Acute acalculous cholecystitis on a COVID-19 patient: a case report

INTRODUCTION

We report an extremely rare case of acute acalculous cholecystitis on a COVID-19 patient. In our knowledge, this is the first report of laparoscopic cholecystectomy performed on a COVID-19 patient.

PRESENTATION OF CASE

A COVID-19 patient was diagnosed with acute acalculous cholecystitis and a multidisciplinary team decided to perform a percutaneous transhepatic biliary drainage (PTBD) as the first treatment. SARS-CoV-2 RNA was not found in the bile fluid. Because of deterioration of the patient's clinical conditions, laparoscopic cholecystectomy had to be performed and since the gallbladder was gangrenous, the severe inflammation made surgery difficult to perform.

DISCUSSION

Acalculous cholecystitis was related with mechanical ventilation and prolonged total parenteral nutrition, in this case the gangrenous histopathology pattern and the gallbladder wall ischemia was probably caused by vascular insufficiency secondary to severe acute respiratory distress syndrome of COVID-19 pneumonia. The percutaneous transhepatic gallbladder drainage (PTBD) was performed according to Tokyo Guidelines because of high surgical risk. Laparoscopic cholecystectomy was next performed due to no clinical improvement. The absence of viral RNA in the bile highlights that SARS-CoV-2 is not eliminated with the bile while it probably infects small intestinal enterocytes which is responsible of gastrointestinal symptoms such as anorexia, nausea, vomiting, and diarrhoea.

CONCLUSIONS

Although the lack of evidence and guidelines about the management of patient with acute cholecystitis during COVID-19 pandemic, laparoscopic cholecystectomy, at most preceded by PTGBD on high surgical risk patients, remains the gold standard for the treatment of acute cholecystitis on COVID-19 patients.

Laparoscopic sleeve gastrectomy for morbid obesity: role of intraluminal and intraperitoneal postoperative drainage

BACKGROUND AND AIMS

Bleeding and staple line leak are the most common postoperative complications of LSG. To prevent and/or to promptly identify such complications, conventional peri-operative protocols imply post-operative gastric decompression (NGT) and staple line drain (IAD). Our aim was to evaluate the role of naso-gastric tube (NGT) and intra-abdominal drain (IAD) in preventing and/or facilitating identification and treatment of post-operative complications after sleeve gastrectomy.

PATIENTS AND METHODS

A retrospective observational study on two consecutive series has been undertaken to evaluate the real utility of routine placement of NGT and IAD at the end of a LSG to prevent (primary end-point), promptly identify (secondary end-point) and manage (tertiary end-point) bleeding and staple line leakage. Collected outcome data of all consecutive cases, which underwent primary LSG at our Department, were analyzed. The first 100 consecutive patients (group A) received the standard perioperative protocol and the other consecutive 100 (group B) received a fast track protocol (no NGT neither IAD).

RESULTS

The two groups were not different in their outcome. Two bleeding occurred in Group A and were conservatively treated. One abscess developed in group B soon after surgery. It was diagnosed by an abdominal CT performed because patients presented fever, leucocitosis and tachycardia. It was successfully treated by percutaneous ultrasound-guided drainage. One fistula occurred in group B after discharge on 30th post-operative day. Fistula was suspected based on fever and tachycardia in absence of any abdominal discomfort and was confirmed by an abdominal CT. The patient was successfully treated in 40 days by endoscopic positioning of a gastric tube-prosthesis and percutaneous ultrasound-guided drainage of abdominal collection. A third patient in group B experienced bleeding suspected due to hemoglobin drop and confirmed by abdominal CT. He also was conservatively treated.

CONCLUSIONS

In conclusion, placement of drains does not facilitate detection of leak, abscess, or bleeding after primary LSG.

Supergiant fecaloma as manifestation of chronic constipation

Fecaloma is common in patients with damage to the autonomic nervous system in the large bowel associated with Chagas disease (inflammatory and neoplastic) or Hirschprung's disease, in psychiatric patients and, more commonly, in elderly patients suffering with chronic constipation. Symptoms of fecaloma are usually nonspecific. Clinical examination can give the appearance of an abdominal tumor. Most cases of fecaloma are treated conservatively with digital evacuation and enemas. In severe and unremitting cases, surgery is required to prevent significant complications. Fecaloma should be considered in the differential diagnosis of any patient with history of chronic constipation and abdominal mass. We present the clinical case of an 85-year-old man with a history of chronic constipation presented to the emergency room with vague abdominal pain of 2 days' duration. An erect abdominal X-ray and computed tomography revealed a supergiant faecaloma extending from the pubis up to the diaphragm associated to a megarectum and megacolon. The patient was treated successfully with digital evacuation and enemas.

Does the margin width influence recurrence rate in liver surgery for hepatocellular carcinoma smaller than 5 cm?

OBJECTIVE

Liver surgery is considered a curative treatment for hepatocellular carcinoma (HCC) but the importance of resection margin width remains controversial. The aim of this study is to clarify the role of 5-10 mm surgical margin width on post-operative recurrence and overall survival after resection.

PATIENTS AND METHODS

We analyzed recurrence rate and overall survival rate of 72 patients who underwent curative hepatic resection for HCC smaller than 5 cm with 5-10 mm surgical margin width between January 2005 and December 2014.

RESULTS

The mean follow-up period was 36 months. Among the seventy-two patients, thirty-one (31/72; 43%) developed recurrence but only eleven (11/31; 15.3%) along the resection margin. The disease-free survival was 77.2%, 50%, 41.4% at 1, 3 and 5 years respectively, and the overall survival was 89.9%, 78.8%, 60% at 1, 3 and 5 years respectively.

CONCLUSIONS

5-10 mm surgical resection margin for HCC smaller than 5 cm seems to be safe as a wider surgical margin because does not increase the risk of marginal recurrence and does not decrease overall survival rate. Further prospective and randomized studies are required to definitively clarify the importance of surgical margin width in hepatic resection for HCC.

Right leg swelling as primary presentation of metastatic Merkel cell carcinoma

Merkel cell carcinoma (MCC) is a rare malignant cutaneous neuroendocrine tumour with an aggressive behaviour and frequent regional lymph node and distant metastases. It mostly occurs in old patients and the commonest sites are the skin of the head, neck and the extremities. Typically, the primary tumour presents as a fast-growing, painless, reddish nodule with an iceberg-like effect, broadening in the depth. Although the pathogenesis of MCC remains largely unknown, ultraviolet radiation and immunosuppression are likely to play a significant pathogenetic role. The authors describe an unusual case of MCC clinically presenting as lymphedema on the right leg due to an inguinal lymphonodal metastasis. Although extensive investigations were performed the authors were unable to discover the cutaneous primary tumor. The authors examine the etiopathogenesis and hypothesis of this rare tumour and describe the clinical differential diagnosis. They suggest that clinical features together with imaging studies and morphological and immuno-histochemical findings are important for the correct diagnosis.

Barium study associated with water siphon test in gastroesophageal reflux disease and its complications

PURPOSE

The aim of this study was to evaluate the role of digital cineradiography associated with the water siphon test (WST) in the diagnosis of gastroesophageal reflux and to compare the results with oesophageal motility study, pH monitoring and endoscopy associated with biopsy and histology.

MATERIALS AND METHODS

One hundred and sixty consecutive patients underwent digital cineradiography with WST, motility study, pH monitoring and endoscopy with biopsy. The presence of gastroesophageal reflux, oesophagitis, Barrett's oesophagus and intestinal metaplasia was evaluated.

RESULTS

WST vs. pH monitoring showed sensitivity of 71%, specificity of 31%, positive predictive value (PPV) of 53% and negative predictive value (NPV) of 50%; when middle-proximal refluxes only were considered, sensitivity decreased to 45% and specificity increased to 55%. Furthermore, the association between reflux and oesophagitis demonstrated by the chi-square (chi(2)) test proved to be statistically significant both for WST and pH monitoring, whereas the association between reflux and Barrett's oesophagus was not significant for either WST or for pH monitoring. With regard to intestinal metaplasia, WST (middle-proximal refluxes) showed higher sensitivity (64% vs. 58%) and specificity (63% vs. 51%) than pH monitoring, whereas the statistical association between reflux and metaplasia proved to be significant for WST but not for pH monitoring.

CONCLUSIONS

WST is a simple, inexpensive and reliable test that might be useful in the diagnosis of gastroesophageal reflux disease (GERD). A positive WST might be an additional indication for endoscopy with biopsy.

Multiple primary malignancies. A rare case of five metachronous tumours

The Authors report on a patient admitted several times for the occurrence of five multiple metachronous primary malignancies (laryngeal carcinoma, endometrial adenocarcinoma, rectal cancerous polyp, Vaterpapilla carcinoma and transverse colon cancer). All five carcinomas were independent primary cancers and the lenghty time intervals between the onsets of each individual tumours confirm their independent non-metastatic origin. Classification, pathogenesis, genetic and environmental interactions of these tumours are discussed; in the case reported a family history of colon cancer was present, while no genetic markers abnormalities or chronic exposure to carcinogens were found. The case report suggests that an aggressive, appropriate surgical approach together with a through follow-up monitoring offers a chance of long-term survival for patients with metachronous malignant primary tumours.

[Short account of the history of thyroid surgery]

Historical writings have described abnormalities of the thyroid gland for more than 3500 years. The relationship between the thyroid gland and goiter has been unknown until the XX century. Originally, what we know today as goiter was described as bronchocele. It was Wharton who in 1656 named the gland "thyroid", not because of the shape of the gland but because of the proximity to the thyroid cartilage. Rare attempts at thyroidectomy were made early on primarily for prevention of suffocation secondary to goiter with little success and a mortality rate as high as 40%. In 1791, Desault performed the first successful partial thyroidectomy. The most notable surgeon of 20th-century was Emil Theodore Kocher, who is considered the father of thyroid surgery. Christian Albert Theodor Billroth also made significant contributions to thyroid surgery.

Long-term ethanol administration enhances age-dependent modulation of redox state in different brain regions in the rat: protection by acetyl carnitine

Chronic alcoholism is a major public health problem and causes multiorgan diseases and toxicity. Although the majority of ethanol ingested is metabolized by the liver, it has intoxicating effects in the brain. Evidence is accumulating that intermediates of oxygen reduction may be associated with the development of alcoholic disease. Several studies have shown the capacity of carnitine and its derivatives to influence ethanol metabolism. We have previously demonstrated that preadministration of L-carnitine to rats receiving ethanol significantly reduced fatty acid ethyl esters in different organs and that the carnitine/acylcarnitine system is crucial for maintaining a functional acetyl-CoA/CoA ratio under conditions in which cellular homeostasis is exposed to the deleterious effects of accumulating organic acids. Ethanol, administered to rats for 20 months, induced significant changes in the status of glutathione, primarily in the brain regions of hippocampus and cerebellum, followed by cortex and striatum, where a decrease in reduced glutathione (GSH) and the GSH/oxidized glutathione ratio was found. The same brain regions showed a significant increase in free radical-induced luminescence and hydroxynonenal (HNE), which were associated with decreased GSH reductase activity. Long-term supplementation with acetyl carnitine significantly reduced GSH depletion, particularly in the brain regions of hippocampus, an effect associated with decreased luminescence and HNE formation. In addition, acetyl carnitine treatment increased GSH reductase and arginase activities. Our results indicate that decreased GSH reductase activities associated with thiol depletion are important factors sustaining a pathogenic role in alcohol-related pathologies. Administration of acetyl carnitine greatly reduces these metabolic abnormalities. This evidence supports the pharmacological potential of acetyl carnitine in the management of alcoholic disturbances.

[Our experience in the surgical treatment of gastrointestinal stromal tumors]

The authors carry out a retrospective review of 30 patients with gastrointestinal stromal tumours (GISTs) who underwent surgical treatment over the period from 1974 to 2001. Sixteen were male and 14 female, with an average age of 60.9 years. Histologically, 19 tumours showed evidence of differentiation towards smooth muscle elements (10 benign and 9 malignant), 9 towards neural elements (3 benign and 6 malignant) and 2 iacked differentiation towards either cell type. Twenty-one tumours were located in the stomach, 1 in the duodenum, 3 in the jejunum and 5 in the ileum. The main symptoms were abdominal pain and abdominal masses, and the most sensitive diagnostic techniques were abdominal CT scan and endoscopy in gastroduodenal locations. In 21 gastric GISTs, the surgical procedures were local resection (15 cases), partial gastric resection (3 cases), subtotal gastrectomy (2 cases) and total gastrectomy (1 case). In 8 small bowel GISTs, we performed a typical intestinal resection while duodenal undifferentiated GIST was managed by pancreatico-duodenectomy. There was no operative mortality or morbidity. Among the 13 patients with benign GISTs, 1 died of causes unrelated to the disease, while 12 patients are still alive and in good health after a mean follow-up of 148.5 months (range: 6-262). Among patients with malignant muscular GISTs (6 gastric and 3 ileal), 3 with gastric tumours were lost to follow-up, 3 with gastric and 1 with ileal neoplasms are alive and free from disease after a median follow-up of 58 months (range 3-108), while 2 patients with ileal neoplasms died of metastatic disease 39 and 29 months after the surgical procedure. Among 6 patients with malignant neural GISTs (2 gastric, 2 jejunal and 2 ileal) 1 with a gastric tumour and 1 with a jejunal tumour were lost to follow-up, while 3 are still alive and in good health after a median follow-up of 67.6 months (range 19 to 94); another with jejunal disease developed liver metastases 14 months after small bowel resection and died 12 months later. The two patients with undifferentiated GIST both died of liver metastasis 38 months after pancreatico-duodenectomy and 43 months after total gastrectomy. The most frequent symptoms were abdominal pain and a palpable mass, but no specific signs were detected. In gastroduodenal lesions endoscopy plays a very important diagnostic role and CT scan is the most sensitive diagnostic technique in the evaluation of location, size, invasion of adjacent organs and metastases. Prognostic prediction on the basis of histological findings is difficult and in our experience undifferentiated tumours are always malignant.

[Duodenal duplication. Report of 2 cases in adults and review of the literature]

Two cases of adult male patients with symptomatic duodenal duplication cysts are reported. The clinical manifestations were vomiting and epigastric pain in the first case and recurrent pancreatitis with a palpable mass in the right upper quadrant of the abdomen in the second. In both cases the diagnosis was only histological and the patients recovered after local excision of the duplication and duodenopancreatectomy, respectively. These two cases prompted an evaluation of the diagnostic features and surgical treatment of duodenal duplication cysts.

Effectiveness of porto-intracaval shunt to reduce the negative effects of portal and caval clamping in the rabbit

In performing experimental liver surgery, it is difficult to prolong anhepatic time because the animals do not tolerate prolonged portal and caval clamping. To counteract prolonged venous stasis, the authors previously developed a simple porto-intracaval shunt. The shunt consists of a self-constructed inverted Y silicone tube. The effectiveness of this shunt was studied comparing two groups of 10 rabbits with shunt (S) versus those with clamped portal and inferior caval vein (C). In the group of rabbits that underwent porto-intracaval shunt, the results concerning intraoperative mortality, intraoperative increase in distal portal vein pressure, and incidence of the histologic signs of gut damage were clearly improved. The proposed porto-intracaval shunt was therefore effective in reducing some principal negative effects of portal and caval clamping. This type of porto-intracaval shunt can be therefore useful allowing improvement of experimental models concerning liver surgery in little animals.

Palliative treatment of malignant esophageal stenosis: the role of self-expanding stent endoscopic implantation

Endoscopic tube implantations were carried out in 40 patients with malignant stenosis of the esophagus and gastric cardia using self-expanding metallic stents. The indications for endoscopic intubation were the advanced stage of the tumor in 27 cases and risk factors that made resection inadvisable in 13 cases. In three patients, it proved impossible to implant a stent endoscopically because we were not able to pass the guide wire through the stenosis, whereas correct stent placement was achieved in 37 cases. Functional results were good in 33 patients, but four patients did not show any improvement of symptoms. Complications occurred in nine patients (24.3%): two bleedings, three neoplastic obstructions, one food obstruction, and three distal dislodgements of the prosthesis were observed, but could be readily corrected. No deaths occurred. The median survival time was 151 days (range 25-545 days). This study suggests that endoscopic placement of metallic self-expanding stents is safe and is to be preferred to plastic stents for easier implantation and lower morbidity.

[Multiple primary malignant neoplasms. Report of a rare case with 5 metachronous tumors]

The Authors report on a patient admitted several times for the occurrence of five multiple metachronous primary malignancies (laryngeal carcinoma, endometrial adenocarcinoma, rectal cancerous polyp, ampulla of Vater carcinoma and transverse colon cancer). All five carcinomas were independent primary cancers, and the lengthy time intervals between the onsets of the individual tumours supports their independent non-metastatic origin. Classification, pathogenesis, genetic and environmental interactions of multiple tumours are discussed. In the case reported, a family history of colon cancer was present, while no genetic marker abnormalities or chronic exposure to carcinogens were found. The case report shows that an aggressive, appropriate surgical approach together with thorough follow-up monitoring offers a chance of long-term survival for patients with metachronous malignant primary tumours.

[Surgical treatment of redundant colon after retrosternal esophagocolonoplasty for caustic esophageal stenosis]

The Authors report two cases of transposed colon redundancy occurring after surgical treatment in 37 patients with caustic oesophageal strictures by retrosternal oesophagoplasty. Surgical management was required because of persistent dysphagia and weight loss in both patients. The technique performed was a resection of the redundant loop with a termino-terminal colo-colonic anastomosis via a right thoracic approach.

[Malignant stromal tumors of the duodenum. Report of a case]

The Authors report a rare case of undifferentiated duodenal malignant stromal tumour in a 69-years-old man radically managed by pancreaticoduodenectomy and resection of a liver metastasis. Several preoperative tests were performed (barium meal, endoscopy, ultrasonography and CT scan) but failed to yield a differential diagnosis between a tumour of the pancreatic head and a retroperitoneal neoplasm. The diagnosis was only histological. The tumour was considered to be high-grade due to its large size, high mitotic index, and the presence of necrosis and liver metastasis. Thorough surveillance revealed several hepatic metastases 29 months after resection, and chemotherapy performed at this stage proved completely ineffective. The patient died 38 months after surgery.

[Intrathoracic goiter: experience with 61 surgically treated cases]

Sixty-one patients with substernal goiter--42 women and 9 men (female:male ratio 2.2:1), mean age 57.5 years--underwent surgical resection in the General and Thoracic Surgery Division of the Surgery Department of the University of Catania from January 1980 to March 1999. Six patients (9.8%) had previously undergone cervicotomy. Forty-nine patients (80.3%) had symptoms (2 with acute respiratory failure); 22.9% had metabolic symptoms. Fifty-one patients (83.6%) had cervicomediastinal goiter, 8 (13.1%) migrated mediastinal goiter and 2 (3.3%) ectopic goiter. Forty-one cases (69.5%) were prevascular and 18 (30.5%) retrovascular; of the latter 5 were pre-visceral and 13 retrovisceral. Fifty-one thyroidectomies (6 subtotal) were performed, as well as 5 mediastinal excisions to complete removal and 4 resections confined to the mediastinal component. The 51 patients with cervicomediastinal goiter underwent cervicotomy in 42 cases (82.4%), cervicosternotomy in 7 cases (13.7%) and cervicosternothoracotomy in 2 cases (3.9%). The 8 migrated mediastinal goiters were removed via sternotomy in 6 cases, cervico thoracotomy in 1 and thoracotomy in 1. This latter approach was also used for the 2 ectopic goiters. The goiter presented signs of neoplastic degeneration in 2 cases (3.2%). Postoperative complications were: recurrent nerve palsy in 5 cases (1 bilateral definitive, 1 monolateral definitive, 3 monolateral transient), respiratory failure in 2, mediastinal hematoma in 1 and hypocalcemia in 8 (transient in 6). There was one postoperative death due to cardiorespiratory failure after cervicosternotomy. Surgical excision of substernal goiters is the best choice of treatment in view of the very low postoperative mortality and morbidity.

[Esophageal achalasia. Personal experience with 76 patients]

The Authors report their experience on 76 patients managed for oesophageal achalasia from 1973-1997. 65 patients have been surgically treated with Heller miotomy (19 cases) or miotomy with antireflux procedures (46 cases); 11 patients underwent an endoscopic pneumatic dilation. 54 patients, 43 surgically and 11 endoscopically treated, have been followed for a mean length of time of 6 years and 6 months. Complete cure or significant improvement of symptoms have been noted in 86% and 72.7% of patients treated respectively with surgery or pneumatic dilatation. The results have been evaluated according to the recent data from the literature and diagnostic and therapeutic aspects of primitive achalasia are discussed.

[Current trends in the surgical treatment of lesions caused by caustic ingestion]

During a twenty-six year period from 1973 to 1999 a total of 78 patients with severe esophago-gastric lesions after caustic ingestion were referred to and managed at our unit. Hydrochloric acid was the most frequently involved caustic agent and the lesions were located in the esophagus (52.6%), in the stomach (19.2%) and in both the esophagus and stomach (28.2%). Thirty-seven patients were managed by endoscopic dilation of esophageal stricture that gave permanent relief of dysphagia in 13 cases only. Twelve patients are still managed with endoscopic dilation and in another 12 we performed bypass surgery. Two perforations developed and spontaneously sealed after T.P.N. for 6-8 weeks. No death occurred. Fifty-three patients were operated on in emergency or during survey period or for stenotic lesions. Surgical procedures were: in esophageal strictures a substernal esophago or pharyngocologastroplasty without esophagectomy; in esophago-gastric strictures, after an esophago-gastrectomy, an esophago or pharyngocolojejunoplasty in one or two steps; in total gastric stenosis without esophageal involvement a total gastrectomy followed by a Roux-en-Y esophago-jejunal anastomosis and in antropyloric strictures a Billroth I or II partial gastrectomy. The morbidity rate was 32% with a 5.6% mortality rate.

Laparoscopic cholecystectomy: an analysis on 114,005 cases of United States series

114,005 cases from 40 United States series of laparoscopic cholecystectomies (LC) were reviewed. Indications, conversion rates, rates of intra-operative cholangiography (IOC), and incidence of bile duct stone and iatrogenic bile duct injuries were assessed. Indications included acute cholecystitis in 11.6% and gallstone pancreatitis in 2.1% of reported cases. Conversion rate was to be primarily related to inflammation. Unsuspected bile duct stones were detected intra-operatively in 7.8% of cases. 561 major bile duct injuries (BDI) and 401 bile leaks (BL) were recorded and acute or chronic inflammation was their most important potential predisposing factor. In series with a high rate of IOC performed during LC, BDJ and BL were slightly lower and lesions recognized intra-operatively were much higher than in series with low rate of IOC. BDJ occurred in the first 50 patients of the surgeon's experience in about 91% of the cases.

[The physiopathological and therapeutic aspects of esophageal diverticula]

The authors reviewed 23 surgical cases of symptomatic oesophageal diverticula. In Zenker's diverticula (7 cases) the surgical treatment consisted of extramucosal cricopharyngeal myotomy and diverticulectomy (6 patients) or diverticulum suspension (1 patient). The operations in epiphrenic (15 patients) and mid-thoracic (1 patient) diverticula were as follows: diverticulectomy, longitudinal extramucosal myotomy and antireflux surgery (11 cases); myotomy and antireflux surgery (4 cases); myotomy alone (1 patient). There was no operative mortality. Postoperative complications occurred in 3 patients (13%). 15 patients were followed for an average time of 60 months. None of them developed postoperative dysphagia. Pathogenesis, diagnostic methods and surgical options are discussed.

[Iatrogenic biliary lesions and stenosis]

Pathogenetic, diagnostic and therapeutic aspects of postoperative bile duct injuries are reviewed. Treatment options are discussed in relation to the time of diagnosis. Lesions detected during the same operation must be immediately repaired through an end-to-end biliary anastomosis or a bilioenteric anastomosis. In limited lesions of the bile duct a T-tube placement should be sufficient. Bile duct lesions recognized postoperatively can be managed through a multimodal surgical, endoscopic, and radiologic approach. In the early postoperative period, surgery is indicated when a complete section of the biliary tract or a severe peritonitis is recognized, or when endoscopic and radiologic treatment has failed. Surgery is also the treatment of choice in the late complete stenosis of the bile duct. Roux-en-Y hepatico-jejunostomy is the most common surgical procedure for the treatment of bile duct lesions and strictures. However, in high bile duct lesions, especially if the risk of anastomotic dehiscence is increased the Authors emphasize the Rodney-Smith technique for the reconstruction of the biliary tract.

[Mixed-type pancreatoblastoma. Report of a clinical case]

Pancreatoblastoma is a very rare tumor of the pancreas, affecting children in the first decade of life. Ultrasound and CT scan may be useful but pre-operative diagnosis is often quite difficult. High level of seric alpha-fetoprotein could be suggestive of pancreatoblastoma. The definitive diagnosis is however made by histologists when an organoid structure, well encapsulated, consisting of acinar cells with zymogen-like granules and squamoid corpuscle is demonstrated, sometimes associated with mesenchymal tissue (mixed-type pancreatoblastoma). Immunohistochemical studies may help in differentiating pancreatoblastoma from papillary cystic tumors, acinar cell carcinomas and endocrine pancreatic tumors of the pancreas. We report a case of mixed-type pancreatoblastoma in a 12-year-old female patient, located in the head of the pancreas. The treatment has been surgical, consisting of a duodeno-cephalo-pancreasectomy. Neither radiotherapy nor chemotherapy has been performed. The patient is alive, without recurrence, four months after the operation. Diagnostic, therapeutic and prognostic aspects are discussed.

[Treatment of iatrogenic lesions of the common bile duct]

The authors report 32 patients admitted to the hospital with iatrogenic bile duct stricture. Cholecystectomy with or without bile duct exploration was the most frequent (84.3%) surgical procedure responsible for the lesion, followed by BII gastric resection. Six patients had undergone one previous attempt at repair in another institution. Most patients had undergone a hepatojejunostomy, which has the procedure of choice in the last cases. Mortality and morbidity rates were 0 and 15%, respectively. The complications reported were a biliary fistula and 2 post-repair bile strictures that required one or more re-operations. During the follow-up 2 other patients developed episodes of cholangitis, treated medically. Clinical, diagnostic and therapeutic aspects of iatrogenic bile duct strictures are reviewed.

[Esophageal achalasia: cardiomyotomy or pneumatic dilatation?]

Sixty-four patients with achalasia of the esophagus were surgically treated during the period 1973-1990. They were analyzed a late follow-up (mean = 78 months) by means of subjective and objective parameters. The Authors emphasize the efficiency of the diagnostic approach so that surgical treatment offers better results. The surgical technique of choice consists of an anterior esophagomyotomy (extending from 6 cm above the esophagogastric junction down to 1-2 cm below it) with the addition of an anterior Dor antireflux procedure through a laparotomy. The other therapeutic approach to achalasia is pneumatic dilatation of lower esophageal sphincter. A retrospective comparison of two different treatments is made through the analysis of the literature (medlars 1986-1990). Relief of dysphagia is reported in 92.78% of patients treated by myotomy and in 78.71% of those treated by forceful dilatation. The morbidity rate is greater after pneumatic dilatation (6% vs 5%) and the mortality rate is 1.1% after myotomy and 0.2% after dilatation. There are not rigorous criteria of choice between the two treatment methods but the Authors indicate that Heller's myotomy with an antireflux procedure achieve better and lasting results.

[Emergency treatment of caustic lesions of the upper digestive tract]

The role of an early multidisciplinary approach to the management of upper digestive tract caustic lesions in the acute phase is stressed. The accurate evaluation of the lesions through early endoscopy, performed within 24-48 hours of ingestion, is the best means of assessing the degree of injury after caustic ingestion. Massive gastric and/or oesophageal necrosis, tracheoesophageal fistula, massive gastric haemorrhage, gastric and/or duodenal perforation are indications for emergency surgery. Management techniques of acute lesions are controversial because results of the different surgical procedures proposed are not satisfactory. Surgery of complications is mandatory, but up to date morbidity and mortality rates are still high.

[J-reservoir in the treatment of ulcero-hemorrhagic rectocolitis]

The Authors report their experience on ileal-anal anastomosis with a J-pouch. A videotape illustrates the surgical technique. At last functional results are shown.

[Current role of radical surgery in the treatment of breast tumors]

Though currently conservative surgical procedures have an ever-growing importance in breast cancer treatment, there is still place for radical surgery. The Authors describe radical techniques and their indications. The surgeon must know how to choose the proper radical technique, when it is not possible to perform a conservative surgical procedure.

[Neuroendocrine response to anesthesia with isoflurane]

The effects during surgery of a new halogenated volatile anaesthetic, isoflurane, on the hypothalamo-hypophyseal-thyroid-suprarenal axis were studied. In fact, it was important to prove whether this new halogenated anaesthetic would provide better protection, for the patient, from surgery and anaesthetic stress compared with other anaesthetic agents in use. The study was carried out in 16 young class ASA I patients who were to undergo appendicectomy. Before and during operation, blood was taken to measure ACTH, cortisol, TSH, T3, T4 and PRL plasma levels. A remarkable increase of PRL, cortisol and T4 plasmatic rate was found, especially at the end of the operation. It was concluded that isoflurane, just like enflurane, did not prevent the increase of PRL, cortisol and T4 that usually takes place during surgery.

Plasma and CSF morphine concentrations after i.m. and epidural administration

Morphine concentrations in plasma and CSF after i.m. and epidural morphine administration were assayed in patients undergoing surgery of the low abdomen. Morphine concentration in CSF after i.m. administration of this drug is remarkably lower than morphine concentration in plasma. The highest value is attained in CSF after about 90' and is followed by a slow downsloping to lowest values, which were observed 4 hours after drug administration. Kinetics of morphine passage into plasma after epidural administration is similar to that found after i.m. administration. In the latter experimental condition (epidural administration), concentrations of morphine in CSF 30' after administration are markedly lower than those found in plasma. However, 60 min. after epidural administration plasma and CSF morphine concentrations are similar, in particular CSF concentrations are 4 to 8 times higher than those obtained after i.m. administration. Such high levels persist for a long time.

Ultrastructural changes of the pulmonary parenchyma after experimentally induced endotoxic shock in dogs with and without drug protection

The authors describe the ultrastructural alterations of the pulmonary parenchyma produced in dogs by endotoxic shock, and they examine the effects that a 'secretolytic' drug (bromexine) has in modifying those changes. In the animals under shock there is a complete breakdown of the normal structure of the pulmonary parenchyma. According to the authors, these lesions are caused by the damage of the lining layer and of the cells which produce the constituents of the surfactant system. In dogs under shock and treated with bromexine the authors have seen a better organization of the pulmonary parenchyma: the cellular limits of the pneumocytes of types I and II were more clearly defined and the osmiophilic bodies were increased both in number and volume. The authors conclude that the damage of the lining layer and of the pneumocytes of type II plays an important role in the development of the ARDS and they say that bromexine can improve clinical and morphological aspects of that syndrome.

[Prolactin in pathology of the breast. Clinical study ]

In the last years many Authors on the grounds of clinical and experimental studies have assumed the possibility of a connection between the prolactin and the breast pathology especially the carcionoma. In the present work the Authors give the results of the doses of the prolactin plasmatic basal levels, performed on 122 subjects belonging to 4 different groups: 1) patients with carcinoma of the breast; 2) patients with benign tumors of the breast; 3) patients with fibrocystic breast disease; 4) subjects of control. In patients who have undergone an operation further doses of blood prolactin have been carried out on 5th, 10th, 30th day after operation. On the grounds of such results the Authors propose new hypothesis of work wich will help to clear this problem.

[Behavior of the plasma level of digoxin in the rat in induced experimental hyperreninemia]

PRA, plasma and urine aldosterone levels and plasma digoxin were measured in rats in which digoxin had been administered under conditions of high PRA and high aldosterone levels experimentally induced by administering distilled water load and in rats in which digoxin had been administered without distilled water load. Results show that under conditions of high PRA and high aldosterone levels, plasma digoxin concentrations as measured 6 h after treatment were higher (45,3%) than in rats having received digoxin without water load. In assays carried out on rats sacrificed 12 h after digoxin treatment (with or without water load) all values approach basic levels again, thus suggesting that in rats too aldosterone might compete with digoxin at the level of tubular excretion.