[Hypothesis of the pathology of mediation in surgery (2)]. / L'ipotesi della patologia da mediazione in chirurgia (2a parte).

There are clearly numerous examples of mediation pathology in surgery. They go far beyond what may be defined as severe forms, in which the entire body is involved in the precipitating disease process and in which the mediation appears more easily recognizable, in that it evokes a resonance which wipes out all specificity and becomes the true protagonist of the critical situation. Forms which can be traced to a well defined pathogenesis, and others to a more debatable pathogenesis, afford great scope for mediation. May one, for instance, be justified in suggesting a mediation hypothesis for a classic surgical disease such as duodenal ulcer?

[Hypothesis of the pathology of mediation in surgery (3)]. / L'ipotesi della patologia da mediazione in chirurgia (3 parte).

There are three aspects to mediation: the first of these is purely physiological, or rather is concerned with performance of service functions such as ovulation, sexual activity, sleep, etc.; the second, strictly speaking, may be defined as pathophysiological, as its starting point is considered to be an aggressive event, even when a routine occurrence (in the stomach, for instance, aggression is a constant feature, even when of only slight intensity, as produced by the physical characteristics of the enormous quantities of food transiting the stomach and by particular environmental conditions; the third aspect is distinctly pathological, in that it constitutes the basis for the aggravation of a pathological situation already in progress, sometimes according to the logic of plain addition, but more often according to a more catastrophic process of multiplication (less frequently it takes the form of induction of a prevalent or independent disease condition). This break-down of mediation into distinct types, though necessary from the point of view of academic classification, proves extremely difficult to apply in practice. The validity of this latter consideration obviously depends on the specific area we are tackling. As regards the sex glands and male genital organ, the service role is unquestionable; elsewhere, we can be equally sure that we faced with pathophysiological aspects. In the stomach, for example, the difference between "normality" and "disease" does not lie so much in the absence, as opposed to the presence, of lesions, but rather in their extent and duration. This makes it extremely difficult to draw the line between physiology and pathology, and at the same time suggests that the state of health may be an unstable equilibrium phase somewhere midway between divergent forces belonging to the same mechanism. This latter mechanism may therefore be the key factor both in vital performance and in disease processes, whereas the "classic" aetiological factor may actually be relegated to a secondary role, at least in most cases.

[Hypothesis of the pathology of mediation in surgery (1)]. / Ipotesi della patologia da mediazione in chirurgia (1 Parte).

The mediation pathology hypothesis is not new. As early as 1955, Laborit hinted at something of the kind in his phrase "N'est malade que l'organisme qui le vent bien". Today, however, in the light of free oxygen radicals, which together with other mediators may possibly represent only the tip of an enormous iceberg, we may venture a number of admittedly cautious theoretical considerations. This would appear to be particularly relevant today, in that surgery at this precise moment, I would venture to say, is at a turning point. On the one hand, surgery is pushing to extremes its classic restrictive morpho-mechanistic approach to disease, while on the other, together with cardiology, it is quick to perceive new biological horizons, which until very recently were unimaginable and, as such, constitute its elective target of interest. Paradoxically, to all intent and purposes at least, the biological rite appears to have found the most natural place for its celebration precisely on the site where the morpho-mechanistic ritual seems to have reached its zenith and, at the same time, its moment of glory.

[Biology and surgery: a bound pair or merely a couple of disciplines? (3)]. / Biologia e chirurgia: una cordata o una coppia di discipline? (3a Parte).

In the following reports two main problems are questioned by the Authors. To start with, a sharp distinction is made between the so-called "theoretical physiology" and the "actual" use of the physiological functions adopted by the single man and woman. The second question is concerned with the biological consistency of the different surgical approaches. In the neoplastic treatments, surgeon can draw a conclusion that goes behind the single therapeutic event casting over other different areas of the surgery itself. To answer this second question by no means represents the solution of the aimed goal, on the contrary it is the starting-line towards a surgery, which, having left behind his old, obsolete, but pompous garments, does wear those, which, apparently shabby, are, on the other hand, enriched of many lapels, such as those naturally offered by the self-healing behaviour.

[Biology and surgery: a bound pair or merely a couple of disciplines? (2)]. / Biologia e chirurgia: una cordata o una coppia di discipline? (2a Parte).

Carcinoma of the breast, to our way of thinking, appears to be capable of providing what is virtually a master key to the interpretation of surgical oncological pathology. In the wake of the acquisitions made in this field--not always as a result of the initiative of the surgeon - a definite process of revision of the age-old concept of surgical radicality is underway, albeit in a somewhat surreptitious manner. Oncological surgery is clearly passing through a difficult phase, almost a crisis of identity, and, in the authors' opinion, may to some extent come back into its own, albeit only after a great deal of painstaking effort, by adopting a "biological" approach with greater respect for the morpho-functional integrity of the patient, who must no longer be viewed as merely the victim of disease, but rather as the prime mover of the disease itself.

[Biology and surgery: a team of disciplines or merely two disciplines? (1)]. / Biologia e chirurgia: una cordata di discipline o una coppia di discipline? (1a parte).

The present work questions itself about the "ideal" relation between biology and surgery, the necessarily bloody arm of medicine, namely, of that science man has been preparing, parallel with his culture, to enrich the wideness of the defensive slope of his biologic curriculum. Does the instructiveness, we were accustomed to by the university route, give a satisfactory answer? Does not the preparation of a biologic basis seem nearly the arrangement of a compulsory stage, from which to subsequently deviate also in name of technology and by means of same? Surgery can draw advantages or disadvantages from such a way? In the oncologic field it represented the introduction to the anatomical and mechanistic principles which inspired Halsted's thought about radical intervention. At the same time, a sort of dam against the biologic questions was built. Yet, to-day the first leaks occurred, and through them biology prepares itself to flood into surgery, more and more massively.

[Surgical treatment of pulmonary metastases of colorectal cancer]. / Il trattamento chirurgico delle metastasi polmonari da cr. del colon retto.

The pulmonary metastatic locations due to colorectal cancer were considered, in not remote times, not worthy of surgical treatment. At present, according to our experience and some other Authors' one, the surgical removal of metachronal pulmonary metastases should be considered suitable to improve the period of life free from symptoms and the survival. The surgical treatment has improved the survival in the single or double pulmonary locations, whereas the monolaterality of multiple pulmonary lesions, in respect of the bilaterality, was not significantly bettered the prognosis (Hiroshi Takita, Francis Edgerton). The survival, moreover, seems to be affected by the interval free from illness and by the doubling time of the metastatic location. The surgical indication to the pulmonary metastasectomy is done on condition of the absence of any metastases in other organs. In our experience, out of 742 interventions with radical purposes for colorectal cancer, we documented 15 cases where lung appeared as the first and sole metastatic filter (many patients were lost for their non-cooperation in the follow-up). In 7 cases pulmonary resections were performed, in patients selected and free from secondary locations in other organs, with a satisfactory result. Casuistry and personal results are reported.

[Hepatic cystadenocarcinoma: presentation of a clinical case and review of the literature]. / Cistoadenocarcinoma epatico: presentazione di un caso clinico e revisione della letteratura.

The finding of a case of cystadenocarcinoma supplies the opportunity for a reviewing of the literature concerning this rare liver neoplasm. From a diagnostical standpoint, the instrumental tests result non-specific. Only the needle-biopsy of papillary formations set forth through the echography within hepatic formations of cystic type is able to supply diagnoses of cystadenocarcinoma. Yet, the procedure is not exempt from risks. Decisive may be the peroperative histologic testing on fragments of the cyst wall. In consideration of the better prognosis of cystadenocarcinoma in respect of hepatocarcinoma and cholangiocarcinoma, and the risk of relapse, the election surgical treatment should be represented by hepatectomy.

[The other face of oxygen (1)]. / L'altra faccia dell'ossigeno (1 Parte).

The other face this two-faced Janus, the oxygen, allows us, by now, to see dimly is the bad, aggressive one shown by its free radicals, should they escape the respiratory machine, or, rather, should they follow the respiratory explosion of leucocytes and macrophage, or the same compromission of the cellular structure. The antioxidative mechanisms, although articulate and quibbled, appear inadequate, also because the oxygen radicals are formed on the outer side of the cellular membrane, and, just in the intercellular space, the defensive protections are extremely poor. If lung deserves a particular status, being the usual point of aggression by the oxygen radicals: here, these active metabolites are produced by its macrophage, but also by its endothelial cells, especially in conditions of hyperoxy; all organs and segments are their targets. Besides the immediate results, which are also caused by oxidizers having a long half-life, there are mediate results, essentially rotating around the arachidonic acid, a sort of multiplicating pin, with its products of the cyclooxygenase line (thromboxane A2, endoperoxides, prostacyclins) and the lipoxygenase line (the wide range of leukotrienes). But not even this "free body", in a position to escape, provided it wants so, the enzymatic control, seems inclined to free itself, what attenuates its bad face, from a basic rule in animal biology, that is, "negative feedback".