Modified Subtotal Cholecystectomy: Results of a Laparotomy Procedure During the Laparoscopic Era

Background   Laparoscopic cholecystectomy is now indisputably the gold standard for managing most gallbladder diseases. However, subversion of the Calot triangle anatomy cannot always be managed by laparoscopy and often requires a laparotomy conversion. This report discusses our patients treated with our personal technique. Methods  Patients undergoing subtotal cholecystectomy performed by the same surgeon with a personal technique from January 1999 to December 2007 were considered for the present study. Sex, age, symptoms, co-morbidities, diagnostic modality, time between hospitalization and surgery, length of postsurgical hospitalization, morbidity and mortality, and follow-up were assessed. Results  Four men and six women, aged 23 to 88 years, were included. Every patient had symptoms of acute cholecystitis. Four patients had had symptoms for an average of 2.5 days and six for an average of 5.1 h. All patients were studied by ultrasonography, and seven underwent computed tomography. The operation was performed within 48 h in all patients. The average hospital stay from surgery to discharge was different for patients who underwent primary open cholecystectomy (10 days, range 5–16 days) and those having a conversion after a laparoscopic attempt (7.8 days, range 4–16 days). During the postoperative period only one patient presented a self-limiting biliary leak. No postoperative mortality occurred. At follow-up, any recurrences of stone in the biliary tract or newly formed pouch were recorded. Conclusions  The results suggest that this new approach can be considered effective in every instance of subversion of the normal anatomy of Calot’s triangle.     

Case report: Leishmaniasis of the upper lip.

We report a case of leishmaniasis localized to the upper lip in a 77-year-old Italian man. The disease was characterized by a severe swelling which involved the right side of the upper lip. The swelling was slightly erythematous with crusts and scaling. Consistency was parenchymatous-hard. The lesion was asymptomatic. Histopathologic examination showed an inflammatory infiltrate consisting of lymphocytes, histiocytes, and plasma cells. Several Leishmania spp. amastigotes were observed in the cytoplasm of macrophages. Cultural examination on Novy-MacNeal-Nicolle medium was positive for Leishmania spp. Polymerase chain reaction was positive for Leishmania infantum. The patient was treated with i.m. N-methylglucamine antimonate, with complete remission in approximately 6 weeks. During follow-up of 9 months, no relapses were observed.     

Frequent diagnostic errors in cardiac PET/CT due to misregistration of CT attenuation and emission PET images: a definitive analysis of causes, consequences, and corrections.

Cardiac PET combined with CT is rapidly expanding despite artifactual defects and false-positive results due to misregistration of PET and CT attenuation correction data-the frequency, cause, and correction of which remain undetermined. METHODS: Two hundred fifty-nine consecutive patients underwent diagnostic rest-dipyridamole myocardial perfusion PET/CT using (82)Rb, a 16-slice PET/CT scanner, helical CT attenuation correction with breathing and also at end-expiratory breath-hold, and averaged cine CT data during breathing. Misregistration on superimposed PET/CT fusion images was objectively measured in millimeters and correlated with associated quantitative size and severity of PET defects. Misregistration artifacts were defined as PET defects with corresponding misregistration on helical CT-PET fusion images that resolved after correct coregistration using a repeat CT scan, cine CT averaged attenuation during normal breathing, or shifted cine CT data that coregistered with PET data. RESULTS: Misregistration of standard helical CT PET images caused artifactual PET defects in 103 of 259 (40%) patients that were moderate to severe in 59 (23%) (P = 0.0000) and quantitatively normalized on cine or shifted cine CT PET (P = 0.0000). Quantitative misregistration was a powerful predictor of artifact size and severity (P = 0.0000), particularly for transaxial misregistration >6 mm occurring in anterior or lateral areas in 76%, in inferior areas in 16%, and at the apex in 8% of 103 artifactual defects. CONCLUSION: Misregistration of helical CT attenuation and PET emission images causes artifactual defects with false-positive results in 40% of patients that normalize on cine CT PET using averaged CT attenuation data during normal breathing comparable to normal breathing during PET emission scanning and shifting cine CT images to coregister visually with PET.     

术中射频消融后病灶刮除治疗脊柱转移瘤

目的:探讨术中射频消融(RFA)后再行病灶刮除术治疗脊柱转移瘤的可行性及疗效.方法:2004年～2006年,对11例脊柱转移瘤患者术中实施RFA后再行病灶刮除术,将FRA前后病灶标本进行光镜和电镜病理检查,随访患者疼痛缓解情况及肿瘤复发情况.结果:术中未出现脊髓和神经根损伤,RFA后瘤组织固缩,刮除顺利,出血量350～3800ml,平均1024.5ml.全部病例得到6个月以上随访,平均9.8个月,全部患者生存期超过6个月,VAS评分术前平均5.8分,术后6个月时平均1.9分.1例出现局部肿瘤复发.RFA前的标本光、电镜检查均未见肿瘤组织坏死.RFA后光镜检查3例无明显坏死,9例肿瘤细胞完全坏死:电镜检查10例肿瘤细胞完全坏死,1例肿瘤细胞部分坏死,1例无明显坏死.结论:术中RFA后再行病灶刮除治疗脊柱转移瘤安全可行,有利于肿瘤的刮除,减少局部复发的风险.     

Effects of atorvastatin on arterial endothelial function in coronary bypass surgery

Objective: Endothelial dysfunction represents a critical early component of organ injury following cardiopulmonary bypass. Recent studies demonstrate that the treatment with atorvastatin is associated with a significant improvement of endothelial function independently of its efficacy on cholesterol levels. Therefore, we investigated the effects of preoperative atorvastatin treatment on endothelium function after coronary surgery. Methods: Forty patients undergoing coronary surgery were randomized to treatment with atorvastatin (20 mg/die; N = 20) or placebo (N = 20) 3 weeks before surgery. Twenty normal patients served as control group. The flow-mediated dilations (FMD) of the brachial artery after both reactive hyperemia (endothelium dependent) and nitroglycerin administration (endothelium independent) were evaluated at baseline, at 48 h, and 5 days postoperatively. Results: At baseline, the endothelium-dependent FMD was significantly attenuated in coronary versus normal patients (normal 10.3 ± 1.8% vs coronary 4.1 ± 1.6%, p < 0.01). At 48 h postoperatively all patients exhibited a reduced FMD compared with baseline values: the endothelium-dependent dilatation showed a drop of 60.1 + 15% in the patients of the placebo group compared with 45.8 + 16.6% (p < 0.05) those in the atorvastatin group. At the univariate analysis, no significant correlation was found between serum levels of either total cholesterol or HDL cholesterol and FMD. The nitroglycerin-induced dilation was not significantly influenced by extracorporeal circulation as well as by atorvastatin treatment. Conclusions: The endothelial dysfunction following cardiopulmonary bypass is improved by the treatment with atorvastatin, by a mechanism unrelated to the drug efficacy of controlling serum cholesterol levels.     

Cholinergic balance in dementia with Lewy bodies: reversible worsening of Parkinsonism at rivastigmine dosage modulation

We describe a patient with probable dementia with Lewy bodies (DLB) whose Parkinsonism worsened after administration of rivastigmine within the therapeutic dose range. Some extrapyramidal signs (EPS) then reversed to pre-treatment level after rivastigmine dose reduction. We draw attention to the need of EPS monitoring during titration of cholinesterase inhibitors in patients with DLB. This is the first report to our knowledge of iatrogenic worsening of Parkinsonism which was successfully managed by dose reduction.

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Sommario Si descrive il caso di un paziente affetto da Demenza a corpi di Lewy (Dementia with Lewy Bodies, DLB) probabile, in cui si è assistito ad un peggioramento del parkinsonismo dopo somministrazione di rivastigmina a dosi terapeutiche. Alcuni segni extrapiramidali sono regrediti al livello pre-trattamento con una riduzione posologica di rivastigmina. Si sottolinea la necessità di un monitoraggio dei segni extrapiramidali durante la titolazione della terapia con inibitori dell’acetilcolinesterasi cerebrale in pazienti con DLB. Questo è il primo caso descritto, a nostra conoscenza, di un peggioramento iatrogeno di parkinsonismo efficacemente gestito con una riduzione posologica della terapia con rivastigmina.

     

Early reconstruction of the abdominal wall in giant omphalocele.

Omphalocele is the most common congenital defect of the abdominal wall. Mortality rate is between 20 and 70% and early closure of the abdominal wall, within 10 days of life, is vital to the successful outcome of the surgical treatment. The authors describe the use of two bipedicled flaps of abdominal skin to correct the defect of the midline as soon as the reduction of all viscera has been accomplished.     

MR findings in pituitary haemosiderosis

A girl with Diamond-Blackfan syndrome and hypopituitarism was suspected of having pituitary haemosiderosis because of the clinical picture and the long history of blood transfusions. On T1-weighted MR images the pituitary exhibited a markedly hypointense anterior lobe (mimicking the empty sella), suggesting iron deposition, while on T2W MRI the low signal of the pituitary was surrounded by the high signal of the CSF. MR may be considered the examination of choice for detecting iron overload in the pituitary. Received: 10 November 1997 Accepted: 21 November 1997     

Echo-guided percutaneous puncture: a safe and valuable therapeutic tool for amebic liver abscess

To clarify the therapeutic role of echo-guided percutaneous puncture (EPP) in management of amebic liver abscess, 20 patients (24 abscesses) received metronidazole plus EPP. Fluid was aspirated through Chiba needles under real-time sonographic guidance so as to reduce cavity size to less than 3 cm. Not more than two EPPs were necessary in the majority of cases and no complication followed the procedure. This scheme resulted in a shortening of time of both hospitalization (less than or equal to 20 days) and liver lesion healing as assessed by ultrasound (less than or equal to 4 months). It is concluded that EPP is a valuable and safe therapeutic tool for hepatic amebic abscess.