Role of surgery in the treatment of gastric cancer. Personal experience.

BACKGROUND: Although the decreased incidence of gastric cancer, nevertheless many surgical questions are topical, especially the entity of resection and the extent of lymph node dissection. METHODS: We analyzed retrospectively 38 patients operated for gastric adenocarcinoma in our Surgical Division from January 1997 to December 2001. We excluded cancers of cardia and gastroesophageal junction. We evaluated gastric site, macroscopic and microscopic aspect, TNM staging and grading of gastric cancer (UICC 1997), surgical treatment, postoperative complications and survival, in order to identify the rationale surgical approach to gastric cancer in a suburban hospital. RESULTS: Most of patients affected by gastric cancer were older than 60 years (28/38=73.68%). The cancer was prevalently localized in the antral-pyloric region (21/38=55.27%), in the ulcerated form (27/38=71.05%) and differentiated as intestinal subtype (21/38=55.27%). Regarding the UICC staging we found an almost unvarying distribution, but most of cancers were at stage IV (12/38=31.58%). In 71.05% of cases (27/38) a radical operation was feasible. The most performed operation was a total gastrectomy (19/27=70.37%). We performed a D1 dissection in 85.18% of radical operations (23/27). In the resective surgery we reconstructed the intestinal continuity by a mechanical circular stapler Roux en Y anastomosis. CONCLUSIONS: When possible we perform a total gastrectomy. D1 is our standard lymph node dissection, awaiting a defined D2 role in gastric cancer surgery. In the resective surgery we reconstruct the intestinal continuity by a mechanical circular stapler Roux en Y anastomosis. Morbidity was 10.5% (4/38) and mortality was 7.89% (3/38). Old age and pre-existing pathologies have an important role on surgical outcome. Prognosis of advanced gastric cancer is poor, despite a resective surgical treatment. We emphasize the importance of prevention and early diagnosis as fundamental steps of the oncological gastric surgery.

[Dislocation into the cardial lumen of a PTFE prosthesis used in the treatment of voluminous hiatal sliding hernia, A case report]. / Dislocazione nel lume cardiale di protesi in PTFE utilizzata per il trattamento di voluminosa ernia jatale da scivolamento. Descrizione di un caso clinico.

The authors report a case in which a PTFE prosthesis, used to treat a voluminous hiatal sliding hernia, dislocated inside the cardial lumen. Within two months the prosthesis had become decubitant and penetrated the cardial lumen, causing dysphagia, inappetence and weight loss. The use of radiological and tomographic imaging failed to provide a clear diagnosis; endoscopy alone was conclusive. Surgery was required to remove the prosthesis by resecting the distal esophagus and reconstructing the continuity of the digestive tract using terminolateral esophagogastric anastomosis (front wall of the stomach) in CEEA 21. The absence of a clear etiopathogenetic sequence of the migration of the prosthesis prompted the authors to stop using this type of surgery.

[Lymphatic cyst of the mesentery]. / Cisti linfatica del mesentere.

Lymphatic cyst of the mesentery is a rare lesion; one case per 100,000 hospital admissions is reported. A case of lymphatic cyst in a sixty-one-year-old woman is presented. The symptoms are extremely variable, not characteristic and correlated to the location and size of the cyst. Abdominal ultrasonography and computed tomography may lead to a correct diagnosis, which is regularly made at the time of abdominal exploration. In this case the cyst was enucleated from the mesentery with open surgery.

[Surgical treatment of recurrent inguinal hernia using prosthetic materials]. / Il trattamento chirurgico delle ernie inguinali recivide mediante l'impiego di materiali protesici.

The authors affirm that plastic surgery using graft materials is a feasible technique also in case of recurrent inguinal hernia. They follow with interest the evolution of laparoscopic techniques which are still the cause of some perplexity. The paper reports a series of nine recurrent inguinal hernias out of 447 inguinal hernias operated during the period May 1994-May 1996.

[Intestinal occlusion caused by Morgagni-Larrey diaphragmatic hernia]. / Occlusione intestinale da ernia diaframmatica di Morgagni-Larrey.

Morgagni-Larrey's hernias, which are both infrequent and generally asymptomatic, are often diagnosed by chance during routine diagnostic tests performed for other pathologies. Usually congenital in adults, they are often small or only take the form of a pre-hernia lipoma. Intestinal occlusion is rarely described and frequently entails diagnostic difficulties before hydroaerial levels are demonstrated in the thoracic region. In these cases, surgery using an abdominal approach should be preferred in order to treat compressed abdominal viscera at the same time and to exclude the bilateral nature of the lesion. The authors present two cases of an adult man and woman who were referred to their attention for occlusive pathologies. Both were operated using a laparotomy approach. The reduction of abdominal viscera did not present any difficulties. The hernial sac was only removed in the first patient. Plastic surgery was completed by attaching the diaphragmatic flap to the costal and sternal wall using separate non-reabsorbing suture stitches. No complications were reported.

[Mucinous cystadenocarcinoma (malignant mucocele) of the cecal appendix]. / Cistoadenocarcinoma mucinoso (mucocele maligno) dell'appendice cecale.

Mucinous cystadenocarcinoma of the cecal appendix is a very rare malignant neoplasia. The majority of these tumours are discovered during surgery performed for other pathologies or as a chance finding in the histological analysis of surgically removed inflamed appendix. There is no characteristic symptomatology of this neoplasia which requires oncologically correct surgery, such as right hemicolectomy. The authors report a case study o peritoneal recidivation of a mucinous cystadenocarcinoma of the appendix.

[Volvulus of the sigmoid colon]. / Il volvolo del sigma.

Sigmoid colon is the most frequent side for a volvulus. We present four cases of sigmoid volvulus admitted to our department during the period July 1994-December 1995. Intestinal volvulus, despite its benignity, has a quite high morbidity and mortality. Important factors such as the patient's features and frequent late diagnosis can influence the complicated outcome of the disease. Plane X-ray of the abdomen is helpful while barium enema can be therapeutical because of the pressure of the inflated air. Sigmoid resection is the most effective treatment for the disease.

[Chyloperitoneum after traumatic rupture of subdiaphragmatic thoracic duct. A clinical case]. / Chiloperitoneo da rottura traumatica del dotto toracico sottodiaframmatico. Caso clinico.

Chyloperitoneum following traumatic rupture of the subdiaphragmatic thoracic duct is a very rare lesion and in fact no case was found when reviewing the last five years of international literature. The authors report a case of traumatic chyloperitoneum caused by a penetrating sidearm wound in a young 19-year-old woman. Emergency exploratory laparotomy enabled the precise identification of the site of the thoracic duct lesion and to proceed to its immediate suture. At one year after the operation the patient is in good health.

[Inguinale hernia: alloplasty with polypropylene surgical mesh]. / Ernia inguinale: alloplastica con rete di polipropilene.

INTRODUCTION: Alloplasty with prosthetic graft (marlex net, dacron, mersilene, etc.) represents an undoubted progress in the surgical treatment of inguinal hernia. Having completed the isolation and possible resection of the hernial sac, the posterior wall of the inguinal canal is no longer reconstructed using musculo-aponeurotic plastic surgery (Bassini, Postemski, etc.), but by encouraging a granulomatous reaction using a prosthetic graft which provides a solid posterior wall to the inguinal canal. METHODS: A total of 447 cases were examined of patients undergoing alloplastic surgery with the use of a prosthetic polypropylene graft who were controlled at one week, one month and one year after surgery. RESULTS: Mortality was zero whereas morbidity was 21 cases: 7 hematoma, 5 funicular edema, 8 seroma. A total of 9 recidivations were recorded (2%).

[Carcinoid of the cecal appendix]. / Il carcinoide dell'appendice cecale.

Carcinoid tumors are infrequent but not exceptional neoplasias. The gastroenteric tract is affected in 80% of cases and almost half of these involve the appendix where they almost always represent an occasional finding after appendicectomy due to acute or subacute appendicitis. Although they have a low malignancy potential in this site, with a reduced index of metastasization and scant capacity to determine clinical symptoms, they are of considerable clinical importance in view of the prognostic and therapeutic type problems that their diagnosis entails. The authors report the case of a female 14-years-old patient, operated for acute appendicitis, and the finding of a yellowish hard tumefaction with a diameter of around 2 cm near the appendicular cone which histological tests showed was a relatively benign classic carcinoid.

[Our experience in the surgical treatment of perforated peptic ulcer]. / La nostra esperienza nel trattamento chirurgico dell'ulcera peptica perforata.

The authors report their experience in the treatment of perforated peptic ulcer. From August 1992 to December 1995 a total of 23 patients (14 cases of gastric ulcer and 9 cases of duodenal ulcer), mean age 67.5 years, underwent emergency surgery for perforated peptic ulcer. The operations performed included: simple gastrorrhaphy in 19 cases (11 for gastric ulcer, 8 for duodenal ulcer); gastrorrhaphy with pyloroplasty + GEA in 1 case of gastric ulcer; gastrorrhaphy with pyloroplasty in 2 cases (1 for gastric ulcer, 1 for duodenal ulcer); gastric resection in 1 case of gastric ulcer. One case of perioperative mortality occurred, equivalent to 4.3%, whereas the percentage of complications observed was 13% (2 cases of IRA, 1 case of wound infection). The mean age of patients (67.5 years) and the high percentage of associated major pathologies (39.1%) oriented the choice of therapy towards ulcerorrhaphy. In the authors' opinion this rapid and easy to perform method represents the best treatment of perforated peptic ulcer; the validity of ulcerorrhaphy is confirmed by the reduced mortality (4.3%) and the low percentage of morbidity (13%) found in this series.

[Surgical treatment of pancreatic pseudocysts]. / Trattamento chirurgico delle pseudocisti pancreatiche.

The pancreatic pseudocysts are a serious complication of acute or chronic pancreatitis. Personal experience in the treatment of 5 cases of pancreatic pseudocysts observed in the last six years is reported. In elective surgery the operation of choice in the treatment of the typical postnecrotic pseudocysts and which gives the best results in cystojejunostomy with a Roux-en-Y loop. The external bypass is indicated in the cases of infected or ruptured pseudocysts. Pancreatic resection is considered useful in the rare cases of multiple pseudocysts affecting the body and the tail of the pancreas.

Resident and faculty differences in student evaluations: implications for changes in a clerkship grading system.

Data were collected for 163 students completing a surgical clerkship including scores on patient write-ups, ward performance evaluations, oral examinations, and National Board of Medical Examiners (NBME) Surgery subscores. Oral examination scores and patient write-ups were rated from 74 (failing) to 100 (honors) by faculty members. The ward performance evaluation included ratings on nine components of ward performance from 1 (unsatisfactory) to 4 (superior) and an overall ward score of 74 (failing) to 100 (honors). Similarities and discrepancies in the way that evaluators viewed clerks were found. Weights given to ward component ratings in relationship to the overall ward score were equivalent for faculty members and residents. Residents rated clerks higher than faculty members on five ward components. Faculty ratings were poorly correlated with resident ratings. Faculty members and residents gave different ratings to the same students in contrast to the similarities in which faculty members and residents gave weight to the ward component ratings. Resident ratings were better than faculty ratings in predicting the NBME Surgery subscore. Although these results suggest that residents are better evaluators of a clerk's performance than are faculty members, other studies indicated the opposite. The elimination of participation of either faculty or residents in the grading of students is unwise. Periodic monitoring of evaluation practices is necessary to ensure fairness in grading procedures.