[Complex partial seizure in patient with insulinoma: importance of early diagnosis]. / Crisi parziali complesse in un paziente affetto da insulinoma: l'importanza di una diagnosi precoce.

Insulinoma, usually benign (90%), is clinically characterized by symptoms as tremulousness, tachycardia, weakness, sweating, fatigue, hunger, headache, dizziness, disorientation and unconsciousness. However rarely it has an unusual presentation. We present a case of insulinoma misdiagnosed as neurologic disease. A 48-year-old man was admitted to our Emergency Division because of car accident caused by loss of consciousness. A diagnosis of complex partial seizure was made one year before. The patient appeared pale, tachycardic, BP 130/85 mmHg. Laboratory tests showed a severe hypoglycemia (30 mg/dl). He was treated with hypertonic glucose solution and the resolution of symptoms was obtained. Dosages of insulin and C-peptide, CT-scan and RMN confirmed a diagnosis of insulinoma. Seizure disappeared after surgical excision. The diagnosis of insulinoma is sometimes delayed up to more than 20 years. Neurologic or psychiatric presentation like disorientation, personality changes, amnesia, irritability, seizures, bizarre behavior, visual difficulties, neuropathy in patients affected by insulinoma could be cause of misdiagnosis. Diagnosis of insulinoma should always be considered whenever these symptoms occur, especially if unresponsive to specific therapy. Insulinoma is curable in most cases and an early diagnosis can avoid adverse consequences including neurologic damage.

Meckel's diverticulum masked by a long period of gastric symptoms--a case report.

Meckel's diverticulum (MD) is the most frequent congenital abnormality of the small bowel and it is often difficult to diagnose. The authors report a case of a patient with long-term symptoms erroneously not related with MD disease and developing a diverticulum perforation.

[Rule of early diagnosis for sigmoid volvulus. Case report]. / Ruolo della diagnosi precoce nel volvolo nel sigma. Caso clinico.

The sigmoid colon is the most frequent site for a volvulus due to anatomical and pathological reasons. When the rotation of the loop occurs slowly, the sigma can greatly blow up and stretch. We report the clinical case of an 80-year-old woman admitted to our Department for an enormous volvulus of sigmoid colon. Physical examination, abdominal X-ray and CT-scan were performed to diagnose the disease. At the surgical procedure the sigma was about 50 centimetres in length and 15 centimetres in diameter, with a gangrenous necrosis of the loop; the treatment was a sigmoidectomy by Hartmann procedure. Surgical resection is the only therapeutical option for volvulus in advanced stage due to a late diagnosis.

[Cutaneous ascites as complication of the placement of a totally implantable arterial system]. / Filtrazione ascitica cutanea come complicanza del posizionamento di un sistema totalmente impiantabile arterioso.

The Authors report the case of a patient with intrahepatic colangiocarcinoma, operated on for totally implantable arterial device (TIAD) implant in view of hepatic chemotherapy. The postoperative course was characterized by cutaneous drainage of ascites fluid from the wound of the TIAD implant. Its aetiology and therapy are discussed.

Intraluminal hamartoma of the ileum in a child: a rare cause of intestinal occlusion.

A case of small-intestinal obstruction in a 12-year-old boy caused by an intraluminal hamartoma of the ileum is reported. The rarity of the lesion, its location, symptomatology, histology, and diagnosis are discussed.

[Appendiceal mucoceles. A case report]. / Il mucocele appendicolare. Analisi di un caso.

A case of benign mucocele presenting as a subocclusive syndrome is reported; the surgical treatment consisted in a right colectomy. Appendiceal mucoceles are rare lesions of the appendix, characterized by a gross enlargement of the appendix from accumulation of mucoid substance within the lumen. It is a rare condition, encountered in only 0.1-0.4% of all appendectomies with a female predominance and an average age at the time of diagnosis over 50 years. Following careful review of the literature, the difficulties in differential diagnosis are underlined, especially between benign and malignant forms and the possibility of a pre-operative diagnosis is examined. Abdominal ultrasound and CT scan of the abdomen or colonoscopy may suggest the diagnosis. However, often the diagnosis is an incidental event. The pathogenesis, histologic aspect of the lesion and the different surgical strategies are discussed. A frozen section examination should be performed in all patients, while the abdomen is open, because it may be impossible to predict the underlying pathology merely by inspecting the serosal surface of a dilated appendix. If a simple retentional cyst is uncovered, without atypia, appendectomy should be curative; if cystadenoma or cystadenocarcinoma of the appendix are found, more extended resection was necessary. However if the operation is done as an emergency, a frozen section examination is not always available: in those patients a more extended resection is suggested.

Does cholecystectomy always resolve biliary disease?

OBJECTIVE: To evaluate long-term effects of cholecystectomy on typical gallstone symptoms and associated digestive syndrome. DESIGN: Clinical prospective study on selected patients. SETTING: First Surgical Clinic--Catania University. SUBJECTS: 143 gallstone patients, divided in highly symptomatic Group 1 (79) and mild symptomatic Group 2 (64), who underwent cholecystectomy during period 1991/92. MAIN OUTCOME MEASURES: 125/143 patients compiled a set questionnaire to detect any subjective postoperative disorders and to evaluate whether they were similar to preoperative symptoms or were new ones. RESULTS: 125/143 patients completed the 12-month follow-up programme, which revealed a 30% (38/125) with postcholecystectomy symptoms and 13.4% (17) with a postcholecystectomy syndrome. Moreover, 10% (13) of the patients reported the same digestive symptoms as before treatment. Statistical analysis confirmed that cholecystectomy was efficacious in curing gallstone related symptoms and digestive disorders in both Groups with a general improvement in clinical picture (p > 0.01). No significant statistical difference in the incidence of postcholecystectomy dyspeptic symptoms was found between the 2 Groups. CONCLUSION: Cholecystectomy is often efficacious in curing both typical gallstone related symptoms and digestive syndrome. Cholecystectomy patterns of failure in curing digestive disorders is unpredictable preoperatively on the basis of clinical features of the disease.

Which kind of surgery in elderly people for colorectal cancer?

Colo-rectal cancers are of high incidence in elderly patients. Different clinical features and the peculiar behavior of the tumor may influence surgical results and should be considered in the decision making, when the surgeon has to decide whether to perform radical gut resection or less straining palliative procedures. In a retrospective study, 102 large bowel cancer patients are analyzed submitted to surgery in the period 1989-1994. Patients were divided in two age classes: Group A: above 70 years of age, 45 cases (44.2%); Group B: under 70 years of age, 57 cases (55.8%). Emergency surgery procedures were necessary in 35 patients (34.4%), 20 cases (57%) in Group A and 15 cases (43%) in Group B. Radical resections could be performed in 25 (37%) old patients, 67% of the cases underwent a curative resection. Perioperative mortality and surgical complication rates were significantly higher in Group A than in Group B. The technical and biological difficulties in performing radical curative resections, the high complication rates and the occurrence of negative results of treatments provide a reason for careful evaluation of the risk/benefit ratio in older patients, where less straining palliative therapies may sometimes offer similar results.

[Surgery in neoplasms of the low rectum. Analysis of the Knight-Griffen technique]. / La chirurgia delle neoplasie del retto inferiore. Analisi della tecnica di Knight-Griffen.

The major advantage offered by the "double stapling technique" in the treatment of low rectum cancers is sphincter preservation while respecting oncological criteria of radicality. The authors report their experience in surgical treatment of rectal neoplasms, considering a 24 patient group observed between 1989 and 1991, when new staplers were available in Italy. They also present primary results obtained with modified Knight-Griffen technique evaluating a series of 10 patients with rectal cancers placed between 5 and 10 cm from the anal verge. The authors describe surgical procedures and, analyse the complication rate, report a 10% anastomotic leak with no clinical stenosis and 20% relapses. Showing a 2-year follow-up data, a 61.1% surviving actually free of disease in the all 24-patient group is referred. The authors conclude that double stapling technique, while safe and effective, should be always performed accordingly to oncological radicality, reminding that the aim of surgery is the treatment of cancer and sphincter saving should be considered secondary.

Acute effects of partial hepatectomy on liver blood flow in the jaundiced rat.

The aim of this study was to define the effects of hepatic resection on liver blood flow and portal pressure in the presence of obstructive jaundice. Liver blood flow and portal pressure were measured in 17 jaundiced animals (5 days bile duct ligation) and 16 control animals. A 70% liver resection with or without hepatic artery ligation was performed in the control animals. On day 5, the animals underwent a second operation. Hepatic artery ligation alone was performed in a group of control animals. In jaundiced rats there was a decrease in liver blood flow (1.24 +/- 0.23 ml/min per g vs. normal 1.91 +/- 0.38 ml/min per g, P < 0.01) and an increase in portal pressure (11.2 +/- 3.47 mmHg vs. normal 6.93 +/- 1.01 mmHg, P < 0.01). After partial hepatectomy, a significant increase in liver blood flow was observed in controls (2.44 +/- 0.74 ml/min per g, P < 0.01) but not in jaundiced rats. Hepatic artery ligation did not affect blood flow or portal pressure either before or after resection. Small but significant portal-systemic shunting was found in all jaundiced rats (2.19 +/- 2.1% vs. 0.026 +/- 0.015%, P < 0.05). These results demonstrate that partial hepatectomy results in a significant increase in total liver blood flow. Acute cholestasis appears to prevent this increase. Even in the early stages of obstructive jaundice in the rat, there were signs of portal-systemic shunts.

Comparison of outcome between extended and nonextended liver resections for neoplasms.

BACKGROUND: An aggressive approach to liver resection for neoplasms was adopted during a 5-year period. The results were evaluated by comparing the outcome between extended and nonextended liver resections. METHODS: Among 73 consecutive patients undergoing liver resections for neoplasm or suspicion of neoplasm, 33 underwent extended liver resections (26 extended right lobectomies and 7 extended left lobectomies) and 40 underwent resections of lesser extent. Mortality, morbidity, and survival between the two groups were compared. RESULTS: Overall morbidity was 21% and perioperative mortality was 5.4%. Morbidity and mortality were not significantly different between extended and nonextended liver resections (24% vs 18% and 6.1% vs 5.0%, respectively). Liver resections for extrahepatic cholangiocarcinomas were found to be associated with a higher morbidity (6 of 10) and mortality (2 of 10) when compared with liver resections for noncholangiocarcinomas. Bile leaks occurred mainly in patients with cholangiocarcinomas (4 of 6) and contributed to an increased overall morbidity in this series. After a median follow-up of 31 months, there was no difference in survival between extended and nonextended liver resections. CONCLUSIONS: Extensive liver resections for neoplasms can be carried out without significant increase in the operative risk. Short-term survival is comparable between patients undergoing extended and nonextended liver resections.

[Cystic lymphangioma of the retroperitoneum. A case report]. / Linfangioma cistico del retroperitoneo. Contributo clinico.

Cystic lymphangioma of the retroperitoneum is a primary mesodermal derived benign neoplasm, arising from retroperitoneal lymphatics. The Authors report a case of cystic lymphangioma of the retroperitoneum recently observed, and a review of the international literature registering 181 cases from 1958 up to nowadays. Retroperitoneal localization, sub-clinic evolution and the impossibility to preoperatively define the histological type of the tumour, in spite of the modern diagnostic techniques, explain the difficulties to reach a correct differential diagnosis. The authors conclude that surgery only allows to exactly localize the tumour, yet the definition of cystic lymphangioma is an histological goal.

[Significance of prognostic parameters in acute pancreatitis]. / Significato degli indici prognostici nella pancreatite acuta.

The diagnostic and therapeutic approach to Acute Pancreatitis (A.P.) is directly related to the clinical presentation. The Authors reviewed the data of 66 patients, hospitalized between October 1989 and December 1991, to verify the effectiveness of the prognostic criteria suggested by Ranson (1974), Mercadier (1977) and Imrie (1978). A.P. was of biliary origin in the majority of the patients (63.5%); five patients (7.5%) had an acute alcoholic pancreatitis, while the aetiology was traumatic or unknown in the remaining cases. A complicated clinical course was defined by the development of pseudocyst, pancreatic abscess, digestive haemorrhage, death or prolonged hospitalization (more than 20 days). The 28.8% of the patients developed complications during hospitalization. There were seven pancreatic pseudocysts, six pulmonary complications, three renal insufficiencies, two vascular complications, two sepsies and a gastrointestinal haemorrhage. The mean hospitalization period was 15.1 days (range 1-112). The Authors conclude that the three different prognostic criteria are equally useful to test the severity of A.P. attacks allowing to identify patients with the higher risk to develop complications during hospitalization.

Hepatic resection using a water jet dissector.

The mortality and morbidity in major hepatic resection is often related to hemorrhage. A high pressure, high velocity water jet has been developed and has been utilized to assist in hepatic parenchymal transection. Sixty-seven major hepatic resections were performed for solid hepatic tumors. The tissue fracture technique was used in 51 patients (76%), and the water jet dissector was used predominantly in 16 patients (24%). The extent of hepatic resection using each technique was similar. The results showed no difference in operative duration (p = .499). The mean estimated blood loss using the water jet was 1386 ml, and tissue fracture technique 2450 ml (p = .217). Transfusion requirements were less in the water jet group (mean 2.0 units) compared to the tissue fracture group (mean 5.2 units); (p = .023). Results obtained with the new water dissector are encouraging. The preliminary results suggest that blood loss may be diminished.

[A new fluid-jet dissector in hepatobiliary surgery]. / Un nuovo dissettore a getto fluido nella chirurgia epatobiliare.

Increasing experience with major hepatic resections has stimulated the development of improved resectional techniques and tools. The authors describe a recently developed high pressure, high velocity water jet which offers significant advantages over previously developed methods like ultrasonic dissectors and low pressure water jet machines. The pressure of the system is significantly elevated (between 200 and 600 Bars) and the ejection speed is over 300 m/sec. although the flux remains low. It has been successfully used in 22 major hepatic resections (2 left hepatectomy, 4 extended left, 3 right, 8 extended right and 5 segmental resections) and also during 6 peripheral biliodigestive bypasses (3 segment III bypasses and 3 peripheral segment III bypasses). The blood loss was low and the visibility excellent. The amount of fluid required by the instrument was small reducing the risk of complications. Previous report demonstrated that the water jets are more effective when compared with ultrasound dissectors. The technical characteristic of the new high pressure water jet improves on those intrinsic qualities allowing a more rapid dissection of both fibrous and normal parenchyma and simplifying the use of the instrument. The authors conclude that the new high pressure, high velocity water jet is an effective tool for biliodigestive surgery.

Microsurgical treatment of varicocele.

The authors report their experience of the surgical treatment of varicocele. After having performed modified Palomo's method for many years, recent pathogenetic data have induced them to adopt a microsurgical technique. This technique involves vascular anastomoses which allow drainage of the testicular blood into an area with lower venous pressure. They used Fox's technique (anastomosis between 2-3 veins of the pampiniform plexus and saphena vein) and Belgrano's technique (anastomosis between internal spermatic vein and inferior hepigastric vein). The authors report their series of 30 patients treated with these techniques between 1984 and 1987. The results obtained from 20 who were followed-up one year after surgery demonstrated an improvement in the physical examination in 70% of cases and a decreases in hyperthermia in 75% of patients. A spermiogram improvement has been obtained in 66.6% of 18 patients, as two of them were of pediatric age.

Non-operative treatment in the management of traumatic lesions of the spleen--a new kind of therapy?

The onset of severe episodes of sepsis in splenectomized patients has induced surgeons to perform conservative operations in order to save at least partial functioning of the spleen. Recently, great interest has been focused on the non-operative treatment of traumatic lesions of the spleen, which involves careful and continual observation of patients with splenic nauma to monitor their course towards recovery. This method of treatment was recently adopted by our department for two patients whose case histories are presented herein. Non-operative treatment is suitable only in strictly selected subjects, who must be carefully monitored in an intensive care unit where constant examination and sophisticated diagnostic procedures are readily available. Although the non-operative treatment of splenic trauma is not new, it is only recently that its management, programming and role have been updated.