Laparoscopic resection of large gastric GISTs: feasibility and long-term results.

BACKGROUND: Laparoscopy is the procedure of choice for the resection of gastric Gastrointestinal stromal tumors (GISTs) smaller than 2 cm; there is still debate regarding the most appropriate operative approach for larger GISTs. The aims of this study were to evaluate the safety and long-term efficacy of laparoscopic resection of gastric GISTs larger than 2 cm. METHODS: Between 2007 and 2011, we prospectively enrolled all patients affected by gastric GIST larger than 2 cm. Exclusion criteria for the laparoscopic approach were the presence of metastases and the absence of any involvement of the esophago-gastric junction, the pyloric canal, or any adjacent organ. Final diagnosis of GIST was confirmed by histological and immunohistochemical analysis. Follow-up assessment included abdominal CT scans every 6 months for the first 2 years and yearly thereafter. RESULTS: Twenty-four consecutive patients were enrolled. Twenty-one patients (87.5%) were symptomatic. The most common symptoms were gastrointestinal bleeding and abdominal pain. The mean tumor size was 5.51 cm (range 2.5-12.0 cm). GISTs were located in the lesser curvature in five cases (20.8%), in the greater curvature in seven cases (29.1%), in the posterior wall in one case (4.1%), in the anterior wall in eight cases (33.3%), and in the fundus in 3 cases (12.5%). Laparoscopic resection was possible in all cases and took on average of 55 min (range 30-105 min). Median blood loss was 24 ml. No major intraoperative complications were observed. Mortality rate was 0%. Median postoperative stay was 3 days. No patients were lost to follow-up. No recurrences occurred after a median follow-up period of 75 months. CONCLUSION: Although larger randomized controlled trials comparing different surgical strategies for large gastric GISTs are warranted, our study supports the evidence that laparoscopic resection of gastric GISTs is feasible, safe, and effective on long-term clinical outcome even for lesions up to 12 cm.

Laparoscopic treatment for unsuspected common bile duct stones by transcystic sphincter of Oddi pneumatic balloon dilation and pressure-washing technique.

BACKGROUND: Unsuspected common bile duct stones (CBDS) are found in 4-5 % of patients with cholelithiasis. The optimal strategy for the treatment of asymptomatic CBDS, diagnosed during laparoscopic cholecystectomy (LC), is not yet well established. A one-stage solution is preferable to solve the CBDS during the LC and to avoid the exposure of patients to the risks of a second procedure, such as complications or failure. METHODS: We attempted to remove CBDS by transcystic sphincter of Oddi pneumatic balloon dilation and common bile duct pressure-washing in all cases of intraoperative identification of CBDS since September 2008. RESULTS: In 29 cases, unsuspected CBDS was identified by intraoperative cholangiography; in 28 cases a single stone with a mean diameter of 4.3 mm (range = 3-6) was detected and in one case three 5-8-mm-diameter stones were identified. Clearance of the common bile duct was obtained in 27 cases (96 %), with a mean operative time of 54 min (range = 36-90) and mean length of hospital stay of 2.5 days. CONCLUSION: Treatment of unsuspected CBDS detected by intraoperative cholangiography during LC with this original technique was safe and effective and a viable alternative of the transcystic endoscopic approach.

Treatment of haemorrhoidal disease with micronized purified flavonoid fraction and sucralfate ointment.

Hemorrhoidal disease is a very common disease characterized by the presence of a mucous prolapse of the rectum and by varicosis of the hemorrhoidal plexus. Medical therapy is mainly indicated for the treatment of symptoms such as bleeding, pain and itching. The use of the micronized purified flavonoid fraction (MPFF) has proven to be effective in treating symptoms of hemorrhoidal disease. Topical use of sucralfate has shown good results in the reduction of hemorrhoidal pain and itching. Our experience with three cases treated with combined use of MPFF and a topical medical device in the form of rectal ointment, composed by sucralfate and herbal (calendula, witch hazel leaf (hamamelis), chamomile) extracts, has shown good results in terms of pain and itching control and in edema reduction.

Malignant intestinal obstruction: useful technical advice in self-expanding metallic stent placement.

BACKGROUND: The use of endoluminal self-expanding metallic stents is an effective alternative to surgery in neoplastic gastrointestinal tract obstructions. It is often difficult to mark the proximal segment of the stricture under fluoroscopic guidance (due to patient movements or change of markers' position). PATIENTS AND METHODS: We placed Ultraflex precision colonic stent (Microvasive, Boston Scientific) in ten patients with neoplastic stricture of the rectosigmoid colon. Before placement of the delivery catheter, a radiopaque proximal marker was identified on the delivery catheter under fluoroscopic guidance. The external side of the delivery catheter was coloured (in correspondence with the radiopaque marker) with non toxic colour. After the introduction of the delivery catheter, we placed the proximal coloured marker just above the distal tumour margin under endoscopic guidance. RESULTS: The procedure was successful in relieving the obstruction in all patients, without mortality or complications. In all patients the coloured marker was identified and the stent correctly placed. CONCLUSION: The location of a coloured marker in the external side of the delivery catheter permits an accurate and correct placement of the stent, without unnecessary exposure to X-rays.

Hürthle cell tumors of the thyroid gland. Personal experience and review of literature.

BACKGROUND: Oncocytic cell neoplasm of the thyroid is currently recognized as a histological entity, but doubts still exist about its clinical and evolutionary categorization. Controversies concern occurrence and frequency of malignant forms, natural history and therapeutic strategies. MATERIALS AND METHODS: The authors report six cases of Hürthle cell tumor. Five cases were adenoma, one was carcinoma. Morpho-functional pre-operative evaluation and inter-operative histopathological test were performed in all patients. One patient underwent lobectomy (absence of unusual characteristics of the adenoma Hürthle cell) and five underwent total thyroidectomies (1 carcinoma). All patients were treated with suppressive hormonal therapy. RESULTS: No mortality and morbidity was recorded. All patients are undergoing follow-up (adenomas: average 64.2 months; carcinoma: 132 months) and none of them show recurrent symptoms. DISCUSSION: Hürthle cell tumors can be diversified in adenoma and carcinoma. Almost all reports classify oncocytic nodules as malignant when capsular and/or vascular invasion is present or when there is peri-thyroid tissue infiltration or lymphatic or hematic metastases. A clear differentiation between adenoma and carcinoma is determined by a histological test. Also an intra-operative histopathological analysis is sometimes unable to show minimal signs of invasion. Conflicting observations about the biological behaviour of Hürthle cell neoplasm lead to different therapeutic strategies. The authors believe lobectomy is the treatment of choice when a clear histological diagnosis of adenoma has been made. When carcinoma is diagnosed or when doubts exist after intraoperative histological test, the authors recommend total thyroidectomy followed by scintigraphic test and preventive radio-active therapy. All patients should be treated with suppressive hormonal therapy and undergo periodic check-ups.

Lymph node dissection in papillary or follicular thyroid carcinoma.

BACKGROUND: Prospective randomized studies aimed at evaluating the different therapeutic protocols for the treatment of papillary or follicular carcinoma are lacking at the moment. Although total thyroidectomy is widely accepted, indication to locoregional lymphadenectomy is strongly debated. MATERIALS AND METHODS: Fifty-four patients with papillary or follicular thyroid carcinoma (45 papillary and 9 follicular) underwent functional evaluation of the gland before intervention, FNAB included Surgical management was carried out as follows: 41 total thyroidectomy, 6 lobectomy with further totalization in 5, 6 total thyroidectomy plus central compartment lymphadenectomy and 1 left laterocervical lymphadenectomy (papillary carcinoma, treated elsewhere through total thyroidectomy plus central and right laterocervical lymphadenectomy). All operated patients were submitted to whole body scintigraphy and treated thereafter by radiometabolic therapy and chronic hormone suppressive therapy. RESULTS: Fifty-one patients are currently alive, 3 died from non-related causes; surgical complications included 1 permanent impairment of inferior laryngeal nerve function and 1 case of hypoparathyroidism. The follow-up was from 1 to 139 months. DISCUSSION: The optimal treatment of lymph node metastases, especially for papillary carcinomas, has not yet been defined. Two trends are evident concerning lymphadenectomy: the first one suggests routine lymphadenectomy, the second supports lymphadenectomy by necessity. In follicular carcinoma lymphadenectomy is recommended only in the presence of clinical evidence of lymph node involvement. Occult differentiated carcinoma does not require any further treatment of lymph nodes. CONCLUSION: Considering the high efficacy of radiometabolic treatment after total thyroidectomy combined with chronic TSH inhibition through L-tyrosine administration, lymphadenectomy is suggested only by necessity.

Laparoscopic total mesorectal excision for ultralow rectal cancer with transanal intersphincteric dissection as a first step: a single-surgeon experience.

Laparoscopic intersphincteric resection (ISR) after neoadjuvant chemoradiation is helpful in the management of patients with low rectal cancer. With the advent of this technique, the need for performance of abdominoperineal resection seems to have decreased in patients with very low rectal tumors. The aim of the present study was to evaluate the feasibility of laparoscopic ISR preceded by transanal rectal dissection low rectal cancer. Between December 2009 and June 2011, we performed laparoscopic ISR for 30 patients with very low rectal cancer. Patients received preoperative concurrent chemoradiation (5 days a week for 5 weeks). The surgical procedure was performed 6 weeks after radiotherapy and included total mesorectal excision, ISR, transanal coloanal anastomosis with coloplasty and loop ileostomy. Clinical data of 30 patients were analyzed retrospectively. Thirty patients (21 men, nine women) had a median age of 65 years (range, 37 to 75 years), a median body weight of 67 kg (range, 43 to 96 kg), and body mass index of 24 kg/m(2) (range, 19 to 33 kg/m(2)). The distance of the tumor from the anal verge was 5 cm (range, 2 to 11 cm). The operative time was from 240 to 360 minutes, and estimated blood loss was 100 to 520 mL. There were no conversions and no postoperative mortality. This procedure is feasible and has favorable short-term results for radical treatment of very low rectal disease while preserving anal function.

Incidence and circumstances of cervical hematoma complicating thyroidectomy and its relationship to postoperative vomiting.

BACKGROUND: Cervical hematoma is hardly a predictable complication of thyroid surgery. Postoperative vomiting has been reported as a likely risk factor. METHODS: Five hundred sixty-two patients undergoing thyroidectomy were prospectively enrolled in the study and divided into 2 groups. Patients in group A received ondansetron to prevent postoperative vomiting. In group B, patients with low vomiting risk received ondansetron whereas patients at high risk received ondansetron plus dexamethasone. Postoperative outcomes of the groups were analyzed and compared. RESULTS: Cervical hematomas developed in 3 patients (0.53%): 2 in group A and 1 in group B. All hematomas occurred after 6 hours. The incidence of postoperative vomiting was 11.4% in group A and 6.4% in group B (p = .04). CONCLUSION: Careful hemostasis remains of prime importance in preventing cervical hematoma. Postoperative vomiting has not been confirmed by this study as a risk factor for the development of hematoma. Ambulatory thyroid surgery is not advisable.