Right pneumothorax secondary to colonoscopic perforation: a case.

AIM: The purpose of this study is to determine the anatomical aspects, mechanisms, risk factors and appropriate management of development of pneumothorax during a routine colonoscopy. CLINICAL CASE: We report a case of an accidental bowel wall injury during diagnostic colonoscopic with consequent pneumoperitoneum; this was followed by expansion of gas through diaphragmatic fenestration perhaps congenital, in right pleural cavity causing pneumothorax. DISCUSSION: Rarely, colonic perforation during colonoscopy can occur into the extraperitoneal space, thus leading to the passage and diffusion of air along the fascial planes and large vessels, possibly causing pneumoretroperitoneum, pneumomediastinum, pneumopericardium, pneumothorax, and subcutaneous emphysema. The combination of intraperitoneal and extraperitoneal perforation has also been reported. Pneumothorax following a colonoscopy sigmoid perforation is an extremely rare but severe and often lifethreatening complication. CONCLUSION: If the patient develops dyspnea and pneumoderma during or after this procedure, a chest radiogram or thoracoabdominal CT should be taken for diagnostic purposes. Urgent treatment, starting with chest tube insertion(s) and laparotomy or laparoscopy could be lifesaving.

Abdominal scar endometriosis: case report.

Abdominal scar endometriosis, corresponding to the presence of an endometrial tissue near or inside an abdominal surgical incision, is a rare clinical event that can occur in women after gynecological or obstetric surgery. Generally, a triad consisting of underlying mass at the incision, cyclic menstrual scar pain, and history of previous gynecological or obstetric surgery leads to the preoperative diagnosis. In rare cases, the clinical presentation is atypical and the differential diagnosis with incarcerated incisional hernia, granuloma, abscess or other soft tissue tumors can be difficult. The authors describe the case of 39-year-old woman who underwent three previous cesarean sections, with a 20-week history of underlying palpable mass at the Pfannenstiel incision, associated to continuous pain. In this case, a surgical excision followed by the histology definitely clarified the diagnosis.

Total intravenous anesthesia (TIVA) with propofool and remifentanil during operative endoscopy tracheobronchial laser therapy.

Background: The aim of our study was to assess how total intra-venous anaesthesia (TIVA) achieved by propofol and remifentanil continuous infusion could ensure proper success of the endobronchial laser therapy, in optimal conditions for the endoscopist, determining at the same time an adequate hypnosis and a good analgesia. Methods: We studied 50 patients (28M - 22F), ASA class I-IV, mean age 42 ± 32.5 years , subjected to laser endoscopy to repair tracheal stenosis. TIVA was performed in all patients, and spontaneous breathing was maintained. Results: 10.2% of patients experienced episodes of coughing during induction. The depth of the anaesthesia plan, monitored by BIS, was 55 ± 5. The awakening was fast in all patients, with an Aldrete score of 7.71 ± 1.14 at 1 minute and 9.31 ± 1.12 at 10 minutes. Conclusion: The results of this study allow us to state that the continuous infusion of propofol and remifentanil proved to be the gold standard in patients ASA I-II-III undergoing endobronchial laser therapy. The use of TIVA has also allowed to perform endoscopic intervention on patients who suffered from a significant decrease of both cardiac and respiratory functions.

Fracture and migration in right atrium of a permanent venous central access system in a elderly patient: case report and literature review.

Abstract: Catheter dislocation and fracture with migration of central venous lines have been reported in the International literature. Catheter fracture with consequent migration has been observed in 0.5-3.0% and may either be consequent to catheter removal or it can occur spontane-ously. Our case report concerns the migration of a Hickman catheter connected to a venous port to the right atrium in a 61-year old patient. A literature up-to-date has been performed to assess the risk of port-a-cath positioning. The position of catheter tip is considered critical for the risk of migration, that is greater as higher the tip localization respect to the carina. The aim of our study is to underline the critical role of X-ray to visualize the exact location of the catheter tip, regard-less of the approach used for catheter positioning.

[Hormone replacement therapy after total thyroidectomy. Can the combined treatment be considered effective to get metabolic adequacy? Preliminary results]. / Terapia ormonale sostitutiva dopo tiroidectomia totale. Il trattamento ormonale combinato può essere considerato efficace strumento di adeguatezza metabolica? Risultati preliminari.

INTRODUCTION: Even if T4 is standard treatment for hypothyroidism after thyroidectomy, a treatment with T4 plus T3 has been proposed as an alternative reproducing carefully the physiology of the thyroid. We performed an observational study about the effects of the combined replacement therapy with T4 and T3 in patients who underwent total thyroidectomy. PATIENTS AND METHODS: Fifty thyroidectomized patients (not for cancer), in T4 replacement therapy, were included in the study. Such a therapy has been changed by administering T3 and T4 in proportion 1/16. Adverse effects, clinical parameters and general health perceptions (SF36 Questionnaire) have been considered at the time of enrollment (T0), after 30 days (T1) and after 60 days (T2). RESULTS: No differences in weight, cardiac frequency and blood pression have been found between T0 and T2. A not statistically significant reduction has been found in total cholesterol (3 mg/dL) and triglycerides (3.29 mg/dL) levels. A reduction of complaints referred by the patients at T0 has been revealed in T2: anxiety from 21 to 13 patients; headache from 22 to 13; tiredness from 17 to 8 (p<0.05); sleepiness from 25 to 15 (p<0.05). About the questionnaire, in the General Health Perception sub-score has been found a not significant increase of the parameter. DISCUSSION AND CONCLUSIONS: T4 replacement therapy is of proved efficacy, notwithstanding some complaints afflict a share of patients. To improve the quality of life of these patients, we consider relevant the reduction of complaints and the improvement of well-being and cognitive function obtained by the combined T4 and T3 treatment. Moreover, even if the production of T3 from T4 usually ensures euthyroidism in all tissues, contemporary pathologies and alterations determined by the oldness can disturb the enzymatic activity, which is the essential requirement of T4 therapy. These preliminary findings in a small group of patients encourage further studies on a larger patient population.

[Colorectal carcinoma in the young. Prognostic factors]. / Il carcinoma colo-rettale nel giovane. Fattori prognostici.

Colorectal carcinoma is the third most frequently diagnosed malignant neoplasm. Usually patients affected by this neoplasia belong to VI decade of life. However approximately 2-8% of tumors arise in patients with age under 40 years. Aim of the study was to analyse the results of surgical treatment of colorectal cancer in patients aged under forty. From January 1987 to December 2002, 46 patients under forty years with colorectal cancer underwent surgical procedure. No perioperative mortality was registered, and complications were evidenced in nine patients (20%). Actuarial five years survival was 33%, and overall mean survival was 53 months. Univariate and multivariate analyses identified as prognostic factors the tumor grade, Dukes' stage, nodal status, and length of symptoms.

Management of benign biliary strictures: biliary enteric anastomosis vs endoscopic stenting.

HYPOTHESIS: Although advances in endoscopic procedures have provided alternative options for relieving biliary obstructions, the overall chance of cure for patients with benign biliary stricture is the same using surgical or endoscopic treatment. DESIGN: Case-control study. SETTING: Tertiary care university hospital. PATIENTS: Of 163 patients referred for treatment with diagnoses of benign strictures of the common bile duct between January 1, 1975, and July 1, 1998, we studied 42 patients with postcholecystectomy stricture and a follow-up longer than 60 months. Twenty of these patients were treated with endoscopic stenting and 22 with surgery (hepaticojejunostomy, choledochojejunostomy, or intrahepatic cholangiojejunostomy). MAIN OUTCOME MEASURES: Postoperative mortality and morbidity and long-term outcome. The rate of restenosis was also determined. RESULTS: Morbidity occurred more frequently in patients treated with endoscopic procedures than with surgical ones (9 vs 2; P = .34). Hospital mortality was 0%. Surgery achieved excellent or good long-term outcome in 17 of 22 patients. Endoscopic biliary stenting was successful in 16 of 20 patients. Overall, excellent or good outcomes were achieved in 34 patients (81%). CONCLUSION: The ability to achieve steady, long-term results confirms hepaticojejunostomy as the best procedure in the treatment of benign biliary strictures, even if endoscopic procedures are gaining a new role in the treatment of a greater number of patients.

Total mesorectal excision and low rectal anastomosis for the treatment of rectal cancer and prevention of pelvic recurrences.

HYPOTHESIS: Total mesorectal excision lowers the rate of pelvic recurrence and positively affects the survival after surgical treatment of rectal cancer. DESIGN: Case series. SETTING: Tertiary care university hospital. PATIENTS: Fifty-three consecutive patients were admitted with curative intent to surgery at the First Department of Surgery of the University of Rome "La Sapienza," Rome, Italy, with diagnoses of rectal carcinoma. The mean follow-up was 68.9 months; follow-up was complete for all patients who entered the trial. INTERVENTIONS: Low anterior resection and total mesorectal excision were performed in all cases, regardless of the location of the rectal cancer. A straight mechanical colorectal anastomosis was performed on a rectal stump, never exceeding 5 cm. No kind of adjuvant therapy was given. Mesorectum and open rectum were studied by serial transverse section at 5-mm intervals. A search for depth of penetration and distal intramural extension of the tumor was made. Lymph nodes were detected by clearing method, and nodal metastases (NM) and nonnodal metastases (NNM) were recorded as situated proximally, distally, or at the level of the tumor. RESULTS: There was no postoperative mortality. Clinical and radiologic leaks occurred in 2 and 4 patients, respectively. Mean disease-free survival was 65.9 months. Pelvic recurrence occurred in 5 patients (9%). Overall 5-year survival rate was 75%. Involvement of mesorectum by NM and NNM was detected in 27 and 24 cases, respectively. Both NM and NNM were found to be distal in 33% and 40% of cases, respectively. CONCLUSIONS: Microscopic spread to the distal mesorectum may exceed the intramural spread of rectal cancer. Failure to perform total mesorectal excision leaves a potentially residual disease in the distal mesorectum, thus predisposing the patient to pelvic recurrence.

Clinical significance of serum gastrin levels in patients with colorectal cancer.

AIMS: An association between elevated serum gastrin levels and the presence of human colorectal cancer has been reported, and gastrin has been shown to stimulate the growth of experimentally induced colon neoplasia. The aim of this study was to determine the preoperative and postoperative concentrations of serum gastrin in 53 patients with colorectal cancer and to assess the correlation between gastrin levels and tumor characteristics and prognosis. MATERIALS AND METHODS: A prospective study was performed over a six-year period during which 53 patients received potentially curative surgery for colorectal cancer. The prognostic variables used for the analysis included age, sex, tumor site, stage and degree of differentiation, preoperative and postoperative serum values of carcinoembryonic antigen (CEA) and gastrin, cancer-related mortality, and survival. CEA and gastrin serum values were determined using radioimmunological methods. Follow-up was carried out with clinical and radiological tests. RESULTS: The mean preoperative gastrin concentration was 51.2+/-27.4 pg/mL (range 12-146). Significantly increased serum gastrin concentrations, which returned to normal after surgery, were detected only in patients with well-differentiated cancer (74.2+/-28.3 pg/mL; moderately differentiated, 52.1+/-23.8; poorly differentiated, 29.9+/-12.3, p=0.02). The prognosis was unrelated to serum gastrin level; instead, tumor stage, preoperative CEA value, and degree of differentiation affected patient survival. CONCLUSIONS: This study showed that the serum gastrin concentration is not an appropriate clinical oncogenic factor. Although occurring only in well-differentiated tumors, serum gastrin is unrelated to the prognosis of patients with colorectal cancer.

Preservation of the inferior mesenteric artery in colorectal resection for complicated diverticular disease.

BACKGROUND: Preservation of the inferior mesenteric artery (IMA) and consequential blood flow to the rectum would reduce the risk of leakage of a colorectal anastomosis. METHODS: One hundred and sixty-three patients undergoing left colectomy for complicated diverticular disease of the colon were randomly placed into two groups: A, n = 86; and B, n = 77. In group A, the integrity of the IMA was preserved by artery skeletization (IMAS); in group B, the IMA was divided at its origin. Variables recorded included duration of the surgical procedure, need for blood transfusion, length of hospital stay, operative mortality and morbidity, staple-ring disruption, and radiologic and clinical leakage. Anastomotic stenosis and recurrence of diverticular disease were noted. RESULTS: Surgical time was superior in the IMAS group. Radiologic and clinical leakages were significantly higher in group B (P = 0.02, P = 0.03, respectively). In group A a significant lower number of staple-ring disruptions was observed, evolving into clinical dehiscence. CONCLUSION: Preserving the natural blood supply to the rectum and the ensuing use of a healthy well-nourished rectal stump are suggested as the main aspects of IMAS in preventing and healing leakage of colorectal anastomosis.

Clinical significance of normobasemia in early post-operative outcome of hepatic resections.

BACKGROUND: Major hepatic resections are usually followed by acid-base unbalance. Adjustment of the acid-base disorders is considered central when dealing with these critical patients and normobasemia is thought to be a favourable prognostic factor when occurring in the immediate postoperative outcome after major surgery. The present study was undertaken to investigate the influence of acid base balance on the early outcome after hepatic resection. METHODS: A series of fifty-seven cirrhotic patients was submitted to liver resection for hepatocellular carcinoma. Forty-eight patients experienced an uneventful early postoperative outcome (CTR group). Nine died in the postoperative course (HD group). In all patients pulmonary, renal and hepatic functions were monitored pre- and postoperatively. The pH values were detected daily preoperatively and in the course of the first three days after hepatic resection. In the same days acid base balance and arterial ketone body ratio were assessed on arterial blood samples. Data were collected in a data base and statistical analysis was performed. RESULTS: A significantly higher metabolic alkalosis was found to characterize the first and second postoperative days (POD1 and POD2) in the CTR group (pH 7.43+/-0.007 vs pH 7.33+/-0.001; pH 7.45+/-0.006 vs pH 7.35+/-0.009; p<0.05). Lower values of pH and an associated impaired energetic status of the liver were found to characterise the postoperative course of the poor prognosis patients. At POD1 AKBR decreased in both groups but while recovering at POD2 in patients of CTR group maintained significantly lower values in HD group (AKBR 1+/-0.3 vs 0.5+/-0.2; p<0.01). A lower energetic status of the liver is associated with an inadequate tricarboxylic acid cycle and is responsible for an impaired production of HCO3-. CONCLUSIONS: Apparent normobasemia is then expressive of liver failure leading to poor postoperative outcome.

Impact of axillary level I and II lymphnode dissection on the therapy of stage I and II breast cancer.

BACKGROUND: Routine performance of axillary node dissection (AND) in the treatment of stage I and II breast cancer has become controversial because of pretended morbidity of this procedure and progressing consent for sentinel lymphadenectomy. METHODS: Ninety-four consecutive patients who underwent AND for clinical stage I and II breast cancer were evaluated for a range of 48.3 months after surgery for movement and sensory alterations and arm swelling. Arm circumference was measured in all patients at the same four sites on both the operated and non operated sides preoperatively and in the immediate and late postoperative course. Capacity for movement was assessed pre- and postoperatively as active ranging at the shoulder joint. Postoperative numbness and paresthesias were assessed by standard questions. RESULTS: No patient had axillary recurrence. None of the detected differences between the preoperative and postoperative arm circumferences reached statistical significance. No persistent motion limitation was observed. Pain, numbness, paresthesia were detected in almost all patients in the immediate postoperative period but resolved spontaneously in all cases within 6 months. The obese body habit was detected on multivariate analysis as the only significant predictor of edema. CONCLUSIONS: No significant morbidity and no axillary recurrence were observed in current experience to follow AND. These findings suggest that axillary level I and II dissection remains an effective and safe tool for diagnostic, as well therapeutic, purposes in the treatment of stage I and II breast cancer. Further studies are necessary before it can safely be reported that axillary node dissection is an optional part of the treatment of stage I and II breast cancer.

The influence of somatostatin on bacterial translocation.

BACKGROUND: Bacterial translocation is defined as the passage of bacteria from the gastrointestinal tract to extraintestinal sites mostly as a consequence of the loss of the gut barrier function. Somatostatin and octreotide, exerting many inhibitory effects on the gastrointestinal tract, have been evidenced to promote bacterial translocation. DESIGN: experimental research. SETTING: University teaching Hospital. INTERVENTIONS: Sixteen pigs forming the study group received 25 mg/kg of octreotide twice a day for ten days. A control group (n=16) received an equal volume of saline solution for the same period. All animals were sacrificed and tissue cultures were obtained from mesenteric lymph nodes (MLN), liver and spleen. Portal venous and central venous blood samples were also withdrawn for culture. RESULTS: In the octreotide group, cultures were positive for bacteria in 43.7% (7/16) of animals. Viable bacteria were recovered from MLN, liver and spleen. Portal and systemic blood cultures showed no growth of bacteria. The mean value of bacterial detection in MLN, liver and spleen was 196+/-13 CFU/g, 190+/-26 CFU/g, and 173+/-0 CFU/g, respectively. P value was not statistically significant. Bacterial translocation did not occur in the animals of the control group. Fisher s exact test revealed a statistically significant difference (p<0.007) between the two groups regarding bacterial translocation to MLN. CONCLUSIONS: The administration of octreotide is followed by a conspicuous increase in bacterial translocation in pigs. Further clinical studies are needed to demonstrate similar effects on humans.

Presacral myelolipoma in a patient with colon carcinoma.

Myelolipoma is an uncommon benign tumor, composed of an admixture of adipose tissue and hematopoietic cells, usually discovered within the adrenal glands. Extra-adrenal myelolipomas are rare and approximately half of the reported cases were presacral. We report a case of an asymptomatic presacral myelolipoma measuring 9x8x7 cm, incidentally found in a 71-year-old woman with a stenosing colon cancer. Ultrasonography, computed tomography and magnetic resonance imaging of the presacral mass evidenced a well circumscribed tumor with heterogeneous features due to a nonuniform composition. Surgical excision of the mass was performed.

Maximum gastric cancer diameter as a prognostic indicator: univariate and multivariate analysis.

It was suggested that there are no stronger prognostic factors in gastric cancer than nodal involvement or depth of wall invasion. The present paper evaluated the influence of maximum tumor diameter (MTD) value, measured on fixed resected specimens, on the extent of disease progression and the outcome in gastric cancer patients. Clinicopathological data were retrospectively retrieved from records of 122 patients who underwent curative gastrectomy. The patients' MTD values were grouped as follows: MTD1, up to 26 mm; MTD2, between 26 and 50 mm; and MTD3, over 50 mm. The three groups evidenced significant differences with regard to 5 year survival (MTD1: 54%, MTD2: 31%, MTD3: 20%; p = 0.00027), furthermore they were significantly different with respect to the type of gastrectomy (p = 0.021), depth wall invasion (p = 0.000), lymphatic microinvasion (p = 0.014), perineural microinvasion (p = 0.017), stromal reaction (p = 0.025), and stage (p = 0.035). ROC curve analysis individuated a best accurate MTD threshold value for nodal involvement of 32 mm (sensitivity = 56.6%; specificity = 60.9%; positive predictive value = 52.6%; negative predictive value = 64.6%). The logistic regression analysis suggested that the depth of wall invasion was the only independent variable associated with MTD value (p = 0.0005). Multivariate analysis showed that independent prognostic risk factors were sex (p < 0.0025), number of involved nodes (p < 0.001) and MTD (p < 0.001). In conclusion, the maximum tumor diameter value of gastric cancer may be a factor with greater prognostic implications than previously believed.

[Aneurysmal cysts of the jaws. The nosological picture and a clinical case report]. / La cisti aneurismatica dei mascellari. Inquadramento nosologico e presentazione di un caso clinico.

After discussing the classification of aneurysmatic cyst with particular reference to its characteristics for differential diagnosis with other pathologies of various origin, a personal case is reported. The diagnosis and treatment protocol of the clinical case in question is presented together with clinico-therapeutic problems and the results obtained with the diagnostic and therapeutic aids used.

[Acquired abnormalities of the biliary tract. Preoperative diagnosis and surgical risk in the laparoscopic era]. / Le anomalie acquisite della via biliare. Diagnosi preoperatoria e rischio chirurgico nell'era laparoscopica.

Acquired anomalies of the biliary tract are rare. The aim of this work was to examine their frequency and to assess potential associated danger when performing a laparoscopic cholecystectomy. A retrospective analysis of clinical charts of 3.870 patients undergoing elective cholecystectomy between 1959 and 1997 was performed. Eighteen cases of choledoco-duodenal fistula, 9 of cholecysto-duodenal and 12 of cholecysto-choledochal fistulas were observed. Two cases of acquired absence of the cystic duct and one cholecysto-colic fistula were also encountered. The traditional contrastographic radiology showed to be more accurate in defining presence and nature of the acquired anomalies. Etiopathogenesis of the main anomalies and consequent risks in performing laparoscopic cholecystectomy were discussed.

[Use of ileostomy and colostomy as temporal derivation in colorectal surgery]. / L'impiego della ileostomia e della colostomia come derivazioni temporanee in chirurgia colo-rettale.

A retrospective study on 41 patients with primary stoma creation after low anterior resection of the rectum was made. Among the 41 patients 24 had a loop colostomy (Group A) and 17 had a loop ileostomy (Group B). The two groups were well matched for each of the data analysed and there was no significant difference in the rate of complications related to stomas creation and closure. In this study the Authors suggest that loop ileostomy is the best procedure to electively defunctionate colorectal anastomoses.

[Functional results of experimental autologous transplantation of the pancreas]. / Risultati funzionali dell'autotrapianto sperimentale di pancreas.

The autotransplant of the left lobe of the pancreas in the latero-cervical region has been successfully performed in 38 adult beagles with a mean cold ischemia time of 52 minutes. Juice volume and amylase, protein and bicarbonate outputs were resumed postoperatively as soon as 6 hours. A single case of thrombosis of the mesenteric vein occurred; all other pancreatic grafts showed good histological vitality at 30 days. This procedure of autografting is proposed as a valid experimental model for the pathophysiologic study of acute pancreatitis.

[Rare locations of hydatid disease]. / Localizzazioni infrequenti della malattia idatidea.

The authors report their experience with uncommon hydatid cyst locations. Between 1970 and 1995 a total of 16 patients suffering from hydatid cysts located in various organs other than liver and lungs were observed. There were 7 women and 9 men with a mean of 53.3 years. In 10 cases uncommon locations were found to be isolated and in 6 associated to contemporary or previously treated hepatic cystic disease. Pathogenesis of these uncommon locations, whether being primary or secondary, as well as specific items of diagnosis and surgery are discussed.