First case of bronchiolar-pleural fistula repair with platelet-leukocyte rich gel.

Bronchiolar-pleural fistulas are a frequent complication of thoracic surgery. Current treatment strategies and their invasiveness are quiet different, but often surgeons decide for a new surgical intervention and definitive closure of the breach. We report the case of a bronchiolar-pleural fistula in a 75 years old man with important co-morbidities that we treated with instillation of platelet-leukocyte rich gel (PLR-G). We discuss actual indications for PLR-G as well as its possible role in thoracic surgery.

Stapled hemorrhoidopexy in the treatment of hemorrhoid disease. Our eight-year experience.

AIM: Stapled hemorrohoidopexy using Longo technique (PPH) is accompanied by good postoperative outcomes. The aim of this study was to report the data regarding our experience with stapled hemorrhoidopexy, the results of the operations and the complications rate in comparison with those published in the literature. METHODS: In our Department 127 patients with symptomatic hemorrhoids have been selected between November 2000 and December 2008 for PPH. This retrospective study included patients with a rectal prolapse from second to fourth degree. RESULTS: Two patients had an anal bleeding on the day of surgery. All of them were returned to the operating theatre. A third patient had an anal bleeding that did not require a second surgical intervention. In one case a postoperative stenosis occurred that required a reoperation three days after the dismission from hospital. In one case an urgency occurred, with transitional fecal incontinence, spontaneously regressed two weeks after the intervention. No urinary retention occurred in our caseload. Pain was referred by 37 patients and was controlled by standard analgesia in all cases. No cases of chronic pain were detected. There were no cases of anal stenosis, permanent incontinence or deaths in this series. CONCLUSION: Among the cases examined important complications occurred in five (3.9%), but reintervention was necessary only for three patients (2.4%). This study confirms that PPH, used on patients with a rectal prolapse from second to fourth degree, is feasible and safe.

Surgical treatment of retrosternal goiter.

BACKGROUND: The definition of substernal goiter is not uniform and varies among authors. We can define substernal--or retrosternal-goiter a thyroid formation with cervical departure that goes beyond the superior thoracic strait for at least 3 cm and that preserves, generally, the connections between the cervical and thoracic portion, maintaining a direct vascularization supplied by the thyroid arteries. The "forgotten" goiter is an extremely rare disease: a mediastinic thyroid mass found after total thyroidectomy. MATERIALS AND METHOD: 595 patients with thyroid pathology have been treated surgically in our Department. Fifty (8.4%) of these were suffered from a cervico-mediastinic goiter. The diagnosis has been confirmed by the thyroid ecotomography, by the radiologic examination of the chest, by the neck-chest CT examination, by the MR of the mediastinum and by the thyroid scintigraphy. DISCUSSION: The surgical treatment, in retrosternal goiters, is related to the experiences of surgeons. For the majority of the surgeons almost all antero-superior mediastinal goiters can be removed across a cervicotomy, only in few cases in association with a sternal split. In our experience the cervical approach is the only surgical access used for all the patients. The complication rate following substernal goiter resection is higher than the average rate for cervical thyroidectomy. However, in our series we did not observed permanent recurrential lesions, only in one case a light hypophonia has been observed. After the intervention, in all patients the symptomatology caused by the mediastinal compression has disappeared.

Anaplastic thyroid carcinoma: a case of a young women that reports a survival exceeding 6 years.

Anaplastic thyroid carcinoma (ATC) is an uncommun and highly aggressive malignancy. Differentiated follicular and papillary thyroid carcinomas account for most (80-90%) thyroid malignancies with ATC accounting for less than 5%. A diagnosis of ATC is usually fatal with a mean survival of 3-9 months and only 10-15% alive at 2 years. Histologic examination reveals that many of them contain a papillary structure or follicular components in focal areas and genetic alteration is the driving for genesis of cancer and progression. These studies showing that ATC represents a terminal "de-differentiation" of pre-existing differentiated carcinoma. Most of patients are incurable, nevertheless a multimodality approach, incorporating surgery with the aim to obtain complete macroscopic resection and achieve clear resections margins followed by adjuvant treatment RT (radiotherapy) and/or chemotherapy, improve local control and extend the survival. The aim of the present study has been to review a case of a young women with ATC that reports a survival exceeding 6 years.

The minimally invasive surgical approach in thyroid diseases.

AIM: The targets of minimally invasive thyroidectomy could be summarised by: achievement of the same results as those obtained with traditional surgery, better postoperative course and improved cosmetic RESULTS: In minimally invasive surgical approach the skin incision should not exceed 30 mm in length. In our experience this limit may be extended of 5 mm for thyroid between 25 and 50 mL in volume. This way allows more patients, excluded before, to take the advantages of minimally invasive approach. The aim of this work has been to demonstrate that the central neck minimally invasive approach is safe, less painful, better for cosmetic results and easily reproducible in surgical practice. METHODS: From January 2003 to June 2007, 75 patients have been selected for minimally invasive thyroidectomy. The procedure was carried out through a central skin incision performed ''high'' between the cricoid and jugular notch. Our ''modified Miccoli-procedure'' consists in five-easily repeatable steps. In the postoperative stay, all patients were asked to evaluate the pain that feel and the cosmetic result by means of a numeric scale. RESULTS: The skin incision performed was from 25 to 30 mm (mean 27.39 +/- 2.6 mm). We obtained in all cases excellent results about patients cure rate and comfort, few postoperative pain and attractive cosmetic CONCLUSION: In this study we demonstrate that the central neck minimally invasive approach is safe, less painful, better for cosmetic results, with less paresthetic consequences and easily reproducible in surgical practice. In our opinion a longer incision (up to 35 mm), does not affect negatively the advantages of minimally invasive procedure. This way allows more patients to take the advantages of minimally invasive approach.

Total thyroidectomy in amiodarone-induced thyrotoxicosis. Preoperative, intraoperative and postoperative considerations.

A female patient was admitted to our Department for total thyroidectomy in amiodarone-induced thyrotoxicosis. The drug was prescribed for ventricular arrhythmia and atrial paroxysmal fibrillation in dilated cardiomyopathy due to chronic aortic regurgitation with left ventricular dysfunction (ejection fraction 35%; Class Functional NYHA III) and moderate-severe respiratory insufficiency. The cardiologist-anesthetist team has allowed to evaluate the surgical-cardiovascular-anesthesiologic risks and the balance between the improvement by the amiodarone administration for the arrhythmia, and the discontinuation of this treatment in order to prevent aggravation of the thyrotoxicosis. These hypotheses were subsequently discharged for the two reasons listed below: - several other antiarrhytmic drugs (that didn't show equivalent efficacy as amiodarone in preventing or converting such ventricular and atrial arrhythmias) may be proposed in the place of amiodarone. However, this could expose the patient to an arrhythmia; - a clear proof that the suspension of amiodarone can allow restoring normalization of the thyroid function doesn't exist. Therefore, the patient has been successfully submitted to the surgical intervention and in the follow-up we brought her back to a state of normalized thyroid function and cardiovascular conditions. In patients that cannot safely discontinue amiodarone or when medical therapy is ineffective in controlling thyrotoxicosis, thyroidectomy is the treatment of choice.

Breast cancer in young women: case report and a review.

BACKGROUND: Breast cancer in patients under 40 years is uncommon. Surveillance, Epidemiology and End Results (SEER) program reveals that 75% of breast tumors occur in women age > 50 years, only 6.5% in women age < 40 years, and a mere 0.6% in women age < 30 years. Breast-conserving surgery with subsequent chemo-radiotherapy has become the treatment of choice in women with breast neoplasm. CASE REPORT: Two young patients, 30 and 28 years respectively, with breast cancer. One patient with an atypical medullary breast carcinoma diagnosis, pT2 pN1 bipMx, Grade 3 Stage IIB, negative for receptors, Ki 67: 47%, cERB-2 negative; the other with an intraductal breast carcinoma, pT1c pN0 pMx, Grade 2 Stage I, negative for receptors, Ki 67: 85%, cERB-2 negative, p53 negative, Bcl-2 negative. The first patient underwent right radical mastectomy sec. Madden and axillary lymphoadenectomy in October 2001, started six cycles of adjuvant chemotherapy and radiotherapy on the right side of the chest and on axillary and supraclavicular lymph nodes area. After 2 years an ecotomography revealed small hypoechogenic nodules in the left breast. In December the patient underwent left radical mastectomy with positioning of an expander device. The histological exam revealed a not much differentiated intraductal carcinoma, pT1a N0 Mx, Stage I. After the surgical therapy, she follows another adjuvant chemotherapy. The second patient underwent left quadrantectomy with axillary limphoadenectomy in November 2004. Like the first-will follow several cycles of adjuvant chemotherapy and radiotherapy. DISCUSSION: Breast cancer in women under 40 years of age differ from breast cancer in older women in numerous clinical, pathological and biological features. The studies demonstrate that breast cancer arising in women under 40 years have a more aggressive profile than those of older patients. In both our patients family history of breast cancer was reported. That suggests a possible genetic susceptibility of these patients through BRCA1 and BRCA2 germ-line mutations. Breast conservative surgery with chemio-radiotherapy is the most commonly used treatment breast cancer, expecially in consideration of the aggressiveness of the lesions.

Diagnostic and surgical management of submandibular gland sialolithiasis: report of a stone of unusual size.

Sialolithiasis of the salivary glands is a relatively rare occurrence. It is the most common cause of acute and chronic infections. Sialoliths occurs in the submandibular gland in 80% of the cases and its etiology is associated with some anatomical factors proper of it. In many cases the diagnosis is easy due to obvious clinical features but, for treatment, imaging studies are always necessary. The most of the sialoliths are usually of 5 mm in maximum diameter and all the stones over 10 mm should be reported as a sialolith of unusual size. For these reason we considered useful to report our case in the managing of a stone 13 mm placed in the submandibular gland context and its treatment by surgical resection of the entire gland.

Giant mesenteric fibromatosis.

Mesenteric fibromatosis is a proliferative fibroblastic neoplasia of the small intestine mesentery which may occur as a unique or multiple formation. Mesenteric fibromatosis represents the 8% of all desmoid neoplasm. Giant mesenteric fibromatosis is uncommon by itself (2-4 case/milion/year). Since the rarity of this tumor and the difficulties in diagnostic and therapeutic ambit, we believe it justified to describe a case of giant mesenteric fibromatosis which came to our observation.

Substernal goiters.

BACKGROUND: Substernal goiter, also said cervico-mediastinic goiter, is a thyroid formation with cervical departure that goes beyond, with stretched neck, the superior thoracic strait for at least 3 cm and that preserves, generally, the parenchimal or fibrous connections between the cervical and thoracic portion, maintaining a direct vascularization supplied by the thyroid arteries. The prevalence of this pathology is very variable and fluctuates between 1.7% and 30% of all thyroid damages. The actual classification is provided by the radiologic examination of the chest and, above all, by the new techniques of imaging. METHODS: In the period between January 1998 and December 2003, 332 patients with thyroid pathology have been treated surgically. Forthy-five (13.5%) of these were afflicted with a cervico-mediastinic goiter. In 32/45 (71.1%) cases a total thyroidectomy has been performed by collar carving in accordance with Kocher; in 11/45 (24.5%) cases an hemithyroidectomy has been performed by collar incision; in 2/45 (4.4%) cases, already submitted to surgical intervention of isthmus-lobectomy a totalization has been performed. RESULTS: The surgical technique foresees always an anterior collar neck incision. This way of access is to prefer in the substernal goiters, both for the presence of a cervical vascularization easy to control and for the possibility, nearly always realizable, to dislocate the goiter by that way. As for what concerns the results of the histological examination, in 2/45 (4.5%) cases it has been set a diagnosis of follicular carcinoma (one of them surely invading and the other, leastly invading), in 3/45 (6.6%) cases papillary carcinoma, in 4/45 (8.8%) cases colloido-cystic goiter, in 33/45 (73.5%) cases micro-macrofollicular hyperplasia (in one of which contemporarily compromise from lymphoma of Hodgkin); in 3/45 (6.6%) cases of adenomatous hyperplasia of the thyroid. DISCUSSION: The surgical approach has been in all cases the collar neck incision in accordance to Kocher, and it has never been necessary to associate a sternotomy or thoracotomy. After the intervention, in all the patients the symptomatology tied to the mediastinal compression has disappeared. The goiter showed signs of neoplastic degeneration in 11.1% of the cases, with prevalence of the papillary carcinoma in the 6.6% and, in the remaining 4.5%, of follicular carcinoma. These data are superimposable to the data gathered in other surveys. All the patients passed the post-operating hospitalization in optimal conditions and have been discharged during the fourth post-operating day with the prescription of increasing levothyroxine doses according to the body weigh.

Warthin's tumor of parotid gland: treatment of a retroneural lesion by enucleation.

The papilliferous cystadenomas lymphomatosum or Warthin's tumor is a relatively rare and generally benign neoformation whose incidence is second only to the pleomorfic adenoma. 84% of all Warthin's tumor strikes the parotid gland. We report the two cases that come to our observation paying particular attention to the second one in which occurred a synchronous bilateral manifestation, a rarity in the clinical circle. We want to highlight that enucleation should be the preferred treatment in most cases due to extremely small dimension of Warthin's tumor. Moreover it is possible to perform this kind of surgical treatment even in the case of a retroneural lesion without causing any damage to the facial nerve and its main branches. As regards complications and sequelae we noticed neither a permanent nor a temporary injury of the facial mimicry and sensibility.

Lung microcytoma: a multidisciplinary therapeutic approach.

This report is of 26 patients diagnosed with microcytoma of the lung in stages I, II, and IIIa. All patients received surgical treatment as well as postoperative chemoradiotherapy when indicated by stage. Mean survival rates were 16 months for stage 1, 10 months for stage II and 6 months for stage IIIa disease. For many years surgery was considered contraindicated in the treatment of pulmonary microcytoma. Now a multidisciplinary approach is being used in which surgery has a crucial role. Microcytoma of the lung has a poor prognosis due to its early metastasis and rapid growth. It is crucial to have early diagnosis and accurate, consistent staging as the basis for treatment. A review of literature shows that the use of surgery, chemotherapy and radiotherapy are all important in treatment of microcytoma. Chemotherapy is successfully utilized preoperatively to improve local control, decrease neoplastic mass, induce histological regression and as postoperative adjuvant therapy. Radiotherapy has been shown to be effective preoperatively to reduce local mass and prophylactically for cerebral metastasis. Surgery is crucial to irradicate the neoplastic mass, improve staging accuracy, decrease the possible selection of neoplastic clones resistant to postoperative therapy, decrease local recurrence and allow less aggressive chemoradiotherapy. We feel the most effective protocol for pulmonary microcytoma includes preoperative chemotherapy and radiotherapy when indicated followed by surgical intervention and finally successive adjuvant therapy. The limited number of our cases does not consent a statistically significative conclusion. Our data confirm the importance of the surgical procedure in stages I and II, where according also to other authors, the best results are obtained. Surgical indication in stage IIIa is still discussed due to precocius lymphnode dissemination that significantly affects long-term survival.

Papillomatosis and breast cancer: a case report and a review of the literature.

Papillomatosis is a relatively common (22%) benign microscopic lesion in the breast and rarely seen in women less than 30 years old. It is a papillary proliferation of the ductal epithelium which partly fills up smaller ducts and to degree distends them. The histological classification of this entity is controversial because similar or identical lesions have been classified using different terms such as epitheliosis and epithelial hyperplasia, and interpretation of published series has been difficult due to imprecise definition of this term. Clinical, radiological and histological patterns of this entity are often sufficient to raise concern as to possible malignancy. Moderate or florid hyperplasia without atypia is considered to carry slight (1,5-2 times) increase in risk of later developing cancer, while in the atypical hyperplasia the risk is four to five times that of the general population. The authors describe a case of papillonlatosis recentely observed in a 67 years old female patient and, confirmed the importance to establish an accurate preoperative diagnosis. It is important that the surgeon works with the pathologist to produce clear descriptive report of epithelial changes from normal through hyperplasia to atypias in order to establish a precise surgical indication.

A rare case of pulmonary neurofibroma: clinical and diagnostic evaluation and surgical treatment.

The authors report a rare case of a pulmonary neurofibroma treated by surgical excision. The case report is accompanied by a review of the literature and the discussion of the diagnostic problems posed by neurogenic tumors of the thorax.

Sentinel node role in breast cancer surgery.

Radical surgery of breast cancer includes lymphadenectomy of axilla as well as the dissection of the neoplastic tissue. However recently many works have raised doubts on the opportunity of performing routinary axillary dissection, which elevates morbidity risk, in absence of axillary metastases. However, unfortunately, information on axillary lymph node pathology, is not available with any other technique excluding complete dissection and istopathological examination. Sentinel node technique is a new methodology that consents evaluation of lymph node status in the operating theatre. It allows the surgeon to judge on the opportunity of carrying out the lymphadenectomy or not.

[Functional changes in the esophagus and action of pentagastrin on the competence of the lower esophageal sphincter (LES) after esophageal vagotomy]. / Modificazioni funzionali dell'esofago ed azione della pentagastrina sulla competenza del LES dopo vagotomia esofagea

In pursuance of an investigation of oesophageal physiopathology, a study has been made of the problem of the functional regulation of the inferior oesophageal sphincter in the light of new findings. Experiments carried out on six dogs made it possible to study functional modifications of the oesophagus after vagotomy, completing the technique by administering pentagastrin for the first time in vivo. Radiological and mano metric controls showed in the post-operative period a dilated oesophagus with a fall, in the lower third, of normal pressure values that did not undergo change, unlike what happened in the non-denervated oesophagus after administration of pentagastrin. The results obtained show that the integrity of the nervous structures is not only necessary for the perfect coordination of oesophageal peristalsis, but vital for normal functional response of the inferior oesophageal sphincter, since gastrin action is always mediated by release of acetylcholine by the post-gangliar vagal nerve endings.

[Ambulatory phlebectomy with Müller procedure in the treatment of lower limb varices. Indications, technique and long-term results]. / La flebectomia ambulatoriale sec. Müller nel trattamento delle varici degli arti inferiori. Indicazioni, tecnica e risultati a distanza.

The authors report the results of more than five years experience of phlebectomies, according to Müller's method, performed both in general anesthesia during stripping operations and in local practice. The results confirmed the validity of this complementary surgical treatment for its radicality, execution simpleness and best respect for aesthetics.

[Bronchial obstruction exacerbated during beta blocker therapy]. / Béta-blokkoló kezelés alatt exacerbáló hörgöobstructio krónikus obstructív légzési betegeken.

The authors analyse data of 40 patients with chronic obstructive pulmonary disease, in whom the bronchial obstruction made such a severe progress during beta-blocker therapy necessary to admit them to the hospital. Most of them were middle-aged patients with chronic bronchitis, only 8 suffered from bronchial asthma. Because of cardial disorders, usually beta-blockers were given for several days (1/3-rd of the patients received Betaloc, a cardioselective drug), besides 2/3-rd of them received bronchodilator therapy, too. In spite of this, all patients needed hospitalize because of dyspnoea, obstruction, and hypoxaemia in 1/3-rd. Although deterioration of their condition has resulted, beta-blocker wasn't discontinued by the medical attendant, notwithstanding chronic obstructive pulmonary disease was known previously in 33 patients.

Wernicke's encephalopathy post subtotal extended gastrectomy.

Wernicke's encephalopathy, neuropathy caused by a deficiency of thiamine is a syndrome characterized by memory troubles, mental confusion, ophthalmoplegia and nystagmus. The authors present a case that came up in a patient who underwent a subtotal gastrectomy because of malignant neoplasm of the stomach. More or less three months after the intervention the patient's general conditions were considerably declined and characterised by alimentary vomit, sensory obnubilation and neuromuscular deficit. After appropriate diagnostic ascertainments a repetition of the neoplastic disease was to be excluded locally and at a distance. So the authors analysed the different etiopathogenic possibilities to get a better clinical view of the syndrome in the surgical patient.

The palliative treatment of bronchial carcinoma with lasertherapy and stent.

The obstruction of the airways represents a severe complication in bronchial neoplasia. Endoscopic laser resection associated with the positioning of a stent represents a therapeutic praesidium that ensures the potency of the airways. The authors describe a case of bronchial carcinoma treated with endobronchial laser resection and positioning of a Dumon stent.