Value of extended lymph node dissection in the treatment of gastric cancer.

Regional lymph node metastasis is a critical prognostic factor in gastric cancer, and extended lymph node dissection and routine microscopic examination of all resected nodes could potentially provide accurate information regarding lymph node status. On the other hand, the therapeutic value of extended lymph node dissection is controversial. While retrospective and prospective non-randomised comparative studies have shown that extended lymph node dissection significantly improves the survival rate, prospective randomised trials have failed to demonstrate the efficacy of extended dissection, although the number of patients in these studies was limited. The present review of the literature therefore considers the prognostic significance of regional lymph node metastases and the therapeutic efficacy of lymph node dissection performed for gastric cancer.

Chronic sinusitis complicating sinus lift surgery.

Sinusitis has been reported as a complication of sinus lift surgery with antral bone augmentation. The procedure involves the creation of a submucoperiosteal pocket in the floor of the maxillary sinus for placement of a graft consisting of autogenous, allogenic, or alloplastic material. This can result in inadvertent tearing of the mucoperiosteal flap with extrusion of graft material into the antrum. Obstruction of the sinus outflow tract by mucosal edema and particulate graft material may result in sinusitis. We will discuss the clinical presentation and management of 14 cases of chronic sinusitis following sinus lift surgery with alloplastic hydroxyapatite (HA) augmentation of the maxillary antrum.

Histopathologic evaluation of the ethmoid bone in chronic sinusitis.

Chronic rhinosinusitis (CRS) is defined as a condition lasting for a period greater than 12 weeks, and manifested by an inflammatory response involving the mucous membranes of the nasal cavity and paranasal sinuses, fluids within these cavities, and/or the underlying bone. The mucosal changes that occur in CRS have been well described, and include edema, decreased number of ciliated cells, and goblet cell hyperplasia. However, the changes that may occur in the underlying ethmoid bone have only recently been investigated. We evaluated decalcified ethmoid bone specimens from 20 patients undergoing endoscopic sinus surgery for CRS. Our analysis revealed histopathologic changes consistent with varying grades of bone remodeling. Polarized light microscopy demonstrated changes in the extracellular matrix, such as bone resorption and neoosteogenesis. Preoperative clinical data and CT staging were recorded on all patients and correlated with the histopathologic findings. These findings suggest that CRS may be associated with osteitis of the underlying ethmoid bone.

Middle turbinate resection: issues and controversies.

Diversity of opinion continues to exist among otolaryngologists regarding the potential benefits of preservation or resection of the middle turbinate during endoscopic ethmoidectomy. Rhinologists in favor of middle turbinate preservation cite the potential loss of olfactory function as well as diminished humidification and filtration of inspired air following its resection. In addition, the middle turbinate remnant could lateralize, causing frontal recess obstruction and frontal sinusitis. In general, it is accepted that a diseased or flail middle turbinate should be resected during ethmoidectomy to create a marsupialized surgical bed. However, in the case of a structurally sound middle turbinate, indications for resection vary significantly. We are reporting on 100 primary endoscopic ethmoidectomies for chronic rhinosinusitis followed for at least 2 years. Of these 100 sides, 50 included conservative partial middle turbinectomy and 50 were performed with middle turbinate preservation. The postoperative clinical and endoscopic findings revealed no difference in the incidence of frontal sinusitis or frontal recess stenosis between groups. We compared additional data and present our technique of conservative middle turbinate resection, which preserves a portion of this structure as an important anatomic landmark.

A novel approach to laryngeal suspension after partial laryngectomy.

OBJECTIVES: Supraglottic laryngectomy is a well-established surgical therapy for selected carcinomas of the larynx and hypopharynx. Most compromised by this procedure and its variations is the laryngeal mechanism that protects the lower respiratory tract from aspiration. Laryngeal suspension serves to compensate for the loss of the resected laryngeal elevator muscles by pulling the larynx upward and forward beneath the tongue base. In this study we describe a method of laryngeal suspension in supraglottic laryngectomy using a cartilage-anchored suture carrier device. STUDY DESIGN: Report of this novel approach to laryngeal suspension using seven suture anchors in two patients undergoing supraglottic laryngectomy. METHODS: Seven Mitek Micro anchors (Mitek, Westwood, MA) were used to perform laryngeal suspension in two patients undergoing supraglottic laryngectomy. Our technique is compared with traditional methods. Operative data as well as postoperative functional results are reviewed. RESULTS: Laryngeal suspension using suture anchors was successful, with failure of only one anchor. Oral alimentation was quickly reestablished in both patients. There were no perioperative or postoperative complications. CONCLUSIONS: We describe a novel approach to laryngeal suspension that overcomes some of the technical challenges inherent in traditional suturing techniques. This novel approach is technically easier and more efficient than traditional methods and accomplishes distribution of stress forces on the thyroid cartilage remnant.

Compliance with anti-reflux therapy in patients with otolaryngologic manifestations of gastroesophageal reflux disease.

OBJECTIVES: The otolaryngologic manifestations of gastroesophageal reflux include sore throat, throat clearing, sensation of postnasal drip, hoarseness, and globus. This constellation of laryngeal and pharyngeal symptoms can be referred to as laryngopharyngeal reflux (LPR). Many patients with LPR are treated empirically and the results are often rewarding. The objective of this study is to evaluate compliance with antireflux therapy in this patient population. STUDY DESIGN: A prospective analysis of 30 patients referred to an otolaryngology clinic for the above symptoms. METHODS: The patients were treated for LPR using a standardized behavior modification form in combination with medical management. Patient compliance was followed with a patient questionnaire and evaluation of medication renewal from pharmacy records. RESULTS: The patients were followed for an average of 4 months and 80% reported an improvement of their symptoms. Evaluation of patient questionnaires revealed that 50% of patients reported taking their medications as prescribed. Compliance varied widely with regard to behavioral modifications. The degree of symptomatic improvement was significantly correlated with overall compliance with both medications and behavioral changes (Pearson correlation coefficient, P < .05). The individual behavioral changes that were significantly correlated with the reduction of symptoms were avoidance of food and liquid before sleep and elevation of the head of bed, but not food habits. CONCLUSIONS: The treatment plan for gastroesophageal reflux disease requires behavioral modifications and prescription medications that many patients may find difficult to follow. However, those patients who comply with the treatment plan can be expected to have an improvement of their symptoms. Furthermore, simplifying the treatment regimen including those elements most correlated with symptomatic improvement may increase patient compliance.

Otologic surgery in patients with HIV-1 and AIDS.

Otologic disease in patients infected with HIV occurs frequently and usually represents rhinologic disease and associated eustachian tube dysfunction rather than manifestations of HIV infection. As in all patients, the decision to operate on an HIV-infected individual who would benefit from major otologic surgery is a balance between the risks of the procedure and the possible benefits to the patient. Many concerns regarding wound infection and healing have been raised. The objective of this study is to evaluate the outcome of otologic procedures in this population. The charts of 9 men and 4 women were reviewed. Seven patients (54%) met the Centers for Disease Control and Prevention criteria for AIDS. Patients with chronic otitis media (46%) underwent tympanomastoidectomies, and the cases of acute mastoiditis (31%) were managed with simple mastoidectomies. Other procedures included repair of cerebrospinal fluid leak (15%) and stapedectomy (8%). Two patients had early complications and died during their hospitalizations. Three patients had prolonged hospital courses requiring long-term antibiotics. These 5 patients underwent urgent procedures and were severely immunocompromised. Of the remaining 8 patients only 2 had AIDS, and all had an uncomplicated postoperative course. Six of these patients were followed up for more than 1 year, and only 2 developed subsequent otologic disease.

Effect of unilateral tympanotomy on auditory induced c-fos expression in cochlear nuclei.

The immediate early gene, c-fos, signals expression of target genes. Three natural occurring physiological entities: (1) learning, (2) plasticity, and (3) stress are proposed to use c-fos gene expression to signal molecular changes in neurons. The objective of this study was to determine whether c-fos expression is predominately activated by stress or by novel events associated with learning and plasticity. The approach was to quantitate the number of neurons in cochlear nuclei which express Fos protein following short-term novel sound stimuli together with either uni- or bilateral tympanotomy so as to differentiate novel sound stimuli from stress activation. The results show that routinely experienced sounds do not elicit c-fos expression in medullary cochlear nuclei, but novel sounds produced a 25-fold increase in the number of active cells. Following unilateral tympanotomy with novel sound stimulation, only a small number of cells were activated, ipsilaterally, (partially deafened side) while contralaterally, there was a 30-fold increase. After normalization of the data for control values, the data clearly indicate that novelty of sound stimuli induce c-fos gene expression. Furthermore, bilateral tympanotomy (bilateral partial deafening) with sound stimulation activated both sides by 20-fold, indicating that the c-fos response followed the sound stimulation. The data allow us to conclude that stress generates only a small contribution to c-fos gene expression while novel stimuli are potent signals, strongly implicating c-fos in novelty induced adaptation processes involved in learning and plasticity.

[Mechanical trans-sutural colorectal anastomoses in the treatment of rectal cancer]. / Le anastomosi colo-rettali meccaniche trans-suturali nel trattamento del cancro del retto.

The Authors report on 52 rectal cancers treated with anterior resection and mechanical anastomosis according to the Knight and Griffen technique. Such technique is quite practical, allows for easier sphincter-saving operations and is followed by a very low percentage of fistulas and anastomotic stenoses. In this series, a good anorectal function was restored in 6-12 months even in very low anastomoses; sexual complications were registered in 8% of cases; urinary troubles were not significant. The Authors conclude that the Knight & Griffen procedure is useful and advantageous.

[A conservative Taylor's method in the treatment of peptic perforation]. / Il metodo conservativo di Taylor nel trattamento della perforazione peptica.

Forty-eight patients affected by perforated ulcer and treated with Taylor's method are examined. Non-operative therapy was successful in forty-two patients; six patients subsequently underwent surgery. All forty-eight patients recovered. The Taylor method is effective in selected cases and represents a therapeutic option which may integrate surgery.

Carcinoma of the rectum: factors influencing the prognosis.

Three hundred and thirty one patients with cancer of the rectum and rectosigmoid junction, operated on during the period 1968-1985 are here examined. The study shows the prognostic value and the impact that stage, histopathological grade, number and location of nodal metastases, morphology of the primary tumour, occurrence of obstruction, perforation, and haemorrhage have on the natural history of the tumour. Stage and histopathologic grading resulted as the most outstanding prognostic parameters also because they are correlated to the presence, number, and location of nodal metastases as well as occurrence of obstruction, perforation and haemorrhage. The study concludes that: a) stage according to the Dukes-Gabriel classification still has a reliable prognostic predictivity, since it faithfully reflects major anatomic situations observed in rectal cancer; b) Dukes' stage C cases should be considered as a non-homogeneous group with a distinct biological behaviour depending on the number and site of the lymph nodes involved; c) intraoperative staging of the tumour, if possible, should guide the excision extent on a curative aim, where the term means a prospective evaluation based on statistical data correlating stage and survival.

[Raynaud's disease and syndrome. Presentation of clinical experience]. / Malattia e sindrome di Raynaud. Presentazione di un'esperienza clinica.

The Authors report their experience concerning 256 cases of Raynaud's Disease and Syndrome observed from 1968 to 1987; 23 patients underwent surgery for the treatment of dystrophic or gangrenous lesions of the extremities (12 cervico-thoracic and 8 lumbar sympathectomies, 1 popliteal aneurysmectomy, 2 scalenotomies): a significant improvement of the clinical picture was observed in 91.30% of the patients who underwent the operation. The pharmacologic treatment obtained satisfactory results in 51.26% of all the patients. The Authors propose a three stage classification of raynaudian symptoms: I stage: sporadic vasoconstrictive crises; II stage: recurrent vasoconstrictive crises not invalidating working activity and "restitutio ad integrum" between attacks; III stage: recurrent and frequent crises invalidating working activity with asphyxia and/or ulcer-gangrene of the extremities. Both pharmacological and surgical treatment obtained the improvement of the clinical condition to an inferior stage in a high rate of patients. In three patients only (two of whom underwent scalenotomy and one popliteal aneurysmectomy) the complete and definitive cessation of raynaudian crises was observed.

[Natural history of synchronous hepatic metastases from a non-treated colorectal cancer]. / Histoire naturelle des métastases hépatiques synchrones dérivées d'un cancer colo-rectal et non traitées.

The authors present a retrospective study concerning 135 cases of untreated synchronous metastases from colorectal cancer. The median survival is 5.5 months and the natural history is depending on the percentage of liver replacement, on the "performance status" of each patient and on the stage of primary tumors classified according to Dukes. The seric levels of Alkaline Phosphatase and CEA are other useful prognostic factors. The age of patients and systemic chemotherapy (5-Fluorouracil) are not able to influence the evolution of the disease. At last different techniques, both curative and palliative, used in the current treatment of liver metastases from colorectal cancer are discussed and the reported survival improvements reaching with these forms of treatment are compared to the natural history of the disease.

[Inguinal hernia in children]. / La hernie inguinale chez les enfants.

The authors report 611 cases of inguinal hernias of childhood operated between 1967 and 1985, which represent 28% of operations performed in all children in the same period. The mean age of patients was 33 +/- 4.1 months and the ratio M:F = 5.43:1. The right side was the most frequently affected (64.64%) with a bilaterality of 14.89%. The incarceration, observed at the rate of 13.23%, needed the surgical treatment in urgency in the 35.63% of the cases. A relapsing hernia appeared only two times (0.45%) and the incidence of contralateral metacronous hernias was 7.99%. They perform herniorrhaphy in the only symptomatic side without preoperative herniorrhaphy and operate on the silent contralateral side only when there a hernia will became symptomatic, as they think that herniorrhaphy and bilateral inguinal exploration cause a high number of unnecessary, sometimes harmful operations.

Adenine and pyridine nucleotides in the red blood cells of subjects with solid tumors.

The concentration of adenine (ATP, ADP, AMP) and pyridine (NADP+, NADPH, NAD+, NADH) nucleotides in the erythrocytes of subjects affected by solid tumors was evaluated using a method which allows their simultaneous extraction and reverse-phase high-performance liquid chromatographic analysis. The results showed a lower level of ATP in the erythrocytes of subjects affected by solid tumors, whereas no significant modifications were observed in the other compounds. In fact, the mean value of ATP in these subjects was 27% lower than that of normal adults. This fact is discussed in relation to other enzymatic and metabolic modifications previously observed in red blood cells.

Conservative treatment in the clinical stage T1N0 of breast cancer.

A 18-year experience with 643 cases operated for breast cancer is reported. 161 cases belonged to the clinical stage T1N0: 78 underwent modified radical mastectomy (group 1) and 83 underwent conservative surgery (group 2). Conservative treatment consisted in quadrantectomy and axillary dissection of 1st, 2nd and 3rd level with postoperative radiotherapy (5000 rad). Within the two groups the patient's characteristics were homogeneous with juxtaposable curves of overall and disease-free survival after modified radical mastectomy and after conservative surgery. In 15.38% of cases undergoing modified radical mastectomy and in 13.25% of cases undergoing quadrantectomy, histologic examination showed the presence of lymph node metastases (pT1N1) not identified at the clinical examination. The analysis of results showed that early neoplastic recurrence is almost exclusively limited to cases pN1, but the fall in the survival curve it similar in group 1 as well as in group 2. Therefore it should be understood that the prognostic risk is related to positive lymph nodes and not to the chosen treatment. Postoperative complications, irrelevant in group 1, tend to disappear in group 2. The cosmetic result after conservative surgery was excellent in 37.3%, satisfactory in 54.2% and poor in 8.4% of cases, respectively.

Solid tumors and enzyme activity in human lymphocytes.

A study on the enzyme activity of glucose metabolism in the lymphocytes of patients with solid malignant tumors is reported. The results have shown a 30% mean increase of the hexokinase (HK) activity in patients with solid malignant tumors as compared to the mean value observed in a group of healthy subjects. A relationship between level of HK increase and stage of tumor was also observed. The other examined enzyme activities, phosphofructokinase (PFK), pyruvate-kinase (PK), phosphoglycerate-kinase (PGK), phosphoglucoisomerase (PGI), glyceraldehyde-phosphate dehydrogenase (GAPD) glucose-6-phosphate dehydrogenase (G-6PD), 6-phosphogluconate dehydrogenase (6-PGD) and enolase did not show significant changes. It is concluded that even though the use of HK as tumor marker cannot be hypothesized at the present time, a significant relation between an increased activity of this enzyme and presence of the tumor is unquestionable. Therefore, this biochemical effect induced away from the neoplastic tissue deserves further study.