The choice of surgical therapy in adenocarcinoma of the cardia

AIM: From 1996 the adenocarcinoma of the esophago-gastric junction (AEG) is divided into 3 types according to Siewert's classification. For AEG type I and III the surgical treatment is codified, while for type II is still controversial. The aim of our study is to understand what is the better surgical treatment for AEG type II. METHODS: From 1990 to 2002 we have performed 111 resections for adenocarcinoma of the cardia: 25 for AEG type I (all esophago-gastric resection), 39 for type II (22 esophago-gastric resection, 17 extended total gastrectomy with esophageal resection) and 47 for type III (8 esophago-gastric resection, 39 extended total gastrectomy with esophageal resection). RESULTS: The morbidity and mortality rates are 17 and 5.4%, without significant difference between the different surgical treatment (p>0.01). The 5 year survival rate is 35%. Significant prognostic factors are the staging TNM (p=0.002) and principally the presence of metastatic lymph nodes (p=0.001). For AEG type II any significant difference in survival is associated with surgical strategy, also in early stage (p>0.01). CONCLUSIONS: According to the results of our study and those of the other authors, who have showed that a 10 cm distance of the neoplasm by the gastric side and the esophageal one could assure oncologic radicality and also that metastatic lymph nodes below pylorus and near greater curvature are uncommon, we can consider esophago-gastric resection for AEG II a speedy, safe and oncologically correct surgical treatment.     

Leukocyte adherence inhibition test: cell-mediated reactivity to tumor antigens in colorectal and lung tumor long survivors.

Cell-mediated immunity versus tumor antigens (cytosols) of the same histotype and site was evaluated by means of the leukocyte adherence inhibition (LAI) test in 44 colorectal adenocarcinoma and 17 lung squamous-cell carcinoma patients 3-10 years after surgical resection. LAI-positivity was observed in 17/44 (38.6%) and 13/17 (76.5%) patients, respectively, together with serum blocking factors in 7/17 (41.2%) compared to 0/13. These results indicate that a high percentage of long survivors retain an immunologic memory of the tumor antigen to which they have been exposed. The prognostic significance of serum blocking factors is less clear.     

Hyperparathyroidism, an emerging disease

A retrospective study based on 35 years of personal experience was done. Up to today 2,175 patients were operated, 1,318 for primary hyperparathyroidism (HPT) and 857 for secondary and tertiary HPT. Considering recent years (1999 to July 2010), 918 patients were operated for primary HPT. Preoperatively all the patients performed a cervical ultrasound and/or a sestamibi scan. Open mininvasive procedure was preferred: it is an easily reproducible and costless technique. Using magnifying glasses up to 2.5, an excellent three-dimensional vision was obtained. The operating time is short and if there are any doubts it is possible to extend the exploration to the other side of the neck. Immediate and long-term results were excellent, with a cure rate greater than 99%. Complications in the treatment of a single adenoma are around 0.3%. Patients can be discharged 24–48 h after the operation. Regarding reoperations, a correct diagnostic and therapeutic approach is essential. CT, MRI and SPECT must correlate with the information given by ultrasound and scintigraphy. The intraoperative PTH assay (io-PTH) is required and the approach should be limited to the area where the missed gland probably is. The functionality of the autotransplantation (AT) performed immediately was good. The functionality of the cryopreserved tissue is better for the HPT I in comparison with HPT II. Considering HPT I or HPT II the use of io-PTH is helpful. MIBI scanning is helpful but not essential, except in reoperations. Surgeon experience is another very important factor for good results.     

Successful surgical management of a delayed pharyngo-esophageal perforation after anterior cervical spine plating

A case report of a 41-year-old man who had a delayed pharyngo-esophageal perforation without instrumentation failure 7 years after anterior cervical spine plating is presented and the literature on this issue is reviewed. This injury resulted from repetitive friction/traction between the retropharyngo-esophageal wall and the cervical plate construct leading to a pseudodiverticulum and perforation. Successful treatment of the perforation was obtained after surgical repair using a sternocleidomastoid muscle flap. This case stresses the necessity of careful long-term follow-up in patients with anterior cervical spine plating for early detection of possible perforation and the use of muscle flap as the treatment of choice during surgical repair.

     

Fissures in biliary calculi. Personal contribution (author's transl)

In a series of 70 patients suffering from biliary lithiasis, the roentgenologic findings of fissures in the calculi was observed in 5 cases examined by means of cholecystography and in 7 cases who underwent cholangiocholecystography. Fissures were demonstrated 11 times in calculi after surgery. The "Mercedes-Benz" sign was never observed at the abdominal examination without contrast medium. The presence of fissures may be an additional sign in the radiologic diagnosis of biliary calculi, but its value is not determinant.     

Endoscopic insertion of 248 prostheses in inoperable carcinoma of the esophagus and cardia: short-term and long-term results

We present our findings after 248 endoscopic intubations with the Nottingham introducer and more recently with the Dumon-Gilliard system for inoperable carcinoma of the esophagus and cardia. Mortality within the first week was 7.6% decreasing to 4.3% with the Dumon-Gilliard method. Survival after 3 months was 61.5%, after 6 months 32.3%, after 1 year 4.8%. The quality of swallowing was very good in 51.5% of the cases, while 36.7% of the patients suffered from dysphagia for semisolids and 10.1% for semiliquids. Obstruction occurred in 36 cases; proximal and distal dislocations were found in four cases each. In 20 patients with esophagorespiratory fistula we had an operative mortality of 15%, but 6-month survival was 35.7% and 1 year survival was 7.1%.