Type III dissection according to DeBakey. Comments on 45 cases treated.

BACKGROUND: There is uncertainty regarding the most suitable form of treatment for both chronic and even more so the acute forms of DeBakey's type III aortic dissections. This retrospective study analyses the indications and methods used in 20 acute cases and 25 chronic cases of type III dissection. METHOD: The 45 patients included in this study presented a high index of operability given that they were selected from more than one coronary unit and referred to our service for this purpose. This study also confirmed a clear indication for medical treatment in uncomplicated acute forms, whereas it is necessary to opt for surgery in the case of ongoing or threatened complications. In chronic forms aorta diameter and/or thrombosis of the false lumen are a valid parameter. RESULTS: The incidence of mortality was 33.3% in the 12 acute forms undergoing surgery, with 4 deaths; in the case of chronic forms undergoing surgery, the incidence was 15% with 3 deaths. Of the 8 patients with acute pathology who were not operated, 87.5% died; whereas of the 5 non-operated chronic patients, 60% died (3 cases). During the post-operative period rethoracotomy was only necessary in 1 case following hemothorax on day 5, whereas at a respiratory level only 50% of patients were extubated within 48 hours, and in 12 cases it was necessary to continue until day 5-7, whereas tracheostomy was performed in 5 cases. CONCLUSIONS: The modern tendency in the treatment of DeBakey's type III acute dissections is to opt for surgery not only in the presence of manifest complications, but also when faced with threatened complications or the failure of medical treatment. Chronic forms present the two key indications for surgery, namely aneurysmatic evolution of the wall (> 5-6 cm) and absent thrombosis of the false lumen.

The dacron aorta.

Total aorta replacement is a major and increasingly successful surgical procedure. The paper describes a patient whose progressive aneursymatic disease spread from the ascending segment to the bifurcation over a three-years period during which time after three separate operations, the aorta was totally replaced. The paper describes the diagnostic and surgical procedures deployed and shows the results of angiographic and CT scans. Credit for the success of the replacement is also given to the highly skilled anaesthetists and nurses involved.

[Surgery of the descending thoracic and thoraco-abdominal arteries. Report of 105 cases]. / La chirurgia dell'aorta toracica discendente e toraco-addominale. A proposito di 105 casi.

The Authors show their casistic of about 105 cases of thoracic descending and thoraco-abdominal aorta pathologies between 1.1.1993 and 30.12.1995. After a short introduction about the improvements in anesthesia and reanimation of these pathologies as well as the good reliability of diagnostic and currently available instruments, mortality and mobility parameters are taken into account, the last one referring to paraplegia and ARF. The casistic is evaluated splitting the cases into 2 groups, urgent surgery and election surgery, and differentiating the aneurysm type from the dissection type. Besides, the mortality and mobility are reported for any pathology, with a discussion of the parameters which drove the choice of the most suitable methodology to be adopted (ECC femoro-subclavian shunt, simple clamping). The results achieved show a mortality of 40% in urgency, between 5 and 15% in election, with a rate of paraplegia around 8-10% and a ARF between 5 and 15%. These data match the literature statistics and support the quality of the adopted methodologies.

[The superior vena cava occlusion syndrome. A case of neoplastic thrombosis due to hepatocarcinoma and cirrhosis]. / Sindrome da occlusione della vena cava superiore. Su di un caso di trombosi neoplastica da epatocarcinoma su cirrosi.

The authors report their experience with 11 patients, surgically treated since 1990, affected with superior vena cava syndrome. A peculiar case of neoplastic thrombosis in hepatocarcinoma is stressed. In fact a similar case hadn't been reported in the last ten-year literature, although hepatocarcinoma may spread in different organs. A subject review and a discussion are presented.

Surgical treatment of carotid kinking.

The authors take in exam 34 anatomical variation in the extracranial internal carotid artery (compared with more than 450 operated carotid artery), 15 of which involved kinking in patients with overt neurological symptoms, underwent corrective surgical treatment, and test the most useful and appropriate techniques in any case.

[Spinal cord protection in surgery of the thoracic, descending, and thoraco-abdominal aorta. Comparison of methods]. / La protezione midollare nella chirurgia dell'aorta toracica, discendente e toraco-addominale. Metodiche a confronto.

The authors compare the strategus needed for the elimination of paraplegia and for protection of abdominal organs after replacement of descending thoracic or thoraco-abdominal aorta. They analyse single technique considering the advantages and the controindications; furthermore they compare these properties and those of possible variants in the light of the presentation; type of disease and general conditions of the patient. These considerations are in agreement with later literature as well as the attitude of the surgeon.

[Pseudoaneurysms after carotid endarterectomy]. / I pseudoaneurismi postendoarterectomia carotidea.

Pseudoaneurysms after TEA of the internal carotid artery are one of the rarest and most severe complications of this form of surgery. Their etiology appears to depend on 3 causes: a suturing defect due to technical errors made by the surgeon or to the incorrect choice of threads; an infections, and lastly the arterial wall weakened by TEA. The patch increases the risk of false aneurysm approximately four fold. We therefore agree with other authors that, in spite of the undoubted value of the patch in the prevention of restenosis, it must only be used in the presence of an internal carotid of small diameter (less than 4 mm). Contrary to what is reported in the literature we performed both these operations under loco-regional anesthesia and a detailed knowledge of this method allows is to be performed on the carotid axis. Only through a careful follow-up of all the carotids operated can the small dilations which often do not require surgical treatmente identified. The two cases reported here were treated by the removal of the pseudoaneurysms and its replacement with a prosthesis in one case and with the vena saphena in the other. Both were monitored with clinical examination and echo-Doppler and no recidivation has been reported to date.

[Invasion of the chest wall in primary lung neoplasms]. / L'invasione della parete toracica nelle neoplasie polmonari primitive.

The authors analyse a series of 5 patients who underwent pulmonary and parietal resection between 1990 and 1993 due to non.microcytoma bronchogenic carcinoma with invasion of the thoracic wall. The patients comprised four men and one woman aged between 45 and 69 years old. Thoracic pain was present in two patients. Pulmonary resection with extrapleural stripping was performed in two patients whereas a block resection from one to five ribs and the corresponding intercostal spaces was performed in the other three patients. The authors' approach is not to perform these operations according to rigid protocols but to adapt them according to the local status of tumour invasion. Therefore to resort to extrapleural resection when there is a free cleavage plane between parietal pleura and rib wall; resection in block of the wall where the carcinoma has infiltrated the endothoracic fascia or deeper. The authors do not report any major complications and record a postoperative mortality rate of 0%. In two cases the thoracic wall was reconstructed using a sheet of Gore-Tex which did not provoke rejection phenomena. Radiotherapy was carried out in cases with positive lymph nodes. The series presented here is too recent to provide significant data regarding survival. However, the only factor seen to influence prognosis in the five patients was the presence or otherwise of lymph node metastasis, irrespective of the histological type and operation performed. The five year survival rate of T3N0M0 patients is in fact similar to that of T2N0M0 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Hepatic resection. A contribution and its analysis]. / Resezioni epatiche. Un contributo e la sua analisi.

The authors outline their experience in the field of resective hepatic surgery, both with regard to benign and malignant pathologies, and analyse the results in relation to indications and techniques, but also focusing attention on the assessment of postoperative functional alterations, in order to evaluate the hepatic reserve and the organ's response to demolitive surgery. All operations were carried put in the First Division of Surgery at the Ospedale Civile, Asti, from January 1989 to September 1992. In all cases, even in major hepatectomies, a "trans-parenchymal" technique was adopted. Before surgery tests were carried out in relation to the topography of disease, its nature, associated pathologies and the functional hepatic reserve. Operative mortality was zero and morbidity was negligible, probably because rigorous selection criteria and indications for surgery were adopted. Morbidity was even restricted in the two patients suffering from HCC on cirrhosis (?) and this may probably be attributed to the limitation of resection to solely oncological purposes and their classification as Child-Pugh's stage A. The results regarding the liver response to demolitive surgery appear to be indicative and revealed a highly significant and discriminating difference between elective and emergency surgery.

[The suprainguinal approach in surgery on the internal saphenous vein for varices of the lower limbs]. / La via di accesso soprainguinale nella chirurgia della vena safena interna per varici degli arti inferiori.

The authors report their experience relative to 134 patients with lower limb varices surgically treated. An upper inguinal incision of the skin was employed to approach the saphenofemoral junction, obtaining by this means an aesthetic suture, with better asepsis and lower incidence of local complications.

[Major and minor complications in carotid surgery]. / Complicanze maggiori e minori in chirurgia carotidea.

The Authors report their experience of major and minor complications in carotid surgery. They analyse the causes and emphasize that a thorough preoperative study and a quick surgical technique are very important in reducing the rate of complications in this essentially preventive form of surgery.

[Tumors of the anus]. / I tumori dell'ano.

On the basis of an analysis of a personal series of anal tumours, it is concluded that the polychemotherapeutic protocol with mitomycin and 5-fluorouracil and extensive local tumour removal proposed by Nigro et al. could present a valid alternative to Miles anorectal amputation. The treatment proposed offers better quality of life for the patient without changing oncological radicality and survival.

[Lesions of the colon caused by pancreatitis]. / Lesioni del colon da pancreatite.

A case of stenosis of the splenic flexure of the colon consequent on acute pancreatitis is reported. Literature reports on the colic complications of pancreatitis are examined, analysing the pathogenetic mechanisms, clinical pictures and therapeutic problems involved in this pathology.

[Palliative gastric resection]. / Le resezioni gastriche palliative.

The surgical treatment of stomach carcinoma is reassessed. Stress is laid on the more aggressive attitude with regard to advanced gastric cancer where total or partial palliative resection is the only operation offering good results. This tendency emerges both from the series presented and those reported in the literature. It is concluded that if more aggressive surgery is justified in IVth stage stomach tumours it must still depend on the patient's general condition.

[Diabetes mellitus as a risk factor in vascular surgery]. / Diabete mellito quale fattore di rischio in chirurgia vascolare.

The paper reports a series of 23 diabetic patients affected by occlusive arterial disease of the lower limbs treated by reconstructive vascular surgery. Revascularisation interventions were performed in 9 patients affected by claudication, with good long-term results. Fourteen patients underwent operations for limb salvage. The major amputation rate was 35%.

[True or primary splenic cysts]. / Cisti vere o primarie della milza.

Two cases of splenectomy are reported following the diagnosis of a rare pathology of the spleen in the form of two primary, non-parasitic and non traumatic spleen cysts. One was located on an epithelial wall and the other on an endothelial wall.

[Early gastric cancer. A follow-up of 20 cases]. / Early gastric cancer. Follow-up di 20 casi.

The paper describes 20 cases of early gastric cancer diagnosed by endoscopy and multiple biopsies, combined with x-ray tests using a double contrast medium, with the aim of reducing the number of false negatives. Surgery was modified according to the site and macroscopic characteristics of the neoplastic lesion (type 1, 2a, 2b: total gastrectomy + extended lymphadenectomy; type 2c and 3: gastric resection, except for different indications according to the site). In line with data reported by other Authors, the five-year survival rate was 90%.

[Gastric polyps: endoscopic and surgical treatment]. / I polipi gastrici: trattamento endoscopico e chirurgico.

A personal series of gastric polyps is reported. The therapeutic approach is described together with the results obtained. Comparison are made with literature.

[Type III entrapment syndrome of the popliteal artery. Presentation of a clinical case with diagnostic and therapeutic discussion]. / Sindrome da "entrapment" della poplitea tipo III. Presentazione di un caso clinico con discussione diagnostica e terapeutica.

Following a short review of the various types of possible abnormalities in the popliteal artery entrapment syndrome, a case is presented which was misdiagnosed for more than 2 years. Problems concerning the differential diagnosis are discussed together with details of the surgical approach performed using the medial incision and the PTFE prosthesis.