Acute biliary pancreatitis: staging and management.

BACKGROUND/AIMS: Acute biliary pancreatitis is a clinical entity with a high morbidity rate (15-50%) and mortality rate (20-35%). Early diagnosis has a primary importance for an appropriate treatment (75% of cases of idiopathic acute pancreatitis are of biliary origin). METHODOLOGY: Diagnosis of acute biliary pancreatitis in 78 patients was based on careful clinical and instrumental assessment: ultrasonography (76.9% of cases) and laboratory tests in 23.1% of cases. In our study we used the Ranson and APACHE II scores and 24 of the cases (30.7%) were classified as severe, while 54 (69.2%) were mild. All patients with severe acute biliary pancreatitis underwent emergency endoscopic retrograde cholangiopancreatography + endoscopic sphincterotomy (within 24-48 hours) followed by laparoscopic cholecystectomy (10 days). Patients with mild acute biliary pancreatitis underwent laparoscopic cholecystectomy associated with intraoperative cholangiography, within 10 days. RESULTS: In 19 patients with severe acute biliary pancreatitis operative endoscopy was curative. Subsequent laparoscopic cholecystectomy provoked subcutaneous emphysema only in one case but did not show any other serious morbidity. In the remaining 5 cases laparotomy was required because of necrosis, with a mortality rate of 60%. In all cases of mild acute biliary pancreatitis, laparoscopic cholecystectomy was successfully performed with a morbidity rate of 7.3%. Common bile duct stones were revealed with intraoperative cholangiography in 31.4% of the mild cases and in 75% of the severe cases. CONCLUSIONS: In conclusion acute biliary pancreatitis treatment is always surgical; in almost all severe cases it is performed with minimally invasive procedures (endoscopic retrograde cholangiopancreatography + endoscopic sphincterotomy with laparoscopic cholecystectomy < or = 10 days) if surgery is carried out within 24-48 hrs, as well in the mild cases (laparoscopic cholecystectomy + intraoperative cholangiography) when surgery is performed within 10 days.

The value of omentoplasty in protecting colorectal anastomosis from leakage. A prospective randomized study in 126 patients.

BACKGROUND/AIMS: Anastomotic leakage is a major cause of mortality in colorectal surgery. Several methods have been evaluated in order to prevent anastomotic leakage. To decrease the rate and severity of anastomotic leakage, omentoplasty (OP) has been proposed by several authors on the basis of experimental and clinical studies. A prospective, randomized trial was designed to study the influence of omentoplasty on anastomotic leakage after colorectal resection. METHODOLOGY: One hundred and twenty-six patients undergoing elective or emergency surgery for malignancy, benign tumor, diverticular disease and other were randomly assigned to omentoplasty (OP group) or not (NO group). The primary end point was the rate of clinical and radiological anastomotic leakage. Both groups were comparable in terms of demographic data, preoperative characteristics and intraoperative findings. RESULTS: Eighteen patients (14.3%) had anastomotic leakage, 4 (6.4%) in the OP group and 14 (21.9%) in the NO group. Significant differences (P<0.05) between the two groups were also found in terms of repeat operation (3.2% vs. 14.1%) and deaths (3.2 vs. 7.8%). Other factors associated with anastomotic leakage were the distal site of anastomosis (<5 cm from anal verge) and the emergency. CONCLUSIONS: Omental wrap, with its mechanical and biological properties, seems to be effective in lowering the rate and the severity of anastomotic leakage after colorectal surgery.

Evaluation of immune response in patients after open or laparoscopic cholecystectomy.

BACKGROUND/AIMS: Laparoscopic cholecystectomy is a so called mini-invasive surgical procedure, and on this basis, we investigated whether and how the immune response is modified in patients after laparoscopic cholecystectomy compared to patients who underwent open cholecystectomy. METHODOLOGY: In a prospective, nonrandomized trial, 35 patients underwent laparoscopic cholecystectomy and 31 open cholecystectomy. Immune activity (neutrophils, total lymphocytes, lymphocyte subpopulations, human leukocyte antigen (HLA-DR), interleukin 6, skin Multitest) was evaluated before surgery and respectively, 1, 3, and 6 days postoperatively. RESULTS: One day after surgery, an increase in interleukin 6 (P < 0.01) was noted in patients who had undergone open cholecystectomy, while this parameter was almost unchanged in patients with laparoscopic cholecystectomy. Moreover, skin tests showed a hypo or anergic response in the majority (81.8%) of open cholecystectomy patients compared to laparoscopic cholecystectomy patients (10.5%), (P < 0.01). Finally, monocyte antigen HLA-DR was also reduced in open cholecystectomy patients (P < 0.05). In this group, we noted 2 cases (6.45%) of respiratory tract infection. CONCLUSIONS: Even though laparoscopic cholecystectomy requires a longer surgery, it reduces postoperative pain, and hospitalization. It also facilitates rapid recovery, a return to normal activity, avoids postoperative immunosuppression and shows a better postoperative morbidity compared to open surgery.

[Diagnosis and treatment of non-palpable breast lesions: from the biopsy to the microhistology results. Our experience]. / La diagnosi ed il trattamento delle lesioni non palpabili della mammella: dalla biopsia su repere alla microistologia. Nostra esperienza.

The aim of modern senology lies in the diagnosis and treatment of non-palpable breast lesions (NPBLs). Through the diffusion of regional mammography screening the lesions being observed are continuously smaller, thus calling for more and more accurate methodology. Our experience in this area is based on the use of certain methods for retrieval and removal of NPBLs, such as Kopan's sec. philo-guide, ultrasound and advanced breast biopsy instrumentation. In our opinion methods allowing total removal of lesions in order to obtain complete histopathological characterization and enabling adequate therapeutic programs are to be preferred. In reviewing case studies a noteworthy increase of initial carcinoma (DCIS or LCIS), from 19.5% to 57.1%, has been observed in the last three years due to the extensive use of the aforementioned methods.

[Can analysis of the molecular status of the p53 gene contribute to improving the therapeutic strategy for breast carcinoma?]. / L'analisi dello stato molecolare del gene p53 può contribuire ad innovare le strategie terapeutiche nel carcinoma della mammella?

The occurrence of mutations in the p53 tumor suppressor gene is a specific and recurring genetic event in solid tumors. P53 plays a pivotal role in multiple cellular processes such as cell growth control, DNA repair and programmed cell death. Genotoxic damage, also induced by chemotherapy or radiotherapy, induces p53 overexpression in order to control the rate of proliferating damaged cells, thus triggering the mismatch repair or apoptotic pathways. P53 inactivation determines a condition of genetic instability, justifying the subsequent susceptibility to acquire mutations of different other genes. P53 mutations are associated with worse prognosis and with chemo/radioresistance, due to the inability to trigger p53-dependent programmed cell death. Molecular diagnostic strategies show 32% p53 mutations in breast cancer. The analysis of the p53 gene performed by FAMA (Fluorescence Assisted Mismatch Analysis) in high-risk breast cancer patients with > or = 10 involved axillary nodes may help identify a subset of very high risk BC patients (vHR-BC) with poorer prognosis and a subset with better prognosis, potentially responsive to medical treatments. The accurate evaluation of the p53 status can predict prognosis and sensitivity to chemotherapy, thus representing the first step toward better definition of therapeutic strategies according to the molecular characterization of the individual patient.

The role of laparoscopic adhesiolysis in chronic abdominal pain.

BACKGROUND: Intraperitoneal adhesions seem to be a possible cause of chronic abdominal pain, but reports of their etiological role are controversial. Laparoscopic adhesiolysis has been proposed as treatment of choice, even tough reports of success are contradictory. The aim of our prospective study, was to determine whether laparoscopic adhesiolysis ameliorates chronic abdominal pain in patients with pathological abdominal adhesions. METHODS: Forty-five patients with chronic abdominal pain, lasting for more than 6 months, without abnormal findings other than pathological intraperitoneal adhesions found at laparoscopy, underwent laparoscopic adhesiolysis. RESULTS: Forty-one patients (91.1%) were available for follow-up after an average time interval of 18 months (range: 12-41 months): 24 patients (58.5%) were free from abdominal pain; 10 (24.4%) reported significant amelioration of pain, while 7 (17.1%) patients had no amelioration. CONCLUSIONS: Laparoscopy is an efficient means of assessing patients with chronic abdominal pain, and laparoscopic adhesiolysis cures or ameliorates. Chronic abdominal pain in more than 80% of patients.

[Omentoplasty is effective in lowering the complications of ano-rectal resections]. / L'omentoplastica riduce le complicanze della chirurgia resettiva del retto e del canale anale.

AIM: The aim of this prospective, randomized study was to investigate the influence of omentoplasty on complications following colorectal resection, Hartmann's intervention and abdominoperineal amputation. METHODS: One hundred and seventy-one patients undergoing elective or emergency surgery for malignancy, benign tumor, diverticular disease and others were randomly assigned to omentoplasty (OP group) or not (NO group). The primary goal was to evaluate the rate of clinical and radiological anastomotic leakage. The secondary goal was to assess the morbidity (mainly septic complications) following Hartmann's and Miles' procedures. RESULTS: In colorectal anastomosis, 18 patients (14.3%) had anastomotic leakage, 4 (6.4%) in the OP group and 14 (21.9%) in the NO group. Differences between the 2 groups were also found in terms of repeat operations (3.2% vs 14.1%) and deaths (3.2% vs 7.8%). Other factors associated with anastomotic leakage were the distal site of anastomosis (<5 cm from anal verge) and the emergency. In Hartmann's and Miles' procedures, septic complications were reduced in the OP group. CONCLUSION: Omental wrap, with its mechanical and biological properties, seems to be effective in lowering the rate and the severity of complications after colorectal and anal surgery.

[Polyps (single or multiple) and juvenile polyposis]. / Polipi (singoli o multipli) e poliposi giovanile.

The authors underline the important aspects of juvenile familial polyposis (JFP), a disease transmitted as an autosomal dominant trait. A case of JFP characterized by the presence of hundreds of polyps in the colo-rectal intestinal tract, is analyzed. The single juvenile polyp, multiple polyps (=/>5 polyps) and the sporadic form are examined. These are mucous hamartomas which can undergo neoplastic transformation (in carcinoma in 68% of untreated cases), a behaviour similar to that of adenomatous polyps. They differ from the later due to the following features: epidemiology (earlier appearance age), anatomopathology (stroma), clinical observation (self-recovery in some cases) and genetics (10q23.3-18q21, genetic mutations in a locus different those of adenomatous polyps). It is also necessary to determine its extension by means of colonoscopy, ileoscopy, gastroscopy and small bowel barium enema. Patients' screening through construction of the genealogical family tree is fundamental. Isolation of possible degenerative aspects of the polyps through biopsy is also fundamental. Single or multiple polyps are treated endoscopically, the juvenile polyposis is treated surgically (colectomy, total colectomy). A rigorous follow-up of the patients and their family members is recommended.

[Response of interleukin-6 in patients undergoing a laparoscopic or laparotomic cholecystectomy]. / Risposta della interleukina-6 in pazienti sottoposti a colecistectomia laparoscopica o laparotomica.

BACKGROUND: It is well known that surgery induces an acute inflammatory response associated with significant increase of interleukin-6 (IL-6) and C reactive protein (CRP). Laparoscopic cholecystectomy (LC) is a so called "mini-invasive" surgical intervention and on the basis of this consideration it has been investigated if and how serological markers of inflammation are modified in patients after laparoscopic cholecystectomy compared to patients undergoing open cholecystectomy. METHODS: The acute phase of inflammation (IL-6, CRP and body temperature) was evaluated in 53 patients one day before surgery and p.o. after 1, 3 and 6 days; 26 patients underwent "open" cholecystectomy and 27 LC. RESULTS: One day after surgery patients with open cholecystectomy showed significant increase (p < 0.05) of IL-6, CRP and body temperature, while these parameters were almost unchanged in patients with LC. In patients with "open" cholecystectomy, 2 p.o. complications (pneumonia) were observed. CONCLUSIONS: In conclusion, LC, although it requires longer operative time, strongly reduces p.o. pain, hospitalization, promotes earlier recovery and return to normal activity, avoiding the acute phase of p.o. inflammation with better p.o. morbidity compared to open surgery.

Immunohistochemical assessment of peroxidase-like immunoreactivity in the thyroid gland and its correlation with biochemical assay.

BACKGROUND: Peroxidase content has been recently evaluated in normal thyroid and in different thyroid disorders by biochemical, histochemical, ultrastructural and immunocytochemical methods. Nevertheless immunocytochemical detection of thyroid peroxidase in thyroid samples conventionally processed for histology has never been done using a commercially available antibody, neither its correlation with the biochemical activity on adjacent samples. METHODS: In this study we have analyzed normal thyroid tissue (3 patients), follicular adenoma (2 patients) and multinodular goiter (2 patients) conventionally processed for histology and stained by immunocytochemistry (Avidin Biotin System) using a polyclonal (rabbit) antibody for horseradish peroxidase (Serotec). Biochemical assay was performed on adjacent samples according to Hosoya method. RESULTS: Normal thyroid showed peroxidase immunoreactivity in the majority of follicular cells; neoplastic cells of adenomas were variably stained. Biochemical assay showed positive correlation with ICC ranging from 20.4 micrograms/mg/prot a in multinodular goiter to 42.12 in normal thyroid, up to 122 of follicular adenoma. CONCLUSIONS: Peroxidase content in the thyroid gland may be of clinical interest in several thyroid diseases, and in this study we have demonstrated that thyroid peroxidase can be detected by ICC in routinely processed thyroid samples using a commercially available antibody.

[Treatment of acute biliary pancreatitis in the aged in the endolaparoscopic era]. / Il trattamento della pancreatite acuta biliare nell'anziano nell'era endolaparoscopica.

BACKGROUND: Acute biliary pancreatitis (ABP) still retains high morbidity (15-50%) and mortality (20-35%). Therefore it appears to be crucial to clearly assess the aetiological factors (50% of idiopathic are in fact biliary pancreatitis) and to establish the severity in order to plan the appropriate treatment. METHODS: In this study we have considered 61 patients divided into 2 groups. Group 1 had 29 ABP patients aging less than 65 years, group 232 patients aging more than 65 years; the diagnosis was made by ultrasound and serological values in 78.5% of cases, while in the remaining 21.5% was only serological. Following Ranson and APACHE II scoring 18 cases (29.5%) were classified as severe [6 (20.6%) in group 1; 12 (37.5%) in group 2: p < 0.01], 43 (70.4%) as mild. All patients with severe ABP had emergency ERCP + ES (within 24-48 hrs) followed by LC (< or = 10 days). Patients with mild ABP had LC within 10 days; in these cases IOC was always done. RESULTS: In severe cases operative endoscopy cured pancreatic inflammation in 13 cases. Subsequent LC never showed serious morbidity, apart subcutaneous emphysema in one case. In 5 cases laparotomy was required since pancreatic necrosis was present, with 60% mortality. In patients with mild pancreatitis LC was successfully performed in all cases, with 6.9% morbidity. IOC showed choledochal stones in 32.5% of cases, while in severe cases stones in the biliary tree were showed in 88.8% of cases. No significant differences were detected between group 1 and 2. CONCLUSIONS: In conclusion ABP treatment is always surgical, and almost always with minimally-invasive procedures in severe cases (ERCP + ES with LC < or = 10 days) if surgery is performed within 24-48 hrs as well as in mild cases (LC + IOC) when surgery is done within 10 days, independently from the age of the patients.

[Structure, function, and levels of neutrophil elastase after laparoscopic cholecystectomy]. / Struttura, funzione e livelli dell'elastasi neutrofila dopo videolaparocolecistectomia.

Neutrophil elastase is a neutral proteinase present mainly in the azurophilic granules of segmented granulocytes, the main cells involved in the inflammatory response reaction. In our study we attempted to determine whether an enzyme such as neutrophil elastase produced by polymorpho-nuclear leukocytes could be an indicator capable of determining the degree of surgical trauma, comparing two surgical approaches, namely, laparoscopic cholecystectomy and open cholecystectomy. Plasma neutrophil elastase was determined photometrically, using an immune-activation immunoassay, in 66 patients (32 patients underwent open cholecystectomy and 34 laparoscopic cholecystectomy) 1 day before surgery and 1, 3, 6 and 12 days after surgery. We established a reference range for elastase by measuring the serum elastase concentration in 48 healthy control patients. A significant increase (p < 0.05) in plasma neutrophil elastase levels was observed on days 1, 3 and 6 after surgery in patients undergoing open cholecystectomy, whereas the levels of the enzyme were almost stable in patients undergoing laparoscopic cholecystectomy. We recorded two cases (6.2%) of respiratory tract infections in the "open" group. Neutrophil elastase is a good indicator for discriminating the severity of the surgical trauma, which is certainly more severe in laparotomy than in laparascopic cholecystectomy. Peripheral leukocyte function seems to be better preserved after laparoscopic surgery than after laparotomy.

[Is cell-mediated immunity affected by laparoscopic cholecystectomy?]. / L'immunità cellulo-mediata è influenzata dalla colecistectomia laparoscopica?

It is well known that surgery significantly decreases cell-mediated immunity. Laparoscopic cholecystectomy is a so-called minimally invasive surgical procedure, and on the basis of this consideration we investigated whether and how the immune system is modified in patients after laparoscopic cholecystectomy compared to those undergoing open cholecystectomy. Immune activity (neutrophils, total lymphocyte count, lymphocyte subpopulations, multiple skin tests) was evaluated in 82 patients on postoperative day 1 and on postoperative days 1, 3 and 6. Forty-two patients underwent open cholecystectomy and 40 laparoscopic cholecystectomy. On postoperative day 1 patients treated by open cholecystectomy showed a significant increase (P < 0.05) in plasma neutrophils, whereas this parameter was unchanged in patients undergoing laparoscopic cholecystectomy. Skin tests revealed a hypo- or anergic response in the majority of patients (81.8%) undergoing open surgery compared to those treated laparoscopically (10.5%). Total lymphocyte count and lymphocyte subpopulations were normal in the two groups. Four cases of respiratory tract infection (4.8%) were detected after open cholecystectomy. Laparoscopic cholecystectomy substantially reduces postoperative pain and hospitalisation, promotes an earlier recovery and return to normal activity and is not associated with postoperative immunosuppression, with a more positive postoperative morbidity profile compared to open surgery.

[Acute cholecystitis: video-laparoscopic or laparotomic treatment? Role of the immune system]. / Colecistite acuta: trattamento videolaparoscopico o laparotomico? Ruolo del sistema immunitario.

Recent clinical studies suggest that laparoscopic cholecystectomy (LC) causes less depression of cell-mediated immunity than open cholecystectomy. LC is a so called "mini invasive" surgical presidia, and on the basis of this consideration we have investigated if and how the immune response is modified in patients with acute cholecystitis after laparoscopic cholecystectomy compare to patients undergone open cholecystectomy. Immune-activity (neutrophils, total lymphocytes count, lymphocytes subpopulations, HLA-DR, 6-Interleukin, skin multitests) was evaluated in 28 patients 24-36 hours before surgery and p.o. after 1, 3 and 6 days: 16 patients underwent "open" cholecystectomy and 12 LC. One day after surgery patients with open cholecystectomy showed significant increase (p < or = 0.05) of plasma neutrophils and 6-Interleukin, while these parameters were almost unchanged in patients with LC. Moreover, skin tests showed ipo or anergic response in the majority (81.8%) of patients with "open" surgery compare to patients with LC (10.5%): (p < or = 0.05). Finally monocyte antigen HLA-DR was also reduced in patients with "open" cholecystectomy: in this group we also recorded 2 cases (12.5%) of respiratory tract infection. In conclusion, LC for acute cholecystitis, avoids p.o. immunosuppression with better p.o. morbidity compare to open surgery.

[Clinical assessment of juvenile polyposis with particular reference to the risk of neoplastic malignancy. Analysis of 412 patients reported in the international literature]. / Inquadramento clinico della poliposi giovanile con particolare riferimento al rischio di degenerazione neoplastica. Analisi dei 412 pazienti riportati dalla letteratura internazionale.

The authors extensively review the international literature on juvenile polyposis, with particular reference to the risk of malignancy in the various forms of the disease (colorectal vs. generalized, familial vs. sporadic). Sixty-eight out of a total of 412 patients presented adenomatous changes in the polyps. In addition, 68 cancers were found. The rate of degeneration was analysed for all variants of juvenile polyposis, but no statistically significant differences were detected. The authors conclude that juvenile polyposis should be considered as being as challenging to the surgeon as familial polyposis syndromes and outline protocols for the screening, endoscopic and surgical treatment and follow-up of these patients.

[Inflammatory markers after laparoscopy versus laparotomy cholecystectomy]. / Markers infiammatori post colecistectomia laparoscopica versus laparotomica.

OBJECTIVE: The study is carried out to determine whether the level of IL-6 is altered and in what way after surgery as well as if such a change could be an indicator of increased morbidity after surgical treatment. MATERIALS OF THE STUDY: Chemiluminesence immunoeassay system was used in order to establish IL-6 level in blood samples of 71 patients that underwent abdominal surgery, 36 Laparoscopic Cholecystectomy (LC) and 35 Open Cholecystectomy (OC) at time 0 (before the operation), 1 h, 2 h, 3 h, 6 h, 24 h and 48 h after the operation. RESULTS: Plasma IL-6 levels are significantly increased after OC; we observed 3 cases of post-operative infections, in which IL-6 returned to normal levels 6 days after surgery. Analogous variation to the IL-6 levels was noted for the C-reactive protein levels. DISCUSSION: Laparoscopic cholecystectomy, a so called mini-invasive surgical procedure, is associated to a small increase of IL-6 serum levels and provides better post-operative conditions to the patients by reducing surgical stress and the infectious complications correlated to the surgical procedure. CONCLUSIONS: During OC there is a significant higher elevation of IL-6 serum levels than after laparoscopic cholecystectomy. Variation of C-reactive protein serum levels after surgery is analogous to variation of IL-6 levels.

[Endoscopic diagnosis and treatment of juvenile solitary polyps, in the light of the unusual but proven neoplastic potential]. / Considerazioni di diagnosi e terapia endoscopica dei polipi giovanili solitari, alla luce della rara ma dimostrata potenzialità neoplastica.

For many years a neoplastic potentiality of the juvenile polyps has been denied. The authors performed a critical review of the international literature about the neoplastic transformation of the juvenile polyps. Each examined case had to respect three conditions: 1) exhaustive hystological findings certifying a clear neoplastic degeneration of a juvenile polyp; 2) clear evidence of single juvenile polyposis (< 5), presence in the colon and rectum only and absence of familiarity; 3) reliable diagnostic practice (endoscopic and/or hystological evidence). During the review we collected 271 cases of juvenile polyposis observed in 12 countries, 97 of which (35.79%) showed neoplastic transformation, adenomatous type in 50 (18.45%) and carcinomatous type in 47 (17.34%), and 13 cases of neoplastic degeneration of single juvenile polyps. The review shows clearly and strongly that the risk of cancer in the juvenile polyposis can reach the risk of the adenomatous polyposis. The neoplastic degeneration exists in the single juvenile polyps even if in a lower degree.

[Post-mastectomy breast reconstruction: esthetic-psychological rebalance]. / Ricostruzione mammaria postmastectomia riequilibrio estetico-psicologico.

Patient motivation and desire are the main indications for restoring the breast. Breast reconstruction can alleviate the sense of deformity that may develop after mastectomy or conservative treatment.

Effects of laparoscopic and conventional (open) cholecystectomy on human leukocyte antigen-DR expression in peripheral blood monocytes: correlations with immunologic status.

It is well known that surgery significantly decreases immune responses. Laparoscopic cholecystectomy (LC) is a "miniinvasive" surgical procedure; and on the basis of this consideration we have investigated if and how the immune response is modified in patients after laparoscopic cholecystectomy compared to patients who underwent open cholecystectomy. Immune activity [neutrophils, total lymphocytes count, lymphocytes subpopulations, human leukocyte antigen-DR (HLA-DR)] was evaluated in 53 patients 1 day before surgery and respectively, 1, 3, and 6 days after surgery; 26 patients underwent "open" cholecystectomy and 27 LC. A day after surgery, patients with open cholecystectomy showed a significant increase (p < 0.05) in plasma neutrophils, while they were almost unchanged in LC patients. Monocyte antigen HLA-DR was reduced in patients with "open" cholecystectomy. We recorded two cases (7.6%) of respiratory tract infection in the "open" group. In conclusion, LC strongly reduces postoperative (p.o.) pain and hospitalization, and it promotes earlier recovery and return to normal activity, avoiding p.o. immunosuppression, mostly due to conservation of HLA-DR activity, with less p.o. morbidity compared to that seen with open surgery.