Stage I-IIIC right colonic cancer treated with complete mesocolic excision and central vascular ligation: quality of surgical specimen and long term oncologic outcome according to the plane of surgery.

AIM: Complete removal of mesocolon "as an envelope" (complete mesocolic excision, CME) with central vascular ligation and apical node dissection (CVL) in the surgical management of right sided colonic cancer is a novel technique focused on resection of the colon surrounded by its intact primitive dorsal mesentery containing the tumors and all the routes of initial cancerous diffusion; our aim was to evaluate quality of surgical specimens and the relative impact on long-term oncologic outcome when compared to less radical planes of surgery. METHODS: Data were collected in 159 staged I-IIIC right sided colon cancers operated on with the concept of CME and CVL, between 2008 and 2013. RESULTS: Morbidity and mortality were 37.7% and 1.9% respectively. Overall and disease free survival were 80.5% and 69.8% at five years. Mesocolic, intramesocolic and muscolaris-mucosa planes of resection were achieved in 64.7%, 22.6% and 12.5% of cases, respectively: mesocolic plane of surgery impacted significantly on R0 resection rate (98%), CRM<1 mm (2.9%) and overall survival (81.5% at 5 years) when compared to muscolaris propria plane of surgery, with R0 resection rate and 5 years survival falling to 65% and 60%, respectively, and CRM<1 mm rising to 35%, being all statistically significant; statistical difference was also recorded for intramesocolic plane of resection, with survival, R0 resection rate and CRM<1 mm of 72.2%, 86.1% and 13.8%, respectively. Stratifying patients for stage of disease, CME with CVL significantly improved survival in stage II, IIIA/B and in a subgroup of IIIC patients, with not metastatically involved apical nodes. CONCLUSION: CME with CVL follows the oncologic principle based on resection of the primitive embryological mesenterium as an intact envelope, along with central lymphadenectomy up to the apical nodes, translating in higher surgical specimens quality and significant impact on locoregional control and overall survival when compared to less radical planes of surgery.

Completely laparoscopic versus open total gastrectomy in stage I-III/C gastric cancer: safety, efficacy and five-year oncologic outcome.

AIM: Laparoscopic gastrectomy is becoming a minimally invasive procedure widely accepted by laparoscopic surgeons; yet, many doubts remain about its oncologic efficacy in treating malignant neoplasia. Aim of this study was to analyze our experience comparing completely laparoscopic total gastrectomy to its laparotomic counterpart, about safety, efficacy and five-year oncologic outcome. METHODS: From January 2003 to October 2009, 25 patients with stage I-III/C gastric cancer (TNM Seventh Edition, 2010) were operated on and retrospectively compared to an homogeneous group of patients, stratified for age, stage of disease and comorbidities. Length of surgery, estimated blood loss, postoperative ileus, resumption of oral intake, morbidity, 30 days mortality, number of lymph nodes harvested, five years overall and disease free survival were analyzed, comparing the two groups. RESULTS: There was no conversion. Thirty days mortality was zero for both groups, while morbidity was 16% in the lap group, 32% in the open group (P<0.05). Length of operation was 211±23 min for the lap group, and 185±19 min for the open group (P>0.05); the estimated blood loss was 250±150 mL for the lap group, 495±190 mL for the open group (P<0.05). Number of lymph nodes harvested was 35±18 for the lap group, 40±16 for the open group (P>0.05). No port site metastatic implantation occurred in any patient treated laparoscopically; five years overall and disease free survival were 55.7% and 54.2% for the lap group, 52.9% and 52.1% for the open group, respectively, with no statistical difference (P>0.05). Completely laparoscopic total gastrectomy represents a new challenge for the laparoscopic surgeon. In spite of clear advantage for patients, some debate remains about its oncologic efficacy in the middle and long period, even if many authors report comparable results to open total gastrectomy. In our experience, it is a safe and valid alternative to its open counterpart, with no statistically different number of lymph nodes harvested, five years overall and disease free survival in respect to the open gastrectomy. Yet, it remains a complex procedure requiring high laparoscopic skill. CONCLUSION: In our opinion, completely laparoscopic total gastrectomy is a safe and effective procedure, with long term oncologic results not statistically different from the open procedure; yet, it requires high laparoscopic experience, especially to carry out an extended lymphadenectomy and to fashion the anastomosis. More randomized prospective trials are needed to state this procedure as a new gold-standard in treating stage I-III/C non metastatic gastric cancer.

Laparoscopic versus open total mesorectal excision for stage I-III mid and low rectal cancer: a retrospective 5 years analysis.

INTRODUCTION: Total mesorectal excision (TME) is the cornerstone of a correct surgical therapy for extraperitoneal rectal cancer. Aim of the study is to evaluate our 5 years experience confronting retrospectively laparoscopic (lap) TME in respect to its laparotomic (open) counterpart. PATIENTS AND METHODS: 30 patients were treated laparoscopically for stage I-III extraperitoneal rectal cancer and retrospectively compared to a homogeneous group, stratified for sex, age, comorbidities and stage of disease. RESULTS: 30 days mortality was zero for both groups, while morbidity was 20% for the lap group and 36.6% for the open group. Mean lymph nodes harvested was 24 ± 12 for the lap group, 26 ± 14 for the open group (p > 0.05). Five years overall and disease free survival was respectively 82.2% and 81.4% in the lap group, 79.9% and 79.6% in the open group, without statistical significance (p>0.05). Discussion. Minimally invasive TME resulted a safe, effective and oncologically adequate procedure when retrospectively compared to its laparotomic counterpart, with 5 years overall survival and disease free survival reaching no statistical significance compared to the open approach, but with all the advantages of the laparoscopy such as less pain and blood loss, faster recovery, less morbidity and better cosmetics. CONCLUSIONS: Our study has retrospectively demonstrated that laparoscopic TME is feasible and oncologically effective, even if it remains a complex minimally invasive procedure, requiring adequate skill. More prospective, randomized studies are necessary to define such a procedure as the new gold standard in treatment of stage I-III extraperitoneal rectal cancer.

Laparoscopic versus open appendectomy for the treatment of complicated appendicitis.

AIM: Laparoscopic Appendectomy (LA) is widely performed for the treatment of acute appendicitis. However the use of laparoscopic approach for complicated appendicitis is controversial, in particular because it has been reported an increased risk of postoperative IntraAbdominal Abscess (IAA). The aim of this study was to compare the outcomes of LA versus Open Appendectomy (OA) in the treatment of complicated appendicitis, especially with regard to the incidence of postoperative IAA. PATIENTS AND METHODS: A retrospective study of all patients treated at our institution for complicated appendicitis, from May 2004 to June 2009, was performed. Data collection included demographic characteristics, postoperative complications, conversion rate, and length of hospital stay. RESULTS: Thirty-eight patients with complicated appendicitis were analysed. Among these, 18 (47,3%) had LA and 20 (52,7%) had OA. There were no statistical differences in characteristics between the two groups. The incidence of postoperative IAA was higher (16,6%), although not statistically significant, in the LA compared with OA group (5%). On the other hand the rate of wound infection was lower (5%) in the LA versus OA (20%). CONCLUSION: Our study indicated that LA should be utilised with caution in case of perforated appendicitis, because it is associated with an increased risk of postoperative IAA compared with OA.

Prosthetic carotid bypass graft for in-stent restenosis performed for post-endarterectomy recurrent stenosis: technical details.

AIM: Carotid artery stenting (CAS) is the treatment of choice for recurrent stenosis after carotid endarterectomy (CEA). However a significative incidence of in-stent restenosis could be occurred. Despite classical CEA leads to good results, in selective cases bypass graft may be the best treatment of in-stent restenosis. CASE REPORTS: We describe two cases of carotid bypass graft performed to treat a recurrent in-stent stenosis after CAS for post-CEA restenosis. No death and cardiac complication occurred and no cranial nerves impairment was detected. CONCLUSION: Prosthetic bypass graft is safe and effective in treatment of in-stent recurrent restenosis after CEA restenosis.

Laparoscopic versus open radical nephrectomy in T1-T2 renal carcinoma: personal 5-year experience about the oncologic outcome.

AIM: Since 1990 when it was firstly performed, radical laparoscopic nephrectomy has gained wide popularity because of its less morbidity and adequate oncologic outcome. The aim of this study was to report our experience about oncologic 5-year outcome of laparoscopic radical nephrectomy. METHODS: Fifteen patients were treated laparoscopically and retrospectively compared to a group of patients treated laparotomically, omogeneous for age, stage of disease and comorbidities. RESULTS: There was no conversion in the laparoscopic group and duration of both procedure showed no statistical difference. Laparoscopic procedures showed less intraoperative blood loss, less postoperative ileus, shorter hospitalization and less morbidity, all with statistical significance. Overall 5 years survival showed no statistical significant difference in the two groups (88.9% laparoscopic group vs. 86.2% laparotomic group). CONCLUSION: Laparoscopic radical nephrectomy has clear advantages compared to the traditional surgery, especially about less morbidity, less blood loss, shorter hospitalization, with an oncologic outcome absolutely comparable to the laparotomic procedure. Laparoscopic radical nephrectomy is a safe and oncologically adequate surgical procedure with clear advantages compared to the its open counterpart, so it must be considered as a valid alternative to laparotomic surgery in case of non metastatic T1-T2 kidney cancer.

[Results of open repair of infrarenal abdominal aortic aneurisms in patients unfit for endovascular treatment]. / Risultati della chirurgia tradizionale nel trattamento degli aneurismi dell'aorta addominale sottorenale con controindicazione alla terapia endovascolare.

INTRODUCTION: Purpose of the study was to assess how the introduction of endovascular treatment has affected mortality and morbidity of the traditional surgery for infrarenal abdominal aortic aneurysms (AAA). PATIENTS AND METHODS: From January 2002 to December 2009 we treated 230 patients with AAA (mean age 71.6; 121 male 70.7%); 171 (74.4%) were treated with surgery, 59 (25.6%) underwent to endovascular exclusion .We divided the patients into two groups: Group A, before the beginning of our "endovascular"; Group B, after the beginning of our endovascular experience. A total of 171 patients were treated with traditional surgical intervention, 99 in Group A and 72 in Group B. We evaluated the morbidity and mortality between the two groups by statistical analysis (by Student t test and χ ² test) considering a significant p-value <0.001. RESULTS: e 30-day mortality was 4% respectively in group A and 5.5% in group B (P = not significative, n.s.). The incidence of renal and ischemic peripheral complications was, respectively, 2% and 4% in group A, and 4.1% and 8.3% in group B showing statistical significance (P <.001). There were no documented statistically significant differences between the two groups in terms of cardiac and respiratory complications (P = n.s.). CONCLUSIONS. The results of the traditional surgery for the infrarenal AAA not suitables for endovascular repair suffer from the difficult anatomy of aorto-iliac district. Although the incidence of complications of open surgery is increased, the mortality is similar to anatomical not complicated aneurysms.

[Totally laparoscopic total gastrectomy with esophago-jejunal termino-lateral anastomosis by Or-Vil device for carcinoma. Our experience in ten consecutive patients]. / Gastrectomia totale totalmente laparoscopica con anastomosi esofago-digiunale termino-laterale (sistema Or-Vil) nel trattamento del cancro gastrico: nostra esperienza su 10 casi consecutivi.

INTRODUCTION: Laparoscopic gastrectomy represents an alternative procedure for treatment of gastric cancer. Yet, some debate remains about its efficacy, basically from an oncologic point of view. Aim of this study is to analyze our experience with totally laparoscopic total gastrectomy with termino-lateral esophago-jejunal anastomosis by Or-Vil device. PATIENTS AND METHODS: From February 2007 to February 2008, 10 patients underwent the procedure with Or-Vil device for the esophago-jejunal termino-lateral anastomosis. ASA score, UICC-AJCC stage, number of lymph nodes harvested, mortality and morbidity were analyzed. RESULTS: All procedures were concluded laparoscopically. No mortality was observed, morbidity was 20%. Median of lymph nodes harvested was 30+/-14. No port implantations were observed. Discussion. Laparoscopic gastrectomy, both partial and total, is a new challenge, with clear advantages for the patients, but it still must demonstrate its efficacy, especially from the oncologic point of view. In our experience, we can state that totally laparoscopic total gastrectomy is safe, effective and oncologically correct; yet, it is technically demanding and more studies are required to confirm its oncologic efficacy when compared with laparotomic gastrectomy. CONCLUSIONS: Totally laparoscopic total gastrectomy with esophago-jejunal termino-lateral anastomosis by Or-Vil device represents, in our experience, a valid alternative to open procedure; yet, more prospective randomized trials are needed to define this procedure as a new standard for gastric cancer treatment.

[Burkitt's lymphoma of the caecum in a patient with AIDS: clinical case and review of the literature]. / Linfoma di Burkitt del cieco in paziente con AIDS conclamato: caso clinico e revisione della letteratura.

Overall, lymphomas of the gastrointestinal tract are rare, although they are the most frequent extranodal location. The incidence of primary colic lymphoma, above all in the non-Hodgkin variant, is clearly higher in the HIV positive population, especially in subjects with AIDS. The authors present the case of a 51-year-old patient with AIDS undergoing antiviral therapy; he was suffering from abdominal pain and presented a palpable mass in the right iliac fossa; diagnosis was caecal non-Hodgkin lymphoma (NHL); radical right hemicolectomy was carried out with definitive histological diagnosis of Burkitt-type small cell NHL. The NHL of the colon represents no more than 1.2% of all malignant cancers of this part of the intestinal tract. Nevertheless such cases are comparatively frequent in patients with HIV virus, especially in the active phase and clinically proven to be due to immunodeficient syndrome. Of cardinal importance is the differential diagnosis between primary and secondary forms because of the different treatment and prognosis. Frequently such forms are observed in patients with AIDS, at advanced stages and with differentiated and hence more aggressive histotypes, also because they are present in organisms weakened by the underlying disease and by immunodeficiency. Primary NHLs of the colon are relatively frequent and aggressive in patients with AIDS; early diagnosis and treatment are therefore of fundamental importance to improve the oncological outcome for these patients.

[Hypoglossal artery and carotid endarterectomy. Case report]. / Persistenza dell'arteria ipoglossa ed endoarteriectomia carotidea. Case report

The persistence of hypoglossal artery is a rare malformation. Association of carotid stenosis with persistent hypoglossal artery can lead to cerebral posterior symptoms due to ischemia intolerance. The Authors report a case of unexpected intraoperative detection of this anomaly in a patient with high grade stenosis of the right internal carotid artery. Right carotid endarterectomy was performed, and no shunt was used. The postoperative course was normal. The literature was reviewed.

Prejudices and realities in the use of 'unsuitable' saphenous vein graft for infrapopliteal revascularization.

BACKGROUND: Aim of this paper is to evaluate the safety and the patency rate of the infrapopliteal bypass grafts performed with the great saphenous vein (GSV) with small (<2.5 mm) or large calibre (>5 mm). PATIENTS AND METHODS: Between January 2003 and May 2007, 73 infra-genicular bypass with autologous saphenous vein were performed in patients affected by atherosclerotic femoropopliteal disease. In 8 cases a bypass grafts with small saphenous vein (diameter 2.2-2.5 mm) were performed, in 4 cases a bypass with segmental varicose saphenous vein (diameter 5.7-6.4 mm ) were carried out. In 64 cases the bypass was carried out with the reversed technique, in 9 cases with the in situ technique. RESULTS: Thirty day mortality was 3/82 (3.6%) and 30 day cumulative patency rate was 95.1% (78/82) with limb salvage of 96.3% (79/82). All the patients with small diameter vein showed a normal patency at the follow-up and at the duplex scan examination no complications occurred. The mean calibre of the arterialized vein increased to 2.6-3,4 mm at 1 week with maintenance during the follow-up. Patients with varicose vein implanted present a mean dilatation of 6.4-7.2 mm at 1 week and no dilatative complication were detected at the follow-up. CONCLUSION: The risk of stenosis, graft thrombosis or aneurysm degeneration doesn't seem to be higher respect normal GSV either for small or for large veins. Large series and longer follow up are mandatory for an extensive clinical application.

The role of cross-over bypass graft in the treatment of acute ischaemia of the lower limb.

INTRODUCTION: The Authors reports their experience with the use of femoro-femoral cross-over bypass graft in the management of acute lower limb ischaemia. PATIENTS AND METHODS: Fourteen femoro-femoral bypass graft were performed for acute lower limb ischaemia due to unilateral thrombosis of iliac and femoral artery in 8 cases, late unilateral occlusion of a branch of previous aortobifemoral bypass in 3 cases, acute thrombosis of abdominal aorta in 2 cases and in the last one for an injury of common iliac artery during urological procedure. In all the cases the operations were carried out under local anaesthesia and a subcutaneous bypass with 'C' shape type configuration with 8 mm Dacron prosthesis were performed. The first and second year primary and secondary patency rates and limb salvage rates were evaluated. RESULTS: One and two year patency rate was 83.3 (10/12) and 70% (7/10) respectively. Secondary patency rate and limb salvage rate was 91.6% (11/12) and 80% (8/10) respectively. A tight amputation had to performed in 3 failed reconstruction (3/12, 25%). Two patient died within 30 days after surgery from acute myocardial infarct. In 1 case infection occurred and re-do femorofemoral cross-over bypass with saphenous vein was carried out (8.3%). CONCLUSIONS: Cross-over bypass is an attractive technique, especially in case of acute ischemia because of its simplicity, low morbidity and mortality, and good long term results.

An unexpected anatomical variant of the femoral artery in a patient with acute lower limb ischemia: case report.

We report a case of acute embolic ischemia of the right lower limb in a patient with unexpected intraoperative anatomic variant of femoral artery. In this anomaly, the deep femoral artery arises from the external iliac artery, 2 cm above the inguinal ligament, runs with a parallel course with the superficial femoral artery, and placed between the branches of femoral nerve. In consideration of the difficulty to achieve extensive and optimal control of the external iliac artery with the femoral approach, a retrograde embolectomy of the iliac artery by two separate arteriotomies on the deep and superficial femoral arteries were successfully performed. The literature reviewed about this anomalies. In these unexpected intraoperative cases a ductile and ingenious approach seems to be mandatory to perform a safe operation with low systemic impact.

Laparoscopic complete mesocolic excision with central vascular ligation in right colon cancer: Long-term oncologic outcome between mesocolic and non-mesocolic planes of surgery.

AIM: To analyze our experience in translating the concept of total mesorectal excision to "no-touch" complete removal of an intact mesocolonic envelope (complete mesocolic excision), along with central vascular ligation and apical node dissection, in the surgical treatment of right-sided colonic cancers, comparing "mesocolic" to less radical "non-mesocolic" planes of surgery in respect to quality of the surgical specimen and long-term oncologic outcome. METHOD: A total of 115 patients with right-sided colonic cancers were retrospectively enrolled from 2008 to 2013 and operated on following the intent of minimally invasive complete mesocolic excision with central vascular ligation. RESULTS: Morbidity and mortality were 22.6% and 1.7%, respectively. Mesocolic, intramesocolic, and muscularis propria planes of resection were achieved in 65.2%, 21.7%, and 13% of cases, respectively, with significant impact for mesenteric plane of surgery on R0 resection rate (97.3%), circumferential resection margin <1 mm (2.6%), and consequent survival advantage (82.6% at 5 years) when compared to muscularis propria plane of surgery, with R0 resection rate and overall survival falling to 72% and 60%, respectively, and with circumferential resection margin <1 mm raising to 33.3%, all being statistically significant. Stratifying patients for stage of disease, laparoscopic complete mesocolic excision with central vascular ligation significantly impacted survival in patients with stage II, IIIA/B, and in a subgroup of IIIC patients with negative apical nodes. CONCLUSION: In our experience, minimally invasive complete mesocolic excision with central vascular ligation allows for both safety and higher quality of surgical specimens when compared to less radical intramesocolic or muscularis propria planes of "standard" surgery, significantly impacting loco-regional control and thus overall survival.