Gallstone cholangitis: a 10-year experience of combined endoscopic and laparoscopic treatment.

BACKGROUND: To date, no procedure has yet been identified as the gold standard for the treatment of gallstone cholangitis in the laparoscopic era. METHODS: The data of 109 consecutive patients with acute cholangitis were prospectively entered into a computerized database. All patients were managed according to a standard protocol. The main treatments were endoscopic retrograde cholangiography (ERC) combined with endoscopic sphincterotomy (ES), followed by interval laparoscopic cholecystectomy (LC). Patients in whom ERC or endoscopic stone clearance failed were managed by emergency open common bile duct exploration. LC was performed with a standardized four-cannula technique. The mean duration of surgery, conversion rate, and postoperative outcome of these patients were evaluated. RESULTS: ERC was successful in 103 patients (94.5%). In five of these patients (4.8%), no bile duct stones were found. The 98 patients (95.2%) with common bile duct stones were referred for ES. The bile duct stones were successfully removed after ES in 93 cases (94.9%). The overall failure rate of ERC and ES for choledocholithiasis was 10.1%. Self-limiting pancreatitis occurred in four patients (4.3%). Overall, two of the 109 patients died (1.8%). After ES, 81 patients underwent LC. LC was performed successfully in 74 patients (91.3%). Conversion to open surgery was required in seven patients (8.7%). The morbidity rate after cholecystectomy was 7.4%; the morbidity rate after open bile duct exploration was 36.4% (p<0.05). Fifteen patients were managed conservatively after initial endoscopic management of their cholangitis. The overall incidence of recurrent biliary symptoms was significantly higher among patients with gallbladder in place than for patients who underwent cholecystectomy (38.5% vs 1.5%, p<0.001). CONCLUSIONS: ES followed by LC is a safe and effective approach for the management of gallstone cholangitis; cholecystectomy should be performed in patients with gallstone cholangitis unless the operative risk is extremely high. These high operative risk patients and those who refuse surgery after ES should be warned that they are at high risk for recurrent biliary symptoms.

Scoring system to predict asymptomatic choledocholithiasis before laparoscopic cholecystectomy. A matched case-control study.

BACKGROUND: The purpose of this prospective study was to evaluate if a recently proposed score system based on six preoperative parameters [history of colic pain and/or jaundice, dyspepsia, cholecystitis, ultrasound (US), evidence of common bile duct stones (CBDS), number and size of gallbladder stones at US, level of serum glutamic oxalacetic transaminase and/or alkaline phosphatase is effective in the selection of patients undergoing laparoscopic cholecystectomy (LC) with asymptomatic CBDS and could allow a significant reduction of the total number of preoperative examinations. METHODS: In the case group, 408 patients were categorized into low-, medium-, and high-risk classes and underwent, respectively, no further preoperative assessment of the bile duct, intravenous cholangiography (IVC), and endoscopic retrograde cholangiography (ERC). Intraoperative cholangiography (IOC) was performed whenever the surgeon was in doubt as to biliary anatomy or bile duct clearance. These patients were compared with 408 retrospectively matched patients (control group) undergoing routine preoperative IVC and/or ERC. RESULTS: In the case group, significantly lower numbers of IVC (120 vs 392) and IOC (3 vs 16) were performed ( p < 0.005), whereas no difference in the total number of ERCs was noted. One patient in the control group had retained CBDS detected during follow-up evaluation, whereas none occurred in the case group. CONCLUSION: The proposed scoring system allows selective use of IVC, ERC, and/or IOC in patients undergoing elective LC.

[Calcium antagonists vs ACE inhibitors in the treatment of essential arterial hypertension in the aged]. / Calcio-antagonisti versus ACE-inibitori nel trattamento dell'ipertensione arteriosa essenziale dell'anziano.

Numerous epidemiological studies have shown that systolic and systodisystolic hypertension constitute major risk factors for damaging or fatal cardiovascular accidents in the elderly as well as the young. Furthermore reducing the blood pressure also reduces the risk. In 1983 Fleckenstein investigated the Ca++ and MG++ contact of human arteries and clearly demonstrated that titres of both but especially Ca++ in the arterial wall increased progressively with age. The Authors themselves caused calcinosis of the arterial wall in rats treated with Vitamin D3 and Dihydrotachysterol and were able to prevent the occurrence with Verapamil. It is against this background that the present study compared the efficacy and tolerability of two anti-hypertensive drug groups in the calcium antagonists and the ACE inhibitors (Enalapril Maleate) used individually on two groups of elderly hypertensives. A group of 123 out patients with a mean age of 73 and all suffering from slight-to-moderate hypertension were monitored for 6 months being subjected to the following examinations: clinical assessment including blood pressure measurements lying and standing, biohumoral tests, remote heart X-rays, echocardiography (to establish the Reichek systolic wall stress index) and ECG. The clinical examination and ECG were repeated every 2 weeks for the first 6 months and once a month thereafter. The heart X-rays, echocardiogram and biohumeral tests were performed every 6 months. The patients were divided into two groups I and II and assigned to the selected treatment. The Group I patients were then divided into 3 subgroups and treated with 3 different calcium antagonists (Nifedipine R; Verapamil R and Diltiazem). All group II patients were treated with Enalapril Maleate.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cancer of the gastric stump after resection for ulcer]. / Il cancro del moncone gastrico nei resecati per ulcera

Fourteen cases of primary cancer of the gastric stump as a long-term sequel to resection for ulcer are presented. Surgery was undertaken in all cases, though radical intervention was only possible in 6. Questions of diagnosis and surgical tactics associated with this type of neoplasia are discussed. It is felt that early ascertainment could be aided by fibrogastroscopic controls carried out on a large scale at the time of the symptomatological overture. The possibility of preventive examination is also mooted.

[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.

[Videolaparoscopy and carcinoma of the gallbladder]. / Videolaparoscopia e carcinoma della colecisti.

There have been several reports claiming that there is a risk that laparoscopic cholecystectomy might worsen the prognosis of unexpected gallbladder cancer. The objective of this study was to evaluate which factors influence the prognosis of such cancers. A clinicopathological study was conducted in 25 patients with unexpected gallbladder cancer. The results of 10 patients undergoing laparoscopic cholecystectomy were compared with those of 15 patients undergoing open cholecystectomy. Correlations were evaluated between cumulative survival rates and seven prognostic factors, namely, age, sex, histopathological grade, pathological stage, occurrence of bile spillage, type of cholecystectomy (laparoscopic or open) and additional surgical treatments. Seven patients after laparoscopic cholecystectomy (70%) and 9 patients after open cholecystectomy (64%) had cancer recurrence: the difference was not statistically significant. There was a statistically significant correlation between survival rate and tumour stage (P < 0.01) and occurrence of bile spillage (P < 0.05). There was no difference in survival depending on whether cholecystectomy was carried out using laparoscopic or traditional techniques. Laparoscopic cholecystectomy does not adversely affect the prognosis of unexpected gallbladder cancer. Once the histological findings have been examined, the surgeon will decide whether it is necessary to extend surgery, regardless of whether laparoscopic or open cholecystectomy is carried out.

[Multimodal treatment of intrahepatic lithiasis with traditional surgery, endoscopy, and extracorporeal lithotripsy. Report of a clinical case]. / Trattamento multimodale della calcolosi intraepatica mediante chirurgia tradizionale, endoscopia e litotripsia extracorporea. A proposito di un caso clinico.

A patient with residual intra-/extra-hepatic bile duct stones, previously admitted in emergency for acute necrotic pancreatitis and cholangitis, underwent the following procedures: 1) endoscopic sphincterotomy and naso-biliary tube drainage; 2) surgical operation (choledocholithotomy, operative choledochoscopy and T-tube external biliary drainage); 3) extracorporeal shock-wave lithotripsy; 4) endoscopic sessions of fragmented stones removal. The above mentioned multimodal treatment, which resolved the intrahepatic lithiasis as shown 12 months later by endoscopic retrograde cholangiography, is therefore suitable in order to avoid, at least initially, invasive radiologic or surgical procedures, i.e. transparenchymal approaches, intrahepatic derivations and hepatic resections.

[Anatomo-surgical notes on mesenterico-caval anastomosis with interposition of a prosthesis]. / Annotazioni anatomo-chirurgiche in tema di anastomosi mesenterico-cava mediante interposizione protesica

On the base of 17 interposition meso-caval shunts and of 24 cadaver dissections, the Authors discuss some technical details concerning this method of portal decompression. The segment of the superior mesenteric vein more suitable has his superior limit at the mid-point of the third duodenal portion, where his diameter is already as at the converging point with the splenic vein. The length of this segment nevertheless is conditioned by the different anatomical rapports with the third duodenal portion. The insertion of the graft can be obtained either dissecting through the mesenteric root, either after mobilization of the right colon. With the last procedure resulted easir the inferior vena cava dissection, while no technical differences where encountered during the procedures with the superior mesenteric vein isolation.

[Blind pouch after choledochoduodenostomy (author's transl)]. / Il fondo cieco sottoanastomotico dopo coledocoduodenostomia.

In order to define the role of the blind pouch as causal factor of late complications after lateral choledochoduodenostomy ("sump" syndrome), the Authors have reviewed 37 patients previously operated on for common duct stones and/or benign papillary stenosis. In 19 patients, clinical and laboratory data have been associated to cholangiography, barium meal and 99mTc HIDA hepatobiliary scanning. Although we considered a few cases, the results were satisfactory. Slight symptoms noticed in some patients do not derive from "sump syndrome", as proved by the lack of correlations between clinical results and roentgenologic and radioisotopic data.

[Colon-rectal anastomosis with mechanical sutures (personal experience in 96 cases)]. / Anastomosi colo-rettale con suturatrice meccanica (esperienza personale di 96 casi).

From 1 October 1981 to 30 September 1985 ninety-six patients underwent colorectal resection with EEA Auto-suture stapled anastomosis for cancer or diverticula. As compared with manual suture, the mechanical procedure involved some technical problems and peroperative drawbacks (partial leakage, hemorrhage), which decreased after the initial phase of our experience. The EEA Stapler proved a reliable and useful procedure, especially in low colo-rectal anastomoses, which present a higher risk of leakage, owing to difficulties with manual technique. Clinical or x-ray fistulas occurred in four patients after colon-to-colon (5.8%) and were six following colorectal anastomoses (22.2%). Only in three cases a colostomy was necessary. In spite of suitability of the mechanical procedure, a colostomy was carried out to protect low colo-rectal anastomoses, when general risk factors were present or when the suture was improperly performed or transection circles were incomplete. The introduction of the EEA Stapler allowed for a higher number of anterior resection of the rectum, with a corresponding decrease of abdominoperineal procedures, and promoted a more extensive indication to palliative anterior resection. It is still a matter of concern whether the high number of anterior resections would be followed by an increased local recurrence rate, in consideration that radicality depends on a wide exeresis with a complete lymphoadenectomy.

[Interposition meso-caval shunt for haemorrhage or ascites in hepatic cirrhosis. Report of twenty-eight cases (author's transl)]. / Analisi di 28 osservazioni di anastomosi mesenterico-cava con protesi per emorragia od ascite da cirrosi epatica

The results are set out of emergency or electiver surgery for bleeding oesophageal carices or for intractable ascites in hepatic cirrhosis. The procedure adopted, a meso-caval shunt with prothesis interposition, led to a low percentage of thrombosis, markedly lowered portal pressure, and gave effective clinical results. Although angiography indicated that the portal flow to the liver had dropped considerably, or even ceased altogether, the bad effect on liver function and the incidence of encephalopathy seemed reduced than generally reported after porta-cava shunts. No deaths occurred among the patients for who surgery had been planned, but the rate was still high in emergency cases. This indicates that although well tolerated, the interposition meso-cava shunt is best performed after careful pre-operative selection and preparation.

[Further comments on changes in hepatic function after interposition meso-caval shunt (author's transl)]. / Ulteriori rilievi sulle modificazioni della funzione epatica dopo shunt mesenterico-cava

Further to a previous paper, the Authors followed up ten cirrhotic patients who had all undergone meso-caval shunt with Dacron prosthesis, for ascites or haemorrhage, Functional and anzymatic investigations were carried on over periods up to 10 months. No constant changes in hepatic function parameters were found during the post-operative period, compared to those before surgery. This observation suggests that these investigations might be more useful in defining liver disease than in practical assessment of transient, post-operative liver failure.

[Correlation between histological findings and clinical behavior following surgery for portal hypertension in cirrhosis (author's transl)]. / Correlazioni tra quadro istologico e decorso clinico nella chirurgia dell'ipertensione portale da cirrosi

This is a retrospective study of 29 cirrhotic patients who underwent surgery for haemorrhage or ascites due to portal hypertension, carried out to look for any correlation between histological findings and clinical outcome. When Mallory's bodies and signs of activation are found, indicating that the cirrhosis is progressing, the clinical results are often discouraging. A careful choice of which cirrhosis patients are likely to gain from surgery should take account of selective histological criteria as well as full clinical and haemodynamic data.

Lipase clearance in experimental acute pancreatitis.

Renal clearance of lipase, expressed as a proportion of simultaneous creatinine clearances was evaluated in an experimental model of acute pancreatitis in the rat. The lipase creatinine clearance ratio resulted very low in normal and control animals, while in rats with acute pancreatitis it increased regularly, significantly and proportionally to the degree of pancreatic damage. These observations indicated that, in this experimental model, the increased lipase creatinine clearance ratio is a sensitive index of acute pancreatitis, providing a basis for using the test in clinical practice.

Cholelithiasis and colorectal cancer.

To assess whether the higher risk of colorectal cancer is related to cholelithiasis rather than to cholecystectomy, a retrospective epidemiologic study was carried out on 350 patients operated for colorectal cancer. The incidence of a previous cholecystectomy or concomitant cholelithiasis was shown to be significantly higher in colorectal cancer patients with respect to controls (relative risk: 1.48 and 1.99 respectively). The association in both cases was more frequent for colorectal cancer. These results permit to hypothesize that the association with colorectal cancer does not concern previous cholecystectomy but rather cholelithiasis which is contemporaneously present or responsible for cholecystectomy.