Total and subtotal laparoscopic gastrectomy for adenocarcinoma.

BACKGROUND: Laparoscopic gastrectomies are currently performed in many centers, but compliance with oncologic requirements still represents a subject open to debate. The aim of this work was to compare the short-term and oncologic outcomes after laparoscopic and open surgery in gastric adenocarcinoma. METHODS: From June 2000 through June 2005, 147 patients in our institution underwent gastrectomy by open or mininvasive approach for adenocarcinoma. The laparoscopy group included 48 patients, 29 with early gastric cancer (EGC) and 19 with antral advanced gastric cancer (AGC). The short-term results and oncologic data were compared to those obtained in 99 patients who underwent open surgery. Survival in the laparoscopy group was analyzed. RESULTS: In the laparoscopy group no intraoperative complications were observed, and conversion was needed in only one patient with a large advanced tumor. Overall, 32 lymph nodes were collected by D2 dissection, 30 for EGC, 34 for advanced cancers. The resection margin was 6.7 cm (range: 4-8 cm). The mean operating time was 240 min (range: 150-360 min), with a blood loss of 150 ml on average (range: 70-250 ml). Morbidity included two duodenal leaks that healed without reoperation; after enclosing or reinforcing the staple line, no further leaking was noted. There was one death from massive bleeding in a cirrhotic patient. Ambulation and oral feeding started significantly earlier than in open surgery. The mean hospital stay was 10 days (range: 7-24 days), significantly shorter than the stay of 18 days after open surgery (p < 0.05). All patients treated laparoscopically were alive without recurrence at the end of this study. CONCLUSIONS: Short-term results with laparoscopic gastrectomy were better than with open surgery in this study. Oncologic radicality was a major concern, but in the authors' experience the extent of lymphadenectomy was the same as in open surgery. This study suggests that laparoscopic gastrectomy in malignancies is a reliable tool and oncologic requirements can be warranted.

Outcomes of laparoscopic Miles' operation in very low rectal adenocarcinoma. Analysis of 32 cases.

AIMS: Minivasive techniques for excision of low rectal tumours have spread worldwide with good results, but their employment is still under discussion. The purpose of this study is to assess short term results and survival of laparoscopic abdominoperineal resection (LAPR) in very low rectal cancers. METHODS: The charts of 32 patients undergoing LAPR for very low rectal adenocarcinoma (0-2cm from dentata line) were reviewed retrospectively. Outcomes were evaluated considering surgical procedure, short and long-term results and survival. RESULTS: A thorough LAPR was performed in 31 patients and conversion to laparotomy was required in 1 patient. Mean operating time was 244min. The length of hospital stay (LOS) was 13,3days. The mean number of nodes collected was 12 and the distal margin was 3,6cm on average. There was 1 post-operative death. In the follow up no pelvic recurrence was observed, while metachronous metastases were observed in 5 patients and peritoneal carcinosis in 2 patients. No port site metastasis was registered. Cumulative 5year survival probability was 0,50. CONCLUSIONS: The outcomes of this study suggest that LAPR in very low rectal cancer is a reliable procedure, operating time and LOS were acceptable. Oncologic principles were respected: length of specimen, distal margin and number of nodes retrieved were quite acceptable. Pelvic recurrence frequency was nil. Long term results were comparable with those of other series.

Laparoscopic splenectomy: A retrospective review of 75 cases.

Laparoscopic splenectomy (LS) is considered a safe procedure for spleens of normal size as well as for larger spleens. Seventy-five consecutive patients underwent LS. Splenomegaly was defined by diameter >15 cm and by weight >400 g. Thirty patients had splenomegaly. The outcomes with spleens <15 cm and spleens >15 cm were compared. LS was successfully completed in 73 cases (97.4%). Spleens >15 cm required longer operating time and were associated with greater blood loss (P < 0.001), longer hospital stay, and more complications. Two patients needed blood transfusion. No overwhelming postsplenectomy infection was registered, and operative mortality was zero.

[Criteria for training in laparoscopic gastric surgery: guidelines and experience of 30 cases]. / Criteri di apprendimento nella chirurgia laparoscopia delle lesioni gastriche. Proposta di linee guida es esperienzxa di 30 casi.

AIM: Although many studies on laparoscopic surgery of the stomach have been conducted so far, yet they have not provided surgeons with criteria for gradual and safe training with this technique. The results of gastric surgery with 30 patients operated on by laparoscopic approach are hereby described. The aim of this issue is to provide surgeons with guide lines for progressive training, respectful to patients, complying with oncologic criteria and useful to reduce conversion rate or drawbacks at the start of the experience. METHODS: The Authors made a retrospective analysis on 30 patients affected by gastric lesions, 5 benign chronic ulcers and 25 neoplasms of the stomach. Our guide lines suggest that the training begin with the treatment of benign lesions, followed by early gastric cancer (EGC) and by advanced gastric cancer (AGC) of the antrum. Our experience started with 4 laparoscopic subtotal distal gastrectomies (LSGs) for benign ulcer; independent of the guidelines hereby proposed 1 laparoscopic total gastrectomy (LTG) was done after the intraoperative finding of a benign ulcer of the lesser curve penetrating into the left hepatic lobe. The beginning of training included also 1 LSG for distal stromal tumor (GIST). Subsequently 13 early gastric cancers (EGC) were operated on: echoendoscopy could demonstrate 12 T1 m and 1 T1 sm and no evidence of nodal involvement. The diameter of EGCs was 1,3 cm on average ( range 0,7-4 cm), all were marked by Indian ink to allow performance of 10 LSGs and 3 LTGs. Moreover, 8 LSGs for advanced gastric carcinoma (AGC) of the antrum were carried out. The training in malignancies progressed with LTG for 2 non-Hodgkin gastric lymphomas; 1 lymphoma required conversion to laparotomy due to infiltration of the diaphragmatic crus. A D2 lymphadenectomy was associated to gastrectomy in adenocarcinomas. RESULTS: The feasibility of laparoscopic gastric surgery was confirmed by this study, with operating time of 240 minutes (range 150-360), intraoperative blood loss was 180 ml (range 100-250), and only 1 patient required blood transfusion for postoperative bleeding. The specific morbidity rate was 10% owing to duodenal leakage in 3 cases in the early phase of this study (3/30): 1 required laparotomy. The mortality rate was 3% due to 1 serious postoperative bleeding and acute hepatic failure in a patient with post-alcoholic cirrhosis. The conversion rate was 3% (1/30). The nasogastric tube was removed on the 4(th) postoperative day, and the oral intake started on the 6(th) postoperative day after a barium follow-through examination. The mean postoperative hospital stay was 16 days (range 10-25). The number of nodes retrieved was 18 on average and it improved with the experience: from the minimum of 9 nodes in benign ulcers, it grew to 20 in EGCs and to 25 in AGCs, so that this data confirmed the guide lines proposed in this issue . The histologic examination of EGC confirmed the data of echoendoscopy about nodal status. CONCLUSIONS: Laparoscopic surgery is a safe and feasible procedure both for benign and for malignant lesions of the stomach. The results analysed hereby suggest that at the start of training be treated patients affected by benign lesions, followed by patients with EGC and then by patients with AGC. For gastric cancers, the average number of 18 nodes harvested from each patient was adequate, complying with the requirements suggested by the latest TNM classification. This choice of progressive selection of patients for training represents a good means to get an optimal performance level, especially in view of the oncologic requirements, and can prevent surgeons from elevated conversion rates and disappointing outcomes at the beginning of experience.

[The role of superextended lymphadenectomy (D4) in gastric cancer]. / Il ruolo della linfadenectomia superestesa (D4) nel cancro gastrico.

AIM: The outcome of surgery in gastric cancer differs in Japan and Western countries and the extension of lymphadenectomy may play a crucial role in survival. In Japan the choice of performing extended (D2) and superextended (D4) lymphadenectomies is based on retrospective studies, and a prospective randomized study comparing D2 and D4 is still in course. In Western countries the randomized trials comparing D1 and D2 could not provide definite indications, D2 is not yet performed as a routine procedure and D4 is accepted only by few surgeons. We report our experience and discuss indications and results. METHODS: Since January 2000 through December 2002 we performed 27 superextended lymphadenectomies for the radical treatment of advanced gastric cancer. Early gastric cancers and patients over 80 years of age received conventional D2 gastrectomies. Selection of patients for D4 was made after laparotomy, when intraoperative peritoneal lavage cytology could rule out the presence of malignant cells, while D2 was done in case of peritoneal micrometastases. RESULTS: Every patients had 39.5 nodes removed on average (range 17-94), and micrometastases in tier 16 were found in 7 cases (26%). Early post-operative surgical morbidity was 18% (5 patients) and mortality was 3.7% (1 patient). As much as 30% of patients complained of diarrhea as a late complication. The follow up could demonstrate a 3 year overall actuarial survival of 76%. Actuarial survival was 100% for N- and 70% for N+. A remarkable data was that 4 out of 5 patients who died from recurrence in the follow-up, were N4+. Actuarial survival at 3 years for N4+ patients was 34%, and the difference in survival between N4+ and other N+ was statistically significant (p<0.05). CONCLUSIONS: Superextended lymphadenectomy in gastric cancer is feasible with postoperative morbidity and mortality rates not exceeding the rates of other lymphadenectomies. Actuarial survival at 3 years with D4 was better than in previous personal experience with D2, although the patients who underwent D4 were selected by intraperitoneal lavage cytology, while D2 patients had not been selected. The prognosis for N4- patients was better than for N4+ with micrometastases in tier 16. The presence of N4 micrometastases worsens the prognosis, but it is still uncertain whether D4 does improve survival: it is undoubtedly a new means of more accurate staging in gastric cancer surgery. The newer TNM classification regards the number of nodes removed as an indicator of radicality. Every surgeon should consider that superextended lymphadenectomies could comply with R0 radicality, and perform it within the ranges of low morbidity and mortality, until randomized trials with definitive results are available.

Laparoscopic treatment of sigmoid diverticulitis: a retrospective review of 103 cases.

BACKGROUND: Laparoscopic treatment of sigmoid diverticulitis is commonly accepted in Hinchey cases I and II, whereas it is debated in the case of purulent peritonitis, and not indicated for fecal peritonitis. METHODS: A single-center experience of 103 patients treated for Hinchey I-III sigmoid diverticulitis was reviewed. One-stage laparoscopic resection and primary anastomosis constituted the planned procedure. Abscesses in patients with Hinchey IIa were drained percutaneously before surgery. Patients with Hinchey III underwent surgery in emergency. A four-trocar approach with left iliac fossa minilaparotomy was used. Fistulas were treated laparoscopically with Harmonic Scalpel dissection. RESULTS: Laparoscopic treatment was successfully completed for 100 patients. Intraoperative complications occurred in 2.9% of the cases. Postoperative procedure-related morbidity was 8%, occurring mainly in Hinchey I patients. A longer hospital stay was recorded among Hinchey IIb patients treated for colovescical fistula. No mortality was observed. CONCLUSIONS: Laparoscopic surgery for sigmoid diverticulitis in experienced hands can be a safe and effective gold standard procedure also for patients with fistula or purulent peritonitis.

Extended (D2) lymphadenectomy in gastric cancer: a five year experience.

The extent of lymph node dissection in stomach adenocarcinoma is currently under debate. Japanese data strongly support the therapeutic value of extended lymphadenectomy (D2 node dissection), whereas in Western countries several prospective trials have recently been completed with contrasting results. During the period May 1993 to May 1998, 164 patients with gastric cancer were observed: 136 patients, treated with a radical surgical procedure including lymph node dissection according to the guidelines of the Japanese Research Society for Gastric Cancer, were eligible for our analysis. Clinical, histopathological, and surgical factors were examined for their influence on long-term survival. Our results on morbidity and mortality rates are similar to Japanese series: we suggest that the experience and training of the surgeon and his personal attitude towards extensive lymph node dissection may, therefore, be a major factor influencing the morbidity associated with the procedure. The relatively high estimated 3-year survival rate (52%) suggests support for extended lymphadenectomy (D2 dissection) in gastric cancer as standard treatment.

[Laparoscopic treatment of complicated colonic diverticulosis]. / Trattamento laparoscopico della malattia diverticolare complicata del colon.

Despite certain controversies over applying a laparoscopic approach to neoplastic pathologies of the colorectum, it seems to be an ideal form of treatment for benign lesions. The Authors have analysed the results of videolaparoscopic treatment in 23 cases of complicated diverticular disease of the colon using their experience of 205 mininvasive colonic operations. Age, sex, diagnosis, time morbidity and type of intervention such as intra and postoperative, length of hospital stay and the parameters that characterise it (length of nasogastric probe, canalisation and restoration of feeding) were the variables considered in both absolute and comparative methods among the various stages of the disease. The aim was to find the best possible treatment. Out of the 23 patients in the study group, immediate recanalisation was impossible in only one case and all interventions were performed according to the predicted video-assisted technique. A partial ureteral lesion was the only single intraoperatory complication found and was intraoperatively repaired by means of transureteral endoscopy. In three cases non specific complication were encountered. The average length of the intervention was 180 minutes, nasogastric tube was taken 3 days, patients passed and start to feed at the 3rd and 4th postoperative day. These data overlap in the various stages of the disease. An adequate preoperatory study and good experience in major laparoscopic interventions resulted in the common difficulties that surgeons might encounter in this pathology to be overcome. We can therefore conclude that based on our results as well as those found in the literature, diverticular disease can ideally be treated with mininvasive surgery.

[Complicated Spigelian hernia. A case report]. / Ernia di Spigelio complicata. Caso clinico.

Prompted by the observation of a case of lateral ventral Spigelian hernia complicated by strangulation and manifested by symptoms of small intestine occlusion, the authors describe the anatomo-surgical characteristics of the abdominal site of this pathology. They analyse the various diagnostic and subsequently surgical options available to the surgeon when dealing with this pathology. This is achieved with reference to data reported in the current international literature on the subject. Lastly, the authors provide a series of evocative images obtained during the diagnosis of the patient treated and of the results achieved following surgery and a 1-year follow-up after the operation.

[Mechanical entero-enteral anastomosis in surgery of the upper digestive tract]. / L'entero-entero anastomosi meccanica nella chirurgia del TGE superiore.

The authors analyse the results relating to the use of a technical variation of entero-enteroanastomosis preparation in the reconstruction of the continuity of upper digestive tract with a defunctionalised Roux en Y loop. This variation includes the use of a circular Proximate ILS mechanical stapler. The series examined, operated during the period June 1993 to November 1994, includes a total of 57 patients, of which 51 with gastric neoplasia. 43 cases underwent total gastrotectomy with R1-R2 lymphoadenectomy and 8 cases underwent gastroresection; a further 3 emergency operations were performed for benign pathologies responsible for upper digestive tract hemorrhage. Moreover, in the 3 remaining cases 2 cysto-jejunal derivations for pancreatic pseudocysts were also performed using the same method, together with 1 hepaticojejunostomy secondary to calculosis of the common hepatic duct. Attention is focused on the analysis and description of the operating technique in order to identify the basic key stages as accurately as possible. In conclusion, the authors indicate that, in view of the excellence of results and the simple and rapid technical execution of this entero-enteroanastomosis, the use of this method was amply justified and undoubtedly advantageous both for surgeons and patients.

[The use of the BAR-Valtrac-type pressure stapler in surgery of the large intestine]. / L'impiego delle suturatrici a pressione tipo BAR-Valtrac nella chirurgia del grosso intestino.

A total of 148 patients underwent colon resection between June 1993 and November 1994 at the General Surgery Division of Busto Arsizio Hospital; anastomosis was performed using BAR Valtrac in 58 patients (39%), namely 28 males and 30 women with a mean age of 66.3 years. Surgery was elective in 90% of cases and in 84% of patients was secondary to neoplastic pathologies. Recanalisation occurred within a mean of 5.5 days after surgery, whereas the average hospital stay was 14.4 days. The authors report the absence of mortality and the low morbidity levels connected to the use of this anastomotic technique. Emphasis is also laid on the absence of anastomotic stenosis in all endoscopic controls performed to date.

[Amyloid goiter]. / Il gozzo amiloide.

Amyloid goitre, defined as diffuse hyperplasia of the thyroid due to infiltration of amyloid substance, has been rarely reported as in confirmed by the latest reviews of the literature. This paper reports the case of a 23-year-old patient with a long history of systemic amyloidosis probably secondary to a Mediterranean fever with diffuse lymphoadenopathy, hepatosplenomegaly and chronic renal insufficiency, who was referred to our attention due to a struma which had increased in volume over the past few years. Aspirated needle biopsy showed the presence of amyloid and the patient underwent total thyroidectomy; the histological test confirmed amyloid struma. The postoperative evolution was normal and characterised by a slight but transient deterioration of renal function. The authors stress the importance of cytological tests using aspirated needle biopsy under polarised light and after Congo Red staining; this is the only test which enables a preoperative diagnosis to be made, thus conditioning the choice of surgery, even if full thyroidectomy is almost certain given the size of the goitre and the systemic pathogenesis of amyloidosis.

[Cervical thymic cysts. A clinical case report]. / Le cisti timiche cervicali. Presentazione di un caso clinico.

The presence of thymic residues in a laterocervical site is very rare, as is cystic degeneration. The paper reports the case of a six-year-old boy who presented a swelling in a left laterocervical site; preoperative tests (especially echography and fine needle aspiration) identified the cystic nature of the swelling which was then confirmed intraoperatively; histological test diagnosed a thymic cyst. The paper analyses the embryological, anatomopathological and clinical aspects of these formations and underlines the difficulty of making a differential diagnosis from other neck pathologies, especially branchial cysts. In conclusion, preoperative tests can only determine the cystic component but not the thymic origin of these formations which can only be confirmed by final histological tests.

[Diverticulitis of the right colon. Presentation of a clinical case]. / La diverticolite del colon destro. Segnalazione di un caso clinico.

The recent observation of one case of diverticulitis of the right colon led to an evaluation of clinical diagnostic and therapeutic aspects of this comparatively rare condition, on the basis of reported data. Preoperative diagnosis is very difficult because it clinically resembles acute appendicitis in many ways, or because of the objective observation of a mass in the right iliac fossa. Instrumental examinations require preparation times that are often incompatible with the degree of surgical urgency. In the reported case, the inflammatory process was modest and treatment was straightforward, there being no diagnostic doubts. This confirms the fact that in so-called "usual" cases, the idea surgical approach must be as conservative as possible. In so-called "hidden" cases, on the other hand, the doubt as to the nature of the pathology often leads to extensive surgery, such as right hemicolectomy.

[Papillary carcinoma in thyroglossal duct cyst remnant: review of the literature and presentation of a clinical case]. / Carcinoma papillare in cisti del residuo del dotto tireoglosso: revisione della letteratura e presentazione di un caso clinico.

The authors report a case of papillary carcinoma arising from thyroglossal duct remnant. It was the only case observed in the last 20 years among 9000 thyroidectomies performed. After a survey of Literature, the role of total thyroidectomy combined to Sistrunk's technique is underlined.