Reconstruction of the nasal dorsum with autologous rib cartilage.

The authors present their experience with the correction of deformities of the nasal saddleback using rib cartilage grafts. They present a review of international literature on this topic, analyzing 33 patients selected from 452 cases of rhinoplasties performed between January 1990 and December 2004 at the Department of Plastic and Reconstructive Surgery of the University of Rome "Tor Vergata." Nasal saddleback is one of the most complicated defects to correct surgically. It can be a consequence of nasoethmoid-orbital fractures and is in this case associated with other evident signs like telecanthus, teleorbitism, or orbital dystopia. It can be also a consequence of surgical procedures in the nasal area where a loss of bone or septal cartilaginous support has occurred. They compare the techniques employed in the reconstruction and describe the advantage of the use of cartilage from the 11th rib and evaluate the results of an engineering analysis of tension forces on the rib cartilage. Of the total number of patients treated, good cosmetic results were obtained in 84% of the cases and excellent functional results in almost all of the cases (94%).

Autologous cartilage graft rhinoplasties.

BACKGROUND: The authors report their experience with autologous graft rhinoplasties. METHODS: Data were collected retrospectively, with selection of only autologous grafts from 2,000 rhinoplasties performed at the Plastic and Reconstructive Department of the University of Rome Tor Vergata. RESULTS: A total of 62 patients from January 1995 to January 2005 were selected. Most of the patients were treated with the "open tip" technique, whereas 9.7% had a classic endonasal approach. Follow-up evaluation was performed with outpatient visits at 2 and 6 weeks, then at 3, 6, and 12 months. Good aesthetic results were obtained for 93.5% of the patients, and 83.7% had complete satisfaction. CONCLUSION: Autologuos cartilage graft rhinoplasty is an affordable technique easy to learn that widens possibilities of interventions for nasal pyramid reconstruction.

Infectious complications in renal transplant recipients.

Renal transplantation has become a well-established therapeutic option for end-stage renal disease, but infectious diseases remain a significant cause of morbidity and mortality. Although a wide variety of pathogens may cause infection, viral ones must be regarded as the single most important class of infections. Progress has been made both in the prevention and the early recognition treatment of infections that are closely linked to rejection. Immunosuppressive therapy is central to the pathogenesis of both. Because of the particular characteristics of transplant recipients, it is desirable to establish a close collaboration between nephrologists, surgeons, and infectious disease specialists for the management of these patients. In this article, we describe the different kinds of infectious disease that may affect patients with kidney transplant and the fundamental principles of clinical management, particularly our experience in Polyoma virus (BK) infection.

Radiofrequency fistulectomy vs. diathermic fistulotomy for submucosal fistulas: a randomized trial.

BACKGROUND: Anal fistula represents one of the most frequent anorectal disease. Fistulotomy is considered the gold standard treatment but related problems are numerous (postoperative pain, bleeding, delayed or impaired wound healing). Fistulectomy lowers the recurrences but is less feasible with longer operating time and healing process. We applied the radiofrequencies to fistulectomy and compared the early and late results with those obtained from traditional fistulotomy. METHODS: Twenty patients were randomized to undergo radiofrequency fistulectomy (10 patients, Group A) or conventional fistulotomy (10 patients, Group B). We analysed the first postoperative day pain, intra- and postoperatory bleeding, operating time, complications (impaired or delayed wound healing, fecal incontinence) and any recurrences. RESULTS: The mean values for operative time have been 18.3 min for group A (range 15-26 min) and 17.9 min for group B (range 13-21 min). According to VAS scale, first postoperative day pain mean values were 2.8 for group A (range 2-4) and 4.1 for group B (range 3-5). Intra- and post-operative bleeding has always been negligible and faecal incontinence was never observed. Healing time mean values have been 3.5 weeks for group A (range 3-5) and 5.9 weeks for group B (range 4-8 weeks). Long-term results did not evidence complications or recurrences for both groups. CONCLUSIONS: The application of radiofrequencies to fistulectomy renders more feasible and easies the operation. Postoperative pain is smaller than traditional fistulotomy because of the lower temperatures used and for the shorter time spent in coagulating. This gives a faster wound healing. In conclusion we think that radiofrequency fistulectomy is technically more advantageous than traditional fistulotomy and furnishes better results.

A randomised trial comparing submucosal haemorrhoidectomy with radiofrequency bistoury vs. diathermic haemorrhoidectomy.

BACKGROUND: Haemorrhoid disease has become more and more frequent during the past years among western populations. Great attention has been paid in development of surgical procedures, in order to reduce post-operative pain (the main adverse effect of surgical treatment for haemorrhoids) and shorten execution time and hospital stay. This randomised clinical study compares the results obtained using submucosal haemorrhoidectomy with radiofrequency vs. diathermic haemorrhoidectomy. METHODS: Thirty-one patients were randomised to undergo submucosal haemorrhoidectomy with radiofrequency bistoury (16 patients, Group A) or diathermic haemorrhoidectomy (15 patients, Group B). The operating time, amount of pain and postoperative analgesic requirement, intra and post-operative complications and patient satisfaction were documented. RESULTS: The mean values for operative time have been 35.8 min for group A and 23.2 min for group B. According to pain score, patients' mean values for first day postoperative pain were 3.8 (A) and 5.8 (B). Pain at first evacuation 4.7 (A) and 6.5 (B). Pain at 7th postoperative day was 2.3 (A) and 3.7 (B). Patient's postoperative satisfaction rate was 6.0 (A) vs. 5.2 (B) at 3rd day and 6.7 (A) and 5.7 (B) at 6 months. CONCLUSIONS: In spite of relatively difficult execution and longer operating times, submucosal haemorrhoidectomy with radiofrequency bistoury appears to be the most precise and accurate treatment for IV degree haemorrhoids. Performing submucosal haemorrhoidectomy with radiofrequency bistoury allows us to reduce postoperative pain, bleeding and shorten hospital stay.

Prospective randomized trial of submucosal hemorrhoidectomy with radiofrequency bistoury vs. conventional Parks' operation.

BACKGROUND: Postoperative pain has always been the main adverse effect of the surgical treatment for hemorrhoids. Surgical techniques evolved mainly to solve this problem as well as postoperative bleeding, stenosis and recurrence. This randomized study compared the results obtained using submucosal hemorrhoidectomy with radiofrequency bistoury with those of the conventional Parks' operation. METHODS: A total of 102 patients were randomized to undergo submucosal hemorrhoidectomy with radiofrequency bistoury (51 patients) or conventional Parks' haemorrhoidectomy (51 patients); loss of some patients at follow-up resulted in 49 and 45 patients available for analysis, respectively. The operating time, amount of pain (VAS scale, 1-10), postoperative analgesic requirement, intra- and postoperative complications, length of hospital stay and patient satisfaction were documented. RESULTS: In comparison to Parks' technique, use of radiofrequency bistoury reduced mean operating time (61.2 min vs. 37.4 min; p<0.05), first postoperative day pain score (5.9 vs. 4.0; p<0.05), pain score at first evacuation (5.7 vs. 4.2; p>0.05), postoperative stay (2.2 days vs. 1.3 days; p<0.05), and pain score on postoperative day 7 (3.6 vs. 2.8; p>0.05). Fecal incontinence was never observed. Incontinence to flatus with spontaneous resolution within 2-3 weeks was reported by 4 subjects in each surgical group. Urinary retention requiring catheterization occurred in 21 subjects in the radiofrequency bistoury group and in 18 patients in the control group. No complications nor recurrences were reported at the 6-month follow-up in either group. CONCLUSIONS: Performing submucosal hemorrhoidectomy with radiofrequency bistoury improves the results obtained with Parks' technique, allowing us to simplify the surgical procedure, reduce operating time, postoperative pain and bleeding, and shorten the hospital stay.

Sirolimus in kidney transplantation from marginal donors.

Nephrotoxicity caused by calcineurin inhibitors can lead to either delayed graft function or long-term decline of renal function after kidney transplantation. Therefore, recipients of renal transplants from marginal donors require non-nephrotoxic immunosuppression. Eighteen patients received kidney transplants from marginal donors, with a calcineurin inhibitor-free immunosuppressive regimen, based on basiliximab, mycophenolate mofetil, steroids, and sirolimus. Renal graft biopsy was performed in all cases before surgery. Mean follow-up was 11.8 months. We report immediate renal function in 9 patients, delayed graft function in 5 and acute tubular necrosis in 4 patients. One patient was successfully treated for biopsy-proven acute rejection. Hypercholesterolemia and hypertriglyceridemia were the most common adverse effects (n = 13) associated with arthralgia (n = 2) and thrombocytopenia (n = 2). Five patients underwent a switch to tacrolimus, due to sirolimus-induced side effects. Immunosuppression without the use of calcineurin inhibitors is a safe and effective regimen in kidney transplantation, although sirolimus-related side effects still represent a morbidity factor in these patients.

Marginal donors in liver transplantation.

Marginal liver donor criteria included the following: obesity (weight >100 Kg or BMI >27), age >50 years; macrovesicular steatosis >50%; intensive care unit stay >4 days; prolonged hypotensive episodes of >1 hour, and <60 mm Hg with high inotropic drug use (dopamine, [DPM] > 14 microg/kg per minute); cold ischemia time >14 hours, peak serum sodium >155 mEq/L; sepsis, viral infections, and alcoholism; high levels of bilirubin, ALT, and AST, or extrahepatic neoplasia. Between August 1992 and May 2003, we performed 251 liver transplants in 241 patients of whom 155 are presently alive. We used 124 (49.4%) standard donors and 127 (50.6%) marginal donors. Among the group that received a standard donor, 81 (65.3%) are still alive. Among recipients of organs from marginal donors. 81 (63.8%) are still alive. We also assessed the quality of donors according to the severity of recipient disease. For standard donors these outcomes were 61.5% for UNOS 1, 37.5% for UNOS 2A, 73.2% for UNOS 2B, and 80% for UNOS 3 for marginal donors they were 46.1% for UNOS 1, 53.6% for UNOS 2A, 70.7% for UNOS 2B, and 63.6% for UNOS 3. Among the patients who received a liver from a donor >60 years old, there were no survivors in UNOS 1 and 2A, but there were good results in groups 2B and 3. These results suggest there is no difference between marginal and standard donors, even in sick patients, with the exception of donor age.

Polyoma virus BK and renal dysfunction in a transplanted population.

INTRODUCTION: Reactivation of polyoma virus BK (BKV) is increasingly recognized as a cause of severe renal-allograft dysfunction. The aim of the present study was to evaluate prevalence of BKV infection and activity in a population of kidney (KT) and liver (LT) transplant patients and search for a possible correlation with renal dysfunction. METHODS: We studied 118 patients for BKV viruria and, when present, for BKV viremia. We also assessed HCV status. RESULTS: Among 16 patients with BKV viruria (5 LT and 11 KT), eight showed BKV viremia (one LT and seven KT). Among BKV viruria-positive patients, three LT recipients were HCV-positive. All LT BKV viruria-positive patients showed normal renal function with a mean serum creatinine (sCr) blood level of 0.9 mg% and a mean blood urea nitrogen (BUN) value of about 36 mg%. The mean transplant age was 2.5 years. In contrast, KT BKV viruria-positive patients showed impaired renal function which was slightly worse in patients who also displayed BKV viremia, namely, a mean sCr blood level 1.7 mg% and a mean BUN value about 80 mg%. The mean transplant age was 7 years. CONCLUSION: Based on these findings, it seems that BKV viruria in renal allograft recipients may be associated with viremia and related to nephropathy that may lead to allograft rejection. The study will be completed with a 2-year follow-up of positive patients to assess the possible relationship between BKV active infection and eventual decrease of renal function and loss of transplanted organ.

[Long-term clinical experience in post-dilution HFR]. / Diciotto mesi di esperienza clinica su HFR on-line in post-diluizione.

PURPOSE: Hemodiafiltration reinfusion (HFR) is characterized by the use of regenerated ultrafiltrate as replacement fluid. We devised a new technique, post-dilution HFR, aimed at increasing the purification efficiency, treatment tolerability and at reducing inflammatory state. METHODS: We performed post-dilution HFR in six uremic patients during 18 months. Dialytic efficacy, filter blood rest and cytokine behavior were evaluated. RESULTS: Neither pyrogenic reactions nor other adverse phenomena were recorded. The tolerance to the treatment was excellent. We observed a high rate of urea extraction and optimal Kt/V values, a high extraction of beta2 microglobulin (beta2-m) and a reduction in blood rest; in addition, interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) significantly decreased. CONCLUSIONS. The inversion of the standard HFR configuration allowed us to improve the removal of both urea and beta2-m, and the blood rest, with an optimal tolerability. Moreover, the reduction in cytokine levels could attenuate the uremic microinflammatory state.

[Comparison between two different on-line dialytic techniques: Standard HFR vs post-dilutional HFR]. / Emodiafiltrazione con reinfusione di ultrafiltrato rigenerato in pre- e post-diluizione: due tecniche on-line a confronto.

PURPOSE: Among hemodiafiltration (HFD) techniques, hemodiafiltration reinfusion (HFR) seems unable to achieve an optimal depurative efficacy. This study aimed to evaluate whether the HFR technique as suggested in its original configuration could be improved by devising a new technique (post-dilution HFR (PDHFR)) inverting the purification sequence to increase the purification efficiency of the entire system. METHODS: We performed standard HFR in six uremic patients during 6 months and, subsequently, during a further 6 months, PDHFR was performed. The dialytic efficacy of the two techniques and the filter blood rest were evaluated. In addition, we studied the behavior of cytokines during the inverted HFR sessions. RESULTS: We observed a significant increase in urea extraction and in Kt/V. An equally significant improvement was observed with regard to beta2-microglobulin (beta2-m) extraction and blood rest. Furthermore, interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) significantly decreased after inverted HFR treatment. CONCLUSIONS: The inversion of the original configuration allowed us to improve the depurative efficacy of standard HFR, increasing the removal of both urea and beta2-m, and reducing the blood rest. Finally, it was notable that the reduction in cytokine levels could attenuate the uremic microinflammatory state.

[Description of a case of giant adrenal myelolipoma and survey of the literature]. / Presentazione di un caso clinico di mielolipoma surrenalico gigante e revisione della letteratura.

Adrenal myelolipoma is a benign tumor affecting the adrenal gland. It is composed by adipose cells and myelopoietic cells present in each normal differentiating stage of the bone marrow. The neoplasia is often asymptomatic, sometimes leading to very large adrenal masses (more than 10 cm in diameter). These are often called "giant myelolipoma". A case is reported and a survey of the literature on this topic is made; the present knowledge of this disease as well as its diagnosis and treatment are discussed also.

Plasmaperfusion on triptophan columns can improve the clinical outcome of patients affected with myasthenia gravis.

UNLABELLED: Myasthenia Gravis (MG) is a neuromuscular disease often associated with thymic pathology due to neuromuscular transmission impairment by circulating antibodies directed against the cholinergic postsynaptic receptor on the neuromuscular junction (Anti-AchR-Ab). The treatment of MG includes cholinesterase inhibitors, steroids and thymectomy. Plasmapheresis can remove Anti-AchR-Ab but more recently plasma-perfusion (PP), a more specific apheresis for selective removal of noxious plasma components, has been developed. AIM OF THE STUDY: To study the effect of PP treatment, performed by using specific immunocolumns for Anti-AchR-Ab, on the clinical outcome of MG patients non-responder to steroid therapy or thymectomy. MATERIALS AND METHODS: We treated 8 patients suffering from severe MG by a cycle of 6 sessions of PP. We used columns containing triptophan as a specific ligand for Anti-AchR-Ab. In order to evaluate the effectiveness of treatment we used functional tests (muscular tests, respiratory function, electromyography) and laboratory tests (Anti-AchR-Ab; immunoglobulins, complement fractions, immunocomplexes). RESULTS: After one to three PP sessions, early clinical improvement in bulbar and respiratory symptoms were found in all patients and EMG showed improvement of neuromuscular transmission. Serum concentration of immunological markers decreased progressively and significantly during the treatment. Clinical improvements were progressive despite the tendency for Anti-AchR-Ab to reach initial values between one session and another. We observed no side effects due to the type of immunocolumns used. CONCLUSIONS: Triptophan columns appear to be able to remove large quantities of Anti-AchR-Ab and immunological markers from plasma. Our experience shows that PP performed using triptophan columns in patients suffering from severe MG provides good clinical results, improving patients' outcome, without any risk linked to the procedure.

Minimal sentinel node procedure for staging early breast cancer.

AIMS AND BACKGROUND: Sentinel lymph node dissection (SLND) has recently been evaluated as a new staging technique for early breast cancer. To minimize the extent of surgery, the feasibility of eradicating primary breast lesions and the relative sentinel lymph nodes (SLN) under regional anesthesia was evaluated in this study. METHODS AND STUDY DESIGN: A selected population of 76 patients with suspected operable breast cancer and no clinically palpable lymph nodes was enrolled in the study. Intra- and perilesional administration of a radiotracer was performed. Lymphoscintigraphy was carried out to confirm the drainage pathway and locate the SLN. The following day, after inducing a nervous block induction of the ipsilateral intercostal nerves, we performed the surgical procedure with the help of a hand-held gamma-detecting probe. In case the primary lesion was diagnosed as invasive carcinoma by frozen section, the SLN and the remaining axillary lymph nodes (non-SLNs) were removed. The status of SLN and non-SLNs was compared. RESULTS: The primary breast lesion was located and excised in all cases (identification rate: 100%). Lymphoscintigraphy positively identified SLNs in 40/45 (89%) patients; in five patients no lymphatic drainage was detected. In 38 cases an average of 1.5 SLNs and 14 non-SLNs per patient were removed and pathologically analyzed; the remaining two patients showed SLNs in the internal mammary chain, which were not excised. Twenty-nine percent of the patients showed metastatic disease in the lymph nodes examined. Of all patients with affected nodes, 55% had cancer cells only in the SLN. No false negatives (skip metastases) were found. No immediate or long-term anesthesia-related complications (e.g., pleural lesions, intravascular injection) were observed. CONCLUSIONS: Our data confirm the feasibility of single radiotracer administration for both occult lesion and SLN localization as well as the usefulness of SLND in staging early breast cancer. Regional anesthesia resulted in easy management and good patient compliance. This time-saving procedure allowed the completion of the whole surgical plan, reducing the recovery time without modifying the effectiveness of surgery.

Sentinel lymphadenectomy in cutaneous melanoma.

AIMS AND BACKGROUND: In the last ten years validation of the sentinel lymph node (SLN) concept has led to modification of the surgical approach for patients with intermediate-risk cutaneous melanoma. METHODS AND STUDY DESIGN: Forty-eight patients affected by cutaneous melanoma with a Breslow thickness between 0.65 and 4 mm were enrolled in the study. Approximately 2 mCi of radiotracer and 1 mL of vital blue dye were injected in each patient around the site of the primary lesion. Lymphoscintigraphy was performed until the lymphatic basin and the respective SLN were localized. The whole surgical procedure consisted of enlargement of the surgical margins followed by localization and excision of the SLN(s) by using both radiotracer and vital dye. Whenever the SLN proved to be histologically positive for metastasis, complete regional lymphadenectomy was performed. RESULTS: Within 15 minutes of radiotracer administration the lymphatic basin was localized in all 4 patients by lymphoscintigraphy. Vital dye and radiotracer successfully allowed SLN localization and excision in 46 of 48 patients (97%); in one case the SLN was detected by radiotracer alone. The SLN proved to be metastatic in six (13%) of 46 evaluable patients; interestingly, in three of them the presence of metastatic cells was revealed only by immunohistochemistry. All patients with tumor-positive SLNs had primary lesions with a Breslow thickness = 2 mm. CONCLUSIONS: Sentinel lymphadenectomy is able to identify lymph node involvement in patients with cutaneous melanoma with a Breslow thickness > 1 mm, thus avoiding the risks associated with radical regional lymphadenectomy. Lymphoscintigraphy proved to be an important tool to obtain correct preoperative localization of the drainage basin, especially for melanomas located on the face and trunk.

Identification of the novel allele B*4427 and a confirmatory sequence (B*44022).

This report presents a novel allele, HLA-B*4427, which was identified in a bone marrow donor of Caucasian origin, and a confirmatory sequence (B*44022). Sequence analysis revealed the new allele differs from B*44021 by a single nucleotide exchange at position 668 (C-->T), which is located in exon 4. At the protein level, it is the only B*44 variant to produce an Ala in place of a Val at codon 199. Its structure suggests that it may have originated from a point mutation in B*44021 or by gene conversion with a variety of HLA-B alleles. Cloning and sequencing of the allele B*44022 revealed a sequence identical to B*44021 and B*44 exon 4, with the codon GTC (Val) in position 199.

Surgery versus interventional radiology in the management of thrombosed vascular access for hemodialysis.

Thrombosis is the most frequent complication occurring in vascular access (VA). The two widely used treatment strategies for thrombosed VA are surgical and endovascular. Which is the best and whether different approaches should be used on proximal versus distal VA, is still debated. This is a retrospective study. Over a three years period, we studied among a population of 475 dialysis patients, 54 VA thromboses in 46 patients. Surgical procedure was successful in 14/17 (82%) distal artero-venous fistulas (AVF) while, in 9 proximal AVF, it led to initial success in 6 patients (66%), with a six months primary patency respectively of 93% and 84%. Radiological procedure resolved 6/10 distal AVF (initial success 60%) with primary patency of 66%, and was successful in 16/18 proximal AVF (initial success 89%) with primary patency of 81%. Taking our data all together, no differences are found between two thrombolitic (surgical and endovascular) procedures. But results were different in thrombosed proximal VA (where endovascular treatment should be preferred) versus distal ones (where surgery seems better).