Laparoscopic dual mesh repair of a diaphragmatic hernia of Bochdalek in a symptomatic elderly patient.

Bochdalek hernia is a congenital posterolateral diaphragmatic defect. It is usually diagnosed in newborns and children; the mortality rate is high due to further congenital anomalies such as pulmonary hypoplasia and pulmonary hypertension. In adulthood, the diagnosis is often incidental, while sometimes it is related to gastrointestinal or respiratory symptoms, or to herniated viscera complications. Thus, surgical treatment is advocated. We herein report a case of an 86-year-old woman with dyspnea and dysphagia. After the diagnosis by barium enema and CT scan of the herniated stomach and the greater omentum through a left side foramen of Bochdalek, she underwent a successful laparoscopic dual mesh repair and was discharged on the 6th postoperative day.

[Intestinal perforation due to accidental ingestion of foreign bodies]. / Perforazione intestinale da ingestione accidentale di corpo estraneo.

Usually the ingested foreign bodies (IFB) pass the gastrointestinal tract making no lesions. Sometimes IFB could lead to a gastrointestinal perforation. The most frequently perforating IFB are chicken or fish bones and toothpicks, while risks factors are mental retardation, alcohol or drug abuse, denture usage, quick eating or habitual chewing of toothpicks. The accidentally ingestion in a high risk patient with unclear symptoms, added to a low sensitive diagnostic imaging, lead to intraoperative diagnosis in one half cases of gastrointestinal perforation by IFB. Furthermore the surgical treatment range between the less minimal invasive laparoscopic IFB extraction and intraabdominal hole suture to a laparotomic bowel or colic resection. Herein we describe our experience in 3 cases of gastrointestinal perforation by IFB have been diagnosed at surgery and treated by IFB extraction and hole suture (in 2 patients; 1 laparoscopy, 1 laparotomy) or open right emicolectomy (1 patient).

[The transesophageal echocardiographic evaluation of the hemodynamic effects of the pneumoperitoneum in laparoscopic hemicolectomy]. / Valutazione con ecocardiografia transesofagea degli effetti emodinamici del pneumoperitoneo nell'emicolectomia per via laparoscopica.

MATERIALS AND METHODS: Ten patients undergoing laparoscopic left hemicolectomy were monitored by transesophageal echocardiography in order to assess the effects of pneumoperitoneum and head-down tilt on the following parameters: end-diastolic left ventricular volume, stroke volume, cardiac output, left ventricular ejection fraction, mean blood pressure and cardiac frequency. Pneumoperitoneum, by a mean CO2 pressure of 13 mmHg, was performed in five of them; for the other patients, mechanical abdominal wall suspension was used, without any increase in abdominal pressure. RESULTS: The group treated by abdominal wall suspension underwent an increase in end-diastolic left ventricular dimension, stroke volume, cardiac output and blood pressure, while the group treated by pneumoperitoneum had no significant changes in hemodynamic parameters. CONCLUSIONS: In this surgical context, pneumoperitoneum seems to be safe and to have a low hemodynamic impact, as its effects on venous return seem to be opposite to those of the Trendelenburg position.

Sigmoid volvulus in west Africa: a prospective study on surgical treatments.

To evaluate the efficacy of different types of surgery, we performed a prospective, randomized trial in 31 consecutively hospitalized patients with sigmoid volvulus. These patients represented 8 percent of 377 cases of emergency surgery. At the time of surgery, the patients were divided into two groups according to the absence (Group A) or presence (Group B) of bowel gangrene. At random, each group was assigned two surgical treatments. Seventeen patients entered Group A and underwent mesosigmoidopexy (seven patients) or resection and primary anastomosis (10 patients). Fourteen patients entered Group B and underwent Hartmann's procedure (eight patients) or resection and primary anastomosis (six patients). Overall mortality was four patients among 31 (13 percent), with a significant prevalence in the group with gangrene (21.4 percent vs. 5.8 percent). In Group A, the rate of success in patients treated with resection-anastomosis was higher than that in patients undergoing mesosigmoidopexy (90 percent vs. 71.5 percent). In Group B, a meaningful difference was observed between the rate of success of patients undergoing Hartmann's procedure and that of those undergoing resection and primary anastomosis (87.5 percent vs. 50 percent). The mortality rates were 12.5 percent and 33.3 percent, respectively. The results of our study show that the therapeutic approach to sigmoid volvulus should be diversified according to the absence or presence of gangrenous colon. The treatment of choice seems to be resection with primary anastomosis in patients with viable colon and Hartmann's procedure in patients with gangrenous colon.

[Effects of somatostatin peridurally administered in the treatment of postoperative pain]. / Effetti della somministrazione della somatostatina per via peridurale nel trattamento del dolore post-operatorio.

Somatostatin (SMS), a hormone extensively found within the CNS, has shown to have a powerful analgesic effects administered either via the epidural or subdural route. The aim of the present study was to evaluate the efficacy of SMS administered epidurally compared with placebo, for the treatment of post-operative pain in patients receiving epidural anaesthesia for surgery. Of the 86 patients observed, 58 entered the study and were randomized to receive either SMS or placebo in a double blind fashion. They were also divided into 3 groups according to the site of the operation (group A: procto-anal; group B: inguino-crural; group C: other), 28 of them receiving SMS and 30 placebo. The post-operative pain evaluation was obtained via VAS at the moment of request of treatment (basal) and after an hour. Twenty-eight of the 86 observed (32.5%) didn't complain of pain that necessitated analgesic treatment. A statistically significant difference in reduction of intensity of pain was observed in the somatostatin treated group (6.42 +/- 0.37 vs 3.64 +/- 0.59) and in the somatostatin treated subgroup A and B (6.4 +/- 0.4 vs 3.8 +/- 0.7 and 6.3 +/- 0.8 vs 3.0 +/- 0.6 respectively). No adverse reactions of any kind were observed. SMS has shown to be a safe and effective drug, reducing by 50% the intensity of pain in patients undergone procto-anal or inguino-crural surgery.

Role of thyrotropin-releasing hormone in stress ulcer formation in the rat.

The role of the hypothalamic peptide thyrotropin-releasing hormone in stress ulcer formation was investigated. In experiment 1, TRH was peripherally administered (10 micrograms/kg) to rats subjected to cold-restraint stress and compared to an inactive peptide; in experiment 2, TRH was administered intracerebroventricularly (0.02, 0.1, and 0.5 microgram/kg) to rats with no adjunctive experimental stress; in experiment 3, TRH antiserum was given intracerebroventricularly to rats subjected to stress and compared to normal rabbit serum. When TRH was administered subcutaneously in rats subjected to stress, it significantly aggravated ulcer formation, and this effect was inhibited by atropine and vagotomy. When administered intracerebroventricularly, TRH alone induced, in a dose-dependent fashion, the formation of gastric ulcers. TRH antiserum infused intracerebroventricularly inhibited ulcer formation induced by cold-restraint stress. In conclusion, TRH seems to play a role in stress ulcer formation, possibly by a cholinergic mediated mechanism.

Effect of somatostatin in controlling bleeding from esophageal varices.

A multicenter double-blind clinical trial was undertaken to evaluate the efficacy of a short-term somatostatin treatment versus a short-term vasopressin treatment on acute hemorrhage from esophageal varices in patients with liver cirrhosis and portal hypertension. Forty-nine patients with massive hemorrhage and endoscopic diagnosis of bleeding esophageal varices completed the study. Patients were randomly assigned to somatostatin treatment (24 patients: 250 micrograms/hr i.v. for 48 hrs) or vasopressin treatment (25 patients: 0.1 U/min i.v. for 48 hrs). The Sengstaken-Blakemore tube was utilized, when needed, for a six hour period. In case of failure the patients were crossed-over to the other treatment. Patients in whom the bleeding stopped at 48 hrs, were randomly assigned to somatostatin (250 micrograms/hr i.v.) or placebo for seven days. Bleeding stopped in 68% of patients treated with somatostatin and in 28% of patients treated with vasopressin (p less than 0.0013). Mortality rate was lower, but not significantly so, in the somatostatin group compared to the vasopressin group. No differences were noted between somatostatin and placebo in preventing bleeding recurrences. These data suggest that somatostatin, when combined if necessary with a 6 hour period of balloon tamponade, is more effective than vasopressin at low doses in controlling severe hemorrhage from esophageal varices in patients with liver cirrhosis and portal hypertension. A clinical use of somatostatin seems to be indicated in these patients.

Ranitidine and somatostatin. Their effects on bleeding from the upper gastrointestinal tract.

In a randomized, double-blind placebo-controlled clinical trial, the effect of ranitidine was compared with the effect of somatostatin in the control of massive gastrointestinal tract bleeding. Ninety-six patients completed the study. Rates of continuing bleeding and death, incidence of surgery, and blood transfusion requirements were not significantly different in the three treatment groups. Eighteen of the 96 patients presented with a visible vessel at endoscopy. In this group the percent of patients with continuing bleeding, mean transfusion requirements, and mortality were significantly higher than in patients without a visible vessel. Seven patients with a visible vessel underwent surgery and six survived; 11 patients underwent conservative measures and eight died. Ranitidine and somatostatin do not seem to alter the clinical course of patients with upper gastrointestinal tract hemorrhage.

Effect of caerulein in patients with biliary colic pain.

A randomized placebo-controlled double-blind trial was carried out in 24 patients with biliary colic pain in order to evaluate the analgesic effect of caerulein (CRL). Caerulein (1 ng/kg . min infused intravenously over 15 min) showed an analgesic effect that was significantly higher than placebo (p less than 0.001). The analgesic action of CRL was not inhibited by naloxone (0.4 mg intravenously, administered two times). Further, the effect of i.v. CRL or saline on artificially induced biliary tree hypertension was studied in 7 patients with a T-tube common bile duct drainage. During saline intravenous administration, increasing biliary tree pressure resulted in pain in 5 patients, with the threshold for pain being 40 cmH2O. During CRL intravenous infusion, significantly higher perfusion pressures were required to achieve a given common bile duct pressure and the pressure threshold for pain was not reached. Consequently, pain was prevented in all patients. These data suggest that CRL relieves biliary colic pain by reducing biliary tract pressure.

Effect of ceruletide on rest pain in patients with arterial insufficiency of the lower extremity.

The effect of ceruletide (CRL), a synthetic decapeptide analogue of cholecystokinin, on rest pain and arterial blood flow was evaluated in 8 patients with advanced, occlusive atherosclerosis of the lower extremities. CRL 1, 2, or 4 ng kg-1 or placebo were infused intravenously in random order, and in a double-blind fashion. Pain relief, assessed by a scoring system, was significantly better (p less than 0.01) following the 2 and 4 ng kg-1 doses of CRL (2.71 and 2.66, respectively) than following placebo (0.75). Arterial blood flow was not affected by either CRL in any dose or by placebo. Pretreatment with naloxone, a pure opioid antagonist, abolished the analgesic effect of CRL. Following the 2 ng dose of CRL, beta-endorphin levels were significantly elevated from a basal value of 125 +/- 15 pg/ml to 191 +/- 35 pg/ml 5 h after CRL administration (p less than 0.05). Circulating levels of ACTH, prolactin and GH were not affected by CRL. It is concluded that CRL was effective in relieving ischaemic rest pain, and that the mechanism was related to the release of endogenous opioids.

Cimetidine and antacid prophylaxis of acute upper gastrointestinal bleeding in high risk patients. Controlled, randomized trial.

A randomized, controlled clinical trial was performed to compare the efficacy of prophylactic cimetidine treatment, antacid treatment and no treatment in high risk patients. Sixty patients received cimetidine (200 mg every 6 hours), 52 patients received antacids (Maalox, 10 ml/hour), and 56 patients received no treatment. One hundred thirty-five patients completed the study. Eight patients in the control group and one patient in the antacid-treated group presented with upper gastrointestinal bleeding. No bleeding occurred in the cimetidine-treated group. Patients considered at low risk had no bleeding. Cimetidine or antacid prophylaxis significantly decreased the incidence of upper gastrointestinal bleeding in the high risk patients.

Management and long-term results in patients with two-thirds gastrectomy and stomal ulcer.

In 67 patients with two-thirds gastrectomy and endoscopically proven stomal ulcer, serum gastrin levels were measured under basal conditions and after intravenous infusion of bombesin (15 ng/kg/min), calcium (4 mg/kg/hour) and secretion (2 units/kg). All patients underwent medical or surgical therapy. The long-term results were evaluated according to the Visick grading system (average follow-up, 3.1 years).