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Objective The objective of this study was to compare outcomes of patients with favorable neck angulation (FNA) and hostile neck angulation (HNA) treated with the Treovance stent graft (Terumo Aortic [formerly Bolton Medical], Sunrise, Fla). Methods Patients with abdominal aortic aneurysms suitable for endovascular repair with Treovance were included in the RATIONALE postmarket surveillance registry. A post hoc subgroup analysis compared patients with infrarenal neck angles Results After 1 year, 179 FNA (89.5%) and 21 HNA (10.5%) patients were analyzed. Both groups were similar in terms of sex (male, 92.7% FNA and 95.2% HNA) and age (73.0 years vs 72.6 years), but the HNA group had more Asian or other race representation (7.3% vs 19.0%) and more patients assigned to American Society of Anesthesiologists class 3 and class 4 (57.6% vs 66.7%). Mean suprarenal angles (standard deviation) were 13.1 (±13.5) degrees vs 29.0 (±16.4) degrees; mean infrarenal angles were 23.2 (±16.4) degrees vs 65.4 (±4.6) degrees, respectively. Aneurysm sac size maximum diameter was 58.1 (±9.8) mm vs 62.0 (±14.1) mm. There was a significant difference in unplanned adjunctive procedures (2.2% vs 19.0%; P = .01). Mean procedural duration was also significantly different for HNA patients, who underwent protracted operations (111.3 [±47.3] minutes vs 153.5 [±44.5] minutes; P Conclusions Patients with high neck angulation treated with Treovance underwent more complex procedures but showed equally good technical success and 1-year clinical success parameters.

Renal artery aneurysms (RAA) are rare (general population incidence is 0.09%). At this time, the appropriateness of the type of intervention ‑ surgical or endovascular ‑ is based on single center experiences rather than large randomized trials. Endovascular therapy offers less morbidity but surgery has excellent long-term results. In reality, the choice of the treatment relies on the operative risk. A patient with a RAA and good surgical risk should be offered open surgery. If the patient is deemed to be at high risk from surgery then the choice of the type of endovascular treatment (stent grafting, coil/glue embolization, multilayer stenting) should be based on the location and shape of the RAA. RAA should be treated by surgeons/interventionalists who have demonstrated expertise in renal artery procedures.

A lactose-free diet is commonly prescribed to subjects with hypolactasia. We tested the effectiveness of a single ingestion of tilactase (a beta-D-galactosidase from Aspergillus oryzae) in adults with hypolactasia, previously assessed by lactose H(2)-breath test.After measurement of orocecal transit time (OCTT, by lactulose H(2)-breath test) and lactose H(2)-breath testing plus placebo, a total of 134 subjects were positive to hypolactasia and underwent lactose H(2)-breath testing plus either low (6750 U) or standard (11,250 U) doses of tilactase. The appearance of gastrointestinal symptoms during the tests was monitored.OCTT was longer in malabsorbers (subjects without bloating, abdominal pain and/or diarrhoea, n = 25) than in intolerants (bloating, abdominal pain and/or diarrhoea, n = 109, P0.02). Malabsorbers had longer time to H(2) peak (P0.03), lower H(2) peak levels (P0.002) and smaller integrated H(2) excretion levels (P0.005) than intolerants. After tilactase ingestion, integrated H(2) levels were decreased by 75% (low dose) and 87% (standard dose) in malabsorbers, and by 74% (low dose) and 88% (standard dose) in intolerants. In the latter group, total symptom score were decreased by 76% (low dose) and by 88% (standard dose) (P0.0001).A single oral administration of tilactase is highly effective in decreasing symptoms and hydrogen excretion of hypolactasia assessed by lactose H(2)-breath test. If confirmed by long-term observations, ingestion of tilactase might be a better option than exclusion diets in intolerant subjects with hypolactasia.

The biological importance of the aquaporin family of water channels was recently acknowledged by the 2003 Nobel Prize for Chemistry awarded to the discovering scientist Peter Agre. Among the pleiotropic roles exerted by aquaporins in nature in both health and disease, the review addresses the latest acquisitions about the expression and regulation, as well as physiology and pathophysiology of aquaporins in the hepatobiliary tract. Of note, at least seven out of the thirteen mammalian aquaporins are expressed in the liver, bile ducts and gallbladder. Aquaporins are essential for bile water secretion and reabsorption, as well as for plasma glycerol uptake by the hepatocyte and its conversion to glucose during starvation. Novel data are emerging regarding the physio-pathological involvement of aquaporins in multiple diseases such as cholestases, liver cirrhosis, obesity and insulin resistance, fatty liver, gallstone formation and even microparasite invasion of intrahepatic bile ducts. This body of knowledge represents the mainstay of present and future research in a rapidly expanding field.

Angiotensin converting enzyme inhibitors (ACE-i) and angiotensin II receptor blockers (ARB) are considered to be equally effective for patients with diabetic kidney disease, while only ACE-i have been shown to determine a significant reduction in the risk of all-cause mortality, predominantly cardiovascular, in these patients. Studies on the cardio-renal efficacy of combined therapy with ACE-i and ARB are not available or not conclusive, in a population with cardiovascular risk with micro- or macroalbuminuria. In this paper, we present the protocol of a randomized controlled clinical trial that will address the question. The LIRICO (Long-term Impact of RAS Inhibition on Cardiorenal Outcomes) study will evaluate the comparative efficacy for cardiovascular and renal outcomes of combined therapy with ACE-i and ARB versus monotherapy with ACE-i or ARB in micro/macroalbuminuric individuals at cardio-renal risk. The study will enrol 2100 patients allocated to monotherapy with ACE-i, ARB or combined treatment with ACE-i + ARB. The LIRICO study is a randomized comparative trial, with PROBE (Prospective Randomized Open Blinded End-Point) design. The study has been approved and funded by the Agenzia Italiana del Farmaco (AIFA) within the 2005 funding plan for independent research on drugs. Availability of funding for this study provides, for the first time in our Country, an opportunity to organize a collaborative national network of nephrology, internal medicine and diabetology outpatient clinics to develop a large multicentre trial collaboration. The results of this trial will establish the optimal therapy for micro/macroalbuminuric individuals with cardiovascular and renal risk.

The aim of this study was to evaluate the technical success and clinical outcome of surgical revascularization, angioplasty and/or stenting for renal artery stenosis (RAS) in patients with renovascular hypertension (RVH). The secondary aim was to identify independent negative predictors of blood pressure control after successful renal revascularization.From January 1998 to July 2006, we treated 97 cases of RAS in 83 RVH patients. Inclusion criteria were RASor =80% associated with hypertension refractory to medical control with at least three drugs including a diuretic. Therapeutic options were surgical revascularization in 15 cases (11 renal endarterectomies, 4 aortorenal bypasses) and endoluminal treatment in 82 (14 balloon angioplasties, 68 stents).Technical success was 100% for both surgical and endovascular procedures; 13 cases of restenosis (or =80%) were detected: 12 (14.6%) in the endoluminal group and one (6.6%) in the surgical group (P=0.68). During the follow-up period (average 37 months, range 6-94), blood pressure control improved in 43% of patients, disease stabilized in 37% and the natural course of RVH deteriorated in 20%. Multivariate Cox regression analysis showed that only a long history of antihypertensive drug use was a predictor of inefficacy of blood pressure control after revascularization (P0.04).The complete resolution of RVH associated with severe RAS appears unrealistic in several cases. Early and long-term results in terms of technical success and restenosis were acceptable and similar for surgical and endovascular renal intervention. An early diagnosis of RVH could improve the control of hypertension after successful renal revascularization.

The clinical aspects and the diagnostic features of gallstone disease are described. The natural history of silent gallstones is overviewed, and the risk of developing symptoms and complications is also discussed. The importance of colicky pain as a specific gallstone symptom is highlighted, and the role of both laboratory tests and diagnostic investigations for differential diagnosis is discussed. Finally, we describe the diagnostic features of gallbladder stone disease, including indications, sensitivity, specificity, and limitations of different test investigations under special circumstances.

Accidental aspiration of fuel in fire eaters can cause an acute chemical pneumonitis known as 'fire-eater's pneumonia". We report a case in a 29 year-old fire-eater. Six hours after aspiration of kerosene, he developed fever up to 39,5 degrees C, dyspnea, cough and chest pain. Chest radiograph showed infiltrates in the middle and lower parts of the lungs and left pleural effusion. He was treated with an antibiotic and antipiretic therapy and then with corticosteroids. The acute stage lasted four weeks and the patient recovered without sequelae within 3 months. Hazard related to main fuels used for fire eating is discussed.

Background Since 1990 our group has been using extracorporeal circulation to ozonate blood by an original method, known as extracorporeal blood oxygenation and ozonation (EBOO), with the aim of amplifying the results observed with ozone autohemotherapy. Objective To verify the hypothesis that EBOO improves the skin lesions typical of peripheral artery disease (PAD) patients. Methods Twenty-eight patients with PAD were randomized to receive EBOO or intravenous prostacyclin in a controlled clinical trial. The primary efficacy parameters were regression of skin lesions and pain, and improvement in quality of life and vascularisation. Results Patients treated with EBOO showed highly significant regression of skin lesions with respect to patients treated with prostacyclin. Other parameters that were significantly different in the two groups of patients were pain, pruritus, heavy legs and well-being. No significant differences in vascularisation of the lower limbs before and after treatment were found in either group. No side effects or complications were recorded during the 210 EBOO treatments. Conclusion EBOO was much more effective than prostacyclin for treating skin lesions in PAD patients and also had a positive effect on patient general condition without any apparent change in arterial circulation. This suggests other mechanisms of action of EBOO.

Erythrocyte membrane modifications in patients with cholestasis are supposed to reflect those of hepatocytes.Erythrocyte membrane composition (cholesterol, phospholipids, fatty acids, protein sulphydrils and carbonyls) was assessed and related to the stage of liver disease in patients with primary biliary cirrhosis before and after 1 year of ursodeoxycholate treatment.Compared with controls, patients showed lower levels of protein sulphydrils (28.9 +/- 7.1 vs. 65.6 +/- 1.8 nmol mg(-1) prot) and accumulation of carbonyls (4.7 +/- 1.7 vs. 1.4 +/- 0.1 nmol mg(-1) prot). Phosphatidylethanolamine level was lower in stage III-IV cirrhosis while phosphatidylcholine and cholesterol levels were higher; as a consequence the phosphatidylcholine/sphingomyelin ratio was higher than in controls (4.25 +/- 0.55 in the I-II stage and 2.89 +/- 0.44 in the stage III-IV vs. 1.61 +/- 0.30). These changes were particularly evident in patients with more advanced stages of liver disease. Protein sulphydrils and carbonyls, phosphatidylethanolamine and cholesterol levels correlated (P0.05) with the histological stage of the liver disease, serum and membrane cholesterol levels were significantly related (r=0.66, P0.05). One year of ursodeoxycholate administration was accompanied by major changes of the membrane lipid composition, partial reversal of protein oxidation, and improvement of serum parameters.This study indicates that major alterations in protein status and lipid composition occur in erythrocyte membrane of patients with primary biliary cirrhosis. These changes were more pronounced in patients with advanced liver disease. Ursodeoxycholate was able to revert in part serum and erythrocyte alterations, especially in patients with early stages of liver disease.

Fatty accumulation per se does not appear to affect liver function; however, interest has recently renewed to fatty liver because of the clinical relevance of non alcoholic steato-hepatitis (NASH) and for the increased risk of post-transplant failure in grafted livers with steatosis. Clinical and experimental studies have doubtless demonstrated that oxidative stress ensues in steatotic livers. Mitochondria represent the preferential target of the oxidative injury associated to fatty degeneration and show reduced content of glutathione, higher levels of oxidative products and damages to enzymes involved in the process of ATP synthesis, which become more evident under stressing conditions. Although obese patients with fatty liver are advantaged by weight loss, clinical and experimental observations suggest that fatty livers poorly tolerate excessive food deprivation. These observations represent the rationale for treatment strategies based on the supplementation of antioxidants and energetic substrates rather than solely a diet restriction. This review focuses on data emerging from a series of investigations performed in rats with fatty livers induced by a choline-deficient diet, which resembles human steatosis due to an excessive intake of carbohydrates, and aims to give the cue for the development of therapeutic options able to preserve hepatic function after transplantation of steatotic organs.

High fecal deoxycholate levels may promote colonic cancer. Phospholipids protect against bile salt-induced cytotoxicity. We therefore aimed to examine whether the dietary phospholipid sphingomyelin could decrease hyperproliferation induced by deoxycholate. In CaCo2 cells, hyperproliferation (by bromodeoxyuridine assay), phosphorylation state of cellular proteins, and apoptosis with concomitant caspase-3 activity were evaluated after incubation with 50-500 microM deoxycholate, with or without sphingomyelin. At 2 and 4 hr of incubation, deoxycholate induced dose-dependent apoptosis, with concomitant caspase-3 activation. At 16 hr, apoptosis had decreased markedly, but there was dose-dependent hyperproliferation (with changed phosphorylation status of cellular proteins) at this time point. Sphingomyelin dose-dependently reduced deoxycholate-induced apoptosis and hyperproliferation. In conclusion, sphingomyelin reduces deoxycholate-induced hyperproliferation and apoptosis. These findings may have implications for colonic cancer prevention by dietary modification.

Patients with colonic inertia, the most severe form of chronic functional constipation, may present with a more diffuse panenteric motility disorder. We describe a case of a woman with severe longstanding colonic inertia associated with chronic functional dyspepsia and defective gastric, gallbladder and small intestinal motility, as confirmed by several diagnostic tests including two breath tests with the 13C-stable isotope. A subclinical form of authonomic sympathetic neuropathy was diagnosed, providing a possible pathophysiological explanation for the presence of simultaneous multiple motility defects of the gastrointestinal tract.

Transient alterations of gallbladder morphology and dynamics have been reported in patients with during acute hepatitis A. The presence of dyspepsia also suggests involvement of gastric motility. During a 60-day follow-up, we investigated gallbladder and gastric motility in relation to dyspepsia in acute viral hepatitis A patients. Twenty patients were assessed at referral (day 0) and at days 7, 21, 42 and 60 and compared with 20 healthy volunteers. Gallbladder morphology and motility and gastric motility were assessed in the fasting and postprandial period by functional ultrasonography using a liquid test meal. Dyspeptic symptoms were scored. At day 0, fasting gallbladder volume was 5.9 +/- 1.3 mL, 32.6 +/- 4.6 mL, and 21.5 +/- 1.9 mL (mean +/- SE) in patients with gallbladder sludge (n = 7), without sludge (n = 13) and controls, respectively (P0.05 in sludge vs. no sludge and controls; P0.05 in no sludge vs. controls, ANOVA). Small fasting gallbladder volume in patients with sludge increased and sludge disappeared within 7 days. At day 0, patients with sludge also had increased thickness of fasting gallbladder wall and increased serum transaminase levels compared with patients without sludge and controls. Gallbladder contraction was similar in patients and controls. However, patients had delayed gastric emptying, which positively correlated with dyspepsia score. Gallbladder morphological changes observed in the acute phase of hepatitis A are transient and are associated with hepatocellular damage. Gastric emptying is delayed during the first week of disease and is associated with dyspeptic symptoms.

The interplay between contraction and relaxation in the gall-bladder muscularis leads to appropriate gall-bladder emptying and refilling during fasting and in the postprandial state in vivo. Several studies in both human and animal models have focused on cellular and molecular events in the gall-bladder wall in health and disease in vitro. Principal methods to study gall-bladder smooth muscle function include receptor binding studies (at the level of plasmamembranes or histological sections), phase contrast microscopy (at the level of isolated smooth muscle cells), and tensiometry (at the level of smooth muscle strips or the whole gall-bladder). At a very early stage, cholesterol gallstone disease is characterized by exposure of the gall-bladder wall to excess of biliary cholesterol and the cytotoxic effect of the bile salt deoxycholate. On a long-term basis, a form of gall-bladder leiomyopathy develops with defects involving the mechanisms of signal transduction at the level of plasmamembranes. The end-stage result is pathological contraction and/or relaxation of smooth musculature, impaired gall-bladder motility and gall-bladder stasis, all key factors in the pathogenesis of biliary cholesterol crystallization and gallstones.

Little is known about gallbladder motility in patients with black pigment stones when compared to cholesterol gallstone patients, or about their relationship to biliary composition, crystallization and stone characteristics.Fasting and postprandial gallbladder volumes were studied by ultrasonography in 49 gallstone patients with pigment (n = 14) or cholesterol (n = 35) stones and 30 healthy controls. After cholecystectomy stone composition, gallbladder wall inflammation, cholesterol saturation index and appearance of platelike cholesterol crystals in bile were evaluated in gallstone patients.Fasting gallbladder volume was significantly (P0.05) increased in cholesterol stone patients (31.7 +/- 1.9 mL) but not in pigment stone patients (21.9 +/- 3.1 mL), compared to controls (21.0 +/- 1.5 mL). Postprandial emptying was delayed in patients (half-emptying time: 31 +/- 2 min, 35 +/- 3 min, 24 +/- 2 min in cholesterol stone patients, pigment stone patients and controls, respectively, P0.05) and incomplete (residual volume: 43.2 +/- 2.7%, 40.0 +/- 4.3%, 15.8 +/- 1.6% min in cholesterol stone patients, pigment stone patients and controls, respectively, P0.05). The inflammation of the gallbladder wall was mild or absent in all cases. Biliary cholesterol saturation index was 152.3 +/- 8.5% and 92.9 +/- 4.8% in patients with cholesterol and pigment stones, respectively (P0.01). Whereas cholesterol crystals never appeared during 21 days in biles from patients with pigment stones, crystal observation time in patients with cholesterol gallstone was 5 days (median) and was significantly shorter in patients with multiple (4 days) than in patients with solitary (12 days) cholesterol stones (P = 0.0019).Patients with black pigment stones who do not have excess cholesterol and do not grow cholesterol crystals in bile have decreased gallbladder emptying, although to a lesser extent than patients with cholesterol stones. Thus, gallbladder stasis is likely to put a subset of subjects at risk for the formation of pigment gallstones, and pathogenic mechanisms need to be further investigated.

In the last year at the Department of Surgery of the University of Siena two patients presenting a clinical feature of intestinal infarct have been operated. In these patients a wide intestinal resection has been performed. After this surgical operation, a patient had a residual tract of 40 cm of bowel and the other 50 cm. It was not possible during operation to preserve the Bauin valve in a case; in the other, this valve has been sacrificed during a previous operation for cecal neoplasm. In the postoperative period, patients were transferred temporarily in the intensive care unit, and after some days they returned to the department where total parenteral nutrition with progressive decreasing mixture in calories over time was administered. Enteral nutrition was also started and the quantity of water, calories and azote was slavly increased. In a second time an oral diet was started up to completely weaning from parenteral and then enteral nutrition. At present, these patients are enlisted in quarterly follow-up and are completely stabilized. They are independent from artificial nutrition and they have a good quality of life.

In the last year the Authors operated two patients presenting with a clinical feature of intestinal infarct. A wide intestinal resection was performed and patients had a residual tract of 40 cm and 50 cm of bowel respectively, later manifesting as short bowel syndrome. It was not possible during the operation to preserve the Baubin valve in one case, in the other one the value had been sacrificed during a previous operation for right colonic malignancy. In the postoperative period, patients were temporarily transferred to the intensive care unit, returning in the surgery ward after few days, and counting total parenteral nutrition with progressive decreasing mixture in calories. Contemporarly enteral nutrition was started slowly increasing the quantity of water, calories and azote administration. In a second time oral diet was started up to completely weaning parenteral and enteral nutrition. At the present patients are enlisted in quarterly follow-up, completely stabilized, and independent from artificial nutrition with a good quality of life. Furthermore a saving of sanitary costs was obtained.

The primum movens in cholesterol gallstone formation is hepatic cholesterol hypersecretion and chronic supersaturation of bile. A cascade of events will then include: (i) multiple biochemical defects: increased total biliary proteins (and qualitative shift to cholesterol crystallization-promoting factors), increased proportions of hydrophobic bile salts, increased mucin secretion, and rapid nucleation/crystallization of cholesterol from cholesterol-enriched biliary vesicles; (ii) multiple motility defects: impaired gallbladder contractility in vitro and gallbladder stasis in vivo, delayed intestinal transit. A genetic predisposition (together with environmental factors) might also be important. Therapy should be offered to patients with symptomatic gallstones. Cholecystectomy remains the only radical therapy for cholelithiasis. For a subgroup of patients with symptomatic, uncomplicated cholesterol stones who are unwilling to undergo surgery, or who have a significant surgical risk, alternative non-invasive therapies include: (i) oral litholysis of small stones by bile salts, (ii) fragmentation of 1-3 medium-sized stones by extracorporeal shock-wave lithotripsy, and (iii) topical dissolution of multiple stones by methyl tertbutyl ether. A major disadvantage of all non-surgical therapies, however, is the 50% recurrence rate of stones at 5 years. A number of prokinetic agents can improve gallbladder and/or intestine transit, two important contributing factors in gallstone disease. In selected patients, administration of these agents might enhance the clearance of cholesterol crystals/gallstones or might impede/delay gallstone formation and recurrence.

We describe the role of US, in the diagnosis of LMPR and in differentiating LMPR from other renal disease, such as hydronephrosis and parapelvic cysts. In 10 patients mild to moderate hydronephrosis showed at the US, bilateral in 8 cases, was not confirmed at IVP and CT scan evaluation. Instead, compression of the collecting system by multiple cysts arising from the renal sinus was revealed by CT scan in 8 cases and by IVP in 2. At the U.S. the profile of the calices appeared irregular, differing from the features of hydronephrosis; furthermore calices were adjacent each other, separated only by a thin membrane. All patients were asymptomatic. The examination of the cystic liquor and wall, obtained percutaneously or during surgical procedures, showed the lymphatic origin of them. We cannot provide definitive data regarding how to differentiate LMPR from hydronephrosis at U.S.. In asymptomatic patients the U.S. evidence of dilated calices with irregular profile and thin membrane separating each other, can strongly suggest the diagnosis of LMPR.

Fasting and postprandial gallbladder volumes have been measured by sonography both in healthy subjects and gallstone patients ingesting: (a) tauroursodeoxycholic acid; (b) ursodeoxycholic acid; (c) placebo. Each bile salt was given at a dose of 10 mg kg-1. Sonography was repeated in gallstone patients fed tauroursodeoxycholic acid or ursodeoxycholic acid (10 mg kg-1 day-1) for 1 month. Gallstone patients had gallbladder stasis (increase in fasting and residual volumes) and decreased postprandial emptying. Acute ingestion of tauroursodeoxycholic acid or ursodeoxycholic acid did not modify postprandial gallbladder emptying in both groups of subjects. After one month's therapy with tauroursodeoxycholic acid or ursodeoxycholic acid, fasting gallbladder volume further increased in gallstone patients, although gallbladder emptying remained unchanged. Thus, therapeutic doses of tauroursodeoxycholic acid or ursodeoxycholic acid do not acutely modify postprandial gallbladder emptying in either healthy subjects or gallstone patients. Chronic treatment with either bile salts results in an increase in fasting gallbladder volume without interfering with the extent of postprandial gallbladder emptying.

To evaluate whether a low dose of oral cholestyramine improves gallbladder emptying in gallstone patients.Gallbladder volumes were assessed by sonography in 36 patients with cholesterol gallstones and 18 healthy controls. On three different days subjects ingested: 1) test meal alone, 2) test meal plus cholestyramine (4 g), and 3) cholestyramine alone (4 g).Fasting gallbladder volume (mean +/- SE, 25.9 +/- 1.8 ml and 19.2 +/- 1.3 ml for patients and controls, respectively, p0.05) and postprandial gallbladder residual volume (48.7 +/- 3.9% and 21.6 +/- 2.8% of fasting volume in patients and controls, respectively, p0.001) were larger in patients than controls, indicating impaired gallbladder emptying. Gallstone patients were divided into 19 "contractors" and 17 "hypocontractors" (residual gallbladder volume smaller or greater than mean +/- 2 SD of controls). Compared with the test meal alone, the addition of cholestyramine induced a further decrease of residual volume in contractors (from 30.4 +/- 2.1% to 19.8 +/- 1.9%, p0.001), hypocontractors (from 69.3 +/- 3.9% to 56.7 +/- 7.4%, p0.05), and controls (from 21.6 +/- 2.8% to 5.0 +/- 1.0%, p0.0004). Two hours after test meal plus cholestyramine gallbladder volume was still markedly reduced in both patients and controls. Fasting gallbladder volume 24 h after test meal plus cholestyramine was decreased in patients and in controls. The ingestion of cholestyramine alone initiated gallbladder evacuation comparable to that of test meal in both contractors and hypocontractors.A low dose of cholestyramine in combination with test meal induces a considerable decrement of gallbladder volume compared with test meal alone in gallstone patients. Cholestyramine alone causes a decrease of gallbladder volume which is comparable to that observed in response to test meal alone.

A prospective blind study was performed to compare sonographic with postoperative findings of gallstone burden in 34 patients (10 males, 24 females; mean age 52 years). Gallstone size was assessed in single calculi (n = 15) by measuring the largest diameter by ultrasonography (US). The ellipsoid algorithm was used to estimate US volume for both single and multiple gallstones. After cholecystectomy, diameters were measured in single stones; stone volume was assessed by the ellipsoid formula (single stones) and fluid displacement (single and multiple stones). Stone volumes assessed by the ellipsoid formula and fluid displacement correlated closely (r = 0.98; p0.0001, n = 15). In the case of single gallstones, the mean length assessed by US was 25.3 +/- 3.2 mm and compared well with the value measured "in vitro" (24.8 +/- 3.1 mm). A highly significant and positive relationship existed between the sonographic size and the true stone size (r = 0.93; p0.0001, n = 15). Stone volumes assessed "in vivo" and by fluid displacement were comparable and correlated for both single (US: 6.6 +/- 1.3 vs fluid displacement: 5.8 +/- 1.4 ml; r = 0.79; p0.0005, n = 15) and multiple stones (US: 3.8 +/- 0.8 vs fluid displacement: 3.7 +/- 0.8 ml; r = 0.85; p0.0001, n = 19).(ABSTRACT TRUNCATED AT 250 WORDS)

Crystalline lactulose (Laevolac Cristalli, CAS 4618-18-2), a pure form of the disaccharide widely employed in the therapy of complications of liver cirrhosis, was administered, after a pharmacological wash-out of 10 days and following a randomized design, to 10 cirrhotic patients for 30 days at the dosage of 60 g/d, while another 10 subjects with similar characteristics received no treatment. Besides the parameters usually monitored for the evaluation of liver function and state of hepatic encephalopathy, immunological patterns such as lymphocyte subpopulations CD3, CD4, CD8, CD16(NK), CD25 and antibacterial activity against Ty2 strain of Salmonella typhi were evaluated. At the end of the study (day 30) a significant decrease of blood ammonia was observed, as expected, only in the group treated with lactulose with respect to the control group, as well as a significant increase of CD16 and antibacterial activity (1/3); an enhanced level of CD25, although not significant, was also noticed in the treated group with respect to the control group. These findings seem to show an effect of activation on cell-mediated immune system depressed during liver cirrhosis, produced by lactulose. Further studies are needed to confirm these data and to clarify the possible mechanisms involved.

The influence of gender, age, body size, cholelithiasis, and obesity on fasting gallbladder volume (GBV) was investigated by real-time ultrasonography in a general population cohort of subjects whose ages were between 30 and 69 yr, living in Bari, a Southeastern Italian city. Of the 2076 subjects analyzed, 1246 (60%) were males and 830 (40%) were females (mean age 50 yr). Among them, 1703 subjects were healthy, 108 had gallstones, and 265 were obese. Fasting GBV in healthy individuals was larger in males (M) than in females (F) [M, 18.7 +/- 0.3 (SEM) ml vs. F, 17.0 +/- 0.3 ml; p less than 0.001] and obese (M, 23.4 +/- 1.5 ml vs. 19.7 +/- 0.9 ml; p less than 0.05). The trend was similar in gallstone patients, but it was not statistically significant (M, 23.0 +/- 2.0 ml vs. F, 18.8 +/- 1.5 ml; t = 1.64). Gallbladder size correlated positively with body size in the lean healthy population (p less than 0.01), increased with age in healthy nonobese males (p less than 0.01), and was smaller in healthy males than in males with gallstones (0.01 less than p less than 0.02) and obese, in both sexes (p less than 0.01). We conclude that fasting GBV 1) is larger in lean healthy and obese males than females, 2) increases with age in lean males and with body size in healthy lean females, and 3) is greater in patients with gallstones and in obese subjects, and this might partially account for the defective gallbladder motor function reported in these patients.

The effects of niperotidine, a novel histamine H2-receptor antagonist, on nocturnal gastric acid secretion in healthy volunteers, have been investigated. Twenty subjects were randomly assigned to the placebo (M:F = 7:3; Age 34 +/- SD3 yrs) or to the niperotidine-treated group (M:F = 7:3; Age: 37 +/- 6 yrs) in which 460 mg were administered at 22.00. Intragastric acidity was assessed by means of 24-hour pH-measurement (10.00-22.00) using sensitive antimony monocrystalline electrodes. The percentage of daytime gastric acidity (prandial and interprandial) was similar in both groups (median; interquartile range): placebo group 87.5; 69.5-90.1 vs niperotidine 85.8; 59-89.1. Niperotidine increased the intragastric pH during the period 22.00-10.00. The percentage of time above pH 4 was higher in the treated group (28.4; 14.8-50.7% vs 7.4; 1.4-10.7%; p less than 0.02). The duration of niperotidine action was 5 to 7 hours. The nocturnal pH frequency curve after niperotidine was shifted toward alkaline values with a decrease of acidity in the pH range 1-2 (p less than 0.04). We conclude that a bedtime dose of niperotidine inhibits nocturnal gastric acid secretion in healthy subjects.

The effect of a novel CCK-antagonist (lorglumide, CR 1409) was evaluated by "in vitro" tensiometric studies on 16 human (gallstone patients) and 12 guinea pig gallbladder smooth muscle strips. In the animal experiments, increasing doses of lorglumide (0.2-6.5 uM) caused a rightward shift of the dose-response curves of CCK-OP, with an increase of the ED50 from 8.2 nM +/- 1.62 SEM, n = 12; to 100 nM +/- 12, n = 4) without affecting the maximal effect (Emax). Schild plot gave an affinity constant of 7.19. In human gallbladders, the effect of lorglumide was also present (ED50 increased from 47 nM +/- 8 SEM, n = 16; to 300 nM +/- 10 SEM, n = 4) coexisting with a large inter-sample variation for CCK-OP ED50s and maximal contractions, most likely due to the histological changes of the wall in chronic cholecystitis. The affinity constant was similar to that found in animal experiments. We confirm the studies previously reported in animals on the existence of a competitive antagonism of lorglumide on CCK gallbladder receptors. Moreover, our results on gallbladders from gallstone patients show that lorglumide is a highly effective antagonist of CCK-induced contractions despite the presence of chronic cholecystitis. Our study might help for a better comprehension of the role of these new anti-CCK drugs in the treatment of biliary pain.

With the usual echographic technics, the Wirsung duct, when dilated can be only episodically seen: the seesaw motion of the transducer produces some undesirable echoes, which rub out the lumen of the Wirsung duct. In order to obtain steadily pictures of the dilated Wirsung duct, the transducer must be used with a sweep motion in only one direction, while a positive pressure is exerted on the epigastrium. When transversally intersected, the Wirsung duct appears spindle shaped; it can be displayed on a rather good length. When sagittaly intersected, it presents, itself like a curved shaped picture, 4 mm to 2 cm in diameter, empty of echoes, in the center of the pancreatic section. The Wirsung duct, with the former technics, had been displayed 20 times in 140 cases of chronic pancreatitis; whe have found it in 4 cases in our 10 last cases of chronic pancreatitis. These case have been verified by endoscopic Wirsungography.

The contribution of echotomography in the surgical approach to intra-abdominal masses is illustrated through description of several clinical observations. In order to effect frontal reconstruction of ultrasonic seriography, the authors used a manual-scanning B echotomograph probe working in the range of grays. This technic afforded detection of the intraperitoneal and extraperitoneal abdominal masses under investigation as well as precise definition of their location, size, and nature. Because of its rapidity and painlessness, echotomography should be adopted as firstchoice procedure for the diagnostic exploration of intraabdominal masses. Frontal reconstruction enables the surgeon to verify the topography of said masses with remarkable precision, and hence to plan surgery more intelligently.

In order to verify the influence of the adrenergic system on the gallbladder contraction the Authors studied the effect of isometeptene, a sympathomimetic drug active on beta receptors, on gallbladder emptying. The gallbladder was studied on 6 subjects using a real-time (linear array) equipment with a 3,5 MHz transducer. In fasting subjects the gallbladder emptying was obtained by a fatty meal. In the next day the fatty meal stimulation was associated with the administration of isometeptene. The mean values +/- S.D. of the follow parameters were evaluated: -gallbladder basal volume -gallbladder residual volume both after fatty meal and after the association with isometeptene -gallbladder maximum emptying percentage in two experiences. The results show that the isometeptene doesn't inhibit significantly the gallbladder emptying induced by a fatty meal.

The use of inert plastic (Prolene mesh, 0,027 inches in thickness fournited by Ethicon) as preperitoneal prosthesis in repair of incisional hernias and inguinal hernia recurrencies has been investigated in 28 patients operated upon then 1977 to 1984. In 9 patients the inguinal approach was used with one recurrence (11%). In 9 patients the posterior approach through a midline incision has been used with two recurrences (22%). In 10 patients with incisional hernias there was only one recurrence (10%). Total recurrences rate was 14%. Most recurrences occur in patients operated from 1977 to 1980 (40%). Patients operated in the last period from 1980 to 1984 had no recurrences.

The investigation methods of gallbladder physiology in normal man are usually limited because often they are invasives and hazardous (radiations). The gallbladder size was accurately evaluated by US with study "in vitro". The variations in gallbladder-size measurements in the same observer and among many observers by US, demonstrate that Real-Time ul-ultrasonography is a simple, accurate, non-invasive and potentially valuable mean in the study of gallbladder motility.

10 esophagojejunostomies by EEA Stapler were performed on adult patients (8 males and 2 females, mean age 54 years), after total gastrectomy for gastric cancer. No postoperative bleeding or stricture were observed. 2 anastomotic leaks occurred (20%). The major cause of anastomotic failure is probably technical (incorrect assembly or lubrication of the instrument). According to the our experience and to literary data, the use of stapling devices for performance of esophagojejunostomies is recommended.

In 4 patients who under went low anterior resection for cancer of mid and lower 1/3 of the rectum, with colo-rectal anastomosis by posterior transphinteric approach, anorectal pressure profiles have been studied by open tip technique 30 d. 6 months following operation. Bowel movements, gas and feces discrimination and anal continence were also controlled. Resting pressure, delta % pressure changes during recto-anal reflex, pressure in voluntary contraction, altered in the first post-operative period, become normal in 6 months. Although volume and pressure at urgent rectal sensation, volume and rectal sensation and compliance altered after surgery did not change after 6 months, suggesting that the reservoir function of the rectum is lost, patients achieved a good control of bowel movements, and a good gas and feces discrimination and anal continence within the first 6 months of operation.

To assess the prevalence of gallstone disease and the behavior of gallbladder (GB) volume in childhood and adolescence, an ultrasonographic survey was carried out on 1570 subjects (age range 6-19 yr). Entered in the study were 750 males and 752 females (attendance rate, 95.7%). Gallstones were detected in two females aged 13 and 18 yr, respectively. None of the subjects in the study population had undergone cholecystectomy. The overall prevalence of gallstone disease was equal to 0.13% (0.27% in the female sex). A positive family history for biliary calculous disease was present in one of the two lithiasic girls. A progressive increase of GB volume with age was observed in both sexes, and figures were greater in males, than in age-matched females. A positive and statistically significant relationship was found between GB volume and body mass index (BMI) in both sexes. Obesity was recognized in 188 males (25.3%) and 167 females (25.0%). Obese subjects exhibited larger GB volumes than the nonobese age- and sex-matched controls. The study supports the view of a very low prevalence of gallstone disease in people younger than 20. It also provides information on GB size in relation to age, sex, and BMI.

The gallbladder volume has been evaluated in 22 normal volunteer subjects (12 men and 10 women) by the real time ultrasound B scanning, using the formula V = 1/6 abc (a = length; b = width, c = antero-posterior diameter). The fasting GB volume, the residual GB volume after Bronner's meal (every 15 min. for 90 min.) and the maximum emptying (%) were evaluated in each subject. It was not observed any statistically significative difference between the two groups (fasting volume: 18.5 +/- 6.0 ml in men and 15.2 +/- 5.1 ml in women; residual volume: 4.3 +/- 1.5 ml in men and 3.5 +/- 1.3 ml in women). The maximum GB emptying in women occurs later. In order to verify its reproducibility, the experience has been repeated in two different days in seven men without any statistically significative difference.

Sequential changes in pancreatic secretion were evaluated during a 2- to 3-year follow-up study in 8 dogs provided with Thomas gastric and duodenal fistulas. Four animals were given intragastric ethanol (2 g kg-1) daily for 3 years; 4 others served as controls. In alcohol-fed animals: (1) Flow rate and bicarbonate output in response to 1 clinical unit kg-1 hr-1 of secretin were increased at the end of 2 years but not after 1 year of alcohol feeding. (2) At the end of 2 years, the dose-response curve of pancreatic secretion to cholecystokinin was unchanged but the maximal bicarbonate and water secretion in response to high doses of secretin were increased. Modifications (1) and (2) are explained by reduplication of pancreatic ducts secondary to the development of chronic pancreatitis, verified by biopsy. (3) The previous report by our group of an increased cholecystokinin release in the course of chronic alcohol consumption in dogs seems to be attributable to an artefact. This work shows that the pancreatic response to intraduodenal oleic acid is not significantly modifed by 3 years of alcohol feeding.

Two groups of men, nonalcoholics (mean daily alcohol consumption less than 40 g) and alcoholics (mean daily alcohol consumption greater than 100 g) were compared with respect to the effects of intravenous ethanol on hormonally (secretin + CCK) submaximally stimulated pancreatic and bile secretion and chymotrypsin secretion during the basal state and after a Lundh test meal. Intravenous ethanol injection (600 mg/kg) significantly decreased pancreatic secretion of lipase (-74%), chymotrypsin (-78%), volume (-53%), and bicarbonate (-58%) in nonalcoholic but not in alcoholic men: The secretory pattern of the exocrine pancreatic response to an intravenous infusion of ethanol was therefore changes by the regular consumption of ethanol. The chymotrypsin concentration during the basal state was higher in alcoholic than in nonalcoholic men. This difference progressively disappeared after a test meal showing that chronic alcohol consumption modifies more basal than meal-stimulated pancreatic secretion.