[Recurrent leiomyoma of the rectum treated by endoscopic transanal microsurgery]. / Leiomioma recidivo del retto trattato mediante microchirurgia endoscopica transanale.

The Authors report a case of recurrent leiomyoma of the rectum treated by Transanal Endoscopic Microsurgery (T.E.M.). Leiomyoma of the rectum is a rare entity (0.1-0.3%) (the incidence of smooth muscle tumours being 7% in the digestive tract). Benign leiomyomas are usually asymptomatic; discomfort or pain, related or not to defecation, sensation of foreign body, change in bowel habits, rectal bleeding are rarely reported. The distinction between a benign leiomyoma and a leiomyosarcoma is often difficult and requires an accurate microscopic study. In most cases rectal leiomyoma is detected incidentally in the course of a rectal examination. Endoscopic examination of the rectum with biopsies and endorectal ultrasonography are useful for the diagnosis, while rarely a plain radiologic examination is sufficient. Leiomyoma of the rectum also presents a high tendency to local recurrence (31%). Therefore the choice of an adequate treatment is often difficult. The Authors believe that the treatment of rectal leiomyoma by T.E.M. may substitute conventional methodics (transanal excision, proctectomy with or without amputation of the sphincter and coloanal anastomosis, endoscopic electroexcision of the neoplasm). T.E.M. allows short-term hospitalization and implies minimal surgical trauma.

[The use of laser through thoracoscopy in the treatment of spontaneous pneumothorax. Presentation of a clinical case]. / L'impiego del laser per via toracoscopica nel trattamento del pneumatorace spontaneo. Presentazione di un caso clinico.

The authors present the case of a patient with right plurirecidive pneumothorax. During the 12 months before the operation the patient suffered from 3 episodes of pneumothorax, treated with the insertion of an intrapleural drainage. Preoperative exams showed the presence of multiple emphysematous blebs with diameter ranging from 0.5 cm to 3 cm. The patient was treated with Nd:YAG laser photocoagulation of the blebs and mechanical abrasion of the parietal pleura through thoracoscopy. The laser photocoagulation of the blebs was performed using the contact technique and a 25 Watt power. After operation a TX of the thorax, using the high resolution technique, showed the presence of residual blebs involving the apex and the mediastinal surface of the inferior lobe of the right lung. After a 12 month follow-up no recidive pneumothorax occurred and the general conditions of the patient were good. The authors state that the laser treatment of spontaneous pneumothorax secondary to bullous emphysema is effective and safe and it is also successful in patients with multiple blebs. As it is often difficult to find and treat all the blebs, it may be useful to perform thoracography during thoracoscopy.

[Complications of surgery of Dupuytren disease. Comparison of total and partial aponeurectomy]. / Le complicanze nella chirurgia della malattia di Dupuytren. Confronto tra aponeurectomia totale e parziale.

Total and partial aponeurectomy are the most usual operations performed for the treatment of Dupuytren's disease. Eighteen patients, for a sum of 23 treated hands, were submitted to total aponeurectomy in 20 cases and to partial aponeurectomy in 3 cases. Recurrence was present in 4 cases. Postoperative morbidity was 50% (10/20 cases) following total aponeurectomy and 0% (0/3 cases) following partial aponeurectomy. In patient with recurrence disease postoperative complications were present in 3/4 cases (75%) while in patients, operated for the first time, morbidity rate was 36.8% (7/19 cases). Postoperative complications following total aponeurectomy are extremely frequent, especially if recurrence is present. Partial aponeurectomy allows to achieve functional result as good as total aponeurectomy with significative reduction of postoperative morbidity.

Tinea capitis in the Florence area between 1985 and 1993.

This paper describes the main epidemiological findings in 203 patients with tinea capitis and in seven other patients with dermatophytosis that had also extended to the scalp. The patients were observed over a 9-year period (from 1985 to 1993) at the Department of Dermatology of the University of Florence. Tinea capitis was the fourth most frequent dermatophytosis. Most of the patients were children, although 23 were adults. The most frequent aetiological agent was Microsporum canis. It is interesting to note that there were 12 cases of tinea capitis due to Trichophyton violaceum in African immigrants. This dermatophyte was believed to have disappeared from Italy. One case was due to Epidermophyton floccosum.

[Superior laryngeal nerve in thyroid surgery]. / Il nervo laringeo superiore nella chirurgia della tiroide.

In this paper, the authors discuss the risks of lesions to the external branch of the superior laryngeal nerve during surgical procedures on the thyroid gland. These lesions result in significant functional impairment consisting on the patients' impossibility of emitting high-pitched sounds, an easy tiredness in vocalizing, huskiness, or a combination of these symptoms. Recently, in effect, with the increasing use pre and postoperatively of newer diagnostic tools such as electromyography (EMG) of the cricothyroid muscle, a fairly high incidence of permanent or temporary, including single or bilateral lesions to this nerve was demonstrated. The necessity of using appropriate surgical techniques with the objective of avoiding or markedly reducing the incidence of lesions to the superior laryngeal nerve is discussed in detail by the authors.

[The surgical treatment of thyroglossal duct cysts and fistulae]. / Il trattamento chirurgico delle cisti e fistole del dotto tireoglosso.

The authors report the results of treatment in 20 patients with thyroglossal duct cysts and/or fistula. Three patients underwent the standard Sistrunk's operation (excision of the cyst with resection of the duct above the hyoid bone with the portion of the muscle surrounding to the foramen caecum), 13 patients were submitted to a modified Sistrunk's operation (removal of the cyst and/or fistula and resection of the middle portion of the hyoid bone with dissection above it only with macroscopic evidence of duct epithelium) and 4 patients underwent less radical procedures. There were no recurrence in those patients operated upon with the standard or modified Sistrunk's operation. On the contrary two recurrence were observed in patients operated in elsewhere by simple excising the cyst without hyoid bone resection. In conclusion the authors strongly support the modified Sistrunk's operation as treatment of choice in patients with thyroglossal duct cysts and fistula; This operative procedure can avoid long-term recurrence even though many authors suggest that only the standard Sistrunk's operation can guarantee the lowest rate of failures.

[Endometriosis of the abdominal wall: a clinical case report and a review of the literature]. / Endometriosi della parete addominale: presentazione di un caso clinico e revisione della letteratura.

The authors report one case of abdominal wall endometriosis secondary to cesarean section. They emphasize the rarity of this localization and discuss about the incidence of extrapelvic endometriosis stressing the importance of this pathology in the differential diagnosis with other disease.

The influence of tumor lymphocytic infiltration on long term survival of surgically treated colorectal cancer patients.

Prognostic significance of host-immune response, as gathered by the degree of tumour lymphocytic infiltration (TLI), and its relationship to other prognostic variables were investigated in 361 colorectal cancer patients admitted to our Institution for curative resection from January 1960 to December 1978. The presence of a local immune reactivity was significantly related to a less advanced stage of disease and a better differentiated tumour. A poorer prognosis was detected in patients with minor or no lymphocytic infiltration. TLI was the single most important prognostic parameter, according to the Cox model and to logistic regression analysis. These findings suggest that also TLI should be considered in the current Staging System of colorectal cancer.

Extracapsular lymphnode metastases in the staging and prognosis of gastric cancer.

The aim of this study was to evaluate the influence of the degree of nodal involvement (extracapsular vs intracapsular) on survival of 121 patients radically resected for gastric adenocarcinoma with nodal metastases at the Department of Clinica Chirurgica I of "La Sapienza" University of Rome. Patients with extracapsular nodal metastases had a worse 10-year survival rate than those with intracapsular nodal involvement (7.9% vs 22.4%). A better prognosis among patients with intracapsular node metastases was observed in each p-TN subgroup. In the multifactorial analysis (3-way ANOVA) survival was correlated with the depth of invasion of the gastric wall and the degree of lymphnode involvement (p less than 0.01) but not with the level of nodal involvement (N1 vs N2). Our results suggest that the degree of nodal involvement is an important independent prognostic factor that should be considered in the current staging system for curative resection in gastric carcinoma.

[Age as a prognostic factor following excisional surgery for colorectal cancer]. / L'età come fattore prognostico dopo chirurgia di exeresi per cancro del colon retto.

On a series of 369 patients with colorectal cancer who underwent curative resections at the I Instituto di Clinica Chirurgica della Università "La Sapienza" of Rome between 1960 and 1980, age was related to survival. All patients were followed for a minimum of ten years; 79 of them were aged over 65 years and 290 under at the time of the operation. The survival was correlated to the age and to other prognostic parameters: post surgical stage (TNM UICC classification) degree of differentiation of the tumour (NG--Black classification), degree of lymphocytic infiltration of neoplasm (LI Black classification) as expression of immunological immune-response of the host. Patients less than 65 years old had a better survival than patients greater than = 65 years old (median survival 72 months and 44 months respectively) (p = 0.006). These differences where true in subgroups with stage 2 of disease (p TNM UICC) and a favourable immunological reactivity (LI greater than = 2). These results suggest a possible independent role of age in defining the outcome of patients with colorectal cancer.

[Tracheobronchial carcinoids: current therapeutic trends]. / Carcinoidi tracheo-bronchiali: attuali orientamenti terapeutici.

Tracheobronchial carcinoids are relatively uncommon neoplasms potentially curable with surgery. However, the extent of excision which results in the best long term local and distant tumour control is still controversial. A series of 522 patients who underwent surgical treatment for tracheobronchial carcinoids reported by the literature which included 52 cases of tracheobronchial neuroendocrine tumours observed between 1960 and december 1983 at the Institute of I Clinica Chirurgica of Università "La Sapienza" Rome was reviewed. Local recurrence rate range between 1% and 1.8% after major surgery and between 11.8% and 16.7%, after bronchial wall resection and endoscopic treatment respectively. Local recurrences were detected after a mean period of 110.2 month (median = 9 years). 15 years survival rate was above 70%. Long term prognosis was related to the degree of malignancy (typical or atypical forms) and locoregional (N) and distant metastases (M). Factors related to the possibility to obtain free margins by the surgical procedure (pneumonectomy/lobectomy or sleeve resections vs simple bronchial wall resection or endoscopic resection), the degree of bronchial wall involvement (endobronchial, iceberg, peripheral), the biology of primary tumour (atypical vs typical) and the presence of regional and/or distant metastases are of prognostic importance for both local and distant tumour control. The Authors describe their strategy for managing this disease: endoscopic treatment or simple bronchial wall resection are available for endobronchial typical carcinoid tumours. Atypical carcinoid neoplasms or tumours involving bronchial wall or peripheral lung parenchyma need more extended resection and lymphadenectomy.

[Ambulatory surgical therapy in varices of the lower limbs. Notes on surgical anatomy and surgical technique based on personal case series]. / Terapia chirurgica ambulatoriale delle varici degli arti inferiori. Note di anatomia chirurgica e tecnica operatoria sulla base della casistica personale.

The Authors report their experience of 2,806 operations for varicose veins of the lower extremities in the last 13 years and demonstrate the importance of a few operation times, such as groin incision, ligature of the medial accessory saphena and technique of multiple phlebectomies at thigh and leg level.

[Radical surgery and loco-regional chemotherapy in the treatment of liver metastases of stomach and colorectal cancer]. / Chirurgia di exeresi e chemioterapia loco-regionale nel trattamento delle metastasi epatiche da cancro dello stomaco e del colon retto.

The results of surgical treatment of hepatic metastasis from stomach and colo-rectal cancer in a series of 28 patients have been assessed. 21 cases were subjected to hepatic resection (stomach cancer: 7 cases; colorectal: 14 cases) and 7 underwent locoregional chemotherapy through the gastroduodenal artery with fully implantable catheters (stomach ca.: 1 case; colorectal ca.: 6 cases). Of patients who underwent hepatic resection, 3 died postoperatively and 4 are still alive 5 years after the operation. Of the 7 patients treated with locoregional chemotherapy, 4 can be evaluated: 2 responded to treatment, 1 stabilised and 1 progressed. Clinically noteworthy toxicity was observed in one patient only.

Characteristic cholescintigraphic images in space-occupying lesions.

Patients with space-occupying lesions (SOL) were studied using cholescintigraphy and varying results found. In 24 cases of SOL of 40 patients studied, we observed: (1) the presence of focal defects; (2) displacement of the intrahepatic biliary tree; (3) blocking of the passage (stop) of radioactivity to the intrahepatic biliary tree. The first indication, the presence of focal defects, had a sensitivity of 0.81 and a specificity of 0.78. The displacement and radioactivity stop was less frequent, but more specific. This is due to the fact that cholescintigraphy permits the specific study of the biliary tree and its pathological alterations. In our patients, the diagnostic errors were due to extreme hepatic damage, which produced an unclear image of the liver parenchyma and the biliary tree. This is observed in complete obstruction and in some cases of cirrhosis. When signs of displacement and stop were closely associated with focal defects, the diagnosis of SOL was highly specific.