Biomedical subjects
Publications and source records attributed to M Gafà.
The authors report a case of anaphylactic reaction in a 58-year-old woman during total gastrectomy under general anesthesia. Before induction a peridural catheter had been inserted for the purpose of postoperative antalgia. Anaphylaxis occurred fifteen minutes after the start of surgical resection. The tests performed later led the authors to regard latex as the triggering agent.
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.
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.
We reviewed 26 consecutive patients from 1.1.81 to 30.6.89, 21 males and 5 females, mean age 72 (+/- 6.7) years, range 51-81, admitted and operated on for ruptured (19 cases) or leaked (7) abdominal aortic aneurysm in a general surgery unit at the University of Parma. Since we deal mainly with gastroenterologic and oncologic surgery, emergency operations were 70.2% of the overall series of aortic aneurysms, and were carried out over an actual 776 day period of emergency admission service. Nineteen patients had shock, ten being already anuric. Ultrasounds were carried out in nineteen cases, with an accuracy of 91.6% for ruptured and 57.1% for leaking aneurysms. Mortality rate, 50% was significantly related to the number of perioperative blood transfusions and anuria, which express the degree of shock and blood loss. Operative results were similar to other major series. A successful approach and management of aortic ruptured aneurysm is an uncommon challenge even in non-specialized surgical units. A vascular surgical training is therefore necessary for general surgeons.
The Authors take into consideration some topical subjects, with reference to their own experience. The percentage of patients diagnosed as having localized disease, despite improvement in diagnostic techniques, has not changed over the last decade. In local recurrences without distant metastases, surgery is the sole treatment which may improve the survival. Resection however has to be thought over, since surgery of local recurrences may be considered as curative only in a few cases and the probability of a poor result in survival and quality of life does not justify a surgical procedure when it is associated with a high operative risk. In cancers of the middle 3rd and lower rectum, staplers have favoured the choice of anterior resection, which does not show a high rate of recurrences, when compared to abdominoperineal excision. At last, progress in surgery, anaesthesiology and intensive care determined a different therapeutical attitude in the aged, either due to a lower incidence of postoperative complications, or because life expectancy in the elderly seems to justify, whenever possible, a curative procedure.
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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.
A prospective analysis was carried out on 19 adult patients who had undergone total gastrectomy for gastric cancer with truncular vagotomy and postoperative TPN, to evaluate the gallstone formation sequence in man. The patients underwent gallbladder ultrasonography before surgery, then at least once a day during the period of postoperative fasting and TPN (about 15 days) and during the first days after oral refeeding. No patients showed cholelithiasis or biliary sludge at preoperative ultrasonography; none showed cholesterol crystals at preoperative duodenal drainage. 10 of the 19 patients were sludge-positive during the first two weeks of TPN (2 after 3 days, 7 at day seven, 9 at day nine). 6 patients who were initially sludge-positive developed microlithiasis: 1 after 7 days, 2 during TPN and 3 after oral refeeding. These results lead the authors to suggest that human lithogenesis in particular conditions may be faster than that observed so far in animal models, and that the very rapid events in gallstone formation observed in this study concern the formation of pigment stones.
The chemical composition of biliary microcalculi obtained at 20 consecutive cholecystectomies was investigated with infrared spectroscopy. This method permits qualitative and quantitative analysis also of substances such as bilirubin which often remain in amorphous states. A PYE UNICAM spectrophotometer was used, with KBr pellet technique. A bile sample from each patient was taken for bacteriologic examination. The study confirmed previously observed high incidence of pigment microcalculi (60%). Calcium palmitate was more common (in 15% of all the studied microliths and 25% of the pigment type) than in reports in the literature concerning larger gallstones. Calcium carbonate was present in only 10%. These findings suggested pathogenetic peculiarities of microlithiasis, as did the high incidence of positive bacteriologic tests.
A significant association was found between colorectal cancer, especially of the right colon, and concomitant gallstones. This was noted especially in female patients and in those over the age of 65. The existence of such an association is of advantage in terms of secondary prevention of colorectal cancer. The possible screening methods are discussed for those gallstone patients at risk.
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The influence of bile flow interruption on the pathogenesis of acute pancreatitis has been evaluated in the rat. The pancreatitis was induced by Pfeffer's technique and the severity of the disease was assessed by a macroscopic examination of the pancreatic damage and the calculation of amylase-to-creatinine clearance ratio (ACCR) as well. The results showed that the bile reflux into the pancreas made the pancreatic lesions caused by stasis in the gland associated with hyperstimulation of exocrine secretion more severe. On the other hand the bile reflux had no influence when the pancreatitis was due to flowing back of duodenal contents into the pancreas (closed duodenal loop). It was concluded that the bile effect is probably consistent with a pressure mechanism. In addition the reliability of ACCR in the diagnosis of acute pancreatitis was confirmed, and the test was effective in detecting even milder pancreatic damages.
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To assess whether the higher risk of colorectal cancer is related to cholelithiasis rather than to cholecystectomy, a retrospective epidemiologic study was carried out on 350 patients operated for colorectal cancer. The incidence of a previous cholecystectomy or concomitant cholelithiasis was shown to be significantly higher in colorectal cancer patients with respect to controls (relative risk: 1.48 and 1.99 respectively). The association in both cases was more frequent for colorectal cancer. These results permit to hypothesize that the association with colorectal cancer does not concern previous cholecystectomy but rather cholelithiasis which is contemporaneously present or responsible for cholecystectomy.
Acute experimental pancreatitis was induced in rats, with a polyethylene splint placed into the duodenum, by the closed duodenal loop technique. Ranitidine (20 mg . kg-1) or saline were administered intraperitoneally every 8 hrs, beginning 15 min prior to surgery. The degree of pancreatitis and the amylase to creatinine clearance ratio (ACCR) were evaluated in all the animals after sacrifice. Ranitidine-treated animals showed significant by reduced pancreatic damage and ACCR values in comparison with non-treated rats. These data confirm the efficacy of ranitidine as a preventive agent in the development of acute pancreatitis and suggest that controlled trials should be performed with this H2-antagonist in the human subyects with this disease.
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