Marsupialization of fistulotomy and fistulectomy wounds improves healing and decreases bleeding: a randomized controlled trial.

BACKGROUND: Marsupialization of anal fistulotomy/fistulectomy wound leaves less raw unepithelialized tissue. The suture results in a more rapid healing and is likely to reduce the risk of bleeding but at the cost of an increased pain and infection. The aim of this prospective study was to compare the outcomes of marsupialization and open wound. METHODS: Forty-six consecutive patients with anal fistulae were recruited in a randomized controlled trial. Fistula tracks were treated by fistulotomy and/or fistulectomy. The resulting wounds were marsupialized to the skin edges with locking continuous absorbable sutures (M group) or left open (O group). The clinical outcome was then evaluated. The intra-operative effect of the suture on wound size was recorded as well as the postoperative pain using a 0-10 visual analogue scale (VAS) and the occurrence of both wound bleeding and infection. RESULTS: Twenty-two patients were randomized to the M group and 24 to the O group. There were no differences in the age, sex and fistula type between the groups. Mean follow-up times were 10.5 and 13.8 months, respectively. No significant difference was observed in postoperative pain, the VAS being 3.5 +/- 1.5 in the M group and 3.4 +/- 1.6 in the O group at 12 h (mean +/- s.e.m.; n.s). The marsupialization nearly halved the size of the wound intra-operatively from an area of 1749 +/- 66 mm2 to 819 +/- 38 mm2 (P < 0.001), which subsequently decreased to 217 +/- 15 mm2 after 4 weeks (P < 0.01). No significant reduction of wound size was observed in the O group (from 1171 +/- 31 mm2 to 543 +/- 19; n.s). Bleeding occurred less frequently in M group than in O group (36%vs 46%, P < 0.05), whereas the difference in the postoperative sepsis rate was not significant, being 14% in M vs 21% in the O group. Three reinterventions were needed in both groups due to wound sepsis. CONCLUSION: Marsupialization after fistulotomy/fistulectomy significantly reduces the size of the wound and the risk of bleeding, without increasing postoperative pain and sepsis.

Intracavitary therapy of noninvasive transitional cell carcinomas of the upper urinary tract. A review of the literature.

Noninvasive (stages Ta, T1, Tis) transitional cell carcinomas of the upper urinary tract are suitable for a conservative therapeutic approach. Intracavitary therapy (alone or as adjuvant treatment) has recently been proposed and successfully used by some authors. Even though bacillus Calmette-Guérin is the most frequent agent employed, chemotherapeutic drugs, such as mitomycin C and thiotepa, have also been successfully used. The current information available in the literature is therefore reviewed. According to the data available, intracavitary therapy is a worthwhile conservative therapeutic option for noninvasive upper urinary tract urotheliomas with acceptable side effects. For this reason it may be included in the routine urological armamentarium.

[Histopathologic examination of the intervertebral lumbar disk. Evaluation of its usefulness and limitations]. / L'esame istopatologico del disco intervertebrale lombare. Valutazione dell'utilità e dei limiti.

A retrospective clinical-pathological review of 192 lumbar intervertebral discs removed via an interlaminar approach or percutaneous nucleotomy from patients suffering from sciatic pain was carried out in order to assess if routine examination is useful. Only for a case of our series, which showed ill defined features at preoperative neuroradiologic imaging, an intraoperative pathologic examination was necessary. Immunohistochemical study was never required. A routine examination with a hematoxilin-eosin stain was sufficient also to recognize postoperative scar in patients reoperated. In conclusion we think that routine examination of the intervertebral disc is a procedure which is not expensive and useful to assess the nature of the lesion in reoperated patients and in rare cases showing unclear radiologic pattern.

Calf pseudohypertrophy in a patient with double neurogenic pathology.

A pseudohypertrophy of the calf can be rarely associated with neurogenic pathologies as S-1 radiculopathy, poliomyelitis, spinal muscular atrophy, traumatic lesions of peripheral nerves, intraspinal neurinoma. The causes of this particular phenomenon are unknown. The authors present the case of a 52-year-old man with an enlargement of the left calf suffering from a mild form of spinal paralytic poliomyelitis in the early childhood and episodes of severe left sciatica in the last four years. Electromyography demonstrated a pattern of denervation in both legs and an H-reflex absent when the left tibial nerve was stimulated. An open muscle biopsy of the left calf was performed. Light microscopic and ultrastructural examination of the muscle confirmed the presence of a pattern of "neurogenic type" pseudohypertrophy. Our results could be interesting for the understanding of the mechanism of neurogenic pseudohypertrophy. This case suggests that timing of stimulus or "dose" of denervation may be important factors in such a phenomenon.

[A case of peritoneal tuberculosis. Contribution of mini-endoscopy]. / Un caso di tubercolosi peritoneale. Contributo della miniendoscopia.

BACKGROUND: Tuberculosis in the genital and peritoneal region is increasing in last years. For this reason, the high value and efficacy of laparoscopy using a small caliber endoscope for the diagnosis of this disease, which often presents no specific and heterogeneous clinical features, is underlined. METHODS: A case of peritoneal tuberculosis in a young female presenting fever, asthenia and peritoneal effusion, is reported. Blood tests, X-ray and cytological examination of the peritoneal fluid all failed to point out the right diagnosis. Then multiple biopsies of the peritoneum and the external surface of uterus and ovaries were made using laparoscopy. RESULTS: Laparoscopy clearly showed the miliary nodules. The histology showed multiple granulomas composed by inner caseous necrosis and outer layer of epithelioid histiocytes and Langhans cells, leading thus to the diagnosis of peritoneal tuberculosis. The patient, treated with streptomycin and rifampicin, five months after diagnosis, did not show any feature of tubercular disease. CONCLUSIONS: Because of its safety, laparoscopy is a very useful and powerful diagnostic technique especially in those young women presenting with painful abdominal symptoms without any clear evident cause.

Telangiectatic osteosarcoma of the skull. A post-Paget case.

We report a case of post-Paget telangiectatic osteosarcoma of the skull in a 75-year-old woman. Such a neoplasia is a rare variant of osteosarcoma, a tumor rare in the cranic bones. The patient was submitted for a careful analysis by the following procedures: technetium scintigram, X-rays, CT scan, and MRI. After the surgical procedure, pathological examination confirmed the diagnosis. Both radiological and pathological pattern of this tumor are discussed in relation to the differential diagnosis. Our report shows that benign lesions may represent a possible cause of diagnostic errors. They must be excluded by histological analysis.

Organ procurement: experience from a southern Italian region.

The authors report their experience of organ procurement during the last 5 years to evaluate a program that began in 1988 to improve organ retrieval in Calabria. In this region only two donations were reported up to 1988, one each in 1980 and 1985. Because of the large population on dialysis and the willingness of a group of surgeons and anesthesiologists, this program was undertaken in 1988 under the supervision of C.C.S.T. (Co-ordination of Centre and South Italy for Transplantation). This program was designed to act on two levels: to create a large group of people directly involved in health care (physicians and nurses) motivated in organ procurement and transplantation, and to diffuse the "culture" of organ donation among lay people. This was achieved by means of scientific meetings inside the hospital and with conventions and TV programs, supported by an Association of Volunteers, where ethical and scientific problems of organ donation and transplantation were discussed in simple language. Various meetings were also held with high school students. During these meetings a questionnaire was distributed among students. Results of this questionnaire show that the main obstacles to organ donation are the "unclear" concept of "brain death" and religious feelings, but after the concept of brain death was explained, a significant number of students showed a different attitude toward organ procurement and transplantation. Results of this program are extremely encouraging (23 organ donations during the last 3 years). We hope to improve our results in the near future, and we do believe that a further and significant increase to our preliminary good results could be achieved by the possibility of performing at least kidney transplantation in our institution.

[Results of the multicenter study (A.C.O.I. Stapler Study Group) on 420 cases of esophagojejunal and 544 cases of colorectal anastomoses]. / Risultati dello studio multicentrico (A.C.O.I. Stapler Study Group) su 420 anastomosi esofago-digiunali e 544 colorettali.

The introduction of staplers in general surgery allowed to perform gastrointestinal anastomoses easier and with better results. Because many series report an important incidence of complications even using stapling instruments, the A.C.O.I. (Italian Association of General Hospital Surgeons), with the support of Auto Suture Italy, promoted a collaborative trial in Italy to evaluate the real incidence of complications after stapled colorectal or esophago-jejunal anastomoses. The study has been carried out during the period April 1990-December 1991 and 58 Centres throughout Italy participated with 420 esophagojejunostomies after Total Gastrectomy and 544 Colorectal anastomoses after Anterior Resection of the Rectum. Many variables were evaluated such as patients general conditions, the pathology and the site of anastomosis, the instrument used, the technique of reconstruction, if it was an urgent or an elective procedure, the incidence of intraoperative problems and the surgical experience. The most frequent complications were bleeding, leakage and stenosis. The incidence of bleeding was low in both groups, it was an occasional event not related with any of the variables previously described. Furthermore it was never important and never required reoperation or caused death of the patient. Leakage was the most frequent and serious complication (12.4% in colorectal anastomoses and 5.5% in esophagojejunostomies) and was mainly related to the incidence of intraoperative technical problems (tearing of the stump or purse string failure), to urgent procedures, to low and ultra low colorectal anastomoses and to centres with less experience, particularly with an experience of less than 50 mechanical anastomoses. Late complications such stenoses, were particularly frequent (8.4%) after a leakage and in very low colorectal anastomoses. Perioperative Mortality was very low in birth groups (1.1% for colorectal anastomoses and 2.6% for esophagojejunostomies) one of the lowest described in the Literature. This study seem to confirm that staplers are effective, safe and easy to use, showing a low incidence of complications and they make possible anastomoses otherwise technically impossible.

[Treatment of secondary intrahepatic calculosis]. / Il trattamento della calcolosi intraepatica secondaria.

The secondary intrahepatic stone is generally associated with an extrahepatic stone and depends on it. Since April 1979 to April 1988 10 cases of secondary I.S. have been treated by the authors. Four cases were treated by papillo-sphincterectomy and the stones were removed i.o. by choledochoscopy. Five cases were treated by a B-D anastomosis and the following extraction of the other stones were done by means of transhepatic choledochoscopy. Another case was treated by a B-D anastomosis while the remaining stones were removed by using both transhepatic choledochoscopy and the ESWL, treatment. The I.S. treatment has not been codified yet. The aim is to remove not just the stones but also to eliminate the responsible cause of stenosis. If surgery has been not able to solve the problem, other methodologies might be used in presence of big stones or stones of the fifth or the third segment.

Ultrastructural study of parietal cells before and after parietal cell vagotomy in patients with duodenal ulcer.

The records of 16 patients of a total of 402 who underwent parietal cell vagotomy without a drainage procedure for duodenal ulcer were reviewed. Biopsies of gastric mucosa were taken before the operation and six months, two years and three years postoperatively. Ultrastructural studies using electron microscopy detail the modifications of the parietal cells which are the main target of the vagal denervation procedure. The parietal cells are greatly modified within six months after parietal cell vagotomy with a significant reduction of the secretory surface of the cells and a sharp increase of tubulovesicular formations regain their preoperative morphologic appearance after two to three years but not their secretory capacity.

[Ultrastructural changes of hypertrophied myocardium in severe experimental hypoxia. Effects of diphosphothiamine and of an antagonist of the vitamin B1. (author's transl)]. / Modificazioni ultrastrutturali del miocardio ipertrofico in corso di ipossia sperimentale. Effetti della difosfotiamina e di una antivitamina B1

The ultrastructural changes occurring in hypertrophic heart cases during severe experimental hypoxia, conducted intermittently for 140 and 250 hours, are reported in the present study. For this purpose, serial right myocardial specimens of control and treated groups of animals were obtained and examined by electron-microscopy. Most areas of the individual myocardial tissue taken during prolonged degrees of exposures to normobaric hypoxia, showed an increased number of mitochondria, their prominent destructive changes, enlargement of cisternae of sarcoplasmic reticulum, reduction and derangement of the cristae and an increase of glycogen and lipif droplets cellular content. Different responses were associated with the various experimental designs which include simple hypoxia, hypoxia with administration of Diphosphothiamine (DPT, 30 mg/hie/Kg body weight) and hypoxia with administration of an antagonist of the vitamin B1, neopyrithiamine (PyTh, 20 mg/die/Kg body weight). Alterations in the fine structure of myocardial cells and cellular organelles could complement the increased glycolitic activity and phospholipid biosynthesis for the compensatory mechanism of the heart to hypoxic stimulus. These changes were most evident in the hypoxic animals treated with PyTh because of a large disturbance of energy production caused by the antivitamin. Most of ultrastructural and glycogen content changes disappeared when DPT was administered to the animals in hypoxia. However, the mitochondria were larger in size and their matrices had higher electron density than in the normal control animals. The significance of the morphological and biochemical findings are discussed.