Gene expression analysis of early and advanced gastric cancers.

Gastric carcinoma is one of the major causes of cancer mortality worldwide. Early detection results in excellent prognosis for patients with early cancer (EGC), whereas the prognosis of advanced cancer (AGC) patients remains poor. It is not clear whether EGC and AGC are molecularly distinct, and whether they represent progressive stages of the same tumor or different entities ab initio. Gene expression profiles of EGC and AGC were determined by Affymetrix technology and quantitative polymerase chain reaction. Representative regulated genes were further analysed by in situ hybridization (ISH) on tissue microarrays. Expression analysis allowed the identification of a signature that differentiates AGC from EGC. In addition, comparison with normal gastric mucosa indicated that the majority of alterations associated with EGC are retained in AGC, and that further expression changes mark the transition from EGC to AGC. Finally, ISH analysis showed that representative genes, differentially expressed in the invasive areas of EGC and AGC, are not differentially expressed in the non-invasive areas of the same tumors. Our data are more directly compatible with a progression model of gastric carcinogenesis, whereby EGC and AGC may represent different molecular stages of the same tumor. Finally, the identification of an AGC-specific signature might help devising novel therapeutic strategies for advanced gastric cancer.

Videolaparoscopic appendectomy: the current outlook.

BACKGROUND: Mini-invasive techniques have revolutionized surgery, but the superiority of laparoscopic access for appendectomy is widely debated. The authors analyze their monocentric experience with 1,347 laparoscopic appendectomies. METHODS: Between October 1991 and December 2002, all the patients with an indication for appendectomy underwent surgery (301 emergency and 1,046 interval appendectomies) using the laparoscopic approach. RESULTS: For 1,248 patients, appendectomy was performed laparoscopically, whereas for 99 patients (7.3%), it was converted to an open procedure because of technical reasons (90 patients, 6.7%) or intraoperative complications (9 patients, 0.6%). For 59 patients (4.4%), the appendectomy was associated with another procedure. Histology showed "acute" alterations in 261 of the 301 emergency surgeries and in 148 of the 1,046 elective operations. Postoperative complications arose in 37 patients (2.7%), with 5 patients (0.3%) requiring invasive treatment. The mean postoperative stay was 30 h. CONCLUSIONS: Laparoscopic appendectomy offers unquestionable advantages, but it is not yet considered the "gold standard" for appendiceal pathology. Many centers reserve it for selected patients (e.g., obese patients and women suspected of having other pathologies). No randomized trials or metaanalyses have definitively proved its superiority.

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.

State of the art in thoracospic surgery: a personal experience of 2000 videothoracoscopic procedures and an overview of the literature.

BACKGROUND: Herein we compare our personal experience with a series of > 2000 videothoracoscopic procedures with those reported in the literature to identify the procedures now accepted as the gold standard, those still regarded as investigational, and those considered unacceptable. METHODS: Between June 1991 and December 2000, we performed 2068 videothoracoscopic procedures, including lung cancer staging (n = 910), wedge resections (n = 261), lobectomies (n = 221), pneumonectomies (n = 6), the diagnosis and treatment of pleural diseases (n = 200), the treatment of pneumothorax (n = 170), giant bullae (n = 57), lung volume reduction surgery (LVRS) for emphysema (n = 41), the diagnosis and treatment of mediastinal diseases (n = 133), the treatment of esophageal diseases (n = 39), and 30 other miscellaneous procedures. RESULTS: A review of the literature indicates that videothoracoscopy is usually considered the preferred approach for the treatment of spontaneous pneumothorax, the diagnosis of indeterminate pleural effusions, the treatment of malignant pleural effusions, sympathectomy, and the diagnosis and treatment of benign esophageal or mediastinal diseases. The videoendoscopic approach to LVRS for emphysema is still under evaluation. Videothoracoscopic wedge resections for the diagnosis of indeterminate nodules and the treatment of primary lung cancer, metastases, and other malignancies are still controversial due to oncologic concerns. Videoendoscopic major pulmonary resections are usually considered investigational or even unacceptable due to oncologic concerns, technical difficulties, and the risk of complications. CONCLUSIONS: Although we generally agree with the foregoing recommendations, we consider videoendoscopy the best approach for LVRS and particularly useful for the staging of lung cancer, where we always perform it as the first step of the operation. We widely perform videoendoscopic major pulmonary resections, but we believe that these procedures should only be used in strictly selected cases and at specialized centers.

Major vascular injuries in laparoscopic surgery.

BACKGROUND: Major vascular injuries (MVI) still occur in laparoscopic surgery. METHODS: We report our institution's experience of two MVI (aortic lesions) in a series of 3545 laparoscopies (July 1991-December 2000). We compared this experience with other series reporting MVI from Medline, Embase, Current Contents, and Best Evidence. RESULTS: There were no deaths, but we had 23 postoperative and eight intraoperative bleedings, including two hepatic vessel lesions during dissection and six vascular lesions (four minor vessels and two aortic) related to trocar insertion. Prevention and treatment options are also discussed. CONCLUSIONS: The incidence of MVI reported in the literature is 0.05%, but the true incidence is difficult to estimate because results are not always comparable and there is a possibility of underreporting. The mortality rates (8-17%) are high. No technique or instrumentation is completely safe; therefore, a high level of alertness must be maintained at all times and precautions must be adopted to avoid major complications.

False radiographic appearance of a right bronchial stump following extended right pneumonectomy.

The authors describe three cases in which postoperative frontal chest radiographs following extended right pneumonectomy showed a right hilar lucency producing the false appearance of a residual main bronchus that is shown by additional studies to represent a dilated esophagus.

[Relationships between clinico-therapeutic parameters and immunological status in patients with lung cancer]. / Rapporti tra parametri clinico-terapeutici e stato immunitario nel paziente portatore di cancro del polmone. Analisi di 150 casi.

150 patients with lung cancer have been studied from the immunological point of view: the two years that elapsed between the study and processing of the data permitted an evaluation of the prognosis in terms of immunology also. This study has been carried out in vivo by means of skin tests (BCG, PPD, Candida, Varidase, CCB, Mumps, BNCB) and in vitro with lymphocyte blastization in the presence of PHA and dependent antibody cytotoxicity. Serum factors which can interfere with lymphocyte cytotoxicity have also been studied. Peri- and intra-tumour lymphocyte infiltration and the lymph node activation stage have been analyzed in patients who underwent surgery. A real depression of the cell mediated immunity observed in the negative response to skin tests has been found. The study of in vitro parameters showed a deficient blast response in 86% of the cases examined, decreased cytotoxicity in 62% and the presence of inhibiting serum factors in 53%. No correlation was observed between positivity to skin tests, normal response to PHA, normal concentration of inhibiting serum factors on the one hand and survival on the other. The only finding which seems to be correlated with survival is lymphocyte infiltration; its peri- and intrastromal presence on the neoplasia may be associated with a significantly better prognosis.

[Clinical significance of cell kinetics in lung cancer]. / Significato clinico della cinetica cellulare nel cancro del polmone.

A series of 24 lung cancer cases was studied: 12 epidermoid carcinomas, 9 adenocarcinomas, 2 giant-cell carcinomas and 1 carcinoid. The patients were staged on the basis of the TNM classification system as 9 stage I, 5 stage II, 9 stage III and 1 stage IV. Using fresh tumour cell samples 2 cell cultures were prepared for each patient: one to identify the percentage of S phase cells (Labelling Index) using the tritiated thymidine method and one for cytogenetic analysis. A gentic map was obtained in 6 cases and revealed no specific numerical or structural alterations. The Labelling Index (L.I.) was calculated for all patients and compared with all TNM parameters. This revealed a certain connection between L.I. and parameters T, SN and G but no link with parameters.

The versatility of pectoralis major muscle and musculocutaneous flaps in the reconstruction of the oral cavity and of the anterior chest wall.

Musculocutaneous flaps, allowing one stage reconstructions and reducing the stay in hospital and rehabilitation period, have revolutionised modern plastic surgery. Muscle flaps are a good alternative to provide adequate coverage of tissue losses but with limited scarring. The authors report their 5 year clinical experience in the reconstruction of oral cavity and chest wall defects using the pectoralis major as muscle or musculocutaneous flap. The preliminary data of an angiographic study, confirming the segmentation of the pectoralis major muscle into two subunits, each provided with its own vascular supply (mainly the clavicular and the sternocostal segment), are also presented. The short and long-term results confirm the excellent viability and versatility of the pectoralis major musculocutaneous and muscle flap. In particular the complications rate is so low that this procedure can be considered safe and reliable.

Videothoracoscopic operative staging for lung cancer.

The authors describe their experience in performing Videothoracoscopy as the first step of the operation in patients affected by lung cancer: they refer to this procedure as Videothoracoscopic Operative Staging (VOS). In 286 patients, already proposed for curative surgical resection on the basis of conventional staging, VOS was carried out in order to reach a conclusive judgement of resectability. VOS discovered unsuspected causes of inoperability in 17 patients (5.7%), while 269 patients underwent surgical operation but in 9 of them this consisted in an exploratory thoracotomy (ET). Furthermore, VOS allowed us to assess the operability of 11 patients in whom preoperative computed tomography (CT) had suggested unresectability but without providing a definitive judgement. Based on their experience the Authors conclude that VOS should be performed in every patient affected by lung cancer in order to obtain a more detailed staging and to reduce to a minimum the number of ETs. By using VOS it was possible to decrease the rate of exploratory thoracotomies to less than 4%.

Major thoracoscopic operations: pulmonary resection and mediastinal mass excision.

After the great success of laparoscopy in the field of abdominal surgery, the mini-invasive approach has opened interesting new possibilities in the field of thoracic surgery too. At present, in many centres, thoracoscopy is the surgical approach of choice for the treatment of recurrent pneumothorax, giant bullous lung disease, peripheral benign lesions. In very few centres a new phase is now starting, having the objective of verifying the validity of more complex thoracoscopic surgical operations. The authors describe their experience in performing major thoracoscopic operations such as excision of mediastinal masses and major pulmonary resections. The series includes 36 patients submitted to thoracoscopic excision of mediastinal masses and 113 patients submitted to video-thoracoscopic major pulmonary resections. Every kind of mediastinal lesion as well as every kind of major pulmonary resection was performed; the evidence of no intra-operative deaths confirms the possibility of a useful employment of the mini-invasive approach in this kind of surgery.

Anastomotic healing in dogs under cortisone treatment. A pilot study comparing compression and stapled anastomosis.

Colonic anastomoses made both by a new Compression Anastomotic Device (CAD) and by a traditional stapler (Autosuture CDEEA) were evaluated in impaired anastomotic healing induced by systemic cortisone in the dog. Twenty dogs were given daily i.m. hydrocortisone (25 mg/kg) starting one month before surgery and then until sacrifice. Eight untreated dogs served as controls. Surgery consisted of colonic transection and anastomosis done with CAD-25 in half the cases and with CDEEA-25 in the remaining half. The dogs were sacrificed six and 13 days after surgery. Macroscopic assessment, bursting pressure test, and histology were performed on the anastomosis. One dog died from peritonitis due to anastomotic dehiscence. No other clinical complications were observed. Although the number of observations was too small to attain statistical significance, CAD anastomoses appeared better than stapled ones as regards peri-anastomotic adhesions, anastomotic index, and histology. This preliminary study suggests that compression is as reliable as the stapler in the construction of colon anastomosis even in such situations of delayed anastomotic healing. Further experience is required to substantiate this conclusion.

Videoendoscopic thoracic surgery.

Personal experience of 42 videothoracoscopic operations is reported. From September 91 to May 92 we performed 10 major lung resections (1 pneumonectomy, 8 lobectomies, 1 segmentectomy) 9 wedge lung resections, 4 excisions of pulmonary bullae, 12 pleurectomies with or without apicectomy, 6 excisions of mediastinal masses (3 thymomas, 2 mediastinal cysts, 1 thoracic disembryoma), 1 removal of esophageal leiomyoma. No major complications occurred. Except for one patient submitted to bullectomy with pleurectomy who required a second thoracoscopy due to postoperative bleeding, all patients had excellent p.o. course. We describe technical details employed in different videothoracoscopic operations and discuss personal results and principles of videothoracoscopic approach. Different fields of videoendoscopic chest surgery are examined. Present data seem to advocate videothoracoscopic treatment for many thoracic diseases and also for major lung resections, due to its minimal trauma and little functional impairment. Nevertheless this still remains avant-garde surgery. Further improvement in endoscopic instrumentation is necessary and may lead to future extensions of videothoracoscopic surgical possibilities.

[A case of recurrent hemoperitoneum caused by hepatocarcinoma]. / Su di un caso di emoperitoneo recidivante da epatocarcinoma

A case of recurring haemoperitoneum caused by liver cancer is presented. This neoplasia, rare itself in Italy, may have a variety of clinical pictures. Recurring haemoperitoneum is quite exceptional and mistaken diagnosis and aetiopathogenetic interpretation are the likely results. The symptomatology is illustrated and the problem of diagnosis is discussed.

[Remote results and critical review of the use of the Sparks-Mandril prosthesis]. / Risultati a distanza e revisione critica dell'uso della protesi di Sparks-Mandril.

Long-term clinical results and pathologic features, both macroscopic and microscopic, of 24 Sparks-Mandril grafts as femoro-popliteal substitutes are reviewed. High rate of complications and low percentage of patency are stressed. Further use of this graft is not recommended.

[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.

[Segmental splenectomy. Usefulness of linear surgical staplers]. / La splenectomia segmentaria. Utilità delle suturatrici meccaniche lineari.

As the high risk of sepsis after splenectomy is well recognized, reliable conservative surgical techniques in splenic surgery are widely advocated. Among these, segmental splenectomy carries specific and increasing indications. The use of linear staplers makes this operation quicker and safer. On the basis of a personal observation, Authors examine the anatomical features on which this operation is based, the surgical technique and the technical details to be followed using these devices. The advantages offered by staplers in this surgery allow to widen the indications to partial splenectomy, so as to yield a true primary prophylaxis of the post-splenectomy sepsis.

[Typical, atypical and malignant bronchial carcinoid]. / Il carcinoid bronchiale tipico, atipico e maligno.

A series of 54 bronchial carcinoids operated in the course of 12 yr is presented. There were three histological types: typical, atypical and malignant. A parallel was also apparent between histological appearance and clinical pattern. Correct prognosis, however, demands the examination of other parameters, such the tendency of the neoplasia to infiltrate, and the presence of metastatic lymph nodes.