Retroperitoneoscopy.

From October 1992 to June 1994, 12 nephrectomies (all for benign diseases), one nephropexy and 7 adrenalectomies (one pheochromocitoma, three adenomas, one cyst) were performed. In all the cases the retroperitoneal working space was created with direct CO2 insufflation (without balloon) with the patient in prone position. Four 10-12 mm ports were always inserted in the lumbar area. Eighteen procedures were successful (90%), 2 failed (one nephrectomy and one adrenalectomy) and underwent open surgery. Twelve procedures were carried out with the patients in prone position, six (one nephropexy and 5 nephrectomies) were performed with the patients in lateral de cubitus. The removal of organs was managed either through an enlarged port (phi 2 cm.) or by joining vertically the stabs of the two ports lateral to the sarcospinalis muscle. The average operative time was 4.10 hours) range 2.30-5.20). Both CO2 absorption and blood loss were negligible. No major complications were observed. Postoperative pain never required medications. All patients were able to stand on the 1st postoperative day. Mean postoperative hospitalisation was 4 days. Direct retroperitoneal approach provides optimal access for laparoscopic renal, proximal ureteral and adrenal surgery, avoiding extensive dissection and handling of intraperitoneal structures.

[Sleep disorders in patients in recovery. Preliminary results in 20 patients]. / I disturbi del sonno nei pazienti in rianimazione. Risultati preliminari su 20 pazienti studiati.

Various aspects of the critically ill patient sharing pain, physical distress, anxiety, environmental components, predispose him to develop some sleep disorders (SD). We studied 20 conscious patients, age 16-80 (mean 48.15 SD of mean +/- 25), undergoing ICU mean 14.3 days (SD of mean +/- 7.5), to evaluate SD rate and their possible leading causes. Through Spearman Rank test SD was related to Apache II score, admission state anxiety, satisfactory sedation, days of ICU stay and age respectively. Conclusive results showed SD rate in all our patients. Excepted a statistical trend to significativity of SD versus satisfactory sedation: RS 0.311 (threshold value for 20 patients: 0.377), no relation was found between SD and data recorded. These preliminary results emphasize the importance of looking for SD in ICU patients though many factors may play a role to develop them.

Streptococcal toxic shock-like syndrome. Report of two cases from Italy.

Two cases of streptococcal toxic shock-like syndrome that occurred at our hospital are described. They represent the second and third cases reported from Italy. Both patients were women, had a portal of entry from cutaneous infection of a limb and suddenly developed high degree fever, severe hypotension, necrotizing fasciitis, acute renal failure, hepatic damage, thrombocytopenia and bleeding from a stress-related duodenal ulcer. One patient was leukopenic. The first patient needed resuscitation in the intensive care unit and emergency surgical debridement of the affected limb, whereas the second improved with medical therapy, but needed duodenal surgery for uncontrolled bleeding. Both patients slowly recovered and survived. Finally, a short update on the pathogenesis of the syndrome is also presented.

[Rhabdomyolysis in meningoencephalitis caused by echovirus]. / Rabdomiolisi in corso di meningoencefalite da echo virus.

We report one case of atraumatic rhabdomyolysis associated with Echo group viral encephalitis, not complicated by acute renal failure. Clinical and bio-humoral outlines are described, characterized by favourable evolution despite high muscular enzymatic peaks. We emphasize that the positive course is probably due to the early institution of prophylactic measures, and that, anyway, the subject still remains exposed to major rhabdomyolysis risk in the presence of stress factors, including general anesthesia.

[The organizational problems of the hospitals of the Nord Italia Transplant Program (NITp) engaged in the activities of organ retrieval for transplantation. The Collaborative Group of Resuscitation Anesthetists]. / Problemi organizzativi degli Ospedali del Nord Italia Transplant (NITp) impegnati nell'attività di reperimento di organi a scopo di trapianto. Il Gruppo Collaborativo degli Anestesisti Rianimatori.

If the quality of results of organ transplantation in NITp is highly satisfactory, the same cannot be said for the number of transplants performed, which only cover 20-25% of the requirement. To understand the causes of organ shortage, a study group of Anaesthesiologists and Transplant Coordinators from the North Italy Transplant Program (NITp) investigated, through a questionnaire addressed to the Heads of 103 Intensive Care Units (ICU) in 92 Hospitals in the NITp area, some of the organizational problems linked to donor identification and treatment and to organ retrieval. The questionnaire took into consideration the number of possible donors identified in 1990, those retrieved and the causes for non retrieving organs and examined a number of variables linked both to retrieval and to ICUs and Hospitals organization. The results show that potential donors were 461: 143 (31%) were used, 138 (30%) were lost due to family opposition to organ donation, 192 (20%) for clinical reasons and 88 (19%) for organizational reasons. The latter figure represents 5% of non retrieval in the most active ICUs and increases to 50% in the Hospitals that had procured no donors in 1990. The main obstacles for ICUs to procure organ donors are: convey the Medical-Legal Committee, carry out of complicated administrative procedures, availability of round the clock specialized equipment for neurological assessment (especially for ICU outside Neurosurgical and Neurological departments), inadequate number of medical and nursing staff, most of all at night, and finally the difficulty in the management of non-traumatic cerebrovascular patients.

[Neuroleptanalgesia in patients undergoing percutaneous, ultrasound-directed radiofrequency for primary or secondary, single or multiple hepatic neoplasms]. / Neuroleptoanalgesia in pazienti sottoposti a radiofrequenza percutanea ecoguidata per neoplasie epatiche primitive o secondarie, singole o multiple.

BACKGROUND: The use of percutaneous ultrasound-directed radiofrequency is a recent technique in non-surgical therapy of some neoplastic liver lesions. Purpose of this study is to demonstrate that the use of a narcosis-free analgesia allows to perform this procedure, which is generally painful and badly by the patient. METHODS: We treated 51 patients for a total of 126 procedures; the first 17 patients underwent a mono- or multipolar technique with uncooled electrodes, while the remaining 34 patients have been treated with double perfusion lumen electrodes with the chance of tipcooling. We used diidrobenzoperydol and fentanyl with a mean dose for each session of 209 micrograms for the first 17 patients and 109 micrograms for the other 34. RESULTS: Using VAS, we obtained a painless procedure in 42 patients and mild-pain sensations in 9 patients, while one hour after the procedure painless or light-pain sensation were observed in 49 patients and mild-pain in 2 patients, which required the use of FANS i.v. At discharge, all patients were pain-free or with very light pain sensation. We reduced the intra-hospital observation of patients from 5 to 3 hours, once the technique has been modified. 4 patients complained about nausea and 1 of these emesis. We did not observe any cardiovascular, respiratory and/or neurological complications. CONCLUSIONS: The use of neuroleptanalgesia allowed us to perform the described procedure with a good feeling by the patients.

Percutaneous US-guided radio-frequency tissue ablation of liver metastases: treatment and follow-up in 16 patients.

PURPOSE: To determine the potential efficacy of radio-frequency (RF) ablation of liver metastases during long-term follow-up. MATERIALS AND METHODS: Sixteen patients with 31 hepatic metastases were treated with percutaneous, ultrasound-guided RF ablation. RF was applied to monopolar electrodes (2-3-cm tip exposure) either individually or within a multiprobe array (two to four probes) for 6 minutes at 90 degrees C over one to four treatment sessions per metastasis. RESULTS: In only one of 75 sessions, a moderate complication, self-limited intraperitoneal hemorrhage, was observed. Four patients (four lesions) underwent surgical resection 15-60 days after RF treatment. Residual, viable tumor was seen in all of these patients. The remaining 12 patients were followed up for 9-29 months (mean, 18.1 months). In these patients, 18 of 27 lesions remained stable or decreased in size and showed no enhancement at computed tomography and/or magnetic resonance imaging for at least 9 months. Two patients died of disseminated disease at 13 months and one at 16 months. Disease-free survival was achieved in eight patients. CONCLUSIONS: RF ablation appears to be a simple, safe, and potentially effective treatment for selected patients with liver metastases and may become a less invasive alternative to surgical therapy.