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Imipenem serum pharmacokinetics, lung tissue and pericardial fluid concentrations were measured in 10 patients undergoing thoracotomy, following a 1 g intravenous infusion of imipenem-cilastatin. The serum concentrations of imipenem 0.5 h and 4 h after the end of the 40 min infusion were 53.3 (±16.7) and 2.0 (±0.3) mg/l, respectively. The concentration of imipenem in lung tissue at 1 h was lower than in pericardial fluid and at 2.25 h the mean concentration of imipenem in pericardial fluid was 10.5 mg/l, vs. 0.28 mg/kg of lung tissue. Imipenem concentrations in pericardial fluid remained above 5 mg/l, well above the MIC for most pathogens, for 1 h whereas in pericardial fluid the concentration was 10.5 mg/l at 2.25 h. [ABSTRACT FROM PUBLISHER]

The herniation of abdominal viscera in the thorax can immediately follow diaphragmatic rupture or be delayed even years after the injury. The herniated viscera can strangulate; this consequence may lead to a dangerous misdiagnosis which could be lethal for the patient. Radiological procedures, serial chest X-ray studies, CT and MRI scans are mandatory to confirm diagnosis. The insertion of a naso-gastric tube is a very helpful method in ruling out hypertensive pneumothorax in the presence of an air-fluid level in the thorax. We report 2 cases of strangulated traumatic hernia of the diaphragm occurring just a few hours (case 1) and 18 months (case 2) after the trauma. During thoracotomy, a rupture of the left diaphragmatic cupola was demonstrated with herniation of the stomach in case 1, the stomach, spleen and transverse colon in case 2. No postoperative mortality or morbidity were detected.

The diagnosis of traumatic hernia of the diaphragm can be obtained at the time of injury or months-years after the trauma. The Authors report a case of traumatic hernia of the diaphragm, diagnosed 3 years after a blunt thoracic trauma in a 47-year-old man. The patient was admitted to the hospital for a pneumothorax caused by perforation of the herniated colon. He underwent colonic resection and reduction of the herniated viscera but unfortunately he died of septic shock on the 40th postoperative day. Pneumothorax is a very rare complication of traumatic diaphragmatic hernia and few cases are reported in literature. The diagnosis in the delayed phase is not easy since the correlation with the trauma is not always clear.

Aim: Retrospective evaluation of 19 diaphragmatic ruptures due to blunt trauma., Materials and Methods: We collected all patients with thoracic and/or abdominal blunt trauma who were admitted to the department of surgery (Clinica Chirurgica and Chirurgia generale C) from 1970 to 1995. We selected patients with ascertained diaphragmatic rupture., Results: We considered 17 cases of TDR (15 males and 4 females). Mean age was 38 years (range 16-67). Radiologic findings were consistent with TDR in 10 cases out of 17 (58.8%). Right hemidiaphragm was injured in 6 cases (31.6%). 10 patients (52.6%) presented at operation with intrathoracic visceral herniation. 8 patients underwent laparotomy, 7 both laparotomy and thoracotomy, 4 thoracotomy alone. Perioperative mortality was 15.7% (3 patients)., Discussion and Conclusions: The clinical features were complicated by a large number of associated lesions; radiologic diagnosis is comparatively easy if visceral herniation into the thorax is present, repeated radiologic examinations facilitate diagnosis. The surgical access is determined by concomitant associated injuries which may require urgent operation.

Cervical mediastinic emphysema usually does not demand emergency procedures: nevertheless its ethiology must be promptly assessed though his achievement may prove less than easy owing the vague clinical presentation and to the limits imposed by regional topography. Among the possible etiologic factors one should take into account the rare abdominal source too. Indeed the cervical region is connected to the retroperitoneal space through a virtual "visceral space" via the thoracic cavity and some diaphragmatic break-throughs variable in size. The communication allows, in some pathologic conditions, the unopposed circulation of air and fluids. Our interest in the topic is due to the occurrence of a cervical mediastinic emphysema in a patient suffering from a colonic perforation.

We report the results of an investigation conducted in 992 healthy control subjects (854 adults and 138 adolescents) and in 116 subjects with lung cancer (LC) for the purpose of detecting those individuals with a possible genetic predisposition to lung cancer. The test consists of the oral administration of 64 mumol of dextromethorphan (DMP) with collection of urine samples over the following 8-h period and urine assay of the drug (DMP) and its main metabolite, dextrorphan (DOP). The ratio of the urinary concentrations of DMP to those of DOP is called the metabolic ratio (DMP/DOP) and is inversely proportional to the DMP demethylation rate. The pattern of the metabolic ratio (Log10 DMP/DOP) allowed, using a maximum likelihood approach, the identification of three subpopulations in the 854 control subjects (adults): (1) probable homozygous extensive metabolizers with Log10 DMP/DOP < -1.74 (73.1 percent); (2) probable heterozygous intermediate metabolizers with Log10 DMP/DOP in the -1.74 to -0.40 range (22.3 percent); and (3) probable homozygous poor metabolizers with Log10 DMP/DOP > -0.4 (4.6 percent). Most of the patients with LC (89 percent) were probable homozygous extensive metabolizers. As the latter have a cancer risk that is 2.54-fold greater than that of intermediate metabolizers (95 percent confidence interval [CI]: 1.37 to 4.73) and 7.43-fold greater than that of poor metabolizers (95 percent CI: 1.01 to 54.5), their identification by means of the DMP test may be particularly useful for subjects exposed to environmental and occupational carcinogens. The phenotype test used is similar to that of the debrisoquin test, but presents the advantage that DMP is a widely used, harmless drug with a faster and simpler urinary assay procedure.

9 patients (8 males 1 female, middle age 24.3 years, range 20-41) affected by primary mediastinal germ cell tumor were surgically treated in our department. They were 4 seminomas, 2 embryonal carcinomas, 1 malignant teratoma and 2 benign teratomas. Three patients were asymptomatic; cough, dyspnea and chest pain were the most frequently observed symptoms. The staging work-up did not show signs of metastatic disease in the malignant types. Benign teratomas underwent complete excision. In one patient suffering from seminoma radiotherapy and chemotherapy caused complete remission of the disease. In the others cases remission of the neoplasm was obtained by resection and adjuvant therapy in 3 cases, by neoadjuvant treatment and excision of the residual mass in 3 cases. Among the patients suffering from seminoma, 2 are dead at 60 months since initial treatment and 2 are alive at 132 and 120 months respectively. Among the patients with malignant nonseminomatous tumours, 2 are alive at 60 and 36 months and 1 patient is dead at 13 months. Two patients with benign teratoma are alive at 189 and 168 months respectively. At present a multimodality treatment including surgery, radiotherapy and cisplatin-based combination chemotherapy, give the most satisfactory results in the treatment of malignant mediastinal germ cell tumours.

Four cases of iatrogenic rupture of the oesophagus are presented. The site of the lesion was in the cervical tract in 1 case and in the thoracic tract in the other 3 cases. Their etiology was pneumatic endoscopic dilatation for achalasia in 2 cases, endoscopic insertion of a Celestin tube for carcinoma of the thoracic tract of the oesophagus in 1 case, and diagnostic endoscopy in the last one. Instrumental findings were relevant in all cases. All patients underwent surgery. In the patients suffering from achalasia, the rupture was repaired by a patch of the gastric fundus. The patient suffering from carcinoma underwent an oesophageal resection, the one with cervical perforation underwent a mediastinal drainage. There were no deaths or considerable post operating complications. In a patient suffering from achalasia gastro-oesophageal reflux was demonstrated after some months following the operation.

Thoracoplastic operations had ruled the field in the past as treatment of choice in the surgical antituberculous collapse therapy; they have had a notable revival during the last years as an efficient therapeutic modality in the treatment of chronic empyemas of the most various etiologies. They are thoracoplasties done with particular modalities, imposing, setting out case by case to suppress the infected pleural space. It is usually joined with a thoracotomy and it permits also the execution of other surgical intrathoracic manoeuvres such as decortications, treatment of fistulas, myoplasties. Situations such as chronic empyemas, without any solution before, have found a brilliant solution by the use of this operation.

27 patients suffering from carcinoid of the lung (18 females and 9 males, middle age 52 years, range 26-68) underwent surgery in our department. The neoplasms were located at the pulmonary hilum in 21 cases. The diagnosis was occasional in 6 cases, cough (51.8%) and recurrent bronchitis (37%) were the most frequent symptoms. No instances of carcinoid syndrome were detected. Preoperative staging ruled out pathologic mediastinal lymph nodes or hematogenous metastases. 26 patients underwent complete excision of the neoplasm (11 lobectomies, 9 pneumonectomies, 4 bilobectomies, 1 segmental resection, 1 bronchial wedge resection). Histologically, 4 cases were categorized as atypical carcinoids. Two patients died within 1 year, one suffering from atypical carcinoid because of disease progression, and an other one (suffering from atypical carcinoid) who underwent only at exploratory thoracotomy followed by chemotherapy. A patient suffering from typical carcinoid died within 1.5 years because of gallbladder carcinoma. From our experience and from the literature review it appears that carcinoids has to be considered as malignant neoplasms and treated according to.

A 34-year-old man and a 71-year-old woman underwent radical removal of mediastinally sited chondrosarcoma, presumably originating in the periosteum of the vertebral body. The man (with mesenchymal chondrosarcoma) died of remote metastasis 6 years postoperatively. The woman (poorly differentiated chondrosarcoma, grade 2-3) is still alive 2 years after the operation.

A 44-year-old male affected by mesenchymoma of the mediastinum was treated surgically. The neoplasm, localized in the postero-inferior mediastinum with prevalent development to the left, was found to consist of adipose, leiomuscular and myxoid tissue. The patient was asymptomatic. Complete removal of the neoplasm proved possible, and one year after surgery no signs of recurrence were present. Few cases of mediastinal mesenchymoma have been reported.

The long-term fate of patients treated surgically for carcinoma of the lung is not well known. In a careful review of the literature the authors found only nine papers with a postoperative followup of at least 10 years; the mean survival was 16,3% of patients so treated. Factors making for a good long-term prognosis include small initial tumor size, absence of mediastinal lymph node invasion, a favorable histologica type, and the type of surgery performed (partial exeresis). Translated into TNM code, this means that the best candidates for prolonged survival are patients with lung carcinoma of the squamous cell type, stage I, treated by limited lung exeresis.

The Authors describe one case of pulmonary oncocytoma successfully treated by ablative surgery. The patient was a man aged 38 with an asymptomatic nodule, about the size of a walnut, in his right lower lobe. The whole right lower lobe was removes surgically, and histological examination resulted i na diagnosis of pulmonary oncocytoma. In the discussion, the authors point out that this type of malignancy is extremely rare, with only 7 cases reported in the more recent literature to the best of their knowledge.

The authors report on a case of granular cell tumour localized in the lower third of the thoracic oesophagus. The patient, a 49-year-old male, suffering from symptoms of dysphagia over the previous few months, was treated surgically by thoracotomy enucleation of the neoplasm. Despite its slow growth, this rare benign neoplasm, which probably originates in Schwann's sheath, is a candidate for endoscopic or surgical resection.

The Authors show 10 cases of traumatic disruption of diaphragm, subsequent to close or open trauma, all subjected to urgency operation. They discuss the problems concerning diagnosis and surgical tactics, and point out the frequency of visceral and osseous associated lesions and their importance in conditioning prognosis.

The Authors face the diagnostic and therapeutical problems involved in the tardy recognition of diaphragmatic breakages. On the basis of two clinical cases observed, they emphasize the relative frequency of this lesion, the variability of the clinical pictures, the limits of the clinical and radiological diagnostics, the utmost seriousness of the complications. They face the problem of the choice of the surgical way of approach and the techniques for repairing the diaphragmatic lacerations.

A case of mediastinal Castleman's disease is reported. A 46-year-old male patient presented a mass 9 X 5.5 X 3 cm wide, located in the supero-posterior mediastinum. The mass was removed by right thoracotomy. On histologic examination it was diagnosed as Castleman's disease of hyaline vascular type.

Nine cases of bronchial carcinoids treated by surgery are reported. Six of them were females and three males. Their ages ranged from 37 to 68 years (median 52.8 years). Lobectomy was carried out in four instances (bilobectomy in one) and pneumonectomy in three. Based on preoperative histology two conservative operations were performed: one patient underwent segmental resection of the right upper lobe for a peripheral carcinoid and the other sleeve resection of the bronchus. The operations were complicated only in one case in which a broncho-pleural fistula appeared postoperatively and was successfully treated by thorachoplasty. There was no postoperative death. The only patient with an atypical carcinoid died one year after pneumonectomy. The other eight patients, with typical carcinoids are alive and without recurrent disease at 6 months to 8 years from surgery. Lymph node and parenchymal infiltration, observed in 3 patients, were not fatal. It is concluded that carcinoids should now be considered malignancies; typical carcinoids carry a more favorable prognosis than atypical ones and can be managed by conservative operations without affecting the survival rate. The spreading of the tumor to lymph nodes and surrounding tissues was not associated with an increased mortality in the reported cases.

The authors describe one case of lipoid granuloma of the lung in a patient with PARKINSON'S disease. The cause of this pulmonary sequel is probably to be found in the alteration of the mechanism of deglutition, typical of PARKINSON'S disease, with aspiration bronchopneumonia and subsequent evolution to granuloma formation. In the case presented (a man of 64) the X-ray picture resembled the irregular mass opacities and bronchial amputations characteristically associated with cancer of the lung. As the actual anatomical extent of the process exceeded the limits indicated by radiological examination, the whole left lung was removed at surgery; histological studies, however, revealed the essentially benign nature of the lesion. The patient was discharged in due course of time as surgically cured. There was no major deterioration of his neurological status either at discharge time or at later rechecks.

In this paper the Authors describe two cases of carcinoma of the lung with cavitary aspects that came under their observation. There are various hypotheses on the formation of such cavities: it is possible that the neoplastic cells may have a growth trend in a centrifugal direction, or that the cavity is due to a necroic-colliquaive process of the mass itself or to extensive phenomena of autophagism. In other cases the neoplastic cells carpet already existing air cysts, giving the appearance of thin wall cavitation. It is precisely this type of cavitation that poses problems of differential diagnosis. In fact, when other instrumental investigations such as bronchoscopy or needle biopsy, always combined with cytology of the sputum, are not decisive, a relatively certain diagnosis can be obtained only by observing the evolution of the picture for some time, as was the case in the patients referred to above.

Thirteen cases of congenital anomalies of the bile passages are described, as observed in the Verona Surgical Clinic during the period 1970-75, out of a total of 908 operations on the biliary passages and hence with a frequency of about 1.6%. They consisted of one case each of agenesis of the gall-bladder, septal gall-bladder, clepsydra gall-bladder, Hartmann's sac, diverticulum of the gall-bladder, outlet of the right hepatic in gall-bladder, outlet of cystic duct in third duodenal portion, accessory cholecystobiliary ducts, three cases of outlet of cystic duct in right hepatic duct, and two cases of common choledocho-wirsunghian canal. After a brief description of the individual types of anomaly, the main data in the relevant literature are considered, with a review of the semeiological and therapeutic aspects of the most frequent anomalies.

A multivaried statistic process, the linear discriminant analysis, applied to VEMS, CV, I.T., FEF 25-75, pH, PaO2, PaCO2, was used by the authors to foresee, in 42 patients suffering from bronchogenous carcinoma, the arising or absence of respiratory complications after operation. With such method, the falsely positive or negative previsions, resulted to be 13 with a total percentage of error as high as 30%. These results suggest that, even when elaborated through the multivaried analysis, the parameters studied do not allow to adequately discriminate the patients who would develop, after operation, bronchopulmonary complications from those who would be exent from them.

The Authors show a case of a 68 year old woman underwent a successful operation for spontaneous stomach heavage. The linear solution of continuity, 5-6 cms long, was sutured on the small gastric curve. The treatment consisted in suturing the lesion and performing a decompressive gastrostomy.

The Authors study the pre- and post-operative nutritional treatment of the patients suffering from oesophageal stenosis, principally neoplastic, waiting to undergo the radical operation. Although the compensation of the nutritional situation of these patients through the enteral and parenteral nutrition results difficult to be effected, the results encourage to apply this clinical practice everywhere a demolitive operation, always long, heavy, and burdened by a high morbidity and mortality, is foreseen.

The Angelchik prosthesis was used in 26 cases of gastroesophageal reflux disease resistant to medical therapy. The operations were crowned with success in 24 cases out of 26 (92.3%), with complete disappearance of reflux. The procedure failed in two cases: the prosthesis was removed in one case due to postoperative acute haemorrhagic gastritis with a subsequent positive outcome; in this patient the Angelchik ring had been removed as a precaution. Failure in the second case, a patient with oesophageal stenosis and a short oesophagus, was due to mediastinal migration of the prosthesis. In this latter case, a successful duodenal bypass was created with antrectomy and a long Roux-en-Y anastomosis. The only intraoperative complication in the patient sample was a splenectomy for rupture of the splenic capsule. Postoperative complications not directly related to the prosthesis were perforation of a duodenal ulcer not diagnosed preoperatively and treated with raphia without impairing the functional efficacy of the ring, one case of pulmonary embolism and one case of cardiac infarction, all resolved with medical therapy. In all, the prostheses were removed in 3 cases out of 26 (11.5%). In addition to the two cases already described, the prosthesis was removed in one patient one year after the operation at the patient's specific request for "psychological" reasons. Migration of the prosthesis occurred in four cases of severe oesophageal stenosis with a short oesophagus, in three of which the prosthesis functioned perfectly even in the intrathoracic site. At follow-up examinations there was radiological disappearance of the hiatal hernia in 20 cases out of 25. In one case there was no hernia even before the operation, and in four cases there was a short oesophagus with severe oesophagitis. Owing to the very easy performance of the operation together with its unquestionable antireflux efficacy, in our opinion three reliable indications emerge, namely: (i) in elderly patients at high surgical risk; (ii) in obese, brachytypical patients; and (iii) in the presence of severe oesophagitis, even with a short oesophagus.

The authors report three cases of endobronchial lipoma, and study the etiopathogenesis and the main clinical and therapeutical aspects of such neoplasiae. Both diagnosis and treatment should be timely, in order to prevent irreversible damages to lung parenchyma, compelling surgeons to mutilating operations making the function of the apparatus heavier.

Ten patients (9 males and 1 female; mean age: 44.8 yrs) with bullous lung disease were treated. Frequent patient-history findings were smoking and spontaneous pneumothorax. Nine cases were treated surgically either by bullectomy or atypical resection. In one case, an attempt at endobullous aspiration failed owing to the patient's very poor general condition. Among the postoperative complications in three cases we observed difficult pulmonary re-expansion and infection of the surgical wound with consequent pleural empyema in another.