Key factors for best control of the systemic leakage during hyperthermic isolated limb perfusion (HILP) in ECC. A critical synthesis of our experience.

The L-PAM-ILP procedures under true hyperthermal regime (41.5-41.8 degrees C) require both close control of the physical parameters of the treatment (temperatures profiles and time duration, artero-venous pressure, perfusate flow rate) and medical rationale (drug, dosage, fractioning, timing). All the above essential procedures must be supported by rigorous methodology, reliable operation of the medical devices and apparatus and real-time monitoring of the treatment parameters. Real-time monitoring is essential for proper trimming and modulation of the parameters during treatment. This paper delineates the technical improvements that we have implemented for drug leakage monitoring and control in the systemic circulation aimed at improving the therapeutic efficacy and at reducing the occurrence of unexpected complications.

Optimal procedure for thermal delivery in hyperthermic/chemotherapeutic treatments in the isolated perfusion of the the limbs.

Isolated locoregional limbs perfusion treatments of various malignancies have demonstrated synergistic efficacy when hyperthermia was associated with chemotherapy. This paper delineates the criteria, the technical provisions and the specifications that have been improved and implemented at our Institution. It is believed that, following the indications offered in this paper, several, apparently still unsolved problems of treatment planning and implementation will be overcome, offering closely controlled and highly reproducible procedures with a significant progress in the feasibility of reliable comparisons of the results among different research centres and in the reduction of the occurrence of controversial results or unexpected complications.

[Complicated colon cancer: the experience at an Operative Surgery Unit]. / Il cancro del colon complicato: esperienza di una Unità Operativa Chirurgica.

INTRODUCTION: Prognosis of colon cancer is worse if complications are present at the moment of diagnosis. The high mortality rate with surgery in emergency in such cases needs a careful reflection about the best suitable operation to perform. MATERIALS AND METHODS: 107 consecutive patients observed along a 9 year-period for colon-rectal cancer are retrospectively analysed. 27 of them were complicated at the presentation for obstruction (19 patients), colon perforation (6 patients) or rectal hemorrhage (2 patients). In the whole experience 5 patients underwent primary resection of the tumour and direct anastomosis; 5 only a decompressive colostomy; 6 were primarily resected and anastomized under the protection of a cecostomy; 6 other patients underwent a Hartmann procedure; 2 were treated with only an intestinal by-pass; 1 was treated with Miles procedure; 1 with an anterior rectal section and the last one was resected-anastomosed in two steps, after a temporary decompressive colostomy. RESULTS: Intraoperative mortality was of 11.1% (3 patients) and morbidity 18.5% (5 patients). General 5 years survival was 62.1% among the cases complicated at presentation. The recurrence rate was 8.45%. Both these figures are below a statistical significance (p = 0.57). CONCLUSIONS: The necessity to treat in emergency the colon cancers reduces the possibility to adopt the best rules of modern programmed oncologic surgery giving up the chemotherapy w/o neoadjuvant radiotherapy with which a preoperative down-staging of the tumour were possible. For these reasons in emergency not only mortality and morbidity are higher than in case of elective surgery, but also metastasization and recurrence are worse because of a more difficult radicality in surgery.

[The treatment of inguinal hernia: experience of a Operative Surgery Unit]. / Il trattamento dell'ernia inguinale: esperienza di una Unità Operativa Chirurgica.

INTRODUCTION: 550 patients submitted to surgical hernia reparation are reviewed for a retrospective analysis. PERSONAL EXPERIENCE: The case report shows a predominance of prosthesis reconstruction according to Trabucco (254 patients) and of the surgical technique of Shouldice (191 patients). Other procedures of the experience refer to the surgical techniques of Bassini (46 patients), Lichtenstein (46 patients), Mugnai/Ferrari (7 patients), Postenski (3 patients), Rives (2 patients), and Stoppa (1 patient). RESULTS: The reconstruction procedure was performed from a number of surgeons, all let free to choice the kind of operation following his personal skill and preference, but always in the most correct technique way. The results were satisfying in terms of short hospital stay, both precocious and late low complications, and always without failure. DISCUSSION: A first consideration is that there is no data from the literature that any prosthesis procedure offers a lower postoperative complication incidence than the Shouldice's technique, and our experience confirms this option. CONCLUSIONS: A surgeon can nowadays freely cultivate his preference for any of the possible procedures in reconstructing an inguinal hernia, but it is highly advisable that all the possibilities, also the pure surgical ones, remain in the surgeon's possibility of choice not to waste a precious previous surgical culture.

Surgical conservative treatment for Bauhin's syndrome.

BACKGROUND AND STUDY AIMS: Hypertrophy of ileocaecal sphincter seems to be the basic etiological factor of Bauhin's valve syndrome (BVS). In the rare literature all cases are treated by means of an hemicolectomy. A patient with Bauhin's valve syndrome is described, whose pathologic characteristics were hypertrophy of ileocaecal sphincter and a circular submucosal lipoma on the caecal side of the valve. Lipomata, although uncommon, may arise throughout the whole gastrointestinal tract, mostly asymptomatic, and submucosal layer is most frequently involved than subserosal one. More than two-thirds of gut lipoma are found in the large bowel, where they represent the most common benign lesion after adenoma. PATIENTS AND METHODS: A 36 year old woman suffering from periodic upper abdominal pain, nausea and diarrhea, was submitted to an explorative surgical procedure, after imaging study of the bowel showed only an indistict mass in the caecum. Though a caecotomy a dissection of an hypertrophic and swollen portion of the ileocaecal valve was performed, saving the ileo-caecal sphincter. The residual mucosal margins were sutured, the last tract of the ileum was fixed to the caecum, completing with a caecorrhaphy and appendectomy. RESULTS: Normal post-operative period, discharging the patient after few days. Since the operation all symptoms disappeared, and after four years there is a total well-being of the patient with complete disappearance of the former symptoms. CONCLUSIONS: If the BVS is only due to a lipomatous hypertrophy of the mucosa and submucosa of ileo-caecal valve, hemicholectomy seems to be not justified: it is an exceedingly invasive procedure for a non-malignant disease. It is important a throughout radiological diagnosis and a caecotomy direct control during an operative exploration for a correct surgical choice.

Chronomodulated infusion of cisplatin, 5-fluorouracil and folinic acid: lack of activity in advanced colorectal cancer.

BACKGROUND: The chronomodulated infusion of 5-FU, FA and oxaliplatin allows a significant increase in dose intensity and antitumor efficacy in patients with metastatic colorectal cancer. Here we investigated if substitution of oxaliplatin with cisplatin produced a similar antitumor activity in previously untreated patients with advanced colorectal cancer. METHODS: We enrolled 21 consecutively evaluated ambulatory patients with metastatic colorectal cancer. Each treatment cycle consisted of a 5-day course of continuous chronomodulated venous infusion of drugs. Daily doses were 600 mg/m2 5-FU, 150 mg/m2 FA (L-form), and 12 mg/m2 cisplatin. The cycles were repeated every 21 days. RESULTS: All patients completed at least 3 cycles. Overall a total number of 105 cycles were administered. One partial response (lasting 3 months) and 13 stable disease (lasting from 3 to 12 months) were observed. The remaining 7 patients had progression of the disease. Hematologic and gastrointestinal toxicity was always < or = G2 in all cycles. CONCLUSIONS: The results of this study discourage the substitution of cisplatin for the more active compound, oxaliplatin, in a chronomodulated schedule of infusion with 5-FU and FA in patients with metastatic colorectal cancer.

A phase II study of neoadjuvant chemotherapy with cisplatin epirubicin and VP-16 for stage III unresectable non-small cell lung cancer.

BACKGROUND: The survival rate for surgically resected stage III N2 non-small cell lung cancer (NSCLC) patients is less than 10%. METHODS: A phase II study of cisplatin, epirubicin, and VP-16 (PEV) was undertaken in an attempt to improve the curative potential of surgery. Forty-one patients with stage III N2 NSCLC received 3 cycles of pEV. Patients with either complete response (CR) or partial response (PR) underwent surgery and 3 additional courses of PEV. RESULTS: The response rate in the whole patient population was 58%. Eighteen patients were resected; twelve resections were complete and 6 were incomplete. Toxicity was mild and consisted mainly of myelosuppression. Twenty-six patients have died, and the median survival of all 41 patients was 18.1 months, with a 3-year survival of 23%. The median survival for those patients who were resected was 27 months with a 3-year survival of 42%. CONCLUSIONS: PEV is an effective low toxic drug combination for limited NSCLC.

[The bronchogenic carcinoma-laryngeal cancer association: the experience of our school]. / L'associazione carcinoma broncogeno-cancro del laringe: esperienza di Scuola.

In a 20 year period (1974-1995), 3451 patients with bronchogenic carcinoma were observed. Retrospective analysis of these cases allowed to study the relationship between primary pulmonary malignancies and laryngeal tumours. In 32 patients synchronous or metachronous carcinoma of the larynx and lung were found. All laryngeal tumours were curable but only fifteen of these second primary lung tumours were successfully treated. None of unresected patients survived beyond 2 years.

[Diagnosis of thoraco-pulmonary disorders: role of videothoracoscopy]. / Diagnostica delle affezioni toraco-polmonari: ruolo della VTS.

Videothoracoscopy can be used for diagnostic purposes when the other non-invasive methods are not satisfactory for an accurate histological diagnosis in lung and pleural pathology. The role of VTS was confirmed in the cases, observed from 1993 and surgically treated, which are herein discussed.

[Inflammatory pseudotumor of the lung]. / Lo pseudotumore infiammatorio del polmone.

An inflammatory pseudotumour of the lung was occasionally observed at radiology and is reported. Such lesions account for 1% of all lung tumours and are frequently asymptomatic; the findings on physical and laboratory examinations are usually nonspecific. Radiographic findings and invasive diagnostic procedures--including bronchoscopy and transthoracic fine needle biopsy--may be not sufficient for histological diagnosis. Surgery is then important for both diagnostic and therapeutic reasons; the treatment of choice is complete but non extensive excision. Radiotherapy should be considered in patients who had incomplete surgical resection or postoperative recurrences and in patients non resectable due to associated medical conditions.

[Intraoperative echography as a therapeutic aid in the treatment of nephrolithiasis]. / Ecografia intraoperatoria quale ausilio terapeutico nel trattamento della litiasi renale.

Intraoperative ultrasonography was performed in 24 patients with intrarenal pelvis or with recurrent or multiple stones. The stones were located by a 22 or 25 gauge needle, manually introduced under ultrasonography: they were then extracted through a small incision performed along the tract of the exploratory needle. This preliminary experience has shown that the real time B-mode intraoperative ultrasound can provide valuable results in urologic surgery.

[Perforations of the colon]. / Le perforazioni del colon.

Perforations of the colon are a difficult problem for any surgeon, due the emergency they represent and the multiple clinical and pathological findings. Personal cases are revised and the opportunity of a case-by-case evaluation and of an eclectic surgical choice are stressed.

[Bronchogenic carcinoma staging: comparison of magnetic resonance/computerized tomography]. / Stadiazione del carcinoma broncogeno: confronto risonanza magnetica/tomografia computerizzata.

The staging of bronchogenic carcinoma is an important factor to select the appropriate treatment. Indeed, the definition of locoregional spread and of hilar and mediastinal node involvement is essential for both correct preoperative assessment and prognostic evaluation of bronchogenic carcinoma. CT and MR imaging are the methods of choice in the evaluation of T and N, even though other techniques--e.g., US and nuclear medicine--can also provide valuable diagnostic information. The authors examined 50 patients with primary bronchogenic carcinoma by means of plain radiographs, CT and MR of the chest. MR and CT findings were compared with surgical results on the basis of TNM classification. In the evaluation of T, sensitivity and specificity were 66% and 88.6%, respectively, for CT and 76% and 92% for MR imaging. No statistically significant differences were found between the two imaging methods (p = 0.19). In the evaluation of N, sensitivity and specificity were 56% and 78%, respectively, for CT and 76% and 88% for MR imaging. A statistically significant difference was found between MR and CT accuracy rates (p = 0.934). CT and MR results were in disagreement especially in the evaluation of hilar lymph nodes. To date, MR imaging cannot be considered a substitute for or a routine adjunct to CT in the staging of bronchogenic carcinoma due to its poor spatial resolution, to the presence of artifacts (especially with high-intensity fields), its cost and limited availability. However, in the evaluation of specific anatomical regions--e.g., the pulmonary apex and the peridiaphragmatic region--MR can provide more diagnostic information than CT thanks to its multiplanarity and better contrast resolution.

[Pericardial and pulmonary vascular involvement]. / L'estensione pericardica e vascolare polmonare.

Over five hundred lung resections were considered, out of a series of 1570 cases of lung cancer. Histology of resected patients resulted squamous (348), adenocarcinoma (107), large cells (21) and small cells carcinoma (37). According to Mountain staging, 41% of patients were related to stage Ist, 12% to the IInd, 40.9% to the IIInd A: in such a group, a special class T3N0M0 was considered, due to the better follow-up observed in such cases. Lobectomies and minor resections were performed in 321 cases, pneumonectomies in 192. An analysis was done of differences in Histology, staging, early mortality, complications and late results after pneumonectomy which was traditional in 117 patients and required an intrapericardial section of great vessels in 68 cases: 16 patients had some pericardial resection, specific ECG disturbances, early mortality and recurrence within five years proved to be higher in the patients who had some pericardial operation: also as far as no connection was recognized with histology, the responsibility of such results can be attributed to the stage, that in those patients required a more aggressive operation.

[Parietal infiltration of the superior vena cava during bronchogenic cancer: problems of treatment]. / Infiltrazione parietale della vena cava superiore in corso di cancro broncogeno: problemi di trattamento.

One case of S.V.C.S. pas observed during surgery for cancer of lung, resection was performed and dacron graft was used. Possibilities of vascular graft in such cases, as well as peculiar situation of emergency which create the opportunity for insertion of synthetic graft were discussed.