[Cervical lymphorrea after nodal dissection: role of fasting based on clinical evidence]. / Linforrea cervicale dopo svuotamento linfonodale: ruolo del digiuno basato sull'evidenza clinica.

The management of chylous fistula, subsequent to neck nodal dissection, includes either unstandardized conservative procedures and reoperation. The main reason of controversy in literature is probably due to the rarity (1-2.5%) of such troublesome complication due to inadvertent disruption of the thoracic duct itself or of its tributary branches. We report one case of severe cervical chylous fistula, occurred after left lateral dissection for advanced papillary thyroid carcinoma, and successfully restored by a conservative approach. None of the following treatment modalities was effective: pressure dressing, low-fat diet, octreotide, etilefrine, and local tetracycline sclerotherapy. Instead, fasting combined with total venous nutritional replacement was successful in curing the leak. It may be hypothesized that the beneficial effect on chyle production observed in the present patient in fasting condition, could be explained by a decrease of splancnic blood flow consequent to intestinal feeding rest. The other treatment procedures can be adjunctive methods with impredictable effect. As a standard approach with the aim to prevent and treat cervical lymphorrea, we suggest preoperatory fat meal, intraoperative search for milky leak by positive respiratory pressure, ligation of the thoracic duct (a mesh coverage when necessary) if inadvertently damaged, but not a systematic search for it. Moreover, according to the amount and the duration of the leakage, fasting combined with venous supplement by central or peripheral access, in combination with local treatment by sclerosing agents appears to be efficacious. In our opinion, neck reoperation or intrathoracic ligation of the thoracic duct represent the last therapeutic option of unresponsive or untractable cases.

Selective variceal decompression and its role relative to other therapies.

Seventy patients, selected from 265 patients with proved variceal bleeding, underwent a distal splenorenal shunt (DSRS) procedure with or without splenopancreatic disconnection (SPD). Alcoholic cirrhosis was the cause of portal hypertension in 57% of the patients. The operative mortality was 13% (Child's classes A and B 2%, class C 66%). Despite fewer varices in all of the patients, variceal rebleeding and death occurred in one patient (2%). Late portal perfusion was observed in 91% of the patients, with worsening in 23%, compared with the preoperative study. Persistent hepatocyte necrosis and incomplete SPD were the most significant prognostic factors for decreased perfusion (presence and absence of necrosis, 38% and 12%, respectively; DSRS and DSRS with SPD, 43% and 12%, respectively). SPD also decreased ongoing hepatocyte damage. Post-shunt encephalopathy was clinically evident in 7% of the patients, but after electroencephalographic evaluation, it increased to 24.6%. Significant factors in its development included decreased portal perfusion (62% versus 14%), active hepatitis (48% versus 17%), and incomplete SPD (43% versus 14%). The higher late liver-related mortality was associated with a lack of or decreased portal perfusion and the absence of SPD.

Liver transplantation with vena cava in situ and selective use of temporary portacaval shunt or portal clamping.

BACKGROUND/AIMS: The recipient hepatectomy with vena cava in situ in liver transplantation has overcome the need of venous-venous bypass thanks to temporary porta caval shunt or portal clamping. METHODOLOGY: 150 orthotopic liver transplants in 137 patients were performed and the vena cava in situ technique was used in 142 (venous bypass in 7, temporary porta caval shunt in 49, portal clamping in 87). The suprahepatic cava veins anastomosis was performed with Belghiti in 97 and piggyback techniques in 45. RESULTS: There were no differences in operative and warm ischemia times nor in blood requirements, while a greater stability of body temperature was documented in the vena cava In Situ group: in the latter temporary porta caval shunt preserved the temperature better than portal clamping (P < 0.01). In anhepatic phase mean artery pressure decreased in veno-venous bypass and increased in the vena cava In situ groups (P < 0.01). The venous return and the cardiac performances (anhepatic phase) were better preserved in the vena cava In Situ group. (P < 0.0001). CONCLUSIONS: Temporary portal caval shunt or portal clamping and piggyback or Belgiti Techniques allow a better hemodynamic stability through out the procedure, obviating the need for veno-venous bypass or fluid overload, if selectively used.

[Observations on lipid metabolism in normal pregnancy and in some pathological pregnancy disorders]. / Osservazioni sul metabolismo lipidico nella gravidanza fisiologica e in alcuni quadri di patologia gravidica.

Chemical determination of total and esterified cholesterol and electrophoretic separation of plasma lipoproteins was carried out in a chemico-clinical approach to the pathology of lipide metabolism in pregnancy. In a future study, the investigation will be extended to the neonatal aspect of the problem. 136 women were studied, with 446 samples being taken, specifically: 65 controls, i.e. pregnant women not presenting pathology that might obviously involve lipide metabolism, 36 hypertense pregnant women, 28 diabetic and 7 with gravidic hepatosis. Observation of the data confirms that in pregnancy there is a steady, meaningful increase in cholesterolaemia and that the electrophoretic picture shows a steady reduction in alpha-lipoproteins, with stimulatneous increase in pre-beta proteins, reaching a peak in hepatosis cases, and an increase in beta lipoproteins. All this agrees with functional and teleological modifications in lipide metabolism during gestation.

[Lipid metabolism in newborn infants at birth. Obstetrical-pediatric aspects]. / Alcune osservazioni sul metabolismo lipidico del neonato alla nascita. Aspetti ostetrico-pediatrici.

Lipid parameters in the cord blood of neonates and that of their mothers at birth were studied in a series of 67 subjects divides in accordance with prior disease or diseases arising during pregnancy. From the results obtained in this albeit restricted study, agreement is expressed with the literature view that there is a common genetic control of lipid metabolism in the foetus, which is unusual and independent of that in the mother. An interesting, though unexplained finding was the absence of prebetalipoproteins in the cord blood of 71.5% of the control group.

[Isolated rupture of the right hemidiaphragm with complete herniation of the liver into the thorax. Considerations of diagnosis and therapy]. / Rottura isolata dell'emidiaframma destro con erniazione completa del fegato in torace. Considerazioni sulla diagnosi e sul trattamento.

The Authors report a case of right diaphragmatic hernia due to road-traffic accident. They discuss the problems of early diagnosis because it is delayed for multiple associated lesions or a low index of suspicion. The ratio of laceration of the left side to that of the right is twenty to one. The clinical and diagnostic data best able to lead to a rapid preoperative diagnosis are considered. The Authors recommended early operative treatment and the thoracic approach; thoracoabdominal incisions are more suitable whenever abdominal lesions are coexisting. The Authors stress the use of safety belts with three point fastener which have significantly decreases cranial and abdominal lesions, particularly if associated with two rolls up.

[The L.A.I. test and tumor markers (Ca 19-9 and TPA) in the diagnosis of pancreatic carcinoma]. / L.A.I. test e markers tumorali (Ca 19,9 e TPA) nella diagnosi del carcinoma pancreatico.

A particular cell-mediated immune response is tested in this work: the leukocyte adherence inhibition (L.A.I.) in the presence of organ tumor antigens. Forty-two patients suspected of having pancreatic cancer were submitted to the L.A.I. test and Ca 19.9 and TPA determination. The diagnosis of pancreatic cancer was eventually surgically confirmed and staged in 30 patients. The most important features of the L.A.I. test were good specificity (94%) and the ability to diagnose stage I cancers (3/4 cases, 75%), while the other markers are more likely to diagnose more advanced stages. The L.A.I. test seems to be also useful during the follow-up period since its positivity may even be some months previous to the clinical symptoms. During follow-up the L.A.I. test proved useful in supervising the neoplastic disease course from the moment of relapse to advanced clinical symptoms.

[Surgical treatment of post-traumatic mobile costal flaps]. / Il trattamento chirurgico dei lembi costali mobili post-traumatici.

Twelve cases of surgical management of post-traumatic mobile costal flap are reported. An account is given of the indications for surgery and the various types of costal immobilisation suitable for the anatomical features of the flap. The technique is described in detail and the results are discussed.

[Proctologic day-surgery. Results of 2000 surgical interventions]. / Chirurgia proctologica in day-surgery. Risultati di 2000 interventi chirurgici.

The aim of the study was the evaluate of results of 2000 surgical operations for ano-rectal disease performed in the day-surgery setting (7-24 hours hospital stay) with improvement of both cost effectiveness and patient comfort. From January 1980 to December 1998, 2000 patients underwent surgical operations: 1011 for haemorrhoids; 708 for anal fissure; 172 for fistula in ano; 80 for pylonidal disease; and 45 for anal stenosis. 97.6% of patients were operated on with loco-regional anaesthesia; the others with narcosis and peripheral anaesthesia. The hospital-stay was 24 hours in 697 patients (34.5%), while 1319 (65.5%) operated on under loco-regional anaesthesia were hospitalised for 7-10 hours. Three patients (0.2%) developed acute hemorrhage after hemorroidectomy during the immediate postoperative period. They underwent reintervention under general anaesthesia with a hospital stay of 7 days. Four patients (0.6%) with perianal abscess after internal sphincterotomy underwent incision 10 days after the operation. Two patients with perianal hematoma after sphincterotomy prolonged the hospital stay for three days. In 1048 patients (51.9%) clinical recovery was observed at first follow-up (7 days); 48% had recovered at the 2nd follow-up (14 days). In 1608 patients (98%) anatomical recovery was observed at the follow-up three months after surgery. Patient satisfaction 6 month after operation was high in 79%; good in 27%; low in 1%. These results seems confirm the feasibility of proctological day surgery in almost all patients, with both a considerably cost reduction and enhanced patient comfort and compliance.

[The palliative treatment of hepatocarcinoma: chemoembolization vs. the combination of tamoxifen plus beta-interferon]. / Il trattamento palliativo dell'epatocarcinoma: la chemoembolizzazione vs l'associazione tamoxifene più beta-interferon.

Clinical and experimental data show that beta-IFN enhances the effect of tamoxifen on advanced breast cancer. There is a similarity between breast and liver as far as the proliferating effect on normal and neoplastic tissue of estrogen and progestin receptors is concerned. The authors tested this pharmacological association in unresectable liver neoplasms. They considered 76 (not randomized) patients affected with HCC; 38 were treated by trans-arterial chemoembolization (TACE) and 38 to beta-INF and tamoxifen (the 2 groups were comparable according to age, sex, Child-Pugh score, Okuda and TNM stages, cirrhosis etiology). The treatment response (positive when a tumor diameter decreased or stabilization was observed) was similar in the two groups; in the TACE group, the presence of a peritumoral capsula had a significant influence on survival (p < 0.02); on the other hand, in the patients treated with beta-INF and tamoxifen important factors for a better prognosis were the TNM stage (I and II, p < 0.02) and a symptom-free condition (p < 0.04). The authors believe the beta-INF and tamoxifen treatment could represent an effective alternative in the management of unresectable HCC. A better knowledge of the presence and meaning of estrogen and progestin receptors in the neoplastic tissue may allow a better selection of patients.

[The role of laparoscopy and peritoneal cytology in the preoperative staging of pancreatic carcinoma]. / Il ruolo della laparoscopia e della citologia peritoneale nella stadiazione pre-operatoria del carcinoma pancreatico.

The staging of pancreatic cancer still represents a challenge for surgeons involved in this field; radiological diagnostic methods used routinely (CT, NMR, angiography) may under-estimate this neoplasm; in fact, the presence of peritoneal or subglissonian hepatic micrometastasis (< 2 cm) is a frequent surprise at laparotomy and force the surgeon to undertake a palliative procedure. This policy need not be followed because it is possible to perform non-surgical palliation of jaundice or pain respectively by percutaneous radiological stent insertion and coeliac alcoholisation. Pre-operative staging thus acquires an important role in the correct treatment, surgical or medical. Laparoscopy allows us to overcome the understaging of the more common diagnostic methods and view directly the coelomatic space and the surface of the abdominal viscera; moreover during this procedure it is possible to perform a peritoneal wash to obtain other information on the cancer stage. We judged 56 patients by radiological diagnosis; 31 were excluded from surgery by laparoscopy; 10 of the other 25 cases were submitted to radical resection. The resectability operative rate was 40%, compared with 18% if we had submitted patients to surgery. Several patients underwent peritoneal wash, always with negative results; all were submitted to surgery and radically resected. In our opinion, laparoscopy and peritoneal wash represent useful tools in the staging of patients affected with pancreatic cancer.

Importance of the liver in the regulation of platelet activity: effect of its functional exclusion (Eck fistula).

The functional exclusion of the liver, obtained with end-to-side anastomosis of the porta into the cava vein results in impairment of platelet activity. In fact the maximal amplitude and velocity of platelet aggregation in vitro are reduced in animals which undergo the operation and are examined 1 month later. Adding fibrinogen to the platelet-rich plasma after portacal anastomosis restores a normal type of aggregation indicating that the lack of this factor is involved in the phenomenon, even if alterations occurring to platelets may be implied, too.