Risk of ileocolic anastomosis failure after right hemicolectomy for cancer. A comparison between different techniques.

BACKGROUND: In recent years, the role of laparoscopic approach in the surgical treatment of right colon cancer has increased. Results comparing the different techniques of ileocolic anastomoses are controversial, with studies only reporting some advantages of the intracorporeal laparoscopic technique. The aim of this study is to compare the outcomes between laparoscopic versus open hemicolectomy for right colon cancer, focusing on anastomotic techniques (intracorporeal vs extracorporeal in the laparoscopic procedure, and manual vs mechanical in the laparotomic procedure). METHODS: This is a retrospective single center study enrolling patients with right colon cancer from January 2016 to December 2020. Primary endpoint of the study was the rate of anastomotic leak (AL). RESULTS: A total of 161 patients who underwent right hemicolectomy were enrolled: 91 were performed with laparoscopic technique, and 70 with open technique. Overall, AL occurred in 15 pts (9.3%). We observed 4 AL in intracorporeal (12.9%) and 6 in extracorporeal (10%) anastomoses, respectively. In the laparotomy group 5 patients (7.1%) developed AL, of which 3 (5.7%) and 2 (11.1%) manually and mechanically performed, respectively. CONCLUSIONS: Based on our findings, laparoscopic hemicolectomy has a higher incidence of anastomotic leak. In the laparoscopic group, we observed the lowest rate of AL with extracorporeal mechanical anastomosis. When performed extracorporeally with open technique, hand-sewn anastomosis has better results than mechanical. KEY WORDS: Anastomosis, Cancer, Ileotransverse, Leakage, Right Colectomy.

Short course radiotherapy and delayed surgery for locally advanced rectal cancer in frail patients: is it a valid option?

OBJECTIVE: The endpoint of the present study was to evaluate the outcomes of short-course radiotherapy (SCRT) and SCRT with delayed surgery (SCRT-DS) on a selected subgroup of frail patients with locally advanced middle/low rectal adenocarcinoma. METHODS: From January 2008 to December 2018, a total of 128 frail patients with locally advanced middle-low rectal adenocarcinoma underwent SCRT and subsequent restaging for eventual delayed surgery. Rates of complete pathological response, down-staging, disease free survival (DFS) and overall survival (OS) were analyzed. RESULTS: 128 patients completed 5 × 5 Gy pelvic radiotherapy. 69 of these were unfit for surgery; 59 underwent surgery 8 weeks (average time: 61 days) after radiotherapy. Downstaging of T occurred in 64% and down-staging of N in 50%. The median overall survival (OS) of SCRT alone was 19.5 months. The 1-year, 2-year, 3-year and 5-year OS was 48%, 22%, 14% and 0% respectively. In the surgical group, the median disease-free survival (DFS) and median OS were, respectively, 67 months (95% CI 49.8-83.1 months) and 72.1 months (95% CI 57.5-86.7 months). The 1, 2, 3, 5-year OS was 88%, 75%, 51%, 46%, respectively. Post-operative morbidity was 22%, mortality was 3.4%. CONCLUSIONS: Frail patients with advanced rectal cancer are often "unfit" for long-term neoadjuvant chemoradiation. A SCRT may be considered a valid option for this group of patients. Once radiotherapy is completed, patients can be re-evaluated for surgery. If feasible, SCRT and delayed surgery is the best option for frail patients.

A rare case of metachronous neuroendocrine tumor after a colorectal adenocarcinoma: qualitative critical review of synchronous and metachronous gastrointestinal NET.

Gastrointestinal neuroendocrine tumor (NET) associated with a metachronous intestinal adenocarcinoma is rare. We report the case of a 71-year-old man with an ileal NET. Patient has previously undergone a left colectomy for sigmoid cancer. We report a complete review both of the metachronous and synchronous NET. A comprehensive systematic literature search in PubMed, EMBASE, and MEDLINE identified a total of 35 relevant studies. This study includes an analysis of review articles, case reports, case series, retrospective studies and population-based studies. In the English literature to date, there are 21 case reports (19 synchronous cases and 2 metachronous cases), 3 case series and 3 review articles, and less than 10 retrospective studies or population-based studies. A total of 31 patients in 24 articles were included in the study: 28 patients with a synchronous gastrointestinal NET and colorectal adenocarcinoma and 3 patients with metachronous gastrointestinal NET and colorectal adenocarcinoma. The incidence of synchronous cancer (particularly for colorectal and gastric cancer) with a gastrointestinal NET ranges from 10 to 50%, while for the metachronous ones it is still unclear. This is the third metachronous case report and the first descriptive case of gastrointestinal NET diagnosed 2 years after a colorectal adenocarcinoma. An endoscopic follow-up program for gastrointestinal NET patients and/or for first-degree relatives of NET patients appears recommendable.

Impact of different dosage of protamine on heparin reversal during off-pump coronary artery bypass: a clinical study.

INTRODUCTION: Currently, a dose of protamine equal to 1 mg for each 100 units of heparin given is used to reverse the residual heparin activity following off-pump coronary artery bypass. We hypothesized that a 1:1 ratio (ratio of protamine to heparin) could be higher than necessary inducing post-operative disturbance of hemostasis. METHODS: Between January and March 2014 in 9 patients undergoing off-pump coronary artery bypass, we evaluated the effect of a dose of protamine equal to 1 mg per 100 units of heparin (Total Calculated Dose) on hemostasis as evaluated by means of thromboelastomery. Two data analyses were performed: the first after the administration of 2/3 of the Total Calculated Dose of protamine and the second after the administration of the Total Calculated Dose of protamine. RESULTS: We found that the administration of 2/3 of Total Calculated Dose of protamine was always able to reverse the anticoagulant effect of heparin and that a significant clotting time elongation was induced by the infusion of the second part of the Total Calculated Dose of protamine. No modification in clot firmness was observed. CONCLUSIONS: The present study seems to suggest that the commonly applied ratio equal to 1:1 (ratio of protamine to heparin) could be higher than needed with potential and hazardous impacts on the efficacy of the coagulation system.

Preoperative trans-jugular porto-systemic shunt for oncological gastric surgery in a cirrhotic patient.

Abdominal surgery in cirrhotic patients with portal hypertension is associated with high incidence of disease and mortality. In these patients, oncological gastric procedures with lymph-nodes dissection show much higher complication rates than in normotensive portal vein patients. Thus, normalization of portal vein pressure may be a favorable determinant factor to reduce complications. We report a case of a patient with hepatitis C virus-related hepatic cirrhosis, esophageal varices, portal hypertension and gastric cancer. We demonstrated the efficacy of a preoperative trans-jugular porto-systemic shunt to perform oncological radical resection more safely. We retained preoperative the trans-jugular porto-systemic shunt in the patients with elevated portal pressure and gastric cancer to perform a gastrectomy more safely and to decrease morbidity and mortality of these cases.

One-step laparoscopic and endoscopic treatment of gallbladder and common bile duct stones: our experience of the last 9 years in a retrospective study.

The optimal timing and best method for removal of common bile duct stones (CBDS) associated with gallbladder stones (GBS) is still controversial. The aim of this study is to investigate the outcomes of a single-step procedure combining laparoscopic cholecystectomy (LC), intraoperative cholangiography (IOC), and endoscopic retrograde cholangiopancreatography (ERCP). Between January 2003 and January 2012, 1972 patients underwent cholecystectomy at our hospital. Of those, 162 patients (8.2%; male/female 72/90) presented with GBS and suspected CBDS. We treated 54 cases (Group 1) with ERCP and LC within 48 to 72 hours. In 108 patients (Group 2) we performed LC with IOC and, if positive, was associated with IO-ERCP and sphincterotomy. In Group 1, a preoperative ERCP and LC were completed in 50 patients (30%). In four cases (2%), an ERCP and endobiliary stents were performed without cholecystectomy and then patients were discharged because of the severity of clinical conditions and advanced American Society of Anesthesiologists score (III to IV). Two months later a preoperative ERCP and removal of biliary stents were performed followed by LC 48 to 72 hours later. In Group 2, the IOC was performed in all cases and CBDS were extracted in 94 patients (87%). In two cases, the laparoscopic choledochotomy was necessary to remove large stones. In another two cases, an open choledochotomy was performed to remove safely the stones with T-tube drainage. In three cases, conversion was necessary to safely complete the procedure. The mean operative time was 95 minutes (range, 45 to 150 minutes) in Group 1 and 130 minutes (range, 50 to 300 minutes) in Group 2. The mean hospital stay was 6.5 days (range, 4 to 21 days) in Group 1 and 4.7 days (range, 3 to 14 days) in Group 2. Five cases (two in Group 2 and three in Group 1) presented with CBDS at 12 to 18 months after surgery. They were treated successfully with a second ERCP. There was no perioperative mortality. Our experience suggests that when clinically and technically feasible, a single-stage approach combining LC, IOC, and ERCP to the patients diagnosed with chole-choledocholithiasis is indicated. The IO-ERCP with CBDS extraction is a safe and effective method with low risk of postoperative pancreatitis. One-step treatment is more comfortable for the patient and also reduces the mean hospital stay.

On the mechanism of levosimendan-induced dopamine release in the striatum of freely moving rats.

The Ca(2+) sensitizer levosimendan (LEV) improves myocardial contractility by enhancing the sensitivity of the contractile apparatus to Ca(2+). In addition, LEV promotes Ca(2+) entry through L-type channels in human cardiac myocytes. In this study, which was performed using microdialysis, infusion of LEV at 0.25 microM for 160 min increased dopamine (DA) concentrations (up to fivefold baseline) in dialysates from the striatum of freely moving rats. Ca(2+) omission from the perfusion fluid abolished baseline DA release and greatly decreased LEV-induced DA release. Reintroduction of Ca(2+) in the perfusion fluid restored LEV-induced DA release. Chelation of intracellular Ca(2+) by co-infusing 1,2-bis (o-amino-phenoxy)ethane-N,N,N',N'-tetraacetic acid tetra (acetoxymethyl) ester (BAPTA-AM, 0.2 mM) did not affect basal DA release and scarcely affected LEV-induced increases in dialysate DA. In addition, co-infusion of the L-type (Ca(v) 1.1-1.3) voltage-sensitive Ca(2+)-channel inhibitor nifedipine failed to inhibit LEV-induced increases in dialysate DA, which, in contrast, was inhibited by co-infusion of the N-type (Ca(v) 2.2) voltage-sensitive Ca(2+)-channel inhibitor omega-conotoxin GVIA. We conclude that LEV promotes striatal extracellular Ca(2+) entry through N-type Ca(2+) channels with a consequent increase in DA release.