Laparoscopic cholecystectomy and intraoperative endoscopic sphincterotomy in the treatment of cholecysto-choledocholithiasis.

BACKGROUND: A single-stage minimally invasive procedure would be optimal for management of cholecysto-choledocholithiasis. Two alternative strategies are available: management by laparoscopy alone or a combined laparoscopic-endoscopic approach. This study evaluates the results of the latter procedure. METHODS: From June 1993 to September 1997, 1400 patients with symptomatic biliary stone disease were evaluated for laparoscopic cholecystectomy. Intraoperative cholangiography was performed on the basis of a preoperative suspicion of bile duct stones; bile duct stone treatment was by intraoperative endoscopic retrograde sphincterotomy. RESULTS: Intraoperative cholangiography was performed because of a preoperative suspicion of a bile duct abnormality in 141 of 1400 patients (10%) undergoing laparoscopic cholecystectomy because of biliary stone disease. Of those 141 patients, 54 (38.3%) presented with pathologic findings (bile duct stone [52] and papillary stenosis [2]); all 54 underwent intraoperative endoscopic sphincterotomy. Complete clearance of the ductal stones was achieved in 43 patients (82.7%) by intraoperative sphincterotomy, and in 9 patients by an additional postoperative endoscopic procedure. Laparoscopic cholecystectomy was carried out in all cases. There were no conversions to an open operation. Postoperative course in the uncomplicated cases was comparable to that for laparoscopic cholecystectomy alone. The postoperative complication rate was 5.6% and mortality 1.8%. Mean hospital stay was 3.3 days (range 2 to 16). At a mean 38 months follow-up, no complications related to the laparoscopic-endoscopic procedure were observed. CONCLUSION: The intraoperative combined laparoscopic-endoscopic approach seems to be a feasible and effective management of cholecysto-choledocholithiasis, saving patients a subsequent invasive procedure.

Differential effect of stress on gastric somatostatin, prostaglandin E and gastrin release in the rat.

BACKGROUND: The relationship between gastric mucosal damage induced by stress, peptides present in the gastric mucosa and is not clear. Aim of this study was to determine whether cold-restraint stress affected the release of gastric somatostatin, gastrin and in the isolated perfused stomach preparation. METHODS: Male Sprague-Dawley rats were used, 12 cold-restraint stressed and 12 unstressed controls. 4 additional unstressed rats were treated with aspirin (100 mg/kg p.o.). After 30 minutes, isolated stomachs were perfused for 50 minutes with Krebs-Ringer buffer added with isoproterenol or carbamylcholine plus somatostatin-14 or carbamylcholine alone, somatostatin, gastrin and prostaglandin E2 release in the portal vein effluent were measured by radioimmuno-assay. Histology of the gastric mucosa was obtained from a further 4 stressed and 4 unstressed rats. RESULTS: In the stomach from stressed animals, the somatostatin response to isoproterenol and the prostaglandin E2 response to carbamylcholine plus somatostatin were significantly lower than in the controls, whereas gastrin response to carbamylcholine was enhanced by stress. Treatment with aspirin abolished the prostaglandin E2 response to stimulation. Gastric mucosa histology from stressed and unstressed animals showed no significant lesions. CONCLUSIONS: The inhibition of gastric somatostatin and prostaglandins release coupled to an enhanced acid stimulatory influence appear to antidate gastric mucosal injury and should play a role in the stress ulcer genesis.

[Echographic and ERCP-manometric study of gallbladder and Oddi's sphincter behavior in biliary colic in patients with cholelithiasis. Effects of cerulein]. / Studio ecografico e CPRE-manometrico del comportamento della colecisti e dello sfintere di Oddi in corso di colica biliare in pazienti con colelitiasi. Effetto della ceruleina.

In a previous study, we have shown that caerulein relieves biliary colic pain in gallstone patients. This study was initiated to determine gallbladder and sphincter of Oddi behaviour during biliary colic and their response to caerulein. In 10 gallstone patients gallbladder volume was measured by real-time ultrasonography during a biliary colic episode and 72 hours after cessation of pain, before and after caerulein administration. Basal sphincter of Oddi pressure was determined by CPRE manometry in 10 gallstone patients during biliary colic and three days after cessation of pain, before and after caerulein. The results of this study show that, during biliary colic, gallbladder volume is 8 times greater than in the post-colic state. Basal sphincter of Oddi pressure was also significantly higher during biliary colic than in the post-colic state. Caerulein relieved in all cases the biliary colic pain while reducing gallbladder volume and decreasing the sphincter of Oddi.

Laparoscopic excision of posterior gastric wall leiomyoma.

The development of laparoscopic surgery has suggested new technical procedures for the treatment of several pathologies. Herein we report a case of laparoscopic excision of a posterior gastric wall leiomyoma. The technique reproduces that used in conventional surgery but with a transgastric approach, and the advantages of minimally invasive surgery are maintained. This laparoscopic approach may be considered an alternative strategy for surgical treatment of benign tumors of the stomach.

[Chronic gastritis and prostaglandins. Results of endoscopic screening]. / Gastriti croniche e prostaglandine. Risultati di uno screening endoscopico.

An endoscopic screening was carried out during the period between July 1989 and December 1991 in the Municipality of Roccagorga (LT) in order to: a) evaluate the presence of various forms of gastritis and pre-cancerous lesions; 2) verify the effect of the administration of prostaglandins (Misoprostol) on the evolution of superficial chronic gastritis (CG). A total of 468 endoscopy were performed (17% of the population aged between 20 and 75 years old). 22% of the subjects examined were found to be endoscopically normal; 34% presented symptoms of mild esophagitis and 4% of moderate esophagitis. The prevalence of duodenal ulcer was 10.6% and gastric ulcer 3.4%. Gastric carcinoma was diagnosed in 6 patients (1.2%). 8.5% of patients were found to have atrophic CG and 15.3% superficial CG. Thirty-six patients with superficial CG were randomly divided into two groups: A) treated with Misoprostol 600 mg/day for 6 months; B) controls (placebo). The administration of Misoprostol did not influence the evolution of CG, whereas it caused a reduction in the incidence of type 1 intestinal metaplasia. Misoprostol also led to an improvement in dyspeptic symptoms. The results of the present study do not suggest a role of prostaglandins in the natural evolution of CG.