The possible role of radiofrequency as complementary treatment of locally advanced gastric cancer.

AIM: The prognosis of locally advanced gastric cancer (T3-T4) is bad. The presence of lymph nodes (N3-N4) or haematogenous metastases (liver, lung) gets worse the evolution; principally the hepatic malignancies are cause of scarce survival. The possible use of a palliative treatment as radiofrequency ablation (the good results are note about the treatment of hepatic malignancies by colo-rectal cancer) is reported in recent series. Therefore we decide to use radiofrequency ablation for the treatment of hepatic metastases by gastric cancer, difficulty treated surgically. MATERIALS AND METHODS: From January 2001 to December 2002, 25 patients affected by hepatic metastases underwent to radiofrequency thermal ablation, 2 of them were affected by gastric adenocarcinoma. Case 1: A.P., 58 year-old man, one year before underwent to subtotal gastric resection according to Billroth II. After repeated postoperative chemotherapy cycles, he presented metastases at IV hepatic segment. The patient underwent to percutaneous radiofrequency ablation. The control CT scan confirmed metastasis disappearance. After three months, a partial recurrence was treated by the alcoholization. Three months after, we observed marked jaundice for multiple diffused metastases, followed by the exitus. Case 2: B.G., 63 year-old man, with advanced gastric adenocarcinoma (T4) at the pylorus and hepatic metastasis at IV segment. The patient underwent to gastrojejunostomy and to intraoperative radiofrequency ablation. Ultrasonography and CT scan controls were performed before discharge. The patient didn't undergo to successive controls. After 7 months, the patient returned with marked jaundice for diffused hepatic metastases; he refused any treatment, and then he died one month after. CONCLUSIONS: Our preliminary results don't show complications related to the intra and peri-operative radiofrequency, with an important increase of the mean survival. The results, limited by poor experience, may indicate the complementary role of the radiofrequency in the palliative treatment of the hepatic metastases by advanced gastric cancer, difficulty treated surgically.

[Liver injuries. Clinico-diagnostic and therapeutic problems]. / I traumi epatici. Problemi clinico-diagnostici e terapeutici.

Out of 116 cases of abdominal trauma observed, 6 (23%) consisted of hepatic lesions. In 2 cases (33.3%) the hepatic lesion was isolated. In the other cases, it was associated with lesions to the diaphragm, duodenum, pancreas or thorax. After emphasis on the gravity of such lesions and the high mortality rate (33.3% in the cases observed) the factors contributing to the extremely gloomy prognosis are discussed and the basic therapeutic approach to injuries of varying gravity is outlined.

[Changes in the levels of reverse triiodothyronine (rT3) during and after surgery of the thyroid gland]. / Variazioni dei livelli di reverse-T3 (rT3) nel corso e dopo interventi chirurgici sulla tiroide.

The thyroid activity of twenty euthyroid patients, with single or multiple "cold" nodules was investigated, with determination of seric T3, T4, reverse-T3 (rT3) and TSH. The blood-drags were performed respectively, during (with seric samples from the inferior thyroid vein ipsilateral to the affected lobe) and after (1, 3 and 7 days) surgery. The results of this study--and particularly the significative decrease of T3 and the rapid rT3 increase, either during or after operation - suggests a condition similar to the described "Low T3 syndrome", as expression of both the stress determined by surgery and the correlated thyroid metabolic "adaptation". The clinical and biochemical euthyroidism, expressed by normal levels of TSH in all the samples, confirm the persistence of normal feed-back mechanism by the diencephalon-hypophysis-thyroid axis, even in stress conditions.

[Cytologic aspiration biopsy in the diagnosis and therapy of solitary cystic nodular thyropathies]. / La cito-biopsia aspirativa nella diagnosi e nella terapia delle tireopatie nodulari cistiche solitarie.

Between January and December 1983, 36 patients with single and benign cystic thyroid nodules underwent fine needle aspiration. They received, after fine needle aspiration, medical treatment (antiinflammatory drugs and L-T4). Clinical and ultrasonographic follow-up was performed either 6 and 18 months after FNA, to evaluate the lesion evolution. The six-month follow-up demonstrated no ultrasonographic signs of cystic lesion in 11 cases (30.6%); a decreased volume in 21 (58.3%) and four recurrences (11.1%), which underwent surgical treatment (lobectomy). In 21 patients with persistent lesions at 18 month follow-up, a cystic reduction in a 79.9% rate was documented. These data suggests the diagnostic importance of FNA and the safety of this method not only to surgical selection of patients, but also to the treatment of benign thyroid cysts.

[Recent advances in surgical therapy of hepatocarcinomas. 5 questions on the exeresis of carcinomas of the cirrhotic liver]. / Recenti progressi nella terapia chirurgica degli epatocarcinomi. Cinque quesiti sulla exeresi dei carcinomi su fegato cirrotico.

The surgical treatment of cancers in cirrhotic liver has two main objectives: 1) to remove the cancer with low mortality and mobility rate; 2) to carry out a radical operation with a survival index of 50% three years after the operation. For this purpose, five queries may contribute to programming the most suitable surgery. 1) What patients can be operated? a) those without abdominal ascitic effusion; b) anicteric patients; c) those with fairly well preserved liver function. 2) What liver cancers can be resected? Mainly those with a single localisation. 3) What investigations offer a picture of the extent of tumoral invasion? a) ultrasonography; b) arteriography with simultaneous injection of Lipiodol and later echography; c) intraoperative echography. 4) What surgical operation should be carried out? Liver resection as "economical" as possible (cirrhotic liver) but at the same time as "radical" as possible (hepatocarcinoma). 5) What results can be expected? a) 5% mortality; b) 30% survival 3 years after operation. As the prognosis of liver cancers in cirrhotic livers is better the more limited are the dimensions of the tumour at the time of operation, only systematic screening of cirrhotic patients by repeated ultrasonography permits their treatment at an earlier stage.

[Spontaneous cholecysto-cutaneous fistula]. / La fistola colecisto-cutanea spontanea.

A recently observed personal case of spontaneous cholecystospontaneous fistula is reported. Factors leading to the relative infrequency of this form in recent years are described, and its rarity is demonstrated by the fact that the case reported was the first to be noted in about 1000 operations on the bile ducts. A brief account of the genesis, diagnosis and treatment of the condition is given. The interest of the case lay in the unusual site of the orifice (epigastrium).

[Hemorrhoidectomy by Arnous and Parnaud's method: its role in the magnitude of postoperative pain]. / L'emorroidectomia secondo Arnous e Parnaud: il suo ruolo sull'entità del dolore post-operatorio.

To evaluate the role of internal sphincterotomy with hemorrhoidectomy on postoperative pain, 50 patients with III and IV degree hemorrhoids were subdivided in two groups. Patients of Ist group underwent classic Milligan-Morgan operation; in the IId group, Arnous-Parnaud's hemorrhoidectomy was performed. Ist group's patients needed analgesic in the immediate postoperative period and during hospital stay until clinic healing. IId group's patients needed analgesic only in the first postoperative hour. No significative differences were seen between two groups about mean hospital stay and both clinic and anatomic healing. Two patients of Ist group developed postoperative stenosis and underwent reoperation. Long-term results were good in the two groups of patients. The effectiveness of sphincterotomy on both postoperative pain and prevention of postoperative stenosis is confirmed.

[Ambulatory hemorrhoidectomy: results of 500 surgical operations]. / L'emorroidectomia ambulatoriale: risultati di 500 interventi chirurgici.

To evaluate the results of outcome hemorrhoidectomy, 500 Ferguson-Khubchandani's operations performed between January 1989 and December 1993, were reviewed. 272 of the patients (54.4%) were males (average age 37 years). In 76.6% of patients haemorrhoids were III degree. After outcome pre-operative study, the patients were operated using local anaesthesia and discharged two hours after the operation. Telephone contact was established with patients until the 6th day after surgery and they were reviewed 7 and 14 days after operation. 320 patients were followed up for 12 months. The results were evaluated on the basis of the following criteria: grading of post-operative pain; complications and late sequelae; grading of patients satisfaction with the surgical operation. 291 patients (39.2%) reported light post-operative pain; in 61 (12.2%) the pain was high and needed multiple analgesic (ketorolac) infusions. Post-operative complications were respectively: haemorrhage (7 cases); perianal abscess (2 cases); transitory gas incontinence (3 cases). Late sequela were: II degree stenosis (2 cases) and return of haemorrhoids (3 cases). In 89.9% of patients results were well satisfactory. 2% of patients were not satisfied with the operation. This study and the literature confirm the technical improvement in hemorrhoidectomy: with the introduction of new antalgic drugs, this procedure is now well established in an ambulatory setting with good results and low cost.

[Diagnostic and therapeutic problems with traumatic lesions of the pancreas]. / Problemi diagnostici e terapeutici delle lesioni traumatiche del pancreas.

The Authors report 6 cases of pancreatic traumas observed from january 1973 to december 1985, among 83 abdominal traumas operated on in the same period. They outline the frequence of associated abdominal lesions, which seems complicate the prognosis of these lesions. Problems of diagnostic approach of these traumas are discussed. The necessity of exeretic treatment in case of parenchimal rupture is stressed.

[Development of suture materials: from the beginning to our day]. / Evoluzione dei materiali di sutura: dalle origini ai nostri giorni.

The history of suture materials from the beginnings to the II World War is reported. In this period, catgut and silk were the most employed sutures. The appearance and successive development of synthetic materials revolutionized the field of surgical sutures. This evolution is still active, to the search of ideal suture line.

[Traumatic lesions of the diaphragm (personal experience)]. / Le lesioni traumatiche del diaframma (esperienza personale).

From 1971 to 1982, 126 blunt thoraco-abdominal trauma were seen: in 9 cases (7,1%), diaphragmatic rupture was present. Automobile accidents were the most frequent cause of diaphragmatic rupture and, in only one case, the injury was single. Diaphragmatic rupture was suspected preoperatively in two patients, who had positive physical and radiologic chest findings. The lesion was seen intraoperatively in the other patients, who underwent surgical operation because of severe intra-abdominal injuries. In the author's experience, roentgenologic examinations and adjuntive studies were not important for diagnosis of diaphragmatic injuries. Surgical treatment depended on entity of associated intra-abdominal and intrathoracic injuries, especially in patients observed during immediate post-traumatic period. Authors conclude that single diaphragmatic injury, generally, give no surgical or prognostic problems. High mortality rate seen in these patients is due to multiple organ involvement.

[Treatment of acute cholecystitis, yesterday and today: the role of diagnostic research]. / Il trattamento della colecistite acuta, ieri ed oggi: ruolo delle indagini diagnostiche.

To evaluate the influence of both ultrasonography and cholescintiscan on the choice of the treatment and prognosis of acute cholecystitis, the authors reviewed their series of 187 patients observed between 1974 and 1985. On the basis of diagnostic investigations employed, two distinct periods are considered, 1974-79 and 1980-85. In the I period, the exact diagnosis of the disease was obtained in 31 patients (26.3 percent) and the treatment was conservative in 81.3 percent of cases and surgical in 18.7 percent. In the II period, the disease was exactly diagnosed in 95.6 percent and all patients underwent surgery. The overall mortality and complication rate was respectively 5.1 percent and 11.8 percent in the I period and 1.1 percent and 5.8 percent in the II period. Authors conclude that ultrasonography and cholescintiscan, arising rapidly to the exact diagnosis of disease, influenced markedly the choice of surgical treatment, improving the prognosis of these patients.

[Acute appendicitis: clinico-diagnostic and therapeutic considerations]. / Appendicite acuta: considerazioni clinico-diagnostiche e terapeutiche.

Since january 1970-december 1982, 58 patients underwent emergently appendectomy for acute appendicitis. 31 (53,4 percent) where males; the average age was 21 +/- 2,3 years (M +/- SEM). The duration of symptoms ranged from 1-6 hours (10,3 percent of cases) to over 48 hours, before the hospital admission (15,4 percent of cases). 27 patients (46,5 percent) had a clinical examination at home by a physician. 21 patients (36,4 percent) came to hospital emergency unit without previous physical examination; 10 (17,2 percent) were transferred from other departments. In 6,9 percent of cases was present a perforated appendicitis with peritonitis. During operation, in 50 percent of patients was performed a therapeutic peritoneal lavage. In 63,7 percent of cases multiple drains were placed in peritoneal cavity. In all patients was effected postoperative antibiotic profilaxis. The mortality rate was 3,4 percent. General complications were observed more in patients with perforated appendicitis. This review suggests the following remarcable data: morbidity of this disease is still high; the physical examination is more important than laboratory work (especially in the elderly patients, which are often immunodepressed and in children, with leucocitosis-lack at hospital admission); early surgery is the most important factor to the improvement of prognosis in these cases and the results of surgical treatment are improved by large vertical incisions, peritoneal lavage and application of multiple intracavitary drains.

[Current orientation in the surgical treatment of cancer of the thyroid]. / Attuali orientamenti nel trattamento chirurgico del cancro della tiroide.

The authors reviewed their series of thyroid cancers and analyzed possible factors of the low incidence of these neoplasms in their experience. They outline the importance of total thyroidectomy which must be performed as soon as possible. Cervical lymphadenectomy must be reserved only to papillary cancers in which intraoperative histologic examination give the evidence of multiple metastasis of cervical nodes.

[Solitary and multiple thyroid nodular pathology (results of 1,300 surgical interventions)]. / Patologia nodulare tiroidea solitaria e multipla (risultati di 1.300 interventi chirurgici).

To evaluate the results of single and multinodular thyropathies surgical treatment, 1.300 cases operated on from january 1974 to december 1987 were reviewed. 842 patients (64.7%) were female; the average age was 41 +/- 2.4 year. Thyroid pathology was represented by solitary nodule in 643 cases (49.4%); multinodular goitre in 559 cases (43.0%) (377 euthyroid, with multinodular lesions extended to the entire gland; 182, hyperthyroid); retrosternal goitre in 78 cases (5.9%); recurrent goitre in 20 cases (1.5%). The patients underwent to: total thyroidectomy (525 cases); subtotal thyroidectomy (132 cases); total lobectomy (322 cases); subtotal lobectomy (321 cases). Post-operative follow-up (clinical exam; T3, T4, TSH, calcemia and phosphatemia) was performed at 3, 6, 12, 18 and 24 months after surgery). The overall mortality was 0.13 percent (two deaths, respectively after total = 0.1% and subtotal thyroidectomy = 0.7%). Immediate postoperative complications were: recurrent palsy (9 cases: 0.6%; acute respiratory failure with temporary tracheostomy (10 cases: 0.7%); hypoparathyroidism (3 cases: 0.2%). Late sequelae (1-3 year) were: recurrent nerve palsy in 7 patients (0.5%); hypoparathyroidism in one case (0.07%). 46 patients (34.8%) which underwent subtotal thyroidectomy were hypothyroid to T3, T4, TSH tests (1 year). Such sub-clinic pathology required levo-thyroxin treatment. New concepts on the pathogenesis of multinodular goitre (growth autonomy of goitre human tissue; the lack of levo-thyroxin therapy to prevent relapses after subtotal thyroidectomy) and the results drawed from the revision of this series seems confirm the indication to lobectomy for solitary "cold" nodules and thyroidectomy for treatment of normo and hyperthyroid multinodular goitre.

[Proctologic day-surgery. Results of 2000 surgical interventions]. / Chirurgia proctologica in day-surgery. Risultati di 2000 interventi chirurgici.

The aim of the study was the evaluate of results of 2000 surgical operations for ano-rectal disease performed in the day-surgery setting (7-24 hours hospital stay) with improvement of both cost effectiveness and patient comfort. From January 1980 to December 1998, 2000 patients underwent surgical operations: 1011 for haemorrhoids; 708 for anal fissure; 172 for fistula in ano; 80 for pylonidal disease; and 45 for anal stenosis. 97.6% of patients were operated on with loco-regional anaesthesia; the others with narcosis and peripheral anaesthesia. The hospital-stay was 24 hours in 697 patients (34.5%), while 1319 (65.5%) operated on under loco-regional anaesthesia were hospitalised for 7-10 hours. Three patients (0.2%) developed acute hemorrhage after hemorroidectomy during the immediate postoperative period. They underwent reintervention under general anaesthesia with a hospital stay of 7 days. Four patients (0.6%) with perianal abscess after internal sphincterotomy underwent incision 10 days after the operation. Two patients with perianal hematoma after sphincterotomy prolonged the hospital stay for three days. In 1048 patients (51.9%) clinical recovery was observed at first follow-up (7 days); 48% had recovered at the 2nd follow-up (14 days). In 1608 patients (98%) anatomical recovery was observed at the follow-up three months after surgery. Patient satisfaction 6 month after operation was high in 79%; good in 27%; low in 1%. These results seems confirm the feasibility of proctological day surgery in almost all patients, with both a considerably cost reduction and enhanced patient comfort and compliance.

[Current facts on ulcer disease]. / Attualità in tema di malattia ulcerosa.

In the second half of this century, some important changes characterized the peptic ulcer history. The overall incidence of ulcer disease markedly decreased, with some differences in the various geographic areas and according to socioeconomic development of population. Peptic ulcer seems now more frequent in women and in the elderly patients, in comparison with the past. The appearance of H2-Receptor Antagonists determined a decline of ulcer surgery, because the ulcer is become a medical disease. Pyloric stenosis also, after ten years of H2-Receptor Antagonists treatment, markedly decreased. Indeed, the problem of acute complications is still actual. The detailed analysis of patients hospitalized, shows significative decrease of acute complications in patients with chronic ulcer and a marked anamnestics. The efficacy of medical treatment in the control of acute ulcer complications, seems to be balanced with new etiopathogenetic factors, which are able to start the appearance of acute complications of the disease (increased assumption of ulcerogenic drugs; smoke and alcohol abuse; increased socio-politic engagement of women and improved resuscitations technics).

[The surgical treatment of Zenker's diverticula by stapler diverticulectomy and myotomy under local anesthesia]. / Trattamento chirurgico dei diverticoli di Zenker mediante diverticolectomia meccanica e miotomia, in anestesia locale.

From 1990 to 1997, 12 patients with Zenker's diverticulum underwent TA 30-stapler diverticulectomy and cricopharyngeal myotomy. All patients were operated on under local anaesthesia. No death was observed. In two cases subcutaneous infection was drained with recovery. No post-operative fistulas were observed with radiologic control. At 6 months follow-up all patients were well. Advantages of both stapler diverticulectomy and local anesthesia are outlined.

[Nodular thyreopathies. Results of 1300 operations]. / Thyréopathies nodulaires. Les résultats de 1300 interventions.

To evaluate the results of surgery for nodular thyreopathies, 1300 cases operated on from January 1974 to December 1987 were reviewed. 842 patients (64.7%) were female; the average age, 41 +/- 2.4 year. Thyroid pathology was represented by solitary nodule in 643 cases (49.4%); multinodular goitre in 559 cases (43.0%) (377 euthyroid and 182 hyperthyroid patients); retrosternal in 78 cases (5.9%); recurrent goitre in 20 cases (1.5%). The patients underwent total thyroidectomy (525 cases); sub-total thyroidectomy (132 cases); total lobectomy (643 cases). Post-operative follow-up (clinical exam; T3, T4, tsh analysis); was performed at 3, 6, 12 and 24 months. The overall mortality rate was 0.13 percent (two deaths, respectively after total-0.1% - and sub-total thyroidectomy-0.7%). Immediate post-operative complications were: recurrent palsy (9 cases, 0.6%); acute respiratory failure (2 cases, 0.7%); hypoparathyroidism (3 cases, 0.2%). Late sequelae (1-3 year) were recurrent nerve palsy in 7 patients (0.5%); hypoparathyroidism in one case (0.07%). 46 patients which underwent sub-total thyroidectomy were hypothyroid to T3, T4, TSH analysis and required thyroxine support treatment. New concepts on the pathogenesis of multinodular goitre (growth autonomy of goitre human tissue; failure of thyreosuppressive therapy to prevent relapses after sub-total thyroidectomy) and the results of this review of 1300 interventions seems confirm the indication to total thyroidectomy in the treatment of both euthyroid and toxic multinodular goitre.

[Cholelithiasis and peptic ulcer surgery. Personal experience (author's transl)]. / Lithiase vésiculaire et interventions chirurgicales pour ulcère gastro-duodénal. Expérience personnelle.

In veiw of the interest represented by the possible development of cholelithiasis after peptic ulcer surgery, the authors report their results in 848 patients undergoing surgery for peptic ulcer, 521 were followed up in order to determine whether the biliary complication developed and in how many cases. They conclude that their results showed nothing which might support the possibility of the development of cholelithiasis after any from of surgery for peptic ulcer.