Cerebrospinal fluid diversion in patients with enlarged Virchow-Robin spaces without ventriculomegaly.

OBJECTIVE: Enlarged Virchow-Robin spaces (eVRS) are an MRI biomarker in several neurological diseases of inflammatory, neurodegenerative, vascular, metabolic, or genetic origin. We report on a further condition in which eVRS were observed in patients with an ongoing chronic hydrocephalus-like clinical picture without ventriculomegaly who improved after CSF diversion, and we discuss the possible mechanisms underlying this finding. MATERIALS AND METHODS: A retrospective study of seven patients presenting progressive gait, cognitive, and urinary disturbances in association with eVRS was undertaken. RESULTS: All patients presented an Evans ratio <0.30 and >20 eVRS at the level of basal ganglia and periventricular parenchyma as assessed by T2-weighted MRI. All patients underwent prolonged external lumbar drainage (PELD) with good response. Six patients received ventriculoperitoneal shunt with improvement of their clinical status compared to that before PELD (follow-up: 8-58 months, mean 24.6). The seventh patient did not undergo ventriculoperitoneal shunt and received a second PELD with persistent improvement (follow-up: 14 months). CONCLUSIONS: Our results indicate that a mechanism involving CSF accumulation and stasis in the subarachnoid space was at least a concurrent factor of this clinical picture. This study should stimulate new perspectives on the role of CSF disturbances in the pathogenesis of diseases associated with VRS enlargement.

Indications and Coverage of Metabolic and Bariatric Surgery: A Worldwide IFSO Survey Comparing Different National Guidelines.

INTRODUCTION: Knowing how metabolic and bariatric surgery (MBS) is indicated in different countries is essential information for the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO). AIM: To analyze the indications for MBS recommended by each of the national societies that comprise the IFSO and how MBS is financed in their countries. METHODS: All IFSO societies were asked to fill out a survey asking whether they have, and which are their national guidelines, and if MBS is covered by their public health service. RESULTS: Sixty-three out of the 72 IFSO national societies answered the form (87.5%). Among them, 74.6% have some kind of guidelines regarding indications for MBS. Twenty-two percent are still based on the US National Institute of Health (NIH) 1991 recommendations, 43.5% possess guidelines midway the 1991s and ASMBS/IFSO 2022 ones, and 34% have already adopted the latest ASMBS/IFSO 2022 guidelines. MBS was financially covered in 65% of the countries. CONCLUSIONS: Most of the IFSO member societies have MBS guidelines. While more than a third of them have already shifted to the most updated ASMBS/IFSO 2022 ones, another significant number of countries are still following the NIH 1991 guidelines or even do not have any at all. Besides, there is a significant number of countries in which surgical treatment is not yet financially covered. More effort is needed to standardize indications worldwide and to influence insurers and health policymakers to increase the coverage of MBS.

Evaluation of the anterior pituitary function in the acute phase after spontaneous subarachnoid hemorrhage.

BACKGROUND: Subarachnoid hemorrhage (SAH) is a potential cause of hypopituitarism. Most of the studies regarding the relationship between SAH and anterior pituitary function were retrospective and hormonal assessment was performed several months after SAH. AIM: To prospectively evaluate the prevalence of anterior pituitary hormone deficiencies in the acute phase after spontaneous SAH and their possible correlation with clinical and radiological parameters. METHODS: Pituitary function was tested in 60 patients within 72 h after spontaneous SAH. RESULTS: 56.9% of the patients showed at least one anterior pituitary hormone deficiency: gonadotropin and GH secretion failure represented the most prevalent hormonal deficiencies (33.3 and 22.0%, respectively), whereas ACTH and TSH deficiency was less frequent (7.1 and 1.8%, respectively). With the exception of secondary hypogonadism, the prevalence of other pituitary hormone deficiencies is in agreement with previous studies, which evaluated pituitary function on longterm follow up after SAH. No correlation was found between hypopituitarism and clinical status, as assessed with Hunt-Hess and Glascow Coma Scales. Moreover, no correlation was found between hypopituitarism and bleeding severity evaluated with Fisher's scale. CONCLUSIONS: We demonstrated a high prevalence of anterior pituitary hormone deficiencies acutely after SAH. Although part of GH and gonadotropin deficiencies might be a consequence of functional alteration due to SAH itself, the finding of low cortisol levels in this stressful condition strongly suggests the presence of true hypocortisolism. Therefore, an evaluation of pituitary function shortly after SAH might be useful to identify a subset of patients who deserve a more accurate follow-up.

Progress in restorative neurosurgery: human fetal striatal transplantation in Huntington's disease. Review.

The purpose of this paper was to offer a review of the rationale, methods, biological and clinical results of human fetal striatal transplantation (HFST) in the treatment of Huntington's disease (HD). HD is a heritable neurodegenerative disease in which degeneration of neurons in the striatum leads to motor, psychiatric and cognitive deficits. The disease is progressive and inexorably lethal. At present there are no curative treatments for HD. A restorative therapy based on the intrastriatal transplantation of striatal neuroblasts taken from human fetus is currently being explored as potential treatment in selected HD patients. Pilot clinical trials of HFST have been started in few neurosurgery restorative centres. Results demonstrated that HFST is feasible and safe without relevant adverse effects; grafted neuroblasts survive, grow without evidence of neoplasia or teratoma, build new tissue with striatal-like imaging features, and move into the host brain towards short and long-distance cortical and sub-cortical targets. HFST delays disease progression and provides a period of improvement and stability. Even though larger-scale studies are still necessary to establish the true value of such a treatment, at this time, HFST represents a promising experimental therapy for patients with HD and one of the most interesting clinical application of restorative neurosurgery.

A magnetic internal mechanism for precise orientation of the camera in wireless endoluminal applications.

BACKGROUND AND STUDY AIMS: The use of magnetic fields to control operative devices has been recently described in endoluminal and transluminal surgical applications. The exponential decrease of magnetic field strength with distance has major implications for precision of the remote control. We aimed to assess the feasibility and functionality of a novel wireless miniaturized mechanism, based on magnetic forces, for precise orientation of the camera. MATERIALS AND METHODS: A remotely controllable endoscopic capsule was developed as proof of concept. Two intracapsular moveable permanent magnets allow fine positioning, and an externally applied magnetic field permits gross movement and stabilization. Performance was assessed in ex vivo and in vivo bench tests, using porcine upper and lower gastrointestinal tracts. RESULTS: Fine control of capsule navigation and rotation was achieved in all tests with an external magnet held steadily about 15 cm from the capsule. The camera could be rotated in steps of 1.8 degrees . This was confirmed by ex vivo tests; the mechanism could adjust the capsule view at 40 different locations in a gastrointestinal tract phantom model. Full 360 degrees viewing was possible in the gastric cavity, while the maximal steering in the colon was 45 degrees in total. In vivo, a similar performance was verified, where the mechanism was successfully operated every 5 cm for 40 cm in the colon, visually sweeping from side to side of the lumen; 360 degrees views were obtained in the gastric fundus and body, while antrally the luminal walls prevented full rotation. CONCLUSIONS: We report the feasibility and effectiveness of the combined use of external static magnetic fields and internal actuation to move small permanent intracapsular magnets to achieve wirelessly controllable and precise camera steering. The concept is applicable to capsule endoscopy as to other instrumentation for laparoscopic, endoluminal, or transluminal procedures.

Improving Nausea and Vomiting Post-Elipse Balloon: a Novel Single-Dose Regimen of 300 mg Netupitant/0.5 mg Palonosetron Hydrochloride.

BACKGROUND: Post intragastric balloon placement symptoms like nausea and vomiting have been the major cause of a high rate of early removal. Common therapy with ondansetron alone, or in combination, with prokinetic agents have been shown to have very little or no effect. Recently, an improved therapy based on aprepitant and ondansetron combination showed a significant improvement in symptoms management. Lack of aprepitant availability in several countries and patients difficulties to follow the right prescription convinced us to explore other pharmacological options. OBJECTIVE: Evaluate safety and efficacy of a netupitant and palonosetron-combined drug and to reduce and control post Elipse® placement symptoms METHODS: Between January and March 2018, 30 patients (9 male, 21 female), (mean weight 97.8 and mean BMI 34.7), underwent Elispe® placements, at 550 ml volume, in an outpatient fashion. All patients received a single pill 300 mg netupitant/0.5 mg palonosetron 6 h prior to placement. All patients received ondansetron 4 mg prescription to be taken as needed. A daily VAS score to report intensity of nausea, vomit, cramps, gastric pain, satiety for the first week post-placement was completed. RESULTS: 4/30 (13%) reported vomiting on days 1, 2, and 3; 9/30 (30%) reported nausea higher than score 4 on days 1, 2, and 3; 8/30 (26.6%) reported gastric pain higher than score 4 on days 1, 2, and 3. CONCLUSION: In our experience, the use of a single-pill netupitant/palonosetron resulted to be very easy to administer and effective in reducing vomit, nausea, and gastric pain in 87%, 70%, and 73.4% patients respectively, ameliorating the post Elipse™ placements symptoms safely.

A one-session circumferential reconstruction in thoracic and lumbar spine fractures using a small expandable cage.

AIM: Circumferential reconstruction of thoracic and lumbar vertebrae is most frequently performed in two sessions. The authors assessed feasibility, safety and results of a surgical technique in which the use of a small cage allows a less invasive strategy. In addition, since the authors perform urgent decompression in specific cases of spinal cord injury, feasibility of this technique in emergency was verified. METHODS: In two Neurosurgical Departments, between May 2001 and May 2006, 62 patients with thoracic or lumbar fractures were operated on using this technique. X-rays were performed postoperatively and around 45 days from surgery. Three-dimension-computed tomography (3D-CT) scans were performed at 3, 6 and 12 months. Neurological evaluations were repeated at every outpatient visit. After screw insertion at the adjacent levels and traditional transpedicular circumferential decompression, further bone is removed to excavate a niche in the vertebral body and the contiguous discs are removed. The expandable cage, filled with bone fragments, is inserted horizontal or oblique laterally to the sac and applied vertical inside that niche and then expanded. The circumferential stabilization is completed with bone grafting and posterior instrumentation. RESULTS: 3D-CT scans showed sound fusion and no manifest correction loss. Nineteen patients improved at least one grade in the ASIA scale and 11 gained neuromeric levels. CONCLUSION: This technique, fairly undemanding and feasible also in emergency, proved to be safe and resistant. Two-year follow-up demonstrated thriving fusion and steady alignment. It is a valuable surgical therapy to selected cases of burst fracture.

Enterogenous cysts of the cerebellopontine angle: short review illustrated by two new patients.

Intracranial enterogenous cysts are an uncommon entity rarely found in the midline within the posterior cranial fossa. The occurrence of an enterogenous cyst in the cerebellopontine angle is exceptional. We present two new cases of cerebellopontine angle (CPA) enterogenous cysts and review the literature to clarify the diagnosis and the management of these lesions. Eighteen cases of CPA intradural enterogenous cysts have been reported to date, including the two cases presented in this article. All of them were symptomatic and underwent surgical treatment. After surgery, the symptomatic recurrence occurred in 31% of the patients, most of which had partial excision. Considering our patients and the published cases in the literature we suggest that the aim of surgery should be total removal of cyst and its content whenever possible. When partial resection of the cyst is performed, we recommend long-term clinical and neuroradiological follow-up.

Radius surgical system and conventional laparoscopic instruments in abdominal surgery: application, learning curve and ergonomy.

We illustrate our experience with a new class of instruments, the mechanical manipulators (MM), whose main features are an improved mobility, and ergonomy and a modular structure. A specific MM, the Radius Surgical System (RADIUS), has been used both for educational purposes as well as in clinical studies, demonstrating that it can represent an efficient tool to support surgeons performing surgical complex procedures, with a short learning curve for the postural attitude.

Francesco Rizzoli (1809-1880) and the elusive case of Giulia: the description of an ''arteriovenous aneurysm passino through the wall of the skull''.

The improved knowledge of clinical and emodynamical aspects of extracranial arteriovenous malformations in the 18 th century provided a foundation for the understanding and treatment of cerebrovascular pathology. It was not until the late 19 th century that detailed clinicopathological reports of intracranial arteriovenous malformations were published. In this historical context, a seminal report written by the Italian surgeon Francesco Rizzoli is worthy of notice, the Giulia case. A 9-year-old girl presenting with seizures and an occipital pulsanting swelling was examined in 1873 by Rizzoli. He was able to use Giulia's signs and symptoms to predict the complex angioarchitecture of her ''arteriovenous aneurysm passing through the wall of skull''. The postmortem dissection completely confirmed the supposed diagnosis, disclosing a direct communication between the hypertrophic branches of the ocipital artery and the transverse sinus. The clinical course of that case is briefly reviewed in this article and the diagnosis of this unusual arteriovenous shunt is discussed in light of the current neurosurgical knowledge.

A professional and cost effective digital video editing and image storage system for the operating room.

We propose an easy-to-construct digital video editing system ideal to produce video documentation and still images. A digital video editing system applicable to many video sources in the operating room is described in detail. The proposed system has proved easy to use and permits one to obtain videography quickly and easily. Mixing different streams of video input from all the devices in use in the operating room, the application of filters and effects produces a final, professional end-product. Recording on a DVD provides an inexpensive, portable and easy-to-use medium to store or re-edit or tape at a later time. From stored videography it is easy to extract high-quality, still images useful for teaching, presentations and publications. In conclusion digital videography and still photography can easily be recorded by the proposed system, producing high-quality video recording. The use of firewire ports provides good compatibility with next-generation hardware and software. The high standard of quality makes the proposed system one of the lowest priced products available today.

Extra-arachnoidal cranio-cervical decompression for syringomyelia associated with Chiari I malformation in adults: technique assessment.

BACKGROUND: The osteo-dural decompression of the cerebellar tonsils at the cranio-cervical junction is generally considered the most effective treatment for syringomyelia-Chiari I complex. However much controversy concerning a great number of surgical adjuvants to the standard bony decompression is still present. In this work an extra-arachnoidal cranio-cervical decompression (CCD) without duroplasty is described and the surgical results are reported. METHOD: Between 2000 and 2005, 24 adult patients underwent surgery for symptomatic syringomyelia-Chiari I complex not associated with hydrocephalus. In all cases, the surgical procedure consisted of a limited suboccipital craniectomy and laminectomy of C1 (when necessary C2 as well) followed by dural opening leaving the arachnoid membrane intact. The dura mater is left open and stitched laterally to the muscles. FINDINGS: With a mean clinical long term follow-up of 44 months (range, 12-78 mo), neurological disturbances improved in 21 of 24 patients (87.5%) as result of extra-arachnoidal CCD. The postoperative complications occurred when the arachnoid was accidentally violated (4 cases, 16.6%). The complications included aseptic meningitis (one patient), nucal pseudomeningocele (two patients) and postoperative hydrocephalus requiring a ventriculoperitoneal shunt (one patient). Finally, one patient received an additional C2 laminectomy in order to obtain symptoms improvement and syrinx shrinkage. Postoperative MRI studies demonstrated that the syrinx decreased in size or collapsed in 20 patients (83.3%) and stabilized in 4 (16.7%). CONCLUSIONS: The extra-arachnoidal CCD is a safe and effective treatment for syringomyelia associated with Chiari I malformation in adults without intraoperative evidence of adhesive arachnoiditis. However a larger number of patients and longer follow-up will be necessary to determine the efficacy of extra-arachnoidal CCD.

Intracranial meningioma containing metastatic colon carcinoma.

Tumour-to-tumour metastasis is a rare pathological entity. Meningioma is the most common intracranial tumour to host metastases, the majority of which arise from breast and lung cancers. We present the first report of a colonic cancer metastasis within an intracranial meningioma.A 76-year-old woman presented with a one month history of partial seizures. Her medical history included resection of an adenocarcinoma of the descending colon followed by adjuvant chemotherapy 1 year before our evaluation. Magnetic resonance imaging revealed a homogeneously enhancing lesion in the right frontal convexity.A well capsulated tumour attached to the frontal dura was surgically removed. The pathological examination demonstrated a mixture of fibrous meningioma and colloid adenocarcinoma. Possible explanations for the development of a cohesive chimeric mass of composite pathology are investigated.

BioEnterics Intragastric Balloon: The Italian Experience with 2,515 Patients.

BACKGROUND: The temporary use of the BioEnterics Intragastric Balloon (BIB) in morbidly obesity is increasing worldwide. The aim of this study is the evaluation of the efficacy of this device in a large population, in terms of weight loss and its influence on co-morbidities. METHODS: Data were retrospectively recruited from the data-base of the Italian Collaborative Study Group for Lap-Band and BIB (GILB). After diagnostic endoscopy, the BIB was positioned and was filled with saline (500-700 ml) and methylene blue (10 ml). Patients were discharged with diet counselling ( approximately 1000 Kcal) and medical therapy. The BIB was removed after 6 months. Positioning and removal were performed under conscious or unconscious sedation. Mortality, complications, BMI, %EWL, BMI loss and co-morbidities were evaluated. RESULTS: From May 2000 to September 2004, 2,515 patients underwent BIB (722M/1,793F; mean age 38.9+/-14.7, range 12-71; mean BMI 44.4+/-7.8 kg/m(2) ; range 28.0-79.1; and mean excess weight 59.5+/-29.8 kg, range 16-210). BIB positioning was uncomplicated in all but two cases (0.08%) with acute gastric dilation treated conservatively. Overall complication rate was 70/2,515 (2.8%). Gastric perforation occurred in 5 patients (0.19%), 4 of whom had undergone previous gastric surgery: 2 died and 2 were successfully treated by laparoscopic repair after balloon removal. 19 gastric obstructions (0.76%) presented in the first week after positioning and were successfully treated by balloon removal. Balloon rupture (n=9; 0.36%) was not prevalent within any particular period of BIB treatment, and was also treated by BIB removal. Esophagitis (n=32; 1.27%) and gastric ulcer (n=5; 0.2%) presented in patients without a history of peptic disease and were treated conservatively by drugs. Preoperative co-morbidities were diagnosed in 1,394/2,471 patients (56.4%); these resolved in 617/1,394 (44.3%), improved (less pharmacological dosage or shift to other therapies) in 625/1,394 (44.8%), and were unchanged in 152/1,394 (10.9%). After 6 months, mean BMI was 35.4+/-11.8 kg/m(2) (range 24-73) and %EWL was 33.9+/-18.7 (range 0-87). BMI loss was 4.9+/-12.7 kg/m(2) (range 0-25). CONCLUSIONS: BIB is an effective procedure with satisfactory weight loss and improvement in co-morbidities after 6 months. Previous gastric surgery is a contraindication to BIB placement.

Obese teenagers treated by Lap-Band System: the Italian experience.

BACKGROUND: Little is known about obesity surgery in young and adolescent patients. The aim of this study is to evaluate results of laparoscopic adjustable gastric banding in obese teenagers. METHODS: Patients < or = 19 years old selected from the database of the Italian Collaborative Study Group for Lap-Band were analyzed according to mortality, comorbidities, laparotomic conversion, intra- and postoperative complications, body mass index (BMI), and % excess weight loss (EWL) at different times of follow-up. Data were expressed as mean +/- SD. RESULTS: Fifty-eight (1.5%) of 3813 patients who underwent operation with the Lap-Band System were < or = 19 years old: 47F/11M; mean age, 17.96 +/- 0.99 years (range, 15-19); mean BMI, 46.1 +/- 6.31 Kg/m2 (range, 34.9 - 69.25); mean % excess weight, 86.4 +/- 27.1 (range, 34 - 226.53). Sixteen (27.5%) of the 58 patients were superobese (BMI > or = 50). In 27/58 (46.5%) patients, 1 or more comorbidities were diagnosed. Mortality was absent. Laparotomic conversion was necessary in 1 patient with gastric perforation on the anterior wall. Overall postoperative complications occurred in 6/58 (10.3%). The band was removed in 6/58 (10.3%) patients for gastric erosion (3 patients), psychologic, intolerance (2 patients), and in the remaining patient was converted 2 years after surgery (BMI 31) to gastric bypass or gastric pouch dilatation. Patient follow-up at 1, 3, 5, and 7 years was 48/52 (92.3%), 37/42 (88.1%), 25/33 (75.7%), and 10/10, respectively. At these times, mean BMI was 35.9 +/- 8.4, 37.8 +/- 11.27, 34.9 +/- 12.2, and 29.7 +/- 5.2 Kg/m2. Mean %EWL at the same time was 45.6 +/- 29.6, 39.7 +/- 29.8, 43.7 +/- 38.1, and 55.6 +/- 29.2. Five/25 (20%) patients had < or = 25% EWL at 5 years follow-up, while none of the 10 patients subject to follow-up at 7 years had < or = 25% EWL. CONCLUSIONS: Lap-Band System is an interesting option for teenagers suffering obesity and its related comorbidities, which deserves further investigation.

Adult syringomielia. Classification, pathogenesis and therapeutic approaches.

Syringomyelia is characterized by the presence of cystic cavities inside the spinal cord, with an incidence estimated of 8.4 new cases/year/100 000 people. The cavities are usually located inside the cervical cord, although they can extend upwards and/or downwards. The underlying cause of all types of syringomyelia is an alteration in physiologic cerebrospinal fluid (CSF) flow dynamics. Four different main types may be described in descending order of frequency: associated with Chiari I malformations, associated with vertebral trauma, associated with basilar invagination and associated with hydrocephalus. Conservative treatment is not recommended as the surgical procedure stops the progress of the disease with clinical improvement being the rule. Early surgical treatment is highly recommended before the establishment of gross neurological deficits occurs. Treatment is urged in case of clinical deterioration or when the follow-up MRI studies show increase in size and extension of the syringomyelic cavity. The first step in the surgical treatment is a precise diagnosis of its etiology to direct the treatment to the underlying cause. Treatment directed to normalize CSF flow homeostasis should be case tailored. Surgical measures that aim to reconstruct the continuity of the subarachnoid space at the site of the block are the first treatment option. Shunting is advocated when reestablishment of the pathways proves impossible or as a second procedure.

Oligodendrogliomas lacking O6-methylguanine-DNA-methyltransferase expression.

O6-Methylguanine-DNA-Methyltransferase (MGMT) is a DNA repair protein considered to be a chemosensitivity predictor. We evaluated the immunohistochemical MGMT expression in 28 consecutive oligodendroglial tumors (21 oligodendrogliomas, 5 mixed oligoastrocytomas, and 2 glioblastomas with prominent oligodendroglial features; 13 treated with CCNU) and compared it with that of 13 glioblastomas. Twenty-six (93%) oligodendroglial tumors were MGMT-negative, 2 (7%) were MGMT-positive. Twelve (92%) patients treated with CCNU had MGMT-negative lesions and their median survival was 73 months; 1 patient had an MGMT-positive oligodendroglioma and is alive at 28 months. Three (23%) glioblastomas were MGMT-negative and 10 (77%) MGMT-positive. The lower MGMT expression in oligodendroglial tumors compared to glioblastomas (P < 0.05), which have different chemosensitivity, suggests a possible role of MGMT in the determination of chemoresistance. Nevertheless, the heterogeneous outcome of our MGMT-negative oligodendroglial tumors treated with CCNU, indicates that MGMT expression alone is insufficient to predict the response to alkylating drugs, presumably because of the numerous mechanisms involved.

Italian Group for Lap-Band System: results of multicenter study on patients with BMI < or =35 kg/m2.

BACKGROUND: The Lap-Band System is the most common bariatric operation world-wide. Current selection criteria do not include patients with BMI < or = 35. We report the Italian multicentre experience with BMI < or = 35 kg/m(2) over the last 5 years. PATIENTS AND METHODS: Data were obtained from 27 centres involved in the Italian Collaborative Study Group for Lap-Band System. Detailed information was collected on a specially created electronic data sheet (MS Access 2000) on patients operated in Italy since January 1996. Items regarding patients with BMI < or = 35 were selected. Data were expressed as mean +/- SD except as otherwise indicated. RESULTS: 225 (6.8%) out of 3,319 Lap-Band patients were recruited from the data-base. 15 patients, previously submitted to another bariatric procedure (BIB =14; VBG= 1) were excluded. 210 patients were eligible for study (34M/176F, mean age 38.19+/-11.8, range 17-66 years, mean BMI 33.9+/-1.1, range 25.1-35 kg/m(2), mean excess weight 29.5+/-7.1, range 8-41). 199 comorbidities were diagnosed preoperatively in 55/210 patients (26.2%). 1 patient (0.4%) (35 F) died 20 months postoperatively from sepsis following perforation of dilated gastric pouch. There were no conversions to laparotomy. Postoperative complications presented in 17/210 patients (8.1%). Follow-up was obtained at 6, 12, 24, 36, 48 and 60 months. At these time periods, mean BMI was 31.1+/-2.15, 29.7+/-2.19, 28.7+/-3.8, 26.7+/-4.3, 27.9+/-3.2, and 28.2+/-0.9 kg/m(2) respectively. Co-morbidities completely resolved 1 year postoperatively in 49/55 patients (89.1%). At 60 months follow-up, only 1 patient (0.4%) has a BMI >30. CONCLUSIONS: Although surgical indications for BMI < or = 35 remain questionable, the Lap-Band in this study demonstrated that all but 1 patient achieved normal weight, and most lost their co-morbidities with a very low mortality rate.

Results of the Italian multicenter study on 239 super-obese patients treated by adjustable gastric banding.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is the most common bariatric operation. This study is a retrospective analysis of the multicenter Italian experience in patients with BMI > 50 over the last 4 years. METHODS: An electronic data sheet made for LAGB-operated patients since January 1996, was mailed and e-mailed to all surgeons involved in this kind of procedure in Italy. Items regarding patients with BMI > 50 were selected. Analysis used Fisher's exact test and logarithmic regression analysis (P < 0.05 significant). Data were expressed as mean +/- SD. RESULTS: 239 patients (13.3%), out of 1,797 Lap-Band operated patients entered the study (179F / 60M), with mean age 37.6 +/- 11.3 years (19-69) and mean BMI 54.6 +/- 4.8 (50.1-83.6). Laparotomic conversion rate was 5.4% (44/239). Postoperative complications occurred in 24 / 239 patients (9.0%). Follow-up was obtained in 218 / 218, 198 / 198, 121 /147, 75 / 93, 30 / 38 LAGB patients at 6,12, 24, 36, and 48 months respectively. At these time periods, mean BMI was 46.7, 43.9, 42.2, 41.9, and 39.3 kg/m2. At the same intervals, mean %EWL was 24.1, 34.1, 38.8, 38.9, and 52.9%. The number of patients with < 25% EWL at 12, 24, 36, and 48 months follow-up were 34, 10, 4, and 0. Serious co-morbidities (189 in 124 of 239, 57%) had completely resolved 1 year postoperatively in 74 / 124 of the patients (59.6%). CONCLUSION: Although super-obese patients following the LAGB remain obese with BMI > 35, in the short-term most lose their co-morbidities, with a very low morbidity and mortality rate.

Absent innervation of skin and sweat glands in congenital insensitivity to pain with anhidrosis.

OBJECTIVES: A case of a 10-year-old girl with congenital insensitivity to pain with anhidrosis (CIPA) is reported. METHODS AND RESULTS: Parents referred several hyperpyretic episodes without sweating occurring since birth, and insensitivity to pain, noticed when the child was 2 years old. Her body had many bruises and scars, bone fractures and signs of self-mutilation. Neurological examination was normal except for insensitivity to pain. Her IQ was 52. Electrical and tactile sensory nerve conduction velocities were normal. The patient was unable to detect thermal stimuli. Histamine injection evoked a wheal but not a flare; pilocarpine by iontophoresis did not induce sweat. Microneurography showed neural activity from A-beta sensory fibers while nociceptive and skin sympathetic C fiber nerve activity was absent. No small myelinated fibers and very rare unmyelinated fibers were found in the sural nerve. Immunohistochemistry showed a lack of nerve fibers in the epidermis and only few hypotrophic and uninnervated sweat glands in the dermis. CONCLUSIONS: The lack of innervation of the skin (C and A-delta fibers) appears to be the morphological basis of insensitivity to pain and anhidrosis, and is consistent with the loss of unmyelinated and small myelinated fibers in the sural nerve biopsy.