Tracheal varices caused by mediastinal compression of a large intrathoracic goiter: report of a case.

INTRODUCTION: Tracheal varices are a rare condition but they can be an important source of massive or recurrent haemoptysis. Usually they are related to increased pressure in the pulmonary veins. Mediastinal goiter is often associated to compressive effects on the surrounding structures, including mediastinal vessels with potential superior vena cava syndrome. CASE REPORT: We describe a case, not previously reported in literature, of mediastinal goiter with hemoptysis as first clinical manifestation. Bleeding was attributed to a superior vena cava syndrome associated to a tracheal fragile mucosa with an easily bleeding intramural nodule which was diagnosed as tracheal varices after total thyroidectomy. The nodule in fact disappeared together with the venous hypertensive signs after venous decompression of the mediastinum. CONCLUSIONS: Compressive symptoms including tracheal varices, related to mediastinal goiter, can be treated surgically by total thyroidectomy via cervicotomy and when required with associated median sternotomy.

Totally cervical thymoma from the orthotopic thymus.

Totally cervical thymoma is extremely rare and usually arises from ectopic thymic tissue. We report a case of a B1 thymoma localized in the neck, misdiagnosed for a decade as a thyroid nodule. Fine needle aspiration biopsy led to a preoperative suspicion of the correct diagnosis. The tumor was resected intact through a cervical collar incision, along with the upper thymic horn from which it originated. A pathogenetic hypothesis was formulated.

[Complications of thyroid surgery: cervical thoracic duct injuries]. / Complicanze chirurgiche della tiroidectomia: le lesioni del dotto toracico.

Thoracic duct injury is uncommon in surgery of the neck: relatively more common after laryngeal and esophageal surgery, rare in thyroid surgery. From January 1986 to June 2009 were treated 14 patients with lesions of the cervical thoracic duct undergo surgery for thyroid disease: 4 goitre cervico-mediastinal and 10 total thyroidectomy for cancer, 9 of which have laterocervical left lymphadenectomy. In 2 cases, the intraoperative detection has allowed immediate ligature. In 12 patients a cervical chylous fistula without chilothorax was found: 5 low-flow fistulas and 7 high-flow fistulas. Of the 5 cases of low-flow fistula, 4 were recovered after 1 month of conservative treatment, only 1 patient required surgical correction. The 7 patients with high-flow fistula were undergoing surgery: 4 in the first week post-operative and 3 after a period of more than 30 days of medical therapy. In patients with high-flow fistula prolonged medical treatment does not provide benefit and increase the risk of complications during and after surgery.

[Surgical treatment of well differentiated neuroendocrine tumours of the lung]. / Terapia chirurgica dei tumori neuroendocrini ben differenziati del polmone.

The bronchial tree represents the most frequent site of origin of carcinoids (around 25% of the total). The spectrum of differentiation of lung neuroendocrine tumors ranges from low-malignancy (carcinoids) to highly aggressive forms (small cell lung carcinoma) Diagnostic and therapeutic strategies therefore vary greatly. In well differentiated tumors (carcinoids) signs and symptoms are related to the airways obstruction in central forms, while peripheral forms are mostly discovered accidentally if asymptomatic. Clinical or subclinical paraneoplastic syndromes are associated in a minority of cases. Diagnostic work-up includes CT multislice, bronchial endoscopy and Octreoscan with chest Single Photon Emission Computed Tomography (SPECT). Further contribute may be added by the (68), Ga-DOTA-D-Phe(1)-Tyr(3)-ocreotide (DOTATOC) and 5-hydroxytryptophan (5-HTP) PET-CT, at present available only in a few centres, and by endobronchial ultrasound (EBUS), fluorescence bronchoscopy and virtual bronchoscopy. Surgery is the treatment of choice, while medical therapy is useful to treat the hypersecretion in paraneoplastic syndromes and to control tumor proliferation in metastatic or/and inoperable disease.

Thymic neuroendocrine carcinoma (carcinoid) in multiple endocrine neoplasia type 1 syndrome: the Italian series.

Neuroendocrine tumors may occur in the setting of multiple endocrine neoplasia type 1 (MEN1) syndrome. Among these, a probably underestimated prevalence of well differentiated neuroendocrine thymic carcinoma (carcinoid), a neoplasm characterized by very aggressive behavior, has been described. We report characterization of the seven Italian cases in which this association occurred among a series of 221 MEN1 patients (41 sporadic and 180 familial cases; prevalence, 3.1%). All of the patients were male, and six of seven (85%) were heavy smokers. No associated hormonal hypersecretion was detected. The first diagnosis was between the second and fifth decades. Familial clusters were present in three of seven (42.8%). No genotype-phenotype correlation was found. All seven cases were associated with hyperparathyroidism. In one patient, prophylactic thymectomy revealed a small nodular lesion suggestive of a thymic carcinoid, providing evidence that preventive thymectomy might prevent additional growth of an occult thymic carcinoid. These findings confirm that thymic carcinoids are associated with a very high lethality, with a near-total prevalence in smoker males. Therefore, prophylactic thymectomy should be considered at neck surgery for primary hyperparathyroidism in MEN1 male patients, especially for smokers, and, due to the frequent familial clusters distribution of this pathology, in subjects with affected relatives presenting this feature. Thus, we recommend screening every patient affected with a neuroendocrine thymic neoplasm for MEN1 syndrome.

The role of silicone stents in the treatment of cicatricial tracheal stenoses.

OBJECTIVE: Tracheal stenting for cicatricial stenoses is reserved for patients whose lesions are deemed inoperable for local or general reasons. The aim of our study was to verify the long-term results of silicone tracheal stents in such a clinical setting. METHODS: Clinical data of 45 patients treated by tracheal silicone stents, between 1987 and 1999, were reviewed. All patients had highly symptomatic cicatricial stenoses; they were selected for stenting rather than for surgery because of local and general conditions. This series has been divided in two groups according to the purpose of stenting: bridge to surgery or definitive treatment. Follow-up ranged between 12 and 83 months. Twenty-seven patients received a Montgomery T tube (Hood Laboratories, Pembroke, Mass), 16 a Dumon stent (Novatech, Plan de Gras, France), and 2 a Dynamic stent (Rusch, Kernen, Germany). RESULTS: No procedure-related mortality was observed. Nine patients underwent curative resection and reconstruction after a variable stenting period; one had a recurrent stenosis and was treated for palliation with a T tube. Tracheal stenting was performed for palliation as a definitive treatment in 37 patients. Among this group, 11 patients died of unrelated causes at a median of 10 months after the endoscopic treatment. The stent was permanently removed in 10 after a median interval of 32 months (range 9-70 months); in 4 others, symptomatic recurrence of the stenosis was observed within 6 weeks of stent removal. None of the patients successfully decannulated had a completely normal tracheal lumen but all remained asymptomatic because the residual stenosis was mild or well tolerated for concomitant limitation of physical activity. CONCLUSIONS: Long-term treatment with a silicone stent was safe and well tolerated in cicatricial tracheal stenoses. This procedure can be considered as a bridge to curative surgery or as a definitive treatment. The latter, generally performed for palliation, may provide satisfactory therapeutic results in selected patients, even in the presence of severe circumferential stenoses.

Chest wall stabilization with synthetic reabsorbable material.

Experimental results and preliminary clinical experience with synthetic reabsorbable materials in chest wall reconstruction are reported. Six beagle dogs underwent chest wall resection involving three or four consecutive ribs. Reparative procedure was performed by construction of a polydioxanone-band grid, anchored to the adjacent undamaged ribs. A mild wound infection developed in 1 animal but resolved without rejection of the prosthesis. The experimental material has shown favorable properties, both mechanical and biological. Subsequently, 11 patients, with different indications, underwent reconstructive procedures of the chest wall with reabsorbable prostheses. No complications have occurred. Long-term stability was excellent in all patients, with a mean follow-up longer than 6 months. The advantages of reabsorbable compounds are pointed out along with the possible applications for chest wall reconstruction after chest wall resection.

Bone heterograft for chest wall reconstruction after sternal resection.

BACKGROUND: Experimental and clinical results of chest-wall reconstruction with bone heterograft after sternectomy are reported. METHODS: Seven dogs underwent subtotal or total sternectomy and reconstruction by implantation of a cortico-spongy bone heterograft sandwiched between two layers of a reabsorbable mesh. RESULTS: No major postoperative complications were observed. The implant has shown favorable mechanical and biological properties. Six and 9 months after operation all animals were sacrificed and pathologic examination showed good incorporation of the implanted bone with only partial resorption of its spongiosa. Subsequently, 2 patients underwent sternal resection with different indications and reconstruction was achieved by the technique developed experimentally. No complications were observed. Excellent immediate chest-wall stabilization was obtained, persisting for a follow-up period longer than 6 months. CONCLUSIONS: In comparison with autologous bone, sterile bone heterograft seems to offer the same mechanical properties with a significantly reduced surgical trauma.

Resection with curative intent after endoscopic treatment of airway obstruction.

BACKGROUND: Endoscopic treatment of malignant central airway obstructions usually is done for palliation. The exact role of such a procedure as preparatory to operation remains controversial. METHODS: From 1987 through 1996, 24 patients at our institution underwent tracheobronchial pulmonary resection after preliminary endoscopic treatment. During the same period, 304 patients underwent 449 operative rigid bronchoscopies for airway obstructions, most involving the use of a neodymium:yttrium-aluminum-garnet laser. The indications for operation were squamous cell carcinoma in 14 patients, bronchial gland tumors in 8 patients, and papillary thyroid cancer infiltrating the trachea in 2 patients. The total resection rate was 9.5% (5% for squamous cell carcinoma, 75% for low-grade malignant bronchial tumors, and 75% for papillary thyroid cancer). The median period between operative rigid bronchoscopy and operation was 18 days. RESULTS: No complications were observed after endoscopic treatment. There were two perioperative deaths (adult respiratory distress syndrome after carinal resection and pulmonary embolism after pneumonectomy) and one major complication (poor postoperative pulmonary function after pneumonectomy). No anastomotic complications were observed in the tracheobronchoplastic procedures. Follow-up was possible in every patient but 1: 6 patients died at a median of 30.5 months after operation (range, 3 to 46 months), 2 patients are alive with disease, and the rest are alive without evidence of disease at a median of 21 months (range, 2 to 61 months). CONCLUSIONS: Most patients who require endoscopic therapy for malignant airway obstructions are not candidates for operative resection. Preliminary endoscopic relief of obstruction can increase operability and improve surgical results in a highly selected group of patients.

Long-term safety and tolerance of silicone and self-expandable airway stents: an experimental study.

BACKGROUND: A variety of respiratory stents are currently available, but the ideal airway prosthesis seems far from being recognized. The objective of this study was to verify safety and long-term effect on the bronchial wall of three different types of airway stents. METHODS: Twelve healthy adult sheep were divided in three groups, scheduled to receive: (1) bare self-expandable metallic stents (Gianturco); (2) silicone stents (Dumon); and (3) covered self-expandable synthetic stents (Polyflex). Insertions were performed through a rigid bronchoscope under general anesthesia. Chest roentgenogram was performed 1 and 6 months after surgery, and flexible bronchoscopy after 6 months. Twelve months postoperatively, the animals were killed and a postmortem examination was carried out. RESULTS: All Polyflex stents migrated during the observation period; one late migration was observed in the Dumon group. Microscopic study showed: (1) Gianturco stents: full-thickness perforation of the bronchial wall covered by a thick layer of a chronic inflammatory infiltrate. Infection by Candida at the bottom of some ulcerations; (2) Dumon stents: mild bronchial inflammation (squamous metaplasia, submucosal inflammatory infiltrates; granuloma-like infiltrates). In case of displacement, no significant changes of the previously stented bronchus occurred; and (3) Polyflex stents: no changes of the previously stented bronchi. CONCLUSIONS: Gianturco stents proved unsafe in the long term, owing to the risk of severe airway wall damage. The Polyflex stent is well tolerated but presents a high migration rate. Silicone stents show several limitations but appear to be well tolerated by the host mucosa.

Clinical significance of serum gastrin levels in patients with colorectal cancer.

AIMS: An association between elevated serum gastrin levels and the presence of human colorectal cancer has been reported, and gastrin has been shown to stimulate the growth of experimentally induced colon neoplasia. The aim of this study was to determine the preoperative and postoperative concentrations of serum gastrin in 53 patients with colorectal cancer and to assess the correlation between gastrin levels and tumor characteristics and prognosis. MATERIALS AND METHODS: A prospective study was performed over a six-year period during which 53 patients received potentially curative surgery for colorectal cancer. The prognostic variables used for the analysis included age, sex, tumor site, stage and degree of differentiation, preoperative and postoperative serum values of carcinoembryonic antigen (CEA) and gastrin, cancer-related mortality, and survival. CEA and gastrin serum values were determined using radioimmunological methods. Follow-up was carried out with clinical and radiological tests. RESULTS: The mean preoperative gastrin concentration was 51.2+/-27.4 pg/mL (range 12-146). Significantly increased serum gastrin concentrations, which returned to normal after surgery, were detected only in patients with well-differentiated cancer (74.2+/-28.3 pg/mL; moderately differentiated, 52.1+/-23.8; poorly differentiated, 29.9+/-12.3, p=0.02). The prognosis was unrelated to serum gastrin level; instead, tumor stage, preoperative CEA value, and degree of differentiation affected patient survival. CONCLUSIONS: This study showed that the serum gastrin concentration is not an appropriate clinical oncogenic factor. Although occurring only in well-differentiated tumors, serum gastrin is unrelated to the prognosis of patients with colorectal cancer.

[The role of surgery in the treatment of small cell lung cancer]. / Ruolo della chirurgia nel trattamento del microcitoma polmonare.

Small cell lung cancer (SCLC) is a biologically aggressive tumor with a low long-term survival rate. SCLC is highly responsive to chemotherapy and surgery has a very limited role in its treatment because the disease is usually widely disseminated at the diagnosis. Good results from surgery have been reported in the small subgroup of T1-2 N0 M0 patients. In N1 peripheral SCLC, surgery in combination with other treatments, can obtain fair results. Surgical treatment does not influence the prognosis in SCLC as stage III and IV.

Synthetic prostheses in repair of chest wall defects after exeresis of malignancies.

Five cases of chest wall repair with synthetic prostheses following thoracectomy for malignant tumours are reported. Two patients were submitted to partial sternal resection (manubrium); in the first case Marlex mesh alone and in the second a composite graft with Methyl-methacrylate were used. The remaining cases underwent extended thoracectomy and reconstructive procedure based upon Marlex prosthetic replacement and myoplasty. No postoperative complications were observed and satisfactory stabilization of the chest wall with good cosmetic results were obtained.

Severe subglottid stenosis, well-tolerated for many years.

A 45 year old man was admitted to our hospital due to dyspnoea. At the age of 1 yr, he had undergone orotracheal intubation for croup diphtheria resulting in dysphonia. He was in good health up to the age of 39 yrs when exertional dyspnoea arose. He had had irregular therapy by aerosol without improvement. At admittance, the flow-volume curve indicated an impairment at high flows (peak expiratory flow (PEF) and maximum expiratory flow at 75% (MEF75%)). Fibreoptic bronchoscopy revealed a thin and smooth diaphragm, with a small (7-8 mm) central orifice in the subglottid area. CO2 laser therapy improved symptoms by increasing the cross-sectional area of the diaphragm orifice.

[Embryologic and anatomo-surgical presuppositions in intraoperative injuries of the spleen. A clinical study]. / Presupposti embriologici ed anatomo-chirurgici delle lesioni intraoperatorie della milza. Studio clinico.

Records related to 2559 patients submitted to main abdominal surgery have been reviewed. Accidental splenic injury and subsequent splenectomy occurred in 4.5% of cases. A study of the embryological development and anatomical patterns of the splenic peritoneum has been carried out as well as an analysis of the site and the shape of the capsular damage in order to assess the mechanism of injury. Avulsion of splenic capsule occurring from traction on the peritoneal attachment of the spleen appears to be the most common mechanism of injury. Previous surgery and geriatric age seem to be factors predisposing to splenic injury.

[Surgical treatment of thyroid cancer in 243 cases]. / Trattamento chirurgico del cancro della tiroide in 243 casi.

The incidence of thyroid cancer, which accounts for 1-2% of all malignancies, constantly increasing. Its management requires an integrated approach, in which the surgeon plays a pivotal role, providing the basis for further treatment. At present, the extent of exeresis, the lymph-node dissection technique and the management of upper respiratory-digestive tract infiltration are still debatable issues. The authors report on their experience with 243 surgically treated thyroid malignancies over the period from January 1986 to December 1999. The operations performed were: total thyroidectomy 226 cases, lobo-isthmectomy 3 cases, total thyroidectomy + lung metastasectomy 1 case, total thyroidectomy + SE quadrantectomy 1 case, total thyroidectomy + monolateral modified neck dissection 30 cases, total thyroidectomy + bilateral modified neck dissection 17 cases, total thyroidectomy + radical neck dissection 1 case, total thyroidectomy + tracheal sleeve resection 5 cases. In 9 cases, extensive tracheal involvement (5.5 cm), age or neoplastic histology allowed only palliative treatment (endoscopic recanalization + tracheal endoprosthesis or tracheostomy. Nd-Yag laser endoscopic recanalization was performed in 2 patients as a preliminary stage in subsegmental radical treatment, and in 5 cases for palliation. Recurrent laryngeal nerve palsy occurred in 3 cases, long-term hoarseness in 2, and hypoparathyroidism in 4. The overall mean hospital stay was 4.8 days. Of 299 patients still alive, 215 are free of disease. Surgery is the treatment of choice, with the goal of completely removing the neoplasm, together with any anatomical structures involved in infiltration (muscles, respiratory-digestive tract, lymph nodes). Satisfactory palliation can be achieved by endoprosthesis deployment or tracheostomy in all cases where surgery is ruled out due to extent of disease, patient age or histological type.

[Significance of biliary lithiasic pathology in the etiopathogenesis of carcinoma of the large intestine]. / Significato della patologia litiasica biliare nella etiopatogenesi del carcinoma del grosso intestino.

With the purpose to study the eventual existence of a correlation between biliary lithiasis and colon-rectum carcinoma, the authors effected a retrospective study of the clinical material concerning 1283 patients hospitalized in the 1st Surgery Institute for large intestine carcinoma. The relative anamnestic data were compared with those of a control population. The results emerging from the research, checked in their statistic significance, seem to support the existence of such correlation. The hypothesis of a possible common etiopathogenesis of both diseases is proposed.

[Surgery of pulmonary and hepatic metastases]. / Chirurgia delle metastasi polmonari ed epatiche.

In recent years surgery for hepatic and pulmonary metastases has been undertaken with a curative intent in a growing percentage of cases. In the present study the Authors evaluate their own experience in such a field, and summarize the state of the art, as it appears from a review of the international literature. At present, the subject is not settled, as several aspects are matter of debate (prognostic significance of free interval, tumor doubling time, number and location of metastatic lesions, histologic type, and stage, of the primary tumor, approach to synchronous metastases, accuracy of preoperative diagnosis), with different therapeutic implications according to the hepatic or pulmonary site. Pulmonary metastases should be managed by resection through a median sternotomy, in order to allow thorough exploration of both lungs. Hepatic lesions (from colorectal primaries) should be resected with a free margin not less than 1-2 cm. The need for uniformity of selection criteria and for the establishment of protocols including adjuvant therapy is strongly felt.

[Use of the Dynamic Stent in the palliation of carinal and distal tracheal stenosis]. / Impiego del Dynamic Stent nella palliazione delle lesioni della carena e dell'estremo distale della trachea.

Satisfactory palliation of the lesions involving the carinal region is difficult to achieve because the stenting is conducted in an unsuitable anatomy, in highly symptomatic patients. During the period 1987-2000 we performed 785 operative rigid bronchoscopies in 524 patients, 184 of whom received a respiratory stent. The stenting of the carinal region was carried out in 27 patients with the use of the Frietag Dynamic stent. In this group of patients indication for stenting was as follows:--advanced lung cancer (22);--esophageal cancer invading the lower trachea (1);--severe tracheobronchomalacia (2);--postintubation stenosis of the lower trachea (2). No perioperative mortality was observed. All patients experienced symptomatic improvement. Follow-up ranged from 1 to 60 months: all neoplastic patients died for advanced disease without significant respiratory problems with a median survival of 5.6 months; three patients treated for benign diseases are still alive at 2, 31 and 65 months from stent deployment. No major complications were observed: in two patients the stent was removed after few days due to mucous retention; furthermore we observed symptomatic respiratory infections caused by a residual space between the tracheal wall and the prosthesis in other two patients with severe COPD. Dynamic stent is to be considered the stent of choice for palliation of the carinal region because it is effective and well tolerated with a low complications rate. The main limitations of such prosthesis are the shortness of the right bronchial branch and the size, sometimes inadequate.