Gallstone ileus in patient with Crohn's disease: report of a clinical observation.

Gallstone ileus is an uncommon form of bowel obstruction, related in the majority of cases to a cholecystoenteric fistula. In patients with Crohn's disease the stone can obstruct the diseased bowel. We report a case of gallstone ileus in a patient with Crohn's disease. An explorative laparoscopy and a minimally-invasive laparotomy were achieved to resolve the obstruction. Cholecystectomy and closure of the cholecystoduodenal fistula were not performed. The association of gallstone ileus and Crohn's disease is very rare; only few cases are reported in the literature. Laparoscopic approach could identify the extension of the disease and the site of impaction, allowing the differential diagnosis in particular in patients with Crohn's disease. In the cases described, cholecystectomy and the closure of the fistula were not performed considering the absence of any residual stone in the gallbladder and the associated risk of treating the cholecysto-duodenal fistula in an emergency settings.

Laparoscopic treatment of pancreatic insulinoma.

Laparoscopy and laparoscopic ultrasonography (LUS) have been proposed for the diagnosis and treatment of pancreatic insulinoma. We present for cases of pancreatic insulinoma approached by laparoscopy guided by LUS. In three cases, insulinomas were in the pancreatic body and in one case in the pancreatic head. All lesions were detected preoperatively by abdominal US and confirmed by computed tomography. Laparoscopy was performed under general anesthesia. LUS was performed using a 10-mm flexible probe. In two cases the adenoma was enucleated using scissors and electrocoagulation, major vessels were controlled using clips, and enucleation was completed using a 30-mm endo-GIA. In one case a laparoscopic distal pancreatectomy with spleen preservation was performed. In one case the adenoma was deep in the pancreatic head; minilaparotomy was performed and the adenoma enucleated. Patients were discharged in good health 5-7 days after surgery. The postoperative course was complicated in one case of enucleation by peripancreatic fluid collection that was treated percutaneously. Our experience confirms that accurate localization followed by excision of tumors via the laparoscopic approach constitute a significant advance in the management of insulinoma.

Is laparoscopic sonography a reliable and sensitive procedure for staging colorectal cancer? A comparative study.

BACKGROUND: Laparoscopic colectomy has developed rapidly with the explosion of technology. In most cases, laparoscopic resection is performed for colorectal cancer. Intraoperative staging during laparoscopic procedure is limited. Laparoscopic ultrasonography (LUS) represents the only real alternative to manual palpation during laparoscopic surgery. METHODS: We evaluated the diagnostic accuracy of LUS in comparison with preoperative staging and laparoscopy in 33 patients with colorectal cancer. Preoperative staging included abdominal US, CT, and endoscopic US (for rectal cancer). Laparoscopy and LUS were performed in all cases. Pre- and intraoperative staging were related to definitive histology. Staging was done according to the TNM classification. RESULTS: LUS obtained good results in the evaluation of hepatic metastases, with a sensitivity of 100% versus 62.5% and 75% by preoperative diagnostic means and laparoscopy, respectively. Nodal metastases were diagnosed with a sensitivity of 94% versus 18% with preoperative staging and 6% with laparoscopy, but the method had a low specificity (53%). The therapeutic program was changed thanks to laparoscopy and LUS in 11 cases (33%). In four cases (12%), the planned therapeutic approach was changed after LUS alone. CONCLUSIONS: The results obtained in this study demonstrate that LUS is an accurate and highly sensitive procedure in staging colorectal cancer, providing a useful and reliable diagnostic tool complementary to laparoscopy.

Laparoscopic compared with open appendicectomy for acute appendicitis: a prospective study.

OBJECTIVE: To assess the benefits of laparoscopic appendicectomy over open appendicectomy and to evaluate the impact of the severity of appendicitis and of peritonitis on the advantages of the laparoscopic approach. DESIGN: Prospective unrandomised study. SETTING: University hospital, Italy. SUBJECTS: 137 consecutive patients with acute appendicitis, 60 of whom were treated by open and 77 by laparoscopic appendicectomy. Patients were subdivided according to the severity of appendicitis and the presence of peritonitis. MAIN OUTCOME MEASURES: Duration of operation, consumption of analgesics, duration of hospital stay, overall complications, wound infection. RESULTS: Hospital stay (median 2.5 days, range 1-18 compared with 4, range 2-22 p < 0.0001). and wound infection (3/77 (4%) compared with 13/60 (22%), p 0.02) were significantly lower after laparoscopic operation. The incidence of wound infection was significantly lower when subgroups were analysed separately. CONCLUSIONS: Hospital stay and wound infection rates were significantly lower after laparoscopic appendicectomy. With the exception of the wound infection rate, the variables studied may differ depending on the severity of the appendicitis and the presence of peritonitis. Result of comparative studies should be carefully interpreted when the two groups are not stratified for these features.

Laparoscopic sonography: a real alternative to cholangiography during laparoscopic cholecystectomy?

BACKGROUND/AIMS: The routine use of intraoperative cholangiography (CGP) during laparoscopic cholecystectomy (LC) is still under debate. Previous reports suggest that intraoperative sonography can replace CGP in the evaluation of common duct lithiasis during open cholecystectomy. The present study was performed to evaluate the possible role of sonography during LC. PATIENTS AND METHODS: 45 patients were submitted to laparoscopic sonography of biliary tree during LC. In all cases, CGP was performed. RESULTS: In 37 cases, sonography did not show the presence of stones; in 7 cases, common bile duct stones were identified by sonography; one false negative was observed. A sensitivity of 87.5%, a specificity of 100% and an overall accuracy of 97.8% were obtained. A false positive was obtained with CGP with a sensitivity of 100%, a specificity 97.3%, and an overall accuracy of 97.8%. CONCLUSIONS: Laparoscopic sonography can represent an adequate substitute for CGP as a screening procedure during LC.

Constrictive pericarditis versus restrictive cardiomyopathy: the role of Doppler echocardiography in differential diagnosis.

Doppler ultrasound recordings of velocities of flow across the mitral and tricuspid valves and in the hepatic veins, and their variation with respiration, were recorded in seven patients with constrictive pericarditis and in six patients with restrictive cardiomyopathy. Deceleration of mitral and tricuspid flow was also evaluated during apnea. Color flow Doppler was performed in order to evaluate mitral and tricuspid regurgitation. Eight healthy adults served as controls. The patients with constrictive pericarditis showed higher peak diastolic velocities of mitral flow, as well as marked increase of velocity of flow at the onset of expiration and decrease at the onset of inspiration. Reciprocal respiratory variation of the velocities were also observed across the tricuspid valve. The patients with restrictive cardiomyopathy showed moderate or severe mitral and tricuspid regurgitation. They also showed shorter deceleration of flow across the mitral and tricuspid valves during apnea. The pattern of flow in the hepatic veins showed reversal during systole with accentuated reversion during inspiration. These results suggest that patient with constrictive pericarditis and restrictive cardiomyopathy can be differentiated by comparing Doppler echocardiographic data, along with changes induced by respiration.

Echocardiographic detection of right-sided cardiac thrombi in pulmonary embolism.

Echocardiography has proved useful in detecting right-sided heart thrombi in cases of pulmonary embolization. We found echocardiographic evidence of right-sided cardiac thrombi in six of seven patients affected by pulmonary embolism referred to our hospital within the past five months. In one patient with clinical evidence of pulmonary and paradoxic embolization, echocardiography revealed, besides thrombi within the inferior cava and right atrium, a transient, wide, systolic movement of the valvula foraminis ovalis toward the left atrium, suggesting an interatrial communication that was confirmed by contrast echocardiography. Five patients had a good outcome, with disappearance of the thrombi following IV heparin therapy, and one patient died.

[Prognostic value of echocardiographic finding of valvular vegetations in patients with infectious endocarditis]. / II valore prognostico del rilievo ecocardiografico di vegetazioni valvolari in pazienti con endocardite infettiva.

42 consecutive patients with infective endocarditis on native valves, according to Pelletier and Petersdorf's criteria of definite (13 pts), probable (12 pts.) and possible (17 pts) endocarditis, were identified and prospectively followed-up with M-mode and two-dimensional echocardiography, since 1980. We compared: 1) these three groups; 2) survivors not referred for surgery versus surgical patients plus nonsurvivors; 3) patients who suffered embolic events versus those who did not; 4) patients with severe-moderate heart failure versus those with no failure or mild failure; 5) patients with aortic valve echocardiographic vegetations versus those with mitral valve vegetations. Furthermore 11 of these patients who did not undergo surgery (9 with mitral and 2 with mitro-aortic vegetations on echo) were serially followed-up with echocardiography for 6-42 months (average: 32 months). The presence of ultrasound detectable vegetations itself and their size, without considering their site, did not identify a major risk of embolization, heart failure, death or need of surgery. The site of vegetations was the only significant feature in our series. It identified a high-risk group and a relatively low-risk group. Aortic valve involvement, with echocardiographic vegetations, was related to severe or moderate heart failure (P less than 0.01), death or need of surgery (P less than 0.05). Mitral valve involvement carried on a relatively low risk. The 9 patients with mitral valve vegetations only, not referred for surgery and followed-up, did well on medical treatment and returned to work. They did not have relapses or embolization. On serial echocardiographic examinations, mitral vegetations become smaller in the long run. Two years after the acute episode, usually echocardiography did not allow identification of vegetations.

[Diagnostic value of echocardiographic examinations in the evaluation of patients with infectious endocarditis of aortic and/or mitral valve localization]. / Utilità diagnostica dell'esame ecocardiografico nella valutazione dei pazienti con endocardite infettiva a localizzazione valvolare aortica e/o mitralica.

We estimated sensitivity, specificity, predictive value and efficiency of echocardiography in detecting vegetations and ruptured valves in patients with aortic and/or mitral valves infective endocarditis. We studied two groups of patients, in whom both high quality echocardiography examination and surgical inspection of heart valves were available. Group I: 16 patients (32 valves) with aortic and/or mitral valves endocarditis and surgical demonstration of vegetations and/or ruptured valves. In this group the prevalence of vegetations was 65.6%, the prevalence of ruptured valves was 43.7%. Group II was composed of the 16 patients of group I with endocarditis and of 93 other patients without endocarditis. In this group (139 valves) the prevalence of vegetations was 15%, the prevalence of ruptured valves was 13.6%. Echocardiographic detection of valve vegetations. Sensitivity (71.4%) was the same in group I and II. Specificity was 91% in group I and 91.5% in group II. The positive predictive value was 93.7% in group I and 60% in group II. The negative predictive value was 62.5% and 94.7% respectively. Echocardiographic detection of ruptured valves: sensitivity was 50% in I and 42% in group II. Specificity was 94.4% in group I and 99% in group II. The positive predictive value was 87.5% in group I and 89% in group II. The negative predictive value was 70.8% in group I and 91.5% in group II. The echocardiographic efficiency was higher in group II: 88.4% for vegetations and 91.3% for ruptured valves. This reflects the high specificity and the high definition of normal valves in this unselected low-risk group. The efficiency was lower in group I: 78% for vegetations and 75% for ruptured valves. This reflects the poor sensitivity and the failure of the test to identify all the vegetations or the ruptured valves in this selected high-risk group.

[Prolapsing echoes in the left ventricular outflow tract and in the left atrium in patients with infective endocarditis. M-mode and cross-sectional echocardiography combination]. / Le strutture prolassanti nel tratto di efflusso del ventricolo sinistro e in atrio sinistro, in pazienti con endocardite infettiva. Utilità dell'integrazione dell'esame ecocardiografico in M-mode con il cross-sectional.

In two patients with infective endocarditis and prolapsing echoes in the left ventricular outflow tract (patient with aortic valve involvement) and in the left atrium (patient with mitral valve involvement), easy differentiation between prolapsing vegetation and flail valve leaflet was made possible by means of M-mode and cross-sectional echocardiography.