Small bowel intussusception due to malignant melanoma: primary lesion or metastases? A case report.

Intussusception is a rare condition in the adult population: it is responsible for 1% of all bowel obstructions. In most of intussusceptions a malignant tumor is involved; a lot of studies show that approximately 50% of malignant metastases causing small bowel intussusception are metastatic melanomas. In present paper a case of a small bowel intussusception probably due to metastases of an occult melanoma, in a 69-year-old patient, is presented. Surgery resection, careful research of possible primitive neoplasms and an accurate follow-up program has been the treatment of choice. All the investigations carried out did not allow to identify a possible primitive neoplasm. The last whole body PET carried out 44 months after surgery resulted disease-free.

Multidetector helical angio CT oblique reconstructions orthogonal to internal carotid artery for preoperative evaluation of stenosis. A prospective study of comparison with color Doppler US, digital subtraction angiography and intraoperative data.

AIM: The recent introduction to clinical practice of multidetector helical angio CT (MHACT) has generated a new interest in the diagnosis of carotid artery atherosclerosis. In recent years there has been a redefinition of the indications to carotid artery endarterectomy; there is a tendency to appraise plaque morphology and composition, and not only stenosis degree. The aim of this prospective study is to analyze the validity of MHACT in the diagnosis of atheromasic stenosis of the carotid bifurcation, in comparison with US color Doppler (USCD), digital subtraction angiography (DSA) and intraoperative evidence (OP). Special emphasis is given to the analysis of plaque composition and to precise evaluation of the stenosis percentage computed as an area rate on oblique reconstructions performed exactly orthogonal to the axis of the vessel at the point of maximal stenosis. METHODS: Twenty-seven carotid stenosis (in 24 patients) were preoperatively evaluated by USCD, MHACT, DSA. We calculated the stenosis degree with USCD, by the ECST method, both as a diameter rate and as a bidimensional value. By MHACT we computed the percentage of stenosis as an area rate, in an MPR oblique plane orthogonal to the vessel axis, at the point of maximal stenosis; by DSA we used NASCET and the common carotid artery method (CC). DSA measurements have been mathematically converted as area rate (NASCET2 and CC2). All the patients were operated on with the eversion technique (EEA); it was always possible to obtain an intact cylindrical specimen of the plaque and to perform a reliable and accurate evaluation of the degree of stenosis by sectioning and measuring it on the desk. We gave a score to the presence and amount of lipid and calcium components, and these data were compared to those obtained with the different diagnostic instruments. RESULTS: Statistical analysis of the 7 data sets showed an important underestimate of the angiographical method (DSA), even if the measurements were carried on by a precision caliper. The mathematical conversion of a linear stenosis rate into an area rate gives these values more reliability, indicating, as for NASCET2, non statistically significant differences when compared to surgical evidence, notwithstanding a high standard deviation. The rates obtained by USCD (area rate) and MHACT proved to be very accurate with respect to surgical evidence. In this study there was no significant difference in the detection of various components (lipid and calcium) of the atheromasic lesion, by MHACT and surgical evidence (OP). CONCLUSION: MHACT promises to be a very accurate instrument in the detection of plaque components and identification of the stenosis degree. It shows some limits in very calcific lesions and occasionally, in relevant cardiac failure, may be useless. Hence one feels the need to reassess the role of DSA, once considered the "gold standard", with more extensive prospective studies, including comparison with MHACT and USCD.

Late rupture of an abdominal aortic aneurysm after Parodi's endoprosthesis replacement.

Endovascular surgery as a whole, and specifically in the context of aortic aneurysms, is a very interesting methodology the potential of which is increasingly being recognized. Follow up information on patients who underwent these procedures will be critical to validate the different techniques which have been developed and to identify the most appropriate situations for this type of surgical procedures. The authors present a case of aortic aneurysm rupture who had undergone Parodi's endoprosthesis placement two years before. CT angiographic evaluation showed a wide endoleak due to distal stent detachment, a complete dislodging of the endoprosthesis itself and retroperitoneal haematoma. Prosthesis replacement through a laparotomic approach was carried out and the patient was discharged 10 days postoperatively, surgically cured.

Steroid-independent activation of ER by GnRH in gonadotrope pituitary cells.

In the rat pituitary gland the mechanism responsible for ERalpha regulation has not been fully elucidated. Using transient transfection assays in alphaT3-1 cells, a cell line of gonadotrope origin, we show that GnRH stimulates estrogen response element-containing promoters in an estrogen-independent manner. This effect was strictly ER and GnRH receptor dependent, as no activation of the reporter gene was observed in presence of the anti-estrogen ICI 182,780 or a GnRH antagonist. These data suggest that the GnRH-triggered signaling pathway results in 17beta-estradiol-independent trans-activation of the ERalpha in alphaT3-1 cells. Furthermore, an additive activation was achieved when cells were treated with both GnRH and 17beta-estradiol. In primary pituitary cells, GnRH alone (100 nM) did not cause a significant stimulation of reporter gene activity, presumingly due to the low amount of gonadotropes. Interestingly, the combination of 17beta-estradiol and GnRH resulted in a significant increase in ERalpha trans-activation compared with that in cells treated with 17beta-estradiol alone. This enhancement was prevented by ICI 182,780, showing an ERalpha requirement. Moreover, we show that the effects of GnRH on ERalpha transcriptional activity in gonadotrope cell lines are mediated by the PKC/MAPK pathway. In conclusion, our data demonstrate that GnRH is an important signal in the regulation of ERalpha trans-activation in gonadotrope cells.

Brain involvement in extracranial internal carotid artery aneurysms.

BACKGROUND: No prospective study of extracranial internal carotid artery aneurysms (EICAA) has been reported to date. The aim of this study was to evaluate central nervous system complications associated with surgical intervention for EICAA. PATIENTS AND METHODS: A total of seven patients, representing all cases observed at our institution from December 1997 to December 1998, were entered in this prospective study. Three patients had bilateral involvement. The aneurysms were both atherosclerotic and dysplastic. All patients were males, with mean age of 70 years (range 65 to 74). Internal or common carotid artery to EICAAs diameter ratios were calculated on the angiograms. The transverse diameter as well as the craniocaudal extension of the lesions were accurately measured intraoperatively. Follow-up evaluations were performed at three, six and twelve months postoperatively, and consisted of a clinical evaluation by both a neurologist and a vascular surgeon who were not part of the primary surgical team. RESULTS: Six patients presented with neurological symptoms ranging from non-hemispheric TIAs to hemispheric stroke. One patient was asymptomatic. The severity of symptoms was correlated with the size of the aneurysm. Preoperative symptoms were more severe in EICAAs of > or = 3 cm in transverse diameter. One case had a postoperative stroke, no perioperative deaths occurred. All the internal carotid arteries operated on were patent during follow-up evaluations. No new neurologic event was observed during follow-up. CONCLUSIONS: The severity of central neurologic symptoms seems to depend on the size of the aneurysmatic lesion. Prompt surgical management of small EICAAs may reduce the occurrence of severe CNS complications, both preoperatively and postoperatively, due to the lower risk of embolization associated with small aneurysms compared to larger lesions.

Endoscopy and surgery. A combined strategy for diagnosis and therapy of polyposis-cancer sequence in the colon.

BACKGROUND: The aim of the paper is to evaluate retrospectively the series of patients affected by colon polyps and colon cancer to purpose a planned follow-up for patients who underwent colon polypectomy. METHODS: Out of 198 patients affected by colon carcinoma, the authors describe 95 cases of previous, synchronous or metachronous polyps, with a global prevalence of 47.9%, and respectively of 13.6%, 16.6%, and 17.6%. RESULTS: The evolutive sequence between colon polyp and carcinoma is shown through both clinical experience and experimental tests. The epidemiologic curve of adenoma rate precedes by five years the curve of carcinoma, and such is the average period of time for the transformation of an adenoma into invasive carcinoma. In clinical practice, it is frequent to note synchronous or metachronous polyps with respect to colon carcinoma. It is also possible to note carcinoma in patients with previous polypectomies. CONCLUSIONS: On the basis of the retrospective evaluation of the clinical cases, and reviewing international literature, the authors suggest their diagnostic-therapeutic and endoscopic follow-up protocol for patients affected by colon neoformations (Fig. 1).

Two incidental cases of abdominal aortic aneurysm and gallbladder cancer. Further data influencing the management of patients affected by aneurysm and gallbladder disease.

Abdominal aortic aneurysm and cholelithiasis are two common diseases in the elderly population. The prevalence of abdominal aortic aneurysms ranges between 1.8 and 6.6% in autoptic series and it's estimated that 2.5% of the over sixty year old population is affected. Carcinoma of the gallbladder is the most common malignant tumor of the biliary tract and in the United States is the fifth most frequent digestive tract malignancy; it's incidence ranges between 2 to 10 cases of 100,000 persons/year. No adequate guidelines are now available to assist the surgeon, in the case of concomitant gallbladder disease and abdominal aortic aneurysm. In this paper the management of abdominal aortic aneurysm in a patient with gallbladder disease is discussed in order to assist the surgeon deciding whether to perform concomitant aneurysm resection and cholecystectomy. In 162 aneurysmectomies (1987-1997) 18 (11.11%) patients underwent combined aneurysmectomy and cholecystectomy operation. The patients ranged in age from 49 to 88 years (average 69 years). In two cases the anatomo-histological specimen examinations (twelve sections) demonstrated a gallbladder carcinoma. The overall mortality rate was 5.56% either for aneurysmectomy alone or for combined therapy. In case of abdominal aortic aneurysm and concomitant gallbladder disease, in choosing simple endoaneurysmectomy, the surgeon has to consider the risk of early and late complications of leaving a diseased gallbladder in place. In case of concomitant performance of both operations, the risks of a possible septic graft contamination must be considered. We believe that the patient may be best served by performing the vascular and nonvascular procedures in the same operation. In this paper a new proof, till now never considered in the international literature, is presented to support our opinion: the possibility of concomitant unknown cancer or precancerous lesions in a lithiasic gallbladder. Diagnosis of these lesions is, indeed, not easy to perform in the preoperative phase and is often a postoperative anatomo-histological detection.

[Primary jejunal liposarcoma]. / Liposarcoma primitivo del degiuno.

A case of primary jejunal liposarcoma is reported. Liposarcoma of the small intestine is very rare (four cases in the international literature). The early clinical symptoms of these malignancies are unclear non specific and for this reason the disease is often diagnosed at an advanced stage. The prognosis of these lesions is generally poor owing to the diffusion of the disease at the time of diagnosis. Usually small bowel neoplasms are preoperatively identified only in 27-72%. The percentage of surgical removal is from 65 to 80% according to the recent literature. Aim of this paper is to present a rare case of jejunal liposarcoma.

Recurrent aneurysms: late complication for patients previously submitted to graft replacement for abdominal aortic aneurysm.

BACKGROUND: The possibility to perform easy and cheap ultrasonographic examinations of the abdomen allows us to face the problem of possible development of new paraanastomotic aneurysms or aneurysms on native arteries in subjects already submitted to endoaneurysmectomy of the abdominal aorta. The idea of planning accurate programs of ultrasonographic follow-up of operated patients is sustained by the hypothesis that the aortic aneurysm is an expression of a systemic disease due to a connectival defect of genetic nature. METHODS: Two different follow-up experiences are described: the first was a simple follow-up based only on clinical evaluation of patients previously submitted to aortic surgery in the last ten years at the Department of General and Cardiovascular Surgery of the University of Milan, and the second experience a planned follow-up programme based on instrumental evaluation of the patients. RESULTS: Thirty-one cases of recurrent aneurysms of native arteries in 13 subjects already operated for AAA from 3 to 13 years before are described. Despite the patients were evenly inserted in a clinical follow-up, as a matter of fact, 25 of these lesions were detected during occasional investigations performed for other reasons or for rupture, while during the last two years, the planned ultrasonographic follow-up of 95 patients detected 6 new aneurysms. CONCLUSIONS: Incidental detections of new paraanastomotic true aneurysms or ectasia of native arteries far from the graft are more and more frequent in patients already submitted to aortic replacement for abdominal aneurysm. In the international literature only few papers have been published about perspective studies based on instrumental follow-up of operated patients. The planning of such controls is mandatory, at present, also in order to evaluate the clinical development of aneurysmatic disease.

[Malignant neoplasia of the small intestine. Apropos of 7 cases. Clinical discussion and review of the literature]. / Neoplasie maligne dell'intestino tenue. A proposito di 7 casi. Discussione clinica e revisione della letteratura.

The authors report seven cases of primary malignancies of the small intestine observed and treated between 1989 and 1995 at the First Surgical Division of Treviglio Hospital. Three patients were affected by adenocarcinomas (two involving the duodenum and one the jejunum), two patients had non-endocrine carcinoid tumors of the ileum, one presented a jejunal liposarcoma and one a lymphoma of the ileum. Four patients died (respectively at three months, 15 months, 18 months and five years after surgical intervention). Three patients are still alive. The early clinical features of these malignancies are typically vague and non specific and for this reason the disease is often diagnosed at an advanced stage. The prognosis of these lesions is generally poor owing to the diffusion of the disease at the time of diagnosis. In fact these neoplasms are preoperatively identified only in 27-72%. The percentage of surgical removal ranges between 65 and 80% according to the recent literature. This study is aimed at analysing the clinical and pathologic characteristics of the observed cases and the difficulties of the diagnostic procedure. The adopted surgical techniques and the outcome of the operative treatment are also examined.

Endoscopic resection of esophageal lymphangioma incidentally discovered.

A pedunculated lymphangioma of the esophagus was unexpectedly discovered during an endoscopic investigation performed for epigastric pain in a patient affected by diabetic arteriopathy treated with antiplatelet drugs. The patient neither complained of dysphagia nor other symptoms related to the presence of the lymphangioma which therefore can be considered as an endoscopic "incidentaloma".The lesion was removed endoscopically and a follow up, 6 months later, showed no scar or recurrence.The authors present this case both for the extreme rarity of this lesion and for the evidence of low-medium grade dysplasia in the overlying mucosa, particularly since it is only case ever noted in literature.This aspect suggests that, even if malignant degeneration of these lesions has never been observed, their endoscopic removal is recommended. However, when endoscopic procedures are not feasible, thoracotomic surgical exeresis should be only considered for obstructing and symptomatic lesions; an accurate endoscopic and bioptic follow up can be useful for asymptomatic lesions.

[Plasma-cell granuloma of the sigmoid colon concomitant with adenocarcinoma of the cecum. Viewpoint for debate, literature review on pseudotumors, idiopathic colitis and cancer]. / Concomitanza di granuloma plasmacellulare del sigma e adenocarcinoma del cieco. Spunto per una discussione ed una revisione della letteratura in tema di pseudotumori, coliti idiopatiche e cancro.

A case of colonic pseudotumor, causing intestinal occlusion, concomitant with a caecum neoplasia is reported. A male 69 years old was referred to our Institution for colic abdominal pain: colonoscopy aborted because of an insuperable sigma stenosis; diagnostic enema confirmed the sigmoid stenosis, originally advised as neoplastic. As operation, the sigmoid tumor appeared accompanied with enlarged draining lymph nodes and peritoneal sac was disseminated of miliary-like whity granules. Hystological examination showed a plasma-cell granuloma with nodular and peritoneal chronic inflammatory reaction. A pancolonoscopy, performed fourty days later, discovered an unsuspected adenocarcinoma neoplasia of the caecum, that was resected with a second operation. Regional nodes were not involved. The authors make a review of international literature about of plasma-cell granuloma, pseudotumor and inflammatory chronic bowel diseases in order to identify possible correlations between pseudotumor and neoplasms. The extremely low incidence of plasma-cell granulomas in the alimentary tract (17 case since 1970 to 1994) and the reported association with concomitant neoplasms (29%) suggest to consider extremely useful an accurate study of patients with intestinal pseudotumors in order to identify neoplasms of the gastrointestinal tract as well as of other organs.

Immunohistochemical study of secretogranin II in 62 neuroendocrine tumours of the digestive tract and of the pancreas in comparison with other granins.

An immunohistochemical study on 62 cases of gastrointestinal and pancreatic neuroendocrine tumours was performed in order to test the interest and specificity of a new anti-human secretogranin II antibody and compared to the other granin markers (chromogranin A and chromogranin B). Specific immunoglobulins were purified by affinity chromatography from an antiserum raised against a recombinant secretogranin II. Gastric tumours did not express secretogranin II, and ileal and appendiceal tumours only rarely expressed it (1/10 and 1/7 respectively), unlike the other classic neuroendocrine members of the granin family. In duodenal and pancreatic tumours, secretogranin II was detected when the other granins were also expressed. On the other hand, all rectal tumours expressed secretogranin II (7/7), frequently in the absence of chromogranin A. Though the granins expressed in tumoral tissue and in adjoining non tumoral tissue are mostly related, strong secretogranin II positivity occurred in 4 tumours while mucosa was secretogranin II negative. These observations highlight the interest for associating another antigranin such as secretogranin II to the classical markers of neuroendocrine tumours.

Cell-specific mechanisms of estrogen receptor in the pituitary gland.

Analysis of the mechanism of action of estrogen receptor shows protein and mRNA polymorphism within distinct pituitary receptor-positive cells. The lactotropes exhibit unique properties in these mechanisms that distinguish them from gonadotropes. Therefore, this cell type constitutes an especially interesting model in the male as well as in the female for estrogen receptor studies.

[The "sump syndrome": a case treated by surgical endoscopy. A discussion about biliodigestive diversions and endoscopic sphincterotomies]. / "Sump syndrome": un caso trattato mediante endoscopia operativa. Spunto di discussione in merito a derivazioni biliodigestive e sfinterotomie endoscopiche.

A case of "sump syndrome", occurred in our department, suggested the discussion about the opportunity of endoscopic operative procedures in choledocholithiasis and in biliary tract surgery complications. Improvement of endoscopic operative procedures allow extensive indication of ERCP sphincterotomy instead of traditional choledochoduodenostomy or transduodenal papillosphincterotomy. Additionally, operative endoscopic procedures are good alternative to reoperation for traditional biliary tract surgery complications.

[The role of ERCP in the diagnosis and therapy of Mirizzi's syndrome. Apropos a clinical case]. / Ruolo della ERCP nella diagnosi e terapia della sindrome di Mirizzi. A proposito di un caso clinico.

Mirizzi syndrome is a rare variant of obstructive jaundice due to compression of the hepatic duct caused by a stone inserted in the cystic duct or in the Hartmann recess and it is referred with a prevalence of 0.05-1% of patients with cholelithiasis. These percentages are, nevertheless, unreliable because only an accurate preoperative cholangiography allow to detect a Mirizzi syndrome and so, very often, the real cause of the jaundice remains unacknowledged. Early diagnosis of the syndrome is particularly important because it suggests an accurate and prudential surgical approach considering the frequent fibrotic adherences caused by chronic inflammation. In this paper the authors present a clinical case quickly and successfully cured operative endoscopy, followed by traditional surgery. The authors believe that the study of obstructive jaundices must include an ERCP either for the diagnosis or because operative endoscopy could ameliorate clinical feature and hepatic performance in order to allow a safer surgical operation.

Non occlusive ileocaecocolic intussusception caused by caecum cancer--case report.

A case of ileocaecocolic intussusception caused by a caecum carcinoma is presented. The authors stress the peculiarity of clinical manifestation, without intestinal obstruction despite the presence of a big abdominal mass involving vessels and bowel, revealed by CT scanning and angiography. Endoscopy was not able to identify the nature of the lesion. Laparotomy performed with the idea to find a mesenchymal neoplasia, permitted to achieve the diagnosis.

Endoscopic treatment of postoperative external biliary fistula in a patient operated on for hepatic injury due to multiple trauma.

After surgery for hepatic injury as a result of blunt abdominal trauma from a motorcycle accident, an external biliary fistula developed in a young patient. The authors describe the rapid and complete healing of the fistula by use of a nasobiliary catheter. These findings emphasize the importance of endoscopic operative technique for postoperative and traumatic external biliary fistulas.

[Anastomotic pseudoaneurysm, true para-anastomotic aneurysm and recurrent aneurysm following surgery for abdominal aortic aneurysm. Is a unifying theory possible?]. / Pseudoaneurismi anastomotici, aneurismi veri para-anastomotici e aneurismi ricorrenti in soggetti operati per aneurisma dell'aorta addominale. E possibile una teoria unificante?

BACKGROUND. Recurrent aneurysms (RA) and true para-anastomotic aneurysms (TPA) are currently reported as anecdotal findings during occasional follow-up of subjects previously operated for abdominal aortic aneurysm (AAA). In several instances concomitant false anastomotic aneurysms (FAA) are found, not attributable to infection nor to suture or graft degradation. PURPOSE. To discuss the possibility that RA of inborn arteries, TPA, and non infectious FAA, when concomitantly present in the same subject, may reflect a peculiar late presentation of multiarterial aneurysmal disease. MATERIAL. Three cases of occasionally discovered concomitant RA, TPA, and FAA in subjects previously operated for AAA are reported. The finding of new aneurysms and FAA in subjects previously operated for AAA may be theoretically justified by the currently recognized pathogenetic mechanisms, molecular, enzymatic or genetically determined, implicated in the formation of AAA. This points out the need for a correct surgical management of AAAs and for accurate accomplishment of follow-up programmes supported by ultrasound echography of graft-arterial anastomoses and of the arteries at risk of aneurysmal disease.

Early detection of secretogranin-II (SgII) in the human fetal pituitary: immunocytochemical study using an antiserum raised against a human recombinant SgII.

Secretogranin-II (SgII) is a protein contained within secretory granules of mainly gonadotrophs. The purpose of this study was to determine whether SgII immunoreactivity (SgII-IR) in the human fetal pituitary was temporally related to gonadotropin immunoreactivity. A specific antihuman SgII antiserum was thus required. A complementary DNA clone with an open reading frame for human (h) SgII was synthesized by reverse transcription-polymerase chain reaction from pituitary total RNA. This clone was used to obtain the SgII polypeptide (-9 to 152) as a fusion protein, in a heterologous expression prokaryotic system. Antisera against the fusion protein were raised in rabbits and checked for specificity and sensitivity through Western blotting. Human fetal pituitaries from week 6 of gestation onward were used for immunocytochemical studies. Consecutive semithin sections were treated with the specific antisera against hSgII, beta-endorphin, and hPRL and with monoclonal antibodies to hCG alpha, hLH, and hFSH. SgII immunoreactivity appeared at week 8 and was restricted to pituitary cells expressing beta-endorphin (100% colocalization). At week 9, FSH-positive cells did not contain SgII. From week 10, gonadotrophs progressively exhibited SgII-IR, up to 50% of that in FSH-containing cells at week 26. The granin was never found in PRL cells whatever the stage of development. The present data demonstrate that SgII-IR is detected very early in fetal life; however, the positive cells are not gonadotrophs, but corticotrophs. Within gonadotrophs, SgII appears subsequent to hormones. At birth, more than 90% of SgII-IR cells are represented by corticotrophs and gonadotrophs.