Clinical identification and long-term surveillance of 22 hereditary non-polyposis colon cancer Italian families.

OBJECTIVE: To assess the efficacy of a hereditary non-polyposis colon cancer (HNPCC) identification and surveillance policy. METHODS: Familial clustering of colorectal cancer (CRC) and extracolonic cancers (ECs) was investigated in 1520 consecutive CRC patients and relatives. HNPCC was identified by Amsterdam criteria, and individuals at risk were offered biennial colonoscopy and other examinations, starting from age 25 years. RESULTS: Twenty-two HNPCC families were identified. The CRC prevalence was 27.8% (121/435), decreasing from 59.4% in the first generation to 24.4% and 8% in the second and third generation, respectively. Twenty-nine patients had multiple CRC and 34 patients (in 12 families) had ECs.A total of 199/331 at-risk individuals accepted surveillance. The mean follow-up was 48+/-32 months. CRCs were detected at first surveillance in four out of 199 surveilled individuals (2%); in two surveilled individuals (1%), three CRCs developed during follow-up. The overall CRC incidence was 7/199 (3.5%) in surveilled individuals and 5/132 (3.7%) in unsurveilled individuals. CRCs were less advanced in surveilled than in unsurveilled patients. Eleven individuals had 22 adenomas (one with high-grade dysplasia). Three individuals had adenomas at first surveillance; two of them and eight more individuals during surveillance. Seven surveilled individuals and six unsurveilled individuals, all belonging to families with a history of EC, had EC during the study period. All patients with CRC detected by surveillance are alive. One of the unsurveilled patients who had CRC died 18 months after the diagnosis. CONCLUSIONS: Data confirm the importance of the family history collected in each patient with CRC for identification of HNPCC and support the efficacy of repeated colonoscopies for early diagnosis and prevention of CRC in at-risk members. Reasons for surveillance failure could be an accelerated progression of small adenomas and a lesion missing at colonoscopy. Longer follow-up is required to assess the efficacy of surveillance for EC.

Insulin resistance in the aged: a quantitative evaluation of in vivo insulin sensitivity and in vitro glucose transport.

It has recently been made clear that reduced sensitivity to exogenous insulin can be demonstrated in the course of aging. This phenomenon has been further investigated with the aid of sophisticated techniques, such as the euglycemic clamp, which, when coupled with the measurement of hepatic glucose production, showed that "impaired tissue sensitivity to insulin is the primary factor responsible for the decrease of glucose tolerance in advancing age." Nevertheless, this study did not establish whether such impairment reflects reduced sensitivity (receptor deficiency) or reduced response (postreceptor or receptor plus postreceptor defect), as shown in other diseases. Evidence in favor of the view that receptor deficiency is responsible can be seen in our observation of an approximately 50% reduction in receptors in a study of insulin binding on isolated human fat cells. Two aspects of this question appeared to require further investigation: tissue sensitivity to receptor-saturating insulin concentration (euglycemic clamp at about 1000 microU/mL plasma insulin), and the glucose transport system coupled to the receptor. A decrease in receptors alone should shift the insulin sensitivity curve to the right, both in vivo (euglycemic clamp) and in vitro (glucose transport), with no reduction of the maximum effect. A solution to this question is proposed in the light of a study conducted on young volunteers and subjects over 65 years old.

Insulin receptors in children's erythrocytes. Study on aging cells.

Aim of this study was to evaluate the influence of the red cell aging process on insulin receptor binding. In erythrocytes from 8 children with high reticulocyte count and 9 healthy age-matched subjects we studied insulin receptor binding in correlation with pyruvate kinase (PK) activity and creatine levels. Moreover maximum 125I-insulin bound % and PK activity were tested in four red cell fractions of different age. Our data show a significant correlation between 125I-insulin bound and either PK activity or creatine levels. In vitro experiments on red cell fractions of different age (as tested by creatine levels) evidence a lower decay of PK activity than insulin bound (p less than 0.05). Our results indicate that creatine content is the best marker of red cell age for insulin receptor studies.

Management of postoperative bile leakage with endoscopic sphincterotomy (EST) and a naso-biliary drain (NBD).

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.

[Medical or surgical treatment of the elderly bleeding ulcer patient]. / Trattamento medico o chirurgico nell'ammalato ulceroso sanguinante anziano.

In recent years there has been a distinct decline in the total number of operations for ulcers while the number performed for ulcerous complications has remained more or less constant. Hesitation between medical and surgical treatment most frequently arises in the case of bleeding especially when the patient is elderly. A retrospective study is conducted on 526 ulcer patients encountered in 1976-84 and a comparison is made with the literature as a means of identifying the limitations of conservative treatment. Certain parameters of possible use in the treatment of bleeding ulcers in the elderly are identified.

[Teleconsulting and telediagnosis in emergency surgery]. / Teleconsulenza e telediagnosi in chirurgia d'urgenza.

A colour video picture transmission system in real time with data transmission via a broad wave optical fibre cable has been set up to link Turin University's Orthopaedic Traumatology Centre and Emergency Surgery Clinic. The system consists of two stations. The transmitter station is equipped with a mobile TV camera or TV monitor and various electrical medical equipment. The receiving station consists of a picture reception monitor. The coded video signal is transmitted via the optical fibre; sound transmission is via a special telephone line. This experimental system was set up to see if patients with multiple injuries could receive diagnosis at a distance, thus avoiding unnecessary travelling. Experience of 100 link-ups has demonstrated that the system effectively cuts diagnosis and therapy times and is as efficient as in loco inspection by a surgeon. In addition it can be used to provide specialised consulting services to rural hospitals without special equipment. This reduces waiting times for emergency treatment and can also prevent the pointless transfer of patients to big hospitals in cases where the specialist can prescribe intermediate therapy or surgery.

[Use of computers in intensive care. EGAGE: a program for combined blood gas analysis and analysis of expired gas]. / L'uso dell'elaboratore in terapia intensiva. EGAGE: Un programma per l'esame combinato dell'emogasanalisi (EGA) e dell'analisi dei gas espirati (AGE).

The large amount of data resulting from arterial and venous HGA's and analysis of expired gases carried out during the monitoring of critical surgical patients has been statistically reduced to only seven parameters. Personal Mini Computer software able to quantify or predict the necessity for mechanical ventilatory assistance in individual cases has been developed on the basis of the 7 parameters. The system, presently used only as a check, has been found very reliable. Two cases are reported in order to illustrate its use in intensive treatment.

[Postoperative treatment of liver injuries in the surgical intensive care unit]. / Il trattamento post-operatorio dei traumi epatici nell'unità di terapia intensiva chirurgica.

Personal experience in the postoperative treatment of patients with liver traumas is reported, and a comparison is made between those treated in ordinary wards and those admitted to intensive care units. The latter had shorter stays (24 days as opposed to 40) and fewer postoperative complications, assuming a comparable picture of preoperative shock and associated lesions. The difference is attributed to the possibility offered by such units of providing closer surveillance and more rational management.

[Postoperative monitoring of patients operated on for digestive tract neoplasms using tumor markers. Preliminary results]. / Monitoraggio postoperatorio di pazienti operati per neoplasia digestiva mediante marcatori tumorali. Risultati preliminari.

The report analyses the comparative efficacy of three different tumour markers (CEA, GICA and TPA) in providing indications for the postoperative monitoring of patients treated for cancer of the digestive tract. Assessment of effectiveness of chemotherapy produced different results according to the site of the tumour (stomach, colon or pancreas). In the case of cancers of the pancreatic head, the influence of jaundice on the markers was also evaluated, to discover which marker provided most information on the tumour investigated.

[Use of a single daily dose of tobramycin sulfate for the prevention of infections caused by the positioning of fixed drains in body cavities]. / Uso della tobramicina solfato a dose unica giornaliera nella prevenzione delle infezioni da posizionamento di drenaggi a dimora in cavità corporee.

The clinical and bacterial efficiency of tobramycin sulphate administered once a day (150 mg/day) in the prevention of pleural cavity and bladder infections was evaluated by considering 30 surgical patients fitted with thoracostomic tubes or bladder catheters. Pleural cavity sterility was maintained in 74% of cases and bladder sterility was maintained or obtained in 100% of cases. These results confirm the success of the treatment.

[The use of metal vascular prosthesis in the palliative treatment of neoplastic esophago-gastric stenosis]. / Impiego di protesi metalliche vascolari nel trattamento palliativo delle stenosi neoplastiche esofago-gastriche.

The paper reports the authors' experience regarding the use of expandable metal prostheses designed for vascular stenoses but adapted for unoperable esophago-gastric stenoses. Their first impressions are very positive so much so that they affirm that these prostheses are close to being ideal since they are flexible and have an insertion diameter of 3 mm which does not therefore require dilatation. As a result: 1) they involve limited trauma to the patient; 2) reduce the risk of perforation to virtually zero. Moreover: 3) they can be inserted in twisted and angled stenoses and in esophaguses with difficult access due to axial deviations and restriction of the upper cervical aperture; 4) they function well even in notoriously "difficult" sections such as the cardia and esophago-jejunal anastomoses; 5) the unfastening system is easy and rapid. On the strength of these characteristics the authors suggest that these prostheses should be used in an outpatient setting, as occurred in the case of the last of the 10 patients treated, and even at a preoperative stage in preparation for resective surgery so as to preserve normal oral feeding. The structure of these prostheses renders them contraindicated for use in stenoses associated with fistulas in air paths and requires an evaluation of long-term results to verify the incidence with which the following occur: 1) tumoral growth between the mesh; 2) food obstruction; 3) hemorrhage due to compressive necrosis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Palliative endoscopic treatment of esophageal neoplastic stenosis]. / Considerazioni sul trattamento palliativo endoscopico delle stenosi tumorali dell'esofago.

The authors examined a series of 231 patients suffering from unoperable neoplastic dysphagia of the esophagus and treated using prevalently palliative endoscopic methods (photocoagulation and/or intubation) during the period 1980-1991. They draw the following conclusions: a) endoscopic methods are better than surgical techniques; b) there are a greater number of indications for endoscopic intubation than for photocoagulation (approximately 2 to 1); c) some situation which are indicated for photocoagulation are not contraindicated for intubation; d) the sole contraindication for intubation is stenosis in which the proximal limit is less than 2 cm from the upper esophageal sphincter; e) contraindications for photocoagulation are long stenoses and/or those of the infiltrating type, and/or involving the upper third of the esophagus; f) sometimes the two methods may be complementary in the sense that intubation may be preceded by a few photocoagulation sessions in order to necrotize the vegetating portion of an infiltrating tumour; g) it is best to choose intubation wherever possible since this technique is less expensive and the quality of remaining life better, even if the percentage of severe and generally fatal complications (perforation) is still too high; h) the possible introduction of expandable metal prostheses might increase indications for intubation and reduce the number of severe complication.

[Treatment of postoperative biliary fistulas by endoscopic papillosphincterotomy and nasobiliary drain]. / Trattamento delle fistole biliari postoperatorie con papillo sfinterotomia endoscopica (EST) e sondino naso-biliare (SNB).

Personal experience in the non-surgical treatment of postoperative biliary fistulas observed between July 1987 and October 1990 is reported. Leakage were treated with an endoscopic technique (papillosphincterotomy+nasobiliary drain) in 11 of 12 patients in an average time of 2 weeks. The 12 patient, who presented a lesion of an intrahepatic duct, needed 2 months to heal following combined endoscopic-percutaneous manoeuvres. On the basis, then, of the good results obtained, it is recommended that in these cases, non-surgical treatment should be carried out on principle, choosing endoscopy as the initial access route.

[Use of the rendez-vous technique in endoscopic insertion of biliary prosthesis in malignant obstructive jaundice]. / Impiego del rendez-vous per l'inserimento endoscopico di protesi biliari nell'ittero ostruttivo maligno.

The paper describes the Authors' personal experience of the use of the rendez-vous technique (using a combined endoscopic-transhepatic route) for the endoscopic insertion of biliary prosthesis in cases of malignant obstructive jaundice. Having illustrated the series of cases, the paper proposes the use of this technique in the event of endoscopic failure due to the smaller incidence of complications compared the use of a wholly transhepatic route.

[Colorectal tumors and hormonal receptors. A critical review of the literature]. / Tumori del colon retto e recettori ormonali. Una revisione critica della letteratura.

The importance of sexual hormones in the development of cancers of the large bowel is strongly supported experimentally and epidemiologically. The clinical search for the presence of hormonal receptors in the cells of patients operated for tumours of the colon and rectum has been common since 1975. This investigation ought to have opened up new diagnostic and therapeutic prospects for these tumours which have given such a little curative satisfaction. The present review considered reported data. Unfortunately the emerging picture is irregular in cases and results. It is personally considered that these studies are not for the moment likely to produce important novelties for the treatment of tumours of the large bowel tract.

[First impressions regarding the use of expandable esophageal prosthesis]. / Prime impressioni sull'uso di protesi esofagee espansibili.

The authors report their views on the treatment of unoperable neoplastic esophago-gastric stenoses with Nitinol prostheses. Despite a number of advantages (reduced trauma, greater tolerability) in relation to plastic prostheses, the paper highlights some problems (difficulty of unfastening, incomplete opening) which may be eliminated by improved materials.

[Palliative endoscopic intubation of esophago-gastric neoplastic stenosis: analysis of factors that may influence immediate results]. / Intubazione palliativa endoscopica delle stenosi tumorali esofago-gastriche: analisi dei fattori che possono influenzare i risultati immediati.

The paper examines a series of 172 patients undergoing endoscopic intubation with plastic stent due to unoperable esophago-gastric tumoral stenoses during the period 1980-1991. An analysis of the data enabled the following conclusions to be drawn: (1) The majority of perforations occur during the treatment of distal stenoses (15%), anastomotic stenosis (20%) and extrinsic compression stenoses (23% vs 7% in the case of stenosing primary esophageal neoplasia). (2) Severe respiratory problems may occur during treatment of cervical stenoses. (3) Malfunctioning of prostheses is more frequent in the treatment of cardias stenosis (10%). Having a few technical comments on the subject of passing the guide thread through the most twisting and narrow stenoses, the authors express the wish that expandable metal prostheses will be more widely used in order to render the method less traumatic, increase the percentage of success (extending the indications regarding the site and type of stenosis) and reduce severe complications.

[Gastric carcinoma. Our experience]. / Il carcinoma gastrico. Nostra esperienza.

This study analysed 66 cases of gastric cancer from 1985 to 1992. Twenty-seven patients (41%) has been treated with anti-H2 drug, either medical care or Jerkily "a la demande": 12 patients have been treated several years. Of the 66 patients: 52 (89%) were operated on while the other 16 received medical treatment because of the extension disease and their precarious condition. Long-term 35 (67%) patients (of the 52 operated) died four years later, independently of the stage and PKT of the first and the second level. The 27 patients treated with anti-H2 drug showed the most undifferentiated grading and 88% belong to the third and the fourth stage; moreover 81% underwent first diagnostic endoscopy notwithstanding a clinical and surgical history of gastric ulcer. Is it possible, therefore, that anti-H2 drug delay the diagnosis.

[Somatostatin in severe peptic ulcer hemorrhage]. / La somatostatina nelle severe emorragie da ulcera peptica.

Somatostatin was compared with intensive antacid and thrombin in a randomised controlled study on 15 patients with severe haemorrhages of the upper digestive tract deriving from peptic ulcers and identified endoscopically in order to assess the efficacy of the two drugs. The results in both groups were similar but somatostatin appeared more effective than antacids and thrombin in terms of blood transfusions required and the average time it took to stop the bleeding. The insignificance of these results is in contrast with the data from similar studies using other drugs (anti-H2) and reported by others. This shows the need for controlled polycentric studies conducted on large groups of homogeneous patients.

[Clinical use of a minicomputer in the evaluation of chemico-clinical parameters in the diagnosis of hepato-biliary-pancreatic diseases of surgical significance. 3 methods compared]. / L'uso clinico di un minicomputer per la valutazione di alcuni parametri chimico-clinici nella diagnostica delle malattie epato-bilio-pancreatiche di interesse chirurgico. Tre metodi a confronto.

Bayes theorem; multivariance analysis, and the discriminating function of Mahalanobis applied to sixteen laboratory examinations employed in the diagnosis of diseases of the extrahepatic bile ducts and pancreas gave the following results: 1) the weight of each test was first measured in general terms, and then with regard to different levels of differentiation, with a classification in decreasing order in each case; 2) little redundancy was noted, and few examinations were of relatively negligible importance; furthermore, combinations of several tests did not lead to positive results; 3) reclassification according to the formula of Bayes and by means of the discriminating function proved sound supports for clinical decision, since they provided 70% and 80% of exact classification respectively; 4) the importance of the minicomputer in the construction of experimental diagnostic models was substantiated.