Synchronous "skip" facial metastases from colorectal adenocarcinoma: a case report and review of literature.

BACKGROUND: Skin metastases from colorectal adenocarcinoma are rare conditions that are metachronous in most of cases and may represent the first sign of a recurrence. These lesions are usually located to the abdominal wall on postoperative scars, perineum and chest due to direct spread from the tumor or to the lymphatic and venous dissemination. We describe a rare case of synchronous skin metastases in a patient affected by sigmoid adenocarcinoma with no sign of liver and lung repetitive lesions. CASE PRESENTATION: We admitted a 59 years old male, with no relevant medical history. He was evaluated by our tertiary center of colorectal surgery complaining diarrhoea and abdominal pain. The physical examination revealed a palpable mass in left flank of the abdomen. The colonoscopy showed a sub-stenosis of the sigmoid colon (G2 adenocarcinoma). No repetitive lesions were detected by the preoperative CT scan. The patient reported a rapid grow of a soft supralabial and chin nodules in the last 2 months, which he believed to be related to the use of the mask due to COVID-19 pandemic. A laparoscopic left hemicolectomy with complete mesocolic excision and a local excision of both facial nodules were performed. The histological examination revealed a poorly differentiated signet ring cell colorectal adenocarcinoma with metastases in seven pericolic lymphonodes. The excisional biopsy of the skin nodules revealed a subcutaneous metastases from primary colorectal tumour. CONCLUSIONS: As far as we know, synchronous facial metastases from colorectal cancer in the absence of any other metastases has never been described before. The onset of new skin nodules in patients affected by colorectal cancer should raise-up the clinical suspicion of metastatic lesions even when repetitive lesions are not detected in the liver or lungs.

Ageing with sacral nerve modulation for fecal incontinence: how many patients get benefit after more than 10 years?

Sacral nerve modulation (SNM) has represented a major advancement in the minimally invasive management of patients with fecal incontinence (FI). Although the success rate in the short-medium term has widely been demonstrated, the very long-term outcomes are poorly investigated. This study aims to assess the effectiveness of SNM in a cohort of patients with a follow-up longer than 10 years. Clinical records of patients submitted to SNM for FI in our tertiary referral colorectal Unit between 1998 and 2010 were retrospectively reviewed looking for status of the implantable pulse generator (IPG), follow-up duration, severity of FI by the St Marks' score and quality of life. 58 patients fulfilled the entry criteria and 36 (58%, median follow-up, 12 years) accepted to take part to the telephone interview, while 22 (38%) were lost to the follow-up. Nineteen patients had their IPG removed (Group A) while 17 (27%) had the SNM still active after a median follow-up of 13 years (Group B). In the group A, the median baseline St Marks' score was 13 and did not change after the IPG removal. In group B, the median baseline St Marks' score was 14, at last IPG substitution, it was of 7 and at the last follow-up dropped to 4. In the group A, the median SF-12 physical and mental scores did not change significantly while they improved significantly in group B. A progressive deterioration of the success rate of SNM with the time has been documented after a very long-term follow-up.

Persistent dyspepsia after laparoscopic cholecystectomy. The influence of psychological factors.

BACKGROUND: Many patients with gallstone disease continue to report gastrointestinal symptoms after cholecystectomy, but the predictive value of preoperative factors is not well understood. We aimed to investigate whether psychological symptoms can be associated with poor outcome after cholecystectomy in patients with gallstones and dyspepsia. METHODS: A sample of 52 consecutive patients with uncomplicated gallstone disease and dyspepsia (conceived in a broader sense to include symptoms of the whole digestive tract) were assessed for psychological (revised 90-item Hopkins Symptom Checklist) and gastrointestinal symptoms (Gastrointestinal Symptom Rating Scale). One year after laparoscopic cholecystectomy, patients rated their gastrointestinal symptoms and were divided into improved and unimproved on the basis of the change in symptoms. RESULTS: Twenty-one (40.4%) patients did not improve after surgery. Improved and unimproved patients did not differ in terms of sex, age, education or illness duration. Unimproved patients showed significantly higher psychological and dyspeptic symptoms than improved patients before surgery. Logistic regression showed that psychological factors were significantly associated with unimprovement after surgery. CONCLUSIONS: Patients with gallstone disease and dyspeptic symptoms are unlikely to improve 1 year after surgery if they show psychological distress before surgery. Psychological symptoms were strongly associated with poor post-cholecystectomy outcome, thus highlighting the clinical relevance of joint assessment of psychological and gastrointestinal symptoms before surgery.

[Recurrence of varicose veins after treatment. Multicenter study by the Italian Doppler Club, Clinical and Technological Society]. / La comparsa di varici dopo loro trattamento. Studio multicentrico del Doppler Club Italiano Società di Clinica e Tecnologia.

BACKGROUND: The first results of a multicentric study dealing with recurrent varicose veins after surgery are presented. The aims of the study are: identifying the type of varicose vein, specifying the most frequent complaints (esthetical or functional), locating the causes of recurrence, establishing the causes and the most frequent seat of recurrence, clarifying whether it is enough to call recurrent all the varicose veins which appear after surgery or whether it is necessary to distinguish various typologies. METHODS: 194 patients (139 women and 55 men) aged 51.6 average (range 28-87), have been studied up to now with duplex and color scanner following a precise protocol which consisted of three stages: before treatment, within 2 months from treatment and after recurrence of varicose veins or venous insufficiency symptoms. RESULTS: Recurrent varicose veins represented 65.7%, residual ones 14.3%, new ones 2.5%. It has not been possible to identify the type of varicose vein in 8.3% of cases. Stripping of the great saphenous veins was carried out in 88% of cases, short stripping in 4.1%, stripping of the short saphenous veins in 6.9%. Recurrent varicose veins were due to technical error in 78.7% of cases, to diagnostic error in 9.2%, to unidentifiable causes in 12% of cases. CONCLUSIONS: Data relating to the prospective study of the research will be published in subsequent papers.

[Surgical therapy of the peptic ulcer in a hospital specializing in gastroenterology. Effects of therapy with h2 antagonists]. / La terapia chirurgica dell'ulcera peptica in un Ospedale specializzato in gastroenterologia. Effetti della terapia con anti-H2.

To evaluate how the introduction of H2-receptor antagonists has modified the epidemiology of surgical management of peptic ulcer, we examined data records of patients operated on for gastric or duodenal ulcer in our Institute. Patients were divided into two groups: a) patients operated from 1970 to 1979 and b) patients operated from 1980 to 1992. The comparison between the two groups showed the following variations: decrease in male/female ratio from 8 to 4.4:1 (p = 0.0009); decrease in duodenal/ gastric ulcer ratio from 5 to 3.5:1 (p = 0.02); decrease in elective/emergency surgery ratio from 16 to 6.4:1 (p = 0.00006); increase in mean age of patients undergoing emergency operations from 51 to 58 years (p = 0.05); decrease in elective/emergency surgery ratio for gastric ulcer from 17.5 to 5.3:1 (p = 0.03), above all for the increase in emergency operations for hemorrhage; decrease in the prevalence of operations for refractory duodenal ulcer from 49% to 36% (p = 0.00009). Our findings show that H2-receptor antagonists have greatly modified the epidemiology of surgical treatment of peptic ulcer with a clear decrease in elective surgery for refractory duodenal ulcer in men and an increase in emergency surgery for gastric ulcer.

[The palliative surgery of periampullary neoplasms. Our experience]. / La chirurgia palliativa delle neoplasie peri-ampolari. Nostra esperienza.

The increased incidence of peri-ampullar neoplasia and the low percentage of cases in which radical surgery is possible fuel interest in the use of palliative treatment for this pathology. The authors report their 10-year experience of palliative surgery for peri-ampullar cancer and evaluate immediate and long-term results. Between January 1980 and December 1990 the authors operated 91 patients with peri-ampullar carcinoma (head of the pancreas, Vater's ampulla, terminal choledochus). Eight (9%) underwent radical surgery and 83 (91%) underwent palliative surgery. The distribution of cases according to tumour origin in the latter group was as follows: head of the pancreas 60 cases (72%); intra-pancreatic choledochus 13 (16%); Vater's ampulla 10 (12%). The most frequent symptoms were pain (70%) and jaundice (63%). The mean interval between the appearance of symptoms and diagnosis was 1 month (range: 5 days-12 months). The most frequently performed biliodigestive derivative surgery was cholecystojejunostomy (72% of cases). Complications were observed in 18% of cases. Mortality was 12%. Mean survival was 5 months (range: 2-43 months). The recent use of endoscopic techniques for the treatment of jaundice in patients with inoperable peri-ampullar carcinoma now requires prospective studies to compare these techniques with surgery.

Influence of the method of digestive tract reconstruction on gallstone development after total gastrectomy for gastric cancer.

The aim of this study was to evaluate whether total gastrectomy performed for gastric cancer leads to an increased risk of cholelithiasis and whether the method of reconstruction of the digestive tract influences that risk. A total of 102 patients who had undergone total gastrectomy for gastric cancer between 1980 and 1990 were studied. The preoperative prevalence of cholelithiasis was 4% in men and 12% in women. Eighty-seven patients (85%) without gallstones before surgery were reexamined after gastrectomy. The postoperative prevalence of cholelithiasis in this group was 36% in men and 19% in women. Before surgery, the difference between the expected frequency of cholelithiasis (calculated on the basis of the data of a community survey) and the observed frequency was not statistically significant (p > 0.05) either in men or women. After surgery, the observed frequency of gallstones was significantly higher than the expected frequency in men (p < 0.0001) but not in women (p = 0.06). The risk of cholelithiasis was significantly higher in patients with Roux-en-Y reconstruction (n = 55) than in those with jejunal interposition (n = 32) (log-rank test, p = 0.03), and that risk was independent of age, sex, and body mass index.

[Cholelithiasis after total gastrectomy for gastric cancer]. / Calcolosi della colecisti dopo gastrectomia totale per cancro gastrico.

After gastric resection for peptic ulcer and total gastrectomy for Zollinger-Ellison syndrome, there is an increased prevalence of cholelithiasis. In order to assess whether this increased prevalence also exists after total gastrectomy for cancer, we evaluated the rate of cholelithiasis (echographic diagnosis) both before and after this operation. Between 1980 and 1990, 89 patients underwent total gastrectomy for cancer in the Surgical Department of our Institute. The pre-operative prevalence of gallstones was 5% in the males and 13.8% in the females. Seventy-four of the eighty-nine patients (83%) were examined post-operatively (7 patients with pre-operative cholelithiasis, 3 who died during the post-operative stay and 5 lost to follow-up were excluded from the study). The median post-operative follow-up was 24 months (range 3-115 months). The post-operative prevalence of cholelithiasis in the 74 patients was 39.6% in the males and 19% in the females. We also calculated the expected frequency of gallstones in both the pre- and post-operative groups from prevalence data in the population of the city where our Institute is based (taken from an echographic survey). We then compared the observed frequency of cholelithiasis with the expected frequency and we found that the difference in pre-operative frequencies, both in the males and females, was not statistically significant (p > 0.05). The same was true of the post-operative frequencies in the females (p = 0.48), but in the males there was a statistically significant difference between the observed frequency of cholelithiasis and that expected after total gastrectomy (p < 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Polyamines and estrogen-receptor concentrations in human colorectal carcinomas.

We assayed the estrogen receptors and polyamine levels (putrescine, spermidine and spermine) in the neoplastic and "normal" surrounding tissue of patients with colorectal cancer. Polyamine levels and the spermidine/spermine ratio were significantly higher in the neoplastic tissue than in the "normal" surrounding colonic mucosa of the same patients. Estrogen receptors were fewer in neoplastic mucosa than in the surrounding tissue, and polyamine levels were higher in estrogen-receptor negative tumours than in estrogen-receptor positive ones, although this was statistically significant only in the case of spermidine. Polyamine levels and estrogen receptor concentrations did not correlate with the tumour site, histological differentiation, or the age and sex of patients.

[Reconstruction of the digestive tract after total gastrectomy. A comparison of Roux anastomosis with Nakayama's beta-anastomosis]. / Ricostruzione del tratto digestivo dopo gastrectomia totale. Confronto tra anastomosi secondo Roux e beta-anastomosi secondo Nakayama.

Digestive tract reconstruction following total gastrectomy can be classified into two types according to whether the duodenal tract is excluded or preserved. Two groups of patients who underwent digestive tract reconstruction excluding the duodenal tract following total gastrectomy due to cancer were compared retrospectively: Nakayama's anastomosis was used in 20 patients (57%), and a Roux-en-Y anastomosis was performed in 15 (43%). The main technical difference between the two groups consists in the distance between esophagojejunostomy and jejunojejuno anastomosis: 20 cm in the case of Nakayama's technique and 50 cm in the case of the Roux-en-Y reconstruction. Results showed that 40% of patients with Roux-en-Y anastomoses were asymptomatic compared to 60% of patients with Nakayama's beta-anastomosis (chi-square test, p = 0.36). The most frequent symptom in patients with Roux-en-Y reconstructions was a feeling of postprandial fullness (33%), whereas pyrosis (25%) was the most common compliant in patients with Nakayama's reconstruction. Endoscopy revealed the presence of esophagitis in 35% of patients with Nakayam's beta-anastomosis compared to 6.5% in patients with Roux-en-Y anastomosis (chi-square test, p = 0.012). Results confirm that a minimum distance of at least 50 cm between the esophagojejunal and jejunojejunal anastomoses is decisive in reducing the frequency of reflux esophagitis after total gastrectomy.

[Colorectal carcinoma. A review of our cases]. / Carcinoma del colon-retto. Nostra revisione casistica.

A retrospective study was carried out on patients who underwent surgery for colorectal carcinoma between January 1980 and December 1987 in order identify additional prognostic factors. A total of 203 patients were studied. The probability of survival in relation to time and other variables (sex, age, stage of disease) was assessed using Cox's proportional method with the aid of an EPILOG III statistics pack. The overall 60-month survival rate was 55% and no difference was found between colon and rectum. The following factors were taken into account as prognostic markers: the site of the carcinoma (colon or rectum), sex, age, the tract of the colon involved (right, transverse, left and sigma colon) and the stage of disease. None of these parameters, with the exception of the stage of disease, were statistically significant. On the contrary, the division into stages of disease showed a statistically significant difference in the 60-month survival curve which fell from approximately 80% for stages A, B1, B2 and B3 to 50% for stage C and to 0% for stage D.

[Disabling outcomes and psychological disorders in the patient with an enterostomy]. / Esiti invalidanti e disturbi psicologici nel paziente portatore di enterostomia.

The authors carried out a retrospective study of patients undergoing enterostomy during the past 9 years. From 1981 to present a total of 60 patients (39 males and 21 females) were operated and subsequently followed-up. The aim of the study was to examine the following factors: the diagnosis which led to operation, the type of stoma used, early and late complications, the behaviour of the alvus, psychological disorders and Karnofsky's Performance-Status Index. After having presented the findings, the surgical results obtained are discussed together with the patient's psychological reactions to stoma. All types of early surgical complications were absent in 66.6% of patients, whereas late complications were absent in 41.6%. Even in those cases where surgical techniques and prostheses permitted a satisfactory post-operative outcome, the sociopsychological and sexual problems relating to the wound and the perceived difference between the real and ideal Ego are highlighted.

[Primary carcinoma of the gallbladder]. / Il carcinoma primitivo della colecisti.

Primary carcinoma of the gallbladder is still a controversial issue. The paper reports a series of 25 patients affected by carcinoma of the gallbladder, observed from May 1975 to October 1989. Patients presented symptoms which in most cases were similar to those of cholelithiasis. Instrumental tests enabled a preoperative diagnosis to be made in only 8 cases (32%). In the remaining 17 cases (68%), diagnosis was only possible during the operation following the histological examination of the affected part. Mean survival was 7.3 months. These findings are in line with those reported in the literature, from which it is clear that carcinoma of the gallbladder, even when identified using instrumental tests, cannot be treated by radical surgery except in a very small percentage of cases.