[Laparoscopic cholecystectomy. The beginning of a new era]

An important breakthrough in the field of general surgery, laparoscopic cholecystectomy (LC) offers significant advantages for patients. Major reasons for the rapid worldwide acceptance of this new surgical procedure is that patients experience reduced postoperative pain, ileus is virtually abolished, and the patient is able to leave the hospital the following day without a major abdominal scar. This appears to respond to patients' desire for less invasive approaches to the treatment of gallstone disease. LC is thus becoming the treatment of choice for symptomatic gallbladder disease. Its rapidly growing popularity is evident in Italy where many centers are offering LC routinely, in alternative to open cholecystectomy. A critical appraisal of this new technology is necessary, in light of recent data from centers presenting results and complications of large series of LCs. Adequate training of surgeons who will perform LC is also becoming a major concern. In this review the authors describe patient evaluation and selection for LC. Effective therapeutic strategies are illustrated, including the central, but nevertheless controversial role of endoscopic retrograde cholangiopancreatography (ERCP) as an approach to common bile duct lithiasis. Currently, LC should be performed in centers with the availability of an endoscopist with expertise in ERCP. Following the success of LC, other minimally invasive techniques will evolve in various surgical specialties. New generations of surgeons will thus have to familiarize with these emerging techniques while maintaining a critical attitude of evaluation.

[Mayer-Rokitansky syndrome. Case report]

Uterine anomalies associated with congenital renal agenesis and skeletal abnormalities represent an uncommon pathology that often presents important diagnostic problems. A case of Mayer-Rokitansky syndrome is reported. The embryologic, clinical, pathologic and therapeutic implications of this disease are briefly discussed.

[Local recurrence after gastrectomy for cancer. Presentation of 2 clinical cases]

The Authors report two cases with local recurrence after partial gastrectomy for advanced gastric carcinoma. The Authors suggest that chemo and/or radiotherapy associated with surgical treatment can improve the prognosis in some patients with recurrence. Response to chemotherapy and time elapsing before recurrence appears may select this group of patients.

[Leiomyoma associated with esophageal diverticulosis]

The Authors report a case of leiomyoma located in an epi-phrenic diverticulum. The development of the leiomyoma may have weakened the esophageal wall and caused the diverticulum to appear. Surgical treatment consisted of diverticulectomy with myotomy and a Belsey MK IV antireflux procedure.

[Occlusion of the duct with a fibrin glue and preservation of the pylorus after resection of the duodenum and head of the pancreas for periampullary carcinoma]

Dehiscence of pancreaticojejunostomy represent the main technical postoperative complication after duodenocephalopancreasectomy for periampullary carcinoma. The incidence of this complication is particularly high in cases of narrow duct and a tender pancreatic gland. In this case the authors suggest a technique of occlusion of the residual pancreatic stump using a fibrin sealant. This approach was utilized in 6 consecutive patients affected by resectable periampullary carcinoma. No postoperative mortality was observed. Pancreatic fistula developed in 5 cases and all of them resolved spontaneously in 1-4 months. The sixth patient underwent, at 3 months p-o, a CT-guided percutaneous aspiration of an intraabdominal fluid collection and with no further complications. 3 patients died at 3, 9 and 11 months because of liver metastases. Currently 3 patients are alive and apparently disease free at 25, 7 and 5 months. Pancreatic endocrine function was assessed in 5 patients at 3 months p-o. Blood glucose and insulin, glucagon and C-peptide plasma levels, all fasting and 1 our after a standard meal, revealed a normal glucose metabolism. The authors conclude that, since fibrin sealant avoids the pancreatic fibrosis which could be induced by non-absorbable polymers and the benign evolution of this type of pancreatic fistula, this method for handling the exocrine secretion is a safe and satisfactory approach which is particularly indicated in case of a pancreatic stump at risk for intestinal anastomoses.

[Adenocarcinoma of the cardia: results of resection with nic interposition]

The incidence of cancer of the cardia is increasing. Surgical treatment, in a small percentage of patients in early stage, consists in esophagectomy and total gastrectomy, followed by colon interposition. The operation can be performed through the thorax or by an abdominal and cervical approach. From 1982 to 1989 twenty-five patients were operated on. Between 1980 and 1982 the cancer was resected opening the thorax in 9 patients (group A), while from 1983 to 1989 the esophagus was removed through diaphragmatic hiatus in 16 patients (group B). All cases were analyzed as for histology, staging and resection margin. Average clinical follow-up was 22 +/- 32.7 months (range 1-102). Morbidity was 77.7% in group A and 68% in group B. Mortality dropped to 14% in the last 7 patients. Mean survival time was 23 +/- 34 months in group A and 11.2 +/- 13.7 months in group B (p = N.S.). Follow-up controls showed that all patients, in whom the esophagus was replaced with colon, were able to feed adequately.

[Biologic response modifiers in the treatment of solid tumors]

This study concerns the clinical applications in Oncology of Biologic Response Modifiers; the authors focus the results reached in neoplasms, such as renal cell carcinoma or melanoma, whose sensitivity to this treatment has been proved. Prospective studies, published in 1990 have been reviewed, considering only those in which route and rate of response (complete and partial) were clearly specified. At present clinical efficacy concerning this topic is controversial and it probably depends on different reasons: immunogenicity of cancer, variable route of administration, lack of predictors. It should be stressed that more in depth studies about cancer immunology are required; a wide spread of immunotherapy will be feasible only by improving therapeutic strategies and limiting adverse effects of this treatment.

Local recurrence after curative resection for colorectal cancer: frequency, risk factors and treatment

Analysis of 498 patients with colorectal carcinoma was retrospectively reviewed to evaluate the incidence, risk factors and therapy of local recurrent carcinoma following curative resection. Complete follow-up information was obtained in all but four patients (99.2%). After a median follow up of 42 months, 64 out of 469 (13.6%) patients developed local recurrence (LR). The incidence of LR was higher in rectal than in colon cancer patients (18.3% vs 8.9%) (P less than 0.005). Separate univariate and Cox analyses for rectal patients showed tumor site (P less than 0.02). Dukes stage (P less than 0.002), and adjuvant radiotherapy (P = 0.05) determined risk of LR. For colon cancer patients risk of LR was determined by histological tumor grade (P less than 0.01). Out of 64 patients, 5 (7.8%) underwent radical excision of LR. Forty percent of these survived at 5-year (P less than 0.08). Palliative treatment (radio-chemotherapy) obtained a 5-year survival of 15.3%, with no survivors in no-treatment group. These results suggest that local recurrent colorectal carcinoma remain a difficult treatment problem. More effective combinations of surgery and adjuvant therapy are therefore mandatory to reduce the incidence of local failure in high risk colorectal patients.

[Indications and limitations of the surgical treatment of portal hypertension]

The authors report a review of the literature and describe their personal experience with treating esophageal varices; all types of surgical approaches (selective and total shunts, esophageal transection) are examined and compared to the results obtained with non surgical treatment (particularly endoscopic sclerotherapy). Indications and results of surgical treatment are discussed from three definitive viewpoints: prevention of first bleeding or prophylactic treatment, control of acute bleeding or emergency treatment and prevention of rebleeding or elective treatment.

Squamous-cell carcinoma of the colon. Experience at the University of Chicago, review of the literature, report of two cases

Primary squamous-cell and adenosquamous-cell carcinoma of the colon are uncommon and their characteristics not well known. This paper reports the clinical features and pathologic findings of two colonic adenosquamous carcinomas and reviews other reports of adenosquamous and squamous carcinoma of the colon from the English medical literature. Including these two cases, 63 cases have been reported since 1927. Of these, six occurred in patients with ulcerative colitis, three occurred at the colonic opening of chronic colocutaneous fistulas, and concomitant schistosomiasis was present in two patients. Synchronous squamous-cell carcinoma of the colon was present in 3.2 percent of cases and 10 percent had either antecedent, synchronous, or metachronous adenocarcinoma of the colon. These lesions appeared to be distributed uniformly throughout the colon. The five-year survival after resective therapy for primary squamous-cell and adenosquamous-cell carcinoma of the colon calculated with life table analysis is 50 percent for Dukes' B lesions, 33 percent for Dukes' C lesions, and 0 percent for Dukes' D lesions.

Nuclear DNA analysis of insulinomas and gastrinomas

The potential for malignancy of an islet cell tumor of the pancreas is difficult to cytologically judge when one evaluates only the primary lesion, because a malignant condition is usually determined by the presence of regional or distant metastases. Nuclear DNA cytometric measurements have proved helpful both in the evaluation of the malignant potential of other endocrine and nonendocrine lesions and in the determination of the "aggressiveness" of these tumors. Thirty-six islet cell tumors or their metastases from 25 patients were studied. Eleven patients had insulinomas and typical insulinoma syndromes, and 14 others had gastrinomas with the Zollinger-Ellison syndrome. Tissue from each tumor was stained by the Feulgen technique, and nuclear DNA cytometry was performed by means of the microTICAS system designed by the Cytopathology Laboratory of the University of Chicago. Ploidy measurements of insulinomas, taken alone, did not discriminate well between benign and malignant states. However, the single malignant insulinoma could be clearly recognized, for it was one of only two lesions in that group with 5N-exceeding rate (5N-ER) values of 1% or greater. (5N-ER is defined as the percentage of aneuploid nuclei with nuclear DNA content greater than 5N.) On the other hand, seven of eight malignant gastrinomas had ploidy values of 2.5N or greater (our definition of an aneuploid state) and/or had 5N-ER values of 1% or greater, while five of six benign gastrinomas had ploidy values of less than 2.5N and had 5N-ER values of 0%. In addition, the two most aggressive tumors had the highest ploidy and 5N-ER values. Nuclear DNA cytometric studies appear to offer promise as an aid in the evaluation of pancreatic islet cell tumors, particularly gastrinomas.

[Papillomatosis of the bile ducts: a clinical case]

A case of diffuse papillomatosis of the bile duct, treated with external biliary drainage, is reported on account of its rarity. The extent and anatomopathological characteristics of the lesion make radical surgery impossible, so that the above-stated surgical solution appears to the Authors to be the most suitable one for resolving the biliary stasis and consequent cirrhosis.