Measurement of intra-abdominal pressure in large incisional hernia repair to prevent abdominal compartmental syndrome.

INTRODUCTION: The repair of large incisional hernias may occasionally lead to a substantial increase in intra-abdominal pressure (IAP), and rarely to abdominal compartmental syndrome (ACS) with subsequent respiratory, vascular, and visceral complications. Measurement of the IAP has recently become a common practice in monitoring critical patients, even though such measurements were obtained in the early 1900s. PATIENTS AND METHODS: A prospective study involving 54 patients undergoing elective abdominal wall gap repair (mean length, 17.4 cm) with a tension-free technique after incisional hernia was conducted. The purpose of the study was to determine whether or not urinary pressure for indirect IAP measurement is a reliable method for the early identification of patients with a higher risk of developing ACS. IAP measurements were performed using a Foley catheter connected to a HOLTECH® medical manometer. IAP values were determined preoperatively, after anesthetic induction, upon patient awakening, upon patient arrival in the ward after surgery, and 24 h after surgery before removing the catheter. All patients were treated by the same surgical team using a prosthetic composite mesh (PARIETEX®). RESULTS: Incisional hernia repair caused an increase in the mean IAP score of 2.68 mmHg in 47 of 54 patients (87.04%); the IAP was decreased in two patients (3.7%) and remained equal in five patients before and 24 h after surgery (9.26%). FEV-1, measured 24 h after surgery, increased in 50 patients (92.6%), remained stable in two patients (3.7%), and decreased in two patients (3.7%). The mean increase in FEV-1 was 0.0676 L (maximum increase = 0.42 L and minimum increase = 0.01 L) in any patient who developed ACS. CONCLUSIONS: Measurement of urinary bladder pressure has been shown to be easy to perform and free of complications. Measurement of urinary bladder pressure can also be a useful tool to identify patients with a higher risk of developing ACS.

Anti-endothelial cell antibodies in rheumatic heart disease.

To evaluate the anti-endothelial cell antibodies (AECA), anti-cardiolipin antibodies (aCL) and serum mannose-binding lectin (MBL) profiles of a large cohort of Yemeni patients with rheumatic heart disease (RHD) and to correlate these findings with clinical features of the disease. Patients (n = 140) were recruited from Al-Thawra Hospital in Sana'a, Yemen. All had RHD diagnosed according to modified Jones' criteria. We also studied 140 sex- and age-matched healthy blood donors from the same area. Echocardiography was performed according to the recommendations of the American Society of Echocardiography. Solid phase enzyme-linked immunosorbent assays (ELISAs) were used to measure AECA and aCL titres and serum MBL levels. Forty per cent of the patients were AECA-positive, but only 7·8% were positive for aCL antibodies. Serum MBL levels were significantly lower in the RHD group (median 4221 ng/ml versus 5166 ng/ml in healthy controls). AECA titres were correlated positively with patient age, duration of RHD and the severity of aortic stenosis, as determined by echocardiographic findings. In several autoimmune rheumatic diseases, such as systemic lupus erythematosus, vasculitis and scleroderma, AECA have been shown to play pathogenic roles by producing proinflammatory and procoagulant effects (increased expression of adhesion molecules and tissue factors, increased cytokine release) in endothelial cells. In RHD, these autoantibodies might represent a pathological link between activation of the valvular endothelium and valvular damage.

Treatment for persistent chronic neuralgia after inguinal hernioplasty.

Following an inguinal hernia repair with open or laparoscopic technique, 1-15% of patients show persistent neuralgia, a severe, potentially debilitating, complication. Several therapeutic procedures have been proposed, but consensus regarding choice of treatment has not yet been achieved. We performed a prospective study on 32 such cases. Patients underwent anaesthetic infiltration to identify, when possible, the involved nerve, and we then carried out a step-by-step therapeutic protocol. In the initial phase, patients were treated with oral analgesic and afterwards with repeated infiltrations of anaesthetic and cortisone. Surgery was reserved for patients not responding to the infiltrations, though with no good success. The authors believe that noninvasive methods are to be preferred, whereas neurectomy interventions should be reserved for selected cases.

Spigelian hernia: a case report and review of the literature.

Spigelian hernia is a rare abdominal hernia that occurs through Spigelian aponeurosis. The Authors present a case of Spigelian hernia associated with narrowing of sigmoid colon and diverticular pathology. They also described historical background, surgical anatomy and etiopathogenesis of this hernia. By a remarkable revision of literature, they sum up epidemiology and clinical features of Spigelian hernia. Furthermore, they discuss diagnostic and therapeutic principles.

Large incisional hernia in the elderly: which kind of treatment?

Incisional hernia is one of the commonest long-term complications of open abdominal surgery. Especially in old patients (over 70 years), the incisional hernias represent an invalidating pathology whose treatment, for the high incidence of associated respiratory and cardiovascular disease, offers difficulties related to the preoperative and postoperative management as well as to the surgical treatment. This paper reports the Author's experience about the surgical treatment of large incisional hernia (> 10 cm) with open prosthetic mesh repair in geriatric patients.

The benign cystic lymphoepithelial lesion of the parotid gland is a viral reservoir in HIV type 1-infected patients.

The presence of HIV-1 in cystic fluid aspirates from six cases of benign cystic lymphoepithelial lesion (BLL) of the parotid gland, a rare disorder affecting HIV-1-infected patients, has been investigated. HIV-1 p24 protein was present at a concentration ranging from 3 to 15 ng/ml, while it was undetectable in the peripheral blood of the same patients. The number of RNA copies of HIV-1 in the cystic fluids was high, ranging from 0.5 x 10(7) to 7.2 x 10(7) RNA copies/ml. BLL cystic fluid aspirates, despite the high level of HIV-1 RNA, were found to contain only a few infectious virions. The low infectivity correlated with the infrequent detection by electron microscopy of complete HIV-1 particles. The pathogenic mechanism leading to virus accumulation in the cystic fluid was studied by immunohistochemistry of tissue sections. p24 protein was associated with DRC-1+/S-100+ follicular dendritic reticulum cells, which were also present within the cystic cavities. Our findings are consistent with the possibility that the large amounts of virus present in the fluid derive from continuous shedding of HIV-1-infected cells from the surrounding lymphoid tissue.

Transsternal approach to closure of bronchopleural fistulas after pneumonectomy. A fifteen cases report.

A treatment method for main bronchus fistula after pneumonectomy via median sternotomy was described by P. Abruzzini in 1961. This operation is performed in an area not involved with infection. Fifteen patients underwent the procedure in our surgical department; one of them died of myocardial infarction while all the others survived for different periods of time, closely associated with the original disease; seven were long-term survivors. The transmediastinal approach seems an effective means of managing such a difficult complication.

Cystic lymphoepithelial lesions of the parotid gland in HIV-1 infection.

The benign cystic lymphoepithelial lesion (BLL) of the parotid gland is a rare disorder affecting HIV-1-infected patients. Here we describe the clinical and histopathological features of 10 cases of BLL, who presented to our observation between November 1992 and December 1996, before the combination antiretroviral therapy was introduced.

[Injury of the popliteal artery]. / Il trauma dell'arteria poplitea.

Injuries to the lower limbs are now commonplace, in particular due to the increased number of car accidents, work accidents, injuries from knives or fire arms, or sporting injuries. The popliteal artery is involved in 6% of all these injuries. A clinical case is described of a subject who was injured, causing laceration to the popliteal artery, and brought to our attention six months after the event.

[Anastomotic dehiscence in colorectal surgery and the total parenteral nutrition. A clinical study]. / Deiscenze anastomotiche in chirurgia colo-rettale e NPT. Studio clinico.

After analysing previous investigations into the incidence of anastomotic dehiscence in colorectal surgery, the paper reports experience with a group of 27 patients treated by a "routine"-TPN after major surgery. In addition, a second group of 67 patients, treated by TPN alone after a postoperative complication, was included in this study. The results show the utility of TPN in the prevention or faster healing of anastomotic dehiscences.

[The guaiac test and colorectal pathology. Clinical evaluation]. / Test al guaiaco e patologia colo-rettale. Valutazione clinica.

The paper reports the results of a study carried out in 187 out-patients who were examined for various reasons. A guaiac test was performed in all patients and those with positive results were further examined using more complex methods. The results obtained showed that, due to its high levels of sensitivity and specificity, as well as its low cost, the "Hemoccult test" still represents the most suitable means for the mass-screening of non-selected populations.

[Local anesthesia in the surgery of inguinal hernia. Technical notes]. / L'anestesia locale nella chirurgia dell'ernia inguinale. Note di tecnica.

Routine use of local anaesthesia associated with tension-free hernioplasty in surgical treatment of inguinal hernia allows an immediate patient walking and prompt discharge from the hospital unit: with this technique 89 cases in two years were operated. The anaesthesia-related discomforts and complications are minimal. The addition of an intravenous sedative (propofol) premis to extend this approach to anxious patients too.

[Total parenteral nutrition in patients undergoing total gastrectomy in cancer of the stomach. A clinical study]. / La nutrizione parenterale totale (NPT) nel paziente candidato a gastrectomia totale per cancro. Studio clinico.

Total gastrectomy is the elective therapy for gastric cancer, but anastomotic dehiscences often improve the results of this surgery, performed in patients with malnutrition due to the neoplasy. The authors present a group of 27 patients treated with total gastrectomy and a routine postoperative TPN; the incidence of dehiscences and postoperative complications is very low. The preoperative evaluation of surgical risk and the choice of pre- and/or postoperative, parenteral and/or enteral nutritional therapy, are discussed.

[Pulmonary carcinoids. Analysis of 53 cases]. / Carcinoidi polmonari. Analisi di 53 casi.

We have performed a retrospective analysis of 53 cases of bronchial carcinoids using our own patient data from more than 4700 lung tumors and 1632 resections. The male/female ratio was 1:12 (28/25) and the age range 13 to 75 years (mean 52.2). Fifty-three tumors resections of varying extent were performed, including one radical pneumonectomy in a patient who had previously undergone a lobectomy, and one limited resection of the main left bronchus; there was no intraoperative mortality. After histological examination, 44 tumors (83%) were found to be typical carcinoids and nine (17%) atypical carcinoids. The median follow-up period was 4.56 years, with a range from 1 to 10 years. Only one patient with an atypical carcinoid tumor had a relapse and died three years after, while another patient underwent surgery of the contralateral lung for a second primary lung cancer (SPLC). On the basis of these observations we would like to underline the importance of an accurate histopathological classification for both therapeutic and prognostic purposes; given the higher aggressiveness of atypical carcinoids, these tumors would be eligible for a therapeutic approach analogous to that adopted for bronchogenic carcinoma.

Surgical treatment of T3 lung cancer invading the chest wall.

Lung tumors invading the chest wall are classed as belonging to the T3 group and are considered potentially resectable. Their management, however, is controversial, and extrapleural resection, when possible, is preferred to en bloc resection which is regarded as a far more invasive and dangerous operation. Five year survival rates for completely resected cases range in the literature from 25 to 35%, but survival rates are much worse if lymph node metastases are present. These poor outcomes have prompted the development of combined surgical approaches: preoperative radiation therapy, with or without chemotherapy, has been used with an improvement in resectability rates, but only modest results in terms of median survival; in a number of case series, increased operative morbidity and mortality have been reported with this approach. The present report relates to 122 patients treated by en bloc (20 cases) or extrapleural (102 cases) resection, 31 of whom also received neoadjuvant treatment. The operative mortality was 4.6%. Median survival was 17 months after en bloc resection and 19 months after extrapleural resection. Though no statistically significant difference was found, extrapleural resection would appear to yield better results than the en bloc procedure.

Treatment of gunshot wounds to the colon: experience in a rural hospital during the civil war in Somalia.

BACKGROUND: In the last few decades there has been a clear tendency in civilian practice towards primary repair of gunshot wounds to the colon, resulting in a substantial decrease in the number of colostomies performed for this type of injury. METHODS: The series described here comprises 24 patients with gunshot wounds to the colon treated at the hospital of Jowar in the Middle Shebelle region of Somalia between 1999 and 2001. All injuries were caused by war arms firing high-velocity projectiles. RESULTS: In 18 patients surgery consisted of resection and immediate anastomosis, while in the remaining six patients colostomies were performed including five loop colostomies and one terminal colostomy. The sepsis-related mortality was 25% (6/24). CONCLUSION: Our experience had a peculiar setting, namely that of a civil war in a developing country. In this kind of "difficult" situation there probably exists no ideal procedure and the decisions taken at the operating table are influenced by various factors that are often related to subjective assessment.

[Bilateral retroperitoneal lymphadenectomy in tumors of the testis: anatomo-clinical considerations]. / La linfadenectomia retroperitoneale bilaterale nei tumori del testicolo: considerazioni anatomo-cliniche.

Bilateral retroperitoneal lymphadenectomy is usually indicated for non-seminomatous testis tumour at stage IIA and IIB. For seminoma is generally used radiotherapy, although some Authors prefer the surgical approach. Radical retroperitoneal lymphadenectomy must be bilateral, because metastatic cell can often spread to the contralateral lymph nodes. Lymphadenectomy is used not only for therapy, but also for staging: thus clinical evaluation and other diagnostic techniques are not always correct (30% of understaging). Permanent sexual disfunction can follow radical surgery, due to extensive retroperitoneal dissection and exeresis of lumbar sympathetic nerves; so it is proposed, for stage I tumors, a monolateral or limited retroperitoneal lymphadenectomy. Eight patients with non-seminomatous testicular tumours are reported by the authors; 2 (stage I) were treated with monolateral, 4 (stage IIA and IIB) with bilateral retroperitoneal lymphadenectomy; in 2 patients (stage IIC and IID) chemotherapy was followed by debulking surgery. Relapses were observed between 3 and 19 months. Sexual dysfunctions after surgery were present in 5 patients (69%); in all of these a bilateral retroperitoneal lymphadenectomy was performed.

[Reoperations in lung surgery]. / I reinterventi in chirurgia polmonare.

A second thoracotomy in patients who have undergone previous chest surgery can be performed soon or immediately after the first operation and is usually aimed at resolving severe or even life-threatening postoperative complications. Late reoperations, on the other hand, are either performed to resolve complications of previous surgery or to remove second primary lung tumors (SPLCs) or metastases. The most exacting reoperation in this context is completion pneumonectomy, which is particularly indicated in the case of failure of the residual lobe to re-expand after primary surgery; it is also used for--rarely occurring--fistulas of the lobar bronchi and for new ipsilateral primary lung tumors. This type of surgery is technically complicated and has been associated, in our experience and that of others, with a certain mortality. Technically less difficult is a second ipsilateral thoracotomy for exploratory purposes or minor parenchymal resection, and the same is true of contralateral lobar or sublobar resections. Lastly, Abruzzini's operation, for fistulas of the primary bronchus, is relatively complicated but often leads to good results; we have performed 15 such operations with only one death occurring due to acute myocardial infarction.

[Adrenal hemorrhagic cysts: apropos of a clinical case and review of the literature]. / Cisti emorragiche del surrene: a proposito di un caso clinico e revisione della letteratura.

Adrenal cysts are uncommon lesion and present complex problems in differential diagnosis. The treatment options are not univocal. Starting from the study of a personal case the authors review the existing literature and discuss the problem of diagnosis and treatment.

[Use of the eutectic ointment EMLA (Eutectic Mixture of Local Anesthetics) in the surgical treatment of inguinal hernia under local anesthesia]. / L'uso della crema eutettica EMLA nel trattamento chirurgico dell'ernia inguinale in anestesia locale.

The use of EMLA eutectic cream is very effective and well tolerated in superficial anaesthesia. It is particularly indicated in surgical treatment of inguinal hernia by local anaesthesia, to achieve the analgesia of superficial layers. This allows to reduce the total dose of anaesthetics administrated by infiltration, reducing the risk of overdose, eliminating the pain due to injection, and is very agreeable for the patients.