Should a History of Extraperitoneal Disease Be a Contraindication to Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Colorectal Cancer Peritoneal Metastases?

BACKGROUND: Survival improvements have been reported in selected patients affected by colorectal peritoneal metastases who were undergoing cytoreductive surgery with intraperitoneal hyperthermic chemotherapy. Treatment of peritoneal metastases associated with extraperitoneal disease is still controversial. OBJECTIVE: We assessed the prognostic impact of a history of extraperitoneal disease that was curatively treated either at the same time as or before the onset of peritoneal metastases. DESIGN: We reviewed 2 prospective databases. Peritoneal involvement was scored by Peritoneal Cancer Index. SETTINGS: Our study was conducted in 2 high-volume peritoneal malignancy management institutions. PATIENTS: A total of 148 patients with peritoneal metastases were included. In 27 patients, extraperitoneal disease involving the liver (n = 23), lung (n = 1), both lung and liver (n = 2), or inguinal lymph nodes and liver (n = 1) was curatively treated either simultaneously with peritoneal metastases (n = 22) or before their onset (n = 5). INTERVENTIONS: All of the macroscopic tumors were removed by means of peritonectomy procedures and visceral resections. Microscopic residual disease was treated by mitomycin C/cisplatin-based hyperthermic intraperitoneal chemotherapy. MAIN OUTCOME MEASURES: Overall survival was the primary outcome measure. RESULTS: After a median follow-up of 34.6 months (95% CI, 22.6-65.7 mo), 5-year survival of patients treated for both peritoneal and extraperitoneal disease versus peritoneal metastases alone was 16.5% versus 52.0% (p = 0.019). After multivariate analysis, reduced survival correlated with extraperitoneal disease (p = 0.001), Peritoneal Cancer Index >19 (p = 0.004), and peritoneal residual disease >2.5 mm (p = 0.018). Three prognostic groups were defined, and median survival was not reached for group 1 (Peritoneal Cancer Index ≤19 and no extraperitoneal disease), reached in 27.0 months for group 2 (Peritoneal Cancer Index ≤9 and extraperitoneal disease), and reached in 11.6 months for group 3 (Peritoneal Cancer Index >19 and no extraperitoneal disease or Peritoneal Cancer Index >9 and extraperitoneal disease). LIMITATIONS: The main study limitation is its observational nature. CONCLUSIONS: A history of extraperitoneal disease is associated with poorer prognosis. However, survival benefit may be obtained in selected patients with limited peritoneal involvement. See Video Abstract at http://links.lww.com/DCR/A655.

Hyperthermic Intraperitoneal Chemotherapy (HIPEC) at the Time of Primary Curative Surgery in Patients with Colorectal Cancer at High Risk for Metachronous Peritoneal Metastases.

BACKGROUND: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) are maximally effective in early-stage colorectal cancer peritoneal metastases (CRC-PM); however, the use of HIPEC to treat subclinical-stage PM remains controversial. This prospective two-center study assessed adjuvant HIPEC in CRC patients at high risk for metachronous PM ( www.clinicaltrials.gov NCT02575859). METHODS: During 2006-2012, a total of 22 patients without systemic metastases were prospectively enrolled to receive HIPEC simultaneously with curative surgery, plus adjuvant systemic chemotherapy (oxaliplatin/irinotecan-containing ± biologics), based on primary tumor-associated criteria: resected synchronous ovarian (n = 2) or minimal peritoneal (n = 6) metastases, primaries directly invading other organs (n = 4) or penetrating the visceral peritoneum (n = 10). A control group retrospectively included 44 matched (1:2) patients undergoing standard treatments and no HIPEC during the same period. The cumulative PM incidence was calculated in a competing-risks framework. RESULTS: Patient characteristics were comparable for all groups. Median follow-up was 65.2 months [95 % confidence interval (CI) 50.9-79.5] in the HIPEC group and 34.5 months (95 % CI 21.1-47.9) in the control group. The 5-year cumulative PM incidence was 9.3 % in the HIPEC group and 42.5 % in the control group (p = 0.004). Kaplan-Meier estimated 5-year overall survival (OS) was 81.3 % in the HIPEC group versus 70.0 % in the control group (p = 0.047). No operative death occurred. Grade 3-4 [National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE) version 4] morbidity rates were 18.2 % in the HIPEC group and 25 % in controls (p = 0.75). At multivariate analysis, HIPEC correlated to lower PM cumulative incidence [hazard ratio (HR) 0.04, 95 % CI 0.01-0.31; p = 0.002], and better OS (HR 0.25, 95 % CI 0.07-0.89; p = 0.039) and progression-free survival (HR 0.31, 95 % CI 0.11-0.85; p = 0.028). CONCLUSION: Adjuvant HIPEC may benefit CRC patients at high-risk for peritoneal failure. These results warrant confirmation in phase III trials.

Learning curve for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in peritoneal surface malignancies: analysis of two centres.

BACKGROUND: We assessed the learning curve (LC) of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in treating peritoneal surface malignancies (PSM) in two centers and evaluated in which extent surgical tutoring could abbreviate the learning process. METHODS: Six hundred and forty-one cases submitted to CRS using peritonectomy procedures and HIPEC were considered. After having overcome its own LC, the NCI of Milan has provided technical assistance to Bentivoglio's centre for the development of a new PSM program since 2003. The risk-adjusted sequential probability ratio test (RA-SPRT) was employed to assess the LC of the two centers. Outcomes were incomplete cytoreduction, G3-5 morbidity (NCI-CTCAE.v3) and procedure-related mortality (PRM). RESULTS: Rates of incomplete cytoreduction, G3-5 morbidity, and PRM were 8.4%, 30.1%, and 3.9%, respectively, in the entire series. The breaking points of the LC concerning incomplete cytoreduction, G3-5 morbidity, and PRM were achieved at 141, 158, and 144 cases, in the Milan's experience, and at 126, 134, and 60 cases in the Bentivoglio's experience. CONCLUSIONS: Surgical tutoring could substantially shorten the steep LC associated with CRS and HIPEC. Our data should be confirmed by further studies on LC focusing oncological outcomes. Other factors that could influence the length of learning process should be identified.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy as upfront therapy for advanced epithelial ovarian cancer: multi-institutional phase-II trial.

OBJECTIVE: The primary end-point of this multi-institutional phase-II trial was to assess results in terms of overall survival after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in treatment-naive epithelial ovarian cancer (EOC) with advanced peritoneal involvement. Secondary end-points were treatment morbi-mortality and outcome effects of time to subsequent adjuvant systemic chemotherapy (TTC). METHODS: Twenty-six women with stage III-IV EOC were prospectively enrolled in 4 Italian centers to undergo CRS and closed-abdomen HIPEC with cisplatin and doxorubicin. Then they received systemic chemotherapy with carboplatin (AUC 6) and paclitaxel (175 mg/m(2)) for 6 cycles. RESULTS: Macroscopically complete cytoreduction was achieved in 15 patients; only minimal residual disease (≤2.5 mm) remained in 11. Major complications occurred in four patients and postoperative death in one. After a median follow-up of 25 months, 5-year overall survival was 60.7% and 5-year progression-free survival 15.2% (median 30 months). Excluding operative death, all the patients underwent systemic chemotherapy at a median of 46 days from combined treatment (range: 29-75). The median number of cycles per patient was 6 (range: 1-8). The time to chemotherapy did not affect the OS or PFS. CONCLUSIONS: In selected patients with advanced stage EOC, upfront CRS and HIPEC provided promising results in terms of outcome. Morbidity was comparable to aggressive cytoreduction without HIPEC. Postoperative recovery delayed the initiation of adjuvant systemic chemotherapy but not sufficiently to impact negatively on survival. These data warrant further evaluation in a randomized clinical trial.

Jejunal adenocarcinoma: still an elusive diagnosis. Case report and review of the literature.

Tumours arising in the small bowel are rare, accounting for less then 2% of all gastrointestinal neoplasms. Adenocarcinoma accounts for 40% of small bowel malignancies. They are rarely considered as a differential diagnosis, and their discovery is usually greeted with surprise. We present a case in which aspecific symptoms of this neoplasm, non-informative instrumental examinations and a coexisting hiatal hernia led to the misdiagnosis of reflux disease until a complication such as abdominal occlusion occurred. To the best of our knowledge this is the second case in the literature in which a jejunal adenocarcinoma mimicked a gastro-oesophageal reflux disease and delayed the correct diagnosis.

[Adjuvant hyperthermic intraperitoneal chemotherapy in patients with colorectal cancer at risk of carcinomatosis: preliminary experience of a single centre]. / Chemioipertermia intraperitoneale adiuvante in pazienti con carcinoma colorettale a rischio di carcinosi: esperienza preliminare di un singolo centro.

The treatment of patients at high risk of developing colorectal peritoneal carcinomatosis is still debated since the absence of peritoneal disease synchronous with the primitive cancer makes the application of aggressive treatments less obvious. In this subset of patients hyperthermic intraperitoneal chemotherapy (HIPEC), after the resection of the primitive cancer, may improve long-term survival. Over the period from December 2003 to June 2008 142 patients affected by different kinds of cancers underwent HIPEC in the surgical division of Bentivoglio Hospital, A.U.S.L. Bologna. In 13 patients HIPEC was combined only with the resection of the primitive cancer and no major cytoreductive surgery was performed. Nine of these 13 patients were affected by colorectal cancer and at high risk of developing carcinomatosis. The average surgical time was 420 min (range: 300-510). No intraoperative complications occurred, but 3 cases of postoperative morbidity were reported; only 1 of these was a major complication At an average follow-up of 22 months 1 patient with a liver metastasis died of complications unrelated to progression of the disease, 1 patient had a lymph node relapse and is currently on systemic chemotherapy, while the remaining 7 patients are alive and free from peritoneal disease.

Hamartochondroma arising from a tracheal bronchus.

Tracheal bronchus is a congenital abnormality rarely described in the literature. It is mostly completely asymptomatic. This condition may rarely be associated with inflammatory diseases. Exceptional are those cases in which the condition is associated with malignancy. We describe a case of a 45-year-old man in whom a 3-month history of non-productive cough and chest pain led to a diagnosis of a solitary pulmonary nodule associated with a tracheal bronchus. The histopathological examination after VATS enucleation showed the presence of a hamartochondroma. To the best of our knowledge this is the first case in which a hamartochondroma has been found to be associated with a tracheal bronchus.

Synchronous nephrectomy and right hepatectomy for metastatic chromophobe renal cell carcinoma: report of a case and review of the literature.

The prognosis of metastatic renal cell carcinoma is poor, since non-operative modalities for advanced renal carcinoma have failed to yield effective results. In fact, there is no indication for radiotherapy, except for palliative treatment of symptomatic bone metastases, and systemic chemotherapy is not effective. Despite the promising early results with immunotherapy, a complete response occurs in less than 15% of patients and is rarely lasting. Surgery, when indicated, seems to be the only therapeutic option possible. Liver metastases occur in 20% of cases and are often multiple. Experience with hepatectomy for metastatic renal tumours has rarely been reported. Not only does a small group of patients have isolated liver metastases that may be treated with radical surgery, but also extrahepatic metastases ordinarily coexist at the time of diagnosis. We report a case of a 55-year-old man with a chromophobe renal cell carcinoma with a single synchronous hepatic metastasis that were treated simultaneously with radical nephrectomy and right hepatectomy. To the best of our knowledge this is the first case of a single metastasis of a chromophobe renal cell carcinoma treated with synchronous kidney and hepatic resection.

Predicting conversion to open surgery in laparoscopic left hemicolectomy.

PURPOSE: The objective of this study was to quantify the risk of conversion to open surgery of laparoscopic left hemicolectomy at an early stage of the learning curve. METHODS: A multiple logistic regression analysis of 100 laparoscopic left hemicolectomies completed between April 2001 and May 2004 was performed. RESULTS: The overall conversion rate was 12%. At univariate analysis, 2 factors were found to be predictive of conversion to open surgery: malignancy (17.2% vs. 5%; P=0.046), and weight level (<60 kg=6.1%; 60 to 90 kg=11.3%; >90 kg=28.6%; P=0.049). At multiple logistic regression, the risk of conversion rose only for patients weighing more than 90 kg. CONCLUSIONS: On the basis of the results of this study, the surgeon will be able to quantify the risk of conversion to laparotomy with some precision in order to obtain the informed consent of the first 100 patients to whom laparoscopic left hemicolectomy is proposed.

Hypovolemic shock caused by a true aneurysm of the pancreatico-duodenal artery: case report and review of the literature.

True pancreatico-duodenal artery aneurysm (PDAA) is a rare condition that since 1973 has been described in only 54 cases. It is frequently associated with celiac axis stenosis and often present with rupture. Even if most PDAAs that are not ruptured are asymptomatic and are diagnosed during investigation for other diseases, they may have some symptoms, such as chronic abdominal discomfort and an abdominal pulsating mass, that can be helpful for diagnosis. The treatment of this condition has evolved in time from a merely surgical one to an angiographic noninvasive approach. We present a case of a PDAA that manifested with sudden hypovolemic shock requiring an emergency operation, and through a review of the literature, we discuss the different diagnostic/therapeutic protocols to use in different situations.

Number of lymph nodes examined and prognosis of TNM stage II colorectal cancer.

The diagnosis of a lymph node-negative colorectal carcinoma should imply a good prognosis; however, the outcomes for TNM stage II patients remain variable. Few studies have examined the relationship of the number of lymph nodes examined to the prognosis of this stage. The aim of this study was to determine whether the number of lymph nodes examined has an effect on prognosis of a relatively large sample of patients undergoing curative surgery for stage II colorectal cancer at a single institution. Data on patients who underwent surgery for colorectal cancer between January 1980 and April 2000 were prospectively collected in a database. Patients with TNM stage II or stage III tumours who were treated with curative intent were removed. Patients over 80 years of age were excluded from the survival analysis. Survival comparisons were made using Kaplan-Meier curves and the log-rank test. Multivariate analysis was performed using a Cox regression model. A total of 625 cases of TNM stage II cases and, for comparison purposes, 415 stage III cases, were analysed. Lymph node retrieval in stage II cases was affected by the patient's age (P=0.04) and gender (P=0.02), tumour grade (P<0.0001), tumour site (P<0.0001), and necessity to carry out extended resection (P<0.0001). In stage III cases, lymph node retrieval was affected by patient age (P<0.0001), tumour grade (P=0.02), and tumour site (P=0.002). Decreased lymph node detection was associated with increasing hazard ratios among the 480 TNM stage II patients under 80 years of age, but not among the 345 patients with TNM stage III tumours. Five year survival rate for patients with stage III tumours with only 1-3 positive lymph nodes (52.6%) was similar to that of patients with stage II tumour who had nine or fewer lymph nodes examined (51.3%). These results demonstrate that the prognosis of TNM stage II colorectal cancer is dependent on the number of lymph nodes examined. Patients with few nodes examined have a poorer prognosis. It is possible that a smaller number of lymph nodes examined reflects a diminished immune response. It can be presumed that those patients with stage II tumour with only a few nodes examined should be offered postoperative chemotherapy on a routine basis.

The changing distribution and survival of colorectal carcinoma: an epidemiological study in an area of northern Italy.

OBJECTIVE: This study analyses the inter-relations of anatomical tumour location, gender, age and incidence rates for colorectal cancer from 1978 to 1999 in an area of northern Italy: the Parma district. METHODS: Data were obtained from the Parma Cancer Registry. Age-adjusted incidence rates were analysed by gender, age and colorectal cancer subsites. In addition, 5 year observed survival rates were determined. RESULTS: In the Parma area, the incidence of colorectal cancer is rising. We have observed a true increase in the rate of the age standardized incidence of right colon cancer, linked to an increased incidence of left colon cancer, while the incidence of rectal cancer has remained constant. The frequency of right-sided colon cancer was higher in aged patients, and in women. Age-standardized relative survival of patients after diagnosis of colorectal cancer between 1992 and 1996 was found to be significantly higher than age-standardized relative survival after diagnosis between 1978 and 1982. CONCLUSIONS: In the Parma area there has been an increased incidence of right colon cancer, linked to an increased incidence of left colon cancer, while the incidence of rectal cancer has remained constant. We feel that this shift, whatever the reason for it, has important implications for the choice of screening techniques.

Brunner's gland hamartoma: 'over-treatment' of a voluminous mass simulating a malignancy of the pancreatic-duodenal area.

CONTEXT: Brunner's gland hyperplasia is rarely associated with clinical symptoms. Most of the lesions are less than 1 cm in diameter and accounts for about 6.8% of all endoscopically removed duodenal polyps. When symptoms occur, this hyperplasia can be effectively treated with endoscopy. However, when the lesion is too large to pass through the endoscopic snare, endoscopic treatment is not possible and surgical treatment is necessary. This treatment may vary from local excision to more complex operations. When Brunner's gland hyperplasia does not have common dimensions, it may also mimic a malignancy of the duodenal-pancreatic area. In this case, a biopsy is indicated even though its result may be not informative. CASE REPORT: We report the case of a 60-year-old man with a large Brunner's gland hyperplasia mimicking a malignancy and in which the impossibility of a correct diagnosis by pre-operative and intra-operative biopsy led to 'over-treatment' involving a duodenocephalopancreatectomy. CONCLUSION: This 'over-treatment' may be justified since nowadays the consequences of leaving an undiagnosed pancreatic cancer are much worse than the risk of undergoing a major pancreatic operation.

Giant fibroma of the lesser omentum: report of a rare case.

UNLABELLED: We report a case of a 43 years old male that presented to emergency room for epigastric and mesogastric pain associated with a palpable abdominal mass. Explorative laparotomy showed a well capsulated tumour of the lesser omentum, sized 20 x 16 x 10 cm. Histologically the mass was charaterized by thick fibrous capsula, with areas of moderate cellularity alternated to areas of sclerosis, spots of hemorragies and infartual necrosis, spindle-shaped cells within collagen bundles that did not present mitotic activity or atipies and showed a low proliferation index with Ki 67 and histochemical positivity for CD 34 and negativity for C-Kit, anti-smooth cell and S100 antigen. FINAL DIAGNOSIS: solitary fibroma of the lesser omentum. To our knowledge only one case of lesser omentum fibroma has been reported in litterature.

Calf metastasis of colorectal cancer: report of a case.

Colorectal cancer metastases rarely develop outside liver, lungs and lymph nodes, and only exceptionally in skeletal muscle. The very low incidence of such metastasis sites may be due either to underestimation of the problem or to their intrinsic rarity. We report a case of metastasis from colorectal cancer that developed in the left calf and manifested itself as a painful non-fluctuating mass. The relevant literature is also reviewed.

[Diagnostic and therapeutic management of choledocholithiasis associated with gallstone disease: nine years' experience]. / Il percorso diagnostico- terapeutico nella coledocolitiasi associata a calcolosi della colecisti: nove anni di esperienza.

Different approaches are described in the literature for the detection and treatment of common bile duct stones in patients undergoing laparoscopic cholecystectomy (pre-, intra- or postoperative treatment; combined endoscopic and laparoscopic or total laparoscopic management). No particular "gold standard" treatment can be identified, since too many variables and too many techniques need to be compared. Since it is impossible to establish any single protocol, the reviewing of different large experiences is useful to identify the pros and cons of each procedure. We present the evolution of our own experience over the period 1991-2000 in 1741 patients treated by laparoscopic cholecystectomy for gallbladder stones. We have chosen to assess and treat patients with symptomatic common bile duct stones preoperatively, whereas in the asymptomatic cases we have adopted a protocol that has been modified over the years, consisting first in routine intravenous cholangiography and then in the use of a scoring system which, with the aid of ultrasound data, has allowed us to assess the risk of choledocholithiasis and to administer selective preoperative treatment for common bile duct stones.

[Laparoscopic colorectal surgery: is the "learning curve" necessary?]. / Chirurgia colo-rettale laparoscopica: e necessaria la "curva di apprendimento"?

AIM OF THE STUDY: To present the early experience of the Authors' division in the field of colorectal laparoscopic surgery, in order to evaluate the so-called "learning curve". MATERIALS AND METHOD: From February 2003 to May 2004, we have performed 220 surgical procedures for colorectal pathology: 63 were conducted by a laparoscopic approach with 10 patients who, converted to a laparotomic procedure in theatre, were not taken under consideration. The present work is thus based on a population of 53 patients, 27 men and 26 women, at a median age of 64.4 y.o. (range 42-81). RESULTS: We performed 1 total colectomy, 24 right hemicolectomy, 1 resection of the splenic flexure, 12 left hemicolectomy (in 1 case a left hepatic lobectomy was associated), 11 anterior resection of the rectum, 1 Hartmann' sigmoid resection and 3 abdomino-perineal resection. Mean operative time was 200.34 +/- 64.17 min, while the mean hospital stay was 6.44 +/- 2.68 days. Peri-operative mortality was 0%, 30-days mortality was 1/53 patients (9%) while morbidity was 5/53 patients (9.4%): in 2 cases reintervention was necessary. DISCUSSION: From the evaluation of the results, we found some significant data: first, the conversion rate was similar to those reported by other authors, so also the mortality and morbidity rates. CONCLUSIONS: The advantages of the laparoscopic technique, indirectly documented by shorter in-hospital stay. At least for patients submitted to right or left hemicolectomy without complications (5.5 e 5.7 days, respectively), could be seen also after only a 1 year of activity. As far as the "learning curve" is concerned, dividing our activity into 3 times, we verified a progressive shortening of the operative time and, at least for the patients submitted to a right emicolecomy, also of the morbidity rates.

Abnormal Fhit protein expression and high frequency of microsatellite instability in sporadic colorectal cancer.

The role of Fhit protein in the oncogenesis of colorectal cancer is still in debate. Recent studies have revealed that reduced Fhit protein expression is associated with a deficiency of the mismatch repair protein. One hundred and twenty unselected patients who underwent curative resection for sporadic colorectal cancer in a three-year period were evaluated for microsatellite instability (MSI) using six microsatellite markers, and for the presence of Fhit and mismatch repair (MMR) proteins (Mlh1 and Msh2) by means of immunostaining. The relations between these markers were analysed. Reduced or absent Fhit expression was noted in 18 out of 118 patients. This altered expression was significantly higher in right-sided cancer (P = 0.005), mucinous tumours (P = 0.005) and in poorly differentiated histological types (P = 0.0001). MSI was found in 22 out of 109 patients, more so in right-sided cancer (P = 0.0001), poorly differentiated histology (P = 0.0001), and mucinous tumours (P = 0.0001). No association was found with TNM stage. MSI was present in 66.7% of tumours with altered Fhit expression and in only 10% of tumours with preserved or intermediate Fhit expression (P = 0.0001). Of the tumours with reduced or absent Fhit expression, 72.2% had loss of nuclear Mlh1 or Msh2 expression compared with only 14% of the preserved or intermediate Fhit expression tumours (P = 0.0001). These results support the hypothesis that deficiency in a MMR gene could be a cause of the high frequency of alterations in Fhit expression, and they permit the suggestion that FHIT gene alteration may be part of the genetic pathway involving MSI through which some colorectal cancers arise.

Enterolith ileus complicating afferent loop syndrome simulating acute pancreatitis.

Afferent loop syndrome after Billroth II gastrectomy is usually caused by those events that impair the evacuation of the afferent duodenal loop. The formation of an enterolith in an afferent loop is a rare but dangerous event. We present a unique report of a patient in whom a huge enterolith developed in the afferent loop of a Billroth II anastomosis, which led to intestinal occlusion. This migration occurred after a laparoscopic procedure, so we hypothesized that this procedure could be the cause of enterolith migration.

The rationale for cecorectal anastomosis for slow transit constipation.

The most usual reconstruction after subtotal colectomy is ileo-rectal anastomosis, which requires the removal of the caecum. We propose the treatment of chronic slow-transit constipation with subtotal colectomy and antiperistaltic caecoproctostomy. The sparing of the caecum, the ileo-caecal valve and the distal ileal loop, leaving a physiologic reservoir, allowing the presence of colic bacterial flora which metabolizes the undigested starch and produces short chain fatty acids, should guarantee a normal stool consistency, normal absorption of water, sodium and vitamin B12 and the prevention of renal and gallbladder lithiasis. In 1992, we started a study on the outcome of 19 patients who had undergone subtotal colectomy and antiperistaltic caeco-rectal anastomosis for slow-transit constipation. The surgical procedure was carried out without any serious complications and without mortality. The mean clinical follow-up was 64 months (range 5-132). Six months after surgery, 13 patients reported normal bowel movements with solid stool consistency, 5 reported diarrhoea and the need for antidiarrhoeal agents, and one reported constipation easily controlled with laxatives. Fifteen patients considered their quality of life as having improved compared with that before surgery. Selection of patients justify such very satisfying results. It is well known that colic resection is effective only in the case of slow transit constipation, and thus a careful physiologic assessment is needed to rule out other causes of constipation, such as outlet obstruction syndrome.