Giant fibrovascular polyp of the esophagus.

Giant fibrovascular polyps are uncommon benign esophageal tumors almost always originating from the cervical esophagus, frequently from the upper esophageal sphincter. The case of a 74-year-old man with a long history of dysphagia and a weight loss of 9 kg is presented. Neither barium esophagogram, computed tomogram or magnetic resonance imaging correctly evidenced the lesion. Only fiberoptic endoscopy suggested the correct diagnosis because the mass fluctuated endoluminally with the spasm of vomiting. A left cervical exploratory incision with esophagotomy was performed following the experience of two previous similar cases. A giant fibrovascular polyp was observed and excised. If a malignant or benign extensive intramural tumor had been identified, a total esophagectomy would have been performed. In our opinion the possibility of the presence of a fibrovascular polyp should always be considered in the presence of an undetermined esophageal mass, and in these cases a left cervical incision is the preferred surgical access. Once the correct diagnosis is established, a major esophageal resection should always be avoided.

[The choice of surgical therapy in adenocarcinoma of the cardia]. / La scelta della terapia chirurgica nell'adenocarcinoma del cardias.

AIM: From 1996 the adenocarcinoma of the esophago-gastric junction (AEG) is divided into 3 types according to Siewert's classification. For AEG type I and III the surgical treatment is codified, while for type II is still controversial. The aim of our study is to understand what is the better surgical treatment for AEG type II. METHODS: From 1990 to 2002 we have performed 111 resections for adenocarcinoma of the cardia: 25 for AEG type I (all esophago-gastric resection), 39 for type II (22 esophago-gastric resection, 17 extended total gastrectomy with esophageal resection) and 47 for type III (8 esophago-gastric resection, 39 extended total gastrectomy with esophageal resection). RESULTS: The morbidity and mortality rates are 17 and 5.4%, without significant difference between the different surgical treatment (p>0.01). The 5 year survival rate is 35%. Significant prognostic factors are the staging TNM (p=0.002) and principally the presence of metastatic lymph nodes (p=0.001). For AEG type II any significant difference in survival is associated with surgical strategy, also in early stage (p>0.01). CONCLUSIONS: According to the results of our study and those of the other authors, who have showed that a 10 cm distance of the neoplasm by the gastric side and the esophageal one could assure oncologic radicality and also that metastatic lymph nodes below pylorus and near greater curvature are uncommon, we can consider esophago-gastric resection for AEG II a speedy, safe and oncologically correct surgical treatment.

Acute hyperparathyroidism: our experience with 36 cases.

OBJECTIVES: Acute hypercalcemia is a serious condition and represents a physician-surgical emergency: the difficulty in setting a precise diagnosis is due to several possibilities that can cause the condition. It is our purpose to critically evaluate the most actual schemes of treatment and the conditions that could favour the appearance of a hypercalcemic acute crisis. MATERIALS AND METHODS: A retrospective study was performed considering 1321 patients (638 primary HPT, 683 secondary or tertiary HPT) operated from 1975 to December 2002 for Primary, Secondary and Tertiary HPT. RESULTS: It should be noticed that out of 638 cases of Primary HPT this syndrome was present in 35 patients (Ca higher than 15 mg/dl): if you compare these cases with the hyperparathyroid population with calcium less than 15 mg/dl it is possible to observe that a double adenoma or a carcinoma were more frequently found in acute HPT, as the cystic appearance of the lesion. The weight of the adenoma and the PTH assay are strictly correlated with the appearance of this syndrome. The mortality rate is also higher (2.8% to 0.1%) than in the hyperparathyroid patient who underwent parathyroidectomy without hypercalcemic crisis. CONCLUSION: These characteristics suggest that an early operation is mandatory in the patients in whom such a possibility could be expected, before serious involvement of the cardiovascular, renal or neuromuscular system. We can point out the rarity of this syndrome in Secondary and Tertiary HPT: just one case in Secondary out of 683 patients operated on from 1975 until December 2002.

[Adenocarcinoma of the cardia: surgical strategies compared]. / Adenocarcinoma del cardias: strategie chirurgiche a confronto.

BACKGROUND: The incidence of adenocarcinoma of the cardia is increasing. The choice of surgical strategy for AEG type II of Siewert classification is the subjects of controversial discussion. The aim of our retrospective study is to analyse the surgical results in 12 years. MATERIAL AND METHODS: Since 1990 to 2002, 111 patients underwent resection for adenocarcinoma of the cardia at III Division of General Surgery, University of Turin. Twenty-five patients had AEG type I, 39 had type II and 47 type III. Transthoracic or transhiatal oesophagectomy with resection of the proximal stomach were performed in 55 cases and extended total gastrectomy with transthoracic or transhiatal oesophagectomy in 56. RESULTS: The morbidity and mortality rates are 17% and 5.4%. The 5 years survival rate is poor (35%) for all Siewert type. Survival is significantly associated with stage and the presence of lymph node metastasis, but not correlated with Siewert classification and surgical approach. Also in the AEG II the survival is not modified by the surgical approach. CONCLUSION: In patient with AEG I the therapy of choice is a radical transthoracic or transhiatal oesophagectomy with resection of the proximal stomach. For type III extended total gastrectomy with transthoracic or transhiatal oesophagectomy is the procedure of choice. The superiority of the thoracoabdominal approach is therefore evident in terms of oncologic radicality. Survival is similar in AEG type II patients for both operations. A oesophagectomy with proximal gastric resection should be adopted for these tumors as the standard procedure in the majority of cases.

[Continuous brachial plexus blockade for shoulder surgery]. / Il blocco continuo del plesso brachiale per la chirurgia della spalla.

Continuous brachial plexus block is the technique of choice for postoperative shoulder pain treatment. The localization of the plexus is usually obtained drawing landmarks on the skin and using the electrical nerve stimulator; these and other different modalities are applied in order to reach safely and precisely nerve roots to be blocked with an anaesthetic solution. The Author presents a new anatomical perspective to guide the localization of the brachial plexus. It is shown how it is possible to detect the pathway of the brachial plexus from the cutaneous surface, linking between each other various landmarks: a) the apex of the scalene triangle, at the cross of a line leaving from the cricoid process and directed posterior to the posterior border of the sternocleidomastoid muscle, b) the midline of the clavicle c)the deltoid-pectoral sulcus d) the midpoint between the coracoid process and the chest profile e) the pulsation of the artery in the axylla. Following the guide of the so formed anesthetic line, is possible to place the needle, with a direction from distal to proximal, in a tangential route towards the interscalenic groove, thus allowing to perform a block of the plexus in a simple and efficacious way.

[Two in one block for carotid surgery]. / Blocco 2 in per la chirurgia della carotide.

The choose of the best anaesthesia for carotid surgery is a very debated item: the locoregional techniques probably offer more hemodynamic stability and a direct neurologic monitoring, while general anaesthesia allows the complete control of airways and ventilation and reduces the global stress for the patient. This review analyzes the data of studies that compare general and locoregional anaesthesia. Among the latter, possibly elective techniques, the one described by Winnie combines an optimal analgesic efficacy with the lowest rate of adverse effects. A single bolus of a local anesthetic injected at a C4 level (apex of scalene muscles triangle) guarantees a complete block of the superficial and deep cervical plexuses.

[Cervical mechanical anastomosis by transhiatal approach with a new circular stapler, Ehicon ECS 21]. / Anastomosi meccanica cervicale per via transiatale con una nuova suturatrice circolare, Ethicon ECS 21.

Authors describe a new technique of mechanical cervical anastomosis using a new, particularly long, stapler, the ECS Ethicon. Mechanical anastomosis at neck level is difficult to perform with stapler now in use, so manual anastomosis is usually preferred. However the percentage of leakage is relatively high. The possibility of doing a mechanical anastomosis introducing the stapler through the pylorus is described. At the moment cases are too few to give a full evaluation of this new technique, but certainly it could be a valid alternative, safer and quicker, to manual anastomosis.

[The combined radiochemotherapy of inoperable esophageal neoplasms: a feasibility study]. / Radio-chemioterapia combinata delle neoplasie esofagee inoperabili: studio di fattibilità.

January, 1994, through January, 1995, eighteen patients (17 men; median age: 59.9, range: 32-73) with biopsy-proved squamous cell carcinoma (n = 15), adenocarcinoma (n = 2) or undifferentiated carcinoma (n = 1) of the esophagus were treated with concurrent chemo-radiotherapy. All patients had inoperable lesions for unresectable disease (11 patients) or concomitant illness (7 patients); median Karnofsky score was 70 (range: 60-80). According to the 1988 American Joint Committee on Cancer Staging system, one patient was graded as Stage IIA (T2N0 + oropharyngeal cancer T4N1), two Stage IIB (T2N1), twelve Stage III (8 T3N1, 1 T4N0, 3 T4N1) and three Stage IV (2 T3N0M1, 1 T4N0M1). Treatment consisted of two courses of chemotherapy by cisplatin (75 mg/m2 i.v. on days 1 and 29) and 5-FU (1000 mg/m2/24 hours by continuous infusion from days 1 to 4 and from days 29 to 32) along with one course of concomitant radiotherapy at 45 Gy (1.8 Gy per fraction, one fraction per day and 5 fractions a week). After 15-30 days, the patients were treated with a boost dose of 7 Gy by high-dose-rate intraluminal brachytherapy. All patients are assessable for toxicity and seventeen for response. The combined treatment was generally well tolerated, with only one case of WHO grade III toxicity (thrombocytopenia). Eight of the eighteen patients had a complete response (47%); four a partial response (24%); four a minimal response (24%) and one showed stable disease (5%). Only one patient developed local progression, and four distant metastases. All the eight patients with CR are alive without local recurrence (two distant metastases) with a mean follow-up of 6 months. This treatment regimen provides good local tumor resolution with no major toxicity. The value of this study protocol will be determined by the rate of long-term survivors.

[Clinical and therapeutic approaches in angina pectoris of esophageal origin]. / Orientamenti clinici e terapeutici nel dolore anginoso di origine esofagea.

The authors, on a basis of experience acquisted since 1984 on two groups of patients, respectively 55 and 174 subjects with angina like chest-pain, individuated in the first group 45%, and 66.1% in the second group, the presence of GER-EMD with the execution of functional stationary manometric and 24 hour pH-metrical exams, without undergoing chemical, pharmacological, mechanical stimulation. They make note that 43 patients out of the second group, underwent, after a certain time, another cardiological study (negative for heart disease when recluted) due to graveness of the symptoms and 33 risulted holders of heart disease, 24 of whom also affected with EMD. The treatment with anti-H2 and procinethycs had succes in 39 patients out of 59, with GER; 10 patients underwent, with success, Nissen-Rossetti funduplication. Medical treatment with sublingual nifedipine was successful in 17 cases out of 56, with EMD; 19 underwent esophageal miotomy surgery commisurated on manometrical dates, with excellent results; 8 patients with hypertension of LES underwent pneumatic dilation with good results; 12 patients live, tolleratig angina like chest-pain. The final considerations are the following: it is not indispensable to look for contemperaly EMD and pain to afferm that pain is of esophageal origin; EMD must be clearly defined; the exclusion primarily of heart pathology must not exclude the possibility of the insorgence of heart desease, in the presence of EMD; the medical therapy, satisfactory in GER, is scarsely efficent in EMD, the decision for surgery must be taken on the gravity of pain associated with an esophageal pathology well defined with numerous diagnostic exams.

[Evaluation of cardiac risk in patients undergoing major vascular surgery. Usefulness and limitations of transesophageal atrial pacing]. / Valutazione del rischio cardiaco in pazienti da sottoporre a chirurgia vascolare maggiore. Utilità e limiti del pacing atriale transesofageo.

Patients undergoing vascular surgery are at high risk of developing cardiac events in the perioperative period. The aim of the study was the evaluation of the predictive accuracy of transesophageal atrial pacing (TAP) in identifying patients at higher risk of developing major cardiac events (cardiac death, acute myocardial infarction, unstable angina, heart failure and sustained ventricular tachyarrhythmias). We studied 96 consecutive patients, 80 males and 16 females, median age 63, requiring arterial surgery (aortofemoral or aortoiliac bypass and thromboendoarterectomy, abdominal aneurysm resection and extracranial carotid thromboendoaterectomy). TAP was performed without cardioactive drugs in all patients, but one. After surgery CK and CKMB serial assessment and ECG recording were performed daily until the seventh postoperative day. Preoperatively all patients were admitted to the Intensive Care Unit and submitted to haemodynamic monitoring with Swan-Ganz catheter at least for 72 hours. Three patients did not undergo surgery because of severe ST depression during TAP. Thus, 93 patients (96.8% of the series) were the subject of this report. In the postoperative period only two events (2.1% of the patients) were recorded, one relapsing acute myocardial infarction and one ventricular fibrillation, both in patients with negative TAP. No death occurred. Our study shows a very low prevalence of major cardiac events.(ABSTRACT TRUNCATED AT 250 WORDS)

["ARCHIDIA": a system for patients' data collection and computerized filing. Part I. Methodology]. / Sistema di raccolta dati paziente e archiviazione computerizzata "ARCHIDIA". Parte I--Metodologia.

This report describes a computer based program of patient clinical data collection: the ARCHIDIA system. The project relies on descriptive analysis of clinical events according to well defined methodological criteria. This allows the formulation of a concise diagnosis which is, at the same time, exhaustive of all essential information. Two are the basis principles of this methodology: To define, as accurately as possible, the logical steps necessary to elaborate the diagnosis, that is construed by a sequence of codes. To define all the conditions that must be followed so to use any code in a controlled and independent way. These criteria were derived from literature. The major claim of the system is likely to be the introduction of a "common language" between different ICUs. Uniformed diagnostic and clinical criteria are the main source of large data collection for descriptive, analytic and prospective studies. After a one year pilot study performed by 4 ICUs, ARCHIDIA was used, in 1991, by 20 centers from the area of Milan, Pavia, Como, Varese (70% of total) and 4148 patient data were collected. A descriptive analysis will be reported in the following paper.

["ARCHIDIA": a system for patients' data collection and computerized filing. Part II. General description of a caseload]. / Sistema di raccolta dati paziente e archiviazione computerizzata "ARCHIDIA". Parte II--Descrizione generale della casistica.

OBJECTIVE: To describe a population of patients admitted in ICU in an homogeneous urban area by means of a computed system. EXPERIMENTAL DESIGN: Observational study. SETTING: 20 general intensive care units of general and university hospitals. PATIENTS: Patients admitted in ICU from 1-1-1991 to 31-12-1991. 3 centers collected patients only for 6 months, starting on 1-6-1991. MEASUREMENTS: For each patient demographic data, hospitalization data, outcome, diagnosis and diagnostic procedures used during hospitalization according to defined criteria previously described, were collected. Data have been collected on PC using dedicated software. RESULTS: All centers concluded data collection, none abandoned the study. General characteristics of 4148 valuable patients were reported. Age was 52.9 years, SAPS 12.4 and mortality 21.7%. The patients spent 8.7 days in ICU and, when transferred to a general ward, the following hospitalization was 21.5 days. CONCLUSIONS: Data collection demonstrated the project feasibility. It realizes a continue up to date system inside each unit and allows the use of a "common language" and homogeneous methodology between centers.

Cancer of the esophagus: ten years' experience.

The paper reports the authors' ten-year experience of the surgical treatment of cancer of the esophagus. A total of 625 patients with esophageal carcinoma were observed during the period 1980-89 of whom 490 were admitted to hospital and, of the latter, 172 (35.1%) were operated with a sectile rate of 86% (148 patients). Data from this period were analysed both retrospectively and prospectively using a computerised system. There were 105 radical operations (70.9%) and 43 palliative operations (29.1%). The 3-year actuarial survival rate was 21.7% and the difference between radical and palliative resections was at the limit of significance (p less than 0.1).

TAF test in primary esophageal carcinoma: comparison with other tumor markers.

An ELISA method for the determination of circulating specific HSV-TAA antibodies has recently become available (TAF test). The presence of TAF was tested in serum of 154 patients with primary esophageal carcinoma, collected in three institutions. The overall TAF-test positivity rate was 57.1%, being significantly lower in stage IV than in stage III patients. The concordance rate between TAF and CEA, ferritin, TPA, SCC and TATI was low, suggesting that TAF is probably independent of the other tumor markers evaluated. The clinical role of TAF-test determination in patients with esophageal carcinoma is currently under evaluation.

[The clinical relevance of epidemiology in the surgical treatment of esophageal carcinoma]. / Rilevanza clinica dell'epidemiologia nel trattamento chirurgico del carcinoma esofageo.

The paper reports the epidemiology and causal factors of esophageal carcinoma, and compares the authors' personal experience with already published data. The clinical importance of epidemiology is stressed as a means of identifying risk factors for esophageal carcinoma, thus aiding an early diagnosis. The authors underline the central role of surgery in the treatment of esophageal carcinoma.

Clinical importance of tumour markers in the diagnosis of squamous-cell carcinoma of the esophagus.

In order to evaluate the diagnostic value of three tumour markers, CEA, CA 19-9 and TA4-scc, 50 patients affected by squamous-cell carcinoma of the esophagus were studied together with 70 normal controls and 22 patients affected by benign esophageal pathologies. The three tumour markers were assessed in all patients and data were evaluated statistically in order to reveal their sensitivities, specificities and diagnostic values. It was concluded that further studies should be carried out on the marker TA4-scc given its high specificity and sensitivity towards esophageal neoplasias at a relatively early stage.

Gastric angiography: data for oesophagogastroplasty.

A report is presented on an angiographic study of the gastric arterial system conducted on 20 human stomachs taken from cadavers during routine autopsies. The aim of the study was to define the anatomical bases for the supply of blood to the isoperistaltic gastric tubule in oesophagogastroplasty operations. The study reveals that on its own the right gastroepiploic artery cannot ensure adequate vascularisation of the gastric fundus. The importance of pressuring the right hand section of the vascular arch along the small curve was also noted and is due to the constant presence of major anastomoses at antral level with the right gastroepiploic artery. The study also revealed the constant presence of a direct intramural anastomotic circulation between the right and left gastroepiploic arteries.