[Gastroduodenal artery pseudoaneurysm ruptured at the pancreatic head]. / Pseudoaneurisma dell'arteria gastroduodenale rotto nella testa del pancreas.

The presence of splancnic aneurysms associated with pancreatitis represents an uncommon evidence (10%) but extremely formidable for the high mortality related to the elevate risk of rupture (50%). A case of a broken gastroduodenal artery pseudoaneurysm plugged in the pancreatic head in a patient with chronic pancreatitis surgically treated is reported. The Authors believe that in presence or in suspicious of peripancreatic pseudoaneurysm bleeding, showed by abdominal echography or CT scan, is mandatory the execution of splancnic and peripancreatic vessels angiography to determine the correct localization of the aneurysm, essential to determining the best surgical treatment. Gastroduodenal artery before the origin from the right epatic artery has been tied in presence of an anatomic variant of origin and division of the hepatic arteries, previously showed with the angiographic examination. The exclusion and the complete thrombosis of the false aneurysm was demonstrated with the intraoperatory Doppler control and confirmed by CT scan before the dismission. This surgical strategy avoid a pancreatic resection, potentially burdened from an higher risk of mortality and morbidity as than the artery exclusion.

[Vascular trauma of the upper extremities]. / I traumi vascolari degli arti superiori.

The aim of this study was to evaluate short- and long-term results of the treatment of upper extremities vascular trauma considering aetiology of the lesions, percentage of limb salvage and residual functional disability. The Authors retrospectively evaluated 17 patients accounting for 21 vascular lesions of the upper extremities (16 arterial and 5 venous injuries). Age, sex, modality of trauma, site of the vascular lesions and of the associated injuries, diagnostic procedures at the admission, ischemic time, arterial and venous repair performed were analyzed. The over all peri-operative mortality was 5.8%. Of the 16 arterial injuries long-term reconstruction viability was obtained in 15 patients (93.7%). In all cases limb salvage was obtained. In 3 patients invalidating functional defects due to associated injuries of the major brachial plexus were observed. The Authors believe that associated nervous lesions are the main factor determining invalidating residual disability. In this series ischemic time, technique of vascular repair performed, associated skeletal injuries didn't influence the functional outcome of the reconstruction.

[Vascular trauma of the lower limbs]. / I traumi vascolari degli arti inferiori.

BACKGROUND: This study was conducted to evaluate the results of treatment of vascular trauma of the lower extremities and those factors associated with limb loss. DESIGN: a retrospective evaluation of a series with lower extremities vascular trauma. SETTING: University Hospital. METHODS: Thirty-one patients accounting for 45 vascular lesions of the lower extremities (27 arterial and 18 venous injuries), over a 15 years period ending December 1998. Age, sex, modality of the trauma, site of the lesion and associated skeletal injuries, diagnostic procedures, ischemic time, arterial and venous repair performed were analyzed. RESULTS: Perioperative mortality was 7.4%. For arterial injuries, limb salvage was obtained in 22 patients (81.5%). Five amputations (18.5%), 1 primary and 4 secondary have been performed. Amputation rate was 26.7% for popliteal lesions versus 8.3% for other locations, 40% when a skeletal lesion was associated versus 5.9% for those without such injuries, 37.5% for reverse saphenous vein interpositions versus 5.6% for arterial repair without interposition. CONCLUSIONS: In this study, the factors influencing limb loss in vascular trauma of the lower extremities are popliteal location, the association with skeletal injuries, the need of saphenous vein interposition for arterial repair.

[Hilar localization of splenic cyst does not always exclude the possibility of resective treatment]. / La localizzazione ilare di una cisti splenica non sempre esclude la possibilità del trattamento resettivo.

Non parasitic cysts of the spleen require surgical treatment because of their progressive growth and in order to prevent the potential severe complications associated with such cysts. Since it is now well known that total splenectomy, especially in young patients, has potential for short- and long-term complications, much emphasis has been placed on splenic salvage, suggesting partial splenectomy as procedure of choice for splenic cysts. However various Authors suggest that many but not all splenic cysts can be treated with partial splenectomy. In particular cystic mass arising from the anterior aspect of the hilum near to vascular peduncle contraindicate partial resection requiring splenectomy. In a case observed TC scan demonstrated a very large epidermoid cyst penetrating hilar parenchyma just above splenic vessels insertion. Preoperative imaging suggested splenectomy as the only possible procedure to remove the cyst. At operation the exposure of the splenic artery extended proximally along the pancreatic tail showed an arterial branch running with satellite vein in the splenopancreatic ligament for inferior segment of the spleen. As we found this branch it was possible to resect cyst preserving a large inferior parenchymal segment normally perfused and functioning at postoperative scintigraphic controls. In conclusion not all hilar cysts must be considered an absolute indication to splenectomy. An accurate and extensive exposure of splenic artery and vein can demonstrate vascular anatomical variations permitting resection also for large cysts located near the splenic hilum.

[Splenectomy in immune thrombocytopenia and other hematological diseases]. / La splenectomia nelle trombocitopenie immuni ed in altre malattie ematologiche.

The Authors report a retrospective study of 74 splenectomies performed for hematologic diseases. The role of splenectomy has changed over recent years with increased indications for immune thrombocytopenic purpura (ITP). The aim of this study was to assess indications to surgery in relation to clinical presentation with typical hemorrhagic features or severe thrombocytopenia only; interval between onset of symptoms and splenectomy; failure of medical management and complications from steroid administration; scintigraphic studies predictive of response to splenectomy and preoperative treatment in patients with severe thrombocytopenia were also studied. The Authors reported response rates to splenectomy of 84% without mortality and only 11% of postoperative complications. These results encouraged to surgery for treatment of those patients with severe thrombocytopenia, who fail to obtain remission or develop serious complications after medical therapy. The splenectomy cured severe thrombocytopenia also in some patients with acquired immunodeficiency (HIV+). Moreover the Authors discuss the indications in patients with chronic lymphatic leukaemia and lymphoma diseases. In selected patients the splenectomy has the potential to relieve symptoms due to splenomegaly, correct cytopenias, specify hystological diagnosis and modify the disease course of malignant lymphomas. In fact splenomegaly sometimes complicated the course of malignant lymphomas because of hematologic abnormalities that are inconsistent with active chemotherapy.

Life-threatening digestive haemorrhage from duodenal recurrence of gastric cancer.

Invasion of the duodenum by gastric carcinoma is not uncommon. The duodenal invasion by transpiloric infiltration through the submucosal layer or lymphatic spread frequently being microscopic and in minimal number of cases involving the mucosa, is generally asymptomatic and detected only in postmortem examinations. We report a case of life-threatening gastrointestinal bleeding from cancer recurrence at duodenal stump after subtotal gastrectomy for gastric carcinoma. In such cases it can be very hard to find the haemorrhagic source because of the difficulties encountered in endoscopic and radiological evaluation of the duodenal stump.