Monitoring surgical treatment of screen-detected breast lesions in Italy.

The object of this study was to assess quality of care and adherence to treatment guidelines of screen-detected lesions in Italy using a new audit system. Data on screen-detected cases surgically treated in 1997 were collected using a system (QT 2.3) developed within the Italian Group for Planning and Evaluating Mammographic Screening Programmes (GISMa) and the European Breast Cancer Screening Network. Results of 18 performance parameters were considered compared with the reference standards. In 1997, 515 lesions (335 invasive, 60 in situ and 120 benign) in 496 patients were collected from 14 departments in the Central and Northern area of Italy. The 18 indicators were analysed and grouped according to six quality objectives. Some results were good and others were excellent, such as intraoperative identification, breast conservation surgery, adequate axillary procedures and completeness of pathology reports, but most of them failed: waiting times, preoperative diagnosis, employment of frozen section on small lesions and avoiding axillary procedures in ductal carcinoma-in-situ. This work is a first attempt in Italy to evaluate and uniform the criteria adopted for quality control of breast cancer treatment, using a standardised system. Some results are good or excellent, the overall level of compliance with quality indicators is not satisfactory and corrective actions should be undertaken for a number of issues. A continuous monitoring should be performed and appropriate action taken in order to verify the effectiveness of the corrective actions and to provide screen-detected patients with the best quality of care.

Laparoscopic surgery for colorectal cancer.

Despite the widespread use of laparoscopic techniques in many fields, in the realm of malignant diseases, a great concern has been raised regarding safety, efficacy, and long-term results. The authors report their experience of 163 patients operated on for colorectal malignancies by minimally invasive access. The conversion rate (20.4%), morbidity (15.1%), and null mortality compare well with other studies published worldwide. The postoperative outcome was characterized by a prompt return to activity (1.3 days) and of bowel movements (2.9 days), while length of stay and an adequate oral resumption were comparable to those of open surgery. Peritoneal lavage did not show tumor cells disseminated during the operative maneuvers. The distance of tumor from resection margins and the number of lymph nodes harvested with the operative specimen did not vary from those obtained in open surgery. Two patients (1.2%) recurred at the mini-laparotomy and port sites, but, in both cases, the traumatic manipulation of the cancer specimen was probably responsible for the event. After a mean follow-up of over 3 years, 34 patients died of neoplastic recurrence, and 17 are alive with disease relapse. The laparoscopic approach to colectomy has not yet gained an unquestioned place in the experience of the colorectal surgeon. However, if sound surgical method and judgement are used to minimize local recurrences, and if a better preservation of postoperative immune function proves to be of clinical significance in the long term, laparoscopic colectomy may prove to be a safe and less stressful approach to colon resection.

[Prosthesis and emergency surgery of hernia]. / Prothèse et chirurgie herniaire en urgence.

Use of prostheses in emergency surgery is a controversial issue due to the risk of infection. We report our experience with a series of 31 strangled hernias treated in emergency situations with a polypropylene (n = 29) or a vinyl (n = 2) sheath placed in a pre-peritoneal or retro-muscular position. There were three small bowel resections and 13 resections of the omentum for necrosis. There were no cases of infectious complications during the post-operative period. There were no recurrent hernias during the follow-up. The absence of any supplementary morbidity after emergency prosthesis is in agreement with the data in the literature. These results suggest that a prosthesis can be proposed for strangled hernias when the weakness of the parietal wall would compromise a conventional procedure. Excluded are cases with severe infection, including peritonitis by gangrenous perforation of an incarcerated loop and associated colonic resections.

[A rare case of primary abdominal actinomycosis]. / Un raro caso di actinomicosi addominale primitiva.

The authors describe a case of primary abdominal actinomycosis operated on because of peritonitis sustained by a tubo-ovarian abscess. They discuss the pathogenesis of the case: the patient had been on intrauterine device contraception till two months earlier and had been operated on for breast cancer. Preoperative diagnosis is quite impossible and only the microscopic observation of the specimen can show the causative agent. Surgical options are reported, stressing the need for an adequate period of antimicrobial therapy.

PIP: In September 1993 a 43-year-old female patient with cancer underwent left mastectomy followed by immediate reconstruction. 6 days passed without problems, but then she presented at the emergency ward with abundant exudation of serous material from the cicatrices. Microbiological test showed evidence of Staphylococcus epidermitis. Drainage of the skin and smooth muscle was performed and the secretion was immediately reduced and seemed to disappear in a short time. In the next 3 days fever arose accompanied by abdominal pain. Blood test showed leucocytosis (24,500 GB), increase of the suppressor lymphocytes (CD8) and the reduction of CD4/CD8 ratio. Abdominal-pelvic echogram showed evidence of an enlarged right adnexum as well as that of the homolateral tube, but no discharge of fluid in the pelvic cavity. Gynecological examination in this patient, who had worn an IUD two months prior, excluded lesions in the portio or vagina and the vaginal flora did not show fungi or parasites. Diagnostic laparoscopy followed, which demonstrated in the pelvic cavity a large para-uterine tumefaction. The pelvic organs were adhering to the parietal layer of the peritoneum and in the whole peritoneal cavity, including the interhepatic-diaphragmatic space, fibrin plaque and pus was observed. Laparotomy was performed, which confirmed a parauterine mass and a tubo-ovarian complex with numerous recesses containing fetid, grayish pus. Complete right adnexectomy was carried out with abundant lavage and multiple drainage of the peritoneal cavity. Subsequently, the abdominal situation improved, but a new examination of drained liquid showed the presence of cutaneous bacterial flora but no fungi or parasites. Ovarian actinomycotic abscess with acute peritonitis and salpingitis was demonstrated. Subsequent antibiotic therapy consisted of piperacilline for 15 days, and 4 months after the episode the patient was well without return of the foci of infection.

[Effect of menstrual cycle on the immune response to surgical stress]. / Effetto del ciclo mestruale sulla risposta immunitaria all'aggressione chirurgica.

The Authors have studied the effects of different surgical interventions on some factors of humoral and cell-mediated immuno-competence: 112 premenopausal women, operated on mainly for benign conditions, have been considered in order to evaluate the influence of various phases of menstrual cycle on surgical immunosuppression. Two schemes were used to stratify the study sample: in the first analysis, we have subdivided the patients in 59 cases in perimenstrual phase (0 through 6 and 21 through 36 days from last menstrual period, LMP) and 53 in periovulatory (7-20 days from LMP). The second stratification relied on the hormone-dependent phases determined by the putative time of ovulation 14 days after LMP: 51 cases in follicular phase and 61 cases in luteal phase have been considered. Immune parameters have been evaluated before surgery and the day after intervention. The first comparison stresses the worst outcome of immune parameters in patients operated on in the perimenstrual period (CD4, activated lymphocytes and C3 have significantly reduced post-operatively). The second part of the study shows no significant difference in the two groups as to such parametres.

[A case of primary non-Hodgkin's lymphoma of the adrenal gland]. / Su di un caso di linfoma non-Hodgkin primitivo del surrene.

The paper reports a case of non-Hodgkin's primary lymphoma of the adrenal gland which is justified by the rarity of this pathology as can be seen from the literature. Following adrenalectomy and subsequent polychemotherapy, a complete remission of the disease was obtained. The Authors report that, in the absence of particular symptoms, diagnosis is generally based on X-ray examinations performed to clarify the causes of aspecific symptoms such as, for example, fever and asthenia. Lastly, it is underlined that the disease may be diagnosed during surgery when CT reveals the presence of an adrenal mass with a diameter of more than 3 centimetres.

[Reimplantation of the inferior mesenteric artery during surgery of abdominal aortic aneurysm. Current trends]. / Il reimpianto dell'arteria mesenterica inferiore nella chirurgia dell'aneurisma aortico addominale. Moderni orientamenti.

After a review of world literature and on the basis of personal experience, the problem of ischaemic colitis following abdominal aortic aneurysmectomy is examined. After remarks on the aetiopathogenesis and clinical picture of the condition the paper stresses the need for early detection of patients at high risk, to prevent a clinical picture that is insidious but serious and tends to develop rapidly. The use of preoperative angiography to study the SMA and IMA as well as intraoperative stump-pressure measurement is considered essential. The paper concludes that ischaemic colitis following abdominal aortic reconstruction can be avoided in a large percentage of cases by IMA implantation on the Dacron prosthesis, a surgical technique that is easy and not time-consuming.

[Second look yes, second look no, in the surgical therapy of intestinal infarct]. / "Second look sì", "second look no" nella terapia chirurgica dell'infarto intestinale.

The thorny second-look problem is examined on the basis of personal experience of 65 cases of intestinal infarction over a period of 10 years. The medical literature is particularly lacking in indications on this point and only from careful assessment of reported experience and personal experience itself has it been possible to find indications and limitations. Data are reported which do not pretend to be absolute but do provide a useful aid for those faced with doubtful anatomopathological pictures during operation for acute intestinal ischaemia.

Computer-assisted analysis of clinical and laboratory data in acute pancreatitis: early formulation of a predictive score.

The results of a retrospective study of 111 cases of acute pancreatitis are reported. Based on diagnostic investigations and clinical outcome, patients have been divided into three groups: oedematous, limited and extensive necrotizing pancreatitis. The step-wise statistical analysis of clinical and laboratory parameters at the time of admission related to the pathological findings has allowed the formulation of a severity score to be applied to every new case of acute pancreatitis. By discriminant function coefficients a concordance percentage of actual and predicted classification has been obtained in over 90% of the cases. The presence of shock after 12 hours of intensive treatment, the hemorrhagic appearance of the peritoneal fluid and tachypnea are the variables with highest discriminating power. In view of the high concordance percentage between actual and predicted classification results, this predictive score could be applied, to every new case of acute pancreatitis at admission.