Day hospital for incisional hernia repair: selection criteria.

AIM: The authors report their experience with incisional hernia repair and set criteria for the safe performance of the procedure on a day hospital basis. MATERIALS AND METHODS: From January 1994 to July 2005, 29 day hospital procedures for incisional hernia were performed under local anaesthesia. Selection criteria included: a hernial defect < 10 cm, a reducible hernial sac and negative history for obstructive symptoms. The repair was achieved with a polypropylene plug in defects < 3 cm and a double layer mesh in larger defects. RESULTS: All patients were discharged within 7 hours of surgery. Postoperative pain was mild and required hospital analgesia in 30% of cases. Back at home analgesia was needed in only three patients (10%). Six patients (20%) developed a seroma that reabsorbed spontaneously. During a follow-up ranging 6 to 120 months (mean 75), no recurrence has been recorded. CONCLUSIONS: In selected patients, incisional hernia repair as day hospital procedure is feasible, safe and absolutely effective. The use of polypropylene plugs and meshes accounts for a sound repair with low risk of complications.

[Endometriosis of the abdominal wall (authors' experience)]. / L'Endometriosi della parete addominale (esperienza personale).

Endometriosis is a very common gynecological disease, although the abdominal wall localization is a rare clinical problem in the everyday practice and this explains the incomplete reports in literature and the difficulty of a standard treatment. The authors report four cases of abdominal wall endometriosis, underlining how the surgical therapy represents the golden standard of decisive treatment, thanks also to prosthetic reconstruction techniques who allow more radical demolitions. On the contrary, the medical treatment should be reserved to selected cases such as especially the less symptomatic umbilical primitive diseases.

[Surgical tactics in abdominal wall neoplasia]. / La tattica chirurgica nelle neoplasie della parete addominale.

Abdominal wall neoplasms represent more or less 1% of human neoplasms in the adult. The authors reports their own experience based on 9 cases during over 20 years. The prognosis of these tumors is almost influenced from a lot of factors such as: histology, localization, staging, grading, sex, surgical margins, number of local recurrences. Abdominal wall neoplasm are less aggressive for compartmentalization of muscle layer and with a better prognosis because of their localization, and surgical opportunities of extensive resection (not less of 2 cm from tumor's macroscopic limits) allowed by modern prosthetic reconstruction techniques. Polipropilene seems to be the ideal material for such kind of reconstruction even if also mersilene, PTFEe and others were employed. PTFEe and Dual-meshes could be useful in those malignant tumors in which peritoneum resection is necessary.

[Bilateral breast cancer]. / Il carcinoma mammario bilaterale.

Bilateral breast cancer has a cumulative incidence of 3-13% in patients with primary breast cancer, and the majority of these lesions are metachronous. The synchronous and metachronous bilateral breast cancer have at greater risk for distant metastasis than unilateral breast cancer. There was no difference in overall survival when comparing metachronous and synchronous bilateral patients to those with unilateral disease.

[Breast cancer screening in the elderly]. / Lo screening del carcinoma mammario in età geriatrica.

The incidence and mortality of breast cancer increase with increasing age, and almost half of all breast cancer cases are diagnosed in women aged 65 years and older. Moreover many studies have indicated that the elderly are less screened, and have lesser and frequently inferior treatment. In contrast, clinical trials focusing on the elderly suggest that they do as well with surgery, radiation, and standard chemotherapy regimens as their younger counterparts. Our study suggest that in women aged 65 years, and older, breast cancer can be detected at an earlier stage by mammographic screening.

[Undifferentiated carcinoma of the thyroid]. / Il carcinoma indifferenziato della tiroide.

Anaplastic thyroid carcinoma is a rare and highly lethal cancer. Between 1969 and 2002, 9 cases with anaplastic carcinoma were reviewed. Surgical treatment with radiotherapy and chemotherapy were performed in all cases. All patients died of their disease within 5 years. The mean survival was 10 months. There is still controversy as to what constitutes adequate treatment for anaplastic thyroid carcinoma, and combined multimodal therapy seems to be the most common management strategy for this aggressive disease.

Plug-technique for small incisional hernia.

OBJECTIVE: The authors report their experience with a new prosthetic technique for the repair of incisional hernia defects smaller than 3 cm. METHODS: From January 1995 to September 2002, 16 operations for small incisional hernias have been performed. Local anaesthesia was used in 12 out of 16 patients (75%). The repair was achieved by insertion of a polypropylene plug sutured to the margins of the hernial defect. RESULTS: All patients were discharged within 24 hours of surgery. Postoperative pain was mild and required hospital analgesia in 25% of cases. Back at home analgesia was needed in only 1 patient. During a follow-up ranging 3 to 91 months (mean 46), no recurrence has been recorded. CONCLUSION: The proposed technique allows a sound repair of small incisional hernias with minimal pain, quick rehabilitation and early return to unrestricted work.

Analogic evaluation of pain during inguinal hernioplasty under local anaesthesia.

OBJECTIVE: The authors evaluate intraoperative pain in patients undergoing tension-free inguinal hernioplasty under local anaesthesia. MATERIAL AND METHODS: One hundred and fourteen primary inguinal hernia repairs were carried out at the Department of General Surgery I of Catania University Polyclinic from January to September 2002. 2% Mepivacaine cloridrate was the local anesthetic of choice. Intraoperative pain was measured by a visual analog scale. RESULTS: A mean analogic score of 1.9 (range 0-2.9) was obtained. Intraoperative complications were recorded only in 2 patients (1.7%). There was no operative mortality. All patients were up and about straightaway after surgery, had a light meal two hours later and were discharged within one day of operation. CONCLUSIONS: Inguinal hernia repair under local anaesthesia is well tolerated and is associated with a low risk of complications.

[Tension-free prosthetic repair in the surgical treatment of epigastric hernia]. / La riparazione protesica tension-free per il trattamento chirurgico dell'ernia epigastrica.

From November 1994 to June 2001, the authors have performed 16 operations for epigastric hernia. Local anaesthesia was used in 8 patients with small hernias, in the remaining 8 general anaesthesia was preferred. In defects smaller than 4 cm, the repair was achieved by insertion of a polypropylene dart plug sutured to the margins of the hernial defect. In larger defects a double layer mesh placed in the pre-peritoneum was used. All patients were discharged within 24 hours of surgery. Postoperative pain was mild and required hospital analgesia in 25% of cases and domiciliary analgesia in 1 patient only. During a follow-up ranging 3 to 79 months (mean 31.2), no recurrence has been recorded. The proposed technique is simple, safe and absolutely effective, allows immediate rehabilitation with a low risk of complications.

[Plug-technique for umbilical hernia repair in the adult]. / La tecnica del piccolo plug nella riparazione dell'ernia ombelicale nell'adulto.

BACKGROUND: Umbilical hernia represents 6% of all abdominal wall hernias in the adult. Surgical repair should always be carried out due to possible occurrence of complications. Aim of this paper is to evaluate the efficacy of the plug-technique. METHODS: From October 1995 to April 2000, the authors performed 21 operations for acquired umbilical hernia with a defect smaller than 4 cm. Local anesthesia was used and a light intravenous sedation added in particularly anxious patients. The repair was achieved by insertion of a polypropylene dart plug sutured to the margins of the hernial defect. RESULTS: All patients were up and about straightaway and were discharged within 24 hours of surgery. Postoperative pain was mild and required hospital analgesia in only 19% of cases and domiciliary analgesia in 24%. During a follow-up ranging from 6 to 60 months (mean 30), only one recurrence has been recorded. CONCLUSIONS: This tension-free technique allows immediate rehabilitation, with few complications and a low recurrence rate.

[Breast carcinoma in the elderly]. / Il carcinoma della mammella in età geriatrica.

Breast cancer represents 40% of all carcinomas and is responsible for the 20% of deads due to a cancer in female population. Patients in more of 50% age over 65 years. 150 patients with breast cancer older then 65 years underwent surgery. T1 and T2 < 2 cm patients were treated with quadrantectomy and radiotherapy. T2 > 2 cm and T3 patients underwent radical mastectomy. T4 patients were treated with neoadjuvant chemotherapy before surgery. Mean follow up was 48 (range 12-78) months. 43 patients (28.6%) had a progression of the neoplasia. Five years mortality rate was 18.6%. Surgery nowadays represents the treatment of choice for breast cancer even in elderly woman. Associated diseases in these patients shouldn't always considered an absolute contraindication for surgery.

[Current approach in the treatment of desmoid tumors of the abdominal wall]. / Attuali orientamenti nel trattamento dei desmoidi della parete addominale.

Desmoids of the abdominal wall are rare tumours with an incidence of 2-4 cases per million. From our experience which is reported here in detail (5 cases observed over the past 20 years), we draw the conclusion that the only completely reliable diagnosis is still histological, in spite of the use of ultrasound, CT scans and the new imaging possibilities afforded by NMR. After comprehensive excision of at least 2 cm of macroscopically healthy tissue from the tumour margins, reconstruction using prosthetic materials, such as Mersilene, PTFE or Prolene was performed. Neither radiotherapy nor chemotherapy were used, since there were doubts as to their usefulness. The functional and cosmetic results were satisfactory in all cases. Over follow-up periods ranging from 3 to 13 years, none of the patients has presented recurrences or incisional hernias.

[Tension-free lumbar hernioplasty]. / L'ernioplastica lombare tension-free.

The authors report a case of a 51 year-old woman with spontaneous Grynfeltt's hernia. Computerized tomography accurately displayed the anatomy of the lumbar region, thus aiding diagnosis and treatment. A double layer polypropylene mesh was used for the repair, placed in the pre peritoneum and sutured to the margins of the hernial defect avoiding muscles and fascias. The use of a double layer prosthesis and reduction of tension on the suture line allow a sound repair, with minimal postoperative pain and immediate resumption of daily activities.

Enteral nutrition in patients with chronic neurological diseases.

BACKGROUND: Malnutrition is commonly considered an important risk factor that can produce a negative influence on the prognosis of patients with chronic neurological diseases. The reduced caloric or proteic intake due to the motor or cognitive dysfunction, the hypercatabolic state due to infections, the abnormal gastrointestinal motility are the main mechanisms responsible for a state of malnutrition. METHODS: Between January and December 1999 fourteen patients with chronic neurological diseases were treated. Ten of them had had a stroke, four due to Amyotrophic Lateral Sclerosis (ALS). After the evaluation of nutritional status the patients received enteral nutrition (EN) by placement of a nasointestinal feeding tube or a Bengmark tube. Glycaemia, blood urea nitrogen, serum creatinine, electrolytes, glycosuria, glutamic-oxalacetic and glutamic pyruvic transaminase were monitored in all patients. Polymeric enteral feeding was administered by an infusion pump. Standard nourished patients (7/14) received a 30 Kcal/kg/day support, the undernourished ones (6 low, 1 moderate malnutrition) received a 35-40 Kcal/kg/day support. RESULTS: The complete caloric supply was reached in three-four days. Both of the groups received continuous feeding infusion during hospitalization. For the patients who continued the nutritional support at home (3/14) refeeding was performed only during night-time. In the patients with stroke the optimal/standard weight was reached within one month. In these patients oral nutrition was started within 45 days of treatment taking into account the restored swallowing function. In the patients with ALS the improvement of nutritional standards was reached within the first month and complete restoration within the second/third month. CONCLUSIONS: On the basis of our experience enteral nutrition represents an effective refeeding procedure in patients with chronic neurological diseases.

Iron and porphyria cutanea tarda.

In order to evaluate the pathogenetic role of iron in Porphyria cutanea tarda (PCT), the metabolism of iron was studied in 440 patient with PCT and associated chronic liver disease (CLD) and in 91 nonporphyric CLD patients (used as a control group). The parameters considered were the following: serum iron, ferritin, Total Iron Binding Capacity (TIBC) and percent saturation of transferrin. The statistical analysis showed that the differences between the means, in the two groups, were not significant in any of the parameters examined. To investigate the possible relationships between iron metabolism and other chemico-clinical parameters concerning the porphyric disease, the associated hepatic disease and hemometry, we studied the correlations between iron parameters and total urinary and serum porphyrins, serum copper, serum albumin, hemoglobin, red blood cells, ALT, AST, CHE and GLDH. This investigation was only possible in the last 99 cases. In addition to the obvious correlations between the parameters concerning iron metabolism, the highly significant (p < 0.001) correlation between ferritin and enzyme activities which indicate cytolysis (ALT, AST, GLDH) is extremely interesting. The results seem to point to the tentative conclusion that the alterations of iron metabolism are more related to the hepatocellular necrosis than to the metabolism of porphyrins.

The symptomatic accessory tarsal navicular bone: assessment with MR imaging.

PURPOSE: To determine if a symptomatic accessory navicular bone, a normal variant, displays a pattern of altered signal intensity on magnetic resonance (MR) images indicative of an abnormality that could account for the patient's foot pain. MATERIALS AND METHODS: Both feet were imaged in seven patients with an accessory navicular bone on radiographs and unilateral foot pain. Five patients had focal medial foot pain, and two had vague, diffuse pain. T1-weighted spin-echo and T2-weighted fat-suppressed sequences were used. RESULTS: A bone marrow edema pattern (BMEP) was noted in the accessory navicular bones of the five patients with focal pain and in the adjacent navicular tuberosities of three of them. The two patients with vague pain showed no osseous or soft-tissue abnormalities. Two patients with positive MR images underwent surgical excision of the accessory navicular bone, and histologic examination revealed osteonecrosis in one patient. CONCLUSION: The BMEP in a symptomatic accessory navicular bone is indicative of chronic stress and/or osteonecrosis. This information can furnish an objective basis for surgical or conservative management.

[Fixed retention in orthodontics--some considerations]. / Contenção fixa em ortodontia--algumas considerações.

A new type of making a fixed retention on orthodontics is presented. The retention is accomplished by a mesh inserted and fitted to the lingual surfaces of the involved teeth by a cured composite resin.

[An unusual mechanism of lead poisoning. Presentation of a case]. / Inconsueta modalità d'intossicazione da piombo. Presentazione di un caso.

A case is described, that came to our attention for suspected acute intermittent porphyria, with abdominal pain and ascending tetraplegia. The patient (HIV positive and with a HBsAg positive chronic aggressive hepatitis) was a heroin addict. In urine: high porphyrins with extremely increased delta amino-levulinic acid (ALA) and normal porphobilinogen. High protoporphyrin was present in blood red cells. The lead poisoning was confirmed by a very low ALA-dehydratase activity in erythrocytes and a high content of lead in urine and plasma. With Ca-versenate and penicillamine the abdominal and neurological symptoms rapidly disappeared. The possibility of contact with lead, professional or environmental, was ruled out. It was found however, that shortly before the appearance of symptoms, the patient had used a batch of unrefined brown sugar heroin, which was probably mixed with lead salts. It is noteworthy that during the same period, other young heroin addicts died with similar symptoms.

Familial porphyria cutanea tarda with normal erythrocytic urodecarboxylase: an exception to the rule?

The possibility that the differentiation between sporadic and familial porphyria cutanea tarda cannot always be made on the basis of the measurement of the erythrocytic uroporphyrinogen decarboxylase activity has been examined. Two cases of porphyria cutanea tarda, with a normal erythrocytic enzyme activity in a father and son, are described. The authors exclude that these are 2 cases of sporadic or toxic porphyria cutanea tarda within the same family. These 2 cases provide additional evidence for the existence of a form of familial porphyria cutanea tarda in which erythrocytic uroporphyrinogen decarboxylase activity is normal.