Impact of totally laparoscopic combined management of colorectal cancer with synchronous hepatic metastases on severity of complications: a propensity-score-based analysis.

BACKGROUND: Thanks to widespread diffusion of minimally invasive approach in the setting of both colorectal and hepatic surgeries, the interest in combined resections for colorectal cancer and synchronous liver metastases (SCLM) by totally laparoscopic approach (TLA) has increased. Aim of this study was to compare outcome of combined resections for SCLM performed by TLA or by open approach, in a propensity-score-based study. STUDY DESIGN: All 25 patients undergoing combined TLA for SCLM at San Raffaele Hospital in Milano were compared in a case-matched analysis with 25 out of 91 patients undergoing totally open approach (TOA group). Groups were matched with 1:2 ratio using propensity scores based on covariates representing disease severity. Main endpoints were postoperative morbidity and long-term outcome. The Modified Accordion Severity Grading System was used to quantify complications. RESULTS: The groups resulted comparable in terms of patients and disease characteristics. The TLA group, as compared to the TOA group, had lower blood loss (350 vs 600 mL), shorter postoperative stay (9 vs 12 days), lower postoperative morbidity index (0.14 vs 0.20) and severity score for complicated patients (0.60 vs 0.85). Colonic anastomosis leakage had the highest fractional complication burden in both groups. In spite of comparable long-term overall survival, the TLA group had better recurrence-free survival. CONCLUSION: TLA for combined resections is feasible, and its indications can be widened to encompass a larger population of patients, provided its benefits in terms of reduced overall risk and severity of complications, rapid functional recovery and favorable long-term outcomes.

Laparoscopic Approach for Primary Colorectal Cancer Improves Outcome of Patients Undergoing Combined Open Hepatic Resection for Liver Metastases.

BACKGROUND: Safety and efficacy of simultaneous resections for patients with colorectal cancer and synchronous liver metastases have been widely reported, while the topic of approach (laparoscopic or open) to hepatic and colorectal resection is still a debated issue. The aim of this study was to assess short-term outcome of combined resection of left colon or rectum cancer and liver metastases, comparing the results of the primary tumor resection performed by laparoscopic or open approach. STUDY DESIGN: From January 2004 to March 2014, 106 patients underwent combined resection of colorectal cancer and synchronous liver metastases. Sixty-nine patients underwent laparoscopic colorectal resection (laparoscopic colorectal surgery, LCS Group), and were compared with 37 patients undergoing colorectal resection by laparotomy (totally open surgery, TOS Group). Hepatic resection was performed by open approach in all the patients. RESULTS: Groups were comparable in terms of patients and disease characteristics, extent of liver resection, and length of surgery. In LCS Group, blood loss (400 vs. 650 mL, p < 0.001) and rate of intraoperative transfusions (19.3 vs. 47.2 %, p = 0.04) were lower compared to TOS Group. LCS Group was associated with reduced postoperative morbidity (24.6 vs. 44.4 %, p = 0.039), and shorter postoperative median hospital stay (9 vs. 13 days, p < 0.001). LCS and TOS Groups had comparable oncologic radicality in terms of primary tumor lymphadenectomy (median number of removed nodes 19 and 20, respectively, p NS) and rate of R1 colorectal resections (two patients in both Groups). Multivariate analysis revealed significant correlation morbidity with preoperative chemotherapy, blood loss, and approach to primary tumor. CONCLUSIONS: Laparoscopic resection of colorectal cancer in patients undergoing simultaneous open resection of liver metastases is associated with a reduction of blood loss, morbidity, and postoperative hospital stay, without affecting oncologic radicality. Outcome is mainly conditioned by approach to intestinal surgery, rather than the extent of liver resection.

Gastroenteric neuroendocrine neoplasms classification: comparison of prognostic models.

BACKGROUND: Gastroenteric neuroendocrine neoplasms (GE-NENs) display highly variable clinical behavior. In an attempt to assess a better prognostic description, in 2010, the World Health Organization (WHO) updated its previous classification, and the European Neuroendocrine Tumors Society (ENETS) proposed a new grading and TNM-based staging system. In the current study, the authors evaluated the prognostic significance of these models and compared their efficacy in describing patients' long-term survival to assess the best prognostic model currently available for clinicians. METHODS: The study cohort was composed of 145 patients with extrapancreatic GE-NEN who were observed from 1986 to 2008 at a single center and were classified according to the WHO and ENETS classifications. Survival evaluations were performed using Kaplan-Meyer analyses on 131 patients. Only deaths from neoplasia were considered. A P value < .05 was considered significant. Prognostic efficacy was assessed by determining the Harrell concordance index (c-index). RESULTS: Both the 2010 WHO and the ENETS classification were able to efficiently divide patients into classes with different prognoses. According to the model comparison, the ENETS TNM-based staging system appeared to be the strongest. All combined models were effective prognostic predictors, but the model that included the 2010 WHO classification plus ENETS staging had a higher c-index. CONCLUSIONS: Both the 2010 WHO classification and the ENETS staging system are valid instruments for GE-NENs prognostic assessment, with TNM-based stage appearing to be the best available choice for clinicians, both alone and in association with other classifications.

Laparoscopic TME with APPEAR (Anterior and Perineal PlanE for ultra-low Anterior Resection of the Rectum) technique for distal rectal cancer.

BACKGROUND: Laparoscopic sphincter saving rectal resection for low rectal cancer is hampered by narrow pelvis and limitations of current stapling devices. The APPEAR (Anterior Perineal PlanE for Ultra-low Anterior Resection of the Rectum) was proposed by Williams et al. as an alternative to the abdominal-perineal resection to perform very low rectal resection and anastomosis through a perineal wound. We adapted the original technique to the laparoscopic approach, avoiding any other abdominal incision. METHODS: Between December 2011 and April 2012, five patients (2 females; median age 72 years (range 60-78)) with rectal cancer not involving the sphincters underwent laparoscopic total mesorectal excision (TME) with APPEAR. Mean distance of the tumor from anal verge was 3.2 ± 1.1 cm (range 2-5). RESULTS: All of the procedures were completed laparoscopically. All of the anastomoses were stapled, and a protective stoma was always constructed. The surgical specimens were retrieved from the perineal wound, and the stoma performed through one of the port sites, without any further abdominal incision. Mean operative time was 333 ± 47 min (range 295-405), postoperative stay 12 ± 5 days (range 6-17). Perineal wound infection was observed in three patients, two of whom also had anastomotic fistula, and was treated conservatively with prolonged suction drainage. Histological examination showed three pT3N+, one T2N0, and one complete response after neoadjuvant radiochemotherapy, with a mean distal clear margin of 1.27 ± 0.5 cm (range 0.5-1.7). After a median follow-up of 9 months (range 8-12), one stoma reversal has been performed and the patient is fully continent. CONCLUSIONS: Our experience shows the feasibility of the APPEAR technique with laparoscopic TME, without any other abdominal incision. This technique offers advantage over the limitations of current laparoscopic stapling devices and their scanty maneuverability in the pelvis, allowing resection and anastomosis under direct vision, with adequate distal clearance, while sparing the anal sphincters.

Laparoscopy-assisted gastrectomy versus open gastrectomy for gastric cancer: a monoinstitutional Western center experience.

BACKGROUND: Laparoscopic gastrectomy (LAG) is safe for benign lesions; however, such surgery for cancer remains controversial. The aim of this study was to compare technical feasibility and oncologic efficacy of laparoscopic versus open gastrectomy for gastric carcinoma. METHODS: Between January 2002 and November 2008, 109 gastric cancer patients underwent LAG (92 distal gastrectomy and 17 total gastrectomy) at our hospital. These patients were compared with 269 gastric cancer patients who underwent conventional open gastrectomy (OG; 171 distal gastrectomy and 98 total gastrectomy) during the same period. RESULTS: Operation time was significantly longer in the LAG group than in the OG group. Estimated blood loss in the LAG group was significantly less than in the OG group. The morbidity rate was higher than in the OG group (p < 0.0001). The distance of the proximal resection margin was significantly lower in the OG group (2.8 ± 1.9 vs. 3.8 ± 2.5; p = 0.014). The mean number of nodes resected with LAG was 31 ± 14 and that with OG was 27 ± 13 (p = 0.002). The mean survival time was 53 months in both groups. There were no differences regarding overall patient survival at a mean time of follow-up of 33 months. CONCLUSIONS: LAG with extended lymphadenectomy for gastric cancer is a feasible and safe procedure and has several advantages despite a higher rate of morbidity. Moreover, this method can achieve a radical oncologic equivalent resection and it does not have a deleterious effect on cancer-related outcome.

Sentinel node mapping during laparoscopic distal gastrectomy for gastric cancer: technical notes.

BACKGROUND: With increasing experience, sentinel node navigation has been applied even to gastric cancer. Sentinel lymph nodes are identified by injecting lymphatic tracer dye and radioisotope-labeled particles around a gastric tumor into the submucosa endoscopically. The aim of this video was to demonstrate the feasibility of laparoscopic sentinel node navigation (SLN) in gastric cancer. METHODS: A 71-year-old man with a diagnosis of gastric cancer was admitted to the authors' department. The preoperative workup demonstrated a uT1 node-negative gastric cancer. The patient was scheduled for laparoscopic distal gastrectomy with SLN. The day before surgery, the patient was submitted to endoscopy. During the procedure, the radiotracer (technetium-99) was injected at four points around the tumor. The operation was performed with the patient in the Lloyd-Davies position using four trocars. After opening of the gastrocolonic ligament, the patient underwent an intraoperative endoscopy, and blue dye (patent blue) was injected at four points around the tumor. The lymphatic basin was identified with the probe and the blue dye. The sentinel node then was identified. No pickup technique was used. A standard laparoscopic gastrectomy with intracorporeal anastomosis was concluded successfully. Through a supraumbilical incision, the specimen was extracted. The sentinel node was dissected at the bench table after the operation. RESULTS: The pathologic report demonstrated a gastric carcinoma, namely, pT1, pN1 (Sentinel node (Sn), 1/36), G3 gastric cancer. Only the sentinel node was positive, containing a micrometastasis. The patient's postoperative course was uneventful. CONCLUSIONS: Sentinel node navigation with a double tracer during laparoscopic gastrectomy for cancer is feasible. Nevertheless, it is mandatory to standardize the method of SLN identification to increase the diagnosis of lymph node metastases.

Effect of prednisolone on local and systemic response in laparoscopic vs. open colon surgery: a randomized, double-blind, placebo-controlled trial.

PURPOSE: This study was designed to assess whether preoperative, short-term, intravenously administered high doses of methylprednisolone (30 mg/kg 90 minutes before surgery) influence local and systemic biohumoral responses in patients undergoing laparoscopic or open resection of colon cancer. METHODS: Fifty-two patients who were candidates for curative colon resection were randomly assigned to laparoscopic or open surgery and, in a double-blind design, assigned to receive methylprednisolone (n = 26) or placebo (n = 26). Pulmonary function, postoperative pain, C-reactive protein, interleukins 6 and 8, and tumor necrosis factor alpha were analyzed, as was patient outcome. RESULTS: The steroid and placebo groups were well balanced for preoperative variables, as were the subgroups of patients who underwent laparoscopic (methylprednisolone, n = 13; placebo, n = 13) and open surgery (methylprednisolone, n = 13; placebo, n = 13). No adverse events related to steroid administration occurred. In the methylprednisolone groups, significant improvement in pulmonary performance (P = 0.01), pain control (P = 0.001), and length of stay (P = 0.03) were observed independent of the surgical technique. No differences in morbidity or anastomotic leak rate were observed among groups. CONCLUSION: Preoperative administration of methylprednisolone in colon cancer patients may improve pulmonary performance and postoperative pain, and shorten length of stay regardless of the surgical technique used (laparoscopy, open colon resection).

Laparoscopic wedge resection for gastrointestinal stromal tumour of the duodenum.

We report the case of a 40-year-old male patient who presented with melaena and acute anaemia. Endoscopic ultrasound examination revealed a lesion with a central depression measuring 2.5 cm, arising from the lateral wall of the second portion of the duodenum. Because of this rare location, a very invasive procedure (duodenopancreatectomy) might have been required for tumour resection. We avoided this operation and implemented an alternative solution. A laparoscopic wedge resection of the duodenal tumour was successfully completed. Operating time was 200 min and blood loss 50 ml. The patient was discharged on postoperative day 3, after an uneventful postoperative recovery. Histopathologically, the tumour was diagnosed as a low-risk gastrointestinal stromal tumour. Despite the fact that laparoscopic surgery requires more complex technique than open surgery and the acquisition of advanced laparoscopic skills depending on prior laparoscopic experience, laparoscopic wedge resection should be considered as a valid treatment for duodenal stromal tumour.

Laparoscopic intersphincteric resection for low rectal cancer.

The goal of this review is to outline some of the important surgical issues surrounding the management of patients with low rectal cancer submitted to laparoscopic intersphincteric resection (ISR). Surgery for rectal cancer continues to develop towards the ultimate goals of improved local control and overall survival, maintaining quality of life, and preserving sphincter, genitourinary, and sexual function. Nevertheless, all progress in the development of oncologic therapy (i.e., radiation and chemotherapy), radical surgical removal of the tumour is the only chance for permanent cure of rectal cancer. Beside this main objective, the preservation of faecal continence is the second-most important goal to reach an acceptable quality of life with preservation of sphincter function. Information concerning the depth of tumour penetration through the rectal wall, lymph node involvement, and presence of distant metastatic disease is of crucial importance when planning a curative rectal cancer resection. Preoperative staging is used to determine the indication for neoadjuvant therapy as well as the indication for local excision versus radical cancer resection. In appropriate patients, minimally invasive procedures, such as local excision, TEM, and laparoscopic resection with ISR allow for improved patient comfort, shorter hospital stays, and earlier return to preoperative activity level. Data from small, non-randomized studies evaluating laparoscopic ISR suggest that this procedure is feasible by experienced surgeons. A literature search identified five studies [Uchikoshi F, Nishida T, Ueshima S, Nakahara M, Matsuda H. Laparoscope-assisted anal sphincter-preserving operation preceded by transanal procedure. Tech Coloprocto 2006;10:5-9; Bretagnol F, Rullier E, Couderc P, Rullier A, Saric J. Technical and oncological feasibility of laparoscopic total mesorectal excision with pouch coloanal anastomosis for rectal cancer. Colorectal Disease 2003;5:451-3; Rullier E, Sa Cunha A, Couderc P, Rullier A, Gontier R, Saric J. Laparoscopic intersphincteric resection with coloplasty and coloanal anastomosis for mid and low rectal cancer. British Journal of Surgery 2003;90:445-51; Watanabe M, Teramoto T, Hasegawa H, Kitajima M. Laparoscopic ultralow anterior resection combined with per anum intersphincteric rectal dissection for lower rectal cancer. Diseases of the Colon and Rectum 2000;43(Suppl. 10):S94-7; Miyajima N, Yamakawa T. Laparoscopic surgery for early rectal carcinoma. Nippon Geka Gakkai Zasshi 1999;100:801-5]. The aim was to find those studies that documented potential clinical application of laparoscopic ISR. These studies concluded that a laparoscopic approach can be considered in most patients with low rectal cancer in which laparoscopic ISR represents a feasible alternative to conventional open surgery. Hopefully, randomized controlled trials, which utilize these alternative procedures, will in future determine the results of laparoscopic ISR in terms of sphincter function, faecal continence, disease free and overall survival. The reviewed studies concluded that high quality and less invasive surgery could be achieved if ISR and laparoscopic surgery were combined.

Total mesorectal excision (TME) with laparoscopic approach: 226 consecutive cases.

BACKGROUND: Total mesorectal excision (TME) of the rectum has been advocated as the gold surgical treatment of the middle and low third rectal cancer. Laparoscopy has gained acceptance among surgeons in the treatment of colon malignancies, while scepticism exists about laparoscopic TME in term of safety, and its oncological adequacy. OBJECTIVE: To evaluate the impact of laparoscopic TME on surgical and oncological outcome in a group of consecutive unselected patients. METHODS: 226 unselected patients with rectal cancer underwent laparoscopic TME from January 1998 to August 2007. Patients staged cT3/4 cTxN+ were submitted to neoadjuvant treatment. Postoperative complications and oncological outcome were registered. RESULTS: Mean distance of the tumour from the anal verge was 6.2+/-2 cm. 48.6% of patients were enrolled in "long-course" neoadjuvant chemo-radiotherapy (partial and complete response rates 72.4% and 20.1%, respectively). Surgical procedures were 202 anterior and 24 abdominal-perineal resections. Mean operative time 245.3+/-58.4 min, mean blood loss 203+/-176 mL. Conversion rate 6.1%. Thirty-days morbidity rate 31.8% without mortality. Anastomotic leaks rate was 16.8%. Reoperation rate 6.6%. Gastrointestinal recovery rate was 3.1+/-1.4 days and hospital stay 10.4+/-4.6 days. Concerning adequacy of oncologic resection, mean distance between tumour and margin of resection was 2.7+/-2 cm with a nodal sampling of 14.4+/-4.6. Six patients (2.6%) had a R1 margin. With a mean follow-up of 39.8 months non port-site metastases occurred. Local recurrence rate was 6.1%. Five years cumulative overall survival was 81% and disease-free survival was 70% (Kaplan-Meier method). CONCLUSIONS: Laparoscopic approach for rectal tumour is a technically demanding procedure, but it is safe and it has the feature of an oncologic procedure.

[The role of neoadjuvant radio-chemotherapy in the treatment of rectal cancer]. / Il ruolo della radiochemioterapia neoadiuvante nel trattamento del tumore del retto.

OBJECTIVE: To evaluate oncological and surgical outcome of patients submitted to neoadjuvant therapy for advanced rectal cancer. PATIENTS AND METHOD: One hundred thirty eight patients (86 male, 52 female, mean age 61.4 years), with tumour of lower (58; 42%), middle (66; 48%), upper rectum (14; 10%), showing a clinical stage II (23; 17%) or III (115; 83%) and with an average distance from anal verge of 6.5 cm, submitted to fractionated "long-course" RT with CT locally staged by US and MR before and after neoadjuvant therapy and operated on after 4-6 weeks by its end. RESULTS: Surgical procedures (71 of which laparoscopic) were: 114 AR (83.8%), 19 APR (14%) and 3 TEM (2.2%). Mean nodal-sampling was 14.9. A complete or partial response was observed in 48.5% of the patients (67/138). With a mean follow-up of 30 months, local recurrence rate was 5.7%. Five-years overall survival and disease-fee-survival were respectively 73% and 60%. DISCUSSION: We observed a significant clinical (p < 0.004) and pathological (p < 0.005) downstaging. Pre-treatment clinical stage was not significant. On the contrary, postoperative yTNM was significant for yT (p < 0.001) and yN (p < 0.0003). Non-responder patients had worse prognosis (5-years survival 30%). The variable with higher prognostic significance was yN (p < 0.0003), especially if we distinguish N1 by N2 (p < 0.0004). CONCLUSIONS: The response to neoadjuvant therapy represents a significant prognostic variable.

Extracorporeal vs. Intracorporeal Ileocolic Stapled Anastomoses in Laparoscopic Right Colectomy: An Interim Analysis of a Randomized Clinical Trial.

AIM: The role of intracorporeal anastomosis (IA) in right colectomy is still controversial. Primary endpoint of the present study is to evaluate the impact of IA versus extracorporeal anastomosis (EA) on recovery of bowel function and length of stay in right colon cancer patients. MATERIALS AND METHODS: Adult patients with histologically proven cancer of the right colon were randomized to laparoscopic right colectomy with IA or EA anastomosis. Admitting a two-sided type I error level of 0.01 and an estimated power of 80%, 79 patients for each group were needed to test the primary endpoint. RESULTS: At the time of this interim analysis, 60 patients were randomized; 30 were assigned to the IA group and 30 to the EA group. The two groups were homogeneous with respect to demographics, American Surgical Association score, and tumor stage. In the IA group, a longer operating time (P = .04), an earlier recovery of bowel function (P = .048), and a lower incidence of postoperative ileus (P = .05) were observed. No differences were observed between the two groups with respect to length of stay (P = .70) and complication rate (P = .89). Anastomotic leak rate occurred in two patients in the IA group, while no leak occurred in EA. CONCLUSIONS: Intracorporeal anastomosis could be considered a valuable option in the hands of expert surgeons, with favorable effect on recovery of bowel function and postoperative ileus. Definitive answers on its safety and efficacy will be given once the present randomized controlled trial (RCT) will be complete.

[Prognostic factors for long-term outcome of hepatic resection for colorectal liver metastases]. / Fattori prognostici dell'outcome a lungo termine della chirurgia resettiva epatica per metastasi da carcinoma colorettale.

The aim of the study was to analyse the prognostic factors for long-term outcome of liver resections for metastases from colorectal cancer. The retrospective analysis included 297 liver resections for colorectal carcinoma liver metastases. The following prognostic factors were considered: age, gender, stage and grade of differentiation of the primary tumour, node metastases, site of the primary colorectal cancer, number and diameter of the hepatic lesions, time interval from primary cancer to liver metastases, preoperative CEA level, adjuvant chemotherapy after hepatic resection, type of hepatic resection, use of intraoperative ultrasound and portal triad clamping, blood loss and transfusions, postoperative complications and hospital stay, tumour-free surgical margins, clinical risk score (as defined by the Memorial Sloan-Kettering Cancer Centre group, MSKCC-CRS). Overall survival rates were estimated according to the Kaplan-Meier method and were compared at univariate analysis using the log-rank test. Multivariate analysis was performed including significant variables at univariate analysis using the Cox regression model. Differences were considered significant at p < 0.05. The 1, 3, 5 and 10-year overall survival rates were 90.6%, 51%, 27.5%, and 16.9%, respectively. The univariate analysis revealed a statistically significant difference (p < 0.05) in overall survival in relation to: grade of differentiation of the primary cancer (5-year survival of grades G1-G2 vs grades G3-G4: 30.7% vs 14.4%, p = 0.0016), preoperative CEA level > 5 and > 200 ng/ml (5-year survival of CEA < 5 ng/ml vs CEA > 5 ng/ml: 51.1% vs 15.5%, p = 0.0016; 5-year survival of CEA < 200 ng/ml vs CEA > 200 ng/ml: 27.9% vs 17.4%, p = 0.0001), diameter of major lesions > 5 cm (5-year survival of diameter < or = 5 cm vs > 5 cm: 30.0% vs 18.8%, p = 0.0074), disease-free interval between primary tumour and liver metastases longer than 12 months (5-year survival of patients with disease-free interval < or = 12 months vs > 12 months: 23.0% vs 36.1%, p = 0.042), high MSKCC-CRS (5-year survival of MKSCC-CRS 0-1-2 vs 3-4-5: 36.4% vs 1 6.3%, p = 0.017). The multivariate analysis showed three independent negative prognostic factors: G3-G4 primary cancer, CEA level > 5 ng/ml, and high MSKCC-CRS class. No single prognostic factor turned out to be associated with such disappointing outcomes after hepatic surgery for colorectal liver metastases as to permit the identification of specific subgroups of patients to be excluded on principle from undergoing liver resection. However, in the presence of a number of specific prognostic factors (G3-G4 grade of differentiation of the primary tumour, preoperative CEA level > 5 ng/ml, high MSKCC-CRS) enrolment of the patient in trials exploring new diagnostic tools or new adjuvant treatments may be suggested to improve the preoperative staging of the disease and reduce the incidence of tumour recurrence after liver resection.

[Laparoscopic pancreatic resection: preliminary experience]. / Chirurgia laparoscopica del pancreas: esperienza preliminare.

The aim of the study was to evaluate the results of laparoscopic pancreatectomy for pancreatic tumours. Four women and three men underwent laparoscopic pancreatectomy and were recruited into the study retrospectively over the period from June 2002 to February 2004. Pancreaticoduodenectomy (n = 4), intermediate pancreatectomy (n = 1) and distal pancreatic resection with splenectomy (n = 2) were successfully performed. Operative mortality was nil. The postoperative morbidity included two low-output pancreatic leaks. Mean operating time, blood loss and hospital stay were 342 minutes, 289 mL and 14 days, respectively. The pathological diagnosis was ductal adenocarcinoma in one, neuroendocrine tumour in five and metastatic melanoma in one. All patients are still well after a median follow-up of 7 months (range: 1-20 months). The patients appear to benefit from laparoscopic pancreatectomy for pancreatic tumours. The minimally invasive approach ensures adequate treatment but requires the expertise of highly skilled laparoscopic surgeons.

Short and long-term outcomes of laparoscopic colectomy in obese patients.

AIM: To investigate the impact of laparoscopic colectomy on short and long-term outcomes in obese patients with colorectal diseases. METHODS: A total of 98 obese (body mass index > 30 kg/m(2)) patients who underwent laparoscopic (LPS) right or left colectomy over a 10 year period were identified from a prospective institutionally approved database and manually matched to obese patients who underwent open colectomy. Controls were selected to match for body mass index, site of primary disease, American Society of Anesthesiologists score, and year of surgery (± 3 year). The parameters analyzed included age, gender, comorbid conditions, American Society of Anaesthesiologists class, diagnosis, procedure, and duration of operation, operative blood loss, and amount of homologous blood transfused. Conversion rate, intra and postoperative complications as were as reoperation rate, 30 d and long-term morbidity rate were also analyzed. For continuous variables, the Student's t test was used for normally distributed data the Mann-Whitney U test for non-normally distributed data. The Pearson's χ(2) tests, or the Fisher exact test as appropriate, were used for proportions. RESULTS: Conversion to open surgery was necessary in 13 of 98 patients (13.3%). In the LPS group, operative time was 29 min longer and blood loss was 78 mL lower when compared to open colectomy (P = 0.03, P = 0.0001, respectively). Overall morbidity, anastomotic leak and readmission rate did not significantly differ between the two groups. A trend toward a reduction of wound complications was observed in the LPS when compared to open group (P = 0.09). In the LPS group, an earlier recovery of bowel function (P = 0.001) and a shorter length of stay (P = 0.03) were observed. After a median follow-up of 62 (range 12-132) mo 23 patients in the LPS group and 38 in the open group experienced long-term complications (LPS vs open, P = 0.03). Incisional hernia resulted to be the most frequent long-term complication with a significantly higher occurrence in the open group when compared to the laparoscopic one (P = 0.03). CONCLUSION: Laparoscopic colectomy in obese patients is safe, does not jeopardize postoperative complications and resulted in lower incidence of long-term complications when compared with open cases.

Feasibility of an adaptive strategy in preoperative radiochemotherapy for rectal cancer with image-guided tomotherapy: boosting the dose to the shrinking tumor.

PURPOSE: To investigate the feasibility of preoperative adaptive radiochemotherapy by delivering a concomitant boost to the residual tumor during the last 6 fractions of treatment. METHODS AND MATERIALS: Twenty-five patients with T3/T4N0 or N+ rectal cancer were enrolled. Concomitant chemotherapy consisted of oxaliplatin 100 mg/m(2) on days -14, 0, and +14, and 5-fluorouracil 200 mg/m(2)/d from day -14 to the end of radiation therapy (day 0 is the start of radiation therapy). Radiation therapy consisted of 41.4 Gy in 18 fractions (2.3 Gy per fraction) with Tomotherapy to the tumor and regional lymph nodes (planning target volume, PTV) defined on simulation CT and MRI. After 9 fractions simulation CT and MRI were repeated for the planning of the adaptive phase: PTVadapt was generated by adding a 5-mm margin to the residual tumor. In the last 6 fractions a boost of 3.0 Gy per fraction (in total 45.6 Gy in 18 fractions) was delivered to PTVadapt while concomitantly delivering 2.3 Gy per fraction to PTV outside PTVadapt. RESULTS: Three patients experienced grade 3 gastrointestinal toxicity; 2 of 3 showed toxicity before the adaptive phase. Full dose of radiation therapy, oxaliplatin, and 5-fluorouracil was delivered in 96%, 96%, and 88% of patients, respectively. Two patients with clinical complete response (cCR) refused surgery and were still cCR at 17 and 29 months. For the remaining 23 resected patients, 15 of 23 (65%) showed tumor regression grade 3 response, and 7 of 23 (30%) had pathologic complete response; 8 (35%) and 12 (52%) tumor regression grade 3 patients had ≤5% and 10% residual viable cells, respectively. CONCLUSIONS: An adaptive boost strategy is feasible, with an acceptable grade 3 gastrointestinal toxicity rate and a very encouraging tumor response rate. The results suggest that there should still be room for further dose escalation of the residual tumor with the aim of increasing pathologic complete response and/or cCR rates.

Experience on surgical treatment of gastrointestinal stromal tumor of the stomach.

In spite of their rarity, gastrointestinal stromal tumors (GISTs) represent a complex clinical problem, mainly diagnostic and therapeutic, for their unpredictable biological course and their long-term prognosis, the most involved site being the stomach. Although a great number of tyrosine-kinase inhibitors has been developed for blocking their proliferative pathways (constitutive CD117 and PDGFRa activation), surgical treatment still remains the only curative one. Nevertheless, their particular non-lymphatic spread and their tendency to peritoneal seeding have emphasized technical issues that are still greatly debated. The definition of the best surgical procedure aiming at the complete R0 resection of the tumor has changed in the recent years and, with the improvement of laparoscopic techniques, the minimally invasive approach of gastric GIST has become feasible in most cases. In this paper we present our experience on surgical treatment of 43 gastric GISTs observed from 2001 to 2008 taken from our case study (75 patients from 1994). The risk class, treatment and long-term follow-up (mean 36 months) has been analyzed. All patients underwent a surgical procedure; 10 of them were also treated with molecular tyrosine-kinase inhibitors as adjuvant treatment. Overall survival at 60 months was 89.3%, with a disease-free survival of 87.68%.

Analysis of prognostic factors influencing long-term survival after hepatic resection for metastatic colorectal cancer.

BACKGROUND: The aim of this study was to analyze the prognostic factors associated with long-term outcome after liver resection for colorectal metastases. The retrospective analysis included 297 liver resections for colorectal metastases. METHODS: The variables considered included disease stage, differentiation grade, site and nodal metastasis of the primary tumor, number and diameter of the lesions, time from primary cancer to metastasis, preoperative carcinoembryonic antigen (CEA) level, adjuvant chemotherapy, type of resection, intraoperative ultrasonography and portal clamping use, blood loss, transfusions, complications, hospitalization, surgical margins status, and a clinical risk score (MSKCC-CRS). RESULTS: The univariate analysis revealed a significant difference (p < 0.05) in overall 5-year survival rates depending on the differentiation grade, preoperative CEA >5 and >200 ng/ml, diameter of the lesion >5 cm, time from primary tumor to metastases >12 months, MSKCC-CRS >2. The multivariate analysis showed three independent negative prognostic factors: G3 or G4 grade, CEA >5 ng/ml, and high MSKCC-CRS. CONCLUSIONS: No single prognostic factor proved to be associated with a sufficiently disappointing outcome to exclude patients from liver resection. However, in the presence of some prognostic factors (G3-G4 differentiation, preoperative CEA >5 ng/ml, high MSKCC-CRS), enrollment of patients in trials exploring new adjuvant treatments is suggested to improve the outcome after surgery.

Laparoscopic vs. open colectomies in octogenarians: a case-matched control study.

PURPOSE: The aim of this study was to define any benefits in terms of early outcome for laparoscopic colectomy in patients over 80 years old compared with open colectomy. METHODS: Sixty-one patients undergoing laparoscopic colectomy for colorectal cancer were matched to 61 open colectomy patients for gender, age, year of surgery, site of cancer, and comorbidity on admission. Independence status on admission and at discharge from the hospital was also evaluated. RESULTS: Mean (standard deviation) age was 82.3 (3.5) years in the laparoscopy group and 83.1 (3.3) years in the open group. Conversion rate was 6.1 percent. Operative time was 49 minutes longer in the laparoscopy group (P = 0.001). The overall mortality rate was 2.4 percent. The morbidity rate was 21.5 percent in the laparoscopy group and 31.1 percent in the open group (P = 0.30). Patients in the laparoscopy group had a faster recovery of bowel function (P = 0.01) and a significant reduction of the mean length of hospital stay (9.8 vs. 12.9 days for the open group, P = 0.001). Laparoscopy allowed a better preservation of postoperative independence status compared with the that of the open group (P = 0.02). CONCLUSION: Laparoscopic colectomy for cancer in octogenarians is safe and beneficial including preservation of postoperative independence and a reduction of length of hospital stay.