[Pancreatic carcinoma presenting with invasion of the vena porta or the superior mesenteric vein: our experience and review of the literature]. / Carcinoma del pancreas con infiltrazione della vena porta o della vena mesenterica superiore: nostra esperienza e revisione della letteratura.

AIM: Adenocarcinoma of the pancreas can present with invasion of the vena porta or the superior mesenteric vein (SMV). Pancreatectomy with resection of the vena porta and/or the SMV remains controversial although the procedure is potentially curative. The aim of this study was to validate the indication for resection on the basis of our experience and evidence from recently published studies. METHODS: Studies published in the last 10 years on pancreatectomy (duodenocephalopancreatectomy, total and distal pancreatectomy) with resection of the vena porta and/or the SMV were retrieved from the Medline database and reviewed. A total of 18 studies meeting the inclusion criteria were analyzed for information about indications, type of intervention, use of adjuvant therapies, histopathology, perioperative results and survival in 620 patients with adenocarcinoma of the pancreas undergoing pancreatectomy with resection of the vena porta and the SMV. This data set was then compared with our experience with this procedure from the last 3 years. RESULTS: The mortality and postoperative complication rates varied between 0% and 7.7% and 12.5% and 54%, respectively. The median survival varied from 12 to 22 months; the 1 year survival rate was between 31% and 83%; the 5-year survival rate was between 9 and 18% according to the studies reviewed. CONCLUSION: On the basis of evidence from the literature and our experience, en bloc resection of the vena porta and/or the SMV during pancreatectomy appears to be a safe procedure with acceptable outcomes, and should be considered in patients with pancreatic cancer presenting with venous invasion. Venous resection increases the surgical cure rate, prolonging survival in patients selected according to correct indications.

[A rare presentation of Amyand's hernia. Case report and review of the literature]. / Un raro caso di ernia di Amyand.

Amyand's hernia is defined as an inguinal hernia within the hernial sac containing the appendix. It is a rare disease, reported in 1% of cases of inguinal hernia repair. The appendix can be complicated by acute appendicitis in 0.13% of cases. This disease is often very difficult to diagnose, and most of the time it can be confused with an incarcerated or strangulated inguinal hernia. Often, it requires an emergent surgical treatment. This article describes the case of a 82-year-old female who was admitted for an intestinal obstruction and a bulge in the right inguinal region. An abdominal computed tomography scan showed dilated small bowel loops with multiple air/liquid levels and one loop herniating into the right inguinal canal. The patient underwent a laparotomy that showed the presence of an acute appendicitis and a necrotized ileal loop protruding into the right inguinal canal. The patient underwent an appendectomy and small bowel resection and she was discharged on postoperative day 10. Amyand's hernia can be a challenge for the surgeon. Its treatment depends on the grade of inflammation of the appendix. In fact, it can range from the simple repair of the abdominal defect with a prosthetic mesh, to appendectomy, small bowel resection and repair of the abdominal wall defect without a mesh.

Laparoscopic Heller myotomy with or without partial fundoplication: a matter of debate.

AIM: To present our experience of laparoscopic Heller stretching myotomy followed by His angle reconstruction as surgical approach to esophageal achalasia. METHODS: Thirty-two patients underwent laparoscopic Heller myotomy; an anterior partial fundoplication in 17, and angle of His reconstruction in 15 cases represented the antireflux procedure of choice. RESULTS: There were no morbidity and mortality recorded in both anterior funduplication and angle of His reconstruction groups. No differences were detected in terms of recurrent dysphagia, p.o. reflux or medical therapy. CONCLUSION: To reduce the incidence of recurrent achalasia after laparoscopic Heller myotomy, we believe that His' angle reconstruction is a safe and effective alternative to the anterior fundoplication.

Angiolymphoid hyperplasia with eosinophilia: a rare artery lesion.

BACKGROUND: Angiolymphoid hyperplasia with eosinophilia (AHE) is a rare skin condition of unknown aetiology. The lesion seems neoplastic in nature, or at least an abnormal vasoproliferative reaction. CASE REPORT: A 40-year-old man presented with an 18-month history of erythematous papula over the right temporal area without a history of trauma. The patient reported a history of Hodgkin lymphoma at the age of 20, treated by radiochemotherapy. A subcutaneous nodule was found on the superior branch of the right temporal artery. An echocolordoppler revealed a normal temporal artery flow with pariental thickness. An excisional biopsy was performed and the patient remained asymptomatic at 24 months. The histological diagnosis was angiolymphoid hyperplasia with eosinophilia of the temporal artery. CONCLUSION: More appropriate studies are necessary to assess whether AHE is a manifestation of an unknown immunological disorder. If a correlation could be found between an altered immunological system and AHE, an intensive follow-up could be applied to patients. We report this case to encourage further studies to highlight potential challenges in the diagnosis and management of variants of vascular processes, such as AHE.

Monodermal highly specialized teratoma of the ovary: a sebaceous gland tumor.

Teratomas are neoplasms that originate in pluripotential cells and contain representations of all three germ layers in a rather mature state. Specialized forms of teratoma with unilateral development of certain tissues, such as struma ovarii, argentaffin tumors, cholesteatoma, primary choriocarcinoma of the ovary, pseudomucinous cystoma and neurogenic cysts are known. In this paper we describe an ovarian teratoma consisting entirely of sebaceous glands.

Synchronous and metachronous retroperitoneal sarcomas: two case reports.

BACKGROUND: Retroperitoneal sarcomas represent less than 1% of all diagnosed human neoplasias. They are generally malignant and can infiltrate retroperitoneal structures. The value of chemotherapy and radiotherapy are difficult to evaluate and the dominating factor in the outcome is the ability to resect the tumor. A few patients develop distant metastases. Recurrence of sarcoma at the operative site and on peritoneal surfaces is a prominent cause of morbidity and mortality. CASE REPORTS: Here we report two patients who underwent surgery for retroperitoneal sarcoma. In each of them at least two primary retroperitoneal tumors were diagnosed. The neoplasms were histologically different, thus they cannot be considered local recurrence but rather primary tumors. CONCLUSION: This is the first report underlying the synchronous or metachronous presence of different histological subtypes in this neoplastic pathology. In explanation of the occurrence of satellite tumors and multiple primary tumors, a virus-associated etiology or polyclonality of the tumor or pluripotentiality of tumor stem cells should be considered.

[Ambulatory surgical treatment for breast carcinoma]. / Trattamento ambulatoriale del carcinoma della mammella.

BACKGROUND: The aim of the study is to demonstrate the feasibility and the oncologic effectiveness of quadrantectomy plus sentinel node biopsy performed under local anesthesia, and to demonstrate the economic and psychologic advantages. METHODS: From October 1996 to March 2000, 71 patients affected with clinical T1 N0 breast cancer, underwent quadrantectomy or tumor resection plus sentinel node biopsy and clinically suspicion axillary nodes biopsy, under local anesthesia at the Casa di Cura "Villa Mafalda" in Rome. RESULTS: Twenty tumors were T1a, 26 T1b e 25 T1c. A mean of 2 sentinel nodes (range 1-4) and a mean of 8 axillary nodes were removed during the procedure. In 2 cases sentinel nodes were not identified. Intraoperative histologic examination showed metastatic sentinel nodes in 11 cases. An axillary node dissection was performed in all cases (>12 nodes) and no other metastatic nodes were found. In all patients clinically suspected nodes were removed. In two cases no evidence of metastasis was found in sentinel nodes, while histologic examination revealed in a patient micrometastasis in one node, and in another patient two metastatic nodes. CONCLUSIONS: Fifty-three patients rated the overall surgical, anesthetic and recovery experience as "very satisfactory", 13 "satisfactory" and 5 "unsatisfactory". Patients typically expressed their pleasure at the possibility to return home and stressed the ease of recovery.

Hemangioma of the breast: an unusual lesion without univocal diagnostic findings.

Hemangiomas of the breast, either capillary or cavernous, are thin-walled, blood-filled vascular spaces, separated by fibrous septa, with extensive fibrosis and sometimes phleboliths. Clinical diagnosis is rather difficult. Generally they are coincidental microscopic findings. We report herein a case of breast hemangioma misdiagnosed at ultrasound and mammography. A 63-year-old woman described intermittent sharp pain in the right breast. Physical examination, mammography and ultrasonography were not sufficient for the diagnosis. Surgical excision of the lesion was performed. At histology it was found to be a cavernous hemangioma without cellular atypia. The patient is now 9 months post surgery and is well. The role of the single diagnostic examination is limited. The Authors believe the complementary role of all available techniques in the evaluation of a breast lesion.

Does extended lymphadenectomy influence prognosis of gastric carcinoma after curative resection?

BACKGROUND/AIMS: It is unclear whether gastric cancer prognosis is improved by extended lymph node dissection more than by lymph node dissection limited to the contiguous N1 perigastric lymph nodes. METHODOLOGY: Four hundred and thirty-eight patients treated by curative gastrectomy were evaluated. Outcomes of D1/D1.5 lymphadenectomy, limited lymph node dissection and of D2/D2.5 lymphadenectomy, extended lymph node dissection and histopathological prognostic factors as in the 1993 TNM staging classification supplement were analyzed. RESULTS: Estimated overall 5-year survival was 54.9%. Five-year survival was 58.4% in the limited lymph node dissection group and 54% in the extended lymph node dissection (P n.s.). Stage I 5-year survival was 59% after D2.5 lymph node dissection, 58% after D1.5 and 50% after D2 dissection (P n.s.). Stage II 5-year survival was 86% in D2.5 group and 56% in D1.5 group (P = 0.041). Stage IIIa survival was 61% in the D2.5 group and 22% in the D1.5 group (P = 0.001). Stage IIIb 5-year survival was 42% after D2.5 resection and 0% in D1.5 group (P = 0.001). In the pT3 group 5-year survival was 72% after D2.5 dissection and 33% after D2 dissection (P = 0.001). In the positive N1 lymph nodes group 5-year survival was better after extended lymph node dissection than after limited lymph node dissection. In pN2a patients 5-year survival was 57% after D2.5 resection and 0% after D2 resection (P < 0.001). In pN2b and pN2c patients extended lymph node dissection did not statistically improve survival. CONCLUSIONS: Even if no statistical differences were found in overall survival, prognosis was improved by extended lymph node dissection in stage II and III, particularly in T2 and T3 subgroups and in N1 and N2a subgroups. When large numbers of positive nodes were found, improved survival was dependent upon resection of extragastric nodes distal to the uppermost echelon of positive nodes.

[Use of vascular endostapler in surgery of the lower rectum]. / Impiego dell'endostapler vascolare nella chirurgia del retto basso.

A practical and effective method for rapid and bloodless preparation of the rectum using endovascular stapler devices during low anterior resection, or abdominal-perineal excision, is described. This method is presented as an effective means for easily dividing the anterior and lateral attachment of the rectum. The application of this technique is the absence of intraoperative bleeding related to injury of middle hemorrhoidal vessels, with minimal risk of autonomic pelvic nerve damage. An additional factor relevant in the choice of this technique, is the easier possibility to perform rectal dissection of an oncologically adequate tumor clearance from the margin of rectal tumor and with complete radical transection of the lateral ligaments fastly proceeding with the downward mobilization of the rectum close to the pelvic side walls, between the parietal and visceral layer of the pelvic fascia.

Effective vascular endostapler techniques in hepatic resection.

The purpose of this report is to describe the technique of liver resection using an endovascular stapling device. A total of 31 patients underwent major hepatic resections with stapling techniques. The authors have used various approaches to portal structures and hepatic veins with the application of a vascular endostapler device. The specific techniques of different hepatectomies are described and illustrated. There were no deaths. A minor complication (biliary fistula) occurred in one patient, related to binary leak from parenchymal transection. No complications directly attributable to stapler ligations of portal pedicle or hepatic veins were observed. Stapling techniques can be helpful in major hepatic resection procedures. The vascular endostapler can significantly reduce both portal vein and hepatic vein closure time and may expedite the transection of the liver, eliminating the risk of slipped ligature following simple ligation.

[Totally implantable venous access systems. Analysis of complications]. / Sistemi di accesso venoso totalmente impiantabili. Analisi delle complicanze.

UNLABELLED: Totally implantable central venous access devices (Port-a-Cath, PaC) allow better treatment of cancer patients, with safe administration of chemotherapeutic agents, and are well accepted by the patients. The aim of the present paper is to analyze the complications of the different implant techniques on the basis of a personal experience of 92 central venous access devices. MATERIAL AND METHODS: A total of 92 PaC (Port-a-Cath, Pharmacia: Celsite Braun) have been implanted in 88 patients between August 1992 and June 1995 for cancer treatment. Age ranged between 19 and 79 years (median 52 years), 56 were male and 32 women. PaC have been implanted by percutaneous cannulation of the subclavian vein, with Seldinger technique, in 34 cases; by venous cutdown respectively on the cephalic vein in 46 cases, the jugular vein in 7 cases, the basilar vein in 4 and the saphenous vein in 1 case. Four patients experienced a double implant. In 84 cases the implant was done under local anesthesia, while in 8 required general anesthesia, during operation for the primary neoplasm. RESULTS: A total of 7 complications were experienced (7.6%, 7/92): 4 sepsis and 3 mechanical. No cases of pnx were observed. Sepsis occurred after 29, 45, 64, 401 days of implantation respectively, and culture demonstrated S. aureus in 2 cases, and E. coli and Klebsiella oxytoca in 1 case each. Mechanical complication comprehends 2 cases of catheter dislodgement and 1 case of port rotation. No complications were noticed in case of implant during surgery for primary cancer (8 cases). In 7 cases the procedure has been converted from cephalic vein cutdown to percutaneous cannulation of the subclavian vein due to anatomic reasons (13.2%, 7/53). Five PaC have been explanted for complications. DISCUSSION: On the basis of the personal experience we think that PaC are of easy implant, with few complications and of good acceptance from the patients. We prefer venous cutdown on cephalic vein as implant technique because of avoidance of pnx or bleeding complications. Percutaneous puncture of subclavian vein is useful for implantation during major surgery, because less time consuming, and in case of anatomical anomalies fo the cephalic vein. Basilic vein cutdown has been utilized exclusively for esthetic reason in young people, to avoid the scar in the upper thoracic region. Alternative implant techniques has been employed in special conditions, such as catheter position in the inferior v.cava, or early in our experience (internal jugular vein). A total of 7 complication have been reported (7.6%), 4 sepsis and 3 mechanical (2 dislodgement, 1 rotation). Sepsis were not related to implant technique, presenting on day 29, 45, 64 and 401 respectively; all required the explant of the PaC as a treatment. Mechanical complications are related to surgical technique; all required re-exploration with 1 explant and 2 reposition of the PaC. In PaC positioning during surgery for primary cancer (8 cases) no morbidity has been reported. All but the 5 PaC explanted were functioning until patient's need; maximum length reported is 42 months.

[Carcinoma of the gastric stump. Our experience in 28 treated cases]. / Carcinoma del moncone gastrico. Nostra esperienza su 28 casi trattati.

A chart review was conducted on 28 patients with gastric stump cancer who were radically treated at the First Department of Surgery of University "La Sapienza" of Rome between 1978 and 1990. The data obtained were compared with those of 401 patients radically treated, in the same period, for primary cancer of the proximal third of the stomach. There were no significant differences between the two groups in terms of stage and nodal involvement. Surgical treatment was total gastrectomy in 86% of cases, and an extended procedure in 57% of patients. The morbidity rate was similar to patients treated for primary gastric cancer, as well the 5-year survival, which depend on the stage of disease. We can conclude that gastric stump cancer must be treated surgically with radical intent as the prognosis is similar to that of primary gastric cancer.

Alternative insertion sites for permanent central venous access devices.

Permanent central venous access devices (PCVAD) are used widely in the management of chronically ill patients, particularly in neoplastic diseases. The standard approach consists of positioning the catheter in the superior vena cava (SVC) either using subclavian or internal jugular vein puncture, or cephalic or external jugular vein cut-down, with the port implanted in a subcutaneous pouch of the thoracic region. Alternative insertion sites could be used in selected cases. In our experience, consisting of 158 PCVAD, 12 cases required a different insertion site: six cases of an SVC catheter and port on the forearm using a basilic vein cut-down, and six cases of an inferior vena cava (IVC) catheter and port in the abdominal region using a great saphenous vein cut-down. Comparing standard to alternative approaches, we observed a total morbidity rate of 8.9% and 8.3%, respectively (P=NS), while the explant rate was 5.4% vs 8.3% (P=0.1). Our data show non-significant differences in morbidity and explant rates between the two groups of patients. Alternative insertion sites for the PCVAD implant seem to be a valid possibility in the management of chronically ill patients.

Modality of failure following resection of stage I and stage II non-small cell lung cancer.

The pattern and sites of recurrence were studied in 270 patients with resected Stage I (NO) or Stage II (Nl) non-small cell lung cancer (NSCLC). Survival, incidence, and type of intrathoracic locoregional recurrence versus distant extra-thoracic recurrence after surgical excision were analyzed. Prognostic parameters, such as postsurgical stage, histologic type, degree of cellular differentiation, and surgical approach, were examined to discern their influence on tumor recurrence. The total incidence of recurrence in patients with stage I and II tumors was high, with a radical surgical approach often resulting ineffective, because of incomplete locoregional neoplastic extirpation due to micrometastases. Lymph node metastases worsened prognosis, with Nl tumors demonstrating a significantly higher recurrence rate at 5 years (63%) than NO neoplasms (48%) (p < 0.01). Stage I tumors showed an elevated incidence of local recurrence (45%), with tumor T-factor making a significant contribution in such cases. N1-factor combined with an elevated T-factor (Stage II Subclass pT2Nl neoplasms) promoted a higher incidence of distant rather than local recurrence. A shorter disease-free interval was observed in patients with N tumors as opposed to NO neoplasms. Histologic type did not play a statistically significant role (p = ns) in the total incidence of recurrence. A similar total incidence of recurrence was observed in Stage I and II tumors treated by lobectomy (51%) or pneumonectomy (56%), with locoregional recurrence appearing more frequently after lobectomy.

Management and survival of patients affected with obstructive colorectal cancer.

Between 1978 and 1984 a consecutive series of 571 patients with colorectal cancer were admitted to the First Department of Surgery of the University of Rome. Patients were divided into a group of 82 patients affected with obstructive cancer and a control group of 489 patients with non-obstructive tumors. In the obstructed group there was a significantly higher incidence of lesions localized in the left colon. Depending on the advancement of lesions a significantly higher incidence of Dukes D tumor, nodal involvement, hepatic metastases and peritoneal dissemination and a significantly lower incidence of Dukes A tumors, were found in the obstructed patients. No significant differences were found in the two groups according to age distribution, duration of symptoms and degree of differentiation of neoplasms. The mortality and morbidity rate were 9.7% and 12.2% respectively in the obstructed patients, and 3.5% and 8.3% respectively in the non-obstructed patients. The rate of complications was greater in the two groups when serum albumin values were under 3 g/l, being 40% vs. 3.3 and 20% vs. 5.2% in obstructed and nonobstructed groups respectively. When Hb levels were under 10 g/l the incidence of complications was 16.7% and 14.4% for the two groups, while when it was higher than 10 mg% the morbidity rate was 8.7% and 6.3% in obstructed and non-obstructed patients respectively. The execution of surgical treatment within 24 hours was related to a morbidity and mortality rate of 50% and 22.2% in obstructed patients, and 40% and 20% in the non-obstructed group.(ABSTRACT TRUNCATED AT 250 WORDS)