Emergency surgery for complicated colorectal cancer. A two-decade trend analysis.

BACKGROUND/AIMS: Emergency procedures for colorectal cancer have worse outcomes than elective resections. Temporal trends in emergency surgery are analyzed by comparing two decade-related series of colorectal cancer patients. METHODS: The clinical data of 985 patients undergoing colorectal cancer surgery were collected during two decades (1975-1984 and 1995-2004). Rates of emergency surgery, operative mortality, 5-year cancer-related and overall survival were compared retrospectively. RESULTS: The rate of emergency surgery decreased from 81 out of 513 cases (16%) during 1975-1984 to 41 out of 471 cases (9%) during 1995-2004 (p = 0.005). Over the same time, the rate of curative resections in emergency increased from 46% (37/81 cases) to 76% (31/41 cases) (p < 0.001), while patient and tumor characteristics remained similar. Operative mortality after emergency procedures decreased from 14% (11 deaths) to 5% (2 deaths) and cancer-related survival increased from 21 to 42% (p = 0.03). However, when excluding palliative procedures, survival after emergency surgery increased from 52 to 58%, while after elective treatment it increased from 56 to 78% (p < 0.001). CONCLUSIONS: Frequency and operative mortality of emergency colorectal cancer surgery decreased substantially from 1975-1984 to 1995-2004. No significant improvement in long-term survival was observed when curative emergency resections only were considered. Further efforts are needed to reverse the diverging trend of long-term outcomes between emergency and elective curative procedures.

[Severe obesity and insulin resistance. Result obtained by the bilio-pancreatic diversion independentely for an associated gastroresection or gastropreservation]. / Obesità grave e insulino resistenza. Risoluzione indotta dalla diversione biliopancreatica indipendentemente dalla gastroresezione o gastroconservazione associata.

INTRODUCTION: Type 2 diabetes is the paradigm of an obesity-related disease. In most cases it exists because of the obesity and will disappear with weight loss. AIM OF THIS STUDY: To evaluate the glicemic control in obese patients after two malabsorbitive procedure, the bilio-pancreatic diversion with ad hoc stomach resection (BPD-AHS) and the bilio-pancreatic diversion with transitory gastric restriction (BPD-TGR). MATERIAL AND METHODS: The effect of weight loss following malabsorbitive procedures was studied on 38 patients operated on between the May 1999 and July 2002. Ten patients were diabetes 2 type (group A, 4 patients with oral antidiabetic therapy and 6 with insulin therapy; mean BMI: 49.4 +/- 8.2 Kg/m2), 18 patients were glucose intolerance (group B; mean BMI: 48.2 +/- 6.4 Kg/m2) and 10 patients were in normal glicemic control (group C; mean BMI: 51.2 +/- 8.3 Kg/m2). Five patients in group A were operated on BPD-AHS and 5 patients on BPD-TGR. Ten patients in the group B were operated on BPD-AHS and 8 patients on BPD-TGR. After 3 months from the malabsorbitive procedure group A patients stopped antidiabetic (mean BMI was: 42.3) and group B patients had normal values of glucose and insuline (mean BMI: 41.8). No significant statistically differences were observed in terms of glicemic control, BMI and Excess Weight Loss (EWL%), comparing the two malabsorbitive procedure. RESULTS: Weight loss after both BPD-AHS and BPD-TGR had a beneficial and durable effect on the fasting plasma glucose and serum insuline levels in diabetic and non-diabetic obese patients. The gastric procedure did not change the glicemic control.

Enteric neuropathology of the terminal ileum in patients with intractable slow-transit constipation.

Slow-transit constipation is usually considered a colonic motor disorder. However, there is some evidence that abnormalities may be present in locations other than the colon. In particular, several studies have reported abnormal motor activity of the small bowel in these patients. We evaluated the neuropathological aspects of the terminal ileum in patients with slow-transit constipation to see whether abnormalities are present that may explain an abnormal motility of the small intestine. Specimens of the terminal ileum were obtained from 16 female patients (age range, 42-76 years) with slow-transit constipation undergoing surgery for intractable symptoms. Fifteen age- and sex-matched controls were used for comparison. Histologic and immunohistochemical evaluation of the myenteric plexus and the smooth muscle of the proximal ileal resection margin was carried out by means of hematoxylin and eosin, trichrome and periodic acid-Schiff stain, neuron-specific enolase, S-100, CD117, CD34, anti-alpha-actin, desmin, and vimentin antibodies. The patient group displayed a significantly reduced number of glial cells, compared with controls, in both the submucosal and the myenteric plexus. Only 1 of the 3 populations of interstitial cells of Cajal (that associated with the deep muscular plexus) was decreased in patients. No differences were found between patients and controls concerning ganglia neurons, fibroblast-like cells, enteric neurons, apoptotic phenomena, and smooth muscle. Patients with slow-transit constipation display neuropathological abnormalities of the terminal ileum to a lesser extent than those we previously found in the colon, which might explain the abnormal motor aspects sometimes found in these patients.

[Prognostic value of peritoneal lavage cytology in gastric cancer]. / Valore prognostico della citologia su lavaggio peritoneale nel cancro gastrico.

The microscopic detection of free peritoneal tumour cells in peritoneal lavage fluid in gastric cancer patients is a useful predictor of peritoneal recurrence and poor prognosis. The aim of this study was to verify the prognostic significance of intraoperative peritoneal lavage cytology and its value as a predictor of peritoneal recurrence. We evaluated the presence of free peritoneal tumour cells with extemporary cytological examination in a series of 170 peritoneal washing samples from patients undergoing gastrectomy for gastric cancer over the period from January 1992 to June 2001. Twenty-eight patients (16%) had positive extemporary lavage cytology and there were no false-negatives as compared with the final examination. All patients with positive cytology presented serosal infiltration (T3/T4). Positive peritoneal lavage cytology was a predictor of poor prognosis and peritoneal recurrence: the 24 month survival rate was 17% for positive and 60% for negative cases (P = 0.003); in positive cases 71% of recurrences were located in the peritoneum. Intraoperative cytological examination of peritoneal washings can detect the presence of free malignant cells in the peritoneal cavity and can be used to select patients who may benefit from intraperitoneal chemotherapy.

Liver abscess due to acute cholecystitis. Report of five cases.

Acute cholecystitis is one of the most frequent causes of admissions to surgical departments. The development of liver abscesses is an uncommon and underrated complication of acute cholecystitis. In this study we report on our experience with the treatment of 5 cases of liver abscesses secondary to acute cholecystitis. All 5 cases were characterised by a lengthy period between the onset of acute cholecystitis symptoms and the subsequent diagnosis of a secondary liver abscess. In 4 out of 5 patients, admission for liver abscess occurred 12, 30, 50 and 120 days, respectively, after the acute cholecystitis episode. The liver abscesses were successfully treated with percutaneous drainage under US guidance (4 cases) and 4 patients underwent percutaneous cholecystostomy to treat the acute cholecystitis. After resolution of the acute phase, an elective cholecystectomy was performed in 4 out of 5 cases. Failure to diagnose acute cholecystitis at onset or inappropriate treatment of the condition could lead to the development of liver abscesses.