Pneumomediastinum, subcutaneous emphysema and pneumorrhachis in asthmatic children

Pneumomediastinum (PM), subcutaneous emphysema (SE) and pneumorrhachis (also known as epidural air (EDA) or epidural emphysema) are very rare findings in children. PM is defined as the passage of air from intra-alveolar space to interstitium and, later, to the mediastinum. From the mediastinum, the air may catch up subcutaneous tissue (usually of the neck) and/or epidural space via the cervical fascial planes and neural foramina, forming respectively SE and EDA. The PM can be divided in spontaneous (or idiopathic) and secondary PM. Only few studies have evaluated the exact incidence of PM and its complications in children, and to define the correct diagnostic work up, treatment and outpatient follow-up. We report the case of a 9-year-old child with undiagnosed asthma that, during severe asthmatic flare secondary to acute infection of high airway, developed PM, SE and EDA.

[Lung cancer with bronchial stenosis due to foreign body and Entoameba gingivalis infection]

Oral cavity infection by protozoarian agents may lead to pathologies such as stomatitis and gengivitis. An higher incidence has been reported in immunocompromised patients and in patients with dental disorders. Entoameba gingivalis localizes into oral cavity and in particular into interstitial and interdental spaces. Infection propagation to bronchial or lung parenchyma represents a complication. In this report the Authors, starting from a recently treated case, discuss on the incidence, complications and surgical management of lung infection by Entoameba gingivalis.

[Bilateral and multiple traumatic pulmonary pseudo-cysts: a case report]

Traumatic pulmonary pseudocyst is a very rare consequence of blunt chest trauma characterized by formation of cystic like parenchymal lesions. Generally multiple and bilateral distribution is more rare than a single localization. The computed tomography (CT) scan has an higher diagnostic value compared with conventional chest X-ray. Prognosis of traumatic pseudocysts is generally good with benign clinical course and spontaneous resolution within several months. However initial strictly patient follow-up is necessary to early discover and treat potentially severe complications. Utility of chest magnetic resonance imaging (MRI) to exclude potentially severe infectious complications is described. Any complications required percutaneous drainage or surgical resection.

[Etiology, pathophysiology and management of post-traumatic pneumomediastinum: our experience]

The Authors reported the cases of posttraumatic pneumomediastinum came to their observation over the past 8 years. The etiology, pathophysiology, diagnosis, treatment and blunt injures eventually associated are discussed. Conclude that in the absence of associated injuries the treatment and the course of post-traumatic pneumomediastinum are the same that spontaneous pneumomediastinum.

[Pneumotorax and cannabis]

AIM

After having read the articles by Treasure and Beshay about the particular incidence of spontaneous pneumothorax (SP) in patients with daily consumption of Cannabis the authors took a strictly control of these subjects reviewing their personal experience in the treatment of this condition. In particular, the prevalence of SP has been evaluated through genomic assay of monocorial twins. The strong impact of the inflammatory phenomena that have always supported the emphysema burning is 10 time higher among worldwide population and patients with SP.

METHODS

In order to determine the real incidence of spontaneous pneumothorax in patients with proved daily assumption of Cannabis a retrospective analysis of patients with history of Cannabis drug abuse has been performed. In the period from January 2002 and June 2007,12 consecutive patients with SP and history of Cannabis abuse were enrolled. Selection criteria were: 1) age <16 years; 2) single-sided spontaneous pneumothorax; 3) history of daily Cannabis assumption. Patients with previous thoracic surgery/trauma and positive anamnesis for other drug assumption (ODA), snorkelling or work exposition to pollutions were excluded. In order to avoid the clinical overlapping of pathology and clinical symptoms due to other factors, patients with pleural effusion and documented similar episodes were excluded. This series focused on particular on twins. In all the patients an endopleuric drainage tube was inserted, and 3 patients underwent toracostomy.

RESULTS

No operatory mortality and/or complications were observed.

CONCLUSIONS

The role of the thoracic surgeon is important to sensitize on the problem of the circulation of light drugs among young people and their effects on the lung activity.

Chronic transverse sternal fracture. Role of CT scan and repair by an alternative use of the Synthes-Titanium Sternal Fixation System

Chest wall fractures, including injuries of the sternum, usually heal spontaneously without specific treatment. However sometimes, they need surgical treatment. To treat these patients the selection criteria often are subjective in spite of many surgical devices for sternal osteosynthesis are available nowadays. One of the most recent device is the Synthes-Titanium Sternal Fixing System, usually used to treat post-sternotomy dehiscence. We describe the case of a 67-year-old man with previous history of chest trauma presenting to our institution with chronic transverse sternal fracture. We describe the pre-operative study, stressing the particular role of the CT scan and a surgical approach by an alternative use of the Synthes.

Misunderstood cardiac involvement with heart impairment in traumatic sternal fracture: an enzyme-guided evaluation

BACKGROUND

Isolated sternal fractures occur more and more frequently in traffic road accidents in particular after the introduction of the seat-belt law. This study sets out to assess by laboratory parameters the incidence and consequences of pericardial and myocardial involvement in sternal injury.

PATIENTS AND METHODS

Between June 1997 and March 2007, 50 consecutive patients were admitted to our Thoracic Surgical Unit with acute traumatic sternal fractures. X-ray, CT scan, standard 12-lead electrocardiogram (ECG) and echocardiographic evaluation were obtained in all patients. (28 males, 22 females), with displaced and undisplaced fractures. The patients were hospitalised for cardiorespiratory monitoring, pain control and physiotherapy. Oxygen implementation was performed to obtain an arterial saturation above 96%. Supplementary investigations or therapeutic interventions were assessed if clinically indicated.

RESULTS

Our data, according to literature, show that sternal trauma must be careful evaluated by monitoring of vital parameters. In our collection we have no mortality with complex comorbidity. The interparametric relation between laboratory values and cardiac involvement was not significant anyway . The prolonged CK-MB peak level in a large number of patients is related with cardiac impairment.

CONCLUSIONS

Our results suggest that in traumatic sternal fractures enzymatic activity of CK-MB, echocardiographic investigation and careful monitoring for the first 96 hours are necessary. The cardiac compliance is inadequate in polytrauma patients and can lead to cardiac impairment.

[Thoracic trauma: incidence, social and economic costs, educational opportunities. Experience on the last eight years of Thoracic Surgical Unit of Messina University]

The Authors, after extensive introduction on the incidence, etiology, classification, pathophysiology, possible complications, diagnosis and treatment of thoracic trauma, relate their experience on the last eight years, stressing the diagnostic and therapeutic strategy in management of trauma simple and complicated and assessing finally serious social impact of these pathologies and the educational opportunities provided.

Endovascular repair of aortic lesions associated to video-assisted thoracoscopy surgery after chest trauma

AIM

Trauma of the thoracic aorta for blunt trauma shows a very high incidence of mortality. Hospital mortality rate after aortic open surgery is between 15% and 30%. Endovascular management represents an alternative treatment Associated lesions are usually seen in those critical patients. Hemothorax may be present. The authors propose a combined treatment of endovascular repair for the aortic lesion and video-assisted thoracoscopy surgery (VATS) for the treatment of chest bleeding complications.

METHODS

The authors report a series of three patients with post-traumatic aortic lesion and hemothorax. In two patients endovascular procedure was first performed, followed by VATS, few days later, for retained hemothorax. In the third patient the two procedures were performed at the same time because of the patient's critical conditions.

RESULTS

There was technical success of stent-graft placement in all the treated cases. No postoperative mortality. No postoperative paraplegia. No VATS converted to thoracotomy. The postoperative follow-up time range between 10 and 19 months.

CONCLUSION

Considering the relatively short procedural time and minimally invasive approach of both techniques, the concomitant use of them may represent an alternative to standard open surgery in cases of thoracic aorta lesions associated with hemothorax. Those procedures may be performed sequentially or together in emergency cases with intra-thoracic more active bleeding to exclude or to treat intra thoracic bleeding.

Lung cancer and cardiovascular diseases: occurrence, comorbidity and surgical timing

AIM

The authors discuss tumor histological type, TNM staging and time of first occurrence of lung cancer, as well as related cardiovascular diseases, underlining type of treatment, surgical timing, surgical mortality, post-surgical complications and potentially additional therapies.

METHODS

A total of 189 patients underwent surgery for non-small cell lung cancer (NSCLC) (Stage I-II), 35 (17.5%) of which presented with surgically relevant concurrent cardiovascular disease (8 coronary artery disease, 4 carotid stenosis, 8 obstructing artery disease, 15 aortic aneurysm). In most cases, surgical timing provides for cardiovascular disease treatment completion first, followed by lung resection only afterwards. Alternatively, concomitant cardiovascular and lung cancer treatment averts the need for repeated surgery, even though the intraoperative complications rate is higher, as long as patients are hemodynamically stabile.

RESULTS

No remarkable surgical mortality was observed; stay in hospital ranged from 8 to 18 days. A 5-year follow-up was carried out in only 95/189 patients; 11/18 (61%) with concurrent cardiovascular disease and 46/77 (59%) with lung cancer alone are still alive.

CONCLUSIONS

In 17% of cases, surgical treatment by the simultaneous and the differentiated approach for cancer and cardiovascular disease proved essential; comorbidity as an identifier of the strong correlation between the two diseases had a major impact on prognosis.

["Intentionally" limited pulmonary resection versus lobectomy for the treatment of peripheral stage IA non-small cell lung cancers]

BACKGROUND

The purpose of this study is to assess, through the retrospective analysis of our experience and the literature review, whether the limited pulmonary resection is comparable to lobectomy for treatment of the peripheral stage IA (T1N0M0) non-small cell lung cancers (NSCLC), in terms of oncologic radicality, survival and rate of local, regional and systemic recurrences. Moreover it has been considered the impact of the limited resections in comparison with the lobar resections on the postoperative pulmonary function.

PATIENTS AND METHODS

We have analyzed a consecutive series of 36 patients, 28 men and 8 women, of inclusive age among the 61 to 81 years (average 73 years), who underwent surgical resection from January 2000 to December 2003 for T1N0M0 peripheral NSCLC; 11 limited resections and 25 lobectomies have been performed. Comparatively survival and recurrences (follow-up period of 3-5 years) are been analyzed, as well as the pulmonary function tests at 1 year after surgery.

RESULTS

The 3-year and 5-year survivals were 88% and 82% in the patient's group underwent to limited resection , 93% and 88% in the patient's group underwent to lobectomy. Postoperative local recurrence was noted in 1 patient (9%) of the first group and in 1 patient (4%) of the second group. One year after surgery was noted a moderate decline in the forced expiratory volume in 1 second (FEV1) and in the diffusing capacity for carbon monoxide (DLCO) in the patients who underwent to lobar resection, whereas in the patient's group submitted to limited resection was observed a substantial maintenance, except for the DLCO, of the preoperative pulmonary function tests.

CONCLUSIONS

Our limited experience, according to the actual tendencies of the literature, show that the limited pulmonary resections, in selected patients with peripheral stage IA NSCLC, represents a valid alternative to lobectomy in terms of survival and recurrence's rate, also determining a lower decrement of the postoperative pulmonary function. Therefore the segmentectomy can be considered, in such cases, the gold-standard procedure even if the patient is able to bear a wider resection.

[Indications, surgical strategies and evaluation of prognostic factors in the treatment of pulmonary metastases]

Pulmonary metastases resection is a method universally accepted in selected patients. Long-term survival reaches good levels after complete resection of lung metastases independently of primary tumour histology. The Authors emphasizes literature data; they report data of their experience no statistically significant but useful for valuation of results. They discuss of advantages vs disadvantages of the surgical procedures. In conclusion they believe metastasectomy is a safe treatment of pulmonary metastases.

[Post-operative analgesia in thoracic surgery: physiopathological features, therapeutic framework and methodologies]

Pain after surgery is a major handicap for patients as it bounds and decreases ability for spontaneous movement, cough and deep breathing, aiding the onset of complications and invalidating the recovery capabilities of operated patients. In thoracic surgery, the need to compile and employ guidelines for post-surgical pain management has become a pressing requirement in recent years. Currently available protocols include several options of treatment that are frequently a subject in the most recent scientific papers and play a key role, as they constitute the framework upon which building with changes and fixes that take account of incidental circumstances, in relation to both patients and surgery, again for both the organizational and structural features of the surgical environment. Purpose of this job is a thorough analysis of post-operating analgesic treatments for thoracic surgery, introducing the most effective ones currently available as for channels and procedures of administration, as well as possible side effects or complications.

[Percutaneous radio frequency thermal ablation of non-resectable lung cancer: state of the art]

BACKGROUND

Unfortunately, as of yet, most lung cancers are not operable as soon as diagnosis is available; in these situations chemo- and radio-therapy still play a key role, albeit palliative, improving survival rate moderately, but are not lacking in toxic effects, especially in case of concurrent pathology, reduced cardio-respiratory functionality or being advanced in years. Therefore thermal ablation mini-invasive techniques, already employed as ancillary treatments of hepatic cancer or in place of surgery, have been performed for these pathologies.

AIM

Aim of this work is to define the current state of the art for Radio-Frequency Ablation (RFA) to be performed on non-resectable lung cancer, also by means of a thorough review of international literature, from which to infer purposes, suggestions, methodologies, effectiveness, safety, complications and achievements, also in terms of the possible improvement of life quality and/or survival expectancy.

PATIENTS AND METHODS

Patients have been carefully selected. Pulmonary nodules have been treated with TC or echo-guided percutaneous thermal ablation and, afterwards, evaluated by radiological and clinical (sometimes histopathological) follow-up.

RESULTS

The size of the RFA-treated nodules is necessary in order to evaluate full or partial necrosis extent and, therefore, average survival rate.

CONCLUSIONS

Availability of more extensive and homogeneous case histories, as well as standard follow-up (TC and/or histopathological sampling) methodologies, is required. Nevertheless several authors agree that RFA is a safe and effective technique within the framework of a substitutive or complementary treatment of non-operable lung cancer. The best results can be achieved for cancers less than 3 cm wide; RFA, performed before chemo- and/or radio-therapy, plays a neoadjuvant role for larger cancers, decreasing cancer volume and weakening the symptoms.

[Safety and effectiveness of lung volume reduction surgery for treatment of chronic obstructive pulmonary disease]

Lung volume reduction surgery (LVRS) has been proposed and performed in order to decrease dyspnea and improve wordly life without major impairments in oxygen-dependent patients affected by serious chronic obstructive pulmonary disease (COPD) and severe dyspnea that doesn't suffer drastic alterations notwithstanding rehabilitation procedures tailored for the specific case. The purpose of LVRS is to optmize thoraco-pulmonary dynamics, considerably compromised in these patients, relaxing the serious expiratory restraint to airflow and improving the muscular respiratory functionality. In this work the authors bring forth the physio-pathological foundations that justify the use of LVRS, also analyzing data brought by the international literature about surgery guidelines, short-term morbidity and mortality, clinical-functional effects and long-term survival. They also underline the need for careful evaluation research, aimed at getting a precise account of cardio-respiratory functional outcome, that will enable the positive accomplishement of the demanding and risky surgery, especially whenever the pathology has reached remarkable proportions or appears to be bilaterally localized. Only committing to painstaking analysis, setting and customization protocols, the latter especially addressing carefully chosen patients, can the surgeon rely on to achieve both short and long-term positive outcomes.

[Malignant pleural mesothelioma: early diagnosis and multimodality management]

Malignant pleural mesothelioma (MPM) is a cancer with a poor prognosis, and its incidence increase, mainly as a result of exposure to asbestos. Universally acknowledged therapeutic approaches still don't exist at the moment, because of its refractory behaviour to all standard therapies; treatment protocols inclusive of either surgery, radiotherapy or chemotherapy have been largely employed, but usually with little impact on survival. For potentially operable pleural mesotheliomas new treatments tend to combine surgery both with new chemotherapy drugs and radiotherapy, in order to improve remarkably survival rates in selected cases. Other approaches, i.e. palliative, proved to be useful in the treatment of two major symptoms, namely dyspnea and thoracic pain. In this work the Authors are reporting their experience with malignant pleural mesothelioma, stressing the role of videothoracoscopy in the early diagnosis, weighing the radical cancer resection option and the effectiveness of multimodal treatment.

[Haemothorax and chylothorax: surgical approach]

Diseases causing blood accumulation in the pleural space (or haemothorax) are usually very demanding for diagnosis and require a multidisciplinar therapeutical approach in emergency. So, their treatment should always be immediate and should aim to restore the optimal patient's haemodynamic conditions and to find the site of bleeding. Chylothorax, a lymphatic effusion in the pleural space, is also a very important pathology, as it effects the nutritional and immunological state of the patient causing pleural involvement and respiratory insufficiency. Stabilisation of vital parameters with adequate systemic therapies (blood perfusions, fluids and pro-coagulation factors, TPN) preceeds surgery, which can be the placement of a thoracic drain or emergency thorascopy and/or thoracotomy. The Authors report the casistic of the latest three years for diagnosis and treatment of haemothorax and chylothorax stressing the advantages of a minimal invasive approach for evacuation and identification of the origin of bleeding and haemorrhage and/or lymphatic effusion control.

[Bronchial arteries: anatomical and clinical studies and strategies in surgical approach]

One of the most important and controversial aspects of thoracic surgery is due to the topographical and surgical anatomy of the vascular structures involving the mediastinum. The knowledge of the so-called "vascular time", in fact, allows to face more complicated surgical situations, typical of the most specialistic thoracic surgery. The bronchial arteries represent a paradigm of what we have just stated. The study of their anatomy (number, position, origin, distribution and relationships with the mediastinal structures) is of relevant importance, not only for the interest the bronchial vascular tree arises in tracheo-bronchial surgery and in pulmonary transplantology, but also for the knowledge of the pathogenesis of some processes regarding pulmonary and pleural pathologies. The aim of this paper is to evaluate the real clinical interest of bronchial arteries, with an analytic study of the anatomy of vessels, and with the possibility to show the most frequent and characteristic anomalies involving the origin and course of these arteries.

[Surgical treatment of hydatid cysts]

Hydatidosis represents a form of helminthic zoonosis with a stronger medical, social and economic impact. It is endemic in some areas of the world including Mediterranean countries, and therefore Italy. The disease is often diagnosed in an advanced phase, due to the poor symptomatology in the early stages. The best treatment is surgery. Emergency surgery is similar to elective surgery, though in some cases is preferable only a drainage procedure until the stabilization of the genreal and local conditions of the patient allow a radical intervention. The Authors report on their five year experience of surgical treatment of compliated pulmonar hydatidosis pointing out that exeresis must be aimed at preserving pulmonar function as much as possible.

[Surgical treatment of celomic cysts]

Celomic cysts (pericardiopleural or serous cysts) are rare, as they account for about 30% of all the homoplastic disembryogenetic lesions of the mediastinum. There is not usually a characteristic symptomatology associated with this anomaly, which is, however, easily diagnosed by means of the most common radiologic techniques. The TC together with the MRI provides all the necessary data for an appropriate management of the patient. The Authors report on their five year experience of the surgical treatment of celomic cysts, pointing out that surgery must be aimed at preserving pulmonary function as much as possible. They finally maintain that the first surgical approach should be video-thoracoscopic with the aid of a minithoracotomy, if necessary.

[Combined video-thoracoscopic, surgical and endovascular treatment in a case of ascites and recurrent bilateral pleural effusion]

Among recurrent pleural effusions a role of remarkable importance is held by those combined with ascitis due to the difficulty of their treatment, even using widely tested techniques. The incidence of such pathology varies from 4% to 6% of patients suffering from cirrhotic pathology, reaching 10% in cases with advanced illnesses. Pleural effusions involve the right emithorax more frequently than the left one, but it can show up bilaterally too. Its etiopathogenesis is tied up to the direct passage of ascitic liquid into the chest and, during the past years, numerous theories have been described to explain this migration. The Authors report the case of a patient with interesting considerations for the diagnostic difficulties and the peculiarity of the treatment performed.

[Evaluation of lung function as a prognostic index before and after surgical resection due to NSCLC]

BACKGROUND

Although there were several studies on survival, death and morbidity rates after lung resection, considering both limited and extended resections, lung exercise capacity has been quite seldom taken into account as an index for prognosis. The aim of this study compare the consequences of three kinds of lung resections (pneumonectomy, lobectomy and wedge resection), to test pre- and post-surgery exercise capacity for patients affected by NSCLC in order to obtain more detailed prognostic indices.

METHODS

All the patients were studied by means of thorough lung static function and hemogas analytical tests before and after surgical resection, from 15 days to 12 twelve months' time past surgery.

RESULTS

In fact, in relation to lung resection due to neoplasms, several studies pointed out that zone-limited resections show an obvious anatomical benefit in terms of parenchyma spair compared to lobectomy; however, it is underlined that the functional benefits of small resections don't really prevail over post-lobectomy anatomical advantages. Furthermore local relapses are more common after small resections rather than after lobectomy.

CONCLUSIONS

Neither limited lung resection nor lobectomy alone, therefore, in accordance with nearly all the recent and still ongoing studies in this huge research field, has a significant effect on exercise capacity. Only pneumonectomy is associated with impaired exercise performance, and, nevertheless, quite below our expectations.

[Role of thymectomy in the treatment of myasthenia gravis: considerations and personal cases]

The therapeutic impact of thymectomy on the clinical course of myasthenia gravis is still very controversial. In fact, while nowadays the surgical approach is widely adopted for thymomas, its role is still debatable in patients suffering from myasthenia gravis. The surgical approach of choice for total thymectomy is represented by median sternotomy. Other surgical methodologies include cervical access and partial sternotomy. All these approaches have shown excellent results in the exeresis of the thymus. More recently video-assisted thoracoscopic thymectomy has been proposed as a less invasive and similarly effective technique for the removal of this organ and the treatment of myasthenia gravis. Aim of the present study is to report Author's experience with thymectomy, emphasizing the data available in the international literature on the surgical mortality, complications and aesthetical results of the different surgical accesses.

[Intraoperative pleural lavage for restaging of bronchogenic carcinoma]

BACKGROUND

Although lung cancer staging has been recently reviewed, a significant number of recurrences and an increased incidence of mortality is common also in the initial stages of the disease. All that is probably due to disease staging underestimation and emphasizes that an exact system of staging cannot be considered a stand-alone prognostic and therapeutic index.

METHODS

Between October 2000 and November 2001, 37 patients have undergone surgical intervention for NSCLC in our Surgical Unit; 28 of them were male (75.7%), 9 female (24.3%), aged between 55 and 70. Neither cancer-related pleural effusion, nor mediastinal lymphoadenopathy had been detected under Rx and TC inspection in any patient.

RESULTS

Pre-surgical pleural washing (PLC), which defines the positiveness of the cytological result (D+), in 17 patients (45.9%) was positive, in the remaining 20 (54.1%) negative. The positiveness of PLC was 35.3% (6/17) and 64.7% (11/17) in the initial stage of T (T1 and T2) and in the advanced stage (T3 and T4) respectively.

CONCLUSIONS

On the basis of personal experience, the authors, suggest that pre-surgical resection pleural washing searching premature microscopic pleural disseminations in NSCLC-affected patients should become an important prognostic factor for the disease outcome. Moreover, they emphasize how this procedure is easy, with a small increase in the surgical intervention time, and nearly costless.

Primary aortoduodenal fistula including the afferent loop of a Billroth II anastomosis. A case report

Primary aortoenteric fistula is a very rare consequence of the evolution of an abdominal aortic aneurysm (AAA). The 3rd and 4th portion of the duodenum are involved in up to 80% of all cases. Frequently, gastrointestinal bleeding represents the first symptom, and diagnosis is difficult because of the aspecific clinical presentation and course, characterized by alternating remission and relapse; this is the reason why surgical treatment is usually delayed and therefore such events are managed as emergencies with a preoperative and intraoperative high death rate. We report the case of a 76-year-old man with a primary aortoduodenal fistula, who was submitted to gastric resection according to Billroth II 20 years before. This case could be interesting for its anatomical peculiarities favourable to the formation of the fistula.

[Traumatic rupture of the esophagus caused by foreign body. Surgical treatment and results]

The aim of the study was the evaluation of emergency surgical treatment of traumatic oesophagus rupture due to the foreign body observed between 1990 and 1999. In three cases there was fortuite ingestion of foreign bodies (metallic money; alimentary particle; dentary prosthesis) and in one case it was a suicide attempt with ingestion of mascellary prosthesis. One case of death (25%) was observed, due to septic mediastinitis with pleuric compromision. The rarity of these lesions with high rate of mortality from septic mediastinitis and importance of early treatment are outlined.

[Pulmonary hernia]

Chest-wall hernia is a very unusual pathological event. The Authors report a singular diagnostic case of chest-wall hernia, miming rib tumor. Instrumental diagnostic tools and surgical treatment is reported. Finally patient's follow-up is discussed.

[Intestinal angiodysplasia]

Intestinal angiodysplastic lesions represent one frequent source of gastro-enteric tract serious bleedings, endowed with present-day therapeutic implications. The Authors report a singular case of a bleeding of this kind. A selective arteriography analysis of the superior mesenteric artery immediately pointed out the necessity for a surgical intervention, which however has not proved being resolutive for recovery, because massive intestinal hemmorrhage recurrence occurred. The left gastric artery anomalous origin, being discovered in the first branch of the mesenteric artery, which was not recognized fully in advance, stressed, in fact, the need for a partial gastrectomy, firstly, and a full gastrectomy, subsequently. The post-surgery course got more serious for a small leak of the oesophageus-digiunal anastomosis and for a serious renal failure. NPT and haemodialysis helped to quickly solve those complications. Other hemorrhagic events have not occurred anymore, 5 years having passed since the surgical intervention.

[Endoscopic obstruction treatment]

The Authors reported the last year personal experience of disobstruction endoscopic therapy; they described therefore an examination of the several techniques proposed from the international literature and in particular dwell upon laser-therapy and airway stents implantation. They emphasized the treatment importance, mostly palliative, but the effective symptomatology improvement due to airway obstruction, bleeding, pain and secretions retenction. They emphasize finally the necessity of a careful and scrupulous patients selection for disobstruction endoscopic therapy.

[Treatment of bleeding esophageal varices: sclerotherapy or surgery?]

To evaluate therapeutic options to improve the prognosis of haemorrhage from oesophageal varices, a study was performed on 422 patients observed from 1983 to 1998. Patients were classified according Child-Campbell method after improvement of general conditions (class A: 7%; B: 68%; C: 25%). Thirty-two patients (7.8%) died during emergently pharmacologic treatment in the first 24 hours; 182 patients (44.6%) because of persistent haemorrhage underwent endoscopic sclerotherapy. In 164 (90.1%) bleeding stopped and 14 cases (7.6%) underwent emergency surgical treatment (9 splenectomies and splenorenal shunts, 5 mesenterico-caval shunts). Teu other patients (with rebleeding 3-7 days after sclerotherapy) underwent emergency surgical treatment (7 azygos-portal thoracotomic deconnections, 3 splenectomies and spleno-renal shunts). The rates of therapeutic success were respectively 80% for surgical treatment and 90% after sclerotherapy. Factors of prognostic improvement of these emergently disease are examined. The advantages of both endoscopic and surgical treatment are outlined.

[Azygos lobe and spontaneous pneumothorax]

The association azygos lobe-pneumothorax is a very rare event described in literature. The Authors report a case observed. The surgical procedure performed by traditional thoracotomy, was carried out with the section of the azygos and the resection of small blebs in pulmonary apex. Finally, emphasized possible different pathogenetic mechanisms.

[Thyroid surgery yesterday, today, tomorrow]

The Authors, after a bibliographic research on the matter, report the development of thyroid surgery, from the beginning at today.

[Surgical indications in pulmonary tuberculosis]

Since the begin of the century, the surgery for treatment of pulmonary tuberculosis showed an important evolution. The procedure has proved to be useful in the 20% of patients. It appears that the percentage is drug-resistant or complicated. The authors describe their experience in the years from 1992 to 1997 and, in accordance with the literature in this field, outline the good prognosis to 5 years, with a percentage of 90-96% of non-infected patients. Very important is the time of surgical intervention, the compliance of the medical treatment in the previous 6 months, excepting in the emergency, and the perfect obliteration of pleural cavity to avoid next reinfection and the development of broncopleural fistulas.

[Surgical treatment of arterial hypertension: experience and results]

Hypertension is a wide spread disease. In a small percentage of cases (nephrosclerosis, renovascular hypertension, endocrine hypertension) surgical treatment could be resolutive. The Authors describe their experience of the last five years about the subject, emphasize the technical detail taken and the results achieved; they outline the necessity to give the indications for surgery in wise manner considering clinical, laboratory and instrumental findings.

[Thyroid surgery in assisted local anesthesia]

To evaluate the advantages of thyroidectomy under assisted local anesthesia, 35 cases operated on from January 1998 to February 1999 were reviewed. The patients were studied in ambulatory setting and adequately informed on the program of thyroid operation under local anesthesia. Multinodular goitre was present in all the cases. In 12 cases, it was intrathoracic. The morning of operation, all the patients underwent to pre-operative sedation and, in operative room, to local anesthesia with Mepivacaine 1% and adrenaline 1,200,000 U. The operations were performed with a mean of 30 cc of local anesthetic. During operation, in none case the conversion to general anesthesia was necessary. No mortality and morbility were registered. In the majority of cases, an analgesic was necessary meanly 4 hours after operation. The evening of operation in all the patient oral nutrition was restored. Twenty-nine patients were discharged from the hospital 48 hours after surgery. Eight days after operation, surgical recovery was evident in all the patients reviewed in the out patients setting. The advantages of thyroid surgery under assisted local anesthesia are outlined.

[Elective and emergency minimally invasive surgery in pleural diseases]

In the last years the video-assisted thoracic surgery (V.A.T.S.) assumed an important order for the diagnosis and treatment of the pleural disease. In this particular field, the procedure allows obtaining almost the same outcomes of traditional surgery and is very safety. V.A.T.S. reduces hospital time and trauma with a fast return to the working life. The Authors describe their experience and outline the diagnostic and therapeutic indications for the treatment of choice and emergency.

[Reconstruction of the thoracic wall]

The resection of the thoracic wall for cancer, traumas or results of radiotherapy could require a reconstruction of the same wall with prosthetic material of different nature to the purpose of protect the important intrathoracic structures, avoid the flail chest and maintain a ventilation adjusted with aesthetically acceptable results. Numerous and varied they have been and they are the materials used to such aim, but the more numerous experiences concern the reconstructions of the wall with the employment of nets of Marlex or the patch of Gore-Tex. In the complete two years eight patients have arrived at our observation in which a prosthetic reconstruction has been performed with heterologous material. In three of them has been used the net of Marlex, in five the patch of Gore-Tex of two millimeters of thickness. The prostheses have stayed well you bear and in all the patients the authors have gotten a good stabilization of the thoracic wall.

[Open-window surgery of pleural empyema]

Thoracoscopic is performed for treatment of pleuric empiema with 65% of recovery. In the old patients the Authors achieved high grade of recovery with open window (OW) procedure. In the last two years, 7 patients with pleuric empiema underwent this treatment. In two patients the origin was tuberculosis, in 4 empiema was post-pneumonitic; in one case the cause was broncho-pleuric fistula after pneumonectomy. All the operations were performed under general anesthesia. The Authors began with thoracoscopy, drainage of cavity and then they performed the resection of one or more ribs and a pleuro-cutaneous flap: 5 patients recovered without complications. OW seems to be very useful in the case in which more radical approach is impossible. Continuous irrigations of the cavity, with rapid pulmonary expansion, permits recovery without the use of myocutaneous flaps.

[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.