Infection prevention in endoscopy practice: comparative evaluation of re-usable vs single-use endoscopic valves.

Re-usable air/water and suction valves used in endoscopes often demonstrate risk of infection. To the authors' knowledge, the safety and efficacy of re-usable and single-use valves have not been compared to date. As such, a laboratory investigation was undertaken to compare the safety and efficacy of re-usable and single-use valves at 11 Italian endoscopy sites. Safety was evaluated by analysing the rinse liquid of reprocessed re-usable valves ready for use, and efficacy was assessed based on the completion of endoscopic procedures without valve malfunction. This study found significantly lower contamination of single-use valves compared with re-usable valves (0 vs 29.1%, respectively; P=0.007) and similar efficacy (97.6 vs 98.8%, respectively; P=ns). Microbiological analysis of the rinse liquid of reprocessed re-usable valves identified various surviving micro-organisms and highlighted their potential pathogenicity. Such data suggest that sterile single-use valves may be safer than re-usable valves, and have comparable performance.

[Muscle metastasis of bronchopulmonary carcinoma]. / Le metastasi muscolari da carcinoma broncopolmonare.

Typical sites of bronchogenic carcinoma metastases are liver, brain, bones or adrenal glands. Rarely and in advanced dissemination phase it could involve the skeletal muscle. Two cases of metastases in the skeletal muscle from bronchogenic carcinoma, one of which revealed this neoplasia, are reported.

[Residual gastric mucosa after gastrectomy: development of precancerous lesions]. / Mucosa gastrica residua a gastroresezione: dinamica delle lesioni precorritrici del carcinoma.

The gastric remnant can be regarded as a model to investigate the events of gastric carcinogenesis of intestinal type. Histologic changes precursor of the malignancy develop in higher incidence in the postoperative stomachs than in non-resected ones. 316 patients hemi-gastrectomized for peptic ulcer were assessed by an endoscopic-histologic study to provide further informations on the sequential chain of histologic lesions that precede the development of cancer. The anastomosis was by far the commonest diseased area at endoscopy, particularly in the patients with a Billroth II resection (p < 0.0004). The 10% of the 233 patients biopsied evidenced a normal gastric mucosa, in the others Superficial Gastritis 74%, Chronic Atrophic Gastritis 36%, Cystic Dilatation 52%, Foveolar Hyperplasia 29%, Intestinal Metaplasia 39%, moderate-severe Dysplasia 6% as single abnormality or variously associated were observed. The stoma was the most damaged area at histology. The occurrence of the DC, the FI and the IM at the anastomotic site was significative (p values between 0.02 and 0.001). The earliest postoperative histologic lesion was the CAG, evidenced, in mean 13 years after operation, the latest the DC observed in mean 18 years after surgery (p < 0.004). The IM, the IF, the CD, and the dysplasia in association with the CAG were observed at postoperative intervals shorter when non-associated with CAG (respective p value: NS, < 0.03, < 0.0002, NS). The probability of transition from an histologic lesions to a more advanced one in our patients was similar to that of a non resected population at medium--high risk of gastric cancer.

[Current aspects of therapy of primary biliary cirrhosis]. / Moderni orientamenti di terapia della cirrosi biliare primitiva.

The authors expose the epidemiological features of PBC and outline the role of the immunologic disorders in the disease's pathogenesis. The main clinic and laboratory features of the PBC, its course and pathology are also synthesized. The authors describe the drugs employed in the therapy of the PBC: cortisone, azathioprine, metotrexate, chlorambucil, colchicine, D-penicillamine and hydrophilic bile salts; the favourable risk-benefice rate of colchicine, azathioprine and hydrophilic bile salts is outlined, even if they are poorly active on the disease's course. The use of lyposoluble vitamins is stressed, to improve malabsorption's syndromes. At the end the role of orthotopic liver transplant is regarded.

[Acute abdominal pain in emergency surgery. Clinical epidemiologic study of 450 patients]. / Il dolore addominale acuto in chirurgia d'urgenza. Studio clinico-epidemiologico su 450 pazienti.

A retrospective study on 450 patients admitted in emergency with acute abdominal pain in a general surgical unit of the Ist Institute of Surgery of the University of Rome "La Sapienza" was carried out during a 7 years period. The aim of the study was to identify the most frequent causes of acute abdominal pain correlated with age, sex, onset of pain and other conditions in order to improve diagnosis and reduce mobility for mortality. Appendicitis was the most frequent diagnosis (75 pts = 16.4%). Non-specific abdominal pain (NSAP), found in 71 pts (15.5%), cholelithiasis in 57 pts (12.5%), abdominal malignancy in 47 pts (10.3%) were other frequent conditions. The largest number of admissions occurred in the age groups 60-70 years (16.6%) and 20-30 years (14.2%). Surgical operations were performed in 206 patients (45.7%). The overall mortality was 4.2% (19/450 pts) and the rate increased significantly in patients aged > 60 years. Postoperative mortality was 5.8% (12/206 pts) while mortality rate in non-operated patients was 2.8%. The causes of perioperative death included perforated peptic ulcer, abdominal malignancies (15.4%) and urgent colonic resections (9.4%). The duration of inpatients stay increased significantly with the age of the patients, including those with nsap. The results of the study indicate a need to review the methods of diagnosis of appendicitis and to obtain a better clinical performance in patients with nsap.

[Alcoholism and HCV-antibody association. Effects on the course and severity of chronic liver disease]. / Etilismo e HCV-anticorpo positività associati. Effetti sul decorso e la gravità delle epatopatie croniche.

BACKGROUND: The authors evaluated the role of the association alcohol-hepatitis C virus on the course and severity of chronic liver disease; they also regard the researches of many authors on this subject. MATERIALS AND METHODS: 280 consecutive patients, suffering from chronic liver disease and admitted to the Department of Medical Hydrology of Rome University ''La Sapienza'' are studied. Fifty-nine of them were affected by chronic alcoholic liver disease without evidence of hepatitis virus infection (AC-), 58 were alcoholic and positive for HCV antibody (AC+), 163 positive for HCV antibody and non alcoholic (NAC+). They are divided according to the diagnosis into chronic hepatitics, cirrhotics and those affected with hepatocarcinoma; among them 193 patients, age and sex matched, are evaluated as regards the course and severity or the chronic liver disease. RESULTS: In the total of 280 patients the hepatic damage arises significantly faster in the alcoholic and anti-HCV positive than in other patients. In the age and sex matched, in alcoholic and HCV positive patients the hepatocarcinoma significantly prevailed (AC-: 8.2%, NAC+: 9.4%, AC+: 19%; p=0.04). The three groups of cirrhotics did not show a significant difference with respect to the severity of the disease evaluated according to Child-Pugh criteria. CONCLUSIONS: Our research confirms the role of the association of HCV virus infection and alcoholism on the severity and impairment of chronic liver disease.

[Endoscopic and histologic findings of gastric mucosa and Helicobacter pylori prevalence in patients suffering from chronic liver disease]. / Quadro endoscopico ed istologico della mucosa gastrica e prevalenza dell'Helicobacter pylori in pazienti con epatopatia cronica.

In this research we evaluated the prevalence of Hp in the gastric mucosa in patients suffering for chronic liver disease, either chronic hepatitis or liver cirrhosis. Sixty-three patients 27 with chronic hepatitis and 36 with liver cirrhosis, were examined by EGDS; of them we evaluated: endoscopic findings of stomach and duodenum, histology of gastric mucosa (antrum and corpus-fundus), presence of Hp in the histologic samples. We compared the positivity for Hp with the following parameters: presence of esophageal varices, macroscopic aspect of the gastric and duodenal mucosa, presence of hystological findings of gastritis, gastritis's activity, grading of the hepatic damage. In the our research we didn't point out greater prevalence of the Hp in the gastric mucosa with respect to hepatic damage, esophageal varices or macroscopic signs of gastric pathology. The Hp is significantly associated with histologic evidence of gastritis and also with the grade of gastritis's activity. The data of the present work don't suggest any correlation within the pathologic changes of the gastric mucosa caused from the liver cirrhosis and the presence or the growth of Hp.

[Pilonidal sinus in a patient with Buckley's syndrome. A case report]. / Sinus pilonidalis in paziente con sindrome di Buckley. Presentazione di un caso.

Buckley's syndrome is a nosologic entity characterized by the presence from birth of extremely elevated levels of circulating immunoglobulin E and an important deficiency of polymorphonuclear chemotaxis. The consequences of such alterations are represented by the premature rising of recurrent cutaneous, pulmonary and articular infections, slowing down of growth and quite significant disturbances of the immune system. We report a case which presents all the characteristics of Buckley's syndrome: familial history for atopy; otorhinolaryngologic, gynecologic and pulmonary recurrent infections from birth (caused by Staphylococcus, Candida albicans but also Proteus, Enterococcus, Pyocyanea and Moraxella) some of which necessitate surgery therapy; immune disturbances. The patient had hospitalized in our Surgery Department for sinus pilonidalis abscess. At a first treatment of removal of the primary orifice and accurate curettage of the cavity (Marti's intervention) there followed another operation of larger exeresis for an abscess relapse of the sinus at a distance of 2 months. In the interval between the two treatments, an eczematous patch of 8 cm diameter appeared on the left buttock, a probable manifestation of the state of hypersensitivity of the patient. We believe, therefore, that in patients with Buckley's syndrome who must be subjected to surgical intervention it is necessary to resort to a radical treatment from the beginning, given the particular tendency to an infection relapse presented in these cases.

[Role of ultrasonography in emergency surgery]. / Ruolo dell'ecografia in chirurgia d'urgenza.

A prospective study was carried out to compare the value of ultrasound examination with conventional management in patients presenting with emergency surgical problems. During an 4 years period the authors followed 301 patients referred to the Ist Institute of Surgery of the University of Rome "La Sapienza". After immediate clinical evaluation one or more US examinations were performed in each patient following a standard protocol of study. Abdominal emergencies were the most frequent conditions, found in 75% of the cases and the acute abdomen due to trauma in 17.6% of the cases. The overall sensibility, specificity and accuracy of clinical examinations and US examinations were respectively of 88%, 33%, 70% and 95%, 94%, 95%. In 38 patients (12.7%), a diagnosis was made up by sonographic examination which had not been clinically expected (group A). The principal condition in this group was gynaecological pathology, found in 17 patients. In 161 patients (53.3%) sonography confirmed the first diagnosis clinically suspected (group B) and in 23 cases the second or third differential diagnosis (group D). Sonography made no contribution to the diagnosis in 77 cases (25,5%) and only in 2 cases was considered misleading. The result of this study demonstrate the usefulness of emergency ultrasonography in gynecological, gall bladder, pancreatic and vascular diseases. Moreover sonography must be considered the principal diagnostic tool in patients with trauma. In order to recognize gynecological diseases which can simulate appendicitis US examination must be considered necessary in young female patients. When appendicitis is suspected US is useful in children and in older patients too.

Laparoscopic appendectomy. A study of 154 consecutive cases.

The recent development of mini-invasive surgery includes appendectomy. We report our results of 4 years experience in this type of approach. We have operated on 154 patients (61 men, 93 women), mean age 26.7 years, presenting with clinical signs of appendicitis. The operation was completely carried out by laparoscopy in 144 cases, including treatment of abscess in 13 and peritonitis in 8 cases. Operation was converted into laparotomy in 10 cases, 4 of which because of some difficulty in appendix dissection. No deaths were recorded. Eight (5.2%) post-operative complications occurred: 4 infections of the trocar hole, one of which the cause of readmission; 3 cases of pain and fever (in one a re-laparoscopy was performed because of suspicion of leakage of the appendicular stump); 1 residual hematoma requiring second laparoscopy. Mean duration of hospitalisation was 4.9 days (range 2-25 days): at present, mean hospitalisation is 2 and 6 days respectively in cases with and without peritonitis. In conclusion, laparoscopic appendectomy appears to be feasible in the majority of cases, with better results when the appendix is ectopic and/or in the presence of peritoneal reaction.

[Cholecystectomy via laparoscopy in situs inversus totalis. A case report and review of the literature]. / Colecistectomia per via laparoscopica in situs inversus totalis. Presentazione di un caso e revisione della letteratura.

The authors report a case of symptomatic cholelithiasis in a patient with situs inversus totalis, in which the surgical treatment was performed by laparoscopy. They discuss the etiopathogenesis of this anomaly and malformations often associated, moreover related clinical and surgical problems. Finally, they describe operative technique stressing the real possibility to perform the operation by laparoscopy on condition that the surgeons have sufficiently experience of biliary and laparoscopic surgery.

[False positive results in breast diagnosis after treatment]. / I falsi positivi in diagnostica senologica dopo QU.A.RT.

The authors referring to a case with a false positive diagnosis which recently came to their observation, describe the clinical, mammographic and echographic patterns to be considered in order to reach a differential diagnosis between benign and malignant lesions of the breast, which occur on surgical scars following quadrantectomy and subsequent radiotherapy. In particular, after an attentive research of the data reported in literature and after careful evaluation based on their personal experience, they conclude that the traditional clinical evaluation occupies a very prominent role in the follow-up of patients who underwent breast cancer surgery. They also believe that the diagnostic techniques, undoubtedly useful and necessary, must always be subjected to a critical evaluation in order to avoid, to the maximum, the possibility of diagnostic errors.

[A case of a left-sided gallbladder treated surgically via laparoscopy]. / A proposito di un caso di colecisti a sinistra trattato chirurgicamente per via laparoscopica.

The authors relate about a case of symptomatic cholelithiasis, in which the organ was located in the inferior face of III hepatic segment and the surgical treatment was performed by laparoscopy. They discuss about etiopathogenesis of this anomaly, symptomatology referred by the patients and diagnostic procedures. Finally, they stress the necessity, in this case, to perform the cholecystectomy by anterograde approach in order to well visualize the anatomic structures and be safe to avoid injury of hepatic pedicle.

[Celioscopic treatment of acute obstructions of the small intestine. Immediate results in 25 patients]. / Traitement coelioscopique des occlusions aiguës du grêle. Résultats immédiats chez vingt-cinq malades.

Laparoscopic treatment of small intestinal obstruction is associated with immediate advantages and it may be expected that the recurrence rate will be decreased because of the reduction of wound scars. Between september 1989 and september 1991, 25 patients (16 men and 9 women), mean age 53.8 years, underwent initial laparoscopy for acute small intestinal obstruction. These patients had undergone a total of 43 (1.7 per patient) laparotomies an average of 13 years previously. One patient had never been operated on, 13 had one previous laparotomy, five had two, four had three, and two had four previous laparotomies. Laparoscopic treatment of intestinal obstruction was possible in nine cases including three cases of bands and six cases of adhesions. In sixteen cases, laparoscopy had to be completed by laparotomy, 13 immediately and 3 secondarily. The cause of immediate failure was the impossibility of finding and/or treating the cause in seven instances, four cases of intestinal wounds, on case of intestinal necrosis which required resection, and one case of missed right colonic carcinoma. The cause of secondary failure were incomplete release of adhesions, volvulus, and missed left colonic carcinoma in one case each. Mean hospital stay and postoperative ileus were significantly shorter in the "laparoscopy" group than in the laparoscopy + laparotomy group (p < 0.001). Two complications, with one death, were noted in the laparoscopy + laparotomy group. In conclusion, laparoscopic treatment of intestinal obstruction seems possible but in less than half of cases. Failures are related to the difficulty with which the abdomen may be explored. Laparoscopic treatment should not be pursued in case of problems.(ABSTRACT TRUNCATED AT 250 WORDS)

[Laparoscopic cholecystectomy. The beginning of a new era]. / La colecistectomia per via laparoscopica. Inizio di una nuova era.

An important breakthrough in the field of general surgery, laparoscopic cholecystectomy (LC) offers significant advantages for patients. Major reasons for the rapid worldwide acceptance of this new surgical procedure is that patients experience reduced postoperative pain, ileus is virtually abolished, and the patient is able to leave the hospital the following day without a major abdominal scar. This appears to respond to patients' desire for less invasive approaches to the treatment of gallstone disease. LC is thus becoming the treatment of choice for symptomatic gallbladder disease. Its rapidly growing popularity is evident in Italy where many centers are offering LC routinely, in alternative to open cholecystectomy. A critical appraisal of this new technology is necessary, in light of recent data from centers presenting results and complications of large series of LCs. Adequate training of surgeons who will perform LC is also becoming a major concern. In this review the authors describe patient evaluation and selection for LC. Effective therapeutic strategies are illustrated, including the central, but nevertheless controversial role of endoscopic retrograde cholangiopancreatography (ERCP) as an approach to common bile duct lithiasis. Currently, LC should be performed in centers with the availability of an endoscopist with expertise in ERCP. Following the success of LC, other minimally invasive techniques will evolve in various surgical specialties. New generations of surgeons will thus have to familiarize with these emerging techniques while maintaining a critical attitude of evaluation.

[Gastric schwannoma. A case diagnosed by puncture biopsy]. / Schwannome gastrique. Un cas diagnostiqué par ponction biopsique.

One case of schwannoma of the stomach diagnosed with ultrasound-guided biopsy puncture is reported. This diagnosis is usually not established with radiographic and endoscopic examinations. A preoperative diagnosis allows partly predicting the type of exeresis to be performed. On the other hand, guided biopsy puncture seldom allows establishing a prognosis, for which the criteria are based on the analysis of the whole tumor and the possible discovery of synchronous or metachronous metastases.

[Non-palpable lesions of the breast: identification, localization, significance]. / Lesioni non palpabili della mammella: rilevamento, localizzazione, significato.

The authors report the diagnostic protocol used in the Breast Disease Unit of the 1st Surgical Department - University of Rome "La Sapienza" - (1987-1990) as well as the techniques for identifying and localizing nonpalpable lesions of the breast. Mammographic screening in women over 40 years, ultrasonography in women under 40 years, X-ray and ultrasound-guided fine needle aspiration and stereotactic guide wire placement with excisional biopsy, resulted to be diagnostic in 79 cases of carcinoma of the breast (2.0%) of which 13 (16.4%) were nonpalpable lesions. Moreover, the importance of nonpalpable lesions is discussed, pointing out how "very early" diagnosis of carcinoma of the breast plays a fundamental role with respect to both prognosis and treatment. The very early diagnosis of a "minimal" carcinoma ensures a significant increase in survival as well as more conservative surgical procedures that offer a better quality of life being less psychologically traumatic.

[Appendectomies by celioscopy. Results in 78 patients]. / Appendicectomies par coelioscopie: Résultats chez soixante-dix-huit malades.

The recent development of laparoscopic surgery has included the treatment of acute appendicitis. We report our results after three years' experience of this type of surgery. We have operated on 78 patients (54 men, 44 women) mean age 28.9 years, suspected of varying degrees of acute appendicitis. The operation was completely carried out by laparoscopy on 71 occasions, including treatment of an abscess in 4 cases and peritonitis in 4 cases (3 of which were sub-mesocolic and one was generalised). The laparoscopy was transformed into laparotomy in 7 cases, 4 of which were due to difficulties of appendix dissection. Mortality was zero. Four complications occurred: 2 minute infections of the trocar hole, one more severe parietal infection which was a cause of readmission and antibiotic treatment, one "syndrome of the fifth day". In conclusion, laparoscopic appendicectomy appears to be quite feasible in the majority of cases, particularly when the appendix is ectopic, with marked abdominal thickening and peritoneal reaction. The postoperative course is uneventful. The laparoscopic technique is very comfortable for the patient during the postoperative period. This technique is becoming increasingly feasible with the operator's experience, and this appears to us to constitute good training for any form of laparoscopic surgery.

[Etiopathogenetic and histopathologic aspects of acute necrotico-hemorrhagic pancreatitis in experimental animals]. / Aspetti etiopatogenetici ed istopatologici della pancreatite acuta necrotico-emorragica nell'animale da esperimento.

In this study, the Authors have provoked experimentally acute pancreatitis in the rat by different methods, in order to find out morphological modifications of the pancreas in the initial stage of the disease. In case of biliary and pancreatic duct obstruction with pure pancreatic reflux, both oedema and inflammatory infiltrations were evident, whereas, in the presence of biliary reflux too, more serious histological features were detected. In conclusion, the first sign of alteration in acute pancreatitis could be represented by the association of intraductal hypertension and pure pancreatic reflux.