Acute diverticulitis with colon perforation in renal transplantation.

INTRODUCTION: Acute diverticulitis with colon perforation is a serious condition in transplant recipients. The aim of this study was to analyze our experience with colon perforations among 875 renal transplant recipients between January 1986 and September 2004. METHODS: Patients were analyzed by age, gender, steroid dosage, time interval from the transplantation, delay between symptoms and surgery, clinical presentation, surgical procedure, graft and patient outcomes. RESULTS: We identified 8 patients with colon perforation. The incidence of perforation was 0.9%. Mean age at the the time of perforation was 58.5 years. Fever, abdominal pain, localized or diffuse signs of peritonitis, and leukocytosis were present in 7 patients (87.5%). Three patients (37.5%) were on steroid-free immunosuppression, whereas in 2 cases (25%) the steroid dosage was >20 mg/d. The mean interval between transplantation and perforation was 4.1 years. Two episodes (25%) occurred within 1 month following transplantation and the other 6 (75%) between 1 and 15 years. The interval between the onset of symptoms and surgery was longer than 48 hours in 1 patient (12.5%). In 5 cases (62.5%), a Hartmann procedure was performed; in 2 patients (25%), a resection with primary anastomosis was preferred. The last patient had a direct suture of the colon. Mortality rate was 12.5%. At a median follow-up of 6.1 years, 6 patients (75%) are alive with 5 functioning grafts. CONCLUSIONS: Colon perforations in renal transplant recipients remain a challenging surgical problem. An aggressive diagnostic attitude and an immediate surgical treatment may contribute to significantly decrease the incidence and the mortality of this complication.

Technetium-99m HIDA hepatobiliary scanning in evaluation of afferent loop syndrome.

A study of 118 patients, operated on with Billroth II gastrectomy for peptic disease and affected by postgastrectomy syndromes, was carried out. Fifty patients were investigated by means of technetium-99m HIDA hepatobiliary scanning. In 18 patients, in whom an afferent loop syndrome was clinically suspected, hepatobiliary scanning demonstrated an altered afferent loop emptying in 8 and atonic distension of the gallbladder without afferent loop motility changes in 10. Among the patients in the first group, four were treated with a biliary diversion surgical procedure and in the second group, two patients underwent cholecystectomy. Our findings indicate that biliary vomiting, right upper abdominal pain pyrosis, and biliary diarrhea in Billroth II gastrectomized patients are not always pathognomonic symptoms of afferent loop syndrome. Technetium-99m HIDA hepatobiliary scanning represents the only diagnostic means of afferent loop syndrome definition. A differential diagnosis of abnormal afferent loop emptying and gallbladder dyskinesia is necessary for the management planning of these patients, and furthermore, when a surgical treatment is required, biliary diversion with Roux-Y anastomosis or Braun's biliary diversion seems the treatment of choice for afferent loop syndrome, whereas cholecystectomy represents the best procedure for atonic distension of the gallbladder.

Gastric carcinoid tumor and its precursor lesions. Ultrastructural study of a case before and after antrectomy.

Antrectomy has been proposed as the preferential treatment of hypergastrinemic patients with nonantral gastric carcinoids since it removes the main growth factor for the tumors and their precursor lesions, ie, hypergastrinemia. To investigate the cellular basis of the mechanism for postantrectomy regression in nonantral endocrine cells, a light and electron microscopic morphometric study was performed in a case of enterochromaffinlike-cell gastric carcinoid associated with hypergastrinemia before and 4 and 10 months after antrectomy. The withdrawal of sustained hypergastrinemia obtained by antrectomy was associated with a progressive reduction of the volume density, cross-sectional area, and number of profiles of endocrine cells in the remaining nonantral mucosa, in which gastrin-dependent proliferations were regarded as the carcinoid precursor lesions. Ultrastructural morphometry demonstrated that the changes selectively involved the enterochromaffinlike cells, ie, the specific cell target for the trophic action of gastrin and the usual component of gastric carcinoids. The volume fractions of enterochromaffin and X cells (producing serotonin and endothelin, respectively) were increased 10 months after antrectomy. Persistence of a modest elevation of gastrin levels, likely due to the occurrence of gastrin cells in areas of pyloric metaplasia of the nonantral mucosa, did not prevent the hypotrophic effects of antrectomy.

[Are small-size depressed-type colorectal neoplasias really the expression of a early stage of colorectal cancer. Apropos of a clinical case]. / Le neoplasie colo-rettali depresse di piccole dimensioni sono realmente espressione di uno stadio precoce del cancro colo-rettale? A proposito di un caso clinico.

A route of colorectal cancer development other than the adenoma-carcinoma sequence has recently become an issue due to the discovery of the depressed-type early colorectal cancers. Despite the protruding shapes of depressed-type early colorectal cancers, they probably have biological characteristics which differ from those of the usual polyp lesions. They show more aggressive behavior than the polypoid type and can arise de novo. Depressed-type lesions, in contrast to flat-type or protruded-type lesions, tend to invade the submucosa rapidly, so it is better treat them surgically from the outset. We report a case of a small depressed-type colorectal cancer involving the caecum of a 79-year-old male patient.

Duodenogastric reflux and gastric damage from non-steroidal antiinflammatory drugs.

The authors describe cases urgently admitted for iatrogenic gastric lesions due to non-steroid antiinflammatory treatment during the past year. Nine patients were affected by peptic ulcer (bleeding in five cases), while in the remaining 11 an erosive acute gastritis could be observed. Among them, ten patients had been taking acetylsalicylic acid, one indomethacin and the others ketoprofen, indoprofen or similar drugs. In 11 patients, five presenting gastric ulcer and six affected by haemorrhagic gastric damage, an evident duodenogastric reflux was demonstrated. Fifteen patients were treated pharmacologically and complete healing of the lesions was obtained, while in five patients surgical treatment was necessary. The authors conclude by pointing out the high incidence (over 50%) and the pathogenetic role of duodenogastric reflux in gastric lesions appearing in patients treated with non-steroidal antiinflammatory drugs.

[Gastrin: review of current knowledge]. / La gastrina: rassegna sintetica delle attuali conoscenze.

The Authors review recent advances in understanding of the chemical composition and site of elaboration of gastrin; then they describe the physiological actions of the hormone and its connections with gastrointestinal pathology. They also discuss recently developed diagnostic procedures aiming at a more accurate clinical definition of hypergastrinism and hypogastrinism.

[Significance of esophagogastroduodenoscopy before cholecystectomy]. / Significato dell'esofagogastroduodenoscopia prima della colecistectomia.

The aim of the study was to assess the significance of oesophagogastro-duodenoscopy (EGDS) before cholecystectomy. Over the period from 1988 to 1999 EGDS was performed in 384 patients before surgery out of a total of 1439 cholecystectomies. 42.8% presented no lesions, whereas pathological findings were detected in 57.2%. The lesions observed were divided into major and minor. EGDS performed prior to cholecystectomy detected major lesions in elderly patients and in patients with atypical biliary symptoms.

[Clinical applications of the carcinoembryonic antigen (CEA) determination in colorectal cancer (observations of 119 cases)]. / Applicazioni cliniche del dosaggio dell'antigene carcioembrionario (CEA) nel cancro del colon-retto. (osservazioni su 119 casi).

The AA., on the base of their personal experience and the data of literature, value clinical uses of dosage of carcino-embryonic antigen (CEA), made on the blood of patients who suffered of colon-rectal cancer. Their personal experience is based on 119 patients, 70 who had radical exeresis of neoplasm and 49 the palliative treatment. In the patients who had radical treatment the evolution of disease was overseen with this method for a period from a minimum of 1 year to 3 years and in 10 cases they could put in evidence the restarting of neoplasm too early. In regard to the patients who had a palliative treatment, with the observations of CEA works, they obtained a quantitative valuation of antiblastic chemiotherapy effects and electrocoagulative treatment. The AA. end that, while CEA dosage has not negligible limits for a diagnosis, this method is very useful for the precocious diagnosis of neoplasm restarting. On the contrary the information, that we can obtain about the effects of palliative therapy, is limited.

[Colonic perforation in patients undergoing colonoscopy]. / Perforazione del colon in pazienti sottoposti a colonscopia.

Colonic perforations associated with colonoscopy are uncommon. We determined the incidence, clinical presentation, and medical and surgical treatments of iatrogenic colon perforations. We present the medical records of 8 patients with iatrogenic colorectal perforations seen over a period of 17 years. The median age 68.3 years. Emergency laparotomy was performed in 7 patients. One case was treated with a medical approach. One postoperative death occurred. In the absence of significant contamination primary repair is the best treatment. Non-operative management is indicated in patients without peritoneal irritation.

[Evaluation of long-term results in 254 patients surgically treated by gastric resection for peptic ulcer]. / Valutazione dei risultati a distanza in 254 pazienti operati di resezione gastrica per ulcera peptica.

The authors checked 254 patients, operated on with gastric resection according to Billroth II for peptic ulcer, at an interval ranging from 7 up to 20 years from the operation, and, on the basis of the results recorded, these patients were subdivided according to Visick's grading (15,7% in grade 1; 30,6% in grade 2; 26,4% in grade 3 S; 4,7% in grade 3 I; 14,6% in grade 4). On the whole, the remote results were considered satisfactory in 205 patients (80,7%) and unsatisfactory in 49 (19,3%): the latter represent those included in Visick's grades 3 I and 4, wherein the most serious post-resection syndromes had been ascertained; their incidence appeared absolutely higher (91,8%) in the patients subjected to gastric resection for non-complicate peptic ulcer. The Authors therefore conclude the failures of such type of operation are to be ascribed, in high percentage, to uncorrect indications thereto.

[Breast carcinoma in accessory gland: a case report]. / Il carcinoma mammario insorto su tessuto ghiandolare soprannumerario: a proposito di un caso.

The Authors we report the case of a 50 year old woman with accessory breast cancer in the thoracic region. The examination revealed a mass of 1 cm diameter and a tumorectomy showed a ectopic breast with an intraductal carcinoma. Nodal dissection, chemo-, radio- and hormonal therapy there performed. The follow up didn't show a relapse of breast carcinoma after 5 years.

[Surgical treatment of pancreatic pseudocysts]. / Trattamento chirurgico delle pseudocisti del pancreas.

The Authors report their experience of 62 consecutive patients with pancreatic pseudocysts observed within the period 1973-1993. Spontaneous resolution of the pseudocyst occurred in 16 cases. Forty-five patients were surgically treated (31 post-necrotic cysts, 5 post-traumatic cysts and 9 retention cysts); operations included internal drainage in 32 (cystojejunostomy in 13, cystogastrostomy in 18 and cystoduodenostomy in one), external drainage in 8 and pancreatic resection in 5 patients. One patient underwent percutaneous catheter drainage of a post-necrotic pseudocyst. Indications for surgery included complications, nonresolution or persistence of symptoms, and extension. The operative mortality and morbidity rates were higher in the patients submitted to external drainage (22.2% vs 6.2%; 55.5% vs 21.8% respectively). On the basis of the results the Authors conclude that the internal drainage, particularly cystojejunostomy, should be considered the operation of choice for pancreatic pseudocysts because of the lower mortality and morbidity. On the contrary, external drainage is indicated for infected or ruptured pseudocysts.

[One-lobe Caroli's disease (report of a clinical case]. / Malattia di Caroli unilobare (presentazione di 1 caso clinico).

A patient affected by Caroli's disease without congenital fibrosis, 80 y. old is reported. The Caroli's disease was asymptomatic all life long; this was a intraoperative finding and only in the last year the patient presented recurrent cholangitis. The "simple" Caroli's disease is less common than other forms. We analyze the literature and the ethiopathogenetic mechanisms hypotisized.

[Gastric polyps: possible causes of pyloro-duodenal obstruction]. / I polipi gastrici: possibile causa di ostruzione piloro duodenale.

We reported three cases of transpyloric prolapsed polipoid lesions. Abdominal pain, early satiety are the most common presenting features. Endoscopies and polipectomy are important for a correct diagnostic evaluation. Large polyps (> 2 cm), if prolapsed, can require a surgical excision.

[Clinical features of 27 cases of ischemic colitis (author's transl)]. / "Considerazioni su 27 osservazioni di differenti quadri clinici di colite ischemica".

The Authors report own experience of ischemic colitis, related to 27 cases, that includes either primitive forms (transient ischemic colitis, ischemic stricture and necrotic-gangrenous ischemic colitis) or secondary (occlusive ischemic colitis, ischemic colitis following abdominoperineal excision of the rectum). Pathogenetic findings, now not completely defined, are discussed with reference to the literature on this subject. The important diagnostic problems are also evaluated, particularly in the evaluation of radiologic and endoscopic findings of spontaneous ischemic colitis; these, altogether, represent an almost specific clinical picture of ischemic colitis. At last are considered the problems related to surgical treatment, overall in the forms in which the irreversibility of the ischemic lesions has been ascertained.

Hormonal studies in a patient with PP-producing tumors.

Five years after the removal of pure pancreatic polypeptide (PP) producing tumors, concentrations of circulating levels of PP, insulin, glucagon, and growth hormone in the basal state, after insulin-induced hypoglycemia, and after a protein-rich meal were determined in a patient with previous truncal vagotomy and Billroth II gastrectomy. Basal plasma levels of PP ranged between 2180 and 2660 pg/ml suggesting persistence or recurrence of PP producing tumors. Concentrations of the other hormones were within normal values. After insulin injection (0.1 U/Kg) levels of PP and glucagon were not modified while those of GH rose from 3.2 to 22.6 ng/ml. After a protein meal (450 gms. of cooked ground beef meat) a sharp rise of plasma PP was observed to a peak of 11310 pg/ml at 10 min. Moreover, plasma levels of immunoreactive insulin also showed an equally prompt rise to a peak of 532 microU/ml while plasma glucagon rose simultaneously to 448 pg/ml. The cause of the abnormal PP, insulin and glucagon responses could not be ascertained but we postulate that they are derived from pancreatic tumors of mixed cell type.

Pharmacokinetics of omeprazole in cirrhotic patients.

Omeprazole (CAS 73590-58-6), an H+, K+ ATPase inhibitor, is a potent suppressor of gastric acid secretion and a very active substance in the treatment of duodenal and gastric ulcers. The kinetic profile of omeprazole is well defined for healthy volunteers and for some high-risk population, but not so far for patients with liver disease. As the substance is mainly metabolized in the liver, changes in liver circulation and/or function might lead to changes in the pharmacokinetics of omeprazole. Aim of the study was to evaluate the kinetic profile in patients with liver disease and compare the results obtained in healthy volunteers, 16 subjects were included in the study: 8 patients with liver cirrhosis and 8 healthy volunteers. A single oral dose of omeprazole 20 mg was administered: plasma samples were collected for 24 h since omeprazole administration. The principal pharmacokinetic parameters were estimated for the two studied populations.