Macrodontia associated with growth-hormone therapy: a case report and review of the literature.

BACKGROUND: Macrodontia is a rare dental anomaly, and isolated macrodontia is even more infrequent. The aim of this article is to report on a young male patient with macrodontia of the mandibular premolars. CASE REPORT: We herein present a case report of a young male patient receiving pharmacological growth hormone therapy for 10 years, who was diagnosed with macrodontia of the mandibular premolars. The patient underwent surgical treatment at the School of Dentistry of the University of Buenos Aires and was followed-up for more than 3 years. CONCLUSION: Macrodontia is a rare condition. Early diagnosis and treatment of this anomaly favors adequate formation of the dental arches. In the light of this case report, a review of paediatric patients who received growth hormone therapy during the tooth formation stage would seem relevant.

[Predisposing factors for development of cardial adenocarcinoma]. / Fattori predisponenti l'adenocarcinoma del cardias.

After a careful revision of the various papers and on the basis of their personal experience, the persons responsible for this project analyse the factors that, today, influence the development of an adenocarcinoma in the region of the gastro-esophageal junction. They also study therapeutic strategies on the basis of new findings in anatomic-physiological matters of this region. From this analysis, specialists notice an increase in adenocarcinomas which affect the gastric region of the cardia, in comparison with carcinomas which affects the gastric region in toto. By considering Barrett, Hayward, Riedel and Ruol's studies, they maintain that the fundamental factor which causes the development of cardial adenocarcinoma is the gastroesophageal reflux. This reflux acts as a chronic irritative stimulus on the esophageal wall and therefore it provokes an increase in mucous secretion and the formation of metaplasia. This metaplasia is initially mucosecreting, acid-secreting and in the end it becomes intestinal. This also leads to the appearance of absorbent calciform cells; the absorption of toxic or mutagenic substance for the cell itself, will be the next step for the development of an adenocarcinoma. Nowadays the therapy of intestinal metaplasia provides for different therapeutic levels: from the endoscopic monitoring (which is used for the most serious cases of dysplasia), to the PPI medical treatment(today in disuse), to the surgical laparoscopic treatment with non-refluxing plasty (Nissen, Toupet). This last treatment is today associated with endoscopic esophageal mucosectomy in order to achieve a better effectiveness. This happens through the use of various methodologies, for example the multipolar electrocoagulation.

Lymph node dissection in surgical treatment of esophageal neoplasms.

BACKGROUND: Until now therapy of carcinoma of the esophagus has presented an aura of pessimism, resulting in an attitude among physicians that cure was impossible. Presently the overall 5-year survival is between 38.3% and 55% thanks to new radical surgical techniques. The aim of this work is to evaluate lymph node dissection in treatment of esophageal carcinoma by analyzing morbidity, mortality, survival and quality of life. METHODS: From 1975 to 1995, 170 patients with carcinoma of the esophagus and cardia underwent operation, of whom 165 underwent 2-field lymphadenectomy and four 3-field lymphadenectomy; one patient was submitted to self-transplanting jejunal loop to neck. One hundred and twenty-two patients had standard resection and 47 en bloc resection. RESULTS: Lymph node involvement is often found in patients with superficial carcinoma and it greatly influences outcome after esophagectomy. In 2-field lymphadenectomy morbidity and mortality are more frequent in en bloc resections; global 3-year survival was better in patients with early lesions. Three-field lymphadenectomy was performed in only few cases, not sufficient to express a definitive opinion. CONCLUSIONS: On the basis of our experience, we conclude that the better survival is particularly dependent on early diagnosis, histological type of neoplasia and following surgical treatment, especially on the type of resection with 2 or 3-field lymphadenectomy.

[Lung surgery in the elderly]. / La chirurgia polmonare dell'anziano.

Lung surgery in the elderly, once considered a major risk, to be avoided if possible has become more popular in recent years as a result of many factors. First: lung cancer incidence has increased significantly in every age group but mostly in the elderly. Second: diagnosis at an early stage of the disease is higher in patients over 70 due to more frequent medical control in old subjects. Third: we now have more and more humans over 80 and a life expectancy increasing over the years. Fourth: preoperative, operative and postoperative medical supports are now safer and more reliable than previously. Operability criteria in the elderly are substantially the same as in younger group of patients for lung cancer. There are no reasons to refuse surgery in a subject over 80 because he is old. Lobectomy is the procedure of choice for lung cancer even in the elderly. Pneumonectomy must be avoided preferring a less radical procedure (wedge resection) so avoiding the risk of a postoperative respiratory failure that is often fatal for a patient with in border line functional respiratory tests, as often happens in the elderly. Thoracoscopic atypical resections must be considered in patients when a wedge resection is indicated preoperatively and almost always metastatic pulmonary lesion.

[Simultaneous bilateral pneumothorax. Case report]. / Presentazione di un caso di pneumotorace a contemporanea insorgenza bilaterale.

A case report of a 44 year-old white man admitted to the surgical unit for a bilateral simultaneous pneumothorax is presented. The pneumothorax occurred on day one after a surgical operation for discal hernia; in the past the patient already presented a right spontaneous pneumothorax at 32 years of age and a left pneumothorax at 37 years of age, both treated with a pleural drainage. A thoracic drain was bilaterally positioned with a good result only in the right side. The persistence of the left pneumothorax induced the authors to perform a postero-lateral thoracotomy bullae excision and pleurectomy with a good postoperative course. After a few months a new right pneumothorax occurred and the patient was treated with a right postero-lateral thoracotomy, bullae resection and pleurectomy. On the basis of the case reported, the authors consider the different opportunities in the treatment of spontaneous pneumothorax in relation to the present knowledges and technologies. Surgical procedure is to be preferred in case of persistence of pneumothorax despite a pleural drain and in case of pneumothorax in high risk subjects. Even if thoracoscopy seems to give better results regarding postoperative pain, it is not always possible with such a method to perform a careful pleurectomy neither to obtain it in all cases (above all in secondary pneumothorax). Every case must then be carefully studied to choose the best treatment at present available.

[Current diagnosis of gastroesophageal reflux disease: learning experience]. / Diagnosi attuale della malattia da reflusso gastroesofageo: esperienza di scuola.

The authors report their study on gastro-esophageal reflux disease, a pathology that has become increasingly common over the past years reflecting both a real increase and the use of new and more sophisticated and reliable diagnostic methods and tests. It can be included in the group of pathologies absorbing the largest proportion of financial resources, even exceeding biliary lithiasic disease according to American studies. The authors start by analysing the symptoms of gastroesophageal reflux disease, drawing a distinction between typical (heartburn, epigastric pain and postprandial regurgitation) and atypical symptoms (laryngotracheal symptoms, bronchopulmonary symptoms and esophageal motor incoordination). They outline the diagnostic iter and tests most widely used today to achieve a correct diagnosis. Lastly, they report their experience of 160 patients attending their esophageal diagnostic unit since January 1999 who underwent a number of different instrumental tests, the results of which are compared. Three different aspects are compared: the presence of symptoms, 24-hour pH-metry and endoscopic tests. All these are necessary for a correct diagnosis of gastroesophageal reflux disease and to evaluate the possibility and efficacy of surgery. They emphasise the diagnostic importance of 24-hour pH-measurement as the only test that can directly reveal gastroesophageal reflux. Positive pH results represent a discriminating element in deciding whether the patient should undergo surgery.

[Gastroduodenal reflux after laparotomic or laparoscopic cholecystectomy]. / Il reflusso duodeno-gastrico dopo colecistectomia laparotomica o laparoscopica.

BACKGROUND: The authors analyse gastroduodenal reflux (GDR) in the light of the progress made over the past ten years. The good results achieved using mini-invasive techniques in cholecystectomy prompted the authors to compare laparotomic and laparoscopic cholecystectomy in order to evaluate the influence of both techniques in determining GDR and clinical symptoms. METHODS: Symptoms were evaluated before and after surgery in 30 patients operated using a laparotomic technique and in 30 patients operated using a laparoscopic technique. Two groups of 10 patients, operated respectively using laparotomic and laparoscopic techniques, were studied both clinically and endoscopically before and after surgery. RESULTS: The analysis of the results shows a lower incidence of GDR and typical symptoms of GDR in patients undergoing laparoscopic surgery. The rationale underlying the lower incidence of GDR and its symptoms in these patients compared to the more conventional group is not completely clear. CONCLUSIONS: These results may be influenced by reduced surgical trauma and the careful selection of case or the laparoscopic technique, hence the exclusion of cases complicated by severe cholecystitis.

Surgical treatment of differentiated microcarcinomas of the thyroid.

Thyroid microcarcinomas (TMC) are histologically malignant diseases, despite their limited dimensions and non-aggressive behaviour; frequent multifocality of the disease and local recurrence is really possible after conservative resection. Modern therapeutic approaches to thyroid microcarcinoma include both radical surgical treatment, influenced by the frequent locoregional diffusion of TMC, consisting of a total thyroidectomy with an eventual central and/or functional unilateral lymphadenectomy, depending on the clinical evidence of lymh node metastases and conservative treatment based on more limited resections which take into account the slow clinical progression of this type of tumour. The aim of our work is to examine the therapeutic guidelines for surgical treatment of TMC which, in our experience, are closely dependent on clinical presentation type. From 1991 to 2000, more than 400 patients with thyroid disease were referred to the Department of Surgical Science and Applied Medical Technologies "F. Durante". Threehundred-seventythree patients received surgical treatment: in 311 patients a benign disease was diagnosed, while in 62 neoplasia was present. In total we observed 30 TMC, consisting of 28 papillary and 2 follicular microcarcinomas. On the basis of clinical presentation we divided patients in three groups: A--patients with a clinically suspicious neoplastic lesion before surgical treatment; B--patients in whom histological diagnosis of cancer was "incidental" after an operation performed for benign disease; C--patients in whom a neck lymph node metastases were clinically found before diagnosis of an "occult" papillary carcinoma in the thyroid gland. 27 total thyroidectomies and 3 conservative resections, that required successive total exeresis, were performed. In 5 cases a central neck lymph node dissection was carried out and in 5 + 1 cases functional modified lateral neck dissections was deemed necessary. Our data suggest that an evaluation of tumor's malignancy cannot be carried out on the basis of its dimensions alone. Indeed, biological aggressivity, whether local or at a distance, is a prerogative of both large and small tumours. Therefore a microcarcinoma must be considered a full-blown form of thyroid cancer and as such must be treated. Total thyroidectomy may be followed by identification of possible local metastases. "Whole body" scintigraphy allows to identify and treat with radioiodine therapy, possible recurrent lesions. Therefore in conclusion, total resection is not only a useful, but also a necessary treatment for the correct diagnostic and therapeutic follow-up of these patients.

[Surgery of large ventral hernias. Personal experience in 1990-1997]. / La chirurgia dei grandi laparoceli. Esperienza di scuola 1990-1997.

BACKGROUND: The surgical treatment of large wall defects conventionally defined as an extension over 10 cm is discussed. The difficulty to contain the bowels that have lost law of domicile in the abdominal hollow, constitutes motive for notable increase of the endo-abdominal Pressure with serious consequences in the postoperative course and this leads to the use of prothesis meshes that allow the closing of the abdominal hollow with the Tension-Free technique. METHODS: Personal experience embraces 45 patients, with large wall defects, divided into 21 patients with overumbilical location, 14 with umbilical location, 10 with periumbelical location; a simple suture has been used in 7 cases, the reconstruction of the wall according to Stoppa in 36 cases and the apposition of Goretex net internally and Marlex net externally in 2 cases. RESULTS: There have been neither mortality, neither recidivists of illness, but only some complications: 9 cases of superficial infection, 1 case of intestinal occlusion and 2 of subcutaneous seroma. CONCLUSIONS: According to their experience and wide literature review, the authors draw some conclusions: an accurate toilet and a careful evaluation of the respiratory functionality are fundamental; it's necessary to postpone surgical intervention in presence of local inflammation and, where this is improrogable it's opportune to avoid the use of prothesis meshes or refold on readsorbible prothesis; special care must be taken to the hemostasis and an aspirative drain for 24-48 hrs preserves from the risk of postoperative hematomas and following local infections. The submuscular mesh permits a Tension-Free suture and for this reason it would have nowdays a more extensive use. Finally it's pointed out the choice of a PTFEe mesh in contact with the intestinal skein.

[Essential varicocele. Which treatment?]. / Il varicocele essenziale. Quale trattamento?

Purpose of the paper is to sum up the problem of surgery of idiopathic varicocele according to the present possibilities, both surgical and sclerotic. A wide review of the literature underlines a high rate of relapses and persistence of the disease (with a percentage from 10 to and 10%) following the two most used technique: retrograde sclerotic therapy under radioscopic control and surgical retroperitoneal or inguinal ligature of the internal spermatic vein; this technique was preferred by us until 1997. The percentage of failures, high with reference to the benign form of the disease (over 10% in our series of more than 100 patients submitted to clinical and flow-meter examinations) let the authors suggest a combined and simultaneous operation of ligature both internal and external of the spermatic vein at the level of the internal inguinal ring. Anatomical reasons confirm the opportunity of this procedure since the involvement of the system of the external spermatic vein is present in about the 20% of the cases of idiopathic varicocele in accordance with various flebografic studies. The possibility of escape through the external spermatic vein is eliminated in the case in which such vessel is preserved, and it seems frequent above all in 3rd degree idiopathic varicocele where many anastomotic vessels between the two systems are present. This procedure can be made both in general or local anaesthesia, it doesn't involve postoperative hospital stay and present the same acceptable postoperative complication of other proposed operations. The laparoscopic treatment even if easily performed at the level of the internal inguinal ring, doesn't seem justified for the higher cost and equal compliance for the patient. Besides, it is not possible to proceed laparoscopically under local anaesthesia.

[Secondary costal myxoid chondrosarcoma. Presentation of a clinical case]. / Condrosarcoma mixoide costale secondario. Presentazione di un caso clinico.

A type of malignant neoplasm of not frequent observation is reported and the difficulties concerning the distinction from the benign counterpart are underlined, for which a detailed instrumental study is made necessary, integrated with pre and, above all, postoperative histologic analysis. A white male patient of 83, affected by plurirecidivant chondromyxoma of the rib, was admitted for local recurrence. The lesion objectively appeared not dissimilar from the preceding ones, as an ovalar mass fixed on the underlying plains. Radiologic and ultrasonographic examinations seemed to confirm the admission diagnosis; at the end the patient underwent a new intervention. Histologic examination of the lesion yielded a diagnosis of chondromyxosarcoma. The clinical case is made even more interesting by the finding, through the TC technique, preoperatively performed, of a metastatic repetition on the opposite side. The authors examine the problem of the early recognition of a malignant neoplasm developing, in a patient with a clinical history of recidival chondromyxoma. Physical examination and laboratory analysis are not useful in the assessment of the occurring transformation. At molecular level chondromyxosarcoma is characterized by several genomic rearrangements and mutations. Though primitive chondromyxosarcoma often involves the ribs, chondromyxoma's transformation into its malignant counterpart is not a common event. The development of distant metastasis characterizes long term cases. Given the lack of encouraging results about chemo and radio-therapy efficacy in influencing the natural course of the disease, a systematic approach will be made necessary in patient management.

Therapeutic approach of carcinoid tumours of the lung.

In the carcinoid tumours of the bronchopulmonary tract surgical resection is still the primary goal. Many problems are, however, unclear: the extent of resection, formal lymph node dissection or not, the role of Video-Assisted Thoracic Surgery (VATS) and of the multidisciplinary approach. In the Department of Surgical Sciences and Applied Medical Technologies, "La Sapienza", Rome's University, from 1969 to 1994, we observed 18 patients with carcinoid tumours of the lung: 13 typical carcinoid (TC) and 5 atypical carcinoid (AC). In our series, the choice of therapeutic procedure was made on the basis of histological criteria and TNM classification. We performed 3 conservative and 10 extensive resections on typical carcinoid and 5 extensive resections on atypical carcinoid tumours. In our series VATS played a minor therapeutic role. Formal lymph node dissection was carried out on all our patients except in the cases of those with typical carcinoid tumours without enlarged hilar and mediastinal lymph nodes. The efficacy of adjuvant chemotherapy in carcinoid tumours treatment is controversial and will be confirmed by further trials. In bronchial carcinoid tumours the long-term prognosis is excellent. In our series the ten-year survival rate is 77 per cent in typical carcinoid and 40 per cent in atypical carcinoid cases.

[Spontaneous retroperitoneal hematoma: a case report]. / Ematoma retroperitoneale spontaneo: presentazione di un caso clinico.

The A.A. present a case report of retroperitoneal spontaneous hematoma and put in evidence the difficulties in making an etiopathogenetic diagnosis of spontaneous renal cyst rupture. The patient was a 72 years old man admitted to the hospital in emergency for a painful ipogastric syntomatology and biliary vomit. The ecography showed a distanced gallbladder and the endoscopy evidenced a duodenal stenosis with compression of the gastric posterior wall, so that we were initially directed towards a pancreatic tumor even if the modest increase of the serum bilirubinemy and mostly the fact that direct component was almost normal, gave us strong doubts. The spiral TC gave finally the diagnosis of retroperitoneal hematoma and the presence of a bilateral polycystic kidney with several subcapsular cyst, let us suggest, as well as the anamnestic report of a physical stress, a renal origin of the bleeding. A wild literature review did not evidence other similar cases, but the ecclusion of other possible causes of retroperitoneal hematoma, suggested this conclusion.

[The diagnosis and therapy of dysphagic disorders of the LES]. / Diagnosi e terapia dei disturbi disfagici del LES.

Primary motor disorders of LES causing dysphagia consist in cardial achalasia and intermedius motor disorder (IMD), the last one different from achalasia because of normal motor pattern of the esophageal body. In this paper diagnostic and therapeutic procedures are examined according to an experience of 94 surgically treated cases (22 rioperations for surgical failures). Cardial dilatation as treatment of choice is recognized only for IMD in which a normal peristaltic behaviour of the esophagus can avoid the high danger of GER. Surgical procedure, now laparoscopically performed, consisting in Heller's myotomy + Dor partial fundoplication is to be preferred in cases of true achalasia.

Hyperthyroidism and concurrent thyroid carcinoma.

In the last twenty years, medical studies have reported a significant increase in thyroid neoplasms among patients with hyperthyroidism. Aim of the present work is to reconsider the real incidence of this not uncommon association and to establish a model for surgical treatment of hyperthyroidism for a possible concurrence with thyroid carcinoma. At the Department of Surgical Sciences and Applied Medical Technologies "La Sapienza" Rome's University, during the period 1994 to 1999, an homogeneous group of 82 patients was surgically treated for hyperthyroidism. Of our patients, fifty-four (66%) had a "multinodular toxic goiter" (MTG), twenty (24%) a "functional autonomous nodule" (FAN) while the remaining patients were affected by Graves' disease. The surgical procedures adopted were: 1) total extracapsular ipsilateral lobectomies and isthmectomies in sixteen patients with FAN; 2) total extracapsular thyroidectomy in all patients with MTG and with Graves' disease and in the remaining four patients with FAN after a long time treatment with thyrostatic drugs. On six (7%) of our patients we found out a thyroid carcinoma: five with MTG and one with Graves' disease. However, no association with thyroid carcinoma was observed in anyone with FAN. The correct treatment of thyroid surgical diseases is a single definitive operative approach. The procedure must be a total thyroidectomy in MTG and Graves' disease. However, in patients with FAN it's possible, after careful evaluation, to carry out a total extracapsular ipsilateral lobectomy with isthmectomy, justified by the normal morphology of the remaining thyroid tissue. It is always possible, in these cases, a subsequent complete exeresis if a carcinoma is present in the removed lobe.

[Surgery of dysphagic diseases. Personal experience (349 surgical interventions)]. / Patologie disfagiche di competenza chirurgica. Esperienza di scuola (349 interventi chirurgici).

The authors report their surgical experience relating to dysphagic diseases of the esophagus (349 cases). In the light of these results, they describe the different surgical techniques used in the various pathologies: 1) Esophageal diverticula: The value of a careful evaluation of subdiverticular spasm is emphasised using preoperative manometry in cervical and epiphrenic diverticula, leading to subdiverticular myotomy when present. 2) esophageal achalasia and intermediate motor disorder: A clear difference must be drawn between these two diseases owing to the different motor behaviour of the esophagus. Dilatation of the LES is only useful in intermediate motor disorder and should be avoided in esophageal achalasia where a gastroesophageal reflux is produced if dilatation fails. Intraoperative manometry is very useful during the extramucosa myotomy phases as an indication of the complete removal of the sphincteric barrier, thus avoiding the risk of persisting disease. 3) Non-neoplastic stenosis. In primary stenosis (caused by caustic agents, primary GER or associated with JE) a conservative approach is advisable, whereas in iatrogenic stenosis (mainly linked to dilatation or cardiac surgery), owing to the anatomic complexity of the esophagogastric junction, a more radical approach is often required in the form of esophagogastric resection or even sub-total esophagectomy. 4) Neoplastic stenosis: Leiomyomas, although unusual, represent a clear indication for thoracoscopic access, provided that the dimensions allow it. Esophageal cancers represent a major surgical problem. A radical approach is represented by TE and the subsequent use of the stomach, or more rarely, the colon to reconstruct the alimentary tract. In spite of the very low resectability rate owing to locoregional spreading, until recently palliative surgery was essential to allow patients to eat. The introduction of autoexpanding prostheses, positioned using endoscopic methods, has provided a better solution to this problem.

[Dilatation versus surgery in the treatment of cardial achalasia]. / Dilatazioni versus chirurgia nel trattamento della malattia acalasica del cardias.

Both surgery and dilatation are useful for the treatment of cardial achalasia. The authors make a wide review of the literature with particular attention to reports comparing results of these procedures. This review evidences that surgery gives better results than dilatations (84.4% of good results with surgery against 71.4% with repeated dilatations) and is certainly more stable over the years. Mini-invasive surgery points out even more strongly that surgery is nowadays to be preferred. Laparoscopy makes it possible to avoid postoperative pain, to discharge the patient in a couple of days and finally to eliminate surgical scars. Complications, even more frequent after surgery (5.5% against 2.1% of dilatation) are still acceptable in number and not heavy in quality.