[Acute pancreatitis: resultos of a diagnostic-therapeutic protocol in 80 consecutive cases]. / Pancreatiti acute: risultati di un protocollo diagnostico-terapeutico in 80 casi consecutivi.

The treatment of acute pancreatitis cannot be standardized in the absence of a prompt diagnosis and of an accurate severity and prognostic score. This study, based on 80 consecutively observed patients, compared the aetiological, clinical, diagnostic (laboratory and imaging) and prognostic data used to select the most appropriate therapy for each patient. The results confirm that the Ranson score shows a satisfactory prognostic relationship between the number of positive parameters and the severity of the disease. Ultrasound, which is useful for defining the aetiologic factors and in the follow-up of peripancreatic effusions, has proved to be limited as a means of imaging abnormalities of the pancreatic parenchyma. CT scans are confirmed as being the only method of accurately demonstrating the presence of necrosis and of evaluating its effective extent. ERCP was performed as soon as possible in the presence of biliary stasis or of suspect ultrasonographic signs. Surgical treatment proved necessary only in 7.5% of cases, on each occasion to drain infected necrotic foci. Promptness of the surgical indication plays an important role in the outcome of necrosectomy and drainage performed with the closed technique. Mortality was limited to 1.25% in our series. A correct diagnostic approach together with prompt treatment can reduce the mortality rate of this disease to a minimum.

[Tetanus. Physiopathology and intensive care treatment]. / Tetano. Fisiopatologia e trattamento in terapia intensiva.

BACKGROUND: Tetanus as a topic illness is underlined on the basis of the increased cases as well as the appearance of new populations at risk of infection. The tetanospasmins of mechanism action is stressed in order to evaluate the etiopathogenetic role of common therapies as well as the new ones. Ten cases of serious infection personally observed are analysed. METHODS: The case records of ten tetanus patients treated in our Intensive Care Unit between 1986 and 1997 have been retrospectively analysed. The prognosis correlated to the seriousness of the case. The most common clinical symptoms on admission were trismus and dysphagia (100% of patients). In 70% of cases, the illness was considered serious enough to warrant the use of neuro-muscular blockers and controlled ventilation. Among the complications observed pulmonary problems had the highest incidence (90%), followed by cardio-vascular ones (80%). Respiratory infections were the most frequently observed (9 patients). Autonomic dysfunction was a constant feature in patients with severe forms of the illness. RESULTS: The observed mortality rate was 30%. It was higher in males at the extremes of the age range. CONCLUSIONS: In the light of the survival results as well as the most recent literature data, guidelines for the approach of serious tetanic patients are outline. It is underlined that therapy effectiveness is higher when from being a symptom therapy it becomes an etiopathogenetic therapy.

[Unilateral pulmonary embolectomy without extracorporeal circulation. A report of a clinical case]. / Embolectomia polmonare unilaterale senza circolazione extracorporea. Considerazioni su un caso clinico.

The surgical treatment of pulmonary embolectomy is currently indicated for acute massive obstruction of the pulmonary artery with severe haemodynamic failure and, as in this case, when medical treatment with anticoagulants or thrombolytic drugs is contraindicated. In this work, the Authors focus on the technique of unilateral pulmonary embolectomy through a median sternotomy; this approach allowed an easier and safer embolectomy without extracorporeal circulation.

Trauma care in Italy: evidence of in-hospital preventable deaths.

The quality of a trauma system can be assessed by the rate of preventable deaths. A random selected sample of 110 trauma patients was examined using both clinical and autopsy data. The assessors were asked the following question: If this patient had sustained the accident in front of the hospital in a normal working day, might death have been prevented? Death was found to be unavoidable in 61 cases, in 25 cases death was classified potentially preventable; 11 cases were classified as clearly preventable death. The main failures of treatment were identified as errors and delays during the first phases of in-hospital assessment and care. An improvement in the pre-hospital phase will be almost useless if the quality of the definitive in-hospital management is not addressed.

[Emergency resections of the left colon with immediate reconstruction protected by resorbable staples. A new possibility tested on animals]. / Resezioni in urgenza del colon sinistro con ricostruzione immediata protetta da agraphes riassorbibili. Una nuova possibilità sperimentata sull'animale.

Anastomosis recovery still represents a problem in colon surgery, particularly when the resection is performed in emergency or on a suffering and not adequately prepared bowel. The authors describe a new technique successfully tested in the animal. The operation consists in a bowel resection followed by immediate reconstruction with a protective colostomy and an exclusion anastomosis obtained by a proximal suture in resorbable clips. Results in animals have been satisfactory, with a spontaneous and gradual resumption of physiological canalization, according to authors expectations. Technical details and several histological features are herein described.

[Aneurysms of the popliteal vein. Description of 2 cases]. / Anévrysmes de la veine poplitée. Description de deux cas.

Primitive vein popliteal aneurysms are an extremely rare pathology whose treatment is still matter of controversy. Its rare incidence, the diagnostic and clinical problems ensuing to the possible pulmonary embolism, explain the interest developed by these lesions. The authors report two cases of popliteal vein aneurysm observed in their Institute and diagnosed because seat of vein thrombosis and source of pulmonary embolism.

Successful treatment of an impressive primary lymphedema of the extremities.

We report the case of an impressive primary lymphedema of the four extremities which did not response to previous conservative and partial surgical treatments and imposed the amputation of both the lower extremities and of the left arm. We have successfully treated the involved right arm by means of radical excisional procedure and skin graft. After five years no recurrence of the disease was observed and morphologic and functional recovery is complete.

Dissection of the thoracic aorta following partial clamping.

A case is reported in which an extensive dissection of the thoracic aorta was observed after partial clamping during surgery on that blood vessel. The unfavourable outcome of the operation and the accurate investigation of the post-mortem material suggest a lesion of the artery wall secondary to tangential clamping by Satinsky's clamp. The possible pathogenetic mechanisms of lesions induced by vascular clamping are also discussed.

Multiple splanchnic artery aneurysms. Report of a case.

It is reported the case of a patient with multiple visceral aneurysms (seven). These aneurysms are more common than usually appreciated but their multiplicity is rarely reported in the literature. Angiography should always follow surgery when a splanchnic aneurysm is recognized by chance only at operation and when the surgeon is already aware of the multiple aneurysms. It is indicated a contemporary treatment of all of them to avoid the subsequent risk of rupture which has been suggested to increase after laparotomy.

The vasodilator effect of human atrial natriuretic factor (99-126) on human omental arteries.

The effect of synthetic human atrial natriuretic factor [ANF-(99-126)] on human omental arteries was investigated. The compound produced concentration-dependent relaxation, 10, 50 and 90% of maximum effect being observed at about 1, 10 and 100 nmol/l, respectively. These concentrations are considerably higher than those measured by radio-immunoassay in human plasma, even under extreme conditions (0.001-0.3 nmol/l). Therefore, ANF can dilate human resistance-size arteries, but whether it does so under physiological conditions has not been established.

[Magnetic resonance of the thoracic aorta]. / Risonanza magnetica dell'aorta toracica.

Various pathological conditions of the thoracic aorta were studied by MR Imaging in 31 patients: 23 were aneurysms (branching and non-branching), 2 arterio-venous fistulae, 2 aortic prostheses, 2 Marfan's syndromes, 1 coronary sinus aneurysm, and 1 isthmic stenosis. MRI studies were always performed on patients who had been examined by other imaging procedures. A comparative study was carried out on the results of MRI, angiography, computerized tomography, and ultrasounds. The possibility of propedeutic protocol was explored. Our experience, in accordance with the literature on the subject, indicates MRI as the procedure of choice in the study of aneurysms of the thoracic aorta. The advantages offered by MRI--the high natural contrast between circulating blood and the supporting structures, the possibility of obtaining multiplanar images as well as data on intraluminal, parietal, and extraparietal conditions--make it a highly competitive procedure if compared to either CT or angiography. While awaiting further evidence, the use of a propedeutic protocol in non-aneurysmatic diseases is still not advisable, due to insufficient patient population, and to the lack of a consistent literature on the subject.

Nonrandom expression of polypeptide hormones in pancreatic endocrine tumors. An immunohistochemical study in a case of multiple islet cell neoplasia.

One hundred four endocrine tumors found in the body and tail of the pancreas of a patient with the Zollinger-Ellison syndrome (ZES) and multiple endocrine neoplasia (MEN-I) were investigated by immunohistochemistry for insulin, glucagon, somatostatin, pancreatic polypeptide (PP), and gastrin. The results for each tumor were scored into six grades according to the frequency of immunoreactive cells. Pancreatic polypeptide, glucagon, insulin, and somatostatin were demonstrated in 96, 80, 62, and 42 tumors, respectively. When only the higher scores of cell frequency (3-5) were considered, PP and glucagon (accounting for 71 and 49 tumors, respectively) differed markedly from insulin (two tumors) and somatostatin (0). The frequency of PP-immunoreactive cells was higher in tumors of large size whereas that of glucagon cells was higher in the smaller neoplasms. No significant associations of the tumoral hormonal expressions were found with the type of histologic structure (trabecular versus gyriform), the occurrence of stromal fibrosis, and the intrapancreatic location of the neoplasms, except for a higher number of somatostatin cells in fibrotic tumors. Gastrin-immunoreactive cells never were found in the tumors in spite of the concomitant hypergastrinemia. In conclusion, the nonrandom expression of the hormonal phenotype by the neoplastic islet cells, as shown by the immunohistochemical, semiquantitative analysis of a large number of tumors, suggests that in our MEN-I patient the genetically determined neoplasms also are affected by other mechanisms, possibly nongenetic.

Stenosis of the carotid artery and thrombosis of the internal contralateral carotid. Analysis of surgical results in thirty patients.

Carotid thrombosis and stenosis of the contralateral axis is a hemodynamic situation which results in reduced blood supply to the brain, and consequently in risk of transitory or permanent ischemic episodes. In fact, 40% of patients are symptomatic for TIA or Little Stroke and 50% of them will develop a complete stroke. Of the 255 patients who underwent TEA, over a period of 5 years, only 30 presented the above mentioned bilateral feature. A continuous electroencephalographic recording (EEG) was intraoperatively carried on for cerebral monitoring, as well as mean residual arterial pressure (MRAP), and according to variations in these parameters Javid's shunt was used in 50% of cases. No death was recorded either during surgery or hospitalization, while 2 transitory post-operative neurological deficits (6.6%) in correspondence to the stenotic vessel, and a late permanent deficit contralateral to the stenosis were reported. We believe TEA of the stenotic carotid artery to be a rational choice considering the great incidence of strokes on the stenotic side (Grillo, 1975) and the greater benefit for patients with symptoms resulting from the occluded carotid (Riles, 1980), who account for 46.6% of our case histories. We are convinced that surgery is an absolute indication in this particular category of patients, even at the cost greater intraoperative risks, provided it is carried out by an experienced surgical team well aware of problems involved in intraoperative cerebral monitoring.

Carotid occlusive disease: an electrophysiological macular investigation.

Thirteen patients with carotid stenosis were studied by the authors by the measuring the Visual Evoked Potentials (VEPs) before and after thromboendarterectomy. This test of retinal function measures the recovery time of the amplitude of the major positive peak (P100) after photostress. When compared to that we observed in controls, we found, a significant increase of the P100 recovery time in patients suffering from carotid disease with severe stenosis. The method proved suitable for the functional evaluation of the vascular reconstruction of the carotid area, since four weeks after surgery a physiological recovery of the amplitude of VEP was observed. This method is proposed by the authors for the long-term functional evaluation of patients subjected to carotid thromboendarterectomy for tight stenosis of the carotid bifurcation.

[Glomus tumor: apropos of a case]. / Il tumore glomico: a proposito di una osservazione.

A case of a carotid body tumor is presented, which was observed in a forty-four-years-old patient. This in an uncommon type of neoplasia whose incidence and clinical features are discussed. It is underlined the role of carotid angiography as the most reliable diagnostic tool. Moreover in these cases it is suggested a complete angiographic evaluation of both subclavian ad carotid vessels including endocranial circulation, for the important influence on the surgical approach. Surgical technique is mainly conditioned by the close relationship with fine anatomic structures like vessels and nerves of the neck. As a consequence it is emphasized the need of a technical achievement in modern carotid surgery as a necessary requisite for a complete removal and a low complication incidence.