Impact of age on the quality of lymphadenectomy for colorectal cancer.

The aim of this study was to evaluate the impact of patient age on the number of lymph nodes dissected during surgery for colorectal cancer. Clinical and histopathological data of 231 consecutive patients who underwent elective surgery for colorectal cancer were reviewed retrospectively. Patients were divided into those aged ≤70 years and >70 years. Our findings suggest that patient's age influences the number of lymph nodes detected in surgical specimens; this number was lower in patients aged >70 years and decreased with further aging.

Correction of an end colostomy prolapse with the Delorme technique. A case report.

INTRODUCTION: We report a case of correction of an end colostomy prolapse with Delorme technique in an advanced stage oncologic patient to emphasize the clinical implications and advantages of this procedure. CASE REPORT: A 51-year-old male patient with a stage IV rectal adenocarcinoma underwent laparoscopy for a palliative end colostomy at our institution. Approximately 6 months later, a prolapse of the colostomy occurred during chemotherapeutic treatment. The patient complained of progressive onset of pain and bleeding during defecation as well as difficulty managing the pouch system. Given the stage of the disease and the on-going chemotherapy, a minimally invasive approach was desirable for prolapse correction and we opted for the Delorme procedure under local anesthesia. The postoperative course was excellent with no complications, the symptoms regressed rapidly, and defecation was normal immediately after surgery. The patient was discharged on the second post-operative day. After discharge the stoma was periodically controlled, confirming the success of the procedure. The last clinical evaluation was performed 3 months after surgery and stability was observed. CONCLUSIONS: The Delorme technique is a minimally invasive procedure used to correct an end colostomy prolapse. This technique guarantees excellent results in selected patients and permits the avoidance of more invasive procedures.

Conservative management of minor anastomotic leakage after open elective colorectal surgery.

INTRODUCTION: The utility of prophylactic drainage in colorectal surgery is controversial. The aim of the present article is to study the role of drainage tubes on the management of minor anastomotic dehiscences. PATIENTS AND METHODS: We retrospectively review clinical reports of 18 consecutive patients with anastomotic dehiscence after open elective colorectal surgery. The mean age was 63 years and the male - female ratio was 5:1. Nine (50%) patients underwent re-operation for fecal peritonitis (group A) while the remaining nine (50%) were managed conservatively (group B). The parameters evaluated in both groups were: time of the anastomotic breakdown, clinical findings, amount of fluid drained the day of the dehiscence, diagnostic means used, length of stay and mortality. RESULTS: Anastomotic leakages were observed medially after 3, 6 days from surgery in group A and after 5.6 days in group B. The most frequent clinical manifestations were: fecal material through the tubes (88.9%), pelvic pain (88.9%) and fever (77.8%). Patients in group A had a median faecal fluid flow of 235cc the day of the dehiscence and 130cc those in group B. Imaging was employed only in three cases in group A and in all cases in group B. The length of hospital stay was longer in patients treated surgically: 37 days versus 29 in those treated conservatively. CONCLUSIONS: Minor anastomotic leakages generally occur later than greater ones, they have a milder clinical presentation and can be managed conservatively with the use of drain tubes.

T2-T4 sympathectomy versus T3-T4 sympathicotomy for palmar and axillary hyperhidrosis.

OBJECTIVE: To evaluate and compare the immediate and long-term outcomes of videothoracoscopic T2-T4 sympathectomy and T3-T4 sympathicotomy for the treatment of palmar and axillary hyperhidrosis. METHODS: Between October 1993 and September 2007, we treated a total of 88 patients affected by palmar and axillary hyperhidrosis. Twenty-four patients underwent T2-T4 sympathectomy with 5-10 mm trocars (Group A), 43 T2-T4 sympathectomy with 2-5 mm trocars (Group B), 15 T3-T4 sympathicotomy with 5-10 mm trocars and 6 T3-T4 ganglion block with 2-5 mm trocars (Group C). The mean operative time, for each side, was 15 min for sympathicotomy and 28 min for sympathectomy. In September 2008, we recontacted 98% of patients (total 86), by telephone, to establish long-term results (follow-up range 1-15 years). RESULTS: In this series, we did not find any significant difference between T2-T4 sympathectomy and T3-T4 sympathicotomy in terms of postsurgical palmar anhidrosis or onset of compensatory hyperhidrosis, while both methods show high efficacy for remission of palmar hyperhidrosis. The slightly higher recurrence rate in our early experience (Group A) can be attributed to the learning curve. Using smaller trocars (2-5 mm), we reduced postsurgical intercostal pain and obtained better aesthetic results and a higher grade of patient's satisfaction. INTERPRETATION: Thoracoscopic approach to hyperhidrosis has evolved in the last few decades with a consequent decrease in side effects. In this series, all patients experienced an improvement in quality of life even in case of recurrence or onset of compensatory hyperhidrosis. Due to these results, the shorter operative time and easier performance of sympathicotomy, we prefer this method.

Surgical management of the glomus tumors of the fingers: a single center experience.

INTRODUCTION: Glomus tumors are rare neoplasms arising from the subcutaneous glomus apparatus. They account for 1 - 5% of the soft tissue tumors of the upper extremity, occurring in most cases in the nail bed. The typical clinical presentation includes paroxysmal pain and hypersensitivity to cold which limit the use of the affected hand causing practical, professional and often emotional discomfort for the patient. MATERIALS AND METHODS: Four patients with finger glomus tumor were treated in our institution in the last 30 years. Three patients had a right hand tumor (1st, 3rd and 4th finger) and one patient a left hand tumor (2nd finger). Three tumors were placed in the nail bed and one in the finger tip. In all cases duplex ultrasonography was employed preoperatively and during surgery to ensure complete resection of the tumor. All patients underwent surgical excision of the tumor with local block anesthesia. RESULTS: Intense point pain and hypersensitivity to cold was observed in all cases (100%). Two out of 4 patients (50%) presented an irradiation of the pain at the ipsilateral arm and shoulder. Surgical procedure was performed successfully in all cases, with total excision of the tumor and no intraoperative or postoperative complications. No recurrences occurred. CONCLUSIONS: Diagnosis of glomus tumors of the fingers is generally easy when manifested with the classical clinical picture and duplex ultrasonography is employed. Complete surgical excision is curative, providing immediate relief of symptoms and improvement of eventual professional or psychological discomfort.

[IPTH dosage as a prognosis predictor of postoperatory hypocalcemia in patients submitted to total thyroidectomy]. / II dosaggio del iPTH come indicatore prognostico di ipocalcemia postoperatoria nei pazienti sottoposti a tiroidectomia totale.

INTRODUCTION: Hypocalcemia is the most frequent complication after total thyroidectomy (TT) and represents the main cause of prolonged hospital stay because of the need to monitor the calcemic status of the patients. The aim of this study is to evaluate the role of serum iPTH as a predictor of post-thyroidectomy hypocalcemia in order to allow patients' early and safe discharge. MATERIALS AND METHODS: Fifty patients who underwent TT without autotransplantation of parathyroid tissue were prospectively included in the study The mean age was 52 years and the male/female ratio was 1/6. The iPTH serum level were determined 1 hour after the operation and the calcium serum values after 24 and 48 hours. The cut-off value assumed for testing the sensitivity, specificity, PPV and NPV was 16 pg/ml. RESULTS: Nineteen patients (38%) presented hypocalcemia within 48 hours after TT and 16 of them (84.2%) had iPTH serum levels lower than 16 pg/ml. The normocalcemic patients were 31 (62%) and only 4 of them had iPTH serum levels inferior to the cut-off value. Postoperative iPTH serum level determined 1 hour after the operation had a sensibility of 84.2%, specificity of 87.1%, PPV and NPV of 90% and 80% respectively. CONCLUSIONS: The dosage of iPTH serum levels after total thyroidectomy reliably predicts patients who are likely to develop hypocalcaemia. It may be useful in clinical practice in order to reduce the number of postoperative blood tests and the hospital length of stay for the patients who are not at risk of postoperative hypocalcemia.

[Surgical management of a voluminous abdominal paraganglioma and review of the literature]. / Management chirurgico di voluminoso paraganglioma dell'addome. Case report e revisione della letteratura.

UNLABELLED: The Authors report a case of a voluminous abdominal paraganglioma and a review of the literature on the surgical management of paragangliomas. CASE REPORT: A 58 years old woman was admitted to our Institution with acute endocrine impairment and simultaneous intestinal necrosis resulting from the mass effect of the tumor on the mesenteric vessels. Clinical and biochemical preoperative work up posed the suspect of paraganglioma. Previous intensive care treatment, the patient, underwent surgical resection of the tumor and left hemicolectomy, with immediate remission of both endocrine and abdominal syndromes. Histological examination confirm the preoperative clinical hypothesis. Paragangliomas are rare tumors of the extra-adrenal chromaffin tissue. A paraganglioma may be discovered in the absence of any symptom. When symptomatic, the clinical findings are related to the hypersecretion of catecholamines or to the compression of several anatomical structures from a growing mass. Combined acute syndromes of hormonal impairment and contemporaneous mass effect, as in our case, are exceptional. The diagnosis of the secreting forms may be obtained on the basis of biochemical dosage of serum and urinary catecholamines and metanephrines. The assessment of malignancy for paragangliomas is not always feasible. Several imaging, cytological and histological parameters have been proposed as predictors of malignancy, but the only element widely accepted is the existence of distant metastasis. Surgery represents the treatment of choice for paragangliomas. Benign forms, catecholamine secreting forms and tumors compressing neighbouring anatomical structures can be treated surgically with success. In general, an accurate follow-up after complete resection must be considered.

Multimodality approach to malignant pleural mesothelioma. A case report.

INTRODUCTION: We report a case of diffuse malignant pleural mesothelioma (DMPM) in a 68-years-old male patient who was admitted for right sited pleural effusion. The patient was treated by multimodality approach consisting in surgical treatment with Extrapleural Pleuropneumonectomy followed by chemotherapy with Cisplatin and Pemetrexed. He had a disease free period of one year and survived for 31 months. CASE REPORT: The patient was admitted to our Institute for a right sited pleural effusion diagnosed on chest X ray. Anamnesis revealed professional asbestos exposure and the patient presented dyspnea, dry cough, right sited chest pain, low fever and loss of weight. As thoracentesis and CT scan did not reveal pathological findings except of the effusion, we performed videothoracoscopy. Several grey nodular lesions involving the costal, diaphragmatic and mediastinic parietal pleural sheets were found. Histological examination of the specimens extracted revealed the presence of epithelial malignant pleural mesothelioma with sarcomatoid areas. Further examinations staged the lesion as Butchart I. Extrapleural pleuropneumonectomy was performed followed by a chemiotherapic treatment with Cisplatin and Pemetrexed. The patient underwent a follow up program with CT scan every four months. The disease free period was of about one year and the patient died after 31 months from diagnosis for septic complications related to chronic effusion. DISCUSSION: Single treatments do not demonstrate an acceptable efficacy on the treatment of DMPM. Multimodality therapy provides good survival improvement and acceptable quality of life for the patients.

[The role of cervical mediastinoscopy and video assisted thoracoscopy in the diagnosis and staging of thoraco-mediastinal neoplastic diseases]. / Ruolo della mediastinoscopia e della video toracoscopia per la diagnosi e la stadiazione delle patologie neoplastiche toraco-mediastiniche.

INTRODUCTION: In this work we evaluate the role of mediastinoscopy and video-assisted thoracoscopy in the diagnosis and staging of coin lesion of the lung and of mediastinal masses. MATERIALS AND METHODS: 72 patients, 55 males and 17 females, affected by lung coin lesion without any previous histological diagnosis have been admitted to our Institution from 1997 to 2007. Mean age was 59.4 for males (range 29-82) and 57.2 for females (range 14-79). RESULTS: Mediastinoscopy resulted to be diagnostic in 95% of cases. In just one case mediastinoscopy failed and video assisted thoracoscopy was performed, which permitted to obtain diagnosis. Video assisted thoracoscopy was able to lead to diagnosis in 98.1% of cases, as we observed only one failure. In this single case we converted the thoracoscopic approach to open, but although the conversion it was not possible to make diagnosis. DISCUSSION: In these ten years, thanks to adequate indication for mediastinoscopy and video assisted thoracoscopy, the use of thoracotomy for diagnosis and staging of pulmonary neoplastic diseases has been reduced: thus we avoided 80% of unnecessary thoracotomies in patients affected by not resectable lung cancer, metastases (treated by atypical thoracoscopic resection) or benign diseases. CONCLUSION: The minimally invasive surgical exploration of mediastinum and thoracic cavity allows to obtain all necessary informations (in terms of histology and staging) to programme an adequate therapeutic protocol, reducing postoperative pain and hospital stay, in comparison to thoracotomy.

[Surgical treatment of a patient with retrosternal thyroid goiter]. / Trattamento chirurgico del paziente con gozzo tiroideo immerso.

INTRODUCTION: The term thyroid goiter is accepted worldwide, while the terms "substernal", "retrosternal" or "intrathoracic" are not clearly agreed on. The tendency to enlarge and to compress adjacent anatomical structures and the chance of malignancy impose the surgical excision as the principal treatment option. We present our experience on the management of substernal goiter and through this, a rapid review of the literature. MATERIALS AND METHODS: The last seventeen years we treated 94 patients with substernal goiter. The mean age was 57 years and the male - female ratio was 1:5. All patients had preoperatory assessment with chest X ray, ultrasound and CT scan of the neck. We performed a total thyroidectomy through cervical access in 96.7% of cases and in 3.2% through sternotomic access. RESULTS: We found 95.7% cases of anterior and 4.3% cases of posterior goiters, with only one ectopic goiter. Pathologic examination reveal 72.3% colloidocystic goiters, 18% adenomas, 7.4% carcinomas and 2.3% cases of thyroiditis. The most important postoperatory complications were: 2 cases of persistent hypoparathyroidism, 3 cases of recurrent damage and 2 cases of chylothorax. No deaths were observed. CONCLUSIONS: It is necessary a scientific agreement on the definition of substernal goiter, in order to uniform epidemiological and clinical data. Preoperative assessment is based on chest X ray, ultrasound and CT scan of the neck. Cervicotomic access represents the most frequent approach and total thyroidectomy is the procedure recommended. Postoperative complications are almost the same as for cervical goiters and mortality is nowadays extremely low.