Robotic approach to hepatobiliary surgery.

Robot-assisted hepatobiliary surgery has been steadily growing in recent years. It represents an alternative to the open and laparoscopic approaches in selected patients. Endowristed instruments and enhanced visualization provide important advantages in terms of selective bleeding control, microsuturing, and dissection. Cholecystectomies and minor hepatectomies are being performed with comparable results to open and laparoscopic surgery. Even complex procedures, such as major and extended hepatectomies, can have excellent outcomes, in expert hands. The addition of indocyanine green fluorescence provides an additional advantage for recognition of the vascular and biliary anatomy. Future innovations will allow for expanding its use and indications. Robotic surgery has become a very important component of modern minimally invasive surgery and the development of new robotic technology will facilitate a broader adoption of this technique.

[Robotic approach to hepatobiliary surgery. German version]. / Roboterassistierte hepatobiliäre Chirurgie.

Robot-assisted hepatobiliary surgery has been steadily growing in recent years. It represents an alternative to the open and laparoscopic approaches in selected patients. Endowristed instruments and enhanced visualization provide important advantages in terms of selective bleeding control, microsuturing, and dissection. Cholecystectomies and minor hepatectomies are being performed with comparable results to open and laparoscopic surgery. Even complex procedures, such as major and extended hepatectomies, can have excellent outcomes, in expert hands. The addition of indocyanine green fluorescence provides an additional advantage for recognition of the vascular and biliary anatomy. Future innovations will allow for expanding its use and indications. Robotic surgery has become a very important component of modern minimally invasive surgery and the development of new robotic technology will facilitate a broader adoption of this technique.

A statistical approach to discriminate between non-fallers, rare fallers and frequent fallers in older adults based on posturographic data.

BACKGROUND: Identification of future non-fallers, infrequent and frequent fallers among older people would permit focusing the delivery of prevention programs on selected individuals. Posturographic parameters have been proven to differentiate between non-fallers and frequent fallers, but not between the first group and infrequent fallers. METHODS: In this study, postural stability with eyes open and closed on both a firm and a compliant surface and while performing a cognitive task was assessed in a consecutive sample of 130 cognitively able elderly, mean age 77(7)years, categorized as non-fallers (N=67), infrequent fallers (one/two falls, N=45) and frequent fallers (more than two falls, N=18) according to their last year fall history. Principal Component Analysis was used to select the most significant features from a set of 17posturographic parameters. Next, variables derived from principal component analysis were used to test, in each task, group differences between the three groups. FINDINGS: One parameter based on a combination of a set of Centre of Pressure anterior-posterior variables obtained from the eyes-open on a compliant surface task was statistically different among all groups, thus distinguishing infrequent fallers from both non-fallers (P<0.05) and frequent fallers (P<0.05). INTERPRETATION: For the first time, a method based on posturographic data to retrospectively discriminate infrequent fallers was obtained. The joint use of both the eyes-open on a compliant surface condition and this new parameter could be used, in a future study, to improve the performance of protocols and to verify the ability of this method to identify new-fallers in elderly without cognitive impairment.

Inflammatory markers in Alzheimer's disease and multi-infarct dementia.

Inflammation has been involved in the pathogenesis of dementia. The study evaluates the presence and the source of pro- and anti- inflammatory cytokines in the blood of patients with Alzheimer's disease (AD), multi-infarct dementia (MID) or in non-demented elderly people (controls). Tumor necrosis factor (TNF)-alpha, interleukin (IL)-1beta, IL-6, IL-10, IL-1 receptor antagonist (IL-1Ra) and soluble TNF receptor I (sTNF-RI) plasma concentrations and release from blood cells stimulated with lipopolysaccharide (LPS, 1 microg/ml) were determined. The results show that TNF-alpha released from blood cells is significantly decreased (27%) in all demented patients compared to controls. Circulating TNF-alpha is increased (400%) only in MID patients. In these patients plasma levels of sTNF-RI are increased (53%) and IL-10 from stimulated blood cells decreased (47%) compared to non-demented subjects. The results show that: (1) peripheral production of TNF-alpha is blunted in demented (both AD and MID) patients compared to non-demented age-matched subjects; (2) AD patients have a selective disregulation of the peripheral TNF-alpha system; (3) different cytokines are up- or down- regulated in MID patients showing that in this condition the pro- and anti-inflammatory peripheral cytokine system is more widely affected.

[Clinical, immunological and radiological correlations in an initial attack of multiple sclerosis]. / Corrélations cliniques, immunologiques et radiologiques au cours d'une première poussée de sclérose en plaques.

In a 20 year-old woman with a first attack of MS there were strong correlations between clinical findings, radiological changes and immunological abnormalities. The presence of early immunological changes in peripheral blood and CSF together with a focal alteration of the blood-brain barrier suggests that such abnormalities may play a primary role in plaque formation.

[A case of postprandial hypotension in an elderly subject]. / Un cas d'hypotension postprandiale chez un sujet âgé.

This is a case report of a 74-year old woman who from March 1994 to April 1995 was admitted to our hospital because of three episodes of syncope. Each general physical examination was normal except for a grade 2/6 systolic murmur. No abnormalities were disclosed after several resting electrocardiograms and Holter monitoring. The Schellong and the tilt tests were normal. During the last admission the patient had a syncope 30 minutes after a meal. Blood pressure reduction was documented and postprandial hypotension was diagnosed. Postprandial decreases in systolic blood pressure in the elderly may predispose the subject to symptomatic hypotension and to falls, dizziness, weakness, angina pectoris, stroke and syncope. The mechanism of postprandial hypotension is not fully understood. It is defined as a decrease in postprandial systolic blood pressure of 20 mmHg or more. Because postprandial hypotension is a common problem in older, frail, institutionalized patients, all physicians caring for elderly patients should be aware of the hypotensive effects of food intake and should consider postprandial hypotension in the evaluation of falls, syncope and other ischemic cerebral symptoms.

Hypothyroidism presenting as destructive arthropathy of the fingers.

A patient presenting with destructive arthropathy of the proximal interphalangeal (PIP) joints of the hands is described. She was initially believed to have rheumatoid arthritis but non-steroidal anti-inflammatory drugs were of no help. The patient was subsequently found to have hypothyroidism and erosive osteoarthritis of the fingers. Joint swelling, pain and stiffness responded dramatically to thyroid hormone substitution. The PIP joint spaces reappeared on the radiographs within 9 months. This case suggest that hypothyroidism may induce destructive arthropathy of the finger joints. As thyroxine replacement may reverse the rheumatic complaints, hypothyroidism should be considered in the differential diagnosis of a destructive arthropathy of unclear aetiology.

[Doppler color-echo and flowmetric evaluations in ovarian tumors in postmenopausal patients]. / Eco-color-Doppler e valutazioni flussimetriche nei tumori ovarici nelle pazienti nell'età postmenopausale.

The use of color Doppler techniques in transvaginal sonography (US) permitted the identification of some typical flowmetric patterns of malignant ovarian cancers, because of such characteristics of neoplastic vessels as no media in the vessel wall, the presence of A-V shunts, and so on. These features reduce vascular impedance, from which low pulsatility index and resistance index values result. Eighty-one patients with ovarian masses were examined: in 19 of them histopathology revealed malignant lesions in different stages. Eighteen of those lesions exhibited suspect transvaginal patterns; in one case only the US patterns suggested a benign lesion, which was a serous cystadenocarcinoma with thin and regular septa. In all the malignant lesions flow could be sampled in six sites at least; the lowest pulsatility index values, obtained by multiple samplings in the same lesion, were considered as the most representative of the histologic features of the lesion. The average of the lowest pulsatility index values in 18 of 19 malignant lesions was 0.75. In one case only (the only false negative in the series) the lowest pulsatility index value was 1.20. Doppler signals were detected in 58 of 62 benign lesions only and the average of the lowest pulsatility index values was 1.80. The only kind of condition with low pulsatility index was the inflammatory disease (all the 6 sampled cases). If we consider a pulsatility index < 1 as the cut-off value for malignant lesions, the sensitivity and the specificity of color Doppler US were 95% and 91%, respectively, in our series. The positive predictive value of the exam was 75% and its negative predictive value was 95%.

Lipomatous tumors of the uterus: ultrasonographic findings in 11 cases.

We reviewed the ultrasonographic findings in eight patients with 11 lipomatous uterine tumors studied with transabdominal (eight cases) and transvaginal (six cases) techniques. A transvaginal color Doppler study was obtained in five patients. Two patients had more than one nodule (two and three uterine nodules, respectively). All lipomatous tumors had regular margins and were hyperechoic. Transvaginal sonography allowed the identification of one small previously undetected tumor but was not able to image the entire extent of two large lipomatous masses. In one case, it helped to establish the actual uterine origin of an eccentric pelvic mass. Color Doppler sonography showed complete absence of flow in all tumors examined. We believe that lipomatous tumors of the uterus can be diagnosed with a high degree of certainty by ultrasonography if a homogeneously hyperechoic avascular mass can be clearly identified to be of uterine origin.

Superior thyroid artery lesion after US-guided chemical parathyroidectomy: angiographic diagnosis and treatment by embolization.

A 71-year-old woman presented with a life-threatening thyroid hemorrhage after US-guided chemical parathyroidectomy. The diagnosis was made by angiography followed by immediate embolization of a pseudoaneurysm of the left superior thyroid artery. Embolization controlled the hemorrhage, obviating the need for surgery. The patient made a full recovery with no evidence of further hemorrhage. Pseudoaneurysm of the superior thyroid artery is a rare cause of hemorrhage and percutaneous embolization is an effective method of treatment.

Refsum's disease: management by diet and plasmapheresis.

A case of Refsum's disease treated by serial plasma exchanges together with a moderate low phytanate diet is reported. Serial plasma exchanges determined a rapid significant clinical improvement (neuropathy and cerebellar ataxia) that allowed immediate return to full-time employment. The initial improvement could be maintained by intermittent serial plasmapheresis despite partial failure of the initially introduced low phytanate diet bringing 20 mg phytanic acid daily. A new dietary regimen bringing 10 mg phytanic acid was later introduced that was well tolerated. No liquid formula was used. The clinical improvement was clearly correlated to a fall in serum phytanic acid from 45.3 to 16.2 mg/100 ml.

Sonographic features of incidentally detected, small, nonpalpable ovarian dermoids.

PURPOSE: We describe the transvaginal sonographic features of incidentally detected, small, nonpalpable ovarian dermoid cysts. METHODS: A total of 38 small (less than 3 cm in diameter), nonpalpable, incidentally discovered ovarian dermoids in 35 women were retrospectively reviewed; 3 patients had small bilateral lesions, and 7 had a small ovarian dermoid detected during preoperative evaluation of a symptomatic, large, contralateral lesion. RESULTS: Transvaginal sonography permitted identification of all 38 dermoids, whereas abdominal sonography detected only 22 of the lesions. Three main structural patterns were observed with transvaginal sonography: (1) 20 of 38 lesions had a solid, hyperechoic appearance, either homogeneous (11) or heterogeneous (9); (2) a fluid-filled area with a hyperechoic focus in its wall was seen in 10 cases; and (3) a mixed pattern, with solid and liquid areas, was seen in 8 cases. Calcifications were appreciated in 7 lesions. Acoustic shadowing was noted in 30 cases, either as a shadow posterior to the hyperechoic portion of the mass or as an edge shadow lateral to the lesion. Doppler studies were obtained for 20 lesions but proved inconclusive: 4 mixed-pattern dermoids had a few internal signals with a low resistance pattern; in the remaining cases, there were signals at the periphery of the cysts, but it could not be determined whether these were from vessels within the lesions or from vessels in the surrounding ovarian parenchyma. Surgery confirmed benign cystic dermoids in all 38 cases. CONCLUSIONS: Sonographically, small ovarian dermoids have a variety of textural patterns quite similar to those encountered in large, symptomatic lesions. The increased resolution capabilities provided by transvaginal sonography allow incidental detection of previously unsuspected dermoids and permit identification of their nature.

High resolution sonography of the flexor tendons in trigger fingers.

A sonographic study was conducted to analyze changes of the flexor tendons in patients with trigger fingers. We evaluated thickness and echotexture of the flexor tendons of the fingers in 54 patients with 66 symptomatic digits using 10 and 13 MHz "small parts" transducers; the results were compared with those observed in 20 normal controls. Images were obtained on the volar surface of the hand, at the head of metacarpals, and at the base of first phalanx, where the first annular pulley of the digital canal is located and where the changes occurring during passive assisted extension of the fingers were evaluated. Normal tendons were 2.9 to 4.4 mm thick (mean, 3.71 +/- 0.46) and had fibrillar echotexture. Patients had tendons ranging from 3.8 to 6.7 mm (mean, 5.41 +/- 0.94); the difference from controls was highly significant (P < 0.001). A cyst was attached on the volar surface of the involved tendons in 15 cases. Diffuse thickening of the synovial sheath was present in 20 tendons, whereas 17 tendons had irregular internal echotexture. Extension movements caused changes in shape of both cysts and peritendinous envelopes. In conclusion, sonography seems able to identify a variety of pathologic changes affecting tendons in these patients and may help both to explain the pathophysiology of their clinical situation and guide therapeutic decisions.