Late follow-up of polypoid lesions of the gallbladder smaller than 10 mm

OBJECTIVE

To determine the variation in number, size, and symptoms in patients with polypoid lesions of the gallbladder.

SUMMARY BACKGROUND DATA

A polypoid lesion is any elevated lesion of the gallbladder mucosa. Several studies have been reported in patients undergoing cholecystectomy, but little information exits regarding the natural history of these lesions in nonoperated patients.

METHODS

A total of 111 patients with ultrasound diagnosis of polypoid lesions smaller than 10 mm were followed up by clinical evaluation and ultrasonography. Twenty-seven patients underwent cholecystectomy.

RESULTS

There was no difference in terms of gender. Nearly 80% of the lesions were smaller than 5 mm; they were single in 74%. In nonoperated patients, 50% remained of similar size at the late follow-up, 26.5% increased in number and size, and 23.5% shrank or disappeared. Among the operated patients, 70% corresponded to cholesterol polyps. None of the patients developed symptoms of biliary disease or gallstones or adenocarcinoma.

CONCLUSIONS

Ultrasound is useful in the follow-up of patients with polypoid lesions of the gallbladder. Lesions smaller than 10 mm do not progress to malignancy or to development of stones, and none produced symptoms or complications of biliary disease.

[Results of cholecystectomy realized 10 years ago]

BACKGROUND

The "post cholecystectomy" syndrome comprises a series of vague symptoms referred by patients subjected to this surgical procedure. These symptoms are unspecific and their association with the operation is dubious.

AIM

To assess the frequency of digestive symptoms among patients subjected to a cholecystectomy ten years ago.

PATIENTS AND METHODS

One hundred patients subjected to a cholecystectomy between 1987 and 1990, were contacted by mail. They were invited to a clinical interview and to an abdominal ultrasound examination.

RESULTS

Two invited patients had died of an acute myocardial infarction. Therefore, 98 patients (78 women), aged 30 to 85 years old, were assessed. Seventy two percent had diverse dyspeptic symptoms, 90% had no food intolerance and 94% had gained weight after the operation. Ninety six percent was satisfied with the surgical results, 3% had severe symptoms due to gastroesophageal reflux or depression. One patient had a residual choledocholithiasis and refused any treatment.

CONCLUSIONS

Cholecystectomy is well tolerated and has good long term results.

[Preliminary results of horizontal gastroplasty with Roux in Y anastomosis in patients with severe and morbid obesity]

BACKGROUND

Morbidly obese subjects have a high incidence of complications. The poor results of dietary treatments, has prompted the search of new therapies for obesity and among these, surgical procedures.

AIM

To report the long term results of horizontal gastroplasty with Roux en Y anastomosis in morbidly obese subjects.

PATIENTS AND METHODS

Fifty patients with an initial body mass index of 41.3 +/- 6 kg/m2 have been subjected to a horizontal gastroplasty with Roux en Y anastomosis. During the study period, surgical techniques were modified, reducing the gastric pouch size, adding a truncal vagotomy, cholecystectomy, and increasing the length of the Roux en Y loop from 70 to 100 cm. Twenty five patients have been followed for two years.

RESULTS

There was no operative mortality and one patient had an anastomotic leak that required 35 days of hospitalization. During follow up, in one patient, the stapled suture line loosened. After two years of follow up, weight decreased from 112 +/- 19 to 77.2 +/- 14 kg.

CONCLUSIONS

Horizontal gastroplasty with Roux en Y anastomosis achieved an adequate weight loss with a low rate of complications in this group of morbidly obese subjects.

Prevalence of common bile duct stones according to the increasing number of risk factors present. A prospective study employing routinely intraoperative cholangiography in 477 cases

BACKGROUND/AIMS

To determine if the use of Intraoperative choliangiography (IOC) should be routinely performed and, if not, which criteria should be used to select patients requiring IOC during open or laparoscopic cholecystectomy.

METHODOLOGY

495 Patients with 1 or more gallstones were included in a two-year study. Twelve clinical, laboratory, ultrasonographic and intraoperative factors were chosen and evaluated in all cases. Prior to cholecystectomy, IOC was performed after having identified the common bile duct (CBD) and cystic duct. The majority of the patients were operated on by the same surgeon to avoid differences in criteria and techniques. Statistical evaluation made use of the exact Fisher test and chi square test and, a p-value less than 0.05 was considered as significant.

RESULTS

IOC could be performed in 479 out of the 495 cases. IOC resulted in a normal CBD in 76.0%, had a false positive in 2.7%, a false negative in 0.48%, and a presence of 1 or more stones in the CBD in 20.9%. The study revealed that when none of the 12 risk factors were present, there were no cases with CBD stones. As the number of risk factors increased, so did the number of cases presenting with CBD stones.

CONCLUSION

Not all 12 risk factors show the same index of predictability; only 5 in particular (jaundice, ultrasound diameter CBD 7 mm, bilirubin over 26 umol/it, cystic duct > 4 mm and CBI, diameter over 9 mm) showed a high rate of predictability. However, when careful measurement and evaluation of risk factors for CBD stones are undertaken, it is possible to avoid the routine use of IOC.

[Clinical and laboratory characteristics of patients with pathologic chronic gastroesophageal reflux]

BACKGROUND

Sixty percent of adults has typical symptoms of gastroesophageal reflux in Chile.

AIM

To report the clinical and laboratory features of patients with gastroesophageal reflux.

PATIENTS AND METHODS

Five hundred thirty-four patients (255 male) with gastroesophageal reflux were included in a prospective protocol that included clinical analysis, manometry and endoscopy in all patients, barium swallow in 427, scintigraphy in 195, acid reflux test in 359, 24 h pH in 175, and differential potential of gastroesophageal mucosa in 73 patients.

RESULTS

There was no correlation between the severity of symptoms and the endoscopical severity. Patients with Barret esophagus were 12 years older, were male in a greater proportion and had a higher proportion of manometrically incompetent sphincters than patients with esophageal reflux but without esophagitis or with erosive esophagitis. Severity of acid reflux, measured with 24 h pH monitoring was proportional to the endoscopical damage of the mucosa. There was a close relationship between the mucosal change limit determined with differential potentials and with endoscopy. No short esophagi were found.

CONCLUSIONS

Patients with symptoms of gastroesophageal reflux must be assessed using several objective measures to determine the severity of their pathological alterations.

Prevalence of Helicobacter pylori infection in 190 control subjects and in 236 patients with gastroesophageal reflux, erosive esophagitis or Barrett's esophagus

A prospective study was performed in 190 control subjects and in 236 patients with different degrees of endoscopic esophagitis in order to determine the prevalence of Helicobacter pylori infection at duodenal gastric and esophageal mucosa and its correlation with histological findings. All patients with pathologic gastroesophageal reflux had 24-h pH monitoring studies confirming the presence of acid reflux into the esophagus. Besides the endoscopic findings, biopsies were taken from the duodenal bulb, gastric antrum, gastric fundus and distal esophagus or at the specialized columnar epithelium in patients with Barrett's esophagus. Patients with pathological gastroesophageal reflux were divided into three groups: 55 with absence of endoscopic esophagitis (gastroesophageal reflux), 81 patients with erosive esophagitis and 100 patients with Barrett's esophagus. There was no H. pylori infection present at duodenal or esophageal mucosa or at the specialized columnar epithelium of the distal esophagus in any case. The prevalence of H. pylori infection at gastric antrum was similar in controls and in any group of patients with reflux disease (20-25% of H. pylori infection). No differences in age and sex distribution were seen. H. pylori infection at gastric fundus was very low (less than 5%). The presence of HP infections was correlated with the finding of chronic active superficial or athrophic gastritis while, in the absence of H. pylori infection, gastric mucosa was normal. In the presence of intestinal metaplasia, no H. pylori infection occurred. Based on these findings, it seems that there is no significant evidence for an important pathogenic role for H. pylori infection in the development of pathologic chronic gastroesophageal reflux, erosive esophagitis or Barrett's esophagus, and the presence of antral gastritis in patients with Barrett's esophagus is closely related to the presence of H. pylori infection, and probably not related to an increased duodenogastric reflux.

[Long-term follow-up of non-operated patients with symptomatic and asymptomatic cholelithiasis]

BACKGROUND

In Chile, cholelithiasis is a serious public health problem and there are no studies about its natural history.

AIM

To assess the long term evolution of patients with symptomatic and asymptomatic cholelithiasis.

PATIENTS AND METHODS

Ninety two patients with cholelithiasis (57 female), aged 15 to 80 years old and that were not operated, were followed during a period of 9 to 14 years.

RESULTS

Thirteen patients were initially asymptomatic. Of them, seven bad complications or symptoms during follow-up and two were operated. Among the 69 symptomatic patients, 38 (55%) were not operated during follow-up, and seventeen (25%) did not have symptoms again. Ten patients died during follow-up, four due to complications of biliary tract stones.

CONCLUSIONS

The present finding suggest that the evolution of cholelithiasis in Chile is more aggressive than abroad, and an early surgical treatment is warranted.

[Subjective and objective evaluation of the results of laparoscopic antireflux surgery in patients with gastroesophageal reflux]

BACKGROUND

Laparoscopic antireflux surgery is a minimally invasive procedure that should have similar results than classical surgical treatment.

AIM

To report the results of a prospective study of laparoscopic antireflux surgery in patients with gastroesophageal reflux.

PATIENTS AND METHODS

Thirty two patients with gastroesophageal reflux and without Barret's esophagus, were subjected to endoscopy, manometry and measurement of intraesophageal pH before and after laparoscopic surgery.

RESULTS

There were no postoperative deaths or complications. Gastroesophageal sphincter pressure and abdominal sphincter length increased from 9.1 +/- 3.9 to 13.0 +/- 3.5 mm Hg and from 8.1 +/- 6.2 to 13.5 +/- 5.4 cm after surgery (p < 0.01). There was a decrease in acid reflux in 82% of patients.

CONCLUSIONS

Laparoscopic antireflux surgery reproduces exactly the results of open surgical procedures.

Counts of bacteria and pyocites of choledochal bile in controls and in patients with gallstones or common bile duct stones with or without acute cholangitis

BACKGROUND/AIMS

The number of colonies of bacteria and the number of pyocites present per ml of choledochal bile was studied.

PATIENTS AND METHODS

There were 42 controls, 100 patients with symptomatic gallstones, 42 patients with common duct stones without cholangitis and 24 patients with common duct stones and acute cholangitis.

RESULTS

Control subjects had no bacteria present at gallbladder bile. Only 3% of patients with gallstones had more than 10(5) colonies per ml which increased to 36% in patients with common duct stones without cholangitis and to 84% among patients with acute cholangitis (p < 0.001). There were more polybacterial flora among patients with acute cholangitis and anaerobic bacteria were not seen in patients with gallstones. Patients with acute cholangitis had significantly more pyocites present at choledochal bile.

CONCLUSION

There is a direct correlation between the number of colonies present per ml of choledochal bile and the severity of biliary tract disease. Patients with acute cholangitis had significantly more pyocites present at choledochal bile compared to gallstones or patients with CBD stones without cholangitis.

Simultaneous bacteriologic assessment of bile from gallbladder and common bile duct in control subjects and patients with gallstones and common duct stones

OBJECTIVES

To determine the simultaneous prevalence of bacteria in bile from the gallbladder and common bile duct and to determine the influence of the number of stones present on bacteriologic findings.

METHODS

A prospective study was performed in 467 subjects divided into seven groups: 42 control subjects with normal biliary tracts, 221 patients with symptomatic gallstone disease, 12 patients with hydropic gallbladder, 52 patients with acute cholecystitis, 67 patients with common bile duct stones without cholangitis, 49 patients with common bile duct stones and acute cholangitis, and 24 patients with previous cholecystectomy and common bile duct stones. In all except controls, bile samples from the gallbladder and common bile duct were taken simultaneously for aerobic and anaerobic cultures.

RESULTS

Control subjects had no bacteria in gallbladder bile. Patients with gallstones, acute cholecystitis, and hydropic gallbladder had similar rates of positive cultures in the gallbladder and common bile duct, ranging from 22% to 46%, but the rate was significantly higher in patients with common bile duct stones without cholangitis (58.2%). Patients with cholangitis or previous cholecystectomy had a high rate of positive cultures of common duct bile (93% to 100%). Age greater than 60 years had a significant influence on the rate of positive bile cultures. There was no relationship between the number of stones in the gallbladder or common bile duct and the percentage of positive cultures. In 98% of the patients, the same bacteria were isolated from gallbladder and common duct bile.

CONCLUSIONS

In normal subjects, no bacteria were present in the biliary tract. Among patients with common bile duct stones, there was an increasing percentage of positive cultures according to the severity of the disease. Age had an important influence, but sex and the number of common bile duct stones had no influence on positive cultures.

Prospective study of esophageal motor abnormalities in patients with gastroesophageal disease reflux according to the severity of endoscopic esophagitis

BACKGROUND/AIMS

This prospective study evaluates the peristaltic activity of the thoracic esophagus in a group of patients with gastroesophageal reflux disease grouping them according to the endoscopic findings.

MATERIALS AND METHODS

The peristaltic activity and the manometric features of the lower esophageal sphincter were prospectively evaluated in 109 controls and 321 patients with reflux esophagitis, divided according to the degree of endoscopic esophagitis employing Savary's classification.

RESULTS

Gastro esophageal sphincter pressure was progressively lower according to the severity of the tissue damage. Motor peristaltic activity of the thoracic esophagus measured by several different parameters was significantly altered in Grade IV esophagitis compared to other groups (p < 0.01). The manometric changes were more pronounced at the distal esophagus compared to the proximal esophagus. The percentage of patients with severe motor disturbances, defined as lower esophageal sphincter (LES) pressure less than 6 mm, less than 50% of peristaltic waves after swallowing and amplitude of contractile waves of less than 50 mmHg were significantly greater in patients with severe esophageal injury (p < 0.001).

CONCLUSION

Gastroesophageal esophageal reflux may exhibit a wide spectrum of motor disturbances in the distal part of the esophagus even before the presence of the tissue damage, but it increases in proportion to the severity of endoscopic esophagitis.

[Epidemiological and etiological aspects of upper digestive hemorrhage. Multicenter study in nine Chilean hospitals (1980-1990)]

An epidemiological survey about the incidence of upper gastrointestinal bleeding during three periods (1980, 1985 and 1990), was performed in 9 Chilean hospitals. Its annual incidence decreased in 1990, when compared to 1980. Likewise the etiologies changed, with an increase in the incidence of duodenal ulcers and a decrease in the incidence of erosive gastritis and bleeding of unknown origin in 1990. A seasonal variation with higher bleeding rates in autumn was also recorded.

Bacteriological studies of bile from the gallbladder in patients with carcinoma of the gallbladder, cholelithiasis, common bile duct stones and no gallstones disease

OBJECTIVE

To compare the presence of bacteria of bile from the gallbladder in control subjects, patients with gallstones, and patients with carcinoma of the gallbladder.

DESIGN

Prospective open study.

SETTING

University department of surgery.

SUBJECTS

372 patients of whom 36 had no signs of gallbladder disease; 211 underwent cholecystectomy for either symptomatic gallstone disease (n = 165) or acute cholecystitis (n = 46); 67 had common bile duct stones and 58 were operated on for carcinoma of the gallbladder.

INTERVENTIONS

Aspiration of bile from the gallbladder.

MAIN OUTCOME MEASURES

Prevalence of pathogenic bacteria in bile from the gallbladder and correlations between the presence of bacteria, the presence of cancer, and age.

RESULTS

No pathogenic bacteria were grown from the bile of the patients who had no signs of gallstones disease. Among the 165 with symptomatic gallstone disease 52 (32%) had pathogens in their bile, and among the 46 with acute cholecystitis the corresponding figure was 19 (41%) while among patients with common bile duct stones this figure was 39 (58%). Among the 58 patients with carcinoma of the gallbladder the bile grew organism in 47 (81%). Patients over the age of 60 years tended to be more likely to have organism in their bile than patients aged 60 or less, and the difference was significant for symptomatic gallstone disease (p < 0.003). Significant differences were also found between patients with symptomatic gallstone disease and those with carcinoma of the gallbladder in both age groups (p < 0.002 in each case). Most of the organism were aerobic or anaerobic Gram negative species, irrespective of type of disease or age.

CONCLUSION

Bacteria may have a role in the development of carcinoma of the gallbladder.

[Magnitude of acid gastroesophageal reflux measured by 24-hour esophageal pH monitoring compared to the degree of endoscopic esophagitis]

Twenty four hour esophageal pH monitoring was performed in 110 patients, placing a pH electrode 5 cm above the proximal border of the lower esophageal sphincter. This test allows to measure the total lapse in which there is an acid pH in the esophagus, the ability of the esophagus to get rid of the acid reflux and documents the relationship between esophageal pH and symptoms. Upper GI endoscopy showed a normal esophagus in 38 patients, and esophagitis grade I in 25, grade II in 11, grade III in 25 and grade IV in 11. There was a high correlation between the severity of esophagitis and the total time in which the esophagus was exposed to an acid pH. It is concluded that this test can be used as a "gold standard" for gastroesophageal reflux detection.

[Intestinal malabsorption in patients treated with total gastrectomy]

Weight loss, chronic diarrhea and fat malabsorption are frequent after total gastrectomy. The aim of this work was to study parameters of intestinal absorption and the histology of jejunal mucosa in 26 patients subjected, at least one year ago, to total gastrectomy and without evidences of tumoral relapse. There was a mean weight loss of 9 kg (range 4 to 20) and 46% of patients had intermittent or episodical diarrhea. Hemoglobin was below 12 g/dl in 4 patients, serum albumin was below 3.5 g/dl in 3, serum carotene was below 40 micrograms/dl in 5 and serum iron was below 80 micrograms/dl in 5. Jejunal biopsies were normal and steatocrit was abnormal in all patients. Present findings suggest that fat malabsorption in these patients is intraluminal and due to an unequal mix of pancreatic and biliary secretions, as a consequence of Y en Roux transit reconstruction.

[Biliary surgery mortality in Chile in 1990. Cooperative study in 17 hospitals]

A survey about surgical procedures performed in 1990 was answered by 17 surgical services. With these data the operative mortality of biliary surgery was analyzed. During 1990, 39,643 patients were subjected to major surgery of which 9,654 (24.3%) corresponded to benign biliary tract diseases. Forty nine percent of patients had chronic cholecystitis, 36% acute cholecystitis and 16% choledocholithiasis. Global mortality of these procedures was 0.58% and mortalities for chronic cholecystitis, acute cholecystitis and choledocholithiasis were 0.06, 0.6 and 2% respectively. These numbers increased significantly in patients over 60 years old, are lower than those reported 10 years ago and could be useful as "gold standards" for laparoscopic cholecystectomy.

Location of the lower oesophageal sphincter and the squamous columnar mucosal junction in 109 healthy controls and 778 patients with different degrees of endoscopic oesophagitis

In this study the location of the lower oesophageal sphincter measured by manometry and the location of the squamous columnar junction measured by endoscopy were determined in 109 healthy controls and 778 patients with different degrees of endoscopic oesophagitis. No significant differences in the prevalence and severity of the heartburn and regurgitation were observed when different degrees of oesophagitis were compared but dysphagia was more common and severe in patients with complicated Barrett's oesophagus (p < 0.001). This group also showed a male predominance and older age compared with other groups. The total length of the oesophagus, measured by the location of the distal end of the lower oesophageal sphincter was similar in all patients; however, the location of the squamous columnar junction extended more proximally and was related to the increasing severity of endoscopic oesophagitis. The manometric defects at the cardia were more frequent in severe oesophagitis (p < 0.001). These results suggest that, during the course of oesophagitis, the squamous columnar junction is displaced proximally. This displacement is limited to the mucosa, however, and does not involve the muscular layer, because the lower oesophageal sphincter undergoes no dislocation.

Histological studies of Auerbach's plexuses of the oesophagus, stomach, jejunum, and colon in patients with achalasia of the oesophagus: correlation with gastric acid secretion, presence of parietal cells and gastric emptying of solids

Histological changes in the Auerbach's plexuses of the oesophagus, stomach, jejunum, and colon were analysed in a prospective study in 34 patients with achalasia of the oesophagus. At the distal end of the oesophagus ganglia cells were absent in 91% of cases as well as in the middle third of the stomach (20%). The Auerbach's plexuses were normal in the jejunum and colon. The results of gastric acid secretion showed that the peak acid output was significantly lower in achalasia patients compared with controls (p less than 0.001). There was no correlation between the mean ganglion neuronal count in the gastric plexuses and the rate of gastric acid output (r = 0.33). Gastric emptying of solids was also evaluated, but there was no correlation between gastric emptying and the mean ganglion neuronal count in the gastric Auerbach's plexuses. The rate of gastric emptying of solids was similar in controls and patients with achalasia. These studies suggest that denervation of the oesophagus in patients with achalasia, which is a constant finding in several previous reports may extend beyond the oesophagus to the stomach in nearly half the cases.

Long-term tissue tolerance of titanium-encapsulated cobalt-samarium implants

The tissue reactions of titanium-coated cobalt-samarium magnets were investigated following their full-thickness implantation into the skulls of dogs and pigs (six of each species). The implants, together with the surrounding bone, were removed en bloc 1, 2, 3, 6, 9, and 12 months postoperatively. Following physical and radiological examinations, the excised samples were subjected to histologic investigation. The osseointegration process was observed to follow a normal course around the titanium capsule. The magnetic field did not give rise to any tissue changes that could be demonstrated by means of classical histologic methods.

Comparison of forceful dilatation and esophagomyotomy in patients with achalasia of the esophagus

In the present paper we have reviewed the results of forceful dilatation as compared with surgical esophagomyotomy in patients with achalasia. The review of 4 retrospective and uncontrolled studies revealed that in all, surgery produced a more effective late result than dilatation, with minimal side effects and very low or no mortality. In the only prospective randomized study comparing both treatments by the same group, good late results were seen after surgery in 95% of the cases, as compared with 65% after dilatation (p less than 0.001). The resting gastroesophageal sphincter pressure was predictive of the quality of the late results. Reflux occurred in 8% of the dilated and in 19% of the operated group as measured by standard acid reflux test. The old, classical concept that dilatation is the first choice and preferable method of treatment for patients with achalasia should be reviewed, and the idea that surgery should be reserved only for patients in whom dilatation has failed should be abandoned. We propose that surgical treatment should be the initial choice in the majority of patients with achalasia of the esophagus.

[Clinical characteristics of patients with multiple or giant peptic ulcers]

The incidence and clinical characteristics of multiple or giant ulcers (over 20 mm for duodenal ulcer or 25 mm for gastric ulcer) was evaluated among 1434 patients with peptic ulcers. For gastric ulcers, multiple and giant lesions were found in 27% and 14% of patients respectively. Among duodenal ulcers the corresponding figure were 16% and 2.4%. Patients with triple gastric ulcers have a greater incidence of massive bleeding. Patients with triple duodenal ulcers are older, have more massive bleeding and have a greater incidence of gastric retention and hypersecretion when compared to patients with single or double duodenal ulcers. Giant gastric ulcer was associated to a shorter history and more massive bleeding; giant duodenal ulcer was associated to older age, more massive bleeding and gastric retention, when compared to patients with common size ulcers.

[The significance of ketonuria in lactating cows]

In two large sized farms in Hungary and in several small and medium farms in Bavaria the authors studied the development of ketonuria in cows after calving. In two flocks without problems 30 percent of the cows developed ketonuria, whereas the rate was 56 percent in one problematic flock. Milk yield of the cows observed was above 5000 kg per year, their age differing only slightly. Cows with ketonuria revealed an increased enzyme activity of AST and a decreased plasma-glucose concentration in comparison to the ketone-free animals. Also, the ketonuria cows showed higher amounts of free fatty acids in plasma and lower amounts of total cholesterol. Additionally, these animals more often revealed reproductive disorders. The rate of culling and emergency slaughter was also increased, whereas their pregnancy rate was decreased.