[The role of laparoscopy in surgical treatment of pancreatic cancer]. / Il ruolo della laparoscopia nel trattamento chirurgico del carcinoma pancreatico.

AIM: The authors reviewed their experience in surgical treatment of pancreatic cancer between 2003-2008. METHODS: Eighty two pancreatic cancer patients (median age 66.7 +/- 12.5) with obstructive jaundice were enrolled in our study: 36 (44%) had an endoscopic biliary stent; 46 patients (56%) were eligible for surgery: 14 received a curative surgery (pancreatoduodenal resection; 4 had a laparoscopic procedure) and 32 patients with non resectable tumor a palliative surgery: 18 had a gastro-jejunal with a biliary anastomosis (in 4 patients the hepatic-jejunal anastomosis was performed in laparoscopy), 6 had a gastro-jejunal anastomosis (2 laparoscopic procedure and 8 patients had only an explorative laparoscopy. RESULTS: The resectability rates was 17.1%. Median age in patients treated with endoscopic biliary stent was significantly higher than those underwent surgery (72.3 +/- 12.2 vs. 63.5 +/- 9.6; p < 0.05). Hospital length of stay in patients underwent radical surgery was significantly higher than those who received palliative surgery (18 +/- 6 vs. 10 +/- 5; p < 0.05). Morbility rate, including operative mortality of .3%, was 15.2%. CONCLUSIONS: Laparoscopy is largerly used in major oncologic surgery for several reasons: it minimized surgical manipulations and so post-operative complications. There is enough scientific evidence of low incidence of post-operative complications and long-term results compared to those achieved with traditional surgery.

[Extra-ampullary duodenal neoplasms]. / Le neoplasie duodenali in sede extra-ampollare.

The authors report on twelve cases of non-ampullary duodenal neoplasm and remark the rarity of this pathology. According to the literature, the traditional endoscopy is the mainstay diagnostic test, because of aspecific digestive symptoms, but the authors stress the importance of the "longue" endoscopy or endoscopy integrated with duodenography in non-responders patients who had non-diagnostic traditional endoscopy for neoplasm. Duodeno-cephalo-pancreatectomy and segmentary duodenal resection are proposed by tumor site. Better results for prognosis can be obtained only with an early diagnosis and radical surgical therapy, because of chemotherapy and radiotherapy don't improve survival.

Large bowel multiple tumours.

The medical records of all patients with colorectal cancer seen at the "G. Marinaccio" Department of Surgery in Bari between 1997 and 2004 were examined. Cases included in the study met the criteria advocated by Warren and Gates and Moertel et al. Over such period we operated on 103 patients with colon neoplasms, mostly males (64 patients) and aged over 65 (64 patients). Both palliative and radical operations were performed either as elective treatment or as emergency surgery; in some of the latter cases the diagnosis of neoplasm was made casually following the final histological test on the operative specimen. Ten cases of multiple malignant tumours were recorded, corresponding to 9.7%; in particular 1 synchronous-metachronous tumour (0.97%), 3 synchronous tumours (2.7%) and 6 metachronous tumours (5.8%) were observed; two of the metachronous tumours were detected in the same patient and one in a patient that had previously been operated on for a synchronous carcinoma, thus making a total of 8 patients in all. It is concluded that full examination of the colon in all patients presenting with primary colorectal cancer is mandatory and that, in the light of this experience and recent reports in the literature, this should be done by pre- or perioperative colonoscopy. Colonoscopy not only provides accurate detection of lesions, but also allows the surgeon to perform polypectomies, thereby obviating the need for extending surgery at the time of resection of the coexisting cancer. In conclusion, we recommend preoperative colonoscopy for all patients who present non-obstructive colorectal neoplasms.

[Acute acalculous cholecystitis: pathophysiology and treatment]. / Le colecistiti acute alitiasiche: fisiopatologia e trattamento.

The absence of reliable correlation between clinical features and pathological evolution and the molteplicity of risk factors, often related to various pathophysiological pathways, make of acute acalculous cholecystitis a clinical entity well distinct from other affecting gallbladder. In spite of the slight incidence, its occurrence among serious multiple trauma patients may reach 90%. The arguability of diagnostic criteria and the missed or delayed recognition, then affecting timing of surgery are important in determining morbidity and mortality of this condition. The Authors reviewed 16 patients operated for acute acalcolous cholecystitis. US, although sometimes underestimate the severity of affection and cause false negatives, had been the first choice investigation because of its rapidity, facility of execution and repeatability. TC adds subsequent information when US images were doubtful and reveleated pericholecystic involvement more carefully. Hepatobiliary scintigraphy has high diagnostic accuracy but needs of too long execution time. Reasons of early cholecystectomy lay on clinical and experimental evidences that focal or diffuse ischemic damage of gallbladder's wall may affect natural history of the illness and infectious overwhelming is a late event. Surgical intervention has been performed in 16 patients, must within 24 hours. Morbility has been very low, mortality scored 18.7%.

[Extensive small bowel resections]. / Le resezioni estese del tenue.

Bowel resections of at least 70% of the total length give rise to nutritional and metabolic disorders. The consequences are also related to the site of the resection itself, to the causative disease and thus to the patient's morphological and functional adaptation capacity. Over the past 20 years we have operated on 32 patients for vascular disorders, Crohn's disease, intestinal volvulus, actinic enteritis, and ileo-caecal carcinoma. In all patients total parenteral nutrition was started and followed by enteral nutrition and oral feeding after variable periods of time. The postoperative course, in terms of adaptation and stabilisation, was regular on most cases: only in the patients operated on for Crohn's disease was symptom and nutritional remission belated or incomplete. The perioperative mortality was 34% (11 patients). The extent of the resection was often conditioned by the topography of irreversible anatomico-pathological lesions and only in one case did a colic resection prove necessary. In more extensive resections, involving a longer adaptation time, enteral nutrition was supplemented with total parenteral nutrition for lengthier periods.

[Gastric anisakidosis: personal experience]. / L'anisakidosi gastrica: esperienza personale.

Anisakidosis is a parasitic disease of the human gastrointestinal tract caused by ingestion of marine nematode larvae such as anisakis simplex or, rarely, Pseudoterranova, present in raw or undercooked fish. Frequent sites of involvement by anisakis are the stomach, small intestine, rarely the colon, or the peritoneum, liver, pancreas, lung and tonsils, anisakidosis is a self-limiting disease; the symptoms arise 12-24 hours after ingesting raw fish and include nausea, diarrhoea, and severe abdominal pain, but also anaphylactic reactions. At the site of penetration, anisakis causes marked oedema, eosinophilic infiltration and granuloma formation. There are haematological abnormalities such as marked leukocytosis of the peripheral blood, eosinophilia, and positive PCR and serum antibodies to the larva's surface antigens. The diagnosis of anisakidosis can be made by endoscopy, radiology and US, but the disease is often diagnosed at surgical intervention. In the gastric form of anisakidosis, EGIDS has both a diagnostic role and a therapeutic one because it is possible to remove the worm using biopsy forceps. We report on one case of gastric anisakidosis, in a women, hospitalised for intense epigastric pain and vomiting after ingesting raw fish. She underwent gastroscopy. A worm was extracted from the gastric mucosa using biopsy forceps. This was followed by clinical improvement. The worm was identified by its macroscopic and microscopic characteristics as an anisakis larva. At laboratory examination, marked leukocytosis and eosinophilia of the patient's peripheral blood were observed 3-4 days after ingestion of anisakis.

Subareolar injection may be more accurate than other techniques for sentinel lymph node biopsy in breast cancer.

BACKGROUND: The aims of this study were to compare peritumoral injection of (99m)Tc-labeled albumin and subdermal injection of blue dye with subareolar (SA) injection of blue dye alone in terms of success of the sentinel lymph node identification rate, false negative (FN) rate, overall accuracy, and sensitivity of the two procedures. METHODS: From January 1999 to October 2002, 155 patients with localized breast cancer were treated. Patients were subdivided into two groups. In patients in group 1 (n = 115; January 1999 to December 2001), lymphoscintigraphy together with injection of vital dye was performed. In patients in group 2 (n = 40; January 2002 to October 2002), SA injection of blue dye alone was performed. RESULTS: In patients in group 1, the overall successful identification rate was 94.8%. The success rate of identifying a sentinel lymph node by a combination of the two techniques was 95%. With blue dye alone, the successful identification rate was 94.6% in patients in group 1 (subdermal) and 97.5% in group 2 (SA). The FN rate was 9% in group 1 and 0% in group 2. The overall accuracy of lymphatic mapping was 97% in group 1 and 100% in group 2. Sensitivity was 91% in group 1 and 100% in group 2. CONCLUSIONS: This study of dye-only injection into the SA plexus demonstrates a high sentinel node identification rate, absent FN rate, and rapid learning curve. On the basis of these findings, we propose that injections into the SA lymphatic plexus are the optimal way to perform dye-only lymphatic mapping of the breast.

[Gastrointestinal stromal tumors: current issues]. / Tumori stromali gastrointestinali: attuali problematiche.

Gastrointestinal stromal tumours are rare neoplasms originating from the connective tissue of the digestive tract and constitute most of the non-epithelial primitive digestive tumours, with a percentage incidence of less than 1%. The term itself was first used in 1983 by Mazur and Clark to identify a heterogeneous group of tumours, all of them histologically characterised by hyperplastic fused cells, not necessarily leiomuscular ones, but even neural ones. The original stem cell has not been identified yet, but such tumours constantly present the expression of the surface antigens CD34 and CD117 which can be determined immunohisto-chemically. US endoscopy and fine needle aspiration with subsequent immunohistochemical analysis and study of c-kit gene mutation afford the best diagnostic accuracy. Current research is focused mainly on primary cells, probably the cells of Cajal, and on the study of the biological behaviour of gastrointestinal stromal tumours, which can be postulated by assessing several parameters, the most accurate of which seems to be the mitotic index. More recently, the possible therapeutic use of a tyrosine kinase inhibitor has been studied in tumours expressing the c-kit gene. Our experience is based on the histopathological and immunohistochemical study of 11 submucosal tumours (1 liposarcoma, 2 leiomiomas, and 8 gastrointestinal stromal tumours) out of a total of 75 submucosal tumours diagnosed. In the majority of cases a generic diagnosis of submucosal tumour was obtained with oesophagogastro-duodenoscopy and a surgical resection was then performed because of the symptoms. Only in 4 cases was the neoplasm found occasionally in the course of surgery for other reasons. The definitive diagnosis of gastrointestinal stromal tumour, as currently defined, was made only postoperatively by analysis of the histopathological and immunohistochemical findings. In all cases we evaluated the same parameters, i.e. actin, vimentine, S100, CD34, CD117, and Ki67, and confirmed constant high positivity for CD34 and above all for CD117. Even in the absence of unfavourable prognostic indicators, all patients are regularly followed-up.

[Granular cell tumors of the colon. Clinical case and review of the literature]. / Tumori a cellule granulose del colon. Caso clinico e revisione della letteratura.

Abrikossoff's tumours are better known as granular cell tumours because of the typical microscopic aspect of their cytoplasm. They are uncommon neoplasms, probably of neurogenic origin, typically subepithelial and often benign. Rarely, they may be localised in the digestive tract, where they are mostly asymptomatic and tend to be discovered incidentally during endoscopic examinations indicated for other diseases. Histological examination with immunohistochemical staining usually yields the definitive diagnosis. Most authors agree as to the indication for endoscopic resection because of the possible, though rare, aggressive biological behaviour of these tumours. In the present paper we report on a case of granular cell tumour of the caecum, endoscopically resected and staining positively at the immunohistochemical search for the S100 protein.

Effect of the use of vital dye, lymphoscintigraphy, or a combination for axillary lymphatic mapping and sentinel node biopsy in breast cancer.

Axillary dissection in patients with breast cancer is associated with significant morbidity. Because 85% of the patients with a cancer < or = 1 cm have negative axillary nodal status, axillary dissection in these patients is only a staging procedure. A study of the sentinel lymph node (SLN) biopsy has been developed to determine axillary nodal status by means of a minimally invasive procedure. The aim of our study was to estimate the degree of reliability for identifying the SLN using a vital dye or lymphoscintigraphy, or a combination of the two. From January 1999 to May 2000 a series of 60 patients with breast cancer were evaluated for enrollment in the study. For the mapping procedure, lymphoscintigraphy in combination with injection of vital blue dye was performed in 24 patients, and vital dye alone was utilized in 36. Complete axillary dissection was performed in all patients after SLN biopsy. The mapping procedure was possible in 59 cases (98.3%). The SLNs were positive in 19 patients (32.2%) and negative in 40; in 38 of the 40 patients all axillary nodes were negative. There was concordance in 57 of 59 cases (96.6%). The false-negative rate was 5% (2/40). The overall sensitivity of the SLN biopsy was 90.4% (19/21), with a negative predictive value of 95% (38/40). Our results indicate that SLN biopsy guided by a gamma probe in combination with vital dye can identify a negative axilla with high accuracy. We conclude that the use of both techniques produces an optimal result, as they are complementary.