Naples Prognostic Score, Based on Nutritional and Inflammatory Status, is an Independent Predictor of Long-term Outcome in Patients Undergoing Surgery for Colorectal Cancer.

BACKGROUND: The existing scores reflecting the patient's nutritional and inflammatory status do not include all biomarkers and have been poorly studied in colorectal cancers. OBJECTIVE: The purpose of this study was to assess a new prognostic tool, the Naples prognostic score, comparing it with the prognostic nutritional index, controlling nutritional status score, and systemic inflammation score. DESIGN: This was an analysis of patients undergoing surgery for colorectal cancer. SETTINGS: The study was conducted at a university hospital. PATIENTS: A total of 562 patients who underwent surgery for colorectal cancer in July 2004 through June 2014 and 468 patients undergoing potentially curative surgery were included. MaxStat analysis dichotomized neutrophil:lymphocyte ratio, lymphocyte:monocyte ratio, prognostic nutritional index, and the controlling nutritional status score. The Naples prognostic scores were divided into 3 groups (group 0, 1, and 2). The receiver operating characteristic curve for censored survival data compared the prognostic performance of the scoring systems. MAIN OUTCOME MEASURES: Overall survival and complication rates in all patients, as well as recurrence and disease-free survival rates in radically resected patients, were measured. RESULTS: The Naples prognostic score correlated positively with the other scoring systems (p < 0.001) and worsened with advanced tumor stages (p < 0.001). Patients with the worst Naples prognostic score experienced more postoperative complications (all patients, p = 0.010; radically resected patients, p = 0.026). Compared with group 0, patients in groups 1 and 2 had worse overall (group 1, HR = 2.90; group 2, HR = 8.01; p < 0.001) and disease-free survival rates (group 1, HR = 2.57; group 2, HR = 6.95; p < 0.001). Only the Naples prognostic score was an independent significant predictor of overall (HR = 2.0; p = 0.03) and disease-free survival rates (HR = 2.6; p = 0.01). The receiver operating characteristic curve analysis showed that the Naples prognostic score had the best prognostic performance and discriminatory power for overall (p = 0.02) and disease-free survival (p = 0.04). LIMITATIONS: This is a single-center study, and its validity needs additional external validation. CONCLUSIONS: The Naples prognostic score is a simple tool strongly associated with long-term outcome in patients undergoing surgery for colorectal cancer. See Video Abstract at http://links.lww.com/DCR/A469.

Management of obstructed defecation.

The management of obstructed defecation syndrome (ODS) is mainly conservative and mainly consists of fiber diet, bulking laxatives, rectal irrigation or hydrocolontherapy, biofeedback, transanal electrostimulation, yoga and psychotherapy. According to our experience, nearly 20% of the patients need surgical treatment. If we consider ODS an "iceberg syndrome", with "emerging rocks", rectocele and rectal internal mucosal prolapse, that may benefit from surgery, at least two out of ten patients also has "underwater rocks" or occult disorders, such as anismus, rectal hyposensation and anxiety/depression, which mostly require conservative treatment. Rectal prolapse excision or obliterative suture, rectocele and/or enterocele repair, retrograde Malone's enema and partial myotomy of the puborectalis muscle are effective in selected cases. Laparoscopic ventral sacral colporectopexy may be an effective surgical option. Stapled transanal rectal resection may lead to severe complications. The Transtar procedure seems to be safer, when dealing with recto-rectal intussusception. A multidisciplinary approach to ODS provides the best results.

Ileocecal-colonic intussusception caused by cecal adenocarcinoma A case report.

INTRODUCTION: Intussusception in adults is an infrequent cause of intestinal occlusion that is usually due to neoplasm lesions. The unspecific nature of the clinical presentation often delays diagnosis. It is most commonly emergency explorative laparotomy which clarifies the etiology of the occlusion. The authors report a case of intestinal occlusion caused by ileocecal-colonic invagination with a small cecal adenocarcinoma as lead point, in a 74-year-old woman. CASE REPORT: A 74-year-old woman came to the Emergency Department, complaining of crampy pain in the mid- and lower abdomen. An abdominal ultrasound revealed a "pseudokidney sign" apparently involving the cecum. Because there were no clear signs of occlusion, the patient was dicharged on the same day. Three days later, upon admission, the patient complained of episodes of abdominal pain with intervals of moderate well-being, associated with nausea, vomiting and an inability to pass stool (but not gas) for 36 hours. On clinical examination her abdomen was distended and tender on palpation in all quadrants, especially in the right iliac fossa where a large mass could be felt. Standard abdominal x-Ray documented gaseous distension of some loops of the jejunum-ileum with some air-fluid level. The patient underwent an abdominal CT scan which showed advanced intussusception that appeared to be ileocolic and multiple enlarged lymphnodes were found in the invaginated mesentery at the base of which there appears to be a thickening of the intestinal wall that is probably neoplastic in nature. The patient underwent explorative laparotomy. Ileocecal-colonic intussusception caused by a cecal growth 5 cm in diameter was found on examination of the surgical specimen. Histology showed that the cause of the large swelling of the ascending colon was a vegetating ulcerated adenocarcinoma (medium grade differentiation: G2), measuring 6.5x 4.0 cm, arising from a tubulovillous adenoma infiltrating the submucosa. CONCLUSIONS: Most cases of intussusception are caused by structural lesions, a large percentage of which are malignant, especially in the colon. In our patient the lead point was a small cecal polyp which, together with the last loop of the ileum and the ileocecal valve, was pulled into the ascending colon. Although most cases of intussusception in adults are diagnosed at the operating table, noninvasive diagnostic tools like ultrasonography and CT scanning are very useful. Treatment in adults is usually surgical and involves en bloc resection of the lesion. Manual reduction of the intussusception is not advisable because of the risk of dissemination if the lead point is malignant. KEY WORDS: Cecal adenocarcinoma, Itestinal resection, Intussusception in adults.

Combined Burch urethropexy and anterior rectopexy in pelvic organ prolapse: skip the mesh.

PURPOSE: Pelvic organ prolapse (POP) is a common accompaniment of advancing age. Current repair techniques incorporate transvaginal and transabdominal approaches with or without prosthetic mesh insertion. In this paper, we present the short- and medium-term results of a unit policy directed at patients with POP of combined abdominal rectopexy and Burch retropubic urethropexy without the use of prosthetic mesh assessing its safety profile in selected cases. METHODS: Between January 2009 and January 2011, 16 women with tri-compartmental prolapse who had all undergone prior hysterectomy underwent combined surgical pelvic floor repair. Preoperative symptom assessment by validated questionnaires and clinical examination were pre- and postoperatively recorded. Cures were defined as either optimal or satisfactory outcomes based on combined clinical, radiological examinations and reported patient satisfaction. RESULTS: The mean age of the 16 patients was 57.2 years, and their mean BMI was 28.6 (±5 SD). Pelvic examination revealed a POP-Q stage III prolapse in 12 patients and stage IV in 4 patients. The mean operating time was 57.5 min (range 40-85), with a mean length of hospital stay of 4.5 days. Cystocele and enterocele resolution was noted in every case on dynamic magnetic resonance imaging (MRI). CONCLUSIONS: Our results in a small patient cohort employing a simple 'all-in-one' repair approach combining a retropubic colposuspension with an anterior rectopexy appear to be satisfactory. Further larger randomized studies are required, incorporating a laparoscopic arm in order to determine the longer-term effectiveness of this approach.

Ambulatory laser-assisted surgery: a multicenter application and experience.

BACKGROUND: The widespread use of surgical lasers has found place in dermatologic and aesthetic surgery largely because they are well tolerated with a reduced incidence of postoperative haemorrhage and oedema, few associated adverse events and a high rate of patient satisfaction. PATIENTS AND METHODS: A retrospective analysis of 1232 consecutive patients was performed on patients undergoing a range of laser treatments between January 2005 and January 2010. A mixed variety of indications for laser use included dermatologic surgeries for the removal of fibromas, angiomas and naevi, aesthetic surgeries for acne, superficial vascular conditions, facial rejuvenations and remodelling and tattoo removals as well as many miscellaneous conditions. A range of lasers were employed including CO2, Erbium: Yttrium Aluminum Garnet (Er:YAG), diodes, Alexandrite, Ruby and Neodymium:Yttrium Aluminum Garnet (Nd:YAG) lasers with variable use for different indications in combination with a selective protocol of topical anaesthesia and local cooling systems. RESULTS: Patient satisfaction was high overall (92.4%) with most reported failures amongst those treated for general surgical conditions where there were the highest recorded complication rates. The main failures occurred in those with small cutaneous telangiectases (36.2% incomplete treatment response and 31.9% dissatisfaction rate). In those patients where lasers were used for aesthetic reasons,(most notably in those undergoing tattoo or scar removal and in those with hypertrichosis and dermatofolliculitis), incomplete results occurred in 7.2% with an 11.8% dissatisfaction rate and rare complications (0.9%). In this group, the highest reported incomplete results occurred in patients undergoing tattoo removal (13.9%), followed by scar removal (12.5%) and then by those undergoing treatment for hypertrichosis and dermatofolliculitis (8.8%). CONCLUSIONS: Laser use in general surgery is associated with a high success rate for a wide variety of conditions with high patient satisfaction and a low incidence of adverse events in experienced hands. The advantages and disadvantages as well as the specific recommendations for different laser types are presented with clinical advances resulting from the development of non-ablative laser systems designed for dermal remodeling.

Surgical management of hemorrhoids. State of the art.

Most patients with hemorrhoidal disease may be treated conservatively Along the years several surgical options have been proposed. including closed open and semiclosed hemorrhoidectomy (HC), radiofrequency HC (LigaSure), piles' suture or Farag operation, manual and stapled haemorrhoidopexy (PPH) with or without excision of anal tags, doppler hemorrhoidal artery ligation with or without recto-anal mucopexy ano-mucosal flap circumferential HC or Whitehead-Rand procedure. Randomized prospective trials and metanalyses have been carried out with the aim of finding the gold standard operation. When carried out for advanced disease, HC appears to be more effective than PPH, which achieves good results in third degree, but carries high reintervention rate in fourth degree piles. Almost all trials comparing open and closed HC show similar outcomes. None of the costly innovations appears to be superior when compared with conventional procedures in terms of cure of the disease in the long term. PPH carries less postoperative pain and a shorter convalescence than HC On the other hand, while carrying a higher rate of complications, it may be responsible of the so-called "PPH syndrome", consisting of proctalgia, tenesmus and urgency Occasional recto-vaginal fistulas have been described after PPH, if not even of rectal perforation and other life-threatening complications. Postoperative pain is very rare after Doppler hemorrhoidal arteries ligation and may be reduced following HC using nitrate ointments and botulin toxin injection, aimed at releasing anal spasm after surgery, more safely than by an internal sphincterotomy LigaSure HC decreases the risk of severe postoperative bleeding, which may be effectively treated by rectal balloon tamponade. Permanent and gross anal incontinence are unlikely to follow both HC and PPH Most cases of anal stricture following HC may be treated by anal dilation. Societies' guidelines recommend a tailored surgery, i.e., the use of different procedures according to the grade of haemorrhoids, which suggests that patients should be operated by a specialist colorectal surgeon, able to perform different surgeries and to deal with complications and failures.