Coagulation Factor Levels in Non-Metastatic Colorectal Cancer Patients

There is evidence that high plasma levels of factor (F) VIII, FIX, FXI and fibrinogen are independent risk factors for venous thromboembolism.

Aim

To determine the plasma concentrations of several coagulation factors and C4b-binding protein (C4BP) in a group of patients with non-metastatic colorectal cancer in order to investigate some aspects of cancer-acquired thrombophilia. Methods: Plasma fibrinogen, FII, FV, FVII, FVIII, FIX, FX, FXI and FXII activity levels and C4BP concentrations were determined in 73 patients with non-metastatic colorectal cancer (48 colon and 25 rectum) and in 67 matched control subjects. No one in either group had had previous thrombotic events.

Results

Mean plasma concentrations of fibrinogen (functional and antigen), FVIII, FIX, FV and C4BP were significantly higher in colorectal cancer patients than in control subjects, while FVII and FXII levels were significantly decreased. Several correlations were found between the increased coagulation factors and C4BP concentrations, while FVII was highly correlated with FXII.

Conclusions

In colorectal cancer patients high plasma fibrinogen, FVIII and FIX levels might represent further risk factors for venous thrombotic complications in the immediate post-surgery period, while decreased FVII and FXII concentrations may be an index of intravascular coagulation activation, still in a subclinical phase.

Antiphospholipid Antibodies and Acute-Phase Response in Non-Metastatic Colorectal Cancer Patients

Aim

To investigate the plasma levels and prevalence of the most common antiphospholipid antibodies, as well as their relationships with several plasma markers of inflammation, in order to characterize some aspects of cancer thrombophilia.

Materials and methods

Eighty-three cancer patients with non-metastatic colorectal solid tumors and 94 control subjects were tested for the presence of IgG/IgM/IgA anti-cardiolipin and anti-β2-glycoprotein I antibodies and of several acute-phase reactants, i.e., fibrinogen, factor VIII:C and C4b-binding protein.

Results

In cancer patients the plasma levels of the acute-phase reactants and the IgA/IgG anti-cardiolipin and IgA anti-β2-glycoprotein I antibodies were significantly higher; the acute-phase reactants were significantly correlated with anti-cardiolipin antibodies; the prevalence of antiphospholipid antibodies was not significantly higher.

Conclusions

In patients with non-metastatic colorectal cancer the acute-phase response is associated with antiphospholipid generation. This could represent a further pathogenetic mechanism for the short-term post-surgery thrombotic complications of patients with colorectal cancer.

Antiphospholipid antibodies and acute-phase response in non-metastatic colorectal cancer patients

AIM

To investigate the plasma levels and prevalence of the most common antiphospholipid antibodies, as well as their relationships with several plasma markers of inflammation, in order to characterize some aspects of cancer thrombophilia.

MATERIALS AND METHODS

Eighty-three cancer patients with non-metastatic colorectal solid tumors and 94 control subjects were tested for the presence of IgG/IgM/IgA anti-cardiolipin and anti-Beta2-glycoprotein I antibodies and of several acute-phase reactants, i.e., fibrinogen, factor VIII:C and C4b-binding protein.

RESULTS

In cancer patients the plasma levels of the acute-phase reactants and the IgA/IgG anti-cardiolipin and IgA anti-Beta2- glycoprotein I antibodies were significantly higher; the acute-phase reactants were significantly correlated with anti-cardiolipin antibodies; the prevalence of antiphospholipid antibodies was not significantly higher.

CONCLUSIONS

In patients with non-metastatic colorectal cancer the acute-phase response is associated with antiphospholipid generation. This could represent a further pathogenetic mechanism for the short-term post-surgery thrombotic complications of patients with colorectal cancer.

Long-term results of laparoscopic treatment for advanced rectal cancer

BACKGROUND

The management of advanced rectal cancer has changed into a multidisciplinary treatment model. Only limited randomized data are available for patients with rectal cancer treated laparoscopically.

AIM

We report a multimodal treatment of advanced rectal cancer: preoperative oncological treatment, use of endoscopic stent (for malignant obstruction), minimal invasive treatment.

METHODS

The Authors reported a series of 45 laparoscopic rectal resections for adenocarcinoma, some of them with malignant obstruction. Long-term oncological results were reviewed.

RESULTS

The 30-day mortality was 2.2%. Of 45 adenocarcinoma, 4 cases were obstructed. Successful stent positioning was obtained in all patients and treated with radiochemiotherapy before laparoscopic resection. The 5-year global survival rate (including stage IV) was 62.2%; for stage II was 77.9% and 53.8% for stage III.

CONCLUSION

This study indicates that laparoscopy for advanced rectal cancer have good long-term results. In high and middle rectal malignant obstructions, we considered the use of stents to be useful.

Coagulation factor levels in non-metastatic colorectal cancer patients

There is evidence that high plasma levels of factor (F) VIII, FIX, FXI and fibrinogen are independent risk factors for venous thromboembolism.

AIM

To determine the plasma concentrations of several coagulation factors and C4b-binding protein (C4BP) in a group of patients with non-metastatic colorectal cancer in order to investigate some aspects of cancer-acquired thrombophilia.

METHODS

Plasma fibrinogen, FII, FV, FVII, FVIII, FIX, FX, FXI and FXII activity levels and C4BP concentrations were determined in 73 patients with non-metastatic colorectal cancer (48 colon and 25 rectum) and in 67 matched control subjects. No one in either group had had previous thrombotic events.

RESULTS

Mean plasma concentrations of fibrinogen (functional and antigen), FVIII, FIX, FV and C4BP were significantly higher in colorectal cancer patients than in control subjects, while FVII and FXII levels were significantly decreased. Several correlations were found between the increased coagulation factors and C4BP concentrations, while FVII was highly correlated with FXII.

CONCLUSIONS

In colorectal cancer patients high plasma fibrinogen, FVIII and FIX levels might represent further risk factors for venous thrombotic complications in the immediate post-surgery period, while decreased FVII and FXII concentrations may be an index of intravascular coagulation activation, still in a subclinical phase.

[Laparoscopic repair of incisional and umbilical hernias. Our experience]

BACKGROUND

Incisional hernia is a frequent complication of abdominal surgery (2-20% of all cases). Recurrence rate after simple repair without mesh is very high. The use of prosthetic materials has reduced the recurrences. Over the past decade, laparoscopic repair of incisional and umbilical hernias has become an interesting alternative to open procedure.

PATIENTS AND METHODS

The aim of this retrospective study was to evaluate efficacy, safety and advantages of laparoscopic approach in the treatment of incisional and umbilical hernias. From February 2000 through June 2006, a total of 127 incisional hernias (primary and recurrent), 21 umbilical and 19 epigastric hernias, were treated by laparoscopic approach. The exclusions for laparoscopy were: defect size less than 2 cm or more 20 cm, anesthesiologic problems, hemocoagulative disorders. The females/males ratio was 0/7, with a mean age of 59 years (range 24-83). The abdominal associated disease treated were 26. Three cases were treated as urgencies (strangulated hernias).

RESULTS

The conversion rate was 2 cases (1.2%). Mean operative time was 78 min (range 25-170). The mean postoperative hospital stay was 2.1 days (range: 1-5). The intra- and postoperative complication rate was 5% (above all seromas). The recurrence rate was 1.8% (3 cases).

CONCLUSIONS

More studies with long-term follow-up are necessary to prove the advantages of laparoscopic technique, but this large experience of more than 5 years, demonstrates that in selected cases the laparoscopic approach may be an interesting and effective alternative to open technique.

The biliopancreatic diversion. A comparison of laparoscopic and laparotomic techniques

AIM

Morbid obesity has increased its frequency in the last 20 years in association with the increase of a country's richness. Bariatric surgery has developed a role which is becoming more and more important. The aim of this study, after 10 years of experience with the biliopancreatic diversion, is to compare the laparoscopic versus open technique

RESULTS

METHODS

From March 1993 to December 2004, 150 patients were operated by biliopancreatic diversion. We divided our experience into 2 groups: laparotomic and laparoscopic techniques. We compared the following variables in the 2 groups: total operating time, intestinal functions, postoperative pain, patient's discharge and recovery time, major postoperative complications, postoperative mortality, late complications, incisional hernia incidence and anastomotic ulceration.

RESULTS

We found a significant difference in both the reduction of the postoperative pain and the recanalization time in the laparoscopic group. Equally, we found a reduction in the incidence of abdominal wall complications, especially the reduction of incisional hernia and infections. The mean operative time was longer in the laparoscopic group, in particular due to the hard learning curve.

CONCLUSIONS

The laparoscopic biliopancreatic diversion is a feasible and safe operation with good results: less postoperative discomfort, shorter recanalization and ospedalization time, less incidence of abdominal wall morbidity (incisional hernia). However, the procedure may prove difficult and it needs a highly experienced surgeon in laparoscopic technique.

[Laparoscopic colon-sigmoid resection with mesenteric artery preservation for diverticular disease]

AIM

About 2/3 of the Western population over the age of 80 years are affected by colic diverticulosis; 25% will develop diverticular disease with or without complications: fistula, obstruction, pericolic abscess, free perforation or hemorrhage. Laparoscopic approach for benign diseases of the colon such as diverticulosis, Chrohn's disease, etc. is unanimously considered as a very effective procedure. We have performed a retrospective analysis of 9 years with laparoscopic approach of the diverticular disease. The purpose of this study was to determine the feasibility, safety and benefits of laparoscopic approach.

METHODS

From May 1994 to November 2002, 69 patients affected by non-complicated diverticular disease, were treated laparoscopically, at the Mininvasive Surgery Department of Spoleto. In the same period other 213 patients suffering from cancer of the colon-rectum were operated through laparoscopic surgery. A colosigmoid resection with mesenteric inferior artery preservation was performed in 46 cases (67%).

RESULTS

We have performed only a laparoscopic colectomy technique (no hand-assisted procedures); the convertion rate was of 7.2%, the mean operative time was 145 min, no intraoperative complications were observed and finally the mean hospital stay was of 7.4 days (6-9). The postoperative complications were 1 case of infection of the umbilical scar and 1 case of pleural effusion with bronchopneumonia.

CONCLUSIONS

Elective laparoscopic colectomy for diverticular disease is feasible, safe and gives very good results: minimum postoperative discomfort, rapid recovery, low mobility and postoperative stay, rapid return to normal activities. However, in some cases, this procedure can be extremely difficult because of previous inflammatory complications (adhesions, fistulas or stenosis), therefore, high surgical skills in laparoscopic-colic surgery are required.

Protein S in cancer patients with non-metastatic solid tumours

AIMS

To study protein S, as an acute phase protein, for its relationships with C4b-BP (C4BP), fibrinogen and Factor VIII:C in a group of patients with solid tumours, without proven metastases.

METHODS

Eighty-one consecutive patients with gastrointestinal or pelvic adenocarcinoma (TNM staging: T1-3, N0-2, M0) and 58 healthy subjects were evaluated for plasma free and total protein S antigen, protein S activity, C4BP, fibrinogen and Factor VIII:C.

RESULTS

When compared to the control group, the total protein S, the C4BP, the fibrinogen and the Factor VIII:C mean levels were significantly higher in the cancer group, but there was no significant difference for the free and the functional protein S mean concentrations. In both groups the free protein S was correlated with the functional and the total protein S; moreover the latter was significantly correlated with the C4BP, whereas it was significantly correlated with the fibrinogen and the Factor VIII:C only in the cancer group. In addition, a high correlation was found among the C4BP, the fibrinogen and the Factor VIII:C.

CONCLUSIONS

Our data show that in these patients there is an acute phase response and suggest that, in the thrombophilic early cancer screening, determination of free protein S is redundant.

[Non palpable lesions of the breast: the Mammotome-biopsy in the preoperative management of breast cancer]

BACKGROUND

Breast tumour takes first place for frequency in women in Western Countries and is in constant increase. The diagnosis of the so-called non palpable lesions is increased remarkably above all due to the diffusion of mammographic screening and to a greater awareness of the problem. Furthermore it is helped by an important development of mininvasive diagnostic methods: the traditonal cytology with fine needle is supported by various trans-skin bioptic procedures (micro-histological examination). This methods almost always replaces the surgical excisional biopsy and frozen intraoperative examination, still used but reserved for particular cases.

PATIENTS AND METHODS

In our Department of General and Mininvasive Surgery, from December 1999 to September 2004, we carried out 214 biopsies, with the collaboration of the radiological Service, under echographic guidance using vacuum--assisted biopsy (Mammotome) with 11-Gauge needle. The results are examined and discussed here in this report with regard to diagnostic accuracy, quantity and quality of information, significant for subsequent surgical management.

RESULTS

Of 214 biopsies carried out with Mammotome technique, 89.3% of the cases are clinically non palpable lesions, with a average diameter of 8 mm. The average age of patients was 57.6 years (range 31-88). There are 90 cases of positive malignant pathology (42%). In the atypical ductal iperplasia and radial scar cases (6%) surgical removal of lesion was carried out which confirmed the previous bioptic diagnosis in 100% of cases. The 19% of patients submitted to a Mammotome biopsy was subject previously to cytology with fine needle. Comparing the results of both methods the diagnostic reliability of Mammotome was significantly superior (p < 0.05) as also the amount of information obtained (histotype, invasivity, grading, estrogen receptor, etc.); discomfort linked to the procedure, valued as pain (VAS), resulted inferior to the discomfort of biopsy with fine needle. The only complication of Mammotome biopsy is represented by haematoma in the biopsy site (8% of cases). The number of false negatives was one case due to incorrect targeting.

CONCLUSION

In the present situation, the choice of method is conditioned by the degree of radiological suspicion, taking into account the information obtained thereby, in order to ensure the appropriate surgise management. Mammotome biopsy of non palpable lesions of the breast, in our experience, is preferable if suspicion of malignancy is high. In this way a correct preoperative strategy can be prepared. Including the sentinel lymphnode method. Consequently a decision regarding the type of surgery can be taken (generally conservative), as well as making easier the intraoperative localisation of lesion by positioning the metallic clips during biopsy.

[Neoplastic residues in the trocar tract in oncologic laparoscopic surgery]

AIM

The laparoscopic approach to malignant diseases runs up against both old and new problems: respect for the principles of radicality, operating times, the postoperative course and surgical complications, long-term oncological results in terms of survival and recurrence of the disease. One of the problems which has received most attention regards the onset of a metastasis on a trocar scar or a mini-laparotomy recurrence. Trocar site tumor recurrences have been described in the literature following laparoscopic surgery in almost all abdominal malignant pathologies (colorectal, gynaecological, pancreatic, etc.) and even after thoracoscopy. The real frequency is currently of the order of 1% (0-2%) in colic surgery and of 14% (10-17%) after cholecystectomy for occult gallbladder carcinoma.

METHODS

A retrospective survey was carried out of our laparoscopic experience; between 1994 and 2002 213 colic resections were carried out for cancer; we also observed 18 occult carcinomas of the gallbladder in 2386 laparoscopic cholecystectomies for lithiasis.

RESULTS

Respectively 2 cases (11%) of trocar site neoplastic recurrences in gallbladder carcinoma and 2 cases (0.9%) from colon carcinoma were observed.

CONCLUSIONS

The real extent of the problem would appear to be on a much lesser scale at the moment than was initially thought, especially as regards colic surgery. The multifactorial aetiology of the problem explains the importance of their prevention, on the basis above all of rigorous respect for the rules and protocols of laparoscopic technique.

Experimental internal anal sphincter replacement with demucosated colonic plication

BACKGROUND

Selective re-creation of a new internal anal sphincter could be indicated when the natural one is irreversibly damaged or excised.

METHODS

In this preliminary experimental work, surgical techniques of internal anal sphincter replacement in pigs were investigated. After preoperative anorectal manometry, surgical procedure was done in two phases: abdominal, mobilization of the colon-rectum to the pelvic floor; and perianal, dissection of the anal canal from the external anal sphincter through the intersphincteric space. The fully mobilized anorectal segment, including the internal anal sphincter, was pulled down through the anus and resected. The distal colonic stump was then demucosated and two types of plications of the demucosated segment were accomplished, each type in three animals. The plicated segment was then returned into the anal canal, inside the external sphincter. Short-term follow-up with clinical and manometric evaluations was performed and, subsequently, histological analysis of the plicated segment, after the animals were sacrificed.

RESULTS

None of the animals became incontinent. Anal manometry identified a high-pressure zone and relaxation reflex in the new anal canal. Histologic studies showed hypertrophy of smooth muscle layers without degenerative changes.

CONCLUSION

This study indicates that a plication of colonic smooth muscle wall can re-create a high-pressure zone in the anal canal after the internal anal sphincter has been excised.

[Endoscopic treatment of intestinal anastomotic leakage in low anterior resection of the rectum by using fibrin adhesive. Our experience]

BACKGROUND

Personal experience about treatment of anastomotic leakage in low anterior resection of the rectum by using human fibrin adhesive "Tissucol" is reported.

METHODS

Eight cases of anastomotic leakage treated with using human fibrin adhesive "Tissucol", are analyzed in a retrospective study. Patients had three/six months-one year follow up. Treatment with human fibrin adhesive "Tissucol" was performed in our Endoscopic ambulatory. Six cases had either an immediate resolution or an ambulatorial follow-up; in 2 cases only, general complications forced to a prolonged hospital stay. The study concerns 58 patients subjected to low anterior resection of the rectum and endoscopic treatment of 8/58 patients with anastomotic leakage. Fistulas were sealed with human fibrin adhesive "Tissucol" by using flexible endoscope. Anastomotic leakage identification leakage was made and low anterior resection of the rectum and sealing with human fibrin adhesive "Tissucol" were performed.

RESULTS

Complete sealing of fistula and rectum patent.

CONCLUSIONS

The excellent results obtained with this non invasive and fast treatment, easily practicable even in ambulatorial regimen, lead the authors to consider it effective and as first-choice treatment of this dangerous complication. The cost/benefit ratio is favorable if compared with the long hospital stay required for other treatments, which also present loaded high morbidity and mortality.

[Surgical treatment of pancreatic carcinoma. Our experience]

BACKGROUND

Currently, pancreatic exocrine carcinoma presents high mortality, poor survival after curative surgery and poor resectability rates at the time of diagnosis. The factors which mostly influence prognosis and therapeutic management (curative surgery or palliative treatments) of the patient affected by pancreatic carcinoma, particularly the peroperative stage, are analyzed and discussed in this article.

METHODS

From 1969 to 1997, 142 patients with pancreatic ductal carcinoma were admitted to our Department: at the time of diagnosis only 32 patients (22.5%) were considered resectable, and 30 pancreaticoduodenectomies (PD), 1 distal pancreatectomy (DP) and 1 total pancreatectomy (TP) were performed.

RESULTS

Postoperative morbidity and mortality was 53.1% and 12.5% respectively; the survival at 1, 3 and 5 years was 45.5%, 36.4% and 17.6% respectively. The worst prognosis was seen in N+ and T4 patients, with a mean survival of 9 and 10 months.

CONCLUSIONS

On the basis of these results and of the literature, the indications for curative surgery, the operative strategy and the lymphoadenectomy extension are discussed: these problems are still open and not resolved definitively. The authors conclude by indicating the need for curative surgery for T1/2 N0 M0 tumors: for T3/4 and/or N+ tumors a careful evaluation of single case is necessary, because of high risk/benefit rate. Pancreatic resections (PD, DP) and standard lymphoadenectomy (D1) are performed by the authors, rather than total pancreatectomy and radical lymphadenectomy (D2-3).