Biomedical subjects
Publications and source records attributed to M Bezzi.
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BACKGROUND: The treatment of lymphoproliferative diseases requires extensive histological, immunohistochemical, and cytogenetic diagnosis. The aim of this study was to analyze the results of 66 laparoscopic procedures in the diagnosis, staging, and restaging of hematological malignancies localized in the abdominal cavity. METHODS: Between July 1993 and March 1998, 64 consecutive patients (28 male and 36 female; mean age 46.6 years, range 7 to 69) with diagnosed or suspected lymphoproliferative diseases were referred for primary diagnosis or reassessment and for staging/restaging. RESULTS: Sixty-two out of 66 procedures (93.9%) were completed laparoscopically. CONCLUSIONS: The minimally invasive approach, in the management of lymphoproliferative diseases, is able not only to provide an adequate specimen for proper diagnostic techniques, but also, when compared with open surgery, to offer a large number of advantages.
OBJECTIVE: Our purpose was to assess the accuracy of CT with drug-induced hypotonia and water filling in revealing the depth of tumor invasion of the gastric wall, according to the T factor of TNM classification, and to verify the capability of this technique in differentiating diffuse from intestinal gastric cancer. SUBJECTS AND METHODS: Forty patients (age range, 35-78 years) with histologically proven gastric tumors underwent CT, in the prone position, with drug-induced hypotonia and water filling. The images were prospectively reviewed by two radiologists who were asked to assess the depth of tumor invasion in the gastric wall. The thickening of the hypodense layer and the contrast enhancement of lesion were measured. RESULTS: CT correctly assessed gastric wall invasion in 77% and 82% of cases for observers A and B, respectively; overstaging was 20% and 15%, respectively; and understaging occurred in 3% of cases for both observers. Diagnostic sensitivity for serosal invasion was 100% for both observers; specificity was 80% and 87%, respectively. Substantial agreement between the observers was obtained (kappa = .6). Diffuse and intestinal cancers could be differentiated by CT in 92% of cases, considering the thickening of the hypoattenuating layer of the gastric wall (diffuse cancer: 7 +/- 1.2 mm; intestinal cancer: 1.4 +/- 0.4 mm) and contrast enhancement (diffuse cancer: 85 +/- 8.2 H; intestinal cancer: 51 +/- 3 H). CONCLUSION: CT with patients in a drug-induced hypotonia and in a prone position, and using water filling, is a promising technique for evaluating the depth of tumor invasion and for differentiating intestinal from diffuse gastric cancer.
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Transjugular intrahepatic portosystemic shunt (TIPS), a new technique for the treatment of portal hypertension, has been successful in preliminary studies to treat acute variceal hemorrhage and to prevent variceal rebleeding. The purpose of this multicenter, randomized controlled trial is to compare the efficacy of TIPS with that of endoscopic sclerotherapy in the prevention of variceal rebleeding in cirrhosis. Eighty-one cirrhotic patients, with endoscopically proven variceal bleeding, were randomized to either TIPS (38 patients) or endoscopic sclerotherapy (43 patients). Randomization was stratified according to the following: if bleeding occurred < 1 week (stratum I); if bleeding occurred 1 to 6 weeks (stratum II); and if bleeding occurred 6 weeks to 6 months (stratum III) before enrollment. Follow-up included clinical, biochemical, Doppler Ultrasound, and endoscopic examinations every 6 months. During a mean follow-up of 17.7 months, 51% of the patients treated with sclerotherapy and 24% of those treated with TIPS rebled (P = .011). Mortality was 19% in sclerotherapy patients and 24% in TIPS patients (P = .50). Hepatic encephalopathy (HE) developed in 26% and 55%, respectively (P = .006). A separate analysis of the three strata showed that TIPS was significantly more effective than sclerotherapy (P = .026) in preventing rebleeding only in stratum I patients. TIPS is significantly better than sclerotherapy in preventing rebleeding only when it is performed shortly after a variceal bleed; however, TIPS does not improve survival and is associated with a significantly higher incidence of HE. The overall performance of TIPS does not seem to justify the adoption of this technique as a first-choice treatment to prevent rebleeding from esophageal varices in cirrhotic patients.
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OBJECTIVE: Intraoperative ultrasound has gradually expanded in the last two decades to a variety of surgical specialties and has gained an established role in many surgical procedures. Laparoscopic and thoracoscopic ultrasound are the latest modes of intraoperative sonography. They have been introduced mainly to overcome the two major drawbacks of laparoscopy, i.e. the capability of showing only the surface of the organs and the lack of manual palpation of the anatomical structures. We review and discuss the established and the most recent applications of intraoperative and laparoscopic ultrasound. MATERIAL AND METHODS: The technology, new indications and results of intraoperative and laparoscopic ultrasound are reviewed. This review is based on the experience gained in our Institution during more than 500 surgical procedures and the analysis of the literature on the subject. RESULTS: The yield of intraoperative and laparoscopic ultrasound consists in confirming preoperative studies and acquiring new data which would not be available otherwise. An important role of these techniques is determining the anatomy of the involved organs, thus providing a guidance for surgery. Both techniques have an important role in surgical decision-making, particularly with respect to hepatic, biliary and pancreatic malignancies. In some series the rate of major changes in the surgical strategy can be as high as 38%. A relatively new application of intraoperative ultrasound is the possibility to perform interstitial therapy of tumors at the time of the initial surgery. This can be useful, for example, in patients undergoing liver resection, when other unresectable lesions are found in a different segment or in the contralateral lobe. Finally, laparoscopic sonography has an important role in staging abdominal neoplasm, providing more information than preoperative imaging and laparoscopic exploration. This feature can be used to effectively stage gastrointestinal malignancies, pancreatic carcinoma, and abdominal lymphomas. CONCLUSION: The application of intraoperative ultrasound will increase in the era of minimally access surgery and this will be dependent not only on technical improvements in ultrasound technology. Indeed, it may be expected that a variety of open procedures will be performed with videolaparoscopic monitoring and will need the guidance of laparoscopic sonography. In the future, the staging of abdominal neoplasm may be markedly improved by laparoscopy combined with laparoscopic ultrasound; however a cost-benefit analysis of these techniques and a comparison with preoperative tests should be carried out.
INTRODUCTION: Focal nodular hyperplasia (FNH) is a benign liver lesion requiring a prompt diagnosis and a conservative management. Aim of our study was to prospectively integrate enhanced CT, MRI, nuclear medicine in the noninvasive diagnosis of FNH. MATERIAL AND METHODS: 20 FNH lesions (diameter ranging 1.5-13 cm) in 18 asymptomatic patients were investigated with MRI and nuclear medicine. MRI examinations were performed with a 1.5 T superconducting system (Philiphs NT) by acquiring T1-weighted, T2-weighted, T2-weighted fat-suppressed Turbo Spin-Echo and dynamic MRI sequences, with breath-hold T1-weighted Turbo Field Echo and Gd-DTPA. Nuclear medicine included in all cases 99mTc sulfur colloid or 99mTc iminodiacetic acid studies. Diagnostic sensitivity of MRI was compared with that of nuclear medicine, and the sensitivity of the two modalities combined. The definitive diagnosis was made by percutaneous core-needle biopsy (12 lesions), surgery (2 lesions) and longterm follow-up (6 lesions). RESULTS: In 13 lesions larger than 3.5 cm typical findings, such as the central scar and homogeneous pattern, were observed in 9 cases (75%) with enhanced CT, in 10 cases (83%) with unenhanced MRI and in 11 cases (91%) after gadolinium injection. Hepatobiliary scintigraphy showed increased tracer uptake in delayed scans in 10/12 cases (83%) while sulfur colloid studies were diagnostic in 2/12 cases only (16%), showing the same tracer uptake than the surrounding liver parenchyma. In 7 lesions smaller than 3.5 cm, only 1 case showed typical findings; dynamic MRI showed typical early hypervascularity in 5 of the 6 remaining lesions (71%) which persisted on late images. In lesions smaller than 3.5 cm, sulfur colloid studies were diagnostic in 1/7 lesions (14%) and hepatobiliary scintigraphy in 3/7 lesions (42%). Considering all 20 lesions, MRI-nuclear medicine integration performed better than MRI alone. CONCLUSIONS: Enhanced MRI and biliary scintigraphy are important tools to make the final diagnosis of FNH. In small lesions both examinations should performed, but in large lesions MRI may be sufficient to make an unquestionable diagnosis, limiting hepatobiliary scintigraphy to questionable cases.
A total of 35 patients (age range 35-78 years) with gastric tumors on the lesser curve, or in the antro-pyloric region, underwent angio-CT in the prone position after filling the stomach with 500 ml of water and intravenous administration of glucagon. The films were reviewed by three radiologists independently, staging each tumor according to the TNM classification preoperatively. The overall accuracy of tumor staging ranged between 66-77 %, overstaging between 17-25 %, and understaging between 3-8.5 %. The diagnostic sensitivity, specificity, and accuracy for serosal invasion ranged between 90 and 100, 76 and 84, and 80-88 %, respectively, and the overall accuracy for N staging was 46, 48, and 51 % for the three observers. If, however, N1 and N2 tumors were considered as a single group, N-stage accuracy increased, ranging between 63 and 77 %. The "K test" for analyzing the interobserver agreement was 60 %, i. e., the diagnostic results are reproducible. Water filling of the stomach optimizes visualization of the gastric wall on contrast-enhanced CT. The prone position and drug-induced hypotony allows for good distension without any disturbing artifact reduction obscuring the lower gastric body.
Small bowel (SB) neoplasms are very rare tumours, but are still associated with high mortality rates, since the tumour-related symptoms occur late and are non-specific. In addition, endoscopy is not feasible in most cases, and radiological contrast studies do not reach the high accuracy obtained in the evaluation of upper and lower gastrointestinal tract. Cross-sectional imaging, and particularly CT, is becoming increasingly relevant in the diagnosis of these tumours. Both US and CT allow tumour detection, even when performed on an emergency basis, and are capable of showing the lesion as well as possible complications. Moreover, CT offers the possibility of a preoperative staging by evaluating tumour extension through the bowel wall, lymph node involvement and possible metastases. Finally, in most cases a direct correlation between cross-sectional findings and histology can be found, thus permitting tumour characterisation.
Portal thrombosis may complicate the clinical course of cirrhosis, but the pathophysiologic mechanism is unclear. Aim of the study was to evaluate the behavior of clotting system and endotoxemia in portal vein and in peripheral circulation of 11 cirrhotic patients undergoing transjugular port-systemic shunt (TIPS). Portal blood showed higher values of F1 + 2 [Median (range): 2.5 (1.1-5.3) vs. 1.1 (0.6-2.1) nM, p < 0.01], D-dimer [765 (184-1713) vs. 192 (64-813) ng/ml, p < 0.01] and endotoxemia [31 (16-47.2) vs. 13.7 (7.5-23.5) pg/ml, p < 0.01] than peripheral circulation. In the portal vein, all but one sample had F1 + 2 > 1.2 nM (upper limit of control values), all but one had D-dimer > 216 mg/dl (mean + 2 SD of controls) and 100% had values of endotoxemia > 9.6 pg/ml (upper limit of control values). Fibrinogen was lower in the portal circulation compared to peripheral circulation but the difference was not significant [85 (58-195) vs. 134 (75-244) mg/dl, p > 0.05]. Endotoxemia was directly correlated with F1 + 2 (Rho = 0.92 p < 0.006) and D-dimer (Rho = 0.93, p < 0.005). This study shows that an ongoing prothrombotic state is present in the portal circulation of cirrhotic patients and may play a pivotal role in the thrombotic episodes occurring in this clinical setting.
The aim of our study was to evaluate the performance and efficacy of a new self-expanding stent (nitinol Strecker stent) in the transjugular intrahepatic portosystemic shunt (TIPS) procedure. We have successfully placed 64 nitinol Strecker stents in 48 patients. The average portosystemic gradient decreased from 22 to 11 mm Hg. Balloon dilatation was necessary in 12 of 35 angiographically controlled cases at 5 days (34%), because of incomplete stent expansion, small thrombi within the stent or obstruction. At 1-6 months stent malfunctions occurred in 8 of 23 patients who underwent control angiography (34%) and at 6-24 months in 6 of 7 patients (85%). Rebleeding occurred in 2 of 39 patients (follow-up > 1 month) (5%) and temporary crises of de novo encephalopathy were observed in 11 of 48 patients (23%). Refractory ascites completely resolved in 4 of 6 patients (66%) and improved in the remaining 2 cases. Compared with other self-expanding stents, nitinol Strecker stents seem to be equally effective in TIPS; no increase in complication rate was observed, either clinical or stent-related.
Forty-seven consecutive patients were prospectively evaluated to study the incidence of hepatic encephalopathy as well as modifications in the PSE index after TIPS. Various clinical, laboratory, and angiographic parameters were also recorded to identify risk factors for the development of post-TIPS hepatic encephalopathy (HE). Mean follow-up was 17 +/- 7 months. During follow-up, six patients died and one underwent transplantation. All other patients were followed for at least a year. Fifteen patients (32%) experienced 20 acute episodes of precipitated HE (hospitalization was necessary in 10 instances), and five patients (11%) presented a continuous alteration in mental status with frequent spontaneous exacerbation during follow-up. Both precipitated and spontaneous HE occurred more frequently during the first three months of follow-up. Moreover the PSE index was significantly worse than basal values one month after TIPS, thereafter returning to near basal values. HE was successfully treated in all patients but one who required a reduction in the stent/shunt diameter. Increasing age (>65 years) and low portacaval gradient (<10 mm Hg) were predictors of HE after TIPS. A gradual dilation of the stent/shunt should be performed to obtain a portacaval gradient >10 mm Hg to avoid an unacceptable rate of HE after TIPS.
Despite the availability and wide use of modern imaging techniques, the diagnosis of Meckel's diverticulum is difficult. The signs and symptoms vary from none to those of an acute abdomen or gastrointestinal bleeding. Findings on physical examination may be inconsistent because of the variable location of the diverticulum, and bleeding may occur with no appreciable physical findings. Finally, small diverticula are often concealed by overlying small-bowel loops on routine small-bowel barium studies. The purposes of this article are to review the use of available techniques for the imaging diagnosis of Meckel's diverticulum, to discuss the relative advantages and indications for the various procedures, and to emphasize the role each plays in specific clinical circumstances. The embryology, anatomy, and clinical presentation of Meckel's diverticulum are also briefly discussed.
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The diagnostic and therapeutic approaches used for patients referred for bile duct injuries and other major complications after laparoscopic cholecystectomy (LC) were reviewed and the results of a coordinated radiologic, endoscopic, and surgical approach were assessed. From April 1991 to October 1993, 23 patients were observed. Seven patients had biliary strictures, five had biliary lesions, five presented with retained common bile duct (CBD) stones, and one had a minor cystic duct leak. Five patients had miscellaneous abdominal fluid collections; in addition, biloma or bile ascites were present in 10/23 cases. Correct definition of iatrogenic lesions was mainly made by endoscopic retrograde cholangiography (ERCP) (n = 15), associated in six cases also with percutaneous cholangiography (PTC). "Minimally invasive" treatment included the full range of endoscopic and interventional radiological procedures. Six patients with biliary strictures, one patient with a biliary lesion, all five patients with residual CBD stones, and four patients with abdominal collections were treated by "minimally invasive" techniques: Therefore, laparotomy was avoided in 70% of cases (16/23 patients). Open surgery was necessary in 7/23 patients (30%), because of ductal lesion (n = 4), ductal stricture by endoloop (n = 1), iliac artery injury (n = 1), and phlegmon of gallbladder bed (n = 1). It appears that careful assessment of complications after LC is mandatory and often requires the combined use of ERCP/PTC and cross-sectional imaging.(ABSTRACT TRUNCATED AT 250 WORDS)