[The diagnosis and therapy of dysphagic disorders of the LES]. / Diagnosi e terapia dei disturbi disfagici del LES.

Primary motor disorders of LES causing dysphagia consist in cardial achalasia and intermedius motor disorder (IMD), the last one different from achalasia because of normal motor pattern of the esophageal body. In this paper diagnostic and therapeutic procedures are examined according to an experience of 94 surgically treated cases (22 rioperations for surgical failures). Cardial dilatation as treatment of choice is recognized only for IMD in which a normal peristaltic behaviour of the esophagus can avoid the high danger of GER. Surgical procedure, now laparoscopically performed, consisting in Heller's myotomy + Dor partial fundoplication is to be preferred in cases of true achalasia.

[Surgery of dysphagic diseases. Personal experience (349 surgical interventions)]. / Patologie disfagiche di competenza chirurgica. Esperienza di scuola (349 interventi chirurgici).

The authors report their surgical experience relating to dysphagic diseases of the esophagus (349 cases). In the light of these results, they describe the different surgical techniques used in the various pathologies: 1) Esophageal diverticula: The value of a careful evaluation of subdiverticular spasm is emphasised using preoperative manometry in cervical and epiphrenic diverticula, leading to subdiverticular myotomy when present. 2) esophageal achalasia and intermediate motor disorder: A clear difference must be drawn between these two diseases owing to the different motor behaviour of the esophagus. Dilatation of the LES is only useful in intermediate motor disorder and should be avoided in esophageal achalasia where a gastroesophageal reflux is produced if dilatation fails. Intraoperative manometry is very useful during the extramucosa myotomy phases as an indication of the complete removal of the sphincteric barrier, thus avoiding the risk of persisting disease. 3) Non-neoplastic stenosis. In primary stenosis (caused by caustic agents, primary GER or associated with JE) a conservative approach is advisable, whereas in iatrogenic stenosis (mainly linked to dilatation or cardiac surgery), owing to the anatomic complexity of the esophagogastric junction, a more radical approach is often required in the form of esophagogastric resection or even sub-total esophagectomy. 4) Neoplastic stenosis: Leiomyomas, although unusual, represent a clear indication for thoracoscopic access, provided that the dimensions allow it. Esophageal cancers represent a major surgical problem. A radical approach is represented by TE and the subsequent use of the stomach, or more rarely, the colon to reconstruct the alimentary tract. In spite of the very low resectability rate owing to locoregional spreading, until recently palliative surgery was essential to allow patients to eat. The introduction of autoexpanding prostheses, positioned using endoscopic methods, has provided a better solution to this problem.

Jejunal interposition for peptic stenosis of the esophagus following esophagomyotomy for achalasia.

Retrospective analysis of the results of esophagojejunogastrostomy in 21 patients with peptic stenosis after esophagomyotomy for achalasia is reported. All patients complained of severe dysphagia. The esophagogram showed the presence of a 2 to 3 cm long stenosis in the lower esophagus with a diameter < 10 mm. Endoscopic dilatation was possible in 18 cases and it was pursued until the passage of the endoscope was possible. Manometry confirmed the presence of an aperistaltic esophagus with incompetent LES in all cases examined. GERD was detected by 24 hour pH-metry in 15/21 patients (71.4%). One patient died because of postoperative cardiopulmonary failure. Other minor complications occurred in 6 patients. During an 11 year mean follow-up good results were achieved in 17 patients (85%), fair in 2 (10%) and poor in 1 (5%), in whom redundant jejunal loop was resected after 8 years. Resective surgery in peptic strictures after esophagomyotomy is the treatment that guarantees the best long-term results. Esophagojejunogastroplasty represents a valid technique. Careful selection of patients and an accurate surgical technique are fundamental to reduce mortality and morbidity.

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.

Efficacy of octreotide in the prevention of pancreatic fistula after elective pancreatic resections: a prospective, controlled, randomized clinical trial.

BACKGROUND: A prospective, randomized controlled clinical trial was conducted in 33 Italian surgical departments with the aim of evaluating the efficacy of octreotide in the prevention of pancreatic fistula after elective pancreatic resections. METHODS: Between July 1990 and May 1992, 278 patients were enrolled in the study. Fifty-four dropped out because of unresectable disease and six were excluded because of protocol violation; the remaining 218 were randomly assigned to the octreotide group (n = 111) or to the placebo group (n = 107). There were 131 men and 87 women with a mean age of 58.2 +/- 11.7 yrs. Pancreaticoduodenectomy was the most common operation performed (n = 143), sixty-four percent of patients had a pancreatic or periampullary cancer; chronic pancreatitis accounted for 8.2% of cases. RESULTS: Mortality rate was 6.9%. A pancreatic fistula occurred in 31 patients (14.2%), 9% in the octreotide group and 19.6% in the placebo group (p < 0.05). Morbidity rate was significantly lower in the octreotide (21.6%) than in the placebo group (36.4%) (p < 0.05). When specific pancreatic complications were grouped together and evaluated, they occurred less frequently in the treated (15.3%) than in the placebo group (29.9%) (p < 0.05). CONCLUSIONS: Octreotide was able to reduce significantly the incidence of pancreatic fistula after elective pancreatic resections.

Low rectal cancer--what is the choice?

In patients operated on for low rectal cancer, the functional results, disease recurrence, and survival have been evaluated with respect to the type of surgery performed. Particular attention was paid to analysis of the pathologic aspects, considered in our opinion, as risk factors for recurrence. The investigation was carried out on 131 patients, of whom 70 received anterior resection, 55 abdominoperineal resection, and 6 local treatment. Abdominoperineal resection was carried out in more advanced disease. Postoperative mortality was 2.1 percent after anterior resection and 0 after abdominoperineal resection or local treatment. Follow-up, carried out in 96 patients (44 anterior resections, 46 abdominoperineal resections, and 6 local treatments), ranged from 12 to 84 (mean, 33.3) months. Recurrence rate was 53.3 percent after abdominoperineal resection and 28.9 percent after anterior resection. Recurrence appears not be related to the treatment performed, but rather depend on certain aspects of the neoplasm such as diameter exceeding 5 cm, extraparietal infiltration, lymphangitis, and tumor indifferentiation. We observed anastomotic recurrence in 28.6 percent of patients with a margin of less than 2 cm. An intensive follow-up scheme enabled us to recognize this type of recurrence early and to reoperate with radical intent. One year after anterior resection functional results were encouraging. No severe incontinence was reported. Local treatment was performed in carefully selected patients (T1, N0) and no cases of mortality or recurrence were observed.

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)

Regional heterogeneity and complementation in the expression of the tumor-associated glycoprotein 72 epitopes in colorectal cancer.

We analyzed the immunohistochemical expression of three epitopes of the tumor-associated glycoprotein 72 (TAG-72) in whole cross-sections of primary colorectal carcinomas and in regional lymph node metastases using monoclonal antibodies (MAbs) B72.3, CC-49, and CC-83, which recognize distinct carbohydrate antigenic determinants. B72.3, CC-49, and CC-83 reacted with 13 of 27 (48%), 25 of 27 (92%), and 21 of 27 (77%) carcinomas, respectively. The immunoreactivity with lymph node metastases followed a similar pattern; MAb CC-49 was again the most reactive of the three antibodies, since it labeled 13 of 15 metastatic lesions. Positive reactions of the MAbs with the primary tumors were not always predictive of the immunorecognition of their metastases. Distinct areas within whole cross-sections of TAG-72-positive primary carcinomas demonstrated marked differences in the expression of the three epitopes. CC-49 tended to react with the highest number of areas and with the highest percentages of carcinoma cells within each area. In no instances did B72.3 demonstrate reactivity superior to that of either CC-49 or CC-83. Tumors negative for the CC-49 epitope in any area also did not express the other two TAG-72 epitopes. However, the comparison of the immunostaining obtained with each MAb in TAG-72-positive primary lesions revealed areas where CC-83 was clearly more reactive than CC-49. Moreover, one lymph node metastasis, negative for CC-49, was recognized by CC-83. Thus, the combined use of MAbs CC-49 and CC-83 resulted in additive immunostaining of primary and metastatic colorectal carcinoma cells. The study provides evidence of intratumoral heterogeneity in the glycosylation pattern of the TAG-72 antigen in colorectal cancer and emphasizes the advantages of cocktails of anti-tumor-associated antigen MAbs in the immunodetection of colorectal tumor cells.

Patient selection and factors affecting results following resection for hepatic metastases from colorectal carcinoma.

Personal experience is reported of 47 consecutive liver resections for metastatic colorectal carcinoma treated in the I Clinica Chirurgica of the University of Rome for the purpose of contributing to treatment and evaluating the clinical factors and possible determinants of prognosis that could be potentially predictive of outcome and length of survival after liver resection: Duke's stage of primary colorectal cancer, synchronous or metachronous disease, number of hepatic lesions. Patients were classified according to the proposed staging system of the "Istituto Nazionale Tumori" in Milan. For Stage I and II patients the median survival time was 15 months, while in Stage III patients survival time was reduced to only 4.5 months. The 3- and 5-year survival rate was 20% and 12% respectively for Stage I patients; no patients at stage II or III survived more than 3 years.

Hepatic resections for colorectal metastases: the Italian multicenter experience.

In 1989 there were 151,000 new cases of colorectal carcinoma in the United States. Approximately 50% of these patients will be at risk of developing liver metastases together with other sites of recurrence. However, the liver will be the main site of relapse in only 14,000 patients with colorectal cancer. Approximately 25% of patients with colorectal carcinoma have technically resectable hepatic metastases at the time of operation for primary lesion, and an additional 8-25% will develop metachronous hepatic metastases after primary resection. Recent reported experiences with surgical treatment of metastatic colorectal cancer in the liver seem to indicate that hepatic resection has become more acceptable, safe and effective therapy, and offers today when technically possible, the best prospect of survival in a conspicuous number of patients. For these reasons, although a prospective randomized trial has not been done comparing resection with nonresection, resection seems to give the best hope for cure and actually is the treatment of choice for selected patients. In fact in these patients is reported a significant prolongation of survival compared with those patients with unresectable liver metastases treated only with adjuvant therapy in the form of chemotherapy or radiation therapy. Median survival of resected patients with hepatic metastases has been reported to range from 6-12 months, and for patients with single metastases is reported to range from 4.5-6.2 months to 11 and 21 months. The benefits of surgical therapy have been emphasized by different experience, with a 5-year overall survival rate ranging from 20-40%. In a recent multicenter survey a 33% 5-year survival rate was demonstrated in 859 patients resected for hepatic metastases.

Prevention by ambroxol of bronchopulmonary complications after upper abdominal surgery: double-blind Italian multicenter clinical study versus placebo.

A double-blind multicenter study was carried out to evaluate the effectiveness of ambroxol, a drug able to promote surfactant synthesis, in the prevention of postoperative bronchopulmonary complications. A total of 252 patients with chronic obstructive lung disease (COLD) undergoing upper abdominal surgery were randomly allocated to receive either 1 g/day of ambroxol intravenously for 6 consecutive days in the perioperative period or placebo. Pulmonary complications were evaluated by clinical studies, radiographic, and blood gas analysis. There was a significant difference in atelectasis between the 2 groups (10.6% ambroxol vs 23.9% placebo). In addition, analysis of variance showed that the PaO2 values of the ambroxol-treated group after surgery decreased less than those of the placebo-treated group (p less than 0.05) from the preoperative values. The treatment was well tolerated, although nausea was significantly more frequent in the ambroxol-treated group. We think that ambroxol should be considered as an alternative and new pharmacologic approach for the prevention of postoperative pulmonary complications.

Heller-Belsey and Heller-Nissen operations for achalasia of the esophagus.

From 1972 to 1985, 101 consecutive patients underwent Heller's myotomy and Belsey repair (H + B) (n = 43) or Nissen fundoplication (H + N) (n = 58) for achalasia of the esophagus. There was no operative mortality after either operation; minor pulmonary complications occurred after H + B procedure in 9.3 per cent of the patients. Good to excellent long term results were achieved in 87 per cent of the patients after H + B repair and 83 per cent of the patients undergoing H + N. The failure rates were 2.5 and 11.3 per cent, respectively. The analyses of postoperative esophageal symptoms showed that the incidence of heartburn was greater after H + B repair and the incidence of obstructive symptoms was greater after H + N. The inability to vomit or belch, or both, was 10.2 per cent in the H + B group and 13.1 per cent in the H + N group. Finally, 56.4 per cent of patients after H + B repair and 41.0 per cent of those after myotomy and H + N were considered to be cured after the operative procedure was performed. Patients were improved in 41.0 and 47.3 per cent, respectively.

Effect of preoperative colonoscopy on the incidence of synchronous and metachronous neoplasms.

Colonoscopy and air-contrast barium enema performed preoperatively in 389 patients with colorectal cancer revealed synchronous cancer in 4% and polyp in 14%. Nine of the 16 synchronous cancers were located in other surgical segments than the index cancer, and six of the nine were in stage A or B1. Of the 54 synchronous polyps, 28 were located in such other segments. Half of the synchronous cancers and almost half of the synchronous polyps were missed at double-contrast barium enema. All synchronous cancers and three-fourths of the synchronous polyps were detected at colonoscopy. No patient with preoperative colonoscopy presented with metachronous cancer within 3 years from surgery, and only two were subsequently found to have adenocarcinoma arising from an adenomatous polyp. Endoscopic polypectomy was performed in 21 cases during follow-up. Extensive use of preoperative colonoscopy is recommended in the evaluation of colorectal cancer, in order to promote detection of synchronous tumors, reduce the incidence of 'early metachronous' cancer and avoid malignant degeneration of adenomatous polyp.

The role of CEA, TPA and CA 19-9 in the early detection of recurrent colorectal cancer.

Eighty-eight consecutive patients who underwent curative resection for colorectal cancer between 1983 and 1985 were studied prospectively to evaluate the roles of sequential CEA, TPA and CA 19-9 determinations and independent clinical examination in the early diagnosis of resectable recurrences. Twenty nine recurrences were detected between 8 and 38 months after primary surgery. CEA, TPA and CA 19-9 showed a sensitivity of 72%, 62% and 38%, and a specificity of 78%, 86% and 97%, respectively. Of eight recurrences in which CEA was not raised, five induced a rise in TPA and two a rise in CA 19-9. The rise in the serum concentration of one of the three markers was the first sign of relapse in 23 (79%) patients. Two second-look laparotomies based solely on a rise in serum markers were performed. In one case diffuse recurrent disease was found, and in the other a resectable solitary hepatic metastasis was found.

Belsey and Nissen operations for gastroesophageal reflux.

From 1972 to 1985, 37 consecutive patients underwent primary Belsey repair and 40 consecutive patients underwent primary Nissen fundoplication because of reflux disease. The operative procedures were performed by a single surgeon in each group. For the purpose of comparison, both groups were divided into two subsets: (1) patients with proved reflux, and (2) patients with different indications. The first subset consisted of 30 patients in the Belsey series and 32 in the Nissen series. The remaining patients were included in the second subset. One death occurred in the Belsey series; morbidity consisted of minor pulmonary complications in the Belsey series (10.8%) and spleen injuries requiring splenectomy (5%) in the Nissen series. In patients with proved reflux good-to-excellent results were achieved in 89.3% of subjects of the Belsey series and 86.6% of patients of the Nissen group. The failures rates were 7.1% and 10%, respectively. Inability to vomit and/or belch was reported in 7.1% of patients with proved reflux of the Belsey group and 10% of patients with proved reflux of the Nissen group. In patients with different indications there were no failures after either operation. Finally 82.2% of subjects in the Belsey group and 73.3% of patients in the Nissen group declared that they were satisfied with the operative results. In conclusion the Belsey and the Nissen procedures are equally able to achieve long-term control of reflux disease in comparable groups of patients. Failures and gastrointestinal symptoms are equally frequent after either procedure and do not affect the overall patient acceptance of antireflux surgery.

Colorectal cancer in young patients.

Colorectal cancer is rare in patients under 40 years of age. We reviewed all colorectal cancer patients treated at the First Department of Surgery of the University of Rome, to determine the true incidence of large bowel cancer in young patients. During the period 1978-1984 a total of 571 patients were indexed. Out of these 44 were 39 years of age or less. A group of 527 patients 40 years of age or over served as a control. Neoplasms were localized in the right colon in 19 cases and in the left colon in 25 patients, in the young group. In the control group 178 patients presented neoplasms localized in the right colon, while 349 presented tumors localized in the left colon. According to tumor advancement in the young group tumor classification from A stage tumor through D stage was: 4, 6, 14, 5, 9, 6. In the control group 22 patients presented A stage tumors, 106 B1, 139 B2, 50 C1, 118 C2, 92 D tumors. The operability rate was 93.2% in the young group, and 92% in the old one. The operative mortality rate was 0% in the young group, and 2.5% in the old one. Four complications occurred in the young patients, and 57 in the old patients. The five years survival rate was 56.7% and 52.1% in young and old patients respectively. The results of our study indicate that there are no significant differences in prognosis and five years survival in young patients with colorectal cancer.

Relationship of symptom duration and survival in patients with colorectal carcinoma.

An early diagnosis in asymptomatic patients and a prompt treatment lead to an improved survival rate in patients with carcinoma of the colon. Patients with a short symptomatic history of colon cancer do not have a better prognosis than patients with a long history. 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. All patients were classified into five groups according to the duration of specific intestinal symptoms. In Group 1 (51 cases) asymptomatic patients were included, or patients with no specific symptoms such as asthenia, anemia, occult fecal blood. In Group 2 there were 129 patients with intestinal symptoms of less than 3 months' duration before treatment. In Group 3 there were 192 patients with symptoms of between 4 and 6 months' duration; 151 patients with symptoms of between 6 and 12 months were included in Group 4, and finally 48 patients who presented with symptoms of more than 1 year were included in Group 5. No relationship was noted between tumor site and duration of symptoms. Similarly, no relationship was noted between the duration of intestinal symptoms and stage and tumor differentiation. On the other hand, asymptomatic patients showed a higher incidence of T1N0M0 stage tumor and a lower percentage of undifferentiated neoplasms. The resectability rate was 79% and it was significantly related to the absence of intestinal symptoms. Follow-up data were available in 454 patients (80%). The overall survival rate was 52.4%. In Group 1 through Group 5 the 5-year survival rate was: 83.7%, 50%, 50%, 46.3%, 46.9%. The results of our study indicate that patients admitted in asymptomatic phase presented less-advanced stage tumors and, thus, best survival rate. On the other hand, from our data the duration of intestinal symptoms is not related to the stage and prognosis of tumors.

Right colon cancer: long-term results after curative surgery and prognostic significance of duration of symptoms.

Between 1976 and 1986, a consecutive series of 195 patients with right colon cancer were admitted at the First Department of Surgery of the University of Rome. Patients were divided into five groups according to the absence of intestinal symptoms (group 1) and the duration of the symptomatic phase (groups 2-5). Analysis of the preoperative investigation showed that colonoscopy was able to identify 33 (26.2%) of tumors misdiagnosed by double contrast X-ray barium enema. We did not notice any correlation among symptom duration and tumor stage, tumor differentiation, operability rate, and survival. Patients admitted in the asymptomatic phase presented tumors of less advanced stage and, thus, had the best survival rate (71.4%). In this group, patients promptly treated had a better survival rate (87.5%) than those treated after 2 months (50%). Our study suggests that only neoplasms diagnosed in asymptomatic patients and treated promptly are related to a good survival rate. We, therefore, emphasize the importance of education of patients and family physicians about right colon cancer and the necessity to investigate all patients with a suspected right colon cancer by means of colonoscopy.