A rare case of extraskeletal osteosarcoma of the esophagus: an example of difficult diagnosis.

Sarcomatous lesions of the esophagus are rare. We describe a controversial case of a malignant aggressive tumor of the aesophagus, with a very poor prognosis and rapid outcome for the patient. A 74-year-old man underwent endoscopic examination for recurrent thoracic pain and dysphagia. A 8 cm mass was found in the cervical esophagus. A sarcomatous tumor with osteoid aspects was observed on the histopathological examination, without any carcinomatous component.

Sporadic flat ileal adenocarcinoma: an intriguing challenge in the comprehension of a rare neoplasia and its genesis. Case report and review of literature.

Small bowel adenocarcinoma is a rare tumor, with a still not well studied tumorigenesis process, usually presenting in an advanced stage. The clinical diagnosis is often difficult; surgery is the treatment of choice when feasible, while the chemotherapeutic approach is still not well standardized. We describe the case of a 71-yr-old male patient, presenting with an acute right abdomen. At laparotomy the terminal ileum appeared chronically inflamed and thickened. An ileocecal resection with latero-lateral ileocolic anastomosis was performed. The gross appearance resembled an inflammatory bowel disease, but microscopic examination revealed the extensive presence of an infiltrating ileal adenocarcinoma. Literature about small bowel adenocarcinoma has been reviewed for better understanding its pathogenesis.

Acute abdomen in the elderly. A peripheral general hospital experience.

We reviewed our experience on 291 consecutive patients aged over 65 years who were operated on for acute abdomen during the period 2003-2007 at "Santo Spirito" Hospital of Casale Monferrato, a peripheral hospital in the Piedmont region. The mean age of the patients was 78 years and the male/female ratio was 149/142. A total of 126 patients (43%) had one or more associated disease. The most common causes for an emergency operation were mechanical bowel obstruction (45%), hollow viscus perforation (18%) and strangulated hernia (18%). 234 patients (80%) recovered and were free from major complications. The remaining 57 (20%) developed at least one major complication (including death). The 30-days postoperative deaths were 33 (11%). Nonlethal major complications were 24 (8%). The commonest complications were cardio-respiratory. Septic complications were 15. Total reoperations for surgical complications were 5. Mesenteric ischaemia and secondary peritonitis were the most important causes of fatal outcome (respectively 42 and 17% of mortality). We also reported high mortality among patients with peritoneal carcinomatosis (24%). Emergency surgery was relatively safe for the remaining groups of patients, with a complexive mortality ratio of 5.3%. We conclude that "acute abdomen" is still an appreciably frequent cause of death in the older age group. A high level of vigilance and early attention is therefore advocated. Anyway, excluding some severe conditions, the overall success of surgical interventions for abdominal emergency is satisfactory in the majority of older people. About the debated role of peripheral hospitals in the health care system, we conclude that the surgical treatment of the acute abdomen in the elderly is safe and feasible in the peripheral hospitals, and that these hospitals play a determining role in the management of old patients, especially in emergency.

[Post-thyroidectomy cervical hematoma]. / L'ematoma cervicale postoperatorio nella chirurgia tiroidea.

AIM: Postoperative hematoma is a complications of thyroid surgery uncommon but potentially life threatening. It has implications for the trend toward outpatient procedures. METHODS: Retrospective review of 1.221 thyroidectomies performed at our institution over a 6-years period, to identify patients with hematomas requiring reoperation. Symptoms, treatment and findings at reoperation were evaluated. A control group (n=120) was compared for perioperative risk factors and outcome. RESULTS: Eighteen patients (1.5%) developed a postoperative hematoma. Symptoms included neck pain/pressure in 10 patients, respiratory distress in 9, wound drainage in 2, dysphagia in 1, agitation and sweating in 1. Mean time to symptom onset was 12 hours (range: 1.3-40 hours). Six hematomas presented between 7 and 24 hours, and 3 beyond 24 hours. Six patients required bedside hematoma evacuation. The bleeding source was identified in 15 patients. All patients recovered well, but one required a temporary tracheostomy. Case/controls comparison yielded in the study group a higher prevalence of hyperthyroidism (55.6% vs 25.8%, P=0.022) and intrathoracic goiter (50% vs 22.5%, P=0.029), and a longer mean hospital stay (5.22 vs 4.1, P=0.012); morbidity was not increased. CONCLUSIONS: Postoperative hematoma is an uncommon complication of thyroid surgery. If treated promptly, serious consequences can be avoided. The relatively long interval between the initial operation and the hematoma development needs to be considered when establishing outpatient practice guidelines.

[Surgical treatment of Graves' disease: results in 108 patients]. / Trattamento chirurgico del morbo di basedow: risultati in 108 pazienti.

AIM OF THE STUDY: To evaluate morbidity and functional results of surgical treatment in patients with Graves' disease. METHODS: A retrospective study was performed in 108 patients operated on during 1993-2003. Main indications for surgery were failure of treatment with antithyroid drugs (80.6%), large goiter (46.3%) and/or severe ophthalmopathy (23.1%). Surgical procedures were extensive subtotal thyroidectomy (EST; n = 33; uni- or bilateral remnant of <2 g) or total thyroidectomy (TT; n=75). Functional results were established in 89 patients (27 EST patients and 62 TT patients) after a mean follow-up of 5.9 years. RESULTS: Operative mortality was zero. There were 4 (3.7%) transient unilateral recurrent laryngeal nerve (RLN) palsies and no cases of permanent RLN palsy. Temporary hypocalcemia occurred in 15 patients (13.9%) and permanent hypoparathyroidism resulted in two (1.9%). Four patients (3.7%) developed a postoperative hematoma that required reoperation. There was no significant difference in the rate of complications between EST and TT, although temporary hypocalcemia was more common following TT than EST (17.3% vs. 6.1%) and permanent hypoparathyroidism affected only TT patients. None of the patients developed recurrent hyperthyroidism; all patients are maintained on levothyroxine. CONCLUSIONS: Surgery is an effective therapy for selected cases of Graves' disease. When performed by experienced surgeons, it can be carried out with no mortality and minimal morbidity. EST (with uni- or bilateral remnant of <2 g) and TT are both effective in order to achieve a definitive cure of hyperthyroidism.

[Clinico-epidemiological study of patients with phlebolymphatic diseases admitted to the hospitals of the Piedmont region 1976-1979. I. Analysis of all phlebolymphatic diseases]. / Studio clinico-epidemiologico sui pazienti affetti da patologie flebolinfatiche ricoverati negli Ospedali della Regione Piemonte nel periodo 1976-1979. Parte I. Analisi delle flebolinfopatie in toto.

In conjunction with the University Calculation Centre and the Piedmont Region, a computerised study was made of all patients (31,514 cases) admitted to Piedmont hospitals for phlebopathy and peripheral lymphopathy, including pulmonary embolism, in the period 1976-79. An account is given of the method used, the material, and the statistical technique. An 18.9% prevalence of women was noted. Occupation, age category, type of pathology, and treatment adopted were assessed for phlebopathies in toto and for each type. The data for each public health unit, divided by age category, were correlated with the general cases for the Region and those for each unit. In this way, it was possible to determine the incidence of phlebopathies in each unit and over the Region as a whole in relation to age. A map of the Region showing areas of higher, lower, and not significantly different from the regional mean hospitalisation (i.e. phlebopathy) was prepared. The significance of the different incidences in the several units is discussed in relation to their populations, geographical location, raye of migration, and types of occupational activity.

[Clinical studies on peripheral arteriosclerotic lesions in the Piedmont region]. / Ricerche cliniche sulle lesioni arteriosclerotiche periferiche nella Regione Piemonte.

The assistance of the Piedmont Region calculation centre was obtained in the evaluation and detailed examination of data on all patients admitted to hospitals in the Region for peripheral atherosclerotic arteriopathy during a three-year period. Age, sex, site of lesion, occupation, geographical distribution, and type of treatment employed were all analysed statistically. A difference between age categories in relation to sex was noted for incidence and site of lesions, while occupation was not correlated to the clinical progress of the disease. Regional incidence (for all Piedmont local health units) was both above and below the general average in some areas. It also appeared that the greatest incidence lay along the Alps.

[Ischemic colitis manifested as Crohn's disease. A case report]. / Colite ischemica manifestatasi quale morbo di Crohn. Case report.

Ischaemic colitis has many and different clinical features as it is often linked to the severity of ischaemic injury. In this paper two patients with clinical features of Crohn's disease are reported. In both patients the diagnosis has been confirmed with endoscopy and biopsy. They have been treated with specific therapy until they developed bowel obstruction in one case and peritonitis in the other. Both patients underwent laparotomy and the histological specimen showed a picture of ischaemic colitis. In one case a Dixon's resection was done, in the other Hartmann's operation.

[Calcified pseudocyst of the spleen. Report of a case]. / Pseudocisti calcifiche della milza. Descrizione di un caso.

The description of a case of calcific pseudocyst of the spleen has provided the opportunity for a review of the literature on the subject and for further study, on the basis of clinical and anatomo-pathological data, of the problem of the aetiopathogenesis of non-parasite splenic cysts.

[Parathyroid transplantation and cryopreservation techniques]. / Trapianto di paratiroidi e techniche di crioconservazione.

This report reviews several aspects of parathyroid transplantation, including some technical aspects of cryopreservation. The problems concerning the control of autograft are also presented, with a little review of the more recent references. These results lead to the recommendation that total parathyroidectomy and autotransplantation should be considered as the method of choice in the treatment of secondary hyperparathyroidism.

[Diagnostic approach to extra-renal pheochromocytoma]. / Approccio diagnostico ai feocromocitomi extra-surrenalici.

Stress is laid on certain principles of diagnostic research in the event of extra-suprarenal pheochromocytomas. The importance of CT is recalled, specifying the usefulness of complementary examinations such as selective venous catheterism and above all of scintigraphy with 131I MIBG.

[Study of 357 cases of phlebitis of the lower extremities in 2 inter-regional samplings. II. Clinical and diagnostic data and therapeutic conclusions]. / Studio su 357 casi di flebiti degli arti inferiori in due campioni interregionali. Parte II: Dati clinici, diagnostici e conclusioni terapeutiche.

In Piedmont, the incidence of superficial and deep forms is the same percentage-wise. In the Trento area, however, deep forms are more common, though no significant differences can be discerned with respect to the side affected, the site (other than that related to the type of phlebitis), or the symptoms. At least one complication was noted in 241-261 and 27-96 cases in Piedmont and Trento respectively. The treatment initially employed proved inadequate. The risks involved are known solely with respect to patients with complications. The resort to surgical management was much more frequent in the Trento region. An attempt is made to evaluate the risk factors associated with thrombophlebitis of the lower limbs, and the measure of agreement between the aetiopathogenetic, clinical and therapeutic data obtained for the two regions.

[Study of 357 cases of phlebitis of the lower extremities in 2 inter-regional samplings. I. Methods, epidemiological data and analysis of etiopathogenetic elements]. / Studio su 357 casi di flebite degli arti inferiori su due campioni interregionali. Parte I: Metodica, dati epidemiologici ed analisi degli elementi etiopatogenetici.

Using a specially designed record card, 357 cases of superficial and deep thrombophlebitis and phlebothrombosis of the lower extremities have been investigated. Of these 261 were observed in Piedmont and 96 in the Trentino region. A comparative study of aetiopathogenetic data in the two regions was made possible by means of punched cards and subsequent computer processing. The study was completed by statistical analysis. Apart from the region of birth and residence, sex (prevalently female) and age which in both samples mainly affects subjects aged between 30 and 45, the type of working activity was considered in relation to sex and age, frequency of absenteeism (higher in Piedmont), family history of venous disease, incidence of orthostatism, the use of contraceptive pills, the period in which the first clinical signs occurred with considerable diversity between the two regions, traumas (more frequent in Piedmont) and the incidence of the different causes which was vastly different in the two samples, were assessed. On the basis of the comparative data obtained, an interpretation of the real significance of the results is attempted, reference also being made to the type of population under examination, the Piedmontese being considered of mixed strain and the Trentino pure.

[Poorly differentiated "insular" carcinoma of the thyroid: long-term survival]. / Il carcinoma scarsamente differenziato "insulare" della tiroide: sopravvivenza a distanza.

Poorly differentiated "insular" thyroid carcinoma is a rare, aggressive and often lethal variant of thyroid cancer. Thirty-one cases of this entity were encountered over a 18-yr period. In most of them surgical therapy consisted of total or near-total thyroidectomy. Six patients had distant metastases and/or mediastinal or tracheal infiltration at presentation. Fifteen out of 25 apparently cured after surgery (60%) developed recurrence in the neck and/or distant sites. Radioiodine was employed to destroy thyroid remnants (22 cases) and subsequently to treat persistent/recurrent disease (17 cases). Thirteen patients showed radioiodine uptake in neoplastic lesions and in 3 cases complete resolution was observed. After a mean follow-up of 4.5 years (range 1-16) 6 patients had died of their tumor, 12 are alive with persistent/recurrent disease, 13 do not show any evidence of disease. This experience confirms that "insular" carcinoma tends to have an aggressive behavior, but therapy can be effective. Recognition of this entity is therefore important for planning adequate surgical approach and subsequent patient management.

[Integration of B-mode and color Doppler ultrasonography in the preoperative diagnosis of thyroid lesions. Preliminary experience in 91 cases]. / Integrazione ecografica B-mode e color-Doppler nella diagnosi preoperatoria di lesioni tiroidee. Esperienza preliminare in 91 casi.

Ninety-one patients affected with thyroid diseases (97 lesions) were examined with conventional B-mode and color-Doppler US. To verify if color-Doppler is able to provide additional elements in the US diagnosis, for each lesion were expressed two diagnosis: the first found on conventional US patterns and the second on color-Doppler patterns. US diagnosis was compared with histologic findings that identify 73 benign lesions and 24 malignant lesions. With conventional B-mode US the diagnosis was correctly expressed in 62/73 benign lesions (85%) and in 18/24 malignant lesions (75%) while it misdiagnosed as positives 11/73 case (15%) and as negatives 6/24 cases (25%). If we completed the conventional US diagnosis with color-Doppler patterns, the false negative reduced to 4% and false positive to 6.8%. On the whole, although any correlation between color-Doppler patterns and different histological types was found, the color-Doppler had a high predictive value of benignity in patterns I, II, and IV while pattern III is not peculiar because it includes either malignant or benign lesions.

[Surgical treatment of functional tumors of the adrenal gland]. / Le traitement chirurgical des tumeurs fonctionnelles de la glande surrénale.

The authors evaluated and operated 40 cases of Cushing's syndrome, 8 cases of Conn's syndrome and 19 cases of phaeochromocytoma. The diagnosis was frequently delayed due to inadequate hormonal analysis. Cancer of the adrenal gland was observed in 17% of cases of Cushing's syndrome, while all cases of Conn's syndrome corresponded to an adenoma. There was a female predominance for both Cushing's syndrome and Conn's syndrome. Four malignant lesions were observed in the series of 19 tumours of the adrenal medulla (21% of cases). CT scan was found to be the most accurate of modern diagnostic techniques and was able to define the site and the dimensions of the adrenal tumour. Arteriography was particularly useful in cases with large, highly vascular tumours. The preferred surgical approach was lumbotomy, less frequently laparotomy, and, in cases of invasive tumour, thoraco-phreno-laparotomy. Removal of the tumour by adrenalectomy led to resolution of the symptoms and, in benign cases, complete cure.

[Survival in a sample of patients operated on for carcinoma of the colorectum]. / Studio della sopravvivenza in un campione di pazienti operati per carcinoma del colon-retto.

The authors report the results of different types of surgical treatment performed on a sample group of 51 patients chosen on a total of 308 patients operated for cancer of the colon rectum in the period 1965-1979. They also make their considerations about the most common complications arising in the early and late post operative period, the quality of life achieved by the patients and the survival rate related to the various types of operations performed.

[Analysis of 101,379 cases hospitalized for calculi of the bile dusts in the Region of Piedmont]. / Analisi su 101,379 casi di ricovero ospedaliero per patologia litiasica biliare nella Regione Piemonte.

In a study from hospitals in Piemonte (Italy) were identified (from 1976 to 1981) 101,379 recovery for cholelitiasis. Among this group we have examined some factors like sex, age, residence, surgical procedures, etc. It is concluded that there is a continuous decreased in cholecistectomy rate and that can be explained by a simultaneous rise of new instrumental and farmacological procedures in the treatment of this pathology.

[Clinical study and surgical treatment of primary hyperparathyroidism]. / Studio clinico e trattamento chirurgico dell'iperparatiroidismo primario.

A series of 26 patients with primary hyperparathyroidism surgically treated between 1970 and 1985 was reviewed to examine the clinical approach, the operative procedure and the results of surgical treatment. The study pointed out the reliability of PTH determination to confirm the diagnosis and the absence of efficacious diagnostic techniques for the preoperative localisation of the responsible lesion(s). Long term results were re-evaluated in 15 cases (58%), after a postoperative interval ranging from 1 to 13 years. The follow-up demonstrated a complete recovery in 12 patients, the persistence of a borderline symptomatology in 2, the relapse in one case.

[Transduodenal papillotomy and divulsion of the papilla in the treatment of benign obstructions of the common bile duct (retrospective analysis of 186 cases)]. / Papillotomia transduodenale e divulsione della papilla nel trattamento delle ostruzioni benigne della via biliare principale (analisi retrospettiva di 186 casi).

An analysis is presented of 186 cases of biliary benign obstruction, treated with transduodenal sphincterotomy or dilatation-divulsion of the papilla of Vater. The morbidity and mortality rates due to specific complications were 5.4% and 1.6% respectively. No cases of post-operative pancreatitis were observed. Long-term results were re-evaluated in 46 patients after a mean post-operative interval of 18 years. The follow-up demonstrated that the result was completely satisfactory in 70% of cases; fair in 17%, with gastroenterological symptoms not likely related to the biliary disease; poor in 13%, with residual stones or stenosis of the sphincter of Oddi.