Laparoscopic versus open surgery for extraperitoneal rectal cancer: a prospective comparative study.

BACKGROUND: The role of laparoscopic resection (LR) in the management of extraperitoneal rectal cancer still is unclear. This study aimed to compare perioperative and long-term results of laparoscopic and open resection (OR) for low and midrectal cancer. METHODS: A prospective nonrandomized trial comparing patients submitted to OR or LR for low and midrectal cancer at a single institution was conducted. RESULTS: The study included 191 consecutive patients: 98 patients who underwent LR and 93 who underwent OR. The mean follow-up period was 46.3 months for LR and 49.7 months for OR. The conversion rate for LR was 18.4%. With the use of LR, the mean time for complete patient mobilization was shorter (1.7 vs 3.3 days; p < 0.001) and patients were earlier in passing flatus (2.6 vs 3.9 days; p < 0.001) and stools (3.8 vs 4.7 days; p < 0.01), and in resuming oral intake (3.4 vs 4.8 days; p < 0.001). The mean hospital stay was shorter for LR, but the difference did not reach significance (11.4 vs 13 days). Morbidity and mortality rates were similar: LR (24.4% and 1%) and OR (23.6% and 2.2%). Laparoscopic patients presented a higher rate of anastomotic fistulas (13.5% vs 5.1%) and reoperations (6.1% vs 3.2%) but the difference was statistically nonsignificant. Laparoscopic resection presented a significantly lower local recurrence rate (3.2% vs 12.6%; p < 0.05). The cumulative survival and disease-free rates at 5 years were, respectively, 80% and 65.4% after LR and 68.9% and 58.9% after OR (nonsignificant difference). Stage-by-stage comparison showed prolonged cumulative survival for stages III and IV cancer in LR (82.5% vs 40.5%; p = 0.006 and 15.8% vs 0%; p = 0.013, respectively) and a reduced rate of cancer-related death for stage III in LR (11.4% vs 51.9%; p = 0.001). CONCLUSIONS: As compared with conventional open surgery, LR for low and midrectal cancer is characterized by a faster recovery and similar overall morbidity (but a higher rate of anastomotic leakages), and does not present any adverse oncologic effect.

Mutations in CYP11B1 gene converting 11beta-hydroxylase into an aldosterone-producing enzyme are not present in aldosterone-producing adenomas.

In the human adrenal cortex, cortisol and aldosterone are synthesized by the isozymes 11beta-hydroxylase and aldosterone synthase, respectively, encoded by the 93% identical CYP11B1 and CYP11B2 genes. In vitro mutagenesis of CYP11B1 complementary DNA, resulting in the replacement of CYP11B1 codons by those encoding the corresponding amino acid residues of CYP11B2 enzyme (exon 5, Ser288Gly; exon 6, Val320Ala), yields a complementary DNA encoding a mutant enzyme with an efficient aldosterone synthase activity. Identical somatic mutations in the CYP11B1 gene in vivo would produce a gene encoding an enzyme with C18 activity and that would preserve ACTH responsiveness due to the retained 5'-promoter in the mutated CYP11B1 gene. An ACTH-responsive aldosterone synthase activity of this type is commonly seen in patients with aldosterone-producing adenomas (APA). We examined the occurrence of mutations in exons 5 and 6 of the CYP11B1 gene in APA from 10 patients with primary aldosteronism. Patients were selected on preoperative evidence of a 50% or greater plasma aldosterone decrease after short term dexamethasone trial and no aldosterone response to upright posture. DNA from adenomas was amplified by PCR using two pairs of primers spanning the regions of CYP11B1 gene, i.e. exons 3-5 and exons 6-9, where mutations could be located. Targeted regions were screened for mutations by automated sequencing of PCR products. No point mutations of the CYP11B1 gene over the two regions examined were found in APA. This argues against involvement of mutations in the pathogenesis of ACTH-responsive APA.

Laparoscopic vertical banded gastroplasty for morbid obesity. Assessment of efficacy.

BACKGROUND: The advantages of treating morbidly obese patients via the laparoscopic approach have been demonstrated, in particular, for adjustable silicone gastric banding, but this operation is associated with a high rate of late complications. Gastric bypass and malabsorbitive procedures are feasible via the laparoscopic approach, but they entail a prolonged operating time and a consistently high morbidity rate. Laparoscopic vertical banded gastroplasty represents an effective alternative. METHODS: We performed 250 consecutive LVBG between November 1995 and February 2000. The procedure consisted of a personal technique designed to reproduce, by laparoscopy, MacLean's modification of the standard open Mason vertical-banded gastroplasty, with a calibrated transgastric window, a complete division between the staple lines, and a 5-cm-circumference polypropylene collar. RESULTS: The operative time was 95 min and the conversion rate was 0.8%. Operative mortality was nil; early and late complications, respectively, were 4.4% and 4%; the reoperation rate was 2%. Global results at 4 years were as follows: excess weight loss (EWL) 61%, success rate (excess weight <50%) 76.9%, body mass index (BMI) 29.4 kg/m2. In morbidly obese patients, the EWL at 4 years was 62.2%, with a 77.4% success rate and a 28.4 kg/m2 BMI; in superobese patients, the EWL at 4 years was 54.9% with a 50% success rate and a 35.5 kg/m2 BMI. The overall follow-up rate was 92%. CONCLUSIONS: LVBG is an effective and safe operation in morbidly obese patients, providing good weight loss with a low morbidity rate, no mortality, and minimum discomfort. However, in superobese patients, the weight loss results are disappointing; in these patients, LVBG is questionable and more complex procedures should be considered.

Laparoscopic vs open hepatic resection: a comparative study.

BACKGROUND: Although the feasibility of minor laparoscopic liver resections (LLR) has been demonstrated, data comparing the open vs the laparoscopic approach to liver resection are lacking. METHODS: We compared 30 LLR with 30 open liver resections (OLR) in a pair-matched analysis. The indications for resection were malignant disease in 47% of the LLR and 83% of the OLR. The average size of the lesions was 42 mm for LLR and 41 mm for OLR. Five wedge resections, 12 segmentectomies, and 13 bisegmentectomies were performed in each group. RESULTS: The conversion rate for LLR was nil. The mean operative time was 148 min for LLR and 142 min for OLR. Mean blood loss was minimal in the LLR group (320 vs 479 ml; p < 0.05). Postoperative complications occurred in 6.6% of the patients in each group; there were no deaths. The mean postoperative hospital stay was shorter for LLR patients (6.4 vs 8.7 days; p < 0.05). In tumors, the resection margin was <1 cm in 43% of the LLR patients and 40% of the OLR patients ( p = NS). CONCLUSIONS: Minor LLR of the anterior segments has the same rates of mortality and morbidity as OLR. However, the laparoscopic approach reduces blood loss and postoperative hospital stay.

Robot-assisted vs laparoscopic adrenalectomy: a prospective randomized controlled trial.

BACKGROUND: The aim of this study was to assess the benefits and disadvantages of robot-assisted laparoscopic surgery for disorders of the adrenal gland in terms of feasibility, safety, and length of hospitalization. METHODS: Twenty consecutive patients with benign lesions of adrenal gland were randomized into two groups: Patients in the laparoscopic group underwent traditional laparoscopic adrenalectomy (LAP), whereas those in the robotic group underwent robot-assisted adrenalectomy (ROBOT) using the da Vinci robotic system. RESULTS: There was no significant difference between the groups in terms of age, sex, body mass index, and size or locations of lesions. Operative times were significant longer in the ROBOT group (total operative time, 169.2 min [range, 136-215] vs 115.3 min (range, 95-155) p < 0.001. Skin-to-skin time was 107 m (range, 77-154) vs 82.1 min (range, 55-120) (p < 0.001). There were no conversions to open surgery. However, conversion to standard laparoscopic surgery was necessary in four of 10 ROBOT patients (40%; left, one right). Perioperative morbidity was higher in the ROBOT group (20% vs 0%). There was no difference in length of hospital stay. In the following ROBOT group, hospital stay was 5.7 days (range, 4-9) vs 5.4 days (range, 4-8) in the LAP group (p = NS). The total cost of the ROBOT procedure ($3,467) was significantly higher than that for LAP ($2,737) (p < 0.01). CONCLUSION: Laparoscopic adrenalectomy is superior to robot-assisted adrenalectomy in terms of feasibility, morbidity, and cost.

Transperitoneal laparoscopic adrenalectomy: experience in 72 procedures.

PURPOSE: To evaluate the safety and effectiveness of transperitoneal laparoscopic adrenalectomy for a variety of adrenal diseases. PATIENTS AND METHODS: Seventy-two patients underwent laparoscopic adrenalectomy from January 1995 until March 1999. The indications for the treatment were limited to either functioning or nonfunctioning adrenal masses without radiologic evidence of involvement of the surrounding tissues. The indication for bilateral adrenalectomy was Cushing's disease after the failure of other therapies or Cushing's syndrome secondary to ectopic ACTH secretion without the discovery of a primary neoplasm. RESULTS: Thirty-five of the adrenalectomies were performed on the left side and 33 on the right side, and 4 were performed bilaterally. The right-sided procedures required a mean operating time of 130 minutes (range 85-200 minutes), the left-sided procedures required a mean operating time of 140 minutes (range 95-200 minutes), and the bilateral procedures required a mean operating time of 240 minutes (range 210-290 minutes). A conversion from laparoscopy to laparotomy was necessary for 3 patients (4%). Intraoperative complications were reported in 6 patients (8%). Postoperative complications likewise occurred in six patients. CONCLUSIONS: These procedures proved to be safe and able to remove the majority of either functioning or nonfunctioning benign adrenal masses. Some controversy remains regarding the safety of laparoscopic adrenalectomy for large lesions and the safety of bilateral laparoscopic adrenalectomy because of bleeding risks, anesthetic risks, and long operative times. The effectiveness of laparoscopic adrenalectomy for nonfunctioning adrenal masses with histologic findings of carcinoma has not yet been proved.

Tubaric pregnancy - an excellent idea?

Until now, the treatment in cases of tubal pregnancy has been focused on the patient and has not been concerned with saving the embryo. We consider a hypothetical operation: the transfer of the tube, the seat of developing pregnancy, with its vascularization, to the inside of the uterus cavity by an incision in the myometrium, and binding of the breach. In order to support this hypothesis, a review has been made of the literature on surgical treatments of transplantation of the ovary into the uterus at the beginning of the century.

[Septic complications in subclavian vein catheterization]. / Complicanze settiche dell'incannulamento della vena succlavia.

Authors have studied the incidence of septic complications due to subclavian vein catheterization, According to literature, have considered that this is generally connected to the operating ability. Septic contamination, though of high incidence, only exceptionally is reason of a septic clinical condition.

[Immunotrypsinogen and amylase isoenzymes in pancreatic diseases]. / Immunotripsinogeno e isoenzimi dell'amilasi nelle pancreatopatie.

Serological tests used in pancreatic diseases, especially isoamylase analysis and trypsin radioimmunoassay are presented. The results show that these markers are helpful in the diagnosis of chronic pancreatic diseases.

[Problems of general surgery in the cardiosurgical patient]. / I problemi della chirurgia generale nel paziente cardiochirurgico.

The preoperative problem is analysed with proposal of a heart risk index table and assessment of the manifold problems involved. Stress is thenn laid on the importance of careful postoperative treatment, establishing rules of surgical and resuscitatory behaviour to be followed in the general surgery of the heart patient. These rules of behaviour permit prevention of surgical complications, which are fully illustrated. Particular attention is paid to the selection of those conditions of pertinence to general surgery which have treatment of choice prior to heart surgery. Personal experience of 75 general surgery operations between 1977 and 1979 in the Villa Pia Clinic is then reviewed.

Laparoscopic Heller cardiomyotomy with intraoperative manometry in the management of oesophageal achalasia.

Results of an ongoing clinical study treating achalasia patients with laparoscopic Heller myotomy and Dor anterior fundoplication are presented. 18 patients underwent surgery between August 1991 and July 1995. Completeness of myotomies and calibration of fundoplications were measured using intraoperative manometry. Only one intraoperative complication, a perforation of the mucosa sutured laparoscopically, was encountered. There were no surgical mortalities nor postoperative morbidities. Mean hospital stay was 3.4 days. Complete relief of dysphagia and modifications of radiological and manometric patterns were achieved in all patients. All patients remain asymptomatic at 2 to 48 months from surgery. These results compare favourably with those of traditional surgery and of pneumatic dilatation.

[Uric acid and pre-eclampsia]. / Acido urico ed eclampsia imminente.

The cause of hypertensive disorders of pregnancy remains unknown. More than 100 clinical, biophysical and biochemical tests have been recommended to predict the development of hypertensive disorders in pregnancy. The findings of numerous studies have been inconsistent. The purpose of this review is to assess the serum uric acid currently proposed for predicting the development of preeclampsia. Hyperuricaemia (> 6 mg/100 ml) correlates with the severity of the preeclamptic lesion, as well as the poor fetal outcome.

[Cervix incompetence]. / Incontinenza cervico-istmica.

The incontinence cervix is one of the most controversial topics in obstetrics and gynecology. The cause of cervical incontinence is due to trauma to the cervix resulting from injury during childbirth, mechanical dilation, or surgery. Dilatation of the internal cervical os is difficult to detect by digital examination in patients with a closed external cervical os. Transvaginal ultrasonographic assessment of the cervix should be adopted as the "gold standard".

[Good rules for cervical cytologic sampling]. / Le buone regole per il prelievo citologico cervicale.

There are still many little problems concerning methods about cervical cytology sampling. Are there some risks of teaching Papanicolaou smear technique? In which day of the cycle is it better to do sampling? How long in advance is it better to avoid sexual relations, and do not use any vaginal douching? Is it better to remove in advance cervical mucus? When should the sampling be done if the colposcopy is made in the same time? How should you behave if the cervix is not exposed? How many slides have to be spreaded? Which is better, the fixation with alcohol or aerosol? Where should the sampling be repeated? Is the patient anamnesis reliable? What should it mean the presence of some parasites and some foreign bodies manifested on the slide? Different answers have been given to reply to these questions and to some others. Smear's collecting is a simple method, but it needs an exact manual skill and an adherence to some precise rules. A relevant part of the final result depends how sampling has be done. Improvements must be done in every link of chain events.

[Cholecystectomy by video celioscopy in the elderly. An obligatory choice?]. / La colecistectomia per via videocelioscopica negli anziani. Scelta obbligata?

The videocelioscopic technique is becoming increasingly widely used in the treatment of cholelithiasis. In view of the results obtained, the authors underline the advantages of this method in geriatrics.

[Physiopathology of pneumoperitoneum]. / Fisiopatologia del pneumoperitoneo.

INTRODUCTION: Laparoscopic surgery contributes to many clinical advantages, but pneumoperitoneum in human body has new physiopathological consequences. MATERIALS AND METHODS: The aim of this study was to review recent literature about the effects of pneumoperitoneum. Cardiovascular, pulmonary and liver functions were examinated after pneumoperitoneum. RESULTS: There is a correlation between the increase in intra-abdominal pressure and properties of gas chosen (CO2 vs helium). There is a correlation between serum level modifications of liver functionality in postoperative laparoscopic surgery. CONCLUSIONS: Laparoscopic surgery has contributed to many clinical advantages (postoperative pain reduction, swift resumption, etc.), but pneumoperitoneum modifies physiological function. The aim of our next work will be the assessment of postoperative liver function, without clinical symptoms.

[The use of intraoperative topical bupivacaine in the control of postoperative pain following laparoscopic cholecystectomy]. / L'utilizzo della bupivacaina per via topica intraoperatoria nel controllo del dolore postoperatorio dopo colecistectomia laparoscopica.

Taking the starting point of a trial conducted on female patients who had undergone laparoscopic gynaecologic operations, which shows a good control of the postoperative pain through intraperitoneal infusion of local anaesthetic during the operation, the authors have proposed to reproduce the study on patients undergoing a laparoscopic cholecystectomy. The trial was conducted on two groups, a 50 patients each, undergoing an intraperitoneal infusion of local anaesthetic (bupivacaine) and placebo (physiologic solution) respectively. The results regarding the rate of patients who had felt postoperative pain (88% in the first group, 96% in the second group) and the different places of it, the pain in the right shoulder particularly (28% in the first group, 22% in the second), the intensity in the time and the different requests of analgesics new recorded. The results don't show statistically significant differences and they are different from the gynaecologic ones. The authors suggest, as reasons for these differences, the various moments of the liquid inoculation (at the beginning of the operation in gynaecology, at the end of it in cholecystectomy) and the Trendelemburg position of patients during the gynaecologic operation, on the contrary of cholecystectomy operations. They suggest, in the end, that the trials esecutions on numerically larger groups could bring more significant results.

[Cloacogenic carcinoma of the anus. Description of a clinical case]. / Carcinoma cloacogenico dell'ano. Descrizione di un caso clinico.

A clinical case of cloacogenic anal carcinoma is reported. These neoplasms, deriving from embryonal residuals at different levels of the ano-rectal junction, have a better prognosis than squamous carcinomas; the surgical alternative to abdomino-perineal resection is a simple local exeresis for small tumours that do not invade the muscular layer, with a good radical result as reported by the literature.

[Carcinoma of the gallbladder. Our experience]. / Carcinoma della colecisti. Nostra esperienza.

A series of 14 patients (6 males and 8 females) suffering from gallbladder cancer has been examined. Postoperative mortality, mean survival, quality of life understood as time free from symptomatology, and the incidence of early postoperative complications in relation to the various types of radical and palliative intervention performed were evaluated.

[Spontaneous rupture of the spleen caused by primary amyloidosis. Description of a clinical case]. / Rottura spontanea di milza da amiloidosi primaria. Osservazione di un caso clinico.

Spontaneous rupture of the spleen in primary amyloidosis is an uncommon event. After a review of the pertinent literature (10 case-reports between 1948 and 1987) a case of spontaneous splenic rupture with hemoperitoneum is presented. The diagnosis depends on the demonstration of amyloid deposit in splenic and hepatic tissues.