Endoscopic pancreatic stenting in pancreatic cancer.

Most pancreatic carcinomas are unresectable at the time of diagnosis; therefore, palliative treatment is very often the main concern of clinicians in this setting. The main symptoms resulting in the need for palliation in pancreatic cancer are obstructive jaundice, duodenal obstruction and pain. Therapeutic endoscopy plays a major role in the palliation of obstructive jaundice by stent placement into the biliary ducts. Initial experience has also been gained recently with endoscopic placement of expandable metallic stents to treat gastric outlet obstruction. Much less is known about the possible role of endoscopic pancreatic stenting in patients with unresectable pancreatic carcinoma. The main indication for pancreatic ductal stenting is 'obstructive' pain related to meals in patients with dilated main pancreatic duct beyond the stricture and intraluminal brachyradiotherapy. The technique of endoscopic pancreatic stenting does not substantially differ from that applied on the biliary tree. When technically possible, placement of 10 French plastic stents is preferred. According to the authors' indications, only about 15% of patients with advanced pancreatic cancer (55 of 355 in the present study) may potentially benefit from this technique. Pancreatic stenting may be obtained in more than 80% of these selected patients, with low morbidity (less than 10%) and no procedure-related mortality. According to the authors of the present and other studies reported in the literature, about 60% of patients treated because of 'obstructive' pain become symptom-free, and another 20% to 25% significantly reduce the amount of analgesic drugs required. Intraluminal brachyradiotherapy with 192iridium in the main pancreatic duct is a feasible and safe method to deliver high radiation doses to the tumour while sparing adjacent organs. Brachyradiotherapy may be performed alone or in conjunction with external beam radiotherapy. Because of the small number of patients suitable for this treatment, only a multicentre study will be able to detect whether intraluminal brachyradiotherapy in pancreatic cancer may have any positive impact on survival.

[Gastric vascular ectasia (GAVE) or watermelon stomach (WS): infrequent cause of anemia]. / Ectasia vascular del antro (EVA) ó Watermelon Stomach (WS). Poco frecuente causa de anemia.

The gastric vascular ectasia (GAVE) or watermelon stomach (WS) is an unfrequent cause of anemia or evident upper gastrointestinal bleeding in elderly patients. We presented five female patients, average age 79 years, 4 of them with a long evolution anemia and one with melena. Three of them showed a typical WS endoscopy, 2 of them with diffuse patent. All 5 cases with positive pathologic findings: vascular ectasia, fibrin thrombi and fibromuscular hyperplasia. The endoscopic biopsy is as accurate as the study of the antrectomy piece. None of them had portal hypertension although the GAVE would be different entity from the cirrhotic vascular gastropathy. The treatment consisted in monopolar electrocoagulation of the lesions after the failure with the medical treatment in one case, corticosteroid and ferrous therapies in the three cases and one of them didn't require treatment up to now.

Ectasia vascular del antro (EVA) o watermelon stomach (WS): poco frecuente causa de anemia / Gastric vascular ectasia (GAVE) or wartemelon stomach (WS): unfrequent cause of anemia

La ectasia vascular del antro (EVA) o watermelon stomach (WS) es una causa poco frecuente de anemia o hemorragia digestiva alta manifesta en pacientes de edad avanzada. Presentamos 5 apcientes, todas mujeres, edad promedio 79 años, 4 anémicas de larga evolución y 1 con melena. Tres tenían endoscopía típica de WS, 2 tenían patente difusa. Las 5 con anatomía patológica positiva: ectasias vasculares y/o microtrombos fíbrinosos y proliferación fibromuscular en la l mina propria. La biopesia esdoscópica es tan fiel como el estudio de la pieza de antrectomía. Ninguna tenía hipertensión portal, aunque la EVA sería una entidad diferente a la gastropatía vascular del cirrótico. El tratamiento conssitió en electrocoagulación monopolar de las lesiones tras fracaso del tratamiento médico en 1 caso, corticoterpia mas ferroterapia en 3, mientras que el restante no requiere tratamiento por el momento. Conclusiones: la EVA debe tenerse presente en pacientes anémicos crónicos sien diagnóstico, de edad avanzada. Las im genes endoscópicas no siempre son las típicas del estómago en sandía (WS). Se debe biopsiar el antro gastrico ante la duda. Si no responden al tratamiento con corticoides y/o hierro, el tratamiento de elección es el laser o el "heat electrocoagulación monopolar o la esclerosis. La cirurgía es el último recurso a aplicar. (AU)

Ectasia vascular del antro (EVA) o watermelon stomach (WS): poco frecuente causa de anemia / Gastric vascular ectasia (GAVE) or wartemelon stomach (WS): unfrequent cause of anemia

La ectasia vascular del antro (EVA) o watermelon stomach (WS) es una causa poco frecuente de anemia o hemorragia digestiva alta manifesta en pacientes de edad avanzada. Presentamos 5 apcientes, todas mujeres, edad promedio 79 años, 4 anémicas de larga evolución y 1 con melena. Tres tenían endoscopía típica de WS, 2 tenían patente difusa. Las 5 con anatomía patológica positiva: ectasias vasculares y/o microtrombos fíbrinosos y proliferación fibromuscular en la l mina propria. La biopesia esdoscópica es tan fiel como el estudio de la pieza de antrectomía. Ninguna tenía hipertensión portal, aunque la EVA sería una entidad diferente a la gastropatía vascular del cirrótico. El tratamiento conssitió en electrocoagulación monopolar de las lesiones tras fracaso del tratamiento médico en 1 caso, corticoterpia mas ferroterapia en 3, mientras que el restante no requiere tratamiento por el momento. Conclusiones: la EVA debe tenerse presente en pacientes anémicos crónicos sien diagnóstico, de edad avanzada. Las im genes endoscópicas no siempre son las típicas del estómago en sandía (WS). Se debe biopsiar el antro gastrico ante la duda. Si no responden al tratamiento con corticoides y/o hierro, el tratamiento de elección es el laser o el "heat electrocoagulación monopolar o la esclerosis. La cirurgía es el último recurso a aplicar.

Reliability of clinical examination and computed tomography in the diagnosis of extreme lateral disc herniation.

Twenty-eight cases of extreme lateral and foraminal disc herniation diagnosed by CT are reported. All cases have been surgically verified. In four cases (14%) CT diagnosis failed. The clinical pattern in these cases was not very different from that of typical disc herniation. The reliability of clinical diagnosis is 71%. EMG is seldom diagnostic. Myelography is uniformly of no value as a diagnostic measure.

Vertebral osteomyelitis with chronic cervical extradural abscess in a heroin addict.

Chronic extradural abscess at C5-C6 level due to vertebral osteomyelitis is reported. The patient, a 26-year-old woman who had taken heroin intravenously for four years, developed progressive tetraparesis. Blood cultures and, at operation, the culture of the abscess drainage, grew Staphylococcus aureus. High resolution CT scan allowed for prompt diagnosis. Decompressive laminectomy and complete removal of the extradural mass were performed immediately, followed by multiple subtotal somatectomy (MSS) in order to obtain anterior decompression and mechanical reconstruction of the cervical column. The pathogenetic, diagnostic and surgical problems of spinal extradural abscess are discussed. Multiple subtotal somatectomy and its indication are described.

Venous saclike aneurysm of the central nervous system.

A case of cerebral venous saclike aneurysm of the parietal cerebral cortex is presented with surgical and histological confirmation. Computed tomographic findings are non-specific but very useful for detecting the lesion. Angiographic findings are not so obvious as with an arteriovenous malformation, but are necessary for the final diagnosis of a cerebral varix.

[Deferred surgery of cerebral aneurysms. Long-term follow-up in 103 cases]. / La chirurgia differita degli aneurismi cerebrali. Risultati a distanza in 103 casi.

Between January 1981 and December 1985, 120 consecutive SAH patients were admitted. 73% were in satisfactory conditions and 27% in poor ones. All the patients underwent treatment with antifibrinolytics. Angiographic examination was performed 10 days after the last hemorrhagic event, while the patient's general and neurologic conditions were stable. The reparative operation was carried out immediately after. During the waiting phase there were 16 relapses, (15.5%), resulting in death in 11 (10.7%), and 13 cases of symptomatic vasospasm (12.6%), resulting in death in 5 (4.9%). Overall mortality was 20.4%, with a 17.5% preoperative mortality. On 89 operations carried out on 85 patients, the intraoperative mortality was 3.5%, and neurologic morbidity (transitory in all cases) was 3.5%. All patients underwent intra- or post-operatory angiography to prove the complete exclusion of the aneurysms. After an average follow-up of 36 months, on a total of 103 aneurysm SAH cases, there were 18 preoperative deaths and 3 surgical deaths (within 30 days from the operation); one patient died of unrelated causes during the follow-up period. Seventy-three patients (72.9%) were fully recovered (51.5% returned to their previous job and 21.4% obtained lesser employment). 5.8% of the patients had a varying degree of invalidity. The results of this series were satisfactory both for the low surgical mortality and morbidity rates and for the high percentage of total recoveries. Nevertheless the prevalence of fatal relapses still leaves room for alternate medical and/or surgical treatments.

[Giant and intracavernous aneurysms of the carotid arteries. Their treatment by extracranial-intracranial bypass and gradual occlusion of the carotid artery in the neck]. / Aneurismi giganti ed intracavernosi della carotide. Loro trattamento mediante by-pass extra-intracranico ed occlusione graduale della carotide al collo.

Intracavernous aneurysms are a clinical diagnostic and technical problem. The risk of a direct surgical clipping, whenever possible, is high. Carotid ligation remains the classical surgical treatment for inaccessible aneurysms. Internal carotid artery (ICA) ligation is more effective than common carotid artery (CCA) ligation but carries a higher risk of cerebral ischaemia. The performance of ipsilateral extra-intracranial by-pass (EIAB) helps to maintain blood flow in the cerebral hemisphere. It also decrease the collateral flow formation through the circle of Willis with turbulence in the aneurysmal sac, thus enhancing thrombosis. A series of five cases is reported. The results are satisfactory except in one patient who died in the immediate postoperative period for malignant hemispheric edema, in spite of the patent by-pass. The EIAB can reduce but not eliminate the risk of ischaemic complications related to ICA ligation.

[Spontaneous cerebral hematomas. Treatment and follow-up studies]. / Gli ematomi intracerebrali spontanei. Trattamento e risultati a distanza.

How to manage spontaneous intracerebral hemorrhage has been in the past years a subject open to discussion. The therapeutic approach, medical or surgical, has constituted a question of debate for the neurosurgeon. The most recent experience, however, attempts to establish the clinical and neuroradiological criteria for medical treatment and clarify the indications, as well as the limitations of surgical treatment. The Authors present 84 cases of spontaneous intracerebral hemorrhage studied by both CT scan and cerebral angiography (October 1980-April 1985). The acute mortality of intracerebral hemorrhage was 17.8%. Determinant for the immediate prognosis was the level of consciousness and the volume of the hematoma. At follow-up, at a median of 3 years after intracerebral hemorrhage, total mortality was 30.9% and 48% had returned work.

Prostacyclin and vasospasm in subarachnoid hemorrhage from ruptured intracranial aneurysm. A preliminary clinical study.

Experimental and clinical observations suggest the importance of arachidonate metabolites in the genesis of symptomatic cerebral vasospasm after subarachnoid hemorrhage. Prostacyclin (PG12) has a well demonstrated vasodilator action. The authors monitored CSF prostacyclin concentration in 12 consecutive cases of subarachnoid hemorrhage with the purpose of correlating the prostacyclin concentration trend with the clinical course and the risk for vasospasm. In three cases patients presented with clinical and radiological signs of vasospasm. CSF prostacyclin concentration showed a typical decreasing trend, which amounted to a minor form of protection from vasospastic agents. The nine cases which did not develop vasospasm demonstrated no significant changes in the prostacyclin CSF concentration trend. The authors also presented four cases in which cisternal CSF samples were available. In one case of developing vasospasm, the cisternal prostacyclin concentration was seven times lower than the highest lumbar CSF concentration. In three cases without evidence of vasospasm cisternal CSF demonstrated a balanced biochemical situation and a minor risk of vasospasm.

Reversal by indomethacin of renal effects of dopamine in subjects with normal renal function.

In five subjects with normal renal function, intravenous dopamine, at a rate of 6 ug/kg/min, produces a renal vasodilation, increase in Na excretion and reduction in urinary osmolality, without modification in glomerular filtration rate. These effects were reversed by intravenous indomethacin (2 mg/kg), suggesting that the renal effects of dopamine might depend on normal prostaglandins production.

Acute effect of amiloride on urinary magnesium excretion in dogs.

Under the effect of amiloride Na excretion increased and K excretion decreased. These urinary changes were mainly due to alterations in urinary concentration of Na and K with little or no change in urinary volume. Neither plasma Mg concentration nor urinary Mg excretion were modified by the drug. From these results we conclude that, in dogs without Mg loading, Mg transport at distal sites, where amiloride effects take place, is not altered by this diuretic; thus, the change of transepithelial potential difference produced by amiloride would not affect Mg transport.

Extradural haematoma of the posterior fossa: a report of eight cases and a review of the literature.

The authors review the literature and present 8 cases of extradural haematoma of the posterior fossa operated from 1979 to 1985 at the Neurosurgical Clinic of the University of Pavia. Emphasis is placed on the importance of an early diagnosis of the symptoms which are often ignored due to the absence of specific clinical signs. The authors recognize a substantial improvement in results because of the recent introduction of CT scanning facilities which permit an early and precise diagnosis of this traumatic pathology.

Surgical treatment of multiple supratentorial aneurysms.

Multiple aneurysms are a common radiological finding in patients who have had a SAH. The doubtful question in the treatment of multiple aneurysms is whether to delay operation or treat the unruptured aneurysms conservatively. Patients with multiple intracranial aneurysms treated conservatively, have a late-rebleeding rate of 3% every year. We report our experience in seven cases treated surgically with complete exclusion of all the aneurysms. Surgical morbidity and mortality rates vary between 5 and 10%, although surgical procedures must be performed as soon as possible and should be preferred to delayed treatment.

Reversal by indomethacin of renal effects of dopamine in subjects with normal renal function.

In five subjects with normal renal function, intravenous dopamine, at a rate of 6 ug/kg/min, produces a renal vasodilation, increase in Na excretion and reduction in urinary osmolality, without modification in glomerular filtration rate. These effects were reversed by intravenous indomethacin (2 mg/kg), suggesting that the renal effects of dopamine might depend on normal prostaglandins production.

Acute effect of amiloride on urinary magnesium excretion in dogs.

Under the effect of amiloride Na excretion increased and K excretion decreased. These urinary changes were mainly due to alterations in urinary concentration of Na and K with little or no change in urinary volume. Neither plasma Mg concentration nor urinary Mg excretion were modified by the drug. From these results we conclude that, in dogs without Mg loading, Mg transport at distal sites, where amiloride effects take place, is not altered by this diuretic; thus, the change of transepithelial potential difference produced by amiloride would not affect Mg transport.

Peripheral PICA aneurysm. Case report.

One case of aneurysm of the right distal posterior inferior cerebellar artery (PICA), arising from the telo-velo tonsillary segment, is reported; the patient, a 73 years-old woman, was successfully treated by clipping procedure. Few similar cases are reported in literature. Among all intracranial aneurysms, PICA aneurysms account for 0.5-0.7%; most of them arise from vertebro-basilar junction, while only 72 distal PICA aneurysms are reported in literature, till now, with complete anatomo-radiological study. We recommend four vessel angiography because these aneurysms are likely to be missed. When determining the surgical approach it is important to know from which segment the aneurysm arises.

Mitral valve prolapse and transitory cerebral ischemia. Report on 8 cases.

Non-complicated mitral valve prolapse (MVP) may cause transitory ischemic attacks (TIA) of a probable micro-embolic nature, especially in young people. This study presents 119 cases of TIA, 41 occurring in patients under 45 years of age. All of the 119 patients were given a brain CT scan and associated risk factors such as dislipidemia, diabetes, arterial hypertension, polycythemia were corrected. In addition, 115 patients underwent an angiography. The 41 patients under 45 were given an echocardiogram. The 8 patients who were found to have mitral valve prolapse were submitted to a 24-hour continuous monitoring of the ECG (Holter test) and only 4 patients were given an angiography. On the basis of the results obtained the Authors propose: (1) to use CT scan and electrocardiograms to study youthful patients who have had one or more events of TIA, (2) not to give them an angiography if they suffer from MVP, (3) to conduct the Holter test on these patients and, (4) to establish a therapy using blood-platelet anti-aggregants. The use of anti-coagulants is debatable, even in cases with recurring events.

[Possibilities and limits of neurosurgery in the management of cerebral ischemia]. / Possibilità e limiti della neurochirurgia nel trattamento della malattia ischemica cerebrale.

Surgical treatment of occlusive cerebrovascular diseases is based on the theory that improved cerebral blood flow in the occluded areas can potentially limit the degree of ischaemic damage. This, it is thought, will at least partially normalise neuron metabolism. The two commonly used surgical techniques are carotid endarterectomy and extracranial-intracranial anastomosis. The importance of the criteria used in selecting patients for surgery is discussed and it is emphasised that the most satisfactory results will only be obtained if the correct surgical indication is carefully established for each patient. The results obtained in 40 carotid endarterectomies and 94 E.I.A.B. are also presented. Mortality and morbidity rates for both procedures are minimal and the results were satisfactory in over 90% of the case, the neurological deficit being corrected or drastically reduced.