[Biliary lesions after laparoscopic cholecystectomy]. / Lesioni biliari dopo colecistectomia laparoscopica.

Laparoscopic cholecystectomy is the suitable treatment for symptomatic cholelithiasis, even if the incidence of biliary lesions following this procedure may be up to threefold higher than that of open cholecystectomy. We report our experience concerning the incidence, aetiopathogenesis, diagnosis and treatment of complications in a homogeneous group of laparoscopic cholecystectomies. In a total of 492 laparoscopic cholecystectomies only three bile duct lesions were observed (0.6%); they were classified according to Bismuth and re-assessed according to Strasberg. They consisted in two biliary leakages and one bile duct stricture. All patients were evaluated by full blood test, ultrasonography and endoscopic retrograde cholangiopancreatography. Endoscopic treatment was successful in the two patients with biliary leakage, while the patient with a stricture required surgical therapy. In conclusion, we suggest that a correct knowledge of the aetiopathogenesis together with a multidisciplinary approach to the diagnosis appear to be the best method for the detection, complete classification and most suitable treatment of symptomatic cholelithiasis.

Simple versus double jejunal pouch for reconstruction after total gastrectomy.

BACKGROUND: Even though many types of reconstruction after total gastrectomy have been proposed to reduce postgastrectomy syndromes, choosing a method that would further improve the quality of life and nutrition of the gastrectomized patient is controversial. Hunt-Lawrence single pouch reconstruction seems to obtain better results compared with the more common Roux-en-Y technique, but both of these reconstructive approaches are associated with some reduction in food intake and some problems in achievement of ideal body weight. METHODS: In this prospective, randomized trial, after total gastrectomy 18 patients had reconstruction according to the Hunt-Lawrence or single pouch technique (SP group), whereas for 23 patients, the technique was modified with construction of a second pouch in the distal portion of the jejunal loop (DP group). Patients in the two groups were compared at 12 months after surgery for problems in gastrointestinal function, quality of life, improvement in body weight and nutritional parameters, serum albumin, hemoglobin level, and serum protein. RESULTS: The DP group demonstrated fewer symptom problems, better weight maintenance, and better laboratory values when compared with patients undergoing standard single jejunal pouch reconstruction. CONCLUSIONS: Reconstruction with use of a double pouch as a gastric substitute leads to better outcome assessments than with a single pouch reconstruction. Our double pouch technique has demonstrated significant improvement in quality of life and nutritional recovery in terms of functional results as well as patient satisfaction.

[Vascular clamping in cirrhotic liver surgery]. / Il clampaggio vascolare nella chirurgia del fegato cirrotico.

Different vascular clamp methods in liver surgery have led to less complications. The aim of this study was to evaluate the results after hepatic resection involving different vascular clamping methods and liver function outcome. Our study examined 46 patients who underwent surgery for liver lesions, developed on cirrhotic and noncirrhotic livers, applying the technique of selective clamping and pedicular clamping. There was one death (1/17; 5.9%) due to postoperative liver failure which occurred in a cirrhotic liver patient who underwent left hepatectomy with pedicular clamping. Complication rate was higher, but not significant (4/7; 57.1%) in the group with selective clamping compared to those with pedicular clamping (3/10; 30%). Hemorrhagic complications were observed in a higher rate among patients with selective clamping (3/7; 42.9%) compared to those with pedicular clamping (1/10; 10%). Selective clamping seems to find major indications in patients with chronic liver disease undergoing minimal hepatic resections. Intermittent pedicular clamping seems to be more effective in regards to blood loss and postoperative hepatic function.

Surgical approach to nipple discharge: a ten-year experience.

BACKGROUND AND OBJECTIVES: The actual relationship between malignancy and secreting breast has not yet been extensively verified, mainly in patients with nipple discharge but without evidence of a breast lump. This study was carried out in 1,251 consecutive patients to evaluate the reliability of cytology combined with galactography in order to assess the relationship of malignant and premalignant lesions with discharge without the presence of a breast lump. METHODS: Those patients with bilateral discharge were approached endocrinologically, whereas the patients (433) with unilateral secretion were evaluated by cytology, mammography, fine needle biopsy, and galactography. Of 194 patients without a breast lump, 94 with positive cytology were surgically treated after mammogalactography. Surgical treatment included ductgalactophorectomy in 53, segmentectomy in 23, microdochectomy in 13, and mastectomy in 5 patients. RESULTS: Pathologic findings showed a solitary papilloma in 49 cases, minimal breast cancer in 20, fibrocystic disease in 11, papillomatosis in 7, lobular cancer in 5, and, finally, a duct ectasia in 2. CONCLUSIONS: In the patients with secreting breast but without lump, cytological analysis in addition to galactography seems to be useful in identifying minimal breast cancer and in detecting premalignant lesions like papillomatosis.

Blind versus open approach to laparoscopic cholecystectomy: a randomized study.

Intraabdominal structures may be damaged during blind introduction of the first trocar for laparoscopic operations. In this study, 150 patients with gallbladder lithiasis who underwent laparoscopy were randomly assigned to two groups, a blind (V group) or an open (H group), in order to compare the results and the rate of complications. No mortality was observed. Major complications occurred in 3/75 (4%) patients of the V group and in 1/75 (1.3%) patient of the H group (p < 0.05). Minor complications occurred in 5/75 (6.7%) patients of either group. The achievement of pneumoperitoneum required 4.5+/-0.4 min in the V group and 3.2+/-0.2 min in the H group (p < 0.05). The open laparoscopic technique is safer and faster than the blind approach; therefore, it is proposed that this approach be routinely used in all laparoscopic procedures.

Transmucosal potential difference as an index of esophageal mucosal integrity.

All the epithelia lining the gastrointestinal (GI) tract, including that of the esophagus, exhibit a transmucosal electrical potential difference (PD). The luminal surface of the GI mucosa is indeed electrically negative when compared with the serosal one. Although it was initially felt that the body of the esophagus exhibits a PD near 0 or slightly positive, recent studies, using parenteral reference electrodes, have shown a negative PD of around -15 mV. Measurement of esophageal PD has been mainly used to locate both the lower and the upper esophageal sphincters but very rarely to evaluate esophageal mucosal integrity in clinical settings, most probably due to the difficulties encountered during measurement of mucosal PD. Reliable techniques to measure esophageal PD simultaneously with esophageal pressure or mucosal pH are now available. Application of these recently developed methodologies showed that measurement of esophageal PD during either manometry or endoscopy provides meaningful information about mucosal integrity. Indeed, tissue injury, either neoplastic of inflammatory, usually results in a less negative PD. In contrast, an abnormally high negative PD is very often observed in patients with columnar-lined lower esophagus. In patients with microscopic reflux esophagitis, PD exhibits less negative values which are significantly correlated with the degree of the mucosal damage. Normalization of the altered PD after either medical or surgical treatment makes it an additional parameter to evaluate the effect of a given therapy.

[The role of necrosectomy and continuous peritoneal lavage in the treatment of acute necrotic-hemorrhagic pancreatitis]. / Il ruolo della necrosectomia e del lavaggio peritoneale continuo nel trattamento della pancreatite acuta necrotico-emorragica.

Acute necrotizing pancreatitis involves high mortality. When diagnosed, the disease implies a choice of suitable timing and proper technique of surgical approach. The experience on 16 patients with acute necrotizing pancreatitis, 9 males and 7 females, mean age of 54.7 +/- 3.3 years, is presented in this study. Necrosectomy and continuous local lavage of abdominal collections and pancreatic necrotic surfaces was the most appropriate surgical treatment. The method seems able to remove necrosis and active biological compounds and would appear to achieve a limited mortality and morbidity. Necrosectomy and postoperative local lavage represent a therapeutic effective procedure.

[Urogenital sequelae in surgery of rectal carcinoma]. / Sequele urogenitali nella chirurgia del carcinoma rettale.

Seventeen consecutive patients with rectal cancer underwent surgery at our institution between January 1988 and December 1990. The aim of this study was to assess the urogenital symptoms after radical resection of the rectum. Ten of these patients were suitable for the study, 9 of whom had an Anterior Resection (with colorectal anastomosis in 7 cases and with coloanal anastomosis in 2) and 1 a Miles operation. We observed urogenital disturbances in 2 patients (20%), 1 male with urinary tract dysfunction and 1 female with difficulties of sexual activity. The disease-free interval, at 36 months, was 100%. We suggest that curative surgery for rectal cancer can be associated, in overall cases, with a low incidence of urogenital disturbances. This allows the improvement of quality of life without evidence of loco-regional recurrence. A resective approach of rectal cancer, able to preserve nervous fiber of pelvic plexus but providing at the same time a radical excision of the tumor, seems to be a determining factor.

[Reflux esophagitis. What factors influence the choice of antireflux surgery?]. / Esofagite da reflusso. Quali fattori influenzano la scelta della chirurgia antireflusso?

The surgical goal of gastroesophageal reflux treatment is to restore the ability of antireflux barrier. The basal tone and the length of lower esophageal sphincter are commonly considered the most important factors in the assessment of gastroesophageal reflux symptoms. However, reflux symptoms may also occur after surgical correction of sphincter incompetence. In the present study, 20 patients were evaluated pre- and postoperatively by 24 hours pH monitoring, esophageal manometry, endoscopy and analysis of gastric emptying of solids, in order to verify surgical results and connected functional changes. Preoperative data suggested to perform a partial fundoplication in 12 patients and a total fundoplication in 8 cases. Our results can indicate that fundoplications are able to significantly control reflux symptoms, to improve the competence of lower esophageal sphincter and finally to normalize gastric emptying of solids. This study emphasizes the value of normalizing a delayed gastric emptying to assure a satisfactory clinical outcome. The postoperative impaired gastric emptying rates in fact appear to associate with persistent symptoms.

[The role of esophageal sphincter tonus and of gastric motility in the extent of reflux esophagitis]. / Ruolo del tono sfinteriale esofageo e della motilità gastrica sull'entità dell'esofagite da reflusso.

Thirty-two patients with symptomatic gastroesophageal reflux disease were investigated by esophagogastroduodenoscopy, 24 h pH monitoring, esophageal manometry and measurement of gastric emptying of solids, in order to elucidate the relative importance of lower esophageal sphincter tone, amount of acid reflux and gastric emptying on the degree of esophagitis. The mechanical competency of lower esophageal sphincter was significantly deranged in patients with moderate/severe esophagitis than in patients with mild esophagitis. The gastric emptying time was significantly delayed in patients with moderate/severe esophagitis than in patients with mild esophagitis. No relationship was observed between amount of acid reflux, lower esophageal sphincter function and gastric emptying time. Our results suggest that resting pressure of lower esophageal sphincter and the gastric motor function play a major role in severity of reflux esophagitis.

Different effects of bombesin on glucose- and tolbutamide-induced insulin release in man.

1. The effect of bombesin, a neurogastrointestinal peptide, on basal and stimulated insulin release was studied in man. 2. Two different stimuli were used, hyperglycaemic (20 g glucose) and hypoglycaemic (1 g tolbutamide). They were injected intravenously to two groups of male healthy volunteers during saline or bombesin (5 ng kg-1 min-1 for 60 min) infusion. 3. The peptide had no significant effect on basal levels of glucose and insulin. However, the insulin response to intravenous glucose was strongly potentiated by bombesin, the integrated insulin response being 2.23 +/- 0.59 mu ml-1 . 90 min and 0.98 +/- 0.19 mu ml-1 . 90 min during infusion of bombesin and saline, respectively (P less than 0.05). The behaviour of plasma glucose was not significantly modified by the peptide. Indeed, the glucose disappearance rate (K of Conard, mg min 10(-2)) changed from 2.5 +/- 0.3 during saline to 2.4 +/- 0.4 during bombesin infusion. 4. When the hypoglycaemic stimulus (i.e. tolbutamide) was used, no effect of the peptide on insulin release could be detected. Here again, the drop in plasma glucose (expressed as Marigo's coefficient) was not affected by the peptide, with a value of 92.8 +/- 12.6 and 84.0 +/- 10.9 during bombesin and saline administration. 5. These data therefore show that, at normal or low blood glucose levels, the dose of bombesin used is unable to modify insulin release and suggest that this peptide might be regarded as a glucose-dependent insulinotropic peptide.

Effect of bombesin on glucose-induced insulin release in humans.

The effect of bombesin on basal and glucose-stimulated insulin release was studied in male healthy volunteers. Glucose was administered by oral, intravenous or intraduodenal route during saline or bombesin infusion (5 ng/kg/min for 60 min). The peptide had no significant effect on basal levels of glucose and insulin. However, during its administration, the insulin response and the expected rise in blood glucose after oral glucose load (50 g) were strongly inhibited, and the gastric emptying of liquids was significantly delayed. On the contrary, the insulin response to intravenous glucose (20 g) was significantly increased by bombesin without changes in plasma glucose levels. Finally, when glucose was infused into the duodenum, thus bypassing the stomach, the insulin response was significantly increased by the peptide. In this case, too, plasma glucose levels after glucose load were virtually identical during either bombesin or saline infusion. These data clearly demonstrate that the direct effect of bombesin on insulin release is stimulatory and suggest that the inhibitory effect observed after oral glucose is connected with the action of the peptide on gastric emptying, the delay of which slows the entry of glucose into the small bowel.

[Gastric emptying of solids in gastroesophageal reflux]. / Vidange gastrique des solides au cours du reflux gastro-oesophagien.

Delayed gastric emptying has been assumed to play an important role in the pathogenesis of gastroesophageal reflux (GER), even though this relationship has not been definitely established. Eleven patients with symptomatic GER were studied by esophageal manometry, endoscopy, gastroesophageal scintiscanning and gastric emptying of a mixed meal. Nine healthy subjects served as controls. Gastric emptying of solids (evaluated both as emptying half-time and emptying index) in GER patients was significantly slower than in controls. In comparison with a "normal" range previously established in 50 healthy subjects, only 2 of 11 (18.2 p. 100) of GER patients had a normal emptying rate. In addition, a significant correlation was found between the emptying half-time and the degree of esophageal lesions. These results suggest that impaired motor function of the gastric antrum could influence the natural history of GER disease and especially the appearance of esophagitis. The lack of esophageal lesions in the only two patients with "normal" emptying strongly supports this hypothesis.

Opposite effects of bombesin on insulin and gastrin response to food in humans.

The effect of bombesin on insulin and gastrin response to a standard labelled meal was studied in eight healthy male volunteers. The gastric emptying of solids was simultaneously evaluated. During intravenous infusion of the peptide (5 ng/kg/min) the insulin release after eating was greatly reduced whereas food stimulated gastrin release was significantly enhanced. Both effects of bombesin are likely to be connected with the marked inhibition of gastric emptying induced by the peptide.

[Indications and role of ultrasonography, transhepatic percutaneous cholangiography and endoscopic retrograde cholangiography in obstructive pathology of the distal choledochus]. / Indicazioni e ruolo della ultrasonografia (us), della colangiografia percutanea transepatica (ptc) e della colangiografia retrograda endoscopica (erc) nella patologia ostruttiva del coledoco distale.

The authors refer the results obtained with ultrasonography (US), percutaneous transhepatic cholangiography (PTC) and endoscopic retrograde cholangiography (ERC) in the diagnosis of obstructive jaundice. One-hundred and forty-four patients have been investigated, on the basis of biological, clinical and ultrasonographic findings, by PTC or ERC. The high percentage rate observed in PTC-approached patients suggests that the combination of US-PTC would appear to provide an important role in diagnosing obstructive jaundice.

Usefulness of carcinoembryonic antigen measurement in gastric juice of patients with gastric disorders.

Due to conflicting reports on the role of CEA measurement in the gastric juice of patients with gastric malignancy, we have assessed gastric CEA levels in a variety of both nonmalignant and malignant lesions of the stomach. The average gastric CEA levels were higher in patients with gastric ulcer and gastric cancer than in healthy subjects and those with duodenal ulcer. In addition, the frequencies of abnormally high values were significantly (P less than 0.001) higher in gastric ulcer or gastric cancer than in healthy or duodenal ulcer groups, whereas there was no difference between gastric ulcer and gastric cancer groups. The evaluation of gastric CEA levels in relation to gastric inflammatory changes leads us to suggest a close relationship between gastric CEA values and the degree of gastric inflammation. Gastric lavage cytology did not provide a sensitive tool for detection of gastric disorders. This study suggests little value for gastric CEA determination in gastric cancer detection. However, we believe the association of rising gastric CEA levels with various types of gastritis justifies measuring gastric CEA to recognize "precancerous" mucosal changes of the stomach.