Mid-transverse colon cancer and extended versus transverse colectomy: Results of the Italian society of surgical oncology colorectal cancer network (SICO CCN) multicenter collaborative study.

INTRODUCTION: Transverse colon cancer (TCC) is poorly studied, and TCC cases are often excluded from large prospective randomized trials because of their complexity and their potentially high complication rate. The best surgical approach for TCC has yet to be established. The aim of this large retrospective multicenter Italian series is to investigate the advantages and disadvantages of both hemicolectomy and transverse colectomy in order to identify the best surgical approach. MATERIALS AND METHODS: This was a retrospective cohort study of patients with mid-transverse colon cancer treated with a segmental colon resection or an extended hemicolectomy (right or left) between 2006 and 2016 in 28 high-volume (more than 70 procedures/year) Italian referral centers for colorectal surgery. RESULTS: The study included 1529 patients, 388 of whom underwent a segmental resection while 1141 underwent an extended resection. A higher number of complications has been reported in the segmental group than in the extended group (30.1% versus 23.6%; p 0.010). In 42 cases the main complication was the anastomotic leak (4.4% versus 2.2%; p 0.020). Recovery outcomes also showed statistical differences: time to first flatus (p 0.014), time to first mobilization (p 0.040), and overall hospital stay (p < 0.001) were significantly shorter in the extended group. Even if overall survival were similar between the groups (95.1% versus 97%; p 0.384), 3-year disease-free survival worsened after segmental resection (78.1% versus 86.2%; p 0.001). CONCLUSIONS: According to our results, an extended right colon resection for TCC seems to be surgically safer and more oncologically valid.

Chelating Surfaces for Oriented Human Serum Albumin Molecules.

Protein immobilization in a specific conformation or orientation at an interface is influenced by specific interactions with the outer layer of the surface. A strategy to build-up a complex construct which is able to orient protein molecules, based on metal-cation chelation processes, is reported. The proposed methodology implies the formation of a mercaptoundecanoic acid monolayer on a gold surface that is activated to attach covalently the tripeptide glycyl-l-histidyl-l-lysine (GHK) on the surface, whose sites are then employed to chelate copper ions, providing a selective platform for the orientation of human serum albumin (HSA) molecules. The protein adsorption process on GHK and GHK-Cu(II)-complex surfaces was monitored by the in situ quartz crystal microbalance with dissipation monitoring (QCM-D) and force spectroscopy technique. The changes in frequency and dissipation factor as well as the D- f plots from QCM-D measurements help to characterize the changes in the protein conformation and are confirmed by force curve spectroscopy results. An improved kinetic model, based on random sequential adsorption with variable protein footprints, has been developed to predict and simulate the experimentally found HSA average surface coverage onto the GHK and GHK-Cu(II)-complex surfaces.

Structure of a liquid/liquid interface during solvent extraction combining X-ray and neutron reflectivity measurements.

We have resolved the molecular structure of a bulk oil/water interface that contains amphiphilic ligand molecules using a combination of X-ray and neutron reflectivity measurements for the first time. This new capability can greatly impact future work in the field of ion separation by phase transfer, i.e. liquid/liquid extraction.

Synchronous double cancers of the colon and the pancreas: a case report.

The authors report a clinical case of a synchronous double cancer of the colon and pancreas. Having carefully examined the scarce literature, they dwell on the incidence of this disease referring to frequencies that in the literature range from 0.06% and 0.55% while considering that some series do not show any association between the two neoplasms. The authors analyze the role of the colorectal follow-up. In fact, such a follow-up, even if only providing a relative improvement in disease-free survival, has allowed for a treatment of the two certainly not-advanced tumors ensuring the patient a good prognosis. Finally, the authors analyze how endoscopic ultrasound-guided fine-needle aspiration made possible a preoperative diagnosis of small pancreatic cancer, and show that, the positive predictive value (PPV) of this method was 100%.

Combined duodenal and pancreatic major trauma in high risk patients: can a partial reconstruction be safe?

Pancreatic trauma is an uncommon injury, occurring in only about 0.2% of blunt abdominal injuries, while duodenal injuries represent approximately 4% of all blunt abdominal injuries. When trauma of the pancreas and duodenum do not permit reparation, pancreatoduodenectomy (PD) is mandatory. In the reconstructive phase, the use of ductal ligation as an alternative to standard pancreaticojejunostomy has been reported by some authors. We report a case of polytrauma with pancreatic and duodenal injury in which the initial diagnosis failed to recognize the catastrophic duodenal and pancreatic situation. The patient was submitted for PD and the pancreatic stump was abandoned in the abdominal cavity after main pancreatic ductal ligation. This technique can minimize the morbidity and mortality of PD in patients with other organs or apparatus involved severely and extensively in trauma.

Primary neuroendocrine lung tumor presenting with acute ileal obstruction. Case report.

The authors describe a clinical case of a patient with neuroendocrine carcinoma of the lung diagnosed after the onset of an intestinal obstruction from an ileal metastasis. A review of literature reveals that the incidence of symptomatic gastro-intestinal metastases from lung cancer has been estimated to be about 2-3% and is exceedingly rare that the intestinal symptoms may be the initial presentation of cancer of the lung. The authors emphasize the difficulty of preoperative diagnosis of gastro-intestinal metastases which is made, almost always, too late because of the lack of specific symptoms. In our case, on account of the computed tomography, we leaned towards the diagnosis of lymphoma because of the double mediastinal and abdominal localization. Furthermore, this diagnosis was supported by the fact that the pulmonary lesion did not have clear radiological features of a lung cancer. The prognosis is poor because once intestinal metastases occur, other metastatic sites, which would make surgery only a palliative measure, are already present. The review of the literature shows that the average survival rate of these patients is 136 days. In our case the patient survived 277 days.

Late cutaneous fistula after inguinal hernia repair without prosthesis.

Late onset of cutaneous fistulas associated with inguinal hernia repair represents an extremely rare complication that occurs especially after affixing a prosthesis. The authors report a case of a patient developing this complication after a hernia repair (Shouldice's technique), emphasize that the fistula appeared after more than 12 years (the longest interval reported in the literature), and explain how it resolved only with the surgical removal of the suture used for hernia repair. The authors emphasize the aetiology of this complication and stress that it can occur even after a hernia repair without prosthesis.

A study about mechanisms of des-gamma-carboxy prothrombin's production in hepatocellular carcinoma.

AIM: Des-gamma-carboxy prothrombin (DCP) is an abnormal prothrombin, increased in serum of patients with hepatocellular carcinoma (HCC) as result of an acquired defect of post-translational carboxylation of prothrombin's precursor. It is unclear if the reduced activity of gamma-carboxylase is secondary to vitamin K deficiency or to an altered gene encoding this enzyme. The aim of this study was to evaluate the effect of vitamin K administration on DCP and alpha-fetoprotein (AFP) levels, to identify a relationship between vitamin K and DCP serum levels and to investigate mechanisms of serum elevation of DCP levels. METHODS: The authors determined DCP and AFP serum levels and vitamin K concentration in 64 cirrhotics with HCC and in 60 cirrhotic subjects without HCC. In HCC subjects DCP and AFP levels were measured before and after vitamin K administration. A t-test for unpaired data was applied (P values <0.05 statistically significant). RESULTS: Only HCC patients had detectable levels of DCP and significant AFP levels. Administration of vitamin K reduced DCP but not AFP levels in HCC patients. No correlation was observed between vitamin K concentration and DCP levels: vitamin K concentration was similar both in HCC patients and in control group without HCC; HCC patients had the same vitamin K concentration regardless of elevated o reduced DCP levels after vitamin K administration. CONCLUSION: DCP detectable serum levels are the result not only of vitamin K deficiency or selective defects of carboxylase, because probably alterations of membrane receptors or cytoplasmatic transfers, that are necessary for the function of vitamin K, are involved.

Metachronous liver metastases and resectability: Fong's score and laparoscopic evaluation.

BACKGROUND AND AIMS: The aim of this retrospective study was to establish whether Fong's risk score can predict rate of resectability and whether laparoscopic exploration with ultrasonography can reduce the number of useless laparotomies to any extent. MATERIAL AND METHODS: Fong's score was calculated for each of the 43 potential resectable patients. We analysed: the relation between score and resectability; the probability of unnecessary laparotomy with respect to each level of score; and which of the five Fong parameters was the most indicative of non-resectability. None of our patients was submitted to preoperative laparoscopic staging. RESULTS: All patients with Fong's score 0 were submitted to liver resection, whereas only 76.9% with score 1, 58.3% with score 2, and 66.6% with score 3. No patients had score 4 and 5. "CEA level" is the parameter that best predicts the "non-resectability" of metastases. In the subgroup with score 0-1, laparoscopy would have spared 12% of unnecessary laparotomies, whereas in subgroup 2-3 this percentage would have risen to 38.9. CONCLUSIONS: The above data allowed us to quantify statistically the risk associated with non-resectability of liver metastases in a directly proportional manner as the score progresses.

Usefullness of the ultrasonically activated scalpel in laparoscopic cholecystectomy: our experience and review of literature.

Laparoscopic cholecystectomy (LC) actually represents the most used and proper treatment for gallbladder lithiasis, because its many and known advantages in comparison with 'open' abdominal surgery. But there are some problems during and after LC due to the use of the electric scalpel and these have brought to the search of an alternative system of dissection and coagulation. The ultrasonically activated scalpel (Harmonic Scalpel, HS) allows to perform dissection and coagulation with a minimal thermal side effect for surrounding tissues, unlike the electrocoagulation. Furthermore, the use of the HS brings a series of advantages in comparison to the other electromagnetic forms of energy (electro-scalpel, laser). HS cuts and coagulates with the same effectiveness of the electro-scalpel but, unlike this, it doesn't introduce risks of wandering currents. Moreover, HS contributes to have a more clean and clear (smokes-free) field of operation and it reduces the operative time, the bleeding and the costs of the operation without an increase of the complications and of the percentages of 'open' conversion, and perhaps leads to a less negative influence on the postoperative systemic immune response. The Authors report their experience that confirm these observations, according also with results reported in a brief review of the recent scientific literature, and support wider diffusion and technical development of this ultrasonically-operating surgical team.

[Myasthenia gravis and intestinal resection: is dehiscence likely to occur?]. / Myasthenia gravis e resezione intestinale: deiscenza in agguato?

Experimental and clinical data have proved that anticholinesterase drugs are responsible for vigorous peristaltic contractions and for an increase of the intraluminal pressure, because they determine muscarinic effects on the smooth muscle of the intestine both in small and large intestine. Therefore, a greater incidence of intestinal anastomotic disruption has been supposed when anticholinesterases are used both in the early postoperative period, to reverse curarization, and in myasthenic patients. The authors report a case of a patient with myasthenia gravis who received maximal doses of pyridostigmine and underwent left hemicolectomy and small intestine resection and afterwards total colectomy in order to treat a sigmoid perforated diverticulitis. In the postoperative course an anastomotic leak developed after both surgical operations. The authors believe that pyridostigmine could have had an important role in the pathogenesis of the leak and assert that, when an intestinal resection has to be performed in a myasthenic patient, it could be useful to reduce in the preoperative period the administration of anticholinesterase drugs and always perform a protective ileostomy.

Laparoscopic cholecystectomy (LC): predictive role of preoperative ultrasounds.

AIM: We studied several ultrasounds patterns concerning gallbladder, biliary tract and gallstones to identify some predictive signs of difficulties during LC. PATIENTS & METHODS: 112 patients (24 females), 25-75 years old, upper abdomen operated patients not included. From 7 ultrasounds patterns 4 degrees of potential intra-operative difficulty (0-3) were obtained. During the operation 7 conditions of true intra-operative problems were also classified. RESULTS: Patients showing grade 0: regular gallbladder wall stones < 20 mm, regular Main Biliary Tract (MBT) = 62 LC and 2 open surgery conversion (OSC); grade 1: wall < 4 mm, stones > 20 mm= 24 LC and 7 OSC; grade 2: hydrops, wall > 4 mm, infundibular stone = 6 LC and 6 OSC, grade 3: wall > 4 mm, stones > 20 mm, empyema of gallbladder, MBT > or = 6 mm = 3 LC and 0 OSC. Inflammation near gallbladder and wall > 4 mm were mainly responsible for transition of LC in OSC. CONCLUSION: Several predictive conditions for intraoperative difficulties are often detectable by accurate preoperative ultrasounds examination, with the aim of best surgical planning and to select those patients to entrust to surgeons during their learning phase.

[Correlation between positive lymph nodes and metastasis of colorectal cancer. Personal experience]. / Correlazione tra numero di linfonodi positivi e metastasi da cancro colorettale. Esperienza personale.

The authors, in a group of 190 patients treated with curative surgery for colorectal cancer, have studied the correlation between lymph nodes positive of primary tumor and rising of liver metastases. Even if the B2 stage nodes were negative, liver metastases were found in 6.25% of the patients probably due to an understaging; in C1 + C2 stage the rate of liver metastases was 28.1%, however in this group has not been demonstrated a statistical correlation with the number of positive nodes as a predictive negative prognostic factor.

[En bloc lymphadenectomy for colorectal cancer, number of lymph nodes and ratio as prognostic factors: personal experience]. / Linfoadenectomia en bloc per cancro colorettale numero di linfonodi e ratio come fattori prognostici esperienza personale.

The authors have re-evaluated the lymph node status of 221 patients operated on for colorectal cancer and submitted to a five years follow-up in order to evaluate the role of the number of positive nodes and its "ratio" as negative prognostic factors of recurrences. In the patient classified as B2 stage, the recurrences occurred in spite of adequate number of negative nodes, in C1 + C2 stage the lymph node "ratio" could be considered an appropriate prognostic factor.

[Rare malignant tumors of the thyroid]. / I tumori maligni rari della tiroide.

The incidence of rare malignant tumors of the thyroid is about 4 cases/100,000 people and represent only 1.8% of all the thyroid cancers. When we talk about "rare" tumors, obviously, we do not refer to the most frequent cancers (papillary, follicular), or less frequent tumors (medullary, anaplastic), but to some types of thyroid tumors that have been almost always sporadically observed. Mucoepidermoid carcinoma and squamous carcinoma have been described in the literature. They present occasional papillary formation so that, according to some authors, could be considered as variants of the papillary carcinoma. Teratoma is another rare tumor which in the paediatric age is benign, but its prognosis could be unfavourable because it causes an important respiratory distress, while in the adult it presents a very aggressive clinical course like the anaplastic carcinoma. Lymphoma is the most frequent of the "rare" tumors of the thyroid (1-5% of all the thyroid cancers). It arises often in a setting of a long history of goitre and Hashimoto thyroiditis. Fine-needle aspirate is important to make diagnosis and to start a correct treatment which allows a 5-year survival up to 85% in the favourable cases.

Splenic trauma following colonoscopy.

A case of splenic trauma after colonoscopy is reported. After description of their experience, the Authors report a review of the literature and some considerations about clinical diagnosis and surgical or medical therapy for this pathology.

Evaluation of the prognostic accuracy of Astler-Coller's and Jass' classifications of colorectal cancer.

AIM: The study aim was to determine whether the Jass classification is superior to that of Astler-Coller (modification of Dukes' stage) in determining prognosis of patients treated for colorectal carcinoma. STUDY DESIGN: The authors used Jass' classification to restage 263 patients who had undergone radical colorectal surgery and classified according to Astler-Coller. RESULTS: The results revealed that: 1) Astler-Coller's classification enables more accurate selection of patient groups where life expectancy can be predicted; 2) Jass' classification enables statistically significant (P <0.05) improved prognostic discrimination of Astler-Coller's B2 patients, for which the probability of nonrecurrence of the disease is around 60%. CONCLUSIONS: Although Astler-Coller's classification is still valid, Jass' classification is useful for the prognostic discrimination of Astler-Coller's B2 patients.

Experimental research and surgery: why, how, and when?

Experimental research faces two great problems: the significant reduction of public funding and the firm opposition of the public opinion. The law forbids the use of large animals, so that it is possible to use small animals only, which require microsurgical techniques. However, even a skillful surgeon does not know how to perform microsurgery and has to begin a long and tiring training to master techniques. We think that experimental surgery should play a role because it tests the validity and safety of new surgical techniques and allows special pathophysiological aspects to be studied. Furthermore experimental surgery could represent an essential stage in the training of young surgeons. We should find a balance between observance of the law and respect of the animals and, on the other hand, the role of experimental surgery because we should not forget that its most important aim is the improvement of the health of the humankind.

Carcinoid of the ileocaecal valve: a case report.

The authors present a case of carcinoid of the ileocaecal valve. The patient complained for over one year of mild pain in the right lower quadrant of the abdomen. Colonoscopy had shown hyperaemia on the colic side of the ileocaecal valve which appeared substenotic and biopsy revealed micronodules formed by chromogranin-A-positive neuroendocrine cells. Roentgenography of the small bowel and barium enema revealed a specular filling defect in the caecum and in the terminal ileum near the ileocaecal valve. Right hemicolectomy was performed and the definitive diagnosis was carcinoid of the ileocaecal valve. The tumour had spread to all layers of the intestinal wall and 4/19 lymph nodes were metastatic. The patient refused an oncological examination; however, three years after surgery there are no signs of recurrence. Carcinoids have been included in the APUD system and usually present endocrine activity. The 5-year survival of patients with gastrointestinal carcinoids is 80% when located in the appendix and rectum as against 50% in the stomach, jejunum and colon, because the localisation in the appendix and rectum is marked by clinical signs of appendicitis and rectal bleeding, which suggest diagnostic examinations useful for an early diagnosis. Radical operations according to the rules of oncologically correct surgery are the treatment of choice, while complementary treatments have yet to be codified.

Multimodal therapy of hepatocarcinoma: personal experience on 90 cases.

BACKGROUND/AIMS: In recent years, surgical and non-surgical options have been developed in the treatment of hepatocellular carcinoma in cirrhotic patients. We review our personal series from 1995-1999, in order to assess the choice of treatment. METHODOLOGY: Of 90 cases of hepatocellular carcinoma observed in the years 1995-1999, 15 underwent curative resective surgery; in 42 cases TAE, PEI or RITA were utilized (9 of them as multimodal therapy). In the remaining 33 patients any kind of therapy was scheduled. RESULTS: The mean survival of the 15 resected patients was 18 months, non-statistically better than RITA survival, compared by Log-Rank test. Perioperative mortality calculated in all procedures was 5.2% (2 pts surgery, 1 pt TAE). CONCLUSIONS: The high percentage of not treated hepatocellular carcinomas in our series is generally due to large tumor size diagnosed in advanced Child's stage. PEI, TAE and RITA have to be considered effective and safe for palliation for HCCs. However, surgical resection represents the curative therapy in selected cirrhotic patients affected by HCC.