achalasia]. / Ipotesi eziopatogenetica sull'evoluzione delle discinesie esofagee con particolare riguardo alle forme di transizione tra spasmo esofageo, acalasia vigorosa e acalasia scompensata.

The aetiology of oesophageal motor disturbances (OMD) including achalasia is unknown. Many causes have been hypothesised including: autoimmune inflammatory lesions, mechanical obstruction, degeneration of the dorsal nucleus of the vagus etc. to explain the anatomopathological lesions of Auerbach's plexus. On the basis of the manometric studies carried out so far on motor disturbances of the oesophagus, it is considered that dyskinesia develop into decompensated achalasia. The disturbance would appear to begin as an oesophageal spasm, turn into vigorous achalasia and finally reach the point of decompensated achalasia characterised by hypotonic, synchronous waves and the absence of relaxation of the lower oesophageal sphincter. A personal series of 76 cases of OMD chosen from among 420 monometries carried out from 1980 to 1987 showed that the duration of the wave, namely the length of time the abnormal pressure is maintained is as important as the pressure of the peristaltic wave and the lower oesophageal sphincter. In fact, wave pressure is generally greater than the systolic pressure of the patient and hence, during contraction, the oesophageal walls are ischaemic and this ischaemia might be the cause of the anatomopathological lesions of Auerbach's plexus observed in decompensated achalasia.

Evidence for an increased somatomedin-C/insulin-like growth factor I content in primary human lung tumors.

Immunoreactive somatomedin-C/insulin-like growth factor I (SM-C/IGF I) content was measured in human neoplastic lung tissue obtained from surgery on 10 patients (seven epidermoid carcinoma, three adenocarcinoma), and in normal lung tissue obtained from the same excised portion. SM-C/IGF I content in lung tumors was 615 +/- 123 (SE) milliunits/g of tissue (range, 214-1531), significantly higher (P less than 0.01) than normal tissue (234 +/- 51 milliunits/g of tissue; range, 37-537); in particular, every subject showed a clear-cut difference of SM-C/IGF I content between neoplastic and normal tissue (ratio, 3.41 +/- 0.69; range, 1.4-7.2). The results were essentially unchanged when data were expressed relative to hemoglobin or DNA tissue content. By contrast, in peripheral plasma SM-C/IGF I concentration was 0.51 +/- 0.17 units/ml, significantly lower (P less than 0.01) than in 59- to 70-yr-old control subjects (1.10 +/- 0.13 units/ml). In conclusion, the lung tumors studied, irrespective of their histological structure, contain more SM-C/IGF I than does normal tissue. Whether this is due to a primary in situ production of SM-C/IGF I or is secondary to overproduction of other inducers such as platelet derived growth factor-like peptides is yet to be clarified. The reduced circulating SM-C/IGF I concentration seems to be related more to the nutritional status of the patients.

Relationships between diaphragmatic hiatus and infra-diaphragmatic esophagus: a combined X-ray and manometry study.

The relationship between the diaphragmatic hiatus, the infra-diaphragmatic esophagus and a manometric tube were examined in 10 patients not suffering from hiatal hernia or gastroesophageal reflux. During surgery, two metal markers were attached to the diaphragmatic hiatus and two others were fixed at the vertex of the angle of His. X-ray examinations were taken during manometric recordings of the high pressure zone (HPZ) both at rest and during relaxation. Comparison between the radiographs showed that during swallowing the manometric tube did not move with respect to the vertebral bodies; contraction of the esophagus caused complete disappearance of the infra-diaphragmatic esophagus. It was also observed that during pressure drop in the HPZ (so-called lower esophageal sphincter relaxation), the manometric recording site is located below the vertex of the angle of His, i.e. in the gastric cavity. These findings provide the basis for a hypothesis to explain the passage of a solid bolus through the lower esophagus into the stomach.

[Medical management of reflux esophagitis]. / La terapia medica delle esofagiti da reflusso.

When the cause of oesophagitis has been discovered, patients for whom surgical management is impossible may be successfully treated by improving oesophageal peristalsis, increasing the tone of the LES, and speeding up the emptying of the stomach. The best results are obtained in peptic oesophagitis, since the latest secretion-inhibiting drugs ensure constant reduction of the acidity of the gastric juice, as has been demonstrated by continuous pH monitoring.

[Personal experience in the treatment of serious hepatic insufficiency]. / La nostra esperienza nel trattamento dell'insufficienza epatica grave.

Personal clinical experience and the results obtained in the treatment of patients suffering from severe hepatic insufficiency observed in the last seven years, out of a total of some 200 cases, are reported. The modalities employed in the application of intensive basic care and special treatment in 50 cases of initial or clear hepatic coma of various aetiological origin are reviewed. Whereas basic treatment involves more purely medical measures, such as reintegrative and nutritional treatment by the venous route, activation of renal function, the prophylaxis of infectious complications and reinfusion of ascitic fluid, that applied to cases of clear coma involves a more properly surgical technique. It makes use of an original biological clarification technique in extracorporeal circulation by means of isolated and perfused heterologous liver, and an isovolaemic exsanguinotransfusion technique. Indications and features are illustrated in detail.

[Functional studies after pulmonary autografts or hilar stripping. Experimental research]. / Studio funzionale dopo autotrapianto o stripping ilare polmonare. Ricerche sperimentali.

pO2, pCO2, pH and ERO2 were controlled in the autotransplanted lung and after hilar stripping. The contralateral lung was excluded by ligation of the right pulmonary artery. It appeared that such ligation is not sufficient for this purpose, whereas hilar stripping offers an adequate experimental model for the simulation of autotransplantation.

[New apparatus for the treatment and reinfusion of ascitic fluid]. / Presentazione di un nuovo apparecchio per il trattamento e la reinfusione del liquido ascitico

A new apparatus for the reinfusion of ascitic fluid, offering effective clarifying action as well as the typical concentration of this therapeutic technique is presented.