Curative gastric resection for the elderly patients suffering from gastric cancer.

The improvement of the socio-economic conditions and the progress of medicine have extended the life span of the world's population and as a result, the number of patients with malignant neoplasms has increased. Gastric cancer is the third most common cancer (after lung and prostate) and the second leading cause of death caused by cancer (after lung bronchogenic cell carcinoma) in males; while it's the fifth cancer by frequency and the fourth cause of cancer death in females. It presents a peculiar geographical distribution with a lower incidence in Western Europe and North America, and higher incidence in the Far East, South America and Eastern Europe. Its incidence in Italy is 122 cases per 100000 inhabitants in males and 83 cases per 100000 inhabitants in females (in Italy). It occurs more frequently in old age, is quite rare in individuals under the age of 45. The aim of this work is to analyze the clinical and pathological characteristics of gastric carcinoma and the feasibility of curative surgery in patients over 75, identifying the factors affecting mortality, morbidity, survival and quality of life after surgery. These data have been compared with those of younger patients to assess the correct type of surgery.

Pancreas divisum: correlation between anatomical abnormalities and bile precipitation in the gallbladder in seven patients.

Pancreas divisum is a genetic defect associated with recurrent acute pancreatitis due to insufficient drainage of the accessory pancreatic duct. Seven young patients diagnosed with pancreatic divisum and thickening of the gallbladder bile as shown on magnetic resonance cholangio-pancreatography without pancreatic ductal changes underwent laparoscopic cholecystectomy. During the mean follow-up of 32 months no episode of pancreatitis was reported. There is an association between PD and higher concentration of bile in the gallbladder. Cholecystectomy can be considered curative in patients with PD in the absence of indications for major surgery.

Linear versus volumetric CT analysis in predicting tension-free fascial closure in abdominal wall reconstruction.

BACKGROUND: Improved outcomes of abdominal wall reconstruction (AWR) have been shown when tension-free fascial closure (TFFC) is achieved. Our objective was to determine the clinical and radiologic predictors of TFFC in patients undergoing AWR. STUDY DESIGN: We conducted a single institution retrospective cohort study of adults who underwent AWR between 2007 and 2018. Demographics, hernia characteristics and operative data were collected. Linear and volumetric variables were obtained from preoperative abdominal CT scans, the latter following 3D reconstruction. Logistic regression was used to evaluate predictors of TFFC. Area under the curve (AUC) ≥ 0.70 was considered to have acceptable discrimination. RESULTS: A total of 108 patients were eligible for analysis. The mean age was 57 ± 11 years and 53 (49%) were female. 42 (39%) hernias were recurrent, 10 (9%) patients had a stoma and 9 (8%) had a history of open abdomen. The mean defect width was 11 ± 4 cm and mean defect surface area was 150 ± 95 cm2. The most common AWR technique was endoscopic component separation 75 (69%). TFFC was achieved in 90 (83%) patients. No demographics or 3D volumetric measures were predictive of TFFC (all AUC < 0.7). European hernia society (EHS) class M1 was predictive of failure of TFFC [AUC = 0.70; odds ratio 7.0 (referent M3); 95% confidence interval, 2.1-23.8]. Linear variables of rectus muscle separation were the most predictive of TFFC (AUC 0.73-0.77). CONCLUSION: In contrast to clinical characteristics, radiologic characteristics of large incisional hernias requiring AWR are predictive of TFFC. In particular, EHS class M1 and linear variables of rectus muscle separation appear to be better predictors of TFFC than volumetric measurements.

The role of hypoxic stop-flow perfusion and high dose chemotherapy in the treatment of regionally advanced colorectal cancer.

The primary or secondary forms of colorectal cancers involving local structures or spreading in the abdomen or pelvic area without extra-regional metastases are identified as regionally advanced colorectal cancers (RACRC). They are unresectable and thus radiotherapy and chemotherapy are the fundamental treatment methods. However, these regimens have failed to check the diffusion of tumor satisfactorily in most forms of RACRC. The abdominal and pelvic regions can be isolated from corporal circulation by temporary occlusion of the aorta and cava and perfused with high doses of chemotherapeutic drugs. The hypoxic abdominal or pelvic stop-flow method for delivering high-dose antiblastic agents to these body districts to avoid toxicity by chemofiltration has been suggested. This study examines the possibility of using this method to treat various forms of RACRC.

[Immunomorphology of lymph nodes and prognosis in lung cancer]. / Immunomorfologia linfonodale e prognosi nel cancro del polmone.

BACKGROUND: Many studies have investigated locoregional immune responses and long-term survival in various types of cancer; few have focused on lung cancer. This study was designed to assess the prognostic value of immunomorphologic changes in locoregional lymph nodes in patients resected for bronchogenic carcinoma. METHODS: In a retrospective analysis, immune responses in locoregional lymph nodes were studied histologically in 172 selected patients. Lymph node morphology was studied according to the system of Cottier et al.: sinus histiocytosis (SH) and paracortical lymphoid cell hyperplasia (PCA) were considered as a cellular immune response, and follicular hyperplasia of the cortical area (CA) as a humoral reaction. The survival rate was estimated by the Kaplan-Meier product-limit method. Log-rank test and Cox proportional-hazards model were used to determine statistical significance in univariate and multivariate survival analysis. RESULTS: 35.5% of the patients had no evident response in regional nodes; 19.8% had a marked cellular response; 11% a marked humoral response; and 33.7% a mixed cellular-humoral response. A nodal cellular response improved long-term survival rates even in patients with regional node metastases. Multivariate analysis identified an independent variable as having high prognostic value: lymph node immunoreactivity. CONCLUSIONS: Lymph node immunoreactivity significantly influences long-term survival after curative surgery for lung cancer and may be useful in stratifying patients for prospective trials of adjuvant treatment including immunotherapy.

[Radical surgery and loco-regional chemotherapy in the treatment of liver metastases of stomach and colorectal cancer]. / Chirurgia di exeresi e chemioterapia loco-regionale nel trattamento delle metastasi epatiche da cancro dello stomaco e del colon retto.

The results of surgical treatment of hepatic metastasis from stomach and colo-rectal cancer in a series of 28 patients have been assessed. 21 cases were subjected to hepatic resection (stomach cancer: 7 cases; colorectal: 14 cases) and 7 underwent locoregional chemotherapy through the gastroduodenal artery with fully implantable catheters (stomach ca.: 1 case; colorectal ca.: 6 cases). Of patients who underwent hepatic resection, 3 died postoperatively and 4 are still alive 5 years after the operation. Of the 7 patients treated with locoregional chemotherapy, 4 can be evaluated: 2 responded to treatment, 1 stabilised and 1 progressed. Clinically noteworthy toxicity was observed in one patient only.

[Ambulatory treatment of hemorrhoidal pathology with elastic bands according to a modified Barron technique]. / Il trattamento ambulatoriale della patologia emorroidaria con legature elastiche secondo la tecnica di Barron modificata.

The authors report their experience in the treatment of hemorrhoids by rubber band ligation according to Barron's modified technique which foresees that the ligation is performed thanks to the suction of the hemorrhoidal node through the shaft of the band applicator connected with an aspirator. Eighty-four patients underwent consecutively this treatment over a 18-month period; all were performed with a minimum follow-up of 6 months. Forty male patients (mean age 46.6 years) showed symptoms lasting since 9 years. Forty-four female patients (mean age 42.6 years) showed such pathology since 8.9 years. 70.2% of the patients were classified as III stage of disease, 19% II stage and 10.7% I stage. Thirty-four patients had anal pain, 49 bleeding, 5 anemia, 21 thrombosis of the hemorrhoidal plexus, 54 prolapse of the ano-rectal mucosa. These symptoms and signs were present in most of the patients contemporaneously. Three patients had previously received rubber band ligations, 4 hemorrhoidectomy, 1 sclerotherapy and 1 rubber band ligation and sclerotherapy. In the whole we performed 285 sessions and 304 rubber band ligations. Each treatment consisted of 3.4 sessions and 3.6 rubber band ligations. Recovery was achieved with only one session in 9 patients; 66.7% of them showed 1st degree disease. Multiple sessions were necessary in patients with advanced disease degree; 100% at stage II and 94.9% at stage III. Sixty-five patients did not refer immediate and long-term significant complications. The remaining patients complained during the first hours about heavy feeling and/or tenesmus and two, 2 weeks after the end of treatment, showed bleeding episodes, which cleared up spontaneously. In 5 cases it was necessary, during follow-up, to carry out a completion rubber band ligation and in 3 we performed trimming surgery at the out-patients' department by resection of the exceeding skin and anal mucosa. The technique enables to achieve results just as valid as those of traditional methods in the treatment of hemorrhoidal pathology with the advantage that it can be performed in an out-patient's department, it does not need local anesthesia, it enables the patient to immediately return to his normal working activity and, restricted to the observation period (6- and 12-month follow-up) it allows a satisfactory control of the disease.

[Totally implantable systems in oncology: the cephalic vein as an elective access port]. / Sistemi totalmente impiantabili in oncologia: la vena cefalica come via d'accesso di elezione.

The use of totally implantable systems (TIS) has noticeably reduced risks and enhanced quality of life for cancer patients undergoing long-term chemotherapy. One aspect remains open to discussion: site of venous access and placement procedure. Opinions are divided between two techniques: percutaneous access by direct puncture of the subclavian vein or surgical access through the veins afferent to the subclavian: the cephalic, the jugular, or other minor veins. We report our experience with 63 patients undergoing surgical placement of TIS through the cephalic vein. The operatory procedure is divided into four phases: 1) Preparation of vein and cannulation; 2) X-ray control; 3) creation of subcutaneous sheath; 4) reconstruction. None of the 63 patients developed immediate complications. 46 patients are currently using TIS for a period ranging from 17 to 1862 days. 16 patients died during the time their TIS was in place. In only one patient was the TIS removed after treatment was completed. From our results it is clear that the surgical access through the cephalic vein is the most reliable method of TIS placement, with fewer risks concerning immediate and post operatory complications.

[The use of laser through thoracoscopy in the treatment of spontaneous pneumothorax. Presentation of a clinical case]. / L'impiego del laser per via toracoscopica nel trattamento del pneumatorace spontaneo. Presentazione di un caso clinico.

The authors present the case of a patient with right plurirecidive pneumothorax. During the 12 months before the operation the patient suffered from 3 episodes of pneumothorax, treated with the insertion of an intrapleural drainage. Preoperative exams showed the presence of multiple emphysematous blebs with diameter ranging from 0.5 cm to 3 cm. The patient was treated with Nd:YAG laser photocoagulation of the blebs and mechanical abrasion of the parietal pleura through thoracoscopy. The laser photocoagulation of the blebs was performed using the contact technique and a 25 Watt power. After operation a TX of the thorax, using the high resolution technique, showed the presence of residual blebs involving the apex and the mediastinal surface of the inferior lobe of the right lung. After a 12 month follow-up no recidive pneumothorax occurred and the general conditions of the patient were good. The authors state that the laser treatment of spontaneous pneumothorax secondary to bullous emphysema is effective and safe and it is also successful in patients with multiple blebs. As it is often difficult to find and treat all the blebs, it may be useful to perform thoracography during thoracoscopy.

[Age as a prognostic factor following excisional surgery for colorectal cancer]. / L'età come fattore prognostico dopo chirurgia di exeresi per cancro del colon retto.

On a series of 369 patients with colorectal cancer who underwent curative resections at the I Instituto di Clinica Chirurgica della Università "La Sapienza" of Rome between 1960 and 1980, age was related to survival. All patients were followed for a minimum of ten years; 79 of them were aged over 65 years and 290 under at the time of the operation. The survival was correlated to the age and to other prognostic parameters: post surgical stage (TNM UICC classification) degree of differentiation of the tumour (NG--Black classification), degree of lymphocytic infiltration of neoplasm (LI Black classification) as expression of immunological immune-response of the host. Patients less than 65 years old had a better survival than patients greater than = 65 years old (median survival 72 months and 44 months respectively) (p = 0.006). These differences where true in subgroups with stage 2 of disease (p TNM UICC) and a favourable immunological reactivity (LI greater than = 2). These results suggest a possible independent role of age in defining the outcome of patients with colorectal cancer.