ERas and COLorectal endoscopic surgery: an Italian society for endoscopic surgery and new technologies (SICE) national report

Background

Several reports demonstrated a strong association between the level of adherence to the protocol and improved clinical outcomes after surgery. However, it is difficult to obtain full adherence to the protocol into clinical practice and has still not been identified the threshold beyond which improved functional results can be reached.

Methods

The ERCOLE (ERas and COLorectal Endoscopic surgery) study was as a cohort, prospective, multi-centre national study evaluating the association between adherence to ERAS items and clinical outcomes after minimally invasive colorectal surgery. The primary endpoint was to associate the percentage of ERAS adherence to functional recovery after minimally invasive colorectal cancer surgery. The secondary endpoints of the study was to validate safety of the ERAS programme evaluating complications’ occurrence according to Clavien-Dindo classification and to evaluate the compliance of the Italian surgeons to each ERAS item.

Results

1138 patients were included. Adherence to the ERAS protocol was full only in 101 patients (8.9%), > 75% of the ERAS items in 736 (64.7%) and > 50% in 1127 (99%). Adherence to > 75% was associated with a better functional recovery with 90.2 ± 98.8 vs 95.9 ± 33.4 h (p = 0.003). At difference, full adherence to the ERAS components 91.7 ± 22.1 vs 92.2 ± 31.6 h (p = 0.8) was not associated with better recovery.

Conclusions

Our results were encouraging to affirm that adherence to the ERAS program up to 75% could be considered satisfactory to get the goal. Our study could be considered a call to simplify the ERAS protocol facilitating its penetrance into clinical practice.

Our orientation regarding the ductal carcinoma in situ of the breast

AIM

The ductal carcinoma in situ is a malignant proliferation of mammary ductal epithelial cells without invasion beyond the basement membrane. The management of patients with DCIS is complex, controversial and has undergone changes over time.

MATERIAL OF STUDY

We treated 65 patients diagnosed with DCIS between 2002 and 2005. We surveyed women aged between 28 and 71 years (average age 51.4), the DCIS in 16 patients appeared as a palpable mass (about 2.2 cm) - group I and in 49 patients as microcalcifications detected on mammography - group II.

RESULTS

The most frequent histological type was found to be the comedocarcinoma. After 3 years of follow-up, we had 3 cases of recurrence (4.6%) in patients undergoing conservative surgery, with Van Nuys Prognostic Index between 3 and 4.

DISCUSSION

15-25% of cases of breast cancer are DCIS. Most of these are comedocarcinomas. Comedo form DCIS is an insidious cancer. Surgical treatment ranges from mastectomy to excision of the lesion, often the latter, followed by radiotherapy.

CONCLUSION

We prefer, with regard to surgical treatment, quadrantectomy with systematic control of the free margins. The search for the axillary sentinel node represents for us, too, the gold standard.

Benign thyroid disease: treatment notes

AIM

The treatment of benign thyroid disease is a topic widely debated, ranging from "Lobectomy" to "Total Thyroidectomy". This study aims to contribute to the thinking on treatment strategies for benign thyroid disease.

MATERIALS OF STUDY

Thirty five patients underwent surgical treatment following the pre-surgical diagnosis of benign thyroid disease between 2003 and 2005 at the Complex Unit of General and Geriatric Surgery at the Second University of Naples (S.U.N.). In 26 cases total thyroidectomies were performed, in 3 subtotal thyroidectomies, in 6 simple lobectomies.

DISCUSSION

Post-surgical course was optimal in the majority of cases. The large number of total thyroidectomies performed is consistent with the trend favoured by this type of strategy. When backed by FNA, non-radical surgery can be opted with greater confidence for single nodules and when surgical risks are high. The refinement of surgical techniques and directions for the identifying and preparing the recurrent nerve have enabled a radical approach in treating thyroid nodular disease.

CONCLUSIONS

In our opinion, for a solitary nodule with residual diseased parenchyma we believe total thyroidectomy should be prescribed. If, however, the residual parenchyma is unharmed a lobectomy may be considered. In conclusion, we recommend the individual assessment of each pathology, though we favour total thyroidectomy.

The surgical treatment of benign breast lesions in young adolescents

AIM

There is much controversy surrounding the treatment of benign breast lesions in young adolescents: on one side the need for surgical treatment and on the other doubts in regard to operating on young patients with a benign disease. Another element sparking the debate is the correlation between the appearance of fibroadenomas and the presence of elevated prolactin levels in the blood.

MATERIAL OF STUDY

42 patients between the ages of 14 and 21 being treated at the General surgery and Geriatrics Unit of the Department of Gerontology, Geriatrics and Metabolic Diseases at the Second University of Naples between 2001 and 2004. In addition, blood prolactin levels were measured in 24 patients.

RESULTS

Only 4.76% of the patients examined (2 cases) had a family history of breast tumours. Out of a total of 42 adolescent patients that were operated on, we detected fibroadenomas in 35 (83.34%), fibrocystic disease in 3 (7.14%), adenosis in 3 patients (7.14%) and a phylloid tumour in 1 (2.38%). Blood prolactin was measured in 24 patients and in 17 cases we detected increased plasmatic levels of this hormone; in addition, anamneses revealed that of these 17 patients, 9 were using oral contraceptives.

DISCUSSION

The most common cause of palpable breast masses in adolescents under 21 years of age are fibroadenomas. The connection to hormonal, genetic and family factors is still unknown, both during the genesis of this pathology and as concerns an increased risk of possible malignant development. The correlation between fibroadenomas and elevated prolactin serum levels still remains controversial today. Various studies, measuring the blood concentration of prolactin in many patients have demonstrated that both elevated blood levels of this hormone and the use of oral contraceptives play a role in the development and growth of benign breast lesions.

CONCLUSION

Fortunately, breast disease is rare in adolescents; these patients do not often develop nodules and where these do occur the vast majority of cases involve benign lesions. A thorough follow-up on patients with nodular breast lesions is thus useful. As concerns the connection between prolactin and fibroadenomas, we also reported interesting data; this represents 70.83% of our subjects.

KEYWORDS

Blood prolactin levels, Fibroadenomas, Surgical treatment.

Primary thyroid angiosarcoma: an unusual localization

The finding of thyroid nodules is a very common occurrence in routine clinical practice. Approximately 5% to 7% of the entire population have thyroid nodules. Vascular lesions are one of the most controversial issues in thyroid pathology. These include benign lesions such as hemangiomas and, rarely, malignant tumors such as angiosarcomas or undifferentiated angiosarcomatoid carcinomas. In particular, angiosarcoma of the thyroid gland is a rare, highly aggressive malignant vascular tumor and in Italy the greatest geographical incidence of this lesion is witnessed near the Alps. Here, a case of thyroid angiosarcoma in a 71-year-old man with a history of goiter for about 20 years is described. The unusual localization of this lesion, the difficulties in reaching a definitive diagnosis for this particular histological type of primary tumor and a history of long-standing multinodular goiter in thyroid of an older man from outside the Alpine region prompted us to report this case of thyroid angiosarcoma mainly to discuss surgical, histopathological and immunohistochemical features.

Antibiotic prophylaxis in catheter-associated urinary infections

This study aimed to assess the usefulness of antibiotic prophylaxis with Levofloxacin (LVFX) in short and mediumterm catheterisations. This study was developed to evaluate and confirm the effectiveness and need for prophylaxis in preventing catheter-associated UTIs, using LVFX at a dose of 250 mg administered orally to patients who had been subjected to short and medium-term urinary bladder catheterisation following surgery (3-14 days). The study was designed as a phase III study with parallel groups, multicentre, randomised, controlled with a placebo in three groups. The study was double-blind in treatment groups A and B and single-blind in group C. The study involved the recruitment of 120 patients, 40 for each treatment group. We show two types of results, one based on primary effectiveness variables and the other on the secondary effectiveness variables. The group treated with LVFX displayed a greater tendency toward the negativisation of bacteriuria and pyuria tests than that recorded for the placebo group, and was essentially comparable to that recorded for the group of patients treated with Ciprofloxacin. We can thus affirm that LVFX may be useful for preventing short and medium-term CAUTIs.

The sentinel lymph node: a suitable technique in breast cancer treatment?

AIM

The sentinel lymph node biopsy (SLNB) was firstly introduced by Giuliano and co. in 1994 for the treatment of breast cancer; in comparison to the axillary lymph node dissection (ALND), the sentinel lymph node biopsy has shown both a lower morbidity and acceptable distance results. We want to show that this technique is reliable and should be used routinely in selected cases.

MATERIALS OF STUDY

The study on the sentinel lymph node has been carried out, prior informed consent, in 128 patients aged between 27 and 80 years and suffering from non-multicentric infiltrating breast carcinoma, with a diameter not greater than 3 cm, clinically negative axillary, and hospitalized from January 1998 to September 2005 at the Department of Gerontology, Geriatrics and Metabolic Diseases of the Second University of the Study of Naples. For the recruitment of patients subjected to the sentinel lymph node research study, we have respected the inclusion criteria.

RESULTS

Histological examination of the tumor revealed 95 cases of ductal carcinoma, 16 cases of mucinus carcinoma, 13 of lobular carcinoma and 4 of medullary carcinoma. The sentinel lymph node was detected through lymphoscintigraphy in 96.9% of the cases (124 patients), whereas it was not possible to identify it in 4 patients (3.1% of the cases), 2 of which had previously been subject to excision biopsy.

DISCUSSION

The SLNB is characterized by an identification rate of SLN > 90% with a false negative rate less than 5%. In our study we have found an SLN identification rate of 96.9% with false-negative rates of 3.9%. Our data show that in only 6,3% of the patients (4 non- identified and 4 false-negative cases) it was necessary to perform ALND because the SLN resulted positive; however no metastasis were observed in level III lymph nodes.

CONCLUSIONS

Since its inception, the sentinel lymph node technique has gained an increasingly important role in the conservative treatment of the breast carcinoma due to the short duration of the surgery, the decrease of post-operative pain, the risk of lymphedema onset and hospital confinement, the high predictive power and the diagnostic accuracy. We strongly believe that the sentinel lymph node technique is reliable and should be used routinely in selected cases.

Clinical considerations on the retroperitoneal liposarcomas

AIM

It presents a clinical case of undifferentiated retroperitoneal liposarcoma with 5 years' recurrence from the first operation for the rarity of the occurrence, the problems related to surgery and complementary therapeutic approach.

MATERIAL OF STUDY

Male patient aged 73 was operated for removal of retroperitoneal mass with involvement of the right kidney at the Second University of Naples in the 2003. In accordance with the interdisciplinary board, complementary therapy is not indicated and follow-up program. The successive controls were negative until at least 2007. Reoperation for recurrence in 2008 for the presence of massive bone formation occupying a large part in the right half of the abdomen at the sub-hepatic level. In both cases histological examination showed undifferentiated liposarcoma.

DISCUSSION

It is of unknown etiology and only 25% occurs in well-differentiated cells are also more than 100 histological subtypes, 85% are malignant. The most affected is the male sex and from the beginning looks like malignancy. The trend of growth in general is slow, and in most cases tends to recur over time. The role of chemotherapy and radiation therapy is controversial.

CONCLUSIONS

The peculiarity of our case is higher than the average survival despite advanced age and presence of recurrence. This confirms the importance of surgical treatment, thus offering the patient a chance of better long-term survival.

Our experience of total mesorectal excision for rectal cancers

BACKGROUND/AIMS

The total mesorectal excision (TME) for rectal tumours was introduced in 1982 by Heald et al. and has led both to a 5% de crease of local recurrences 5 and 10 years after the operation when compared with cases treated with conventional surgery, and to an increase of survival up to five years estimated in 80% of all cases. In Italy TME was firstly introduced for distal rectal carcinomas about 20 years ago, and has shown the same rate of local recurrences reported by Heald. The aim of our work is to highlight TME advantages and demonstrate how this more demanding and longer lasting method has an acceptable risk for the surgery of rectal tumours.

METHODOLOGY

We have compared two groups of patients operated for rectal carcinoma; the first, "historical control group" (no TME, including 46 patients) was treated with the standard surgery technique, while the second group (TME, 47 patients) underwent the total mesorectal excision technique. 14 of non TME patients belonged to Dukes stage A, 20 to stage B and 12 to C; whereas in the TME group 16 patients belonged to Dukes stage A, 23 to B and 8 to C. The patients of both groups undergone the exams of follow up (blood test, hepatic ultrasonography, abdominal CT, thorax Ro); the follow up pattern included periodic controls with a check-up every three and six months, from one to five years.

RESULTS

Postoperative complications in both groups do not show important differences in rates, although, the first group (no TME) had 11 cases with postoperative complications confronted with the 8 cases of the second group (TME). The complications taken into consideration were: anastomotic bleeding (3 patients no TME, 6% vs 1 patients TME, 2%), intestinal obstruction (1 patient no TME, 2% vs 1 patient TME, 2%), parietal infection (4 patients no TME, 9% vs 3 patients TME, 6%), anastomotic fistulae (2 patients no TME, 4% vs 2 patients TME, 4%), retention of urine and vesicular disorder (1 patient no TME, 2% vs 1 patient TME, 2%). Tumours closer to the anus have shown more complications compared with tumours at higher levels. As a matter of fact, 9 cases of no TME and TME patients with low located tumours have undergone complications compared with the 3 cases of no TME and TME patients with tumours being more distant from the anus; the rest 7 cases belonged to the middle rectum. A higher rate of local recurrences was noticed in the no TME group: 6 (13%) compared with the TME group: 3 (6%). Other tardy complications taken into consideration were: hepatic metastasis (5 patients no TME, 11% vs 4 patients TME, 8%), pulmonary metastasis (3, 6% of the no TME vs 2, 4% of the TME), anastomotic stenosis (4, 9% of the no TME vs 2, 4% of the TME), impotence (2, 4% of the no TME vs 1, 2% of the TME). We also noticed that most of the tardy complications in the TME group belonged to Dukes stage C.

CONCLUSION

From our experience, we concluded that, in TME patients, complications are lower than in no TME patients; the site of the tumour affects the appearance of complications which are more frequently in distal localizations. An important result is the minor incidence of local recurrences after TME, which brings us to the conclusion that TME can be considered a valid method with an acceptable risk for the surgery of rectal tumour.