Rehabilitative orbital decompression for Graves' orbitopathy: results of a randomized clinical trial.

PURPOSE: Orbital decompression (OD) is a consolidated procedure for the treatment of exophthalmos in Graves' orbitopathy (GO). The efficacy of the various procedures remains unclear due to the variability of the techniques used. To address this issue, we performed a randomized clinical trial to compare the efficacy of two surgical techniques. The primary endpoint was the reduction in proptosis. Secondary aims were the risk of post-operative diplopia (POD) in primary gaze and other surgical complications. PATIENTS: 38 patients (76 orbits) affected with GO were enrolled and randomized into single lateral decompression (LD) (n = 19) or balanced medial plus lateral wall decompression (MLD) (n = 19). Following surgery, patients were seen for a follow-up ophthalmological evaluation at 6 months. Pre-operative diplopia in secondary gaze was present in 13/38 patients (34.2%, 8/19 treated with LD and 5/19 treated with MLD). RESULTS: The reduction of exophthalmos was greater in patients treated with MLD (5.1 ± 1.5 mm, range 2-8 mm) than in those treated with LD (3.5 ± 1.3 mm, range 1-6.5 mm) (p = 0.01). The overall incidence of POD in primary gaze was 5/38 (13.2%) and all of these patients had pre-operative diplopia in secondary gaze (5/13, 38.5%, vs patients with no pre-operative diplopia p = 0.005). Two of 19 patients (10.5%) treated with LD and 3/19 (15.8%) treated with MLD, developed POD in primary gaze, with no statistical difference between the two techniques. CONCLUSION: MLD provides a better result in terms of proptosis reduction compared to LD. The two techniques used here appear to have a similar safety profile in terms of POD. Pre-operative diplopia in the secondary gaze remains a major risk factor for development of POD.

Comparison of the effectiveness and tolerability of intravenous or oral glucocorticoids associated with orbital radiotherapy in the management of severe Graves' ophthalmopathy: results of a prospective, single-blind, randomized study.

Eighty-two consecutive patients with moderate-to-severe and active Graves' ophthalmopathy were randomly treated with orbital radiotherapy combined with either oral (prednisone; starting dose, 100 mg/d; withdrawal after 5 months) or iv (methylprednisolone; 15 mg/kg for four cycles and then 7.5 mg/kg for four cycles; each cycle consisted of two infusions on alternate days at 2-wk intervals) glucocorticoids. The two groups did not differ for age, gender, duration of hyperthyroidism and ophthalmopathy, prevalence of smokers, thyroid volume, and pretreatment ocular conditions. Both groups of patients received radioiodine therapy shortly before treatment for Graves' ophthalmopathy. Follow-up lasted for 12 months. A significant reduction in proptosis (from 23.2 +/- 3.0 to 21.6 +/- 1.2 mm in the iv glucocorticoid group, P < 0.0001; and from 23 +/- 1.8 to 21.7 +/- 1.8 mm in oral glucocorticoid group, P < 0.0001) and in lid width (from 13.3 +/- 2.5 to 11.8 +/- 2.2 mm, and from 13.6 +/- 2.0 to 11.5 +/- 1.9 mm, respectively; P < 0.001 in both cases) occurred, with no difference between the two groups. Diplopia significantly improved in both groups: it disappeared in 13 of 27 (48.1%) iv glucocorticoid patients (P < 0.005) and in 12 of 33 (36.4%) oral glucocorticoid patients (P < 0.03). The degree of amelioration of diplopia did not significantly differ between the two groups (P = 0.82). Optic neuropathy improved in 11 of 14 iv glucocorticoid (P < 0.01) and only in 3 of 9 oral glucocorticoid (P = 0.57) patients, with no significant difference in these outcomes. The Clinical Activity Score decreased from 4.5 +/- 1.2 to 1.7 +/- 1.0 (P < 0.0001) in the iv glucocorticoid group and from 4.2 +/- 1.1 to 2.2 +/- 1.2 (P < 0.0001) in the oral glucocorticoid group; final Clinical Activity Score was significantly lower in iv glucocorticoid than in oral glucocorticoid patients (P < 0.01). By self-assessment evaluation, 35 (85.3%) iv glucocorticoid and 30 (73.2%) oral glucocorticoid patients reported an improvement of ocular conditions (P = 0.27). Overall, both treatments produced favorable effects in most patients, but responders in the iv glucocorticoid group (36 of 41, 87.8%) were more than in the oral glucocorticoid group (26 of 41, 63.4%) (P < 0.02). Moreover, iv glucocorticoid treatment was better tolerated than oral glucocorticoid treatment. Side effects occurred in 23 (56.1%) iv glucocorticoid and 35 (85.4%) oral glucocorticoid patients (P < 0.01); in particular, cushingoid features developed in 5 of the former and 35 of the latter patients. One iv glucocorticoid patient had severe hepatitis of undetermined origin at the end of glucocorticoid treatment, followed by spontaneous recovery. In conclusion, high-dose iv glucocorticoid and oral glucocorticoid (associated with orbital radiotherapy) are effective in the management of severe Graves' ophthalmopathy, but the iv route seems to be more effective and better tolerated than the oral route and associated with a lower rate of side effects.

[Complications after total thyroidectomy in thyroid carcinoma]. / Complicanze post-tiroidectomia totale per carcinoma della tiroide.

Authors report the postoperative complication rate in 52 patients who had undergone total thyroidectomy for cancer between 1984 to 1989. Total thyroidectomy has been performed in 9.8% of patients surgically treated for nodular thyroid pathology. Patients age average 49 years in a range 16-75; they were 49 women and 3 men. In 50% of cases we found papillary cancer, follicular in 40%, medullary 4% and anaplastic 6%. We shared postoperative complications in two mean groups: 1) aspecific complications as cardiocirculatory failure, respiratory failure, wound infections or collections, granulomas, keloids; 2) surgery related complications such as hypocalcemia, dysphagia, recurrent++ paralyses. The first group, we noticed just one case of respiratory mechanical failure due to severe tracheomalacia that required a temporary tracheostomy performed at the end of surgical procedure; we did not notice any death due to cardio-circulatory or respiratory failure, nor did we notice any postoperative hemorrhage; one patient presented a wound seroma, two patients presented granulomas due to subcutaneous stitches, and three developed papulous drug-induced erythema. The second group, eight patients developed a transient hypocalcemia beginning on the second postoperative day, without relevant tetanic crisis, well treated by calcium administration; only two of these patients developed permanent hypoparathyroidism. In 3 cases we had to perform exeresis of a laryngeal inferior nerve involved by the cancer, while in 5 more cases we noticed a transient monolateral paralysis that disappeared in 2 or 3 months. Three patients presented dysphagia before intervention and healed post-surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

[Use of superior musculus rectus abdominis flap in the reconstruction of the thoracic wall]. / L'impiego del T.R.A.M. Superiore nella ricostruzione della parete toracica.

The paper reports the Author's experience of the use of the muscle-skin flap of the upper rectum homolateral to the abdomen in the reconstruction of defects of the anterior thoracic wall following cancer surgery or radionecrosis, and compares it to that using other flaps (lower T.R.A.M., Latissimus dorsi, etc.). The well known anatomy of the flap, which is fed by the upper epigastric artery, also requires a precise surgical technique to isolate the muscular fibres without damaging vascularisation, a fundamental requisite for the vitality of the flap itself. Equally important for the vitality of the operation is a detailed study of the skin above the flap in patients treated with radiotherapy. The common and specific (epigastric hernia) complications of this operation are also examined, together with the precautions used by the Authors to prevent their occurrence.

[Prognostic factors in neoplasms of the upper 2/3 of the stomach compared to the lower 1/3. Our experience]. / Fattori di prognosi nelle neoplasie dei 2/3 superiori dello stomaco rispetto a quelle del 1/3 inferiore. Nostra esperienza.

The choice of the type of surgical treatment used in gastric cancer, in cases where it is possible to operate in relation to the extent of cancer, raises the question of whether the surgeon should perform a total exeresis of the organ, even in cases where the tumour is located in the 3rd distal of the stomach. A retrospective study was carried out on patients admitted to the Surgical Department of the University of Perugia between January 1963 and December 1988. Having rejected 123 cases because of incomplete data or insufficient follow-up, 1.140 cases were selected from a total of 1.263 patients. The sites of neoplasia were as follows: terminal esophagus: 1.76% of cases; cardia: 6.67%; fornix of the stomach: 9.37%; the body of the stomach and lesser curvature: 23.65%; body of the stomach (other portions): 10.07%; angulus: 3.63%; gastric antrum: 37.82%, pylorus: 4.45%; the remaining 2.58% showed a diffuse form involving two or more the above parts. The subdivision of the cases into stages, using the TNM classification, revealed the following groupings: 7.04% of patients were first observed at stage I, 20.70% at stage II, 42.04% at stage III and 30.20% at stage IV. From the above figures it is evident that radical surgical was indicated only in some of the patients observed. The prognostic factors examined in the comparative study of different tumour sites were: age, sex, macroscopic and histological tumour type, size, infiltration of neoplasia through gastric wall coat, lymph node and/or systemic diffusion.(ABSTRACT TRUNCATED AT 250 WORDS)

[Our experience with early gastric cancer]. / La nostra esperienza in tema di early gastric cancer.

Gastric cancer has always required surgical therapy since in the majority of cases at the moment of treatment symptoms are already at an advances stage. Over the past years many advances have been made in the early diagnosis of many forms of neoplasia, but the rate of progress has been much slower with regard to gastric cancer. Only the preventive and regular use of gastroscopy will allow the disease to be diagnosed at a non-advanced stage. The term early gastric cancer is used to describe a carcinoma which only infiltrates the mucosa, or the mucosa and submucosa, irrespective of lymph node or other metastases. The present study was based on a retrospective analysis of cases of stomach cancer observed in the Surgical Department of the University of Perugia from January 1963 to December 1988. A total of 1,263 patients were affected by cancer of the stomach during the above period. One hundred and twenty-three cases were not included because of incomplete data or insufficient follow-up. A total of 1,140 patients were therefore included in the study; of these only 99 cases were affected by early gastric cancer. Age, sex, earlier gastric diseases, life styles, familial occurrence of disease, and symptomatology were among the different parameters evaluated. In addition, the site of disease, diagnostic methods, pre- and post-operative staging, intramural diffusion of the disease and surgical treatment were taken into account. In older cases the 5-year survival rate was calculated, whereas in more recent cases statistical methods, based on accumulated data, were used to estimate survival rates.(ABSTRACT TRUNCATED AT 250 WORDS)

[Afferent loop syndrome as an epiphenomenon of neoplasms of the gastric stump]. / La sindrome dell'ansa afferente come epifenomeno della neoplasia del moncone gastrico.

A clinical case is the basis for a report on the possibility that afferent loop syndrome might present as an epiphenomenon in gastric stump cancer. Stress is laid above all on the rarity of the syndrome and on the clinical and diagnostic difficulties of demonstrating it. The possibility that it might be a pointer to a pathology of greater clinical importance is pointed out.