Intraluminal bypass devices as an alternative to protective ostomy for prevention of colorectal anastomotic leakage: a systematic review of the literature

AIM

Anastomotic leakage (AL) is the most important complication of colorectal surgery, leading to high morbidity and mortality. Protective ostomy, the current standard of care for protecting a colorectal anastomosis, has important drawbacks that require the creation of an alternative strategy. Over the past 30 years, several intraluminal bypass devices, designed to shield the anastomosis from the faecal stream, have been developed. The aim of this literature review was to create an updated overview of the devices available and their effectiveness in preventing AL, and to investigate whether they could serve as an alternative to protective ostomy in the future.

METHOD

A systematic review of the literature on intraluminal bypass devices used for preventing colorectal AL was performed. The MEDLINE and Cochrane Library databases were searched, and articles were marked as relevant if an intraluminal bypass device was studied in an animal or human population.

RESULTS

The database search yielded 24 relevant articles related to 10 intraluminal bypass devices protecting a colorectal anastomosis. These articles included experimental animal studies, preclinical (pilot) studies, as well as retrospective and prospective clinical studies. Each device was assessed with regard to surgical technique, effectiveness and device-related complications.

CONCLUSION

Intraluminal bypass devices show promise in preventing AL and its clinical consequences. However, there is insufficient high-level evidence to draw firm conclusions. There is a need for randomized controlled trials that directly compare these devices with the protective ostomy.

Blood transfusion, hospital stay and learning curve in robotic assisted total hip arthroplasty

Total Hip Arthroplasty (THA) has been defined the surgical procedure of the century considering its outcome and cost-benefit ratio (1). Both standard and robotic assisted procedures are increasing, thus, comparison between standard and robotic surgery become useful to understand the cost-benefit of the latter. The prerequisites of the robotic assisted arthroplasty are precision, accuracy, limitation of errors and safety but, on the other hand, its cost is the main drawback. The primary endpoint of our research was to evaluate differences in terms of blood transfusion rates between standard manual and robotic arm assisted THA. All the robotic procedures have been managed using semi active Robotic Arm interactive orthopaedic System (RIO® MAKO Stryker surgical corporation) in a group of patients who underwent primary uncemented total hip arthroplasty (THA) for osteoarthritis or avascular necrosis. Secondary endpoints were the evaluation of length of hospital stay (LOS), age category, gender and the impact of the learning curve on surgical time in the robotic surgery sample. Our retrospective cohort study was conducted between July 2014 and December 2018. Data have been collected from the Tuscany regional hospital discharge register, extracting the relative Hospital Discharge Forms (SDO). During the period of the study, 1537 patients underwent uncemented total hip arthroplasty for osteoarthritis or avascular necrosis. The sample was divided in two subgroups: 1142 patients (74.3%) operated on with standard manual technique and 395 patients (25.7%) operated on with Mako- Stryker Robotic System. In the descriptive analysis, the average values of age and days of hospitalization with 95% CI were calculated. Mean significance was assessed by the T student test. The association between surgical modality and gender was assessed with the chi-square test. The multivariate logistic regression model was used to evaluate the risk of transfusion (outcome variable), between conventional and robotic surgical techniques. The significance threshold was set up at p <0.05. During the period of the study we observed a decrease in standard surgery and an increase in robotic surgery; an increasing number of women per year underwent total uncemented total hip arthroplasty. We found a statistical significance in favor of robotic procedures in terms of transfusion percentage (OR 6.10, 95% CI 2.96-12.59, p<0,001), highlighting the greatest risk in women (OR 1.90, 95%CI 1.30-2.78, p=0.001 ), length of hospital stay (Mr=4.24, SD=2.04, 95% CI 4.04-4.44) (Ms=8.04, SD=2.84, 95%CI 7.88-8.21), (p<0.01). Operative time in the robotic sample decreased substantially with the rise of surgical experience (106.75±13.4 mins in 2014; 82.79±15.95 mins in 2018) (p<0.01). Since the Robotic procedure is a technologically demanding process, an adequate surgical learning curve is mandatory. Our paper, comparing conventional vs robotic assisted THA, showed in favor of the robotic one, a statistically significant reduction of number of transfusions (p<0.001) and length of hospital stay (p<0.01).

Endogenous and artificial miRNAs explore a rich variety of conformations: a potential relationship between secondary structure and biological functionality

Mature microRNAs are short non-coding RNA sequences which upon incorporation into the RISC ribonucleoprotein complex, play a crucial role in regulation of gene expression. However, miRNAs can exist within the cell also as free molecules fulfilling their biological activity. Therefore, it is emerging that in addition to sequence even the structure adopted by mature miRNAs might play an important role to reach the target. Indeed, we analysed by several spectroscopic techniques the secondary structures of two artificial miRNAs selected by computational tool (miR-Synth) as best candidates to silence c-MET and EGFR genes and of two endogenous miRNAs (miR-15a and miR-15b) having the same seed region, but different biological activity. Our results demonstrate that both endogenous and artificial miRNAs can arrange in several 3D-structures which affect their activity and selectivity toward the targets.

Stabilization vs. destabilization of G-quadruplex superstructures: the role of the porphyrin derivative having spermine arms

The interaction of the porphyrin derivative H₂TCPPSpm4, having spermine pendants in the four meso positions, with the G-quadruplex (GQ) structure formed by the DNA aptamer TGGGAG has been investigated by means of UV, electronic circular dichroism and PAGE studies. The results reported here demonstrate that the porphyrin derivative is capable of stabilizing or destabilizing the higher-ordered structures of parallel GQs, depending on the method used to reach their relative stoichiometry (titration vs. single addition). Noteworthily, when two equivalents of H₂TCPPSpm4 were mixed directly with one equivalent of the (TGGGAG)₄ GQ to reach a 2 : 1 H₂TCPPSpm4 : GQ ratio T_1/2 higher than 80 °C was also observed confirming the presence of higher-ordered GQ structures.

Randomized trial of Roux-en-Y gastric bypass versus sleeve gastrectomy in achieving excess weight loss

Background

Robust data on quality of life (QoL) after different techniques of bariatric surgery are sparse. This RCT compared excess weight loss (EWL) and QoL after sleeve gastrectomy versus Roux-en-Y gastric bypass (RYGB).

Methods

Obese patients were assigned randomly to RYGB or sleeve gastrectomy. The primary outcome measure was EWL. Secondary outcomes included QoL, co-morbidity, adverse events, vitamin and glycolipid status. QoL was assessed before and annually after surgery, using the Moorehead–Ardelt Quality of Life Questionnaire II (M-A-QoLQII) and Gastrointestinal Quality of Life Index (GIQLI).

Results

One hundred patients were enrolled, 45 in the RYGB group and 55 in the sleeve gastrectomy group. Mean postoperative EWL at 1, 2, 3 and 5 years was 80·4, 79·8, 83·0 and 74·8 per cent respectively after RYGB, and 83·0, 77·8, 66·3 and 65·1 per cent after sleeve gastrectomy (P = 0·017). Mean M-A-QoLQII score before surgery and at 1, 2, 3 and 5 years after operation was 0·5, 1·6, 1·7, 2·1 and 1·4 respectively after RYGB, and 0·3, 1·7, 1·5, 1·5 and 1·2 after sleeve gastrectomy. Mean GIQLI score before and at 1, 2, 3, 5 years after RYGB was 96·4, 113·8, 113·3, 113·4, 111·7, compared with 90·7, 113·9, 114·5, 113·1 and 113·0 for sleeve gastrectomy. The improvement was significant compared with preoperative values (P &lt; 0·001 for M-A-QoLQII and GIQLI), with no difference between groups (P = 0·418 and P = 0·323 respectively). RYGB resulted in higher readmission rates (P = 0·002) and length of hospital stay (P = 0·006) than sleeve gastrectomy.

Conclusion

RYGB and sleeve gastrectomy resulted in equivalent, long-standing QoL improvement. RYGB resulted in more stable weight loss but was associated with higher readmission rates. Registration number: NCT02475590.

Vortexes tune the chirality of graphene oxide and its non-covalent hosts

The ability of vortexes to tune the chirality of graphene oxide in water sheds light on its complex supramolecular organization allowing for selective noncovalent deposition of a predetermined handedness on a solid surface.

Laparoscopic treatment of incisional and primary ventral hernia in morbidly obese patients with a BMI over 35

INTRODUCTION

Incisional and ventral hernias are common surgical indications. Their management is associated with significant complications and recurrences in open surgery (15-25%). Since laparoscopy has become a standard in bariatric surgery, there has been a natural trend to treat obese patients with parietal wall defects laparoscopically. The aim of our study was to evaluate the feasibility and the results of the laparoscopic management of parietal wall defects in patients with a BMI >35.

MATERIALS AND METHODS

A series of 79 patients were included. Data were acquired prospectively and analyzed retrospectively. The surgical procedure was standardized: 3 ports, mesh type (Parietex™ Composite mesh, Covidien, France), fixation with non-absorbable transfascial sutures, and tackers. Complications were evaluated.

RESULTS

Out of 79 patients (29 men, 50 women), 43 had umbilical and 36 had ventral hernias. Mean age was 52.4 years, and mean BMI was 40.83 kg/m(2). Mean postoperative hospital stay was 2 days. Postoperative pain evaluated by visual analog scale was 2.86. No intraoperative complications or deaths occurred. Seven postoperative complications occurred (8.86%): two parietal wall hematomas treated by radiological embolization, two significant cases of postoperative pain, one postoperative obstruction, one spontaneously resolved respiratory failure, and one early (day 1) parietal wall defect with immediate reoperation. Postoperative seroma rate was 26.58% (21 patients, all of whom were treated conservatively). Postoperative follow-up was 18.10 months (1-84 months), and recurrence rate was 3.8% (3 patients).

DISCUSSION

This study confirms the feasibility and safety of the laparoscopic approach for ventral hernias in morbidly obese patients. Recurrence rates (3.8%) appeared lower than the ones observed in the literature (15-25%). Postoperative hemorrhage and port-site hernia are specific complications of this approach. Postoperative hospital stay is low (2 days) as compared to open surgery. Laparoscopic management of parietal wall defects should be considered a standard option in morbidly obese patients.

Malignant pleural effusions: review of treatment and our experience

More than half of patients with malignancy present with a pleural effusion at some time in their course. Recurrent malignant pleural effusions (MPE) impair functions and worsen the quality of life. Once a patient develops MPE, only mechanical drainage relieves pulmonary compression and dyspnea. Optimal treatment is however, still controversial. During January 2001 to January 2006, our group treated 48 patients with outpatient insertion of chronic indwelling pleural catheter (IPC), Pleurx (Pleurx, Surgimedics, Denver Biomaterials, Denver, CO, USA). Primary malignancy of 48 patients included: 27 lung cancers, 11 mesotheliomas, 5 breast cancers, 3 colon cancers, 2 pancreas cancers and 1 ovarian cancer. Eligibility for IPC required prior thoracentesis with histological confirmation of malignancy and chest roentgenogram evidence of effusion. All patients treated were made aware of their prior malignancy and positive cytology for MPE. Major complications, as systemic or pleural infections, were not registered. Permanence mean time of IPC was estimated as 88 days. Median time of draining interval was 7.0 days with maximum amount of effusion drained off being 1000 ml. Pleurodesis occurred in 23 of 48 (47.92%) patients with a mean time of pleurodesis being 43 days. IPC allows ambulatory treatment with a safe and effective drainage of MPE and is an alternative treatment to procedures in use.

Performance of a fungal based SBR under pH extreme and shock phenolic exposure

An investigation was performed to explore the capabilities of a filamentous fungal biomass to grow non-aseptically in a glucose-fed Sequencing Batch Reactor system in very extreme environment (pH 3.5) conditions. Trichoderma viride Pers: Fr. Isolate 8/90 was used as inoculum. Microscopic investigations were carried out to confirm fungal dominance in the open culture. In batch tests, the fungal biomass showed a significant ability to grow and remove the applied organic load (2000 mg(Glucose) L(-1) d(-1)), with high biomass yields. Furthermore, the biomass showed an ability to resist gallic acid toxicity at high concentraions (1 g L(-1)) without any pre- exposure acclimation of the biomass. The biomass (about 2.5 g(VSS) L(-1)) demonstrated significant aerobic removal of gallic acid in a timeframe of 20 h from initial exposure. The robust characteristics of this SBR system demonstrate potential for future development of fungal based treatment for recalcitrant feedstocks or operation under extreme environmental conditions.

Surgical treatment of pararenal aortic aneurysms in the elderly

AIM

Until fenestrated endografts will become the standard treatment of pararenal aortic aneurysms, open surgical repair will currently be employed for the repair of this condition. Suprarenal aortic control and larger surgical dissection represent additional technical requirements for the treatment of pararenal aneurysms compared to those of open infrarenal aortic aneurysms, which may be followed by an increased operative mortality and morbidity rate. As this may be especially true when dealing with pararenal aneurysms in an elderly patients' population, we decided to retrospectively review our results of open pararenal aortic aneurysm repair in elderly patients, in order to compare them with those reported in the literature.

METHODS

Twenty-one patients over 75 years of age were operated on for pararenal aortic aneurysms in a ten-year period. Exposure of the aorta was obtained by means of a retroperitoneal access, through a left flank incision on the eleventh rib. When dealing with interrenal aortic aneurysm the left renal artery was revascularized with a retrograde bypass arising from the aortic graft, proximally bevelled on the ostium of the right renal artery.

RESULTS

Two patients died of acute intestinal ischemia, yielding a postoperative mortality of 9.5%. Nonfatal complications included 2 pleural effusions, a transitory rise in postoperative serum creatinine levels in 3 cases, and one retroperitoneal hematoma. Mean renal ischemia time was 23 min, whereas mean visceral ischemia time was 19 min. Mean inhospital stay was 11 days.

CONCLUSION

Pararenal aortic aneurysms in the elderly can be surgically repaired with results that are similar to those obtained in younger patients.

[Smoking cessation and weight gain]

Cigarette smoking is the single most important preventable cause of death and illness. Smoking cessation is associated with substantial health benefits, but weight gain after smoking cessation is perceived to be a barrier against quitting smoking. The aim of the study was to analyse predictors of weight gain after smoking cessation. The sample included 1067 residents, aged 18-70 years, in a health district of Rome who answered to an anonymous postal questionnaire. Among them 482 were former smokers; 398 provided lifetime histories of both body weight and smoking and were considered in the analysis. 52.5% (49.3% M; 60.5% F) reported weight gain after smoking cessation; among these 25.4% reported a weight gain > or =5 kg. The multivariate logistic regression analysis showed a direct association between female gender (OR 1.9, CI 95% 1.1-3.2), age - 45 years (45-65 years: OR 2.5, CI 95% 1.4-4.4; > 64 years OR 2.1, CI 95% 1.0-4.0), number of cigarettes per day >20/day (OR 3.8, CI 95% 1.3-11.5) and weight gain after smoking cessation. The relevance of weight gain following smoking cessation suggests that health benefits associated with smoking cessation may to some extent be negated by the detrimental effects on health of associated weight gain. Smoking cessation programmes should therefore consider incorporating follow-up support to prevent weight gain; regular measurements of body weight together with dietary indications and increase of physical activity are basic factors to implement in the intervention of smoking cessation.

[Revascularization of the carotid and vertebral arteries in the elderly]

From January 1994 to July 2004, 323 patients underwent 348 revascularization of carotid bifurcation for atherosclerotic stenoses. Eighty eight patients (group A) were 75 year-old or older, whereas 235 (group B) were younger than 75 years. Postoperative mortality/neurologic morbidity rate was 1% in group A, and 1.4% in group B. At 5 years, patency and freedom from symptoms/stroke were, respectively, 91% and 92% in group A, and 89% and 91% in group B. None of these differences was statistically significant. In the same time period, 26 internal carotid arteries were revascularized in 24 patients, 75 or more aged, for a symptomatic kinking. Postoperative mortality/morbidity rate was absent, whereas, at 5 years, patency and freedom from symptoms/stroke were, respectively, 88% and 92%. Twelve vertebral arteries were revascularized in 12 patients, 75 or more aged, for invalidating symptoms of vertebrobasilar insufficiency. Postoperative mortality/neurologic morbidity rate was absent. In one case postoperative recurrence of symptoms occurred, despite a patent revascularization. Patency and freedom from symptoms/stroke were 84% and 75%, at 5 years. Revascularization of carotid and vertebral arteries in the elderly can be accomplished with good results, superposable to those of standard revascularization of carotid bifurcation in a younger patients' population.

The surgical treatment of ilio-femoral venous obstruction

METHODS

A series of 9 patients of a mean age of 48 years, operated on for compression of the ilio-femoral venous axis is reported. The cause of obstruction was external compression in 3 cases, a retroperitoneal sarcoma in 1 case, and an infrarenal aortic aneurysm in 2. Two patients presented with a Cockett's syndrome, 3 with a chronic ilio-femoral thrombosis, and one with a post-traumatic segmentary stenosis. Treatment consisted in a resection/Dacron grafting of 2 infrarenal aortic aneurysms, one femoro-caval bypass graft, 2 transpositions of the right common iliac artery in the left hypogastric artery for Cockett's syndrome, 3 Palma's operations for chronic thrombosis, and one internal jugular vein interposition for segmentary stenosis.

RESULTS

There were no postoperative deaths and no early thromboses of venous reconstructions performed. All the patients were relieved of symptoms during the follow-up period, whose mean length was 38 months.

CONCLUSION

The cause of venous obstruction and the presence of symptoms which are resistant to medical treatment are the main indications to ilio-femoral venous revascularization. The choice of the optimal treatment in each single case yields satisfactory results.

The treatment of chronic intestinal ischemia

BACKGROUND AND AIMS

Due to the rarity of the condition, large and prospective series defining the optimal method of digestive arteries revascularization, for the treatment of chronic intestinal ischemia, are lacking. The aim of this consecutive sample clinical study was to test the hypothesis that flexible application of different revascularization methods, according to individual cases, will yield the best results in the management of chronic intestinal ischemia.

PATIENTS AND METHODS

Eleven patients, of a mean age of 57 years, underwent revascularization of 11 digestive arteries for symptomatic chronic mesenteric occlusive disease. Eleven superior mesenteric arteries and one celiac axis were revascularized. The revascularization techniques included retrograde bypass grafting in 7 cases, antegrade bypass grafting in 2, percutaneous arterial angioplasty in 1, and arterial reimplantation in one case. The donor axis for either reimplantation or bypass grafting was the infrarenal aorta in 4 cases, an infrarenal Dacron graft in 4, and the celiac aorta in one case. Grafting materials included 5 polytetrafluoroethylene (PTFE) and 3 Dacron grafts. Concomitant procedures included 3 aorto-ilio-femoral grafts and one renal artery revascularization. Mean follow-up length was 31 months.

RESULTS

There was no operative mortality. Cumulative survival rate was 88.9% at 36 months (SE 12.1%). Primary patency rate was 90% at 36 months (SE 11.6%). The symptom free rate was 90% at 36 months (SE 11.6%).

CONCLUSIONS

Direct reimplantation, antegrade and retrograde bypass grafting, all allow good mid-term results: the choice of the optimal method depends on the anatomic and general patients status. Associated infrarenal and renal arterial lesions can be safely treated in the same time of digestive revascularization. Angioplasty alone yields poor results and should be limited to patients at poor risk for surgery.

The surgical treatment of chronic intestinal ischemia: results of a recent series

Due to the rarity of the condition, large and prospective series defining the optimal method of digestive arteries revascularization, for the treatment of chronic intestinal ischemia, are lacking. The aim of this consecutive sample clinical study was to test the hypothesis that flexible application of different revascularization methods, according to individual cases, will yield the best results in the management of chronic intestinal ischemia. Eleven patients, of a mean age of 56 years, underwent revascularization of 11 digestive arteries for symptomatic chronic mesenteric occlusive disease. Eleven superior mesenteric arteries and one celiac axis were revascularized. The revascularization techniques included retrograde bypass grafting in 7 cases, antegrade bypass grafting in 2, percutaneous arterial angioplasty in 1, and arterial reimplantation in one case. The donor axis for either reimplantation or bypass grafting was the infrarenal aorta in 4 cases, an infrarenal Dacron graft in 4, and the celiac aorta in one case. Grafting materials included 5 polytetrafluoroethylene (PTFE) and 3 Dacron grafts. Concomitant procedures included 3 aorto-ilio-femoral grafts and one renal artery revascularization. Mean follow-up duration was 31 months. There was no operative mortality. Cumulative survival rate was 88.9% at 36 months (SE 12.1%). Primary patency rate was 90% at 36 months (SE 11.6%). The symptom free rate was 90% at 36 months (SE 11.6%). Direct reimplantation, antegrade and retrograde bypass grafting, all allow good mid-term results: the choice of the optimal method depends on the anatomic and general patient's status. Associated infrarenal and renal arterial lesions can be safely treated in the same time of digestive revascularization. Angioplasty alone yields poor results and should be limited to patients at poor risk for surgery.

[Intraoperative limphonodal mapping in gastric, pulmonary and large bowel tumors. The sentinel limphonode technique]

The concept of the sentinel lymphatic node was introduced by Cabanas in 1977, but it has proved to be successful for the treatment of the melanoma and breast cancer only since the 90s. Many studies have recently extended this technique to other neoplasias. This study deals with 36 patients who were to undergo surgery for 14 gastric adenocarcinomas, 11 of the colon and 11 pulmonary. Once the neoplastic mass was detected, 2 to 5 ml of a vital dye (Blu Patent) were injected in the serosa along the perimeter of the tumor by means of several 0.5 ml injections. A lymphatic node was diagnosed in 22 patients, respectively 10 gastric neoplasias, 6 pulmonary, 6 of the colon. In 14 cases the lymphatic node was found to be negative, in 8 cases positive. In the remaining 14 patients the lymphatic node was not detected. Although data do not always agree, the sentinel lymphatic node technique seems to have been successful for this kind of tumors. For this reason we have carried out this study and published our first data.

[Small bowel stromal tumors in a "meckelian" location. About a clinical observation]

The Meckels divetriculum has a prevalence of the 0.3-3%. It is surgically removed only when arise a complication or a neoplasia. The Meckels diverticulum tumors are unfrequent and observed in only the 0.5-3.2% of the Meckels diverticula. The 12% of these tumors are a GIST. We report a case of a gastrointestinal stromal tumor with neural immunophenotype, observed in a patient presenting a deep venous thrombosis perhaps with a paraneoplastic origin. We also report some observations about the state of the art about the GIST management and particularly of all of them arising in a Meckels diverticulum.

[Surgical treatment of lung metastasis: experience with 108 cases]

In this study the Author's analyze their experience (between September 1973 and December 2002) with 108 pulmonary resections for metastatic tumors to the lungs to evaluate prognostic factors and the impact on survival of extended metastasectomy. Overall mortality and major morbidity were 1.85% and 2.78%. The actuarial survivals at 5 and 10 years were respectively 46.6% and 39.9%. The best mean survivals are observed in patients with metastases from breast, colorectal, thyroid and urinary tract carcinomas, in cases with disease free interval > 12 months and in the patients who underwent sequentially surgery and chemotherapy. Patients with pulmonary metastases also potentially benefit from iterative pulmonary resection.

[The treatment of malignant pleural effusions: the experience of a multidisciplinary thoracic endoscopy group]

More than half of neoplastic patients show in their clinical history the onset of pleural effusion. Malignant pleural effusion produces dyspnea, decreases respiratory function and quality of life in patients with advanced cancers. Optimal treatment is actually controversial. The aim of this study is to analyze the experience of malignant pleural effusion treatment of the Multidisciplinary Group of Thoracic Endoscopy. Patients are been subdivided in two group, depending on respiratory performance status and they are been submit to a Video-Assisted Thoracic Surgery (VATS) with talc pleurodesis and to positioning of a chronic indwelling pleural catheter. The treatment of malignant pleural effusion with the methods reported above allows, not only to achieve palliation of symptomatology, but also to achieve pleurodesis in patients with limited life-expectancy with good cost-beneficial ratio.

Inguinal hernioplasty: the gold standard of hernia repair

On the basis of a critical review of 936 inguinal hernioplasties performed in 8 years, the authors present their good long-term results with tension-free techniques including the original Lichtenstein technique, Lichtenstein with a sutured mesh and annulorrhaphy of the deep inguinal ring, and Lichtenstein with plug. The only two recurrences in this case series occurred with the original technique. Suturing of the mesh and deep inguinal ring annulorrhaphy proved to be reliable and inexpensive. Results were equivalent with the use of the plug, despite the presence of an additional foreign body. In conclusion, the results obtained with the three variants are practically equivalent, and the choice of technique may depend on the preference and experience of the surgeon.

[Prognostic markers of the epithelial tumors of the large intestine]

The surgical treatment of large bowel malignant tumors is now the most important therapeutic approach. The aim of our study was to evaluate a possible prognostic implication of ploidy and NM23 expression. The study includes 120 non selected patients who underwent surgery for colorectal cancer. The analysis of ploidy was obtained with cytometric test. The cases with only one gaff G0/G1 were considered as diploid. Patteras with more than one aneuploidic population were classified as multiploidic or poliploidic. While NM23 expression was evaluated with a double blind retrospective study by two separate equipe of authors in different centres. NM23 positivity degree was classified in 3 classes: absent or weak if < 10%; moderate if 10-50%; strong if > 50%. Forty-two patients (35%) were classified as diploidic; 30 patients (25%) as aneuploidic; 40 patients (33.2%) as multiploidic; in 8 cases (6.7%) the material was inadequate. Among the two groups who evaluated NM23 expression the group I a positivity: absent or weak in 32 cases (26.7%); moderate in 62 cases (51.7%); strong in 26 cases (21.6%); while the group II shows positivity: absent or weak in 30 cases (25%); moderate in 52 cases (43.3%); strong in 38 cases (31.7%). We cannot consider ploidy and the NM23 research as independent prognostic factor.

NM23 expression as prognostic factor in colorectal carcinoma

BACKGROUND

The current most important prognostic indicator in colorectal carcinoma is tumor stage at the moment of diagnosis. The role of NM23 gene as prognostic factor is controversial. The aim of this study was to investigate NM23 expression.

PATIENTS AND METHODS

The study population included 104 unselected patients who underwent surgery for colorectal carcinoma between 1992 and 1997. NM23 expression was quantified by estimating the percentage of tumor cells with unequivocal reactivity. The percentage was scored: 0 when no tumor cells showed immunoreactivity; 1 when less than 10% of cells showed immunoreactivity; 2 when 11-50% of cells were positive; 3 when more than 51% of cells were positive.

RESULTS

Four cases belonged to group 0.21 to group 1.55 to group 2 and 24 to group 3.

CONCLUSION

NM23 cannot be considered an independent prognostic variable.

[Complications of inguinal hernia repair]

It's shown by literature and confirmed by Author's experience that, on account of the excellent results, prosthetic repair of inguinal hernia is more effective than "conventional" (Bassini, Mc Vay, Shouldice). Between January 1993 and December 2000 were observed 875 patients with inguinal hernia (814 monolateral, 61 bilateral); all patients underwent a Lichtenstein repair both in the primary version and in its variations (internal ring plastic, trasversalis plicate, plug repair). The patients were discharged from hospital within 24 hours after surgery in 90% of cases. No important intraoperative complications were observed; the patients restarting work varied from 3 to 15 days after the discharging in relation to patient anxiety, onset of complications and to the type of work. The complications observed were: urine retention (1.6%), superficial haematoma (1.3%), superficial infection (1%), wound suppuration (0.5%), serous effusion (0.7%), postsurgery pain (2.1%), scrotal edema (1.7%), persistent inguinal neuralgia (0.6), local hypoesthesia (4.3%), ischemical orchitis (0.1%), recurrence (0.2%). In conclusion Authors assert that "tension free" repair allows optimal results both for the surgery point (easiness of the technique, repeatability, less invasivity, scanty incident of recurrences, low frequency of postoperative complications) and in economic terms, allowing an early mobilization of the patients. A further improvement would be obtained with more care in surgical and patient management, with more excellent results.

[Gastrointestinal stromal tumors: a case with mixed muscular-neuronal origin]

GIST have still today controversial aspects of their histogenesis that are reflected on the classification and prognosis. It's showed a particular case with mixed muscular-neuronal histogenesis that supposes totipotent cell origin of these neoplasms. Diagnosis, classification and prognosis are very difficult to evaluate; surgery at the moment is the only useful treatment modality.

[Indications and surgical treatment of acute complicated diverticulitis]

Although the surgical treatment of acute and complicated diverticulitis has been refined over the years, discussion is still ongoing about whether a single or two stage procedure (Hartmann's procedure) should be performed in patients with peritonitis from perforation of a colonic diverticulum. A retrospective review was completed for patients undergoing surgery for acute complicated diverticulitis from 1980 to 1997. All patients were categorized according to Hinchey classification. Of the 186 patients treated, emergency operation was performed in 52 (28 per cent; group I) and an elective operation in 134 (72 per cent; group II). All patients had a resection of the involved colon and anastomosis was performed using CEEA staplers. In the group I, 50 patients underwent resection with immediate reconstruction with or without colostomy and two an Hartmann's procedure. Among the group II, primary anastomosis with or without proximal diversion was performed in 132 patients; two patients underwent an Hartmann's procedure. Post-operative mortality was of 5.76% in the group I and 2.9% in the group II. Nine anastomotic leaks occurred in the group I and 18 in the group II. Comparing these results with the recent literature, we have concluded that primary resection is virtually always possible in acute and complicated diverticulitis. Primary anastomosis with or without colostomy, in expert hands, is a safe procedure for patients in stage I of Hinchey's classification or II, but should be considered on an individual basis in presence of peritonitis. In case of fecal peritonitis, persistent hypotension, ascites, severe immune compromise and extreme malnutrition the Hartmann procedure represent the procedure of choice.

Papillomatosis and breast cancer: a case report and a review of the literature

Papillomatosis is a relatively common (22%) benign microscopic lesion in the breast and rarely seen in women less than 30 years old. It is a papillary proliferation of the ductal epithelium which partly fills up smaller ducts and to degree distends them. The histological classification of this entity is controversial because similar or identical lesions have been classified using different terms such as epitheliosis and epithelial hyperplasia, and interpretation of published series has been difficult due to imprecise definition of this term. Clinical, radiological and histological patterns of this entity are often sufficient to raise concern as to possible malignancy. Moderate or florid hyperplasia without atypia is considered to carry slight (1,5-2 times) increase in risk of later developing cancer, while in the atypical hyperplasia the risk is four to five times that of the general population. The authors describe a case of papillonlatosis recentely observed in a 67 years old female patient and, confirmed the importance to establish an accurate preoperative diagnosis. It is important that the surgeon works with the pathologist to produce clear descriptive report of epithelial changes from normal through hyperplasia to atypias in order to establish a precise surgical indication.