[Penetrating injuries of the neck: review of 16 operated cases]. / Lesioni penetranti del collo: revisione di 16 casi operati.

BACKGROUND: Cervical lesions from penetrating trauma in the neck are increasing together with other types of trauma especially in big towns. Nevertheless in Italy a Register of Trauma is still lacking and no guidelines are available. Conservative management is also advocated and is still under discussion. Comparison of diagnostic tools and evaluation of different treatments in case of vascular damage is also expected. PATIENTS AND METHODS: A series of 16 penetrating lesions of the neck including various degrees of severity were treated over a span of 5 year. The penetrating trauma was due to stab wound or similar causes in 11 cases; to gunshot wound in 3 and to traffic accidents in 2 cases. All of them received surgical treatment. In 56% of cases (9/16) of cases vascular structures were involved, in 4 cases the aerodigestive tract was involved (25%), and in 1 the spinal cord was injured (6%) resulting in a Brown-Sequard syndrome. Other patients presented with superficial lesions, and reconstruction of muscles by simple suture or ligature of veins could obtain complete healing. RESULTS: The penetrating trauma brought about death in 2 cases (1 stab wound, 1 gunshot wound), while 1 lesion of carotid artery and 4 lesions of jugular vein were successfully repaired. In 1 case of lesion in zone 3 a serious bleeding from damage to lingual artery was cured in spite of the minimal width of the external injury. Hypopharyngeal lesions could be treated in 2 cases. One was associated with lethal vascular damage. In 1 case of tracheal lesion with cervical hematoma and dyspnea, patency of the airways became the main concern and and a cannula was placed in the trachea. The Brown-Séquard syndrome could improve with rehabilitation therapy in 3 years. All of the minimal cervical lesions healed with uneventful course. CONCLUSIONS: The penetrating trauma in the neck may show various degrees of severity: nevertheless, no cervical penetrating trauma should be underestimated in spite of the minimal width of the lesion. Surgical exploration was invariably the preferred treatment in our experience.

Metabolic effects of intraportal nutrition in humans.

OBJECTIVE: We investigated the metabolic effects of intravenous nutrition through a portal (PN) or systemic (SN) peripheral vein. METHODS: Twenty patients were randomized to receive PN or SN nutrition after colorectal surgery. The daily regimen included 900 kcal and 100 g of amino acid (AA). Visceral proteins and hepatic enzymes were measured on days 0, 1, 3, 5, and 7, and plasma arterovenous differences and limb flux of AA were measured on days 0, 3, and 7; urinary nitrogen and 3-CH3-histidine were analyzed daily. RESULTS: Serum albumin on day 7 was still depressed (P = 0.01) in SN and fully restored in PN patients. Prealbumin levels increased significantly (P = 0.05) in the PN group only. Plasma levels of glutamine and asparagine were higher in PN than in SN patients, and this difference was statistically significant (P = 0.05). SN patients had significantly more negative limb-muscle balance of valine and tyrosine, whereas PN patients had a higher muscle release of citrulline and taurine. CONCLUSIONS: In conclusion, short-term PN is safe and has some metabolic benefits: it accelerates recovery from postoperative hypoalbuminemia and hypopnealbuminemia and is associated with a higher plasma level of glutamine and an AA plasma pattern that is closer to normal. PN blunts the catabolic response of the muscle, decreasing loss of proteins and release of some AA involved in hepatic gluconeogenesis.

[Acute biliary pancreatitis. Therapeutic trends]. / La pancreatite biliare acuta. Nostro orientamento terapeutico.

BACKGROUND: Treatment of biliary pancreatitis includes suppression of the biliary cause by cholecystectomy and common bile duct clearance. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy for eradication of biliary stones and laparoscopic cholecystectomy (L.C.) for residual gallbladder stones would be ideal but were once considered to be contraindicated by most surgeons. The timing of definitive biliary tract surgery and the role of ERCP have been the focus of discussion in recent years. METHODS: During a two-year study period 51 patients with acute biliary pancreatitis were studied. Seven patients (14%) underwent emergency laparotomy, necrosectomy, cholecystectomy, exploration of the common bile duct and T-tube insertion, because unstable clinical conditions, with evidence of pancreatic and peripancreatic necrosis on CT-scan. Elective open cholecystectomy and CBD exploration were performed in 7 patients after the resolution of acute pancreatitis during the same hospital admission. RESULTS: Early ERCP and L.C. were associated with favourable outcomes. 33 patients underwent ERCP preoperatively: 17 within 72 hours of admission and 16 after signs of clinical improvement. Laparoscopic cholecystectomy performed 3-25 days after admission was successful in 27 of 29 patients. Postsphincterectomy bleeding occurred in one patient and was treated successfully by endoscopic epinephrine injection. For median hospital stay and recurrence there were statistical differences between early and delayed ERCP. CONCLUSIONS: ERCP and sphincterectomy have a certain role in conjunction with laparoscopic cholecystectomy in the management of patients with acute biliary pancreatitis, particularly in institutions where there is easy access to expert interventional endoscopic techniques. This policy should reduce the risk of cholangitis and recurrent pancreatitis.

[Contusion of the liver. Importance of associated lesions in polytraumatized patients]. / Les contusions du foie. Importance des lésions associées chez les polytraumatisés.

Between January 1984 and June 1993, we treated 120 contusions of the liver in a situation of polytrauma. There were 24 patients in Stage I, 47 in Stage II, 22 in Stage III, 13 in Stage IV and 14 in Stage V according to the Organ Injury Scaling Committee of the American Association for the Surgery of Trauma. A total of 107 patients were operated. Polytrauma related mortality was high. Besides the gravity of the liver lesion, prognosis was a function of other associated intra or extra abdominal lesions. In our series, other associated lesions were the cause fo death in 26 patients (64%) and 15 deaths (36%) were directly related to the hepatic lesion. The gravity of the Stage V lesions was related both to the state of shock of operation and the difficulties in reestablishing haemostasis. Packing decreased the effect of hypovolaemia and coagulopathy. The prognosis of supra hepatic venous lesions and hepatic resections remain disastrous. Our surgical schema has changed towards more conservative surgery and, when haemodynamic stability has been achieved, to abstention and careful monitoring. Different extra-hepatic trauma causing damage to other organs directly compromises simple hepatic lesions. The result of our series confirms the correlation between mortality and the gravity of the polytrauma as evaluated according to the Injury Severity Score proposed by Baker.

Anticatabolic properties of branched chain amino-acids in post-operative patients. A prospective study.

The effect of infusion of branched chain amino-acids (BCAA) on post-operative protein metabolism was analysed in 19 elective surgical patients treated for the first 5 post-operative days with a nutritional regimen of 30 kcal kg(-1) day(-1) and 2 g of amino-acids kg(-1) day(-1). The patients were divided into three groups whose only difference was the amount of BCAA delivered. Our results showed that an increased BCAA input improved nitrogen balance and reduced protein catabolism as estimated by the excretion of 3-methyl-histidine. Since nitrogen retention was maximal during the first 3 post-operative days and the reduction in 3-methylhistidine excretion was observed only on post-operative days 4 and 5, a dual action of BCAA on improving protein synthesis and reducing catabolism is postulated, even though the reduction in catabolism seems to be the main action. This dual action may reflect the unique role of BCAA, which is both 'nutritional' (as they constitute 40% of total amino-acid daily requirements of the healthy subject) and 'pharmacological (as they reduce protein catabolism and improve synthesis in muscle and liver with a dose-dependent effect). Of the three BCAA, isoleucine and leucine seemed to have an 'anticatabolic' effect, whereas an analysis of literature data showed that valine probably has none.

Reappraisal of surgical treatment of small hepatocellular carcinomas in cirrhosis: clinicopathological study of resection or transplantation.

Thirty-two patients with hepatocellular carcinoma (HCC) occurring in individuals with cirrhosis had a potentially curative surgical procedure. Twenty-two had segmental hepatic resections (HR), and 10 underwent orthotopic liver transplantation (OLTx). The diagnosis of hepatic malignancy was established in each case preoperatively, and each case was studied intraoperatively by means of sonography. Postoperatively each surgical specimen was examined pathologically with attention to the possibility of intrahepatic tumor spread. Twenty-three of the 32 patients had single small HCC lesion (less than 5 cm diameter) identified preoperatively. Sixteen of these underwent HR and seven underwent OLTx. Multiple additional neoplastic lesions were found in 19% of the 16 HR cases and in 14% of those undergoing OLTx when the resection specimens were examined pathologically. Vascular invasion was present in 43% of the OLTx patients and in 25% of the HR patients. Subtotal hepatic resection for small HCC occurring in cirrhosis has produced few long-term survivals. Both pre- and intraoperative sonography have been shown to underestimate the extent and distribution of these tumors. Based upon this experience that (1) vascular spread occurs often in HCC and (2) a high risk of postoperative hepatic failure can be expected after HR in cirrhotic individuals, OLTx is the most rational surgical procedure for such cases as it has the potential to cure.

Pylorus preserving pancreatoduodenectomy versus Whipple procedure for adenocarcinoma of the head of the pancreas.

Thirty eight patients underwent pancreatoduodenectomy for histologically confirmed adenocarcinoma of the head of the pancreas. Twenty one underwent a pylorus preserving pancreatoduodenectomy and seventeen the classical Whipple procedure. We undertook this retrospective analysis to compare longterm survival following the two different surgical procedures. Patients in the two groups were comparable for preoperative laboratory data, age and pathological staging. Minor and major morbidity was not different between the two group (33.3% and 35.2% respectively). In the pylorus preservation group a delayed resumption of full oral diet and a consequent prolonged hospital stay has been noted (21.3 days vs 15.4 days, p less than 0.05). Mean survival was 21 months in the pylorus preservation group and 17 in the Whipple group. No statistical difference was observed between the two survival curves. According to these data the pylorus preserving pancreatoduodenectomy represents a reasonable option for adenocarcinoma of the head of the pancreas.

Management of lymphatic fistulas by total parenteral nutrition.

Lymphatic fistula is a rare surgical complication, which mainly occurs after cervical or retroperitoneal lymph node dissection and which frequently requires a surgical repair. A small series of nine postoperative lymphatic fistulas treated conservatively with total parenteral nutrition (TPN) is reported. All the patients were malnourished at the beginning of the TPN, and all exhibited an objective improvement of their nutritional status after completion of the treatment. Due to the interruption of the enteral alimentation or to the nutritional repletion, spontaneous closure of the fistula was achieved in eight of nine patients treated with TPN longer than 1 week. The authors conclude that whenever the immediate surgical repair is not recommended, or it is not successful, a 2- to 3-week course of TPN may be used with the chance of spontaneous healing. In any case, patients conservatively treated by TPN can undergo a delayed operation with minimal risk because of the improved nutritional status.

A case of pancreatoduodenectomy as resolutive treatment for a solitary metastasis of breast cancer.

A 49-year-old woman was hospitalized for obstructive jaundice 4 years after extended mastectomy for lobular infiltrating carcinoma. After routine investigations that detected a malignant lesion of the pancreas head, the patient underwent pancreatoduodenectomy. The surgical specimen revealed unexpected breast carcinoma metastatic to the pancreas and duodenum wall. The woman is alive and free of disease at 10 years from the mastectomy and 6 years from the pancreatoduodenectomy. This experience confirms the validity of a surgical radical treatment for metastatic lesions in selected cases.

Impact of cancer, type, site, stage and treatment on the nutritional status of patients.

This study analyzed the nutritional status of cancer patients in relation to type and site of origin of the tumor, stage of disease, and previous chemical or radiation therapy. The analysis was performed on 321 patients (280 with cancer and 41 controls). The nutritional parameters included per cent of weight loss, anthropometric indices (arm circumference, triceps skinfold, arm muscle circumference), creatinine-height index, serum protein, albumin, total iron binding capacity and cholinesterase, C3 and C4 components of complement, total peripheral lymphocytes, and skin tests. The statistical comparison between patients with different tumors and controls, between patients with different stages of the same tumor, and between patients treated with or without previous chemical or radiation therapy led to the following conclusions: 1) malnutrition is mainly related to the type and site of origin of the tumor and, in the early stages of disease, is more pronounced in patients with cancer of the esophagus and stomach; 2) except in patients with breast and cervix cancer, malnutrition gets more severe as the disease becomes advanced; 3) chemical or radiation therapy has a variable impact on the nutritional status, but in selected patients it causes a drop in body weight, arm circumference, arm muscle circumference, and peripheral lymphocytes; 4) body weight, cutaneous delayed hypersensitivity and serum albumin are the most commonly altered parameters.

Results of extended surgery for cancer of the rectum and sigmoid.

The clinical records of 61 patients who underwent extended surgery, including resection of parietes or other viscera, from 1965 to 1977 for cancer of the rectum and sigmoid were reviewed. Abdominoperineal resection was performed in 41 patients, anterior resection in 18 and Hartmann's resection in 2. The postoperative mortality rate was 8.2 per cent, the non-lethal morbidity rate 30.3 per cent, but 4 patients presented multiple complications. The 5-year survival rate was evaluated separately for patients with and without microscopic evidence of neoplastic involvement of the simultaneously excised structures; in the first group it was 32 per cent, in the second 75 per cent. Local or distant recurrence occurred in 66 per cent of patients with microscopic infiltration and in 24 per cent of patients without microscopic infiltration. These results compare favourably with those reported after ordinary resections of Dukes' C cancers of the rectum and sigmoid, and seem to justify the use of extended surgery when cancer of the rectum and sigmoid has invaded contiguous structures.

Pathogenesis and predictability of central venous catheter sepsis.

The purposes of this study were to analyze the causes and routes of infection of indwelling central venous catheters and to improve the diagnosis of catheter sepsis before the removal of the cannula. One hundred forty catheter tips were prospectively studies; also, cultures of 52 proximal segments of catheters, 44 swabs of the subcutaneous segment, 195 skin entry sites, 181 infusional fluids, 208 blood samples, and 106 infected distant sites were examined. The catheter sepsis rate was 7.6%, but this sepsis was primary in only 3.4%, because in 4.2% prior isolation of organisms from the wound, urine, throat, or sputum was possible, indicating that the catheter was not primarily responsible for the infection. Primary infection always disappears with removal of the cannula (with or without antibiotics), whereas the course of the secondary infection is related to the gravity of the infected foci and the involved microorganisms. Contamination of the infusional fluid, the skin entry site, and some distant foci carry a real risk of seeding the catheter (from 5.8% to 19.5%). The cultures of the skin entry sites, infusional fluids, distant foci, and the subcutaneous segment of the catheter did not prove useful in predicting the infection. Only the blood cultures were a reliable diagnostic tool: a positive blood culture meant colonization of the catheter tip in 44% of cases and sepsis in 36%. Although the potential colonization varied greatly for different microorganisms, the growth of microorganisms in the blood was a strong indication for removing the cannula.

Clinical considerations on 8 cases of abdominal carcinoids.

Eight cases of abdominal carcinoids are reported, 5 males and 3 females, whose age ranged from 21 to 66 years. The site of the carcinoids was appendix in 3 cases, ileum in 3, cecum in 1 and the ovary in 1. Synchronous metastases were present at regional lymph nodes and liver in 5 of the 8 cases. Radical surgery was performed in 3 patients, whereas in 3 cases nonradical surgery, due to the presence of nodal or hepatic metastases, was followed by chemotherapy (2 cases) and radiotherapy (1 case). The patients radically operated on are alive and free of disease at 22, 27 and 27 months. Surgery should be resorted to, when possible, even in the presence of liver metastases, since the life expectancy for these patients is longer than that of patients with liver secondaries from tumors other than carcinoids. Chemotherapy and radiotherapy seem to play a complementary role, if any.

Effect of supportive intravenous hyperalimentation on the nutritional status of cancer patients.

The effect of intravenous hyperalimentation on the nutritional status of 84 cancer patients treated at the Istituto Nazionale Tumori, Milan, has been evaluated. The body weight increased in 78% of patients, mid upper arm circumferance in 93%, triceps skinfold in 73%, mid upper arm-muscle circumference in 73%, creatinine/height index in 30%, serum albumin in 32%, transferrin in 35%, total peripheral lymphocytes in 38%. Lymphocyte blastogenesis increased in 74% of the patients examined and skin tests were converted from negative to positive in about 20% of patients. In addition 8 our of 18 patients responsive to IVH benefited from chemotherapy and/or radiotherapy indicating that the nutritional repletion of the host did not significantly affect the growth of the tumor. These findings support the opinion that neoplastic cachexia may depend partially on malnutrition and can be often reversed by IVH. Moreover, IVH might have an adjunctive role as potentiator of chemotherapy which however must be confirmed by clinical trials.