[The Hickman catheter as vascular access in bone marrow transplantation]. / Il catetere di Hickman come accesso vascolare nel trapianto di midollo osseo.

From 1984 to 1995, 522 Hickman catheters were placed in the Institute of Clinica Chirurgica B of the University of Genova to treat malignant haemathologic diseases. Aims and reasons of this choice, surgical technique, advantages and related problems are reported here.

[Smoking as a risk factor in arteriopathies]. / Il fumo come fattore di rischio nelle arteriopatie.

Tobacco use represents the most powerful chemical addiction, which has been defined as "the inability to discontinue smoking" and it is one of the main cardiovascular risk factors. It produces alterations in platelet activity, blood viscosity and vascular wall and clinical signs related to the different vascular districts. The probability of carotid lesions increases up to 32% for 10 years/smoking and the progression of the disease is proportional to tobacco consumption; on the contrary smoking cessation may be helpful. Furthermore the risk of PAOD increases 2 to 9-fold, irrespective the number of cigarettes and these modify significantly the long-term patency of the femoro-distal reconstructions (57% vs 78% at 2 years). Very impressive indeed the data concerning major amputations (21% vs 2%) and the mortality rate for cardiovascular diseases (83% vs 33%) between smokers and non-smokers. For the abdominal aortic aneurysm too smoking represents the main independent risk factor and the mortality rate rises 6 to 25-fold compared to the normal population. The conclusions are obvious and can be shortly summarized in the following sentence: "Stop smoking and keep walking".

End-to-end arteriovenous fistula for chronic haemodialysis: 11 years' experience.

Between January 1979 and December 1989, an end-to-end arteriovenous fistula for chronic haemodialysis was performed at the anatomical snuffbox in 140 patients with a mean age of 51 (range 14-81) years and at the wrist in 248 with a mean age of 53 (range 19-83) years. The choice of site depended on the characteristics of the vessels and on the arterial blood pressure. No operative mortality, major complications or side effects occurred. The primary median patency for the arteriovenous fistula at the anatomical snuffbox was 36 months with a patency rate of 77.3% at 1 year, 36.3% at 5 years and 18.9% at 10 years. For the arteriovenous fistula at the wrist the median patency was 64 months and the patency rate 75.5% at 1 year, 54.5% at 5 years and 30.7% at 10 years. The higher incidence of thromboses in the patients with a fistula in the snuffbox may reflect an excessive enthusiasm for this technique because of initially promising results.

Immunoprophylaxis in "septic risk" patients undergoing surgery for gastrointestinal cancer. Results of a randomized, multicenter clinical trial.

The results of a randomized, multicenter clinical trial of immunoprophylaxis of post-operative infections with intravenous Immunoglobulins (IVIG) (Sandoglobulin) in "septic-risk" patients undergoing surgery for gastrointestinal cancer are presented. "Septic-risk" patients were selected by an original multiparametric test based on delayed hypersensitivity skin testing and serum protein electrophoretic sub-fractions. This screening test had shown 76% positive predictivity in a previous validation assessment. In the present study, 159 "septic-risk" patients were selected prospectively from 369 patients undergoing colo-rectal (colon) and other kinds of gastrointestinal (non-colon) oncologic surgery: 80 "septic-risk" patients were included in the colon and 79 in the non-colon group. Immunoprophylaxis with IVIG (15 g on the day prior to operation, on the 1st and 5th postoperative days) was randomly associated with antibiotic prophylaxis (cefoxitin: 2 g one hour prior to, followed by 2 g at the end of operation plus 2 g every six hours for 24 hours) in colon surgery while the prophylactic schedule in non-colon surgery was only based on random administration of IVIG, at the same dosage as in the colon group. There was a clear-cut reduction of post-operative infections both in colon and non-colon "septic-risk" patients who had IVIG prophylaxis; in the colon group, 37 and 21 infections (P < 0.004) in antibiotic (A) versus IVIG plus antibiotic (IVIG + A) subset, respectively; in the non-colon group, 33 and 19 infections (P < 0.01) in control (C) versus (IVIG) subset, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Prophylaxis of infection with intravenous immunoglobulins plus antibiotic for patients at risk for sepsis undergoing surgery for colorectal cancer: results of a randomized, multicenter clinical trial.

BACKGROUND: The results of a randomized, multicenter clinical trial with perioperative short-term antibiotic plus intravenous immunoglobulins (IVIG + A) versus antibiotic alone (A) for prevention of postoperative infections in patients at risk for sepsis undergoing surgery for colorectal cancer are presented. METHODS: The patients at risk for sepsis were selected by an original multiparametric test based on delayed-hypersensitivity skin testing and serum protein electrophoretic subfractions. This screening had shown 76% positive predictability in a previous validation assessment. Eighty patients at risk for sepsis were selected prospectively from 210 patients undergoing surgery for colorectal cancer; 43 patients were randomly assigned to the IVIG + A group and 37 to the A group. IVIG was administered on the day before operation, on the first and fifth postoperative days. RESULTS: There was a clear-cut reduction of postoperative infections in the IVIG + A group: 21 infections in 20 patients versus 37 infections in 29 patients in the A group (p less than 0.004). With regard to serum immunoglobulin (Ig) G monitoring, basal IgG levels were significantly lower in patients given IVIG + A who had postsurgical infections (p less than 0.005) compared with patients with a regular outcome, whereas the same was not true in the A group of patients. CONCLUSIONS: A significant decrease (p less than 0.001) of postoperative IgG was evidenced in the A group of patients who had infections as opposed to a significant increase (p less than 0.001) of postoperative IgG in IVIG + A patients with a normal outcome.

[Hyperthermic-antiblastic isolation perfusion for advanced melanoma of the limbs. The technic, immediate results and a review of the literature]. / La perfusione isolata ipertermico-antiblastica per il melanoma avanzato degli arti. Tecnica, risultati immediati e revisione della letteratura.

Hyperthermic antiblastic isolated perfusion is a method largely used for the treatment of locally advanced limb melanoma. The method requires vascular isolation and hyperthermic perfusion of the limb using an extracorporeal circuit and administering the melphalan as antiblastic drug. Twenty-six patients with primary or recurrent melanoma of the limbs have undergone this treatment at our Institute. There were no cases of operative mortality and systemic toxicity was negligible. The local complications were transitory and no patient showed symptoms of nervous toxicity or permanent functional damage. Two cases of deep thrombophlebitis and two of lymphocele were documented a few months after treatment. Four clinically complete responses, 3 partial and 2 cases of stable disease were observed in the 9 patients treated with unexcised lesions. Our data like the totality of the present experience points to the safety of this method in the therapy of locally advanced limb melanoma. Nevertheless further controlled studies are required to define its role in order to improve survival.

[Distal gastrectomy with Y gastroenteroanastomosis not associated with vagotomy in elective surgical treatment of gastroduodenal ulcer. Clinical and functional long-term results]. / La gastrectomia distale con gastroenteroanastomosi a Y non associata a vagotomia nel trattamento chirurgico di elezione dell'ulcera gastroduodenale. Risultati clinici e funzionali a lungo termine.

During the period 1977-1984, 53 patients with peptic ulcer resistant to H2-blockers (29 gastric and 24 duodenal ulcers) were submitted to distal gastrectomy with Roux-en-Y gastroenteroanastomosis not associated with vagotomy. The indication was used as an alternative to proximal vagotomy in cases with delayed gastric emptying, high acid output, perforation or bleeding. The study plan consisted of serial clinical and instrumental controls including determination of basal (BAO) or maximal (MAO) acid output. Operative mortality was nil. At various times after the operation, 4 patients died for unrelated reasons and 3 were lost to follow-up. Median follow-up was 84 months with an interval of from 4 to 137 months. Fifty-one patients were followed up for at least one year and 49 for at least two. Five patients (2 gastric and 3 duodenal ulcers) developed peptic recurrences (Visick IV, 9.8%) by the end of the first postoperative year and, in all cases but one, healed stably by the second year after medical (3 cases) or surgical (1 case) therapy. In the remaining patients, Visick was grade III in 6 cases (4 gastric and 2 duodenal ulcers), grade II in 6 and grade I in 34. Before operation, mean values (+/- SD) of BAO and MAO were respectively 5.84 +/- 5.03 and 29.6 +/- 18.6 mEq/h. In the immediate postoperative period there was a considerable reduction in BAO (p less than 0.02) and MAO (p less than 0.03) which continued up to the third postoperative year with a tendency to further progressive reduction in MAO. In spite of a considerable individual variability in dimensions and temporal evolution, the phenomenon occurred qualitatively in all cases. No significant difference was observed in the behaviour of BAO and MAO in gastric ulcers by comparison with duodenal ulcers and in cases with recurrence and Visick III compared to those with a favourable clinical result.

[Pre-operative identification of patients at risk for septic complications after surgery for neoplasms of the digestive system. A multiphasic multicenter study]. / Identificazione pre-operatoria del paziente "a rischio" di complicanze settiche dopo chirurgia per neoplasia dell'apparato digerente. Studio policentrico multifasico.

One hundred ninety-six patients undergoing surgical treatment for digestive tract cancer were recruited in a polycentric, multistep study to value significant differences of pre-operative nutritional and immunologic parameters between patients with or without post-operative infections. Such parameters might be useful for the identification of "septic risk" patients. Primarily, 63 patients were given a complete anthropometric evaluation, laboratory screening and immunologic assessment (surface marker analysis of peripheral blood mononuclear cells, polymorphonuclears in vitro chemotaxis and phagocytosis). Only a few serologic parameters were significantly reduced in patients with post-operative infections, namely: total serum proteins (p less than 0.02), albumin (p less than 0.02), beta-globulins (p less than 0.01), and C3c (p less than 0.05). These parameters were elaborated with Fisher's linear discriminant function to detect the optimal discriminant threshold able to identify "septic risk" patients. The predictivity of this discriminant function was validated in a second group of patients (n = 49) in which total serum protein with electrophoresis were pre-operatively assayed as well as skin test reactivity to intradermal injection of recall antigens (Multitest skin-testing); discriminant sensitivity was 80%, the specificity 50%, and positive predictivity 62%. This low discriminant power of the equation based only on serum proteins assessment coupled with the significant negative relationship between skin testing and post-operative infections (male, p less than 0.005; female, less than 0.025) suggested a re-elaboration of the discriminant function, including the skin-testing score. The definite assessment of this new discriminant equation was evaluated in the third sample of patients (n = 84) which showed 67% sensitivity, 88% specificity, and 76% positive predictivity, thus suggesting the high reliability of this test for the pre-operative selection of "septic risk" patients.

Changes in vascularity of liver tumours after hepatic arterial embolization with degradable starch microspheres.

The role of vascularity as a prognostic factor was investigated in 35 patients undergoing arterial chemotherapy for liver tumours. Compared with parenchyma, tumour vascularity was classified as hot (18 cases), cold (12 cases), and mixed (12 cases) using 99mTc-macroaggregated albumin (MAA) hepatic arterial scans. The proportion of patients showing complete and partial responses to treatment was higher in the hot group (56 per cent) than in the combined cold and mixed group (12 per cent). In 15 cases (six hot, six cold and three mixed lesions), additional MAA scans were performed immediately after arterial embolization with degradable starch microspheres (DSMs). Either complete or partial reversal of tumour vascularity was observed after DSM-embolization in five and seven cases respectively, two and two of them respectively showing native cold lesions. As tumour vascularity appears to be a prominent prognostic factor, DSM-embolization should improve the efficacy of treatment by improving liver extraction of drugs and causing flow redistribution towards hypovascular areas.

Starch microsphere-induced arterial flow redistribution after occlusion of replaced hepatic arteries in patients with liver metastases.

In four patients with major anomalies of the hepatic artery undergoing intra-arterial chemotherapy, aberrant lobar vessels were ligated and catheters were inserted into the contralateral artery. Catheter perfusion scans performed early after ligation with 99mTc-macroaggregated albumin (MAA) showed a defective perfusion of the lobe supplied by the occluded artery (0.43, 0.23, 0.11, and 0.28, respectively, as compared to the contralateral lobe). Further MAA scans performed after catheter infusion of 90,000,000 parts of degradable starch microspheres (DSM) showed a near normal perfusion of the ischemic lobe (0.91, 0.96, 0.87, and 0.98). On the contrary, simple MAA scans performed in the first two patients 114 and 135 days after ligation showed a still defective arterial perfusion of the ischemic lobe (0.60, and 0.24). The DSM-induced redistribution of flow towards ischemic portions of the liver suggests a possible new role of DSM in regional treatment of liver tumors in cases with either occlusion of aberrant vessels or "hypovascular" tumors.

Redistribution of arterial blood flow in metastases-bearing livers after infusion of degradable starch microspheres.

Changes in intrahepatic arterial blood flow after intraarterial injection of degradable starch microspheres (DSM) were studied in four patients undergoing hepatic arterial chemotherapy. All four livers contained metastases, three from colorectal cancer and one from melanoma. Using a CT scanner with a dynamic program, 8 mm liver sections were studied in each patient before and after the DSM infusion (180(-6) in 3 min). Density plots were obtained from 12 tumoral and 12 parenchymal areas after 5 ml push arterial injections of nonionic contrast medium. The areas under the curves (ID) were calculated. The ID after DSM infusion was reduced by 94% in a single hyperdense colorectal metastasis and by a mean of c. 82% in ten parenchymal areas. By contrast, nine hypodense colorectal metastases showed an average ID decrease of c. 156%. The ID of two melanoma metastases was reduced after DSM (-48% and -68%), while the ID of two matched parenchymal areas showed an approximately similar degree of increase (+36% and +64%). Since ID after contrast injection can be assumed to be a function of blood volume, mutual changes of parenchymal and tumoral blood flow appear to take place in metastases-bearing liver after arterial infusion of DSM. This phenomenon may be of diagnostic and therapeutic value for intraarterial chemotherapy of liver tumors.

Initial experience with Hemasite vascular access device for maintenance haemodialysis.

Thirteen uraemic patients having undergone chronic haemodialysis from a minimum of 16 months to a maximum of 15 years (mean 6.5 years) with unsuitable peripheral vessels for standard arteriovenous fistulae, received Hemasite, a new vascular access device which provides vascular access without needle puncture. Eight devices are still being used routinely with enthusiastic acceptance by the patients. Three subjects died because of unrelated causes, two of whom had a functioning device. Nine thromboses occurred in five patients. Thrombectomy was successful in three subjects. There were two cases of infection with loss of one device. In conclusion, the main advantage of Hemasite is the possibility of performing haemodialysis without needles, thus potentially maintaining the longevity of graft fistula. The only disadvantage of the device is its cost.

Nine years' experience with end-to-end arteriovenous fistula at the 'anatomical snuffbox' for maintenance haemodialysis.

One hundred and seventy-seven end-to-end arteriovenous fistulas were created at the 'anatomical snuffbox' between 1 January 1972 and 31 December 1980. The survival rate of the fistulas was 83.1 per cent at 1 year and 46.3 per cent at 6.5 years; 10.2 per cent failed immediately. Local and general complications were virtually absent. Forty fistulas stopped functioning after a period varying from 10 days to 6.5 years following the operation. The main cause of late failure (50 per cent) was aneurysm formation due to repeated needle venepuncture at the same site and subsequent obliteration of the upper venous segment. The end-to-end anastomosis seems to be preferable to other techniques because of the absence of local vascular complications and a lower risk of cardiac embarassment. The 'anatomical snuffbox' site is convenient and spares the proximal vessels for reoperation if necessary.