Gallstone Classification in Western Countries.

In order to compare gallstone disease data from India and Asian countries with Western countries, it is fundamental to follow a common gallstone classification. Gallstone disease has afflicted humans since the time of Egyptian kings, and gallstones have been found during autopsies on mummies. Gallstone prevalence in adult population ranges from 10 to 15 %. Gallstones in Western countries are distinguished into the following classes: cholesterol gallstones that contain more than 50 % of cholesterol (nearly 75 % of gallstones) and pigment gallstones that contain less than 30 % of cholesterol by weight, which can be subdivided into black pigment gallstones and brown pigment gallstones. It has been shown that ultrastructural analysis with scanning electron microscopy is useful in the classification and study of pigment gallstones. Moreover, x-ray diffractometry analysis and infrared spectroscopy of gallstones are of fundamental importance for an accurate stone analysis. An accurate study of gallstones is useful to understand gallstone pathogenesis. In fact, bacteria are not important in cholesterol gallstone nucleation and growth, but they are important in brown pigment gallstone formation. On the contrary, calcium bilirubinate is fundamental in black pigment gallstone formation and probably also plays an important role in cholesterol gallstone nucleation and growth.

Gallbladder cancers: associated conditions, histological types, prognosis, and prevention.

INTRODUCTION: Gallbladder cancer has a poor prognosis, with a reported 5-year survival of 5%. The prognosis improves when an R0 resection is feasible, but an early diagnosis is rare. The aim of the present study is to analyze the different conditions associated with gallbladder carcinomas and to report the main prognostic factors for these tumors to enable prevention. MATERIALS AND METHODS: From 1986 to 2012, 75 patients were found to have gallbladder cancer during the study of 2942 patients affected by biliary tract diseases; 34 of these patients had gallbladder and gallstones, and had been subjected to bile analysis. Pancreatobiliary reflux was studied by biliary trypsin and C-Ki-ras genes were analyzed in 11 cases. RESULTS: Gallstones were found in 72 of 75 gallbladder cancer patients; in particular, large gallstones were associated with 88.88% of squamous-cell carcinoma, 68.2% of adenocarcinoma, and never with papillary adenocarcinoma. Pancreatobiliary reflux was associated with papillary adenocarcinoma in 100% of cases, but seldom with squamous cell carcinoma. C-Ki-ras mutations were found in 100% of patients with papillary carcinoma. DISCUSSION AND CONCLUSION: R0 resection in in-situ cancer has the best prognosis. Preventive cholecystectomy should be performed in high-risk patients (gallstones larger 3 cm; adenomatous polyps>1 cm; pancreatobiliary reflux, porcelain gallbladder, segmental adenomyomatosis, xanthogranulomatous cholecystitis). The histological stratification of gallbladder cancer should be carried out before starting further studies because squamous-cell carcinoma, adenocarcinoma, and papillary carcinoma are associated with different risk factors and genetic mutations and have different responsiveness to chemotherapies.

Fistulotomy or seton in anal fistula: a decisional algorithm.

Fistula in ano is a common proctological disease. Several authors stated that internal and external anal sphincters preservation is in the interest of continence maintenance. The aim of the present study is to report our experience using a decisional algorithm on sphincter saving procedures that achieved us to obtain good results with low rate of complications. From 2008 to 2011, 206 patients underwent surgical treatment for anal fistula; 28 patients underwent perianal abscess drainage plus seton placement of trans-sphincteric or supra-sphincteric fistula (13.6 %), 41 patients underwent fistulotomy for submucosal or low inter-sphincteric or low trans-sphincteric anal fistula (19.9 %) and 137 patients underwent partial fistulectomy or partial fistulotomy (from cutaneous plan to external sphincter muscle plan) and cutting seton placement without internal sphincterotomy for trans-sphincteric anal fistula (66.50 %). Healing rates have been of 100 % and healing times ranged from 1 to 6 months in 97 % of patients treated by setons. Transient fecal soiling was reported by 19 patients affected by trans-sphincteric fistula (11.5 %) for 4-6 months and then disappeared or evolved in a milder form of flatus occasional incontinence. No major incontinence has been reported also after fistulotomy. Fistula recurred in five cases of trans-sphincteric fistula treated by seton placement (one with abscess) (1/28) (3.5 %) and four with trans-sphincteric fistula (4/137) (3 %). Our algorithm permitted us to reduce to 20 % sphincter cutting procedures without reporting postoperative major anal incontinence; it seems to open an interesting way in the treatment of anal fistula.

Blackberry pigment (whitlockite) gallstones in uremic patient.

Black pigment gallstones represent nearly the 15% of all gallstones and are usually related with the typical "hyperbilirubinbilia" factors as hemolysis, ineffective erythropoiesis, pathologic enterohepatic cycling of unconjugated bilirubin, cirrhosis and with gallbladder mucosa (parietal) factors as adenomyomatosis. During a prospective study on 179 patients who underwent cholecystectomy for gallstone disease a 69-year-old female with predialysis chronic kidney disease was operated for symptomatic gallstone. The removed gallstones were black pigment gallstones, with an irregular (as small blackberry) surface. Analysis of the stones revealed a great amount of whitlockite (Ca Mg)3 (PO4)2. Recent studies on chronic renal failure patients found that chronic uremia is associated with an increased risk of gallstones formation (22%) as it seems in women affected by primary hyperparathyroidism (30%). The presence of calcium phosphate gallstones in these patients have been never described. In conclusion, further studies could be necessary to establish the role of chronic renal failure and of primary and secondary hyperparathyroidism in gallstones formation and, in particular, if dialysis and predialysis patients have an higher risk to develop cholesterol and black pigment gallstones in particular of the "blackberry" (whitlockite) subtype.

Postpneumonectomy bronchial stump recurrence and bronchopleural fistula.

OBJECTIVE: To reduce the incidence of postpneumonectomy local recurrence, and to prevent the onset of bronchopleural fistula. BACKGROUND: A long bronchial stump with a short tumor-free bronchial margin has been found to be associated with a higher incidence of local recurrence, and with the development of bronchopleural fistula in some cases. METHODS: 134 patients underwent pneumonectomy for non-small-cell lung cancer in 2 institutions. Bronchial stump length was measured intra-and postoperatively. RESULTS: 30-day postoperative mortality was 2.9%. There were 3 postoperative bronchopleural fistulas after right pneumonectomy (3/61) and one after left pneumonectomy (1/73; p=0.2; fistula was more frequent in the long-stump group), which were successfully treated with carina sutures in 75% of cases. The overall incidence of local recurrence was strongly related to the presence of tumoral microinvasion in the resection margin (100%). CONCLUSION: To prevent postpneumonectomy bronchial stump complications, it might be useful to use carina closure instead of bronchial closure. Carina closure can reduce local recurrence, significantly reduce the fistulization rate, and eliminate the stump diverticulum. Reduction of the length of the bronchial stump can be achieved using a TA Roticulator linear stapler.

Limits and perspective of oral therapy with statins and aspirin for the prevention of symptomatic cholesterol gallstone disease.

The prevalence of gallstones disease in Western countries is 10 - 15%. Gallstones can be one of two types - cholesterol or pigment - with cholesterol gallstones representing nearly the 80% of the total. Cholesterol and pigment gallstones have different predisposing factors: cholesterol gallstones are related to supersaturated bile in cholesterol, whereas black pigment gallstones are related to hyperbilirubinbilia factors (hemolysis, etc.); these are necessary, but not sufficient, factors to produce gallstones in vivo. Gall bladder mucosa factors (gall bladder secretion of mucin, local bile stasis and production of endogenous biliary ß-glucuronidase) may coexist with the aforementioned factors and facilitate gallstone nucleation and growth. The gold-standard treatment for symptomatic gallstones is laparoscopic cholecystectomy. Several studies have reported a significant reduction in the onset of symptomatic gallstones disease in patients undergoing chronic therapy with statins, which can reduce bile cholesterol saturation. Aspirin, which has been shown to reduce the local production of gall bladder mucins (mucosal or parietal factors of gallstone formation) in animal experimental models, does not appear to reduce the risk of symptomatic gallstones disease when tested alone. The new horizon of oral therapy for the prevention of symptomatic gallstone disease needs to evaluate the long-term effect of statins and chronic aspirin administration in patients with dyslipidemia and/or atherosclerosis.