Laparoscopic Liver Resection: A South American Experience with 2887 Cases.

BACKGROUND: Laparoscopic liver resections (LLR) have been increasingly performed in recent years. Most of the available evidence, however, comes from specialized centers in Asia, Europe and USA. Data from South America are limited and based on single-center experiences. To date, no multicenter studies evaluated the results of LLR in South America. The aim of this study was to evaluate the experience and results with LLR in South American centers. METHODS: From February to November 2019, a survey about LLR was conducted in 61 hepatobiliary centers in South America, composed by 20 questions concerning demographic characteristics, surgical data, and perioperative results. RESULTS: Fifty-one (83.6%) centers from seven different countries answered the survey. A total of 2887 LLR were performed, as follows: Argentina (928), Brazil (1326), Chile (322), Colombia (210), Paraguay (9), Peru (75), and Uruguay (8). The first program began in 1997; however, the majority (60.7%) started after 2010. The percentage of LLR over open resections was 28.4% (4.4-84%). Of the total, 76.5% were minor hepatectomies and 23.5% major, including 266 right hepatectomies and 343 left hepatectomies. The conversion rate was 9.7%, overall morbidity 13%, and mortality 0.7%. CONCLUSIONS: This is the largest study assessing the dissemination and results of LLR in South America. It showed an increasing number of centers performing LLR with the promising perioperative results, aligned with other worldwide excellence centers.

Impact of routine intraoperative cholangiography during laparoscopic cholecystectomy on bile duct injury.

BACKGROUND: The role of intraoperative cholangiography (IOC) in the diagnosis, prevention and management of bile duct injury (BDI) remains controversial. The aim of the present study was to determine the value of routine IOC in the diagnosis and management of BDI sustained during laparoscopic cholecystectomy (LC) at a high-volume centre. METHODS: A retrospective analysis of a single-institution database was performed. Patients who underwent LC with routine IOC between October 1991 and May 2012 were included. RESULTS: Among 11,423 consecutive LCs IOC was performed successfully in 95.7 per cent of patients. No patient had IOC-related complications. Twenty patients (0.17 per cent) sustained a BDI during LC, and the diagnosis was made during surgery in 18 patients. Most BDIs were type D according to the Strasberg classification. The sensitivity of IOC for the detection of BDI was 79 per cent; specificity was 100 per cent. All injuries diagnosed during surgery were repaired during the same surgical procedure. Two patients developed early biliary strictures that were treated by percutaneous dilatation and a Roux-en-Y hepaticojejunostomy with satisfactory long-term results. CONCLUSION: The routine use of IOC during LC in a high-volume teaching centre was associated with a low incidence of BDI, and facilitated detection and repair during the same surgical procedure with a good outcome.

Mesenteric root pseudocyst: finding in an asymptomatic patient-a case report.

BACKGROUND: Mesenteric cysts are one of the rarest abdominal tumor masses, representing a little-studied pathology. In turn, the variability and non-specificity of clinical manifestations make diagnosis difficult, as it can be reached by imaging findings due to another cause or by non-specific abdominal pain. CASE PRESENTATION: This article describes the case report of an asymptomatic 28-year-old patient who presented a 6-cm abdominal cystic mass with mixed density, which was found incidentally by computed tomography. Exploratory laparoscopy was performed followed by conversion to conventional surgery to extract the tumor mass. The anatomical pathology diagnosis was pseudocyst of the mesentery root. Mesenteric cysts are one of the rarest abdominal tumor masses, representing a little-studied pathology. In turn, the variability and non-specificity of clinical manifestations make diagnosis difficult, as it can be reached by imaging findings due to another cause or by non-specific abdominal pain. CONCLUSIONS: Mesenteric cysts are rare, and their nonspecific symptoms often lead to diagnosis based on imaging findings. Complete laparoscopic enucleation is the standard treatment.

Analysis of the risk of a secondary displacement in conservati- vely treated paediatric distal radius metaphyseal fractures. A multicentric study.

OBJECTIVES: Distal radius fractures represent one of the most fre-quent injuries in children. The treatment of choice is a closed reduction followed by immobilisation in plaster cast; the immediate recourse to osteosynthesis with Kirschner wires is only reserved for certain cases. The displacement rate reported in the literature is 21-39%. The aim of this study is to retrospectively evaluate the risk factors for a secondary displacement of metaphyseal radius fractures in a paediatric population treated in three different centres. MATERIALS AND METHODS: The initial treatment for all 360 patients examined was a closed reduction under general anaesthesia and im-mobilisation in an above elbow cast for 4 weeks. The pre-operative displacement, residual post-reduction displacement and possible di-splacement at 7 and 14 days of follow-up were all assessed clinically and radiographically. RESULTS: A loss of reduction was reported in 102 cases; 51 under-went an additional reduction procedure - some followed by osteo-synthesis - while in the remaining 51 cases, the loss of reduction was acceptable in relation to the expectation of remodelling. The most statistically significant variable for the occurrence of a secondary displacement is a severe primary displacement. The association with the ulna fracture is not significantly correlated. The quality of the plaster cast is important for maintaining the reduction. There are a few things to consider as indicators for a second procedure: age, time elapsed from moment of fracture, fracture site and the absence of an acceptable reduction. CONCLUSIONS: In our experience, a reduction followed by osteo-synthesis with Kirschner wires should be considered the treatment of choice in fractures with a high risk of secondary displacement, namely those with severe initial displacement or unsatisfactory reduction.

Expanding the spectrum of Gorham Stout disease exploring a single center pediatric case series.

Gorham-Stout Disease (GSD), also named vanishing bone disease, is an ultrarare condition characterized by progressive osteolysis with intraosseous lymphatic vessel proliferation and bone cortical loss. So far, about 300 cases have been reported. It may occur at any age but more commonly affects children and young adults. The aim of this study is to retrospectively review our internal patient series and to hypothesize a diagnostic-therapeutic protocol for earlier diagnosis and treatment. Clinical datasets from our center were examined to identify all GSD patients for collection and analysis. We identified 9 pediatric cases and performed a retrospective case-series review to examine and document both diagnosis and treatment. We found that delay in diagnosis after first symptoms played a critical role in determining morbidity and that multidisciplinary care is key for proper diagnosis and treatment. Our study provides additional insight to improve the critical challenge of early diagnosis and highlights a multidisciplinary treatment approach for the most appropriate management of patients with rare GSD disease. Although GSD is an ultrarare disease, physicians should keep in mind the main clinical features since neglected cases may result in potentially fatal complications.

The treatment of femoral fractures in children with cerebral palsy.

OBJECTIVE: The purpose of this study is to retrospectively evaluate a group of children affected by cerebral palsy with a recent femoral fracture, and to analyse the results and complications in relation to the treatment used. MATERIALS AND METHODS: The analysis was performed on 36 children (21 M, 15 F, 8-14 years old) with cerebral palsy (7 diplegia, 28 tetraparesis, 1 hemiplegia) with a metaphyseal or a diaphyseal femoral fracture. The patients were subdivided into two groups according to their Gross Motor Function Classification System (GMFCS) level: level 2-3 (9 patients) and level 4-5 (27 patients), evaluating the presence of complications and malunions for each group at the end of each follow up. RESULTS: The fractures were displaced in 24 patients and nondisplaced in 12 patients. In 26 cases the treatment involved a closed reduction and immobilisation in a long leg hip spica cast for 7 weeks, while in 10 cases the treatment involved an open reduction-internal fixation (ORIF) followed by a 3-week period in a plaster coated fracture bandage. CONCLUSIONS: Taking into consideration the maximum possible recovery of function, an ORIF is preferable to prevent malunion, particularly in distal metaphysis and distal shaft fractures. In the GMFCS level 2-3 patients, surgery has allowed to recover, or at least maintain, the pre-fracture functional level, while in patients with GMFCS level 4-5, it has allowed to reduce the immobilisation times and prevent the development of decubitus lesions.

Assessment and therapeutic choice in septic arthritis of the hip in an intravenous drug abuser: case report at 14 years follow-up and review of literature.

INTRODUCTION: Osteoarticular infections are found frequently in drug addicted individuals, representing one of the main reasons for their hospitalization. Through inoculation, the pathogenic agents can enter the individual's system directly through the skin or parenterally, transmitted, that is, through syringes and other objects used during such practice. In these particular conditions, or when the medical history is vague, a warranted suspicion and the execution of targeted research can help in the diagnosis of high-risk patients such as addicts. DISCUSSION: With this paper, the Authors are presenting a case of septic arthritis in the hip joint, in a drug addicted patient with the habit of injecting narcotics into the femoral vein, in correspondence of the anatomical region known as the triangle of Scarpa. Following an examination of the bacterial culture samples taken by arthrocentesis, the S. Aureus infection was identified and a targeted antibiotic therapy (coxacillin and aminoglycosides) was prescribed. After one year, with clinical examination and medical scans resulting negative for infection, there was a remaining deformity of the femoral head and, therefore, a total hip arthroplasty (THA) was performed. The 14 year post-operative clinical examination and medical scan check-up showed a complete articular functionality and recovery of normal daily and work related activities.

Glucokinase mutations in pediatric patients with impaired fasting glucose.

AIMS: Our aim was to detect the frequency of glucokinase (GCK) gene mutations in a cohort of patients with impaired fasting glucose and to describe the clinical manifestations of identified variants. We also aimed at predicting the effect of the novel missense mutations by computational approach. METHODS: Overall 100 unrelated Italian families with impaired fasting glucose were enrolled and subdivided into two cohorts according to strict and to mild criteria for diagnosis of maturity-onset diabetes of the young (MODY). GCK gene sequencing was performed in all participants. RESULTS: Fifty-three Italian families with 44 different mutations affecting the GCK and co-segregating with the clinical phenotype of GCK/MODY were identified. All mutations were in heterozygous state. In Sample 1, GCK defects were found in 32/36 (88.9%) subjects selected with strict MODY diagnostic criteria, while in Sample 2 GCK defects were found in 21/64 (32.8%) subjects selected with mild MODY diagnostic criteria. CONCLUSIONS: Our study enlarged the wide spectrum of GCK defects by adding 9 novel variants. The application of strict recruitment criteria resulted in 88.9% incidence of GCK/MODY, which confirmed it as the commonest form of MODY in the Italian population. In order to avoid misdiagnosis of GCK/MODY, it could be useful to perform molecular screening even if one or more clinical parameters for the diagnosis of MODY are missing. Computational analysis is useful to understand the effect of GCK defect on protein functionality, especially when the novel identified variant is a missense mutation and/or parents' DNA is not available.

[Solid renal mass up to 4 cm. Analysis of the diagnostic procedures, TNM staging and surgical treatment]. / Masa ocupante renal sólida de hasta 4 cm: análisis de la metodología diagnóstica, estadificación TNM y tratamiento quirúrgico.

OBJECTIVES: We perform a retrospective review of renal tumors operated with a maximum size of 4 cm to determine if the diagnostic methodology was adequate, the TMN staging prognostic accuracy (UICC 2002) and the goal surgical treatment. MATERIAL AND METHOD: Between 1984 to 2005, 78 renal units form 74 patients (4 bilateral synchronous) operated at the Service of Urology of the Hospital Alemán de Buenos Aires. Age distribution, sex, presentation form (incidental and symptomatic), diagnostic methodology, laboratory variables, surgical treatment (partial or radical surgery), histopathology, Fuhrman grade, tumor size, bilaterality, multicentricity, TNM staging, evolution and survival (Kaplan Meier) were analyzed. RESULTS: 78 renal units from a total of 192, 40.62% were analyzed. The median age was 58.72 years. 69% were male and 31% female. The presentation form was 91.90 % incidental and symptomatic 8.10% (Hematuria in 5 and lung metastasis in 1). The diagnosis was performing with ultrasound and CT scan 63 cases, in 4 was also used resonance magnetic imaging (RMI) and in 7 ultrasound and RMI. Arteriography was used in 11 cases, 3 showed tumor and 8 were normal. Biopsy was performing in 5 cases, all positive for clear cells carcinoma. Globular sedimentation was the only one laboratory abnormality in 12 cases. Surgical treatment was radical surgery in 35 renal units (44.87%) and conservative surgery in 43 units (55.13%). Pathology clear cells carcinoma (CCC) 79.48%, papillary carcinoma 1.28%, angiomyolipoma (AML) 8.97%, oncocytoma 7.69% and adenoma 2.56%. The Fuhrman grade was 1 in 76.19%; 2 in 20.63% and 3 in 3.18%. Bilateral tumor were found in 4 cases 2 CCC, 1 CCC and AML and 1 CCC and adenoma. Tumor median size was 2.93 cm. Staging was T1a 96.82%, T3a 1.59% and T3aM+ 1.59%. Follow-up could be made in 54 of 61 cases. At median follow-up of 52.25 months, 50 cases were disease free, 3 died by progression at 18, 33 and 82 months and all of them were symptomatic tumors, 1 died by a non related cause. Survival rate was 94%. CONCLUSIONS: 1)Ultrasound and CT scan obtained a highest diagnostic accuracy for solid renal mass. Biopsy in selective cases could contribute to achieve a correct treatment strategy. 2) Conservative surgery was the goal treatment in selected tumors up to 4 cm. and we believe that TNM staging should contemplate the presentation form to improve the prognostic value.

Apophyseal and epiphyseal knee injuries in the adolescent athlete.

OBJECTIVES: In the context of pediatric sports injuries, the epiphyseal and apophyseal knee fractures represent rather peculiar lesions. The most frequently involved anatomical area is the knee. The peculiar function of the physis and the need to preserve their integrity, makes choosing what treatment methods to employ very important. Objective of this study is to assess the kind and the effectiveness of the most suitable treatment in the apophyseal and epiphyseal knee lesions occurring in the adolescents. MATERIALS AND METHODS: From 2006 to 2011, were treated 41 patients (34 M-7 F) between the ages of 10 and 15, with a diagnosis of traumatic knee injury caused by sports activities. Traumatic physeal fractures of the distal femur, the proximal tibia and its anterior tuberosity and the avulsion of the intercondylar eminence were the lesions that occurred most frequently. The treatment belonged to the type of lesion: closed reduction or percutaneous fixation with K-wires/ screws and a femoral-podalic plaster cast, ORIF with K-wires/screws, arthroscopic reduction and internal fixation using absorbable screws. All the patients were given the POSNA questionnaire at the end of the follow up. RESULTS: The follow up was on average 5 years (4-10 years). We considered as excellent the results obtained in 26 patients, as fair in 12 patients, in 1 case the result obtained was considered as poor. 2 caseswere lost during follow up. The average POSNA score at the end of the follow-up was 98.51. Any early complications recorded were the following: in 1 case infection of the K-wires 32 days after pinning and a reported compression of the popliteal neurovascular bundle, due to a displaced tibial physeal fracture. CONCLUSIONS: Since sport during childhood and adolescence is now practiced more and more frequently, also at a competitive level, thesekinds of fractures in children between the ages of 10 and 15 have been occurring more often, especially in male patients. Sports traumatology of the knee in this age group is characterized by a typology of injuries that are very particular. The knowledge of the anatomy and physiology of children, with an appropriate diagnostic assessment, is essential to identify the most appropriate treatment options for each specific injury. As the nucleus of proximal tibial growth plate progressively closes from posterior to medial side, in patients between 11 and 13 years of age with an apophyseal displacement of the tibial tuberosity, you should always perform a CT exam, to exclude an intra-articular physeal fracture.

Quality of life, clinical and neurophysiological picture in patients operated on for lumbar stenosis.

BACKGROUND: In lumbar stenosis (LS) patients, clinical, neuroradiological and neurophysiological findings were not related to validated measurements of the outcomes that are more relevant to patients such as functional status and symptoms. METHOD: We have retrospectively studied 30 patients surgically treated for LS. We have evaluated the patients by means of self-administered questionnaires (SF-36), clinical examination, and neuroradiological and neurophysiological measurements and we have registered preoperative and follow-up clinical and neurophysiological findings. Finally we evaluated the relations between patient-oriented data and validated conventional clinical and neurophysiological measurements. FINDINGS: The comparison between pre- and post-operative clinical picture showed an improvement of most parameters tested. The comparison between pre- and post-operative neurophysiological picture revealed worsening of most tested parameters. The comparison between the current sample and the Italian normative data for the SF-36 showed a worsening of physical aspects of health related quality of life; conversely there was an improvement of some mental domains. CONCLUSIONS: In our sample of LS patients the most compromised SF-36 domain was Role-Physical that measures the difficulty in every-day activities due to physical problems. Conversely, the clinical findings showed a significant improvement after surgery: patients reported in particular lower sciatica after surgical treatment, but the neurophysiological evaluation did not show any improvement.

Morphological changes in cavernous tissue in spontaneously hypertensive rats.

Erectile dysfunction has an increased prevalence in hypertensive patients and is associated with cardiovascular diseases. For many years the discussion has been polarized on whether in hypertensive patients, it is the arterial hypertension or the antihypertensive therapy that is the cause of male erectile dysfunction. The aim of our study was to determine the morphologic changes in cavernous tissue (CT) in an animal model of arterial hypertension. Male spontaneously hypertensive rats (SHR) (n = 15) and normotensive Wistar-Kyoto (WKY) rats (n = 15) were studied for 8 months. Animals were allowed to drink tap water and fed a standard rat chow ad libitum. Systolic blood pressure (SBP) was measured monthly by the tail/cuff method. At the end of the experiment all the animals were sacrificed for microscopic studies. Cavernous tissue was processed by hematoxylin and eosin, Masson's trichrome, and monoclonal anti-alpha smooth muscle actin. Cavernous smooth muscle (CSM) and vascular smooth muscle (VSM) proliferation and CT fibrosis were evaluated by a semiquantitative score. SHR showed a higher proliferative score in CSM (2.7 +/- 0.28 v 1.1 +/- 0.07; P < .001), as well as in VSM (2.7 +/- 0.25 v 1 +/- 0.05; P < .001), and higher CT fibrosis score (2.8 +/- 0.28 v 0.1 +/- 0.07; P < .001), when compared to WKY rats. Furthermore, SHR showed a positive correlation between SBP and CSM proliferative score (r2 = 0.9277), SBP and VSM proliferative score (r2 = 0.8828), and SBP and CT fibrosis score (r2 = 0.7775). In addition, an increase in the surrounding connective tissue at the perineurium and endoneurium of the amielinic nerves in CT was observed in the SHR group. According to these results we conclude that SHR present morphologic changes in vessels as well as in cavernous spaces of the erectile tissue that have a high positive correlation with high blood pressure. Moreover, the increase in extracellular matrix expansion seems to affect not only the interstitium but also the neural structures of the penis.

Candesartan cilexetil protects cavernous tissue in spontaneously hypertensive rats.

In previous experiments, our group demonstrated morphological changes in erectile tissue from male spontaneously hypertensive rats (SHR). The present study was performed to determine whether an angiotensin II receptor blocker could protect cavernous tissue (CT) from these structural alterations in SHR. Male SHR and Wistar-Kyoto (WKY) rats were studied during 4 months. Rats were divided into three groups: SHR (n=10), SHR with candesartan cilexetil (n=10) and WKY rats (n=10). Candesartan cilexetil 7.5 mg/kg/day was administered orally throughout the study. CT was processed for pathology studies. The amount of (1) cavernous smooth muscle (CSM), (2) vascular smooth muscle (VSM), (3) collagen type III, and the rat endothelial cell antibody (RECA-1)/tunica media ratio in cavernous arteries were evaluated. SHR with candesartan cilexetil showed a lower blood pressure, a lower percentage of CSM, smaller VSM area, with a higher RECA-1/media ratio, and a lower percentage of collagen type III, when compared to untreated SHR. In addition, SHR showed a positive correlation between systolic blood pressure (SBP) and CSM amount (r=0.91; P<0.01), and SBP and the percentage of collagen type III (r=0.88; P<0.01); these correlations were not observed either in SHR treated with candesartan cilexetil or in WKY rats. We conclude that candesartan cilexetil provides a significant protective role against morphologic changes in vessels as well as in cavernous spaces of the erectile tissue, caused by high blood pressure, in SHR.

Prevalence of sexual dysfunctions in Argentina.

The objective of this study consisted in assessing the prevalence of erectile dysfunction (ED) and other sexual dysfunctions in a group of men who attended a prostate awareness week campaign. In total, 2715 men attended to 'Semana de la Prostata 2001' campaign and received an additional questionnaire on sexual health. The prevalence of ED, desire and ejaculatory disorders was of 41.7, 33.8 and 49.3%, respectively; however, not all of them lived these difficulties as a real sexual problem because only 918 men (37.8%) acknowledged having 'any sexual difficulty'. Only 13.7% of the attendees consulted a physician for this reason in the past. This first Argentinean study proves the high prevalence of sexual dysfunctions in our population.

Symptoms and neurophysiological picture of carpal tunnel syndrome in pregnancy.

OBJECTIVE: To evaluate the incidence of carpal tunnel syndrome (CTS) in pregnancy through a validated and multiperspective assessment of CTS. METHODS: During 2000, the Italian CTS study group focussed on the occurrence of CTS in women during the final stages of pregnancy, enrolled in 7 Italian centers. In addition to the physician-centered and neurophysiologic traditional evaluations, we used a validated patient-oriented measurement to obtain more comprehensive and consistent data for severity of symptoms and functional impairment. RESULTS: In our study, CTS was clinically diagnosed in more than half of women (62%). Neurophysiological evaluation provided diagnosis of CTS in around half of women (43% were positive in one hand at least). Our study provides evidence, reported here for the first time, of a correlation between edema and neurophysiological picture. Similarly, our study provides a correlation between validated patient-oriented measurement and edema. Moreover, a significant correlation between a negative trend (subjectively assessed) and smoking and alcohol consumption was observed. CONCLUSIONS: Our observations confirm that the edema of the tissues in the carpal tunnel could induce a mechanical compression of the nerve. Moreover, our data suggest that smoking and alcohol consumption have a negative role in the evolution of the syndrome probably due to impairment of the microcirculation.

[Antibiotic prophylaxis with cefotaxime in gynecological endoscopy]. / Profilassi antibiotica con cefotaxime nell'endoscopia ginecologica.

It is now well known that even short operations of limited scope lower the body's defences by influencing the immune system. As a result this leads to a change in microbial flora which encourages an increase in the number of Gram-negative, aerobic, anaerobic and enterococcal colonies. In order to prevent infective postoperative complications which might occur after endoscopic surgery, the authors suggest using a series of valuable recommendations which are reported in this paper. Among these the most important is antibiotic prophylaxis which is able to limit the episodes of infection, thus making a positive contribution to the postoperative iter. Cefotaxime was chosen by the authors since this molecule offers both reliable and efficacious prophylaxis as has also been shown by other studies in the obstetrics and gynecological field. The results obtained by this study fully concord with data reported in the literature.

[Inflammation of the uterine corpus: endometritis]. / Le flogosi del corpo dell'utero: endometriti.

In industrialised countries endometritis is a problem which represents an increasing risk to personal health and to society. In almost all cases the inflammatory process which affects the uterine mucosa forms part of a more generalised infection which involves the entire internal genital system (PID). The most important problem associated with pelvic phlogosis is increased sterility, a greater number of ectopic pregnancies and chronic pelvic pain. In order to treat the symptoms of genito-pelvic infection, an early diagnosis and adequate medical therapy are indispensable. In this event it may be possible to prevent invalidating effects on fertility and chronic pelvic pain.

[Role of viral infections in the genesis of dysplasias of the uterine cervix]. / Ruolo delle infezioni virali nella genesi delle displasie della cervice uterina.

A study of 80 cases of dysplasia of the uterine cervix showed the coexistence of HPV infections in 52 cases. This association (65%) shows the important role played by the human papilloma virus in the genesis of cancer of the cervix.

[Respiratory distress syndrome in premature births]. / Sindrome da distress respiratorio (RDS) nel parto prematuro.

The paper reports the results of a study of respiratory distress syndrome in premature birth, one of the most common and important forms of respiratory disorders affecting neonates during the first days of life. One hundred and fifty-six premature births from 1 January 1986 to 30 June 1988 were included in the study. From an analysis of results it emerges that there is a lower incidence of respiratory distress syndrome in both vaginal deliveries and cases treated with Ambroxol.

[Clinical study of the use of a new tri-phasic pill]. / Studio clinico sull'uso di una nuova pillola trifasica.

The paper reports the results of a study to assess the contraceptive efficacy of a new triphasic pill (Trinovum - Cilag AG). The pill was administered to 50 women aged between 18 and 41 years for 12 months, giving a total of 600 menstrual cycles. Data confirm the value of this pill which ensures excellent contraceptive efficacy and is well tolerated by patients with very few adverse effects.