Laparoscopic treatment of advanced colonic cancer: a case-matched control with open surgery.

AIM: The safety, feasibility and oncological results of laparoscopic resection for advanced colon cancer were evaluated. METHOD: Seventy consecutive patients with a histologically proven T4 colon cancer who underwent laparoscopic (LPS) right or left colectomy were matched for comorbidity on admission (American Society of Anesthesiologists score), tumour stage and grading with 70 patients who underwent open colectomy over a 10-year period. Short- and long-term outcome measures were evaluated. RESULTS: The overall conversion rate was 7.1%. Less intra-operative blood loss (P = 0.01), a trend toward a longer operation time (P = 0.09) and a lower peri-operative blood transfusion rate (P = 0.06) were observed in the LPS group. A similar number of lymph nodes were retrieved (P = 0.37) and the R1 resection rate (P = 0.51) was no different in the two groups. The overall mortality rate was 1.4%. The overall morbidity rate was 21.4% (15/70 patients) in the LPS group and 27.5% (19/70 patients) in the open group (P = 0.42), with anastomotic leakage rates of 7.1% and 4.2% (P = 0.32). Length of stay was shorter after LPS (P = 0.009). Five-year overall survival rate (P = 0.18) and disease-free survival rate (P = 0.20) did not differ significantly between the two groups. CONCLUSION: Laparoscopic treatment of T4 colon cancer is safe and feasible and provides a similar surgical and oncological outcome compared with the open technique.

Sentinel node mapping during laparoscopic distal gastrectomy for gastric cancer.

BACKGROUND: The goal of this study was to evaluate the feasibility and accuracy of sentinel node (SN) mapping with endoscopic submucosal blue dye injection during laparoscopic distal gastrectomy for gastric cancer. METHODS: Thirty-four patients affected by gastric adenocarcinoma without gross clinical serosal invasion and distant metastasis were prospectively enrolled. At the start of the surgery, 2 ml of 2% patent blue was endoscopically injected into the submucosal layer at four points around the site of the primary tumor. Sentinel nodes were defined as nodes that were stained by the blue dye within 5-10 min after the dye injection. After identification and removal of sentinel lymph nodes, each patient underwent laparoscopic distal gastrectomy with D1 (n = 2) or D2 (n = 32) lymphadenectomy. RESULTS: Of the 34 patients, 14 had positive nodules (41%). SNs were detectable as blue nodes in 27 (80%) of 34 patients. The mean number of dissected lymph nodes per patient was 31 +/- 10 (range = 16-64) and the mean number of blue nodes was 1.5 (range = 1-4). Only five (sensitivity 36%) of 14 N(+) patients had at least one metastatic lymph node among the SNs identified. In these 14 patients the sentinel node was traced in 12 cases. Sentinel node status diagnosed the lymph node status with 74% accuracy. In early gastric cancer (n = 18), three patients had lymph node metastasis. These early gastric cancer patients with nodal metastases had at least one metastatic lymph node among the SNs identified (sensitivity 100%). CONCLUSIONS: Blue dye SN mapping during laparoscopic distal gastrectomy seems to be a feasible and accurate diagnostic tool for detecting lymph node metastasis in patients with early-stage gastric cancer in which the accuracy of the method was 100%. However, in more advanced gastric cancer the results are not satisfactory. Validation of this method requires further studies on technical issues, including selection of the tracers.

Laparoscopic excision of duodenal schwannoma.

BACKGROUND: Benign duodenal tumours are rare and less common than malignant tumours. They comprise a wide variety of pathologies. Schwannoma is an ectodermal neoplasm arising from the nerve sheath that envelops axons. A duodenal location is extremely rare. Therapy consists in the radical excision of the tumour. Our aim was to describe a minimally invasive technique used for the excision of duodenal schwannoma, so that a laparotomy has been avoided. METHODS: A laparoscopic operation under general anaesthesia was undertaken with the patient in supine position with the legs abducted. No macroscopic peritoneal seedling was found. Therefore, a laparoscopic Kocher maneuver was performed. The retroperitoneum was entered using the harmonic scalpel and the dissection extended beyond the vena cava and the duodenum. The location and the size of the lesion have been confirmed using an intraoperative endoscopic ultrasound examination. The excision of the lesion was performed by use the harmonic scalpel. Then, the duodenal wall was sutured by use endoscopic stitches. The resected lesion was then placed in a retrieval bag and extracted through the port incision. Operating time was 300 min and blood loss 200 ml. RESULTS: The postoperative course was uneventful. Histological findings showed a benign schwannoma. CONCLUSIONS: The minimally invasive technique may be a valid alternative to open surgery in the treatment of benign duodenal tumors.

Laparoscopic assisted duodenopancreatectomy.

BACKGROUND: In the past few years, minimally invasive therapy for pancreatic diseases has made significant strides but the role of laparoscopic pancreaticoduodenectomy is still controversial. METHODS: Four patients with a mean age of 44 +/- 11 years were chosen for a laparoscopic pancreaticoduodenectomy. Pathological diagnoses were ductal adenocarcinoma in one, neuroendocrine tumor in two, and metastatic malignant melanoma in one. RESULTS: The procedure was laparoscopically completed in all with a mean operating time, blood loss, and hospital stay of 416 +/- 77 min, 325 +/- 50 ml, and 12 +/- 2 days, respectively. There were no complications attributable to this surgery and there were no deaths. The average number of dissected lymph nodes was 26 +/- 17 (range 16-47). All the patients remained well at a median follow-up of 4.5 months (range 1-10). CONCLUSIONS: It can be inferred from this small but successful experience that laparoscopic pancreaticoduodenectomy can be considered for the treatment of tumors of the pancreas or periampullary region.

Ruptured hepatic adenoma in liver adenomatosis: a case report of emergency surgical management.

In hepatic adenomatosis, multiple liver cell adenomas (usually > or = 10) generally affects patients with no prior history of oral contraceptive use, androgenic steroid use, or glycogen storage disease. We report a rare case of a 44 year-old female who underwent emergency surgery for hemoperitoneum due to spontaneous rupture of a liver cell adenoma in hepatic adenomatosis, after prolonged use of two different contraceptives (Gestodene and Ethinylestradiol).

Langerhans histiocytosis of the choledochus in an adult patient with a history of disseminated disease.

A 43 year-old man with a 15-year history of disseminated Langerhans histiocytosis (LH) in complete clinical remission was admitted with jaundice and abdominal pain. Pathological examination demonstrated LH in the choledochus associated with sclerosing cholangitis in the liver. Immunohistochemistry for S-100 protein and electron microscopy of the choledochus tissue showed Langerhans cell-like elements in the infiltrate. Our findings suggest that, in patients with disseminated Langerhans histiocytosis, liver function should be monitored, particularly, for signs of biliary obstruction, and demonstrate that such a finding is possible in adults.

[Operative risk in elderly patients with gastrointestinal hemorrhage]. / Il rischio operatorio nel paziente grande anziano con emorragia digestiva.

The risk of postoperative complications was evaluated in 16 patients aged 80 or more operated on for gastrointestinal bleeding (morbidity 43.7%, mortality 25%). For each patient was considered: ASA, APACHE II and SAPS scores, proteinemia, natremia and osmolarity (for the volume changes), Hb value and units of blood transfused, preoperative and operative length. APACHE II and SAPS scores resulted the only variables related to prognosis.

[Intestinal obstruction in the elderly. Causes, interventions, postop complications and risk factors]. / L'occlusione intestinale nel paziente grande anziano. Cause, interventi, complicanze postoperatorie e fattori di rischio.

Forty-eight patients aged 80 or more were operated on for intestinal obstruction mainly due to incarcerated hernias (39.6%) and colonic neoplasms (27.1%). The morbility rate was 27.1% and the mortality rate was 8.3%. The study of the variables frequently related to the risk of postoperative complications (cancer, intraoperative contamination, emergency and blood transfusion) showed statistical significance only for blood transfusion. The others (emergency included) did not have a prognostic significance in this series.

[Microbiological analysis of postoperative infectious complications]. / Analisi microbiologica delle complicanze settiche postoperatorie.

A variation among the strains responsible of nosocomial infections was noted in the last years with a revival of Gram + bacteria. Coagulase-negative staphylococci assumed a great importance, particularly those resistant to methicillin. Staphylococcus epidermidis is now an important infective agent, especially in patients with prostheses or other devices. To value the impact of these microbiological variations on surgical patients, we studied data related to 1271 specimens from postoperative septic complication from 1980 to 1988. The incidence of Gram + strains in surgical infections was 46.8% in 1980-1983 period and 59.2% in 1984-1988 period with statistical significance (p less than 0.05).

[Abdominal abscesses: their treatment and the study of prognostic factors]. / Ascessi addominali: trattamento e studio dei fattori prognostici.

The aim of this study is to define outcome predictors that might influence the prognosis and the mortality rate either of percutaneous drainage (DP) or open surgical drainage (DC) for abdominal abscesses. Seventy-one patients with 81 intra-abdominal abscesses were prospectively studied. They were 40 males and 31 females. Mean age was 47 +/- 15 years. Thirty-six (50.7%) patients had a simple abscess, while 35 (49.2%) had a complex abscess. Abscesses occurred most commonly in the sub-hepatic area, pelvic and para-colic space. Thirty-two (45%) patients had a percutaneous drainage, while 39 (54.9%) underwent an operative drainage management. Criteria for treatment selection were not randomized. However the two groups were statistically similar in respect to clinical features, cirrhosis, nutritional status, APACHE II scores), genesis and characteristics (simple, complex) of the abscesses. The treatment was considered successful when not requiring further drainage and the patient survived. Abdominal abscesses were cured in 53 (74.6) patients. In 13 cases (18.3%) a further drainage was necessary to obtain a complex resolution. Post drainage complications were significantly higher in the surgical drainage group (38.4% vs 12%, p < 0.05) because of the high incidence of wound infections. The overall mortality rate was 7%. Using an univariate analysis model, the only significant variable related to unsuccessful outcome in both the percutaneous and surgical group was abscess complexity (p < 0.005). Elderly (p < 0.005), malnutrition (p < 0.03), presence of cancer (p < 0.05), a high APACHE II score (p < 0.005) and the presence of a complex abscess (p < 0.02) were significantly identified as determinants of death.

[Preoperative topical antibiotics in patients subjected to short term prophylaxis for colorectal surgery]. / Antibiosi topica preoperatoria nei pazienti sottoposti a short term prophylaxis per chirurgia colorettale.

In spite of the widespread use of antibiotics wound infection are still a common complication of elective colon and rectal surgery. Oral administration of poorly absorbed antibiotics was for a long time a common practice in preparing patients for elective clo-rectal operations. Systemic antibiotic prophylaxis allowed a significant improvement of septic complication rate. As the clinical effectiveness of the combined antibiotic regimen is still not completely demonstrated, we carried out a study on 165 patients who underwent colo-rectal surgery. A group of 63 patients submitted to short term prophylaxis with Clindamycin and Gentamycin was compared with a 102 patients group who received preoperative topic antibiotics (Neomycin and Metronidazole) plus short term prophylaxis. The two groups did not show a statistically significative incidence of wound infections (6.3% vs 3.9%; p greater than 0.05).

[General criteria for the organization of an intrahospital emergency plan in Italy]. / Criteri generali per l'organizzazione di un piano intraospedaliero per l'emergenza sul territorio.

The purpose of this work is to provide general criteria to draw up a hospital organization plans for emergencies, in order to efficiently manage the consequences of a massive flow of casualties from a major accident or natural disaster.

[Impact of a surveillance and prevention program on the incidence of wound infections in general surgery. A prospective study]. / Impatto di un programma di sorveglianza e prevenzione sull'incidenza delle infezioni della ferita in chirurgia generale. Studio prospettico.

A prospective study on wound infections incidence was performed using a computer archive program. Data of 7000 patients submitted to surgical procedures from 1980 to 1988 were evaluated regarding a surveillance and a prevention program that was performed at 1984 (short term prophylaxis in contaminated and any clean-contaminated procedures; skin washing before the operation with a soapy solution of povidone iodine; regular report of all data about wound infection incidence to staff). Results were evaluated in four classes and regarding nutritional status. The reduction of wound infection incidence was statistically significant (1.8% vs 5.4%; chi square 63.70, p less than 0.001) and an important reduction was recorded in the malnourished patients (3.0% vs 15.4%; chi square 36.91, p less than 0.001).

[Laparoscopic versus conventional surgery in the treatment of colorectal diseases]. / Chirurgia laparoscopica versus chirurgia tradizionale nel trattamento della patologia colo-rettale.

The aim of the study was to compare the results obtained with laparoscopic (LPS) and laparotomic (LPT) colorectal resection after our initial experience with the laparoscopic technique. Fifty-six patients were submitted to colorectal resection, 26 with the LPS and 30 with the LPT technique. Eighteen patients out of 26 in the LPS group and 22/30 in the LPT group had malignancies. All resections were performed with a curative intent. The mean operating time was 220 min in the LPS group and 208 min in the LPT group. Mean blood loss was 287 ml and 312 ml, respectively (blood transfusions were needed in 1/26 and in 7/30 patients). The rates of major complications were 9.5% and 5.7%, respectively. There was no mortality. The conversion rate for the LPS group was 19.2%. In the cancer patients, no significant difference was observed between the two groups as regards postoperative staging. The mean length of specimens and the mean distance of the tumours from the resection margins were adequate. The mean number of lymph nodes harvested was 11.8 in the LPS group as against 18.5 in the LPT group. No early recurrences were observed. Resumption of gastrointestinal function was faster in the LPS patients who underwent the surgical procedure under general anaesthesia associated with epidural anaesthesia/postoperative analgesia. In conclusion, these preliminary results indicate that laparoscopic colorectal surgery is feasible and that the resections in cancer patients appear to be oncologically adequate. Long-term follow-up is needed for reliable assessment of oncological outcomes.

Impact of previous abdominal surgery on the outcome of laparoscopic colectomy: a case-matched control study.

BACKGROUND: Adhesions are a major risk for visceral injury and can increase the difficulty of both laparoscopic and open colectomy. The aim of the present study was to evaluate the impact of previous abdominal surgery on laparoscopic colectomy in terms of early outcome. METHODS: We performed a case-control study of patients who underwent laparoscopic colectomy for colorectal disease. The case group comprised 91 patients with a history of prior abdominal surgery, while the 91 controls had no such history. Case and controls were matched for age, gender, site of primary disease, comorbidity on admission and body mass index. RESULTS: The two groups were homogeneous for demographic and clinical characteristics. Conversion rate was 16.5% in the case group and 8.8% in the control group (p=0.18). Of the 7 patients who underwent conversion because of adhesions, six had prior surgery (cases) and one did not (p=0.001). Operative time was 26 minutes longer in the case group than in the control group (p=0.001). Morbidity rate was 25.3% among cases and 23.1% for controls. Patients in the two groups experienced a similar time to recovery of bowel function, length of postoperative stay, and 30-day readmission rate. CONCLUSIONS: Laparoscopic colectomy in previously operated patients is a time-consuming operation, but it does not appear to affect the short-term postoperative outcome.