Upper gastrointestinal massive bleeding successfully treated intra-operatively with a collagen and thrombin-based high-viscosity gel for haemostasis. Case report.

A 57-year-old male patient was admitted in our Department for a non-variceal upper gastrointestinal massive bleeding. In accordance with the clinical guidelines, the patient underwent an early endoscopy (within 24 hours from admission), which showed the source of bleeding in the second portion of the duodenum. An endoscopic haemostatic injection with dilute adrenalin (epinephrine, 1:10.000) was then performed. After 8 hours, severe recidive bleeding occurred with reduced haemoglobin levels, which led us to an emergency surgical treatment. A gastric resection was performed, followed by the application of high-viscous gel (Floseal) into the source of bleeding within the duodenal lumen. This technique allowed to obtain a definitive haemostasis without long-term complications. Our experience suggests that the intra-operative application of Floseal can be an effective alternative to traditional haemostatic techniques in the emergency surgical treatment of upper gastrointestinal bleeding. This also provides additional time to perform other haemostatic techniques techniques avoiding the precarious haemodynamic conditions of a patient in emergency.

Helicobacter pylori eradication as a surrogate marker for the reduction of duodenal ulcer recurrence.

OBJECTIVES: An abundance of data exists documenting the association of H. pylori eradication with the reduction in duodenal ulcer recurrence. AIM: To evaluate the validity of using H. pylori eradication as a surrogate marker for the reduction in duodenal ulcer recurrence using rigorously controlled studies. METHODS: Three controlled clinical trials were conducted in patients with uncomplicated, active duodenal ulcers. Patients were treated with various combinations of omeprazole and amoxycillin. Ulcer healing and H. pylori eradication were assessed. For patients whose duodenal ulcer healed, duodenal ulcer recurrence was determined over a 6-month period in patients with H. pylori eradication and those remaining positive for H. pylori at least 4 weeks after treatment. To support the data obtained from these clinical trials, a search of the medical literature was conducted to identify additional human clinical trials in which duodenal ulcer recurrence rates were measured and categorized by H. pylori status at least 1 month post-treatment. RESULTS: In 11 controlled trials, the overall 6-18-month duodenal ulcer recurrence rate was 54% among patients remaining positive for H. pylori at least 4 weeks after treatment compared to 6% among patients with H. pylori eradication following treatment. This finding was corroborated by the uncontrolled trials, in which the duodenal ulcer recurrence rate was 64% among patients found to be H. pylori-positive and 6% for patients found to be H. pylori-negative at least 4 weeks after treatment. A time course of duodenal ulcer recurrence rates using pooled data from both controlled and uncontrolled studies demonstrated that duodenal ulcer recurrence rates for H. pylori-negative patients persisted for up to 4 years following treatment. Duodenal ulcer recurrence rates for H. pylori-positive patients increased for the first year, then levelled off. A comparison of the duodenal ulcer recurrence rates for different treatment regimens revealed that eradication regimens based on omeprazole plus antibiotics and bismuth plus antibiotics exhibited similar duodenal ulcer recurrence rates for H. pylori-positive and -negative patients. CONCLUSION: Regardless of treatment regimens, H. pylori eradication produced a consistent and significant reduction in duodenal ulcer recurrence. Therefore H. pylori eradication, 4 weeks post-therapy, can be used as a surrogate marker for reduced duodenal ulcer recurrence in investigational clinical trials.

US double-blind, controlled trials of omeprazole and amoxycillin for treatment of Helicobacter pylori.

BACKGROUND: Widely variable Helicobacter pylori eradication rates have been reported with omeprazole/amoxycillin dual therapy. We present the first US double-blind, controlled trials of this dual therapy. METHODS: Three separate studies were performed: Studies 1 and 2 included patients with an active duodenal ulcer and Study 3 included patients with a documented history of duodenal ulcer. H. pylori eradication regimens in all studies were omeprazole plus amoxycillin vs. omeprazole vs. amoxycillin for 2 weeks. Doses in Study 1 were omeprazole 40 mg b.d. and amoxycillin 500 mg t.d.s., and in Studies 2 and 3 they were omeprazole 20 mg b.d. and amoxycillin 1 g t.d.s. Endoscopic biopsy tests were used for H. pylori diagnosis, and testing for H. pylori eradication was done at least 4 weeks after the completion of therapy. Amoxycillin sensitivities were performed in Study 2. RESULTS: Intention-to-treat (ITT) and per protocol (PP) analyses showed that eradication rates with omeprazole/amoxycillin [ITT: 39%, 40%, 46% (n = 72, 62, 48); PP: 50%, 46%, 54% (n = 54, 52, 37)] were significantly greater than monotherapy with either omeprazole (ITT: 0-4%); PP: 0-5%) or amoxycillin (ITT: 2-5%; PP: 0-11%). No patients taking the dual therapy discontinued therapy due to adverse events. Amoxycillin resistance was not seen at baseline (n = 76) or after amoxycillin therapy (n = 56). CONCLUSIONS: Omeprazole/amoxycillin dual therapy is well tolerated but the eradication rate which can be expected in the USA is at best about 50%.

[The role of video-laparoscopy in the management of ovarian swellings]. / Ruolo della videolaparoscopia nel trattamento delle tumefazioni ovariche.

METHODS: Personal experience in videolaparoscopic treatment of 42 ovarian masses during the period September 1991-December 1995 is reported. Seven patients have been operated in emergency, 35 in election. Resection of the masses has been performed by two methods: dissection and electrocoagulation, generally preferred in benign functional cysts; resection by stapler (endo GIA). RESULTS: In 5 of the patients operated in emergency an hemoperitoneum was found because of the rupture of ovarian cyst; in the other two cases, respectively, a necrotic benign cyst twisted on the adnexal axis and a dermoid cyst twisted and necrotic too were found. In the 35 patients operated in election, 33 benign cysts, 1 serous cystoadenoma 1 granulosa tumour were observed. Postoperative course was always excellent, with no painful symptomatology and hospital-stay and convalescence extremely reduced (dismission from hospital approx two days after the operation). CONCLUSIONS: The different aspects which must be evaluated before choosing mini-invasive treatment are discussed. An accurate preoperative study especially by sonography and serous hormonal dosage (in particular CA 125), besides good surgical experience of the operator, are fundamental requisites in order to minimize risks of this procedure and guarantee excellent results.

Accuracy of CLOtest after Helicobacter pylori therapy.

BACKGROUND: The accuracy of rapid urease testing after Helicobacter pylori therapy has not been widely studied and might be diminished because of decreased numbers of organisms. We assessed CLOtest results after therapy in two randomized, double-blind trials. METHODS: A total of 233 patients (in two separate studies) with true-positive baseline CLOtests (by histology or culture) received 2 weeks of omeprazole/amoxicillin, omeprazole, or amoxicillin. In study 1, patients received an additional 2 weeks of omeprazole therapy (20 mg/day) or placebo; no additional therapy was given in study 2. Endoscopy was repeated 4 weeks after completion of therapy in both studies. A diagnosis of cure required at least two negative endoscopic biopsy tests (histology, culture, CLOtest) and no positive tests. RESULTS: After therapy, 178 patients (76%) remained positive for H. pylori by histology and/or culture for both studies combined. Post-therapy CLOtest sensitivity was 86% and specificity was 95%. Sensitivity was poorer in patients after dual therapy than after monotherapy in both study 1 (68% vs. 89%; p = 0.03) and study 2 (75% vs. 94%; p = 0.03). CONCLUSIONS: CLOtest sensitivity after therapy was lower than expected in our large group of patients with baseline true-positive CLOtests. In addition, sensitivity was lower after the use of more effective therapy (i.e., dual therapy as compared with monotherapy). Although most patients with unsuccessful treatment will be identified with the CLOtest alone, a negative result should not be taken as diagnostic of eradication.

Time of Helicobacter pylori eradication assessment following treatment.

BACKGROUND: The most appropriate time to assess accurately Helicobacter pylori eradication following treatment has been debated, with recommendations ranging from 1 to 3 months. The purpose of this study was to validate the assessment of H. pylori eradication 1 month following treatment. MATERIALS AND METHODS: Three randomized, double-blind, active-controlled clinical trials were conducted in patients with endoscopically verified, active duodenal ulcers and H. pylori infection. Patients were treated with various treatment regimens of omeprazole plus amoxicillin. Ulcer healing, H. pylori eradication, and ulcer relapse were examined. Patients underwent repeat endoscopy and biopsy at 1 and 6 months following treatment (or sooner if symptoms returned) to determine the recurrence of ulcers and H. pylori status. To determine the accuracy of measuring H. pylori eradication at 1 month posttreatment, we compared the H. pylori status at 1 month and 6 months following treatment. RESULTS: In a combination of treatment groups and studies, a total of 384 evaluable patients represented data at both time points and were included in the analysis. Of those eradicated at 1 month posttreatment, 94% (141 of 150) remained eradicated at 6 months posttreatment. The proportion of patients with H. pylori eradicated at 1 month posttreatment did not differ significantly from that at 6 months posttreatment for each study. The overall efficiency of the two tests (agreement between tests) was 93% (359 of 384). Agreement between the 1-month and 6-month posttreatment H. pylori assessment was apparent, regardless of the treatment used. CONCLUSION: H. pylori eradication measured 1 month following cessation of treatment accurately reflects successful treatment of the infection.

[Torsion of uterine fibroma associated with incarcerated inguinal hernia in pregnancy. Case report]. / Un fibroma uterino torto associato ad ernia inguinale intasata in gravidanza. Caso clinico.

The incidence of inguinal hernias in pregnancy is 1:1000 about. Much more frequent are uterine leiomyomas, reported in 0.5-2.6% cases. We describe a rare case of a 31 old woman at the 20th week of pregnancy affected with a torsion of uterine leiomyoma associated with right inguinal incarcerated hernia, operated urgently (myomectomy and Bassini inguinal plastic).

[Varicocele and infertility: clinical framework and therapeutic approach]. / Varicocele e infertilità: inquadramento clinico ed atteggiamento terapeutico.

A diagnostic-therapeutic protocol which can be used in patients affected with varicocele, in order to obtain a complete clinical study of them and try to improve functional results of therapy, is described. The aims of this protocol are: precise diagnosis of venous refluxes, examination of testicular functionality, detection of possible associated pathologies which can cause infertility, establishment of correct indication to hormonal postoperative therapy. The rapid surgical correction of venous stasis, the treatment of prostatic phlogosis, often concomitant, and, in selected patients, the use of hormonal therapy, can improve functional results in the treatment of this pathology.

[Locoregional complications of stomas. Therapeutic approach]. / Le complicanze locoregionali delle stomie. Atteggiamento terapeutico.

Principal local complications of ostomies are examined. Etiologic factors and possibilities of treatment are analyzed. These pathologies are often extremely troublesome and their resolution very difficult, unless appropriate therapy is established and, when possible, causal factors removed. However, because of the particular problems of these patients it would be better for them to be assisted by a specialized staff, in qualified centers.

[Functional and esthetic results of surgery of leg varices]. / Risultati funzionali ed estetici della chirurgia nelle varici degli arti inferiori.

An experience of 1240 patients suffering from varicose veins of the lower limbs and operated from December 1987 to October 1992, is reported. In order to obtain an objective valuation of functional and aesthetic results, a table with subjective symptoms and clinical and instrumental signs was filled in, before the surgical operation. The correction of anatomic and functional defects and the results so obtained were evaluated by filling in another table after the operation and comparing the postoperative to the preoperative situation. We gave different scores to each parameter considered according to the results obtained and the overall result was obtained by adding up all the different scores for each parameter. In 73.6% of the patients we registered the maximum score, 15 (excellent result), in 1.9% of the patients the score obtained was 10 (sufficient result) and in the remaining 24.5% of the patients the score was variable from 14 to 11 (good result).

[Systems of cerebral monitoring and protection in extracranial carotid surgery]. / Sistemi di monitoraggio e protezione cerebrale in chirurgia carotidea extracranica.

The main methods for cerebral monitoring and protection during surgical operations of extracranial carotid are examined, analyzing for everyone advantages and limits. Particularly, the authors discuss benefits and disadvantages of cerebral monitoring using somato-sensorial evoked potentials (EP) associated with the measurement of the stump pressure in patients in which general anaesthesia was performed, comparing this method to the monitoring of patients operated using locoregional anaesthesia. The results obtained allow us to say that EP are a very good method for cerebral monitoring and that, if they are not pathological, also with stump pressure values lower than 40 mmHg, a shunt is not necessary.

[Varicose veins in pregnancy: physiopathology and therapeutic approach]. / Le varici in gravidanza: fisiopatologia e atteggiamento terapeutico.

The Authors examine the endocrinological, mechanical and constitutional factors which are involved in the pathogenesis of varicose veins in pregnancy. Discussing the results of their experience (328 pregnant patients observed, 158 of which affected with various degrees of varicose veins) they suggest a protocol of treatment in the different situations in order to obtain an improvement of the clinical conditions and, if necessary, postpone a surgical operation after delivery, so avoiding useless risks during the pregnancy.

[Giant ovarian dermoid cyst in prepubertal age. Report of a case]. / Una cisti ovarica dermoide gigante in età prepuberale. Case report.

We report a case of a very large (size cm 33 x 41) dermoid cyst in the right ovary in a 11 year old child, causing a complete atrophy of the remaining right ovarian parenchyma and ipsilateral salpinx. Sonography and CT allowed us to diagnose this disease and also showed an associated ureterohydronephrosis. The patient underwent a surgical operation during which a right ovarosalpingectomy was performed. A rapid regression of the ureterohydronephrosis was observed and the patient was discharged from the hospital six days after operation.

[Surgical staplers in surgical emergencies. Our experience]. / Le anastomosi meccaniche in chirurgia d'urgenza. Nostra esperienza.

This study describes the use of staplers during surgical treatment performed in emergency from January 1980 to December 1991. For the different, possible operations, some technical notes are examined and results reported. The advantages and risks related to the use of these devices are analysed.

[Acute cholecystitis in videolaparoscopy]. / La colecistite acuta in videolaparoscopia.

The authors describe their experience in 15 cases of acute cholecystitis treated with laparoscopic cholecystectomy in emergency. Only in one patient, affected with an abscess of the upper right abdominal space, a laparotomy was performed. The results were excellent. The 14 patients treated with laparoscopic cholecystectomy were quickly discharged from the hospital (on an average 4 days after the surgical treatment) and the convalescence period was very short (range 10-15 days). In the patient treated with laparotomic cholecystectomy the postoperatory period was regular.

[Surgical alternatives in the treatment of perforated duodenal ulcer]. / Alternative chirurgiche nel trattamento dell'ulcera duodenale perforata.

The therapy of perforated gastroduodenal ulcer is still discussed, especially today that good drugs and new surgical devices are available for the treatment of this disease. The authors try to establish a valid protocol for the diagnosis and the therapy of patients affected with this disease.

Therapeutic strategies in the surgical management of pancreatic neoplasms in the elderly.

The clinical records of all consecutive patients aged 65 and older undergoing surgical treatment for pancreatic neoplasms between January 1980 and January 1992 were reviewed in order to establish a clinical trial based on the morbidity and mortality rates related to the different surgical procedures. In early diagnosed neoplasms, in patients in good general condition, even in the geriatric age a radical surgical procedure is preferred. In other cases, a palliative surgical procedure has to be performed if possible, namely a bilio-digestive anastomosis, associated if necessary with a gastro-enteric anastomosis.

[Role of the second look in ovarian neoplasia]. / Il ruolo del second look nelle neoplasie ovariche.

The indications for the execution of a second look in patients affected with ovarian cancers and the possible benefits of this procedure, related to the stage of the neoplastic disease, are examined. The second look, at first largely used in patients in which had been performed adjuvant chemotherapy with drugs containing platinum and with no evidence of residual disease, has been later strongly criticized and the effective usefulness of this invasive procedure discussed. At the moment, we think that the indications for its execution are still large because with the second look it is also possible to put into the abdomen a catheter which can be used for locoregional chemotherapy and there is now the opportunity to perform this procedure also in video-laparoscopy.

[Surgery vs PTA in sub-inguinal atherosclerosis]. / Chirurgia versus PTA nella malattia aterosclerotica sottoinguinale.

The authors describe their experience in the treatment of arterial occlusive disease of the lower limbs in the femoro-popliteal and tibioperoneal districts, by surgery (proximal or distal femoro-popliteal by-pass or segment by-pass) and Percutaneous Transluminal Angioplasty (PTA), analyzing indications, advantages, limits and complications of the two methods. Immediate and after one and three year results of surgical by-pass and PTA are compared. On the whole, in the patients in which we performed a surgical by-pass, we obtained slightly better results. Anyway, in the second stage of the arterial occlusive disease and in patients affected with short arterial stenosis and/or obstructions, PTA represents the best treatment.

The anastomotic aneurysms.

The authors describe their experience of anastomotic aneurysm diagnosis and treatment. They are classed into two groups: slowly growing anastomotic aneurysms, which are the most common; and rapidly growing anastomotic aneurysms, which are more infrequent. A follow-up is proposed in order to detect this involvement early, in election. Urgent diagnostic timing is also proposed. Moreover an analysis is made of criteria to follow in their therapy and indications to surgical treatment. In the period from January 1988 to October 1992 we observed 413 patients and 876 anastomosis or arterial sutures in election, discovering 27 anastomotic aneurysms whereas in 6 cases we had patients who were affected with rapidly growing anastomotic aneurysms. These were urgently operated, whereas of the 27 patients with slowly growing anastomotic aneurysms, 22 were operated and in 5 cases we preferred to check them by a close follow-up.