Colorectal cancer: the role of laparoscopy.

Since the first report in 1991 the laparoscopic resection of colon cancer is progressing slowly and just in the last 2-3 years is becoming more popular. The resistance to its use by some general and colo-rectal surgeons is receding. The explanations are that technology is evolving quickly and there is a worldwide diffusion of more sophisticated surgical instruments. Moreover several randomized trials have been published showing that the outcomes of laparoscopic colon surgery are similar or better than those of conventional surgery and the early reports suggesting the tumour dissemination were not confirmed. The revolution in oncological surgery that we are observing in these last decades with the introduction and diffusion of mini-invasive approach is comparable to that regarding conventional surgery during the period of Halsted. Therefore the principles of surgery accepted during the years must not be forgotten.

Preliminary results of laparoscopic colorectal resections: does surgeon's age influences outcomes?

INTRODUCTION: Several randomized controlled trials demonstrated that laparoscopic colon resection is a safe and effective technique for colon and rectum diseases. In fact mini-invasive procedure required an adequate learning curve to safely perform it. Many studies confirm there is a comparatively long learning curve in laparoscopic surgery, with demonstrable decrease in conversion and complication rates with increasing experience. AIMS OF THE STUDY: In this study we want to demonstrate feasibility of laparoscopic colon resection performed by a junior surgeon, referring to short-term outcomes as primary end point. RESULTS: A total of 163 patients underwent colorectal resections of whom 88 were enrolled in the laparoscopic (LCR) and 75 in the open group, respectively. The mean operative time was 183.4 min in the LCR group and 151.2 min in the open group. The mean number of lymph nodes collected was 21.3 in the LCR group and 22.1 in the open group. 10.5% who underwent LCR developed postoperative complications compared with 16% of open group; this difference was statistically significant. Postoperative death occurred in one patient for each group. CONCLUSIONS: Our study demonstrate that results obtained by an under 35-year-old surgeon, fully trained in laparoscopic surgery but with limited overall experience in colorectal resections, can be at least as good as the ones obtained in open surgery. This seems to be true both in term of intra-postoperative complications as well as for oncological results.

The mesenteric and antimesenteric site of the tumor as possible prognostic factor in colorectal cancer: 5-year survival analysis.

INTRODUCTION: Colorectal cancer is still one of the many factors of death both in males and in females. To date, the most important prognostic factors are mainly related to the pathological stage of the disease. AIM OF THE STUDY: The purpose of this study was to analyze the possible role of tumor circumferential localization on the colonic wall (mesenteric (M) or antimesenteric (AM)) as a possible prognostic factor. In this study, we compare the localization of the tumor with patient's survival. The hypothesis of this study is that M tumors, closer to blood and lymphatic vessels, should be more aggressive in terms of hematogenous and lymphatic spread compared to the AM tumors. PATIENTS AND METHODS: All patients undergoing curative resection for colorectal cancer were enrolled in this study; there was no statistical difference for age, sex and co-morbidity. The histopathological examination was carried out in the standard manner. Next, we have taken care to survival of neoplastic patients by examining of our 5-year follow-up archive: we divided patients in different groups concerning the different tumor stage and we compare these results with the different localizations of tumor at the operation. RESULTS: In 45% of cases, we were able to distinguish the different localizations M (160 patients) or AM (47 patients) and this difference is statistically significant (P<0.0001, Pearson Chi-Square-test (PCS-t)). The number of metastatic nodes is statistically higher in the M group compared to the AM group one (P=0.003949). Medium time of follow-up was 36.54 months; AM and M patients have a rather similar survival, only at the end the two curves seem to change but not in a significant manner. Only if we consider the difference between the two groups comparing T3 tumor can we observe a statistically significant difference (P<0.005). CONCLUSIONS: In conclusion, the localization of M or AM colorectal cancer is feasible in 45% of cases. M tumors have significantly more lymph nodes metastases but a better 5-year survival than AM tumors. A possible explanation for such results might be the different pattern of diffusion of cancer cells.

Free radical production in the esophago-gastro-duodenal mucosa in response to acid and bile.

Several studies have demonstrated the role of free radicals in causing esophagus-gastro-duodenal mucosal injury. The present study has been designed to investigate: whether acid, bile salts and a combination of bile + acid could determine the production of O2-derived free radicals by oesophageal, gastric and duodenal mucosa; which agent is capable of producing more free radicals and if O2-derived free radicals production depends on the duration of contact with acid, bile salts and their combination. Wistar rats' gastro-intestinal mucosa were perfused with bile, acid and a combination of bile + acid at pH4 and pH2 for 1 hour and 2 hours. Free radical production (FRP) was assessed by chemoluminescence. After 1 hour, the increase in FRP in comparison with control reached statistical significance (P < 0.05) at all tested pH levels in the duodenum, at pH1, 2 and 3 in the esophagus, and at pH1 in the stomach. Comparing different segments, both the esophagus and duodenum behaved similarly, producing more free radicals than the stomach at all pH values. However, this difference reached statistical significance at pH1 and 2 only. In comparison to control, FRP was increased by bile (pH7) infusion after 1 and 2 hours. There was increased FRP in all segments after the infusion of bile at pH2 and 4 in comparison to control. Infusion of bile at pH2 stimulates more FRP than infusion of bile at pH4 in all segments. This increased FRP reaches statistical significance in the esophagus after 2 hours of infusion, in the stomach after 1 and 2 hours of infusion, but in the duodenum it does not reach statistical significance. Acid, bile and bile + acid at pH2 and 4 can cause free radical production in esophageal, gastric and duodenal mucosa. Their role in producing free radicals is different according to the segment and the chemical composition of the solution.

The mesenteric and antimesenteric location of colorectal cancer: the relationship with lymph nodes.

AIM: Purpose of the study was to evaluate if the circumferential location of colorectal cancer may be identified as a possible prognostic factor. The hypothesis is that tumours located on the antimesenteric (AM) side could have a better prognosis than tumours located on the mesenteric (M) side. METHODS: All patients undergoing curative resection for colorectal cancer were enrolled in the study. The specimens were sent to the pathologist to define the exact location of the tumour, the histological type, grading, T, N status as well as lymphatic, vascular and neural invasion, peritumoural lymphoid reaction, desmoplasia and microsatellite instability. Statistical analyses were performed using the test for proportions (with continuity correction), the Pearson Chi-square test and generalised linear models; p<0.05 were considered statistically significant. RESULTS: From August 2000 to August 2002, 255 patients were enrolled in the study. There was a significantly higher incidence of tumours located on the M (101) compared with the AM (37) site (p<0.0001). M located tumours were associated with higher numbers of metastatic lymph nodes (N1 and N2; p-value=0.014), whereas AM tumours were associated with involved lymph nodes in only 5/37 (13.5%) of tumours. There was no statistically significant relation between AM versus M location and T status: the Pearson Chi-Square test showed that the lymph node involvement and the location (M versus AM) are not statistically independent variables (p-value=0.014). CONCLUSIONS: Our preliminary results show that when M or AM tumour identification is possible, tumour location can be regarded as a prognostic factor. Further longer studies on recurrence rate and survival are required to validate these findings and the clinical usefulness of this putative prognostic factor.

Outcome and long term results of surgical resection for gastrointestinal stromal tumors (GIST).

BACKGROUND AND AIMS: Gastrointestinal Stromal Tumors (GIST) are rare; diagnosis and prognosis of these tumors are often complex. We present short and long term results of surgical resection for GIST at the Department of Surgery, University of Insubria, during a period of 14 years. MATERIAL AND METHODS: All patients' data, tumor characteristics, surgical procedure and survival data were analyzed retrospectively. Tumors were divided in risk classes using a new classification proposed by Fletcher, based on tumor size and number of mitosis. RESULTS: From 1987 to 2001 19 patients underwent surgical resection for GIST. Stomach was the most common site of localization. Complete resection was achieved in 78.9 % cases, while in 21.1% radical resection was not possible. The mean tumor size was 8.4 cm (1.2-30 cm): < 5 cm diameter in 11/19 cases (58%), 5-10 cm in 4/19 (21%) and > 10 cm in 4/19 (21%). Mitotic count was < 10/50 HPF in 68.5 % (13/19) and > 10/50 in 31.5 % (6/19). Using Fletcher's classification, tumors were divided in very low (8/19, 42.2 %), low (3/19, 15.8 %), intermediate (4/19, 21%) and high risk (4/19, 21%). The 5 years overall survival was 63 % and 34 % respectively with a statistically significant difference between tumors < 5cm and > 10 cm in diameter and between complete and incomplete resection. High risk tumors have a significantly shorter survival than low or very low risk. CONCLUSIONS: Our experience confirms that GIST are uncommon and aggressive cancers which prognosis is strictly related to tumor size and number of mitosis. Although significant advances on new chemotherapic regimes have been made, to date, radical surgical removal is the only chance of long term survival.

A new device for minor bleeding control and blunt dissection in minimally invasive surgery.

BACKGROUND: Minor bleeding from small vessels could be a major complication in minimally invasive surgery (MIS). All the devices and techniques commonly used in open surgery to control bleeding or perform blunt dissection may be disappointing in endoscopic surgery. MATERIALS AND METHODS: Hydroxylated polyvinyl acetal tampons (HPA) are made by a synthetic, open cell foam structure able to absorb fluids up to 25 times the initial weight. We tested their efficacy for small bleeding control and tissue dissection during several minimally invasive procedures. RESULTS: HPA tampons have been found extremely useful to absorb blood coming from minor and diffuse loss, helping to control bleeding by a combined action of fluid absorption and local compression. The porous design of the tampon allows the use of the suction device right through the tampon itself. Thanks to the initial mildly hard consistency, we also used HPA tampons as dissecting instruments. CONCLUSIONS: In our experience the use of HPA tampons resulted extremely efficient for minor bleeding control, fluids removal and tissue dissection during MIS.

Emergency laparoscopic splenectomy for "wandering" (pelvic) spleen: case report and review of the literature on laparoscopic approach to splenic diseases.

Wandering spleen (WS) is a rare condition where the spleen, free from its ligaments, is allowed to move inside the abdomen predisposing the patient to life-threatening complications due to torsion of the vascular pedicle; splenic infarction, portal hypertension, bleeding and acute abdomen may occur. WS is rarely suspected at presentation since symptoms are usually not specific and definitive diagnosis is usually reached only by imaging technologies such as color flow ultrasonography and angio-spiral computer tomography. A 42-year-old woman was referred to our institute from the Emergency and Accident ward, complaining of a sudden onset of sharp abdominal pain together with nausea and vomiting. At examination a large, painful mass was present on the left middle-lower abdominal quadrant. A pelvic spleen was revealed at abdominal ultrasonography (US) and confirmed by abdominal CT. Emergency laparoscopy was carried out. The spleen was barely attached to the peritoneum of the anterior abdominal wall, covered by the greater omentum, the small bowel, and the transverse colon. Once mobilization of the spleen was concluded, the vascular pedicle appeared torted and thrombosed and laparoscopic splenectomy was performed. The patient was discharged on the 4th postoperative day with no complications. To date, only 5 cases of laparoscopic approach to WS have been reported. A review of the literature confirms that the reduction of postoperative stay, wound complications, and overall morbidity and a faster return to normal activity make laparoscopy the "gold standard" approach to the spleen as for treatment of many hematological disorders or more unusual splenic diseases.

Primary pancreatic lymphoma.

Primary pancreatic lymphoma (PPL) is a rare form of extranodal lymphoma (less than 0.5% of pancreatic tumors) originating from the pancreatic parenchyma. Histopathological examination is usually mandatory to obtain a definitive diagnosis since symptoms and radiological features are quite similar to those of other pancreatic masses. Percutaneous fine-needle aspiration (FNA) of the pancreas requires experienced cytopathologists as well as advanced immunohistochemical assays to obtain a final diagnosis on a small amount of tissue. A 46-year-old man complaining of watery diarrhea and severe weight loss (more than 20 kg) for more than 1 year was admitted to our hospital due to severe diabetic crisis. Enlarged lymph nodes (2.5 x 1 cm) were found at the right axillary stations. Abdominal ultrasound revealed the presence of a large hyperechogenic mass, mainly located at the pancreatic head. Abdominal computed tomography scan confirmed a diffuse enlargement of the head and body of the pancreas associated with lymphadenopathy along the lesser gastric curvature. Percutaneous ultrasound-guided FNA of the pancreas as well as gross biopsy of the axillary lymph nodes were unable to identify the nature of the mass. Diagnostic laparoscopy was performed: several enlarged lymph nodes along the lesser gastric curvature were revealed. Multiple biopsies of the pancreatic head were taken and lymphadenectomy along the lesser curvature and the hepatic hilus was also performed. The definitive histopathological examination of the pancreatic specimen revealed a primary low-grade non-Hodgkin B cell pancreatic lymphoma. The postoperative course was unremarkable; the patient underwent systemic chemotherapy regime for low-grade B cell Hodgkin lymphoma and he was symptom free at 9-month follow-up.

Primary malignant melanoma of the esophagus: a case report.

Primary malignant melanoma of the esophagus is an uncommon tumor associated with a poor survival (5% at 5 years), even when resected at an early stage. Because its symptoms are no different from those of other malignant tumors of the esophagus, histopathologic examination is usually needed to reach a definitive diagnosis. A 57-year-old white nonsmoking nonalcoholic woman was referred to our department after 2 months of increasing dysphagia, odynophagia, and weight loss (5 kg in 2 months). Esophagogastroscopy revealed a dark blue, pediculated, polypoid lesion. Biopsies were taken. Endoscopic ultrasound showed a hyperechoic heterogeneous tumor. Barium esophagogram showed a filling defect of ~ 6 cm in the middle-low esophagus, and thoracic and abdominal computed tomography (CT) scan showed a well-delimited esophageal tumor with no clear lymph node enlargement. The pathology report described a proliferation of small spindle-shaped or stellate cells arranged in a spiral or fascicular structure. All tumor cells were intensively positive for immunoreaction, using HMB45 antimelanoma antibodies. To remove the tumor, distal esophagectomy through a double abdominal and thoracic approach was performed. No postoperative complications were reported and no chemo- or radiotherapy was given. The patients is still alive with no evidence of recurrence at 9 months after the operation.

Result of liver resection as treatment for metastases from noncolorectal cancer.

BACKGROUND AND OBJECTIVES: While liver resection for metastatic disease from colorectal cancer extends survival in selected patients, the efficacy of hepatectomy for metastases from other malignancies has not been defined. METHODS: Between 1988 and 1998, 20 hepatic resections were performed in 18 patients (2 underwent a double resection due to recurrence) as treatment of noncolorectal metastases. One-, 2-, and 5-year overall and disease-related actuarial survival rates were calculated. RESULTS: No intraoperative or early postoperative deaths were reported. Seven minor (30%) and 1 major (5%) postoperative complications occurred; mean blood loss was 401 +/- 324 ml. In 25% of patients, intra- or postoperative blood transfusion was needed. The mean postoperative hospital stay was 13. 2 days (range 9-23). The overall actuarial survival rate was 54% at 1 year, 42% at 2 years, and 21% at 5 years (mean 38 +/- 11 months). Survival is related to the primary tumor nature. CONCLUSIONS: Hepatic resection for metastases from noncolorectal carcinoma is safe and feasible, with a relatively low incidence of intra- or postoperative complications and a short hospital stay. Although it achieves good results in terms of survival in patients suffering from neuroendocrine metastases, it could also have a cytoreductive effect for other tumors.

Intraoperative localization of gut endocrine tumors with radiolabeled somatostatin analogs and a gamma-detecting probe.

Gut endocrine tumors are sometimes difficult to localize by radiological techniques. Carcinoids and gastrinomas, however, possess high density of somatostatin receptors, thus, scintigraphy with radiolabeled somatostatin analogs may prove useful for detection of occult gastro-enteropancreatic endocrine tumors when conventional diagnostic methods fail. A novel method of radioguided surgery with a hand-held gamma-detecting probe (GDP) has been used to localize gut endocrine tumors by binding radiolabeled somatostatin analogs. We also applied the method in a patient with occult carcinoid: after injecting 125-Iodine (125I)-octreotide intraoperatively, we obtained accurate localization of the jejunal carcinoid and of a liver metastasis previously undetected. Seventeen cases of gut endocrine tumors detected by this technique that have been reported in the literature are reviewed and discussed. Intraoperative localization of gastrointestinal endocrine tumors with radiolabeled somatostatin analogs and a GDP expands the possibility of accurate tumor detection one step beyond that obtained by conventional imaging and by intraoperative inspection and palpation.

Radioimmunoguided surgery benefits in carcinoembryonic antigen-directed second-look surgery in the asymptomatic patient after curative resection of colorectal cancer.

Radioimmunoguided surgery (RIGS) with radiolabeled monoclonal antibodies (MoAbs) has been reported as useful in second-look colorectal cancer procedures to improve surgical decision-making by helping avoid needless extensive surgery and expanding curative resection to sites of recurrence that have been missed previously. Sixteen asymptomatic patients with an history of colorectal cancer surgery underwent second-look surgery using the RIGS system, solely on the basis of rising serum levels of carcinoembryonic antigen (CEA). All patients were injected preoperatively with the anti-tumor-associated glycoprotein (TAG) 125I-labeled MoAb B72.3. Both traditional and RIGS exploration were used to determine the extension of a possible recurrence and its resectability for cure. Recurrent disease was observed in 14 of the 16 patients as the result of this combined exploration. Exploration alone showed the presence of recurrent disease in 9 of 16 patients (56.2%). Thus, RIGS found overlooked tumor in five patients (31.2%). All the additional RIGS-detected tumor sites were locoregional recurrences resectable for cure; conversely, no diagnostic improvements were shown in patients with liver metastases. Resection for cure was obtained by this approach in 9 of 16 patients (56.2%). Two patients without disease at the exploratory laparotomy recurred within 2 months at sites away from the abdomen. RIGS improved the results of colorectal cancer CEA-guided second-look procedures in asymptomatic patients by recruiting one-third of patients to curative resections.

Successful outcomes in stroke following forced use: what are the contributing factors?

Forced use is an experimental treatment designed to overcome nonuse of a hemiparetic upper extremity. It has demonstrated significant and long-lasting effects in regaining functional use of the affected arm with select chronic hemiparetic subjects. Occupational therapists, who frequently treat post-acute hemiparetic patients, may benefit from knowing this technique. Since a search of the OT literature uncovered no information on forced use, studies outside the standard OT resources were used. In particular, this review analyzes forced use in an attempt to determine the factors that contribute to its success. Although many factors such as subject criteria, psychological and motor learning factors, time, and use appeared likely to affect the success of forced use, they could not be confirmed through the existing experiments. Future controlled research on the clinical relevance of forced use is suggested.

Group theories: relevance to group safety studies.

Promoting safety in the workplace has been attempted in a variety of ways. Increasingly, industries are using groups such as safety teams and quality circles to promote worker safety. Group influences on individual behavior and attitudes have long been studied in the social psychology literature, but the theories have not been commonly found outside the psychology arena. This paper describes the group theories of group polarization, risky shift, social loafing, groupthink and team think and attempts to apply these theories to existing studies that examine work group influences on safety. Interesting parallels were found but only one study examined group influences as their primary focus of research. Since groups are increasingly used for safety promotion, future research on safety that studies group influences with respect to current group theories is recommended.

Infected pancreatic necrosis complicated by multiple organ failure.

BACKGROUND/AIMS: Sixteen patients with bacteriologically proven severe infected pancreatic necrosis (IPN) undergoing sequential surgical treatment were studied prospectively. METHODOLOGY: The severity of IPN was documented pre-operatively using the following scores: 1) degree of necrosis by CT scan [< 30% in three patients (19%); 30-50% in nine patients (56%); > 50% in four patients (25%)]; 2) Elebute and Stoner's sepsis score (16 +/- 4 points); 3) Goris' score of multiple organ failure (MOF) (5 +/- 2 points). Sequential surgical treatment was carried out by the same surgical team, as follows: 1) abdominal re-explorations through a zipper for the first 7-10 days; 2) open abdomen and repeated peritoneal debridements for the following 7-10 days; 3) continuous closed peritoneal lavage with multiple drainage, until resolution of infection (range: 15-85 days). No patient required further re-exploration. RESULTS: Mortality occurred in 3/16 patients (19%), due to MOF in all 3 cases. The 13 survivors (81%) were discharged convalescent with closed abdominal wound, feeding orally, after 73 +/- 33 days, without fistulae. These results indicate that by treating severe IPN with the technique of sequential abdominal re-explorations, open drainage and continuous closed lavage, a low 19% mortality can be achieved. CONCLUSION: This study provides an assessment of the pre-operative severity of sepsis and of MOF in each patient with IPN: these data could facilitate future comparison of results obtained with other treatment modalities.

Effects of surgical trauma of laparoscopic vs. open cholecystectomy.

The effects of surgical trauma resulting from laparoscopic cholecystectomy and open cholecystectomy, were compared by assessing the postoperative acute phase alterations of selected plasma proteins, hormones and lymphocyte subpopulations in fifty-seven patients prior to elective cholecystectomy. Patients were prospectively randomized to undergo either laparoscopic cholecystectomy (n = 30) or open cholecystectomy (n = 27). Duration of operation and general anesthesia was similar in the two patient groups. The laparoscopic cholecystectomy patients had a shorter postoperative stay in hospital (3.1 (0.5) days vs. 7.1 (1.6) days; p < 0.001). In open cholecystectomy patients a significantly greater postoperative acute phase increase in plasma C-reactive protein (p < 0.001), cortisol (p < 0.05), and prolactin blood level (p < 0.001) was recorded. The postoperative acute phase decrease in the blood total-T-lymphocyte count (CD3 cells) and in the activated-lymphocyte count (OKDR cells) was significantly greater after open cholecystectomy (p < 0.05). These results, showing that acute phase responses are less marked after laparoscopic cholecystectomy than after open cholecystectomy, support the concept that the laparoscopic procedure is less traumatic.

Role of B72.3 iodine 125-labeled monoclonal antibody in colorectal cancer detection by radioimmunoguided surgery.

BACKGROUND: Radioimmunoguided surgery (RIGS) by means of radiolabeled monoclonal antibodies and a probe has been reported to be useful in recognizing subclinical tumor deposits during operation. Aim of this study was to understand the limits of this technique and to assess the potential diagnostic use of RIGS in colorectal cancer surgery. METHODS: Monoclonal antibody B72.3 reacting with TAG 72 antigen, labeled with iodine 125, was injected in 32 patients with primary tumors and in 22 patients with recurrent colorectal cancer. One hundred thirty-three suspected tumor sites were evaluated during operation by means of probe and resected with immunohistochemistry as control. RESULTS: Primary tumor sites were localized by RIGS in 60% of cases, and recurrent sites were localized in 82% of cases. There was a significant correlation both for primary (p < 0.001) and recurrent (p < 0.001) tumor sites between intraoperative RIGS findings and TAG 72 tumor antigen expression. Results obtained with the probe were instrumental in modifying the surgical approach in six (27%) of 22 patients with recurrences, allowing the removal of tumor masses that would otherwise have been overlooked. CONCLUSIONS: The results of RIGS seems to be encouraging in terms of clinical use. The potential high diagnostic resolution appears to improve surgical ablation of colorectal cancer, especially in patients with recurrent cancer or suspected recurrent tumors who have negative results for intraabdominal disease by all other roentgenographic criteria with rising carcinoembryonic antigen or TAG 72 antigen levels.