Elective subtotal colectomy with ileosigmoid anastomosis for colon cancer preserves bowel function and quality of life.

AIM: We report on our experience of elective subtotal colectomy and ileosigmoid anastomosis for colon cancer with focus on postoperative results, function and quality of life. METHOD: Between 1998 and 2011, 106 consecutive patients with colonic malignancy underwent this procedure electively. Function and quality of life (EORTC QLQ-C30) were evaluated retrospectively with questionnaires sent to all patients free of recurrence. RESULTS: There were 62 men and 44 women (mean age 63 years). Postoperative mortality and morbidity rates were 1.9 and 26.4%, respectively. Persistent ileus was the main early complication (16%). After a mean follow-up of 67 ± 36 months, 50 (78.1) out of 64 patients have been evaluated for function and quality of life. The mean number of bowel movements per 24 h was 3 ± 2 and significantly lower when the length of the remaining sigmoid colon was more than 15 cm (P = 0.049). Compared with a European reference population for EORTC QLQ-C30 results, our patients had significantly more diarrhoea (26 vs 3, P = 0.0002) but less pain (10 vs 25, P < 0.0001) and better global quality of life (77 vs 62, P < 0.0001). CONCLUSION: Elective subtotal colectomy for colon cancer is safe and associated with good function and quality of life. Ileosigmoid anastomosis should be discussed when extended colectomy is required, providing the rectosigmoid junction and its vascular supply can be oncologically preserved. For tumours located in the transverse colon or at the splenic flexure, this procedure may be the best surgical option.

Elevated circulating levels of monocyte chemoattractant protein-1 in patients with restenosis after coronary angioplasty.

Inflammation plays a pathogenic role in the development of restenosis after percutaneous transluminal coronary angioplasty (PTCA). Monocyte chemoattractant protein-1 (MCP-1) is a potent chemoattractant of monocytes; however, its role in the pathophysiology of restenosis is still unclear. We set out to investigate the role of MCP-1 in restenosis after PTCA. In addition, we tested the hypothesis that MCP-1 exerts its effect, at least in part, by inducing O(2)(-) generation in circulating monocytes. Plasma levels of MCP-1 were measured before and 1, 5, 15, and 180 days after PTCA in 50 patients (30 males and 20 females, aged 62+/-5 years) who underwent PTCA and who had repeated angiograms at 6-month follow-up. Restenosis occurred in 14 (28%) patients. The MCP-1 level was no different at baseline between patients with or without restenosis. However, after the procedure, restenotic patients, compared with nonrestenotic patients, had statistically significant (P<0.0001) elevated levels of MCP-1. In contrast, plasma levels of other chemokines, such as RANTES and interleukin-8, did not differ between the 2 groups after PTCA. Higher MCP-1 throughout the study was correlated with restenosis. Moreover, increased MCP-1 was significantly correlated with increased monocyte activity, as reflected by enhanced O(2)(-) generation. Finally, multivariate regression analysis showed that the MCP-1 plasma level measured 15 days after PTCA was the only statistically significant independent predictor of restenosis (beta=0.688, P<0.0001). This study suggests that MCP-1 production and macrophage accumulation in the balloon-injured vessel may play a pivotal role in restenosis after PTCA. MCP-1 may induce luminal renarrowing, at least in part, by inducing O(2)(-) release in monocytes. Further understanding of the mechanism(s) by which MCP-1 is produced and acts after arterial injury may provide insight into therapies to limit the progression of atherosclerosis and restenosis after balloon angioplasty.

Persistence of mammary artery branches and blood supply to the left anterior descending artery.

BACKGROUND: Partial harvesting of the left internal mammary artery (LIMA) is a widespread technique used during minimally invasive coronary operations performed through a left anterior small thoracotomy. The influence of persisting LIMA branches was investigated to evaluate their effect on the blood flow of the left anterior descending artery. METHODS: Thirty patients, 15 with totally (group A) and 15 with partially (group B) harvested LIMAs, were evaluated. All the patients underwent postoperative angiography, during which a flow map of the LIMA was performed. The average peak velocity and the diastolic-to-systolic peak velocity ratio were recorded. The LIMA graft flow pattern was recorded in the proximal and distal thirds of the artery. Intramammary adenosine (12 to 14 microg) was injected and the average peak velocities before and after injection were calculated. RESULTS: The average peak velocity was similar in both groups in the proximal and distal thirds of the LIMA (25 +/- 7 and 26 +/- 5 cm/sec, respectively, in group A versus 27 +/- 5 and 25 +/- 5 cm/sec, respectively in group B; p = NS). The diastolic-to-systolic peak velocity ratio was similar proximally (0.78 +/- 0.3 in group A versus 0.69 +/- 0.3 cm/s in group B; p = NS), but not distally (1.72 +/- 0.1 in group A versus 0.97 +/- 0.3 in group B; p < 0.0005). The LIMA graft flow reserve was similar both proximally and distally (2.6 +/- 0.6 and 2.5 +/- 0.3 cm/s, respectively, in group A versus 2.6 +/- 0.5 and 2.6 +/- 0.3 cm/s, respectively, in group B; p = NS). CONCLUSIONS: The persistence of LIMA branches does not influence the blood flow of the left anterior descending artery after acute adenosine-induced myocardial hyperemia. If a left anterior small thoracotomy is used in left anterior descending artery direct revascularization, complete LIMA harvesting is not mandatory and depends on the personal preference of the surgeon.

Radial artery and inferior epigastric artery in composite grafts: improved midterm angiographic results.

BACKGROUND: The improving results with use of the radial artery and the inferior epigastric artery as coronary bypass conduits were analyzed to assess the suitability of these arteries for myocardial revascularization. METHODS: Both arteries were used in composite arterial conduits with an internal mammary artery as the blood source. The proximal anastomosis was always constructed before the initiation of cardiopulmonary bypass. From October 1991 to January 1995, 240 patients underwent myocardial revascularization using 163 radial arteries and 124 inferior epigastric arteries with one (224 instances) or both (two instances) internal mammary arteries as inflow conduits. Twenty-five saphenous veins were concomitantly used. There were 208 men and 32 women with a mean age of 60.8 +/- 8.6 years (range, 28 to 80 years). In 73 patients (30.4%), the operation was performed on an urgent basis, and in 11 (4.6%), it was a repeat operation. The mean left ventricular ejection fraction was 0.55 +/- 0.12, and in 21 patients (8.8%), it was less than 0.35. Of 681 distal anastomoses, 188 were constructed using the radial artery (35 double and one triple sequential anastomosis) and 125, using the inferior epigastric artery (one double sequential anastomosis). A mean of 3.0 arterial anastomoses per patient were constructed (3.1 anastomoses/patient including saphenous veins). Six patients (2.5%) underwent associated procedures: aortic valve replacement (2), carotid endarterectomy (2), mitral valve replacement (1), and aortic valve and ascending aorta replacement (1). Most of the inferior epigastric arteries were grafted on diagonal branches and most of the radial arteries, the circumflex territory. RESULTS: No deaths occurred in the operating room. Three patients (1.3%) died postoperatively, and 2 patients (0.8%) died 6 months after operation. At a mean follow-up of 18.5 +/- 10.4 months (range, 1 to 39 months), 227 patients (96.6%) were asymptomatic. The cumulative patency rate of the radial artery grafts was 93.1% and of the inferior epigastric artery grafts, 95.7%. CONCLUSIONS: Our data suggest that use of the RA and the IEA in composite conduits for myocardial revascularization is feasible. These arteries can be safely used when bilateral internal mammary artery or sequential internal mammary artery grafting is not advisable.

Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass.

BACKGROUND: We explored the possibility of anastomosing the left anterior internal mammary artery (LIMA) to the left anterior descending artery in a beating heart via a left anterior small thoracotomy. METHODS: This procedure was performed in 155 of 162 scheduled patients; in 7 (4.3%) the left anterior descending artery was not suitable or was too small. The chest was opened in the fourth intercostal space (mean wound length, 10.5 cm) and the LIMA was harvested for about 4 cm. The left anterior descending artery was occluded by means of two 4/0 Prolene (Ethicon, Somerville, NJ) sutures, and the proximal suture was snared. The anastomosis was performed with two 8/0 Prolene sutures while the heart was beating. Early postoperatively all patients underwent repeat angiography or a Doppler flow assessment of the LIMA or both. RESULTS: The LIMA was connected directly to the left anterior descending artery in 144 patients and with interposition of an inferior epigastric artery in 11. In 2 patients the diagonal branch was also grafted using an inferior epigastric artery from the LIMA. One patient (0.6%) died 38 days after the operation due to multiorgan failure. Nine patients (5.8%) had failure requiring a redo operation: 7 (4.5%) early and 2 (1.3%) late. One additional patient had a late percutaneous transluminal coronary angioplasty for anastomotic stenosis. At a mean 5.6 months of follow-up, 143 patients (92.2%) were alive, asymptomatic with or without medical treatment, and without cardiac events. CONCLUSIONS: Left internal mammary artery-to-left anterior descending artery anastomosis performed on a beating heart via a left anterior small thoracotomy is a safe procedure. In selected patients the operation has good early and midterm results.

[Therapy with beta-blockers in the patients with mitral valve stenosis. Clinical and hemodynamic study]. / Terapia con betabloccanti nei malati affetti da stenosi mitralica. Studio clinico ed emodinamico.

Five patients with pure mitral stenosis and atrial fibrillation were studied with cardiac catheterization in the usual fashion before and after administration of 2.5 mg. of propranolol. At the end the selective left ventricular angiocardiography was performed. The following parameters were calculated: heart rate, mean pulmonary wedge pressure, left ventricular end-diastolic pressure, cardiac output, end-diastolic pressure gradient through the mitral valve. Other five patients with slight mitral stenosis and sinus rhythm were treated with propranolol (40-100 mg for day) for a period of one month. Before beginning the treatment and when it was stopped the following parameters were calculated: pulmonary wedge pressure, cardiac output (Fick), heart rate. After all ten patients were treated with propranolol for a period of 6-12 months. The haemodynamic , clinical and angiographic features are analysed and discussed. The Authors conclude asserting the utility of this drug when administered to patients with slight mitral stenosis (I or II NYHA) for its favourable effect to reduce the pulmonary wedge pressure and pulmonary congestion.

[Modern methods of evaluation of sinus node function by means of endocardiac electrophysiological study]. / Moderne tecniche di valutazione della funzione del nodo del seno mediante studio elettrofisiologico endocardico.

Atropine sulfate 0.04 mg/Kg i.v. and propranolol 0.2 mg/Kg i.v. were administered to patients with SSS in an attempt to determine intrinsic heart rate (IHR). Sinus node recovery time (SNRT) was determined before and after autonomic sympathetic and parasympathetic blockade. This method could distinguish SSS patients in two groups: group I was composed of patients with extrinsic sinus node dysfunction, group II was composed of patients with intrinsic sinus node dysfunction. We conclude that this differentiation is of great importance for clinical-prognostic evaluation and therapeutic program in SSS.

[Comparison between one and two dimensional echocardiography in the study of segmentary kinetics of the left ventricle in post-infarct ischemic myocardiopathy]. / Confronto tra la metodica ecocardiografica mono e bidimensionale nello studio della cinetica segmentaria del ventricolo sinistro nella miocardiopatia ischemica postinfartuale.

Sixty two-dimensional M-mode echocardiograms of myocardial infarction patients, performed 3--6 months after acute attack, were compared with those of 30 normal subjects. In one-dimensional echocardiograms, the dimensions of the left ventricle and some segmentary signs of contractility such as diastolic thickness, excursion and systolic thickening of the septum and the posterior wall of the left ventricle were examined, in two-dimensional echocardiograms the contractility of single areas was compared to those adjacent. In heart attack patients parameters studied were changed in a statistically significant way (p less than 0,001); the degree of correlation between the site of hypo-akinesis and the ECG necrosis site was quite high; compensatory hyperkinesia was frequently found in the area diametrically opposite to dyskinetic areas. The two-dimensional examination was also very sensitive especially in the diagnosis of aneurysm, which is sometimes not noted in M-mode.

[Occult pre-excitation. Differential diagnosis between latent Wolf-Parkinson-White syndrome and concealed atrial pre-excitation (endocavitary electrophysiological study)]. / La preeccitazione occulta. Diagnosi differenziale tra sindrome di W.P.W. latente e preeccitazione atriale nascosta (studio elettrofisiologico endocavitario).

Sixty patients (pts) with very disabling symptoms during supraventricular tachycardia (SVT) underwent electrophysiological study to determinate the mechanism of arrhythmia. 20 pts had, during normal sinus rythm (NSR), ECG pattern of ventricular pre-excitation (V-P); 40 pts, instead, had ECG pattern within normal limits (WNL). In V-P pts, circus movement tachycardia by overt accessory pathway (AP) was initiated. Among ECG-WNL pts group: 10 pts showed ectopic atrial rythm; 22 pts had SVT due to A-V nodal reciprocation; and 8 pts revealed the participation of concealed AP in the reentrant circuit of tachycardia. Among these latter, atrial stimulation at various sites and drugs-administration discovered extranodal by-pass liable for concealed V-P in 2 pts; in the remaining 4 pts it was possible to demonstrate concealed atrial preexcitation by ventricular stimulation, during NSR and SVT, and by atrial mapping during ventricular stimulation and SVT. Our report confirms the significative incidence of concealed AP at the basis of numerous cases of SVT (26%) and outlines the distinction between the latent W.P.W. syndrome and the atrial preexcitation, due to anomalous by-pass with anterograde block.

[Paradoxical movement of the interventricular septum and LAE in a case of complex congenital cardiopathy in an adult with predominant overloading of the right ventricle pressure]. / Movimento paradosso del setto interventricolare ed EAS in un caso di cardiopatia congenita complessa dell'adulto a prevalente sovraccarico di pressione del ventricolo destro.

A casually observed case of complex congenital cardiopathy in an adult marked by ECG LAE, and paradoxical movement of the interventricular septum when examined echocardiographically is reported. Haemodynamic investigation established the persistence of a left vena cava superiore draining into the coronary sinus, pulmonary stenosis with a 55 mmHg transvalvular gradient, and a small PDA with left-to-right shunt equal to 20% of the pulmonary capacity. The case is presented on account of the infrequent association of these defects, the unusual ECG LAE, and above all on account of the echocardiographic picture of paradoxical movement of the IVS in the presence of right ventricle overloading.

[A clinical case of restrictive myocardiopathy associated with polyneuropathy]. / Un caso clinico di miocardiopatia restrittiva associata a polineuropatia.

A case of somatic and autonomic polyneuropathy associated with restricive myocardiopathy is reported. No etiology was identified although the presence of amyloid substances was excluded. Several diagnostic hypotheses are discussed including a possible evolution towards Loeffler's myocardiopathy.

[Pathogenetic interpretation of left ventricle obstruction in hypertrophic obstructive myocardiopathy]. / Interpretazione patogenetica della ostruzione del ventricolo sinistro nella miocardiopatia ipertrofica ostruttiva (MCO).

Nine patients affected from IHSS have been studied by 2D-echocardiography examination. Following detected pictures the Authors try to explain the pathogenesis of the dynamic obstruction of the L.V. The Authors conclude ascribing it to the postero-medial papillary muscle that move abnormally towards the IVS. Instead the SAM could be ascribed to the chordee of the mitral value, but these are considered unable to obstruct L.V. The differences between SAM and L.V. obstruction are underlined and discussed.

[Clinical evaluation of the therapeutic effect of D-L-carnitine in the acute phase of myocardial infarct in relation to the behavior of the serum myoglobin concentration curve]. / Valutazione clinica dell'effetto terapeutico della D-L-carnitina nella fase acuta dell'infarto del miocardio in riferimento al comportamento della curva di concentrazione serica della mioglobina.

Clinical experience carried out on 40 patients with AMI - 22 of them treated with 15 g daily of D-L-Carnitine and 18 untreated - is reported. Our interest was to study the therapeutic action of this drug evaluating if it was able to modify the curve of serum myoglobin level released from necrotic or ischaemic areas. The conclusion is drawn that this drug could act feebly only during the earlier stages of AMI, but many reserves are expressed.

[Idiopathic restrictive cardiomyopathy. Description of 4 cases]. / Cardiomiopatia restrittiva idiopatica. Descrizione di 4 casi.

The clinical and instrumental characteristics of four patients suffering from idiopathic restrictive cardiomyopathy are analysed. Patients were diagnosed following hemodynamic and histological tests. The major clinical symptom was cardiac decompensation and/or hyperkinetic or hypokinetic (3rd degree BAV) supraventricular arrhythmia (atrial fibrillation). Electrocardiographic and radiological alterations were not specific. The most typical echocardiographic symptom was the association of: biatrial dilation, dilation and hypertrophy of the right ventricle, normal left ventricular size, normal fractional shortening of the left ventricle. Septal hypertrophy was also observed in one case. Abundant pericardial effusion was present in all cases. When performed, echo-Doppler showed a relatively typical shortened deceleration time through the A-V valve. Catheterism revealed increased ventricular telediastolic pressures and a bi-plateau morphology of the ventricular pressure curve. Heart index was depressed in one patient and the ejection fraction was reduced in one case. Histological tests revealed interstitial fibrosis, cellular hypertrophy and, in one patient, myocardial amyloidosis. One patient underwent a heart transplant, two patients died while waiting for a transplant, one patient is still alive 13 years after the start of 3rd class symptoms.

Intravascular physiologic evaluation of the left anterior small thoracotomy operation: a novel approach to left anterior descending artery revascularization.

BACKGROUND: Efficacy and long-term patency rate of the left internal mammary artery (LIMA) conduits for revascularization of the left anterior descending coronary artery (LAD) has been demonstrated, with improved results as compared to the saphenous vein graft operation. Novel approaches to LAD revascularization including the use of the left anterior small thoracotomy (LAST) operation with persistence of the intercostal arteries compared to the traditional LIMA operation have not been reported. This study evaluated flow characteristics of LAST operation. METHODS: Phasic blood flow velocity in the proximal and distal arterial conduit segments was measured in 30 patients by intravascular Doppler flow wire after surgical revascularization of the LAD: 15 patients were revascularized by conventional operation using the LIMA (Group A), and 15 patients were submitted to the LAST operation (Group B). All patients underwent coronary angiography and ventriculography at 116 +/- 111 days after operation. Only angiographically normal grafts with normal left ventricular wall motion and coronary arteries free from significant distal stenosis were included for coronary flow velocity and reserve measurements. RESULTS: The diastolic/systolic velocity ratio in the proximal portion of the internal mammary artery was similar in the two groups (Group A 0.8 +/- 0.2 vs Group B 0.7 +/- 0.3, p = NS). Distal diastolic/systolic velocity ratio in Group A (1.7 +/- 0.1) was higher than Group B (0.9 +/- 0.3, p < 0.001). There were no differences in basal average peak velocity or coronary flow reserve between the proximal and distal segments for either groups. CONCLUSIONS: Although proximal phasic coronary flow patterns between the two groups were similar, distal diastolic/systolic velocity ratio was higher in the LIMA than in the LAST. This difference may be related to the persistence of the intercostal artery in the LAST operation. These data confirm the continued patency and similar functional flow patterns compared to the conventional LIMA operation, supporting further investigation and application of this novel approach to LAD revascularization.

Pitfalls in familial mediterranean fever: acute intestinal strangulation/obstruction due to primary adhesions.

Familial Mediterranean Fever (FMF) presents in 90% of patients with painful attacks of peritoneal inflammation, which may mimic an acute surgical abdomen. These episodes characteristically resolve spontaneously within 72 hours. However, recurrent episodes of primary peritonitis may lead to the development of primary intraperitoneal adhesions, even in the absence of previous abdominal surgery. When an atypical bout of pain fails to resolve spontaneously and rapidly, the surgeon must consider the diagnosis of intestinal obstruction due to an adhesive band with the associated risk of strangulation with bowel necrosis. In this case report, we describe this rare but classical presentation of FMF for which any delay in diagnosis or treatment may result in severe morbidity.