Resolution of late-onset heart and liver failures after reversion of jejuno-ileal bypass: a case report.

OBJECTIVES: Jejuno-ileal bypass (JIB) was a kind of bariatric surgery performed from 1960s to 1980s, able to induce sustainable weight loss by creating a surgical short bowel syndrome. MATERIALS AND METHODS: We report a case of an octogenarian woman who underwent in the early eighties this kind of surgery with consequent 40 kg weight loss. After 27 years, she first developed a reversible metabolic cardiomyopathy that began with signs and symptoms of heart failure. Thereafter, she was diagnosed with severe intractable liver insufficiency. RESULTS: Despite her old age, the patient underwent reversal of JIB with consequent early improvement of hepatic function. CONCLUSIONS: This case demonstrate that in case of long-term and life-threatening complications, it is possible to successfully reverse JIB surgery after upto 30 years. The hypothesis on pathophysiology of heart and liver insufficiency are discussed.

Surgical treatment of multiple sporadic colorectal carcinoma.

AIM: Many aspects of the surgical management of multiple sporadic colorectal cancer syndrome, either synchronous and metachronous, remain to be cleared, in particular the prognostic influence of the extent of surgical resection. METHOD: A retrospective review was performed of patients diagnosed with multiple colorectal cancer from 1982 to May 2010. Clinical and pathologic data were collected and reviewed. Survival analysis was performed. RESULTS: We identified 23 patients with multiple sporadic colorectal cancers, of which 8 had synchronous (SC) and 15 metachronous cancers (MC). Of the MC patients, 2 (13%) had the second cancer within 2 years, 4 (27%) in the time period of 2-5 years and 9 (60%) after 5 years. Twenty-one patients underwent multiple segmental resections; 2 patients underwent subtotal colectomy. The 5-year overall survival rate of SC and MC patients was 100% and 87% (p<0.001) respectively. The 5-year overall survival rate of multiple segmental resection patients and subtotal colectomy was 94% and 75% (p=0.655) respectively. CONCLUSION: Either synchronous and metachronous MSCRC patients showed good prognosis independently from to the extent of resection. Our results support a less aggressive biological behaviour allowing a more conservative management. Multiple segmental colorectal resections seem appropriate from an oncologic point of view in MSCRC patients.

Morphological Changes in the Carotid Artery Intima after Gastric Bypass for Morbid Obesity.

BACKGROUND: Carotid intima-media thickness (C-IMT) can be considered as an early marker of atherosclerosis, thus representing a reliable cardiovascular risk predictor. Bariatric surgery decreases the burden of cardiovascular disease in obese patients through complex mechanisms, of which weight loss is merely the most evident epiphenomenon. The aim of this study is to evaluate C-IMT variations in patients undergoing Roux-en-Y gastric bypass (RYGB) and possible correlations with biometric parameters and cardiovascular risk factors. METHODS: Thirty patients undergoing RYGB for morbid obesity were enrolled for carotid artery B-mode ultrasound evaluation before surgery and at 1-, 3-, 6-, and 12-month follow-up; C-IMT was recorded at three levels (bulb, common, and internal carotid). At each one of the follow-ups, biometric and serohematic parameters were also collected. RESULTS: The 22 patients who completed the follow-up and were included in the study showed significant C-IMT reduction at all three levels at 12-month follow-up (p < 0.001). Along with a significant BMI reduction and diabetes/hypertension remission, we found a considerable decrease in total cholesterol (219 vs 164 mg/dl; p < 0.001) and uric acid (5.6 vs 4.5 mg/dl; p < 0.01) and a significant increase in HDL cholesterol (43.9vs59.2 mg/dl; p < 0.001). The data imply that the mean 10-year cardiovascular risk score drops by nearly 50 % (5.7 ± 5.6 vs. 2.9 ± 2.7 %, p < 0.001) according to Framingham cardiovascular risk stratification. CONCLUSIONS: RYGB is associated with significant decrease in C-IMT at 1 year. Pathophysiologic processes underlying such a variation, probably involving lipid and urate metabolism and their correlation with cardiovascular risk reduction should be confirmed by long-term prospective trials.

Laparoscopic resection of tailgut cysts: the size is not the issue.

INTRODUCTION: Tailgut cysts are rare retrorectal cystic lesions usually treated by surgical resection, even where asymptomatic, due to the risk of malignancy and recurrence. In the last 20 years, the laparoscopic abdominal approach has been gaining consensus for its better visualization of pelvic structures and minimal invasiveness. CASE REPORT: We present the case of the biggest tailgut cysts managed laparoscopically reported so far. DISCUSSION: Mostly asymptomatic, diagnosis of tailgut cysts is often fortuitous during routine examination. Their malignant transformation is estimated being 14.1% of cases. MRI is particularly indicated to lead the surgical approach, given its superior resolution in soft tissues and assessment of local invasion. Surgical resection is the therapy of choice, performed with different approaches: the laparoscopic abdominal technique, performed by surgeons with expertise in pelvic laparoscopic surgery, allows the best visualization of pelvic viscera with lesser morbidity. Due to rupture and seeding risks, the laparoscopic approach should not be performed if there is any suspicion of malignancy. CONCLUSION: Our case substantiates safety and feasibility of laparoscopic tailgut cysts management, even of large-size cysts. Preoperative imaging is crucial to assess the possible malignancy of the lesion and, in that case, to perform a laparotomic approach. KEY WORDS: Laparoscopy, Retrorectal space, Tailgut Cyst.

Prognostic assessment of gastric cancer: retrospective analysis of two decades.

BACKGROUND: Gastric cancer mortality rates have remained relatively unchanged over the past decades, in spite of progressive decrease in incidence. Nodal status represents a key factor for prognostic assessment, allowing a tailored-made adjuvant therapy for the patients. The aim of this study is to evaluate the prognostic influence of different nodal involvement indicators on the overall survival in a large series of patients submitted to gastrectomy at our Institution. METHODS: we retrospectively collected data from 634 newly diagnosed patients with gastric cancer who underwent curative gastrectomy, with D1/D2 lymphadenectomy during the last 20 years. Prognostic values of age, histologic type, pN, nodal ratio (LNR) and log odds of positive lymph nodes (LODDS) of were analyzed. RESULTS: The median overall survival was 40.2 +/-31 months. Multivariate analysis identified age at diagnosis, diffuse-type tumor, pN and LODDS as independent predictors of worse prognosis. Scatter plots of relationships between LODDS and LNR showed that LODDS seems to better assesses prognosis for patients at LNR stage 0 or 1. CONCLUSIONS: Nodal involvement confirmed to be a strong indicator of prognosis. LODDS demonstrated a theoretical advantage over pN and LNR system allowing more accurate patients stratification, but our results have to be confirmed by further trials.

Cyst of the gastric wall arising from heterotopic pancreas: report of a case.

Heterotopia of pancreatic tissue is a common developmental anomaly, affecting predominantly the gastrointestinal tract. The case of a symptomatic cyst arising from the posterior gastric wall in a 40-year-old man is presented, undergoing laparoscopic gastric wedge resection. Pathology report described a cyst of the gastric wall lined by ductal pancreatic epithelium.

Late surgical complications of subtotal colectomy with antiperistaltic caeco-rectal anastomosis for slow transit constipation A critical analysis.

PURPOSE: Despite a good percentage of success, mainly related to the amelioration of patient selection, surgery for slow transit constipation still presents failures and late complications, often unpredictable, and sometimes related to technical variants. The aim of the study is to critically analyze late surgical complications of subtotal colectomy with caeco-rectal anastomosis (SCCRA), examining the peculiar risks of the procedure and possible prevention measures. METHODS: Follow-up data of 43 compliant patients submitted to SCCRA at our Institution were reviewed. Patients undergoing further surgery for a complication clearly related to SCCRA at our centre were included. RESULTS: We identified three late surgical complications (7%): a caecal distension, an ileo-caecal volvulus and an ileal volvulus. all patients were successfully treated. an evident predisposing condition was found only in the first case. CONCLUSIONS: Peculiar long term complications related to the presence of a dysfunctional or mobile caecal stump may be prevented by careful patient selection and surgical technique. KEY WORDS: Constipation, Complication, Caecal distension, Ileo-caecal volvulus, Subtotal colectomy.

Lymph node ratio improves TNM and Astler-Coller's assessment of colorectal cancer prognosis: an analysis of 761 node positive cases.

BACKGROUND: Prognosis assessment of node-positive colorectal cancer patients by Astler-Coller (AC) and TNM classifications is suboptimal. Recently, several versions of lymph node ratio (LNR; ratio metastatic/examined nodes) have been proposed but are still mostly unused. METHODS: The prognostic value of several criteria, including LNR (two classes-LNR1 and LNR2-identified by a 15% cut-off) was studied in 761 consecutive patients, from 2000 through 2010. The relationships between total examined nodes, N, T and LNR were also analysed. LNR1 and LNR2 patients' survival was analysed within AC and TNM subgroups, and then coupled with them. RESULTS: Age, tumour location and LNR are independent factors predicting survival. The relationships between LNR, N stage and T stage with examined nodes suggest confusing factors. LNR allows for identification of subgroups with different survival within AC and TNM classifications (p < 0.0001). Patients with LNR class discordant from AC stage (LNR1-C2 and LNR2-C1) have a similar 5-year survival (54 and 57%, respectively). LNR2 and TNM stage IIIC define a poor 5-year prognosis (33%). CONCLUSIONS: LNR is a powerful prognosis predictor, easily integrated with TNM and AC classifications to improve prognosis assessment and facilitate clinical use. Possible confusing factors should be considered in future studies.

Palliative care and end-stage colorectal cancer management: the surgeon meets the oncologist.

Colorectal cancer (CRC) is a common neoplasia in the Western countries, with considerable morbidity and mortality. Every fifth patient with CRC presents with metastatic disease, which is not curable with radical intent in roughly 80% of cases. Traditionally approached surgically, by resection of the primitive tumor or stoma, the management to incurable stage IV CRC patients has significantly changed over the last three decades and is nowadays multidisciplinary, with a pivotal role played by chemotherapy (CHT). This latter have allowed for a dramatic increase in survival, whereas the role of colonic and liver surgery is nowadays matter of debate. Although any generalization is difficult, two main situations are considered, asymptomatic (or minimally symptomatic) and severely symptomatic patients needing aggressive management, including emergency cases. In asymptomatic patients, new CHT regimens allow today long survival in selected patients, also exceeding two years. The role of colonic resection in this group has been challenged in recent years, as it is not clear whether the resection of primary CRC may imply a further increase in survival, thus justifying surgery-related morbidity/mortality in such a class of short-living patients. Secondary surgery of liver metastasis is gaining acceptance since, under new generation CHT regimens, an increasing amount of patients with distant metastasis initially considered non resectable become resectable, with a significant increase in long term survival. The management of CRC emergency patients still represents a major issue in Western countries, and is associated to high morbidity/mortality. Obstruction is traditionally approached surgically by colonic resection, stoma or internal by-pass, although nowadays CRC stenting is a feasible option. Nevertheless, CRC stent has peculiar contraindications and complications, and its long-term cost-effectiveness is questionable, especially in the light of recently increased survival. Perforation is associated with the highest mortality and remains mostly matter for surgeons, by abdominal lavage/drainage, colonic resection and/or stoma. Bleeding and other CRC-related symptoms (pain, tenesmus, etc.) may be managed by several mini-invasive approaches, including radiotherapy, laser therapy and other transanal procedures.

Volume-outcome relationship in colon cancer surgery: another biased logical short cut towards questionable centralization policies.

The association between hospital high volumes and good outcomes after complex surgery has given rise to a worldwide controversial debate. Important and unsolved questions have followed, both theoretical and practical, which could have repercussions on health care and health economic policies, such as the centralization/regionalization of major surgical procedures.We read a recent study on the impact of surgery volumes on short-term outcomes after colon cancer resection in Emilia Romagna, Italy, the same geographic area where we operate. Ten issues were submitted to critical analysis and many sources of planning and methodology bias were identified, which, in our opinion, paradigmatically led to unreliable results, inadequate statistical analysis and deceptive conclusions. Despite the authors' admitted awareness of their study's limits, their conclusive message was, surprisingly, that centralization of colon cancer surgery should be substantially encouraged.Unrecognized, systemic biases may easily turn into cognitive biases, into logical short cuts which could confuse healthcare policy-makers. The volume-outcome relationship, in which a direct causal link has never been demonstrated, should not be used as a reliable measure of quality, rather  than less implementable process indicators, to address centralization policies.A disregarded negative consequence of centralization could be that non-high-volume centres, after a further progressive workload decrease and depletion in resources and surgical skills, will have to cope with patients in bad general condition and at high risk, who must be treated in emergency or cannot anyway afford the move for age, indigence or severe co-morbidities. Thus, centralization policies might disadvantage the weak segments of the population, thereby moving towards an iniquitous health service.

Obstructive jaundice by lymph node recurrence of gastric cancer: can surgical derivation still play a role?

BACKGROUND/AIMS: In some cases of bile duct compression by lymph node recurrence of gastric cancer, a second line chemotherapy can lead to prolonged survival; thus, a surgical derivation could represent a reasonable alternative to non surgical drainage, owing to its better long term efficacy. Our study retrospectively compares the surgical approach (SA) and percutaneous transhepatic biliary drainage (PTBD) in this particular oncological condition. METHODOLOGY: 11 patients undergoing biliary-jejunal anastomosis for obstructive jaundice by lymph node recurrence of gastric cancer at our Institution were compared with 10 patients undergoing PTBD. Clinical records and outcome parameters (success rate, complications, survival) were statistically matched in order to assess possible advantages for each technique and to evaluate any particular variable influencing survival. RESULTS: The SA patients experienced a better jaundice resolution (91% vs 50%, p.0.063), a lower major complication rate (9% vs 30%, p:0.311), and a significantly longer survival (317 days vs 85 days, p:0.001). Procedural success and complication rates were found to be correlated with survival. CONCLUSIONS: According to our experience the SA represents a valid alternative to PTBD in the case of lymph node recurrence of gastric cancer, being favoured for patients with better performance status and longer life expectancy.

Totally laparoscopic right colectomy: theoretical and practical advantages over the laparo-assisted approach.

BACKGROUND: The improvement in intracorporeal anastomotic techniques and the consequent switch from a laparo-assisted (LA) to a totally laparoscopic (TL) right colectomy seem to have overcome the initial concerns, giving rise to the widespread use of such a procedure. By comparing the LA and TL approaches, our study was aimed at verifying the possible advantages of the more recent technique, while also focusing on some technical implications for the surgeon. SUBJECTS AND METHODS: We prospectively collected and matched data from 27 consecutive LA right colectomies and 28 consecutive TL right colectomies (TLRCs). Clinical, biochemical, pathological, and cosmetic parameters were examined. Operating times were recorded and analyzed, in order to evaluate the learning curve for the different phases of the procedure. RESULTS: The LA and TL groups were homogeneous for demographic and pathological features. We had no mortality, and surgical complication rates were similar (3.6% versus 3.7%). The TLRC group presented a significantly shorter laparotomy (4.8 cm versus 7.2 cm, P=.002), whereas no significant difference was recorded for outcome parameters. Operating time for carrying out anastomosis was significantly longer for the TL group (55.6 minutes versus 20.6 minutes, P<.0001). A rapid decrease in anastomosis time throughout the series attests to a short learning curve for intracorporeal ileotransverse anastomosis. CONCLUSIONS: Further studies are needed to demonstrate possible clinical advantages of TLRC over the LA approach. The cosmetic benefit for patients along with safety and the prospective usefulness for surgeons (practice in intracorporeal suturing techniques) would seem to justify an inclination toward this technical development.

Long-term results of preoperative 5-fluorouracil-oxaliplatin chemoradiation therapy in locally advanced rectal cancer.

AIM: To evaluate the activity, safety and long-term survival of patients after preoperative oxaliplatin and 5-fluorouracil chemoradiation therapy in locally advanced rectal cancer (LARC). PATIENTS AND METHODS: Patients with resectable, T3-4 and/or nodal involvement rectal adenocarcinoma were treated with oxaliplatin 60 mg/m(2) weekly and 5-fluorouracil 200 mg/m(2)/d infused continuously for five days, over a period of five weeks, and radiotherapy (45 Gy/25 fractions). The primary end-point was pathological complete response (ypCR). Safety, overall survival (OS) and relapse-free survival (RFS) were secondary end-points. RESULTS: Sixty-six patients were treated. Grade 1-2 diarrhea was the most common adverse event. The ypCR rate was 16.7% (95% confidence interval=7.7-25.7%). After a median follow-up of 73.5 months, 23 patients (34.8%) had experienced relapse. Five-year actuarial RFS and OS rates were 64% and 73%, respectively. Five-year actuarial RFS was 91.7% in the ypCR group versus 57.8% in non-ypCR cases. CONCLUSION: Long-term local control and survival after this very well-tolerated regimen appear encouraging.

Laparoscopic subtotal colectomy with antiperistaltic cecorectal anastomosis: a new step in the treatment of slow-transit constipation.

BACKGROUND: Subtotal colectomy with antiperistaltic cecorectal anastomosis (SCCRA) has proved to be an effective alternative to total colectomy for the treatment of severe slow-transit constipation. The laparoscopic approach has made this procedure even more attractive. This is the first controlled trial on laparoscopic SCCRA. The study compares the laparoscopic and the open approach. METHODS: Since 2001, all SCCRAs have been performed laparoscopically at our institution. Only severely symptomatic patients are offered surgery, after stringent patient selection. Laparoscopic SCCRA was performed following the same steps that we first described for the open approach, by utilizing a five-trocar technique. Outcome parameters were prospectively collected every 3 and 6 months. Wexner constipation and incontinence scales (WCS, WI) and gastrointestinal quality of life index (GIQLI) were adopted for functional results. We conducted a case-control study of 15 consecutive patients who underwent laparoscopic SCCRA (VL) and 15 patients previously operated on by the open approach (Op) to compare postoperative and functional outcomes. RESULTS: The VL group had better postoperative outcomes (pain, ileus) while complication rates were similar. Resolution of constipation was impressive in both groups, with no significant difference at follow-up. The VL group presented with a higher number of bowel movements at 3 months (3.8 vs. 2.8, p = 0.039), resulting in a significantly higher incontinence rate at 3 months (WI 6.4 vs. 2.73, p = 0.004), although the difference was no longer significant at 1-year follow-up. The quality of life was good for both groups; the VL group showed a significant improvement at 1-year follow-up (64.18 vs. 114.79, p < 0.01). CONCLUSIONS: Laparoscopic SCCRA confirmed the good functional results of the open approach, with no increase in morbidity rate and a faster postoperative recovery. An early higher incontinence rate did not affect quality of life.

Prospective comparison of laparoscopic incisional ventral hernia repair and Chevrel technique.

PURPOSE: Laparoscopic incisional hernia repair has become an attractive and widely adopted alternative to open procedures. The Chevrel technique is still frequently performed, owing to its safety and effectiveness. Our study prospectively compares the new and the old technique. METHODS: We prospectively collected data from laparoscopic and open incisional ventral hernia repairs performed from January 2006 to December 2008. Twenty-one patients were ultimately enrolled in the open and 20 in the video-laparoscopic (VL) group for the statistical analysis. RESULTS: Open and VL groups were homogeneous for demographics and size of parietal defect. No differences were observed in operating time and postoperative pain, although in the VL group, we found a tendency toward shorter hospital stays and higher postoperative quality of life. We reported a significantly higher rate of wound complications in the open group (7 vs. 1; P=0.03). CONCLUSIONS: Both techniques proved to be effective, although Chevrel presented a high rate of wound complications.

Elective palliative resection of incurable stage IV colorectal cancer: who really benefits from it?

PURPOSE: Despite the encouraging results of chemotherapy in patients affected by incurable colorectal cancer (CRC), surgical resection of a primitive tumor is still a common approach worldwide. The identification of prognostic factors related to short survival (<6 months) may allow excluding from resective surgery those who may not benefit from it. METHODS: A retrospective analysis was performed of 15 variables in a population of 71 patients undergoing nonemergency palliative primary resections of incurable CRC, including patients' demographics and clinical/histopathological characteristics of the tumor. RESULTS: No variables were related to perioperative mortality (8.5% overall). A multivariate analysis revealed that older age (≥80 years) and metastasis to more than 25% of the lymph nodes were associated with survival (4 and 6 months, respectively). Mucoid adenocarcinoma therefore tends to be associated with the prognosis (P = 0.070). CONCLUSIONS: An elderly age tends to be a contraindication to an elective primary tumor resection in patients affected by incurable CRC. Massive lymph node involvement and mucoid adenocarcinoma should also be considered before planning major colonic surgery.

Computed tomography volumetric fat parameters versus body mass index for predicting short-term outcomes of colon surgery.

BACKGROUND: At present, the impact of obesity on short-term outcomes of general surgery remains controversial, especially in the field of laparoscopy. Most studies on the subject have used the body mass index (BMI) to define obesity without distinguishing between visceral and subcutaneous storage. Computed tomography (CT) volumetric analysis permits accurate evaluation of site-specific volume of adipose tissue. The purpose of this study was to compare CT volumetric fat parameters and the BMI for predicting short-term outcomes of colon surgery. METHODS: A retrospective analysis was conducted of 231 consecutive patients undergoing elective colon resection, with open or laparoscopic technique, from January 2007 to April 2009. CT volumetric quantification of abdominal visceral and subcutaneous adipose tissue was performed. Intraoperative and perioperative data were collected. RESULTS: A total of 187 patients were enrolled. BMI showed a direct correlation with fat volumetric parameters but not with the visceral/subcutaneous fat ratio. Operating time was correlated with subcutaneous fat storage and BMI in the laparoscopic right colectomy subgroup. No associations were found with the conversion rate. Length of the hospital stay was correlated with the visceral/subcutaneous fat ratio in the laparoscopic left colectomy subgroup. Whereas the overall postoperative complication rate and mortality were not associated with fat parameters, the postoperative surgical complication rate was associated with visceral volumetric parameters in the laparoscopic left colectomy subgroup. CONCLUSIONS: Short-term outcomes of colon surgery are better predicted by fat volumetric parameters than by the BMI. This study has provided new elements for discussion on the impact of visceral and subcutaneous adiposity in laparoscopic and traditional colon surgery.

Biofeedback therapy plus anal electrostimulation for fecal incontinence: prognostic factors and effects on anorectal physiology.

BACKGROUND: The current literature does not provide unequivocal data on prognostic factors in conservative management of fecal incontinence. Moreover, the physiopathologic effects of pelvic floor rehabilitation on anorectal function are not well understood. Our aim is to identify some prognostic parameters and assess their effects on anorectal physiology of biofeedback therapy plus anal electrostimulation for fecal incontinence. METHODS: We studied prospectively 45 consecutive adult patients with fecal incontinence treated at our institution with biofeedback plus electrostimulation. The outcome parameter was modification of the Wexner Incontinence Score (WIS) at the end of treatment. In addition, we studied the modifications of anorectal manometry and the rectal sensitivity threshold after treatment. RESULTS: At univariate analysis, age, the pretreatment WIS, and the pretreatment resting and maximum squeeze pressures were correlated with the clinical outcome. Patients showed a significant reduction in the rectal sensitivity threshold but no significant change in manometric parameters after treatment. CONCLUSIONS: We identify good sphincter function and mild to moderate symptomatology as favorable prognostic factors in biofeedback and anal electrostimulation therapy. Improvement in rectal sensitivity can be implicated in symptomatic improvement. The impossibility of correlating the clinical results with the effects on anorectal physiology suggests a nonspecific effect of conservative treatment.

Impact of palliative chemotherapy and surgery on management of stage IV incurable colorectal cancer.

BACKGROUND: Recent trials proposed chemotherapy (CHT) as the treatment of choice for patients affected by incurable colorectal cancer (ICRC). Nevertheless, surgery is still commonly offered to these patients. On the other hand, CHT is offered to ICRC patients regardless of the pattern of spread of the disease, local or distant, despite some evidence suggesting that metastatic pattern may influence the response to treatment. METHODS: A retrospective analysis was performed of 133 patients undergoing palliative treatment for ICRC from 1994 through 2007. Palliation consisted of surgery alone until 2002 and surgery with CHT (FOLFOX-FOLFIRI) thereafter. The impact of CHT and surgery was evaluated in the whole series as well as with respect to metastatic pattern (locally aggressive primary tumor and distant metastasis only), tumor site, and grading. RESULTS: Chemotherapy prolonged survival by 9 months (p = 0.001). In patients undergoing CHT, resective surgery did not prolong survival (p = 0.931), whereas in patients not undergoing CHT, it improved prognosis by 5 months (p = 0.023). Considering patients with distant metastasis only, CHT significantly prolonged survival (p < 0.001), whereas it did not improve the prognosis of patients with a locally aggressive primary tumor (p = 0.943). No difference in CHT effectiveness with respect to tumor site and grading was recorded. CONCLUSIONS: CHT should be the preferred option in patients undergoing elective treatment for ICRC, whereas surgery should be considered whenever CHT is not administered. CHT significantly increases survival of patients with unresectable distant metastasis only, whereas it seems to be useless in patients with locally aggressive primary tumors.

Impact of obesity on laparoscopic-assisted left colectomy in different stages of the learning curve.

PURPOSE: This study is aimed at verifying if the surgeon's experience has an impact on the risk of conversion to open surgery of laparoscopic left colectomy performed in obese patients. METHODS: A multiple logistic regression analysis was performed of 181 laparoscopic left hemicolectomies completed between April 2001 and June 2006. The results were analysed statistically in relation to the learning curve, by comparing factors that could have had an impact on the risk of conversion in the first 91 cases and in the last 90 cases. RESULTS: The overall conversion rate was 11%. Only weight level was found to be predictive of conversion to open surgery. No death was observed. Sixteen patients presented postoperative complications (8.8%), with no significant differences between obese and nonobese patients (P=0.95). The conversion rate was higher in the group of the first 91 cases: 15.6% versus 6.6% (P=0.05). Average body mass index of converted patients resulted as being higher than that of nonconverted ones (29.97+/-3.76 vs. 25.48+/-3.72; P<0.001) during the first period of the learning curve, but the difference was not observed during the second period (P=0.87). On multiple logistic regression analysis, obesity was found to be predictive of conversion only during the first period. CONCLUSIONS: The data indicate that the laparoscopic colorectal surgery is feasible and effective in obese patients both when the surgeon is expert in laparoscopic colorectal resection and at the initial phase of the experience. At the initial phase of the experience obesity constitutes a higher risk of conversion to open surgery.