[Efficacy, impact on survival and cost of intensive follow-up after curative resection for colorectal cancer aim]. / Il follow-up intensivo degli operati per cancro colon-rettale.

AIM OF THE STUDY: This retrospective study was aimed at establishing the efficacy, impact on survival and cost of an intensive follow-up program. METHODS: Data from 790 patients who underwent resections for primary colorectal carcinoma were prospectively entered into a data-base. Four hundred fifty-six patients who had radical surgery were followed-up with a 5-year preestablished schedule. Median follow-up was 42 months (range 2-108). RESULTS: Seventy-four adenomas, 7 metachronous carcinomas, 11 extra-colonic carcinomas and 96 recurrences (13 locoregional recurrences, 68 metastases and 15 cases of combined recurrences) were detected. Thirty-eight (39.6%) of 96 recurrences were amenable to salvage therapy and 23 relapses (24.0%) were radically resected. The median survival of patients who had recurrences was 38 months. The 5-year overall survival was significantly better in patients underwent radical surgery than those who were not treated with curative resection (60.0% vs 7.5%, p < 0.0001). Radical re-operations were performed in 2 (4.8%) of the 42 symptomatic patients and in 21 (38.9%) of the 54 cases with asymptomatic relapses. Median overall survival of patients with asymptomatic recurrences was significantly higher than those with syntomatic relapses (20 vs 6 months, p < 0.0001). The follow-up program used showed an efficacy of 4.6% and led to an expense, based on the exclusive cost of the visits and tests included, of 2087,10 Euro for colonic cancer and 2519.90 Euro for rectal cancer. CONCLUSIONS: Our intensive follow-up program after curative colorectal cancer surgery allowed to detect a quite large number of asymptomatic recurrences with a benefit in term of radical re-operation and overall survival.

[Penetrating abdominal trauma: 20 years experience in a Western European Trauma Center]. / Traumi penetranti dell'addome. Esperienza di 20 anni in Trauma Center dell'Europa Occidentale.

BACKGROUND: The incidence of penetrating abdominal trauma in Western Europe is low. While non-operative management of blunt trauma has become the gold standard, the management of penetrating trauma is still controversial. Nonoperative management (NOM) and laparoscopy are currently used in selected patients, reducing the rate of unnecessary laparotomy. METHODS: We retrospectively reviewed a 20-years period from the Trauma Registry of our Trauma Center. 6523 patients were admitted for thoraco-abdominal trauma (5861 blunt vs 662 penetrating). We sorted the 114 patients with penetrating abdominal trauma in 2 groups for period (1989-2000 vs 2001-08, before and after the establishment of dedicated trauma unit) analyzing their demographics, clinical, therapeutic characteristics and the outcome in comparison. RESULTS: In the latest period a significant increase in the incidence of penetrating trauma has been observed (doubled from 4.17/year up to 8.53/year, accounting now for 13.95% of all trauma laparotomies vs 7.8% in the past decade). A reduction of GSW (30% vs 12.5%, p = ns) occurred while no differences have been recorded in sex, age, prognostic parameters at arrival such as mean GCS (11.8 vs 13.2), ISS (22 vs 18), pH, BE and blood transfusion (6.4 vs 4.3 U) requirement. Interestingly a markedly significant change has been observed in the demographics of the victims (67.2% were of extra-EU origin vs 8% in the previous decade, p < 0.01). Recently the use of NOM spread widely in selected stable patients (21.9%). The failure rate of NOM was 14.3%. The percentage of unnecessary laparotomies decreased from 36% to 21.1% (p = ns). The introduction of laparoscopy was helpful in achieving a reliable, less invasive exploration, allowing detection of the peritoneal penetration and complete visceral exploration. Two GSW (4%) vs 3 (5.8%) cases of the latest years required Damage Control Surgery. A recent significant reduction in mortality and morbidity rate has been recorded (respectively 3.85% vs 18%, p < 0.05; 20% vs 39%, p = ns). CONCLUSION: The recent immigration phenomenon and social changes contributed towards a significant rise in the incidence of penetrating trauma in Italy in the last decade associated to changes in the mechanism of injury. The increased use of NOM and laparoscopy contributed in decreasing the incidence of unnecessary laparotomies as well as overall morbidity and mortality.

Prognosis and treatment of pancreaticoduodenal traumatic injuries: which factors are predictors of outcome?

BACKGROUND/PURPOSE: Abdominal trauma rarely causes injuries involving the duodenum and pancreas. Associated injuries occur in 46% of all pancreatic injuries. The morbidity and mortality of pancreaticoduodenal injuries remain high. METHODS: The present study is a retrospective review of our experience from 1989 to 2008 in the surgical treatment of traumatic pancreaticoduodenal injuries. Mortality, morbidity, prognostic factors, and the value of surgical techniques were analyzed. RESULTS: In our level I Trauma Center, between 1989 and 2008, 55 patients had a pancreaticoduodenal injury. In 68.5% of cases pancreatic injuries were found, 20.4% had duodenal injury, and 11.1% suffered combined pancreaticoduodenal injuries; 85.3% of the patients had blunt abdominal trauma, while 14.9% had penetrating injuries. We treated 78.1% of the patients with external drainage and/or simple suture; distal pancreatectomy was performed in 9% of cases and duodenal resection with anastomosis (3.7%) and diversion procedures (3.7%) were performed in an equal number of patients. Age, American Association for the Surgery of Trauma (AAST) grade, organ involved, hemodynamic status, intraoperative cardiac arrest, and operative time remained strongly predictive of mortality on multivariate analysis. The AAST grade represented, on multivariate analysis, the only independent prognostic factor predictive of overall morbidity. In the past decade we have used feeding jejunostomy more frequently, with a reduction of mortality and operating time, due also to a better approach from a dedicated trauma team. CONCLUSIONS: Optimal management and better outcome of pancreaticoduodenal injuries seem to be associated with shorter operative time, and with simple and fast damage control surgery (DCS), in contrast to definitive surgical procedures.