Endovascular preservation of pelvic circulation with external iliac-to-internal iliac artery "cross-stenting" in patients with aorto-iliac aneurysms: a case report and literature review.

Endovascular success depends heavily upon anatomical suitability for secure graft placement. Common iliac artery (CIA) aneurysms frequently extend close to the iliac bifurcation, requiring distal fixation in the external iliac artery (EIA), in turn excluding the internal iliac artery (IIA). The preservation of circulation to at least one IIA artery is highly recommended. We report an endovascular technique for complete preservation of the hypogastric arteries of an aorto-iliac aneurysm extending into the iliac bifurcation and hypogastric artery. A left CIA aneurysm involving the iliac bifurcation was excluded with a covered Fluency stent-graft (Bard Inc., New Jersey, USA) deployed from the EIA into the IIA followed by the internal deployment of a Luminex uncovered stent (Bard Inc.) extended into one branch of the hypograstric artery. IVUS evaluation was essential in determining precise aneurysm and sealing zone measurements. Complete preservation of hypogastric circulation was achieved. The placement of the uncovered stent effectively extended the sealing zones without covering either of the hypogastric distal branches and concurrently corrected the Fluency stent kinking due to severe arterial tortuosity. In CIA aneurysms involving the IIA, an uncovered stent can extend the sealing zones, whilst maintaining complete preservation of pelvic circulation and offers support to the covered stent-graft. IVUS seems necessary for precise neck evaluation.

Daunorubicin and daunorubicinol tissue concentrations in gastric cancer patients after local administration of a liposomal preparation.

BACKGROUND: In order to study a model that maximizes gastric cancer tissue and lymph node exposure to antineoplastic drugs while simultaneously reducing their systemic bioavailability, we implemented a preliminary investigation of the disposition of a daunorubicin liposomal preparation (D) in gastric cancer patients by means of gastric submucosa injection. METHOD: After a dose finding study, 12 patients (candidates for gastric resection because of gastric cancer) were studied by administering two doses of 50 mg of D (the highest tolerated dose) 1 week before surgery. RESULTS: Mean tissue concentrations at surgery were higher in cancer, normal non-injected peritumoral mucosa, and lymph node tissues than in serum or urine, in which there were only trace concentrations. While epigastric pain and histological modifications (inflammation and thickening of the gastric layers) were manifest in patients treated with 75 mg doses in the dose finding session, no clinical signs or symptoms of toxicity were recorded in those administered with 50 mg doses. CONCLUSIONS: Local administration of D may allow it to reach high concentrations in normal non-injected peritumoral mucosa, and lymph nodes, while simultaneously avoiding significant systemic exposure and toxicity. This procedure could merit further investigation, in view of a possible use of anthracyclines against metastatic diffusion through the lymphatic system in gastric cancer patients who are candidates for gastric resection.

Surgical treatment of abdominal aortic aneurysm with concomitant renal cell carcinoma: a single-centre experience with review of the literature.

AIM: The association between abdominal aortic aneurysm (AAA) and renal cancer is becoming more frequent, raising several questions about therapeutic and surgical strategies of management for both diseases. METHODS: Between October 1988 and May 2004, 913 AAA patients underwent surgical or endovascular repair at the I Division of General Surgery of the University of Verona (Italy). In 61 cases (6.7%) an association with a solid neoplasm was found; in 12 cases (1.3%) the neoplasm was a renal cell carcinoma. RESULTS: Ten patients underwent a simultaneous approach to AAA and renal cancer, with aneurismectomy performed first. In 2 cases a two-stage procedure was preferred; 1 patient underwent aneurismectomy first for AAA rupture while a second patient was even affected by gastric cancer and was submitted to nephrectomy and total gastrectomy as primary procedures. There was no mortality and only one postoperative complication was registered. CONCLUSIONS: A simultaneous surgical approach can be done safely, performing aneurismectomy as first step without significant risk of graft infection. Simultaneous treatment has the advantage of avoiding a second major abdominal procedure and eliminate the risk of postoperative aortic aneurysm rupture. Performing a two-stage approach, the procedure for the disease regarded as life-threatening is performed first. Priority should be given to renal cell neoplasm in selected cases.

[Long-term results of neoadjuvant radiochemotherapy in squamous carcinoma of the thoracic esophagus]. / Risultati a lungo termine del trattamento chemio-radioterapico neoadiuvante del carcinoma squamoso dell'esofago toracico.

AIM: Surgery is considered the mainstay of therapy for clinically resectable esophageal cancer, even though neoadjuvant treatments are frequently added. The aim of this study was to analyse our experience on neoadjuvant treatment of squamous cell carcinoma of the thoracic esophagus with special reference to long-term METHODS: The results of 66 patients who underwent neoadjuvant chemo-radiotherapy for squamous cell carcinoma of the thoracic esophagus at the 1(st) Division of General Surgery, University of Verona, from February 1995 to December 2002 were analysed statistically. The median follow-up period for the surviving patients was 65.3 months. RESULTS: The induction treatment was completed in 93.9% of cases, with a null treatment related mortality and a complication rate of 34.8%. Sixty-one out of the 66 patients (92.4%) underwent resection with a R0-resection rate of 83.9%. A major pathological response (responders) was gained in 42.6% of the cases, with a complete response (pTONO) observed in 29.5% of the cases. Overall 5-year survival for the 66 patients was 30%, while the 5-year survival rate raised to 43% in R0-patients. A better long-term survival was observed for responders with respect to ''non-responders'' with a 5-year survival rate of 70% and 13%, respectively (P<0.001). CONCLUSIONS: This neoadjuvant protocol regimen represents a feasible treatment with an acceptable morbidity. The tumor efficacy in term of pathological responses was similar to literature RESULTS: An high rate of R0-resections was achieved with a possibility of cure limited to this group of patients. A better long-term survival was observed in patients with major pathological responses.

Laparoscopic approach to postoperative adhesive obstruction.

BACKGROUND: Some authors have assessed the feasibility of laparoscopy in the treatment of postoperative adhesive obstruction, but conclusions about its effectiveness are related to different selection criteria used for surgery. This paper reports on our experience in laparoscopic adhesiolysis and analyses the results on the basis of the selection criteria used. METHODS: From January 1993 to December 2001, 65 patients were submitted to laparoscopic adhesiolysis for small bowel obstruction according to specific selection criteria. Of the 65 patients, 40 were admitted for acute obstruction and 25 for chronic or recurrent transit disturbances. Correlation between historical and clinical data and the results of surgical treatment were statistically analyzed. RESULTS: The procedure was completed by laparoscopy in 52 patients (conversion rate: 20%). Mean postoperative stay was 4.4 days with a 12.3% morbidity and no mortality. Recurrence rate was 15.4%; a single correlation was found between recurrence and age. CONCLUSIONS: Laparoscopic adhesiolysis in the treatment of small bowel obstructions seems to be effective; further studies are required to define selection criteria for surgery and confirm real advantages in terms of recurrences.

[Superextended lymphadenectomy (D4) in the treatment of gastric adenocarcinoma]. / La linfadenectomia superestesa (D4) nel trattamento dell'adenocarcinoma gastrico.

BACKGROUND: The incidence of paraaortic lymph node metastasis (N4) in relation with the site of the tumour, and survival in patients with gastric cancer who underwent gastric resection and superextended lymphadenectomy (D4), have been analyzed. METHODS: The frequency of paraaortic lymph node metastasis was studied in 132 patients who underwent gastrectomy with D4 lymphadenectomy during the period June 1988 - December 2000. Six patients with plastic linitis and 3 with carcinoma of the gastric stump were excluded from the analysis. RESULTS: In personal experience the most frequent postoperative morbidity were respiratory complication (7.6%) and pancreatic fistula (6.8%). Among the 132 patients the total number of dissected nodes was 6362 and the mean number of dissected nodes per case was 48.2. The total number of retrieved lymph nodes from the paraaortic station was 755 with a mean number 5.7 per patients. N4 nodal involvement was found in 25 (19%) of 132 patients: 14 (36%) patients with carcinoma located in the proximal third, 5 (13%) with tumour located in the middle third and 6 (11%) with carcinoma of the distal third of the stomach. The median survival time and the overall cumulative 5-year survival rate for curatively (R0) resected patients were 74 months and 52% respectively. CONCLUSIONS: The presence of metastasis in paraaortic lymph nodes in 19% of our patients, the low morbidity and mortality, the good survival after superextended lymphadenectomy, suggest that this lymphadenectomy should be considered in the curative surgical treatment of advanced gastric cancer, especially if located in the proximal third of the stomach (N4 in 36% of cases).

[Results of surgical treatment of acute cholecystitis. Prospective study of 280 cases]. / Risultati del trattamento chirurgico della colecistite acuta. Studio prospettico su 280 casi.

The Authors reported the results of surgical treatment of acute gallstone cholecystitis (AGC) in patients in whom different selection criteria have been applied. Two-hundred-eighty patients with a clinical and/or ultrasonographic diagnosis of ALC were admitted to the 1st Division of General Surgery-University of Verona Italy between January 1992 and June 2001, the patients were divided into five groups according to clinical features, laboratory tests and echographic signs. A specific approach was used in the different groups. An urgent laparoscopic cholecystectomy was performed in 67 patients. Elective laparoscopic treatment after urgent US guided percutaneous cholecystostomy (US-PC) was performed in 119 and after US-PC and ERCP in 50 patients. Laparoscopic cholecystectomy was performed in 236 patients with a conversion rate of 7.6%. No mortality, 6.7% morbidity and a mean hospital stay of 7.5 days. A selective therapeutic approach to AGC allow immediate treatment in all cases and correct diagnosis of associated diseases treatment. This approach makes it possible to reduce the conversion rate of laparoscopic cholecystectomy, morbidity and mortality.

[Goseki classification in adenocarcinoma of the cardia]. / La classificazione di Goseki nell'adenocarcinoma del cardias.

BACKGROUND: To assess an additional prognostic value of Goseki histological classification to TNM staging system in adenocarcinoma of the cardia. METHODS: Sixty-one patients curatively resected for advanced (T2, T3 and T4) cardia cancer at the I Division of General Surgery, University of Verona were classified in four different grades according to Goseki. Survival curves were estimated with Kaplan-Meier method and compared by the log-rank test. Multivariate analysis was performed by Cox regression model. c2 test was used to compare Goseki to Lauren classification and grading. After discharge from hospital all patients were followed with a mean follow-up of 39.5 months. RESULTS: Lauren classification and grading were significantly related to tubular differentiation (p<0.01). Kaplan-Meier estimates of survival showed a better 5-year outcome for tumors with good tubular differentiation (19%), even though the difference with poor tubular differentiated tumors was not statistically significant (p'0.06). Diffuse type carcinomas and tumors with poor cytological differentiation showed a worse prognosis at univariate analysis (p<0.01). Multivariate analysis showed no additional prognostic significance of any of the histological classification analyzed. Only T (p<0.02; RR 2.2; IC 1.2-4) and N (p<0.01; RR 5; IC 2.4-11) were independent prognostic factors. CONCLUSIONS: In adenocarcinoma of the cardia, Goseki classification did not add any information to Lauren classification and to TNM staging system.

[Endoscopic, percutaneous and laparoscopic treatment for acute biliary pancreatitis]. / Traitement endoscopique, percutané et coelioscopique des pancréatites aiguës biliaires.

AIM OF THE STUDY: The aim of this study is to evaluate the results of acute gallstone pancreatitis treatment and to discuss indications in relation with the different forms of the disease. MATERIAL AND METHOD: From january 1992 to june 2001, 137 patients have been treated for an acute gallstone pancreatitis. Diagnostic criteria were given by the history, clinical examination, biochemical and radiological findings. After exclusion of patients with a systemic disease, a group of 129 patients have been enrolled in a treatment regimen with an endoscopic retrograde cholangiopancreatography (ERCP) and eventual sphincterotomy, a percutaneous US-guided cholecystostomy (PC) when necessary and an elective laparoscopic cholecystectomy. RESULTS: ERCP has been successfully performed in 121/129 patients. A PC has been performed in 5/8 patients of the failed endoscopic procedure and in 14 with acute cholecystitis. Retrograde and percutaneous cholangiographies showed main bile duct stones in 89 patients, a dilatation of the main bile duct without stones in 26 patients and a negative finding in 6 patients. An endoscopic sphincterotomy has been performed in 117 patients. A laparoscopic cholecystectomy has been performed in 118 patients. Mortality and morbidity rates were 1.6 and 10.3%, respectively. CONCLUSION: ERCP and sphincterotomy seem to be indicated in all patients observed during the first 72 hours. Endoscopic treatment and percutaneous procedure make it possible to reduce at a very low rate the cases with an unfavourable course of the disease. A definitive treatment may then be performed by the way of a laparoscopic cholecystectomy.

Metastases to the para-aortic lymph nodes in adenocarcinoma of the cardia.

OBJECTIVE: To find out the extent of involvement of the para-aortic nodes in patients with adenocarcinoma of the gastric cardia. DESIGN: Open prospective study. SETTING: Teaching hospital, Italy. SUBJECTS: 23 patients with advanced adenocarcinoma of the cardia (type II, n = 10, and type III, n = 13) who were treated by total gastrectomy with resection of the distal oesophagus and extended lymphadenectomy (D4) between January 1997 and June 1999. These were compared with 21 patients with advanced carcinoma of the proximal third of the stomach who had total gastrectomy with D4 lymphadenectomy during the same period. Lymph nodes were retrieved immediately postoperatively and assigned to the appropriate station according to the classification of the Japanese Research Society for Gastric Cancer. MAIN OUTCOME MEASURES: Number of para-aortic and other nodes involved. RESULTS: 22 of the 23 patients had lymph node metastases, and in 5 the para-aortic nodes were involved (N4). N3 lymph nodes were involved in only 1 patient, despite involvement of para-aortic nodes. Among the 5 patients with N4 metastases, 1 had only N1 metastases in addition, with no involvement of N2 or N3 nodes. Patients with involved N4 nodes had more nodes involved overall than those who did not (mean (SD) 17 (5) compared with 8 (12)). CONCLUSIONS: 5/23 patients with advanced carcinoma of the cardia had involved para-aortic nodes. This may have some prognostic value, but larger studies of D4 lymphadenectomy specimens is required.

[Para-aortic lymph node involvement in gastric adenocarcinoma]. / Envahissement des ganglions para-aortiques dans les adénocarcinomes de l'estomac.

AIMS: To determine the significance of superextended lymphadenectomy (D4) in patients with gastric cancer. The incidence of para-aortic lymph node metastases (N4) was analysed as well as its relationship to the site of the tumour. PATIENTS AND METHODS: The frequency of para-aortic lymph node metastases was assessed in 110 patients who underwent gastrectomy with D4 lymphadenectomy during the period from June 1988 to October 1999; five patients with plastic linitis and three with carcinoma of the gastric stump were excluded from the study. RESULTS: The postoperative mortality rate was 2.7% (n = 3) and the postoperative morbidity rate was 29.1% (n = 32). In our experience the most frequent postoperative complications were pancreatic fistulas (7.3%) and respiratory complications (6.4%). Among the 110 patients, the total number of dissected nodes was 5245 and the mean number of dissected nodes per case was 47.7. The total number of retrieved lymph nodes from the para-aortic station level was 639, with a mean number of 5.8 per patient. N4 nodal involvement was found in 20 (18.2%) out of 110 patients: 12 (33%) patients with a carcinoma located in the proximal third, two (6%) with a tumour located in the middle third and six (15%) with a carcinoma of the distal third of the stomach. CONCLUSION: The presence of para-aortic lymph node involvement in 18.2% of the patients suggests that D4 lymphadenectomy should be considered in the curative surgical treatment of advanced gastric cancer, especially if located in the proximal third of the stomach (N4 + in 33% of the patients).

[Results of the surgical treatment of primary gastric lymphoma]. / Risultati del trattamento chirurgico del linfoma gastrico primitivo.

The aim of the study was to verify the long term results obtained in primary gastric lymphoma with a strategy consisting in surgery as first-line treatment. Over the period from January 1988 to December 1999, 44 patients with histologically proven primary gastric lymphoma underwent surgical treatment in the First Department of General Surgery of the University of Verona. Tumours were staged according to the Ann Arbor classification and divided, according to the Kiel classification, into high- and low-grade lymphoma. Patients received adjuvant chemotherapy depending on the grade of malignancy and/or completeness of resection. Of the 44 patients, 40 (90.9%) underwent curative resections, i.e. with complete macroscopic and microscopic tumour removal (R0), consisting in total gastrectomy in 34 cases and subtotal gastrectomy in 6. Twenty-five of 40 patients had stage IE and 15 stage IIE tumours. Adjuvant chemotherapy was given to 33 patients (30 high-grade lymphomas and 3 low-grade lymphomas with N2 metastases). The overall cumulative 10-year survival rate in patients who underwent R0 resection was 79% without any significant differences in 10-year survival between patients with high- and low-grade malignancy (both 79%; P = 0.582) or between patients with or without lymph node metastases (91% and 70%, respectively; P = 0.426). In conclusion, the present investigation suggests that surgery yields prolonged complete remission in a high percentage of patients affected by gastric lymphoma irrespective of histopathologic grade of the disease and nodal involvement.

Rhesus D-phenotype does not provide prognostic information additional to TNM staging in gastric cancer patients.

Recently, the Rhesus D-negative phenotype was identified in multivariate analysis as an important independent risk factor in gastric cancer patients who underwent curative resection. The distribution of Rhesus (Rh) D phenotype was investigated in a group of 268 patients who underwent gastrectomy for gastric cancer from June 1988 to April 1999. After excluding patients with short, potentially guaranteed follow-up or who deceased in the postoperative period, the prognostic significance of Rh D phenotype was evaluated in a subgroup of 239 patients by Cox regression model controlling for gender, age, site, histology, depth of tumor invasion (T), node metastasis (N), and type of resection (R). Two hundred and thirty-six patients (88.1%) presented an Rh+ phenotype and 32 (11.9%) presented an Rh- phenotype. A significant association was found between Rh D- phenotype and the presence of residual tumor after surgery (P = .01). The cumulative 5-year survival rate (95% confidence interval) was 37.3% (18.1-56.6) in patients with Rh- phenotype and 47.0% (39.2-54.4) in patients with Rh+ phenotype. The Rh D phenotype did not affect survival independently either in univariate analysis (P = .27) or in multivariate analysis (P = .55). The relative risk of death in D-negative versus D-positive patients decreased from 1.36 (95% confidence interval, 0.80-2.30) in univariate analysis to 0.84 (0.47-1.49) in multivariate analysis after controlling for depth of tumor invasion, lymph node metastases, and type of resection. Our study did not confirm the prognostic significance of Rh D phenotype in gastric cancer patients.

[Advanced gastric adenocarcinoma with RER+ phenotype presents a good prognosis after 5 years of curative resection]. / L'adenocarcinoma gastrico avanzato con fenotipo RER+ presenta una buona prognosi a cinque anni dalla resezione curativa (R0).

Microsatellite instability (MIN) has been found both in advanced and early gastric cancer. To find out the step played by MSI in gastric carcinogenesis, links between RER+ phenotype and clinical and pathological aspects have been studied. In this work our purpose is to analyze the relationship between MIN+ advanced gastric cancer and prognosis at 5 years after radical surgery. We investigated 34 patients affected by gastric cancer who underwent R0 surgical resection from February 1991 to October 1994. After that, they underwent a four-monthly follow-up for a minimum of 5 years. Genetic abnormalities have been searched including (a) those occurring in common-type CIN carcinomas and (b) those characteristic of MIN cancers. DNA extraction showed the presence of microsatellite instability (MIN) in 9 (26%) of the samples (vs. 74% of chromosomal instability CIN); none of them was M+ (vs. 12% of CIN cancers). Recurrence occurred in 2 out of 9 of the MIN cancers (22%) and in 21 out of 25 CIN cancers (84%). In conclusion, our data suggest that advanced gastric cancers with mutator phenotype show a better outcome at 5 years than the CIN phenotype.

Experience of endoscopic ultrasound in staging adenocarcinoma of the cardia.

AIM: The introduction of endoscopic ultrasonography (EUS) has generally resulted in a more accurate assessment of gastrointestinal regional tumour stage. Knowing the stage and the extent of oesophageal involvement is extremely important as a guide to the choice of surgical approach in cardia cancer. The aim of this study was to evaluate the ability of EUS to accurately predict depth of tumour invasion (T), node involvement (N) and the tumour's invasion length along the oesophagus. MATERIAL AND METHODS: Thirty-five patients with adenocarcinoma of the cardia were studied by EUS and the EUS pre-operative findings were compared with the pathology findings. RESULTS: The overall accuracy in T staging was 55.2% (16/29 cases). The sensitivity in evaluating T1, T2 and T3 classes was 80%, 38.5% and 70%, respectively. The sensitivity was excellent in evaluating N0 class (100%) (5 cases), but it fell to 66.7% in N1 cases. EUS correctly determined the extent of oesophagus invasion in 75.9% (22/29) of cases; moreover, it had a very high accuracy in distinguishing between tumours with an oesophageal invasion greater or lower than 2 cm (93.1%) (27/29 cases). CONCLUSION: EUS proved to be useful in pre-operative staging of cardia adenocarcinoma and, in particular, in the pre-operative identification of the extent of oesophageal invasion.