A comparison of sufentanil vs. remifentanil in fast-track cardiac surgery patients.

We retrospectively compared patients receiving remifentanil with patients receiving sufentanil undergoing fast-track cardiac surgery. After 1:1 propensity score matching there were 609 patients in each group. The sufentanil group had a significantly longer mean (SD) ventilation time compared with the remifentanil group; 122 (59) vs. 80 (44) min, p < 0.001 and longer mean (SD) length of stay in the recovery area; 277 (77) vs. 263 (78) min, p = 0.002. The sufentanil group had a lower mean (SD) visual analogue pain score than the remifentanil group; 1.5 (1.2) vs. 2.4 (1.5), p < 0.001 and consumed less mean (SD) piritramide (an opioid analgesic used in our hospital); 2.6 (4.7) vs. 18.9 (7.3) mg, p < 0.001. The results of our study show that although remifentanil was more effective in reducing time to tracheal extubation and length of stay in the recovery area, there was an increased requirement for postoperative analgesia when remifentanil was used.

Management of corrosive injuries of the upper gastrointestinal tract. Our experience in 58 patients.

BACKGROUND: The ingestion of caustic substances is one of the most difficult conditions to be treated in Emergency Department. PATIENTS AND METHODS: The medical records of patients with caustic ingestion and hospitalized from 2003 to 2008 at the Division of General Emergency Surgery with Polyspecialistic Observation of AORN "A. Cardarelli "in Naples, have been revalued. RESULTS: From 2003 to 2008, 58 patients with caustic ingestion were admitted to our Division. Ten of these patients (17.24%) underwent surgery. Six patients underwent oesophageal and gastric resection with cervical esophagostomy and alimentary digiunostomy in emergency; two underwent exploratory laparotomy, two had gastroenteroanastomosis for antropyloric stenosis. One patient underwent new operation for a complication. In total, three reconstructions of oesophagus with colon were performed . Of the six patients undergoing esofagogastrectomy, two died in the first postoperative day, but four have passed the acute phase. CONCLUSIONS: There is no universally accepted diagnostic and therapeutic procedure for the management of these patients, who are often left - as it appears in literature - to the personal experience of the surgeon who is dealing with this situation.

[Imaging diagnosis of hepatocellular carcinoma. Addendum to hepatocellular carcinoma: diagnosis, staging and treatment strategies]. / Diagnóstico por técnicas de imagen del carcinoma hepatocelular. Addendum de carcinoma hepatocelular: diagnóstico, estadificación y estrategia terapéutica.

This addendum is aimed to review and discuss the updated non-invasive diagnostic algorithm recently published by the American Association for the Study of Liver Diseases (AASLD).

Evolving strategies for the management of intermediate-stage hepatocellular carcinoma: available evidence and expert opinion on the use of transarterial chemoembolization.

Transarterial chemoembolization (TACE) is considered the gold standard for treating intermediate-stage hepatocellular carcinoma (HCC). However, intermediate-stage HCC includes a heterogeneous population of patients with varying tumour burdens, liver function (Child-Pugh A or B) and disease aetiology. This suggests that not all patients with intermediate-stage HCC will derive similar benefit from TACE, and that some patients may benefit from other treatment options. Results of an extensive literature review into the treatment of unresectable HCC with TACE were combined with our own clinical experience to identify factors that may predict survival after TACE. We also report contraindications to TACE and propose a treatment algorithm for the repetition of TACE. In addition, we have constructed a number of expert opinions that may be used as a guide to help physicians make treatment decisions for their patients with intermediate-stage HCC. The data included in the literature review related almost exclusively to conventional TACE, rather than to TACE with drug-eluting beads. Therefore, the findings and conclusions of the literature review are only applicable to the treatment of HCC with conventional TACE. Treating physicians may want to consider other treatment options for patients with intermediate-stage HCC who are not suitable for or do not respond to TACE. By distinguishing those patients who represent good candidates for TACE from those where little or no benefit might be expected, it may be possible to make better use of current treatment options and improve outcomes for patients.

[Hepatocellular carcinoma: diagnosis, staging, and treatment strategy]. / Carcinoma hepatocelular: diagnóstico, estadificación y estrategia terapéutica.

Hepatocellular carcinoma is a tumor with a high incidence and high mortality. These data justify screening programs to enable curative treatments to improve survival rates. Screening the population at risk (mainly patients with cirrhosis of the liver) should include ultrasonographic examination twice yearly. Given the vascular characteristics of hepatocellular carcinoma, it can be detected using dynamic techniques (contrast-enhanced ultrasonography, CT, and MRI). In cases in which the enhancement pattern is not characteristic, these techniques should be complemented with lesion biopsy. Once hepatocellular carcinoma is diagnosed, the tumor is staged, and together with the clinical condition of the patient, the stage will determine the most appropriate treatment strategy in each case.

[Early diagnosis of primary liver cancer: imaging versus genetics]. / Diagnóstico precoz del cáncer primario de hígado: imagen versus genética.

Early diagnosis of hepatocellular carcinoma (HCC) in nodules smaller than 2 cm detected by screening ultrasounds becomes essential given that, at that stage, no vascular invasion is usually detected and treatment is associated with a high rate of long-term survival. Improvements in imaging techniques in the last few years have allowed a conclusive diagnosis of HCC in these small nodules without invasive procedures. However, a conclusive diagnosis of HCC by imaging is not always possible and, in more than half of cases, biopsy is needed. On the other hand, histological confirmation of HCC in such tiny nodules is very complex, and in most cases impossible because of the limited sample obtained. In addition, serum tumor markers currently available show low accuracy and are useless for early diagnosis. Progress in the knowledge of molecular mechanisms associated with malignant transformation will allow the use of new techniques that will facilitate diagnosis for HCC in very early stages.

[Jejunal perforation from metastatic choriocarcinoma. Case report and review of the literature]. / Perforazione digiunale da coriocarcinoma metastatico. Caso clinico e revisione della letteratura.

Choriocarcinoma is a rare malignant genital tract tumor, arising in the uterus or in the testis. Primary or metastatic choriocarcinomas of the gastrointestinal tract are infrequent. We report a case of a testis choriocarcinoma presenting as jejunal metastasis with perforation. Histology revealed the origin of this metastatic tumor, allowing us to recognize the primary neoplasm of the testis. A review of literature with PubMed since 1964 and of the references of the papers retrieved was performed. Since 1933 only 30 cases of jejunal choriocarcinomas have been described in literature. In 13 cases jejunal choriocarcinoma presented gastrointestinal hemorrhage, in 4 intestinal intussusception and in 1 case upper abdominal pain and vomiting. Only 5 cases of jejunal perforation have been described. The case presented is the first in literature of jejunal perforation from a metastatic choriocarcinoma of the testis.

New aspects of diagnosis and therapy of hepatocellular carcinoma.

Hepatocellular carcinoma is one of the major cancer killers. It affects patients with chronic liver disease who have established cirrhosis, and currently is the most frequent cause of death in these patients. The main risk factors for its development are hepatitis B and C virus infection, alcoholism and aflatoxin intake. If acquistion of risk factors is not prevented and cirrhosis is established, the sole option to improve survival is to detect the tumor at an early stage when effective therapy may be indicated. Early detection plans should be based on hepatic ultrasonography every 6 months, whereas determination of tumor markers is not efficient. Upon detection of a hepatic nodule, there is a need to establish unequivocal diagnosis, either through biopsy or through the application of non-invasive criteria based on the specific radiology appearance of the tumor: fast arterial uptake of contrast followed by venous washout. Effective treatment for liver cancer includes surgical resection, liver transplantation and percutaneous ablation. These options provide a high rate of complete responses and are assumed to improve survival that should exceed 50% at 5 years. If the tumor is diagnosed at an advanced stage, the sole option that improves survival is transarterial chemoembolization. Ongoing research should further advance the time at diagnosis and identify new and effective options targeting molecular pathways governing tumor progression.

[Early diagnosis of liver cancer]. / Diagnóstico temprano del cáncer de hígado.

Hepatocellular carcinoma is a frequent neoplasm that usually develops in patients with liver cirrhosis. Because it is the main cause of death in these patients, they should be included in a surveillance program in order to identify these tumors at an early stage and be able to indicate curative treatment (liver transplantation, surgical resection or percutaneous ablation therapy) and to reduce mortality. Surveillance should include determination of alpha-fetoprotein and abdominal ultrasound every 6 months. This strategy should only be applied to patients suitable to receive curative treatment if diagnosed of hepatocellular carcinoma. Using this approach, 40-80% of tumors identified are solitary at diagnosis, although only half of these patients can benefit from curative treatment.

[The role of spiral computed tomography in sigmoid diverticulitis and the diagnostic-therapeutic implications]. / Ruolo della Tomorafia Computerizzata spirale nella diverticolite del sigma e implicazioni diagnostico-terapeutiche.

PURPOSE: Colonic diverticula are saccules made of colonic mucosa and submucosa that herniate from the colonic lumen through the muscular layer of the wall where straight vessels penetrate. Diverticula are localized in the sigmoid colon in 95% of cases. Bacteria pooling in the lumen may cause lumen erosion and eventually perforation. CT is a useful technique in this condition because it can demonstrate intra- and/or extramural inflammation. Aim of this retrospective study was to assess the capabilities of contrast-enhanced helical Computed Tomography (CT) in sigmoid diverticulitis, especially relative to selection of the appropriate treatment. MATERIAL AND METHODS: We retrospectively reviewed the findings of 41 patients referred to our emergency department for diverticulitis. CT scans were performed 65 seconds after i.v. injection of nonionic contrast material (3 mL/s, 120 mL in all) administered by a CT-power injector. The following 7 CT findings were considered at least suggestive of acute diverticulitis: focal wall thickening, intramural abscess, inflammatory changes in the sigmoid mesentery root, pericolic fat inflammation or pericolic abscess formation, fistula, peritonitis. CT results were compared with surgical and physical findings. RESULTS: Based on CT findings, diverticulitis was classified as mild (25 patients) or severe (15 patients). In mild diverticulitis we found: focal sigmoid wall thickening (6 patients), intramural abscess (3 patients), sigmoid mesentery root thickening (5 patients), edema fluid (8 patients) and phlegmon (3 patients). In severe diverticulitis we found: sigmoid mesentery abscess (6 patients), fistula (5 patients) and peritonitis (4 patients). CT findings were questionable in 1 case and thus we could not exclude a perforated carcinoma. CONCLUSION: Contrast-enhanced helical CT is the imaging modality of choice in assessing mild or severe acute diverticulitis because it provides useful information for appropriate treatment planning in the emergency setting. This technique is most useful in questionable cases and in patients with suspected severe diverticulitis where a choice must be made between different treatment options.

[Gallbladder blunt trauma: comparison between radiologic and anatomo-surgical findings]. / Traumi chiusi della colecisti: confronto tra reperti radiologici e anatomo-chirurgici.

PURPOSE: To assess the diagnostic accuracy and the possible role of ultrasonography (US) and Computed Tomography (CT) in a small group of patients who had a blunt abdominal trauma involving the gallbladder. MATERIAL AND METHODS: We retrospectively reviewed the US and CT findings of five patients with surgically confirmed post-traumatic gallbladder injury. The whole series consisted of 196 consecutive patients submitted to laparotomy for blunt abdominal trauma in the past 7 years. The following US and CT findings were considered at least suggestive of a possible post-traumatic gallbladder injury: pericholecystic fluid collection, ill-defined wall margin, collapsed lumen, high intraluminal density. RESULTS: At surgery, the following findings were observed: gallbladder hematoma (1 case), acute colecystitis (1 cases), gallbladder tear (3 cases), gallbladder tear associated with post-traumatic hepatic injuries (2 cases), duodenal tear (2 cases), hemoperitoneum alone (2 cases), hemoperitoneum associated with choleperitoneum (1 case), choleperitoneum alone (1 case). The US and CT findings were pericholecystic fluid collections (4 cases), ill-defined gallbladder wall margins (3 cases), collapsed lumen with intraluminal high density (1 case) and free intraperitoneal fluid collections (4 cases). They were suggestive of a possible post-traumatic gallbladder injury in all the five patients. CONCLUSIONS: The radiologic findings of our five patients were suggestive of a gallbladder damage but did not permit to distinguish minor from major injuries, the latter requiring surgical treatment. US proves to be a useful screening tool which can also help timing surgery in these patients. CT confirmed the US suspicions and also permitted accurate assessment of associated post-traumatic injuries to the liver and duodenum. Nevertheless, the clinical presentation was the most important factor as to the therapeutic management of these blunt abdominal trauma patients.

Comparative analysis of the reduction of oxaloacetate by human hepatoma and normal liver extracts.

An apparent activation of the malate dehydrogenase activity is observed in the double-reciprocal plot at high oxaloacetate concentrations when human hepatoma extracts are analyzed. This phenomenon does not occur in healthy liver samples. In hepatoma extracts, the ratio of lactate dehydrogenase to malate dehydrogenase activities becomes five-fold higher than that of normal liver. Experiments performed with mixtures of both purified enzymes and, conversely, by using oxamate, a specific inhibitor of lactate dehydrogenase, reveal that the deviation in Michaelis-Menten behavior observed is due to the oxaloacetate reductase activity of lactate dehydrogenase instead of the presence of a novel malate dehydrogenase isoenzyme.