A right diaphragmatic eventration incidentally diagnosed and successfully repaired through an abdominal approach. A case report

We report a case of an elderly woman with a large eventration of the right hemidiaphragm, discovered during an episode of acute cholecystitis, with abdominal and pleural effusion, successfully treated by a laparotomic approach.

Use of dissecting sealer may affect the early outcome in patients submitted to hepatic resection

BACKGROUND

Many technological devices have been used to avoid intraoperative bleeding during hepatic parenchymal transection and to avoid morbidity and mortality, but until now none is complete. The aim of this work is to prospectively analyze hepatic resection patients treated with a water-cooled high frequency monopolar device in order to evaluate its effectiveness.

PATIENTS AND METHODS

All consecutive patients who underwent liver resection by use of this device, between January 2003 until December 2007, were analyzed prospectively. The following variables were considered: age, sex, kind of disease, kind of liver resection, number of major/minor resections, total operative time and transection time, number and time of clamping, blood loss, time of hospitalization, morbidity, and mortality.

RESULTS

Between January 2003 and December 2007, 26 patients were analyzed prospectively (69% women, 31% men). Ages ranged from 18 to 84 years. Sixty-five percent of patients had a malignant disease; 35%, a benign disease. The procedures performed were two major hepatectomies (7.6%) and 24 minor hepatectomies (92.4%). Hepatic transection was performed in 35 to 150 min. Total operative time range was 120-480 min. The average blood loss was 325 ml (range 50-600 ml). The mean postoperative stays were nine days for all the patient and six days for non-cirrhotic patients.

CONCLUSION

The water-cooled high frequency monopolar device is useful for reducing ischemia-reperfusion damage due to the Pringle maneuver and for reducing the risk of morbidity. However, the Kelly forceps remains the only inexpensive instrument really essential for liver surgery.

Cholecystoduodenal fistula in a nonagenarian. Can laparotomy play a role in the era of laparoscopic? Case report

Cholecystoduodenal fistula, a rare complication of biliary lithiasis, occurs in 0.5% to 3% of patients affected by cholelithiasis. Diagnosis is not easy and is usually incidental at surgery. The literature guidelines call for a laparoscopic approach to treating these patients; here, however, we report a case of a very elderly patient in which, among other reasons, open surgery was the treatment of choice to decrease morbidity and mortality.

Isolated hydatid cyst of the diaphragm without liver or lung involvement: a case report

The most common targets of the echinococcus are the liver and the lung, but several organs can be affected by this disease. The isolated diaphragmatic location of the cyst, not associated with liver or lung, is very rare. The aim of this work is to report a case of hydatid cyst located in the abdominal side of the diaphragm and to review the literature. The diagnosis was fortuitous and at CT scan the cyst was apparently located on segment VII of the liver. During surgery, after dissection of the adherences with the liver, the cyst remained attached to the diaphragm. Thirty months after the resection, the patient is free of symptoms without any recurrence.

Emergency gastric ulcer complications in elderly. Factors affecting the morbidity and mortality in relation to therapeutic approaches

AIM

In elderly the incidence of the emergency gastric ulcer complications, perforation and bleeding are increasing, with a difficult management of these patients for their concomitant diseases. The aim of this work is to analyze the therapeutical approach of emergency gastric ulcer complications in elderly patients, in order to establish the factors affecting the morbidity and mortality.

METHODS

Patients older than 70 years, presenting gastric ulcer, observed in a tertiary University Hospital from 1995 to 2003, have been considered for the present study. Two groups of diseases have been examined: ulcer perforation and bleeding ulcer. Age, sex, risk factors, comorbidity, methods of diagnosis, ulcer characteristics, treatment, morbidity, mortality, hospitalization time and follow-up have been considered in each group.

RESULTS

Thirteen elderly patients with perforated gastric ulcer have been observed: 9 (69.2%) females and 4 (30.8%) males with a mean age of 80.5 years (range 70-90). Four patients were hospitalized in suburban hospital with an average time between the diagnosis and the surgery of 36 h, while the remnants were hospitalized directly in our Department with a medium waiting time of about 2 h. The surgical procedures were: simple closure with omentum patch in 11 cases (84.6%), and antrectomy in 2 cases (15.4%), in which the antrum was multiply perforated. Two patients presented an ulcer larger than 2 cm treated with simple suture and omental patch without morbidity and mortality. Three patients (23%) died postoperatively, due to septic shock, ventricular fibrillation and intraoperative massive haemorrhage, 2 of these patients came from other hospitals. Twenty-eight elderly patients with bleeding gastric ulcer have been observed during the same period: 13 (46.4%) females and 15 (53.6%) males with a mean age of 79.6 years (range 71-91). Except 2 patients submitted to endoscopic treatment both with adrenaline injection, all the remnant patients were managed with medical therapy (H2-receptor antagonist or proton pump inhibitors and in 7 patients [24.1%] antihaemorrhage drugs), and clinical observation, with a endoscopic control 3-4 days after from the first endoscopy. One of the 2 patients endoscopically treated developed a ulcer perforation after 11 days, and the other one rebled, without possibility of any kind of treatment due to his instable condition of health. Three patients (10.7%) died during their hospital stay not for causes strictly due to the gastric haemorrhage.

CONCLUSIONS

Our results suggest that the early diagnoses and early treatment are 2 basic factor on the prognosis of elderly patients with perforated gastric ulcer. The choice between simple closure, with or without vagotomy, or gastrectomy depends from preoperative and operative health conditions of the patient. In patients with ulcer larger than 2 cm, Graham's technique can be performed safely if the preoperative and intraoperative conditions are favourable. Elderly patients with gastric ulcer bleeding show an high risk of morbidity and mortality, related to the risk factors like non steroid anti-inflammatory drugs (NSAIDs) intake or smoke. Repeated endoscopy and antiulcer drugs can manage the high stage patients of Forrest's classification with a low rate of morbidity and mortality. According to literature surgical treatment should be reserved after the second failure of endoscopic treatment.

[Use of the Floating Ball for hepatic resection in cirrhotic patients affected by hepatocellular carcinoma]

Done to the improvement of knowledges in hepatic surgery and postoperative care, hepatocellular carcinoma (HCC) have been treated more and more frequently by hepatic resection. Aim of this study is to report an initial series of patients affected by HCC treated by hepatic resection utilizing a new water-cooled, high-density, monopolar device, the Tissuelink Monopolar Floating Ball (Tissuelink Medical Inc., Dover, NH, U.S.A.), in order to avoid bleeding during hepatic surgery. Sex, age, kind of disease, viral and Child status, type of surgical procedure, in association to lenght of surgical procedure, blood loss, utilization of the vascular clamping of the liver, hospital stay, morbidity and mortality have been analized. Six liver resections have been performed utilizing this new device. No vascular clamping was established except one. No mortality was recorded. Morbidity was ascites in one case and pleural effusion in a second one. In conclusion the Floating Ball reduces the intraoperative bleeding during hepatic resection in patients with HCC.

Meckel's diverticulum masked by a long period of gastric symptoms--a case report

Meckel's diverticulum (MD) is the most frequent congenital abnormality of the small bowel and it is often difficult to diagnose. The authors report a case of a patient with long-term symptoms erroneously not related with MD disease and developing a diverticulum perforation.

[Assessment of patient's comfort and functioning of a totally implantable venous system placed in the safenous vein]

BACKGROUND

When venous system of superior vena cava is not useful or when chest wall is not utilizable to place a reservoir, saphenous vein can be utilized for totally implantable venous access device (TIVAD) placement. Aim of this work is to establish the best location of the reservoir for the function and the comfort of the patient.

PATIENTS AND METHODS

All the patients submitted to TIVAD placement from January 1995 to October 2004 at the Department of Surgical Science, Organs Transplantations and Advanced Technologies of University of Catania have been considered to the present study. Age, sex, kind of disease, surgical procedure, early and late complications, function of the system and comfort to the patients in relation to the different site of reservoir placement have been studied.

RESULTS

447 TIVAD have been implanted in 258 males and 189 females aged from 31 to 79 years in the period considered for the study. Solid tumors represent the majority of the indications and all the TIVAD have been implanted by surgical cutdown to avoid all the early complications related to the percutaneous approach. Two patients received their TIVAD using saphenous vein by surgical cut-down, and no early complications have been recorded. The reservoirs have been placed respectively: in the chest wall in the first patient; and in the anterior wall of the abdomen, close to the anterosuperior iliac crest, firstly and later in the anterolateral face of the thigh in the second one. The first patient had non complications instead the second one referred discomfort with both reservoir locations.

CONCLUSIONS

For the comfort of the patient related to the reservoir position in case of saphenous vein utilization chest wall should represent the best studies are required to validate the appropriate reservoir location.

[Colorectal liver metastases resected with safe margin achieved by tissuelink monopolar floating ball]

BACKGROUND

Nowadays many technological devices are present in hepatic surgery to permit safer liver resections. Main purpose is decrease the intraoperative blood loss. The aim of this study is to analyze our initial experience in hepatic resections for liver metastasis using the new water-cooled, high-density, monopolar device, the Tissuelink Monopolar Floating Ball and Dissecting Sealer (Tissuelink Medical, Inc., Dover, NH).

MATERIALS AND METHODS

We analyzed patients who underwent hepatic surgery for metastases from colorectal cancer between January 2003 and December 2004. Sex, age, type of surgical procedure, duration of the surgical procedure, blood loss, use of vascular clamping of the liver, length of hospital stay, morbidity, and mortality were analyzed.

RESULTS

Three liver resection, one segmentectomy and two limited resections were performed with the use of these new devices. In one case the devices was used to increase safe free margin of hepatic resection. Average blood loss was 150 ml (range, 50 to 300 ml). No mortality or morbidity were recorder.

CONCLUSIONS

In conclusion, this new device permits a bloodless liver resection avoiding vascular clamping. In plus the effect of radiofrequency waves can be useful to enlarge free resection border in patients submitted to hepatic resection without macroscopically safe margins. Prospective randomized studies are needed in order to establish the effective usefulness.

[Peritonectomy and hyperthermic chemoperfusion in peritoneal carcinomatosis. Preliminary results]

BACKGROUND

Peritoneal carcinomatosis can be actually treated by new surgical and oncological techniques. Aim of this work is to report preliminary results of a group of patients with peritoneal carcinomatosis, submitted to peritonectomy and intraperitoneal hypertermic chemoperfusion (IPHC).

METHODS

Age, sex, type of neoplasm, peritoneal carcinomatosis index (PCI), completeness of cytoreduction (CC), operative time, morbidity and mortality of patients submitted to IPHC have been considered.

RESULTS

From May 2001 to December 2004, 10 patients were submitted to peritonectomy and IPHC: 9 (90%) females and 1 (10%) male, aged from 49 to 72 years. Seven patients (70%) were affected of peritoneal carcinomatosis from ovarian tumor, three patients (30%) from colon cancer. The PCI was ranged from 8 to 25. The operative time was ranged from 6 to 14 hours. Two patients with a CC of 2 developed relaps and died respectively after 2 and 4 months. The remaining patients had a CC between 0 and 1. Of these last patients, 1 affected by ovarian cancer died 24 months after, 1 patient died 3 days after surgery for septic shock; the other patients are still alive with a period ranged from 1 to 30 months.

CONCLUSIONS

Our preliminary results suggest that the peritonectomy and IPHC can be effective only in patients with CC of 0 or 1, in the remaining cases these therapeutical methods should be avoided.

Subclavian vein stenosis following totally implantable venous access device (TIVAD) implant by percutaneous approach. Case report

Totally implantable venous access devices (TIVADs) are more and more used in oncologic patients. Early and late complications frequently occur with the techniques of implantation. Thrombosis is the most important and common late complication. On the opposite stenosis of the vessel is not frequently reported. The Authors report the case of a patient with subclavian vein stenosis after implantation of a TIVAD by percutaneous technique. On the basis of the published knowledges they try to explain this phenomenon and suggest an hypothesis for future works.

[Rule of early diagnosis for sigmoid volvulus. Case report]

The sigmoid colon is the most frequent site for a volvulus due to anatomical and pathological reasons. When the rotation of the loop occurs slowly, the sigma can greatly blow up and stretch. We report the clinical case of an 80-year-old woman admitted to our Department for an enormous volvulus of sigmoid colon. Physical examination, abdominal X-ray and CT-scan were performed to diagnose the disease. At the surgical procedure the sigma was about 50 centimetres in length and 15 centimetres in diameter, with a gangrenous necrosis of the loop; the treatment was a sigmoidectomy by Hartmann procedure. Surgical resection is the only therapeutical option for volvulus in advanced stage due to a late diagnosis.

[Learning curve and early complications of totally implantable venous access devices: is tutoring the solution for the problem?]

During the last years operators implanting totally implantable venous access devices (TIVADs), type of access, and kind of complications are changed. Aim of this work is to evaluate the incidence of early complications during the learning curve of residents in surgery or inexperienced surgeons, besides considering the tutoring to evaluate its rule to prevent early complications. TIVADs, implanted by residents in surgery or by inexperienced surgeons in the Department of Surgical Science Organ Transplantation and Advanced Technologies of University of Catania from January 1995 to October 2003, have been considered for the present study. Age and sex of the patients, indication, type of surgical access and early complications of the TIVADs have been considered. Early complications are those complications that occur within 30 day after the implant. Ninety-five TIVADs were implanted by surgical approach in 95 patients: 58 males (61%) and 37 females (39%), with a mean age of 55 years (range 31-79). Inexperienced surgeons performed 40 implants (42%) instead resident in surgery implanted 55 TIVADs (58%). The migration out of the vein of a catheter 20 days after the operation was the only complication recorded. TIVADs implant by cut-down technique represent the way to avoid early complications. The learning curve is short and the tutoring is limited at the first phase.

[Cutaneous ascites as complication of the placement of a totally implantable arterial system]

The Authors report the case of a patient with intrahepatic colangiocarcinoma, operated on for totally implantable arterial device (TIAD) implant in view of hepatic chemotherapy. The postoperative course was characterized by cutaneous drainage of ascites fluid from the wound of the TIAD implant. Its aetiology and therapy are discussed.

[Importance of nursing in the prevention of complications of totally implantable venous access devices]

The Authors report a case of a patient submitted to chemotherapy that has a complication of its totally implantable venous access device (TIVAD) due to incorrect nursing. The symptoms related to the extravasation of drugs were due to the lateral lesions of the catheter with Huber needle. After X-ray examination the therapy was ablation of the non-functioning device and implant of a new TIVAD. The Authors conclude about careful nursing of the TIVAD in order to avoid further psychological problems in cancer patients.

Structure, bonding, and dipole moment of (CH3)3N-SO3. A microwave study

Six isotopic derivatives of the complex (CH3)3N-SO3 have been studied in the gas phase by microwave spectroscopy. The N-S bond length is 1.912(20) A, and the NSO angle is 100.1(2) degrees. The dipole moment, determined from Stark effect measurements, is 7.1110(69) D, representing an enhancement of 6.5 D over the sum of the dipole moments of the free monomers. Analysis of the 14N nuclear hyperfine structure indicates that about 0.6 e is transferred from the nitrogen to the SO3 upon formation of the complex. Comparison between the gas-phase structure and that previously determined for the adduct in the solid state reveals small but significant differences, indicating that the formation of the dative bond is slightly less advanced in the gas. Gas-phase and solid-state structural data are compared for several related amine-SO3 systems.

Significance of leukocyte concentration in the performance of the quantitative cytomegalovirus (CMV) antigenemia assay

BACKGROUND

The quantitative cytomegalovirus-antigenemia (CMV-Ag) assay is an important technology in the regimen of tests utilized in the care and management of acquired immunodeficiency syndrome (AIDS) and other immunocompromised patient groups. Performance of this assay is contingent upon the appropriate processing of the polymorphonuclear leukocyte (PMNL) compartment of the peripheral blood. However, a cell input standard in the performance of the CMV-Ag assay, has not been established. Interpretive differences between laboratories utilizing the CMV-Ag assay may reflect this lack of test uniformity.

OBJECTIVES

To determine the effect of different PMNL concentrations on the quantitation of CMV in peripheral blood. The leukocyte concentration resulting in optimal rates of viral detection, will be compared with the shell vial assay-indirect immunofluorescent assay (SVA-IFA), and conventional tube culture (TC-CPE).

STUDY DESIGN

A total of 74 freshly collected blood specimens were tested by the CMV-Ag assay, using cytospin preparations consisting of 2 x 10(5), 4 x 10(5) and in preliminary experiments, 8 x 10(5) PMNLs/slide. Data obtained from these studies were compared to SVA-IFA and TC-CPE. Viral load was monitored among 11 symptomatic patients through sequential testing of these patients at the start of ganciclovir (GCV), foscarnet (PFA), or combination drug therapy.

RESULTS

Among 74 blood specimens tested by the CMV-Ag assay, cytospin preparations consisting of 4 x 10(5) compared with 2 x 10(5) PMNLs/slide, affected a mean positive cell increase of 215% (P = 0.03). PMNL slide preparations consisting 8 x 10(5) cells produced background levels which prevented accurate reading of slides. The CMV-Ag assay was more sensitive than the SVA-IFA, but equivalent to TC-CPE. Among 11 patients started on drug therapy, viral load was markedly reduced in 8 within 2-3 weeks; three patients (2 deceased within 3 weeks after receiving therapy), showed no decrease in viral load. One patient was identified as harboring a PFA resistant strain.

CONCLUSIONS

A PMNL concentration of 4 x 10(5) cells facilitated the reading of CMV-Ag assay slide preparations. The modified CMV-Ag assay furthermore, is applicable in the monitoring of viral load for the tracking of susceptible or resistant CMV strains.

Brainstem evoked response abnormalities in late-life depression with vascular disease

OBJECTIVE

The purpose of this study was to examine whether the brainstem evoked responses of geriatric depressed patients with vascular disease show greater changes in wave V latency after increased stimulation than do responses of geriatric depressed patients without vascular disease and elderly comparison subjects with and without vascular disease.

METHOD

Geriatric patients with unipolar depression (N = 53) were recruited from a university psychiatric hospital. Elderly comparison subjects (N = 23) were recruited through advertisements. All subjects were assessed for depressive symptoms, cognitive performance, overall medical burden, vascular disease, and disability. Brainstem evoked response was elicited at stimulation rates of 11.4 and 80.0 clicks/sec.

RESULTS

The interaction between depression and vascular disease had a significant effect on change in wave V latency. This effect was synergistic, more than an additive effect. Post hoc comparisons showed that the depressed patients with vascular disease had greater changes in wave V latency that did the depressed patients without vascular disease, comparison subjects with vascular disease, and comparison subjects without vascular disease. Linear discriminant function analysis showed that 82% of the subjects with abnormal changes in wave V latency (sensitivity: 75%, specificity: 81%) could be identified on the basis of ratings for depression and vascular disease.

CONCLUSIONS

Demyelination afflicting the pons and mesencephalon may explain the greater change in wave V latency for the brainstem evoked response in depressed patients with vascular disease. Further studies combining brainstem evoked response with brain imaging may determine whether depression develops only after vascular disease leads to demyelination.

A clinical and phenomenological study of 185 Spanish adolescents with anorexia nervosa

The objectives of the present study were the following to determine the socio-familial, academic and interpersonal characteristics specific to anorexia nervosa (AN); to study comorbidity in patients with anorexia and morbidity in their parents; and to ascertain whether patients with anorexia nervosa in Spain are similar to those in other countries. The research team revised the clinical records of 185 Spanish adolescents with AN (aged 11-18 years). The results were compared with those obtained from a group of 185 psychiatric patients without AN matched by sex, age, time of consultation and centre. No significant differences were found with regard to broken home, birth order or parent-patient conflict. The parents of patients with anorexia have a higher standard of education and develop more affective disorders. When compared with other patients, the individuals with anorexia nervosa perform much better academically but are more socially withdrawn. Males with anorexia nervosa perform worse academically than females and have more anxiety diagnoses. Patients with anorexia have a high comorbidity for affective and obsessive-compulsive disorders. Sufferers from anorexia nervosa in Spain are clinically analogous to patients with anorexia in other countries. The two characteristics specific to these patients are a high standard of academic performance and an intense degree of social withdrawal, although there are certain factors common to other pathologies relating to adolescence.

Use of solid-phase PCR for enhanced detection of airborne microorganisms

The solid-phase PCR (SP-PCR) was compared with a culture-based technique for the detection of aerosolized Escherichia coli DH1. Results with SP-PCR showed an increase in detection sensitivity over that of culture methods. Therefore, SP-PCR may be useful for the detection of airborne microorganisms which may be nonculturable because of aerosolization or sampling stress.

A directional bias for studies of laterality

We have shown that a directional bias (D), previously thought to be unrelated to cerebral lateralization, is, in fact, intimately associated with it. In a group of fully consistent dextrals without familial sinistrality, the direction of lateral asymmetries depended upon the direction of D. Left-directed dextrals manifested the usual visual field advantages for linguistic and spatial material, while right-directed dextrals did not. D is therefore recommended as moderator variable for future studies of laterality.