Clinical evaluation of sodium hyaluronate in the treatment of patients with sopraspinatus tendinosis under echographic guide: experimental study of periarticular injections.

PURPOSE: The purpose of this study was to examine the effect of periarticular injection of hyaluronate into shoulders with supraspinatus tendinosis under echographic guide. METHODS AND MATERIALS: The subjects were 56 patients with clinical, echographic and magnetic resonance diagnosis of supraspinatus tendinosis. They were divided in two groups by random sampling; 28 patients were assigned in SH group (sodium hyaluronate) and 28 patients in SC group (sodium chloride). The test drug was 20mg sodium hyaluronate (2ml, Hyalgan, Fidia SpA, Abano T., P.M. 500-700.000, 20mg/2ml). RESULTS: Preliminary results showed that sodium hyaluronate presented the highest efficacy in the improvement of clinical symptoms and recovery of functional status in patients with supraspinatus tendinosis in fact the mean V.A.S. score (Visual Analogue Scale) at 1 month after the end of the infiltrative cycle was 8.0 in the SC group vs. 2.8 in SH group and these numerical data were substantially unchanged also after 3 and 4 months. CONCLUSION: Hyaluronate injection under echographic guide should be use not only as a lubricant but also to prevent articular cartilage degeneration and cover and protect the articular cartilage; indeed sodium hyaluronate can decrease inflammatory joint process.

Combined biliary and duodenal stenting for palliation of pancreatic cancer.

The aim of this case report was to evaluate the usefulness of combined biliary and duodenal stenting in the palliation of pancreatic cancer. We report a series of 4 consecutive patients (2 men and 2 women, mean age 58.5 years, range 38-77 years) who underwent combined biliary and duodenal stenting in our department between March 2000 and April 2001. All patients had cancer of the head of the pancreas causing stricture of the common bile duct and second portion of the duodenum. Biliary and duodenal stents were successfully positioned, with relief of symptoms in all cases. No early complications were observed, except for a transient increase in serum lipase and amylase in one case. Mean follow-up was 7.5 months (range 5-14 months). One patient presenting recurrence of vomiting after 4 months because of tumour overgrowth at the distal edge of the prosthesis was successfully treated by insertion of a partially overlapping second coaxial stent. Combined biliary and duodenal stenting for the palliation of pancreatic cancer was performed safely and successfully. Stents allowed effective re-canalization of the biliary tract and duodenum, relieving both jaundice and vomiting. This procedure should be considered as an alternative to palliative surgery, especially in critically ill patients.

Percutaneous vacuum-assisted core breast biopsy with upright stereotactic equipment. Indications, limitations and results.

PURPOSE: To assess the usefulness of stereotactic vacuum-assisted core breast biopsy (VCBB) performed using a stereotactic add-on device and film-screen technology with the patient in an upright seated position. MATERIAL AND METHODS: We reviewed a series of 129 women with non-palpable mammographic abnormalities who required stereotactic VCBB from December 1999 to November 2000. Twenty-seven (20.9%) cases were excluded due to difficulties in keeping the correct position during the procedure, while the other 102 (79.1%) underwent successful VCBB. Patients with lesions consisting of either atypical ductal hyperplasia or lobular carcinoma in situ were considered for excisional biopsy. Patients with either ductal carcinoma in situ or infiltrating breast cancer were referred for definitive surgery. The results of stereotactic VCBB were correlated to the subsequent surgical histology. RESULTS: Stereotactic VCBB was interrupted because of bleeding in 1 case and vasovagal reaction in 5 cases. Two haematomas occurred after the procedure. Overall underestimation rate was 10.5%. No new lesions were discovered after a mean follow-up of 18.7 months. CONCLUSION: Stereotactic VCBB performed using a standard add-on device with the patient in an upright seated position and analog technology is feasible in about 80% of cases, has a low complication rate, is not significantly time-consuming, and can offer the same accuracy as dedicated prone equipment.

Self-expandable metal stents in the management of cervical oesophageal and/or hypopharyngeal strictures.

AIM: To assess the usefulness of self-expandable metal stents in the recanalization of cervical and/or hypopharyngeal strictures. MATERIALS AND METHODS: We report our experience in 10 patients with inoperable cervical and/or hypopharyngeal strictures treated by implantation of 11 uncovered self-expandable metal stents inserted perorally under fluoroscopic guidance. The stent was placed in the hypopharynx and cervical oesophagus in 3 patients and cervical oesophagus alone in 7. There were 8 men and 2 women, mean age 70.2 years, range 45-85 years. All patients but two had malignant stricture caused by squamous cell carcinoma, in one case there was a benign postoperative stenosis secondary to laryngectomy, and in the last patient a local recurrence from thyroid cancer. RESULTS: Eleven stents were placed in 10 patients: technical success was achieved in 9 cases while clinical improvement was obtained in 8 cases. Seven of ten patients had a rapid improvement of dysphagia. One patient had a distal misplacement of the prosthesis, while in the other two cases stent position was very proximal and interfered with swallowing. A mean 9-month follow-up was obtained (range 3-24 months). Four patients with malignant stricture developed proliferation of neoplastic tissue after 2-5 months. The only patient treated for a benign stricture developed inside proliferation of granulation tissue after 4 months. CONCLUSION: Despite several technical difficulties and a high rate of late complications, recanalization of cervical oesophageal strictures by self-expandable metal stents allowed good palliation of symptoms. Stents proved to be effective and well tolerated palliative treatment also for hypopharyngeal stenoses.

Self-expandable metal stents in the treatment of antro-pyloric and/or duodenal strictures.

PURPOSE: To assess the usefulness of self-expandable metal stents in the recanalization of antro-pyloric and/or duodenal strictures. MATERIAL AND METHODS: We report our experience of 15 patients with inoperable antro-pyloric and/or duodenal strictures treated by implantation of 21 self-expandable metal stents (18 uncovered and 3 covered) inserted perorally under fluoroscopic guidance. The patients were 11 men and 4 women, mean age 65.3 years. Fourteen of 15 patients were affected by a malignant stricture of the antro-pyloric region and/or duodenum either primary or secondary in 10 and 4 cases, respectively. Only in 1 case there was a benign stricture from postoperative scarring. Stricture length and diameter varied from 3 to 9 cm (mean 5.4 cm) and from 0 to 4 mm (mean 1.27 mm), respectively. RESULTS: Twenty-one stents were placed in 15 patients: Technical success was achieved in all cases while clinical improvement was obtained in 14 cases. No short-term complications were observed. A mean 4.3-month follow-up was obtained. Two patients had emesis secondary to peritoneal dissemination of the tumor after 1 and 2 months, respectively. Two other patients showed tumor overgrowth of the oral edge of the prosthesis after 3 and 2 months, respectively, and required another coaxial stent to bridge the new stenosis. The patient treated for a benign stricture had jaundice after 3 months and percutaneous internal-external biliary drainage was necessary. CONCLUSION: Self-expandable metal stents are a safe and effective treatment of antro-pyloric and duodenal strictures; therefore, they should be considered an alternative to palliative resection in cases of advanced stage disease or poor general physical condition.

The use of the Valtrac ring in the upper and lower gastrointestinal tract, for single, double, and triple anastomoses: a report of 50 cases.

The Valtrac biofragmentable anastomotic ring (V-BAR) technique has been widely used in clinical practice, particularly in anastomoses of the colon. The success of this method encouraged some surgeons to use it also in anastomosis of the small intestine. We are convinced that the method can be used successfully also in anastomosis of the small intestine and the upper gastrointestinal tract, particularly in cases of technically difficult and high-risk anastomoses. Between 1995 and 1998, we used the V-BAR in 35 patients, performing a total of 50 anastomoses. In 13 patients a double anastomosis was created in the same operation, and in one patient a triple anastomosis was created. In all we performed one end-to-end esophagojejunostomy, one gastrojejunostomy, six gastroileostomies, two duodenojejunal anastomoses, 13 end-to-end duodenoileostomies, one jejuno-jejunal anastomosis, 18 end-to-side ileoileal anastomoses, one ileocolic anastomosis, and seven colocolic anastomoses. Follow-up at between 2 and 36 months showed good overall results with regard to resumption of intestinal transit and canalization, even in those cases in which a double and triple suture was performed using the Valtrac ring. In our experience, the V-BAR can be used in upper gastrointestinal surgery with excellent results. Compared with manual sutures, the ring allows better and faster resumption of transit and canalization.

Effectiveness of "core biopsy" by the mammotome device for diagnosis of inflammatory carcinoma.

OBJECTIVE: To assess the usefulness of "Mammotome" device for the diagnosis of the inflammatory breast carcinoma. MATERIAL AND METHODS: We studied 6 patients, aged 43-79 years, with clinical evidence of inflammatory breast carcinoma. We compared two sampling techniques, a cytologic one by Fine Needle Aspiration (FNA) and a microhistologic one by "Mammotome". RESULTS: Cytologic sampling by FNA permitted certain diagnosis of malignant lesions in 2 out of 6 cases, while the "Mammotome" device confirmed the correct diagnosis in all 6 considered cases. CONCLUSIONS: The "Mammotome" device proved more useful in the diagnosis of inflammatory breast carcinoma than FNA and it can be a valide alternative to surgical biopsy.

[Diagnostic imaging of gastrointestinal leiomyosarcoma. Experience with 12 cases]. / Diagnostica per immagini del leiomiosarcoma con localizzazione gastrointestinale. Esperienza in 12 casi.

PURPOSE: Gastrointestinal (GI) leiomyosarcoma is an uncommon malignant cancer arising in the smooth muscle of the alimentary tract. It is known for its widely variable patterns and aspecific symptoms and signs preventing correct clinical assessment in the majority of cases. We will illustrate the key role of diagnostic imaging in the detection and staging of this lesion, describing the most suggestive imaging findings for the correct diagnosis. MATERIAL AND METHODS: January, 1990, to June, 1998, we examined 12 patients with GI leiomyosarcoma; they were 10 men and 2 women whose age ranged 42 to 85 years (mean: 63.7 years). Four lesions were found in the stomach, 3 in the jejunum and ileum, and 2 in the rectum. Due to the difficult clinical assessment of this type of lesion and to the development of emergency conditions, we could plan no diagnostic protocol in advance; thus, the most suitable diagnostic imaging approach was decided on the spot for studying the supposedly involved GI portions. Double contrast studies, US, CT and endoscopy were performed and each patient underwent at least two examinations. RESULTS: Barium contrast studies were performed in 9 patients: the lesion was detected in 7 cases and tumor site and extent were defined in 5, while the double contrast study of the colon allowed to exclude large bowel involvement in 2 ileal tumors. In all 9 cases US and US-guided endoscopy permitted better assessment of extra-luminal spread and involvement of adjacent organs. CT, which is essential to staging, provided useful information suggesting the lesion nature: a round, inhomogeneous mass in continuity with the intestinal wall, with irregular margins, peripheral enhancement after i.v. injection of contrast material and a central necrotic area. Histology confirmed CT diagnosis in 7/9 cases while an aspecific diagnosis of large retroperitoneal and abdominal lesion was made in 2 cases. CT did not allow to define the origin of 2 large exophytic lesions in the stomach and jejunum and missed peritoneal metastases in 3 cases. CONCLUSIONS: Although the aspecific and quite variable clinical patterns make it extremely difficult to plan a correct diagnostic protocol, in our experience all diagnostic imaging techniques played a fundamental role in identifying and staging alimentary tract leiomyosarcoma. Particularly, CT showed high sensitivity and specificity in characterizing and staging this lesion but exhibited rather poor sensitivity in recognizing peritoneal spread.

[Dilatation of benign colo-colonic and colo-rectal anastomotic stenosis with radiology-guided balloon catheter]. / Dilatazione delle stenosi anastomotiche benigne colon-coliche e colon-rettali mediante catetere a palloncino sotto guida radiologica.

Eleven patients with benign postoperative colonic strictures were treated with balloon dilatation November, 1990, through November, 1995. The anastomosis was sigmoidrectal in 7 patients and colocolic in 4 patients. All patients were submitted to contrast enema and colonscopy to assess the site, shape, grade and length of the stenosis. Biopsy was performed in 7 patients whose strictures had developed 2 months or more postoperatively. The dilatation was performed with 20-mm balloon catheters in the strictures developed 30 days postoperatively, to avoid any complications, and with 30-mm balloon catheters in the other cases. Balloon dilatation was performed under fluoroscopic guidance, with no-drug treatment. The procedure was well tolerated by all patients. One or two dilatation sessions were performed in ten and one patients, respectively. No complications were observed. The results were satisfactory in all cases, with symptom resolution. Follow-up included clinical, endoscopic and radiologic assessment. At follow-up, the technical result was good in all patients and the symptoms were completely relieved. In our experience, radiologically-guided balloon catheter dilatation proved to be an easy, safe and effective tool to treat benign postoperative colonic strictures.

[Lobular carcinoma in situ: the mammographic aspects and the therapeutic problems]. / II carcinoma lobulare in situ: aspetti mammografici e problematiche terapeutiche.

Lobular carcinoma in situ is an uncommon noninvasive breast neoplasm; it accounts for about 0.8-3.8% of breast cancers and presents 3 peculiar characteristics: multicentricity (60-90%), bilaterality (35-59%), and the risk of invasive cancer (17-37%). The latter feature led some authors to consider this lesion as a marker of the development of an invasive cancer rather than a real malignant neoplasm. The main problem after histologic diagnosis is the choice of treatment: follow-up or surgery? Some authors reported, in the patients with lobular carcinoma in situ, the same incidence of ipsilateral invasive carcinoma as that in the normal population, which suggests a "wait and see" policy. This study, carried out on 27 patients (mean age: 49 years) with histologic diagnosis of lobular carcinoma in situ yielded the following aspecific mammographic findings: clustered microcalcifications; stellate masses and irregular nodular lesions with or without calcifications; architectural distortion with calcifications. In 10 surgical patients, 2 ductal carcinomas were demonstrated near the lobular carcinoma in situ. In the 17 patients submitted to follow-up, lobular carcinoma in situ recurrences were found in 4 patients at biopsy; a comedocarcinoma associated with a metastatic axillary node was found in one patient. Thus, we conclude that, in the patients with lobular carcinoma in situ, a "wait and see" policy of close observation should be adopted.

[Localization of non-palpable lesions of the breast using a metallic guide. Potential complications]. / Localizzazione con guida metallica delle lesioni non palpabili della mammella. Possibili complicanze.

The authors reviewed the complications occurred in 393 patients who underwent needle localization breast biopsy from September, 1987, through September 1994. The lesions were located using 20-22 G needles with a teminal hook wire. The maneuver was carried out under US guidance in 7 patients, using stereotaxic equipment in 88 patients and without stereotaxic equipment in 298 patients. Clinical and guide-wire related complications were reported. The former complications were: severe vagal crises (in 3 patients), mild vagal crisis (10 patients) and bleeding (1 patient). Guidewire complications were: wire breakage (in 8 patients) and wire dislodgment (3 patients). Vagal crisis occurred above all in anxious patients. Guide-wire breakage or dislodgement may prevent lesion removal and, subsequently, lead to a diagnostic error. Our experiences suggests that information and continuous radiologist attendance positively influence patient's psychology reducing clinical complications. Moreover, operator's experience and care in choosing the appropriate devices greatly reduce the incidence of maneuver-related complications.

[Temporary caval filters. Indications, problems and results]. / Filtri cavali temporanei. Indicazioni, problemi e risultati.

The authors report their experience with the temporary placement of inferior vena caval filters to prevent pulmonary embolism in acute deep venous thrombosis patients. Twenty devices--6 Filcard and 4 Bruneau type--were positioned and left in situ over a time period ranging 4 to 14 days (mean: 9.8). In one patient the filter was positioned and no adjunctive medical therapy given to provide protection before nephrectomy; five patients were treated with i.v. heparin that provided no vein patency but prevented disease progression. Due to failure in positioning infusion guide catheters within the thrombus, four patients were submitted to fibrinolysis and heparin therapy: when the thrombus stabilized on angiographic images, heparin alone was administered and then followed by orally administered coumarin anticoagulants. In two cases partial thrombosis resolution was achieved, but with no significant improvement in patency rate. Ten patients underwent in situ fibrinolysis: six of them exhibited moderate improvement in femoroiliac axis patency and in three patients the inferior vena cava was successfully recanalized. No patient had any clinical evidence of pulmonary embolism. One case had cranial thrombus spread which was successfully treated with fibrinolysis. In our opinion, to control possible thrombotic involvement of the device, the patients candidate for temporary inferior vena caval filters must be easy to "manage" and exhibit no contraindications fibrinolysis and anticoagulant treatment.

Percutaneous treatment of hepatic cysts by aspiration and sclerotherapy.

We treated 35 patients who had hepatic cysts (30 congenital cysts, 5 hydatid cysts) with percutaneous puncture and sclerotherapy. After puncture and drainage of the cyst, a 95% alcohol solution was instilled as sclerosing agent into the cystic cavity. In all the patients, cyst puncture and drainage was successful. Follow-up in all cases was at least 12 months. In three uncooperative patients, cysts recurred due to incomplete sclerosis of the lining epithelium of the cyst wall. No major complications were encountered in all cases. All congenital cysts were treated on an outpatient basis. Patients with hydatid cyst were hospitalized for 48 h after puncture and aspiration. In our opinion, percutaneous drainage and sclerosis of congenital hepatic cysts can be considered an effective alternative to surgical treatment.

[Percutaneous transluminal renal angioplasty of the solitary kidney]. / L'angioplastica percutanea transluminale renale nel monorene.

We report on our experience with percutaneous transluminal angioplasty (PTA) of the renal artery in solitary kidney patients. PTA was performed on 31 subjects (mean age: 52 years): 7 had a solitary kidney because of nephrectomy and 24 had a solitary functioning kidney. Patients were selected with clinical and laboratory examinations first and then with angiography. PTA was employed to treat renal artery stenoses 60%-95% of the whole arterial lumen. The procedure has been considered technically successful in 29 cases, with 77%-33% reduction of the mean amount of stenosis. As to the clinical evaluation of the results, blood pressure and creatinine values variations were considered. Of the 25 patients on follow-up, 13 appeared to be treated (52%), 8 improved (32%) and 4 unchanged (18%). On the whole, we observed 5 complications (2 hematomas at the approach site, 1 intimal dissection and 2 segmental infarcts), with a 23.4% rate comparable with PTA complications in non-solitary kidney patients. The good revascularization, the reduction in blood pressure values, the very small percentage of complications point to PTA of the renal artery as the procedure of choice in solitary kidney patients.