The importance of lymph node retrieval and lymph node ratio following preoperative chemoradiation of rectal cancer.

AIM: Preoperative chemoradiation (CRT) for rectal cancer decreases the number of examined lymph nodes (NELN) found in the resected specimen. However, the prognostic role of lymph node evaluation including overall numbers and the lymph node ratio (LNR) in patients having preoperative CRT have not yet been defined. The study has assessed the influence of CRT on the NELN and on lymph node number and LNR on the survival of patients with rectal cancer. METHOD: Between 2003 and 2011, 508 patients with nonmetastatic rectal cancer underwent mesorectal excision. Of these 123 (24.2%) received preoperative CRT. Univariate and multivariate analysis was performed to define the role of NELN and LNR as prognostic indicators of survival. RESULTS: Neoadjuvant CRT significantly reduced the NELN (P < 0.0001). Disease-free survival (DFS) and overall survival (OS) of patients with fewer or more than 12 nodes retrieved did not differ statistically. Node-negative patients with six or fewer lymph nodes were significantly associated with a poor DFS and OS on univariate analysis (P = 0.03 and P = 0.03). LNR significantly influenced the DFS and OS on multivariate analysis [DFS, P = 0.0473, hazard ratio (HR) 2.4980, 95% confidence interval (CI) 1.2631-9.4097; OS, P = 0.0419, HR 1.1820, 95% CI 1.1812-10,710]. CONCLUSION: The cut-off of 12 lymph nodes does not influence survival and should not be considered for cancer-specific prediction of patients having neoadjuvant CRT. In contrast LNR is an independent prognostic predictor of DFS and OS in such patients.

Promptness of diagnosis is the main prognostic factor after colonoscopic perforation.

AIM: The authors present their experience of colonoscopic perforation and its management, with an analysis of factors affecting outcome. METHOD: During the last 10 years, 22 cases of colonoscopic perforation (CP) were identified in two different institutions. Multiple logistic regression analysis was used to identify significant predictors of morbidity and mortality. RESULTS: Morbidity and mortality rates were 31% and 13.6%, respectively. Prompt diagnosis was the most powerful predictor of outcome of CP. Multiple logistic regression analysis showed that morbidity and mortality were significantly related to a delay in diagnosis of more than 24 h (P = 0.03 and P = 0.04). CONCLUSION: The results emphasize the importance of prompt assessment of a patient who develops symptoms after colonoscopy.

Safety of a new biological adhesive after pancreatic resection.

AIM: Pancreatic fistula (PF) represents the main complication (10%-29%) after pancreatic surgery. Soft pancreatic texture with a not dilated pancreatic duct represent the major risk factors for PF. Mortality after pancreaticoduodenectomy (PD) is reported in several large series to be <5%. PF and local sepsis are the main causes of delayed arterial hemorrage with a high mortality rate (14-38%). Therefore, any effort should be implemented in order to reduce the incidence of PF. METHODS: In the present study we have extended the use of the biological adhesive Bioglue® to coat pancreatic resection surface after distal pancreasectomy (DP, N.=5) and pancreatico-jejunostomy (PJ) after PD (N.=18) in a RESULTS: Operative mortality was observed in 2 instances: one case after PJ leakage (1/18, 5.5%) and one case after DP not related to PF (1/5, 20%). PF has been documented in 7/23 (30,4%) after pancreatic resection, and in all cases after PD. In 3 cases PF has been successfully treated conservatively by NPO and octreotide. 2 patients required radiological percutaneous transhepatic biliary drainage and 2 patients required surgical drainage of multiple intrabdominal collections and radiological PTBD. CONCLUSION: On the basis of these observations Bioglue® can be safely utilized to coat pancreatic surface after DP and pancreatico-jejunostomy after PD. This experience warrants further larger controlled studies of the potential value of Bioglue® in reducing the incidence of PF after major pancreatic surgery.

Clinical-pathological features of gastrointestinal stromal tumors presenting associated with other neoplasms: a brief report.

AIM: Over the past 10 years, few authors reported the synchronous detection of gastrointestinal stromal tumors (GISTs) and other neoplasms in the 9-33% of GISTs series. The primary aim of the present study was of investigating the features of GISTs detected in patients with other malignancies. METHODS: From 1999 to 2010 the GISTs detected at surgical exploration or preoperative assessment for other malignancies plus primary-GISTs, were recorded and reviewed. RESULTS: All synchronous GISTs were positive for kit/CD34, resulting smaller in size, with a lower mitotic index and occurring in elderly patients, comparing with primary-GISTs (P<0.05). Moreover a prevalence of males and of lower-risk classifications were noted, not reaching, however, a statistical value. CONCLUSION: According with our findings, the synchronous GISTs are mainly asymptomatic/incidentally detected and display some of the low malignant features; we recommend, however, the surgical excision of GISTs occurring in patients with other malignancies in order to define the histology and risk features and since it might result in an incorrect management if misdiagnosed as a metastases.

Peritoneal washing cytology in gastric cancer. How, when and who will get a benefit? A review.

The most frequent cause of treatment failure following surgery for gastric cancer is peritoneal metastasis. The ability to predict the likelihood of peritoneal recurrence should improve the therapeutic approach to gastric cancer. Cytological analysis of peritoneal washings is thought to be useful for direct detection of free cancer cells in the peritoneal cavity. Intraperitoneal free cancer cells (IFCC) isolated during peritoneal washing in patients with gastric cancer, have been demonstrated to be significantly and independently related to the prognosis, influencing both early recurrence and poor survival, so that since 1998 the Japanese Classification of Gastric Carcinoma (JCGC) recommend peritoneal wash cytology (PWC) for the local staging. In Western countries PWC is not uniform practice, because of several controversies regarding the low sensitivity rate of conventional cytology, the correct application of molecular diagnosis (immunostaining and RT_PCR) and the exact role of PWC in the clinical practice. The authors examine the current apply of peritoneal washing in gastric cancer, emphasizing the clinical implication of peritoneal cytology by analyzing the different modality and techniques to perform it (conventional cytology, immunocytochemistry, RT-PCR), when to achieve it during the diagnostic or clinical work-up (at the staging or during the surgical treatment), and who will get a benefit (all patients or selected patients).

[Pancreaticoduodenectomy for adenocarcinoma of the pancreatic head and papilla of Vater]. / Duodenocefalopancreatectomia per adenocarcinoma della testa del pancreas e della papilla di Vater.

AIM: The authors report their consecutive experience in the surgical management of adenocarcinoma (ADC) of head of pancreas and papilla of Vater, in order to review the available literature. METHODS: One hundred and seventy cases (131 in the head of pancreas and 39 in the papilla of Vater) were operated upon for ADC by radical pancreaticoduodenectomy in the period 1972-2005. The stomach was resected in 81 patients (47.7%) and the pylorus was preserved in 89 (52.3%). Follow-up was completed in all patients. RESULTS: Postoperative morbidity was reported in 66 patients (38.8%) and pancreatic fistulae were observed in 39 patients (22.9%). Postoperative mortality was 9.4% (16 patients), but in the last 10 years it was reduced to 4.1% (4/97 patients). Five-year survival for pancreatic ADC was 75% in stage IA, 43.9% in stage IB and IIA, 3.2% in stage IIB. In ADC of the papilla of Vater, for the same stages, the 5-year survival rates were 54.4%, 51.4%, 0% and 37.5%, respectively. None of the III-staged patients survived at a 5-year follow-up in both groups. CONCLUSIONS: Preoperative studies should include laparoscopy with cytological examination of peritoneal lavage, while preoperative biliary drainage is rarely indicated in case of obstructive jaundice. The Wirsung duct has to be anastomosed directly to the jejunum and the pancreatic section needs to be checked. Extended lymphadenectomy, in addition to the standard peripancreatic excision, is seldom indicated, there is no controindication to pylorus preservation and Wirsung drainage is not necessary. This operation should be performed in Centres with substantial experience.

Outcomes for early rectal cancer managed with transanal endoscopic microsurgery: a 5-year follow-up study.

BACKGROUND: This study aimed to evaluate the long-term risk of local and distant recurrence as well as the survival of patients with early rectal cancer treated using transanal endoscopic microsurgery (TEM). METHODS: The study reviewed 69 patients with Tis/T1/T2 rectal cancer treated using full-thickness excision between 1991 and 1999. The pathology T-stages included 25 Tis, 23 T1, and 21 T2. The median follow-up period was 6.5 years (range 5-10.2 years). RESULTS: The overall local recurrence rate was 8.7%. The 5-year local recurrence rate was 8% for Tis, 8.6% for T1, and 9.5% for T2. All six patients with recurrence were managed surgically. The 5-year disease-specific survival rate was 100% for Tis, 100% for T1, and 70% for T2. The overall cancer-related mortality rate was 7.2%. CONCLUSIONS: After local excision of early rectal cancer, a substantial local recurrence rate is observed. Patients with recurrent Tis/T1 cancers who undergo a salvage operation may achieve good long-term outcome. Local treatment without adjuvant therapy for T2 rectal cancers appears inadequate.

Comparison between the fifth and sixth editions of the AJCC/UICC TNM staging systems for hepatocellular carcinoma: multicentric study on 393 cirrhotic resected patients.

AIMS: To compare the prognostic efficacy of the 5th and 6th edition of the TNM staging system for HCC. METHODS: We retrospectively applied the old and the new systems to 393 resected patients, comparing the efficacy of both in prognostic evaluation. RESULTS: The 1-, 3- and 5-year overall survival rates were 89.7, 71.1 and 56.3%, respectively. The 1-, 3- and 5-year disease-free survival rates were 79.4, 54.6 and 39.4%, respectively. Among the factors evaluated, Child's grade B and C (p=0.001) and presence of multiple nodules (p=0.01) were found to be related either to a worse long-term survival or to a worse disease-free survival. Stratifying patient survivals according to the old TNM system, we found significant differences only between stages II and IIIA (p=0.001); otherwise stages I and II (p=0.9) as well as stages IIIA and IVA (p=0.9) showed similar survival rates. Analysing the new TNM system, we found a more homogeneous staging stratification, with significant differences both between stage I and II (p=0.02) and between stage II and IIIA (p=0.05). CONCLUSIONS: In the present multicentric study, long term overall and disease-free survival after liver resection for HCC was strongly affected by the number of tumours and the underlying liver disease. Our results suggest that the new classification appears to achieve an accurate stratification of patients, simpler than the previous edition, as well as a more reliable comparative analysis of outcome after hepatic resection for HCC.

Indications and results of resection for hepatocellular carcinoma.

AIM: In this retrospective series we evaluate our experience in surgical treatment of HCC and examine early and long-term results of 46 hepatic resections. METHODS: Eighty-eight patients with HCC have been observed at our Department. Fifty patients (57%) have been operated, but only 46 (92%) could be resected; 43 patients (93.5%) carried liver cirrhosis. We performed 28 non-anatomical resections (60.8%) and 18 anatomical resections (39.2%). Tumour clearance at resection margin of at least 1cm was considered for a curative resections. RESULTS: Overall mortality and morbidity were 8.7 and 30.4% respectively. These rates significantly decreased in the last years: from 1995 to 2000 no hospital mortality has been recorded. Hospital mortality among non-anatomical and anatomical resection subgroups was 3.5 and 16.6% respectively (P<0.02). After a median f.u. of 41 months, 19 patients (45.2%) had recurrences: it was intrahepatic in 16 (84.4%). We observed a 3-, 5- and 10-years actuarial survival rate 62, 51.1 and 22.5% respectively. Long term survival significantly differed between non-anatomical and anatomical resections, with 5-year and 10-year values of 61.1 and 34.3% vs 37.7 and 18.8% respectively (P=0.0224). CONCLUSIONS: Early results after hepatic resection for HCC can be improved by using a limited surgical approach. Long-term results are still unsatisfactory, because of the high recurrence rate that is not influenced by different surgical approaches.

Risk management of HBsAg or anti-HCV positive healthcare workers in hospital.

Recommendations are made for controlling the transmission of the hepatitis B and hepatitis C viruses from healthcare workers to patients. These recommendations were based both on the literature and on experts' opinions, obtained during a Consensus Conference. The quality of the published information and of the experts' opinions was classified into 6 levels, based on the source of the information. The recommendations can be summarised as follows: all healthcare workers must undergo hepatitis B virus vaccination and adopt the standard measures for infection control in hospitals; healthcare workers who directly perform invasive procedures must undergo serological testing and the evaluation of markers of viral infection. Those found to be positive for: 1) HBsAg and HBeAg, 2) HBsAg and hepatitis B virus DNA, or 3) anti-hepatitis C virus and hepatitis C virus RNA must abstain from directly performing invasive procedures; no other limitations in their activities are necessary. Infected healthcare workers are urged to inform their patients of their infectious status, although this is left to the discretion of the healthcare worker; whose privacy is guaranteed by law. If exposure to hepatitis B virus occurs, the healthcare worker must undergo prophylaxis with specific immunoglobulins, in addition to vaccination.

Spontaneous motor activity increases after portacaval anastomosis in rats.

Spontaneous motor activity was monitored in rats at various times, up to 14 weeks, after portacaval anastomosis (PCA) or sham operation. Total 24 hour activity scores rose significantly after PCA and remained significantly higher than those of sham operated rats for twelve weeks. After PCA, activity during the twelve hour lighted period was greatly increased, whereas dark period activity was unchanged. Increased activity in the light period was found to be well correlated with the degree of elevation in brain concentrations of tryptophan, tyrosine, phenylalanine and glutamine. These results are consistent with previously reported EEG studies and suggest that motor-activity measurement may facilitate the correlation of biochemical changes with behaviour in rats with portal systemic shunting.

The laparoscopic approach with antireflux surgery is superior to the thoracoscopic approach for the treatment of esophageal achalasia. Experience of a single surgical unit.

BACKGROUND: Since its first description in the early 1990s, minimally invasive Heller myotomy has become the treatment of choice for esophageal achalasia. We report the experience of a single unit with thoracoscopic Heller myotomy (THM) and laparoscopic Heller myotomy (LHM) and we analyze the short- and long-term surgical outcomes in patients treated by each of the two approaches. METHODS: We evaluated retrospectively 33 patients who underwent surgical treatment for achalasia. Sixteen patients underwent THM without an antireflux procedure, and 17 patients underwent LHM and partial anterior fundoplication (n = 10) or closure of the angle of His (n = 7). RESULTS: Mean operative time was significantly shorter for LHM than for THM (150 vs 222 min, respectively) (p = 0.0001). Mean hospital stay was significantly shorter after LHM than after THM (2.0 +/- 1.0 vs 5.1 +/- 2.2 days, respectively) (p = 0.0001). Six of 16 patients (37.5%) in the THM group experienced persistent or recurrent dysphagia compared to one of 17 patients (5.8%) in the LHM group (p = 0.04). Heartburn developed in five patients (31.2%) after THM and in one patient (5.8%) after LHM (p = 0.07). Regurgitation developed in four patients (25%) after THM and in one patient (5.8%) after LHM (p = 0.149). Lower esophageal sphincter (LES) basal pressure decreased significantly from 30.1 +/- 5.07 to 15.3 +/- 2.1 after THM and from 32.1 +/- 5.9 to 10.5 +/- 1.7 after LHM (p = 0.0001). Mean esophageal diameter was significantly reduced after LHM compared to THM (from 54.5 +/- 5.7 mm to 27.1 +/- 3.3 mm vs 50.8 +/- 7.6 mm to 37.2 +/- 6.9 mm, respectively) (p = 0.0001). CONCLUSION: In our experience, LHM is associated with a shorter operative time and a shorter hospital stay, and it is superior to THM in relieving dysphagia. LHM with partial anterior fundoplication should be considered the treatment of choice for achalasia.

Hepatic resections for hepatocellular carcinoma (HCC): short and long-term results on 106 cirrhotic patients.

To evaluate the short and long term outcome of liver resections for hepatocellular carcinoma in cirrhotic patients. A retrospective analysis was performed on 106 consecutive cirrhotic patients with hepatocellular carcinoma resected between June 1974 and September 2002 at the Department of Surgery "Pietro Valdoni" - University of Rome "La Sapienza" and at the Liver and Multivisceral Transplant Unit of the University of Modena. Univariate and multivariate analyses were performed on several clinicopathological variables to analyze factors affecting the long-term outcome and intrahepatic recurrence. Overall mortality and morbidity were 10.7% and 26% respectively. These rates significantly decreased in the last years: from 1997 to 2002 no hospital mortality has been recorded. After a median follow-up of 19 months (interquartile range: 10-36), tumour recurrence appeared in 25 patients (23,5%). The 1-, 3-, and 5-year overall survival rates were 86,6%, 70,3%, and 60,6%, respectively. The 1-, 3-, and 5-year disease-free survival rates were 86,3%, 58,1%, and 40,7%. On univariate analysis, viral ethiology of cirrhosis (p=0.03), presence of multiple nodules (p=0.02) and vascular invasion (p=0.05) were found to be related to a worse long-term survival. At the multivariate analysis only the viral ethiology of cirrhosis and the presence of multiple nodules were confirmed as indipendent prognostic factors. Early results after hepatic resection for HCC can be improved by using a limited surgical approach. The viral ethiology of cirrhosis, the presence of multiple nodules and vascular invasion negatively affected recurrence rate and long-term survival.

Lactitol in the treatment of chronic hepatic encephalopathy--a randomized cross-over comparison with lactulose.

The effect of lactitol, a new non-absorbable disaccharide, in the treatment of chronic hepatic encephalopathy was assessed in 14 cirrhotic patients with non-selective portosystemic anastomosis in a randomized, cross-over study. At the time of inclusion, all patients showed alterations in mental state, and/or psychometric performance, and in the electroencephalogram. Moreover, 10 out of 14 patients suffered from recurrent episodes of hepatic encephalopathy in the 12 months prior to the study. Patients were randomly treated for two consecutive periods of six months with either lactitol or lactulose. The PSE index was calculated to quantify the neuro-psychiatric impairment. Twelve patients completed the study. The patients required a daily dose of 38.2 g +/- 19 of lactulose or 36.3 g +/- 5 of lactitol to produce two semi-soft stools per day. No deterioration in the mental state or in the other neuro-psychiatric parameters were observed, neither during lactitol nor during lactulose therapy. During the study, mild episodes of recurrent encephalopathy occurred in 60% of the patients taking lactulose, and in 25% of the patients taking lactitol, the difference not being significant (X = 1.54, p = 0.21). Flatulence, the major side-effect noted during the study, was present in 7 of the 12 patients during lactulose treatment, and in 2 patients during lactitol treatment; one patient on lactitol complained of nausea. The side effects which occurred during lactitol of the dosage, while those occurring during lactitol appeared when the dosage was higher than 40 g. Lactitol may be considered at least as effective as lactulose in the treatment of chronic hepatic encephalopathy.

Role of delayed cutaneous hypersensitivity reaction in classifying patients with bronchial carcinoma.

Cell-mediated immune response was evaluated in 150 patients with histologically confirmed bronchopulmonary carcinoma using bacterial and fungal recall antigens injected intradermally (PPD, candida, trichophyton). In the study group negative skin test reaction was found in 51 of 150 patients (34.0%), whereas in the control population it was found in 5 of 33 cases (15.1%) (p less than 0.05). Histologic cell type and stage of disease were defined for each patient. It was possible to calculate the growth rate of the primary tumor only in 68 of 150 patients, and it was recorded as doubling time. Evaluation of the skin test reaction in each prognostic subgroup showed no statistically significant differences. The only statistically significant differences were found when each prognostic subgroup was compared with the control population according to the frequency of a negative response to the skin test, particularly in stage III M1 (p less than 0.05) and stage III M0 (p less than 0.02). The delayed cutaneous hypersensitivity studied with recall antigen stimulation was mainly correlated with the stage of disease, and it should not be considered as an independent prognostic factor.

[Evaluation of hepatic encephalopathy in portacaval shunts and mesenterico-caval bypass with the jugular vein]. / Valutazione dell'encefalopatia epatica nello shunt porta-cava e nel by-pass mesenterico-cava con vena giugulare

Data relating to 30 patients subjected to side-to-side porta-cava anastomosis and 30 to mesenterico-cava by-pass with the internal jugular vein are presented. At follow-up after a period of over 1 yr, encephalopathy was observed in 40% and 21% of the two groups respectively. Angiography of the coeliac tripod and superior mesenteric showed the existence of a post-operative hepatopetal flow in 80% of porta-cava cases. This incidence was only 30% in the mesenterico-cava group. The relation between the clinical and angiographic data is briefly discussed and neuropsychiatric findings in patients with a picture of hepatic encephalopathy are also presented.

[Changes in the lymphocyte subpopulations in a patient with orthotopic transplant of the liver]. / Variazioni delle sottopopolazioni linfocitarie in un paziente con trapianto ortotopico di fegato.

Earlier experimental studies have shown that the cyclosporin immunosuppressive effect (CsA) can be modulated by drug timing as well as dose. More specifically treatment during the night was constantly associated with a statistically significant improvement in the prevention or delay of allograft rejection. The present study reports on the circadian variations in T-lymphocyte subpopulations in the peripheral blood of a patient given an orthotopic liver allograft and treated with CsA and steroids. In particular, a statistically significant circadian rhythm (p = 0.012) was observed for the T-helper (OKT4) subset with a peak time (acrophase) occurring during the night at 4:27 A.M. In this patient, CsA treatment was, therefore, adapted to the T-helper cycle with the aim of marching CsA blood level variations to that curve. The results suggest that CsA timing can provide a tool for daily dose reduction and then improve the success rate of drug treatment.

[The echographic aspects of the splenoportal axis in patients with esophageal varices]. / Aspetti ecografici dell'asse spleno-portale in pazienti con varici esofagee.

In the present study the A. try to assess the usefulness of ultrasound in detecting blending risk in portal hypertension. Endoscopic and sonographic findings of 35 cirrhotic patients with esophageal varices were compared to a control group of 27 hepatopathy patients without portal hypertension, observed in the same department and in the same interval. The medium caliber of portal vein was 14.64 +/- 2.59 and 11.8 +/- 1.33 mm, respectively in the study and in the control group (p less than 0.01). Statistic correlations were also found in subgroups of patients with varices of different degrees. A portal vein greater than 16 mm was found in 10 of 11 patients with large varices; this pattern provides a sensitivity of 71.4% and a specificity of 94.1%. In our experience this echographic finding should represents a clear indication for close endoscopic follow-up, even in patients without previous bleeding from esophageal varices.

[Colorectal neoplasms in patients with ulcerative rectocolitis. Their surgical treatment and follow-up]. / Le neoplasie del colon retto in pazienti affetti da rettocolite ulcerosa. Trattamento chirurgico e follow-up.

Patients with ulcerative colitis (UC), especially those with a long-term standing or severe disease, show a higher incidence of colorectal neoplasms. Dysplasia represents the most important risk-factor for malignancy in patients with UC. From 1989 to 1999, 71 patients with UC, were surgically treated at our Institution. Indications for surgery were: non responding disease or refractory bleeding in 61; pathologic evidence of severe dysplasia during endoscopic surveillance in 5 patients, evidence of a neoplasm in the remaining 5 patients. Operative mortality was 1.4%. Infections of the surgical wound has been the most common postoperative complication. In 4 cases pouchitis has been reported. In 7 patients because of progression of the proctitis a second surgical treatment has been made. When surgical treatment is indicated in the course of ulcerative colitis, several operations may be performed. In the large majority of patients, total colectomy, mucosectomy and ileal pouch-anal anastomosis is the procedure of choice.