[Intestinal perforation by ingested foreign bodies in the digestive tract: an insidious pathology always of interest. Our experience]

The authors want to present five cases (from May 1999 to May 2009) of acute abdomen from perforation of the foreign body introduced with food. They highlight how the accidental ingestion is very common but the perforation is rare. The preoperative diagnosis, in these cases, is always very difficult and the radiological examinations are not always able to resolve the diagnostic doubt with other acute intestinal diseases that are responsible of perforation. Then, the surgery procedure is, necessarily, the only possible diagnostic and therapeutic means. The mortality and the morbidity remain still high first of all for the delay in the diagnosis and the advanced age of patients.

Massive bleeding from a Dieulafoy's lesion of the duodenum successfully treated with "adjuvant" transarterial embolization and endoscopic laser coagulation

Dieulafoy's lesions, very rare in the duodenum, are considered uncommon causes of gastrointestinal bleeding and occur from pinpoint non-ulcerated arterial lesions. We report a case of Dieulafoy's lesion of the duodenum, in which a first diagnostic approach by using endoscopy and angiography was not successful; then, due to a high operative risk, we performed an "adjuvant" embolization of the gastroduodenal artery with the aim of reduce the flow through the artery, allowing the endoscopic localization of the site of bleeding and subsequent effective treatment. To our knowledge, this is the first case reported in the literature, in which, without aetiological diagnosis, an "adjuvant" embolization of the gastroduodenal artery was performed with the aim of reduce the blood flow in the duodenal wall, permitting an easier endoscopic diagnosis of Dieulafoy's duodenal lesion and successful treatment with laser coagulation.

Quintuple primitive malignant neoplasms. A case report

The authors describe the case of a patient who developed during 31 months, five malignant tumours, three synchronous and two metachronous. The primitive origin and the long interval of time between the occurrence of each tumour, allow to set them in the group of Multiple Primitive Malignant Neoplasm. The authors, reviewing the classifications and the pathogenesis of these tumours, underline the importance of the follow-up in oncology patients and emphasize the role of nosographic setting in order to plan the most suitable therapeutic approach.

Evaluation of quality of life of patients submitted to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinosis of gastrointestinal and ovarian origin and identification of factors influencing outcome

BACKGROUND

The prognosis of patients with peritoneal tumors has been improved by the association of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy, though still with an unclear impact on patients' quality of life. The purpose of our study was to evaluate the quality of life in 18 cases submitted to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy and particularly to identify the factors that influence it.

PATIENTS AND METHODS

Quality of life was evaluated using the functional assessment of cancer therapy; the results were correlated with 25 parameters.

RESULTS

The study demonstrated that the patients'quality of life was not modified by treatment with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy; the dose of mitomycin C, the site of the primary tumor, gastrointestinal, renal and neurological toxicity, adjuvant chemotherapy, the patients' age and leukopenia were factors that influenced the quality of life.

CONCLUSION

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy allows conservation of preoperative quality of life.

[Multiple primitive lipoma of the transverse mesocolon: a rare disease]

The Authors describe a case of multiple lipomatosis of the mesocolon and, after a careful review of the literature, they examine particular findings and discuss diagnostic difficulties, anatomopathological features and treatment. Intraabdominal lipoma is very rare and presents difficulties in diagnosis, both for aspecific symptoms and for the unusual site which does not allow early identification. As it is a tumor which arises from primitive and totipotent mesenchymal cells, radical surgery is the only therapeutic option. The correct diagnosis depends on histological testing which can differentiate the lesion from other mesenchymal tumors.

Serum levels of interleukin 1beta, interleukin 8 and tumour necrosis factor alpha as markers of gastric cancer

Despite the efforts made, a serum marker reliable for the screening and follow-up of patients with gastric cancer has not yet been identified. The aim of this preliminary study was to test the role of pro-inflammatory cytokines interleukin 1beta, interleukin 8 and tumour necrosis factor alpha in patients with gastric cancer and in control groups. The statistical analysis of cytokines serum levels in the group with gastric cancer versus control groups has shown considerable differences (p < 0.001) in their mean rates. The results indicate that the cytokines interleukin 1beta, interleukin 8 and tumour necrosis factor alpha might perhaps act as diagnostic markers in patients with gastric cancer. Therefore, it is hypothesized that after more extended trials, their use in the screening and prognostic assessment of these patients could be a possibility.

[Endoscopic prosthetic treatment of the esophagojejunal leaks after total gastrectomy: clinical experience]

The Authors, on the basis of their experience on the use of self-expanding prostheses in abdominal surgery, report on the use of these prostheses in two patients who, having undergone a gastrectomy for cancer, developed a fistula of the esophago-jejunal anastomosis. Given recent data from literature, using a prosthesis for an anastomotic fistula may be a valid alternative to a second operation, which, apart from obvious difficulties, has a high mortality rate in patients in weakened general health conditions. In these cases, after the application of a stent, excellent results can be obtained and, after some days, the patients can begin a semi-liquid diet, then proceeding to a semi-solid diet, improving quality of life; in addition, within a reasonable time span, after the healing of the fistula, the prosthesis can easily be removed by endoscopy.

Acute gallstone cholecystitis in the elderly: treatment with emergency ultrasonographic percutaneous cholecystostomy and interval laparoscopic cholecystectomy

BACKGROUND

The treatment of acute cholecystitis in the elderly is still a subject of debate, particularly with reference to the timing of surgery and the role of laparoscopy.

PATIENTS

From January 1994 to June 2002 we observed 27 patients aged over 70 years with acute calcolous cholecystitis. The patients were submitted to ultrasonographic percutaneous cholecystostomy within 12 h of the acute attack. For two patients (7.4%) at high operative risk, we chose a conservative treatment. Twenty-five patients (92.6%) were submitted, in 15 cases (60%) within 5 days and in 10 patients (40%) within 8 days, to a laparoscopic cholecystectomy. Statistical significance was accepted when the value of p was less than 0.05.

RESULTS

Ultrasonographic percutaneous cholecystostomy was performed successfully in all patients, without major morbidity or mortality, and complete resolution of clinical symptoms was obtained within 48 h. The conversion rate of laparoscopy was 20% (13.3% in patients submitted to surgery within 5 days and 30% in the group submitted within 8 days--p > 0.05). The postoperative morbidity rate was 24%; it was higher (40% versus 15%) in patients converted to laparotomy (p > 0.05); mortality was 4%. The period of hospitalization was 11 days in patients operated laparoscopically and 21 days in those converted to open cholecystectomy (p < 0.001).

CONCLUSIONS

The more rational treatment of acute calcolous cholecystitis in elderly patients is represented by ultrasonographic percutaneous cholecystostomy followed, within 5 days, by laparoscopic cholecystectomy using an abdominal insufflation maximum to 12 mmHg and a limited 10-15 degrees head-up tilt.

[The capillary hemangioma of the stomach: an unusual cause of haemorrhage. Case report]

Gastric haemorrhages are common clinical emergencies which often directly involve the surgeon in diagnosis and treatment; among these, rare vascular neoplasms deserve particular attention. The Authors report a rare case of benign vascular tumour of the stomach, a capillary angioma. After a literature review they highlight the importance of specific exams to reveal these small neoformations which, generally, show up clinically with acute bleeding, which may be severe, and which may not be discovered if the clinical evaluation is not very detailed. The surgical excision supported by a frozen sections is the most effective treatment.

[Caroli's disease: literature review and characteristics of a clinical case]

The Author's report the case of the simple form of Caroli's disease, a rare malformation, and review literature pointing out the difficulty of an early diagnosis, because disease can be silent for a long time too and it is identified for complication. Today, imaging, endoscopy and interventionist radiology are the most valid tools for a correct diagnosis and treatment, above all in a case of emergency, when other therapeutic solutions are not possible.

[Diagnostic and therapeutic implications in two cases of pancreatic cystic tumours: mucinous and serous]

Cystic tumours of the pancreas include a pathologically heterogeneous and rare group of tumours, which however have many common clinical features. They represent about 10% of pancreatic cystic lesions and 1% of all forms of neoplasms, thus having a certain relevance in organ surgery. So far two distinct categories of cystic tumours have been identified, the basically benign serous form and the potentially malign mucinous form, which may sometimes show malignant features as early as the diagnostic stage. As neoplasms are very difficult to interpret before operation, it is essential that diagnosis is as accurate as possible in order to streamline surgery, which will have to be carried out after histological tests have been performed on an adequate number of tumour sections. Basing on these two cases of cystic tumours of the pancreas and on current literature, the Authors discuss the effectiveness of imaging techniques, such as contrast echography, dosage of specific tumour markers and histological tests backed up by immunohistochemistry in identifying these neoplasms, in order to study this rare but interesting pathology more accurately.

[Angiodysplasia in the gastrointestinal haemorrhage of the elderly patient. Our experience]

Angiodysplasia of the digestive tract is one of the main causes of acute bleeding and is a frequent reason for admittance to the emergency surgery unit. This pathology, previously considered rare and often not recognised, has only recently acquired a precise anatomo-pathology thanks to endoscopy. Besides having a decisive diagnostic role, endoscopy also allows the control and successful treatment of lesions, often in a definitive way, which were previously only dealt with surgery, with significant advantages for the elderly patient, reducing the rate of morbidity and mortality. There are still many discussions today, above all on the priority of various diagnostic investigations to be carried out in digestive bleeding and on the choice of treatment in the case of angiodysplasic lesions in geriatric age. Some cases of acute bleeding from intestinal angiodysplasia, observed by the Authors, have led them to study the etiopathogenesis, diagnosis and emergency treatment of such lesions.

["Switch prophylaxis one a day" with levofloxacin in laparoscopic cholecystectomy]

BACKGROUND

Special attention is paid today to the advisability of carrying out routine antibiotic prophylaxis in laparoscopic cholecystectomy (LC) and to the dosage protocol to be adopted in order to reduce the incidence of infections at the site of the surgical operation which, albeit with lower incidence than in "open" surgery, 5.3% vs 14%, can vanify the advantages of the mini-invasive approach. The demonstrated validity of administering the antibiotic beyond 24 hours after the operation led the authors to verify the clinical effectiveness and tolerance of "switch prophylaxis one a day" (SPOD) with levofloxacin in the prevention of septic complications after LC.

METHODS

The experience reported relates to 185 patients suffering from symptomatic and/or complicated lithiasis of the gall-bladder subjected from January 1999 to April 2001 to LC and to antibiotic prophylaxis in accordance with the following dosage protocol: levofloxacin 500 mg i.v. 30 min before operation and 500 mg per os in the 3 days subsequent.

RESULTS

The postsurgical evaluation documented the onset of 2 superficial infections in patients in whom LC had been of necessity converted and of a subhepatic abscess in an ASA III patient with acute cholecystitis. Prevention of infections at the surgical site totalled 98.4%. Nausea and slight diarrhoea and an increase in transaminasaemia were observed respectively in 3% and 4% of patients.

CONCLUSIONS

The results obtained led the authors to standardise the use of SPOD with levofloxacin in LC operations which, in their opinion represents a rational alternative to the antibiotic prophylaxis regimes most commonly used up to the present (STP and USTP).

[Hemorrhage and gastric perforation in patients with percutaneous endoscopic gastrostomy (PEG)]

INTRODUCTION

PEG is more and more used for those patients who need a medium and above all long term enteral nutrition, especially at home. This is the closest technical system to the requirements to have an ideal nutritional access; however it is burdened, on average in 32.5% of cases, with complications linked to technical mistakes of positioning or to a wrong management, such as haemorrhage and gastric perforation.

CASE REPORT

A patient, subjected to supraglottic laryngectomy, to removal of tongue's base and to bilateral laterocervical lymphadenectomy and PEG carrier for 4 months, has arrived to our observation for a clinical outline of acute abdomen for perforation of hollow internal organ, preceded by progressive anaemia due to high digestive haemorrhage. Performed an exploratory laparotomy, it was discovered on the gastric fore face, between body and antrum, in proximity to the small curvature and in front of the PEG gastric access, a perforation with max 2 cm of diameter, crossed by probe's internal disk of retention. They proceeded to remove that, to unstick the gastric stoma from the parietal peritoneum, to suture the access of gastrostomy and the perforation by omentoplasty. Finally they carried out a jejunostomy for enteral feeding.

DISCUSSION

We think we can pathogenetically identify the cause of the haemorrhage and of the stomach's perforation, occurred in a short time in the case we have examined, in the probe's movement for incorrect fixing of the plate of external anchorage or for excessive slimming of the patient due to not balanced nutritional supply, as well as in the consequent extension of its intraluminal part with continuous rubbing by internal disk on the gastric wall and with onset decubitus ulcer. Physiopathologic moments, connected with the supposed etiological factor, make both occurred complications as an unique pathologic entity, which has to be observed in the PEG carriers, in order to be able to diagnose it and treat it precociously and above all in order to be able to prevent it. Only a correct technique of positioning and of nursing and of management of nutritional supply is able not to thwart the finality of the PEG device which can be considered, in the elective indications and for the favourable requisites that marks it, a valid access to enteral nutrition realization.

[The switch prophylaxis with levofloxacin in surgical procedures for prosthetic inguinal hernia repair in one day surgery]

The installation of synthetic prosthesis in the repair of the hernial defects of the inguinal region, though it is part of cleaned surgical operations, it needs of an antibacterial prophylaxis for the prevention of the septic complications of the surgical wound and these, compared with complications following hernioplasty by straight suture, have a meaningful morbidity that can outweigh social and economic advantages of the hernioplasties. The Authors' experience is relative to 112 patients submitted to prosthetic hernioplasty by anterior approach (94 cases) and by transabdominal preperitoneal laparoscopy (TAPP) (18 cases) and underwent to "switch prophylaxis" with Levofloxacin using this posologic scheme: 500 mg ev 30 m' before the surgical operation and 500 mg os in seven days following. The evaluation of the surgical wound has never evidenced septic and suppurative complications; only 11 of the 122 surgical wounds (9%) have documented light phlogosis never advanced to evident suppuration. No patients have showed signs of pharmacologic local intolerance; about collateral general effects as sick and diarrhoea are appeared in 5% of patients, but these have been of light entity; an increase of the transaminase, quickly reverted to the suspension of the therapy, has interested 4% of cases. On the basis of these satisfactory results about clinical efficacy on the prophylaxis of the phlogistic complications of the surgical wound, with reduction of the incidence and gravity and in relation to large and complete antibacterial spectrum included Staphylococcus aureus and epidermidis, and about excellent tolerability without collateral effects, the Authors consider to be important the standardized use of this prophylaxis in the prosthetic hernial surgery of the inguinal region. This choice is correlated to the typical pharmacologic characteristics of the Levofloxacin and particularly to the total bioequivalence between endovenous and oral formulation and besides in relation to perseverance, not inferior to 24 hours, of the plasmatic and tissutal concentrations above bactericide IMC on the most part of organic districts, included skin and soft tissue. The assurance of Levofloxacin's employment in the "switch prophylaxis" also is correlated to patient's elevated compliance, above all if he is operated on regimen of "one day surgery", and to a favorable relationship between costs and benefits.

[Combined diagnosis in breast carcinoma: preoperative role of mammoscintigraphy with Tc99m-sestamibi. Our Experience]

The Authors, taking recent literature on tumoral pathology breast studies in to consideration, studied a group of patients with a node or a suspect adenous zone by clinical and instrumental examination with mammoscintigraphy. 22 patients were selected by clinical examination, mammography and ultrasonography. A mammoscintigraphy (Tc 99m Sestamibi) was performed before the surgical operation. The histologic examination revealed 14 cases of breast cancer; 12 of these (86%) resulted positive after scintigraphy, while 2 were false negative. In this study, the scintigraphic exam and its diagnostic accuracy were analyzed, both in relation to anatomical structure of the mammary gland (thick breast, fibrocystic mastopathy, postsurgical scars, etc.) and also in relation to characteristics of the suspected node, the nature of which was not possible to determine from other exams carried out. In conclusion, after comparison between our experience and those reported in literature, we conclude that because of its high specificity and sensibility the mammoscintigraphy exam assumes an important comparative index in obtaining elements for an additional evaluation when other instrumental examinations are dubious.

[Myogenic stromal tumors of the stomach: personal experience]

Myogenic gastric tumours are a rare pathology and present difficulties in terms of nosographic classification, which in most cases can be overcome thanks to improvements in imaging and immunohistochemical techniques. Over the period 1995-1999 we observed 5 patients with aspecific dyspeptic symptoms and occasional epigastric pain, suffering from non-epithelial gastric tumours, associated, in one case, with a carcinoma of the stomach. Histological examination of endoscopic biopsies was inconclusive for a definite histopathological diagnosis, while intraoperative biopsies showed the myogenic origin and the absence of morphostructural abnormalities. In the light of these data, we performed three wedge resections, one distal gastric resection and, in the patient with advanced gastric cancer, a D3 total gastrectomy. Histological examination, immunohistochemistry and cytofluorometry enabled us to diagnose stromal tumours with a low risk of malignancy in all cases. At follow-up after 9-54 months all patients are still alive and free of disease. Though the preoperative diagnosis of stromal tumours is possible with endosonography and CT, only histology, immunohistochemistry and cytofluorometry enable us to define the condition nosographically and establish a prognosis with sufficient accuracy to allow correct surgical treatment. A prolonged follow-up is always necessary to identify eventual relapses and/or metastases, which are particularly frequent in the borderline group or in cases with a high risk of malignancy.

[Idiopathic varicocele. Diagnosis and follow-up with CW-Doppler and Echo-Color-Doppler: our experience]

The Authors outline their experience on routine use of Doppler velocimetry in pre- and post-operation studies on patients affected with idiopathic varicocele. This instrumental study, characterized by non-invasive techniques and repeatability, if correctly carried out, allows both accurate identification of anatomical alterations which are at the bottom of varicocele and correct indications for surgical treatment. Moreover the Authors confirm the importance of spermatic veins ligature following the Ivanissevich method in the treatment of male infertility.

[The Allgrove syndrome]

Allgrove syndrome, rare autosomal recessive pathology, characterized by adrenocortical insufficiency, achalasia and alacrimia, rises usually in pediatric age, while its observation in adults is very rare. A clinical case appeared in an adult, observed by the Authors, is the reason to evaluate the etiopathogenetic mechanisms of this syndrome, with particular attention about potential role of genetic abnormalities and about others factors, again not well known.

[Clinical and etiopathogenetic evaluation of a rare cause of spontaneous pneumoperitoneum and volvulus of the ileum: pneumatosis cystoides intestinalis. Report of a case]

A case of pneumatosis cystoides intestinalis with pneumoperitoneum and volvulus complications is reported. After careful examination of the literature, etiopathogenic, pathophysiological and clinical features of the disease are analyzed by the Authors, also in the light of recent findings. Major diagnostic and therapeutic implications are discussed regarding possible complications requiring a different therapeutic approach. PCI, a lesion which can be benign, primary or secondary in many conditions, may be characterized by the presence of spontaneous pneumoperitoneum which only requires a careful, but not aggressive therapy, unlike other complications such as volvulus or intestinal occlusion which, instead, require timely surgical action. The Authors describing the therapy adopted, highlight the positive role of the enteral nutrition (NE) and oxygen therapy in the clinical course of the disease.

[Diaphragm rupture caused by closed trauma. A more and more frequent condition]

The Authors report a case of rupture of the diaphragm in blunt trauma of the abdomen, to examine the more significant features of this condition whose incidence proves to be increasing, after a review of the literature data, parallel to the increase of accidents on the road and at work. They examine the most important pathogenic problems and these related to the mechanism leading to diaphragmatic lesion and they highlight the deeper pathophysiological changes suffered from the patient with such a condition. They draw attention to what they consider to be the most important aspect, and therefore the diagnosis. In fact, in accordance with the various series of cases reported in the literature, it is crucial in the diagnostic problem is when the possible cause of the rupture is suspected and necessary diagnostic cascade (Rx, echotomography, TC) is activated so to highlight the lesion. Therefore a quick diagnostic fitting is necessary for the survival of the acute patient with hernia of the thorax cavity, as well as quick surgical correction of the lesion that, as in the case described, serves to achieve the best possible anatomic-functional results.

[A case of strangulated trans-omentum hernia]

After a review of the Literature, the Authors report a case of intestinal obstruction caused by trans-omentum hernia. This unusual disease is due to a defect of the greater omentum with herniation and secondary strangulation of small bowel. The clinical presentation was that of an intestinal obstruction with rare possibility of preoperative diagnosis. Therefore, a correct knowledge of this pathology and immediate surgery are necessary for the prognosis.

[A case of appendiceal mucocele associated with adenocarcinoma of the left colon]

The Authors report an unusual case of appendiceal mucocele associated with a large bowel carcinoma occasionally observed in the course of examinations for the first pathology. Due to the rareness of the association of the two affections, the clinical problems and pathogenetic theories are reviewed, also analysing the histological differences of the various mucoceles which need a different surgical approach. They conclude stating that the preoperative diagnosis of appendiceal mucocele, is easier today than in the past, thanks to the routine use of ultrasonography and tomography through which it is possible to reveal concomitant pathologies often clinically silent.

[Authors' experience with the role of preoperative ultrasonography in the study of benign lesions of the gallbladder]

The benign parietal lesions of the gallbladder are diseases that, as known, found their pathogenetic moment on hyperplasia of constituent tissues of the gallbladder wall and comprises the controversial chapter of "cholecystosis". The Authors, to contribute to their better clinical and pathogenetic staging, report their experience on 25 cases. They debate on the usefulness of ultrasonography, surely a diagnostic progress for these formations, which are small structures more or less echogenic and that they develop in the gallbladder; the echographic imaging, for its sharpening, has substituted the cholecystographic procedure. The aim of present study is to analyse the results obtained by using echography as diagnostic preoperative procedure of "cholecystosis". The ultrasonography supplies the surgeon an indication to prophylactic surgical treatment as single, effective procedure in preventing the gallbladder carcinoma.

Diagnostic possibilities and clinical indications of policlonal labeled Ig in the bowel inflammatory disease

BACKGROUND/AIMS

Ulcerative colitis (UC) and Crohn's disease (CD) represent the more common forms of idiopathic inflammatory bowel disease. They have a peculiar course, which is characterized by exacerbation and submissions, and a symptomatology that changes in relation to severity and extension of the lesions. The aim of this study is to establish the diagnostic usefulness of 99m Tc human policlonal immunoglobulin (HIG) imaging in patients with inflammatory bowel disease (IBD).

METHODOLOGY

During the period between September 1995 and September 1997 we submitted a group of 32 patients affected by UC (n = 22) and CD (n = 10), to Human Immunoglobulin labeled with Technetium 99m (99m Tc-HIG) scintigraphy. The diagnosis of IBD was obtained in all cases by endoscopy with biopsy.

RESULTS

Scintigraphic examination with labeled HIG showed an abnormal intestinal fixation (ileal or colic) of the marked immunoglobulins in 17 patients (77.2%) affected by UC and in 8 patients (80%) affected by CD. In 5 (22.7%) and 2 (20%) patients, respectively, the scintigraphic examination revealed a normal distribution of the immunoglobulins without appreciable focal accumulation. Among the patients with a negative scintigraphic examination, only one presented an endoscopic and histologic report that documented UC in an active stage. The histologic and endoscopic findings observed in all cases of CD were similar to that of HIG scintigraphy in 7 of the 8 scintigraphic-positive cases and in 1 of the 2 scintigraphic-negative patients.

CONCLUSIONS

The authors, on the basis of their results, suggest that this diagnostic strategy may have a significant role in the diagnostic protocol and in the follow-up of chronic inflammatory bowel disease.

[The surgical treatment of Zenker's diverticula by stapler diverticulectomy and myotomy under local anesthesia]

From 1990 to 1997, 12 patients with Zenker's diverticulum underwent TA 30-stapler diverticulectomy and cricopharyngeal myotomy. All patients were operated on under local anaesthesia. No death was observed. In two cases subcutaneous infection was drained with recovery. No post-operative fistulas were observed with radiologic control. At 6 months follow-up all patients were well. Advantages of both stapler diverticulectomy and local anesthesia are outlined.

[Intercostal incisional hernia: case report]

The authors report a case of intercostal incisional hernia following marsupialization of liver hydatid cyst stressing the considerable rarity of the pathology and describing the restorative procedure by intercostal plastic with polypropilene Mesh and rib's approach with stainless steel wires.

[Spigelian hernia: clinical, diagnostic and therapeutical aspects]

The Authors describing a case of Spigelian hernia observed point out clinical, diagnostic and therapeutic considerations about this rare pathology of abdominal wall. They specify the anatomic characteristics of the region and underline as any diagnostic difficulties are by passed by use of USG and TC imaging for formulation of correct preoperative diagnosis. They confirm as surgical treatment by a correct access isn't different by a normal hernioplasty and guarantee the long term surgical outcome.

[Our experience in using a synthetic prostacyclin analog in the treatment of critical ischemia of the extremities]

The authors, after examination of pharmacologic profile of Iloprost, prostacyclin synthetic analogue, report their clinical experience from January 1992 to June 1997 on 105 patients with severe ischaemia of inferior limbs. They utilize two protocols: 0.5-2 ng/kg/min x 6 hs once a day x 28 days and 1-1.5 ng/kg/min x 6 hs twice a day x 12 days. The first protocol were practise along the first 2 years; the second on following period as long as today. The results, evaluated on clinical criteria, are referred entity and time of pain remission and decrease of analgesic use, performance status improvement, increase of gear autonomy and, if present, wound healing. The incidence of amputation was 4.76% (5 pts). The authors issue that Iloprost is a conservative treatment, often alternative with amputation, giving sometimes to patients a longtime functional "restitutio ad integrum".

[Clinical considerations and therapeutic options in papillomatosis of common bile duct. Clinical case]

The Authors report a case of endoscopic treatment of common biliary tract papillomatosis. This therapeutic option derive by patient's clinical evaluation and clinical reports from literature. Agreeing with Cornud, we have opted for endoscopic conservative management with drainage of common biliary tract; furthermore endoscopic procedure permit, by an intensive follow-up, identification and management of possible recurrences. This approach, minimally invasive, is in our opinion the first option for the biliary papillomatosis management.

[Spontaneous rupture of the spleen in a patient treated with chemotherapy and growth factors for stem cell mobilization]

The Authors report a case of spontaneous spleen rupture in a woman with breast cancer treated with chemotherapy and growth factors for stem cell mobilization. After a wide review of the literature, they suppose this therapy, causing a considerable increase of immature cells, that promote the stasis of the splenic microcirculation, can sometime elicit a spontaneous rupture of the organ.

[Necrotizing fasciitis: apropos of a case]

Necrotizing fasciitis is an infection which involves soft tissues up to the fascia, with wide areas of necrosis, and is mainly caused by group A beta-hemolytic Streptococcus. The Authors report a case recently observed and after an accurate review of the Literature, taking into account the most recent pathogenetic knowledges, confirm the necessity of an early diagnosis based on clinical criteria but above all on histological biopsy. The treatment is mainly surgical, and allows, together with the medical treatment, to subdue the rapid progression of the infection which notwithstanding maintains an high mortality rate.

[Primary echinococcosis of the thyroid gland: apropos of a case]

The Authors report a case of primary hydatid cyst of the thyroid. After a review of the literature, they underline the rarity of the case and discuss pathogenesis, clinical and diagnostic related problems. The Authors conclude that, although modern imaging techniques have allowed diagnostic improvements, preoperative diagnosis is still difficult.

[Primary gastrointestinal localization of N-H lymphoma: authors' experience]

Primary non-Hodgkin lymphoma of the alimentary tract is a rare pathological entity with few peculiar clinical aspects, therefore characterized by problems of differential diagnosis with other neoplastic and inflammatory diseases. The Authors report on some cases of primary gastrointestinal N-H lymphoma observed in their experience and discuss about the most significant clinical and pathological data. They conclude that currently surgical treatment is the first fundamental step of a multidisciplinary therapeutic program, which may allow an improvement of the prognosis.

[Therapeutic considerations on a case of mixed teratoma of the testis with seminomatous component]

The Authors present a case of mixed teratoma of the testis with seminomatous cells, occurred in a teenager. Performed the preoperative oncological staging, the patient was submitted to trans-inguinal left orchifunicolectomy. The presence of cells originated by the three embryonal layers, of stroma distributed in a periepithelial fashion and big cells with clear cytoplasm, permitted to formulate the hystological diagnosis of mixed teratoma, mature and immature, associated with seminomatous cells. The observation of this case offer the opportunity for prognostic and therapeutic considerations.

[Inguinal hernia repair in the elderly: modified Shouldice procedure, 10 years of experience]

Authors relate their experience of 10 years period (1984-1994) with Shouldice technique for inguinal hernia repair in the elderly. This technique, in the Author's clinical practice, replaced the Bassini operation. The personal series is costituted of 190 patients underwent to inguinal repair during a 10 years period from 1984 to 1994 with recurrence rate of 1.1% (2 pt.). Authors consider Shouldice operation to be most valid from the methods of direct suture, with lower recurrence range.

Malignant degeneration of pilonidal cysts

Malignant degeneration is a rare occurrence in pilonidal disease. The authors present three new cases with a review of the world's previously published 41 cases. Among the total 44 cases, 36 were squamous cell carcinoma. All cases occurred in the setting of long-standing pilonidal disease, with the mean duration of antecedent disease being 23 years. Five of six patients presenting with inguinal metastases died within 16 months. Four patients received adjuvant radiation therapy, one received adjuvant chemotherapy, and one patient in the current series received both adjuvant chemotherapy and radiation. Six patients with recurrence underwent potentially curative resection, with three patients surviving greater than 10 years with no evidence of disease. The authors propose consideration of adjuvant chemotherapy and radiation as a new modality to decrease the local recurrence rate.

Palliative endoscopic treatment of malignant esophagorespiratory fistula: case report

The authors report on a case of esophagorespiratory fistula due to squamous carcinoma of the esophagus treated on an emergency basis by endoscopic insertion of an Atkinson prosthesis following dilation of the malignant stenosis with Savary dilators. The authors suggest the endoscopic insertion of a prosthesis as the first approach in the emergency treatment of a malignant esophagorespiratory fistula because of the easiness of the technique, and its low morbidity and mortality rates; furthermore, this procedure relieves digestive and respiratory symptoms rapidly and reduces hospital stay while providing the patient with a better quality of remaining life.