[Perioperative changes in the plasma levels of fibrinogen and D-dimer during laparoscopic cholecystectomy: the preliminary results of a prospective randomized clinical study]. / Modificazioni perioperatorie dei tassi plasmatici di fibrinogeno e D-dimero in corso di colecistectomia laparoscopica: risultati preliminari di uno studio clinico prospettico randomizzato.

AIM: Considering that laparoscopic procedure is associated with increased resistance to lower-limb venous return and subsequent stasis, with possible implications in terms of thromboembolic complications, the aim of our study was to investigate prospectively the coagulative-fibrinolytic profile, in laparoscopic and open cholecystectomy, in patients randomly alloted to receive or not preoperative heparin. METHODS: We prospectively analyzed 36 patients (20 laparoscopic and 16 open) and we randomly divided the patients in two groups: Group-A (28 patients--16 laparoscopic and 12 open) didn't take any preoperative thromboprophylaxis, Group-B (8 patients--4 laparoscopic and 4 open) took preoperative subcutaneous heparin. We took blood venous samples before surgery, at time 0 and + 30 min., at the end and 1 and 24 hours postoperatively. The following parameters were assessed: prothrombin time, partial thromboplastin time, fibrinogen and D-dimer. We statistically analyzed the differences by ANOVA test. RESULTS: In Group A, fibrinogen and D-dimer were significantly higher (p < 0.0001 and p = 0.0266) in open group as compared with laparoscopic one and we observed significant time-depending changes of fibrinogen's concentration (p = 0.0168). In Group B we obtained a higher fibrinogen's value in laparoscopic group than in conventional one, with a significant difference (p = 0.0283); also, the sampling-time affected the result in a very significant meaning (p = 0.0041). Comparing fibrinogen levels between Groups A and B, we observed lower values in heparin-treated group than in the other one (p < 0.0001), while in laparoscopic surgery there was not a significant difference between two groups of treatment. CONCLUSIONS: Our preliminary data suggest that, perioperatively (besides a smaller laparoscopic acute-phase response) the coagulative-fibrinolytic changes are lower in laparoscopic cholecystectomy than in open one and heparin treatment significantly reduces these changes in open surgery but doesn't seem to affect laparoscopic group. Our results seem to show another possible advantage of the laparoscopic surgical procedures over the traditional ones.

[Choledochojejunostomy using a mechanical stapler]. / La coledoco-digiunostomia con suturatrice meccanica.

Authors performed the mechanical termino-lateral bilio-digestive anastomosis, adopting a circular 21 mm stapler device. The patient was affected by non neoplastic papillary stenosis producing a common biliary tract dilatation so large to allow the stapler's head introduction. A 12 month follow-up was performed using ultrasonography and MRI cholangiopancreatography, that obtained a good demonstration of both biliary tract and bilio-digestive anastomosis.

[Splenic pseudoaneurysms following acute pancreatitis]. / Gli pseudoaneurismi splenici conseguenti a pancreatite acuta.

Splenic artery pseudoaneurysms are the most common of visceral artery pseudoaneurysms. Splenic pseudoaneurysms appear to have developed as a consequence of inflammatory processes adjacent to the splenic artery, particularly acute pancreatitis and chronic pancreatitis with associated pseudocysts. They are often asymptomatic and picked up on abdominal examination for ultrasound or CT scanning for other conditions. Complications include rupture with retroperitoneal hemorrhage or intraperitoneal hemorrhage. Two cases of splenic pseudoaneurysms, following acute pancreatitis, are reported between the years 1987 and 1996.

Adenocarcinoma arising from a recurrent fistula-in-ano.

Anal fistulas are frequent events which often recur after an inadequate surgical treatment. Nevertheless their evolution into malignant diseases is infrequently observed. The authors report one case of mucinous adenocarcinoma arising out of a recurrent, long-lasting fistula-in-ano. As reported, abdomino-perineal resection combined with radiotherapy can be the choice treatment. The difficulty is to obtain a reliable differential diagnosis. No imaging technique nor histologic examination can establish a definitive reliable diagnosis; nevertheless, as the risk of adenocarcinoma developing from a long-lasting recurrent fistula-in-ano, although small, is real, authors believe that operative exploration and biopsy of recurrent abscesses and fistulas should be recommended.

[Perihepatic packing combined with wrapping in the treatment of major bi-lobar hepatic trauma]. / Il packing periepatico associato a wrapping nel trattamento dei grandi traumi epatici bilobari.

After the spleen the liver is the most exposed organ to injury in abdominal blunt trauma. The improvement in imaging techniques and in anesthesia and intensive care have contributed to a fallen in mortality rate and an enhanced possibility in non-operative management. In unstable patients the packing may be used to defer the definitive operation. The Authors report a case of liver injury of two lobes where the packing was followed by liver wrapping with an absorbable mesh. The patient, a female aged 67, resulted to have a bilobar liver injury of IV degree in the injury severity score. The delay of reoperation was 15 days. The procedure was complicated by a subphrenic abscess, successfully managed with non-operative procedures. Wrapping after liver packing may be considered a good option in unstable patient affected, by severe liver injuries after blunt abdominal traumas.

[Controversies in timing of preoperative staging of pancreatic carcinomas]. / Controversie nel timing per la stadiazione preoperatoria dei carcinomi pancreatici.

In recent years pancreatic cancer has shown an increasing incidence. Preoperative staging represents a main problem for its surgical management. Recent behaviour in the treatment of the disease led to considerably more encouraging results. The Authors describe the cases treated at the Dept. of Surgery of the University of Perugia and review the most important international reports on preoperative staging of pancreatic cancer.

Surgery of local recurrence in rectal cancer.

The local recurrence, after radical exeresis of a large intestinal cancer represents until now an extremely interesting question, taking into consideration that it represents the cause of death in 50% of operated patients. Frequency is higher after an exeresis of a rectal cancer, with a range of 2.6-83% in the different case histories, than after a surgical intervention on a colon cancer, whose incidence is lower than 5%. The early diagnosis of rectum cancer recurrence is the first step towards the favourable issue of treatment. Surgical treatment of loco-regional recurrences of rectum cancer can be curative when it is possible to perform a total resection of the recurrences and of the infiltrated structures, without microscopic residuals of disease, or palliative, aiming to reset the intestinal and urinary functions or to reduce pain. At the Department of Surgery of the University of Perugia, from January 1984 to December 1983, 153 patients with rectal cancer-79 males (52%) and 74 females (48%)-were treated. The operations, all involved total removal of the affected segment and were in 88 cases (58%) an anterior resection and in 65 cases (42%) an abdomino-perineal amputation. The analysis was made of 128 patients with a follow-up of at least five years; the local recurrence incidence was 12.5%. The authors adopted a follow-up protocol based on clinical examination, CEA antigen and routine Lab tests, chest X-rays, colonoscopy, abdominal ultrasonography, pelvic CT scan; these procedures are performed starting 3 months after operation.

Surgical care in octogenarians.

The general surgical profile of octogenarians compared with that of younger patients, and risk factors predictive of operative mortality and morbidity, were determined retrospectively using a computer database for all patients admitted between 1989 and 1993. There were 934 admissions of octogenarians and surgery was performed in 447 cases (47.9 percent). The admission rate of patients over 80 years of age increased during the 5-year period from 4.6 to 9.0 per cent, and was significantly higher than that of geriatric patients aged 65-79 years (P < 0.01). Emergency admissions (63.6 percent) and operations (42.3 percent) were more frequent in patients aged over 80 years (P < 0.01); emergency operations increased during the 5 years from 38 to 59 percent. Altogether, 83 deaths and 171 complications were recorded. The mortality rate of octogenarians was greater than that of younger patients (P < 0.01). Postoperative mortality and morbidity rates were 10.1 and 32.2 percent respectively. After multiple logistic regression analysis with stepwise backward elimination, an American Society of Anesthesiologists score of II-V (P < 0.01), the presence of two associated diseases (P < 0.01) and laparotomy procedures (P < 0.03) appeared to be independent risk factors for postoperative mortality and morbidity.

[Penetrating wounds of the thorax]. / Ferite penetranti del torace.

From January 1989 to December 1993 at the Institute of Clinical Surgery of the University of Perugia, 5 patients were under observation for penetrating chest injuries. Two of them had show-wounds, one a slash, one a stabbing and slash and one a cutting blow. One of the patients with shot-wounds died on the operating table from a haemorrhage while the other was saved by surgery. One patient successfully underwent surgery for loss of tissue in the thorax walls. Another had a mini-thoracotomy plus lung suture which were successful. Finally, in the patient with a slash in the front region of the thorax and a slight pneumothorax, we inserted a chest thorax tube and so obtained a complete re-expansion of the lung. Total mortality was 20%. Surgical exploration of the thorax we believe is necessary wherever there is a risk of haemorrhage or possible lung damage requiring only surgery. According to many authors, video-thoracoscopy has the advantage of a reliable diagnosis and above all, enable us to repair lung wounds without opening the thorax. In one of our patients we could have avoided the mini-thoracotomy and used thoracoscopy to repair the lung damage.

[Flail chest]. / Volet costale.

From January 1989 to December 1993 at the Department of Clinical Surgery at the University of Perugia, 7 patients were under observation for multiple costal fractures and flail chest. One of them died almost immediately after his admission and therefore received no more than the initial medical treatment. Another died 17 days after costal osteosynthesis of cerebral complications. Four others successfully underwent a costal osteosynthesis, while the 7th patient received medical therapy with a positive outcome. In the case of a critical flail chest with very serious physio-pathological consequences, if the fractures are in technically favourable places, we think it is better to stabilize immediately, since the operating trauma is minimum and in many cases the patient is already intubated and curarized.

[General surgery in the octogenarian patient. One year's clinical experience]. / La chirurgia generale nel paziente ottuagenario. Esperienza clinica di un anno.

BACKGROUND: As the number of people over the age of 80 years is rapidly increasing, it may be expected that demand for surgical care for the elderly will also rise during the next decade thus contributing to a change in surgeon attitude. AIM OF THE STUDY: Because little literature is available on the surgical care requested by the over eighties, the aim of this study is to focus on the present surgical demand of the octogenarians in general surgical practice. METHODS: Two hundred-five admissions of 187 patients of above 80 years during one year were recorded retrospectively and statistical evaluation (Fisher exact test or Chi square test) of main clinical features was performed. RESULTS: The rate of surgical admission of octogenarians was 6.5% (205/3135). Half of the patients were admitted as emergencies (52.7%). This percentage was significantly higher (p < 0.000) than in < 80 year old patients (20.8%). The mortality rate for all admissions was 11.2%. In 65.4% of cases a surgical procedure was necessary with a correlated mortality rate of 8.2%. The mortality (2.9%) and morbidity (17%) rate in elective surgery were significantly lower (p = 0.0176 and p = 0.003 respectively) than in emergency surgery (13.6% and 42% respectively). Of all admissions 74.4% were uneventful and, in patients who underwent surgery, complications occurred in 29.8% with no statistically significant differences between patients with or without coexisting disease. The mean hospital stay was 11.4 days and in operated patients was 14.4 days. Almost the total number of patients could be sent home directly. CONCLUSIONS: In octogenarians, surgery is performed more frequently when a complication occurs, but this attitude should be changed because the mortality and morbidity rate are significantly higher. New standards of management and new resources will be requested for the elective surgical care of this rapidly increasing aged group of patients.

Ultrasonography in the management of acute appendicitis.

BACKGROUND: Ultrasonography (US) shows promise in the diagnosis of acute appendicitis. METHODS: The authors present their own experience in ultrasonography (US) employed in the diagnosis of appendicitis, based on 40 patients admitted to the Department of Surgery of the University of Perugia. RESULTS: US was found to be easily obtainable and reliable; it had good specificity and sensitivity, was not very time consuming, and had a good cost/benefit ratio. CONCLUSIONS: The authors believe US is an important diagnostic tool that can reduce useless laparotomies for false acute appendicitis, particularly in cases presenting with unclear clinical findings.

[Intestinal lymphangiectasis in adults]. / La linfangectasia intestinale nell'adulto.

Although rarely, several conditions may cause malabsorption through lymphatic obstruction. Primary lymphangiectasia, a genetically determined disease characterized by diarrhoea, steatorrhoea and protein-losing enteropathy, is one of these conditions. The Authors report their experience in three cases of small bowel lymphangiectasia occurring in adults and discuss diagnostic and therapeutic problems of the disease.

Effect of aspirin and dipyridamole treatment on prostacyclin production by human veins.

Patients admitted for surgical removal of varicose veins were treated in a blinded manner for 48 hours prior to surgery with either placebo, low-dose aspirin (25 mg twice daily), dipyridamole (150 mg twice daily) or both. Segments of vein excised at surgery were incubated with or without sodium arachidonate and subsequent prostacyclin (PGI2) production was measured without knowledge of treatment given. During the first 5 minute period of incubation in the presence of arachidonate, veins from dipyridamole-treated patients demonstrated increased (by 75%) arachidonate-stimulated PGI2 production compared to placebo-treated patients. By contrast, PGI2 production was reduced by 64% by aspirin treatment and 67% by aspirin plus dipyridamole compared to placebo-treated patients (p = less than 0.05). In unstimulated vein segments incubated in the absence of arachidonate, spontaneous PGI2 production during the first 5 minute incubation period was increased 32% following dipyridamole treatment but was unchanged following aspirin treatment. By contrast, unstimulated (spontaneous) PGI2 production in patients treated with aspirin plus dipyridamole was reduced by 57% (p = less than 0.05), compared to both placebo- and aspirin-treated patients, and by 71% (p = less than 0.05) compared to dipyridamole-treated patients. With repeated change of incubation medium, the ability of vein walls to produce PGI2 declined. This exhaustion was not prevented by drug treatment. However, drug effects between patient treatment groups were consistent over successive incubation periods. These results suggest that certain therapeutic benefits that might be achieved by enhancement of PGI2 production from vascular endothelium following dipyridamole treatment may be reduced by simultaneous aspirin treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased prostacyclin production from human veins by dipyridamole: an in vitro and ex vivo study.

The effect of dipyridamole on prostacyclin (PGI2) production in the presence or in the absence of sodium arachidonate was examined in human veins collected from otherwise normal subjects undergoing saphenous vein removal. Vein segments, maintained in ex vivo culture, that were removed from subjects treated with dipyridamole for two days prior to surgery synthesized 2.5 times more PGI2 (p less than 0.05) than veins that were removed from placebo-treated subjects when incubated in the presence of arachidonate. This difference decreased progressively when vein segments were washed repeatedly and then re-incubated in the presence of arachidonate. Direct addition of dipyridamole to vein segments incubated in vitro resulted in a dose-dependent increase in PGI2 production when the incubation was carried out in the presence of arachidonic acid. No effect of dipyridamole was observed in experiments performed in the absence of arachidonic acid. A mathematical analysis based on both ex vivo and in vitro experiments of the rate of decline of endothelial cell PGI2 biosynthesis suggested that the elevation of PGI2 with dipyridamole treatment resulted from increased PGI2 synthesis rather than decreased PGI2 catabolism. These data support the hypothesis that dipyridamole both ex vivo and in vitro enhances and prolongs PGI2 production by human vessels.