[Glucagonoma syndrome. Clinico-therapeutic data relative to personal experience and review of the literature].
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Adenoma, Islet Cell↗
Biomedical subjects
P Tonelli
Publications and source records attributed to P Tonelli.
[Surgical treatment of oroantral fistula. Experience with the use of fibrin glue].
Personal surgical experience in the treatment of oro-antral fistulas is reported. Fifteen patients underwent plastic surgery (palatal strip) and fibrin glue was used to guarantee a better take of the strip.
Fibrin Tissue Adhesive↗
[Nimesulide in oral surgery. Clinical experience in postoperative treatment].
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Adult↗
Billroth I versus Billroth II partial gastrectomy in the treatment of gastric ulcer.
Short- and long-term results of B-I and B-II reconstructions were compared in order to assess which anastomosis is to be recommended after partial gastrectomy for gastric ulcer. All the patients (287) electively operated for gastric ulcer 10-20 years ago were considered for the study. Operative mortality did not significantly differ, while duration of post-operative time before discharge and post-operative morbidity were significantly lower after B-I. Long-term percentage probability of survival was higher after B-I than after B-II (87.0 and 63.7 after 19 years, respectively), while quality of life was similar in the two groups. In the 64 subjects (26 B-I and 38 B-II) who underwent the study protocol, fasting bile reflux appeared more abundant and bile acid concentration greater after B-II than after B-I. While bacteria and nitrite concentrations did not differ in the two groups, bile acid pattern differed in a greater deoxycholic acid percentage concentration in the B-II group. In spite of an increased deoxycholic acid concentration and therefore a probably more lithogenic bile, gallstones were shown in 23.11% and 39.41% of the B-I and the B-II subjects, respectively, without significant differences. In conclusion, when partial gastrectomy is indicated for gastric ulcer, B-I reconstruction seems preferable to B-II because of its lower post-operative mobility, less evident entero-gastric reflux and histological consequences, less evident bile acid pattern changes from normal, and an apparently longer life-expectancy after discharge.
Adult↗
An insight into post-gastrectomy "alkaline reflux gastritis".
One hundred and ten partially-gastrectomized patients were studied in order to assess prevalence of symptoms, entero-gastric reflux, endoscopic erythematous changes and histological gastritis and to explore some aspects of the pathogenesis of gastritis syndrome. Prevalence of symptoms (37.2% of the patients) was lower than prevalence of reflux (86.9% and 72.9% of patients with fasting bile reflux or scintigraphic assessment, respectively) endoscopic hyperaemia (72.7% of patients) and remnant chronic gastritis (88.3% of patients). Histological appearance in the perianastomotic area was mostly identifiable as hyperplastic-regenerative. While histological findings, gastric pH, bacteria and nitrite concentration and patients' age were reciprocally correlated, symptoms, endoscopic changes, remnant chronic gastritis and gastric environmental changes were not more severe in patients with more abundant enterogastric reflux. Therefore, as far as the methods for reflux assessment used in the present study are concerned, postgastrectomy findings (symptoms, extent of erythematous changes, severity of remnant chronic gastritis) are not related to reflux. These results suggest that the term "alkaline reflux gastritis syndrome", at this stage of knowledge, should be used with caution.
Adult↗
Folate deficiency in operated terminal ileitis (Crohn's disease).
In a series of 39 subjects previous results for serum folate levels were confirmed while intraglobular folate did not differ from those in a control group. To verify the hypothesis that SASP administration could be responsible for serum folate deficiency three different sub-groups were considered. 11 patients had never taken SASP (sub-group I), 16 patients had taken SASP in the past but the treatment had been withheld at least 2 months before (sub-group II), 12 patients were still taking the drug at the time of the study (sub-group III). Differences in serum folate levels between each one of the three sub-groups and the control group were significant. The same was not true for the differences between each one of the three sub-groups and the other. These findings seem to confirm that SASP treatment is not the major cause of serum folate deficiency, but a multifactorial pathogenesis might account for it.
Adolescent↗
Factitious hypoglycemia: an unusual clinical picture within Von Münchausen's syndrome.
Two cases of hyperinsulinism from insulin self-administration are described, both patients being admitted to hospital with a diagnosis of insulinoma. In the first case, the diagnosis was clarified after a left pancreatectomy elsewhere, thanks to the discovery of a bottle of insulin. In the second case, the diagnosis was confirmed by the measurement of C-peptide during a hypoglycemic attack. The simultaneous sharp decrease in glucose levels, an exceptional increase in insulinaemia and a reduction or disappearance of serum C-peptide is indicative of this particular type of hyperinsulinism. The two cases described here were remarkably similar. Apart from the most common features, both reported a severe hypoglycemic syndrome of recent onset; negative tolbutamide and calcium tests; a frequent relapse shortly after glucose administration.
Adult↗
Ofloxacin concentrations in human inflamed pericoronal tissue after oral administration.
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Administration, Oral↗
[Gastric carcinomas of the "bare area". Their anatomo-surgical definition and proposal of an en bloc total gastrectomy].
INTRODUCTION: Regarding the surgical treatment, carcinomas of the gastric proximal third and cardia are considered as an uniform problem. Particularly no difference exists between the gastric tumors of the anterior wall and those of the posterior wall. Nevertheless, cancers of the posterior wall of the proximal third are more difficult to cure and therefore less success has been achieved than with those of the anterior wall. The cause of this different behaviour must consist in an anatomical characteristic, the fact that the posterior wall of the fundus and subcardial portion is not covered by the visceral peritoneum ("bare area"). MATERIAL AND METHODS: Our study group consisted of 22 patients who presented carcinoma of the stomach risen in the area without peritoneal lining. Our treatment of this condition consisted of an operational procedure wherein we removed en bloc the stomach, left pancreas, spleen, and lymph nodes of the compartment I, II and III. In each case we considered the pathological situation, the involvement of the retroperitoneal structures and the condition of the lymph nodes in the compartment III specially, and actuarial statistics. RESULTS: We divided the 22 patients in 4 groups based on the neoplastic involvement of the retroperitoneum. Only in 3 cases (14%) of group 1 the cancer invasion was limited to the gastric muscular layer. In all of the rest, tumor involved the retroperitoneal structures. Postoperative mortality rate was 9%. The five year survival rate was 100% in the 3 cases of group 1 only and 10.5% in all other cases. DISCUSSION: The results show that carcinomas of the "bare area" cause a real jump in the degree of severity of the biological neoplastic process and hence of the prognostic evaluation. When the growth involves the gastric muscular layer, it indicates invasion of the retroperitoneum. Therefore, as with surgical treatment of esophageal carcinoma with the en bloc esophagectomy, we propose an en bloc total gastrectomy which should be performed in every carcinoma arising in the "bare area" because it allows more radical removal than can be obtained from traditional surgical procedures, without risking an increased mortality rate.
Esophagectomy↗
[New developments in Crohn's disease: solution of doctrinal mysteries and reinstatement as a surgically treatable disease. 1. The process is not a form of enteritis but lymphedema contaminated by intestinal contents].
INTRODUCTION: It is unanimously acknowledged that the aetiopathogenesis of Crohn's disease (CD) is still a mystery despite the fact that almost 70 years have elapsed since it nosological identification. Another mystery and major problem of CD of the bowel is its histopathology, which has yet to be clarified; consequently, we do not know what kind of disease it is, that is to say, which process, among the ones known to us, it actually corresponds to. MATERIAL AND METHODS: The present paper presents the results of a new histopathological interpretation of the disease on the basis of 100 surgical cases of Crohn's ileitis and ileocolitis. RESULTS AND CONCLUSIONS: The disease is not a form of enteritis, but a lymphoedema of the intestinal wall, caused by a congenital lack of patency of the mesenteric lymphatic collectors, giving rise to stasis of lymph in the lymphatic network of the corresponding bowel segment and consequently to hypertension which dilates the lymph vessels in the intestinal wall. The lymph, which cannot be reabsorbed by the veins, because the venous wall denies entry to protein macromolecules, accumulates in the interstitial space with the result that the intestinal wall thickens considerably. Since the process takes place in the intestine perfused by a continuous flow of septic matter, the process is complicated by the development of lymphocytic lymphangitis, which occurs throughout almost the entire lymphatic network, obstructing the dilated lumen, limiting the dispersion of lymph and preventing gross spread of the intestinal contents into the dilated lymphatic vessels. The lymphocytic lymphangitis causes "transparietal phlogosis", which is rightly regarded as a characteristic of the disease, but is wrongly interpreted by those who have studied it. This transparietal phlogosis is neither excessive nor disproportionate to its task of obstructing the intestinal contents; it is transparietal because the lymphatic network where it takes places is itself transparietal. The reactive lymphocytic lymphangitis prevents the gross spread of the intestinal contents into the dilated lymphatic network, as stated above, but cannot prevent the limited uptake of dissolvable toxic bacterial substances (FMLP, PG-PS, LPS) conjugated in immuno-complexes. The immuno-complexes developing in the lymphatic network undergo lymph- and blood-borne spread, causing; obstructive lymphangitis in branches of the mesenteric lymphatic collectors which are still patent, increasing the degree of lymphatic obstruction and thus the extent of the intestinal lesions; general complications of so-called "metastatic Crohn's disease", which were once interpreted as autoimmune processes, but actually correspond to forms of vasculitis which may be localised in any of the organs or apparatuses of the body, sometimes proving extremely serious. Lymph dispersion in the intestinal lumen, causes not only diarrhoea, but often also lymphocytopenia and hypoproteinaemia, and therefore an immunodepression syndrome, which in the long term may give rise to intestinal and extraintestinal cancer.
Colitis↗
[New development in Crohn's disease: ++unravelling the mystery and its reinstatement as a surgically treatable condition. Part 2. Potential etiopathogenesis of "terminal ileitis" and extension of the disease to mesenteric small intestine and the colon].
INTRODUCTION: The aetiopathogenesis of terminal ileitis is still unknown, as is the cause of its spread to the small and large bowel. The aim of this study was to shed light on these unknown aspects of Crohn's disease. CONCLUSIONS: The lack of patency of the ileal branch of the ileocolic lymphatic collector which causes terminal ileitis, usually in the earlier part of life, is likely to occur in the foetus around the 10th week of pregnancy as a result of a minor abnormality of the physiological regression of the vitelline duct. Excessive atrophy of the lymphatic network seems to occur, also affecting the rudimentary lymphatic vessels in the midgut destined to become the terminal ileum. The terminal ileitis spreads to the large bowel in an increasing percentage of cases and is directly related to duration of the disease, causing first ileitis plus right colitis, and then ileitis plus total colitis (which, however, does not include the rectum). It may also include the jejunum, causing skip lesions. This spread of lesions is not due to any genetic predisposition (that is to say, it is not predetermined in empirical terms), but rather to the extent of the lymphatic obstruction caused by the spread of immunocomplexes via the lymphatic network. This is shown by the fact that secondary lesions of the jejunum and large bowel are also typical of lymphoedema and that their spread is segmentary. In the light of these pathogenetic mechanisms, it is reasonable to assume that the spread of the process from the ileum to the colon might be prevented by prompt surgery during the initial phase of the ileitis. If these views are correct, the traditional subdivision of Crohn's disease forms into ileitis, ileocolitis and solitary colitis should be replaced by a very simple scheme showing the spread of the primary ileitis very often to ileocolitis, first confined to the right colon and then total. We cannot include either solitary colitis (not clearly defined in the literature) or anorectal Crohn's disease (whose forms have yet to be fully acknowledged) in this scheme.
Colonic Diseases↗
[New developments in Crohn's disease: unravelling the mystery of its etiopathogenesis and its reinstatement as a surgically treatable condition. Part 3: The rational principles of surgical therapy].
The diagnosis of Crohn's disease makes surgery mandatory in any form of the disease, because it is ingravescent, spreads in the bowel, and is unresponsive to any type of pharmacological treatment; it invariably involves major consequences and often leads to serious complications such as perforation and cancer in the long term. The operation has to be performed promptly, because the commonest complications, such as obstruction and perforation, may occur at any stage of the disease, including the initial phase. Moreover, it is advisable to prevent the spread of the disease to the colon and jejunum, which occurs in increasing percentages of patients and is related to duration of the disease. As a rule, surgery has to take the form of a resection of the diseased bowel, which includes not only the lesions already in progress, but also those which may be expected to develop. Therefore, since the disease is segmentary, the resection, too, has to be segmentary, even when part of the diseased segment is apparently sound. Inadequate resection is often followed by dehiscence of the anastomosis and sooner or later by an inevitable recurrence. Three types of resection are performed for Crohn's disease depending on whether it manifests as ileitis, ileitis plus right colitis, or ileitis plus right and left colitis. Ileitis requires an ileocolic resection. Because the resection has to be segmentary and the proximal limit of the segment, i.e. of the lesions, cannot be determined at external examination of the intestine, the surgeon has to perform an approximate, temporary resection and examine the resected specimen, open along its entire length, before constructing the anastomosis. The borderline between the diseased and intact ileum, where convinient valves, appear with their thin, delicate outline, can be identified exactly in the mucosal surface. The resection has a "safety margin" of 10 cm. Section of the ascending colon can be performed wherever the surgeon prefers. The ileitis plus right colitis forms require resection of the ileum according to the procedure described and of the right colon, even when the lesions are confined to the caecum. Section and anastomosis must be performed in the initial tract of the transverse colon. The ileitis plus right and left colitis forms call for total colectomy in addition to resection of the ileum, even when the lesions are confined to the transverse colon. The operation is completed with an ileorectal anastomosis constructed on the lower portion of the intraperitoneal rectum (drained by the hypogastric collectors).
Crohn Disease↗
[Odontogenic chronic maxillary sinusitis: regenerative possibilities of oro-antral defect].
Odontogenic maxillary sinusitis often develops into a chronic picture of unilateral inflammation, progressively interesting the whole antrum mucosa. The only decisive therapy of this pathology is a surgical one that, by completely removing pathologic tissues, starts sinus restoration by a healthy respiratory mucous membrane. This tissue grows from the nasal cavity after the radical surgery (according to Caldwell-Luc), presupposing an antrum drainage through that same cavity. Nevertheless, if the inflamed area is just limited in the central and posterior recesses, and the hiatus semilunaris of the medial wall remains open, it is possible to avoid a surgical access to the nasal cavity. In this way, an alternative surgery is proposed for chronic sinusitis which, using principles of Guided Bone Regeneration, permits to completely remove pathologic tissues and to start bone reformation in the damaged alveolar.
Chronic Disease↗
[Laparoscopic approach to the "acute" and "chronic" bowel obstruction].
AIM OF THE STUDY: To retrospectively evaluate a series of patients with acute and chronic small bowel obstruction and discuss the indications of laparoscopic vs laparotomic approach and the outcome of both these techniques. PATIENTS AND METHOD: 85 patients with acute and chronic small bowel obstruction who underwent to either emergency or elective surgery since January 1999 up to October 2001 were enrolled. Subjects were divided into three groups: 39 treated with emergency laparotomy (group I), 13 with emergency laparoscopy (group II) and 33 with elective laparoscopy for chronic/subacute obstructions (group III). RESULTS: 1) the most frequent indication of the laparotomic approach was either multiple or major previous surgery as well as neoplastic diseases; 2) patients of the second group had frequently previous either minor or laparoscopic surgery; 3) the incidence of previous emergency surgery were maximum among the III group; 4) both post-operative ileus and mean hospital stay lasted less in the II than in the I group. The mean operative time and the morbidity was equal in the two groups; 5) we observed more intra-operative complications, a higher conversion rate and a longer both post-operative ileus and mean hospital stay in the II than in the III group. CONCLUSIONS: Our data support the role of laparoscopy in patients with chronic/subacute small bowel obstruction. Patients with acute obstruction may undergo laparoscopy after a careful selection, excluding subjects with previous either multiple or major surgery as well as neoplastic diseases. Such results need future confirmations from prospective randomized studies.
Acute Disease↗
[Extensive lymphadenectomy in the therapy of cancer of the left colon and rectum: an analysis of the anatomicopathological data].
In the last 12 years in our surgical service, radical resection was performed in 142 patients with cancer of left colon and in 145 patients with rectal cancer. Extended lymphadenectomy was always realized: preaortocaval lymphadenectomy in colonic cancer; preartocaval and pelvic lymphadenectomy in rectal cancer. The incidence of C stage was 40.14% in cancer of left colon and 40.68% in rectal cancer. Neoplastic diffusion in preaortocaval lymph nodes was only in a patient with colonic cancer, never in patients with rectal cancer. The incidence of neoplastic diffusion in pelvic nodes was 3.12% (0 in superior rectum; 6.25% in medium rectum; 2.4% in inferior rectum). In 1 of 90 patients with tumour of medium or inferior rectum, we relieved tumoural involvement of pelvic nodes without neoplastic diffusion in regional nodes. These anatomo-pathological data subline: a) the low incidence of neoplastic diffusion in preaortocaval nodes in cancer of left colon and rectum; b) the importance of pelvic lymphadenectomy in cancer of medium and inferior rectum.
Adult↗
Counting of platelet derived growth factor and transforming growth factor-beta in platelet-rich-plasma used in jaw bone regeneration.
AIM: Growth factors (GFs) as platelet derived growth factor (PDGF) and transforming growth factor (TGF-beta), found in platelet beta-granules also present in platelet-rich-plasma (PRP), accelerate bone revascularization and regeneration and for this reason they have been employed successfully in dental and maxillofacial surgery. Platelet concentrate is commonly used for this purpose as long as platelet release reaction and the consequent GFs loss are avoided. To reduce this phenomenon we set up an easy and fast procedure for preparing a satisfying clotted PRP by adding CaCl2 only (no exogenous thrombin). METHODS: ELISA essay has been used to measure PDGF and TGF-beta in plasma, platelets and serum and platelet GMP-140, with the cytofluorometric technique in order to quantify the degranulation entity. RESULTS: In the 13 examined patients receiving clotted PRP to enhance bone regeneration in post-extractive alveolar sockets, PRP showed no sign of platelet activation (degranulation) and short recalcification times (8-12 min). The autologous clotted PRPs specimen have been evaluated in laboratory in terms of GFs percent: 76% of initial GFs content could be recovered in clotted PRP. This result confirms the absence of platelet degranulation in our procedure. CONCLUSIONS: Significant clinical results in alveolar bone regeneration are reached only with a high percentage of GFs inserted in bone matrix, avoiding early platelet degranulation.
Adult↗
[Ultrastructural relief of unaffected mucosa in recurrent oral ulcer patients. 2].
Electron microscopy was performed on clinically normal vestibular mucosa biopsies of two patients affected with recurrent oral ulcers. Apoptotic cells were absent from vestibular mucosa; this is in contrast with the pathogenetic theory proposed by Honma et al., 1985 (1). Only a few modifications in the keratinization process (intracytoplasmic desmosomes, electrondense granules in basal keratinocytes) and an unusually high number of dendritic cells were found; dendritic cells could be involved in local immunological iperreactivity, responsible for the ulcers of these subjects.
Dendritic Cells↗