[Intraoperative anaphylaxis from latex. A case report]. / Anafilassi intraoperatoria al lattice. A proposito di un caso.

The authors report a case of anaphylactic reaction in a 58-year-old woman during total gastrectomy under general anesthesia. Before induction a peridural catheter had been inserted for the purpose of postoperative antalgia. Anaphylaxis occurred fifteen minutes after the start of surgical resection. The tests performed later led the authors to regard latex as the triggering agent.

[A critical review of the history of the systems for staging colorectal cancer]. / Rivisitazione critica della storia dei sistemi di stadiazione del cancro colo-rettale.

A great debate is still open in literature about the available staging systems of colorectal cancer. Therefore, an historical analysis of the several systems suggested in the last decades was performed; pathological, clinicopathological and more recent score clinicopathological staging systems were evaluated. From this historical review it appears that subsequent modifications of various classifications allowed only for a poor improvement in predictivity. A more careful histopathological examination of surgical specimen and more exact information about involvement of other organs and tissues allow a correct classification of patients affected by colorectal cancer independently of the staging system used.

[Occult hepatic metastases from colorectal carcinoma: diagnostic and prognostic considerations]. / Metastasi epatiche occulte da carcinoma colo-rettale: considerazioni diagnostiche e prognostiche.

Occult hepatic metastases (OHM) from colorectal cancer are those not evident to the surgeon at laparotomy. In this retrospective and "deductive" study the Authors evaluated the accuracy of hepatic CT scan and ultrasonography (US) to detect hepatic metastases. The CT and US accuracy rate was 78.4% and 79.8% respectively, and proved to be correlated to the intraoperative dimensions of the lesions. Sensitivity of these examinations, in the light of OHM identification, decreased to 69% and 69.2% respectively. This study shows that hepatic US and CT scan are not sufficient to identify OHM; the attempt to reduce the frequency of OHM by means of intraoperative ultrasonography could allow to obtain a more careful stadiation and prognosis of these neoplasms with possible therapeutic advantages.

[Pelvic recurrences after curative surgery for rectal cancer]. / Recidive pelviche dopo chirurgia curativa per cancro del retto.

This report updates an experience with local recurrences of rectal cancer after curative surgery. Overall 13 year period (1976-1988) 254 patients were operated on in the II Surgical Clinic of Parma University for rectal cancer. Only 122 patients who underwent potentially curative resection were examined. Approximate recurrence rates according to patients age, site, type and stage of primitive tumour, tumour complications and surgical procedures were evaluated. The overall local failure rate was 17.2% with 12 patients having local failure alone and 9 patients having concurrent local failure and distant metastasis. Local failure occurred predominantly in tumour bed, involving the anastomosis in 2 cases. Relapse developed primarily at colo-rectal anastomosis in only 1 patients, 20% of recurrences were diagnosed within the first postoperative year; 65% within the second and 90% within the third. Stage of primary tumour was the most predictive factor for eventual relapse. Minute foci of tumour not encompassed by the first operation led to local recurrences in most of the cases, but relapses were independent of operative procedures adopted. The authors conclude that surgery, even if correctly performed, is not sufficient to prevent the risk of local recurrence of rectal cancer. They believe that routine adjuvant radiation therapy after surgical treatment of rectal cancer should improve survival rate.

[Locoregional recurrences following curative surgery for colon cancer]. / Recidive loco-regionali dopo chirurgia curativa per cancro del colon.

This study explores the patterns of local recurrence after curative operations for colonic cancer. Over a 13 year period (1976-1988) 486 patients were operated on in the Surgical Clinic of Parma University for colonic cancer, but only 296 patients who underwent potentially curative resection were examined. The influence of patients' age, disease stage, site and grade, presence of obstruction or perforation and type of surgical procedures were examined as prognostic factors for local cancer recurrence. A total of 28 patients (14%) relapsed after surgery and 19 were found to have simultaneous distant metastasis. 86% of recurrences were evident within the first 2 years. Local recurrence rate increased with more advanced Duke's stage and stage of the primary tumour was most predictive for eventual relapse. The recurrences occurred within the operative resection site involving the anastomosis by inward growth at the suture line. Minute foci of adenocarcinoma not encompassed by the first operation might lead to local recurrences; the authors do not rule out, however, the rare possibility of the implantation of exfoliated malignant cells. Despite the attempt to carry out an intensive followup in terms of early diagnosis of recurrence in colonic surgery, the presence of local recurrences is associated with extremely poor prognosis independent of operative procedure performed. The authors believe that routine adjuvant radiation therapy after surgical treatment of locally advanced colonic cancer could improve survival rate.

[Emergency aneurysm of the abdominal aorta in a general surgery department]. / L'aneurisma dell'aorta addominale in urgenza in un reparto di chirurgia generale.

We reviewed 26 consecutive patients from 1.1.81 to 30.6.89, 21 males and 5 females, mean age 72 (+/- 6.7) years, range 51-81, admitted and operated on for ruptured (19 cases) or leaked (7) abdominal aortic aneurysm in a general surgery unit at the University of Parma. Since we deal mainly with gastroenterologic and oncologic surgery, emergency operations were 70.2% of the overall series of aortic aneurysms, and were carried out over an actual 776 day period of emergency admission service. Nineteen patients had shock, ten being already anuric. Ultrasounds were carried out in nineteen cases, with an accuracy of 91.6% for ruptured and 57.1% for leaking aneurysms. Mortality rate, 50% was significantly related to the number of perioperative blood transfusions and anuria, which express the degree of shock and blood loss. Operative results were similar to other major series. A successful approach and management of aortic ruptured aneurysm is an uncommon challenge even in non-specialized surgical units. A vascular surgical training is therefore necessary for general surgeons.

[Current status of the surgical treatment in colorectal carcinoma]. / Attualità nel trattamento chirurgico del carcinoma colorettale.

The Authors take into consideration some topical subjects, with reference to their own experience. The percentage of patients diagnosed as having localized disease, despite improvement in diagnostic techniques, has not changed over the last decade. In local recurrences without distant metastases, surgery is the sole treatment which may improve the survival. Resection however has to be thought over, since surgery of local recurrences may be considered as curative only in a few cases and the probability of a poor result in survival and quality of life does not justify a surgical procedure when it is associated with a high operative risk. In cancers of the middle 3rd and lower rectum, staplers have favoured the choice of anterior resection, which does not show a high rate of recurrences, when compared to abdominoperineal excision. At last, progress in surgery, anaesthesiology and intensive care determined a different therapeutical attitude in the aged, either due to a lower incidence of postoperative complications, or because life expectancy in the elderly seems to justify, whenever possible, a curative procedure.

[Iatrogenic biliary lithogenesis in surgery]. / Litogenesi biliare iatrogena in chirurgia.

Iatrogenic biliary lithogenesis has been often observed in surgery. The authors, on the basis of the personal experience and literature, have tried to point out its etiologic factors and give a common interpretation to its different clinical manifestations observed in surgery. This study reports 19 patients who underwent total gastrectomy with truncal vagotomy and postoperative TPN and subsequently serial ultrasonographic scans to determine content and volume of the gallbladder. In 5 patients it was possible to take out a bile sample daily, using a naso-duodenal tube, for chemical analysis. In 10 out of 19 patients postoperative ultrasonography revealed the fast appearance of biliary sludge; 6 of the latter 10 developed microlithiasis. In all cases examined ultrasounds revealed a defect of the contractility of the gallbladder and the microscopic analysis of bile content showed pigment granules. The authors underline how different etiologic factors are involved in different clinical models. They conclude that gallstones observed in their experience are mostly pigmentary and are quickly formed owing to the interaction of many etiological factors. Finally prophylactic measures are discussed.

Cholesterol microlithiasis: bacteriology, gallbladder bile and stone composition.

It is not known whether microcalculi possess structural differences compared with larger stones or whether they represent simply an earlier stage in stone disease. We carried out a controlled study on 10 patients affected by gallbladder cholesterol microlithiasis (CM). In all patients, samples from all parts of the stones were studied by X-ray diffraction and by infrared spectrophotometry. Bile analysis was carried out to determine cholesterol, phospholipid and total bile acid content. The cholesterol saturation indices (C.S.I.) were calculated. In all samples, bacterial bile culture was carried out. The results were compared with those of 10 patients who had undergone cholecystectomy for large cholesterol stones, and for 10 patients who had undergone abdominal surgery but without biliary pathology. Patients in these latter groups were matched with the first according to sex and age. Microcalculi proved to be layered (nucleus and external layer) in only 2 cases and larger stones in 9; cholesterol was seen to be the principal crystalline component in all cases. Traces of bilirubin were found in 7 CM and in the nuclei of 5 larger stones. These results show that the structural composition of microcalculi is similar to that of the nucleus of larger stones. No substantial differences exist, however, between the two groups of patients regarding the other parameters taken into consideration.

[Cancer of the colon and cholelithiasis: bile bacteria, composition of the stones and the bile]. / Cancro del colon e colelitiasi: bactibilia, composizione dei calcoli e della bile.

Our recent studies have shown a significant association between lithiasic biliary disease and colorectal cancer. This could be due to the existence of risk factors common to both disease or to a cause-effect correlation between them. This latter hypothesis is supported by the observation in gallstone patients of the increase of biliary and fecal concentrations in secondary biliary acids. These could have co-carcinogenic effect on the colon. With a view to singling out further elements which might help us to understand more clearly the possible cause-effect correlation between cholelithiasis and colon cancer, we examined 12 patients affected by both diseases. In these, we evaluated the composition of the gallbladder stones, by means of spectrophotometry and diffractometry. Bile samples were taken from the gallbladder and used to examine the lipidic composition and the cholesterol saturation index according to Carey. In addition bacteriological examinations were carried out. The results were compared with those of 10 patients with cholelithiasis but not cancer, 10 with cancer but not cholelithiasis and 10 with neither. Analysis of the results did not reveal significant differences in gallstone and bile composition between colon cancer patients with concomitant gallstones and control groups. However, in cancer patients with gallstones a higher incidence of bile bacteria (35.7%) was observed than in the other groups. Bile bacteria were observed more frequently in right colon cancer patients who had pigment stones in 75% of the cases. The results seem to evidence peculiarities in patients with a cancer of right colon.(ABSTRACT TRUNCATED AT 250 WORDS)

Pigment vs. cholesterol microlithiasis: comparison of clinical features, bacteriology, stone and gallbladder composition.

We compared 16 cases of pigment microlithiasis with 12 cases of cholesterol microlithiasis. In each case we made a spectrophotometric and diffractometric analysis of the composition of the stones, also analysing bile bacteriology, bile lipid composition and cholesterol saturation indices. The two groups were comparable as regards sex, age, symptoms and clinical features. Pigment microcalculi were often asymptomatic (41.7%), but more often associated with bile bacteria (43.7%) or acute pancreatitis (25%). The results were such as to permit us to view cholesterol microlithiasis and pigment microlithiasis as having different pathogenetic and clinical aspects, and thus as being different diseases.

Cholesterol crystals in biliary microlithiasis.

A recent study put forward the hypothesis that microlithiasis may represent an early stage in the development of biliary calculi. It is an established fact that cholesterol crystals are the product of an inevitable stage in the sequence leading to gallstone formation. To test the hypothesis stated above ten patients affected by gallbladder cholesterol microlithiasis (CM) were examined in the lipid composition of the bile, the cholesterol saturation index and the presence of cholesterol crystals being calculated. The results were compared with those of 14 patients affected by pigment microliths, 24 with larger stones (LS) and ten control patients. The cholesterol saturation index was above one in all CM patients, whereas in some LS patients the gall-bladder bile was not supersaturated. Cholesterol crystals were observed in the gallbladders of all CM patients and seven LS patients. These results would seem to provide support for the hypothesis of microcalculi as being "young stones", with the bile of CM patients maintaining the conditions leading to gallstone formation.

Composition of biliary microcalculi studied with infrared spectrophotometry.

The chemical composition of biliary microcalculi obtained at 20 consecutive cholecystectomies was investigated with infrared spectroscopy. This method permits qualitative and quantitative analysis also of substances such as bilirubin which often remain in amorphous states. A PYE UNICAM spectrophotometer was used, with KBr pellet technique. A bile sample from each patient was taken for bacteriologic examination. The study confirmed previously observed high incidence of pigment microcalculi (60%). Calcium palmitate was more common (in 15% of all the studied microliths and 25% of the pigment type) than in reports in the literature concerning larger gallstones. Calcium carbonate was present in only 10%. These findings suggested pathogenetic peculiarities of microlithiasis, as did the high incidence of positive bacteriologic tests.

Rapid sequence of events in gallstone formation in man.

A prospective analysis was carried out on 19 adult patients who had undergone total gastrectomy for gastric cancer with truncular vagotomy and postoperative TPN, to evaluate the gallstone formation sequence in man. The patients underwent gallbladder ultrasonography before surgery, then at least once a day during the period of postoperative fasting and TPN (about 15 days) and during the first days after oral refeeding. No patients showed cholelithiasis or biliary sludge at preoperative ultrasonography; none showed cholesterol crystals at preoperative duodenal drainage. 10 of the 19 patients were sludge-positive during the first two weeks of TPN (2 after 3 days, 7 at day seven, 9 at day nine). 6 patients who were initially sludge-positive developed microlithiasis: 1 after 7 days, 2 during TPN and 3 after oral refeeding. These results lead the authors to suggest that human lithogenesis in particular conditions may be faster than that observed so far in animal models, and that the very rapid events in gallstone formation observed in this study concern the formation of pigment stones.

Sludge and microlithiasis of the biliary tract after total gastrectomy and postoperative total parenteral nutrition.

We have evaluated the incidence and evolution of sludge, microlithiasis and lithiasis formation of the biliary tract in 12 patients who underwent total gastrectomy and postoperative total parenteral nutrition (TPN) beginning immediately after operation. To this end, serial ultrasonographic studies are carried out every 72 hours during TPN and every seven days after oral refeeding and then once a month for three months. Sludge of the gallbladder was demonstrated in five of the 12 patients after a minimum period of nine days after the operation, and in four of these, microlithiasis of the biliary tract was subsequently revealed. In two of these four patients, the stones dissolved spontaneously, while in the remaining two patients, no change occurred in dimension after intervals of six and seven months, respectively. In all instances, sludge and microcalculi were completely "silent." This study was done to underline the high incidence of biliary tract sludge and microlithiasis in the patients examined and to indicate the necessity for preventive measures against the possible and serious complications of this disease as well as acute pancreatitis.

Prevention of colorectal cancer. Role of association between gallstones and colorectal cancer.

A significant association was found between colorectal cancer, especially of the right colon, and concomitant gallstones. This was noted especially in female patients and in those over the age of 65. The existence of such an association is of advantage in terms of secondary prevention of colorectal cancer. The possible screening methods are discussed for those gallstone patients at risk.

Gallstones and risk of colonic cancer: a matched case-control study.

The aim of the research was to verify the existence of an association between neoplasms in the colon and cholelithiasis, treated surgically or non-surgically. The case-control study was carried out on 109 patients operated on for cancer of the colon, and on 109 control patients operated on for benign pathology. Matching was carried out according to sex, age, region of origin and dietary habits of the patients. Results showed a significant association of cancer of the colon with concomitant cholelithiasis (odds ratio = 2.42) but not with previous cholecystectomy. This correlation was more evident in female patients (odds ratio = 3.2), over 65 years of age (odds ratio = 3.6), with neoplasms in the right colon (odds ratio = 5). Observations suggest cholecystectomy has a protective role as regards an increased risk of cancer of the colon in cholelithiasic patients. A confirmation of this association might also be beneficial in terms of early diagnosis of cancer of the colon, thereby allowing identification of a large population of risk patients to be submitted to monitored screening.