How reliable is assessment of true vocal cord-arytenoid unit mobility in patients affected by laryngeal cancer? a multi-institutional study on 366 patients from the ARYFIX collaborative group.

PURPOSE: In clinical practice the assessment of the "vocal cord-arytenoid unit" (VCAU) mobility is crucial in the staging, prognosis, and choice of treatment of laryngeal squamous cell carcinoma (LSCC). The aim of the present study was to measure repeatability and reliability of clinical assessment of VCAU mobility and radiologic analysis of posterior laryngeal extension. METHODS: In this multi-institutional retrospective study, patients with LSCC-induced impairment of VCAU mobility who received curative treatment were included; pre-treatment endoscopy and contrast-enhanced imaging were collected and evaluated by raters. According to their evaluations, concordance, number of assigned categories, and inter- and intra-rater agreement were calculated. RESULTS: Twenty-two otorhinolaryngologists evaluated 366 videolaryngoscopies (total evaluations: 2170) and 6 radiologists evaluated 237 imaging studies (total evaluations: 477). The concordance of clinical rating was excellent in only 22.7% of cases. Overall, inter- and intra-rater agreement was weak. Supraglottic cancers and transoral endoscopy were associated with the lowest inter-observer reliability values. Radiologic inter-rater agreement was low and did not vary with imaging technique. Intra-rater reliability of radiologic evaluation was optimal. CONCLUSIONS: The current methods to assess VCAU mobility and posterior extension of LSCC are flawed by weak inter-observer agreement and reliability. Radiologic evaluation was characterized by very high intra-rater agreement, but weak inter-observer reliability. The relevance of VCAU mobility assessment in laryngeal oncology should be re-weighted. Patients affected by LSCC requiring imaging should be referred to dedicated radiologists with experience in head and neck oncology.

A multicenter validation of the revised version of the Milan system for reporting salivary gland cytology (MSRSGC).

INTRODUCTION: Fine-needle aspiration cytology (FNAC) is a basic step in the diagnosis of salivary gland tumors that have a wide variety of histological types. The recent Milan system for reporting salivary gland cytopathology (MSRSGC) can correlate the risk of malignancy with precise cytological features. A revised version was recently proposed to improve the surgical relevance and facilitate uniform management. MATERIAL AND METHODS: A multicenter study retrospectively used the original and revised MSRSGC criteria to classify a series of patients who received surgery after FNAC. RESULTS: We enrolled 503 patients from three tertiary centers. The risk of malignancy for the MSRSGC resulted 19.5% in cat. I, 14.3% in cat. II, 17.6% in cat. III, 3.6% in cat. IVa, 24.6% in cat. IVb, 66.7% in cat. V, and 96.8% in cat. VI. The results from the revised MSRSGC were consistent with the original values. CONCLUSION: The MSRSGC is a promising classification system. In our opinion, the revised version of the MSRSGC supplements FNAC with some crucial clinical information and can better identify the appropriate treatment in each category.

Surgical treatment of iatrogenic lesions of the proximal common bile duct.

Between January 1979 and September 1999 a series of 96 patients were operated on at our institution for iatrogenic biliary injuries, and among them 62 involved the proximal biliary tract. Injuries, according to the Strasberg classification, were type E2 in 18 patients, type E3 in 29 patients, and type E4 in 15 patients. The most frequent primary surgical procedures were laparoscopic cholecystectomy in 27 of the 62 patients (43.6%) and open cholecystectomy in 30 patients (48.3%). Previous repair had been attempted in 25 patients (40.3%). A total of 58 cholangiojejunostomies were performed. Repair had been performed directly, and a T-tube had been left in the main bile duct in four patients with E2 Strasberg lesions. Postoperative death occurred in four patients (6.4%). Outcome was graded as excellent, good, or poor depending on clinical symptoms, liver function tests, and the need for reintervention due to anastomotic stricture. The final outcome was evaluated in 54 patients. The mean follow-up was 5.9 +/- 0.3 years, with the longest follow-up 10.2 years. Following our first repair 49 of the 54 patients (90.7%) had excellent results, 1 (1.9%) had good results, and 4 (7.4%) had poor results. None of the patients who underwent immediate or early repair had complications. Diagnostic and therapeutic courses are given on the basis of the type of lesion and the timing of repair. We emphasize the importance of timing (i.e., carrying out surgical repair as soon as possible) and of cholangiojejunostomy reconstruction in respect to defined technical principles. Moreover, we believe that repair treatment at a hepatobiliary center with multidisciplinary competence greatly influences the final long-term outcome.

D1 versus D2 pancreatoduodenectomy in surgical therapy of pancreatic head cancer.

BACKGROUND/AIMS: The aim of this study was to evaluate the influence of standard pancreatoduodenectomy versus pancreatoduodenectomy with extended lymphadenectomy and the role of adjuvant therapy on survival in patients with ductal adenocarcinoma of the pancreatic head. In addition the problems related to resection are discussed. METHODOLOGY: A total number of 124 pts operated on between 1985 and 1999 were divided into three groups according to our different strategies. Standard resection (D1) was performed on 48 patients (group A), extended resection (D2) on 45 patients (group B) and combined treatment (extended resection plus adjuvant therapy) on 31 patients. The outcome of these three groups was compared with regard to postoperative morbidity and survival. RESULTS: There was no significant difference in terms of survival between group A and B, while adjuvant therapy (group C), achieved statistical significance as factor influencing survival, together with tumor stage. CONCLUSIONS: Our data suggest that no further improvement can be obtained on long-term survival by extended retroperitoneal dissection while chemoradiotherapy showed a doubling of median survival.

Role of p53 mutations on survival after pancreatoduodenectomy for ductal adenocarcinoma of the pancreatic head.

BACKGROUND/AIMS: To determine the role of p53 mutations on survival after pancreatoduodenectomy for adenocarcinoma of the pancreatic head. METHODOLOGY: Resected specimens were assessed for expression of wild-type or mutated p53. Survival of p53-negative and- positive patients was investigated, and differences noted at 0.05 level. RESULTS: Expression of wild-type p53 is associated with a significant improvement in overall survival, especially for patients without nodal metastases. CONCLUSIONS: Preoperative p53 determination could enable further patient selection for aggressive surgery.

Combined laparoendoscopic approach for biliary lithiasis treatment.

BACKGROUND/AIMS: The treatment of common bile duct stones diagnosed during videolaparoscopic cholecystectomy is still under debate. In cases of suspected common bile duct stones, a double approach with endoscopic retrograde cholangiopancreatography either prior to, or following videolaparoscopic cholecystectomy is the current routine in many centers. An intraoperative endoscopic retrograde cholangiopancreatography with endoscopic papillosphincterotomy and stone extraction has recently been proposed. METHODOLOGY: We compared the approaches for suspected common bile duct stones in 21 cases of combined intervention endoscopic retrograde cholangiopancreatography during videolaparoscopic cholecystectomy to 17 cases of sequential intervention (endoscopic retrograde cholangiopancreatography prior to videolaparoscopic cholecystectomy). Complications and postoperative monitoring are discussed and reported on the basis of hospital stay. RESULTS: Although the efficacy and the complications are similar, patients treated with the sequential approach stayed in the hospital longer because of the double monitoring period during both after endoscopic retrograde cholangiopancreatography and after videolaparoscopic cholecystectomy. CONCLUSIONS: A combined approach to suspected common bile duct stones during videolaparoscopic cholecystectomy could be an effective and a financially worthwhile treatment.

Surgery for hilar cholangiocarcinoma: an Italian experience.

From January 1980 to June 1997 we treated 159 patients with carcinoma of the hepatic duct confluence. Seventy-five patients underwent surgical resection (overall resectability rate: 47.2%), and radical resection was attempted in 46 patients (radical resectability rate: 28.9%) classified in the first three stages of our staging system. Perioperative mortality was 10% (16 patients). The 5-year survival rate for 46 patients with curative resection was 17.5% with a median survival of 19 months. The 5-year survival rate for those patients who underwent combined caudate lobectomy (n = 17) was 25%, whereas the survival rate for those who did not was zero. The difference between these two groups' results was statistically significant. The importance of careful preoperative staging is stressed. Preoperative tests should be limited to investigations (ultrasound with Doppler scan, spiral computed tomography, percutaneous transhepatic cholangiography) supplying most information about intra- and extrabiliary diffusion of the tumoral mass. We conclude by highlighting the importance of resection as the only treatment potentially improving long-term survival. On the basis of these results, caudate lobectomy is always recommended in association with resectional treatment of the neoplasm.

Klatskin tumour: radical and palliative treatment.

Primitive neoplasms of proximal extrahepatic bile ducts keep their peculiar morphological and spreading patterns, as firstly described by J. Klatskin. Diagnostic and therapeutic approach were modified in the last year, on the basis of technological progress in imaging and more aggressive surgical attitude. Authors reviewed their clinical experience from 1970 to 1995 concerning proximal extrahepatic bile ducts tumors management, mainly evaluating the evolution of diagnostic work-up and the role of resection. Preoperative work-up is now trimed to non invasive techniques, in order to evaluate the intra and extra biliary diffusion; PTC-PTBD performed preoperatively give a clear biliary map, and could be the first step of a palliative definitive treatment in case of non operable patients. Radical resection remains the gold standard of therapy, with the best long-term results. Palliation must be obtained by the easiest comfortable method for the patient (i.e. self-blocking percutaneously inserted endoprosthesis).

Intrahepatic lithiasis above a bilio-digestive anastomosis.

The authors review their experience of twenty-five cases of intrahepatic lithiasis proximal to a bilio-digestive anastomotic stricture. Patients were operated on between 1970 and 1990, with a later follow-up in 1993. The pathogenesis of stone formation, in these cases, was relatable to multiple factors: biliary infection, presence of lithogenic nuclei (e.g. foreign bodies such as suture stitches), biliary stasis due to the stenosis. Management of this peculiar disease must take into account both surgical options and percutaneous as well as endoscopic methods. Our approach is the reconstruction of the stenotic anastomosis at its highest point, associated with intraoperative lithotomy followed by post-operative lithotomy and lithotripsy (if necessary) using PTCS (percutaneous transhepatic cholangioscopy). The best results are achieved with cooperation between surgeon, radiologist and endoscopist, aimed at preventing post-operative complications and severe consequences for the patient.

Neoplasm of the hepatic hilum: the role of resection.

A series of one hundred cases of primitive tumors of the biliary confluence (Klatskin tumor) observed between 1970 and 1990 are reviewed with respect to the variations occurring in the diagnostic backup and treatment policy. The need for peroperative staging is noted: On the basis of their clinical experience, the authors restricted the preoperative study to those investigations providing more information about endo- and exobiliary diffusion of tumoral mass (ultrasound, direct cholangiography). The review demonstrates the possibilities of a surgical approach to a palliative or resectional treatment in all patients in whom no local or general contraindications are present. Other cases are treated with percutaneous or endoscopic biliary stenting. The authors conclude that tumor resection with bilio-digestive anastomosis is the treatment of choice in selected patients, and results in a better quality of life with an improved "comfort index".

Primitive hepatic hilum neoplasm.

One hundred ten cases of primitive hepatic hilum neoplasms (Klatskin tumor) observed from January 1970 to June 1992 are reviewed and the variations occurring in the diagnostic back-up and treatment policy are considered. The importance of careful preoperative staging is stressed. Preoperative tests should be limited to investigations supplying most informations about endo- and esobiliary diffusion of the tumoral mass (ultrasound, direct cholangiography, portography). This paper demonstrates that a surgical approach with both palliative or resective aims is suitable for all patients with no local or general contraindications. Other cases are treated with percutaneous or endoscopic biliary stenting. The authors conclude by pointing out that tumoral resection with biliodigestive anastomosis is in any case the treatment of choice in these patients as it gives a better quality of life (improved "comfort index").

Percutaneous transhepatic biliary drainage--twelve years' experience.

Our experience with percutaneous transhepatic biliary drainage in a total of 362 patients carried out between January 1977 and December 1988 is described. Three hundred and fifty drains were correctly placed, and results were good in 285 (81.5%), fair in 53 (15.1%) and poor in 12 (3.4%). In 12 of the total number of cases (3.4%) it was not possible to position the drain effectively. The mortality rate of the method was 0.8% (3 cases). Complications were as follows: obstruction 7 (1.9%), dislodgement 15 (4.1%), hemobilia 15 (4.1%), hemoperitoneum 1 (0.2%), cholangitis 6 (1.6%), and choleperitoneum 10 (2.7%). In view of the good results and low incidence of complications the conclusion is that in skilled hands, percutaneous transhepatic biliary drainage is a very useful method that should be available in any center specializing in hepatobiliary surgery.

Percutaneous transhepatic biliary drainage twelve years' experience.

Experience with a total of 362 percutaneous transhepatic biliary drainage (PTBD) carried out between January 1977 and December 1988, is described. Of these, 350 drains were correctly placed and 285 (81.5%) showed a good result, 53 (15.1%) a fair result and 12 (3.4%) a poor outcome. In 12 of the total number of cases (3.4%) it was not possible to position the drain effectively. The mortality rate of the method was 0.8% (3 cases). Complications were as follows: obstruction 7 (1.9%), dislodgement 15 (4.1%), hemobilia 15 (4.1%), hemoperitoneum 1 (0.2%), cholangitis 6 (1.6%), choleperitoneum 10 (2.7%). In view of the good results and low incidence of complications it is concluded that in skilled hands PTBD is a very useful method that should be available at any center specializing in hepatobiliary surgery.

Technique and endoscopic monitoring of the healing process in bilioenteric anastomoses.

Thirty-three patients were given cholangiojejunoanastomoses: 13 for benign postoperative stenoses of the biliary tract (BT) with or without lithiasis; five for massive intra and extra-hepatic lithiasis; 15 for malignant stenoses on the upper third of the biliary ways. The 15 patients in Group A were given a muco-mucosal anastomosis and the 18 in Group B extramucosal anastomosis after excision of the excess mucosa on the jejunotomy. In both groups an interrupted suture using fine, slow-absorption thread was employed. Three patients (two from Group A and one from Group B) were excluded from the study due to postoperative filtration of the anastomosis. Transhepatic cholangioscopic monitoring of the healing process on the 15th, 20th, 30th and 40th day showed that while both types of anastomosis were equally secure, the extramucosal suture after excision of excess mucosa produced wider anastomoses and is therefore advisable in all cases of bilioenteric anastomosis (BEA) but especially when the biliary ways are narrow or tendentially thin-walled.