Bench surgery in right kidney transplantation.

The problems deriving from the anatomic differences between the two harvested kidneys make the bench surgery necessary to solve some technical difficulties in transplantation. This condition is particularly real in the case of right kidney transplantation, especially in presence of arterial anomalies. In this study, we focused our attention on venous reconstruction in cases of short renal right veins. In 3 years, we performed 55 consecutive cadaveric renal transplants in patients with an end-stage chronic renal insufficiency. The right kidney was used in 30 patients, eight of whom had two or more arteries attached to a single aortic patch, and 22 had a single artery. In these right transplanted kidneys, the elongation of renal vein was performed end-to-side to the external iliac vein, reconstructing a "T-patch" (angular reconstruction) in 28 patients and a "linear" one in two cases. The vascular anastomoses had no thrombotic problems. We have followed the progress of the patients for more than 2 years; no one has lost the graft due to chronic rejection or other complications. In conclusion, elongation of the right renal vein with a T-patch constitutes a feasible, physiological procedure without vascular complications or apparent reverberations for graft blood flow.

Posttransplant renal monitoring with B-flow ultrasonography.

B-flow ultrasonography (BFU) is a new technology to detect blood circulation. It has been developed by using digitally encoded sonography, showing higher spatial and temporal resolution than Doppler imaging because of the clearer definition of the vessel lumen. Our study was performed on 55 patients, including 37 men (67.3%) and 18 women (32.7%), of overall mean age of 45.8 years (range = 16-60 who underwent kidney transplantation from deceased donors. The patients underwent an ultrasonography check postoperatively with successive daily controls to compare evaluations with both techniques: the combination of color and power Doppler versus BFU. In 25 patients (45.5%), visualization of cortical blood flow was clearer than with the standard techniques. The parameters of intrarenal circulation were easy to measure. In conclusion, BFU was effective to visualize hemodynamic flow and to detect stenotic lesions in the renal artery. Combined with the conventional B-mode technique, BFU seems to be useful in the evaluation of renal anasthamotic stenosis, especially among patients with vascular diseases.

Low limb and allograft rescue with iliofemoral graft for external iliac artery dissection: case report.

The technical difficulties in performing a transplantation can often be joined by an accident that demands an urgent solutions, putting the life of the patient in serious risk. In our case we were forced to perform an iliofemoral PTFE graft substitution to save the vascularization of the right lower limb. The cause was constituted by a dissection in the external iliac artery wall immediately after upstream declamping. Fortunately quick understanding of the complication made us stop the lesion downstream before it involved the femoral district. In addition the renal artery was already not declamped and the organ not perfused. Successively we anastomosed the renal artery to the PTFE graft with an end-to side anastomosis. Our first target was obviously to preserve the low limb vascularization but, with this solution we managed also to save the allograft. Actually renal function is conserved and with an optimal state of the vascular graft.

Acute rejection after liver transplantation: Is there a specific immunological pattern?

The aim of the study was to assess various T-cell subsets and cytokine secretion patterns both in liver tissue and in the peripheral blood of 24 liver transplant patients to assess possible specific immunological involvement in early acute rejection episodes after liver transplantation. Particularly, we studied CD4+ CD7+, CD8+ CD38+, and CD4+ CD25+ T cells by flow cytometry, as well as contemporaneously, interleukin (IL)-2 and IL-10 secretion by ELISpot to determine possible Th1-like immune responses and the immunomodulation expressed by Treg cells in acute liver rejection, respectively. As a control group we included patients transplanted without acute rejection. Early acute rejection within the first 4 weeks was proven histologically in 42% of patients. It was associated with a greater expression of CD4+ CD7+ and CD8+ CD38+ T cells in the liver than in the blood (P < .001). A contemporaneous reduced expansion of liver Treg cells was evident in patients with acute rejection (P < .001). Our data suggested that a preferential Th1-like immune mechanism operated in local fashion as characterized by a decreased presence in the liver and blood of Treg cells.

[Duodenal angiodysplasia and Turner's syndrome. Case report]. / Angiodisplasia duodenale e sindrome di Tuner.

UNLABELLED: The Turner's syndrome is the most common chromosomic disease in the women and touches 1:2,500 women born live. The most important anomaly is the presence of short stature and ovarian failure. Others disorders are increasing in case reports: osteoporosis, hypothyroidism, renal diseases and gastroenteric diseases. The Authors, after careful review of the literature, that proves rarity of the disease, report a case of duodenal vascular anomaly associated with Turner's syndrome and describe surgical therapy, peculiar to this atypical localization. CASE REPORT: A 31 years old woman, genotypic XO and female phenotypic, with diabetes mellitus type I, arterial hypertension and hypertransaminasemia. Since three days the patient reports epigastric pain discontinuous, not widespread, not nocturnal, with wretch, bowel open only to gas. The patient underwent Rx abdomen, Rx with gastrografin, TC abdomen. Diagnosed as a high digestive occlusion, the patient underwent explorative laparotomy. As laparotomy she had a necrotic-hemorrhagic lesion in duodenum D3-D4 and first jejunal loop, with stenosis of the jejunal lumen, perforation of serosa and blood in peritoneal cavity. Resection of necrotic loop and reconstruction with Y loop performing manual duodenum jejunal L-L anastomosis, mechanical gastroenterostomy and enteric-enteric L-L mechanical anastomosis. After operation hemorrhage from anastomosis was observed, treated with omeprazole therapy and total parenteral nutrition. The patient was discharged in 14th p. o. day. After two years she is in good health without gastrointestinal symptoms. In patients with Turner's syndrome gastrointestinal vascular anomalies have to be considered as diagnostic hypothesis in cause of abdominal pain.

[Extrauterine endometriosis: three new cases]. / L'endometriosi extrauterina: tre nuovi casi.

Extragonadal endometriosis is rarely diagnosed preoperatively due the variety of its localizations. Presentation to general surgeons may be atypical and pose diagnostic difficulties. The Authors report three cases surgically treated between 2000-2003. The Authors stress the peculiarity of one of these cases with endometrial tissue involvement of the intestinal mucosa. They also discuss about various aetiological hypothesis, symptomatology, differential diagnosis and need for multidisciplinary treatment.

[Complete rectal prolapse in a patient with Hirschsprung disease: a clinical case]. / Prolasso rettale completo in paziente con malattia di Hirschsprung: caso clinico.

The disease of Mya-Hirschsprung (HD) it's rare and congenital, usually diagnosed in child age, but that it can also remain unknown until the adult age. It's associated to genetic mutations and it can involve other pathologies and malformations. The variability of the anatomopathological and clinical phenomena is correlated to the length of the aganglionic segment. The Authors describe the clinical case of one young female patient, who presented chronic constipation (less than 3 evacuations to week), tenesm, meteorism, abdominal pain. To the inspection of the anal region after the evacuation the presence of complete rectal prolapse (3) cylinders of the length of 30 cm was appraised, with presence of ulcerations of the mucosa. The patient came subordinate to diagnostic study that they demonstrated the presence of HD. The Authors operated the patient with the technique of Frykman and Goldberg. In the follow-up the patient had the complete remission of the symptomatology and resumption of the rectoanal inhibitory reflex, remarkable diminished in the preoperative manometric examination. The pathogenesis of the association of HD and rectal prolapse goes searched in the presence of ultrashort HD (aganglionic defect of a limited segment of rectum), pathological variety somewhat rare that can determine subocclusive phenomena and that it favors the prolapse of the rectum for the continuous evacuating strains.

[Parietal metastasis in laparoscopic surgery of colorectal carcinoma]. / Metastasi parietali nella chirurgia laparoscopica per carcinoma colorettale.

The role of videosurgery in the treatment of gastrointestinal cancers is still controversial. However port-site metastases, reported with high rate (0.6-21%) have reduced the enthusiasm and still represent object of research. Port-site metastases pathophysiology is not yet clear. However in the last years the incidence is decreased at a percentage less than 2% and similar to that reported after traditional surgery (0.6-5.3%) due to a patient selection and a better videosurgical technique. Implant for direct contact, pneumoperitoneum, gas utilized, trocar positioning and relative tessutal trauma, visceral manipulation, frequent instrumental reintroduction represent the main pathophysiologic factors involved. Pneumoperitoneum produces an increase of the abdominal pressure with turbulent flows and the CO2 (stimulating of neoplastic cells growth?) transports neoplastic cells at the port site. However metastases occurs only when an elevate cellular concentration is present "gas less" videosurgery is not free from this complication but with a lower incidence. "Chimney effect", due to the leakage of gas or fluid containing aerosol neoplastic cells at port site, represents another important factor. In accord with such studies employing alternative gas (Helium) reduces the implant of neoplastic cells. Port site parietal trauma produces fibrin deposites that represents a substratum for cellular implant, growth and protection against immunitary host defense. Wound ischemia induces a macrophagic activity decrease. In view of these concepts the surgeon must respect some mandatory principles in the videosurgical approach to neoplastic diseases. Safety parietal trocar fixation avoiding gas or fluid port site leakage such as abdominal desuffling only through trocars in site are mandatory. Instrumental cleaning with cytoxic solution (Betadine)--neoplastic cells are isolated from instrumental lavage liquid--such as as irrigation and sterilization (5 FU) of porte site are very important rules. Wound incision--never too small--must be accurately sutured. During operation cutting through or handling tumor are contraindicated, especially when the neoplasm involves serosa. Surgical specimens must be extracted in bags absolutely through parietal protection system. High vascular ligature represents another technical rule to respect in every case like in traditional surgery.