Cancers of the papilla of vater: mutator phenotype is associated with good prognosis

Cancer of the papilla (ampulla) of Vater is an uncommon disease that kills 60% of affected patients. There is general agreement that local spread of the tumor (T stage) is the only significant and independent prognostic factor for this cancer, whereas the predictive value of tumor grade and lymph node metastases is controversial. The genetic anomalies involved in this process have the potential to serve as additional prognostic markers. We explored 25 ampullary cancers for the occurrence of instability at simple repeat DNA sequences (microsatellites) of the type seen in replication error phenotype (RER-positive) cancers. Ten microsatellites from five different chromosomes were amplified by PCR from both normal and cancer tissue DNA of the same patients. A tumor was defined as RER-positive when microsatellite instability was found in the majority (>/=6) of the loci analyzed. Five cancers (20%) showed a RER phenotype and were associated with long survival of patients (32-96 months), whereas RER-negative cancers had a significantly poorer prognosis (Mantel-Cox test; P = 0.0084), with a median actuarial survival of 17 months. We also report that three (12%) patients belonged to cancer-prone families and four (16%) were cancer-prone individuals.

[Reconstruction technique after pancreaticoduodenectomy]

The many techniques proposed for the reconstruction of the digestive path after pancreaticoduodenectomy show the continuous research of the most anatomical and safest way to achieve the best results. Most of the technical variations concern the treatment of the pancreatic stump and are directed to prevent the pancreatic fistula that is the most frequent cause of postoperative mortality and morbidity. None of the pancreatico-digestive reconstruction ways is absolutely better than the others and we think neither the total obstruction of the Wirsung duct is the solution of the problem of the pancreatic fistula. The accuracy and technical precision, the availability to modify the technique in relationship to different anatomy and functional conditions of the pancreatic stump are essential to improve the results. To achieve this goal is decisive the experience and patients volume of the surgeon and of the institutional team.

Does extended pancreaticoduodenectomy increase operative morbidity and mortality vs. standard pancreaticoduodenectomy?

The poor prognosis of pancreatic carcinoma after resection is related to distant metastases and local recurrence that is characterized by a strong tendency to infiltrate the retroperitoneal tissue and spread along the neural plexuses and lymph nodes. Thorough clearance of these tissues around the celiac and mesenteric axes, aorta, and inferior vena cava from the diaphragm to the inferior mesenteric artery (extended pancreaticoduodenectomy may lower the rate of local recurrence, but the procedure has been criticized for its higher morbidity and mortality. Our aim was to compare extended pancreaticoduodenectomy (EPD) with standard pancreaticoduodenectomy (SPD) in terms of postoperative morbidity and mortality. Data from 47 patients who underwent either EPD (n=24) or SPD (n=23) between November 1992 and October 1995 were retrospectively analyzed. Preoperative laboratory findings, operative risk (according to the American Society of Anesthesiologists classification), type of operation (classic Whipple vs. pylorus-preserving Whipple), operative time, intraoperative blood and plasma transfusion, postoperative morbidity and mortality, and postoperative hospital stay were scrutinized. The results showed that all of the parameters considered were similar in the EPD and SPD groups (intraoperative blood transfusion 800+/-490 ml vs. 700+/-586 ml, postoperative mortality 0% vs. 4.3%, overall morbidity 45.8% vs. 47.8%, surgical morbidity 37.5% vs. 34.7%, and postoperative hospital stay 16+/-8.1 days vs. 17+/-13.1 days. These two groups differed only in the operative time, which was significantly longer for EPD than for SPD (360+/-68.9 minutes vs. 330=66.9 minutes, P=0.02). Although the operative time is increased with EPD, there does not appear to be an increase in intraoperative complications, postoperative morbidity and mortality, or postoperative hospital stay with this procedure. However, definitive confirmation of these results can only be provided by a prospective randomized study.

[Complete congenital atrioventricular block: a case report and review of the literature]

The description of a clinical case of a newborn with congenital complete atrioventricular block, due to maternal connective-tissue disease, is the occasion for a review of the literature. The clinical elements allowing an early diagnosis and treatment of these patients, who often need a permanent pacemaker, are described.

[Laparoscopic cholecystectomy after myocardial revascularization using the gastro-epiploic artery]

The authors report the case of a man operated by coronary artery bypass graft using the right gastro-epiploic artery. Laparoscopic cholecystectomy had to be performed postoperatively because of cholecystitis. Surgeons must be aware of the possibility of coeliotomy in the context of coronary artery surgery: this is a small incision, the sternotomy incision is only slightly lengthened towards the epigastrium. A history of such surgery requires certain precautions during subsequent abdominal incisions, particularly laparoscopic, and during dissection of the porta hepatis.

Endocrine tumors of the pancreas: Ki-67 immunoreactivity on paraffin sections is an independent predictor for malignancy: a comparative study with proliferating-cell nuclear antigen and progesterone receptor protein immunostaining, mitotic index, and other clinicopathologic variables

Prediction for malignancy of pancreatic endocrine tumors (PET) is often a formidable challenge for the pathologist. The authors evaluated the role of the proliferative activity and progesterone receptor protein (PgRP) in predicting prognosis and survival of PET. Twenty-three functioning (FT) and 31 nonfunctioning tumors (NFT) were evaluated for mitotic activity and immunostaining for Ki-67 antigen, proliferating cell nuclear antigen (PCNA), and progesterone receptor protein (PgRP) on paraffin sections. The results were expressed as a percentage (index) of immunoreactive or mitosing cells. All 54 cases showed immunostaining for Ki-67 and PCNA, and valuable mitotic index, whereas only a fraction of tumors (25 of 54 cases) exhibited PgRP expression. Ki-67 and PCNA indexes correlated strongly between themselves and to mitotic index, whereas an inverse relationship was observed between cell proliferation and PgRP status in both FT and NFT. Although univariate analysis showed that Ki-67, PCNA, mitotic and PgRP indexes, stage, immunoreactivity for hormones other than insulin, diameter, and nonfunctioning type of tumor were statistically correlated to survival, Cox's regression method let only Ki-67 index emerge as an independent predictor of survival using a cutoff value of 5% in both FT and NFT.

Papillary cystic neoplasm of the pancreas: radiological findings

We report a series of 10 papillary cystic neoplasms of the pancreas evaluated in our institution. The lesions are analyzed in retrospect to define the existence of eventual specific imaging patterns as well as to point out the existing problems of differential diagnosis versus other pancreatic tumors.

Lymphoepithelial cyst of the pancreas. Report of two cases and review of the literature

CONCLUSION

Lymphoepithelial cyst of the pancreas (LC) is a very rare benign lesion and preoperative diagnosis is difficult. Conservative surgery seems to be the appropriate therapy in symptomatic patients or when a precise preoperative diagnosis is not achieved. The benign behavior of all reported cases suggests that the asymptomatic patients with a certain morphological preoperative diagnosis might be clinically followed up. The histogenesis of LC remains to be elucidated.

BACKGROUND

LC of the pancreas is a cyst that is histologically characterized by a fibrous tissue, a lymphoid component and a lining squamous epithelium.

METHODS

Clinical and pathological findings of two personal cases are reported with review of the literature.

RESULTS

A 56-yr-old man, complaining of epigastric pain, and a 47-yr-old man, with a history of alcohol abuse, were admitted to hospital. In both cases the lesion was detected with abdominal ultrasound but a certain diagnosis was obtained only after histological examination of the resected cysts.

Papillary cystic neoplasm of the pancreas: radiological findings

We report a series of 10 papillary cystic neoplasms of the pancreas evaluated in our institution. The lesions are analyzed in retrospect to define the existence of eventual specific imaging patterns as well as to point out the existing problems of differential diagnosis versus other pancreatic tumors.

Solid and cystic papillary neoplasm of the pancreas: a clinico-cytopathologic and immunocytochemical study of five new cases diagnosed by fine-needle aspiration cytology and a review of the literature

We report here on five new cases of solid and cystic papillary neoplasm (SCPN) of the pancreas diagnosed by fine-needle aspiration cytology (FNAC). All cytologic samples were obtained by ultrasonography, and the smears were conventionally fixed and stained. Special histochemical and immunocytochemical stains were also performed in some samples. Cytology revealed in all but one case numerous pseudopapillary structures composed of fibrovascular stalks lined with one or more layers of bland-appearing, uniform tumor cells. The tumor cells had round-to-oval euchromatic nuclei with frequently folded smooth contours and one or two small nucleoli. Their cytoplasm often contained eosinophilic, PAS-positive, and diastase-resistant inclusions. Foamy cells, psammoma bodies, blood, and cellular debris were found in the background. The criteria for the differential diagnosis versus other pancreatic lesions are discussed in some detail, as is the role of immunocytochemistry (ICC). In the literature, only 28 cases of cytologically investigated SCPN have been reported to the best of our knowledge. The most helpful criteria for the conclusive identification of SCPN by FNAC include the pseudopapillary arrangement with bland-appearing tumor cells, and, especially, the finding of acidophilic, PAS-positive, and diastase-resistant cytoplasmic granules.

[Role of transesophageal echocardiography in aortic dissection]

Aortic dissection, especially type A, is a life-threatening condition, that requires a prompt and accurate diagnosis to ensure a rapid and precise therapeutic approach. Transesophageal echocardiography (TEE) is a highly reliable technique because of its sensitivity and specificity (near 100%; almost similar to nuclear magnetic resonance), and because it is a very low risk, rapid and easy diagnostic tool. Two hundred sixty-one patients were admitted at our institution in a 6-year period (1988-1994), because of a suspicion of aortic dissection. Two hundred forty-seven of them were submitted to TEE and the diagnosis was compared with surgical data in 124. There was only one false positive by TEE. Sensitivity of TEE vs surgery was 100%, specificity 93.7%, diagnostic accuracy 99%. Agreement between TEE and surgery in the setting of intimal tear was 69.2%. These data confirm the usefulness of TEE in the diagnostic approach to aortic dissection and the therapeutic decision, without using other methods.

ras-family gene mutations in neoplasia of the ampulla of Vater

Mutations in the first and second exons of Ha-, Ki- and N-ras oncogenes were investigated in 17 epithelial tumors of the ampulla of Vater by single-strand conformation polymorphism analysis and direct sequencing of DNA fragments amplified by polymerase chain reaction. The panel included 12 intestinal-type adenocarcinomas, 3 villous adenomas, 1 papillary carcinoma and 1 neuroendocrine carcinoma. Six cases (35%) contained ras mutations, affecting codon 12 of Ki-ras in 2 adenomas and 3 carcinomas, and of N-ras in 1 adenoma. All mutations were found in adenomas and among cancers with adenomatous areas, whereas none of the cases lacking adenomatous areas contained mutations. This suggested that ampullary cancers represent heterogeneous diseases with respect to the presence or absence of adenomatous areas and, among those with adenomatous areas, with respect to the presence of activated ras genes. Ki-ras mutated cases included 3 of 4 tumors which mainly involved the intraduodenal bile duct, thus suggesting that a proportion of Ki-ras-mutated ampullary cancers might correspond to those originating from the epithelium of the bile duct component of the ampulla.

Retroperitoneal paragangliomas: role of immunohistochemistry in the diagnosis of malignancy and in assessment of prognosis

OBJECTIVE

To present our experience of 10 patients with extra-adrenal retroperitoneal paragangliomas, and assess prognostic tests.

DESIGN

Retrospective study of casenotes.

SETTING

University hospital, Italy.

SUBJECTS

10 Patients who presented with paragangliomas between 1970 and 1991.

MAIN OUTCOME MEASURES

Histological and immunohistochemical results, and outcome.

RESULTS

All tumours were completely resected and there was no operative mortality. Of the 8 patients who had no metastases at presentation 3 died of recurrence 3, 5, and 10 years later, respectively; 4 were alive and free of disease 2-7 years after diagnosis. The 2 patients with synchronous bone metastases at presentation died 1 and 4 years later. Immunohistochemical analysis of type I cells (chromogranin A and neurone-specific enolase) showed little correlation with progression of disease, but there was a correlation between the presence of type II cells (S100 protein) and good prognosis.

CONCLUSIONS

Excision is the treatment of choice for paraganglioma. Immunohistochemical techniques may provide useful information about prognosis, in particular about those patients who are at increased risk of recurrence. Long term follow up is essential, because successful management of recurrence is dependent on early recognition.

[Surgical resection for pancreatic neoplasms in the past 20 years]

Over the last 20 years there has been substantial progress in histopathological and biological understanding of pancreatic tumours. This has allowed surgical removal to be planned according to the aggressiveness and natural history of the tumours with benign (cystoadenomas, insulinomas) or low grade tumours (borderline mucin producing tumours, cystic papillary tumours), the trend towards cost effective surgery (conservative pancreatectomy) may be linked to the neighbouring organs (spleen, stomach, duodenum) in an attempt to bring about more rapid functional recovery for the patient and an improvement in the quality of life. On the other hand, the drastic reduction in operative mortality, which is currently less than 5% of cases following duodeno-pancreatectomy, has encouraged a more aggressive surgical technique in order to increase radical resectability for malignant tumours. Moreover, for highly malignant tumours such as ductal adenocarcinoma, the role of pancreatic resection for palliative purposes, in order to improve the quality of life with an acceptable operative risk, has been confirmed. It is foreseeable that as a result of a more accurate selection and grading of patients for surgery, there may in the future be improvements in survival even in those patients operated on for ductal adenocarcinoma. Until now, these patients have received no significant benefit from the undoubted progress achieved in diagnostic and operative techniques.

Dermoid cyst of the head of the pancreas area

We report a case of dermoid cyst of the head of the pancreas area in a 26-yr-old woman radically treated with pancreatoduodenectomy and alive with no recurrence at 6-yr follow-up. The diagnostic and surgical procedures are described, and the literature is reviewed.

A new model to evaluate the hypertensive response to noxious stimuli in the anesthetized, spontaneously hypertensive rat

We have developed a method to evaluate the hypertensive response after noxious stimuli in anesthetized rats. Anesthetic level, stimuli, and responses were standardized by using an etomidate infusion, a series of stimuli of increasing intensity applied to the tail, and measuring maximal changes in systolic blood pressure (delta SBP) after each stimulus. Normotensive Sprague Dawley rats (SD) (n = 7) were studied using an etomidate infusion of 4.2 mg.kg-1 x h-1. This method was then applied to spontaneously hypertensive rats (SHR) anesthetized with three rats of etomidate infusion: Group 1 (n = 8), 7.0 mg.kg-1 x h-1; Group 2 (n = 8), 5.6 mg.kg-1 x h-1; and Group 3 (n = 11), 4.2 mg.kg-1 x h-1. Under anesthesia, three types of noxious stimuli were applied to the tail at 1-min intervals (13 total): (a) Type 1:11 2-s electrical stimuli of increasing intensity (0.4-12 mA, to produce threshold to maximal responses); (b) Type 2: one intense, prolonged electrical stimulus (10 mA, 5 s); and (c) Type 3: tail-clamping. After each stimulus, delta SBP was measured. In the SHR, comparing single delta SBP responses to single noxious stimuli after each of the three most intense stimuli showed no statistically significant differences among the three anesthetic groups. In contrast, comparison of dose-response curves of multiple delta SBP responses to multiple Type 1 (2-s) stimuli demonstrated a significant difference among the three anesthetic groups of SHR.(ABSTRACT TRUNCATED AT 250 WORDS)

Pancreatic adenocarcinomas frequently show p53 gene mutations

Thirty-four pancreatic adenocarcinomas were studied for the presence of p53 gene mutations by the single-strand conformation polymorphism method and by direct sequencing of PCR-amplified fragments. p53 protein expression was immunohistochemically evaluated using monoclonal PAb1801 and polyclonal CM1 antibodies. Mutations were detected in 14 cases. The transitions were six G to A and two A to G; the transversions were one C to G and two A to C; the remaining three were frameshift mutations. Immunostaining results were identical with both antibodies. Nuclear immunohistochemical p53-positive cells were found in nine p53 mutated cases and in 12 cases in which no mutation was detected. In most of these latter cases only a minority of cancer cells showed immunohistochemical positivity. Twenty-nine cases, including all p53 mutated cancers, were known to contain codon 12 Ki-ras gene mutations. Also in the light of the demonstrated cooperation of ras and p53 gene alterations in the transformation of cultured cells, our data suggest that p53 mutation is one of the genetic defects that may have a role in the pathogenesis of a proportion of pancreatic cancers.

Neoplasia of the ampulla of Vater. Ki-ras and p53 mutations

Eleven tumors of the ampulla of Vater (5 stage IV and 2 stage II adenocarcinomas, 1 stage II papillary carcinoma, 1 neuroendocrine carcinoma, and 2 adenomas, one with foci of carcinoma) were examined for Ki-ras and p53 gene mutations by single-strand conformation polymorphism analysis and direct sequencing of polymerase chain reaction-amplified DNA fragments. Ki-ras mutations were found in one adenocarcinoma and in the adenoma with foci of carcinoma, both involving mainly the intraduodenal bile duct component of the ampulla. Seven cases showed p53 gene mutations: four advanced-stage adenocarcinomas, the papillary carcinoma, the neuroendocrine carcinoma, and the adenoma with foci of carcinoma. Nuclear accumulation of p53 protein was immunohistochemically detected in the morphologically high-grade areas of the five cancers harboring a p53 gene missense point mutation. The adenomas, the two frame shift-mutated cancers, and the adenomatous and low-grade cancer areas of mutated carcinomas were immunohistochemically negative. Our data suggest that in ampullary neoplasia 1) p53 mutations are common abnormalities associated with the transformation of adenomas and low-grade cancers into morphologically high-grade carcinomas, and 2) Ki-ras mutations are relatively less frequent and might be restricted to tumors originating from the bile duct component of the ampulla.

[Treatment of pain in advanced-stage intra-abdominal neoplasms]

Different types of pain are present in far advanced intra-abdominal cancer, sometimes in the same site too. An accurate semeiological analysis of pain is important because different types of pain often differently respond to the available therapeutical tools. In this paper the results and the complications of the most important methods of pain management in far advanced intra-abdominal cancer are examined. Analysis of the data reveals that the association of more methods, pharmacological and non, should be a rule rather than the exception.

Immunodetection of proliferating cell nuclear antigen assesses the growth fraction and predicts malignancy in endocrine tumors of the pancreas

Thirty-five endocrine tumors of the pancreas, 17 functioning and 18 nonfunctioning, were immunohistochemically studied for the expression of proliferating cell nuclear antigen (PCNA) using 19A2 and PC10 monoclonal antibodies. The proportion of PCNA-reactive cells (PCNA index) ranged from 0.2 to 27% in functioning tumors and from 0.1% to 55% in nonfunctioning tumors. PCNA index showed a statistically significant correlation with mitotic and Ki67 indexes. The median values of PCNA index identified three groups of patients: group A (PCNA < or = 2%), including 13 functioning and six nonfunctioning tumors; group B (PCNA between 2 and 5%), including three functioning and three nonfunctioning tumors; group C (PCNA > 5%), including one functioning and nine nonfunctioning tumors. All group A tumors were confined to the pancreas. In group B, the functioning tumors were limited to the pancreas, and the nonfunctioning tumors extended to extrapancreatic tissues. All group C patients had extrapancreatic extension of the disease. At follow-up, a PCNA index higher than 5% correlated to a decreased mean survival. Our data suggest that PCNA index is a reliable tool to assess the growth fraction, discern local from advanced diseases, and predict malignancy in pancreatic endocrine tumors.

[Pneumothorax in multiple trauma. Radiologic and CT study]

This study was aimed at evaluating the necessity to perform chest Computerized Tomography (CT) in multiple traumatized patients to diagnose pleuropulmonary lesions and, particularly, pneumothorax: the correct identification of this condition, although minimal, is important especially in prevision of long anesthesias and/or positive end-expiratory pressure (PEEP) therapy. This assisted respiratory technique improves arterial oxygenation but causes a barotrauma which may cause some complications; particularly, a small undetected pneumothorax can suddenly increase so as to cause pulmonary collapse with sometimes dramatic symptoms. Chest X-ray films and CT scans, performed in rapid succession on patient's admission in Emergency Ward, were compared in 21 subjects. CT is indispensable in case of severe chest parietal lesions which can mask the radiological evidence of pulmonary or pleural conditions, as it occurred in 3 of our cases. Moreover, CT resulted more reliable than chest X-rays (18 versus 10 correct diagnoses) especially in the detection of small antero-inferior pneumothorax flaps, in which direct radiological signs cannot be identified, in default of radio-geometrical assumptions. Indirect radiological signs of pneumothorax must be recognized but critically considered in order to avoid over-staging.

Cystic islet cell tumors of the pancreas. A clinico-pathological report of two nonfunctioning cases and review of the literature

Cystic islet cell tumors of the pancreas are extremely rare. The authors report their personal experience with two cases of nonfunctioning cystic endocrine neoplasms. The tumor was diagnosed preoperatively in one case by ultrasonography (US)-guided fine-needle aspiration cytology, while in the other it was identified only in the surgical specimen after a clinical-radiologic diagnosis of pancreatic mucinous cystic tumor. Immunohistochemical assay showed positivity for the generic neuroendocrine markers (neuron specific enolase, or NSE, synaptophysin, and chromogranin A) in both cases and also for glucagon in one case. The neoplasms were resected by distal pancreatectomy with splenectomy and intermediate pancreatectomy respectively. Both patients are alive and recurrence-free 6 mo and 2.5 yr, respectively, after surgery. The authors also review the existing literature, discussing the pathogenesis of such tumors and the imaging techniques and surgical strategies adopted in their management.

Intraoperative ultrasonography in pancreatic cancer

Intraoperative ultrasonography (I.US) has been introduced in order to overcome the limits of the preoperative imaging modalities (notably, ultrasonography and computed tomography), both in pancreatic cancer diagnosis and staging. The authors' experience encompasses 32 cases, selected according to the following criteria: lesions that could not be detected both preoperatively and at surgical exploration; lesions detected but not properly characterized, requiring differential diagnosis between cancer and pancreatitis; tumoral lesions with a perspective of radical surgery, in which the preoperative judgment of resectability had to be verified. In the only case of the first group, I.US allowed the identification of a small cancer in a jaundiced patient. In the 11 cases of the second group, I.US-guided fine-needle aspiration biopsy showed three cancers; however, among the other 8 lesions classified as pancreatitis there was one false negative diagnosis (a tumoral mass with liver metastases was demonstrated by computed tomography 6 mo later). Regarding the intraoperative staging of the proven cancers (20 cases of the third group; 4 cases of the first and second groups), I.US changed the planned surgical approach in 9 cases (showing vascular involvement or detecting liver metastases and enlarged lymph nodes not seen preoperatively); in 12 cases it confirmed the possibility of radical surgery. Finally, in the remaining 3 cases, I.US provided dubious information: only vascular dissection during surgery could achieve a correct evaluation, ruling out vascular involvement and thus allowing tumor resection.

Cystic tumors of the pancreas: evaluation by ultrasonography and computed tomography

The personal series of 30 cystic tumors of the pancreas [12 serous cystic tumors (SCT) and 18 mucinous cystic tumors (MCT)] is presented. All neoplasms were evaluated with ultrasonography (US) 28 of 30 with computed tomography (CT); the tumoral histotype could be correctly defined in 73% of cases (seven of 12 SCT and 15 of 18 MCT). Percutaneous fine-needle aspiration (FNA) with diagnostic aims (preparation of cytological smears and/or biochemical assays) was performed in only 10 of 30 cases, yielding a 100% sensitivity; on the whole, the combined use of imaging modalities and FNA allowed correct characterization of the cystic tumors in 27 of 30 cases (90%). The usefulness of a precise diagnostic workup of these neoplasms is emphasized, due to their prognostic and therapeutic outcome.

The contribution of ultrasonography and computed tomography in the diagnosis of nonfunctioning islet cell tumors of the pancreas

The personal series of 12 nonfunctioning islet cell tumors (NFIT) of the pancreas is reported. The ultrasound and computed tomography features of NFIT are analyzed, and a few signs are identified that may be useful in the differential diagnosis vs ductal carcinoma. The necessity to complete the diagnostic work up by means of fine needle aspiration biopsy and cytologic smears is also emphasized.

[Diagnostic imaging of pancreatic metastasis]

The authors present their personal series of pancreatic metastases (8 cases) which were evaluated with different imaging modalities--i.e., sonography, computed tomography, and angiography. Possibilities and limitations of non-invasive modalities are pointed out, and the usefulness of angiography is emphasized for the identification of small hypervascular lesions. The fairly rare diagnosis of these tumoral lesions is due to 3 causes: low incidence of pancreatic metastases; their frequently small size which justifies eventual false negatives; the frequent lack of symptoms calling for imaging modalities. Moreover, pancreatic metastases are usually diagnosed in an advanced stage. Thus, the therapeutic approach must be planned in every single case, in relation to the perspectives of survival and to the residual quality of life.

Necrosectomy by lavage in the surgical treatment of severe necrotizing pancreatitis. Results in 263 patients

A conservative surgical technique for treatment of necrotizing pancreatitis is described. Standardized since 1976, the technique is based on washout mechanical necrosectomy accomplished by lavages via intraoperatively placed wide-bore drainage tubes. The overall mortality rate from necrotizing pancreatitis was thereby reduced from 61% (with resective technique) to 18%, and in 106 cases observed from the onset of the disease the mortality fell to only 6.6%. The series included also patients with fulminant acute pancreatitis and multiorgan failure.

[Spontaneous hemoperitoneum caused by gallbladder rupture: description of a case and review of the literature]

The Authors report a case of spontaneous haemoperitoneum following the rupture of the gallbladder. After a review of the literature, clinical, pathogenetic, diagnostic and therapeutic problems are discussed. It is stressed that, although this condition is rare, its incidence is increasing due to the widespread use of anticoagulant therapy.

Mediastinal chondrosarcoma. Case report

A 34-year-old man and a 71-year-old woman underwent radical removal of mediastinally sited chondrosarcoma, presumably originating in the periosteum of the vertebral body. The man (with mesenchymal chondrosarcoma) died of remote metastasis 6 years postoperatively. The woman (poorly differentiated chondrosarcoma, grade 2-3) is still alive 2 years after the operation.

Small-cell neuroendocrine carcinoma of the ampullary region. A clinicopathologic, immunohistochemical, and ultrastructural study of three cases

We report the clinicopathologic, immunohistochemical, and ultrastructural features of three small-cell neuroendocrine carcinomas of the ampullary region of the duodenum. All patients were men; their ages were 51, 62, and 66 years. The therapy consisted of pancreatoduodenectomy. All patients died of the disease; median survival was 10 months from the diagnosis. The histological appearance was identical to pulmonary and extrapulmonary small-cell carcinoma. The neuroendocrine differentiation was demonstrated ultrastructurally by the presence of dense-core granules, and by the positive immunoreaction for neuron-specific enolase and Leu-7 in each case. One case expressed a focal positivity for chromogranin A (PHE-5) and argyrophilic granules. The same case showed the presence of neurofilaments on frozen material. Neurofilament proteins could not be demonstrated in any case in paraffin sections. Neoplastic cells exhibited cytoplasmic immunostaining for cytokeratins (CAM 5.2) in all cases. In one case, a large number of neoplastic cells (60-70%) exhibited nuclear Ki-67 positivity. We postulate that the disease's histogenesis was from epithelial stem cell expressing both epithelial and neuroendocrine characteristics. The clinical behavior of small-cell neuroendocrine carcinomas of the ampullary region appears to be extremely aggressive, with early metastases and fatal outcome.

Thoracic complications of pancreatitis

Pancreatitis may be associated with thoracic complications, notably chronic massive pleural effusion (CMPE) and, rarely, pseudocysts with mediastinal extension (PME) and enzymatic mediastinitis (EM). Our personal experience with 14 cases of thoracic complications (nine CMPE, two PME associated with pleural effusion, and three EM of 670 patients who underwent surgery; of these, 191 had acute and 479 had chronic pancreatitis) during 16 years (1970-1986) is reported. In the patients with CMPE, the initial symptoms were progressive dyspnea eventually associated with cough and chest pain. In the PME cases, there was dysphagia associated with left subscapular pain and left chest pain. The initial signs in the patients with EM were sudden dyspnea, cyanosis, retrosternal pain, tachycardia, and acute heart failure. A fistula between the pancreatic ductal system and the pleural cavity in seven of the nine patients with CMPE was demonstrated by intraoperative pancreatography and/or cystography. On the contrary, preoperative endoscopic pancreatography demonstrated the sinus tract in only three of the seven. In both cases of PME, computed tomography (CT) provided a correct diagnosis that was confirmed at surgery. In the patients with EM, the diagnosis was suggested by the clinical appearance and was confirmed by the chest roentgenogram and by CT. All patients had operations after varying periods of unsuccessful 2-4-week-long conservative treatment. One patient with infected ascites died postoperatively. There were no thoracic recurrences of pancreatic disease among the other patients at a 10-month-10-year follow-up observation after surgery.

Surgical strategy in primary retroperitoneal tumours

Sixty-nine patients with primary retroperitoneal tumours (17 benign, 52 malignant including 4 malignant tumours of uncertain origin) were reviewed to determine the best form of surgical strategy. Total resection was performed in 88 per cent of benign cases and in 65 per cent of malignant cases. In 62 per cent of the total resections for malignant tumours, en bloc excision included adjacent organs or anatomical structures. Operative mortality rate (in terms of the total number of operations performed) was 5 per cent. Postoperative complications occurred in 14 per cent and recurrences in 35 per cent. The overall 5-year survival rate was 67 per cent in patients with totally resected tumours and zero in patients whose tumours were treated by partial resection or biopsy. An aggressive surgical approach aimed at total excision of the tumour is the best form of therapy currently available. In the totally resected retroperitoneal tumour, the use of adjuvant radiotherapy and/or chemotherapy depends on the grade of the malignancy and clearance as assessed histologically. Careful follow-up based on the use of computerized axial tomography and ultrasound allows early identification of recurrence at a stage when the recurrence is amenable to total resection.

[Spontaneous rupture of the esophagus (presentation of a case)]

The authors describe the case of a 67-year-old patient with spontaneous rupture of the middle third of the oesophagus, occurring apparently without any involvement of intraluminal hypertension. The surgical treatment consisted in the execution of an aspiration drainage of the left pleural cavity, followed by a right thoracotomy with exploration of the mediastinum. A gastrostomy according to Witzel was also performed. Total parenteral nutrition was instituted in the post-operative period. Healing of the oesophageal lesion was confirmed radiologically 2 months after admission to our department.

Atenolol and amiodarone: a comparative study of their anti-ischaemic effect

A total of 10 patients with mixed angina were entered into a study to compare the anti-ischaemic efficacy of atenolol and amiodarone. The study was divided into three parts: (a) placebo for 2 weeks; (b) 100 mg atenolol given for 8 weeks; and (c) amiodarone given for 8 weeks, divided into week 1, 200 mg three times daily; week 2, 200 mg twice daily; weeks 3 and 4, 200 mg once daily; weeks 5-8, 200 mg once daily for 5 days a week. Clinical examination, basal and multi-stage effort electrocardiograms were performed at the end of each treatment. The number of anginal attacks and the amount of trinitrin taken by the patients were significantly reduced by both drugs with no significant difference between them. Compared with placebo, both drugs induced a significant increase in work capacity and in the time to decrease the ST-segment by 1 mm. At rest, atenolol reduced systolic blood pressure, heart rate and the systolic blood pressure--heart rate product compared with placebo. Systolic blood pressure was also reduced significantly compared with patients given amiodarone. Amiodarone did not influence these parameters. At maximum effort, amiodarone reduced heart rate and the systolic blood pressure--heart rate product compared with placebo. This reduction was greater for atenolol. The ST-segment depression was comparable between patients given either test drug. Amiodarone, therefore, exerts an anti-ischaemic effect similar to that shown by atenolol with different haemodynamics: atenolol reducing myocardial oxygen demand, amiodarone having an additive increase of coronary flow. Such an effect was obtained with a lower dose of amiodarone than is commonly used.

[Treatment of perineal breach in radical surgery of the rectum: notes on the surgical technic]

The Authors review the various techniques used in closing and draining the pelvic basin after total resection of the rectum due to neoplastic and/or inflammatory disease. The examine their experience with 248 cases of total resection of the rectum and propose closure of the perineal breach as the first step in through closure of the pelvic peritoneum.

[Esophagogastroplasty in the treatment of squamous carcinoma of the esophagus (our experience)]

The authors report on their experience with 42 cases of squamous carcinoma of the oesophagus subjected to oesophagectomy and oesophagogastroplasty. The patients' mean age was 55.2 years (range: 41-70) with a 13:1 male/female ratio. A positive history of cigarette smoking and of alcohol consumption was found in 87% and 80% of patients respectively. The sites of the neoplasms were as follows: 24 in the mid 3rd of the oesophagus, 9 in the lower 3rd, 6 in the upper 3rd of the thoracic oesophagus and 3 in the cervical oesophagus. In 39 patients the operation was performed in two stages according to Lewis and in 2 cases it was performed in 3 stages according to McKeown, while one patient was treated with a pull-through operation according to Akiyima. Six patients died during the first 30 days postoperatively as a result of circulatory complications or ARDS. Fistulization of the anastomosis as observed in 5 cases, though this was clinically manifest only in two. Mean survival was 5.9 months, 18.6 months and 10.5 months according to the period considered.

[Epithelial splenic cysts]

The authors describe a case of an epithelial cyst of the spleen treated successfully by splenectomy. Diagnostic techniques and the principles adopted in treatment this rare disease are discussed.

[Hepatic angiomyelolipoma (considerations on a case brought to our attention)]

Liver lipomas are exceedingly rare: the authors present a case of angiomyelolipoma of the liver in a 65-year-old woman resected by right hemihepatectomy. Radiologic findings and indications to surgical treatment are discussed.

[Retroperitoneal neurilemmoma (considerations on 4 cases)]

The authors show 4 cases of retroperitoneal neurilemmoma, surgically treated by simple excision of the tumour. From the general observations, as well as from the analysis of the literature, they can remark the rareness of the location in such anatomical region. The clinical symptoms are common to those of the region retroperitoneal tumours, and are due to the compressive effect developed by the tumour on the contiguous structures. As regards the diagnostic procedures, they emphasize the primary value of axial computed tomography in the evaluation of the retroperitoneal pathology. The diagnosis cannot be but histologic, and is based upon the presence of the typical histologic pictures according to Antoni A and B types.

[Nd-YAG laser disobstruction of esophageal endoprostheses occluded by neoplastic development in the palliative treatment of esophageal cancer]

Since August 1984 18 patients suffering from inoperable esophageal cancer have been treated by Nd. Yag Laser therapy under endoscopic control in the Verona University Institute of Clinical Surgery. Three patients, all males ranging in age from 68 to 80 years, had endo-esophageal prostheses which were occluded as a result of the neoplasms. Occlusion of the prostheses had been ascertained by both x-rays and endoscopy. The symptoms consisted of severe dysphagia of solid foods in 2 cases and of solids and liquids in 1 case. The original sites of the tumors were the lower 3rd in two cases and the mid 3rd in 1 case. Histologically, the tumors were identified as 2 squamous-cell carcinomas and 1 adenocarcinoma. Laser treatment was given on average once every 7 days. Patients were admitted to the day hospital, thus avoiding negative repercussions in terms of quality of life or length of hospital stay. In 2 cases there was an improvement in symptoms with the possibility of semi-solid nutrition after a single treatment with 6000-5032 Joules. In the third case, to obtain the same result, 2 treatments were necessary at an interval of 7 days with a total of 9396 J. One patient died of cardiorespiratory failure 24 days after the first treatment. A second patient was treated a further 3 times with a total of 12356 J and is now on a liquid and solid diet 5 months after the first treatment. The third patient was treated 4 times with a total of 15769 J; this patient was on a liquid and solid diet, but died of cardiorespiratory failure 3 months after the first treatment. In the light of our experience, Nd. Yag Laser disocclusion of endo-esophageal prostheses occluded by neoplasms presented no complications and was an appropriate indication in these cases with satisfactory long-term results.

[Indications and results of surgery in native valve infectious endocarditis. Apropos of 104 surgically-treated cases]

From 1972 to 1984, 104 cases of aortic valve infectious endocarditis were treated surgically. The average age of the patients was 40 years and the majority were men (69/104). Forty patients had no previous cardiac disease; 44 patients had documented valvular heart disease, which was unlikely in the remaining 20 patients. There were 16 mitral valve, 55 aortic valve, 1 tricuspid, 30 mitro-aortic, 1 mitro-tricuspid and 1 mitro-aorto-tricuspid valve infections. Aerococcus viridans was isolated in only 4 out of 71 positive cultures: the prevalence of the infecting organisms was otherwise normal (30 staphylococcus, 30 streptococcus, 7 rare organisms). Forty one patients were operated because of haemodynamic deterioration, 13 for resistant infection and 13 for an association of both indications; 37 patients were operated for embolism or threatening vegetations. Eight patients were in functional Class I, 26 in Class II, 52 in Class III and 17 in Class IV. The patients were divided into 4 groups according to the degree of surgical emergency (26 extremely urgent, 26 semi urgent, 32 controlled endocarditis and 20 chronic endocarditis). The actuarial survival rate was 70% at 5 years. Poor prognostic factors were the presence of previous valve disease, the isolation of a staphylococcus and an aortic valve localisation. The degree of emergency and the precise surgical indication did not seem to be important. Most patients at long term were in functional Classes I or II. There was no preferential indication for bioprosthetic or mechanical valve replacement in endocarditis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Pregnancy and enterostomy]

The authors describe the difficulties and possible complications of pregnancy in colonostomized women. In the neoplastic forms, generally appearing in advanced age, the knowledge of the basic disease discourages any possible attempt at pregnancy. In the chronic inflammatory diseases (ulcerous rectocolitis and Crohn's disease), typical of young age, pregnancy, if opportunely followed and programmed, can get an absolutely favourable course. The authors report their own experiences and some other authors' ones.

[Hepatic cystadenocarcinoma: presentation of a clinical case and review of the literature]

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.

[Primary seminoma of the mediastinum: diagnostic and therapeutic approach]

The Authors show three cases of mediastinal seminoma, and discuss the epidemiologic, etiopathogenetic and clinical aspects of such neoplasms; they dwell upon the criteria allowing to define as primitive an extragonadal germinal tumour, and emphasize the importance of the multidisciplinary therapeutical approach in controlling these neoplasms, characterized anyhow in the pure forms by a remarkable sensitiveness to radium; promising looks the use of the tumoral markers (beta-HCG and AFP) for a diagnostical specification, for the choice of the treatment and for the evaluation of its effects.

[Benign epithelial neoplasms of Vater's ampulla. Usefulness of the "epithelial dysplasia" concept in prognosis and surgical strategy]

The surgical behaviour in front of the benign epithelial tumors (adenomas) of Vater's ampulla is object of discrepancies due to the possible malignant evolution of such neoplasms. The authors stress the basic importance of a careful examination of histological bioptic material before and/or during operation, which, through the identification of the degree of epithelial dysplasia, may lead to the choice of the tecnique to be adopted. In 2 of the 3 cases reported by the authors, showing a low degree dysplasia of the papillary tumor, a submucous papillectomy was performed; in the third case, where histology showed severe dysplasia and some other elements of risk were present (patient's age and macroscopic features of the tumors), the surgeons performed a duodenopancreatectomy. Semiseriated histological sections of the surgical specimen revealed the presence of carcinomatous areas. The authors think simple papillectomy to be the surgical procedure to follow when low grade dysplasia of ampulla is documented, and duodenopancreatectomy to be performed in high risk conditions as high grade dysplasia and macroscopic features suggestive of malignancy. In addition, the authors deal with epidemiology, clinics and instrumental diagnostics of such benign neoplasms of ampulla, on the basis of their own experience and the review of the few cases reported in literature.

[Surgical therapy of gastric carcinoma in an advanced stage (clinical cases)]

The Authors study the casuistry of the Verona Surgical Clinic concerning the interventions for gastric cancer; they particularly study 35 cases of plurivisceral demolition for neoplasm in advanced phase. After a discussion of the data supplied by the literature; the Authors, as a conclusion, suggest not to consider the overcoming of the gastric barrier in multivisceral sense as a rigid element for the exclusion of these patients from surgery, although they exclude widely demolitive interventions in seriously weakened patients, or in bearers of such spreadings as to involve tremendous operative risks, not rewarded with a satisfactory advantage.