The renal resistive index as a predictor of acute hydronephrosis in patients with renal colic.

INTRODUCTION: The objective of this study was to determine whether the renal resistive index (RI) can predict hydronephrosis in patients with renal colic (RC) and whether or not its performance is time-dependent. MATERIALS AND METHODS: The study population was composed of 54 patients admitted for unilateral RC. At the time of the first observation (time point I, tpI), each patient underwent routine examinations, abdominal ultrasonography, and renal color Doppler ultrasound (CDUS) with measurement of the RI. The two imaging studies were repeated 6, 12, 18, 24, 36, and 48 h later (tpII, tpIII, tpIV, tpV, tpVI, tpVII). In addition, each patient underwent non-contrast urinary tract CT 48-60 h after admission. A mean renal RI of >0.70 (mRI+) for the symptomatic kidney was considered indicative of obstruction. Patients were retrospectively divided into two groups: those who developed dilatation (group A) and those who did not (group B). RESULTS: A mRI+ on CDUS predicted the onset of hydronephrosis with 100% sensitivity, 84% specificity, 92.6% accuracy, PPV and NPV of 87.9% and 100%, and diagnostic efficiency of 84%. In group A, mRI+ were always observed before onset of hydronephrosis in a time-dependent manner. In group B, mRI+ were observed occasionally in 4/25 patients (16%) and all were recorded at tpII. In these cases, the RI had returned to normal by tpIII. CONCLUSIONS: In our RC patients, renal RI obtained with CDUS predicted the onset of acute dilatation with higher sensitivity, specificity, accuracy, and diagnostic efficiency than ultrasonography, and it can be used routinely in the emergency department to supplement ultrasound findings.

[The surgical treatment of the diastasis recti abdominis: an original technique of prosthesis repair of the abdominal wall]. / Il trattamento chirurgico degli sventramenti spontanei: tecnica originale di protesizzazione della parete addominale.

The Authors talk about on the surgical correction of the diastasis recti abdominis and underline its indications and aims. Firstly, they specify the possibilities and define the limits of the traditional surgical method. Secondly, they illustrate the rational of an innovating and original technique of prosthesis repair of the abdominal anterior wall setted up to treat the important diastasis recti abdominis. Particularly, this technique is the result of a kind of eclecticism and integration of some phases of the Quénu's self-plastic surgery and of the Welti-Eudel and Chevrel's technique. Thirdly, the authors describe the sequence of the times of the new technique and present the preliminary clinical experience carried out with it. Therefore, they determine gratifying and encouraging the findings of this method as regards the immediate and enduring curative efficacy (cosmetic and functional), the security and the compliance of the patient. Finally, in accordance with the outcomes, the authors decide to defend the undoubted reliability of the prosthesis repair of the abdominal wall to treat the big diastasis recti abdominis. Moreover, they intend to pass definitive judgement on the method after further clinical experiences on larger series of cases.

[The employment of an original ring handle forceps in anterior repair of the primitive inguinal hernia]. / L'impiego di un'originale pinza nella chirurgia per via anteriore dell'ernia inguinale primitiva.

The Authors propose the employment of an original dissecting and ribbon-carrier bevelled ring handle forceps in inguinal prosthetic tension-free hernioplasty with mini-inguinotomy. The surgical instrument, of stainless steel and 16 centimetres long, consists of two jaws with ring handle, ratchets and box lock nearly identical to those of common surgical instruments; is slightly curved in his distant part, where shows a large bevelled end and a large seizing, entirely original. The peculiar surgical instrument gives possibility to operator to make easily and delicately the atraumatic mobilization in proximity to the pubic tubercle of the spermatic cord from the back wall of the inguinal passage, in place of the index finger hook-shaped who, used roughly and by pulling in large incisions, cannot be used instead in the mini-incisions because of limited available space in the surgical site. On end, the new ring handle forceps allows to keep in suspension the spermatic cord by rubber ribbon more simply and rapidly than the usual big ligature-carrier. On the whole, the dissecting and ribbon-carrier bevelled ring handle forceps, whose the Authors use habitually the prototype in inguinal prosthetic tension-free hernioplasty with mini-inguinotomy, allows the execution of easy, prudent, elegant, precise, effective and above all safe surgical gestures.

New model of liver regeneration induced through use of vascular endothelial growth factor.

INTRODUCTION: Vascular endothelial growth factor (VEGF) is an endothelial cell mitogen. The objective of this study was to verify the proregenerative effects of VEGF in an experimental model of acute liver failure. MATERIALS AND METHODS: Sixty four rats that underwent intraperitoneal injection of carbon tetrachloride (CCl(4)) were randomly divided into two groups: group B animals received intravenous injection of VEGF(164) 1 hour following CCl(4) poisoning. Group A hosts were untreated. To obtain daily liver function tests (LFTs) and histological samples, on each day up to 8 days we sacrificed four rats in each group. RESULTS: The laboratory examinations showed notable alteration of LFTs in group A, while group B revealed only slight changes. The histological examination showed greater liver damage in group A compared with group B. CONCLUSION: Our results suggest that administration of exogenous VEGF protects the liver from CCl(4)-induced acute hepatic failure. Further studies are underway to assess whether exogenous VEGF is effective in other liver injuries.

Hemorrhage from primitive rectal varices in patient with idiophatic thrombosis of portal vein: case report.

INTRODUCTION: Rectal varices, primitive or secondary to hypertensive or thrombotic disorders of mesenteric-portal circle, represent an uncommon cause of lower digestive bleeding. The presence of rectal varices associated to idiopathic venous portal thrombosis represents a distinct nosologic entity, with important clinical and therapeutic problems related to it. CASE REPORT: Patient of young age, with positive anamnesis for primitive rectal varices, admitted to our department for a serious recttorragy. The laboratory underlined moderate anaemia and the endoscopy documented the presence of multiple rectal varices, without evident signs of bleeding; the endoscopy documented the presence of two esophageal small varicose cords F1. The hepatobiliary sonography and the portography showed the massive thrombosis of the portal vein. The new serious episode of rectal bleeding induced us to subject the patient to a surgical operation of Hartmann recto-sigmoid resection. CONCLUSION: Because of the slight number of reported cases of primitive rectal varices and because of the scattering of many dates it is difficult to draw an univocal diagnostic and therapeutic algorithm. Clinical framing and subsequent therapeutic approach rise often up from personal experience rather than well defined guidelines. The treatment is controversial, time by time many therapeutic options are reported either conservative or interventionist. The failure of conservative therapy and the recurrent episodes of bleeding give indication to surgical treatment, that is represented by Hartmann colonic resection and/or the porto-systemic shunts in the cases of portal hypertension; in our case we made colonic resection sec. because of lapsed performing status of the patient.

[Innovative use of the vascular endothelial growth factor in an experimental model of acute liver failure]. / Utilizzo innovativo del fattore di permeabilità vascolare in un modello sperimentale di insufficienza epatica acuta.

Vascular Endothelial Growth Factor (VEGF) is an endothelial cell mitogen and an important stimulator of sinusoidal endothelial cell proliferation. The aim of this research was to study the effects of exogenous VEGF in a rat model of acute liver failure. The study was conducted on 64 rats (240-300 g). All rats underwent intraperitoneal injection (5 ml/kg) of 25% carbon tetrachloride (CCl4) and 75% paraffin oil. This dosage of CCl4 was devised to induce nonfatal acute liver failure with spontaneous recovery in 7 days. The animals were randomly divided into 2 groups. Group B animals underwent i.v. injection of 200 ng of VEGF165 one hour following intra-peritoneal injection of CCl4. To obtain daily liver functional tests (LFTS) and histological liver samples, 4 rats in each group were sacrificed daily up to 8 days. In group A, the liver histology showed massive periportal hepatocyte necrosis associated with portal lymphocytic infiltrates. The peak of the damage was documented at 72 hours following CCl4. Group B showed minimal necrosis, moderate periportal edema and a minimum periportal steatosis. At 48 hours steatotic changes had disappeared and the periportal edema was resolving. LFTs demonstrated severe liver damage in rats in group A. In group A the peak AST (mean 322.5 IU/L) and ALT (mean 250.25 IU/L) were recorded at 72 hours. In group B, at 72 hours the mean AST was 137 IU/L (normal < 95 IU/L) and ALT 68 IU/L(normal < 45 IU/L). The maximum levels of AST and ALT, in group B, were 152.3 IU/L and 72.3 IU/L, at 24 hours. According to our results exogenous VEGF successfully protects the liver from CCl4 induced acute liver failure. Further studies will demonstrate if exogenous VEGF can be effective in other liver injuries.

[Angiodysplasia in the gastrointestinal haemorrhage of the elderly patient. Our experience]. / Le angiodisplasie nelle emorragie digestive del paziente anziano. La nostra esperienza.

Angiodysplasia of the digestive tract is one of the main causes of acute bleeding and is a frequent reason for admittance to the emergency surgery unit. This pathology, previously considered rare and often not recognised, has only recently acquired a precise anatomo-pathology thanks to endoscopy. Besides having a decisive diagnostic role, endoscopy also allows the control and successful treatment of lesions, often in a definitive way, which were previously only dealt with surgery, with significant advantages for the elderly patient, reducing the rate of morbidity and mortality. There are still many discussions today, above all on the priority of various diagnostic investigations to be carried out in digestive bleeding and on the choice of treatment in the case of angiodysplasic lesions in geriatric age. Some cases of acute bleeding from intestinal angiodysplasia, observed by the Authors, have led them to study the etiopathogenesis, diagnosis and emergency treatment of such lesions.

Incidence, predisposing factors, and results of surgical treatment of incisional hernia after orthotopic liver transplantation.

The literature provides little data about incisional herniae (IH) developing after orthotopic liver transplantation (OLTx). We evaluated the incidence, predisposing factors, and results of surgical treatment of this pathological condition. We reviewed the records of 718 consecutive OLTx performed in 623 patients between April 1986 and May 2002. Patients whose IH developed after transplantation were included in the study. We identified 31 patients (incidence, 4.9%) whose IH developed from 2 to 140 months after the transplantation. This complication was significantly more frequent in men. Important predisposing factors included: virus-correlated cirrhosis, body mass index >25, severe ascites, incision type for OLTx (bilateral subcostal extended upper midline to xiphoid), and post-OLTx complications. In 17 patients, repair of hernia was performed using direct fascial approximation, in 20 patients, it required a prosthesis. After hernia treatment, we observed no deaths but a morbidity rate of 6.4%, a mean postoperative hospital stay of 8 days and a recurrence rate of 6.4%. IH post-OLTx need surgical treatment.

Pyoderma gangrenosum of the "sinus mammarum" in ulcerative colitis.

The first part of this article deals with the report of a patient suffering from pyoderma gangrenosum of the "sinus mammarum" associated with asymptomatic ulcerative colitis. This is followed by a revision of the present epidemiological, etiological, pathogenetic and clinical knowledges about this systemic manifestation of chronic phlogosis of the colon. The Authors have analysed the treatment for this condition and emphasized the resistance of the cutaneous ulcer encountered to conventional medical therapy of the underlying colonic disease which proved to be efficacious only on the latter; this led to integrate traditional treatment with the use of perilesional injections of small doses of calcic heparin as an alternative to immunosuppressive drugs or surgery. Topical antithrombotic treatment, which can be justified by the histological findings of phenomena of the vasculitis in the edge of pyoderma gangrenosum, demonstrated to be crucial and represents a peculiarity in the case here reported, which is unique in the literature as far as the Authors know, since it has not been experimented by anyone else.

["Switch prophylaxis one a day" with levofloxacin in laparoscopic cholecystectomy]. / "Switch prophylaxis one a day" con levofloxacina nelle laparocolecistectomie.

BACKGROUND: Special attention is paid today to the advisability of carrying out routine antibiotic prophylaxis in laparoscopic cholecystectomy (LC) and to the dosage protocol to be adopted in order to reduce the incidence of infections at the site of the surgical operation which, albeit with lower incidence than in "open" surgery, 5.3% vs 14%, can vanify the advantages of the mini-invasive approach. The demonstrated validity of administering the antibiotic beyond 24 hours after the operation led the authors to verify the clinical effectiveness and tolerance of "switch prophylaxis one a day" (SPOD) with levofloxacin in the prevention of septic complications after LC. METHODS: The experience reported relates to 185 patients suffering from symptomatic and/or complicated lithiasis of the gall-bladder subjected from January 1999 to April 2001 to LC and to antibiotic prophylaxis in accordance with the following dosage protocol: levofloxacin 500 mg i.v. 30 min before operation and 500 mg per os in the 3 days subsequent. RESULTS: The postsurgical evaluation documented the onset of 2 superficial infections in patients in whom LC had been of necessity converted and of a subhepatic abscess in an ASA III patient with acute cholecystitis. Prevention of infections at the surgical site totalled 98.4%. Nausea and slight diarrhoea and an increase in transaminasaemia were observed respectively in 3% and 4% of patients. CONCLUSIONS: The results obtained led the authors to standardise the use of SPOD with levofloxacin in LC operations which, in their opinion represents a rational alternative to the antibiotic prophylaxis regimes most commonly used up to the present (STP and USTP).

Kidney preservation in pigs with University of Wisconsin and Celsior solution.

BACKGROUND: Although University of Wisconsin (UW) solution continues to be the most commonly used for intra-abdominal organs a new solution, Celsior, already utilized for heart and lungs, has been proposed for kidney and liver preservation. The aim of this research was to assess the effect of Celsior compared to UW on the immediate graft function of pig autotransplanted kidneys. METHODS: We used an autotransplantation pig model to avoid immunological interferences. After harvesting the graft was immediately bench perfused through the renal artery with 200 cc of solution and preserved for 24, 32 and 48 hrs. After cold ischemia grafts were autotransplanted on cava vein and aorta and a ureteral-ureteral anastomosis was performed. Contralateral nephrectomy was carried out at the end of this procedure. Each experimental group was composed of 5 animals. All animals were sacrificed after 1 week. RESULTS: All animals with 24 hr and 32 hr preserved grafts survived up to sacrifice; kidney function was recovered in all animals of 24 hr groups and in most of the animals of 32 hr preserved grafts (4/5) without any differences between the 2 solutions. In Celsior and UW 48 hr groups only 5 animals survived (3 and 2, respectively) and in all these animals kidney function was not totally recovered. CONCLUSIONS: Our data show that preservation of kidneys with the Celsior solution in the experimental setting is equivalent to UW solution.

Surgical strategy in abdominal organs retrieval from elderly donors.

BACKGROUND: There are no literature data on surgical problems that can be encountered during harvesting of grafts from elderly donors. The aim of our study was to report our experience during liver harvesting from donors over 70 years old and during transplantations of these grafts. METHODS: From April 1986 to December 2001, 686 OLT in 599 patients were performed at the Liver Transplant Unit of the S. Orsola Hospital in Bologna. In particular we harvested 68 livers from donors with mean age of 75.4+/-4.5 years (range 70-87). The cause of brain death was a spontaneous cerebral haemorrhage in 58 cases and trauma in 10 cases. Thirteen donors were previously submitted to cardiovascular surgery. Three subjects had an abdominal aorta aneurysm 5, 6 and 7 cm large respectively, involving the iliac arteries, not diagnosed before the harvesting procedure. In 60 donors atherosclerosis was present. RESULTS: Out of 68 transplanted patients with donor over 70 years of age we observed 13 arterial complications (19.1%): 7 hepatic artery thrombosis, 3 hepatic artery stenosis, 1 iliac graft thrombosis, 1 splenic artery stump rupture and 1 hepatic artery rupture both leading to fatal hemoperitoneum. A primary non-function occurred in 4 cases treated with retransplantation. The 1- and 3-year graft survival was 74 and 56.2%, respectively; the 1 and 3-years patient survival was 85.8 and 72.5% respectively. CONCLUSIONS: Harvesting technique from old donors is not so different from standard procedure: however it is fundamental surgeon's experience to optimize organ retrieval from these donors.

[Blunt hernia trauma with ileal perforation and incidental finding of Taenia saginata infestation]. / Trauma contusivo erniario con perforazione ileale a reperto incidentale di infestazione da taenia saginata.

Taking as their starting point the observation of a patient with blunt trauma of a voluminous inguinoscrotal hernia and with peritonitis due to perforation of the small bowel within the hernia, the Authors illustrate the aetiological, pathogenetic and physiopathological mechanisms of "seat belt syndrome". In the case described, they postulate that the incidental presence of taenia saginata in the small bowel lumen contributed considerably to the rupture. They then go on to focus on the difficult clinical diagnosis of this pathology and analyze its treatment. In view of the direct correlation between the prognosis and the therapeutic interval, they stress that resorting to diagnostic laparotomy in doubtful cases is a rational course of action. Laparoscopy today also constitutes an effective diagnostic and therapeutic option.

[Identification of an experimental model of partial portocaval shunt]. / Identificazione di un modello sperimentale di derivazione porto-cava parziale.

Portacaval shunt with interposition of 6 mm H-graft of PTFE is a real partial shunt. In this experimental study, the operation has been well tolerated and has been compared with 8 mm H-graft and direct "vein to vein" portacaval shunt. Intraoperative data show that 6 mm is the ideal diameter for a portacaval shunt to prompt an experimental model based on partial decompression of portal bed in animals in this size.