[Aneurysms of the superior mesenteric artery]

Splanchnic arteries aneurysmatic pathology is rare, even if, in the last decades it has been noticed an increase of its incidence, owing to the worldwide use of the recent diagnostic tools as echography, TC, MR and angiography. Among visceral aneurysms those of the superior mesenteric artery (SMA) range the 5.5-8%. In the majority of cases SMA aneurysms are of mycotic etiology (60%), of atherosclerotic ones are less frequent, even if their incidence has increased in the last decades. Other causes are exceptional. Dimensions are generally moderate (1-3 cm.), yet aneurysms of a significant diameter, ranging from 4 to 8 cm., are reported in the most recent literature. Aneurysms can be symptomatic with abdominal upper quadrants pain, due to the compressive mass effect on the contiguous structures. In some cases typical signs of claudication abdominis are present. A pulsating epi-mesogastric abdominal mass is present in the 50% of subjects. In the 20% of the cases the patients come to medical attention presenting a situation of hemorrhagic shock for aneurysmatic rupture in the peritoneal cavity, or in the digestive tract, considering also the possibility of a thrombosis with consequent acute bowel ischemia. Urgent surgical operations, when possible, imply an high mortality rate. For these reasons, there is indication of elective surgery for all SMA aneurysms, both symptomatic and of occasional finding. The performable surgical techniques are: proximal and distal ligation, with or without aneurysmectomy, that is the most utilized because commonly performed during emergency operations. This technique requires the presence of a sufficient collateral vascular supply. Endoaneurysmorraphy can be performed only in the case of mild-dimension saccular aneurysms. Revascularization techniques through substitution or by-pass are mandatory in managing voluminous mass aneurysms. It is reported a case of SMA aneurysm of exceptional dimensions (diameter approximatively 10 cm.) that for its enormous volume substituted completely the mesenteric axis, involving the origin of the jejuno-ileal and ileo-colic branches. In this case it has been mandatory the performing of the aorto-mesenteric by-pass technique, distally patch modelled and sutured to the residual posterior SMA wall, on the purpose to allow the revascularization of the emerging jejunal arteries and adapted to the residual distal stump to irrorate ileo-colic branches.

[Lipohyperplasia of the ileocecal valve: unusual cause of severe digestive surgery]

The lipohyperplasia of the ileocaecal valve is a condition of rare clinical observation mainly characterized by an abnormal accumulation of adipose tissue along the submucosal layer of the ileocaecal valve. This pathology presents an unspecific symptomatology that can make difficult the differential diagnosis with a local neoplastic process. Sometimes this pathology can be the cause of gastrointestinal bleeding of unknown origin. The Authors report a case of their observation that requested an emergency surgical operation for the massive digestive haemorrage at presentation. The definitive diagnosis could have been precised only after histological exam.

[Acute postoperative mediastinitis: retrospective analysis of various treatment methods]

Infective acute mediastinitis is a postoperative complication reported in 0.5-1% of patients undergoing open chest operations. The treatment of choice for this life-threatening complication is still a matter of debate. The aim of this study was to retrospectively analyse the efficacy of different therapeutic approaches in the treatment of postoperative infective mediastinitis. In the 2nd Division of Cardiac Surgery, from October 1986 to May 2000, 10,234 patients underwent cardiac surgery operations. In 42 patients (0.4%) the operation was complicated by acute infective mediastinitis requiring surgical treatment. On the basis of the treatment opted for, these patients were subdivided into 5 groups: 23 patients underwent continuous iodopovidone (Betadine) mediastinal irrigation (GL) associated with surgical omentoplasty in 8 patients (GLO); 5 patients underwent isolated omentoplasty (GO), and 4 patients were treated with a pectoral muscle flap (GF). In 8 patients other different procedures were performed (GS). There were no deaths in GF and GS despite 24% and 20% mortality reported among patients who underwent mediastinal irrigation (GL) and isolated omentoplasty (GO), respectively. The mean hospital stay was 15 +/- 1 days in GF, 16 +/- 1 days in GS, 25 +/- 11 in patients who underwent omentoplasty and 27 +/- 14 in patients who underwent mediastinal irrigation. Predictors of death were low cardiac output syndrome (P < or = 0.009) and respiratory insufficiency (P < or = 0.032) when found before treatment. Our study suggests that surgical omentoplasty should be the treatment of choice in deep mediastinal infections, whereas wound sterilisation, associated with surgical chest wall reconstruction, seems to be a better procedure in superficial infective disease. A more extended clinical series would be needed to confirm these preliminary data.

[Necrotizing soft tissue infections as the only clinical manifestation of retroperitoneal colonic perforation]

Necrotizing infections are rapidly progressive potentially lethal bacterial diseases of the soft tissues. In based on the widely varying levels of soft tissues affected and the variety of the microflora, two types of necrotizing soft tissue infections need to be delineated: pure Chlostridial myonecrosis and other necrotizing soft tissue infections (NSTI). From an etiopathogenetic point of view NSTI can be secondary to perianal or urogenital abscesses, traumatic lesions, wound infections, trophic or decubitus ulcers, oral cavity abscesses; only in a limited number of cases their origin can be idiopathic. Exceptionally it can happen that a NSTI could represent the only clinical manifestation of a retroperitoneal colic perforation. The Authors report their experience regarding two clinical cases recently observed. The first patient, who previously underwent colic resection for sigmoid carcinoma and adjuvant chemotherapy, had developed as only clinical manifestation of retroperitoneal anastomotic fistula a necrotizing infection at the root of the hip, extended along the whole leg. The second patient, with diverticular perforated disease, had developed rhe necrotizing infection in the lumbar region and in the perirenal tissues. Here will be discussed the sensitivity of the possible diagnostic investigative techniques and the therapeutical strategies that brought both the patients to a complete recovery.

Solitary metachronous splenic metastases: an evaluation of surgical treatment

Splenic metastases occurring after primary tumor removal and apparently solitary have been documented only recently in Literature. They are, most of the times, clinically asymptomatic and their presence is casually determined by ultrasonographic follow-up in subjects otherwise in good conditions. The belief that splenic metastases occur only in disseminated cancer is today no longer accepted. Some Authors consider solitary splenic metachronous metastases eligible for surgical treatment as well as pulmonary or hepatic metastases. In the case presented, surgery was required due to abscess formation of a splenic metastasis, which was not responding to chemotherapy. Our experience, like others reported in Literature, verified a long-term post-operative survival in spite of limited disease-free time. Surgical treatment by splenectomy can be indicated in selected patients, considering that chemotherapy has been proved to be ineffective in the treatment of splenic metastases.

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.

[Benign non-parasitic cysts of the spleen]

The present retrospective study is related to 7 cases of non-parasitic splenic cysts, 5 post-traumatic and 2 true epidermoid. Symptoms of displacement and pressure on adjacent viscera or physical examination showing an enlarged spleen have caused the beginning of diagnostic investigation in some patients, in others the cyst has been incidentally discovered. The young age and the positive history for prior trauma suggest for pseudocyst but they didn't give us absolute value. We have valued the contribution of the different radiological techniques (scintigraphy, US, CT, selective celiac arteriography, percutaneous biopsy) in the diagnosis of these lesions. The CT has shown to be the gold standard but it wasn't able to distinguish the post-traumatic from true splenic cysts. Such diagnosis is often not sure neither thought the histological study since the epithelial lining typical of the true cysts may have partially or completely destroyed by secondary alterations. However it can be observed also in the pseudocysts by proliferation of epithelial cells included in the traumatic hematoma. Surgery is primarily recommended for the prevention of complications as infection, hemorrhage, rupture in both types of cysts. Partial splenectomy according to the anatomic vascular distribution have permitted in 3/7 cases to resect the cyst preserving the functioning splenic tissue avoiding the long-term adverse effects of splenectomy.