Rosangela Muratori

Value of splanchnic Doppler ultrasound in the diagnosis of portal hypertension.

The accuracy of various Doppler parameters of portal circulation in the diagnosis of relevant portal hypertension (presence of gastroesophageal varices) was prospectively validated. The following parameters were compared in 51 patients with chronic liver disease (40 with cirrhosis and 11 with chronic hepatitis): portal vein flow velocity and congestion index, hepatic and splenic arteries resistance indexes (RI), modified liver vascular index (portal flow velocity/hepatic artery RI) and portal hypertension index, a new index calculated as: [(hepatic artery RI x 0.69) x (splenic artery RI x 0.87)]/portal vein flow velocity. Highest accuracy was achieved by the splenic artery RI and the portal hypertension index (both around 75%) at cut-offs, respectively, of 0.60 and 12 cm/s(-1), which appeared to be, therefore, the most favorable parameters for the clinical practice. Their use may limit the need for endoscopy to search for varices.

Indications for laparoscopy before and after the introduction of ultrasonography

We compared the outcome of laparoscopy performed from 1973 to 1974, prior to the introduction of routine ultrasound diagnostics, with that of examinations during the period 1980-1981 when ultrasound had become a well-established technique in the diagnosis of hepatic lesions. Our data reveal statistically significant changes in the use of laparoscopy in the diagnosis of cholestasis and tumors of the hepatic parenchyma. Laparoscopy now has fewer indications in the study of the jaundiced patient with suspected extrahepatic cholestasis which is easily identified at ultrasound. Given the high sensitivity and specificity of ultrasonography in detecting metastases, laparoscopy has become a secondary examination. However, there has been an increase in the use of laparoscopy to identify benign hepatic lesions, particularly hemangiomas.

Cancer of the gastric stump in Italy, 1979–1986

Sixteen thousand fiberoptic endoscopies were reviewed. Gastric stump cancer was found in 24 patients of 368 who had had gastric resection for benign peptic disease. A direct relation between the percentage of patients with cancer of the gastric stump and the postsurgical interval was observed. Patients with partial gastrectomy who are 15 to 20 years postoperative should have an endoscopy irrespective of presence or lack of symptoms. Multiple biopsies should be taken in view of the multicentric growth pattern of early carcinoma.

Laparoscopy compared with ultrasonography in the diagnosis of hepatocellular carcinoma

In recent years, various newer imaging procedures have superseded laparoscopy in the detection of many diseases. The role of laparoscopy in the diagnosis of hepatocellular carcinoma is still subject to debate. To assess the value of laparoscopy compared with that of ultrasonography, we compared data obtained from a series of 54 patients with hepatocellular carcinoma, all of whom had both procedures performed at nearly the same time. In our study, ultrasonography proved superior to laparoscopy in detecting the presence and extent of the hepatocellular carcinoma. Supplemental findings attributable to laparoscopy did not alter management, whereas additional information obtained by ultrasonography often did influence the choice of treatment. We conclude that ultrasonography is the primary diagnostic method of choice in the assessment of hepatocellular carcinoma and that laparoscopy should be reserved for only selected cases.

Stimulation of pancreatic secretion by sulpiride

Sulpiride is a nonsedative neuroleptic, pharmacologically related to metoclopramide, which has previously been shown to affect various gastric functions and to exert a beneficial effect in the treatment of duodenal ulcer. In the present study the authors investigated the effects of sulpiride on pancreatic exocrine secretion. The intravenous injection of sulpiride (100 mg) during a constant infusion of secretion (0.5 CU/kg/hr) and cholecystokinin (0.5 IDU/kg/hr) significantly increased outputs of bicarbonate and enzymes in nine healthy subjects. The increase was maximal 20–30 min after sulpiride administration and lasted for the duration of the study (1 hr). Compared to presulpiride control levels, the mean maximum percent increase was 35% for bicarbonate, 39% for lipase, and 32% for chymotrypsin. It is concluded that sulpiride augments pancreatic secretion stimulated by submaximal doses of secretin and cholecystokinin. The mechanism of this effect is unknown.

Safety and efficacy of extracorporeal shock-wave lithotripsy in the management of biliary stones after orthotopic liver transplantation

needle has also been reported [3]. Exclusive fine-needle aspiration has been used, but does carry risk of recurrence [4]. Safety and efficacy of extracorporeal shock-wave lithotripsy in the management of biliary stones In the literature mean duration of follow-up varied from 6 to 12 months, and most patients had satisfactory outcomes after complete tumour resection. Regarding post-surgical anastomotic oedema, preventive jejunal stoma may be beneficial, since it is associated with lower rates of severe complications, better nutrition status [5], shorter hospital

Gallbladder endoscopic drainage plus extracorporeal shock wave lithotripsy for Mirizzi syndrome type I complicated by acute cholecystitis

in 3) in al (13 mm) of extra-hepatic bile duct, were noted. The endoscopic retrograde cholangiography (ERCP) revealed a 10 mm stone impacted in the distal cystic duct (CD) at its low insertion in CBD; however the CBD resulted itself compressed by the CD stone, thereby allowing a diagnosis of Mirizzi syndrome (MS) type I. After biliary sphincterotomy, revealing a big outflow of pus, passage of the balloon in the CBD yielded some sludge without any stone. In order to achieve CD stone clearance, given the high-risk surgery, CD cannulation was performed. However, after several failed attempts, likely because of the narrow angle and the impacted stone, a 7 Fr naso-biliary drainage (Cook Ireland, Ltd.), as previously reported [3], was placed into the gallbladder for the purpose of extracorporeal shock wave lithotripsy (ESWL) and to achieve a drainage bridge to surgery (Fig. 1A). Two sessions of ESWL were performed resulting in good stone fragmentation and spontaneous clearance (Fig. 1B and C). After these procedures serum bilirubin levels gradually returned to normal. Fifteen days post-EWSL, intraoperative cholangiography was performed during laparoscopic cholecystectomy, confirming the absence of residual CD stones. Mirizzi syndrome (MS) is characterized by common hepatic duct obstruction owing to mechanical compression and surrounding inflammation by a gallstone impacted at CD or gallbladder neck (type I). Type II occurs when a stone produces a cholecystocholedochal fistula and migrates into the CBD. Presence of a long CD or low insertion of the CD into CBD increases the risk of developing this syndrome. Although surgical therapy remains the mainstay, urgent surgery is associated with higher risk of CBD injury and need of bilio-enteric anastomosis [1,2]. Surgery is the gold standard for treating of MS type I complicated by acute cholecystitis and alternative treatments ge to

Ductal Stones Recurrence After Extracorporeal Shock Wave Lithotripsy For Difficult Common Bile Duct Stones: Predictive Factors

BACKGROUND & PURPOSE Extra-corporeal shock wave lithotripsy (ESWL) can be considered in difficult common bile duct stones (DCBDS), with a success rate greater than 90% but data on stone recurrence after ESWL are limited. We performed a retrospective analysis to evaluate long-term outcomes in patients who underwent ESWL for DCBDS. METHODS From May 1992 to October 2012, patients who underwent ESWL treatment for DCBDS, not amenable to endoscopic extraction, were included. Data on long-term outcome were collected through phone interviews and medical records. RESULTS A total of 201 patients with a successful clearance of DCBDS after ESWL were included. During a median follow-up period of 4.64 years, 40 patients (20%) developed a recurrence of bile duct stones. Logistic regression analysis showed that the common bile duct diameter, gallstones presence and the maximum stone size were significantly associated with recurrence. CONCLUSIONS We observed a recurrence rate of 20% over a median follow-up of 4 years. Gallbladder stones, stone size and a dilated common bile duct diameter are risk factors for recurrent stone formation, while ursodeoxycholic acid treatment did not influence recurrence in our population.