[Systemic Salmonella Arizona infection: description of a rare surgical case]. / Infezione sistemica da Salmonella Arizona: discussione di un raro caso chirurgico.

Salmonella arizona enteritis has been described in patients resident in the southern states of the USA and in Mexico, whereas in Europe it is rarer. The virulence of this bacillus is, however, still little known and we have few descriptions of severe systemic infections, which are all present in patients with immune system impairment. Only two cases have been reported in Italy where the infection has occurred as severe sepsis with the pathogenic agent being isolated in the blood. Here we report what is, on the basis of our knowledge, the third case in Italy of a systemic Salmonella arizona infection.

[Popliteal trauma due to posterior dislocation of the knee]. / Lesioni traumatiche dell'arteria poplitea da lussazione posteriore del ginocchio.

Popliteal artery injuries have an incidence ranging between 5% and 19% of all traumatic arteria lesions. A high index of amputation, when associated with lesions of the infrapopliteal branches, and a 4-5% overall mortality are recorded in these conditions. Three patients with popliteal artery injury due to posterior knee dislocation were operated upon in our department during the last 12 months. In one case, the physical examination revealed a warm limb, with peripheral pulse; angiography showed a pseudoaneurysm of the popliteal artery with intimal dissection and partial thrombosis. In the last two cases an acute ischemia of the limb was present; in one case the angiographic study showed a complete transection of the artery, while in the second case an obstruction of popliteal artery. In all cases the dislocation was corrected and a the reconstruction carried out by inverted autologus saphenous vein with termino-terminal anastomosis. In all cases a good patency of the popliteal reconstruction was achieved with limb salvage. Prognosis of popliteal injuries is related to an early diagnosis and they should be suspected even in absence of overt signs of acute ischemia. Surgical timing cannot be the same in all cases. The need for a preliminary orthopedic phase with its modality must be established case by case, relating to the severity of ischemia, to the time elapsed between trauma and surgery, to the peculiarities of skeleton and joints lesions.

Carotid surgery without angiography is possible and safe.

BACKGROUND: To evaluate the possibility to perform carotid surgery without angiography. METHODS: From January 1994 to June 1998, 514 patients with carotid obstructive disease were operated upon, 225 of them (43.8%) without previous angiography; 55 out of 68 (80.8%) during the last six months. Eighty-one (36.0%) had lateralizing symptoms, 50 aspecific ones (22.2%) and 94 were asymptomatic (41.8%). All patients were investigated by color-coded duplex sonography (CDS) of the arteries at the neck and by transcranial Doppler (TCD) and computed tomography (CT). One hundred eighty-eight patients were operated upon under local anaesthesia and 37 under general anesthesia; 204 had a carotid endartereotomy (90.7%) with patch angioplasty in 154 (75.5%), and 21 required a bypass graft (9.3%). In 26 patients (11.5%) an indwelling shunt was needed. RESULTS: Findings at surgery were consistent with CDS for plaque composition, ulcerations and degree of stenosis. There were no early deaths. Neurologic or ocular deficits occurred in 2 cases (0.9%). No strokes were observed in follow-up from 6 to 34 months. CONCLUSIONS: Carotid endarterectomy can be done without angiography in selected cases provided CDS plus TCD are of high quality. Under such conditions it can be considered a safer way to deal with carotid obstructive disease.

Tall cell variant of papillary carcinoma coexisting with chronic lymphocytic thyroiditis. A case report.

BACKGROUND: Recent studies have shown a correlation between lymphocytic thyroiditis and papillary carcinoma of the thyroid. It is thought that autoimmune thyroiditis could be a risk factor for the development of thyroid carcinoma, mainly for the papillary variant. CASE: A 59-year-old female presented with a history of enlargement in the neck and five months of dysphagia. Clinical examination showed generalized expansion and an increase in the hardness of the thyroid gland. Hormonal outline showed subclinical hypothyroidism with serum levels of TSH slightly elevated (5 micrograms/dL; range, 0.25-4). Thyroglobulin antibodies and thyroperoxidase titers were moderately positive. Given these results, a diagnosis of chronic thyroiditis was made. Thyroid ultrasound scan showed diffuse gland irregularity and the presence of a solitary nodule (2.3 cm in diameter) localized in the right lobe. Fine needle aspiration biopsy (FNAB) of the nodule was performed under ultrasound guidance. CONCLUSION: Although clinical and laboratory results supported the diagnosis of autoimmune thyroiditis only, FNAB of the nodular lesion provided evidence of a rare case of papillary carcinoma, tall cell variant, confirmed by histologic results.

[Value of immunohistocytochemistry in the diagnosis of laterocervical masses in patients with a previous history of thyroid carcinoma]. / Valore della immunocitochimica nella diagnosi di masse laterocervicali in pazienti con pregresso carcinoma della tiroide.

BACKGROUND: The aim of this study is to evaluate the additional diagnostic significance of immunocytochemical staining of thyreoglobulin (TG) in Fine Needle Aspiration Biopsy (FNAB) of neck lymph-nodes, in patients with a previous history of thyroid carcinoma. METHODS: Twenty-five smears performed by ultrasound-guided FNAB on laterocervical nodes with a 21-23 gauge needle were evaluates. All smears were stained according to Papanicolaou and microscopically examined. RESULTS: Of these 25 smears, 15 were diagnostic and 10 were non diagnostic. Of the 15 diagnostic cases, 10 were positive for metastatic lesions from thyroid neoplasm and the other 4 were classified as reactive lymphoadenitis. One smear for each case was selected for the immunohistochemical stain. All the 10 non-diagnostic cases showed no reaction to thyreoglobulin. Neoplastic cells, from 9 out of 11 cytologically positive smears, expressed thyreoglobulin in the cytoplasm. In one case no reaction was evident and the other one was discarded for technical reasons. In 3 of the 4 cases cytologically classified as lymphoadenitis, immunoreactive thyreoglobulin was not found. In the fourth case, blastic-like cells showed a scanty cytoplasmic rime which was immunoreactive for TG and thus was classified as a metastatic tumour. On this basis, it is suggested that FNAB should be performed routinelly in the diagnostic evaluation of neck masses of unknown origin in patients with a previous history of thyroid neoplasm. CONCLUSIONS: If the FNAB is inconclusive, a second aspiration should be performed while immunoperoxidase stain to evidentiate TG may be an adjuntive diagnostic tool in cytologically negative cases.

Aorto-iliac/femoral reconstructions in patients with vasculogenic impotence.

One hundred and forty-eight patients out of 386 undergoing aorto-iliac or aortofemoral bypass had preoperative impotence, 37 of these were diabetics. In all of them Doppler studies revealed a penile/brachial pressure index less than 0.6 and an abnormal waveform analysis. Nocturnal penile tumescence was investigated in 44 cases and found to be abnormal. Angiography showed unilateral or bilateral obstructive lesions of the hypogastric arteries in 80%, in addition to aortic, common and external iliac and femoral lesions. One hundred and thirty patients (87.8%) had straight aorto-iliac/femoral bypass grafts inserted without a direct attempt to revascularise the hypogastric arteries but 24 had distal anastomoses to the bifurcation of the common iliac artery. In the remaining 18 patients the hypogastric artery was reconstructed on one side by an additional bypass or reimplantation on the graft. In 22 of 106 patients (20.7%) undergoing aortofemoral bypass, 18 of 24 (75%) with the distal anastomosis to the iliac bifurcation, and 14 of the 18 (77.7%) with revascularisation of the hypogastric arteries, erectile function was regained. A good result was obtained in only five of the diabetic patients (13.5%). Our experience suggests that: (1) impotence, as indicated by non-invasive investigations, was vasculogenic in origin since patients with the most effective revascularisation of the hypogastric arteries had the best results; (2) when it is feasible, revascularisation of the hypogastric arteries should be carried out more often, during the aorto-iliac or aortofemoral reconstructions, particularly in younger impotent patients; (3) aorto-iliac revascularisation restores potency in only a few diabetic patients.

Prevention of deep venous thrombosis in vascular surgical procedures by LMW-heparin.

The risk of Deep Venous Thrombosis (DVT) in the immediate postoperative period varies from 0.8 to 96% of cases depending on major or minor operations and on age of patients. We have employed 8,000 I.U. AXa/daily of LMW-Heparin injected subcutaneously from one day preoperatively and prolonged for 8 days after surgical procedures in 40 patients operated upon by an aorto-femoral bypass in 25 cases, a femoro-popliteal below the knee in 8 and an extra-anatomical bypass in 7. The onset of DVP in the lower limbs was investigated by clinical examination, venous Doppler pressure evaluation, waveform analysis and echotomography and the 125I-Fibrinogen uptake test. There was no intraoperative increased bleeding and the preclotting of the prosthetic grafts was inaffected. A DVT was detected during the second postoperative day, by means of the 125I-Fibrinogen test in the calf of only one patient (1/40-2.5%), submitted to an aorto-bifemoral bypass, in whom the clinical pattern and ultrasound investigations were negative. The single daily subcutaneous administration has never caused side effects in the site of injection and it seems a real improvement in the heparin treatment. These results emphasize the advantage of the use of LMW-Heparins in patients submitted to arterial surgical reconstructions of the lower limbs for the prevention of the DVT.

Arterial repair of the lower limbs: prevention of prosthetic grafts occlusion by LMW-heparin.

The postoperative thrombosis of prosthetic grafts may be due to many factors: technical errors, poor run-off, prosthetic material, graft length, trauma by subcutaneous tunnellization or repeated microtrauma across the joint areas, evolution of atherosclerotic lesions, emorheological changes. In 50 patients submitted to surgical arterial repair of the lower limbs, we have employed 8,000 I.U. AXa/daily of LMW-Heparin, injected subcutaneously for 6 months after the operations to prevent immediate and late thrombosis. During the follow-up, one patient died, four stopped any treatment and in two the medication was changed. Hence our results are based on 43 cases: 10 patients operated upon by aorto-femoral bypass, 19 femoro-popliteal and 14 extra-anatomical procedures. During the follow-up all the patients were investigated by ultrasounds (pressure measurement, waveform analysis and duplex scanning echotomography); moreover 13/43 (30%) were studied by angioscintigraphy and 11/43 (25.5%) by a conventional or digital subtraction angiography. Thrombosis of the grafts at one year term occurred in none aorto-femoral, in one femoro-popliteal (5.2%) and in one extra-anatomical bypass (7.1%). This figure compares favourably with the results obtained in our experience in the patients treated by a variety of drugs. In such group the incidence of occlusion is 3.9% in aorto-femoral, 9.3% in femoro-popliteal and 11% in extra-anatomical grafts. Those results emphasize the possibility to improve the patency of the grafts in the arterial repair of the lower limbs by LMW-Heparin overall in femoro-popliteal and extra-anatomical areas.

The salvage of the lower limbs: choice of the prosthetic material in femoro-distal and axillo-femoral bypass.

The choice of the prosthetic material in arterial surgery of patients with rest pain and/or impending gangrene of the lower limbs still presents several problems. The poor run-off, the small caliber of the distal vessels, the crossing of the joint areas and the length of the bypass may lead to early occlusion of the prosthesis. This experience is based on 268 femoro-distal (214 femoro-popliteal below the knee and 54 femoro-tibial) and on 121 axillo-femoral/popliteal bypasses (89 axillo-femoral, 28 axillo-bifemoral and 4 axillo-popliteal). In the 389 surgical procedures we have employed the autologous saphenous vein in 208 cases, Polytetrafluoroethylene (PTFE) straight or tapered in 66, PTFE external supported (EXS) in 33, Dacron in 12, homologous saphenous vein in 7 and PTFE EXS Thin Wall in 5. In 58 cases a composite graft (autologous saphenous vein plus synthetic prosthesis) was used. The cumulative long term (12-96 months) patency is 75.96% for autologous saphenous vein bypass, 62.12% for PTFE, 75.75% for PTFE EXS, 41.66% for Dacron, 42.85% for homologous saphenous vein and 84.48% for the composite graft. All the PTFE EXS Thin Wall grafts are still patent (12 months).(ABSTRACT TRUNCATED AT 250 WORDS)

Doppler C.W. study of the lower limb venous hemodynamics during pregnancy and prevention of thrombotic complications.

Thirty-two women (14 primiparae and 18 multiparae) were submitted to clinical and ultrasound investigations during the 1st, 2nd and 3rd quarter of pregnancy and after childbirth, for the evaluation of the lower limb venous system. An increase of the venous pressure in the standing position was present in all the women during the last quarter of pregnancy. In 14 cases varices (6 primiparae, 8 multiparae) with incontinence of the saphenous-femoral valve in 10 (3 primiparae, 7 multiparae), were detected during pregnancy. In these patients a compressive bandage associated, in selected cases, to calcium-heparin therapy (25000 IU/daily) was employed. After childbirth the venous pressure resumed physiological values in 20 of the 32 women while the varices remained in 12 cases. No thrombotic complication of the superficial and/or deep venous system neither hemorrhagic episodes related to calcium-heparin therapy occurred.

Isolated symptomatic lesions of the vertebral artery: cure after surgical repair.

Nine patients with uni-or bilateral stenosis of vertebral arteries, not associated with other lesions of supraaortic trunks are reported. They showed a vertebrobasilar insufficiency syndrome not due to other assessable causes. Seven of them underwent surgical treatment always as reimplantation of the vertebral into the subclavian artery. The procedure was unilateral also in cases with bilateral lesions. In all 7 patients a favourable result was obtained: 5 patients recovered completely and 2 showed a marked improvement. The study demonstrates that the surgical repair of symptomatic unilateral lesions of vertebral arteries is able to cure the vertebrobasilar insufficiency syndrome.