Search

A case of forearm compartment syndrome due to a minor trauma is reported. The severe clinical conditions due to a shock state lead to an initial misdiagnosis of clostridial myonecrosis. The patient, 68 y-old woman, was admitted to the intensive care unit of Authors' hospital for a traumatic injury of the right forearm. A diagnosis of gas gangrene due to clostridial myonecrosis was done and forearm amputation suggested. In spite of this indication a decompression fasciotomy of the forearm compartments was performed as well as a hyperbaric oxygene therapy. Since culture of necrotic tissue samples did not demonstrate any bacterial growth, the Authors decided to avoid amputation and perform a radial arteriovenous fistula to improve venous return and reduce distal edema and continuous bleeding, with a complete recovery within 40 days. Good evaluation of patient with suspected compartment syndrome means correct and not delayed treatment, avoiding invalidating outcome.

From 1992 to November 1999, 225 consecutive cases of acute abdomen were observed: 163 suspicious acute appendicitis, 7 ovarian cysts with suspect torsion, 4 intestinal occlusions, 1 digestive hemorrhage due GIST (Gastro-Intestinal Stromal Tumor), 1 case of hemoperitoneum after laparoscopic appendectomy and 49 cases of acute cholecystitis. In the 225 cases of emergency laparoscopic operations for acute abdomen the diagnostic accuracy has been of 99.5%, with only one case of conversion in to laparotomy for diagnosis. The conversion from laparoscopic to laparatomic surgical technique was registers in 2 cases (1%). The realimentation started in all the cases with a liquid diet as soon as 6 hours after the operation and with solid foods the following morning. The Authors haven't registered wound contaminations. The patients of working age rehabilitated in 8 days (between 7 and 21 days). In the athletic patients the average rehabilitation time was 15 days. On the base of the results obtained with their video-laparoscopy experience in acute abdomen emergency surgery, the Authors confirm that this technique can be advised as Emergency Surgery's first choice treatment.

The authors report an uncommon renal oncocytoma rate stressing difficulties that modern diagnostic modalities meet in a correct preoperative differential diagnosis with nephrocarcinoma. Oncocytoma is a low multifocal involvement. Surgical treatment is the primary choice, nephrectomy about localized monofocal lesions in advisable, with short and long term positive outcomes. In ambilateral involvement case without malignancy evident signs (scarce likelihood to infiltrate nephritic capsule, without lymphoadenopathy) conservative operations with partial resections are suggested with a five years survival from 84 to 96%.

The authors report an uncommon gastric bleeding rate due to splenic hilum compression by a pancreatic cyst. The syndrome to be brought back to some sectorial portal hypertension form (left-sided portal hypertension) is difficult to diagnose because of absence of esophageal varices and other portal hypertension signs in an unchanged liver functionality patient. To put a correct diagnosis about gastric bottom bleeding varices without hepatic origin, the authors recommend to use arteriography and CT. Surgical treatment is proved to be the election one because of useless attempt of bleeding control through hepatic artery endoscopic sclerosis or embolization.

The Authors, after a short introduction concerning the primary carcinoma of the cystic duct and the exact definition according to Farrar's criteria, report a case occurred to their observation, the 35th case of international literature. In particular the importance of some hemato-clinical parameters and instrumental investigation (ERCP, angio-CT) to underlined in order to surgical indication. In the case here reported cholecystectomy uses informed with partial resection of the hepato-choledochus and excision of some periductal and pericholedochus lymph nodes. Finally, the Authors discuss about clinical data and diagnostic and therapeutic trends, on the case of their experience and literature review.

The Authors present an original case record simplified for urgency and emergency, with the aim to allow a quick and exact framing of the "acute" and consequently with a great saving of time. This is possible also thanks to the simple but efficacious graphic representation of the human body and his main districts. Moreover, it is possible to report data in a computerized system.

The Authors report a case of blunt renal trauma in a nine-year-old boy. Clinical and therapeutic approaches are discussed in the light of a wide review of the literature.

The Authors point out how AEFs represent a serious complication of aortic vascular surgery. Special attention is given to the diagnostic and therapeutic approach, also supported by a wide review of the literature.

The Authors report two cases of primary carcinoma of the colon-rectum largely invasive, characterized signet ring cells. This is an uncommon neoplasm representing only 2% of primary carcinoma of the colon-rectum. The Authors discuss the diagnostic and therapeutic approach through a wide review of the literature.

The Authors report a wide review of the literature on open and blunt renal traumas. All the problems related to this pathology as well as all the instrumental and laboratory tests currently available for the correct diagnosis are illustrated. Both conservative and surgical management are also discussed.

Boerhaave's syndrome is a rare and severe syndrome, with a mortality rate around 40%. The Authors report a case recently observed and through a Literature review stress the importance of an early diagnosis and quick surgical treatment as far as quoad vitam prognosis is concerned.

The Authors, after a Literature review on endovascular invasive procedures used for inferior limbs obstructive arteriopathy, describe the use of a new device for mechanical endarterectomy. Through the latest acquired experience the importance of dissecting progressively the single layers of the atheroma plaque without arriving to a complete denudation of the arterial wall, so avoiding the risk of myointimal hyperplasia reactions, is outlined. The possibility of using endoarterial stents in case of more indaginous recanalization is also stressed.

Acute arterial obstruction of the limbs represents one of the most frequent events in Emergency Surgery. In 95% of the cases, the cause has to be searched in embolus parting from the heart in patients with rheumatic or fibrillary disease. Currently the two therapeutic methods used for peripheral arterial obstruction are thrombolytic therapy and surgical dysobstruction using Fogarty's catheter. The Authors compare the two methods on the basis of their experience in 129 cases underlying how the thrombolytic therapy (Urokinase, Streptokinase) should be instituted in the early hours from presentation of symptoms, otherwise, the possibility of revascularization will heavily drop. Better results are obtained by positioning a catheter under radiologic guide for intra-arterial infusion. The Authors also believe that up-to-date the surgical approach with Fogarty's catheter represents one of the best procedures, either for its feasibility of for the costs of the thrombolytic therapy. Furthermore, the thrombolysis may be not complete, and account for possible haemorrhagic complications.

The ingestion or introduction of foreign bodies is a common situation in emergency surgery. The patients who usually ingest foreign bodies for different reasons are children, psychotics, alcoholics, prisoners and old people. The authors analyzed 65 cases observed in the I Institute of Surgery of the University of Rome "La Sapienza": 45 males and 20 females. Both the anal introduction and ingestion may be accidental or voluntary. The incidence of complications is estimated about 5 to 7%. The authors underline the opportunity of a conservative removal through endoscopic procedures especially for intraesophageal corps. This procedure is recommended to reduce morbidity and mortality rates, as well as hospitalization and social costs.

In relation to their experience, the Authors affirm that currently an early diagnosis of breast cancer, in an absolute preclinical stage, is obtainable by adequate screening using specific methods especially among women who are at greater risk. Primary prevention is not achievable at present; however some considerations based on protocols which provide a surgical prophylactic therapy in high risk breast pathologies and in very selected patients, are possible. In the light of these considerations secondary prevention has a predominant role and may be more effective and curative if the treatment is carried out in the earliest stages of the disease.

The Authors report their experience in 38 cases (January 1990-Septembre 1994) of "difficult" gallstone disease of the main bile duct treated with electrohydraulic intracorporeal lithotripsy. Nineteen patients were affected with giant stones of the biliary tree, 6 with multiple stones of the main bile duct, 13 with stones of one or both hepatic ducts. The approach to the biliary tree was peroral transpapillary in 16 patients and transhepatic in the remaining 22. Twenty-five patients were previously submitted to surgery of the biliary tree (13 hepaticojejunostomy, 8 choledochoduodenostony, 4 papillostomy), while 5 had required a cholecystectomy, and 6 a gastroresection according to Billroth II. In 80% of the cases two lithotripsy sessions were enough to achieve the complete clearing of the bile duct. There was no mortality and morbidity was 5.3%. Total clearing was obtained in 97.4% of the cases. 6-48 months after treatment 37 patients still do not show clinical, laboratory or echographic signs of gallstone stasis or disease relapse.

Surgical infections represent one of the main causes of postoperative morbidity and mortality, especially in emergency surgery, with negative consequences on health costs. The Authors examined 2002 cases of emergency admission for surgical pathologies at the I Surgical Department of the University of Rome ¿La Sapienza¿ from 1987 to 1992. Overall septic complications were 13,7%, with a mortality rate of 1,2%. The Authors underline the lack in Italy of either an accurate system for monitoring septic complications or a useful method for data collection. At last the attention is focused on the main causes of septic complications, their diagnosis and treatment.

After reviewing current and past medical Literature regarding celiac axis aneurysms the case of a 70 year-old emphysematous patient with an aneurysm of the celiac axis measuring 6 cm in diameter is reported. The patient's pulmonary function testing status strongly precluded a surgical option. Angiographic embolization of the aneurysm was then performed. The Authors observed that embolization with immediate occlusion of all afferent vessels of the celiac axis leads to no serious short or long-term consequences as long as an adequate collateral hepatic circulation is maintained through the gastroduodenal and inferior pancreaticoduodenal arteries. This case would appear to be the first described in the Literature and the Authors hold this technique to be a valid alternative whenever a surgical procedure would be difficult or impossible to perform.

Approximately 80% of liver trauma cases have a good prognosis and do not create decision-making problems for the surgeon, while in the remaining 20% the correct choice still represents a problem. Recently there has been a trend toward more conservative surgical management with emphasis on hemostasis and debridement, as well as a move toward a non-surgical alternative (surgical abstention) where feasible, relying in such cases on first-line CT scans for trauma evaluation. We report 51 cases of liver trauma observed in the period 1985-1993 graded according to the AAST Liver Injury Scale as follows: 12 grade I lesions (23.5%), 7 grade II lesions (13.7%), 19 grade III lesions (37.3%), 7 grade IV lesions (13.7%), and 6 grade V lesions (11.8%). In managing these cases we relied on two first-line diagnostic procedures: diagnostic peritoneal lavage (DPL) and CT scans. DPL, performed on 10 blunt trauma victims with unstable vital signs, was positive in 7 who thus underwent immediate surgery, and negative in 3 who subsequently underwent CT scan. Another 14 blunt trauma victims with stable vital signs underwent first-line CT scanning. In the event of a CT grade III or IV lesion patients underwent surgery, while patients with a CT grade I or II lesion were followed expectantly. Deaths (14) occurred only among patients with grade III or IV lesions (including 9 multiple trauma victims) who underwent surgery.

The authors report a case of arteriomegaly and underline the importance of a correct diagnosis. A review of the literature, in fact, confirms the incidence of the disease is higher than usually believed. Therefore, a complete diagnostic evaluation is necessary to recognize the disease and assure the adequate treatment.

Two cases of hydatid cyst of the hepatic dome, complicated by rupture in the thoracic cavity, are reported. The Authors stress the frequency of human hydatidosis, still high in Italy, and the severity of the above mentioned complication. Surgical treatment is also discussed.

In this study, the Authors have provoked experimentally acute pancreatitis in the rat by different methods, in order to find out morphological modifications of the pancreas in the initial stage of the disease. In case of biliary and pancreatic duct obstruction with pure pancreatic reflux, both oedema and inflammatory infiltrations were evident, whereas, in the presence of biliary reflux too, more serious histological features were detected. In conclusion, the first sign of alteration in acute pancreatitis could be represented by the association of intraductal hypertension and pure pancreatic reflux.