Vascular malformations: the need for a multidisciplinary treatment. Considerations on a clinical case

The case reported here is a paradigm of a complex vascular malformation with a therapeutic approach which involved both vascular radiology and surgery. The case came to our attention in 1999 and consisted in a tumefaction of the left gluteal region in a 14-year-old female. The lesion had previously been evaluated by ultrasonography and magnetic resonance imaging. The lesion was described as a dysplastic malformation with a high vascular factor. After angiography, we decided to embolize the mass. A second embolization also yielded no result, and therefore we decided to remove the dysplasia surgically. The dysplasia, however, was resolved only in 2001 after a third embolization. Because of the multiple types of symptoms, a multidisciplinary approach is required to obtain both a correct classification and treatment of the vascular malformations.     

Considerations regarding a case of leiomyoma of the urinary bladder

In spite of its rarity, leiomyoma of the bladder deserves to be better known as its diagnosis is not always obvious, depending as it does mainly on urography confirmed by anatomo-pathological examination, and particularly because its treatment is simple and the prognosis always favourable, a fact worthy of note in dealing with a tumour of the bladder.     

Surgical therapy of goiter plunged in the mediastinum. Considerations regarding our experience with 165 patients

Thyroid goiter is called plunged when, starting from the cervical region, it grows in the anterior-superior mediastinum to a depth of more than 2 cm. The highest frequency (48.44%) is evident in the age range from 60 to 70. From February 2002 to August 2005, performed 133 (80.6%) near total thyroidectomies, 26 total thyroidectomies (15.7%), 4 lobectomies (2.4%) and 2 (1.2%) totalisations of recurrences for plunged goiter in the 7th Division of General Surgery of the Second University of Naples. The goiters were classified using Lamke and Ferrante's topographical classification, which distinguishes between prevascular and retrovascular cervico-mediastinal goiters depending on the position assumed by the part plunged in the mediastinum in relation to the vascular layer of the epiaortic trunks. Retrovascular goiters are further subdivided into: pre-tracheal, laterovisceral and retrovisceral goiters depending on the relation to the trachea, oesophagus and epiaortic trunks. Among the patients who underwent near total thyroidectomy, there were 3 cases of permanent hypocalcaemia, 7 (7.2%) of temporary hypocalcaemia and only 1 (0.6%) monolateral temporary recurrent nerve lesion. Among those who underwent total thyroidectomy there was 1 case (0.6%) of temporary hypocalcaemia, and 1 (0.6%) of permanent hypocalcaemia. Postoperatively we also observed 3 cases (1.8%) of haemorrhage and 3 (1.8%) transfers to intensive care for respiratory insufficiency; 1 of these patients died 25 days after the operation. Ligature of the inferior and superior thyroid artery near the thyroid capsule protects the vascularisation of the parathyroid glands as well as the recurrent nerve and its division branches.     

Considerations on surgical treatment for elderly patients with intracranial aneurysms

BACKGROUND: The purpose of this study was to investigate why elderly patients have poorer outcomes and to determine indications for surgery in elderly patients. METHODS: One hundred fifty-four patients with intracranial aneurysms admitted to the Department of Neurosurgery, Showa University School of Medicine, from 1990 through 1996 were reviewed. The patients were classified by age into three groups (young group, middle-aged group, elderly group). RESULTS: Forty-four patients (28.6%) were in the elderly group (mean age, 73 years). No difference in outcome was found between middle-aged and elderly patients if patients were stratified according to clinical grade. In addition, the main factors related to unfavorable outcomes in elderly patients were infection, organ failure, aneurysm rerupture before operation, and delayed ischemic deterioration. Elderly patients were more likely to experience rebleeding and have poor outcomes. CONCLUSIONS: Our results suggest that elderly patients should have early surgery. Furthermore, we found that the presence of hypertension or atherosclerosis had no significant effect on outcome. We conclude that early surgical treatment of aneurysms is indicated for elderly patients with good clinical grades in the absence of organ failure.     

Treatment of esophageal perforations. Considerations on a clinical case

The Authors describe a rare case of esophageal perforation occurred after Transoesophageal echocardiography in 68 years old patient and review the literature relating to the causes and management of this pathology. Transoesophageal echocardiography, which is a semi-invasive investigation increasingly used in cardiology and cardiac surgery and intensive care units, is a rare though extremely dangerous cause of such complications. Perforation of the esophagus continues to present a formidable diagnostic and therapeutic challenge. The diagnosis depends on a high degree of suspicion and on the recognition of clinical features and is confirmed by contrast esophagography. The outcome after esophageal perforation depends on the location of the injury, the presence or otherwise of concomitant esophageal disease and the time elapsing between the injury and inititian of treatment. Reinforced primary repair of the perforation is the procedure most frequently employed and preferred for the surgical management of the esophageal perforation. In the case reported here, early diagnosis and prompt surgical treatment consisting in primary repair of the esophageal perforation contributed to the successful management of this serious pathology.     

Abdominal actinomycosis and retroperitoneal fibrosis. Considerations on a clinical case

Abdominal actinomycosis is a rare disease which often resembles an acute suppurative infection or/and abdominal tumour causing abscesses, fistulas and massive fibrosis. The preoperative diagnosis is difficult and surgical exploration is always needed because of major involvement of visceral and retroperitoneal structures. The disease can be diagnosed with certainty only on the basis of findings of bacterial colonies in histopathologic sections and typical sulphur grains in secretions from fistulas. The authors describe a case of abdominal actinomycosis involving the caecum and right colon, causing extensive retroperitoneal fibrosis and a fistula tract with an external cutaneous orifice at the level of the right iliac crest. These features resembled an acute appendicitis at first, and several surgical explorations were required before a correct diagnosis could be achieved. Abdominal actinomycosis can be treated by simple administration of antibiotics. With a correct diagnosis, medical therapy alone has proved effective in a substantial percentage of patients, thus avoiding the need for surgery, if important visceral or retroperitoneal structures are not involved. Abdominal actinomycosis always requires a careful differential diagnosis and must be considered in patients presenting abdominal tumours associated with abscesses and/or fistulas since early and efficient medical therapy, along with surgical intervention, where necessary, can lead to definitive recovery. Useful diagnostic tools are abdominal CT and selective FNAB.     

A case of retroperitoneal leiomyosarcoma. Considerations]

A case of retroperitoneal leiomyosarcoma is reported. The retroperitoneal localization is quite unusual and early diagnosis is really difficult. Only operation can offer any chance for cure of this neoplasm and radiotherapy and chemotherapy can be very useful. Tumor size and location are the major prognostic factors.     

Anesthesiologic management for lower pulmonary lobectomy intervention in patients with heart transplant. A clinical case

The Authors describe the case of a patient who had undergone human allograft cardiac transplant seven months before inferior pulmonary lobectomy for neoplasia. The pulmonary neoplasia had been revealed by X-rays during the periodic check-up examinations. Because of the high risk of infection following corticosteroid and immunosuppressive therapy, sterile equipment for invasive monitoring and oro-tracheal intubation has been used. The denervated heart presents peculiar haemodynamic and pharmacological aspects that the anaesthetist must pay attention to in the conduction of a general anaesthesia; moreover, arrhythmias are common in the recently transplanted heart. Anaesthesia has been induced and maintained by an association propofol-fentanyl that showed a good cardiocirculatory stability; neither arrhythmias have happened, nor the need for drugs different from those of anaesthesia and resuscitation have occurred.     

Considerations in the treatment of cerebral palsy patients with spinal deformities

The natural history of spinal deformities in the cerebral palsy patient is different than that in the idiopathic patient. Consequently, the approach to the patient with cerebral palsy and the surgical decision-making are different from that in the idiopathic patient. The present article gives the UTMB approach to the treatment of the cerebral palsy patient and the unique considerations that must be taken into account when treating these patients. Specific references are made to the use of L-rod instrumentation to stabilize the spinal deformity in the cerebral palsy patient.     

Poisoning with shoe dye. A clinical case

The paper reports the case of a young male which was severely poisoned by anilyne shoe black. After a few hours, he was in a semicomatose state, accompanied by "very dark" arterial blood gases with oxygen tension in excess of 100 mmHg. Following the administration of intravenous methylene blue (2 mg/kg), methemoglobin was reduced to hemoglobin and the level of consciousness immediately improved.     

Nivolumab treatment for advanced renal cell carcinoma: Considerations for clinical practice

Background

Nivolumab is an important new therapy option for patients with advanced renal cell carcinoma, and has a different mechanism of action compared with vascular endothelial growth factor -targeted therapies. It is a programmed death 1 immune checkpoint inhibitor antibody with response patterns, efficacy, and safety profiles that differ from those of conventional antiangiogenic or mammalian target of rapamycin inhibition therapy.

Photodynamic inactivation of microorganisms present on complete dentures. A clinical investigation

The aim of this study was to evaluate the effectiveness of photodynamic therapy (PDT) for the disinfection of complete dentures. Biofilm samples were collected from dentures of 60 denture users who were randomly divided into four experimental groups (n?=?15 each): subjects whose maxillary dentures were sprayed with 50 and 100 mg/l of Photogem® suspension (groups P50S and P100S) and patients whose maxillary dentures were treated with 50 and 100 mg/l of Photogem® gel (groups P50G and P100G). Dentures with photosensitizers were left in the dark for 30 min (pre-irradiation time) and then irradiated with blue LED light at 37.5 J/cm² (26 min). Denture samples were taken with sterile cotton swab before (left side surfaces) and after (right side surfaces) PDT. All microbial material was diluted and plated on selective media for Candida spp., Staphylococcus mutans spp., streptococci and a non-selective media. After incubation (48 h/37°C), the number of colony-forming units (cfu/ml) was counted. Microorganisms grown on selective media were identified using biochemical methods before and after PDT. The data were submitted to McNemar and Kruskal–Wallis tests (α?=?0.05). No growth after PDT was observed in 60, 53, 47, and 40% of dentures from P100G, P50G, P100S, and P50S groups, respectively. When evidence of microorganisms’ growth was observed, PDT regimens eliminated over 90% of microorganisms on dentures. This clinical study showed that PDT was effective for disinfecting dentures.     

Combined treatment with indomethacin and low-dose heparin after total hip replacement. A double-blind placebo-controlled clinical trial

We studied the safety of combining the postoperative use of a non-steroidal anti-inflammatory drug with low-dose heparin. In a double-blind, placebo-controlled clinical trial we reviewed the complications in 235 patients after total hip replacement, all treated with low-dose heparin and either indomethacin or a placebo. The incidence and type of complications in the two groups were nearly equal; indomethacin-treated patients had no increase in complications related to bleeding. Postoperative bleeding into drains was marginally greater in the indomethacin group, although the difference was not statistically significant. We conclude that treatment with indomethacin and low-dose heparin after hip replacement does not significantly increase the bleeding or other complications. We also found that patients receiving indomethacin were mobilised an average of one day before those on placebo.