Peristomal hernia following end-colostomy: a conservative approach.

Available data from follow-up of 183 patients who survived abdominoperineal excision for cancer of the rectum are reviewed. Sixteen patients developed a peristomal hernia, but none required surgical correction for over 20 years of observation. An additional group of 50 long-survivors has been recently examined to verify whether our restrictive surgical indications are adequate. Seven of these patients presented with a hernia, but none suffered obstructive symptoms and surgery was judged unnecessary in every case. Thereby, in our view, the benign evolution of peristomal hernias support a conservative approach based on a confident observation, control of the diseases which increase the abdominal pressure, and hernia compression by a colostomy belt.

Successful treatment of intraoperative rupture of the left ventricle after mitral valve replacement: report of a case and review of the literature.

A case of intraoperative left ventricular rupture following mitral valve replacement, promptly detected and successfully treated, is reported, and the literature concerning 19 other patients successfully treated for this complication is reviewed. Routine inspection of the posterior atrioventricular groove and left ventricular wall is to be recommended after prosthetic mitral valve replacement and before cardiopulmonary bypass is discontinued, to allow recognition of the early signs of ventricular rupture.

Usefulness of transhepatic portal catheterization in the treatment of insulinomas.

Twenty-four per cent of beta-cell tumours require more than one operation to control the hypoglycaemic syndrome. Almost all of them are small insulinomas undetectable by palpation of the pancreas. Arteriography is too insensitive to detect non-palpable tumours. Transhepatic catheterization of the splenic and portal veins (TPC) can detect the position at which there is an abrupt increase in insulin level indicating the site of the tumour. Routine use of TPC allowed us to locate all 9 insulinomas in which this technique was employed, whereas of 15 patients not studied by TPC only 12 tumours were located at first operation, 2 of which were found by blind resection of the tail of the pancreas. We believe that routine application of TPC to all cases of suspected insulinoma would reduce the incidence of surgical failures, unsuccessful blind resections and lengthy trials of medical therapy before laparotomy.

Pulmonary hypertension in mitral valve surgery.

The operative and long-term results of 72 patients with moderate to severe pulmonary hypertension, operated upon from 1970 to 1972 for isolated mitral valve replacement with Hancock prosthesis were analyzed. A correlation exists between pulmonary hypertension and high mortality risk as well as good hemodynamic recovery of the survivors in the late follow-up, often unrelated with other function tests (pulmonary ventilation and perfusion).

Acute bacterial endocarditis requiring emergency triple valve replacement and pace-maker implant.

A case of triple valve involvement in acute bacterial endocarditis is reported. Replacement of aortic, mitral, and tricuspid valves and permanent epicardial pacing were successfully accomplished.

Long-term results (from 5 to 7 years) with the Hancock S-G-P bioprosthesis.

This communication is concerned with the long-term results of the first 113 patients who underwent single or multiple heart valve replacement with the Hancock-SGP bioprosthesis at the Department of Cardiovascular Surgery, University of Padova Medical School, in a two years period (March 1970-March 1972). Hospital mortality was 18.5%; of the 92 survivors, whose follow-up is now 5 to more than 7 years, the authors report the clinical reevaluation, the complications and the causes of late death. Hemodynamic reevaluation has been performed so far in 26 patients and the prostheses have shown to function properly both in the mitral and the aortic position. The data available to date indicate that the glutaraldehyde preserved porcine valve is durable and its use is warranted in any valvular position.

Anomalous origin of the right coronary artery from the main pulmonary artery.

A case of anomalous origin of the right coronary artery from the main pulmonary artery, in a previously asymptomatic young woman, is presented. Direct transposition into the aortic root of the anomalous vessel was performed. To our knowledge this is the 4th case of this malformation to be successfully corrected.

[The experience with permanent cardiac pacing at the Surgical Clinic of the University of Padua Medical School (author's transl)]. / Esperienza della Clinica Chirurgica dell'Università di Padova nella elettrostimolazione cardiaca permanente.

A computer analysis is reported of the most significant data concerning 1624 pacemaker implantations and 1386 battery replacements. The patients were treated by endocardial stimulation with transvenous electrodes in 91% of the cases; the remainder: 9% received epicardial electrodes. The mode of stimulation was 2189 times "demand", 138 "synchronized" and 683 "asyncronous". Pacers of 13 different brands were used. At the beginning of our experience, the catheter was introduced through the superficial or profunda giugular vein: since 1969 the cephalic vein has been preferred. Epicardial electrodes were implanted via a left thoracotomy but in the most recent years the extrapleural phrenico-pericardial approach has been adopted. In a number of cases external pacemakers have been employed for permanent stimulation. The most common post-operative complications were infection (3.9%), skin erosion (2.2%), catheter rupture (3.5%), electrode dislodgement (1.7%). Such complications are becoming less frequent since 1969, due to technical improvements.

Heart valve replacement with the Hancock bioprosthesis. Analysis of long-term results.

Between March 1970 and May 1976, 564 patients have undergone single or multiple heart valve replacement with the Hancock "SGP" bioprosthesis in our institution. Of these patients, 335 had single mitral, 102 aortic, one tricuspid, and 126 double or triple valve replacement, for a total of 629 xenografts. The long-term results, in terms of clinical improvement, survival, and complications, have been analyzed. Significant valve insufficiency secondary to primitive tissue alterations occurred in three patients, while reoperations were required in two for endocarditis and in two others for mitral stenosis caused by tissue ingrowth. We found that thromboembolic episodes occurred mainly in the early postoperative period up to the third month in 10 cases (1.76%). Three patients suffered peripheral embolization during the late follow-up period. Anticoagulants were not administered beyond 3 months postoperatively. Hemodynamic re-evaluation has been performed in 42 patients and the prosthesis has been shown to function properly either in the mitral or the aortic position. The data available to date indicate that the glutaraldehyde-preserved porcine valve is durable and we feel that its use is warranted in any valvular position.

Rupture of the posterior wall of the left heart at the atrio-ventricular groove following mitral valve replacement.

The authors report 8 cases of left heart rupture at the insertion of the posterior leaflet of the mitral valve out of 693 mitral valve replacements. Special attention is paid to the anatomy of this area and to the technique of removal of annular calcifications, when present. In reviewing the literature, the authors analyze the cases reported up to now with particular reference to the age of patients, number of valves replaced, size and amount of calcifications, volume of the left ventricular cavity, type and size of the prosthesis employed, supra- or subannular insertion, time between valve application and rupture of the heart, techniques of repair with cardiopulmonary by-pass with a beating or arrested heart. The authors maintain that this dramatic iatrogenic complication can be avoided in most instances with some modifications of the surgical technique which has been adopted in the last 200 mitral valve replacements.

[Rupture of the posterior wall of the left ventricule after replacement of the mitral valve: a description of 8 cases (author's transl)]. / La rottura della parete posteriore del ventricolo sinistro dopo sostituzione valvolare mitralica. Descrizione di 8 casi

Eight cases of left ventricular rupture at the atrio-ventricular groove among 693 mitral valve replacements, isolated or associated with other surgical procedures, are reported. In the authors' opinion, the surgical technique of the mitral valve's removal, especially if calcific or with subvalvular disease, as well as the method and the site of implantation of the prosthesis, are the main factors in determining this severe complication. In order to avoid the rupture of the posterior wall of the left ventricle, a simple modification of the surgical technique which reinforces the valvular annulus is suggested.

Thoracic aorta-to-femoral artery by-pass. For the treatment of complete obstruction of the abdominal aorta at the level of the renal arteries.

Complete obstruction of the abdominal aorta at the renal artery level is often a difficult surgical problem in case of long standing thrombosis, short suprarenal aortic space, and extensive periarterial inflammatory reaction. Six patients in whom revascularization of the lower extremities was performed through a prosthetic by-pass from the thoracic aorta to the femoral arteries, were reported here. One patient underwent also a left nephrectomy for renal hypertension, chronic renal artery obstruction, shrunken kidney. Both the short and long term results have been satisfactory in all cases.