Gas in the Portal Vein: An Emergency or Just Hot Air?

We report the case of a 87-year-old woman admitted to our Emergency Department for mild abdominal pain associated with vomiting. An abdominal X-ray showed gas present in the portal venules of the left hepatic lobe, a finding associated with numerous surgical and medical conditions. The patient was successfully managed with conservative treatment. Isolated intrahepatic gas is a rare radiologic finding; emergency surgery should be performed only when there are signs of associated acute intestinal infarction.

Comparison between subjective and objective assessment of the long-term results after the Heller-Dor operation in patients affected by oesophageal achalasia.

INTRODUCTION: Nowadays the subjective assessment of Health-Related Quality of Life after surgery for achalasia is often associated with the instrumental methods in order to evaluate long-term results of therapy. AIMS: To assess the long-term objective and subjective results of the surgical treatment of achalasia and to study the correlation between clinical-instrumental methods and those based on the patient's self-assessment and on Health-Related Quality of Life questionnaires. METHODS: One hundred and twenty-four patients consecutively submitted to trans-abdominal Heller-Dor operation were periodically followed up with clinical examination, endoscopy, barium swallow and manometry. The Health-Related Quality of Life was assessed using the 36 item short form (SF-36) and the Psychological General Well-Being Index questionnaire. The statistical comparison between the results of the self-assessment questionnaires and the long-term clinical-instrumental result was calculated by means of linear regression analysis. RESULTS: Over the years, 123 patients underwent at least one complete clinical-instrumental check-up and filled the self-assessment questionnaires. Mean follow-up was 105 months (range 12-288) with a median of 82.5 months. The result of the surgery was considered satisfactory in 93.5% of the patients, while the reflux oesophagitis observed in 6.5% of the cases was the main cause of failure. Clinical scores for dysphagia and for gastro-oesophageal reflux symptoms were significantly reduced after surgery. The results of the SF-36 and Psychological General Well-Being Index questionnaires were in our population very high and clinical correlation (p<0.05) emerged in physical function, in role physical, in mental health and in vitality domains of SF-36 questionnaire, and in self-control and general health scales of Psychological General Well-Being Index questionnaire. CONCLUSIONS: Health-Related Quality of Life questionnaires can be considered valid aids in evaluating surgical results, but the clinical-instrumental evaluation remains the cardinal point of every long-term assessment in order to diagnose complications, the disease-related conditions of the patient and to acquire reliable data on which scientific discussion can be based.

[Vesica ileale Padovana (VIP): surgical technique, long-term functional evaluation, complications and management]. / La vejiga ileal Padovana (VIP): Técnica quirúrgica, evaluación funcional a largo plazo, complicaciones y conducta a seguir.

OBJECTIVE: An original technique for complete bladder replacement using an ileal segment--the VIP pouch--is described. The long-term functional results and early and late complications are presented. METHODS: The records of 209 VIPs performed following radical cystectomy for invasive bladder cancer from 1987 through 1995 were reviewed. Follow-up ranged from 6 to 87 months (mean: 24 mo.); the age of the patients ranged from 35 to 76 years (mean: 59.6 yrs.). RESULTS: 188 patients with a follow-up of at least 6 months have been evaluated. There was 1 postoperative death from massive pulmonary embolism, 23 pts. died from tumor progression and 4 are still alive with metastases. Early complications were observed in 10.5% of the pts., comprising 9 cases of prolonged ileus (5 functional and 4 obstructive), 3 pelvic hematomas, 2 deep venous thrombosis and 2 fistulas between the enteric anastomosis and the VIP pouch. Late complications were observed in 39.5%, in particular, 28 uretero-ileal stenosis (15%), 21 urethro-ileal stenosis (11%) and 15 laparoceles (8%). Clinically relevant metabolic disturbance has not been observed. Complete daytime continence was achieved in more than 90% of the cases and night-time continence was observed in 75% of the patients. The mean VIP manometric capacity was around 400 ml with low pressure during reservoir emptying; 39 patients (20%), showed voiding problems with a mean postmicturition residual of 150 ml (3 pts. require clean intermittent self-catheterization). CONCLUSIONS: VIP offers a simple and easy-to-perform surgical technique to provide a good capacity, low pressure, non refluxing reservoir employing only a 40 cm. ileal segment. The clinical and urodynamic results are good and offer high quality of life to patients undergoing cystectomy. The overall rate of late complications is fairly high, although conservative management is effective in most cases.

Bone density and skeletal metabolism in patients with orthotopic ileal neobladder.

The interposition of a bowel segment as a bladder substitute into the urinary tract may result in impaired calcium metabolism. We studied 25 male patients (aged 45 to 77 yr) who had undergone a Vescica Ileale Padovana (VIP) reconstruction following cystectomy 29 to 75 mo before. Bone mineral density of the spine and femur was measured by dual x-ray absorptiometry. Blood and 24-h urine samples were analyzed for the main parameters of bone metabolism. Sixteen healthy men were enrolled as a control group. Although blood pH did not differ between patients and control subjects, VIP subjects showed lower levels of plasma HCO3- (P < 0.005) and higher serum chloride (P < 0.001). Bone alkaline phosphatase was higher (P < 0.001), and urine calcium, phosphate, and creatinine levels were lower in VIP patients (P < 0.01, P < 0.01, and P < 0.05, respectively). Bone mineral density at the femoral neck (P < 0.03) and Ward's triangle (P < 0.05) was decreased in VIP patients. When subdivided according to time since operation, patients who had the ileal neobladder implanted for a shorter period of time showed lower blood pH (P < 0.03) and urine calcium (P < 0.05) levels and higher urinary hydroxyproline (P < 0.02). Duration of the ileal neobladder was positively correlated with PTH (r = 0.46, P < 0.03) and blood pH (r = 0.47, P < 0.02). Furthermore, pH values were positively correlated with urine calcium (r = 0.48, P < 0.02). In conclusion, in patients with ileal neobladder, a mild metabolic acidosis is responsible for an increased bone turnover and lower bone mass. Moreover, a decrease over time in the absorption capacity of the ileal pouch might result in calcium malabsorption, which represents an additional risk factor for reduced bone mass in these patients.