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Objective: The evaluation of innovative biomarkers of myocardial damage in the perioperative period.Methods: Twenty-four patients with gastric or colorectal cancer were studied and samples were collected for the measurement of myoglobin, troponin I (cTnI), creatine kinase isoenzyme MB (CK-MB), glycogen phosphorylase isoenzyme BB (GPBB), carbonic anhydrase III (CA III), fatty acid-binding protein (FABP), and CK presurgery and on the first, seventh, and thirtieth days post-surgery.Results: Troponin I values were unchanged throughout the study period. Myoglobin, GPBB, CA III, and FABP were significantly increased on day 1 after surgery. On the seventh day, GPBB, myoglobin, and FABP were still increased, whereas CK was decreased. Thirty days after surgery no significant variations were observed except a decrease of CK and CA III.Conclusions: These results show cTnI and CK-MB are unaffected by surgery, while the measurement of CA III, FABP, GPBB, and myoglobin might be unsuitable for diagnosing an acute coronary syndrome perioperatively. [ABSTRACT FROM AUTHOR]

Background: Intra-thoracic desmoid tumours with mediastinal invasion are very rare. Although rare they have to be taken into account in the differential diagnosis of a thoracic mass and therapeutic options have to be weighted since surgical treatment may require wide excision., Case Presentation: A 48-year-old male diabetic, dyslipidaemic, former heavy smoker with psychiatric illness was operated by sternotomy for a triple aorto-coronary bypass 4 years before, presented with complains of recent onset such as constant and oppressive chest pain. At surgery a mass extending from the aortic arch into the entire anterior mediastinum and to most of the right pleural cavity was found. The mass was separated from sternal periosteum and vessels of aorto-coronary by pass were isolated starting from the aortic arch up to the pericardium. The histological examination revealed aggressive fibromatosis., Conclusion: Although technically demanding, radical surgical excision is actually the most indicated therapeutic approach for intra-thoracic desmoid tumours.

Background: This study analyzed the impact on long-term results of an increase in the dosage of an induction chemoradiotherapy protocol for squamous cell carcinoma (SCC) of the thoracic esophagus., Methods: Two groups were considered among 177 patients who underwent preoperative chemoradiotherapy for SCC of the thoracic esophagus. Group A includes 111 patients (from 1987 to 1995) who were submitted to cisplatin and 5-fluorouracil (two cycles) and radiotherapy (3,000 cGy). Group B includes 66 patients (from 1995 to 2002) in which the doses were raised both in terms of chemotherapy (three cycles) and radiotherapy (5,000 cGy)., Results: The induction treatment was completed in most of the patients (92.1%) with an acceptable treatment-related mortality (2.6%). Surgery was accomplished in 148 patients; 78.4% and 92.4% in groups A and B, respectively (p = 0.015). The postoperative in-hospital mortality was 8.8%. Tumor resection was possible in 91.8% with a better R0-resection rate for group B (83.9%; p = 0.004). Responders represented 34.9% of the patients with 20.1% of "complete" responses (29.5% in group B; p = 0.018). The overall 5-year survival rate was improved in group B (30.2%; p = 0.017), and when survival analysis was restricted to responders (70.1%; p = 0.027)., Conclusions: No differences in feasibility and complication rate were observed during the two study periods. A higher rate of R0-resections was achieved in group B. The increased dosage led to an increased rate of complete responses and to an improved overall 5-year survival.

Aim: To present a case of acute mesenteric and portal vein thrombosis treated with thrombolytic therapy in a patient with ulcerative colitis in acute phase and to review the literature on thrombolytic therapy of mesenteric-portal system. Treatment of acute portal vein thrombosis has ranged from conservative treatment with thrombolysis and anticoagulation therapy to surgical treatment with thrombectomy and/or intestinal resection., Methods: We treated our patient with intraportal infusion of plasminogen activator and then heparin through a percutaneous transhepatic catheter., Results: Thrombus resolved despite premature interruption of the thrombolytic treatment for neurological complications, which subsequently resolved., Conclusion: Conservative management with plasminogen activator, could be considered as a good treatment for patients with acute porto-mesenteric thrombosis.

Objective: We sought to compare the experience of 2 different surgical units in the treatment of hepatocellular carcinoma (HCC) on cirrhosis with resection or percutaneous radiofrequency ablation (RFA), respectively., Summary Background Data: When allowed by the hepatic functional reserve, surgery is the therapy for HCC on cirrhosis; alternative treatments are proposed because of the high tumor recurrence rate after resection. RFA is being widely adopted to treat HCC., Methods: Over a 4-year period, 79 cirrhotics with HCC underwent resection in 1 surgical unit (group A) and another 79 had RFA at a different unit (group B). Patient selection, operative mortality, hospital stay, and 1- and 3-year overall and disease-free survival were analyzed., Results: Group A (surgery): mean follow-up was 28.9 +/- 17.9 months; operative mortality was 3.8%, mean hospital stay 9 days; 1- and 3-year survival were, respectively, 83 and 65%. One- and 3-year disease-free survival were 79 and 50%. Group B (RFA): mean follow-up was 15.6 +/- 11.7 months. Mean hospital stay was 1 day (range 1-8). One- and 3-year survival were 78 and 33%; 1- and 3-year disease-free survival were 60 and 20%. Overall and disease-free survival were significantly higher in group A (P = 0.002 and 0.001). The advantage of surgery was more evident for Child-Pugh class A patients and for single tumors of more than 3 cm in diameter. Results were similar in 2 groups for Child-Pugh class B patients, Conclusions: RFA has still to be confirmed as an alternative to surgery for potentially-resectable HCCs.

Background: Comparison among different studies regarding adenocarcinoma of the cardia has been difficult since the Siewert classification was introduced. This study analyzed the experience of a single institution in the treatment of gastric cardia cancer with the aim of assessing principal prognostic factors and long-term outcome., Methods: The results of 96 patients who underwent resection with curative intent for gastric cardia cancer at the First Division of General Surgery, University of Verona, from January 1988 to February 2000, were analyzed statistically with special reference to Siewert type., Results: Despite a high number of curative resections (85.4%), the 5-year survival rate was poor (24%) for all Siewert types (p = 0.8), and for early tumors (51%) also. Chance of cure was limited to pN0 and pN1 patients. Multivariate analysis showed that microscopic or macroscopic residual tumor and pN-positive categories had a significantly higher risk of death (risk ratio, 2.18 and 2.68, respectively) and the pN2 and pN3 category had the most negative prognostic factor (risk ratio, 7.6)., Conclusions: The long-term prognosis for gastric cardia cancer remains poor and is independent of Siewert type, with cure limited to pN0 and pN1 patients.

Background: Lymph node metastases are present in only about 15% of patients with early gastric cancer (EGC) and for this reason, the majority of these patients do not require lymphadenectomy. In Japan, EGC patients undergo less invasive treatment (endoscopic mucosal resection, wedge resection, laparoscopy). However, the indications for and results of these types of treatment are still uncertain., Methods: In a multicentre retrospective study, we analysed the clinicopathological data referring to 584 early gastric cancer patients who underwent D2 gastrectomy. A comparison was made between patients with and without lymph node metastases in relation to numerous pre- and postoperative variables. Long-term survival and risk factors for lymph node metastases were analysed. The primary aim was to compare our results with those of Western and Japanese authors; we also evaluated the possibility of identifying a subset of patients at low risk of lymph node metastases who may be candidates for endoscopic treatment., Results: The incidence of lymph node metastasis was 14.4%. Univariate and multivariate analyses showed that submucosal infiltration, diffuse histotype, tumour size and Kodama Pen A type were all related to the presence of lymph node metastases. Patients with types I, IIa and IIb mucosal tumours did not present lymph node metastases. Postoperative mortality was 2.2%. Five-year survival in relation to lymph node groups was 95% in N0 patients, 77% in N1 patients and 60% in N2 patients (p = 0.0001, Japanese N-stage). The number of positive lymph nodes also had a prognostic value. Patients with three or fewer positive lymph nodes presented a better 5-year prognosis (83%) than those with more than three positive lymph nodes (48%) (p = 0.0001)., Conclusions: Our study confirms that lymph node involvement is an extremely important prognostic factor. For this reason, the therapeutic strategy of our surgical units is as follows: 1) D2 gastrectomy is the standard treatment even in early gastric cancer (EGC); 2) endoscopic mucosal resection (EMR) could be considered first in types I, IIa and IIb tumours that are diagnosed as limited to the mucosal layer.

BACKGROUND: Perigastric lymph node metastases in gastric cancer are classified differently by different staging systems: the distance of positive nodes from the primary tumor is considered by the 1987 International Union Against Cancer (UICC)-TNM system, but not by the Japanese staging system (of the Japanese Research Society for Gastric Cancer [JRSGC]); the new UICC-TNM system of 1997 is based on the number of involved nodes without differentiating perigastric from regional nodes. The aim of the present study was to assess which classification was more useful to predict prognosis in gastric cancer patients with metastases to the perigastric nodes.METHODS: The results for 107 patients with lymph node metastases to the first and second tiers who underwent curative gastrectomy for gastric cancer from March 1988 to October 1997 were analyzed. In particular, we compared the clinical characteristics and the survival probabilities of: (1) patients with metastases to perigastric nodes located within 3 cm from the primary tumor, classified as N1; (2) patients with metastases to perigastric nodes located 3 cm beyond the primary tumor (N2 in the UICC-TNM and N1 in the Japanese classification), classified by us as N1-N2; and (3) patients with metastases to the second tier (classified by us as N2). We also assessed the number of positive nodes dividing the patients into groups according to the 1997 UICC TNM system.RESULTS: On multivariate survival analysis, the mortality risks in the N1 and N1-N2 patients were comparable (relative risk [RR], N1-N2 versus N1, 1.32; 95% confidence interval [CI], 0.53-3.51) and were half the mortality risk in N2 patients (RR, N2 versus N1, 2.52; 95% CI, 1.33-4.79). The N1 and N1-N2 categories, while presenting markedly different distributions in the number of metastatic nodes (patients with more than seven metastatic nodes constituted less than 20% of the N1 group and more than 60% of the N1-N2 group), showed similar prognostic significance.CONCLUSION: In the present series, the distance of perigastric nodes from the primary tumor did not seem to exert a significant effect on prognosis, and the use of a combined classification based on anatomical location (JRSGC) and number of node metastases (UICC-TNM 1997) could be more useful than either system alone for prognostic purposes.

BACKGROUND: Precise knowledge of the abdominal nodal spread of cardia adenocarcinoma in relation to the depth of invasion of the tumor and its longitudinal extension may be very important for the surgeon as a guide in choosing the type of resection and lymphadenectomy.METHODS: The frequency of node metastases in each abdominal station of the first and second tier was prospectively studied in 101 patients with type II and III cardia cancer (defined as approved by the consensus conference held during the second International Gastric Cancer Conference in Munich in April, 1997) who underwent total gastrectomy with D2 lymphadenectomy during the period January 1994 to April 1998. Lymph nodes were retrieved immediately after operation by the surgeon and assigned to the appropriate station according to the classification of the Japanese Research Society for Gastric Cancer.RESULTS: In early gastric cancer, of both type II and type III, lymph node involvement was limited to the perigastric nodes of the upper half of the stomach and to the lymph node station of the celiac trunk. In advanced cancers, whether of type II or type III, there was a fairly high frequency of metastases to the perigastric nodes of the lower half of the stomach; there was also high frequency of metastases at N2 stations, without differences in frequency between pT2 and pT3 tumors (staged according to the classification of the Japanese Research Society for Gastric Cancer).CONCLUSIONS: The results of our study provide evidence for the need to perform a total gastrectomy with D2 lymphadenectomy in all patients with advanced cardia cancer type II or type III. In early cancers, a less extensive resection (proximal gastrectomy) with D2 lymphadenectomy may be indicated.

From June 1987 to March 1992, 70 patients with squamous cell carcinoma of the esophagus were entered into a treatment protocol that included a preoperative course of radiotherapy (3,000 cGy) and chemotherapy (cisplatin and 5-fluorouracil). The preoperative therapy was well tolerated. Forty-nine of these patients underwent esophageal resection (total or subtotal) and 6 patients died subsequently (12.2%). The morbidity was not dramatically affected by preoperative treatment. Histopathologic studies showed no residual disease in the resected specimen of 11 patients (19.2%), only some residual microscopic clusters of neoplastic cells in 8 patients (14%) and macroscopic cancer in the remaining patients (66.8%). The estimated overall Kaplan-Meier survival at 1, 2, and 3 years was 53.6%, 28.6%, and 21.5%, respectively. Our study, like other reports, demonstrates an improved survival in the group of patients who had a complete response after radiotherapy or chemotherapy (p = 0.002). Moreover, the lack of diagnostic procedures to evaluate the presence of residual tumor after radiotherapy and chemotherapy, suggests that only surgical resection can provide an accurate prognostic information and a complete treatment.

We have systematically reviewed the literature concerning iatrogenic chylothorax and shall report our personal observations on the subject. Despite an increasing number of thoracic operations, injuries to the thoracic duct are infrequent. Cardiovascular and esophageal procedures are the most frequent causes of chylothorax. Malformations of the thoracic duct and other organs of the mediastinum have often been involved in lymphatic injury. Consequently, we believe that a complicating chylothorax may result from varied causes rather than solely from a surgical error.