Biomedical subjects
Publications and source records attributed to R Rivolta.
The Authors, reporting a recent case of small bowel lymphoma, review progress in diagnosis, methodology and therapeutical approach. They also stress the crucial role of surgery as diagnostic and therapeutic tool, sometimes curative in early stages, and however necessary for a proper staging and definition of these rare neoplasms of intestinal tube.
OBJECTIVE: Intestinal involvement is frequently observed in systemic sclerosis (SSc) and is associated with malnutrition and a decreased survival rate. Vascular lesions are claimed to underlie and precede these changes. The aim of this study was to establish whether a reduced mesenteric blood flow was present in SSc patients with no signs or symptoms of small bowel involvement. METHODS: Superior mesenteric artery (SMA) blood flow in the fasting state was measured by colour Doppler ultrasonography in 27 SSc patients and in 25 controls. The effect of a balanced liquid meal on mesenteric blood flow was measured in six matched patients and controls. RESULTS: In fasting SSc patients, there were reductions in mean SMA diameter (P<0.001), blood flow (213+/-92 vs 398+/-125 ml/min in controls, P<0.0001) and pulsatility index (3.49+/-1.0 vs 4.13+/-0.97 in controls, P<0.07). In both groups, the meal increased basal flow values and the differences between controls and patients in the fasting state were not significant. CONCLUSIONS: In the absence of symptoms of small bowel involvement, reversible SMA vasoconstriction is demonstrable in the fasting state in SSc patients.
The Authors report a very rare case of clear cell renal cancer associated with sarcoidosis, incidentally discovered in a 39 year-old man, admitted for a not correlated pathology (multiple left rib fractures due to automobile crash). Problems related to a proper assessment of sarcoidosis are discussed as well as potential arising of a neoplasm during the entire follow-up period: for that, it must always be complete and accurate.
Although the vestigial retrorectal cysts are still rare, the number of the observed ones is destined to increase, as methods by imaging become routinely used in the clinical practice. Once diagnosed, the removal of retrorectal lesions should be mandatory. Therefore, by reporting three clinical cases, the Authors propose notes of technique above the abdominal approach used for the surgical treatment of these retrorectal congenital neoformations. In their experience, the anterior route had no postoperative complications, short stay, no neurological consequences and good long-term results.
General surgeons are more and more frequently requested to prepare an operative exposure of the spine, in order to perform anterior maneuvers of removal and stabilization of the vertebral bodies. Since 1989 to date, in collaboration with the neurosurgical équipe of Prof. G. Cantore, Neurological Sciences Department, La Sapienza University of Rome, the Authors have collected 116 cases of vertebral diseases: among them, 48 involved the thoraco-lumbar junction of the spine (D12-L2). In this paper, Authors' aim is to state precisely the surgical technique of the anterior access to the thoraco-lumbar junction: attention has been focused on this tract of the column stating its anatomical complexity and the high invasivity of the procedures requested for its exposure. Therefore, such notes of technique have been elaborated to make safer the neurosurgical demolitive and reconstructive procedures and, most of all, to reduce the surgical trauma whenever it is possible.
The Authors report their experience matured during the last decade in the Institute of III Surgical Clinic of the University "La Sapienza" in Rome, relatively to 174 patients operated of splenectomy of which 8 for not parassitair benign cystic pathology. After the nosologic organization of the varied types of cystics splenopaty is examined the different symptomatology and is discussed the different treatment.
An abnormal vascular status is present in the transplanted kidney. To define whether vascular factors might influence kidney function of the graft, the renal volume, blood flow and vascular resistance of a group of healthy subjects were compared with those of a group of well functioning renal transplants by color Doppler ultrasonography. Sixty healthy subjects and 75 well functioning cadaver renal transplant recipients were compared by color Doppler ultrasonography. Subsequently, 15 couples of donors and recipients of a living related renal graft were compared to observe the differences between the two organs of the same subject in a different environment. The variables studied were: the diameters and the volume of the kidney, renal blood flow and renal resistance index (RI). The group of cadaver renal transplant patients showed higher mean blood pressure (P = 0.009), higher serum creatinine levels (P = 0.0001) and lower endogenous creatinine clearance (P < 0.0001) than healthy controls. The length (P < 0.00001) and volume (P < 0.001) of the kidneys of cadaver transplanted patients were significantly greater than those of healthy subjects, while the length and volume of the living donors kidneys were identical to those of the recipients. RI, measured on renal vessels, showed lower values in healthy subjects and in kidney donors than in transplanted patients (P < 0.00001). Well functioning transplanted kidneys showed increased renal arterial RI. This non-immunologic factor did not appear to be detrimental with renal function in time, at least until 50 months after successful grafting.
The recent observation of a new HNPCC patient case induced the Authors to review their experience with the syndrome as well as to make an up to date of the problems related to diagnosis, surgical management, surveillance and genetic counselling for such patients with a lifelong high cancer risk. Patients with HNPCC and their first-degree relatives, whose risk of early colorectal carcinoma (especially in the proximal colon) as well as a variety of extracolonic cancers (particularly endometrium, ovary, stomach, small bowel, ureter and renal pelvis) is significantly higher then that of patients with sporadic carcinoma, should be properly managed with surgery and then with endoscopic examination (ideally all life long) starting--in unaffected individuals--at early age (25 years old). Problems related to genetic counselling are considered as well.
Percutaneous transluminal renal angioplasty (PTRA) alone or in combination with stent implantation, is increasingly used as an alternative technique to surgical revascularization for treatment of renal artery stenosis (RAS) wich may cause hypertension or jeopardize renal function. Herein we report the results obtained with 305 PTRAs performed in 242 hypertensive patients, 144 of whom had atherosclerotic RAS, 69 fibromuscolar dysplasia, 15 Ras in transplanted kidneys, 6 restenosis in surgically revascularized kidneys, 4 Takayasu arteritis and 4 neurofibromatosis. Stents were implanted in 68 cases, mostly in atherosclerotic stenoses. The technical success was achieved in 261 arteries (85.6%), with 33 failures (10.8%) and 11 (3.6%) procedures not completed for anatomical reasons. PTRA related complications were observed in 23 cases (7.5%), but no fatalities occurred. An overall benefit on blood pressure control was observed in 41% of patients with atherosclerotic RAS and in 68% of those with fibromuscolar dysplasia. It appears that independently from the ethiology PTRA is technically effective in correcting RAS; yet the position of PTRA with respect to that of medical or surgical treatment needs to be better delineated through randomized, controlled studies aimed at comparing the clinical efficacies of these different approaches.
Urological vascular complications (UVC) are largely secondary to percutaneous procedures that are nowadays extensevely used by the urologists and the nephrologists. The major frequency of UVC is observed after the renal biopsy, in a percentage varying from 7 to 17% in different series; UVC are less frequent after a nephrostomic procedure (near 1-3%). UVC consist of artero-venous fistulas (AVF) and pseudoaneurysms (PA), that generally cause haemorrhage, particularly macroscopic hematuria. In the vast majority of cases hematuria resolves spontaneously or with conservative therapy but, in the 4 to 9% of patients persists and requires an adequate therapy, often in emergency. Interventional radiology permits an effective and timely treatment of the lesions, using the techniques of transcatheter embolization that are greatly improved in the last 20 years and that present rate of technical success greater than 80%. Moreover radiological embolization shows a low incidence of complications and lower hospitalization cost with respect to surgical treatment. Herein we describe the different techniques of embolization, the indications and the results as appears from the literature and the personal experience. The latter is based on a series of 31 procedures performed in 26 patients, with a rate of technical and clinical success of 93.5%.
OBJECTIVE: To evaluate the prevalence and the clinical evolution of patients with an initial diagnosis of indeterminate colitis. DESIGN: Retrospective, observational study. SETTING: Fifteen gastrointestinal units in northern Italy. PARTICIPANTS: Patients with an initial diagnosis of indeterminate colitis seen between 1988 and 1993. INTERVENTIONS: Patients were traced through a common database and centres were requested to update their clinical follow-up. MAIN OUTCOME MEASURES: Frequency of patients with an initial diagnosis of indeterminate colitis among those with IBD; rate of patients who subsequently had a definite diagnosis of either Crohn's disease or ulcerative colitis. RESULTS: Fifty out of 1113 IBD patients (4.6%) had been diagnosed as having indeterminate colitis. During follow-up, 37 patients (72.5%) had a definite diagnosis of either Crohn's disease or ulcerative colitis. The cumulative probability of having a definite diagnosis of either ulcerative colitis or Crohn's disease was 80% 8 years after the first one (i.e. the first diagnosis). The probability of having a diagnosis of Crohn's disease was increased in patients with fever at onset, segmental endoscopic lesions or extra-intestinal complications and in current smokers. The probability of having a diagnosis of ulcerative colitis was increased in patients who had not undergone appendectomy before diagnosis. CONCLUSIONS: In our area, indeterminate colitis accounts for about 5% of initial diagnoses of IBD. In about 80% of patients, a diagnosis of either ulcerative colitis or Crohn's disease is made within 8 years. Several clinical and demographic features can help in identifying those patients more likely to have a subsequent diagnosis of Crohn's disease and those more likely to have a subsequent diagnosis of ulcerative colitis.
The Authors report their three year experience with five patients suffering from gastric leiomyoma, each with different anatomical and clinical characteristics. The Authors have performed a research of the different diagnostics, clinical and therapeutic problems of these rare tumors that sometimes are asymptomatic in spite of the large size they reach, but more frequently they present with haemorrhagic symptoms which tend to point to other more frequent pathological conditions. Diagnosis can only be suspected, but cannot be reached without a histological examination, also if the classifications of these tumors have been argument of many changes, particularly by the light of the recent diagnostics possibilities offered by ultrastructural and immunohistochemical examination.
The usefulness in cirrhotic patients of hemodynamic measurements by Doppler ultrasonography (US) is still not defined. We investigated the relationships between Doppler measurements and the severity of ascites. Portal blood flow velocity and volume, and hepatic and renal arterial resistance indexes (RI) were measured in 57 cirrhotic patients (19 without ascites, 28 with responsive ascites, and 10 with refractory ascites) and 15 healthy controls. The renal arterial RI were obtained for the main renal artery, interlobar vessels, and cortical vessels. Cirrhotic patients had decreased portal blood flow and an increased congestion index (CI). Only the CI was correlated to the severity of ascites, showing that it is also a reliable measure of the severity of portal hypertension in patients with ascites. The hepatic and renal artery RI were increased in cirrhotic patients, and the two values were correlated (r = .68; P = .00001). The RI of renal interlobar and cortical vessels were higher in patients with refractory ascites than in patients without ascites (P < .02 and P < .009), and correlated with sodium excretion rate (r = -.45; P < .003), the renin-aldosterone system, and creatinine clearance (r = -.62; P < .0002). The RI decreased from the hilum of the kidney to the outer parenchyma in healthy subjects and patients with responsive ascites, but this difference disappeared in patients with refractory ascites. This indicates that the degree of renal vasoconstriction varies in different areas according to the severity of the ascites. Cortical vessels are involved mainly in patients with refractory ascites, suggesting that the intrarenal blood flow distribution in cirrhosis tends to preserve the cortical area and that severe cortical ischemia is a feature of refractory ascites.
To investigate possible correlations between thyroid vascularization and activity of Graves' disease, we measured blood flow (TBF) at the inferior thyroid artery and intraparenchymal vascularization (number of vessels per square centimeter) by color Doppler ultrasonography (CDU) on Graves' patients at different phases of the disease. We studied 88 patients cross sectionally: 22 untreated; 17 euthyroid after 6 months of methimazole; 49 euthyroid at drug withdrawal after 12 to 24 months of treatment. The patients of the latter group were followed up for 29.1 +/- 6.3 months after discontinuation of treatment. On the day of CDU examination, free triiodothyronine (FT3), free thyroxine (FT4), thyrotropin (TSH), antiperoxidase and anti-TSH receptor (TRAb) antibodies were measured. Vascularization indices were significantly higher in the Graves' patients than in controls. In the patients euthyroid under treatment, vascularization was not significantly lower than in the untreated group, but TBF and vessel number both appeared clearly reduced in the patients tested at drug withdrawal. The vascularization indices at drug withdrawal were significantly higher in the patients who relapsed than in those in stable remission: TBF (mL/min) 50.6 +/- 36.8 vs. 23.8 +/- 17.5, p = 0.001; vessel number/cm2 1.8 +/- 0.8 vs. 0.8 +/- 0.5, p = 0.002. A multivariate analysis, evaluating the predictive value of vascularization, hormonal and immunological parameters for relapse, demonstrated a significant predictive value for TRAb (RR 8.2; p = 0.001) and a weak predictive value for TBF (RR 1.1; p = 0.02). In conclusion, CDU examination confirms that thyroid hypervascularization in Graves' disease is not related to thyroid hormone circulating levels. The association of increased TBF and high levels of TRAb in the relapsing forms of disease suggests that thyroid hypervascularization is probably related to the activity of the underlying autoimmune processes.
PURPOSE: To assess the usefulness of ultrasonography (US) in the selection and monitoring of patients with sialolithiasis to be treated with extracorporeal electromagnetic shock wave lithotripsy. MATERIALS AND METHODS: US was performed in 80 symptomatic outpatients who were to undergo shock wave lithotripsy because they were not candidates for endoral extraction of calculi. The location and diameter of stones and the condition of the affected gland and duct were determined. RESULTS: Swollen and sclerotic glands and dilated ducts were the most frequently observed characteristics. After lithotripsy, stone clearance or a residual fragment of less than 2 mm in diameter was seen at US in 37 of 56 patients with submandibular gland calculi and in all 24 patients with parotid gland calculi. Favorable outcome after lithotripsy was associated with smaller (less than 7 mm) stone diameter (P < .001) and, in the case of submandibular gland stones, with intraductal location (P < .05). A return to a normal parenchymal echotexture was seen in all patients in whom the stone was completely eliminated; a limited reduction in swelling was observed in patients with residual fragments. CONCLUSION: US is useful in the selection of candidates for extracorporeal electromagnetic shock wave lithotripsy and in monitoring the progress of treatment.
In order to assess whether the transplanted nephronic mass plays a role in the progression of chronic graft dysfunction, 83 well-functioning renal transplants were investigated. Plasma creatinine, creatinine clearance, renal volume, blood flow and renal vascular resistance were measured. The weight of the donor was considered as an index of the transplanted renal parenchyma and the weight of the recipient as an index of the required nephronic mass. To evaluate the adequacy of the transplanted nephronic mass, the ratio between the donor and the recipient's weight was calculated. This ratio showed a mean of 1.06 +/- 0.18 and a range between 0.63 and 1.6, indicating that a parenchymal mass between 30 and 80% of the physiologic one was transplanted in these subjects. Patients were divided into two groups: group A patients with a ratio > 1, group B patients with a ratio < 1. In group A, a regression analysis did not show any relationship between transplant age and creatinine clearance, renal volume, blood flow and renal vascular resistance as assessed by echo-color-Doppler ultrasonography. In patients with reduced nephronic mass, group B, there was a negative relationship between renal blood flow and transplant duration (p = 0.03) and a positive relationship between transplant age and renal vascular resistance (p = 0.01) and renal volume (p = 0.01). These data support the hypothesis that the difference in weight between donor and recipient may influence the outcome of the graft.
OBJECTIVE: To investigate the effect of iloprost, a stable prostacycline analog, on kidney blood flow in patients with systemic sclerosis (SSc), using color flow Doppler sonography. METHODS: The acute effect of the drug was studied in 10 patients with SSc with elevated resistance index (RI) levels (all RI values reported are multiplied by 100). Iloprost was administered intravenously (2 ng/kg/min for a period of 8 h). To study the effects of chronic drug administration, 16 patients with SSc were randomly assigned to 2 groups of 8 cases each. The first group was treated with 9 infusions of iloprost in 6 mo. The second group was treated with slow release nifedipine (40 mg/day) for 6 mo. RESULTS: Interlobar artery RI (median 67 vs 61; p = 0.02) and cortical vessel RI (median 65 vs 54; p = 0.001) were reduced after acute treatment. In chronic drug administration, RI values were not modified by nifedipine, while iloprost reduced the RI of the interlobar (median 69 vs 61; p < 0.03) and cortical arteries (median 66 vs 58: p < 0.01). CONCLUSION: Our findings suggest iloprost might be useful for treatment of scleroderma renal vasospasm.
A reappraisal of the results obtained after potentially curative resection for rectal cancer compared with "historical" results is reported. An increase of the overall survival rates was registered as well as a corresponding lowering of the pelvic recurrences: 4.54% in the group of patients with a-two-year follow up. As for relapse surgery, however, reviewing the series from January 1991 to December 1994, the results are still poor because relapses were not resectable in 85.7% of the cases.