Laparoscopic cholecystectomy and endoscopic sphincterotomy under a single anesthetic: a case report

Several options have been described for the management of unsuspected common bile duct stones diagnosed for the first time by transcystic cholangiography during laparoscopic surgery. These include immediate conversion to open laparotomy and formal common bile duct exploration, laparoscopic bile duct exploration, or postoperative biliary endoscopy (i.e., ERCP with sphincterotomy and stone extraction). Herein we describe a fourth option which allows the surgeon to manage both cholelithiasis and choledocholithiasis at the time of laparoscopic intervention: endoscopic sphincterotomy performed immediately after laparoscopic cholecystectomy under one anesthetic. This option seems the most logical when the surgeon wishes to preserve the minimally invasive approach.

[A report of a rare case of primary angiosarcoma of left atrium and a review of the literature]

A 66[correction of 60]-year-old female patient was admitted to hospital for clinical signs of pericardial tamponade. The pericardiocentesis revealed an hematic effusion and a left appendage mass was diagnosed by transesophageal echocardiography. At surgery, a left atrial tumour was resected which histological examination showed to be an undifferentiated angiosarcoma-endothelioma with difficult histological classification. The tumoral screening was negative and the patient was discharged from the hospital. Seven months later the patient was readmitted for two parasternal tumours which anatomopathologic study revealed to be subcutaneous metastases. The rare localization in the left atrium and subcutaneous metastatic spread were discussed.

[Conservative mitral surgery for a tear of the valvular leaflets post-percutaneous mitral commissurotomy]

A case of a 32-year-old woman who developed acute mitral insufficiency after percutaneous mitral dilatation is presented. In spite the fact of having torn both leaflets, successful plastic repair of her valve was performed.

[Bullet embolism of the right ventricle following gunshot wound]

Bullet embolism to the right ventricle after a gunshot wound is exceptional. We describe a patient in whom the bullet after entering through the superior vena cava migrated for the venous system with further embolism to the right ventricle. Clinical history, diagnosis and treatment are discussed.

The Monostrut Björk-Shiley valve. Seven years' experience

The results of cardiac valve replacement with the Monostrut Björk-Shiley prosthesis (Shiley, Inc., Irvine, Calif.) during a 7-year period are presented. A total of 984 valves were implanted in 820 patients from May 1983 to April 1990. Aortic valve replacement was performed in 378 patients, mitral replacement in 294, and multiple replacement in 148. In addition, 180 patients (22%) underwent associated procedures. Mean age was 52.6 +/- 11 years. Operative (30 days) mortality was 5.9% (49 patients): 3.9% (15 patients) for aortic, 7.8% (23 patients) for mitral, and 7.4% (11 patients) for multiple valve replacement. All patients were given long-term anticoagulation therapy. Follow-up was 99% complete (eight patients were lost to follow-up), with a closing interval of 3 months, and totaled 2422 patient-years. Valve-related complications, expressed as percentage event-free (+/- standard error) at seven years were as follows: structural deterioration, 100%; nonstructural dysfunction, 98.3% +/- 0.6%; thromboembolism, 90.2% +/- 1.7%; anticoagulant-related hemorrhage, 88.7% +/- 2.8%; and prosthetic valve endocarditis, 98.1% +/- 0.8%. There were no cases of valve thrombosis. Actuarial survival (free from operative, valve-related, and sudden death) was 88.4% +/- 1.2% at 7 years. Freedom from reoperation was 96.8% +/- 0.1%. Probability of being free from all valve-related morbidity and mortality was 70% +/- 3%, and 708 (93%) of the survivors were in New York Heart Association class I or II. Serial Doppler echocardiograms were done prospectively in 243 patients (with 154 aortic and 120 mitral prostheses), both postoperatively and at regular intervals up to 3 years. Mean prosthetic gradients ranged from an average of 20.9 to 7 mm Hg in the aortic prostheses (21 to 29 mm) and from 6.1 to 4.8 mm Hg in the mitral prostheses (25 to 31 mm). The gradients in each patient did not change significantly during the follow-up period. Our 7 year's experience with the Monostrut valve shows a low rate of valve-related complications, a durable design, and good hemodynamic and functional results.

[An obstruction of a valve prosthesis implanted in the tricuspid position]

Dysfunction of a prosthesis implanted in tricuspid position is a severe complication that may develop with minimal symptoms. A patient who presented clinical manifestations of heart failure for two weeks due to obstruction of a mechanical prosthesis in tricuspid position is described. Fibrinolytic treatment was given unsuccessfully, therefore prosthetic replacement was performed. In the removed prosthesis, a fibrotic pannus which developed in the strut and disc was seen. We review the clinical manifestations, the diagnosis and treatment of the dysfunction of a prosthesis implanted in tricuspid position.

[A critical review of the history of the systems for staging colorectal cancer]

A great debate is still open in literature about the available staging systems of colorectal cancer. Therefore, an historical analysis of the several systems suggested in the last decades was performed; pathological, clinicopathological and more recent score clinicopathological staging systems were evaluated. From this historical review it appears that subsequent modifications of various classifications allowed only for a poor improvement in predictivity. A more careful histopathological examination of surgical specimen and more exact information about involvement of other organs and tissues allow a correct classification of patients affected by colorectal cancer independently of the staging system used.

Findings on Doppler echocardiography in asymptomatic intravenous heroin users

To detect potential cardiac abnormalities induced by intravenous heroin use, 68 persons without a previous episode of infective endocarditis were studied by Doppler echocardiography. A control group of 41 normal subjects was studied for comparison. The following measurements were considered: (1) diameter of heart chambers, (2) systolic left ventricular function, (3) morphologic valvular abnormalities, (4) presence of valve regurgitations, (5) Doppler indexes of diastolic function, and (6) estimation of pulmonary arterial resistances. Results showed no significant differences regarding the size of the heart chambers or systolic left ventricular function. A significantly higher incidence of valvular abnormalities (focal thickening or valve prolapse) was found in drug addicts (p = 0.0009) at the mitral and tricuspid valves, as was valvular regurgitation detected by Doppler (p = 0.04). Also, a significantly prolonged deceleration time of mitral and tricuspid early diastolic Doppler flow was found in the study group (p = 0.0001 and 0.027, respectively) although a different hemodynamic condition in the study group (pharmacologically reduced preload) precluded these findings to be attributable to an actual diastolic dysfunction. No differences were observed in pulmonary arterial resistances. It is concluded that mitral and tricuspid valve abnormalities can be detected by echocardiography in asymptomatic intravenous heroin users, whereas no apparent effects are observed in morphologic or functional parameters of cardiac structures other than the valves.

[Ambulatory transesophageal echocardiography: 2 years of experience]

In this report we study the value of ambulatory transesophageal echocardiography (TEE) in the clinical setting after a 2-year experience at our department. Since December 1988 until February 1991, 470 TEE examinations were indicated in 430 patients. Excluded were 8 cases, two out of them due to a formal contraindication and six who did not tolerate the procedure. The clinical indications for the examination, in the 462 studies performed, were as follows: possible cardiac source of emboli in 165 (35%); native mitral valve disease in 91 (20%); prosthetic valve dysfunction in 54 (12%); diseases of the aorta in 44 (10%); suspected infective endocarditis in 41 (9%); study of left ventricular function in 26 (6%); congenital heart disease in 18 (4%); tumor or intracardiac mass in 11 (2%); miscellaneous in 12 (2%). Based on this experience, we can conclude that TEE is a clinically useful technique for: 1) the study of mitral regurgitation, either native or prosthetic; 2) the detection of vegetations and abscesses in infective endocarditis; 3) the evaluation of a possible cardiac source of emboli; 4) the examination of the aorta in cases of suspected dissection; 5) the completion of the anatomic study in some congenital heart diseases, particularly after a surgical correction; 6) the study of patients with a technically inadequate transthoracic approach.

[Occult hepatic metastases from colorectal carcinoma: diagnostic and prognostic considerations]

Occult hepatic metastases (OHM) from colorectal cancer are those not evident to the surgeon at laparotomy. In this retrospective and "deductive" study the Authors evaluated the accuracy of hepatic CT scan and ultrasonography (US) to detect hepatic metastases. The CT and US accuracy rate was 78.4% and 79.8% respectively, and proved to be correlated to the intraoperative dimensions of the lesions. Sensitivity of these examinations, in the light of OHM identification, decreased to 69% and 69.2% respectively. This study shows that hepatic US and CT scan are not sufficient to identify OHM; the attempt to reduce the frequency of OHM by means of intraoperative ultrasonography could allow to obtain a more careful stadiation and prognosis of these neoplasms with possible therapeutic advantages.

[Pelvic recurrences after curative surgery for rectal cancer]

This report updates an experience with local recurrences of rectal cancer after curative surgery. Overall 13 year period (1976-1988) 254 patients were operated on in the II Surgical Clinic of Parma University for rectal cancer. Only 122 patients who underwent potentially curative resection were examined. Approximate recurrence rates according to patients age, site, type and stage of primitive tumour, tumour complications and surgical procedures were evaluated. The overall local failure rate was 17.2% with 12 patients having local failure alone and 9 patients having concurrent local failure and distant metastasis. Local failure occurred predominantly in tumour bed, involving the anastomosis in 2 cases. Relapse developed primarily at colo-rectal anastomosis in only 1 patients, 20% of recurrences were diagnosed within the first postoperative year; 65% within the second and 90% within the third. Stage of primary tumour was the most predictive factor for eventual relapse. Minute foci of tumour not encompassed by the first operation led to local recurrences in most of the cases, but relapses were independent of operative procedures adopted. The authors conclude that surgery, even if correctly performed, is not sufficient to prevent the risk of local recurrence of rectal cancer. They believe that routine adjuvant radiation therapy after surgical treatment of rectal cancer should improve survival rate.

[Locoregional recurrences following curative surgery for colon cancer]

This study explores the patterns of local recurrence after curative operations for colonic cancer. Over a 13 year period (1976-1988) 486 patients were operated on in the Surgical Clinic of Parma University for colonic cancer, but only 296 patients who underwent potentially curative resection were examined. The influence of patients' age, disease stage, site and grade, presence of obstruction or perforation and type of surgical procedures were examined as prognostic factors for local cancer recurrence. A total of 28 patients (14%) relapsed after surgery and 19 were found to have simultaneous distant metastasis. 86% of recurrences were evident within the first 2 years. Local recurrence rate increased with more advanced Duke's stage and stage of the primary tumour was most predictive for eventual relapse. The recurrences occurred within the operative resection site involving the anastomosis by inward growth at the suture line. Minute foci of adenocarcinoma not encompassed by the first operation might lead to local recurrences; the authors do not rule out, however, the rare possibility of the implantation of exfoliated malignant cells. Despite the attempt to carry out an intensive followup in terms of early diagnosis of recurrence in colonic surgery, the presence of local recurrences is associated with extremely poor prognosis independent of operative procedure performed. The authors believe that routine adjuvant radiation therapy after surgical treatment of locally advanced colonic cancer could improve survival rate.

[Intraoperative transesophageal echocardiography: initial experience with 60 patients]

To assess the usefulness of intraoperative transesophageal echocardiography (ITE), this technique was applied in 60 non-selected cardiac patients operated on in our hospital by the surgical team. Only one case was excluded because it was not possible to introduce the probe, and no complications were observed in any patient. ITE permitted: 1) to obtain images without interruption and with no interference with the surgeons or anesthesiologists; 2) to confirm the preoperative diagnosis; 3) to facilitate the surgical approach; 4) the monitoring of left ventricular function, and 5) to evaluate the immediate results of the surgical procedures, particularly the assessment by Doppler technique of residual valvular regurgitations after valve repair. A minor but not disdainable inconvenience of ITE relates to the strategy of its application, as it requires a completely dedicated equipment and operator in the surgical area.

[Long-term results in patients with tricuspid prosthesis]

A retrospective study was undertaken of 31 patients submitted to tricuspid valve replacement between 1977 and 1988, either alone or associated to mitral or aortic replacement. The cause of the tricuspid lesion was rheumatic in 19 patients, congenital in seven, prosthetic valve thrombosis in two and miscellaneous in the remaining 3 patients (endocarditis, carcinoid syndrome, iatrogenic operative tricuspid regurgitation). Of the 31 tricuspid prostheses reviewed, 26 were mechanical (St Jude, Björk-Shiley) and five of the biological type (Ionescu, Hancock). Results showed that 25% of patients died in the hospital; 75% of them had been operated previously. With a follow-up averaging 3.9 years the complications related with the prosthesis were: thrombosis of the tricuspid prostheses in 1 patient (1.2% patients-year) and hemolytic anemia in another. Ninety percent of patient included in the follow-up were in NYHA class I or II. Three patients (14%) died due to a cause not directly related to the prosthesis. An actuarial analysis showed intrahospital survival rates of 55%, 100% and 75% in patient with 3, 2 and 1 prostheses, respectively; at 6 months postoperatively the figures were 55%, 87% and 75%, and at a follow-up of 3 years, 55%, 67% and 66%. In conclusion, in patients submitted to a tricuspid valve replacement mortality is high before hospital discharge, and is related to the clinical situation. A sustained improvement is observed in survivors once discharged, independently of the number of prostheses implanted. Complications related to the tricuspid prosthesis are comparable to those observed with prostheses in mitral or aortic position.

[Iatrogenic biliary lithogenesis in surgery]

Iatrogenic biliary lithogenesis has been often observed in surgery. The authors, on the basis of the personal experience and literature, have tried to point out its etiologic factors and give a common interpretation to its different clinical manifestations observed in surgery. This study reports 19 patients who underwent total gastrectomy with truncal vagotomy and postoperative TPN and subsequently serial ultrasonographic scans to determine content and volume of the gallbladder. In 5 patients it was possible to take out a bile sample daily, using a naso-duodenal tube, for chemical analysis. In 10 out of 19 patients postoperative ultrasonography revealed the fast appearance of biliary sludge; 6 of the latter 10 developed microlithiasis. In all cases examined ultrasounds revealed a defect of the contractility of the gallbladder and the microscopic analysis of bile content showed pigment granules. The authors underline how different etiologic factors are involved in different clinical models. They conclude that gallstones observed in their experience are mostly pigmentary and are quickly formed owing to the interaction of many etiological factors. Finally prophylactic measures are discussed.

Pigment vs. cholesterol microlithiasis: comparison of clinical features, bacteriology, stone and gallbladder composition

We compared 16 cases of pigment microlithiasis with 12 cases of cholesterol microlithiasis. In each case we made a spectrophotometric and diffractometric analysis of the composition of the stones, also analysing bile bacteriology, bile lipid composition and cholesterol saturation indices. The two groups were comparable as regards sex, age, symptoms and clinical features. Pigment microcalculi were often asymptomatic (41.7%), but more often associated with bile bacteria (43.7%) or acute pancreatitis (25%). The results were such as to permit us to view cholesterol microlithiasis and pigment microlithiasis as having different pathogenetic and clinical aspects, and thus as being different diseases.

Cholesterol crystals in biliary microlithiasis

A recent study put forward the hypothesis that microlithiasis may represent an early stage in the development of biliary calculi. It is an established fact that cholesterol crystals are the product of an inevitable stage in the sequence leading to gallstone formation. To test the hypothesis stated above ten patients affected by gallbladder cholesterol microlithiasis (CM) were examined in the lipid composition of the bile, the cholesterol saturation index and the presence of cholesterol crystals being calculated. The results were compared with those of 14 patients affected by pigment microliths, 24 with larger stones (LS) and ten control patients. The cholesterol saturation index was above one in all CM patients, whereas in some LS patients the gall-bladder bile was not supersaturated. Cholesterol crystals were observed in the gallbladders of all CM patients and seven LS patients. These results would seem to provide support for the hypothesis of microcalculi as being "young stones", with the bile of CM patients maintaining the conditions leading to gallstone formation.

Cholesterol microlithiasis: bacteriology, gallbladder bile and stone composition

It is not known whether microcalculi possess structural differences compared with larger stones or whether they represent simply an earlier stage in stone disease. We carried out a controlled study on 10 patients affected by gallbladder cholesterol microlithiasis (CM). In all patients, samples from all parts of the stones were studied by X-ray diffraction and by infrared spectrophotometry. Bile analysis was carried out to determine cholesterol, phospholipid and total bile acid content. The cholesterol saturation indices (C.S.I.) were calculated. In all samples, bacterial bile culture was carried out. The results were compared with those of 10 patients who had undergone cholecystectomy for large cholesterol stones, and for 10 patients who had undergone abdominal surgery but without biliary pathology. Patients in these latter groups were matched with the first according to sex and age. Microcalculi proved to be layered (nucleus and external layer) in only 2 cases and larger stones in 9; cholesterol was seen to be the principal crystalline component in all cases. Traces of bilirubin were found in 7 CM and in the nuclei of 5 larger stones. These results show that the structural composition of microcalculi is similar to that of the nucleus of larger stones. No substantial differences exist, however, between the two groups of patients regarding the other parameters taken into consideration.

Prospective validation of detection and quantitative assessment of chronic aortic regurgitation by a combined echocardiographic and Doppler method

To establish the accuracy of Doppler echocardiography in the assessment of chronic aortic regurgitation (AR), 87 patients were included in a two-step prospective study. In a first consecutive series of 56 patients, two-dimensional directed M-mode echocardiography and pulsed wave Doppler (PWD) studies were performed within a 24-hour interval of a conventional contrast aortic angiography, which showed AR in 46 patients. Sensitivity and specificity of PWD in the detection of AR were both 100%. To quantitate AR, a left ventricular outflow tract (LVOT) PWD mapping was scored. Significant differences between 1, 2, and 3 to 4 angiographic grades of AR were obtained. As some overlap existed between groups, a multifactorial analysis of PWD and echocardiographic measurements was performed: optimal discrimination was obtained when a new score combining LVOT mapping by PWD, diastolic left ventricular diameter, and aortic root dimension was considered. A prospective validation of this combined echocardiographic-Doppler method was then applied on a second group of 31 catheterized patients with AR. Correlation obtained (r = 0.86; p less than 0.001) confirmed the accuracy of this new method in the prediction of the severity of AR.

Pulsed Doppler assessment of tricuspid regurgitation: usefulness of regurgitant signal patterns for estimation of severity

A study on the value of pulsed Doppler in the detection and quantitative assessment of tricuspid regurgitation (TR) has been conducted on 33 consecutive adult patients with valvular heart disease. Only 1 patient had to be excluded owing to a technically inadequate Doppler examination. Data for comparison were obtained from a right heart catheterization performed within a twenty-four-hour interval from the Doppler study. Sensitivity and specificity in the detection of the lesion were 88% and 100%, respectively. A previously undescribed pulsed Doppler method for the estimation of the degree of TR was tested, based on the consideration of two distinctive patterns of the regurgitant Doppler signal: type I: a protosystolic regurgitant signal with progressively fading intensity along systole; and type II: a homogeneously intense pansystolic signal. Correlation between these patterns and the angiographic degrees of TR showed that milder lesions correspond to the type I Doppler pattern, whereas significant regurgitations present a type II pattern, this allowing a clinically useful method of assessment of TR.

Non-invasive preoperative assessment of chronic valvular heart disease by Doppler ultrasound

Between February 1986 and June 1987, 306 consecutive patients were included in a programme of non-invasive preoperative assessment of valvular heart disease using M-mode and cross-sectional echocardiography and Doppler ultrasound. In 285 cases (93%), echocardiography provided all the necessary preoperative information. Coronary angiography was performed in 74 patients because of angina and in 55 because of their age. Invasive investigation was needed in 21 cases because of discrepancies between clinical data and echo-Doppler results. The results were definitely misleading in six patients, mainly due to erroneous assessment of valvular regurgitation. One hundred and ninety one patients underwent valve surgery (179 evaluated exclusively by echocardiography, 79 with coronary angiography as the sole invasive procedure). No discrepancies were observed between echo-Doppler diagnosis and macroscopic evaluation of valvular heart disease at surgery. Operative mortality (3.6%) was not significantly different from that observed during the preceeding period when preoperative catheterisation was performed (3.3%). It is concluded that echo-Doppler techniques are perfectly satisfactory for the preoperative assessment of patients with valvular heart disease. Cardiac catheterisation is only infrequently required, although coronary angiography remains mandatory in a selected group of these patients.