Pre and Post-Operative Ph-Metry in Videolaparoscopic Surgery for Gastro Oesophageal Reflux Disease

Gastro-oesophageal reflux is common in children, especially in the first year of life, and it may be regarded as physiological. Good functioning of the lower oesophageal sphincter depends largely on the anatomical relationships between oesophagus, stomach and diaphragm hiatus. Relative immaturity of these structures in newborn babies and young children is a risk factor in reflux disease, which may result in a wide variety of typical and/or atypical symptoms and, sometimes, serious complications such as oesophagitis and stenosis. Reflux disease may be diagnosed and studied, basing on morphological and functional aspects and, since the advent of pH-metry, it is possible to personalise the therapeutic approach to children with reflux. Surgical treatment of reflux disease in children has recently been improved due to a mini-invasive surgical approach. Absolute indications are recurrent pneumonia, intractable pain due to oesophagitis and retarded growth, often in association with neurological impairment. In the last three years, 18 children with reflux disease underwent videolaparoscopic surgery in our department, 14 by the Nissen and 4 by the Toupet technique. Post-operative pH-metry always showed a reduction in exposure of the distal oesophagus to acid (integral of H+) and an improvement in oesophageal clearance (short refluxes percentage) indicative of good functioning of the gastro-oesophageal junction. PH-metry proved to be an invaluable technique for planning therapeutic strategy. In follow-up evaluations, it enabled us to monitor functioning of the gastro-oesophageal junction and to avoid other more difficult and invasive tests in patients with severe neurological impairment.

Congenital Cystic Adenomatoid Malformation of the Lung Tipe II: Three Cases Report

Congenital cystic adenomatoid malformation (CCAM) is a rare congenital lung lesion. It may appear since birth (30-35%) with difficulty breathing or may have a late onset (60-65%) with recurring pulmonary infections or growth failure; in a small percentage of cases, the lesion can be completely asymptomatic. Fetal or post-natal surgery can be used as surgical treatment of these lesions. Postnatal surgery consists of a lobectomy, bilobectomy or pneumonectomy, based on the size of the lesion. The best age to undergo this surgery is around 2 years, but only if the injury is stable and the child has no complications. The study describes three cases of CCAM, observed at the Pediatric Surgery Section of the University of Siena. We analyzed those 3 cases whose approach was defined by the onset of symptoms, age and clinical condition of patients. In the first case the surgery was performed a few hours after birth due to the worsening of the clinical conditions; in the other two cases it was delayed because the patients were asymptomatic. The purpose of this study is to review the management of patients with CCAM in relation to clinical onset and the type of injury.

[Criss-cross dermis suspension in the treatment of breast hypertrophy]

AIM

The results obtained with a technique using the dermis suspension associated with a central pedicled dermo-glandular-adipose flap, for the durable filling of the superior pole over time, are presented.

METHODS

Forty patients, affected by marked mammary hypertrophy, have been selected and divided into 2 groups (A, B) of 20 patients each. In both groups we have used a reduction mammaplasty technique based on a superior-medial dermo-glandular flap associated with a central pedicled dermo-glandular-adipose flap. In group B we have associated the preparation of the dermal brassiere crossed as a bra (criss-cross). In the follow-up of 15 months in average (range 8-24), we evaluated: the sensitiveness of the nipple-areola complex (NAC) using a visual analogic scale; the degree of mammary ptosis measuring the distance of the NAC from the jugulum and the distance between the areola and the submammary fold; the persistence of the filling of the superior pole, initially emptied, and the length of the scars.

RESULTS

The sensitiveness of the NAC in both groups was satisfactory in 72% (29/40) of the cases (P<0.001). The filling of the superior pole by a central pedicled dermo-glandular-adipose flap was satisfactory in both groups in the initial phase. The comparison between the 2 groups of patients showed, in the follow-up of 24 months, an areolar ptosis of 1.5 cm inferior in average (1 cm group A against 2.5 cm group B in average) and a marked decrease of the ptosis of the lower pole (P<0.001).

CONCLUSIONS

In the patients of group B the preparation of the dermal brassiere (criss-cross) led to an improvement of the stabilization of the form over time and a considerable decrease of the postoperative ptosis.

The use of recombinant human erythropoietin stimulating factor in plastic surgery

Erythropoietin is the most important factor in the regulation of erythropoiesis. This study aimed to evaluate the efficacy of rhuESF for patients undergoing plastic surgical procedures during which notable blood loss is expected (reduction mammoplasty in cases of macromastia and abdominoplasty obese patients) to improve the full blood count and reduce the need for transfusion. The levels of hemoglobin were significantly greater for patients pretreated with erythropoietin and iron than for the control group.

Verapamil inhibits interleukin-6 and vascular endothelial growth factor production in primary cultures of keloid fibroblasts

An increased secretion of cytokines and growth factors has been hypothesised to play a role in the abnormal growth of keloid fibroblasts. The aim of this study was to evaluate the effect of the calcium antagonist verapamil on the interleukin-6 (IL-6) and vascular endothelial growth factor (VEGF) secretion, as well as on cellular growth, in primary cultures of fibroblasts derived from the central part of keloid lesions. These cells grew faster than peripheral keloid and nonkeloid fibroblasts, and, in long-term cultures, became stratified assuming a three-dimensional structure. Compared with peripheral and nonkeloid fibroblasts, central keloid fibroblasts presented an increased production of both IL-6 and VEGF (P<0.03 and P<0.005, respectively). Verapamil (100 microM) decreased IL-6 and VEGF production (P<0.03 and P<0.005, respectively) in central keloid fibroblasts cultures at 72 h. Moreover, verapamil decreased cellular proliferation by 29% and increased apoptosis to an absolute value of 8%. The results of this study demonstrate that in primary cultures of central keloid fibroblasts verapamil reduces the sustained basal IL-6 and VEGF production and inhibits cell growth; these data may offer the link with the beneficial effect of calcium antagonists on keloid scars in vivo.

[Use of dermo-adipose grafts in facial morphology restoration in cases of progressive partial lipodystrophy]

Two cases of partial progressive lipodystrophy syndrome with extensive soft tissue atrophy of the face and of the upper part of the trunk, with kidney and blood alteration, are presented. On the basis of the psysical examination and pathological history of the patients, blood and instrumental tests have been performed in both cases. The diagnosis of partial progressive lipodystrophy syndrome has been made and a surgical treatment with dermal fat graft from the inguinal region was proposed to the patients after several information and was performed to improve the facial contour. After a follow up of 18 months a resorption of 50% of dermal fat graft was found according to surgeons' expectations with a good esthetic improvement of the face.

Prevention and treatment of keloids with intralesional verapamil

BACKGROUND

The current treatment of keloids is based on surgery, medical therapy and physical treatment. The optimal treatment remains undefined.

OBJECTIVE

This clinical study determines the effectiveness of verapamil hydrochloride on the prevention and treatment of keloids.

METHODS

Two groups of patients with keloids were divided according to lesion site and age. The first group was treated by perilesional surgical excision of keloids and topical silicone, combined with adjuvant treatment of intralesional 2.5 mg/ml verapamil hydrochloride injections administered at timed intervals. The second group served as control, receiving the same treatment except the verapamil hydrochloride.

RESULTS

A periodical examination to check specific clinical parameters and an 18-month follow-up determined that keloids were cured in 54% of the cases in the first group, compared to 18% in the second group. Moreover, in the remaining 36% of patients in the first group in whom keloids recurred, there was an improvement in size and above all in consistence.

CONCLUSION

These findings suggest that verapamil hydrochloride is an effective tool for the prevention and therapy of keloids.

Dermatofibrosarcoma protuberans: experience with 14 cases

Dermatofibrosarcoma is a rare, low-grade malignant skin tumour that can be considered the equivalent of malignant non-cutaneous soft tissue fibrohistiocytoma. The high rate of recurrence of this tumour is correlated with poor surgical management because lesions, often smaller than 2 cm in diameter, may be confused with dermatofibroma or keloid. Our findings confirm the importance of accurate diagnosis of primary lesions and the need for aggressive surgical treatment (excision of 5 cm of surrounding tissue) to lower the incidence of local relapse.

Extracorporeal septoplasty with paramarginal incision

To reconstruct the airways in the case of serious nasoseptal deviation it is preferable to remove the cartilaginous septum, reshape it, and put it back. This may be done through an open rhinoplasty approach with a transcolumellar scar resulting in wide visual access to the septal structures. As the transcolumellar scar may give problems in some cases, it might be helpful to use an extended paramarginal incision. A traditional open rhinoplasty approach was used in eight patients and the extended paramarginal incision technique in 19 patients. Two of the eight patients who had the open rhinoplasty technique developed unsatisfactory transcolumellar scars. Of the 19 patients who had paramarginal incisions no patient developed late problems. The paramarginal approach was superior to the traditional open rhinoplasty approach despite the slightly better visualisation with open rhinoplasty.

Skin island urethroplasty in deep urethral lesions--a long-term follow-up of 25 consecutive patients

Strictures and ruptures of the bulbomembranous urethra have traditionally been treated by a two-stage scrotal skin inlay technique (Johanson B. Reconstruction of the male urethra in strictures. Acta Chir Scand 1953; Suppl 176). For the last 10 years we have treated the patients instead with a skin-dartos island flap pedicled on intertesticular septal vessels. The skin island has been taken from the scrotum, the penile base, or the penile shaft. Twenty-five consecutive patients were treated until 1993 and followed up for at least 5 years. Five of the patients had had open urethroplasty before. Fifteen of the patients had urethral strictures and 10 had complete ruptures. Of the 25 patients 6 had to have a further operation; in 4 patients this was because of restricture, in 1 patient a urethral pouch had to be reduced, and in the final patient the operation was both for restricture and pouch formation. At final follow-up impaired micturition occurred in three patients: two of them had had a ruptured urethra treated previously, and one had a chronic infectious stricture. Problems related to hirsutism were low. No obvious advantage was detected from using distal penile skin, so a skin-dartos island from the penile base is advocated. In conclusion, a one-stage skin-dartos island flap pedicled on the intertesticular septal vessels may be recommended in the treatment of both strictures and complete ruptures in the bulbomembranous urethra.

Nipple reconstruction with a modified S-flap technique

A modified S-flap method for nipple reconstruction with two local opposing skin flaps, was used for a series of 21 women with a mean age of 50 years (range 30-64). Four patients had bilateral breast reconstructions, so the total number of reconstructed nipple areola complexes (NAC) was 25. The patients were examined 29-46 months (mean 36) after the reconstruction with particular reference paid to projection, size, sensation, and colour of the nipples. The patients also answered a questionnaire about their assessment of the final result. The mean projection of the nipples was 3.9 mm (range 0-9). Five patients had various degrees of necrosis of the skin flaps. One third of the women had some sensation in their reconstructed nipples. Two thirds of the nipples were pale. The patients estimated the final result as 8.2 (range 1-10) on a visual analogue scale.

[Lip carcinoma. Various therapeutic options]

Lip carcinoma is a relatively unique malignant disease because the lip is a junctional structure. The lip is bounded externally by the facial skin and it is in continuity with the buccal mucosa of the oral cavity. The lymphatic drainage of the upper and lower lips is primarily directed to the mandibular group of lymph nodes. To a lesser extent, drainage may go to submental intraparotid, or internal jugular lymph nodes. Lip carcinoma is almost exclusively a squamous cell carcinoma, the major etiologic factor being prolonged iar exposure. Treatment for lip carcinoma is usually surgical, in the form of full-tickness excision. Neck dissection is also performed when clinically palpable lymph nodes are present.

Clinical experiences with the external tissue extender

Forty one patients were operated on for different skin defects using the external tissue extender (ETE). The indications were similar to those in which ordinary tissue expanders were used with a prevalence of scars (n = 20, 46%) and previous skin grafts (n = 12, 28%). The ETE was used all over the body but mainly on the upper (n = 18, 42%) and lower (n = 12, 28%) extremities. The mean treatment time was eight days, and the complication rate was 8% compared with the reported 25% using ordinary tissue expanders. The advantages of the ETE compared to ordinary tissue expanders are that it saves time and money for doctors and patients, it is easy to handle, and it is almost always possible to operate under local anaesthesia.

[The use of polypropylene (Marlex) mesh in ambulatory care of inguinal hernia]

The use of Marlex mesh in the treatment of inguinal hernia produces a series of advantages, if compared with traditional techniques. According to the authors, these advantages can be identified with the ambulatorial treatment of this pathology, with the possibility to use the local anaesthetic, with a minimum postoperating pain, with a possible collaboration of the patients with the surgeon during the operation, and with a considerable reduction of relapses. The authors explain the different steps of their techniques.