[Morphologic anomalies of the extracranial internal carotid artery. Our experience]

Cerebro-vascular insufficiency may be caused by morphologic anomalies of the extracranial internal carotid artery (10-15% of symptomatic patients). These alterations are characterized by anomalous elongation which conditions particular attitudes of the carotid: tortuosity, coiling, kinking. In the first case the artery assumes an "S" or "C" shape; in the second the elongation is more emphasized and the artery develops one or more loops; kinking, the most frequent morphologic anomaly, is a sharp angulation of the first part of the internal carotid artery. The etiology of these anomalies seems to be related to congenital causes, that may be unmasked by arterial growing old process. Surgical correction, indicated for symptomatic patients or patients with important hemodynamic alteration, requires rectilinearisation of the internal carotid artery associated with TEA eversion of the same.

[Surgical treatment of cervical fistula after esophagogastroplasty (EGP)]

The authors report their experience on cervical anastomosis dehiscence in patients who had total esophagectomy and esophagogastroplasty for esophageal neoplasms. They describe, accurately and step by step, the plastic reconstructive technique (by using a vascularized transposed cutaneous flap), used to treat a symptomatic cervical fistula which occurred in 3 of the 24 patients who had esophagectomy and cervical-esophagogastroplasty. This kind of treatment led to complete healing of the fistulas, without clinical and radiological signs of fistula recurrence in all the patients treated.

[Primary torsion of the greater omentum. A case report and review of the literature]

The Authors report a case of acute abdominal syndrome, caused by primary torsion of the greater omentum. They describe the still unknown aetiopathogenetic factors, pointing out the problems of preoperative diagnosis.

Cholesterol vesicles in areas of gastric metaplasia of gallbladder epithelium

Gastric metaplasia is a frequent epithelial change in gallbladder of lithiasic patients. Particles consistent with cholesterol-containing vesicles were searched in areas overlying gastric metaplastic cells, in gastric metaplastic cells, in areas overlying normal-looking epithelial cells and in normal-looking epithelial cells in 25 patients with radiolucent calculi and 10 control patients undergoing cholecystectomy for other reasons. Important trends were found confirming the peculiar role of mucous layer adherent to metaplastic gallbladder epithelium in beginning the nucleation process and interesting pictures concerning the formation of uni- and multilamellar vesicles in these "nucleating areas" were seen.

[Treatment of spontaneous pneumothorax with video-assisted mini-invasive thoracic surgery. First long-term results]

The spontaneous pneumothorax (pnx. s.) is a type of pathology with a high per cent of relapse so its aetiological treatment can't be done only with a pleural drainage. With the resection of the bubble (that is the cause of it) instead, the problem will be resolved without possibilities of relapses. In the past, this was possible only with a thoracotomy, now with the new techniques of video-thoracoscopy, the therapeutical approach to this pathology has been revolutionized. In fact, this methodology resolves definitively the pulmonary lesion, can avoid the relapses, can guarantee a short stay in hospital and a very good restarting of the working and social activity.

[Atraumatic skin closure with Fasterzip]

The Authors report their experience of skin closure using a new device, a surgical "zipper", without applying any sort of sutures. The application of this device, the functional and aesthetic advantages and the results obtained are described.

Peritoneal cystic mesothelioma treated with minimally invasive approach

A case of peritoneal cystic mesothelioma in a young woman was treated with a minimally invasive approach. The technique and a review of the literature are presented.

[Carcinoid of the pancreas. 2 case reports]

Two cases of carcinoid tumors are reported: the most important characteristic of these neoplasms are that they are uncommon and are accidentally and difficulty diagnosed. Surgery, when possible, is the treatment of choice for the carcinoid tumors of the pancreas, but in unresectable tumors chemotherapy, radiotherapy and interferon are used.

[Pleural drainage vs video-assisted minimally invasive surgery in the treatment of spontaneous pneumothorax. A retrospective study]

The most frequent cause of spontaneous pneumothorax is bleb's disease of the lung. Considering that, pnx s. has a remarkable bent for relapsing, we think that it's necessary an aggressive treatment to resolve it. That's because pleural drainage is useful for a symptomatic resolution, VATS for an etiologycal one. To value the real efficacy of the treatment of VATS, we have effected a retrospective research between two classes of patients suffering from pnx s. admitted in our Institute from 1987 until 1991, one treated with pleural drainage (class A, 11 patients) and the other with VATS (class B, 13 patients). 1) Patients treated with pleural drainage were nearly double compared to class B. 2) In class A, the mean value of drainages were nearly double compared to class B. 3) Class A had a number of relapses 10 times more compared to B. 4) Considering the period of hospitalization, class A had a value nearly triple compared to B. 5) We've noticed that the mean value of the cost for episode of pnx s. in class A was more than 15% compared to class B and the cost for patient in class A was nearly double than in class B. We can affirm that, for the treatment of pnx s., the method of VATS rappresents a real success. We're passed from the "symptomatological treatment" of it to an aetiological one, joined to the prophylaxis of the relapse.

[Use of PGE1 in severe ischemia of the lower extremities. Clinical study]

Lower limb critical ischemia is a clinical condition typical of patients with severe chronic obstructive arterial disease (Fontaine's IIIb and IV degree). This condition often leads to amputation of the limb involved. The authors present to the use PGE1 in 50 patients with Fontaine's IIIb-IV degree chronic obstructive arterial disease of lower limbs in which the indication of amputation was done. All the patients, admitted to the emergency ward, complain of rest pain and distal ulcers. The administration of PG5(1) was given as follows: 40 mg/bid/e.v./20 days. A 6 months long follow-up was installed with the instrumental evaluation of: Transcutaneous oxygen pressure; Distal blood perfusion with Doppler; cardiac pulse; blood pressure. Eighteen patients became to a Fontaine's II degree during the next 2 months after therapy, 25 patients came back to a severe claudicatio: of them 18 underwent successfully vascular surgery, 7 underwent amputation of the lower limb. In 7 patients the PGE1 did not influence the natural progression of the disease. Among the side-effects of therapy we can mention: headache (4%), erythema and pain of injected vein (8%), sick (4%). All the side effects were transient and never led to interruption of therapy.

[Vascularization of the gastric stump tubule in esophagogastroplasty (EGP)]

The authors present the results of the vascular supply of tubulized gastric stump in patients who had sub-total oesophagectomy and cervical oesophago-gastroplasty (OGP) for oesophageal carcinoma, evaluating the importance of altered tubulized gastric stump's vascular supply on oesophago-gastric anastomosis efficiency. From April 1989 up today 51 patients who had OGP entered this study. Among these 2 had intestinal reconstruction by whole stomach and 49 by tubulized gastric stump. These 49 patients had celiac and upper mesenteric arterial angiography 30 days after surgery. As regards vascular patency angiography allowed us to divide the tubulized gastric stump into three parts; giving useful information above all on the distal part of the stump, considered "at risk" as concerning vascular supply. The authors thus demonstrate that the anastomosis high rate dehiscence is preferably due to the oesophageal stump vascular supply (strongly affected by cervical dissection) rather than to the poor vascular supply of the distal third of the transposed tubulized gastric stump.

[Video-assisted mediastinoscopy: clinical uses]

The experience with video-assisted mediastinoscopy in 16 cases examined, is reported. Initially the classic mediastinoscopic device with the aid of an operative thoracoscopy was used. Starting from April 1994 the Authors used the video-assisted mediastinoscopy which, enlarging the surgical field, allows to improve the operative performance and may be a good aid for multiple teaching.

[Deep venous thrombosis and surgery. Assessment of the main risk factors]

Deep venous thrombosis is a quite frequent pathology with a high degree of morbidity and death-rate. Two are the main problems of this disease: the risk of pulmonary embolism and outcome of a post-thrombotic syndrome, leading patients to infirmity. The patients max exposed to the risk of deep venous thrombosis are the surgical ones: the authors, with a retrospective study on 480 surgical patients, examine the risk factors mostly related with the onset of deep venous thrombosis. At the end they refer about connection between the risk factors studied and the clinical display of in surgical patients.

Chilaiditi's syndrome as a surgical and nonsurgical problem

Hepatodiaphragmatic interposition of the intestine is a rare anomaly (0.025 to 0.28 percent of the general population) described by Chilaiditi in 1911 and often believed to be of irrelevant clinical interest. To the contrary, recent studies stated that this syndrome is a potential source of abdominal problems requiring emergency or elective operation. From a retrospective analysis of records since 1976, four instances of Chilaiditi's syndrome have been found (three males and one female). Interposition of the proximal transverse colon was found in three patients and the small intestine in one patient. The findings of plain roentgenograms of the chest were determinants for diagnosis in three patients. In one patient, a barium meal was given to obtain a better definition. Two patients were admitted for malignant neoplasms (metastatic carcinoma of the breast, carcinoma of the gastrointestinal tract and cirrhosis of the liver) and died within a few months. The other two patients complained of abdominal pain. Patient No. 4 had gastric volvulus. Chilaiditi's syndrome was diagnosed intraoperatively in that patient and a surgical treatment with hepatopexy was performed, by suturing the falciform, the coronaria ligament and the anterior margin of the liver to the diaphragm with interrupted absorbable stitches. After a two year follow-up evaluation, this patient is as well as the patient who underwent medical therapy. Volvulus of the stomach, as was found in Patient No. 4, is an unusual condition and, to our knowledge, the patient is the second reported instance.

[An aneurysm of the extracranial carotid. A report of an interesting clinical case]

One case of extracranial carotid artery aneurysm observed is reported. This uncommon and interesting vascular disorder is still under discussion even if the present tendency is to treat it actively by reconstructive surgical procedures that make it possible to avoid the natural aneurysm complications with a low risk of postoperative neurological lesions.

[Isthmic coarctation of the aorta. Description of an anomalous case]

An anomalous (because of the advanced age of its onset) case of isthmic coarctation of the aorta in preductal site observed at the persistence of hypertensive symptomatology associated with cephalgic and lipothymic attacks is reported. Instrumental examinations confirmed the clinical suspicion and resective-reconstructive surgical treatment led to complete resolution of both cause and effect.

[Retroesophageal right subclavian artery. Description of a clinical case]

A case of retroesophageal right subclavian artery, occasionally observed in a patient submitted to diagnostic investigation and surgical treatment for bilateral steno-obstructive involvement of the carotid district, is described.

[Importance of intraoperative H/R ultrasonography in the immediate evaluation of the results of thromboendarterectomy of the carotid bifurcation]

Personal experience on the intraoperative use of HR echography for the evaluation of the immediate surgical results in carotid bifurcation T.E.A. is reported. It is already assessed that early failure in vascular surgery is due to technically incorrect procedures.