Acute mediastinitis: spectrum of computed tomography findings.

The objective of this study was to describe CT findings and to determine the diagnostic value of CT in diagnosis of acute mediastinitis. CT findings were retrospectively studied in 40 patients with suspected acute mediastinitis, including 28 postoperative patients, five with acute descending necrotizing mediastinitis (ADNM), and seven with suspected post-traumatic perforation of the esophagus. Findings included increased attenuation of mediastinal fat (100%), localized mediastinal fluid collections (55%), free gas bubbles in the mediastinum (57.5%), mediastinal lymph nodes (35%), pericardial effusions (27.5%), pleural effusions (85%), lung infiltrates (35%), sternal dehiscence (40%), and pleuromediastinal fistula (2.5%). The sensitivity and specificity of CT in postoperative patients in the first 17 days was 100% and 33% respectively, and after day 17, 100% and 90%. In patients with ADNM sensitivity was 100% while in patients with suspected esophageal perforation sensitivity and specificity were 100%. CT is a highly sensitive technique for the detection of mediastinitis of various causes. For the postoperative patients there is clear time dependence for CT interpretation and accuracy. In patients with suspected ADNM, and traumatic esophageal perforation CT is highly specific early after clinical presentation.

Liver and brain mucormycosis in a diabetic patient type II successfully treated with liposomial amphotericin B.

A case of liver and brain mucormycosis in a 73-y-old diabetic patient is described. The patient presented with fever and a moderate, tender hepatomegaly and a C/T scan examination of the abdomen and brain showed multiple hepatic and cerebral nodular lesions. The largest of the liver lesions was aspirated and broad hyphae of mucor were demonstrated in the purulent material obtained. The patient was treated successfully (for 40 d) with intravenous liposomal amphotericin B and then with itraconazole for 3 months. To our knowledge, this is the first case of a diabetic patient with both liver and brain mucormycosis who has been treated successfully.

Intravenous cyclophosphamide pulse therapy for the treatment of lung disease associated with scleroderma.

Until recently, renal crisis was the most significant cause of morbidity and mortality in patients with scleroderma (SSc). Nowadays, following the introduction of angiotensin-converting enzyme inhibitors used in renovascular hypertension, pulmonary fibrosis and pulmonary hypertension have become the most common causes of death in SSc. Consequently, the early diagnosis and treatment of pulmonary fibrosis is essential to improve morbidity and mortality in SSc patients. The aim of this study was to investigate the effect of intravenous cyclophosphamide pulse therapy in patients with SSc and evidence of active alveolitis assessed on a high resolution computed tomographic (HRCT) scan, and to compare the effect of cyclophosphamide pulse therapy with oral therapy. Sixteen consecutive patients with SSc were allocated alternately to the two treatment groups. Eight patients were treated with monthly cyclophosphamide pulse therapy (750 mg/ m2) for 12 months; the other eight patients were treated with oral cyclophosphamide (2-2.5 mg/kg/day) for the same period. All patients received concurrently prednisone (10 mg/day). Pulmonary function tests and HRCT scans were performed before therapy and at 6 and 12 months. In the oral cyclophosphamide group, three patients with a grade I pattern showed regression of disease extent. In the other five patients (one with grade II and four with grade III) the pattern and extent of disease remained stable during the study. No statistical differences were found in forced expiratory volume in 1 s, forced vital capacity and total lung capacity during the study period. The diffusing capacity for carbon monoxide increased significantly between baseline and 12 months (p = 0.043). In the cyclophosphamide pulse therapy group, seven patients with a grade I pattern showed regression of disease extent at 6 months (p = 0.018) and 12 months (p = 0.012). One patient with grade III remained stable during the study. In both groups the regression of the extent of disease estimated on HRCT was due to a decrease in the ground glass appearance. The extent of the reticular appearance remained stable throughout the study. Our results indicate that cyclophosphamide pulse therapy is effective in suppressing active alveolitis (ground glass appearance). Although in this study it is not possible to compare pulse therapy with oral therapy because of the different pattern seen on HRCT between the two groups, it seems that oral therapy is also effective in suppressing active alveolitis. Neither regimen improved pulmonary involvement when the reticular appearance predominated over the ground glass appearance on HRCT. It is concluded that either pulse or oral cyclophosphamide therapy may improve the outcome of SSc patients.

[Impalement injuries. A clinical case]. / Lesioni da impalamento. Caso clinico.

The authors present a case of penetrating injury of the extraperitoneal rectum, in a worker of 41. The treatment required a simple suture, because the conditions were favourable, such as simple lesions, without peritoneum contamination. Moreover, the authors propose a review of the literature, to single out the factors which influence mortality and mobility, as well as the most recent pathogenetic and therapeutic findings. Lesions caused by impalement are usually a difficult surgical problem. The mechanism of the injury, is usually a direct one, commonly diffused among workers. The entity of these lesions depends on the fall height, the penetrating object dimensions and the patient's weight. The diagnosis is based on anamnestic, clinical, radiological and endoscopic observations. The prognosis depends on several factors, such as: 1) the trauma extension and the presence of associated lesions; 2) the time elapsed between the trauma and the treatment influences the degree of bacterial contamination; 3) the patient's age and his physical conditions; 4) the assistance quality at the moment of the occurrence. The mortality, as far as complex lesions are concerned, is nowadays very high (50-75%).

[The washout in emergency surgery of the colon. A technical note]. / Il wash-out nella chirurgia del colon in urgenza. Nota di tecnica.

The authors report their experience in the treatment of 179 cases of colonic neoplasm between January 1985 and August 1992. Particularly, they emphasize the advantages of one-stage colectomy with anastomosis because of an obstructing carcinoma of the left colon, used on 41 cases. This treatment can be practicable by using the intraoperative "wash-out" technique. The one-stage colectomy with anastomosis can be advisable because the long survival can be compared to that deriving from the non obstructing carcinoma. Moreover this technique offers several advantages such as the one-stage treatment, the absence of colostomy, the improvement of the cost-benefit relationship, etc. On 41 cases treated by this technique, the authors lament only one decease caused by a total dehiscence of the anastomosis, notwithstanding reintervention. Moreover, 9 cases of partial dehiscence were treated by NPT (Total Parenteral Nutrition) except one which demanded a reintervention.

[Acute appendicitis in pregnancy. Our experience]. / L'appendicite acuta in gravidanza. Nostra esperienza.

The authors' aim is to review the medical literature dealing with diagnostic and therapeutical problems, after observations in pregnancy because of acute appendicitis in 9 cases. Diagnosis is difficult because of the aspecificity and the alterations both of the site of symptoms and clinical manifestations, particularly during the last period of gestation. As there is an upward displacement of the viscus by the pregnant uterine. Notwithstanding the use of some not invasive methods, such as graded-compression sonography, the diagnosis is always effected by the clinical examination. Surgical treatment is always possible in the presence of acute appendicitis, as pregnancy isn't a reason for delay. The maternal mortality is at a zero level, the fetal one varies from 2% to 43% in cases of perforated appendicitis.

[Acute cholecystitis: timing of surgery]. / Le colecistiti acute: timing of surgery.

The authors report their own experience about 156 cases of acute cholecystitis observed between January 1991 and October 1992. The most part of the patients were between 30 and 65 years old (84 cases observed). In 27 cases, for the positive evolution of the pathology, it was put on practice a non operative treatment. The other 129 cases were treated surgically. The patients with lithiasic cholecystitis were 148; those affected by non lithiasic cholecystitis were 5; and 3 of them presented an acute cholecystitis as a manifestation of a carcinoma. Between the various diagnostic methods, the echography, executed in emergency, is considered as an indispensable one, for having changed completely the diagnostic approach. It is discussed, particularly, the timing of surgery, an aspect able to influence considerably the therapeutic iter and its results. There are analysed the criteria for whom some authors are favourable to a medical treatment of the acute cholecystitis, postponing the operation, while other of them are favourable to an early surgical treatment. The authors' casuistry put in evidence 110 operations effectuated in emergency (< 12 hours), 19 operations after an 12-72 hours interval, no operations at a long distance (1-10 months). The results are to be considered satisfactory: 1 deceased (on 129 operated cases, 0.78%); 10 immediate complications (7.75%): 8 suppurations of the wound, 1 biliar fistula and 1 internal hemorrhage after video-laparoscopic operation; 2 late complications (1.55%): they were relapsing gallstones. The aim of this work is to offer a contribution to codification of the treatment of the acute cholecystitis, on the ground of the acquired experience.

[Strangulated laparoceles. Our experience]. / I laparoceli strozzati. Nostra esperienza.

The authors present their own experience of emergency in strangulated laparoceles. Between January 1984 and June 1992 they treated at the Division of Emergency Surgery of the Hospital "A. Cardarelli" in Naples 133 cases of laparocele, 63 of which were strangulated. 48 of the 63 cases were treated by simply vertical or transversal laparoplasty ("waistcoat"); in 4 cases a direct plastic surgery; was executed in 11 cases a synthetic patch was used: in 2 cases a Teflon prosthesis was used; in one case a double prosthesis: a reabsorbable Vicryl patch internally and an external Marlex reticulated; in 8 cases a Marlex prosthesis. Moreover in most cases, before the laparoplasty of the abdominal wall operations of viscerolysis, were carried out intestinal and/or epiploon resection because of ischemia, colostomy, a Hartmann (one case). Of the 11 patients treated with synthetic patches, only 4 presented local complications: a seroma, two suppurations of the wound and a skin necrosis. These complications were treated with a medical therapy. In no case it was necessary to remove the prosthesis, as there were no general complications or deaths. We have to underline that notwithstanding the great advances both in surgery and in prosthesis' materials, the problem of the strangulated laparocele still represent a great engagement for the surgeon. The main reasons are: concomitant pathologies ("eventration disease"') and complications. The complications may be local (infection of the wound) or general (cardiocirculatory and respiratory problems due the viscus reduction in the original abdominal cavity).(ABSTRACT TRUNCATED AT 250 WORDS)