Novel Modality of Endoluminal Anastomotic Integrity Assessment with Fluoroangiography After Left-sided Colorectal Resections

BACKGROUND

Several methods have been described for the intraoperative evaluation of colorectal anastomotic integrity. Technological evolution has allowed to progress from basic mechanical methods to the use of more sophisticated techniques. This study describes a novel endoluminal modality of colorectal anastomotic assessment through the use of a Disposable Rigid Scope Introducer (DRSI) also allowing for intraoperative endoluminal perfusion evaluation by indocyanine green (ICG) fluoroangiography in patients undergoing left-sided colorectal resection.

METHODS

The DRSI consists of an endoluminal introducer device made up of an insertion tube and port connected to an insufflation bulb to manually insufflate the sigmoid and rectum and is compatible with any laparoscopic camera, also allowing for ICG fluoroangiography for perfusion purposes.

RESULTS

The DRSI was successfully used to assess anastomotic integrity after left-sided colorectal resections performed in 16 consecutive patients. The DRSI allowed to visualize by fluoroangiography the quality of tissue perfusion at the anastomotic site in all cases, contributing to the decision of avoiding loop ileostomies in low rectal resections. In 2 cases, the DRSI showed the presence of significant anastomotic bleeding which was successfully controlled by laparoscopic suture placement. No adverse event resulted from the use of this device.

CONCLUSIONS

The DRSI combines direct endoluminal visualization of the anastomosis together with real-time evaluation of its blood flow. This device holds great potential for prompt intraoperative detection of anastomotic alterations, possibly reducing the risk of postoperative anastomotic bleeding or leaks related to mechanical construction/perfusion issues. Potential advantages of this device warrant larger cohort studies and prospective randomized trials.

Lung Tumor Skin Metastasis: Case Report of a Solitary Cutaneous Ulcerated Lesion as Initial Manifestation of Lung Carcinoma

Lung cancer has the highest cancer incidence, and it is the most common cause of cancer death worldwide. Cutaneous metastases are infrequent compared to hilar nodes, adrenal glands, liver, brain, and bones. However, unusual skin lesions in patients at high risk of lung cancer should be regarded carefully to rule out a metastatic manifestation of an occult primary site tumor. Surgical excision, or incisional biopsy when the former is deemed unfeasible, should be performed to allow histopathological examination in case of occult primary site. In patients affected by advanced lung tumors, surgical excision could be beneficial in terms of pain control and improvement of the quality of life. We report a case of a solitary large skin lesion as an early manifestation of a lung adenocarcinoma.

Simultaneous Laparoscopic Cholecystectomy and Endovascular Infrarenal Aortic Aneurysm Repair

Background/Aim: With the increasing use of endovascular aneurysm repair (EVAR) and the availability of laparoscopic cholecystectomy (LC) for treating abdominal aortic aneurysms (AAA) and cholelithiasis, respectively, the association between these elective treatments is not yet well-defined. Thus, this study aimed to evaluate the results of elective and simultaneous EVAR and LC.

Methods: Thirteen patients (mean age, 72 years) with concomitant large and asymptomatic AAA and asymptomatic cholelithiasis underwent simultaneous EVAR and LC.

Results: Post-operative mortality was absent, and the morbidity rate was 7%. The mean total duration of the procedure was 142 min. The mean duration of fluoroscopy was 19 min, and the mean radiation dose was 65 mGy. The mean amount of iodinated contrast injected was 49 mL. The timing of oral fluid intake was 28 h (range, 24–48 h) and that of the oral low-fat diet was 53 h (range, 48–72 h). No patient presented with an aortic graft infection during the entire follow-up period (mean duration, 41 months). The mean length of post-operative hospital stay was 6 days (range, 5–8 days). Late survival was 85%, and the exclusion of AAA was 100%.

Conclusion: Simultaneous EVAR and LC can be performed safely, allowing effective and durable treatment under both AAA and cholelithiasis conditions.

May predictors of difficulty in thyroid surgery increase the incidence of complications? Prospective study with the proposal of a preoperative score

Background

Although thyroidectomy is one of the most common surgical procedures performed worldwide, some permanent complications, despite the considerably reducing incidence, may affect dramatically the patients quality of life. The purpose of this study is to evaluate whether factors identified preoperatively and expressed in a score could be predictors of major surgical difficulty during total thyroidectomy and influence the incidence of complications.

Methods

A total of 164 patients who underwent total thyroidectomy were examined. For each patient we calculated a preoperative score, including seven parameters, which we evaluated to be predictors of difficulty in thyroid surgery, that is, sex, body mass index (BMI), neck length, neck extension, thyroid gland volume, thyroiditis, and increased parenchymal vascularization. The overall score was also compared with peri- and post-operative factors describing objectively the difficulty in thyroid surgery. These factors are the duration of the operation, the length of hospitalization, the incidence of complications such as hemorrhage, hypoparathyroidism, and recurrent laryngeal nerve injuries.

Results

There was no statistically significant association between our score and either the percentage of postoperative complications or the length of hospitalization. The operative time was the only variable remarkably associated with the score value (p < 0.00001). Comparing the duration of the operation with each of the preoperative predictive factors, we found that none of the factors reached the value of statistical significance, but a close association could be noted with the thyroid volume and the BMI.

Conclusions

In our study, predictors of difficulty in thyroidectomy did not affect morbidity rates, as suggested by previous studies, but only operative times, which were significantly increased in patients with higher score. Although our results have limited statistical significance, they allow us to confirm the fundamental role of a systematic use of optical magnification and microsurgical technique in thyroidectomy. Further studies, with a larger cohort of patients, are needed to validate our results and to formulate a universally accepted predictive score of difficulty in thyroidectomy preoperatively.

Laparoscopic lavage/drainage as a bridge treatment for perforated diverticulitis with purulent peritonitis associated with an abdominal aortic aneurysm A retrospective case-control study

AIM

Laparoscopic lavage /drainage (LALA) or surgical resection are both methods of treatment for perforated diverticulitis with purulent peritonitis (Hinchey Stage III). In case of associated abdominal aortic aneurysm (AAA), laparoscopic lavage/drainage could be an interesting bridge option to treat sepsis before endovascular exclusion of the aneurysm and resection of the sigmoid. We performed LALA as a bridge treatment of peritonitis before elective, staged endovascular exclusion of the aneurysm (EE) and elective resection of the colon.

MATERIAL AND METHODS

Seven patients presenting a perforated diverticulitis with purulent peritonitis (Hinchey III), associated with an uncomplicated AAA of a mean diameter of 6 cm, underwent LALA followed by staged EE and resection. They were retrospectively reviewed for a case-control study. The mean length of follow-up after completing all the procedures was 28 months. Primary endpoints were mortality and morbidity of each procedure, complications related to each procedure and to the untreated disease in the interval between each one of them, late outcome and complications related to each treatment method. As secondary endpoints, the mean length of surgery for resection, of stay in the hospital, of the interval between each procedure, and of time required for the treatment of both the diseases were considered.

RESULTS

Postoperative mortality was absent. Morbidity consisted of a sigmoido-vescical fistula 18 days after resolution of peritonitis and sepsis, not hindering EE,and a delayed healing of the surgical wound for access to the common femoral artery (28.6%). No complications of untreated disease in the interval between each procedure were observed. No late complications of both diseases occurred. The mean interval between LALA and EE,and between EE and resection was, respectively, 19 days and 18 days. Both the diseases were treated within a mean delay of 37 days after LALA (range, 24-61 days).

CONCLUSIONS

LALA, as a bridge treatment, before EE and resection, in patients presenting a perforated diverticulitis with purulent peritonitis, associated with an uncomplicated AAA, may be an effective treatment option.

KEY WORDS

Perforated diverticulitis, Purulent peritonitis, Abdominal aortic aneurysm.

Laparoscopic modified double stapling technique with transanal resection for low anterior resection of rectal cancer

BACKGROUND AND AIM

Anterior resection of the rectum with a total mesorectal excision is the standard surgical technique for the treatment of rectal cancer. Laparoscopic low anterior resection (LALAR) is an alternative to open surgical approach and was validated in diverse randomized control trials to be as safe and oncologically effective. That said, confronting a low rectal tumor in an obese patient with a narrow pelvis can be technically challenging even for the most expert surgeon.

METHODS

We propose a modified double stapling technique with transanal eversion and staple resection of the rectal stump.

RESULTS

We applied the above technique in 3 patients with a dubious distal resection margin due to patient/tumor characteristics. The mean length of operation was 272 minutes and a R0 resection with a mean number of 16 nodes could be obtained in all the patients. No recurrence occurred during a follow-up of 28 months.

CONCLUSIONS

We conclude that this technique is a feasible, safe and valid adjunct to the double staple technique whenever intraabdominal application of the linear staple is difficult or unsafe.

KEY WORDS

Colorectal cancer, Laparoscopic anterior resection, Double, Low colorectal anastomosis, Stapling technique.

Clinical problems in patient with Ehlers-Danlos syndrome and Multiple Chemical Sensitivity undergoing total thyroidectomy

Clinical practice sometimes brings to face with situations quite peculiar, potentially dangerous for the patient's life. In the great majority of cases, pathologies associated with each other (cardiovascular, respiratory, neurological), while in other cases we can treat rare diseases or syndromes. It's considered exceptional the simultaneous presence of "rare" pathologies in a single patient. This exceptionality has been a push to treat a patient as a "unique" asking for help to deeper studies of pharmacogenetics. Our case reports the management of a patient with Ehlers-Danlos syndrome (EDS) and Multiple Chemical Sensitivity (MCS), undergoing a total thyroidectomy. We found several problems, and we tried to find effective solutions for the management of the patient during the whole peri-operative process, from a clinical, pharmacological and also from a surgical point of view.

Microsurgical approach for unusual and unexpected malignant fibrous histiocytoma of the forearm: A case report

Soft tissue sarcomas are rare tumors with a dismal prognosis. Among the most common histological types of sarcomas of the extremities, malignant fibrous histiocytoma (MFH) is the one with the highest incidence. Surgery is considered to be the first choice of treatment for MFH. To the best of our knowledge, this is the first case report in the literature of a patient with MFH within the abductor pollicis longus (APL) muscle. This unusual location was also unexpected by the treating surgeons, as the preoperative magnetic resonance imaging localized the tumor inside a different muscle. A 79-year-old Caucasian man presented with a swelling in the middle third of the dorsal aspect of the left forearm. MFH was diagnosed following biopsy and instrumental diagnostic examinations. Surgical excision and simultaneous reconstruction was performed by the same microsurgical team, achieving an excellent functional outcome. The present case highlights the significance of microsurgical approach for improving strategic planning in oncologic surgery. Accurate surgical dissection, performed by a team of microsurgeons, allowed for the identification of the unusual and unexpected tumor localization within the APL muscle. For this reason, a change of surgical strategy allowed for preservation of the extensor digitorum communis muscle, which would otherwise have to be resected, with tendon transfer and successful restoration of the thumb abduction function.

Primitive sarcoma of the breast: new insight on the proper surgical management

BACKGROUND

Primitive sarcoma of the breast is a rare and challenging disease at high risk of recurrence and with poor prognosis. There are controversies in the diagnosis and management of such solid tumor due to its rarity and heterogeneity. This sarcoma is poorly responsive to both chemotherapy and radiotherapy, thus, surgery is the first and most important therapeutic approach. However, given the rarity of this type tumor it has not be possible to standardize unique guidelines for the proper surgical strategy to adopt. Here, we performed a retrospective study of new 10 cases of primitive sarcoma of the breast that underwent either mastectomy or a more conservative quadrantectomy, in the attempt to better standardize correct surgical indications.

METHODS

Ten new cases of primitive sarcoma of the breast were registered between 2002 and 2012 and constituted the study group. They underwent either mastectomy or quadrantectomy and the clinical, prognostic and survival characteristics after surgery were analysed.

RESULTS

Within the group of patients treated with mastectomy, two had metastasis and died because of that. Among the five patients treated with quadrantectomy four are alive and free of disease after 3 to 5 years follow-up, while the patient with sarcoma arising in pregnancy, although is still alive, developed lung metastases four years after surgery.

CONCLUSIONS

The first and most important therapeutic approach to primary sarcomas of the breast is surgical which has the purpose to achieve radical tumor excision to prevent local recurrence and skip metastases. However, given the rarity of the condition and the consequent small number of cases in this, like in similar studies, it is not possible to draw any definitive conclusions and further studies with larger numbers are necessary. However it would appear that performing a larger procedure such as mastectomy rather than performing a more limited one such as a quadrantectomy, has no advantage in terms of overall prognosis.

Appendiceal abscess in a giant left-sided inguinoscrotal hernia: a rare case of Amyand hernia

The hernia of Amyand is an inguinal hernia containing the appendix in the sac. It is a rare pathology often diagnosed only intra-operatively. We report a case even more rare of a giant left-sided inguinoscrotal Amyand hernia with appendiceal abscess without clinical findings of incarceration/strangulation, occlusion, perforation, or acute scrotum and with the presence in the sac of the caecum and other anatomical structures (last ileal loops, bladder and omentum). The 68-years-old man patient successfully underwent surgical treatment only through the hernia sac (meshless repair according to Postempski technique).

Original technique for preoperative preparation of patients and intraoperative localization of parathyroid adenomas

Surgical approach of single parathyroid adenoma treatment is turning to a less invasive surgery, allowing us to obtain better aesthetic results, reduction of duration of surgical operation, reduction of post-operative morbidity and hospital stay. Tc99m-sestaMIBI scintigraphy is mainly performed for preoperative localization of parathyroid adenomas. Our technique is instead based on the possibility to inhibit the interference of Tc99m-sestaMIBI uptake of the thyroid gland by means of the administration of Lugol's solution. Indeed, to confirm the identification and removal of the hyperfunctional parathyroid, it is accepted as adequate an ex vivo radioactivity count of the adenoma 20% or 40% greater than the value of the post-excisional background radioactivity, in association or not with intraoperative measurement of PTH. This method allows us to perform surgery with no timetable restriction, and to clearly distinguish the radioactivity of parathyroid adenoma from that of the surrounding tissues and thyroid gland.

Breast Mondor's disease: Diagnosis and management of six new cases of this underestimated pathology

Mondor's disease is an unusual and little-known pathology of the breast, characterized by superficial thrombophlebitis. The causes are still unresolved. Most of the patients do not fall under case studies of the scientific literature, given the reported incidence rate between 0.5% and 0.8%. The Mondor's disease patients are not always properly identified, and they are frequently treated as outpatients, even considering the benign course of the disease which often spontaneously resolves without any medical therapy. We report here six new cases of Mondor's disease, two of them were likely due to a trauma and were easily resolved with the use of non-steroidal anti-inflammatory drugs; the third one was apparently due to the stretching of the mammary veins in a patient with gigantomastia; the fourth one was subsequent to hormonal stimulation for in vivo fertilization and following gestation; and the last two cases (one was a man) were diagnosed after undergoing surgery for breast carcinoma.

Laparoscopic cholecystectomy in Steinert's myotonic dystrophy. About two clinical cases

Myotonic dystrophy type 1, or Steinert's myotonic dystrophy, is a rare RNA-mediated autosomal dominant disease. Here we describe two clinical cases of patients with Steinert's disease who underwent laparoscopic cholecystectomy under general anaesthesia in conjunction with thoracic peridural anaesthesia, without muscle relaxants. Using such an anaesthesiological technique allowed for rapid recovery from anaesthesia, quick and complete recovery of autonomous breathing, and a significant haemodynamic and arterial blood gases stability, as well as an adequate and complete analgesic coverage over the entire perioperative period.

Contralateral axillary metastases from breast cancer. Personal experience and review of literature

The contralateral axillary lymph node metastasis (CAM) from breast cancer are very rare, and pose a number of classification problems and therefore also on the surgery attitude to be adopted and the subsequent surgical oncological approach, making a distinction between synchronous and metachronous cases. You must always wait for a reasonable period of time to exclude the presence of an occult cancer in the contralateral breast. You make assumptions about the lymphatic pathways that determine this metastasis underlining that in the literature (rare) cases are reported in which the lymphoscintigraphic sentinel lymph node search has shown an uptake of contralateral axillary lymph nodes.

KEY WORDS

Breast cancer, Controlateral axillary lymph node metastasis, Lymph node metastasis.

Treatment of renal angiomyolipoma: surgery versus angioembolization

Renal angiomyolipoma (AML) is a benign mesenchymal tumour. AML often leads to haemorrhagic complications such as retroperitoneal haematoma. Treatment varies from case to case, ranging from minimally invasive approaches such as selective embolization of the renal artery to invasive wedge resection, partial nephrectomy or, in more severe cases, radical nephrectomy. Here we report a case of retroperitoneal haematoma secondary to AML, treated with conservative approach by super-selective embolization of the lower-pole segmental renal artery.

[Advantages and limits of tumescent anesthesia in outpatient surgery]

The Authors report the results of the tumescent anesthesia in 187 patients submitted to various outpatient surgical procedures comparing with those in patients submitted to local anesthesia by direct infiltration.

[Acquired rectourethral fistula: case report]

Rectourethral fistulas are an uncommon complication of urinary or rectal surgery, trauma, inflammatory disease, radiation therapy for prostate cancer; they represent an unique challenge for the surgeon. Although closure can occure spontaneously, most cases of acquired rectourethral fistula need surgical repair. Despite a century of surgical experience, no single approach has been universally accepted. We report a case of a rectourethral fistula occurred in a 73 year-old man after a radical retropubic prostatectomy and external beam irradiation for prostate cancer, successfully treated with perineal approach.

Laparoscopic retroperitoneal lymphadenectomy for stage I non-seminomatous testicular tumors

Retroperitoneal lymph node dissection (RPLND) is the most accurate method to evaluate the presence and extent of retroperitoneal nodal metastases in clinical stage I non-seminomatous germ cell testicular carcinoma. In our Department the open "nerve sparing" RPLND is already the standard surgical treatment for these tumors and laparoscopic technique is employed in surgical treatment of digestive diseases as cholelithiasis, hiatal hernias and gastrointestinal tumors; we report our first experience with laparoscopic RPLND in patients with low stage non-seminomatous germ cell testicular tumors (NSGCTT). A laparoscopic modified template RPLND was performed in 5 high-risk patients with non-seminomatous germ cell clinical stage I tumors by a transperitoneal approach. In 4 of the 5 cases a template dissection was performed. In one pathological stage II tumor a limited lymph node dissection was performed and the patient underwent postoperative chemotherapy. Mean operative time was 190 minutes (range 160-210). No retrograde ejaculation occurred. The mean number of dissected nodes was 21 (range 16-25). At mean follow-up of 16.3 months (range 12-21) the 4 operated patients with pathological stage I NSGCTT are disease free without ejaculatory or urinary dysfunction. Our preliminary experience suggests that laparoscopic RPLND for stage I NSGCTT is feasible and safe for surgeons largely trained in either laparoscopic digestive surgery or open RPLND for whom the learning curve of that minimally invasive approach is lower than expected.

Choice of the surgical treatment in early gastric cancer

BACKGROUND/AIMS

The authors report their experience in choosing the surgical treatment for early gastric cancer.

METHODOLOGY

A retrospective study was conducted to examine the long-term outcome of 18 patients with early gastric cancer (10%) on a series of 180 patients treated for gastric carcinoma by the same surgical équipe from January 1986 to June 1997. Radical surgery with gastrectomy and extended lymphadenectomy ("regional" from 1986 to 1991; D2 from 1992 to 1997) was chosen as standard treatment for early gastric cancer except in elderly or high-risk patients and in cases of mucosal tumors diagnosed at definitive histology after surgery for benign diseases in which limited surgery was performed.

RESULTS

All patients received curative (R0) surgery. One patient with mucosal-N1 tumor and another one with submucosal-N0 tumor died because of gastric cancer at 51 and 42 postoperative months respectively. The mean follow-up time was 99.8 (11-193) months. The overall 5-year and 10-year survival rates are 86.7% and 86.7% respectively. The 5- and 10-year survival rates for intramucosal tumors are 91% and 91% respectively and for submucosal cancer are 75% and 75% (P=0.39).

CONCLUSIONS

According to the prognostic value of nodal involvement and the difficulty in achieving a preoperative accurate diagnosis of depth of invasion and of nodal involvement in early gastric cancer, a radical gastric resection with D2-lymphadenectomy should be performed.

[Thyroid anaplastic tumor: our experience]

We report our experience over the past 10 years in the treatment of thyroid anaplastic carcinoma analysing retrospectively 21 cases of surgical treatment (7 total thyroidectomies, 12 partial resection of the tumours and 2 biopsies). We consider the prognosis, which is invariably fatal, with no survival at 19 months and a mean survival of only 9 months, and assess the validity of a combined therapeutic approach (surgery + radiotherapy + chemotherapy) to increase survival and, above all, the patient's quality of life. The importance is stressed of through monitoring of risk factors consisting in concomitant or previous benign or malignant thyroid disease, considering total thyroidectomy to be necessary in principle for any variety of thyroid cancer. Lastly, we examine the survival trend in terms of residual disease and the presence or otherwise of remote metastases.

[Treatment of hemorrhoids with circular mechanic stapler]

In a pilot study undertaken in collaboration with the Department of Surgery of "San Carlo di Nancy" Hospital in Rome, over the period form January 1998 to February 2000, 128 patients with haemorrhoidal disease underwent surgery using a circular stapler to "lift" the mucous-haemorrhoidal prolapse, according to the pathogenetic theory discussed here below. We compared the results of our series with those of a retrospective series of 80 patients that undergoing traditional surgery (Khubchandani 45, Milligan-Morgan 30, Whitehead 5), evaluating length of operation, postoperative pain and complications. Our preliminary data show that the technique requires only a short learning period, reduces the length of the operation, reduces the medium- and long-term pain and allows mables the patient to resume full working activity earlier.

[Pseudosarcoma of the urinary bladder. Report of a case]

A case of myofibroblastic pseudosarcomatous tumor of the bladder occurred in a patient previously submitted to TURB is reported. Aim of this investigation is to demonstrate, on the basis of the literature, the importance of histopathology in the diagnosis of bladder pseudosarcoma, since endoscopical and radiological methods can erroneously show a neoplasm. A 65-year-old male patient with hematuria, submitted to ultrasonography and cystoscopy, revealed a bladder superficial papillary formation. A TURB was performed and the histological study showed a superficial bladder cancer (T1-G1-2). After a second hematuria episode with stranguria a new bladder formation was diagnosed and resected; the histological study revealed a bladder pseudosarcoma. The absolute benignity of the lesion and the slight difference in the symptomatology between urothelial carcinoma and pseudosarcoma are underlined. Furthermore, the importance of histopathology to obtain an accurate diagnosis is stressed. The difficulty of a preoperative diagnosis without histopathological examination is pointed out.

[Gastrointestinal carcinoids and carcinoid syndrome: classification, diagnosis and therapy]

Historically, carcinoids have long been known as a morphologically distinct class of rare intestinal tumors which behave less aggressively than the more common intestinal adenocarcinomas. In recent decades refined methods in pathology improved our knowledge on the diffuse neuroendocrine system, leading to some confusion in classification and nomenclature of carcinoids. The World Health Organization (WHO) classification of endocrine tumors has cleared the definition of carcinoids. The Authors report on 7 cases of midgut carcinoid tumors and 1 case of carcinoid syndrome focusing on the newer approaches to the diagnosis, localization, and role of surgery and peptide therapy.

[Artificial nutrition in acute pancreatitis]

Nutritional support for acute pancreatitis is a matter of debate, clear guidelines based on objective data do not exist. We report our experience in patients with severe disease. Parenteral nutrition appears to be a safe initial therapy, but the enteral route has many practical and theoretical advantages and should be started as soon as possible.

[Blind-ending branch of bifid ureter: apropos of a case]

The Authors report on a case of blind-ending ureter. A young woman (29 years old) underwent surgery because of recurrent urinary tract infections and left loin pain. The operation consisted in a radical resection of the blind branch together with Coen's operation for the coexistence of vesicoureteral reflux. Authors' goal was to review the international Literature on this rare pathology pointing out their opinion on the existing terminology which is still far from being clear and definite.

[The intraoperative visualization of the bile ducts by the use of fluorescent substances. A feasibility study]

Iatrogenic bile duct injury during cholecystectomy is the most serious complication of this surgical procedure. Initial reports suggest that this complication is particularly problematic during laparoscopic cholecystectomy. Proper identification of biliary anatomy in the subhepatic region is the only way to avoid this severe complication. The potential benefit from a simple, reliable method for intraoperative delineation of biliary anatomy is self-evident. In this experimental work the Authors-study the possibility and the feasibility of intraoperative biliary tree imaging with two fluorescent molecules (rolitetracyclin and fluorescin).

The value of endoluminal ultrasonography and computed tomography in the staging of rectal cancer: a preliminary study

A prospective study was carried out in 14 patients with rectal cancer. Tumors were staged preoperatively by endoluminal ultrasonography (EU) and computed tomography (CT). Patients were followed postoperatively for 2 years by the same modalities. Extramural spread was 100% (9/9), accurately assessed by EU and 77.8% (7/9) with CT. Lymph node sensitivity was 87.5% for EU and 37.5 for CT (P less than 0.05). Overall accuracy of lymph node metastases was 85.7% for EU and 57.1% for CT (P less than 0.1). In conclusion, the study shows EU to be statistically more accurate for nodal metastases than CT; therefore, its routine use can be recommended in the preoperative staging of rectal carcinoma in those patients for whom a sphincter-saving procedure is considered.

Endoluminal ultrasound for early detection of local recurrence of rectal cancer

The diagnostic potential of endoluminal (endorectal and endovaginal) ultrasound to detect asymptomatic resectable local recurrence after rectal cancer surgery has been assessed in 120 patients: 17 recurrences (14 per cent) were detected. The method showed 97 per cent accuracy, 94 per cent sensitivity and 98 per cent specificity; the positive predictive value was 85 per cent and the negative predictive value was 99 per cent. A longer follow-up is, however, necessary to confirm these results. Of the 17 patients with local recurrence, six were asymptomatic and underwent reoperative surgery. Of the other 11 patients with symptomatic recurrence, only two underwent reoperative surgery.