Tallo: A global tree allometry and crown architecture database

Data capturing multiple axes of tree size and shape, such as a tree's stem diameter, height and crown size, underpin a wide range of ecological research-from developing and testing theory on forest structure and dynamics, to estimating forest carbon stocks and their uncertainties, and integrating remote sensing imagery into forest monitoring programmes. However, these data can be surprisingly hard to come by, particularly for certain regions of the world and for specific taxonomic groups, posing a real barrier to progress in these fields. To overcome this challenge, we developed the Tallo database, a collection of 498,838 georeferenced and taxonomically standardized records of individual trees for which stem diameter, height and/or crown radius have been measured. These data were collected at 61,856 globally distributed sites, spanning all major forested and non-forested biomes. The majority of trees in the database are identified to species (88%), and collectively Tallo includes data for 5163 species distributed across 1453 genera and 187 plant families. The database is publicly archived under a CC-BY 4.0 licence and can be access from: https://doi.org/10.5281/zenodo.6637599. To demonstrate its value, here we present three case studies that highlight how the Tallo database can be used to address a range of theoretical and applied questions in ecology-from testing the predictions of metabolic scaling theory, to exploring the limits of tree allometric plasticity along environmental gradients and modelling global variation in maximum attainable tree height. In doing so, we provide a key resource for field ecologists, remote sensing researchers and the modelling community working together to better understand the role that trees play in regulating the terrestrial carbon cycle.

Extended lymphadenectomy in cephalic pancreatoduodenectomy. Personal observations

BACKGROUND/AIMS

Long-term survival in patients with cancer of the pancreatic head is disappointing. Surgery is the only curative therapy. Unfortunately the prognosis of resected patients (10-15%) is extremely poor due to loco-regional cancer recurrence (50%). Lymphatic and perineural invasion may account for local recurrence. Japanese studies have reported the importance of an extended lymphadenectomy during the classic Whipple exeresis (40% of patients present lymph node metastases).

METHODOLOGY

At the General Surgical Clinic of Pavia University 20 patients (14 men, 6 women, mean age 62.4 yr) with pancreatic head cancer (17 adenocarcinoma, 1 lymphoma, 2 carcinoma) underwent Whipple's exeresis with a regional (peripancreatic or R1) and juxta-regional (para-aortic or R2) lymphadenectomy according to the Ishikawa technique, between 1996-2000. R1 nodes consisted of lymph nodes at the pylorus, superior pancreatic head, common bile duct, anterior pancreaticoduodenal region, inferior pancreatic head and superior mesenteric vessels. R2 nodes consisted of lymph nodes at the superior and inferior pancreatic body, mid colic region, common hepatic duct, celiac axis and para-aortic region.

RESULTS

The wide dissection was quite easy in patients with a serious cholestatic disease. Intraoperative mortality was 0%. Operative mortality was 5%. Postoperative complications (20%) consisted of 1 sepsis, 1 hepato-renal syndrome with hepatic coma, 1 intestinal obstruction by adhesive bands, and 1 wound infection. Eight patients (40%) died during a mean follow-up period of 6 months (neoplastic recurrence 50%). Notwithstanding the advanced disease (stage III 50%; N1+ 50%), 12 patients (60%) had a median postoperative survival rate of 18.4 months (range 1-48 months) without neoplastic recurrence. Tumor diameter was less than 4cm in 83.3% of cases.

CONCLUSIONS

An earlier diagnosis (with tumor diameter <4 cm) can improve pancreatic head cancer prognosis. A wide surgical exeresis with R2 lymph nodes clearance together with surrounding connective and nervous tissue can remove micrometastases and better control local recurrence.

[Radical surgical treatment of gastric cancer. Personal experience]

After surgical therapy the survival outcome of gastric cancer is still poor. Early diagnosis and radical surgery are the two most important means to improve the prognosis. Radical surgery must include all lymph nodes embryologically related to stomach. The aim of this study was to verify whether an aggressive surgical strategy can increase postoperative survival rate. In the period 1990-1994 eighty two patients with gastric cancer were operated on. The M:F ratio was 1.6:1 and the mean age was 65.3 years (range 23-89). Palliative operations (6 gastroenterostomy) were performed in 7.3% of cases. In the other patients, 36 total gastrectomies (43.9%), 8 total gastrectomies extended to spleen, pancreas and colon (9.7%), 32 distal subtotal gastrectomies (39.1%) were performed. Gastric exeresis was always associated with lymph node dissection extended to level I and II (R2). In some cases level III and IV lymphadenectomy (R3) was performed according to Maruyama-Mishima technique. There were no intraoperative deaths. The operative mortality was 13.6% for total gastrectomies and 3.1% for subtotal gastrectomies. Postoperative complications occurred in 15.9% of total gastrectomies (3 anastomotic fistula, 2 wound infection, 1 subphrenic abscess, 1 melena) and in 3.1% of subtotal gastrectomies (1 sepsis). Stage III and IV cancers represented 74.4% of all cases (stage IIIA 19.6%, IIIB 21.9%, IV 32.9%). Metastatic lymph node involvement (N2+) affected 53.1% of T3 and 88.2% of T4 cancers. The mean survival rate of patients subjected to gastroenterostomy was 6 months. The 2-year survival for total gastrectomies was 42%, for subtotal gastrectomies 28.1%. In our experience, wide removal of lymph nodes and total or extended gastrectomies were performed without any increase of mortality and morbidity. In advanced stages, a wider exeresis increased survival and prevented local recurrence.

[Extended lymphadenectomy for carcinoma of pancreatic head. Personal experience]

Long-term survival in patients with cancer of the pancreatic head is disappointing. Surgery is the only curative therapy. Unfortunately the prognosis of patients resected (10-15%) is extremely poor due to loco-regional cancer recurrence (50%). Lymphatic and perineural invasion might account for local recurrence. Japanese studies reported the importance of an extended lymphadenectomy during the classic Whipple exeresis (40% of patients present lymph node metastases). During the period 1996-2000 at our Institution 20 patients (14 M, 6 F, mean age 62.4 years) with pancreatic head cancer (17 adenocarcinoma, 1 lymphoma, 2 carcinoma) underwent Whipple's exeresis with a regional (peripancreatic or R1) and juxta-regional (para-aortic or R2) lymphadenectomy according to Ishikawa technique. R1 nodes consisted of lymph nodes at the pylorus, superior head, common bile duct, anterior pancreaticoduodenal region, inferior head and superior mesenteric vessels. R2 nodes consisted of lymph nodes at the superior body, inferior body, mid colic region, common hepatic duct, coeliac truncus and para-aortic region. This wide dissection was quite easy also in patients with a serious cholestatic disease. Intraoperative mortality was 0%. Operative mortality was 5%. Postoperative complications (20%) were 1 sepsis, 1 hepato-renal syndrome with hepatic coma, 1 mechanical intestinal obstruction, 1 wound infection. Eight patients (40%) died in 6 months in average (neoplastic recurrence 40%). Notwithstanding the advanced disease (stage III 50%; N1+ 50%), twelve patients (60%) have a mean postoperative survival rate of 18.5 (range 1-48) months without neoplastic recurrence. Tumour diameter was less than 4 cm in 83.3% of cases. An earlier diagnosis (with tumour diameter < 4 cm) can improve pancreatic head cancer prognosis. A wide surgical exeresis with a R2 lymph nodes clearance together with surrounding connective and nervous tissue can remove micrometastases with a better control local recurrence.

[Surgical resection of hepatic hilar tumors]

Hepatic hilar cancer has an extremely poor prognosis and resection for cure is a realistic possibility in only 15-20% of patients. Tumours confined strictly to the biliary confluence can often be excised locally without resorting to hepatic resection (Bismuth's type I, II). Tumours extending beyond the second order bifurcation (Bismuth's type III) require hepatic resection. In the period 1996-1998 ten patients with hilar cancer (adenocarcinoma) underwent curative resection at our Institution. There were 9 men and 1 women with a mean age of 61.7 years (range 49-76 yrs). One neoplastic lesion was Bismuth's type I, five type II, four type III. The mean preoperative bilirubin level was 20 mg% and the mean duration of jaundice was 4 weeks. Four patients had skeletonization resection of the tumour and extrahepatic bile ducts, clearing all lymphocellular and other tissue from the hepatic pedicle and coeliac axis. Bilioenteric continuity was reestablished by a Roux-en-Y jejunal loop with separate biliary duct anastomoses. Six patients required also hepatic resection to adequately remove the tumour (1 right hepatectomy, 2 right lobectomy, 2 left hepatectomy, 1 segmentectomy III). Three patients had liver metastases. One patient had involvement of the left arterial and portal branch. The postoperative staging was 2 stage II, 1 stage III, 7 stage IV. In 5 patients hepatic lymph nodes (N1) were involved. In no patient the tumour was found at the margin of resection. The median estimated blood loss for hepatic resection was 1,000 ml and for skeletonization 500 ml. Intraoperative mortality was 0%. Operative mortality was 20%. Three patients had a complicated postoperative course (1 cerebral TIA, 1 multiorgan failure, 1 ictus cerebri). All patients died. The mean postoperative survival was 7.4 months. Four patients (N1+) died of local tumour recurrence at 8, 11, 6, and 8 months. In our experience resective procedures can achieve a longer survival and a better quality of life. The operative mortality may be kept to a minimum by adequate selection of patients and technical expertise.

Prediction of the impact of logging activities on forest cover: a case-study in the east province of Cameroon

The objective of this study was to test the value of the concept of the net commercial value of standing timber in predicting the impact of logging activities on forest-cover modifications. A study area was selected in the East province of Cameroon which contains major primary forests and which contributes strongly to national timber production. A Geographic Information System containing ecological and economic variables was used in combination with remote sensing data to define the net commercial value of standing timber in the East province. Taking account of the potential commercial value of standing timber improves our understanding of the spatial determinants of logging activities and of the resulting forest-cover modifications. The occurrence of logging-induced forest-cover modifications increases with the value of forest rent. In one of the study sites, half of the very high rent areas have already been logged. In that site, therefore, it is mostly the low rent or marginal forest areas that remain unlogged. This was not the case, however, throughout the study area as shown by the observations at another site.

Alcohol carousel and children's school drawings as part of a community educational strategy

Within a community action research program, messages for the community population can be conveyed through already existing channels (newspapers, magazines, TV, radio) or special tools can be created. As part of the Rifredi Health District (16,900 inhabitants), Florence, Italy, Community Alcohol Action Research Project, 5,500 alcohol carousels (translated and adapted from the Stockholm carousel) were distributed during 1996 in the project's area where they were freely available. Two samples, one of a consumers' association (response rate 26%) and the other of school parents, employed a questionnaire. A few local key people underwent a qualitative interview. In all circumstances the carousel proved to be understandable, useful, and able to elicit discussions about alcohol issues. In 1996-97, after a 2-year training program in communication skills and alcohol prevention, 13 teachers in local preschools, elementary schools, and middle schools planned and implemented a health education program on the issues of alcohol and food. One outcome was nine drawings produced by the school children. The drawings were exhibited in some schools and supermarkets, and were hung in city buses.

[Neoplastic obstruction of the vena cava inferior in general surgery]

Patients with primary or secondary tumoral occlusion of the inferior vena cava are difficult to be managed with safety and success. Nevertheless, their survival may be prolonged by an aggressive surgical approach according to the technical advances of liver transplantation. In fact, it is possible to perform a tumoral exeresis including the inferior vena cava by a total vascular exclusion of the liver (HVE) and a pump-driven veno-venous bypass (ECC). The Authors report the management of 8 patients with inferior caval tumoral involvement (8 M, 1 F, mean age 63.7 yrs). Vascular occlusion was caused by caval leiomyosarcoma (n 1), renal cell carcinoma (n 3), hepatocellular carcinoma (n 1), liver metastases (2 colorectal, 1 renal). Five patients (62.5%) underwent surgical treatment (2 laparotomy, 2 wide nephrectomy with partial caval wall resection in HVE, 1 ex vivo liver resection with caval venoplasty in HVE and ECC). Operative mortality was 40%. Three patients underwent medical treatment (radio-chemotherapy, chemoembolization). Total survival rate was 75% at 3 months, 50% at 6 months, and 25% at 24 months. Two patients (25%) are still alive at 3 months from the diagnosis and at 36 months from the operation.

[The surgery of lung metastases of melanoma]

Melanoma is considered one of the most lethal cancers and surgical therapy of its pulmonary metastases is rarely indicated. The only hope for a successful surgical treatment of secondaries from melanoma is a radical resection. Considering the very frequent multiorgan involvement of melanoma metastases, surgery is usually possible in less than 5% of cases. Nevertheless, in selected cases without lymph nodal involvement a 5-year survival rate of 31% has been reported. In any way, it must be remembered that about 10% of lung tumours thought to be metastases are primary cancers. In this occurrence surgery could be a rescuing solution. So, a pulmonary resection is always imperative when some diagnostic doubt exists.

[Surgical therapy of metabolic liver diseases (glycogenosis, hypercholesterolemia)]

Up-to-date, most patients with serious chronic hepatic disease are best treated by liver transplantation. It has been confirmed the striking benefit of liver transplantation also for patients with glycogen storage disease or homozygous familial hypercholesterolemia who were refractory to medical treatment. Nevertheless, the advantage of achieving palliation without transplantation, thereby avoiding the need for chronic immunosuppression, is obvious. With reference to the mentioned above diseases, end-to-side portacaval shunt was used. A favourable effect was noted on body growth and a number of metabolic abnormalities. Hepatic failure did not occur, although in a few patients blood ammonia concentrations and serum alkaline phosphatase levels increased relative to preoperative values. To avoid an incomplete palliation provided by portacaval shunt, appropriate case selection is a problem. The Authors report their personal experience with portacaval shunt for the treatment of glycogenosis and familial hypercholesterolemia.

[Primary and secondary pulmonary tumors associated with head and neck carcinoma]

The authors analyze personal and literature results in surgery of primary and secondary lung cancer associated with head and neck malignancies. Eighteen patients with primary lung cancer associated with head and neck cancer were compared with six patients affected by pulmonary metastases from head and neck cancer. In the first group the 3-year postoperative survival rate was 60.5%, in the second group 33%. Differential diagnosis between primary and metastatic lung tumours may be easy when multiple pulmonary nodes are present. When only one pulmonary node is present, diagnosis is more difficult. Thoracotomy is necessary to perform the correct diagnosis and the best postoperative medical treatment.

[Surgical treatment of pulmonary metastasis from breast carcinoma. Personal contribution and considerations on the experience in the literature]

Considering a series of twelve patients operated on at the General Surgical Clinic of the University of Pavia, the authors discuss the results of surgical therapy of pulmonary metastases from breast cancer. According to literature data their results are not so good with a 5-year survival rate of 11%. Nevertheless, selected series of patients have been reported with a 5-year survival rate of 43% after pulmonary resection. So, by a careful selection of the indications the possibility of a surgical treatment would not be eliminated. After breast cancer exeresis it is certain that surgery is the best treatment for a solitary pulmonary nodule when there is some doubt about the diagnosis of primary or secondary lung cancer.

Purification, partial characterisation and mode of action of enterococcin EFS2, an antilisterial bacteriocin produced by a strain of Enterococcus faecalis isolated from a cheese

Enterococcus faecalis strain EFS2, isolated from the surface of a traditional cheese, produced a bacteriocin active against Gram-positive bacteria including Listeria spp. and some Staphylococcus aureus strains. The bacteriocin, named enterococcin EFS2, has been purified to homogeneity by ammonium sulphate precipitation and reversed-phase high performance liquid chromatography (RP-HPLC). The molecular weight was determined by mass spectrometry to be 7149.6. The amino acid composition of enterococcin EFS2 revealed that it contained 67 amino acid residues and had a blocked amino-terminal end. Enterococcin EFS2 induced viability loss, efflux of K+ ions and ATP, and cell lysis. Kinetic study of bactericidal activity of enterococcin EFS2 on Listeria innocua strain LIN11 indicated slower cell destruction than by nisin. At pH 7.0, the activity of enterococcin EFS2 was the highest at 35 degrees C and was lost at 15 degrees C. The bacteriocin was more active against L. innocua strain LIN11 in broth adjusted to pH 6.0, 7.0 and 8.0 than to pH 4.5 at 30 degrees C.

[Surgical approach to posthepatitic cirrhotic patient today]

A posthepatitic cirrhotic patient may undergo elective or urgent abdominal operation for an extra-hepatic or hepatic disease. According to the high postoperative morbidity (61%), surgery is indicated only for symptomatic or complicated cholelithiasis. A surgical procedure for refractory ascites has been devised to create a permanent peritoneo-venous shunt by a one way pressure-sensitive valve (Leveen). The procedure is simple and brings a long lasting relief with recovery in strength and nutrition and improved kidney function. Sclerotherapy is widely used to treat acute variceal bleeding while repeated sclerotherapy is used in the long-term management to eradicate varices. When indicated, liver transplantation is the best treatment to prevent variceal bleeding recurrence. Also portosystemic shunts effectively prevent recurrent variceal bleeding. They are, however, major operations with an important morbidity and mortality, particularly in poor risk patients. The most advocated shunts today are the Warren distal splenorenal shunt and the Sarfeh portacaval shunt using a small diameter prosthetic H-graft. The transjugular intrahepatic portosystemic stent-shunt (TIPSS) is a new treatment for portal hypertension and its complications. From a haemodynamic point of view it allows balanced hepatic perfusion. Postoperative mortality is rare; further bleeding and encephalopathy are reasonably acceptable. The most relevant complications concern dislocation of the prosthesis, stenosis and thrombosis of the shunt, which can be corrected by non-invasive dilatation. Encephalopathy is the main complication of surgical portosystemic shunts. It is usually controlled by protein diet restriction, and administration of lactulose or oral antibiotics. In severe forms the patients may be treated by an oesophageal transection with oesophagogastric devascularization, and by a postoperative suppression of the portosystemic shunt using external maneuvers. Posthepatitic liver cirrhosis is frequently complicated by the onset of an hepatocellular carcinoma. Early detection (aFP, DCP, Echography) and curative resection are the best ways to improve long term prognosis. Segmentectomy achieves a good balance between liver function preservation and radical exeresis for tumours less than 5 cm in diameter. Liver transplantation may be considered for the treatment of long-staging cirrhotic patients in whom hepatocarcinoma development has been recognized at an early presymptomatic stage. Hepatic arterial chemoembolization (gelfoam, lipiodol, mitomycin C or doxorubicin) may improve the survival of patients with unresectable malignant disease of the liver. A marked reduction in liver size may occur in the weeks following an effective chemoembolization with objective (CT scan) and subjective improvement (amelioration of specific symptoms). Liver chemoembolization is absolutely contraindicated in the presence of jaundice disordered liver function (Child C) or complete portal venous obstruction. In the last years, the number of patients treated by liver transplantation has greatly increased. Surgical technique, postoperative management, and immunosuppressive therapy account for the dramatic improvement of the results. However, indications for selection of patients and the timing for liver transplantation are still not well defined.

Bench surgery and liver autotransplantation. Personal experience and technical considerations

Advances in hepatic transplantation have opened the possibility of bench surgery for liver disease. Thus, nonconventional methods such as the ex vivo approach (bench procedure) or the in vivo ex situ preserved liver surgery have been performed in selected cases. These methods have been confined to situations and tumour stages otherwise deemed untreatable, or to situations where resection may not be sufficiently radical. To date, primary liver tumours (hepatocellular, cholangiocellular) and colo-rectal metastases are considered to be suitable conditions. The technique used is that of liver grafting. Hypothermic liver perfusion (U.W., 4 degrees C) and pump-driven veno-venous bypass from portal vein and inferior vena cava to the superior vena cava are performed. The principal aim of bench surgery is to avoid the unnecessary removal of a large amount of normal parenchyma. Resection lines follow the segmental structure of the liver. Sometimes, an atypical hepatectomy with a parenchymal exeresis "à la demande" is required. Authors' experience with four patients undergoing ex vivo operation of the liver (three patients) or surgery on an ex situ hypothermic perfused liver (one patient) is reported. The patients had liver metastases from colonic carcinoma (1 M, 2 F) and from renal carcinoma (1 M). Major hepatic resections were performed. One patient (M) died from neoplastic intestinal recurrence after 16 months. Two patients (F) died after 24 and 9 days for sepsis and pulmonary embolism. One patient (M) died intraoperatively from a massive retroperitoneal bleeding. Being able to remove otherwise unresectable hepatic neoplasms is a worthy objective. In the presence of diffuse chemoresistant colo-rectal hepatic metastases, liver bench surgery is a promising therapeutic hope. At the basis of a good hepatic function there are a correct organ preservation, a perfect bench surgical technique with respect for vascularization and biliary drainage of the hepatic remnant, and an accurate hemostasis of the resection surface.

[Surgical treatment of pulmonary metastases in colorectal carcinoma]

After surgical exeresis of pulmonary metastases from colorectal carcinoma the 5-year survival rate is 30% vs 5% in non treated patients. Postoperative survival is longer for patients with a primary rectal cancer. Single pulmonary metastatic lesions, negative ilar and mediastinal lymph nodes, and Dukes' stages A and B are favourable prognostic criteria. The authors review literature's data and report and analyze their clinical observations.

[Surgical treatment of pulmonary metastases of sarcoma]

Lungs are the most common target of metastases from osteogenic and soft tissue sarcomas. Metastases can be successfully treated by surgery. Only a few patients with non treated pulmonary metastases from sarcomas are alive after 5 years. In fact, without surgery the 1-year mortality is 50%. The number of metastases, the site in one or both lungs, the disease-free period and the tumoral doubling time have important prognostic significance. The authors report two interesting cases successfully treated with surgical therapy.

[Surgical treatment of pulmonary metastases of primary neoplasms of the urogenital tract]

The authors review the literature data concerning the surgical therapy of pulmonary metastases from genital and urinary tumours. In both cases a combined chemo-surgical treatment is able to increase longterm survival. Some personal cases successfully treated are reported. The case is reported also of a young girl operated on for pulmonary metastases from a Wilms tumour. Successively, a heart transplantation was performed. She is alive and well.

[An update of Bassini's operation for the treatment of inguinal hernia]

Although the Bassini hernioplasty has been criticized, particularly by North American surgeons because of a high incidence of recurrence, among the techniques used for inguinal hernia repair, the Bassini method, in authors' opinion, is still the best if correctly performed. In fact, the transversalis fascia division is fundamental to obtain a better mobilization of the triple layer (transversalis fascia, transversus abdominis, internal oblique) which can approach the inguinal ligament without tension. Hernia repair is achieved by suturing this layer to the pubic tubercle and inguinal ligament with separated stitches.

[What future for clinical xenograft of the liver?]

In the cyclosporine era liver orthotopic allotransplantation has shown to be very effective in the treatment of many end-stage liver diseases. Currently, the major limitation in clinical transplantation is the shortage of donor organs unlikely solvable by alternative policies or approaches such as living donors and artificial organs. Animals have been considered as an alternative source of organs offering the following advantages: availability of a predictable and ready supply of donor organs, opportunity to practice transplantation as an elective procedure, possibility to match the size of the graft recipient. However, immunologic barriers are thought to make xenotransplantation impractical between widely divergent (discordant) species. Hyperacute xenograft rejection, in fact, consists of an immediate, diffuse intravascular coagulopathy followed by an aggressive cellular reaction. Recipient preformed natural antibodies and complement are involved in the humoral phase of hyperacute rejection. The violence of this reaction depends on the titer of natural antibodies and on the divergency of the species involved. Species more closely related (concordant) exhibit a less aggressive reaction characterized by an acute cellular rejection. Hepatic allografts and xenografts, though, are unusually resistant to humoral injury and undergo a combination of both humoral and cellular rejection. Preliminary studies have demonstrated a prolonged reduction in natural antibodies accomplished by plasmapheresis and cyclophosphamide combined treatment. Furthermore, new therapeutic agents such as FK 506, rapamycin and deoxyspergualin may find widespread application in clinical transplantation. FK 506 has shown to possess a remarkable efficacy in reversing refractory hepatic allograft rejection as well as ability to inhibit humorally mediated immunity.(ABSTRACT TRUNCATED AT 250 WORDS)

[Pyogenic liver abscess: a caseload contribution]

Pyogenic hepatic abscesses have been recognized since the time of Hippocrates, but an understanding of their etiology, bacteriology, diagnosis and treatment is an event of the twentieth century. Fortunately mortality rate has declined due to improvements in diagnosis, intensive care, medical and surgical management. In particular, the use of CT and ultrasound scanning has reduced the incidence of unrecognized and therefore untreated liver abscesses. Considering nine patients operated on for liver abscess, the Authors affirm that laparotomic surgical drainage is still the most effective therapy in the majority of cases.

[Hepatic carcinoma in cirrhosis. Segmental liver resections]

Liver cirrhosis is frequently complicated by the onset of an hepatocellular carcinoma. An accurate monitoring of the cirrhotic patient often assures an early diagnosis, so that an hepatic resection is still possible. Hepatectomy has been accepted as the only chance of cure, but selection of the appropriate extent of surgery has to be made taking into account both the risk of postoperative hepatic failure and oncologic needs. Intraoperative sonography and intermittent hepatic vascular clamping lead to a safer liver resection, while the postoperative course is improved by monitoring the hepatic function and preventing sepsis. In the period November 1973-March 1991, 34 hepatic segmentectomies (unisegmentectomy 47%, bisegmentectomy 38.3%) were performed in our Service in cirrhotic patients with hepatocellular carcinoma. The clinical stage was defined using a modified Child-Bismuth's grading (A 67.6%, B 32.4%). In the majority of cases (53%), tumors were less than 5 cm in diameter. Perioperative blood loss was less than 1,500 ml and fresh frozen plasma was preferred for volume substitution. The operative (one month) mortality rate was 20.5%. Postoperative complications occurred in 45% of cases. The mean survival rate was 14 months. The above results suggest early detection and curative resection as the best way to improve long term prognosis. Segmentectomy achieves a good balance between liver function preservation and radical exeresis. Postoperative intensive care is needed to prevent complications which might lead to hepatic failure.

[Hepatic cystadenoma: a case report]

Hepatic cystadenoma is a rare tumor arising from the biliary system. Although ultrasound and CT scan show peculiar features, diagnosis is not easy preoperatively. Because of the unreliable natural history of cystadenoma, total excision of the neoplasm by hepatic resection seems to be the treatment of choice. A case of benign cystadenoma treated by minor liver resection is reported.

[The diagnostic elements and therapy principles in thyroid cancer: the Pavia experience 100 years after Bottini]

The diagnostic and operative management of thyroid cancer is controversial as the nature of the disease is heterogeneous in its growth rate, pattern of spread, and histological type. Therefore, surgery must be extensive enough to minimize the chances of recurrence and death. In the period 1962-1989, 159 thyroid cancers were observed. According to the histological type, 61 total thyroidectomies, 34 hemithyroidectomies with isthmusectomy, and 29 subtotal thyroidectomies were performed. Cervical lymph node dissection was performed in 55 patients. The 10-year postoperative survival rate was 70.59% with lymphadenectomy and 65.71% without lymphadenectomy.

Preventing relapses of breast cancer with modified radical mastectomy

Better prevention and early detection have improved the percentage of early cancers among all the treated breast tumors to about 40%. After the first demonstration in Milan in 1981 that even conservative surgery can effectively prevent tumor relapses, radical and modified radical mastectomy was compared in 136 and 127 women, respectively. The groups were well stratified as regards age, menopause, T- and N-status. No difference was found in 10-yr survival (58.8 and 59.8%, respectively) or local relapses (9.5 and 10%, respectively) or general relapses. The median disease-free survival was 10 yr in both groups. The results suggest that in T1-T2a, N0-N1b M0 unilateral breast cancer relapses are prevented as effectively with modified radical as with radical mastectomy.

Delaying rejection in discordant heart xenografts in the rat: efficacy of cyclosporin, prostaglandin I2 and exchange transfusion

If effective modes of prevention of hyperacute rejection were available, the problem of the absence of enough suitable donors could be solved by the use of organ xenografts. Organ xenograft rejection is principally mediated by preformed antibodies which are responsible for the hyperacute pattern of rejection. We decided therefore to study various methods of prevention of rejection in the guinea pig to Lewis rat combination (donor-recipient discordant species) in which hyperacute rejection is particularly intense. Three series of experiments were performed. In the first series immunosuppression of the recipient was induced using an oral solution of cyclosporin A. In the second series antiplatelet-aggregation therapy was administered to the recipient, using intravenous prostacyclin (PGI2). In the third series antibody depletion of the recipient was attempted using exchange transfusion with or without prostacyclin perfusion. The most significant (p less than 0.01) prolongation of graft survival time was observed when combining exchange transfusion (8 ml) and PGI2 infusion (620 ng/kg/min). This observation suggests that, if antibody depletion in the recipient is the primary goal, measures aiming at reducing the consequences of the antigen-antibody reaction are also necessary to improve the results of organ xenografting.

[A modification of the Sweet-Allen simple reconstruction technique after total gastrectomy]

The Authors report their personal modification of Sweet-Allen's esophago-jejunal reconstruction after total gastrectomy. In their opinion, it enables to combine the advantages of the omega-shaped loop (easier and faster surgical technique, reduced postoperative morbidity) with those typical of the Roux-en-Y loop, that is complete elimination of biliary reflux, leading to better long term functional outcome and quality of life for the totally gastrectomized patient.

Cytogenetic findings in a case of anaplastic carcinoma of the pancreas

A cytogenetic study was performed on a short-term culture of a biopsy from a primary anaplastic carcinoma of the pancreas. The modal chromosome number was 60. Six numerical clonal anomalies involving chromosomes #2, #6, #7, #10, #15, and #16 were found, and marker chromosomes involving #1, #3, #5, #8, #11, #12, #13, #15, #16, #18, #20, #22, and X. Premature chromosome condensation (PCC) was observed with a high frequency. The results are discussed with reference to the scarce literature on chromosome changes in pancreatic cancer.

[Bilateral splanchnicectomy according to the Dubois method in pain caused by chronic pancreatitis and by inoperable neoplasms of the pancreas]

The authors report a personal series of 12 p. undergoing splanchnicectomy through Dubois' transhiatal approach because of abdominal pain of pancreatic origin. They underline this technique produces immediately a total, lasting pain relief, improving quality of life of these patients.

[Treatment of esophagotracheal and esophagobronchial fistulas secondary to carcinoma of the esophagus]

An experience with 16 patients with respiratory tract fistula (RTF) related to carcinoma of the esophagus is presented. The malignant fistula was present at the time of initial presentation and/or before any therapeutic intervention in 11 patients, and developed either during or following a course of radiation therapy in 5 patients. Bronchoscopy examination in 8 patients prior to RTF development showed tracheobronchial invasion or impingement in all. The patients were divided in five groups according to the treatment received. One patient received no specific therapy although was fed via nasogastric tube. Three patients had a feeding gastrostomy. Four patients underwent insertion of a Celestin tube. Three patients were submitted to esophageal exclusion with combinations of cervical esophagostomy, feeding gastrostomy and ligation or complete division of the gastroesophageal junction; drainage of the excluded esophagus was provided by a red rubber catheter. Five patients received by-pass operation: four had Kirschner-Ong operation with gastric by-pass placed substernally and distal esophagus anastomosed to a Roux-en-Y jejunal loop; in one patient an isoperistaltic gastric tube brought to the neck substernally was used for esophageal by-pass. These patients had, by far, the best palliative results with complete relief of their respiratory tract symptoms and restoration of the ability to eat and drink. Substernal gastric by-pass of the RTF is therefore advocated if the general conditions of the patient are improved with the institution of parenteral hyperalimentation and antibiotic therapy.

[Current role of surgery in the treatment of pulmonary metastasis]

During the period between november 1964 and december 1982, 48 patients were operated upon for metastatic lesions of lung from previous or actual carcinomas and sarcomas elsewhere in the body. The most frequent sites of origin of the primary malignancy were colon, testis and breast. The usual approach was through a thoracotomy; bilateral lung metastases were removed with one-stage procedure through a median sternotomy in two patients. The operative mortality was 2%. Overall five-year survival was 26%, which was not influenced by tumor histology, disease-free interval, or extent of pulmonary excision. In view of these findings, conservative pulmonary resection of metastatic lesions is advocated, regardless of the tumor histology or the disease-free interval, when the following criteria are adhered to: primary site controlled or controllable; no extrapulmonary metastases demonstrable; good operative risk; no other effective means of treatment available.