[Myasthenia gravis and intestinal resection: is dehiscence likely to occur?]. / Myasthenia gravis e resezione intestinale: deiscenza in agguato?

Experimental and clinical data have proved that anticholinesterase drugs are responsible for vigorous peristaltic contractions and for an increase of the intraluminal pressure, because they determine muscarinic effects on the smooth muscle of the intestine both in small and large intestine. Therefore, a greater incidence of intestinal anastomotic disruption has been supposed when anticholinesterases are used both in the early postoperative period, to reverse curarization, and in myasthenic patients. The authors report a case of a patient with myasthenia gravis who received maximal doses of pyridostigmine and underwent left hemicolectomy and small intestine resection and afterwards total colectomy in order to treat a sigmoid perforated diverticulitis. In the postoperative course an anastomotic leak developed after both surgical operations. The authors believe that pyridostigmine could have had an important role in the pathogenesis of the leak and assert that, when an intestinal resection has to be performed in a myasthenic patient, it could be useful to reduce in the preoperative period the administration of anticholinesterase drugs and always perform a protective ileostomy.

Laparoscopic cholecystectomy (LC): predictive role of preoperative ultrasounds.

AIM: We studied several ultrasounds patterns concerning gallbladder, biliary tract and gallstones to identify some predictive signs of difficulties during LC. PATIENTS & METHODS: 112 patients (24 females), 25-75 years old, upper abdomen operated patients not included. From 7 ultrasounds patterns 4 degrees of potential intra-operative difficulty (0-3) were obtained. During the operation 7 conditions of true intra-operative problems were also classified. RESULTS: Patients showing grade 0: regular gallbladder wall stones < 20 mm, regular Main Biliary Tract (MBT) = 62 LC and 2 open surgery conversion (OSC); grade 1: wall < 4 mm, stones > 20 mm= 24 LC and 7 OSC; grade 2: hydrops, wall > 4 mm, infundibular stone = 6 LC and 6 OSC, grade 3: wall > 4 mm, stones > 20 mm, empyema of gallbladder, MBT > or = 6 mm = 3 LC and 0 OSC. Inflammation near gallbladder and wall > 4 mm were mainly responsible for transition of LC in OSC. CONCLUSION: Several predictive conditions for intraoperative difficulties are often detectable by accurate preoperative ultrasounds examination, with the aim of best surgical planning and to select those patients to entrust to surgeons during their learning phase.

[Therapeutic strategy in thymomas]. / Strategia terapeutica nei timomi.

Between July 1989 to February 1994 eight patients with thymoma were operated in the First surgical Clinic of University of Catania; in seven the neoplasia was associated with myasthenia gravis, the severity of which was evaluated according to the Osserman's classification. The surgical treatment has been: total thymectomy in four patients, in two total and partial resection was carried out respectively, and in two a macrobiopsy was performed. The postoperative staging was carried out according to Masaoka. The neoadjuvant chemotherapy and postoperative radiation therapy have been analyzed. The authors concluded that a rigorous anatomo-surgical and histopathological classification is the best way for the right use of postoperative adjuvant therapies to reduce the incidence of local and distant recurrence of these tumors.

[The surgical therapy of renal carcinomas. The prognostic factors and long-term results]. / Terapia chirurgica dei carcinomi renali. Fattori prognostici e risultati a distanza.

BACKGROUND: Image diagnosis of kidney neoplasms allows good preoperative staging using the TNM system, but surgical management cannot be based on these data because a tumour apparently confined to the kidney may have produced metastasis in extraregional lymph nodes. METHODS: Thirty-three patients with renal carcinoma were observed over a seven-year period. Preoperative staging using the TNM system was performed and then compared with postoperative staging. Radical nephrectomy and regional lymphadenectomy were performed in all patients. Extensive lymphadenectomy was undertaken in 10 cases presenting neoplasms larger than 10 cm. At the preoperative assessment, 20 patients were stage T2, 13 stage T3, for factor N six were N1, two M1; postoperative staging confirmed T2 in 15 cases, whereas five T2 became T3. After postoperative staging, the N1 patients increased from 6 to 13. Fifteen patients were at Robson's stage II, four at stage IIA, twelve IIIB and two stage IV. RESULTS: The 5-year survival rate was 63.2%. CONCLUSIONS: The authors conclude that from an analysis of the correlation between tumour size and lymph node metastasis it can be seen that low T values do not represent grounds for conservative treatment.

[Idiopathic varicocele: incidence in 517 subjects]. / Varicocele idiopatico: incidenza su 517 soggetti.

A sample population of 517 subjects was screened in order to evaluate the incidence of idiopathic varicocele. Subjects were examined clinically and underwent tests using a Doppler flow-meter. Following a brief introduction to the didymoepididymal disease, the findings of the study are reported. In conclusion, the important role of orthostasis as a causal factor leading to the onset of disease in subjects with a predisposition to diathesis is underlined.

Oesophageal perforation after sclerotherapy. Description of a case.

Surgery is considered mandatory for major oesophageal perforations but the operative risk in cirrhotic patients is very high. The best treatment of these perforations is unknown as these have been always analyzed together with all other kinds of oesophageal perforations. A case is reported of spontaneous healing of severe postsclerosal perforation in an aged cirrhotic patient treated conservatively who otherwise should have been treated surgically. Conclusions are that due to the rarity and the cirrhosis, the common guidelines for the treatment of major esophageal perforations are not to be automatically extended to these perforations as postsclerosal perforation is clinically particular, etiologically and prognostically different than all other oesophageal perforations. Conservative but active treatment is to be tried first also with major postsclerosal oesophageal perforations.

[The diagnostic significance of the small bowel enema in lesions of the small intestine requiring surgery]. / Importanza diagnostica del clisma del tenue nelle lesioni di interesse chirurgico del piccolo intestino.

Given its anatomical location the small intestine is the section of the digestive tract most inaccessible to objective clinical and instrumental examination. For this reason, traditional investigation methods provide inadequate data. In the barium meal X-ray, images are superimposed and the barium excessively fragmented due to the tortuosity and length of the intestinal loop. Access problems limit the value of endoscopy. The indications to angiography are fairly restrictive. Ultrasound and CT scans provide no conclusive evidence in this area. The so-called Small Bowel Enema technique based on the direct infusion of an opaque contrast medium after duodenal intubation remains the only way to obtain images with a satisfactory diagnostic value and should be the method of choice in examinations of the small intestine. Introduced in the twenties, the value of the technique was long questioned, mainly because it was difficult to perform correctly and it is only quite recently that several decisive technological innovations have made it highly reliable. The present paper describes its use on a series of patients with suspected pathologies of the small intestine requiring surgical treatment. The aim is to specify the correct indications to this technique as well as its limitations with a view to promoting its appropriate use in routine practice. MATERIALS AND METHODS. The study covers 42 small bowel enemas performed on 29 male and 13 female patients aged 12-85 years. Indications to the enema included chronic abdominal pain in 28.5%, chronic diarrhea in 21.4%, pain+diarrhea in 14%, subocclusion in 16.5%, faecal blood in 11.9%, abdominal pain+diarrhea+intestinal haemorrhage in 4.7%, anaemia in 2.4%. We adopted the Sellink technique involving intubation with a French 14 Bilbao-Dotter probe and the infusion of 200-350 cc barium sulphate in a 90%-70% P/V concentration at a speed of 100 ml/min, followed by the infusion of 1000-1500 cc 0.5-1% methylcellulose in a 50-50 mixture with water for double contrast purposes. Mean duration of procedure 35-40 mins. RESULTS. We found lesions of the small intestine in 18 cases or 45% (true positives) and no alterations in 18 or 42.8% (true negatives). In 3 cases (7%) the examination was inconclusive. One false positive and one false negative complete the series, making a diagnostic accuracy of 89.1%. In 23.8% of the total series the diagnosis of Crohn's disease was confirmed; cancerous lesions were found in 11.9% and adhesions following earlier surgery in 9.7%. Surgery confirmed this diagnosis in 10 cases (5 tumours, 3 stenoses caused by adhesion fragments, 2 Crohn's disease) and disproved it in one case. Biopsy was used, for objective confirmation in 5 cases (2 Crohn's disease, 3 negatives). In the other cases reliance was placed on clinical course and the patients' response to treatment. DISCUSSION AND CONCLUSIONS. Examination of our results reveals that in most clinical cases the small bowel enema was used to confirm suspected Crohn's disease (31 cases out of 42) and with a very high degree of diagnostic accuracy (96.7%). In line with data in the literature we decided to base the indication to this examination on certain primary symptoms such as chronic abdominal pain, diarrhea, blood in the faeces, whether in isolation or in combination. On this rather general basis the diagnosis of Crohn's disease concerned only 23.8% of the cases studied, an incidence that rose dramatically in the few cases in which the indications were made more specific. We therefore conclude that the adoption of more restrictive criteria will improve the cost-benefit ratio for this test. Another major pathology in which small bowel enema possesses a high diagnostic value is partial obstruction of the small intestine.(ABSTRACT TRUNCATED AT 400 WORDS)

[Morphologic and endocrine changes in the male reproductive system after porta-caval anastomosis in rats. Experimental research]. / Alterazioni morfologiche ed endocrine dell'apparato riproduttivo maschile dopo anastomosi porta-cava nel ratto. Ricerche sperimentali.

Quantitative alterations of the sexual hormones are present in cirrhotic patients whose testicular volumes are decreased with tubular atrophy in more than 50% of cases. The authors performed an experimental study utilizing end-to-side portacaval anastomosis in the rat in order to evaluate the consequences of the complete interruption of the portal blood to the liver in the male genital system, i.e. testicular alterations, due to the missing hepatic inactivation. Forty male Sprague-Dawley rats were used for this study. Twenty rats were subjected to end-to-side porta-caval anastomosis according to Lee, 10 rats underwent sham-operation while the remaining 10 rats were utilized as negative controls. The rats were weighed and necropsied three and six months after surgery and the liver and genital organs were weighed. In rats subjected to porta-caval anastomosis loss of weight was shown, about 20 g three months after surgery and 30 g six months after surgery, while other rats (sham-operated and negative controls) showed an increase of its weight, about 60 g after three months and 80 g after six months. In rats subjected to porta-caval anastomosis the liver was hypotrophic and its weight was decreased in comparison with the control group. In the same rats testicular volumes were decreased and hypotrophic in comparison with the control groups with average length 0.5 to 1 cm, while control groups showed values of 1.7 to 2.5 cm. Testosterone levels were 0.50 ng/ml in rats subjected to porta-caval anastomosis while in control groups the levels were 2.20 ng/ml.(ABSTRACT TRUNCATED AT 250 WORDS)

[Benign tumors of the liver]. / Tumori benigni del fegato.

Diagnostic and therapeutic findings of benign hepatic tumors are analysed. In particularly the authors describe the more frequent tumors such as angioma, adenoma and FNH, but also give a guidelines on how to approach less frequent lesions.

Giant esophageal polyp: a rare and benign neoplasm.

Giant esophageal polyp is a very rare neoplasm, usually benign but often demanding both for diagnostic and/or therapeutical procedures and for dramatic symptomatologic onset in the patient (regurgitation and asphyxia). The authors present a brief clinical report of a patient with a 20 cm.-long esophageal polyp removed by left lateral cervicotomy and esophagotomy for 8 cm. below the upper esophageal sphincter (histologic examinations showed a pedicled polypoid fibrolipoma with a remarkable presence of myxoid and vascular components). The authors also describe diagnostic and therapeutic methods to manage this rare disease and they gave a brief review of recent literature.

[A rare case of sigmoidoduodenal neoplastic fistula (author's transl)]. / Su di un raro caso di fistola neoplastica sigmoido-duodenale.

The clinical case of a patient with sigmoidoduodenal neoplastic fistula is taken as the starting-point for a review of the relevant literature. The great rarity of fistulisation of a sigmoid tumour of the 4th portion of the duodenum is stressed. A clinical definition of the disease is followed by a discussion of the various methods of surgical treatment, with emphasis on the problem presented by reconstruction of the duodenum owing to its anatomosurgical difficulties.

[Probable correlations ultrastructural anomalies of the central nervous system and hyperammonemia following portacaval anastomosis in rats]. / Corrélations probables entre les anomalies ultrastructurelles du système nerveux central et l'hyperammoniémie après anastomose porto-cave chez le rat.

The correlation between hyperammonemia, during porto-systemic encephalopathy, and brain's lesions in patients died for porto-systemic encephalopathy is not demonstrated. The aim of this study has been to try a demonstration. A histological study of the brain, cerebellum, brainstem, and spinal cord was made in 60 rats: in 40 rats 1, 3 and 6 months after portocaval shunt, and in 20 rats sham operated. The brain, cerebellum, brainsteam and spinal cord have been fixed with paraformaldehyde (4%) and then sectioned for optical and electronic microscopic study. Ammonemia was measured regularly in the 40 rats with portocaval shunt, all the rats have been hyperammonemia since 10 weeks, after this period in 4 rats ammonemia was normal. In 20 rats sham-operated ammonemia was always normal. One month after surgery electronic microscopy revealed changes in the astrocytes characterized by nuclear swelling and lobulation. Three months after surgery this lesion was increased. After six months most lesions were noted in the hyperammoniemic rats. No similar lesions were observed in control rats. These results suggest that hyperammonemia is responsible of nuclear changes in the astrocytes of the patients died from hepatic encephalopathy.

[Toxic adenoma of the thyroid gland: personal experience]. / L'adenoma tossico della tiroide: esperienza personale.

The Authors analyzed the thyroid diseases series of the Institute of 1a Clinica Chirurgica of the University of Catania which includes 1022 patients over the last 17 years, reviewing clinical and laboratory tests usually used in a register of diagnosis for autonomous adenomas of the thyroid. The Authors discuss pathogenesis, likely etiology and epidemiology of Plummer's adenoma, taking into consideration the therapy and the complications related to the therapy itself. They conclude stating that the adenoma is a pathology where the surgical operation solves the dismetabolic condition in a lasting way.

[Motor disorders of the esophagus in gastro-esophageal reflux disease]. / I disordini motori dell'esofago nella malattia da reflusso gastro-esofageo.

The Authors report their experience in the study of oesophageal motor abnormalities in patients with gastroesophageal reflux disease. By an electromanometric test in 50 subjects (20 healthy volunteers and 30 patients with oesophagitis), they evaluated the results concluding that: 1) LES low pressure is correlated significantly with oesophagitis; 2) oesophageal peristaltic dysfunction could be the effect of oesophagitis rather than its cause.

Splenic trauma following colonoscopy.

A case of splenic trauma after colonoscopy is reported. After description of their experience, the Authors report a review of the literature and some considerations about clinical diagnosis and surgical or medical therapy for this pathology.

[Somatostatin in the treatment of acute pancreatitis and prevention of postoperative acute pancreatitis. Personal experience]. / La somatostatina nel trattamento della pancreatite acuta e nella prevenzione della P.A.P.O.--esperienza personale.

Authors' personal experience is reported in the use of somatostatin for the treatment of acute pancreatitis and after bilio-pancreatic surgery. The drug has proved to be highly effective in reducing the pain and in controlling the biohumoral balance. The preliminary results appear to confirm the opinion that somatostatin is a major therapeutic tool in the treatment of bilio-pancreatic diseases.

[Rare malignant tumors of the thyroid]. / I tumori maligni rari della tiroide.

The incidence of rare malignant tumors of the thyroid is about 4 cases/100,000 people and represent only 1.8% of all the thyroid cancers. When we talk about "rare" tumors, obviously, we do not refer to the most frequent cancers (papillary, follicular), or less frequent tumors (medullary, anaplastic), but to some types of thyroid tumors that have been almost always sporadically observed. Mucoepidermoid carcinoma and squamous carcinoma have been described in the literature. They present occasional papillary formation so that, according to some authors, could be considered as variants of the papillary carcinoma. Teratoma is another rare tumor which in the paediatric age is benign, but its prognosis could be unfavourable because it causes an important respiratory distress, while in the adult it presents a very aggressive clinical course like the anaplastic carcinoma. Lymphoma is the most frequent of the "rare" tumors of the thyroid (1-5% of all the thyroid cancers). It arises often in a setting of a long history of goitre and Hashimoto thyroiditis. Fine-needle aspirate is important to make diagnosis and to start a correct treatment which allows a 5-year survival up to 85% in the favourable cases.

[Carcinoma of the male breast]. / Il carcinoma della mammella maschile.

The Authors, after a brief review of the most important epidemiologic, etiologic, diagnostic and therapeutic problems related to male breast cancer, report their personal experience. They point out the importance of an early diagnosis in order to obtain satisfactory results, comparable to those achieved in female breast cancer treatment.

[Role of gonadal phlebography in the diagnosis of cryptorchidism]. / Ruolo della flebografia gonadica nella diagnostica del criptorchidismo.

The authors describe the diagnostic procedures for testicular localization in patients with non palpable undescended testes. They consider the procedures as invasive and non invasive. The first procedures include ultrasonography, C.T. and N.M.R., the second ones laparoscopy, selective arteriography and venography of the spermatic vessels. Anatomy of spermatic venous system and catheterization techniques are described. Conclusions are that when non invasive procedures fail to localize the testis, gonadal venography is the procedure of choice for the correct diagnosis. Preoperative testicular localization often reduces the extent of surgical exploration and the anesthesia time. These patients have to undergo surgical treatment also when gonadal venography shows a blinding end vein in the inguinal canal, because of the intra-abdominal testis possible degeneration.

Synchronous double cancers of the colon and the pancreas: a case report.

The authors report a clinical case of a synchronous double cancer of the colon and pancreas. Having carefully examined the scarce literature, they dwell on the incidence of this disease referring to frequencies that in the literature range from 0.06% and 0.55% while considering that some series do not show any association between the two neoplasms. The authors analyze the role of the colorectal follow-up. In fact, such a follow-up, even if only providing a relative improvement in disease-free survival, has allowed for a treatment of the two certainly not-advanced tumors ensuring the patient a good prognosis. Finally, the authors analyze how endoscopic ultrasound-guided fine-needle aspiration made possible a preoperative diagnosis of small pancreatic cancer, and show that, the positive predictive value (PPV) of this method was 100%.