Surgical Anatomy of the Papilla of Vater and Biliopancreatic Ducts

The present research was aimed at defining the surgical anatomy of the biliopancreatic ducts and of Oddi's sphincter. The numerous anatomic variations of the papilla, the millimetric distribution of its muscle fibres, and any morphological detail of clinical significance have been investigated. An integrated analysis of radiographic, tridimensional (casts), and histologic findings has been carried out in 49 of 64 autoptic bilio-duodenopancreatic specimens. Exact limits of the choledocus and Wirsung sphincters were defined. A consistent accumulation of circular muscle fibres could be seen, on the choledocus duct side, up to a mean distance of 13.6 mm from the papillary pore. However, more rarefied fibres were present up to 20.5 mm. Muscle fibres were seen to stop roughly on the pancreatic duct side at 7.3 mm from the papillary pore. The beginning of the sphincter was observed 2-3 mm above the papillary pore. There was no evidence suggesting the presence of upper, middle, and lower biliary sphincters. Five anatomic diversities of the Wirsung-choledocus confluence were found. The Y type was the most frequent (61.2%), followed by the U type (22.4%), V (14.3%), and II (2.1%). Santorini's duct with a normal papilla was present in 16 per cent of the cases. These data along with other interesting observations on antireflux mechanisms (Santorini's valves) and on the ductal space orientation appear to be useful guidelines for a physiopathological understanding of bilio-pancreatic diseases and for any therapeutic procedure on these structures

A simple ultrasonographic test for preoperative haemodynamic evaluation of varicocele

According to the haemodynamic classification of varicocele type I is caused by renospermatic reflux due to a proximal nutcracker phenomenon or to valvular insufficiency of the left internal spermatic vein. Type II is due to ileospermatic reflux and type III may be characterized by a combination of I and II refluxes. Although this classification proposed by Coolsaet is precious for decision making, it is seldom used in clinical practice being based on a complex angiographic evaluation which is invasive and exposes the patient (often a teenager or with infertility disturbances) to excessive radiations. The aim of the present study was to work up an original ultrasonographic test for preoperative haemodynamic evaluation of varicocele in order to indicate the most appropriate microsurgical treatment. Sixty-three patients underwent a preoperative clinico-echographic dynamic test which allowed to classify 76.9% of the cases as haemodynamic type I, 10.7% as type II and 12.3% as type III. Microsurgical shunts were performed in all cases and evaluation of recurrences was accurately carried out with ultrasonographic measurement of residual varicosities. In 6% of the cases varicosities were consistently reduced in size and in 94% absence of varicosities was demonstrated. Varicocele increased in size or was unchanged in none of the cases. In conclusion the test hereby described was shown to be simple and easily reproducible. It allowed a haemodynamic and objective classification of varicocele offering a unique opportunity for tailoring to the individual patient the most appropriate treatment. Furthermore, ultrasonographic postoperative follow-up is the most reliable and objective method to control the "true" incidence of post-varicocelectomy recurrences

Il drenaggio microchirurgico del varicocele idiopatico. Risultati a distanza dei primi 100 casi.

Obiettivo. Vengono riportati i risultati a lungo termine degli shunt microchirurgici per il trattamento del varicocele primitivo. Metodi. Novantasette pazienti per un totale di 100 varicoceli (3 bilaterali) hanno avuto un follow-up da 6 mesi a 10 anni. La valutazione ecografica del grado di varicocele eseguita sia pre- che post-operatoriamente, è stata considerata di grande importanza per ridurre le possibilità di errore dovuto ad una diagnosi clinica soggettiva e per conseguire quindi un follow-up standardizzato, obiettivo e documentabile con immagini. Gli shunt microchirurgici sono stati adattati al tipo di reflusso: renospermatico (77%), iliospermatico (11%) o misto (12%). Risultati. Per il 94% dei pazienti si è verificata una completa scomparsa morfologica del varicocele, mentre nel 6% dei casi si è avuta un'importante riduzione delle dimensioni del varicocele, nonostante le ectasie venose fossero ancora evidenti all'esame ecografico. Conclusioni. È stato osservato nel postoperatorio un significativo miglioramento dei parametri seminali nei pazienti affetti da severa infertilità e questo ha mostrato un'importanza statisticamente significativa in pazienti al di sotto dei 30 anni

Circumferential choledochoplasties with autologous venous and arterial grafts.

Circumferential choledochoplasties with vascular grafts have rarely been attempted either experimentally or in clinical practice. In this study, choledochoplasties using autologous venous and arterial grafts were performed in rats. Sixty-four rats were randomly selected into five treatment groups: A) venous interpositional graft replacement of a choledochus gap without a stent; B) venous graft with prolene stent; C) venous graft with polyethylene stent; D) arterial graft; E) a control group with simple resection between ligatures in the choledochus. The operative mortality in treatment groups B, C, D, and E, was 0, and 13% in group A. At 12 weeks follow-up, all the rats in group E had died, whereas, 52.2% (P < .05) of the rats in group A, 30% of the rats in group B, 57% of the rats in group C, and 92.8% of the rats in group D survived treatment. Surviving animals were sacrificed at 3 months for further examination. The morphology and caliber of the common bile duct of these rats were normal in 25% of the rats in group A, 33% of the rats in group B, 25% of the rats in group C, and 84.6% of the rats in group D. Proximal dilations were found in the rats presenting with abnormal morphology. The dilations were less marked in the group treated by arterial choledochoplasties. Laboratory and clinical cholestatic parameters were within normal ranges in the presence of common bile duct dilations less than four times the normal duct calibe