Laparoscopic complete mesocolic excision with central vascular ligation in right colon cancer: Long-term oncologic outcome between mesocolic and non-mesocolic planes of surgery.

AIM: To analyze our experience in translating the concept of total mesorectal excision to "no-touch" complete removal of an intact mesocolonic envelope (complete mesocolic excision), along with central vascular ligation and apical node dissection, in the surgical treatment of right-sided colonic cancers, comparing "mesocolic" to less radical "non-mesocolic" planes of surgery in respect to quality of the surgical specimen and long-term oncologic outcome. METHOD: A total of 115 patients with right-sided colonic cancers were retrospectively enrolled from 2008 to 2013 and operated on following the intent of minimally invasive complete mesocolic excision with central vascular ligation. RESULTS: Morbidity and mortality were 22.6% and 1.7%, respectively. Mesocolic, intramesocolic, and muscularis propria planes of resection were achieved in 65.2%, 21.7%, and 13% of cases, respectively, with significant impact for mesenteric plane of surgery on R0 resection rate (97.3%), circumferential resection margin <1 mm (2.6%), and consequent survival advantage (82.6% at 5 years) when compared to muscularis propria plane of surgery, with R0 resection rate and overall survival falling to 72% and 60%, respectively, and with circumferential resection margin <1 mm raising to 33.3%, all being statistically significant. Stratifying patients for stage of disease, laparoscopic complete mesocolic excision with central vascular ligation significantly impacted survival in patients with stage II, IIIA/B, and in a subgroup of IIIC patients with negative apical nodes. CONCLUSION: In our experience, minimally invasive complete mesocolic excision with central vascular ligation allows for both safety and higher quality of surgical specimens when compared to less radical intramesocolic or muscularis propria planes of "standard" surgery, significantly impacting loco-regional control and thus overall survival.

Stage I-IIIC right colonic cancer treated with complete mesocolic excision and central vascular ligation: quality of surgical specimen and long term oncologic outcome according to the plane of surgery.

AIM: Complete removal of mesocolon "as an envelope" (complete mesocolic excision, CME) with central vascular ligation and apical node dissection (CVL) in the surgical management of right sided colonic cancer is a novel technique focused on resection of the colon surrounded by its intact primitive dorsal mesentery containing the tumors and all the routes of initial cancerous diffusion; our aim was to evaluate quality of surgical specimens and the relative impact on long-term oncologic outcome when compared to less radical planes of surgery. METHODS: Data were collected in 159 staged I-IIIC right sided colon cancers operated on with the concept of CME and CVL, between 2008 and 2013. RESULTS: Morbidity and mortality were 37.7% and 1.9% respectively. Overall and disease free survival were 80.5% and 69.8% at five years. Mesocolic, intramesocolic and muscolaris-mucosa planes of resection were achieved in 64.7%, 22.6% and 12.5% of cases, respectively: mesocolic plane of surgery impacted significantly on R0 resection rate (98%), CRM<1 mm (2.9%) and overall survival (81.5% at 5 years) when compared to muscolaris propria plane of surgery, with R0 resection rate and 5 years survival falling to 65% and 60%, respectively, and CRM<1 mm rising to 35%, being all statistically significant; statistical difference was also recorded for intramesocolic plane of resection, with survival, R0 resection rate and CRM<1 mm of 72.2%, 86.1% and 13.8%, respectively. Stratifying patients for stage of disease, CME with CVL significantly improved survival in stage II, IIIA/B and in a subgroup of IIIC patients, with not metastatically involved apical nodes. CONCLUSION: CME with CVL follows the oncologic principle based on resection of the primitive embryological mesenterium as an intact envelope, along with central lymphadenectomy up to the apical nodes, translating in higher surgical specimens quality and significant impact on locoregional control and overall survival when compared to less radical planes of surgery.

Anastomotic leaks after anterior resection for mid and low rectal cancer: survey of the Italian Society of Colorectal Surgery.

BACKGROUND: The aim of the survey was to assess the incidence of anastomotic leaks (AL) and to identify risk factors predicting incidence and gravity of AL after low anterior resection (LAR) for rectal cancer performed by colorectal surgeons of the Italian Society of Colorectal Surgery (SICCR). METHODS: Information about patients with rectal cancers less than 12 cm from the anal verge who underwent LAR during 2005 was collected retrospectively. AL was classified as grade I to IV according to gravity. Fifteen clinical variables were examined by univariate and multivariate analyses. Further analysis was conducted on patients with AL to identify factors correlated with gravity. RESULTS: There were 520 patients representing 64% of LAR for rectal cancer performed by SICCR members. The overall rate of AL was 15.2%. Mortality was 2.7% including 0.6% from AL. The incidence of AL was correlated with higher age (p<0.05), lower (<20 per year) centre case volume (p<0.05), obesity (p<0.05), malnutrition (p<0.01) and intraoperative contamination (p<0.05), and was lower in patients with a colonic J-pouch reservoir (p<0.05). In the multivariate analysis age, malnutrition and intraoperative contamination were independent predictors. The only predictor of severe (grade III/IV) AL was alcohol/smoking habits (p<0.05) while the absence of a diverting stoma was borderline significant (p<0.07). CONCLUSION: Our retrospective survey identified several risk factors for AL. This survey was a necessary step to construct prospective interventional studies and to establish benchmark standards for outcome studies.

[Splenic artero-venous fistula and portal hypertension. A case report with review of the literature]. / Ipertensione portale secondaria a fistola artero-venosa splenica. Descrizione di un caso clinico e revisione della letteratura.

Splenic artero-venous fistula (SAVF) is a rare but potentially curable cause of pre-hepatic portal hypertension. About 100 cases have been reported in the world medical literature. The Authors report a case of 46-year-old man with a splenic artery aneurysm and a large SAVF treated by surgical resection of splenic vessels and splenectomy. The literature about SAVF is reviewed to recognize etiology, anatomical location, main symptoms at presentation, diagnostic findings and management of this rare syndrome.

Gastrointestinal autonomic nerve tumor: case report and review of the literature.

Gastrointestinal autonomic nerve (GAN) tumor is an uncommon specialized form of gastrointestinal stromal tumor (GIST). We report the case of a 46-year-old man affected by this tumor. The neoplasm arose from the sigmoid colon. The patient underwent surgery but eight months later an omental relapse occurred. A second laparotomy was successfully performed and the patient is free of disease at 21 months of follow-up. To our knowledge this is the first case of a large bowel GAN tumor described in the literature.

[Combined intra-arterial locoregional and systemic treatment of nonresectable hepatic metastases of colorectal carcinoma]. / Trattamento combinato locoregionale intra-arterioso e sistemico delle metastasi epatiche non resecabili da carcinoma del colon-retto.

Intra-arterial hepatic chemotherapy (LAHC) results in significantly higher response rate than the best systemic treatment of liver metastases from colorectal cancer, but no survival advantage has to date shown because of extra-hepatic progression. From June 1991 to December 1994, twenty patients with hepatic metastases from colorectal cancer were enrolled. All patients underwent laparotomy for the placement of an intra-arterial catheter into the gastroduodenal artery connected with a subcutaneous port. All patients underwent cholecystectomy and biopsy of liver lesion to confirm metastatic disease. Locoregional schedule was: 5-fluorouracil (5FU) 500 mg/sqm, epirubicin (EPI) 13 mg/sqm, mitomycin-C (MMC) 7 mg/sqm, in bolus every 3 weeks. Systemic therapy consisted of leucovorin 500 mg/sqm, over 2 hours and 5FU 600 mg/sqm in bolus every week. Treatment was planned over a six month period. The complete response (CR) plus partial response (PR) rate was 50% of the entire group. The median survival was 18 months and 1- and 2- and 3-year survival rates were 71%, 38% and 20% respectively. Prior to chemotherapy, LDH value and % of liver involvement were the only significant prognostic parameters. Toxicity was absent or mild and no patient stopped treatment because of side effects. Combined systemic and IAHC is an effective treatment for liver metastases from colorectal cancer, with a mild or moderate toxicity. However, more trials are needed, to improve the control of the extrahepatic disease.

[Sequential endoscopic and laparoscopic and one-step treatment of cholecysto-choledochal calculosis. New perspectives for the surgeon]. / Il trattamento sequenziale endoscopico e laparoscopico ed in tempo unico della calcolosi colecisto-coledocica. Nuove prospettive per il chirurgo.

The Authors describe 132 cases of sequential treatment of cholecysto-choledochal lithiasis by videolaparoscopic cholecystectomy after endoscopic Common Bile Duct (CBD) clearance and 3 endoscopic sphincterectomy and CBD stone extraction during laparoscopic cholecystectomy. No complications occurred during the procedure. Even though the second one is not a routine method undoubtedly represents the best solution when the surgeon meets an unexpected choledocholithiasis. However, laparoscopic CBD exploration requires a good experience of the surgeon and currently there are not sufficient data to support this procedure.

[Resection surgery in malignant neoplasms of the exocrine pancreas: our experience, 1987-1994]. / La chirurgia resettiva nelle neoplasie maligne del pancreas esocrino: nostra esperienza 1987-1994.

From 1987 to 1994, 24 patients underwent resection for pancreatic cancer; they represented 24% of all patients observed in that period. Surgical procedures were a pancreatoduodenectomy (PD) in 20 cases, a distal pancreatectomy in 4 cases, a palliative intervention in 61 cases, an exploratory laparotomy in 13 cases and a video laparoscopy in 2 cases. Adjuvant treatments were given in addition to resection in 20 patients. In the 20 patients undergoing PD, mortality was 20% and morbidity 20%. There was no mortality and no morbidity in distal pancreatectomy. The 1-year survival in pancreatoduodenectomy was 50% and 0% for distal pancreatectomy. Pancreatic resection, radical and palliative, whenever technically possible, represents the treatment of choice for pancreatic cancer.

[Long-term survival of patients operated on for carcinoma of the lung (author's transl)]. / La sopravvivenza a lungo termine degli operati per carcinoma del polmone.

The long-term fate of patients treated surgically for carcinoma of the lung is not well known. In a careful review of the literature the authors found only nine papers with a postoperative followup of at least 10 years; the mean survival was 16,3% of patients so treated. Factors making for a good long-term prognosis include small initial tumor size, absence of mediastinal lymph node invasion, a favorable histologica type, and the type of surgery performed (partial exeresis). Translated into TNM code, this means that the best candidates for prolonged survival are patients with lung carcinoma of the squamous cell type, stage I, treated by limited lung exeresis.

[Carcinoma of the appendix. Presentation of one clinical case and review of the literature (author's transl)]. / Il carcinoma dell'appendice. Presentazione di un caso clinico e revisione della letteratura.

After presenting one case of carcinoma of the appendix of their own observation, the authors discuss several aspects of the anatomopathology, clinical course, and diagnosis of tumors of the appendix. From a review of existing literature it emerges that no case of carcinoma of the appendix was ever diagnosed preoperatively. The authors evaluate the difficulties inherent in such diagnosis and recommend some means of investigation that are currently applied to other organs.

[Percutaneous transhepatic biliary drainage]. / Il drenaggio biliare transepatico-percutaneo.

The authors describe their experience in 23 cases of biliary tract drainage by the transhepatic-percutaneous approach in the course of obstructive jaundice of diversified origin. This can be done for essentially three reasons, namely to alleviate jaundice preoperatively, to provide permanent bile drainage in patients not amenable to surgery, and to relieve excess pressure in surgical anastomoses of the biliary passages. On the basis of biological considerations (relationship between severity and duration of cholestasis on the one hand and postoperative mortality and morbidity on the other), and in light of their own results, the authors argue in favor of this procedure, explaining that it is only mildly traumatic to the patient, easy to perform, attended by a low quota of complications, and above all effective as a drainage; also, it does not unduly prolong the preoperative period for patients scheduled for further and major surgery. Also in view of the current role of PTC in the diagnosis of obstructive jaundice, they submit that transhepatic-percutaneous drainage should be done right next to recognition of dilatation of the intrahepatic bile passages by CAT or echotomography.