L Bonati’s research while affiliated with University of Milan and other places

Early detection of a pheochromocytoma is necessary to avoid the cardiovascular complications of hypertension and to recognize the 10% of malignant neoplasms. Hypertensive changes, particularly hypertensive spikes and stable hypertension are the most common clinical features. A pheochromocytoma must be suspected in presence of various symptoms of which cephalea, tachycardia, diaphoresis are the most frequently encountered. Plasma catecholamines and 24-hours urine metabolites measurements have 60-100% and 72-99% sensitivity respectively. Radiologic procedures commonly used to locate a pheochromocytoma include CT and RM: they achieve 100% sensitivity for unilateral adrenal lesions and respectively 64% and 88% sensitivity for extra-adrenal lesions. Scintigraphic localization with MIBG provides functional informations and is recommended for follow-up of the recurrent or metastatic pheochromocytoma. Preoperative medical treatment using alpha and beta blocking agents or calcium channel blockers has contributed to reduce perioperative morbidity and mortality. Anterior transabdominal approach is advocated as the standard operative procedure; this approach allows ready access to any site where tumors are obviously present and permits thorough exploration of the abdominal cavity for additional contralateral adrenal or extra-adrenal lesions. An accurate preoperative localization of a sporadic, unilateral, of less than 7-10 cm, benign neoplasm constitutes the indication for the laparoscopic adrenalectomy. Pheochromocytoma-free survival were 92% and 80% at 5 and 10 years respectively; in living patients without recurrence, hypertension-free survival was 74% and 45% at 5 and 10 years respectively. Extra-adrenal pheochromocytomas are frequently malignant (36%) and are associated with a high incidence of persistent or recurrent disease (32%).

An incidentally discovered adrenal mass involves two main questions: the first is the evaluation of the hormonal activity of incidentalomas, that by definition are considered clinically silent. The second problem is to establish preoperatively the biologic behaviour of the masses, whether they are benign or malignant. An essential endocrinological screening of these masses includes the 24 hour urine VMA determination, serum potassium level, and a 1 mg overnight dexamethasone suppression test. Furthermore, the recent observation of a possible partial deficit of 21-hydroxylase suggests the advantage of 17-hydroxyprogesterone dosage after ACTH stimulation. At present no biochemical or radiologic markers can reliably distinguish benign from malignant masses. For this reason the association of imaging study with scintigraphy seems to be helpful, providing "concordant" or "discordant" patterns with CT images. As regard to therapeutic indications, the resection of all hypersecretive masses, proved malignant or increased in diameter tumors is suggested. As regards to biochemically silent lesions, the tumor size has been deemed to be the most helpful determinant of the nature although controversy remains over the size cutoff below which the masses can safely be presumed to be benign and therefore observed. The threshold to proceed surgically has been based on the perceived risk of cancer balanced against the operative risk. However it seems reasonable to recommend excision or surgical exploration for hormonally silent tumors greater than 3 cm, particularly in younger patients. According to personal opinion the laparoscopic approach might represent the gold standard in the treatment of incidentally discovered adrenal masses.

A case is reported of an 85-year-old woman with subacute intestinal obstruction due to a large Morgagni hernia containing the transverse colon. The repair was carried out laparoscopically without a mesh. The procedure lasted 45 min, and the patient was discharged after 4 days. According to the literature, mini-invasive repair of a Morgagni hernia can be performed easily and without complications. In only few cases was a mesh necessary. The Morgagni hernia must be considered a clear indication for laparoscopic surgery, which should be offered as the first approach to this disease.

In the assessment of incidentally discovered adrenal masses the detection of hormonal activity and the evaluation of benignity or malignity, either primary or metastatic, constitute the most important issues. This article reports 9 asymptomatic adrenal masses: The histopathological diagnosis consisted of cortical adenoma in 5 cases, adrenal metastatic mass in 2, respectively from a pulmonary microcytoma and from a renal carcinoma, a myelolipoma with leukemic infiltration and an hemorrhagic pseudocyst in the remnants. Evaluation of biochemical activity showed no endocrinological abnormality in all patients except in two cases of adenoma: the positivity of the 1 mg dexamethasone test, the low serum DHEAS levels and a concordant scintigraphic uptake were consistent with the pre-Cushing syndrome in the first case, whereas the ACTH inhibition revealed by low serum DHEAS levels without other hormonal alterations were the biochemical pattern in the second. Ultrasonography has been helpful in the diagnosis of adrenal mass in 6 cases, whereas CT scan allowed an etiopathogenetic diagnosis in 8 cases. All patients were submitted to adrenalectomy through the conventional surgical accesses; in 4 cases the adrenalectomy was performed as a associated intervention during vascular or gastrointestinal surgery. No postoperative death occurred. At follow-up ranging from 3 to 6 years, we recorded 4 deaths: the causes were represented by the progression of the primary malignancy in 2 patients that have been operated on for adrenal metastatic tumors, by hemorrhagic shock from an aorto-duodenal fistula and by systemic infectious complications respectively in the remnant two cases. The other patients were well and the endocrinological assessment showed normal findings. The Authors, according with data from literature, suggest an essential biochemical screening to evaluate the adrenal function in case of incidentally discovered mass: it is characterized by determination of plasma and urinary electrolytes, catecholamines, serum DHEAS and 17-OH progesterone levels, dexamethasone suppression test. In case of asymptomatic mass suspect for pheochromocytoma we advocate the MIBG scintigraphy.. The adrenocortical scintigraphy (NP 59) provides both anatomical and functional characterization of the adrenal glands: the concordant or discordant imaging patterns are useful in the diagnosis of benignity or malignancy. Although the management of patients with incidentally discovered masses remain controversial, we advocate adrenalectomy when they are hormonally hypersecreting, increasing in the diameter or malignant and in association with other abdominal operation.

This study reports 10 cases of uninodular bronchiolo-alveolar carcinoma (BAC) operated on in the General Surgery and Organ Transplantation Institute of the University of Parma between January 1st 1981 and December 31st 1995. Seven patients were males and three females, mean age was 65 (DS 11, range 37-75) and globally accounted for 6.4% of all surgically treated lung malignant tumors. Hospital mortality was null; one patient was treated with assisted ventilation four days after surgery for respiratory insufficiency. Actuarial survival at 36 and 60 months was 48% and 36% respectively; survival rates were not significantly different at log-rank test from squamous carcinoma (46.2% at 36 months, 35% at 60 months) and adenocarcinoma (50.5% at 36 months, 34.3% at 60 months). The analysis of other series of literature shows significantly higher survival rates at 5 years for BAC than for adenocarcinoma (55.6% vs 40%). Broader series are needed for statistical confrontation with other histological types by stage and grade. There is no evidence of peculiar prognostic or clinical features in this histological type of pulmonary malignancy, prognosis so far is in fact conditioned by the same factors of other non small cell lung carcinomas.

Four cases of carcinoid tumors of the vermiform appendix are reported. Clinical presentation in 3 cases was suggestive of acute appendicitis and they were submitted to appendicectomy. The carcinoid tumor was discovered by the pathologist on specimen of appendix. The tumors's size, less than 2 cm, the absence of serosal involvement and lymphatics invasion suggested that simple appendicectomy was a satisfactory treatment for such patients. Occasionally clinical presentation of appendiceal carcinoid is characterized by symptoms of intestinal obstruction or intussusception, palpable mass, bleeding. In the fourth patient, that had symptoms consistent with ileal occlusion, we found at laparotomy a bulky tumor of the base of appendix infiltrating and obstructing the cecum and right colon, without liver metastases. A right hemicolectomy with end-to-end anastomosis was performed. Aggressive behaviour of this tumor was also revealed by the single pulmonary metastasis, finding very uncommon in carcinoid of appendix. This patient died postoperatively, at 25th day, of septic abdominal complications, secondary to anastomotic leak. The former patients at clinical and radiological (CT scan) follow-up performed at 3, 12, 36 months respectively, are still alive and disease free.

A case of haemorrhagic cyst of the adrenal gland (pseudocyst) is reported. The interest is related to the histologic and pathogenetic aspects which are still controversial. In this case the cyst may be explained as a consequence of an hamartomatous vascular anomaly or as a traumatic consequence: the histopathological finding characterized by the presence of irregular vascular channels in the outer fibrous wall of the cyst may suggest that haemorrhage occurred in a preexisting blood vascular anomaly, whereas the anamnestic information of a trauma in the past suggests a traumatic origin of the mass. Clinical findings were characterized by lumbar tension and pain without palpable mass; the specific diagnosis was made preoperatively by ultrasonography and CT scan of the abdomen. Left adrenalectomy was performed through an anterior extraperitoneal approach following a supraumbilical incision.

The authors report their experience in the management of 54 patients who underwent emergency surgery for rupture of an abdominal aortic aneurysm, correlating results to time of diagnosis. The overall mortality rate was 55.5%. The extent and the site of bleeding, free blood in peritoneal cavity or retroperitoneal hematoma alone, were critical factors influencing survival and were correlated to early of diagnosis. Patients with small hematomas had no mortality; cases with more extensive hematomas had a mortality rate of 53%; in case of intraperitoneal bleeding the mortality rose to 73% (p = 0.001). The median times between symptoms' onset and surgical intervention was correlated with a significant value to extent of retroperitoneal hematoma (p = 0.003). This time is also significantly different in dead patients compared to survivors (p < 0.001). In patients with incorrect admitting diagnosis the mean times between onset of symptoms and surgical treatment was significantly different from time of correctly diagnosed patients (p < 0.001). Our findings emphasize the need for rapid recognition of prodromal symptoms of rupture and the earlier referral of patients with known abdominal aneurysm; we suggest that in an unstable patient with a suspected ruptured aneurysm immediate surgery should be performed without delay for confirmatory tests or full resuscitation.

Open adrenalectomy needs surgical incisions often large and traumatic, with a not negligible morbidity. Laparoscopic adrenalectomy, according to the experiences reported in the literature, certainly initial, but nevertheless considerable, seems to offer a sound option and will probably become one of the strongest indications of the minimal-access surgery of the retroperitoneal space. Operative times are certainly longer initially than in open surgery but morbidity is very low and mortality almost nil. The authors make a review of the literature about laparoscopic adrenalectomy with about 400 operations collected, analyzing the results and the technical details. The collected data support the conclusion that the adrenal pathology, with the exception of the malignant tumors, will be treated in the future mainly laparoscopically. Even the size of the tumor, in case of a not malignant mass, can not be considered probably a true contraindication.