The role of lymphoscintigraphy in rectal laparoscopic surgery: can the sentinel node concept be applied to rectal carcinoma?

BACKGROUND: Lymphadenectomy for rectal cancer, whether by open surgery or laparoscopy, is still a controversial subject. If we consider that approximately 20% of patients have nodal obturator metastases, then we must concede that extended lymphadenectomy is useless in the other 80% of patients. We set out to determine whether lymphoscintigraphy could show the lymphatic drainage from the cancer toward the obturator lymph nodes and thus help us to select the patients who would benefit by their removal. We also analyzed the possibility of applying the concept of the sentinel node to the treatment of rectal cancer. METHODS: Among 42 people who underwent laparoscopy for rectal cancer 11 patients with TNM stages T2-T3N0M0 were studied by CT & MRI, rectal ultrasonography, and lymphoscintigraphy with a colloidal injection of human albumin labeled with 99mTc at the base of the neoplasm. Afterward, the 11 patients underwent a lymphadenectomy that extended to the obturator nodes. RESULTS: In two patients, lymphoscintigraphy showed lymphatic drainage toward the obturator nodes. In one case, there were metastases. Lymphoscintigraphy did not show lymphatic drainage toward the obturator nodes in any of the other patients, and there were no metastases among them. It was not possible to identify a sentinel node. CONCLUSION: Lymphoscintigraphy can be used to select patients with rectal cancer who will be helped by a lymphadenectomy extended to the obturator nodes. However, the concept of the sentinel node cannot be applied to rectal cancer.

[Sentinel lymph nodes in skin melanoma]. / Il linfonodo sentinella nel melanoma cutaneo.

BACKGROUND: Early node dissection offers increased survival in patients with node metastases only. The study of sentinel node (SN) using blue dye and radiolocalization permits to identify patients who could undergo lymphadenectomy. METHODS: At Department of Surgery of Macerata General Hospital 22 patients with melanoma of trunk or limbs at I and II stage were submitted to SN biopsy. RESULTS: SN was identified in all cases by combined approach. Dynamic lymphoscintigraphy permitted identification of SL when it was not the node nearest the tumor. Nodal metastases were found in 2 cases (9.1%) and the patients underwent regional lymphadenectomy. In 1 patient the SN was the only node with metastases. Both patients had high thickness melanomas. The measurement of radioactive exposition for operating room personnel and pathologist demonstrated that the technique is safe and without risks. CONCLUSIONS: Biopsy of SN is effective for identification of occult nodal metastases from cutaneous melanoma. Combined technique allows to localize SN in 100% of cases. There is not radio-exposition for operators.

[Original reconstruction technique after duodenopancreatectomy]. / Tecnica originale di ricostruzione dopo duodenocefalopancreasectomia.

The authors present an original reconstruction technique after pancreaticoduodenectomy, with anastomosis between the pancreatic stump and the posterior wall of the stomach, using two Roux-en-Y loops to separate the hepaticojejunostomy from the pancreaticogastrostomy and gastrojejunostomy in order to reduce postoperative complications and mortality. Eighteen consecutive patients underwent the procedure. There was no mortality and no pancreaticogastrostomy leaks occurred. Two (11.1%) gastric bleeds occurred in the first two cases. Twelve cases (66.6%) presented alimentary emesis on postoperative day 5 or 6 after food intake. Three patients (16.6%) had postoperative diarrhea. There were no complications calling for reoperation. The mean hospital stay was 14.4 days. No significant late complications were observed. The procedure is easy and safe with no mortality and with one of the lowest complication rates in the literature.

[Sentinel lymph node identification in the staging of cutaneous melanoma. Blue dye vs. radioguided localization]. / Identificazione del linfonodo sentinella nella stadiazione del melanoma cutaneo. Blue dye vs localizzazione radioguidata.

BACKGROUND: The purpose of this study is to emphasize the usefulness of combined intraoperative gamma-detecting-probe (C-Trak) and blue dye guided research of sentinel nodes (SN) in the treatment of cutaneous melanoma. METHODS: At the Department of General Surgery of Macerata Hospital, after informed consent, 22 consecutive patients (10 males and 12 females) with mean age 53 years (20-78 years) affected by histologically proved cutaneous malignant melanoma in stage I (TC, ultrasonography and bone scintigraphy) were studied by dynamic lymphoscintigraphy with 10.8-22.2 MBq of 99mTc albumin microcolloids 18-22 hours before surgery and by intradermal injection of blue dye at induction of anaesthesia. Intraoperative mapping technique to localize SN has been done by using a combination of a vital blue dye and a radioactive tracer. RESULTS: A total of 42 SN were identified. Micrometastases were found in 2 (9.1%) patients; 13 SN were well-coloured (31%), 23 SN were poorly-coloured (55%), and 6 SN were not coloured (14%). Overall localization with blue dye was 86%. All SN were radiolabeled, but identification with gamma detecting probe was possible only in 41 cases (95%). Combined techniques was effective in 100% of cases. CONCLUSIONS: Combined use of radiocolloids and blue dye is the gold standard for correct identification and biopsy of SN with 100% of favourable results. The technique is simple, fast and effective and permits to select the patients that need other surgical and oncologic procedures.

[Our experience with Spigelio's hernia]. / Nostra esperienza con l'ernia di Spigelio.

The authors present their experience about diagnosis and therapy of Spigelian hernia in five cases observed. Clinical examination is the foundation of the diagnosis and radiological findings (ultrasonography, colonic X-rays, CT and NMR) permit to exclude other pathologies which concern differential diagnosis. They suggest prosthetic repair, similar to the therapy of groin hernias, using a tension-free technique. This method of treatment avoids relapses and does not alter the functionality of muscular and aponeurotic apparatus.

[Boerhaave's syndrome]. / La sindrome di Boerhaave.

The authors report a personal case of "Boerhaave's syndrome" recovered by immediate reconstruction of perforated distal esophagus. They stress the value of early diagnosis by using X-ray study of upper gastrointestinal tract and immediately surgical treatment, very important for favourable prognosis.

[Role of surgery in the treatment of pleural mesothelioma]. / Il ruolo della chirurgia nel trattamento del mesotelioma pleurico.

The authors present a review of the cases of pleural mesothelioma diagnosed and treated in the Institute of Special Surgical Pathology of the University of Ancona. They confirm the causative role of asbestos in the aetiology of this disease and indicate that the surgical approach is the best diagnostic means available via open biopsy and that the only curative procedure is pleuropneumonectomy. Such surgery, however, is confined to patients properly studied according to the scheme proposed by Butchart, namely stage I patients in excellent physical condition.

[A case of malignant pancreatic apudoma producer of serotonin and pancreatic polypeptide]. / Su un caso di apudoma maligno pancreatico a produzione di serotonina e polipeptide pancreatico.

Taking as their starting point the observation of a pancreatic malignant endocrine neoplasm with mixed production of serotonin and pancreatic polypeptide, the authors go on to review the literature on the diagnosis and treatment of pancreatic apudomas. The possibility of performing an extempore intraoperative histological examination makes it possible to obtain a correct diagnosis of endocrine neoplasm and thus to proceed with surgery which could not be contemplated in adenocarcinomatous forms at an equivalent stage. Chemotherapy may then provide additional therapeutic possibilities, using specific markers for malignancies of the APUD system in order to detect possible recurrences.

[Spontaneous pneumothorax: surgical aspects]. / Pneumotorace spontaneo: aspetti chirurgici.

The authors illustrate the cases of spontaneous pneumothorax observed in their institute along with the diagnostic and therapeutic aspects. In accord with the experience of others as reported in the literature, they stress the importance of a precise, immediate diagnosis for the purposes of adopting the treatment of choice: in the presence of closed, partial forms a conservative approach is to be preferred, whereas in open and/or hypertensive cases an aspirative thoracic drainage must be provided without delay. Aggressive surgical treatment, with resection of the bullous lesions responsible for bronchopleural fistulas, will resolve the condition and should be implemented after a reasonable waiting period with aspirative drainage, or even, electively, in the first instance, in the presence of multiple relapses. In any event, the authors stress the need to avoid uncertainty and delay in view of the youthful age of most of the subjects affected and the potential danger of the complications of this apparently banal disease.