Morphine plus bupivacaine vs. morphine peridural analgesia in abdominal surgery: the effects on postoperative course in major hepatobiliary surgery.

Anaesthesia and surgical procedures lead to a reduction of intestinal motility, and opioids may produce a postoperative ileus, that might delay postoperative feeding. The aim of this prospective randomised study is to test whether or not different kinds of epidural analgesia (Group A: morphine 0.0017 mg/kg/h and bupivacaine 0.125%-0.058 mg/kg/h; Group B: morphine alone 0.035 mg/kg/12h in the postoperative period) allow earlier postoperative enteral feeding, enhance intestinal motility a passage of flatus and help avoid complications, such as nausea, vomiting, ileus, diarrhoea, pneumonia or other infective diseases. We included in the study 60 patients (28 males and 32 females) with a mean age of 61.2 years (range 50-70) and with an ASA score of 2 or 3. All patients had hepato-biliary-pancreatic neoplasm and were candidates for major surgery. We compared two different pharmacological approaches, i.e., morphine plus bupivacaine (30 patients, Group A) versus morphine alone (30 patients, Group B). Each medication was administered by means of a thoracic epidural catheter for the control of postoperative pain. In the postoperative course we recorded every 6 hours peristaltic activity. We also noted morbidity (pneumonia, wound sepsis) and mortality. Effective peristalsis was present in all patients in Group A within the first six postoperative hours; in Group B, after 30 hours. Six patients in Group A had bowel motions in the first postoperative day, 11 in the second day, 10 in the third day and 3 in fourth day, while in Group B none in the first day, two in the second, 7 in the third, 15 in the fourth, and 6 in the fifth: the difference between the two groups was significant (p<0.05 in 1st, 2nd, 4th and 5th days). Pneumonia occurred in 2 patients of Group A, and in 10 of Group B (p < 0.05). We conclude that epidural analgesia with morphine plus bupivacaine allowed a move rapid return to normal gut activity and early enteral nutrition compared with epidural analgesia with morphine alone.

Inflammatory pseudotumor of the liver: case report and review of the literature.

Inflammatory pseudotumors of the liver (IPL) are extremely rare focal lesions of the parenchyma. Up to now, the ethology of IPL has not been completely understood. Usually the clinical presentation is with fever, chills, hepatic mass. The fine needle biopsy shows a large amount of inflammatory cells, while the most common imaging techniques are not specific and do not reach a definitive preoperative diagnosis between a benign and a malignant tumor. From the examination of the Literature, the Authors found a mortality rate of 40% among patients treated by antibiotic therapy, while surgical procedures were successful in all but one case. Moreover, in Authors' case, successfully treated by hepatic resection, the preoperative diagnostic procedures were not helpful in differential diagnosis with a malignant lesion. For these reasons, the Authors believe surgery is the best therapeutic choice in case of a suspected IPL without an early clinical resolution after antibiotic therapy.

[Role of surgical splanchnicectomy in the treatment of pancreatic carcinoma]. / Il ruolo della splancnicectomia chirurgica nel trattamento del carcinoma pancreatico.

Palliative surgical procedures offer considerable benefit for the patients with unresectable pancreatic cancer: surgical splanchnicectomy performed in conjunction with biliary-enteric by-pass offers good results as regard pain relief without increased morbidity and mortality. We treated 25 patients with unresectable pancreatic cancer by mean of biliary-enteric by-pass plus bilateral splanchnicectomy performed through different surgical approaches. In this series of patients postoperative mortality was nil, mean survival time was 7.2 months (range 3-14 months). Preoperatively, we assessed all patients as affected by visceral pain: Scott-Huskisson 10 mark-scale value in quantitative assessment of pain was equal or above the 7th mark in 87.5% of patients. One month later in the postoperative follow-up, 96% of the patients had a significant reduction in pain intensity from a preoperative median of 7 mark to a postoperative median of 1.5 mark (p = 0.0001). The mean period free of pain recurrence was 4.8 months. However, after 6 months only 46% of survivors were pain-free with such rate decreasing further to a 10% of survivors after 8 months. Nevertheless, the patients had around 70% of their survival span free of pain. We strongly believe that failure in relief of pain is due to a mistake in preoperative evaluation of the type of pain (somatic and not visceral, or both) and to the onset of somatic pain in the course of the disease rather than to surgical technical errors. Recurrence of pain has been considered inevitable in the biological progression of unresected cancer, and would be treated by combination of therapies, such as non steroidal anti-inflammatory drugs, transaortic coeliac plexus block, narcotics and cervical cordotomy.

[Anatomo-surgical notes on splanchnicectomy: original research on 15 autopsy observations]. / Premesse anatomo-chirurgiche alla splancnicectomia: ricerca originale su 15 osservazioni autoptiche.

Surgical splanchnicectomy for the relief of neoplastic pain is a palliative strategy in cases of unremovable pancreatic cancer. The first step in the achievement of satisfactory and long-lasting relief of pain is the correct identification of semilunar ganglia and splanchnic nerves during laparotomy. In this light, we tried to estimate the exact location, number, shape, and length of splanchnic nerves and ganglia in 15 corpses (mean age 39.9 years, range 21-74, F/M/ = 5/10). Right and left splanchnic nerves always pierce the diaphragm laterally to the crus. On the right side, the splanchnic nerve always enters the abdomen posterior to the inferior vena cava, on the right edge in 10%, on the middle in 73%, on the left in 17% of the cases. On the left side, the splanchnic nerve pierces the diaphragm strictly thickened to the left edge of the aorta in 66.6% of the cases, close to the left edge in 26.6%, and close to the right edge of the left adrenal gland in 6.8%. The right splanchnic nerve slides almost horizontally on the diaphragmatic bundles, and reaches an area delimited by the coeliac trunk and the superior mesenteric artery. The length of the right splanchnic nerve is 41 mm of the mean (range 20 to 55 mm): the thickness is between 4 and 6 mm. The left splanchnic nerve is shorter (mean 24 mm, range 15; 30 mm). The right splanchnic nerve varies from 2 to 6 ganglionar bodies and varies in size from 4.5 mm to 30 mm; the left nerve varies form 2 to 4 (sizes between 4 mm to 26 mm).(ABSTRACT TRUNCATED AT 250 WORDS)

Fetus in fetu removal in a 47-year-old man.

A case of removal of a fetus in fetu in a 47-year-old man is reported. The patient had an upper abdominal mass since birth that had never caused any subjective symptoms. A preoperative computed tomographic scan was useful to confirm the diagnosis. The operative specimen consisted of a cystic mass about 20 cm in diameter, situated in the upper retroperitoneal space. The cyst was full of a yellowish fluid and hairs. A bony structure, about 10 cm in diameter, contained a vertebral axis connected to the ribs and was adherent to the cystic wall. To our knowledge this is the first reported case of fetus in fetu described in an adult man. The tumor, present for 47 years, did not grow or cause any complications and did not show any sign of malignancy.

Repeated hepatic resection.

Sixteen patients underwent repeated hepatic resections over a 16 year period. The cases were divided into two groups: group A, non-planned repeated resections (14 cases), and group B, planned repeated resections (two cases). Group A is composed of patients requiring re-resection as a result of the hepatic re-recurrence of the neoplasia (three hepatocellular carcinomas, nine metastases from colorectal carcinoma, and two metastases from carcinoid tumor). Group B is composed of two cases (hepatocellular carcinoma and metastases of leiomyosarcoma) where the extent of the disease was incompatible with radical resection in a single time thus making necessary to plan for repeated operations. The need for correct preoperative assessment of hepatic performance using CT, US and Tc 99m HIDA scan, as well as intraoperative ultrasonography is stressed.