Predictive factors for cholelithiasis complications.

BACKGROUND: Cholelithiasis is a benign disease that is very frequently encountered throughout the world. Its surgical mortality is usually minimal (0.1%), but the risk is considerably greater (2-10%) in patients developing complications particularly if they are elderly. The identification of possible predictive signs of complications is therefore crucial for the indication of preventive surgery. METHODS: The present study retrospectively examined 490 patients admitted to hospital because of complicated and uncomplicated cholelithiasis in order to establish the existence of previous (clinical or instrumental) symptoms that may be predictive of the course of the disease. The analysis of some variables (age, sex, pregnancy, diet, ethanol consumption, smoking, previous/concomitant diseases, and blood chemistry and instrumental test results) and the specific symptoms of cholelithiasis made it possible to identify two potential risk factors: an age of more than 60 years and the onset of biliary colic. RESULTS: The risk of developing complications is 3.2 times greater in patients aged more than 60 years than in those who are younger, and 3.3 times greater in symptomatic than in asymptomatic patients. Statistical analysis also revealed that the risk of complications is about ten times greater in patients with both risk factors than in those with neither. CONCLUSIONS: In conclusion, the indication for surgery must be considered absolute in symptomatic patients aged more than 60 years and relative to younger symptomatic patients.

[A comparative evaluation of the efficacy of the excisional new attachment procedure (ENAP) relative to root planing in the etiological phase of periodontal therapy]. / Valutazione comparativa dell'efficacia della excisional new attachment procedure (ENAP) nei confronti della levigatura radicolare nella fase etiologica della terapia parodontale.

BACKGROUND: In the present study, the effectiveness of root planing has been compared to the excisional new attachment procedure (ENAP) during the etiological phase of periodontal therapy, after the supragingival scaling, in order to establish if a technique offering an easy access to the subgingival areas could reduce the need for a surgical phase in the periodontal treatment. METHODS: Twenty-seven patients, affected by moderate periodontitis, participated in this study; in each of them root planing was performed in a half of the oral cavity (control site) and the ENAP in the other half (test site). The main clinical parameters of periodontal health (probing depth--PD-, attachment loss--AL-, plaque index--PlI- and gingival index--GI-) were evaluated before and 1, 2 and 6 months after the periodontal treatment. RESULTS: The results of the study showed that the parameters related with the amount of plaque and with the conditions of the marginal gingival tissue were not influenced by the different treatments used. Better improvements were found in PD and AL values in teeth treated by ENAP compared to those treated by root planing; this result is explained by a better access to the roots offered by the ENAP. CONCLUSIONS: We can conclude that, within the limits of the present study, the ENAP can reduce the need for a further surgical treatment of the periodontal patient.

Problematic bile duct stones: polyvalent treatment.

BACKGROUND: The availability of different methods for the non-surgical treatment of complicated bile duct stones makes it possible to choose the most appropriate therapy on the basis of the particular characteristics of each individual case and a careful evaluation of their related risks/benefits/costs. METHODS: The present study involved 26 patients treated using different techniques; in some cases, after the failure of the first approach, one of the alternative treatments was adopted. Twenty-one of the patients had isolated stones that were large (> 20 mm in diameter: 11 cases), impacted (5) or upstream of a stenotic tract; five had multiple stones (two of whom had undergone previous biliodigestive anastomosis and two had Caroli's disease). The initial treatment in 24/26 cases was chemical litholysis with a 2:1 v/v association of monooctanoin and methyl tert-butyl ether. RESULTS: Total dissolution was obtained in nine cases and partial dissolution leading to subsequent elimination (spontaneous or by means of a basket and/or saline washout) in eight. In the seven patients in whom chemolitholysis was unsuccessful, clearance was obtained surgically (6 cases) or by means of extracorporeal shockwave lithotripsy (ESWL). The remaining two patients were successfully treated by means of first-choice ESWL and saline washout.

Treatment of intrahepatic calculi in Caroli's disease by non-invasive saline washout.

The case of a 59 year old pluriparous woman who underwent cholecystectomy and exploration of the main biliary pathway for cholecystic and common bile duct stones is described. Postoperative T-tube cholangiography showed a voluminous saccular dilatation stacked with calculi located on the left main hepatic duct. The patient was immediately transferred to our Centre, and a T-tube was used to introduce a guidewire/M 0.035 (Terumo, Tokyo, Japan) at the bottom of the cystic dilatation. A 6.0F drainage catheter (Angiomed, Germany) was placed over the subsequently withdrawn guidewire and a 60-minute saline washout was administered (625 ml). Subsequent cholangiography showed the total clearance of the cyst; papillotomy and a second saline washout led to some of the larger stones, which had remained in a prepapillary location, being made to flow easily into the duodenum. Discharged five days after admission, the patient is well one year later and has not experienced any further disturbance; an ERCP has shown the persistence of the biliary clearance. When the circumstances allow it, this noninvasive treatment of intrahepatic calculi is proposed before undertaking any surgical or invasive procedure.

In vitro study comparing the ability of mono-octanoin and mono-octanoin plus methyl tert-butyl ether to dissolve biliary stones.

This in vitro study compared the gallstone dissolution rates of mono-octanoin, mono-octanoin plus 10% distilled water, and mono-octanoin plus methyl tert-butyl ether 2:1. Sixteen stones were treated with each solvent at a slow perfusion rate of 3-4 ml/h and a rapid perfusion rate of 2.5 ml/30 min with 20-sec instillation/aspiration cycles, both with and without bile. The stones were weighed before, and 3, 6, 12 and 24 hrs after the start of treatment: the solvent was changed every 30 min. After 24 hrs of instillation/aspiration without bile, the mono-octanoin/methyl tert-butyl ether mixture reduced the weight of the stones by 93%, mono-octanoin plus water by 63%, and mono-octanoin alone by 52%; with bile, the figures were, respectively, 86%, 42% and 40%. The mono-octanoin/methyl tert-butyl ether mixture thus took approximately half the time needed by the other two preparations to dissolve the stones to the same extent, a finding which may be relevant for the clinical dissolution of bile duct stones.

Long-term effects in bilio-digestive shunts.

Duodenogastric reflux (DGR) and its effects were studied in patients with bile stones, operated by various bilio-digestive by-pass techniques, and followed up for 13-73 months. Ten patients underwent cholecystectomy and choledochoduodenostomy (CD), eight cholecystectomy and transduodenal sphincteroplasty (TDS) and ten cholecystectomy and endoscopic papillotomy (EP). The control group consisted of eight patients who had undergone minor surgery. DGR was studied by 99mTc-DISIDA scanning, and primary and secondary bile acids were assayed in reflux fluid. The effects were studied by gastroduodenoscopy and biopsies from the body of the stomach and antrum. Only patients operated by TDS (7/8) presented significant increases in DGR and bile acids (p < 0.008). Half the patients in this same group (4/8) had chronic atrophic gastritis and major clinical disorders. Some physiopathological mechanisms possibly involved in DGR and its effects are suggested.

Mono-octanoin and methyl tert-butyl ether mixture for bile duct stones.

A new litholytic mixture of mono-octanoin (MO) and methyl tert-butyl ether (MTBE) in a ratio of 2:1 (v/v) was employed in 42 patients with bile duct stones, 29 of them failures after papillotomy. Twenty-two of these patients had complicated stones. The new solvent mixture was given for 4-6 h/day and 2-3 ml were instilled every 30 min. Gentle aspiration and instillation were alternated so as to "stir" the preparation around the stones. Perfusion was given for up to six days. The mixture contributed to success in 37 cases (88%), 19 of them with complicated stones. Total dissolution was attained in 18 cases, and in the other 19 cases clearance was achieved after partial lysis followed by easy crushing with a basket. The mean volume of solvent perfused (+/- SD) was 84.9 +/- 39 ml (range 25-150), the mean duration of treatment was 16.5 +/- 7.4 h (range 5-30). Hospital stay averaged 4.6 +/- 1.6 days (range 2-7). There were five failures: in one patient eight large concretions were eliminated only after extracorporeal shock wave lithotripsy (ESWL). Two were re-operated and pigment stones were found. The last two refused alternative treatments. Side effects were minimal and easily managed by withdrawal of a few ml of bile. Treatment with the new solvent may be indicated as first-instance therapy in place of ESWL, laser endoscopy, electrohydraulic or mechanical lithotripsy for patients with complicated biliary stones, or in cases in which endoscopic papillotomy has failed.

Selective and early increase of IL-1 inhibitors, IL-6 and cortisol after elective surgery.

After trauma, inflammatory, immunological and hormonal changes are well documented. Surgical intervention is a form of programmed trauma. Through the study of surgical patients, changes in early endogenous mediators of inflammation, immune response and tissue repair can be investigated. Here we analysed changes in serum levels of IL-1 inhibitors, IL-1 beta, IL-6, tumour necrosis factor-alpha (TNF-alpha) and cortisol in patients undergoing elective surgery. C-reactive protein (CRP) was measured as a marker of the acute-phase response. Rises in serum levels of IL-1 inhibitors, IL-6 and cortisol were detected as early as 1 h after the intervention. Peak levels were reached between 2 and 5 h. Serum levels of IL-6 and cortisol remained elevated for several days implying a persistent production. Serum levels of IL-1 and TNF did not change after the intervention. CRP levels peaked on day 2. The communication system sustained by endogenous mediators is activated after surgery as shown by selective changes in IL-1 inhibitors, IL-6 and cortisol. These mediators have different kinetics in serum and IL-6 is not the only early mediator detected. Some IL-1 inhibitors might be involved in the immunological depression observed after major surgery, in the regulation of the inflammatory response or in tissue repair. IL-6 and cortisol seem to act synergistically to activate the acute-phase response. A systemic role for IL-1 and TNF is not evident, even if the possibility that these lymphokines may act locally is not ruled out.

[Treatment of residual and recurrent biliary calculi: the surgical option]. / Il trattamento dei calcoli biliari residui e ricorrenti: la scelta chirurgica.

Retained and recurrent bile duct stones can be treated with a variety of non-surgical methods. The list includes endoscopic papillotomy, chemical dissolution, by T-tube extraction, percutaneous or extracorporeal lithotripsy. The various attempts at non-surgical therapy are described in two patients with retained bile duct stones before biliary clearance was achieved by re-operation. The failure of oral dissolution using biliary acids, endoscopic papillotomy and by T-tube extraction, led to a delay of 6 and 8 months respectively in the elimination of the retained stones in each patient. Surgical re-exploration proved relatively simple due to the long interval after the first operation, and the stones were removed without particular difficulties. The paper underlines the importance of the choice of treatment for use in cases of secondary common bile duct calculi, evaluated on the basis of a correct assessment of the cost/benefit, risk/benefit ratios.

Infusional therapy for post-surgical biliary stones.

A variety of effective non-surgical forms are used for dealing with retained and recurrent biliary stones. These are endoscopic papillotomy, infusional therapy, intraductal laser or electrohydraulic lithotripsy and extracorporeal shock waves. Saline washout or chemical stone dissolution is currently used in high-risk subjects or in cases in which endoscopic papillotomy fails. For many years now drugs that should dissolve stones topically have been tested by direct infusion into the biliary tract. This approach has given better results over the last ten years with the adoption of Monooctanoin (Mo) and more recently Methyl tertbutyl ether (MTBE). Both preparations have their pros and cons, which are weighed.

Dissolution of bile duct stones with monooctanoin: in vitro study.

Mono-octanoin (Mo) is the drug of choice in the topical litholytic treatment of residual gallstones following cholecystectomy. Although this drug does not produce significant side effects, it requires a lengthy period of treatment (15-20 days). The purpose of this study was to verify the in vitro efficacy of the mixture Mo + 10% H2O vs pure Mo in human cholesterol stones. The findings indicate that this mixture can reduce dissolution time by 15.8% and increase the dissolution rate by 27.9% vs pure Mo. A further significant reduction (p = 0.0001) in dissolution times can be obtained by constant exchange of the solvent at the surface of the stone (stirring).

[Pros and cons of chemical litholysis in bile duct calculi]. / I pro e i contro della litolisi chimica per i calcoli dei dotti biliari.

Chemical litholysis of biliary stones is currently performed using monooctanoin (Mo) and methyl tert-butyl ether (MTBE). These two solvents dissolve cholesterol gallstones at different speeds due to their viscosity, high for Mo (47 cps) and low for MTBE (0.2 cps). A third compound was recently used which was produced by combining the previous two agents, Mo and MTBE, at a ratio of 2:1 v/v. The mixture has an intermediate viscosity (2.8 cps) and has shown good tolerability, management and efficacy with a 90% success rate in the treatment of post-surgical gallstones in 28 patients.

[Primary therapy after radical removal of sinus pilonidal]. / Guarigione per prima intenzione dopo intervento radicale di asportazione del sinus pilonidalis.

The successful closure of the operative wound after removal of the Sinus pilonidalis, is linked, in our opinion, to the application of certain measures that should be taken during surgery. Specifically: 1) careful haemostasis, 2) correct positioning of effective deep drainage with exit into the left gluteal region, 3) diligent suture of the deep layers, 4) correction of tension at operative wound level. Two-year follow-up of 29 of 32 operated patients did not reveal relapses.

[A new therapeutic approach to retained biliary calculi. Results in 6 patients]. / Nuovo approccio terapeutico ai calcoli biliari residui. Risultati in sei pazienti.

A new three-phase therapeutical approach to retained biliary stones (RBS) is designed to shorten the long treatment times with Monooctanoin (Mo). In the first phase, the litholytic agent is infused to soften the stones. In the second one the calculi are crushed, and in the last complete elimination of the fragmentary stones into the duodenum is obtained after 1-2 flushings with ceruletide. In 6 patients a complete clearance of the stones was obtained (success 100%) together with a reduction in the litholytic agent dose (52%) and the infusion time (62%), in comparison with the results of using Mo. alone.

Unexpected dilatation of the common bile duct after methyl tertiary butyl ether (MTBE) in rabbits. Possible implications to findings in man.

Methyl tertiary butyl ether (MTBE) rapidly dissolves cholesterol gall stones in vitro and in vivo. To further characterise tolerability and safety of this aliphatic ether, either MTBE (1 ml/kg body wt daily for two days) or an equal amount of saline was infused into the common bile duct (CBD) of eight cholecystectomised rabbits. Transient vomiting, dyspnoea and somnolence developed during MTBE instillation. Post-treatment values of serum transaminases and alkaline phosphatase were significantly higher in MTBE than in saline treated animals. Cholangiography one week after the last intraductal infusion showed a five-fold increase of CBD size in MTBE v control rabbits. At autopsy histological signs of chemical cholangitis and mild duodenitis were noted in MTBE treated animals. Prompted by these findings, we performed a cholangiography in two patients who had received intraductal MTBE (about 0.2 ml/kg body wt daily for one or two days) one year before: an abnormal dilatation of the CBD was present, which might represent a specific, hitherto undescribed permanent sequela of MTBE administration.

Prevention of S-adenosylmethionine of estrogen-induced hepatobiliary toxicity in susceptible women.

Women with past histories of intrahepatic cholestasis of pregnancy (ICP) exhibit a congenital exaggerated sensitivity to estrogens, which may express as abnormal hepatic reactivity to oral contraceptive intake and increased risk of developing gallbladder disease. Since previous investigations have shown that S-adenosylmethionine (SAMe) is effective in antagonizing ICP, we wondered whether its administration to subjects with previous ICP could 1) protect them from a challenge with ethynylestradiol (EE) or 2) normalize the cholesterol saturation index (CSI). To test the first hypothesis, six women volunteered to receive EE (0.1 mg/day orally for 1 wk) and, after 3 months, the same EE dose plus oral SAMe (800 mg/day for 1 wk). EE significantly increased serum values of transaminases, conjugated bilirubin, and total bile acids with respect to basal values. In the rechallenge with EE plus SAMe, liver function tests did not differ from basal levels and were significantly lower than the values obtained after EE. In the second experiment, we gave oral SAMe (800 mg/day for 2 wk) to seven women with previous ICP who exhibited cholesterol supersaturation of duodenal bile. Both subjects were nonpregnant and nonobese and had cholecystograms negative for gallstones. Bile CSI decreased from a basal value of 1.35 +/- 0.07 to 0.98 +/- 0.08 after SAMe (p less than 0.01). These findings indicate that SAMe protects women with previous ICP from EE-induced liver toxicity and normalizes bile CSI in the same subjects who secrete lithogenic bile. The data support the belief that SAMe acts as a physiological antidote against estrogen hepatobiliary toxicity in susceptible women.