Laparoscopic antireflux surgery: indications, preoperative evaluation, techniques, and outcomes.

BACKGROUND/AIMS: During the past decade, the development of mini-invasive surgery has determined a resurgence in popularity of the antireflux surgery. The purpose of this study is to examine indications, preoperative evaluation, surgical techniques, and outcomes after mini-invasive surgery. METHODOLOGY: From 1996 to 2000, 25 patients with gastroesophageal reflux disease associated to hiatal hernia underwent laparoscopic surgery. The indication for surgery was failure of long-term medical therapy. All patients had severe acid reflux on 24h-pH monitoring, endoscopic evidence of esophagitis, and defective lower esophageal sphincter. Nissen fundoplication was performed in 16 patients with normal esophageal body motility, and 270 degrees posterior fundoplication in 9 patients with low esophageal motility. RESULTS: Mortality and conversion rate were 0. Mean operative time was 130 minutes and mean postoperative hospital stay 5 days. Twenty-four (96%) patients were completely cured of reflux symptoms off all medications. Transient, mild postoperative dysphagia occurred in 3 patients (12%). There was a significant improvement of the results in postoperative esophageal manometry and 24h-pH monitoring. CONCLUSIONS: Despite the fact that few patients were treated by using laparoscopic approach, results are encouraging with less morbidity and great advantages for patients. Precise selection of patients and surgical techniques are essential.

[Techniques and outcomes of laparoscopic surgery in gastroesophageal reflux disease]. / Tecniche e risultati della chirurgia laparoscopica nella malattia da reflusso gastroesofageo.

BACKGROUND: The purpose of this study is to report personal experience in laparoscopic antireflux surgery and to analyze the clinical and functional outcomes of this procedure, also in relation to the different techniques used. METHODS: From 1996 to 2000, 20 patients with gastroesophageal reflux disease associated with hiatal hernia underwent laparoscopic surgery. The indication for surgery was failure of long-term medical therapy. All patients had severe acid reflux on 24 hrs-pH monitoring, endoscopic evidence of esophagitis and hiatal hernia, and defective lower esophageal sphincter. A Nissen fundoplication was performed in 13 patients with normal esophageal body motility, and a 270 degrees posterior fundoplication in seven patients with low esophageal motility. RESULTS: Mortality and conversion rate were 0. Mean operative time was 135 min and mean postoperative hospital stay 5 days. Operative morbidity was 15%. All the patients were completely cured of reflux symptoms; transient mild postoperative dysphagia occurred in two patients (10%). There was a significantly improvement of the results in postoperative esophageal manometry and 24 hrs-pH monitoring. CONCLUSIONS: This preliminary experience suggests that laparoscopic surgery represents a safe and effective procedure for the treatment of gastroesophageal reflux disease. Precise selection of patients and adequate surgical technique are essential.

Survival after pancreaticoduodenectomy for ductal adenocarcinoma of the head of the pancreas.

Recent reports have demonstrated an improvement in 5-year actuarial survival of patients with resected ductal adenocarcinoma. The purpose of this study was to determine the factors favoring long-term survival after pancreaticoduodenectomy. Between 1974 and 1995, 75 patients with pancreatic head carcinoma underwent pancreaticoduodenectomy in our department. The overall postoperative mortality rate was 5.3% and morbidity was 24%. Median survival following resection was 17 months. The estimated 1-, 2- and 5-year survival rates were 68%, 46.7% and 18.7%, respectively. Five-year survival was significantly greater for node-negative versus node-positive patients (41.7% vs 7.8%, P < 0.001), for smaller (< 3 cm) versus larger tumours (33.3% vs 8.8%, P < 0.006), and for negative versus positive resection margins (23.3% vs 0, P < 0.001). Other factors, including gender, age, and blood transfusion had no significant effect on survival. The multivariate analysis was done using the Cox proportional hazards model to determine independent prognostic determinants of survival. The presence of positive resection margins was the strongest independent predictor of decreased survival. Lymph node metastasis, tumour size > 3 cm, and poor histologic differentiation were also independent predictors of poor survival. The most favorable subset consisted in 17 patients who had negative resection margins, negative lymph nodes, and tumor size < 3 cm. Their 5-year survival rate was 52.9%.

Factors influencing survival after resection for ductal adenocarcinoma of the head of the pancreas.

BACKGROUND AND OBJECTIVES: Recent reports have demonstrated improvement in the 5-year actuarial survival for patients with resected ductal adenocarcinoma. The purpose of this study is to determine the factors favoring long-term survival after pancreaticoduodenectomy. METHODS: Between 1974 and 1995, 75 patients with pancreatic head carcinoma underwent pancreaticoduodenectomy in our department. RESULTS: Overall postoperative mortality rate was 5. 3% and morbidity was 24%. Median survival following resection was 17 months. Estimated 1-, 2-, and 5-year survival rates were 68%, 46.7%, and 18.7%, respectively. Five-year survival was greater for node-negative than for node-positive patients (41.7% vs. 7.8%, P < 0. 001) and for smaller (<3 cm) than for larger tumors (33.3% vs. 8.8%, P < 0.006). The 5-year survival in patients with negative margins (n = 60) was 23.3%, whereas no patient with positive margins (n = 15) survived at 13 months (P < 0.001). Multivariate analysis, performed by the Cox proportional hazards model, indicated that margin status, lymph node metastasis, tumor size, and poor histological differentiation were independent predictors of poor survival. CONCLUSIONS: Five-year survival for patients undergoing pancreaticoduodenectomy for ductal adenocarcinoma of the pancreas was 18.7%. Survival was greater in the group of patients with negative lymph nodes, tumor size <3 cm, and negative margin status.

A pitfall with the use of 111In-pentetreotide scintigraphy in the resected bronchopulmonary carcinoids follow-up: a case report.

AIM: To re-evaluate the use of 111In-pentetreotide scintigraphy (Octreoscan) in the follow-up of patients operated for carcinoids, as second-step investigation, after chest X-ray, CT-scan and serological marker' levels. METHODS AND RESULTS: We describe the case of a female patient, 58-year-old, operated on for a non-secretory lung carcinoid. Five years after surgery, the CT-scan showed the enlargement of the bilateral hylo-mediastinal lymph nodes, suggestive for carcinoid recurrences. In order to confirm that, the patient was submitted to an Octreoscan that showed the presence of enlarged hylo-mediastinal adenopathies matching with the lesions observed at the CT-scan. Because the serological examination of NSE, chromogranin and serotonin, and the 5-HIIA were in the normal range, the patient was submitted to a lymph node biopsy through a mediastinoscopy. The histological examination of the specimens revealed a sarcoidosis and the patient was started on steroid therapy with good outcome. CONCLUSIONS: We conclude that: 1. the octreoscan scintigraphy in the follow-up of resected carcinoids can give false-positive results and 2. in consequence, the mediastinoscopy is a discriminating investigation in case of mediastinal lymph nodes disease.

Difficulties with CT-guided needle biopsy and VATS, as combined approach for the diagnosis and treatment of peripheral pulmonary nodules: a case report.

AIM: To re-evaluate the use of CT-guided needle biopsy and VATS, as our combined approach protocol for the diagnosis and treatment of peripheral pulmonary nodules. METHODS AND RESULTS: We describe the case of a male smoking patient, 50-year-old, who came to our service for the histological diagnosis of a right pulmonary lesion incidentally revealed. He was submitted to our diagnostic and therapeutic protocol for peripheral pulmonary nodules, that is a combined approach of CT-guided needle biopsy, anchorage of the lesion and VATS resection. Difficulties with this technique can raise when: 1. the cytological CT-guided needle biopsy is not diagnostic, 2. the anchorage is not successful, 3. the malignancy of the lesion cannot be surely determined by the extemporary histological examination. In this patient all these difficulties were encountered. CONCLUSIONS: We conclude that our diagnostic and therapeutic protocol for peripheral pulmonary nodules is not invalidated by this experience, even in consideration of the fact that we applied successfully the protocol in several previous cases.

Significance of lymph node metastases in the surgical management of pancreatic head carcinoma.

Recent reports have demonstrated a reduction in the morbidity and mortality of pancreatic resections and improvement in the 5-actuarial survival for patients with resected ductal adenocarcinoma. However, the prognosis for patients with lymph node metastases remains uncertain. The purpose of this study is to determine if the presence of lymph node metastases influences the survival in patients with otherwise potentially curable pancreatic head carcinoma. Between January 1974 and December 1995, 340 patients with pancreatic carcinoma, including 238 patients with pancreatic head tumours, were evaluated and treated in our Department. Seventy-seven (32.3%) patients with pancreatic head carcinoma underwent pancreaticoduodenectomy. Ages ranged from 40 to 76 years, with a mean age of 61 years. Fifty patients were male, twenty-seven were female. The overall postoperative mortality rate was 5.2% (4 patients) and morbidity was 23.4%. Median survival following resection was 17 months (range 0 to 79). The estimated 1-, 2-, 3- and 5-year survival were 68.8%, 48.1%, 23.4% and 18.2%, respectively. There were 14 five-year survivors. Of the 77 patients, 25 (32.5%) had negative lymph nodes. The median and 5-year survival in these node-negative patients were 33 months (range 5 to 79) and 40%, respectively. Whereas the median survival and 5-year survival in 52 patients with lymph nodes metastases were 14 months (range 0 to 61) and 7.7%, respectively (P<0.0001). There were 4 five-year survivors in the group of patients with lymph node metastases; in 2 patients was performed extensive lymph node dissection (R2) and in other 2 patients R1 procedure. In the patients with lymph node metastases undergoing R1 resection (n = 39), the 1-, 2- and 5-year survival rates were 48.7%, 23.1% and 5.1%, respectively. Whereas in the patients with positive lymph nodes undergoing R2 resection (n = 14), the 1-, 2- and 5-year survival rates were 92.9%, 64.3% and 14.3%, respectively (P<0.02). As expected, tumour size and margin status in specimen proved to be two significant factors predicting survival. Pancreatoduodenectomy can be performed with low operative mortality. Lymph nodes metastases are found in 67.5% of patient undergoing resection. Pancreaticoduodenectomy offers good palliation for patients with lymph nodes metastases and encouraging long-term survival rates as well as a chance for cure in patients with negative lymph nodes and negative margins of resection.

Transfer factor as an adjuvant to non-small cell lung cancer (NSCLC) therapy.

The rationale for using transfer factor (TF) in lung cancer patients is that the possibility of improving their cell-mediated immunity to tumour associated antigens (TAA) may improve their survival. From Jan 1984 to Jan 1995, 99 non-small cell lung cancer (NSCLC) resected patients were monthly treated with TF, extracted from the lymphocytes of blood bank donors. In the same period, 257 NSCLC resected patients were considered as non-treated controls. The survival rates of the TF treated group appear significantly improved both for patients in stages 3a and 3b, and patients with histological subtype "large cell carcinoma" (P < 0.02). Survival of TF treated patients is also significantly higher (P < 0.02) for patients with lymph node involvement (N2 disease). The results of this study suggest that the administration of TF to NSCLC resected patients may improve survival.

Functional outcome in handsewn versus stapled ileal pouch-anal anastomosis.

Eighty-eight of 119 patients who underwent ileal pouch-anal anastomosis for ulcerative colitis were evaluated. Forty patients had a handsewn anastomosis (Hs) with mucosectomy, and 48 had a stapled anastomosis (St). In each patient, we evaluated operative, morphologic, functional, and manometric features. The results in the Hs and St groups were similar when the anastomosis was within 1 cm of the dentate line. In particular, there was no correlation between the type of anastomosis and the number of bowel movements in a 24-hour period, the presence of the urge to defecate, and the use of antidiarrheal drugs. Leakage was significantly higher in the Hs group, even when the anastomosis was less than 1 cm from the dentate line. Pouchitis was more frequent in the Hs group, and, within this group, among those with a short distance between the anastomosis and the dentate line. No correlations were found between the presence of columnar epithelium or active colitis in the mucosa below the anastomosis, the functional outcomes, and the incidence of pouchitis.

[Myasthenia and muscle relaxants]. / Miastenia e miorilassanti.

Eighteen myasthenic patients have been operated on under general anaesthesia; 14 subjected to thymectomy and 2 to emergency procedures (caesarean section and laparotomy because of intestinal obstruction). Atracurium (0.3 mg/kg) and vecuronium (0.06 mg/kg) exhibited a long duration of action only in the two cases affected by the more severe signs and symptoms of the disease.

Intensity, latency and duration of post-thoracotomy pain: relationship to personality traits.

The relationship between personality traits and post-surgical pain was studied in 126 patients submitted to a particular set of procedures. The personality was studied by MMPI, STAI, EPI tests before surgery. After surgery, pain intensity was positively related to duration, and pain latency negatively related to both intensity and duration. According to multiple regression analysis, pain intensity was found to be predictable from both the state anxiety and psychoasthenia scales, pain latency from state anxiety and masculinity/femininity, pain duration from aggressivity and hysteria. Results suggest that personality traits constitute strong modulatory factors of the overall pain experience.

The "Kergin pneumonectomy".

Out of a series of 211 stage III (A and B) lung cancers radically resected with routine lymphadenectomy from 1971 to 1987, a total of 11 were squamous cell carcinomas invading the right main bronchus and lateral portion of the trachea. These patients were managed using a particular technique that we have always arbitrarily called, "Kergin pneumonectomy," after the Toronto surgeon who described it in 1952. These patients, today, are staged III B. There was no operative mortality and only 2 minor complications. Two patients survived 3 years and 1 is alive and free of disease 7 years from surgery. This technique should be considered before embarking on more perilous surgery such as "sleeve pneumonectomy," a procedure which still carries high mortality and morbidity rates and requires special equipment and intensive postoperative care.

Immunohistochemical study of basement membrane antigens in bronchioloalveolar carcinoma.

Bronchioloalveolar carcinoma (BAC), not yet completely defined as a biologic entity, has recently been classified into two different types. Immunohistochemical investigations, aimed at characterizing basement membrane (BM) behavior in the two types of BAC, revealed different distribution patterns. The first (Type I BAC) showed a linear staining for laminin and Type IV collagen similar to normal lung. Fibronectin was widely present in the septal interstitium and patchily distributed along the BM. The second (Type II BAC) showed a variable reaction for Type IV collagen and fibronectin, whereas laminin was absent or appeared as short, interrupted tracts around the epithelial neoplastic population, similar to conventional adenocarcinoma of the lung. These results suggest that only Type I BAC shows structural characteristics different from those of conventional adenocarcinoma of the lung.

Small cell carcinoma of the lung: is there a place for surgery?

In many cases, surgery is not considered for anaplastic small cell carcinoma even in localized lesions. A review of the literature and the results obtained in our series of 30 patients prompt us to recommend surgery in stage I disease.

Tracheobronchial ruptures due to cuffed Carlens tubes.

At our institution in the past 22 years, more than 3,000 patients have undergone chest procedures, and 2,700 of them were intubated with a cuffed Carlens endotracheal tube. In this paper we report on 5 patients with tracheobronchial ruptures caused by intubation with these tubes. We believe this hazard should be brought to the attention of physicians.

Technique for the management of anterior flail chest.

A technique for the management of anterior flail chest consisting of osteosynthesis and the positioning of two long Kirschner wires behind the sternum in the form of a St Andrew's cross is described. The procedure is easy to perform, the patient is ambulant early, and the results are good.