[Surgical treatment of Crohn's disease complications. Our experience]. / La terapia chirurgica nelle complicanze della malattia di Crohn. Nostra esperienza.

Thirty-five patients with Crohn's Disease (CD) were observed: 18 have been treated with medical therapy and 17 (48.6%) underwent to surgical treatment : 1) intolerance to the medical treatment in 5.9% (1 case); 2) local complications in 94.1% (16 cases: 6 stenosis, 2 occlusions, 3 abscesses, 3 fistulas, 1 perforation with peritonitis, 1 case toxic megacolon). The operations have been 19: resective interventions 14 (bowel and/or colon resections), conservative interventions 5. The mortality was 0, the morbidity 35,29%. The incidence of the recurrences in a follow up of 5 year was 42,9%. The Authors conclude that the surgery, indicated for the treatment of complications, can be resective surgery (perforating Crohn disease: fistulas, abscess) or conservative surgery (stenosing Crohn disease: stenosis). Recently the conservative intervention are proposed in the treatment of fistulas and abscesses too, but when the inflammation is mild and in patients that underwent to extensive intestinal resection with risk of short bowel syndrome.

Prognostic indicators of local recurrence in patients operated for rectal cancer.

BACKGROUND/AIMS: To identify subgroups of patients at high risk of local relapse after curative surgery for rectal cancer. METHODOLOGY: Thirty-five variables of 216 patients observed from January 1987 to December 1995 were retrospectively analyzed according to univariate and multivariate methods. Median follow-up was 38 months. RESULTS: High and moderate grade (P = 0.0001), Size > or = 5 cm (P = 0.013), lymph nodes involvement (P = 0.002) and patients with locally advanced rectal cancer underwent extensive surgery and postoperative radiation significantly increased local relapse; whereas surgical procedure and experience of surgeons had no influence. CONCLUSIONS: The above-mentioned prognostic factors of rectal cancer that show a risk of local relapse 2- to 3.5-times higher than comparative conditions could be useful in identifying subgroups of patients at high risk for local recurrence. These patients should undergo a careful selection according to risk factors of relapse in order to increase local control of disease performing "optimal" primary surgery, effective postoperative radiation and tailored follow-up.

Is intensive follow-up really able to improve prognosis of patients with local recurrence after curative surgery for rectal cancer?

BACKGROUND: Because more than 90% of local recurrences after curative surgery for rectal cancer appear within the first 36 months after surgery, an intensive and strict follow-up program during this period could improve early diagnosis and, thus, prognosis of patients. METHODS: Of the 216 patients who underwent surgery for rectal cancer, 127 entered an intensive follow-up program (median follow-up: 42 months); the clinical outcome of the remaining 89 patients was reconstructed with the help of their general practitioners. RESULTS: Fifty eight (26.8%) of the 216 patients who were treated with curative surgery alone developed a local recurrence; pelvic recurrences were prevalent. Eleven (30.5%) of the 36 patients who had recurrence during follow-up, and 6 of the 22 who had not undergone follow-up, had a reoperation with curative intent; the median survival was 19 months vs. 8 months, respectively (P = ns). Four (44.4%) curative reoperations were performed on the 9 asymptomatic patients and in 13 (26.5%) of the 49 cases with symptomatic local recurrences. Median survival was 15 months vs. 14 months, respectively (P = n.s). All patients except one (living after 42 months from reoperation) died within 48 months. CONCLUSIONS: In our study, adherence to a strict follow-up program unfortunately proved to be ineffective for improving long-term survival for patients who underwent reoperation with curative intent.

Local control after curative surgery for cancer of the extraperitoneal rectum. Twenty years of experience.

A retrospective study was carried out in 264 patients with low rectal cancer surgically treated with curative intent from January 1975 to December 1995 to analyze the influence of stapling devices on surgical and disease outcome. Patients were classified as follows: group 1 underwent surgery from 1975 to 1980, when staplers were not employed, and group 2 from 1981 to 1995, when stapling devices were routinely used. The use of stapling devices determined a corresponding increase in low anterior resection (LAR) and a decrease in postoperative mortality. A statistically significant difference in local recurrence rate between abdominoperineal resection (APR) patients and LAR sutured cases of group 1 was observed. In T3, N+ cases local recurrence rate was comparable in APR patients and LAR cases with stapled anastomosis. Improved local control occurred in stapled group 2 patients which was independent of the distal clearance. Although APR still plays an important role in treatment of lower rectal cancer, results indicated that a similar outcome after stapled LAR can also be expected in locally advanced carcinoma of the distal rectum, if accurate excision of perirectal tissue is carried out.

[Renal hemangiopericytoma. Anatomo-pathologic and clinico-therapeutic considerations. A case report]. / L'emangiopericitoma renale. Considerazioni anatomo-patologiche e clinico-terapeutiche. Descrizione di un caso.

The Authors report a case of renal hemangiopericytoma, whose interest is related to the extreme rarity (24 cases reported until today), its insidious growth, the late in diagnosis, its uncertain clinical-biological evolution, not always predictable. Considering chemotherapy and radiotherapy ineffectiveness, an adequate treatment for such a neoplasm requires the surgical therapy, which must be followed by a careful follow-up.

[Adenocarcinoid of the appendix: a case report and anatomo-pathological and clinico-therapeutic considerations]. / L'adenocarcinoide dell'appendice: presentazione di un caso e considerazioni anatomo-patologiche e clinico-terapeutiche.

The Authors underline the most important pathological, clinical and therapeutic aspects of appendiceal adenocarcinoid. Appendiceal adenocarcinoid is quite a rare tumor, presently considered as a single entity; it differs from typical carcinoid of the appendix because of its well definite histology, its aggressive behaviour and its poorer prognosis. There are no precise prognostic and therapeutic criteria to direct the operative choice between appendectomy and hemicolectomy. In particular the tumor diameter is of no use since the tumor often present diffuse rather than nodular growth. According to most Authors appendectomy is not sufficient in the following cases: liver lymph-node or retroperitoneal metastases; cecal meso-appendiceal or peritoneal spreading; histological poorly differentiated tumors, with nuclear atypia and high mitotic count. Some Authors performed hemicolectomy and bilateral oophorectomy in all case with peritoneal involvement since the ovaries are a frequent site of metastases.

Factors influencing incidence and extension of metachronous liver metastases of colorectal adenocarcinoma. A multivariate analysis.

BACKGROUND/AIM: Three hundred and eighty-seven patients surgically treated for colorectal adenocarcinoma were assessed by a multivariate analysis and the factors influencing incidence and extension of metachronous liver metastases studied. METHODOLOGY: A series of 387 patients which had been surgically treated for colorectal adenocarcinoma between January 1980 to December 1990 and followed-up over a minimum of a 5-year period was retrospectively studied. RESULTS: The most reliable prognostic markers are represented by tumor site (p < 0.05) and, more specifically, by wall infiltration (p < 0.01) and metastatic lymph-nodes (p < 0.05). The only independent variable with a significant impact on stage of metachronous liver metastases was proved to be the depth of wall infiltration (p < 0.05). CONCLUSION: This study confirms the reliability of some indicators of primary tumor in influencing incidence, but not extension, of metachronous liver metastases and this is the main problem when it comes to using prognostic factors in order to modulate the intervals of postoperative follow-up according to risk category.

[Critical review of treatment outcome in 54 patients with synchronous liver metastasis of colorectal cancer]. / Revisione critica dei risultati del trattamento di 54 pazienti portatori di metastasi epatiche sincrone da cancro colorettale.

Short- and long-term results of the treatment of 54 patients (12.5%) with synchronous hepatic metastases were critically reviewed by means of retrospective analysis of 431 colorectal cancer patients surgically treated over a period ranging from January 1980 to December 1989. Incidence and stage of hepatic metastases (Gennari Classification, 1984) are not significantly correlated to stage (T3), grade (G2-G3) and mucinous colorectal tumours; but they are significantly correlated to metastatic lymph nodes (p < 0.01). Actuarial survival is significantly influenced by surgery (p < 0.01) and stage of liver metastases (p < 0.05). The restriction of preoperative exclusion criteria and the simultaneous surgical treatment of primary colorectal and secondary hepatic metastases seem to be responsible for the high rates of operative mortality.

Chromogranin-A expression in neoplastic neuroendocrine cells and prognosis in colorectal cancer.

AIMS: Chromogranin-A (CG), a cytoplasmic glycoprotein, is one of the markers most frequently used to identify the presence of neuroendocrine cells in the human gastrointestinal tract. Several authors have identified a subgroup of colorectal cancer patients with a sever prognosis whose tumors contained neuroendocrine CG-positive cells. In the present study, CG expression in 100 patients with colorectal adenocarcinoma treated from January 1983 to December 1988 with potentially curative surgery was analyzed and correlated with other prognostic factors and 5-year survival rate. METHODS: Samples tested immunohistochemically for CG were divided into three groups: I) negative; II) less than 1 CG-positive cell/mm2; III) more than 1 CG-positive cell/mm2. RESULTS: Of 100 patients with primary colorectal adenocarcinoma, 79% had tumors comprised of CG-negative cells, 17% had rare CG-positive cells, and 4% of cases could be classified in group III. No significant relation between CG expression and location of primary tumor, bowel wall infiltration, stage of disease or tumor grade according to Broders and Jass was observed. The 5-year survival was 53% and 52% for CG-positive and CG-negative lesions, respectively. Survival of patients with Dukes-Kirklin stage C and D was comparable in patients with CG-positive (33.3%) and CG-negative (30%) tumors. CONCLUSIONS: CG expression cannot, at present, be recommended as a marker to identify prognostic subgroups in colorectal cancer patients.

Preoperative intra-arterial mitomycin-C in the management of sigmoid adenocarcinoma: long-term results of a pilot study.

AIMS AND BACKGROUND: In patients undergoing potentially curative surgery for colorectal adenocarcinoma, the presence of occult disease is thought to be responsible for distant metastases, particularly of the liver. During the 1980's preoperative intra-arterial chemotherapy was used in patients with adenocarcinoma of the sigmoid colon since it was thought that the biological effects induced by radiation in rectal lesions could be induced by cytotoxic agents in sigmoid cancer which was found to be less sensitive to radiation. The aim of the present paper is to report long-term results of an early pilot study on 20 patients with sigmoid colon adenocarcinoma treated with a 6 preoperative intra-arterial infusion of mitomycin-C followed by curative surgery. METHODS: From January 1980 to December 1986, 20 patients with adenocarcinoma of the sigmoid colon were treated with a 6 hours preoperative intra-arterial infusion of mitomycin-C followed by potentially curative surgery (Group A). Eighteen hours prior to surgery the patients underwent selective arteriography of the inferior mesenteric artery through puncture of the femoral artery at the inguinal fold. The Seldinger technique was applied and Cook BP6 catheter was used. At the end of the examination, the catheter was positioned in the inferior mesenteric artery and mitomycin-C, 10 mg/m2, was infused in 500 ml of normal saline over a 6 hours period after which the catheter was definitively removed. Within 18 hours following intra-arterial mitomycin-C infusion all 20 patients underwent potentially curative surgery of their sigmoid adenocarcinoma. During the same period, 48 comparable sigmoid colon cancer patients underwent potentially curative resection alone (Group B). RESULTS: At 5 years overall recurrence rate was 30% and 39.6% in Group A and B patients, respectively (P = n.s.). In patients with Stage C disease, recurrence was less frequently observed in Group A (44.4%) than in Group B (77.7%) (P = n.s.). Overall survival at 5 years was comparable in the two groups of patients (70% and 64% for Group A and B, respectively) and median survival was > 60 months in both groups. In patients with Stage C lesions, there was a trend for improved survival at 5 years in Group A patients (55%; median > 60 months) compared to Group B (22%; median 27 months) patients (P = n.s.). CONCLUSIONS: Although the difference indicating decreased recurrences and improved survival for Stage C patients treated with preoperative intra-arterial mitomycin-C were not statistically significant, the long term results of this small pilot study are encouraging.

[Spectroscopic analysis of biliary calculi: correlations of the type of calculi and clinical data of 25 consecutive surgical patients]. / Analisi spettroscopica dei calcoli biliari: correlazioni tra tipo di calcoli e dati clinici di 25 pazienti chirurgici consecutivi.

The Authors considering cholelithiasis as an heterogenic pathological entity report their experience of 25 surgical consecutive patients: 20 with cholesterol or combination gallstones and 5 with black pigmented gallstones. In this series the most frequent factors associated with cholesterol gallstones were LDL hypercholesterolemia and hypertriglyceridemia; while the most frequent factors associated with black pigmented gallstones were hepatopathies. The most frequent symptom was dyspepsia. Only the black pigmented and the mixed gallstones were associated with jaundice and pancreatitis. According to the Literature infection is associated to brown pigment gallstones in 95% of cases, in this series infection is rarely associated with other types of gallstones. Treatment with oral bile salts is useful only in pure cholesterol gallstones, so the distinction among different types of gallstones is useful not only for a better knowledge of their pathogenesis but also for a correct choice of the therapeutic options.

Primary mucinous adenocarcinomas and signet-ring cell carcinomas of colon and rectum.

Of 352 patients with colorectal carcinoma followed for a minimum of 5 years after surgery, 39 cases (11.1%; median age 60 years) had mucinous adenocarcinoma, and 4 (1.1%; median age 62 years) had signet-ring cell carcinoma. Mucinous carcinomas were most frequently located in the rectum (61.5%) and in the sigmoid colon (15.3%) and presented with stage C and D disease in 41 and 15% of the cases, respectively. Disease recurrence was more frequently observed in patients with mucinous (51.7%) or signet-ring lesions (100%) as compared with adenocarcinomas. Five-year survival was 45 (median 48 months), 28 (median 27), and 0% (median 15 months) in patients with adenocarcinomas, mucinous adenocarcinomas, and signet-ring cell carcinomas, respectively (p < 0.05). Mucinous carcinomas of the rectum had had a significantly worse prognosis (5-year survival 17%, median 33 months) as compared with adenocarcinomas of the same site (5-year survival 34%, median 25 months; p < 0.05).

Primary gastric lymphoma.

The records of 30 patients with primary gastric lymphoma and a minimum of 5 years of follow-up were reviewed and clinical and pathologic prognostic factors analyzed. The overall 5-year survival was 40% (median 23 months). No significant relationship between surgical and patient age, sex, duration of symptoms, macroscopic appearance, or size of the primary lesion or degree of serosal infiltration was demonstrated. Stage of disease and site of primary had an impact on prognosis. Survival was improved in patients with stage I-II disease (P < 0.05) and in patients with primary located in the distal third of the stomach (P < 0.05). Although histology in all three classifications did not correlate well with survival, patients with low-grade lymphoma according to Kiel showed improved outcome (P < 0.05). Five-year survival of 11 patients with positive lymph nodes, 6 of whom were treated with cytotoxic therapy, was 54% and comparable to that of 7 patients (56%) with no nodal involvement who did not receive chemotherapy after surgery.

Extension of lymph node dissection and survival in primary gastric cancer.

The histories of 429 patients who underwent surgery for primary gastric cancer at our ward from January 1970 to December 1985, were reviewed. All patients underwent surgery: potentially curative surgery, 54.8%, non-curative resection, 18.2%; palliative surgery, 27%. Nodal status was as follows: N0, 28%; N1, 17.7%; N2, 44.5%; N3, 9.8%. The incidence of N0 cases was significantly increased in Stage T1 and T2 disease compared to Stage T3 and T4 lesions (p < 0.001). In Stage T3 and T4 patients the incidence of distant metastases increased if lymph node involvement was also present (p < 0.005). In patients without nodal metastases 5-year survival was 70% (median survival: 60+ months) whereas, in patients with lymph node involvement survival was 32% (median survival: 24 months) (p < 0.001). Our data suggest that elective extensive lymph node dissection (R2) is indicated in all patients because survival is improved by this procedure. We recommend R3 lymph node dissection only in macroscopic N3 node involvement patients.

[The prognostic value of Jass' histopathological classification of cancer of the left colon and rectum]. / Valore prognostico della classificazione istopatologica di Jass nel cancro del colon sinistro e del retto.

Histological material from 121 patients who underwent surgery for cancer of the left colon and rectum was reexamined by two pathologists according to criteria put forward in Jass' histopathological classification. A prevalence of Jass' grades II (36.4%) and III (47.9%) were observed in this series. There was no correlation between the site of neoplasia but there was a clearly increased incidence of advanced stages C and D according to Dukes-Kirklin's classification within Jass' grades II, III and IV (p less than 0.005) and growth pattern, but not for the configuration of tubules. The new histopathological model proved to be more reliable in prognostic terms in the case of cancer of the rectum compared to that of the left colon, but at present its clinical significance is limited to specifying the site and stage of the neoplasia. The latter was found to be the most reliable prognostic parameter.

[Tumor markers. II. Their significance in the follow-up of patients after radical resection of lung neoplasms]. / Marcatori tumorali. II. Loro significato nel follow-up dei pazienti sottoposti a resezione radicale di neoplasie polmonari.

The clinical field in which tumor markers proved to be most useful is the monitoring of cancer patients. The present study was carried out in order to evaluate the role of tumor markers in the prognostic assessment, and pre-clinical identification of disease recurrence in patients with completely resectable non-small cell bronchial carcinoma. Tumor markers have been measured: a) pre-operatively, in 109 patients with resectable lung cancer and b) post-operatively, in 61 patients who underwent complete resections and were followed for at least one year after surgery. The carcinoembryonic antigen (CEA), the neuron specific enolase (NSE), the tissue polypeptide antigen (TPA), the carbohydrate antigen 19-9 (CA 19-9) and the carbohydrate antigen 50 (CA 50) have been determined in each patient. Long-term survival was significantly correlated with serum levels of the CEA, CA 50 and CA 19-9, while not with those of TPA and NSE. For pre-clinical detection of cancer recurrence, TPA and NSE were the most suitable indicators.

[Tumor markers. I. Their significance in the preoperative assessment of lung neoplasms]. / Marcatori tumorali. I. Loro significato nella valutazione pre-chirurgica delle neoplasie polmonari.

The present study has been carried out in order to evaluate the role of tumor markers in the presurgical assessment of patients with bronchial carcinoma. The carcinoembryonic antigen (CEA), the neuron specific enolase (NSE), the tissue polypeptide antigen (TPA), the carbohydrate antigen 19-9 (CA 19-9) and the carbohydrate antigen 50 (CA 50) have been preoperatively measured in 133 subjects with potentially resectable lung cancers, and in 75 healthy smokers. Sixty-one patients had squamous cell carcinoma, 55 adenocarcinoma and 17 small cell carcinoma. Lobectomy (or bilobectomy) was performed in 74 cases, pneumonectomy in 36 cases, exploratory thoracotomy in 15 cases and a palliative resection in 8 cases. When individual markers were considered, TPA showed the highest sensitivity (85%) and CA 19-9 the lowest sensitivity (11%). Specificity was uniformly superior to 90%. When marker associations were considered, the combined measurement of TPA and NSE gave the best results: both the sensitivity and specificity rates approached 90%. The application of the TPA-NSE association allowed detection of 94% of small cell carcinomas, 89% of adenocarcinomas and 85% of squamous cell carcinomas. A positive correlation was found between the complete resectability of lung cancer and serum levels of CEA, CA 50 and CA 19-9. By using the discriminant analysis, a statistical model yielding identification of about 74% of patients with tumors which were judged potentially resectable according to the pre-operative non-invasive diagnostic procedures and were found to be unresectable at thoracotomy, has been get available.

[Extended and palliative surgery in the treatment of gastric cancer in advanced stage]. / Chirurgia allargata e palliativa nel trattamento del cancro gastrico in fase avanzata.

Five hundred and fifty patients operated between 1965 and 1983 for stomach carcinoma were included in the study. Of these, 244 (44.4%) underwent extended (54 patients) or palliative surgery (190 patients) due to the extragastric diffusion of the neoplasia. Global postoperative mortality for patients undergoing extended surgery was 16.7% and the five-year survival rate was 18.5%; in the case of those undergoing palliative surgery the postoperative mortality rate was 30.5% and the two-year survival rate was 14% for resection and 4% for derivatives. Patients who underwent a derivative operation showed an easing of symptoms and an improved quality of life. On the basis of these results the Authors consider that the possibility of extended surgery should still be carefully evaluated in patients in whom a stomach tumour has exceeded the gastric boundary, irrespective of its extent, since the limit of radical surgery is not related to the extension of surgical demolition but to the entity of the extragastric diffusion of the neoplasia. In addition, surgical abstention is not always justified even in patients in whom surgery cannot be curative since a 10% five-year survival rate was observed in patients undergoing palliative resection.

[Prosthesis replacement of the inferior vena cava]. / Sostituzione protesica della vena cava inferiore.

The development of reconstructive venous surgery has been hampered by the lack of suitable graft materials. Fourteen carbon fibre grafts (phi: 8 mm), 30 glutaraldehyde treated ovine collagen grafts and 29 polytetrafluoroethylene (PTFE) grafts were used to replace a 35 mm segment of infrarenal inferior vena cava in pigs. Prostheses were removed 1 hour and 7, 14, 28, 56 and 112 days after implantation. All specimens were examined by light and scanning electron microscopy. The 112 day patency rate was 67% for ovine collagen grafts, while all carbon and PTFE grafts thrombosed. The difference was statistically significant (p less than 0.01). During the first hour after implantation, a thick (800-900 microns) thrombotic layer deposited on the inner surface of carbon grafts. This layer possibly caused the subsequent complete occlusion of the tubular segments. A thin neointima (less than 200 microns) developed on the flow surface of ovine collagen prostheses. This favoured complete endothelialization of the graft inner surface as soon as four weeks after surgery. In conclusion, glutaraldehyde treated ovine collagen would represent the first sound material to be used as venous substitute.