Perforation of the esophagus was retrospectively analysed in six patients. The age span was 30 years to 81 years, and the male to female ratio was 2 to 1. Each case was studied with regard to presentation, etiology, treatment and complications. The diagnosis was made at postmortem examination only in 1 patient. The perforation was iatrogenic in 1 of the patients and spontaneous in 5. Management was nonoperative in 3 cases and primary repair with drainage was performed in 2 patients. Overall mortality rate for the series was 33%. This series accumulated from a review of the literature emphasizes the importance of the influence of different methods of treatment and time lapsed between occurrence and therapy.
A case of Primary Malignant Lymphoma of the Spleen (PMLS) with exclusive red pulp involvement is described and discussed. Although the unusual topographic presentation the authors emphasize the physiologic arrangement of lymphoid cell in splenic red pulp cords that can give origin to the neoplasia. They moreover discuss problems of differential diagnosis with Malignant Histiocytosis (MH), Hairy Cell Leukemia (HCL) and Myeloid Process, both by morphology and immunohistochemistry.
Five patients were operated on for gallstone ileus over a 10-year period. Plain abdominal radiograms performed at admission were diagnostic in only 2 patients while other procedures such as ultrasonography and gastroduodenoscopy were required in 2 patients. Obstructing stones were located in the terminal ileum in three patients and in the duodenum in two. A one-stage procedure consisting in the removal of the impacted stone, fistula repair, and cholecystectomy was performed in three patients, two of whom died. Removal of impacted stones was the only surgical treatment in the remaining two patients, with no mortality. The Authors conclude that enterolithotomy alone should be the standard procedure for gallstone ileus. The repair of cholecysto-enteric fistula should be scheduled on elective basis and only if there are continuing or recurrent symptoms.
Despite the well demonstrated fundamental role of dendritic cells (DC) in generating antitumor immunity in experimental conditions, to date there are only few preliminary studies which investigate the percent of DC in the peripheral blood of cancer patients. Several cell surface markers have now been described which are specific to cultured DC, however their expression in vivo is still controversial. Recently, however, two DC subsets, consisting of immature and mature DC, have been shown to be present in peripheral blood, which can be recognized as CD123+ and CD11c+ cells, respectively. On this basis, we decided to investigate the presence of both mature and immature DC in the peripheral blood of early or advanced cancer patients. The study included 40 solid tumor patients, 18 of whom had a locally limited disease, while the other 22 showed distant organ metastases. CD123+ and CD11c+ cells were detected by FACS using monoclonal antibodies, and expressed as the percent of total leukocytes. The control group consisted of 50 healthy subjects. The mean percent of both CD123+ and CD11c+ cells was significantly lower in cancer patients than in controls. Moreover, the mean percent of both DC subsets was significantly lower in metastatic patients than in the non-metastatic ones. This study, demonstrating significantly lower percents of both immature and mature DC in the peripheral blood of cancer patients, particularly in those with distant organ metastases, suggests that DC deficiency may play a role in inducing cancer-related immunosuppression. Therefore, the demonstration of a diminished percent of DC in peripheral blood may represent a new interesting biological marker predicting a poor prognosis in human neoplasms, as with lymphocytopenia, the unfavourable prognostic significance of which has been well demonstrated.
Generally, when a splenectomy is performed to treat either a severe hypersplenism or another splenic affection in a cirrhotic patient with uncomplicated esophageal varices, the question arises whether to associate or not a prophylactic shunt. In fact, splenectomy alone does not lower the portal pressure and does not affect positively the esophageal varices. Because of this, 36% of these patients will eventually undergo a bleeding episode from varices. Furthermore, in the patients surviving the first bleeding, the occurrence of splenoportal thrombosis following splenectomy does prevent a therapeutic shunt to be performed. For this reason splenectomy with a complementary prophylactic shunt was performed in 24 patients. This operation, which showed 16% mortality rate, significantly prevented bleeding (0%). Furthermore in the treated patients, splenectomy has lowered the portal pressure. Encephalopathy occurred in 30% of cases, however the accuracy in the selection of patients together with a proper diet and medical treatment have avoided severe complications. The 5 year survival rate was 60%. Nevertheless, the indication to a prophylactic shunt must be limited to these particular cases.
Conservative management of distal gastro-intestinal bleeding is successful in most cases; 10% of patients hospitalised with this diagnosis will however undergo emergency surgery. Preoperative localisation of the bleeding site allows to perform a limited, segmental colectomy even in emergency. This has been shown to be associated with a lower operative mortality and morbidity when compared with subtotal colectomy. In this retrospective study we reviewed the notes of 134 patients admitted with lower gastro-intestinal bleeding. 22 of these required more than 4 units of blood transfusion and 12 underwent emergency surgery. Preoperative localisation of the source of bleeding was possible in 7 cases (58%); the remaining 5 underwent a subtotal colectomy. The operative mortality was 8%. The Authors emphasise the importance of an aggressive diagnostic work up in all cases of massive bleeding (i.e. more than 4 units of blood requirement in the first 24 hours following hospitalisation) in order to minimise the number of emergency subtotal colectomy.
The use of the modern diagnostic imaging techniques allows in most cases a diagnosis of nature of the lesions involving parenchymal organs. The authors report a case of renal xantogranuloma, rare pseudotumoral inflammatory pathology, treated by radical extended nephrectomy on the basis of a pre-operative diagnosis of malignant tumor. Despite the risk of false positives, in front of a renal mass whose nature is sufficiently characterized by the imaging techniques, the routine use of more invasive investigations such as arteriography and percutaneous needle biopsy seems not justified.
The authors report their experience about one case of popliteal artery aneurysm. The patient was treated with aneurysm resection and dacron by-pass graft. The good surgical results and high risk of natural complications of popliteal aneurysms suggest that operation in the asymptomatic stage should always be attempted.
