Does rifaximin prevent complications of diverticular disease? A retrospective study.

While the treatment of complicated diverticular disease (DD) is standardized, the approach to the symptomatic DD and prevention of relapsing complicated DD is still debated. An open question is whether nonabsorbable antibiotics may reduce the incidence of major complications of DD. We wanted to retrospectively analyze the prevalence of this disease in a large population of patients undergoing colonoscopy in our center in the last 10 years. Patients with symptomatic or complicated DD were treated with rifaximin 1,200 mg/die for 10-12 days during the acute phase in addition to the appropriate systemic antibiotics, followed by a prophylactic regimen with 800 mg/die for 7 days every month. The patients were followed up to December 2003, and the incidence of new complications and the relapses of symptomatology were determined. A total of 11,344 patients were screened. Of them, 2,287 showed an anatomical diverticulosis, and 408 had a diagnosis of complicated DD. The results indicate that the prevalence of DD--either in the uncomplicated or complicated form--in our area (Abruzzo, Italy) is identical to that of European countries, whose diet is characterized by a low amount of fiber and a high content of calories and refined sugars. Along a period of 10 years, a relapsing symptomatology of DD was observed in 112 patients treated with rifaximin (4.89%), while new complications of the DD were observed in 27 patients (1.18%). The comparison of these data with those of larger published series suggests a possible role of rifaximin in the prevention of DD main complications.

Laparoscopic versus open cholecystectomy. An analysis of clinical and financial aspects.

BACKGROUND: The aim of this study is to assess the clinical and financial aspects of laparoscopic cholecystectomy (LC) compared to open cholecystectomy (OC). METHODS: Thirty-six patients treated with LC were prospectively, not randomized, compared with 35 patients that underwent OC. The data used were taken from local registers, patient-statistics and hospital accounting systems. We evaluated the costs, morbidity and mortality for both surgical procedures. RESULTS: Significant differences were observed concerning the number of days that pain was suffered (mean 7.6 days in LC versus 18.5 days in OC), the duration of postoperative hospitalization (LC mean 2-3 days; OC 7-9 days), the extent of postoperative monitoring performed, and the number of days in order to return to normal activity (mean 4.4 days in LC; mean 7.6 days in OC). Calculation of the costs was based on the Diagnosis Related Groups (DRG). The profit for a DRG is the result of the difference between the reimbursement obtained from the execution of the operation and the cost in order to carry it out. The total cost for the execution of LC is Italian 3,332,632 pound sterling with a profit of Italian 1,208,807 pound sterling while for OC the cost is 4,007,359 pound sterling and the profit is 347,041 pound sterling. CONCLUSIONS: The results of our study is that, clinically and financially, LC has obvious advantages over OC.

[Polyps (single or multiple) and juvenile polyposis]. / Polipi (singoli o multipli) e poliposi giovanile.

The authors underline the important aspects of juvenile familial polyposis (JFP), a disease transmitted as an autosomal dominant trait. A case of JFP characterized by the presence of hundreds of polyps in the colo-rectal intestinal tract, is analyzed. The single juvenile polyp, multiple polyps (=/>5 polyps) and the sporadic form are examined. These are mucous hamartomas which can undergo neoplastic transformation (in carcinoma in 68% of untreated cases), a behaviour similar to that of adenomatous polyps. They differ from the later due to the following features: epidemiology (earlier appearance age), anatomopathology (stroma), clinical observation (self-recovery in some cases) and genetics (10q23.3-18q21, genetic mutations in a locus different those of adenomatous polyps). It is also necessary to determine its extension by means of colonoscopy, ileoscopy, gastroscopy and small bowel barium enema. Patients' screening through construction of the genealogical family tree is fundamental. Isolation of possible degenerative aspects of the polyps through biopsy is also fundamental. Single or multiple polyps are treated endoscopically, the juvenile polyposis is treated surgically (colectomy, total colectomy). A rigorous follow-up of the patients and their family members is recommended.

[Endoscopic diagnosis and treatment of juvenile solitary polyps, in the light of the unusual but proven neoplastic potential]. / Considerazioni di diagnosi e terapia endoscopica dei polipi giovanili solitari, alla luce della rara ma dimostrata potenzialità neoplastica.

For many years a neoplastic potentiality of the juvenile polyps has been denied. The authors performed a critical review of the international literature about the neoplastic transformation of the juvenile polyps. Each examined case had to respect three conditions: 1) exhaustive hystological findings certifying a clear neoplastic degeneration of a juvenile polyp; 2) clear evidence of single juvenile polyposis (< 5), presence in the colon and rectum only and absence of familiarity; 3) reliable diagnostic practice (endoscopic and/or hystological evidence). During the review we collected 271 cases of juvenile polyposis observed in 12 countries, 97 of which (35.79%) showed neoplastic transformation, adenomatous type in 50 (18.45%) and carcinomatous type in 47 (17.34%), and 13 cases of neoplastic degeneration of single juvenile polyps. The review shows clearly and strongly that the risk of cancer in the juvenile polyposis can reach the risk of the adenomatous polyposis. The neoplastic degeneration exists in the single juvenile polyps even if in a lower degree.

[The general surgeon's experience in emergency gynaecological laparoscopy]. / L'esperienza videolaparoscopica del chirurgo generale di fronte alle urgenze rivelatesi ginecologiche.

BACKGROUND: Early laparoscopy plays a very important role in the diagnosis and treatment of uncertain surgical diseases. Its use is not very clear, in part because it is a very new technique and secondly because its application in emergency surgery is very recent. The aim of this study is to evaluate the efficacy of this surgical approach. METHODS: In the last six years, during emergency laparoscopy, we diagnosed various gynaecological diseases. We performed 4 ovarian cystectomies (25%), 2 salpingectomies (12.5%), 6 salpingo-oophorectomies (37.5%), 2 myomectomies (18.75%), 1 endocoagulation (6.25%). RESULTS: Neither conversion in open surgery, nor major postoperatory complications were noted. Intervention time was shorter than that of the open technique. Return to normal activity was earlier. CONCLUSIONS: The results of this study contribute to demonstrate that, in emergency surgery, laparoscopy constitute a valid and efficient diagnostic and therapeutic technique. It is indicated for the treatment of acute abdomen of unknown origin.

Increased enterocyte apoptosis and Fas-Fas ligand system in celiac disease.

Our aim was to evaluate whether increased enterocyte apoptosis was responsible for mucosal flattening in celiac disease (CD), and, since the mechanisms responsible for tissue injury in this condition are unknown, we studied the possibility that the Fas-Fas ligand (FasL) system may be involved. Endoscopic duodenal biopsy specimens from 12 patients with untreated and 12 with treated CD and 12 control subjects were evaluated for enterocyte apoptosis by the terminal deoxynucleotidyl transferase-mediated digoxigenin-deoxyuridine triphosphate nick-end labeling assay and for Fas and FasL expression by immunohistochemistry. A coculture of isolated enterocytes (targets) and purified lamina propria mononuclear cells (LPMCs) (effectors) was performed in the absence or presence of an antagonistic ZB4 anti-Fas antibody. We found a significant correlation between the degree of villous atrophy, morphometrically evaluated, and the level of enterocyte apoptosis, suggesting that mucosal flattening is a consequence of exaggerated epithelial cell death. Most celiac enterocytes express Fas, and LPMCs express FasL. The abolishment of enterocyte apoptosis observed in the presence of ZB4 antibody suggests that enterocytes are potential targets of lymphocyte infiltrate. These results directly demonstrate that FasL-mediated apoptosis is a major mechanism responsible for enterocyte death in CD.

[Inflammatory markers after laparoscopy versus laparotomy cholecystectomy]. / Markers infiammatori post colecistectomia laparoscopica versus laparotomica.

OBJECTIVE: The study is carried out to determine whether the level of IL-6 is altered and in what way after surgery as well as if such a change could be an indicator of increased morbidity after surgical treatment. MATERIALS OF THE STUDY: Chemiluminesence immunoeassay system was used in order to establish IL-6 level in blood samples of 71 patients that underwent abdominal surgery, 36 Laparoscopic Cholecystectomy (LC) and 35 Open Cholecystectomy (OC) at time 0 (before the operation), 1 h, 2 h, 3 h, 6 h, 24 h and 48 h after the operation. RESULTS: Plasma IL-6 levels are significantly increased after OC; we observed 3 cases of post-operative infections, in which IL-6 returned to normal levels 6 days after surgery. Analogous variation to the IL-6 levels was noted for the C-reactive protein levels. DISCUSSION: Laparoscopic cholecystectomy, a so called mini-invasive surgical procedure, is associated to a small increase of IL-6 serum levels and provides better post-operative conditions to the patients by reducing surgical stress and the infectious complications correlated to the surgical procedure. CONCLUSIONS: During OC there is a significant higher elevation of IL-6 serum levels than after laparoscopic cholecystectomy. Variation of C-reactive protein serum levels after surgery is analogous to variation of IL-6 levels.

[Diagnosis of severity as a basic parameter in the treatment of acute biliary pancreatitis]. / La diagnosi di gravità come parametro fondamentale per il trattamento della pancreatite acuta biliare.

BACKGROUND: Acute biliary pancreatitis (ABP) still retains high morbidity (15-50%) and mortality (20-35%). Therefore it appears to be crucial to clearly assess the aetiological factors (50% of idiopathic are in fact biliary pancreatitis) and to establish their severity in order to plan the appropriate treatment. METHODS: 58 ABP patients were diagnosed by ultrasound (77.5%) or by laboratory findings (22.4%). Following Ranson and APACHE II scoring 17 cases (29.3%) were classified as severe, 41 (70.6%) as mild. All patients with severe ABP, had emergency ERCP + ES (within 24-48 hrs) followed by LC (< or = 10 days). Patients with mild ABP had LC within 10 days; in these cases IOC was always done. RESULTS: In severe cases operative endoscopy cured pancreatic inflammation in 12 cases. Subsequent LC never showed serious morbidity, apart from subcutaneous emphysema in one case. In 5 cases laparotomy was required since pancreatic necrosis was present, with 60% mortality. In patients with mild pancreatitis LC was successfully performed in all cases, with 7.3% morbidity. IOC showed choledochal stones in 31.7% of cases, while in severe cases stones in the biliary tree were shown in 88.2% of cases. CONCLUSIONS: In conclusion ABP treatment is always surgical, and almost always with minimally-invasive procedures in severe cases (ERCP + ES with LC < or = 10 days) if surgery is performed within 24-48 hrs as well as in mild cases (LC + IOC) when surgery is done within 10 days.

[Is cell-mediated immunity affected by laparoscopic cholecystectomy?]. / L'immunità cellulo-mediata è influenzata dalla colecistectomia laparoscopica?

It is well known that surgery significantly decreases cell-mediated immunity. Laparoscopic cholecystectomy is a so-called minimally invasive surgical procedure, and on the basis of this consideration we investigated whether and how the immune system is modified in patients after laparoscopic cholecystectomy compared to those undergoing open cholecystectomy. Immune activity (neutrophils, total lymphocyte count, lymphocyte subpopulations, multiple skin tests) was evaluated in 82 patients on postoperative day 1 and on postoperative days 1, 3 and 6. Forty-two patients underwent open cholecystectomy and 40 laparoscopic cholecystectomy. On postoperative day 1 patients treated by open cholecystectomy showed a significant increase (P < 0.05) in plasma neutrophils, whereas this parameter was unchanged in patients undergoing laparoscopic cholecystectomy. Skin tests revealed a hypo- or anergic response in the majority of patients (81.8%) undergoing open surgery compared to those treated laparoscopically (10.5%). Total lymphocyte count and lymphocyte subpopulations were normal in the two groups. Four cases of respiratory tract infection (4.8%) were detected after open cholecystectomy. Laparoscopic cholecystectomy substantially reduces postoperative pain and hospitalisation, promotes an earlier recovery and return to normal activity and is not associated with postoperative immunosuppression, with a more positive postoperative morbidity profile compared to open surgery.

Cytolytic mechanisms of intraepithelial lymphocytes in coeliac disease (CoD).

The effector arm of the mucosal immune system comprises lymphocytes scattered at intraepithelial and lamina propria levels. Intraepithelial lymphocytes (IEL) are a large population of oligoclonal resting cells which exhibit phenotypic and functional characteristics of cytolytic T cells when activated. Several mechanisms have been demonstrated to account for their cytotoxicity. Among them, one is mediated by perforin and granzyme molecules, another is mediated by Fas ligand (FasL) which delivers apoptotic signals through Fas receptor on target cells. There is good evidence that a flat intestinal mucosa may be produced by activated T cells. The aim of our study was to evaluate FasL and perforin expression by IEL, and its possible correlation with the increased enterocyte apoptosis in coeliac mucosa. Endoscopic duodenal biopsy specimens from 10 untreated coeliac patients, 10 treated coeliac patients, and 10 biopsied controls were evaluated for enterocyte apoptosis by terminal deoxynucleotidyl transferase-mediated digoxigenin-deoxyuridine triphosphate nick end label method, for perforin expression by immunohistochemistry, and for FasL expression by immunocytochemistry. In untreated CoD there was a significant increase of percentage of both FasL+ and perforin+ IEL which positively correlated with enterocyte apoptosis in comparison with controls. All these parameters were significantly lower in treated CoD, even though they did not normalize. Our study demonstrates that in untreated CoD FasL and perforin expression by IEL is increased, and significantly correlates with the level of enterocyte apoptosis.

[Clinical assessment of juvenile polyposis with particular reference to the risk of neoplastic malignancy. Analysis of 412 patients reported in the international literature]. / Inquadramento clinico della poliposi giovanile con particolare riferimento al rischio di degenerazione neoplastica. Analisi dei 412 pazienti riportati dalla letteratura internazionale.

The authors extensively review the international literature on juvenile polyposis, with particular reference to the risk of malignancy in the various forms of the disease (colorectal vs. generalized, familial vs. sporadic). Sixty-eight out of a total of 412 patients presented adenomatous changes in the polyps. In addition, 68 cancers were found. The rate of degeneration was analysed for all variants of juvenile polyposis, but no statistically significant differences were detected. The authors conclude that juvenile polyposis should be considered as being as challenging to the surgeon as familial polyposis syndromes and outline protocols for the screening, endoscopic and surgical treatment and follow-up of these patients.

[Structure, function, and levels of neutrophil elastase after laparoscopic cholecystectomy]. / Struttura, funzione e livelli dell'elastasi neutrofila dopo videolaparocolecistectomia.

Neutrophil elastase is a neutral proteinase present mainly in the azurophilic granules of segmented granulocytes, the main cells involved in the inflammatory response reaction. In our study we attempted to determine whether an enzyme such as neutrophil elastase produced by polymorpho-nuclear leukocytes could be an indicator capable of determining the degree of surgical trauma, comparing two surgical approaches, namely, laparoscopic cholecystectomy and open cholecystectomy. Plasma neutrophil elastase was determined photometrically, using an immune-activation immunoassay, in 66 patients (32 patients underwent open cholecystectomy and 34 laparoscopic cholecystectomy) 1 day before surgery and 1, 3, 6 and 12 days after surgery. We established a reference range for elastase by measuring the serum elastase concentration in 48 healthy control patients. A significant increase (p < 0.05) in plasma neutrophil elastase levels was observed on days 1, 3 and 6 after surgery in patients undergoing open cholecystectomy, whereas the levels of the enzyme were almost stable in patients undergoing laparoscopic cholecystectomy. We recorded two cases (6.2%) of respiratory tract infections in the "open" group. Neutrophil elastase is a good indicator for discriminating the severity of the surgical trauma, which is certainly more severe in laparotomy than in laparascopic cholecystectomy. Peripheral leukocyte function seems to be better preserved after laparoscopic surgery than after laparotomy.

[Treatment of acute biliary pancreatitis in the aged in the endolaparoscopic era]. / Il trattamento della pancreatite acuta biliare nell'anziano nell'era endolaparoscopica.

BACKGROUND: Acute biliary pancreatitis (ABP) still retains high morbidity (15-50%) and mortality (20-35%). Therefore it appears to be crucial to clearly assess the aetiological factors (50% of idiopathic are in fact biliary pancreatitis) and to establish the severity in order to plan the appropriate treatment. METHODS: In this study we have considered 61 patients divided into 2 groups. Group 1 had 29 ABP patients aging less than 65 years, group 232 patients aging more than 65 years; the diagnosis was made by ultrasound and serological values in 78.5% of cases, while in the remaining 21.5% was only serological. Following Ranson and APACHE II scoring 18 cases (29.5%) were classified as severe [6 (20.6%) in group 1; 12 (37.5%) in group 2: p < 0.01], 43 (70.4%) as mild. All patients with severe ABP had emergency ERCP + ES (within 24-48 hrs) followed by LC (< or = 10 days). Patients with mild ABP had LC within 10 days; in these cases IOC was always done. RESULTS: In severe cases operative endoscopy cured pancreatic inflammation in 13 cases. Subsequent LC never showed serious morbidity, apart subcutaneous emphysema in one case. In 5 cases laparotomy was required since pancreatic necrosis was present, with 60% mortality. In patients with mild pancreatitis LC was successfully performed in all cases, with 6.9% morbidity. IOC showed choledochal stones in 32.5% of cases, while in severe cases stones in the biliary tree were showed in 88.8% of cases. No significant differences were detected between group 1 and 2. CONCLUSIONS: In conclusion ABP treatment is always surgical, and almost always with minimally-invasive procedures in severe cases (ERCP + ES with LC < or = 10 days) if surgery is performed within 24-48 hrs as well as in mild cases (LC + IOC) when surgery is done within 10 days, independently from the age of the patients.

N-nitroso compounds and Helicobacter pylori in the gastric remnant.

AIMS AND BACKGROUND: The aims of this study were to investigate the role of N-nitroso compounds (NOC) and Helicobacter pylori (H. pylori) in gastric stump carcinogenesis. METHODS AND STUDY DESIGN: Analyses of biochemical parameters such as pH and NOC concentration were carried out on 65 fasting gastric juice samples obtained at endoscopy from 45 patients previously submitted to partial gastrectomy for benign peptic ulcer disease (23 Billroth I, 22 Billroth II/Reichel-Polya) and 20 normal controls. Biopsy specimens were taken to determine histology and H. pylori status. RESULTS: Significantly higher mean pH values and NOC concentrations were found in partial gastrectomies compared to normal controls. In relation to surgical methods, higher mean pH values and NOC concentrations were observed in the gastric juice of patients with Billroth II compared to Billroth I gastrectomies. Independently of the type of surgical reconstruction, higher mean NOC levels were recorded in patients with more severe histological changes and H. pylori infection. CONCLUSIONS: All these data suggest that high levels of NOC in gastric juice and H. pylori infection could be cofactors in gastric stump carcinogenesis.

Prospective randomized evaluation of preoperative endoscopic vital staining using CH-40 for lymph node dissection in gastric cancer.

BACKGROUND: CH-40 is a suspension of activated carbon particles that was developed in Japan to carry anticancer drugs to regional nodes and peritoneal seedings of gastric cancer. METHODS: Forty-five consecutive patients who had surgical resection and D2 lymph node dissection for gastric cancer over a 2-year period were randomly assigned to preoperative endoscopic submucosal injection of CH-40 (group A) or no staining (group B). A total of 21 patients in group A and 24 in group B were available for analysis. RESULTS: The number of resected nodes per patient was significantly higher (t = 6.06; 40 df; P < .0001) in group A (mean+/-S.E. = 35.3+/-1.24) than in group B (mean+/-S.E. = 25.5+/-1.02). The rate of metastatic nodes resected was significantly higher (chi2 = 6.903 ; 1 df; P = .009) in stained (22.5%) than in non-stained (14.7%) nodes of group A and also (chi2 = 6.906; 1 df; P = .009) in stained nodes of group A than in group B (15.8%). CONCLUSIONS: Preoperative endoscopic vital staining with CH-40 proved to be rapid, safe, and effective in all cases in this series. Its use allowed surgeons to resect a higher number of lymph nodes. and to identify and examine more metastatic nodes. It also permitted identification of nodal micrometastases on routine histopathologic examination.

N-Nitroso compounds, bacteria, and carcinoembryonic antigen in the gastric stump.

Analyses of biochemical and microbiological parameters such as pH, N-nitroso compound (NOC) concentration, carcinoembryonic antigen (CEA) level, and total viable counts (TVCs), and identification of microorganisms were carried out on 65 fasting gastric juice samples obtained at endoscopy from 45 patients previously submitted to partial gastrectomy for benign peptic ulcer disease (23 Billroth I, 22 Billroth II/Reichel-Polya) and 20 normal controls. Biopsy specimens were taken to determine histology, the Helicobacter pylori status, and both tissue CEA immunoreactivity and level. Significantly higher mean pH values, NOC and CEA concentrations, and TVCs were found in partial gastrectomies compared with normal controls. In relation to surgical methods, higher mean pH values, NOC concentrations, TVCs, and anaerobic bacterial counts were observed in the juice of patients with Billroth II compared with Billroth I gastrectomies. Mild CEA immunoreactivity and apical CEA localization were found significantly more often in Billroth II than in Billroth I stumps. Intensive CEA immunoreactivity and cytoplasmatic localization were found significantly more often in Billroth I than in Billroth II stumps. Independent of the type of surgical reconstruction, higher mean NOC levels were recorded in patients with more severe histological changes and H. pylori infection. Higher mean CEA levels in gastric juice and tissue were detected in the gastric stumps with more severe histological changes. All these data suggest that high levels of NOCs in the gastric juice could be a cofactor in gastric stump carcinogenesis and determination of CEA level in gastric juice and tissue could be included as a very useful marker in quantifying this process.

[Acute biliary pancreatitis: mini-invasive treatment]. / Pancreatite acuta biliare: trattamento mini-invasivo.

Acute biliary pancreatitis (ABP) still retains high morbidity (15-50%) and mortality (20-35%). Therefore it appears to be crucial clearly assessing the aetiological factors (50% of idiopathic are in fact biliary pancreatitis) and establishing the severity in order to plan the appropriate treatment. Forty-nine ABP patients were diagnosed by ultrasound (75.5%) or by laboratory findings (22.5%). Following Ranson and APACHE II scoring, 15 cases (30.6%) were classified as severe, 34 (69.3%) as mild. All patients with severe ABP had emergency ERCP + ES (within 24-48 hours) followed by LC (< or = 10 days). Patients with mild ABP had LC within 10 days; in these cases IOC was always done. In severe cases operative endoscopy cured pancreatic inflammation in 11 cases. Subsequent LC never showed serious morbidity, but subcutaneous emphysema in one case. In 4 cases laparotomy was required since pancreatic necrosis was present, with 75% mortality. In patients with mild pancreatitis LC was successfully performed in all cases, with 8.8% morbidity. IOC showed choledochal stones in 32.5% of cases, while in severe cases stones in the biliary tree were showed in 80% of cases. In conclusion ABP treatment is always surgical, and almost always with minimally-invasive procedures in severe cases (ERCP + ES with LC < or = 10 days) if surgery is performed within 24-48 hours as well as in mild cases (LC + IOC) when surgery is done within 10 days.

[A case of gastric hemangiopericytoma]. / Un caso di emangiopericitoma dello stomaco.

The authors report a case of gastric hemangiopericytoma. This tumor, histogenetically derived from pericytes, has been detected in any tissue or structure. According to the review of the literature, the hemangiopericytoma of the stomach occurred very uncommonly, being published only 29 cases. Diagnosis is based on histological and immunohistochemical techniques. Surgery is the main therapy but the impredictable biological behaviour require different strategies.

[Digestive hemorrhage caused by rupture of an aneurysm of the superior pancreaticoduodenal artery]. / Emorragia digestiva causata dalla rottura di un aneurisma dell'arteria pancreatico-duodenale superiore.

Aneurysms of the pancreaticoduodenal artery are rare. Nonoperative management of an iatrogenic superior pancreaticoduodenal artery aneurysm which ruptured into the duodenal stump of a Billroth II partial gastrectomy, is described here. Based on a literature review, both aetiology and site of rupture of this observation are very uncommon. Super-selective angiography was used for diagnosis and embolisation for definitive treatment.