Right post-traumatic diaphragmatic hernia with liver and intestinal dislocation.

Right diaphragmatic hernia is an uncommon injury following abdominal trauma. A case of delayed right post-traumatic diaphragmatic hernia is presented. The patient referred us with wheezing and cough since 1 month. A chest-abdominal computed tomography scan demonstrated a large diaphragmatic defect with liver and intestinal dislocation. The patient underwent surgical intervention with diaphragmatic repair. No complications were observed during admission and follow-up is actually negative for recurrence.

Black esophagus: acute esophageal necrosis, clinical case and review of literature.

Black esophagus is a rare, multifactorial disease. A case of acute black esophagus following pancreatic resection is presented. The patient referred us with a specific gastrointestinal bleeding. An esophagogastroduodenoscopy confirmed the diagnosis. We performed conservative treatment with complete esophageal re-epithelization and negative follow-up for stenosis or necrosis relapse.

A standardized protocol for the perioperative management of myasthenia gravis patients. Experience with 110 patients.

BACKGROUND: Video-assisted thoracoscopic extended thymectomy (VATET) is well established in the treatment of myasthenia gravis; however, patient selection remains controversial. Perioperative management protocol is lacking, and concerns regarding post-operative myasthenic crisis still remain. We performed a retrospective observational study evaluating the impact of the introduction of a protocol in the perioperative management of patients with myasthenia gravis who underwent VATET. METHODS: The perioperative management protocol was developed by a team of neurologists and anesthesiologists who reviewed the literature and their previous experience on myasthenia gravis patients. Respiratory, clinical, and neurological patient features were included in the protocol evaluation. A retrospective review of patients who underwent VATET before and after introduction to the protocol was finally performed. RESULTS: The medical records of 66 patients (pre-protocol group) and 44 patients (protocol group) were available for the study. In the pre-protocol group, 17 patients (26%) were admitted to intensive care unit (ICU) during the post-operative period, while three patients (6.8%) of the protocol group met the criteria for ICU post-operative admission. This resulted in a reduction of 73.5% of patients admitted to ICU (P = 0.023) and in an 80% (P = 0.002) reduction of the use neuromuscular blocking agents. Two post-operative myasthenic crises preceded by bulbar symptoms (1.8%) were identified in the pre-protocol group patients. CONCLUSIONS: Although the application of our protocol results in a substantial reduction in the recovery of patients in the ICU and in hospital costs, there was no substantial difference in mortality and morbidity between patients admitted to the surgical ward or to ICU.

Clinical and histopathological risk factors to predict sentinel lymph node positivity, disease-free and overall survival in clinical stages I-II AJCC skin melanoma: outcome analysis from a single-institution prospectively collected database.

BACKGROUND: To investigate if the tumour infiltrating lymphocytes (TILs) are able to predict the sentinel lymph node (SLN) positivity, the disease-free survival (DFS) and overall survival (OS) in clinical stages I-II AJCC primary cutaneous melanoma (PCM). METHODS: The study included consecutive patients with PCM, all diagnosed, treated and followed up prospectively. Logistic regression was used to investigate the association between DFS, OS, SLN positivity and Breslow thickness, Clark level, TIL, ulceration, lesion site, gender, regression and age. RESULTS: From November 1998 to October 2008, 1251 consecutive patients with PCM were evaluated. Median age was 51 (range 15-96) with 32.2% (N=393) of them older than 60; 44.8% of them were males. Of the whole series, a total of 404 patients with primary vertical growth phase (VGP) melanoma and no clinical evidence of metastatic disease underwent SLN biopsy. Of these, 74 (18.8%) had a positive SLN. In a multivariate analysis, primary melanoma on the extremities versus that on the axial locations (truncal and head/neck) (OR 0.49, 95% CI 0.25-0.98, p 0.04) and TILs (TILs versus no TILs) (OR 0.47, 95%CI 0.25-0.90, p 0.02) were predictive for lower probability of SLN involvement, while thickness (>4mm versus 0-1mm) (OR 24, 19, 95% CI 4.91-119.13, p<.001) was predictive for higher risk of SLN positivity. A multivariate stepwise analysis confirmed these results. The histological status of the SLN was the most significant predictor of DFS and OS. Patients with a negative SLN had a 5-year DFS of 75.9%, compared with 35.2% in patients with a positive SLN (p<.0001) and a 5-year OS of 88.7% versus 42.9%, respectively (p<.0001). CONCLUSIONS: Our study demonstrates that the absence of TILs predicts SLN metastasis, in multivariate analysis the SLN positivity predicts DFS and OS.

Laparoscopic transduodenal papillosphincteroplasty.

In the past 20 years, the approach to biliary lithiasis has changed tremendously as a result of advances in endoscopic and laparoscopic techniques. The two most important open surgical techniques involve extraction of the stones from the common bile duct combined with choledochoenterostomy and papillotomy followed by transduodenal papillosphinteroplasty. Ideally, the choledochotomy is followed by the insertion of a T-tube in the common bile duct. The transcystic approach has never been considered. The first endoscopic papillotomy was performed in 1973. Subsequently, it became the most widely used method for removal of common bile duct stones. In this report we explore the possibility of performing a laparoscopic transduodenal papillosphincteroplasty, following the strict rules commonly used in surgery. After cholecystectomy, a Fogarty catheter, is introduced through the cystic duct. This is followed by a minimal duodenotomy, then incision of the papillar sphincter. In this surgical proposal, we do not intend to substitute technique, but this method should be considered the ultimate solution in the laparoscopic approach to cholecystic choledocholithiasis.

Isolation and characterization of mammalian eumelanins from hair and irides.

A new enzymatic procedure was developed for isolation of eumelanin from black human hair which might provide a substantially intact pigment for structural characterization. Sequential digestion with protease, proteinase K and papaine in the presence of dithiothreitol afforded a pigment with a 6% w/w protein content. HPLC analysis of pyrrole acids resulting from alkaline H(2)O(2) degradation, carboxyl content determination, and ferricyanide titration showed that the isolated pigment is made up of 5,6-dihydroxyindole (DHI)- and 5, 6-dihydroxyindole-2-carboxylic acid (DHICA)-derived units at a 6:1 ratio, exhibiting a significant degree of oxidative degradation. For comparison, a different eumelanin isolated from black bovine irides by a similar enzymatic procedure was analyzed. Matrix-assisted laser desorption ionization (MALDI) mass spectrometry of the final pigment provided evidence for homologous series of DHICA oligomers, while chemical analysis allowed an estimate of 2:1 DHICA/DHI-derived units in the polymer, with a substantial proportion of intact o-diphenolic functions. Iris melanin proved able to promote the Fenton oxidation of deoxyribose while hair melanin was ineffective. Overall, these results provide, for the first time, unambiguous evidence for marked structural differences of mammalian eumelanins which may be directly related to the diversity of the sites of biosynthesis and storage, as well as to functional role of these pigments.

5,6-Dihydroxyindoles in the fenton reaction: a model study of the role of melanin precursors in oxidative stress and hyperpigmentary processes.

Increasing evidence supports the view that diffusible melanin-related metabolites do not serve merely as pigment precursors, but may also act as modulators of the responses of the pigmentary cell melanocyte to external stimuli, especially to inflammation. In this study, the effect of melanin precursors 5, 6-dihydroxyindole (DHI) and 5,6-dihydroxyindole-2-carboxylic acid (DHICA) on the Fenton-induced oxidation of deoxyribose was investigated as a model of the oxidative stress processes triggered by the release of iron during inflammation. DHICA caused a powerful inhibition of the H(2)O(2)-Fe(II)/EDTA oxidation under both aerobic and anaerobic conditions, proving to be more efficient than typical hydroxyl radical (HO(*)) scavengers even at low concentrations with respect to deoxyribose. Conversely, DHI in air was a prooxidant at low indole:Fe(II) ratios, but shifted to an antioxidant at higher ratios (>6). The magnitude of the prooxidant effect increased by lowering the pH of the medium or by replacing Fe(II) with Fe(III), but was suppressed by exclusion of oxygen. Both the indoles retained their effects on the Fenton reaction in the absence of EDTA, as a result of their ability to chelate iron ions as evidenced by spectrophotometric experiments. Investigation of the reaction of DHI and DHICA with the Fenton reagent led to the conclusion that the indoles interact efficiently with HO(*), yielding indolesemiquinone species which are then converted to melanin pigments by self-coupling or disproportionation. At low DHI:iron molar ratios, the ability of semiquinones, generated by autoxidation of indoles, to recycle Fe(II) ions prevails, accounting for the observed prooxidant effect. Collectively, the results of this study provide new evidence for melanogenic 5,6-dihydroxyindoles as a novel class of biological antioxidants and point to these compounds as the key to interpreting the response of melanocytes to oxidative injuries. Moreover, the rapid formation of melanin following the exposure of 5, 6-dihydroxyindoles to the Fenton oxidation suggests new mechanisms of skin hyperpigmentation associated with inflammation.

Nitric oxide-induced oxidation of 5,6-dihydroxyindole and 5,6-dihydroxyindole-2-carboxylic acid under aerobic conditions: non-enzymatic route to melanin pigments of potential relevance to skin (photo)protection.

Diffusible melanin-related metabolites have recently been suggested to subserve a variety of functions that are critical for protection of skin against inflammatory stimuli and oxidative tissue injury. We report here the results of in vitro studies showing that 5,6-dihydroxyindole (DHI) and its 2-carboxylic acid (DHICA) exhibit a marked reactivity toward potentially cytotoxic nitrogen oxides produced by autoxidation of nitric oxide (NO) under physiologically relevant conditions. Exposure of DHI or DHICA to NO in air-equilibrated 0.1 M phosphate buffer, pH 7.4, resulted in a fast, concentration-dependent consumption of the substrates and the concomitant deposition of dark melanin-like pigments. All NO-induced oxidations were completely inhibited in the absence of oxygen. Addition of 10 microM DHI and DHICA completely prevented the oxidation of 10 microM alpha-tocopherol in 0.1 M phosphate buffer, pH 7.4 in the presence of 300 microM NO. Overall, these results shed light on novel oxidative pathways of melanin-related metabolites of possible relevance to the mechanisms of skin hyperpigmentation under oxidative stress conditions.

Nitric oxide-induced oxidation of alpha-tocopherol.

Exposure of alpha-tocopherol (alpha-T) to nitric oxide under aerobic conditions resulted in a complex oxidation process whose final outcome was dictated by the nature of the reaction medium. In a cyclohexane solution, a prevailing route led to a mixture of relatively unstable polar products positive to Griess reagent. On standing at room temperature these were partially converted to the novel 2,3-dimethyl-4-acetyl-4-hydroxy-5-nitroso-2-cyclopentenone derivative. Reaction of alpha-T via a secondary oxidation path led to the formation of alpha-tocopherylquinone (alpha-TQ) as well as of little amounts of the corresponding nitrite ester. A quite different product pattern was observed when the reaction was carried out on a suspension of alpha-T in 0.1 M phosphate buffer, pH 7.4. Besides a significant formation of alpha-TQ and its nitrite ester, product analysis revealed a characteristic pattern of apolar compounds consisting of a yellow dimer and a series of related oligomers. These results provide an improved chemical background to inquire into the role of alpha-T in nitric oxide-induced tissue injury.

Detection and morphology of thymic remnants after video-assisted thoracoscopic extended thymectomy (VATET) in patients with myasthenia gravis.

Thymectomy is often an extremely useful therapeutic procedure in myasthenia gravis (MG) and is usually indicated for adult patients with generalized disease. Because remnants of thymus may remain in extrathymic fat, an extended thymectomy is recommended. A new surgical approach without sternotomy: video-assisted thoracoscopic extended thymectomy (VATET) was performed in 30 MG patients. The weight of removed thymus ranged from 10.8 to 113 grams. The weight of fatty tissue removed from pretracheal, anterior mediastinal and costophrenic areas ranged from 6.3 to 74.8 grams. Histological examination revealed thymic remnants in 14.8% of pretracheal fat samples and in 33.3% of samples from anterior mediastinal plus costophrenic areas. These findings indicate that VATET is a radical procedure and may be the first choice surgery for young female MG patients, since aesthetic sequelae are reduced compared to procedures involving sternotomy.

[Mini-invasive surgical treatment of gallstones and common bile duct calculi]. / Trattamento chirurgico mini-invasivo della calcolosi colecisto-coledocica.

Between June 1st 1990 and December 31st 1991, 449 patients with cholelithiasis were operated on. All patients with isolated cholecystolithiasis (400) were offered video-laparoscopic (VLC) treatment. Forty-nine patients had both cholecystolithiasis and choledocholithiasis. They all underwent further evaluation by ERCP, on the basis of which 30 patients were selected for sequential endoscopic and laparoscopic treatment with endoscopic papillosphincterotomy (EPST) followed by VLC. Three patients were selected for VLC and ideal laparoscopic choledocholithotomy. No complications were observed. At present, sequential ERCP-PST and VLC treatment seems to be the ideal approach to combined cholecystic and choledochal lithiasis in terms of safety, efficacy and tolerability. The increasing surgical skill in the field of minimally invasive surgery and the availability of sophisticated laparoscopic instrumentation allow to consider VLC and laparoscopic choledocholithotomy a valid alternative in terms of reduced surgical trauma and patient discomfort.