Renal tuberculosis: a case report.

Tuberculosis or TB (tubercle bacillus) remains a major public health problem in developing countries. Over the last decades extrapulmonary locations of the disease have become more frequent due to the increased prevalence of acquired immune deficiency syndrome and the increase number of organ transplants. The urogenital localization represents about 27% of all extra-pulmonary localizations of TB and may be due either to a disseminated infection or to a primitive genitourinary localization. The majority of patients, has pyuria, sometimes with hematuria. The diagnosis of urinary tuberculosis is based on the finding of pyuria in the absence of infection by common bacteria. The initial medical treatment includes isoniazide, rifampicin, pyrazinamide, ethambutol and streptomycin. This disease should be suspected in patients with unexplained urinary tract infections, especially if immunocompromised and/or coming from endemic areas.

[Surgical treatment of acute diverticulitis. Our experience]. / La terapia chirurgica della malattia diverticolare in fase acuta. Nostra esperienza.

The treatment of the acute diverticulitis is still a stimulating and complex problem sustained by several anatomopathological and clinical factors and the possibility of different therapeutic options, being the operative mortality among 5% and 45%. With the modern technologies it is possible to follow the evolution of the illness so to perform more appropriate therapeutic plan. From 1997 to 2007 we have observed 278 patients with acute diverticulitis. In 219 (78,7%) patients the inflammatory and sub-occlusive condition has been faced with medical therapy, with resolution of the disease in 170 (61%) cases. In 49 (17,6%) patients we have gotten the resolution of the inflammatory disease, but not of the sub-occlusion and therefore we liked to submit them to surgical treatment in election. In 1 case we have found a colovesical fistula. A total of 59 (21,2%) patients with signs of acute abdomen have been submitted to surgery in urgency, within the 24 hours from the hospitalization. We have performed a primary resection with anastomosis and without stoma in all the patients, except in 3 cases in which we have done the Hartmann procedure for the cheap general conditions. We have not recorded intra and postoperative mortality and only in 3 cases we have had a leakage, that has not needed a surgical treatment. In 9 cases we observed infection of the wound, treated with antibiotic therapy. In our experience, performing a surgical procedure, without derivative stoma and manual anastomosis, it seems to be the fittest and less expensive procedure, also in situation of emergency-urgency, without increase of mortality and morbidity.

[Traumatic retroperitoneal haematoma]. / L'ematoma retroperitoneale post-traumatico.

The management of traumatic retroperitoneal haematomas is still a much debated question. Although the diagnosis has become easier using CT with contrast medium, the therapeutic decisions are still difficult because of the great variability of the lesions, which may be simple but very often complicated. Our study is based on 1086 treated patients, 29.5% of the 3682 critical abdominal polytrauma seen in 35 years. Mortality has been 12.9% with a medium ISS (Injury Severity Score) of 23.4. 71.4% of the cases were closed traumas, 28,6% were open traumas. The most common single lesions have been pelvic (43%), followed by the renal traumas (39%). Regarding the associated lesions, the thoracic traumas cause an increment of the ISS score up to 26.2% and of mortality up to 14.6%. The maxillofacial traumas associated with traumatic retroperitoneal haematomas represent 11%, mainly associated with motorcycle accidents, which have increased in the last years from 2,4% in the 70s to 32% these days. Our approach to these patients has been basically conservative. Following the indications obtained by the CT, we widely used interventional angiography, especially for renal lesions and, after pelvic stabilization, for pelvic haematomas. We have chosen surgery considering the kind of traumas (open or closed), the location of the haematoma and especially, the clinical course of the patient's hemodynamic condition.

[Total thyroidectomy: initial experience of a territorial reference center]. / La tiroidectomia totale: esperienza iniziale di un centro di riferimento territoriale.

Authors report their initial experience in surgical treatment of thyroid diseases in an area with high percentage of thyroid tumors. Since January 2006, we examinated 428 patients. By clinical features, hormonal profile, imaging and US-guided FNAB, we selected 134 of them for surgery; 93 patients underwent thyroidectomy in January-November 2006. The Authors analyse therapeutic choises and surgical techniques, stressing the high percentage of thyroid neoplasms.

[The femoral hernia: problems in emergency surgery]. / L'ernia crurale: problematiche chirurgiche in urgenza.

The femoral hernia can be defined as infrequent, and predominantly found in females, with the highest incidence between 30 and 40 years of age. It shows a high tendency to strangulation, also up to 40% of cases, due to the presence of the Gimbernat ligament, which with its tense fibrous margins, aids strangling known as "raised crest". The diagnosis may not be easy, overall in the clinical presence of acute abdomen in elderly patients, disabled people or people who are uncooperative during physical examination. Therefore, it should be sought with an adequate bilateral exploration of the region in all occlused patients and especially with the use of radiological images of the small intestine. The solution currently practiced is prosthetic, proposed by Lichtenstein, and variously modified by Gilbert, Rutkow, Bendavid, and other which uses a prolene plug in the shape of a cigar, umbrella, or basket, according to the size and characteristics of the parietal defect. In emergency conditions, the technique doesn?t change; but if there is stercorary contamination, it is advisable to use direct repair according to the old method of Bassini. In the last 10 years, we have treated 37 femoral hernias in emergency, using direct repair in only 2 cases. In 3 cases we used PTFE; in the other 32 cases prolene was always used; 20 patients were operated under local anesthetic, 12 under general anesthetic and 5 under peridural anesthetic. Satisfactory results were achieved, with average hospital recovery time of 1.4 days, with an early recovery between 3 and 5 days, with only 2 relapses.

["Acute scrotum" caused by torsion of the hydatid of Morgagni]. / "Scroto acuto" da torsione dell'idatide del Morgagni.

By "acute scrotum" is meant a sudden, painful tumefaction in one or both testicles with local and systemic symptomatologies. It can be caused by spermatic cord torsion in about 50% of cases in paediatric age, while in adults such a cause is much rarer. In addition to the clinical examination, Doppler, eco colour-Doppler and scintigraphy with 99mTc pertecnetate may be of use even though these investigations are not often immediately employable. In addition, as the hours pass, the damage caused to the gonad becomes irreversible; this, of course, influences therapeutic conduct. Starting from the description of a recently observed case of torsion of Morgagni's hydatid, the authors discuss the importance of differential diagnosis to protect the vitality of the testicle and show that surgical exploration, in cases where a definite aetiological diagnosis is missing, is the preferable and most rational therapeutic choice.

[Postoperative complications after thyroid surgery. Review of the literature and personal experience]. / Le complicanze post-chirurgiche dopo intervento sulla tiroide. Revisione della letteratura ed esperienza personale.

The authors make a review of the literature on the complications which occur after thyroidectomy. They report, moreover, a study carried out on 192 thyroidectomy performed between January 1992 and May 1995. The surgical technique employed foresees the systematic search for and saving of laryngeal nerves fibers and the parathyroid gland. Results were the incidence of postoperative hypocalcemia and of permanent hypocalcemia. The authors also analyse problems related to laryngeal nerves in matters of thyroid surgery. After a short introduction on surgical anatomy, attention is drawn to the "recurrent nerve risk" but also the superior laryngeal nerve too, often injured with modifications of the vocal tone and serious consequences for particular professional groups.

[Biliodigestive fistulae. Apropos 2 cases with opposite symptomatology]. / Fistola bilio-digestiva. A proposito di due casi con sintomatologia contrapposta.

Biliodigestive fistulas are the most frequent internal biliary fistulas and occur when a calculus or neoplasia perforates the wall of the biliary tract of intestine at any point. Symptoms vary given that completely asymptomatic cases have been reported in which the findings of a biliodigestive fistula was completely coincidental, but there are also cases in which the severe clinical conditions at onset require immediate surgery. The Authors report two cases with opposing symptoms and underline the importance of diagnostic imaging in the preoperative analysis. They also underline that a correct therapeutic approach is fundamentally important in these cases.

[Postoperative pain control]. / Controllo del dolore postoperatorio.

Pain was and in part still is a constant feature of surgical practice: before, during and after surgery. To start with painful symptoms represent a fundamental diagnostic element, given that in over 60% of cases pain is the primary indication for surgery. During the operation, pain used to constitute the main impediment to the surgeon's activities, until the introduction of ether and the birth of modern anesthesia. Lastly, the postoperative period is also painful so much so that whereas until fifty years ago patients were above all afraid of the operation, patients nowadays are concerned about the pain during the days after the operation. Moreover, over 50% of patients undergoing surgery are unsatisfied with the treatment of postoperative pain, in spite of the fact that drugs are available which enable us to control it. The authors studied the quality of postoperative analgesia in 357 patients, who received treatment with ketorolac tromethamine 30 mg i.v. on leaving the operating theatre, and subsequently i.m. every 8 hours starting from 3 hours after surgery. The use of ketorolac tromethanine demonstrated effective analgesia and was well accepted by patients, without revealing any particular collateral effects.

[Surgical rehabilitation of stomal disease]. / La riabilitazione chirurgica delle patologie stomali.

The Authors report their experience in the surgical rehabilitation of patients with complicated ileo- or colostomy. Mechanical and psychosocial implications as well as different rehabilitative methods are discussed. The results of a surgical protocol in the treatment of stomal diseases observed in 63 patients are herein reported. In 14 patients the surgical treatment was performed in general anaesthesia, while in 49 local anaesthesia was used. The latter was better tolerated by the patients. In conclusion, surgery should play a major role in this rehabilitation protocol, either in terms of prevention or definitive treatment.

[Postoperative chylous ascites: its etiology and treatment]. / Ascite chilosa post-operatoria: etiologia e trattamento.

Postoperative chylous ascites is a rare clinical condition that occurs as a consequence of disruption of the abdominal lymphatics after retroperitoneal dissection. Generally the management is conservative based on a low fat diet and total parenteral hyperalimentation. However, such therapy requires weeks to months before resolution of the ascites. On the other hand, surgical approach is associated with a high failure rate to ligate leaky lymphatics. The Authors, therefore suggest a surgical resolution of the ascite with the use of fibrin glue to occlude rapidly and permanently the lymphatics ruptured.

[Acute abdomen caused by the rupture of a solitary non-parasitic cyst of the liver]. / Addome acuto causato dalla rottura di una cisti solitaria non parassitaria del fegato.

A rare case of acute abdomen caused by the rupture of a solitary, non-parasitic cyst of the liver is reported. Considering the rarity of the event, it was considered interesting to examine the anatomo-pathological, clinical and diagnostic aspects as well as the various surgical and other treatment possibilities for these conditions. Stress is also laid on the fact that surgical treatment is only indicated in the case of complications, while in uncomplicated forms the treatment of choice of alcoholisation.

[Corono-radicular amputation of mandibular molars: indication, technic and prosthetic utilization. Apropos of a clinical case]. / L'amputazione corono-radicolare dei molari mandibolari: indicazioni, tecnica ed utilizzazione protesica. A proposito di un caso clinico.

Lesions to the radicular bifurcation generally entail the removal of the tooth in question. This leads to the need to create a prosthetic bridge to compensate for the absence of the extracted tooth. This solution is not readily accepted by the patient who wishes to avoid involving other teeth. In these cases rhizectomy and the execution of an inlay on an adjacent tooth may satisfy the patient and resolve the clinical symptoms. The authors report a case of rhizectomy and prosthetic reconstruction of a tooth using inlay.

[A novel diagnostic method to study the residual pelvic cavity after Miles abdomino-pelvic resection]. / Proposta di una metodica diagnostica originale per lo studio dello scavo pelvico residuo dopo RAP secondo miles.

Local pelvic perineal recurrence represents the most frequent site of failure following abdominoperineal resection (APR) for rectal cancer. Patients con be studied at this level by Computerized Tomography (CT) scan, Magnetic Resonance Imaging (MRI), suprapubic or, in women, endovaginal ultrasound (US). CT scan and MRI show sensitivity and specificity in excess, respectively, of 70 and 90%, but the high cost and the invasiveness of CT scan controindicate their frequent use. Suprapubic US has no value in terms of diagnostic accuracy, whereas endovaginal US shows a good specificity, but it is quite refused by the patients since the discomfort of the examination. 34 patients from the Rehabilitation Unit of Colostomy Patients at the University of Rome, "La Sapienza", have been blindly followed by transperineal US. The results have been compared with those obtained by CT scan or MRI. Specimens have been obtained of any suspicious mass by needle biopsy. The diagnostic accuracy of transperineal US has resulted comparable to CT scan and MRI. The authors also describe the morphology and US pattern of the pelvic hollow as demonstrated by transperineal US and the distinctive features of abnormality seen.

[Multicenter study on the application of a continence device for ++ostomized patients]. / Studio multicentrico sull'applicazione di un dispositivo di continenza per pazienti stomizzati.

The restoration of continence is a fundamental step in the rehabilitation of stomised patients. The latest generation of continence prosthesis, represented by Conseal must be seen in this context. The authors performed a multicentre study based on a protocol using Conseal Uni in patients with low terminal digestive stomies (ileum or colostomy). The only criteria for patient selection was the absence of marked stomal and peristomal pathologies (large prolapse, fistula). The three centres taking part in the study inserted the new device in 50 patients (25 M; 25 F) with a mean age of 57.5 years (range 18-87) of whom 45 had undergone left terminal colostomy and 5 terminal ileostomy. A weekly evaluation was made of the use of the prosthesis for 4 weeks and a follow-up control was performed after 24 months in 22 patients. The results obtained shown that Conseal received a positive judgement in 88% of patients, better results were obtained in colostomized patients receiving irrigation (positive judgement in 100% of cases), whereas the success rate in non-irrigated patients only amounted to 50%. An additional application for the use of Conseal emerged from the study, namely its utilisation by ileostomised patients. Using various technical procedures, it was possible to obtain 8-hour continence in ileostomised patients. This result is of considerable importance since it shows the research, technological and clinical effort that has been made to achieve a form of continence in ileostomised patients.

[Endometriosis of the sigmoid: 2 new cases and a review of the literature]. / Endometriosi del sigma: due nuove osservazioni e revisione della letteratura.

Endometriosis of the sigmoid colon is a pathology which is not frequently reported but may be manifested with symptoms in the form of intestinal occlusions and/or subocclusions and rectorrhagia. Diagnosis is difficult because there are no typical radiological and endoscopic findings. The authors report two cases of sigmoid endometriosis which were manifested by recurrent subocclusive attacks and rectorrhagia. Moreover, they stress the rarity of the site and review the literature in order to summarise the etiopathogenetic hypotheses and anatomopathological aspects. They also focus on clinical symptoms and on endoscopic and radiological findings. Lastly, they examine the problems of differential diagnosis and the therapeutic options.

[A case of umbilical endometriosis following cesarean section]. / Su di un caso di endometriosi ombelicale dopo taglio cesareo.

Umbilical endometriosis is a rare pathology whose etiopathogenesis is still uncertain and the theories put forward are all controversial. Diagnosis is therefore frequently difficult. The authors report a case of umbilical endometriosis which occurred in a scar left by an earlier cesarean section. Moreover, they discuss the aspects which might facilitate the diagnostic approach and a correct therapeutic management.

[Lymphoma of the residual gastric stump]. / II linfoma del moncone gastrico residuo.

The authors report a case of non-Hodgkin's lymphoma (lymphoplasmocytoid type) arisen on the gastric stump of a patient operated 18 years before according to Billroth II gastric resection for peptic ulcer. They underline the extraordinary rarity of the event because this type of neoplasia never arises on the gastric stump, where would be more likely to find, due to irritative chemical stimuli of the biliary reflux, phenomena of intestinal metaplasia or severe dysplasia highly predisposing to adenocarcinomas. Furthermore, they stress the importance of a "deep" bioptic examination for a diagnosis as early as possible of this type of pathology.