Benign pneumatosis intestinalis with massive portomesenteric venous gas in a very old man. A case report.

INTRODUCTION: Pneumatosis intestinalis (PI) is described as the presence of air within bowel wall. PI aetiology is various: it can be associated with non-urgent or life-threatening conditions. Clinical management is based on physical examination, blood tests and radiology, in particular abdominal CT. The cause of PI suggests the correct therapy. When PI is linked to gas in portal and mesenteric venae (PMVG), bowel ischemia or infarction is possible, and surgery needed. CASE REPORT: A 91 years-old man was admitted to Emergency Department reporting abdominal pain and vomit. Acute abdominal symptoms, radiological finding of small bowel PI with massive PMVG, severe neutrophilia, and high serum lactate forced us to perform exploratory laparotomy, from which it was observed a diffuse band-like pneumatosis of all the small bowel and mesentery without ischemic or peritonitis signs. The patient was imposed to fast and treated with oxygen, intravenous fluid and antibiotic therapy, without performing further surgery, and was discharged to a rehabilitation facility after symptomatology resolution. DISCUSSION: Scientific literature underlines the importance of PMVG to consider as critic a patient with PI, but it is always essential to assess also physical examination, vital parameters, and blood exams. In our case, several signs were suggestive for bowel infarction: its absence and the swift recovery of the patient were unexpected. CONCLUSION: Although non-surgical treatment is recommended for primary PI of unknown aetiology, in case physical examination and radiological signs aren't decisive surgery is necessary to rule out bowel infarction. This case stresses the difficulty of PI management.

Bloodless hepatic resection with automatic bipolar radiofrequency generator and multielectrode device.

Liver resection is a standard treatment for liver tumours. Intra-operative blood loss remains a major concern during liver resection due to its association with higher postoperative complications and shorter long-term survival. To perform bloodless hepatic resection we realized an apparatus consisting of an incremental, bipolar radiofrequency generator and a probe with six in-line needles (SURTRON SB). Several ex-vivo and in-vivo pig liver experiments and a first-phase clinical study allowed the realization of a prototype radiofrequency (RF) generator that works at 470 kHz, 150 watts maximum power delivered. The probe consists of six needle electrodes of 1.5 mm diameter, with 4.5 mm free space, 6.0 mm centre to centre, between each. We obtained a coagulation of 35 mm length and 12 mm width. The transection was performed with a common scalpel after coagulation of liver parenchyma. We observed good healing of the liver edge both in animal model and in ongoing pilot clinical study. Coagulation with SURTRON SB allows a feasible, easy and safe bloodless liver resection. This method is tolerated with no systemic complication or adverse reaction. This technique offers a method for a bloodless hepatic transection without the need for sutures, ties, staples or tissue glue.

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%.

[Postoperative pain in inguinal hernioplasty: does it exist?]. / Il domani doloroso dell'ernioplastica inguinale: esiste?

Tension-free hernioplasty in the Day Hospital or Short Stay Surgery setting is now considered the gold standard for hernia treatment, but early discharge is not synonymous with a rapid recovery, and pain in the inguinal region may persist for months after the operation. The authors examined 100 tension-free hernioplasties, performed in 1999. 72 Lichtenstein and 28 Trabucco hernioplasties were performed in 97 men and 3 women (min age 18 yrs., max. 90 yrs., mean 55 yrs.). Three months after hernioplasty residual inguinal pain was present in 10 patients (mild in 9, moderate in 1). Hypo-dysaesthesia in the inguino-crural region was also present in 8 patients (mild in 7, moderate in 1). Operative technique, emergency surgery and the surgeon himself were not correlated with results; occupational status was significantly associated with residual pain, which affected active workers more than retired patients.

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.

[The imaging quality of the ureteral intramural tract in the adult male. A comparison between suprapubic and transrectal echography]. / Qualità dell'immagine del tratto intramurale dell'uretere nel maschio adulto. Confronto tra ecografia sovrapubica e transrettale.

PURPOSE: US is usually considered of little help in studying the ureters because it only shows proximal and distal tracts. The distal ureter is also difficult to study with most of the other imaging methods. Transrectal probes improve depiction of the intramural and pelvic tracts of the ureter, as well as image quality, dramatically providing good results in a short time. The first and, to our knowledge, the only report on this procedure has been Holm's (1994), where the author reported good results though in a small series. For years we have used transrectal US, performed for prostate studies, also to examine intramural ureters and have obtained good results in a short time. Thus we decided to compare the transrectal with the transabdominal approach. MATERIAL AND METHODS: We examined 92 randomly selected male patients with various urologic conditions but no ureter involvement using 3.5 MHz convex and 5.0 MHz biplane transrectal probes. Image quality was rated on an arbitrary scale (0-4) and then submitted to statistical analysis. RESULTS: Transrectal images were clearly superior to transabdominal ones (p = 0.012) and particularly, ureters were depicted in 93% versus 60% of cases, respectively. The amount of urine in the bladder appears to play a major role (the greater the amount the worse the image quality), while ureter depiction is independent of body habit and bladder squeezing. CONCLUSIONS: Our results are clearly superior to Holm's. Also, considering that the transrectal examination requires a short time, is cost-effective and little invasive, we believe that this method can play an extremely important role in lower ureter studies.

[Lymphadenopathy as specific ultrasonography index of subacute thyroiditis. Preliminary data]. / Le linfoadenopatie quale indice specifico ecotomografico di tiroidite subacuta. Dati preliminari.

INTRODUCTION: We report the preliminary results of a study on the importance of juxtajugular and supraisthmian lymph node enlargement at US as a sign of occult subacute thyroiditis. MATERIAL AND METHODS: We examined patients submitted to thyroid US for noninflammatory thyroid conditions and for positive familiarity and studied the presence of supraisthmian and juxtajugular lymph node enlargement. The patients were then divided into two groups: the clinical history, antibody titer and symptoms were studied in group A (patients with enlarged lymph nodes) and the antibody titer, symptoms and US findings were studied in group B (patients with a history of thyroiditis). RESULTS: Fifty-nine of 600 patients were allocated to group A and 25 of 600 to group B. Of the former 59 asymptomatic patients (10% of the total), 29% had supraisthmian and 85% juxtajugular lymph node enlargement, with some patients positive at both sites. Forty-seven patients (80%) had subacute thyroiditis (33 of them with positive antibodies and 23 with a clinical history); we had 12 false positives. Twenty-two of 25 group B patients (91%) had supraisthmian (40%) or juxtajugular (83%) lymph node enlargement: 3 patients with no enlarged lymph nodes had an over 3-year history of low antibody titers. DISCUSSION: Forty-seven of 600 (8%) asymptomatic patients who had been never examined are or were affected with subacute thyroiditis. Ninety-one per cent of all thyroiditis patients had supraisthmian or juxtajugular lymph node enlargement, more frequently the latter than the former. CONCLUSIONS: Supraisthmian and/or juxtajugular lymph node enlargement appears to be a very useful US sign of subacute thyroiditis, even though these data need confirmation from larger series of patients.

[Clinico-pathological study of microcarcinoma of the thyroid]. / Studio clinico-patologico del microcarcinoma della tiroide.

We have analysed the results of surgical treatment for microcarcinoma of the thyroid (MCT). In sixteen patient clinical and follow-up data were retrospectively evaluated during a 35.1-month follow-up. Thyroid hyperfunctional state us was present in two subjects. A single nodule was detected by echotomography in 11 patients, while multinodular diffuse goitre was revealed in 3 patients. In the last two subjects, thyroid gland appeared completely normal at ultrasonography, despite laterocervical lymph node metastases. Fine-needle aspiration biopsy was performed in 6 patients and its diagnostic accuracy was high (83,3%). MCT was classified as "incidental" in 12 patients and "occult" in the remaining 4 patients. Eight subjects underwent total thyroidectomy and 8 hemithyroidectomy plus isthmectomy. No postoperative complications were recorded. In 10 patients MCT histotype was papillar adenocarcinoma, in 5 was follicular adenocarcinoma and in the remaining case it was medullary carcinoma. Goitre was associated in 75% of the cases. Only in a patient disease progressed to death because of hematogenous metastases. In conclusion, we believe that incidental MCT is a low-grade malignancy with a benign biological behaviour. Occult MCT is a potentially lethal disease. We did not observe differences in the long-term results between different surgical treatments of MCT.

[Extracranial aneurysm of the internal carotid artery]. / Aneurisma della carotide interna extracranica.

The Authors present a case of extracranial internal carotid aneurysm of atherosclerotic nature. They review the most common pathogenetic factors of this uncommon disease and they focus attention on its natural history. The neurological complications in untreated patients are very high (50-70%). The treatment should be carried out with a revascularization technique after removal of the aneurysm; leaving ligature for difficult situations or to memories of the past.

[Cystic adventitial disease of the popliteal artery. Report of 2 cases and review of the literature]. / Malattia avventiziale cistica dell'arteria poplitea. Presentazione di due casi e revisione della letteratura.

Two cases of cystic adventitial degeneration of the popliteal artery are reported and aetiopathogenetic theories, diagnosis and treatment discussed. One of the cases presented is of special interest because, at surgery, it was possible to observe the relationships of the artery with the articular capsule of the knee through a genicular vessel which, when sectioned, showed an exit of mucinous material the equivalent of that contained in the vasal cyst. This observation gives even more credence to the so-called "articular" aetiopathogenetic theory. The two cases were treated surgically with resection of that segment of the artery and contralateral saphenous vein graft giving an excellent short-term and long-term result and protecting from recurrences.

[Iatrogenic occlusion of the anterior descending branch of the left coronary artery. Description of a case]. / Occlusione iatrogenica del ramo discendente anteriore della coronaria sinistra. Descrizione di un caso.

A 27 years old man was admitted in our Institute for exertion dyspnea, palpitation and a single syncopal attack; five months before admission he was subjected to thoracotomy for pericardial and myocardial haemostatic suture because of a slash. Clinical, phonocardiographic and echocardiographic data suggested diagnosis of combined aortic stenosis and aortic regurgitation. An anterior myocardial necrosis was in ECG and VCG, Cardiac catheterization confirmed previous report. Coronary arteriography showed total occlusion of left anterior descending artery soon after the second diagonal branch. Right coronary was undamaged. Furthermore left ventricular angiocardiography showed a changed ventricular function. The Authors point out the iatrogenic cause of the coronary occlusion; it was due to the inclusion of left anterior descending artery in the surgical myocardial and pericardial haemostatic suture and/or post-traumatic fibrosis. It is necessary to watch over the patient as the changed ventricular function can develop in an aneurismatic area.