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.

Short- and mid-term outcome after laparoscopic repair of large incisional hernia.

PURPOSE: To compare the outcome after laparoscopic incisional and ventral herniorrhaphy (LIVH) for fascial defect larger or equal than 15 cm in width with the outcome after LIVH in patients with hernia defect smaller than 15 cm. METHODS: From 2003 through 2010, 350 patients were submitted to LIVH. In 70 cases, hernia defect was ≥15 cm in width and in 280 was <15 cm. Incisional hernias were often recurrent, double or multiorificial. In the group of larger hernias, the rate of obesity, recurrent hernia and multiorificial hernia was 27.1, 24.2 and 12.8 %, respectively, and in the group of smaller hernias 27.3, 16.1 and 2.8 %, respectively. Patients were interviewed using McGill pain score test to measure postoperative quality of life (QoL) in the mid-term. RESULTS: LIVH for hernia ≥15 cm required longer surgical time (p = 0.034) and postoperative hospital stay (p = 0.0001). Besides, there were higher rate of postoperative prolonged ileus (p = 0.035) and polmonitis (p = 0.001). Overall recurrence rate was 2.6, 8.6 % for larger and 1.1 % for smaller incisional hernias, p = 0.045. Mc Gill pain test revealed no significant difference in the two groups of patients in postoperative QoL within 36 months. CONCLUSIONS: Laparoscopic approach seems safe and effective even to repair large incisional hernia, the rate of recurrence was higher, but acceptable, if compared to smaller hernias. To the best of our knowledge, this is the largest reported series of incisional hernias ≥15 cm managed by laparoscopy.

Prospective trial evaluating new circular and linear stapler devices for gastrointestinal anastomosis: preliminary data.

Several commercial models of stapler devices are available. This study evaluated the ease of use, effectiveness and safety of new commercial stapling devices for gastrointestinal anastomosis. A total of 11 patients (5 men) requiring surgical therapy for benign or malignant disease of the digestive tract were recruited between July and October 2006. Eleven patients were treated with KYGW circular stapler or KYFB linear stapler (Changzhou Kangdi Medical Stapler). In these patients, 14 staplers were used and 21 stapled sutures (16 linear, 5 circular) were performed. Number of anastomoses successfully completed, postoperative anastomotic fistula or dehiscence, days to take fluid and normal diet, length of hospital stay and anastomotic stenosis were recorded. A 10-point questionnaire enquiring about the instrument and anastomotic features was administered to surgeons immediately after the operation in the study group and in 10 control patients treated with standard CDH circular and SDH linear staples (Ethicon Endo-Surgery). Mean scores on the questionnaire for the experimental and control groups were good (>7.5) and did not significantly differ for handling, closing ease, bleeding, and overall satisfaction. No case of intra-abdominal sepsis, leakage or intestinal obstruction was recorded in the study group. In the 5 patients with colorectal anastomosis, the anastomotic lumen at 15 days was wide open and at 3 months there were no strictures. These new instruments are valuable for performing gastrointestinal anastomosis and are in conformity with clinical requirements; their use is simple and seems to be safe.

PEFG (cisplatin, epirubicin, 5-fluorouracil, gemcitabine) regimen as second-line therapy in patients with progressive or recurrent pancreatic cancer after gemcitabine-containing chemotherapy.

OBJECTIVE: The therapeutic arsenal for salvage therapy in pancreatic cancer is limited. PEFG (cisplatin, epirubicin, 5-fluorouracil [FU], gemcitabine) regimen is an effective upfront treatment in advanced pancreatic cancer. The activity and safety of this combination regimen were assessed by means of an observational study in a population of patients with progressive or recurrent pancreatic adenocarcinoma after gemcitabine-containing chemotherapy. METHODS: Patients with age <76 years, Karnofsky performance status >50 were treated with either classic PEFG (until April 2004: cisplatin and epirubicin 40 mg/m day 1, gemcitabine 600 mg/m day 1 and 8, FU 200 mg/m/d continuous infusion day 1-28) or dose-intense PEFG (since May 2004: cisplatin and epirubicin 30 mg/m, gemcitabine 800 mg/m every 14 days; FU 200 mg/m/d continuous infusion day 1-28) until progressive disease or a maximum of 6 cycles of 28 days. RESULTS: Forty-six patients (37 metastatic) received 69 cycles of classic PEFG (18 patients) or 104 cycles of dose-intense PEFG (28 patients) as second-line therapy. Prior treatment consisted of single agent gemcitabine (N = 17), gemcitabine-based chemotherapy (N = 4), or PEFG regimen (N = 25). Median previous progression-free survival was 7.6 months. Dose intensity (mg/m/wk) with classic PEFG was cisplatin and epirubicin 8.5; gemcitabine 230; FU 1035 and with dose-intense PEFG was cisplatin and epirubicin 11.5 (+36%); gemcitabine 259 (+13%); FU 1046 (+1%). Main grade >2 toxicity consisted of neutropenia in 26 patients (56%), thrombocytopenia in 10 (22%), anemia in 11 (24%), fatigue and stomatitis in 4 (9%), vomiting, diarrhea and hand-foot syndrome in 2 (4%). Partial response was observed in 11 patients (24%) (5 classic PEFG 28% + 6 dose-intense PEFG 21%). Median and 1-year survival was 8.3 months (8.0 vs. 9.0 months) and 26% (17% vs. 32%). Median and 6-months progression-free survival was 5.0 months (4.5 vs. 5.0 months) and 34% (33% vs. 38%). CONCLUSIONS: PEFG regimen in gemcitabine refractory pancreatic cancer had an acceptable toxicity profile and interesting activity, and may constitute a treatment option in this setting.

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.

Dose-intense PEFG (cisplatin, epirubicin, 5-fluorouracil, gemcitabine) in advanced pancreatic adenocarcinoma: a dose-finding study.

The aim of this study was to assess the maximum tolerated dose (MTD) of an intensified PEFG regimen administered every 14 days to patients with Stage III or metastatic pancreatic adenocarcinoma. Twenty-nine patients received fixed doses of both epirubicin (30 mg/m2) and 5-fluorouracil (200 mg/m2/day on Days 1-14) and of escalating doses of cisplatin and gemcitabine. The MTD was cisplatin 30 mg/m2 and gemcitabine 800 mg/m2. With respect to classical PEFG, intensified regimen potentially improved the dose-intensity of both cisplatin and epirubicin by 50 percent and of gemcitabine by 33 percent, reduced Grade 3-4 haematological toxicity and the number of outpatient accesses.

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.

Dose-intense PEFG (cisplatin, epirubicin, 5-fluorouracil, gemcitabine) in advanced pancreatic adenocarcinoma.

BACKGROUND: PEFG regimen (cisplatin and epirubicin 40 mg/m2 day 1, gemcitabine 600 mg/m2 days 1 and 8, 5-fluorouracil (FU) 200 mg/m2/day continuous infusion) significantly improved the outcome of patients with advanced pancreatic adenocarcinoma (PA) with respect to standard gemcitabine in a previous phase III trial. This regimen was subsequently modified in a dose-finding study by increasing dose intensity of cisplatin and epirubicin (both at 30 mg/m2 every 14 days) and of gemcitabine (at 800 mg/m2 every 14 days). Results of a consecutive series treated by dose-intense PEFG regimen are herewith reported. MATERIAL AND METHODS: Dose-intense PEFG was administered to chemotherapy-naive patients with stages III-IV PA, < 75 years, performance status (PS) > 50, till progressive disease or for a maximum of 6 months. RESULTS: Between January 2004 and June 2005, 49 (31 or 63% metastatic) patients, median age 62 years, median PS 80, were treated with dose-intense PEFG. Partial response and stable disease was observed in 24 (49%) and 16 (33%) patients, respectively; 31 patients were progression-free at 6 months (PFS-6 = 63%). Median survival was 10.5 months and 1-year overall survival (OS) was 48% (95% confidence interval: 33-61%). Main grade 3-4 toxicity was: neutropenia in 26% of patients, stomatitis and fatigue in 8%, anaemia, diarrhoea, nausea/vomit in 6%, febrile neutropenia and thrombocytopaenia in 4%, hand-foot syndrome in 2%. CONCLUSION: When compared with 84 patients treated by classical PEFG at the same institution, dose-intense PEFG was not inferior in terms of PFS-6 (63 versus 57%), 1-year OS (48 versus 42%) and response rate (49 versus 49%); it allowed to increase dose intensity for gemcitabine by 32%, for cisplatin and epirubicin by 36% (FU reduced by 3%), to significantly reduce grade 3-4 hematological toxicity (neutropenia: 26 versus 86%; P < 0.00001; thrombocytopaenia: 4 versus 58%; P < 0.00001) and to reduce by one-third the number of outpatient accesses. The new PEFG schedule appears more suitable for clinical use and should be preferred as a basis for further development of therapeutic strategies against pancreatic cancer.

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.

Triple arterial reconstruction improves vascularization of whole pancreas for transplantation.

We assessed the effect on duodenal stump vascular supply of reconstruction of the gastroduodenal artery performed before pancreas transplantation. The median pancreas graft and patient survival times were 144 and 72 months for cases with or without gastrointestinal bleeding. Transmural blood flow values were significantly different between the donor duodenal stump and the recipient anastomosed jejunum (P < .01). The rate of gastrointestinal bleeding was lower in patients who received a pancreatic graft with back-table reconstruction of the gastroduodenal artery (P = .005).

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.

[Multimodal approach to rectal carcinoma with hepatic metastasis]. / Approccio multimodale al carcinoma del retto con metastasi epatica.

BACKGROUND: The role of surgery in the treatment of rectal cancer has been demonstrated worldwide. Moreover, curative liver resection of colorectal liver metastases is the only treatment offering a chance of long-term survival. Unfortunately, the liver resection can be performed in only 10% of the patients. AIM: In order to extend the frontiers of surgical indications in the treatment of liver metastases from colorectal cancer, we describe, in the video, a multimodal approach to rectal cancer with liver metastasis in the right lobe. Patient and methods. A 51 years old woman was admitted to our Department for adenocarcinoma of the distal rectum and a resectable solitary synchronous liver metastasis located across the right and the middle hepatic vein. Unfortunately, the future remnant liver was too small, risking severe post-operative liver failure. For this reason, a portal vein embolization or occlusion has been proposed. First of all, the patient has been submitted to laparoscopic low anterior resection with simultaneous right portal vein ligature. Two months later, after a CT estimation of liver volume in vivo, she was submitted to right hepatectomy (open surgery). RESULTS: Both postoperative courses were uneventful. CONCLUSIONS: As a preparation for large hepatic resection for liver rectal metastasis the laparoscopic ligature of the right portal vein performed simultaneously to the laparoscopic low anterior resection is feasible and safe.

[Prognostic factors of gastric neoplasms: experience with 1,074 cases undergoing surgical treatment at a single center]. / Fattori prognostici delle neoplasie gastriche: esperienza su 1074 casi sottoposti a trattamento chirurgico presso un singolo centro.

AIM: The aim of our study was to identify clinicopathological predictors of survival among patients undergoing potentially curative resections for gastric carcinoma. PATIENTS AND METHODS: From January 1987-March 2004, 1074 patients have been submitted to curative gastric resection for gastric cancer (647 males and 427 females, mean age, 65 +/- 12, min 22, max 92). The surgical procedure consisted of 289 (27%) total and 785 (63%) subtotal gastrectomies. The extent of lymph node dissection was limited D1 (n = 376, 35%) or extended D2 (n = 578, 54%) and D3 (n = 12, 1%); no lymphadenectomy was performed in 108 (10%) cases. The pathological nodal status has been defined based on the number of involved lymph nodes (N1: 1 to 6 positive nodes; N2: 7 to 15 positive nodes; N3: more than 15 positive nodes). The distribution of N stage was: N0 = 278 (26%), N1 = 344 (32%); N2 = 215 (20%); N3 = 129 (12%). Univariate analyses were performed for gender, age, pT stage, pN stage, tumor site, tumor size, and extent of lymphadenectomy. Significant factors were then entered into a Cox regression analysis. RESULTS: The median number of examined lymph nodes was 17 (mean, 18). Overall, 688 (64%) of patients had lymph node metastases. Of these patients, the median number of involved nodes was 2 (mean, 6). In the univariate analysis age, pT stage, pN stage, tumor size, and extent of lymphadenectomy were found to be significant factors. In the multivariate analysis T stage, N stage, and extent of lymphadenectomy were all independent predictors of survival. The median and mean survival time were 69 and 87 months, respectively. Overall survival was 80%, 51% and 40% at 1, 5, and 10 years, respectively. CONCLUSIONS: T stage, N stage, and extent of lymphadenectomy were all independent predictors of survival in patients submitted to curative gastric resections.

[Colorectal laparoscopic surgery. Single center experience with 599 cancer patients]. / Chirurgia laparoscopica colorettale. Esperienza monocentrica su 599 pazienti neoplastici.

PURPOSE: To analyze the results of laparoscopic colectomy for cancer of colon and rectum on early outcome. METHODS: Fifty hundred and ninety-nine consecutive unselected patients who underwent laparoscopic colectomy for cancer of the colon or rectum between January 1998 and December 2004 in a single Institution were prospectively evaluated. Tumor classification was by TNM stage. Patients were monitored for postoperative complications for 30 days after surgery. Follow-up was done by direct patient contact. RESULTS: Mean (SD) age was 65.8 (11.7) years. Mean (SD) ASA score was 2.0 (0.5). The following operations were performed: 248 left colectomies, 131 right colectomies, 26 sigmoid resections, 164 rectal resections, 21 abdominoperineal resections (Miles operation) and 9 total colectomies. Conversion rate was 7.2% (43/599 pts). The overall morbidity rate was 23.3% (143/599 pts). The mortality rate was 0.3% (2/599 pts). Anastomotic leak occurred in 45/599 (7.3%) patients. Re-operation rate was 4.6% (26/599 pts). Mean (SD) length of stay was 9.9 (5.8) days. The mean number (SD) of lymphnodes intraoperatively collected was 16.7 (9.8). Median (range) time of follow-up period was 20.2 months (6-68). One port-site metastasis was found at 18 months after surgery. Overall 5-years survival was 81%. Local recurrence rate in patients who underwent TME of the rectum was 4.4%. CONCLUSION: Laparoscopic colectomies is safe and effective in the treatment of colon and rectal cancer.

[Minimally invasive esophagectomy for adenocarcinoma of the lower esophagus and the gastroesophageal junction]. / Esofagectomia mininvasiva per adenocarcinoma siewert i della giunzione gastroesofagea.

BACKGROUND: Adenocarcinoma of lower esophagus and GEJ shows worldwide an increasing incidence. The optimal approach to resection is still controversial. One of the major disadvantages of radical esophagectomy with extensive lymphadenectomy with open technique is its high rate of morbidity and mortality. Recent advances in minimally invasive surgical technology have allowed surgeons to apply laparoscopy and thoracoscopy to perform esophagectomy. PATIENT AND METHODS: In the video we report the case of a 79 years old man with Siewert I adenocarcinoma of GEJ, who was submitted to a 3-stage minimally invasive esophagectomy by laparoscopy, right thoracoscopy and cervicotomy. Preoperative endoscopic ultrasound and CT scan showed a marked thickening of the wall of the distal esophagus, with extension proximal to the mediastinal pleura and the anterior surface of the aorta, but still showing features of resectability. Four ports were used for the abdominal approach. A complete mobilization of the stomach preserving the right gastroepiploic arcade was achieved. The patient was then turned to the left lateral decubitus position proned to 30 degrees. Three ports were needed for right thoracoscopy. Mobilization of the thoracic esophagus was carried out from the diaphragm to the thoracic inlet. After extraction of the specimen through a small abdominal incision, the stomach was pulled up to the neck and esophagogastric anastomosis with the Orringer technique was constructed through a left cervicotomy. Pathology showed pT3 pN1 G3 adenocarcinoma. CONCLUSIONS: The minimally invasive approach to adenocarcinoma of the lower esophagus, in center with expertise in minimally invasive surgical technique, is feasible and safe.

[Gastrectomy and laparoscopic lymphadenectomy for carcinoma: preliminary experience with 59 cases]. / Gastrectomia e linfoadenectomia laparoscopica per carcinoma: esperienza preliminare su 59 casi.

BACKGROUND: Laparoscopic surgery has been used in the treatment of gastric cancer with low mortality and morbidity and improvement in patient's quality of life. AIM: To evaluate the results of laparoscopic gastric resection. METHODS: A retrospective review of 59 patients after laparoscopic surgery for gastric cancer was performed. The patients were 31 males and 28 females with a mean age of 67 (+/- 11) years (min 39, max 90). RESULTS: Tumor stage was IA in 15 patients, IB in 10, II in 9, IIIA in 6, IIIB in 9, and IV in 10. In 15 cases the tumor was an early gastric cancer. The mean number of dissected lymph nodes was 29 +/-10. Conversion rate was 16%. Morbidity rate was 37%. The median length of hospital stay was 10 days. Operative mortality was 3%. The mean time of follow-up was 23 months. Two-year survival was 75%. CONCLUSIONS: Laparoscopic radical total or subtotal gastrectomy with extended lymphadenectomy for gastric cancer is a feasible, safe, and oncologically effective procedure.