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To compare extensive with limited lymph node dissection in the surgical treatment of gastric cancer, 320 patients undergoing gastric resection during 1981-1990 were divided into two groups. Although patients undergoing extended lymphadenectomy (n = 157) had a longer operating time (P = 0.0001) and a greater intraoperative blood transfusion requirement (P = 0.009) than those receiving limited dissection (n = 163), the incidence of postoperative complications (22.3 versus 28.2 per cent, P = 0.13) and the hospital mortality rate (3.8 versus 7.4 per cent, P = 0.12) were similar in the two groups. The 5-year survival rate after curative resection (117 and 121 patients after extensive and limited lymph node dissection respectively) was 65.4 versus 50.1 per cent (P = 0.01): 85.9 versus 82.2 per cent for stage I disease (P = 0.60), 66.1 versus 57.8 per cent for stage II (P = 0.82) and 48.7 versus 29.8 per cent for stage III (P = 0.02). Multivariate analysis using the Cox model showed that the extent of lymphadenectomy was an independent prognostic factor for survival (P = 0.01). The results support the value of extensive lymph node dissection in the surgical treatment of gastric carcinoma.

Lymph node involvement in colorectal cancer, one of the most important prognostic factors, can be sometimes underestimated. In this study the authors report the results of two different techniques of specimen preparation and examination. In 240 patients (Group I), histologic examination was performed using a conventional procedure. In Group II (60 cases) the resected bowel and its mesentery were separately stretched, pinned on to a cork board, and fixed. The mesentery was divided according to node location (intermediate and principal) and evaluated by sight and palpation to identify lymph nodes. The bowel segment was divided from 5 cm proximally to 5 cm distally to the tumor every 10 mm in serial 3 mm slices. Three and 10 mm slices were then carefully examined by sight and palpation. Isolated lymph nodes embedded in groups (10-12 per paraffin block) were stained and investigated for neoplastic involvement. The specimen examination procedure used in Group II resulted in identification of a higher number of lymph nodes (mean = 41.1) and nodal metastases (mean = 10) compared to the standard technique used in Group I (mean = 11.3 and 2.4, respectively--P < .05). The percentage of N+ cases also was increased in Group II (48.3%) when compared to that in Group I (30.4%; P < .05). The new technique is simple, inexpensive, and efficacious for the detection of lymphatic metastases in colorectal cancer.

In our University, many different radiosurgical options are available to treat rectal carcinoma. Selecting the patients to submit to treatment requires accurate clinical and radiological staging. A team of radiologists, radiotherapists, surgeons, endoscopists and pathologists has been created to stage the patients and to follow the final results. The team have decided the diagnostic and therapeutic protocols. The patients with rectal cancer undergo radiotherapy after staging and are subsequently restaged. If indicated, surgery is performed and histology is compared with restaging, to assess the accuracy of the diagnostic procedures. All diagnostic and therapeutic decisions are made collectively by the team, during scheduled meetings. All data are stored in a computer program. This paper deals with the working method we used, its advantages and the outcome of the first 23 studied patients. Restaging was compared with histology: transrectal US (performed in 8 patients) showed 100% accuracy in evaluating local tumor spread (T). CT had 91% accuracy in defining T and 60% accuracy in N, with a tendency to overstaging. In 78% of patients > 50% reduction of tumor size was observed and the distance from the anal canal increased in 95.5%. This study will provide the overall accuracy of the clinico-radiologic staging, the survival rates and the indication of prognostic signs.

Intraoperative radiation therapy (IORT) was delivered to remnant rat liver after partial hepatectomy to determine the chronic effects of treatment on survival, blood chemistry, liver weight, and histology. Survival at one year was 100%. Remnant liver weight was markedly increased in all animals. Liver function appeared to be unaltered in all groups and at all observation times. Inflammatory cell infiltration occurred immediately after treatment in all animals, showing a slight progression until day 45; by day 180 the values had returned to baseline. Vascular changes were seen early in all groups, then progressively decreased; the vascular score was back to baseline at days 180 and 365. Nuclear alterations were observed in both irradiated and nonirradiated hepatic cells; in all cases these were limited to isolated or focal areas of hepatocytes. There was little fibrosis formation and by day 180 all scores were back to baseline. We conclude that the chronic effects of whole liver IORT after one-third hepatectomy are minimal in the rat and are similar to those observed after surgery alone.

A retrospective study of 103 thymectomies examines the effects of the integration of surgical and medical therapy in patients affected by myasthenia gravis accompanied by thymoma. An extended thymectomy via a median longitudinal sternotomy was used in 102 patients. The operative mortality was 4.85% (5/103 patients), the 10-year survival rate was 78% with a recurrence rate of 3.06% (3/98). Neoplastic infiltration and postoperative radiotherapy did not influence the survival rate. There was no correlation between a preoperative Osserman's class better than III and postoperative outcome. The improvement of medical treatment, and anaesthesiological and intensive care techniques resulted in a decrease of the operative mortality and long-term death rate during the last 10 years of our 20-year series. Extended thymectomy via sternotomy is the best intervention in patients with myasthenia gravis associated with thymoma judged by the low operative mortality and the favorable 10-year survival rates.

The Authors report their experience and a review of the literature on the "telescopic" pancreatojejunostomy following pancreatoduodenectomy. The alternative modalities proposed for the management of the pancreatic stump and their results are also described. Although no technique seems free from complications, the relatively low rate of anastomotic leaking (7.9%) encountered convinced the Authors to adopt this technique on routine basis.

Results of cultured islet transplantation in the management of insulin-dependent diabetes are still unsatisfactory. The main problem preventing success is the swift and resolute host immune rejection. To obviate this we designed and experimented a model of bioartificial pancreas, made of polymeric hollow fibers, put into the blood circulation as an artero-venous bypass to immunoisolate endocrine tissue from leucocytes and immunoglobulins. We tested four different membrane bioreactors (BR1-4). BR1 and 2 had seven hollow fibers, the others more than 6,000 smaller fibers. In BR4 a connecting tube with a high-permeability membrane was inserted between the islet compartment and the bioreactor outlet to improve the ultrafiltration flow. In vitro, the islets inside the bioreactor perfused with glucose solutions (300 mg%) showed a rapid, high insulin secretory response, related to the glucose stimulation. The use of the outside connection allowed a twofold increase of insulin production.

The use of pancreatic islet transplantation in membrane bioreactors put in vascular circuits aims at resetting the glucose homeostasis in diabetic or pancreatectomized patients, avoiding immune host rejection. Our experience was carried out at following stages: porcine pancreas explantation and enzymatic separation of endocrine tissue from exocrine fraction by collagenase; evaluation of islet functionality (culture tests); in vitro tests of the islets-bioreactor system, to assess the metabolic response to the glucose; in vivo evaluation to assay the haemodynamic behaviour. The trials showed a good metabolic bioreactor functionality and a decreasing incidence of coagulative problems.

A prospective randomized study was performed with 61 patients undergoing elective surgery for colorectal cancer, to evaluate the prophylactic effect of two different parenteral antibiotic regimens. All patients were randomly allocated into two groups, comparable in age, sex, nutritional status and operative procedures. The patients in Group A (n. 31) received 1 g i.v. of imipenem-cilastatin at induction of anesthesia. Patients in Group B (n. 30) were given cefuroxime (1.5 g i.v.) plus metronidazole (0.5 g i.v.) at the time of anesthesia and two other administrations of the combined antibiotics (cefuroxime 0.75 g plus metronidazole 0.5 g i.v.) every 8 hours. The severity of sepsis was evaluated according to the scoring system proposed by Elebute and Stoner. No significant differences were found in terms of the rate of surgical infections: 9% in Group A and 16% in Group B. Infections not of surgical origin were found only in Group B (10.4%). These data suggest that a single dose of intravenous imipenem-cilastatin appears to be as effective as three doses of cefuroxime and metronidazole as prophylaxis against infection in elective colorectal surgery.

The presence of epidermal growth factor, estrogen, and progesterone receptors (EGFR, ER, and PR) was investigated by a competitive binding assay in 43 colorectal adenocarcinomas and 32 normal colorectal mucosa specimens. EGFR were expressed in most of the tumor specimens analyzed at levels comparable with normal mucosa. There was no correlation between EGFR and tumor localization, tumor size, tumor stage, and grading. Among tumor specimens, 13.9% and 6.9% expressed very low but detectable ER and PR levels, respectively. No statistically significant difference was found between steroid hormone receptor levels in the tumor and normal mucosa specimens, and neither was there any correlation of ER and PR with the pathological findings. Our results suggest that the EGFR system may play a role in regulating the growth of colorectal tissues. Further studies should demonstrate whether, despite the lack of correlation with histopathological parameters, EGFR expression may have a biological significance in human colorectal cancer.

One hundred patients with pancreatic cancer were evaluated between March 1981 and December 1989. This study showed that 61 were not candidates for definitive surgery because of nonoperability (28 patients) or nonresectability (33 patients). An additional 25 patients had cancers that were unresectable because of metastases (13 patients) or local spread of disease (12 patients) discovered at laparotomy. Fourteen patients had resectable cancers. Ten were treated by total pancreatectomy, three by distal pancreatectomy and one by pancreatoduodenectomy (Whipple). There were two operative mortalities. The median patient survival time was 20.5 months. Two patients survived 5 years. Five patients are alive at 3, 14, 18, and 47 months. Palliative surgical procedures performed in 18 patients included 10 biliary bypasses, 9 gastrojejunostomies, and 6 T-tube placements. This was associated with an operative mortality rate of 11%. The median survival time was 5 months. Other palliative measures included endoscopic placement of biliary and pancreatic stents (47 patients, 2.7% mortality rate), endoluminal radiation therapy, interstitial radiation therapy and external beam radiation therapy. The median survival time of patients so treated was 4.5 months.

To clarify the risk factors contributing to postoperative complications in elderly patients undergoing total gastrectomy, 84 patients with primary gastric cancer were evaluated. Twenty-seven patients were older than 65 years of age; they had much more preoperative cardiac (P = 0.00003), respiratory (P = 0.0008), and multiorgan impairment (P = 0.009) than did the control group (age less than 65 yrs). Although overall morbidities (44.4% vs. 19.2%; P = 0.01) and overall septic complication rates (33.3% vs. 12.2%; P = 0.02) were higher in aged patients, no significant differences between the two groups were found in the incidence of major surgical complications (18.5% in aged patients vs. 10.5% in control groups; P = NS), serious septic (sepsis score greater than 10) complications (18.5% vs. 7.0%; P = NS) and hospital mortalities (11.1% vs. 3.5%; P = NS). In older patients the occurrence of multiorgan impairment and malnutrition was significantly related to postoperative complication rates. These results suggest that the degree of organ impairment rather than age is predictive of postoperative difficulty and should be used in assessing preoperative risk.

The clinical, laboratory, and pathologic data of 361 patients who had curative resections for colorectal cancers were collected and analyzed in a multiple stepwise regression model. In univariate analysis, among clinical factors, bowel obstruction and emergency surgery showed the most significant prognostic value (P = 0.002, P = 0.004, respectively). Vegetating growth, Astler-Coller stage of tumor, intramural spread, lymph node involvement, and synchronous liver metastases resulted in the pathologic variable significantly affecting the prognosis (P = 0.006, P less than 0.001, P = 0.036, P less than 0.001, P less than 0.001, respectively). In the multivariate analysis, stage was the predictive factor with the highest hazard ratio in conjunction with bowel obstruction (P less than 0.0001 in both cases). Processing data excluding stage ("multiparametric factor" itself), hepatic metastases, lymph node involvement, bowel obstruction, and intramural spread appeared as independent predictors of survival (P less than 0.0001, P less than 0.0001, P = 0.0004, P = 0.0316, respectively). Other variables, as biologic and molecular factors, should be more widely tested in order to assess their impact on prognosis.

In a consecutive series of 175 patients with gastric carcinoma, 66.8% underwent gastric resection: 74 total gastrectomies with R3 lymphadenectomy and 43 distal subtotal gastrectomies with R2 lymphadenectomy were performed. 73% (86 cases) of resective procedures proved to be "absolute curative" according to Japanese criteria (JRSGC). Nodal involvement was present in 62 out of 117 resected patients (52.9%): 29.9% N1, 9.4% N2, 13.6% N3; a significant relationship (p = 0.012) between depth of invasion of the gastric wall and lymph node metastases was revealed. The hospital mortality after R2-R3 gastrectomy was 4.2%, major surgical complications occurred in 6.8% of cases. The actuarial 5-year survival after curative resection was 59%. The results suggest that extended lymphadenectomy (R2-R3 gastrectomy) is justified in the surgical treatment of gastric cancer; this procedure can be safely performed and permits "absolute curative" resections in a remarkable percentage of cases.

Pancreatic abscess is a major cause of death from acute pancreatitis; its reported frequency is between 1.7 and 25 per cent of all patients presenting with acute pancreatitis. The mortality varies between 13 and 54 per cent. Despite apparently adequate initial surgical treatment, the recurrence rate is about 30 per cent. The key to survival in pancreatic abscess is adequate drainage of cavity. Proponents of open treatment claim that it allows better drainage of the viscid content of the pancreatic abscess which often cannot easily pass down a drain. In the present case, following laparotomy for severe intra-abdominal sepsis due to pancreatic abscess, the abdominal cavity was left open to heal by granulation. The procedure permitted early resolution of the septic process. Total parenteral nutritional support resulted in definitive wound healing. We regard laparostomy as a valuable technique in the management of pancreatic abscess; the successful of this technique hinges on expert nursing care and the capability of maintaining complication-free long term parenteral nutrition.

We studied the feasibility of delivering a large single dose of intraoperative radiation as an adjuvant to partial hepatic resection. Intraoperative radiation therapy (IORT) was delivered to the remaining liver of 84 rats after partial hepatectomy to determine the acute and chronic effects of treatment on blood chemistry values, histology, survival, hepatic regeneration, and cellular appearance of the normal liver. Transient elevations in SGOT, SGPT, and alkaline phosphatase were attributed both to hepatectomy and to liver parenchymal damage induced by IORT. Microscopic examination upon necropsy, performed at frequent intervals post-treatment revealed hepatic capsular thickening with some alteration of liver architecture mainly underneath the capsule, with localized inflammation and some areas of necrosis. Survival in all groups was 100% at 45 days. Liver weight increase proved to be dose-dependent and displayed a bisphasic pattern. This study demonstrated that IORT is a feasible adjunct to surgical resection of the liver in the rat model.

The performance of the ileal conduit (Bricker's operation) is a well and minutely known surgical procedure (choice of a particular ileal loop; uretero-ileal anastomosis; uretero-cutaneostomy); however we can still observe several and different details in the operative technique management. The Authors, on the basis of their own experience of 55 cases, and after a complete review of the literature, emphasize the technical controversies of ileal loop urinary diversion; moreover they analyze the technic changes previously pointed out be several Authors, to avoid surgical complications. They conclude that the ileal conduit urinary diversion shall have less complication if: 1) the ileal loop is a short one, but with a very good blood supply; 2) antireflex techniques are not used; 3) Brooke's technique is used in performing uretero-cutaneostomy.

Insulin adsorption to ethylen vinyl acetate, 3-liter bags injected with 10 insulin units, during 24-hr infusion has been studied. Three different infusions systems (A, B, and C) were tested and eight bags for each system were used. An elevated insulin adsorption resulted in each system. The maximal insulin recovery, expressed as percentage of the original theoretical 3333 microIU/ml insulin concentration, was 19.54% (at time 6), 20.93% (at time 4), and 16.95% (at time 22) for system A, B, and C, respectively. "Dismissed insulin amount" after 24-hr infusion was 1590 +/- 279.5 microIU, 1505.8 +/- 430.5 microIU, and 1253.3 +/- 369.8 microIU for system A, B, and C, respectively. Comparison of insulin concentration values at different times revealed significant differences only at time 18 (if compared with times 0,2.4,6,8,12,14,16) ant at time 20 (if compared with time 4,6,8,10) for system A, and at time 4 (if compared with time 12,14,16,18,20,22,24) for system B. We conclude that a constant but low insulin delivery can be achieved using 3-liter EVA systems and a 24-hr infusion.

Records of 38 consecutive patients affected by enterocutaneous fistulas were reviewed concerning etiology, site, management, results and prognostic factors. Thirtyfive fistulas resulted from surgical complications, 2 from Crohn's disease and one from pancreatic blunt trauma. Thirty (78.9%) out of 38 fistulas were treated successfully: 22 (57.8%) healed after nutritional treatment, 8 (21.3%) required definitive surgical repair. A significant difference (p = 0.007) in the incidence of medical closure was observed between upper gastrointestinal tract and small bowel fistulas (73.1%) and those located in the large bowel (25%). Large bowel fistulas required definitive surgical repair in 53.8% of cases. Eight patients died prior to fistula resolution; sepsis constituted the major cause of death. Results suggest that the treatment of enterocutaneous fistulas should include early control of infections and appropriate nutritional support. An earlier surgical approach for patients with large bowel fistulas is suggested.

Of 359 patients with colorectal cancer admitted over a period of about 11 years, 17 (4.7%) were 40 years of age or younger (group 1) and 342 (group 2) were older. In group 1 at the time of diagnosis, there were 9 men and 8 women; the average age was 34.2 years. Abdominal pain and diarrhea were the most common presenting symptoms. The average delay between onset of symptoms and treatment was 8.2 months (7.2 in group 2). Tumor stage at the time of diagnosis or at laparotomy was not more advanced than in group 2, the incidence of Dukes C lesions being 17.6% and 24.8%, and distant metastasis 17.6% and 18.7%, respectively. Analysis of tumor according to the stage (Astler and Coller classification), pelvic fat involvement, lymph node metastases and grading revealed no statistically significant differences between the 2 groups. The age factor had no impact on survival. It is concluded that in the present series, colorectal cancer in young patients differs in no respect from the disease in older patients.

The role played by the surgical route on the immediate post-operative course has been studied on the basis of personal experience of thymectomy for myasthenia gravis (75 operated cases). Time of respiratory assistance, pleuropulmonary complications, operative mortality and recourse to trachetomy were evaluted in two homogenous groups of patients thymectomized cervically (group I: 36 cases) or trans-sternally (group II: 39 cases). It is was found that the average duration of respiratory assistance was significatly less in the first than in the second group (it was often not necessary at all), pleuropulmonary complications were halved, tracheotomy was never indicated and operative mortality was nil. The cervical approach thus offers enormous functional advantages and devers a leading place in surgery of the thymus; it would appear to be contraindicated only in the presence of radiologically evident thymomas and at times in cases where tracheotomy has been performed previously.

In order to assess the significance of malnutrition in determining surgical complications and the possibility of their reduction by preoperative nutritional support (PNS), a randomized controlled trial is being performed at our institution. The results relative to 100 patients who underwent major surgery for gastrointestinal disease, are presented here. In the treatment group 49 patients received 30 kcal/kg/day and 200 mg/kg/day of nitrogen for at least 7 days in the immediate preoperative period (nine patients were excluded from this group due to early surgery--seven cases; or refusal to accept PNS--two cases. Data analysis with their inclusion or exclusion showed similar results.) Fifty-one patients constituted the control group. The observed septic complication rate was, respectively, 30 and 35.3% (p:NS). When the analysis was restricted to the patients with abnormal instant nutritional assessment (INA), as defined by Seltzer et al (serum albumin less than 3.5 g/dl and/or total lymphocyte count less than 1500 cells/mm3), a statistically significant difference was observed in the incidence of sepsis between the two subgroups (21% vs 53.3%, p less than 0.05). Analogous results were obtained from the patients who underwent gastrectomy for gastric cancer: 16.7% of septic complications in the malnourished treated patients and 100% in the malnourished control ones (p less than 0.05). The occurrence of serious sepsis (sepsis score greater than or equal to 10, according to the scoring system developed by Elebute and Stoner) in the malnourished subgroups was 5.2% and 26.7%, respectively, (p = 0.09). The postoperative mortality rate was not significantly changed by the PNS (reduction from 3.9% to 2.5%, p:NS).(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective randomized study was performed with 65 patients undergoing elective surgery for colorectal cancer, to evaluate the prophylactic effect of two different parenteral antibiotic regimens. All patients underwent rigorous mechanical cleansing of the bowel (enemas, laxatives), received low-residue diet 3 days pre-operatively, and were given oral metronidazole (250 mg) five times a day for 3 days preoperatively. They were divided into two groups comparable in age, nutritional status and operative procedure. The patients in group A (36) received 2 g i.v. of cefotetan at induction of anaesthesia and two other administrations every 12 h. Patients in group B (29) were given clindamicin (600 mg, i.v.) at induction of anaesthesia plus aztreonam (1 g, i.v.); two other doses of the same combined antibiotics were administered every 8 h. Five patients were excluded from the study because they underwent Miles procedure; two others because they underwent explorative laparotomy only. The overall incidence of post-operative septic complications was 6.9% (4/58). No significant differences were found in terms of the rate of surgical infections: 3.1 in group A (1/32) and 0% in group B. Urinary tract infections (1 case) and respiratory tract infections (2 cases) were observed only in group B: the rate was found to be 11.5% (3/26); two anastomotic leakages were observed in group A (6.25%) and one in group B (3.8%). These data suggest that cefotetan appears to be as effective as clindamicin plus aztreonam in prophylaxis against infection in elective colorectal surgery.