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Background The extended lymphadenectomy (D2) was recently introduced in several guidelines as the optimal treatment for gastric cancer, based only on the 15-year follow-up results of the Dutch randomised trial, while the British Medical Research Council (MRC) study failed to demonstrate a survival benefit over the more limited D1 dissection. The Italian Gastric Cancer Study Group randomised controlled trial (RCT) was also undertaken to compare D1 versus D2 gastrectomy, and a tendency to improve survival in patients with advanced resectable disease (pT > 1N+) was documented despite negative results in the entire patient population. Now we present the 15-year follow-up results of survival and gastric cancer-related mortality. Methods Between June 1998 and December 2006, eligible patients with gastric cancer who signed the informed consent were randomised at 5 centres to either D1 or D2 gastrectomy. Intraoperative randomisation was implemented centrally by phone call. Primary outcome was overall survival (OS); secondary end-points were disease-specific survival, postoperative morbidity and mortality. Analyses were by intention to treat. Strict quality control measures for surgery, lymph node removal, pathology and patient follow-up were implemented and monitored. Registration number: ISRCTN11154654 ( http://www.controlled-trials.com ). Findings A total of 267 eligible patients were assigned to either D1 (133 patients) or D2 (134) procedure. Median follow-up time was 16.76 years. Analyses were done both in overall patient population and in pT > 1N+. One hundred patients (38.5) were alive without recurrence. OS and disease-specific survival (DSS) were very high in both arms. In overall population, they were not different between D1 and D2 arm (51.3% vs. 46.8% and 65% vs. 67% respectively, p = 0.31 and p = 0.94). DSS was significantly higher after D2 in pT > 1N+ patients (29.4% vs. 51.4%, p = 0.035). OS and DSS were better after D1 in patients older than 70 years (p = 0.003 and p = 0.006). DSS was higher after D1 also in early stages (p = 0.01). Interpretation After 15-year follow up, despite no relevant difference in overall population, DSS and gastric cancer-related mortality of patients with advanced disease and lymph node metastases are improved by D2 procedure. Further data available from this trial suggest that D1 procedure should be preferably used in older patients and in early disease. As accurate detection of advanced diseases can be currently provided by adequate preoperative workup in referral centres, D2 procedure should be recommended in these cases. Funding Piedmont Regional fund for Finalized Healthy Research Project, Application 2003 for data collection.

The formation of adhesions after abdominal surgery is a very frequent event, often burdened by complications. Different techniques and materials have been tested in order to reduce peritoneal damage and the onset of adhesions. While the introduction of improved surgical techniques has been decisive, the use of drugs and irritating solutions has not produced significant results. Promising results have been obtained by the use of barrier systems that allow the peritoneal surfaces to be mechanically separated during healing and re-epithelialization: Interceed (TC7)--Absorbable Adhesion Barrier--appears to be the most appropriate material for this purpose at present, given that it has been demonstrated to be of use in reducing both the incidence and extent of adhesions. The use of this material in general surgery over the past to years or so appears to the authors to be indicated in the event of secondary abdominal surgery with detachment and extensive peritoneal damage, and in more restricted surgery performed on the true pelvis in women of child-bearing age.

The surgical techniques best suited for timely management of spontaneous pneumothorax are described. Results in 266 cases are discussed and compared with the recent literature. Reference is also made to a little known technique: photothermostimulation, and the results it offers are illustrated. Encouraging results have been obtained from rapid frottage of the parietal pleura and this is described. Emphasis is placed on the advisability of early operation to forestall possible surgical and anatomofunctional complications, to ensure good recovery of respiratory capacity, and to prevent mechanical sequelae involving the cardiorespiratory system.

Seven cases of pancreatic pleuropneumopathy are presented and the relevant literature is examined. Treatment of this unusual complications is an offshoot of the modern management of the underlying disease. Attention is drawn to the possibility of serious and sudden acute chest pictures with a clinical picture reminiscent of pancreatic storm. Resuscitation, pneumological and surgical management is required. The histological data for the series shows that a pleural response to the action of matter excreted by the pancreas was responsible. Early local treatment and physiotherapy may be followed by a surprising degree of functional recovery.

A brief reference is made to the part once assigned to scintiscanning as a method of approach to diseases of the pancreas. It is felt that the lack of confidence now displayed in this technique is based preconceptions. A new diagnostic approach is therefore proposed and briefly described. The advantages and disadvantages of the diagnostic techniques included in the proposed scheme are examined. The view is expressed that a fresh assessment should be made of nuclear pancreatography, since it is still a fundamental diagnostic tool.

After a brief statement on the procedure of selection of the patients, the article describes how the cases were studied, since some difficulties arose through the lack of homogeneity of the subjects. The cases are then commented and an effort is made to evidence the outstanding data which can be deduced, and in particular a study is made of the percentage of overall unreliability of scintillographic examination, the "false positives" and the "false negatives", which are rather low. The Authors conclude with the consideration that scintiscanning of the pancreas now constitutes a valid method of investigation of pancreatic pathology.

The authors have examined a new colorimetric test, set up by Nixon in 1973 and appropriately modified by them. They have found out 80,14% positive reactions in 146 cases of neoplasms and 82,54% negative reactions in 126 patients suffering from tubeycular and different diseases; lastly 95% negative reactions in apparently healthy individuals. According to the authors' opinion, this test seems to be useful in the diagnosis of neoplasms, when joined, of course, with other diagnostic means now in use.

Reference is made to several indicative cases in a personal series. Their comparative examination with a scanner and a gamma camera computer showed that: a) noticeably different findings were given by the two methods with regard to cystic, neoplastic, and inflammatory lesions of the pancreas, whereas; b) computerised subtraction was much more sensitive in lesions due to cysts and pancreatitis, even though there was no significant difference between the two methods in the case of neoplasia.

The results obtained with levamisole in the immunostimulating of 59 resected and non-resected lung carcinoma patients are presented. The effectiveness of the treatment was assessed in terms of survival, length of the free interval, etc. Cutireaction to the drug was repeatedly monitored. It is felt that the overall results were insufficient evidence of the true effectiveness of this manner of treatment, even though some data indicative of the therapeutic action of the drug were obtained.

On the basis of some personal cases and with reference to world literature on the subject, the surgical treatment of liver and lung localized echinococcus cyst is discussed. Special attention is paid to 1) thoracotomy which may in some cases become a thoraco-phreno-laparatomy, the only approach which leads to really effective control of the field; 2) problems of suction drainage, particularly as regards diaphragm mobility in cases of thoraco-phreno-laparatomy.

The occasions on which lung embolism is likely to occur and proceed with or without initial clinical symptoms are described. Lung scintiscanning technique, complemented by special expedients and personal experience, is explained. It is felt that the method helps in the early detection of suspect or clinically silent forms, as well as in the corroboration or ruling out of a clinical diagnosis as soon as this is possible. Scintiscanning is also of assistance in showing the anatomopathological features and extent of the process. The technique is simple and readily tolerated, even by patients with slight respiratory or circulatory disturbances. On the other hand, it is not competitive with conventional and well-tried angiopneumography.

Radioopaque hemithorax is frequently observed. The various situations in which it may occur are examined aetiopathologically, along with the general and specifically radiological methods used for its investigation. Particular attention is given to the employment of radio-isotopes for this purpose and the methods involved. Results obtained with perfusion are noteworthy, and even more so those achieved with positive tracers such as 67Ga citrate and 57Co Blm, especially in the differential diagnosis of pleural effusion and mesothelioma through what is described as the "paradox effect".

The authors focus on a physiopathologic manifestation, most often misdiagnosed, which present as a "lipomatous-like mass in the supraclavicular fossa". This is generally at the origin of sophisticated radiologic tests and, not infrequently of useless biopsies. The paper analyzes the different reasons leading, alone or in combination, to the phenomenon by which the mediastinal fat is pushed toward regions where no limits anatomic structures exist, such as the supraclavicular fossa. Knowledge of the above causes, together with a careful physical examination plus a standard postero-anterior-X-ray can easily lead to a correct diagnosis of "pseudotumor of the supraclavicular fossa", avoiding costly and needless diagnostic and therapeutic interventions.

Following a number of remarks on the desirability of introducing into the practice of bronchopulmonary cancer surgery certain immunological ideas, a monitoring programme to be adopted in candidates for lung exeresis and for their subsequent monitoring is presented. The data to emerge thus far may be correlated fairly precisely with the prognosis and from this point of view their use in the selection of patients to be operated might be hypothesised.

A degree course lecture based on a review of the relevant literature and experience gained at a 1000-bed lung hospital (S. Luigi Hospital, Orbassano) is presented in a shortened form. Attention is drawn to the revival of discarded techniques due to anaesthesiological and medical advances. This has considerably extended the surgical indications.