Significance of lymph node metastases in the surgical management of pancreatic head carcinoma.

Recent reports have demonstrated a reduction in the morbidity and mortality of pancreatic resections and improvement in the 5-actuarial survival for patients with resected ductal adenocarcinoma. However, the prognosis for patients with lymph node metastases remains uncertain. The purpose of this study is to determine if the presence of lymph node metastases influences the survival in patients with otherwise potentially curable pancreatic head carcinoma. Between January 1974 and December 1995, 340 patients with pancreatic carcinoma, including 238 patients with pancreatic head tumours, were evaluated and treated in our Department. Seventy-seven (32.3%) patients with pancreatic head carcinoma underwent pancreaticoduodenectomy. Ages ranged from 40 to 76 years, with a mean age of 61 years. Fifty patients were male, twenty-seven were female. The overall postoperative mortality rate was 5.2% (4 patients) and morbidity was 23.4%. Median survival following resection was 17 months (range 0 to 79). The estimated 1-, 2-, 3- and 5-year survival were 68.8%, 48.1%, 23.4% and 18.2%, respectively. There were 14 five-year survivors. Of the 77 patients, 25 (32.5%) had negative lymph nodes. The median and 5-year survival in these node-negative patients were 33 months (range 5 to 79) and 40%, respectively. Whereas the median survival and 5-year survival in 52 patients with lymph nodes metastases were 14 months (range 0 to 61) and 7.7%, respectively (P<0.0001). There were 4 five-year survivors in the group of patients with lymph node metastases; in 2 patients was performed extensive lymph node dissection (R2) and in other 2 patients R1 procedure. In the patients with lymph node metastases undergoing R1 resection (n = 39), the 1-, 2- and 5-year survival rates were 48.7%, 23.1% and 5.1%, respectively. Whereas in the patients with positive lymph nodes undergoing R2 resection (n = 14), the 1-, 2- and 5-year survival rates were 92.9%, 64.3% and 14.3%, respectively (P<0.02). As expected, tumour size and margin status in specimen proved to be two significant factors predicting survival. Pancreatoduodenectomy can be performed with low operative mortality. Lymph nodes metastases are found in 67.5% of patient undergoing resection. Pancreaticoduodenectomy offers good palliation for patients with lymph nodes metastases and encouraging long-term survival rates as well as a chance for cure in patients with negative lymph nodes and negative margins of resection.

Adenomyoepithelioma of the breast. A case report.

Adenomyoepithelioma is a proliferative disorder of both epithelial and myoepithelial cells. This lesion may be found in salivary glands, skin appendages and, very rarely, in the mammary gland. Adenomyoepithelioma was first described in 1970 and very few cases have so far been reviewed in the literature. This paper reports the clinical, histological and immunohistochemical characteristics of an adenomyoepithelioma in a 24 year old woman; to our knowledge this is the first published case in such a young patient. The clinical feature suggested a fibroadenoma. A more complete study of the excised tumor tissue by immunohistochemical and ultrastructural analysis proved that the correct diagnosis was adenomyoepithelioma. Whether adenomyoepithelioma is a benign or a low-grade malignant lesion is still controversial and, therefore, the therapeutic approach is not well defined.

[Surgical treatment of severe obesity. Criteria of choice of operation. Personal technic]. / Terapia chirurgica dell'obesità di grado elevato. Criteri di scelta dell'intervento. Note di tecnica personale.

The criteria underlying the choice of operation in a given case and the personal technique adopted are described. The technique in question is a personal modification of end-to-side jejuno-ileal bypass codified by Payne. To minimize reflux into the blind loop, a number of technical steps are considered indispensable: 1) fluted section of the jejunal stump; 2) isoperistaltic construction of the anastomosis and, particularly, 3) the creation of a single or double valve system upstream from the anastomosis by spiral introflexion of the mucosa using seroserous stitches parallel and perpendicular to the ileal lumen. Other techniques in use are reported. These are held to be extremely interesting but are not yet supported by a long enough follow-up.

[Jejuno-ileal bypass in the treatment of severe obesity: transverse or vertical approach?]. / Il by-pass digiuno-ileale nel trattamento dell'obesità d'alto grado: via di accesso verticale o trasversale?

The criteria applicable to the selection of the approach route in the surgical management of essential gross obesity by means of a jejunal-ileal by-pass are discussed. Median vertical and transverse incision are compared in the light of early and late hypoxaemia in the immediate postoperative period; postoperative acidosis and alkalosis; rapidity; exposure; extendibility; tightness; postoperative pain; cosmetic results. A preference for the vertical approach is both stated and justified.

Hepatico-jejuno-duodenoplasty for biliary stricture.

The authors present the results of their experience in the therapy of biliary strictures, using a jejunal loop interposed between the biliary tract and duodenum. This procedure allows extensive biliary discharge and aims to prevent the pathophysiologic disturbances of gastroduodenal functions, which result from Roux-en-Y anastomosis, and has the advantages of both Roux-en-Y and choledochoduodenostomy procedures. The authors report nine years positive experience with this technique. No gastroduodenal postoperative complaints are reported in their series, whereas an 8% incidence of duodenal ulcers is reported after Roux-en-Y anastomoses.

[Personal experience with bilio-digestive anastomosis]. / La nostra esperienza in tema di anastomosi bilio-digestive.

The indications and contraindications for the various types of bilio-digestive anastomosis operations are assessed with due allowance for the physiopathological aspects of main bile way function. Careful analysis of the data obtained in pre- and intra-operative investigation permits a precise choice of the required intervention in all cases. The advantages offered by restoral of bile flow at duodenal level, as occurs in EDDP, are stressed.

[Local treatment of tumors of the rectum]. / Il trattamento locale dei tumori del retto.

Local treatment of tumours of the rectum currently rests on clear-cut indications, restricted to cases in which psychological reasons, the extremely poor condition of the patient, or an over-high element of risk militate against destructive surgery. An account is given of the main techniques employed and their advantages, and a critical assessment of their merits is attempted.

Survival after pancreaticoduodenectomy for ductal adenocarcinoma of the head of the pancreas.

Recent reports have demonstrated an improvement in 5-year actuarial survival of patients with resected ductal adenocarcinoma. The purpose of this study was to determine the factors favoring long-term survival after pancreaticoduodenectomy. Between 1974 and 1995, 75 patients with pancreatic head carcinoma underwent pancreaticoduodenectomy in our department. The overall postoperative mortality rate was 5.3% and morbidity was 24%. Median survival following resection was 17 months. The estimated 1-, 2- and 5-year survival rates were 68%, 46.7% and 18.7%, respectively. Five-year survival was significantly greater for node-negative versus node-positive patients (41.7% vs 7.8%, P < 0.001), for smaller (< 3 cm) versus larger tumours (33.3% vs 8.8%, P < 0.006), and for negative versus positive resection margins (23.3% vs 0, P < 0.001). Other factors, including gender, age, and blood transfusion had no significant effect on survival. The multivariate analysis was done using the Cox proportional hazards model to determine independent prognostic determinants of survival. The presence of positive resection margins was the strongest independent predictor of decreased survival. Lymph node metastasis, tumour size > 3 cm, and poor histologic differentiation were also independent predictors of poor survival. The most favorable subset consisted in 17 patients who had negative resection margins, negative lymph nodes, and tumor size < 3 cm. Their 5-year survival rate was 52.9%.

[Laparoscopic appendectomy and laparotomy appendectomy: comparison of methods]. / Appendicectomia laparoscopica ed appendicectomia laparotomica: metodiche a confronto.

The study compares the real advantages of laparoscopic appendicectomy using only a transumbilical trocar, with laparotomic appendicectomy in the management of acute and/or chronic pain in the lower right abdominal quadrant. From May 1997 to April 2000, 88 patients were treated: 27 (group I) with the laparoscopic approach, and 61 (group II) with laparotomy. We compared operating times, incidence of complications, hospital stay and cosmetic result. We also reviewed the literature on this subject over the past ten years. Average operating time was 45 minutes in group I and 30 minutes in group II; complications consisted in 2 cases of omphalitis in the laparoscopic group and 3 infections of the wound and 2 cases of lipolysis of the abdominal wall in the laparotomic group. The average hospital stay was 3.2 days in the laparoscopic group against 4.7 days in the laparotomic group. Resumption of work and sport occurred after 10 to 20 days and 15 to 45 days in groups I and II, respectively. The total cost was lower in the laparoscopic group. The laparoscopic approach appears to be an effective technique for the management of acute and chronic appendicitis, as it allows both treatment of the pathology and diagnosis and treatment of other unknown pathologies, with exploration of the abdominal cavity. In addition, it guarantees a good cosmetic result, a short hospital stay with a low incidence of complications and an advantageous cost/benefit ratio.