Endoscopic treatment of gastrointestinal fistulas using an over-the-scope clip (OTSC) device: case series from a tertiary referral center.

Gastrointestinal perforations and post-surgical fistulas are dreaded complications that dramatically increase morbidity and mortality. A new endoscopic over-the-scope clip (OTSC) system may be potentially useful for sealing visceral perforations in several clinical settings. We evaluated the advantages and clinical impact of the placement of OTSCs on the management of non-malignant gut leaks in 12 consecutive patients. OTSCs of 9.5 or 10.5 mm were used, according to the diameter of the defect within the wall. The indications for treatment were mainly related to post-surgical fistulas. Healing of the fistula was assessed by endoscopic or radiological means, and failed only once. No OTSC-related complications occurred. Endoscopic closure of perforations and post-surgical fistulas with the OTSC system is a simple and minimally invasive technique. This approach, when feasible, may be less expensive and more advantageous than a surgical approach.

Laparoscopic cholecystectomy and endoscopic sphincterotomy under a single anesthetic: a case report.

Several options have been described for the management of unsuspected common bile duct stones diagnosed for the first time by transcystic cholangiography during laparoscopic surgery. These include immediate conversion to open laparotomy and formal common bile duct exploration, laparoscopic bile duct exploration, or postoperative biliary endoscopy (i.e., ERCP with sphincterotomy and stone extraction). Herein we describe a fourth option which allows the surgeon to manage both cholelithiasis and choledocholithiasis at the time of laparoscopic intervention: endoscopic sphincterotomy performed immediately after laparoscopic cholecystectomy under one anesthetic. This option seems the most logical when the surgeon wishes to preserve the minimally invasive approach.

[A critical review of the history of the systems for staging colorectal cancer]. / Rivisitazione critica della storia dei sistemi di stadiazione del cancro colo-rettale.

A great debate is still open in literature about the available staging systems of colorectal cancer. Therefore, an historical analysis of the several systems suggested in the last decades was performed; pathological, clinicopathological and more recent score clinicopathological staging systems were evaluated. From this historical review it appears that subsequent modifications of various classifications allowed only for a poor improvement in predictivity. A more careful histopathological examination of surgical specimen and more exact information about involvement of other organs and tissues allow a correct classification of patients affected by colorectal cancer independently of the staging system used.

Today's treatment of cholelithiasis: laparoscopic surgery.

The speed at which laparoscopic biliary tract surgery has been introduced to such a large number of surgeons is without precedent in modern surgical history. At least 4 factors work together to explain such a rapid success: 1) Laparoscopic cholecystectomy removes the diseased gallbladder and ensures permanent cure; 2) Laparoscopic approach allows a telescopic vision and dissections are very precise; 3) Laparoscopic cholecystectomy allows minimal wound pain with complete resolution within a few days, a short hospital stay and the ability of many patients to return to work within a week of operation; 4) There are economic advantages to the patient, his community and the healthcare provider. The procedure proved to be as safe and feasible to use as conventional surgery. Obviously adequate training and credentialing are important processes to faster good patient outcomes. There are some contraindications to laparoscopic surgery, the most part of them are depending upon the experience of the surgeon. The successful application of therapeutic laparoscopy changed the diagnostic approach to lithiasic biliary disease. Whereas the most popular method of documenting gallbladder abnormalities before performing conventional surgery is ultrasonography, most surgeons who have embraced laparoscopic surgery argue for routine cholangiography because of the necessity to document duct anatomy besides minimizing the incidence of retained GBDS.

[Laparoscopic surgery: planning program]. / Chirurgia videolaparoscopica: aspetti organizzativi.

Performing laparoscopic surgery requires an initial training program. A well-planned organization is essential and the surgeon has to become first familiar with the new procedures; the choice of the necessary equipment is the second step. Upkeep of surgical instruments and a careful consideration of legal aspects are the next important steps. Several areas of a planning program are evaluated on the basis of the authors' experience.

[Reflection on 19 months of laparoscopic cholecystectomy]. / La colecistectomia videolaparoscopica: considerazioni su 19 mesi di attività.

The introduction of laparoscopic cholecystectomy (LC) has aroused enthusiasm on the part of the mass media and perplexity on the part of many medical workers. In an attempt to reconcile the two points of view, the video-laparoscopic activity in a surgical ambient was audited over 19 months. 450 LC were carried out during this period. The number of cholecystectomies performed by this method has risen significantly in the recent past thanks to the high esteem in which it is held by the public in general and by gastroenterologists in particular. The average age of patients is lower since young people accept more readily a type of surgery involving a lesser degree of traumatism, a relatively short convalescence and less aesthetic damage. After a brief initial period of scepticism, the method has also been received favourably by anaesthetist, and by operating theatre and ward nursing staff. Morbidity and mortality rates are not different from those noted after traditional cholecystectomy, which confirms the method as being safe and thus meriting the success it has widely achieved.

[The importance of preoperative study of cholelithiasis during the laparoscopic era]. / Importanza dello studio preoperatorio della via biliare in era videolaparoscopica.

Preoperative x-ray examination of the biliary tree has in the last decade been entrusted to ultrasonography. The diagnostic procedure was completed with an accurate evaluation of the main biliary tract by means of intra-operative cholangiography. However, recently-developed methods such as operative endoscopy and laparoscopic surgery require essential pre-operative information about the state of the biliary tract which ultrasonography is not able to provide. In our view, the most useful examination for this purpose is i.v. cholangiography; the results of this study, relating to 303 patients undergoing laparoscopic cholecystectomy, of whom 39 affected by cholecysto-choledochal lithiasis, would seem to confirm these view.

[Tension-free laparoscopic hernioplasty]. / Ernioplastica "tension free" per via laparoscopica.

Hernia recurrence after traditional "open" hernioplasty is an observed event. The tension undergone by anatomical structures of the area is believed to be responsible in large part for these failures. Thus, techniques involving "tension free" hernioplasty have been developed, some of which involve laparoscopic access. Here an experience is reported regarding laparoscopic hernioplasty carried out to repair groin hernias, first of all on an animal model (pigs: 7 cases) then in the clinical field. The technique chosen was the endo-peritoneal positioning of a PTFE prosthesis. The results revealed several advantages over the traditional methods, basically the possibility of reinforcing the entire inguinal floor at the same time as repairing the hernia, and the decrease in groin area discomfort and less time off from work for the patient.

[Elective and emergency diagnostic laparoscopy]. / La laparoscopia diagnostica in elezione ed in urgenza.

A report is presented concerning 31 patients treated by laparoscopic approach under both elective and emergency conditions. The mini-invasive approach to an abdominal disease allows both the making of a direct visual diagnosis and the carrying out of biopsy or actual therapy without the need for laparotomy. Elective diagnostic laparoscopy has proved efficacious in the screening of patients affected by abdomino-pelvic neoplasms, determining the extension of the latter, staging them and judging their operability. Under emergency condition this method lends itself in particular to the study and the treatment of some cases of traumatic haemoperitoneum, intestinal obstructions resulting from adhesions and peritonitis of dubious aetiology. Explorative laparoscopy thus constitutes a valuable diagnostic and therapeutic aid, its possibilities being destined to increase with the improvement of laparoscopic techniques.

[Videolaparoscopy and conservative treatment of splenic injuries]. / Videolaparoscopia e trattamento conservativo dei traumi della milza.

The treatment of lesions due to blunt abdominal trauma has changed considerably in the last decade. With a view to the prevention of immediate and later complications of splenectomy, conservative surgical technique have been put forward, or else, when the haemodynamic conditions of the patient permit, techniques of non-operative monitoring of splenic lesions. Laparoscopy today constitutes an approach to the diagnosis and treatment of blunt abdominal trauma which decisively favours conservative treatment. The experience presented bears witness to the potential usefulness of laparoscopy in these cases. Technological progress will widen the possibilities of this method and more detailed studies will define its exact indications.

[Experimental intestinal laparoscopic resection]. / Resezione intestinale laparoscopica sperimentale: note di tecnica.

At present, there is a debate in the literature regarding the possibility of extending the laparoscopic approach to intestinal resection. Some techniques have been developed, but certain imperfections and problems remain. This experimental contribution suggests answers to some technical problems arising in the course of a small-bowel laparoscopic resection on a pig.

[Occult hepatic metastases from colorectal carcinoma: diagnostic and prognostic considerations]. / Metastasi epatiche occulte da carcinoma colo-rettale: considerazioni diagnostiche e prognostiche.

Occult hepatic metastases (OHM) from colorectal cancer are those not evident to the surgeon at laparotomy. In this retrospective and "deductive" study the Authors evaluated the accuracy of hepatic CT scan and ultrasonography (US) to detect hepatic metastases. The CT and US accuracy rate was 78.4% and 79.8% respectively, and proved to be correlated to the intraoperative dimensions of the lesions. Sensitivity of these examinations, in the light of OHM identification, decreased to 69% and 69.2% respectively. This study shows that hepatic US and CT scan are not sufficient to identify OHM; the attempt to reduce the frequency of OHM by means of intraoperative ultrasonography could allow to obtain a more careful stadiation and prognosis of these neoplasms with possible therapeutic advantages.

[Pelvic recurrences after curative surgery for rectal cancer]. / Recidive pelviche dopo chirurgia curativa per cancro del retto.

This report updates an experience with local recurrences of rectal cancer after curative surgery. Overall 13 year period (1976-1988) 254 patients were operated on in the II Surgical Clinic of Parma University for rectal cancer. Only 122 patients who underwent potentially curative resection were examined. Approximate recurrence rates according to patients age, site, type and stage of primitive tumour, tumour complications and surgical procedures were evaluated. The overall local failure rate was 17.2% with 12 patients having local failure alone and 9 patients having concurrent local failure and distant metastasis. Local failure occurred predominantly in tumour bed, involving the anastomosis in 2 cases. Relapse developed primarily at colo-rectal anastomosis in only 1 patients, 20% of recurrences were diagnosed within the first postoperative year; 65% within the second and 90% within the third. Stage of primary tumour was the most predictive factor for eventual relapse. Minute foci of tumour not encompassed by the first operation led to local recurrences in most of the cases, but relapses were independent of operative procedures adopted. The authors conclude that surgery, even if correctly performed, is not sufficient to prevent the risk of local recurrence of rectal cancer. They believe that routine adjuvant radiation therapy after surgical treatment of rectal cancer should improve survival rate.

[Locoregional recurrences following curative surgery for colon cancer]. / Recidive loco-regionali dopo chirurgia curativa per cancro del colon.

This study explores the patterns of local recurrence after curative operations for colonic cancer. Over a 13 year period (1976-1988) 486 patients were operated on in the Surgical Clinic of Parma University for colonic cancer, but only 296 patients who underwent potentially curative resection were examined. The influence of patients' age, disease stage, site and grade, presence of obstruction or perforation and type of surgical procedures were examined as prognostic factors for local cancer recurrence. A total of 28 patients (14%) relapsed after surgery and 19 were found to have simultaneous distant metastasis. 86% of recurrences were evident within the first 2 years. Local recurrence rate increased with more advanced Duke's stage and stage of the primary tumour was most predictive for eventual relapse. The recurrences occurred within the operative resection site involving the anastomosis by inward growth at the suture line. Minute foci of adenocarcinoma not encompassed by the first operation might lead to local recurrences; the authors do not rule out, however, the rare possibility of the implantation of exfoliated malignant cells. Despite the attempt to carry out an intensive followup in terms of early diagnosis of recurrence in colonic surgery, the presence of local recurrences is associated with extremely poor prognosis independent of operative procedure performed. The authors believe that routine adjuvant radiation therapy after surgical treatment of locally advanced colonic cancer could improve survival rate.

[Laparoscopic cholecystectomy as evolution of traditional cholecystec- tomy. Comparative evaluation]. / La videolaparocolecistectomia come evoluzione della colecistectomia tradizionale. Valutazioni comparative.

Laparoscopic cholecystectomy (LC) is a minimally invasive method of removing the gallbladder that has become an accepted procedure all over the world. Authors performed 200 LC and compare the results of first 70 procedures with a matched group of patients who have undergone traditional cholecystectomy (TC) to evaluate its safety and efficacy. The average length of operation in the LC group was 64.5 +/- 26.3 min as compared to 68.5 +/- 22.5 min in the TC group. The difference between the incidence of postoperative complications in the 2 group was not statistically significant. The average length of stay in the LC group was 2.3 +/- 1.9 days versus 5.2 +/- 1.4 in the TC group. The difference is statistically significant. The comparison between the 2 methods shows less discomfort for LC patients during postoperative course. Pain was minimal, bowel evacuation was early and spontaneous, urinary retention only occurred in 2 patients versus 21 in TC group. The difference is statistically significant. Our results confirm laparoscopic cholecystectomy is a safe, effective and cost-efficient alternative to open cholecystectomy.

[Iatrogenic biliary lithogenesis in surgery]. / Litogenesi biliare iatrogena in chirurgia.

Iatrogenic biliary lithogenesis has been often observed in surgery. The authors, on the basis of the personal experience and literature, have tried to point out its etiologic factors and give a common interpretation to its different clinical manifestations observed in surgery. This study reports 19 patients who underwent total gastrectomy with truncal vagotomy and postoperative TPN and subsequently serial ultrasonographic scans to determine content and volume of the gallbladder. In 5 patients it was possible to take out a bile sample daily, using a naso-duodenal tube, for chemical analysis. In 10 out of 19 patients postoperative ultrasonography revealed the fast appearance of biliary sludge; 6 of the latter 10 developed microlithiasis. In all cases examined ultrasounds revealed a defect of the contractility of the gallbladder and the microscopic analysis of bile content showed pigment granules. The authors underline how different etiologic factors are involved in different clinical models. They conclude that gallstones observed in their experience are mostly pigmentary and are quickly formed owing to the interaction of many etiological factors. Finally prophylactic measures are discussed.

Cholesterol microlithiasis: bacteriology, gallbladder bile and stone composition.

It is not known whether microcalculi possess structural differences compared with larger stones or whether they represent simply an earlier stage in stone disease. We carried out a controlled study on 10 patients affected by gallbladder cholesterol microlithiasis (CM). In all patients, samples from all parts of the stones were studied by X-ray diffraction and by infrared spectrophotometry. Bile analysis was carried out to determine cholesterol, phospholipid and total bile acid content. The cholesterol saturation indices (C.S.I.) were calculated. In all samples, bacterial bile culture was carried out. The results were compared with those of 10 patients who had undergone cholecystectomy for large cholesterol stones, and for 10 patients who had undergone abdominal surgery but without biliary pathology. Patients in these latter groups were matched with the first according to sex and age. Microcalculi proved to be layered (nucleus and external layer) in only 2 cases and larger stones in 9; cholesterol was seen to be the principal crystalline component in all cases. Traces of bilirubin were found in 7 CM and in the nuclei of 5 larger stones. These results show that the structural composition of microcalculi is similar to that of the nucleus of larger stones. No substantial differences exist, however, between the two groups of patients regarding the other parameters taken into consideration.

Pigment vs. cholesterol microlithiasis: comparison of clinical features, bacteriology, stone and gallbladder composition.

We compared 16 cases of pigment microlithiasis with 12 cases of cholesterol microlithiasis. In each case we made a spectrophotometric and diffractometric analysis of the composition of the stones, also analysing bile bacteriology, bile lipid composition and cholesterol saturation indices. The two groups were comparable as regards sex, age, symptoms and clinical features. Pigment microcalculi were often asymptomatic (41.7%), but more often associated with bile bacteria (43.7%) or acute pancreatitis (25%). The results were such as to permit us to view cholesterol microlithiasis and pigment microlithiasis as having different pathogenetic and clinical aspects, and thus as being different diseases.

Cholesterol crystals in biliary microlithiasis.

A recent study put forward the hypothesis that microlithiasis may represent an early stage in the development of biliary calculi. It is an established fact that cholesterol crystals are the product of an inevitable stage in the sequence leading to gallstone formation. To test the hypothesis stated above ten patients affected by gallbladder cholesterol microlithiasis (CM) were examined in the lipid composition of the bile, the cholesterol saturation index and the presence of cholesterol crystals being calculated. The results were compared with those of 14 patients affected by pigment microliths, 24 with larger stones (LS) and ten control patients. The cholesterol saturation index was above one in all CM patients, whereas in some LS patients the gall-bladder bile was not supersaturated. Cholesterol crystals were observed in the gallbladders of all CM patients and seven LS patients. These results would seem to provide support for the hypothesis of microcalculi as being "young stones", with the bile of CM patients maintaining the conditions leading to gallstone formation.

Composition of biliary microcalculi studied with infrared spectrophotometry.

The chemical composition of biliary microcalculi obtained at 20 consecutive cholecystectomies was investigated with infrared spectroscopy. This method permits qualitative and quantitative analysis also of substances such as bilirubin which often remain in amorphous states. A PYE UNICAM spectrophotometer was used, with KBr pellet technique. A bile sample from each patient was taken for bacteriologic examination. The study confirmed previously observed high incidence of pigment microcalculi (60%). Calcium palmitate was more common (in 15% of all the studied microliths and 25% of the pigment type) than in reports in the literature concerning larger gallstones. Calcium carbonate was present in only 10%. These findings suggested pathogenetic peculiarities of microlithiasis, as did the high incidence of positive bacteriologic tests.