Portomesenteric vein thrombosis following sleeve gastrectomy: Case report focusing on the role of pathogenetic factors.

INTRODUCTION: Sleeve gastrectomy has currently become the most commonly performed bariatric. procedure worldwide according to the last IFSO survey, overtaking gastric bypass with. a share of more than 50% of all primary bariatric-metabolic surgery. Gastric leak, intraluminal bleeding, bleeding from the staple-line and strictures are the most common complications. Portomesenteric vein thrombosis (PMVT)after sleeve gastrectomy is. another complication that has been increasingly reported in case-series in recent.years, although it remains uncommon. In this case report is described an extended portomesenteric vein thrombosis after. sleeve gastrectomy interesting splenic vein too with a favorable course and an. uneventful follow-up. We try to search in this case for pathogenetic factors involved in. this complication. CASE REPORT: A 42-year old man, with a body mass index (BMI) of 45 kg/m2, with a medical history of Obstructive Sleep Apnea Sindrome (OSAS) underwent laparoscopic sleeve gastrectomy. Early postoperative course was uneventful. Six days after discharge he complained abdominal pain and was admitted at the Emergency Department. A CT scan with intravenous contrast showed an occlusion of the portal vein, of the intrahepatic major branches and an extension to the superior mesenteric vein and the splenic vein. The patient received heparin and oral anticoagulation together with intravenous hydration and proton pump inhibitors. Considering the favourable course the patient was discharged after six days with long-term oral anticoagulation therapy. Anticoagulation with acenocumarol was continued for six months after a CT scan showed resolution of the PMVT without cavernoma. He had no recurrence of symptoms. DISCUSSION: Porto-mesenteric thrombosis after sleeve gastrectomy is a rare complication but it has been increasingly reported over the last 10 years along with the extensive use of sleeve gastrectomy. Because PMVT is closely associated with sleeve gastrectomy in comparison with other bariatric procedures, we need to investigate what pathogenetic factors are involved in sleeve gastrectomy. Thrombophylic state, prolonged duration of surgery, high levels of pneumoperitoneum, thermal injury of the gastroepiploic vessels during greater curvature dissection, high intragastric pressure, inadequate antithrombotic prophylaxis and delayed mobilization of the patient after surgery have been reported as pathogenetic factors of portmesenteric vein thrombosis. Most of the cases presented in the literature such as our clinical case resolve with medical therapy, although portal vein thrombus extends into the superior mesenteric vein and the splenic vein. CONCLUSION: Portomesenteric venous thrombosis is a rare but serious complication of bariatric surgery, especially associated with sleeve gastrectomy. Diagnosis is based on CT examination with intravenous contrast, and initial therapy is anticoagulation. Etiologic factors reported in the literature include a long duration of surgery, a high degree of pneumoperitoneum, high intragastric pressure after sleeve gastrectomy and thermal injury to the short gastric vessels and gastroepiploic arcade. Limited operative time, controlled values of pneumoperitoneum, careful dissection with energy device of gastric greater curvature, appropriate prophylaxis with low molecular weight heparin may be useful tools to prevent and limit this complication. Nonetheless we have to search which factors may condition the evolution of an extended PMVT as that described in this case towards resolution or to a further worsening clinical state. Early diagnosis? Correct treatment? Undiscovered patientrelated factors?

Cavitary lung metastasis as relapse of prostate cancer.

Prostate cancer is the most common non-cutaneous malignancy diagnosed in men. It usually metastasizes to bone as osteoblastic lesions on radiographs and regional lymph nodes, and uncommonly to lung, liver and brain. Metastatic prostate cancer recurrence after definitive local therapy can occur in any tissue. The role of fine needle aspiration cytology (FNAC) for diagnosis of metastatic malignancies is well established in literature. We describe a 74 years old male, previously treated for localized prostate cancer, admitted to our Department after total body computed tomography revealed multiple irregular lung lesions some of which had an excavated appearance.

New records of larval stages of the eel cod genus Muraenolepis Günther 1880 (Gadiformes: Muraenolepididae) from the western Antarctic Peninsula.

Three newly discovered larval specimens of the genus Muraenolepis collected from the waters of the western Antarctic Peninsula are described. Knowledge of their natural history is sparse and information about their early life history is based on only a few larval stages. Here, the available literature on larval eel cods is reviewed, and the specimens placed in context.

Role of the quantiferon-TB test in ruling out pleural tuberculosis: a multi-centre study.

Diagnosing pleural tuberculosis (plTB) might be difficult due to limited sensitivity of conventional microbiology tools. As M. tuberculosis (MTB)-specific T cells are recruited into pleural space in plTB, their detection may provide useful clinical information. To this aim, in addition to standard diagnostic tests, we used the QuantiFERON-TB Gold In-Tube (QFT-IT) test in blood and pleural effusion (PE) samples from 48 patients with clinical suspicion of plTB, 18 (37.5%) of whom had confirmed plTB. Four of them (22.2%) tested positive with a nucleic acid amplification test for MTB. The tuberculin skin test was positive in most confirmed plTB cases (88.9%). Positive QFT-IT tests were significantly more frequent in patients with confirmed plTB, as compared to patients with an alternative diagnosis, both in blood (77.7 vs 36.6%, p=0.006) and in PE samples (83.3% vs 46.6%, p=0.02). In addition, both blood and PE MTB-stimulated IFN-gamma levels were significantly higher in plTB patients (p=0.03 and p=0.0049 vs non-plTB, respectively). In blood samples, QFT-IT had 77.8% sensitivity and 63.3% specificity, resulting in 56.0% positive (PPV) and 82.6% negative (NPV) predictive values. On PE, QFT-IT sensitivity was 83.3% and specificity 53.3% (PPV 51.7% and NPV 84.2%). The optimal AUC-derived cut-off for MTB-stimulated pleural IFN-gamma level was 3.01 IU/mL (77.8% sensitivity, 80% specificity, PPV 68.4% and NPV 82.8%). These data suggest that QFT-IT might have a role in ruling out plTB in clinical practice.

Performance of two commercial blood IFN-gamma release assays for the detection of Mycobacterium tuberculosis infection in patient candidates for anti-TNF-alpha treatment.

The reactivation of latent tuberculosis (TB) is a major complication of tumor necrosis factor (TNF)-alpha inhibitors. Screening for TB infection is recommended before anti-TNF therapy is initiated; however, the use of tuberculin skin testing (TST) is controversial, due to the high rate of false-negative results in patients receiving immunosuppressive treatment. To compare the performance of two commercial interferon (IFN)-gamma release assays (IGRA), T-SPOT.TB (TS-TB) and QuantiFERON-TB Gold "In-tube" (QFT-GIT), with TST for the detection of TB infection in patients due to start anti-TNF therapy, 69 human immunodeficiency virus (HIV)-negative Italian patients (mean age: 45.2 +/- 12.6 years; male=39) were enrolled between September 2005 to August 2006. Patients affected by rheumatoid arthritis (n = 18), psoriatic arthritis (n = 26), ulcerous rectocolitis (n = 6), and Crohn's disease (n = 19) were tested simultaneously with TST, TS-TB, and QFT-GIT. Overall, 26% of patients were positive by TST, 30.4% by TS-TB, and 31.8% by QFT-GIT. Agreement with TST was similar (kappa = 0.21, p = 0.0002 and kappa = 0.26, p < 0.001, respectively). In 11 TST-negative cases, IFN-gamma release assays were positive. In addition, in seven Mantoux-positive cases with no TB risk factors, TST result agreement was achieved with at least one blood test. Indeterminate results were detected in 5.8% and 2.8% of cases, respectively, with TS-TB and with QFT-GIT (p = not significant [ns]). In conclusion, our results suggest that IGRAs may be helpful for screening purposes in patient candidates for anti-TNF therapy to confirm positive TST results and in selected cases when false-negative results are suspected. The utility of blood tests in patients with low or no TB risk remains to be assessed.

[Magnetic resonance study of renal function. Preliminary evaluation]. / Studio della funzionalità renale con risonanza magnetica. Valutazioni preliminari.

The amount of functioning renal parenchyma can be estimated by MRI by considering the ratio between the mean intensities of cortical and medullar zones of the kidney. Fifty-six patients and 5 healthy volunteers were studied by MRI in our department. Scanning was performed with a superconductive magnet system operating at 0.5 Tesla. Pulse sequence was Spin-Echo with TR 300/TE 30 ms. The cortico-medullary ratio (CMR) and differentiation (CMD) were standardized and related with creatine blood levels. CMR data ranged from 1.05 to 3.00, while CMD data ranged from 0.04 to 0.50. High values (good cortico-medullary contrast) were observed in subjects with normal renal function. Patients with renal diseases had low CMR and CMD, proportionally to the degree of renal failure, as proved by laboratory findings. Our preliminary study seems to demonstrate that MRI is an useful technique in the follow-up of patients with chronic renal disease.

[Role of magnetic resonance in the staging and post-chemotherapeutic follow-up of malignant maxillo-facial tumors]. / Ruolo della risonanza magnetica (RM) nello staging e nel follow-up post-chemioterapico dei tumori maligni maxillo-facciali.

Ten patients with squamous cell carcinomas located in the maxillo-facial region were studied. In all cases the staging by Computed Tomography (CT) and Magnetic Resonance (MRI) revealed metastatic lesions in stage T3-T4. All patients underwent polichemotherapy before surgery. MRI proved to be more accurate in the staging of tumors in 3 cases only, while in 7 cases both techniques showed the same diagnostic accuracy. In the follow-up, MRI allowed the evaluation of the effect of chemotherapy on the carcinomas: it demonstrated the regression and necrosis of 9 tumors out of 10 (the patients could undergo surgery), and the progression of the tumor in 1 case. The study of bioptic specimens demonstrated the lack of correlation between histological grading of the tumors with MRI signal intensity and T1, T2 relaxation time, as measured by spectroscopy.

[The application of Law 194/1978 in our hospital. Study of its use in the first 5 semesters]. / L'applicazione della Legge 194/1978 nel nostro ospedale. Indagine sull'utenza nei primi cinque semestri.

PIP: 5555 hospital files were examined with regard to abortion (in accordance with Article No. 194 of 1978) carried out at the San Camillo de' Lellis Hospital between July 1978-December 1980. The following characteristics of the group were studied: age group, civil status, parity, previous abortions, profession, duration of amenorrhea, certification, type of operation, and anesthesia/length of stay in hospital/complications. The following characteristics of abortion were noted: a 6-month review, the major effects, and similarities between surveys carried out on a regional, national, and international basis. In the 2nd section of this work, abortions were broken down into districts of origin in order to analyze the subsequently organized groups and to determine those areas which benefit most from the S. Camillo Hospital under the implementation of the law. By using the abortion rates, which are the basic indicators for evaluating abortion both quantitatively and qualitatively, it was possible to carry out more detailed studies of the 2 districts which benefitted most from the San Camillo Hospital. A study of the abortion rates led to a reappraisal of the surveys made of the sample group on which abortions had been carried out, thus making it possible to determine the main characteristics of the women most affected by abortion in the studied districts. (author's)^ieng