[Current role of the surgeon in the treatment of venous thromboembolism]. / Il ruolo del chirurgo, oggi, nella terapia del tromboembolismo venoso.

The most frequent complications of deep venous thrombosis (DVT) are post-thrombotic syndrome (PTS) and pulmonary embolism (PE); the main purpose of DVT therapy is to prevent their onset. A range of treatment is now available, including physical, medical and surgical forms. Physical: elastic compression mobilization postural therapy. Medical: anticoagulants (heparin, LMW heparins, oral anticoagulants), thrombolytic agents. Surgical: if DVT is diagnosed at an early stage, anticoagulant treatment may be accompanied by attempted surgical deobstruction, above all if DVT is localised at the popliteal and femoral confluents (greater risk of evolution towards severe "ischemic" forms potential cause of venous gangrene). These treatments include locoregional endogenous thrombolysis followed after phlebography, by surgical thrombectomy in the event of thrombotic residue, enabling the possible embolization of the pulmonary district using a caval filter. The combined medical and surgical approach reduces the long-term incidence of PTS. Temporary caval filters are also available. In short, a modern approach to the clinical problem of DVT now takes the form of early diagnosis and combined thrombolysis-surgery, which appears to be the most appropriate choice, ensuring the best form of venous functional recovery. However, this requires hospitalization in specialist units and multidisciplinary skills (hematological, medical, radiological and surgical) to ensure the best results.

[Intestinal carcinoid. A propos of a case]. / Il carcinoide intestinale. A proposito di un caso.

In this paper the authors report a case of carcinoid neoplasm in a rare localization like sigmoid colon. They describe the clinical and biological aspects of this kind of tumors, with particular regard to the tumor site and its biochemical products. A rational and prompt clinical approach to this neoplasm is considered important for the good chance of long survivals, achievable in the case of early diagnosis.

Gastric Banding for Treatment of Morbid Obesity: Preliminary Results.

BACKGROUND: gastric banding (GB) has been used for treatment of morbid obesity. METHODS: a banding device, introduced by Broadbent and consisting of a self-blocking nylon strip covered with a silicone tube, was used in 13 patients who have completed 1-year follow-up. This device was used for its mechanical properties, biocompatibility, ease of insertion and low cost. RESULTS: at 1 year, mean excess weight loss was 51.6%, with all but one patient losing more than 25% of excess weight. Associated illnesses resolved. There were two complications (15%): one patient required band removal for self-induced vomiting and one patient required repair of an incisional hernia. CONCLUSIONS: GB has had good results thus far. Reported differences depend on materials, stoma diameter, pouch size, and developing techniques.

Etoposide, doxorubicin (Adriamycin) and cisplatin regimen in advanced gastric adenocarcinoma: experience with a lower dose schedule.

A phase II trial of etoposide (100 mg/m2) on days 4, 5, 6, doxorubicin (Adriamycin, 20 mg/m2) on days 1, 7, and cisplatin (30 mg/m2) on days 2, 8 (EAP) was carried out in order to reduce toxicity associated with a full-dose EAP regimen for advanced and/or metastatic gastric adenocarcinoma. Out of 21 evaluable patients, 2 (10%) had a complete response (CR), 7 (33%) had a partial response (PR), 4 (20%) showed no change and 8 progressed (38%). The mean duration of response (CR+PR) was 8.4+ months. Survival of the whole group was 7.5+ months. Treatment was quite well tolerated by most patients on an outpatient basis. Grade 3 vomiting and leukopenia were seen in 30% and 35% of cases respectively. One patient had grade 3 esophagitis, and 1 patient was hospitalized for severe grade 4 febrile leukopenia. Although the EAP regimen cannot be considered a standard therapy for gastric cancer, the EAP schedule employed in this study seems to be better tolerated than those reported by other authors, and can safely be given on an outpatient basis.

Subcutaneous octreotide versus oral loperamide in the treatment of diarrhea following chemotherapy.

Forty patients with chemotherapy-related diarrhea were randomized to receive (i) octreotide 0.5 mg three times per day s.c. or (ii) loperamide 4 mg three times per day p.o. until complete remission of diarrhea was achieved. In the octreotide group 80% of patients showed complete resolution of loose bowel movements within 4 days of therapy, while in the loperamide group this goal was obtained in only 30% of cases (p < 0.001). If after 4 days no benefit was seen, patients were considered to have failed antidiarrheal therapy. Failure was recorded in only one case (5%) treated with s.c. octreotide and in five patients (25%) who received loperamide. The mean duration of antidiarrheal therapy necessary to achieve remission was 3.4 days in the octreotide group and 6.1 days in the loperamide group (p < 0.001). Treatment with octreotide was very well tolerated with mild abdominal pain in 15% of cases and pain in the injection site in 15% of patients. Subcutaneous octreotide is highly effective in the management of chemotherapy-related diarrhea in cancer patients.

A prospective evaluation of the activity of human granulocyte-colony stimulating factor on the prevention of chemotherapy-related neutropenia in patients with advanced carcinoma.

After informed consent, 86 patients with advanced cancer undergoing potentially myelosuppressive cytotoxic chemotherapy were randomized to receive placebo or subcutaneous granulocyte-colony stimulating factor (G-CSF) 5 micrograms/Kg/day in order to prevent severe neutropenia and its related morbidity. The incidence of neutropenia (absolute neutrophil count < 1,000/mm3) was significantly reduced in patients receiving G-CSF than in controls (18% versus 42%; P < 0.05). The duration of neutropenia was also shortened by the administration of G-CSF (4.8 versus 8.2 days; P < 0.05). Therapy with G-CSF has also a positive impact on the dose-intensity of employed regimens. Patients treated with G-CSF showed oral fungal disease in 9% of cases, while control patients had a 21% incidence (NS). Patients treated with G-CSF received 91% of the programmed dose-intensity as compared to 71% of control patients (P < 0.05). These data strengthen the clinical usefulness of G-CSF in the prevention of chemotherapy-related neutropenia, infections, and reduction in dose-intensity. Further studies are required to establish if the increase in dose-intensity allowed by G-CSF treatment may positively influence the outcome of cancer patients.

[Postoperative venous thromboembolism in bariatric surgery]. / Le tromboembolie venose post-chirurgiche in chirurgia bariatrica.

The authors discuss the problem of venous thromboembolism as a complication of bariatric surgery. They consider obese patients at risk for these complications, even if different opinions exist about this topic in the literature. They report their experience in bariatric surgery consisting of 53 patients submitted to biliopancreatic diversion. Antithrombotic prophylaxis consisted for every patient in elastic bandaging of the lower limbs, preoperative hemodilution, early post-operative mobilization, and subcutaneous heparin. Complications consisted in one popliteo-femoral deep venous thrombosis (DVT) (1.6%), and two pulmonary embolisms (PE) (3.2%) of which one caused patient's death; total morbidity for venous thromboembolism. These results compared with literature are similar with other series of bariatriac surgery and slightly higher than general surgery series. This difference is not however significant. Even in the absence of this significance, thromboembolism, as desumed from more than 2900 cases considered in the literature, remains the main cause of morbidity and mortality in the post-operative course of bariatric surgery patients, deserving particular attention in terms of prevention, also because of difficulty existing in early clinical diagnosis of DVT in obese people. Further studies intended to identify pathogenesis and risk factors of venous thromboembolism in obese people will allow a more correct prophylactic and therapeutic approach.

[Laparocele. A late complication of bariatric surgery]. / Il laparocele. Complicanza tardiva della chirurgia bariatrica.

In this paper the authors consider the problem of incisional hernias as late complications of bariatric surgery. After a description of relationships between obesity and incisional hernias they report their experience on this topic, consisting of 56 patients submitted to bilio-pancreatic diversion between March 1989 and September 1991, for surgical treatment of morbid obesity. Incisional hernias developed in 28% of cases. Analysis of some risk factors like infections, epidemiological patterns, materials and techniques used to suture the abdominal wall, has not allowed identification of significant associations with incisional hernias occurrence. Only early reinterventions (3 cases) have always determined a subsequent development of incisional hernias. The authors confirm the close relationship existing between obesity and incisional hernias. They suggest incisional hernia repair to be undertaken once weight loss has terminated and stabilized, and in the absence of other specific or aspecific morbid obesity surgery complications.

[Autotransfusion in bariatric surgery]. / L'autoemotrasfusione nella chirurgia bariatrica.

The authors, after some brief remarks on homologous blood transfusion discuss autotransfusion techniques, and haemodilution principles, they report their experience of autohemotransfusion with preoperative sampling in bariatric surgery, pointing out physiopathologic mechanisms and many advantages.

[Prophylactic cholecystectomy in bariatric surgery]. / Opportunità della colecistectomia profilattica in chirurgia bariatrica.

In this paper the authors discuss about prophylactic cholecystectomy in bariatric surgery. Having analyzed the mechanisms that increase bile lithogenicity after bariatric surgery, they evaluate advantages and disadvantages of prophylactic cholecystectomy. They present 53 obese patients submitted to biliopancreatic diversion and prophylactic cholecystectomy for surgical treatment of morbid obesity, because of the high incidence of pathological findings in the specimens and the absence of surgical complications related to cholecystectomy, the authors, in agreement with the literature, suggest routine cholecystectomy as an obvious adjunct to bariatric surgery. This attitude protects against the higher risk of subsequent cholecystectomy and against the misinterpretation of non-invasive diagnostic tests too, because of known limits of echography in obese people.

Levo folinic acid and 5-fluorouracil plus high dose epidoxorubicin as first line treatment for metastatic breast carcinoma.

Twenty-two women affected by metastatic breast carcinoma have been treated with a combination of levo folinic acid 100 mg/m2 plus 5-fluorouracil 450 mg/m2 i.v. on day 1-2, and epidoxorubicin 75-90 mg/m2 on day 2. This treatment cycle was repeated every 21-28 days. No patients had previously received chemotherapy for metastatic disease. Fourteen patients (64%) showed a major objective response with 3 complete (14%) and 11 partial responses (50%). Three patients showed a stabilization of disease and 5 (23%) progressed. All patients received ondansetron as antiemetic treatment which led to complete protection from vomiting in 68% of cases. Grade 1-2 diarrhea was recorded in 27% of the patients. Ten patients received recombinant human granulocyte-colony stimulating factor (rhG-CSF) as leukopenia-preventive treatment. In this group of patients the interval between chemotherapeutic cycles was shorter than in the group of 12 patients who did not receive rhG-CSF.

Biliopancreatic Diversion: early complications.

The experience and early complications in 66 morbidly obese patients who underwent biliopancreatic diversion are presented. There was one death, due to a pulmonary embolus (PE) at home on the 15th postoperative day. Postoperative complications occurred in nine patients, consisting of gastric hemorrhage (2), gastric outlet obstruction (2), non-lethal PE (1), deep vein thrombosis (1), wound dehiscence (1), and asymptomatic gastric leak (1). In addition, there were 12 superficial wound infections. Four patients required urgent reoperation for gastric hemorrhage (2), gastric outlet obstruction (1), and wound dehiscence (1). The high complication rate is believed to represent the early part of the learning curve. Some reports of the early complications following other bariatric operations are discussed.

Subcutaneous recombinant-human-erythropoietin prevents chemotherapy-related anemia in patients with advanced cancer.

Nineteen patients with advanced cancer were randomly allocated to receive: (i) rhEpo 150 UI/kg subcutanously three times/week starting 24 hours after the completion of cisplatin- or carboplatin-based chemotherapy; or (ii) normal saline. There were 17 patients with advanced head and neck carcinoma and 2 patients with small cell lung cancer. Patients were monitored for hemoglobin level, hematocrit, WBC, PLT and reticulocytes. Patients who received rhEpo overall showed a 7.2 +/- 6.3% mean increase in Hb level over their pretreatment values, while control patients had a 26.4 +/- 12% decrease. This difference was statistically significant (p<0.001). No patients in the rhEpo group required transfusion, while 4 patients in the control group received packed red cell transfusion. No significant side-effects attributable to rhEpo were recorded, but 1 patient showed a transitory increase in PLT count. In conclusion, subcutaneous rhEpo may be safely administered to patients with advanced cancer and effectively prevents cisplatin- or carboplatin-related anemia.

[Use of BICAP by endoscopic route in the palliative treatment of neoplastic stenosis of the esophagus]. / L'impiego del BICAP per via endoscopica nel trattamento palliativo delle stenosi neoplastiche dell'esofago.

Over the years the palliative treatment of neoplastic stenosis of the esophagus in patients who cannot be operated has seen a variation of endoscopic methods which aimed to reopen the alimentary canal either using simple dilatation, or the insertion of endoprostheses, or sclerosing injection or antiblastic therapy, or lastly using disobstructive laser therapy. In particular, the use of Neodymium YAG laser in endoscopic therapy for the deobstruction of neoplastic esophageal stenosis is currently widely used. More recently deobstruction of the stenosis may also be achieved using bipolar diathermocoagulation with BICAP following esophageal dilatation. Recent comparative studies of the use of BICAP and laser therapy in the treatment of neoplastic esophageal stenosis have tended to reveal the complementary characteristics of the two techniques. The present paper reports the Authors' experience in this respect which has been satisfactory with regard to both methods, in line with the findings of other studies. In the study of two groups of 8 patients treated with BICAP and laser therapy respectively, recanalisation was obtained in 100% of cases with good functional results in 75% of patients treated with BICAP and 87.5% of those receiving laser therapy. The time interval between one treatment session and the next in relation to the efficacy of the therapy was similar in both methods and ranged from a minimum of 4 weeks to a maximum of 12 weeks. Complications were scarce in both groups.

Atherothrombotic microembolism of the lower extremities (the blue toe syndrome) from atherosclerotic non-aneurysmal aortic plaques.

Six patients with no hemodynamically significant atherosclerotic lesions of the lower limb arteries but with ischemic changes of the feet or toes were studied and diagnosed as having atherothrombotic microembolism. All patients were non claudicators and had peripheral Doppler examinations on admission. Five patients experienced more than one separate episode of microembolization involving both extremities. None presented with a history of heart disease or diabetes. Biplanar arteriograms revealed in every case atherosclerotic degeneration of the aorta without any obstructing lesions and anatomical arterial continuity between the aorta and the site of distal embolization. Three patients who refused operation, were treated conservatively, with a combination of dipyridamole plus aspirin. Three other patients had surgical repair of their atheromatous infrarenal aorta: in two cases thromboendarterectomy was performed, and in the other a Dacron bifurcated graft interposition. No amputations resulted in the patients treated medically, but one of the surgical group lost one toe. This study confirms that atherothrombotic microembolism from an ulcerated atherosclerotic aorta is a potential threat to the extremities and indicates that the optimal therapy for this syndrome has yet to be found.