Anal endosonography: a survey of equipment, technique and diagnostic criteria adopted in nine Italian centers.

BACKGROUND: Anal endosonography (AES) has become an essential part of the pre-operative diagnostic workup in both organic and functional anal diseases. METHODS: Nine Italian centres with an average volume activity of >10 exams/week each were surveyed with the aim of determining the concordance with respect to indications for the procedure and interpretation of the results. RESULTS: Overall, anal sepsis, faecal incontinence and anorectal tumours were the more common indications for AES while evacuation dysfunctions and anal pain were not always considered indications. All centres use the same diagnostic criteria for simple and complicated perirectal sepsis and sphincteric defects, but adopt different classifications for stage 1 and stage 2 anal tumours. Participants agreed in that lymph-node staging by AES is less precise than tumour staging, especially after chemoradiation therapy. CONCLUSIONS: A list of recommendations and guidelines based on the groups's experience has been produced for those radiologists and coloproctologists interested in the use of AES and accreditation of their centres.

Contribution to the surgical anatomy of the ligaments of the rectum.

PURPOSE: Many authors have discussed the presence and the importance of the lateral ligaments of the rectum. Our contribution aims at clarifying some aspects of surgical anatomy that help in the preservation of the urogenital functions and may influence the surgical practice. METHODS: From 1994 to 1998 we examined 27 fresh cadavers and five embalmed pelves. We performed all dissections with a technique similar to that used for the surgical mobilization of the rectum. RESULTS: The lateral ligaments of the rectum are trapezoid structures originating from mesorectum and are anchored to the endopelvic fascia; as lateral extensions of the mesorectum, they must be included in the surgical specimen. According to our results, three main structures can be recognized laterally to the rectum: 1) the lateral ligament, which does not contain important structures; 2) the inferior hypogastric plexus and the urogenital bundle; and 3) the lateral neurovascular pedicle of the rectum that comprises the nervi recti and the middle rectal artery, both running under the lateral ligament, although at different angles. CONCLUSION: At the point of insertion into the endopelvic fascia, the lateral ligaments run close to the urogenital bundle. Nevertheless, the dissection at its attachment is safe if the urogenital bundle is kept under visual control.

CT-guided transthoracic needle biopsy in the diagnosis of chest tumours.

Percutaneous Transthoracic Needle Biopsy (PTNB) is an accepted technique for the diagnosis of suspected intrathoracic malignancy and, although the appropriate indications have not been clearly defined yet, its use has rapidly expanded in the last years. The authors reviewed retrospectively their experience over one-year time biopsies and analyzed some controversies regarding this diagnostic procedure.

A case-control study on lymphocytic subsets in elderly bearing a gastroenteric cancer.

The aim of this work is to evaluate the differences in lymphocytic sub-classes between elderly patients with gastroenteric cancer and elderly patients with a non neoplastic disease. A group of 88 patients over 60, consecutively admitted to the III Division General Surgery for gastro-enteric cancer has been collected for the study, the control group consisted of 74 patients also over 60, consecutively admitted over the same period for benign abdominal diseases. In all patients the following data were measured: body mass index (BMI), white blood cells (WBC), total lymphocytes, total T lymphocytes (CD3+), helper T lymphocytes (CD4+), suppressor T lymphocytes (CD8+), CD4+/CD8+ ratio, B lymphocytes, CD5+ B lymphocytes, activated T lymphocytes (CD3+ HLA-DR+), CD4+ "naive" lymphocytes (CD4+ CD45 RA+), CD4+ "memory" lymphocytes (CD4+ CD45 RO+), NK lymphocytes (CD16+ 56+), red blood cells (RBC), total serum cholesterol, albumin, total serum proteins. The main lymphocytic subsets were on an average lower in the cancerous elderly group with respect to the non cancerous. As the tumour progressively increases in size (T), total lymphocytes significantly decrease, while CD4+ progressively decreases with nodal involvement (N). In the cancerous elderly, we found a lower immune response. The immune system appears to be less efficient also in association with tumor growth, especially when T and N get worse. The response of effector cells to the tumour seems not specific.

One year follow-up results in the surgical treatment of gastroesophageal reflux disease.

BACKGROUND: Gastroesophageal reflux disease (GERD) is a common intestinal disorder. Although fundoplication immediately achieves good results, some problems arise about duration. METHODS: From 1990 to 1992, thirty-seven patients underwent operation for GERD, the indications for surgery being: persistence of reflux symptoms after at least 6 months of medical therapy, esophagitis, manometric evidence of LES incompetence, augmented esophageal exposure to gastric juice documented by 24 hours pH monitoring. Nissen-Rossetti was the technique used; intraoperative calibration was 29.8 mmHg. RESULTS: Twenty-five patients were studied 12 months after the operation. They were submitted to clinical examination, gastroscopy, manometry, 24 hours pH monitoring. Clinically 2 patients were unable to belch. All of them showed LESP and intra-abdominal HPZ length decreased (32.3% and 13.5% respectively). The factors influencing LESP 12 months after surgery are age and intraoperative calibration. Pressure decrease is related to age and calibration. An older patient will show a smaller decrement, to a higher intraoperative pressure corresponds a higher pressure decrease with time. CONCLUSIONS: For these reasons we do not recommend hypercalibration especially in the elderly.

Low and ultra-low rectal resection: results and prospectives.

We present our experience in the treatment of middle-lower rectal cancer particularly in reference to the use of those operative techniques which permit to save the sphincteric system. From 1990 to April 1995 seventy-two patients were operated on for middle-lower rectal cancer applying the Knight-Griffen technique. Such a method has already demonstrated the characteristics of a valid anastomosis, being simple, fast and safe. The introduction of stapler devices in the rectal surgery, particularly in its middle-lower tract has significantly modified the quality of life of such patients, reducing drastically the number of colostomies. The possibility to extend the rectal resection towards the anus with colo-anal anastomosis has showed a loco-regional recurrence rate not different from abdominal-perineal resection, even though with some sphincteric troubles due to incontinence. The satisfying surgical results obtained with low and ultra-low recta resections, by now widewordly accepted, should not anyway mask the importance of an early diagnosis as the main factor governing the prognosis (i.e. the overall mortality).

A new extracellular type solution for lung preservation: "in vitro" comparison with Beltzer, low potassium Dextran and Euro-Collins solutions by means of human lung fibroblasts.

UNLABELLED: The attempt to synthesise efficacious solution to prolong lung preservation is, at present one of the most interesting challenges in transplant research. Recently, several issues emphasise the central role of ionic composition of lung-flush solutions, underlining, however, that colloid-free solutions are clearly detrimental. We have been studying a complex extracellular type solution (SPAL UP) synthesised to minimise the pathological events that occur during both preservation and reperfusion period. We report the results of toxicity of SPAL UP on normal human fibroblasts obtained from foetal lung (WI-38). WI-38 cells were seeded at 1.4 x 10(4)/cm2 in disposable plastic 12-well plates. After 3 days, cells were incubated in SPAL UP, Beltzer (UWS), Low Potassium Dextran (LPD) and Eurocollins (ECS) solutions for 6 hours at 10 degrees C. Cellular viability was evaluated by the rate of protein synthesis exploiting the incorporation of 35S-Methionine (2 microCi/ml) in growth medium with 10 mM unlabelled Methionine during 30 minutes incubation at 37 degrees C. The results were expressed as nmol. 35S-Methionine/mg of proteins/minute, and presented as means +/- SD of data of three (n = 3) well for each solution studied. RESULTS: the viability at time 0 before incubation (considered as control) was 1.65 +/- 0.1; after hypothermic preservation the data were respectively as follow: SPAL UP 0.51 +/- 0.09; UW 0.24 +/- 0.02; ECS 0.19 +/- 0.01; LDP 0.19 +/- 0.05. CONCLUSIONS: in this "in vitro" model SPAL UP solution provides a significantly (p < 0.05) better cell preservation than regular UW, ECS and LPD solutions.

Single lung transplantation in the rabbit: an alternative proposal for the study of preservation devices.

The authors report their standard protocol for single lung transplant in New Zealand rabbit, the anaesthesiological approach consisted of a premedication with Ketamine 35 mg/kg i.m., Atropine sulphate 0.25 mg/kg s.c. and Fentanil 0.1 mg/i.m.; a jugular vein was cannulated and the anaesthesia was carried out administering Ketamine 10-15 mg/kg every 20 min., plus Fentanil 0.1 mg every 30 min. The rabbit was intubated through a tracheostomy, curarized and room air was administered using an appropriate ventilator device. The heart-lung en bloc removal from the donor was performed through a midline sternotomy. The left lung was then separated leaving an adequate cuff of left atrium inclusive of right pulmonary veins which were ligated using a 7-0 thread the graft prepared in this way was then preserved by putting it into the perfusion solutions. The recipient rabbit, after anaesthesia, underwent left pneumonectomy through a left toracotomy the bronchial anastomoses was first performed, followed respectively by the arterial and the atrial sutures. The controlateral pulmonary artery was then clamped and sequential arterial samples were taken from descending aorta previously cannulated to obtain arterial gases tests. The recipient rabbit has been followed up this way no more than 2 hour time, than it was sacrificed.

The influence of high and low doses of diltiazem on isolated alveolar type II cells during normothermic and hypothermic ischemia: cytoprotection or cytotoxicity?

The alteration of calcium homeostasis is of outstanding importance for the cytotoxic reactions that place after ischemia, for this reason calcium channel blockers have been used with the purpose to protect the lung during transplantation. This work analyses the effect of Diltiazem at two different doses (10 mg/l and 50 mg/l) on Wistar rat alveolar type II cells, incubated for 8 hours at 37 degrees C and at 4 degrees in an electrolytic solution. Total protein content and the rate of protein synthesis derived from 35S Methionine uptake were used to evaluate cells viability. The data showed that Diltiazem did not improve cellular viability after warm and cold metabolic ischemia either using 10 mg/l or 50 mg/l, while at 4 degrees C a significantly cytotoxic effect (p < 0.05) was observed. At this temperature toxicity was independent on the dose used.