Chirurgia italiana
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The authors report a case of a pancreatic pseudocyst, due to alcoholic chronic pancreatitis, that was transformed into a pseudoaneurysm of the splenic artery as a result of vascular erosion and that manifested itself with massive haematemesis due to spontaneous fistulisation in the stomach. After defining the incidence of the pancreatic disease and of this unusual form of gastric bleeding, particular attention is devoted to the clinical data and to the aetiopathogenic and physiopathological mechanisms involved in the vascular glandular and periglandular damage, outlining the sources and sites of bleeding. ⋯ After a review of the conditions that make the treatment difficult, the authors stress the importance of a certain measure of eclecticism and careful planning to obtain effective and safe results. Only the combined, integrated efforts of the interventional radiologist and the surgeon can ensure rapid stabilisation of the bleeding and the desired improvement in survival.
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The term acute mediastinitis describes a number of clinical conditions, usually secondary to diseases of other aetiology with which they tend to share the severity of the clinical picture. In these situations even a timely diagnosis and adequate therapeutic management are not always enough to ensure healing. Over the period 1987-2002 15 patients with acute mediastinitis were observed (8 male, 7 female), aged from 22 to 90 years (mean age: 57.9), distributed as follows: descending necrotising mediastinitis, 4 cases; iatrogenic oesophageal rupture, 2 cases; iatrogenic tracheal rupture, 3 cases; oesophageal perforation (foreign body), 4 cases; Boerhaave's syndrome, 1 case; oesophageal perforation (lye ingestion), 1 case. ⋯ In 4 cases (2 descending necrotising mediastinitis, 2 acute mediastinitis secondary to oesophageal perforation) repeated interventions were necessary in order to drain pleural or mediastinal effusions. Acute mediastinitis remains a serious clinical entity, the outlook of which is often poor. Factors influencing outcome are the patient's age and general condition (adequate immune response), a timely diagnosis, preoperative localisation of effusions, an aggressive therapeutic approach including drainage of infection sites in the mediastinum, neck and/or pleural cavities, alimentary tract diversion in cases of oesophageal lesions observed late, adequate antibiotic therapy, and nutritional support (total parenteral/enteral nutrition).
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Randomized Controlled Trial Clinical Trial
A prospective randomized clinical trial on pain control after major abdominal surgery.
This study was conducted in order to investigate the advantages and limitations of four analgesic modalities: a) epidural morphine; b) intravenous morphine; c) patient controlled intravenous morphine (patient-controlled analgesia); and d) non-steroidal anti-inflammatory drugs. Eighty patients undergoing major abdominal surgical procedures were prospectively and randomly treated with one of the above-mentioned analgesic methods. Evaluation of pain perception was done using the visual analogue pain score and the simple descriptive scale 4 hours after the procedure, in the early morning on postoperative day 1 and in the afternoon on postoperative days 1, 2 and 3. ⋯ Morphine proved to be the drug of choice. Drug titration may be modulated in relation to the psychological characteristics of the patient. The best drug titration modality, in fact, is patient-controlled analgesia.
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Review Case Reports
[Intestinal occlusion caused by persistent omphalomesenteric duct and Meckel's diverticulum: report of 2 cases].
Two rare cases of mechanical intestinal obstruction due to an omphalomesenteric duct remnant and/or to a Meckel's diverticulum, respectively, are reported. The first case was a 20-year-old man and the second an 87-year-old woman. ⋯ A complete diagnosis was possible only at operation and early surgery was important to prevent strangulation and gangrene of the bowel. The authors conclude that prompt and appropriate surgical treatment reduces the mortality risk in all patients with intestinal obstruction, including even resected cases.