Palliative surgery for gastric cancer in elderly patients.

Poor survival rate of elderly patients affected by locally advanced or metastatic gastric cancer is related to primary tumour complications. Bleeding is the most important adverse event, other major complications are gastric outlet obstruction and nutritional deprivation. Rarely the patients will perforate the stomach cancer and there is a sudden end to their life; contamination of the ascites result in a rapid death. Thus, an aggressive approach toward palliation of this condition is resection: in this manner the expected survival is approximately one year. Derivation techniques or endoscopic treatments are applied in those patients whose operative risk is inacceptable; in these cases poor median survival is expected. The aim of this report in to refer about the experience in palliative surgery for gastric cancer in the Department of Geriatric Surgery of the University of Padua.

[Bleeding gastric lymphoma: report of two cases]. / Linfoma gastrico sanguinante: descrizione di due casi clinici.

We report two cases of bleeding gastric lymphoma. The stomach is the most common site of primary extranodal Non-Hodgkins Lymphomas. The best treatment for primary gastric lymphoma has not yet been defined. For many years the treatment of choice has been the gastric resection. Helicobacter pylori (H. pylori) has been associated with many gastric pathologies, including gastric lymphoma. Eradication of H. pylori is now considered essential for the treatment of this pathology, and usually consists of antibiotic therapy, combined with acid suppression by a proton pump inhibitor. This simple treatment in patients with low grade histology and tumor confined to the stomach can often obviate the need for surgical intervention. Surgery is a necessary treatment, independently of the grading and the staging of lymphoma, in the bleeding complication as the cases we showed.

[Surgical risk in the elderly]. / Il rischio operatorio nell'anziano.

In our Country 16% of population is over 65 years old and on 2010 a quarter of people will be over 70 years old. More over the percentage of patients over 70 years admitted in surgical departments is triple than 10 years ago and the percentage of octgenarian patients is ten times. In the last years new methods of diagnosis and care have been introduced to reduce morbility and mortality; the preoperative evaluation to define the risk factors is complex. The surgeon should respect some primary points: the patient interest, true surgical treatments, multimodal management, valid pain therapy, discharge as soon as possible, ambulatory or day hospital management, expecting and quality of life.

[Septic shock: surgical and medical problems in the elderly]. / Shock settico: problematiche chirurgiche e mediche nell'anziano.

The sepsis is a bacterial invasion of the organism producing many manifestations which are able to amplify themselves. In the United States of America there are 100,000 death per year and the incidence is among 300,000-500,000 cases. The major surgery in the elder (especially if it is in emergency) has a great percental of risk because the preoperative study isn't often complete. Fever, agitation, panting, bullation, abdominal splinting, enteroplegia, are signals of evolving inflammatory situation. Moreover there are disorders of biochemical values: leukocytosis, thrombocytopenia, increased levels of VES, PCR, amylase and biliribinaemia. The more common radiological examinations are the straight radiography of abdomen and horax, abdomen ultrasonography, CT or MRI. In the last years pro-calcitonin, interleukin-6 , C-reactive protein, and nitric oxide from endothelial and muscularis cells have been evaluated as prognostic factors in the septic shock.

[Treatment of the early form of rectal carcinoma in the elderly]. / Il trattamento delle forme iniziali di carcinoma rettale nell'anziano.

The early rectal cancer which needs conservative surgical treatment should present some pathological characters: intramucosal site without muscularis invasion (pT1), high or moderate differentiated grading (GI-G2), no lymph node metastasis or vascular invasion. Total mesorectal excision is the gold standard for these neoplasms and permits very low resection or colo-anal anastomosis with sphincter function preserving. However, this type of surgery has still a high percentage of postoperative morbidity and mortality (some authors report respectively 40% and 5%). Therefore the local excision in selected cases is able to preserve the sphincter function and to reduce the postoperative complications with high probability of recovery.

[Intestinal infarction in the elderly]. / L'infarto intestinale nell'anziano.

The bowel infarction is till affected by high mortality in spite of new diagnostic methods and therapy. In our experience was observed about 45 patients with bowel infarction by different etiology; fast diagnosis and therapy are necessary for a good prognosis. The arteriography, at the light of this experience, is the gold standard but it is still performed in a low number of patients. The laparoscopy, in the advanced pathologies, is able to avoid an ineffectual laparotomy and permits a better diagnosis in borderline cases.

[Therapeutic strategy in neoplasia of the pancreas and ampulla]. / Strategie terapeutiche nelle neoplasie del pancreas e dell'ampolla.

The major symptoms of periampullary neoplasia are jaundice, lowering of weight, abdominal pain extending behind; diabetes, pancreatitis or exocrine pancreatic failure are uncommon. In the last years, surgery has been considered as the gold standard of the therapy because new technologies are able to reduce morbility and mortality. In the too advanced neoplasia, palliative surgical care permits better survival and quality of life. The duodenopancreatectomy today has a low perioperative mortality (0-3%) and an acceptable survival (15.25%). Good results were found for palliative surgery in unresectable neoplasms while in the inoperable patients we consider endoscopic and radiological treatments better than chemotherapy because they are able to correct the jaundice, improving quality of life (but not survival).

Prevalence of intestinal metaplasia in the distal oesophagus, oesophagogastric junction and gastric cardia in symptomatic patients in north-east Italy: a prospective, descriptive survey. The Italian Ulcer Study Group "GISU".

BACKGROUND: Incidence of adenocarcinoma of distal oesophagus and gastric cardia, probably arising from areas of intestinal metaplasia, has been increasing rapidly. AIMS: To define prevalence of intestinal metaplasia of distal oesophagus, oesophagogastric junction and gastric cardia and to evaluate potential associated factors, by means of a prospective multicentre study including University and teaching hospitals, and primary and tertiary care centres. PATIENTS: Each of 24 institutions involved in study enrolled 10 consecutive patients undergoing first-time routine endoscopy for dyspeptic symptoms. METHODS: Patients answered symptom questionnaires and underwent gastroscopy Three biopsies were taken from distal oesophagus, oesophago-gastric junction and gastric cardia, and were stained with haematoxylin and eosin. Specimens were also evaluated for Helicobacter pylori infection. RESULTS: A total of 240 patients (124 male, 116 female; median age 56 years, range 20-90) were enrolled in study. Intestinal metaplasia affected distal oesophagus in 5, oesophago-gastric junction in 19 and gastric cardia in 10 patients. Low-grade dysplasia was found at distal oesophagus and/or oesophago-gastric junction of 3/24 patients with intestinal metaplasia vs 2/216 without intestinal metaplasia (p<0.05). A significant association was found between symptoms and presence of intestinal metaplasia, regardless of location, and between Helicobacter pylori infection and intestinal metaplasia at oesophago-gastric junction. CONCLUSIONS: Intestinal metaplasia of distal oesophagus, oesophagogastric-junction and gastric cardia is found in a significant proportion of symptomatic patients undergoing gastroscopy and is associated with dysplasia in many cases. Although prevalence of dysplasia seems to decrease when specialized columnar epithelium is found in short segment, or even focally in oesophago-gastric junction, these small foci of intestinal metaplastic cells may represent source of most adenocarcinomas of cardia.

Atrial tachycardia masquerading as atrial flutter following ablation of the subeustachian isthmus.

We report a case of atrial tachycardia masquerading as atrial flutter in a man who had previously undergone catheter ablation for atrial flutter. The recurrent arrhythmia was electrocardiographically almost identical to the prior atrial flutter; at repeat electrophysiologic study, although bidirectional conduction block was observed in the tricuspid annulus-inferior vena caval isthmus, the atrial arrhythmia was readily initiated. Activation mapping suggested typical atrial flutter, but entrainment techniques demonstrated intra-atrial reentry not involving the ablated isthmus. This case illustrates the need to apply entrainment techniques even in cases of apparent "typical" atrial flutter to confirm that putative ablation targets are necessary for tachycardia perpetuation.

[Usefulness of chromogranin A determination in the diagnosis of neuroendocrine neoplasia]. / Utilità del dosaggio della cromogranina A nella diagnosi delle neoplasie neuroendocrine.

Neuroendocrine gastroenteropancreatic tumor diagnosis is a very difficult and expensive procedure. This study compared Chromogranin A (CgA) to Neuron-specific enolase (NSE) in 55 patients affected by neuroendocrine tumors. Advanced local or metastatic neoplasia was found in 43 patients. Radical operation was performed in 12 patients. Seventeen cases of lung microcystoma, 23 cases of other intestinal tumors and 19 patients affected by irritable bowel syndrome were used as controls. CgA sampling demonstrated sensitivity of 73% and specificity of 66%, a positive predictive value of 77% and a negative predictive value of 61% while NSE sampling showed sensitivity of 100%, specificity of 36%, a positive predictive value of 15% and a negative predictive value of 100%. CgA values demonstrated a statistically significant difference between patients with neuroendocrine tumors and tumor-free resected patients (p = 0.0015), microcystoma patients (p = 0.0087), other types of neoplasia (p = 0.01) and irritable bowel syndrome patients (p = 0.0004). No significant difference was found among the same groups when NSE values were analyzed. The high diagnostic accuracy of CgA sampling renders it very useful in early neoplastic detection, even in cases of nonfunctioning neoplasms or absence of liver metastases. In addition, CgA sampling may be an effective screening test in patients with irritable bowel syndrome or with liver or lung metastases when there is no evidence of the primitive tumor.

Clinical evaluation and safety of loxiglumide (CCK-A receptor antagonist) in nonresectable pancreatic cancer patients. Italian Pancreatic Cancer Study Group.

The effects and safety of loxiglumide, a cholecystokinin-A (CCK-A) receptor antagonist, on advanced pancreatic cancer were investigated in humans. A perspective, controlled (2.4 g/day vs. placebo), randomized, double-blind, parallel-group study was performed in 64 patients affected by nonresectable histologically diagnosed pancreatic cancer. The patients were stratified according to sex and stage (A, T3/N0-N1/M0; B, T1-T2-T3/N0-N1/M1; C, relapse after surgical exeresis). Tumor size (by computed tomography scan) and mortality rate were evaluated as efficacy criteria. Clinical symptoms and physical signs, laboratory tests, and adverse reactions were checked every 6 weeks as efficacy/tolerability criteria. Forty-two male and twenty-two female patients were considered. A homogeneous distribution of the patients was demonstrated in the two treatment groups. Group C was not statistically evaluated for survival and tumor evolution because of its small number. Three patients dropped out for causes not related to the therapy. No toxic reactions to the drug were reported. Tumor size monitoring within groups A and B demonstrated a similar increase in both the loxiglumide and the placebo group. Survival in group A was higher than in group B (p = 0.0003). In group B, survival was lower in females (F) than in males (M) (F = 61.00 +/- 6.47 days, M = 140.44 +/- 22.15 days; p = 0.012), while survival by sex was similar in group A and in global analysis. Survival by treatment was similar for groups A and B. Survival by surgery was higher (p = 0.049) for surgical palliation than for nonoperated patients. The tumor grade affected survival but it did not vary by therapy. In conclusion, sure efficacy of loxiglumide in advanced pancreatic cancer was not demonstrated by our results. In consideration of its documented tumor growth inhibiting action, we suggest that loxiglumide be tested for recurrence prevention after resective surgery.

[Breast cancer in elderly women]. / Il carcinoma della mammella nell'anziana.

Breast cancer represents an important epidemiological and clinical problem, and the elderly age represents a large proportion of women with breast cancer. In patients older than 65-year, the frequency of breast cancer is 50% and more. Early diagnosis and adequate therapy may play an important role also in the elderly. We performed a retrospective analysis of 146 women older than 65-year to determine the effect of age in management of the disease.

[Complications of peptic ulcer disease in the elderly]. / Le complicanze della malattia peptica nell'anziano.

Peptic disease is even more described in the elderly patients. Is it different from the young people peptic disease? Is it a specific syndrome? These questions are debated by the authors from their experience about in the old age surgery. In 1997, out of 569 oesophago-gastro-duodenoscopies positive for peptic disease, about 2/5 of the patients were older than 65-year with a high percentage of hypersecretive patients. Also the incidence of complications is similar in the aged and young patients, but their course is much more serious in the elderly. NSAID therapy was not always demonstrated as a determining factor of complications in the elderly. The ulcer perforation is the most serious complication; in the over-70 year aged persons a very severe course is often demonstrated. In conclusion in the elderly a specific diagnostic and therapeutic care is recommended to avoid the high incidence of deadly complications.

[Stomach cancer in the elderly]. / Il cancro gastrico nell'anziano.

Gastric cancer often affect very old patients even if it is not a typical disease of the elderly. The Authors report their experience on 108 patients (mean age of 77.8 years) affected by gastric cancer; early diagnosis and surgical technique are discussed.

[Surgery of inguinal and femoral hernia in the elderly]. / La chirurgia dell'ernia inguinale e crurale nell'anziano.

Old people are continuously increasing in frequency but age is not a significant factor to value the operative risk in hernia surgery. From June 1985 to December 1996, 189 patients, aged > 80-year, were submitted to hernia surgery. No complications were noted when elective surgery was performed. Emergent procedure was undertaken in 7% of the patients major perioperative complications and one death were registered in this group of patients. Mean hospital stay has decreased in the period of the study: was 2.2 days in the last two years. Local anesthesia permitted a day surgery procedure in 60% of cases.

Effect of cholecystokinin analogue caerulein and cholecystokinin antagonist lorglumide on pancreatic carcinogenesis in the rat.

The effects of the cholecystokinin (CCK)-analogue, caerulein, and CCK-receptor antagonist lorglumide (CR-1409) on pancreatic carcinogenesis induced by 7,12-dimethylbenz(a)anthracene (DMBA) were studied. One hundred thirty rats were divided into the following 10 treatment groups: group 1, DMBA (2-3 mg); group 2, DMBA + caerulein (5 micrograms/kg); group 3, DMBA + caerulein + CR-1409 (12 mg/kg); group 4, caerulein + DMBA; group 5, caerulein + CR-1409 + DMBA; group 6, DMBA + CR-1409; group 7, CR-1409 + DMBA; group 8, caerulein; group 9, CR-1409; and group 10, sham operation + saline. DMBA was surgically implanted into the pancreas. Caerulein and/or CR-1409 was administered twice daily for 15 days after (in groups 2, 3, and 6) or before (in groups 4, 5, and 7) DMBA implantation. Six months after carcinogen administration, all rats were sacrificed and autopsied. The incidence of pancreatic cancer appeared significantly (P < 0.001) increased when caerulein was administered following DMBA implantation. CR-1409 significantly inhibited (P < 0.02) caerulein effects and reduced tumor growth when injected after carcinogen exposure.

Cystic neoplasms of the pancreas: problems in differential diagnosis.

From 1970 to 1990 we observed 18 patients with histologically proven pancreatic cystic tumors. The average duration of symptoms prior to diagnosis was 14.1 months. A presumptive diagnosis was made preoperatively in nine patients. CT-guided fine needle cytology performed in three cases correctly showed a benign lesion in one patient and malignancy in two patients. Amylase and tumoral marker levels (CEA, CA19-9) were low in cystic fluid of two patients with cystadenomas who underwent preoperative percutaneous aspiration. Intraoperative biopsy of the cystic wall failed to detect epithelial lining in two cases; one patient had internal drainage for cystadenocarcinoma mistaken for pancreatic pseudocyst. Sixteen patients underwent surgery, two of whom died. Of the seven patients with a malignant condition, resection for cure was performed on three. The preoperative diagnosis of these very rare tumors remains difficult. Fine-needle cytology and cystic fluid examination may be a promising technique, but resection of all suspected lesions, whenever possible, is the procedure of choice for diagnosis and treatment.

Evaluation of surgical risk in palliation and resection of pancreatic cancer. Perspective study and tables to calculate the risk.

High morbidity and mortality rates are reported for bypass and resective surgery of pancreatic cancer. In a retrospective study we correctly predicted the postoperative course in 88% of the patients who underwent bypass surgery and 83% of those who had a resection for pancreatic cancer. Before starting with clinical application of this scoring system, we undertook a prospective study to confirm its predictive value. Sixty-seven consecutive patients with pancreatic cancer were included: 42 patients underwent bypass surgery and 25 pancreatic resections. The operative mortality was 14% for palliative surgery and 0% for resective surgery. Surgical team and nurses were totally unaware of the predicted risk. The preoperative forecast proved to be correct in 81% of bypass surgery and in 88% of resective surgery, although surgical mortality had decreased from 21 to 14% for bypass surgery and from 17 to 0% for resective surgery. Tables are included to calculate the surgical risk for each of 162 combinations of the risk factors considered in the predictive model (81 for bypass surgery and 81 for resective surgery). Calculation of surgical risk is important when evaluating different treatments for pancreatic cancer are available.