Free perforation of the bowel due to cancer in Crohn's disease is very rare. One case found among 75 cases of Crohn's disease is reported. The perforation occurred in a mucinous adenocarcinoma of the ascending colon in a 54-year-old woman with a 17-year history of Crohn's disease, who had undergone two previous operations of small bowel and colonic resection. A right hemicolectomy was performed; the patient had an uneventful recovery and does not show recurrence of cancer at 31-month follow-up. This is in contrast with a recent review, in which a very poor prognosis was claimed for the perforated colonic cancer in Crohn's disease.
A case of associated ovarian and cervical thyroid struma in a 24-year old female, is reported. The patient was affected by a right thyroid cold nodule which at fine needle aspiration biopsy showed the cytological pattern of benign follicular adenoma; as the nodule was increasing after one year of suppressive therapy, the patient was selected for surgery. At admission during routine physical examination a previously undetected left pelvic mass was discovered: at laparotomy it proved to be a cystic tumor consisting of benign thyroid tissue at the level of left ovary. Histology confirmed the diagnosis of follicular adenoma of the right thyroid nodule after right lobectomy. Albeit cases of thyroid tissue in the ovary have been reported, true struma ovarii is a rare occurrence. A concomitant hyperthyroidism is seen in only 1/4 of cases and the patients can be divided into three groups: hyperthyroid, ascitic and asymptomatic: our patient was in the asymptomatic group.
A rare case of idiopathic lithiasis in the urinary bladder in an Ethiopian female child is reported. Possible causes of the disease, with a high morbidity in Ethiopia, and a highly different incidence between males and females, are discussed.
Four cases of localized lipogranuloma of the spermatic cord without evident predisposing factor, are presented. The mass was associated with a small vaginal hydrocele. Wide excision of the intact mass proved successful in all cases. There was no recurrence or regrowth up to one-year follow up. At histology a lipogranuloma was diagnosed but its cause could not be assessed. A spontaneous specific tissue reaction of the cord tunics to an unknown injury, is hypothesized.
A case of accessory biliary duct draining segments V and VI of the liver, accidentally injured during cholecystectomy and repaired by biliary-enteric anastomosis, is reported. An accessory bile duct may occur in 15-20% of these patients. Ligation or repair is always recommended depending on the size and volume of bile flow. Roux-en-Y loop reconstruction is to be preferred as it provides the best results with the lowest risk of leakage, stenosis and cholangitis.
Out of 436 patients operated on using aorticobifemoral grafting, 60 cases (mean age 66) had an extra-peritoneal approach to the abdominal aorta. 28 patients underwent aorticobifemoral revascularization, three of them had, in addition visceral artery grafts. In the 60 cases, perioperative mortality was 1.7%. The extra-peritoneal approach to the abdominal aorta is safer than the intraperitoneal approach, because it reduces the risk of shock connected with the large laparotomy. It is emphasized that, by using an extraperitoneal approach, a greater number of elderly patients can be considered suitable for aorticobifemoral grafts.
Lymph node metastases from occult thyroid papillary carcinoma are not a rare event. An unusual case of cystic lymph node metastases from this type of carcinoma is reported, suggesting that fine needle aspiration biopsy or frozen section biopsies should always be performed in the presence of a cystic lesion of the neck.
Two cases of young patients with an acute abdomen caused by a necrotizing angiitis of the cecum and ascending colon are reported. The absence of any systemic disease and a history of medical treatment in both cases led to the diagnosis of hypersensitivity vasculitis by a serum sickness-like reaction. An extensive review of the literature is also presented.
Over about a 7-year period, 138 colorectal cancer patients undergoing potentially curative surgery were prospectively entered into postoperative surveillance programs that differed according to risk category. Of the 138 patients, 28 (20%) have been lost to follow-up. Of the 110 remaining patients, thirty (27.3%) were classified as low risk cases since they had stage A-B1, well differentiated tumors (G1) primary tumors with preoperative CEA values of less than 7.5 ng/ml (group 1) and the remaining 80 patients (72.7%) were considered high risk cases (group 2). Overall 5 year survival was 64.5%; group 1 patients had a significantly better 5-year survival rate (90%) as compared to group 2 patients (55%) (p less than 0.01). Of the 20 asymptomatic patients with distant metastases only 4 (20%) underwent potentially curative surgery, whereas of 13 asymptomatic patients who recurred locally surgery was undertaken in 9 (69%) (p less than 0.05). At 5 years from the diagnosis of local recurrence, 5 of 11 patients (45.4%) who underwent curative second-look surgery are still alive. The survival of low risk patients was not negatively influenced by less frequent follow-up. Endoscopy and echotomograms were the most useful diagnostic tools in detecting early local anastomotic recurrence and hepatic metastases, respectively. Individualized follow-up programs for various risk categories of colorectal cancer patients are recommended.
Thirty-three anti-HIV positive patients with persistent generalized lymphadenopathy (PGL) who underwent lymph-node biopsy were studied to assess the diagnostic and prognostic relations existing between clinical, histological and laboratory findings. Patients were also examined for known risk factors, laboratory and bacteriological tests, and mononuclear cell surface marker analysis. 4 histological types were identified according to Ràcz's classification. At biopsy, there were 21 cases of LAS (64%), 6 cases of ARC (18%) and 6 cases of AIDS (18%); a clear prevalence of type 1 was evidenced in LAS/ARC patients, while only type 4 was present in the AIDS group. An ARC type 3 patient developed manifest AIDS within 13 months from biopsy. These results suggest that anti-HIV positive asymptomatic patients with PGL apparently do not require lymph node biopsy, as none of them showed histologic findings suggestive of opportunistic infections, malignant lymphoma or Kaposi's sarcoma. On the contrary, lymph node biopsy can play a diagnostic and prognostic role in anti-HIV negative subjects with PGL, and in ARC and AIDS patients.
Surgical complications after total thyroidectomy (TT) and subtotal thyroidectomy (STT) are analysed in a series of 364 patients operated on over a 36-month period. All operations were carried out because of the following 3 groups of disease: malignant tumors, multinodular goiter and Graves' disease. The difference among the incidence of surgical complications resulted to be not statistically significant when as discriminating factors the type of surgery or disease were used, while the difference was statistically significant when the results obtained in the 2 groups of patients operated only once or undergoing reoperative surgery for recurrence, were compared. Based on these observations, the surgical approach consistent with the above mentioned types of thyroid disease is reported, and the preference for total thyroidectomy is justified to a larger extent by what has been done to-date also in case of benign thyroid disease. The choice of the type of surgery should always be made, based on a careful clinical and intraoperative assessment of each case.
Midline and transverse incision are commonly used in upper abdominal surgery. A comparison of the two procedures with respect to the respiratory function, assessed by spirometry, blood gas analysis, inspiratory and expiratory pressures, and thoraco-abdominal respiratory synchronism, was made in two groups of patients after surgery on the abdominal aorta. 32 patients affected by abdominal aortic obstructive or aneurysmatic disease, candidates for aortoiliac revascularization, were randomized into two groups of 17 (group A) and 15 (group B) patients respectively. Group A underwent midline laparotomy and group B supraumbilical transverse laparotomy. Ventilatory function and blood gas analysis were determined on the day before operation and on the second and eight postoperative day. All patients showed a depressed ventilatory function postoperatively, but the impairment was significantly minor after transverse laparotomy.
18 elderly patients submitted to major surgery for malignancies or other disease were studied to assess the relationship between changes of blood coagulation factors and inhibitors in the early post-operative period and the appearance of lower limb deep vein thrombosis. A decrease in serum antithrombin III (AT III) Protein C antigen (PC: Ag) and Plasminogen activity (PLG) levels from the second to the fourth postoperative day, together with a simultaneous increase in serum fibrinogen (FG) and von Willebrand Factor (vWF:Ag) antigen levels was observed. In 8 patients, PC:Ag levels dropped below the limit considered at risk to develop DVT (less than 60 U/dl). A patient with the lowest PC:Ag levels had deep vein thrombosis From the analysis of data it was concluded that in the postoperative period, blood coagulation changes occur in elderly patients, predisposing to the risk of deep vein thrombosis.
A case-double control study on 318 personally interviewed patients with large bowel neoplasia has been carried out to establish the possible role of cholecystectomy in the development of colorectal cancer. The dietary habits both of the cancer patients and control subjects were investigated. All controls were considered free of neoplastic lesions on the basis of a negative fecal occult blood test. Data from the study showed that the prevalence of cholecystectomy in the overall patients was similar to that of the two control groups. However, analysing the data for colon and rectum, the relative risk of colonic cancer after cholecystectomy was significantly increased in males (RR = 2.75; p less than 0.05), whereas that of rectal cancer appeared to be decreased in females (RR = 0.18; p less than 0.02). Subsite analysis demonstrated that right-sided neoplasia after long-standing cholecystectomy (greater than or equal to 10 years) was responsible for the increased colonic risk. In conclusion, the present data support the hypothesis that cholecystectomy may be considered a risk factor for right-sided colon cancer, but indicate that this operation seems to play a protective role for rectal cancer.
The incidence of recurrent goiter after different surgical procedures for colloid-cystic goiter has been studied in 210 patients. The results of the study confirm the high incidence of recurrence (35.7%). This incidence was shown to be higher in patients undergoing more conservative surgery. Furthermore, the incidence resulted also higher in younger patients, while it was lower after postoperative replacement therapy.
The incidence of synchronous cancer has been reported to be 1.5% to 7.6%. A retrospective review of all colorectal cancer patients was conducted to determine the incidence of synchronous cancers. 47 synchronous cancers were identified in an operative series of 2586 patients with an incidence of 1.8%. The patients were divided into two groups based on preoperative diagnostic examinations. The first group included 1608 patients examined by double contrast x-ray barium enema (1141) and/or single contrast barium enema (381) and/or rigid sigmoidoscopy (112). The second group included 978 patients examined by double contrast barium enema (459) and/or flexible sigmoidoscopy (631) and/or colonoscopy (389). The incidence of synchronous tumors was 1.6% for patients evaluated only with double contrast roentgenographic study and 4.1% for patients who underwent preoperative colonoscopy. Fifty percent of synchronous cancers detected by colonoscopy were missed at double contrast x-ray barium enema. While twenty two percent of synchronous tumors detected by barium enema were located in different surgical segments and were all "advanced" tumors, when preoperative colonoscopy was performed, 56.2% of synchronous tumors were not located in the same surgical segment, and 66.7% of these were "early" cancers. None of the patients who underwent preoperatively colonoscopy developed a metachronous tumor within 3 years. One percent of patients undergoing flexible sigmoidoscopy or double contrast barium enema developed a second tumor 3 years after surgery. An extended use of preoperative colonoscopy in the diagnosis of colorectal cancers, to increase the detection od synchronous tumors and to decrease the incidence of the so-called "early" metachronous cancers, is stressed.
A case of peritoneal scintigraphy performed in a patient eligible for peritoneal locoregional treatment with previous positioning of an implantable device is reported. The result of scintigraphy has played a major role in the diagnosis of adhesion and thus in the subsequent therapeutic approach. Indications for peritoneal scintigraphy in the preliminary stage of locoregional treatment by completely implantable devices, are also briefly discussed.
Using survival corrected for intercurrent deaths as an endpoint, the prognostic significance of age, sex, histology, clinical extent of disease, size of primary tumor, type and result of treatment, was assessed in a series of 133 patients with differentiated thyroid carcinomas treated over a 16-year period. The following parameters were shown to be unfavourably related to survival: old age, follicular moderately-differentiated histological type, extrathyroid growth of the primary tumor and/or presence of distant metastases at diagnosis. In patients not cured after surgery, postoperative radioiodine therapy was correlated with, better survival rates. A multivariate statistical analysis (Cox model) showed that tumor stage and age at diagnosis were the major determinants of prognosis. Based on this data a risk index was worked out and three low/intermediate/high risk subgroups, characterized by significantly different survival rates, were identified in the study population.
A rare case of primary malignant melanoma of the lung in a 30 year-old female is reported. A chest x-ray and C.T. scan revealed a mass 3 cm in diameter. The patient underwent left lower lobectomy for cure.
