Anatomical variations of the median nerve and of the vascular-nervous structures at the wrist.

Three cases of anatomical variation of the median nerve at the wrist found during our surgical activity led us to take the opportunity to expose anatomical variations by reviewing already published reviews. Consequently, on the basis of anatomical studies, clinical reports and imaging, as a result of careful examination of the published literature, it has been observed that the interventions in such anatomical area must take into account these variations. In particular, the most performed procedure is the lysis of the transverse carpal ligament (TCL), which is not free from complications. In our opinion it is therefore necessary, in order to avoid the complications of the nervous, vascular and tendinous sections, to use some specific technical procedures.

Age-related ultrastructural and monoamine oxidase changes in the rat optic nerve.

The aim of this paper is to study the morphology and the distribution of the monoamine oxidase enzymatic system in the optic nerve of 4 month-old Wistar (young) and 28 month-old Wistar (old) rats. The optic nerve was harvested from 20 young and old rats. The segment of optic nerve was divided longitudinally into two pieces, each 0.1 mm in length. The first piece was used for transmission electron microscopy. The second piece was stained with histochemical reaction for monoamine oxidase. The agerelated changes in the optic nerve of rats include micro-anatomical details, ultrastructure and monoamine oxidase histochemical staining. A strong decrease of the thin nerve fibers and a swelling of the thick ones can be observed in optic nerve fibers of old rats. Increased monoamine oxidase histochemical staining of the optic nerve of aged rats is well demonstrated. The increase of meningeal shealth and the decrease of thin nerve fibers of the optic nerve in old rats are well documented. Morphological, ultrastructural and histochemical changes observed in optic nerve fibers of the old rats show a close relation with aging.

[Endovascular laser treatment of lower limbs varicose veins: results of a three-years experience]. / Trattamento laser endovasale delle varici degli arti inferiori Risultati di una esperienza triennale (2001-2004).

The aim of this work is to report our three-years experience in the endovascular laser treatment of lower limbs varicose veins. After the evaluation of results after a middle-term follow-up, Authors discuss about an enlargement of indications to this method, and suggest some original technical details.

[Office surgery. Personal clinical experience]. / Office surgery. Esperienza clinica personale.

BACKGROUND: A methodology which had a substantial development in the last decade: Office Surgery, is described. This is a branch of Day-Surgery, adapted to provate medical practice with the same characteristics of a Hospital Operating Unit with daily recovery. The aim of the study is to examine the costs-benefit of this methodology compared to international results. METHODS: The OS structure is described as well as the specific requirements needed for its hygienic-sanitary certification, giving particular attention to its structural characteristics, according to the relevant legislation and optimal functionality. The personal clinical experience is based on 1771 cases submitted to surgery in such a structure. The aim of the study is to compare the results with those reported by the international literature. The type of surgery performed was mainly esthetic-reconstructive, laser surgery, minor urology and phlebologic surgery. RESULTS: The results were promising, with a careful follow-up showing 65 cases of complications (3.6% of the treated cases), thanks also to an accurate criterium of patients' selection including various clinical evaluation parameters and a careful discharge followed by the physician. CONCLUSIONS: On the basis of the results, obtained it is possible to confirm that this discipline is interesting as far as patient's grading, cost control morbility and mortality index are concerned, even if it is limited to short-term surgery with local anesthesia or sedation, and low septic and hemorrhagic risk. However, a number of doubts still exists concerning the legislation of this methodology and a right clinical and insurance acknowledgment for the patient and the physician.

[Office surgery: legislative, medicolegal and economic aspects]. / Office surgery: aspetti legislativi, medicolegali ed economici.

An analysis of Italian legislation shows that while there are national guide lines (not organic on the subject of day surgery), a more fragmentary situation exists at a regional level (the authors work in Lazio and give details on the specific regional legislation). These differences may engenger confusion or, worse, discretion in their application. It has also been seen that at an international level there are no organic laws, except in rare cases. At both a national and international level, experience has been acquired in this direction, always with positive RESULTS. The authors underline the pre, intra and postoperative role of nurses and the economic aspects are analysed, regarding both the resources needed to create structures and provide maintenance costs, as well as those to cover the cost of individual procedures. In conclusion, the authors affirm that the matter is not clear in statutory terms. In some disciplines and for some types of surgery in suitable areas, day surgery is reliable; it is also economically and psychologically beneficial. The authors hope that the legislation will be harmonised and specific evaluation structures will be set up to monitor the quality of structures and also to authorize them.

[Legislative, medicolegal and economic aspects of day hospitals]. / Aspetti legislativo, medicolegale ed economico del Day Hospital.

After a short historical review and having dwelled on the nomenclature and legislative framework, the authors describe the medicolegal implications of the day hospital. They describe international experience within the various disciplines, with reference to economic aspects in terms of costs and the increased efficacy of these structures, the quality of service and government policies, in particular in industrialised countries. The authors conclude that day hospitals present considerable advantages both in economic terms and for patients. However, the organisation of the system needs to be improved and, where possible, procedures standardised. Bearing in mind the importance of costs to modern medicine, it is impossible not to take economic aspects into account, while also improving the quality of relations between doctors, patients and the health system.

[Breast reconstruction: a possible balance between oncological therapy, reconstructive methods and the patients]. / La ricostruzione mammaria: un equilibrio possibile fra terapia oncologica, metodiche ricostruttive e paziente.

BACKGROUND: Based on their experience of oncological surgery and wishing to respond to the patients' reconstructive requirements, the authors analyse the damage caused by medical therapy (chemo-hormone therapy and radiotherapy) in terms of reconstructive techniques; they aim to establish whether the tissues used in reconstruction interfere with the diagnosis and treatment of recidivations and to identify the best reconstructive strategy in relation to "timing"; lastly, they examine the possibility of realising a cosmetically improved breast. METHODS: A 2-year retrospective study was made during which 3 patients underwent immediate reconstruction using expanders (including 2 with bilateral reconstruction) and 1 patient underwent postradiotherapy differed reconstruction; all patients were followed up for a maximum of 4 years. The following surgical methods were used to improve cosmetic results: 1) conservation of the pectoralis minor which was turned sideways to create the muscular pocket; 2) costal and sternal disinsertion of the pectoralis major; 3) the implant was covered with the muscular pocket in the upper quadrants and with subcutaneous tissue in the lower quadrants; 4) realisation of a mammary groove; 5) immediate mastopexy of the surviving breast. All patients underwent intraoperative and postoperative polychemotherapy. RESULTS: At present (January 1997) none of the patients treated shows signs of locoregional recidivation or general metastases. Complications were observed in the form of subacute infection of the prosthetic flap exposing the expander and infection of the suture material used to reshape the breast in contralateral mastopexy in the patient undergoing reconstruction after radiotherapy. When evaluating the cosmetic results, scar diastasis varied in all patients. Smoothing of the scars, slight implant distortion observed echographically, grade 2 contraction of the periprosthetic capsule were assessed using Baker's scale and all patients were found to be grade I or II. In the light of these results and their personal experience, the authors then analyse, with reference to the literature, the effect of radiotherapy on reconstruction using tissular expansion, the effect of chemotherapy on reconstruction using expansion or autologous implants; the combined effect of radio and chemotherapy on reconstruction using autologous implants or tissues. Timing and the difficulty of diagnosis locoregional recidivation are also discussed. CONCLUSIONS: The authors fully agree with the need to carry out immediate reconstruction, when indicated (above all in bilateral reconstruction) using implants since it is simpler. Chemotherapy does not interfere with the expansion process whereas, if it is deemed necessary to use radiotherapy, it is certainly better to undertake reconstruction using autologous tissues. For special reconstruction methods (replacement of the expander, differed reconstruction with expander), greater use should be made of the day hospital, or better still office surgery.

[Synergism between cyclosporin and gangliosides in anti-rejection therapy. Experimental in vivo model]. / Sinergismo tra ciclosporina e gangliosidi nella terapia antirigetto. Modello sperimentale in vivo.

In vivo gangliosides (GS) bring about inhibitory effects on the immune response which is attributable to a weakening of the interaction between interleukin-2 (IL-2) and its receptor. In a previous paper we showed that the GS are capable of bringing about in vitro the immunosuppressive power of cyclosporin A CyA2 in this paper we have tried to associate gangliosides (GS) and low dose of CyA in the grafting of rat allogen cutis in order to have in this way in vivo a confirmation of the results previously obtained in vitro. Cutaneous strips taken from Lewis rats were grafted into Sprague Dawley rats and treated for 21 days with intraperitoneal administration of GS, of Cya, and a mixture of the two. The rats were not treated and the rats treated with GS and with CyA separately rejected the graft of the cutis. On the other hand, the use of an association of Gs and CyA brought about a successful graft in 8 rats out of 10. Splenic cells extracted 21 days after the graft from rats treated with GS and with CyA separately were stimulated in vitro with Packweed mitogen (PWM); on the contrary the cells extracted from rats treated with a combination of the two drugs did not react to the stimulation with PWM. Our results show that the GS brings about in vivo the immunosuppressive effects of low doses of CyA.

Correction of pectus excavatum with a self-retaining seagull wing prosthesis. Long-term follow-up.

Between June 1958 and December 1991, 315 patients (217 male and 98 female, mean age = 17.8 +/- 5.5 years) affected by pectus excavatum (PE) were surgically treated. Most of the patients required operation for aesthetic reasons only (299 patients; 95 percent). The grade of PE (Chin classification) was I in 72 patients, II in 152, and III in the remaining 91. The surgical technique consisted of a double transversal sternotomy at the level of the lowest and highest part of the depression associated with a longitudinal sternotomy. A wedge resection of the ribs was then performed and the sternum was fixed using a stainless steel strut molded into a seagull wing prosthesis. The strut was removed 12 months postoperatively. There were no operative mortalities. Four patients had sternal wound infection that was successfully treated. The mean follow-up was 15.8 years per patient and was 60 percent complete. From the aesthetic point of view, the postoperative results were excellent in 246 patients (78 percent), good in 57 (18 percent), and poor in 12 (4 percent). All subjective symptoms, when present, disappeared after surgery. The seagull wing prosthesis appears to be safe, easy to implant and to remove, and comfortable for the patient. This technique has shown good long-term results independently of type of deformity and patient age.

[Office surgery: organization, legislative, and medico-legal problems. Personal experience]. / Office surgery: problematiche organizzative, legislative e medico-legali. Esperienza personale.

INTRODUCTION: The authors approach the subject of office surgery by underlining the advantages of this procedure. In particular, they focus attention on the anesthesiological and legislative problems. Depending on the setting used for surgery and the duration of hospitalisation, ambulatorial surgery can be divided into: day-hospital, office surgery, one-day surgery, short-stay surgery, same-day surgery, MATERIALS AND METHODS: The authors report their own experience relating to 103 cases with relative complications. A total of 103 operations of medium-to- major ambulatorial surgery were performed (100 females and 3 males, mean age 36.8). One week prior to surgery all patients attended a medical out-patient examination in order to fill in medical records and be prescribed routine hematochemical tests, chest X-ray and ECG. The preoperative anesthesiological evaluation was made at the time of surgery. All patients received antibiotic prophylactic treatment. RESULTS: Postoperative complications were reported above all following neuroleptoanalgesia and amounted to a total of 5 cases: nausea (4 cases) associated with vomit (1 case), and postural hypotension (1 case). No infective complications were observed. DISCUSSION AND CONCLUSIONS: The authors emphasise the importance of a careful preoperative selection of patients; an out-patient structure equipped with the appropriate instrument and machinery for surgery and the constant presence of anesthetists to ensure correct anesthesia (local, neuroleptoanalgesic, peridural general), reanimation and postoperative care. The aims of ambulatorial surgery are, in broad terms, the safety of procedures, convenience for the patient and organisational and economic savings for health structures. Ambulatorial surgery has an extremely high acceptance rate by patients. Lastly, the authors also report the juridical and bureaucratic problems faced by ambulatorial surgery and look forward to its wider diffusion. In the future office surgery might represent an important contribution to surgical therapeutic strategies, allowing, if well organised, an excellent compromise between safety, convenience and reduced costs for the patient.

[Traumatic diaphragmatic hernia]. / Ernie diaframmatiche traumatiche.

The authors analyse a series of 10 patients urgently treated for traumatic disruption of the diaphragm. Main aetiopathogenetic, pathophysiological, diagnostic and surgical aspects of the condition are discussed.