Gastrocolic trunk of Henle and its variants: review of the literature and clinical relevance in colectomy for right-sided colon cancer.

PURPOSE: Venous vascular anatomy of the right colon presents a high degree of variability. Henle's Gastrocolic Trunk is considered an important anatomical landmark by colorectal surgeons. The classical description concerns a bipod vascular structure or tripod, but several variants are associated to it. The aim of this study is to merge the most updated literature on the anatomy knowledge of the Gastrocolic Trunk by evaluating all possible variants, as well as to underline its surgical importance due to its topographical relationships. METHODS: Twelve studies describing the anatomy of the gastrocolic trunk were selected, each of them dealing with a more or less extensive series of cases. A distinction was drawn between the gastropancreatic trunk, devoid of the colonic component, and the gastrocolic trunk; and then the frequency of the different resulting variants was reported. The data obtained from cadavers and radiological studies were analyzed separately. RESULTS: The Gastrocolic Trunk is found in 74% of cadaver studies, and in 86% of radiological studies. Its most frequent configuration is represented by the union of right gastroepiploic vein + anterior superior pancreaticoduodenal vein + superior right colic vein, respectively, 32.5% and 42.5%, followed by the right colic vein which replaces (26.9%, 12.3%) or is added (10%, 20.1%) to the superior right colic vein. CONCLUSIONS: The superior right colic vein joins the right gastroepiploic vein and the anterior superior pancreaticoduodenal vein thus forming, in most cases, the gastrocolic trunk. The anatomical knowledge of vascular structures forms the basis for both the interpretation of preoperative radiological images and the surgical procedure itself, despite the considerable anatomical variability of tributaries.

Diagnostic Accuracy of 3-Dimensional Endoanal Ultrasound in Identifying Perianal Crohn's Fistulas.

BACKGROUND: Perianal fistulizing Crohn's disease is a challenging clinical situation that requires proper management. Some features seen on the endoanal ultrasound can be helpful in discriminating between cryptoglandular and Crohn's disease fistulas. OBJECTIVE: The aim of this study was to define the diagnostic accuracy of 3-dimensional endoanal ultrasound in differentiating between Crohn's disease and cryptogenic fistulas. DESIGN: This was a prospective observational study. SETTINGS: The study was conducted in the colorectal unit of an IBD referral center. PATIENTS: Consecutive patients referred for suspected perianal sepsis from September 2015 to December 2016 were included. INTERVENTIONS: Three-dimensional endoanal ultrasonography was the studied intervention. MAIN OUTCOMES MEASURES: Sensitivity, specificity, and positive and negative likelihood ratios of 4 ultrasonographic features (Crohn's ultrasound fistula sign, the presence of a double track, debris or an abscess within the fistula track, and the maximum width of the track) in discriminating between cryptoglandular and Crohn's disease fistulas were calculated. The interobserver agreement for each feature was quantified. RESULTS: In this study, 158 patients, of whom 33 had a diagnosis of Crohn's disease, were included. The interobserver agreement was good for all of the ultrasonographic features. All of these features were more frequent in cases of Crohn's disease fistulas (p = 0.0001). The maximum width of the fistula track was highly accurate for discriminating between cryptogenic and Crohn's disease fistulas (area under the receiver operating characteristic curve = 0.922). The simultaneous presence of 2 features was suggestive of Crohn's disease fistula. In particular, the presence of a track width >4 mm in conjunction with either a double track or the Crohn's ultrasound fistula sign showed very high specificity (1.00). Conversely, a fistula track width ≤3 mm had high sensitivity (0.97). LIMITATIONS: Patients included in the cryptogenic group might be diagnosed as having Crohn's disease at follow-up. CONCLUSIONS: The combination of specific endoanal ultrasonographic features allows for highly accurate discrimination between Crohn's disease and cryptogenic fistulas. See Video Abstract at http://links.lww.com/DCR/A619.

Ileostomy reversal with handsewn techniques. Short-term outcomes in a teaching hospital.

INTRODUCTION: Fecal diversion is considered an effective procedure to protect bowel anastomosis at high risk for leak. Some concerns exist regarding the risk for a significant morbidity associated to ileostomy creation itself and moreover to its closure. Surgical expertise and closure techniques are considered potential factors influencing morbidity. Aim of the study is to present a single-institution experience with ileostomy closures, in a teaching hospital, whereas ileostomy reversal is mainly performed by young residents. METHODS: A prospective database was investigated to extract data of patients who underwent loop ileostomy closure between January 2005 and December 2014. Ileostomy reversion was always realized in a handsewn fashion, performing either a direct closure (DC) or a resection plus end-to-end anastomosis (EEA). Postoperative morbidity was graded according to Clavien-Dindo classification. Outcomes after DC and EEA were compared by Fisher's exact test and Wilcoxon rank-sum test. RESULTS: Two hundred ninety-eight patients were included. Ileostomy reversal was performed by EEA in 236 patients (79.19 %) and by DC in 62 patients (20.81 %). Surgery was performed with a peristomal access in 296 cases (99.33 %). Incidence of anastomotic leak was 0.67 % (2/298). Overall reoperation rate was 0.34 % (1/298). Short-term overall morbidity rate was 20.47 %; but major complications (≥ grade III) occurred in only one patient (0.34 %). Mortality was nil. No significant differences in postoperative morbidity were found between the DC and EEA group. CONCLUSION: Loop ileostomy reversal is a safe procedure, associated to a low major morbidity and excellent results, even if performed with a handsewn technique by supervised trainee surgeons.

Ventral mesh rectopexy versus conventional suture technique: a single-institutional experience.

AIMS: Anterior mesh rectopexy is a novel surgical technique for the treatment of complete rectal prolapse, a common disorder in female elderly patients. Aim of the study was to evaluate functional outcomes after ventral mesh rectopexy and conventional suture rectopexy. PATIENTS AND METHODS: Forty patients have been enrolled in this prospective study. Patients were divided into two groups: 20 patients (group A) had a conventional suture rectopexy with a standard technique and 20 patients (group B) underwent an anterior mesh rectopexy. Each patient had a clinic and defecographic diagnosis of full-thickness rectal prolapse, which was further investigated with manometry and clinical questionnaires (Wexner Constipation and Incontinence Score, Rome III criteria). Postoperative outcomes were evaluated through clinical questionnaires, a rigid rectosigmoidoscopy and a defecography, 1 year after surgery. RESULTS: Preoperative Wexner constipation score was greater than 15 in all the patients (21 in group A and 22 in group B); median postoperative score was 15 in group A and 11 in group B, and the difference was significant. Median preoperative incontinence score was 11 in group A and 12 in group B; median postoperative score was 9 in group A and 6 in group B. Three patients experienced recurrence in group A and only 1 patient in group B. CONCLUSION: Ventral mesh rectopexy is feasible, safe and effective for the treatment of full-thickness rectal prolapse in a well-fit geriatric population. Better functional results have been achieved compared with conventional suture technique with a trend toward a lower recurrence rate.

Venous anomalies of the axilla: a single-institution experience.

AIM: Surgical treatment is still the cornerstone in the treatment of breast cancer, a very common neoplasia, particularly affecting the female elderly population. Axillary dissection is crucial in the treatment of some tumours, but variations in axillary vessels anatomy are poorly described in standard anatomy and surgical textbook. We aimed to describe anatomical variations in axillary vessels found in our institutional experience. PATIENTS AND METHODS: A prospective 3-year study was conducted in our institution from January 2012 to December 2014. Sixty-one consecutive axillary lymph node dissections (ALNDs) were performed in 61 patients who underwent surgery for stage II and III invasive breast cancer. Anatomical details of axillary vascular anatomy and its variations have been evaluated, described and stored in a prospective database. RESULTS: Sixty-one ALNDs have been performed in the study period. The anatomy of lateral thoracic vein, angular vein and axillary vein was studied and compared with standard anatomical description. Eighteen percentage of venous variations were found out of the 61 dissection performed. CONCLUSIONS: Vascular anatomy of axilla is complex and variable. A better knowledge of all possible variations might be helpful in preventing injuries during ALND.

Cancer recurrence following conversion during laparoscopic colorectal resections: a meta-analysis.

INTRODUCTION: Evidence regarding long-term oncological outcomes following conversion to open surgery (COS) during laparoscopic colorectal resection (LCR) is controversial. The aim of this study is to assess the impact on cancer recurrence of a failed laparoscopic attempt. METHODS: MEDLINE, Scopus and ISI Web of Knowledge databases were searched for articles reporting data on cancer recurrence in patients undergoing completed LCR and COS. Data were pooled by fixed or random effect modeling, according to the presence of heterogeneity. Primary outcomes were local recurrence (LR) and distance recurrence (DR). RESULTS: Seven studies involving 2493 patients (completed LCR, n 2201 and COS, n 292) were included. The pooled analysis showed that COS resections have an higher risk of LR (OR 1.97, 95% CI 1.14-3.42, p = 0.1); no difference was found in DR (OR 1.09, 95% CI 0.67-1.77, p = 0.71). However, an higher rate of T4 tumor was present in the converted group (OR 2.62, 95% CI 1.71-4, p = 0.0). Subgroup analysis including studies with T stage matched populations showed no significant statistical difference in LR rate; however, a trend toward higher recurrence was still clear. CONCLUSION: There is no consistent evidence that a failed laparoscopic attempt does not result in a poorer oncological outcome; therefore, a careful selection of patients for LCR for cancer is required.

Confocal laser endomicroscopy in breast surgery: a pilot study.

BACKGROUND: Breast neoplasms include different histopathological entities, varying from benign tumors to highly aggressive cancers. Despite the key role of imaging, traditional histology is still required for a definitive diagnosis. Confocal Laser Endomicroscopy (CLE) is a new technique, which enables to obtain histopathological images in vivo, currently used in the diagnosis of gastrointestinal diseases. This is a single-center pilot feasibility study; the main aim is to describe the basic morphological patterns of Confocal Laser Endomicroscopy in normal breast tissue besides benign and malignant lesions. METHODS: Thirteen female patients (mean age 52.7, range from 22 to 86) who underwent surgical resection for a palpable breast nodule were enrolled. CLE was performed soon after resection with the Cellvizio® Endomicroscopy System (Mauna Kea Technologies, Paris, France), by using a Coloflex UHD-type probe; intravenous fluorescein was used as contrast-enhancing agent. The surgical specimen was cut along the main axis; dynamic images were obtained and recorded using a hand-held probe directly applied both to the internal part of the lesion and to several areas of surrounding normal tissue. Each specimen was then sent for definitive histologic examination. RESULTS: Histopathology revealed a benign lesion in six patients (46%), while a breast cancer was diagnosed in seven women (54%). Confocal laser endomicroscopy showed some peculiar morphological patterns. Normal breast tissue was characterized by a honeycomb appearance with regular, dark, round or hexagonal glandular lobules on a bright stroma background; tubular structures, representing ducts or blood vessels, were also visible in some frames. Benign lesions were characterized by a well-demarcated "slit-like" structure or by lobular structures in abundant bright stroma. Finally, breast cancer was characterized by a complete architectural subversion: ductal carcinoma was characterized by ill-defined structures, with dark borders and irregular ductal shape, formingribbons, tubules or nests; mucinous carcinoma showed smaller cells organized in clusters, floating in an amorphous extracellular matrix. CONCLUSIONS: This is the first pilot study to investigate the potential role of confocal laser imaging as a diagnostic tool in breast diseases. Further studies are required to validate these results and establish the clinical impact of this technique.

Oncological Outcomes and Quality of Life After Rectal Cancer Surgery.

Surgery for rectal cancer has been completely revolutionized thanks to the adoption of new technologies and up-to-date surgical procedures that have been applied to the traditional milestone represented by Total Mesorectal Excision (TME). The multimodal and multidisciplinary approach, with new technologies increased the patients' life expectancies; nevertheless, they have placed the surgeon in front of newer issues, represented by both oncological outcomes and the patients' need of a less destructive surgery and improved quality of life. In this review we will go through laparoscopic, robotic and transanal TME surgery, to show how the correct choice of the most appropriate technique, together with a deep knowledge of oncological principles and pelvic anatomy, is crucial to pursue an optimal cancer treatment. Novel technologies might also help to decrease the patients' fear of surgery and address important issues such as cosmesis and improved preservation of postoperative functionality.

The role of MRI in predicting Ki-67 in breast cancer: preliminary results from a prospective study.

PURPOSE: In the last decade contrast-enhanced magnetic resonance imaging (MRI) has gained a growing role as a complementary tool for breast cancer diagnosis. Currently the relationship between the kinetic features of a breast lesion and pathologic prognostic factors has become a popular field of research. Our aim is to verify whether breast MRI could be considered a useful tool to predict Ki-67 score, thus resulting as a breast cancer prognosis indicator. METHODS: From June to December 2014, we enrolled patients with breast cancer who underwent preoperative dynamic contrast-enhanced MRI at the local health agency. We analyzed the time-signal intensity curves calculating the mean values of the following parameters: the basal enhancement (Ebase), the enhancement ratio (ENHratio), the maximum enhancement (Emax), and the steepest slope of the contrast enhancement curve (Smax). Scatterplots and Pearson correlation test were used to investigate the eventual associations among these parameters. RESULTS: A total of 27 patients underwent breast MRI during the study period. The mean ± SD Ki-67 percentage was 27.03 ± 16.8; the mean Emax, Smax, Ebase, and ENHratio were 433.9 ± 120.2, 267.3 ± 96.8, 165.5 ± 77.1, and 187.1 ± 94.8, respectively. Scatterplots suggest a positive correlation between Ki-67 and both Emax and Smax. The correlation tests between Ki-67 and Emax, Ki-67 and Smax showed statistical significance. CONCLUSIONS: Our preliminary data suggest that enhancement pattern is closely linked to breast cancer proliferation, thus proving the relationship between more proliferating tumors and more rapidly enhanced lesions. This is hypothesis-generating for further studies aimed at promoting breast MRI in the early estimation of cancer prognosis and tumor in vivo response to chemotherapy.

Can axillary node dissection be safely omitted in the elderly? A retrospective study on axillary management of early breast cancer in older women.

INTRODUCTION: Sentinel lymph node biopsy (SLNB) is a minimally invasive technique to stage the axillary lymph node status. The burden of nodal metastasis is of great concern, as the clinical relevance and therapeutic implications of pN1mi and pN0(i+) in the sentinel lymph node (SLN) remain a matter of debate. MATERIALS AND METHODS: We examined the pathological features of 901 patients above the age of 65 presenting with clinical T1-T2 N0M0 breast tumours (<3 cm), detecting tumours related to llary non-sentinel node (NSN) metastases when the SLN was minimally involved. RESULTS: A total of 270 patients underwent complete axillary lymph node dissection (cALND) after their SLNB specimen tested positive for macrometastasis, micrometastasis and isolated tumour cells (ITCs). Seventy-six patients were diagnosed with micrometastatic disease pN1mi (27.5%), whilst ITCs (pN0i+) were detected in seven patients (2.5%). NSNs were found to be involved in two patients (2.6%) with micrometastases at the SLN. No further metastatic disease was detected in NSNs when the SLN contained ITCs. At a median follow-up period of 5.8 years, no axillary recurrence was observed among pN1mi and pN0(i+) patients. Lobular histotype, multicentricity and lymphovascular invasion were found to be associated with NSN involvement. DISCUSSION: The results from our case series are supported by IBCSG 23-01 level 1 evidence, which demonstrated a local recurrence rate of 1% in 'minimally involved not-surgical treated axilla'. CONCLUSIONS: Based on current evidence, we spare well-informed and consenting patients from further axillary surgery when the SLN is minimally involved in early breast cancer within an agreed protocol, whilst scheduling adjuvant treatment based on the patients' primary tumour characteristics.

Laparoscopic colorectal surgery in learning curve: Role of implementation of a standardized technique and recovery protocol. A cohort study.

BACKGROUND: Despite the proven benefits, laparoscopic colorectal surgery is still under utilized among surgeons. A steep learning is one of the causes of its limited adoption. Aim of the study is to determine the feasibility and morbidity rate after laparoscopic colorectal surgery in a single institution, "learning curve" experience, implementing a well standardized operative technique and recovery protocol. METHODS: The first 50 patients treated laparoscopically were included. All the procedures were performed by a trainee surgeon, supervised by a consultant surgeon, according to the principle of complete mesocolic excision with central vascular ligation or TME. Patients underwent a fast track recovery programme. Recovery parameters, short-term outcomes, morbidity and mortality have been assessed. RESULTS: Type of resections: 20 left side resections, 8 right side resections, 14 low anterior resection/TME, 5 total colectomy and IRA, 3 total panproctocolectomy and pouch. Mean operative time: 227 min; mean number of lymph-nodes: 18.7. Conversion rate: 8%. Mean time to flatus: 1.3 days; Mean time to solid stool: 2.3 days. Mean length of hospital stay: 7.2 days. Overall morbidity: 24%; major morbidity (Dindo-Clavien III): 4%. No anastomotic leak, no mortality, no 30-days readmission. CONCLUSION: Proper laparoscopic colorectal surgery is safe and leads to excellent results in terms of recovery and short term outcomes, even in a learning curve setting. Key factors for better outcomes and shortening the learning curve seem to be the adoption of a standardized technique and training model along with the strict supervision of an expert colorectal surgeon.

Clinically cN0 breast cancer in elderly: what surgery?

INTRODUCTION: Breast carcinoma is the most common cancer in women worldwide. The incidence increases with age. Elderly patients have more advanced disease than younger ones, but they have a more favorable biologic tumor profile overall. The management of breast cancer in elderly is controversial. We report our experience with breast cancer in older than 65 years in the last 5 years, in order to assess how many axillary dissection may have been avoided, according to disease free survival (DFS) and overall survival (OS). MATERIALS AND METHODS: We enrolled in our retrospective study all over 65 year old patients referred to the Breast Unit of our Department of Clinical Medicine and Surgery at the University of Naples Federico II from January 2009 to December 2013. The end points were: evaluation of the rate of axillary treatment avoidable, DFS and OS. RESULTS: We recruited 133 over 65 year old patients. Axillary lymph node was not palpable in 109 patients. The rate of involved axillae in patients without palpable nodes treated was 11.8%. The mean follow up was 35.7 months. At the time of data collection 3 patients had developed IBTR. No one had axillary recurrence, independently from the chosen treatment. 2 patients died for causes different from breast cancer. CONCLUSION: DFS and OS are the same both in patients with treated and no treated axilla. Even if evidences about the treatment of breast cancer in elderly are still controversial, each patient deserves a multidisciplinary approach to discuss the best treatment option.

Intersphinteric resection for rectal cancer: role in fecal continence and Quality of Life.

AIM: Aim of this study is to evaluate the presence of fecal incontince and its impact on life-quality after intersphincteric resection for low rectal cancer. MATERIAL AND METHODS: Twentyeight patients (18 males and 10 female) underwent intersphincteric resection for low rectal cancer between 2006 and 2008. The presence of fecal incontinence was evaluated by Wexner score pre-operatory and 3, 6 and 12 months after ileostomy closure; Quality of Life was evaluated by Fecal Incontinence Quality Of Life (FIQL) score. RESULTS: Wexner score was significatively (p<0.01) higher in the post-operative period (14,07 ± 1.94, 13.36 ± 2.3 and 12.29 ± 2.3 at 3.6 and 12 months) than the pre-operative one (0.72 ± 0.71). Post-operative life-quality specifically related to fecal incontince was worse than in the pre-operative period (FIQL: 10.84 ± 2.52 at 12 months vs 16 preoperative period). DISCUSSION: Wexner score results show a significative worsening in fecal incontinence after intersphincteric resection, even if this condition seems to improve during the follow-up. These results agree with literature. CONCLUSIONS: Intersphincteric resection for low rectal cancer is associated, in the short term (12 months), with a significative state of fecal incontinence. This state has a significative impact on life-quality. However a longer follow-up probably might show an improvement in life-quality parameters.

Lobular intraepithelial neoplasia arising within breast fibroadenoma.

BACKGROUND: Fibroadenomas are the second most common breast pathology occurring in young women under the age of 35 years old. Fibroadenomas can be classified as simple or complex according to histological features. Complex fibroadenomas differ from simple fibroadenomas because of the presence of cysts (3 mm), sclerosing adenosis, epithelial calcifications, or papillary apocrine changes. Most fibroadenomas are clinically identifiable. In 25% of cases, fibroadenomas are non-palpable and are diagnosed with mammography and ultrasound. Differential diagnosis with well differentiated breast cancer is often necessary, particularly with medullary or mucinous tumors. Calcification findings within fibroadenomas by mammogram have to be investigated. The age of a lump is usually reflected by calcifications. Microcalcification can hide foci of carcinoma in situ when they are small, branching type, and heterogeneous. However, many morphological possibilities may not be reliable for deciding whether a certain calcification is the product of a malignant or a benign process. From a radiological point of view, fibroadenomas containing foci of carcinoma in situ can be indistinguishable from benign lesions, even if the incidence of carcinoma within fibroadenomas is estimated as 0.1-0.3%, and it could be a long-term risk factor for invasive breast cancer. CASE PRESENTATION: A 44-year-old woman presented with a 1.5-cm palpable, smooth, mobile lump in the lower-inner quadrant of her right breast. Standard mediolateral oblique and craniocaudal mammograms showed a cluster of eccentric popcorn-like calcifications within the fibroadenoma. After lumpectomy, a definitive histological examination confirmed the intra-operative diagnosis of a benign mass. However, lobular intraepithelial neoplasia foci were found, surrounded by atypical lobular hyperplasia. CONCLUSIONS: The possibility of an old benign breast lump might be supported by fine needle aspiration biopsy or core biopsy before initiating follow-up. According to our experience, when patients are older than 40 years and have a familial history of breast cancer, we prefer to carry out lumpectomy with follow up to avoid the risk of underestimation in situ foci within the lump.

Functional results after TME: J-pouch vs straight coloanal anastomosis and role of neoadjuvant radiochemotherapy.

AIM: Purpose of this study was to evaluate short and long term functional outcomes after TME (total mesorectal excision) for rectal cancer. The role of straight anastomosis or colonic J-pouch reconstruction is investigated, as well as the impact of preoperative chemoradiotherapy is analyzed as a cause of the so called "anterior resection syndrome". METHODS: We enrolled 40 patients (17 male and 23 female), in which a low anterior resection was performed: they were divided in four groups: A1 (Straight and no RCT), A2 (Straight and RCT), B1 (J-pouch and no RCT), B2 (J-pouch and RCT). Follow-up was performed six and twelve months after surgery, through a clinical questionnaire ( to assess: stool frequency, incomplete emptying, the presence of fecal leakage, urgency and incontinence ) and through anorectal manometry ( to assess rest pressure, squeeze pressure, max tolerated volume and compliance). Results were evaluated through T-Student and Chi-Squared test. RESULTS: Six months after surgery, colonic J-pouch offers the best clinical and functional results, in both radiated and not radiated patients (except for incomplete emptying); in the straight group, however, there is an improvement of results after twelve months. Chemoradiation therapy is always associated with worse functional results. DISCUSSION: RCT seems to invalidate J-pouch function in particular, in fact twelve months after surgery the difference between J-Pouch and Straight groups is not statistically different for most of the parameters. CONCLUSION: J-pouch gives a real functional advantage for only six months after surgery, especially in patients treated with neoajuvant chemoradiation therapy.