Malignant pleural effusions: review of treatment and our experience.

More than half of patients with malignancy present with a pleural effusion at some time in their course. Recurrent malignant pleural effusions (MPE) impair functions and worsen the quality of life. Once a patient develops MPE, only mechanical drainage relieves pulmonary compression and dyspnea. Optimal treatment is however, still controversial. During January 2001 to January 2006, our group treated 48 patients with outpatient insertion of chronic indwelling pleural catheter (IPC), Pleurx (Pleurx, Surgimedics, Denver Biomaterials, Denver, CO, USA). Primary malignancy of 48 patients included: 27 lung cancers, 11 mesotheliomas, 5 breast cancers, 3 colon cancers, 2 pancreas cancers and 1 ovarian cancer. Eligibility for IPC required prior thoracentesis with histological confirmation of malignancy and chest roentgenogram evidence of effusion. All patients treated were made aware of their prior malignancy and positive cytology for MPE. Major complications, as systemic or pleural infections, were not registered. Permanence mean time of IPC was estimated as 88 days. Median time of draining interval was 7.0 days with maximum amount of effusion drained off being 1000 ml. Pleurodesis occurred in 23 of 48 (47.92%) patients with a mean time of pleurodesis being 43 days. IPC allows ambulatory treatment with a safe and effective drainage of MPE and is an alternative treatment to procedures in use.

[The treatment of malignant pleural effusions: the experience of a multidisciplinary thoracic endoscopy group]. / Il trattamento del versamento pleurico maligno: l'esperienza del gruppo multidisciplinare di endoscopia toracica.

More than half of neoplastic patients show in their clinical history the onset of pleural effusion. Malignant pleural effusion produces dyspnea, decreases respiratory function and quality of life in patients with advanced cancers. Optimal treatment is actually controversial. The aim of this study is to analyze the experience of malignant pleural effusion treatment of the Multidisciplinary Group of Thoracic Endoscopy. Patients are been subdivided in two group, depending on respiratory performance status and they are been submit to a Video-Assisted Thoracic Surgery (VATS) with talc pleurodesis and to positioning of a chronic indwelling pleural catheter. The treatment of malignant pleural effusion with the methods reported above allows, not only to achieve palliation of symptomatology, but also to achieve pleurodesis in patients with limited life-expectancy with good cost-beneficial ratio.

[Total thyroidectomy in recurrent goiters (anatomicosurgical observations with the operating microscope)]. / La tiroidectomia totale nelle recidive di gozzo (osservazioni anatomo-chirurgiche con l'ausilio del microscopio operatorio).

The relapses of the multinodular goitre, often linked with an insufficient surgical treatment of primitive lesions, make serious problems about the operating technique. The current guidance of surgeons is directed towards the complete thyroidectomy which profits, during the operating time, by the use of microscope to identify and to protect the recurrent nerves. This equipment has to be used by those equipped which know how to use it. In our work we report the results obtained with this technique and it's underlined how the complete thyroidectomy for the benign relapsing goitre could be considered curative towards those cases which present hidden microcarcinoma.

Management of postoperative bile leakage with endoscopic sphincterotomy (EST) and a naso-biliary drain (NBD).

Between July 1987 and December 1990, 13 patients with postoperative bile leakage were treated with endoscopic sphincterotomy and a naso-biliary drain. All the leaks healed in two weeks, except for one (intrahepatic) that needed two months to heal in association with percutaneous management. The non-surgical treatment of bile leakage is the preferred approach on account of the superior safety, efficacy and cost-effectiveness as compared with surgical repair, which is associated with significant morbidity, mortality and costs. The treatment of choice has to be endoscopic, which is much easier and safer than the transhepatic approach, especially in the non-dilated duct, while another advantage over radiology includes the possibility for rapid definitive treatment of distal obstruction (e.g. residual stones). A leak from an extrahepatic duct heals rapidly, while a leak from an intrahepatic duct takes longer to heal and sometimes needs associated percutaneous drainage. Finally, the authors propose treating an extrahepatic bile leak merely with naso-biliary drainage without cutting the papilla, and an intrahepatic bile leak with endoscopic sphincterotomy, nasobiliary drainage and a bilio-duodenal endoprosthesis.

[Usefulness of preoperative biliary drainage: comparison of therapeutic strategies]. / Sull'utilita' del drenaggio biliare preoperatorio: strategie terapeutiche a confronto.

This work shows the results obtained by the comparison between a period in which obstructive icterus was treated only surgically and a mixed period, based on endoscopic or endoscopic surgical treatment. In a period of 9 years (1979-87), 186 patients suffering from obstructive icterus were admitted into the 1st Division of General Surgery at Ospedale Maria Vittoria, Turin. In the first five years (1979-83) all the patients (78) were indistinctly operated after the usual diagnostic controls. In the following four years (1983-87) 62 out of 108 patients, considered as high-risk ones, underwent drainage by endoscopic way. In the high-risk patients, both neoplastic and not, morbidity rate, death rate and average stay in hospital were evidently lower after endoscopic or endoscopic-surgical treatment than after surgery alone. In conclusion, endoscopic pre-operating drainage in selected and/or high-risk patients greatly reduces perioperative complications and mortality.

[Treatment of large laparoceles: review and personal experience]. / Trattamento dei grandi laparoceli: rassegna ed esperienza personale.

Surgical correction of laparocele is still today a problem for the surgeon. Physiopathological aspects, preparation to surgery and most of all the indications to the use of synthetic prosthesis are reviewed. Easy application and lesser evidence of recurrency and complications suggest a wider field of indications of these procedures. Attention should be payed to the rules of a careful operative technique involving the use of foreign bodies.

[Bleeding gastroduodenal ulcer: indications for surgical intervention]. / Ulcere gastroduodenali sanguinanti: indicazioni all'intervento chirurgico.

The best chance for a patient with a bleeding gastroduodenal ulcer is: "a diligent doctor and a reluctant surgeon". It is necessary to evaluate clinical and endoscopic elements and to check haemodynamic and general conditions of the patient. A better prognosis is ensured by prompt initiation of therapy. All patients with a bleeding since 12 hours or rebleeding must be selected for urgent surgery. The success of surgical intervention is the result of an exact indication and the most correct surgical procedure. Selection of patients for surgery must ensure careful local haemostasis and control of hyperchlorhydria.

[Traumatic rupture of the diaphragm]. / Rotture traumatiche del diaframma.

A survey based on 122 personal observations of traumatic rupture of diaphragm, involving stomach and spleen herniation into the chest, is presented. The importance of clinical symptoms for proper diagnosis and treatment is discussed, in relation to the different trends in the literature.

[A case of hernia of the liver following a traumatic lesion of the diaphragm]. / Considerazioni su un caso di ernia del fegato conseguente a lesione traumatica del diaframma.

The authors describe a case of liver -hernia ensuing a right diaphragmatic rupture. This is a rare event. However, the difficult diagnosis and possible ways of surgical access are discussed.

[Cystic dilatation of the choledocus]. / Dilatazione cistica del coledoco.

Choledochal cyst is an uncommon congenital lesion of the pancreatobiliary system. The pathologic features are cystic dilatation of the common bile duct, normal liver parenchyma, a normal intrahepatic biliary system and partial obstruction of the terminal common bile duct. More than 1400 cases have been reported in tre literature, 83 per cent of which have been diagnosed in patients below the age of 30. A triad of abdominal pain, jaundice and a palpable abdominal mass in the right hypocondrium has been classically associated with this condition. Ultrasonography and CT scanning are usually successful in demonstrating the mass. Cholangiography by the endoscopic retrograde approach may demonstrate the cystic dilatation of the common bile duct. The precise relation ship of the cyst to the biliary tree should be demonstrated by cholangiography at operation. The common type I fusiform cyst is currently treated either by excision combined with a biliary intestinal anastomosis of by anastomosis of the cyst to the intestinal tract. Treatment of the rare type II diverticulum consist of simple excision, while the rare type III choledococele is treated by transduodenal excision of the cyst wall. The current mortality rate of choledochal cyst treated by surgical decompression is 5 to 10 per cent. A case of choledochal cyst in a 58 years old woman is described. The anatomopathologic, clinic features and therapeutic lines are pointed out.

[Gallstone ileus, observations on 13 cases]. / Ileo biliare, considerazioni su 13 casi.

The authors expose some considerations about clinical features of this unusual condition. Thirteen cases of gallstone ileus are reported. The medium age was 70 years. The postoperative course was regular for 12 cases, and only one patient died seven days after the operation.

[Experimental porto-systemic diversion in the rat: a comparative analysis of technics and results]. / Le derivazioni porto sistemiche sperimentali nel ratto: analisi comparativa di tecniche e risultati.

A number of techniques for performing portacaval end-to-side and side-to-side pancreaticoduodenal and mesenterico-caval shunts in rats are described. These shunts, transposition and arterialization are valuable objects for training in microvascular surgery. Effects of shunts, liver function, hemodynamics, metabolic and neurological changes related to portal flow, liver metabolism, and portal pressure are compared.

[Open and closed injuries of the abdomen (review of 107 surgically treated cases)]. / Traumi aperti e chiusi dell'addome (revisione di 107 casi sottoposti ad intervento chirurgico).

The authors relate about 107 cases of multiple injuries observed from 1975 to 1984. The causes of trauma, the different injuries caused by trauma, the association of different injuries intra and extra abdominal are examined; the diagnostic procedure, the results obtained, mortality, complications. The studied patients are divided on the basis of the trauma occurred. These data support the position that, in patients with severe multiple injuries, certain criteria, as rapidly increasing abdominal distension or uncorrectable hypotension and isolated rigidity of abdominal wall, eliminate the need for diagnostic examinations and make these procedures unwise waste of valuable time.

[Liver lesions in abdominal traumatology]. / Le lesioni epatiche nella traumatologia addominale.

Hepatic traumas are one of the most common sequelae of abdominal injuries. The Authors report 24 cases of hepatic traumas about a casuistry of 104 patients, that, in the decade '74-'84, had an abdominal traumatism. The quality of injuries, the therapeutic actions, and results are described.

[Presence of dilatations of the aneurysm type in the abdominal aorta after experimental terminoterminal anastomosis in the rat]. / Osservazioni sulla presenza di dilatazioni di tipo aneurismatico nel tratto addominale dell'aorta dopo intervento sperimentale di anastomosi termino terminale nel ratto.

We have examined the aneurysmal dilatations in the wall of abdominal aorta after microsurgical experimental operation of end-to-end anastomosis. We observed this alteration both by macroscopic examination and by optical light microscopy. The wall presents various damages, particularly in the media, that seems thick, disarranged and often necrotic.

[Behavior of the principal blood coagulation parameters in rats with portacaval anastomosis]. / Comportamento dei principali parametri emocoagulativi in ratti sottoposti ad anastomosi porto-cava.

The aim of our research was to evaluate same coagulative parameters in the rat after end-to-side porto-caval shunt, comparing the data with "sham operated" rats. At 180th day in each group the following parameters were controlled: platelet, fibrinogen, prothrombin time, partial thromboplastin time, T.E.G. The results have shown a significant diminution in the following parameters: PLT, PT, fibrinogen, and T.E.G.

[Metabolic changes following termino-lateral portacaval anastomosis in the rat]. / Alterazioni metaboliche conseguenti ad anastomosi porto-cava termino-laterale nel ratto.

The purpose of these present experiences was to evaluate some metabolic parameters, which can show liver damage after end-to-side porto-caval shunt, comparing the data with "sham operated" rats. At 180th day in each group the following parameters were controlled: ALT, AST, Alkaline phosphatase, gamma GT, bilirubin, Cholesterol, albumin and ammonia blood level. The results showed a significant increase of gamma GT, APh, bilirubin and ammonia blood level in porto-caval shunt operated rats.

[A case of association between gastric carcinoma and leukemia (author's transl)]. / Communicazione su di un caso clinico di associazione di carcinoma gastrico e leucemia linfoide cronica.

The authors present a case of association between gastric carcinoma and leukemia. After briefly mention of etiopathogenesys, they discuss the difficulties of differential diagnosis between a primitive neoplasia and a secondary infiltration through the gastric walls, caused by leukemia. They then mention the necessity of a surgical intervention in case of doubtful diagnosis, or in case of a pronounced alteration in the intestinal tract.