[Endoscopic percutaneous gastrostomy with gastropexy: a safe technical choice]. / La gastrostomia percutanea endoscopica con gastropessi: una scelta tecnica sicura.

Percutaneous endoscopic gastrostomy is an interesting method of providing enteral nutrition or gastric decompression in patients who are candidates for operative gastrostomy or nasoenteric tube feeding. We report our experience with percutaneous endoscopic gastrostomy with gastropexy (Introducer T-Fastener) in 41 patients. This method uses a technique in which the anterior gastric wall is non-surgically sutured to the anterior abdominal wall before catheter insertion. This technique was successful in all patients, including one subject with a Billroth II hemigastrectomy. Enteral nutrition was started in all cases within 24 hours of the end of the procedure. The medium enteral nutrition period to date is 482.5 days. There were no deaths related to the procedure and no patients had major specific abdominal complications requiring urgent surgical repair. Eight patients complained of minor specific complications which were successfully resolved in all cases with simple conservative procedures and/or therapies. These results indicate that the Introducer T-Fastener method for performing percutaneous endoscopic gastrostomy is rapid, safe, and inexpensive.

[Isolated rupture of aneurysm of the internal iliac artery]. / Rottura isolata di aneurisma della arteria ipogastrica.

Isolated aneurysms of the internal iliac artery are rare and often asymptomatic. They are frequently diagnosed as a result of complications such as rupture. The authors describe in detail two cases of ruptured aneurysms of the internal iliac artery treated by emergency surgery with no perioperative mortality or morbidity.

Benign biliary stricture. Personal experience and technical notes.

BACKGROUND: Benign biliary strictures are a binding situation for clinicians when choosing the best treatment. This is a benign disease and needs safe, effective and lasting therapy. Up to day non surgical treatment have been suggested as the first therapeutical option but surgery seems to support the best late results. METHODS: The authors report their experience in 206 patients, 64 males and 142 females, aged from 27 to 77 years, affected by postoperative (160 patients) or inflammatory (46 patients) biliary strictures. All the patients but three had been treated by surgical procedures. RESULTS: Postoperative morbidity and mortality were 18.4% and 3.4% respectively. Follow-up ranged from 2 to 16 years. Late stricture of bilio-enteric anastomosis has been observed in 8.2% of patients and peptic ulcer or cholangitis in 4.9% of cases. Restenosis appeared after a mean time of 2.5 years (range 20 months-6 years), supporting the need for a long term follow-up. Effective late results have been reported in 91.5% of patients. No late complications of ineffective results have been observed after transduodenal sphincterotomy. CONCLUSIONS: The authors propose some guidelines for choice charce of treatment, analysing the limits of non surgical therapy and underlying the best surgical tactics. Bilio-enteric anastomosis is a safe, effective and lasting therapy for biliary strictures; Hepp-Couinaud hepatico-jejunostomy is the best choice for high-medium stricture; transduodenal sphincterotomy preserves its important role in low biliary stenosis.

[Intralobular pulmonary sequestration: apropos a case]. / La sequestrazione polmonare intralobare: a proposito di un caso.

The authors report their experience with a patient suffering from an intralobar bronchopulmonary sequestration (IBS). The lesion was misdiagnosed as metapneumonic lung abscess. IBS is a rare, diagnostically binding lung congenital malformation. So far, TC and MR angiography achieve pathognomonic findings with low invasivity. The best treatment of IBS could be surgical resection.

[Mannhein index in the prognosis and treatment of acute peritonitis]. / L'indice di Mannheim nella prognosi e nel trattamento della peritonite acuta.

BACKGROUND: Early prognostic evaluation of patients affected by acute peritonitis is really desirable to program a correct therapeutic plan, selecting high-risk patients for more aggressive therapeutic procedures. The Mannheim peritonitis index is reliable and easy to apply, so its use is possible without the need of intensive care units. METHODS: Between 1991 and 1995 a total of 235 patients were operated on for acute peritonitis. A retrospective study on this group of patients was performed in order to estimate prognostic reliability of Mannheim peritonitis index. RESULTS: The overall mortality was 8.1%; for patients with a score less than 26 the mean mortality rate was 2% and for score greater than 26, 40.5%. This score is the threshold over which the therapeutic approach have to be more aggressive; planned multiple laparotomies or the open abdomen technique could be the best options to explore and clean up the peritoneal cavity from septic debris. In personal experience, all patients who died had residual sepsis in peritoneal cavity.

Induction chemotherapy with cisplatin, doxorubicin, and cyclophosphamide (CAP) in a combined modality approach for locally advanced and inflammatory breast cancer. Long-term results.

Thirty-one patients with locally advanced and inflammatory breast carcinoma (stage IIIA and IIIB) were treated with a combined modality approach between 1985 and 1989. All patients received as induction chemotherapy a combination of cisplatin, doxorubicin, and cyclophosphamide (CAP). Responsive patients and patients with operable stable disease underwent modified radical mastectomy followed by concurrent radiotherapy and CMF (cyclophosphamide, methotrexate, 5-fluorouracil) adjuvant chemotherapy. Thirty patients were evaluable for response to CAP. The rate of objective response to induction chemotherapy was 76.7% with 2 patients (6.7%) obtaining a complete response and 21 patients (70%) a partial response. Twenty-five patients were rendered disease-free after induction chemotherapy and surgery. Only 2 of these had pathological complete response (8%). The median overall survival was 48.7 months, the median time to progression was 22.4 months and the median disease-free survival was 29.1 months. The patients with noninflammatory breast tumor had a significantly better overall survival, disease-free survival, and time to progression. The overall survival and the time to progression were statistically superior in patients with primary tumor size < or = 8 cm. At a median follow-up of 6 years, 29% (95% CI, 13.05 to 45.01) of patients were alive and 28% (95% CI, 10.4 to 45.6) were disease-free. This combined modality treatment seems feasible with quite acceptable toxicity; the CAP combination is an effective alternative to the other standard chemotherapeutic regimens. Our results, although encouraging, are still poor, and new drugs and strategies are required to improve the long-term outcome.

Intraoperative ultrasonography for pancreatic insulinomas.

BACKGROUND/AIMS: Islet cell adenomas of the pancreas are both single and benign tumors in more than 90% of the cases. Even with the use of increasingly innovative diagnostic techniques, a percentage of tumors are not located in the preoperative or, sometimes, even intraoperative phase. This study compares the results of various diagnostic techniques and provides a brief review of the literature. MATERIALS AND METHODS: Between January 1978 and December 1994, 15 patients (11 females and 4 males) averaging 49 years of age (range 27-70) affected by pancreatic insulinoma underwent surgery at the Department of General Surgery of the "R. Silvestrini" Hospital. RESULTS: In 8 cases the tumor intrapancreatic position was indicated in the preoperative stage. On the contrary, intraoperative ultrasonography allowed the correct location in all the cases, but one. Surgery allows for the complete cure from the diseases when the removal of adenoma is complete. All of our patients underwent surgery which involved enucleation or resection of the distal portion of the pancreas. CONCLUSION: The choice of the type of operation to perform, as well as the consequential morbidity and mortality, seems to depend essentially on the size and position of the insulinoma. All of the patients, except for one who died because of a pancreatic fistula, are alive and normoglycaemic.

New technique for retrograde cerebral perfusion during arch aneurysm repair.

Many techniques are used to reduce brain damage during surgery for dissecting aneurysms of the ascending aorta and arch. Recently, new techniques of protection were proposed, consistent with hypothermic circulatory arrest in association with retrograde cerebral perfusion via superior vena cava. We propose a simple, time-saving method, which does not require any manipulation of the heart. We use a multilumen cannula for cardioplegia (D 860-DIDECO FUNDARO') with pressure transducer. This cannula is inserted in superior vena cava by means of a simple purse-string, and linked to the arterial line with a "Y" derivation, allowing retrograde perfusion of the brain and monitoring the perfusion pressure at every moment. The superior vena cava placed downstream from the cannula is closed by a small vascular clamp, to avoid blood reflux in the right atrium. This method is time- and money-saving, is readily available, and can be prepared whenever necessary, also in the middle of the surgical procedure.

A phase II trial of combined chemotherapy and surgery in stage IIIA non-small cell lung cancer.

A poor prognosis for patients with Stage IIIA clinical N2 treated by surgery alone has led clinical researchers to find a new treatment modality to improve the curative potential of surgery. Many Phas II trials have been carried out with induction chemo- or chemo-radiotherapy prior to surgery. From June 1988 to July 1991, 46 patients with non-small cell lung cancer (NSCLC) Stage IIIA clinical N2 entered a Phase II induction-chemotherapy trial. Patients received 2-3 cycles of high-dose cisplatin and etoposide. Forty-five were evaluable for response; the response rate was 82% (37/45: 3 CR, 34 PR). Toxicity was primarily hematologic. Surgical resection was performed in 35 patients; radical resection was possible in 28 patients (62%); three patients were incompletely resected and two patients were only explored. Three deaths were surgery-related. Median survival was 24.5 months with a 2-year survival of 53%. Cisplatin with etoposide is an active and safe induction chemotherapy regimen for NSCLC Stage IIIA N2 with a high response rate. The median survival seems to be prolonged and therefore, randomized trials are needed to compare this approach with other treatment modalities.

Neoadjuvant cisplatin and etoposide for stage IIIA (clinical N2) non-small cell lung cancer.

In an attempt to improve the curative potential of surgery, 46 patients with unresectable Stage IIIA (Clinical N2) non-small cell lung cancer received neoadjuvant chemotherapy with cisplatin and etoposide. After 2 or 3 cycles, 45 patients were evaluable for response; the overall response rate was 82% (37/45) with 3 complete and 34 partial responses. Toxicity was primarily hematologic. Surgical exploration was performed on 35 patients, but resection was possible in only 33 (73%). Of these, 28 resections were complete (62%). Four patients (2CR, 2PR; 9%) had no tumor in biopsy specimen. Three deaths were surgery-related. Median survival of the entire 46 patients was 24.5 months with a 2-year survival of 53%. Cisplatin and etoposide is an effective chemotherapeutic regimen for regionally advanced non-small cell lung cancer; the resection and survival rates justify further trials to compare this approach to other treatment modalities.

[Surgery after neo-adjuvant therapy of non-small cell lung cancer. Preliminary results]. / Chirurgia dopo terapia neo adiuvante del cancro del polmone non a piccole cellule. Risultati preliminari.

The Authors report their personal experience of surgical treatment following neo-adjuvant therapy in NSCLC (III a N2) in order to assess: 1) the feasibility and safety of surgical treatment following major responses to neoadjuvant chemotherapy; 2) the sectile rate; and 3) the survival rate. Preliminary results show that: 1) chemotherapy using cisplatin and VP-16 gives a high rate of major responses in these patients; 2) surgery is feasible; 3) there is high radical sectile rate; 4) further research is needed to obtain statistical significance.

[Pre- and postoperative radiotherapy of operable carcinoma of the rectum]. / Radioterapia pre- e postoperatoria del carcinoma del retto operabile.

This was a non-randomized prospective study on the "sandwich" radiosurgical treatment of resectable rectal and rectosigmoid carcinomas. From December 1984 to December 1989, 100 patients were treated 86 of them are now evaluable. Mean follow-up was 38 months (range: 9-69). Surgery was abdomino-perineal resection in 33 cases and anterior resection in 53 cases. Radiotherapy was preoperative pelvic irradiation, with a single 500-Gy fraction, the day before surgery. To stages B2, C1 and C2 patients (Astler and Coller) postoperative radiotherapy was administered for a total dose of 4500 Gy (180 Gy/fraction, 5 fractions/week), with box technique, from a Co 60 unit or Linear Accelerator (photon 18 MV). Preliminary results indicate 8% (7/86) local recurrences and 9.3% (8/86) distant metastases. Five-year actuarial disease-free survival is 63.2% +/- 8 for stage B1, 55.6% +/- 19 for stage B2, and 40.2% +/- 13 for stages C1 + C2. Overall 5-year actuarial disease-free survival is 53% +/- 10. No lethal or severe complications were observed following treatment.

[Perforated duodenal ulcer. Personal experience]. / Ulcera duodenale perforata. Nostra esperienza.

Reference is made to personal experience in affirming that the treatment of perforated duodenal ulcer should set out to resolve both the perforation and the ulcer at the same time. Troncular vagotomy combined with pyroloplasty is put forward as an effective way of achieving this, and long-term results on a par with those obtained electively are described.