[Typology of defunctioning colostomy and state of art in the treatment of bowel emergencies]. / Indicazioni attuali e tipologia della colostomia di protezione nelle urgenze coliche.

BACKGROUND: A trend toward avoidance of a defunctioning colostomy at emergency large-bowel surgery has been placed in recent years. The surgical management of patients with acute colonic disease has been evolving from multiple to single operations with a reduced use of colostomy. METHODS AND RESULTS: One hundred four consecutive non-selected patients underwent surgery for left-sided large bowel emergencies between 1980-2003. Defunctioning colostomy was performed in 10 out of 58 resection-anastomosis procedures. Thirty-seven patients underwent Hartmann procedure, 9 received only diverting colostomy. Postoperative morbidity was 28.8%. Postoperative mortality 8.2%. Anastomotic leak occurred in 1 and 6 patients with and without defunctioning colostomy respectively. Four out of the 6 patients without colostomy needed reintervention, while patient with covering colostomy underwent conservative treatment. Six (10.5%) out 56 patients with colostomy experienced major stoma related complications and underwent reintervention. DISCUSSION: Although there is general acceptance of one-stage surgery for right-sided colon emergencies, the surgical management of left-side large bowel obstruction and peritonitis remains controversal. Risk of anastomotic dehiscence associated with large-bowel anastomosis in unfavourable circumstance must be balanced against the high complications and low closure rates of a temporary colostomy. CONCLUSION: Primary resection and anastomosis without diverting colostomy for left-sided acute obstruction and peritonitis may be performed in selected patients. Diffuse purulent and faecal peritonitis are contraindications to one-stage surgery being necessary a two- stage procedure with loop or end colostomy. Colostomy remain a valid surgical option when high risk of dehiscence is suspected.

[Surgical treatment of carotid chemodectoma: our experience]. / II trattamento chirurgico del chemodectoma carotideo: nostra esperienza.

Carotid chemodectoma is a tumor that affects the bifurcation of the carotids. It is not a frequent event, but it has great importance for surgical and diagnostic problems involved. In this article three cases of chemodectoma observed and surgically treated are reported.

[Pancreatic metastasis of renal cell carcinoma: a case report and review of the literature]. / Metastasi pancreatica di carcinoma renale a cellule chiare: presentazione di un caso clinico e revisione della letteratura.

The pancreas is an uncommon site of metastases from renal cell carcinoma; however in the literature late pancreatic metastases are described. In this report a 74 years-old asymptomatic man was referred for evaluation of a mass in the distal portion of the pancreas, found on CT 4 years after right nephrectomy for a renal cell carcinoma. A distal pancreatectomy and splenectomy were performed and histopathological analysis revealed to be a metastases from renal cell carcinoma. A postoperative pancreatic fistula was treated in a conservative way. The patient is alive and doing well 3 years after pancreatic surgery. This clinical report suggests that late pancreatic metastases are rare but not impossible and should be taken into consideration during a careful long-term follow-up for renal carcinoma. In addition, as it is also desumed by the Literature on survival, pancreatic metastases should be treated when possible with radical resection.

Contrast-enhanced gray-scale and color Doppler voiding urosonography versus voiding cystourethrography in the diagnosis and grading of vesicoureteral reflux.

PURPOSE: The purpose of this study was to compare contrast-enhanced gray-scale voiding urosonography (CE-VUS) and contrast-enhanced color Doppler voiding urosonography (CE-CDVUS) with voiding cystourethrography (VCUG) to verify whether the use of color Doppler imaging improves the diagnosis and grading of vesicoureteral reflux (VUR). METHODS: In 74 patients, CE-VUS and CE-CDVUS were compared with VCUG, which was used as the gold standard. SHU 508 A (Levovist) was used as the echo-enhancing contrast agent. VUR was diagnosed if hyperechoic dots or color signals were visualized in the ureter on sonograms. VUR grading was based on morphologic and dynamic findings on CE-VUS and morphologic and color findings on CE-CDVUS. VCUG was performed conventionally, and grading by VCUG was in accordance with the international system of radiographic VUR grading. Patients who voided during 1 examination only (either CE-VUS and CE-CDVUS or VCUG) were excluded from the study. Agreement between the results of CE-VUS and VCUG and between those of CE-CDVUS and VCUG in diagnosing VUR was calculated by kappa statistics. CE-VUS and CE-CDVUS were compared for diagnostic accuracy by the McNemar test. RESULTS: The agreement between CE-VUS and VCUG in predicting VUR was 90% (kappa score, 0.77; p < 0.001). The agreement between CE-CDVUS and VCUG was 96% (kappa score, 0.91; p < 0.001). CE-CDVUS showed a significantly higher diagnostic accuracy than did CE-VUS (96% versus 90% of cases correctly classified; McNemar chi2 = 4; p < 0.05). This was mainly related to the lower number of false-negative results for grade I and grade II VUR when CE-CDVUS was used. CONCLUSIONS: The use of color Doppler imaging significantly improves the accuracy of contrast voiding urosonography in the detection and grading of VUR.

Fallopian tube disease: the cobblestone pattern as a radiographic sign.

PURPOSE: To identify radiographic signs of mucosal damage by comparing hysterosalpingography with salpingoscopy in a prospective study. MATERIALS AND METHODS: Forty-one candidates for laparoscopy underwent hysterosalpingography and peroperative salpingoscopy; at both, tubal patency was noted. Radiographic criteria for mucosal abnormality were rounded filling defects (ie, the cobblestone pattern) and the absence of longitudinal radiolucent bands in the ampullary tract. At salpingoscopy, tubal mucosa was categorized by means of inspection into five classes of fold pattern: classes I and II, normal; classes III-V, abnormal. Hysterosalpingographic and salpingoscopic results were compared by means of a two-by-two table and kappa statistics. RESULTS: Seventy-four tubes were evaluated. At hysterosalpingography, 31 tubes were distally nonpatent. Of these, 26 showed a distal obstruction at salpingoscopy. None of the patent tubes at hysterosalpingography showed obstruction at salpingoscopy. The agreement between hysterosalpingography and salpingoscopy in detecting abnormal mucosal pattern was 89.2% (kappa, 0.73; P: <.001). The cobblestone pattern always corresponded to intraluminal adhesions at salpingoscopy. The absence of radiolucent bands corresponded to abnormal mucosa at salpingoscopy in four of six cases. The cobblestone pattern was found only in hydrosalpinges and never in patent tubes. Six normal patent tubes at hysterosalpingography showed intraluminal adhesions at salpingoscopy. CONCLUSION: Results indicate that the cobblestone pattern is an effective radiographic sign of intraluminal adhesions in hydrosalpinges and suggest that intraluminal disease in patent tubes might not always be excluded on normal hysterosalpingograms.

Improvement of hysterosalpingographic accuracy in the diagnosis of peritubal adhesions.

OBJECTIVE: Our purpose was to compare hysterosalpingography with laparoscopy in the diagnosis of peritubal adhesions and to verify whether a combination of radiographic signs improves hysterosalpingographic accuracy. SUBJECTS AND METHODS: Thirty candidates for laparoscopy underwent hysterosalpingography before surgery. Two radiologists evaluated the presence or absence and types of radiographic signs of peritubal adhesions (convoluted tubes, vertical tubes, loculation of contrast medium in peritoneum, halo effect, and fixed laterodeviation of the uterus) using two different criteria for normality or abnormality: no sign means a normal result, one or more signs mean an abnormal result (first criterion); no sign or one sign means a normal result, two or more signs mean an abnormal result (second criterion). Interpretation discrepancies were resolved by consensus. Peritubal and periovarian adhesions were evaluated by a single operating surgeon during laparoscopy (recorded on S-VHS videotape) and by a different surgeon reviewing the videotape. The radiographic results obtained using the two criteria in radiologically patent as well as in distally nonpatent tubes were compared with corresponding laparoscopic results by 2 x 2 tables and were statistically analyzed (kappa statistics). RESULTS: The first criterion displayed poor diagnostic accuracy. The correlation with laparoscopy was not statistically significant in either radiologically patent or distally nonpatent tubes. The second criterion greatly improved the agreement with laparoscopy, but only in patent tubes (kappa = 0.7789; p<0.001). CONCLUSION: Hysterosalpingographic accuracy in peritubal adhesion diagnosis can be improved in patent tubes by taking into account more than one of the reported radiographic signs.

Adult medullary cystic disease of the kidney and pancreatic cystic disease: a new association.

A rare case of a woman with the adult form of medullary cystic disease associated with pancreatic cysts in pancreas divisum is described, which suggests that specific attention should be paid to computed tomography findings in the presence of pancreatic and renal cysts.

[Neurinoma of the vagus nerve. Description of 2 cases and review of the literature]. / Neurinomi del nervo vago. Descrizione di due casi e revisione della letteratura.

The Authors report two rare cases of schwannoma of the cervical and thoracic portion of the vagus nerve. Schwannomas of the vagus nerve are particularly uncommon; patients suffering from these neurogenic tumors typically exhibit a paucity of symptoms and in the majority of cases they present with an asymptomatic mass noted on incidental chest X-ray. Chest pain and cough may occur with tumors arising next to and compressing the trachea or major bronchi. In the cases observed, schwannomas appeared like a mass whose size had increased during the last months without producing any clinical symptom. Clinical features of the mass, laboratory tests, ultrasound, CT scanning, magnetic resonance imaging were useful only to define its extension and relationships with the adjacent structures. Needle aspiration of these lesions is not indicated because of the paucity of the material obtained for the exact diagnosis. Surgery, with preservation of the vagus nerve when possible, is the treatment of choice also for a correct diagnosis of nature and to prevent further growth and compression on adjacent structures. When the individual fibers of the vagus nerve are displayed over the surface of the tumor within a discrete capsule nerve preservation is possible. On the contrary, when it is technically difficult to preserve the nerve trunk microsurgical procedures allow to reanastomose the cut ends. Injury of homolateral recurrent nerve often is the complication of a radical removal. Recurrence of benign lesions is not usual; malignant tumors carry a poor prognosis with patients rarely surviving beyond 1 year.

[Pilonidal sinus: long term results of excision and closure technic. Review of the literature]. / Sinus pilonidalis: risultati a lungo termine del trattamento con tecnica di escissione e chiusura. Revisione della letteratura.

The Authors report their experience in the surgical management of pilonidal sinus with modified Leichtling technique. Long term results of various treatments proposed in the past are analyzed: it is not possible to identify a satisfactory procedure for the treatment of pilonidal sinus. Ideal treatment should avoid hospital admission and general anaesthesia, assure a short time of healing, a reduced number of complications, a low risk of recurrence and a minimal time off from work. Authors' variations to the original technique show good results for non recurrent pilonidal sinus and a lower number of failed primary healing. Recurrences are probably related to the patient anatomical status which may be modified only by flattening natal cleft or surgically changing follicles orientation of presacral skin, together with a meticulous hygiene and shaving of the presacral healing area as well as a dietary regimen for obese patients.

[Extraskeletal retroperitoneal osteosarcoma. A case report and review of the literature]. / Osteosarcoma extrascheletrico retroperitoneale. Presentazione di un caso e revisione della letteratura.

Extraskeletal osteosarcomas, localized in the retroperitoneal space, are very rare neoplasms (only 200 cases have been described); the case indicated is the second one observed in Literature. The extraskeletal osteosarcomas are very malignant mesenchymal neoplasms reproducing osseous and cartilaginous tissue disconnected from the skeletal system. From a histological point of view, the extraskeletal osteosarcomas are constituted of osseous and cartilaginous tissue with osteo-fibro-chondroblastic cells: the different representation of three types of cells define the variety of extraskeletal osteosarcomas (osteoblastic, chondroblastic, fibroblastic). Histological and ultrastructural study failed to find differences between skeletal and extraskeletal osteosarcomas. In the clinical history of some patients traumas or irradiation has been referred; although extraskeletal osteosarcomas etiology is frequently unknown. Diagnosis is generally delayed because symptoms are often absent of uncertain. Prognosis of these neoplasms is always very poor, and specially in relation to the dimension and to the possibility of its radical removal. All patients died until 2-3 years after surgery.

[Endobronchial lipoma: endoscopic resection or surgical excision? Report of a case and review of the literature]. / Lipoma endobronchiale: resezione endoscopica o exeresi chirurgica? Descrizione di un caso e revisione della letteratura.

The Authors report a case of endobronchial lipoma, a rare, benign lung lesion. Literature data show that a correct preoperative diagnosis of nature is possible in less than 50% of all the cases and a thoracotomy is mandatory in 85% of the patients because FNAB or brushing rarely allow a certain cytological diagnosis. When a benign tumor is suspected, an endobronchial resection is the treatment of choice, allowing a correct histological diagnosis and in the same time a definitive therapy with resolution of symptoms. Surgical option is reserved for the not certainly determined benign or malignant lesions.

Thoracic desmoid tumors: a rare evolution of rib fracture. Etiopathogenesis and therapeutic considerations.

The Authors report a case of thoracic desmoid tumor. The strict correlation between a previous chest injury and the site of desmoid tumor in this patient seems to strengthen the possible etiological role of trauma, as already suggested.

[The sternotomy and thoracotomy approaches in the treatment of differentiated thyroid cancer in an advanced phase]. / Approccio sternotomico e toracotomico nel trattamento del cancro differenziato della tiroide in fase avanzata.

The authors report their experience in the treatment of well-differentiated thyroid cancer. The analysis of 5 cases treated with extensive surgery give the opportunity to discuss about the use of sternotomy or thoracotomy to eradicate mediastinal lymph nodes. The importance of preoperative assessment, especially by histological examination is stressed as well as the role of surgery in the multidisciplinary approach for the treatment of the disease.

Protective role in vivo of coenzyme Q10 during reperfusion of ischemic limbs.

The authors prepared an experimental animal model of ischemia and reperfusion of the limbs to evaluate in vivo the reactive oxygen species involvement and protective role of coenzyme Q10 in reperfusion injury. A group of male rabbits (untreated group) underwent clamping of abdominal aorta for 3 hr and then declamping; at intervals blood sampling was drawn for coenzyme Q10, vitamin E, lactic acid and creatine kinase assays. Another group of male rabbits (treated group) underwent the same ischemia period but before declamping coenzyme Q10 was administered intra aorta. In untreated group, coenzyme Q10 and vitamin E plasma levels decreased while lactic acid and creatine kinase plasma levels increased during reperfusion. These data demonstrate that, after only 3 hr of ischemia, the extremities show a biochemical reperfusion injury, and this involves an increased consumption of antioxidants such as coenzyme Q10 and vitamin E. In the treated group, the increase of creatine kinase plasma levels during reperfusion was not significant, while the decrease in vitamin E was more marked.

[Short-term antibiotic prophylaxis in surgery. Our experience with the use of piperacillin in 261 patients]. / La profilassi antibiotica "short term" in chirurgia. Nostra esperienza con l'uso della piperacillina in 261 pazienti.

Personal experience of short-term chemoprophylaxis with piperacillin in 261 consecutive "clean" and "non-contaminating" operations is reported. Piperacillin was employed in a dose of 2 g i.m. every 8 hours for a total of 48 hours, the first administration being carried out at the same time as pre-anaesthesia. Results of the study showed 8 cases (3.06%) of hyperpyrexia (greater than 38.5 C for at least 3 days) and no cases of wound, bronchopulmonary or urinary infection or systemic sepsis were encountered. It is concluded that the use of piperacillin enables "clean" and "non-contaminating" general surgery interventions to be carried out almost without risk of infection.

[Diagnosis and treatment of hepatic echinococcosis with fistulas of the major bile ducts]. / Diagnostica e trattamento dell'echinococcosi epatica fistolizzata nelle vie biliari maggiori.

The authors report their experience of secondary major biliary fistula (MBF) for hepatic echinococcosis. The analysis of the results of the surgical treatments showed that "conservative" operations have major mortality than "radical" operations. The importance of an exact preoperative diagnosis of presence, side and size of MBF, in order to a correct choice of the most suitable operations, is underlined. Endoscopic retrograde cholangio-pancreatography seems to be a reliable diagnostical technique, also if compared with traditional methods (U.S., C.T.).

[Morphological and functional study of the liver using scintigraphy with 99m-Tc-HIDA before and after major resection for echinococcosis]. / Studio morfologico e funzionale del fegato mediante scintigrafia con 99m-Tc HIDA prima e dopo resezioni maggiori per echinococcosi.

Personal experience in the monitoring of liver function and morphology after resection using hepatobiliary HIDA 99mTc scintigraphy is reported. This investigation provides useful functional and morphological data. In three patients subjected to right hepatectomy for echinococcosis the examination performed preoperatively and 25 and 90 days after surgery revealed functional normalisation of the residual liver and biliary excretion. On the basis of this experience and data from the literature the value of the technique is confirmed and it is suggested that it might be usefully adopted in the study of other liver conditions such as neoplasms, traumas as well as in the monitoring of transplanted livers.