High-grade dysplastic spondylolisthesis: surgical technique and case series.

PURPOSE: The aim of the present study is to evaluate the results of our all posterior-one stage surgical technique for the reduction and fusion of high-grade high-dysplastic spondylolisthesis. METHODS: Patients over 11 years old with high-grade spondylolisthesis treated by reduction and circumferential fusion with a posterior-only approach were reviewed. Data about operative time, blood loss, length of stay, intra- and postoperative complications were collected. Meyerding grade (M), lumbar lordosis (LL), thoracic kyphosis (TK), pelvic incidence (PI), pelvic tilt (PT), lumbosacral angle (LSA), slip angle (SLIP), lumbar index (LI) and severity index were measured on preoperative and last follow-up. Sagittal vertical axis (SVA) was used to assess sagittal balance. RESULTS: Of the 14 included patients, L5-S1 arthrodesis was performed in 12 cases, and L4-S1 was performed in 2 cases. Average surgical time was 275 ± 65 min; average blood loss was 635 ± 375 mL. Average length of stay of was 3.9 ± 1.5 days. The SLIP angle improves from 33.8° ± 7.3° to 6.4° ± 2.5°, (p = 0.002); the lumbosacral angle improves from 68.8° ± 18.6° to 100.7° ± 13.2°, (p = 0.01); and the SVA decreased from 49.4 ± 22.1 mm to 34.4 ± 8.6 mm (p = 0.02). No significant changes were observed in PI, PT and SS. Thoracic kyphosis (TK) and lumbar lordosis (LL) did not change significantly. At last follow-up, no patient had surgical site infection or mechanical complications; no pseudoarthrosis was observed. No revision surgery was performed. CONCLUSION: Although technically demanding, reduction and fusion with one stage all posterior approach prove to be a safe and effective.

Freehand power-assisted pedicle screw placement in scoliotic patients: results on 5522 consecutive pedicle screws.

Pedicle screws is the current gold standard in spine surgery, achieving a solid tricolumnar fixation which is unreachable by wires and hooks. The freehand technique is the most widely adopted for pedicle screws placing. While freehand technique has been classically performed with manual tools, there has been a recent trend toward the use of power tools. However, placing a pedicle screw remains a technically demanding procedure with significant risk of complications. The aim of this article is to retrospectively evaluate safety and accuracy of free-hand power-assisted pedicle screw placement in a cohort of patients who underwent correction and fusion surgery for scoliosis (both idiopathic and non-idiopathic) in our department. A retrospective review of all patients with scoliosis who underwent surgery and received a postoperative CT scan in our department in a 9-year period was undertaken. Screw density, number and location of pedicle screws were measured using pre and postoperative full-length standing and lateral supine side-bending radiographs. Then, postoperative CT scan was used to assess the accuracy of screw placement according to Gertzbein-Robbins scale. Malpositioned screws were divided according to their displacement direction. Finally, intra and postoperative neurological complications and the need for revision of misplaced screws were recorded. A total of 205 patients were included, with a follow-up of 64.9 ± 38.67 months. All constructs were high density (average density 1.97 ± 0.04), and the average number of fusion levels was 13.72 ± 1.97. A total of 5522 screws were placed: 5308 (96.12%) were grade A, 141 (2.5%) grade B, 73 (1.32%) grade C. Neither grade D nor grade E trajectories were found. The absolute accuracy (grade A) rate was 96.12% (5308/5522) and the effective accuracy (within the safe zone, grade A + B) was 98.6% (5449/5522). Of the 73 misplaced screws (grade C), 59 were lateral (80.80%), 8 anterior (10.95%) and 6 medial (8.22%); 58 were in convexity, while 15 were in concavity (the difference was not statistically significant, p = 0.33). Intraoperatively, neither neurological nor vascular complications were recorded. Postoperatively, 4 screws needed revision (0.072% of the total): Power-assisted pedicle screw placing may be a safe an accurate technique in the scoliosis surgery, both of idiopathic and non-idiopathic etiology. Further, and higher quality, research is necessary in order to better assess the results of this relatively emerging technique.

The feasibility of laparoscopic rectal resection in patients undergoing reoperation after transanal endoscopic microsurgery (TEM).

BACKGROUND: The success of transanal endoscopic microsurgery (TEM) for early rectal cancer depends on proper indications and strict patient selection. When unfavorable pathologic features are identified after TEM operation, total mesorectal excision is recommended to minimize the risk of recurrence. In this study, data were collected in a retrospective series of patients to determine the results of laparoscopic reoperation after TEM. METHODS: All patients underwent an accurate rectal-digital examination and clinical tumor staging by transanal endosonography, CT, and/or MRI. The histologic examination included an evaluation of the free margins, depth of tumor infiltration according to International Union Against Cancer guidelines, degree of tumor differentiation, and the presence of lymphovascular and perineural invasion. When a high-risk tumor was identified, reoperation was performed within 6 weeks from TEM. The patients were divided into two groups according to the procedure performed: laparoscopic anterior resection (LAR) or laparoscopic abdominal perineal amputation (LAPR). RESULTS: Sixty-eight patients (5.3%) underwent reoperation: 38 underwent LAR and 30 underwent LAPR. The mean operative time was 148.24 min (± 35.8, p = 0.62). Meanwhile, the mean distance of the TEM scar from the anal verge differed statistically between the two groups (p = 0.003) and was statistically correlated with abdominal perineal amputation (p = 0.0001) in multivariate analysis. Conversion to open surgery was required in 6 patients (15.7%) in the LAR group and 3 patients (10%) in the LAPR group (p = 0.38). The histologic examination revealed residual cancer cells in 3 cases (3 pT2N0) and 1 case (1 pT3N0), respectively, and lymph node metastases in 4 cases. No residual neoplasms were detected in the remaining 60 cases (88.3%). After a mean follow-up of 108 months, the overall disease-free survival was 98% (95% CI 88-99%). CONCLUSIONS: In our experience, reoperation after TEM using a laparoscopic approach is feasible and safe, with low conversion rates and optimal postoperative results.

[Breast scintigraphy with 99mTc-MIBI in the study of breast cancer]. / La scintigrafia mammaria con 99mTc-MIBI nello studio del carcinoma della mammella.

BACKGROUND: The literature latest data point out the 99mTc-MIBI scintimammography role as a mammography diagnostic complement for a better nosologic definition of the breast nodular pathology. The object of this study is to evaluate the device sensibility and specificity with reference to the several dimensions of the neoplastic nodule. METHODS: A group of 50 patients, with breast nodule has been studied comparing scintimammography, mammography, echography and istological examination of the removed nodule. RESULTS: 38 nodules out of 50 were carcinomas, 22 were T1 and 16 T2. As far as scintimammography is concerned, the sensibility is 86% in T1 grade and 100% in T2 grade. The specificity is 91.6%. CONCLUSIONS: Since the mammography often need integration with invasive examinations, (aspiration biopsy, and biopsy) scintigraphy-mammography, global specificity 92%, is suggested as a second level examination in the mammary nodule diagnosis, for the simple performance and for the little risk for the patient.

[Gn-RH analogs in the treatment of benign gynecologic diseases: current trends]. / Gli analoghi del Gn-RH nel trattamento della patologia ginecologica benigna: orientamenti attuali.

Gn-RH analogues have been recently employed for the treatment of oestrogen-dependent benign gynaecological disorders, such as uterine myomata, endometriosis or metrorrhagia. They induce a "pharmacological castration", inducing a marked reduction of serum oestrogen levels. They proved more effective than other drugs used up to now in the medical treatment of these benign gynaecological diseases. Thus they were initially employed in every case. Later it became clear that Gn-RH analogues need a selective indication. The authors herein report their series of 70 patients with benign gynaecological disorders (45 uterine fibroids, 10 endometriosis, 15 metrorrhagia), treated with a Gn-RH analogue depot for 2-3 months preoperatively. They evaluated the efficacy of the treatment in the group with uterine fibroids in terms of disappearance of metrorrhagia, better haemoglobin level in anaemic patients, reduction of fibroids size allowing for a simpler and less extensive surgery (vaginal surgery, myomectomy, hysteroscopic resection). The authors discuss those cases when preoperative treatment with Gn-RH analogues is not indicated, or should be employed only under careful surveillance (in the preparation of multiple myomectomies, big submucosal myomas). In the group of 10 patients with endometriosis we observed the disappearance of pelvic pain and dyspareunia, whereas the size of endometriomas was only minimally reduced. The authors discuss the usefulness of this treatment in case of patients with endometriosis grade I or II (minimal or mild), with desire of children. In the group of 15 perimenopausal patients with metrorrhagia, 10 became amenorrhoic after termination of treatment, thus avoiding surgery. The major benefit for the other 5 patients was a better haemoglobin level at the time of surgery.

Ondansetron-induced headache. Our experience in gynecological cancer.

Chemotherapy-induced emesis is one of the major problems in the treatment of oncologic patients. Recently, a novel class of compounds, the selective 5HT3 receptor antagonists, has been introduced, achieving a dramatic improvement in the control of emesis. The absence of extrapyramidal side effects adds to their safety and good tolerability. The Authors herein analyse their experience on 269 cycles of chemotherapy in 47 patients treated for gynaecological and breast malignancies, with particular regard to adverse events such as headache. Their most frequent side-effects are headache and constipation, that are usually mild and self-limiting. Nevertheless, in some cases, severe, rebel headache has been reported, leading in our experience in 6.4% of cases to discontinuation of the antiemetic regimen. A previous history of recurrent or severe headache or migraine is not correlated with the occurrence of ondansetron-induced headache, as severe headache occurred after ondansetron only in 28.4% of the patients with positive anamnesis, and 70% of the patients that experienced had never suffered from severe headache before. In those patients complaining of severe headache, the Authors suggest an antiemetic association, with a loading dose of ondansetron i.v., followed by metoclopramide i.m. orally for the following days.

Complications in the surgical treatment of carcinoma of the endometrium.

The authors report their experience in medical and surgical complications after surgical treatment of endometrial carcinoma, from January 1976 to December 1992, 301 cases of adenocarcinoma were operated by abdominal or vaginal route. From 1980 onwards abdominal route was the most frequent (radical hysterectomy with bilateral adnexectomy Rutledge type II-III with pelvic and/or aortic lymphadenectomy). No lesion occurred either during surgery or later, in the urinary or intestinal apparatus or to the great abdomino-pelvic vessels. The only medical complication observed was one episode of cerebral ictus three days after operation. Two cases of adynamic ileus and five of ventral hernia occurred.

Pre-operative staging of endometrial carcinoma: magnetic resonance imaging versus ultrasounds and hysteroscopy.

Ultrasound, hysteroscopy and magnetic resonance imaging has been considerated to assess the loco-regional or extrapelvic extension of the endometrial carcinoma. Sonography has demonstrated a certain inaccuracy in predicting myometrial invasion or the involvement of the canal. Hysteroscopy allows us to characterize neoplasia and to assess its extension in the cervical canal. MR imaging is more helpful in the diagnosis of channel invasion. The assessment of ovarian metastasis requires ultrasonography or coronal planes RM imaging. As regards the involvement of the pelvic and extrapelvic lymph nodes MR is more accurate than ultrasound scan.

Intracystic carcinoma of the breast. Our experience.

Malignant tumours of the breast occurring as cysts present an incidence from 0.3% to 0.7%. The Authors report their experience during 15 years in 470 patients with carcinoma of the breast. Endocystic carcinoma appeared in 0.6% of patients: the diagnosis is not always possible with cytology, but ultrasound scans make possible to identiphy cysts which have to undergo biopsy because solid areas within the cystic cavity have been detected. In this case surgery is advised even if the cytological examination has been negative.

[Metastatic syndrome involving multiple cranial nerves on the right]. / Sindrome da interessamento multiplo dei nervi cranici di destra di origine metastatica.

Reported is a patient who has shown, over a period of five months, a progressive involvement of the V, VI, VII; IX, X, XI, cranial nerves of the right side. Radiologically, an osteolithic lesion of the right petrous pyramid, attributed to a metastasis of prostatic carcinoma, has been demonstrated. The main syndromes of the base of the skull involving the pertinent cranial nerves are revised, and it is concluded that the patient realizes a combination of the syndromes of Gradenigo and Vernet.