Abstract: Since 2001 we have conducted a prospective randomised study of right laparoscopic-assisted hemicolectomy vs open right hemicolectomy for right colon cancer in order to assess the differences in intraoperative and postoperative results as well as oncological clearance. Thirty-three patients with right colon cancer received laparoscopic-assisted right hemicolectomy (LRH) and were compared with 33 patients who underwent open right hemicolectomy (ORH). We analysed morbidity and mortality, number of postoperative days of starving, postoperative days tolerating a liquid diet and a soft diet, duration of postoperative ileus, as well as the distance of the resection margin from the tumour (< 5 cm or >5 cm), and the number of lymph nodes found in the resected specimen. We also compared the length of operative time, blood loss, and any associated surgery. Morbidity occurred in 1 patient undergoing LRH (3.0%) as against 4 patients (12.1%) in the ORH group (p < 0.05). Postoperative ileus lasted 3.15 days (range: 3-5 days) in the LRH group vs 3.0 days (range: 1-4 days) in the ORH group. Median operative time was 251 min (range: 130-360 min) in the LRH group vs 222.9 min (range: 135-360 min) in the ORH group, while blood loss amounted to a median of 135 mi (range: 100-300 ml; SD +/- 42.9 mi) in the LRH group vs. 404.1 ml (range: 250-1000 ml; SD +/- 159.3 ml) in the ORH group (p <0.05). The distance of the resection margin from the tumour was more than 5 cm in both groups. In the LRH group a median of 12.7 lymph nodes were removed (range: 9-31; SD +/- 4.5) vs. 18 lymph nodes in the ORH group (range: 8-29; SD +/- 3.9) (p < 0.05). Associated surgery was performed in 15.1% of cases in both groups. In our experience LRH presents a statistically significant advantage in terms of morbidity and blood loss compared to ORH. Equivalent oncological clearance was obtained, fulfilling the stated criteria of 5 cm free resection margins and number of lymph nodes resected, though we removed fewer lymph nodes in LRH compared to ORH (p < 0.05).
Abstract: Amyand's hernia is defined as an inguinal hernia within the hernial sac containing the appendix. It is a rare disease, reported in 1% of cases of inguinal hernia repair. The appendix can be complicated by acute appendicitis in 0.13% of cases. This disease is often very difficult to diagnose, and most of the time it can be confused with an incarcerated or strangulated inguinal hernia. Often, it requires an emergent surgical treatment. This article describes the case of a 82-year-old female who was admitted for an intestinal obstruction and a bulge in the right inguinal region. An abdominal computed tomography scan showed dilated small bowel loops with multiple air/liquid levels and one loop herniating into the right inguinal canal. The patient underwent a laparotomy that showed the presence of an acute appendicitis and a necrotized ileal loop protruding into the right inguinal canal. The patient underwent an appendectomy and small bowel resection and she was discharged on postoperative day 10. Amyand's hernia can be a challenge for the surgeon. Its treatment depends on the grade of inflammation of the appendix. In fact, it can range from the simple repair of the abdominal defect with a prosthetic mesh, to appendectomy, small bowel resection and repair of the abdominal wall defect without a mesh.
Abstract: Laparoscopic adrenalectomy is now regarded as the procedure of choice for most adrenal glands presenting surgical pathology. The primary adrenal-specific contraindication to laparoscopic adrenalectomy today is the presence of a large adrenal mass with evidence of local infiltration or venous invasion. We used our multicentre experience to compare the transperitoneal (TLA) and retroperitoneal (RLA) minimally invasive approaches. In our study we found statistically significant differences between RLA and TLA in terms of duration of surgery (148 minuti vs. 112; p < 0.005), intra-operative blood loss (439 cc vs 333 p < 0.005; p < 0.005) and time of first oral intake (1.2 +/- 0.5 days vs 1.8 +/- 1.08 days; p < 0.005). The RLA approach is preferable in cases of previous abdominal surgery, but its learning curve is extremely steep. TLA access needs a less demanding learning curve and tends to be faster than RLA, where the working area is penalised by limited manoeuvring space. There is no clear preference between TLA and RLA in the literature. However, the experience of the surgeon still remains the most important variable when choosing between the two approaches.
Abstract: BACKGROUND: Gastrointestinal stromal tumors (GIST) of the stomach are the most frequent followed by those of the intestinal tract, while colon and rectum represent rare sites. GIST of the anal canal are extremely rare. They have been studied along with GIST of the rectum, as a single entity, and along with them they represent 5% of GIST. GIST arising from the anal canal account for only 2%-8% of the anorectal GIST. Thus anal GIST must be considered an exceptional case. CASE PRESENTATION: A 78-year-old man was referred to our Institution for an anal mass, in absence of any symptom. The patient was treated by local excision. An histological diagnosis of a low grade GIST was made. No further treatment was necessary. No local recurrence of distant metastases were found at follow-up. CONCLUSION: At the moment, only ten cases of c-kit positive anal GIST are reported in the literature. These few data are not sufficient to establish a widely accepted approach for this neoplasia.We recommend to perform an initial local excision, to define the risk of aggressive behavior and the resection margins and proceed to a more aggressive treatment, if the GIST belongs to high or very high risk group. The role of adjuvant therapy is still uncertain. Although inhibitors of tyrosine-kinase receptor needs further studies before their routine use, their role in case of distant or local recurrence has been accepted. Patients' close follow up is mandatory to disclose as soon as possible local recurrences or metastases.
Abstract: BACKGROUND: Retroperitoneal sarcomas represent less than 1% of all diagnosed human neoplasias. They are generally malignant and can infiltrate retroperitoneal structures. The value of chemotherapy and radiotherapy are difficult to evaluate and the dominating factor in the outcome is the ability to resect the tumor. A few patients develop distant metastases. Recurrence of sarcoma at the operative site and on peritoneal surfaces is a prominent cause of morbidity and mortality. CASE REPORTS: Here we report two patients who underwent surgery for retroperitoneal sarcoma. In each of them at least two primary retroperitoneal tumors were diagnosed. The neoplasms were histologically different, thus they cannot be considered local recurrence but rather primary tumors. CONCLUSION: This is the first report underlying the synchronous or metachronous presence of different histological subtypes in this neoplastic pathology. In explanation of the occurrence of satellite tumors and multiple primary tumors, a virus-associated etiology or polyclonality of the tumor or pluripotentiality of tumor stem cells should be considered.
Abstract: BACKGROUND AND OBJECTIVES: The aim of our study was to retrospectively evaluate the results of 2 groups of patients admitted and treated for rectal cancer. METHODS: One hundred and fifty-one patients were available for evaluation. Eighty (group A) were radically operated with the standard technique; 71 (group B) underwent total mesorectal excision (TME). Groups were similar according to demographics, staging, and pathological data. Mean follow-up was 73.5 months. RESULTS: No operative mortality was observed. Complications were 15% in group A and 32% in group B. Local recurrence rates were 41.2% in group A and 12.6% in group B. Distant metastases occurred in 21.2% and 7.6%, respectively, in groups A and B. Cancer-related mortality was 62.5% in the non-TME group and 19.5% in the TME group. Overall 5-year survival rates were 32.4% in group A and 70.5% in group B. Disease-free survival rates were 25% in group A and 62.3% in group B. CONCLUSIONS: TME appears to lower the incidence of cancer-related mortality, with a higher incidence of postoperative complications. Further studies need to be done to assess the real benefits of TME in the surgical treatment of rectal cancer.
Abstract: The echinococcosis represents a common condition in many parts of the world with maximum incidence in Uruguay (32 cases/100,000/year), in Argentina (21 cases/100,000/year), and in Morocco (7.2 cases/100,000/year). Italy is among the middle-high risk countries with beyond 1000 annual surgeries for hydatid cyst. Liver (45-75%) and lung (10-50%) are the most frequent localizations of echinococcosis. The other localizations represents the 13% of total. The hydatid cyst of pancreas constitutes the 1%. The Authors report the clinical case of a 28 years old woman, admitted for abdominal pain. Abdominal ultrasound, angio-CT and angiography of celiac trunk and superior mesenteric artery have been undertaken and the presence of a 10 x 10 cm lesion in the body-tail of pancreas has been showed, and the diagnosis of pseudocyst or cystadeno-carcinoma of pancreas has been formulated. The patient underwent surgery with body-tail pancreatectomy plus splenectomy. The histopathological examination showed the presence of hydatid cyst contained clear fluid and daughter cysts. The treatment of this infrequent localization of hydatid cyst is exclusively surgical. The tactic and surgical technique must aim to radical cyst's removal, with the maximum saving of the stricken organ, maintaining a good pancreatic function, either exocrine and endocrine.
Abstract: A practical and effective method for rapid and bloodless preparation of the rectum using endovascular stapler devices during low anterior resection, or abdominal-perineal excision, is described. This method is presented as an effective means for easily dividing the anterior and lateral attachment of the rectum. The application of this technique is the absence of intraoperative bleeding related to injury of middle hemorrhoidal vessels, with minimal risk of autonomic pelvic nerve damage. An additional factor relevant in the choice of this technique, is the easier possibility to perform rectal dissection of an oncologically adequate tumor clearance from the margin of rectal tumor and with complete radical transection of the lateral ligaments fastly proceeding with the downward mobilization of the rectum close to the pelvic side walls, between the parietal and visceral layer of the pelvic fascia.
Abstract: Between 1978 and 1984 a consecutive series of 571 patients with colorectal cancer were admitted to the First Department of Surgery of the University of Rome. Patients were divided into a group of 82 patients affected with obstructive cancer and a control group of 489 patients with non-obstructive tumors. In the obstructed group there was a significantly higher incidence of lesions localized in the left colon. Depending on the advancement of lesions a significantly higher incidence of Dukes D tumor, nodal involvement, hepatic metastases and peritoneal dissemination and a significantly lower incidence of Dukes A tumors, were found in the obstructed patients. No significant differences were found in the two groups according to age distribution, duration of symptoms and degree of differentiation of neoplasms. The mortality and morbidity rate were 9.7% and 12.2% respectively in the obstructed patients, and 3.5% and 8.3% respectively in the non-obstructed patients. The rate of complications was greater in the two groups when serum albumin values were under 3 g/l, being 40% vs. 3.3 and 20% vs. 5.2% in obstructed and nonobstructed groups respectively. When Hb levels were under 10 g/l the incidence of complications was 16.7% and 14.4% for the two groups, while when it was higher than 10 mg% the morbidity rate was 8.7% and 6.3% in obstructed and non-obstructed patients respectively. The execution of surgical treatment within 24 hours was related to a morbidity and mortality rate of 50% and 22.2% in obstructed patients, and 40% and 20% in the non-obstructed group.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: Personal experience is reported of 47 consecutive liver resections for metastatic colorectal carcinoma treated in the I Clinica Chirurgica of the University of Rome for the purpose of contributing to treatment and evaluating the clinical factors and possible determinants of prognosis that could be potentially predictive of outcome and length of survival after liver resection: Duke's stage of primary colorectal cancer, synchronous or metachronous disease, number of hepatic lesions. Patients were classified according to the proposed staging system of the "Istituto Nazionale Tumori" in Milan. For Stage I and II patients the median survival time was 15 months, while in Stage III patients survival time was reduced to only 4.5 months. The 3- and 5-year survival rate was 20% and 12% respectively for Stage I patients; no patients at stage II or III survived more than 3 years.
Abstract: Colonoscopy and air-contrast barium enema performed preoperatively in 389 patients with colorectal cancer revealed synchronous cancer in 4% and polyp in 14%. Nine of the 16 synchronous cancers were located in other surgical segments than the index cancer, and six of the nine were in stage A or B1. Of the 54 synchronous polyps, 28 were located in such other segments. Half of the synchronous cancers and almost half of the synchronous polyps were missed at double-contrast barium enema. All synchronous cancers and three-fourths of the synchronous polyps were detected at colonoscopy. No patient with preoperative colonoscopy presented with metachronous cancer within 3 years from surgery, and only two were subsequently found to have adenocarcinoma arising from an adenomatous polyp. Endoscopic polypectomy was performed in 21 cases during follow-up. Extensive use of preoperative colonoscopy is recommended in the evaluation of colorectal cancer, in order to promote detection of synchronous tumors, reduce the incidence of 'early metachronous' cancer and avoid malignant degeneration of adenomatous polyp.
Abstract: The incidence of synchronous cancer has been reported to be 1.5% to 7.6%. A retrospective review of all colorectal cancer patients was conducted to determine the incidence of synchronous cancers. 47 synchronous cancers were identified in an operative series of 2586 patients with an incidence of 1.8%. The patients were divided into two groups based on preoperative diagnostic examinations. The first group included 1608 patients examined by double contrast x-ray barium enema (1141) and/or single contrast barium enema (381) and/or rigid sigmoidoscopy (112). The second group included 978 patients examined by double contrast barium enema (459) and/or flexible sigmoidoscopy (631) and/or colonoscopy (389). The incidence of synchronous tumors was 1.6% for patients evaluated only with double contrast roentgenographic study and 4.1% for patients who underwent preoperative colonoscopy. Fifty percent of synchronous cancers detected by colonoscopy were missed at double contrast x-ray barium enema. While twenty two percent of synchronous tumors detected by barium enema were located in different surgical segments and were all "advanced" tumors, when preoperative colonoscopy was performed, 56.2% of synchronous tumors were not located in the same surgical segment, and 66.7% of these were "early" cancers. None of the patients who underwent preoperatively colonoscopy developed a metachronous tumor within 3 years. One percent of patients undergoing flexible sigmoidoscopy or double contrast barium enema developed a second tumor 3 years after surgery. An extended use of preoperative colonoscopy in the diagnosis of colorectal cancers, to increase the detection od synchronous tumors and to decrease the incidence of the so-called "early" metachronous cancers, is stressed.
Abstract: Colorectal cancer is rare in patients under 40 years of age. We reviewed all colorectal cancer patients treated at the First Department of Surgery of the University of Rome, to determine the true incidence of large bowel cancer in young patients. During the period 1978-1984 a total of 571 patients were indexed. Out of these 44 were 39 years of age or less. A group of 527 patients 40 years of age or over served as a control. Neoplasms were localized in the right colon in 19 cases and in the left colon in 25 patients, in the young group. In the control group 178 patients presented neoplasms localized in the right colon, while 349 presented tumors localized in the left colon. According to tumor advancement in the young group tumor classification from A stage tumor through D stage was: 4, 6, 14, 5, 9, 6. In the control group 22 patients presented A stage tumors, 106 B1, 139 B2, 50 C1, 118 C2, 92 D tumors. The operability rate was 93.2% in the young group, and 92% in the old one. The operative mortality rate was 0% in the young group, and 2.5% in the old one. Four complications occurred in the young patients, and 57 in the old patients. The five years survival rate was 56.7% and 52.1% in young and old patients respectively. The results of our study indicate that there are no significant differences in prognosis and five years survival in young patients with colorectal cancer.
Abstract: An early diagnosis in asymptomatic patients and a prompt treatment lead to an improved survival rate in patients with carcinoma of the colon. Patients with a short symptomatic history of colon cancer do not have a better prognosis than patients with a long history. Between 1978 and 1984 a consecutive series of 571 patients with colorectal cancer were admitted to the First Department of Surgery of the University of Rome. All patients were classified into five groups according to the duration of specific intestinal symptoms. In Group 1 (51 cases) asymptomatic patients were included, or patients with no specific symptoms such as asthenia, anemia, occult fecal blood. In Group 2 there were 129 patients with intestinal symptoms of less than 3 months' duration before treatment. In Group 3 there were 192 patients with symptoms of between 4 and 6 months' duration; 151 patients with symptoms of between 6 and 12 months were included in Group 4, and finally 48 patients who presented with symptoms of more than 1 year were included in Group 5. No relationship was noted between tumor site and duration of symptoms. Similarly, no relationship was noted between the duration of intestinal symptoms and stage and tumor differentiation. On the other hand, asymptomatic patients showed a higher incidence of T1N0M0 stage tumor and a lower percentage of undifferentiated neoplasms. The resectability rate was 79% and it was significantly related to the absence of intestinal symptoms. Follow-up data were available in 454 patients (80%). The overall survival rate was 52.4%. In Group 1 through Group 5 the 5-year survival rate was: 83.7%, 50%, 50%, 46.3%, 46.9%. The results of our study indicate that patients admitted in asymptomatic phase presented less-advanced stage tumors and, thus, best survival rate. On the other hand, from our data the duration of intestinal symptoms is not related to the stage and prognosis of tumors.
Abstract: Eighty-eight consecutive patients who underwent curative resection for colorectal cancer between 1983 and 1985 were studied prospectively to evaluate the roles of sequential CEA, TPA and CA 19-9 determinations and independent clinical examination in the early diagnosis of resectable recurrences. Twenty nine recurrences were detected between 8 and 38 months after primary surgery. CEA, TPA and CA 19-9 showed a sensitivity of 72%, 62% and 38%, and a specificity of 78%, 86% and 97%, respectively. Of eight recurrences in which CEA was not raised, five induced a rise in TPA and two a rise in CA 19-9. The rise in the serum concentration of one of the three markers was the first sign of relapse in 23 (79%) patients. Two second-look laparotomies based solely on a rise in serum markers were performed. In one case diffuse recurrent disease was found, and in the other a resectable solitary hepatic metastasis was found.
Abstract: Between 1976 and 1986, a consecutive series of 195 patients with right colon cancer were admitted at the First Department of Surgery of the University of Rome. Patients were divided into five groups according to the absence of intestinal symptoms (group 1) and the duration of the symptomatic phase (groups 2-5). Analysis of the preoperative investigation showed that colonoscopy was able to identify 33 (26.2%) of tumors misdiagnosed by double contrast X-ray barium enema. We did not notice any correlation among symptom duration and tumor stage, tumor differentiation, operability rate, and survival. Patients admitted in the asymptomatic phase presented tumors of less advanced stage and, thus, had the best survival rate (71.4%). In this group, patients promptly treated had a better survival rate (87.5%) than those treated after 2 months (50%). Our study suggests that only neoplasms diagnosed in asymptomatic patients and treated promptly are related to a good survival rate. We, therefore, emphasize the importance of education of patients and family physicians about right colon cancer and the necessity to investigate all patients with a suspected right colon cancer by means of colonoscopy.
Abstract: Thirty-four patients with metachronous colorectal cancer who underwent surgical procedures at the First and Fourth Department of Surgery of the University of Rome were reviewed. 55.9% of the patients developed a second carcinoma within five years after the first operation, and the time interval for the entire group ranged from 13 to 228 months. Adenomatous polyps occurred in 14 patients. Two patients developed a third metachronous cancer. We followed up eight patients using colonoscopy regularly. In this group we found two early cancers, five submucosal cancers and only one advanced tumor. In the other group we found 16 advanced cancers and ten submucosal cancer. The curability rate at second operation was 88.2%, and at the third 50%. The management of metachronous tumors should imply total colonoscopy, at a mean interval of 12-18 months.
Abstract: The role of tissue CEA localization as a complementary factor in prognosis of patients affected by gastric cancer is analyzed. In a group of 31 gastric tumors, tissue CEA was always present in the apical portion of the tumor cell cytoplasm and in the glandular lumen, while in 23 cases it was found in the stroma, and in superficial and deep cell cytoplasm in 26 and 20 cases respectively. The serum marker levels were over 3 ng/ml in 19 patients. A relationship between CEA localization and tumor stage was observed. The more the tumors were advanced, the more the marker was found in the stroma and in the cytoplasm of superficial and deep cells. The same was found for CEA localization and serum CEA levels. The opposite trend was evidenced for the degree of tumor differentiation. In well differentiated tumors in a high percentage of cases the marker was present in the stroma and in the cytoplasm of superficial and deep cells as compared with undifferentiated tumors. No relationship between the histologic type and CEA localization was found.
Abstract: The role of tissue CEA determination as a complementary test in the staging of colorectal cancer and monitoring of the marker in the follow-up of patients, is stressed. In a group of 44 colorectal cancer patients, tissue CEA was determined by the immunoperoxidase assay in the apical and cytoplasmic portion of tumor cells, stroma, glandular lumen, and cytoplasm of superficial and deep cells. A correlation has been observed between spread and stage of tumor and CEA localization at the level of the stroma and cytoplasm of deep cells. It has been also evidenced that in all cases where CEA was present in the stroma and cytoplasm of deep cells, high serum levels of the marker were detected.
Abstract: A 20-year-old man with congenital choledochal dilatation associated with carcinoma was treated. At the age of 10 years he underwent a cholecystectomy and partial resection of the cyst. At admission the patient complained of hypochondriac and back pain combined with bilious vomiting. He underwent a palliative operation. A review of the literature is presented on treatment and prognosis of patients with carcinoma arising in choledochal congenital dilatation previously treated by surgery other than excision. It is emphasized that the cystic dilatation should be removed at the time of the first operation. Furthermore, in patients who underwent surgical treatment without excision of the choledochal dilatation, the dilated biliary tract should be removed even in absence of subjective symptoms.
Abstract: Eighty-six patients operated for stenosis caused by previous iatrogenic lesions of main bile duct over a 13-year period are reported. The incidence of operative lesions of main bile duct is 0.2 to 0.7% and a number of them are caused by surgery on the biliary tract (90%-95%), gastric resection or portacaval shunt. Sixty-five cases were treated by hepaticojejunostomy, 3 by hepaticojejunoduodenostomy and the remaining 18 patients underwent choledochoduodenostomy. Postoperative complications and long term results are also examined.
Abstract: Results obtained using 99mTc HIDA in the follow-up of 17 patients who underwent hepaticojejunal bypass for different indications are examined. Results are also compared to other commonly used procedures such as echography and cholangiography (I.V. or PTC). Preliminary results appear to confirm that cholescintigraphy is an accurate procedure which allows an anterograde and physiologic visualization of the anastomosis.
