Biomedical subjects
Publications and source records attributed to V Violi.
Two cases of intrahepatic subcapsular hematoma as an early complication of laparoscopic cholecystectomy are described. The clinical course of these two patients is described, and possible causes of, and treatment modalities for, this unusual complication are discussed.
Massive gastric bleeding in a 28-yr-old woman requiring emergency surgical treatment was found to originate from a polypoid carcinoid tumor 1.3 cm in diameter. Histologically, the tumor was found to be associated with a complex vascular malformation apparently originating from the underlying submucosa, crossing the tumor and ending in large mucosal sinusoids that opened on the mucosal surface. A similar clinical presentation was reported in three previous cases of small gastric carcinoids, one of which revealed an anomalous intratumoral bleeding artery. We recommend that in the absence of more common causative lesions of gastric bleeding, gastric carcinoid be considered in cases of focal massive hemorrhage requiring emergency treatment.
Despite the tendency toward sphincter-saving surgical procedures, a small proportion of rectal cancers must still be treated by abdominoperineal resection (APR). The physical, psychological and social consequences of a permanent abdominal stoma are a challenge to perform a continent perineal colostomy. Most of the attempts originate from experiences with gracilis muscle transposition in the treatment of fecal incontinence, in particular Pickrell's operation. Functional results are however conditioned by the fact that the transposed muscle takes up a different function and its natural evolution, if not adequately stimulated, consists of atrophy and fibrosis. The most important series of graciloplasty in APR is reported by Cavina and coworkers (75 cases from 1985 to 1993), who at first obtained good functional results by external electromyostimulation (EMS) and biofeedback, then registered a further improvement using internal, continuous low-frequency EMS by implantable pulse generators (IPG). The surgical technique involves, after APR: bilateral dissection of the gracilis up to the proximal neurovascular pedicle and detachment of the distal tendon; mobilization of the muscles, through the subcutaneous tissue, into the perineum, where the colonic stump is drawn out; positioning the right gracilis behind the colonic stump, as a puborectalis sling, and the left gracilis around it, in a sort of "alpha" configuration; suturing the colonic stump to the perineal skin; optionally, temporary diverting loop colostomy. The operation is completed by the insertion of two electrodes near the nerve, for external or internal EMS (in the last case: implantation of IPG). The external EMS may be carried out by current cardiac temporary electrodes, drawn up through the skin of the iliac area. It is aimed at preserving the trophism and the contractility of the muscle and enabling the patient to learn a new function of continence (actually, it is a "pseudocontinence"), thanks to a program of intermittent stimulation and biofeedback. Electrodes and other devices are not expensive. The internal EMS requires specific electrodes, connected to an IPG, implanted in a subcutaneous abdominal pocket. The continuous stimulation gives rise to a tonic activity of the gracilis, resulting in higher resting anal pressure and "true" continence. The IPG is programmed under telemetry control, step by step until the most suitable EMS parameters are reached. A magnet allows the patient to turn the IPG "off" of "on", according to the necessity to void the bowel. A complete set of 1 IPG and 2 electrodes costs about $10,000. Cavina reports good continence in 71% of the cases treated by external EMS and 100% of the patients with IPG. Our first graciloplasty in APR was performed in April 1994. Since then we have carried out 6 operations. Because of its high cost, we decided that, at least at a first phase, the IPG should be implanted, from the 7th month on, only in disease-free patients, when functional results suggested a possible clinical improvement. Until today, 3 patients have had the abdominal stoma closed and can be evaluated from a functional viewpoint. We recorded 1 "excellent" and 2 "fair" results. In the two patients with a "fair" result we implanted a pulse generator about a month after the closure of the abdominal colostomy. A good manometric and clinical improvement was registered. The patient with "excellent" functional result had a recurrence one month after the closure of the stoma. Though limited, our experience is absolutely favourable as to graciloplasty, but an evaluation from us whether external or internal EMS is better, is too early at the moment. In absolute functional terms, the internal, continuous EMS is preferable, but problems of cost and oncologic prognosis restrict the use of IPG.
The tumors of the small bowel are uncommon. About one-third are jejunal, for the most part adenocarcinomata. From 1976 to 1994 we operated on 8 patients affected by jejunal adenocarcinoma, mean age 59 years (+/- 15.2), range 37-78, which are 0.33% of all the malignant epithelial neoplasms of the digestive tract, treated in the same period. In six cases the diagnosis was preoperative, by x-ray or instrumental investigations. In the other two patients the neoplasm was found intraoperatively. Only five operations were curative. In six cases the neoplasm invaded the serosa and, in three, also the mesenterium. A chemotherapy was carried out in the last five patients. One of these underwent right hepatectomy for single metastasis, 26 months after the primary operation. Until now we registered three deaths, one of which for causes unrelated to the cancer. After discussing epidemiology and diagnostics, the authors evaluate the therapeutical possibilities, mainly consisting of surgery, and dwell upon technical aspects and results.
Several decision support systems (DSSs) for acute pancreatitis (AP) were analyzed with reference to development methods, procedure limits and operational performances. Almost all the DSSs have been addressed to the early definition of severity, which appears the only decisional point in the approach to the management of AP. None of the three groups of methods, multifactor, scoring and bayesian systems, provides an explicit evidence of effectiveness. The multifactor systems (Ranson and successive) show inadequacy of design and operational limits which involve poor reliability and conflicting indications from the different centers. The scoring systems (APACHE, SAPS) have been projected and developed for clinical situations quite different from the AP at the onset, and seem more properly to be applicable to the monitoring of its complications. The bayesian systems, although the models used until now present important methodological shortcomings, are those which furnished the best results but are lacking in clinical validation and present a form hardly accepted by the clinician. Despite the disappointing operative results and their limited use in the AP, the DSSs probably constitute one of the most effective tools to improve the management of the severe forms, on condition that the methodology of design enad trial is correctly adjusted.
Early identification of severity is one of the most important problems in acute pancreatitis, both for decision-making and classification. Predictive criteria show a wide range of accuracy: clinical examination (on admission: 76-85%); single laboratory data (PCR: 68-98%, C3-C4: 63-72%); multifactorial scoring systems (Ranson: 65-82%, Imrie: 78-95%); diagnostic peritoneal lavage (72-90%); CT features (52-81%). In 1982 we started a prospective evaluation of the prognostic performances of a bayesian statistical model for the prediction of severe vs mild pancreatis and death vs survival, which uses the outcome-related patterns of several variables, assuming their independence, analysed on a data of 44 patients. The performances have been calculated prospectively by comparing the expected vs actual results on 88 further patients (accuracy, sensitivity and specificity, respectively, in the prediction of severe pancreatitis: 92%, 92%, 93%; in the prediction of death: 95%, 97%, 87%). Moreover, the model can represent classes of risk by combining prediction of death + severe pancreatitis (DSP), survival + severe pancreatitis (SSP) and survival + mild pancreatitis (SMP) (accuracy, sensitivity and specificity, respectively, in the prediction of DSP: 97%, 83%, 100%; in the prediction of SSP: 95%, 87%, 97%; in the prediction of SMP: 95%, 97%, 90%). Our model enables clinicians dealing with other population to re-determine different variables or integrate them with new information, whenever available. It seems to be transferable and adaptable, even with a probable further increase of the performances, without compromising the objectivity of the predictive judgement and the homogeneity of the classes of risk.
A report is presented concerning 31 patients treated by laparoscopic approach under both elective and emergency conditions. The mini-invasive approach to an abdominal disease allows both the making of a direct visual diagnosis and the carrying out of biopsy or actual therapy without the need for laparotomy. Elective diagnostic laparoscopy has proved efficacious in the screening of patients affected by abdomino-pelvic neoplasms, determining the extension of the latter, staging them and judging their operability. Under emergency condition this method lends itself in particular to the study and the treatment of some cases of traumatic haemoperitoneum, intestinal obstructions resulting from adhesions and peritonitis of dubious aetiology. Explorative laparoscopy thus constitutes a valuable diagnostic and therapeutic aid, its possibilities being destined to increase with the improvement of laparoscopic techniques.
The treatment of lesions due to blunt abdominal trauma has changed considerably in the last decade. With a view to the prevention of immediate and later complications of splenectomy, conservative surgical technique have been put forward, or else, when the haemodynamic conditions of the patient permit, techniques of non-operative monitoring of splenic lesions. Laparoscopy today constitutes an approach to the diagnosis and treatment of blunt abdominal trauma which decisively favours conservative treatment. The experience presented bears witness to the potential usefulness of laparoscopy in these cases. Technological progress will widen the possibilities of this method and more detailed studies will define its exact indications.
We reviewed 26 consecutive patients from 1.1.81 to 30.6.89, 21 males and 5 females, mean age 72 (+/- 6.7) years, range 51-81, admitted and operated on for ruptured (19 cases) or leaked (7) abdominal aortic aneurysm in a general surgery unit at the University of Parma. Since we deal mainly with gastroenterologic and oncologic surgery, emergency operations were 70.2% of the overall series of aortic aneurysms, and were carried out over an actual 776 day period of emergency admission service. Nineteen patients had shock, ten being already anuric. Ultrasounds were carried out in nineteen cases, with an accuracy of 91.6% for ruptured and 57.1% for leaking aneurysms. Mortality rate, 50% was significantly related to the number of perioperative blood transfusions and anuria, which express the degree of shock and blood loss. Operative results were similar to other major series. A successful approach and management of aortic ruptured aneurysm is an uncommon challenge even in non-specialized surgical units. A vascular surgical training is therefore necessary for general surgeons.
The Authors take into consideration some topical subjects, with reference to their own experience. The percentage of patients diagnosed as having localized disease, despite improvement in diagnostic techniques, has not changed over the last decade. In local recurrences without distant metastases, surgery is the sole treatment which may improve the survival. Resection however has to be thought over, since surgery of local recurrences may be considered as curative only in a few cases and the probability of a poor result in survival and quality of life does not justify a surgical procedure when it is associated with a high operative risk. In cancers of the middle 3rd and lower rectum, staplers have favoured the choice of anterior resection, which does not show a high rate of recurrences, when compared to abdominoperineal excision. At last, progress in surgery, anaesthesiology and intensive care determined a different therapeutical attitude in the aged, either due to a lower incidence of postoperative complications, or because life expectancy in the elderly seems to justify, whenever possible, a curative procedure.
One hundred six early features were retrospectively collected on 44 patients with acute pancreatitis and stored in a database programmed on a microcomputer. Intraoperative/autopsy findings or clinical course categorized patients as having severe (n = 16) or mild (n = 28) pancreatitis. The frequency of 88 early available variables was analyzed. Twenty significant differences were found and used to program a Bayesian prediction of severity, assuming their independence. The computer's performance was assessed by retrospective testing of the patients, and a further 47 (14 severe, 33 mild) were studied prospectively, with a comparison carried out involving the unaided prediction of the clinicians. Finally, all 91 patients were retrospectively tested with the early predictive Ranson's signs and the results were compared with the computer's output. In the prospective evaluation, the computer's performance was 89.4% accuracy, 100% sensitivity, 84.8% specificity, while that of the physicians was 65.9%, 71.4%, 63.6%, respectively, like the performances of Ranson's criteria. Methodologic problems were: selecting patients to study, based on wide inclusion and exclusion in hindsight of the false-positives; dividing them into groups, based on both pathologic and clinical criteria; and the assumption of independence within the variables. The use of the procedure in other populations requires a specific analysis of the discriminant variables, but this study suggests a method to compare several samples of patients which allows prospective and controlled clinical trials.
Sixty-nine cases of early gastric cancer (EGC) were taken into consideration, out of a series of 585 operations for gastric cancer, carried out between January 1976 and June 1988. Differences between two groups (I: EGC limited to the mucosa; II: EGC with invasion of both the mucosa and submucosa) have been assessed with reference to familiarity for gastric cancer, previous gastric and duodenal pathology, symptoms, site of the lesion, histological features, lymph node metastatic involvement and results. Despite some pathological and clinical differences, modification of current surgical treatment with endoscopic management is not justified by any features, even when dealing with intramucosal, intestinal type EGC, because of possible lymph node involvement or long-term recurrences.
There are numerous systems and computerized procedures which have been developed and tested as a guide to clinical decisions. The methods used in the development of these systems can be divided into two large groups: mathematical and logical. None of these can be considered as better than the other in absolute, but the efficiency of each system depends on that problem is to be described and solved. The mathematical methods seem more suitable in the description of biological systems and for the selection of groups which have discriminant and sufficiently defined characteristics. Meanwhile the logical methods are better in the description and the formalization of more complicated clinical problems, characterized by uncertainty and availability of more or less numerous alternatives. It is foreseen that in the next years the systems for aided decision making will be programmed making use of methods belonging to both categories, and particularly, the expert systems will be planned using both artificial intelligence techniques and mathematical and statistical methods. The increasing frequency in the use of such systems in clinical practice will cause a reevaluation and a checking of most aspects of medical proceedings, as seen by the new methodologies or the traditional methods whose use could be driven by computer.
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Twenty-four patients about to undergo colorectal resection for cancer were randomly divided into two groups of 12: A and B. All had an uninterrupted colonic preparation for colonoscopy and surgery involving dietary restrictions for 4-8 days (450 calories; 25 g. proteins daily). In the group B an additional intake of 1200 Kcal. and 32 g. protein daily was given by a low-residue diet. Body weight, lymphocytes, albumin, prealbumin, C3, C4 and Complement activity (CH100) were evaluated on admission and after bowel preparation. In group A statistically significant decrease were found in all the parameters. In group B significant reduction occurred only in C4. The data confirm a relationship between immuno-nutritional state and preparation for colonic surgery, and suggest that a preoperative nutritional support may avoid or limit bio-humoral changes, indicative of an immuno-nutritional impairment.
Fifteen cases of intrahepatic lithiasis are reported, on 1798 operations for non malignant diseases of the biliary tract (0.8%), carried out by the Authors in the last 11 years. Two cases were described separately, consisting respectively of an "eastern" hepatolithiasis, and a secondary form, due to stenosis of a choledochoduodenostomy, which had been performed after surgical injury of the common bile duct. The other 13 patients had a "mixed" form. Jaundice was present in 8 of these cases, cholangitis in 4. Intrahepatic stones were diagnosed preoperatively in 3 cases and intraoperatively in 10. A bilioenteric anastomosis was carried out in 9 cases, a sphincteroplasty in 3, and a T-tube drainage in a patient with suppurative cholangitis. Two patients died postoperatively, both from sepsis: the first in the early postoperative phase, after emergency operation for cholangitis; the other, with "primitive" hepatolithiasis, 3 months after the operation. Clinical results are satisfactory after 1-11 years. On the basis of data from current literature, diagnostic and therapeutic aspects are set forth, with specific reference to the mixed and secondary forms: the bilioenteric anastomoses seem to give better chances of success, but the need to have access to lobar ducts may sometimes impose hilar derivations. Spincteroplasty may have a few indications, solely in selected patients.
A correlation was sought, in 40 patients operated on for gastric cancer, between a number of immunological and nutritional variables and oncological stage. Prealbumin, transferrin, C3, C4, total complement (CH100), total serum lymphocytes, IgG, IgA and IgM were evaluated preoperatively prior to commencing any nutritional treatment. Statistical analysis was performed with a view to assessing whether the values of the above-mentioned parameters, taken singly or as a whole, differed in the 4 in the 4 oncological stages (UICC 1978). Analysis of individual parameter values showed a significant difference between stage I and stage IV with regard to prealbumin and between stages I and II with regard to C3 (p = 0.0165 and p = 0.0329, respectively). When evaluating the 9 parameters as a whole, no significant differences emerged, though such differences might be detected on increasing the study population and by adopting statistical procedures aimed at eliminating the least significant variables from the model.