Search

To investigate the role of oxygen free radicals in hepatocellular carcinoma we assayed tissue scavenger enzymes (superoxide dismutase and selenium-dependent glutathione peroxidase) in liver homogenate, plasma concentrations of vitamins A and E and the serum selenium level from 19 control patients, 23 cases of hepatocellular carcinoma and 18 cases of metastases to liver from different carcinomas. In hepatocellular carcinoma tissue the enzyme activities were all significantly lower than in control liver and in metastases-bearing liver; the enzyme activities of the latter tissues were not different from control liver. In contrast, normal liver adjacent to the hepatocellular carcinoma had decreased activity of superoxide dismutase. Serum selenium concentrations were significantly decreased in patients with hepatocellular carcinoma and those with liver metastases, while vitamin A was significantly decreased only in the former. These findings suggest that hepatocellular carcinoma develops in liver with severe impairment of cellular antioxidant systems, since, in patients with liver metastases from different cancers, despite low selenium concentrations, cellular scavenger enzymes have normal activities.

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.

Our personal series of 20 cases of focal nodular hyperplasia (FNH) of the liver is presented. All lesions were studied with computed tomography (CT), 16 of which with surgical control. Retrospective evaluation of the CT features of the identified FNH, along with those of five hepatocellular adenomas (HCA) and 30 hepatocellular carcinomas (HCC), allowed the definition of specific patterns leading to a correct characterization of FNH in 78% of cases. This greatly reduced the diagnostic errors, with the sole exception of patients with fatty liver in whom nuclear medicine may eventually provide a correct characterization. Fine-needle biopsy is thus only necessary in the dubious cases. A precise diagnostic workup of FNH is necessary, since it may avoid the surgical intervention.

The authors present their experience with 5 biliary cystadenomas (BCA) and 1 cystadenocarcinoma (BCAC). BCA are rare but intriguing lesions of the liver for the possibility of the former to evolve into malignant lesion. Preoperative diagnosis is often difficult also at ultrasound and CT scan. The possibility of BCA and BCAC should be always ruled out in every cystic lesion of the liver. In every doubt lesion surgical exploration is indicated and at least a biopsy should be performed. The procedure of choice for BCA is radical resection, while palliative procedures may be justified only in poor risk patients.

The development of major hepatic resective surgery during the last 50 years is due to a better knowledge of both hepatic regenerative capacity and intraparenchymal vascular and biliary anatomy. Two approaches of major hepatic resection have been described: 1) primary hilar approach; 2) primary transparenchymal approach. The authors review the indications of major hepatic resections in the treatment of hepatic tumors and discuss the advantages and the disadvantages of primary hilar and primary transparenchymal approaches, reviewing the data from the literature and the experience gained at the Clinica Chirurgica of the University of Verona from 1970 to 1989 of 289 major hepatic resections.

Obstacles of vascular type may hinder or prevent pancreatic destruction for tumours of the pancreas or periampullary tumours. Out of 72 major pancreatic demolitions (cephalic duodenopancreatectomy or subtotal pancreatectomy from rt to lt) there were vascular difficulties on 26 occasions (36%), of which 15 were in existence prior to development of the neoplasia (anomalies of rise and course of peripancreatic vessels, stenosis/obliteration of the common hepatic artery in pancreatic head or periampullary tumours) and 11 due to tumoral growth (direct involvement of the mesenteric-portal tract, the hepatic artery and the superior mesenteric artery). The technical solutions used are discussed individually in the light of the physiopathological repercussions consequent on any temporary or permanent interruption of important hepatic and splanchnic vascularisation vessels (hepatic artery and various mesenteric a.), in relation to operating mortality and the prospects of long-term survival. In the most complex cases of direct vascular involvement by the neoplasia, the Author's trend was orientated to a position which, while accepting demolition decisions useful for the widening of the surgical radicality margins, nevertheless avoids extensive demolition solutions imposed by conditions of necessity or considerations of principle that probably do not bring significant advantages as regards long-term prognosis for these tumours.

The authors describe one case of cystadenoma of the bile ducts removed by left hemi-hepatectomy. They stress the importance of a complete angiographic examination, both in the arterial and in the venous return phase, for diagnostic purposes and correct planning of the surgical procedure.

The authors describe their experience in 23 cases of biliary tract drainage by the transhepatic-percutaneous approach in the course of obstructive jaundice of diversified origin. This can be done for essentially three reasons, namely to alleviate jaundice preoperatively, to provide permanent bile drainage in patients not amenable to surgery, and to relieve excess pressure in surgical anastomoses of the biliary passages. On the basis of biological considerations (relationship between severity and duration of cholestasis on the one hand and postoperative mortality and morbidity on the other), and in light of their own results, the authors argue in favor of this procedure, explaining that it is only mildly traumatic to the patient, easy to perform, attended by a low quota of complications, and above all effective as a drainage; also, it does not unduly prolong the preoperative period for patients scheduled for further and major surgery. Also in view of the current role of PTC in the diagnosis of obstructive jaundice, they submit that transhepatic-percutaneous drainage should be done right next to recognition of dilatation of the intrahepatic bile passages by CAT or echotomography.

The authors discuss the main features of the complex pathophysiology of patients subjected to duodenocephalopancreatectomy, and particularly the difficulties inherent in clinical assessment of the digestive and metabolic impairment consequent upon the duodeno-gastro-pancreatic mutilation. Out of a total of 57 cases of this description, they singled out for recheck 23 patients who had undergone duodenocephalopancreatectomy not less than six months and not more than seven years before (chronic pancreatitis, 11 cases; various malignancies of the periampullar area, 10 cases; Zollinger-Ellison syndrome, 1 case; retroperitoneal lymphoma, 1 case). Seventy-six per cent of patients who had been gainfully employed were able to resume their jobs after surgery. Steatorrhea, assessed in terms of fecal fats, was present in all cases; notwithstanding, 70% of the patients gained weight (average increase 7 kg). All patients were on enzyme replacement therapy. Only 4% developed diabetes, and none developed postoperative peptic ulcers. Conversely there was a high incidence (65%) of bone structure reshuffling, signally osteoporosis, probably imputable to steatorrhea and vitamin D malabsorption, plus the often associated increase of serum alkaline phosphatase activity.

In 12 normal subjets we studies the effects of beta-adrenergic stimulation (Salbutamol, 500 microgram inhaled) on the closing volume (CV) and the closing capacity and on the ratios of these indexes to the vital capacity (VC) and the total lung capacity, respectively. CV and CV/VC % increased in ten subjects wereas it decreased in two subjects. On an average, the changes were small but significant (p less than 0.01) and could be duplicated in four subjects. Similar studies have yielded variable results. The reasons for those variation could be attributed either to technical or/and individual differences in the resulting effect of beta stimulation on respiratory mechanics.

In this paper the Authors describe two cases of carcinoma of the lung with cavitary aspects that came under their observation. There are various hypotheses on the formation of such cavities: it is possible that the neoplastic cells may have a growth trend in a centrifugal direction, or that the cavity is due to a necroic-colliquaive process of the mass itself or to extensive phenomena of autophagism. In other cases the neoplastic cells carpet already existing air cysts, giving the appearance of thin wall cavitation. It is precisely this type of cavitation that poses problems of differential diagnosis. In fact, when other instrumental investigations such as bronchoscopy or needle biopsy, always combined with cytology of the sputum, are not decisive, a relatively certain diagnosis can be obtained only by observing the evolution of the picture for some time, as was the case in the patients referred to above.

The Authors compare two groups of patients suffering from obstructive jaundice due to neoplasia of the head of the pancreas or the terminal bile duct who undergo bile drainage by means of cholecystostomy via the percutaneous transhepatic route, in order to reduce icterus, and subsequently undergo a duodenocephalopancreatectomy. The two groups are then compared with a third group in which duodenocephalopancreatectomy was performed without a preoperative reduction in the jaundice. The decrease in bilirubin and alkaline phosphatase, the drainage period, the nature and length of the post-operative course and the average total hospitalisation period are analysed. Whereas the recovery of hepatic function is comparable in the three groups, in the group undergoing percutaneous transhepatic bile drainage the post-operative course is decidedly better (lower morbidity and a shorter period of hospitalisation).

Personal experience of 135 operations on the left colon and the rectum, with simultaneous formation of decompressive transversotomy, is presented. According to the Authors, decompressive transversotomy is the sole method capable not of avoiding anastomotic dehiscences, but of ensuring that they do not become clinically manifest, and hence of reducing the mortality connected therewith. The doubts sometimes raised with regard to the method seem in the Authors' opinion to be linked to technical shortcomings in performance of the transversotomy itself.

Percutaneous transhepatic cholangiography (PTC) has come back into greater use thanks to Chiba's needle. PTC, however, is useful only in obstructive jaundice (OJ). Since in OJ the dilatation of the intrahepatic biliary tract (IHBTD) is constant, the authors discussed CTs reliability in evaluating IHBTD in a series of 33 patients with OJ studied with PTC. The threshold of CT diagnosis of IHBTD was found to be equal to a doubled caliber of the normal biliary tract. This value is reached by 85% of the patients 2 weeks after the onset of OJ and in 98% between 2 and 3 weeks. CT is therefore usable as a screening method of PTC, as long as it is not performed before 2 weeks after the onset of OJ. After 2 weeks, if CT does not reveal IHBTD, it is possible to exclude OJ.

Sixteen patients underwent repeated hepatic resections over a 16 year period. The cases were divided into two groups: group A, non-planned repeated resections (14 cases), and group B, planned repeated resections (two cases). Group A is composed of patients requiring re-resection as a result of the hepatic re-recurrence of the neoplasia (three hepatocellular carcinomas, nine metastases from colorectal carcinoma, and two metastases from carcinoid tumor). Group B is composed of two cases (hepatocellular carcinoma and metastases of leiomyosarcoma) where the extent of the disease was incompatible with radical resection in a single time thus making necessary to plan for repeated operations. The need for correct preoperative assessment of hepatic performance using CT, US and Tc 99m HIDA scan, as well as intraoperative ultrasonography is stressed.

6 cases of solitary angioma of the liver, treated with major hepatic resections, are presented (2 rt hemihepatectomies - 2 lt hemihepatectomies - 1 lt lateral sect. and 1 segmentectomy of the VIth). Their anatomopathological definition (solitary angioma, multiple angiomas, hemangiomatosis) is discussed in relation to the various therapeutic possibilities. From the diagnostic standpoint, an outstanding part is played by angiography. In addition to demonstrating the presence of hepatic mass, C.A.T. can, according to their experience, also allow diagnosis of quality on the basis of demonstration of vascular lacunae. It is considered that the treatment of choice of for solitary angiomas is surgery, which must be performed by skilled surgeons and consist in hepatic resections conduced by typical route. This is especially true for the giant forms, owing to their particular tendency to growth and spontaneous rupture. For small angiomas it is considered better in principle to remove them, generally by small cuneiform resections, unless they are situated in sites difficult to attack surgically and with high risk. In this case frequent check-up is necessary since, although they are sometimes found to be stationary and even in exceptional cases regressive, personal experience (2 cases) has demonstrated a tendency to expansion.

Twelve adults with hepatocellular carcinoma (HCC) and 8 individuals with histologically normal liver, were measured for serum selenium concentration and glutathione peroxidase (GSH-Px) of liver tissue. It was found a reduced serum selenium and liver GSH-Px in patients with HCC. Serum selenium concentration and the enzyme activity were positively correlated (p less than 0.01). The increased risk of carcinoma in selenium deficiency may be partially due to a reduced activity of GSH-Px, one of the most important scavenger enzymes of oxygen toxic radicals.

The authors report a case of bilemia of their own--with traumatic genesis--complicated by liver abscess, treated through outside biliary drainage and piloted transhepatic percutaneous drainages along the line of the echotomography and computerized axial tomography (T.A.C.). They report the treatment adopted, and emphasize the importance of the instrumental methods followed in the diagnostical and therapeutical approach of both diseases.

Survey of 18 cases of cancer in the Papilla of Vater, which were observed during the years between 1971 and 1979 at the Surgical Clinic of Padua University - Seat of Verona - with particular regard to the diagnostic means and their reliability. The histological investigations gave the following results: All lesions were found to be adenocarcinomas; 6 cases well differentiated, 4 cases fairly well differentiated, 2 cases little differentiated, 3 cases indifferentiated. The following operations were carried out: 15 Duodenopancreatectomies, 3 Internal derivations of the biliary flow, one of which associated with gastroenteroanastomy. Of all the patients who underwent to the radical operation, 1 survived 3 years after the operation, and then was lost to the follow-up, 2 were surviving 19 months after the operation, 2 were surviving 12 months after the operation, 1 was surviving 10 months after the operation, 1 died 18 months after the operation, 7 died between the 2nd and the 12th month after the operation, 1 died in the postoperative period. Of those patients who underwent the palliative operation, none survived longer than one year.

The Authors report their experience regarding two primitive tumours of the confluent and one tumour of the gall bladder involving the biliary confluent, all treated by major hepatic demolitions--one left hemihepatectomy and two extended right hemihepatectomies--with removal of the biliary tree en bloc and appropriate reconstruction. These highly demolitionary operations were performed with the aim of achieving greater radicality. The indications for such type of operation, dictated by notions of tumoral biology and reasons of surgical technique, are discussed. The Authors make a comparison of their experience with the data obtained from literature, which up to now reports only twenty-two; no statistical judgment on the effectiveness of the method is therefore possible, even if the results obtained and the theoretical presuppositions would seem to confirm its validity.

The diagnostic findings of hepatocellular adenoma and focal nodular hyperplasia became more frequent in the last years in our as in western experience. The improvement in diagnostic technique, a correct pathological identification and the diffusion of oral contraceptives explain this increase of incidence. In our series were present 11 hepatocellular adenomas and 19 focal nodular hyperplasias: all the HCA cases were radically resected, while only 15 FNH were resected, only two biopsied and two submitted to periodical follow-up. The tendency to spontaneous bleeding and the presence of diagnostic uncertainty versus well-differentiated hepatocellular carcinoma are mandatory indications for radical resections in all the HCA cases. FNH resection is reserved to symptomatic cases and wide wedge biopsy is at least required in presence of diagnostic doubts: the asymptomatic FNH ("hot spot" on Tc99m-HIDA scintigraphy) may be followed-up only.

The present study deals with the natural history of 37 asymptomatic patients with cirrhosis and hepatocellular carcinoma, 25 with 2-9-cm tumors who were not surgically treated (first group) and 12 with tumors smaller than 4 cm who underwent resection (second group). All patients were in Child's A class. Two-year survival (according to life-table analysis by the Kaplan-Meier method) was 50% in the first group and 39% in the second group. This difference was not significant. In the first group no relation was found between survival and initial tumor size or alpha-fetoprotein levels. Ultrasound examinations at 3-mo intervals revealed the following patterns of tumor growth: (a) no significant growth during the follow-up (9 patients); (b) significant growth (tumor size at least doubling) only in the final stage of the disease (11 patients); (c) initial significant growth followed by a period of no increase in size (5 patients). These findings show that in our geographical area (a) 2-yr survival of untreated asymptomatic patients with hepatocellular carcinoma associated with cirrhosis does not differ from that of similar patients undergoing resection and (b) the tumor can exhibit long periods of no growth alternating with periods of exponential growth.

The presence of tubercle of Zuckerkandl (TZ) of the thyroid gland has been investigated in 20 specimens obtained from patients died from diseases not concerned to the cervical area. The project mas undertaken to elucidate the presence and the role of TZ as normal anatomical landmark. Special attempt has been paid to the relationships of the TZ with parathyroid gland and recurrent laryngeal nerve and the branches of the inferior thyroid artery. The tubercle was constantly found on the postero-medial surface of the thyroid lobe which showed constant relations with the branches of the inferior thyroid artery, superior parathyroid gland and recurrent laryngeal nerve. The outcomes of this preliminary report prove that TZ is an useful anatomical landmark to detect both superior parathyroid gland and laryngeal nerve in thyroid surgery.

The Authors' aim was to assess the effectiveness of Sequential Scintiphotography of the Liver with 99mTc-HIDA (SSFH) in the evaluation of post operative jaundice, in operations of biliary derivation (43 observations in 28 patients). SSFH proved to be highly reliable even in comparison with more laborious procedures (such as Transhepatic Cholangiography), and superior to equally simple procedures such as Echo Tomography and Computerised Tomography, evidencing itself as the investigation of choice for the study of this pathology, especially in long-term follow-ups.

The Authors report their own casuistry of malignant tumours of exocrine pancreas, collected in the period from 1970 up to 1981. The question was of 214 cases, namely 136 of head and 78 of body-tail or diffused. The male/female ratio was 2.3:1, the most affected decades were 6th and 7th, with a range of 27-86 years. The resecability was 27% for tumours of head and 24% for those of tail; the operative mortality was 10.8% and 17.6% respectively; the survival after 3 years was 6.8% (head) and 5.8% (body-tail), after 5 years 6% (head) and zero (body-tail). In analysing the etiopathogenetic rôle of some factors and some pathological associations, the Authors particularly point out the predisposing rôle of both tobacco smoke and diabetes, remarked in 50% and 33% of the cases observed, respectively. From a symptomatologic standpoint, the symptoms are subdivided into initial symptoms (retrospectively interpreted as first manifestation of the disease), symptoms of alarma (leading to the attending physician's), symptoms at the entrance (hospitalization), and importance is given to the exploitation of the initial symptoms for the purpose to reach a diagnosis as precocious as possible, since 40% of the tumours of head are hospitalized only after 8-16 weeks and 33% of the tumours of body-tail after 16-32 weeks from the arising of the first symptom.

The use of immunohistochemistry and radioimmunological assay of the pancreatic polypeptides in the plasma has contributed substantial advances to the histophysiopathology and preoperative diagnosis of tumours of the endocrine pancreas and the related functional syndromes. Consequently, in addition to furthering knowledge on clinical pictures already known for some time, it has been possible to define new categories of the disease which were previously misunderstood or confused with others. The physiopathology and diagnostic methodology (clinical, biohumoral and instrumental) of each main known syndrome (insulinoma, Zollinger-Ellison Syndrome, Verner-Morrison disease and glucagonoma) are described in detail; there are notes on hormonal syndromes that are not fully known and which constitute a field of research in evolution (pluriendocrine and carcinoid syndromes, polypeptidoma, somatostatinoma, nesidioblastosis). The problems of preoperative preparation, intraoperative diagnostic tactics and surgical technique are illustrated. Lastly the possibilities of alternative therapeutic treatment are outlined.

To evaluate the prognostic value of serum copper (S-Cu) and ceruloplasmin and their pathophysiologic significance in human hepatocellular carcinoma (HCC), we studied 49 patients with HCC (20 of which were submitted to partial hepatectomy) compared with 110 patients with liver cirrhosis. In HCC both S-Cu and ceruloplasmin were higher than in cirrhosis; moreover, S-Cu was correlated with the extension of HCC, evaluated by instrumental data and by surgical inspection. In cirrhotic patients, mean S-Cu was 122.9 micrograms/dl (SD, 29.3), in early HCC, 153.0 micrograms/dl (SD, 34.5), and in advanced HCC, 193.1 micrograms/dl (SD, 37.7). Variance analysis gave F = 59.4. In HCC patients S-Cu was positively correlated with ceruloplasmin and with fibrinogen. Survival, evaluated by Mantel's test stratified for surgical therapy, was longer in patients with S-Cu levels lower than 175 micrograms/dl and in those at an earlier stage. We therefore conclude that S-Cu has a relevant diagnostic value in detecting HCC also in early stage and allows prognostic evaluation as regards survival.