NPWTid in the treatment of infected diabetic foot.

Negative Pressure Wound Therapy with instillation therapy and dwelling time (NPWTid) represents a good tool to treat severely infected non-healing wounds. This topical treatment consists of negative pressure and retrograde instillation of antiseptic/antibiotic Romasolutions into the wound surface, to promote cleansing and consequently the healing process. We reported our initial experience (five cases) in the treatment of severely infected diabetic foot, that can be considered a life-threatening condition. In our case reports, patients presented with clinical signs and symptoms of severe sepsis. Our treatment based on multidisciplinary approach (surgical, NPWTid, interventional radiology, skin grafts) had satisfying results. NPWT represented an important support to treatment of these diabetic patients.

Meckel diverticulum: one pathology, different clinical presentations. A report of two cases.

Meckel diverticulum is the most prevalent congenital malformation of gastrointestinal tract and usually it remains asymptomaRomatic. Approximately in 25% of cases Meckel diverticulum comes to be symptomatic with various clinical presentations where lower gastrointestinal hemorrhage or intestinal obstruction represent the most frequent clinical outcome. In present paper two cases of complicated Meckel diverticulum in young patients are described; in both cases diagnosis was difficult and initially mistaken with other pathologies. Surgical resection was the treatment of choice.

Small bowel intussusception due to malignant melanoma: primary lesion or metastases? A case report.

Intussusception is a rare condition in the adult population: it is responsible for 1% of all bowel obstructions. In most of intussusceptions a malignant tumor is involved; a lot of studies show that approximately 50% of malignant metastases causing small bowel intussusception are metastatic melanomas. In present paper a case of a small bowel intussusception probably due to metastases of an occult melanoma, in a 69-year-old patient, is presented. Surgery resection, careful research of possible primitive neoplasms and an accurate follow-up program has been the treatment of choice. All the investigations carried out did not allow to identify a possible primitive neoplasm. The last whole body PET carried out 44 months after surgery resulted disease-free.

Multidetector helical angio CT oblique reconstructions orthogonal to internal carotid artery for preoperative evaluation of stenosis. A prospective study of comparison with color Doppler US, digital subtraction angiography and intraoperative data.

AIM: The recent introduction to clinical practice of multidetector helical angio CT (MHACT) has generated a new interest in the diagnosis of carotid artery atherosclerosis. In recent years there has been a redefinition of the indications to carotid artery endarterectomy; there is a tendency to appraise plaque morphology and composition, and not only stenosis degree. The aim of this prospective study is to analyze the validity of MHACT in the diagnosis of atheromasic stenosis of the carotid bifurcation, in comparison with US color Doppler (USCD), digital subtraction angiography (DSA) and intraoperative evidence (OP). Special emphasis is given to the analysis of plaque composition and to precise evaluation of the stenosis percentage computed as an area rate on oblique reconstructions performed exactly orthogonal to the axis of the vessel at the point of maximal stenosis. METHODS: Twenty-seven carotid stenosis (in 24 patients) were preoperatively evaluated by USCD, MHACT, DSA. We calculated the stenosis degree with USCD, by the ECST method, both as a diameter rate and as a bidimensional value. By MHACT we computed the percentage of stenosis as an area rate, in an MPR oblique plane orthogonal to the vessel axis, at the point of maximal stenosis; by DSA we used NASCET and the common carotid artery method (CC). DSA measurements have been mathematically converted as area rate (NASCET2 and CC2). All the patients were operated on with the eversion technique (EEA); it was always possible to obtain an intact cylindrical specimen of the plaque and to perform a reliable and accurate evaluation of the degree of stenosis by sectioning and measuring it on the desk. We gave a score to the presence and amount of lipid and calcium components, and these data were compared to those obtained with the different diagnostic instruments. RESULTS: Statistical analysis of the 7 data sets showed an important underestimate of the angiographical method (DSA), even if the measurements were carried on by a precision caliper. The mathematical conversion of a linear stenosis rate into an area rate gives these values more reliability, indicating, as for NASCET2, non statistically significant differences when compared to surgical evidence, notwithstanding a high standard deviation. The rates obtained by USCD (area rate) and MHACT proved to be very accurate with respect to surgical evidence. In this study there was no significant difference in the detection of various components (lipid and calcium) of the atheromasic lesion, by MHACT and surgical evidence (OP). CONCLUSION: MHACT promises to be a very accurate instrument in the detection of plaque components and identification of the stenosis degree. It shows some limits in very calcific lesions and occasionally, in relevant cardiac failure, may be useless. Hence one feels the need to reassess the role of DSA, once considered the "gold standard", with more extensive prospective studies, including comparison with MHACT and USCD.

Late rupture of an abdominal aortic aneurysm after Parodi's endoprosthesis replacement.

Endovascular surgery as a whole, and specifically in the context of aortic aneurysms, is a very interesting methodology the potential of which is increasingly being recognized. Follow up information on patients who underwent these procedures will be critical to validate the different techniques which have been developed and to identify the most appropriate situations for this type of surgical procedures. The authors present a case of aortic aneurysm rupture who had undergone Parodi's endoprosthesis placement two years before. CT angiographic evaluation showed a wide endoleak due to distal stent detachment, a complete dislodging of the endoprosthesis itself and retroperitoneal haematoma. Prosthesis replacement through a laparotomic approach was carried out and the patient was discharged 10 days postoperatively, surgically cured.

Steroid-independent activation of ER by GnRH in gonadotrope pituitary cells.

In the rat pituitary gland the mechanism responsible for ERalpha regulation has not been fully elucidated. Using transient transfection assays in alphaT3-1 cells, a cell line of gonadotrope origin, we show that GnRH stimulates estrogen response element-containing promoters in an estrogen-independent manner. This effect was strictly ER and GnRH receptor dependent, as no activation of the reporter gene was observed in presence of the anti-estrogen ICI 182,780 or a GnRH antagonist. These data suggest that the GnRH-triggered signaling pathway results in 17beta-estradiol-independent trans-activation of the ERalpha in alphaT3-1 cells. Furthermore, an additive activation was achieved when cells were treated with both GnRH and 17beta-estradiol. In primary pituitary cells, GnRH alone (100 nM) did not cause a significant stimulation of reporter gene activity, presumingly due to the low amount of gonadotropes. Interestingly, the combination of 17beta-estradiol and GnRH resulted in a significant increase in ERalpha trans-activation compared with that in cells treated with 17beta-estradiol alone. This enhancement was prevented by ICI 182,780, showing an ERalpha requirement. Moreover, we show that the effects of GnRH on ERalpha transcriptional activity in gonadotrope cell lines are mediated by the PKC/MAPK pathway. In conclusion, our data demonstrate that GnRH is an important signal in the regulation of ERalpha trans-activation in gonadotrope cells.

Brain involvement in extracranial internal carotid artery aneurysms.

BACKGROUND: No prospective study of extracranial internal carotid artery aneurysms (EICAA) has been reported to date. The aim of this study was to evaluate central nervous system complications associated with surgical intervention for EICAA. PATIENTS AND METHODS: A total of seven patients, representing all cases observed at our institution from December 1997 to December 1998, were entered in this prospective study. Three patients had bilateral involvement. The aneurysms were both atherosclerotic and dysplastic. All patients were males, with mean age of 70 years (range 65 to 74). Internal or common carotid artery to EICAAs diameter ratios were calculated on the angiograms. The transverse diameter as well as the craniocaudal extension of the lesions were accurately measured intraoperatively. Follow-up evaluations were performed at three, six and twelve months postoperatively, and consisted of a clinical evaluation by both a neurologist and a vascular surgeon who were not part of the primary surgical team. RESULTS: Six patients presented with neurological symptoms ranging from non-hemispheric TIAs to hemispheric stroke. One patient was asymptomatic. The severity of symptoms was correlated with the size of the aneurysm. Preoperative symptoms were more severe in EICAAs of > or = 3 cm in transverse diameter. One case had a postoperative stroke, no perioperative deaths occurred. All the internal carotid arteries operated on were patent during follow-up evaluations. No new neurologic event was observed during follow-up. CONCLUSIONS: The severity of central neurologic symptoms seems to depend on the size of the aneurysmatic lesion. Prompt surgical management of small EICAAs may reduce the occurrence of severe CNS complications, both preoperatively and postoperatively, due to the lower risk of embolization associated with small aneurysms compared to larger lesions.

Endoscopy and surgery. A combined strategy for diagnosis and therapy of polyposis-cancer sequence in the colon.

BACKGROUND: The aim of the paper is to evaluate retrospectively the series of patients affected by colon polyps and colon cancer to purpose a planned follow-up for patients who underwent colon polypectomy. METHODS: Out of 198 patients affected by colon carcinoma, the authors describe 95 cases of previous, synchronous or metachronous polyps, with a global prevalence of 47.9%, and respectively of 13.6%, 16.6%, and 17.6%. RESULTS: The evolutive sequence between colon polyp and carcinoma is shown through both clinical experience and experimental tests. The epidemiologic curve of adenoma rate precedes by five years the curve of carcinoma, and such is the average period of time for the transformation of an adenoma into invasive carcinoma. In clinical practice, it is frequent to note synchronous or metachronous polyps with respect to colon carcinoma. It is also possible to note carcinoma in patients with previous polypectomies. CONCLUSIONS: On the basis of the retrospective evaluation of the clinical cases, and reviewing international literature, the authors suggest their diagnostic-therapeutic and endoscopic follow-up protocol for patients affected by colon neoformations (Fig. 1).

Two incidental cases of abdominal aortic aneurysm and gallbladder cancer. Further data influencing the management of patients affected by aneurysm and gallbladder disease.

Abdominal aortic aneurysm and cholelithiasis are two common diseases in the elderly population. The prevalence of abdominal aortic aneurysms ranges between 1.8 and 6.6% in autoptic series and it's estimated that 2.5% of the over sixty year old population is affected. Carcinoma of the gallbladder is the most common malignant tumor of the biliary tract and in the United States is the fifth most frequent digestive tract malignancy; it's incidence ranges between 2 to 10 cases of 100,000 persons/year. No adequate guidelines are now available to assist the surgeon, in the case of concomitant gallbladder disease and abdominal aortic aneurysm. In this paper the management of abdominal aortic aneurysm in a patient with gallbladder disease is discussed in order to assist the surgeon deciding whether to perform concomitant aneurysm resection and cholecystectomy. In 162 aneurysmectomies (1987-1997) 18 (11.11%) patients underwent combined aneurysmectomy and cholecystectomy operation. The patients ranged in age from 49 to 88 years (average 69 years). In two cases the anatomo-histological specimen examinations (twelve sections) demonstrated a gallbladder carcinoma. The overall mortality rate was 5.56% either for aneurysmectomy alone or for combined therapy. In case of abdominal aortic aneurysm and concomitant gallbladder disease, in choosing simple endoaneurysmectomy, the surgeon has to consider the risk of early and late complications of leaving a diseased gallbladder in place. In case of concomitant performance of both operations, the risks of a possible septic graft contamination must be considered. We believe that the patient may be best served by performing the vascular and nonvascular procedures in the same operation. In this paper a new proof, till now never considered in the international literature, is presented to support our opinion: the possibility of concomitant unknown cancer or precancerous lesions in a lithiasic gallbladder. Diagnosis of these lesions is, indeed, not easy to perform in the preoperative phase and is often a postoperative anatomo-histological detection.

Wall lesions of abdominal aortic aneurysms threatening an impending rupture: prognostic evaluations.

BACKGROUND: Final events preceding aneurysm rupture are not completely known. The current study relates to incomplete aortic aneurysm wall lesions (i.e. malacia, dark staining and blebs or blisters) as possible sites of aneurysm rupture. METHODS: 162 abdominal aortic aneurysms, resected between 1988 and 1996, have been reviewed and 27 cases of aneurysms presenting wall thickness lesions are reported. The lesions were scheduled by operative reports and compared to ultrasound and CT scans. RESULTS: The authors classify aortic aneurysms into three phases, depending on the degree of wall degeneration viz 1. Flawless wall aneurysms. 2. (a-b-c) Aneurysms with intraparietal lesions. 3. Ruptured aneurysms. CONCLUSIONS: It is concluded that stage 2 aortic aneurysms must be urgently operated on. They carry a high surgical risk and, consequently, higher morbidity and mortality compared with stage 1 aneurysms.

[Primary jejunal liposarcoma]. / Liposarcoma primitivo del degiuno.

A case of primary jejunal liposarcoma is reported. Liposarcoma of the small intestine is very rare (four cases in the international literature). The early clinical symptoms of these malignancies are unclear non specific and for this reason the disease is often diagnosed at an advanced stage. The prognosis of these lesions is generally poor owing to the diffusion of the disease at the time of diagnosis. Usually small bowel neoplasms are preoperatively identified only in 27-72%. The percentage of surgical removal is from 65 to 80% according to the recent literature. Aim of this paper is to present a rare case of jejunal liposarcoma.

Non specific aorto-arteritis. Clinical picture, diagnosis and therapy.

This study is aimed at analyzing clinical features, angiographic findings and evolution of Takayasu's arteritis and the criteria adopted to establish the indication for non-surgical versus operative treatment. Eighteen patients affected by non specific aortarteritis were observed and treated at our Department between 1973 and 1996. All patients met the American College of Rheumatology 1990 criteria of classification of Takayasu's arteritis. Sixteen patients were young females. Two patients were males. Nine patients underwent surgical procedures. One young female underwent a PTA. All eight asymptomatic patients were only medically treated. One patient died some days after an aorto-bicarotid bypass graft due to acute myocardial infarction. Two other patients died two and four years after intervention for renal and cardiac failure respectively. One patient after an aorto bicarotid bypass underwent a left hemiplegia due to thrombosis of the right graft branch. All the other 14 patients either surgically or medically treated are well and are under strict surveillance through rigorous follow-up. The 10 patients who underwent surgical or interventional radiological treatment were certainly the most seriously affected patients and were symptomatic (presented neurological disturbances or a severe hypertensive state). This fact explains, to some extent, the mortality and morbidity rate observed in this group. The seven medically treated patients were completely asymptomatic in spite of a major involvement of various vascular districts.

Recurrent aneurysms: late complication for patients previously submitted to graft replacement for abdominal aortic aneurysm.

BACKGROUND: The possibility to perform easy and cheap ultrasonographic examinations of the abdomen allows us to face the problem of possible development of new paraanastomotic aneurysms or aneurysms on native arteries in subjects already submitted to endoaneurysmectomy of the abdominal aorta. The idea of planning accurate programs of ultrasonographic follow-up of operated patients is sustained by the hypothesis that the aortic aneurysm is an expression of a systemic disease due to a connectival defect of genetic nature. METHODS: Two different follow-up experiences are described: the first was a simple follow-up based only on clinical evaluation of patients previously submitted to aortic surgery in the last ten years at the Department of General and Cardiovascular Surgery of the University of Milan, and the second experience a planned follow-up programme based on instrumental evaluation of the patients. RESULTS: Thirty-one cases of recurrent aneurysms of native arteries in 13 subjects already operated for AAA from 3 to 13 years before are described. Despite the patients were evenly inserted in a clinical follow-up, as a matter of fact, 25 of these lesions were detected during occasional investigations performed for other reasons or for rupture, while during the last two years, the planned ultrasonographic follow-up of 95 patients detected 6 new aneurysms. CONCLUSIONS: Incidental detections of new paraanastomotic true aneurysms or ectasia of native arteries far from the graft are more and more frequent in patients already submitted to aortic replacement for abdominal aneurysm. In the international literature only few papers have been published about perspective studies based on instrumental follow-up of operated patients. The planning of such controls is mandatory, at present, also in order to evaluate the clinical development of aneurysmatic disease.

Acute vascular abdomen. General outlook and algorithms.

Acute vascular abdomen is a severe and life-threatening pathology due to arterial degeneration, leading to hemorrhage or arterial occlusion leading to ischemia. Differential diagnosis of patients with severe abdominal pain and/or shock include several vascular and traumatic diseases, the most common being rupture of abdominal aortic aneurysm (AAA), or less frequently rupture of visceral artery aneurysm. Also acute aortic dissection, iatrogenic injury and acute mesenteric ischemia may lead to acute vascular abdomen. Clinical evaluation of the haemodynamic status of the patient may be very difficult, and may require airway maintenance and ventilation with a rapid treatment of hemorrhagic shock. In the stable patient with an uncertain diagnosis, CT scan, NMR and selective angiography may be helpful in diagnosis before vascular repair. On the contrary, the unstable patient, after hemodynamic resuscitation, must be operated on expeditiously. We present our vascular algorithms, to assess timing of diagnosis and treatment of this severe acute disease.

[Malignant neoplasia of the small intestine. Apropos of 7 cases. Clinical discussion and review of the literature]. / Neoplasie maligne dell'intestino tenue. A proposito di 7 casi. Discussione clinica e revisione della letteratura.

The authors report seven cases of primary malignancies of the small intestine observed and treated between 1989 and 1995 at the First Surgical Division of Treviglio Hospital. Three patients were affected by adenocarcinomas (two involving the duodenum and one the jejunum), two patients had non-endocrine carcinoid tumors of the ileum, one presented a jejunal liposarcoma and one a lymphoma of the ileum. Four patients died (respectively at three months, 15 months, 18 months and five years after surgical intervention). Three patients are still alive. The early clinical features of these malignancies are typically vague and non specific and for this reason the disease is often diagnosed at an advanced stage. The prognosis of these lesions is generally poor owing to the diffusion of the disease at the time of diagnosis. In fact these neoplasms are preoperatively identified only in 27-72%. The percentage of surgical removal ranges between 65 and 80% according to the recent literature. This study is aimed at analysing the clinical and pathologic characteristics of the observed cases and the difficulties of the diagnostic procedure. The adopted surgical techniques and the outcome of the operative treatment are also examined.

Endoscopic resection of esophageal lymphangioma incidentally discovered.

A pedunculated lymphangioma of the esophagus was unexpectedly discovered during an endoscopic investigation performed for epigastric pain in a patient affected by diabetic arteriopathy treated with antiplatelet drugs. The patient neither complained of dysphagia nor other symptoms related to the presence of the lymphangioma which therefore can be considered as an endoscopic "incidentaloma".The lesion was removed endoscopically and a follow up, 6 months later, showed no scar or recurrence.The authors present this case both for the extreme rarity of this lesion and for the evidence of low-medium grade dysplasia in the overlying mucosa, particularly since it is only case ever noted in literature.This aspect suggests that, even if malignant degeneration of these lesions has never been observed, their endoscopic removal is recommended. However, when endoscopic procedures are not feasible, thoracotomic surgical exeresis should be only considered for obstructing and symptomatic lesions; an accurate endoscopic and bioptic follow up can be useful for asymptomatic lesions.

[Plasma-cell granuloma of the sigmoid colon concomitant with adenocarcinoma of the cecum. Viewpoint for debate, literature review on pseudotumors, idiopathic colitis and cancer]. / Concomitanza di granuloma plasmacellulare del sigma e adenocarcinoma del cieco. Spunto per una discussione ed una revisione della letteratura in tema di pseudotumori, coliti idiopatiche e cancro.

A case of colonic pseudotumor, causing intestinal occlusion, concomitant with a caecum neoplasia is reported. A male 69 years old was referred to our Institution for colic abdominal pain: colonoscopy aborted because of an insuperable sigma stenosis; diagnostic enema confirmed the sigmoid stenosis, originally advised as neoplastic. As operation, the sigmoid tumor appeared accompanied with enlarged draining lymph nodes and peritoneal sac was disseminated of miliary-like whity granules. Hystological examination showed a plasma-cell granuloma with nodular and peritoneal chronic inflammatory reaction. A pancolonoscopy, performed fourty days later, discovered an unsuspected adenocarcinoma neoplasia of the caecum, that was resected with a second operation. Regional nodes were not involved. The authors make a review of international literature about of plasma-cell granuloma, pseudotumor and inflammatory chronic bowel diseases in order to identify possible correlations between pseudotumor and neoplasms. The extremely low incidence of plasma-cell granulomas in the alimentary tract (17 case since 1970 to 1994) and the reported association with concomitant neoplasms (29%) suggest to consider extremely useful an accurate study of patients with intestinal pseudotumors in order to identify neoplasms of the gastrointestinal tract as well as of other organs.

Immunohistochemical study of secretogranin II in 62 neuroendocrine tumours of the digestive tract and of the pancreas in comparison with other granins.

An immunohistochemical study on 62 cases of gastrointestinal and pancreatic neuroendocrine tumours was performed in order to test the interest and specificity of a new anti-human secretogranin II antibody and compared to the other granin markers (chromogranin A and chromogranin B). Specific immunoglobulins were purified by affinity chromatography from an antiserum raised against a recombinant secretogranin II. Gastric tumours did not express secretogranin II, and ileal and appendiceal tumours only rarely expressed it (1/10 and 1/7 respectively), unlike the other classic neuroendocrine members of the granin family. In duodenal and pancreatic tumours, secretogranin II was detected when the other granins were also expressed. On the other hand, all rectal tumours expressed secretogranin II (7/7), frequently in the absence of chromogranin A. Though the granins expressed in tumoral tissue and in adjoining non tumoral tissue are mostly related, strong secretogranin II positivity occurred in 4 tumours while mucosa was secretogranin II negative. These observations highlight the interest for associating another antigranin such as secretogranin II to the classical markers of neuroendocrine tumours.

The use of fiberoptic bronchoscopy during percutaneous dilatational tracheostomy with laryngeal mask.

UNLABELLED: The aim of our research is to evaluate the advantage by the combined use of fiberoptic bronchoscopy and laryngeal mask during the performance of percutaneous dilatational tracheostomy in an intensive care unit. PATIENTS: 16 adult patients who were candidates to middle-long term mechanical ventilation. ENVIRONMENT: Intensive Care Unit of a Community General Hospital. RESULTS: We experienced 3 minor complications (2 minor bleedings and 1 neck emphysema). Difficulties were found in 3 patients with particular anatomical conformation (obese patients with short neck and limited mobility of the cervical spine). CONCLUSION: The combined use of fiberoptic tracheo-bronchoscopy with the laryngeal mask permits a better endoscopic visualisation of the operatory field, providing a more secure and precise procedure.