Flavio Lirussi

Needle and Trocar Injuries in Diagnostic Laparoscopy under Local Anesthesia: What Is the True Incidence of These Complications?

Laparoscopy is a relatively safe invasive procedure, but complications can occur, mainly related to Veress needle and trocar insertion. The rate of these complications is generally reported to be low, but the true incidence may be higher because of underreporting. We retrospectively studied the records of 2650 consecutive diagnostic laparoscopies performed by the same operator with the aim of assessing the true incidence and nature of these complications. Major complications occurred in 0.41% of cases and included bladder injury, bowel perforation, hemoperitoneum, and abdominal wall hematoma. Minor complications, including omental and subcutaneous emphysema, occurred in 1.58% of cases. Some of these resolved spontaneously, whereas others required surgical or medical treatment. We believe that all laparoscopic complications should be reported to a registry so that their potential risk can be quantified. Simply reporting complications as major or minor on the basis of the follow-up does not allow laparoscopists to understand their true incidence completely.

The Effect of Drugs on Bile Flow and Composition: An Overview

SummaryMany drugs are eliminated via the hepatobiliary route, after biotransformation in the liver. Some of them may affect bile flow and/or the hepatic secretion of biliary lipids such as bile acids, cholesterol and phospholipids.Bile acids are the most potent agents which increase bile flow, especially unconjugated bile acids. Other drugs which increase bile flow include phenobarbitone (phenobarbital), theophylline, glucagon and insulin. In contrast, ethacrynic acid, amiloride, ouabain, oestrogens and chlorpromazine are among those agents which decrease bile flow. Biliary bile acid secretion is altered by a variety of drugs, including cheno- and ursodeoxycholic acids (CDCA and UCDA), the bile acid sequestrants cholestyramine and colestipol, and ethinyloestradiol.The composition of bile can also be altered by drug therapy. Thus, clofibrate increases biliary cholesterol secretion, and reduces bile acid concentrations, without altering biliary phospholipid concentrations. However, other clofibrate derivatives may produce changes of a different pattern, suggesting that the risk of developing gallstones may differ for each derivative. Nicotinic acid and d-thyroxine also increase biliary cholesterol saturation, while CDCA and UDCA reduce biliary cholesterol concentration.The potential consequences of drug-induced changes in bile flow and composition extend to the liver, the gallbladder and the intestine. If adverse effects are to be avoided, further study in this often overlooked area is required.

The global challenge of type 2 diabetes and the strategies for response in ethnic minority groups

Ethnic minorities living in high‐income countries usually exhibit a greater risk of developing diabetes along with higher morbidity and mortality rates. We evaluated the effectiveness of interventions to improve glycaemic control in ethnic minority groups. Results of major controlled trials, systematic reviews and meta‐analyses were included in the review. Only 1/47 studies addressing diet and exercise interventions reported details on the ethnicity of the studied population. Self‐management education was successful if associated with increased self‐efficacy; delivered over a longer period; of high intensity; culturally tailored; and when using community educators. Strategies adopted in community‐gathering places, family‐based, multifaceted, and those tackling the social context were likely to be more effective. A positive relationship was found between social support and self‐management behaviour as well as quality of life, but there is little evidence about the impact of organizational changes within health‐care services on diabetes control. More research is needed to strengthen the evidence on effective strategies for response to diabetes in ethnic minorities. Also, there is a need to take into account diabetes beliefs and communication difficulties, as well as potential protective factors. Globally, many health‐care systems are inadequately equipped to improve diabetes prevention and disease outcomes in these communities. Copyright

Effect of Silibinin on biliary lipid composition experimental and clinical study

The effect of Silymarin, a natural flavonoid, on biliary lipid composition, was studied in rats and humans. Bile flow, biliary cholesterol, phospholipid and total bile salt concentrations were measured in 23 control rats and in 27 rats treated with Silibinin, the active component of Silymarin, at the dose of 100 mg/kg body weight i.p. (n = 21) or 50 mg/kg body weight i.p. (n = 6) for 7 days. Biliary cholesterol and phospholipid concentrations were significantly reduced after the higher Silibinin dose (60.9 and 72.9% of the control values), whereas bile flow and biliary total bile salt concentration were unchanged. After the lower Silibinin dose all parameters remained unchanged. Total liver cholesterol content was not affected by Silibinin. On the other hand, in vitro determination of rat liver microsomal 3-hydroxy-3-methylglutaryl-CoA (HMG-CoA) reductase activity showed a significant dose-dependent inhibition by Silibinin (0.5-8 mg/kg). Biliary lipid composition was also assayed in four gallstone and in 15 cholecystectomized patients before and after Silymarin (420 mg per day for 30 days) or placebo administration. In both groups, biliary cholesterol concentrations were reduced after Silymarin treatment and the bile saturation index significantly decreased accordingly. These data suggest that Silibinin-induced reduction of biliary cholesterol concentration both in humans and in rats might be, at least in part, due to a decreased synthesis of liver cholesterol.

Gallstone disease in an elderly population: the Silea study.

BACKGROUND Little is known on gallbladder emptying and gallstone composition in the elderly. AIMS AND SUBJECTS: Cross-sectional survey on the prevalence of gallstone disease and associated factors, gallstone characteristics and gallbladder emptying in a population aged > or = 60 years. METHODS Gallstone number and size as well as gallbladder motor function were assessed by ultrasound. Gallstone composition and pattern were evaluated by conventional radiology and computed tomography (CT) based on Hounsfield units (HU). RESULTS Gallstones were found in 148/1,065 subjects (13.9%), while 136 subjects (12.8%) were cholecystectomized with an overall prevalence of gallstone disease of 26.7% (sex ratio: F > M). Multiple gallstones (62.7%) and small gallstones (52%, diameter < or = 15 mm) were seen; silent gallstones accounted for 93.9% of the total. Only diabetes mellitus in women was significantly associated with cholelithiasis. Gallbladder fasting volumes were larger in gallstone carriers than in controls (P < 0.01); residual and ejection volumes were also significantly greater in gallstone carriers, whereas ejection fractions were similar in the two groups (50.3% +/- 2.4 versus 54.9% +/- 3.0; not significant). Gallstone calcifications were detected in 29/91 gallstone carriers by X-ray and in another 20 by CT (HU > 90). Moreover, 35 gallstone carriers had a score < or = 50 HU and six had attenuation values between 50 and 90 HU. Six gallstone patterns were identified: hypo-isodense, homogeneously dense, rimmed, laminated, core-hyperdense, gas-containing. CONCLUSIONS In the elderly, the prevalence of gallstone disease is very high, especially in women, but gallstone size, number and pattern and gallbladder emptying do not differ from those reported in the middle-aged gallstone population. Advanced age is associated with a high rate of calcified, probably pigment stones.

Hepatitis C virus infection and related chronic liver disease in a resident elderly population: the Silea study

The prevalence of hepatitis C virus (HCV) infection increases with advancing age, but the disease has been poorly studied in the elderly. A population‐based study was therefore carried out to investigate the prevalence of HCV infection and the severity of HCV‐related chronic liver disease in the elderly. One thousand and sixty‐three people (≥60 years of age) were screened for antibodies to HCV (anti‐HCV) and for possible abnormalities of common liver function tests. Positive subjects and sex and age‐matched anti‐HCV‐ negative controls were recalled 12 months later for measurements of liver enzymes, confirmatory testing of anti‐HCV, HCV RNA analysis and HCV genotyping. All subjects answered a specific questionnaire concerning medical history and possible risk factors. Forty‐four subjects were positive for anti‐HCV, the prevalence being 4.1%. Thirty‐five positive subjects and 35 controls were investigated further. Risk factors for acquiring HCV were found to be: blood transfusion, surgical intervention and the use of non‐disposable syringes. Abnormal alanine aminotransferase levels were found in 13 patients (37.1%). HCV RNA genotyping showed type 1b in three (15.8%), type 2a in 13 (68.4%) and not classified in three (15.8%) patients. There was no relationship between abnormalities of serum aminotransferase, the rate of HCV RNA positivity and HCV genotypes. Ultrasound abnormalities were present in 13 (37.1%) patients. In this elderly population the relatively high prevalence of HCV infection was thought to be caused by previous parenteral exposure. The low incidence of liver disease could be related to the prevalence of HCV genotype 2a in the majority of these patients, and hints at the possibility of an HCV carrier state in elderly individuals.

Epidemiology of Gallstone Disease in an Older Italian Population in Montegrotto Terme, Padua

allstone disease (GD), which includes the presence of G stones in the gallbladder and cholecystectomy, has a higher prevalence in females than in males.’-8 Prevalence increases with age,’-’ and environmental factors seem to be of etiological importance.” Most estimates of the prevalence of GD have been obtained from autopsy and from clinical series.s76 The real prevalence of the disease in a general population is debated because of limitations in investigative methods and biased sampling. With the advent of ultrasonography, epidemiological studies have been carried out with some degree of reliability on a large number of subjects.” However, many published studies include only people between 20 and 60 years of and therefore, only limited information is available on subjects older than 60.l3-I6 The clinical presentation of GD in older subjects is similar to that seen in younger patients, but often symptoms do not correlate with the severity of the disease.” Gallstone disease is associated with higher mortality and a higher complication rate in older adults than in younger adults,”*18 even if GD is commonly considered a benign condition.’’ In this epidemiological study, carried out in an older resident population, we investigated the prevalence of GD by ultrasonography. The clinical features and biochemical indices reported to be associated with GD were also evaluated in order to characterize the condition in this age group.

Are liver cirrhosis and portal hypertension associated with an increased risk of bleeding during laparoscopy? A retrospective analysis of 1,000 consecutive cases.

Laparoscopy is a relatively safe invasive procedure. However, the rate of bleeding complications during this procedure is still debatable. Moreover, it is not clear whether portal hypertension may increase the risk of this event. The authors analyzed retrospectively the records of 1,000 consecutive patients with chronic liver disease undergoing laparoscopy and guided direct-vision hepatic biopsy, and they examined the rate of bleeding complications from the trocar site after insertion of the Veress needle or after liver biopsy. A total of 400 of 1,000 patients had liver cirrhosis. Of these, 22.7% had splenomegaly, 13.0% had laparoscopic signs of portal hypertension, and 8.2% had esophageal varices. Bleeding occurred in 0.9% of patients from the trocar site, in 0.2% from the biopsy site, and in 0% from the Veress needle site. These figures were independent of the presence of advanced liver disease, with or without portal hypertension. Bleeding complications occur rarely during laparoscopy with guided liver biopsy and do not seem to be related per se to the presence of liver cirrhosis and portal hypertension. If anything, bleeding complications represent an unpredictable event in most cases.

BLADDER INJURY DURING DIAGNOSTIC LAPAROSCOPY. A CASE REPORT.

We report the case of a bladder injury that was incurred during diagnostic laparoscopy in a 19-year-old man with hepatomegaly, neuropsychiatric disturbances, and urinary retention whose final diagnosis was Wilsons disease. In order to define the nature of his hepatomegaly, the patient underwent laparoscopy. However, the lack of recognition of urinary retention by the operator and the absence of cooperation by the patient caused bladder injury during the insertion of the Veress needle, resulting in the leakage of a yellow fluid consistent with urine. Since the injury was small, it was managed with antibiotics and bladder drainage, alone and deemed not to require surgical repair. We also discuss potential risk factors and describe some approaches that can help to avoid this laparoscopic complication.

Effect of Silybin on biliary lipid composition in rats.

The authors studied the influence of Silybin in rats, administered i.p. for 7 days (daily dose of 100 mg/kg/b.w.) on the biliary lipid composition and on the maximal excretory rate of bile salts. Following this treatment, biliary cholesterol excretion was reduced, while the other lipids and bile flow were not significantly modified. After sodium cholate infusion (1.6 mumol/min/100 g b.w. i.v. for 80 minutes), the Tm of bile salts and bile flow remained unchanged in Silybin pretreated rats. The mechanism by which Silybin treatment reduces cholesterol excretion, is discussed.