Serum carcinoembryonic antigen pre-operative level in colorectal cancer: revisiting risk stratification.

BACKGROUND: Biomarkers may play a role as predictive and prognostic factors in colorectal cancer patients. The aims of the study were to verify the prognostic role of pre-operative serum carcinoembryonic antigen (CEA) level in predicting overall survival and risk of recurrence in a cohort of colorectal cancer patients and to evaluate optimal cut-off values. METHODS: A retrospective cohort analysis was performed on colorectal cancer patients undergoing elective curative surgery between 2004 and 2019 at an Italian Academic Hospital. Main outcomes were overall survival, disease-free survival at 3-years and risk of local, loco-regional and distant recurrence during follow-up. A receiver operating characteristic (ROC) curve analysis was plotted using CEA pre-operative values and follow-up data in order to estimate the optimal cut-off values. RESULTS: A total of 559 patients were considered. The mean CEA value was 12.1 ± 54.1 ng/mL, and the median 29.3 (0-4995) ng/mL. The ROC curve analysis identified 12.5 ng/mL as the best CEA cut-off value to predict the risk of metastatic development after surgery in stage I-III colorectal cancer patients, and 10 ng/mL as the best CEA cut-off value to predict overall survival and disease-free survival in stage III-IV patients. These data suggest a stratification of colorectal cancer patients in three classes of risk: a low risk class (CEA <10 ng/mL), a moderate risk class (CEA 10-12.5 ng/mL) and a high risk class (CEA >12.5 ng/mL). CONCLUSION: In conclusion, pre-operative serum CEA measurements could integrate information to enhance patient risk stratification and tailored therapy.

Indocyanine green-enhanced fluorangiography (ICGf) in laparoscopic extraperitoneal rectal cancer resection.

Anastomotic leak (AL) is one of the worst complications of rectal anterior resection (RAR) and its incidence varies according to the anatomical site, increasing in lower anastomoses. Many etiological factors have been evaluated and most of these are related to bowel perfusion. Indocyanine green-enhanced fluorangiography (ICGf) has been proposed to help surgeons assess colonic perfusion with higher reliability than subjective clinical judgment. The aim of the study was to evaluate the efficacy of this tool in patients subjected to elective laparoscopic RAR for extraperitoneal rectal cancer. All the patients subjected to elective laparoscopic RAR for extraperitoneal rectal cancer between May 2015 and January 2017 were considered. In all of them, ICGf was performed to evaluate bowel perfusion. The control group included an equal number of patients subjected to the same procedure from January 2014 to April 2015, before the start of routine use of this tool at our institution. The endpoint of the study was to compare the incidence of AL between the two groups. A total of 33 patients were included in both groups. Relying on fluorescence intensity in the indocyanine green (ICG) group, we changed the level of resection in 6/33 patients (18.2%). An AL developed in 2/33 patients (6%) in the ICG group versus in 7/33 patients (21.2%) in the control group. The routine use of this technique may help surgeons in selecting the best level of proximal bowel resection during RAR.

Sacral nerve stimulation in slow-transit constipation: effectiveness at 5-year follow-up.

AIM: The aim of this study is to evaluate the short- and long-term efficacy of sacral nerve stimulation (SNS) for treating slow-transit constipation (STC). METHOD: This is a retrospective cohort analysis of the efficacy of SNS in treating patients affected by STC, who previously failed to respond to conservative therapies. Only patients free of concomitant diseases were enrolled in our study. A temporary stimulation lead was initially implanted; patients with a > 50% symptom reduction were eventually deemed eligible for a permanent implant. RESULTS: This study enrolled 25 patients who underwent a SNS test stimulation; 21 patients (13 women; median age 32 years) eventually got a permanent implant. The median preoperative Cleveland Clinic Constipation Score (CCCS) was 21 (16-25). Preoperative colorectal transit time recorded a median of 10 markers (7-19) retained in the colorectal tract. At 6-month postoperative follow-up, the total number of markers retained in the colorectal tract decreased to 3 (0-4). The CCCS score improved during the first postoperative year (P < 0.001), but progressively worsened over the longer term. The SF-36 questionnaire showed an improvement in all 8 scales measuring physical and psycho-emotional states; all parameters recorded into the bowel diary also improved. Overall, at 60-month follow up, the overall neuromodulator removal rate was 48%. CONCLUSIONS: The SNS is a minimally invasive surgical procedure that we tested for treating STC. The short-term outcome was promisingly after 6 months; however, there was a declining trend beyond this interval. Thus, the long-term efficacy of SNS needs to be further assessed.

Preoperative Abdominal Computed Tomography at Rest and During Valsalva's Maneuver to Evaluate Incisional Hernias.

Background. Incisional hernias (IHs) can develop in up to 15% of patients who underwent an abdominal surgical procedure. Abdominal computed tomography (CT) is the best examination to evaluate these patients before surgical repair. The aim of this study is to assess the usefulness of the abdominal CT scan during Valsalva's maneuver in patients who are candidates for surgery. Methods. A retrospective cohort analysis conducted on prospectively recorded data was performed on 26 consecutive patients affected by IHs who underwent a preoperative abdominal CT scan both at rest and during Valsalva's maneuver between January 1, 2015, and December 31, 2016. Results. Five patients (19%) had IH classified as M1-M2, 10 (39%) as M3, and 11 (42%) as M4-M5. Both the median IH orifice area (IHOA) and the median volume of the IH increased during straining (P = .001 and P < .001, respectively). The percentage of the difference in volume ratios increased as the localization of the IH moved caudally. At the binary logistic regression analysis M3 IH, body mass index >28, IHOA > 156 cm2 at rest, and IHOA > 138 cm2 during Valsalva's maneuver were risk factors for posterior component separation. Conclusions. The preoperative CT scan both at rest and during Valsalva's maneuver seemed useful to estimate the risk of difficult IH repairs. Moreover, it could allow surgeons to decide if the patient should be addressed to more specialized centers.

Effect of a mixture of diosmin, coumarin glycosides, and triterpenes on bleeding, thrombosis, and pain after stapled anopexy: a prospective, randomized, placebo-controlled clinical trial.

PURPOSE: We evaluated the efficacy of oral administration of a mixture of diosmin, coumarin glycosides, and Centella asiatica (Venoplant®) in preventing bleeding, pain, and thrombosis of internal and external hemorrhoids after stapled anopexy (SA). METHODS: SA was conducted in 182 patients with third-degree hemorrhoids. Preoperatively, patients were randomized evenly into two groups. Group A patients were administered Venoplant for 30 days post-SA, and group B received a placebo for 30 days post-SA. Patients received paracetamol for postoperative pain. Visit (v)1, v2, and v3 took place 7, 15, and 30 days postoperatively, respectively; bleeding (clinical examination), visual analog scale (VAS), thrombosis (clinical examination), and pain (paracetamol dosage, VAS) were evaluated. RESULTS: At v1, v2, and v3, the numbers of patients with bleeding in groups A and B were 21 and 46, 3 and 25, and 1 and 5, respectively (p < 0.05). At v1, v2, and v3, the numbers of patients in groups A and B with thrombosed internal hemorrhoids were 3 and 13, 2 and 11, and 1 and 8, respectively (p < 0.05). The number of patients who took at least one paracetamol tablet was similar in both groups at v1 but was significantly greater in group B than group A at v2 and v3 (p < 0.05); pain VAS scores were equivalent at v1 and significantly greater in group B than group A at v2 and v3 (p < 0.05). CONCLUSIONS: Venoplant effectively reduced bleeding after SA, decreased the incidence of thrombosed internal hemorrhoids, and decreased postoperative pain.

Small bowel intussusception from renal cell carcinoma metastasis: a case report and review of the literature.

BACKGROUND: Renal cell carcinoma is the most frequent malignant neoplasia of the kidney accounting for 90 % of all renal solid tumors. Metastases from renal cell carcinoma are rarely located in the small bowel and generally their clinical presentation includes bleeding and obstruction. Intussusception in adults is an extremely rare pathological condition and only 30 to 35 % of small bowel intussusceptions are derived from malignant lesions. CASE PRESENTATION: We report here a clinical case of a 75-year-old white man hospitalized for anemia and subocclusion. An abdominal ultrasound and computed tomography showed a small bowel intussusception. During a surgical exploration, a polypoid lesion was found to be the lead point of the intussusception. His small intestine was resected and a functional side-to-side anastomosis was performed. The histological features of the surgical specimen confirmed the diagnosis of metastatic renal cell carcinoma. CONCLUSIONS: Small bowel intussusception from renal cell carcinoma metastasis should always be considered in the setting of unexplained intestinal subocclusion in patients with a history of renal cell carcinoma.