Takayasu's arteritis associated with Crohn's disease. Report of a case.

The authors report a rare case of Takayasu's arteritis with aortic arch and abdominal aorta involvement associated with Crohn's disease of the colon which both occurred in a young female patient. The coexistence of two immune mediated diseases in the same subject is unusual for they are generally considered to be independent of each other, however a hypothesis of their possible interrelationship is put forward.

[Tularemia: considerations on a new case in the Monte Amiata]. / Tularemia: considerazioni su un nuovo caso sul Monte Amiata.

One sporadic case of tularemia induced by direct contact with an infected hare is described. Human epidemiological data of the last ten years in Tuscany, emphasize that this infection, although at low incidence, shows the presence and persistence of Francisella tularensis in the animals and the ensuing transmission to humans so that it continues to be responsible for significant morbididy in "at risk" territories. Difficulties in the differential diagnosis, above all for glandular and pharyngeal forms, are reviewed.

[The Gullino 3-way tube for lavage and active aspiration in the treatment of post-pneumonectomy septic complications and subphrenic abscess]. / Il tubo a tre vie (di Gullino), di lavaggio ed aspirazione attiva, nel trattamento delle complicanze settiche post-pneumonectomia e dell'ascesso sottofrenico.

(Gullino's) three-way tube consists of a large 30-35 cm long suction tube, with a diameter of 10 x 14 mm, closed at the proximal end close to which 6-8 holes have been made for suction along a 5 cm stretch. Two small tubes of equal length and with a diameter of 4-6 mm are glued or bound to the tube: one represents an air intake with a sealed opening above the suction holes; the other, used for washing, opens freely at the level of the closed proximal end of the large section tube. After a short review of the drama and disappointments in lung surgery concerning the treatment of postoperative septic complications, the authors briefly describe the advantages of the use of two-way suction drainage tubes: using air suction (Saratoga's and Shirley's model), and above all water suction, with irrigation-washing (Luizy's and Vankemmel's models). Compared to the two-way tubes, the paper then emphasises the advantages of the three-way model: using the flow of the lavage solution for the top, it is possible to obtain an improved, continuous and rapid washing and sterilisation of the pleural cavity, while suction from below serves to avoid stasis and in the event of bronchial fistula it is therefore easy to prevent broncho-pulmonary inundation. The three-way tube was used in two cases of post-pneumonectomy pyothorax, one of which was complicated by a bronchial fistula, and in a case of sub-phrenic abscess. In the treatment of pyothorax, the three-way tube must be divided into two parts: the large suction tube and the small air-intake tube, the two-way tube, and the small washing tube. The two-way tube must be positioned on the posterior axillary line in contact or nearly with the diaphragm, the small washing tube in the 1st anterior intercostal space and the patient must change decubitus with a certain rolling rhythm. Simple pyothorax may be resolved in 48 hours; bronchial fistula in 25 days and sub-phrenic abscess in 9. These are undoubtedly exceptional results, but require further confirmation.

[Perianal glands of Hermann and their pathology. Review of the literature. Apropos of a cyst case]. / Les glandes péri-anales de Herrmann et leur pathologie. Revue de la littérature. A propos d'un cas de kyste.

We present a case report of a cyst of Herrmann's glands. These glands have a vestigial origin and are present in more than 50% of the population. They are located in the posterior part of the anal duct. Their excretory duct, when it is permeable communicates with an anal krypt. They have their own microscopic, epithelial characteristics, and produce a mucoid secretion. They can cause acute (abscess) or chronic (fistula) infections of the peri-ano-rectal region. Cancer or cystic transformations are exceptional but typical. All these characteristics are so specific that Herrmann's glands cannot be longer denied as a distinct clinical entity.

[Transposition of the omentum to the thigh, for the vascular salvage of a limb. Apropos of 17 cases]. / Transposition de l'épiploon à la cuisse, pour le sauvetage vasculaire d'un membre. A propos de 17 cas.

A new procedure to supply effective anastomotic blood supply via the omentum transpositioned to the hip in cases of impaired lower limb vascularization was proposed in 16 cases of stage III and stage IV obliterative artherosclerosis including one case of massive venous thrombosis. The results demonstrated that under rigorously controlled fundamental conditions, circulation can be established and the limb can be saved. 1--good omentum vascularization is essential: the two gastroepiploic arteries must have a large caliber and form a complete anastomotic circle. 2--After disconnecting the omentum from the stomach, while carefully protecting the gastro-epiploic arcade, one pedicle is sectioned and the other is saved depending upon the side the omentum is transpositioned. It is best to save the right pedicle which has a stronger flow even for the left limb. If the omentum is ample enough, the anatomic situation does not require a lengthening plasy. 3--If the omentum is insufficiently long, it is lengthened by a second counter-section between the two gastro-epiploic and epiploic arcades. The ends of the arcades can thus be placed in direct contact forming a unique continuous arcade. This plasty is only possible if the anastomotic circle of the gastro-epiploic arcade is complete. 4--Transposition to the hip is made by including the omentum between the rectus and its posterior sheath through a newly formed channel widening the crural canal. The omentum is thus incorporated as a bridge forming a major circulatory route between the subclavian artery and the pelvic and lower limb arteries. 5--We recommend transpositioning the omentum after lumbar sympathectomy to favour strong vasodilatation and lower flow resistance helping create favourable conditions for the new anastomotic circulation. 6--Based on these specific conditions, we have had excellent results in 80% of the cases for the entire life-span of the patients who underwent the operation. The two cases with poor results occurred after a major technical error due to a lengthening plasty on an omentum without a complete gastro-epiploic arcade.

[Fetal diaphragmatic hernia. Clinical and prognostic considerations and early diagnosis]. / Ernia diaframmatica fetale. Considerazioni clinico-prognostiche e diagnosi precoce.

Fetal diaphragmatic hernia depends on a retarded closing during the first trimester of pregnancy of embryological structures in the chest that lead to the formation of diaphragmatic muscle. The defect occurs in form 1:2,000 to 1:5,000 livebirths and it is associated with other structural abnormalities (neural tube defects, cleft lip/palate, omphalocele, cardiopathy, etc). In 20% of cases it is associated with a chromosomal syndrome. Antenatal ultrasonic diagnosis has been reported, at 18-40 weeks of pregnancy. We describe a case of early diagnosis, at 17 weeks of pregnancy, of fetal diaphragmatic hernia by ultrasound. Plexus choroid cysts were detected too and fetal karyotyping resulted 47XX + 18. Prognosis of pregnancy in all cases of fetal diaphragmatic hernia is poor because fetal and neonatal losses are very heavy.

[Diaphragmatic pseudocyst of the pleuro-peritoneal membrane (pseudocyst of Bracket's membrane at the site of Bochdalek's orifice). Apropos of a case]. / Pseudo-kyste diaphragmatique de la membrane pleuropéritonéale (pseudo-kyste de la membrane de Brachet dans le siège de l'orifice de Bochdalek). A propos d'un cas.

After surgical exeresis of a large diaphragmatic cyst located at the Bochdalek orifice and with predominating endoabdominal extension, the pathological examination revealed it to be a pseudocyst involving the pleuroperitoneal Bracket membrane. This pseudocyst may have resulted from defective development of the primary lymphatic system of the pleuroperitoneal folds or of the pleuroperitoneal membrane. According to this hypothesis, myoblastic colonization of the membrane which gives the posterior part of the diaphragm would have been interrupted. The only clinical sign of this pseudocyst is a heavy painful feeling. Diagnosis is made on the basis of echography and tomodensitometry. Treatment to date is strictly surgical with very satisfactory outcome and no cases of mortality.

Early prenatal sonographic diagnosis of neuropathic arthrogryposis multiplex congenita with osseous heterotopia.

A prenatal diagnosis of arthrogryposis multiplex congenita (AMC) has been carried out on a 19-week-old fetus by means of echography. The ultrasonographic characteristics were unnatural position of the four limbs associated with articular anomalies together with absence of active fetal movements. A therapeutic interruption of pregnancy was performed and the diagnosis was confirmed. At autopsy, architectural disorder of the motor neurons of the anterior medullary horn revealed a neuropathic pathogenesis of the arthrogryposis. Moreover, at the lumbar level the spinal cord was progressively replaced by heterotopic bony tissue which caused a more severe deformity of the lower limbs compared with the upper. The aspects of anatomo-pathological, genetic, and differential diagnosis are discussed showing the precocity of the prenatal diagnosis and the peculiarity of the aetiology of our case.

[Internal hernia of the abdomen. Apropos of 14 cases]. / Les hernies internes de l'abdomen. A propos de 14 cas.

Internal abdominal hernias develop when one or more viscera extrude through an intraperitoneal orifice but remain within the peritoneal cavity. The orific may be normal (Winslow's foramen) or paranormal (peritoneal fossae: paraduodenal, ileocecal, inter- and mesosigmoidal, paracolic, supravesical, of the large ligament of uterus). All these hernias possess a sac and are true hernias. The orifice may also be abnormal: pathologic origin if formed in a mesentery or an omentum (trans-mesenteric, trans-mesocoloic, trans-omental, by colo-omental disinsertion) or in the form of an anomalous orific if it occurs in a congenital anomaly of a ligament (falciform ligament of liver) or a mesentery (mesentery of Meckel's diverticulum): all these hernias lack a sac and are "internal prolapses or procidentia". Of the 14 cases presently reported, 6 were hernias through a paranormal orifice: 2 left and 2 right paraduodenal, 1 intra-mesosigmoidal and 1 retrocecal; 6 were hernias through a pathologic orifice: 2 trans-mesenteric, 1 in the posterior cavity through a colo-omental dissinsertion hole and 3 trans-omental, and 2 were hernias through an anomalous orifice from absence of the falciform ligament of liver. Incidence of these hernias reported in the literature is between 0.2 and 0.9% of autopsies and 0.2 and 2% of parietal hernias, findings in our series being 0.098% (14 of 14,199 cases) of laparotomies and 0.32% (14 of 4,374 cases) of parietal hernias. Of 1,871 cases described in the occidental or near occidental literature (in French, English, Italian or German), 160 (8.55%) were hernias through Winslow's foramen, 1035 (55.31%) through a para-normal orifice and 676 (36.1) through an abnormal orifice (pathologic and anomalous). The sex ratio showed a male prevalence (3:2), age distribution demonstrating the onset of internal hernias at all ages with a preference for the 5th decade and a mean age of 46 years. Symptomatology was totally non specific, subacute to acute occlusive symptoms or even signs of already installed necrotizing-peritonitis being detected in 80 to 90% of cases. In 10 to 15% of patients the hernia was an unexpected finding during laparotomy for another affection, an almost typical feature of the largest para-normal hernias, the paraduodenal hernias. Preoperative diagnosis is practically impossible, and in many cases cannot be made because of time restriction, but it is sometimes possible with the largest hernias after a longer sub-occlusive period by radiologic, arteriographic and scan imaging. However, the primary task of the surgeon is not so much to establish the diagnosis as to assess the need for urgent operation. Hernias provoking large displacements of viscera can even make intraoperative diagnosis difficult with subsequent errors, and surgeons must recognize all possible types of these hernias, especially those passing through a para-normal orifice, and must be able to pinpoint the fixed guiding points. They must also work in as large an operative field as possible and should therefore always start by a median infra-supra-umbilical laparotomy to allow its maximum extension. Reduction of herniated viscera can be simple, by gentle traction, or difficult requiring dilatation of the hernial orifice and/or opening of the sac.(ABSTRACT TRUNCATED AT 400 WORDS)

[Down's syndrome caused by robertsonian translocation with cystic hygroma]. / S. Down da traslocazione robertsoniana con igroma cistico.

An echographic examination in a 33 year old woman at the 12th week of pregnancy revealed a foetus with a cystic hygroma of the neck. The amniocentesis was performed at the 14th week and the karyotype analysis showed a trisomy 21 with a translocation 21q21q.

[Enteropexy (the Reymond procedure) in the treatment of small-intestine obstruction. The experience of 133 cases]. / L'entéropexie (procédé de Reymond) dans le traitement des occlusions du grêle. Expérience sur 133 cas.

The indication for a pexis operation is entirely dependent on the condition of the intestinal peritoneum. If detachment of peritoneum is absent or very superficial then pexis is not indicated (prophylactic pexis). If, however, multiple regions of peritoneal detachment extending to the subperitoneal layer exist then curative pexis is justified, and must extend to the whole or almost the whole of the small intestine, and be performed using absorbable suture thread.