Primary retroperitoneal abscess extending to the calf

A 77-year-old man with diabetes mellitus presented with a 2-month history of lumbago radiating to the right lower limb as well as high fever spikes. Physical examination revealed a distended abdomen with right lower quadrant tenderness. A computed tomographic scan of the abdomen revealed a large right retroperitoneal cavity containing an air-fluid level that was consistent with a gas-producing abscess. The patient began receiving intravenous antibiotics, but fever and abdominal pain persisted and a large, fluctuating, tender swelling appeared on the medial aspect of his right thigh and right calf. The patient underwent surgical exploration: a right lateral abdominal incision was performed, and the pus collection in retroperitoneal space was completely evacuated. We also made 3 separate incisions on the medial aspect of the right thigh and 1 incision on the upper calf, resulting in the drainage of pus. The patient made a slow but steady recovery.     

Gastrointestinal stromal tumours and acute haemorrhage: description of four cases

Gastrointestinal stromal tumours are uncommon neoplasias arising from stromal tissue of the intestinal wall. Discovery of the protooncogene c-kit and the presence of the CD117 protein on the neoplastic cells of the majority of gastrointestinal stromal tumours may suggest their possible origin from Cajal cells. The clinical symptoms of gastrointestinal stromal tumours are related to tumour size and are generally aspecific: acute or chronic bleeding, abdominal pain and palpable mass are some of the most common signs. Digestive endoscopy or US-endoscopy for gastroduodenal tumours, ultrasonography and CT scans are the procedures of choice in the evaluation of the location, size, invasion of adjacent organs and metastases. Surgery is the only curative therapy for gastrointestinal stromal tumours. Chemotherapy or radiotherapy are of no use for metastatic disease, but good results are obtained with ST1571 in advanced disease. In the absence of metastases, it is quite difficult to distinguish between benign and malignant lesions. The most important prognostic factors are number of mitoses and tumour size. We report here on 4 consecutive cases of gastrointestinal tumours, 2 gastric and 2 duodenal, which presented with acute gastrointestinal bleeding.     

Does the Roux-en-Y-stasis syndrome still exist?

Roux-en-Y-stasis syndrome (RYS) is a complication of subtotal gastrectomy characterized by delayed gastric emptying and vomiting. The aim of the study was to analyze RYS frequency with particular attention to diagnosis and therapy. From November 1996 to June 2004, we performed 147 distal gastrectomies with 5 cases of RYS: mean age 78 years, 3 male, 2 female, 4 adenocarcinoma and 1 GIST. Among the 5 cases, RYS was due to different causes: it was functional in 2 cases (with difficult gastric emptying due to a long gastric remnant in one patient, while the other was associated with duodenal fistula) and healed through medical therapy in both; a third patient had an edematous stenosis of the gastrojejunal anastomosis treated with medical therapy and the remaining 2 patients had jejunal obstruction due to adherences and required reoperations. RYS is a rare complication of subtotal gastrectomy determined by different causes. Recognizing the cause is very important for choice of appropriate therapy.     

Two-year survival after multiple bilateral lung metastasectomies for cranial meningioma

The lung represents a common site of metastases from extrathoracic malignancies, and several studies have strengthened the evidence that complete resection of pulmonary metastases is a useful therapeutic treatment for prolonged survival in selected patients. However, fewer data are available in the literature regarding the role of lung metastasectomy in rare malignancy. We present a case of extensive bilateral lung metastases due to recurrent cranial meningioma, which was successfully treated by aggressive, staged metastasectomies.     

Is Contralateral Carotid Artery Occlusion a Risk Factor for Carotid Endarterectomy?

Occlusion of the contralateral internal carotid artery (ICA) is considered to have a significant impact on the outcome of carotid endarterectomy (CEA). The purpose of this study was to review one center’s experience concerning CEA opposite an occluded ICA, to see whether results differed from those obtained in patients with patent contralateral ICA in terms of relevant neurologic complication rate (RNCR, fatal + disabling stroke), stroke-free rate, and survival rate. From January 1997 to December 2002, 1,381 patients underwent a total of 1,445 CEAs at the Department of Vascular Surgery of Padua University. Patients were divided into two groups: group A included 144 patients with occlusion of the contralateral ICA and group B consisted of 1,237 patients with a patent contralateral ICA. There was no postoperative mortality in patients of group A, while in group B, two patients died as a result of myocardial infarction and cardiac failure and one died as a direct result of perioperative stroke. Postoperative disabling strokes occurred in one (0.7%) patient in group A and 10 (0.8%) patients in group B (p > 0.5). At 72 months, there were no statistical differences between the two groups in terms of RNCR, stroke-free rate, and late death. Our results show that contralateral carotid occlusion does not reduce the safety of CEA. The efficacy in terms of RNCR, stroke-free rate, and late survival is no different in patients with contralateral carotid occlusion.     

Transperitoneal versus retroperitoneal laparoscopic partial nephrectomy: patient selection and perioperative outcomes

PURPOSE: We compared the results of transperitoneal (T) and retroperitoneal (R) approaches to laparoscopic partial nephrectomy (LPN) in regard to perioperative outcomes and technical considerations, thereby, identifying patient selection guidelines for each approach. MATERIALS AND METHODS: The choice of approach was dictated primarily by tumor location, that is TLPN for anterior or lateral lesions and RLPN for posterior or posterolateral lesions. The approaches differed primarily by the hilar control technique. During TLPN en bloc hilar control was achieved with a Satinsky clamp, while during RLPN individual vessel control was obtained with bulldog clamps. RESULTS: In a 3-year period 100 TLPNs and 63 RLPNs were performed for renal tumor. Of posterior tumors 77% were managed by RLPN, whereas 97% of anterior tumors were managed by TLPN. TLPN was associated with significantly larger tumors (3.2 vs 2.5 cm, p <0.001), more caliceal suture repairs (79% vs 57%, p = 0.004), longer ischemia time (31 vs 28 minutes, p = 0.04), longer operative time (3.5 vs 2.9 hours, p <0.001) and longer hospital stay (2.9 vs 2.2 days, p <0.01) than RLPN. Blood loss, perioperative complications, postoperative serum creatinine, analgesic requirements and histological outcomes were comparable between the groups. CONCLUSIONS: We perform TLPN for all anterior or lateral tumors as well as for large or deeply infiltrating posterior tumors that require substantive resection (heminephrectomy). The limited retroperitoneal space makes RLPN technically more challenging but provides superior access to posterior and particularly posteromedial lesions. When feasible, we prefer to perform laparoscopic partial nephrectomy by the transperitoneal approach because of its larger working area and superior instrument angles for intracorporeal renal reconstruction.     

Effects of two types of hormonal contraception--oral versus intravaginal--on the sexual life of women and their partners

BACKGROUND: Data relating to the influence of hormonal contraception on sexual life are conflicting and mostly they refer to oral contraceptives. In this randomized, controlled, prospective study we compared the effect of an intravaginal hormonal contraceptive with the effect of a combined oral contraceptive on sexual function. METHODS: Fifty-one healthy women with a permanent partner and an active sexual life were randomly divided in two groups according to a computer-generated randomization list: 26 women (group A) used an intravaginal contraceptive releasing 120 microg/day of etonogestrel and 15 microg/day of ethinylestradiol (EE) and 25 women (group B) used an oral contraceptive containing 20 microg di EE and 150 microg of desogestrel. Twenty-five women participated in the study as control group (group C). A specific questionnaire was completed by the patients and their partners at the start of the study and after cycles 3 and 6 of contraceptive use. RESULTS: Within 3 months of contraceptive use, women from both groups A and B reported a global improvement in sexual function. A statistically significant increase in sexual fantasy was reported only by patients of group A. Whereas partners of the women in both groups A and B reported an improvement in sexual function after 3 months of contraceptive intake, only patients' partners of group A reported a significant increase in sexual interest, complicity and sexual fantasy. CONCLUSIONS: Both hormonal contraceptives tested were seen to have a positive effect on some aspects of sexual function. The intravaginal contraceptive ring seems to exert a further positive effect on the psychological aspect of both women and their partners, which is evident from an improved complicity and sexual satisfaction.