[Color Doppler echography in the diagnosis of deep venous thrombosis of the lower limbs]. / L'ecocolordoppler nella diagnosi della trombosi venosa profonda degli arti inferiori.

Deep venous thrombosis (DVT) is a common and severe disease which can produce a pulmonary embolism as an acute consequence and post-phlebitic syndrome as a late complication. Since DVT symptoms and clinical features are almost no sensitive and specific, its diagnosis is usually achieved by instrumental exams. Until few years ago phlebography was considered the "gold standard" diagnostic test, although its invasivity prevented it from becoming routinely used in symptomatic and non-symptomatic patients. The aim of our study was to emphasize the usefulness of echo color Doppler (ECD), a non-invasive method, as a first-choice exam to diagnose and manage the therapy of DVT symptomatic patients and to address an early diagnosis in high risk non-symptomatic patients. We studied 375 patients, aged from 13 months to 92 years. In most of the cases patients were seen because suffering from DVT symptoms, after surgery, or because suspected to have a pulmonary embolism. All the patients underwent a venous ECD of the lower limbs, whereas 16 of them had also a phlebography. ECD disclosed an acute DVT in 15% of the patients and a chronic DVT in 3% of them, whereas 17% of the cases were diagnosed as having other pathologies which can clinically mimic a DVT. ECD sensitivity and specificity is higher than that of other exams, both invasive and non invasive, as it allows a thorough assessment of both iliac and distal vessels, a better detection of non-occluding wall thrombi, and has been found to be very helpful in the evaluation of chronic DVT changes.

Duplex ultrasound diagnosis of symptomatic proximal deep vein thrombosis of lower limbs.

Real time ultrasound (US) was used to examine 165 consecutive inpatients with clinically suspected deep vein thrombosis of lower limbs. In order to evaluate accuracy, the results of non-invasive techniques were compared with ascending venography, performed in all patients. Assessment included only femoro-popliteal veins, because of difficulty in visualizing calf vein with US. Diagnosis of thrombosis was based on noncompressibility of the examined veins; pulsed Doppler provided further information by evaluating blood flow. In our series Duplex ultrasound was very accurate in detecting acute thrombosis of the proximal veins, sensitivity being 97% and specificity 98%. With US it is also possible to detect conditions that mimic deep vein thrombosis, such as muscular rupture, hematoma, popliteal cyst or compressive tumors. In conclusion US is considered a valid alternative to contrast venography in the diagnosis of proximal vein thrombosis of lower limbs.

[Recanalization with laser and angioplasty of atherosclerotic lesions of the legs. Personal experience with 31 treated lesions]. / Ricanalizzazione mediante laser ed angioplastica nelle lesioni aterosclerotiche degli arti inferiori. Esperienza personale su 31 lesioni trattate.

From January to November 1989, 31 iliac and femoro-popliteal atherosclerotic lesions were treated in 29 patients (age range: 33-80 years) by means of percutaneous laser-assisted angioplasty. The lesions were 6 iliac tubular stenoses, 6 iliac occlusions and 19 femoro-popliteal occlusions, 2-20 cm long. The laser equipment employed was in 10 cases a Cardiolase 4000 Nd:YAG "hot tip" unit, and in 21 cases a Nd:YAG "sapphire contact probe" unit. Initial success was achieved in 23/31 lesions (74%); the follow-up, by clinical examination, Doppler US, and ankle-arm pressure index performed every 4th month, showed 1-year actuarial patency of 80% for femoro-popliteal occlusion and 100% for iliac lesion, with 87% cumulative patency. Overall complication rate was 22.5%. There were 6 local complications, 4 of which were hematomas at the arterial puncture site, and 2 were performation of the superficial femoral artery, all without any clinical sequelae; one patient developed rethrombosis within 72 hours from treatment, which needed amputation after an emergency bypass. Our preliminary results show no significant improvement when compared with conventional balloon angioplasty results both in immediate success rate and in short-to-midterm patency; furthermore, laser therapy was burdened by a higher complication rate. We believe that laser angioplasty should be employed only in arterial occlusion uncrossable with angiographic guidance alone.

Transinguinal dissection of the femoral artery for aorto-bifemoral bypass.

The authors report a surgical technique for high approach to the common femoral artery, just below the inguinal ligament, which can be useful in cases of difficult dissection of the femoral region or those with diffuse fibrosis or multiple scars. It is also useful when there is a concomitant inguinal hernia to repair.

[Ultrasonography in the diagnosis of deep venous thrombosis of the legs]. / Gli ultrasuoni nella diagnosi di trombosi venosa profonda dell'arto inferiore.

One hundred consecutive inpatients with clinically suspected deep venous thrombosis (DVT) were examined by US; the last 19 cases were studied also by means of color-Doppler US. In order to evaluate the method reliability, US results were compared with those obtained with contrast venography, which was performed on all patients. The studied region included the femoro-popliteal vein, while no attempt was made to image the calf veins, which are difficult to evaluate with US. In our series, venographic results were in substantial agreement with US findings, with 99% and 100% sensitivity and specificity, respectively. Diagnosis was based only on noncompressibility of the thrombotic vein, despite the absence of visible clots; pulsed Doppler information supported diagnosis by evaluating blood flow. Further diagnostic progress was provided by color-Doppler US, which allows flow lumen to be defined in color. US also allowed the detection of the conditions mimicking DVT, such as muscular ruptures, hematomas, popliteal cysts, or compressive tumors. In conclusion, US and color-Doppler US prove to be valid alternatives to contrast venography in the diagnosis of proximal DVT of the lower limbs.

[Fractures of the pelvis and associated abdominal lesions]. / Fratture del bacino e lesioni addominali associate.

106 cases of pelvic fracture and blunt abdominal trauma are reported and relationships between type of fracture, associated lesions and prognosis assessed. The presence of associated lesions, with the exception of urologic types, would appear to be correlated to the extent and prevalent application site of the trauma rather than to fracture morphology. The prognosis for patients with pelvic fractures is related to the frequency of associated lesions of intra-abdominal viscera and urological or retroperitoneal vascular structures.

[Reliability of ultrasonic diagnosis in hypertrophic stenosis of the pylorus]. / L'affidabilità della diagnosi ecografica nella stenosi ipertrofica del piloro.

Ultrasound diagnosis of pyloric stenosis depends on the typical "target" and "cervix" pictures, respectively in transverse and longitudinal scan. Furthermore, pyloric dimensions can be considered pathologic when the muscular wall is greater than or equal to 4 mm. in width, having a maximum diameter greater than or equal to 5 mm. and the pyloric canal is greater than or equal to 18 mm in length. At the Department of Paediatric Surgery of Parma, from 1986 to 1988, 34 infants were studied by ultrasound, basing on clinical suspect of pyloric stenosis. 22 of them were subsequently operated on. Pyloric ultrasound was diagnostic in 20 cases, negative in 1 and doubtful in 1, confirming its reliability in 90-95% of cases. No false positive findings were recorded. Basing on these results, the Authors believe that ultrasound must be the first choice in case of clinical suspect of pyloric stenosis in infancy, because of its high diagnostic value and safety. X-ray studies should be indicated only in doubtful cases.

Diagnostic problems in a Wilms' tumour of the horseshoe kidney.

The authors report on a case of Wilms' tumour in a horseshoe kidney in a child with correct preoperative diagnosis. They emphasise the superiority of the ultrasound and CT scan studies. A brief discussion of the surgical approach in the different presentations is made. The authors suggest, because of the predisposition of the horseshoe kidney to develop Wilms' tumour to perform, an annual ultrasound study for its surveillance.

Rapid sequence of events in gallstone formation in man.

A prospective analysis was carried out on 19 adult patients who had undergone total gastrectomy for gastric cancer with truncular vagotomy and postoperative TPN, to evaluate the gallstone formation sequence in man. The patients underwent gallbladder ultrasonography before surgery, then at least once a day during the period of postoperative fasting and TPN (about 15 days) and during the first days after oral refeeding. No patients showed cholelithiasis or biliary sludge at preoperative ultrasonography; none showed cholesterol crystals at preoperative duodenal drainage. 10 of the 19 patients were sludge-positive during the first two weeks of TPN (2 after 3 days, 7 at day seven, 9 at day nine). 6 patients who were initially sludge-positive developed microlithiasis: 1 after 7 days, 2 during TPN and 3 after oral refeeding. These results lead the authors to suggest that human lithogenesis in particular conditions may be faster than that observed so far in animal models, and that the very rapid events in gallstone formation observed in this study concern the formation of pigment stones.

Sludge and microlithiasis of the biliary tract after total gastrectomy and postoperative total parenteral nutrition.

We have evaluated the incidence and evolution of sludge, microlithiasis and lithiasis formation of the biliary tract in 12 patients who underwent total gastrectomy and postoperative total parenteral nutrition (TPN) beginning immediately after operation. To this end, serial ultrasonographic studies are carried out every 72 hours during TPN and every seven days after oral refeeding and then once a month for three months. Sludge of the gallbladder was demonstrated in five of the 12 patients after a minimum period of nine days after the operation, and in four of these, microlithiasis of the biliary tract was subsequently revealed. In two of these four patients, the stones dissolved spontaneously, while in the remaining two patients, no change occurred in dimension after intervals of six and seven months, respectively. In all instances, sludge and microcalculi were completely "silent." This study was done to underline the high incidence of biliary tract sludge and microlithiasis in the patients examined and to indicate the necessity for preventive measures against the possible and serious complications of this disease as well as acute pancreatitis.

[Renal oncocytoma. Ultrasonographic study of 4 cases]. / L'oncocitoma renale. Studio ultrasonografico di 4 casi.

The authors report four cases of renal oncocytoma investigated by echography and proved by histology after surgery. Describing the clinical cases, after a brief review of the literature, the radiologic findings are analysed with particular regard to the sonographic signs that can preoperatively differentiate oncocytomas from carcinomas. The authors conclude that the only sonographic distinguishing feature is a quite characteristic central hyperechoic streak corresponding to the fibrous scar, frequently found in this benign tumor.

[Hepatic abscesses secondary to peritonitis: puncture and ultrasonically guided transparieto-hepatic drainage]. / Ascessi epatici secondari a peritonite: puntura e drenaggio transparietoeopatico ecoguidato.

The Authors describe one case of duplex and separated hepatic abscesses secondary to perforated appendicitis and peritonitis. A contemporary literature review confirms the actual rarity of this entity. The patient was treated by percutaneous and transhepatic puncture and drainage of abscesses under sonographic control in two different stages. Material and methods of this technique are herein reported, in particular those concerning the management of the smaller of the two abscesses, located posteriorly into the lower segment of the right lobe of the liver, having a more difficult approach. The therapeutic results were excellent: either few days later percutaneous treatment than two months later after the patient was discharged, the clinical and sonographic controls confirmed a successful recovery.

[Villous adenoma of the duodenum]. / Gli adenomi villosi del duodeno.

The authors study the diagnostical problems, especially those involved in the preoperative diagnosis of malignancy, of four cases of duodenal villous adenoma. A more frequent use of endoscopy can allow the observation of this lesion in early stage, such as to ensure recovery through an intervention as scarcely demolishing as possible. However, surgeons plotting the strategy of operation should bear in mind the potential malignancy of duodenal villous adenoma.