Role of transcranial Doppler and stump pressure during carotid endarterectomy.

BACKGROUND AND PURPOSE: The aim of our study was to clarify the pathophysiology of perioperative cerebral complications during carotid endarterectomy in our series. METHODS: By means of transcranial Doppler ultrasonography and stump pressure measurement, we monitored 112 patients who underwent carotid endarterectomy under general anesthesia for symptomatic or asymptomatic severe carotid stenosis. RESULTS: Of 18 patients who underwent carotid endarterectomy with intra-arterial shunt, 2 (11.1%) developed an ischemic stroke. Of the other 94 patients, one suffered a nucleocapsular hemorrhage and 5 had cerebral ischemic complications. In these 5 patients, the duration of clamping was significantly longer (mean +/- SD, 16.4 +/- 1.1 versus 12.7 +/- 2.6 minutes; P = .0019), and the decrease of middle cerebral artery mean velocity on clamping was significantly greater (mean +/- SD, 56.4 +/- 4.9% versus 28.8 +/- 20.2%; P = .0031), while stump pressure was not significantly different. Microembolic signals were recorded in 70 patients (62.5%) and were not associated with cerebral ischemic complications. The 7 patients who developed cerebral ischemic complications had a significantly higher percentage of stenosis in the contralateral internal carotid artery (mean +/- SD, 82.0 +/- 17.8% versus 29.3 +/- 36.4%; P = .0018). CONCLUSIONS: The results of our study suggest that the major complications of carotid endarterectomy may be due to hemodynamic factors. Stump pressure alone is not a reliable indicator of hemodynamic changes that predict cerebral ischemia. Particulate microembolism may cause more subtle changes in cerebral parenchyma, but further studies are needed to clarify this point.

[Hepatic cysts: a case report and anatomicopathological and clinico-therapeutic considerations]. / Le cisti epatiche: presentazione di un caso e considerazioni anatomo-patologiche e clinico-terapeutiche.

The recent observation of a case of non-parasitic cyst of the liver brought the authors to a literature review. A 62 year old male, affected by type 2 diabetes and hypertension, after a CT scan and ETG, underwent resection and "capitonnage" of the cyst. Three months after surgery a CT scan showed a complete repletion of the cavity previously occupied by the cyst as a consequence of regeneration and reorganization of the hepatic parenchyma. In conclusion, hepatic cysts are rare and clinically relevant only when huge. The diagnosis is possible with the use of ETG and CT scan of the abdomen, however, in some cases angiography is also useful. The intervention of choice is the "capitonnage" of the cyst.

[Carotid surgery and its monitoring in our experience]. / La chirurgia carotidea e il suo monitoraggio nella nostra esperienza.

Carotid endarterectomy (CEA) is the elective surgical procedure to prevent stroke due to stenosis of the carotid bifurcation. During a period of 17 years the Authors performed 215 operations on the carotid arteries of 168 patients. The average age was 64.6 and the male/female ratio was 3/1. Patients were symptomatic in 75.8% of cases and asymptomatic in the remaining 24.2%. Preoperative investigations consisted of echo-Duplex scanning, arteriography, cerebral CT or MRI. Indications for surgery were: stenosis wider than 70% in 173 cases, ulcerated or "high-risk" stenosis in symptomatic patients in 37 cases, and carotid malformation in 5 cases. The intraoperative use of shunt (12% of the operations) was selective, depending from the results of our monitoring system: stump pressure and transcranial Doppler (TCD) of the middle cerebral artery (MCA) ipsilateral to the procedure. The global major stroke/mortality rate was 3.3% (7/215), the minor morbidity was 8.8% (19/215). Mortality rate was 0.5% (1/215). The major stroke/mortality rate for symptomatic patients was 4.2% and for asymptomatic patients was 0%. The average follow up was 58 months (range 1-192) for 200/215 patients, with 15/215 patients (7%) lost. The postoperative incidence of stroke after 4 years was 8.5% (17/200), with an annual mortality rate of 1.6% (min. after 2 months, max. 118, average 55 months). CEA is a safe procedure to prevent cerebral infarctions, but it still carries an operative risk. A better monitoring would allow to understand the mechanisms of clamp-induced ischaemia and prevent it, therefore decreasing the operative risks and extending the surgical indications to a higher ratio of asymptomatic subjects. TCD is becoming essential for our goal: it is useful in deciding to insert an intraoperative shunt, check the carotid flow, recognize embolic events, and also during the initial phase of carotid preparation.

[Femoro-femoral crossover bypass in monolateral obstructions of the iliac artery]. / Il bypass femoro-femorale cross over nelle ostruzioni monolaterali dell'arteria iliaca.

The Authors report the result of their ten-years experience with femoro-femoral crossover bypass in 26 patients affected with unilateral occlusion of the iliac artery. This bypass is an easy and quick procedure, useful in both short and long term. The patency rate after 58 months is 84.6%. Thus, its use indicated in a high number of patients, not only for a limb salvage treatment of a disabling claudication. The indications for this bypass can be extended to low surgical risk subjects, and it does not have to be considered only for the high-risk patients, instead of major surgery procedure on the aorto-iliac axis. The minimal necessary conditions of the limbs for performing the femoro-femoral crossover bypass are a pressure gradient of 35 mmHg and the angiographical demonstration of the unilateral occlusion. If the contralateral axis appears patent, but there are also multiple atherosclerotic sites, we consider other bypasses as therapeutical choices: aorto-bifemoral, ilio-femoral and the femoro-femoral cross-over itself; in the latter case we previously perform a transluminal angioplasty or an endarterectomy of the donor iliac artery. In these situations is essential to evaluate of the benefit/risk rate for every single patient.

[Adenocarcinoma of the small intestine. A case report and the clinico-therapeutic considerations]. / L'adenocarcinoma dell'intestino tenue. Presentazione di un caso e considerazioni clinico-terapeutiche.

Adenocarcinoma of the small bowel is a rare tumor. The diagnosis is often tardy and surgical treatment is still palliative in most cases. A major interest toward this kind of tumor as well as an early diagnosis may give the opportunity to perform a radical operation allowing better results in terms of survival.

[Massive intestinal hemorrhage caused by leiomyoma of the jejunum. Report of a case]. / Emorragia intestinale massiva da leiomioma del digiuno. Descrizione di un caso.

Small-bowel leiomyoma is a rare tumour. The authors report a case complicated by severe bleeding. Esophagus-gastro-duodenal endoscopy was not decisive enough, while TC was the most reliable instrumental investigation. Because of dimensions basic than 10 cm, the presence of a pseudocapsule end the absence of cariokinetic figures, the histopathologic test supports the hypothesis that it was a benign disease. One year follow-up, negative for relapse, confirm that the lesion is benign.

[Obstructive jaundice caused by residual and/or recurrent choledochal lithiasis: endoscopic and surgical treatment]. / Ittero ostruttivo da litiasi residua e/o recidiva del coledoco: trattamento endoscopico e chirurgico.

Results of surgical and endoscopic treatment in 79 patients (58 females and 21 males, age 40-89, mean 62), affected with jaundice, due to secondary choledochal lithiasis, are reported. Thirty-four patients (43%) underwent surgical operation: choledochotomy and T-tube 12, choledocho-jejunostomy 4, choledochoduodenostomy 3, papillosphincteroplasty 15. In 45 patients (57%) EST has been performed. Comparison of results has been obtained after 30 days and after 3-105 months (mean 49). Optimal results have been achieved in 94.9% of patients: 100% after surgery and 94.1% after EST. Morbidity and mortality outcomes in patients who underwent EST (11.1% and 0% after 30 days respectively, 8.1% and 8.1% after several months) are better compared to those ones after surgical treatment (17.6% and 5.8% after 30 days, 20% and 16% after several months). We conclude that EST is nowadays the therapy of choice in patients with jaundice due to choledochal lithiasis, either relapsing or residual.

[Leiomyosarcomas of the small intestine]. / I leiomiosarcomi del tenue.

The main clinical and anatomico-pathological aspects of small bowel leiomyosarcomas are stressed. These are rarely observed malignant tumours, which sometimes prove difficult to diagnose and have a poor prognosis. Also characteristic is the substantial difficulty often encountered in defining the malignancy grade histologically.

[The ileocecal valve as a prognostic factor in extensive resection of the small intestine]. / La valvola ileociecale quale fattore prognostico nelle resezioni estese dell'intestino tenue.

The aim of the study was to examine the role of the ileocaecal valve in relation to the nature and extent of symptoms following extensive bowel resection (EBR) in 13 patients with short bowel syndrome (SBS) referred to our department over the period 1962-1988. The results obtained do not allow us to assess the effective role of the ileocaecal valve in determining the severity of SBS. The factors conditioning the extent of the aftermath of EBR and effectively affecting prognosis are, in fact, multiple and act in various interrelated ways, thus making it difficult to define the precise role of any one of them. The ileocaecal valve, however, does play a substantial role, in that, on the one hand, it performs sphincter and barrier functions against ileocolic reflux of bacteria, while, on the other, its removal involves excision of the right colon (reserve area for reabsorption of water and ions) and of the terminal ileum (a site specialized in absorption of vitamin B12 and bile salts).