Manlio Carboni

Roux-en-y Hepaticojejun ostomy: A Reappraisal of its Indications and Results

A critical evaluation is made of 131 patients submitted to choledocho or hepaticojejunostomy. The main indications for hepaticojejunostomy were iatrogenic strictures of CBD (60 patients), and choledocholithiasis with markedly dilated duct (41 patients). The overall mortality rate was 4% representing principally renal hepatic failure, bile peritonitis and bleeding. The complications following hepaticojejunostomy included only in one case biliary fistula which required reoperation. The long-term results of 80 patients available for a followup study were as follows: 63 patients (78.7%) were symptom-free at 2-13 years followup; 8 patients had brief episodes of cholangitis which responded to antibiotic and corticosteroid treatment; 9 patients required reoperation for stricture of anastomosis. These overall results are a strong argument for hepaticojejunostomy which, compared with choledochoduodenostomy, avoids the hazards of the so-called sump syndrome and of the reflux of enteric contents in the CBD. An increased incidence of peptic ulcer disease in the patients submitted to hepaticojejunostomy was not observed. In very high strictures and in reinterventions anastomosis between left hepatic duct and Roux-en-Y jejunal limb was carried out. The results achieved with this technique, which was performed in 26 patients, were about the same following hepaticojejunostomy.

Evaluation of the Maruyama Computer Program Accuracy for Preoperative Estimation of Lymph Node Metastases from Gastric Cancer

Controversy still exists about the optimal lymph node (LN) dissection for potentially curable gastric cancer. For rational LN dissection it is important to know the incidence of metastasis at each LN station. For this purpose a computer program was developed using data from 4302 primary gastric cancers treated at the National Cancer Center Hospital in Tokyo between 1969 and 1989. To evaluate the accuracy of the computer program, the differences between the individual reports generated by the computer and the stored data were investigated in 282 Italian patients submitted to curative gastrectomy and D2 or more extended LN dissections for gastric cancer. Receiver operating characteristic (ROC) analysis was used to assess the sensitivity and specificity of the program for predicting LN metastases in each of the 16 regional LN stations. The computer program showed good predictive ability for LN metastases in most of the 16 LN stations, as the areas under the curve ranged from 0.741 (station 15) to 0.944 (station 8), with a mean of 0.856. A critical cutoff point of 18% of the programs expected percentage was the value maximizing the validity of the prediction. Using an “absolute” cutoff point of 0%, the overall rate of false-negative (FN) predictions in 176 N+ patients was 11.9%; of these, 11 (6.2%) were absolute FNs, in which the program totally failed to estimate LN metastases; the remaining 10 cases (5.7%) were relative FNs because the specific prediction was positive for a different depth of stomach invasion. The low number of D3/D4 lymphadenectomies in the historical database may affect the low estimate of metastases to N3/N4 nodes generated by the program. Based on these data, the program predicts with good accuracy the extent of LN metastases from gastric cancer, but it is not recommended for directing the surgeon to perform more extensive lymphadenectomy.

Causes of Death and Recurrence after Surgery for Early Gastric Cancer

Abstract. The postoperative course of 172 patients with early gastric cancer (EGC) was followed for a median 7 years to evaluate the causes of death, incidence and patterns of recurrence, and characteristic findings in the recurrent cases. The cumulative 10-year mortality rate (± SE) was 22 ± 3.7%. Seven patients (4.1%) died of operative mortality, 11 (6.4%) died of a recurrence of the gastric cancer, and 13 (7.6%) died of unrelated causes. Unrelated causes of death were metachronous primary cancer (n = 6), cardiovascular disease (n= 2), pneumonia (n= 3), sepsis (n= 1), and car accident (n= 1). Four patients died from gastric stump recurrence, three from liver metastases, two from lymph node metastases, and two from peritoneal dissemination. Using Cox multivariate analysis, histologic type had the most significant effect on recurrence. Although influenced by the tumor nature, the EGC prognosis is relatively good. Based on the results of this study, particularly in Western institutions, histologic examination of resection margins and lymphadenectomy should be improved. Moreover, patients must be carefully followed for late recurrence and metachronous cancer.

Transduodenal sphincteroplasty: Its use in the treatment of lithiasis and benign obstruction of the common duct

Summary On the basis of the results obtained in 712 patients, an evaluation of the effectiveness of transduodenal sphincteroplasty is presented. This procedure has proved to be appropriate in treating benign obstruction of the common bile duct as well as choledocholithiasis. Mortality was 1.1 per cent and long-term results were satisfactory in 97 per cent of the cases. Only sixteen patients required reoperation for residual or recurrent stones or for stricture of the sphincter of Oddi. Compared with choledochoduodenostomy, sphincteroplasty avoids the hazards of the so-called sump syndrome and of ascending cholangitis by reflux of intestinal contents into the common duct. A high incidence of postoperative pancreatitis in patients who undergo sphincteroplasty has not been observed.

Immunohistochemical study of fatty acid synthase, Ki67, proliferating cell nuclear antigen, and p53 expression in hyperplastic parathyroids

Patients with secondary hyperparathyroidism following chronic renal disease frequently develop hyperplastic parathyroids. Hyperplastic parathyroids have an increased number of chief cells, a decreased amount of stromal fat, and a nodular or diffuse histologic pattern. Hyperplastic parathyroids may also express higher proliferative activity compared with controls. We evaluated the morphologic features and immunohistochemical expression of fatty acid synthase (FAS), Ki67, proliferating cell nuclear antigen, and p53 protein in 78 hyperplastic parathyroids from 20 patients with secondary hyperparathyroidism. Twenty normal parathyroids incidentally removed during nonneoplastic thyroid surgery were used as controls. Our results showed that hyperplastic glands overexpress FAS (P =.06). Statistical analysis also revealed a significant association between FAS and p53 protein (P =.006) and between FAS and hyperplastic glands with a predominant nodular pattern (P =.02). Hyperplastic parathyroids from patients with chronic renal failure strongly express FAS. Fatty acid synthase may therefore be a potential biological indicator of highly proliferating parathyroid cells.

Prospective randomized evaluation of preoperative endoscopic vital staining using CH-40 for lymph node dissection in gastric cancer

AbstractBackground: CH-40 is a suspension of activated carbon particles that was developed in Japan to carry anticancer drugs to regional nodes and peritoneal seedings of gastric cancer. Methods: Forty-five consecutive patients who had surgical resection and D2 lymph node dissection for gastric cancer over a 2-year period were randomly assigned to preoperative endoscopic submucosal injection of CH-40 (group A) or no staining (group B). A total of 21 patients in group A and 24 in group B were available for analysis. Results: The number of resected nodes per patient was significantly higher (t=6.06; 40df; P<.0001) in group A (mean±S.E.=35.3±1.24) than in group B (mean±S.E.=25.5±1.02). The rate of metastatic nodes resected was significantly higher (χ2=6.903 ; 1df; P=.009) in stained (22.5%) than in non-stained (14.7%) nodes of group A and also (χ2=6.906 ; 1df; P=.009) in stained nodes of group A than in group B (15.8%). Conclusions: Preoperative endoscopic vital staining with CH-40 proved to be rapid, safe, and effective in all cases in this series. Its use allowed surgeons to resect a higher number of lymph nodes, and to identify and examine more metastatic nodes. It also permitted identification of nodal micrometastases on routine histopathologic examination.

Hypoglycemia and insular hyperplasia: review of 148 cases.

On the bases of personal experience and the series of 148 cases from an international inquiry and a review of the literature, the relation between insular hyperplasia and hypoglycemia was examined. The fundamental points in this investigation included: age, diagnostic investigations, histological findings and postoperative results. The data on the patients with insular hyperplasia indicates that 83% were of adult age. Insular hyperplasia was the only abnormal factor determined to be present. Through treatment a high percentage of cases (71%) was cured. From a practical surgical point of view, differentiation between occult insulomas and insular hyperplasia is not critical. Consequently, good results can be achieved in botlh diseases by practicing a progressive blind resection guided by examination of the operated specimen and by intra-operative blood sugar levels.

The microflora of the gastric juice after Billroth I and Billroth II partial gastrectomy.

Detailed analyses of biochemical and microbiological variables such as pH, nitrite concentration, total viable counts (TVC), nitrate reductase-positive bacterial counts (NRPBC), and identification of microorganisms were carried out on 76 fasting gastric juice samples obtained at endoscopy from 64 patients previously submitted to partial gastrectomy (22 end-to-end Billroth I, 42 Billroth II/Reichel-Polya) and from 12 normal controls. Samples from normal controls were sterile, but bacteria were detected in the juice from all the operated patients. Significantly higher mean pH values and nitrite levels (p less than 0.001) were found in partial gastrectomies than in normal controls. In relation to surgical methods, higher mean pH values (p less than 0.005), nitrite levels (p less than 0.01), TVC (p less than 0.01), and NRPBC (p less than 0.005) were observed in the juice of patients with Billroth II as compared with Billroth I gastrectomies. Anaerobic bacteria, typical of faecal flora, and particularly Escherichia coli (p less than 0.05) characterized Billroth II samples. All these data suggest that the presence of bacteria in the gastric juice of gastroresected patients can be considered a risk factor of gastric neoplasia and that the type of operation used for the reconstruction of digestive continuity may influence the magnitude of this risk.

Retrograde jejunogastric intussusception : is endoscopic or surgical management more appropriate?

Jejunogastric intussusception (JGI) is a rare complication which can develop after partial gastrectomy, gastroenteroanastomosis or enteroanastomosis. Although its management is usually surgical, an endoscopic reduction can alternatively be attempted. We present herein a case of acute JGI in which failure of endoscopic reduction required surgical resection and reconstruction. This is followed by a discussion based on the current available literature.

The value of arteriography in the diagnosis and treatment of insulinomas

Six arteriograms were performed in five patients with insulinoma. The method showed with precision the size and location of the tumor in five instances, whereas in one instance the method was unsuccessful. Arteriography was performed again with more refinements in technic, but was adequate in locating only the largest tumor. Since diagnostic accuracy of arteriography depends on the size of the tumor, and nonpalpable tumors are only occasionally located, the main problems in surgical treatment of insulinomas are unresolved.