Abstract: The prevalence of gallstones disease in Western countries is 10 - 15%. Gallstones can be one of two types - cholesterol or pigment - with cholesterol gallstones representing nearly the 80% of the total. Cholesterol and pigment gallstones have different predisposing factors: cholesterol gallstones are related to supersaturated bile in cholesterol, whereas black pigment gallstones are related to hyperbilirubinbilia factors (hemolysis, etc.); these are necessary, but not sufficient, factors to produce gallstones in vivo. Gall bladder mucosa factors (gall bladder secretion of mucin, local bile stasis and production of endogenous biliary β-glucuronidase) may coexist with the aforementioned factors and facilitate gallstone nucleation and growth. The gold-standard treatment for symptomatic gallstones is laparoscopic cholecystectomy. Several studies have reported a significant reduction in the onset of symptomatic gallstones disease in patients undergoing chronic therapy with statins, which can reduce bile cholesterol saturation. Aspirin, which has been shown to reduce the local production of gall bladder mucins (mucosal or parietal factors of gallstone formation) in animal experimental models, does not appear to reduce the risk of symptomatic gallstones disease when tested alone. The new horizon of oral therapy for the prevention of symptomatic gallstone disease needs to evaluate the long-term effect of statins and chronic aspirin administration in patients with dyslipidemia and/or atherosclerosis.
Abstract: Rokitansky-Aschoff sinuses are the result of hyperplasia and herniation of epithelial cells through the fibromuscular layer of the gallbladder wall and are usually referred to as adenomyomatosis. The role of this study is to demonstrate that Rokitansky-Aschoff sinuses of the gallbladder are a risk factor for the formation of black pigment gallstones. A total of 179 removed gallbladders, were hystologically examined. Sixty-four of the 179 consecutive cholecystomized patients had typical adenomyomatosis. Thirty-eight of the 64 patients with adenomyomatosis had black pigment gallstones, alone (n=22) or in association with single (n=12) or multiple (n=4) cholesterol gallstones in the same gallbladder. Twelve of these patients did not have the typical risk factors for black stones (hemolysis, cirrhoses, gastrectomy, etc). Gallstones were examined by infrared spectroscopy and X-ray diffractometry. In addition, in a subset of 14 patients, the gallstones and the gallbladder wall were examined by scanning electron microscopy. At least in the initial phases of formation, Rokitansky-Aschoff sinuses were found close to small intraparietal vessels and sometimes they contained black pigment microstones. After the fourth to fifth decades of life, black gallstones can be found in the Rokitansky-Aschoff sinuses and in the main gallbladder lumen. Black pigment gallstones can form in Rokitansky-Aschoff sinuses of the gallbladder in absence of the typical risk factors for bilirubin suprasaturation of bile.
Abstract: A combination of sclerotherapy, rubber band ligation and infrared coagulation was performed in 7850 patients seen an outpatient clinic over a period of 9 years. The most common symptom was bleeding followed by prolapse, pain and itching. Results were considered satisfactory in 7100 patients (90.5%); 750 (9.5%) required a formal hemorrhoidectomy. Complications were mild to moderate pain in 1777 cases (22.6%), severe pain in 157 cases (2.2%), mild hemorrhage in 199 (2.5%) and hemorrhage requiring transfusion in 10 cases (0.1%). In conclusion, non-surgical outpatient treatment has a great impact on patient's perception of the disease and results in considerable savings for the healthcare system.
Abstract: PURPOSE: In 1980, operative mortality for esophageal resection was 29%. Over the last 15 years, technical and critical care improvements contributed to the reduction of postoperative mortality rate to 8%. The aim of this study is to analyze retrospectively the role of different factors (surgical procedure, stage of the disease, and anesthetic risk) on the postoperative mortality of 63 patients that underwent esophagectomy with gastric interposition for cancer. METHODS: Seventy-two patients underwent esophagectomy. The stomach was the esophageal substitute in 63 cases. Surgical procedures included transthoracic esophagectomy in 49 patients and transhiatal esophagectomy in 14 cases. Among the 49 transthoracic esophagectomy patients, there were 18 patients with a high anesthetic risk (ASA III). Among the patients that underwent transhiatal esophagectomy, there were 10 patients with a high anesthetic risk (ASA III). RESULTS: The operative mortality rate was 14% (2/14) in transhiatal esophagectomy group and 22% (1(1/4)9) in transthoracic esophagectomy group (P = ns). The postoperative mortality of patients with a high anesthetic risk (ASA III) was 47% (8/17) after transthoracic esophagectomy and 10% (1/10) after transhiatal esophagectomy (P <0.05). DISCUSSION: In our experience, the operative mortality was nearly 18% (16.6% after transhiatal esophagectomy and 20.8% after transthoracic esophagectomy). Among the patients with a high anesthetic risk (ASA III) that underwent surgery, the postoperative mortality was significantly lower after transhiatal esophagectomy (10%) compared to transthoracic esophagectomy (47%) (P <0.05).
Abstract: In the era of video-laparoscopic surgery there are a lot of surgeons that still continue to perform open appendectomy. This choice is the consequence of the good results of open appendectomy (clinical, cosmetic, hospital stays and hospital costs). Published trials on laparoscopic appendectomy don't show that it is superior to the open approach. The aim of this study is to critically review the literature on laparoscopic and traditional appendectomies and to report a clinical experience on 86 consecutive patients that underwent open appendectomy. PATIENTS AND METHODS: From September 2000 to March 2001, in the Department of Emergency Surgery of Villa Scassi Hospital in Genoa, 86 patients underwent open appendectomy (32 men; mean age 29.8 years; range 15-54 years/54 women; mean age 22.4 years; range 13-80 years). All the patients underwent blood examinations, abdomino-pelvic ultrasonographys and the women gynecological evaluation. The Authors used, almost always, the Stropeni way of access (cutaneous Mac Burney and right para-rectal incision of the muscles). Discharge has been done as soon as possible. Removed appendices were submitted to histological examination and were classified as normal or pathologic according to the severity of the lesion. Review of articles has been done on Medline. RESULTS: Suspected appendicitis have been confirmed by histological examination that documented 1 normal appendix, 7 chronic appendicitis, 45 acute catharralis, 22 acute suppurative and 11 gangrenous or perforated appendicitis. The specificity of open appendectomy has been 97.6% (100% for men). Post-operative complications were: 2 wound infections and 1 recurrence of an abscess (2.58%). Open appendectomy did carry an hospital bill of 2,500,000 IT liras (1,200 USA dollars) for non complicated appendicitis and 2,000 USA dollars for perforated appendicitis. The early discharge allowed us to spend 119 millions IT liras less in 7 months (99,600 USA dollars in a year). DISCUSSION: The role of laparoscopic appendectomy isn't still established. After a critical review of the literature we can suggest that: 1) laparoscopic appendectomy increase operative time (63 vs 43 minutes: p < 0.0001); 2) laparoscopic approach can reduce the length of post-operative stay in hospital; 3) hospital bill is strongly reduced by open appendectomy (4,274 vs 7,923 USA dollars). On our experience the cost of the hospital for uncomplicated appendicitis is 2,500,000 IT liras (1,200 USA dollars). Otherwise it has been suggested that laparoscopic appendectomy has a better diagnostic accuracy respect to open appendectomy. Some Authors report a percentage of "negative" appendices of 16-50%. In Authors experience the percentage of "negative" appendices is 1.3% and so the diagnostic accuracy is 96% in women and 100% in men, probably because we systematically performed a preoperative abdomino-pelvic ultrasonography and, for the women, a gynecological evaluation. In conclusion, laparoscopic appendectomy should be done in case of suspected appendicitis in women. In the other cases, when there is a strong clinical suspect of appendicitis and, in particular, in case of suppurative appendicitis, the Authors recommend to perform an open appendectomy using the Stropeni approach. In case of perforated appendicitis with abdominal abscess they recommend to perform an open appendectomy using the right para-rectal approach or the median umbilical-pubis approach.
Abstract: Chordomas are rare tumours arising from embryonic notochord tissue remnants. The commonest affected segment is the sacrum. This localization may present diagnostic and therapeutic problems. Two cases of chordoma treated by surgery and radiation are reported.
Abstract: In this paper the Authors report their experience of Orringer operation in 12 patients with oesophageal cancer observed from 1978 to 1992, and stress the possibility to extend the indications to Akijama oesophagectomy without thoracotomy for the treatment of malignant tumors of the entire oesophagus.
Abstract: The authors report their series of 7 adenocarcinomas of the hepatic hilum. Five patients with a stage IV tumor underwent palliative surgery while the remaining 2 patients underwent radical surgery. One patient died and 3 reported postoperative complications. Overall survival was 2 years and 6 months: these results can be considered satisfactory taking into account the advanced stage and the bad prognosis of this type of tumor. The aim of a better quality of life may represent a reasonable indication to surgery.
Abstract: From our experience in 16 patients with persistent chylothorax from fistulas of the thoracic duct or its tributaries, we conclude that no standard treatment is uniformly successful and multimodality therapy should be considered. In selected patients, an anastomosis between ectatic lymphatics or hyperplastic lymph nodes and an adjacent vein may be attempted. Chylothorax from "leakage" of the thoracic duct or its tributaries is rare. Rupture of the thoracic duct superior to the sixth thoracic vertebrae generally results in a left-sided chylothorax; below that level, injury usually results in a right-sided chylothorax. The etiology is heterogeneous and includes blunt trauma, penetrating wounds (1), iatrogenic operative injury and lymphatic obstructions due to congenital abnormalities, inflammatory processes or neoplasms. Based on our experience in 16 patients with persistent chylothorax from thoracic duct complex lesions, we review the available treatment options.
Abstract: Adenocarcinoma of the anal glands is a rare slow-growing tumor with a more favorable prognosis compared with colorectal adenocarcinoma, especially if an early diagnosis is established. Clinical symptoms of this disease, often associated with a fistula in ano as in the reported case, include: perianal pain, rectal bleeding and presence of perianal mass. Also perianal Paget's disease may be a not rare association with adenocarcinoma of the anal glands. We believe, therefore, that a histological examination of the resected fistulas in ano should be performed, in searching for the presence of mucinous granules. In addition, it's very important to carry out a careful examination of those patients presenting pruritus ani or eczematous lesions of the anal region. In fact adenocarcinoma of the anal glands may be due to a chronic irritation of the epithelium over a period of years. Radiation therapy and chemotherapy have proved not to provide survival benefit in the treatment of this disease; the same result is obtained with a local excision of the lesion. The only chance for cure, therefore, is early diagnosis followed by radical operation. Miles abdominoperineal resection represents the approach of choice we have adopted for our patient. A radical groin dissection should be carried out only if there are metastases to the inguinal nodes. If necessary, abdomino-perineal resection may be folowed by adjuvant irradiation.
Abstract: The Authors report their experience in 290 cases of thoracic outlet syndrome (TOS) and 71 cases of Paget-Schroetter syndrome, that is a condition due to thrombosis of the subclavian and/or axillary vein. They point out that diagnosis is mainly clinical-instrumental and the ulnar nerve conduction velocity (UNCV) test is of fundamental importance. The Authors emphasize how the good results obtained could be related to the complete removal of the first rib and to the axillary approach that they strongly support.
Abstract: Esophageal cancer has a poor prognosis. The Authors in reviewing esophageal carcinogenis stress the importance of an early diagnosis to improve surgical results and compare their experience with those of other Authors.
Abstract: The treatment of colorectal obstructions is a surgical problem. The surgeon can choose between primary resection with anastomosis and the staged operations. The one stage procedures need colon decompression or intraoperative colonic lavage. In our experience between 1990 and 1993, 23 patients required an emergency intervention for colon obstruction; between them 13 patients were affected by a left colonic obstruction and were treated with a staged procedure (like Hartman operation) in 9 cases and with intraoperative colonic wash-out with primary anastomosis in 4 cases. The last group had a good postoperative course without an increased incidence of anastomotic leakage (no one in our limited experience). Compared with staged surgery, immediate resection and anastomosis had significant advantages for the patients because: 1) the quality of the life is better (absence of colonstomy); 2) the cumulative hospitalization is reduced (15 days vs 32 days); 3) there is a reduction in operative risk and in the cumulative intra- and postoperative immunodepression. The correct evaluation of the effect on the long-term survival of these factors needs larger series and of longer follow-up.
Abstract: Medical approach to gastroduodenal ulcer has dramatically changed with the advent of anti-H2 drugs. There is still a role for surgery, but it has been confined to the treatment of the complications (perforation, stenosis and some cases of haemorrhage). In this paper the Authors collected the data of 43 patients (27 males and 16 females, mean age 45), operated between July 1988 and December 1992; 12 patients were operated for pyloric stenosis, 16 for gastrointestinal bleeding and 15 for perforation. Surgery was accomplished as an emergency procedure in 20 cases, delayed emergency procedure in 4 cases and elective procedure in 19 cases. 39 out of 43 patients were under anti-H2 treatment for a previous diagnosis of peptic ulcer. In conclusion, anti-H2 therapy, even correctly carried on, may not be effective in avoiding possible complications. This goal may be obtained in patients under omeprazole treatment.
Abstract: AIMS AND BACKGROUND: In patients undergoing potentially curative surgery for colorectal adenocarcinoma, the presence of occult disease is thought to be responsible for distant metastases, particularly of the liver. During the 1980's preoperative intra-arterial chemotherapy was used in patients with adenocarcinoma of the sigmoid colon since it was thought that the biological effects induced by radiation in rectal lesions could be induced by cytotoxic agents in sigmoid cancer which was found to be less sensitive to radiation. The aim of the present paper is to report long-term results of an early pilot study on 20 patients with sigmoid colon adenocarcinoma treated with a 6 preoperative intra-arterial infusion of mitomycin-C followed by curative surgery. METHODS: From January 1980 to December 1986, 20 patients with adenocarcinoma of the sigmoid colon were treated with a 6 hours preoperative intra-arterial infusion of mitomycin-C followed by potentially curative surgery (Group A). Eighteen hours prior to surgery the patients underwent selective arteriography of the inferior mesenteric artery through puncture of the femoral artery at the inguinal fold. The Seldinger technique was applied and Cook BP6 catheter was used. At the end of the examination, the catheter was positioned in the inferior mesenteric artery and mitomycin-C, 10 mg/m2, was infused in 500 ml of normal saline over a 6 hours period after which the catheter was definitively removed. Within 18 hours following intra-arterial mitomycin-C infusion all 20 patients underwent potentially curative surgery of their sigmoid adenocarcinoma. During the same period, 48 comparable sigmoid colon cancer patients underwent potentially curative resection alone (Group B). RESULTS: At 5 years overall recurrence rate was 30% and 39.6% in Group A and B patients, respectively (P = n.s.). In patients with Stage C disease, recurrence was less frequently observed in Group A (44.4%) than in Group B (77.7%) (P = n.s.). Overall survival at 5 years was comparable in the two groups of patients (70% and 64% for Group A and B, respectively) and median survival was > 60 months in both groups. In patients with Stage C lesions, there was a trend for improved survival at 5 years in Group A patients (55%; median > 60 months) compared to Group B (22%; median 27 months) patients (P = n.s.). CONCLUSIONS: Although the difference indicating decreased recurrences and improved survival for Stage C patients treated with preoperative intra-arterial mitomycin-C were not statistically significant, the long term results of this small pilot study are encouraging.
Abstract: In this review the authors after an introduction on the risk factors, the symptoms and diagnostic aspects of rectal carcinoma, show the different surgical techniques, used second the literature and personal experience on 37 cases for the upper, middle and lower neoplastic lesions of the rectum.
Abstract: The Authors considering cholelithiasis as an heterogenic pathological entity report their experience of 25 surgical consecutive patients: 20 with cholesterol or combination gallstones and 5 with black pigmented gallstones. In this series the most frequent factors associated with cholesterol gallstones were LDL hypercholesterolemia and hypertriglyceridemia; while the most frequent factors associated with black pigmented gallstones were hepatopathies. The most frequent symptom was dyspepsia. Only the black pigmented and the mixed gallstones were associated with jaundice and pancreatitis. According to the Literature infection is associated to brown pigment gallstones in 95% of cases, in this series infection is rarely associated with other types of gallstones. Treatment with oral bile salts is useful only in pure cholesterol gallstones, so the distinction among different types of gallstones is useful not only for a better knowledge of their pathogenesis but also for a correct choice of the therapeutic options.
Abstract: After a careful review of the Literature, diagnostic and therapeutic strategies for Primary Retroperitoneal Tumours (PRT) are reported. The Author analyzes the experience of the Institute of Clinica Chirurgica "R" (Chief: Prof. E. Tosatti) as well as that of Anatomia Chirurgica (Chief: Prof. E. Cariati),--University of Genoa--in the management of PRT, stressing the importance of preoperative staging for a correct surgical approach.
Abstract: Gallbladder cancer is usually a fatal complication of cholelithiasis. It is the most common malignant lesion of the biliary tract (1). In the different countries it has large variations of incidence. It has an annual incidence of 0.4 (men) - 1 (women)/100000 in USA and of 3.8-10.3/100000 among American Indians of New Mexico (1). The highest incidences (up to 7.5 per 100000 for men and 15 per 100000 for women) are seen in Bolivians (1). The incidence rises with age with a peak among females over the age of 65 (1). Surgical treatment in advanced cases is ineffective. The prognosis is poor: only 0-10% five-year survival rate for all stages (2, 3). The etiology of this tumour is multifactorial. In fact, Gallbladder carcinomas can be divided in: a) carcinoma related to gallstones (squamous cell carcinoma, adeno-squamous cell carcinoma, the majority of adenocarcinomas); b) carcinoma non associated at all with gallstones but with other factors or conditions as pancreato-biliary reflux, pancreaticobiliary maljunction and gallbladder adenoma (gallbladder polyps of 1 cm. or more) (4).
However the 80% of gallbladder cancer is associated with large cholesterol or combination gallstones (1, 5) and in particular with long-standing gallstones (4). The progression from epithelium dysplasia to invasive carcinoma of the gallbladder is nearly 15 years. Several studies have shown that the overall incidence of carcinoma of the gallbladder in patients with cholelithiasis is 0.1-1% (8, 9).
The prevalence of gallstones in the adult general population range from 10 % (men) to 20 % (women) in Europe and it increases with age (10). It means that among adult population the prevalence of gallstones is 10000 (men)- 20000 (women)/100000.
It is possible to estimate that in low incidence areas for gallbladder cancer as USA and Italy (0.5-1/100000) (1) a group of 20000 women with gallstones will develop a gallbladder carcinoma during a 20-year period in 20 cases. The prevalence of gallstones in Chile is nearly 20% in men and 40% in women (11). The annual incidence of gallbladder carcinoma in these populations is 5-15/100000. It means that, in these areas, in a group of 40000 women with gallstones, 300 will develop a gallbladder carcinoma over a 20-year period.
In theory, the prophylactic cholecystectomy among people with asymptomatic gallstones could prevent almost the 80% of all gallbladder cancer. The main limit of this procedure is the excessive cost. In fact, actually elective laparoscopic cholecystectomy has a cost of nearly 2000,00 euro (12, 13). It means that in high risk areas the secondary prevention of 300 gallbladder cancers would cost 80.000.000,00 euro (40000 x 2000,00 euro).
Actually nearly the 20% of the women with gallstones underwent operation for symptomatic disease (14). It means that in a group of 40.000 women with gallstones 8000 would be operated at the time of the diagnosis for biliary diseases and among the other 32000 patients another 20% (6400) would be operated during the successive 20 years (total 14400). Three hundreds women would be cured or operated for gallbladder cancer (each DRG fro biliary or pancreatic malignant diseases in Italy is 10.000,00 euro) with a cost of 300.000,00 euro. The comprehensive costs are of 28.800.000,00 euro (14400 x 2000,00 euro) for cholelithiasis and 300.000,00 euro for gallbladder cancer (total: 29.100.000,00 euro) with a spare of nearly 50.000.000,00 euro.
In conclusion, the secondary prevention of gallbladder cancer among people with asymptomatic gallstones would triplicate the costs of public health for the treatment of benignant and malignant biliary tract diseases.
At the moment the secondary prevention of gallbladder cancer in low - and high-risk countries can be achieved by prophylactic cholechystectomy in selected high risk groups as: patients with porcelain gallbladder (15), patients with cholesterol or combination stones larger than 3 cm. (5), patients with gallbladder polyps larger than 1 cm. (16).
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