[Primary hyperparathyroidism and acute pancreatitis. A rare clinical association]. / Iperparatiroidismo primitivo e pancreatite acuta. Una rara associazione clinica.

Hyperparathyroidism and hypercalcaemia are considered to be a rare cause of acute pancreatitis. The relationship between hyperparathyroidism and pancreatic inflammatory disease remains controversial, but it may be related to the translation from inactive to active trypsinogen by hypercalcaemia. Surgical correction of parathyroid disease and normalization of serum calcium levels may ameliorate the acute pancreatitis. Also the mechanism of pathologic zymogen activation during acute pancreatitis remain unknown; probably the pancreatic "autodigestion" is the result of anomalous intracellular transport of secretory proteins activated by lysosomal hydrolases. A case of acute pancreatitis and hyperparathyroidism due to solitary parathyroid adenoma occurred in a 66-years-old woman is reported. After the excision of parathyroid adenoma the serum calcium levels and the function of the pancreas returned to normal. This suggests a cause and effect relationship between hyperparathyroidism and acute pancreatitis.

Non specific aorto-arteritis. Clinical picture, diagnosis and therapy.

This study is aimed at analyzing clinical features, angiographic findings and evolution of Takayasu's arteritis and the criteria adopted to establish the indication for non-surgical versus operative treatment. Eighteen patients affected by non specific aortarteritis were observed and treated at our Department between 1973 and 1996. All patients met the American College of Rheumatology 1990 criteria of classification of Takayasu's arteritis. Sixteen patients were young females. Two patients were males. Nine patients underwent surgical procedures. One young female underwent a PTA. All eight asymptomatic patients were only medically treated. One patient died some days after an aorto-bicarotid bypass graft due to acute myocardial infarction. Two other patients died two and four years after intervention for renal and cardiac failure respectively. One patient after an aorto bicarotid bypass underwent a left hemiplegia due to thrombosis of the right graft branch. All the other 14 patients either surgically or medically treated are well and are under strict surveillance through rigorous follow-up. The 10 patients who underwent surgical or interventional radiological treatment were certainly the most seriously affected patients and were symptomatic (presented neurological disturbances or a severe hypertensive state). This fact explains, to some extent, the mortality and morbidity rate observed in this group. The seven medically treated patients were completely asymptomatic in spite of a major involvement of various vascular districts.

[Malignant pheochromocytoma. A case report and comments on a rare pathology]. / Il feocromocitoma maligno. Case report e considerazioni sulla rara patologia.

Pheochromocytomas and functioning paragangliomas are rare tumors arising from the primitive neural crest, and found in the adrenal medulla or elsewhere within the sympathetic paraganglion axis. Clinical symptoms are related to catecholamine production or less frequently to dopamine or other neuropeptides secretion. Malignant pheochromocytomas are very rare tumors comprising between 5-35%, but this value is uncertain because the usual criteria for malignancy, such as mitotic activity, nuclear pleomorphism, are not suitable to discern benign from malignant pheochromocytomas. A specific diagnosis of malignancy requires evidence of invasion of the adjacent organs and the occurrence of metastases. Personal experience is presented with 92 patients affected by: adrenal pheochromocytomas (51 cases), cervical paragangliomas (32 cases), and extra-adrenal paragangliomas (9 cases). Malignant forms were observed in a 23-year-old young woman affected by malignant pheochromocytoma with lymphatic para-aortic metastases (1.9%), and in 2 patients affected by cervical paragangliomas (1 CBT, 1 VBT) with lymph nodal metastases. Careful follow-up of all patients with measurement of the urinary catecholamine is necessary to detect metachronous neoplasm and later metastases, identified with RMN and 131I-MIBG scintiscan.

[Primary retroperitoneal tumors. Treatment modality and prognostic factors]. / I tumori retroperitoneali primitivi. Modalità di trattamento e fattori prognostici.

BACKGROUND: Primary Retroperitoneal Tumors (PRT) form a heterogeneous group of malignant mesenchymal and neuroectodermal neoplasms making up only 1% of all solid neoplasms. METHODS: From 1965 to 1997, 27 patients (16 females and 9 males, age range 19-79 years) underwent operations at the General and Cardiovascular Institute of University of Milan for primary retroperitoneal tumors (22 malignant and 5 benign, sarcomas represented 68% of all malignant tumors). A retrospective analysis of these patients was performed to determine the prognostic parameters associated with a favourable prognosis. All patients were admitted with severe abdominal pain or a palpable mass, other symptoms included fewer and weight loss. The median duration of symptoms before presentation was 16 months (range 15 days-5 years). Before surgical treatment abdominal and pulmonary CT scanning and MRN were undertaken on all patients with PRT to define the size of the tumor and the involvement of other retroperitoneal structures. RESULTS: Complete resection was possible in 54% of malignant tumors (n = 12), incomplete resection was performed in 14% (n = 3) and in 31% (n = 7) only biopsy was possible. Recurrent tumor developed in 25% of patients with total resection (n = 3), (median time to recurrence 5 years). Independent treatment variables (size, signs and symptoms, histopathologic findings and grade) and treatment-dependent variables (type of surgical treatment and adjuvant chemotherapy) were analyzed. Patients with complete resection had a 12 month survival of 100% (n = 12) compared to 50% (n = 1) for those undergoing partial resection and 14.2% (n = 1) for those with simple biopsy. A 24-month survival of the patients undergoing complete resection was 25% (n = 3). Median survival for type of surgical treatment was 28 months for complete resection compared to 14 months for partial resection and only 8 months for biopsy. Twelve-months survival for tumor grade was 100% (n = 7) for low grade tumor (G1), compared to 66.6% (n = 4) for median differentiated tumors (G2), and 37.5% (n = 3) for high grade tumors (G3). Twenty-four-months survival was 28.5% (n = 2) for low grade tumors compared to 16.6% (n = 1) of median differentiated tumors. High grade tumors were associated with a 35-month median survival time compared to 17 months for median differentiated tumors and 10 months for low grade tumors. Other variables (histopathologic findings, size, symptoms) had not significant impact on survival. Operative mortality rate was 3.7% (n = 1). The overall 2 years survival rate in patients with totally resected tumors was 25% (n = 3), (2G1, 1G2), while the 5 year survival rate was 16.6% (n = 2), (2G1). CONCLUSIONS: Complete surgical excision and low grade of the tumor are the most important parameters of survival. Recurrent disease is a vexing problem; a careful and prolonged follow-up based on the use of CT and MRN is recommended.

Acute vascular abdomen. General outlook and algorithms.

Acute vascular abdomen is a severe and life-threatening pathology due to arterial degeneration, leading to hemorrhage or arterial occlusion leading to ischemia. Differential diagnosis of patients with severe abdominal pain and/or shock include several vascular and traumatic diseases, the most common being rupture of abdominal aortic aneurysm (AAA), or less frequently rupture of visceral artery aneurysm. Also acute aortic dissection, iatrogenic injury and acute mesenteric ischemia may lead to acute vascular abdomen. Clinical evaluation of the haemodynamic status of the patient may be very difficult, and may require airway maintenance and ventilation with a rapid treatment of hemorrhagic shock. In the stable patient with an uncertain diagnosis, CT scan, NMR and selective angiography may be helpful in diagnosis before vascular repair. On the contrary, the unstable patient, after hemodynamic resuscitation, must be operated on expeditiously. We present our vascular algorithms, to assess timing of diagnosis and treatment of this severe acute disease.

[Secondary aorto-enteric fistula]. / Le fistole vasculo-enteriche secondarie.

Aortic graft fistula is a rare and life-threatening complication after aortic reconstruction. The incidence ranges from 0.5 to 4%, and even if the diagnosis and treatment is appropriate, the results of surgery are poor: mortality rate ranges from 14 to 70%. The optimal method of treatment is still controversial; prosthetic removal and extra-anatomic bypass has been advocated as the standard method, but more recently, because the high mortality rate associated with this procedure, some have prompted to recommend in situ aortic graft replacement as a more successful treatment. Personal experience with incidence (0.7%) outcome and mortality (57%) in 7 patients treated over a period of 6 years (1990-1996) is reported. Results from this group are compared with another group (6 patients) previously treated (1975-1982) for the same pathology. Our results after 10 years, show the same incidence (0.7 vs 0.6%) and an elevated and unchanged mortality (57 vs 66%). Better results in the management of aorto-enteric fistulas could be achieved with the removal of infected infrarenal aortic prosthetic grafts and in situ homografts replacement.

[Malignant neoplasia of the small intestine. Apropos of 7 cases. Clinical discussion and review of the literature]. / Neoplasie maligne dell'intestino tenue. A proposito di 7 casi. Discussione clinica e revisione della letteratura.

The authors report seven cases of primary malignancies of the small intestine observed and treated between 1989 and 1995 at the First Surgical Division of Treviglio Hospital. Three patients were affected by adenocarcinomas (two involving the duodenum and one the jejunum), two patients had non-endocrine carcinoid tumors of the ileum, one presented a jejunal liposarcoma and one a lymphoma of the ileum. Four patients died (respectively at three months, 15 months, 18 months and five years after surgical intervention). Three patients are still alive. The early clinical features of these malignancies are typically vague and non specific and for this reason the disease is often diagnosed at an advanced stage. The prognosis of these lesions is generally poor owing to the diffusion of the disease at the time of diagnosis. In fact these neoplasms are preoperatively identified only in 27-72%. The percentage of surgical removal ranges between 65 and 80% according to the recent literature. This study is aimed at analysing the clinical and pathologic characteristics of the observed cases and the difficulties of the diagnostic procedure. The adopted surgical techniques and the outcome of the operative treatment are also examined.

[Intestinal anastomosis with a biofragmentable rind (BAR). Results in comparison with mechanical and manual anastomosis]. / Anastomosi intestinali con anello bioframmentabile (BAR). Risultati e confronto con le anastomosi meccaniche e manuali.

METHODS: The use of the biofragmentable anastomosis ring (Valtrac-BAR) was attempted in 25 selected patients (group I) undergoing elective colonic resection for primary colon cancer, at the General and Cardiovascular Institute of the University of Milan. The results were compared with those of 30 selected patients who underwent elective colonic resection for the same pathology during the same period, and had their bowel anastomosis stapled (group II) or hand-sutured (group III). RESULTS: In group I there were 2 complications requiring reoperation: a little tear of the bowel near the BAR, and a postoperative ileus, compared with none in group II, that developed only 3 cases of abdominal wall infections. In group III, 2 patients developed a leakage of the anastomosis, one of them required reoperation. In the perioperative course there were 2 deaths (3.6%), in group II and III due to cardiovascular diseases. The results obtained showed no significant difference in the clinical course of the patients, or time of return of bowel function, and hospital stay. CONCLUSIONS: The conclusions is drawn that Valtrac-BAR device is a safe and reliable alternative to conventional suture anastomosis in all areas of the intestinal tract, except the low rectum.

[Adrenal carcinoma. Clinical and anatomopathological prognostic factors]. / I carcinomi del surrene. Fattori prognostici clinici ed anatomopatologici.

We performed on 9 patients with adrenal cortical carcinoma a retrospective study during 1967-1995 to evaluate the most important prognostic factors. Four patients were males and five females (mean age: 40.3 years). Five patients had endocrine symptoms (55%) and four had "non-functioning" tumors (45%). The tumor involved the left adrenal gland in 5 cases and the right in 4. The mean diameter of the neoplasm was 9.5 cm, with a mean weight of 411 g. The average duration of symptoms before diagnosis was 7.3 months. One patient had invasion of the inferior vena cava with liver metastases. Eight patients underwent curative surgery, the median survival time was 13.7 months, only 1 patient is alive after 18 months from surgical resection. We concluded that adrenal carcinomas have poor prognosis; staging and grading of the neoplasm, and age of the patient at diagnosis are predictors of survival.

Ruptured abdominal aortic aneurysms: factors affecting the early postoperative outcome.

BACKGROUND: In spite of the progress in diagnosis and treatment of ruptured abdominal aortic aneurysms (RAAA) the mortality rate still remains very high (varying from 15% to 50% according to various experiences). This study is aimed at analyzing the relative contribution of preoperative hemodynamic conditions and of operative and postoperative factors to outcome of patients operated on for ruptured abdominal aortic aneurysms. METHODS: For this purpose a retrospective case series involving 152 patients operated on in emergency for RAAA, during the period 1990-1994, has been reviewed. In this group we examined the site of rupture, the size of the aneurysms, the presence or not of a shock condition at admission, the existence of inflammatory aspects, the adopted type of prosthesis. RESULTS: The mortality rate was 24.3% (37 patients). In 10 patients (27%) the cause of death was an irreversible hemorrhagic shock. Eight patients (21.6%) died for an intestinal infarction. In 7 patients the fatal outcome was due to the development of an acute renal failure. Five patients (13.5%) underwent an acute myocardial infarction and other five a multiorgan failure. Two patients (5.5%) eventually died for respiratory insufficiency. CONCLUSIONS: The results of our study seem to confirm that the outcome of patients affected by rupture of abdominal aortic aneurysms depends not only on the preoperative hemodynamic condition but also on the expertise of the surgical team.

[Traumatic lesion of the subclavian and axillary arteries]. / Le lesioni traumatiche delle arterie succlavia ed ascellare.

This study comprises 11 patients with traumatic vascular injuries of the subclavian and axillary vessels treated in the last 13 years at the Institute of General and Cardiovascular Surgery of Milan. Nine patients were male and two were female. In two patients the cause of injury was a penetrating trauma; blunt trauma occurred in nine patients. The majority of injuries were caused by motor vehicle accidents. Two patients suffered complete brachial plexus palsies with complete transection of the median nerve. Seven patients were affected by multiple bone injuries, while major venous injury was present in one case. Diagnosis was established by angiography performed in all stable patients. Vascular repair was performed in 10 patients; 4 patients were treated by primary repair, and 6 patients by interposition grafts. In one case we performed a transluminal percutaneous angioplasty (PTA) during angiographic examination, with a good result. There were no postoperative vascular complications and no patient died.

[So-called "spontaneous" lesions of the popliteal artery]. / Lesioni cosiddette "spontanee" dell'arteria poplitea.

The term "spontaneous", when attributed to a stenotic or obliterative arterial lesion, could seem ambiguous and doesn't completely explain the anatomical substrate that is the basis of this morbid condition. However, it is true that injuries can occur without the patient being aware of any traumatic event, and can cause a symptomatology arising suddenly and, apparently, "spontaneously". In this study, three cases of patients observed for acute or chronic lower limb ischemia are presented. All patients were male, young and underwent an angiographic examination that demonstrated, in an otherwise normal arterial tree, filling defects or obstruction involving the popliteal artery. Two patients underwent a reconstructive surgical procedure. The third was medically treated. CAT or MNR examinations were performed in order to exclude developmental defect such as an anomalous course of popliteal artery determined by a displacement due to medial head of the gastrocnemius muscle. Actually in these three cases, a definite etiology of the arterial damage was not demonstrated and therefore it is suggested that a physical effort could have injured an already weakened arterial structure.

[Critical evaluation of the reconstruction of the intestinal continuity after total gastrectomy by the Moricca technique]. / Valutazione critica della ricostruzione della continuità intestinale dopo gastrectomia totale secondo Moricca.

The authors analyze a series of 48 total gastrectomies for gastric carcinomas performed between 1987 and 1994. Seven out of these 48 gastrectomies were performed adopting the double circuit esophagojejunoduodenal plasty according the procedure described in 1976 by Francesco Moricca. The double jejunal loop represents a sort of "digestive reservior" allowing to avoid the sensation of epigastric fullness after eating. Moreover, this technique permits a better absorption of the liquids and the partial mixing of the bolus with the bilio-pancreatic secretion stimulates the duodenal secretin and cholecystochinin release. The possibility of a "dumping syndrome" is diminished by the presence of the double possibility of diversion of the alimentary bolus. On the contrary the segment of jejunum transposed between the esophagus and duodenum is antiperistaltic and this fact can cause sometimes an esophagitis at the lower third of the esophagus due to the prolonged alkaline reflux. This study is aimed at verifying the entity and frequency of the esophagitic complication in patients who underwent a total gastrectomy and at analyzing the procedures adopted to cure this severe complication that seriously affects the wellness and the nutritional status of the gastrectomized patients.

[Atherosclerotic aneurysm of a branch of the deep femoral artery]. / Un aneurisma aterosclerotico di un ramo dell'arteria femorale profonda.

Peripheral arterial aneurysms present characteristic locations. In the lower limbs, atherosclerotic aneurysms of the deep femoral artery are very rare. Authors report an interesting case of arteriosclerotic aneurysm of a branch of the profunda femoris artery observed in a 80 year-old man, and associated with an abdominal aortic aneurysm. Endo-aneurysmectomy was performed with a dacron patch interposition. Surgical treatment of this rate disease is discussed.

Indications and role of isolated profundaplasty in patients affected by limb ischemia.

The deep femoral artery is the primary source of blood supply to the lower extremity in presence of superficial and/or popliteal occlusion. The atherosclerotic involvement of the profunda femoris artery is relatively less frequent and generally is localized in the initial segment of the artery. The profundaplasty employed to relieve limb threatening ischemia is infrequently used as an isolated procedure. However many authors demonstrated that restoration of flow through this vessel alone, in patients without significative lesions of the aorto-femoral district, will effectively relieve ischemia when the superficial femoral artery is also occluded. Our experience gained in the last eight years concerns 24 patients (21 male, 3 female). All the patients had severe ischemia of the lower limb with invalidating claudication (13), rest pain (9) and gangrene (2). On the basis of our results, we think that the operation is recommended, whenever possible, in patients with critical ischemia when the possibilities of more extensive revascularizing procedures are absent.

Ruptured aneurysm of the internal iliac artery.

The aneurysms of the internal iliac artery are rare and very often asymptomatic. Because of the anatomic location of this artery, it can be difficult to diagnose this kind of aneurysm, when isolated. Frequently it is diagnosed in consequence of aneurysmatic complication, such as rupture and/or impending rupture. In this work we report our experience concerning 6 cases of ruptured aneurysm of the internal iliac artery, observed in 5 patients. In three of these cases the lesion was isolated. In two cases the patients had already been operated on for abdominal aortic aneurysm, 4 and 6 years before. All the five patients were operated on. In 5 cases we ligated the aneurysm, without using any vascular graft. In one case where the external iliac artery was involved, we used a vascular graft between the common iliac and common femoral artery, in order to repair the vascular axis. One case of mortality was observed and a rare complication occurred in one case. An 83-year-old man treated in emergency for ruptured aneurysm of the left internal iliac artery, with regular post-operative course, was hospitalized again 24 days later with sepsis and pain in the left lower abdomen. A CT scan and a following urography showed a urinary fistula probably due to an ischemic necrosis of a segment of the ureter. A percutaneous nephrostomy has been performed and the patient successfully discharged.

[Malignant neoplasms invading into the inferior vena cava. Surgical indications]. / Neoplasie maligne ed invasione della vena cava inferiore. Indicazioni chirurgiche.

Clinical conditions requiring resection and replacement of the inferior vena cava (IVC) are rare and have included tumors, traumatic or iatrogenic injuries. Intraluminal extension or direct mural involvement of the IVC is seen with a variety of tumors: renal cell carcinomas, adrenal cortical tumors, leiomyosarcomas and pheochromocytomas. Surgical treatment requires tumor resection with simultaneous en bloc resection of the involved IVC. Resection of the lower and middle segments of IVC is possible in nearly all cases and surgical reconstruction is generally made with a polytetrafluoroethylene (PTFE) tube graft. Resection at suprahepatic vein level is indicated only rarely: tumor invasion of the suprahepatic veins require liver transplantation. Venous bypasses have lower patency rates than prosthetic replacement because of the low pressure and lower-flow of the venous system.

Takayasu's arteritis in Italian patients.

OBJECTIVE: To evaluate the clinical features, angiographic findings and evolution of Takayasu's arteritis in Italian patients. METHODS: Retrospective analysis of the case records of 27 Italian patients with Takayasu's arteritis, all meeting the 1990 ACR criteria for classification of this vasculitis, with a median disease duration of 9.5 years. RESULTS: The patterns of arterial involvement and the frequencies of systemic and specific symptoms were similar, with some exceptions, to those reported in the literature. In our patients weight loss was rare, the incidence of respiratory symptoms and seizures was low, and no clinical manifestations of intestinal involvement were reported. All of the patients were treated with antiplatelet or anticoagulant medications, and 14 were also treated with corticosteroids and immunosuppressants; a stabilization of the vascular involvement was seen in most of them. Thirteen patients underwent surgery, and 5 had percutaneous transluminal renal angioplasties. Five pregnancies were observed, without complications. Two patients died, one after an angiographic evaluation and one for reasons unrelated to the disease. CONCLUSIONS: Takayasu's arteritis is heterogeneous in presentation, evolution and response to therapy. In our series of patients the disease seems to have showed a more favorable course than that previously reported. This can be attributed to the effectiveness of therapy, but also, at least partially, to the better prognosis that the disease seems to have for Western than for Eastern subjects.

[Renal arteriovenous fistulae]. / Fistole arterovenose renali.

Arteriovenous fistulas (AVFs) involving the kidney are rare. They are generally classified as congenital, idiopathic or acquired. The authors present 5 cases of renal arterio-venous communications observed in recent years. These cases don't include the congenital type and represent the forms of AVFs that are more frequently observed (1 idiopathic, 3 iatrogenic, 1 associated with malignancy). This study is aimed at examining the clinical picture and the procedures of detection and monitoring of renal AVFs. The various adopted therapeutic procedures (nephrectomy, surgical ablation, radiological embolization) are analyzed.

[Inflammatory aneurysms of the subrenal aorta. Histopathological, diagnostic and therapeutic aspects]. / Gli aneurismi infiammatori dell'aorta sottorenale. Aspetti istopatologici, diagnostici e terapeutici.

Inflammatory abdominal aneurysms (AIAA) represent a clearly defined clinical entity with an incidence ranging between 1.2% and 15%. In spite of the increasing number of observations reported in recent years, the etiopatholgenesis and natural history have not been defined. The lesion can present in an acute, subacute or chronic manner and the histopathological studies reveal prevalently two components: an inflammatory infiltrate and a diffuse fibrosis, in varying degree. This study aimed to analyze the more recent imaging procedures in order to correctly diagnose this lesion. In our experience the incidence of AIAA is about 2.5%. On the basis of macro microscopic pictures the authors divided patients into two groups: one constituted by the acute or subacute inflammatory forms, the other by chronic clear inflammatory aneurysms. All patients underwent on operative treatment. The surgical adopted techniques and the obtained results are reported.