Single-incision versus standard multiple-incision laparoscopic cholecystectomy: a meta-analysis of experimental and observational studies.

OBJECTIVE: The advantages of single-incision surgery for the treatment of gallstone disease is debated. Previous meta-analyses comparing single-incision laparoscopic cholecystectomy (SILC) and standard laparoscopic multiport cholecystectomy (SLMC) included few and underpowered trials. To overcome this limitation, we performed a meta-analysis of randomized and nonrandomized studies. METHODS: A MEDLINE, EMBASE, and Cochrane Library literature search of studies published in and comparing SILC with SLMC was performed. The primary outcome was safety of SILC as measured by the overall rate of postoperative complications and biliary spillage. Feasibility was another primary outcome as measured by the conversion and operative time. Postoperative pain, length of hospital stay, perioperative blood loss, time to return to normal activity, and cosmetic satisfaction were secondary outcomes. RESULTS: We identified 43 studies of which 30 were observational reports and 13 experimental trials, for a total of 7489 patients (2090 SILC and 5389 SLMC). The overall rate of complications was comparable between groups (relative risk [RR] = 1.08; 95% CI = 0.87-1.35; P = .46), as were the rates of biliary spillage (RR = 1.16; 95% CI = 0.73-1.84; P = .53) and conversion rate (RR = 0.88; 95% CI = 0.53-1.46; P = .62). Operative time was in favor of SLMC (weighted mean difference = 0.73; 95% CI = 0.67-0.79; P < .0001). Secondary outcomes favored SILC, but with marginal advantages. CONCLUSIONS: SILC is a feasible technique but without any significant advantage over SLMC for relevant end points. Although secondary outcomes favored SILC, the small magnitude of the advantage and the low quality of assessment methods question the clinical significance of these benefits.

A prospective evaluation of short-term and long-term results from colonic stenting for palliation or as a bridge to elective operation versus immediate surgery for large-bowel obstruction.

BACKGROUND: The efficacy and safety of self-expandable metallic stent (SEMS) placement as a bridge to elective surgery or definitive palliation versus emergency operation to treat colorectal obstruction is debated. This study aimed to evaluate the outcomes of patients with colorectal obstruction treated using different strategies. METHODS: Subjects admitted to the authors' department with colorectal obstruction (n = 134) were studied prospectively. They underwent endoscopic stenting as a bridge to elective surgery (SEMS group: n = 49) or for definitive palliation (n = 34). A total of 51 patients underwent immediate surgery without stenting (NO-SEMS). Treatment was decided by the senior on-call surgeon. RESULTS: Placement of SEMS was technically successful in 95.3 % and clinically successful in 98.7 % of cases. The short-term complications in the SEMS group were perforation (n = 1, 1.2 %), migration (n = 4, 4.9 %), occlusion (n = 4, 4.9 %), colon bleeding (n = 3, 3.7 %), and abdominal pain (n = 6, 7.4 %). The postoperative complication rate was 32.7 % in the SEMS group versus 60.8 % in the NO-SEMS group (P = 0.005), with a significant reduction in wound infections (26.5 vs 54.9 %; P = 0.004), abdominal abscess (14.3 vs 39.2 %; P = 0.006), respiratory morbidity (10.2 vs 37.3 %; P = 0.002), and intensive care treatment (10.2 vs 33.3 %; P = 0.007). The median postoperative hospital stay was 10 versus 15 days (P = 0.001). The in-hospital mortality rate in both groups was 2 %. Long-term follow-up evaluation showed less incisional hernia (6.3 vs 22.0 %; P = 0.04) and definitive stoma formation (6.3 vs 26.0 %; P = 0.01) in the SEMS group than in the NO-SEMS group, respectively. Kaplan-Meier survival curves showed a benefit for the SEMS group (log-rank test, 0.004). The long-term SEMS-related complication rate for the palliative patients was 43.8 %. The hospital readmission rate for SEMS complications was 34.4 %. Overall clinical success was 81.2 %. CONCLUSIONS: In case of colorectal obstruction, endoscopic colon stenting as a bridge to elective operation should be considered as the treatment of choice for resectable patients given the significant advantages for short- and long-term outcomes. Palliative stenting is effective but associated with a high rate of long-term complications.

Surgical treatment of liver metastases of gastric cancer: state of the art.

BACKGROUND: The prognosis of patients with liver metastases from gastric cancer (LMGC) is dismal, and little is known about prognostic factors in these patients; so justification for surgical resection is still controversial. Furthermore the results of chemotherapy for these patients are disappointing. The purpose of this study was to review recent outcomes of hepatectomy for LMGC and to determine the suitable candidates for surgery, assessing the surgical results and clinicopathologic features. Moreover we compare these results with those obtained with alternative treatments.

Surgical site infections following colorectal cancer surgery: a randomized prospective trial comparing common and advanced antimicrobial dressing containing ionic silver.

BACKGROUND: An antimicrobial dressing containing ionic silver was found effective in reducing surgical-site infection in a preliminary study of colorectal cancer elective surgery. We decided to test this finding in a randomized, double-blind trial. METHODS: Adults undergoing elective colorectal cancer surgery at two university-affiliated hospitals were randomly assigned to have the surgical incision dressed with Aquacel Ag Hydrofiber dressing or a common dressing. To blind the patient and the nursing and medical staff to the nature of the dressing used, scrub nurses covered Aquacel Ag Hydrofiber with a common wound dressing in the experimental arm, whereas a double common dressing was applied to patients of control group. The primary end-point of the study was the occurrence of any surgical-site infection within 30 days of surgery. RESULTS: A total of 112 patients (58 in the experimental arm and 54 in the control group) qualified for primary end-point analysis. The characteristics of the patient population and their surgical procedures were similar. The overall rate of surgical-site infection was lower in the experimental group (11.1% center 1, 17.5% center 2; overall 15.5%) than in controls (14.3% center 1, 24.2% center 2, overall 20.4%), but the observed difference was not statistically significant (P = 0.451), even with respect to surgical-site infection grade 1 (superficial) versus grades 2 and 3, or grade 1 and 2 versus grade 3. CONCLUSIONS: This randomized trial did not confirm a statistically significant superiority of Aquacel Ag Hydrofiber dressing in reducing surgical-site infection after elective colorectal cancer surgery. TRIAL REGISTRATION: Clinicaltrials.gov: NCT00981110.

Surgical treatment of liver metastases of gastric cancer: is local treatment in a systemic disease worthwhile?

OBJECTIVES: The prognosis of patients with liver metastases of gastric cancer (LMGC) is dismal, but little is known about prognostic factors in these patients; thus justification for surgical resection is still controversial. The purpose of this study was to review recent outcomes of hepatectomy for LMGC and to determine which patients represent suitable candidates for surgery by assessing surgical results and clinicopathologic features. METHODS: Outcomes in 21 patients with LMGC who underwent hepatectomy between 1998 and 2007 were assessed. Isolated metastases and potential to perform a curative resection were requisite indi-cations for surgery. Surgical outcome and clinicopathologic features of the hepatic metastases were analysed. RESULTS: Overall 1-, 3- and 5-year survival rates after hepatic resection were 68%, 31% and 19%, respectively; three patients survived for >5 years without recurrence. Univariate analysis revealed a solitary metastasis, negative margin (R0) resection and the presence of a peritumoral fibrous capsule as significant favourable prognostic factors. These characteristics were present in all of the three patients who survived for >5 years. CONCLUSIONS: Solitary metastases from gastric cancer should be treated surgically and confer a better prognosis. Surgical resection should provide microscopically negative margins (R0). A new prognostic factor, the presence of a pseudocapsule, may be associated with improved prognosis.

Safety, feasibility, and tolerance of early oral feeding after colorectal resection outside an enhanced recovery after surgery (ERAS) program.

INTRODUCTION: It is generally believed that resumption of feeding after colorectal resection is indicated only after recovery of bowel function. This study was designed to verify safety, feasibility, and tolerance of early oral postoperative feeding (EOF) outside an enhanced recovery after surgery (ERAS) program. MATERIALS AND METHODS: One hundred patient candidates to elective colorectal resection were prospectively enrolled in an EOF program. Feeding was started on postoperative day (POD) 1 with oral nutritional supplement (ONS). On POD 2, patients had normal food plus ONS to reach 1,000-1,200 kcal/day with progressive increase until 1,800-2,000 kcal/day. Results were compared with historical controls (n = 100) in whom oral feeding was allowed only after full bowel function recovery. The ERAS program was not applied in both groups. RESULTS: The EOF group had a better recovery of short half-life protein synthesis compared with the control group (P < 0.001). Stool canalization occurred after a median of 3 days (range, 1-6 days) in the EOF group versus 5 days (range, 2-8 days) in the control group (P = 0.001). The feeding protocol was completed in 89 patients within POD 5. Tolerance to resumption of feeding was similar in the two groups. The overall rate of postoperative complication was 22% in the EOF group vs. 27% in the control group (P = 0.51). The median length of hospitalization was 9 days (range, 6-25 days) in the EOF group vs. 12 days (range, 6-31 days) in controls (P = 0.01). CONCLUSIONS: EOF after colorectal operations is feasible and safe outside an ERAS program.

Gut oxygenation and oxidative damage during and after laparoscopic and open left-sided colon resection: a prospective, randomized, controlled clinical trial.

BACKGROUND: Pneumoperitoneum (PP), established for laparoscopic (LPS) operation, has been associated with potential detrimental effects, such as mesenteric ischemia-reperfusion injury. The objective of the trial was to measure intestinal tissue oxygen pressure (PtiO2) and oxidative damage during laparoscopic (LPS) and open colon surgery and during the postoperative course. METHODS: Forty patients candidate to left-sided colectomy were randomized to undergo open or LPS resection (20 patients/group). During the operation, PtiO2 was measured at established changes of PP pressure (from 0-15 mmHg) and for 6 days postoperatively. PtiO2 was determined by a polarographic microprobe implanted in the colon wall. Ischemia-reperfusion injury was assessed by plasma malondialdehyde (MDA). ClinicalTrial.gov registration number: NCT01040013. RESULTS: LPS was associated with a higher PtiO2 at the beginning of surgery (73.9±9.4 vs. 64.3±6.4 in open; P=0.04) and at the end of the operation (57.7±7.9 vs. 53.1±4.7 in open; P=0.03). PtiO2 decreased significantly during mesentery traction vs. beginning in both groups (respectively 58.7±13.2 vs. 73.9±9.4 in LPS and 55.3±6.4 vs. 64.3±6.4 in open group; minimum P=0.02). During LPS, there was a significant decrease of PtiO2 only when PP was increased to 15 mmHg (63.2±7.5 vs. 76.6±10.7 at 10 mmHg; P=0.03). PtiO2 also was significantly better in the LPS group during the first 3 days after operation (minimum P=0.04 vs. open). MDA significantly increased in both groups after mesentery traction and at the end of operation vs. baseline levels with no difference between techniques. CONCLUSIONS: LPS seems to be associated with a better intra- and postoperative PtiO2. High-pressure PP may impair PtiO2.

Bipolar vessel sealing system vs. clamp crushing technique for liver parenchyma transection.

BACKGROUND/AIMS: To evaluate the impact of the traditional clamp-crush technique and a radiofrequency bipolar vessel sealing device (BVSD) for liver resection on operative blood loss, transfusion rate, duration of operation, length of hospitalization and morbidity. METHODOLOGY: From a database, 100 patients who underwent elective liver resection were retrospectively selected. In 40 patients parenchyma transection was performed by BSVD (LigaSure system) and 60 patients were operated using traditional clamp-crush technique (CC group). RESULTS: The two groups were well-matched for baseline and surgical characteristics. Peak of transaminases was significantly higher in the BSVD on postoperative days 1, 3 and 5 (minimum p = 0.02 vs. CC). There was no significant difference between CC group and BVSD group in median operation time (180 vs. 190 min), blood loss (600 vs. 700 mL), transfusion rate (48.0% vs. 60.5%), hepatic failure (3.2% vs. 2.5%), morbidity rate (26.6% vs. 27.5%), and hospital stay (13 vs. 12 days). CONCLUSIONS: Increased tissue damage in the BSVD group did not seem to correlate with organ dysfunction or postoperative morbidity. The two techniques appear equivalent in term of outcome and thus the choice of transection strategy remains according to the surgeon preference and experience.

[Immunotherapy in radical surgery of colorectal carcinoma]. / Immuno-modulazione nella chirurgia radicale del carcinoma del colon-retto.

Cancer-associated immunodeficiency is seriously worsened by surgical trauma. Short-term preoperative interleukin-2 (IL-2) immunotherapy abolishes postoperative immunodeficiency and can induce immunological control of the growth of minimal residual disease. Growth factors play an important role in oncological practice in treating neutropenia (G-CSF) or associated anaemia during chemotherapy (erythropoietin). Unfortunately, lymphocytopenia is not considered a biological marker with regard to survival. On the other hand, the role of the immune response to surgical trauma has been emphasised by many surgeons, and to counteract it immune nutrition (omega 3 fatty acid, mRNA, arginine) or thymic hormone have been tried. We believe that the obvious method of counteracting postoperative lymphocytopenia is the administration of the specific growth factor for T lymphocytes, i.e. IL-2. The aim of this study was to report on our experience with IL-2 preoperative immunoactivation in colorectal cancer and the long-term outcome of patients treated in comparison with a control group operated on without immunotherapy. In order to obtain activated lymphocytosis at the time of operation administration of IL-2 (6 million I.U. twice daily subcutaneously) for 3 preoperative days is sufficient, starting 4 days before surgery. The inclusion/exclusion criteria were histologically documented colorectal cancer, elective surgery, laparotomic surgery, no second tumour, age 20-80 years, no cardiovascular, hepatic or renal failure. From June 1992 to December 2005, 67 patients were treated (Dukes B/C: 46/21) with IL-2 immunotherapy. The clinical and biological results were compared with those of a control group of 173 patients (Dukes B/C 114/59) operated on in the same period and recruited with the same criteria. Dukes stage-C patients in both groups underwent adjuvant chemotherapy plus radiotherapy for rectal cancer. Data were statistically analysed using Fisher's exact test, Student's T-test and analysis of variance, as appropriate. The overall survival curves were plotted with the Kaplan-Mayer method. After a median follow-up of 69 months (range: 12-169) the progression rate was 15/67 (22%) vs 68/173 (39%) in controls (p = 0.02). Important results were obtained in Dukes-B patients: progression rate 7/46 (15%) vs 37/114 (32,4%) in controls (p = 0.03). We can conclude that immunotherapy is well tolerated. IL-2 is capable of counteracting surgery-induced immunodeficiency. The amplification of the immune response in the post-operative period is capable of controlling minimal residual disease after radical surgery, of reducing the progression rate, and of improving the prognosis and overall survival.

[Duodenal perforation post-ERCP: diagnostically and therapeutic management]. / Strategia diagnostico-terapeutica nelle complicanze perforative post-colangiopancreatografia retrograda endoscopica (ERCP).

OBJECTIVE: Author's experience with periduodenal perforation after ERCP and there systematic approach is presented. METHODS: A retrospective study of 6 instances of duodenal perforation related to endoscopic retrograde cholangiopancreatography. The study follows these parameters: type of perforations, clinical presentation, diagnostic methods, time to diagnosis, methods of management, surgical procedures, length of stay, mortality and morbidity. RESULTS: Traditionally duodenal perforation after ERCP has been managed surgically; however in last decade management has been shifted to a more selective approach, but some authors promotes non surgical routine management: the reported death rate of medical treatment is high as 50%. In our experience an aggressive diagnostically and therapeutically management may reduce mortality. The decision to manage patients without surgery is a dynamic one and should undergo frequent reevaluation whenever the clinical circumstances demonstrate even the slightest untoward development. CONCLUSION: A selective management scheme and an aggressive but selective surgical approach may influence overall mortality.

Skin antisepsis with chlorhexidine versus iodine for the prevention of surgical site infection: A systematic review and meta-analysis.

BACKGROUND: Surgical site infection (SSI) is one of the most frequent health care-associated infections. One of the practices to reduce their incidence is preoperative skin antisepsis. Two of the most commonly active components used are chlorhexidine gluconate and povidone iodine. Of 3 reviews conducted between 2010 and 2012 comparing antiseptics, 2 were in favor of chlorhexidine; however, the latest was unable to draw conclusions. PURPOSE: To verify whether recent evidence supports the hypothesis that chlorhexidine in preoperative antisepsis is more efficient than other antiseptics in reducing SSI rates. PROCEDURES: We conducted a systematic review from 2000-2014 in all languages. The primary end point was SSI incidence and secondary skin bacterial colonization. RESULTS: Nineteen studies were included. Meta-analysis were conducted for comparable studies for both outcomes. The results of the meta-analysis, including all of the studies in which chlorhexidine was compared with iodophor, were in favor of chlorhexidine for both SSI incidence (risk ratio [RR], 0.70; 95% confidence interval [CI], 0.52-0.92) and bacterial skin colonization (RR, 0.45; 95% CI, 0.36-0.55). CONCLUSIONS: There is moderate-quality evidence supporting the use of chlorhexidine for preoperative skin antisepsis and high-quality evidence that the use of chlorhexidine is associated with fewer positive skin cultures. Further rigorous trials will be welcomed to attain stronger evidence as to the best antiseptic to be used before surgery.

Pre-operative immunoprophylaxis with interleukin-2 may improve prognosis in radical surgery for colorectal cancer stage B-C.

Cancer-associated immunodeficiency is seriously worsened by surgical trauma. Short-term pre-operative interleukin-2 (IL-2) administration abolished post-operative immunodeficiency. The effects of a pre-operative IL-2 immunotherapy on the prognosis of colorectal cancer patients (Dukes' stages B and C), undergoing radical surgery, are reported. The study included, after post-operative stratification, 86 consecutive patients with colorectal cancer Dukes' stage B (57) and C (29), undergoing radical laparotomic surgery, randomised to be treated pre-operatively, with or without a short-term course of subcutaneous (s.c.) IL-2 immunotherapy. Human recombinant IL-2 was given s.c. at 6x10(6) I.U. twice daily pre-operatively for 3 consecutive days. Surgery was performed 36 hours after the last IL-2 injection. Dukes' C patients of both groups received standard adjuvant chemotherapy consisting of 5-FU plus folates and radiotherapy for rectal cancer patients. After a median follow-up of 54 months (range 18-86), the progression rate was significantly lower in patients pre-treated with IL-2 than in controls: 9/42 (21.4%) IL-2 group vs. 19/44 (43.1%) controls, (p <0.03). The positive effect of immunotherapy was detected both in the Dukes' B group, with 5/29 (17%) progression in the IL-2 group vs. 9/28 (32%) in controls, and Dukes' C patients with 4/13 (30%) vs. 10/16 (62%). This study shows that a 3-day pre-operative course of IL-2 immunotherapy may improve prognosis in patients with colorectal cancer at Dukes' stages B and C, as previously demonstrated in patients with more advanced disease. Therefore, the early activation of the antineoplastic immune system in the first post-operative days following a presurgical activation with IL-2 may counteract the growth of minimal residual disease and prevent late disease progression.

Impact of postoperative infections on survival in colon cancer patients.

PURPOSE: We investigated the prognostic significance of postoperative infections for the outcome of 192 patients with colon cancer. METHODS: The 5-year survival rates were analyzed by the Kaplan-Meier technique. Univariate and multivariate analyses were done to evaluate prognostic variables using Cox's proportional hazard model. RESULTS: Forty-three patients developed deep incisional or organ/space surgical site infections. The groups with and without infection were comparable. Multivariate analysis showed that only Dukes' stage (p=0.048) and postoperative infection (p=0.011) were independently associated with outcome. In patients with infective complications, the survival rate was significantly lower than in subjects without infection (log rank p=0.0004). CONCLUSIONS: These results stress the importance of evaluating variables other than the classical tumor stage in predicting long-term cancer outcome.

[Multiple abdominal trauma: therapeutical options]. / I traumi addominali complessi: opzioni terapeutiche.

OBJECTIVE: To revise a series of multiple abdominal trauma in order to evaluate the type of diagnosis process and therapy undertaken, the complication and patient survival rates. PATIENTS: Three hundred ten patients of whom 294 (94.8%) with a single abdominal organ injury associated or not with trauma of extra-abdominal organs (thorax, mediastinum, brain, bone) and 16 patients with a multiple abdominal injury (2 or more organs) associated or not with trauma of extra-abdominal organs. Age, gender, vital parameters, injury dynamics, number of organs, site of injury, Injury Severity Score (ISS), Abdominal Trauma Index (ATI) and Glasgow Coma Scale (GCS) have been recorded at admission. RESULTS: Multiple abdominal trauma represent 5% of all abdominal trauma. All trauma were closed ones: 14 street accident and 2 precipitations. A non operative management was undertaken in 6 patients, successfully completed in 2, while 4 patients required a surgical intervention to control bleeding within 12 hours of observation. Ten patients underwent immediate operation for unstable vital signs. The mean number of abdominal organs damaged was 2.8/patient. The mortality rate was 43.7% (7/16). All patients died during surgery. By comparing dead and surviving patient, initial haemodynamics and severity of ISS, GCS, and ATI scores were significant negative prognostic factors. The median length of hospitalisation of survivors was 12 days. CONCLUSIONS: Non operative management of multiple abdominal injury seems to be feasible in a small percentage and possibly only in selected cases.

Effect of oral mesalamine on inflammatory response in acute uncomplicated diverticulitis.

AIM: To evaluate the impact of mesalamine administration on inflammatory response in acute uncomplicated diverticulitis. METHODS: We conducted a single centre retrospective cohort study on patients admitted to our surgical department between January 2012 and May 2014 with a computed tomography -confirmed diagnosis of acute uncomplicated diverticulitis. A total of 50 patients were included in the analysis, 20 (study group) had received 3.2 g/d of mesalamine starting from the day of admission in addition to the usual standard treatment, 30 (control group) had received standard therapy alone. Data was retrieved from a prospective database. Our primary study endpoints were: C reactive protein mean levels over time and their variation from baseline (ΔCRP) over the first three days of treatment. Secondary end points included: mean white blood cell and neutrophile count over time, time before regaining of regular bowel movements (passing of stools), time before reintroduction of food intake, intensity of lower abdominal pain over time, analgesic consumption and length of hospital stay. RESULTS: Patients characteristics and inflammatory parameters were similar at baseline in the two groups. The evaluation of CRP levels over time showed, in treated patients, a distinct trend towards a faster decrease compared to controls. This difference approached statistical significance on day 2 (mean CRP 6.0 +/- 4.2 mg/dL and 10.0 +/- 6.7 mg/dL respectively in study group vs controls, P = 0.055). ΔCRP evaluation evidenced a significantly greater increment of this inflammatory marker in the control group on day 1 (P = 0.03). A similar trend towards a faster resolution of inflammation was observed evaluating the total white blood cell count. Neutrophile levels were significantly lower in treated patients on day 2 and on day 3 (P < 0.05 for both comparisons). Mesalamine administration was also associated with an earlier reintroduction of food intake (median 1.5 d and 3 d, study group vs controls respectively, P < 0.001) and with a shorter hospital stay (median 5 d and 5.5 d, study group vs controls respectively, P = 0.03). CONCLUSION: Despite its limitations, this study suggests that mesalamine may allow for a faster recovery and for a reduction of inflammatory response in acute uncomplicated diverticulitis.

Multi-Center Randomized Controlled Trial on the Effect of Triclosan-Coated Sutures on Surgical Site Infection after Colorectal Surgery.

BACKGROUND: Surgical site infection (SSI) remains the most frequent complication after colorectal resection. The role of sutures coated with antimicrobial agents such as triclosan in reducing SSI is controversial. METHODS: This was a multi-center randomized controlled trial with patients and outcome assessors blinded to treatment. The study was performed in four university referral hospitals. Patient candidates for elective colorectal resection were assigned randomly to abdominal incision closure with polyglactin 910 triclosan-coated sutures (triclosan group) or with polyglactin 910 without triclosan (control group). The primary outcome was the rate of SSI within 30 d after hospital discharge. The secondary outcomes were the overall rate of incision complications and length of hospital stay (LOS). RESULTS: Two hundred eighty-one patients (triclosan group: 140; control group: 141) were analyzed after randomization. The rate of SSI was 12.9% (18/140) in the triclosan group versus 10.6% (15/141) in the control group (odds ratio: 1.24; 95% confidence interval: 0.60-2.57; p=0.564). Secondary outcome analysis showed an overall incision complication rate of 38.3% in the control group versus 45.7% in the triclosan group (odds ratio: 1.36; 95% confidence interval: 0.84-2.18; p=0.208). Median LOS was 11 d in both groups (p=0.55). CONCLUSIONS: Surgical sutures coated with triclosan do not appear to be effective in reducing the rate of SSI.

Effects of IL-2 preoperative immunotherapy on surgery-induced changes in angiogenic regulation and its prevention of VEGF increase and IL-12 decline.

BACKGROUND/AIMS: IL-2 preoperative immunotherapy has been proven to abrogate surgery-induced immunosuppression in cancer patients. In contrast, at present there are no data about the possible influence of IL-2 on angiogenesis-related molecular changes determined by the surgical operation. At present, it is known that VEGF (vascular endothelial growth factor) is the main endogenous angiogenic factor, whereas the antitumor cytokine IL-12 has appeared to play an anti-angiogenetic role. On this basis, a study was planned to evaluate the influence of IL-2 presurgical immunotherapy on the perioperative changes in VEGF and IL-12 secretions. METHODOLOGY: The study was performed on 30 colorectal cancer patients undergoing radical surgery, who were randomly chosen to be treated with or without preoperative immunotherapy of IL-2 (12 million IU/day subcutaneously for 3 consecutive days prior to surgery). Serum levels of VEGF and IL-12 were measured by ELISA for blood samples collected before surgery, and at days 3, 7 and 10 of the postoperative period. RESULTS: VEGF mean concentrations progressively and significantly increased during the postoperative period in patients treated with surgery alone. Mean values of VEGF were enhanced also in patients pretreated with IL-2, but VEGF increase observed in the IL-2 group was delayed, more transient and significantly lower with respect to that found in controls. IL-12 mean concentrations significantly decreased during the postoperative period only in the control patients, whereas in the IL-2-treated patients IL-12 postoperative mean values were not significantly lower than those found before surgery. CONCLUSIONS: This preliminary study would suggest that IL-2 preoperative immunotherapy may abrogate surgery decline in IL-12 levels and reduce, although not completely prevent, VEGF increase during the postoperative period in surgically treated cancer patients. These results would suggest that IL-2 presurgical immunotherapy may counteract surgery-induced stimulation of the angiogenesis, by either opposing the decline in blood levels of the anti-angiogenetic cytokine IL-12, or reducing the increase in those of the angiogenic factor VEGF.

Correlation between postoperative infections and long-term survival after colorectal resection for cancer.

INTRODUCTION: Predicting long-term survival and cancer recurrence in patients with colorectal cancer is difficult because of the many factors that may affect the prognosis. This study investigated the prognostic significance of postoperative infections for patient outcome. METHODS: From an electronic database we selected 192 patients undergoing elective radical surgery for Dukes' stage B and C colorectal adenocarcinoma. The five-year survival rates were analyzed by the Kaplan-Meier method. Univariate and multivariate analyses were carried out to evaluate the potential prognostic variables using the Cox proportional hazard model. RESULTS: Forty-three patients developed deep incisional or organ/space surgical site infections, while the remaining 149 were complication free. The two groups were comparable for baseline, surgical and histopathological characteristics. At univariate analysis, Dukes' stage and infections were negative prognostic factors, while peritumoral infiltration of lymphocytes and eosinophils and fibrotic tissue appeared as protective variables. However, multivariate analysis showed that only Dukes' stage (P = 0.048) and occurrence of postoperative infectious complications (P = 0.011) were independently associated with outcome. In patients with infectious complications, the survival rate was significantly lower than in patients without infections (log-rank = 0.0004). CONCLUSIONS: The present results suggest the importance of evaluating other variables besides tumor stage in the prediction of long-term outcome. In prognostic studies more attention should be paid to postoperative infections.

Axillary lymphadenectomy for breast cancer. A randomized controlled trial comparing a bipolar vessel sealing system to the conventional technique.

AIM: To compare safety and efficacy of a bipolar vessel sealing system (BVSS) to the conventional technique in axillary node dissection. METHODS: 116 women with breast cancer were randomized to conventional node dissection surgical technique (control; n = 58) by scalpel and monopolar cautery or using an electrothermal BVSS (study group; n = 58). RESULTS: The median (range) total volume of fluid collected by drain and aspirations was 305 (30-1420) mL in the study group and 335 (80-1070) mL in the control group (p = 0.325). The median (range) total volume of lymph collected by percutaneous aspirations was 207.5 (40-1050) mL in the study group and 505 (270-705) mL in the control group (p = 0.010). The incidence of seroma was similar in both groups (p = 0.845). The axillary drain was removed earlier in the study group than in controls (p = 0.046). CONCLUSION: The use of a BVSS offers marginal advantages when compared to the conventional technique.