Second look laparotomy in the management of malignant epithelial ovarian neoplasias

In the present study we examined 15 patients with malignant epithelial ovarian neoplasms who underwent primary surgery and chemotherapy at the Institute of Obstetric and Gynecologic Clinic of the University of Pisa between 1983 and 1985. At the time of diagnosis and monthly during chemotherapy plasma levels of CEA, CA 19-9, CA 125 and TPA were detected. At the end of pharmacological treatment a second-look laparotomy was performed in each patient to assess the status of cancer. At this time the clinical response was complete in 13 patients and partial in 2. These results were confirmed at second-look laparotomy in 11 of 13 cases of complete clinical remission and in 1 of the 2 cases of partial clinical remission. Two patients in complete clinical remission showed persistent disease. The other one in partial clinical remission was surgically found to have unmodified tumor. Tumoral markers, and especially CA 125, have a good correlation with the clinical course of the disease. However these tumor associated antigens cannot replace second-look laparotomy for assessing the response to cytostatic drugs. In fact patients with normal serum levels of these markers at the end of chemotherapy, were surgically found to have both complete pathological remission and persistent disease. Therefore we have come to the conclusion that the second-look laparotomy and the evaluation of tumor markers have to be performed together in the management of malignant ovarian neoplasms.     

Endoscopic retrograde cholangiopancreatography in carcinoma of the pancreas.

The value of gastroduodenal endoscopy and retrograde cholangiopancreatography has been assessed in 55 patients subsequently confirmed to have pancreatic carcinoma. The technique provided a precise and accurate diagnosis in 45 patients. In nine of these patients, the diagnosis was obtained by duodenoscopy and biopsy alone. Cannulation of the duct was attempted in 47 of the 55 patients; roentgenograms of the pancreatic or biliary tree, or both, were obtained in 40 studies, 36 of which were diagnostic. Tumors were most common in the head of the pancreas, and virtually all roentgenograms showed duct obstruction or a major stricture with upstream dilatation. One pancreatogram of poor quality was reported as normal. Endoscopic cholangiograms were often diagnostic when pancreatography failed in patients with tumors of the head of the pancreas. Endoscopic retrograde cholangiopancreatography is a precise technique for the diagnosis of patients with tumors of the papilla of Vater which may present relatively early and prove resectable. Patients with tumors of the pancreas itself usually present with advanced disease, and in this series, endoscopic retrograde cholangiopancreatography provided no clear benefit in terms of operability or patient survival. However, the efficient documentation of inoperable tumors is important, and endoscopic retrograde cholangiopancreatography sets a standard against which other techniques can be evaluated.     

Clinical and experimental study of pancreatic exocrine function after pancreaticoduodenectomy for periampullary carcinoma

The residual pancreatic exocrine function before and after pancreaticoduodenectomy (PD) for periampullary carcinoma was studied clinically as well as experimentally. In clinical instances (n = 35), the N-Benzoyl-L-Tyrosil-p-Aminobenzoic Acid test (BTPABA test) before and within two months after PD revealed reduction of the function compared with those in the control study. However, the test result one year after PD was improved compared with those before and within two months after operation, without differences from that of the control group. In new canine PD models in which drainage of the pancreatic duct, 50 per cent pancreatectomy and duodenojejunectomy were performed after three months of pancreatic duct obstruction, fibrosis surrounding the pancreatic duct was disclosed. However, the results of examination five months after PD revealed a milder degree of pancreatic fibrosis without aggravation of the lesion. The aforementioned findings indicated that the exocrine pancreas before PD was impaired due to obstructive pancreatitis and that the postoperative pancreatic function was well preserved at the level close to that in the control group even after approximately 50 per cent resection of the pancreas, if pancreatic duct drainage was effectively performed.     

Second primary malignancy in endometrial carcinoma patients

An epidemiologic study of multiple primary malignant neoplasms in endometrial cancer patients in Israel is presented. During the 7-year period of the study, 104 patients (10.3%) out of 1007 patients diagnosed as having endometrial cancer had another primary cancer. There was a significant difference in the incidence of multiple primary cancers between various ethnic groups, women of European/American origin having higher incidence than women of Asian/African origin. A significantly higher than expected incidence of second primary cancers occurred at the following sites: breast (relative risk, 4.1), ovary (relative risk, 11.6), cervix (relative risk, 5.1), and colon (relative risk, 5.9). The prognosis was mainly influenced by the site of the second primary cancer. The increased incidence of multiple primary malignancies justifies a high level of alertness to the possibility of second primary cancer in endometrial cancer patients.     

Another look at the second-assessment procedure for ovarian epithelial carcinoma

Over a 10-year period, 65 of 196 patients (33%) with ovarian epithelial malignancy, previously treated with chemotherapy, had a second-look operation if the disease was clinically absent. All procedures were done by one of three gynecologic oncologists, and 48% of the patients had a positive second-look procedure. Of patients with original stage I, II disease, 25% had a positive second-look operation, contrasting with 61% of patients with stage III, IV. Significant perioperative morbidity occurred: one patient had intraoperative vascular collapse; 15% had prolonged ileus; 17% had small bowel resections at the time of the second-look operation or in the postoperative period. Of all patients with negative second-look operations, 24% have had recurrent disease from 5 to 23 months after the procedure. These recurrences were in the liver or distant sites in 63% of the patients. Second-look operations, if still indicated by negative noninvasive techniques, should be performed in tertiary care centers under study situations in a standard fashion.     

Resectional surgical procedures for carcinoma of the head of the pancreas

Of a total series of 103 patients with preoperatively diagnosed carcinoma of the head of the pancreas (including ampullary carcinoma, carcinoma of the distal part of the common bile duct and pancreatic duct and acinar cell carcinoma), 78 underwent pancreatic resection. The remaining 25 had palliative surgical treatment, either a gastric or biliary bypass, and are not included in the present study. Three of the 78 patients who underwent pancreatic resection died, and ten patients required early reoperation. Predictive criteria could be formulated for the prognosis and outcome of the patients with carcinoma of the head of the pancreas. The most reliable index for survival time of the patients proved to be the radicality of the resection, which was directly related to the differentiation of the primary tumor. Forty-three of 48 patients who underwent radical resection are alive, with a survival time ranging from three to 49 months. Eleven of 23 patients who underwent palliative resection are alive, with a survival time ranging from two to 29 months. Of 44 patients with well or moderately differentiated adenocarcinoma who underwent radical resection, 38 are alive, with a survival time ranging from six to 41 months (mean of 29 months).     

Surgical importance of oblique projection in arteriography for carcinoma of the pancreas.

Oblique projections in celiac and superior mesenteric angiography have been of value in patients with carcinoma arising in various parts of the pancreas. Oblique views allow better perception of the slight and uncertain changes in the pancreatic vessels, which are not discernible on anteroposterior projections because of overlapping with the extrapancreatic vessels and the spine. Anteroposterior and oblique views of both celiac and superior mesenteric arteries are the first, and, therefore, the most essential, step in angiography of lesions of the pancreas.     

Percutaneous biopsy of carcinoma of the pancreas guided by angiography.

Histologic verification of the angiographic diagnosis of carcinoma of the pancreas may be achieved by percutaneous, transperitoneal fine-needle aspiration biopsy. The method was used in conjunction with the angiographic procedure in 29 patients with tumors of varying size down to 3 centimeters in diameter. Positive diagnosis was obtained in 22. Complications were not encountered. Since the method is simple and harmless it is recommended whenever histologic verification is desired.     

Vaginal repair in the radical operation for cervical carcinoma.

An attempt was made to preserve postoperative sexual function and the recovery of bladder function by a simple modification of technique in 22 cases of radical operations for invasive carcinoma of the cervix. The procedures consisted of two parts. After removal of the specimen, the bladder peritoneal flap is sutured to the anterior vaginal wall leaving a 2 to 3 cm margin between the line of suture and the edge of the peritoneum. Similarly, the posterior peritoneal flap is sutured to posterior vaginal wall leaving a margin. Both edges of the peritoneum are then closed forming a pouch as an extension of vaginal canal. The length of the vagina was successfully elongated by this procedure, thus adding to better postoperative sexual function.     

The Kraske operation for carcinoma of the rectum.

Kraske's methodology was classic: develop the operation in the laboratory, try it initially on patients as a last resort and, if it works, expand its use to patients with less severe disease. His operation immediately gained acceptance and was popular for the next quarter of a century. It was subsequently modified by Hochenagg, Billroth and Rydygier. These men merely altered the amount or manner of sacral removal. The operation was largely abandoned after Miles (3) showed that the lymphatic spread from carcinoma of the rectum is toward the liver. Kraske's procedure, however, stands as a landmark in preantibiotic operations on the colon. Combined with abdominal exploration, this type of procedure can be used to preserve the anus in certain instances of carcinoma of the rectum today.     

Treatment of carcinoma of the cervix by combination of irradiation and operation

A series of 1,371 cases of carcinoma of the cervix where the treatment has been intracavitary irradiation followed by radical operation in all cases suitable for operation is presented. The series which has been collected from 1950 through 1967 is reviewed and the results listed. Although operative mortality and morbidity rates were high at the beginning, both have been reduced to acceptable levels and the results have shown a steady improvement.     

Second look laparoscopy; evaluation of two different antibiotic regimens after treatment of acute salpingitis

In order to have their diagnoses verified, etiology determined and treatment evaluated, 64 patients with suspected acute salpingitis (AS) underwent laparoscopy during which specimens were taken. The patients were referred to groups of either a mild (16/64), a moderate (26/64), or a severe (22/64) form of salpingitis. They were then randomized to one of two groups for treatment with either doxycycline/bensylpenicillin-procain (DC/BP) or trimethoprim-sulfamethoxazole (TMP-SMZ). The results were evaluated by second-look laparoscopy 3–6 months later when adhesions and tubal passage were looked for. Isolates from the cervix were culture positive for Chlamydia trachomatis (CT) in 36/64 (56%) (9/16 with a mild form, 13/26 with moderate form and 14/22 with a severe form of salpingitis). Neisseria gonorrhoeae (NG) was isolated from the cervix in 15/64 (23%) (5/16 with a mild form, 4/26 with a moderate form and 6/22 with a severe form of the disease). Oviductal cultures for CT were found in 12/64 (19%) (1/16 with a mild form, 4/26 with a moderate and 7/25 with severe form of salpingitis). Oviductal isolates for NG were found in 2/64 (13%) (2/16 from the group with a mild form of the disease). Second-look laparoscopy revealed totally occluded oviducts in two patients from the group with a severe form of salpingitis (one from each treatment group).     

Recurrence of nasopharyngeal carcinoma in the parotid region after parotid-gland-sparing radiotherapy

This study reported our experience of the clinical characteristics of periparotid recurrence of nasopharyngeal carcinoma (NPC) after parotid-gland-sparing radiotherapy. We retrospectively reviewed the charts of 296 patients with NPC who underwent parotid-gland-sparing radiotherapy at the Tri-Service General Hospital from 1998 to 2008. Eighty-three patients underwent three-dimensional conformal radiotherapy, and 205 patients underwent intensity-modulated radiotherapy; parotid glands were spared bilaterally in all patients. None of these patients had undergone previous radiotherapy or surgical treatment of the head and neck. Disease recurred in a spared parotid gland in three patients (1.04%). Two of these patients had undergone three-dimensional conformal radiotherapy and the third underwent intensity-modulated radiotherapy. All three patients had undergone parotidectomy. Adjuvant radiotherapy or concurrent chemoradiation was administered. One patient died of metastatic disease 26?months after diagnosis of recurrence; the others were well with no evidence of disease at 63 and 6?months after initial recurrence. Periparotid recurrence is an uncommon pattern of locoregional failure after parotid-gland-sparing radiotherapy for NPC. Early diagnosis and aggressive therapy for patients with periparotid recurrence may improve outcomes.     

Palliative surgical treatment of sixty-eight patients with carcinoma of the head of the pancreas

A retrospective study is presented of 68 patients who underwent biliary enteric bypass procedures for carcinoma of the head of the pancreas between the years of 1960 through 1975. Forty patients underwent some form of biliary enteric bypass only. Twenty-six patients were treated with concomitant gastrojejunostomy, and only two patients in this group underwent vagotomy. Two patients underwent gastrojejunostomy for obstruction at the gastric outlet without jaundice. Five operative deaths occurred among the 40 patients who underwent solely some form of biliary enteric bypass procedure, and three deaths occurred among the 26 patients who underwent concomitant gastrojejunostomy. The over-all operative mortality for biliary enteric bypass procedures was eight deaths among 68 patients. Obstruction of the duodenum developed in seven patients after undergoing a biliary enteric bypass operation. The mean postoperative interval for the development of complications was 5.57 months. All but one patient underwent a second operation, with no operative deaths. Among the 26 patients treated with concomitant gastrojejunostomy, obstruction developed in two patients because of anastomotic failure; there was massive upper gastrointestinal tract bleeding from a marginal ulcer in four patients, and one patient had a perforated marginal ulcer. The mean survival time after biliary enteric bypass was 6.69 months and after combined biliary enteric bypass and gastrojejunostomy, 9.90 months. The over-all mean survival time was 8.00 months.