Indications and results of the surgical treatment in Raynaud's phenomenon.

203 patients submitted in the last 20 years to surgery, first by Smithwick's sympathectomy, then by Adson's gangliectomy and lastly by Telford's gangliectomy, were controlled. The frequency of true Raynaud's disease is with time decreasing and is found today in the minority of the patients suffering from Raynaud's phenomenon and surgically treated. Immunological tests detect frequent associated autoimmune disorders to be treated before surgery. Surgical indication is today selective. For this reason long term results are improving: 90% of positive results in the last series against 73% and 60% respectively in the previous series.

Prevention and early diagnosis of cancer in the rectal stump of ulcerative colitis patients after colectomy and topical treatment.

Ulcerative colitis with malignant degeneration and dysplasia can be a precancerous lesion. Therefore, it is necessary to prevent or, at least to diagnose as early as possible any development toward neoplasia in the colon or rectum of the colitis patients. The only reliable guide for a risk of malignant tissue degeneration is dysplasia of the mucosa. A group of 31 patients was studied after total colectomy with ileorectal anastomosis and subsequent topical treatment with enemas containing sulphasalazine and corticosteroids. Two of these patients had mild rectal dysplasia before surgery, seen in a biopsy specimen obtained endoscopically. All the patients were followed for a long time after surgery, with endoscopy and microscopic and ultrastructural observation of rectal biopsy material taken from different sites in the mucosa, both from areas that looked dysplastic by endoscopy and from those that appeared normal. The two patients with presurgical dysplasia, when examined later, one 12 months and one 18 months after surgery, had no rectal dysplasia; the mucosal covering was moderately complete and the anastomosis was functioning. It is considered that to prevent development of cancer in the rectal stump, colectomy should always be followed by regular topical treatment and there should be a check-up at short intervals for early diagnosis of any premalignant areas that might develop. Regression of such lesion was observed to lesser degrees after continuous treatment with the topical medication.

[Bile-dependent gastrointestinal dyspepsia]. / Le dispepsie gastrointestinali biliodipendenti.

"Indigestion" caused by organic and functional alterations in the biliary ways was examined. The difficulty of accurately identifying this form of dyspepsia, whose frequency explains the interest it arouses, is emphasised. Dyspepsia attributable to dyskinesia of the biliary ways and post-cholecystectomy syndrome is specifically analysed. After a review of the results obtained by the medical and surgical treatment of biliary dyspepsia, a more accurate nosologic and pathogenetic classification of the disease is recommended, together with a more detailed definition of the action mechanism of the biliary acids.

Surgical treatment of morbid obesity.

The classical indications for the surgical treatment of morbid obesity is weight of at least 50% (males) and 80% (females) over the ideal body weight, in patients between 14 and 55 years of age. These limits are now being extended both to less overweight patients and to patients over 55 years of age. Jejunoileal bypass is the treatment of choice for severely overweight patients in good general condition, allowing them to continue with their eating habits. Gastric bypass is indicated in elderly patients or in patients with previous liver diseases. It should not be performed in younger patients because of the irreversibility of the procedure. A careful postoperative long-term follow-up is necessary to prevent the complications associated with each type of operation.

Pneumatosis cystoides intestinalis and jejunoileal bypass.

The authors present a case of pneumatosis cystoides intestinalis, observed by chance in a patient previously subjected to end-to-end jejunoileal bypass for severe obesity. Using their observation and the cases reported in the literature as a starting point, the authors discuss the etiopathogenetic and clinical aspects of the disease, and briefly indicate what is, at present considered the correct therapeutic approach.

Topical treatment of experimental skin lesions in rats: macroscopic, microscopic and scanning electron-microscopic evaluation of the healing process.

The effects of the topical antiseptic agents mercurochrome and silver nitrate and of sodium hyaluronate on the process of wound healing were assessed by macroscopic examination, light microscopy histology, electron microscopy and scanning electron microscopy of wounds made by cutting or by abrasion of the skin of rats. It was found that wounds treated with hyaluronic acid underwent longer periods of inflammation (proportional to the presence of mastocytes) and greater amounts of collagen deposition than wounds that were either untreated controls or treated with silver nitrate or mercurochrome, but this did not impede the formation in the early stages of healing of bridges of fibrin between the edges of the wounds.

Pouch ileitis in excluded reservoir: an unusual complication of restorative proctocolectomy for ulcerative colitis.

One case of pouch ileitis after restorative proctocolectomy for ulcerative colitis is described. Diagnosis was made by endoscopy, histology and electron microscopy. The most prominent feature was intense inflammation of the mucosa and submucosa, with atrophy of the villi, and colonic metaplasia, occurring before closure of the loop ileostomy. The patient improved after a course of metronidazole therapy, but ileostomy closure was postponed. It appears that the ileum mucosa of patients with ulcerative colitis is highly prone to the development of inflammation and careful, regular follow-up is recommended.

Surgical therapy for morbid obesity.

The results of jejunoileal bypass for morbid obesity were studied in 192 operated patients. Mean weight loss was 39.3% of initial weight and 80.5% of overweight. Medical benefits (such as improved glucose tolerance, lowered blood pressure, healed Pickwick syndrome, etc.) were maintained during the follow-up (average five years). The most feared complication of the jejunoileal bypass is severe hepatic failure, which appeared in 2.3% of the cases, only after the end-to-end jejunoileal bypass, and never more than 12 months after surgery. Most patients had satisfactory and lasting results due to a careful and assiduous postoperative follow-up, and to the strict co-operation between the medical staff and the patient. Medical therapy in the preoperative period was useful to control the weight gain by administration of a hypocaloric definite diet. In the postoperative period, we usually got benefits for the bypass induced intestinal malabsorption by administration of supportive vitamins and electrolytes. To prevent liver diseases we often found intestinal-specific antibiotics, aminoacidic solutions, hyperproteical diet and anti-steatosis agents helpful.

The role of mast cells in wound healing.

Mast cells are known to participate in three phases of wound healing: the inflammatory reaction, angiogenesis and extracellular-matrix reabsorption. The inflammatory reaction is mediated by released histamine and arachidonic acid metabolites. Compound 48/80 and disodium-cromoglycate are both able to increase skin breaking strength shortly after wounding. Under light and electron microscopy we found that small, granule-poor, irregular mast cells (MLMC) accumulate in the wound. This suggests that the small MLMC (mucosal-like mast cells) migrate into the skin during wound healing, and that both CTMC (connective-tissue mast cells) and MLMC are involved in tissue repair. Moreover, there is some evidence that mast cells participate in angiogenesis, since heparin is able to stimulate endothelial-cell migration and proliferation in vitro, and protamine to inhibit these processes and also angiogenesis in vivo. When the effect of protamine on wound breaking strength was examined, we encountered a decrease which was not prevented by heparin administration. Further studies are needed to demonstrate that protamine is specifically involved in inhibiting heparin-mediated angiogenesis in wounded tissue. Finally, mast cells may play a role in the extracellular matrix remodelling, on the basis of in-vitro experiments (but there are still no in-vivo data).

Differential diagnosis of Crohn's disease of the colon from ulcerative colitis: ultrastructure study with the scanning electron microscope.

Mucosal biopsies from patients with Crohn's disease and with ulcerative colitis were studied by scanning electron microscopy. Important abnormalities of the mucosal surface were found in both diseases. For Crohn's disease, the characteristic abnormality was loss of the regularity of the polygonal units, but with preservation of the mucosal integrity and of the normal mucosal design. For ulcerative colitis, the abnormalities were disorganization of the cells, signs of sloughing, and superficial erosions. Patients with Crohn's disease always had a significantly increased number of muciparous cells, while those with ulcerative colitis had obvious signs of decreased mucus production. The lesions of ulcerative colitis could be seen under the scanning electron microscope in mucosal areas that appeared normal endoscopically. We feel therefore that scanning electron microscopy of biopsy specimens from patients with inflammatory bowel diseases can be of great help in differential diagnosis.

Prostaglandin cytoprotection in man: effectiveness of rosaprostol.

We studied the effect of a new prostaglandin analogue, 9-hydroxy-19,20-bis-norprostanoic acid (rosaprostol), on the duodenal mucosa of humans after administration of 40% ethanol. Eighteen healthy volunteers entered the study, which followed a blind cross-over design. At time 0 all the volunteers received rosaprostol or placebo; 5 minutes later, 40% ethanol (50 ml dose) was given. The mucosa was examined for lesions 3, 60 and 180 min later under endoscopy, light and scanning microscopy. It was found that: (i) 40% ethanol damaged the duodenum, with blood extravasation, inflammation and necrosis of the mucosa, (ii) rosaprostol significantly protected the mucosa 3 min after 40% ethanol, and (iii) the damage became worse after 3 h when placebo was given, whereas it was reduced after 1 h when PG was administered. The results suggest that PGs not only protect the mucosa against ethanol damage, but also stimulate its recovery.

[Microsurgery and associated therapies for the treatment of lymphedema of the limbs]. / La microchirurgie et les thérapies associées pour le traitement des lymphoedèmes des membres.

Between 1967 and 1986, 170 cases of primary or secondary lymphedema of upper or lower limbs were operated upon using the indirect lymphaticovenous anastomosis technique proposed by Degni. For the lymphedema of upper limbs secondary to axillary lymphadenectomy for breast cancer, satisfactory results were obtained in 40% of cases, the figure rising to 72 and 74% for primary and secondary lymphedema of lower limbs respectively. When surgery is unsuccessful or contraindicated a new therapeutic method is proposed: thermotherapy as developed by Pr. Chang's team in Shanghai based on an ancient traditional Chinese medical method. With the collaboration of a biomedical engineer, a new microwave oven has been constructed and tested for the treatment of lymphedema, and its characteristics are described. Treatment is ambulatory, 45 minutes per day, 5 days per week over 3 weeks. It is very important that patients wear an elastic contention stocking (40 mmHg) between sessions. A total of 55 patients have been treated in this way, most (45) failing to improve after other medical or surgical treatment. All cases treated were of severe lymphedema and subjective and objective (ultrasonography) improvement was noted in 51%, the other 49% obtaining only subjective relief. According to Chinese authors results are maintained after 10 years. Follow up of the present series has been a maximum of one year and longer surveillance is necessary to assess long-term efficacy.

[Treatment of cancer of the lung. Considerations on a current problem]. / Trattamento del cancro del polmone. Considerazioni su di un problema di attualità

In spite of its limitations, surgery is still the only effective means of treating lung cancer, particularly in cases where an early diagnosis has been made. Reference is made to various points associated with diagnosis, indications and treatment. It is felt that surgical management should be conducted on a radical basis, provided the patient is left with an acceptable degree of respiratory function.

[The natural history of breast cancer. The impact of prevention and therapy]. / La storia naturale del cancro della mammella. L'impatto della prevenzione e della terapia.

Four periods are recognizable in breast carcinoma treatment: the first period can be called as "era of the incurable disease". It begins at the arising of the mankind and lasts up to the end of the 19th century. During this period the disease was usually diagnosed in far advanced stage and any therapeutical attempt was unable to cure a significant percentage of patients. The second period begins with Halsted and ends in the late 60's. It should be considered as the "eve of the surgical treatment of the breast cancer". In these years an increasing number of patients was diagnosed in earlier, curable stage and about half of them was definitively cured. In the early 70's several multimodality treatments of breast cancer were proposed by different Cancer Centers worldwide. Usually a local treatment (surgery+radiotherapy) was adopted combined with a systemic treatment (chemotherapy or monotherapy), commonly in N+ patients. Such approach cured a further 25% of patients that the local treatment alone could not cure. Moreover conservative surgical procedures were extensively carried up. In the last ten years the increasing amount of clinical data leads us to adopt a tailored therapeutical plan for nearly every patient. Numerous subgroups of patients with different level of risk were identified (patients with inflammatory carcinoma, young women at high risk, elderly patients etc.). The early data show that some further advantages in survival rates, in cost saving policy and in cosmetic outcome can be achieved.

[Pefloxacin versus ceftriaxone in single-dose antibiotic prophylaxis in general clean-contaminated surgery. The Pefloxacin Study Group]. / Pefloxacina versus ceftriaxone nella profilassi antibiotica in monodose in chirurgia generale pulita-contaminata. Gruppo di Studio Pefloxacina.

Single-shot surgical prophylaxis is today used in all clean-contaminated surgery, because it is able to reduce the incidence of post-surgical infections. The aim of this clinical trial is to evaluate the efficacy of Pefloxacin 800 mg i.v. slow infusion in single administration 1-2 hours before surgery versus ceftriaxone 2 g i.v. 1-2 hours before surgery in 297 patients suffering from clean-contaminated surgery, especially biliary surgery and gastrectomy. Efficacy of prophylaxis in 259 patients, evaluable according to the protocol, was evaluated in terms of appearance of post-surgical infections (urinary, respiratory and wound infections). In the Pefloxacin group (128 patients), no cases of wound infections were observed, except one case of wound sterile secretion, without dehiscence, (0.81%), one case of urinary infection (0.81%) and three cases of respiratory infections (2.34%). In the ceftriaxone group (131 patients), three cases of wound sterile secretion without dehiscence (2.36%), one case of urinary infections (0.76%) and four cases of respiratory infections (3.05%) were observed. From this study we can conclude that single-shot surgical prophylaxis with pefloxacin, drug with microbiological and pharmacokinetics characteristics suitable for prophylaxis, is able to prevent postsurgical nosocomial infections as well as ceftriaxone, considered a reference drug largely used in this indication.

[Pefloxacin + metronidazole versus netilmicin + metronidazole in the prevention of nosocomial infections in contaminated surgery. Pefloxacin Study Group]. / Pefloxacina + metronidazolo versus netilmicina + metronidazolo nella prevenzione delle infezioni nosocomiali in chirurgia contaminata. Gruppo Di Studio Pefloxacina.

Pefloxacin plus metronidazole versus netilmicin plus metronidazole in the prevention of nosocomial infections during contaminated surgery. Surgical prophylaxis is widely used in contaminated surgery, especially colorectal surgery. In this clinical trial the efficacy of pefloxacin 800 mg i.v. slow infusion associated to metronidazole 500 mg i.v. 1-2 hours before surgery and then metronidazole alone after 6 and 12 hours versus netilmicin 200 mg i.m. associated to metronidazole 500 mg i.v. 1-2 hours before surgery and then both after 6 and 12 hours were evaluated in 97 patients suffering by colorectal surgery. Efficacy of prophylaxis in patients was evaluated in terms of appearance of post-surgical infections (abdominal, urinary, respiratory and wound infections). In pefloxacin + metronidazole group (53 patients), two cases of wound infections (3.8%) and three cases of respiratory infections (5.8%) were observed. In netilmicin + metronidazole group (44 patients), two cases of wound infections (4.9%), three cases of urinary infections (7%), three cases of respiratory infections (7.5%) and one case of intra-abdominal infection were observed. Our data confirmed that in colorectal surgery, the association pefloxacin, drug with microbiological and pharmacokinetics characteristics suitable for prophylaxis + metronidazole, active against anaerobes pathogens, prevents post-surgical infections as well as a reference association (netilmicin + metronidazole), with the advantage of a single administration.

[Treatment of peri-anal fistulas. A current problem]. / Trattamento delle fistole peri-anali. Un problema d'attualità.

This problem of the treatment of perianal fistulas is examined and current principles of correct, effective therapeutic conduct set out. The techniques available vary with the type of fistula and the school of proctology. The as yet controversial point revolves about the way and the extent of possible sphincteric section. 80 cases reported provide a basis for some practical considerations.

[Plasma and erythrocyte magnesium concentration in the postoperative period. Relations between calcium and magnesium]. / La concentrazione del magnesio plasmatico ed eritrocitario nel decorso postoperatorio. I rapporti tra calcio e magnesio

Transient hypomagnesiaemia was noted postoperatively, particularly on the 1st day in patients submitted to intestinal procedures. Slight hypocalcaemia was also observed; this was often related to a low plasma Mg value. A hormonal mechanism is presumed to be the cause of this stress-linked fall in blood magnesium.

[Doppler color echography in the diagnosis of impotence]. / Eco-color-Doppler nella diagnostica dell'impotenza.

This study reports the experience achieved with duplex and color Doppler ultrasonography in 120 impotent patients. The following morphodynamic parameters of the cavernosal arteries were studies before and after intracorporal injection of a mixture of vasoactive drugs: arterial diameter, wall pulsatility, morphology of the spectral waveform, peak systolic velocity, end diastolic velocity and flow volume. The veno-occlusive mechanism of the corpora cavernosa was studied directly by determination of flow along the deep dorsal vein of the penis and indirectly by serial evaluation of the diastolic flow of the cavernous arteries.

[Horizontal gastroplasty in surgery for morbid obesity: an unjustified condemnation?]. / Gastroplastie horizontale dans la chirurgie de l'obésité morbide: une condamnation injustifiée?

Horizontal gastroplasty has been performed on 100 pathologically obese patients over the last nine years. In our series, the mean age was 39.3 +/- 8.2 years and the mean body weight was 120.8 +/- 19.6 kg. One year after surgery the average weight loss was 29.7 kg which corresponds to a reduction of 24.6% of the preoperative weight (BMI:-24%). After three years, the body weight stabilised, reaching a total weight reduction of 30.5% (BMI:-28.7%), corresponding to 36.8 kg. The incidence of complications directly related to surgery was generally acceptable. The absence of specific malabsorption problems, the low incidence of severe complications and the satisfactory weight loss induced and maintained make, in our opinion, horizontal gastroplasty one of the most suitable and effective interventions in the long-term management of morbid obesity.