[Emergencies in colorectal carcinoma: negative prognostic factor?]. / L'urgenza da carcinoma colorettale fattore prognostico negativo?

The authors analyze a consecutive series of 219 patients affected by complicated colorectal cancer who underwent surgery in emergency. In hospital mortality, 5-year survival and recurrence's incidence in 104 of these patients who underwent curative treatment are calculated and compared with a series of 701 patients who underwent elective surgical treatment. There was no significative statistical difference between emergency and elective group. At the multivariate analysis only the stage of the tumor was an independent prognostic factor.

The treatment of inguinal hernia in the elderly: open technique or laparoscopic approach?

Well defined and shared quality standards characterize the ideal treatment of inguinal hernia: it should be the least traumatic as regards both the requested type of anaesthesia and the operative technique and the least expensive; it should have the least per-and post-operative morbidity. The chosen technique should be also the easiest to learn and to perform; and his positive results should be the most reproducible. While there are a lot of studies about the comparison between open and laparoscopic surgery, the number of the studies about the specific evaluation of the problem in the aged is very limited. Aim of the paper is to aid in evaluation of the problem in a group of patients, on the basis of the reports and on an initial departmental experience. In conclusion the laparoscopic repair is a complementary choice and not an alternative to the open surgery in the elderly patients.

[The multidisciplinary management of acute pancreatitis: a review of 244 cases]. / Il trattamento multidisciplinare della pancreatite acuta: considerazioni su 244 casi.

BACKGROUND: Acute pancreatitis (AP) has still a high mortality rate; therefore the accuracy of the predictors of severity actually employed and the therapeutic choices are under debate. The aim of this work is to valuate the accuracy of the prognostic factors actually employed and the results of a multidisciplinary treatment of the AP. METHODS: A consecutive series of 244 patients affected by AP (168 mild, 76 severe) is analysed. Mean age 64.4 years (range 17-94 years old). As regard as aetiology is concerned, 166 are biliary pancreatitis, 42 alcoholic, 27 idiopathic, 9 iatrogenic. Ranson's score, Balthazar criteria, and ASA are employed to assess the high-risk patients. The treatment is medical and in severe AP the patient is admitted in ICU. 80 patients affected biliary AP undergo an ERCP. An endoscopic papillotomy is performed in 55 cases and in 49 biliary stones are removed. 90 patients underwent a delayed colcistectomy. 11 patients underwent a surgical treatment: 9 for infected necrotic pancreatitis, 1 for a hemorrhagic shock, 1 for peritonitis. The overall mortality, the mortality related to the severity of the AP, the prognostic evaluation of the etiology, the ASA index, the Ranson and Balthazar scores are evaluated. RESULTS: The overall mortality rate is 2.8% (0.6% in the mild AP and 7.8% in the severe AP). In the surgical group the mortality rate is 18.1%. The Ranson's score is the only independent factor in the multivariate analysis (p<0.0374) while also the Balthazar classification is significant in the univariate analysis. CONCLUSION: As regard as the prognostic factors in AP are concerned, the Ranson's score and Balthazar criteria are reliable even if many other predictors of severity are tested to make progress in the early detection of the complications. As regard as the therapy is concerned, the endoscopic papillotomy and the endoscopic removal of the biliary stones is the gold standard in the treatment of the biliary AP. In the other cases of AP medical treatment shall be started as early as possible with intensive care management in the severe AP. In patients with infected pancreatic necrosis or haemorrhage or peritonitis, surgery is the only therapeutic choice while the surgical treatment in case of sterile pancreatic necrosis with MODS unresponsive to medical therapy is still under debate.

[Functional complications of the lower urinary tract after curative exeresis for cancer of the rectum]. / Le complicanze funzionali delle basse vie urinarie dopo exeresi curativa per cancro del retto.

The aim of the study is to assess the incidence and the pathogenesis of urinary dysfunction in the surgical treatment of rectal cancer. A series of 219 patients, who underwent surgery for rectal cancer with normal urinary preoperative function, was submitted to a prospective follow-up for the urinary function. Symptomatic patients in the follow-up were studied by ultrasonography, cystomanometry and pressure-flow electromyography. In the immediate follow-up only 17 patients with urinary dysfunction were observed (14 at stage 2, 2 at stage 3 an1 at stage 4 according Saito classification). Six months later only 8 patients had urinary dysfunction. In 1 of these cases neurogenic bladder requiring catheterization was observed no significative correlation with staging, radiotherapy, size of tumor, surgical technique was observed. Worst functional results were observed in patients who underwent abdomino-perineal resections.

[Preoperative CEA: prognostic significance in colorectal carcinoma]. / CEA preoperatorio: significato prognostico nel carcinoma colo-rettale.

The prognostic meaning of preoperative CEA level and its relation to the other risk factors are still under debate. In 512 patients who underwent surgical treatment for colorectal cancer, CEA preoperative plasma level had been evaluated. The prognostic value of CEA was compared with other prognostic factors and the characteristics of the tumor. There was no significant ratio between CEA overexpression and stage, diameter, grading, ploidy, site and shape of the cancers. As regard as the long-term results are concerned, the patients with normal preoperative CEA levels had a better prognosis. In the Dukes B and C tumors, the level of CEA over the cut off point lets identify a group of patients with high risk whom more aggressive adjuvant therapies and follow up could be addressed to. This study suggests that CEA preoperative is an independent prognostic factor and may be useful in the therapeutic planning.

[Role of intensive follow-up in colorectal cancer surgery patients]. / Ruolo del follow-up intensivo nell'operato per carcinoma colo-rettale.

Authors analyze the role of follow-up after curative resection for colo-rectal cancer. In 129 patients (29.6%) a recurrence was observed, whilst in 6 (1.4%) a metachronous carcinoma was detected by endoscopy. Liver involvement was observed in 59 patients, lung metastasis in 18 and both liver and lung metastasis in 4. In 23 patients local recurrence (LR) was observed and in 25 both LR and liver metastasis were detected. 31 patients (24%) were submitted to surgery and 21 (16.2%) with curative purpose. As far as LR is concerned, 5 patients were operated (10%) with curative purpose and a 5 years survival of 40% was observed. Five years survival in 9 patients submitted to surgery with curative purpose (8.4%) for liver metastasis was 57.1%, whilst in 7 patients operated for lung metastasis (31.8%) it was 76%. All the 6 patients operated for metachronous carcinoma are still alive with a 2-5 years follow-up.

[Indications for splenectomy in the surgical treatment of gastric cancer]. / Indicazioni alla splenectomia nel trattamento chirurgico del cancro gastrico.

The extent of lymphadenectomy in the treatment of gastric cancer is still a matter of debate. Splenectomy, which has to be performed using the common surgical techniques to remove the lymph nodes of the splenic hilus, is part of this problem. The indications for splenectomy in the treatment of gastric cancer are examined, considering the results in terms of operative mortality and morbidity and long term survival. The Authors analyze a consecutive series of 129 patients who underwent total gastrectomy with D2 or D3 lymphadenectomy for gastric cancer. Forty-seven splenectomies were performed among 79 patients submitted to total gastrectomy. Splenectomy did not influence the perioperative mortality. Morbidity was higher in the patients who underwent splenectomy (33.3%) than in the patients without splenectomy (28.12%). This difference was not statistically significant. Five-year survival was higher in the group that did not undergo splenectomy (37.6% vs 27%) without any significant difference. Also considering the results in literature, splenectomy is associated with an increase in morbidity, and, for some authors, also in mortality, without any significant improvement in long-term survival. The indication for splenectomy in gastric cancer is based on an accurate evaluation of the localization and the depth of the parietal infiltration of the tumor.

[Primary hyperparathyroidism: diagnostic and therapeutic trends]. / Iperparatiroidismo primitivo: evoluzione diagnostica e terapeutica.

The most interesting aspects of parathyroid disease are the increased incidence of primary hyperparathyroidism, which nowadays is diagnosed more and more frequently through the casual discovery of hypercalcaemia, the various diagnostic methodologies used, the ongoing debate as to the function of parathyroidectomy in asymptomatic patients and the new video-assisted surgical techniques which have recently been developed. The authors retrospectively review 31 consecutive cases of primary hyperparathyroidism. The clinical onset was characterised in 26 cases by an osteoarthralgic syndrome associated with renal and biliary pathology. Five cases were asymptomatic. Prior to surgery, all patients underwent both biochemical and instrumental tests. MIB scintigraphy was found to yield the most reliable diagnosis, leading to identification of 83.6% of diseased parathyroids. As regards surgical treatment, 29 cases were treated with a simple parathyroidectomy, 1 with a bilateral inferior parathyroidectomy and 1 with a thyroid lobectomy. Associated thyroid surgery was performed in 8 cases for concomitant thyroid disease: 1 total thyroidectomy, 2 subtotal thyroidectomies and 5 lobectomies. In 3 cases radioimmunoguided surgery was used. There were no cases of mortality, and 9.6% of patients presented specific morbidity characterised by some degree of paraesthesia. As stated by other researchers, the authors argue that MIBI scintigraphy is the most reliable test for the diagnosis of hyperparathyroidism and that surgical treatment is the first choice for symptomatic primary hyperparathyroidism. The surgical strategy depends on the abnormality underlying the hyperparathyroidism: in the event off an adenoma, a bilateral exploration of the neck and removal of the diseased parathyroid are required; in the case of hyperplasia, a subtotal parathyroidectomy is necessary with marking of the residual parathyroid which will simplify any possible reoperation; in the event of carcinoma, a thyroid loboisthmectomy and ipsilateral parathyroidectomy are performed with removal of the fatty tissue of the antero-superior mediastinum and ipsilateral cervical functional lymphadenectomy.

[Sigma volvulus: diagnostic and therapeutic features (considerations on 10 cases)]. / Il volvolo del sigma: aspetti diagnostici e terapeutici (considerazioni su 10 casi).

BACKGROUND: Sigmoid volvulus is associated with a high mortality because affects elderly patients who often have severe comorbid conditions that increase their surgical risk. OBJECTIVES: The aim of this study was to evaluate the most common procedures of diagnosis and treatments to obtain better results. METHODS: The clinical presentation, diagnosis and treatment of 10 consecutive patients with sigmoid volvulus are reviewed. Ages ranged from 30 to 93 years. Endoscopic decompression was tried in 6 and was successful in 3 cases. Seven patients had emergency surgery: surgical procedures were resection in 1 case and distortion with sigmoidopexy in 6; two patients had elective surgery after endoscopic decompression: surgical procedure was resection. RESULTS: All patients had abdominal pain. Other symptoms were constant only in the half of the cases. Significant was the correlation between leucocytosis and bowel ischaemia. Plain abdominal radiographs was not specific while sigmoidoscopy was diagnostic in all the cases. Two patients died: one after non operative reduction and another after emergency derotation and sigmoidopexy (operative mortality: 14%). The only complication was an anastomotic fistula. There were no recurrences at the time of follow-up (1-9 years after operation). CONCLUSION: Sigmoid volvulus is difficult to diagnose preoperatively and is associated with a high mortality. It may be diagnosed and treated by sigmoidoscopy followed by elective surgery. The treatment of choice is resection but good choice results can be obtained also with derotation and sigmoidopexy.

[Biliary ileus: diagnosis and therapy]. / L'ileo biliare: aspetti diagnostici e terapeutici.

BACKGROUND: Gallstone ileus represents 1-3% of mechanical obstructions of the bowel. The surgical treatment performed in urgency has a mortality rates of 10-13% because galistone ileus is frequent in the elderly. Some diagnostic and therapeutic problems are debated in this paper. METHODS: 9 cases of gallstone ileus were analysed retrospectively in a series of 736 mechanical obstructions of the bowel submitted to surgery since 1969. The Authors report the clinical and physical data, the laboratory data and the results of the radiological procedures performed (plain abdominal X-ray, abdominal US, CT, MNR). The patients are stratified according to ASA system and the surgical treatment. The accuracy of the diagnostic procedures and the surgical mortality and morbidity are reported. RESULTS: The preoperative diagnosis was correct in 5 patients. History, clinical and laboratory findings are not specific. The plain abdominal X-ray was specific in 1/9 case, Us in 4/9, CT in 2/3, MNR in 1/1. 1 patient was included in ASA 1 class, 3 in ASA 2 class, and 5 in ASA 3 class. Enterolithotomy alone was performed in 3 cases and the one stage treatment (enterolithotomy and bilio-digestive fistula repair) in 6. No patient was submitted to two stage procedure because 2 of the patients submitted to enterolithotomy alone had a neoplastic fistula and 1 had a very high operative risk. No intraoperative mortality was registered. A wound infection developed in 4 patients. None of the patients had a recurrence of gallstone ileus. CONCLUSION: Evidence from this study supports one stage treatment when the diagnosis of gallstone ileus is correct because it is possible to delay the surgery and to perform a preoperative treatment to decrease the operative risk in the elderly. The correct preoperative diagnosis is often difficult but CT and MNR heve an high sensibility and specificity.

Local excision for rectal cancer.

BACKGROUND AND OBJECTIVES: The aim of this retrospective study is to evaluate the results of local excision (LE) for rectal cancer for curative purposes. METHODS: From 1969 to December 1997, a total of 456 operations were performed for surgical treatment of rectal carcinoma (262 males and 194 females, mean age 66 years). Twenty patients (4.1%) underwent LE (7 males and 13 females, median age 65 years). Patients were selected for LE if they met the following criteria during preoperative staging: tumors staged as T1-T2,N0,M0, grading G1 or G2, and accessible location. Types of LE performed were: 13 transanal excisions (Francillon's technique), 2 Mason surgeries, 2 endoscopic excisions, and 3 transanal endoscopic microsurgeries. RESULTS: There was no in-hospital mortality among LE patients. Thirteen tumors were T1 and 7 were T2; all 20 were adenocarcinoma, 14 G1 and 6 G2. There was no specific morbidity, and aspecific morbidity was minimal (5%). There were no local recurrences, but 2 patients (10%) had secondary lesions. Five-year overall survival following LE was 87.4%. Comparing T1 and T2 tumors treated with abdominoperineal resection (APR) and SSR (17 T1 and 42 T2, all adenocarcinoma), in-hospital mortality and specific morbidity were respectively 1.7% (P = 0.55) and 28% (P = 0.007). There were 5 (8.5%) local recurrences (P = 0.17) and 6 (10.2%) metastatic lesions. Five-year overall survival was similar to LE (88.3%; P = 0.76). CONCLUSIONS: LE for rectal carcinoma might only be successfully performed in selected patients with correct preoperative staging. In the LE cases reported five-year overall survival, local recurrence, and in-hospital mortality were similar to APR and SSR, while there was a statistically significant difference following LE in terms of specific morbidity.

[Surgical treatment of differentiated carcinoma of the thyroid. Follow-up of 99 cases]. / Il trattamento chirurgico del carcinoma differenziato della tiroide. Follow-up su 99 casi.

The surgical treatment of differentiated thyroid carcinoma continues to be a matter of considerable debate in terms of defining the appropriate extent of thyroid or lymph node resection to ensure optimal patient survival. Whereas, at organ level, the majority of surgeons are in favor of total thyroidectomy, both the extent and timing of lymphadenectomy remain controversial issues. In the light of this, the Authors have conducted a retrospective study in 99 consecutive patients with differentiated thyroid carcinoma. As regards the distribution of the cancers in terms of TNM staging, 60 were stage I, 27 stage II, 11 stage III and 1 stage 4. Almost all the patients underwent total thyroidectomy. Lymphadenectomy was performed at the same time as thyroidectomy in papillary cancers when the nodes were clinically palpable and at a later date in those cases where the nodes subsequently became palpable at follow-up. The in-hospital mortality was 3% and was unrelated to the operation. The median follow-up was 95.8 months (7.98 years). Sixty-nine patients are still alive (71.8%), 66 of them disease-free (68.7%) and 3 with lymph node metastases (3.1%). Our results and those of other investigators suggest that total thyroidectomy should be the first therapeutic choice in differentiated cancers of the thyroid, but allow us to draw no firm conclusions regarding the controversial issue as to which type of lymphadenectomy can best ensure patient survival. To solve this problem we believe that multicenter randomized trials will be necessary. However, progress in molecular biology and tumor genetics is likely to enable us to identify new prognostic factors which may prove useful when deciding on the most appropriate therapeutic option.

[Surgical therapy of right colon cancer]. / La terapia chirurgica del cancro del colon destro.

The debate about the management of frequent advanced right colon cancer is still opened: the opportunity of extended resections when the surrounding organs or tissues are infiltrated, the lymphadenectomy extension and its role, the possibility of identifying prognostic factors that could be useful to decide adjuvant therapy, the definition of the role of laparoscopy. Considering these problems, we have reviewed a series of 159 operations performed by the Institute of Clinical Surgery of the University of Trieste from 1980. 112 of these operations had a curative goal. The reconstruction of intestinal continuity was carried out manually in 28 cases and with mechanical stapler in 78. As far as the curative resection are concerned, in 89 of them an extended lymphadenectomy was performed (D3), while in 18 cases the lymphadenectomy was limited to the lymph nodes of first and second level due to the general bed conditions of the patient. 27 of the curative exeresis were performed in patients with T4 tumor infiltrating the nearby tissues. Referring to Dukes' classification, 8 were included in stage A, 59 in stage B and 40 in stage C, while as far as the depth of wall infiltration is concerned 2 were categorized as T1, 9 as T2, 69 as T3 and 27 as T4. The overall operative mortality was of 5 patients, the overall morbidity of 14%, that specific of 4.6%. The final incidence of local recurrences was 13.8% for Dukes A cancers, 10.9% for Dukes B and 120.5% for Dukes C (p = 0.0614). Half of the recurrences (50%) occurred in patients with a cancer infiltrating the nearby tissues. The 5 year survival rate for patients with Dukes A lesions was 100%, for patients with Dukes B lesions 73.4% and for Dukes C 52.3% (p = 0.00510). With Cox' multivariate analysis only the stage disease, T and grading showed a significative correlation with the survival rate. Our experience, therefore, suggests the execution of an exeresis with lymphadenectomy D3 in each cases where the local site of the lesion and the general conditions of the patients allow it and an extended exeresis where possible from a technical point of view and when the lymph nodes are involved.

[Management of breast cancer in geriatric age; observations on 164 cases]. / La terapia del cancro della mammella in età geriatrica: considerazioni su 164 casi osservati.

Progressive increasing of the life expectancy and the ever more frequent finding of breast cancer in elderly women have focused the attention on the treatment of this pathology in the elderly women. Today most studies support a more aggressive locoregional and systemic therapy in older patients in good physical condition. Authors analyze retrospectively a series of 164 women with breast cancer aged over 69 years treated with combined modality therapy regarding the stage of disease and the status of the patient. Survival by stage, tumor characteristics, node involvement have been compared with a series of patients less than 70 years treated on the same period. Survival curves were not significantly different between the two groups, except for T1 which showed a better survival in younger patients. Also survival according to node involvement did not show significant differences between the two groups. in conclusion, older women should be treated with the same surgical procedures, according to stage, of the younger patients, if they are not too frail to undergo surgery. Only the definitive results of prospective randomized trials will better define the indications and limits of a further reduction of the extent of surgical excision.

[Extended resection in locally advanced colon cancer]. / Gli interventi allargati nella chirurgia del cancro del colon localmente avanzato.

Colorectal malignant tumors with a mono o multivisceral involvement have a poor prognosis and surgery is the only treatment with a hope to be curative. Aggressive surgical management of locally advanced colo-rectal cancer seems to be justified by good oncological results. At the Institute of Clinica Chirurgica of the University of Trieste 58 extended resections were performed for advanced tumors of colon and rectum. The specific morbidity rate was 24% for standard and 24.1% for extended resections. Operative morality was 15.2%; hystological specimen confirmed in 31 cases neoplastic infiltration of contigous structures. The 5 year survival rate was 38.5% in right colonic tumors and 53.3% in left colonic tumors. The literature favors an aggressive approach when the tumor adhesions are suspected. The excision of adjacent organs, whether or not they are microscopically involved by the tumor, is necessary to avoid leaving potentially curable disease The authors, analyzing their results, have also reported good results by management including resection of the colon and contigous organs if involved. Palliative therapy must be performed only if liver metastases are detected or in those cases when primary resection is not thecnically feable or in patients not able to tolerate the procedure.

[Evaluation of the surgical risk and preparation to major surgical intervention in geriatric surgery]. / La valutazione del rischio operatorio e la preparazione all'intervento di "major surgery" in chirurgia geriatrica.

BACKGROUND: The progress in surgery, anaesthesia, pre and postoperative care improves the number of old patients undergoing major surgery. The preoperative physiologic assessment is very important to identify patients who are at higher risk group and to plan the therapeutical strategics. METHODS: This study has been carried out on 849 patients aged 70 years and over who underwent major surgery; biliary tract surgery in 314 cases, colorectal in 279, gastroesophageal in 144, vascular in 48, jejunal in 32, pulmonary in 13, pancreatic in 11, hepatic in 8. 158 patients underwent urgency surgery. Mortality and morbidity index are related to the age of the patients, the urgency of the treatment, the time required for the operation, the preoperative physiologic assessment. RESULTS: The overall mortality rate was 13.7%: 84 patients died for cardiovascular complications and 32 for pulmonary complications. Mortality rate was 6% after elective surgical treatment and 48% in urgency. The urgency influences considerably the mortality in the group over 80 years than in younger (p < 0.01). The difference in mortality after elective surgery was less significative (p < 0.06). The time required for the operation doesn't influence the mortality rate. CONCLUSION: The authors emphasize that the preoperative physiologic assessment to identify patients at higher risk and an accurate preoperative care may reduce the mortality rate also in patients over 80 years undergoing major surgery. In urgency, when the patients cannot undergo a preoperative assessment and care, the postoperative mortality is higher in the group over 80 years than in younger.

[Surgical treatment of stomach cancer: analysis of our personal experience]. / La terapia chirurgica del cancro dello stomaco: analisi dell'esperienza personale.

The "curative" treatment of gastric carcinoma includes the complete removal of the tumour and of the nodes involved without any macroscopic residual of disease (RO). Out of 326 patients with gastric cancer observed, a series of 114 consecutive patients underwent surgical resection (total gastrectomy or subtotal distal gastrectomy) with D2 or D3 lymphadenectomy. Overall operative mortality was 5.3%. Since 1988 no postoperative death occurred. Overall morbidity was 15.8%, specific morbidity 10.5%, reduced after 1988 to 6.6%. No significant differences in operative mortality and need of blood transfusions were recorded between D2 and D3 lymphadenectomy. Overall 5-year survival was 32%. Univariate and multivariate analysis showed that only T and N stages are significant prognostic factors, whereas tumour location, total or subtotal gastrectomy in antral cancers, extent of lymphadenectomy (D2 vs D3) and histology were not significantly related to survival. Since most studies have clearly shown that T and N stages are the most important prognostic factors in gastric cancer, the present aim should be to plan the extent of surgical resection according to the T and N stages characteristics of the neoplasm.

[Treatment of chronic pancreatitis today: considerations on 133 observed cases]. / Il trattamento della pancreatite cronica oggi: considerazioni su 133 casi osservati.

Aim of the work is to define the present role of surgery in the treatment of chronic pancreatitis and the criteria of choice of procedures. The authors examined retrospectively 133 patients. They analyze the clinical, laboratory and instrumental features on which has been formulated the surgical indications. Patients treated surgically were those who have intractable pain, jaundice, intestinal obstructions and bleeding. The choice of the procedure is based on the seat and type of the anatomo-pathological lesions and on the features of Wirsung's duct. 54 of the 133 patients observed have been treated surgically or with interventional radiology. The authors carried out 19 resections, 30 drainage procedures, 1 pancreatic biopsy, 2 percutaneous drainage, 1 perendoscopic papillotomy. Neither mortality nor morbidity were observed after radiological and endoscopic procedures, while after surgery we observed 3.9% of mortality and 9.4 of total morbidity and 5.6% of specific morbidity, represented by a pancreatic leakage. The long term results were well in the patients who didn't take on alcohol. In conclusion the authors underline that the progresses of the medical treatment and the radiological and endoscopic procedures imply the decrease of number of patients undergoing surgical intervention. They remind that surgery maintain his importance and, when carried out with correct indications, permits to obtain an effective and lasting result of the symptomatology presented by the patient.

[Latero-lateral portocaval anastomosis in the surgical treatment of portal hypertension: evaluation of a mean follow up of 14 years]. / L'anastomosi porto-cava latero-laterale nel trattamento chirurgico dell'ipertensione portale: valutazione su un follow-up medio di 14 anni.

After the enthusiasm given by the new treatment techniques of complicated portal hypertension (sclerotherapy, TIPS and liver transplantation), various authors in the literature are considering the role of derivative surgery in the treatment of this affection, due to their consolidated experiences and with a long term follow-up. The authors analyse their own long experience, regarding 104 side-to-side porto-caval shunt. It has been done a complete follow-up, of 71 patients, for a period lasting from 4 to 20 years from the operation. Intraoperative mortality was 5,7%, global morbidity was 28%. Haemorrhagic recurrence from rupture of oesophageal varices was found in 2 cases (1 soon after and the other 3 months from the operation). 5 years survival was depending from Child score (96% Child A, 66,4 Child B, 25% Child C) and from the ethology of cirrhosis (70% for alcoholic cirrhosis and 80% for post-hepatitis cirrhosis). The survival was anyhow mainly connected with the persistence of alcohol abuse. The EPS appeared or became worse after the operation in 12 patients out of 71 checked (16.7%). It has never made a patient enable to lead an ordinary life. Due to the results of their own experience, the authors underline the efficacy of side-to-side porto-caval shunt in the prevention of the haemorrhagic recurrence from oesophageal rupture. In selected patients, Child A and B, not responding to the endoscopic treatment and in elective operations, the mortality was very well contained with a good prevention even after many years and a very small occurrence of EPS. For all those reasons, the side-to-side porto-caval shunt still keeps its validity also towards the selective shunts that are much more difficult technically and that can't be done on ascitic patients.

[DNA ploidy and cell kinetics in cancer of the rectum]. / DNA-ploidia e cinetica cellulare nel cancro del retto.

The pathological assessment of rectal cancer remained essentially unchanged for 50 years and it is based mainly on Dukes' classification and histological granding. Alternative methods of classifications have also been developed but, actually, Dukes'taging is the most important prognostic factor. The limit of Dukes' classification is the incomplete discrimination between high risk and low risk patients into the same stages. The measurements of cellular DNA content by flow cytometry is emerging as a prognostic aid in many human tumours. Authors analyze on the basis of their experience on 116 curative operations for the cancer of the rectum, the relationship between tumour's features, CEA, symptoms, recurrences, survival, type of operation and DNA flow cytometry. In 100 cases they studied the percentage of cells in "s" phase. (SPF). Samples of flow-cytometry were prepared using paraffin-embedded tumour blocks. The authors didn't find any statistically significant relation among pathological features, staging, ploidy and SPF. Recurrences rate was 16.6% in diploid tumours and 23% in no diploid (p = 0.3). In SPF < 25% it was 18.2% (p = 0.5). 5-year survival was worse in aneuploid patients (p = 0.06). Using Cox' multivariate regression analysis, ploidy has not independent prognostic significance. In conclusion authors consider ploidy a prognostic factor in rectal cancer, but not independent. However, authors conclude that flow cytometry could help in early staging of the disease, especially in preoperative diagnosis. Flow cytometry has a prognostic significance with informations on tumoral biology and could contribute to select patients for adjuvant therapy or different surgical techniques.