Laparoscopic removal of retroperitoneal accessory spleen in patient with relapsing idiopathic thrombocytopenic purpura 30 years after classical splenectomy

The clinical success of therapeutic splenectomy for idiopathic thrombocytopenic purpura depends on the complete removal of all functional splenic tissue. Among reasons for poor response to splenectomy, failure to remove accessory spleens is mentioned. We present our experience with laparoscopic removal of accessory spleen from retroperitoneal space in a patient with relapse of ITP 30 years after classical splenectomy. A 45-year-old female patient underwent in 1972 classical splenectomy for ITP. Progressive decline in thrombocyte count was observed 7 years ago. Scintigraphy, CT, and ultrasound revealed residual splenic tissue. A laparoscopic approach was proposed. Four trocars placed along left costal margin were used. After dissection of all the adhesions behind the pancreatic tail deep in the retroperitoneal space a round structure 4 cm in diameter, macroscopically resembling splenic tissue, was found. The accessory spleen was removed intact. The patient recovered well; 2 months later steroids were discontinued while the thrombocyte level was 251 x 10(9)/L. Identification of accessory spleen seems to be major intraoperative problem. We believe that accessory spleen can be safely removed laparoscopically, avoiding a major open procedure, and a satisfactory postoperative result could be expected.

The influence of cholecystokinin on gastric myoelectrical activity in duodenal ulcer following Helicobacter pylori eradication--an electrogastrographic study

Cholecystokinin (CCK) plays an important role in the regulation of postprandial gastric motor activity which was found to be abnormal in duodenal ulcer patients. This study was designed to compare the influence of CCK on gastric myoelectrical function in duodenal ulcer patients and healthy controls. Fifteen patients with active duodenal ulcer and Helicobacterpylori (H. pylori) infection and 15 healthy controls were included into this study. Electrogastrography (EGG) was performed before and 4 weeks after the eradication of H. pylori in ulcer patients and in healthy controls. We compared EGG parameters in the fasting and postprandial period and during intravenous infusion of caerulein, an analog of CCK with or without addition of loxiglumide, a specific CCK-1 receptor antagonist. The amplitude of fasting EGG in duodenal ulcer patients was similar to that in control subjects and was not affected by H. pylori eradication. In contrast, the amplitude of postprandial EGG was markedly increased in duodenal ulcer patients when compared to that in healthy controls and it was significantly reduced following the eradication of H. pylori. The blockade of CCK-1 receptors with loxiglumide in healthy controls or H. pylori eradicated ulcer patients significantly enhanced postprandial EGG amplitude almost to the level observed in the infected duodenal ulcer patients, but failed to affect this amplitude in ulcer patients. Exogenous caerulein, an analog of CCK, failed to affect EGG amplitude in duodenal ulcer patients with H. pylori infection, but it reduced significantly EGG amplitude in these patients after H. pylori eradication and in control subjects. This inhibitory effect of caerulein in H. pylori negative ulcer patients and healthy controls was abolished by the addition of loxiglumide. Ulcer patients showed significant dysrhythmia with tachygastria up to 20% of the recording time both under basal conditions and postprandially and H. pylori eradication was followed by a significant decrease in tachygastria to about 5%, the value being similar to that in healthy controls. We conclude that the amplitude and frequency of gastric myoelectrical activity are enhanced in duodenal ulcer patients and impaired in response to CCK but these changes can be normalized by successful H. pylori eradication.

[Laparoscopic surgery of the spleen]

Indications for laparoscopic a surgery of the spleen were presented. Detailed description of the laparoscopic splenectomy and operation of the splenic cyst were given. Complications, drawbacks and advantages of this procedure were discussed.

[Use of laparoscopic technic for treatment of patients with reflux diseases]

Pathophysiology, symptomatology and diagnostic work-out in gastroesophageal reflux disease was presented. Treatment strategies and indication for surgery were discussed. Detailed description of the laparoscopic Nissen fundoplication was given. Complications, drawbacks and advantages of this procedure were discussed.

[Ductal calculi as a diagnostic and therapeutic problem in patients qualifying for laparoscopic cholecystectomy]

Currently used techniques of CBD lithiasis treatment in candidates for laparoscopic cholecystectomy were presented. Advantages and drawbacks of nowadays most popular sequential approach (ERCP + laparoscopic cholecystectomy) were discussed. Technique of laparoscopic CBD exploration, indications, pros and cons were presented.

[The role of laparoscopy in treatment of inguinal hernia]

The epidemiology, symptomatology and complications of the inguinal hernia were presented. Indications for operative treatment were discussed according to contemporary approach to currently used techniques, particularly laparoscopy. The anatomy of the groin seen from the inside as during laparoscopy was described. Different techniques of laparoscopic herniorrhaphy with particular attention to TAPP method were discussed. Drawbacks, advantages and complications of those techniques were given.

[The problem of common bile duct calculi in the era of laparoscopic cholecystectomy]

At our Department in cases of suspected choledocholithiasis according to such criteria as jaundice, ultrasound or biochemical profile we perform ERCP. According to this in 94 (7.67% of 1226 patients scheduled for LC) were preoperatively submitted to ERCP. In 34 no CBD stones were found. In 19 stones were successfully removed. In 41 patients we were not able to extract stones and they were scheduled for open cholecystectomy. 40 patients 3 days to one year after LC were referred to ERCP because of suspected CBD obstruction. 17 had CBD stones, which were successfully removed. In 11 cases obstruction was caused by pancreatitis in another 20 no pathology in the billard tree was seen. Concluding we may say that in a hospital were ERCP is performed routinely LC can be performed in patients with CBD stones.

[Electromyographic and histologic evaluation of intestinal viability]

Myoelectrical small bowel activity was measured intraoperatively with two serosal electrodes in two groups of patients. 16 patients operated electively for other indications than bowel ischaemia and 10 with small bowel ileus with symptoms of ischaemia. In later cases necrotic bowel was resected. Resected ischaemic bowel was submitted to histological examination and changes in intramural neurones were assessed. Areas of mild, moderate and severe ischaemia were compared to unchanged bowel. Both amplitude and frequency of slow waves in ischaemic bowel was markedly diminished corresponding well with changes in bowel histology. Intraoperative measurements of intestine myoelectrical activity might help a surgeon to estimate a bowel viability.

[Endoscopic results of treating malignant polyps of the large intestine]

We present own material of 291 colonoscopic polypectomies performed between 1991 and 1996. In this group 15 (5.1%) polyps contained malignancy (14 adenocarcinoma, 1 lymphoma). Analysis of this material supported well known fact of higher malignant potential of large polyps and of adenoma villosum. In all but one cases of cancers located in polyps histological examination confirmed free margin of electro-resection. There were no local recurrences during follow-up lasting 2 month to 5.5 years. Patient with lymphoma malignum (large polyp over 4 cm in diameter) underwent typical chemotherapy and is now, one year after polypectomy disease-free. In this group colonoscopy is repeated every 3 months during first two years and every 6 months later. In cases of cancer-free margin of electro-ablation colonoscopic polypectomy seems adequate treatment of malignant large bowel polyps.

[The cause of upper gastrointestinal bleeding and the value of emergency endoscopic hemostasis]

Introduction of endoscopy and endoscopic hemostasis had substantial impact on the treatment of diseases of stomach and duodenum complicated by bleeding. We compared two 4-years' periods analysing etiology of bleeding and influence of endoscopic haemostasis on outcome of patients with upper gastrointestinal haemorrhage. Number of patients in both groups were comparable. Ratio of bleeding related to gastric and duodenal ulcer didn't change substantially. Number of patients with haemorrhagic gastritis decreased somehow while those with bleeding oesophageal varies increased. Number of patients submitted to emergency operation for bleeding ulcer decreased significantly. Mortality was lower in the second period of time only in patients with haemorrhage requiring transfusion of 4-7 units of blood.

[Hormonal changes and secretion and stomach mucosal microstructure in the course of H. pylori in patients with duodenal ulcer]

We designed this study to follow exocrine, endocrine and microstructural changes in duodenal ulcer patients with H. pylori infection in the course and after quadruple eradication regimen. Quadruple therapy appeared to be highly effective method of both ulcer healing and H. pylori eradication. We observed enhanced regeneration of gastric mucosa in the course of treatment. Almost immediate decrease of plasma gastrin and increase of plasma somatostatin and EGF concentration in gastric juice were noticed.

[Endocrine and exocrine gastric mucosal secretion in the course of H. pylori eradication in patients with non-ulcer dyspepsia]

Microstructural, endo- and exocrine changes in gastric mucosa of Non-Ulcer Dyspepsia patients with H. pylori infection in the course of eradication has been studied. Before, during and after anti H. pylori therapy plasma gastrin and somatostatin levels, EGF and somatostatin concentration in gastric juice and basal and pentagastrin stimulated gastric acid secretion were measured. Moreover microstructure of gastric mucosa specimens has been studied. Maximal Acid Output initially higher in NUD patients than in healthy volunteers increased slightly in the course of eradication. Plasma gastrin decreased while EGF and somatostatin concentration in gastric juice increased. After treatment the ratio of patients with pronounced features (activity) of gastritis was significantly reduced.

Gastric mucosal expression and luminal release of growth factors in gastric carcinoma and duodenal ulcer patients before and after eradication of Helicobacter pylori

Epidemiological studies have consistently shown an association between infection of Helicobacter pylori (Hp) and duodenal ulcer (DU) and gastric cancer. The mechanism of the ulcerogenic effect of Hp has been related to excessive gastrin release, gastric acid hypersecretion and gastric metaplasia in duodenum. The implication of Hp in gastric carcinogenesis has not been explained. In this study, mucosal expression of EGF and TGF alpha and luminal release of EGF as well as basal and pentagastrin-stimulated acid secretion and plasma gastrin levels have been determined in healthy subjects, gastric carcinoma and DU patients. It was found that Hp positive DU patients show excessive gastrin release and gastric acid secretion combined with increased expression and luminal release of EGF and TGF alpha. These changes returned to normal values two years after the eradication of Hp. Gastric cancer patients also showed increased expression of EGF and TGF alpha and highly increased plasma gastrin but their gastric acid secretion was markedly reduced possibly due to atrophy of oxyntic mucosa. This study indicates that overexpression of growth factors in gastric mucosa may be implicated in the pathogenesis of both duodenal ulcer and gastric cancer and that Hp positive hypochlorhydric and hypergastrinemic patients may be predisposed to development of gastric cancer.

Helicobacter pylori and impaired gastric secretory functions associated with duodenal ulcer and atrophic gastritis

Previous study showed that duodenal ulcer (DU) patients infected with Helicobacter pylori (H. pylori) have increased basal and pentagastrin- or GRP-induced gastric acid secretion and that these disturbances reversed fully after eradication of H. pylori. This study was designed to compare the gastric acid secretory profile, plasma gastrin levels and growth factors (EGF and TGF alpha) expression in gastric mucosa in DU patients with those in atrophic gastritis patients before and six months after verified eradication of H. pylori. In DU patients, basal and stimulated (GRP and pentagastrin) gastric acid secretion was significantly higher than in healthy controls. Six months following the eradication of H. pylori with triple therapy (omeprazole+clarithromycin+amoxicillin), this secretion returned to normal value. In contrast, in patients with atrophic gastritis, such eradication of H. pylori resulted in a significant increase in basal and pentagastrin- and GRP-stimulated acid secretion. Mucosal expression of immunoreactive EGF and TGF alpha was significantly enhanced in H. pylori positive DU and atrophic gastritis patients but this elevation disappeared or was markedly decreased 6 months upon the eradication of H. pylori. We conclude that 1) H. pylori infection is accompanied both in DU and atrophic gastritis patients by an enhanced plasma gastrin and increased mucosal expression of EGF and TGF alpha, 2) basal and GRP-induced acid secretion is significantly elevated in DU, whereas that in atrophic gastritis patients is greatly reduced, and 3) the H. pylori eradication restores gastric acid and plasma gastrin release as well as the mucosal expression of growth factors in DU and atrophic gastritis.

Hormonal, secretory and morphological alterations in gastric mucosa in the course of Helicobacter pylori eradication in patients with duodenal ulcer and non-ulcer dyspepsia

Changes in endocrine and secretory functions and in the morfology of gastric mucosa in the course of quadruple H. pylori eradication regimen in 50 H. pylori positive patients: 25 with duodenal ulcer (DU) and 25 with non ulcer dyspepsia (NUD) were studied and compared to 10 healthy controls. Therapy resulted in ulcer healing in all DU patients and in 92% eradication of H. pylori in both groups of patients-DU and NUD. In DU and NUD patients in the course of eradication significant decrease in plasma gastrin was observed. Somatostatin concentration in gastric juice increased significantly in DU patients after anti-H. pylori therapy. EGF in gastric content of DU and NUD patients has risen statistically significantly in the course of H. pylori eradication. Gastric acid output and volume flow decreased insignificantly in both groups. The elimination of H. pylori from gastric mucosa in both DU and NUD patients led to significant decrease in the density and activity of gastritis.

Short-term eradication therapy for Helicobacter pylori does not reduce the incidence of gastric metaplasia in duodenal ulcer patients

The presence of gastric metaplasia in the duodenal mucosa and Helicobacter pylori infection play an important role in the development of duodenal ulcers and the risk for ulcer relapses. The purpose of the present study was to identify the presence of gastric metaplasia in the duodenum and observation of changes in its extent during eradication therapy for Helicobacter pylori. The study population consisted of 40 patients, 15 women (aged from 29 to 65 years) and 25 men (aged from 22 to 62 years). At baseline and after 6 weeks all patients underwent endoscopic examinations of the upper alimentary tract during which two gastric antral and duodenal biopsies were obtained. The first endoscopy revealed the presence of duodenal ulcers in 22 patients, no ulcers in 11 cases, and postulceration scar in the duodenal bulb in 7 cases. The specimens were stained with hematoxylin and eosin, Giemsa and periodic acid Schiff/Alcian Blue. On first examination Helicobacter pylori infection in gastric antral specimens was detected in 40 patients. Therapy with amoxycillin, metronidazole, ventrisol and omeprazole for two weeks was administered in patients without duodenal ulcers and with omeprazole and ventrisol for additional 14 days in patients with duodenal ulcers. After therapy the presence of Helicobacter pylori was found in 10 cases, thus the degree of Hp eradication in the present study was 75%. Gastric metaplasia in duodenal samples was seen in 15 patients with duodenal ulcers and in 10 nonulcer patients. After therapy only in 4 cases gastric metaplasia was reduced along with Hp eradication, whereas in 9 cases gastric metaplasia in the duodenum was still present despite effective Hp eradication. The present findings indicate that gastric metaplasia is a reversible lesion, although this process is not dynamic and requires more time. The presence of gastric metaplasia in the duodenum after Hp eradication indicates an increased risk for the recurrence of duodenal ulcers, thus providing a useful information for a clinician.

Salivary and gastric luminal release of epidermal growth factor under basal conditions and after pentagastrin stimulation in healthy subjects and in duodenal ulcer patients before and after eradication of Helicobacter pylori

Epidermal growth factor (EGF) is secreted by salivary and Brunner's glands and shows a potent inhibitory effect on gastric acid and stimulatory influence on mucosal growth and protection but little is known about the effect of the Helicobacter pylori (Hp) infection on the release of EGF. In this study the salivary and gastric concentrations of EGF have been measured and gastric mucosal expression of EGF has been determined in 25 Hp positive duodenal ulcer (DU) patients before and after the eradication of Hp (using triple therapy with omeprazole, 20 mg bd, amoxycillin, 500 mg qd and metronidazole, 500 mg bd for 2 weeks) and in 10 healthy controls under basal conditions and following pentagastrin (2 micrograms/kg-h) stimulation. Basal salivary and gastric concentrations of EGF were similar and no significant difference was found between DU patients and healthy controls. Pentagastrin infusion (2 micrograms/kg-h) caused a significant increase in EGF release into saliva and gastric juice both in healthy controls and DU patients but in DU patients the Hp eradication resulted in several folds higher basal and pentagastrin-induced gastric EGF content than that before the anti-Hp therapy, whereas such Hp eradication had no significant influence on basal and pentagastrin-induced salivary EGF. Antral mucosal expression of EGF in Hp-positive DU patients was significantly higher than that in healthy Hp-negative controls and this elevation persisted after eradication of Hp. Basal and pentagastrin-induced gastric acid outputs in Hp-positive DU patients were significantly higher than in healthy controls and they were slightly reduced after the triple therapy. In all DU patients, 4 weeks after termination of anti-Hp therapy, a complete ulcer healing occurred. We conclude that (1) the stomach is capable of secreting large amounts of EGF and pentagastrin appears to be a potent stimulus of salivary and gastric EGF release; (2) the Hp infection reduces the release of gastric EGF and the eradication of Hp results in the augmentation of basal and pentagastrin-induced EGF release into the stomach but not into the saliva and (3) since the eradication of Hp infection in DU patients resulted in DU healing and this was accompanied by an increase in EGF release, we conclude that EGF plays a crucial role in the DU healing process.