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Between July 1987 and December 1990, 13 patients with postoperative bile leakage were treated with endoscopic sphincterotomy and a naso-biliary drain. All the leaks healed in two weeks, except for one (intrahepatic) that needed two months to heal in association with percutaneous management. The non-surgical treatment of bile leakage is the preferred approach on account of the superior safety, efficacy and cost-effectiveness as compared with surgical repair, which is associated with significant morbidity, mortality and costs. The treatment of choice has to be endoscopic, which is much easier and safer than the transhepatic approach, especially in the non-dilated duct, while another advantage over radiology includes the possibility for rapid definitive treatment of distal obstruction (e.g. residual stones). A leak from an extrahepatic duct heals rapidly, while a leak from an intrahepatic duct takes longer to heal and sometimes needs associated percutaneous drainage. Finally, the authors propose treating an extrahepatic bile leak merely with naso-biliary drainage without cutting the papilla, and an intrahepatic bile leak with endoscopic sphincterotomy, nasobiliary drainage and a bilio-duodenal endoprosthesis.

Imipenem was tested on 65 gram-negative bacterial strains consecutively isolated in patients affected by hospital infection and used as empiric therapy in 52 patients presenting a hospital infection suspected of gram-negative origin. More than 96% of the tested strains resulted sensitive to imipenem. This antibiotic showed a good clinical result in more than 80% of the cases when used as therapy. Therefore imipenem could be considered the drug of first choice in patients with a severe prognosis and a nosocomial infection suspected to be due to a gram-negative microorganism.

The results of surgery in 5 cases of traumatic rupture of the duodenum are presented. The site of the laceration, the time between trauma and operation, associated lesions, diagnostic routine and type of operation are specified. The mortality encountered (40%) should be related to the seriousness of the lesions.

A rare case of intestinal metastasis of a neuroendocrine carcinoma of the skin (Merkel Cell Tumor) is reported. The primary tumor was excised from the left arm two years earlier and followed an aggressive course with lymph-nodes, tonsillar and intestinal spread. Histologically, the intestinal lesion was similar to the primary tumor with small, undifferentiated cells. Undifferentiated small cell carcinoma and lymphomas of the gastrointestinal tract are to be considered in the differential diagnosis. Merkel Cells Tumor usually affects head and neck (44%) and extremities (48%), and is a highly malignant neoplasia, with early recurrence and distant metastases. Wide surgical excision of the primary lesion is the treatment of choice, while controversial is the role of prophylactic regional lymphadenectomy. Adjuvant radio- and chemo-therapy is frequently associated.

Host immunosuppression after trauma contributes to septic morbidity. The macrophage is a key element in the host immune response. This study evaluated glucan, a macrophage stimulant, in a prospective, randomized, double-blind study of 38 trauma patients undergoing surgery. Glucan (21 patients), 50 mg/m2, or placebo (17 patients) was given intravenously daily for 7 days. Delayed hypersensitivity skin testing was performed on days 1 and 7 after trauma. Serum interleukin-1 (IL-1) and tumor necrosis factor (TNF) were assayed after trauma. While the total mortality rate was significantly less in the glucan group (0% versus 29%) (p less than 0.05), the mortality rate from sepsis was not statistically different (0% versus 17.6%). Glucan therapy significantly decreased septic morbidity (9.5% versus 49%; p less than 0.05). Serum IL-1 had a greater increase in glucan patients on day 3 after trauma (143.4 +/- 19.3% versus 78.6 +/- 11.7%; p less than 0.05), but there was no difference thereafter. Serum TNF did not vary between groups. Early increase in IL-1 correlated with subsequent skin test conversion to positive. Neither serum IL-1 nor TNF was a reliable indicator of future sepsis. Further clinical trials are indicated to evaluate biologic response modifiers that activate macrophages in the trauma patient.

The role of operative endoscopy as opposed to surgery in the treatment of obstructive jaundice is in continuous positive evolution due to the rapid technical progress made in the use of this method. Of a total of 93 patients treated over the course of 3 years, some received surgical treatment alone, others endoscopic treatment alone, and a third group received endoscopic therapy followed by surgery. Various parameters were taken into consideration for the three groups studied: the pathological cause of jaundice, age, sex, success of the method used, early and late complications, hospital deaths. Results were then compared.

Seventeen cases of segmental portal hypertension due to splenic vein thrombosis are reported. This syndrome may be asymptomatic for a long time and then present suddenly in the form of a serious picture of high digestive haemorrhage due to rupture of gastric fundus varices as a result of hypertrophied submucous collateral drainage circulation. Useful for diagnosis are oesophagogastroduodenoscopy, which points to stomach varices, and splenoportography or splenic artery angiography with venous phase, which highlight pathognomonic dilatation and tortuosity of the gastroepiploic veins. Surgical exploration typically shows: presence of large epiploic vessels, splenomegaly, absence of changes in the liver and in the portal and mesenteric circulation. Curative treatment of choice is splenectomy.

The treatment of traumatic ruptures of the duodenum is one of the greatest controversies in surgery. The injury mechanisms, diagnostic criteria and factors underlying the prognosis are analysed and indications suggested for the various types of intervention. The problem relating to the operating technique are specified.

Two cases of intramural haematoma of the duodenum caused by injury are examined. The clinical signs were non-specific: vomiting and epigastric pain. The salient features of laboratory tests were leucocytosis and hyperamylasaemia. Radiography of the digestive tract revealed classic bunching of the mucous plicae in the second section of the duodenum in one case and a mark on the gastric antrum together with a clear stretch in the third duodenal section in the other. Surgical examination and drainage of the haematoma was performed in one case while the other was given conservative treatment. Both patients were clinically cured on release from hospital.

Introduction. Post-transplant lymphoproliferative disorder (PTLD) is a serious complication due to immunosuppression in solid organ transplant recipients. The incidence is quite variable and the outcome has been reported to be often fatal, although improvements have been observed since the introduction of Rituximab. Aim of the study. To evaluate: frequency, risk factors, and outcome of PTLD in a large series of Liver Transplant (LT). Patients and Methods. Data have been collected on 1,513 patients who underwent LT (127 had one to four re-LT, for a total of 1,648 procedures), over the last 15 yrs. PTLD were diagnosed by histology and immunophenotipical analysis on biopsy specimens. Several parameters were evaluated for possible association with PTLD occurrence, including age, sex, liver disease and HCV state of LT recipient, presence of hepatocellular carcinoma, time elapsed from LT to PTLD, main immunosuppressant therapy (cyclosporine vs. tacrolimus), other drugs for graft rejection. The cumulative incidence of PTLD was determined using the Fine and Gray competing risk regression model. Results. At a median follow-up of 62 mos., 1,224 out of 1,513 patients are alive, with a 5-yr Overall Survival (OS) projection of 80% (see Figure 1). So far, 18 PTLD have been recorded, with a cumulative incidence of 1.0, 1.9 and 4.2% at 5, 10 and 15 yrs respectively. Median time of PTLD occurrence was 32 mos. (range 2–155) since LT. On competing risk multivariate analysis, the use of tacrolimus vs. cyclosporine A was the only factor associated with increased risk of PTLD (SDHR: 2.79, p=0.032). Treatment for PTLD included: i. reduction or discontinuation (4 cases) of the immunosuppression; ii. chemotherapy (15 cases); in addition, Rituximab was delivered to 11 patients (combined with chemotherapy in 5); treatment resulted in Complete Remission in 14 patients, good Partial Remission (PR) in 4; one patient had a transient PR soon followed by disease progression; this was the only patient dying for PTLD; 2 more patients died for causes other than PTLD; at present, at a median follow up of 30 mos., 15 out of the 18 PTLD patients are alive, with a 5-yr OS projection of 88% (see Figure 2). Conclusions. The overall incidence of PTLD in this large series of LT is among the lowest reported so far in patients receiving solid organ transplant; the use of tacrolimus is confirmed as a significant risk factor for PTLD; the outcome of PTLD seems definitely improved; the availability of Rituximab is quite likely to have contributed to the prolonged survival observed. Based on the results of this study, the exclusion of patients with a previous history of lymphoproliferative disease from LT procedures seems questionable. Figure 1. Overall survival of 1,513 patients undergoing LT Figure 1. Overall survival of 1,513 patients undergoing LT Figure 2. Overall survival of 18 patients developing PTLD Figure 2. Overall survival of 18 patients developing PTLD

Background. Combined prophylaxis with hyperimmune human mmunoglobulins (HBIG) and anti-nucleoside analogues has greatly mproved the outcome of liver transplantation (LT) for hepatitis B virus HBV)-related disease. This result is usually achieved by maintaining a stable nti-HBs titre ≥150 U/l indefinitely. However, the optimal way of adminstration and schedule in order to optimize costs and patients’ compliance eeds further investigation. Methods. We assessed the efficacy in preventing HBV recurrence of newly introduced pasteurized intramuscular HBIG (Igantibe®, Grifols arcelona, Spain) administered at a standard dosage of 2000 IU every 14 ays. Anti-HBs were measured before each administration, and a stable nti-HBs titre from month 4 to 6 was considered as endpoint. The drug harmacokinetic profile was investigated, as well as its safety and tolerability. Results. Seventeen HBV transplant patients previously treated with ntravenous HBIG and lamivudine were switched to prophylaxis with the tudy drug plus lamivudine for 6 months. No patient showed HBV recurence or subclinical HBV infection by genomic analysis. Individual anti-HBs hrough titres were >150 IU/l at each time point (Table 1). The peak conentration was reached 4± 3 days from administration, and median half-life as 28 days (range 14–69). No changes in vital signs and laboratory tests, ncluding viral markers, were found. Conclusions. At the proposed schedule, Igantibe® was effective in aintaining a protective anti-HBs titre and preventing graft re-infection ost-transplantation. The drug was safe and well tolerated over a period f 6 months.