Total intravenous anesthesia (TIVA) with propofool and remifentanil during operative endoscopy tracheobronchial laser therapy

Background

The aim of our study was to assess how total intra-venous anaesthesia (TIVA) achieved by propofol and remifentanil continuous infusion could ensure proper success of the endobronchial laser therapy, in optimal conditions for the endoscopist, determining at the same time an adequate hypnosis and a good analgesia.

Methods

We studied 50 patients (28M - 22F), ASA class I-IV, mean age 42 ± 32.5 years , subjected to laser endoscopy to repair tracheal stenosis. TIVA was performed in all patients, and spontaneous breathing was maintained.

Results

10.2% of patients experienced episodes of coughing during induction. The depth of the anaesthesia plan, monitored by BIS, was 55 ± 5. The awakening was fast in all patients, with an Aldrete score of 7.71 ± 1.14 at 1 minute and 9.31 ± 1.12 at 10 minutes.

Conclusion

The results of this study allow us to state that the continuous infusion of propofol and remifentanil proved to be the gold standard in patients ASA I-II-III undergoing endobronchial laser therapy. The use of TIVA has also allowed to perform endoscopic intervention on patients who suffered from a significant decrease of both cardiac and respiratory functions.

Fracture and migration in right atrium of a permanent venous central access system in a elderly patient: case report and literature review

Catheter dislocation and fracture with migration of central venous lines have been reported in the International literature. Catheter fracture with consequent migration has been observed in 0.5-3.0% and may either be consequent to catheter removal or it can occur spontane-ously. Our case report concerns the migration of a Hickman catheter connected to a venous port to the right atrium in a 61-year old patient. A literature up-to-date has been performed to assess the risk of port-a-cath positioning. The position of catheter tip is considered critical for the risk of migration, that is greater as higher the tip localization respect to the carina. The aim of our study is to underline the critical role of X-ray to visualize the exact location of the catheter tip, regard-less of the approach used for catheter positioning.

Right pneumothorax secondary to colonoscopic perforation: a case

AIM

The purpose of this study is to determine the anatomical aspects, mechanisms, risk factors and appropriate management of development of pneumothorax during a routine colonoscopy.

CLINICAL CASE

We report a case of an accidental bowel wall injury during diagnostic colonoscopic with consequent pneumoperitoneum; this was followed by expansion of gas through diaphragmatic fenestration perhaps congenital, in right pleural cavity causing pneumothorax.

DISCUSSION

Rarely, colonic perforation during colonoscopy can occur into the extraperitoneal space, thus leading to the passage and diffusion of air along the fascial planes and large vessels, possibly causing pneumoretroperitoneum, pneumomediastinum, pneumopericardium, pneumothorax, and subcutaneous emphysema. The combination of intraperitoneal and extraperitoneal perforation has also been reported. Pneumothorax following a colonoscopy sigmoid perforation is an extremely rare but severe and often lifethreatening complication.

CONCLUSION

If the patient develops dyspnea and pneumoderma during or after this procedure, a chest radiogram or thoracoabdominal CT should be taken for diagnostic purposes. Urgent treatment, starting with chest tube insertion(s) and laparotomy or laparoscopy could be lifesaving.

Clinical Significance of Serum Gastrin Levels in Patients with Colorectal Cancer

Aims

An association between elevated serum gastrin levels and the presence of human colorectal cancer has been reported, and gastrin has been shown to stimulate the growth of experimentally induced colon neoplasia. The aim of this study was to determine the preoperative and postoperative concentrations of serum gastrin in 53 patients with colorectal cancer and to assess the correlation between gastrin levels and tumor characteristics and prognosis.

Materials and Methods

A prospective study was performed over a six-year period during which 53 patients received potentially curative surgery for colorectal cancer. The prognostic variables used for the analysis included age, sex, tumor site, stage and degree of differentiation, preoperative and postoperative serum values of carcinoembryonic antigen (CEA) and gastrin, cancer-related mortality, and survival. CEA and gastrin serum values were determined using radioimmunological methods. Follow-up was carried out with clinical and radiological tests.

Results

The mean preoperative gastrin concentration was 51.2 ± 27.4 pg/mL (range 12–146). Significantly increased serum gastrin concentrations, which returned to normal after surgery, were detected only in patients with well-differentiated cancer (74.2 ± 28.3 pg/mL; moderately differentiated, 52.1 ± 23.8; poorly differentiated, 29.9 ± 12.3, p=0.02). The prognosis was unrelated to serum gastrin level; instead, tumor stage, preoperative CEA value, and degree of differentiation affected patient survival.

Conclusions

This study showed that the serum gastrin concentration is not an appropriate clinical oncogenic factor. Although occurring only in well-differentiated tumors, serum gastrin is unrelated to the prognosis of patients with colorectal cancer.

Abdominal scar endometriosis: case report

Abdominal scar endometriosis, corresponding to the presence of an endometrial tissue near or inside an abdominal surgical incision, is a rare clinical event that can occur in women after gynecological or obstetric surgery. Generally, a triad consisting of underlying mass at the incision, cyclic menstrual scar pain, and history of previous gynecological or obstetric surgery leads to the preoperative diagnosis. In rare cases, the clinical presentation is atypical and the differential diagnosis with incarcerated incisional hernia, granuloma, abscess or other soft tissue tumors can be difficult. The authors describe the case of 39-year-old woman who underwent three previous cesarean sections, with a 20-week history of underlying palpable mass at the Pfannenstiel incision, associated to continuous pain. In this case, a surgical excision followed by the histology definitely clarified the diagnosis.

[Hormone replacement therapy after total thyroidectomy. Can the combined treatment be considered effective to get metabolic adequacy? Preliminary results]

INTRODUCTION

Even if T4 is standard treatment for hypothyroidism after thyroidectomy, a treatment with T4 plus T3 has been proposed as an alternative reproducing carefully the physiology of the thyroid. We performed an observational study about the effects of the combined replacement therapy with T4 and T3 in patients who underwent total thyroidectomy.

PATIENTS AND METHODS

Fifty thyroidectomized patients (not for cancer), in T4 replacement therapy, were included in the study. Such a therapy has been changed by administering T3 and T4 in proportion 1/16. Adverse effects, clinical parameters and general health perceptions (SF36 Questionnaire) have been considered at the time of enrollment (T0), after 30 days (T1) and after 60 days (T2).

RESULTS

No differences in weight, cardiac frequency and blood pression have been found between T0 and T2. A not statistically significant reduction has been found in total cholesterol (3 mg/dL) and triglycerides (3.29 mg/dL) levels. A reduction of complaints referred by the patients at T0 has been revealed in T2: anxiety from 21 to 13 patients; headache from 22 to 13; tiredness from 17 to 8 (p<0.05); sleepiness from 25 to 15 (p<0.05). About the questionnaire, in the General Health Perception sub-score has been found a not significant increase of the parameter.

DISCUSSION AND CONCLUSIONS

T4 replacement therapy is of proved efficacy, notwithstanding some complaints afflict a share of patients. To improve the quality of life of these patients, we consider relevant the reduction of complaints and the improvement of well-being and cognitive function obtained by the combined T4 and T3 treatment. Moreover, even if the production of T3 from T4 usually ensures euthyroidism in all tissues, contemporary pathologies and alterations determined by the oldness can disturb the enzymatic activity, which is the essential requirement of T4 therapy. These preliminary findings in a small group of patients encourage further studies on a larger patient population.

[Colorectal carcinoma in the young. Prognostic factors]

Colorectal carcinoma is the third most frequently diagnosed malignant neoplasm. Usually patients affected by this neoplasia belong to VI decade of life. However approximately 2-8% of tumors arise in patients with age under 40 years. Aim of the study was to analyse the results of surgical treatment of colorectal cancer in patients aged under forty. From January 1987 to December 2002, 46 patients under forty years with colorectal cancer underwent surgical procedure. No perioperative mortality was registered, and complications were evidenced in nine patients (20%). Actuarial five years survival was 33%, and overall mean survival was 53 months. Univariate and multivariate analyses identified as prognostic factors the tumor grade, Dukes' stage, nodal status, and length of symptoms.

[Primary adenocarcinoma of the ureter. Case report]

Primary ureteral adenocarcinoma is an infrequent histological type of urinary neoplasm. Many authors consider intestinal metaplasia the pivotal event of the pathogenetic process, whether it occurs on a pre-existing urothelial carcinoma or on a normal urothelium. Diagnosis is essentially based on case history and clinical findings (hematuria and pain) and on diagnostic imaging. Treatment is surgical and the ideal procedure is nephroureterectomy with excision of a bladder margin adjacent to the ureteral opening and ispilateral para-aortoiliac lymphadenectomy. A 76-year-old man with primary adenocarcinoma of the ureter case is reported.

Clinical significance of serum gastrin levels in patients with colorectal cancer

AIMS

An association between elevated serum gastrin levels and the presence of human colorectal cancer has been reported, and gastrin has been shown to stimulate the growth of experimentally induced colon neoplasia. The aim of this study was to determine the preoperative and postoperative concentrations of serum gastrin in 53 patients with colorectal cancer and to assess the correlation between gastrin levels and tumor characteristics and prognosis.

MATERIALS AND METHODS

A prospective study was performed over a six-year period during which 53 patients received potentially curative surgery for colorectal cancer. The prognostic variables used for the analysis included age, sex, tumor site, stage and degree of differentiation, preoperative and postoperative serum values of carcinoembryonic antigen (CEA) and gastrin, cancer-related mortality, and survival. CEA and gastrin serum values were determined using radioimmunological methods. Follow-up was carried out with clinical and radiological tests.

RESULTS

The mean preoperative gastrin concentration was 51.2+/-27.4 pg/mL (range 12-146). Significantly increased serum gastrin concentrations, which returned to normal after surgery, were detected only in patients with well-differentiated cancer (74.2+/-28.3 pg/mL; moderately differentiated, 52.1+/-23.8; poorly differentiated, 29.9+/-12.3, p=0.02). The prognosis was unrelated to serum gastrin level; instead, tumor stage, preoperative CEA value, and degree of differentiation affected patient survival.

CONCLUSIONS

This study showed that the serum gastrin concentration is not an appropriate clinical oncogenic factor. Although occurring only in well-differentiated tumors, serum gastrin is unrelated to the prognosis of patients with colorectal cancer.

Maximum gastric cancer diameter as a prognostic indicator: univariate and multivariate analysis

It was suggested that there are no stronger prognostic factors in gastric cancer than nodal involvement or depth of wall invasion. The present paper evaluated the influence of maximum tumor diameter (MTD) value, measured on fixed resected specimens, on the extent of disease progression and the outcome in gastric cancer patients. Clinicopathological data were retrospectively retrieved from records of 122 patients who underwent curative gastrectomy. The patients' MTD values were grouped as follows: MTD1, up to 26 mm; MTD2, between 26 and 50 mm; and MTD3, over 50 mm. The three groups evidenced significant differences with regard to 5 year survival (MTD1: 54%, MTD2: 31%, MTD3: 20%; p = 0.00027), furthermore they were significantly different with respect to the type of gastrectomy (p = 0.021), depth wall invasion (p = 0.000), lymphatic microinvasion (p = 0.014), perineural microinvasion (p = 0.017), stromal reaction (p = 0.025), and stage (p = 0.035). ROC curve analysis individuated a best accurate MTD threshold value for nodal involvement of 32 mm (sensitivity = 56.6%; specificity = 60.9%; positive predictive value = 52.6%; negative predictive value = 64.6%). The logistic regression analysis suggested that the depth of wall invasion was the only independent variable associated with MTD value (p = 0.0005). Multivariate analysis showed that independent prognostic risk factors were sex (p < 0.0025), number of involved nodes (p < 0.001) and MTD (p < 0.001). In conclusion, the maximum tumor diameter value of gastric cancer may be a factor with greater prognostic implications than previously believed.

[Rectal cancer in women]

A retrospective chart review was performed utilizing the First Department of Surgery of the University of Rome "La Sapienza" Medical School database. Ninety-two women who underwent abdominal surgery between 1980 and 1993 for rectal cancer were identified. Data collected included demographics, history, intraoperative findings and complications, cancer histology and stage and follow up. Special attention was focused on intraoperative incidental gynecological findings and follow up. Twenty-two patients being previously submitted to hysterectomy and three with oral intake of hormones were dismitted from the study. Of the remaining 67 patients gynecological procedure was associated to rectal surgery because of a previously undiagnosed gynecological condition. No prophylactic oophorectomies were performed. At follow up 7 patients experienced further surgery for gynecologic disease. The necessity to offer these patients the benefit of a preoperative informed decision about adjunctive gynecologic surgery and indications for bilateral oophorectomy is discussed.

[Cecal volvulus]

A retrospective study on 18 patients with cecal volvulus surgically treated was made. Demographics and clinical data, as well as treatment were determined from clinical reports. The operative procedures employed were cecostomy (56%), cecopexy (22%) and right colectomy (22%). The length of follow up averaged 63 months and there was one recurrence. The Authors suggest that cecostomy should be employed in patients with viable bowel, and resection should be limited to cases with gangrene.

[Carcinoma of the male breast. Prognostic factors and outcome of surgical treatment]

A retrospective study was made on 18 male patients with breast carcinoma treated at the Department of Surgery "Pietro Valdoni" of the University "La Sapienza" of Rome, Medical School. Demographics, pathology, stages, and treatment were determined from clinical reports. All patients but one underwent modified radical mastectomy. The length of follow up averaged 57.5 months. Five years actuarial survival rate was 62%. In the current study the Authors suggest that the clinical, prognostic and treatment features of breast carcinoma in men are similar to those reported in literature for post-menopausal women.

[Pica and intestinal occlusion: a clinical case]

Accidental or voluntary foreign bodies ingestion is a frequent reported event in emergency departments. Complication, foreign body shape related are not often observed and, once occurred, just few a cases need an open surgery approach, about 1%. The Authors report the case of a young woman with pica admitted to their Department in an emergency setting for acute intestinal obstruction due to the ingestion of not specified amount of elastics, which required an open surgery operation.

[Pancreatic anastomotic fistula after pancreaticoduodenectomy: incidence, significance and treatment]

The Authors reviewed the complications, and outcomes in a consecutives series of 97 patients undergoing pancreaticoduodenectomy. The clinical leak rate in this series was 21.8%. There was a difference in the pancreatic leak rate in those patients who underwent pancreatic ductal closure or end to end pancreaticojejunal invagination compared with end to side pancreaticojejunal anastomosis. The postoperative complication rate was 41.8% and the most common complications were pancreatic fistula. 9 deaths occurred in hospital or within 30 days from operation. Univariate and multivariate analysis revealed that operative technique, the pathological status of the pancreatic remnant, and mayor complications were the significant risk factors for the development of pancreatic anastomotic leak. In the 2000s pancreatic leak remains a potentially lethal problem. After pancreaticoduodenectomy, pancreatic remnant management by end to side pancreaticojejunostomy appeared safe in low-risk patients. Morbidity was greatest after pancreatic duct closure without anastomosis.

[Use of ileostomy and colostomy as temporal derivation in colorectal surgery]

A retrospective study on 41 patients with primary stoma creation after low anterior resection of the rectum was made. Among the 41 patients 24 had a loop colostomy (Group A) and 17 had a loop ileostomy (Group B). The two groups were well matched for each of the data analysed and there was no significant difference in the rate of complications related to stomas creation and closure. In this study the Authors suggest that loop ileostomy is the best procedure to electively defunctionate colorectal anastomoses.

Presacral myelolipoma in a patient with colon carcinoma

Myelolipoma is an uncommon benign tumor, composed of an admixture of adipose tissue and hematopoietic cells, usually discovered within the adrenal glands. Extra-adrenal myelolipomas are rare and approximately half of the reported cases were presacral. We report a case of an asymptomatic presacral myelolipoma measuring 9x8x7 cm, incidentally found in a 71-year-old woman with a stenosing colon cancer. Ultrasonography, computed tomography and magnetic resonance imaging of the presacral mass evidenced a well circumscribed tumor with heterogeneous features due to a nonuniform composition. Surgical excision of the mass was performed.

[Ambulatory closed surgery for the treatment of pilonidal sinus]

Pilonidal disease (PD) is a common chronic disorder of the sacrococcygeal region afflecting young people. Despite several methods for treating PD have been described, the management remains controversial. Recent reports have advocated different surgical approaches such as open or closed technique, but recurrence plagues all forms of therapy. We conducted this case review to evaluate the validity of an outpatient closed technique in the treatment of chronic pilonidal disease. Between January 1997 and July 1999, 65 consecutive patients with quiescent chronic PD were electively treated by surgical excision of the cyst and primary closure. There were 47 men (72%) and 18 women (28%) in this study. Patients ranged in age from 14 to 47 years, the average age being 21 years. The median healing time was 8 days and the median time to return to full work was 20 days (range 10-25). Infection and recurrence rates were 1.5% and 4.6% respectively. There was no correlation among recurrence rate, postoperative infection, or prior surgery. Cyst excision and primary closure is a safe, low cost operation with a very high long-term success rate and a negligible rate of complications. It can successfully be performed under local anaesthesia in an outpatient facility.

Late development of bile duct cancer in patients who had biliary-enteric drainage for benign disease: a follow-up study of more than 1,000 patients

OBJECTIVE

To evaluate the correlation between biliary-enteric surgical drainage and the late development of cholangiocarcinoma of the biliary tract.

SUMMARY BACKGROUND DATA

In patients with biliary-enteric drainage, reflux of intestinal contents into the bile duct may occur and cause cholangitis, which is regarded as the most serious complication of these procedures. Lithiasis of the biliary tract and a previous biliary-enteric anastomosis have both been suggested to favor the late onset of cholangiocarcinoma.

METHODS

Consecutive patients (n = 1,003) undergoing three different procedures of biliary-enteric anastomosis (transduodenal sphincteroplasty, choledochoduodenostomy, and hepaticojejunostomy) between 1967 and 1997 were included in this study. The postoperative clinical course and long-term outcome were evaluated by a retrospective review of the hospital records and follow-up. Mean follow-up was 129.6 months.

RESULTS

Fifty-five (5.5%) cases of primary bile duct cancer were found among the 1,003 patients at intervals of 132 to 218 months from biliary-enteric anastomosis. The incidence of cholangiocarcinoma in the three groups was 5.8% in transduodenal sphincteroplasty patients, 7.6% in choledochoduodenostomy patients, and 1.9% in hepaticojejunostomy patients. The incidence of malignancy related to the different underlying diagnosis was 5.9%, 7.2%, and 1.9% in patients with choledocholithiasis, sphincter of Oddi stenosis, and postoperative benign stricture, respectively. Although only one patient who developed cholangiocarcinoma had previous concurrent lithiasis of the biliary tract, 40 patients had experienced mostly severe, recurrent cholangitis. No case of malignancy occurred in patients scored as having no cholangitis in the early and long-term postoperative outcome. Univariate and multivariate analyses have shown the presence of cholangitis as the only factor affecting the incidence of cholangiocarcinoma.

CONCLUSIONS

Chronic inflammatory changes consequent to biliary-enteric drainage should be closely monitored for the late development of biliary tract malignancies.

Preservation of the inferior mesenteric artery in colorectal resection for complicated diverticular disease

BACKGROUND

Preservation of the inferior mesenteric artery (IMA) and consequential blood flow to the rectum would reduce the risk of leakage of a colorectal anastomosis.

METHODS

One hundred and sixty-three patients undergoing left colectomy for complicated diverticular disease of the colon were randomly placed into two groups: A, n = 86; and B, n = 77. In group A, the integrity of the IMA was preserved by artery skeletization (IMAS); in group B, the IMA was divided at its origin. Variables recorded included duration of the surgical procedure, need for blood transfusion, length of hospital stay, operative mortality and morbidity, staple-ring disruption, and radiologic and clinical leakage. Anastomotic stenosis and recurrence of diverticular disease were noted.

RESULTS

Surgical time was superior in the IMAS group. Radiologic and clinical leakages were significantly higher in group B (P = 0.02, P = 0.03, respectively). In group A a significant lower number of staple-ring disruptions was observed, evolving into clinical dehiscence.

CONCLUSION

Preserving the natural blood supply to the rectum and the ensuing use of a healthy well-nourished rectal stump are suggested as the main aspects of IMAS in preventing and healing leakage of colorectal anastomosis.

Clinical significance of normobasemia in early post-operative outcome of hepatic resections

BACKGROUND

Major hepatic resections are usually followed by acid-base unbalance. Adjustment of the acid-base disorders is considered central when dealing with these critical patients and normobasemia is thought to be a favourable prognostic factor when occurring in the immediate postoperative outcome after major surgery. The present study was undertaken to investigate the influence of acid base balance on the early outcome after hepatic resection.

METHODS

A series of fifty-seven cirrhotic patients was submitted to liver resection for hepatocellular carcinoma. Forty-eight patients experienced an uneventful early postoperative outcome (CTR group). Nine died in the postoperative course (HD group). In all patients pulmonary, renal and hepatic functions were monitored pre- and postoperatively. The pH values were detected daily preoperatively and in the course of the first three days after hepatic resection. In the same days acid base balance and arterial ketone body ratio were assessed on arterial blood samples. Data were collected in a data base and statistical analysis was performed.

RESULTS

A significantly higher metabolic alkalosis was found to characterize the first and second postoperative days (POD1 and POD2) in the CTR group (pH 7.43+/-0.007 vs pH 7.33+/-0.001; pH 7.45+/-0.006 vs pH 7.35+/-0.009; p<0.05). Lower values of pH and an associated impaired energetic status of the liver were found to characterise the postoperative course of the poor prognosis patients. At POD1 AKBR decreased in both groups but while recovering at POD2 in patients of CTR group maintained significantly lower values in HD group (AKBR 1+/-0.3 vs 0.5+/-0.2; p<0.01). A lower energetic status of the liver is associated with an inadequate tricarboxylic acid cycle and is responsible for an impaired production of HCO3-.

CONCLUSIONS

Apparent normobasemia is then expressive of liver failure leading to poor postoperative outcome.

Impact of axillary level I and II lymphnode dissection on the therapy of stage I and II breast cancer

BACKGROUND

Routine performance of axillary node dissection (AND) in the treatment of stage I and II breast cancer has become controversial because of pretended morbidity of this procedure and progressing consent for sentinel lymphadenectomy.

METHODS

Ninety-four consecutive patients who underwent AND for clinical stage I and II breast cancer were evaluated for a range of 48.3 months after surgery for movement and sensory alterations and arm swelling. Arm circumference was measured in all patients at the same four sites on both the operated and non operated sides preoperatively and in the immediate and late postoperative course. Capacity for movement was assessed pre- and postoperatively as active ranging at the shoulder joint. Postoperative numbness and paresthesias were assessed by standard questions.

RESULTS

No patient had axillary recurrence. None of the detected differences between the preoperative and postoperative arm circumferences reached statistical significance. No persistent motion limitation was observed. Pain, numbness, paresthesia were detected in almost all patients in the immediate postoperative period but resolved spontaneously in all cases within 6 months. The obese body habit was detected on multivariate analysis as the only significant predictor of edema.

CONCLUSIONS

No significant morbidity and no axillary recurrence were observed in current experience to follow AND. These findings suggest that axillary level I and II dissection remains an effective and safe tool for diagnostic, as well therapeutic, purposes in the treatment of stage I and II breast cancer. Further studies are necessary before it can safely be reported that axillary node dissection is an optional part of the treatment of stage I and II breast cancer.

The influence of somatostatin on bacterial translocation

BACKGROUND

Bacterial translocation is defined as the passage of bacteria from the gastrointestinal tract to extraintestinal sites mostly as a consequence of the loss of the gut barrier function. Somatostatin and octreotide, exerting many inhibitory effects on the gastrointestinal tract, have been evidenced to promote bacterial translocation.

DESIGN

experimental research.

SETTING

University teaching Hospital.

INTERVENTIONS

Sixteen pigs forming the study group received 25 mg/kg of octreotide twice a day for ten days. A control group (n=16) received an equal volume of saline solution for the same period. All animals were sacrificed and tissue cultures were obtained from mesenteric lymph nodes (MLN), liver and spleen. Portal venous and central venous blood samples were also withdrawn for culture.

RESULTS

In the octreotide group, cultures were positive for bacteria in 43.7% (7/16) of animals. Viable bacteria were recovered from MLN, liver and spleen. Portal and systemic blood cultures showed no growth of bacteria. The mean value of bacterial detection in MLN, liver and spleen was 196+/-13 CFU/g, 190+/-26 CFU/g, and 173+/-0 CFU/g, respectively. P value was not statistically significant. Bacterial translocation did not occur in the animals of the control group. Fisher s exact test revealed a statistically significant difference (p<0.007) between the two groups regarding bacterial translocation to MLN.

CONCLUSIONS

The administration of octreotide is followed by a conspicuous increase in bacterial translocation in pigs. Further clinical studies are needed to demonstrate similar effects on humans.

Total mesorectal excision and low rectal anastomosis for the treatment of rectal cancer and prevention of pelvic recurrences

HYPOTHESIS

Total mesorectal excision lowers the rate of pelvic recurrence and positively affects the survival after surgical treatment of rectal cancer.

DESIGN

Case series.

SETTING

Tertiary care university hospital.

PATIENTS

Fifty-three consecutive patients were admitted with curative intent to surgery at the First Department of Surgery of the University of Rome "La Sapienza," Rome, Italy, with diagnoses of rectal carcinoma. The mean follow-up was 68.9 months; follow-up was complete for all patients who entered the trial.

INTERVENTIONS

Low anterior resection and total mesorectal excision were performed in all cases, regardless of the location of the rectal cancer. A straight mechanical colorectal anastomosis was performed on a rectal stump, never exceeding 5 cm. No kind of adjuvant therapy was given. Mesorectum and open rectum were studied by serial transverse section at 5-mm intervals. A search for depth of penetration and distal intramural extension of the tumor was made. Lymph nodes were detected by clearing method, and nodal metastases (NM) and nonnodal metastases (NNM) were recorded as situated proximally, distally, or at the level of the tumor.

RESULTS

There was no postoperative mortality. Clinical and radiologic leaks occurred in 2 and 4 patients, respectively. Mean disease-free survival was 65.9 months. Pelvic recurrence occurred in 5 patients (9%). Overall 5-year survival rate was 75%. Involvement of mesorectum by NM and NNM was detected in 27 and 24 cases, respectively. Both NM and NNM were found to be distal in 33% and 40% of cases, respectively.

CONCLUSIONS

Microscopic spread to the distal mesorectum may exceed the intramural spread of rectal cancer. Failure to perform total mesorectal excision leaves a potentially residual disease in the distal mesorectum, thus predisposing the patient to pelvic recurrence.

[Acquired abnormalities of the biliary tract. Preoperative diagnosis and surgical risk in the laparoscopic era]

Acquired anomalies of the biliary tract are rare. The aim of this work was to examine their frequency and to assess potential associated danger when performing a laparoscopic cholecystectomy. A retrospective analysis of clinical charts of 3.870 patients undergoing elective cholecystectomy between 1959 and 1997 was performed. Eighteen cases of choledoco-duodenal fistula, 9 of cholecysto-duodenal and 12 of cholecysto-choledochal fistulas were observed. Two cases of acquired absence of the cystic duct and one cholecysto-colic fistula were also encountered. The traditional contrastographic radiology showed to be more accurate in defining presence and nature of the acquired anomalies. Etiopathogenesis of the main anomalies and consequent risks in performing laparoscopic cholecystectomy were discussed.

[Layered and mass sutures in the closure of median laparotomies]

A retrospective comparison of 2830 patients with midline abdominal incision closures was made. Dehiscences, infections, hernias were compared examining continuous mass closures (group A) versus interrupted mass closures (group B) and interrupted layered sutures (group C). The three groups were well matched for known risk factors for each of the above complications. Mass closures produced a significant higher number of infections (p = 0.0006) and hernias (p = 0.0001). There was no significant difference in the rate of dehiscences in the three suture groups (p = 0.07). A significant correlation was found in all three groups between the incidence of infections and that of outcoming incisional hernias. In the current study layered closure of the of the midline abdominal wounds yielded better results when compared with both running mass and interrupted mass closures. The knowledge of these findings might help when choosing the procedure to close a midline abdominal incision.

Prospective evaluation of omentoplasty in preventing leakage of colorectal anastomosis

PURPOSE

The aim of this study was to investigate the role of omentoplasty, by means of intact omentum, in preventing anastomotic leakages after rectal resection.

METHODS

Between 1992 and 1997 a total of 112 patients (64 males) with a mean age of 64.7 (range, 39-83) years were randomly assigned to undergo omentoplasty (Group A) or not (Group B) to reinforce the colorectal anastomosis after anterior resection for rectal cancer. The primary end point was anastomotic leakage; the secondary end point included morbidity and mortality related to omentoplasty.

RESULTS

The two groups were comparable in terms of preoperative and intraoperative characteristics. Staple-ring disruption at plain abdominal radiographs was detected in seven instances in Group A and in ten in Group B patients (P = not significant). Two leakages were evident clinically in Group A and seven in Group B (P < 0.05). Three leaks were documented radiologically in Group A and eight in Group B (P = not significant). No complications related to omentoplasty were observed in Group A. There were two repeat operations for anastomotic leakage in Group B. At followup, one stricture developed in Group A and three in Group B (P = not significant)

CONCLUSIONS

Despite a similar incidence of staple-ring defects, a strikingly lower rate of clinically and radiologically detected leaks developed in patients submitted to omentoplasty. Although not affecting the incidence of anastomotic disruption, omentoplasty seems to contain the severity of anastomotic leakage.

Management of benign biliary strictures: biliary enteric anastomosis vs endoscopic stenting

HYPOTHESIS

Although advances in endoscopic procedures have provided alternative options for relieving biliary obstructions, the overall chance of cure for patients with benign biliary stricture is the same using surgical or endoscopic treatment.

DESIGN

Case-control study.

SETTING

Tertiary care university hospital.

PATIENTS

Of 163 patients referred for treatment with diagnoses of benign strictures of the common bile duct between January 1, 1975, and July 1, 1998, we studied 42 patients with postcholecystectomy stricture and a follow-up longer than 60 months. Twenty of these patients were treated with endoscopic stenting and 22 with surgery (hepaticojejunostomy, choledochojejunostomy, or intrahepatic cholangiojejunostomy).

MAIN OUTCOME MEASURES

Postoperative mortality and morbidity and long-term outcome. The rate of restenosis was also determined.

RESULTS

Morbidity occurred more frequently in patients treated with endoscopic procedures than with surgical ones (9 vs 2; P = .34). Hospital mortality was 0%. Surgery achieved excellent or good long-term outcome in 17 of 22 patients. Endoscopic biliary stenting was successful in 16 of 20 patients. Overall, excellent or good outcomes were achieved in 34 patients (81%).

CONCLUSION

The ability to achieve steady, long-term results confirms hepaticojejunostomy as the best procedure in the treatment of benign biliary strictures, even if endoscopic procedures are gaining a new role in the treatment of a greater number of patients.

[Cholelithiasis in men. Observations on a case series of surgically treated 3,047 patients]

Age and clinical presentation as acute cholecystitis have widely been found to be predictors of outcome after cholecystectomy. Recently, male gender has been cited in several studies as a possible prognostic factor. A single Institution cholecystectomy registry (3.047 cases between 1959-1997) comprising 966 (31.7%) men and 2.81 (68.3%) women was retrospectively analysed. Men experienced significantly higher rate of major complications (5.3% vs 3.2%; p < 0.01) and mortality (1.55% vs 0.62%; p < 0.03). By logistic regression analysis, it was found that male gender, acute cholecystitis, respiratory and cardiovascular system disease were significantly related to postoperative morbidity. Age older than 65 years, male gender, respiratory and cardiovascular diseases were factors negatively affecting operative mortality.

Rectal cancer and inguinal metastases: prognostic role and therapeutic indications

PURPOSE

The aim of this study was to analyze the outcome of patients with inguinal metastases from rectal cancer.

METHODS

Clinical records and data concerning the follow-up of patients referred to our institution for rectal cancer were reviewed retrospectively. Patients were divided into four groups based on the time interval between first admission and appearance of inguinal metastases. All patients were followed up until death. Age, gender, tumor stage, and disease-free intervals were examined to assess their impact on prognosis.

RESULTS

Patients with rectal adenocarcinoma (N = 863) were observed from 1965 to 1990. In 21 patients the biopsy-proven diagnosis was of adenocarcinoma metastasizing to the inguinal nodes. Of these 21 patients, 15 were males. The mean age was 69.3 (range, 52-84) years. Primary lesions were exclusively T3, and no patient was found to have negative mesorectal lymph nodes. Survival from the time of diagnosis of inguinal metastases ranged from 2 to 42 (mean, 14.8) months. Patients with a disease-free interval of 12 months or more had a statistically significant longer survival time.

CONCLUSIONS

Inguinal lymph-node metastases from rectal carcinoma occur as a consequence of locally advanced primary tumors or recurrent pelvic malignancy. Because of the frequency of distant metastases and the consequent poor prognosis, only systemic chemotherapy and radiotherapy should be considered. In patients who seem to be free of local recurrence and distant metastases, groin dissection is suggested for debulking and control of disease.

[Anterior approach and simultaneous tension-free repair of bilateral inguinal hernia under local anesthesia]

An analysis of prospectively collected data of 56 patients submitted to bilateral hernia repair is reported. Simultaneous repair was performed in 32 patients (Group S) while a sequential repair in 24 (Group D). Mean operating time was longer for the combination of two sequential repairs than for simultaneous repair (132 min +/- 8.9 vs 123 min +/- 11, p < 0.001). Mean hospital stay was similar in unilateral and bilateral repairs (18.0 hrs +/- 4 vs 21.2 hrs +/- 3.4, p = ns). Ther were no difference in complications between the two groups. Time taken to return to full activity was nearly double in the combination of two sequential repairs than in simultaneous repair (25 days, sd +/- 4 vs 16 days +/- 3, p < 0.001), while postoperative analgesia requirements were similar. The Authors conclude that bilateral simultaneous anterior tension free repair under local anesthesia is the treatment of choice in case of bilateral inguinal hernias.

[Functional results of experimental autologous transplantation of the pancreas]

The autotransplant of the left lobe of the pancreas in the latero-cervical region has been successfully performed in 38 adult beagles with a mean cold ischemia time of 52 minutes. Juice volume and amylase, protein and bicarbonate outputs were resumed postoperatively as soon as 6 hours. A single case of thrombosis of the mesenteric vein occurred; all other pancreatic grafts showed good histological vitality at 30 days. This procedure of autografting is proposed as a valid experimental model for the pathophysiologic study of acute pancreatitis.

[Recurrent liver metastases from colorectal cancer: their surgical treatment]

Records of 8 patients undergoing repeated operation for isolated hepatic metastasis were reviewed for operative morbidity and mortality, survival, disease-free survival. The mean interval between the initial colon operation and first hepatic resection and that between the first and the second hepatic operation were calculated. Both were found to be correlated with survival of these patients. Repeat hepatic operation for recurrent colorectal metastasis to the liver yields comparable results to first hepatic resections in terms of operative mortality and morbidity, survival, disease-free survival. Repeated hepatic operation is the most successful for of treatment for isolated recurrent colorectal metastasis.

[Rare locations of hydatid disease]

The authors report their experience with uncommon hydatid cyst locations. Between 1970 and 1995 a total of 16 patients suffering from hydatid cysts located in various organs other than liver and lungs were observed. There were 7 women and 9 men with a mean of 53.3 years. In 10 cases uncommon locations were found to be isolated and in 6 associated to contemporary or previously treated hepatic cystic disease. Pathogenesis of these uncommon locations, whether being primary or secondary, as well as specific items of diagnosis and surgery are discussed.

[Effects of octreotide (somatostatin analog SMS 201-995) on superior mesenteric artery blood flow in swine. An experimental study using Doppler color ultrasonography]

The effect of octreotide on splanchnic haemodynamics was investigated in 25 domestic pigs by mean of US-colordoppler. In a blind-operator design the superior mesenteric artery (SMA) blood flow was evaluated before and after i.m. injection of 5, 10, 20, 25 micrograms/kg or of an equivalent volume of saline solution. Seven serial measurements were taken every 10 min in each pig excluding the higher and the lower values. The administration of 5 and 10 micrograms/kg determined a rapid and stable (3 hours) decrease of the SMA blood flow (6 and 8.5% respectively) (p < 0.05). The blood flow decreased by 27-29% (p < 0.001) in response to the administration of 20 and 25 micrograms/kg respectively. The reduction started 30 min after injection and the blood flow remained lower than basal for up to 5 hours. Because of the mean standard error of US blood flow assessment is 10% due to the interobserver and intraobserver variations, we considered statistically significant only the reduction occurred after the administration of 20 or 25 micrograms/kg. Authors findings suggest that high dose of octreotide is effective in reducing the splanchnic haemodynamics in the pig. Such animal can be used in experimental setting planed to assess the effect of splanchnic blood flow reduction.

[Preoperative bowel cleansing: outpatient versus inpatient preparation]

This study investigated the safety and efficacy of preoperative outpatient bowel preparation (OBP) and compared it with inpatient bowel preparation (IBP). Records of patients who underwent OBP and IBP for elective colorectal surgery from January 1995 to December 1997 were compared. All patients were instructed to take during the three days before surgery metronidazole (1.5 g pro die) while an oral polyethylene glycol solution was used for the oral lavage during the 12 hours before operation. The two groups, 65 patients, were uniform for age, sex, diagnosis and operations performed. The OBP group had a shorter length of hospital stay (median 9 vs 10 days; p = ns) whereas the complication rate was similar including infectious complications. Data on operating time, perioperative fluid and blood requirements, perioperative diuresis were not significantly different in the two groups. Outpatient bowel preparation for elective colorectal surgery is safe and effective while offering short hospital stay and therefore reduction in medical care cost.

[Increased blood amylase levels in the postoperative period after liver resection]

Preoperative and postoperative values of amylase were assessed in patients submitted to hepatic resections for primary or secondary liver tumours. Among these 40 had underlying liver cirrhosis and 18 normal liver. Preoperative serum amylase levels were increased in patients with cirrhosis. Postoperative amylase levels were found to be overlapping to preoperative one both in patients with normal and cirrhotic liver when no Pringle's manoeuvre was used in the course of surgery. A significant postoperative increase in serum amylase levels was detected in the group of patients where liver resection was carried out under Pringle's manoeuvre. Two patients of the cirrhotic group developed mild pancreatitis. It is suggested that portal congestion relates morphological changes of pancreas and hyperamylasemia and that Pringle's manoeuvre, if prolonged, carries a potential risk of pancreatitis especially in patients with underlying liver cirrhosis.

[Treatment of cecal diverticulitis]

Twenty-three cases of acute solitary diverticulitis of the cecum are reviewed. Cecal diverticulitis continued to be almost indistinguishable from acute appendicitis although longer duration of symptoms and lesser incidence of nausea and vomit are reported. A correct preoperative diagnosis is then seldom performed. On the basis of this experience appendectomy is recommended when diverticulitis is diagnosed in order to avoid further clinical complications. If a carcinoma cannot be completely ruled out or an abscess or rupture is present, then a right colectomy should be performed.

[Primary neuroendocrine carcinoma of the skin: clinical case]

A case of Merkel cell carcinoma of the skin is described. It is a rare primary skin tumor originating within the dermis with an aggressive biologic behavior. Clinical presentation of these tumors are not sufficiently distinctive to allow the preoperative diagnosis. Wide surgical excision with postoperative irradiation to the local site and regional lymphatics is recommended as the therapy of choice. Indications for chemotherapy are discussed and the guidelines for an appropriated follow-up are reported.

[Learning curve for "tension-free" reparation of inguinal hernia]

A prospective randomized study of 106 patients with unilateral primary inguinal hernia who underwent "tension-free" mesh repair was carried out. Fifty-nine procedures (group A) were performed by a single experienced surgeon and 47 (group B) procedures were performed by a team of residents each with an experience level of less than ten cases. In group A the length of operation was statistically shorter; local anesthesia was more frequently used in group A, while intra-operative sedation and general anesthesia were more frequently used in group B. A subgroup of twenty patients (group C) operated on by residents with a personal experience of at least 5 tension free repairs was selected. No statistically significant difference in operation time and in anesthesia used were found between group A and group C. No significant difference was found between group A and group B in morbidity rate, mean postoperative stay, median time to return to work, and recurrence rate. Because easy, efficacy, and minimally invasive, the tension-free mesh repair remains the gold standard in the treatment of inguinal hernia.

Familial and psychological risk factors of ulcerative colitis

BACKGROUND

The aetiology of ulcerative colitis is still unknown. Several theories have been proposed taking into account psychological influences.

AIMS

The present study was undertaken to test the hypothesis of a relationship between certain individual psychological patterns, stress, some familial variables, and ulcerative colitis.

PATIENTS

A series of 122 patients with ulcerative colitis and a matched hospital control population were independently studied by a team of physicians and a team of psychologists.

METHODS

State-Trait Anxiety Inventory (Form Y) and Sacks' sentence completion tests were submitted to all subjects in both populations.

RESULTS

Data showed significantly higher anxiety trait and state in ulcerative colitis patients, whilst 84% of ulcerative colitis patients showed a variety of obsessional traits and an affectivity state characterized by introversion and emotional immaturity. A link was found with regard to relationship with mother, to the condition of single children in the male ulcerative colitis population (41% vs 18% controls), and to last born daughters in the female ulcerative colitis group (47.5% vs 27.9% controls). In addition, a previous stressful life event within the 12-month period prior to the investigation was found in 44.3% of ulcerative colitis patients and in 10.7% of controls.

CONCLUSIONS

Psychological disturbances and familial condition are proposed as risk factors, if not actual aetiological variables of ulcerative colitis.

[Aneurysmal cysts of the jaws. The nosological picture and a clinical case report]

After discussing the classification of aneurysmatic cyst with particular reference to its characteristics for differential diagnosis with other pathologies of various origin, a personal case is reported. The diagnosis and treatment protocol of the clinical case in question is presented together with clinico-therapeutic problems and the results obtained with the diagnostic and therapeutic aids used.