Type III dissection according to DeBakey. Comments on 45 cases treated.

BACKGROUND: There is uncertainty regarding the most suitable form of treatment for both chronic and even more so the acute forms of DeBakey's type III aortic dissections. This retrospective study analyses the indications and methods used in 20 acute cases and 25 chronic cases of type III dissection. METHOD: The 45 patients included in this study presented a high index of operability given that they were selected from more than one coronary unit and referred to our service for this purpose. This study also confirmed a clear indication for medical treatment in uncomplicated acute forms, whereas it is necessary to opt for surgery in the case of ongoing or threatened complications. In chronic forms aorta diameter and/or thrombosis of the false lumen are a valid parameter. RESULTS: The incidence of mortality was 33.3% in the 12 acute forms undergoing surgery, with 4 deaths; in the case of chronic forms undergoing surgery, the incidence was 15% with 3 deaths. Of the 8 patients with acute pathology who were not operated, 87.5% died; whereas of the 5 non-operated chronic patients, 60% died (3 cases). During the post-operative period rethoracotomy was only necessary in 1 case following hemothorax on day 5, whereas at a respiratory level only 50% of patients were extubated within 48 hours, and in 12 cases it was necessary to continue until day 5-7, whereas tracheostomy was performed in 5 cases. CONCLUSIONS: The modern tendency in the treatment of DeBakey's type III acute dissections is to opt for surgery not only in the presence of manifest complications, but also when faced with threatened complications or the failure of medical treatment. Chronic forms present the two key indications for surgery, namely aneurysmatic evolution of the wall (> 5-6 cm) and absent thrombosis of the false lumen.

The dacron aorta.

Total aorta replacement is a major and increasingly successful surgical procedure. The paper describes a patient whose progressive aneursymatic disease spread from the ascending segment to the bifurcation over a three-years period during which time after three separate operations, the aorta was totally replaced. The paper describes the diagnostic and surgical procedures deployed and shows the results of angiographic and CT scans. Credit for the success of the replacement is also given to the highly skilled anaesthetists and nurses involved.

Surgical treatment of carotid kinking.

The authors take in exam 34 anatomical variation in the extracranial internal carotid artery (compared with more than 450 operated carotid artery), 15 of which involved kinking in patients with overt neurological symptoms, underwent corrective surgical treatment, and test the most useful and appropriate techniques in any case.

[Clinical evaluation of phlebopathies of the lower limbs using Doppler ultrasonography]. / Valutazione clinica delle flebopatie degli arti inferiori mediante ultrasonografia Doppler.

After a general introduction on Doppler sonography and the anatomy and physiology of the venous circulation in the lower extremities, personal and other experience of the main sonographic techniques used in the diagnosis of lower limb conditions like deep venous thrombosis, venous insufficiency and post-phlebitic syndrome is described.

[Treatment protocol for duodenal ulcers. Outlines of indications for surgery]. / Protocollo di trattamento dell'ulcera duodenale. Rilievo dell'indicazione chirurgica.

105 duodenal ulcer patients were examined over a two-year period. Apart from anamnesis, endoscopy and radiology, a personal treatment protocol was used to assess the indications for medical or surgical treatment. Endoscopy undeniably plays a central role in identifying the characteristics of the ulcer and its complications and will indicate medical treatment for the majority of duodenal ulcers though it also serves to confirm or modify the indication for surgery.

[Primary malignant tumors of the spleen]. / I tumori maligni primitivi della milza.

A case of angiosarcoma of the spleen is examined. In a review of reports in the literature of primary malignant tumours of the spleen, the extreme variety of this neoplasia and the lack of any precise classification are underlined.

[Early diagnosis of intestinal infarcts]. / La diagnosi precoce degli infarti intestinali.

In view of the often poor prognosis of intestinal infarctions personal experience and reports in the literature are reviewed in order to identify the clinical, laboratory and radiological dates that can contribute to early diagnosis. It is concluded that only emergency selective arteriography of the upper mesenteric artery will enable the surgeon to diagnose and accurately locate the infarction.

[Diabetes mellitus as a risk factor in vascular surgery]. / Diabete mellito quale fattore di rischio in chirurgia vascolare.

The paper reports a series of 23 diabetic patients affected by occlusive arterial disease of the lower limbs treated by reconstructive vascular surgery. Revascularisation interventions were performed in 9 patients affected by claudication, with good long-term results. Fourteen patients underwent operations for limb salvage. The major amputation rate was 35%.

[Gastric polyps: endoscopic and surgical treatment]. / I polipi gastrici: trattamento endoscopico e chirurgico.

A personal series of gastric polyps is reported. The therapeutic approach is described together with the results obtained. Comparison are made with literature.

[Early gastric cancer. A follow-up of 20 cases]. / Early gastric cancer. Follow-up di 20 casi.

The paper describes 20 cases of early gastric cancer diagnosed by endoscopy and multiple biopsies, combined with x-ray tests using a double contrast medium, with the aim of reducing the number of false negatives. Surgery was modified according to the site and macroscopic characteristics of the neoplastic lesion (type 1, 2a, 2b: total gastrectomy + extended lymphadenectomy; type 2c and 3: gastric resection, except for different indications according to the site). In line with data reported by other Authors, the five-year survival rate was 90%.

[Tumors of the anus]. / I tumori dell'ano.

On the basis of an analysis of a personal series of anal tumours, it is concluded that the polychemotherapeutic protocol with mitomycin and 5-fluorouracil and extensive local tumour removal proposed by Nigro et al. could present a valid alternative to Miles anorectal amputation. The treatment proposed offers better quality of life for the patient without changing oncological radicality and survival.

[Lesions of the colon caused by pancreatitis]. / Lesioni del colon da pancreatite.

A case of stenosis of the splenic flexure of the colon consequent on acute pancreatitis is reported. Literature reports on the colic complications of pancreatitis are examined, analysing the pathogenetic mechanisms, clinical pictures and therapeutic problems involved in this pathology.

[True or primary splenic cysts]. / Cisti vere o primarie della milza.

Two cases of splenectomy are reported following the diagnosis of a rare pathology of the spleen in the form of two primary, non-parasitic and non traumatic spleen cysts. One was located on an epithelial wall and the other on an endothelial wall.

[The suprainguinal approach in surgery on the internal saphenous vein for varices of the lower limbs]. / La via di accesso soprainguinale nella chirurgia della vena safena interna per varici degli arti inferiori.

The authors report their experience relative to 134 patients with lower limb varices surgically treated. An upper inguinal incision of the skin was employed to approach the saphenofemoral junction, obtaining by this means an aesthetic suture, with better asepsis and lower incidence of local complications.

[Palliative gastric resection]. / Le resezioni gastriche palliative.

The surgical treatment of stomach carcinoma is reassessed. Stress is laid on the more aggressive attitude with regard to advanced gastric cancer where total or partial palliative resection is the only operation offering good results. This tendency emerges both from the series presented and those reported in the literature. It is concluded that if more aggressive surgery is justified in IVth stage stomach tumours it must still depend on the patient's general condition.

[Hepatic resection. A contribution and its analysis]. / Resezioni epatiche. Un contributo e la sua analisi.

The authors outline their experience in the field of resective hepatic surgery, both with regard to benign and malignant pathologies, and analyse the results in relation to indications and techniques, but also focusing attention on the assessment of postoperative functional alterations, in order to evaluate the hepatic reserve and the organ's response to demolitive surgery. All operations were carried put in the First Division of Surgery at the Ospedale Civile, Asti, from January 1989 to September 1992. In all cases, even in major hepatectomies, a "trans-parenchymal" technique was adopted. Before surgery tests were carried out in relation to the topography of disease, its nature, associated pathologies and the functional hepatic reserve. Operative mortality was zero and morbidity was negligible, probably because rigorous selection criteria and indications for surgery were adopted. Morbidity was even restricted in the two patients suffering from HCC on cirrhosis (?) and this may probably be attributed to the limitation of resection to solely oncological purposes and their classification as Child-Pugh's stage A. The results regarding the liver response to demolitive surgery appear to be indicative and revealed a highly significant and discriminating difference between elective and emergency surgery.

[Type III entrapment syndrome of the popliteal artery. Presentation of a clinical case with diagnostic and therapeutic discussion]. / Sindrome da "entrapment" della poplitea tipo III. Presentazione di un caso clinico con discussione diagnostica e terapeutica.

Following a short review of the various types of possible abnormalities in the popliteal artery entrapment syndrome, a case is presented which was misdiagnosed for more than 2 years. Problems concerning the differential diagnosis are discussed together with details of the surgical approach performed using the medial incision and the PTFE prosthesis.

[Spinal cord protection in surgery of the thoracic, descending, and thoraco-abdominal aorta. Comparison of methods]. / La protezione midollare nella chirurgia dell'aorta toracica, discendente e toraco-addominale. Metodiche a confronto.

The authors compare the strategus needed for the elimination of paraplegia and for protection of abdominal organs after replacement of descending thoracic or thoraco-abdominal aorta. They analyse single technique considering the advantages and the controindications; furthermore they compare these properties and those of possible variants in the light of the presentation; type of disease and general conditions of the patient. These considerations are in agreement with later literature as well as the attitude of the surgeon.

[Major and minor complications in carotid surgery]. / Complicanze maggiori e minori in chirurgia carotidea.

The Authors report their experience of major and minor complications in carotid surgery. They analyse the causes and emphasize that a thorough preoperative study and a quick surgical technique are very important in reducing the rate of complications in this essentially preventive form of surgery.

[The superior vena cava occlusion syndrome. A case of neoplastic thrombosis due to hepatocarcinoma and cirrhosis]. / Sindrome da occlusione della vena cava superiore. Su di un caso di trombosi neoplastica da epatocarcinoma su cirrosi.

The authors report their experience with 11 patients, surgically treated since 1990, affected with superior vena cava syndrome. A peculiar case of neoplastic thrombosis in hepatocarcinoma is stressed. In fact a similar case hadn't been reported in the last ten-year literature, although hepatocarcinoma may spread in different organs. A subject review and a discussion are presented.