Giuseppe Botta

TREATMENT OF ADVANCED COLORECTAL CANCER WITH HIGH-DOSE INTENSITY FOLINIC ACID AND 5-FLUOROURACIL PLUS SUPPORTIVE CARE

This randomised clinical trial, involving patients with advanced colorectal cancer, was carried out to compare the effectiveness of accelerated folinic acid (FA) plus 5-fluorouracil (5-FU) with that of the conventional regimen of 5-FU alone. Both regimens were administered with simulataneous supportive care. 185 patients were eligible: 94 were randomly allocated to receive FA 200 mg/m2 i.v. plus 5-FU 400 mg/m2 i.v. on days 1-5 every 3 weeks; and 91 to receive 5-FU 400 mg/m2 i.v. on days 1-5 every 4 weeks. The response rate was 33.3% in the accelerated FA/5-FU and 18.6% in the 5-FU arm (P = 0.045). Median survival was 13.5 months in the FA/5-FU arm and 7.5 months in the 5-FU arm (P = 0.039). Toxicity was mild and slightly more pronounced in the FA/5-FU arm (P = 0.078). This study indicates that, in patients with advanced colorectal cancer, accelerated chemotherapy with FA and 5-FU and simultaneous supportive care is capable of achieving a higher response rate and longer survival than conventional 5-FU alone, without severe toxicity.

Guidelines for Venous Thromboembolism and Clinical Practice in Italy: A Nationwide Survey

Venous thromboembolism (VTE) is a common health problem for todays society, and considering the role that it plays in surgical patients (general surgery, gynecology, and orthopedics), new advances in our understanding of the procedures and trauma characteristics are relevant and necessary. The most important and recently published guidelines concerning this problem have been taken into consideration, leading to articulate investigations and data evaluation. This project has proposed a data-survey framework available as a questionnaire in order to investigate application of the guidelines for VTE throughout the national territory. Of the total 714 Italian centers, a random sample of 214 were contacted and asked to take part in this study; of these, 146 replied (20.4% of total and 68.2% of the sample): 48 departments of general surgery, 46 departments of gynecology, and 52 departments of orthopedics. About 70% of the centers has appropriate information about surgery as a risk factor for VTE. The answers have provided evidence of an adequate knowledge of the instrumental and laboratory diagnostic pathways, useful to confirm the diagnosis of TE (80%). Data waiting compared with morbidity and mortality rates related to deep vein thrombosis and pulmonary embolism showed an increase of mortality associated with the diagnostic data timing of supply, with an exponential trend linked to the data acquisition delay. Both risk stratification and adequate application of prophylaxis together with treatment devices represent a real tool to control morbidity and mortality for VTE. Moreover, diagnostic data waiting significantly influences adequate prophylaxis. In Italy, only 40% of the centers are ready to provide diagnostic data within 12 hr.

Right gastroepiploic artery arising from the dorsal pancreatic artery: a very rare anatomic variation underlying interesting embryologic implications

The exceptional case of the right gastroepiploic artery (RGE) arising from the dorsal pancreatic (DP) artery in an individual affected by hepatocellular carcinoma is presented. This anatomic variant was demonstrated with a selective angiography of the common hepatic artery that showed a distinct DP artery branching from the injected artery. The DP artery gave off regular pancreatic branches and continued as a long and winding vessel that was identified as the RGE by its general course, the anterior epiploic branches arising from it, and the injection of the distal splenic artery, possibly via the anastomosis with the left gastroepiploic artery. The anatomy of the RGE has few variations, mostly limited to its origin from the superior mesenteric artery. Arising of the gastroepiploic artery from the DP artery has never been previously reported and represents an unexpected possible anatomic variant of which general and heart surgeons should be aware. In particular, this case is of interest in surgical procedures involving resection of the head of the pancreas, gastrectomies or coronary artery bypass grafting using the RGE. The embryology underlying the development of this anatomic variation is reviewed.

RESULTS TO 5 YEARS AFTER ENDOVENOUS LASER TREATMENT

The main goal of any steganographic algorithm is that of hiding a message within an innocuous signal in such a way that the very presence of the hidden message remains secret. The opposite effort of determining the presence of a hidden message within a cover signal is carried out by steganalyzer programs. Blind steganalyzers do not know the steganographic technique used to hide the message, hence they rely on a statistical analysis to understand whether a given signal contains hidden data or not, however this analysis disregards the semantic content of the cover signal. Given the observation above, it may be argued that, from a steganographic point of view it is preferable to embed the watermark at higher semantic levels, e.g. by modifying structural elements of the host signal like lines, edges or flat areas in the case of still images. In this work we presented a new steganographic algorithm for color images (MPSteg-color). It is based on Matching Pursuit (MP) decomposition of the host image. The idea behind this work is to adaptively choose the elements of a redundant basis to represent the host image. In this way, the image is expressed as the composition of a set of structured elements resembling basic image structures such as lines, corners, and flat regions. We argue that embedding the secret message at this, more semantic, level results in a lower modification of the low-level statistical properties of the image, and hence in a lower detectability of the presence of the hidden message. The results confirm the validity of the proposed approach. Objective. The authors, reporting 3 cases operated on in the last 2 years, describe the clinical and radiological features of a relatively very rare pathology or complication, which is part of the elaborated universe of the degenerative lumbar spinal disease. By pointing out the probable etiology, they suggest the most appropriate treatment. Patients and methods. We report 3 cases of lumbar spinal chronic epidural hematomas. The patients, all males aged from 65 to 38, presented with an irritative pluriradiculopathy, low back pain, neurological deficits and intermittent caludication. All patients underwent X-ray, CT and MRI that showed the hematomas to be associated with a significant spinal degenerative disease and disk herniation. They have been operated on with a microsurgical technique and stabilized by intersomatic titanium cages. Results. The outcome, in a 6 months-2 years follow-up, was excellent. All the symptoms and neurological deficits disappeared. Conclusions. Lumbar spinal chronic epidural hematoma is hard to pre-surgically diagnose and infrequently reported with clarity by radiologists. Nevertheless, it is a pathology with precise radiological and histological features, and its etiology derived from a spontaneous, iatrogenic or traumatic bleeding, which is always venous.

The phlebological surgery in elderly patients

The pathogenesis of the lower limbs varicose veins in the elderly patients is the same one as in the juvenile and adult age. What changes is the severity of the clinical picture, because the disease is a chronic pathology and it is aggravated with the passing of the years in absence of prophylaxis and missed or inadequate therapy. Equally the surgical operations on the superficial venous system of the elderly patients from a technical point of view are the same that are practiced in other ages of life. What changes is the anaesthesiological risk, which is increased, because other chronic pathologies are frequently associated with the old ones. Currently both the use of techniques of peripheral anesthesia, as the blocks of the lower limbs nervous trunks, and the introduction of poor toxic anesthetics for the heart in therapeutical practice allow in an incisive way to submit elderly people to surgical procedures. Above all the out-patient hemodynamic surgery of the superficial chronic venous insufficiency, which requires a careful and meticulous instrumental investigation aimed surgical gestures, but simple, effective, of brief duration, has convinced many surgeons of the possibility to operate on the varicose patients of a more and more advance age. On the other hand the rapid postoperative mobilization of those sick, in absence of immediate complications, means that they can be discharged from the hospital on the same day of the operation. This undoubtedly involves positive reflexes on the sanitary expense and it increases at the same time the compliance in terms of motivation and acceptance of the proposed procedure. The elderly patient, perhaps more than the younger adult, once informed of the new anaesthesiological and surgical techniques, gladly gives his consent to the intervention, pleased to return to his own house and tquickly return to his daily occupations. How much I dictate you is translated in our experience, that is carried out near the Phlebological Center of the Siena University, in a progressive increase in the last 5 years both in absolute terms (223) and percentages (12%) of the number of subjects older than sixty-five years old that have been submitted to surgical operations for the venous disease. Of all 223 patients, males are 68 and females are 155; 144of them have an age between 66 and 70 years, 73 belonging to the eighty years of life and 6 subject to the ninty. All patients have been operated in Day Hospital admission. No mortality has been found. Local postoperative complications was encountered in 1,8% of the cases.

The surgical therapy for the lower limb varices in day surgery

Abstract 1775 varicose patients (1318 female, 457 male) with mean age 47.7 years have been operated in One Day Surgery in III Department of General Surgery and in the Phlebology Centre of the University of Siena between June 1 1985 and May 30 1996. 1274 (71.7%) patients underwent internal saphenectomy of which 947 (53.3%) through short stripping, 327 (18.4%) through long stripping, 106 (5.9%) external saphenectomy, 90 (5.1%) revision of the saphenous-femoral junction, 258 (14.5%) phlebectomies; 16 (0.9%) external valvuloplasty sec. Mancin, 31 (1.7%) other operations. All patients were discharged on the same day of operation. The obtained instrumental and clinical results show an improvement of haemodynamics, with 21% varicose residue for incontinence perforating veins on long stripping internal saphenectomy. In their experience in the surgical treatment of varicose veins, the authors affirm that the policy of One Day Surgery is not greatly affected by the surgical technique adopted but more so by the anaestesiological technique used and the clinical condition of the patients.

The Recurrent Varicose Veins of the Lower Limb

The incidence of the varicose recurrence after surgical therapy of the essential varicose veins of the lower limbs is quantifiable with a certain difficulty, being a great deal varying the data brought again in literature. It is gone from the 1 to the 15–20% with an average that is attested currently in the principal worlds case-records around to the 10% [4,7,8].

Comparative Morphometric Study of the Therapeutic Effect of Compression and Saphenectomy Carried out on Cutaneous Biopsies in Patients Affected by Peripheral Chronic Venous Insufficiency

The alteration of the capillary circulation of the lower limbs in patients with chronic venous insufficiency, studied on biopsy-punch in optic microscopy and the complication caused in the cutaneous district, undergo some significant variation after a 3 months elastic-compression treatment and surgical saphenectomy.

The Short Stripping Saphenectomy in the Varices of the Lower Limbs

New techniques have been proposals in the last years in the surgery of the varicose veins of the lower limbs. Some techniques of conservative type, as the external valvuloplasty of the sapheno-femoral junction, are set the objective of take care of the varicose veins, eliminating the long reflux, so that prevent the progressive parietal expansion of the long saphenous vein, that comes left in situ.