[Surgical treatment of gasto-esophageal junction adenocarcinoma: long-term results of a single Italian centre]. / Il trattamento chirurgico dell'adenocarcinoma del giunto esofago-gastrico: risultati a lungo termine di un unico centro italiano.

OBJECTIVE: The present study analysed the experience of a single Italian institution in the treatment of gastro-esophageal junction (GEJ) adenocarcinoma with the aim of assessing the long-term outcome after surgical resection. METHODS: The results of 132 patients who underwent resection with curative intent for GEJ adenocarcinoma at the First Division of General Surgery, University of Verona, from January 1988 to February 2004, were analysed statistically with special reference to Siewert type. The median follow-up period for the surviving patients was 37 months. RESULTS: Long-term survival was limited to patients who underwent RO resections (88.6%) with a 5-year survival rate of 28%. Univariate analysis showed Rp, T and pN categories to be significant prognostic factors (P<0.001), with chance of cure limited to patients with less than 6 involved lymph nodes. At multivariate analysis, R category and lymph node involvement were the most important prognostic factors while pT category lost the significance shown at univariate analysis (P=0.082). Siewert classification did not show any prognostic significance (P=0.969), but the mode of recurrence differed for the three Siewert types: in type I tumors, the majority of relapses were haematogenous (67%), while they were prevalently intra-abdominal in type III (65%) with a high rate of peritoneal carcinosis (26%). CONCLUSIONS: The long-term prognosis for GEJ cancer remains poor, independently from Siewert type, with cure limited to patients with less than 6 involved lymph nodes.

[Esophageal non-variceal hemorrhage: a clinical and epidemiological study]. / Le emorragie esofagee non varicose: studio clinico-epidemiologico.

Aim of this study was to evaluate the incidence of esophageal bleeding in a group of 3741 consecutive patients with acute non variceal upper gastrointestinal hemorrhage observed between January 1990 and January 1999 in the First Division of General Surgery--University of Verona. In 627 patients (16.8%) the source of bleeding was exclusively esophageal; and the most frequent causes of esophageal bleeding were reflux esopagitis (408 cases) and Mallory Weiss syndrome (185 cases). At emergency endoscopy, reflux esophagitis was actively bleeding in 83 cases (20.3%) and these patients presented a significantly higher frequency of cirrhosis and severe esophagitis; moreover a higher percentage of patients with bleeding esophagitis have had recent surgery and/or were hospitalized in an intensive care unit. No death directly related to the bleeding were observed, while ten patients deceased from other causes during the hospitalization. In more than half of the 185 patients affected by Mallory-Weiss syndrome a hiatal hernia was described and 69 (37.3%) were alcoholics with associated cirrhosis in 25 cases. In more than 70% of the cases the bleeding from a mucosal tear followed a vomit episode and the lesions were localized at the gastroesophageal junction. Endoscopic sclerotherapy was performed in 89 patients with active bleeding and hemostasis was initially obtained in all patients; rebleeding occurred in 6 patients (6.7%) who needed a further endoscopic treatment. No patients died during hospitalization. Other causes of esophageal bleeding observed were: Candida esophagitis (19 cases), esophageal malignancy (11 cases), benign polyps (2 cases), angiodysplasia (one case) and one case of aorto-esophageal fistula.

Endoscopic treatment of esophageal granular cell tumors.

There are no standard guidelines for the treatment of granular cell tumor (GCT). The aim of our study was to describe three cases of esophageal GCT and, on the basis of our experience, analyze the indications for and results of their endoscopic treatment. When deciding whether to proceed with surgical or endoscopic resection, endosonography plays a key role in establishing whether the tumor is confined to the submucosa. All three cases were confined within the hyperechoic layer of the submucosa and were successfully treated by endoscopic excision without complications or signs of relapse during the follow-up period.

[Peptic ulcer hemorrhage in the elderly]. / Le ulcere gastroduodenali sanguinanti nel paziente anziano.

BACKGROUND: The aim of this study was to investigate the efficacy of endoscopic injection therapy on the clinical outcome of elderly patients with peptic ulcer bleeding. METHODS: From January 1995 to December 1998, 738 patients with acute peptic ulcer bleeding were observed in the First Division of General Surgery, University of Verona: 359 aged <70 years and 379 =/>70 years. History, clinical and endoscopic findings and outcome were prospectively collected and analyzed comparing old (=/>70 yrs) and young (<70 yrs) patients. Ulcers with active or sign of recent bleeding were submitted to injection therapy using epinephrine and 1% polidocanol. RESULTS: Coexisting diseases were significantly more present in the elderly group except for liver cirrhosis that affected preferentially young patients (12.3 versus 4.0%; p<0.001). Endoscopic treatment was performed in a similar percentage between young and elderly patients (respectively 64.9 e 61.5%) and also the rebleeding rate (14.2 versus 13.2) and the mean duration of hospitalisation were not different. The overall mortality was 12.7% in the elderly group and 8.3% in the young group (p=0.04), whereas mortality after surgery was significantly higher in the young group (respectively 57.1 versus 8.3%; p=0.037). CONCLUSIONS: The clinical and endoscopic features and reebleeding rate were not different between elderly and young patients. Patients aged 70 years or older have a higher number of associated medical diseases except for liver cirrhosis conditions and a highest overall mortality whereas the risk of death after surgery is lower than in the younger group.

[Acute hemorrhage caused by duodenal ulcer. Results of endoscopic treatment of the first bleeding episode and of recurrences]. / Emorragia acuta da ulcera duodenale. Risultati del trattamento endoscopico del primo sanguinamento e delle recidive.

BACKGROUND: The aim of this study was to evaluate the impact of immediate endoscopic treatment of bleeding and rebleeding on the clinical outcome of patients with duodenal ulcer hemorrhage. MATERIALS AND METHODS: Between January 1995 and December 1998, 445 patients with bleeding duodenal ulcers were observed in the First Division of General Surgery--University of Verona. All patients, except two who died for hemorrhage before the endoscopic examination, underwent emergency endoscopy within 2 hours from the admission and ulcers with active or sign of recent bleeding were submitted to injection therapy. History, clinical and endoscopic findings, recurrent bleeding and outcome were prospectively collected and analyzed. Recurrent bleeding underwent immediate endoscopic retreatment as first attempt. RESULTS: Endoscopic therapy was performed in 277 patients with active bleeding and hemostasis was initially obtained in all patients except one. Rebleeding occurred in 62 patients (14%) and endoscopic treatment was successful in 85% of first rebleeding and in 58% of the cases with 2 or more rebleeding. Multivariate analysis showed that systolic blood pressure at admission, ulcer size and Forrest classification influenced independently the recurrence rate. The 30 days mortality was 12.2% in the whole series: 35 deaths (9.2%) in the group without recurrence and 19 (30.6%) deaths in the rebleeding group (p = 0.001). Only 22 patients (5%) underwent surgical treatment with a higher mortality compared to not operated patients (36.4% versus 10.9%). CONCLUSIONS: Endoscopic treatment was associated with reductions of the risk of recurrent bleeding and surgery without increasing mortality rate.

[Acute hemorrhage secondary to gastric ulcer. Results of emergency endoscopic treatment in 775 cases]. / Emorragia acuta da ulcera gastrica. Risultati del trattamento endoscopico d'urgenza su 775 casi.

The aim of this study was to investigate the effects of endoscopic injection therapy on the clinical outcome of patients with gastric ulcer bleeding. Seven hundred and seventy-five patients with gastric ulcer bleeding were observed over a 10-year period (January 1990 to May 2000) in the First Division of General Surgery of the University of Verona. The prognostic and therapeutic implications of endoscopic treatment of acute severe gastrointestinal bleeding were analyzed on the basis of medical history and clinical and endoscopic findings. The ulcers were classified according to Forrest's classification of bleeding activity. Endoscopic therapy was performed in 500 patients with active bleeding. Haemostasis was initially obtained in all patients except one. Rebleeding occurred in 13%. All these patients were treated endoscopically at the first attempt. Multivariate analysis revealed that recent surgery, ulcer site and Forrest classification independently influenced the recurrence rate. The mortality of the entire cohort studied was 8.1%. Only 31 patients (4%) underwent surgical treatment with a higher mortality compared to unoperated patients (19.3% vs 7.7%). Endoscopic treatment is a safe procedure with a low mortality and cost, and, if successful, substantially reduces the need for emergency surgery.