Lung cancer in the young.

A long-term retrospective study was carried out on 1,514 cases of lung cancer to assess whether the disease presents substantial differences in young as compared to older patients. Clinical, epidemiologic, surgical, and survival data were evaluated in all cases. A young group under 45 years of age was studied separately and compared with the remaining older patients. In contrast with the literature, our results showed no percentage increase or variation in the male/female ratio of lung cancer in the young group. No significant difference was found regarding clinical picture, operability, histotype, and prognosis.

Intrathoracic intercostal nerve block with phenol in open chest surgery. A randomized study with statistical evaluation of respiratory parameters.

Seventy-three patients who underwent thoracic surgery were randomly selected for intraoperative intercostal nerve block using phenol (32 block and 41 control subjects). The patients were divided into three groups: pneumonectomies, lobectomies and explorative thoracotomies and evaluated by pain level, respiratory function parameters (VT, IRV, ERV, VC) and blood-gas analysis, both six and 24 hrs after surgery. The patients who had intraoperative nerve block using phenol enjoyed a more comfortable postoperative period. In particular, respiratory parameters were statistically better.

Tracheal sleeve pneumonectomy for bronchogenic carcinoma.

For a long time, primary tumors arising less than 2 cm distal to the carina have presented a contraindication to surgical excision. Tracheal sleeve pneumonectomy technique allows carinal resection and reconstruction but still carries considerable postoperative complications. From 1983 to 1992 we performed 27 right tracheal sleeve pneumonectomies and one left. Fourteen patients had N0 nodes, nine had N1, and five had N2. No anastomotic complications, either fistula or stenosis, were observed. Successful outcome depends on meticulous attention to surgical details and careful anaesthetic management with a new ventilation tube. One patient died on the twenty-second postoperative day from myocardial infarction. Complications included pneumonia (one), vocal cord paresis (two), and pleural empyema without bronchial fistula (one). Conservative treatment allowed complete recovery from all complications. There are seven patients alive at 4 years after operation and one at 5 years. Six patients have been disease-free for between 1 and 32 months. Two patients died free of disease at 13 and 42 months. Two patients died of mediastinal recurrence and 10 of distant metastases within 6 and 54 months.

Portacaval shunt in the treatment of primary Budd-Chiari syndrome.

We have performed a side-to-side portacaval shunt as the treatment of choice in six cases of primary Budd-Chiari syndrome. All the patients (three men and three women, mean age 33 years) had marked hepatomegaly and massive ascites. Four patients had endoscopically proved esophageal varices with no episodes of bleeding. Preoperative angiographic studies, caval pressure measurement, laparoscopy, liver biopsy specimens, liver scanning, and liver function tests confirmed the diagnosis. A possible etiologic factor was evident in only two cases. A plain side-to-side portacaval shunt was performed in four patients, while two required the interposition of a graft. One patient died after surgery of hepatorenal syndrome. Four of the surviving patients are free of ascites and doing well at 29, 27, 25, and 6 months. The remaining patient subsequently developed cirrhosis and died 76 months after surgery. None of the patients who survived developed encephalopathy. Shunt patency was confirmed endoscopically by variceal decompression in the four patients with esophageal varices. We believe the side-to-side portacaval shunt is a reliable and effective procedure for the definitive management of primary budd-Chiari syndrome.

Selective distal splenorenal shunt versus side-to-side portacaval shunt. Clinical results of a prospective, controlled study.

A prospective, controlled study comparing the clinical results of the selective distal splenorenal shunt procedure and the side-to-side portacaval shunt procedure was undertaken in 1980. Ninety-three cirrhotic patients with previous episodes of bleeding from esophageal varices underwent a distal splenorenal shunt procedure (47 patients). The operative mortality rate was 2 percent in both groups. The intraoperative decrease of portal hypertension after the portacaval shunt procedure was higher than after the distal splenorenal shunt procedure (p less than 0.05), and in those with patent shunts, there was a 0 percent incidence of early variceal rebleeding after the portacaval shunt procedure compared with a 9 percent incidence after the distal splenorenal shunt procedure (p less than 0.05). Both shunts, however, had similarly satisfactory results in preventing long-term variceal rebleeding (portacaval shunt 2 percent and distal splenorenal shunt 0 percent). Postoperative ascites was more common after the distal splenorenal shunt procedure (58 percent versus 24 percent; p less than 0.01). Analysis of actuarial survival curves showed no difference between the two procedures. The incidences of long-term episodes of chronic encephalopathy were not statistically different after both procedures. The only three instances of severe encephalopathy occurred in patients with the portacaval shunt (p less than 0.05). The distal splenorenal shunt also seemed to have a less negative effect on postoperative liver function than the portacaval shunt. These data suggest that the selective shunt should be viewed as a first choice strategy in the treatment of portal hypertension.

Clinical application of a new compression anastomotic device for colorectal surgery.

Fifty-six patients underwent large bowel anastomosis by the compression anastomotic device developed by the authors from May 1986 through December 1988. Operations performed were 40 left hemicolectomies or anterior resections of the sigmoid and rectum, 7 left colon resections, 7 right hemicolectomies, and 2 total colectomies. Twenty-one anastomoses were done on the extraperitoneal rectum, in 7 cases less than 4 cm from the anal verge and in 9 cases between 4.5 and 8 cm. Five intraoperative diverting colostomies were done (9%). The rings of the device were evacuated postoperatively after a mean of 11 days with little or no discomfort. Operative mortality was 1.8% (one patient died of myocardial infarction). Anastomotic complications were one (1.8%) clinical and one (1.8%) subclinical leak. Mean postoperative hospital stay was 14 days. This initial clinical experience shows that the anastomotic device is reliable.

Cytogenetic analysis in 28 radically operated non-small-cell lung cancer: preliminary considerations.

Twenty-eight radically operated non-small-cell lung cancer patients were analyzed with regard to chromosomal assessment and DNA content: in 13 cases, different quantitative/qualitative chromosome alterations were found. In particular, in 12 cases marker chromosomes and cytogenetic abnormalities in euploid cells were demonstrated. The prognostic value of these findings will be aim of further studies.

Adjuvant chemotherapy with fluorouracil and CCNU in colon cancer. Results of a multicentric randomized study.

To establish the effectiveness of adjuvant chemotherapy in patients with colon cancer after radical surgery, from 1980 to December 1983, 263 patients were randomized in a multicentric study to no further treatment (131 patients) or to a combination of fluorouracil (5-FU) (400 mg/m2 i.v., days 1-5) and lomustine (CCNU) (100 mg/m2 per os on day 5) every 6 weeks for 9 cycles (132 patients). The two groups were well balanced for age, sex, histology, tumor and nodal extent. Chemotherapy was not given to 30 of the 132 randomized patients, and of 98 treated patients only 38 completed the entire protocol. Analysis, as intention to treat, at 54 months did not show any significant difference between the two treatment groups in terms of relapse-free survival (surgery alone, 74.5%; surgery + adjuvant chemotherapy, 70.9%; p = 0.91). In contrast, a significant difference was observed in overall survival (surgery alone, 78.8%; surgery + adjuvant chemotherapy, 60.8%; p = 0.04). The sites of relapse were identical in the two treatment arms. In conclusion, from this study it appears that adjuvant chemotherapy with 5-FU and CCNU seems to have no efficacy in the cure rate of colon cancer patients.

Venous grafting in femoropopliteal obstructions: a 16-year experience.

Over 15 years, 172 femoropopliteal saphenous vein bypasses were performed on 151 patients with chronic obstructive arterial disease. Follow-up varied from a minimum of six months to a maximum of 12 years. The operative mortality was 1.32%, the survival rates at five and ten years were 66.54% and 33.91% respectively, and the patency at five and ten years was 52.02% and 37.55%. The good results obtained, even in the majority of patients with trophic lesions and/or rest pain, indicate that direct arterial reconstruction should be considered the only effective treatment for saving a limb which would otherwise have to be amputated.

The distal splenorenal shunt: an update on experience of 106 cases.

This paper analyzes experience with 106 patients treated primarily with DSRS during a ten year period. Operative mortality was 5% of cases. Shunt patency was evaluated by postoperative angiography in 70 patients. A shunt thrombosis and a recanalization of the splenic vein were noted in a patient who had a Britton's operation resulting in a side-to-side shunt. In the other 31 cases, shunt patency was indirectly confirmed by the absence of varices at postoperative or long-term endoscopic examination. At postoperative check, esophageal varices had disappeared in only 19% of patients. However, this rose to 60% at long-term check-up. Ten patients bled from varices in the postoperative period (9%). During the follow-up period, no patient bled from varices, while five patients bled from gastroduodenal lesions (5%). During the postoperative period, 52% of cases had ascites. In the long-term, ascites developed in only 15% of cases and was well controlled by standard medical treatment. Analysis of the actuarial curve showed a 5-year survival rate of 63%. During the follow-up period, 17% of patients experienced at least one episode of acute encephalopathy. Chronic encephalopathy appeared in 14% of cases: ten patients suffered a mild form (10%) and four (4%) a moderate form. No patient had severe chronic encephalopathy. DSRS is effective as treatment of portal hypertension with a low long-term morbidity despite a more troublesome early postoperative period.

Surgical treatment of malignant tumors of the Oddian region.

From 1974 through 1984, 24 patients with malignancies of the Oddian region underwent surgery. Four ampullectomies were carried out with one more than 10-year survivor. Nineteen duodenopancreatectomies were performed with no operative mortality, a 21% complication rate and a 4% reoperation rate; mean survival was 42 months; 1-, 3- and 5-year survival was 95%, 53%, and 37% respectively. Nodal metastasis was the major determinant of long-term survival. Duodenopancreatectomy should be considered the operation of choice for malignancies of the Oddian region.

Surgical treatment of substernal goiters.

Fifty-one patients (4.6%) underwent resection of a substernal goiter in a fifteen-year period during the course of 1103 thyroidectomies. Forty-eight (94.2%) goiters were benign and three (5.8%) malignant. Mean age was 55 years. Female:male ratio was 2:1. Four patients (7.8%) had undergone prior thyroid surgery. Most had long-standing goiters (mean duration: 15 years). The most common symptoms included airway compression (56.8%), hoarseness (13.7%), dysphagia (11.7%), superior vena cava syndrome (9.8%). Twelve patients (23.5%) were asymptomatic. Chest X-rays showed a tracheal deviation and/or a mediastinal mass in 43 patients (84.3%). Goiter extended into the right mediastinum in 28 patients (54.9%), into the left in 19 (37.2%), and bilaterally in three (5.8%). A cervical collar incision provided adequate exposure in 42 cases (82.3%). Five patients (9.8%) required a cervical incision plus partial median sternotomy and one (1.9%) a cervical incision plus a right postero-lateral thoracotomy. In three asymptomatic patients (5.8%) thoracotomy was followed by cervical incision due to a preoperative incorrect diagnosis. Major postoperative complications included two cervico-mediastinal hematoma with one subsequent death and four (7.8%) recurrent laryngeal nerve palsy. This series showed that: (1) Standard chest roetgenogram with esophagogram is still the most useful investigation, although CAT scan can help in planning the operation. (2) Cervical collar incision provides adequate exposure in nearly all cases. (3) When goiter enucleation is difficult or at risk, a complementary median sternotomy is indicated in right retrovascular goiters. (4) Operation should be recommended in all but the highest-risk patients. (5) Tracheal intubation with small caliber tubes is nearly always possible in patients with acute tracheal compression.

A microcomputer based interactive system for the recording and automatic analysis of esophageal pH-studies.

A microcomputer based system for the recording and automatic analysis of esophageal pH-studies has been developed. It consists of a microcomputer interfaced with a pH-meter, one video display, two disk-drives for five inch diskettes, one printer and a fully interactive program written in BASIC. Every second, the microcomputer records the values of pH measured by the pH-meter. The options available in the program are: 1) Creation of medical records; 2) pH probe calibration; 3) pH-basal value acquisition; 4) Standard Acid Reflux Test (SART); 5) Acid Clearing Test (ACT); 6) 24-hour pH-monitoring test; 7) Summary of patient's current results; 8) Printing and data file management. Each one of these options provides access to other related functions. This system and its software has the following advantages: 1) it achieves a high standard in the execution of esophageal pH-study tests; 2) it provides an objective real-time analysis of the results; 3) it reduces the total cost of the investigation.

Clinical and immunological study of 150 cases of adenocarcinoma of the lung.

An in-depth retrospective statistical analysis was performed on 150 consecutive cases of adenocarcinoma of the lung. One-hundred and twenty-eight patients (85%) underwent pulmonary resection; 15 (10%) had an explorative thoracotomy and 7 (5%) were considered inoperable. At the time of operation, 72 patients were classified as Stage I, 18 as Stage II and 50 as Stage III. Factors analyzed included age, sex, surgical treatment, staging, immunologic monitoring and survival. When compared with other histotypes of our series a statistically significant difference was found in the male: female ratio (p less than 0.05), surgical resectability (p less than 0.05), frequency of Stage I, and immunologic status evaluated by studies of delayed hypersensitivity skin tests, lymphocyte blastogenesis, antibody dependent cellular cytotoxicity (ADCC), blocking serum factors and intrastromal peritumoral lymphocyte infiltration. There were no significant differences due to age, cigarette smoking, mediastinal lymph node involvement, except for small oat-cell carcinoma or previous pulmonary diseases. In all stages, the five-year survival rate was lower for patients affected with adenocarcinoma than for those affected with other histological types, except small oat-cell carcinoma.

Multidisciplinary approach to extracorporeal respiratory assist for acute pulmonary failure.

A case of acute post-traumatic pulmonary failure was treated by extracorporeal respiratory assist, after conventional therapy had failed. Veno-venous bypass was established, with low extracorporeal blood flow (1.6-2 l min-1), and high exchange surface area membrane lungs (7 m2), according to the technique of low-frequency positive-pressure ventilation with extracorporeal carbon-dioxide removal. After a first disconnection, the evolution of the lung disease necessitated a second surgical procedure, during which a chest tube perforated the patient's right lower, pulmonary lobe. A two-stage right thoracotomy was performed, with the patient connected to the extracorporeal system, and receiving full heparinization. Massive bleeding and severe hypoxia were encountered, but successfully overcome. The patient is now a long-term survivor.

Prophylaxis of fatal pulmonary embolism in general surgery using low-molecular weight heparin Cy 216: a multicentre, double-blind, randomized, controlled, clinical trial versus placebo (STEP). STEP-Study Group.

The effectiveness of low-molecular weight heparin CY 216 in the prophylaxis of fatal pulmonary embolism in patients undergoing general surgery was assessed in a multicentre, double-blind, randomized, clinical trial against placebo. A total of 4,498 patients aged over 40 undergoing general surgery were enrolled in the 18 centres which took part in the trial. Patients received a single daily subcutaneous injection of 7,500 anti-Xa units I.C. of CY 216 or placebo two hours before surgery, 12 hours after the initial injection and then daily for at least seven days. A post-mortem examination had to be carried out in every patient who died. The two groups of patients were well-matched for age, sex, type of disease, site and duration of operation as well as for incidence of risk factors which could predispose to the development of thromboembolism. Twenty-six deaths were recorded and validated: eight (0.36%) in the CY 216 group and 18 (0.80%) in the placebo group (p less than 0.05). At the post-mortem examination, carried out in 23 patients (88.5%), two deaths were found to be directly due to pulmonary embolism (0.09%) in the CY 216 group and four (0.18%) in the placebo group. Pulmonary embolism contributed to death in four other placebo-treated patients. Pulmonary or extrapulmonary thromboembolism was a significantly less frequent direct cause of death (p less than 0.05) in the CY 216 group (two pulmonary embolisms) than in the placebo group (four pulmonary embolisms, one acute myocardial infarction, one disseminated intravascular coagulation, two ischemic cerebral strokes).(ABSTRACT TRUNCATED AT 250 WORDS)

Left lung allotransplantation in pig feasibility and transplanted lung function. Experimental Lung Transplant Group of Ospedale Maggiore of Milan.

Changing attitudes to animals in research and practical considerations prompted the authors to evaluate whether the pig might be a suitable substitute for dog and baboons for single left lung transplants. Twenty-nine paired pigs were used. The first transplants on 13 pairs (group 1) were done to adapt the lung transplant technique to pigs; later transplants on 16 pig pairs (group 2) were done to evaluate operative survival, and function and histological modifications of the transplanted lung in the absence of immunosuppressive treatment. Surgical and anesthetic techniques for both donor and recipient are described in detail. The survival rate in group 2 was 68%. Hemodynamic and blood gas changes were assessed during operation. PaO2 did not drop significantly after occluding the right pulmonary artery by an inflatable cuff placed around it; this suggests that the function of the transplanted lung was preserved. The pigs were put down on the third postoperative day. Vascular and bronchial anastomoses were patent and intact, but the transplanted lung was macroscopically and microscopically altered. Lung transplants can be performed in pigs and the transplanted lung seems to be capable of functioning immediately after the operation. Alteration in the lung after 3 days is probably due to rejection.

Detection and morphology of thymic remnants after video-assisted thoracoscopic extended thymectomy (VATET) in patients with myasthenia gravis.

Thymectomy is often an extremely useful therapeutic procedure in myasthenia gravis (MG) and is usually indicated for adult patients with generalized disease. Because remnants of thymus may remain in extrathymic fat, an extended thymectomy is recommended. A new surgical approach without sternotomy: video-assisted thoracoscopic extended thymectomy (VATET) was performed in 30 MG patients. The weight of removed thymus ranged from 10.8 to 113 grams. The weight of fatty tissue removed from pretracheal, anterior mediastinal and costophrenic areas ranged from 6.3 to 74.8 grams. Histological examination revealed thymic remnants in 14.8% of pretracheal fat samples and in 33.3% of samples from anterior mediastinal plus costophrenic areas. These findings indicate that VATET is a radical procedure and may be the first choice surgery for young female MG patients, since aesthetic sequelae are reduced compared to procedures involving sternotomy.

[Bilateral carcinoma of the breast]. / Il carcinoma bilaterale della mammella

Bilateral breast cancer is examined in the light of the literature data and a personal series. Lobular, asynchronous forms, either in situ or infiltrating, are usually involved. The fact that in situ changes are often found in the second neoplasia, with metastases solely in its tributary lymph nodes, suggests that such carcinoma was already present at the time of the first operation, though not clinically detectable. Since bilateral forms are commonly hormone-dependent, multiple biopsies should be routine on the contralateral breast. Preventive mastectomy associated with ovariectomy shold be performed on the slightest sign of carcinomatous or even precancerous alterations.

[Reconstruction of the thoracic wall in neoplasms of the manubrium of sternum]. / Ricostruzione della parete toracica per neoplasia del manubrio sternale.

The case of a voluminous neoplasia originating at the manubrium sterni is described. Given the rapid growth of the mass and its dimensions, the mass was removed surgically together with the manubrium sterni and the sternal extremity of the clavicle and of the first two ribs. The defect in the anterior wall of the thorax was filled by a net of prolene partially covered with the mobilised pectoral muscles. Functional and aesthetic results were very good. Assisted respiration was not necessary in the immediate postoperative period and the net remained stable and firmly in place during respiration. One month after the operation, respiratory function tests were on a par with those done prior to the operation. The positioning of prolene nets for the reconstruction of the thoracic wall is an extremely effective technique which makes it possible to preserve satisfactory respiratory mechanics even after the removal of extensive portions of the thoracic wall.