Monoconjugated bilirubin as a possible factor in cholesterol gallstone pathogenesis.

HPLC determination of bilirubin conjugates in bile demonstrated a subgroup of patients with cholesterol gallstones who have more monoconjugated than diconjugated bilirubin in their gallbladder bile. None of the patients had abnormal liver function tests nor hemolysis. It was shown that this is not due to differences in liver secretion of the conjugates. In these patients, the more insoluble monoconjugated bilirubin might have provided the nucleus for the subsequent crystallization of cholesterol leading to the formation of cholesterol gallstones.

[Total gastrectomy for gastric neoplasms]. / Riflessioni sulla nostra esperienza nella gastrectomia totale per neoplasia.

In spite of the decreasing incidence of gastric carcinoma, as it is reported in recent reports from the U.S.A., total gastrectomy and its surgical indications results and complications, focus the interest of surgeons. We analize 61 cases of total gastrectomy for carcinoma, treated in the years 1982-1992. Perioperative mortality and long term survival appear highly satisfactory, mainly if one considers that the site and extension of the neoplasms treated would have severely impaired the possibilities of cure or long term survival with surgery of lesser momentum. We believe that nowaday indications for total gastrectomy can be widened in the hope of improving results of gastric cancer surgery with no or little additional risk.

Effects of ischaemia and reperfusion on liver regeneration in rats.

OBJECTIVE: To assess the effects of oxygen free radicals on liver regeneration in rats after 80% hepatectomy. DESIGN: Open laboratory study. SETTING: Institute of Biomedical Sciences, University of Milan, Italy. MATERIAL: Female Sprague-Dawley rats. INTERVENTIONS: After laparotomy 122 rats had ischaemia induced by clamping of the portal vein and hepatic artery, and 93 rats had manipulation of the vessels only. They were then allowed to recover before 80% hepatectomy was done. Absolute controls (n = 16) did not have a laparotomy. Mortality was recorded, and surviving rats were killed one, three, five, and seven days after operation. A further 10 rats had 80% hepatectomies and then underwent a 10 minute period of ischaemia 24 hours later. These animals were killed after three days. In yet more experiments 38 rats underwent 80% hepatectomies and were then divided into four groups: 8 were given allopurinol 50 mg/kg/day starting three days before operation; 8 were given superoxide dismutase 4.16 mg/kg intraperitoneally 30 minutes before induction of ischaemia; 12 were given verapamil 0.1 mg/kg 30 minutes before induction of ischaemia; and 10 were given saline (controls). MAIN OUTCOME MEASURES: Incorporation of tritiated thymidine into DNA, differences in liver weights, and lipid peroxide concentrations. RESULTS: 43 rats died after ischaemia/reperfusion and 19 after hepatectomy alone. Ischaemia/reperfusion caused a significant reduction in the incorporation of tritiated thymidine into DNA 24 hours after hepatectomy (p < 0.01), and significant inhibition of recovery of liver weight three (p < 0.01) and five (p < 0.05) days after hepatectomy. These effects were associated with high lipid peroxide concentrations at three days. Allopurinol (p < 0.01, p < 0.05), superoxide dismutase (p < 0.01, p < 0.01) and verapamil (p < 0.01, N.S.) reduced the effects of ischaemia/reperfusion on liver weights or lipid peroxide concentrations three days after hepatectomy. CONCLUSION: A 10 minute period of ischaemia followed by reperfusion temporarily reduces liver regeneration after 80% hepatectomy in rats.

Laparoscopic cholecystectomy using methyl tert-butyl ether: preliminary results.

We evaluated the usefulness of methyl tert-butyl ether in gallbladder extraction during laparoscopic cholecystectomy when large stones are present. Five patients with symptomatic gallbladder stones larger than 30 mm underwent laparoscopic cholecystectomy according to the standard procedure. Extraction of the gallbladder without enlarging the 10-mm orifice was not possible because of the large stones. We infused MTBE in the gallbladder through a 9-French polyethylene catheter passed into its neck already pulled out of the umbilical port. The solvent was injected, aspirated after 10 to 15 s, and then immediately reinjected. This procedure continued until the stones softened and it became possible to crush and to remove them easily with a forceps or aspirator. The mean duration of the entire procedure was 7.7 +/- 1.57 min. Methyl tert-butyl ether infusion should be considered during laparoscopic cholecystectomy because it is a cheap and fast method to allow gallbladder extraction when large stones are present.

Lymphocytic subpopulation changes after open and laparoscopic cholecystectomy: a prospective and comparative study on 38 patients.

Up to now it has been unclear whether laparoscopic surgery has fewer immunosuppressive effects than traditional laparotomic procedures. In a series of 38 patients affected by symptomatic gallstone disease and operated on either by laparoscopy (group 1) or by traditional open surgery (group 2), we determined the postoperative changes in lymphocyte subpopulations up to postoperative day (POD) 30. We collected 15 ml of venous blood from all patients in both groups on the day before surgery and on POD 1, 7, 15, and 30. A control group (group 3) comprised 56 healthy volunteers; the control group was used only to ensure that baseline values were totally comparable with a normal population; only one blood sample was obtained from the subjects in group 3. Patients undergoing open cholecystectomy had a significant decrease in total lymphocyte count on POD 1. Basal levels of lymphocyte subpopulations did not differ significantly in the study and control groups. No differences were found in the preoperative lymphocyte cell counts in the two groups who underwent cholecystectomy. Pan-T cells (CD3) showed a statistically significant marked reduction throughout the observation period. The counts of helper (CD4), suppressor (CD8), and natural killer NK (CD16) T cells were reduced on POD 1; the NK cell (CD16) count remained low until POD 30, B lymphocytes showed no postoperative reduction. In patients who underwent laparoscopic cholecystectomy, a significant postoperative decrease in total lymphocyte count, and in CD3, CD4, and CD8 subpopulations was observed on day 1 only. There was no reduction in CD16 and CD19 subpopulations. A comparative statistical analysis of lymphocyte subpopulations in the two groups was carried out: In the open cholecystectomy group, compared with the laparoscopy group, CD3, CD4, CD8, and CD16 lymphocyte subpopulations showed marked reductions at different time points. In particular, statistically significant differences were found in CD3 levels from POD 1 through POD 30, in CD4 from day 1 through day 7, and in CD8 and CD16 only on day 1.

Primary liver adenomatosis. Report of two cases and literature review.

BACKGROUND/AIMS: Liver adenomatosis is an uncommon condition and so far only 13 cases fulfilling the requirements for its diagnosis have been reported in the literature. Optimal treatment of the disease and follow-up criteria are still the subject of debate. METHODS: We report on 2 cases of liver adenomatosis. In both cases definite diagnosis was obtained only intraoperatively on biopsy. RESULTS: In neither case was liver transplantation done, due either to patient refusal or foreseeable poor compliance. Prolonged strict follow-up failed to demonstrate malignant changes. CONCLUSIONS: Removal of the huge masses often responsible for abdominal pain is the only real indication for resective surgery. Orthotopic liver transplantation should be reserved for those cases in which malignant changes are suspected due to elevation of the alpha-fetoprotein concentration or gross modifications in the shape of the hepatic lesions.