Intraoperative skeletal traction in the dog: a cadaveric study.

A standard skeletal traction technique was applied to each major segment of the appendicular skeleton of ten fresh dog cadavers. Opposition points and anchorage points for the application of traction were determined for each skeletal segment. Traction was exerted by means of a micrometric traction stand, connected to the limb by bands or a stirrup. Traction was applied to the antebrachium and the tibia through nylon traction bands anchored to the metacarpus and metatarsus, respectively. A traction stirrup applied to the condylar region was used as the anchorage point to load the humerus and femur. Once a peak force of 25 kg weight was achieved, the load was monitored for half an hour to check for any variation. After that, each skeletal segment was osteotomized in the mid-diaphyseal region, and evaluated for any angular malalignment due to a mismatch between the axis of the bone and the applied loading. Any ensuing angular malalignment was successfully corrected by manoeuvres using the traction stand. The technique used in this study to perform intraoperative skeletal traction proved to be reliable and consistent for each segment of the appendicular skeleton.

Clinical application of intraoperative skeletal traction in the dog.

The purpose of this clinical study was to evaluate the technical feasibility of a method for pre-operative and intra-operative traction for reduction of fractures of the appendicular skeleton. Traction was used in 24 diaphyseal fractures in 21 dogs. For each dog, the data pertaining to signalment, limb circumference, fracture type, interval between fracture and surgery, and the traction modalities were recorded. In patients with a latency between trauma and surgery of less than three days, the duration of traction required to realign the bone segments was shorter than that required for older fractures (P = 0.02). Intraoperative malalignments were corrected by manoeuvres performed with the traction stand. Once realigned, fracture segments were kept stable for prolonged periods, without the need for a surgical assistant. Postoperative radiographs were evaluated for fracture reduction and axial alignment. Postoperative alignment was judged excellent in 21 fractures and good in three fractures. Fractures were stabilized using external skeletal fixation (n = 10), plates (n = 11) or locked nails (n = 3), depending on the fracture type. The use of the technique was straight-forward and easily applied in a surgical setting. However, its use requires careful application because of the potential for iatrogenic tissue damage.

Embryonal rhabdomyosarcoma of the lung arising in cystic adenomatoid malformation: case report and review of the literature.

Rhabdomyosarcoma (RMS) of the lung is a very rare lesion, but the association with cystic adenomatoid malformation (CCAM) is unlikely to be a coincidence. Although the etiologic factors predisposing infants and children to pulmonary neoplasms are unknown, pulmonary developmental abnormalities may play a pathogenetic role. A case of embryonal pulmonary RMS is described, which was discovered within a congenital CCAM in a 22-month-old child. The hypothesis regarding histogenesis of this neoplasm are also briefly discussed. Because of the risk of malignant change, early removal of the congenital cystic lesions of the lung is advisable.

[Malignant sacrococcygeal teratoma: report of a case of "explosive" intrauterine growth]. / Teratoma maligno sacro-coccigeo a sviluppo addomino-pelvico: descrizione di un caso ad "esplosiva" crescita intrauterina.

An exceptional case of fetal sacrococcygeal teratoma with an exclusive abdominopelvic growth is described. The tumor was not detected on a "routine" ultrasound study obtained at 31 weeks of gestation showing findings of a severe congenital uropathy. It remained unrecognized until the 34 weeks of gestation when the mass began an explosive growth causing a rectouretral fistula. Despite appropriate obstetrical and surgical management the baby died 24 hours later because inadequate pulmonary maturity. The istological findings showing malignant elements such as embryonal carcinomas.

Postoperative medium-term follow-up of patients with bilateral, massive primary vesicorenal reflux and reduced renal function at presentation.

We report the results of a medium-term follow-up study of 52 patients with bilateral, massive primary vesicorenal reflux (PVRR) with renal damage at presentation. Ten infants between 2 and 5 months of age, with a total of 19 renal units, had a temporary vesicostomy followed by ureteral reimplantation after 12-15 months; 42 patients with 81 renal units had primary ureteral reimplantation. The postoperative observation period covered 9.5 years on average (20 months - 21.5 years). The study showed that: (1) urinary specific gravity remained reduced in about 61% of patients; (2) proteinuria improved significantly, in a direct proportion to the favorable evolution of renal function; (3) the frequency of acute pyelonephritis decreased significantly from 98% to 23%. Postoperatively, 27 patients (51%) had one or more episodes of urinary tract infection (UTI) and 12 (23.0%) still had episodes of acute pyelonephritis. (4) At follow-up 7 patients (13.5%) had stable hypertension, while 3 others had unstable hypertension (19.2%); 8 had chronic renal insufficiency or end-stage renal disease. When only adolescents more than 12 years old were considered, the incidence of hypertension increased to 34.4% (10.29). (5) Some renal scarring developed despite successful antireflux surgery, and parenchymal growth, which was severely impaired prior to surgery, restarted although it remained below - 2 standard deviations from the mean. (6) In the overall series glomerular filtration rates (GFR) significantly improved after successful surgery. However, this improvement was much more evident in patients operated upon within the 1st year of life and in those who had had a temporary vesicostomy. In the subgroup of patients operated upon after 6 years of age, successful surgery had no effect on the further decline of renal function when this was already severely compromised. We conclude that early antireflux surgery or, in selected cases, temporary vesicostomy followed by ureteral reimplantation was effective in significantly improving GFR and sharply decreasing febrile UTIs in patients with massive bilateral PVRR and renal damage at presentation.

Management of urethral strictures in children.

We report the results of a long-term follow-up study in 78 children with urethral strictures. The ages ranged from 1 month to 20 years and the follow-up from 8 months to 15 years (average 5.9 years). Balloon dilation was the primary treatment in 66 patients. Manipulative management (balloon dilation and endoscopic urethrotomy) was performed in 68 cases and was successful in 55. There were no complications. Balloon dilation alone provided an 80% success rate (53/66). Twenty-two patients were treated by one-stage urethroplasty, with an overall 95.5% success rate. The surgical repair was performed in 12 patients as a secondary procedure after failure of conservative treatment. Our data do not support the rather poor results usually reported in the pediatric literature associated with the balloon dilation technique.

[Medullary sponge kidney with severe renal function impairment: a case report]. / Rene a spugna midollare con grave compromissione della funzionalità renale: descrizione di un caso.

The term medullary sponge kidney refers as a renal parenchymal malformation characterized by cystic dilatation of the collecting ducts. Although medullary sponge kidney is a congenital disease, it is rarely identified in childhood and is usually discovered in adulthood. We report a child with bilateral medullary sponge kidney who, in addition to typical urographic findings, presented an unfavorable evolution that ended in renal chronic insufficiency. This outlook is uncommon and is described in only 10% of affected subjects.

[Hemangioendothelioma of the liver in the newborn: description of 2 cases]. / Emangioendotelioma del fegato in età neonatale: descrizione di due casi.

The infantile hemangioendothelioma of the liver is a rare benign vascular tumor that accounts for some 10% of all primary hepatic masses. Two cases were seen at the Department of Pediatric Surgery of Vicenza's Hospital in the last ten years. Both of patients were females and presented in neonatal period asymptomatic. The first patient was found to have hepatomegaly by pediatrician at six weeks of age, the second was an incidental finding following ultrasound neonatal screening. The Authors outline some difficulties met with differential diagnosis between benign versus malignant hepatic tumors. Explorative laparotomy was considered necessary in both the patients. Liver biopsy was the only surgical procedure performed in the nonresectable tumor. Treatment with corticosteroids finally proved to be successful to determine progressive involution of the tumor. In the resectable form, left hepatic lobectomy was successfully performed because of the progressive size increase of the tumor.

[Echographic features of urachal cysts]. / Aspetti ecografici delle cisti uracali.

The authors discuss the anatomical, clinical, and US patterns of 5 cases of urachal cysts observed in pediatric patients (average age: 9.2 months) over the last 4 years. All cases had surgical confirmation. Linear and convex probes with 3.75, 5, and 7.5 MHz frequency were employed. Most of the observed lesions were oval in shape, their size ranging 3-6 cm; they were found in ventral-epivesical regions and had no mobility. Liquid echotexture with hyperechoic deposits on the lower layers was observed in 2 cases, and inhomogeneous solid or complex mass-like echotexture in 3 cases (suppurated cysts). Differential diagnosis includes mesenteric cyst, simple and teratomatous ovarian cyst, bladder diverticulum and hydrometrocolpos. Echotomography exhibited high accuracy in detecting this kind of lesion and allowed guidance of percutaneous drainage for the preoperative treatment of infected cysts. Both cystography and CT appeared to be useless.

[Esophageal atresia, today]. / L'atresia esofagea, oggi.

In recent years there have been remarkable improvements in the treatment of babies with congenital esophageal atresia. This improvement in survival and in preservation of esophagus is due: to progress in neonatal anesthesia and in preoperative and postoperative intensive care; to progress in surgical management of associated anomalies (mainly congenital malformations of the heart); to progress in surgical management of the malformation. Esophageal anastomosis may be performed in the majority of babies with "long gap" esophageal atresia by operative techniques for lengthening of the upper esophageal segment or by elongation of the upper and lower pouches by means of bougienage or mercury-filled bag. Today the indications for replacement of the esophagus by colon interposition or reversed gastric tube are limited.

Treatment of Early Stage Hodgkin's Disease According to Risk Factors.

Between January 1981 and December 1987, 95 patients with stage IA (34 patients), IIA (42 patients) and stage IIB (19 patients) Hodgkin's disease (HD) were evaluated in our institution. Thirty patients defined as "high risk" because of either bulky mediastinal disease, systemic symptoms or both were treated with combined modality therapy (CMT). The remaining 65 patients considered as "standard risk" because they presented at diagnosis without any known adverse prognostic factor, received radiotherapy (RT) only. The median follow-up was 39 months. The complete remission (CR) rate was 97% (92/95). The actuarial 3 year overall (OS) and disease free survival (DFS) were 93% and 72% respectively with no differences between the two groups of patients. All 65 "standard risk" patients achieved CR; thirteen (20%) relapsed after a median time of 22 months. Twenty seven of 30 "high risk" patients (90%) achieved CR and six of them (22%) had early relapses. No severe pancytopenia episodes or life-threatening complications occurred during therapy. As far as the risk of second neoplasms is concerned, we observed only a single case of acute non lymphoblastic leukemia 48 months after the completion of CMT. These results indicate that in unfavourable early stage HD, CMT is effective with a probability of more than a 70% DFS 3 years after therapy with an acceptable acute and late toxicity. Patients without "high" risk factors showed the expected response after RT. About 60% of the patients who failed RT could be salvaged by chemotherapy (CT) while refractory cases or patients who relapsed after CMT did poorly with a third line chemotherapeutic regimen. Therefore alternative therapeutic approaches including high dose CT followed by autologous bone marrow transplantation should be considered for this subset of patients.

[Nephroblastoma with prevalent rhabdomyosarcomatous component. Description of a case with early cerebral metastasis]. / Nefroblastoma a prevalente componente rabdomiosarcomatosa. Descrizione di un caso con metastasi cerebrale precoce.

The malignant rhabdoid tumor of the kidney determines clinical and prognostic evaluations due to the poor therapeutic answer and to the uncertain prognosis. The Authors describe a case of nephroblastoma with anaplasia of the blastemal elements associated to rhabdomyosarcoma areas.

[Ectopic ureter]. / L'uretere ectopico.

Ectopic ureter is quite a rare malformation, and it can be more or less serious depending on its anatomy (monolateral or bilateral ectopy, duplicated ureter, single ureter) and the associated malformations. It's more common in female patients. Ectopic ureteral orifice can be either intravesical (bladder neck) or, more often, extravesical. Ectopia in women is more frequently found in the urethra and the vaginal vestibule; much less frequently in vagina and in uterus. In men it is mostly found in the posterior urethra; in the male genital tract is very rare. In most cases ectopic ureter is associated with pyelo-ureteral complete duplication: the upper kidney usually works badly or doesn't work at all, due to renal dysplasia or pyelonephritis. More rarely ureteral ectopia affects a single urinary system and can be monolateral or, in the most serious forms, bilateral. The main clinical signs are urinary incontinence accompanied by regular micturition (more exactly pseudoincontinence) in the female patients, and urinary infection. In the male there is no urinary incontinence. Authors report their experience about 54 ectopic ureters in 51 children. Treatment is always by surgery: the choice has to be made between conservative or radical attitude. 38 total exeresis of the ectopic excretory pathway (upper heminephroureterectomy or nephroureterectomy), 9 ureteral reimplantations, 1 uretero-pyeloanastomosis have been done. Outcome is always satisfactory in monolateral forms, more uncertain in bilateral forms with single ectopic ureter, due to incontinence and reduced bladder capacity problems and the possible associated renal failure.

[Retroperitoneal lymphangioma. Radiologic aspects and diagnostic protocol]. / Linfangioma retroperitoneale. Aspetti radiologici e protocollo diagnostico.

The authors analyze the radiological aspects and the staging problems of the retroperitoneal lymphangioma, a rare neoplasma of infancy. Echography and computer-assisted tomography contributions are particularly emphasized.

[The ureterocele in childhood. Type of treatment and results]. / L'ureterocele in età pediatrica. Tipo di trattamento e risultati.

Ureterocele is an infrequent urinary malformation in pediatric age, but it is frequently clinically severe. Ureterocele in a duplex pyelo-ureteral system often presents very difficult treatment problems not uniformly dealt with. Authors report their experience with 79 ureteroceles observed in 72 children. 27 children were less than one year old. In the authors experience simple ureterocele with a single collecting system doesn't give any surgical problem. On the contrary ectopic ureterocele, almost always associated with a pyeloureteral duplication, frequently gives some problems of surgical treatment. Treatment is always individualized but in our experience the best results have been achieved with unroofing of the ureterocele and upper heminephroureterectomy in one stage, eventually associated with lower ureteral reimplantation. This treatment can be used successfully in the majority of ectopic ureteroceles in pediatric age.

Treatment of early stage Hodgkin's disease with radiation therapy plus short-cycle (3 MOPP) adjuvant chemotherapy.

Eighty-four consecutive, previously untreated patients with stage I, II A-B and IIIA Hodgkin's disease were treated with combined modality therapy including subtotal or total nodal irradiation, followed by three cycles of MOPP. MOPP was administered before radiotherapy in patients with systemic symptoms or with bulky disease. Seventy-six of 84 patients (90.5%) achieved complete remission, and 8 died from disease progression after a variable period of incomplete remission. Three of 76 (3.9%) relapsed, and 2 of them have been subsequently salvaged. Up to the present time, 70 patients are alive, without evidence of disease; 9 have died from Hodgkin's disease, 2 from acute non-lymphoblastic leukemia, and 3 from intercurrent causes. No death occurred from acute toxicity due to chemotherapy. Actuarial overall survival is 82.3% and freedom from relapse is 81.8% after 48 months' median observation (range: 12-111 months). No significant difference in survival and freedom from relapse has been observed with respect to age, sex, stage, presence or absence of unfavorable prognostic factors. The role of adjuvant chemotherapy and its use in a reduced number of cycles in early stage Hodgkin's disease are discussed.

Treatment of 49 unrandomized patients with advanced Hodgkin's disease.

Forty-nine patients with previously untreated advanced Hodgkin's disease were treated in our Institution between 1973 and 1981. Treatment modalities of these patients were reviewed, and they were divided into 3 groups according to the treatment employed: 13 patients received MOPP only, 22 patients received MOPP plus involved field radiotherapy, and 14 received alternating MOPP/ABVD chemotherapy. The response rates for the 3 groups were respectively 38.5%, 63.6% and 78.6%. A longer follow-up is needed to assess a significant difference in survival curves. The advantages of adjuvant radiotherapy and alternating non-cross-resistant drugs in advanced Hodgkin's disease are discussed.

[A combined method of sialography and CT scan of the parotid gland]. / Metodica combinata scialografia+TC per la parotide.

Computed tomography (CT) of parotid gland was performed on 40 patients, immediately following sialography. The results of the combined CT-sialography were compared with those of sialography alone and are presented here. We have come to the conclusion that the main indication for this method, in the study of the parotid gland, is the mass-pathology, particularly situated in deep-lobe and in the pharyngo-maxillary space.