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A Peracchia

Publications and source records attributed to A Peracchia.

At least 55 records · Page 3Linked to original sources
PubMed1999

Esophageal function studies in the management of gastroesophageal reflux disease.

BACKGROUND: Esophageal function testing, i.e. esophageal manometry and 24-h pH monitoring, are usually carried out to diagnose gastroesophageal reflux disease (GERD) in patients with atypical symptoms, when there is no evidence of esophagitis at endoscopy, or following previous unsuccessful surgery. Additionally, these studies should be considered mandatory before surgery to confirm the diagnosis and to tailor the procedure to the motility pattern of the individual patient. AIM: The aim of this study was to assess the role of esophageal function studies in the management of patients with GERD. METHODS: Patients with a mechanically defective lower esophageal sphincter (LES) and abnormal esophageal acid exposure proven at 24-h pH monitoring were considered for surgery. A 360 degrees fundoplication (Nissen) was performed in patients with good esophageal motility, whereas a partial 180 degrees fundoplication (Toupet) in patients with a defective motility. Five hundred and eighty-six patients were referred to our laboratory for symptoms suggestive of GERD between November 1992 and April 1999. RESULTS: Twenty-four hour esophageal pH monitoring was positive in 65.5% of these patients; manometry showed a defective lower esophageal sphincter and a defective esophageal body motility in 57.8% and 21.7% respectively. One hundred and two patients underwent a total fundoplication, and 43 patients a partial wrap. At a mean follow-up of 36 months (range 5-69) the actuarial success rate in the control of reflux was 90%. Three (2.9%) patients undergoing a Nissen fundoplication complained of persistent dysphagia; two of them had preoperative esophageal body dysfunction. CONCLUSION: Esophageal function studies allow proper selection of patients for surgery and guide in the choice of the antireflux operation.

Adult↗
PubMed1998

Minimally invasive surgery for Zenker diverticulum: analysis of results in 95 consecutive patients.

OBJECTIVE: To assess the effectiveness of transoral stapled diverticulum esophagostomy in relieving symptoms and decreasing outflow resistance at the pharyngoesophageal junction in patients with Zenker diverticulum. DESIGN: Cohort study. From April 1, 1992, until May 31, 1996, the operation was attempted in 95 patients. The median follow-up was 23 months (range, 13-48 months). SETTING: Tertiary care university hospital. PATIENTS: There were 74 men and 21 women, with a median age of 64 years (age range, 37-92 years). All complained of dysphagia and pharyngo-oral regurgitation, and 18 (20%) suffered from recurrent aspiration pneumonia. The median size of the pouch measured by flexible endoscopy was 4 cm (range, 2.5-8 cm). INTERVENTION: The septum between the diverticulum and the esophageal lumen was divided under general anesthesia using a linear endostapler introduced through a Weerda endoscope. In most patients, 2 applications of the endostapler with a modified anvil were used. Operative time averaged 23 minutes. MAIN OUTCOME MEASURES: Morbidity, symptom score, patient's satisfaction, videofluorographic barium transit, hypopharyngeal intrabolus pressure, upper esophageal clearance of radioisotope. RESULTS: A switch to open surgery was required in 3 patients (3.1%), due to difficult exposure of the common wall in 2 cases and a mucosal tear in the other. No postoperative morbidity or mortality was recorded. Oral feeding was started the following day and the median hospital stay was 3 days (range, 2-8 days). Five patients complained of persistent symptoms; 3 of them underwent another endosurgical operation, 1 underwent laser treatment by means of flexible endoscopy, and 1 eventually required open surgery. All patients are asymptomatic at the latest follow-up visit. Postoperative radiologic studies showed free flow of barium in all patients. Manometry showed a significant reduction of hypopharyngeal intrabolus pressure over preoperative values (P=.003). Radionuclide studies showed a significant reduction of upper esophageal residual activity at 1 minute compared with preoperative values (P=.006). CONCLUSIONS: Endosurgical approach to hypopharyngeal diverticula larger than 2 cm is safe and effective. Symptom relief, elimination of the pouch, and decreased outflow resistance at the pharyngoesophageal junction can be obtained without morbidity and with a short hospital stay.

Adult↗
PubMed1998

Curative surgery for colorectal cancer: long-term results and life expectancy in the elderly.

PURPOSE: The long-term prognosis after curative surgery for colorectal cancer was evaluated in relation to age and life expectancy as a possible basis for assessing the risk to benefit ratios in the elderly. METHODS: Data relating to 1,256 patients operated on from 1976 to 1994 were stored in a computer database prospectively from 1987. Patients were subdivided into four age groups (A = <60 years; B = 60-69; C = 70-79; D = > or =80). Distribution of general contraindications to curative surgery was examined. In the 869 patients who underwent curative treatment (A = 206; B = 256; C = 289; D = 118), distribution of tumor stage and elective/emergency surgery and the operative mortality rate were evaluated. Crude and age-corrected survival curves were calculated in 794 patients. The median crude survival of each group was related by gender and tumor stage to demographic life expectancy, assuming as "relative median survival index" the ratio between the two values. RESULTS: General contraindications to curative surgery increased significantly with age. The operative mortality rate was higher in Group D than in Groups A, B, plus C over the total series (P < 0.001) and in both elective (P < 0.001) and emergency surgery (P < 0.05). Intergroup analysis of long-term survival rates showed significant differences between "crude" (P = 0.0057) but not age-corrected (P = 0.66) curves. The relative median survival index increased with age, up to approximately 1 in the local stages of Groups C and D. CONCLUSIONS: To evaluate long-term results, elderly patients should be compared with unaffected, same-age subjects. Because the risks may be very high, the surgical policy in the elderly should be carefully weighed and related to life expectancy and actual results.

Adult↗
PubMed1998

Role of follow-up in management of local recurrences of colorectal cancer: a prospective, randomized study.

PURPOSE: This prospective, randomized, single-center study was designed to evaluate the influence of follow-up on detection and resectability of local recurrences and on survival after radical surgery for colorectal cancer. METHODS: Between 1987 and 1990, 207 consecutive patients who underwent curative resections for primary untreated large-bowel carcinoma were randomly assigned to a conventional follow-up group (Group A; n = 103) and to an intense follow-up group (Group B; n = 104). All the patients were followed up prospectively, and the outcome was known for all of them at five years. Patients in Group A were seen at six-month intervals for one year, and once a year thereafter. Patients in Group B were checked every three months during the first two years, at six-month intervals for the next three years, and once a year thereafter. RESULTS: Of the 103 patients in Group A, local recurrence was detected in 20; 9 (13 percent) of these patients had colon cancer, and 11 (29 percent) had rectal cancer. Of the 104 patients in Group B, local recurrence was detected in 26; 12 (16 percent) of these patients had colon cancer, and 14 (45 percent) had rectal cancer. Twelve cases (60 percent) of local recurrence in Group A and 24 cases (92 percent) in Group B were detected at scheduled visits (P < 0.05). Local recurrences were detected earlier in patients of Group B (10.3 +/- 2.7 vs. 20.2 +/- 6.1 months; P < 0.0003). Curative re-resection was possible in 2 patients (10 percent) in Group A, 1 with colon cancer and 1 with rectal cancer, and in 17 patients (65 percent) in Group B, 6 with colon cancer and 11 with rectal cancer (P < 0.01). Of the Group B patients who had curative re-resections of local recurrence, 8 (47 percent) were disease-free and long-term survivors as of the last follow-up, and 2 (11.7 percent) were alive, but with a new recurrence. The 2 patients in Group A who had curative re-resections died as a result of cancer. The five-year survival rate in Group A was 58.3 percent and in Group B was 73.1 percent. The difference is statistically significant (P < 0.02). CONCLUSIONS: Our data support use of an intense follow-up plan after primary resection of large-bowel cancer, at least in patients with rectal cancer.

Adult↗
PubMed1998

Evaluating results of laparoscopic surgery for esophageal achalasia.

BACKGROUND: Extramucosal myotomy of the lower esophagus and cardia, combined with anterior fundoplication, is, in our opinion, the procedure of choice to treat stage I-III esophageal achalasia. METHODS: After a successful experience with open surgery in over 280 patients, from January 1992 through February 1997, 61 patients underwent laparoscopic Heller-Dor for stage I-III achalasia. Conversion to laparotomy was done in three cases. All procedures were performed under intraoperative endoscopic control. Intraoperative complications were seven mucosal tears, which were sutured laparoscopically in five cases. The sole postoperative complication was bleeding from an acute gastric ulcer (conservative treatment). RESULTS: Follow-up consisted of clinical and radiographic study 1 month after surgery, and endoscopy and manometry within 1 year. After a mean follow-up (F.U.) of 21 months (1-62), clinical results range from excellent to good in 98.2%. One patient (1.7%) complaining of recurrent dysphagia improved after endoscopic dilation. Esophageal diameter reduced from 52 to 27 mm. LES pressure reduced from 30.3 +/- 12.4 to 10.7 +/- 3.5 mmHg (basal) and from 14. 8 +/- 9.3 to 2.9 +/- 2.1 mmHg (residual). CONCLUSIONS: Laparoscopic Heller-Dor operation is feasible, safe, and effective. Special care should be taken in patients with previous endoscopic dilations.

Adolescent↗
PubMed1998

Diverticulectomy, myotomy, and fundoplication through laparoscopy: a new option to treat epiphrenic esophageal diverticula?

OBJECTIVE: To describe the technique and the results of laparoscopic diverticulectomy combined with esophageal myotomy and antireflux wrap for epiphrenic diverticula of the esophagus. SUMMARY BACKGROUND DATA: The epiphrenic diverticulum of the esophagus is a rare disease probably caused by a longstanding impairment of the esophageal motor activity. Although there is almost universal agreement to operate only on symptomatic patients, the optimal treatment is controversial. The best-accepted guideline is to treat the underlying motor disorder. This is generally done through a left thoracotomic approach that allows diverticulectomy, esophageal myotomy, and partial fundoplication. METHODS: From January 1994 through February 1996, 4 patients underwent laparoscopic transhiatal diverticulectomy, esophageal myotomy, and partial fundoplication at our institution. A thorough preoperative study was done with barium swallow, esophagoscopy, and manometry in all patients; 24-hour pH monitoring was done in one case. RESULTS: No postoperative complications were observed. Short- and medium-term results are satisfactory. CONCLUSIONS: No theoretical objection should be made to this approach, because the principle of treatment of the diverticular pouch and the underlying motor disorder and the prevention of reflux is respected. Longer follow-up and a wider series are mandatory to substantiate these initially favorable results.

Diverticulum, Esophageal↗
PubMed1998

Presentation and surgical management of bronchogenic and esophageal duplication cysts in adults.

OBJECTIVE: Bronchogenic and esophageal duplication cysts are congenital anomalies of the tracheobronchial tree and foregut that are often asymptomatic at initial presentation in adults. Surgery is always recommended, even for patients with asymptomatic disease, because of the possible development of symptoms and complications during the natural course of the disease and because definitive diagnosis can be established only on surgical specimen. METHODS: Twenty-seven patients with bronchogenic and esophageal duplication cysts were treated in our institution over the last 2 decades. Ten patients (37%) were asymptomatic at initial presentation. Chest pain and dysphagia were the most common complaints in symptomatic patients affected by bronchogenic and duplication cysts, respectively. RESULTS: A complete excision of the cyst was performed in 26 cases, whereas one patient with intrapulmonary cyst underwent a right upper pulmonary lobectomy. A posterolateral thoracotomy was performed in 23 patients, and a video-assisted thoracoscopy using a three-port technique was performed in the last 4 patients. No postoperative morbidity was recorded. All patients, except one, were asymptomatic at a median follow-up time of 4 years. CONCLUSIONS: Surgery is the treatment of choice for bronchogenic and esophageal duplication cysts. Video-assisted thoracoscopy should represent the first-line approach in these patients.

Adult↗
PubMed1998

Adenocarcinoma of the colon and rectum: some reflections on the immediate and long-term results of surgery.

Colorectal cancer continues to be a major public health problem in western countries. Although some studies have reported an improvement in disease-free and overall survival, few of the diagnostic and therapeutic procedures proposed have found unanimous consent. We report some reflections on both the immediate and the long-term results of colorectal cancer surgery on the basis of our experience, represented by 1164 patients with histologically proven colorectal carcinoma, admitted to the Institute of General Surgery of Parma University between 1976 and 1993 and operated on by the same surgical team, in order to provide data for scientific discussion. A curative resection was possible in 67.9% of the cases. Our experience shows that many colorectal cancer patients will be cured with aggressive surgery, although, in recent years, adjuvant therapy for colorectal cancer has advanced considerably. Statistical analyses reveal that an unfavourable prognosis is correlated with variables indicative of advanced disease. Concerning the problem of local recurrences, our results demonstrate that surgery is the only therapeutic option providing tangible results, and that intense follow-up leads to a greater number of resections carried out for local recurrence and to improved 5-year survival. Comparison of studies and scientific discussions can prove useful, above all regarding secondary prevention and, in particular, the identification of patients at risk who should undergo screening for early diagnosis and early surgical treatment.

Adenocarcinoma↗
PubMed1998

Cell cycle-related gene abnormalities and product expression in esophageal carcinoma.

In esophageal carcinoma, individual genetic alterations of cyclins, cyclin-dependent kinase inhibitors, and final effectors of the G1-to-S transition have been documented. Our aim was to design a comprehensive analysis of the role and clinical significance of some critical genes, namely cyclin D1, MTS1, and Rb. To this end, cyclin D1 gene amplification and protein accumulation, Rb gene allelic loss and protein expression, and MTS1 gene mutation and DNA methylation were investigated in a series of 74 esophageal carcinomas. Cyclin D1 amplification was documented in 17 of 55 (31 %) cases, being a feature of squamous cell type (14 of 17 amplified cases). Cyclin D1 accumulation significantly correlated with lymph node metastasis (p < 0.02), advanced tumor stage (p < 0.05), and a reduced overall survival rate (p < 0.03). Rb gene loss of heterozygosity occurred in 14 of 39 (36%) informative cases and was associated with an unfavorable survival rate (p < 0.01). MTS1 gene mutations were detected in 2 adenocarcinomas only; gene methylation was observed in 17 of 72 cases (24%) without any correlations with the variables investigated. A direct association between cyclin D1 and Rb gene accumulation (p < 0.0005) and an inverse one between RB loss of heterozygosity and MTS1 abnormalities (p < 0.05) emerged from this study. These results have important clinical implications because both cyclin D1 and Rb gene deregulation are significantly related to an unfavorable survival rate. In addition, cyclin D1 amplification is associated with esophageal carcinoma of squamous cell type, being totally absent in adenocarcinomas (p < 0.01). The combined evaluation of these genes also demonstrates that molecular abnormalities of genes belonging to the same pathway are mutually exclusive and unnecessary for the neoplastic transformation and tumor progression.

Carcinoma↗
PubMed1998

Echolaparoscopic-guided alcohol injection of liver metastases.

Ultrasound-guided percutaneous alcohol injection of liver metastases or hepatocellular carcinoma represents a well-established alternative to surgery when surgical resection is contraindicated. The aim of this report is to describe the technique of echolaparoscopic-guided alcohol injection of liver metastases in a patient undergoing palliative treatment for adenocarcinoma of the cardia. This procedure provides a more accurate staging of the disease and a safe approach to liver metastases with difficult anatomical location in patients unsuitable for surgical resection.

Adenocarcinoma↗
PubMed1998

Comparison of laparoscopic rectopexy with open technique in the treatment of complete rectal prolapse: clinical and functional results.

The aim of this retrospective study was to compare the functional and clinical results of laparoscopic rectopexy with those of the open technique in two similar groups of patients with complete rectal prolapse and fecal incontinence. Between November 1992 and June 1997, 21 patients underwent abdominal rectopexy. Thirteen patients (group A: 12 women and 1 man, mean age 52.9 years, range 28-70) and 8 patients (group B: 8 women, mean age 58.2 years, range 20-76) were submitted to Well's rectopexy by the open technique and the laparoscopic approach, respectively, without division of the lateral rectal ligaments. Assignment to each group was done randomly. Before the operation, a detailed clinical history was taken, and patients were studied with inspection and digital examination of the anorectum, proctosigmoidoscopy, determination of pancolonic transit time, dynamic defecography, anorectal manometry, and anal electromyography. After the operation, all patients underwent perineal physiotherapy, external electric stimulation, and perineal biofeedback. The mean follow-up time was 29.5 months (range 6-54) in group A and 25.7 months (range 8-45) in group B. Values were compared by chi-square, Mann-Whitney U, and Wilcoxon tests, as appropriate; differences were considered significant at p < 0.05. In both groups, dyschezia and fecal incontinence improved significantly (p < 0.05) after the operation. Basal pressure of anal sphincter, squeezing pressure, and rectoanal reflex improved without significance, whereas anoperineal pain was not significantly reduced. In group B, the postoperative hospital stay was shorter than in group A, with a marked reduction of costs. Laparoscopic Well's rectopexy has the same clinical and functional results as the open technique, with a shorter postoperative hospital stay and lower costs.

Adult↗
PubMed1997

p53 protein accumulation and p53 gene mutation in esophageal carcinoma. A molecular and immunohistochemical study with clinicopathologic correlations.

BACKGROUND: p53 gene mutation and p53 protein accumulation are common in human cancer. However, their clinical significance is controversial and p53 accumulation may not correlate with gene mutation. The current study investigates the occurrence of p53 alterations in esophageal carcinoma, the correlation between the analyses at the gene and protein level, and their prognostic significance. METHODS: A series of 74 esophageal carcinomas (46 squamous cell carcinomas, 21 Barrett's adenocarcinomas, and 7 undifferentiated carcinomas) was studied by single strand conformation polymorphism (SSCP) analysis and immunohistochemistry (IHC) to detect p53 mutation and accumulation, respectively. RESULTS: p53 mutations in exons 5-8 were detected in 53% of the carcinomas whereas p53 accumulation was observed in 57% of cases. Comparing SSCP and IHC, there were 27 discordant cases (38%). Overall, only 20 tumors (27%) did not display p53 mutation and/or p53 accumulation. No associations were found between p53 aberrations and clinicopathologic parameters, including patients age and gender tumor type, stage, and grade. p53 protein accumulation and p53 gene mutation were not related to patient survival by univariate or multivariate analysis in esophageal carcinomas. CONCLUSIONS: p53 aberrations are very common in esophageal carcinomas. However, p53 gene mutation and p53 protein accumulation have a significant discordance, suggesting that p53 function may be inactivated by mechanisms other than mutation. p53 aberrations do not independently predict prognosis in esophageal tumors.

Adenocarcinoma↗
PubMed1997

Preoperative laparoscopy in management of patients with carcinoma of the esophagus and of the esophagogastric junction.

BACKGROUND AND OBJECTIVES: Adequate preoperative staging of patients with esophageal and cardia carcinoma offers the potential for a rational choice of the therapy. The aim of this study was to assess the diagnostic value of laparoscopy compared to ultrasonography (US) and computed tomography (CT) in detecting intra-abdominal metastatic spread. METHODS: Between November 1995 and December 1996, 36 patients with adenocarcinoma of the cardia and 14 patients with squamous cell carcinoma of the lower third of the esophagus were studied with CT scan and US, followed by laparoscopy performed at the same session of planned surgical resection. Mean operative time of laparoscopy was 20 minutes (range 15-55 min). There was no mortality nor morbidity related to the laparoscopic procedure. RESULTS: Laparoscopy lead to a change of the therapeutic approach in five patients (10%): three patients with peritoneal carcinosis undetected at the imaging examinations, and one patient with advanced liver cirrhosis with signs of portal hypertension did not undergo resection; conversely, one patient with a liver hemangioma simulating a metastatic mass at CT/US underwent esophagogastric resection. Laparoscopy showed a higher sensitivity than US and CT in detecting peritoneal metastases (71% vs. 14% vs. 14%, respectively), macroscopic nodal metastases (78% vs. 11% vs. 55%), and liver metastases (86% vs. 71%). CONCLUSIONS: Laparoscopy represents a safe and effective diagnostic procedure in the preoperative staging of esophageal and cardia carcinoma; it provides the potential to avoid unnecessary exploratory laparotomies and to select the most appropriate treatment.

Adenocarcinoma↗
PubMed1997

Biochemical markers of upper esophageal sphincter compliance in patients with Zenker's diverticulum.

The aim of this study was to investigate the biochemical basis of biomechanical and morphological alterations of upper esophageal sphincter, which have been reported in patients with Zenker's diverticulum. 4-L-Hydroxyproline (4-Hyp) (collagen), isodesmosine (Ides), and desmosine (Des) (elastin) contents were measured in samples of cricopharyngeal muscle (CPM) and muscularis propria of the esophagus below the CPM. The specimens were collected from seven patients operated for Zenker's diverticulum and eight cadavers, without esophageal and connective tissue disease, 4-Hyp was assayed colorimetrically, Ides and Des by high-performance liquid chromatography. Mean (+/-SEM) values were compared by Mann-Whitney U test. In patients, collagen content was significantly increased, both in CPM and in the muscularis propria of the esophagus below the CPM (P < 0.05). In CPM, Ides to Des and collagen to elastin ratios were significantly higher in patients than in controls (P < 0.05). Both the CPM and the upper muscular cuff of the esophagus appear to be involved in the pathogenesis of Zenker's diverticulum. This finding supports the extension of the myotomy to the muscularis propria of the esophagus below the CPM. The alterated Ides to Des ratio suggests a primary disease of CPM as a cause of Zenker's diverticulum.

Aged↗
PubMed1997

Reduced postoperative morbidity after elective laparoscopic cholecystectomy: stratified matched case-control study.

To answer the question whether laparoscopic cholecystectomy (LC) or open cholecystectomy (OC) is safer in terms of complications and to what extent the "learning curve" influences the frequency of complications after LC, we conducted a matched case-control study. First, 200 patients undergoing LC (LC group A), and two groups of 200 patients undergoing LC at two different periods of the learning curve (LC groups B and C) were matched, taking into account sex, age, anesthesiologic risk, and surgical difficulties. We evaluated the frequency and grade of postoperative complications of these patients and of the last 200 patients undergoing OC before the introduction of LC, retrospectively matched with the LC groups. The total rate of complications in the OC group was 16.0% compared with 5.5% in the LC groups (p < 0.003); the difference was particularly significant for complications classified as grade I, in female patients, those younger than 70, those with low anesthesiologic risk (ASA), and those after cholecystectomy without surgical difficulties. Matched case-control analysis revealed that the complication rate in the LC group significantly decreases with experience (P < 0.01). We conclude that LC is today the treatment of choice for symptomatic cholelithiasis and is replacing OC as the gold standard against which new therapies should be compared.

Adult↗
PubMed1997

Cricopharyngeal myotomy for neurogenic oropharyngeal dysphagia.

BACKGROUND: Forty patients (18 women, 22 men) with incapacitating oropharyngeal dysphagia of neurologic origin underwent cricopharyngeal myotomy. The subjective and objective response to myotomy was analyzed retrospectively with a mean postoperative follow-up of 48 months (range 1 to 255 months). RESULTS: Radiologic evidence of functional obstruction caused by incoordination and incomplete relaxation of the upper esophageal sphincter was significantly reduced. Manometric recordings of resting and closing pressures of the upper esophageal sphincter were also significantly altered by the myotomy. Resting pressures decreased from 65 to 18 mm Hg and closing pressures dropped from 69 to 22 mm Hg. The relaxation time and poor coordination at the level of the upper esophageal sphincter, observed in the preoperative period, persisted after the operation. Radionuclide emptying studies in which a single liquid bolus was used showed persistent hypopharyngeal stasis with a 20% retention of radioactive material at 120 seconds. Subjectively, 33 patients initially had frequent aspiration episodes. Twenty became free of symptoms after myotomy (p < 0.01) and in six others the symptoms were improved. Overall, seven patients claimed to be free of symptoms of dysphagia and no longer had pharyngo-oral or pharyngonasal regurgitations and aspirations after their operation. Twenty-three other patients had improvement in symptoms. Ten patients reported no change in symptoms. All of them either were unable to swallow voluntarily or had dysarthria when assessed before the operation. One retropharyngeal hematoma is the only postoperative complication recorded. The operative mortality was 2.5% (1/40). CONCLUSIONS: Cricopharyngeal myotomy palliates neurogenic oropharyngeal dysphagia in patients with intact oral-phase deglutition.

Adult↗