Postoperative hepatic artery aneurysms development and remodeling in Ehlers-Danlos syndrome type IV. Case report

Patients affected by Ehlers-Danlos syndrome (EDS) type IV are at risk for aneurysm formation and rupture. This case report shows the extreme vascular fragility of these patients. We studied a 31-year-old man that developed hepatic artery aneurysms 3 weeks after splenectomy. Computed tomography angiography showed the extreme vascular remodeling of the aneurysms. We conclude that remote site complications should be kept in mind by all surgeons in vascular EDS patients even after general surgery operations.

Pathological evaluation in colorectal polyps endoscopic treatment

This retrospective study shows that endoscopic polypectomy is the technique of choice to remove the majority of polyps; follow-up and pathologic examinations shed light on the carcinogenesis of colorectal lesions. From January 1990 to December 2001, 1302 adenomatous polyps were removed, 1175 endoscopically, 127 with surgical procedures. The anatomical and morphologic conditions of the colon and some characteristics of the polyps represent limits to the feasibility and to the efficacy of polypectomy, and the most important variables for the correct management of the patients affected by colorectal adenomatous polyps.

[Fibrin sealant in tension free hernioplasty: our experience]

The aim of this study was to prove that it is possible to fix mesh sutureless with Tissucol in the Lichtenstein procedure. The mesh fixation with Tissucol was done in 28 patients. Respect the traditional Lichtenstein technique, which was done in the remaining 28 patients, the advantages of using Tissucol are: no surgical trauma, total mesh fixation, no pain, reduced morbidity and reduced costs. Furthermore it is a safe and reproducible method. The results are promising, even if the verification goes more carried out with consisting casuistics and longer follow-up.

Abscess and cecum carcinoma in inguinal hernia: case report

Cecal adenocarcinoma within an inguinal hernial sac is an uncommon clinical condition. A primary adenocarcinoma of the cecum in a right sided inguinal hernia is presented and discussed. This case represents one of the unexpected findings in a hernia sac and also very rare septic evolution. This particular condition is a main dignostic and therapeutic challenge.

[Retroperitoneal leiomyosarcoma: a case report]

The Authors report a rare case of retroperitoneal leiomyosarcoma in a 80 years woman with respiratory symptoms and right abdominal pain. A large neoplasm occupied the right abdomen, looking asymmetric. Upper abdominal CT showed a retroperitoneal neoplasm close to right kidney, liver, aponeurosis of right oblique muscles, producing a left-side dislocation of the intraabdominal organs. A surgical "en bloc" resection of the neoplasm was performed; neoplasm was plurilobed and capsulated. The histologic examination confirmed the diagnosis of leiomyosarcoma. The best treatment of these neoplasms is surgery, that in the last years has drawn advantage from more sensible and specific diagnostic procedures, which show a more radical surgical option. Though metastases are occasional, local recurrences can be taken into consideration and, after a careful tumoral re-staging, they can be resected once more. Therefore, a careful follow-up is necessary on the basis of neoplastic grading, extension and involvement of the closer structures.

[Predictive factors and treatment of small bowel adhesive obstruction]

Our study is based on a retrospective analysis about a ten years' control on patients with a small bowel adhesive obstruction (SBAO) due to primitive abdominal surgical operations. From the valuation of the obtained data and through a literatures review we tried to better define the best treatment. On 297 admissions of 248 patients with a diagnosis of SBAO 196 operations were performed, which indication was based on every clinical data, haematologic and radiologic examinations. Moreover, it was analysed the responsive factor that caused adhesions with a careful valuation of the primitive surgical operation and the possibility of recurrences. From this study it is evicted that SBAO can be considered as a surgical differentiable urgency, where there aren't any signs of intestinal strangulation or peritonitis, and where the principal etiologic factor is represented by colorectal operations in the male and gynecologic operations in the female. Morbility and mortality in the surgical procedures for SBAO show greater percentages than the elderly patients.

[Gastric lymphomas: surgical indications]

Primary gastric lymphoma (PGL) are lymphomas with an exclusive gastric localization. Histologically they are B-like non-Hodgkin lymphomas. Aim of Authors' study is to define the role of surgery in the treatment of PGL, on the basis of their series casistics and a review of the more recent literature data. The Authors observed 41 patients (23 F and 18 M) in a period of 10 years: 35 patients underwent to surgical operation associated in 18 of them to chemotherapic treatment; in 6 cases medical eradication of Helicobacter Pylori (H.P.) was performed as unique treatment. Antibiothic treatment allows the eradication of H.P. in 97% of the patients and a histologic decreasing of MALT lymphoma in 70% of the patients in about 6 months. That represents the first therapeutic choice for the low grade of malignancy MALT PGL at I and II stages. In the cases of partial decreasing or progression of PGL, the Authors consider opportune surgical operation. In the majority of the cases the surgical option represents, according to our advise, the best choice for the high percentage of definitive recoveries, allowing a 10 or more years of surviving of the 90%, if it is done in the first stages of the disease. The results of the association with neoadjuvant or aduvant chemotherapy are still controversial. On the basis of their experience total gastrectomy can be considered the elective choice operation, with IID level lymphadenectomy and possible splenectomy.

[Metachronous carcinoma of the colon: report of a clinical case]

The Authors deal with a rare case of 'meta-metachronous' carcinoma of the colon. A seventy years old man was admitted to ward after being diagnosed an adenocarcinoma of the transverse colon. The anamnestic data pointed out that the patient had already been operated twice for the colon carcinoma, which had been diagnosed in the left colon and in the cecum respectively seven and two years before. A colonoscopy performed sixteen months before did not show any lesion of the residual colon. It is likely that tiny lesions, which were still in the adenoma phase, were not diagnosed by the endoscopy; it is also possible that the adenoma-carcinoma sequence was extremely fast. On the basis of this experience the Authors recommend that patients with metachronus carcinoma undergo either frequent controls or a preventive subtotal colectomy.

[Day-hospital treatment of inguinal hernia]

Aim of the Authors' research was to evaluate advantages of day-surgery treatment for inguinal hernias. The study has been performed on a series of 138 patients, operated because of unrelapsed and uncomplicated monolateral inguinal hernia. Up-to-date therapeutic behaviour relating to hernia is the result of brilliant intuitions: technical order (tension-free repair), technological progresses (using new prosthetic materials), and refinement of anaesthesiological procedures (local and loco-regional anaesthesia). As regards surgical and anaesthesiological methods, general principles have been accepted by now from the most of the Authors. The new frontier of hernias' treatment is the possibility of operate in a day-hospital way: that means real advantages, both as regards patients' compliance and, in consideration of the high incidence of such pathology, as regards the high economic savings and more reasonable management of hospital stays. The significative increase of day-hospital hernioplastic operations in last years is due to standardization of restrictiveless criteria of choice for patients who can be treated with such modality.

[Use of PTF prosthesis in hernia in the elderly]

The paper reports the author's experience of the use intraperitoneal of Gore-Tex Dual Mesh Biomaterial in large incisional hernia operations in patients over seventy. From January 1999 to December 1999 we operated on 24 patients for treatment of abdominal wall defect. In all patients we used a Dual Mesh Plus Biomaterial. Overall mortality was 0. Morbility was 9.5%. Follow-up is too short for definitive considerations about the incidence of recurrences but our initial experience with this material encourages us to use it again for replacement of abdominal wall defects in the age.

[Tension-free hernioplasty in the aged. A report of 94 cases]

BACKGROUND

Tension free inguinal hernioplasty has become the procedure of choice in the elderly. The operation of originally popularized by Lichtenstein and Shulman gives the best early result with low complication rates.

METHODS

Between January 1991 and December 1996, 94 subjects over 70 with inguinal hernia were submitted to hernioplasty. The tension-free technique was adopted utilizing a polypropylene mesh. Peridural anesthesia was the method used in 67 procedures, local anesthesia in 27 procedures.

RESULTS

The mean hospital stay was 48 hours (short stay surgery). Noteworthy general complications were not observed. Superficial wound infection occurred in 2 patients; superficial skin hematoma in 4 patients. No recurrences were observed (mean follow-up 60 months). The primary inguinal hernias in the aged is due to a progressive deterioration of the inguinal floor (collagenolylis, overpowers net collagen synthesis and deposition in the floor of the inguinal canal).

CONCLUSIONS

Tension-free inguinal hernioplasty, originally popularized by Lichtenstein and Shulman, is simple to perform and gives excellent results with low complication rates. Current evidence suggests it as operation of choice in the elderly.

Recurrent hernia of Petit's triangle: a case report

The Authors describe a case of recurrent hernia of Petit's triangle in a 43-year-old man. The most salient feature of lumbar hernias is the difficulty of their treatment. Numerous, more or less complex techniques have been proposed for the repair of lumbar hernias. The classic procedure is that of Dowd (1907). Repair in this case consists of a flap of fascia and aponeurosis from the gluteus medius muscle which is elevated and rotated to cover the defect. Many modifications of this technique have been proposed. The modern prosthetics mesh materials allow a tension-free repair of lumbar hernias without distortion of the normal anatomy. Correct placement of a prosthetic mesh is relatively simple. Recurrences are due not to the material used, but to patches which are too small or too tight.

[Acute cholecystitis in patients over 80 years of age: indication for immediate surgical treatment]

The Authors analyse the results of very early surgical treatment in 43 patients over 80 years of age. The severity of morphological changes in the gallbladder and complicated course of the disease are the main factors causing an unfavorable effect on the results of a later treatment. Echography allows, in a high percentage of cases, to confirm the clinical doubt of acute cholecystitis. Cholecystectomy was carried out in all the patients within the first 6 hours (very early surgery-VES). The overall mortality rate was 7%; the morbility rate was 18%.

[Sarcoidosis with a prevalent splenic localization: surgical option (presentation of a case]

Sarcoidosis is a granulomatosis disease of unknown origin with a variable clinical presentation. The reported frequency of splenomegaly in sarcoidosis ranges from 1% to 40%. Splenomegaly has been associated with clinical evidence of more extensive thoracic and extrathoracic sarcoidosis. We describe an interesting case of sarcoidosis with giant splenomegaly and abdominal pain but no evidence of systemic involvement. Sarcoidosis must be considered in the differential diagnosis of splenomegaly. The main indication for splenectomy is splenomegaly with resulting discomfort and/or haematological abnormalities. Though the natural history of sarcoidosis is generally unchanged after splenectomy, in our patient the operation resolved the abdominal pain completely with no need for further therapy.

Conceptual problems of colon pathologies of surgical interest in the elderly

Case reports of 151 patients above the age of 70 years, treated with colon diseases of surgical interest, have been compared to those of 220 patients treated with similar diagnoses, but in younger ages. The case reports were evaluated on the basis of the available literary data, and interpreted from the points of view of the geriatric pathology. It is concluded that a correct interpretation of surgical pathologies of the colon in the elderly cannot disregard the knowledge of the age-dependent involutive processes concerning particularly this part of the digestive tract, and also other organs and systems in global sense. Aging of the mucosa of colon, after all, represents a more or less expressed reduction of its barrier function against oncogenic factors and pathogenic microorganisms. The degenerative lesions involving continuously the micro- and macrocirculation of the splanchnic regions result in a more frequent occurrence of complications (ischemia, perforations). The instability of the bioimmunological equilibrium and the presence of accompanying diseases complicate further the clinical picture which displays usually a few symptoms even during the evolutive phases of the diseases. Once the diagnosis has been achieved, the therapeutic strategies should be modified individually without giving up the main principles, however, always considering the possible expectations as regards the quality of life of each patients for the remaining life.

Follow-up study in 402 patients after parietal cell vagotomy for duodenal ulcer

In a recent six-year-period, a total of 402 patients underwent parietal cell vagotomy (PCV) for duodenal ulcer. An overall clinical assessment by Visik grading placed 328 (82%) in grade I, 56 (14%) in grade II, 12 (3%) in grade III and 4 (1%) with recurrent ulcer in grade IV. Results of the gastric secretory tests showed that the basal acid output (BAO) was reduced by 83.9% of the preoperative value, after 3 months, by 78.2% after one year, and by 65.3% and 66.4% after three and five years respectively. The maximal acid output (MAO) was reduced by 75.9% of the preoperative value after 3 months, by 45.3% after one year, by 40% and 42% after 3 and 5 years respectively. The radiological gastric emptying time showed no significant difference when compared to the preoperative value. The parietal cells showed significant ultrastructural changes six months after PCV, corresponding to maximum functional secretory depression. Two years after the operation, the parietal cells had regained their preoperative morphology.

[Effect of methisoprinol on postoperative immunodepression in subjects with malignant neoplasms]

The authors investigated the state of immunity, before and after surgery, in a group of 6 methisoprinol-treated patients and in a 10-patient control group both affected by malignant neoplasia. All the patients exhibited various degrees of immuno-depression. Versus the control group the group treated with 1-g methisoprinol injections at the dosage of 4 g daily for 7 days after surgery showed a positive effect on post-surgical immuno-depression.

[Coloportal fistula in ulcerative colitis (massive penetration, through the splenic vein, of barium and air into the portal system during barium enema)]

The authors describe one case of massive penetration of barium and air through the splenic vein into the portal system during administration of a radiopaque enema to a woman suffering from hemorrhagic proctitis in the florid phase. They provide a detailed description of this rare clinical case and discuss the possible etiology and pathophysiology of the observed event.

[Primary closure of the perineum after Miles's abdominoperineal amputation for carcinoma of the rectum (author's transl)]

In view of the results obtained in 32 cases of primary closure of the perineum after amputation of the rectum for cancer, the authors believe that this policy is best after removal of the malignancy by the abdominoperineal approach. Unquestionable advantages are shortening of the patient's hospital stay and a more rapid recovery; the possible disadvantages are relatively rare, from an uncommonly severe dysmetabolic situation to local disorders such as poor hemostasis, contamination of the operation site, inadequate preoperative antibacterial protection, or an unusually large tumor.

[The diaphragmatic relaxatio (author's transl)]

The Authors briefly describe two cases of diaphragmatic relaxatio that they have seen and studied; then they make a revision of the literature about this uncommon disease. They speak about embryogenesis of the diaphragm and about nosology, etiopathogenesis, frequency (ages and sex) and phatological anatomy of this disease. In conclusion the Authors discuss in detail signs and symptoms, diagnosis and surgical treatment of diaphragmatic relaxatio.

[Study of the behavior of gastric secretory function after proximal selective vagotomy for duodenal ulcer]

In 60 patients with duodenal ulcer subjected to S.P.V. operation, a study of gastric secretion (quantity of gastric juice, B.A.O., M.A.O., P.A.O., Hollander's test) and of gastrinemia before the operation, after one month and after one year was made. The results supplied by this study are: a marked reduction (over 50%) in the basal values and those after stimulation of the quantity of gastric juice and of acid secretion, with persistence of such reductions a long time after the operation. The finding of three cases with positive Hollander's test, which was negativised after administration of a beta-blocking drug, induced the Authors to a critical revision of the literature on the relations between sympathetic and parasympathetic innervation of the stomach in relation to gastric secretion.