The value of omentoplasty in protecting colorectal anastomosis from leakage. A prospective randomized study in 126 patients.

BACKGROUND/AIMS: Anastomotic leakage is a major cause of mortality in colorectal surgery. Several methods have been evaluated in order to prevent anastomotic leakage. To decrease the rate and severity of anastomotic leakage, omentoplasty (OP) has been proposed by several authors on the basis of experimental and clinical studies. A prospective, randomized trial was designed to study the influence of omentoplasty on anastomotic leakage after colorectal resection. METHODOLOGY: One hundred and twenty-six patients undergoing elective or emergency surgery for malignancy, benign tumor, diverticular disease and other were randomly assigned to omentoplasty (OP group) or not (NO group). The primary end point was the rate of clinical and radiological anastomotic leakage. Both groups were comparable in terms of demographic data, preoperative characteristics and intraoperative findings. RESULTS: Eighteen patients (14.3%) had anastomotic leakage, 4 (6.4%) in the OP group and 14 (21.9%) in the NO group. Significant differences (P<0.05) between the two groups were also found in terms of repeat operation (3.2% vs. 14.1%) and deaths (3.2 vs. 7.8%). Other factors associated with anastomotic leakage were the distal site of anastomosis (<5 cm from anal verge) and the emergency. CONCLUSIONS: Omental wrap, with its mechanical and biological properties, seems to be effective in lowering the rate and the severity of anastomotic leakage after colorectal surgery.

[Omentoplasty is effective in lowering the complications of ano-rectal resections]. / L'omentoplastica riduce le complicanze della chirurgia resettiva del retto e del canale anale.

AIM: The aim of this prospective, randomized study was to investigate the influence of omentoplasty on complications following colorectal resection, Hartmann's intervention and abdominoperineal amputation. METHODS: One hundred and seventy-one patients undergoing elective or emergency surgery for malignancy, benign tumor, diverticular disease and others were randomly assigned to omentoplasty (OP group) or not (NO group). The primary goal was to evaluate the rate of clinical and radiological anastomotic leakage. The secondary goal was to assess the morbidity (mainly septic complications) following Hartmann's and Miles' procedures. RESULTS: In colorectal anastomosis, 18 patients (14.3%) had anastomotic leakage, 4 (6.4%) in the OP group and 14 (21.9%) in the NO group. Differences between the 2 groups were also found in terms of repeat operations (3.2% vs 14.1%) and deaths (3.2% vs 7.8%). Other factors associated with anastomotic leakage were the distal site of anastomosis (<5 cm from anal verge) and the emergency. In Hartmann's and Miles' procedures, septic complications were reduced in the OP group. CONCLUSION: Omental wrap, with its mechanical and biological properties, seems to be effective in lowering the rate and the severity of complications after colorectal and anal surgery.

The role of laparoscopic adhesiolysis in chronic abdominal pain.

BACKGROUND: Intraperitoneal adhesions seem to be a possible cause of chronic abdominal pain, but reports of their etiological role are controversial. Laparoscopic adhesiolysis has been proposed as treatment of choice, even tough reports of success are contradictory. The aim of our prospective study, was to determine whether laparoscopic adhesiolysis ameliorates chronic abdominal pain in patients with pathological abdominal adhesions. METHODS: Forty-five patients with chronic abdominal pain, lasting for more than 6 months, without abnormal findings other than pathological intraperitoneal adhesions found at laparoscopy, underwent laparoscopic adhesiolysis. RESULTS: Forty-one patients (91.1%) were available for follow-up after an average time interval of 18 months (range: 12-41 months): 24 patients (58.5%) were free from abdominal pain; 10 (24.4%) reported significant amelioration of pain, while 7 (17.1%) patients had no amelioration. CONCLUSIONS: Laparoscopy is an efficient means of assessing patients with chronic abdominal pain, and laparoscopic adhesiolysis cures or ameliorates. Chronic abdominal pain in more than 80% of patients.

[Polyps (single or multiple) and juvenile polyposis]. / Polipi (singoli o multipli) e poliposi giovanile.

The authors underline the important aspects of juvenile familial polyposis (JFP), a disease transmitted as an autosomal dominant trait. A case of JFP characterized by the presence of hundreds of polyps in the colo-rectal intestinal tract, is analyzed. The single juvenile polyp, multiple polyps (=/>5 polyps) and the sporadic form are examined. These are mucous hamartomas which can undergo neoplastic transformation (in carcinoma in 68% of untreated cases), a behaviour similar to that of adenomatous polyps. They differ from the later due to the following features: epidemiology (earlier appearance age), anatomopathology (stroma), clinical observation (self-recovery in some cases) and genetics (10q23.3-18q21, genetic mutations in a locus different those of adenomatous polyps). It is also necessary to determine its extension by means of colonoscopy, ileoscopy, gastroscopy and small bowel barium enema. Patients' screening through construction of the genealogical family tree is fundamental. Isolation of possible degenerative aspects of the polyps through biopsy is also fundamental. Single or multiple polyps are treated endoscopically, the juvenile polyposis is treated surgically (colectomy, total colectomy). A rigorous follow-up of the patients and their family members is recommended.

[Endoscopic diagnosis and treatment of juvenile solitary polyps, in the light of the unusual but proven neoplastic potential]. / Considerazioni di diagnosi e terapia endoscopica dei polipi giovanili solitari, alla luce della rara ma dimostrata potenzialità neoplastica.

For many years a neoplastic potentiality of the juvenile polyps has been denied. The authors performed a critical review of the international literature about the neoplastic transformation of the juvenile polyps. Each examined case had to respect three conditions: 1) exhaustive hystological findings certifying a clear neoplastic degeneration of a juvenile polyp; 2) clear evidence of single juvenile polyposis (< 5), presence in the colon and rectum only and absence of familiarity; 3) reliable diagnostic practice (endoscopic and/or hystological evidence). During the review we collected 271 cases of juvenile polyposis observed in 12 countries, 97 of which (35.79%) showed neoplastic transformation, adenomatous type in 50 (18.45%) and carcinomatous type in 47 (17.34%), and 13 cases of neoplastic degeneration of single juvenile polyps. The review shows clearly and strongly that the risk of cancer in the juvenile polyposis can reach the risk of the adenomatous polyposis. The neoplastic degeneration exists in the single juvenile polyps even if in a lower degree.

Evaluation of immune response in patients after open or laparoscopic cholecystectomy.

BACKGROUND/AIMS: Laparoscopic cholecystectomy is a so called mini-invasive surgical procedure, and on this basis, we investigated whether and how the immune response is modified in patients after laparoscopic cholecystectomy compared to patients who underwent open cholecystectomy. METHODOLOGY: In a prospective, nonrandomized trial, 35 patients underwent laparoscopic cholecystectomy and 31 open cholecystectomy. Immune activity (neutrophils, total lymphocytes, lymphocyte subpopulations, human leukocyte antigen (HLA-DR), interleukin 6, skin Multitest) was evaluated before surgery and respectively, 1, 3, and 6 days postoperatively. RESULTS: One day after surgery, an increase in interleukin 6 (P < 0.01) was noted in patients who had undergone open cholecystectomy, while this parameter was almost unchanged in patients with laparoscopic cholecystectomy. Moreover, skin tests showed a hypo or anergic response in the majority (81.8%) of open cholecystectomy patients compared to laparoscopic cholecystectomy patients (10.5%), (P < 0.01). Finally, monocyte antigen HLA-DR was also reduced in open cholecystectomy patients (P < 0.05). In this group, we noted 2 cases (6.45%) of respiratory tract infection. CONCLUSIONS: Even though laparoscopic cholecystectomy requires a longer surgery, it reduces postoperative pain, and hospitalization. It also facilitates rapid recovery, a return to normal activity, avoids postoperative immunosuppression and shows a better postoperative morbidity compared to open surgery.

[Is cell-mediated immunity affected by laparoscopic cholecystectomy?]. / L'immunità cellulo-mediata è influenzata dalla colecistectomia laparoscopica?

It is well known that surgery significantly decreases cell-mediated immunity. Laparoscopic cholecystectomy is a so-called minimally invasive surgical procedure, and on the basis of this consideration we investigated whether and how the immune system is modified in patients after laparoscopic cholecystectomy compared to those undergoing open cholecystectomy. Immune activity (neutrophils, total lymphocyte count, lymphocyte subpopulations, multiple skin tests) was evaluated in 82 patients on postoperative day 1 and on postoperative days 1, 3 and 6. Forty-two patients underwent open cholecystectomy and 40 laparoscopic cholecystectomy. On postoperative day 1 patients treated by open cholecystectomy showed a significant increase (P < 0.05) in plasma neutrophils, whereas this parameter was unchanged in patients undergoing laparoscopic cholecystectomy. Skin tests revealed a hypo- or anergic response in the majority of patients (81.8%) undergoing open surgery compared to those treated laparoscopically (10.5%). Total lymphocyte count and lymphocyte subpopulations were normal in the two groups. Four cases of respiratory tract infection (4.8%) were detected after open cholecystectomy. Laparoscopic cholecystectomy substantially reduces postoperative pain and hospitalisation, promotes an earlier recovery and return to normal activity and is not associated with postoperative immunosuppression, with a more positive postoperative morbidity profile compared to open surgery.

[Clinical assessment of juvenile polyposis with particular reference to the risk of neoplastic malignancy. Analysis of 412 patients reported in the international literature]. / Inquadramento clinico della poliposi giovanile con particolare riferimento al rischio di degenerazione neoplastica. Analisi dei 412 pazienti riportati dalla letteratura internazionale.

The authors extensively review the international literature on juvenile polyposis, with particular reference to the risk of malignancy in the various forms of the disease (colorectal vs. generalized, familial vs. sporadic). Sixty-eight out of a total of 412 patients presented adenomatous changes in the polyps. In addition, 68 cancers were found. The rate of degeneration was analysed for all variants of juvenile polyposis, but no statistically significant differences were detected. The authors conclude that juvenile polyposis should be considered as being as challenging to the surgeon as familial polyposis syndromes and outline protocols for the screening, endoscopic and surgical treatment and follow-up of these patients.

Biological effects of preoperative radiotherapy on metastatic lymph nodes from rectal cancer.

The quantitative description of the proliferative activity of cancer cells correlates with the aggressiveness of malignant tumors. The aim of this retrospective study was to determine the biological effect of adjuvant therapy on metastatic lymph nodes from rectal cancer and to compare the results between patients treated with surgery alone and patients treated with preoperative radiotherapy. Expression of the proliferating cell nuclear antigen (PCNA) was examined in metastatic lymph node samples of 12 rectal cancer patients receiving and 14 patients not receiving preoperative radiotherapy. PCNA immunostaining was performed by an avidin-biotin complex immunoperoxidase technique. The results of the mean proliferation index (PI) between the two groups were compared. A semiquantitative PCNA grading system was also estimated. In patients receiving preoperative radiotherapy, the PI was 22.8 per cent, and only one patient had high proliferative grade. On the contrary, the PI in nonirradiated patients was 67.6 per cent, and nine patients showed high proliferative grade. Although not sufficient to reach significance in terms of prognosis, the present study confirms the clinical value of radiation therapy, and it supports the suggestion to treat Dukes' C patients with preoperative radiotherapy to decrease the risk of local recurrence.

Juvenile polyposis: case report and assessment of the neoplastic risk in 271 patients reported in the literature.

A case of juvenile polyposis is reported and 271 cases are collected from the literature. The risk for neoplasia is analyzed and the endoscopic or surgical therapy is discussed. The authors conclude that juvenile polyposis should be considered as a challenge to the surgeon with regard to familial adenomatous syndromes, and strongly recommend a close follow-up of patients with juvenile polyposis.

[Biliary lithiasis in childhood. A spectrum of diseases with different clinical significance during fetal life, childhood and adolescence]. / La litiasi biliare in età pediatrica. Uno spettro di patologie con diverso significato clinico nella vita fetale nel lattante, nell'infanzia e nell'adolescenza.

On the basis of a research on fetal cholelithiasis, a review on the various form of cholelithiasis in pediatric age has been carried out. These include, in addition to fetal cholelithiasis, lithiasis in the first year of life and lithiasis in infancy and adolescence. These various expressions of the same pathology differ for incidence, predisposing factors, clinical situation, therapy and follow-up. The research conducted on fetal cholelithiasis showed an incidence of 0.39%, higher than expected. There isn't any maternal, obstetrical or fetal predisposing factor. The diagnosis is purely instrumental and is not correlated with known clinical or humoral data. The most frequent evolution is spontaneous resolution of the biliary echogenic images in absence of clinical manifestations; the complications are rare and not well documented. Cholelithiasis in the first years of life is correlated with malformative, pharmacologic or iatrogenic predisposing factors. The clinical situations include symptomless cases with spontaneous resolution and cases with serious complications. Therapy is to be chosen in each case in accordance with clinical features. Pediatric cholelithiasis beyond the first year of life, especially in the later childhood and adolescence, can be similar to cholelithiasis of adults for epidemiology, pathogenesis, symptomatology and therapy.

[Prospective research on fetal cholelithiasis: incidence, predisposing conditions, echographic diagnosis, and clinical features]. / Una ricerca prospettica sulla colelitiasi fetale: incidenza, condizioni predisponenti, diagnosi ecografica e quadro clinico.

The Authors report a prospective study on fetal cholelithiasis, analyzing its differences with the more widely known cholelithiasis of paediatric age. The study shows that the number of cases diagnosed by ultrasonography is higher than expected (0.39%, 3 cases on 764 pregnancies). The Authors could find no correlation between fetal cholelithiasis and any maternal, obstetrical and fetal factor. They have focused attention on sonographic imaging showing clinical-instrumental correlation between echogenic material, clinical features and their evolution. The study confirms that the most common evolution results in spontaneous resolution of fetal endocholecystic pathological images. Finally, wide review of the international literature is reported on the rare, but possible clinical manifestations and their complications.

[Juvenile polyposis coli associated with hereditary spherocytosis]. / Associazione morbosa tra poliposi giovanile del colon e sferocitosi ereditaria.

The first case of colorectal juvenile polyposis associated with hereditary spherocytosis is reported. Symptoms, diagnosis and therapy of juvenile polyposis are described along with the associated syndromes reported in the literature. The scientific and clinical consequences of this association are discussed.

[Fetal biliary lithiasis: ultrasonographic diagnosis and clinical interpretation. Report of 3 cases]. / La litiasi biliare fetale: diagnosi ecografica e interpretazione clinica. Descrizione di tre casi.

Fetal cholelithiasis was first diagnosed in 1983 and since then there have been only few reports about the presence of gallstones in the fetus. Maternal conditions, fetal or obstetrical predisposing risk factors have been proposed to have a causative role, but the pathogenesis of fetal gallstones remains unknown. Clinical sequelae of fetal gallstones are poorly understood as well as the role of fetal cholelithiasis in predisposing the adult to gallstones. We report on 3 patients whose cholelithiasis was diagnosed by obstetrical ultrasonography. Repeated ultrasound scans were performed in each patient until resolution of the US images. The goal of US was to correctly identify the number, size, and US features of the material within the gallbladder. The presence of distal shadowing or comet-tail artifact was assessed. Multiple, small echogenic foci without distal shadowing were recognized in the fetal gallbladder in our patients. Echogenic material was present at the US exams after birth in two patients and disappeared in the second month of life. In the third case echogenic foci disappeared during pregnancy. In all the cases, US showed no biliary tract abnormality, and neither the mothers nor the patients had clinical or laboratory findings consistent with liver or biliary diseases. The Authors discuss a diagnostic protocol to detect and follow-up gallstones in the perinatal period by ultrasonography. In our experience, fetal cholelithiasis confirmed to be a self-limiting disease without complications and did not require any form of therapy. However, a close follow-up is indicated in these patients until spontaneous resolution is demonstrated by US.

Juvenile polyposis coli and associated anomalies. Review of the literature and report of a case associated with hereditary spherocytosis.

A case of juvenile polyposis associated with hereditary spherocytosis is presented. All the anomalies associated with juvenile polyposis coli reported in the literature are reviewed. The clinical consequences of such a report are discussed along with the different forms of therapy for treating juvenile polyposis coli. To our knowledge, this is the first report in the literature of juvenile polyposis associated with hereditary spherocytosis.

[Pylorus-preserving pancreatoduodenectomy allows a better maintenance of glucose homeostasis]. / La duodenocefalopancreatectomia con conservazione del piloro assicura il mantenimento di una fisiologica omeostasi glicidica.

BACKGROUND: Pancreatic diseases and pancreatic surgery usually cause a derangement of glucose metabolism ranging from a change in glucose tolerance test to insulin-dependent diabetes. The authors assess the changes in glycemia both in basal condition and after a challenge test in a group of patients who underwent Pylorus Preserving Pancreatoduodenectomy (PPPD) according to an original technique of reconstruction with two separate bowel loops. MATERIALS AND METHODS: Ten patients who underwent PPPD either for chronic pancreatitis or ampullar carcinoma were enrolled in this study. Pre- and postoperative assessment of pancreatic endocrine function was carried out in all the patients. The evaluation included: 1) oral glucose tolerance test (OGTT), 2) intravenous glucose tolerance test (IVGTT) and 3) glucagon challenge test. RESULTS: Plasma glucose level in basal condition, after oral glucose tolerance test, intravenous glucose tolerance test and glucagone challenge test, shows that insulin secretion and/or its effectiveness is not impaired after PPPD. Two patients with preoperative insulin-dependent diabetes needed a lower dose of insulin in the postoperative period. One patient responded abnormally to OGTT both in the preoperative and postoperative periods. Seven patients maintained normal glucose homeostasis in the postoperative period. DISCUSSION: PPPD allows a normal control of glucose metabolism. Better digestive and endocrine function noted in our patients in the postoperative period is due to the integrity of the stomach and the reconstruction technique with two bowel loops used to drain biliary and pancreatic secretion separately.

Hürthle cell adenoma of the thyroid: in 32 consecutive cases.

Hürthle cell neoplasms of the thyroid gland are uncommon but potentially lethal lesions, the treatment of which is controversial because of a lack of information about their biological and clinical behaviour. Based on histological criteria Hürthle cell tumours cannot always be separated accurately into benign and malignant. Unexpected evolutions with malignant late recurrence of an adenoma previously labelled as benign have been reported. The authors reviewed the clinical and pathological features of 32 patients with Hürthle cell adenomas. The results suggest that total thyroidectomy 'de principe' is not necessary and that some electron microscopy criteria are useful to understand the nature and to predict the biological deportment of Hürthle cell adenomas.

Totally extracorporeal laparoscopy-assisted colon resection without pneumoperitoneum.

We describe a new totally extracorporeal laparoscopy-assisted technique without insufflation of the peritoneum in the treatment of benign and malignant ascending and sigmoid colon lesions. Colon resection is performed using specially designed instruments that allow the surgeon to avoid insufflation of the peritoneum and, in case of cancer, allow for conventional lymph-adenectomy. With this new technique, the restrictions associated with the laparoscopic technique are nullified, and the surgeon can directly examine intra-abdominal contents. Our preliminary results are encouraging and demonstrate the feasibility of this technique as well as its positive results in terms of curability in selected cases of colon cancer. Additional experience will delineate the real clinical value of this technique in the treatment of malignant disease.

[A case of gastric hemangiopericytoma]. / Un caso di emangiopericitoma dello stomaco.

The authors report a case of gastric hemangiopericytoma. This tumor, histogenetically derived from pericytes, has been detected in any tissue or structure. According to the review of the literature, the hemangiopericytoma of the stomach occurred very uncommonly, being published only 29 cases. Diagnosis is based on histological and immunohistochemical techniques. Surgery is the main therapy but the impredictable biological behaviour require different strategies.