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Purpose: The aim of this paper is to provide a method for measuring the internal anal sphincter on the basis of the quantitative analysis of three-dimensional endosonographic images. A software calculates a large set of measurements which are able to describe the three-dimensional shape of the muscle. Methods: A software provides four types of measurements: thickness, length, area and volume. The different magnitudes are estimated using the same reference system. The measurements obtained are modeled by functions that describe their spatial trend. The precision and reproducibility of the method was tested on a phantom before a study was performed on fifteen healthy patients. The measurements were carried out by two different operators. The inter-observer variability were assessed. Results: In the phantom measurements the mean errors and the standard deviation were: 0.05 ± 0.1 mm for the thickness, 0.02 ± 0.12 mm for the length, −4.43 ± 2.4 mm for the area, −20.69 ± 20.83 mm for the volume. The maximum absolute differences between the measurements carried out by the two operators was: 0.18 mm for the thickness (in the 95% of the case), 1.69 mm for the area (in the 95% of the case), and 0.25 mm for the length, and 29.46 mm for the volume. The human IAS assessments were evaluated on each segment. The mean of the all tissue measurements carried out were (mean ± SD): 1.71 ± 0.34 mm for the thickness, 33.24 ± 6.10 mm for the length, 111.28 ± 29.08 mm for the area. The mean of the volume measurements of the entire tissue was: 4124 ± 1160 mm. Inter-observer variability was observed only in the anterior proximal segment for the thickness measurements by Wilcoxon's signed rank test ( P value = 0.048) and for the volume assessments by the limits of agreement method (−118to 78 mm). The mean percentage errors and the limit of agreement for the measurements of the entire tissue were: 0.27 and (−0.11 to 0.12 mm) for the thickness, −2.32 and (−3.88 to 2.33 mm) for the length, −0.05 and (−9.71 to 9.83 mm) for the area, −1.89 and (−366 to 240 mm) for the volume. Conclusion: The assessments of accuracy and precision of the method result satisfactory for all four type of measurements. The reproducibility analysis confirms very good inter-observer agreement for the phantom measurements and for the most part of the IAS segments evaluations. Inter-observer variability was seen only for the thickness and volume measurements of the anterior-proximal segment. Our method provides a high number of measurements with good accuracy enabling a very detailed study of IAS morphology. [ABSTRACT FROM AUTHOR]

Early restored patency of the papilla has been hypothesized to reduce complications and mortality of acute biliary pancreatitis. The aim of this study was to evaluate the role of urgent laparoscopic cholecystectomy with intraoperative cholangiography and rendezvous when necessary in acute biliary pancreatitis natural history. Patients observed in the early stage of an acute biliary pancreatitis were included in the study. Operative risk assessment based on American Society of Anesthesiologists (ASA) score allowed the performance of urgent laparoscopic cholecystectomy within 72 h from onset of symptoms in 55 patients and a delayed intervention during the same admission in 21 patients. Intraoperative cholangiography was performed in all cases, and clearance of common bile duct was performed by flushing when possible, or rendezvous when necessary. Evolution of pancreatitis was evaluated with clinical and radiological monitoring. Urgent laparoscopic cholecystectomy was performed in all cases without conversion. At intraoperative cholangiography common bile duct was free in 25 patients, a papillary spasm was observed in 9, and common bile duct stones in 21 patients. Patency of the papilla was restored by flushing in 13 patients, while a rendezvous was necessary in 17 patients. The rate of organ failure and pancreatic necrosis was 1.8%, overall mortality was 1.8%, and overall morbidity 21.8%. No infectious complications of peripancreatic collections were observed. Urgent laparoscopic cholecystectomy with selective intraoperative rendezvous may be considered as a treatment option in the early stage of acute biliary pancreatitis. [ABSTRACT FROM AUTHOR]

The detection and classification of hepatic vessels in diagnostic images are essential for hepatic pre-surgery planning. Our team has developed a tool for classification, analysis, and 3D reconstruction of the hepatic and portal systems. Our software first extracts a graphic representation of a set of connected voxels, representing both systems. It then calculates two binary volumes representing the main part of the two venous systems. Finally, it combines these results to obtain the correct vessel classification. Segmentation steps are semi-automatic and require about 40 min to complete. Schematization and classification steps are automatic and require about 17 min for results. The software provides a correct and detailed reconstruction even where pathologies have caused morphological and geometrical variations in the vessels. The time required for the entire procedure is compatible with clinical requirements, providing an efficient tool for diagnosis and surgical planning. [ABSTRACT FROM AUTHOR]

Objective: The evaluation of innovative biomarkers of myocardial damage in the perioperative period.Methods: Twenty-four patients with gastric or colorectal cancer were studied and samples were collected for the measurement of myoglobin, troponin I (cTnI), creatine kinase isoenzyme MB (CK-MB), glycogen phosphorylase isoenzyme BB (GPBB), carbonic anhydrase III (CA III), fatty acid-binding protein (FABP), and CK presurgery and on the first, seventh, and thirtieth days post-surgery.Results: Troponin I values were unchanged throughout the study period. Myoglobin, GPBB, CA III, and FABP were significantly increased on day 1 after surgery. On the seventh day, GPBB, myoglobin, and FABP were still increased, whereas CK was decreased. Thirty days after surgery no significant variations were observed except a decrease of CK and CA III.Conclusions: These results show cTnI and CK-MB are unaffected by surgery, while the measurement of CA III, FABP, GPBB, and myoglobin might be unsuitable for diagnosing an acute coronary syndrome perioperatively. [ABSTRACT FROM AUTHOR]

Background: This study aimed at verifying whether peritoneal cytology could improve the prognostic information provided by TNM staging in gastric cancer patients. Method: The presence of free peritoneal tumor cells was investigated in 168 patients who underwent curative resection for gastric cancer from January 1992 to July 2002 in Verona, Italy. The influence of peritoneal cytology on survival was evaluated by a Cox regression model, controlling for potential confounders. Results: Twenty-three patients (14%) had positive peritoneal cytology. Patients with positive lavage were more likely to present serosal infiltration (100 vs. 46%) and nodal metastases (91 vs. 67%; P < 0.001). Positive lavage was associated with a very poor prognosis: 3-year survival was only 9% (95% Cl 2–27%) when peritoneal cancer cells had been detected, whereas survival reached 50% (95% Cl 42–59%) in patients with a negative cytology. In multivariate survival analysis, peritoneal cytology was an independent predictor of mortality when controlling for sex, age, site, histology, and nodal metastases, but not when adjusting also for depth of tumor invasion (RR of positive versus negative = 1.2, 95% Cl 0.7–2.0). Similarly, the influence of peritoneal cytology on survival was no longer significant when univariate analysis was restricted to T3/T4 patients (RR = 1.5, 0.9–2.5). Conclusions: Positive peritoneal cytology was a marker of poor prognosis in gastric cancer patients. Nevertheless, peritoneal lavage did not increase the prognostic information already provided by the TNM staging system in this Italian series. [ABSTRACT FROM AUTHOR]

Examines the prognostic importance of lymph node involvement in adenocarcinoma of the gastro-esophageal junction. Analysis of the number-based and a site-based tumor node metastasis classification; Recognition of adenocarcinoma of the gastro-esophageal junction as a distinct clinical entity; Basis for the choice of surgical approach for patients with adenocarcinoma of the gastro-esophageal junction.

An intestinal-type epithelium is often present at columnar-lined esophagus, gastroesophageal junction or within the so-called short segment Barrett's esophagus, but ultrastructural study failed to detect enterocytes in columnar-lined esophagus. The authors have analyzed the intestinal aspects present in areas of columnar-lined esophagus in a population of patients with reflux esophagitis to better understand the morphology and histogenesis of the proliferating elements. Columnar-lined mucosa was studied in 35 patients. Columnar surface cells displayed a wide spectrum of ultrastructural features. Well-differentiated columnar secretory cells, secretory-absorptive cells, poorly differentiated columnar cells, atypical columnar cells, and goblet cells were detected. Well-differentiated absorptive cells were never found. These results demonstrate that the areas of intestinal metaplasia show a wide spectrum of ultrastructural phenotypes, ranging from poorly to well-differentiated cells. However, true enterocytes were not found and the most represented phenotype is that of secretory-absorptive cells, whose principal characteristic is the presence of secretory and absorptive aspects together. They can be described as secretory enterocytes or cells with double specialization. To the authors' knowledge, similar cells were not previously described in normal intestinal mucosa, and ultrastructural studies are consistent in describing a broad spectrum of ultrastructural features, suggesting that Barrett's specialized metaplasia is derived from cells with the capacity for a wide range of differentiation. Therefore, despite the wide use of term intestinal metaplasia in the medical literature, experimental data clearly failed to detect enterocytes in the columnar-lined esophagus, and ultrastructural data do not support the concept of intestinal metaplasia. The cellular heterogeneity seems to be the result of a "phenotypic shift" of undifferentiated elements, which show a different pattern of evolution. The result of this process is the formation of new cell types dissimilar from those normally present in esophageal, gastric, or duodenal mucosa. [ABSTRACT FROM AUTHOR]

The prognosis of venous thromboembolism is considerably influenced by an accurate and fast diagnosis. Although the role of D-dimer testing in the diagnosis of suspected venous thromboembolism is well established for out-patients, there is controversial evidence on the clinical usefulness of its measurement in surgical patients. In order to recognize patterns of variation of D-dimer following surgery and identify potential pitfalls in prediction of venous thromboembolic complications, plasma D-dimer was assayed in 30 patients undergoing major elective hip surgery and 20 patients undergoing laparoscopic cholecystectomy for acute cholecystitis. The postoperative variation of plasma D-dimer differed widely between the two subgroups. Patients undergoing laparoscopic cholecystectomy showed D-dimer concentrations persistently increased from the baseline to the 15th postoperative day, whereas patients undergoing hip surgery were characterized by a double peak, on the 1st and 7th postoperative days. Mean inter-individual daily coefficient of variations of plasma D-dimer throughout the postoperative period were 49% (range 39%–61%) for laparoscopic cholecystectomy and 101% (range 72%–156%) for orthopedic surgery. The markedly heterogeneous fluctuation of plasma D-dimer suggests that the postoperative activation of the hemostatic system depends on the type and time since surgery, thus limiting the clinical usefulness of D-dimer testing in the diagnostic approach to postoperative venous thromboembolism. [ABSTRACT FROM AUTHOR]

SummaryBackground: The morbidity and mortality rates associated with acute cholecystitis are higher in the elderly. This study reports the results of treatment of acute cholecystitis in the elderly with emergency ultrasonographically guided percutaneous cholecystostomy followed by elective cholecystectomy after endoscopic treatment of any common bile duct stones diagnosed by percutaneous cholangiography. Methods: From January 1989 to December 1998, 92 patients aged over 70 years were treated for acute gallstone cholecystitis. A group of 84 patients with ultrasonographic signs of severe cholecystitis or an American Society of Anesthesiologists score of II to IV were submitted to ultrasonographically guided percutaneous cholecystostomy. Transcatheter cholangiography was performed in all patients and endoscopic sphincterotomy was performed before operation in patients with common bile duct stones. After resolution of the acute phase and treatment of any associated diseases, patients were submitted to cholecystectomy. Results: Cholecystostomy was performed successfully in 83 patients and permitted resolution of the acute attack in all after a mean period of 1·8 days. Cholangiography yielded a diagnosis of non-gallstone obstruction in one patient and common bile duct stones in 19 patients; preoperative endoscopic sphincterotomy and stone extraction was performed in 18 patients. Elective cholecystectomy was then performed in 70 patients with no deaths and a morbidity rate of 24 per cent. Conclusion: Combining emergency ultrasonographically guided percutaneous cholecystostomy, preoperative endoscopic treatment of common bile duct stones and subsequent elective chole-cystectomy constitutes an optimal treatment regimen for acute gallstone cholecystitis in selected elderly patients with a mortality rate of zero in the authors’ experience. [ABSTRACT FROM AUTHOR]

The study was designed to establish the usefulness of measuring lipoprotein(a) [Lp(a)], total cholesterol, triglycerides, low-density lipoprotein [LDL]-cholesterol, high-density lipoprotein [HDL]-cholesterol, total-to-HDL-cholesterol ratio and fibrinogen in identifying subjects at risk of occlusive complications following vascular and endovascular surgery, including primary successful ileofemoral percutaneous transluminal angioplasty, infrainguinal and aortic bypass graft and carotid endarterectomy. A total of 68 volunteers subjected to vascular and endovascular surgery were recruited to the study. Six months after successful interventions, no occlusive complications verified by angiography were observed in 45 patients (66%; No-restenosis group), whereas significant restenosis or reocclusion occurred in 23 patients (34%; Restenosis group). Significant lower concentrations of Lp(a) (p=0.032), total cholesterol (p<0.0001), LDL-cholesterol (p=0.001) and total-to-HDL-cholesterol ratio (p<0.0001) and higher concentrations of HDL-cholesterol (p=0.048) were observed in the No-restenosis group compared to the Restenosis group. The concentrations of triglycerides (p=0.080) and fibrinogen (p=0.510) did not differ significantly between groups. In multivariate discriminant analysis, the best predictors of restenosis or reocclusion were in decreasing order: LDL-cholesterol, Lp(a), total-to-HDL-cholesterol ratio, HDL-cholesterol and total cholesterol. A statistical difference of particular interest was observed in the overall distribution of Lp(a) concentrations between groups (p<0.0001), occlusive complications being unlikely to occur in patients with Lp(a) concentrations below 50 mg L-1. The potential interference from a concurrent acute phase response, the most common source of elevation of Lp(a) in humans, was less likely in view of the absence of differences in erythrocyte sedimentation rate between the No-restenosis and Restenosis groups (p=0.463). In conclusion, the results of the present investigation point to a definite role of the combined measurements LDL-cholesterol, Lp(a), total-to-HDL-cholesterol ratio, HDL-cholesterol and total cholesterol in the identification of subjects at risk of occlusive events following vascular and endovascular surgical procedures. [ABSTRACT FROM AUTHOR]