Shift work increases the frequency of duodenal ulcer in H pylori infected workers.

AIM: To evaluate whether shift work is associated with an increased rate of peptic ulcer in H pylori infected workers. METHODS: During a two year period, consecutive dyspeptic workers underwent non-invasive evaluation of H pylori status by means of urea 13C breath test or stool testing. Those testing positive were included in the study and divided into two main categories: day-time workers and shift workers. An upper gastrointestinal endoscopy was performed in all workers, and biopsy specimens were taken from the stomach to confirm the presence of H pylori infection (culture and histology). RESULTS: A total of 247 day-time workers and 101 shift workers were included. The prevalence of duodenal ulcer was significantly higher in shift workers than in day-time workers (29 of 101 v 23 of 247; OR = 3.92, 95% CI 2.13 to 7.21), and persisted after multivariate analysis, taking into account possible confounding factors (OR = 3.96, 95% CI 2.10 to 7.47). CONCLUSION: Shift work increases the ulcerogenic potential of H pylori infection and should be considered a risk factor for duodenal ulcer in infected shift workers. Treatment of infection in this high risk group may improve the health of workers and may reduce the economic impact of peptic ulcer.

Helicobacter pylori duodenal colonization is a strong risk factor for the development of duodenal ulcer.

AIM: To test the hypothesis that duodenal colonization represents the final crucial step in the development of Helicobacter pylori related duodenal ulcer. METHODS: Patients with non-ulcer dyspepsia who had gastric colonization by H. pylori were included in the study. At baseline endoscopy, we evaluated the prevalence of duodenal colonization (culture, urease testing and histology), and cytotoxin-associated gene A status (polymerase chain reaction). No patients received eradication during 1 year follow-up. At this time, endoscopy was repeated and the incidence of duodenal ulcer was assessed. RESULTS: Among 181 patients completing follow-up, 53 (29%) had duodenal colonization: 72% of them were cytotoxin-associated gene A positive, versus 37% patients without duodenal colonization (P < 0.001). Duodenal ulcer developed in 12 (22.6%) patients with duodenal colonization and in two (1.6%) without duodenal colonization (odds ratio for duodenal ulcer: 6.29, 95% confidence intervals 2.44-17.45). The incidence of duodenal ulcer was similar among cytotoxin-associated gene A positive and cytotoxin-associated gene A negative subjects with duodenal colonization: 21.05% versus 26.6%. CONCLUSIONS: The assessment of duodenal colonization by H. pylori in patients with non-ulcer dyspepsia is strongly predictive for the subsequent development of duodenal ulcer and may help to stratify patients at risk for this disease.

[Role of radioisotopic lymphoscintigraphy in postphlebitic syndrome of the legs]. / Ruolo della linfoscintigrafia radioisotopica nella sindrome postflebitica degli arti inferiori.

Post-phlebitis syndrome of the lower limbs is a set of symptoms that follow a state of phlebostasis and phlebolymphostasis with consequent oedema and tissue distress. We submitted 36 patients with post-phlebitis syndrome of the lower limbs to radioisotopic lymphoscintigraphy for the purposes of evaluating the vicariant function of the lymphatic system and the possible role of the lymphatic system in the genesis of dermo-epidermal abnormalities. The average age of the patients was 53.2 years (range: 43-69 years; M:F ratio: 0.50). The control group consisted of 6 healthy subjects. The average duration of the post-phlebitis syndrome in the patients studied was 8.5 years. We excluded from the study patients in whom a central cause was identified as being responsible for the pathogenisis of the oedema of the lower limbs. In addition, patients with obliterant arteriopathy were also excluded. Venous pathology was evaluated first clinically and then investigated by continuous-wave Doppler. As a first step, venous pressure was measured by Doppler phlebomanometry in clino- and orthostatism. All patients underwent radioisotopic lymphoscintigraphy with microcolloids using the Rijke technique. Radioactivity was monitored by means of a computerized gamma-camera. We classified the pathological findings of radioisotopic lymphoscintigraphy as follows: 1) delayed transit; 2) obstacles; 3) star-shaped superficial collateral lymphatic circulations; 4) lymphocoele or cutaneous lakes. A significant difference was detected (p < 0.05) between the pressure values in the post- phlebitis lower limbs and the pressure values in normal subjects. Combining the results of our measurements we recorded delayed transit in 5 patients (69.5%). This latter group included the cases with the severest forms of post-phlebitis syndrome. Therefore, better knowledge of the pathophysiology of the lymphatic system would appear to be useful in order to understand the origin and evolution of oedema of the lower limbs of patients with post-phlebitis syndrome. To this end, radioisotopic lymphoscintigraphy may be useful as a first-level examination in order to evaluate the capacity and efficiency of the lymphatic system.

Percutaneous liver biopsy using an ultrasound-guided subcostal route.

Percutaneous biopsy is considered one of the most important diagnostic tools to evaluate diffuse liver diseases. The introduction and widespread diffusion of ultrasounds in medical practice has improved percutaneous bioptic technique, while reducing postoperative complications. Although ultrasonography has become almost ubiquitous in prebiopsy investigation, only one third of biopsies are performed under ultrasound control. Moreover, the one-day procedure, reported in several studies to be safe and cost effective, accounted for only 4% of biopsies done. We report our experience of 142 percutaneous US-guided biopsies performed on 140 patients affected by chronic diffuse liver disease over a four-year period. Liver biopsies were performed under US guidance at the patient's bed using an anterior subcostal route. We evaluated postoperative pain, modifications of blood pressure and red cell count, hospital stay, morbidity and mortality rates, and adequacy of specimens for histologic examination. There was no operative mortality. As for major complications, one case of hemobilia occurred. As for minor complications, two cases of persistent postoperative pain required analgesic therapy. Patients were discharged the day following the procedure in all cases but two, who were discharged on the third and fifth postoperative days. Liver specimens were suitable for histologic diagnosis in all but one case, in which there were no portal spaces. According to our experience, we believe that hepatic biopsy guided by ultrasonography could replace blinded biopsy in the diagnosis of diffuse liver disease. The procedure is suitable to be performed safely on an outpatient basis.

[Retrospective analysis of the use of prophylactic drainage of the pelvis after anterior resection of the rectum]. / Analisi retrospettica sull'uso del drenaggio profilattico della pelvi dopo resezione anteriore del retto.

Although the use of drains is common in clinical practice, its real role in the prophylaxis and therapy of postoperative complications is still not clear. In the literature we can find both supporters of drains, and many opponents who consider their use unnecessary and sometimes even dangerous. In fact, during new experimental and clinical studies, it was impossible to determine the usefulness of prophylactic abdominal drain, at least in the case of colo-rectal anastomosis, it has been demonstrated that use of drains limits the risks of an anastomotic leakage but, in some cases, the same drains could be the cause of some of the complications that should be avoided. Although there is a considerable theoretical and practical evidences in favour of drainage, the dispute about "to drain or not to drain" the peritoneal cavity after elective colo-rectal surgery remains open. This retrospective study made on 150 patients operated on elective surgery for rectal cancer demonstrates that prophylactic drain does not significantly influence the general rate of leakage (3.15% for group A and 5.45% for group B, p > 0.1); in two of the three fistulas in patients with drains, the drains have permitted the diagnosis, but have not permitted the reduction of the number of operations for fistulas.

[Revascularization of the corpora cavernosa in vasculogenic impotence]. / Rivascolarizzazione dei corpi cavernosi nell'impotenza vasculogenetica.

The vasculogenic erectile impotence, caused by occlusion and/or stenosis of arteries supplying the penis, is the most common cause of erectile failure in men over 40 years. The vasculogenic impotence is more found by peripheral vasculopathies like diabetes mellitus and nicotine abuse. It is important that the precise site of vascular lesion is established with selective arteriography of the hypogastric-internal pudendal axis. The specific aim of surgery is to increase the cavernosal arterial perfusion pressure and blood inflow in patients with vasculogenic erectile dysfunction secondary to pure arterial insufficiency. There have been multiple revascularization techniques described for the treatment of proximal or distal occlusion with variable results. Microsurgery is important for distal lesions and we think that the best candidates for the Michal II procedure seem to be those with localized obstruction of the internal pudendal, while venous arterialization is the preferred procedure for patients with pathological cavernous or dorsal penile arteries. In this paper the most important procedures to restore physiological erection are presented; however no single revascularization procedure has been generally accepted as a definitive answer to this problem. There is a need for further prospective studies with longer follow-up and more objective investigations.

[Role of p53 gene in colorectal neoplasms]. / Ruolo del gene p53 nelle neoplasie colorettali.

A prospective study on the role of the p53 gene in sporadic colorectal neoplasms is presented and the level of mutant p53 protein was measured in the tissue removed during colonoscopy from: patients previously operated for colorectal malignant neoplasms, patients with active neoplasms, first degree relatives and during regular checks. 72% of patients with an active tumour showed a positive p53 and 38% in follow-up checks. Longer follow-up periods and a major number of patients are necessary to assess the prognostic importance of the p53 protein.

[Deep venous insufficiency of the lower extremities]. / Insufficienza venosa profonda degli arti inferiori.

Lower limbs chronic venous insufficiency (CVI) is a widespread pathologic condition. Prevalence of venous ulcer in Europe ranges between 0.5% and 1.0%. Venous ulceration can be due to insufficiency of the superficial system, although deep venous insufficiency is responsible for 75% of the cases. Morbidity and socio-economic costs are exceedingly high especially because of frequent recurrences. CVI recognises mainly two causes: 1) increased influx, due to arteriovenous fistulas; 2) difficult outflow usually secondary to postphlebitic or primitive valvular incompetence. The prevalence of CVI and venous ulceration is difficult to assess. Surgical treatment tends to cure the underlying hemodynamic problem. Homans in 1916 first introduced surgical treatment of CVI and venous ulceration: excision of the cutaneous lesion and ligature suprafascial of the communicating veins. Since then different various techniques have been introduced in the clinical practice: Linton in 1938 supported subfascial interruption of the perforating veins but still reported a recurrence rate of 47%. Stripping of internal saphenous vein associated with division of perforating veins is still controversial, because lacks evidence of its real effectiveness in preventing recurrences. Felder's surgical technique is preferred by some authors to Linton's technique, because of the possibility to divide and section incompetent perforating veins without a cutaneous incision in the severely diseased postphlebitic tissues. In personal experience (56 patients) treated by Felder's techniques, we reached a cutaneous ulceration healing rate of 36% has been obtained. Subfascial interruption of perforating veins under endoscopic vision associated to the stripping of the internal saphenous vein could be a valuable option in the treatment of CVI because of the shorter duration of the operation and hospital stay and lesser postoperative complications. Repair and/or replacement of deep venous valves, originally described by Kistner in 1968, could be curative of venous hypertension due to primitive valvular insufficiency (primitive or postphlebitic): the same author in 1975 reported positive results (80% at 5 years). Major advantages of indirect valvuloplastic surgical technique are: 1) venotomy is not necessary; 2) it does not introduce extraneous material in the vasal lumen; 3) clamping of the vein is avoided; 4) heparine or other antithrombotic measures are usually not necessary. Although preliminary encouraging results, subsequent clinical experiences have demonstrated that correction of the reflux of the main axial venous system alone is not curative and durable resolution of venous symptoms also depends on the concomitant correction of all incompetent perforating veins. Venous valves transplantation is theoretically good to correct the deep long reflux and to improve calf pump function, although clinical results are still limited and follow-up not prolonged enough in terms of symptoms resolution and complete ulcer healing.

[Medullary carcinoma of the thyroid. A report of 4 clinical cases and a review of the literature]. / Il carcinoma midollare della tiroide. Presentazione di quattro casi clinici e revisione della letteratura.

Medullary thyroid carcinoma is an uncommon neoplasia among other differentiated carcinomas or the thyroid gland. We have retrospectively analysed four new cases of medullary thyroid carcinoma and a careful review or the literature on the subject has been conducted.

Laparoscopic approach to cholecystocolic fistula: report of a case.

The development of a fistulous tract from the gallbladder is associated with gallstones in 90% of cases. Cholecystocolic fistula (CCF) accounts for 10 to 20% of all enteric biliary fistulas. The conventional treatment advocated is cholecystectomy and closure of the fistulous communication. In this report a case of a patient whose only complaint was severe diarrhea is described. CCF was demonstrated by barium enema. The patient was treated by laparoscopic surgery. The case history and laparoscopic approach to enteric biliary fistula are described.

[Carotid chemodectoma: a clinical case report and review of the literature]. / Il chemodectoma carotideo: presentazione di un caso clinico e revisione della letteratura.

Carotid chemodectoma (CC) is a very rare neoplasia. It originates from Type 1 main cells of the carotid body and affects both sexes almost in the same proportion (mostly in the fourth and fifth decades). It can be on a familiar basis (5-10%) and in these cases it is more frequently multicentric, being sporadically found in association with other paragangliomas. CC is a slow-growing neoplasia, locally aggressive and it can give metastases to regional lymph nodes and surrounding anatomical structures. Once surgically removed, it can reoccur in a small percentage of patients. Early diagnosis is of the utmost importance and surgeon's skill is fundamental as well as awareness of the real nature of the disease. Surgical treatment of CC is difficult and demanding, for the close relation of CC to the neighbouring neurovascular structures. The authors report a case of CC radically operated on. Clinical parameters are analysed as well, and Literature is reviewed.

[Criteria for the endoscopic assessment of hemorrhage risk in esophageal varices]. / Criteri di valutazione endoscopica del rischio di sanguinamento delle varici esofagee.

The natural history of liver cirrhosis shows one third of patients bleeding from esophageal varices. The first episode of bleeding has a 40% mortality rate and 70% of survivors will have another haemorrhage within a year. To overcome this dramatic sequence the following types of prophylactic treatment have been attempted: portocaval shunt, B-blockers, endoscopic sclerotherapy. Medical Literature shows no proven benefits from these procedures. Endoscopic sclerotherapy seems to have the best results. Thus, to be more successful we suggest a better selection of patients to undergo prophylactic sclerotherapy, also improving the prognostic criteria which could predict the bleeding. Esophagoscopy makes it possible to examine some of the predictive signs of impending haemorrhage. However, both the endoscopic and clinical criteria (Child) give a better evaluation of the risk of bleeding.

[A clinical analysis of a group of Down's patients]. / Analisi clinica di un gruppo di pazienti Down.

The authors report their experience of the clinical analysis of 40 handicapped subjects: 28 suffered from various degrees of mental handicap and 12 had Down's syndrome. In particular, the authors focused their attention on anomalies of the stomatognathic apparatus in Down subjects, and examined and compared all those factors which are normally attributed to this pathology. An analysis of these findings shows a heterogeneity of clinical conditions which is not revealed in the literature. In the light of these new experiences, before applying pre-programmed protocols in Down's patients it is important to carry out a careful control of their dental, muscular and functional situation together with the prospects for growth and development.

[Alkaline esophagitis following total gastrectomy]. / Esofagite alcalina dopo gastrectomia totale.

Two cases of severe alkaline esophagitis following total gastrectomy, respectively for a gastric sarcoma and a gastric carcinoma, are reported. In the first case digestive continuity was assured through an Omega loop esophagojejunostomy, while in the second one an esophagojejunostomy according to the Moricca technique was performed. Both patients underwent reoperation and a conversion in Roux-en-Y esophagojejunostomy resolved the reflux related problems. The Authors, therefore, confirm Roux-en-Y esophagojejunostomy as the procedure of choice in preventing and curing esophagitis, which can seriously affect the quality of life and nutritional status of gastrectomized patients.

[The surgical treatment of a differentiated thyroid carcinoma infiltrating the large mediastinal veins]. / II trattamento chirurgico del carcinoma tiroideo differenziato infiltrante i grandi vasi venosi mediastinici.

The authors report on 2 patients affected by well-differentiated, locally advanced, thyroid carcinoma infiltrating the major mediastinal veins. Removal of the neoplastic mass was possible through a combined cervical and trans-sternal approach. Surgical indication, operative strategy and follow up are discussed. A review of the literature is also reported.

[Leiomyosarcomas of the stomach: a report of 3 clinical cases and a review of the literature]. / I leiomiosarcomi dello stomaco: presentazione di tre casi clinici e revisione della letteratura.

Three consecutive malignant smooth-muscle gastric tumor cases are reported. Digestive endoscopy allowed a correct diagnosis in 2 out of 3 cases, when neoplasias were ulcerated, enabling a deep endoscopic biopsy. On the contrary, in the third case the endoscopic diagnosis was a benign leiomyoma and the endoscopic biopsies were completely negative. Even CT scan was not able to reveal the malignant nature of the disease in this patient. Surgical procedures performed were: polar superior gastric resection, Billroth I partial gastric resection and extended total gastrectomy. In one patient, regional lymph nodes were positive for metastases. The patient who died at 6 months from surgery had a large (approximately 12 cm) neoplasia of the gastric fundus.

[Emergency endoscopic sphincterotomy in acute lithiasic cholangitis]. / La sfinterotomia endoscopica d'urgenza per colangite acuta litiasica.

Emergency endoscopic sphincterotomy in acute cholangitis for bile duct stones should be the first choice treatment in patients with and without gallbladder. In fact, emergency surgery carries higher mortality and morbidity rates. Urgent biliary drainage, easily and quickly obtainable by endoscopy is the major goal. Bile duct stone clearance can be attempted subsequently, when the patient general conditions are stable. Elective open surgery can be performed thereafter, if indicated, with less risk. This experience is clearly shown by many surgical and endoscopic, mainly retrospective, studies.

[Solitary ulcer of the rectum: a report of a clinical case associated with rectal prolapse]. / Ulcera solitaria del retto: presentazione di un caso clinico associato a prolasso rettale.

Solitary ulcer of the rectum is an unusual condition occurring more often in young adults. Unfortunately the term is rather confusing, since the lesion may not necessarily be solitary, nor be confined to the rectum; moreover, it may be polypoid rather than ulcerating. The etiology is uncertain, but chronic constipation and fecal impaction could play a role. Today most authors believe solitary ulcer syndrome is a distinct clinical inflammatory manifestation associated with rectal prolapse. Surgical treatment of the prolapse is usually followed by a recovery of the solitary rectal ulcer.