[Acute postoperative mediastinitis: retrospective analysis of various treatment methods]. / Mediastinite acuta postoperatoria: analisi retrospettiva di differenti metodiche di trattamento.

Infective acute mediastinitis is a postoperative complication reported in 0.5-1% of patients undergoing open chest operations. The treatment of choice for this life-threatening complication is still a matter of debate. The aim of this study was to retrospectively analyse the efficacy of different therapeutic approaches in the treatment of postoperative infective mediastinitis. In the 2nd Division of Cardiac Surgery, from October 1986 to May 2000, 10,234 patients underwent cardiac surgery operations. In 42 patients (0.4%) the operation was complicated by acute infective mediastinitis requiring surgical treatment. On the basis of the treatment opted for, these patients were subdivided into 5 groups: 23 patients underwent continuous iodopovidone (Betadine) mediastinal irrigation (GL) associated with surgical omentoplasty in 8 patients (GLO); 5 patients underwent isolated omentoplasty (GO), and 4 patients were treated with a pectoral muscle flap (GF). In 8 patients other different procedures were performed (GS). There were no deaths in GF and GS despite 24% and 20% mortality reported among patients who underwent mediastinal irrigation (GL) and isolated omentoplasty (GO), respectively. The mean hospital stay was 15 +/- 1 days in GF, 16 +/- 1 days in GS, 25 +/- 11 in patients who underwent omentoplasty and 27 +/- 14 in patients who underwent mediastinal irrigation. Predictors of death were low cardiac output syndrome (P < or = 0.009) and respiratory insufficiency (P < or = 0.032) when found before treatment. Our study suggests that surgical omentoplasty should be the treatment of choice in deep mediastinal infections, whereas wound sterilisation, associated with surgical chest wall reconstruction, seems to be a better procedure in superficial infective disease. A more extended clinical series would be needed to confirm these preliminary data.

[Necrotizing soft tissue infections as the only clinical manifestation of retroperitoneal colonic perforation]. / Infezioni necrotizzanti dei tessuti molli come unica manifestazione clinica di perforazione colica retroperitoneale.

Necrotizing infections are rapidly progressive potentially lethal bacterial diseases of the soft tissues. In based on the widely varying levels of soft tissues affected and the variety of the microflora, two types of necrotizing soft tissue infections need to be delineated: pure Chlostridial myonecrosis and other necrotizing soft tissue infections (NSTI). From an etiopathogenetic point of view NSTI can be secondary to perianal or urogenital abscesses, traumatic lesions, wound infections, trophic or decubitus ulcers, oral cavity abscesses; only in a limited number of cases their origin can be idiopathic. Exceptionally it can happen that a NSTI could represent the only clinical manifestation of a retroperitoneal colic perforation. The Authors report their experience regarding two clinical cases recently observed. The first patient, who previously underwent colic resection for sigmoid carcinoma and adjuvant chemotherapy, had developed as only clinical manifestation of retroperitoneal anastomotic fistula a necrotizing infection at the root of the hip, extended along the whole leg. The second patient, with diverticular perforated disease, had developed rhe necrotizing infection in the lumbar region and in the perirenal tissues. Here will be discussed the sensitivity of the possible diagnostic investigative techniques and the therapeutical strategies that brought both the patients to a complete recovery.

[Gastroduodenal artery pseudoaneurysm ruptured at the pancreatic head]. / Pseudoaneurisma dell'arteria gastroduodenale rotto nella testa del pancreas.

The presence of splancnic aneurysms associated with pancreatitis represents an uncommon evidence (10%) but extremely formidable for the high mortality related to the elevate risk of rupture (50%). A case of a broken gastroduodenal artery pseudoaneurysm plugged in the pancreatic head in a patient with chronic pancreatitis surgically treated is reported. The Authors believe that in presence or in suspicious of peripancreatic pseudoaneurysm bleeding, showed by abdominal echography or CT scan, is mandatory the execution of splancnic and peripancreatic vessels angiography to determine the correct localization of the aneurysm, essential to determining the best surgical treatment. Gastroduodenal artery before the origin from the right epatic artery has been tied in presence of an anatomic variant of origin and division of the hepatic arteries, previously showed with the angiographic examination. The exclusion and the complete thrombosis of the false aneurysm was demonstrated with the intraoperatory Doppler control and confirmed by CT scan before the dismission. This surgical strategy avoid a pancreatic resection, potentially burdened from an higher risk of mortality and morbidity as than the artery exclusion.

[Vascular trauma of the upper extremities]. / I traumi vascolari degli arti superiori.

The aim of this study was to evaluate short- and long-term results of the treatment of upper extremities vascular trauma considering aetiology of the lesions, percentage of limb salvage and residual functional disability. The Authors retrospectively evaluated 17 patients accounting for 21 vascular lesions of the upper extremities (16 arterial and 5 venous injuries). Age, sex, modality of trauma, site of the vascular lesions and of the associated injuries, diagnostic procedures at the admission, ischemic time, arterial and venous repair performed were analyzed. The over all peri-operative mortality was 5.8%. Of the 16 arterial injuries long-term reconstruction viability was obtained in 15 patients (93.7%). In all cases limb salvage was obtained. In 3 patients invalidating functional defects due to associated injuries of the major brachial plexus were observed. The Authors believe that associated nervous lesions are the main factor determining invalidating residual disability. In this series ischemic time, technique of vascular repair performed, associated skeletal injuries didn't influence the functional outcome of the reconstruction.

[Benign non-parasitic cysts of the spleen]. / Cisti benigne non parassitarie della milza.

The present retrospective study is related to 7 cases of non-parasitic splenic cysts, 5 post-traumatic and 2 true epidermoid. Symptoms of displacement and pressure on adjacent viscera or physical examination showing an enlarged spleen have caused the beginning of diagnostic investigation in some patients, in others the cyst has been incidentally discovered. The young age and the positive history for prior trauma suggest for pseudocyst but they didn't give us absolute value. We have valued the contribution of the different radiological techniques (scintigraphy, US, CT, selective celiac arteriography, percutaneous biopsy) in the diagnosis of these lesions. The CT has shown to be the gold standard but it wasn't able to distinguish the post-traumatic from true splenic cysts. Such diagnosis is often not sure neither thought the histological study since the epithelial lining typical of the true cysts may have partially or completely destroyed by secondary alterations. However it can be observed also in the pseudocysts by proliferation of epithelial cells included in the traumatic hematoma. Surgery is primarily recommended for the prevention of complications as infection, hemorrhage, rupture in both types of cysts. Partial splenectomy according to the anatomic vascular distribution have permitted in 3/7 cases to resect the cyst preserving the functioning splenic tissue avoiding the long-term adverse effects of splenectomy.

[Primary malignant tumor of the 4th duodenal segment at the angle of Treitz. Report of a case]. / Tumore maligno primitivo della IV porzione duodenale esteso all'angolo di Treitz. Descrizione di un caso clinico.

A case of 34-years old woman with adenocarcinoma of the IVth duodenal segment extended to the angle of Treitz, treated with duodenojejunal segmentary resection, is described. Clinical features and diagnostic strategies are reported. Personal observation compared with Literature confirms the difficulty of an early diagnosis. The most appropriate surgical techniques for the treatment of these particularly and uncommon neoplasms often discovered in advanced stage are discussed. The better prognosis of these adenocarcinomas compared with those of the proximal duodenum (Ist and IInd segments) can be supported by embryological differences currently to be investigated.

[Splenectomy in immune thrombocytopenia and other hematological diseases]. / La splenectomia nelle trombocitopenie immuni ed in altre malattie ematologiche.

The Authors report a retrospective study of 74 splenectomies performed for hematologic diseases. The role of splenectomy has changed over recent years with increased indications for immune thrombocytopenic purpura (ITP). The aim of this study was to assess indications to surgery in relation to clinical presentation with typical hemorrhagic features or severe thrombocytopenia only; interval between onset of symptoms and splenectomy; failure of medical management and complications from steroid administration; scintigraphic studies predictive of response to splenectomy and preoperative treatment in patients with severe thrombocytopenia were also studied. The Authors reported response rates to splenectomy of 84% without mortality and only 11% of postoperative complications. These results encouraged to surgery for treatment of those patients with severe thrombocytopenia, who fail to obtain remission or develop serious complications after medical therapy. The splenectomy cured severe thrombocytopenia also in some patients with acquired immunodeficiency (HIV+). Moreover the Authors discuss the indications in patients with chronic lymphatic leukaemia and lymphoma diseases. In selected patients the splenectomy has the potential to relieve symptoms due to splenomegaly, correct cytopenias, specify hystological diagnosis and modify the disease course of malignant lymphomas. In fact splenomegaly sometimes complicated the course of malignant lymphomas because of hematologic abnormalities that are inconsistent with active chemotherapy.

Life-threatening digestive haemorrhage from duodenal recurrence of gastric cancer.

Invasion of the duodenum by gastric carcinoma is not uncommon. The duodenal invasion by transpiloric infiltration through the submucosal layer or lymphatic spread frequently being microscopic and in minimal number of cases involving the mucosa, is generally asymptomatic and detected only in postmortem examinations. We report a case of life-threatening gastrointestinal bleeding from cancer recurrence at duodenal stump after subtotal gastrectomy for gastric carcinoma. In such cases it can be very hard to find the haemorrhagic source because of the difficulties encountered in endoscopic and radiological evaluation of the duodenal stump.

[Intra- and postoperative changes in blood viscosity]. / Variazioni intra e postoperatorie della viscosità ematica.

Blood and plasma viscosity has been controlled in a group of patients undergone to aorto-iliac reconstruction and in a group of control after thyroidectomy, cholecystectomy, and hernioplasty. The hemodilution induced by intraoperative infusion in the vascular reconstruction produced an important decrease of hematic and plasmatic viscosity which lasted for several days after the operation. Removing the hemodilution effect by a mathematical correction of the viscosity measured values to a standard haematocrit, it has demonstrated as surgical operation, apart from its entity, promoted an increase of the viscosity which persisted long in the postoperative course. For what it concerns the risk of postoperative thrombosis from one side protective effect of hemodilution is confirmed, from the other, in absence of the hemodilution, it would be useful to continue the antithrombotic prophylaxis longer the perioperative time as usual.

[Splenic autografts in omental and subcutaneous pouches. An experimental study]. / Autoinnesti splenici in tasche omentali e sottocutanee. Studio sperimentale.

An accurate morphological study has been done on splenic grafts in rats after 7-15-30 days from their implant in omental or subcutaneous pouches. Observation after 7 days confirmed the necrosis of all the central portion of the implants. Anyway, marginal parts of the graft survived to ischaemia and showed to be supplied by vessels, coming from the contiguous tissues. In these parts the rigenerative process had begun from the structures of red residual pulp, by reticular cells proliferating so to rigenerate the capsula limiting the place of the central necrotic area. After 15 days the neocapsula was completed and from it neoformed trabecolae departed accompanied with chords, sinus capillary, venular and arteriolar vessels which reformed the structure of red pulp both in peripheral and central area, now undistinguishable. After 30 days lymphocytes aggregating around the neoformed vessels promoted a rudimental reconstruction of the white pulp too. In conclusion, splenic implants are able to get over the ischaemic phase and after 30 days the red pulp is morphologically reconstructed and probably functioning, while the white pulp is still primordial.