Echo-guided injection of botulinum toxin versus blind endoscopic injection in patients with achalasia: final report.

AIM: Achalasia, also known as Esophageal achalasia, is an esophageal motility disorder involving the smooth muscle layer of the esophagus and the lower esophageal sphincter (LES). It is characterized by incomplete LES relaxation, increased LES tone, and lack of peristalsis of the esophagus (inability of smooth muscle to move food down the esophagus) in the absence of other explanations like cancer or fibrosis. In our experience, the echo-guided injection technique is the first procedure to implement to cure patients. After endoscopic-echo-guided injection technique, in patients presenting with refractory symptoms, the authors believe in surgical technique (extramucosal myotomy) as a good alternative technique to be implemented. METHODS: From 1999 to 2010, the authors have treated 36 patients (Group A), 24 male and 12 female (age 26-78) with diagnosis of esophageal achalasia. Patients underwent botulinum toxin injection during echo-guided identification of the lower esophageal sphincter. Results were compared with 32 patients (Group B) (age 36-78) who underwent blind treatment. RESULTS: Patients of Group A presented complete relief of obstruction, patients of Group B had an obstruction remission in the 86% of the cases. Results were confirmed by manometric assessments in the early months after endoscopic treatment. CONCLUSION: The authors emphasize the importance of the injection of botulinum toxin into the thicker area of the muscle layer of the lower esophageal sphincter. Patients undergoing echo-guided injection technique presented complete relief of obstruction, confirmed by manometric assessments in the early months after treatment.

Gallbladder carcinoma late metastases and incisional hernia at umbilical port site after laparoscopic cholecystectomy.

A potentially serious complication of laparoscopic cholecystectomy is the inadvertent dissemination of unsuspected gallbladder carcinoma. There are increasing reports of seeding of tumor at the trocar sites following laparoscopic cholecystectomy in patients with unexpected or inapparent gallbladder carcinoma. Although the mechanism of the abdominal wall recurrence is still unclear, laparoscopic handling of the tumor, perforation of the gallbladder, and extraction of the specimen without an endobag may be risk factors for the spreading of malignant cells. The Authors report the case of late development of umbilical metastasis after laparoscopic cholecystectomy; the presence of an incisional hernia and the finding of a stone in subcutaneous tissue demonstrate the diffusion of tumor cells into subcutaneous tissue during the extraction of gallbladder. The patient underwent an excision of the metastases. She is disease free two years after surgical treatment.

[Thyroid maltoma: report of a case without coexistent Hashimoto's thyroiditis]. / Maltoma della tiroide: presentazione di un caso non associato a tiroidite di Hashimoto.

Maltomas of the thyroid are rare neoplasms that originate from parafollicular B lymphocytes and are often associated with autoimmune thyroiditis (Hashimoto's disease). The authors describe a case of a primary thyroid lymphoma in which no evidence for a previous thyroiditis could be found during clinical evaluation (clinical progression of the tumor, diagnostic studies, preoperative cytology, histology of the surgical specimen). Noteworthy was the development of a severe form of pure red cell aplasia (PRCA) about 6 months after the operation without detectable autoantibodies or signs of previous viral infection. The aplasia resolved completely with corticosteroid therapy.

[Surgical treatment of esophageal achalasia. Personal trend]. / Il trattamento chirurgico dell'acalasia esofagea. Nostro orientamento.

AIM: Achalasia of the esophagus involves the entire esophagus from the upper esophageal sphincter (UES) to the lower esophageal sphincter (LES) together with a wide spectrum of physiopathological and clinical variations. Therefore, the need to know exactly the different involvement either of the body of the esophagus or the LES for each case is underlined. In our experience, the cineradiology is the only technique that allows a complete morphologic and functional study of the disease. It is through cinesophagography that we can exactly establish the extension of myotomy according to the physiopathological aspects that will suggest the most accurate surgical treatment. It is our opinion to perform a short myotomy, to the gastroesophageal junction, through an abdominal approach in grade II and III achalasia, when the most important physiopathological aspects involve only the LES area (hypertonic LES or dischalasia). We extend the myotomy from the LES up to the aortic arch through a thoracic approach. METHODS: From 1984 to 2002, we have treated 148 achalasic patients, 90 through an abdominal approach, 22 by VALS (Video Assisted Laparoscopic Surgery) and 36 through a thoracic approach. In the first 2 groups we performed a short myotomy with a Dor antireflux procedure, in the 3rd group we performed a long myotomy with a Belsey Mark IV antireflux procedure. RESULTS: Our trend to calibrate the surgical treatment on the physiopathological and morphofunctional data, allowed to optimize the post-operative clinical results, particularly with a better control of dysphagia. CONCLUSIONS: Surgical treatment of achalasia must be differentiated according to the pathophysiological basis in order to improve the surgical results.

Recruitment strategies used by an allied health education program to increase student enrollment.

OBJECTIVE: To increase student enrollment in and public awareness of a Clinical Laboratory Science (CLS) program so that the program would not be eliminated by the University. SETTING: The Medical Technology (MT) program at the University of Delaware (UD). PRACTICE DESCRIPTION: The MT program is a 2 + 2 university-based program established in 1948. The program is accredited for 26 students. PRACTICE INNOVATIONS: Various recruitment activities were used to increase enrollment including presentation at high schools, and panel discussions and open houses held on campus. Extensive publicity on and off campus was used to inform the community about CLS. MAIN OUTCOME MEASURE: Student enrollment in the program and the results of a survey administered to students enrolled in a CLS introductory course. RESULTS: There were 22 students in the 1993-1994 graduating class compared to 10 in the 1992-1993 class. The enrollment also increased for the junior, sophomore, and freshman classes. Because of increased student enrollment and public awareness, the University decided not to eliminate the MT program. CONCLUSION: No single recruitment activity contributed to the increased numbers; rather, it appears that all of the activities contributed to the rise in enrollment of MT majors at UD.

[The tension-free hernioplasty for primary inguinal hernias: personal experience]. / Il trattamento dell'ernia inguinale con tecnica "tension free". Esperienza personale.

The Authors report their experience in the treatment of primary inguinal hernias using Trabucco's tension-free technique. Since April 1998 to June 2002 four hundred and fifteen patients (399 men and 16 women) were treated in our Department for primary inguinal hernia. The results demonstrate the efficacy of this technique in reducing post-operative complications and in preventing relapses. The reduction of costs is related to a shorter hospitalization and an earlier return to work.

[Gastrointestinal stromal tumors: clinical considerations]. / Considerazioni cliniche sui tumori gastrointestinali stromali.

Gastrointestinal stromal tumors (61ST) are an heterogeneous group of non epithelial tumors of the gastrointestinal tract. They are peculiar to extreme cellular variability and uncertain malignancy. Gist are rare tumors that arise from primitive mesenchymal cells located in all gastrointestinal tract. Till now they are object of discussion about their origin, diagnostic standards, prognostic factors, histopathological classification. They are more frequently in over 40 years old people without difference in two sex, but they can appear in the child too and in the young man suffering from HIV. The authors relate two cases of recent observation, and discuss on the biological behaviour of these rare tumors.

[Pilonidal sinus: an retrospective analysis of 205 cases]. / Sinus Pilonidale. Analisi retrospettiva di 205 casi. Metodo chiuso versus metodo aperto.

Sinus pilonidalis or the sacrococcigea cyst, normally is considered a "small surgical pathology" and actually it is controversial disease regarding its pathogenesis and treatment. Today the congenital hypothesis of this pathology is not considered. The etiopathogenesis exclude vestigia embryonic origin and consider it an inflammatory disease. Traumatism of the sacral region, hirsutism, hormonal secretion stimulating, and furrow sacral furrow cutaneous, explain the prevalence of this pathology in the male sex and in the puberale age. It usually appears after the pubertà and extension one various frequency of presentation in males sex (1.3%) regarding females (0.11%). The symptomatology can be rare or introduce itself in violent and intense way with on abscess of the region, or with only or multiple fistulas orifices from which exit materialclarly purulent. Normally cystic cavity is one, situated in the subcutaneous tissue with annexed inflammatory phenomena. This cavity to times communicates with the skyn fistulating. The treatment of election is surgical and must weighted and be regulated in relation to the entity of the lesion and its inflammatory picture. Sometimes the medical therapy with anti-inflammatory and antibiotic is not control the symptomatology and it need the surgical treatment.

Abrikossoff's tumour: report of a rare case in anal perianal region.

The authors report a rare case of a 47-year old man suffered from Crohn's disease and depression with multiple prominent lesions in the anal and perianal region. The biopsy of these lesions showed the presence of Abrikossoff's tumour. This tumour is very rare in the anal region and usually the lesions are small (0.5-3 cm) and solitary. The authors report this case because they considered it an interesting case for the localization and the appearance of the lesions.

[Primary volvulus of the small intestine: vascular-like acute abdomen]. / Il volvolo primitivo dell'intestino tenue: quadro di addome acuto simil-vascolare.

The Authors discuss etiology, clinical picture, diagnostic and therapeutic possibilities of intestinal volvulus, an uncommon disease in Europe, thinking of a case of primitive small intestine volvulus, recently observed, and considering the literature. The Authors have come to the conclusion that in all the cases of intestinal occlusion, in emergency hospitalization, it is important to suspect the intestinal volvulus and to operate on the patient urgently to avoid the raise of postoperative mortality in all the cases complicated with intestinal gangrene.

[The solitary benign ulcer of the colon: a report of a case located in the cecum]. / L'ulcera solitaria benigna del colon: osservazione di un caso a localizzazione ciecale.

The authors report a case of benign solitary cecal ulcer, occurred recently to their observation and diagnosed during operation. The patient was undergo an operation of right hemicolectomy. The preoperative diagnosis of lesion kind and its localization is difficult because it's a rare disease as well as literature reports; in fact the benign solitary colon ulcer can be differentiated with difficult from a perforated appendicitis, an inflammatory disease and a colon carcinoma. The authors discuss about probable etiologic factors, clinical features and surgical treatment.