[The use of PERT in programming air rescue].
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Aerospace Medicine↗
Biomedical subjects
F Crucitti
Publications and source records attributed to F Crucitti.
Colorectal cancer. Epidemiology, etiology, pathogenesis and prevention.
Colorectal cancer (CRC) is a neoplasm with a steadily growing incidence in Western countries. Moreover the age of 50 and over is a critical risk factor. The relationship between dietary, environmental factors and CRC has been evaluated. At present, a number of genetic risk factors such as the genetic susceptibility, tumor suppressor genes and oncogenes are thought to play a major role. The correlation of CRC with adenomatous polyps and chronic inflammatory disease, ulcerative colitis in particular, has been evaluated. Prevention of CRC is mainly based on a rational diet and in the adoption of mass screening programmes.
Adult↗
Preoperative radiotherapy and IORT in resectable rectal cancer at high risk for local recurrence.
Over a 4-year period 35 patients with mid- (15 patients) and low (20 patients) rectal cancer clinically staged as T2 N1-2, T3 N0-2 underwent a protocol of combined surgery and radiotherapy. The protocol included: preoperative external beam radiotherapy (38 Gy, ICRU50); surgical resection; IORT on tumor bed (10 Gy). Toxicity of preoperative treatment was mild with a single case (2.9%) of grade 3 gastrointestinal toxicity. 18 patients underwent anterior resection and 17 abdominoperineal resection. Perioperative mortality and morbidity were 0% and 17.1% respectively. At a mean follow-up of 25 months all patients were alive. The single anastomotic recurrence observed was rescued with abdominoperineal resection.
Endoscopy↗
Preoperative concomitant radiochemotherapy and IORT in locally advanced rectal cancer.
34 patients with locally advanced (T4) or recurrent rectal cancer have been treated with: 1. external beam radiotherapy (45-48 Gy) + 5FU(1000 mg/m2/daily iv continuous infusion day 1-4) + MMC (10 mg/m2/daily iv, day 1); 2. surgical resection (if feasible) + IORT (10-15 Gy); 3. adjuvant chemotherapy (5FU+leucovorin, 6-8 cycles). Grade 3 acute hematological toxicity was observed in 1 case only. 23 of 34 patients underwent radical surgery. Perioperative mortality and morbidity was 0% and 17% respectively. In the 23 operated patients with a mean follow-up of 18.6 months there were 2 local recurrences, 5 blood metastases, (1 death of disease). 16 patients were shown to be NED (3-36 months).
Antibiotics, Antineoplastic↗
Excisional breast biopsy: when, why and how?
On 673 consecutive patients, excisional biopsy was performed on an outpatient basis using local anesthesia when a palpable breast lump was thought to be benign on clinical, mammographic and cytologic grounds (213 cases) or when the suspicion of cancer was low (100 cases). General anesthesia was performed when the mass was considered to be malignant or highly suspicious for cancer (360 cases). The percentage of correct preoperative diagnosis of benignancy was 96.2% (12 cancers in the outpatient group) and that of malignancy was 98.1% (7 benign lesions in the inpatient group). These data indicate that in the absence of malignant or highly suspicious preoperative findings breast biopsy should be performed under local anesthesia: it is a safe and more economical procedure in terms of medical costs, surgeon's time and patient's anxiety. On 60 patients breast biopsy was performed for non palpable breast lesions detected by mammography. Nineteen cancers were found (35%): the highest percentage was in stellate opacities and in highly suspicious microcalcifications (positive predictive value-PPV-of 45% and 50%, respectively). No cancer was detected in low density masses and in non suspicious calcifications: so, in such patients biopsy should not be recommended for the unacceptable overall biopsy cost.
Adult↗
[Technical aspects of neorectum: restorative proctocolectomy].
In the last decade, restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is considered as the procedure of choice in the surgical management of most patients with familial adenomatous polyposis and chronic ulcerative colitis. Beyond the attraction of this operation, which permit to completely remove disease-bearing mucosa, spare the anal sphincter, and avoid a permanent ileostomy, it remains a difficult procedure with not negligible complication rate. Correct operative technique is required: to the purpose, main technical aspects of IPAA are analysed.
Adenomatous Polyposis Coli↗
Diagnostic and therapeutic ERCP in patients with Billroth II gastrectomy.
Diagnostic and therapeutic endoscopic cholangio- pancreatography (ERCP) are more difficult in patients with Billroth II gastrectomy. A six-year experience including 274 ERCP in 175 Billroth II patients is reviewed. Overall diagnostic success-rate was 88.3% while a complete endoscopic treatment could be accomplished in 92.8% when indicated. Endoscopy related morbidity and mortality were 5.1% and 0 respectively, while in-hospital mortality was 2.3%. Diagnostic and therapeutic ERCP techniques in Billroth II patients are then discussed with special reference to the choice of the scope and of the accessories to perform a safe endoscopic sphincterotomy. The use of the lateral-viewing duodenoscope and of the long-nose sigmoid inverted sphincterotome (originally modified by our group) are emphasized. ERCP and endoscopic sphincterotomy in Billroth II subjects are today as safe and nearly as effective as in the non-gastrectomized patient.
Adult↗
[Carcinoid neoplasms of Vater;'s ampulla. Apropos a case examined].
Carcinoid tumors of the ampulla are an uncommon finding. The authors report an asymptomatic case of ampullary carcinoid in which the diagnosis was obtained only with definitive histology after radical surgery. The differential diagnosis of these tumors is quite difficult, mostly because they are often asymptomatic. Surgery seems to be the only effective therapy of these lesions; a wide resection with regional lymphectomy should be performed in all cases. Although the prognosis of ampullary carcinoids looks better than for adenocarcinoma and it is related to the tumor size, the history in this case suggests a more extensive indication for radical surgery.
Ampulla of Vater↗
Endoscopic diagnosis and treatment of malignant biliary strictures: review of 505 patients.
The role of ERCP and endoscopic drainage in the diagnosis and treatment of patients with malignant biliary obstruction is well established. Endoscopic drainage is an effective therapy for palliation of malignant obstructive jaundice and does not preclude definitive treatment in appropriate candidate. We report our experience, in a retrospective review, of 505 patients with malignant biliary obstruction. In this series, endoscopic biliary drainage is shown to be safe and effective management for these patients. Relief of obstruction was obtained in a large majority of patients with a low, procedure related, morbidity and mortality. We conclude that ERCP, to diagnose and localize obstructive lesions, followed by endoscopic biliary drainage can be strongly considered in all patients with suspected malignant obstructive jaundice.
Adolescent↗
Carcinoma of the pancreatic head area. Epidemiology, natural history and clinical findings.
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Aged↗
Carcinoma of the pancreatic head area. Therapy: resectability and surgical management of resectable tumors.
Surgical resection is being increasingly performed for carcinomas of the area of the head of the pancreas with curative intent. Pre-and intraoperative assessment of the site of origin and the stage of the lesion is of the utmost importance for a more favorable prognosis of non pancreatic forms and for a better evaluation of long term results of treatment adopted. Staging of non pancreatic periampullary tumors is usually very precise since they are most often shown to be resectable on laparotomy. Surgical resection by pancreaticoduodenectomy is the treatment of election based on good long term results. To the contrary, problems involved in the carcinoma of the head of the pancreas are non negligible. Some aspects related to the criteria of resectability of these tumors (diameter of primary lesion, infiltration of adjacent organs and large vessels, lymph node involvement) are discussed. How extensive pancreatic resection (subtotal, total or regional pancreatectomy) should be, is still a debated subject. In fact, it is not directly proportional to an improvement in prognosis. Complementary treatments directed to the improvement of the disappointing results at present achieved with surgery alone, are desirable.
Humans↗
Carcinoma of the pancreatic head area. Therapy: intraoperative radiotherapy.
Pancreatic tumors represent a major field of application of intraoperative radiotherapy (IORT) with electron beams. First clinical studies were carried out principally on unresectable tumors and control of pain was observed in most of them. However, as for prognosis, IORT alone has yielded disappointing results. The use of IORT to boost external beam radiotherapy (ERT) frequently applied in recent trials, has improved local control but not survival rate because of the high incidence of abdominal metastasis. To-date, results of IORT used as an adjuvant to radical surgery have been controversial. As in unresectable tumors, studies have been focused on the combination IORT+ERT, however the intensification of the dose delivered to the tumor bed and the consequent better local control has not resulted in a better prognosis. A more significant contribution of IORT to the treatment of pancreatic tumors may come in the future from the combination of IORT with more effective methods in the control of the abdominal disease ("prophylactic" ERT to the liver or upper abdomen, intra-arterial or intraperitoneal chemotherapy) or from variously timed combinations with ERT (neoadjuvant ERT+IORT).
Combined Modality Therapy↗
[Incidental discovery of adrenal neoplasms: our experience].
Incidental radiologic diagnosis of clinically silent adrenal masses is reported with increasing rates. Between 1981 and 1994 we observed 30 patients with "incidentaloma": for each of them a careful hormonal and instrumental evaluation was obtained. 24 patients were surgically treated. No significant biochemical alterations were observed; ETG, TC and RMN had a sensitivity of 86%, 93% and 83%, respectively. At seleno-cholesterol scintigraphy 5 incidentalomas (all adenomas) had a concordant pattern and 5 (none of these adenoma) had a discordant pattern. MIBG scintigraphy showed an uptaking ganglioneuroma. The observed histotypes were: 10 adenomas, 3 cysts, 1 hematoma, 1 myelolipoma, 1 angiomyolipoma, 1 ganglioneuroma, 1 ganglioneurofibroma, 1 paraganglioma, 1 aspecific granulomatous necrosis, 4 cortical carcinoma and 3 metastatic lesions. We did not observe any postoperative acute adrenal failure. The main problem raised by incidentalomas is to define their nature; hence the need of a careful hormonometabolic, morpho-functional and instrumental evaluation. The available diagnostic procedures, even when combined, cannot always define if an incidentaloma is a benign or a malignant lesion: in the current clinical practice, the size of the mass is still the most important criterion to define a therapeutic approach. Surgical excision is mandatory in presence of an hormonal production, even subclinic, and/or a large size of the mass (over 5 cm). If the tumor size is less than 5 cm, an aggressive strategy may be chosen in selected low-risk patients, because of the low morbidity of adrenalectomy. In our experience, the transperitoneal subcostal approach has been adopted routinely with good results.
Adenoma↗
Cystic neoplasm mistaken for pancreatic pseudocyst.
The authors report a case of cystic neoplasm of the pancreas treated by cystojejunostomy two years and half earlier. On that occasion, a false diagnosis of pancreatic pseudocyst had been suggested. Cystic neoplasm of the pancreas has a far better prognosis than adenocarcinoma. However, early detection is difficult and erroneous initial diagnosis may lead to delayed treatment and poor long-term results. In our case, though surgical treatment was aggressive and apparently radical, early recurrence of neoplasm was observed. Only early accurate diagnosis of pancreatic cystadenocarcinoma might improve the results of surgical treatment.
Cystadenocarcinoma↗
[Aorto-iliac aneurysms and associated gastrointestinal neoplasms. Treatment problems].
In patients affected by aortoiliac aneurysm the concurrent presence of a gastrointestinal tumor is a not infrequent occurrence which poses problems of therapeutic approach (one step operation or prior treatment of one of the two diseases; in the latter case definition of timing and sequence of the surgical treatment). Three cases are reported where an eclectic therapeutic approach has enabled satisfactory results. A patient with an isolated aneurysm of right hypogastric artery associated with rectal cancer was treated with percutaneous embolization of the aneurysm and subsequent excision of the tumor. In a patient with a neoplasm of the left colon and aortic aneurysm, the aneurysm was treated first and after about a month the tumor was resected. In a patient with gastric cancer and aortic aneurysm subtotal gastrectomy was first performed and subsequently, after about 3 months, the aneurysm was treated by extraperitoneal route. Even if an unidirectional approach cannot be defined, it is thought that the two-step treatment of the associated diseases is preferable. In the presence of non stenosed non bleeding colorectal tumors it seems more suitable to treat the aneurysm first (increased postoperative risk for rupture of the aneurysm; more difficult preparation of subrenal aorta in the presence of cicatricial outcomes of colonic surgery; persistence of perianastomotic infections after colonic resection). Gastric tumors should be treated first for their higher biological aggressiveness and unfeasible correct preoperative staging. In particular cases (single unilateral aneurysm of a hypogastric artery associated with gastrointestinal cancer), non surgical treatment of the vascular lesion (embolization during angiography) is the treatment of choice.
Adenoma, Villous↗
Treatment of deep vein thrombosis.
At present, most common initial treatment of deep vein thrombosis is anticoagulant therapy with i.v. heparin. Recently, some reports in literature suggest the efficacy of low molecular weight heparin fractions administered also to outpatients. Thrombolytic therapy as compared to heparin seems to be favorable as for the valvular integrity and function with minor postphlebitic sequels. It is however burdened with a higher incidence of hemorrhagic complications. Probably, it should be reserved for those patients with massive phlebothrombosis or phlebothrombosis associated with relevant clinical signs. At present, it has not definitely been proved that one of the commonly used drugs, streptokinase, urokinase and r-TPA affords substantial advantages in terms of efficacy and safety. Locoregional administration by a catheter inserted into the thrombus with the protection of a caval filter enhances the efficacy of thrombolytic agents, even if data on long-term results of this method are still lacking. Discordant opinions exist on the validity of thrombectomy. As a prophylaxis of pulmonary embolism, thrombus removal has been replaced by caval filters. At present it is commonly indicated for phlegmasia coerulea dolens. In the other forms, even if the vascular patency is restored in a good percentage of cases, it is not similarly effective in preventing the postphlebitic syndrome. For these reasons it should be applied in selected cases.
Anticoagulants↗
Modified Hill operation vs. Nissen fundoplication in the surgical treatment of gastro-esophageal reflux disease.
BACKGROUND/AIMS: The authors compared the results of the Nissen fundoplication technique with the results of the Hill procedure, by using a 10-year history of patients with gastro-esophageal reflux disease. MATERIALS AND METHODS: Seventy two consecutive patients entered the study, 32 of whom underwent a 360 degrees fundoplication according to Nissen and 40 with a modified Hill operation. In the Nissen Group, intraoperative manometry (IOM) was carried out in all patients; in the Hill Group, the patients were randomized in two sub-groups (A and B), before operation; in 20 of them (group A), the procedure was randomly associated to IOM. RESULTS: The overall complications were low in both groups (15.6% in the Nissen Group and 5% in the Hill Group, p = 0.1), and there was no mortality rate. The clinical results were excellent or good in 28 patients (87.6%) of the Nissen Group and in 36 patients (90%) of the Hill Group (p = 0.5); in particular, an excellent outcome was observed in 16 patients (80%) with IOM (sub-group A), while 12 patients (60%) without it (sub-group B) showed similar results. The manometric studies carried out six months after surgical treatment showed a decrease of the lower esophageal sphincter pressures in all patients if compared to the pressure recorded intra-operatively. In comparison to the pre-operative values, both the lower esophageal sphincter length and its intra-abdominal portion were markedly increased in the Nissen Group and in the sub-group A of the Hill patients. CONCLUSIONS: These results support the conclusions that modified posterior gastropexy and 360 degrees fundoplication are effective, well tolerated, and can be properly used in the treatment of Gastro-esophageal reflux disease (GERD), since both techniques showed good clinical results. A favorable clinical outcome depends mostly on adequate lower esophageal sphincter length (LESL) and LESIA extension, which could be more efficiently achieved by the use of intraoperative manometry (IOM).
Adult↗
Radical surgery for liver hydatid disease: a study of 89 consecutive patients.
BACKGROUND/AIMS: This study was designed to evaluate the effectiveness of radical surgery for liver hydatid disease. MATERIALS AND METHODS: Hospital charts of 104 consecutive patients with liver hydatidosis observed in our unit during the period 1982-1994 were reviewed. A total of 121 cysts in 89 patients were treated surgically: with cystopericystectomy in 66 and liver resection in 23. RESULTS: The overall incidence of postoperative complications was 19%: 19.7% and 17.1% after cystoperi-cystectomy and liver resection respectively (p = 0.32). Overall postoperative mortality was 1%. Among the 72 patients available for follow-up, only one (1%) had a local recurrence of the disease. CONCLUSIONS: Results suggest the safety and efficacy of radical procedures in the surgical management of liver hydatid disease. Total cystopericystectomy is the treatment of choice but liver resection is justified in selected cases.
Adult↗