Gallbladder injury in blunt abdominal trauma

A 36-year-old woman was admitted to the hospital for an abdominal blunt trauma. At ultrasound (US) and computed tomography (CT), a gallbladder lesion was suspected, along with a tear of the liver. The patient was submitted to a diagnostic laparoscopy. The gallbladder was partially avulsed and bile was infiltrated in the hepatoduodenal ligament. Intraoperative cholangiography and Kocher's maneuver excluded other lesions. Laparoscopic cholecystectomy was performed, but due to severe hemorrhage from the liver tear, the operation was converted to an open procedure. Gallbladder lesions in blunt trauma are rare occurrences, but they are often associated with other organ injuries. US and CT scan are valuable for their diagnosis, but if a lesion is suspected, diagnostic laparoscopy is advisable in stable patients. It should be accompanied by a cystic duct cholangiography and a Kocher's maneuver to evaluate the integrity of the biliary tree. Laparoscopic cholecystectomy is generally feasible. Associated lesions require laparotomy when they are not amenable to laparoscopic treatment.

Average magnitude of heartbeat fluctuations in healthy subjects after exposure to 4 hours head down bed rest

Orthostatic intolerance, induced by microgravity exposure, has been hypothesized to be related to a disorder of the autonomic control of the cardiovascular system. Non-invasive measurement of Heart Rate Variability (HRV) have been used as a valuable tool to characterize the ability of the autonomic system to modulate the cardiovascular function by analyzing the spontaneous fluctuations of arterial pressure and heart period on a beat-to-beat basis. Concerning this, conflicting results have been reported on the heart rate and blood pressure variability responses during exposure to microG. These differences seem to be due to different experimental designes used. Moreover, the different behavior of normal subjects in response to orthostatic stress after HD, i.e. Symptomatic (S) or Non Symptomatic (NS), could play some role in producing these discrepancies [correction of dicrepancies]. In this study we suggest the analysis of "magnitude" or "volatility" as a new method to study HRV variability. The volatility is a measure of the beat-to-beat excursion capability of the heart, regardless to its direction (positive or negative): the higher the volatility, the greater the excursion. The aim of the present study was to examine R-R volatility before and after 4 hours of HD -6 degrees in normal subjects.

[Laparoscopic fundoplication in gastroesophageal reflux disease: reflexions on a personal caseload]

Ninety-two patients with severe, proton-pump-inhibitor-dependent gastro-oesophageal reflux disease were submitted to surgery and operated on by the same surgeon (SC) over the past 7 years (mean age: 42; range: 23-74 years). Partial fundoplication was performed in 14 patients with impaired oesophageal motility, while 78 total fundoplications were done in the others, 51 without, and 27 with division of the short gastric vessels. The mean follow-up was 29.5 months (range: 1-85 months). Conversion to open surgery was necessary in 6 patients (all in the first 40 cases). Perforation of the gastric fundus and early migration of the stomach into the mediastinum were the two most important complications observed. The mortality was nil. 39% of the patients complained of postoperative dysphagia but only five required endoscopic (4) or surgical (1) treatment. The percentages of dysphagia after partial fundoplication and total fundoplication with or without division of the short gastric vessels were 28%, 37% and 47%, respectively. In 83.7% the patients were satisfied with the clinical results and in 84% of cases medical treatment was avoided after surgery. On the basis of these data, laparoscopic surgery appears to be a good option for gastro-oeophageal reflux disease in selected patients with a poor response to, or dependent on medical treatment. However, the results of surgery may be subject to the limitations of a learning curve, as in all complex laparoscopic procedures.

The use of geographic information systems in major accident risk assessment and management

The paper discusses the use of modern information technologies, and in particular geographic information systems (GIS), in the management and control of major accident risk. For this purpose, the regulatory framework of the recent "Seveso II" Directive is briefly described. This asks for more transparent procedures and decision-making, and requires consultation of the public in land-use and off-site emergency planning. Correspondingly, new demands are put to support tools being developed. The main features of tools dealing with hazard sources mapping, risk assessment, risk management, and emergency planning are discussed and examples are given. Moreover, it is argued that, if appropriately designed, their use can enhance the dialog between plant operators, authorities and the public to facilitate a consensus on risk issues. Finally, limitations in the use of these tools and prospects for future developments are discussed.

[Videolaparoscopy and carcinoma of the gallbladder]

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.

Does laparoscopic cholecystectomy worsen the prognosis of unsuspected gallbladder cancer?

BACKGROUND

Several reports claim that there is a risk that laparoscopic cholecystectomy (LC) might worsen the prognosis of unsuspected gallbladder cancer.

HYPOTHESIS

Several factors rather than LC could influence prognosis.

METHODS

A retrospective clinicopathologic study was performed on 20 patients, 9 patients (3 men and 6 women, aged from 36 to 75 years [mean age, 62.3 years]) undergoing LC and 11 patients (2 men and 9 women, aged from 53 to 91 years [mean age, 65.3 years]) undergoing open cholecystectomy (OC), with postoperatively diagnosed gallbladder cancer. The correlation was evaluated between cumulative survival rates and the following 7 prognostic factors: age, sex, histopathological grade, pathologic stage, occurrence of bile spillage, type of cholecystectomy (LC or OC), and additional surgical treatments.

RESULTS

Seven patients (87%) after LC and 9 patients (82%) after OC had cancer recurrence: the difference is of no statistical significance (P =.9). There were no recurrences of cancer in the abdominal wall after either LC or OC. Survival rate was statistically correlated to tumor stage (P =.007) and to the occurrence of bile spillage (P =.002). Survival rate did not change according to whether the operation was carried out using LC or OC (P =.60).

CONCLUSION

These results would seem to lend support to the opinion that LC does not worsen the prognosis for unsuspected gallbladder cancer.

Through ARIPAR-GIS the quantified area risk analysis supports land-use planning activities

The paper first summarises the main aspects of the ARIPAR methodology whose steps can be applied to quantify the impact on a territory of major accident risks due to processing, storing and transporting dangerous substances. Then the capabilities of the new decision support tool ARIPAR-GIS, implementing the mentioned procedure, are described, together with its main features and types of results. These are clearly shown through a short description of the updated ARIPAR study (reference year 1994), in which the impact of changes due to industrial and transportation dynamics on the Ravenna territory in Italy were evaluated. The brief explanation of how results have been used by local administrations offers the opportunity to discuss about advantages of the quantitative area risk analysis tool in supporting activities of risk management, risk control and land-use planning.

Prospective clinical evaluation and follow-up of a cohort of consecutive VT/VF patients, using a staged-care protocol, including coronary arteriography, programmed electrical stimulation and cardiac surgery

The prospective evaluation and follow-up of 39 consecutive subjects with VT/VF, 6 of whom, with cardiac arrest (CA), are reported. Patients were enrolled in a specific staged-care approach protocol, which included coronary arteriography (CAR) and ventriculography (VC), in order to exclude the need of cardiac surgery, including coronary artery bypass graft (CABG), with and without left ventricular aneurysmectomy (LVA). The protocol included inducibility of VT/VF, which was verified by programmed electrical stimulation (PES) in control conditions and after antiarrhythmic therapy (ADT), to assess persistent inducibility and mainly to verify the hemodynamic sequelae of VT. VT that showed poor hemodynamic tolerance was treated with ICD, while well-tolerated VT was treated by ADT or ablation when indicated. Furthermore, PES was obtained after surgical procedures. As a first step, the patients were assigned to receive amiodarone (AMIO) (200-400 mg/daily) in the presence of EF% < 30% or contraindication to sotalol, (Group A), or sotalol (SOT) (80-140 mg/daily) in the presence of EF > or = 31%. (Group C). Conversely, in case of recurrences, patients were assigned to receive AMIO (200-300 mg/daily) plus metoprolol (MET) (20-100 mg/daily), (Group B) or, in case of intolerance to beta-blockers, to AMIO plus mexiletine (MEX) (200 mg/daily) (Group D). The four groups were similar for the type of VA, with recurrent ventricular tachycardia (RVT) being the most frequent one. The most frequent underlying cardiac disease of VA in this study was post-AMI CAD, with a rate of over 60% in all four groups. Single- and two-vessel lesions were found at CAR in various patients in all four groups, in 5/13 (38%) in Group A, in 8/14 (57%) in Group B, in 5/7 (71%) in Group C, and in 3/5 (60%) in Group D. Cardiac surgery was performed in a similar and limited number of patients in all four groups, in 4/13 (30%) in Group A, in 4/14 (35%) in Group B, in 2/7 (28%) in Group C, and in 2/5 (40%) in Group D. In 8/39 (20.5%) of the patients who underwent CABG, there was no operative or late mortality; 4/39 (10.2%) received CABG and LVA, and two died. For the amiodarone plus metoprolol and sotalol patients only, PES showed a lower residual inducibility, in comparison to the amiodarone and amiodarone + mexiletine groups. In the entire group, 7 out of 26 (27%) were still inducibile at PES while in 19/26 (64%) of the patients, an apparently effective treatment could be found, documenting the relative usefulness of PES. Recurrence rate was the highest in the amiodarone + mexiletine group and in patients with previous CA. Our data show the potential utility and limitations of ADT, even using the most effective antiarrhythmic drugs and association of drugs, mainly because of the high recurrence rate of VT observed in the present study, even in non-inducible patients [14/39 (36%)]. In conclusion, in a prospective and staged-care approach protocol of management of VT/VF patients, only a few patients with VT/VF benefited from cardiac surgery. PES could still play a role in the evaluation of the most effective ADT. Amiodarone + metoprolol seems to be the most effective ADT in these patients. Nevertheless, a high recurrence rate was observed in this patient population, even with an aggressive protocol, in the short follow-up period of 12 +/- 8 months, confirming recent data on the superiority of ICD to ADT, in patients with frequent recurrences or hemodynamically poorly-tolerated VT. In these patients, ICD therapy should definitively be preferred to ADT.

Undiagnosed Mirizzi's syndrome: a word of caution for laparoscopic surgeons--a report of three cases and review of the literature

The Mirizzi syndrome is often undiagnosed before surgery and can carry a high risk of iatrogenic damage to the common bile duct when encountered during open or, especially, laparoscopic surgery. Endoscopic management has recently been reported, but this treatment can be performed only when there is a high index of suspicion based on clinical criteria that the condition is present and therefore suggests the indication for endoscopic retrograde cholangiopancreatography (ERCP). This is not always the case. Consequently, in a considerable percentage of patients, the syndrome is discovered only after the bile ducts have been damaged during surgery. Three cases of Mirizzi's syndrome were observed in our experience of 896 laparoscopic cholecystectomies (0.3%). All patients were without typical symptoms, and the syndrome was unsuspected in spite of preoperative intravenous cholangiography. All patients required conversion to an open procedure, with two injuries of the common bile duct (a complete transection and a tear) being promptly repaired. We conclude that when this syndrome is suspected or found during surgery, the surgeon should follow these guidelines: (1) perform intraoperative cholangiography when possible, even through the gallbladder wall; and (2) dissect the gallbladder from above and, if necessary, open it to extract the stone. Dissection of Calot's triangle should never be attempted. Great expertise is required to complete the operation laparoscopically. The reported cases in the literature refer to a high percentage of conversion, underlining the technical difficulties and making this syndrome, when undiagnosed and unsuspected, a real challenge for laparoscopic surgeons.

Unexpected gallbladder cancer after laparoscopic cholecystectomy: an emerging problem? Reflections on four cases

Gallbladder cancer (GC) has been reported in 0.3-1.5% of cholecystectomies. Since the introduction of laparoscopic surgery, cholecystectomies have increased and occult GC may therefore be more frequent. Herein we analyze our own experience to determine whether there was an increase in GC. We also evaluate the risk factors for this outcome. Four patients with GC undiagnosed before surgery (four of 602 cases, or 0.66%) were submitted to laparoscopic cholecystectomy. The percentage in patients who underwent open surgery was 0.28% (two of 714 cases). Without reoperation, three patients died in the laparoscopic group and one is alive at 12 months. Trocar site metastasis was not observed. Although the percentage of GC (0.28% versus 0.66%) increased, the percentage is still in the referred average. Undiagnosed GC is on the increase. Examination of the gallbladder and a frozen section, if necessary, are recommended. Calcified gallbladders, age >70 years, a long history of stones, and a thickened gallbladder all represent significant risk factors.

[Laparoscopic adrenalectomy. A critical review of the literature]

Open adrenalectomy needs surgical incisions often large and traumatic, with a not negligible morbidity. Laparoscopic adrenalectomy, according to the experiences reported in the literature, certainly initial, but nevertheless considerable, seems to offer a sound option and will probably become one of the strongest indications of the minimal-access surgery of the retroperitoneal space. Operative times are certainly longer initially than in open surgery but morbidity is very low and mortality almost nil. The authors make a review of the literature about laparoscopic adrenalectomy with about 400 operations collected, analyzing the results and the technical details. The collected data support the conclusion that the adrenal pathology, with the exception of the malignant tumors, will be treated in the future mainly laparoscopically. Even the size of the tumor, in case of a not malignant mass, can not be considered probably a true contraindication.

Laparoscopic repair of a Morgagni hernia: report of a case and review of the literature

A case is reported of an 85-year-old woman with subacute intestinal obstruction due to a large Morgagni hernia containing the transverse colon. The repair was carried out laparoscopically without a mesh. The procedure lasted 45 min, and the patient was discharged after 4 days. According to the literature, mini-invasive repair of a Morgagni hernia can be performed easily and without complications. In only few cases was a mesh necessary. The Morgagni hernia must be considered a clear indication for laparoscopic surgery, which should be offered as the first approach to this disease.

In vitro evaluation of the cytotoxic, hemolytic and clastogenic activities of Rhizostoma pulmo toxin(s)

Cytotoxic, hemolytic and clastogenic activities of Rhizostoma pulmo toxin(s) contained in the jelly tissue free of nematocysts were investigated in mammalian cells with in vitro procedures. At the concentration of 37.6 microg/ml the tissue protein produced the death of 50% V79 cells; a similar potency was observed in terms of hemolytic activity. The toxin(s) was not clastogenic for human lymphocytes in culture at the concentration of 5 microg/ml.

Reliability of ultrasounds in detecting common bile duct stones before biliary surgery. A retrospective analysis

The aim of this study is to evaluate the diagnostic benefit of US in the preoperative screening for CBD stones in patients submitted to surgery for biliary lithiasis.

MATERIALS AND METHODS

We analyzed the data of 135 patients admitted for biliary lithiasis, jaundice or biliary pancreatitis in the last three years. Mean age was 63 years (54.8% females), 48% of the cases had an urgent admission. US of the liver and biliary ducts was the first examination performed and the patients were divided in 2 groups on the bases of the results: those with the diameter of the CBD < 1 cm (101 pts-group A) and those with a diameter > 1 cm (34 pts-group B).

RESULTS

In group A were subsequently performed: 35 IV cholangiographies (6 showed CBD stones, 1 was a false negative for CBD stones), 15 intraoperative (I.O.) cholangiographies (1 positive for CBD stones), 9 ERCP for jaundice or pancreatitis (2 positive for CBD stones). The incidence of CBD stones was 8.9% in this group. In group B were performed: 7 IV cholangiographies (2 showed CBD stones), 12 I.O. cholangiographies (6 showed CBD stones), 10 ERCP for jaundice or pancreatitis (7 showed CBD stones). The incidence of CBD stones was 44% in this group. CBD stones were detected by US in 2 cases (22%) in group A and in 6 cases (40%) in group B.

CONCLUSIONS

In our patients there is a relatively high incidence of CBD stones (8.9%) in spite of a normal CBD at US. Considering that the minimally invasive approach for the gallbladder stones is becoming the "gold standard" and the laparoscopic treatment of the CBD stones is not widely diffused, it is important to know the presence of CBD stones before surgery. With this in mind US does not seem to be a reliable diagnostic tool and we suggest that before surgery an IV cholangiography (sensitivity > 95% in our experience) should be performed together with US and ERCP in selected cases. Moreover this could reduce the number of preoperative ERCP leaving the possibility to treat more selectively by endoscopic papillosphincterotomy the patients with CBD stones before laparoscopic cholecystectomy.

[Indications for esophagogastroduodenoscopy (EGD) in the octogenarian: a first-step investigation?]

Esophagogastroduodenoscopy (EGD) is the most reliable diagnostic method to evaluate the upper digestive tract. It is conceivable that a rising number of very aged patients with dyspeptic symptoms will come to observation as a consequence of the increasing mean age of the population; however there is not yet a complete agreement to submit patients with extremely advanced age to an EGD. The aim of this study is to evaluate the indications and the tolerance of the upper digestive endoscopy in patients more than 80 yrs old. EGD. Two hundred sixteen patients (mean age 84.5 yrs) were submitted to an EGD without any sedation and pharyngeal anesthesia in one-third of cases. Indications were specific symptoms in 52.3% and aspecific in 47.7%. Tolerance was very good with only one case requiring heavy sedation. We do not report complications. As expected, a high percentage of proliferative lesions were found, but also phlogistic and peptic lesions were very common. X-Rays were performed in 20% of cases but false negatives were observed in 11.6% and false positive in 23.2%. Moreover radiological procedures were poorly tolerated in a relatively high percentage of cases. Our experience showed that: 1) EGD is a very well tolerated and safe procedure in patients with very advanced age; 2) unsuspected lesions are found even in patients with aspecific symptoms; 3) EGD should be proposed as a first study in dyspeptic very aged patients being more tolerated and more reliable than X-Rays in these cases.

[Splenectomy for hemorrhage from esophageal varices with massive thrombosis of the portal bed in the absence of cirrhosis: an intervention to be reevaluated? Reflections on a clinical case]

It has been suggested that the ideal definitive treatment of hemorrhage from esophageal varices due to extrahepatic portal hypertension should be a selective shunt, avoiding splenectomy, when possible, for its unfavorable effects. We present a case with extrahepatic portal hypertension and polycythemia vera who complained acute recurrent variceal bleeding in spite of multiple sclerotherapy sessions, with a massive thrombosis of the portal bed and radicles without any possibility to perform a shunt. The combined treatment was emergency splenectomy followed by a closed program of sclerotherapy. The result was good at two years of follow-up. The optimal treatment of patients with episodes of bleeding varices for extrahepatic portal hypertension and patency of splenic vein should be a selective shunt; poor long-term results have been reported in patients without patency of the major tributaries of the portal system and treated with other operations than shunts. Splenectomy could gave a role in producing these unhappy results. After splenectomy it has been observed an increased thrombocytosis, venous infarction of the bowel, increased susceptibility to infection and also a paradoxical higher risk of bleeding by removing low risk collaterals. From this anecdotal report it can be argued that splenectomy is not necessarily followed by bad results and can be the first therapeutic option in emergency and in some selected cases with huge, high risk varices, difficult to treat by sclerosis only, and without suitable vessel for a shunt.(ABSTRACT TRUNCATED AT 250 WORDS)

Vital staining of oesophagus in patients with head and neck cancer: still a worthwhile procedure

One hundred three patients with upper aerodigestive cancer were consecutively submitted to upper GI endoscopy with vital staining (Toluidine Blue 1%) of the oesophagus. The aim of the study was not only to confirm the prevalence of synchronous or metachronous tumour but also to verify the usefulness of the vital stain compared to simple endoscopy. Staining was positive in 29 patients (28.1%) for oesophagitis, leukoplakia, Barrett's oesophagus and 3 oesophageal neoplasms (2.9%), two of them unsuspected at endoscopy. We did not observe false positives while 13 cases (13/29-44.8%) were considered normal at endoscopy. Five cases with some endoscopic abnormality of the mucosa did not stain and were considered false negatives. Specificity of the method was 100%, sensibility 85.2%. The recognition of dysplastic changes and neoplasms not suspected at endoscopy should recommend in our opinion the use of vital staining of oesophagus in high-risk groups.

Multiple splanchnic artery aneurysms. Report of a case

It is reported the case of a patient with multiple visceral aneurysms (seven). These aneurysms are more common than usually appreciated but their multiplicity is rarely reported in the literature. Angiography should always follow surgery when a splanchnic aneurysm is recognized by chance only at operation and when the surgeon is already aware of the multiple aneurysms. It is indicated a contemporary treatment of all of them to avoid the subsequent risk of rupture which has been suggested to increase after laparotomy.