Total mesorectal excision and low rectal anastomosis for the treatment of rectal cancer and prevention of pelvic recurrences.

HYPOTHESIS: Total mesorectal excision lowers the rate of pelvic recurrence and positively affects the survival after surgical treatment of rectal cancer. DESIGN: Case series. SETTING: Tertiary care university hospital. PATIENTS: Fifty-three consecutive patients were admitted with curative intent to surgery at the First Department of Surgery of the University of Rome "La Sapienza," Rome, Italy, with diagnoses of rectal carcinoma. The mean follow-up was 68.9 months; follow-up was complete for all patients who entered the trial. INTERVENTIONS: Low anterior resection and total mesorectal excision were performed in all cases, regardless of the location of the rectal cancer. A straight mechanical colorectal anastomosis was performed on a rectal stump, never exceeding 5 cm. No kind of adjuvant therapy was given. Mesorectum and open rectum were studied by serial transverse section at 5-mm intervals. A search for depth of penetration and distal intramural extension of the tumor was made. Lymph nodes were detected by clearing method, and nodal metastases (NM) and nonnodal metastases (NNM) were recorded as situated proximally, distally, or at the level of the tumor. RESULTS: There was no postoperative mortality. Clinical and radiologic leaks occurred in 2 and 4 patients, respectively. Mean disease-free survival was 65.9 months. Pelvic recurrence occurred in 5 patients (9%). Overall 5-year survival rate was 75%. Involvement of mesorectum by NM and NNM was detected in 27 and 24 cases, respectively. Both NM and NNM were found to be distal in 33% and 40% of cases, respectively. CONCLUSIONS: Microscopic spread to the distal mesorectum may exceed the intramural spread of rectal cancer. Failure to perform total mesorectal excision leaves a potentially residual disease in the distal mesorectum, thus predisposing the patient to pelvic recurrence.

Preservation of the inferior mesenteric artery in colorectal resection for complicated diverticular disease.

BACKGROUND: Preservation of the inferior mesenteric artery (IMA) and consequential blood flow to the rectum would reduce the risk of leakage of a colorectal anastomosis. METHODS: One hundred and sixty-three patients undergoing left colectomy for complicated diverticular disease of the colon were randomly placed into two groups: A, n = 86; and B, n = 77. In group A, the integrity of the IMA was preserved by artery skeletization (IMAS); in group B, the IMA was divided at its origin. Variables recorded included duration of the surgical procedure, need for blood transfusion, length of hospital stay, operative mortality and morbidity, staple-ring disruption, and radiologic and clinical leakage. Anastomotic stenosis and recurrence of diverticular disease were noted. RESULTS: Surgical time was superior in the IMAS group. Radiologic and clinical leakages were significantly higher in group B (P = 0.02, P = 0.03, respectively). In group A a significant lower number of staple-ring disruptions was observed, evolving into clinical dehiscence. CONCLUSION: Preserving the natural blood supply to the rectum and the ensuing use of a healthy well-nourished rectal stump are suggested as the main aspects of IMAS in preventing and healing leakage of colorectal anastomosis.

Arteriomegaly and inflammatory abdominal aortic aneurysm. Case report.

In this case report inflammatory abdominal aortic aneurysm (IAAA) was superimposed on an arteriomegaly condition complicated by bilateral aneurysm of the common iliac arteries. Obstruction of the right ureter, mild hydronephrosis of the left system and a slight impairment of renal function were also present. Preoperative cellular and humoral immunological parameters were within normal limits while the erythrocyte sedimentation rate (ESR) was elevated (74 mm). Histological analysis showed numerous scattered lymphoid cells or organized in follicles with germinal centers within the adventitial thickening of the IAAA wall. Immunohistochemical analysis on frozen sections demonstrated that dispersed and perivascular lymphoid cells were mainly composed of similar amounts of CD3+/CD4+ and CD3+/CD8+ T lymphocytes. Histological analysis of the common iliac artery aneurysm showed a mild intimal thickening will small aggregates of macrophages. After aneurysm repair all peripheral blood analysis normalized within one month after surgery. The IAAA observed in our patient with arteriomegaly as underlying arterial disease cannot be interpreted as an inflammatory variation of an atherosclerotic aneurysm. The histological pattern of the inflammatory reaction and its resolution after surgery give, in our opinion, more credit to the etiopathogenetic hypothesis of a reaction elicited by an antigen within the arterial wall of the infrarenal aorta which might be enhanced by the lymphatic stasis subsequent to aneurysm compression.

Reliability of visual and quantitative hepatobiliary scintigraphy in the follow-up of patients who have undergone cholecystectomy and transduodenal sphincteroplasty.

A noninvasive scintigraphic technique to assess the efficacy of a surgical procedure (e.g., cholecystectomy and transduodenal sphincteroplasty) depends on the development of reliable and accurate qualitative or quantitative diagnostic criteria that allow early recognition of the occurrence and site of complications. For this purpose, the authors divided biliary flow into a four-step progression process and analyzed transit times from the peripheral vein to the gallbladder, common bile duct, and duodenum and the transit time from the common bile duct to the duodenum. These quantitative parameters were assessed in nine healthy volunteers and 31 asymptomatic patients who had previous cholecystectomy to validate their reliability. The results indicate that the four-step Tc-99m HIDA progression analysis provides a reliable, noninvasive evaluation of biliary flow, so that it can be applied to patients who have had cholecystectomy.

[Indications and results of thrombo-embolectomy in acute ischemia of the extremities]. / Indicazioni e risultati della tromboembolectomia nelle ischemie acute degli arti.

A personal series of 176 thrombo-embolisms in the extremities, 157 of them operated, observed at the Surgical Clinic of Cagliari University in the period 1969-1977, is reported. The results of surgery are discussed in relation to the factors which most affect prognosis: age, time and degree of ischaemia, anatomo-pathological condition of the arteries and site of obstruction. Severe ischaemia poses the problem of indication for disobstruction: the possible onset of the revascularization syndrome, which almost always causes the death of the patient, should be borne in mind. Recently proposed local wash-out techniques do not complete solve the problem because although they manage to prevent the revascularization syndrome, they do not always save the extremity, which has to be amputated at a later stage after pointless risks to the patient. On the other hand, the poor functional results obtainable from an extremity that has suffered severe ischaemia must be considered. It is therefore preferred to forgo disobstruction when the ischaemia is so serious that revascularization syndrome is probable.

[Extensive lymphadenectomy and long-term survival in right hemicolectomy for carcinoma]. / Linfoadenectomia estesa e sopravvivenza a distanza nell'emicolectemia destra per carcinoma.

Late clinical outbreak in patients with right colon cancer translates into very advanced stage of the tumour. Nevertheless, long term results of radical surgery are favourable, even if susceptible of improvements. While earlier diagnoses are not easy to achieve, a greater surgical radicality can be obtained both by extending resections to the surrounding structures and organs, and by enlarging lymphadenectomy to all the inframesocolic compartment and to the main lymph nodes located at the level of superior mesenteric vessels. A series of 60 right hemicolectomies performed from 1968 to 1990 to treat right colonic cancer is presented. Intraoperative mortality was of 4 cases (6.6%). Lymph node "mapping" was drawn, and in 26 cases (43%) metastases were found. Paracolic nodes were involved in 96% of cases, intermediate in 42%, and principal ones in 34%. Forty four patients, surgically treated up to 1985 and eligible for a 5 year follow up, were all verified. Overall free of disease survival was assessed in 28 cases (63.6%). Survival in relation to Dukes staging was 81.8% (9/11) in C. According to presence (LN+) or absence (LN-) of lymphatic spread, 5 year survival was found to be 70.3% (19/27) in LN-, and 52.9 (9/17) in LN+. Difference between the two groups is 17.4%, much smaller than the mean one of 45% reported by world literature. This figure, together with the finding of a 12, 10 and 5 year survival in patients with principal nodes involvement, suggests that extended lymphadenectomy might play a principal role in improving long term survival rates of advanced right colon cancer.