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.

Biliary microlithiasis and acute pancreatitis.

Forty-two patients with homogeneous biliary microlithiasis were studied to assess the incidence of the various clinical and anatomopathological characteristics of secondary acute pancreatitis resulting from this condition. The findings confirm that the risk of acute pancreatitis is particularly high in these patients and that the steatonecrotic form is the most common. Consequently, the authors stress the importance of thorough pre- and intraoperative investigations whenever the presence of biliary microlithiasis is suspected, and confirm their preference for the radical treatment of this disease.

Gallstones and risk of colonic cancer: a matched case-control study.

The aim of the research was to verify the existence of an association between neoplasms in the colon and cholelithiasis, treated surgically or non-surgically. The case-control study was carried out on 109 patients operated on for cancer of the colon, and on 109 control patients operated on for benign pathology. Matching was carried out according to sex, age, region of origin and dietary habits of the patients. Results showed a significant association of cancer of the colon with concomitant cholelithiasis (odds ratio = 2.42) but not with previous cholecystectomy. This correlation was more evident in female patients (odds ratio = 3.2), over 65 years of age (odds ratio = 3.6), with neoplasms in the right colon (odds ratio = 5). Observations suggest cholecystectomy has a protective role as regards an increased risk of cancer of the colon in cholelithiasic patients. A confirmation of this association might also be beneficial in terms of early diagnosis of cancer of the colon, thereby allowing identification of a large population of risk patients to be submitted to monitored screening.

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.

[Our experience in the treatment of nonneoplastic obstructive pathology of the common bile duct by papillosphincteroplasty (author's transl)]. / Nostra esperienza nel trattamento della patologia ostruttiva non neoplastica della via biliare principale con papillosfinteroplastica.

Starting from a discussion of the controversial views on the indications and correct execution of papillosphincteroplasty (PSP), the Authors report their own experience with the procedure and their first-hand evaluation of its merits, based on a series of 77 patients treated by PSP over the last 3 years (out of a total of 650 patients treated surgically for nonneoplastic pathology of the biliary tract). Their followup to date (up to 3 years after surgery), based on clinical, biohumoral and radiological findings, shows that the long-term results were excellent in 85%, good in 13%, and poor in 2% of the cases.

[Surgical aspects of thrombosis in the portal system (author's transl)]. / Aspetti chirurgici delle trombosi nel territorio portale.

The Authors present and discuss clinical and therapeutic aspects of several cases of chronic portal thrombosis, troncular and radicular, either isolated or variously associated. Splenoportography and selective arteriography do not always provide a clear-cut picture of the vascular situation, particularly in the presence of mural thrombi. Surgery may be needed as an emergency measure in cases of hemorrhage, but the best results are obtained if it can be done electively. Indications, however, must be evaluated very carefully in each individual case, especially for thrombosis not associated with cirrhosis of the liver, in which the tendency to a more favorable natural evolution may invite a more conservative approach. The choice of surgical procedures is dictated essentially by the site of obstruction in the portal system. After discussing the indications for various methods, the authors present some cases of thrombosis involving only the superior mesenteric vein, managed successfully by disobliteration and mesenterocaval anastomosis.

[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.

[Cancer of the colon and cholelithiasis: bile bacteria, composition of the stones and the bile]. / Cancro del colon e colelitiasi: bactibilia, composizione dei calcoli e della bile.

Our recent studies have shown a significant association between lithiasic biliary disease and colorectal cancer. This could be due to the existence of risk factors common to both disease or to a cause-effect correlation between them. This latter hypothesis is supported by the observation in gallstone patients of the increase of biliary and fecal concentrations in secondary biliary acids. These could have co-carcinogenic effect on the colon. With a view to singling out further elements which might help us to understand more clearly the possible cause-effect correlation between cholelithiasis and colon cancer, we examined 12 patients affected by both diseases. In these, we evaluated the composition of the gallbladder stones, by means of spectrophotometry and diffractometry. Bile samples were taken from the gallbladder and used to examine the lipidic composition and the cholesterol saturation index according to Carey. In addition bacteriological examinations were carried out. The results were compared with those of 10 patients with cholelithiasis but not cancer, 10 with cancer but not cholelithiasis and 10 with neither. Analysis of the results did not reveal significant differences in gallstone and bile composition between colon cancer patients with concomitant gallstones and control groups. However, in cancer patients with gallstones a higher incidence of bile bacteria (35.7%) was observed than in the other groups. Bile bacteria were observed more frequently in right colon cancer patients who had pigment stones in 75% of the cases. The results seem to evidence peculiarities in patients with a cancer of right colon.(ABSTRACT TRUNCATED AT 250 WORDS)

[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.

[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.

[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.

[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.

[Diagnostic problems in lymphomas of the gastrointestinal tract]. / Problemi diagnostici dei linfomi a localizzazione gastro-enterica.

The experience of the Authors refers to 10 cases of gastrointestinal lymphomas which came to our observation for December 1975 to July 1980. Of the 10 cases observed, 7 had a primary representation of the disease, the other 3 showed a generalized ò lymphoma. In 6 patients the stomach was affected and the small intestines in 4. Total or subtotal gastrectomy was carried out in 6 patients, Ileal resections in 3 and right hemicolectomy in 1. There were no post-operative mortalities and after treatment 7 patients survived. The Authors emphasize the difficulty created by the lymphomas of the digestive tract, particularly the primary ones, in as far as an exact preoperative diagnosis is concerned.

[Cimetidine after operations on Vater papilla (author's transl)]. / Impiego della cimetidina dopo interventi sulla papilla di Vater.

The effectiveness of Cimetidine in preventing complications, like acute pancreatitis and hemorrhagic gastritis, after operations on Vater papilla (ISP) is studied. In patients treated with Cimetidine the volume of nasogastric secretion was smaller and diastasemia and diastasuria treated values returned to the normal range earlier than in non-treated patients. In the latter group a case of pancreatitis and one of post-operative hemorrhagic gastritis were found. The treated patients, instead, did not suffer these complications. It was concluded that Cimetidine after IPS is useful, because it complies with the request that determined its employ.