[Surgical treatment of non-metastatic gastric GIST: two cases and review of the literature]. / Trattamento chirurgico dei GIST gastrici non metastatici: due casi significativi e revisione della letteratura.

Gastro-Intestinal Stromal Tumors (GISTs) represent an evolving field in oncological surgery and must be approached with specific prognostic and therapeutic criteria. In the GIST's suspicion the surgeon has to consider all the therapeutic possibilities, also for the impossibility to predict the biological behaviour and the aggressiveness of the tumor. The presence of a GIST has to be suspected in patients observed for gastrointestinal bleeding, when another pathology isn't demostrable. Surgical strategy must consider a limited resection as the best treatment, differently from what we do for adenocarcinoma. The extension of the resection can changes, regarding tumor volume and position, from extremely invasive surgery to laparoscopic operations with a partial removal of the gastric wall. Lymphadenectomy is not indicated because these tumors rarely spread to the nodes. We present the clinical case of two patients observed for gastrointestinal bleeding and with preoperative diagnostic suspicion of GIST, submitted to surgical resection. In the first case we performed a superior polar gastrectomy with esofago-gastric anastomosis for the mass proximity to the cardias. In the second patient the intervention has been a limited resection of the fundus of stomach including the tumor.

[A case of amputation neuroma of the bile duct following video-laparoscopic cholecystectomy]. / A proposito di un caso di neuroma d'amputazione della via biliare dopo colecistectomia laparoscopica.

We report a case of neuroma of the common hepatic duct arising five years after cholecystectomy (laparoscopic then converted in laparotomy). A 73-years-old patient was admitted for obstructive jaundice. Ultrasonography, TC and cholangiography showed a nodular lesion of the common hepatic of 1 cm in diameter, causing a regular and important stenosis of the main bile duct. Histologic examination demonstrated neuroma. By the analysis of this and 42 other previously published cases, the following features of bile duct neuroma were outlined: 1) variable interval between cholecystectomy and the onset of jaundice (2 months to 40 years); 2) the same incidence after laparoscopic or laparotomic cholecystectomy; 3) the generally complicated postoperative course after first surgical approach; 4) the various localizations on the biliary tree (cystic, main bile duct, intrahepatic ducts); 5) the circumstances of onset are almost the same (obstructive jaundice); 6) the histologic examination is mandatory for a correct diagnosis; and 7) the best treatment is resection of the bile duct tract involved in neuroma and reconstruction of biliary tree with hepaticojejunostomy.

[Aneurysms of the superior mesenteric artery]. / Gli aneurismi dell'arteria mesenterica superiore.

Splanchnic arteries aneurysmatic pathology is rare, even if, in the last decades it has been noticed an increase of its incidence, owing to the worldwide use of the recent diagnostic tools as echography, TC, MR and angiography. Among visceral aneurysms those of the superior mesenteric artery (SMA) range the 5.5-8%. In the majority of cases SMA aneurysms are of mycotic etiology (60%), of atherosclerotic ones are less frequent, even if their incidence has increased in the last decades. Other causes are exceptional. Dimensions are generally moderate (1-3 cm.), yet aneurysms of a significant diameter, ranging from 4 to 8 cm., are reported in the most recent literature. Aneurysms can be symptomatic with abdominal upper quadrants pain, due to the compressive mass effect on the contiguous structures. In some cases typical signs of claudication abdominis are present. A pulsating epi-mesogastric abdominal mass is present in the 50% of subjects. In the 20% of the cases the patients come to medical attention presenting a situation of hemorrhagic shock for aneurysmatic rupture in the peritoneal cavity, or in the digestive tract, considering also the possibility of a thrombosis with consequent acute bowel ischemia. Urgent surgical operations, when possible, imply an high mortality rate. For these reasons, there is indication of elective surgery for all SMA aneurysms, both symptomatic and of occasional finding. The performable surgical techniques are: proximal and distal ligation, with or without aneurysmectomy, that is the most utilized because commonly performed during emergency operations. This technique requires the presence of a sufficient collateral vascular supply. Endoaneurysmorraphy can be performed only in the case of mild-dimension saccular aneurysms. Revascularization techniques through substitution or by-pass are mandatory in managing voluminous mass aneurysms. It is reported a case of SMA aneurysm of exceptional dimensions (diameter approximatively 10 cm.) that for its enormous volume substituted completely the mesenteric axis, involving the origin of the jejuno-ileal and ileo-colic branches. In this case it has been mandatory the performing of the aorto-mesenteric by-pass technique, distally patch modelled and sutured to the residual posterior SMA wall, on the purpose to allow the revascularization of the emerging jejunal arteries and adapted to the residual distal stump to irrorate ileo-colic branches.

[Acute postoperative mediastinitis: retrospective analysis of various treatment methods]. / Mediastinite acuta postoperatoria: analisi retrospettiva di differenti metodiche di trattamento.

Infective acute mediastinitis is a postoperative complication reported in 0.5-1% of patients undergoing open chest operations. The treatment of choice for this life-threatening complication is still a matter of debate. The aim of this study was to retrospectively analyse the efficacy of different therapeutic approaches in the treatment of postoperative infective mediastinitis. In the 2nd Division of Cardiac Surgery, from October 1986 to May 2000, 10,234 patients underwent cardiac surgery operations. In 42 patients (0.4%) the operation was complicated by acute infective mediastinitis requiring surgical treatment. On the basis of the treatment opted for, these patients were subdivided into 5 groups: 23 patients underwent continuous iodopovidone (Betadine) mediastinal irrigation (GL) associated with surgical omentoplasty in 8 patients (GLO); 5 patients underwent isolated omentoplasty (GO), and 4 patients were treated with a pectoral muscle flap (GF). In 8 patients other different procedures were performed (GS). There were no deaths in GF and GS despite 24% and 20% mortality reported among patients who underwent mediastinal irrigation (GL) and isolated omentoplasty (GO), respectively. The mean hospital stay was 15 +/- 1 days in GF, 16 +/- 1 days in GS, 25 +/- 11 in patients who underwent omentoplasty and 27 +/- 14 in patients who underwent mediastinal irrigation. Predictors of death were low cardiac output syndrome (P < or = 0.009) and respiratory insufficiency (P < or = 0.032) when found before treatment. Our study suggests that surgical omentoplasty should be the treatment of choice in deep mediastinal infections, whereas wound sterilisation, associated with surgical chest wall reconstruction, seems to be a better procedure in superficial infective disease. A more extended clinical series would be needed to confirm these preliminary data.

[Acute pancreatitis: resultos of a diagnostic-therapeutic protocol in 80 consecutive cases]. / Pancreatiti acute: risultati di un protocollo diagnostico-terapeutico in 80 casi consecutivi.

The treatment of acute pancreatitis cannot be standardized in the absence of a prompt diagnosis and of an accurate severity and prognostic score. This study, based on 80 consecutively observed patients, compared the aetiological, clinical, diagnostic (laboratory and imaging) and prognostic data used to select the most appropriate therapy for each patient. The results confirm that the Ranson score shows a satisfactory prognostic relationship between the number of positive parameters and the severity of the disease. Ultrasound, which is useful for defining the aetiologic factors and in the follow-up of peripancreatic effusions, has proved to be limited as a means of imaging abnormalities of the pancreatic parenchyma. CT scans are confirmed as being the only method of accurately demonstrating the presence of necrosis and of evaluating its effective extent. ERCP was performed as soon as possible in the presence of biliary stasis or of suspect ultrasonographic signs. Surgical treatment proved necessary only in 7.5% of cases, on each occasion to drain infected necrotic foci. Promptness of the surgical indication plays an important role in the outcome of necrosectomy and drainage performed with the closed technique. Mortality was limited to 1.25% in our series. A correct diagnostic approach together with prompt treatment can reduce the mortality rate of this disease to a minimum.

[Gastroduodenal artery pseudoaneurysm ruptured at the pancreatic head]. / Pseudoaneurisma dell'arteria gastroduodenale rotto nella testa del pancreas.

The presence of splancnic aneurysms associated with pancreatitis represents an uncommon evidence (10%) but extremely formidable for the high mortality related to the elevate risk of rupture (50%). A case of a broken gastroduodenal artery pseudoaneurysm plugged in the pancreatic head in a patient with chronic pancreatitis surgically treated is reported. The Authors believe that in presence or in suspicious of peripancreatic pseudoaneurysm bleeding, showed by abdominal echography or CT scan, is mandatory the execution of splancnic and peripancreatic vessels angiography to determine the correct localization of the aneurysm, essential to determining the best surgical treatment. Gastroduodenal artery before the origin from the right epatic artery has been tied in presence of an anatomic variant of origin and division of the hepatic arteries, previously showed with the angiographic examination. The exclusion and the complete thrombosis of the false aneurysm was demonstrated with the intraoperatory Doppler control and confirmed by CT scan before the dismission. This surgical strategy avoid a pancreatic resection, potentially burdened from an higher risk of mortality and morbidity as than the artery exclusion.

[Vascular trauma of the upper extremities]. / I traumi vascolari degli arti superiori.

The aim of this study was to evaluate short- and long-term results of the treatment of upper extremities vascular trauma considering aetiology of the lesions, percentage of limb salvage and residual functional disability. The Authors retrospectively evaluated 17 patients accounting for 21 vascular lesions of the upper extremities (16 arterial and 5 venous injuries). Age, sex, modality of trauma, site of the vascular lesions and of the associated injuries, diagnostic procedures at the admission, ischemic time, arterial and venous repair performed were analyzed. The over all peri-operative mortality was 5.8%. Of the 16 arterial injuries long-term reconstruction viability was obtained in 15 patients (93.7%). In all cases limb salvage was obtained. In 3 patients invalidating functional defects due to associated injuries of the major brachial plexus were observed. The Authors believe that associated nervous lesions are the main factor determining invalidating residual disability. In this series ischemic time, technique of vascular repair performed, associated skeletal injuries didn't influence the functional outcome of the reconstruction.

[Vascular trauma of the lower limbs]. / I traumi vascolari degli arti inferiori.

BACKGROUND: This study was conducted to evaluate the results of treatment of vascular trauma of the lower extremities and those factors associated with limb loss. DESIGN: a retrospective evaluation of a series with lower extremities vascular trauma. SETTING: University Hospital. METHODS: Thirty-one patients accounting for 45 vascular lesions of the lower extremities (27 arterial and 18 venous injuries), over a 15 years period ending December 1998. Age, sex, modality of the trauma, site of the lesion and associated skeletal injuries, diagnostic procedures, ischemic time, arterial and venous repair performed were analyzed. RESULTS: Perioperative mortality was 7.4%. For arterial injuries, limb salvage was obtained in 22 patients (81.5%). Five amputations (18.5%), 1 primary and 4 secondary have been performed. Amputation rate was 26.7% for popliteal lesions versus 8.3% for other locations, 40% when a skeletal lesion was associated versus 5.9% for those without such injuries, 37.5% for reverse saphenous vein interpositions versus 5.6% for arterial repair without interposition. CONCLUSIONS: In this study, the factors influencing limb loss in vascular trauma of the lower extremities are popliteal location, the association with skeletal injuries, the need of saphenous vein interposition for arterial repair.

[Primary malignant tumor of the 4th duodenal segment at the angle of Treitz. Report of a case]. / Tumore maligno primitivo della IV porzione duodenale esteso all'angolo di Treitz. Descrizione di un caso clinico.

A case of 34-years old woman with adenocarcinoma of the IVth duodenal segment extended to the angle of Treitz, treated with duodenojejunal segmentary resection, is described. Clinical features and diagnostic strategies are reported. Personal observation compared with Literature confirms the difficulty of an early diagnosis. The most appropriate surgical techniques for the treatment of these particularly and uncommon neoplasms often discovered in advanced stage are discussed. The better prognosis of these adenocarcinomas compared with those of the proximal duodenum (Ist and IInd segments) can be supported by embryological differences currently to be investigated.

[Hilar localization of splenic cyst does not always exclude the possibility of resective treatment]. / La localizzazione ilare di una cisti splenica non sempre esclude la possibilità del trattamento resettivo.

Non parasitic cysts of the spleen require surgical treatment because of their progressive growth and in order to prevent the potential severe complications associated with such cysts. Since it is now well known that total splenectomy, especially in young patients, has potential for short- and long-term complications, much emphasis has been placed on splenic salvage, suggesting partial splenectomy as procedure of choice for splenic cysts. However various Authors suggest that many but not all splenic cysts can be treated with partial splenectomy. In particular cystic mass arising from the anterior aspect of the hilum near to vascular peduncle contraindicate partial resection requiring splenectomy. In a case observed TC scan demonstrated a very large epidermoid cyst penetrating hilar parenchyma just above splenic vessels insertion. Preoperative imaging suggested splenectomy as the only possible procedure to remove the cyst. At operation the exposure of the splenic artery extended proximally along the pancreatic tail showed an arterial branch running with satellite vein in the splenopancreatic ligament for inferior segment of the spleen. As we found this branch it was possible to resect cyst preserving a large inferior parenchymal segment normally perfused and functioning at postoperative scintigraphic controls. In conclusion not all hilar cysts must be considered an absolute indication to splenectomy. An accurate and extensive exposure of splenic artery and vein can demonstrate vascular anatomical variations permitting resection also for large cysts located near the splenic hilum.

Solitary metachronous splenic metastases: an evaluation of surgical treatment.

Splenic metastases occurring after primary tumor removal and apparently solitary have been documented only recently in Literature. They are, most of the times, clinically asymptomatic and their presence is casually determined by ultrasonographic follow-up in subjects otherwise in good conditions. The belief that splenic metastases occur only in disseminated cancer is today no longer accepted. Some Authors consider solitary splenic metachronous metastases eligible for surgical treatment as well as pulmonary or hepatic metastases. In the case presented, surgery was required due to abscess formation of a splenic metastasis, which was not responding to chemotherapy. Our experience, like others reported in Literature, verified a long-term post-operative survival in spite of limited disease-free time. Surgical treatment by splenectomy can be indicated in selected patients, considering that chemotherapy has been proved to be ineffective in the treatment of splenic metastases.

[Indications and short and medium time results of crossover bypasses in the treatment of obstructive arteriopathies of the lower limbs]. / Indicazioni e risultati a breve e medio termine dei pontaggi cross-over nel trattamento della arteriopatia ostruttiva degli arti inferiori.

The authors evaluate the indications, the hemodynamical aspects, the short and medium term results over their track record of 49 crossover bypass (44 dacron and 5 PTFE grafts) performed between 1981 and 1993. Crossover bypass grafts were mainly inserted for unilateral iliac arterial disease in order to avoid aortic manipulation. This procedure was particularly selected when in presence of: young patients (< 60 years old), high surgical risk, poor run-off, high risk of prosthetic infection, thrombosis and/or infection of orthotopic grafts. 3 ilio-iliac, 27 iliofemoral, 18 femorofemoral and 1 femoropopliteal bypass have been performed. The postoperative resting pressure Index increase was highly significant in recipient limbs. There wasn't perioperative mortality; during the follow up (mean 24.4 months) no amputation of recipient limb was observed. 4 patients died of A.M.I. and 1 of neoplastic disease. Late cumulative patency rate was 81% at 2 years and 67.3% at 3 years. These values rise to 97.2% and 86.1% respectively when considering patients with "ideal" indication (excluding 7 patients operated on for complications of previous bypass grafts and 6 with extremely poor run-off). An accurate evaluation of the lesion topography and haemodynamic pattern of donor and recipient iliofemoral districts are stressed as key points for a correct surgical indication.

Ki67 immunohistochemical evaluation in colorectal cancer and normal colonic mucosa. Possible clinical applications.

Cell proliferation was evaluated by Ki67 monoclonal antibody in 33 colorectal adenocarcinomas and in the normal colonic mucosa. Immunoreactivity was assessed independently by two observers in two subsequent evaluations with a semiquantitative method, by counting at least 2000 cells in two distinct neoplastic specimens (central and peripheric section). There was an excellent intra-inter observer agreement in Ki67 score for each specimen. The tumor score range from 7 to 70% (median 48.8), without any significant correlation with sex and age of the patient and location, size, staging and grading of the neoplasm. Tumor Ki67 score was almost identical in central (46.96%) and in peripheral section (49.24%), and always higher than in normal mucosa. There was no distinction in Ki67 score in normal mucosa at various distances from the tumor. In our experience, Ki67 provides a reliable and reproducible method for assessment of proliferative activity; its clinical applications need further studies.

Monitoring of somatosensory evoked potentials during carotid endarterectomy: relationship with different haemodynamic parameters and clinical outcome.

The authors studied the changes of Somatosensory Evoked Potentials (SEPs) performed in 241 anaesthetised patients during 264 carotid endarterectomies (CEs). SEP responses were considered significantly modified when the central conduction time was greater than 1 ms and/or when the amplitude of the complex N20-P25 decreased by at least 50%. Both CCT and N20-P25 have been correlated with different parameters, including the presence or absence of preoperative neurological deficits, the type of general anaesthesia, the status of the contralateral and the ipsilateral carotid artery, stump pressure, the use of an intraluminal shunt and the perioperative results. After carotid cross-clamping SEP responses were within the normal range in 236 CEs (89%), and abnormal in 28 (11%). A shunt was inserted 23 times in 264 (9%) cases. None of the patients operated on in this series experienced a permanent neurological deficit; there were three (1.1%) transient deficits (two Rinds and one TIA) and two deaths from non-neurological causes. Only one of the transient deficits was present when the patient woke from the anaesthetic and this event was predicted by significant modification of the SEP which did not reverse after removal of the clamps (a shunt was not used). None of the patients in our series who did not present significant modifications of SEPs during the operation had any postoperative neurological deficit. The authors conclude that SEP recording is a highly reliable and objective method for continuous monitoring of brain function during CE.

[Carotid thromboendarterectomy in old age]. / La TEA carotidea nell'età avanzata.

Data obtained in 323 carotid bifurcation endarterectomies and in 77 patients affected by extracranial internal carotid artery stenosis not operated, have been analyzed in relation to patients' age: Group 1 less than or equal to 69 years old (268 cases operated on and 59 not operated), and Group 2 greater than or equal to 70 years old (55 cases operated on and 18 not operated). Among the operated patients, the most important anaesthetic risk factors, the type of neurological symptoms, and the diameter of the lesion did not turn out significantly different between the two age groups, except for the patients operated on because of stenoses less than or equal to 50% of carotid lumen reduction (42 cases in Group 1 and 1 case in Group 2, p less than 0.001). The overall operative mortality rate was 1.8% (6/323 carotid endarterectomies): 1.5% in Group 1 (4/268 cases, 2 due to stroke and 2 to heart disease), and 3.6% in Group 2 (2/55 cases, both due to stroke) (N.S.). The overall neurological morbidity was 0.6%, owing to 2 strokes both found in Group 2 (3.6% of patients greater than or equal to 70 years). Therefore, the overall incidence of fatal and non fatal stroke was 1.8% (6/323 carotid endarterectomies): 0.7% (2 cases) in Group 1, and 7.3% (4 cases) in Group 2 (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Peroperative morbidity and mortality in thromboendarterectomy of the carotid bifurcation in patients with a previous stabilized stroke. Our results and review of the literature]. / Morbilità e mortalità perioperatoria della tromboendoarterectomia della biforcazione carotidea in pazienti con pregresso ictus stabilizzato. Nostri risultati e revisione della letteratura.

Carotid endarterectomy (CE), when performed in patients with previous stable stroke followed by complete or almost complete recovery, seems to be affected by a higher peroperative risk. From January 1982 to March 1988, we performed 230 CE in 207 patients, 188 (81.8%, Group 1) in patients with TIA or an asymptomatic plaque and 42 (18.2%, Group 2) in patients with previous strokes. The need for a temporary indwelling shunt has been evaluated with the measurement of carotid back pressure and, in the last 100 CEE, with the monitoring of somatosensory evoked responses (the shunt has however been used routinely anyway in the very first part of our experience). The incidence of carotid back-pressure values and of positive somatosensory evoked responses were similar in the two groups of C.E., even if the differences in the prealable evaluation were not statistically significant. The shunt has been nevertheless used more frequently in Group 2 (40.5 vs 28.2%). Statistical analysis has been performed with the chi 2 method. The incidence of permanent and transient neurologic deficits and of the peroperative mortality due to neurological and non-neurological causes was, respectively, 0.5, 2.6, 1.6, 0% (Group 1) and 2.4, 7.3, 2.4, 2.4% (Group 2) (non-significant). If we exclude the first 50 operations (in which technical and/or anaesthesiological problems may have influenced the neurological outcome of the patients operated upon), the previous values become, respectively, 0,07*, 0,7, 0% (Group 1) and 0, 5,5*, 0, 2,7% (Group 2) (*p less than 0,01, the only significant difference).(ABSTRACT TRUNCATED AT 250 WORDS)