[Celiac artery aneurysm: a case report]. / Aneurisma del tronco celaco: presentazione di un caso clinico.

The aneurysms of the celiac trunk are extremely rare. The authors describe a case of aneurysm of the celiac trunk dealt with aneu-rysmectomy and reconstruction by means of protesic graft made in Dacron. The patient was asymptomatic, and the aneurysm was discovered accidentally during abdominal computerized tomography (CT) for the stadiation of hepatic cirrhosis. The aneurysmectomy and the reconstruction have been executed by means of a prosthetic graft finish-terminal in Dacron, succeeding in preserving the three arteries originating from the celiac trunk (left gastric, hepatic, splenic). The histologic examination documented the degeneration of the medium trunk with loss of elastic fibers and atherosclerotic lesions. The postoperative course was complicated by hepatic ascites, and severe renal insufficiency. As a result of paracentesis and diuretic dose titration, the blood parameters and the conditions of the patient improved progressively until allowing the discharge on XL postoperative day in good conditions. Six months after, abdomen CT documented the integrity of the prosthetic graft and the absence of perianastomotic leak.

Laparoscopic fundoplication versus lansoprazole for gastro-oesophageal reflux disease. A pH-metric comparison.

BACKGROUND: Treatment strategies that abolish abnormal reflux could prevent long-term complications of gastro-oesophageal reflux disease. AIMS: To compare the efficacy of laparoscopic fundoplication and lansoprazole in abolishing abnormal reflux in patients with gastro-oesophageal reflux disease. PATIENTS: Study population comprised 130 patients referred for possible antireflux surgery and with heartburn as the dominant symptom. METHODS: After oesophageal manometric and pH-metric evaluation and detailed information 55 patients asked to undergo laparoscopic antireflux surgery while 75 chose a medical treatment regimen based on lansoprazole. Treatment efficacy was assessed by ambulatory oesophageal pH-monitoring. RESULTS: All 55 patients who underwent fundoplication became free of heartburn: oesophageal pH-monitoring gave normal results in 85%. In patients treated with lansoprazole, at individualized daily dosages titrated to abolish both heartburn and abnormal acid reflux, normal pH-metric results were obtained in 96% of cases (p<0.05 vs surgically treated patients). CONCLUSIONS: Lansoprazole at individualized dosages was significantly more effective than laparoscopic fundoplication, in the short-term, in abolishing abnormal reflux in gastro-oesophageal reflux disease patients.

How to decrease the non-compliance in a clinical trial.

BACKGROUND: A high compliance is an important scientific objective for a multicenter clinical trial and also an ethical responsibility. Some of non-compliance causes can be prevented during the enrollment phase by an accurate selection of subjects (quality of recruitment), other can be controlled after the recruitment, by a good organization of follow-up tests and visits (quality of organization). METHODS: The policy adopted in the Operative Center of the Delegazione Alto Lario della Lega Italiana per la Lotta contro i Tumori di Gravedona (Como) for obtaining a high compliance of women recruited in the Italian Tamoxifen Prevention Study are illustrated. RESULTS: The non-compliance rate of this center is low: 5.6 vs 23.3% of the whole Italian trial. CONCLUSIONS: The low non-compliance demonstrates the efficacy of the policy adopted.

[Gallbladder and common bile duct calculi: treatment with laparoscopy vs laparotomy. Costs and benefits]. / Litiasi colecisto-coledocica: trattamento laparoscopico vs. laparatomico. Costi-benefìci.

The cost-benefit ratio of laparoscopy vs laparotomy was evaluated comparing 2 groups of patients: 500 operated using traditional laparotomy and 500 operated via laparoscopy. The first parameter considered was the average hospital stay, which was 8.4 days (min. 3, max. 22 days) in group I (laparotomy) (Fig. 1) against 4 days (min. 2, max. 13 days) in group II (laparoscopy). Even more interesting were the results related to the average postoperative hospital stay: 5 days for laparotomy, 2 days for laparoscopy. Currently, 90% of patients submitted to laparoscopic cholecystectomy is discharged in the first postoperative day. The cost of the surgical procedure is 1,100,000 It. Lit. for laparotomic cholecystectomy and 2,130,000 It. Lit. for laparoscopic cholecystectomy. However, considering the cost of the daily hospital stay and adding the cost of the surgical procedure we already save 50% with the laparoscopic method. Furthermore, if we consider the time occurring between patients' discharge and return to work a 50% reduction of the postoperative recovery time is obtained. The conclusions of the Authors are the following: Laparoscopic cholecystectomy performed by skilled surgeons presents an incidence of complications comparable to traditional cholecystectomy. The operating time is almost the same for both methods. Operative costs are higher for the laparoscopic technique. Postoperative hospital stay is drastically reduced with the laparoscopic procedure. Return to work is assured in a shorter time after laparoscopy.

Low maternal serum levels of pregnancy associated plasma protein A (PAPP-A) in the first trimester in association with abnormal fetal karyotype.

OBJECTIVE: To assess the relation between maternal serum pregnancy associated plasma protein A (PAPP-A) in the first trimester and the outcome of pregnancy by karyotype. DESIGN: A retrospective study of PAPP-A levels in blood samples collected prior to chorionic villus sampling. SETTING: Milan, Italy. SUBJECTS: Five hundred twenty-two women aged 20 to 47, at 7 to 11 weeks gestation, prior to undergoing chorionic villus sampling. Four hundred forty-five women had a pregnancy with a normal karyotype; in 30 pregnancies the karyotype was abnormal (including 14 cases of Down's syndrome and 7 of trisomy 18). MAIN OUTCOME MEASURES: Normal or abnormal fetal karyotype. Serum PAPP-A at 6 to 11 weeks gestation measured by radioimmunoassay. RESULTS: The median value of PAPP-A in the abnormal group was 0.27 multiples of the normal median (MoM). This is significantly lower than the median value in the normal group (1.01 MoM) (95% CI for the difference 0.46-0.84 MoM; P < 0.00001 Mann-Whitney test). CONCLUSIONS: There is an association between low levels of PAPP-A in the first trimester with chromosome anomalies. Screening by measurement of PAPP-A might detect 60% of cases of Down's syndrome in the first trimester with a false positive rate of 5%.

First-trimester genetic diagnosis in multiple pregnancy: principles and potential pitfalls.

Both the principles of first-trimester genetic diagnosis in multiple pregnancy and the special considerations required to avoid potential diagnostic pitfalls are presented. The experience consisted of 65 cases of twins and one case of quadruplets. Dichorionic twins were recognized by sonography in 54 cases. Transabdominal aspiration was generally preferred to transcervical for obtaining chorionic tissue, although in two cases both approaches were used. Diagnostic error following erroneous sampling was reported in 3 out of 54 sets of dichorionic twins (5.5 per cent). When like-sex dichorionic twins cannot be differentiated by cytogenetic or DNA polymorphism studies, amniocentesis should be recommended to confirm the reliability of the result on chorionic tissue.

Doppler velocimetry in prolonged pregnancy.

Eighty-two patients at 287 days' gestation or longer were tested by nonstress test (NST), amnioscopy, ultrasound assessment of amniotic fluid volume, and Doppler velocimetry. Several maternal and fetal arteries were analyzed: uterine, umbilical, descending thoracic aorta, renal, and middle cerebral. During the study, other maternal-fetal functional indices were recorded: hPL, estriol, hematocrit, platelets, mean platelet volume, and uric acid. No abnormalities were found in the uterine, umbilical, middle cerebral, thoracic descending aorta, and renal artery velocimetry in post-dates gestations. However, a significant reduction of the time-averaged mean velocity in the descending thoracic aorta was associated with an increased incidence of oligohydramnios, meconium-stained fluid, abnormal NST, and cesarean delivery for fetal distress. The present study suggests that serial Doppler flow measurements of mean velocity of the fetal descending thoracic aorta may be a simple and rapid technique for identifying prolonged pregnancies at increased risk for perinatal complications.

Doppler ultrasound studies of the uterine arteries in spontaneous and IVF stimulated ovarian cycles.

The changes of uterine artery blood flow in women were studied throughout normal and in vitro fertilization (IVF) stimulated cycles. The obtained data showed that uterine blood flow variations are correlated to spontaneous or induced hormonal changes. Furthermore, Doppler investigation may be very important in predicting the pregnant state at a very early stage in patients enrolled in an IVF program.

Transabdominal and transcervical chorionic villus sampling: efficiency and risk evaluation of 2,411 cases.

Efficacy and risks of transcervical and transabdominal chorionic villus sampling (CVS) methods were evaluated in 1,501 and 910 cases, respectively. We reported a success rate of more than 99% for both sampling procedures and obtained an adequate amount of chorionic tissue in more than 96% of cases on the first attempt. However, the transcervical method was more difficult to learn and was contraindicated by a higher number of unfavorable clinical and anatomical conditions. Transabdominal sampling proved to be a less time-consuming procedure and could also be used after the 12th week of gestation. Bleeding/spotting (10.1%) and uterine cramping (2.5%) were the most frequent early complications following transcervical and transabdominal sampling, respectively. Uterine infection was rare (0.13%) and was reported only after cervical aspiration. No significant effects on fetal growth, preterm delivery, placenta disorders, congenital defects, and perinatal mortality following transcervical and transabdominal sampling, and for both procedures total fetal loss rate was less than 4%. This experience suggests that transabdominal needle sampling is the method of choice; however, transcervical aspiration appears more likely to succeed in a limited number of well-defined conditions.

Fetal intermediate lobe is stimulated by parturition.

The fetal pituitary gland secretes beta-endorphin in blood in response to delivery. However, other forms of endorphin have recently been observed in the fetal pituitary, such as N-acetyl-beta-endorphin, which is devoid of opiate activity, and a desacetylated form of alpha-melanocyte-stimulating hormone. Both endorphins originate in the pituitary intermediate lobe. The sensitivity of this lobe to labor stress was assessed by the evaluation of beta-endorphin, N-acetyl-beta-endorphin, melanocyte-stimulating hormone, and desacetylated alpha-melanocyte-stimulating hormone in maternal plasma and cord blood in 11 cases of vaginal delivery and 10 cases of elective cesarean section without labor. Plasma peptide levels were determined by specific radioimmunoassays after extraction on Sep-Pak C-18 cartridges and high-performance liquid chromatography fractionation. Cord blood samples of infants delivered vaginally showed higher beta-endorphin (8.5 +/- 1.6 pmol/L, mean +/- SE) and desacetylated alpha-melanocyte-stimulating hormone (13.6 +/- 3.2 pmol/L) levels than those delivered by elective cesarean section (3.7 +/- 0.8 and 4.2 +/- 1.1 pmol/L, for beta-endorphin and desacetylated alpha-melanocyte-stimulating hormone, respectively). N-acetyl-beta-endorphin and alpha-melanocyte-stimulating hormone levels do not differ in relation to the mode of delivery. In maternal circulation beta-endorphin levels were higher in those delivered vaginally (5.2 pm 1) than in women who had cesarean sections (2.5 +/- 0.5 pmol/L), whereas no changes were found for the other peptides. In vaginal deliveries, the level of desacetylated alpha-melanocyte-stimulating hormone was higher in cord blood (13.6 +/- 3.2 pmol/L) than in maternal plasma (6.5 +/- 3 pmol/L); there were no significant differences with regard to the other peptides. Fetal and maternal levels of all the peptides were similar in cases of cesarean section. We conclude that parturition activates proopiomelanocortin peptide release from both the anterior and the intermediate pituitary lobe and that the fetus secretes the appropriate beta-endorphin molecule, that is, the peptide able to bind opiate receptors. Concomitant secretion of desacetylated alpha-melanocyte-stimulating hormone may occur with adrenal androgen activation at birth.

Maternal and embryonal/fetal beta-endorphin concentrations during the first trimester of pregnancy.

In this study, we have determined the beta-endorphin concentrations in the plasma of 11 cases during the first 3 months of pregnancy, as well as the corresponding products of conception, collected by hysterosuction, during the course of voluntary abortion. The purpose of this study is to compare the values obtained by the analysis of maternal plasma and the material collected by hysterosuction. The beta-endorphin concentrations were obtained by radioimmunologic methods using a kit which allows a separation from beta-lipotropin. The specimens obtained by hysterosuction (8 +/- 1.7 pmol/l) showed significantly higher levels of beta-endorphin than those observed in the maternal plasma (2.6 +/- 0.3 pmol/l). Thus, already in the earliest gestational period, the data are consistent with a feto-placental origin for this opioid peptide.

Transabdominal chorionic villus sampling. Clinical experience of 1159 cases.

The efficacy and risks of transabdominal free-hand ultrasound-guided fine needle aspiration technique were evaluated in 1159 pregnancies submitted to chorionic villus sampling (CVS) in the first trimester and early in the second trimester. An adequate amount of chorionic tissue was obtained by two needle insertions in 99.7 per cent of cases, and a second tapping was needed in 3.5 per cent of cases. A local peritoneal reaction was the only early complication clearly related to the procedure, and it occurred in 0.3 per cent of cases without any adverse effect on the maternal and fetal outcome. The correct abortion rate in 716 consecutive concluded pregnancies was 2.4 per cent, while the rate of late obstetrical complications and perinatal mortality and morbidity compares favourably with the rates in the general population. Because of its simplicity and practicability, transabdominal aspiration is the procedure of choice and is especially recommended for intensive CVS routine conditions.

Transabdominal versus transcervical chorionic villus sampling: a randomized trial.

Chorionic villus sampling (CVS) is still considered to be an applied research method and its safety is under evaluation in randomized trials. Moreover, no knowledge is available about the comparative efficiency and risks of transcervical and transabdominal chorionic villus sampling. A preliminary analysis of the first 639 consecutive cases of an ongoing trial in which cases are randomized between transcervical and transabdominal aspiration techniques shows: (a) an overall sampling success rate of greater than 99% obtained by both techniques; however, the number of repeat insertions of the sampling device was higher for the transcervical route; (b) a significant shift towards lighter tissue samples for the transabdominal route; however, very light specimens, less than 10 mg, were equally distributed in both groups; and (c) approximately 10% of cases underwent a different procedure from the allocated one because of an anatomical or clinical contraindication, with a higher rate of deviation for the transcervical technique.

The yolk sac in early pregnancy failure.

An attempt was made to visualize the yolk sac in 845 patients scheduled for chorionic villi sampling. The distribution of yolk sac diameters and the interpolating growth curve up to 11 weeks of development were analyzed in 239 pregnant women who were delivered of normal infants. The highest visualizing rate of the yolk sac in normal pregnancies was 97 at 7 weeks of gestation. A total of 130 miscarriages occurred before chorionic villi sampling. In these cases, the diameter of the yolk sac versus crown-rump length tended to be larger than found in normal pregnancies. The visualizing rate of the yolk sac in miscarriages after the embryo had been formed was significantly higher in those women who demonstrated fetal heart activity (82.1%) than in those who did not (54.5%). On the other hand, the yolk sac was observed in 44% of miscarriages without a visible embryo. These findings suggest different types of missed abortion. An abnormal karyotype was observed in 23 of 29 chromosomal analyses performed on aborted specimens. An abnormal karyotype was observed in all eight cases with only a yolk sac-like structure within the gestational sac.

Prevalence and distribution of chromosome abnormalities in a sample of first trimester internal abortions.

Cytogenetic analysis was performed directly on villus material from 202 samples obtained at the evacuation of the uterine cavity in cases of retained abortion in the first trimester, identified as such by ultrasound examination. A precise delineation of the karyotype was obtained in 94% of the cases, while the efficiency of karyotype analysis in samples of spontaneous abortion was not higher than 50%. An abnormal chromosome constitution was found in 145 fetuses (76.7%) of which 117, including mosaics, were aneuploid (70%), 16 polyploid (8.5%) and 12 had structural abnormalities (6.3%). The relative proportion of chromosome abnormalities in this material is higher than that found in spontaneous abortion for trisomies and double trisomies, but lower for 45,X and polyploidy. The method was found to be efficient in obtaining fetal karyotypes also in those cases in which the villous material was scarce (1 mg), and thus it seems appropriate for routine cytogenetic studies in the first trimester abortions.

Transabdominal chorionic villus sampling: a freehand ultrasound-guided technique.

A simple transabdominal chorionic villus sampling method, carried out with a 20-gauge spinal needle under ultrasound guidance, was evaluated in 100 cases selected for genetic evaluation in the first trimester. Its use was limited to the management of anatomic and clinical conditions that contraindicated transcervical aspiration. The high efficacy of the method was demonstrated by an ability to obtain enough villus tissue for karyotyping in all but one case. In 94% of the cases, only one pass of the needle was required. Although the only complication observed was light bleeding in four cases, the safety of the method needs more extensive evaluation.

Chorionic villus sampling: an analysis of the obstetric experience of 1,000 cases.

Chorionic villus sampling was performed between 7 and 12 weeks gestation in 1,000 patients, 935 of whom intended to continue after fetal diagnosis. Transcervical and Transabdominal aspiration techniques were used providing a sampling success rate of 99 per cent. Anatomical and clinical contraindications to transcervical aspiration were pointed out, and the complementary role of the transabdominal approach evaluated. In the 615 concluded pregnancies an overall abortion rate of 4.1 per cent was observed. A significant association between fetal loss and number of catheter insertions was demonstrated. Bacterial inoculation by catheter insertion and colonization of uterine cavity was suspected as the cause of chorionamnionitis diagnosed in two cases (0.2 per cent) after CVS. Bleeding was the most frequent early complication (12.0 per cent) following chorionic aspiration, but was not significantly related to pregnancy wastage. Late complications, i.e. premature rupture of membranes (0.8 per cent), preterm delivery (6.3 per cent), perinatal losses (1.2 per cent), placental disorders (1.6 per cent), and congenital defects (2.6 per cent) did not exceed the expected values. Normal intrauterine growth patterns were ultrasonically estimated by cross-sectional and longitudinal studies, while the weight at birth was normally distributed in the range of the general population.

Feto-maternal transfusion after chorionic villus sampling: clinical implications.

Feto-maternal transfusion following chorionic villus sampling (CVS) in the first trimester of pregnancy was evaluated by alpha-fetoprotein (AFP) level determination in maternal serum before and after sampling. Some fetal haemorrhage was suggested in 72% of 283 continuing pregnancies by a significant increase of maternal AFP level. Fetal bleeding appeared to stop a short time after CVS, and did not complicate detection of neural tube defects (NTDs) in the second trimester. The change in the maternal serum AFP level was correlated with the size of the chorionic tissue specimen, but no association was observed between fetal and neonatal outcome. The risk of maternal rhesus (Rh) iso-immunization must be taken into account, and anti-D immunoglobulin administrated after CVS. Maternal Rh immunization should be considered as a contraindication to CVS.