Revisione critica dei risultati e nuovi algoritmi decisionali sulla chirurgia dell'OSAS

Obstructive sleep apnoea/hypopnoea syndrome (OSAHS) is the periodic reduction or cessation of airflow during sleep. The syndrome is associated whit loud snoring, disrupted sleep and observed apnoeas. Surgery aims to alleviate symptoms of daytime sleepiness, improve quality of life and reduce the signs of sleep apnoea recordered by polysomnography. Surgical intervention for snoring and OSAHS includes several procedures, each designed to increase the patency of the upper airway. Procedures addressing nasal obstruction include septoplasty, turbinectomy, and radiofrequency ablation (RF) of the turbinates. Surgical procedures to reduce soft palate redundancy include uvulopalatopharyngoplasty with or without tonsillectomy, uvulopalatal flap, laser-assisted uvulopalatoplasty, and RF of the soft palate. More significant, however, particularly in cases of severe OSA, is hypopharyngeal or retrolingual obstruction related to an enlarged tongue, or more commonly due to maxillomandibular deficiency. Surgeries in these cases are aimed at reducing the bulk of the tongue base or providing more space for the tongue in the oropharynx so as to limit posterior collapse during sleep. These procedures include tongue-base suspension, genioglossal advancement, hyoid suspension, lingualplasty, and maxillomandibular advancement. We reviewed 269 patients undergoing to osas surgery at the ENT Department of Forlì Hospital in the last decade. Surgery was considered a success if the postoperative apnea/hypopnea index (AHI) was less than 20/h. According to the results, we have developed surgical decisional algorithms with the aims to optimize the success of these procedures by identifying proper candidates for surgery and the most appropriate surgical techniques. Although not without risks and not as predictable as positive airway pressure therapy, surgery remains an important treatment option for patients with obstructive sleep apnea (OSA), particularly for those who have failed or cannot tolerate positive airway pressure therapy. Successful surgery depends on proper patient selection, proper procedure selection, and experience of the surgeon. The intended purpose of medical algorithms is to improve and standardize decisions made in the delivery of medical care, assist in standardizing selection and application of treatment regimens, to reduce potential introduction of errors. Nasal Continuous Positive Airway Pressure (nCPAP) is the recommended therapy for patients with moderate to severe OSAS. Unfortunately this treatment is not accepted by some patient, appears to be poorly tolerated in a not neglible number of subjects, and the compliance may be critical, especially in the long term if correctly evaluated with interview as well with CPAP smart cards analysis. Among the alternative options in Literature, surgery is a long time honoured solution. However until now no clear scientific evidence exists that surgery can be considered a really effective option in OSAHS management. We have design a randomized prospective study comparing MMA and a ventilatory device (Autotitrating Positive Airways Pressure – APAP) in order to understand the real effectiveness of surgery in the management of moderate to severe OSAS. Fifty consecutive previously full informed patients suffering from severe OSAHS were enrolled and randomised into a conservative (APAP) or surgical (MMA) arm. Demographic, biometric, PSG and ESS profiles of the two group were statistically not significantly different. One year after surgery or continuous APAP treatment both groups showed a remarkable improvement of mean AHI and ESS; the degree of improvement was not statistically different. Provided the relatively small sample of studied subjects and the relatively short time of follow up, MMA proved to be in our adult and severe OSAHS patients group a valuable alternative therapeutical tool with a success rate not inferior to APAP.

International cooperation in endourology: percutaneous and flexible ureteroscopic treatment of lower pole kidney stones

Introduction Lower pole kidney stones represent at time a challenge for the urologist. The gold standard treatment for intrarenal stones <2 cm is Extracorporeal Shock Wave Lithotripsy (ESWL) while for those >2 cm is Percutaneous Nephrolithotomy (PCNL). The success rate of ESWL, however, decreases when it is employed for lower pole stones, and this is particularly true in the presence of narrow calices or acute infundibular angles. Studies have proved that ureteroscopy (URS) is an efficacious alternative to ESWL for lower pole stones <2 cm, but this is not reflected by either the European or the American guidelines. The aim of this study is to present the results of a large series of flexible ureteroscopies and PCNLs for lower pole kidney stones from high-volume centers, in order to provide more evidences on the potential indications of the flexible ureteroscopy for the treatment of kidney stones. Materials and Methods A database was created and the participating centres retrospectively entered their data relating to the percutaneous and flexible ureteroscopic management of lower pole kidney stones. Patients included were treated between January 2005 and January 2010. Variables analyzed included case load number, preoperative and postoperative imaging, stone burden, anaesthesia (general vs. spinal), type of lithotripter, access location and size, access dilation type, ureteral access sheath use, visual clarity, operative time, stone-free rate, complication rate, hospital stay, analgesic requirement and follow-up time. Stone-free rate was defined as absence of residual fragments or presence of a single fragment <2 mm in size at follow-up imaging. Primary end-point was to test the efficacy and safety of flexible URS for the treatment of lower pole stones; the same descriptive analysis was conducted for the PCNL approach, as considered the gold standard for the treatment of lower pole kidney stones. In this setting, no statistical analysis was conducted owing to the different selection criteria of the patients. Secondary end-point consisted in matching the results of stone-free rates, operative time and complications rate of flexible URS and PCNL in the subgroup of patients harbouring lower pole kidney stones between 1 and 2 cm in the higher diameter. Results A total 246 patients met the criteria for inclusion. There were 117 PCNLs (group 1) and 129 flexible URS (group 2). Ninety-six percent of cases were diagnosed by CT KUB scan. Mean stone burden was 175±160 and 50±62 mm2 for groups 1 and 2, respectively. General anaesthesia was induced in 100 % and 80% of groups 1 and 2, respectively. Pneumo-ultrasonic energy was used in 84% of cases in the PCNL group, and holmium laser in 95% of the cases in the flexible URS group. The mean operative time was 76.9±44 and 63±37 minutes for groups 1 and 2 respectively. There were 12 major complications (11%) in group 1 (mainly Grade II complications according to Clavidien classification) and no major complications in group 2. Mean hospital stay was 5.7 and 2.6 days for groups 1 and 2, respectively. Ninety-five percent of group 1 and 52% of group 2 required analgesia for a period longer than 24 hours. Intraoperative stone-free rate after a single treatment was 88.9% for group 1 and 79.1% for group 2. Overall, 6% of group 1 and 14.7% of group 2 required a second look procedure. At 3 months, stone-free rates were 90.6% and 92.2% for groups 1 and 2, respectively, as documented by follow-up CT KUB (22%) or combination of intra-venous pyelogram, regular KUB and/or kidney ultrasound (78%). In the subanalysis conducted comparing 82 vs 65 patients who underwent PCNL and flexible URS for lower pole stones between 1 and 2 cm, intreoperative stone-free rates were 88% vs 68% (p= 0.03), respectively; anyway, after an auxiliary procedure which was necessary in 6% of the cases in group 1 and 23% in group 2 (p=0.03), stone-free rates at 3 months were not statistically significant (91.5% vs 89.2%; p=0.6). Conversely, the patients undergoing PCNL maintained a higher risk of complications during the procedure, with 9 cases observed in this group versus 0 in the group of patients treated with URS (p=0.01) Conclusions These data highlight the value of flexible URS as a very effective and safe option for the treatment of kidney stones; thanks to the latest generation of flexible devices, this new technical approach seems to be a valid alternative in particular for the treatment of lower pole kidney stones less than 2 cm. In high-volume centres and in the hands of skilled surgeons, this technique can approach the stone-free rates achievable through PCNL in lower pole stones between 1 and 2 cm, with a very low risk of complications. Furthermore, the results confirm the high success rate and relatively low morbidity of modern PCNL for lower pole stones, with no difference detectable between the prone and supine position.

Nuove tecniche per il trattamento della malattia paranale di Crohn

Studio prospettico su 75 pazienti con malattia paranale di Crohn che ha come obiettivo quello di confrontare i risultati tra le nuove terapie medico-chirurgiche emergenti. La prima procedura è comune a tutti i pazienti e consiste in un intervento di incisione degli ascessi, fistulectomia e posizionamento di setoni di drenaggio nei tramiti fistolosi per il controllo della sepsi.Successivamente i pazienti vengono divisi in cinque gruppi e sottoposti ai trattamenti per la chiusura dei tramiti fistolosi: terapia sistemica con Infliximab,terapia sistemica con Adalimumab,confezionamento di Flap endoanale, instillazione di colla di fibrina o posizionamento di protesi biologiche. Abbiamo osservato una chiusura completa dei tramiti fistolosi nel 60% dei pazienti trattati con Infliximab, 53% di quelli trattati con Adalimumab, 40% di quelli in terapia con colla di fibrina, 80% di quelli sottoposti a Flap endoanale e 60% di quelli trattati con protesi biologiche. Gli ottimi risultati raggiunti in con le diverse metodiche di trattamento chirurgico locale rappresentano una valida alternativa alla terapia con farmaci biologici. Tali nuove metodiche risultano anzi fondamentali per il trattamento di quei pazienti che dopo una terapia con farmaci biologici non hanno raggiunto una completa risoluzione del quadro (rescue therapy). Terapia biologica e nuove tecniche chirurgiche risultano pertanto complementari, la prima contribuendo al miglioramento della qualità della mucosa del canale anale e del retto basso sulla quale risulta quindi più agevole agire con le seconde con una percentuale di successo sempre maggiore.

Efficacia delle griglie in titanio con osso particolato nella ricostruzione dei difetti alveolari tridimensionali dei mascellari

Questa tesi valuta l’efficacia della tecnica delle griglie in titanio con osso particolato nella ricostruzione dei difetti alveolari tridimensionali ai fini della riabilitazione dentale implanto-protesica. Il primo studio ha considerato la metodica in termini di complicanze post-operatorie e di risultati implanto-protesici. Sono stati considerati 24 pazienti con difetti tridimensionali trattati con l’applicazione di 34 griglie di titanio e osso particolato e riabilitati protesicamente dopo circa 8-9 mesi. 4 su 34 griglie sono state rimosse prima dell’inserimento implantare (11.76% di fallimento totale); 20 su 34 griglie si sono esposte per deiscenza dei tessuti molli (58.82% di complicanze): 4 (11.77%) prima e 16 (47.05%) dopo le prime 4-6 settimane dall’intervento; in nessun caso il piano di trattamento implanto-protesico ha subito variazioni. Dopo un follow-up medio di 20 (3-48) mesi dal carico protesico, nessuno degli 88 impianti ha perso la propria osteo-integrazione (100% di sopravvivenza implantare), con un valore complessivo di successo implantare di 82.9%. Il secondo studio ha calcolato in termini volumetrici la ricostruzione ossea ottenuta con griglie e la sua corre-lazione con l’estensione dell’esposizione e la tempistica del suo verificarsi. Sono stati valutati 12 pazienti con 15 difetti alveolari. Per ciascun sito sono state studiate le immagini TC con un software dedicato per misurare i volumi in tre dimensioni: il volume di osso non formatosi rispetto a quanto pianificato, lacking bone volume (LBV), è stato calcolato sottraendo il volume di osso ricostruito, reconstructed bone volume (RBV) in fase di ri-entro chirurgico dal volume di osso pianificato pre-operativamente, planned bone volume (PBV). LBV è risultato direttamente proporzionale all’area di esposizione della griglia, con un valore del 16.3% di LBV per ogni cm2 di griglia esposta. Si sono evidenziate, inoltre, correlazioni positive tra LBV , la tempistica precoce di esposizione e il valore di PBV.

Oblique ionograms automatic scaling and eikonal based ray tracing

A method for automatic scaling of oblique ionograms has been introduced. This method also provides a rejection procedure for ionograms that are considered to lack sufficient information, depicting a very good success rate. Observing the Kp index of each autoscaled ionogram, can be noticed that the behavior of the autoscaling program does not depend on geomagnetic conditions. The comparison between the values of the MUF provided by the presented software and those obtained by an experienced operator indicate that the procedure developed for detecting the nose of oblique ionogram traces is sufficiently efficient and becomes much more efficient as the quality of the ionograms improves. These results demonstrate the program allows the real-time evaluation of MUF values associated with a particular radio link through an oblique radio sounding. The automatic recognition of a part of the trace allows determine for certain frequencies, the time taken by the radio wave to travel the path between the transmitter and receiver. The reconstruction of the ionogram traces, suggests the possibility of estimating the electron density between the transmitter and the receiver, from an oblique ionogram. The showed results have been obtained with a ray-tracing procedure based on the integration of the eikonal equation and using an analytical ionospheric model with free parameters. This indicates the possibility of applying an adaptive model and a ray-tracing algorithm to estimate the electron density in the ionosphere between the transmitter and the receiver An additional study has been conducted on a high quality ionospheric soundings data set and another algorithm has been designed for the conversion of an oblique ionogram into a vertical one, using Martyn's theorem. This allows a further analysis of oblique soundings, throw the use of the INGV Autoscala program for the automatic scaling of vertical ionograms.

Gestione pre, intra e post-operatoria del cane sottoposto ad ipofisectomia transfenoidale

L’approccio chirurgico agli adenomi ipofisari ACTH secernenti è la terapia d’elezione nell’uomo. L’ipofisectomia transfenoidale è invece una tecnica poco diffusa in ambito veterinario. La terapia più diffusa nel cane con ipercortisolismo ipofisi dipendente (PDH) è di tipo medico e prevede la somministrazione di farmaci inibitori della sintesi del cortisolo. Gli adenomi ipofisari possono aumentare di volume e determinare una conseguente sintomatologia neurologica; in questi casi le uniche opzioni terapeutiche sono rappresentate dall’asportazione chirurgica della neoplasia e dalla radioterapia. Nella presente tesi vengono descritti 8 interventi di ipofisectomia transfenoidale effettuati su 7 cani con macroadenoma ipofisario presso il Dipartimento di Scienze Mediche Veterinarie dell’Università di Bologna. La difficoltà maggiore per il chirurgo è rappresentata dalla localizzazione della fossa ipofisaria rispetto ai punti di repere visibile in tomografia computerizzata o in risonanza magnetica nucleare, oltre ai problemi di sanguinamento durante la rimozione della neoplasia. Nel periodo post-operatorio maggiori complicazioni si riscontrano in soggetti con adenomi ipofisari di maggiori dimensioni. Al contrario, in presenza di adenomi di dimensioni più contenute, la ripresa post-operatoria risulta più rapida e il tasso di successo maggiore. Al fine di poter eseguire nel cane l’exeresi mirata della sola neoplasia ipofisaria, al pari di quanto avviene nell’uomo, è stato condotto uno studio sulla tomografia computerizzata (TC) in 86 cani con PDH. Il protocollo TC non ha tuttavia permesso di individuare con precisione la posizione della neoplasia per guidare il chirurgo nella sua rimozione. In due casi riportati nel presente lavoro si è verificata una recidiva della neoplasia ipofisaria. In un soggetto si è optato per il reintervento, mentre nell’altro caso per la radioterapia. Entrambe le opzioni hanno garantito una buona qualità di vita per più di un anno dall’intervento terapeutico. Questi casi clinici dimostrano come il reintervento e la radioterapia possano essere considerate valide opzioni in caso di recidiva.

Fistole retto-vaginali Crohn-relate trattate mediante trasposizione del muscolo gracile: risultati a lungo termine e qualità della vita

OBIETTIVO: Le fistole retto-vaginali Crohn-relate hanno un impatto significativo sulla qualità della vita. Quando il canale anale è alterato da ulcerazioni e stenosi o in pazienti con difetti estesi del perineo, la chirurgia locale produce risultati insoddisfacenti. Lo scopo di questo studio è quello di valutare l'efficacia della trasposizione del muscolo gracile nelle fistole retto-vaginali Crohn-relate e determinare i suoi effetti sulla qualità della vita. MATERIALI E METODI: Da gennaio 2012 a ottobre 2014 sono state trattate 10 pazienti; sono state raccolte alcune variabili (età, BMI, il fumo, CDAI, setone perioperatorio, precedenti procedure, uso di immunomodulatori e steroidi). Tutte le pazienti sono state sottoposte ad ileostomia temporanea prima della graciloplastica. La percentuale di successo è stata misurata come numero di pazienti con fistola guarita dopo la chiusura della stomia. Sono stati utilizzati tre questionari prima della graciloplastica e 3 mesi dopo la chiusura della stomia al fine di valutare la qualità della vita (SF-36), l’ incontinenza fecale e la funzione sessuale. RISULTATI: La fistola retto-vaginale è stata chiusa in 9 pazienti su 10 dopo graciloplastica, con un follow-up medio di chiusura della stomia di 19 mesi (range 4 -34). È stata documentata una recidiva di RVF. Il tempo operatorio era 90-150 minuti (media, 120). La degenza postoperatoria era 7-16 giorni (media 10). Complicanze postoperatorie precoci includevano deiscenza delle suture perineali in 2 casi. Le complicanze a lungo termine includevano disestesia della cicatrice perineale. Nei dati post-operatori abbiamo riportato un miglioramento della qualità di vita, della funzione sessuale e della continenza fecale. CONCLUSIONI: La chiusura della fistola retto-vaginale utilizzando la trasposizione del muscolo gracile è associata a morbidità minima e un alto tasso di successo.

Development of a hydrogel construct to prevent endoleaks occurrence following endovascular abdominal aortic aneurysm repair

Abdominal aortic aneurysm is the pathological dilation of the abdominal tract of the aorta and, if left untreated, could undergo rupture with a mortality rate of up to 90%. EVAR is the most common method for AAA treatment consisting in the internal coverage of the aorta with a metallic stent to isolate the aneurysmatic segment from the systemic circulation. Although EVAR technical success rate is high, reinterventions are common. Among the causes of reinterventions typeII endoleaks are the most frequent and consist in retrograde blood flow into the aneurysmal sac from collateral aortic branches. Continued perfusion of the aneurysm sac may lead to aneurysm rupture, therefore AAA sac embolization is performed using metallic coils. However, the presence of artifacts caused by the presence of metallic coils is a limitation because they are radiopaque and can hamper the endoleak during imaging follow-up. This study is aimed at developing a biocompatible hydrogel that could be injected into the aneurysmal sac and may allow a selective intraprocedural sac embolization to reduce post procedural typeII endoleak and eventual AAA rupture. P(BT75BSI25) was synthesized by polycondensation and its biocompatibility tested to assess whether the polymers had no toxic effects. HUVEC cell line was used to mimic the environment in which the polymer would be in contact with, PBS was used as a positive control and MTT assay was performed to evaluate cellular viability after being in contact with the hydrogel. MTT assay showed no significant difference between PBS and P(BT75BSI25), thus the polymer is biocompatible, as confirmed by the analysis of apoptosis by flow cytometry. An aromatic copolymer was obtained via polycondensation and was found to be biocompatible in contact with endothelial cells. This suggests that the hydrogel could be potentially used in the clinical setting for the treatment of type II endoleak after EVAR.