Endoscopic ultrasound-guided gallbladder drainage as a first approach for jaundice palliation in unresectable malignant distal biliary obstruction: Prospective study

OBJECTIVES

Endoscopic retrograde cholangiopancreatography (ERCP) represents the gold standard for jaundice palliation in patients with distal malignant biliary obstruction (DMBO). Biliary drainage using electrocautery lumen apposing metal stent (EC-LAMS) is currently a well-established procedure when ERCP fails. In a palliative setting the endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) could represent an easy and valid option. We performed a prospective study with a new EC-LAMS with the primary aim to assess the clinical success rate of EUS-GBD as a first-line approach to the palliation of DMBO.

METHODS

In all, 37 consecutive patients undergoing EUS-GBD with a new EC-LAMS were prospectively enrolled. Clinical success was defined as bilirubin level decrease >15% within 24 h and >50% within 14 days after EC-LAMS placement.

RESULTS

The mean age was 73.5 ± 10.8 years; there were 17 male patients (45.9%). EC-LAMS placement was technically feasible in all patients (100%) and the clinical success rate was 100%. Four patients (10.8%) experienced adverse events, one bleeding, one food impaction, and two cystic duct obstructions because of disease progression. No stent-related deaths were observed. The mean hospitalization was 7.7 ± 3.4 days. Median overall survival was 4 months (95% confidence interval 1-8).

CONCLUSION

Endoscopic ultrasound-guided gallbladder drainage with the new EC-LAMS is a valid option in palliative endoscopic biliary drainage as a first-step approach in low survival patients with malignant jaundice unfit for surgery. A smaller diameter EC-LAMS should be preferred, particularly if the drainage is performed through the stomach, to avoid potential food impaction, which could result in stent dysfunction.

EUS-guided biliary drainage with a novel electrocautery-enhanced lumen apposing metal stent as first approach for distal malignant biliary obstruction: a prospective study

Background and study aims  Endoscopic retrograde cholangiopancreatography (ERCP) represents the gold standard for jaundice palliation in malignant biliary obstruction (MBO) patients. Biliary drainage using electrocautery lumen apposing metal stent (EC-LAMS) is currently a well-established procedure when ERCP fails. We aimed to assess the technical and clinical success of a new EC-LAMS as the first approach to the palliation of malignant jaundice due to MBO in patients unfit for surgery. Patients and methods  Twenty-five consecutive patients undergoing endoscopic-guided biliary drainage with the new EC-LAMS were prospectively enrolled. Clinical success was defined as bilirubin level decrease > 15 % 24 hours after EC-LAMS placement. Results  Mean age was 76.6 ± 11.56 years, and male patients were 10 (40 %). EC-LAMS placement was technically feasible in 24 patients (96 %) and clinical success rate was 100 %. Only one patient (4 %) experienced a misplacement rescued by an immediate second EC-LAMS placement. The mean duration of hospital stay was 4.66 ± 4.22 days. The median overall survival was 7 months (95 % CI 1-7). Conclusions  In this preliminary study, the new EC-LAMS seems to allow a single-step palliative endoscopic therapy in patients affected by jaundice due to MBO, with high technical and clinical success and low adverse events. Further large prospective studies are warranted to validate these results.

People with Type Diabetes Mellitus (T1DM) self-reported views on their own condition management reveal links to potentially improved outcomes and potential areas for service improvement

BACKGROUND

The self-management of type 1 diabetes (T1DM) has moved forward in many areas over the last 40 years. Our study asked people with T1DM what is their experience of blood glucose (BG) monitoring day to day and how this influences decisions about insulin dosing.

METHODS

An on-line self-reported questionnaire containing 44 questions prepared after consultation with clinicians and patients was circulated to people with T1DM 116 responders provided completed responses. Fixed responses were allocated specific values (e.g. not confident = 0 fairly confident = 1). Multivariate regression analysis was carried out. Only those 5 factors with p-value <0.05 were retained.

RESULTS

59% of respondents were >50 years old and 66% had diabetes for >20 years, with 63% of patients reporting HbA1c results ≤8% or 64 mmol/mol. Findings included; 75% used only 1 m; 56% had used the same meter for ≥3 years; 10% had tried flash monitors; 47% were concerned about current BG level; 85% were concerned about long-term impact of higher BG. 72% of respondents keep BG level high to avoid hypoglycaemia; 25% used ≥7 mmol/L as pre-meal BG target to calculate dose; 65% were concerned they might be over/under-dosing; 83% did not discuss accuracy when choosing meter. However 85% were confident in their meter's performance. The factors that linked to LOWER HbA1c included LESS units of basal insulin (p < 0.001), HIGHER number of daily BG tests (p = 0.008), LOWER bedtime blood glucose (p = 0.009), HIGHER patient's concern over long-term impact of high BG (BG) (p < 0.009 but LOWER patient's concern over current BG values (p = 0.009). The final statistical model could explain 41% of the observed variation in HbA1c.

CONCLUSION

Many people still run their BG high to avoid hypoglycaemia. Concern about the longer-term consequences of suboptimal glycaemic control was associated with a lower HbA1c and is an area to explore in the future when considering how to help people with T1DM.

Metronidazole Encephalopathy EEG Features: A Case Report with Systematic Review of the Literature

Metronidazole-induced encephalopathy (MIE) is a rare and often under-recognized iatrogenic condition. The diagnosis should be considered in metronidazole-treated patients presenting with acute encephalopathy, unprovoked seizures and cerebellar signs. While typical magnetic resonance imaging (MRI) findings strongly support the diagnosis, electroencephalography (EEG) features have been rarely reported and poorly described. We present a longitudinal EEG assessment in one patient with encephalopathy due to metronidazole toxicity who presented a peculiar EEG pattern presentation and evolution. During the acute phase of encephalopathy, the EEG showed a monomorphic, sharply contoured theta activity symmetrically represented over frontal regions with an anterior-posterior progression which evolved in parallel with clinical worsening. Together with a systematic review of the literature, we discuss whether this EEG activity may represent a distinct neurophysiological correlate of 'cerebellar encephalopathy'.

EUS-guided trans-esophageal drainage of a mediastinal necrotic fluid collection using the axios electrocautery enhanced delivery system™

Mediastinal collection secondary to necrotic acute pancreatitis, is an extremely rare event caused by the posterior rupture of the pancreatic duct into the retroperitoneal space with the penetration of the pancreatic fluid through the diaphragmatic orifices. Infection of the necrotic collection may occur with a consequent substantial increase of the mortality rate. Due to the rarity of this severe condition, no consensus is known about the management of infected mediastinal necrotic collections. We reported the case of a 61-year-old male who was critically unwell secondary to a large mediastinal necrotic collections after necrotic acute pancreatitis with no improvement after surgery. The patient was successfully treated by EUS-guided trans-esophageal drainage using the AXIOS Electrocautery Enhanced Delivery System™. This procedure proved in this case to be a safe and effective option for the management of infected necrotic mediastinal collections.

Effect of glycaemic control on complications following cardiac surgery: literature review

Introduction

No uniform consensus in the UK or Europe exists, for glycaemic management of patients with Diabetes or pre-diabetes undergoing cardiac surgery.

Objective

[i] Determine the relationship between glycaemic control and cardiac surgical outcomes; [ii] Compare current vs gold standard management of patients with Diabetes or pre-diabetes undergoing cardiac surgery.

Methods

Searches of MEDLINE, NHS Evidence and Web of Science databases were completed. Articles were limited to those in English, German and French. No date limit was enforced.13,232 articles were identified on initial literature review, and 50 relevant papers included in this review.

Results

No national standards for glycaemic control prior to cardiac surgery were identified. Upto 30% of cardiac surgical patients have undiagnosed Diabetes. Cardiac surgical patients without Diabetes with pre-operative hyperglycaemia have a 1 year mortality double that of patients with normoglyacemia, and equivalent to patients already diagnosed with Diabetes. Pre- and peri-operative hyperglycaemia is associated with worse outcomes. Evidence regarding tight glycaemic control vs moderate glycaemic control is conflicting. Tight control may be more effective in patients without Diabetes with pre−/peri-operative hyperglycaemia, and moderate control appears more effective in patients with pre-existing Diabetes. Patients with well controlled Diabetes may achieve comparable outcomes to patients without Diabetes with similar glycaemic control.

Conclusions

Pre / peri-operative hyperglycaemia is associated with worse outcomes in both patients with, and without Diabetes undergoing CABG. This review supports the pre-operative screening, and optimisation of glycaemic control in patients undergoing cardiac surgery. Optimal glycaemic management remains unclear and clear guidelines are needed.

Six-year longitudinal study of Fasciola hepatica bulk milk antibody ELISA in the dairy dense region of the Republic Ireland

Completion of the F. hepatica lifecycle is dependent on suitable climatic conditions for development of immature stages of the parasite, and its snail intermediate host. Few investigations have been conducted regarding temporal variations in F. hepatica status in Irish dairy herds. The current study aimed to conduct a longitudinal study examining annual and seasonal trends in bulk milk seropositivity over six years, while also investigating associations with soil temperature, rainfall and flukicide treatment. Monthly bulk milk samples (BTM) were submitted by 28 herds between March 2009 and December 2014. In all, 1337 samples were analysed using a Cathepsin L1 ELISA. Soil temperature, rainfall and management data were obtained for general estimating equation and regression analyses. A general decrease in milk seropositivity was observed over the six year study period and was associated with an increased likelihood of treating for liver fluke (OR range=2.73-6.96). Annual and seasonal analyses of rainfall and F. hepatica BTM status yielded conflicting results. Higher annual rainfall (>1150mm) yielded a lower likelihood of being BTM positive than annual rainfall of <1000mm (OR=0.47; P=0.036). This was most likely due to farmers being more proactive in treating for F. hepatica in wetter years, although a 'wash effect' by high rainfall of the free living stages and snails cannot be ruled out. Higher seasonal rainfall (>120mm), however, was associated with increased ELISA S/P% values (Coefficient=9.63S/P%; P=0.001). Soil temperature was not found to influence F. hepatica to the same extent as rainfall and may reflect the lack of severe temperature fluctuations in Ireland. Flukicides active against both immature and mature F. hepatica were approximately half as likely to record a positive F. hepatica herd BTM status than a flukicide active against only the mature stage of the parasite (OR≅0.45; P<0.01). This study highlights the importance of examining both annual and seasonal F. hepatica data, which can vary significantly. Additionally, it highlights the progress that can be achieved in fluke control by application of a continuous BTM monitoring program.

US-guided application of Nd:YAG laser in porcine pancreatic tissue: an ex vivo study and numerical simulation

BACKGROUND

Laser ablation (LA) with a neodymium-doped yttrium aluminum garnet (Nd:YAG) laser is a minimally invasive approach able to achieve a high rate of complete tissue necrosis. In a previous study we described the feasibility of EUS-guided Nd:YAG pancreas LA performed in vivo in a porcine model.

OBJECTIVE

To establish the best laser setting of Nd:YAG lasers for pancreatic tissue ablation. A secondary aim was to investigate the prediction capability of a mathematical model on ablation volume.

DESIGN

Ex vivo animal study.

SETTING

Hospital animal laboratory.

SUBJECTS

Explanted pancreatic glands from 60 healthy farm pigs.

INTERVENTION

Laser output powers (OP) of 1.5, 3, 6, 10, 15, and 20 W were supplied. Ten trials for each OP were performed under US guidance on ex vivo healthy porcine pancreatic tissue.

MAIN OUTCOME MEASUREMENTS

Ablation volume (Va) and central carbonization volume (Vc) were measured on histologic specimens as the sum of the lesion areas multiplied by the thickness of each slide. The theoretical model of the laser-tissue interaction was based on the Pennes equation.

RESULTS

A circumscribed ablation zone was observed in all histologic specimens. Va values grow with the increase of the OP up to 10 W and reach a plateau between 10 and 20 W. The trend of Vc values rises constantly until 20 W. The theoretical model shows a good agreement with experimental Va and Vc for OP between 1.5 and 10 W.

LIMITATIONS

Ex vivo study.

CONCLUSION

Volumes recorded suggest that the best laser OP could be the lowest one to obtain similar Va with smaller Vc in order to avoid the risk of thermal injury to the surrounding tissue. The good agreement between the two models demonstrates the prediction capability of the theoretical model on laser-induced ablation volume in an ex vivo animal model and supports its potential use for estimating the ablation size at different laser OPs.

Theoretical assessment of principal factors influencing laser interstitial thermotherapy outcomes on pancreas

The influence of some therapy-relevant parameters on Laser Induced Interstitial Thermotherapy (LITT) outcomes on pancreas is assessed. The aim is to execute a sensitivity analysis for an optimal treatment strategy on in vivo pancreas. A numerical model based on Bioheat Equation has been implemented to assess the influence of laser settings (power P and energy E), applicator radius (r(f)) and optical properties (effective attenuation coefficient, μ(eff)) on temperature (T) distribution. Effects on pancreas undergoing LITT have been evaluated with a twofold approach: 1) T rise and maximum T (T(max)) in tissue; 2) injured volumes (vaporized and coagulated ones). We consider parameters range in typical LITT values (P from 1.5 W to 6 W, E from 500 J to 1500 J, r(f) from 150 µm to 600 µm) and optical values reported in literature. Our analysis shows that, among others, P and μ(eff) are the principal influencing factors of thermal effects on pancreas undergoing LITT: P should be carefully chosen by operator to obtain the desired injured volumes, while the accurate measurement of tissue optical properties is crucial to carry out a safe and controlled thermal therapy on pancreas.

Laser Interstitial Thermotherapy for pancreatic tumor ablation: theoretical model and experimental validation

This study aims to develop and verify a theoretical model to reproduce the thermal response of pancreatic tissue undergone Laser Induced Interstitial Thermotherapy (LITT). The model provides the evaluation of: a) ablated volumes induced by thermal ablation; b) tissue response time to irradiation; and c) heat extinction time. Theoretical volume values were compared with ex vivo healthy tissue and in vivo healthy and neoplastic tissue volume values. The theoretical model takes into account the differences between healthy and neoplastic tissue due to blood perfusion. Mathematical model shows that ablated volume of ex vivo healthy tissue is greater than in vivo one after the same treatment. Moreover, ablated neoplastic in vivo tissue volume is greater than healthy in vivo one, because of tumour angiogenesis. Ablated volume values were compared with experimental data obtained by laser treatment of 30 ex vivo porcine pancreases. Experimental ablated volume values show a good agreement with theoretical values, with an estimated increase of 61% when power increases from 3 W to 6 W, versus 46% of experimental data, and an estimated increase of 14% from 6 W to 10 W, versus 21% of experimental values. LITT could be an alternative or a neo-adjuvant treatment to surgical resection for pancreas cancer removal, and the proposed model could be the basis to supervising the evolution of ablated volumes during tumor treatment.

EUS-guided Nd:YAG laser ablation of normal pancreatic tissue: a pilot study in a pig model

BACKGROUND

Laser ablation with a neodymium:yttrium aluminum garnet (Nd:YAG) laser can achieve a high rate of complete tissue necrosis and has been applied as a minimally invasive, palliative option in hepatocellular carcinoma, liver metastasis in colorectal cancer, and malignant thyroid nodules.

OBJECTIVE

To assess the in vivo feasibility of EUS-guided laser ablation with an Nd:YAG laser of normal pancreatic tissue of a porcine model.

DESIGN

Prospective investigation.

SETTING

Hospital animal laboratory.

SUBJECTS

Eight pigs.

INTERVENTIONS

EUS-guided puncture of the pancreatic tail with a laser-beam fiber. An Nd:YAG laser (1.064 nm) was used, with an output power of 2 and 3 W and a total delivered energy of 500 and 1000 J in continuous mode.

MAIN OUTCOME MEASUREMENTS

The 24-hour follow-up of the pigs was focused on clinical and laboratory aspects. Results of histological studies of the pancreas were obtained 24 hours after the procedure on necroscopy tissue.

RESULTS

There were no technical limitations to the performance of the procedure. Tissue necrosis, localized in the pancreatic parenchyma, was observed in all animals on histological examination. The volume of ablation tissue ranged from a mean of 314 mm(3) to 483 mm(3). The ablation area ranged from a mean of 49 mm(2) to 80 mm(2). No major postprocedure complications were recorded, and all the pigs survived at 24 hours.

LIMITATION

Animal study.

CONCLUSIONS

EUS-guided laser ablation of the pancreas with an Nd:YAG laser is feasible in a porcine model.

Effects of metformin and oleic acid on adipocyte expression of resistin

AIM

The adipocyte-secreted hormone resistin has been implicated in obesity-induced insulin resistance and type 2 diabetes, but pharmacological and dietary factors that regulate resistin gene expression and the effects of resistin on cellular glucose uptake in muscle have not been clearly defined.

METHODS

Expression of resistin mRNA was studied in differentiated 3T3-L1 adipocytes by using real-time semiquantitative reverse transcription-polymerase chain reaction. The effects of resistin on insulin-stimulated and insulin-independent 2-deoxyglucose uptake were evaluated in L6 muscle cells.

RESULTS

Insulin 1 microm and rosiglitazone 10 microm markedly reduced resistin mRNA expression (relative to the control gene TF2D) by 4.7-fold (p < 0.05) and 5.3-fold (p < 0.02), respectively. Similar reductions in resistin mRNA were demonstrated with metformin 100 microm (6.2-fold reduction, p < 0.02) and oleic acid 100 microm (3.9-fold reduction, p < 0.03). Resistin 1 microm significantly reduced maximum insulin-stimulated 2-deoxyglucose uptake in L6 cells from 634 to 383% (relative to 100% for control, p < 0.001), and co-administration of rosiglitazone had no effect on resistin-induced insulin resistance. In the absence of insulin, however, resistin increased glucose uptake dose-dependently (e.g., 1.75-fold at 5 microm, p < 0.001) via a mitogen-activated protein kinase-dependent pathway.

CONCLUSIONS

These results demonstrate that various glucose-lowering therapies and oleic acid reduce resistin gene expression in isolated adipocytes, and that resistin impairs insulin-stimulated glucose uptake in skeletal muscle-derived cells.

The inherited episodic ataxias: how well do we understand the disease mechanisms?

The past few years have seen the elucidation of several neurological diseases caused by inherited mutations of ion channels. In contrast to many other types of genetic disorders, the "channelopathies" can be studied with high precision by applying electrophysiological methods. This review evaluates the success of this approach in explaining the mechanisms of two forms of episodic ataxia that are known to be caused by mutations of ion channels: episodic ataxia type 1 (EA1, caused by K+ channel mutations) and episodic ataxia type 2 (EA2, caused by Ca2+ channel mutations). Although both of these disorders are rare, they raise many important questions about the roles of identified channels in brain function. Indeed, a resolution of the mechanisms by which both diseases occur will represent a major milestone in understanding diseases of the CNS, in addition to opening the way to novel possible treatments.

Clinical, genetic, and expression studies of mutations in the potassium channel gene KCNA1 reveal new phenotypic variability

Episodic ataxia type 1 (EA1) is an autosomal dominant central nervous system potassium channelopathy characterized by brief attacks of cerebellar ataxia and continuous interictal myokymia. Point mutations in the voltage-gated potassium channel gene KCNA1 on chromosome 12p associate with EA1. We have studied 4 families and identified three new and one previously reported heterozygous point mutations in this gene. Affected members in Family A (KCNA1 G724C) exhibit partial epilepsy and myokymia but no ataxic episodes, supporting the suggestion that there is an association between mutations of KCNA1 and epilepsy. Affected members in Family B (KCNA1 C731A) exhibit myokymia alone, suggesting a new phenotype of isolated myokymia. Family C harbors the first truncation to be reported in KCNA1 (C1249T) and exhibits remarkably drug-resistant EA1. Affected members in Family D (KCNA1 G1210A) exhibit attacks typical of EA1. This mutation has recently been reported in an apparently unrelated family, although no functional studies were attempted. Heterologous expression of the proteins encoded by the mutant KCNA1 genes suggest that the four point mutations impair delayed-rectifier type potassium currents by different mechanisms. Increased neuronal excitability is likely to be the common pathophysiological basis for the disease in these families. The degree and nature of the potassium channel dysfunction may be relevant to the new phenotypic observations reported in this study.

Mitochondria exert a negative feedback on the propagation of intracellular Ca2+ waves in rat cortical astrocytes

We have used digital fluorescence imaging techniques to explore the interplay between mitochondrial Ca2+ uptake and physiological Ca2+ signaling in rat cortical astrocytes. A rise in cytosolic Ca2+ ([Ca2+]cyt), resulting from mobilization of ER Ca2+ stores was followed by a rise in mitochondrial Ca2+ ([Ca2+]m, monitored using rhod-2). Whereas [Ca2+]cyt recovered within approximately 1 min, the time to recovery for [Ca2+]m was approximately 30 min. Dissipating the mitochondrial membrane potential (Deltapsim, using the mitochondrial uncoupler carbonyl cyanide p-trifluoromethoxy-phenyl-hydrazone [FCCP] with oligomycin) prevented mitochondrial Ca2+ uptake and slowed the rate of decay of [Ca2+]cyt transients, suggesting that mitochondrial Ca2+ uptake plays a significant role in the clearance of physiological [Ca2+]cyt loads in astrocytes. Ca2+ signals in these cells initiated either by receptor-mediated ER Ca2+ release or mechanical stimulation often consisted of propagating waves (measured using fluo-3). In response to either stimulus, the wave traveled at a mean speed of 22.9 +/- 11.2 micrometer/s (n = 262). This was followed by a wave of mitochondrial depolarization (measured using tetramethylrhodamine ethyl ester [TMRE]), consistent with Ca2+ uptake into mitochondria as the Ca2+ wave traveled across the cell. Collapse of Deltapsim to prevent mitochondrial Ca2+ uptake significantly increased the rate of propagation of the Ca2+ waves by 50%. Taken together, these data suggest that cytosolic Ca2+ buffering by mitochondria provides a potent mechanism to regulate the localized spread of astrocytic Ca2+ signals.

[Ultra-low laparoscopic rectal resection and colo-anal anastomosis. Experimental study on swine]

Nowadays oncologic surgery is defining new criteria in the treatment of rectal cancer: preservation of sfincterial function, ultra-low resections with distal margin at only 2 cm distally to the tumor, role of mesorectum as preferential site of lymphatic diffusion, preservation of lombo-aortic and pelvic nerves. Laparoscopy is showing good results in bowel surgery so as previously got on biliary tract: less visceral manipulation, less stimulation of immunologic system, less pain, early resumption of peristalsis and food intake, better recovery, less hospital stay. We experimented on pig ultra-low laparoscopic resection of the rectum, with preservation of sfincterial function, and mechanical anastomosis at the upper edge of the sfincterial ring. The evaluation of surgical technique, post-operative supervision, and follow-up instrumental control (anal manometry, endo-rectal ultrasonography, sfincterial electtromanometry, Rx barium enema) show technical feasibility and confirm a better recovery with regular defecatory function.

[Segmental liver transplantation. Experimental studies in swine]

Authors report the results of an experimental application of one of the more recent techniques of liver transplantation, which has the preparation ex situ as a basilar step of the procedure. 18 pig were operated on, from september 1991 to march 1993; they were divided in two groups: the first (group A) underwent an auxiliary segmental autotransplantation of left lobe to heterotopic subdiaphragmatic location; in group B an orthotopic segmental autotransplantation of right lobe after ex situ preparation of the liver according the technique of Pichlmayr was performed. The results show that a bigger application of ex situ surgery may help to find a resolution to the problem of the small number of liver donation.

[Accidents and injuries in 4 general hospitals of the Distrito Federal]

We report the injuries for "E" code in 10191 subjects attending four general hospitals of Mexico City. Seventy-nine per cent of them were males and 29.1 per cent were females. THe highest utilization rate of the care unit was during weekends. Only 14 per cent of the study population were admitted to the hospital. People classified as drunk were more likely to have more severe injuries and to be admitted to the hospital and female drinkers had the highest risk of hospitalization (RR = 3.03; IC = 1.85-5.04). Only in 49 per cent of the cases was the external cause of injury coded The main causes were gunshots and stabbing with knife or cutting weapon. In this study we found a greater proportion of fractures in women than in men, pointing toward the possible presence of osteoporosis in the female population.

[The criteria of choice in the palliative therapy of cancer of the pancreas]

Explorative laparotomy and palliative surgery keep on having the leadership, in the treatment of exocrine tumours of the pancreas, in spite of important diagnostic and surgery progress. The authors have looked at international literature and their own experience, to simplify the choice of better treatment for each patient. They compared the reliability of various diagnostic technologies and different surgery options. Metastasis and lymphatic invasion are limiting factors for surgery; the first lymphatic stage and duodenum fixation still consent curative surgery. Biliary decompression through external catheter or transpapillary endoscopic prosthesis has a primary role in the diagnostic therapeutic decision. The authors preferred to reserve gastro-jejunostomy to patients with duodenum obstruction. They choose an anterior trans-mesocolic gastro-jejunostomy with Roux-en-y reconstruction, with an upper bilio-enteroanastomosis. Pain relief is one of the most important goal in pancreas' cancer: anaesthetic and surgery techniques lead to good and long-standing results. Explorative laparotomy is often the only technique that leads to the final decision about a therapeutic plan, because it shows size, location and characteristic of the tumour and his metastasis in lymphatic and anatomic structures. The integration of metasurgery therapy (chemo-, radio-, hormono ...) allows, together with pain treatment, to improve the results above all the quality of life in carcinoma of the pancreas.

[Intestinal gases and digestive pathology: clinical syndromes and their treatment]

A number of annoying and frequent disturbances caused by an increase in intestinal meteorism have aroused the interest of students since the last century. Aerophagy, abdominal distension, flatulence represent the commonest aspects of this frequent gastroenterological pathology. The new diagnostic approaches have made it possible to classify the principal mechanisms involved in the production and elimination of intestinal gases. It has thus been possible to study with greater precision the composition of gaseous content and the origin and removal of intestinal gases. It is possible to demonstrate an increase in intestinal gas in various conditions, not only in relation to concomitant organic factors but also following surgery and disease situations triggered by functional or reflex mechanisms. Basic diagnosis is important because if correctly classified these pathological conditions can be resolved with simple therapeutic aids.

Spinal sympathetic conduction velocity in humans

Simultaneous micro-electrode recordings of muscle sympathetic activity were made in the radial nerve at the mid-humerus level and the peroneal nerve at the fibular head in 8 healthy subjects. Sympathetic impulses occurred spontaneously in multi-unit bursts time-locked to the cardiac rhythm. There was a high degree of similarity between radial and peroneal neurograms with the radial bursts preceding corresponding peroneal ones by approximately 0.35 s. Utilizing this latency difference and previously determined values for peripheral sympathetic postganglionic conduction velocities, we calculated that the spinal conduction velocity for muscle sympathetic activity is 2.8 +/- 0.7 m/s (mean +/- SD). The result agrees with similar data from experimental animals.