[Retractile mesenteritis: case report]. / Mesenterite retrattile: presentazione di un caso.

The Authors report a case al retractile mesenteritis. The disease is a chronic inflammation of the mesentery with the developement of fibrosis. The mesenteritis is a benign disease and sometimes it is related to urogenital neoplasm. The CT fìndings of mesenteritis are non specific and often is necessary a laparotomic or laparoscopic biopsy. The therapy in uncomplicated cases is steroid treatment.

Anastomotic leaks after anterior resection for mid and low rectal cancer: survey of the Italian Society of Colorectal Surgery.

BACKGROUND: The aim of the survey was to assess the incidence of anastomotic leaks (AL) and to identify risk factors predicting incidence and gravity of AL after low anterior resection (LAR) for rectal cancer performed by colorectal surgeons of the Italian Society of Colorectal Surgery (SICCR). METHODS: Information about patients with rectal cancers less than 12 cm from the anal verge who underwent LAR during 2005 was collected retrospectively. AL was classified as grade I to IV according to gravity. Fifteen clinical variables were examined by univariate and multivariate analyses. Further analysis was conducted on patients with AL to identify factors correlated with gravity. RESULTS: There were 520 patients representing 64% of LAR for rectal cancer performed by SICCR members. The overall rate of AL was 15.2%. Mortality was 2.7% including 0.6% from AL. The incidence of AL was correlated with higher age (p<0.05), lower (<20 per year) centre case volume (p<0.05), obesity (p<0.05), malnutrition (p<0.01) and intraoperative contamination (p<0.05), and was lower in patients with a colonic J-pouch reservoir (p<0.05). In the multivariate analysis age, malnutrition and intraoperative contamination were independent predictors. The only predictor of severe (grade III/IV) AL was alcohol/smoking habits (p<0.05) while the absence of a diverting stoma was borderline significant (p<0.07). CONCLUSION: Our retrospective survey identified several risk factors for AL. This survey was a necessary step to construct prospective interventional studies and to establish benchmark standards for outcome studies.

Video-assisted thoracic surgery (VATS) of the lung: analysis of intraoperative and postoperative complications over 15 years and review of the literature.

BACKGROUND: Video-assisted thoracic surgery (VATS) in the diagnosis and treatment of pulmonary diseases has been used since the early 1990s, yet its impact on intraoperative and postoperative morbidity has not yet been fully evaluated. This report aims to provide a retrospective analysis of the literature and the authors' clinical experience with VATS in pulmonary surgery, with the goal of ascertaining rational criteria that explain operative complications and thus improve outcomes. METHODS: Over a period of 15 years 1,615 VATS procedures were performed in our department, 743 of which involved only the lung. The accesses employed were based on the use of three ports through which a thoracoscope, endoscopic instruments, and an endostapler were inserted; for major pulmonary resections, a utility thoracotomy without rib spreader was added. Resections less than segmentectomy were performed using the endostapler directly on the parenchyma, whereas in the anatomic resections all the hilar structures were isolated and separately sectioned. RESULTS: The procedures performed were as follows: surgical biopsy, 98; wedge resection, 412; segmentectomy, 15; lobectomy, 217; pneumonectomy, 1. Besides the cases in which there were intraoperative complications that could be resolved thoracoscopically, it was necessary to convert to open surgery in 80 patients (10.8%): in 24 (3.3%), for general reasons linked to the technique of VATS itself; in 56 (7.5%), for specific causes correlated to the type of exeresis. The overall postoperative morbidity rate was 8.3% with no deaths. CONCLUSIONS: The analysis of the literature and our experience show that VATS is a reliable approach to the diagnosis and treatment of pulmonary diseases with low complication rate. To further reduce intraoperative and postoperative morbidity, however, it is necessary to select the patients carefully, to adhere strictly to oncological surgical principles, and to adopt a meticulous technique. Although conversion to open surgery represents failure of VATS, it is mandatory when the procedure is not completely safe.

Long-term results of video-assisted thoracic surgery lobectomy for stage I non-small cell lung cancer: a single-centre study of 104 cases.

The use of video-assisted thoracic surgery (VATS) for carrying out major pulmonary resections in the treatment of lung cancer is still controversial. In order to contribute to knowledge about the long term results obtained with this technique in the treatment of stage I NSCLC, we present data relating to research in our institute over the past 10 years. From January 1993 to December 2002, 138 patients with peripheral clinical stage I NSCLC were selected to undergo VATS lobectomy. The procedure was based on a mini-thoracotomy without rib spreading, with hilar dissection and separate sectioning of the arteries, veins and bronchi; this was associated with hilar and mediastinal lymph-node sampling. Follow-up consisted of clinical and radiological examination every 6 months in the first 2 years after surgery, then once a year; a CT scan was carried out 1, 3 and 5 years after surgery. The probability of survival was estimated with the Kaplan-Meier method. Surgery by VATS was successfully completed in 122 cases, with a thoracotomy conversion rate of 11.6%. Of these, stage I was confirmed by pathological examination in only 104 cases: there were 56 T1N0 and 48 T2N0. With a mean follow-up of 65 months, the 5-year survival rate was found to be 67+/-10%; in the T1N0 it was 68+/-15%, whereas in the T2N0 it was 67+/-16%. The rate of local or regional recurrence was 4.8% while the systemic recurrence rate was 15.4%. From an appraisal of the study results we consider VATS to be a valid approach for carrying out lobectomy for the treatment of stage I pulmonary carcinoma. The long-term results are comparable to those obtained in open surgery both in terms of survival and the rate of local recurrence. Therefore in selected cases, where there is no increase in surgical risk, VATS may be the preferred approach.

Hepatic intra-arterial chemotherapy (HIAC) of high dose mitomycin and epirubicin combined with caval chemofiltration versus prolonged low doses in liver metastases from colorectal cancer: a prospective randomized clinical study.

A multicenter randomized study comparing high dose of mitomycin and epirubicin given as hepatic intra-arterial chemotherapy (HIAC) combined with caval chemofiltration (CF) versus low doses of the same drugs in unresectable liver metastases from colorectal cancer showed a significant improvement in the survival rate of the 20 patients treated with high dose compared to the 22 patients treated with low doses with a 1 year survival of 69% vs 39%. The median survival was 17 vs 11 months and the responses were 65% vs 33%. Toxicity was colangitis in 50% of patients considered. The extrahepatic progression was similar in the two groups (7/20 vs 8/22).

The role of the -50 region of the human gamma-globin gene in switching.

During the switch from human gamma- (fetal) to beta- (adult) globin gene expression, the gamma and beta genes are expressed competitively by an alternating transcription mechanism. The -50 region of the gamma gene promoter has been proposed to be responsible for the early competitive advantage of the gamma genes and to act as a stage selector element (SSE) in hemoglobin switching. We analyzed the effect of mutating the -50 region of the gamma gene in the presence of a competing beta gene in transgenic mice. This shows that the -50 region does not affect silencing of the beta gene in early development and does not act as a stage selector. However, it affects the ratio of gamma versus beta gene expression in the early, but not later, stages of fetal development. Interestingly, both the wild-type and mutant minilocus constructs show a higher frequency of alternate transcription than observed in the complete locus, suggesting that sequences normally present between the gamma and beta genes facilitate the interaction of the locus control region (LCR) and beta-globin gene in the complete locus.

Video-assisted thoracic surgery major pulmonary resections. Present experience.

OBJECTIVE: The purpose of this report is to review our experience of video-assisted thoracic surgery (VATS) major pulmonary resections. METHODS: From January 1993 to December 1999 we proposed VATS, for major pulmonary resections, with these indications: benign lesions and solitary metastases not removable by wedge resection and stage I non-small cell lung cancer (NSCLC). The maximum size of the lesion had to be less than 4 cm. RESULTS: There were 125 patients, 87 men and 38 women with a mean age of 62. We successfully performed VATS procedure in 112 cases (one hamartoma, one tubercoloma, 12 typical carcinoids, 11 metastases and 87 lung cancers), while in another 13 (10.4%) a conversion to open surgery was required. There were 108 lobectomies, three bilobectomies and one pneumonectomy. Out of the first three cases of NSCLC, in all patients mediastinal node sampling or lymphadenectomy was performed. We recorded 13 (11.6%) postoperative complications, one of which required re-operation (bleeding). In the 99 patients without complications, the mean postoperative stay was 5.8 days. In a mean follow-up period of 36 months with patients having lung cancer we achieved a 3-year survival rate of 85+/-9 and 90+/-8% when only the patients in Stage I were considered. CONCLUSIONS: We believe that VATS, in performing pulmonary lobectomy, is a safe and effective approach and it seems to give the same long-term results as open surgery. Now the main problems concern the indications that should be strictly respected and the conversion to thoracotomy which should be undertaken without hesitation when the anatomic or pathologic conditions are not favourable.

Locoregional therapy for liver metastases from colorectal cancer: the possibilities of intraarterial chemotherapy, and new hepatic-directed modalities.

Liver metastasis of colorectal cancer is a life-threatening prognostic factor. Hepatic resection, when possible, is the best therapeutic modality, although the overall survival rate is still low (30%). The diagnosis has been carried out by clinical examination, abnormal alkaline phosphatase, lactic acid dehydrogenase and tumor markers, abdominal liver echography and computed tomography scan. Angiography and intraoperative echography are useful for resection. The number of hepatic metastases and the surgical margin are probably the most significant prognostic factors. Colorectal cancer may spread predominantly to the liver making regional treatment strategies viable options. Subtotal hepatic resections and segmentectomies are potentially curable procedures for single or small numbers of hepatic metastases without other sites of disease. However, there have been no prospective randomized trials comparing patients with unresected liver metastases and resected metastases. Regional chemotherapy with floxuridine seems useful combined with hepatic resection or as palliative therapy. Gastric ulcer and biliary sclerosis are the main related toxicities. Patients with localized, unresectable hepatic metastases or concomitant bad medical condition may be candidates for radiation, percutaneous ethanol injection, cryosurgery, radiofrequency, hypoxic flow-stop perfusions with bioreductive alkylating agents, hepatic arterial ligation, embolization and chemoembolization. These new hepatic-directed modalities of treatment are being investigated and may offer new approaches to providing palliation and prolonging survival. This review reports the possibilities of intraarterial chemotherapy and other novel hepatic directed approaches to the treatment of liver metastases from this common disease.

Global approach to hepatic metastases from colorectal cancer: indication and outcome of intra-arterial chemotherapy and other hepatic-directed treatments.

Liver metastases of colorectal cancer is present in more than 20% of new diagnosed patients and in 40-60% of relapsed patients. It is a life-threatening prognostic aspect. Hepatic resection, when possible, is the best therapeutic modality, although the overall survival rate is still low (30%). Angiography and intraoperative ultrasonography are useful for resection. The number of hepatic metastases and the surgical margin are probably the most significant prognostic factors. Colorectal cancer may spread predominantly to the liver making regional treatment strategies viable options. Subtotal hepatic resections and segmentectomies are potentially curable procedures for single or small numbers of hepatic metastases without other sites of disease. However, there have been no prospective randomized trials comparing patients with unresected liver metastases and resected metastases. Regional chemotherapy with floxuridine seems usefull combined with hepatic resection or as palliative therapy. Gastric ulcer and biliary sclerosis are the main related toxicities. Patients with localized, unresectable hepatic metastases or concomitant bad medical condition may be candidates for radiation, percutaneous ethanol injection, cryosurgery, percutaneous radiofrequency, hypoxic flow-stop perfusions with bioreductive alkylating agents, hepatic arterial ligation, embolization and chemoembolization. These new hepatic-directed modalities of treatment are being investigated and may offer new approaches to providing palliation and prolonging survival. This review will report the possibilities of intra-arterial chemotherapy and other novel hepatic-directed approaches to the treatment of liver metastases from colorectal cancer.

Video-assisted thoracic surgery (VATS) lobectomy for typical bronchopulmonary carcinoid tumors.

BACKGROUND: Indications for the use of video-assisted thoracic surgery (VATS) lobectomy are a controversial matter. This study aims to provide a retrospective evaluation of VATS lobectomy in typical bronchopulmonary carcinoids. METHODS: Patient selection criteria for VATS lobectomy were as follows: (a) typical carcinoids with clear diagnosis; (b) centrally located lung tumors not amenable to bronchial resection with bronchoplastic procedures, or tumors located in peripheral lung tissues; (c) no hilar or mediastinal lymph node enlargement; and (d) normal respiratory function. Between January 1995 and December 1999, 12 patients (eight men and four women with a mean age of 57 years) were treated, seven with a peripheral and five with a centrally located tumor. Preoperative examination included chest roentgenograms, computed tomography (CT) of the chest, bronchoscopy, and spirometry; diagnosis was established by direct bronchoscopy in five cases, transbronchial biopsy in two cases, transthoracic biopsy in two cases, and video thoracoscopic wedge resection in three cases. Eleven VATS lobectomies and one VATS bilobectomy were performed. All patients underwent hilar lymphadenectomy and mediastinal sampling. RESULTS: There were no intraoperative complications. The only postoperative complication, hematothorax (8.3%), required VATS reoperation. Mean postoperative hospital stay was 5.33 days. Pathological examination of the resected specimens confirmed that the procedure was radical in all 12 patients and revealed eight T1N0 and four T2N0. At a mean follow-up of 30 months, no signs of recurrence were recorded. CONCLUSION: VATS lobectomy in the treatment of selected typical carcinoids, both central and peripheral, seems to yield favorable results and is therefore preferable to thoracotomy since it is less invasive.

[Video thoracoscopic treatment in pleural empyema]. / Il trattamento videotoracoscopico dell'empiema pleurico.

BACKGROUND: To evaluate the possible role and the effectiveness of videothoracoscopy (VATS) in the treatment of pleural empyema. METHODS: Personal experience on 40 cases of pleural empyema treated by (VATS) during 5 years is reported. The underlying diseases were: pneumonia (32), pneumothorax (3), tuberculosis (2), abdominal diseases (2) and lung cancer (1). Before VATS at least one thoracentesis was performed to evaluate the characteristic of the pleural fluid. RESULTS: Due to complications related to thick pleural adhesions, in one case (2.5%) the procedure was converted to open surgery, while in the remaining 39 cases VATS was able to achieve a complete cleaning of the pleural space with re-expansion of the pulmonary parenchyma. The improvement of the clinical symptoms were observed after a mean period of 3.5 days (range: 1-12 days). Chest tube was removed in a mean period of 4.8 days (range: 3-11 days); five patients had prolonged air leak from 6 to 10 days after surgery. CONCLUSIONS: In conclusion we are of the opinion that VATS has to be considered a very important mean for the treatment of pleural empyema; its use in the fibrinopurulent phase of the disease should give very good results, while in the following phase its indications are controversial.

[Liver abscess secondary to ingestion of foreign body. A case report]. / Ascesso epatico secondario ad ingestione di corpo estraneo. Caso clinico.

Hepatic abscess is a serious surgical problem with a high mortality rate. The Authors report a case of a liver abscess following the migration of a toothpick from the stomach into the hepatic left lobe. Percutaneous abscess drainage combined with endoscopical removal of the foreign body were the goal treatment. The Authors stress importance of the laparoscopy-guided drainage with placement of intra-hepatic drains.

Rat tyrosine hydroxylase gene polymorphisms.

The rat tyrosine hydroxylase gene (TH) from a panel of outbred and inbred rat strains has been analysed by Southern blotting, restriction-endonuclease mapping and direct sequencing of PCR-amplified products for detecting DNA polymorphisms. Five polymorphic sites have been characterized. This information may be used in pharmacogenetic studies to determine the influence of the TH gene in animal models of affective disorders and addictive behaviours.

[Does a genetic predisposition for infarction expansion exist? Evaluation of genetic polymorphisms of the renin-angiotensin system]. / Esiste una predisposizione genetica per l'espansione infartuale? Valutazione dei polimorfismi genetici del sistema renina-angiotensina.

Aim of this study is to carry out a genetic analysis of polymorphisms of the renin-angiotensin system in a genetically homogeneous population, in patients with and without myocardial infarction (AMI) expansion and to evaluate the influence of non genetic, mechanical factors. The study was conducted on 299 patients with first AMI. Ecocardiography studies were performed on all patients on day 1 and 3 from the onset of AMI and before discharge. Eighty-four patients were excluded because of inadequate quality of echocardiograms and 215 (163 males, 52 females) were admitted. Of these, 157 had no evidence of AMI expansion (EXP-) while 58 had expansion (EXP+). DNA was extracted by standard methods from blood samples. Age and gender had no influence on AMI expansion. Anterior infarction (p < 0.000001) and Q-wave infarction (p < 0.00002) were found more frequently in EXP+. Peak of creatine phosphokinase was higher in EXP+ than in EXP- (p < 0.00001). The percent of patients treated with thrombolysis or with hypertension and/or left ventricular hypertrophy was not significantly different in the two groups. AGT MT235 polymorphism of angiotensinogen gene, I/D polymorphism of ACE gene and AT1 A1166C of AT1 receptor of angiotensin II were not significantly different in two groups. Stratified analysis showed that in patients with anterior AMI (n = 87), with a higher risk of AMI expansion, there is a significant difference (p < 0.02) in ACE genotype between EXP- and EXP+. Odds ratio assuming the dominant effect of I allele (II+ ID < DD) was 3.35 (confidence interval 1.41-7.56) with increased risk of expansion. More extension studies are need to verify if these results can contribute to early identification of patients at higher risk and to optimize therapeutic approach.

A DNA fragment from Xq21 replaces a deleted region containing the entire FVIII gene in a severe hemophilia A patient.

In this paper we report the molecular characterization of a large deletion that removes the entire Factor VIII gene in a severe hemophilia A patient. Accurate DNA analysis of the breakpoint region revealed that a large DNA fragment replaced the 300-kb one, which was removed by the deletion. Pulsed-field gel electrophoresis analysis revealed that the size of the inserted fragment is about 550 kb. In situ hybridization demonstrated that part of the inserted region normally maps to Xq21 and to the tip of the short arm of the Y chromosome (Yp). In our patient this locus is present both in Xq21 and in Xq28, in addition to the Yp, being thus duplicated in the X chromosome. Sequence analysis of the 3' breakpoint suggested that an illegitimate recombination is probably the cause of this complex rearrangement.

High-dose intra-arterial plus intraperitoneal chemotherapy combined with hemofiltration in liver metastases from colorectal cancer.

AIMS: Twenty-three patients with liver metastases from colorectal cancer were entered into a prospective, phase II pilot study to evaluate the efficacy and feasibility of intra-arterial high-dose chemotherapy (IAHC) + intraperitoneal chemotherapy (IPC) combined with hemofiltration. METHODS: All patients had abdominal laparotomy to position a hepatic artery infusion port and in 15 cases an implantable system for IPC. A double-lumen filtration catheter was placed in the vena cava via the saphenous or femoral vein and connected to a modified hemofiltration unit. The treatment schedule consisted of mitomycin (30-50 mg/m2) and epirubicin (60-90) mg/m2) as IAHC combined with cisplatin (60 mg/m2) given in a 2000 ml saline solution by IPC. The high-dose IAHC-IPC was followed by 4 cycles of intra-arterial standard dose chemotherapy through the arterial port-a-cath (6 mg/m2 mitomycin and 20 mg/m2 epirubicin) and if possible by another cycle of high dose IAHC-IPC. RESULTS: We delivered a total of 31 cycles of IAHC, 21 of which were combined with IPC. Ten cycles of IAHC were administered without concurrent IPC because of painful adhesions, clinical contraindications or patient refusal. Seven of 23 patients (30%) were pretreated and with progressive disease after systemic chemotherapy. Among 22 evaluable patients, we obtained 2 complete remissions (9%) and 11 partial remissions (50%); moreover, 4 of 7 pretreated patients obtained a response to treatment. As a result, an objective tumor response was observed in 59% of patients (13/22). Therefore, a dose-response behavior was demonstrated also in tumors with a low chemosensitivity. The median duration of response and survival was 10 and 14 months, respectively. Toxicity was usually mild, but we reported one toxic death due to treatment complications. CONCLUSIONS: Further prospective randomized studies are needed to confirm the results of our study.

A novel beta-globin structural mutant, Hb Brescia (beta 114 Leu-Pro), causing a severe beta-thalassemia intermedia phenotype.

This study describes a patient with a thalassemia intermedia-like phenotype in whom beta-globin gene sequencing detected a novel abnormal hemoglobin (Hb) due to a T-C substitution at codon 114 of the beta-globin gene arising as a de novo mutation. The abnormal variant was designated Hb Brescia after the place of birth of the propositus. Normal sequences were detected at the in trans beta-globin locus. In addition, alpha-globin gene analysis detected a triple alpha-globin locus which was inherited from the father. The T-C change at position 114 of the beta-globin gene results in a leucine to proline substitution (Leu-Pro) in the G-helix. The resulting Hb tetramer is highly unstable and precipitates forming inclusion bodies in the peripheral red blood cells. Moreover, the Leu-Pro substitution interferes negatively with the four alpha 1 beta 1 contact points of the G-helix most likely adversely affecting the alpha beta dimer formation. The very severe phenotype presented by our patient is unusual in a heterozygote for an unstable Hb variant and may be explained by the coinheritance of the triple alpha-globin locus.

[The correlation of bacteriobilia/wound infections in elective biliary surgery]. / Correlazione bactobilia/infezioni della ferita in chirurgia biliare d'elezione.

The authors report their experience concerning the cultural study of bile samples taken during elective biliary surgery. All the operations were carried out after a randomized preoperative antibiotic prophylaxis. Among the 138 cases examined the presence of surgical infections (wound infection) was taken into account. A lack of correlation between the germs present in the bile and those isolated from samples of complicated cases, was registered. However, the Authors emphasize that, although antibiotic prophylaxis gives a reduced percentage of postoperative infections, it is unable to sterilize the bile.