Hepatic artery aneurysm rupture in a woman with primary antiphospholipid syndrome.

Primary antiphospholipid syndrome (APS) is associated with arterial and venous thrombosis. However, a small number of patients present with visceral aneurysms. Although such aneurysms are rare, their presence in patients who are usually treated with lifelong anticoagulation raises important therapeutic problems, in view of the risk of aneurysm rupture and acute abdominal hemorrhage. We report the case of a young woman with APS who presented with abdominal bleeding due to ruptured common hepatic artery aneurysm. She was successfully treated by proximal ligation. The features of such aneurysms are discussed.

The use of a dedicated rectosigmoidoscope for ultrasound staging of tumours of the upper and middle third of the rectum.

OBJECTIVE: Tumours of the upper rectum, and many in the middle third, are not accessible to endorectal ultrasound staging because of the difficulty in reaching all sites of the rectum with a rigid probe. The aim of this prospective study was to assess whether using a dedicated rectosigmoidoscope, endorectal ultrasonography (ERUS) can accurately stage any rectal lesion irrespective of its distance from the anal verge. METHOD: A total of 173 consecutive patients with a primary rectal tumour were included. A rotating, high multifrequency (5.0-10 MHz) endoprobe was introduced through a dedicated rectosigmoidoscope and advanced above the lesion. A computer allowed for three-dimensional (3D) reconstruction of 2D images. Treatment was selected on the basis of 3D-ERUS findings. ERUS staging was correlated with pathological staging. RESULTS: The depth of invasion was correctly determined by 3D-ERUS in 78.2% of tumours of the lower rectum, 76.4% of tumours extending between the lower and middle third of the rectum, 80.9% of tumours of the middle third of the rectum, 78.5% of tumours extending between the middle and upper third of the rectum and 78.9% of tumours of the upper rectum. The accuracy for the absence of lymph node metastases was 81.2% for tumours of the lower rectum, 78.5% for tumours extending between the lower and middle third of the rectum, 85.7% for tumours of the middle third of the rectum, 83.3% for tumours extending between the middle and upper third of the rectum and 78.5% for tumours of the upper rectum. Analysis showed that there was no difference between the various tumour sites. CONCLUSION: Our findings indicate that using a dedicated proctosigmoidoscope, tumours of the upper and middle third of the rectum are equally accessible to ultrasonographic evaluation. The distance of the tumour from the anal verge does not influence the accuracy of examinations considered adequate by the operator.

[Metastatic gastric neoplasm in the spermatic cord: report of a case]. / Neoplasia gastrica metastatizzata al funicolo spermatico: a proposito di un caso.

The Authors report a case of a 69-year-old male patient recently operated on for a gastric cancer who developed metastasis to the right spermatic cord. They emphasize the rarity of this condition and then go on to review the international literature on the subject.

[Multidisciplinary approach to the patient with oropharyngeal dysphagia]. / L'approccio multidisciplinare al paziente con disfagia oro-faringea.

The Dysphagia Study Group of the Regional Hospital of Treviso uses a multidisciplinary approach to assess patients with oro-pharyngeal dysphagia. From 1996 to 2000, 208 patients with functional dysphagia were studied by the Group. Dysphagia was due to neurological disease in more than 50% of patients, to surgery in 25% and to a functional disease in 17%. In patients less than 20 years old the aetiology was due to the aftermath of traumas; in patients aged from 20 to 45 years the cause was a functional disease or achalasia, while in the majority of the older patients, aged over 45, had cerebral ischaemic lesions. The majority of patients (78%) were submitted to rehabilitation, 9.5% to medical treatment and 2.8% to surgery. Oro-pharyngeal dysphagia calls for a multidisciplinary approach in qualified centers with specialized facilities.

Vesicoureteral reflux after kidney transplantation: clinical significance in the medium to long-term.

103 patients who received a cyclosporine-treated primary cadaver kidney transplant (TX) at our center between 1985 and 1989, whose graft survived for more than 1 year and who accepted to undergo voiding cystography after TX were analyzed and grouped according to the highest grade (regardless to whether active or passive) of vesicourteral reflux (VUR): group 0, absent (n = 14); group 1-2, grade I or II (n = 62); group 3, grade III (n = 27). Patient follow-up ranged from 5 to 10 (median 7) years. Patient and graft survivals and prevalence of hypertension (defined as the persistent need of antihypertensive therapy), did not differ significantly between groups (Mantel-Cox test p: n.s. in all cases). GFR (Cockroft and Gault) and proteinuria were evaluated with ANOVA for repeated measures at 1, 2, 3, 4 and 5 years in the 96 patients (group 0: 13, group 1-2: 56, group 3: 27) whose grafts lasted for 5 years or more. Neither GFR values (p: n.s.) nor GFR behaviour over time (p: n.s.) differed between groups, although a progressive decline of GFR was noted in all groups (p < 0.002). Proteinuria neither showed any significant differences between groups in values (p: n.s.) or behaviour over time (p: n.s.), nor any trend in behaviour over time in all groups as a whole (p: n.s.). Finally, in the first 5 years after TX the 3 groups did not differ for number of urinary tract infections (UTIs) (mean value for all patients: 2.5, range 0-22, episodes/pt/5 years) (p: n.s.), or for number of UTIs with leukocyturia (mean 0.6, range 0-6, episodes/pt/5 years) (p: n.s.), or for number of febrile UTIs (mean 0.3, range 0-5, episodes/pt/5 years) (p: n.s.), or for number of UTIs with sepsis (mean 0.1, range 0-2, episodes/pt/5 years) (p: n.s.). The same results were obtained when, instead of episodes/ pt/5 years, percentages of patients without or with 1 or more of such episodes in the same period were considered. In conclusion, VUR does not seem to be hazardous for the transplanted kidney in the medium to long-term.

[Diagnosis and treatment of gastrointestinal carcinoid. Report of a clinical case with duodenal site]. / Diagnosi e trattamento del carcinoide gastrointestinale. Descrizione di un caso clinico a sede duodenale.

Carcinoid tumors are among the most frequently neuroendocrine neoplasms of the gastrointestinal tract. They occur more commonly as benign diseases but malignant ones can also be found. The peak age incidence varies with the location of the tumor, with appendiceal tumors being diagnosed at an overage of 36 years, whereas non appendiceal tumors are found typically in the fifth sixth decades of life. There is no sex predilection of the tumors. Most carcinoid tumors are found within the appendix (40-50%) or small intestine (25%). Less common sites include the rectum (15%), main bronchus (10%), duodenum (3-8%) and stomach (2%). Most carcinoid tumors are found incidentally at operation and cause no symptoms. If symptoms do occur, they can be either non specific include intermittent crampy abdominal pain, vomiting and distension caused by intestinal obstruction. The prognosis depends on the site of the tumor and its size. Most carcinoid tumors (75%) are less than 1 cm in size and only 5% are greater than 2 cm. The incidence of metastatic disease is related directly to the size of the tumor at all locations. Carcinoid tumor with size less than 1 cm give linfonodal metastasis only in 3-5%; the other with size over 2 cm give metastasis in the 70-75% of the cases. The 5-years survival for all carcinoid tumors are approximately 85%. Five years rate is higher (> 80%) in carcinoid tumors of appendix and rectum than in gastroduodenal, ileal and colonic neoplasm (< 60%). In this paper the authors report a case of malignant carcinoid of the duodenum.

[Retroperitoneal ganglioneuroma. A case report and review of the literature]. / II ganglioneuroma retroperitoneale. Segnalazione di un caso e revisione della letteratura.

Ganglioneuromas are typically of slow growth and benign evolution and may remain clinically silent for a considerable time if favourably situated. Many large examples are discovered incidentally on X-ray examination, routine abdominal palpation or at necropsy. Ganglioneuromas are often encountered in childhood and are found more frequently in the posterior mediastinum than in any other single situation; other sites are the lumbar and pelvic retroperitoneal tissues, the gastrointestinal tract and the mesentery. Diffuse alimentary tract ganglioneuromatosis has been described as port of the multiple endocrine neoplasia syndrome (MEN) type II-B. Sometimes ganglioneuromas are found in the von Recklinghausen Syndrome. The authors report in this paper a rare case of a retropancreatic ganglioneuromas.

Through the nose gastroscopy for the placement of feeding tubes.

Following local anesthesia to the nose, through-the-nose (TTN) passage of a paediatric gastroscope was successful and well tolerated in 82 of 92 patients on whom it was attempted in order to place nasogastric feeding tubes. This technique allows for guidewire placement to be used for insertion tubes or dilators. The ten failures we observed occurred in patients with bilateral narrow turbinates. We conclude that the TTN approach is quicker and easier than conventional methods of feeding tube placement allowing for an additional endoscopic evaluation of the upper GI tract.

Clinical significance of vesicoureteral reflux after kidney transplantation.

In this study 103 out of our 125 CsA-treated patients who received between January 1985 and December 1989 a first cadaver kidney transplant that functioned for at least one year were studied with voiding cystography (VC) for vesicoureteral reflux (VUR). All patients had an external uretero-neo-cystostomy. VUR occurred in 89 (86.4%) patients. Patients were grouped according to VUR: absence of VUR (group 0), VUR grade I-II (group 1-2), and VUR grade III (group 3). The 3 groups were comparable for male/female ratio, cause of renal failure, cause of donor death, recipient and dialytic age, immunosuppressive therapy, follow-up, time of VC performance after transplantation. At 6 months and 1, 2, 3, 4, and 5 years after transplantation graft function, number of rejection episodes, and number of urinary tract infections (UTIs) were similar in the 3 groups. In groups 1-2 and 3 hypertension was more frequent than in group 0 and occurred even after the 6th month (whereas this did not happen in group 0), but the differences between the 3 groups were not significant. However, when only the 13 patients who were followed for 5 years were considered, the prevalence of hypertension after 5 years was significantly higher in groups 1-2 and 3 (both 100.0%) than in group 0 (33.3%) (chi-square = 7.88; p < 0.02). Finally, 4.5% of patients with VUR and no patients without VUR had septic episodes linked to UTIs, but the difference was not significant.(ABSTRACT TRUNCATED AT 250 WORDS)

[Bio-imaging for the study of organic changes in the C.N.S.: comparison between computerized tomography and magnetic resonance]. / Bioimmagini per lo studio di alterazioni organiche del S.N.C.: confronto tra tomografia computerizzata e risonanaza magnetica.

Several comparative studies have been carried out in order to evaluate the possible diagnostic superiority of Computed Tomography (C.T.) vs. Magnetic Resonance Imaging (M.R.I.) in different diseases of the Central Nervous System. The present investigation is aimed at critically revising this problem also including the study of patients clinical data as a criterion of choice. A sample of 69 subjects was examined. It was seen that in demyelinative as well as in chronic cerebrovascular diseases M.R.I. should be preferred because of its higher sensitivity and specificity. Concerning specifically chronic cerebrovascular diseases, clinical data can have a more significant role in justifying the choice of M.R.I. C.T., and M.R.I. should be considered as complementary rather than competitive in studying cerebral tumors and spinal cord pathology; the planning of surgical operations, needing a complete evaluation of data, which in these cases are very variable, requires the use of both methods.

Balloon dilatation of anastomotic intestinal stenoses: long-term results.

Since 1983 we have treated 59 consecutive patients with anastomotic intestinal strictures. In 43 cases the stenosis was located in the esophagus, and in 16 cases in the colon. The balloon catheter was positioned under fluoroscopic and endoscopic control. The number of dilatations required by each patient ranged from one to five, with 47% of our patients receiving only one session, and 23% two sessions. We had no initial treatment failures. We observed stricture relapse in 10.1% of our cases, occurring within two to five months. In these patients repeat dilatation was 100% successful. We had no significant complications. All the patients with esophageal stricture were able to eat solid food after dilatation. Long-term results and relapse-free intervals have been assessed on a clinical basis with a mean follow-up of 26.5 months. Balloon dilatation would seem a safe and reliable method of treating anastomotic strictures, with special emphasis on stenosis with a small diameter, and tortuosity of the gut.

Fournier's gangrene following a perianal abscess.

Fournier's disease is an uncommon form of gas gangrene involving the scrotum and perineum. Described by Fournier as an idiopathic condition, it must be recognized as a synergistic gangrene secondary, in most cases, to a focus of perianal infection. Urinary tract infection and local trauma follow as possible causal factors. Five cases complicating a perianal abscess observed in a period of 11 years have been treated with urgent aggressive surgical debridement and intensive care support. Full-thickness skin grafts were required in three patients. Hospital mortality occurred in one case. Although combination antibiotic therapy and correct postoperative wound management are potentially successful, the mainstay of treatment is complete excision of all necrotic tissue. Colostomy and urinary diversion are not mandatory. Treatment with hyperbaric oxygen is controversial.

[Lipomatosis of the ileocecal valve (author's transl)]. / Lipomatosi della valvola ileo-ciecale.

A case is described with histologic demonstration. The ethiopathogenetic and clinical aspects of the disease are discussed. The differential diagnosis between lipoma and lipomatosis is stressed. Laparotomy may sometimes be necessary for a correct diagnosis. The basic elements for the treatment are presented.

[Jejunostomy for feeding purposes. Considerations on 100 cases]. / La digiunostomia a scopo alimentare. Considerazioni su 100 casi.

Personal experience with 100 cases of jejunostomy for feeding purposes is reported. Stress is laid on the advantages of this feeding technique which include simple, surgical technique, easy administration of diet, speedy metabolic response and the moderate nature of the complications.