[Total thyroidectomy in the surgical treatment of thyroid disease a retrospective clinical study]. / La tiroidectomia totale nel trattamento della patologia tiroidea.

BACKGROUND: Thyroid diseases constitute a group of benign and malignant affections, among which the most represented is multinodular goitre. Nowadays, an important question regards routine total thyroidectomy as the treatment of choice for all thyroid diseases. The aim of the present study is to verify if total thyroidectomy can always represent an option for modern surgery of thyroid disease. METHODS: One hundred-thirty-seven patients underwent operations for thyroid disease during an 11-year period. Fifty-three patients underwent total thyroidectomy, 27 affected by a benign pathology and 26 by a malignant one. RESULTS: Both short term and long term results have been analysed. CONCLUSIONS: In conclusion, the authors affirm that a complete resection of the gland is mandatory for the surgeon in the treatment of malignant diseases because the primary aim for oncologic surgery of the thyroid is the reduction of local recurrence and the increase of survival. As far as benign diseases are concerned, some surgeons affirm that morbility of non-total operations is lower than total thyroidectomy; anyway, the authors affirm that the most important factor to prevent morbility after total thyroidectomy is an appropriate surgical technique. In this way, both the identification of parathyroid glands and the identification preparation of recurrent nerve are considered the most valid method to prevent lesions. Another factor in favour of total thyroidectomy is represented by the risk of carcinoma on the residual tissue.

[Multicenter prospective study of informed consent in general surgery]. / Studio prospettico multicentrico sul consenso informato in chirurgia generale.

To understand the level of acceptance, awareness and usefulness of informed consent, a group of 119 patients (59 men and 60 women) from different types of hospitals were given a questionnaire which required only 'YES or NO' answers, both before and after surgery. The questionnaire concerned the patient's knowledge about pathology, operative risks, approval, anxiety caused, understanding of information received and consent given, and also if he would inform a relative in the same condition. From the analysis of the results it was established that: the more information a patient has about his illness and operation risks, the more he will want to have; the less he knows the less he will want to know, and he will also have more faith in the doctors. Some patients would not inform a relative with a similar pathology. To conclude, informed consent, instead of being a right of the patient is progressively becoming more a right of the doctor. It does not have any real effect on the patient's choice but is useful, as it represents a moment of personalised attention from medical personnel, though the patient may not completely understand the information received. There are few advantages in strictly medical terms but informed consent has increased malpractice litigation.

[Intestinal infarction. Retrospective clinical study]. / L'infarto intestinale. Studio clinico retrospettivo.

Acute mesenteric ischaemia is the result of inadequate blood flow to all or part of the small intestine and the right half of the colon. Irrespective of the cause of the ischaemic insult, the end results are similar, namely, a spectrum of bowel injury ranging from completely reversible alterations of bowel function to transmural haemorrhagic necrosis of the intestinal wall. Depending on the degree of ischaemia and the length of bowel involved, a wide variety of clinical presentations are observed. Mesenteric infarction is a pathology which is encountered fairly often in elderly patients where the concomitance of other diseases make its prognosis more severe, especially since the diagnosis is usually late. The pessimism expressed more than 70 years ago concerning this disease is still shared by many physicians today. The authors report on their experience with 37 cases of mesenteric infarction. The median age of the patients was 77 years (range: 66-91). The mortality rate was 67.5% (25 deaths) which is in line with the results in the literature. The median hospital stay was 17 days (range: 10-71). The authors emphasise the difficulty of diagnosing and treating this entity, also in view of the fact that, in most centres, it is impossible to perform emergency selective angiography of the superior mesenteric artery. The need for an early specific diagnosis is stressed, because the therapeutic options may vary widely in relation to the different causes of acute intestinal ischaemia.

Palpatory method used to identify the recurrent laryngeal nerve during thyroidectomy.

The major complication of thyroid surgery, occurring in 1% to 6% of cases, is injury to the recurrent laryngeal nerve (RLN). A simple method to identify the RLN during thyroid surgery is described by the authors. It consists in palpation of the nerve caudally to the inferior pole of the thyroid, after the nerve has been made taut by the upward and medial traction of the thyroid gland. This method was used on 47 human cadavers and 45 patients with benign thyroid diseases. It made it possible to identify the RLN in all of the cadavers and 52 of the 55 identifications during 45 thyroidectomies (in 10 total thyroidectomies the identification was bilateral). Laryngeal motility was normal in all patients at postoperative laryngoscopy. Using the palpation before dissection in the region of the inferior thyroid artery, the traditional viewing method became easier and safer, reducing the risk of injury where it is most likely to occur to the nerve.

[Diagnostic problems and results of laparoscopic cholecystectomy in chronic acalculous cholecystitis]. / Problemi diagnostici e risultati della colecistectomia laparoscopica nella colecistite cronica alitiasica.

We report on our experience with laparoscopic cholecystectomy in 15 patients, 12 females and 3 males (mean age: 44 years), with chronic acalculous cholecystitis. These patients presented with recurrent episodes of biliary colic together with a dysmorphic or dysfunctioning gallbladder as confirmed by ultrasound and/or cholescintiscan with 99m-Tc HIDA performed in fasting conditions and after meals. First of all, we considered the possible presence of concomitant digestive disease (peptic ulcer disease, recurrent pancreatitis, irritable bowel syndrome, chronic hepatitis) potentially responsible for the pain. Ultrasound investigations revealed a pathological gallbladder in 10 patients. Cholecystectomy was curative in 8/10. Cholescintiscan revealed a pathological gallbladder in 8 patients and cholecystectomy was curative in only 5 of these. No postoperative deaths or significant complications occurred. The mean duration of the operation (35 vs 48 min) and hospital stay (2.1 vs 2.8 days) were reduced in comparison to 346 cholecystectomies performed for gallstones. After 6-36 months' follow-up, resolution of symptoms was successful in 10/15 cases (66.6%); in 3 cases, only dyspepsia was reduced, whilst in the other 2 cases, who also presented concomitant irritable bowel syndrome and gastroduodenitis, there was no improvement in pain. In all but the latter two cases (86.6%), histological examination revealed chronic gallbladder inflammation. In conclusion, laparoscopic cholecystectomy was curative (66.6%) or led to an improvement in symptoms (20%) in patients with chronic acalculous cholcystitis. Cholescintiscans were not always diagnostic for the disease, whereas ultrasound findings were more useful as an indication for surgery.

[VIPoma: surgical treatment]. / VIPoma: trattamento chirurgico.

This paper reports a case of pancreatic VIPoma with widespread hepatic metastasis which was treated for approximately 2 years with a synthetic somatostatin analog (SMS 201/995). The treatment of choice in cases in which the tumour was fully removable is surgical resection. This occurred rarely since approximately 80% of VIPomas are malignant and are operated late when local infiltration is already widespread; in addition, 50% of cases are already metastasised at diagnosis. In this case, due to the infiltration of the superior mesenteric artery by the primary tumour it was necessary to carry out a left pancreasectomy which included two-thirds of the neoplastic mass. This was justified by slow tumour growth and also facilitated control of diarrhea and ensured a greater efficacy of possible postoperative chemotherapy. The use of synthetic somatostatin analog (SMS 201/995) enabled diarrhea to be satisfactorily controlled and is therefore specifically indicated for this type of tumour. NSE serum assay (neuron specific enolase) allowed the evolution of disease to be monitored during follow-up.

[What happened to Zollinger-Ellison syndrome?]. / Dove sono finite le sindromi di Zollinger-Ellison?

Three Zollinger-Ellison syndrome patients were treated during the period January 1977 to June 1978. The first patient is in good health 11 years 3 months after a total gastrectomy as is the second patient, 11 year after the enucleation of a cephalo-pancreatic gastrinoma. However the third patient died from malignancy 5 years after a total gastrectomy and enucleation of a cephalo-pancreatic gastrinoma followed by therapeutic cycles with streptozotocin and 5-fluorouracil. The decline in the Zollinger-Ellison syndrome over the last ten years is examined and the type of surgical treatment is discussed. Total gastrectomy once advocated as the preferred treatment, is now reappraised because of the effectiveness of medical therapy in controlling ulcers and because of the frequent malignancy of pancreatic gastrinomas.

Effect of somatostatin in controlling bleeding from esophageal varices.

A multicenter double-blind clinical trial was undertaken to evaluate the efficacy of a short-term somatostatin treatment versus a short-term vasopressin treatment on acute hemorrhage from esophageal varices in patients with liver cirrhosis and portal hypertension. Forty-nine patients with massive hemorrhage and endoscopic diagnosis of bleeding esophageal varices completed the study. Patients were randomly assigned to somatostatin treatment (24 patients: 250 micrograms/hr i.v. for 48 hrs) or vasopressin treatment (25 patients: 0.1 U/min i.v. for 48 hrs). The Sengstaken-Blakemore tube was utilized, when needed, for a six hour period. In case of failure the patients were crossed-over to the other treatment. Patients in whom the bleeding stopped at 48 hrs, were randomly assigned to somatostatin (250 micrograms/hr i.v.) or placebo for seven days. Bleeding stopped in 68% of patients treated with somatostatin and in 28% of patients treated with vasopressin (p less than 0.0013). Mortality rate was lower, but not significantly so, in the somatostatin group compared to the vasopressin group. No differences were noted between somatostatin and placebo in preventing bleeding recurrences. These data suggest that somatostatin, when combined if necessary with a 6 hour period of balloon tamponade, is more effective than vasopressin at low doses in controlling severe hemorrhage from esophageal varices in patients with liver cirrhosis and portal hypertension. A clinical use of somatostatin seems to be indicated in these patients.

Ranitidine and somatostatin. Their effects on bleeding from the upper gastrointestinal tract.

In a randomized, double-blind placebo-controlled clinical trial, the effect of ranitidine was compared with the effect of somatostatin in the control of massive gastrointestinal tract bleeding. Ninety-six patients completed the study. Rates of continuing bleeding and death, incidence of surgery, and blood transfusion requirements were not significantly different in the three treatment groups. Eighteen of the 96 patients presented with a visible vessel at endoscopy. In this group the percent of patients with continuing bleeding, mean transfusion requirements, and mortality were significantly higher than in patients without a visible vessel. Seven patients with a visible vessel underwent surgery and six survived; 11 patients underwent conservative measures and eight died. Ranitidine and somatostatin do not seem to alter the clinical course of patients with upper gastrointestinal tract hemorrhage.

Surgical treatment of epiphrenic diverticula of the esophagus: is diverticulectomy always necessary? A report of two cases.

Two cases of epiphrenic esophageal diverticula are reported. The surgical treatment was limited to the correction of the associated motor disorder, namely gastroesophageal reflux without diverticulectomy.

[Treatment of pancreatic pseudocysts]. / Traitement des pseudokystes du pancréas.

Based on the results of treatment of a personal series of 13 cases of pseudocyst of the pancreas, between 1974 and the present day, it is suggested that the choice of therapy should be surgical. An internal shunt is preferred for pseudocysts as a result of acute pancreatitis or injury, whereas a wider cysto-wirsung jejunostomy is recommended for cysts developing during the course of chronic pancreatitis. These proposals follow analysis of immediate and long-term (mean: 51 months) follow-up, on the basis of mortality, morbidity, pain symptoms, malabsorption and postoperative diabetes.

Antisecretory activity of pirenzepine versus cimetidine in man: a controlled study.

Antisecretory effect of single oral therapeutic doses of pirenzepine (25 mg and 50 mg) and cimetidine (200 mg and 400 mg) was studied in 12 patients with duodenal ulcer. Gastric secretion was studied in basal condition and after stimulation with pentagastrin. Basal, maximum and peak acid output, basal and maximum acidity, and basal and maximum volume were calculated after computerised correction for pyloric loss and duodenal reflux. Both drugs showed dose-related inhibition of all facets of gastric secretion. Cimetidine (200 mg) had a greater inhibitory effect on gastric basal secretion, but a similar effect on pentagastrin stimulated secretion as with pirenzepine (50 mg). Cimetidine (400 mg) showed about twice the inhibitory activity of pirenzepine (50 mg) both on basal and stimulated secretion.

Enterogenous reduplication cyst of the pancreas. A case report.

A case of enterogenous cyst of the head of the pancreas is reported. The cyst was shown to be endowed with both secreting and absorbing intestinal epithelium. The surgical treatment consisted in the removal of the whole cyst. The approach to be followed in the case of this extremely rare disease is briefly discussed, underlining that the present is the third such case to date reported in the literature.

[Surgery of Zollinger-Ellison syndrome]. / Il trattamento chirurgico della sindrome di Zollinger-Ellison.

Two personal cases of Zollinger-Ellison syndrome (ZES) are described. Total gastrectomy (TG) was performed in the first case as an emergency measure, following acute peritonitis caused by a recurrence of ulcer, with perforation 27 days after the first gastric resection. The patients is in good health, though with persistently high blood gastrin levels. The second case was marked by a long history of recurrent ulcer, with two earlier gastric resections. Here, success was obtained by simply enucleating a small gastrinoma from the head of the pancreas in view of the arteriographic evidence. The patient is in excellent health 2 1/2 yr after surgery with stable, normal blood gastrin. The recent literature and these cases suggest that surgery is the method of choice for ZES, its primary aim being the removal of gastrinomas, since these prove malignant in 60-100% of cases, and TG does not in any way inhibit their growth, as was once supposed. Blood gastrin values permit early diagnosis and postoperative monitoring, while arteriography and transhepatic portal catheterisation constitute a useful guide to the location of the tumour. Hyperchlorhydria can be effectively controlled with H2 receptor inhibitors, both in the preoperative diagnostic stage, and after surgery in the event of failure. TG offers the best results in over 60% of cases, when the tumours is multifocal, widely metastasised, or undiscoverable.