Accumulation and interactions of beta-carotene and alpha-tocopherol in patients with adenomatous polyps.

OBJECTIVE: The aims of the present study were: (1) to determine whether short-term supplementation of beta-carotene (BC) or vitamin E (VE; alpha-tocopherol) would result in their respective accumulation in normal colonic mucosa and in adenomatous polyps; (2) to determine whether the intake of BC would interfere with the concentration of VE in these target tissues. DESIGN: Blood and colonic biopsy samples were taken before and after supplementation. SUBJECTS: Eighteen volunteers with colonic adenomatous polyps were enrolled into this study. INTERVENTIONS: The supplementation lasted for 43 days and patients were examined over the whole period. Subjects were randomised into four groups according to the four different supplementations: placebo, natural BC (25 000 IU/day), natural VE (400 IU/day), combination BC/VE. RESULTS: Initially we were aiming for recruitment of 20 patients in each group, however after 2 y of study (1997-1999), we terminated the study because of slow recruitment and analysed the data. In placebo subjects after supplementation, the plasma concentrations of BC and VE remained unchanged, however only two patients were recruited in this group and therefore we did not include this group in our final analysis. In BC group, the plasma BC concentrations increased significantly (P<0.001), while VE concentrations were unchanged. In VE group, VE concentrations increased (P<0.01) and BC did not change, and in BC/VE group both BC (P<0.001) and VE levels (P<0.01) increased significantly. After supplementation, the tissue concentration of BC in normal colonic mucosa in BC group increased significantly (P<0.01) while the VE concentration did not change. In VE group, the concentration of VE in normal colonic mucosa increased slightly but did not reach statistical significance. However, VE concentration increased significantly (P<0.05) in the polyps of this group. In BC/VE group, in which patients received the combination treatment, the BC concentration of normal colonic mucosa increased (P<0.05) but, surprisingly, the VE concentration decreased significantly (P<0.01). Interestingly in the polyps, although the BC concentration increased (P<0.01), the concentration of VE was reduced moderately but did not reach statistical significance. CONCLUSIONS: Supplementation of BC in doses used in this study may have significantly interfered with the VE concentration in the examined tissue and probably with its metabolic pathway.

Local staging of rectal cancer with transrectal ultrasound and endorectal magnetic resonance imaging: comparison with histologic findings.

PURPOSE: The aim of the present study was to compare the accuracy of endorectal coil magnetic resonance imaging with transrectal ultrasound in staging rectal carcinoma. METHODS: Twenty-six consecutive patients with rectal carcinoma, histologically proven by endoscopic biopsy, were staged with both endorectal coil magnetic resonance imaging and transrectal ultrasound and then underwent radical surgery. The preoperative staging was compared with histologic findings of the operative specimen according to TNM classification. RESULTS: Endorectal coil magnetic resonance imaging showed better results but was not statistically significantly different from transrectal ultrasound in evaluating T (accuracy, 84.6 vs. 76.9 percent): four overstaged and no understaged cases for the former and five overstaged cases and one understaged case for the latter. Both procedures showed similar results in evaluating N: 81 percent sensitivity and 66 percent specificity for endorectal coil magnetic resonance imaging and 72 percent sensitivity and 80 percent specificity for transrectal ultrasound. CONCLUSIONS: An accurate locoregional staging of rectal cancer is essential for the planning of optimal therapy for rectal cancer. Endorectal coil magnetic resonance imaging and transrectal ultrasound showed similar results; the former is more expensive, whereas the latter is operator dependent. At present the use of endorectal coil magnetic resonance imaging seems to be justified only in selected low rectal cancers where transrectal ultrasound yielded doubtful results. However, a more extensive study is necessary to compare the advantages of these diagnostic techniques.

Prevention of postherniorrhaphy persistent pain: results of a prospective study.

Anterior tension-free and laparoscopic inguinal herniorrhaphies represent one of the most common surgical procedure. Postherniorrhaphy persistent pain due to injures of inguinal regional nerves is rare, difficult to cure, often disabling and involving malpractice litigation. In a prospective study, we evaluated the effectiveness of neurectomy of the iliohypogastric nerve in prevention of postoperative persistent pain after anterior tension free herniorrhaphy. Between 1992-1995, we performed 180 anterior herniorraphies in 151 male patients. Iliohypogastric nerve was removed in all the herniorrhaphies. Polypropylene plug and sutured mesh were employed. Postoperative pain and clinical relevance of hypo-anesthesia and paresthesia were assessed. No patient complained of postoperative persistent pain. Hypo-anesthesia, never considered incapacitating, was present in 1% of patients after 2 years. We consider neurectomy of the iliohypogastric nerve a potentially useful surgical step in preventing postoperative persistent pain after anterior tension-free herniorrhaphy.

Total compared with subtotal thyroidectomy in benign nodular disease: personal series and review of published reports.

OBJECTIVE: To evaluate the outcome after total and subtotal thyroidectomy for the treatment of single and multinodular goitres in two comparable groups of patients. DESIGN: Prospective randomised study. SETTING: University hospital, Italy. SUBJECTS: 141 Patients operated on for benign goitre from 1975-85. INTERVENTIONS: 69 Patients were randomised to have total thyroidectomy and 72 subtotal thyroidectomy by standard techniques. MAIN OUTCOME MEASURES: Temporary or permanent palsy of the recurrent laryngeal nerve, temporary or permanent hypoparathyroidism, recurrence of the goitre, and the incidence of iatrogenic injuries after completion thyroidectomy. RESULTS: Patients were followed up for a median of 14.5 years (range 10-21). After total thyroidectomy 2 patients (3%) developed temporary palsy of the recurrent laryngeal nerve but there were no permanent lesions; and 24 (35%) developed temporary and 2 (3%) permanent hypoparathyroidism. After subtotal thyroidectomy 2 (3%) developed temporary and 1 (1%) permanent palsy of the recurrent laryngeal nerve; and 13 (18%) developed temporary and 1 (1%) permanent hypoparathyroidism. In addition, there were 10 recurrent goitres (14%). After completion thyroidectomy (n = 9) there were 2 cases of temporary and 1 of permanent palsy of the recurrent laryngeal nerve, and 2 cases of temporary and 2 of permanent hypoparathyroidism. CONCLUSION: Total thyroidectomy is the procedure of choice for the treatment of benign nodular goitre.

Plasma (carotenoids, retinol, alpha-tocopherol) and tissue (carotenoids) levels after supplementation with beta-carotene in subjects with precancerous and cancerous lesions of sigmoid colon.

OBJECTIVES: (1) To compare tissue and plasma carotenoids status of healthy subjects and subjects with pre-cancer and cancer lesions; (2) to evaluate the effect of beta-carotene supplementation on the concentrations of other carotenoids in tissue (luteine + zeaxanthin, cryptoxanthin, lycopene, alpha-carotene) and in plasma and also retinol and alpha-tocopherol levels. DESIGN: Eighteen subjects were divided into three groups on the basis of colonoscopy and histological analytical findings: four healthy subjects (control group A); seven subjects affected by adenomatous polyps (group B with pre-cancer lesions); seven subjects suffering from colonic cancer (group C). Blood and colonic biopsy samples were taken (of colon and rectal mucosa) before and after beta-carotene supplementation in all subjects. Groups A and B received a daily dose of beta-carotene (30 mg/die) for 43 d. Group C's supplementation was terminated at the time which was performed, usually within 15 d. The tissue and plasma concentration of carotenoids, retinol and alpha-tocopherol were determined by high-performance liquid chromatography. RESULTS: The tissue concentrations of each carotenoid were similar in all the intestinal sites examined as regards groups A and B, although there was a high degree of intra individual variability within each group. Only beta-carotene made significant increases (P < 0.001) after supplementation. The subjects with cancer show tissue levels for each carotenoid lower than those of healthy subjects or subjects with polypous. The plasma levels of alpha-tocopherol did not change after supplementation while significant increases were noted of retinol, alpha-carotene (P < 0.01) and of beta-carotene (P < 0.001). CONCLUSIONS: The patients with colonic cancer seemed to undergo a significant reduction in their antioxidant reserves with respect to the normal subjects and or polyps. We can confirm that oral B-carotene supplementation induces also an increase in plasma alpha-carotene in all groups.

Bouveret's syndrome: case report and review of the literature.

Bouveret's syndrome, or gallstone duodenal pyloric obstruction, almost always presents with abdominal pain or vomiting. It occurs more commonly in females (65%), with a median age of 68.6 years. The diagnosis is made by endoscopy (60%), upper gastrointestinal series (45%) or by direct abdominal x-ray (23%). The syndrome is mainly treated by surgery (93%), but recently, it has also been treated by endoscopy or extracorporeal shock wave lithotripsy. The mortality rate has improved from 33%, as was the case before 1968, to 12% in recent years. Herein we report the case of a 79-year-old female with Bouveret's syndrome.

Benign biliary strictures: a review of 21 years of experience.

BACKGROUND: The treatment of patients with benign biliary strictures remains a challenge for even the most skilled biliary surgeons. Within the wide range of causes of benign biliary strictures, iatrogenic lesions represent one of the major ones. Biliary reconstruction with Roux-en-Y anastomosis remains the treatment of choice for most cases of benign biliary strictures despite recent reports about endoscopic or percutaneous management that have been quite encouraging. STUDY DESIGN: We retrospectively evaluated 194 patients who underwent surgery for benign biliary strictures over a 21-year period. The biliary strictures were classified into eight different types according to their level. The surgical procedures had been tailored mainly to the site and the extent of the structure as well as the overall status of the patient. RESULTS: Postoperative mortality and morbidity rates were 2.6 percent and 20.1 percent, respectively. The results we obtained were 79.6 percent good, 8.9 percent moderate, and 11.5 percent unsatisfactory. The mean follow-up was 9.3 years. In particular, hepati-cojejunostomy performed in low- and mid-level strictures had the best prognosis (good, 85.5 percent), while high and diffuse strictures had worse results (good, 70 percent), although with only hepaticojejunostomy according to Hepp-Couinaud, this percentage increases to 81 percent. CONCLUSIONS: Correct preoperative assessment of the site and extent of the biliary stricture is important in the choice of the gold-standard surgical procedure. Hepaticojejunostomy and hepaticojejunostomy according to Hepp-Couinaud are the treatments of choice in most instances of benign biliary strictures. Cholangiojejunostomy and hepatic resections are rarely indicated and are performed mostly for highly complicated and intrahepatic strictures. Endoscopic or percutaneous balloon dilation should be reserved for high-risk patients.

Antioxidant agents and colorectal carcinogenesis: role of beta-carotene, vitamin E and vitamin C.

In consideration of findings reported in the literature and of our study, we examined the correlation between antioxidants (beta-carotene, vitamin C, vitamin E) and colorectal carcinogenesis. Although diagnostic progress has been made in the last decades, no significant improvements in death rates have been achieved in the western world. Exogenous factors might be responsible for a complex alteration process of might be responsible for a complex alteration process of normal colonic mucosa into adenoma and carcinoma. Free radicals and reactive oxygen metabolites, due to increased production or to reduced inactivation, following a decrease in the antioxidant burden in the mucosa, might cause damage to DNA, thereby resulting in genetic alterations. This might represent the cause of the transformation process: normal mucosa --> adenoma --> carcinoma. In a prospective study, we observed a reduction of beta-carotene levels in normal colonic mucosa in patients with polyps and colorectal cancer. We also showed that beta-carotene supplementation raises levels of this micronutrient in the colonic mucosa of these patients. Findings from the literature and our trials show a significant decrease in the antioxidant capacity of colorectal mucosa in patients affected by colorectal cancer, although there is a significant interindividual variability. Such results suggest a possible chemopreventive role of antioxidant agents in colorectal cancer.

Comparison between computed tomography and magnetic resonance data and pathologic findings in substernal goiters.

Computed Tomography (CT) and Magnetic Resonance (MR) permit the acquirement of important diagnostic elements for the anatomo-topographic staging of substernal goiters, and for their characterization. The authors compared data obtained by CT and MR with intraoperative anatomo-topographic findings and definitive histology in 28 patients with substernal goiters. CT was performed in all these patients while MR only in 9. The results obtained showed an accuracy of 85.7% for CT and 100% for MR regarding the anatomo-topographic correspondence with intraoperative findings, without a significant statistical difference between these two diagnostic procedures. MR is more accurate than CT in showing the vascular dislocations. CT and MR have an accuracy of 82.1% and 77.7% respectively comparing their findings with histologic results obtained in operative specimens, without a significant statistical difference. In conclusion MR has to be considered the more accurate diagnostic procedure and therefore recommended in the study of patients with substernal goiters, while CT can be performed only in selected patients.

Accumulation of beta-carotene in normal colorectal mucosa and colonic neoplastic lesions in humans.

The quantity of beta-carotene (BC) accumulated in colonic polyps and colonic cancerous tissue in humans in situ was determined relative to the quantity accumulated in normal colon and rectal tissue. Serum concentration of BC, retinol, and alpha-tocopherol and tissue BC concentration were determined by high-performance liquid chromatography in samples obtained before and after oral supplementation with BC (30 mg/day). The serum BC and retinol concentrations significantly increased in response to supplementation in control, polyp, and cancer patients, but there was no change in serum alpha-tocopherol concentration. The BC concentration in tissue (colon, rectum, and tumor) of cancer patients was significantly less than that in tissue samples from control and polyp patients. Relative to baseline values, BC accumulated to a significant extent in tissues from all patients, including polyp and tumor tissue, during supplementation. The results indicate that BC does accumulate in colonic neoplastic tissue in humans and may potentially be utilized to augment cytotoxicity of chemotherapeutics or to prevent malignant transformation of cells.

Retroperitoneal malignant schwannoma. A case report.

The isolated retroperitoneal malignant schwannoma unassociated with Von Recklinghausen's disease is an unusual neoplasm, representing 0.01% of all retroperitoneal malignant neoplasms, with a poor prognosis, and an average survival at 5 years of 50% in patients treated by radical exeresis. At present, it is impossible, without histologic and immunohistochemical examinations, to differentiate it from other isolated retroperitoneal sarcomatous neoplasms. The authors report a case of retroperitoneal malignant schwannoma 20 cm in diameter in a 62-year-old woman surgically treated by radical exeresis. Postoperative complications were absent, and the patient, discharged from the hospital on the 12th postoperative day, died 8 months later of diffuse metastases, without local relapse. Despite the patient's short survival, the authors believe radical surgery to be the best therapeutic choice. Only surgery can establish a final diagnosis and can offer the best chance of survival and a significant and sometimes prolonged relief of symptomatology.

[Alkalizing activity of a calcium-bicarbonate-containing water, evaluated for pH, in patients with gastroesophageal reflux]. / Attività alcalinizzante di un'acqua bicarbonato-calcica valutata con pHmetria in soggetti con reflusso gastro-esofageo.

Bicarbonate-calcic water Ferrarelle has been administered both in the fasting state and during meals to patients suffering from gastro-esophageal reflux disease submitted to computerized pHmetry. Marked and lasting increase of esophageal and gastric pH was observed with significant differences from the effect of tap water. In addition, patients reported improvement of heart burn and acidity after the administration of the bicarbonate-calcic water. The alkalizing effect of the mineral water employed is therefore fully confirmed.

[Substernal goiter: new diagnostic methods and treatment]. / Il gozzo immerso: attualità terapeutiche sulla base dei nuovi mezzi diagnostici.

The authors report 47 cases of substernal goiters operated between 1971 and 1990. Forty-five patients had mediastinal-cervical-goiters (g.c.m.) and 2 had ectopic goiter (g.e.). Cervicotomy was performed in the 45 g.c.m., in 3 cases associated with sternal "split". The g.e. were treated with thoracotomy. Computed Tomography (TC) has been performed since 1984 in 26 patients; Magnetic Resonance (RM) since 1987 in 6 patients. The diagnostic accuracy for TC was 84.6% and 100% for MR on anatomical-topographic-definition, and 80.8% and 83.3% for presumptive diagnosis of nature, respectively. Considering the high diagnostic accuracy, the possibility to reconstruct the images in sagittal and coronal planes, the RM seems to be the elective diagnostic procedure for all substernal goiters.

Historical evolution of the surgical anatomy of the liver.

The authors report the history of the anatomy and surgical anatomy of the liver from the paleolithic age up to now. Particular emphasis has been reserved to the changing anatomical knowledge in these last decades which represents the basis of the modern surgery of the liver.