The Role of Computed Tomography Colonography in Detecting Bowel Involvement in Women With Deep Infiltrating Endometriosis: Comparison With Clinical History, Serum Ca125, and Transvaginal Sonography.

OBJECTIVE: We wanted to assess the diagnostic value of computed tomographic colonography (CTC) in recognizing bowel endometriosis in comparison with serum Ca125, transvaginal sonography (TVS), and presence of intestinal symptoms. METHODS: We included in this study 92 women undergoing surgery for symptomatic DIE. Preoperative evaluation included clinical history, Ca125 serum value, and TVS. CTC was performed in 37/92 patients (40.2%), and the results were compared to the other preoperative tools and to surgical exploration, considered the clinical reference standard. RESULTS: Surgery confirmed bowel endometriosis in 49/92 subjects (53.3%). Presence of intestinal symptoms, serum Ca125 values, and TVS were significantly correlated to intestinal involvement, but CTC had the highest accuracy in detecting bowel endometriosis with a sensitivity of 68%, a specificity of 67%, a PPV of 81%, and a NPV of 50% (P = 0.04). CONCLUSIONS: CTC proved to be an accurate and low invasive imaging technique to detect DIE of the bowel and compared favorably with clinical evaluation, serum Ca125 determination, and TVS.

Sonographic diagnosis of acute cholecystitis in patients with symptomatic gallstones.

PURPOSE: The aim of the retrospective study was to assess the diagnostic ultrasound (US) criteria for acute cholecystitis in patients admitted for symptomatic gallbladder stones. METHODS: The medical records of 186 patients who had undergone cholecystectomy within 24 hours after an US examination were reviewed. Acute cholecystitis was defined on the basis of pathology findings. The correlation between standardized US signs and final diagnosis of acute cholecystitis was assessed with univariate and multivariate analyses. The diagnostic values of US based on the correlated signs were then calculated. RESULTS: The prevalence of acute cholecystitis was 52.7% (95% confidence interval [CI], 42.8-64.2). Three US signs were found to be predictive of acute cholecystitis: gallbladder distension, wall edema, and pericholecystic fluid collection. When none of the US signs were registered, sonography proved to have a 72.4% (95% CI, 59.1-83.3) negative predictive value. When registering two or three signs, sonography had positive predictive values of 78% (95% CI, 56.3-92.5) and 100% (95% CI, 58.9-100), respectively. With just one sign, the positive predictive value was 57.6% (95% CI, 47.2-67.4), and such a finding was furthermore observed in only 53.2% of the cases. CONCLUSIONS: The sonografic diagnosis of acute cholecystitis may be achieved by registering only three standardized US signs. Nevertheless, in patients admitted for symptomatic gallstones, US is of some utility in less than half of those patients.

Predictive factors for the diagnosis of severe acute cholecystitis in an emergency setting.

BACKGROUND: The aim of this study was to assess predictive factors for the diagnosis of severe acute cholecystitis. METHODS: The medical records of 295 patients with pathologically confirmed acute cholecystitis were reviewed. Patients were divided, based on pathology findings, into a group with nonsevere acute cholecystitis and a group with severe acute cholecystitis. Preoperative data were compared by univariate and multivariate analyses. Therefore, diagnostic values were assessed based on the statistically significant predictive factors. The same approach was attempted for differential diagnosis between gangrenous and phlegmonous cholecystitis. RESULTS: Among ten variables found to be significantly different at univariate analysis, four were found to be independent predictive factors of severe acute cholecystitis: fever, distension of the gallbladder, wall edema, and preoperative adverse events. Common bile duct stones were confirmed as a protective factor. Leukocyte count, cardiovascular diseases, age, gender, and diabetes were not found to be significant predictive factors of severe acute cholecystitis. No differences were found in any of the preoperative data by comparing phlegmonous and gangrenous cholecystitis. CONCLUSION: Severe acute cholecystitis may be differentiated preoperatively from nonsevere acute cholecystitis based on clinical and US data, and predictive diagnostic values may be estimated according to the number of observed predictive factors. No differences were found when comparing phlegmonous and gangrenous cholecystitis.

Colorectal cancer with microsatellite instability: Right-sided location and signet ring cell histology are associated with nodal metastases, and extranodal extension influences disease-free survival.

Colorectal cancer (CRC) with microsatellite instability (MSI) accounts for 15-18 % of all CRCs and represents the category with the best prognosis. This study aimed at determining any possible clinical/pathological features associated with a higher risk of nodal metastasization in MSI-CRC, and at defining any possible prognostic moderators in this setting. All surgically resected CRCs of the last 20 years (mono-institutional series) with a PCR-based diagnosis of MSI, with and without nodal metastasis, have been retrieved for histological review, which was performed following WHO guidelines. Furthermore, the most important prognostic moderators have been investigated with a survival analysis. The study of 33 cases of MSI-CRCs with nodal metastasis highlighted a high fidelity of histology maintenance between primary tumors and matched nodal metastases. At survival analysis, the strongest prognostic variable in MSI-CRCs with nodal metastasis was the extranodal extension (multivariate analysis, HR: 14.4, 95 %CI: 1.46-140.9, p = 0.022). Furthermore, through a comparison between nodal positive (33 cases) and nodal negative (71 cases) MSI-CRCs, right-sided location (p < 0.0001), pT4 stage (p = 0.0004) and signet-ring histology (p = 0.0089) emerged as parameters more commonly associated with nodal metastasization. These findings shed new light on the biology of MSI-CRC and can be of help for the prognostic stratification of MSI-CRC patients.

Regional hyperthermia added to intensified preoperative chemo-radiation in locally advanced adenocarcinoma of middle and lower rectum.

PURPOSE: To evaluate the safety of delivering pre-operative regional hyperthermia (HT) plus an intensified chemo-radiotherapy (CRT) regimen in patients suffering from locally advanced rectal cancer. METHODS: Between June 2000 and April 2006, 76 patients with locally advanced (cT3-4 N0/+) rectal adenocarcinoma were treated with HT plus CRT. HT was given once a week, to a total of five treatments, 1 to 4 h after radiotherapy (50 Gy with 2-Gy fractions for 5 weeks, plus a 10-Gy boost on the tumour bed, with the same fractionation schedule). Chemotherapy consisted in 5FU 200 mg/m(2) continuous infusion throughout the 6 weeks of irradiation and OXA 45 mg/m(2) in a weekly bolus. Surgery followed 4 to 6 weeks after the completion of HT plus CRT. RESULTS: HT plus CRT was generally well tolerated. At pathologic examination, there was a pathologic complete response (pCR) (ypT0 ypN0) in 18 out of 76 patients (23.6%), a partial response (PR) in 34/76 ones (44.7%) and a stable disease (SD) in 20/76 (26.3%) ones; 4/76 patients (5.2%) had a progression disease (PD) (distant metastases) at the time of surgery. Good predictors of a longer disease-free survival (DFS) were in order ypN status (log-rank test: p = 0.0008), ypT status (p = 0.002) and pCR (p = 0.03). CONCLUSION: Preoperative CRT combined with regional HT yielded acceptable toxicity. The rate of pCR was encouraging, although further studies are needed to prove the long-term efficacy of adding HT to CRT.

Mesenteric vascular and nerve sparing surgery in laparoscopic segmental intestinal resection for deep infiltrating endometriosis.

OBJECTIVE(S): To investigate Mesenteric vascular and nerve Sparing Surgery (MSS) as surgical laparoscopic technique to perform segmental intestinal resection for deep infiltrating endometriosis (DIE). STUDY DESIGN: Prospective cohort study between January 2013 and December 2016. Consecutive patients with suspected intestinal DIE underwent clinical and imaging evaluation to confirm intestinal involvement. Indications for radical surgery and surgical technique (intestinal resection versus shaving) were consistent with Abrão algorithm. Surgeons aimed to perform MSS in all the consecutive patients that required intestinal resection. MSS consists in mesenteric artery, branching arteries, and surrounding nerve fibers preservation by dissecting mesentery adherent to the intestinal wall. Data about history, preoperative and post-operative evaluation, surgery and complications were recorded. Symptoms were evaluated before and 30-60 days after surgery with numeric rating scale for pain. Constipation was evaluated with the Constipation Assessment Scale (CAS). Patients with diagnosis of irritable bowel syndrome, inflammatory bowel diseases, diverticulitis, and previous segmental intestinal resection were excluded. RESULTS: Sixty-two out of 75 (82.7%) consecutive women with intestinal endometriosis underwent laparoscopic segmental intestinal resection performed with MSS. Major complications that required repeated operation occurred in 4 cases (6.5%). Anastomotic leakage occurred in only 1 case (1.6%). Dysmenorrhea (p < .001; r = -0.86), dyspareunia (p < .001; r = -0.80), dyschezia (p < .001; r = -0.86) and dysuria (p < .001; r = -0.56) were significantly improved after surgery. After an average of 33.1 months from surgery, severe constipation was reported only by two patients (3.6%) (CAS: 13-16). The median time from surgery to intestinal function recovery (flatus or stool passage) was one day. Logistic regression analysis showed constipation related to the distance from anal verge and time since surgery. CONCLUSION(S): MSS in laparoscopic intestinal resection for DIE may be reproducible, safe and effective. MSS could be combined with pelvic nerve-sparing surgery as an effective approach to improve intestinal symptoms after radical surgery for DIE that requires segmental intestinal resection.

Role of Epidural Analgesia within an ERAS Program after Laparoscopic Colorectal Surgery: A Review and Meta-Analysis of Randomised Controlled Studies.

Introduction. Epidural analgesia has been a cornerstone of any ERAS program for open colorectal surgery. With the improvements in anesthetic and analgesic techniques as well as the introduction of the laparoscopy for colorectal resection, the role of epidural analgesia has been questioned. The aim of the review was to assess through a meta-analysis the impact of epidural analgesia compared to other analgesic techniques for colorectal laparoscopic surgery within an ERAS program. Methods. Literature research was performed on PubMed, Embase, and the Cochrane Library. All randomised clinical trials that reported data on hospital stay, postoperative complications, and readmissions rates within an ERAS program with and without an epidural analgesia after a colorectal laparoscopic resection were included. Results. Five randomised clinical trials were selected and a total of 168 patients submitted to epidural analgesia were compared to 163 patients treated by an alternative analgesic technique. Pooled data show a longer hospital stay in the epidural group with a mean difference of 1.07 (95% CI 0.06-2.08) without any significant differences in postoperative complications and readmissions rates. Conclusion. Epidural analgesia does not seem to offer any additional clinical benefits to patients undergoing laparoscopic colorectal surgery within an ERAS program.

Clinical factors that predict remission of diabetes after different bariatric surgical procedures: interdisciplinary group of bariatric surgery of Verona (G.I.C.O.V.).

AIMS: The aims of the study were to investigate weight loss and glycemic control parameters after different bariatric surgical procedures in type 2 diabetes (T2D) obese patients and identify patients' factors that predict diabetes remission. METHODS: The study included 105 obese T2D patients (66 women and 39 men) who underwent laparoscopic gastric banding (LAGB, 11 subjects, age 47 ± 10 years, BMI 42.3 ± 8.3 kg/m(2)), or laparoscopic Roux-en-Y gastric bypass (RYBP, 77 subjects, age 50 ± 8 years, BMI 45.7 ± 6.8 kg/m(2)), or sleeve gastrectomy (SG, 17 subjects, age 49 ± 11 years, BMI 50.2 ± 8.8 kg/m(2)) during 2005-2012 period. RESULTS: The average percentage of weight loss at 12 months after surgery was 26.4 ± 9.8 %, and it was maintained at 24 and 36 months of follow-up. Diabetes remission occurred in 68.6 % of study participants (4/11 of LAGB, 54/77 of RYBP and 14/17 of SG). In multivariate Cox analysis, age, duration of diabetes, surgical procedure and glycated hemoglobin <53 mmol/mol (7 %) resulted significant predictors of diabetes remission (age RR = 0.97, 95 %CI 0.94-1.0, p = 0.05; diabetes duration RR = 0.93, 95 % CI 0.86-0.99, p = 0.036; rif LAGB, RYBP RR = 3.9, 95 % CI 1.31-11.57, p = 0.014; SG RR = 5.6, 95 % CI 1.67-18.64, p = 0.005; glycated hemoglobin RR = 0.54, 95 % CI 0.32-0.92, p = 0.024). CONCLUSIONS: Bariatric surgical procedures that modify the upper gastrointestinal tract anatomy (RYBP and SG) are more successful in producing weight loss and remission of T2D than those that simply restrict stomach capacity (LAGB). Younger age, short duration of diabetes and better glucose control confer higher probability of achieving remission of diabetes.