The surgical management of acute bowel ischemia in octogenarian patients to avoid Short Bowel Syndrome: a multicenter study.

BACKGROUND: This is a multicenter study performed in two Italian tertiary care centers: General Emergency Surgery Unit at St. Orsola University Teaching Hospital - Bologna and Department of Surgical Sciences at Umberto I University Teaching Hospital - Rome. The aim was to compare the results of different approaches among elderly patients with acute bowel ischemia. METHODS: Sixty-three patients were divided in two groups: 1) DSgroup- 28 patients treated in Vascular Unit and 2) GEgroup- 35 patients treated in Emergency Surgery Unit. RESULTS: Mean age was 80 years, significantly higher for the GEgroup (p<0.001). Gender was predominantly female in both groups, without statistical difference. Pre-operatively, laboratory tests didn't show any difference in white blood cell count, serum lactate levels or serum creatinine among patients, while increase of c-reactive protein was observed in DSgroup with significant difference (p<0.001). The Romamain cause of acute bowel ischemia was embolism in DSgroup (p=0.03) and vascular spasm in GEgroup (p<0.001). On CT scan, bowel loop dilation was present in 58.7% of patients without statistical difference in both groups. The time lapse from diagnosis to operation didn't show significant differences between two groups (mean 349.4 min). Pre-operative heparin therapy was administered in DSgroup more frequently (p< 0.001). Among DS patients, thrombectomy was the most frequent procedure (19 patients) associated with bowel resection in 9 cases. In GEgroup, 22 patients had an explorative laparotomy (p<0.001), 8 had a bowel resection with anastomosis and 5 a bowel resection plus stoma. A second look was required more significantly in DSgroup (p<0.002). Post-operative morbidity affected significantly GEgroup (p=0.02). The 3-day survival was significantly higher in the DSgroup (p< 0.001). At discharge 32 patients (50.8%) were alive, 21 in DSgroup (p< 0.001). Only one patient among both groups (1.6%) developed a short bowel syndrome. CONCLUSIONS: In octogenarian patients with acute bowel ischemia, surgery should be always pursued whenever the interventional radiology is not assessed as a viable option. Both groups of patients showed an excellent outcome in terms of avoiding a short bowel syndrome. A multidisciplinary management by a dedicated team could offer the best results to prevent large intestinal resections.

[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.

Host defense and survival in patients with lung carcinoma.

BACKGROUND: Numerous studies have investigated locoregional immune responses and long term survival in patients with various types of cancer; few have focused on patients with lung carcinoma. The current study was designed to assess the prognostic value of immunomorphologic changes in locoregional lymph nodes and lymphocytic infiltration of primary tumor (LI) in patients who undergo resection for bronchogenic carcinoma. METHODS: In a retrospective analysis, immune responses in locoregional lymph nodes and at primary tumor sites were studied histologically in 172 selected patients. Lymph node morphology was studied according to the system of Cottier et al. Sinus histiocytosis and paracortical lymphoid cell hyperplasia were considered to be cellular immune responses, and follicular hyperplasia of the cortical area was considered to be a humoral reaction. LI was classified with Black's method. The survival rate was estimated by using the Kaplan-Meier product-limit method. The log rank test and the Cox proportional-hazards model were used to determine statistical significance in univariate and multivariate survival analyses. RESULTS: Among the 172 patients, 35.5% had no evident response in regional lymph nodes, 19.8% had a marked cellular response, 11% had a marked humoral response, and 33.7% had a mixed cellular and humoral response. LI was intense in 36.6% of patients and was absent or scarcely evident in 63.4%. A lymph node cellular response and marked LI improved long term survival rates even in patients with regional lymph node metastases. Multivariate analysis identified two independent variables that had high prognostic value: lymph node immunoreactivity and LI. CONCLUSIONS: Lymph node immunoreactivity and LI significantly influence long term survival after curative surgery for patients with carcinoma of the lung and may be useful in stratifying patients for prospective trials of adjuvant treatment, including immunotherapy.

[Muscle metastasis of bronchopulmonary carcinoma]. / Le metastasi muscolari da carcinoma broncopolmonare.

Typical sites of bronchogenic carcinoma metastases are liver, brain, bones or adrenal glands. Rarely and in advanced dissemination phase it could involve the skeletal muscle. Two cases of metastases in the skeletal muscle from bronchogenic carcinoma, one of which revealed this neoplasia, are reported.

Ultrasound guided excisional biopsy of non-palpable breast lesions: technique and preliminary results.

OBJECTIVE: To develop a simple and accurate technique of incisional biopsy under ultrasonographic guidance to aid the histological diagnosis of non-palpable lesions of the breast DESIGN: Open prospective study. SETTING: Teaching hospital, Italy. SUBJECTS: 35 patients who presented to this hospital with 42 non-palpable lesions diagnosed by echography or mammography during 18 month period 1995-1996. INTERVENTIONS: Creation of a pocket in the breast in which the transducer of the ultrasound scanner was inserted to guide the surgeon while an excision biopsy was taken. MAIN OUTCOME MEASURES: Histological diagnosis, and quality of scar. RESULTS: Mean (SD) diameter of the lesions was 11.6 (3.15) mm on the ultrasound scan, that of the biopsy specimens was 18.1 (5.82) mm, and that of the histological specimens 9.7 (3.52) mm. 29 lesions showed fibrocystic mastopathy with apocrine metaplasia, 10 fibroadenomas, 2 invasive ductal carcinoma, and 1 atypical duct hyperplasia. There were no unsightly scars. CONCLUSIONS: We have developed a simple and accurate technique for incisional biopsy under ultrasound control.

[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.

[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.

[Nonpalpable lesions of the breast. A new technique of ultrasound-guided excision biopsy]. / Le lesioni non palpabili della mammella. Una nuova tecnica di biopsia escissionale ecoguidata.

The authors have developed a simple and accurate technique of excisional biopsy for non-palpable breast nodes using an intraoperative sonographic technique. Identification, localization and exeresis of the lesions are guided by means of a sterilized transducer introduced through the surgical wound. The confirmation of the correct biopsy is evaluated by scanning the specimen gowned with a surgical glove and comparing the intra- and postoperative ultrasonographic images. The results of analysis showed that in all cases the altered area was removed with extreme accuracy and the ultrasonography is reliable in identifying pathological or suspicious areas since the dimensions of the lesion measured with the scanner correspond significantly to the dimensions of the lesions when measured histologically.

Prognostic significance of postoperative empyema in lung cancer.

Four hundred sixty patients who had undergone resection for lung cancer, with a minimum follow-up of 10 years, were analyzed retrospectively. Thirty-eight cases developed postoperative empyema. A comparative evaluation of the long-term survival rate was made of two groups: one in which the patients had developed empyema and one in which the patients had developed no empyema complications. The survival rate was estimated by the Kaplan Meyer Product Limit Method. The prognostic significance of empyema and other factors was analyzed by the Log Rank Test, the chi 2 test in homogeneous series of patients and the Cox Hazard Model. Overall, the ten-year survival rate was 23.7% in the empyema group and 15.9% in the control group. After stratification by post-surgical stage, lymphocytic infiltration of primary-tumor (LI), and histological type, no significant differences in survival between the two groups were demonstrated by the Log Rank Test. The same results were found when the survival distribution of the empyema cases was compared with two control groups of patients without empyema, individually paired to the empyema group for Immune Response (LI), post-surgical stage, and histological type. In the end, after multivariate analysis empyema was not shown to be a factor of prognostic significance.

Gastric cancer: prognosis and lymph node reactivity.

OBJECTIVE: To assess the prognostic value of various immunomorphological variables in the prognosis of gastric cancer after curative resection. DESIGN: Retrospective study. SETTING: University hospital, Italy. SUBJECTS: 180 Patients who underwent curative resection for carcinoma of the distal two thirds of stomach between January 1960 and December 1978. Curative was defined as no residual cancer at the resection margins and no distant metastases. INTERVENTIONS: All living patients were followed-up, and missing survival data were obtained from the Official Census Registry. MAIN OUTCOME MEASURES: Correlation between survival and nuclear grade, lymphocytic infiltration, and types of lymph node reaction such as sinus histiocytosis, paracortical lymphoid cellular hyperplasia, and follicular hyperplasia in the cortical area. RESULTS: Crude 5 year and 10 year survival rates were 46% and 36%, respectively. Sex, site, and histological type of the tumour did not correlate with survival. Multivariate analysis showed that only pTNM stage of disease and degree of sinus histiocytosis were significantly related to survival. CONCLUSION: There may be an argument for using the presence or absence of sinus histiocytosis to stratify patients in prospective studies of adjuvant treatment.

[Long-term survival after resection surgery for cancer of the lung in the elderly patient]. / Sopravvivenza a distanza dopo chirurgia di exeresi per cancro del polmone nel paziente anziano.

Five hundred and twenty (520) patients with lung resection for cancer and known follow-up were studied. The aim of the study was to analyse long-term results in relation to the age of the patients. Two hundred and forty (240) cases were less than 55 years old, 227 were aged between 55 and 65 years, 53 were aged over 65 years. Type of lung resection, extent of resection, histological type, Degree of Nuclear Differentiation of primary tumours (NG), Degree of Lymphocytic Infiltration of primary tumours (LI) and Post-Surgical Stage were tested to assay their influence on long-term survival. The data were statistically analysed by the Number Cruncher Statistical System (NCSS 5.5). Univariate (Logrank Test) and multivariate analyses (Cox's Proportional Hazards Model for survival data) were used to test the influence of age and the above-mentioned prognostic factors on survival. The results of the study demonstrated that age doesn't influence long-term prognosis while Post-Surgical Stage (p < 0.00001), NG (p < 0.0001) and LI (p < 0.00001) are related to survival as independent variables. Then patients should not be denied lung resection on the basis of age alone.

[Surgical excision of lung neoplasms in the elderly. Immediate results]. / Chirurgia di exeresi per cancro del polmone negli anziani. Risultati immediati.

The authors have analyzed a series of 807 patients who underwent resection for Bronchogenic Carcinoma at the "I Istituto di Clinica Chirurgica" of the University of Rome "La Sapienza" since 1950. The aim of the search was to evaluate the immediate results of surgical treatment in relation to age of the patients. Seventy-one patients were < 65 years old, 91 patients were older. The incidence of post-operative complications and mortality rate (within the 30th day from surgery) was related to the following risk factors: concomitant pulmonary and extrapulmonary diseases, cigarette smoking, laboratory values (red blood cell count, protein electrophoresis, urea nitrogen, glucose), type of lung resection, extent of resection, histology and post-surgical stage. The rates of post-operative complications and mortality were 34.1% and 27.5% in elderly patients, while in younger patients they were respectively 26.3% and 16.2%. In the elderly, cigarette smoking, cardiovascular diseases, diabetes, renal failure, type of lung resection and extent of resection, were related to an increase of the post-operative complications and mortality rate. In the younger patients, the extent of resection to adjacent structures was the primary risk factor for immediate results. Screenings in elderly and early diagnosis represent the strategy to allow more conservative surgical treatments and reduction of complications and mortality.

[Prognosis and immunomorphological characteristics in rectal cancer: results of a multivariate analysis]. / Prognosi e caratteristiche immunomorfologiche nel cancro del retto: risultati di una analisi multivariata.

The survival advantage of a pronounced lymphocytic infiltration within and around the primary tumor and some hyperplastic reactions in the regional lymph nodes in specimens of colorectal cancer has been reported in many studies. However, none of these studies allowed the grade of these immunomorphological reactivities to compete with more traditional prognostic variables, using the proportional hazard models. In this study the survival rates of 219 patients who underwent operation for rectal cancer were analyzed statistically according to sex, age, tumor site, type of operation, histology, nuclear grade, p-TNM stage of disease and to the following immunomorphological parameters: lymphocytic infiltration (LI) within and around the primary tumor, paracortical activity (PCA), cortical activity (CA) and sinus histiocytosis (SH) of the regional lymph nodes. The presence of an evident local and regional immune reactivity was significantly related to a less advanced stage of disease and better differentiated tumor. The multivariate survival analysis (Cox model) identified LI, PCA and SH and p-TNM stage as independent prognostic factors. Survival within each stage progressively increased in presence of one or more favourable immunomorphologic features. These results indicate that an adequate prospective evaluation of LI, PCA and SH should improve our ability to assess prognosis in rectal cancer and, therefore, allow a more rational utilization of adjuvant therapy.

[The effect of the degree of lymphocytic infiltration on the long-term survival of patients undergoing surgery for the exeresis of gastric cancer]. / L'influenza del grado di infiltrazione linfocitaria sulla sopravvivenza a distanza dei pazienti sottoposti a chirurgia d'exeresi per cancro gastrico.

The predictive value of tumor lymphocytic infiltration was studied in 186 gastric cancer patients curatively resected. All patients were followed-up for over 10 years. LI was negatively correlated with p-TN stage of disease. A poorer prognosis was detected in patients with minor or no tumor lymphocytic infiltration. LI was an independent prognostic parameter according to the Cox model and logistic regression analysis. These findings suggest that LI should also have been considered in the current staging of gastric cancer.

[Surgical day hospital: technical possibilities and organizational model]. / Day hospital in chirurgia: possibilità techniche e modello organizzativo.

The Authors propose an organizational model for a surgical day hospital program, which is being used for a pilot day surgery unit in the I Department of Surgery of the Rome University "La Sapienza". The program requires little capital investment, as it is closely linked, geographically and administratively, to the main surgical unit, and uses the present staff, facilities and support services. The model is based on a computerized LAN (Local Area Network), providing fast recording, scheduling, management and trannsfer of medical data for each patient. The present situation is reported in detail. Data from the authors' outpatient department for 1988, have been recorded and elaborated. The results show a low use of surgical day care, limited to minor surgical procedures, and with not a single operation performed under general anesthesia. The authors hope to see a growth in the use of day surgery and a more selective use of inpatient care.