Treatment for persistent chronic neuralgia after inguinal hernioplasty.

Following an inguinal hernia repair with open or laparoscopic technique, 1-15% of patients show persistent neuralgia, a severe, potentially debilitating, complication. Several therapeutic procedures have been proposed, but consensus regarding choice of treatment has not yet been achieved. We performed a prospective study on 32 such cases. Patients underwent anaesthetic infiltration to identify, when possible, the involved nerve, and we then carried out a step-by-step therapeutic protocol. In the initial phase, patients were treated with oral analgesic and afterwards with repeated infiltrations of anaesthetic and cortisone. Surgery was reserved for patients not responding to the infiltrations, though with no good success. The authors believe that noninvasive methods are to be preferred, whereas neurectomy interventions should be reserved for selected cases.

Spigelian hernia: a case report and review of the literature.

Spigelian hernia is a rare abdominal hernia that occurs through Spigelian aponeurosis. The Authors present a case of Spigelian hernia associated with narrowing of sigmoid colon and diverticular pathology. They also described historical background, surgical anatomy and etiopathogenesis of this hernia. By a remarkable revision of literature, they sum up epidemiology and clinical features of Spigelian hernia. Furthermore, they discuss diagnostic and therapeutic principles.

[Polypoid lesions of the gallbladder: diagnostic and therapeutic problems]. / Le lesioni polipoidi della colecisti: problemi diagnostici e terapeutici.

The nature of polypoid lesions of the gallbladder is difficult to define. Surgical indication still remains controversial but in some cases mandatory. In this clinical study data were retrospectively evaluated in 25 patients with polypoid lesions who underwent laparoscopic surgery to elucidate the ultrasonic findings and to establish criteria for the best treatment.

Large incisional hernia in the elderly: which kind of treatment?

Incisional hernia is one of the commonest long-term complications of open abdominal surgery. Especially in old patients (over 70 years), the incisional hernias represent an invalidating pathology whose treatment, for the high incidence of associated respiratory and cardiovascular disease, offers difficulties related to the preoperative and postoperative management as well as to the surgical treatment. This paper reports the Author's experience about the surgical treatment of large incisional hernia (> 10 cm) with open prosthetic mesh repair in geriatric patients.

[Necrotizing fasciitis: our experience]. / Le fasciti necrotizzanti: esperienza personale.

Necrotizing fasciitis is a rare and dramatic soft-tissue; infection starting from the subcutaneous tissue, involving the fascia and the underlying muscle and causes necrosis and, suddenly, gangrene. Most frequently the necrotizing fasciitis is localized in anorectal or genitourinary region and in traumatized muscles. Its mortality rate is 20%. Predisposing factors for these infections have included advanced age, obesity, hypertension, atherosclerosis, malnutrition, renal failure, immunosuppression and, primarily, diabetes mellitus. The infection is caused by a lot of gram +, gram -, and anaerobic bacteria that act synergistically. The early diagnosis, a correct chemotherapy, an aggressive surgical treatment of the necrotic area and hyperbaric oxygen treatment allow the patient's recovery, dramatically reducing the functional consequences. The Authors analyze retrospectively five cases of necrotizing fasciitis observed in the last two years (August 2001-August 2003) and stress clinical findings and surgical treatment.

[Intraoperative injuries of the superior laryngeal nerve in thyroid surgery]. / Lesioni intraoperatorie del nervo laringeo superiore in chirurgia tiroidea.

The intraoperative injury of the external branch of the Superior Laryngeal Nerve (SLN) is a disregarded complication of thyroid surgery that becomes a serious one for particular professional groups. The Authors retrospectively evaluate 124 cases of total thyroidectomies performed by the same surgeon from 1999 to 2002. Clinically evaluated SLN lesions (hypomobility of the vocal cord) was registered in six patients (4.8%). Routine identification of SLN and meticulous dissection of the superior thyroid vessels must be the technical benchmark to avoid nerve injury, even if bulky disease, anatomic variations and previous surgery may increase the chance of nerve damaging.

Serum leptin levels and uterine Doppler flow velocimetry at 20 weeks' gestation as markers for the development of pre-eclampsia.

Altered Doppler flow velocimetry of the uterine arteries during the second trimester is correlated with the risk of developing pre-eclampsia. Serum levels of leptin, a protein regulating body weight and secreted by the placenta, are higher in women with severe pre-eclampsia. We investigated whether alterations of uterine arteries' Doppler flow velocimetry during the early second-trimester scan were accompanied by changes in leptin levels, and whether these changes might be an early risk factor for pre-eclampsia. We retrospectively selected 50 women with altered uterine artery velocimetry at the second-trimester scan who subsequently developed pre-eclampsia (group A) and 100 women who did not develop pre-eclampsia, divided into two groups: 50 women with normal velocimetry at the second-trimester scan (group B) and 50 women with altered velocimetry at the second-trimester scan (group C). Serum leptin levels during the second and third trimesters and bilateral uterine artery resistance index during the second trimester were evaluated. No differences were observed in serum leptin levels in the second trimester among the three groups. During the third trimester, women in group A showed significantly higher serum leptin levels in comparison with women in groups B and C (p < 0.01). Serum leptin levels do not seem to be a useful early marker for the development of pre-eclampsia in the presence of altered uterine blood flow, and may be a late compensatory mechanism or reflect a generalized response of the trophoblast to hypoxic stimuli.

Treatment of gunshot wounds to the colon: experience in a rural hospital during the civil war in Somalia.

BACKGROUND: In the last few decades there has been a clear tendency in civilian practice towards primary repair of gunshot wounds to the colon, resulting in a substantial decrease in the number of colostomies performed for this type of injury. METHODS: The series described here comprises 24 patients with gunshot wounds to the colon treated at the hospital of Jowar in the Middle Shebelle region of Somalia between 1999 and 2001. All injuries were caused by war arms firing high-velocity projectiles. RESULTS: In 18 patients surgery consisted of resection and immediate anastomosis, while in the remaining six patients colostomies were performed including five loop colostomies and one terminal colostomy. The sepsis-related mortality was 25% (6/24). CONCLUSION: Our experience had a peculiar setting, namely that of a civil war in a developing country. In this kind of "difficult" situation there probably exists no ideal procedure and the decisions taken at the operating table are influenced by various factors that are often related to subjective assessment.

[Reoperations in lung surgery]. / I reinterventi in chirurgia polmonare.

A second thoracotomy in patients who have undergone previous chest surgery can be performed soon or immediately after the first operation and is usually aimed at resolving severe or even life-threatening postoperative complications. Late reoperations, on the other hand, are either performed to resolve complications of previous surgery or to remove second primary lung tumors (SPLCs) or metastases. The most exacting reoperation in this context is completion pneumonectomy, which is particularly indicated in the case of failure of the residual lobe to re-expand after primary surgery; it is also used for--rarely occurring--fistulas of the lobar bronchi and for new ipsilateral primary lung tumors. This type of surgery is technically complicated and has been associated, in our experience and that of others, with a certain mortality. Technically less difficult is a second ipsilateral thoracotomy for exploratory purposes or minor parenchymal resection, and the same is true of contralateral lobar or sublobar resections. Lastly, Abruzzini's operation, for fistulas of the primary bronchus, is relatively complicated but often leads to good results; we have performed 15 such operations with only one death occurring due to acute myocardial infarction.

[False aneurysm on dacron prosthesis, 20 years after aortofemoral bypass]. / Faux anévrysme sur prothèse en dacron, vingt ans après pontage aortofémoral.

A 85-year-old male developed a false, non septic, non anastomotic aneurysm, 20 years after right aorto-femoral Dacron grafting for claudication. On account of the proximity to the femoral anastomosis, and the association with a profunda femoris stenosis, a conventional surgical repair was preferred to an endovascular treatment. The patient underwent a successful aneurysm resection followed by PTFE interposition between the primary graft and the profunda femoris artery, with uneventful recovery.

[Changes of leptin levels in menopause]. / Modificazioni dei livelli sierici di leptina in menopausa.

One of the main advances in the field of metabolic control of body weight and obesity treatment was the identification of the OB protein or leptin, that plays an important role in controlling body weight, signalling to the CNS the amount of body fat. Indeed, leptin levels are positively correlated to indices of body fat, namely total fat mass, percent body fat and body mass index (BMI). This protein may be also the signal that indicates the nutritional status to the reproductive axis. Whether this signal is exerted directly on the gonads or through the neuroendocrine axis is still to be determined. A sexual dimorphism between male and female in serum leptin levels has been observed, with the latter showing higher serum leptin levels. This evidence has led to the hypothesis that estrogens might have a stimulatory role in leptin secretion. To evaluate this hypothesis, several authors have determined serum leptin levels in postmenopausal women that have estrogen levels comparable to those present in men. The results of these studies are contradictory and the aim of this article has been the revision of data present in the literature regarding serum leptin levels in menopause and to correlate them to body composition changes taking place during menopause.

Serum leptin levels in postmenopausal women: effects of transdermal hormone replacement therapy.

OBJECTIVE: To evaluate serum leptin levels in postmenopausal women who are receiving hormone replacement therapy (HRT) and postmenopausal women who are not receiving HRT with similar body mass index (BMI) to determine whether estrogens exert effects on leptin secretion. DESIGN: Cross-sectional, prospective study comparing serum leptin levels in premenopausal women, postmenopausal women who were not receiving HRT (group A), and postmenopausal women who were receiving HRT (group B). RESULTS: Serum leptin levels were significantly higher in group A in comparison to group B and control women (15.82 +/- 6.6 ng/ml, 8.14 +/- 4.17 ng/ml, and 10.12 +/- 5.48 ng/ml, respectively; p < 0.05). Total fat mass (FM) was found to be significantly higher in untreated postmenopausal women in comparison to the other two groups (22.66 +/- 2.79 kg vs. 19.14 +/- 3.39 kg vs. 18.98 +/- 3.82 kg; p < 0.05). No significant difference was observed in weight, height, BMI, blood pressure, or glucose levels among the three groups. A linear correlation between BMI and serum leptin levels as well as between total FM and serum leptin levels was observed in all groups. No correlation was found between serum leptin levels and months from menopause and months of HRT. CONCLUSIONS: Our results show that serum leptin is increased in untreated postmenopausal women, possibly as a consequence of the increase in FM, and that HRT reduces serum leptin levels to premenopausal values. These data need further investigation by a broader longitudinal study.

[Angiodysplasia of the large intestine: unusual rectal localization]. / L'angiodisplasia del grosso intestino: una rara localizzazione rettale.

The authors report a case of lower gastrointestinal hemorrhage in a 69-year-old male, in which the sequence colonoscopy-angiography identified the source of bleeding as a rare Angiodysplasia (AD) of the rectum. Such vascular abnormalities are one of the most common causes of major lower gastrointestinal tract bleeding in the elderly and usually occurs predominantly in the right side of the colon. The clinical presentation of Angiodysplasia is varied and accurate diagnosis usually requires a combination of diagnostic techniques such as colonoscopy and angiography. The optimal management is uncertain and should be individualized for each patient depending on severity and rate of rebleeding. A conservative medical approach is indicated for many patients, while endoscopic treatment does not seem modify the risk of recurrent bleeding. In case of massive hemorrhage or recurrent bleeding surgery still represents the definitive treatment for Angiodysplasia. However the risk of rebleeding following surgery is a considerable problem and varies in literature from 5% to 30%.

Evaluation of goiter endemia by ultrasound in schoolchildren in Val Sarmento (Italy).

Ultrasonography is an excellent and objective method for assessing thyroid volume, especially in children where clinical evaluation is inaccurate. The aim of this study was to evaluate the presence of goiter by thyroid ultrasound and palpation in 244 schoolchildren, 6 to 14 years old, living in some rural villages of Val Sarmento, a mountain area of Basilicata, Italy. In 1996 we revealed the presence of endemic goiter in 25% of the schoolchildren evaluated by palpation, according to World Health Organization (WHO) criteria, and in 15.9% of the schoolchildren evaluated by ultrasonography (7.5 MHz linear probe). The median urinary iodine excretion, taken from an extemporaneous sample of the first urines in the morning, was 62.2 microg/l. This study includes Val Sarmento, an area with mild-moderate grade (Grade I) of iodine deficiency, suggesting the need for iodine prophylaxis. Furthermore, it proves that the measurement of thyroid volume by ultrasonography is an essential instrumental method for a correct epidemiological study of endemic goiter, particularly in areas where there is mild iodine deficiency.

Metastasis to the breast of a renal carcinoma: a clinical case.

The breast is an unusual site for metastatic disease, and generally the lesion appears same times after the diagnosis of the primary malignancy. Authors report a case of a breast metastasis from a hypernephroma, six years after nefrectomy.

Malignant tumours of the small intestine: a case of jejunal adenocarcinoma.

The Authors analyse the main problems concerning malignant tumours of the small intestine. They report a case of jejunal adenocarcinoma recently observed. They emphasise the importance of surgery, both diagnostic and therapeutic, even in advanced stages, for the treatment of this neoplasm.

[Urinary iodine excretion in the Campania region]. / Escrezione urinaria di iodio nella regione Campania.

Urinary iodine excretion (UIE) was measured on urine samples collected in the morning from 3480 subjects (both adults and children) living in an extended territory of Campania region including urban and extraurban areas, in the period 1993-96. UIE was measured by an autoanalyzer (Bran + Luebbe) and expressed as microgram/l. Means UIE were significantly lower in the patients living in the villages of Avellino (65 +/- 48), Benevento (44 +/- 44) and Caserta (78 +/- 53) respect to the control subjects from the area of Naples (102 +/- 66). These data demonstrate that in many areas of our region a mild-moderate iodine deficiency is still present as indicated by a low urinary iodine excretion and therefore an effective program of iodoprophylaxis is fundamental in this region.

[Partial anterior hypopituitarism caused by toxoplasmosis congenita. Description of a clinical case]. / Ipopituitarismo anteriore parziale da toxoplasmosi congenita. Descrizione di un caso clinico.

A case of incomplete anterior hypopituitarism due to congenital toxoplasmosis is reported. The rare pituitary involvement in congenital toxoplasmosis and the uncommon remark of associated endocrine symptomatology support this description.

[Acromegaly. Physiopathological aspects and description of a clinical case]. / L'acromegalia. Aspetti fisiopatologici e descrizione di un caso clinico.

Recent physiopathological studies suggest that hypersecretion of GH in acromegaly is not necessarily the result of a primary alteration to the GH-secreting pituitary cells. Some suggest that an alteration in the hypothalamic control of the hormone secretion may also be involved. After a general introduction, a clinical case of acromegaly is reported.