Early perioperative results and surgical recurrence after strictureplasty and miniresection for complicated Crohn's disease.

BACKGROUND/AIMS: Strictureplasty (SP) or miniresective 'bowel-sparing' techniques (MR) can prevent the risk of intestinal stomia and short bowel syndrome in patients affected by Crohn's disease (CD). The aim of this study was to analyze the perioperative morbidity and mortality in 104 of 138 consecutive patients treated for CD complications using bowel-sparing techniques. We also considered the factors that may be related to the risk of perioperative complications and the long-term outcome. METHODS: One hundred and four patients were treated with SP and/or MR and then included in a prospectively maintained database. The factors claimed to influence perioperative complications were analyzed using Fisher's exact test for categorical observations and the Mann-Whitney U test for continuous variables. A multivariate analysis, using logistic regression, and a long-term time-to-event analysis using the Kaplan-Meier function, were also performed. RESULTS: Perioperative mortality was nil. In relation to the 6 postoperative complications (5.8%), 4 patients underwent minimal bowel resection (MR), 1 a MR with SP, and 1 SP alone. Three of these patients (2.9%) needed reoperation for septic complications, and 3 (2.9%) were treated as outpatients for enterocutaneous fistulas. A correlation (p < 0.05) was found between low serum hemoglobin levels and postoperative complications at univariate and multivariate analyses. The 5-year surgical recurrence-free rate was 75% overall, 73% for patients treated with SP, 78% with MR, and 77% with MR + SP. CONCLUSIONS: Postoperative complications are not related to conservative or miniresective surgery even when active disease is present at the resection margins or the site of SP. The higher risk reported for patients with low serum hemoglobin and hematocrit levels suggests that surgeons should consider using preoperative iron and vitamin support, parenteral nutrition and erythropoietin therapy, when necessary, in those cases. Our postoperative morbidity, mortality and long-term surgical recurrence rate results support the efficacy and safety of SP and MR surgery in the treatment of complicated CD.

Transcatheter arterial chemoembolization in cytoreduction of inoperable hepatocarcinomas.

Transcatheter arterial chemoembolization (TAE) is often considered a mean of palliation for inoperable liver carcinomas. A few centers use a sequential treatment (TAE followed by surgery). However the role of TAE in bringing to surgery patients with hepatocarcinomas (HCC) considered inoperable at first diagnosis is debated. We report on the case of a 57 y.o. male diagnosed as having HCC, inoperable because of bilateral location and size. The patient was treated with repeated TAEs and the results were monitored with CT scans. After three TAEs, the main tumor mass volume was reduced 2.2 fold and the patient could undergo surgery; the postoperative period was uneventful, with no clinical signs of liver failure. Our experience leads us to suggest that TAE, further to being an option for palliation, can be a valuable tool to lead to surgery otherwise inoperable HCC patients.

Carcinoma of the head of the pancreas: review of 67 cases and comparison with 27 additional periampullary carcinomas.

BACKGROUND/AIMS: Carcinoma of the head of the pancreas is reported with increasing incidence. The classical Whipple procedure, modified by Traverso and Longmire, is a major surgical undertaking and there is question on its indication in the case of lesions which, although technically resectable, are not susceptible to cure. PATIENTS AND METHODS: We review 67 cases of carcinoma of the head of the pancreas comparing the results of radical vs. palliative surgery. The results were then compared with 27 additional cases of periampullary carcinomas. RESULTS: Long term survival was obviously higher after resection, due to the more advanced tumor stage in the palliation group. However, perioperative mortality, supposedly high in extensive resective surgery, was 8.7% (vs 11.9% in the palliation group). CONCLUSIONS: At present, extensive resective surgery carries unacceptable incidence of perioperative mortality. Therefore we suggest that indication for resection should be widened, as it may offer better chances of cure in resectable periampullary carcinomas and, even in non curable cases, it offers better quality of life and the advantages of tumor debulking.

Third segment cholangio-jejunostomy in the treatment of unresectable klatskin tumors.

BACKGROUND/AIMS: Cholangiocarcinoma of the hepatic hilum is a seldom curable lesion when detected and several methods of palliation have been suggested. Bismuth has proposed an intrahepatic cholangiojejunostomy on the third segment of the liver, which in his experience obtains effective biliary drainage with better quality of life compared with other forms of palliation. PATIENTS AND MATERIALS: We have used this technique in nine cases. We evaluate results, mortality and morbidity, in comparison with other authors' reported series. RESULTS: In the early postoperative period one patient died, two patients suffered from immediate postoperative complications, and jaundice resolved completely in six patients. Long term survival was influenced by the underlying disease. CONCLUSION: Our findings support Bismuth preference for this technique of surgical palliation for non resectable tumors of the biliary tract.

Improvement of colo-rectal cancer surgery following introduction of endoscopical approach.

In the period 1968-1993, we treated 399 patients for colo-rectal cancer. Up to 1980, preceding large scale use of endoscopy, 217 patients, out of the group of 399, were submitted to surgery; at time of diagnosis all patients had symptoms of advanced colonic tumor (intestinal obstruction; palpable mass; significant rectal bleeding); none of the lesions detected was in Dukes A or B1 groups; 56 patients were in Dukes B2 and stages C1 + C2 + D were detected in 161 cases. In period 1981-1993 we treated 182 patients; in all cases the diagnosis consisted of endoscopical examinations. Out of this group 69 patients underwent endoscopic resection of polyps with focal neoplastic degeneration: 44 did not require surgery according to Haggitt criteria. In the group of 138 patients who underwent surgery, 89 were in Dukes A + B1 + B2 groups and 49 were in Dukes C1 + C2 + D groups. In our experience endoscopy is not essential in the clear cut colonic neoplasms, however it is an invaluable screening test in early stages, in poor symptomatic population, in elderly patients (> 50 y.o.) and in patients with non specific symptoms. We wish to emphasize how endoscopy has improved the results of colonic cancer surgery.

[Total versus partial pancreatectomy in the surgical treatment of carcinoma of the pancreatic head]. / Pancreasectomia totale vs pancrasectomia parziale nel trattamento chirurgico del carcinoma della testa del pancreas.

This is a review of the recent advances in total pancreatectomy versus regional pancreatectomy for adenocarcinoma of the head of the pancreas. The rationale for total pancreatectomy comes from a tendency for pancreatic cancer to be multicentric, the absence of the pancreatico-enterostomy and the argument that total pancreatectomy is a better cancer procedure (wider lymphadenectomy and soft tissue resection). In spite of these theoretical advantages, any important impact on morbidity, mortality and ultimately on survival has not been realised. We analyse the principal metabolic and functional sequelae of total pancreatectomy, particularly highlighting the importance of glucagone hormone in maintaining correct blood glucose levels. The data suggest, a tendency to use total pancreatectomy in selected patients on the basis of pre- and intraoperative cytodiagnosis to prevent occult neoplasms in the pancreatic remnant.

[Comparison of 67 pancreatic head tumors and 27 periampullary tumors]. / Confronto tra 67 tumori della testa pancreatica e 27 tumori periampollari.

The authors, in the period from Jan. 1980 to Dec. 1990, observed 67 patients with tumor located in the head of pancreas and 27 patient with periampullary tumors. These included 18 tumors originated from the ampulla of Vater and 9 from distal common bile duct. Operability rate ranged from 62.6% pancreatic carcinoma to 94.4% tumors of ampulla, according to the tumor location. Resectability rate ranged from 9.5% for pancreatic adenocarcinoma for 94.1% to ampullary tumors. Considering 23 resections, 18 were pancreatoduodenectomies and 5 local excisions for tumor of ampulla. Mortality was 7.7% after non resectional treatment and two patients (8.7%) died in the immediate postoperative period after radical resection. Multivariate analysis on all patients operated (n. 65) revealed that 5 years survival rate was significantly related to intent of operation (palliative = 0 - curative = 8.6%), histologic type, and site. In fact no patient with pancreatic adenocarcinoma achieved a 5 years survival rate. Two patients with adenocarcinoma of ampulla survived 5 years. Cancer of the head of pancreas is quite malignant because, owing to pancreas position, an early diagnosis is very hard. Most times resective surgical treatment is impossible because of the cancer diffusion.

Histology as a prognostic factor in early gastric cancer.

Of 431 patients with gastric cancer observed in our institution, 23 (5.3%) had early gastric cancer (EGC). Macroscopic presentation, histology, depth of invasion, and lymph node involvement were evaluated in all the cases. All patients underwent surgery and an intensive follow-up was performed. Five of the 23 patients progressed, and the risk factors were examined. Histology seemed to be the main prognostic factor in our study, since intestinal type of EGC was associated to a significantly better prognosis. Total gastrectomy is indicated in the proximal localization of EGC, and should perhaps be performed also in cases presenting undifferentiated histology.

Age as a prognostic factor in primary non Hodgkin lymphoma of the stomach.

We present 20 cases of primary non-Hodgkin lymphoma of the stomach. Histological classification, staging, age of patients and therapeutical approach were evaluated. Median overall survival was 30 months, and 5-year survival was 44%. In our small series, the age of the patients plays an important role: median overall survival is 18 months in patients greater than 60 y.o. (compared to 90 months in patients less than 60 y.o.) and 5-year survival 12.5% (compared to 62%).

[Primary gastric lymphoma: our experience]. / Il linfoma gastrico primitivo: nostra esperienza.

The authors report their experience with 10 cases of primary gastric lymphoma observed in 10 years. Nonspecific symptomatology and bioptic features often misleading to benign lesions (pseudolymphoma) explain why an early diagnosis is difficult to achieve. A correct surgical treatment, with careful pre- and intraoperative staging, associated to pre- and postoperative chemo- and radiotherapy, allows good results in terms of survival.