Open tension-free Lichtenstein repair of inguinal hernia: use of fibrin glue versus sutures for mesh fixation.

PURPOSE: To investigate pain and other complications following inguinal hernioplasty performed by the Lichtenstein technique with mesh fixation by fibrin glue or sutures. METHODS: Five hundred and twenty patients were enrolled in this 12-month observational multicenter study and received either sutures or fibrin glue (Tissucol(®)/Tisseel(®)) based on the preference of the surgeon. Pain, numbness, discomfort, recurrence, and other complications were assessed postoperatively and at 1, 3, 6, and 12 months. Pain intensity was assessed by a visual analog scale (VAS; 0 [no pain] to 10 [worst pain]). RESULTS: One hundred and seventy-one patients received sutures and 349 received fibrin glue. During the early postoperative phase, 87.4% of patients in the fibrin glue group and 76.6% of patients in the sutures group were complication-free (P = 0.001). Patients who received fibrin glue were also less likely to experience hematoma/ecchymosis than those in the suture group (both P = 0.001). The mean pain score was significantly lower in the fibrin group than the sutures group (2.5 vs. 3.2, P < 0.001). At 1 month, significantly fewer patients in the fibrin glue group reported pain, numbness, and discomfort compared with patients in the sutures group (all P < 0.05). Fibrin glue patients also experienced less intense pain (0.6 vs. 1.2; P = 0.001). By 3 months, the between-group differences had disappeared, except for numbness, which was more prevalent in the sutures group. By 12 months, very few patients reported complications. CONCLUSIONS: Tissucol fibrin glue for mesh fixation in the Lichtenstein repair of inguinal hernia shows advantages over sutures, including lower incidence of complications such as pain, numbness, and discomfort, and should be considered as a first-line option for mesh fixation in hernioplasty.

Impact of the endorectal ultrasound probe on uroflow parameters in males.

OBJECTIVES: The aim of this study was to test the null hypothesis that the presence in the rectum of an endorectal ultrasound probe during transrectal voiding ultrasonography (TRVUS) would have no significant effect on uroflowmetry parameters. PATIENTS AND METHODS: We studied 43 randomly selected men undergoing TRVUS of the prostate for non-neurogenic lower urinary tract symptoms. Uroflowmetry was performed immediately before and during the TRVUS. Results were compared with a paired Student's t test; the null hypothesis was confirmed by p values >0.05. RESULTS: Forty patients were able to void with the endorectal probe inserted, and 95% described this micturition as representative of their usual voiding behavior. No significant statistical difference was found between uroflowmetry parameters before and during TRVUS, confirming our null hypothesis. CONCLUSION: Our data suggest that uroflowmetry in combination with TRVUS can be a reliable tool for evaluating disorders of micturition in males, at least in selected cases.

Sonographic evaluation of clinically occult in-transit and satellite metastases from cutaneous malignant melanoma.

PURPOSE: Our purpose was to assess the potential of ultrasonography (US) in the detection of in-transit or satellite metastases. MATERIALS AND METHODS: Following a review of the relevant literature, we present the results of a retrospective study based on 2,000 malignant melanoma patients with complete case records. Of these, we selected 600 patients who had a thick melanoma (>1 mm) at presentation but were clinically free of in-transit or satellite melanoma metastases during follow-up. All patients underwent periodic clinical and imaging investigations, as well as US examination of the site of the surgical wound and surrounding soft tissues. RESULTS AND DISCUSSION: US raised the suspicion of in-transit or satellite metastases in 63 patients. A total of 95 lesions were identified. Average lesion diameter was 0.7 mm, and only four were larger than 1 cm. All suspected lesions were confirmed by surgery, follow-up or US-guided fine-needle aspiration (FNA) with 22-gauge needles using a freehand technique and exploiting the capillarity principle. In this series, there were apparently no false positive or false negative US results although inclusion criteria precluded correct evaluation of possible false negatives. Minimum lesion diameter allowing sonographic detection appears to be around 0.4 mm. US features of in-transit metastases have been well documented. They usually appear as solid lesions, hypoechoic relative to the surrounding subcutaneous fat and with relatively well-defined and regular contours and good US transmission. Internal structure is fairly homogeneous, and sometimes millimetresized fluid areas can be appreciated inside. Larger metastatic lesions may exhibit internal vascular signals at power Doppler imaging. These findings in dermatological sonography are almost exclusive of metastases but may also be seen in glomangioma, which, however, has intense intralesional vascularity. US-guided FNA plays an important role in diagnosis of metastases from malignant melanoma. Of the 32 nodules that were cytologically sampled, a definitive or most probable diagnosis of metastasis was made for nodules with a mean diameter of 0.7 mm (minimum 0.5 mm). CONCLUSIONS: Sonography of soft tissues surrounding the original site of a malignant melanoma should be more widely used and associated with US-guided FNA biopsy.

Our experience in transrectal ultrasonography and biopsy in carcinoma of the prostate.

The Authors present a short review of the literature comparing transrectal ultrasound of the prostate (TRUS) and ultrasound guided biopsy and the results of 694 consecutive prostatic biopsies from their cohort. All the biopsies were US guided with an endorectal biplanar 5 MHz probe and transperineal samples were carried out with an 18 G needle (cutting length 22 mm) over the last 4 years. The histological exam showed 187 prostates affected by cancer while 112 had only inflammation. The operator's opinion, based on ultrasonography and integrated with a digital rectal exam (DRE) and a prostate specific antigen (PSA) blood test, was correct in 80% of the cases, with 90% sensitivity and 70% specificity. The positive prediction rate was 74% and the negative prediction rate was 89%.

[Role of radioisotopic lymphoscintigraphy in postphlebitic syndrome of the legs]. / Ruolo della linfoscintigrafia radioisotopica nella sindrome postflebitica degli arti inferiori.

Post-phlebitis syndrome of the lower limbs is a set of symptoms that follow a state of phlebostasis and phlebolymphostasis with consequent oedema and tissue distress. We submitted 36 patients with post-phlebitis syndrome of the lower limbs to radioisotopic lymphoscintigraphy for the purposes of evaluating the vicariant function of the lymphatic system and the possible role of the lymphatic system in the genesis of dermo-epidermal abnormalities. The average age of the patients was 53.2 years (range: 43-69 years; M:F ratio: 0.50). The control group consisted of 6 healthy subjects. The average duration of the post-phlebitis syndrome in the patients studied was 8.5 years. We excluded from the study patients in whom a central cause was identified as being responsible for the pathogenisis of the oedema of the lower limbs. In addition, patients with obliterant arteriopathy were also excluded. Venous pathology was evaluated first clinically and then investigated by continuous-wave Doppler. As a first step, venous pressure was measured by Doppler phlebomanometry in clino- and orthostatism. All patients underwent radioisotopic lymphoscintigraphy with microcolloids using the Rijke technique. Radioactivity was monitored by means of a computerized gamma-camera. We classified the pathological findings of radioisotopic lymphoscintigraphy as follows: 1) delayed transit; 2) obstacles; 3) star-shaped superficial collateral lymphatic circulations; 4) lymphocoele or cutaneous lakes. A significant difference was detected (p < 0.05) between the pressure values in the post- phlebitis lower limbs and the pressure values in normal subjects. Combining the results of our measurements we recorded delayed transit in 5 patients (69.5%). This latter group included the cases with the severest forms of post-phlebitis syndrome. Therefore, better knowledge of the pathophysiology of the lymphatic system would appear to be useful in order to understand the origin and evolution of oedema of the lower limbs of patients with post-phlebitis syndrome. To this end, radioisotopic lymphoscintigraphy may be useful as a first-level examination in order to evaluate the capacity and efficiency of the lymphatic system.

Percutaneous liver biopsy using an ultrasound-guided subcostal route.

Percutaneous biopsy is considered one of the most important diagnostic tools to evaluate diffuse liver diseases. The introduction and widespread diffusion of ultrasounds in medical practice has improved percutaneous bioptic technique, while reducing postoperative complications. Although ultrasonography has become almost ubiquitous in prebiopsy investigation, only one third of biopsies are performed under ultrasound control. Moreover, the one-day procedure, reported in several studies to be safe and cost effective, accounted for only 4% of biopsies done. We report our experience of 142 percutaneous US-guided biopsies performed on 140 patients affected by chronic diffuse liver disease over a four-year period. Liver biopsies were performed under US guidance at the patient's bed using an anterior subcostal route. We evaluated postoperative pain, modifications of blood pressure and red cell count, hospital stay, morbidity and mortality rates, and adequacy of specimens for histologic examination. There was no operative mortality. As for major complications, one case of hemobilia occurred. As for minor complications, two cases of persistent postoperative pain required analgesic therapy. Patients were discharged the day following the procedure in all cases but two, who were discharged on the third and fifth postoperative days. Liver specimens were suitable for histologic diagnosis in all but one case, in which there were no portal spaces. According to our experience, we believe that hepatic biopsy guided by ultrasonography could replace blinded biopsy in the diagnosis of diffuse liver disease. The procedure is suitable to be performed safely on an outpatient basis.

[Cystadenolymphoma of the salivary glands: is there a familial role?]. / Cistoadenolinfoma delle ghiandole salivari: esiste un ruolo della familiarità?

The authors present two patients (mother and son) affected by cystadenolymphoma (Warthin's tumor) of the salivary glands, both surgically treated. A thorough review of the literature is conducted and the authors suggest that echographic screening of these neoplasia in first-degree relatives could be of value.

[A computerized multivariate analysis in the assessment of the prognosis of breast cancer after surgical excision]. / Analisi multivariata computerizzata nella valutazione della prognosi del cancro della mammella dopo exeresi chirurgica.

BACKGROUND: The prognostic parameters most universally accepted as indicative for the assessment of 5 and 10 year survival in breast cancer are considered. METHODS: The aims of this study were to elucidate the relationships among these parameters and to determine the specific interrelations of these prognostic factors. These parameters (age, grading, tumour size, lymphatic and vascular invasion, necrosis, lymph node status and number of nodes positive) are analysed by univariate and multivariate analysis on a series of 75 patients. RESULTS: The analysis performed confirms prognostic accuracy of age, tumor size, number of nodes positive (p < 0.05, p < 0.001, p < 0.003, respectively) when considered singularly but the impossibility of deriving any benefit from the study of their reciprocal interrelations. CONCLUSIONS: This is due to the importance of each parameter assumes independently from the other and to the reciprocal compensation that occurs when all possible interactions are considered.

[Microsurgical repair of iatrogenic injuries of the recurrent laryngeal nerve]. / Riparazione microchirurgica delle lesioni iatrogene del nervo ricorrente.

In this retrospective study the functional results of microsurgical repair of iatrogenic recurrent nerve lesions (10 patients) faced during years 1983 through 1995 have been analysed. Different parameters were considered (thyroid disease, previous thyroid surgery, microsurgical reconstruction technique, time between surgical damage and microsurgery). Furthermore, a thorough review has been made on the medical literature on subjects such as surgical anatomy of the cervical region, microsurgical nerve repair techniques, and clinical results of microsurgery in different authors experiences.

[Hürthle cell neoplasms of the thyroid gland]. / Le neoplasie della tiroide a cellule di Hürthle.

From 1986 to 1996 the Authors have surgically treated 34 patients affected with Hürthle cell neoplasm of the thyroid (23 benign and 11 malignant). Preoperative diagnosis was obtained mainly by fine needle aspiration biopsy. In thyroid surgery we routinely prepare laryngeal nerve and take great care to avoid devascularization fo the parathyroid glands. Operative procedures performed were hemithyroidectomy plus isthmectomy (18), subtotal thyroidectomy (2) and total thyroidectomy (14). No cervical lymph node dissection was requested, neither we observed post-operative morbidity. Mean follow-up was 116 months. During observation period we documented. No hematogenous metastasis was observed. All patients are now well and alive free of disease. This series stresses the favourable behavior of Hürthle cell neoplasm of the thyroid--even through a prolonged follow-up. A thorough review of the Literature on the topic is conducted. The Authors are in favour of total thyroidectomy as first choice procedure for lesions larger than 40 mm in order to reduce the need of completion thyroidectomy and the potential morbidity.

[Radiotherapy of cancer of the uterine cervix and successive appearance of new malignant growth in the irradiated field]. / Radioterapia per carcinoma del collo dell'utero e successiva comparsa di nuove neoplasie maligne nel campo di irradiazione.

Among the late complications of high-dosage pelvic radiotherapy for cervical cancer, anorectal and bladder malignancies are sporadically reported in the literature. In this study the possible relationships of previous radiotherapy with late appearance of neoplasms are analyzed and in particular post-radiotherapy interval, dosage and type or irradiation to the cervical area. The mechanisms or neoplastic transformation or irradiated tissues are also studied. Three clinical cases or women irradiated in the past because or cervical cancer and recently treated at our surgical Division for the appearance or four new pelvic malignancies in the irradiated field (three rectal and one bladder cancer are presented. In conclusion, the possible cause-effect relationships between previous radiotherapy and subsequent appearance of neoplasms are analyzed as well as the potential therapeutical consequences or considering these women high-risk subjects. The usefulness or recruiting women with history or previous radiotherapy for cervical cancer in a strict follow-up program (ultrasonography, cytology and endoscopy) is suggested in order to make an early diagnosis of the new pelvic malignancy with a better possibility or treatment.

Renal handling of sodium after an oral protein load in adult humans.

This investigation was designed to study (1) renal sodium handling after an oral protein load and (2) its relationship to some known determinants of the hemodynamic response (glucagon, insulin, growth hormone, renin, aldosterone, and plasma amino acid concentration). To this end of group of 8 adult subjects was studied before (three 30-min clearances) and after a meat meal (MM; five 30-min clearances at 30, 60, 90, 120 and 180 min). The MM provided 2 g/kg BW of protein. Within 30 min from the MM an hyperfiltration response was seen, which was paralleled by a 2-fold increase in plasma alanine concentration while total plasma amino acid concentration was not different from the baseline values. The hemodynamic response was associated with a normally operating tubuloglomerular feedback mechanism independent of renin-aldosterone activity, but possibly associated with an early increase in plasma glucagon concentration and later on with a modest increase in postmeal plasma insuling concentration.

Predicted creatinine clearance to assess glomerular filtration rate in chronic renal disease in humans.

The work was designed to assess the suitability of both measured endogenous creatinine clearance (CCR) and predicted creatinine clearance (P-CCR) to evaluate GFR in chronic renal disease (CRD) by utilizing the renal clearance of inulin (CIN) as gold standard. A total of 124 subjects were studied (62 healthy, 62 with CRF). CCR significantly overestimated GFR in healthy subjects as well as in CRF, whereas P-CCR was identical to GFR. The CCR/CIN ratio which calculates the fractional creatinine clearance and provides a rough estimation of the contribution of creatinine secretion in explaining the differences between CCR and GFR was increased in CRD and especially in CRD of glomerular origin. The ration P-CCR/CIN was significantly lower than CCR/CIN in healthy subjects and in patients with CRD of glomerular origin. The data are against the use of CCR in assessing GFR in healthy subjects and in patients with CRD.

Lithium clearance in patients with chronic renal failure.

Lithium clearance (CLi) was studied in the healthy subjects (H) and in patients with chronic renal failure (CRF) with a mean GFR of 36.08 +/- 3.8 ml/min x 1.73 m2 in order to evaluate (1) the variability of CLi measurements; (2) the changes of CLi during the hyperfiltration response to a meat meal (2 g/kg b.w. of protein), and (3) the effects on CLi of different protein intakes. CLi correlated with GFR and with urinary sodium, FeLi correlated with FeNa in H and CRF. The intraindividual standard deviation (IISD) of GRF, CLi and FeLi assessed in triplicate studies in the course of a single experiment averaged 4.70, 7.15 and 10.69% in CRF and 1.77, 4.09 and 4.61% in H. When IISD for GFR, CLi, and FeLi was assessed in triplicate measurements in the course of 3 studies performed at 1-week intervals (day 1, day 8, day 15), it averaged 7.36, 9.21 and 15.72% in CRF and 1.83, 5.08 and 5% in H. During the hyperfiltration response to a meat meal, CLi and FeLi did not change in CRF and increased significantly in H. In 10 patients with CRF who were switched for 3 weeks from a protein intake of 0.85 g/kg to a protein intake of 0.60 g/kg, GFR was significantly (p less than 0.001) reduced by 29%, while CLi was stable. The data indicate that because of its variability, CLi is of little use in experiments designed to study subtle changes in renal Na transport.

Tubular function by lithium clearance, plasma amino acids and hormones following a meat meal in childhood.

Tubular function was measured by lithium clearance (CLi) and by its derived formulae before and after the transient increase (lasting 90 min) in glomerular filtration rate (GFR) following a meat meal (2g protein/kg body weight) in 12 normal children. Three baseline and 4 clearances after the meal were obtained, each lasting 30 min. The mean baseline CLi was 23.1 +/- 1.64 ml/min/1.73 m2. At peak GFR response (60 min from starting the meal), CLi averaged 27.6 +/- 2.4 ml/min/1.73 m2 (p less than 0.025 vs. baseline) and it was further increased (32.2 +/- 5.04 ml/min/1.73 m2, p less than 0.01 vs. baseline) 120 min after starting the meal, while GFR returned to baseline values. Fractional lithium excretion averaged 0.23 +/- 0.04 at baseline and increased continuously after the meat meal and, at completion of the study, it averaged 0.38 +/- 0.07 (p less than 0.025 vs. baseline). The distal absolute and fractional sodium reabsorption increased throughout the studies following the meal and peaked at 120 min. The functional changes were associated with a statistically significant increase in the plasma concentration of insulin, glucagon, and total amino acids after the meal. The latter at the end of the study was almost doubled (5,600 +/- 780 versus 3,200 microM at baseline, p less than 0.01). The data indicate that the tubulo glomerular feedback mechanism operates normally after a meat meal. The finding on increased distal sodium reabsorption might point to the existence of an insulin-dependent mechanism.