Technical note: MRI device for active stress of the knee. The practical approach and preliminary data.

PURPOSE: The aim of this study was to test the potential application of a new nonmagnetic device capable of diagnostically evaluating stress of the knee joint during magnetic resonance imaging (MRI) investigation. MATERIALS AND METHODS: The Knee Loader prototype was applied to an MRI scanner with a 1.5-T superconducting magnet. Twenty healthy subjects were assessed in both baseline conditions and again after applying a known amount of force (in kg) to various joints. Standard MR techniques were employed. The degree of anterior and posterior tibial translation and variations in the width of the rim in varus and valgus were measured in millimetres. RESULTS: In 12 cases, the anterior drawer test demonstrated a rest-stress variation between 0 and 2 mm, and in two cases, the posterior drawer test was between 1 and 3 mm. In the four cases assessed at valgus angulations and the two cases assessed at varus angulations, the opening of medial and lateral compartment was between 1 and 2 mm. CONCLUSIONS: The preliminary data regarding this new MR method, performed using the Knee Loader prototype, demonstrate that it is possible to obtain functional images of the knee comparable with those obtained by traditional radiological techniques. Its potential advantage lies in the fact that, given the absence of ionising radiation, the investigation can be repeated as necessary, ensuring anatomical visualisation of all joint components under stress.

Laparoscopic vs open hepatic resection: a comparative study.

BACKGROUND: Although the feasibility of minor laparoscopic liver resections (LLR) has been demonstrated, data comparing the open vs the laparoscopic approach to liver resection are lacking. METHODS: We compared 30 LLR with 30 open liver resections (OLR) in a pair-matched analysis. The indications for resection were malignant disease in 47% of the LLR and 83% of the OLR. The average size of the lesions was 42 mm for LLR and 41 mm for OLR. Five wedge resections, 12 segmentectomies, and 13 bisegmentectomies were performed in each group. RESULTS: The conversion rate for LLR was nil. The mean operative time was 148 min for LLR and 142 min for OLR. Mean blood loss was minimal in the LLR group (320 vs 479 ml; p < 0.05). Postoperative complications occurred in 6.6% of the patients in each group; there were no deaths. The mean postoperative hospital stay was shorter for LLR patients (6.4 vs 8.7 days; p < 0.05). In tumors, the resection margin was <1 cm in 43% of the LLR patients and 40% of the OLR patients ( p = NS). CONCLUSIONS: Minor LLR of the anterior segments has the same rates of mortality and morbidity as OLR. However, the laparoscopic approach reduces blood loss and postoperative hospital stay.

Laparoscopic cholecystectomy in cirrhosis: contraindication or privileged indication?

Until recently, cirrhosis has been considered to be an absolute or relative contraindication of laparoscopic cholecystectomy. An evaluation of benefits and risks of laparoscopic cholecystectomy in the treatment of gall bladder lithiasis in cirrhotic patients is presented. Thirty-three consecutive laparoscopic cholecystectomies in patients with cirrhosis were performed between March 1990 and March 1997. During the same period, no open cholecystectomy was performed in patients with cirrhosis. There was no morbidity or mortality; the conversion rate was 6% (2/33). No patient received blood transfusion, and the mean hospital stay was 2.8 days. These results favorably compare with the results of open cholecystectomy. Specific advantages of laparoscopic cholecystectomy in patients with cirrhosis include the absence of wound infection and a lower rate of postoperative hepatic failure. Finally, laparoscopic surgery reduces the risk of viral contamination (the hepatitis B virus, the hepatitis C virus, or the human immunodeficiency virus) of the surgical staff.

[The use of intraoperative topical bupivacaine in the control of postoperative pain following laparoscopic cholecystectomy]. / L'utilizzo della bupivacaina per via topica intraoperatoria nel controllo del dolore postoperatorio dopo colecistectomia laparoscopica.

Taking the starting point of a trial conducted on female patients who had undergone laparoscopic gynaecologic operations, which shows a good control of the postoperative pain through intraperitoneal infusion of local anaesthetic during the operation, the authors have proposed to reproduce the study on patients undergoing a laparoscopic cholecystectomy. The trial was conducted on two groups, a 50 patients each, undergoing an intraperitoneal infusion of local anaesthetic (bupivacaine) and placebo (physiologic solution) respectively. The results regarding the rate of patients who had felt postoperative pain (88% in the first group, 96% in the second group) and the different places of it, the pain in the right shoulder particularly (28% in the first group, 22% in the second), the intensity in the time and the different requests of analgesics new recorded. The results don't show statistically significant differences and they are different from the gynaecologic ones. The authors suggest, as reasons for these differences, the various moments of the liquid inoculation (at the beginning of the operation in gynaecology, at the end of it in cholecystectomy) and the Trendelemburg position of patients during the gynaecologic operation, on the contrary of cholecystectomy operations. They suggest, in the end, that the trials esecutions on numerically larger groups could bring more significant results.

[Laparoscopic treatment of non parasitic liver cysts]. / Traitement coelioscopique des kystes non parasitaires du foie.

Various surgical treatments have been proposed for highly symptomatic hepatic cysts: enucleation, fenestration, hepatic resection and liver transplantation. The advent of laparoscopic surgery has provided new opportunities but, at the same time, has increased the uncertainties concerning the correct management of these patients. This study evaluates the results and defines the indications for laparoscopic fenestration of symptomatic nonparasitic hepatic cysts, either solitary or diffuse. 31 patients were observed between November 1990 and October 1995: 15 with solitary cysts and 16 with policystic liver disease (PLD). After a careful review of the symptoms, 8 patients (5 with a solitary cyst and 3 with a PLD) were excluded from surgical treatment and 23 were treated by laparoscopic fenestration. There was no mortality. Ten of the 23 patients had a solitary cyst with a median diameter of 11.6 cm (range 6-20 cm). No conversion to laparotomy was necessary. There were no complications and complete regression of symptoms was obtained in all patients. No recurrences were observed. In the PLD group (13 patients), two patients had to be converted to open fenestration (15%). There were no deaths and the surgical morbidity was limited to two cases of postoperative persistent ascites. Symptomatic relief was obtained in 64% of patients, but symptoms recurred in 36%. A subgroup of PLD at high risk for recurrence was identified and a classification of PLD is proposed: PLD type I characterized by large cysts mainly located in the anterior hepatic segments, and PLD type II characterized by numerous small cysts through the liver which do not represent a good indication for laparoscopic fenestration.

Current management of common bile duct stones in northern Italy.

In order to obtain a complete picture of the current management of cholecystocholedocal lithiasis in northern Italy we've conducted the present survey. In the years 1992-1993, among 7,861 cholecystectomies, 665 patients with gallbladder and common bile duct stones were treated in 49 surgical departments. Some 271 (43%) were treated by traditional methods: open surgery or endoscopic sphincterotomy followed by laparotomic cholecystectomy; 313 patients (49%) were treated by endoscopic sphincterotomy followed by laparoscopic cholecystectomy and only 38 (6%) were treated by one-stage laparoscopy, either by a transcystic approach (27) or by laparoscopic choledochotomy (11). Morbidity and mortality were not significantly different in the different groups. We conclude that open surgery and sequential minimal invasive treatment are the standard approaches to cholecystocholedochal lithiasis in this first stage of the laparoscopic era. The laparoscopic management of common bile duct stones is at present confined to surgical departments specially devoted to laparoscopic surgery.

Preoperative chemoembolization for hepatocellular carcinoma.

In a group of 396 patients who had chemoembolization for hepatocellular carcinoma (HCC) between 1984 and 1991, 67 underwent surgery (segmentary/subsegmentary resections: 31; or transplantation: 36). Morbidity was limited to hepatic insufficiency (seven), arterial thrombosis (two), vasculitis (five), cholecystitis (two), and hepatic abscess (one). Perioperative mortality was 5.5% for transplantation and 6.7% for resection. Histological examination of resected specimens showed a total or subtotal tumor necrosis in 58% of the cases, and a necrosis between 50% and 80% in another 18%. Data on recurrence and long-term survival are not significant if retrospectively compared with non-chemoembolized surgically treated patients. Chemoembolization is known to be an effective palliative treatment of HCC. Its role in the preoperative setting is sustained by a 58% of total or subtotal histological necrosis. A multicentric prospective trial to evaluate the role of preoperative chemoembolization for long-term survival and recurrence of HCC is advocated.

Primary treatment of hepatocellular carcinoma by arterial chemoembolization.

Two hundred and ninety-one patients with hepatocellular carcinoma were treated by chemoembolization (CE), using ethiodized oil, doxorubicin, and a gelatin sponge. Patients with thrombosis of either the portal vein or a main branch were excluded. The mortality rate in the first 2 months after treatment was 7% in noncirrhotic patients, 2.8% in patients with class A cirrhosis, 8% in patients with class B cirrhosis, and 37% in patients with class C cirrhosis. The tumor diameter remained the same in 55.3% of patients, was reduced by up to 50% in 20% of the patients, was reduced by more than 50% in 7.3% of the patients, and almost completely disappeared in 1.8% of the patients. The diameter of the tumor increased in 15.6% of patients. Forty-three patients underwent a resection or transplantation after chemoembolization. Histologic examination of the specimens revealed significant necrosis of the tumor. The long-term survival rate at 2 years was 49% for class A cirrhotics, 29% for class B cirrhotics, and 9% for class C cirrhotics. Complications included cholecystitis (10%), vasculitis (14%), renal decompensation (13%), an increase in ascites (14%), and jaundice (12%). Chemoembolization is an effective and safe initial treatment for hepatocellular carcinoma. It is effective in producing tumor necrosis and reducing the size of the tumor. Improvement in survival was noted when patients who underwent chemoembolization were compared with an historical series of untreated patients, and resection and transplantation are kept as options.

[Angiodysplasia of the colon]. / Le angiodisplasie del colon.

Ascending colon angiodysplasia is a cause of colorrhagia, particularly if the patients are more than 55 years old. Therapy is primarily surgical and it consists generally in right hemicolectomy. Two cases personally observed are reported and a survey of the literature is made.

[Spontaneous rupture of the spleen caused by primary amyloidosis. Description of a clinical case]. / Rottura spontanea di milza da amiloidosi primaria. Osservazione di un caso clinico.

Spontaneous rupture of the spleen in primary amyloidosis is an uncommon event. After a review of the pertinent literature (10 case-reports between 1948 and 1987) a case of spontaneous splenic rupture with hemoperitoneum is presented. The diagnosis depends on the demonstration of amyloid deposit in splenic and hepatic tissues.

[Benign monoclonal gammopathies. Case reports]. / Le gammopatie monoclonali benigne. Contributo casistico.

30 cases of patients presenting a benign monoclonal gammopathy (b.m.g.) have been studied, stress being laid on concomitant conditions, cases with likely typical symptomatology, atypical variations over time in certain patients of the monoclonal Ig level, and cases which, before they can be called benign, need further controls. Two cases of transitory b.m.g., one in a child, with double polymerization state, are also presented.

[Benign monoclonal gammopathies. Critical review]. / Le gammopatie monoclonali benigne. Revisione critica.

During a review of the relevant literature, the view is expressed that the term "monoclonal" expresses no more than an operative concept. A classification of the benign monoclonal gammopathies is proposed in accordance with their aetiopathogenesis. Stress is laid on the importance of antigen stimuli and self-maintenance of the tumour mass below a certain number of cells. Reference is made to the possible typical symptomatology and criteria for the differential diagnosis of myeloma and Waldenström's disease are put forward. Inter alia, emphasis is placed on the little significance of Bence-Jones proteinuria for the purpose of differentiation. Models of atypical behaviour are presented.

[Benign monoclonal gammopathies. General clinical considerations on 30 cases]. / Le gammopatie monoclonali benigne. Considerazioni cliniche generali su 30 casi.

With reference to a previously published series, an electronic computer is used to analyse clinical data and some criteria for diagnosing benign monoclonal gammopathies are set out.