Total rectal resection and complete mesorectum excision followed by coloendoanal anastomosis as the optimal treatment for low rectal cancer: the experience of the National Cancer Institute of Milano.

BACKGROUND: At present, abdominoperineal resection remains the most diffuse method of treatment of very low rectal cancer. Today, we can avoid this method in some patients by using a sphincter-saving procedure. METHODS: From March 1990 to January 1999, 273 consecutive total rectal resections and coloendoanal anastomoses were performed at our Institute; this study concerns 141 consecutive patients treated for a primary adenocarcinoma of the distal rectum, from 3.5 to 8 cm from the anal verge. Patient stratification, based on definitive pathological report, was 31 Dukes' stage A (T2N0), 44 stage B (T3N0), and 66 stage C (T2N+-T3N+). RESULTS: Overall recurrence rate was 9.2%; postoperative morbidity attributable to the procedure was low. A perfect continence was documented in 61% of cases. The only pathological factor related to local recurrence rate is peritumoral lymphocytic reaction inside and around the tumor (P = .0005 and .031) independently from the number of metastatic lymph nodes, depth of fatty tissue infiltration, and lymphatic and venous neoplastic emboli. The minimum follow-up time is 12 months. CONCLUSIONS: Our data, in accordance with other authors, seem to highlight the relevant role that a well-practiced surgery, together with accurate information on the spreading of this disease, has in achieving an optimal local control of cancer.

Optimising local therapy during oral surgery in patients with von Willebrand disease: effective results from a retrospective analysis of 63 cases.

Bleeding after dental extractions is very frequent in patients with von Willebrand disease (vWD) and in the past often necessitated transfusions with factor VIII/von Willebrand factor concentrates (vWFc). To evaluate the benefits of a standard local therapy on bleeding complications during oral surgery, 63 consecutive patients with vWD were analysed retrospectively. All types of vWD were included: type 1 (n=31), type 2 (n=22) and type 3 (n=10). All the patients had dental extractions or periodontal surgery at the same hospital by the same oral surgeons. All cases had been given tranexamic acid (TA) before and for 7 days after surgery. As additional local therapy fibrin glue (FG) was used during surgery in several patients. Additional systemic therapies were: desmopressin (DDAVP, 0.3 microg kg-1) and fVIII/vWF concentrates (vWFc, 40 U kg-1) given as a single dose before surgery. The 29 subjects (46%) treated locally did not bleed. Among the remaining cases, 24 (38%) were given DDAVP as additional systemic therapy and 6 (9.5%) received vWFc. There was bleeding after surgery in only two cases who had been given local FG (type 2 B) or systemic vWFc (type 3), but bleeding was stopped with an additional local application of FG. Our data suggest that a standard local therapy with TA and FG with DDAVP can prevent bleeding complications during oral surgery in the majority of patients (84%) with vWD and reduce the need for concentrates, with all their possible complications and high costs.

The scalp as a donor site in burns.

The scalp can be used as a donor site in the extensively burned patient. A series of 21 patients in whom this procedure has been performed, including up to 12 occasions in the same patient, is reviewed. No associated complications were encountered. The technique of harvesting the split-thickness skin grafts in this area requires the use of Pitkin's syringe and Brown air dermatome. The advantages include the availability of a large donor site that is well concealed and heals rapidly. The anatomic basis of the advantageous characteristics of the scalp and the need for subgaleal injections of fluid to stabilize the scalp are reviewed. The occasionally more pressing need to use this area in the extensively burned child because of relative body surface area distributions is also noted. Excessive blood loss, hypertrophic scarring, and the need for hair transplantation have not been noted. Complete hair regrowth has been experienced in nearly all cases.

Aesthetic anatomy of the non-Caucasian nose.

Aesthetic rhinoplasty in the non-Caucasian patient is a challenging operation, even to the experienced rhinoplastic surgeon used to operating on Caucasians. Only by thoroughly understanding the anatomic differences between the Caucasian and non-Caucasian nose can the plastic surgeon effectively manipulate the various structures to obtain an aesthetically gratifying result. The major differences in the internal and external anatomy of the Caucasian versus the non-Caucasian nose are described.

The survival of free nonvascularized bone grafts in irradiated areas by wrapping in muscle flaps.

In this paper, the concept of vascularizing the bed as opposed to the bone was tested with regard to bone grafting in irradiated areas. Thirteen rabbits underwent cross-transfer of a healthy rib into a bed that received 4500 rads of orthovoltage radiation. Eight of these grafts were wrapped in rotated, nonirradiated latissimus dorsi muscle. At 3 months, these grafts were evaluated radiologically, grossly, and histologically. Seven of eight grafts wrapped in muscle demonstrated evidence of union and survival (88 percent), whereas only one of five of those grafts placed directly into the irradiated bed demonstrated union and survival (20 percent). Statistical analysis showed this to be significant to 97.5 percent, with a lambda 2 value of 5.9.