Robotic versus open total mesorectal excision for rectal cancer: comparative study of short and long-term outcomes.

BACKGROUND: Despite the several series in which the short-term outcomes of robotic-assisted surgery were investigated, data concerning the long-term outcomes are still scarce. METHODS: The prospectively collected records of 65 consecutive patients with extraperitoneal rectal cancer who underwent robotic total mesorectal excision (RTME) were compared with those of 109 consecutive patients treated with open surgery (OTME). Patient characteristics, pathological findings, local and systemic recurrence rates and 5-year survival rates were compared. RESULTS: There were no statistically significant differences in postoperative complications, reoperation and 30-day mortality. There were significant differences comparing groups: number of lymph nodes harvested (RTME: 20.1 vs. OTME: 14.1, P < 0.001), estimated blood loss (RTME: 0 vs. OTME: 150 ml, P = 0.003), operation time (RTME: 299.0 vs. OTME: 207.5 min, P < 0.001) and length of postoperative stay (RTME: 6 vs. OTME: 9 days, P < 0.001). The rate of circumferential resection margin involvement and distal resection margin were not statistically different between groups. There were no statistically significant differences at the 5-year follow-up: overall survival, disease-free survival and cancer-specific survival. The cumulative local recurrence rate was statistically lower in the robotic group (RTME: 3.4% vs. OTME: 16.1%, P = 0.024). CONCLUSION: RTME showed a significant reduction in local recurrence rate and a higher, although not statistically significant, long-term cancer-specific survival with respect to OTME. Prospective randomized studies are needed to confirm or deny significantly better local control rates with robotic surgery.

Treatment of lesions of the rotator cuff.

The impingement syndrome and tendinopathy of the rotator cuff are the most common causes (complaints) of pain and disability of the shoulder. The aim of this study is to evaluate the efficacy of a specific rehabilitative protocol, integrated with the administration of a nutritional supplement, in the conservative rehabilitative treatment, as well as in post-surgery, of patients with lesions of the rotator cuff. Two groups with syndrome of the rotator cuff were formed to follow different therapeutic courses, in relation to the choice of each subject to undergo the conservative treatment (Arm A) or the surgical one (Arm B). In Arm A the study included the association of therapy with ESWT (shock waves) with the proprioceptive Multi Joint System, for rehabilitating joint movement and muscle strength of the shoulder, and a specific nutritional supplement to reduce the pain and conserve the cartilage tissue. Between February 2009 and June 2009, we enrolled 30 subjects (randomized into three homogenous groups A1, A2, A3), average age 45±10 years, with rotator cuff syndrome with calcification of the shoulder, diagnosed through clinical examination and investigative instruments (X-ray, echography or NMR). In Arm B, from September 2009 to January 2010, we enrolled 50 patients (randomized into two groups, B1 and B2), 24 male (average age 58.4: min 28 and max 78) and 26 females (average age 59.5: min 30 and max 80), who had undergone rotator cuff operations and acromionplasty for non-massive lesions without important gleno-humeral instability, with either open or arthroscopic procedures. The analysis of the results of Arm A highlights that in terms of reducing pain the main benefits were found in Group A1 where the supplement was given. From the analysis of the data of Arm B, in both groups an improvement of the first 4 items evaluated was evident. In Group B1, 84 percent of the patients declared to be satisfied and improved and 16 percent were dissatisfied; in Group B2, where the nutritional supplement was given, 92 percent were satisfied and 8 percent were dissatisfied. In conclusion, we retain that in cases of rotator cuff syndrome, an integrated rehabilitative approach, whether conservative or post-surgical, directed at taking total control of the patient, must observe particular attention to the optimization of the articular tissular metabolic balance in order to favour better functional recovery.

Short- and medium-term results of totally laparoscopic resection for colorectal liver metastases.

BACKGROUND: Laparoscopic surgery for primary colorectal cancer is now commonplace but the uptake of laparoscopic surgery for colorectal liver metastasis (CRLM) has been slow, mainly owing to doubts regarding safety, feasibility and oncological efficiency. METHODS: Prospectively collected data of all patients treated for CRLM between 2004 and 2009 were reviewed retrospectively. The database was analysed for operative details, hospital stay, postoperative results and medium-term survival. RESULTS: Over 5 years, 135 patients underwent liver surgery for CRLM. For laparoscopic procedures, the median duration of operation was 220 min and median blood loss was 363 ml; a mean tumour-free resection margin of 17.0 mm was achieved (more than 1 cm in 76 per cent), and no port-site metastasis or surgical-site recurrence was observed. The procedure was converted to open surgery in six patients (two for bleeding). Overall survival for the laparoscopic group approached 90 per cent with median follow-up of 22 months. CONCLUSION: In this series totally laparoscopic CRLM resection had good short- and medium-term results in terms of mortality, morbidity, resection margins, local recurrence or port-site metastasis, and survival. Compared with contemporaneous open experience, the laparoscopic approach was safe and effective in a highly selected consecutive series.

The finding of vascular and urinary anomalies in the harvested kidney for transplantation.

INTRODUCTION: In kidney transplantation, anatomical vascular and excretory anomalies may represent causes of failure. Today's surgical techniques have made the most of the organs with anatomic anomalies and iatrogenic injury successfully used for transplantation. MATERIALS AND METHODS: From January 2000 to June 2006, we harvested 230 kidneys, of including 88 kidneys (20%) with vascular, urinary, or vascular-urinary anomalies; 64 kidneys were implanted and 15 were sent to other transplantation centers. Only 9 kidneys were not appropriate for transplantation. RESULTS: All patients who received kidneys with the above-mentioned anomalies were carefully examined after the transplantation and short-term and long-term complications were evaluated with respect to controls without anomalies. DISCUSSION: Renal anatomic anomalies are frequently observed during kidney transplantation and may produce postsurgical complications. However, the presence of these anomalies does not necessarily imply the impossibility of using the kidney for a transplant, especially because of improved surgical techniques. Our experience in transplantation procedures showed that even if kidneys present the above-mentioned anomalies they can still be considered appropriate for transplantation when we perform a correct harvesting/back-table transplant surgery. So vascular and urinary anomalies have to be considered always an incentive to research new surgical solutions and to perform a careful surgical technique.

Older kidneys donor transplantation: five years' experience without biopsy and using clinical laboratory and macroscopic anatomy evaluation.

INTRODUCTION: The exponential increase in organ demand is not associated with a similar increase of available kidneys. This emergency led to expanded criteria to consider a kidney transplantable. The aim of this retrospective study was to explain our use of older donor kidneys without biopsy. MATERIALS AND METHODS: Between 2000 and 2005, 58 older kidneys were harvested: 27 were transplanted in our center; 13 were discarded; and 18 were transplanted in other centers. We considered 3 factors to define kidney quality: macroscopic anatomy, multiple factors linked to the donor, and clinical-laboratory data. After transplantation, we observed the patients for at least 1 year and up to 6 years. DISCUSSION: At 1 year, 24/27 (89%) patients had a functional kidney, 2 patients showed an initial renal failure and 1 patient lost the kidney. At maximum follow-up, 19 patients (70%) had functional kidneys, 4 with initial renal failure. These results compared with the kidneys harvested using Standard Donor Kidney Criteria are acceptable. Obviously we need long-term follow-up to increase, the amount of data and obtain a definitive outcome. CONCLUSION: Biopsy is the gold standard for the definition of an older kidney's quality. When a biopsy is not feasible, the study of the macroscopic anatomy the kidney's donor and of some donor's parameters represent an acceptable biopsy alternative, being able to rescue some organs that would be otherwise lost.

Healing of surgical incision in kidney transplantation: a single transplant center's experience.

INTRODUCTION: Impaired healing of the surgical incision represents a common complication after kidney transplantation. We led a retrospective study seeking to understand the factors linked to these complications and reasons for their reduction during the last year. PATIENTS AND METHODS: From January 2000 to April 2004, 170 consecutive kidney transplantations were performed in a homogenous patient population. We evaluated the influence of following factors to determine impaired healing of the incision: antirejection drugs, overweight/obesity, age, delayed graft function (DGF), diabetes, and abdominal wall reconstruction technique. RESULTS: Among 165 patients we observed 26 (15.76%) cases of impaired healing of the surgical incision: 17 (65,38%) with first-level and nine with second-level wound complications. CONCLUSIONS: Impaired healing of the surgical incision influences the outcome of kidney transplant patients. In our study we observed that cyclosporine and tacrolimus similary affected the incision's healing. It was not possible to evaluate the role of basiliximab. A univariate analysis of the factors related to complications revealed overweight and DGF. However, all patients developing second-level complications showed more risk factors. Patients who had not had reconstruction of the muscle layers showed a greater incidence of surgical complications, whereas patients who had skin sutured with an intradermic technique did not show an increased risk.

Transplantation and young surgeons in Italy.

The relation between young surgeons and transplantation has always been a "love and hate" one. Until a few years ago this branch of surgery was seen as pioneering, with extreme and and extensive training, and was reserved to few elected members. Nowadays things are different. In this article we try to understand the true reasons that young Italian surgeons avoid transplantation surgery.

Treatment of isolated systolic hypertension: the SHELL study results.

OBJECTIVE: Our aim was to compare the effect of lacidipine and chlorthalidone on cardiovascular outcome as a primary parameter and blood pressure as a secondary in elderly patients with isolated systolic hypertension in a prospective study with an open design. METHODS: 1882 males and females outpatients > or = 60 years were randomly assigned to the administration of chlorthalidone 12.5 mg o.d. or lacidipine 4 mg o.d. Patients were recruited if sitting systolic blood pressure was > or = 160 mmHg with a diastolic blood pressure equal or lower than 95 mmHg. Primary endpoint was a composite of cardiovascular and cerebrovascular events. RESULTS: At randomization mean systolic blood pressure was 178.1 mmHg in the lacidipine and 178.2 mmHg in the chlorthalidone group, the corresponding mean diastolic values being 86.9 and 86.8 mmHg. In both lacidipine and chlorthalidone groups treatment caused a significant (p < 0.001) and marked systolic blood pressure reduction which was maintained throughout the treatment period with a significant (p < 0.001) and steady although less marked reduction in diastolic blood pressure as well. At the end of treatment period (median 32 months), the reduction was 36.8/8.1 mmHg (systolic/diastolic) in the chlorthalidone and 38.4/7.9 mmHg in the lacidipine group, the final on treatment blood pressures being 142.0/79.2 and 143.2/79.5 mmHg, respectively. Treatments were similarly effective in males and females and in age groups between 60 and 69 years (n = 763), 70 and 79 years (n = 744) and > or = 80 years (n = 375). Similar reductions were obtained in a subgroup of patients (n = 209) followed in double-blind fashion for 1 year. The overall incidence of the primary endpoints was 9.3% with no significant between-group difference. Total mortality was also similar between groups. CONCLUSIONS: In elderly patients with isolated systolic hypertension, administration of lacidipine or chlorthalidone markedly reduced systolic blood pressure with no difference in the incidence of cardiovascular events and total mortality.

Acute sarcocystosis in a captive white-tailed deer in Virginia.

A 19-mo-old female captive white-tailed deer in a public wild animal park in Richmond (Virginia, USA) was necropsied and evaluated histologically following spontaneous death after a 1 wk period of lethargy in a captive herd of 22 deer. An acute necrotizing pneumonia was associated with intraendothelial protozoal schizonts that were identified immunohistochemically as Sarcocystis spp. This is the first confirmed report of acute sarcocystosis in a wild ruminant.

[A case of transient hypertrophic cardiomyopathy in a twin infant of a diabetic mother]. / Un caso di cardiomiopatia ipertrofica transitoria in neonata gemella figlia di madre diabetica.

The case is reported of a dizygotic twin infant of a diabetic mother with transient hypertrophic cardiomyopathy. The clinical course and eco-ecg reports are described. The etiopathogenesis is discussed since no evidence of cardiomyopathy was found in the second twin. The importance of a timely diagnosis for a correct therapy is emphasized.

[Adrenal hemorrhage in neonates: three cases with different clinical and echographic findings]. / Emorragia surrenalica nel neonato: presentazione di tre casi con diverso quadro clinico ed ecografico.

Three cases of neonatal adrenal hemorrhage are described. They presented different clinical findings. Ultrasonography was the investigation of choice. It showed different initial patterns: anechoic in one case, hyperechoic in the others. The literature is reviewed. Usefulness of echography in the diagnosis of adrenal hemorrhage is stressed.

[Incidence and significance of heart murmurs in newborn infants admitted to nursery]. / Incidenza e significato del soffio cardiaco in neonati accolti al nido.

In a retrospective study on heart murmurs in healthy newborns we reviewed data concerning all newborns admitted in our nursery in the year 1990 (1387 newborns: male 699, female 688). An heart murmur was recorded in 106 (7.6%); in 32 of these (30%) the murmur was still audible at discharge; in 18 cases (17%) a congenital heart defect was diagnosed. Our data suggest that time of onset and intensity are valuable data for diagnostic approach, as murmurs recorded after the first day of life, and/or of intensity of 2/6 or more, are more likely to be expression of a congenital heart disease and should be further evaluated.

[A case of fetal hydrops due to congenital cardiopathy]. / Un caso di idrope fetale da cardiopatia congenita.

As the frequency of Rh isoimmunization is declining, nonimmune fetal hydrops is becoming the predominant form of hydrops. Authors report a case of hydrops secondary to congenital heart disease and briefly discuss the physiopathology of such condition.

[A case of congenital cytomegalic disease: clinical and virological study]. / Un caso di malattia citomegalica congenita: studio clinico e virologico.

A case of congenital cytomegalovirus infection is reported and its clinical and diagnostic problems are considered. Perinatal and intrauterine transmission of CMV is discussed.

[Neonatal cystic lymphangioma]. / Linfangioma cistico neonatale.

The A.A. reports a case of cystic congenital linphangioma of the face and neck, recently observed on the Neonatal Intensive Care Unit. The therapeutic approach was very difficult and required three times a surgical menagement because of successively relapses. The control and normalization of the compressive and infective complications due to the massa and its removal were hard too. In spite of some aesthetical problems, the results may be considered satisfactory. Our case enphasizes the intrinsec, complex, therapeutical difficulties of the cystic linphangiomas.