Total laparoscopic hysterectomy: our experience from 2008 to 2012.

OBJECTIVES: Nowadays total laparoscopic hysterectomy (TLH) is a surgical procedure increasingly adopted for the treatment of benign and malign uterine disease. The aim of our study is to revise our recent experience of TLH. METHODS: This is a retrospective observational study conduced on 101 patients between 2008 and 2012. The surgical procedure has been performed by the same surgeon and with the same surgical technique. Patients with benign disease and I-II stage endometrial cancer (FIGO 2009) were considered eligible for the study. Data collected were concering weight, height, BMI, age; kind of disease; type of surgery performed and possible variants; surgery duration; intra-operative and post-operative complications. RESULTS: In 80 patients TLH was performed for benign disease, in 42 cases uterine fiboids; salpingo-oophorectomy has been performed in 37 patients; the mean surgical time was 81 minutes for benign disease and 112 minutes for malign disease. In 1 case conversion to laparotomy was required; in 5 patients we recorded post-surgical fever; in 1 patients we recorded deiscence of vaginal vault. None of the considered factors (age, BMI, kind of surgery) was significantly associated with increased frequency of intra- and post-operative complications. CONCLUSIONS: Our clinical experience on TLH is increasing as years pass by, and our results are in line with those reported by other Centers. On the basis of our experience, in agreement with recently published data, we believe that vaginal vault closure should be performed through vaginal access.

Anti-Müllerian hormone serum values and ovarian reserve: can it predict a decrease in fertility after ovarian stimulation by ART cycles?

BACKGROUND: A variety of indicators of potentially successful ovarian stimulation cycles are available, including biomarkers such as anti-Mullerian hormone. The aim of our study was to confirm the usefulness of serum anti-Mullerian hormone assay in predicting ovarian response and reproductive outcome in women eligible for ART cycles. MATERIALS: Forty-six women undergoing ART cycles at the Centre for Reproductive Medicine in Parma were recruited from March-to-June 2010. INCLUSION CRITERIA: age<42 years; body-mass-index = 20-25; regular menstrual cycles; basal serum FSH concentration <12 IU/L and basal serum estradiol concentration <70 pg/mL. The couples included in our study reported a variety of primary infertility causes. All women underwent FSH stimulation and pituitary suppression (GnRH-agonist/GnRH-antagonist protocols). Women were considered poor-responders if they had ≤ 3 oocytes; normal-responders 4-9 oocytes and high-responders ≥ 10 oocytes. Serum samples for the AMH assays were obtained on the first and last days of stimulation. A P value ≤ 0.05 was considered statistically significant. RESULT: FSH levels increased significantly when AMH levels decreased. The total dose of r-FSH administered to induce ovulation was not correlated to AMH. The number of follicles on the hCG, serum estradiol levels on the hCG-day, and the number of retrieved oocytes were significantly correlated to AMH. The number of fertilized oocytes was significantly correlated to the AMH levels. No significant correlation was found between obtained embryos or transferred embryos and AMH. Basal serum AMH levels were significantly higher than those measured on the hCG-day, which appeared significantly reduced. There was a significant correlation between AMH in normal responders and AMH in both high and poor responders. CONCLUSIONS: Our data confirm the clinical usefulness of AMH in ART-cycles to customize treatment protocols and suggest the necessity of verifying an eventual permanent decrease in AMH levels after IVF.

Is CD10 a reliable marker of invasive colorectal cancer?

AIM: Previous studies reported that CD10 positive Colorectal Cancer Cells (CRC) characterized by deeply invasive neoplasia. MATERIALS AND METHODS: We have examined 50 pts surgically treated for colorectal cancer on at least 5 years follow up. TNM, grading score and survival have been compared to CD10 expression. RESULTS: Thirty-four out of fifty cases have been analyzed (18 males and 16 female) of whom nineteen were CD10 positive and fifteen were CD10 negative. The remaining 16 cases were droping out. No difference in survival rate between CD10 positive and negative in N0, N1, N2. No difference on survival rate and grading 1, 2, 3. We have then analyzed CD10 positive and CD10 negative cases, according to neoplasia grading, in patients with positive linphonodes N1 and N2. We showed a statistical difference between the CD10 positive/N2 (grading 1.66 +/- 0.5) and the CD10 negative/N2 (grading 3) (p < 0.005). CONCLUSIONS: We can hypothesize that CD10 positive neoplasia display a more invasive behaviour, independently from the N score and the G score, compared to CD10 negative neoplasia.

Can we define a role for perisentinel lymph-nodes on breast cancer disease?

BACKGROUND: The development of sentinel lymph node biopsy in breast cancer disease and the increasing of using adjuvant systemic therapy provide a rational reduction of axillary dissection in patients with Sentinel Lymph Nodes free from breast cancer cells. The aim of our study was to assess the state of the perisentinel lymph nodes removed and how these nodes can provide further information about the status of the axillary lymph nodes. MATERIALS AND METHODS: We have analysed data about 319 patients undergoing surgery for benign and malignant breast disease from January 2007 to July 2010; 134 cases were subjected to the sentinel lymph node biopsy; 29 cases of these patients had the presence of perisentinel lymph nodes at histological examination. Before the intervention, we have used colloidal albumin marked with 99mtc to select the sentinel lymph node; during the intervention, we identified by probe the ipercaptant lymph node, consequently we removed and sent it to histological extemporaneous definitive examination. RESULTS: In 134 Sentinel Lymph Nodes examined, 15 resulted positive for breast cancer cells at extemporaneous examination. In these cases, we decided to proceed with an axillary dissection in the same operative session, with the discovery of axillary lymph nodes metastases in 3 cases on 15 (20%). The positive predictive value of sentinel lymph node in case of positivity was 0.2. 8 cases (6,7% of the lymph nodes sentinel biopsy made) were negative to extemporaneous examination and positive to definitive histological examination for presence of micrometastasis. In 8 axillary dissection, 3 patients were positive for the presence of metastasis. We have analysed with the test "t-student" these data divided on age and the value of Ki-67. Then we calculated the predictive positive and negative value (patients with negative sentinel lymph node: Mean age (+/- sd) =61.93 +/- 13.8 years, ki-67=10.87 +/- 5.78; patients with positive sentinel lymph node: Age mean (+/- sd) = 64 +/- 12 36 years, ki-67=14.08 +/- 8.005). The study showed no statistically significant differences between the positive and negative sentinel lymphnodes about the age (p=0.58) and the Ki-67 (p=0.184). In the 29 cases in which the sentinel lymph node was negative at extemporaneous histological examination and in which were removed the perisentinel lymph nodes, resulted negative at definitive histological examination, the negative predictive value was equal to 1. CONCLUSIONS: The method of sentinel lymph node has demonstrated to be a reproducible, reliable and safe technique. The positivity of sentinel lymph node at final examination (micrometastasis, cells isolated) in case of extemporaneous examination negative for breast cancer cells, determines specifical considerations on surgical indication to axillary dissection. We think that in selected cases (age, biological characteristic of cancer) in which perisentinel lymph nodes were removed and free from breast cancer cells, may not be indicated in case of sentinel node positivity the axillary dissection.

Choledocholithiasis and endo-laparoscopic rendezvous. Analysis of 59 consecutive cases.

BACKGROUND: Choledocholithiasis is a real problem of major clinical importance. The incidence of cholelithiasis is 10-20%. MATERIALS: We have examined 2907 patients treated with videolaparoscopic cholecystectomy (VLC) between January 2001 and September 2009. 214 cases (7.4%) were affected by choledocolithiasis; among these, 59 consecutive cases were treated by rendezvous, 151 cases by sequential treatment (ERCP-ES before VLC), 3 cases by extraction with Dormia's basket, and 1 case by ERCP-ES after VLC. RESULTS: The complications were one biliary fistula and three hemorrhages (one from the cystic artery, one from the hepatic area and one from trocar's site). The mean hospital stay was 1.38 +/- 0.83 days for the rendezvous group vs 4 53 +/- 0.74 days in the sequential treatment group (p<0.004). The satisfaction scores were 6.6 +/- 1.39 versus 5.7 +/- 0.96 (p<0.004). CONCLUSIONS: The rendezvous procedure reduces hospital stay and has a greater compliance (only one treatment). We can use this option in the management of cases where preoperative ERCP-ES has failed.

Laparoscopic proctocolectomy: analysis of long term complications. Case report.

Surgery can be a curative treatment for ulcerative colitis. The correct surgical procedure is a total proctocolectomy and ileo anal J pouch anastomosis (IPAA). This procedure is feasible also in laparoscopic approach after a correct learning curve. Pouchitis, pouch complications, intestinal occlusion, infertility are the most common long term complications. We present a case of a 37-year-old man treated with laparoscopic proctocolectomy and followed at 18 months.