The timing of surgery for resectable metachronous liver metastases from colorectal cancer: Better sooner than later? A retrospective analysis.

BACKGROUND: The benefit of preoperative chemotherapy in patients with initially resectable liver metastases from colorectal cancer is still a matter of debate. AIMS: We aim to evaluate the role of neoadjuvant chemotherapy on the outcome of patients with colorectal cancer metachronous liver metastases undergoing potentially curative liver resection. METHODS: One-hundred four patients were available for analysis. Tested variables included age, sex, primary tumour TNM stage, location and grading, the number of liver metastases, monolobar or bilobar location, interval time between liver metastases diagnosis and liver resection, Fong Clinical Risk Score (CRS). Neoadjuvant chemotherapy was administered according to the FOLFOX4 regimen. RESULTS: Forty-four patients underwent liver resection without receiving neoadjuvant chemotherapy (group A); 60 patients received neoadjuvant chemotherapy (group B). At univariate analysis, only the time of liver resection seemed to affect overall survival: patients in group A showed a median survival time significantly superior to that of patients in group B (48 vs. 31 months; p=0.0358). CONCLUSIONS: Our findings suggest that, when feasible, resection of liver metastases should be considered as an initial approach in this setting. Further studies are needed to better delineate innovative therapeutic strategies that may lead to an improved outcome for colorectal cancer patients with surgically resectable liver metastases.

Primary carcinoid tumour of the kidney. A case report and review of the literature.

Carcinoid tumours are known to occur frequently in the gastrointestinal and respiratory tracts. A primary carcinoid tumour of the kidney is an extremely rare entity and only 40 cases have been reported in the literature. As a consequence, very little is known about its real histogenesis, and its prognosis and clinicopathological patterns are not precisely defined. We report a case of primary carcinoid tumour of the kidney found in a middle-aged woman treated by nephrectomy, along with a thorough review of the literature concerning this kind of neoplasm.

[Extraordinary role of self-expanding metal stent (SEMS) in the malignant colorectal obstruction: different care in two cases]. / Lo straordinario impatto del Wallstent nelle occlusioni neoplastiche del colon: il differente impiego in due casi clinici.

The colorectal cancer presents with bowel obstruction in 10%-30% of patients. Established treatment of this evolutive condition, until 15 years ago, was emergency surgery. Primary resection with or without ileostomy, staged resection, Hartmann's procedure, or definitive colostomy are the therapeutical options. There is ongoing controversy on the best procedure to apply, because the choice depends on the patient's condition, age, electrolyte imbalances, nutritional status, obstructional grade, comorbidity and surgeon's attitude. However, the obstruction and the emergency operation add risk of complications and mortality instead of elective surgery. The efficacy of self-expanding metal stent to solve the obstruction had recently changed the management of malignant luminal obstruction: it is safe, effective, with very low mortality, low morbidity and also cheap. In the inoperable cases it represents the first line therapy avoiding the colostomy. In the operable patients, instead of two-step surgery, the SEMS had to be preferred because is a one-time and election surgery and avoid colostomy too, even if temporary. SEMS versus emergency primary surgery, without randomized and controlled study, allows a safer single-staged surgery. Finally it improves the quality of life avoiding colostomy, and reducing operative risk. We present two different use of SEMS: the palliation in inoperable patient and the "bridge to surgery" in critical obstructed patient.

[Non-operative management of blunt abdominal injuries]. / Ii trattamento non operativo dei traumi addominali chiusi.

Over the past three decades, non-operative management has been shown to be an effective therapeutic option in hemodynamically stable patients. We retrospectively reviewed the last 7 years of our experience with the non-operative management of blunt abdominal traumas. From January 1998 to July 2005, 123 patients with blunt abdominal traumas and injuries to the spleen, liver and pancreas were admitted to our hospital. Fifty-eight of them (47.2%) were submitted to non-operative management; 5 (8.6%) presented associated splenic and hepatic injuries. We performed non-operative treatment for 27 splenic injuries (33.7% of all splenic injuries), 32 hepatic injuries (62.7% of all hepatic injuries) and 3 pancreatic injuries (75% of all pancreatic injuries). There was no mortality and no complications. We submitted one haemodynamically stable patient who presented a grade V hepatic injury and "contrast pooling" at abdominal CT scan to angiography and transarterial embolisation; this patient was successfully managed non-operatively. The overall success rate of non-operative management was 98.5%. The only non-operative management failure was a patient with both splenic and hepatic injuries. The success rate for injuries to the spleen was 96.3%, to the liver 96.9% and to the pancreas 100%. We conclude that hemodynamically stable patients suffering intra-abdominal injury can be safely managed non-operatively.

[Solid pseudopapillary tumor of the pancreas. A report of 3 cases and a review of the literature]. / Tumore solido pseudopapillare del pancreas. A proposito di 3 casi e revisione della letteratura.

Solid pseudopapillary tumours of the pancreas (SPTP) are a distinct clinico-pathological entity that differs from the other cystic pancreatic neoplasms in the young age of onset, the almost exclusive incidence in the female sex and the low degree of malignancy. SPTP is a rare neoplasm that has shown a progressive increase of incidence, passing from 0.17%-2.7% of all exocrine tumours of the pancreas in the 1980's, to 6% in recent reports in 2003. In addition, it accounts for about 5% of cystic neoplasms of the pancreas. With the present paper, in the world literature, updated to August 2005, 887 cases have been described in 248 articles. The histogenesis of these epithelial neoplasms remains uncertain though it is likely that they originate from pluripotent immature pancreatic cells. The tumour is generally of large size and invariably presents a capsule. The diagnosis in most cases is based on compressive symptoms, pain or finding of a palpable mass, while in about 20% of the patients the finding is occasional during abdominal imaging performed for other pathologies. CT and MR are not always sufficient to differentiate with certainty between this type of tumour and other cystic neoplasms of the pancreas such as pseudocysts, parasitic cysts and congenital cysts. Cytological examination in most cases permits the diagnosis of SPTP. The malignancy of these neoplasms is attenuated and local with capsular invasion, lymp-node spread and, only rarely, liver and peritoneal metastases. The surgical treatment has to be radical since the malignancy can only be defined by postoperative histological examination. The treatment consists of three possible options: duodenocephalopancreatectomy, intermediate pancreatectomy, and distal pancreatectomy with or without splenectomy. Intraoperative histological examination is mandatory for the diagnostic confirmation and for the evaluation of negativity of the pancreatic resection margins. Survival after radical resection is excellent. Moreover, in forma metastasizing to the liver an aggressive attitude may be still curative and assure longer survival. The Authors report their experience with three female patients with an average age 18 years (28,19 and 8 years) operated on between 1995 and 2000 for SPTP. Two of the patients were asymptomatic and the finding of the tumour was occasional. The third patient presented jaundice and abdominal pain. The average diameter of the tumours was 6 cm (4, 7 and 7 cm). In all three cases tumour marker values (CEA, Ca19-9, alphaFP) were normal. Only in one case was the preoperative diagnosis correct. The surgical treatment depended on the location of the neoplasms: for the two tumours in the head, in one case an enucleoresection was performed in relation to an exophytic location, while, in the other, a duodenocephalopancreatectomy was performed. In the somatopancreatic tumour a distal splenopancreatectomy was performed. Only in one case (the DCP) the capsule and the surrounding parenchyma were infiltreted by neoplasm. In all cases there was immunohistochemical positivity for alpha1-antitrypsin and for neuron-specific enolase. Neither mortality nor operative morbidity were observed. Follow-up with CT found no relapses in any of the three patients after 5, 7 and 10 years, respectively, after the operation.

Inability to perform maximal stair climbing test before lung resection: a propensity score analysis on early outcome.

OBJECTIVE: The objective of the present study was to assess whether patients unable to perform a preoperative maximal stair climbing test had an increased incidence of morbidity and mortality after major lung resection compared to patients who were able to exercise. METHODS: Three hundred and ninety one patients submitted to pulmonary lobectomy or pneumonectomy for lung cancer were analyzed. Forty-five of these patients were unable to perform a preoperative maximal stair climbing test for underlying comorbidities. Unadjusted and propensity score case matched comparisons were performed between patients who could and who could not perform a preoperative stair climbing test. Multi-variable analyses were then performed to identify predictors of morbidity and mortality, and were validated by bootstrap bagging. RESULTS: Patients who could not perform the stair climbing test had similar morbidity rates (31.1 vs. 35.6%, respectively, P=0.7), but higher mortality rates (15.6 vs. 4.4%, respectively, P=0.08) and deaths among complicated patients (50 vs. 12.5%, respectively, P=0.025), compared to propensity score matched patients who could perform the stair climbing test. Logistic regression analyses showed that the inability to perform the stair climbing test was an independent and reliable predictor of mortality (P=0.005) but not of morbidity (P=0.2). CONCLUSIONS: Patients unable to perform a preoperative maximal exercise test had an increased risk of mortality after major lung resection. Half of these patients did not survive postoperative complications, due to their decreased aerobic reserve caused by physical inactivity which made them unable to cope with the increased oxygen demand.

A model to predict the decline of the forced expiratory volume in one second and the carbon monoxide lung diffusion capacity early after major lung resection.

The objective of the study was to develop regression models for the prediction of the decline of the forced expiratory volume in one second (FEV1) and the carbon monoxide lung diffusion capacity (DLCO) early after major lung resection. One hundred and ninety patients submitted to pulmonary lobectomy or pneumonectomy for lung cancer performed preoperative and early postoperative (mean 10.9 after operation) pulmonary function tests. One hundred and fifty of these patients also underwent DLCO measurements by the single breath method. The decline of FEV1 and DLCO were expressed as percentage losses from preoperative values. Stepwise multiple regression analyses were performed to develop two models estimating the percent reduction of FEV1 and DLCO from preoperative values. The multivariate procedures were then validated by bootstrap analyses. The following regression equations were derived: estimated percent reduction in FEV1 = 21.34 - (0.47 x age) + (0.49 x percentage of functioning parenchyma removed during operation) + (17.91 x COPD-index); estimated percent reduction in DLCO = 35.99 - (0.31 x age) - (36.47 x FEV1/FVC ratio) + (0.33 x DLCO) + (0.54 x percentage of functioning parenchyma removed during operation). The comparison between observed and estimated losses of FEV1 and DLCO (by using these regression equations) was not significantly different. We think the regression models generated in this study may be reliably used for risk stratification purposes.

Comparison of water seal and suction after pulmonary lobectomy: a prospective, randomized trial.

BACKGROUND: The objective of the present study was to assess whether placing chest tubes on water seal after pulmonary lobectomy reduced the duration of air leak compared with suction. METHODS: One hundred forty-five patients who underwent pulmonary lobectomy for lung cancer and with an air leak on the first postoperative day were prospectively randomly assigned to two groups: in group 1 (72 patients), chest tubes were placed on water seal on the morning of the first postoperative day; in group 2 (73 patients), chest tubes were on continuous suction (-20 cm H(2)O). Eighty percent of the patients who underwent upper lobectomy had also a pleural tent procedure. Preoperative, operative, and postoperative variables were compared between the groups. RESULTS: The two groups were evenly matched for preoperative and operative characteristics. No statistically significant differences were found between group 1 and group 2 in terms of air leak duration (6.5 versus 6.3, respectively; p = 0.9) and the incidence of prolonged air leak cases (27.8% versus 30.1%, respectively; p = 0.8). Similar results were obtained when the analysis was corrected for the length of the stapled parenchyma and the site of resection (upper and lower resections) or restricted to patients with a forced expiratory volume in 1 second less than 80% of predicted. Water seal patients had increased postoperative complications compared with suction patients (31.9% versus 17.8%, respectively; p = 0.056). CONCLUSIONS: Chest tubes placed on water seal after pulmonary lobectomy were generally well tolerated and safe; however, they did not reduce the duration of air leak or the incidence of prolonged air leak compared with suction.

A model for the internal evaluation of the quality of care after lung resection in the elderly.

OBJECTIVES: The objective of this study was to develop a logistic model for internal audit in a population of elderly patients submitted to lung resection. METHODS: Three hundred twenty-six patients older than 70 years of age and submitted to lung resection for lung carcinoma were retrospectively analyzed. Univariate and logistic regression analyses yielded a model for the prediction of postoperative complications that was validated by bootstrap resampling analysis. The model was then used to assess the performance of our unit during two successive periods of activity ('early', 1993-1999; 'late', 2000-2003). RESULTS: Significant independent predictors of postoperative complications were a low ppoFEV1 (P < 0.0001) the presence of concomitant cardiac disease (P = 0.01) and extended resection (P = 0.03). The observed morbidity rate in the late period was higher than that in the early period (48.3 vs. 33.8%; P = 0.008). The predicted morbidity rate was also higher in the late period, compared to that in the early period (44 vs. 39%; P = 0.003). Moreover, no differences were noted between predicted and observed morbidity rates in each of the two periods (early, P = 0.4 late, P = 0.5). CONCLUSIONS: We showed that applying a model of risk-adjustment in elderly patients submitted to lung resection was useful for the internal evaluation of the quality of care and prevented misleading information derived by the comparison of the crude rates of the observed morbidity.

Predictors of prolonged air leak after pulmonary lobectomy.

BACKGROUND: The objective of this study was to identify the predictors of prolonged air leak (air leak longer than 7 days) in patients submitted to pulmonary lobectomy for lung cancer. METHODS: A retrospective analysis on 588 patients operated on of pulmonary lobectomy from January 1995 through June 2003 was performed. Univariate and logistic regression analyses were performed to generate a model predicting the risk of prolonged air leak. Bootstrap resampling technique was used to validate the regression model. RESULTS: A prolonged leak was exhibited by 15.6% of patients. Logistic regression analysis demonstrated that significant independent predictors of prolonged air leak were a reduced predicted postoperative forced expiratory volume in 1 second (p < 0.0001), the presence of pleural adhesions (p = 0.003), and upper resections (p = 0.006). Bootstrap resampling analysis confirmed the reliability of these variables. A regression equation was generated for the prediction of the risk of prolonged air leak. CONCLUSIONS: We report that a low predicted postoperative forced expiratory volume in 1 second, the presence of pleural adhesions, and the upper lobectomy or bilobectomy increased the risk of air leak persisting for more than 7 days. A model was generated to calculate this risk and assist the surgeon in taking extra measures to prevent such complication (ie, optimizing bronchodilator treatment, pleural tent, sealants, buttressed staple lines, water seal, and chest tube drainage).

Stair climbing test as a predictor of cardiopulmonary complications after pulmonary lobectomy in the elderly.

BACKGROUND: The objective of this study was to assess the role of a symptom-limited stair climbing test in predicting postoperative cardiopulmonary complications in elderly candidates for lung resection. METHODS: A consecutive series of 109 patients more than 70 years of age who underwent pulmonary lobectomy for lung carcinoma from January 2000 through May 2003 formed the prospective database of this study. All patients in the analysis performed a preoperative symptom-limited stair climbing test. Univariate and multivariate analyses were performed to identify predictors of postoperative cardiopulmonary complications. RESULTS: At univariate analysis, the patients with complications had a lower forced expiratory capacity percentage of predicted (p = 0.048), predicted postoperative forced expiratory volume in 1 second percentage of predicted (p = 0.049), climbed a lower height at preoperative stair climbing test (p = 0.0004), and presented a greater proportion of cardiac comorbiditiy with respect to the patients without complications (p = 0.02). After logistic regression analysis, significant predictors of postoperative complications resulted in the presence of a concomitant cardiac disease (p = 0.04) and a low height climbed preoperatively (p = 0.0015). CONCLUSIONS: A symptom-limited stair climbing test was a safe and simple instrument capable of predicting cardiopulmonary complications in the elderly after lung resection.

Predicted versus observed maximum oxygen consumption early after lung resection.

BACKGROUND: The objective of this study was to identify the predictors of underestimation and overestimation of postoperative maximum oxygen consumption (VO(2)max). METHODS: A prospective analysis was performed on 229 patients who had 38 pneumonectomies, 171 lobectomies, and 20 segmentectomies. All patients performed a preoperative and postoperative (on average 9.2 days after surgery) maximal stair-climbing test. Predicted postoperative VO(2)max (ppoVO(2)max) was calculated on the basis of the number of functioning segments removed during operation. The patients were divided into three groups: group A (158 cases), patients with a ppoVO(2)max within 1 standard deviation of the observed postoperative VO(2)max; group B (56 cases), patients with a difference between the observed postoperative VO(2)max and ppoVO(2)max greater than 1 standard deviation (underestimation); and group C (15 cases), patients with a difference between ppoVO(2)max and the observed postoperative VO(2)max greater than 1 standard deviation (overestimation). Univariate and multivariate analyses were performed. RESULTS: The only significant predictor of underestimation was a high percentage of functional parenchyma removed during operation (p < 0.0001). The significant predictors of overestimation were a low percentage of functional parenchyma removed during operation (p = 0.01) and a high preoperative VO(2)max (p = 0.002). CONCLUSIONS: The prediction of postoperative VO(2)max was not accurate in all patients. Those with a large amount of functional lung tissue removed during operation tended to have a postoperative VO(2)max greater than expected. Conversely, those patients with a small amount of functional lung tissue resected tended to have a postoperative VO(2)max lower than predicted.

Predictors of exercise oxygen desaturation following major lung resection.

OBJECTIVE: To identify predictors of postoperative exercise oxygen desaturation (EOD) in patients submitted to lobectomy or pneumonectomy for lung carcinoma. PATIENTS AND METHODS: A consecutive series of 227 patients with non-small cell lung cancer submitted to lobectomy or pneumonectomy from January 2000 through October 2002 were prospectively analyzed. Maximal stair-climbing tests were performed preoperatively (the day before the operation) and postoperatively (on average, 9.2 days after operation) in room air for all patients. A fall in oxygen saturation during the exercise below 90% was termed 'desaturation'. Univariate and multivariate analyses were performed to identify predictors of postoperative EOD. RESULTS: Thirty-five patients (15.4%) developed postoperative EOD. After multivariate analysis, the only independent predictor of postoperative EOD resulted a reduction in oxygen saturation during the preoperative exercise (P=0.0004). CONCLUSIONS: Patients with a reduction in oxygen saturation during the preoperative exercise test are at increased risk to develop a postoperative EOD below 90%. A postoperative exercise test should be performed in all these patients. Should EOD be confirmed, an intermittent home oxygen therapy is recommended in order to facilitate recovery from operation and improve the quality of life.

Predictors of early morbidity after major lung resection in patients with and without airflow limitation.

BACKGROUND: The aim of the present study was to identify predictors of morbidity after major lung resection for non-small cell lung carcinoma in patients with forced expiratory volume in 1 second (FEV1) greater than or equal to 70% of predicted and in those with FEV1 less than 70% of predicted. METHODS: Five hundred forty-four patients who underwent lobectomy or pneumonectomy from 1993 through 2000 were retrospectively analyzed. The patients were divided into two groups: group A (450 cases), with FEV1 greater than or equal to 70%, and group B (94 cases), with FEV1 less than 70%. Differences between complicated and uncomplicated patients were tested within each group. RESULTS: Morbidity rate was not significantly different between group A and group B (20.4% and 24.5%, respectively; p = 0.4). In group A, multivariate analysis showed that predicted postoperative FEV1 was the only significant independent predictor of complications. In group B, no significant predictor was identified. CONCLUSIONS: In patients with preoperative FEV1 less than 70% of predicted, predicted postoperative FEV1 was not predictive of postoperative morbidity. Thus, predicted postoperative FEV1 should not be used alone as a selection criteria for operation in these high-risk patients.

Stair climbing test predicts cardiopulmonary complications after lung resection.

STUDY OBJECTIVE: To evaluate the capability of the stair climbing test to predict cardiopulmonary complications after lung resection for lung cancer. DESIGN: A prospective cohort of candidates for lung resection. Spirometric assessment and the stair climbing test were performed the day before operation. Univariate and multivariate analyses were performed to identify predictors of postoperative complications. SETTING: Tertiary referral center. PATIENTS: A consecutive series of 160 candidates for lung resection with lung carcinoma from January 2000 through March 2001. RESULTS: At univariate analysis, the patients with complications were significantly older (p = 0.02), had a significantly lower FEV(1) percentage (p = 0.007) and predicted postoperative FEV(1) percentage (p = 0.01), had a greater incidence of a concomitant cardiac disease (p = 0.02), climbed a lower altitude at the stair climbing test (p < 0.0001), and had a lower calculated maximum oxygen consumption (O(2)max) [p = 0.03] and predicted postoperative O(2)max (p = 0.006) compared to the patients without complications. At multivariate analysis, the altitude reached at the stair climbing test remained the only significant independent predictor of complications. CONCLUSIONS: The stair climbing test is a safe and economical exercise test, and it was the best predictor of cardiopulmonary complications after lung resection.

Pleural tent after upper lobectomy: a randomized study of efficacy and duration of effect.

BACKGROUND: The object of this study was to assess the efficay and maximum duration of effect of the pleural tent in reducing the incidence of air leak after upper lobectomy. METHODS: Two hundred patients who underwent upper lobectomy were prospectively randomized into two groups: 100 patients who underwent an upper lobectomy and a pleural tent procedure (group 1; tented patients) and 100 patients who underwent only an upper lobectomy and not a pleural tent procedure (group 2; untented patients). The preoperative, operative, and postoperative characteristics of both groups were compared. Then multivariate analyses were used to identify factors predictive of prolonged air leaks and their duration. The reduction of incidences of air leak in the two groups was subsequently compared during successive postoperative periods. RESULTS: No differences were detected between the two groups in terms of preoperative and operative characteristics. A significant reduction occurred in group 1 patients for the mean duration of air leak in days (2.5 vs 7.2 days; p < 0001), the number of days a chest tube was required (7.0 vs 11.2 days; p < 0.0001), the length of postoperative hospital stay in days (8.2 vs 11.6 days; p < 0.0001), and the hospital stay cost per patient (4,110 dollars vs 5,805 dollars; p < 0.0001). Logistic regression analyses showed that not having undergone a pleural tent procedure was the most significant predictive factor of the occurrence and duration of prolonged air leaks. A greater reduction in the duration of air leaks was observed before postoperative day 4 in group 1, and logistic regression analysis showed that having undergone a pleural tent procedure was the most significant predictive factor of air leaks that persisted for less than 4 days. CONCLUSIONS: Pleural tenting after upper lobectomy was a safe procedure that reduced the duration of air leaks and the hospital stay costs. The benefit from that procedure was achieved before postoperative day 4.