SEARCH · Search PubMed
Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.
Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.
A case of portal hypertension is presented in which because of the presence of multiple thromboses of the main portal branches one of the usual portasystemic shunts could not be performed. An anastomosis between an enlarged left gastro-epiploc vein and the left renal vein was successfully carried out. Six months after surgery the patient was well and no further haemorrhage had occured.
BACKGROUND: Fibrolamellar hepatocellular carcinoma (FL-HCC) is a rare variant of hepatocellular carcinoma, has distinct pathologic features, and typically occurs in young patients without underlying hepatitis or cirrhosis. METHODS: Forty-one patients with the pathologic diagnosis of FL-HCC evaluated at our institution between 1986 and 2003 were identified from a prospective database. RESULTS: Median age of all patients was 27 years. None of these patients had underlying hepatitis or cirrhosis, and only 3 (7%) patients had an alpha-fetoprotein level > 200 ng/mL. Twenty-eight patients with primary disease underwent complete gross resection, and 13 patients were unresectable. In patients treated with resection, median tumor size was 9 cm (range, 3-17), 9 (36%) had vascular invasion, and 14 (50%) had lymph node metastases. There were no perioperative deaths. With a median follow-up of 34 months, 5-year overall survival for resected patients was 76%. However, 5-year recurrence-free survival was only 18%, and of the 9 resected patients with more than 5 years of follow-up, 7 had recurrences. Lymph node metastasis was the only significant negative prognostic factor. Seventeen (61%) patients underwent a second operation for recurrent disease. Median survival for unresected patients with FL-HCC was only 12 months, and no patient survived beyond 5 years. CONCLUSIONS: FL-HCC occurs in a distinctly different population of patients than common HCC, and patients with FL-HCC generally fare better after complete resection. These tumors have a relatively indolent tumor biology, and late recurrences are common. Repeat resections for recurrence should be considered given the lack of other effective treatment options.
Some 150 tumor specimens from 49 patients with non-small-cell carcinoma of the lung (23 epidermoid, 14 adenocarcinoma, 12 large-cell carcinoma) and three with nonneoplastic lung disease were analysed for cellular DNA content by flow cytometry. Monodispersed cells were stained with ethidium bromide and mithramycin. Normal specimens and samples from patients with nonneoplastic disease constantly yielded a single cell population with diploid DNA content. Twenty of 23 epidermoid carcinomas exhibited one or more than one aneuploid subpopulation. Ten of 12 large-cell carcinomas were characterized by one aneuploid clone and 2/12 by two aneuploid clones. Adenocarcinoma exhibited multiclonal cell subpopulations (one to five aneuploid clones). Further information has been obtained on the differential presence of clones in various tumor areas and in infiltrated lymph nodes. These tumors appear characterized by a remarkable degree of cellular heterogeneity. The cytometric ploidy level(s) and the cell population multiclonal structure yield, in comparison with, and in addition to, pathology, indications of possible clinical interest. A correlation between the clonal DNA content and a prognostic parameter such as the tumor mass doubling time has been demonstrated.
Explore the source record for details and available documents.
Antiphospholipid antibodies are associated with fetal distress and fetal death. Although different therapeutic regimens have been used, the incidence of fetal growth retardation varies between 30 and 60 per cent of reported cases. We report the evolution of fetal growth in patients with antiphospholipid antibody syndrome treated with high-dose intravenous immunoglobulins (IVIG). Fourteen patients with a history of recurrent spontaneous abortion and immunological diagnosis of antiphospholipid syndrome were followed longitudinally. Intravenous immunoglobulin at a dose of 0.5 g/kg body weight for two consecutive days was started from the fifth week of pregnancy and repeated every 4 weeks until the 33rd week of gestation. Fetal biometry was evaluated longitudinally from the appearance of the gestational sac at 4 weekly intervals. In the period between 26 and 34 weeks, the frequency of evaluation was increased to every 14 days. Data obtained were compared with a control group of 70 fetuses with uneventful pregnancies matched for gestational age. Neonatal weight is shown in relation to the centiles for the normal population. One patient out of 14 (7.1 per cent) developed gestational hypertension and abruptio placentae. No other pregnancy complications were seen. No proteinuria was found. The mean maternal age was 31.2 +/- 3.8 years. Median birth weight was 3433 g +/- 287. The median centile of the birth weight was 65.3 +/- 18.6. Mean gestational age at delivery was 1.3 weeks. No fetal or neonatal growth retardation was seen.(ABSTRACT TRUNCATED AT 250 WORDS)
The role of pulsed high-dose dexamethasone (DXM) in the treatment of patients with chronic idiopathic thrombocytopenic purpura (ITP) is still uncertain. Following an early report in which it was described as an effective and well-tolerated treatment with a sustained platelet response in 100% of cases, a number of subsequent studies have failed to confirm such favorable results. As all these studies were conducted on small numbers of patients, we investigated further the effectiveness and side effects of this therapeutic modality in a larger cohort. Thirty-two patients with chronic ITP were scheduled to receive six monthly courses of intravenous DXM at the dose of 40 mg/day for 4 consecutive days. All patients had ITP that had been resistant to between two and five different therapeutic regimens, including 9 patients who had already failed splenectomy. All patients had to be seen 2 weeks after each cycle to asses their response as well as secondary effects. Three patients failed to respond and clinically required other therapy. Thirteen patients (41%) had a partial (platelet count between 50 and 100 x 10(9)/liter) or complete (platelet count >100 x 10(9)/liter) response to treatment, responses being mostly transient. Responses were observed early during the course of treatment, usually right after the first cycle of DXM. There were no late responses. Side effects were mild and did not require discontinuation of treatment. No clinical or laboratory parameter was found to predict treatment outcome. We conclude that high-dose DXM has a limited effect in patients with chronic ITP. Novel approaches and controlled multicenter trials may help identify new therapeutic strategies for this disease.
Since 1989 a national health system (NHS) has been in effect in Italy based on the constitutional principle that health care is a right of all citizens. Until 1992 the NHS had a secondary role in medical education, as the 33 medical schools for postgraduate training are under the control of the Ministry of University. The European Community legislation allowing free movement of M.D.s and specialists between member countries has resulted in standardization of teaching programs and formative curricula in the European Community. Therefore beginning in 1992, every 3 years the Ministry of Health and University establishes the number of specialists that can meet the needs of the NHS and allocates funds to each school for the salary obligations. The actual number of paid residents for surgical specialties is 941 per year (192 for general surgery). Until recently surgical training in Italy was mainly theoretic, as no legislation guaranteed that physicians in training would perform surgery. New legislation, increased exchanges with European hospitals, and improved and loyal cooperation between universities and the NHS will certainly improve the situation in coming years.
The prognostic value of DNA ploidy status was evaluated prospectively in 70 patients with colorectal carcinoma. Cellular DNA content was measured by flow cytometry from fresh specimens with multiple site sampling. Seventy-five percent of cases exhibited a DNA aneuploid pattern. In a univariate analysis, DNA ploidy status showed a statistically significant correlation with survival (p less than 0.05), weaker than Dukes' stage (p less than 0.001). No correlation was observed between survival and presence of multiple DNA stemlines. In a multivariate analysis, Dukes' stage was the strongest prognostic indicator (p = 0.01) while DNA ploidy status did not show an independent prognostic value. It is concluded that DNA ploidy status is associated with pathological features of aggressive malignancy, but it does not have a determinant role in predicting survival.
Explore the source record for details and available documents.
Sixty-six consecutive patients who underwent curative resection for rectal cancer were studied prospectively to evaluate the roles of sequential carcinoembryonic antigen (CEA), tissue plasminogen activator (TPA), and carcinomatous antigen 19-9 (Ca 19-9) determinations in the early diagnosis of resectable recurrences. Thirty-three recurrences were detected between 6 and 42 months. CEA, TPA, and Ca 19-9 showed a sensitivity of 72.7 percent, 78.8 percent, and 60.1 percent, respectively, and a specificity of 60.6 percent, 60.6 percent, and 87.9 percent, respectively. In 23 cases the rise in the value of CEA and/or TPA and/or Ca 19-9 was the first sign of recurrences, and the diagnosis was established later by clinical methods. In this group, the lead time was two months for liver metastases and four months for disseminated metastases. As far as the relationship between localization of recurrence and marker level increase is concerned, of 16 hepatic metastases CEA, TPA, and Ca 19-9 showed a sensitivity of 94 percent (P less than 0.05), 69 percent, and 62 percent, respectively. Of six patients with local recurrences, CEA, TPA, and Ca 19-9 showed a sensitivity of 50 percent, 100 percent (P less than 0.05), and 83.3 percent, respectively. Of three patients with peritoneal carcinomatosis, CEA, TPA (P less than 0.05), and Ca 19-9 showed a sensitivity of 0 percent, 100 percent, and 0 percent, respectively. No significant differences were reported among the three markers according to multiple metastases and metachronous polyps. Fourteen patients (42.4 percent) underwent surgical treatment for recurrent disease, and eight of them (57 percent) showed a resectable disease, for a total resectability rate of 24.2 percent. The findings of our study indicate that a follow-up program based on CEA, TPA, and Ca 19-9 assays is related to an early diagnosis and a good resectability rate for both local and metastatic recurrences from rectal cancer.
PURPOSE: The authors evaluate the effectiveness of routine colonoscopy and marker evaluation in diagnosis of intraluminal recurrent cancer. METHODS: Chart review was conducted on 481 patients who underwent curative resection for colorectal cancer between 1980 and 1990. Clinical visits were scheduled and carcinoembryonic antigen evaluation was performed every three months, and colonoscopy was performed preoperatively, 12 to 15 months after surgical treatment, and then with intervals of 12 to 24 months or when symptoms appeared. RESULTS: About 10 percent of patients developed intraluminal recurrences. More than one-half of metachronous lesions arose within the first 24 months, and median time to diagnosis was 25 months. Patients with left-sited tumors in the advanced stage had a higher risk of developing recurrent intraluminal disease. Twenty-nine patients underwent a second surgical operation, of which 17 cases were radical. In this group, the five-year survival was 70.6 percent, although no nonradically treated or nonresected patients survived longer than 31 months. Twenty-two patients were asymptomatic at time of diagnosis of recurrence, and of these, 12 patients underwent radical operation; on the other hand, of the 24 symptomatic patients, only 5 were treated radically. Carcinoembryonic antigen was the first sign of recurrence in eight cases. Colonoscopy must be performed within the first 12 to 15 months after operation, whereas an interval of 24 months between examinations seems sufficient to guarantee early detection of metachronous lesions. CONCLUSION: Serial tumor marker evaluation is of help in earlier diagnosis of local recurrences. Asymptomatic patients more frequently undergo another operation for cure and thus have a better survival rate.
The role of surgery in the treatment of immune thrombocytopenic purpura (ITP) is still discussed. The aim of this study was to verify our criteria of patient selection for splenectomy, to analyze the results of a protocol for the evaluation of the hemorrhagic risk, and to discuss long-term results of 70 patients with ITP who underwent surgical treatment from 1984 to 1990. All patients received steroid therapy. Sixty-two patients were given high doses of IgG (600 mg/kg/iv bolus) pre-operatively in order to obviate the need for intra-operative platelet transfusions. Forty-three patients showed a significant increase in the platelet count, 8 a moderate increase, while 11 patients did not respond. No operative mortality was observed, however postoperative minor complications occurred in 14 (20%) patients. Accessory spleens were found in 11 (15.7%) patients. Mean follow-up was 21 months. Response to splenectomy was considered as complete (platelets greater than 150,000 mm3 with no need for medical treatment) in 63 (90%) patients. No response was observed in 7 patients. In 2 of the non-responders postoperative indium-111 scan revealed accessory spleens and ITP remitted after accessory splenectomy. All non-responders were in the group of patients who did not respond to the pre-operative infusion of high dose IgG. It can be concluded that splenectomy is a safe and effective treatment for ITP and that response to pre-operative infusion of IgG may be considered as predictive for the outcome after splenectomy.
The treatment by Western countries of bleeding from esophageal varices was reviewed from three definite viewpoints: prevention of first bleeding or prophylactic treatment, control of acute bleeding or emergency treatment, and prevention of rebleeding or elective treatment. Even though prophylactic surgery has been abandoned on the basis of several randomized studies, some authors still perform esophageal transection and report encouraging results. In emergency situations, the role of surgery has been limited by the prohibitive hospital mortality and by the introduction of vasoactive drugs and endoscopic sclerotherapy. Nevertheless, good immediate and long term results have been obtained in specialized centers in which bleeding patients undergo surgery no later than 8 hours after their admission. As regards the prevention of rebleeding, non selective portal decompression gives adequate protection against rebleeding, however, hepatoencephalopathy follows in considerable incidence. In order to avoid this complication, direct operations on varices have been performed, largely with good results. The Warren shunt offers results showing advantage over the non-selective shunt in the first postoperative period but later on, it behaves hemodynamically as a total shunt and the advantage is then cancelled. We report herein a review of the literature and also describe our personal experience with treating bleeding esophageal varices.
Primary squamous-cell and adenosquamous-cell carcinoma of the colon are uncommon and their characteristics not well known. This paper reports the clinical features and pathologic findings of two colonic adenosquamous carcinomas and reviews other reports of adenosquamous and squamous carcinoma of the colon from the English medical literature. Including these two cases, 63 cases have been reported since 1927. Of these, six occurred in patients with ulcerative colitis, three occurred at the colonic opening of chronic colocutaneous fistulas, and concomitant schistosomiasis was present in two patients. Synchronous squamous-cell carcinoma of the colon was present in 3.2 percent of cases and 10 percent had either antecedent, synchronous, or metachronous adenocarcinoma of the colon. These lesions appeared to be distributed uniformly throughout the colon. The five-year survival after resective therapy for primary squamous-cell and adenosquamous-cell carcinoma of the colon calculated with life table analysis is 50 percent for Dukes' B lesions, 33 percent for Dukes' C lesions, and 0 percent for Dukes' D lesions.
A new technique of transcatheter wiring of unresectable aortic aneurysm is described that provides simultaneous transcatheter occlusion of both common iliac arteries followed by axillofemoral bypass. The spring coil used for aortic aneurysm wiring was of our own making. The outer portion of a movable core stainless steel guidewire was bent in a coil shape and introduced into the aneurysm through a 7 French Teflon catheter via the right femoral artery. The same catheter was also used for coil embolus occlusion of both iliac arteries.
Various authors have suggested that laparoscopic adrenalectomy (LA) leads to better surgical outcomes than open surgery. The debate is still open, however, and indications and limitations of minimally invasive surgery have not been completely established. The objective of our study was to compare surgical outcomes of LA and open adrenalectomy (OA), using multivariate analysis to adjust for potential confounding factors (e.g., size of the lesion, histology). Between 1995 and June 2000 at "Careggi" Hospital in Florence, Italy patients with an indication for adrenalectomy were treated laparoscopically if the lesion was < 10 cm and there was no clinical evidence of malignancy. All 79 patients who underwent LA have been included in this study. Among 152 patients who underwent OA at "La Sapienza" University in Rome, 93 had an adrenal lesion < 10 cm and no clinical evidence of malignancy; they were selected for comparison. Multivariate analysis has been used to analyze the effect of the surgical approach (OA vs. LA) on the surgical outcome, controlling for potential confounders. Multiple logistic regression showed that there is no significant difference in intraoperative outcomes (i.e., surgical time > 2 hours, blood loss > or = 500 ml) between patients operated on through a traditional approach and those who underwent LA. On the other hand, patients operated on laparoscopically have a significantly higher probability than the OA group of experiencing a better recovery from surgery (i.e., require less postoperative analgesics and return to normal activities earlier). The results of the present study show that, although LA does not add much benefit in terms of expected intraoperative outcomes, it dramatically speeds patients' recovery from surgery. The two approaches are complementary and should both be integrated into the technical background of all endocrine surgeons.
BACKGROUND: Since its first description in the early 1990s, minimally invasive Heller myotomy has become the treatment of choice for esophageal achalasia. We report the experience of a single unit with thoracoscopic Heller myotomy (THM) and laparoscopic Heller myotomy (LHM) and we analyze the short- and long-term surgical outcomes in patients treated by each of the two approaches. METHODS: We evaluated retrospectively 33 patients who underwent surgical treatment for achalasia. Sixteen patients underwent THM without an antireflux procedure, and 17 patients underwent LHM and partial anterior fundoplication (n = 10) or closure of the angle of His (n = 7). RESULTS: Mean operative time was significantly shorter for LHM than for THM (150 vs 222 min, respectively) (p = 0.0001). Mean hospital stay was significantly shorter after LHM than after THM (2.0 +/- 1.0 vs 5.1 +/- 2.2 days, respectively) (p = 0.0001). Six of 16 patients (37.5%) in the THM group experienced persistent or recurrent dysphagia compared to one of 17 patients (5.8%) in the LHM group (p = 0.04). Heartburn developed in five patients (31.2%) after THM and in one patient (5.8%) after LHM (p = 0.07). Regurgitation developed in four patients (25%) after THM and in one patient (5.8%) after LHM (p = 0.149). Lower esophageal sphincter (LES) basal pressure decreased significantly from 30.1 +/- 5.07 to 15.3 +/- 2.1 after THM and from 32.1 +/- 5.9 to 10.5 +/- 1.7 after LHM (p = 0.0001). Mean esophageal diameter was significantly reduced after LHM compared to THM (from 54.5 +/- 5.7 mm to 27.1 +/- 3.3 mm vs 50.8 +/- 7.6 mm to 37.2 +/- 6.9 mm, respectively) (p = 0.0001). CONCLUSION: In our experience, LHM is associated with a shorter operative time and a shorter hospital stay, and it is superior to THM in relieving dysphagia. LHM with partial anterior fundoplication should be considered the treatment of choice for achalasia.
Explore the source record for details and available documents.