Gastric polypoid lesions. Our experience.

BACKGROUND AND AIM: The Authors report the results of their experience on polypoids lesions of the stomach and on endoscopic polypectomies. PATIENTS AND METHODS: A study on 2000 OGD (oesophagogastroduodenoscopy) has been carried out on 95 patients with polypoid lesions. The authors have analysed the associations existing between histological type and symptomatology and localisation of the lesion and the status of the Helicobacter pylori and the risk of cancerization. The data were confronted with the ones already available. RESULTS: In the majority of the cases, the polypoid lesions were asymptomatic, the localization changed according to the histological type, with the antrum as the most affected area. The presence of Helicobacter pylori does not seem to be correlated to the lesion, except in the case of hyperplastic polyps. The percentage of risks of cancerization increased in case of adenomatous polyps. In one patient signet ring cell carcinoma within a gastric polyp was found. Gastric signet ring cell carcinomas are peculiar for their rarity as well as for the growth in polypoid lesions. CONCLUSION: We confirm the higher frequency of hyperplastic polyps and the correlation between histological type and localization. Endoscopic polipectomy is the first approach in gastric polyps, with lower risk of developing cancer. Only in selected cases, as in one in ours, it is advisable the surgery.

[Adrenal incidentaloma: case report and synthesis of indication and thresholds of surgery therapy]. / Un caso di incidentaloma surrenalico: sintesi delle indicazioni e limiti della terapia chirurgica.

With the term of incidental mass, any mass is identified, occasionally discovered with imaging techniques, in the absence of specific symptoms. In 1982, the term "incidentaloma" was introduced to indicate lesions detected on adrenal regions, found unexpectedly. The incidence percentages vary from 0.6%-3% in CT followed by other indications , to 10% and 25% in all patients who underwent an ultrasound, CT or MRI. An appropriate diagnostic protocol is mandatory to identify and to choose the proper treatment for the functioning lesions, as well as the malignant or potentially malignant lesions (1, 2). Incidentalomas with diameters under 1 cm seem to not have a pathologic significance, and are considered like manifestation of the gland involution in advanced-age subjects, and can remain unseen for a long time. The use of diagnostic imaging techniques has made it possible to identify these masses, even those of small size, in the course of diagnostic surveys done under various guidelines. The mass dimensions are a fundamental parameter used to distinguish benign lesions from malign ones (2, 3). Most Authors suspect malignity in masses above 5-6 cm, while considering those with a diameter under 3 cm to be benign. Whereas the rest remain undefined, thereby valued and treated according to criteria not perfectly established.

[The role of the intraoperative manometry in the esophageal achalasia surgical treatment]. / Il ruolo della manometria intraoperatoria nel trattamento chirurgico dell'acalasia esofagea.

INTRODUCTION: The authors report their experience about the intraoperative manometry in the achalasia surgical treatment. PATIENTS AND METHODS: We have considered 239 patients with achalasia observed from 1994 to 2006; only 79 continued the path diagnostic therapeutic and 31 underwent Heller longitudinal miotomy, with Dor anti-reflux plastic in 25 patients and in 6 Nissen anti-reflux plastic. In 24 we performed the intraoperative manometry (MI) recording the high pressure areas. RESULTS: The patients underwent Heller's procedure with manometric check of the gastric muscular fibre sectioned areas reported the disappearance of the dysphagia. Three of the operated ones without using the MI complained about the persistence of mild dysphagia and it did not depend from the antireflux surgical procedure used. CONCLUSIONS: Our findings confirm that the extramucosal miotomy is the treatment of choice for the achalasia and suggest that by MI a complete miotomy is allowed mostly on the gastric side where the muscular fibres get an important role in the maintenance of the high pressure areas.

[Infected pancreatic pseudocysts: technical notes]. / Pseudocisti pancreatiche infette: note di tecnica.

INTRODUCTION: Starting from the observation of 9 cases of giant infected pancreatic cysts, which occurred from 1994 to 2004 at the Department of Oncological and Surgical Studies, the Authors' aim has been to evaluate whether a more thorough necrosectomy, carried-out under video-endoscopic control, associated with a nose-gastro-cavity tube, which ensures a continuous cleansing of the newly-formed cavity, and an appropriate positioning of the drainages, could reduce the morbidity and allow a shorter recovery of the infected pseudocysts. PATIENTS AND METHODS: Of 73 cases of acute pancreatitis, observed from 1994 to 2004, 9 showed severe and acute pancreatitis, which included giant pseudocysts, as revealed by the abdomen angio-TC. Our nine septic patients underwent cysto-gastro-anastomosis, necrosectomy, intraoperative cleansing of the cavity with an antibiotic solution and positioning of multiple drainages. Three of these patients also underwent a thorough and targeted necrosectomy, assisted by a trans-anastomotic video-endoscopy. A nose-gastro-cavity tube has been placed in all the patients. RESULTS: The disappearance of the septic state in our three patients who underwent a targeted video-assisted necrosectomy occurred after three days of treatment; moreover, the abdomen angio-TC on the 5th postoperative day showed the disappearance of the necrotic areas. The recovery of these three patients was significantly shorter, compared to those undergoing traditional treatment (cysto-gastro-anastomosis, standard necrosectomy and positioning of abdominal drainages). CONCLUSIONS: Our surgical video-assisted technique demonstrated that, with a slight increase in the operative time, a better control over sepsis may be accomplished, as well as a reduction of the post-operative morbidity, which leads to shorter hospitalisation of patients with infected pancreatic pseudocysts.

[Gallstone ileus: diagnosis and treatment. Case report]. / Ileo biliare: diagnosi e trattamento. Case report.

The authors present a case of gallstone intermittent ileus caused by the passage of a big gallstone (about 4 cm in diameter) in the intestinal lumen, through a cholecystoduodenal fistula. They emphasize the peculiarity of the case for the characteristics of symptoms and for casual diagnostic check-up with a ultrasonography. The disease is not frequently diagnosed; today it has a safe recognition by modern imaging. The symptoms can be intermittent and, even when there are the classic signs of intestinal occlusion, the site of the occlusion is various. With a timely endoscopical or surgical approach (open or laparoscopic) it is possible to reduce mortality of patients treated in emergency.

[A gastric polypoid signet ring cell carcinoma]. / Carcinoma con cellule ad anello con castone insorto in polipo gastrico.

AIM: The authors signal a case of gastric polypoid signet ring cell carcinoma, of particular interest for its rarity like show from the review of the literature, which is the first to have been described after Tabaru's citation. METHODS: The study has been carried out at the Department of Surgical and Oncological Sciences of the University of Palermo. It has been based on 2000 cases analysed from June 2001 to December 2003. RESULTS: The authors advance some and emphasizes the diagnostic flow chart and therapeutic choices adopted. CONCLUSIONS: We agree that the endoscopic polypectomy is surgical procedure of first approach, but modifying the therapeutic guideline in relation to histologic examination, like happened in the case in issue.

[Blood filterability at various filtration pressures: a study conducted on normal and diabetic subjects]. / Filtrabilità ematica a diverse pressioni di filtrazione: studio condotto su soggetti normali e diabetici.

Using the Reid et al. technique we have evaluated the blood cellular volume (VBC: ml/min) obtained by changing the negative filtration pressure. From the obtained data it is evident that at the three different filtration pressure values (-20, -15 and -10 cm of H2O) the VBC does not distinguish normal from diabetic subjects. Only at the negative pressure of 20 cm of water did the VBC distinguish diabetics, who were subdivided by type and vascular complications. We have also evaluated the relationship between the values of VBC calculated at the pressures of -20 and -10 cm of water. From this study it emerged that the relationship between the two values present in normals is not different from that present in diabetics and in diabetics subdivided by type and vascular complications.

Essential hypertension. The behaviour of the haemorheological determinants and their trends during beta-blocker treatment.

We examined the haemorheological determinants in a group of 52 hypertensives (diastolic basal pressure greater than 100 mmHg) subdivided in relation to the clinical stage (I and II or III according to the WHO classification) and in a group of 50 normal controls, matched for age and sex. From this study, it is evident that only plasma viscosity, fibrinogen and the fibrinogen/albumin ratio are able to distinguish normals from hypertensives. It is also clear that the clinical stage does not influence the haemorheological findings. These haemorheological factors were also measured in 3 groups of hypertensives treated with either timolol (20 mg/day), metoprolol (200 mg/day) or oxprenolol (160 mg/day). After a basal evaluation, measurements were performed, at regular intervals of 10 days, for a period of 30 days. The only significant changes were obtained using timolol; metoprolol and oxprenolol, did not affect these haemorheological parameters.

[Hemorrheological survey in a group with arteriosclerotic vascular disease treated with suloctidil]. / Rilievi emoreologici in un gruppo di vasculopatici aterosclerotici trattati con suloctidil.

In 17 patients affected by atherosclerotic vascular disease and showing in basal conditions a hyperviscosity state, we have monitored the main hemorheological determinants during treatment with Suloctidil. At the end of treatment carried out for 5 months the results showed that erythrocyte filterability was the only hemorheological determinant influenced. The possible causes of this action are therefore considered.

[Hemorrheological survey in dystrophia myotonica and other muscular dystrophies]. / Rilievi emoreologici nella distrofia miotonica ed in altre distrofie muscolari.

We have determined the main hemorheological parameters in a group of patients suffering from myotonic dystrophy and in another group with oculopharyngeal or limb-girdle myopathy. From the results we have obtained it is evident that of all the rheological parameters considered only hematocrit, fibrinogen and fibrinogen/albumin ratio are different in patients with myotonic dystrophy when compared to that of normal controls. There were no variations in blood, plasma and serum viscosities and in erythrocyte filterability. In addition, hemorheological alterations were not present in patients with oculopharyngeal or limb-girdle myopathy.

[Erythrocyte filterability in diabetes mellitus (a survey carried out by two methods)]. / Filtrabilità eritrocitaria nel diabete mellito (rilievi effettuati con due metodiche).

In 45 diabetic patients (22 men and 23 women) subdivided in relation to type and vascular complications we have evaluated the erythrocyte filterability either by filtering whole blood (VRBC) or red blood cells suspended (5%) in autologous prefiltered plasma (deformability index). From the obtained results it is evident that VRBC is able to distinguish diabetic patients from normal subjects, whereas this does not happen with the deformability index. The explanation of these data is that the whole blood filterability, especially in diabetic patients, depends on the behavior of both cellular and plasmatic extraerythrocyte parameters.

[Blood viscosity in diabetes mellitus (evaluation on the basis of high shear rates)]. / Viscosità ematica nel diabete mellito (valutazione a bassi ed alti shear rates).

In 45 diabetic patients (22 men and 23 women) subdivided in relation to type and vascular complications we have evaluated the blood viscosity at high and low shear rates. From the obtained results it is evident that only at low shear rates this hemorheological parameter distinguishes diabetic patients from normal subjects and diabetic patients without vascular complications from those with these complications. This result is present only because these shear rates are dependent on the influence of the erythrocyte aggregation which is altered in the diabetic disease.

[Hemorheological factors and metabolic parameters in a group of diabetic subjects]. / Fattori emoreologici e parametri metabolici in un gruppo di soggetti diabetici.

Blood viscosity factors and some metabolic parameters were estimated in thirty-eight insulin-treated diabetics. The evaluation was carried out on admission and after eight weeks of controlled therapy. From this study it follows that blood viscosity factors do not permit us to distinguish, at these two stages, diabetics with complications from diabetics without while there is this possibility at the initial observation in diabetics subdivided for sex. Furthermore there are no significant variations, except for the haematocrit, of the average of blood viscosity factors and metabolic parameters at the initial and final observation. Very interesting is the negative relation between the Vrbc, parameter which studies the erythrocyte deformability, and the red cell 2,3-diphosphoglycerate (2,3-DPG) that seems more evident in diabetics with complications. Contrary to what has been reported in literature no relation between Vrbc and glycosylated haemoglobin (GHb) is present.