Gastrointestinal stromal tumors treatment in the Imatinib era. The role of fair indication.

AIM: Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor of the gastrointestinal tract. Surgery remains the elective treatment. We retrospectively compared two group of patients, who underwent surgery for GIST before and after Imatinib advent in order to analyze the recurrence and survival rate. METHODS: Two patient groups who underwent surgery for GIST, from January 1997 to December 2002 (Pre-Imatinib group) and from January 2003 to December 2008 (Post-Imatinib group) were compared. Patients were evaluated on the base of gender, age, clinical manifestations, primary location and metastasis positivity, tumor size, mitotic index, immunoreactivity for CD117 and the outcome, including date of death. RESULTS: In the Pre-IM group only one patient died for prostate cancer, 12 months after operation, the other died because of GIST with a 24.6 months of median survival rate (range 15-51). In the remaining 12 patients the median follow up period was 55 months (range 6-152 months). In the Post-IM group the mean follow up was 50.7 months (range 26-74) and they are still being assessed for oncological as well as surgical treatment. CONCLUSION: Early diagnosis and radical resection remain the standard of cure for GISTs. To date, the use of Imatinib lead to its utilization as adjuvant and neo-adjuvant therapy in adults. Our experience suggests that there is a correlation between the mutational status of KIT and clinical outcome. These aspects should be explored for targeted therapy that can effectively combine biological therapy to surgery.

[Incisional hernia prosthetic surgery: a prospective study comparing laparoscopic and open techniques]. / La chirurgia con protesi dei laparoceli: studio prospettico e di confronto tra le procedure laparoscopica e laparotomica.

BACKGROUND: Incisional hernia is a common complication of abdominal surgery and it is often a source of long-term morbidity. Surgical treatment include many different techniques and up to today the choice may be difficult. The employment of prosthetic materials has contributed to a remarkable improvement in the results of this surgery. We performed a prospective study to compare the outcomes after laparoscopic and open incisional hernia repair. PATIENTS AND METHODS: A total of 60 patients were assigned at random to two groups to be operated for median incisional hernia with mesh. Of these, 30 underwent laparoscopic repair and 30 open repair performed by Rives-Stoppa technique. Early and long-term outcomes were analyzed by a median follow-up of 45 months (range 31-78). Statistical analysis was done to asses differences between the groups. RESULTS: Both groups were homogeneus in terms of patient age, sex, body mass index, American Society of Anesthesiologists score and incisional hernia features. Laparoscopic repair is associated with a significantly lower incidence of wound infections, shorter operative time and hospitalization and faster return to work. The recurrence rate was similar between the two groups. CONCLUSION: In our experience laparoscopic incisional hernia repair appear to be a safe, feasible and effective alternative to Rives-Stoppa technique.

Impact of cardiovascular/diabetic comorbidity on conversion rate during laparoscopic cholecystectomy for acute cholecystitis: a multi-center study on early versus very delayed approach.

BACKGROUND: The impact of diabetes and cardiovascular comorbidity on laparoscopic cholecystectomy has been long debated, evaluating them as risk factors for conversion to an open procedure especially in patients with acute cholecystitis: an "early" procedure, as suggested by 2013 Tokyo guidelines, has been compared to a "very delayed" one in patients under anticoagulant/antiplatelet therapy or treated for diabetes and referred by medical wards to surgery after the acute period. METHODS: We selected 240 patients operated for acute cholecystitis by laparoscopy over the last 4 years at St. Orsola University Hospital-Bologna and Umberto I University Hospital-Rome, comparing 98 diabetic/cardiovascular patients versus 142 subjects as control group: the selection was based on operative timing, "early" (73 patients treated within 3 days) and "very delayed" (167 patients operated after 6 weeks). RESULTS: In the "early" subgroup there was no difference comparing diabetic/cardiovascular patients (31 pts) versus control group (42 pts) while in the "very delayed" subgroup among diabetic/cardiovascular patients (67 pts) there was significantly male predominance, ASA III/IV prevalence and less positive imaging findings versus control group (100 pts). In both subgroups, the conversion rate was significantly higher for diabetic/cardiovascular patients ("early"=25.8% and "very delayed"=8.95%) compared to control groups ("early"=4.76% and "very delayed"=1%), showing a trend (p=0.058) towards an increased conversion rate in the early approach among diabetic/cardiovascular group. CONCLUSIONS: Our study showed a significantly increased conversion rate to an open cholecystectomy for diabetic/cardiovascular patients affected by cholecystitis, especially within 3 days by the acute episode.

[Open mesh technique versus laparoscopic transabdominal preperitoneal (TAPP) approach in inguinal hernia repair. Our experience]. / Tecnica open versus TAPP nel trattamento dell'ernia inguinale. Nostra esperienza.

BACKGROUND: In the last ten years the introduction of various open mesh and laparoscopic techniques has increased the interest in inguinal hernia surgery. Anyway controversy persists about the most effective inguinal hernia repair. The aim of this study was to compare the results of open mesh technique and laparoscopic transabdominal preperitoneal (TAPP) repair for inguinal hernia. PATIENTS AND METHODS: We considered 584 patients, 532 man and 52 woman, between 19 and 86 years: 332 (56.8%) had open mesh repair and 252 (43.2%) laparoscopic TAPP repair of groin hernia. Operative time, complications, recurrences and time to normal activities were recorded in both groups (range follow-up 1-10 years). RESULTS: The median operative time was 71 min for open group and 92 min for TAPP group. No intraoperative complications were observed. Postoperative complication rate was 4,5% in patients open group and 3% in TAPP group. The recurrence rate was less than 1% in both groups (0,6% for open repair and 0,4% for laparoscopic repair). Significant difference was observed in the median time to return to normal activities: 9,8 days in TAPP group versus 13,4 days in open approach. CONCLUSIONS: Our experience confirmed the safety and effectiveness of laparoscopic transabdominal preperitoneal (TAPP) approach to inguinal hernia repair as excellent alternative to conventional surgery. The reduction of operative time, complications and recurrences is correlated to the surgeon's experience and learning curve.

Uni-centric localization of Castleman's disease treated with laparoscopic and traditional approach. Report of two cases.

Castleman's disease (CD) is a rare lymphoproliferative disorder. Clinically CD has been subdivided in two forms: uni-centric and multicentric. The uni-centric type is limited to a single anatomic lymph-node-bearing region. The present report describes two cases of uni-centric CD: the first was an abdominal localization treated with a laparoscopic approach; the second was a submaxillary localization treated with a classical approach. In case 1 the laparoscopic approach permitted to reach diagnosis, not clear after diagnostic imaging procedures, and enabled a total and excellent resolution of the pathology because our patient, after eight months of follow up, has had no evidence of recurrence of the disease. In case 2 we want to highlight that CD should be considered in the differential diagnosis of a solitary neck mass and that the surgical treatment is diagnostic and curative at the same time.

[Telemedicine]. / Telemedicina.

Recent innovations in the area of telecommunications, computer science and technical scientific devices have contributed to the development of interesting future perspectives in the medical sector and in the sanitary structure organization. These innovations may contribute to the sensible reduction of costs in a struggling sanitary system. It may become possible to manage not only the patient from a distance but also the numerous medical, informational and statistical data freeing important medical and paramedical personnel resources from carrying out the most simple activities. The ability to monitor the main vital parameters of a multi-traumatised patient, or the ability to contact a specialist without the need to transfer the patient, would be some of the most simple benefits of the new medical area called telemedicine.

[Adenocarcinoma following restorative proctocolectomy for ulcerative colitis: a case report and review of the literature]. / Adenocarcinoma insorto dopo proctocolectomia restaurativa per rettocolite ulcerosa: presentazione di un caso clinico e revisione della letteratura.

Restorative proctocolectomy with ileal pouch-anal anastomosis has been accepted as the surgical treatment of choice for most patients with ulcerative colitis. The occurrence of adenocarcinoma arising near or into the ileal pouch is rare. Only 19 such cases have been reported so far. The authors report a case of a 67-year old male who developed an adenocarcinoma in the small rectal stump 12 years after a restorative proctocolectomy with double stapled ileal pouch-low rectal anastomosis for ulcerative colitis unresponsive to medical treatment. They, after a literature review, examine same steps of the procedure and emphasize the importance of regular and prolonged follow-up for all patients having restorative proctocolectomy for ulcerative colitis.

[Adenocarcinoma of the appendix. A case report and review of the literature]. / L'adenocarcinoma dell'appendice ileo-ciecale: presentazione di un caso clinico e revisione della letteratura.

Primary adenocarcinoma of the appendix is a rare malignancy that constitutes less than 0.5% of all gastrointestinal neoplasms. Usually the diagnosis is made only after histological examination of surgically removed inflamed appendix. Alternatively represent an unexpected finding, confirmed by frozen section, during surgery performed for acute appendicitis or other non appendiceal pathologies. Natural history is strongly influenced by anatomic peculiarities of the appendix that predispose to early spread and perforation. Frequently is associated with synchronous and metachronous colorectal or extraintestinal cancers. The correct management is the right hemicolectomy as a primary procedure in the case of preoperatively or intraoperatively diagnosis or as secondary procedure, after two-three weeks from appendectomy, when the microscopic examination of specimen reveals the presence of adenocarcinoma. Right hemicolectomy is the best treatment for all histologic types (colonic, mucinous, adenocarcinoid), in presence of perforation and even in Dukes A tumors. A careful intraoperative search for synchronous lesions and a life-long program of surveillance for the detection of early stage metachronous carcinomas are recommended. The Authors report a case of primary adenocarcinoma of the appendix occurred in a 78 year-old female patient, diagnosed incidentally during surgery performed for ileus from suspected cecal neoplasm.

[Complicated diverticular disease. Three cases of colovesical fistulas and review of literature]. / La malattia diverticolare complicata: le fistole colo-vescicati. Presentazione di tre casi clinici e revisione della letteratura.

Colovesical fistulas represent a possible less frequent complication of diverticular disease of colon. They represent a complex condition because of the possible and unexpected evolution into a septic shock with a high risk of death. The Authors report three cases of colovesical fistula as a complication of diverticular disease. They underline the importance of early diagnosis, specific antibiotic therapy and appropriate surgical therapy realized in one or two stages according to general and local conditions of each patient.

[Mininvasive treatment of strangulated paraesophageal hiatal hernia in emergency. Case report]. / Trattamento chirurgico minivasivo d'urgenza di ernia gastrica iatale paraesofagea strozzata. Caso clinico.

The Authors report a case of strangulated paraesophageal hiatal hernia occurred in a elderly woman and treated with laparoscopic approach. After review of the literature regard on this uncommon pathology that present about 5% of the hiatal hernias, they emphasize that the laparoscopic approach is appropriated even in emergency and comprises complete reduction of the stomach in abdomen, control of suitable position of the distal esophagus and cardias and making of effective hiatus-plasty.

Erythrocyte antioxidant enzymes and selenium serum levels in an Andean population.

A preliminary study indicated that erythrocyte antioxidant enzyme activities were enhanced in chronic hypoxaemic patients, in whom an increased oxidant stress could be present as a consequence of augmented haemoglobin autoxidation. We have now evaluated the behaviour of erythrocyte antioxidant enzymes and of their related trace metal serum levels in conditions of chronic hypobaric hypoxia in an Andean population living at high altitude (3800 m above sea level), and in a similar ethnic group living at sea level. The results indicate a significant reduction in erythrocyte glutathione peroxidase activity and a low serum level of selenium in the Andean population. Thus, in contrast to what happens in chronic hypoxaemic patients, this group of Andean subjects seems to be poorly protected against oxidant stress, probably as a consequence of selenium deficiency in the diet.

Serum myoglobin, total CK and MB CK isoenzyme after D.C. cardioversion and during the early phase of acute myocardial infarction.

Myoglobin, total CK and MB CK isoenzyme were determined in the sera of 6 patients admitted with arrhythmias and treated with D.C. countershock and also in 37 patients with acute myocardial infarction or anginal syndrome. All the three tests were increased in patients with myocardial infarction. Serum myoglobin seems sufficiently sensitive and specific but the time required for the assay is a limiting factor for practical use in emergencies. After electrical cardioversion, myoglobin and CPK remain normal, although MB isoenzyme was increased in two of six patients. These results suggest that electrical cardioversion in itself does not influence serum levels of myoglobin. The occasional increase of MB CK observed after cardioversion seems to be the consequence of an easier release of the enzyme due to a myocardial injury.

Stapled sutures in digestive tract surgery.

A six-year experience with mechanical sutures in digestive tract surgery is reported. Forty-nine esophageal resections during azygo-portal disconnection were performed since 1979 up to June 1986. Four patients died in the early postoperative course with no evidence of suture-related complication. One patient developed an anastomotic stricture (2.2%), which was successfully dilated. Fifty-three total gastrectomies with stapled reconstruction were performed between 1980 and June 1986. Two patients died soon after surgery for reasons unrelated to the suturing technique. Two strictures of the esophagojejunal anastomosis (3.9%) occurred two to three months after surgery and underwent successful dilation. One esophagojejunostomy (1.9%) leaked and one (1.9%) underwent uneventful remedial surgery (conversion of an omega-shaped loop to a Roux-en-Y procedure). Ten isoperistaltic jejunal interpositions, six Billroth I partial gastrectomies and 14 Roux-en-Y loops for hepatico- or pseudo-cystojejunostomy were performed since 1983 up to June 1986 in the absence of any operative morbidity or mortality. Twenty-three right colectomies were performed from 1983 to June 1986. The only complication reported was one leakage (4.3%) which spontaneously healed. Ninety-eight patients underwent formal colonic resections (anterior resection of the rectum, left hemicolectomy, subtotal and total colectomy) from 1981 to June 1986. Two patients (2%) died for reasons unrelated to the suturing technique. Three colorectal anastomoses (3%) developed a leak, one of which required surgical revision. One stricture (1%) was recorded in a recurrence-free patient three months after surgery. One patient (1%) complained of minor rectal bleeding. Two patients (2%) developed small anal fissures due to forced passage of the instrument.(ABSTRACT TRUNCATED AT 250 WORDS)

Techniques of rectal oncologic survey.

The possibility of constructing very low anastomoses using stapling devices led many surgeons to reduce the length of the distal clearance to 1-2 cm. This made it possible to perform a low anterior resection instead of an abdominoperineal resection of the rectum in a greater number of cases. Furthermore, the enthusiasm in preserving sphincteric function induced some Authors to perform a local excision for tumors of the distal portion of the rectum. On the other hand, in order to improve patients' survival after curative operations for cancer, either of the rectum or rectosigmoid junction, other surgeons have adopted a more aggressive approach, extending exeresis to the peri-aortocaval and pelvic nodes, and to the possible liver metastases as well. On the basis of our experience (374 cases from 1972 to March 1989) and a critical review of the literature, indications, techniques, and results of curative operations for both rectal and recto-sigmoid junction cancer are examined. The role of extended abdomino-pelvic lymphadenectomy is also discussed. The Authors believe that in the absence of a reliable evaluation of the potential of these tumors, an aggressive approach is required. Local excision is reserved to very selected cases, which should undergo an intensive follow-up in order to detect recurrences at a very early stage.

[Criteria of radicality in surgical therapy of rectal cancer]. / Criteri di radicalità nella terapia chirurgica del cancro del retto.

The Authors discuss on their experience in radical rectal cancer surgery critically reviewing results of the current literature. In particular, the importance of distal clearance, abdominopelvic lymphadenectomy and total excision of the mesorectum is stressed. They conclude that radical surgery, if performed according to certain principles, can improve survival without affecting the incidence of major complications.

[Venous replacement surgery: history, update and perspectives]. / La chirurgia sostitutiva venosa: storia, attualità, prospettive.

The impulse given to vascular surgery by new technologies has facilitated the use of the bypass technique in a number of arterial pathologies with better and better results over time. At the moment, however, we haven't a "sure prosthesis" in venous surgery. Our intention has been to examine the most significant developments, studying all the available material dating from the beginnings of the art up to the present. After a careful examination of the venous pathophysiology as well as the most valid surgical approaches, we tried to evaluate on laboratory animals the results of experimental graft replacement of the inferior vena cava. In this study we analysed prostheses in PTFE, biological prostheses, spiral composite vein grafts, arterial autologous grafts. For the experimental study we used 55 rabbits (New Zealand and Fiandra). Results have been rather successful with respect to biological prostheses (62.5% patency) and PTFE (66.6%). As for spiral composite vein graft prosthesis patency over time was very low (16.6%); this was affected by the different venous graft (heterologous graft) and caval wall thicknesses. Arterial autologous graft was carried out only once because rabbit experimented on did not stand up to surgical stress.

[Surgical staplers in colorectal surgery: 10 years of experience]. / Le suture meccaniche nella chirurgia colo-rettale: dieci anni di esperienza.

The Authors dissert on some technical details for a correct use of staplers in colorectal surgery. Surgical skill and technology assure always better results, nevertheless the experience and knowledge of the single surgeon must be a guide for further research.

[Laparoscopic cholecystectomy in acute cholecystitis]. / La colecistectomia laparoscopica nelle colecistiti acute.

In a 18 month period 19 patients (4.7%) out of 400 affected by acute cholecystitis underwent laparoscopic cholecystectomy. In 18 cases the diagnosis was preoperative on clinical signs or ultrasound scan basis. Intraoperative and histologic confirm was obtained in all cases. Mean age was 44.9, 11 were males and 8 females. The procedure resulted longer and more difficult compared to the global series of the same period: 90 min. versus 56 min. respectively, with a difficulty score higher than 4 in 89% of cases versus 40% of the global series. Furthermore, in 56% of cases versus 23.3% of the global series an intraoperative contamination from gallbladder content was recorded. Nevertheless, only 1 (5%) minor complication was observed, in the form of omphalitis, which recovered in 2 days. Therefore, discharge was possible in average within 4 days, excluding the first two cases operated, respectively discharged in 5th and 7th p.o. day as a precautionary measure. Early coelioscopic cholecystectomy is safe and effective, if carried out by well trained surgeons, even in acute cholecystitis.

[Mini-invasive surgical treatment of gallstones and common bile duct calculi]. / Trattamento chirurgico mini-invasivo della calcolosi colecisto-coledocica.

Between June 1st 1990 and December 31st 1991, 449 patients with cholelithiasis were operated on. All patients with isolated cholecystolithiasis (400) were offered video-laparoscopic (VLC) treatment. Forty-nine patients had both cholecystolithiasis and choledocholithiasis. They all underwent further evaluation by ERCP, on the basis of which 30 patients were selected for sequential endoscopic and laparoscopic treatment with endoscopic papillosphincterotomy (EPST) followed by VLC. Three patients were selected for VLC and ideal laparoscopic choledocholithotomy. No complications were observed. At present, sequential ERCP-PST and VLC treatment seems to be the ideal approach to combined cholecystic and choledochal lithiasis in terms of safety, efficacy and tolerability. The increasing surgical skill in the field of minimally invasive surgery and the availability of sophisticated laparoscopic instrumentation allow to consider VLC and laparoscopic choledocholithotomy a valid alternative in terms of reduced surgical trauma and patient discomfort.

[A specific technique for ileo-anal anastomosis in restorative proctocolectomy: physiopathological evaluation and results]. / Un particolare di tecnica per l'anastomosi ileo-anale nell'intervento di proctocolectomia restaurativa: valutazione fisiopathologica e risultato.

The Authors report an alternative technique for ileo-anal anastomosis in total proctocolectomy with ileal pouch. Their experience and results are discussed.