Reconstruction of the chest wall.

Chest wall reconstructions can be a complex and challenging procedure and may require a multidisciplinary approach. The most common indications for chest wall reconstruction are repair of defects due to tumor resection, infection, radiation necrosis, congenital deformities or trauma. The repair of complex chest wall defects presents a challenging problem for the reconstructive surgeon. Although the majority of such defects can be repaired with the use of local and regional musculocutaneous flaps, more complicated cases require increasingly sophisticated reconstructive techniques. As defects increase in size, microsurgical techniques are necessary to augment blood flow to pedicled flaps or to provide free flap coverage from distant sites. A better understanding of the respiratory mechanics and local anatomy is crucial in managing these complex defects.

Oncogenes in cancer of the pancreas.

A three-step immunoperoxidase staining technique was used in order to estimate the immunohistochemical expression of K-ras, c-fos, c-myc and c-erbB-2 oncoproteins, in paraffin sections of 20 patients, with histologically proven adenocarcinoma of the pancreas. The two oncogenes that were found to be associated with pancreatic adenocarcinoma were K-ras and c-erbB-2. in 15 patients (75%) and four patients (20%), respectively. Positive immunostaining was intense, cytoplasmic and was noted in a great percentage of cancer cells. The same model of expression was observed in the examined cases of metastatic tissue from liver and lymph node metastases. The expression of myc and fos oncogenes was nuclear, weak and was observed in a small number of patients.

Lymphedema of the upper limb after surgery for breast cancer.

Radical mastectomy is followed by swelling of the arm, and although the number of surgeons employing the operation is decreasing, postmastectomy lymphedema continues to be a serious complication. In the present report based on 158 women who underwent modified radical (126) or simple (32) mastectomy and occasionally radiation for histologically proved adenocarcinoma of the breast, the pathogenesis and treatment of postmastectomy lymphedema are discussed. The following conclusions can be drawn: (1) The occurrence of postmastectomy lymphedema diminishes the less extensive the operation. (2) Mild lymphedema that develops early postoperatively tends to subside. (3) Conservative treatment in the majority of cases is effective in controlling postmastectomy lymphedema of a mild to moderate degree. (4) Modified radical mastectomy, which is as radical as Halsted's operation, is rarely followed by lymphedema.

Hepatic hydatid disease: current surgical treatment.

In the 11 years 1980 through 1990, we performed a total of 273 operations for hydatid disease of the liver in 252 patients, including 35 patients who were over the age of 75 years. Cysts were multiple in 24.6%, calcified in 17.9%, and ruptured to adjacent viscera in 12.3% of cases. Ruptured cysts were small as well as large. Coexisting gallstone disease was found in 14.3% of cases. Reoperations for recurrence were performed in 6.4% of cases. We believe that once the diagnosis is made, the treatment should be surgical, without regard to cyst size, the age of the patient, or the presence or absence of symptoms. Total pericystectomy, which eradicates the parasitic disease and thus minimizes the risk of recurrence, is the procedure of choice (17.3% in this series). When total pericystectomy is not feasible and the cysts are large and deeply placed, subtotal pericystectomy, in which only a small piece of the cystic wall is preserved, is a successful alternative (12.5% in this series). For complicated cysts, external drainage of the cystic cavity is necessary despite the known morbidity this procedure entails. In patients in this series undergoing external drainage, infection of the residual cavity and postoperative biliary fistula were the main causes of morbidity.

Replacement of the pyloric sphincter with the ileocecal valve: an experimental study.

BACKGROUND: Several surgical methods have been devised and applied to overcome the complications associated with the loss of the pyloric sphincter after distal gastrectomy. However, none of these methods creates an efficient sphincteric mechanism at the anastomotic site. The purpose of this experimental study in dogs was to replace the pylorus with the ileocecal valve and determine whether its sphincteric function would be preserved in its new location without affecting gastrointestinal motility and the health of the animals. METHODS: Thirteen dogs underwent surgical removal of the pyloric sphincter and a partial distal gastrectomy. The ileocecal valve, with a short segment of ileum, was then relocated so that the ileal segment was anastomosed to the stomach while the cecal segment was anastomosed to the duodenum. Intestinal continuity was reestablished by anastomosing the distal ileum with the ascending colon. Intraileal and intracolic pressures were measured in all animals prior to and following transposition of the ileocecal valve. In 3 of these animals, pre-pyloric (intragastric) and post-pyloric (intraduodenal) pressures were also measured before the pylorus was removed. Pressure measurements on both sides of the transposed ileocecal valve were performed again 4-6 months later. All pressure measurements were made directly with a water manometer. Radiographic and fluoroscopic studies were carried out on all animals to assess gastrointestinal motility, gastric emptying times, and the sphincteric competence of the transposed ileocecal valve. Hematological and biochemical studies intended to assess the nutritional status of all animals were carried out. Also, postoperative measurements were made of gastric basic acid output. RESULTS: All animals were alive and well 4-6 months after the initial operative procedure. Hematological studies and biochemical tests and studies of liver function remained normal. There was a slight reduction in serum B12 levels and, as expected, a significant postoperative reduction in gastric basic acid output. The intraluminal pressure measurements and the radiographic and fluoroscopic studies all showed that the sphincteric mechanism of the ileocecal valve was preserved in its new location, that gastrointestinal motility was not impaired, and that the healthy condition of the animals was maintained. Gross and histological examination of the transposed segments of the intestinal tract did not reveal any abnormalities. CONCLUSION: Because the anatomy and physiology of the human alimentary tract are similar to those of the dog, this technique may be applicable clinically, when indicated, to avoid and/or relieve complications resulting from gastrectomy, when those complications do not respond or have not responded to conservative management.

Serum phosphate levels in acute bowel ischemia. An aid to early diagnosis.

Serum phosphate levels were studied in 18 patients with acute intestinal infarction as proved by laparotomy. Serum phosphate was increased preoperatively (6.12 +/- 0.75 mg/dl) in 94.4 per cent of cases. False-positive results were not recorded. The rise in phosphate was observed 4-12 hr (6.82 +/- 2.65) after the beginning of symptoms and was significantly higher when compared with both normal limits (3-5 mg/dl) and phosphate levels of 24 patients with acute abdominal conditions not associated with intestinal ischemia. This study suggests that determination of serum phosphate should be used as screening method for early detection and treatment of patients with acute intestinal ischemia.

The influence of corticosteroids on ileostomy discharge of patients operated for ulcerative colitis.

The ileostomy output and electrolyte loss was studied in 23 patients undergoing operation for ulcerative colitis, to determine corticosteroid influence. Ten patients did not use corticosteroids and 13 patients received postoperatively 400 mg hydrocortisone intravenously for 4 to 5 days followed by 90 mg prednisone per os thereafter. Ileostomy volume and electrolyte concentration and total loss were measured on the 4th and 8th postoperative days. Patients on corticosteroids presented with a reduction of volume lost from the ileostomy (P less than 0.001), lower sodium concentration and total loss (P less than 0.00001), higher potassium concentration (P less than 0.00001) with similar total loss (P is not significant) and higher calcium concentration (P less than 0.00001) but lower total loss (P less than 0.05). It is concluded that corticosteroid administration influences significantly both volume and electrolyte loss due to the ileostomy discharge in patients operated for ulcerative colitis, suggesting a need for careful maintenance of fluid and electrolyte balance in the early postoperative period.

Postoperative alkaline reflux gastritis following vagotomy.

This study was undertaken to evaluate the incidence and severity of postoperative alkaline reflux gastritis in 798 symptomatic duodenal ulcer patients who had undergone vagotomy. The condition was identified on the basis of the unique endoscopic and histological findings in 116 (14.5%) of them. It was more frequent and severe in patients with truncal vagotomy and gastrojejunostomy than in those with truncal vagotomy and pyloroplasty, while it was not at all observed in cases with proximal gastric vago-tomy, the symptoms depended on the preoperative history of the ulcer disease and the patient's age at the time of surgery, but did not always correspond with the degree of histological findings. The location of the gastrojejunostomy and the size of the pyloroplasty stoma had an influence on the incidence of the syndrome. Helicobacter pylori was found more frequently in biopsy specimens from patients with severe symptoms (30.3%), but was present in only 14.6% of the total number of the patients with postoperative alkaline reflux gastritis after vagotomy.

Autoantibodies in the serum of patients with gastric cancer: their prognostic importance.

To evaluate the presence in serum and the clinical relevance of several antinuclear autoantibodies, we investigated 31 patients with initially diagnosed gastric cancer and 40 age-matched healthy controls. Autoantibodies against ssDNA, dsDNA, cardiolipin, actin, myosin, tropomyosin, GM1, GD1b and GT3 gangliosides, were detected with an enzyme-linked immunoassay (ELISA). Anti-ssDNA, anti-actin, anti-GM1 and anti-GD1b antibodies were detected in the serum of 11 (p = 0.001), 8 (p = 0.02), 11 (p = 0.001), and 9 (p = 0.008) patients with gastric cancer, respectively. There was no significant difference between patients with cancer and the control group, as far as the other autoantibodies were concerned. Most of the patients (90%) had autoantibodies against at least one of the antigens examined. Patients with anti-ssDNA, anti-actin, anti-GM1 and anti-GD1b antibodies were less likely to survive than the patients being negative to the above autoantibodies: the figures are 1 of 11 (9%) compared with 4 of 20 (20%); 1 of 8 (13%) compared with 5 of 23 (22%); 1 of 11 (9%) compared with 4 of 20 (20%); and 1 of 9 (11%) compared with 4 of 22 (18%), respectively. Our findings suggest that 4 of the 9 autoantibodies that we assayed are significantly more likely to be found in serum of patients with gastric cancer, indicating that the immune system has a role in the process of the malignant disease. If our results are confirmed by forthcoming studies, some of the immunological variables that we examined could be used as markers of prognostic value in patients with gastric cancer.

[Cutaneous fistula of hydatid cyst of the liver]. / Fistulisation à la peau d'un kyste hydatique due foie.

We report a case of liver hydatic cyst fistulised spontaneously at the skin. It is an extremely scarce complication.

Use of the pylorus for preventing ileostomy complications. An experimental canine study.

PURPOSE: Conventional ileostomy, as it is well known, presents with persistent watery diarrhea, among other complications. The present-day modified methods of conventional ileostomy cannot effectively prevent these unpleasant consequences. The purpose of this study was to try to use the sphincter mechanism of the pylorus in ileostomy in dogs experimentally to prevent the above symptoms. METHOD: Following a highly selective vagotomy, the antrum with the pylorus and a 3-cm segment of the duodenum were separated from the gastrointestinal tract along with its vasculature and innervation, and the distal duodenal end was closed. Then, the terminal loop of ileum (before an ileostomy was performed) was dissected, and the distal segment was anastomosed with the proximal end of duodenum; the proximal segment of this loop was anastomosed with the stump of the antrum. The gastrointestinal continuity was established by anastomosis of the gastric stump to the first loop of the jejunum. RESULTS: After the procedure, the sphincter mechanism of the pylorus was preserved, and bowel movements became solid and infrequent, so a colostomy bag could be applied consistently. CONCLUSIONS: Similarity of anatomy and physiology of the alimentary tract in dogs and human favors possible application of this procedure to humans, with better results than with conventional ileostomy.

Site distribution of carcinoma of the large intestine. Retrospective study of 600 cases.

The site distribution of large-bowel adenocarcinomas was studied in a retrospective study compromising 600 patients. These patients were divided into two groups according to the year of their operation; group A included patients operated upon between 1978 and 1982, and group B patients were operated upon between 1983 and 1987. Comparing these two five-year periods, a statistically significant increase in the incidence of right colon tumors was noted (P less than 0.05). There was no difference in the distribution pattern of the carcinomas according to sex or age between the two groups (P less than 0.1). The shift to the right of large-bowel neoplasms may indicate the need for an alteration of the diagnostic procedures concerning this disease, with more emphasis given to total colonoscopy and or double-contrast barium enema.

Evaluation of cathepsin D immunostaining in colorectal adenocarcinoma.

BACKGROUND AND OBJECTIVES: Cathepsin D (CD), an estrogen-regulated lysosomal protease, has been detected in a variety of tissues. CD expression has been correlated with the invasive potential of breast cancer, acting as an autocrine mitogen or as a protease that degrades the extracellular matrix. The role of CD expression in predicting prognosis or invasive potential in colorectal carcinomas is mostly unknown. METHODS: CD immunohistochemical expression was studied in 60 surgical specimens of colon adenocarcinomas. A three-step avidin biotinylated, horseradish immuno-peroxidase (ABC-HRP) staining technique was performed on 4 microm paraffin-embedded tissue sections with a polyclonal antibody to CD. RESULTS: Carcinoma cells showed positive CD immunostaining in 41.6% of adenocarcinomas (50%, 43.7%, 37.5%, and 25% of Dukes' Stage A, B, C, and D, respectively). Nonneoplastic stromal cells demonstrated positive staining in 68.3% of the adenocarcinoma specimens (37.5%, 62.5%, 91.6%, and 75% of Stage A, B, C, and D, respectively). Patients with colorectal carcinomas exhibiting simultaneously negative and positive CD expression in malignant and stromal cells, respectively, had a worse 5-year overall survival (P < 0.05). The mean 5-year survival of the 16 patients overexpressing CD in nonneoplastic stromal cells (>15% of stromal cells positive for CD) was significantly worse in comparison with the rest of the adenocarcinomas (n = 44) (27.6 +/- 4.6 vs. 46 +/- 2.7 months, respectively, P < 0.01). CONCLUSIONS: Expression of CD immunoreactivity by the stromal cells may be associated with a more invasive phenotype. Therefore, CD expression in tumor and stromal cells may serve as an important indicator of progression and guide postoperative treatment.

Autoantibodies against insulin and beta-islet cells in pancreatic adenocarcinoma: a possible explanation for diabetes mellitus.

To evaluate the prevalence of autoantibodies against the b-islet cells (ICA) and the molecule of insulin (IAA) in the serum of patients with pancreatic adenocarcinoma (PA), we examined the sera of 36 newly diagnosed pancreatic adenocarcinoma patients for the presence of these antibodies, using an enzyme-linked immuno-assay method. These results were correlated with survival. Ten patients with insulin-dependent diabetes mellitus (IDDM) and 21 healthy volunteers were evaluated as age-matched controls. Twenty out of 36 (57%) PA patients were found to have detectable ICA autoantibodies and 17 (48%) PA patients had detectable IAA antibodies. Five out of 10 (50%) and 3 out of 10 (30%) IDDM patients had ICA and IAA antibodies, respectively. None of the healthy volunteers was positive for either of the autoantibodies examined. The difference was statistically very significant and the presence of high serum titers of both autoantibodies was associated with a worse outcome for these patients than for those without such autoantibodies. Our data suggest that the high incidence of diabetes mellitus in patients with PA may be attributed to the presence of these autoantibodies. Further clinical studies are needed to establish the above autoantibodies as prognostic markers of pancreatic cancer.

Significance of estrogen receptors and cathepsin D tissue detection in gastric adenocarcinoma.

Estrogen receptors (ERs) have recently been reported to be present in carcinomas of stomach, an organ that has so far been considered as nontarget for sex hormones. Cathepsin D is an estrogen-regulated lysosomal protease that has been overexpressed in breast cancer. ER and cathepsin D immunohistochemical expression were studied in this research in order to estimate their association to known histopathological and clinical parameters and their possible prognostic significance as well. Sixty-two patients with gastric adenocarcinomas were included in this study. The cancers were studied immunohistochemically concerning ER positivity in tumor cell nuclei and cathepsin D cytoplasmic expression. Nuclear ER staining was detected in tumor cells of 25% of male and 27% of female patients. ER positivity was demonstrated mainly in the well and moderately differentiated carcinomas; 87.5% of ER(+) tumors were also characterized as cathepsin D positive and a significant correlation between ER and cathepsin D positive expression was demonstrated (P < 0.05). Cytoplasmic cathepsin D expression was observed in carcinomatous cells of 70.9% of gastric tumors. Early tumor stage and good differentiation were significantly associated with increased cathepsin D expression (P < 0.05, P < 0.001). Histologic type, degree of differentiation and tumor stage were significantly correlated to survival (P < 0.05, P < 0.001 and P < 0.001). The patients who were cathepsin D(+) had a significant prognostic advantage over the cathepsin D(-) patients (P < 0.001). The presence of ER and estrogen-regulated cathepsin D indicates the involvement of sex hormonal factors in these tumors and cathepsin D positive expression in tumor cells seems to be related to better prognosis. Their biological, clinical, and prognostic roles remain to be further elucidated.

Current thoughts on the surgical treatment of rectal cancer.

From August, 1971 to May, 1974, 52 cases of rectal cancer belonging to different groups, according to Mason's classification, were seen at the First Surgical Department, University of Athens Medical School. In the majority of the cases the tumor was removed by combined abdominoperineal resection; the variety of other surgical methods in the treatment of rectal cancer are discussed. Emphasis is focused on certain important technical aspects in the surgery of rectal cancer: 1. the need for thorough preoperative preparation of the bowel; 2. the ligation of the inferior mesenteric artery at its origin from the aorta; 3. the intraluminal infusion of cytotoxic agents into the tumor-bearing segment after ligation of the inferior mesenteric vein; 4. the idea of the intra-arterial regional chemotherapy, during the operation; 5. the demarcation of the area with radiopaque clips for acute postoperative radiation,when residual tumor is left behind. The authors consider adherence to the above technical details critical in achieving good surgical results.