Long-term outcomes after laparoscopic colectomy.

AIM: To evaluate long-term outcomes in a large series of patients who randomly received laparoscopic or open colorectal resection. METHODS: From February 2000 to December 2004, six hundred sixty-two patients with colorectal disease were randomly assigned to laparoscopic (LPS, n = 330) or open (n = 332) colorectal resection. All patients were analyzed on an intention-to-treat basis. Long-term follow-up was carried out every 6 mo by office visits. In 526 cancer patients five-year overall and disease-free survival were evaluated. Median oncologic follow-up was 96 mo. RESULTS: Eight (4.2%) LPS group patients needed conversion to open surgery. Overall long-term morbidity rate was 7.6% (25/330) in the LPS vs 11.1% (37/332) in the open group (P = 0.17). In cancer patients, five-year overall survival was 68.6% in the LPS group and 64.0% in the Open group (P = 0.27). Excluding stage IV patients, five-year local and distant recurrence rates were 32.5% in the LPS group and 36.8% in the Open group (P = 0.36). Further, no difference in recurrence rate was found when patients were stratified according to cancer stage. CONCLUSION: LPS colorectal resection was associated with a slightly lower incidence of long-term complications than open surgery. No difference between groups was found in overall and disease-free survival rates.

ERCP in acute pancreatitis: What takes place in routine clinical practice?

AIM: To evaluate the data from a survey carried out in Italy regarding the endoscopic approach to acute pancreatitis in order to obtain a picture of what takes place after the release of an educational project on acute pancreatitis sponsored by the Italian Association for the Study of the Pancreas. METHODS: Of the 1 173 patients enrolled in our survey, the most frequent etiological category was biliary forms (69.3%) and most patients had mild pancreatitis (85.8%). RESULTS: 344/1 173 (29.3%) underwent endoscopic retrograde cholangiopancreatography (ERCP). The mean interval between the onset of symptoms and ERCP was 6.7 ± 5.0 d; only 89 examinations (25.9%) were performed within 72 h from the onset of symptoms. The main indications for ERCP were suspicion of common bile duct stones (90.3%), jaundice (44.5%), clinical worsening of acute pancreatitis (14.2%) and cholangitis (6.1%). Biliary and pancreatic ducts were visualized in 305 patients (88.7%) and in 93 patients (27.0%) respectively. The success rate in obtaining a cholangiogram was statistically higher (P = 0.003) in patients with mild acute pancreatitis (90.6%) than in patients with severe disease (72.2%). Biliary endoscopic sphincterotomy was performed in 295 of the 305 patients (96.7%) with no difference between mild and severe disease (P = 0.985). ERCP morbidity was 6.1% and mortality was 1.7%; the mortality was due to the complications of acute pancreatitis and not the endoscopic procedure. CONCLUSION: The results of this survey, as with those carried out in other countries, indicate a lack of compliance with the guidelines for the indications for interventional endoscopy.

Selective intra-graft apoptosis and down-regulation of lymphocyte bcl-2, iNOs and CD95L expression in kidney-pancreas transplanted patients after anti-Thymoglobulin induction.

Intra-graft infiltrating cells apoptosis was evaluated in 20 consecutive kidney-pancreas transplanted (KP) patients without kidney rejection. Two fine-needle aspirated biopsy (FNAB) and two peripheral blood lymphocytes (PBL) samples were obtained 14 days after transplantation. Immunosuppression was based on anti-Thymoglobulins (ATG) induction for 7 days and cyclosporine/mofetil mycophenolate as maintenance therapy. Ten matched healthy subjects were chosen as controls for PBL. Lymphocyte phenotypes and activation markers, apoptotic rate and lymphocyte expression of pro/anti-apoptotic molecules were analysed by flow cytometry analysis (FACS). Lymphocyte phenotypes and activation markers: higher levels of CD8 and CD4DR were evident in the graft (p < 0.05) than in PBL, CD3CD25 in PBL were higher in transplanted patients than in controls. Apoptotic rate and lymphocyte expression of pro- and anti-apoptotic molecules: a higher expression of annexin V, together with reduced lymphocytes CD95L, iNOs and Bcl-2 expression (PBL = 97.7+/-1.1% vs FNAB = 81.9+/-15.1%; p < 0.05) were evident in the graft than in PBL. In KP patients intra-graft apoptosis and reduced anti-apoptotic molecules were evident after ATG induction.

Preoperative oral arginine and n-3 fatty acid supplementation improves the immunometabolic host response and outcome after colorectal resection for cancer.

BACKGROUND: Previous trials showed that perioperative immunonutrition improved outcome in patients with gastrointestinal cancer. This study was designed to appraise the impact of the simple preoperative oral arginine and n-3 fatty acids supplementation on immune response, gut oxygenation, and postoperative infections. METHODS: Two hundred patients with colorectal neoplasm were randomized to: (a) oral intake for 5 days before surgery of a formula enriched with arginine and n-3 fatty acids (pre-op group; n = 50); (b) same preoperative treatment prolonged after surgery by jejunal infusion (peri-op group; n = 50); (c) oral intake for 5 days before surgery of a standard isoenergetic, isonitrogenous formula (control group; n = 50); and (d) no supplementation before and after operation (conventional group; n = 50). The immune response was measured by phagocytosis ability of polymorphonuclear cells and delayed hypersensitivity response to skin tests. Gut oxygenation and microperfusion were assessed by polarographic probes and laser Doppler flowmetry, respectively. RESULTS: The 4 groups were comparable for demographics, comorbidity, and surgical variables. The 2 groups receiving immunoutrients (pre-op and peri-op) had a significantly better immune response, gut oxygenation, and microperfusion than the other 2 groups. Intent-to-treat analysis showed an overall infection rate of 12% in pre-op, 10% in peri-op, 32% in control, and 30% in conventional groups (P <.04 pre-op and peri-op vs control and conventional). CONCLUSION: Preoperative oral arginine and n-fatty acids improves the immunometabolic response and decreases the infection rate. Postoperative prolongation with such supplemented formula has no additional benefit.