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Background/aims: The role of Billroth I (BI) subtotal gastrectomy (SG) for gastric cancer (GC) remains controversial in Western countries. The aim of the study is to critically analyze the long term outcomes of this procedure in a large single-institution experience., Methodology: Between 1990 and 2004, 158 patients underwent BI SG for GC at the Regina Elena Cancer Institute of Rome. Evaluation focused on cancer recurrence of the gastric stump, functional outcome and endoscopic findings., Results: Actuarial survival rate 10 years after resection in stage I-II was 70.7 per cent. After curative resection, primary cancer of the gastric stump occurred in one patient seven years after resection (0.7 per cent), whereas two patients had early recurrence (1.4 per cent) one and three years postoperatively. There were no oesophageal cancers. In survivors, Visick grades I and II achieved 95 per cent, and postoperative endoscopy showed no evidence of mucosal changes in 85 per cent of the patients. Twelve per cent of the patients took acid blocker regularly, however, the incidence of functional failure was 5 per cent., Conclusions: In selected patients, Billroth I subtotal gastrectomy is a safe and effective procedure that provides long-term survival and very good functional outcome.

We report a case of drug-related toxicity after liver transplantation for hepatocellular carcinoma in a HIV-HCV co-infected patient. Before transplant the patient was on a triple antiretroviral therapy (zidovudine and lamivudine and efavirenz) with a stable CD4+ cell count >500 cells/microL. Liver transplantation was performed with a liver graft showing a 10% of macrosteatosis and with a graft-to-recipient body weight ratio of 1.3. Immunosuppression was achieved with tacrolimus, azathioprine and steroids. The antiretroviral therapy was resumed in the first postoperative day as the early graft function was in the normal range. After a few hours the patient showed myoglobinuria, rhabdomyolysis and a fast-deteriorating graft function. All drugs were withdrawn except steroids and an empiric therapy with riboflavin and glutathione was maintained for five days until myoglobinuria ended. Nevertheless the serum levels of tacrolimus remained in the therapeutic range for six days when it was reintroduced at a reduced dosage (0.01 mg/kg/die). The postoperative course was complicated by tense ascites and severe hyperbilirubinemia without any rejection episodes. The patient was discharged 48 days post-transplantation with a good liver function. During the following year no signs of aggressive HCV-HIV recurrences were observed and the patient is maintaining a CD4+ cells count >400 without antiretroviral therapy.

Background/aims: Delayed massive arterial hemorrhage from the operating field occurs in 1-4% of cases after pancreaticoduodenectomy, with a mortality rate up to 50%. The purpose of this study was to define diagnostic and treatment methodologies to maximize survival., Methodology: Between 1990 and 1999, 84 pancreaticoduodenectomies were performed for periampullary and pancreatic head cancer. After surgery, massive bleeding occurred in two patients (2.3%), 30 and 8 days after resection, respectively., Results: Pancreatic leak and disruption of the pancreaticojejunostomy were reported in both cases. Bleeding was controlled by suture ligation of the stump of the gastroduodenal artery. Completion pancreatectomy and a new pancreaticojejunostomy were respectively performed. Hemorrhage recurred in both cases from a ruptured pseudoaneurysm of the hepatic artery, requiring re-exploration and surgical ligation. The first patient died of re-bleeding despite completion pancreatectomy, the other survived after oversewing the residual pancreatic stump at re-exploration., Conclusions: Early diagnosis and management of pancreatic leak represents the only means to prevent a delayed massive arterial hemorrhage. Transarterial embolization or surgical ligation of the hepatic artery proximal to the celiac axis represents the procedure of choice to control the bleeding. Taking down the pancreatic anastomosis and oversewing the pancreatic stump is safe and effective. Extensive drainage of the operating field should always be associated to prevent multisystem organ failure.

Background/aims: Purpose of this study is to define the effectiveness of surgical resection of liver metastases from operated breast cancer., Methodology: Nineteen patients underwent surgical exploration to resect liver metastases from previously operated breast carcinoma. Seventeen patients were resected: 15 patients had unique metastases and were submitted to a wedge liver resection while 2 had multiple lesions; in these cases a V-VI segmentectomy and a right hepatectomy was required. After liver resection 11 patients received chemotherapy, 2 chemotherapy plus hormone therapy, 2 hormone therapy alone and in the remaining 2 no adjuvant treatment was done., Results: Postoperative mortality was nil and morbidity consisted of 1 subphrenic abscess and 1 pleural effusion. Actuarial 5-year survival rate was 46%. Eight patients are still alive, 7 of whom are disease-free. Nine patients died for neoplastic progression., Conclusions: Surgical resection of liver metastases from breast cancer seems to be able to improve long-term survival in selected patients with unique and isolated lesions especially in association to systemic chemotherapy and hormone therapy.

Background/aims: Minimally invasive surgery has developed as one of the most important advances in surgical techniques. The laparoscopic procedure has been successfully used to perform colonic resections. Inflammatory bowel diseases like ulcerative colitis (UC) and familial adenomatous polyposis (FAP) appear as a main indication for total laparoscopic proctocolectomy., Methodology: At the Second Department of Surgery of the "Regina Elena" Institute for Cancer Research, 5 non-selected patients were submitted within a 3-year period (1993-1996) to a total laparoscopic proctocolectomy with a restorative ileal J pouch-anal anastomosis. They comprised 3 males suffering from UC and 2 females affected by FAP., Results: No patients undergoing laparoscopic procedure were converted. The average operative time was 364 min (480 min in the first case, 290 min in the fifth case). There were no intra-operative or post-operative complications (except a mild peritoneal bleeding in the first case, spontaneously stopped). Post-operative pain was mild and no analgesics were required. Late results were excellent, with good bowel function within 1 year after the operation, without dietetic, working and sport restrictions and without sexual disorders, mainly in males., Conclusions: Laparoscopic total proctocolectomy in the hands of skilled laparoscopic surgeons is a feasible, safe and effective procedure, with early and late results comparable to, and in some aspects better than, those obtained with "open" surgery. Moreover, it does not have the disadvantage of intra-operative fluid loss, prolonged post-operative ileus, pain and, in younger patients, psychological discomfort of the wide scar.

Background/aims: The purpose of this study was to evaluate feasibility, effectiveness and reproducibility of laparoscopy in the diagnosis and management of pancreatic diseases., Methodology: At the Second Department of Surgery of the "Regina Elena" Institute for Cancer Research, between June 1995 and June 1997, possibilities of the laparoscopy in diagnosis and staging of pancreatic malignancies were studied. Twenty-four consecutive cases of pancreatic adenocarcinoma were observed: 10 patients were pre-operatively considered unresectable and 14 cases were submitted to a laparoscopic study. Moreover, in the period from January 1996 to June 1997, a study on the therapeutical potentialities of laparoscopy was performed, attempting 5 pure or assisted laparoscopic pancreatic resections., Results: Three cases (21.4%) out of the 14 evaluated were found to be metastatic (liver and peritoneum); 11 patients were successfully resected with an open standard procedure. Laparoscopy allowed a correct staging in all cases, even in the 21.4% of ultrasonography (US), TC and angiographic false negatives. The 5 operative procedures consisted of one resection of a cystadenoma, one resection of a head cyst, one Wirsung lithotomy with pancreaticojejunostomy for lithiasic chronic pancreatitis, and two body-tail splenopancreatectomies (1 cystadenoma and 1 adenocarcinoma). Satisfactory early results were obtained in all these cases., Conclusions: Laparoscopic diagnosis and staging of pancreatic cancer is a valuable method which allows a very high accuracy. Pancreatic resections, even if feasible, are still to be considered an experimental procedure.

Background/aims: The purpose of this perspective study was to define the role of laparoscopic surgery in the treatment of colorectal carcinoma., Methodology: One hundred colorectal cancer patients were submitted to surgical treatment between 1993 and 1996. Fifty patients were operated on by videolaparoscopy, the other 50 were operated on according to the standard "open" technique. The two groups had similar demographic (age, gender), pathological (site, stage), and surgical (type and extent of resection) data. Early and late results, benefits and drawbacks of the minimally invasive technique are compared to those of standard open surgery., Results: No intra-operative complications and no operative mortality occurred in the two groups. Early results (complications within 30 days from surgery) were: 1 pneumonia, 3 wound sepsis, and 3 fistulas (one required a reoperation) in the laparoscopic group; 2 wound sepsis and 5 fistulas (spontaneously recovered) in the open group. Late complications occurred in the laparoscopic group only: 1 bowel bridle occlusion 2 months after surgery (that required a reoperation), and 2 stenoses of the colorectal Knight-Griffen anastomosis, successfully treated by dilatation. Concerning the oncologic results, data were calculated on 40 laparoscopic and 43 open curative resections (stage I, II and III): 20% (8/40) of the laparoscopic and 23% (10/43) of the open group patients resulted in neoplastic progression. The neoplastic recurrences were single site (liver or regional) in 3 laparoscopic and in 5 open patients; multiple sites of relapse were observed in 5 laparoscopic (liver, peritoneum and 1 trocar site) and in 5 open (liver, peritoneum and 1 scar) cases. Five-year disease-free survival rates (Kaplan-Meier method) were similar in the two groups: 73.2% in the laparoscopic and 70.1% in the open., Conclusions: Laparoscopic surgery seems to be a feasible and effective treatment of colorectal cancer and, with the improvement of technology and surgeon skill, it will represent an excellent alternative to the more diffuse and consolidated open surgery technique.

Background/aims: Primary adenocarcinoma of the duodenum is a rare disease and diagnosis is always late in being confirmed because of the non-specific symptoms, consequently leading to poor prognosis., Methodology: A retrospective review of 89 patients with non-ampullary duodenal adenocarcinoma treated in 36 different surgical departments in Italy between 1980 and 1994 was performed. The signs and symptoms, diagnostic studies conducted, tumor locations, surgical treatment, and survival were analyzed., Results: Duodenography and endoscopy were the most effective diagnostic tests, showing an accuracy of 81.9% and 88%, respectively. The most common tumor site was periampullary, observed in 62.9% of the cases. A curative resection was performed in 65 of the 89 patients (73%), a partial pancreatoduodenectomy in 37, a segmentary duodenal resection in 15 and a wide local excision in 11. The postoperative mortality rate was 10.1% (9 patients), and the overall 5-year survival was 25%, which was significantly better after resection. The most important prognostic factors were stage and tumor location., Conclusion: Early diagnosis of primary duodenal adenocarcinoma is the only way to improve the results, by providing a higher resectability rate.

Background/aims: The purpose of this study was to define the prognostic role of DNA ploidy, proliferative index and EGF-R status in resected gastric cancer., Materials and Methods: Ten clinico-pathological parameters and three biological factors obtained from flow cytometry and immunohisto-chemistry were evaluated in a series of 130 gastric cancer patients who received surgical treatment, including 28 stage IV cases (21.6%), using paraffin-embedded and fresh specimens in 77.7% and 22.3% of the cases, respectively. These variables were first analyzed and tested for correlation within the whole series and then weighted against survival in 117 applicable cases through univariate and multivariate analyses., Results: Aneuploidy was significantly related to higher proliferative activity, EGF-R expression and deeper stomach wall infiltration. Higher proliferative activity was significantly related to deeper stomach wall infiltration and larger tumor diameter. The latter showed a significant relationship to EGF-R expression. Univariate analysis showed the significant variables for survival to be DNA ploidy, pT, pN, M, stage, histological type according to Lauren and tumor diameter. Multivariate analysis calculated on these significant variables using the Cox multiple stepwise regression model detected three factors which independently influence survival: pathological stage (p < 0.00001), histological type according to Lauren (p < 0.002) and DNA ploidy (p < 0.03)., Conclusions: DNA ploidy was shown to be a significant prognostic parameter in resected gastric cancer after pathological stage and histological type according to Lauren. The prognostic roles of proliferative activity and EGF-R status require further investigation.

At least five studies based on more than twenty thousand healthy subjects indicated that fibrinogen is an independent risk factor for cardiovascular events; less clear-cut is the relation between factor VII and risk for arterial thrombotic disorders, which was demonstrated in two of the three studies investigating this association. However, no study has investigated the behaviour of fibrinogen and factor VII in an adolescent population. In a study of Preventive Medicine and Education Program, fibrinogen (clotting method) and factor VIIag (ELISA), in addition to other metabolic parameters, life-style and familial history, were investigated in 451 students (313 females and 138 males, age 15-17 years) from two high schools of Florence. Fibrinogen levels were significantly higher in women than in men, whereas factor VIIag levels did not significantly differ. Both fibrinogen and factor VIIag significantly correlated with total cholesterol (p < 0.05) while only fibrinogen correlated with body mass index (p < 0.01). Factor VIIag was significantly correlated with systolic blood pressure (p < 0.001). This study provides information on coagulation risk factors in a population of adolescents which may be of importance in planning coronary heart disease prevention programs.

The authors present a case study of 100 patients who underwent total gastrectomy out of a total of 376 patients submitted to surgery for gastric cancer between 1970 and 1992. The majority of the neoplasms were located in the middle third of the stomach with histological characteristics of an epithelial type in 92% of the cases, 8 of which were classified Stage IA, 6 Stage IB, 14 Stage II, 24 Stage IIIA, 25 Stage IIIB, and 15 at Stage IV. An R2 total gastrectomy, which included the distal 2-3 centimeters of the esophagus and the proximal 2-3 centimeters of the duodenum, combined with omentectomy and level 1 and 2 lymphadenectomy, was always performed. Thirty-four of the operations were extended and splenectomy was performed in 27 of these. Digestive continuity was obtained in 37 cases with an esophago-jejunostomy on a Roux-en-Y loop. Recanalization of the duodenum was accomplished in accordance with the Moricca technique in 32 cases and the Mouchet-Camey technique in 22 cases. Of the remaining 9, 5 underwent reconstructive surgery as described by Sweet-Allen, 2 as described by Nakayama, and the remaining 2 direct esophago-duodenostomy. The majority of the cases received total parenteral nutrition on the second postoperative day and this was maintained for the following eight days. Post-operative mortality, reported during the initial 30 days was 7%, overall morbidity 17%. A detailed protocol of clinical and diagnostic tests was established for follow-up studies conducted on a 4-month basis.(ABSTRACT TRUNCATED AT 250 WORDS)

Two hundred and seventy-one (271) patients with early gastric cancer from 26 different hospitals were examined in a retrospective study conducted by the I.S.C.G. (Italian Stomach Cancer Group). The patients were divided into two series: the first, comprising 234 patients with negative lymph nodes (Stage ITNM-UICC), had 5-year survival rates of 85%. The second group comprised 37 patients with positive lymph nodes (Stage III TNM-UICC) with a 72% five-year survival rate. Both results appear to be of great significance when compared with the five-year survival rate for advanced gastric cancer, namely 29.3%. As far as the difference between the late results of total gastrectomy and subtotal distal resection are concerned, the latter was associated with a higher five-year survival rate in the case of tumors located in the lower third and in the middle third of the stomach.