Outcomes for early rectal cancer managed with transanal endoscopic microsurgery: a 5-year follow-up study.

BACKGROUND: This study aimed to evaluate the long-term risk of local and distant recurrence as well as the survival of patients with early rectal cancer treated using transanal endoscopic microsurgery (TEM). METHODS: The study reviewed 69 patients with Tis/T1/T2 rectal cancer treated using full-thickness excision between 1991 and 1999. The pathology T-stages included 25 Tis, 23 T1, and 21 T2. The median follow-up period was 6.5 years (range 5-10.2 years). RESULTS: The overall local recurrence rate was 8.7%. The 5-year local recurrence rate was 8% for Tis, 8.6% for T1, and 9.5% for T2. All six patients with recurrence were managed surgically. The 5-year disease-specific survival rate was 100% for Tis, 100% for T1, and 70% for T2. The overall cancer-related mortality rate was 7.2%. CONCLUSIONS: After local excision of early rectal cancer, a substantial local recurrence rate is observed. Patients with recurrent Tis/T1 cancers who undergo a salvage operation may achieve good long-term outcome. Local treatment without adjuvant therapy for T2 rectal cancers appears inadequate.

[Multidisciplinary treatment in Budd-Chiari syndrome: clinical case]. / Trattamento multidisciplinare nella sindrome di Budd-Chiari: caso clinico.

Budd-Chiari Syndrome (BCS) is characterized by obstruction of hepatic venous outflow. When obstruction is limited to the suprahepatic veins, portocaval shunting provides an immediate relief of symptoms. If the obstacle results also from narrowing of the inferior vena cava (IVC), multimodality treatments seem to offer safer and easier alternative. In the patient herein reported, combination of side-to-side portocaval anastomosis with a cavo-atrial shunt through an expandible metallic stent provided immediate relief of symptoms. The patient is doing well after 85 months from combined treatment. In conclusion infracaval stenting combined to side-to-side portocaval shunting should represent the treatment of choice in acute or subacute forms of BCS.

Indications and results of resection for hepatocellular carcinoma.

AIM: In this retrospective series we evaluate our experience in surgical treatment of HCC and examine early and long-term results of 46 hepatic resections. METHODS: Eighty-eight patients with HCC have been observed at our Department. Fifty patients (57%) have been operated, but only 46 (92%) could be resected; 43 patients (93.5%) carried liver cirrhosis. We performed 28 non-anatomical resections (60.8%) and 18 anatomical resections (39.2%). Tumour clearance at resection margin of at least 1cm was considered for a curative resections. RESULTS: Overall mortality and morbidity were 8.7 and 30.4% respectively. These rates significantly decreased in the last years: from 1995 to 2000 no hospital mortality has been recorded. Hospital mortality among non-anatomical and anatomical resection subgroups was 3.5 and 16.6% respectively (P<0.02). After a median f.u. of 41 months, 19 patients (45.2%) had recurrences: it was intrahepatic in 16 (84.4%). We observed a 3-, 5- and 10-years actuarial survival rate 62, 51.1 and 22.5% respectively. Long term survival significantly differed between non-anatomical and anatomical resections, with 5-year and 10-year values of 61.1 and 34.3% vs 37.7 and 18.8% respectively (P=0.0224). CONCLUSIONS: Early results after hepatic resection for HCC can be improved by using a limited surgical approach. Long-term results are still unsatisfactory, because of the high recurrence rate that is not influenced by different surgical approaches.

Angiogenesis as a prognostic indicator in pancreatic ductal adenocarcinoma.

BACKGROUND: Angiogenesis has gained wide acceptance as a reliable prognostic factor in several solid tumors. However, to date, experience in pancreatic adenocarcinoma is limited. MATERIALS AND METHODS: Specimens from 45 patients radically operated on at our departments from 1988 to 1997 were stained immunohistochemically with the antibodies anti-mutant p53, anti-bcl2, anti Ki67 and anti-CD31. All the slides were reviewed by the same pathologist without knowledge of the patients' outcome. RESULTS: Mutant p53, Ki67 index and vessel count were significantly related to tumoral behaviour and patients' outcome. Among patients with nodal involvement (Stage III), cumulative survival between hypovascular and hypervascular subgroups differed significantly (p = 0.03). Angiogenesis was independent from TNM in assessing the patients'prognosis at COX analysis (p = 0.02). CONCLUSION: In patients with pancreatic adenocarcinoma, angiogenesis is a reliable indicator of tumor extension, lymph node status and survival. Its evaluation as a common procedure may contribute to a further improvement in the management of these patients and to a proper selection of those who could benefit from different follow-up protocols or adjuvant treatment.

[Local resection in treatment of rectal tumors]. / Lokale Resektion zur Behandlung der rektalen Tumoren.

We treated 160 patients (96 males, 64 females) with a mean age of 66 +/- 12 years. 63 patients presented adenomas (AD) and 97 adenocarcinomas (ADC). In the ADC group 32 patients received preoperative chemoradiation (RT + CT), and 15 postoperative RT. In 7 patients with RT + CT the tumor disappeared. No hospital mortality was recorded. Morbidity was observed in 13% of AD group and 18% of ADC group. Hospital stay was less than 7 days for 72% of patients. Stages were: 10 pTis, 40 pT1, 29 pT2, 18 pT3. Recurrence was observed in 7 (11%) of AD and 23/97 ADC (24%). 0 pTis, 12% pT1, 24% pT2, 61% pT3. No patient with RT + CT and negative margins had recurrence with a minimum follow-up of 2 years (11 patients). Five-year cumulative survival was 100% for pTis, 92% for pT1, 75% for pT2 and 69% for pT3.

[Transverse minilaparotomy as an access route in right colon disease: a valid alternative to midline laparotomy]. / La minilaparotomia trasversale come via di accesso nella patologia del colon destro: una valida alternativa alla laparotomia mediana.

AIMS OF THE STUDY: 1. To evaluate the feasibility and appropriateness of transverse right minilaparotomy for right colectomy and lymphadenectomy. 2. To identify the clinical advantages, if any, of this access route compared to the more traditional midline incision. PATIENTS: 44 patients with right colon adenocarcinoma undergoing colonic resection via a transverse or midline laparotomy. METHODS: The transverse incision starts 1 cm above the umbilicus, running from the midline to the anterior axillary line. RESULTS: 17 (39%) transverse minilaparotomies and 27 (51%) midline laparotomies were performed, respectively. The mean operative time was 107 min for patients with the transverse incision and 157 min. for those with midline laparotomy. Twelve out of 17 patients (70%) with the transverse incision experienced no or only mild pain as against 11 out of 27 patients (41%) with midline laparotomy. Bowel function was slightly faster in the first group of patients, though the difference was not statistically significant. Forty-seven percent of patients with transverse minilaparotomy were discharged within 8 days postoperatively as against 4% with midline laparotomy (P = 0.001). No major complications occurred in the first group, while 2 patients (7%) operated on via the midline laparotomy experienced complications (haemorrhage, deep venous thrombosis). CONCLUSION: Although this is a preliminary study in only 44 patients, our results support the idea that transverse minilaparotomy is a less traumatic access route to the right colon, in addition to offering an adequate exposure of the operative field, faster postoperative recovery and a shorter hospital stay. We believe it to be a good alternative to midline laparotomy for right colon surgery.

[Antibiotic prophylaxis in the surgical treatment of inguinal hernia: need or habit?]. / La profilassi antibiotica nel trattamento chirurgico dell'ernia inguinale: necessità o abitudine?

BACKGROUND: Prophylactic antibiotics are recommended for clean-contaminated and selected contaminated surgery. In clean surgery antibiotics are suggested if the operation involves the insertion of prosthetic devices and a potential infection is expected to cause serious morbidity or mortality. Inguinal hernia repair is a clean operation, infections are rare; they can usually be cured without removing the prosthesis and recurrence is uncommon even after removal of the mesh. Aim of the study is to evaluate whether the lack of antimicrobial prophylaxis increases the risk of postoperative infections in patients treated for groin hernia, compared to those treated with prophylaxis. METHODS: One hundred and forty-eight patients underwent inguinal hernia repair with mesh: 64 patients (43%) received 2 g cefotaxime by intravenous bolus about 30 minutes before the operation, 84 patients (57%) did not receive any antimicrobic prophylaxis. Mean follow-up was 13 months (range 1-31 months) for both groups. RESULTS: We did not observe any major complication. Among both groups, no patient had developed infection at one week and one month after surgery. CONCLUSIONS: In personal experience, any advantage in terms of prevention of infections with antibiotic prophylaxis in patients operated on for groin hernia has been observed. A review of the literature showed no general agreement on this subject with different risk of infections in different trials. A new prospective randomized trial is necessary to clarify this topic.

Surgery of rectal tumors.

The results of surgical treatment of carcinoma of the rectum have been improved in the last decades, because of the availability of stapling device, the increasing use of adjuvant or neoadjuvant treatment and the development of endoluminal surgery. Herein we present our thirty years experience in the treatment of rectal carcinoma. It deals with 690 patients operated on, 602 with conventional surgery (87%) and 88 with local excision (13%). As regards the first subgroup, in 63 patients (10.4%) the operation was considered palliative, because there were either hepatic metastases or residual tumor; 21% of the whole number had tumor in the upper third, 40% in the middle third and 39% in the lower third. Radical resection was performed in 538 patients (89.6%); 53% of the patients underwent anterior resection and 47% underwent abdomino-perineal resection. Ninety percent of tumors located in the lower rectum were managed with abdomino-perineal resection and 97% of tumors located in the upper rectum were managed with anterior resection. Tumor of the middle rectum were treated indifferently with anterior resection or abdomino-perineal resection. Mortality was 4%; the morbidity was 33%. No statistical difference was found between anterior resection and Miles operation. Mean follow up is 6.8 years. Local recurrence was observed in 17% of patients and was more frequent after Miles operation than after anterior resection. The 5- and 10-year survival is respectively 53% and 43%; according to staging, 5-year survival is 68% for stage I, 64% for stage II, 39% for stage III and 9% for stage IV (p < 0.0001). As regard local excision, lesions usually arised from lower or middle rectum and were less than 3 cm. in the maximum diameter. Sixty per cent of patients received adjuvant or neoadjuvant treatment; we observed complete response with disappearance of the tumor in 28% of T2 patients. The toxicity was low: 3% of patients developed erithema and 21% different grades of proctitis. Mean duration of operation was 179 +/- 98 min' and hospitalization was less than 7 days in most of the patients. No mortality was recorded, while morbidity was 16% (14 patients). On pathological examination we observed 10 Tis (11%), 32 T1 (36%)28 T2 (32%) and 18 T3 (21%). Mean follow up is 3.3 years; local recurrence was related to staging and was respectively 0%, 16%, 25% and 61% (p = 0.0008). We did not observe local recurrence whenever T2 patients had neoadjuvant treatment and negative margins at i.o. pathological examination. Our findings show that anterior resection represents the most appropriate treatment for tumors of the upper and middle rectum; Miles operation should be reserved to tumors located within 5 cm. from the anal verge. Small tumors, confined to the rectal wall, can be properly treated with local excision; local treatment should be always associated to preoperative chemoradiation in tumors involving the muscular layer of the rectal wall.

[Carotid body tumors. Apropos a case and a review of the literature]. / Tumori del glomo carotideo. A proposito di un caso e revisione della letteratura.

Chemodectomas are rare tumors arising from paraganglionic cells located at the level of carotid bifurcation. They are usually benign and non functioning, presenting as a slow growing cervical mass. A preoperative diagnosis is mandatory, based on doppler color flow imaging and angiography. Surgery is the only therapy providing total eradication of this tumor. Subadventitial resection is the most established technique, although resection of a large mass may require carotid replacement by interposition graft. Cranial nerve palsy and stroke are the perioperative complications most frequently encountered. The Authors report here a case of carotid body tumor and a review of the literature in order to define clinical characteristics of the tumor and proper diagnostic and therapeutic approaches to this rare neoplasm.

[An appendiceal-vesical fistula in a patient with cystic fibrosis]. / Fistola appendico-vescicale in un malato di fibrosi cistica.

Cystic fibrosis is an hereditary disease in which abnormally viscous secretion of exocrine glands causes chronic pulmonary infections and gastrointestinal disorders. The authors report the case of a patient with cystic fibrosis and appendicitis complicated by appendico-vesical fistula. The appendico-vesical fistula has been described during appendicitis; its association with the cystic fibrosis however has never been reported in the literature.

The role of surgery in the treatment of primary gastric lymphoma.

BACKGROUND: The aim of the study was to analyze the results of surgical treatment in early and advanced primary gastric lymphoma and to evaluate predictive factors for long-term outcome. MATERIAL AND METHODS: A retrospective study of 92 patients resected for primary gastric lymphoma was conducted. Sixty-eight (74%) patients underwent a curative resection 10 (11%) patients had palliative resection and 14 (15%) patients were deemed unresectable: 33 patients (36%) had a stage IE tumor, 12 (13%) stage IIE1, 22 (24%) IIE2 and 25 (27%) stage IVE. RESULTS: Follow-up ranged from 1 to 336 months (means 44 +/- 70 months, median 18 months). Cumulative actuarial 10-year survival rate was 49.1%. Ten-year actuarial survival rates were 78.9% for stage IE and 100% for stage IIE1 whereas 5-years survival rates were 0% for stage IIE2 and 21.7% for stage IVE (P < 0.00001). CONCLUSION: Surgical treatment is the front line therapy for IE and IIE1 stages of primary gastric lymphoma.

[Sarcomatoid renal carcinoma. A case report]. / Il carcinoma renale sarcomatoso. Presentazione di un caso.

Renal sarcomas are rare tumors. Prognosis is overall dismal. Adjuvant therapies should follow radical nephrectomy but no standardized regimen has been at present defined. We report a case of a patient affected by a sarcomatoid renal tumor to detect the best therapeutic approach to this rare tumor.

[Nodular fasciitis: a case arising from the splenius cervicis muscle]. / La fascite nodulare: un caso del muscolo splenio del collo.

An unusual case of nodular fasciitis, arising from the splenius muscle, is presented. This uncommon lesion is always benign, but a local spread in the surrounding muscular tissue is possible. Through a Literature review, the main pathological, clinical and therapeutic features are discussed.

Renal carcinoma with a solitary synchronous contralateral adrenal metastasis: a case report.

A case of synchronous contralateral adrenal metastasis of renal cell carcinoma occurring in a 64-year-old male is reported herein. The patient underwent a left transperitoneal nephrectomy for renal cell carcinoma and right adrenalectomy. The postoperative course was uneventful. To our knowledge this is the 14th case of contralateral adrenal metastasis of renal cell carcinoma in the international literature.

[Localized fibroma: a rare tumor of pleural origin]. / Il fibroma localizzato: un raro tumore ad origine pleurica.

Localized fibroma represents a rare entity arising from the pleura. Currently its histogenesis and clinical behaviour are still controversial. A case of a 64-year-old male is here presented; clinical and histopathological features are then discussed on the basis of a review of the Literature. At present, an en-bloc resection of the tumor, including wide margins of the surrounding lung tissue, seems to be the most appropriate surgical choice.

[Retroperitoneal schwannoma: report of a clinical case and review of the literature]. / Lo schwannoma a localizzazione retroperitoneale: descrizione di un caso clinico e revisione della letteratura.

The retroperitoneal localization of a schwannoma or neurilemmoma undoubtedly represents an unusual occurrence (0.5-0.7% of all sites); this data, together with the absence of a typical clinical picture and the lack of peculiar instrumental signs, make a preoperative diagnosis of this lesion really hard to ascertain. In this paper, on the basis of a case report successfully treated, the Authors review the literature analysing current diagnostic and therapeutic work up, mainly emphasizing controversies in determining a proper preoperative diagnosis among all retroperitoneal tumours.

[Caroli's disease: 2 case reports and review of the literature]. / La malattia di Caroli: descrizione di due casi clinici e revisione della letteratura.

The most appropriate management of Caroli's disease is still controversial: in fact many surgical modalities have been proposed for patients exhibiting cholangitis or intrahepatic lithiasis, but these approaches have been seldom performed on asymptomatic or oligosymptomatic patients. However, this figure, due to the surgical risk related with a bilio-enteric anastomosis or with an hepatic resection, should be always compared with the possible development of a cholangiocarcinoma within the enlarged biliary tree (7%), as clearly shown in the 2 cases herein reported.

[Clinical and therapeutic features of MEN II]. / Aspetti clinico-terapeutici nelle MEN II.

Multiple Endocrine Neoplasia type 2 is a genetically transmitted poliendocrinopathy, in which pheochromocytoma (PCC), medullary thyroid carcinoma (MTC) and parathyroid disease may occur and coexist with different rates. Although the clinical behaviour of each component is well known and usually predictable, controversies still exist on the most appropriate therapeutical strategy when patients exhibit synchronous lesions; many elements may influence this choice: the evidence of bilateral (PCC) or multicentric (MTC) lesions, the evaluation of their malignancy, the adoption of therapies other than surgery (alpha receptor blockers in PCC). In this paper the Authors report their experience in diagnosing and treating MEN 2; it is based on 5 patients operated from 1972 to 1993 and on the screening of their relatives for thyroid and/or adrenal lesions. The individual manifestations of the disease, with regard to time and extent of organ involvement, are considerably variable; however, an aggressive approach of MTC, even in presence of a synchronous PCC, as well as a unilateral adrenalectomy (with a close follow up of the patient) when surgical exploration does not show an involvement of the remaining gland, is suggested.

Local excision of rectal tumours with transanal endoscopic microsurgery.

Transanal Endoscopic Microsurgery (TEM) is a novel technique, first introduced by Buess and coworkers in 1983 for the treatment of large sessile polyps of the rectum. Due to the excellent results the indication was then extended also for the removal of low risk early adenocarcinomas (pT1, G1-G2). TEM allows, by using an operative proctoscope of an outside diameter of only 4 cm., all the conventional surgical manoeuvers within the rectal lumen, up to 20 cm. from the anal verge. The Authors report a consecutive series of 53 patients submitted to TEM over a 37 month period; apart from 7 patients excluded for different reasons, postoperative diagnosis showed 30 adenocarcinomas (65.2%), 15 adenomas (32.6%) and 1 epidermoidal carcinoma (2.2%). The low recurrence rate observed both for adenomas (0%) and pT1 adenocarcinomas (9%) coupled with the optimum vision allowed by the 6-fold magnified stereoscopic view, make this technique the method of choice for selected patients with these kind of pathologies.