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Two patients had an acute dissection of the right common carotid artery due to catheterization of the vessel during Seldinger angiography. Both patients were evaluated immediately after the traumatic event by means of echo-pulsed Dop pler (duplex scan) to check the hemodynamic significance of the lesion. In the first case, the lesion initially appeared insignificant, but on the second day duplex scanning showed a sudden reduction of the flow in the internal carotid artery due to progression of the carotid dissection: the patient, neurologically asymp tomatic, was operated on successfully.The second patient, also asymptomatic, underwent emergency surgical treat ment after the first duplex scan showed significant reduction of the internal carotid flow. The postoperative course has been uneventful. Both patients are asympto matic eighteen and eight months after surgery.The authors emphasize the important role that duplex ultrasonography played in the management of these 2 patients. [ABSTRACT FROM PUBLISHER]

Doppler above-ankle pressure index (API) was monitored during 368 consec utive bilateral aortoiliac or aortofemoral graft reconstructions performed for aneurysmal or occlusive disease. The aim of this study was to investigate the variations of peripheral pressure, during and just after completion of the proce dure, either when followed by immediate and definitive success or when an intraoperative correction or an early postoperative reoperation was necessary owing to postreconstructive ischemia. For this purpose the API courses were subdivided into three groups: A (705 limbs), which underwent immediately suc cessful reconstructions; B (22 limbs), which needed intraoperative correction; C (9 limbs), which required early reoperation. All 736 limbs were studied individ ually as monolateral reconstructions and classified into six subgroups: 1, pervi ous iliac, pervious femoral artery; 2, occluded iliac, pervious femoral; 3, pervi ous iliac, stenotic femoral (i.e, stenosis > 75% of the superficial femoral artery); 4, occluded iliac, stenotic femoral; 5, pervious iliac, occluded femoral; 6, oc cluded iliac, occluded femoral. APIs were monitored before the operation (PRE), at the completion of the distal anastomosis (DEC), and five, fifteen, thirty, and forty-five minutes after.Data were statistically analyzed by multivariate analysis in regards to 705 immediately successful limbs (group A) and by comparison of all corrected or reoperated cases (groups B and C) with the lower bound of the fifth centiles of group A.The results in group A show that: API-PRE is different in the six subgroups (p < 0.001); API-DEC is lower than API-PRE in the patent iliac artery sub groups (1,3, and 5) and higher than API-PRE in the occluded iliac artery sub groups (2,4, and 6) (p always < 0.001). From declamping time to the forty-five- minutes observation, the mean courses turn out parallel and rising but on dif ferent levels (p < 0.001): pervious femoral, stenotic femoral, occluded femoral. API-forty-five minutes is higher than API-PRE in occluded iliac artery subgroups (2, 4, and 6) (p < 0.001), whereas in the patent iliac artery subgroups only the fifth subgroups reveals a slight but significant rise (p < 0.01), probably owing to the high rate of profunda femoral endarterectomy or angioplasty asso ciated with aortofemoral reconstructions.APIs values of 31 cases in groups B and C, compared with the lower bound of the fifth centile of group A, show that 8/31 cases (26%) remain above that bound, while 23/31 cases (74%) fall below it. [ABSTRACT FROM PUBLISHER]

Background/aims: Post discharge prescriptions and follow-up protocols after non-operative treatment of blunt liver injuries are still controversial. The aim of this study was to detail the evolution of the hepatic injuries considering their different patterns and severity grades, stated by the Liver Injury Scale., Methodology: Analysis of a database concerning 79 consecutive patients submitted to ultrasound follow-up until complete recovery of liver injury., Results: All patients had an uncomplicated course and the liver restoration was demonstrated between 3 and 300 days after the trauma. The median healing time of hematomas increased with the grading (p<0.001): 6 days (IQR=6.75), 45.5 days (IQR=91) and 108 days (IQR=89) for I, II and III grade lesions, respectively. Similarly behaved the lacerations and 29 days (IQR=14.25), 34 days (IQR=43.5) and 77.5 days (IQR=83.5) was the median healing time of II, III and IV grade lesions, statistical significance emerging only comparing II to IV grade lacerations (p<0.035). Considering the different lesion patterns within the same severity grade, the liver restoration was more prompt after lacerations (p<0.001)., Conclusions: These data suggest that medical prescriptions and follow-up protocols can be tailored considering the lesion characteristics.

Boerhaave syndrome is a rare disease with a mortality rate that varies from 10 to 40%. The typical clinical presentation (vomiting, pain, subcutaneuous emphysema) is relatively infrequent. In the case of atypical clinical presentation CT scan with contrast medium administered per os is fundamental for diagnosis. Though there is no general consensus on therapeutic strategies, prognosis is dependent on time interval between onset and diagnosis. We observed four patients with Boerhaave syndrome with an atypical presentation. The time lapse between acute event and diagnosis was less than 6 hours in two cases, 24 hours in one case and 72 hours in the last. All patients presented abdominal pain at admission, preceeded by vomiting in two cases. In all cases diagnosis was carried out by CT scan. All patients were treated surgically: in one case raffia alone was performed, in two cases raffia was associated with temporal bipolar oesophageal exclusion, one case went through oesophageal resection with delayed reconstruction of digestive continuity. One patient with severe COBP died from post-surgical sepsis. One fistula after cervical recanalisation and another after raffia of the oesophageal lesion were successfully treated with endoscopy. We suggest that an aggressive surgical approach is the best treatment for this rare and often severe disease.

Introduction: Peripancreatic arterial pseudoaneurysm is a rare but potentially lethal complication of severe acute pancreatitis because it can massively bleed into the gastrointestinal tract. Since surgical treatment of such cases has a high mortality, percutaneous angiographic embolization of bleeding artery has recently been advocated as an alternative therapy. We report a case of acute pancreatitis complicated by gastrointestinal hemorrhage due to a ruptured gastroduodenal artery pseudoaneurysm, in which hemostasis was achieved by transcatheter arterial embolization., Clinical Case: A 65-year-old woman was transferred from another hospital with a diagnosis of severe acute biliary pancreatitis, and having had hematemesis. Upper GI endoscopy detected bleeding from the papilla of Vater, and CT showed hemorrhage in a pseudocyst at the pancreatic head. Angiography revealed active bleeding from an arterial pseudoaneurysm of the gastroduodenal artery: hematemesis was considered to result from rupture of the pseudoaneurysm (hemosuccus). Transcatheter arterial embolization was performed by a 2-step procedure, both through the celiac trunk, that was stenotic, and through the superior mesenteric artery, and hemostasis was achieved., Conclusions: We conclude that transcatheter arterial embolization is a minimally invasive and highly effective treatment for acute bleeding from a ruptured pseudoaneurysm secondary to acute pancreatitis.

Radiofrequency ablation is considered safe for inoperable liver neoplasms; with small lesions the rate of success is very high, the local recurrence is marginal and generally suitable for a retreatment. We have little information about the possibility of rapid regrowth of the tumor after a response judged as complete. We present four patients, affected by primary (3 patients) and metastatic (1 patient) uninodular cancer. All the lesions were small, superficial and well suited for surgery, but were treated by radiofrequency ablation elsewhere. The early instrumental evaluations stated a complete result in all the patients. Cancer regrowth was diagnosed at 3, 4, 6 and 12 months after radiofrequency ablation, always starting from the treated lesion. In case 1 the whole right lobe was involved together with a controlateral multinodular recurrence; cases 2 and 3 presented an extensive liver and parietal wall involvement; while in the fourth patient a diffuse biliary colonization was observed. Only 1 patient was suitable for surgery; the others died 6, 2 and 4 months, respectively, after recurrence. Recurrence after radiofrequency ablation may show an aggressive evolution precluding any possibility of cure. Radiofrequency ablation must not be considered a suitable alternative to surgery in patients with a low surgical risk.

The aim of the study was to evaluate the accuracy of our imaging protocol with regard to adrenal masses of cystic nature. Seventy-four adrenal lesions were surgically removed over the period 1998-2002. Of these 7 were diagnosed as cysts or pseudocysts. All the patients were studied by abdominal US, CT and/or MRI. In 2 cases, an adrenal primary malignancy was suspected. The lesions of 2 more patients, radiologically identified as cysts, were interpreted as hepatic echinococcus cyst and mesenteric cyst, respectively; these patients underwent open surgery. In 3 cases an adrenal cystic tumour was correctly diagnosed and a laparoscopic adrenalectomy performed. The histopathological examination of the surgical specimens showed that the preoperative diagnosis failed to ascertain the true nature of the lesion in 4/7 cases (57%). The 2 suspected adrenal carcinomas turned out to be an epithelial cyst and a pseudocyst, respectively; the suspected hepatic echinococcus cyst and the mesenterial cyst were adrenal pseudocysts. Two of the 3 remaining cases were endothelial cysts and the third a pseudocysts. In the presence of adrenal masses of cystic nature, the preoperative diagnosis may easily be inaccurate and adversely influence the surgical approach, especially if a misdiagnosis of primary adrenal malignancy is made.

Background and Aim: The surgical management of IPMT is based upon a preoperative suspicion of malignancy, that is difficult to obtain from the available diagnostic tools., Methods: Telomerase gene expression was investigated by means of hTERT/RT-PCR on total RNA from peripheral blood, tumour and non-tumour pancreatic samples of 2 patients with IPMT., Results: Histological diagnosis was mild-grade dysplasia in the first case and invasive carcinoma in the second. Telomerase expression was undetectable in all the samples derived from the first case. Blood and tumour samples from the second patient were positive for telomerase mRNA expression, while the pancreatic non-tumour specimen was not., Conclusions: The following suggestions are made: 1) the telomerase gene expression seems to be implicated in the malignant evolution of IMPT; 2) the malignant transformation may be limited to a single area of the gland; 3) the presence of invasive carcinoma may be preoperatively suspected by peripheral venous blood sample collection. A possible clinical employment of telomerase gene expression determination in the management of IPMT is thus hypothesized.