[Surgery of non tumoral pancreatic hypoglycemias].
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Adult↗
Biomedical subjects
A Peracchia
Publications and source records attributed to A Peracchia.
Thoracoscopic esophagectomy: are there benefits?
Between 1991 and 1995, 18 patients affected by a resectable intramural tumor of the esophagus underwent esophagectomy with thoracoscopic dissection of the esophagus. All patients had a relative contraindication to transthoracic esophagectomy with radical lymphadenectomy. All esophagectomies were completed thoracoscopically and reconstruction of the digestive tract was performed in 17 cases through cervical gastroplasty, and in 1 case, through cervical coloplasty. One cirrhotic patient died in the postoperative period due to a cervical anastomotic leak. Six other patients experienced a postoperative complication (mortality rate, 5.5%; morbidity rate, 33.3%). After a median follow-up of 17 months, 14 patients are alive without evidence of disease. One patient, who had excision of a cutaneous metastasis at a trocar insertion site 6 months postoperatively, eventually died with locoregional recurrence 14 months postoperatively. Another patient died 20 months after surgery with mediastinal recurrence. One patient died 28 months postoperatively after massive hematemesis with a suspect abdominal recurrence. The results of the present series, and those reported by other authors, do not seem to indicate evident advantages at present for the minimally invasive procedure during resection of the esophagus for cancer. Currently, there is no indication that this procedure should be used for standard clinical use. Wider randomized trials, performed in selected centers only, and longer follow-up are needed to further evaluate the procedure.
Aged↗
Heller laparoscopic cardiomyotomy with antireflux anterior fundoplication (Dor) in the treatment of esophageal achalasia.
The technique of Heller laparoscopic myotomy with associated Dor anterior fundoplication for the treatment of esophageal achalasia is described. This operation was performed on three patients with clinical, radiologic, and manometric diagnoses of achalasia. Complete relief of dysphagia and modifications of radiological and manometric patterns were achieved in all patients 1 month after surgery. Laparoscopic treatment of achalasia is technically feasible, reduces surgical trauma, and may be considered a valid alternative to open surgery.
Adult↗
Anastomosis.
Esophageal anastomosis is still associated with a high rate of complications even though they have decreased considerably in recent years. Anastomotic leaks are more frequent in the neck than in the chest, and related mortality rate is not different. The leakage incidence does not depend on suture materials or on technical modalities used to perform the anastomosis. In fact, there is no difference between the leakage rate when comparing manual and mechanical anastomoses. The leak incidence after both mechanical and manual anastomoses is much higher in collective reviews than in reports coming from leading centers. "Frequent" esophageal surgeons can learn from their previous experience and therefore avoid technical errors, whereas "causal" esophageal surgeons do not have this opportunity. Performing an esophageal anastomosis is a technical matter, and suture healing is independent of the patient's biologic situation. Anastomotic fibrotic strictures are frequent after both manual and mechanical anastomoses, and most can be avoided by meticulous suturing technique.
Anastomosis, Surgical↗
Ultrasonographic evaluation of the cervical lymph nodes in preoperative staging of esophageal neoplasms.
BACKGROUND: The detection of cervical lymph node metastases plays an important role in staging of patients affected by esophageal cancer to perform the best therapeutic approach. METHODS: We report our experience concerning the ultrasound evaluation of the cervical area in 174 patients with esophageal cancer. Ultrasonographic evaluation of the neck can be done with a 7.5- or 10 MHz transducer in all cases, with selective scanning of the lymph node chains of the internal jugular veins and supraclavicular regions. The short-to-long axis ratio (S/L) was a useful way to detect lymph node metastasis. Histopathologic diagnoses were obtained by sonographically guided fine-needle aspiration biopsy. RESULTS: At ultrasound examination, we found 18 (10.3%) patients with metastatic cervical nodes. Of these, 17 (94.4%) had metastatic cervical lymph nodes confirmed by cytology from fine-needle biopsy. Lymph node exceeding 5 mm in long axis and with an S/L over 0.5 showed a higher incidence of metastasis than those with an S/L under 0.5. Our experience shows a high incidence of lymph node metastases in patients with esophageal cancer localized to the thoracic supracarinal tract and in patients with cervical and lower esophageal cancer. CONCLUSION: In the ultrasound evaluation of nodes, the most useful parameters are size of nodes, heterogeneity of internal echoes, morphology of the margins, and the deformation caused by compressive instrumental manipulation. These criteria, indicated by the Japanese Society for Esophageal Diseases, yield a high sensitivity and diagnostic specificity when the ultrasonographic studies are performed.
Adult↗
Modified Sujura operation: long-term results.
From January 1980 to January 1986 a total of 93 patients with portal hypertension (59 males, 34 females; average age 51.5 years) underwent the modified Sujura's operation. All patients presented with esophageal varices during the preoperative endoscopic workup. Child's risk category was A in 6 patients and B in the remaining 87. Our technique consisted of: (1) devascularization of the upper half of the gastric corpus and fundus; (2) devascularization of the last 10 to 12 cm of the thoracic esophagus; (3) pyloric divulsion; (4) resection and anastomosis at the esophagogastric junction; and (5) antireflux fundoplication. In the presence of severe hypersplenism we added splenectomy. The surgical approach was through a xiphoumbilical laparotomy, extended to the left side when splenectomy was anticipated. We observed 19.8% early mortality (10% with elective procedures and 27.2% with emergency operations) and two cases of early rebleeding from acute mucosal lesions. Long-term follow-up of 82 patients revealed 30 cases of rebleeding (36.6%). Ruptured esophageal varices occurred in 12 patients (11 were treated with endoscopic sclerotherapy), whereas in 11 patients the cause of bleeding was a hemorrhagic gastritis. Of the remaining patients, two had rebleeding from a gastric ulcer, one from gastric varices, one from duodenal varices; in three patients the source of the hemorrhage remains unknown. The survival for elective procedure patients was 59.2% at 5 years and 40.7% at 10 years.
Adolescent↗
Endoscopic laser ablation of nondysplastic Barrett's epithelium: is it worthwhile?
The clinical value of endoscopic ablation of nondysplastic Barrett's epithelium is controversial. It has been stated that ablation, combined with acid suppression or antireflux surgery, may reduce the risk of adenocarcinoma, thereby obviating the need for endoscopic surveillance in these patients. Eighteen symptomatic patients were enrolled in a prospective study of Nd:YAG laser ablation of Barrett's esophagus followed by treatment with proton pump inhibitors or antireflux surgery. All patients had intestinal metaplasia and no associated dysplasia or carcinoma. Laser treatment was performed with noncontact fibers and a power output of 60 watts. The mean number of treatment sessions was three (range 1 to 5), and the mean energy delivered during each session was 2800 joules (range 600 to 4800 joules). All patients were given a standard dose of omeprazole (40 mg/day) throughout the study period. In two patients a mild distal esophageal stricture occurred and required a single dilatation. Macroscopic and histologic eradication of the specialized columnar epithelium was documented in 8 of 12 patients with tongues of Barrett's metaplasia, in one of four patients with circumferential Barrett's metaplasia, and in two of two patients with short-segment Barrett's esophagus. In five patients (28%) only a partial ablation could be achieved despite repeated laser treatment. Two patients (11%), one with tongues and the other with circumferential Barrett's metaplasia, were considered nonresponders. Adenocarcinoma undermining regenerated squamous epithelium was found, 6 months after eradication, in one patient who underwent esophagogastric resection. Twelve patients agreed to undergo antireflux surgery. Over a mean follow-up period of 14 months (range 4 to 32 months), two patients presented with recurrent Barrett's metaplasia: one at 8 months after successful Nissen fundoplication and the other after 1 year of continuous omeprazole treatment. Progression of Barrett's metaplasia was found in two other patients receiving pharmacologic therapy in whom a partial response to laser treatment had been obtained. In conclusion, Nd:YAG laser therapy of nondysplastic Barrett's esophagus, performed in conjunction with omeprazole treatment and followed by antireflux surgery, allows a partial regression of specialized columnar epithelium in most patients. However, this is a time-consuming procedure that produced only temporary eradication, did not prove effective in reducing cancer risk, and did not obviate the need for endoscopic surveillance.
Adenocarcinoma↗
Lymph node micrometastases in patients with adenocarcinoma of the esophagogastric junction.
Recurrences of adenocarcinoma of the esophagogastric junction are frequent even in patients who are classified as pN0 after radical resection, suggesting that occult nodal metastases may have been missed on routine histologic examination. Immunohistochemical analysis using antibodies to cytokeratin was retrospectively performed in 1301 lymph nodes from 46 patients who underwent surgical resection for adenocarcinoma of the esophagogastric junction through a laparotomy and a right thoracotomy. Compared to routinely stained sections, the total number of metastatic lymph nodes was significantly (P = 0.0001) increased when both serial sectioning and anticytokeratin immunohistochemical analysis were performed. Overall 6 (33.3%) of the 18 patients previously considered N0 were recategorized as N1 for the presence of micrometastases to lesser curvature nodes. Three of these patients had recurrent disease within the first year of follow-up. Both the probability of survival or no recurrence and the disease-free survival were significantly greater in patients in whom the ratio of invaded to removed lymph nodes was less than 0.2. Anticytokeratin analysis identified occult nodal metastases in one third of our patients with adenocarcinoma of the esophagogastric junction. This modified tumor staging and had an impact on overall and disease-free survival.
Adenocarcinoma↗
DNA content in human colon cancer and non-neoplastic adjacent mucosa.
DNA content was determined by flow cytometry in a series of 51 paired fresh tissue samples of primary colorectal carcinomas and the respective non-neoplastic adjacent mucosa in order to assess the relationship between DNA ploidy and the most commonly used prognostic factors. Aneuploidy was observed in 70.6% of the tumors and more than one aneuploid peak was present in 3.9%. Aneuploid tumor frequency was higher in left (93.3%) and right colon (64.7%) cancers than in rectal carcinomas (60.0%), and multiple aneuploid clones were detected more frequently in men than in women and in patients with advanced disease (Dukes stage D). Non-neoplastic mucosa adjacent to aneuploid tumors showed aneuploidy in 4 out of 51 samples (7.8%). The mucosa adjacent to diploid cancers had only diploid characteristics. Ploidy did not correlate with histological abnormalities. These findings suggest that DNA content as determined by flow cytometry needs further study with adequate follow-up to evaluate possible correlations with relapse-free and overall survival. Furthermore the aneuploidy of non-neoplastic mucosa provides evidence for a field defect in mucosa adjacent to colorectal cancer and supports the concept that this alteration may be of influence on carcinogenesis.
Adenocarcinoma↗
[Congenital cysts of the esophagus].
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Adult↗
[Correlation between histological findings and clinical behavior following surgery for portal hypertension in cirrhosis (author's transl)].
This is a retrospective study of 29 cirrhotic patients who underwent surgery for haemorrhage or ascites due to portal hypertension, carried out to look for any correlation between histological findings and clinical outcome. When Mallory's bodies and signs of activation are found, indicating that the cirrhosis is progressing, the clinical results are often discouraging. A careful choice of which cirrhosis patients are likely to gain from surgery should take account of selective histological criteria as well as full clinical and haemodynamic data.
Adult↗
Duodeno-gastro-esophageal reflux after gastric surgery: surgical therapy and outcome in 42 consecutive patients.
BACKGROUND/AIMS: Duodeno-gastro-esophageal reflux is a common event after gastric surgery and can result in severe symptoms and mucosal injury. Medical therapy is largely ineffective. The most common remedial operation consists of a long isoperistaltic Roux-en-Y limb in order to shunt duodenal contents away from the gastric pouch and the esophagus. METHODOLOGY: Between 1980 and 1996, 42 patients underwent duodenal diversion after gastric surgery. The presence of severe symptoms and/or endoscopic esophagitis unresponsive to medical therapy was considered an indication for surgery. Functional studies were performed in selected patients in an attempt to objectively document the presence of excessive duodeno-gastro-esophageal reflux. A 40-60 cm Roux-en-Y limb was constructed in all patients. RESULTS: There was no post-operative mortality. The median follow-up was 28 months (range: 5-114). Symptoms related to delayed gastric emptying persisted in 5 patients (11.9%). Overall, 32 patients (76%) had a Visick I-II score. Best results (90%) were achieved in patients with previous total gastrectomy. CONCLUSIONS: Roux-en-Y duodenal diversion should be reserved for patients with intractable symptoms and documented reflux, and is mostly effective after total gastrectomy. Patients with a residual stomach are less likely to benefit from the procedure, probably because an underlying motor disorder plays a major role in the pathogenesis of the symptoms than does the reflux of duodenal contents.
Adenocarcinoma↗
Diverticulitis of the caecum and ascending colon: an unavoidable diagnostic pitfall?
PURPOSE: The infrequency of right-sided colonic diverticulitis prompted this presentation of our experiences, with emphasis on the diagnostic aspects. PATIENTS AND METHODS: Charts and documentation regarding 20 patients who underwent surgery for diverticulitis of the caecum and/or ascending colon over 22 years were reviewed. RESULTS: Eleven patients underwent pre-operative instrumental examinations: right-sided diverticulitis was recognized in five patients (two by barium enema, two by both ultrasonography and computerized tomography, one by all three examinations) and was suspected in another four. All diagnoses on merely clinical grounds--acute appendicitis in 10 patients and perforated peptic ulcer in one--were erroneous. Surgery consisted of 13 right standard or limited hemicolectomies, six conservative procedures and one Mickulicz' operation and subsequent right hemicolectomy. No operative deaths or long-term failures were reported. CONCLUSIONS: In the presence of clinical features atypical of acute appendicitis, right-sided colonic diverticulitis should be taken into account; pre-operative instrumental examinations might increase diagnostic accuracy, thereby leading to a more correct therapeutic approach.
Adult↗
[Interposition meso-caval shunt for haemorrhage or ascites in hepatic cirrhosis. Report of twenty-eight cases (author's transl)].
The results are set out of emergency or electiver surgery for bleeding oesophageal carices or for intractable ascites in hepatic cirrhosis. The procedure adopted, a meso-caval shunt with prothesis interposition, led to a low percentage of thrombosis, markedly lowered portal pressure, and gave effective clinical results. Although angiography indicated that the portal flow to the liver had dropped considerably, or even ceased altogether, the bad effect on liver function and the incidence of encephalopathy seemed reduced than generally reported after porta-cava shunts. No deaths occurred among the patients for who surgery had been planned, but the rate was still high in emergency cases. This indicates that although well tolerated, the interposition meso-cava shunt is best performed after careful pre-operative selection and preparation.
Adult↗
[Present position of non-shunt surgery for bleeding oesophageal varices (author's transl)].
This is a critical retrospective study of a homogeneous group of 24 patients with hepatic cirrhosis and portal hypertension who underwent emergency surgery for bleeding oesophageal varices. The adopted procedure was the porta-azygos disconnection, according to Torres-Degni, with or without splenectomy. The criterion derived from the need to stop bleeding, from contraindications to a portal-systemic shunt, or from other situations which are illustrated. The difficulty of selecting in these cases the appropriate surgery and the high operative death rate (46%) is commented. In survivors, the long-term outcome depends on the progress of the underlying liver disease.
Adult↗
[Dissection-ligation of the oesophagus according to Vosschulte for bleeding varices (author's transl)].
Ligation of the oesophagus on a Vossschulte prosthesis provides interruption of the venous back-flow in gastro-oesophageal wall occurring in portal hypertension, and therefore renders more effective the disconnection techniques used for oesophageal varices when liver function is too severely impaired to permit a portal-systemic shunt. According the literature and their own initial experience, the Authors stresse the possibilities of the method in controlling active haemorrhage and preventing further bleeding, and discusse its possible complications, represented by portal thrombosis, fistulae and oesophageal stenosis. Unlike shunts, this procedure does not give rise to any worsening in hepatic function, but should nevertheless seriously considered especially if the oesophago-gastric junction is radically isolated.
Adult↗
[Further comments on changes in hepatic function after interposition meso-caval shunt (author's transl)].
Further to a previous paper, the Authors followed up ten cirrhotic patients who had all undergone meso-caval shunt with Dacron prosthesis, for ascites or haemorrhage, Functional and anzymatic investigations were carried on over periods up to 10 months. No constant changes in hepatic function parameters were found during the post-operative period, compared to those before surgery. This observation suggests that these investigations might be more useful in defining liver disease than in practical assessment of transient, post-operative liver failure.
Adult↗
[Mesenterico-caval shunt with interposition of a prosthesis for intractable ascites caused by cirrhosis].
The interposition mesocaval shunt is followed both by a splancnic and sinusoidal decompression, being for this reason considered not only the most effective peripheral porto-systemic shunt, but also one of the indicated operations in the treatment of intractable cyrrhotic ascites. Intractable cyrrhotic ascites was the main indication in 9 cases with very different clinical pictures treated by the Author with mesocaval shunt, having observed no operative mortality and resulting a complete disappearance of ascites in 8 out of 9 cases and of the cohexistent idrothorax in one case. Angiographic pictures showed the patency of the shunt with constant demonstration, after few months, of a reversal portal blood flow (sometimes present before operation). This shunting procedure proved to be a very well tolerated operation with only a transient postoperative modification of liver function tests, excepted for one case in which the patient was lost after seven months because of hepatic encephalopaty with progressive liver failure.
Adult↗