Open sphincter-preserving surgery of extraperitoneal rectal cancer without primary stoma and Fast Track Protocol.

AIM: Fast track protocol (FTP) showed to improve perioperative care. The study aims to evaluate the impact of the FTP in the open extraperitoneal rectal cancer (ERC) surgical treatment without a primary derivative stoma (DS) and the QoL in patients with or without a secondary DS. PATIENTS AND METHODS: 50 patients affected by ERC were enrolled and operated on with open low anterior resection without a primary DS. They were randomized in two groups: one was treated perioperativelly in the traditional way (group T), the other using a modif ed FTP (group FT). A QoL questionnaire was administered prior to discharge and at 1-month follow-up. RESULTS: Five courses (10%) were complicated by anastomotic leakage: 3 (12%) in the FT group (2 minor and 1 maior) and 2 (8%) in the T group (1 minor and 1 maior) (p=n.s.). All the maiors and one minor were treated with a DS. Patients of the group FTP were considered dischargeable earlier that those of group T (p<0.05). Patients with DS had a significantly lower QoL score (p<0.0001). CONCLUSION: FTP with minor modifications is feasible and safe in the ERC open surgery without using a DS. Better results were obtained without increasing complication rate. A secondary DS impacts detrimentally on QoL.

From mininvasive to maxinvasive surgery in colorectal cancer: modem evolution of oncologic specialized units.

In the last years a wide range of new technique offers the possibility to have R0 resection in colorectal cancer. We report our experience about Single Port Laparoscopic Surgery (SPL) for not advanced right colon cancer and about pelvectomy with cilindric Abdominal Perineal Resection (APR) for advanced rectal cancer. SPL offer mainly cosmetic advantages but also quicker recovery. No touch technique with adequate surgical margin and lymphectomy were respected. Operative time of SPL was 85-115 minutes, the incision was 5 cm long. There were no complications. Length of hospital stay was 4-6 days. With advanced pelvic cancer, pelvic exenteration with en-bloc resection is indicated. Then we propose a case of a 55 years old woman with a pelvic recurrence from a metastatic rectal cancer involving the right obturator fossa, the vaginal stump, the right ureter. Modern surgical technique give us the chance to offer the most appropriate oncologic surgical treatment.

Thromboelastographic profiles as a tool for thrombotic risk in digestive tract cancer.

BACKGROUND: Quantification of the magnitude of thrombotic risk associated with malignancy and with anti-cancer therapy is indispensable to use anticoagulant drugs which selectively interfere with haemostatic mechanisms protecting patients from venous thromboembolism (VTE) and probably from tumor progression. However, none of activation coagulation markers has any predictive value for the occurrence of the thrombotic events in one individual patient. Current clotting methods can't reveal the overall dynamic clot formation; in contrast thromboelastographic methods specifically assess overall coagulation kinetics and its strength in whole blood. AIM: Objective of study was to evaluate if the activation of coagulation as eventually revealed by ROTEM thromboelastometry could assess an hypercoagulable state in surgical neoplastic patients. PATIENTS AND METHODS: Fifty consecutive patients with carcinoma of the digestive tract in preoperative period (23 M, 27 F aging 61.5 (45-79 years) and 147 healthy subjects (71 M, 76 F) were studied. A recent thromboelastometric method based on thrombelastography after Hartert was employed. Measurements were performed on ROTEM Coagulation Analyzer. The continuous coagulation data from 50 min course were transformed into dynamic velocity profiles of WB clot formation. RESULTS: Standard parameters (CT, CFT, MCF) of cancer patients were similar to controls. CT (in cancer patients): females 50 s (38.3-58.7), males 50 s (42-71.2) vs 51 s (42-59), p = 0.1210 / 53 s (42-74.8), p = 0.1975 (in controls). CFT (in cancer patients): females 72 s (32- 92.4), males 80 s (50.2- 128.7) vs 78 s (62-100), p = 0.0128 / 80 s (59-124.4), p = 0.9384 (in controls). MCF (in cancer patients): females 70 mm (59.9-82.5), males 63 mm (56-73.7) vs 69 mm (59-95.8), p = 0.9911 / 69 mm (53.6-90), p = 0.0135 (in controls). Females showed a higher MaxVel when compared to males. The MaxVel was increased in cancer patients: females 19 mm /100 s (14.3-49.5) males 18 mm / 100 s (11-27) vs 15 mm 100 s (11.8-22), p < 0.001 / 13 mm / 100 s (10-21.8), p < 0.001 in controls. The t-MaxVel was shortened in cancer patients: females 65s (48.6-112.8), males 81s (50.1-135.9) vs 115s (56.8-166), p < 0.001 / 115 s (59.8-180.8), p = 0.0002 in controls. The AUC was increased in cancer patients: females 6451 mm 100(5511-8148), males 5984 mm 100 (5119-6899) vs 5778 mm 100 (4998-6655), p < 0.001 / 5662 mm 100 (4704-6385), p = 0.0105. CONCLUSION: Unlike other assays measuring variations in a single component during coagulation, the thrombelastographic method records a profile of real-time continuous WB clot formation, and may provide extensive informations on haemostasis in neoplastic patients before surgery.

[Salvage surgery in the treatment of massive abdominal recurrence of uterine leiomyosarcoma. Clinical case]. / Chirurgia di salvataggio nel trattamento di massiva recidiva endoaddominale da leiomiosarcoma uterino. Caso clinico.

Uterine leiomyosarcomas carry a dismail prognosis. Diagnosis is often an unexpected pathology discovery after hysterectomy for fibroma. Prognosis depends on the degree of locoregional extension and thus on early diagnosis. Extended surgery in case of relapse is sometimes the only possible approach for symptoms control and improvement of quality of life. A case of massive involvement of the abdomen by a relapsed uterine leiomyosarcoma treated by extreme surgery is here presented.

[Early evaluation using PET-FDG of the efficiency of neoadjuvant radiochemotherapy treatment in locally advanced neoplasia of the lower rectum]. / Valutazione precoce con PET-FDG della efficacia del trattamento radiochemioterapico neoadiuvante nelle neoplasie del retto inferiore localmente avanzate.

BACKGROUND AND PURPOSE: Preoperative chemoradiation allows downstaging of locally advanced rectal cancer and in selected patients also a sufficient downsizing to ensure sphincter preservation. Selection of patients warranting a preoperative approach is improved by magnetic resonance imaging (MRI) which is able to define the involvement of mesorectal circumferential margin. Similarly it would be crucial to define the response to chemoradiation during the treatment but traditional morphologic imaging techniques may fail in differentiating neoplastic tissue from scarring. PET-FDG has been successfully used in the detection of metastatic colorectal cancer allowing imaging of deposits as small as 0.5 cm and may have a role in evaluating early response to chemoradiation. METHODS: In the present study, in patients with T3-T4 rectal cancer undergoing preoperative chemoradiation PET-FDG and flow cytometry analysis on endoscopic biopsy specimen have been performed before, during and after preoperative chemoradiation. RESULTS: Chemoradiation treatment has been successful in terms of downsizing and downstaging of the tumor. PET-FDG was able to demonstrate local response at only ten-fifteen days after the beginning of neoadjuvant therapy, also identifying non responding patients. CONCLUSIONS: FDG-PET may have a role in defining the response to chemoradiation and modulate the treatments strategy in patients with advanced rectal cancer.

[New thrombophilia markers in digestive tract neoplasia]. / Nuovi marcatori di trombofilia nelle neoplasie del tratto digestivo.

Haemostatic system compounds not routinely studied, have been evaluated to define the individual risk of VTE (venous thromboembolism) and to influence the prognosis using selective drugs. Significantly high values of fibrinogen, free-TFPI, F1 + 2 fragments and TAT complexes on coagulation side and PAI-1 and TAFI on fibrinolysis side have been detected. Thrombin seems to have a role in the inhibition of TAFI dependent fibrinolysis not inhibited by heparin.

[Surgical indications in the phlebopathic patient. The role of air plethysmography]. / L'indicazione chirurgica nel paziente flebopatico. Ruolo della pletismografia ad aria.

A previous history of deep venous thrombosis (DVT) must be carefully evaluated in every patient affected by chronic venous insufficiency (CVI); the assessment of deep venous system patency is the goal of preoperative diagnosis. Air plethysmography examination allows an outpatient noninvasive testing of calf pump function and deep venous outflow. The authors report the results of a study on 37 patients (40 limbs) with a previous history of DVT, suffering from CVI; in 18 limbs air plethysmography showed a marked increase of calf volume on test exercise, suggesting residual venous obstruction. The authors believe that air plethysmography examination is mandatory before operation in patients with a previous history of DVT.

[Surgical options in the palliative treatment of pancreatic cancer]. / L'approccio chirurgico nella palliazione del carcinoma pancreatico.

Pancreatic carcinoma is an aggressive disease and its prognosis is dismal. Patients present with an advanced stage of disease and only a small number of patients undergo resection with a curative intent; thus the 5 years survival rate is very low. Several improvements have been made in the surgical approach with a decrease in perioperative morbidity and mortality. Results offered by chemotherapy and radiotherapy remain unsatisfactory despite a number of new drugs and considerable advancements in irradiation techniques. Jaundice, pain and gastrointestinal obstruction are the main clinical problems to be dealt with in advanced patients. Surgical palliation still represents a widely preferred option but non surgical approaches appear promising. The Authors analyse the possible options in palliation for pancreatic carcinoma. The various surgical procedures for biliary by-pass are described. Hepaticojejunostomy is the operation of choice and offers the best results in terms of quality of life and time of palliation. A possible role for resective operation also in advanced cases has been proposed by some groups and is gaining wide acceptance in referral centres where low morbidity and mortality are now routine. Percutaneous and endoscopic approaches to jaundice represent a valid alternative in some patients with a low life expectancy and in those centres with a high experience. Gastrointestinal by-pass in symptom-free patients or advanced cases only is an unsolved dilemma. New approaches such as locoregional chemotherapy with curative or neoadjuvant intent are also described in this paper. Many chemotherapic agents have been tested in various settings and appear to offer promising results in palliation and also, in some cases, in downstaging tumors then amenable to resection. Pain control is a major aspect in management of advanced pancreatic carcinoma. Appropriate pain therapy has to be established in all patients in order to obtain a better quality of life. Various options are available such as intraoperative alcohol injection or CT guided percutaneous splanchnicectomy. Palliation in patients with pancreatic carcinoma is a major aspect of management because of the high percentage of non curable cases; multimodality approach is mandatory and all possible problems have to be dealt with in order to increase survival and, more importantly, quality of life.

[Magnetic resonance in the study of suprarenal neoplasms. Qualitative and quantitative analysis of signal intensity]. / La Risonanza Magnetica nello studio delle neoplasie surrenaliche. Analisi qualitativa e quantitativa dell'intensità del segnale.

INTRODUCTION: Magnetic Resonance Imaging (MRI) has been proposed as the diagnostic technique of choice to characterize adrenal tumors. However, the results of the current studies are controversial. MATERIAL AND METHODS: Forty-nine patients with unilateral adrenal masses were submitted to MRI for lesion characterization on the basis of MR signal intensity. Cytology and/or histology demonstrated 14 pheochromocytomas (pheos), 11 adenomas, 3 cysts, 2 myelolipomas, 4 carcinomas, 3 metastases and 1 fibrosarcoma; a clinical diagnosis of adenoma was made in the remaining 11 patients. MR studies were performed using spin-echo (SE) sequences with T1 (TR/TE = 600/17 ms) and T2 (TR/TE = 2000/15-90 ms) weighting. T1-weighted images were also acquired after Gadolinium-DTPA (Gd-DTPA) administration. MR studies were integrated with in- and out-of-phase (TR/TE = 100/4-6 ms) chemical-shift (CS) sequences. MR signal intensity (SI) was analyzed qualitatively and quantitatively; MR results were correlated with tumor type and hormone secretion. RESULTS: The qualitative analysis of T2 images showed high signal intensity in the majority (80%) of adrenal lesions (14 pheos, 12 adenomas, 3 cysts, 2 myelolipomas and 8 malignancies). The quantitative analysis of post-Gd-DTPA T1 images permitted to distinguish adenomas, cysts and myelolipomas from pheos and malignancies. The qualitative analysis of post-Gd-DTPA T2 and T1 images permitted to distinguish pheos and cysts from adenomas and malignancies (p < .05); however, pheos and cysts as well as adenomas and malignancies were not differentiated. MR SI was similar in secreting and nonsecreting adenomas from both a qualitative and a quantitative viewpoints. CS MRI permitted to distinguish adenomas (decreased signal intensity on out-phase relative to in-phase images) from other benign and malignant lesions (no signal change from out-phase to in-phase images). CONCLUSIONS: The qualitative analysis of MR SI on conventional T1 and T2 images does not permit to differentiate adrenal masses. The qualitative evaluation of T1 images after Gd-DTPA administration, the quantitative analysis and CS sequences are technical options improving lesion characterization.

Outcome of 67 patients with hepatocellular cancer detected during screening of 1125 patients with chronic hepatitis.

OBJECTIVE: We performed this prospective screening trial in chronic hepatitis virus-infected patients to determine the incidence of hepatocellular cancer (HCC) and the resectability and long-term survival rates of these HCC patients. SUMMARY BACKGROUND DATA: Chronic hepatitis B or C virus infection is a major etiologic factor in human HCC. It is not clear if routine screening of chronic viral hepatitis patients improves the survival of patients who develop HCC. METHODS: Screening for HCC was offered to patients chronically seropositive (>5 years) for hepatitis B or C infection. All patients underwent percutaneous core liver biopsy to assess the histologic severity of chronic liver injury. Patients were screened initially and every 3 months thereafter with serum alpha-fetoprotein and transabdominal ultrasound evaluations; HCC was confirmed by needle biopsy of liver tumors. RESULTS: Screening was performed on 1125 hepatitis-positive patients (804 with hepatitis C, 290 with hepatitis B, 31 with both). On liver biopsy, 800 patients had mild chronic active hepatitis and 325 had severe chronic active hepatitis, cirrhosis, or both. Initial screening detected HCC in 61 patients. HCC was detected in six more patients during follow-up; thus, the incidence of HCC was 5.9% (67/1125). However, 66 of the 67 HCC cases (98.5%) arose in the 325 patients with severe chronic active hepatitis or cirrhosis (66/325 [20.3%] vs. 1/800 [0.1%], p < 0.0001 [Wilcoxon signed rank]). Median follow-up of the 67 HCC patients was 24 months. Locally advanced or metastatic, unresectable HCC occurred in 43 patients (64.2%); 24 patients (35.8%), including the 6 patients detected during follow-up screening, underwent margin-negative resection. The median survival for the 24 resected patients was 26 months, compared to 6 months for the 43 patients with unresectable cancer (p < 0.0001, Wilcoxon signed rank). CONCLUSIONS: HCC was found to arise in 20.3% of patients with chronic hepatitis B or C infection and severe liver injury. Initial screening detected resectable lesions in less than half the HCC patients. Routine screening of chronic hepatitis B or C virus-infected patients with ultrasound and alpha-fetoprotein determination should be reserved for patients with severe chronic active hepatitis, cirrhosis, or both.

[Ambulatory phlebectomy. Literature review and personal experience]. / La flebectomia ambulatoriale. Revisione della letteratura ed esperienza personale.

Outpatient varicose veins surgery, "Phlébectomie Ambulatoire" (FA) introduced by R. Muller in 1966, is now a widespread technique; modified by many authors with personal tips, FA enables most lower limb varicosities to be treated on an outpatient basis and under local anaesthesia. To achieve good functional results, an accurate preoperative diagnostic examination is mandatory; the authors present a review of the indications of FA and their personal experience. Precision in performing micro-incisions, accurate dissection of the varicosities in the subcutaneous tissue and an adequate postoperative elastic bandage guarantee good aesthetic results. At present the treatment of Saphena magna with FA is debated, but some authors have already reported encouraging results.

[Outpatient evaluation of venous diseases. Role of instrumental diagnostic methods]. / L'ambulatorio di flebologia. Ruolo della diagnostica strumentale.

Venous investigations have increasingly gained a large part in daily phlebological activity; with the currently available diagnostic tools it's now possible to achieve a "hemodynamic" evaluation in every single patient. This in mandatory for outpatients varicose veins surgery, where sites of reflux must be exactly mapped to avoid unnecessary dissections. The authors present a personal diagnostic protocol (algorithm), they carefully prepared to assess a large number of patients avoiding useless and time-consuming examinations. Results of 100 consecutive examinations are reported; only 15 highly-selected patients required the use imaging techniques studies (echoDoppler, venography). The authors believe that a standardized diagnostic protocol can effectively reduce the number of expensive examinations required and the patients waiting time.

[Stapling reconstruction after gastric resection. Proposed technical variation]. / Ricostruzione meccanica dopo resezione gastrica. Proposta di variante tecnica.

The authors, considering their experience in the use of stapler, suggests a technical modification of the typical gastroenteral anastomosis, to avoid some surgical complications of the mechanical anastomosis. This new technique, using two GIA 80, reproduces an handmade anastomosis. This suture is easy and fast, physiologic and safe.

[Incidence of local recurrences after conservative treatment of breast cancer: critical review of the literature]. / Incidenza delle recidive locali dopo trattamento conservativo per cancro della mammella, revisione critica della letteratura.

The Regional recurrences following breast conservative surgery appear in relation with the type of surgery, the use or not of adjuvant radiotherapy, and the initial staging of the tumor. This review points on prognostic factors conditioning both short and long time prognosis, and the approach to the problem.