[Duodeno-gastric reflux in gallbladder stones and after laparotomic cholecystectomy]. / Il reflusso duodeno-gastrico nella calcolosi della colecisti e doppo colecistectomia laparotomica.

BACKGROUND: Duodeno gastric reflux (DGR) is still a not well-defined condition, even though it has been the subject of different studies for many years. METHODS: The authors examine its relation with gallstones before and after the surgical removal of the gallbladder. After examining various study techniques, they present their experience of DRG. In this work the methodology used in a group of 40 patients suffering from gallstones and operated by laparotomic cholecystectomy is presented. All patients have been subjected to a clinical questionnaire in order to evaluate their symptoms, before and after cholecystectomy, and at the same time they have been subjected to an endoscopic exam. It s not easy to comment the RESULTS. RESULTS: Actually, of 32 patients (80%) showing DGR symptoms before surgical treatment, 20 showed their persistence, worsening, or the appearance of new symptoms after cholecystectomy, while 12 were completely asymptomatic. Of 8 patients with no symptoms before cholecystectomy, 3 developed a typical DGR symptomatology while 5 were asymptomatic. CONCLUSIONS: So 57% of patients were DGR symptomatic after surgical treatment. The compromised function of cholecystitis with calculi, antrum-pyloric-duodenal motility, continuous bile flux in the duodenum, surgical trauma all interact in determining DGR.

[Gastroduodenal reflux after laparotomic or laparoscopic cholecystectomy]. / Il reflusso duodeno-gastrico dopo colecistectomia laparotomica o laparoscopica.

BACKGROUND: The authors analyse gastroduodenal reflux (GDR) in the light of the progress made over the past ten years. The good results achieved using mini-invasive techniques in cholecystectomy prompted the authors to compare laparotomic and laparoscopic cholecystectomy in order to evaluate the influence of both techniques in determining GDR and clinical symptoms. METHODS: Symptoms were evaluated before and after surgery in 30 patients operated using a laparotomic technique and in 30 patients operated using a laparoscopic technique. Two groups of 10 patients, operated respectively using laparotomic and laparoscopic techniques, were studied both clinically and endoscopically before and after surgery. RESULTS: The analysis of the results shows a lower incidence of GDR and typical symptoms of GDR in patients undergoing laparoscopic surgery. The rationale underlying the lower incidence of GDR and its symptoms in these patients compared to the more conventional group is not completely clear. CONCLUSIONS: These results may be influenced by reduced surgical trauma and the careful selection of case or the laparoscopic technique, hence the exclusion of cases complicated by severe cholecystitis.

[Essential varicocele. Which treatment?]. / Il varicocele essenziale. Quale trattamento?

Purpose of the paper is to sum up the problem of surgery of idiopathic varicocele according to the present possibilities, both surgical and sclerotic. A wide review of the literature underlines a high rate of relapses and persistence of the disease (with a percentage from 10 to and 10%) following the two most used technique: retrograde sclerotic therapy under radioscopic control and surgical retroperitoneal or inguinal ligature of the internal spermatic vein; this technique was preferred by us until 1997. The percentage of failures, high with reference to the benign form of the disease (over 10% in our series of more than 100 patients submitted to clinical and flow-meter examinations) let the authors suggest a combined and simultaneous operation of ligature both internal and external of the spermatic vein at the level of the internal inguinal ring. Anatomical reasons confirm the opportunity of this procedure since the involvement of the system of the external spermatic vein is present in about the 20% of the cases of idiopathic varicocele in accordance with various flebografic studies. The possibility of escape through the external spermatic vein is eliminated in the case in which such vessel is preserved, and it seems frequent above all in 3rd degree idiopathic varicocele where many anastomotic vessels between the two systems are present. This procedure can be made both in general or local anaesthesia, it doesn't involve postoperative hospital stay and present the same acceptable postoperative complication of other proposed operations. The laparoscopic treatment even if easily performed at the level of the internal inguinal ring, doesn't seem justified for the higher cost and equal compliance for the patient. Besides, it is not possible to proceed laparoscopically under local anaesthesia.

[The diagnosis and therapy of dysphagic disorders of the LES]. / Diagnosi e terapia dei disturbi disfagici del LES.

Primary motor disorders of LES causing dysphagia consist in cardial achalasia and intermedius motor disorder (IMD), the last one different from achalasia because of normal motor pattern of the esophageal body. In this paper diagnostic and therapeutic procedures are examined according to an experience of 94 surgically treated cases (22 rioperations for surgical failures). Cardial dilatation as treatment of choice is recognized only for IMD in which a normal peristaltic behaviour of the esophagus can avoid the high danger of GER. Surgical procedure, now laparoscopically performed, consisting in Heller's myotomy + Dor partial fundoplication is to be preferred in cases of true achalasia.

[Surgery of dysphagic diseases. Personal experience (349 surgical interventions)]. / Patologie disfagiche di competenza chirurgica. Esperienza di scuola (349 interventi chirurgici).

The authors report their surgical experience relating to dysphagic diseases of the esophagus (349 cases). In the light of these results, they describe the different surgical techniques used in the various pathologies: 1) Esophageal diverticula: The value of a careful evaluation of subdiverticular spasm is emphasised using preoperative manometry in cervical and epiphrenic diverticula, leading to subdiverticular myotomy when present. 2) esophageal achalasia and intermediate motor disorder: A clear difference must be drawn between these two diseases owing to the different motor behaviour of the esophagus. Dilatation of the LES is only useful in intermediate motor disorder and should be avoided in esophageal achalasia where a gastroesophageal reflux is produced if dilatation fails. Intraoperative manometry is very useful during the extramucosa myotomy phases as an indication of the complete removal of the sphincteric barrier, thus avoiding the risk of persisting disease. 3) Non-neoplastic stenosis. In primary stenosis (caused by caustic agents, primary GER or associated with JE) a conservative approach is advisable, whereas in iatrogenic stenosis (mainly linked to dilatation or cardiac surgery), owing to the anatomic complexity of the esophagogastric junction, a more radical approach is often required in the form of esophagogastric resection or even sub-total esophagectomy. 4) Neoplastic stenosis: Leiomyomas, although unusual, represent a clear indication for thoracoscopic access, provided that the dimensions allow it. Esophageal cancers represent a major surgical problem. A radical approach is represented by TE and the subsequent use of the stomach, or more rarely, the colon to reconstruct the alimentary tract. In spite of the very low resectability rate owing to locoregional spreading, until recently palliative surgery was essential to allow patients to eat. The introduction of autoexpanding prostheses, positioned using endoscopic methods, has provided a better solution to this problem.

[Dilatation versus surgery in the treatment of cardial achalasia]. / Dilatazioni versus chirurgia nel trattamento della malattia acalasica del cardias.

Both surgery and dilatation are useful for the treatment of cardial achalasia. The authors make a wide review of the literature with particular attention to reports comparing results of these procedures. This review evidences that surgery gives better results than dilatations (84.4% of good results with surgery against 71.4% with repeated dilatations) and is certainly more stable over the years. Mini-invasive surgery points out even more strongly that surgery is nowadays to be preferred. Laparoscopy makes it possible to avoid postoperative pain, to discharge the patient in a couple of days and finally to eliminate surgical scars. Complications, even more frequent after surgery (5.5% against 2.1% of dilatation) are still acceptable in number and not heavy in quality.

[Esophago-jejuno-gastroplasty in the treatment of peptic stenosis of the esophagus]. / L'esofago-digiuno-gastroplastica nel trattamento delle stenosi peptiche dell'esofago.

From 1973 to 1994, 21 patients with esophageal peptic stenosis were submitted to esophago-jejuno-gastroplasty with Merendino's technique. In 14 cases peptic stenosis developed after Heller's myotomy for achalasia, associated in 3 cases with fundoplication. In 3 patients the stenosis was secondary to fundoplication. Other 3 subjects presented a primary stenosis. One patient showed Barrett's esophagus with in situ carcinoma. Endoscopic esophageal dilatation was attempted in every patient with no satisfactory results. One patient died for a postoperative cardiopulmonary failure (4.7%). One patient developed a fistula of the esophago-jejunal anastomosis treated with enteral nutrition successfully (4.7%). In another subject splenectomy was performed following a iatrogenic injury (4.7%). Minor complications developed in 5 patients (23.7%). After one year from operation in 1 patient a severe stricture of esophago-jejunal anastomosis appeared; it was treated with anastomotic resection and reconstruction. After 8 years one patient was submitted to a partial resection of interposed jejunal loop, that was redundant. In 18 patients long term follow-up showed good results in 14 patients (78%), discrete in 2 (11%), unsatisfactory in 2 (11%). Our results show that Merendino's esophago-jejunal gastroplasty allows to achieve good results with acceptable rate of mortality and morbidity.

[Prosthetic materials in surgery of esophageal cancer. Personal experience]. / Materiali protesici nella chirurgia del cancro dell'esofago. Esperienza di Scuola.

Even if the incidence of esophageal carcinoma is low (25% in comparison to rectal cancer) the total mortality of this disease is very high (superior to rectal cancer itself according to Am.Ca.SO. data). That's because of the high number of non resectable patients when they are first seen by the physician for dysphagia. The aim of the treatment in such cases is to permit a sufficiently good intake to the patient avoiding non-acceptable gastrostomy. The authors report their experience using esophageal prosthesis (27 cases). Mortality rate was 3.7% distal migration 7.4%. They report 3 cases of "minor" complication (11.1%). The mean survival was 5.3 months, the quality of life was satisfactory in all treated cases.

[Use of an anesthetic cream in the surgical treatment of phimosis]. / Utilisation d'une crème anesthésique pour le traitement chirurgical du phimosis.

The authors present their technique of local anaesthesia in the surgical treatment of phimosis using a cream composed of an eutectic mixture of lidocaine and prilocaine (Emla). This cream, unlike injectable local anaesthetics, allows surgical procedures to be performed on the prepuce without pain.

[Epidemiology of esophageal cancer]. / Epidemiologia del cancro dell'esofago.

The Authors examine the epidemiological features of esophageal cancer. This tumor is today the fourth neoplasm of the digestive tract, and represents 2-5% of all tumors.

[Dysphagia associated with aorto-cardiac compression on the distal esophagus: a rare event but not exceptional in the elderly]. / Disfagia legata a compressione aorto-cardiaca sull'esofago distale: evento raro ma non eccezionale in età senile.

Among the pathologies responsible for dysphagia in the elderly, the aortic compression on the distal oesophagus awakens a certain clinical interest. Cipho-lordosis, which is often present in aged females, worsens the effects of this compression causing other kinkings on the oesophagus already hypokinetic because of the age (presbyoesophagus). This illness often shows scare symptoms, but sometimes requires a pneumatic dilation to allow normal food assumption of the patient. The authors report on their experience of two cases, clearly documented from the diagnostic point of view; the first one was given medical treatment, the second one was treated with a pneumatic dilatation of the cardias.

Subcapsular splenic hematoma due to infectious mononucleosis.

Spontaneous subcapsular splenic hematoma formation without rupture in infectious mononucleosis is a very unusual occurrence. A conservative management is successful in those patients in stable condition. We describe the presentation and the clinical progress of a case in whom a sudden enlargement in hematoma's diameter needed a splenectomy to avoid the risk of blood effusion in the abdominal cavity.

Modality of failure following resection of stage I and stage II non-small cell lung cancer.

The pattern and sites of recurrence were studied in 270 patients with resected Stage I (NO) or Stage II (Nl) non-small cell lung cancer (NSCLC). Survival, incidence, and type of intrathoracic locoregional recurrence versus distant extra-thoracic recurrence after surgical excision were analyzed. Prognostic parameters, such as postsurgical stage, histologic type, degree of cellular differentiation, and surgical approach, were examined to discern their influence on tumor recurrence. The total incidence of recurrence in patients with stage I and II tumors was high, with a radical surgical approach often resulting ineffective, because of incomplete locoregional neoplastic extirpation due to micrometastases. Lymph node metastases worsened prognosis, with Nl tumors demonstrating a significantly higher recurrence rate at 5 years (63%) than NO neoplasms (48%) (p < 0.01). Stage I tumors showed an elevated incidence of local recurrence (45%), with tumor T-factor making a significant contribution in such cases. N1-factor combined with an elevated T-factor (Stage II Subclass pT2Nl neoplasms) promoted a higher incidence of distant rather than local recurrence. A shorter disease-free interval was observed in patients with N tumors as opposed to NO neoplasms. Histologic type did not play a statistically significant role (p = ns) in the total incidence of recurrence. A similar total incidence of recurrence was observed in Stage I and II tumors treated by lobectomy (51%) or pneumonectomy (56%), with locoregional recurrence appearing more frequently after lobectomy.

[Reappearance of esophageal peristalsis after treatment of achalasia. Reality or artifact?]. / Ricomparsa della peristalsi esofagea dopo trattamento per acalasia. Realtà o artefatto?

The authors discuss the question of the reappearance of esophageal peristalsis following surgical or dilating treatment in patients with a diagnosis of cardiospasm. On the basis of their experience and an extensive review of the literature, the authors affirm that the reappearance of motor activity should not be attributed to a condition of pure achalasia but rather to an intermediate motor disorder with pseudo-achalasic characteristics which are difficult to discriminate.

[Special problems in the surgical treatment of megaesophageal cardial achalasia. A clinical case]. / Problemi particolari nella terapia chirurgica dell'acalasia cardiale megaesofagica. Caso clinico.

The paper report the case of a patient brought to the Authors' attention suffering from megaesophageal cardial achalasia who had already undergone gastroduodenal resection according to BII. It was considered worthwhile to report this case due to the problems which arose concerning the choice of a thoracic rather than abdominal route owing to the impossibility of associating cardiomyotomy with anti-reflux plastica surgery because of the reduced dimensions of the stomach.

[Prognostic factors in bronchopulmonary neoplasms]. / Fattori prognostici delle neoplasie broncopolmonari.

The paper aims to illustrate the current state of knowledge regarding the prognostic factors of lung cancer. The disappointing results obtained using therapeutic modes (an overall 5-year survival rate of 15%), together with the considerable variability of the natural history of lung cancer, should be attributed to a group of prognostic factors, of varying importance, which can be subdivided into three categories: those concerning the characteristics of cancer, those inherent to the patient's conditions and those related to the type of operation. The paper underlines that histotype, TNM staging, the assessment of the nuclear degree and ploidy class play a correct and real prognostic role, and that only surgical treatment, if indicated, can offer a real life expectancy (40% 5-year survival rate in operated patients).

[The use of human fibrin glue in fistulous pathology of the lung]. / L'impiego della colla di fibrina umana nella patologia fistolosa del polmone.

Currently, bronchopleural fistulas present a decreasing complication rate in thoracic surgery, especially since surgical management of tubercular infections is no longer needed. The introduction of non-reacting suture materials and the technological advances have also lowered the incidence of such complication. Although fistulas tend to be chronic, their treatment is possible. Today, in fact, the use of human fibrin glue gives positive results which depend on the extent of the fistula as well as the adherence of the glue to the bronchial wall. The authors report their experience in two cases treated with human fibrin glue.

[Current aspects and controversies in reconstructive surgery after esophagectomy: personal experience]. / Attualità e controversie nelle ricostruzioni dopo esofagectomia: esperienza di scuola.

The authors report their series of 184 esophagectomies performed both for benign (44) and malignant (140) diseases. On the basis of their experience and supported by Literature data, it is believed restoration of digestive continuity offers two main points of discussion: choice of the intestinal tract for the interposition and type of anastomosis to perform. The nature of the lesion and its level seems to play the most important role in the choice.

[Reconstruction of the thoracic wall using a Marlex sandwich. Presentation of a clinical case]. / Ricostruzione della parete toracica con sandwich di Marlex. Presentazione di un caso clinico.

The case of a 78-year-old male with a large, firm, not tender mass of the left anterolateral region of the chest is reported. Previously he had been treated with cyproterone acetate for a year, being affected by a locally unresectable prostate carcinoma. At CT-scan of the chest mass appeared solid, extending to the pleural cavity with compression of the lung and erosion of third to fifth rib. Operation consisted in complete removal of the mass with "en bloc" resection of involved ribs. Chest wall was reconstructed by means of a Marlex mesh sandwich. Histology revealed a carcinoma, probably originating from the breast. The role of antiandrogenic chemotherapy in the development of the tumor and the use of plastic mesh for chest wall defects are discussed.