[Surgical management of pancreatic endocrine tumors in patients with MEN 1 syndrome. Considerations on one case observed]. / Problematiche chirurgiche nel trattamento delle neoplasie pancreatiche nel paziente affetto da MEN 1. Considerazioni su un caso osservato.

INTRODUCTION: Particular problems in MEN 1 syndrome come from the morphological identification of pancreatic tumors because of their are often small [<1 cm] and multiple [89% of the cases]. However intraoperatively it could be difficult to identify with palpation the tumors described by preoperative investigations and to decide the most suitable surgical treatment. The authors describe one case recently observed to underline and update the correct management. CASE REPORT: A 34 year old woman was admitted for the surgical treatment of an insulinoma. Polimenorrea, hypercalcemia and familiarity for MEN 1 syndrome were also present. A CT scan showed the tumors in the body and tail of the pancreas [diameter 0.5-1 cm]. MRI described only a small mass in pancreatic head. A calcium angiography was positive for insulin secretion after calcium infusion in hepatic and gastroduodenal artery, and for glucagon secretion after infusion in splenic artery. An intraoperative ultrasonography discovered three nodules that were enucleated. They were one insulinoma and two glucagonomas respectively. After enucleation glycemia became immediately normal. CONCLUSION: To avoid wide surgical resections [es. left pancreatectomy] we suggest a conservative treatment [multiple enucletion with or without a pancreatic-jejunum side-to-side anastomosis] with a meticulous preoperative and intraoperative evaluation of all pancreatic nodules.

Functional results of a personal technique of reconstruction after pancreaticoduodenectomy.

The aim of the study is to propose a new technique of reconstruction after pancreaticoduodenectomy with more attention to the functional aspects. From 1995 and 2003, 25 patients underwent pancreaticoduodenectomy for pancreatic or periampullary cancer. The reconstruction was carried out by: end-to-end gastro-jejunal anastomosis (first jejunal loop); a Roux-en-Y T-T pancreatico-jejunal anastomosis leaving a silastic catheter in the Wirsung; hepatico-jejunostomy and jejuno-jejunostomy below the biliary anastomosis; superselective vagotomy. Mortality was 8%. Regarding the complications, we observed 3 biliary fistulas, mean duration 5 days, with spontaneous healing; 8 pleural effusions and 7 wound infections. Postoperative 3 months reevaluation showed weight gain in 14 patients with no other digestive symptoms (vomiting, fullness, dumping). With a scintigraphic meal we observed a good rythmic and regular gastric emptying. No jejunal peptic ulcers were noted in all patients after the gastric protonic pump inhibitors were discontinued. Fecal fats were evaluated in all cases for malabsorption 3 months after operation with low fat fecal levels. The preliminary results of our recent experience seem to be encouraging. This technique may have a useful application in the clinical setting as far as radicality and quality of life of the patients with pancreaticoduodenectomy.

Topographic diagnosis and surgical treatment of insulinoma.

AIM: Controversy continues to reign with regard to the need for preoperative localization of insulinomas and to which are the most sensitive and accurate diagnostic imaging modalities. Our aim was to determine the role of diagnostic procedures and suggest which of them are really useful. METHODS: Over a 12-year period 34 patients underwent several preoperative diagnostic procedures to localize the insulinoma: ultrasonography (US) in 20 cases, computed tomography (CT) in 26, magnetic resonance imaging (MRI) in 28, selective angiography in 8, arterial stimulation venous sampling (ASVS) in 23 and Octreoscan in 26. All patients underwent surgical palpation and in 32 cases intraoperative ultrasonography (IOUS) was performed. Twenty-six cases underwent enucleation, six had distal pancreatic resections and two patients had only exploratory laparotomy with liver biopsies. We compared the findings of the diagnostic procedures and analyzed the surgical treatment chosen according to the pancreatic site of the tumor. RESULTS: In 32 (94.1%) of the 34 patients with clinically suspected pancreatic insulinoma the tumor was found at surgery. Preoperative US achieved 5.2% sensitivity, CT 29.1%, selective angiography 28.5% and MRI 76.9%. ASVS achieved 91.3% sensitivity and diagnostic accuracy whereas Octreoscan achieved only 65.3% diagnostic accuracy. Surgical palpation performed before IOUS identified the tumors in 30/34 patients: in the other four cases, one was a false-positive result (a cyst in the pancreatic head), two were true negatives and one was a false negative. Surgical palpation therefore yielded 88.2% diagnostic accuracy. IOUS was performed in 32 cases and localized the tumors in 29/32 cases (sensitivity: 96.6%) with one false-negative result (diagnostic accuracy: 96.8%). The operative mortality was 2.9% and the morbidity 24.6% (30.7% in patients treated by tumor enucleation). CONCLUSIONS: No single diagnostic imaging modality is reliable for localizing insulinoma. We therefore suggest combined MRI, ASVS and IOUS. ASVS provides particularly useful information for planning manual palpation and intraoperative ultrasonography.

Impaired human gallbladder lipid absorption in cholesterol gallstone disease and its effect on cholesterol solubility in bile.

BACKGROUND & AIMS: The role of the gallbladder in gallstone pathogenesis is still unclear. We examined the effects of gallbladder mucosal lipid absorption on lipid composition and cholesterol crystallization in bile. METHODS: The in vitro-isolated, intra-arterially perfused gallbladder model was used (1) to compare the absorption rates of lipids from standard bile by gallbladders obtained from 7 patients with cholesterol gallstones and 6 controls; and (2) to measure the microscopic cholesterol crystal detection time in cholesterol-enriched pig bile before and after lipid absorption by the pig gallbladder. RESULTS: Control gallbladders, but not cholesterol gallstone gallbladders, significantly reduced cholesterol (P < 0.02) and phospholipid (P < 0.01) and increased bile salt (P < 0.01) molar percentages in bile over a 5-hour period by efficient and selective cholesterol and phospholipid absorption. A histomorphometric study of the epithelial cells showed significantly higher values for nuclear density (P < 0.01) and nuclear (P < 0.05) and cytoplasmic (P < 0.05) areas in the cholesterol gallstone than the control group. Sequential microscopy of cholesterol-enriched pig bile showed significantly shorter cholesterol filament (P < 0.01) and typical cholesterol plate (P < 0. 02) detection times before than after exposure of bile to the gallbladder lipid absorption. CONCLUSIONS: In cholesterol gallstone disease, the human gallbladder epithelium loses its capacity to selectively and efficiently absorb cholesterol and phospholipids from bile, even if it is hyperplastic and hypertrophic. This epithelial dysfunction eliminates the positive effect that the normal gallbladder exerts on cholesterol solubility in bile and might be a pathogenetic cofactor for cholesterol gallstone formation.

Gastrointestinal emergencies in patients with acute intestinal graft-versus-host disease.

Acute intestinal graft-versus-host disease (GVHD) develops in about 30-50% of allogeneic bone-marrow transplant recipients: 10-20% have gastrointestinal emergencies (hemorrhage or perforation). Mortality reaches 30-60% in patients with acute, grade 2-4 GVHD. We studied 36 bone marrow recipients in whom acute intestinal GVHD developed. Seven had gastrointestinal emergencies: 4 severe gastrointestinal bleeding and 3 acute peritonitis. Three patients with gastrointestinal bleeding and one patient with peritonitis responded to medical therapy. Three needed surgery: one with bleeding and two with peritonitis, while 1 patient had embolization. Of the 7, two patients died, one after embolization and one after surgery. Two of the three surgically-treated cases are still alive several years after operation. From this experience we feel that surgery for gastrointestinal bleeding in acute GVHD is indicated only when medical treatment fails. Severe neutropenia, thrombocytopenia (<10.000 x mm3) and blood cultures positive for CMV have an unfavorable prognostic value.

Videoassisted transhiatal esophagectomy for cancer.

Blunt transhiatal esophagectomy is largely performed in selected cases of esophageal cancer according to the experience of Mark Orringer. We have recently performed eleven consecutive videolaparoscopy assisted transhiatal esophagectomies in order to help esophageal dissection and to avoid injuries to mediastinal structures. In our experience the routine use of laparoscopic assistance during transhiatal esophageal dissection improves the safety of this technique and lowers postoperative complications. The results of neoadjuvant treatments (radio-chemotherapy) recently reported emphasize the role of transhiatal esophagectomy for cancer.

[Video-assisted closed-thorax esophagectomy in cancer. A technical proposal]. / L'esofagectomia a torace chiuso videoassistita per cancro. Una proposta di tecnica.

Blunt transhiatal esophagectomy is largely performed in selected cases of esophageal cancer following the experience of Mark Orringer. We have recently performed five consecutive video-laparoscopy-assisted transhiatal esophagectomies in order to help the esophageal dissection and to avoid injuries to mediastinal structures. In our experience a routine use of laparoscopic assistance during transhiatal esophageal dissection improves the safety of this technique and lowers postoperative complications. The results recently reported from neoadjuvant treatments (radio-chemotherapy) emphasize the role of transhiatal esophagectomy for cancer.

[Primary non-Hodgkin's lymphoma of the intestine associated with asymptomatic celiac disease in adults]. / Linfoma non-Hodgkin primitivo dell'intestino associato a malattia celiaca asintomatica dell'adulto.

Celiac disease (CD), a gluten-induced enteropathy, is characterized by typical intestinal involvement with classical clinic features in childhood and less frequent features in adult patients. Recognizing pauci- and asymptomatic patients is a critical point in the clinical management of CD because of the high mortality associated with the onset of complications. Among these, malignant diseases are the most severe, particularly squamous cell carcinoma and lymphoma, the latter accounting for 50% of all malignancies occurring in CD patients. The authors describe a 57 years old patient with CD and Enteropathy-Associated-T-Cell Lymphoma, who had no intestinal symptoms but only severe pruritus and hypereosinophilia.

[Diagnostic and therapeutic strategy of insulinomas. Apropos of a personal experience of 21 cases]. / Stratégie diagnostique et thérapeutique des insulinomes. A propos d'une expérience personnelle de 21 cas.

Insulinomas account for about 90% of all pancreatic endocrine tumors and their surgical resection leads to cure in 90% of patients. Although current laboratory tests have simplified the clinical diagnosis of insulinomas, despite recourse to an array of most preoperative diagnostic procedures in 10-15% of patients the exact location of the tumor remains undefined. Tumor localization is difficult because: 80% of insulinomas measure less than 2 cm, about 10-12% of insulinomas are multicentric and 4-6% escape detection because are multiple endocrine neoplasms (MEN). If preoperative imaging fails to detect the site of the lesion, the surgeon could be obliged to perform a "blinded resection" with high risks of failure. The Authors refer their experience in a series of 21 patients operated on for insulinoma over the past 8 years (1987-1995). Arteriography with calcium stimulation (ASVS) and scintigraphy with 111-Indium-labeled octreotide performed in the later 16 and 13 cases respectively, achieved a correct tumor localization (confirmed by surgery) in 100% and 84.7% of patients. Intraoperative ultrasonography, performed in 18 cases, allowed not only to localize the tumor but also to study the tumor's neighbouring anatomic structures (Wirsung duct. splenic artery and vein), thus providing the anatomical and surgical information necessary to plan the right surgical strategy (tumor enucleation or pancreatic resection). Tumor enucleation was performed in 15 patients, distal pancreatic resections in 5 cases and multiple liver biopsies in 1 case: this patient had liver micrometastases from a malignant insulinoma without a palpable tumor. Operative mortality was nil. Postoperative complications occurred only in 5 of the 15 enucleations (1 pseudocyst successfully treated with a ultrasound-guided drainage and 4 pancreatic fistula resolved by medical therapy).

[The role of colonoscopy in early diagnosis of intraluminal recurrences in patients already treated for colorectal cancer]. / Ruolo della colonscopia nella diagnosi precoce delle recidive intraluminali nei pazienti già trattati per carcinoma colorettale.

It is a common opinion that the more often and the more rigorously the colon is examined, the more lesions will be discovered and diagnosed. However it has not been shown which methods of colonic examination and which regimen of surveillance should be used. Chart review was conducted on 481 patients who underwent curative resection for colorectal cancer between 1980 and 1990. Colonoscopy was performed preoperatively, after 12-15 months from surgical treatment, and then at an interval of 12-24 months, or when symptoms appeared. About ten percent of patients developed intraluminal recurrences, and more than 25% adenomatous polyps. More than one half of the metachronous lesions arise within the first 24 months. The median time to diagnosis was 25 months for intraluminal recurrences and 22 months for adenomatous polyps. Patients with left sited tumor at an advanced stage run a higher risk of developing recurrent intraluminal disease, and patients who presented associated polyps at the time of the operation for the index cancer have a higher risk of developing new polyps. About 50% of recurrences were detected when patients were asymptomatic. Colonoscopy must be performed within the first 12-15 months after operation, while an interval of 24 months between each examination seems sufficient to guarantee an early detection of metachronous lesion. Asymptomatic patients are more frequently reoperated for cure and thus have a better survival rate.

Surveillance of colorectal cancer: effectiveness of early detection of intraluminal recurrences on prognosis and survival of patients treated for cure.

PURPOSE: The authors evaluate the effectiveness of routine colonoscopy and marker evaluation in diagnosis of intraluminal recurrent cancer. METHODS: Chart review was conducted on 481 patients who underwent curative resection for colorectal cancer between 1980 and 1990. Clinical visits were scheduled and carcinoembryonic antigen evaluation was performed every three months, and colonoscopy was performed preoperatively, 12 to 15 months after surgical treatment, and then with intervals of 12 to 24 months or when symptoms appeared. RESULTS: About 10 percent of patients developed intraluminal recurrences. More than one-half of metachronous lesions arose within the first 24 months, and median time to diagnosis was 25 months. Patients with left-sited tumors in the advanced stage had a higher risk of developing recurrent intraluminal disease. Twenty-nine patients underwent a second surgical operation, of which 17 cases were radical. In this group, the five-year survival was 70.6 percent, although no nonradically treated or nonresected patients survived longer than 31 months. Twenty-two patients were asymptomatic at time of diagnosis of recurrence, and of these, 12 patients underwent radical operation; on the other hand, of the 24 symptomatic patients, only 5 were treated radically. Carcinoembryonic antigen was the first sign of recurrence in eight cases. Colonoscopy must be performed within the first 12 to 15 months after operation, whereas an interval of 24 months between examinations seems sufficient to guarantee early detection of metachronous lesions. CONCLUSION: Serial tumor marker evaluation is of help in earlier diagnosis of local recurrences. Asymptomatic patients more frequently undergo another operation for cure and thus have a better survival rate.

The surgical choice in neutropenic patients with hematological disorders and acute abdominal complications.

The clinical course of patients with hematological disease, especially after treatment, is often complicated by gastrointestinal infections. Between 1986 and 1990 a total of 18 patients affected with hematologic disease and presenting with an acute abdomen were admitted to the surgery department at the University of Rome "La Sapienza". Most patients were affected with acute or chronic myeloid leukemia (61%) and lymphoma. Five patients with acute appendicitis, three with necrotizing enterocolitis, three with spontaneous hemoperitoneum, three with cholecystitis, two splenic infarctions and two intestinal occlusions were diagnosed. Symptoms were often vague and non specific and blood counts revealed neutropenia in all but two patients, while anemia was characteristic in spontaneous hemoperitoneum and in neutropenic enterocolitis. Fungemia occurred in only two cases while bacteremia was present in seven. The most critical patients were those affected by neutropenic enterocolitis and acute cholecystitis. Sonography was meaningful in the diagnosis of hemoperitoneum, splenic infarct and acute cholecystitis. All patients underwent surgical procedures within 48 hours of admission to the department. In all cases peritoneal washing was performed and at least one peritoneal drainage was left. In all cases of necrotizing enterocolitis, intestinal resections, either ileal or colonic, were followed by an immediate anastomosis in two layers. Intensive hematological and antibiotic post surgical care was performed in all patients. Seven patients presented minor complications (38.8%), and only one died (5.5%). Emergency surgical treatment may be safely carried out in patients with hematological diseases presenting with an acute abdomen. Intensive postsurgical care is mandatory for the recovery of patients and the patient's critical condition should not be a deterrent to surgical intervention.

Surgical treatment of immune thrombocytopenic purpura.

The role of surgery in the treatment of immune thrombocytopenic purpura (ITP) is still discussed. The aim of this study was to verify our criteria of patient selection for splenectomy, to analyze the results of a protocol for the evaluation of the hemorrhagic risk, and to discuss long-term results of 70 patients with ITP who underwent surgical treatment from 1984 to 1990. All patients received steroid therapy. Sixty-two patients were given high doses of IgG (600 mg/kg/iv bolus) pre-operatively in order to obviate the need for intra-operative platelet transfusions. Forty-three patients showed a significant increase in the platelet count, 8 a moderate increase, while 11 patients did not respond. No operative mortality was observed, however postoperative minor complications occurred in 14 (20%) patients. Accessory spleens were found in 11 (15.7%) patients. Mean follow-up was 21 months. Response to splenectomy was considered as complete (platelets greater than 150,000 mm3 with no need for medical treatment) in 63 (90%) patients. No response was observed in 7 patients. In 2 of the non-responders postoperative indium-111 scan revealed accessory spleens and ITP remitted after accessory splenectomy. All non-responders were in the group of patients who did not respond to the pre-operative infusion of high dose IgG. It can be concluded that splenectomy is a safe and effective treatment for ITP and that response to pre-operative infusion of IgG may be considered as predictive for the outcome after splenectomy.

Role of CEA, TPA, and Ca 19-9 in the early detection of localized and diffuse recurrent rectal cancer.

Sixty-six consecutive patients who underwent curative resection for rectal cancer were studied prospectively to evaluate the roles of sequential carcinoembryonic antigen (CEA), tissue plasminogen activator (TPA), and carcinomatous antigen 19-9 (Ca 19-9) determinations in the early diagnosis of resectable recurrences. Thirty-three recurrences were detected between 6 and 42 months. CEA, TPA, and Ca 19-9 showed a sensitivity of 72.7 percent, 78.8 percent, and 60.1 percent, respectively, and a specificity of 60.6 percent, 60.6 percent, and 87.9 percent, respectively. In 23 cases the rise in the value of CEA and/or TPA and/or Ca 19-9 was the first sign of recurrences, and the diagnosis was established later by clinical methods. In this group, the lead time was two months for liver metastases and four months for disseminated metastases. As far as the relationship between localization of recurrence and marker level increase is concerned, of 16 hepatic metastases CEA, TPA, and Ca 19-9 showed a sensitivity of 94 percent (P less than 0.05), 69 percent, and 62 percent, respectively. Of six patients with local recurrences, CEA, TPA, and Ca 19-9 showed a sensitivity of 50 percent, 100 percent (P less than 0.05), and 83.3 percent, respectively. Of three patients with peritoneal carcinomatosis, CEA, TPA (P less than 0.05), and Ca 19-9 showed a sensitivity of 0 percent, 100 percent, and 0 percent, respectively. No significant differences were reported among the three markers according to multiple metastases and metachronous polyps. Fourteen patients (42.4 percent) underwent surgical treatment for recurrent disease, and eight of them (57 percent) showed a resectable disease, for a total resectability rate of 24.2 percent. The findings of our study indicate that a follow-up program based on CEA, TPA, and Ca 19-9 assays is related to an early diagnosis and a good resectability rate for both local and metastatic recurrences from rectal cancer.

Extracapsular lymphnode metastases in the staging and prognosis of gastric cancer.

The aim of this study was to evaluate the influence of the degree of nodal involvement (extracapsular vs intracapsular) on survival of 121 patients radically resected for gastric adenocarcinoma with nodal metastases at the Department of Clinica Chirurgica I of "La Sapienza" University of Rome. Patients with extracapsular nodal metastases had a worse 10-year survival rate than those with intracapsular nodal involvement (7.9% vs 22.4%). A better prognosis among patients with intracapsular node metastases was observed in each p-TN subgroup. In the multifactorial analysis (3-way ANOVA) survival was correlated with the depth of invasion of the gastric wall and the degree of lymphnode involvement (p less than 0.01) but not with the level of nodal involvement (N1 vs N2). Our results suggest that the degree of nodal involvement is an important independent prognostic factor that should be considered in the current staging system for curative resection in gastric carcinoma.

[Low colorectal anastomosis using the Knight and Griffen technique]. / L'anastomosi colorettale bassa condotta sec. la tecnica di Knight e Griffen.

The low anterior resection currently represents the procedure of choice in the treatment of middle and low rectal cancer. The double stapling technique described by Knight and Griffen may be considered a safe and valid alternative able to decrease the incidence of complications related to a low colorectal anastomosis.

Surgery in primary gastric lymphoma: impact on clinical staging and long-term survival.

This study analyzes the value of surgery in the treatment, staging and long-term survival of 17 patients affected with primary gastric lymphoma. In 7 patients the neoplasm was localized to the lower third of the stomach, in three to the middle third, in two to the upper third, while in 5 patients there was involvement of the entire stomach. Patients were classified according to the Ann-Arbor classification. Nine patients were stage Ie, five stage Ile, and three stage IVe. A partial gastrectomy was carried out in ten patients and total gastrectomy in 7. In all cases surgical excision of the gastric lymphoma was performed together with intraoperative staging including bilateral hepatic biopsies, and exploration of all abdominal lymph nodes. Two postoperative deaths occurred among the 7 patients who underwent total gastrectomy but no major complications were observed in the remaining 5 patients. No deaths occurred among the 10 patients who underwent partial gastrectomy, but in one case an acute complication developed. Staging laparotomy permitted the correction of clinical staging, and showed that three cases were understaged and one overstaged. All patients received adjuvant chemio-radiotherapy. All but one patient are currently alive, well and free of disease. Survival was correlated significantly with the stage of the disease and extent of gastric involvement, but there was no correlation between survival, histological grade, and the type of gastrectomy performed.

Prophylaxis and treatment of inflammatory anorectal complications in leukemia.

Forty leukemic patients with inflammatory anorectal complications were examined. Twenty two were affected by acute lymphatic leukemia, 10 by chronic lymphatic leukemia, 6 by acute myelocytic leukemia and 2 by non H lymphoma and chronic myelocytic leukemia, respectively. In all cases surgery was indicated not only to treat the anorectal complication, but mainly to resume the antiblastic chemotherapy discontinued because of the risk of sepsis and to prevent the failure of bone marrow transplantation in patients with chronic myelocytic leukemia. The underlying malignant disease and the altered platelet, white blood cell and neutrophil levels were shown to be the major factors conditioning the surgical treatment. In 2 cases, acute recurrence of the underlying disease and the development of a graft verus host disease have been the cause of death. It is concluded that in patients eligible for bone marrow transplantation or undergoing radio and/or chemotherapy, local and general antinfective prophylaxis is of paramount importance to decrease the risk of inflammatory anorectal complications.