[Endocrine ophthalmopathy: surgical treatment]. / Endokrine Orbitopathie: Chirurgische Therapie.

Since the transpalpebral decompression of the orbit by removal of intraorbital fat was introduced in 1985, this technique has become the state of the art in surgical therapy for Graves' ophthalmopathy at the authors' institution. Our experience with a series of 3,210 orbital decompressions in 1,635 patients with endocrine ophthalmopathy represents the largest collective of such patients that has been published yet to our knowledge. Over time the technique has proved to be reliable, effective, safe, and easily performed by a trained and experienced oculoplastic surgeon with long-lasting results, leading to improvement not only in visual function but also in well-being and in patients' social life, with a high benefit to low risk ratio. The promising and satisfying results demonstrated earliest in 1988 have been confirmed in further evaluation at our clinic and others. In summary, this technique, which is associated with very low morbidity, is our method of choice in moderate to severe cases of exophthalmos and even in functionally asymptomatic patients with mild to moderate aesthetic impairment. However, it has to be emphasized that this complex and multifactorial disorder often requires a broad range of long-term medical attendance. Postoperatively the majority of patients showed significant improvements of ocular protrusion, diplopia, visual acuity, swelling of eyelids, headache and retrobulbar "burn". In very rare instances, the surgical technique can be performed as a one-stage procedure. In severe cases (proptosis >28 or extreme muscle hypertrophy), lipectomy can be combined with expansion of the bony orbital cavity (<1% patients).

Long-term outcome of chronic hepatitis B in Caucasian patients: mortality after 25 years.

OBJECTIVE: To assess risk factors for liver-related death, we re-evaluated, after a median follow-up of 25 years, a cohort of 70 Caucasian patients with hepatitis B e antigen (HBeAg) positive chronic hepatitis (CH) at presentation. METHODS: Follow-up studies included clinical and ultrasound examinations, biochemical and virological tests, and cause of death. RESULTS: Sixty-one (87%) patients underwent spontaneous HBeAg seroconversion. During a median period of 22.8 years after HBeAg seroclearance, 40 (66%) patients became inactive carriers, whereas the remaining 21 (34%) showed alanine aminotransferase elevation: one (1%) had HBeAg reversion, nine (15%) detectable serum HBV DNA but were negative for HBeAg, eight (13%) concurrent virus(es) infection and three (5%) concurrent non-alcoholic fatty liver disease. Liver-related death occurred in 11 (15.7%) patients, caused by hepatocellular carcinoma in five and liver failure in six. The 25-year survival probability was 40% in patients persistently HBeAg positive, 50% in patients with HBeAg negative CH or HBeAg reversion and 95% in inactive carriers. Older age, male sex, cirrhosis at entry and absence of sustained remission predicted liver-related death independently. The adjusted hazard ratios (95% CI) for liver related death were 33 (3.01-363) for persistently HBeAg positive patients and 38.73 (4.65-322) for those with HBeAg negative CH or HBeAg reversion relative to inactive carriers. CONCLUSION: Most patients with HBeAg seroconversion became inactive carriers with very good prognosis. The risk of liver-related mortality in Caucasian adults with CH is strongly related with sustained disease activity and ongoing high level of HBV replication independently of HBeAg status.

Utility of the hooking technique for cases of major hepatectomy.

Currently, resective hepatic surgery should be considered an echoguided surgical procedure to guarantee conservative but radical resections. A simple and original technique guided by intraoperative ultrasonography, termed the "hooking technique," had been described previously. It enables the ligation sites of the intrahepatic vessels during systematic segmentectomy to be chosen precisely. This report describes a further application of this technique to allow safe ligation of portal vein main branches invaded by tumor thrombi during major hepatectomies.

Ultrasound-guided reduction of an incarcerated Spigelian hernia.

Spigelian hernia is a rare abdominal hernia. We report a case in which its diagnosis proved ultrasonography to be an effective tool, not only to diagnose an incarcerated Spigelian hernia but, moreover, to reduce it by echo-probe palpation. Ultrasound (US) is an aid for therapy of various diseases. In our experience, US-guidance prevented possible damage related to forced and wrongly applied compression during the hernia reduction, and allowed us to perform surgical repair on an elective basis. In conclusion, if an incarcerated Spigelian hernia is suspected, a US examination should be done on an emergency basis to confirm the diagnosis and to attempt US-guided reduction.

Ultrasonographic detection of portal branches and hepatic vein gas associated with mesenteric artery occlusion: a new finding correlated with patient prognosis?

The diagnosis of bowel infarction is still a challenge. In some cases, portal venous gas is an associated feature and in these patients, the prognosis is very poor. We report on our experience with two consecutive cases in which ultrasonography showed gas in the portal venous branches, and also in the hepatic veins in one of them. At laparotomy, advanced bowel necrosis was found, and both patients died within 24 hours. Other cases of portal venous gas associated with bowel infarction have been reported, but this is the first report of gas also being found in the hepatic veins. There may be a relationship between the amount of gas in the intrahepatic veins and the stage of bowel ischemia. Confirmation of this might improve the selection of patients and eliminate unnecessary procedures.

Drain-site tumour recurrence after laparotomy resection for colorectal cancer.

We report a case of drain-site tumour recurrence 2 years after right colon resection for adenocarcinoma of the ascending colon. A large number of case reports concerning port-site tumour recurrences after laparoscopic procedures have been reported. However, post-laparotomy incision site cancer recurrence is considered a rare occurrence.

[Interstitial percutaneous therapies in primary and secondary liver tumors]. / Terapie percutanee interstiziali dei tumori primitivi e secondari del fegato.

Multiple percutaneous interstitial systems to induce intrahepatic tumor necrosis are classifiable in two major groups: those using chemical agents (ethanol and acetic acid) and those adopting thermal effects (hot saline, radiofrequency, laser and microwave). Indication, technique and results of percutaneous ethanol injection (PEI) are considered. In the case of single hepatocellular carcinoma (HCC), < 5 cm and associated with cirrhosis Child class A long-term results of PEI are comparable with those of best surgical series with 5-years survival which range from 47 to 51%. No mortality and recurrence rates similar to those of surgical cases make PEI as an alternative to surgical resection although the difficulties in comparing retrospectively the different experiences do not enable definitive conclusions. In the case of liver metastases from colorectal cancer or endocrine tumors, which seem more sensitive to locoregional therapies, complete response rates are not adequate yet being 86%, 26%, 11% and 0% respectively in the case of < 2 cm, 2-3 cm, 3-4 cm and > 4 cm lesions and moreover no definitive data are available about long-term prognosis. Waiting for further validation about the encouraging data obtained with the other interstitial methods and in particular with radiofrequency (RF) and laser interstitial photocoagulation (FLI), PEI is a valid alternative to surgery for selected HCC patients and is a good palliation in cases with not resectable liver metastases which are anyway suitable for locoregional treatments.

[Experiences with internal thoracic vessels in breast reconstruction with the free TRAM flap]. / Erfahrungen mit den Thoracica interna-Gefässen bei der Brustrekonstruktion mit dem freien TRAM-Lappen.

In breast reconstruction with free TRAM flaps, the thoracodorsal vessels are most commonly used as recipient vessels. In case of an irradiated and scarred axillary region, the internal thoracic vessels may be an alternative. In the pertinent literature it has been pointed out that the veins may be fragile and thin and, thus, not suitable for microvascular anastomosis. In a series of 31 breast reconstructions with free TRAM flaps, the internal thoracic vessels were dissected and evaluated in 24 cases in order to assess the value of this vascular system as a recipient site for free flap transplantation. In four cases, the veins were too small for anastomosis, and in one case the artery was severed during dissection. End-to-end anastomoses were performed in 19 cases (79%). The following complications were recorded: One marginal necrosis; one venous thrombosis, which was detected and salvaged by revision; one recurrent arterial thrombosis, resulting in flap loss; one pleural lesion healed uneventfully.

[Videothorascopic treatment of benign tumors of the chest wall. Report of a case of neurilemmoma]. / Trattamento videotoracoscopico dei tumori benigni della parete toracica. Rapporto su di un caso di neurilemmoma.

Intercostal nerve sheat tumors are rare and normally benign tumors. The successful thoracoscopic resection of an intercostal neurilemmoma is reported. It occurred in an asymptomatic 44 year-old woman. Diagnostic flowchart consisted in an enhanced CT of the chest and in a fine needle biopsy under CT guidance of the chest wall mass. The videothoracoscopic resection was carried out with three small incisions, in a relatively brief time and without high technical difficulties. Postoperative course was uneventful and the patient was discharged in the fourth postoperative day. In authors' opinion thoracoscopic approach is actually mandatory as a first attempt to cure benign neurogenic tumors of the chest wall.

Simultaneous laparoscopic cholecystectomy and laparoscopically assisted vaginal hysteroadnexectomy.

As a consequence of the wide applications of operative laparoscopy and thoracoscopy, simultaneous surgical procedures have been carried out endoscopically. We report a 51-year-old woman treated by simultaneous laparoscopic cholecystectomy and celioscopically assisted vaginal hysteroadnexectomy for hydropic calculous gallbladder, uterine myomas, and bilateral ovarian policystosis. These procedures were carried out using six abdominal trocar sites, and the gallbladder was removed through the colpotomic access. The patient had an uncomplicated postoperative course and was discharged on postoperative day 5. In our opinion, the multidisciplinary laparoscopic approach, with the original technical solutions, represents an effective, minimally invasive method of treatment that gives new perspective about the indications and the treatment of similar cases.

T cells and orbital connective tissue in endocrine orbitopathy.

In order to analyse the immunological changes in patients with endocrine orbitopathy (EO) the antigenic character of orbital connective tissue was studied. Counter-stimulation assays of patients' lymphocytes with autologous retrobulbar fibroblasts resulted in a markedly increased lymphocyte proliferation in comparison to incubation with retrobulbar control fibroblasts. Proliferation tests of retrobulbar T cell lines showed significant responses to autologous retro-orbital connective tissue proteins, with molecular weights of 6-10 kD and 19-26 kD. Phenotypic analysis of orbital T cell lines indicates that they consisted predominantly of CD4+ cells. Hyaluronic acid production of orbital fibro blasts following co-cultivation with lymphocytes of EO patients or controls revealed a threefold increased synthesis in patients with EO. Furthermore, distribution pattern of orbital extracellular matrix glycosaminoglycans (GAG) differs in EO patients in comparison to controls. The results suggest the presence of autoreactive T cells directed against antigens of orbital fibroblasts, whose stimulation results in an augmented GAG synthesis in patients with EO.

The usefulness of ultrasonography in the diagnosis of the Spigelian hernia.

Normally acquired, the Spigelian hernia is rare. Due to low incidence and frequent atypical presentations diagnosis is often difficult. Controversies exist about the diagnostic approach. We report our experience in two cases in which ultrasonography permitted a correct diagnosis of surgically confirmed Spigelian hernias. One of the two cases proved to be a carrier of bilateral Spigelian hernia at ultrasonography and at surgery. In our opinion ultrasonography represents the gold standard in the diagnosis of Spigelian hernias and we recommend its use as the first step in all cases of abdominal wall mass.

[Cesarean section and left ventricular failure caused by coronary artery disease: anesthetic management]. / Césarienne et insuffisance ventriculaire gauche d'origine coronarienne: technique d'anesthésie.

A Caesarean section was performed in a 34-year-old patient experiencing a major left heart failure secondary to an anterior myocardial infarction which occurred four years before. At the end of pregnancy, she developed a mild pulmonary hypertension. Caesarean section was decided to maintain a stable haemodynamic status. For the same reason, general anaesthesia with etomidate was preferred rather than epidural analgesia. Haemodynamic monitoring allowed the adequate management of blood pressure, heart rate, pulmonary blood pressure and arterial oxygen saturation. Postoperative analgesia was obtained with opioids administered epidurally.

Treatment of exophthalmos by orbital fat removal.

Decompression of the orbit by removal of fat is a safe method to obtain functional and aesthetic improvement in exophthalmos disease. In comparison with traditional orbital wall decompression, the complication rate is low.

[Clinical use of a new compression surgical stapler in surgery of the large intestine]. / Utilizzazione clinica di una nuova suturatrice meccanica a compressione in chirurgia del grosso intestino.

The clinical experience with the use in colorectal surgery of a new compression anastomotic device developed by the Authors is reported. From May 1986 through June 1990, 95 patients underwent large bowel anastomosis using this device. Operations performed included 51 left hemicolectomies or anterior resections of the sigmoid and rectum, 23 left colon resections, 19 right hemicolectomies, and two total colectomies. Twenty-nine anastomoses were performed below the pelvic peritoneal reflection and 18.5% of them resulted less than 4 cms from the anal verge while 20% were located between 4.5 and 8 cms. Five (5.2%) intraoperative diverting colostomies were needed. The rings were evacuated postoperatively after a mean of 10.9 days with none or very little discomfort. Operative mortality was 1.0% (one patient died of myocardial infarction). Anastomotic complications included five (5.2%) clinical and four (4.2%) subclinical leakages. No haemorrhages or stenoses were observed. This initial clinical experience shows the anastomotic device is reliable and justifies further experimentation.

Transpalpebral decompression of endocrine ophthalmopathy (Graves' disease) by removal of intraorbital fat: experience with 147 operations over 5 years.

From 1984 to October 1989 at the Plastic Surgery Unit in Wesseling, we carried out 147 operations on 75 patients with Graves' disease. Intraorbital fat was removed through a transpalpebral incision to achieve decompression. The average amount of fat was 6.0 cm3. We have made a long-term follow-up (more than 6 months postoperatively) study of 57 patients who experienced 108 operations. The first results were published in September 1988. When we compared the results to a traditional decompression operation (with resection of one or two orbital walls), we found that the postoperative complication rate was significantly lower and that the success rate was much higher. Thus the range of indications for surgery may be much wider than previously considered. Patients who are about to lose their vision as well as those experiencing lesser symptoms can be much improved with this operation. At the beginning, before the technique was fully developed, complications such as supraorbital nerve palsy occurred.

[Aneurysms in various segments of the hepatic artery. Treatment by resection]. / Anévrysmes de l'artère hépatique de sièges variés. Traitement par résection.

The authors report two cases of aneurysms of the hepatic artery, one of which, with a intrahepatic localisation, was complicated by rupture and infection. The etiology was atherosclerotic in the case involving the main trunk of the hepatic artery, and polyarteritis nodosa in the case with intrahepatic involvement. Both were resected; the extrahepatic aneurysm was excised and a venous graft inserted, whereas in the one with intrahepatic involvement, right lobectomy was performed. On the basis of these cases, the authors discuss the various etiologies and the problems related to the indications and surgical techniques for aneurysms of the main trunk of the hepatic artery and those of its intrahepatic branches.