Interest of sentinel node biopsy in apparently intrathyroidal medullary thyroid cancer: a pilot study.

PURPOSE: Initial surgery for medullary thyroid cancer (MTC) with no evidence of lymph node involvement in neck compartments consists of total thyroidectomy and prophylactic central neck dissection. This study evaluated the reliability of a radiotracer technique for the intraoperative detection of sentinel lymph nodes (SLNs) in lateral compartments in patients with early MTC. METHODS: Patients with limited (cT1 N0) MTC entered the study (2009-2012). A 0.1-0.3 ml suspension of macrocolloidal technetium-99-labeled human albumin was injected (under echo-guide) in the tumor 5 h before surgery. Preoperative lymphoscintigraphy confirmed the identification of SLNs in the lateral neck. The operation consisted of total thyroidectomy and central neck dissection, and a hand-held gamma-probe (Neoprobe) guide was used to remove the SLNs from the lateral neck. RESULTS: Four patients were recruited. The tracer always indicated a SLN. Pathology reports indicated micrometastases from MTC in SLN in three patients. At a mean follow-up of 30.5 months, all patients were biochemically cured. The technique we describe to detect and remove neck SLN from MTC seemed to be very accurate. It always showed the SLNs (usually two) in the lateral compartments. Micrometastases were detected in three of four patients, allowing their correct staging. CONCLUSIONS: The method described here for the detection of SLNs in early MTC seems effective and reliable and can be used for a more precise N staging of the patients. It could play a role, alone or combined with other techniques, in driving the extent of prophylactic neck dissection or other potential applications.

Role of cyclooxygenase isoforms in the altered excitatory motor pathways of human colon with diverticular disease.

BACKGROUND AND PURPOSE: The COX isoforms (COX-1, COX-2) regulate human gut motility, although their role under pathological conditions remains unclear. This study examines the effects of COX inhibitors on excitatory motility in colonic tissue from patients with diverticular disease (DD). EXPERIMENTAL APPROACH: Longitudinal muscle preparations, from patients with DD or uncomplicated cancer (controls), were set up in organ baths and connected to isotonic transducers. Indomethacin (COX-1/COX-2 inhibitor), SC-560 (COX-1 inhibitor) or DFU (COX-2 inhibitor) were assayed on electrically evoked, neurogenic, cholinergic and tachykininergic contractions, or carbachol- and substance P (SP)-induced myogenic contractions. Distribution and expression of COX isoforms in the neuromuscular compartment were assessed by RT-PCR, Western blot and immunohistochemical analysis. KEY RESULTS: In control preparations, neurogenic cholinergic contractions were enhanced by COX inhibitors, whereas tachykininergic responses were blunted. Carbachol-evoked contractions were increased by indomethacin or SC-560, but not DFU, whereas all inhibitors reduced SP-induced motor responses. In preparations from DD patients, COX inhibitors did not affect electrically evoked cholinergic contractions. Both indomethacin and DFU, but not SC-560, decreased tachykininergic responses. COX inhibitors did not modify carbachol-evoked motor responses, whereas they counteracted SP-induced contractions. COX-1 expression was decreased in myenteric neurons, whereas COX-2 was enhanced in glial cells and smooth muscle. CONCLUSIONS AND IMPLICATIONS: In control colon, COX-1 and COX-2 down-regulate cholinergic motility, whereas both isoforms enhance tachykininergic motor activity. In the presence of DD, there is a loss of modulation by both COX isoforms on the cholinergic system, whereas COX-2 displays an enhanced facilitatory control on tachykininergic contractile activity.

Total parathyroidectomy without autotransplantation for the treatment of secondary hyperparathyroidism associated with chronic kidney disease: clinical and laboratory long-term follow-up.

Forty-six consecutive patients who underwent total parathyroidectomy (tPTX) for hyperparathyroidism associated with end-stage kidney disease (CKD5) in a University Hospital from 1990 to 1999 were included in a long-term observational study. Outcome parameters included symptoms (bone pain, pruritus and muscle weakness evaluated by visual analog scales [VAS]) and laboratory data (intact parathyroid hormone [iPTH], total calcium, and alkaline phosphatase) assessed before, shortly postoperatively and then at a later time point: 40 patients were on maintenance hemodialysis and six on conservative medical therapy. Forty-four patients had four glands removed, while only three glands were found in the remaining two. Perioperative complications consisted of acute symptomatic hypocalcemia in 10 (22%) patients and non-specific complaints in three (7%). No laryngeal nerve palsies occurred. After a median follow-up of eight years, 43 subjects were evaluated: 37 (86%) were cured, three (7%) had persistent and three (7%) recurrent disease. Eleven patients underwent successful renal transplantation and 23 died during the period of observation. iPTH decreased from a mean of 1084+/-505 pg/ml to 120+/-381 pg/ml (p < 0.0001). No subsequent bone fractures, persistent bone pain or disability were reported; this includes patients who later received a functioning renal graft. tPTX was able to correct hyperparathyroidism in most of the patients and was associated with a low long-term relapse rate. iPTH levels remained low in 17 cases without symptoms and no clinically significant side effects. The beneficial effects of tPTX occurred in the majority of patients while renal transplantation was performed in a minority of patients. tPTX should be considered a safe and successful procedure for the treatment of severe secondary hyperparathyroidism associated with chronic kidney disease.

A1 and A2a receptors mediate inhibitory effects of adenosine on the motor activity of human colon.

Experimental evidence in animal models suggests that adenosine is involved in the regulation of digestive functions. This study examines the influence of adenosine on the contractile activity of human colon. Reverse transcription-polymerase chain reaction revealed A(1) and A(2a) receptor expression in colonic neuromuscular layers. Circular muscle preparations were connected to isotonic transducers to determine the effects of 8-cyclopentyl-1,3-dipropylxanthine (DPCPX; A(1) receptor antagonist), ZM 241385 (A(2a) receptor antagonist), CCPA (A(1) receptor agonist) and 2-[(p-2-carboxyethyl)-phenethylamino]-5'-N-ethyl-carboxamide-adenosine (CGS 21680; A(2a) receptor agonist) on motor responses evoked by electrical stimulation or carbachol. Electrically evoked contractions were enhanced by DPCPX and ZM 241385, and reduced by CCPA and CGS 21680. Similar effects were observed when colonic preparations were incubated with guanethidine (noradrenergic blocker), L-732,138, GR-159897 and SB-218795 (NK receptor antagonists). However, in the presence of guanethidine, NK receptor antagonists and N(omega)-propyl-L-arginine (NPA; neuronal nitric oxide synthase inhibitor), the effects of DPCPX and CCPA were still evident, while those of ZM 241385 and CGS 21680 no longer occurred. Carbachol-induced contractions were unaffected by A(2a) receptor ligands, but they were enhanced or reduced by DPCPX and CCPA, respectively. When colonic preparations were incubated with guanethidine, NK antagonists and atropine, electrically induced relaxations were partly reduced by ZM 241385 or NPA, but unaffected by DPCPX. Dipyridamole or application of exogenous adenosine reduced electrically and carbachol-evoked contractions, whereas adenosine deaminase enhanced such motor responses. In conclusion, adenosine exerts an inhibitory control on human colonic motility. A(1) receptors mediate direct modulating actions on smooth muscle, whereas A(2a) receptors operate through inhibitory nitrergic nerve pathways.

Cholecystokinin CCK2 receptors mediate the peptide's inhibitory actions on the contractile activity of human distal colon via the nitric oxide pathway.

BACKGROUND AND PURPOSE: Cholecystokinin is known to exert stimulant actions on intestinal motility via activation of type 1 cholecystokinin receptors (CCK(1)). However, the role played by cholecystokinin 2 (CCK(2)) receptors in the regulation of gut motility remains undetermined. This study was designed to examine the influence of CCK(2) receptors on the contractile activity of human distal colon. EXPERIMENTAL APPROACH: The effects of compounds acting on CCK(2) receptors were assessed in vitro on motor activity of longitudinal smooth muscle, under basal conditions as well as in the presence of KCl-induced contractions or transmural electrical stimulation. KEY RESULTS: Cholecystokinin octapeptide sulphate induced concentration-dependent contractions which were enhanced by GV150013 (CCK(2) receptor antagonist; +57% at 0.01 microM). These effects were unaffected by tetrodotoxin. The enhancing actions of GV150013 on contractions evoked by cholecystokinin octapeptide sulphate were unaffected by N(omega)-propyl-L-arginine (NPA, neuronal nitric oxide synthase inhibitor), while they were prevented by N(omega)-nitro-L-arginine methylester (L-NAME, non-selective nitric oxide synthase inhibitor). In the presence of KCl-induced contractions, cholecystokinin octapeptide sulphate elicited concentration-dependent relaxations (-36%), which were unaffected by NPA, but were counteracted by GV150013 or L-NAME. The application of electrical stimuli evoked phasic contractions which were enhanced by GV150013 (+41 % at 0.01 microM). CONCLUSIONS AND IMPLICATIONS: CCK(2) receptors mediate inhibitory actions of cholecystokinin on motor activity of human distal colon. It is suggested that CCK(2) receptors exert their modulating actions through a nitric oxide pathway, independent of the activity of the neuronal nitric oxide synthase isoform.

"What you see is not what you get". A plea to remove a 'normal' appendix during diagnostic laparoscopy.

BACKGROUND: Diagnostic laparoscopy (DL) is a well established alternative option to coeliotomy for suspected appendicitis. When a 'normal' appendix is found, appendectomy is often believe unnecessary. Little is known however about how normal a normal appearing appendix is. In this study we postulated that a normal appendix seen at DL, may show pathological indications at microscopy, and thus, to leave the appendix untouched may be unsafe. METHODS: A retrospective review of data from 48 patients which, in a five year period (1995-1999), had virtually normal appendices removed as completion of DL for lower abdominal pain. RESULTS: No procedure-related drawback and no subsequent complications were recorded. Symptoms subsided in all the patients. Mean hospital stay was 2.1 days. When receiving specimens, incidence of pathologic changes of the appendix were observed in 58 percent of the cases (n = 28). The negative predictive value of DL was 41 percent. CONCLUSIONS: Due to the consistently false negative rate of DL, and the low morbidity rate for laparoscopic appendectomy, we support incidental appendectomy in patients with lower abdominal pain.

Effect of blood transfusions on disease-free interval after rectal cancer surgery.

BACKGROUND/AIMS: To assess retrospectively the impact of perioperative blood transfusions on disease-free interval after curative surgery of rectal cancer. METHODOLOGY: One hundred and seven (107) subjects (65 men and 42 women, median age: 67) underwent anterior resection of the rectum for rectal cancer between 1990 and 1996. Thirty-six (37%) were transfused perioperatively. Outcome variables measured were: age, sex, distance of the tumor from the anal verge, type of stapled anastomosis, protective colostomy, cancer-free margin in the specimen, grading and staging, leak of the suture line, transfusion, number of blood units given, and adjuvant therapy. RESULTS: Transfusion, nodes involvement and adjuvant therapy had a significant impact on disease-free interval at the univariate analysis. The estimated probability of cancer-free survival at 5 years was 81% for the not transfused, and 63% for the transfused patients (P < 0.05). At multivariate analysis, nodes involvement resulted significantly and independently related to time to recurrence (P < 0.05) but also perioperative blood transfusion showed an important role as independent risk factor for rectal cancer relapse (P = 0.05). CONCLUSIONS: This study suggests that blood transfusion is likely to have a detrimental effect on disease-free interval after resective surgery of rectal cancer.

Laparoendoscopic treatment of gastric ectopic pancreas.

A case of ectopic pancreas located on the anterior gastric wall treated with a combined gastroscopic and laparoscopic approach, which permitted isolation and complete resection of the lesion, is reported. The patient was discharged without complication.

Laparoscopic treatment of appendico-cecal intussusception.

Laparoscopy is a therapeutic possibility in pediatric surgery. A case of appendiceal intussusception treated laparoscopically in a 27-month-old girl is presented. The postoperative course was normal.

Laparo-endoscopic "rendezvous": a new technique in the choledocholithiasis treatment.

BACKGROUND/AIMS: Endoscopic sphincterotomy for common bile duct stone clearance during laparoscopic cholecystectomy may fail due to difficulties in cannulating the papilla major. In this study we propose a new technique that facilitates the cannulation of the papilla and the common bile duct stone clearance during a standard laparoscopic cholecystectomy. Its clearance percentage, complication rate and post-operative stay have been evaluated and compared with standardized procedures such as open surgery and endoscopic sphincterotomy before laparoscopic cholecystectomy. METHODOLOGY: In a group of 16 patients presenting with cholelithiasis and common bile duct stones or papillitis, the sphincterotome was driven across the papilla into the choledochus by a Dormia basket passed in the duodenum through the cystic duct during laparoscopic cholecystectomy. Measures of outcome were clearance rate, mortality, morbidity and hospital stay. Furthermore, data obtained from this sample of patients were compared with those from another two groups of 16 patients in which choledocholithiasis was managed either by endoscopic sphincterotomy performed before laparoscopic cholecystectomy or by open cholecystectomy and trans-duodenal sphincterotomy. RESULTS: The rate of cannulation of the papilla and of the common bile duct stone clearance was 100% when the combined endo-laparoscopic approach was used in 15 patients with endoscopic sphincterotomy (93,7%) and in 15 patients with open sphincterotomy (93,7%), cholecystectomy was successful in every case. The groups were statistically similar with regard to complications; none of the patients required blood transfusion. The mean post operative stay was 95.2 hours (range 48-240) for the first group, 350.1 hours (range 192-1680) for the second and 69.7 hours (range 24-132) for the third. CONCLUSION: The laparo-endoscopic rendezvous, though still in evolution, is an efficacious method which can be used during the laparoscopic strategy of common bile duct clearance.

Trocar site tumor recurrences. May pneumoperitoneum be responsible?

BACKGROUND: Port site metastasis following laparoscopy for cancer is reported with increasing frequency and represents one of the most important limitations of the technique. METHODS: A scintigraphic model was utilized to evaluate a possible role of pneumoperitoneum in tumor cell dissemination. Labeled red blood cells (RBC) were injected at the level of the gallbladder bed during laparoscopic cholecystectomy (LC) performed for symptomatic cholecystolithiasis. LC was performed in two groups with standard CO2 pneumoperitoneum: in one group an endobag for retrieval of the specimen was utilized. In one group a gasless LC with endobag was performed. RESULTS: Radioactivity in the area of the trocar introduction was observed in almost all the patients who underwent standard (CO2) LC but represented a rare event in patients treated with the gasless method. The utilization of a protective bag for the extraction of the surgical specimen did not modify significantly the results. Moreover all patients treated with pneumoperitoneum demonstrated a wide intraperitoneal diffusion of the tracer not observed in gasless patients. CONCLUSIONS: The results of this study confirm that pneumoperitoneum may play an important role in the evolution of port site metastasis after laparoscopy for gastrointestinal cancer.

Adrenal masses in non-small cell lung carcinoma patients: is there any role for laparoscopic procedures?

Surgical treatment of adrenal metastases from non-small cell lung carcinoma (NSCLC) is a current and controversial issue. We analyze our experience with the laparoscopic treatment of NSCLC solitary adrenal metastases. In the last 4 years, six patients underwent laparoscopic adrenalectomy for suspected solitary NSCLC metastasis. A metastasis was removed in four patients and a cortical adenoma in two. Laparoscopy with intraoperative ultrasonography was demonstrated to be an excellent procedure for the diagnostic and therapeutic management of the patient affected by a solitary adrenal metastasis from NSCLC. Longer follow-up and a larger series are necessary to enable definitive conclusions to be drawn about the impact on survival of laparoscopic adrenalectomy for NSCLC metastasis.

[Laparoscopic adrenalectomy. A retrospective comparison with traditional methods]. / Surrenectomia laparoscopica. Un confronto retrospettivo con le metodiche tradizionali.

BACKGROUND: After 3 years from the introduction of laparoscopic adrenalectomy in an endocrine surgery unit the results are retrospectively compared with those achieved by traditional techniques with the aim of comparing the respective advantages. METHODS: During this period 68 laparoscopic adrenalectomies have been performed. The main pre-, intra- e postoperative parameters of the adrenalectomies for benign neoplasm have been examined. Mean follow-up was 51 months (65.3 for open adrenalectomy and 18.8 for laparoscopic). RESULTS: Statistical studies were homogeneous between the two groups. The laparoscopic adrenalectomy--with the same effectiveness--thanks to less peritoneum and parietal stress, is followed by fewer postoperative complications, faster resumption of biological functions, earlier return to work and better cosmetic results. CONCLUSIONS: On the basis of our personal experience laparoscopic adrenalectomy is to be considered the treatment of choice in the majority of adrenal benign neoplasms.

[Intestinal reconstruction after a Hartmann intervention: a high-risk procedure?]. / Ricostruzione intestinale dopo intervento di Hartmann: una procedura ad alto rischio?

BACKGROUND/AIM: Restoration of the bowel continuity after Hartmann's procedure has been reported to carry a high rate of both general and anastomosis-related complications. Aim of the study was to test the hypothesis of the Hartmann's procedure reversal as high-risk surgery. STUDY DESIGN, SETTING: Retrospective analysis of a cases series, University hospital, Italy. MATERIAL: Forty patients (male n = 25; female n = 15) with a mean age of 64.8 yrs. (range 35 to 82 yrs.) who underwent manual (n = 4; 10%) or stapled (n = 36; 90%) colorectal anastomosis. The mean interval between the Hartmann's procedure and the colostomy closure was 259 days. MAIN OUTCOME MEASURES: Mortality, morbidity, anastomotic complications. RESULTS: No death was recorded. The overall complication rate was 37.5 per cent (n = 15 patients), being wound infection the most common (n = 9). Complications of the colorectal anastomosis were observed in n = 5 patients (12.5%). In details, four patients (10%) developed stenosis of the anastomosis and one (2.5%) bled from the suture line. No instance of leak was observed. Surgery was required to correct a recurrent stenosis of the colorectal anastomosis. CONCLUSION: Restoration of the bowel continuity after Hartmann's procedure is safe and has an acceptable rate of general and anastomosis-related morbidity. Most of the anastomotic complications will resolve without further surgery.

Traditional versus laparoscopic surgery in the treatment of pheochromocytoma: a preliminary study.

Laparoscopic removal of adrenal masses has been successfully accomplished by many authors, but some doubts still remain about the surgical treatment of pheochromocytomas by the laparoscopic approach. The outcome of 6 patients who had laparoscopic removal of pheochromocytoma, 1 of which bilateral, was compared with that of 20 patients with pheochromocytoma who underwent open surgery. The following parameters were evaluated: frequency of hypertensive crises, time required for surgery, total volume of infused fluids, severity of postoperative pain, hospital stay, wound suppuration, or occurrence of incisional hernia, persistence or recurrence of hypertension. Laparoscopic patients had shorter hospitalizations, less postoperative fever, less fluid infusion, and absence of scar complications. There was no evident difference in the frequency of intraoperative hypertensive crises between patients who were treated by laparoscopic versus those treated by open procedure. The laparoscopic approach seems to be as safe as the open approach. However, it causes less postoperative distress, better cosmetic results, and permits a faster recovery.

[Prognostic risk factors in patients operated on for perforated peptic ulcer. A retrospective analysis of critical factors of mortality and morbidity in a series of 40 patients who underwent simple closure surgery]. / Fattori di rischio prognostico in pazienti operati per ulcera peptica perforata. Analisi retrospettiva dei fattori critici per la mortalità e morbilità su una serie di 40 pazienti sottoposti ad intervento di sutura semplice.

STUDY OBJECTIVE: To identify factors affecting mortality and morbidity in patients operated on for perforated peptic ulcer. DESIGN: Retrospective analysis. SETTING: University Hospital, Italy. PATIENTS: Forty patients consecutively operated on for perforated peptic ulcer by simple suture procedure performed either by laparotomy (n = 26) or laparoscopic (n = 14) approach. MEASUREMENTS AND MAIN RESULTS: Mortality was 20% (n = 8) and morbidity in survivors was 25% (n = 8). Compared to survivors, non-survivors were older (mean age 79.3 yrs. vs 60.0 yrs., p < 0.01), had worse APACHE II and SAPS scores (mean 20.1 vs 8.5, p < 0.001; and 13.1 vs. 5.5, p < 0.0001 respectively), were treated later (mean interval from outbreak of symptoms to surgery 30.8 hrs. vs. 11.1 hrs., p < 0.01), and the size of their perforation was larger (mean 15.1 mm. vs. 8.6 mm, p < 0.05). The laparoscopic approach was the only factor that significantly was associated with morbidity in survivors (p < 0.01). The presence of at least two risk factors, enhanced the probability of death. CONCLUSION: Old age, great APACHE II and SAPS scores, delay in treatment and large size of the perforation were associated significantly to mortality in perforated peptic ulcer patients. Efforts should be made perioperatively for patients having these risk factors.

Association between perioperative blood transfusion and dehiscence of anastomosis after rectal resection for cancer.

Perioperative blood transfusion (PBT) has proved to increase the risk of sepsis after surgery. The hypothesis that PBT also might increase the occurrence of leak of rectal anastomoses has been tested. The data of 94 patients undergone low anterior resection for rectal cancer were reviewed. Thirty-nine of them (41%) received one or more packed red cells (PRC) units perioperatively. The total dehiscence rate was 14% (13 cases), and it was significantly lower in not-transfused (4%) compared to transfused patients (28%) (p < 0.005). The risk of dehiscence was increased by six-fold if up to two, and by fifteen-fold if more than two PRC units were given. These findings suggest that leakage of rectal anastomoses should be considered among the detrimental effects of PBT. The risk of dehiscence increases with the number of units transfused. A judicious administration of blood might contribute to reduce this complication.

Laparoscopic compared with open appendicectomy for acute appendicitis: a prospective study.

OBJECTIVE: To assess the benefits of laparoscopic appendicectomy over open appendicectomy and to evaluate the impact of the severity of appendicitis and of peritonitis on the advantages of the laparoscopic approach. DESIGN: Prospective unrandomised study. SETTING: University hospital, Italy. SUBJECTS: 137 consecutive patients with acute appendicitis, 60 of whom were treated by open and 77 by laparoscopic appendicectomy. Patients were subdivided according to the severity of appendicitis and the presence of peritonitis. MAIN OUTCOME MEASURES: Duration of operation, consumption of analgesics, duration of hospital stay, overall complications, wound infection. RESULTS: Hospital stay (median 2.5 days, range 1-18 compared with 4, range 2-22 p < 0.0001). and wound infection (3/77 (4%) compared with 13/60 (22%), p 0.02) were significantly lower after laparoscopic operation. The incidence of wound infection was significantly lower when subgroups were analysed separately. CONCLUSIONS: Hospital stay and wound infection rates were significantly lower after laparoscopic appendicectomy. With the exception of the wound infection rate, the variables studied may differ depending on the severity of the appendicitis and the presence of peritonitis. Result of comparative studies should be carefully interpreted when the two groups are not stratified for these features.

Single and double stapled anastomoses in rectal cancer surgery; a retrospective study on the safety of the technique and its indication.

Low anterior resection is commonly believed the main indication to double stapled (DS) technique, because placing the purse-string suture on the distal rectum is difficult or impossible. This study was designed to figure out the safety of the DS technique and to better define its role in rectal cancer surgery. The data of 34 patients that had a DS anastomosis were retrospectively compared to those of 43 that had a single-stapled (SS) anastomosis after anterior resection. Three deaths after SS (7%) and one after DS procedures (3%) were recorded (p = 0.62). Rates of clinical leaks were 12% (four cases) in the DS group and 14% (six cases) in the SS group (p = 0.41). The mean distance of the rectal tumour from the anal verge was significantly lower for DS (mean = 7.7 cm) respect to SS (mean = 12.7 cm) anastomoses (p < 0.0001) and the blood consumption at surgery was significantly greater in patients that had DS (mean = 375 ml) compared to SS-anastomoses (mean = 180 ml) (p = 0.028). Thus, the DS technique was mostly used in patients at high risk for leakage. The study shows that DS technique is a safe and reliable method to perform colorectal anastomosis after anterior resection for cancer. For cancers located in the upper rectum the routine adoption of the DS increases the cost of surgery and does not offer advantages over the SS technique with the exception of making feasible end-to-end mechanical anastomoses involving bowel segments having different diameters.