Clinical outcomes after resectoscopic treatment of cesarean-induced isthmocele: a prospective case-control study.

OBJECTIVE: Isthmocele represents a reservoir on the anterior wall of the uterine isthmus or of the cervical canal at the site of a previous cesarean delivery scar. Recently, it has been clarified that it might be the cause of several gynecologic symptoms, as most common abnormal uterine bleeding. Hysteroscopy and trans-vaginal ultrasound are considered the gold standard for the diagnosis of this defect. Resectoscopic treatment can be considered effective in small size defects, but no randomized clinical trials are available. This is a prospective controlled study to assess feasibility and efficacy of surgical hysteroscopic treatment of cesarean-induced isthmocele on symptom relief. PATIENTS AND METHODS: Diagnostic hysteroscopy was performed as an office procedure in all 47 patients included in the study to confirm and identify the size of the defect. Surgical hysteroscopic treatment was performed in a selected group of patients (n = 23) having no more desire to conceive. Outcomes were measured three months later and compared in the operative hysteroscopy versus diagnostic hysteroscopy group. RESULTS: The duration of periods shortened significantly (p = 0.0003) compared with the duration of menses before operative hysteroscopy in the treated group. Moreover, symptom relief was significantly better in treated patients compared with controls (p < 0.0001). CONCLUSIONS: Resectoscopic treatment of isthmocele offers the possibility of an effective, safe and well-tolerated resolution of associated bleeding symptoms, having an excellent impact on the length of menses. To our knowledge, this is the first prospective controlled trial demonstrating better outcomes of resectoscopic treatment of isthmocele in solving symptoms compared with expectant management.

How often parametrial involvement leads to post-operative adjuvant treatment in locally advanced cervical cancer after neoadjuvant chemotherapy and type C radical hysterectomy?

OBJECTIVE: Parametrial involvement (PMI) is one of the most important factors influencing prognosis in locally advanced stage cervical cancer (LACC) patients. We aimed to evaluate PMI rate among LACC patients undergoing neoadjuvant chemotherapy (NACT), thus evaluating the utility of parametrectomy in tailor adjuvant treatments. METHODS: Retrospective evaluation of consecutive 275 patients affected by LACC (IB2-IIB), undergoing NACT followed by type C/class III radical hysterectomy. Basic descriptive statistics, univariate and multivariate analyses were applied in order to identify factors predicting PMI. Survival outcomes were assessed using Kaplan-Meier and Cox models. RESULTS: PMI was detected in 37 (13%) patients: it was associated with vaginal involvement, lymph node positivity and both in 10 (4%), 5 (2%) and 12 (4%) patients, respectively; while PMI alone was observed in only 10 (4%) patients. Among this latter group, adjuvant treatment was delivered in 3 (1%) patients on the basis of pure PMI; while the remaining patients had other characteristics driving adjuvant treatment. Considering factors predicting PMI we observed that only suboptimal pathological responses (OR: 1.11; 95% CI: 1.01, 1.22) and vaginal involvement (OR: 1.29 (95%) CI: 1.17, 1.44) were independently associated with PMI. PMI did not correlate with survival (HR: 2.0; 95% CI: 0.82, 4.89); while clinical response to NACT (HR: 3.35; 95% CI: 1.59, 7.04), vaginal involvement (HR: 2.38; 95% CI: 1.12, 5.02) and lymph nodes positivity (HR: 3.47; 95% CI: 1.62, 7.41), independently correlated with worse survival outcomes. CONCLUSIONS: Our data suggest that PMI had a limited role on the choice to administer adjuvant treatment, thus supporting the potential embrace of less radical surgery in LACC patients undergoing NACT. Further prospective studies are warranted.

Secondary Cytoreduction in Platinum-Resistant Recurrent Ovarian Cancer: A Single-Institution Experience.

BACKGROUND: The purpose of this study was to observe the role of secondary cytoreductive surgery in platinum-resistant recurrent ovarian cancer (OC) patients. METHODS: We collected data of patients affected by recurrent OC treated between 1995 and 2013. Inclusion criteria were: invasive epithelial OC histologically documented, cytoreductive surgery and platinum-based chemotherapy at first-line treatment with evidence of complete response to treatment, disease-free interval <6 months, and no concomitant neoplasia. Patients considered susceptible of cytoreductive surgery (group A) were compared with a historical series of patients with similar characteristics but not eligible for surgery (group B). RESULTS: Of 122 platinum-resistant patients, 18 met the inclusion criteria for the study and were enrolled. They were compared with a historical series of 18 patients not surgically treated with analogous clinical and pathological features. The most frequent sites of relapse included pelvic and aortic lymph nodes (39 %), peritoneum (33 %), bowel (28 %), and pelvis (22 %). A low rate of intraoperative and postoperative complications was reported. No deaths were recorded. Overall survival was significantly longer in cytoreductive group when compared with the control group (P = 0.035). Median overall survival was 44 months. Estimated 5-year overall survival rates were 57 versus 23.5 % for groups A and B, respectively. CONCLUSIONS: Surgery could represent a useful adjunct to chemotherapy in the management of platinum-resistant recurrent OC patients, carefully selected, in highly selected centers. Larger prospective trials are needed to further confirm our experience.

[Splenic artero-venous fistula and portal hypertension. A case report with review of the literature]. / Ipertensione portale secondaria a fistola artero-venosa splenica. Descrizione di un caso clinico e revisione della letteratura.

Splenic artero-venous fistula (SAVF) is a rare but potentially curable cause of pre-hepatic portal hypertension. About 100 cases have been reported in the world medical literature. The Authors report a case of 46-year-old man with a splenic artery aneurysm and a large SAVF treated by surgical resection of splenic vessels and splenectomy. The literature about SAVF is reviewed to recognize etiology, anatomical location, main symptoms at presentation, diagnostic findings and management of this rare syndrome.

[Diverticular disease of the colon: its epidemiology and etiology]. / La malattia diverticolare del colon: epidemiologia ed eziologia.

Epidemiology for diverticular disease of the colon is rather difficult to assess because of the almost regularly selection of the patients submitted to analysis and described in literature. Therefore data extracted from different experiences are useful only for orientative epidemiologic implications. In the meanwhile these studies have been very useful to understand the possible reasons of its insurgence and evolution. Actually for etiopathogenesis the more diffuse opinion is to give importance to low fibre diet and to intrinsic motor derangement of the colon.

[Surgical treatment of rectal cancer: comparison of anterior resection and abdominoperineal excision]. / Trattamento chirurgico del cancro del retto: resezione anteriore e amputazione addomino-perineale a confronto.

From 1987 to 1992, 91 rectal neoplasms were operated in the Istituto di Patologia Speciale Chirurgica of the University of Bologna: 50 anterior resections and 41 abdomino-perineal amputations. The local recurrence rate shows no significant difference between the two groups. The mortality rate is 7.6% in anterior resections and 14.2% in abdomino-perineal amputations. Our results and literature review show that local recurrence and mortality rates depend more from the tumor stage than from the surgical procedure.

[Primary gastric lymphoma. Diagnostic and therapeutic considerations on 30 cases]. / Il linfoma gastrico primitivo. Considerazioni diagnostico-terapeutiche su 30 casi.

From 1987 to 1992, 30 cases of Primary Gastric Lymphoma were operated in the Institute of Patologia Speciale Chirurgica of the University of Bologna. Clinical features, diagnostic findings, therapeutic procedures and histologic characteristics are reported. The results are discussed after a brief literature review.

[Surgical therapy of obstructive tumors of the large intestine]. / La terapia chirurgica dei tumori occludenti del grosso intestino.

Current option in managing obstructive colorectal carcinoma is a one stage procedure. Between 1987 and 1991, 47 cases of obstructive colorectal cancer were managed. A statistical analysis showed no significant difference in mortality, morbidity and hospital stay when comparing elective and emergency one staged resection and reconstruction.

[Myomatous tumor of the stomach. 3 clinical cases]. / I tumori miomatosi dello stomaco. Tre casi clinici.

Three cases of smooth muscle tumors of the stomach are reported: a leiomyoma, a leiomyosarcoma and a leiomyoblastoma observed over a period of five years. Clinical presentation, diagnostic procedure and surgical treatment are discussed and the literature is reviewed.

[Two cases of chronic constipation in the adult: Hirschsprung disease and idiopathic megacolon]. / Due casi di stipsi cronica nell'adulto: malattia di Hirschprung e megacolon idiopatico.

Two clinical cases of megacolon with long-standing constipation in the adult are presented: the former associated with Hirschprung's disease and the latter idiopathic. Diagnostic procedures and surgical treatment are described. The different criteria of diagnosis and therapy are discussed after a literature review.

[Splenectomy for hemorrhage from esophageal varices with massive thrombosis of the portal bed in the absence of cirrhosis: an intervention to be reevaluated? Reflections on a clinical case]. / La splenectomia per emorragia da varici esofagee con trombosi massiva del letto portale in assenza di cirrosi: un intervento da rivalutare? Riflessioni su un caso clinico.

It has been suggested that the ideal definitive treatment of hemorrhage from esophageal varices due to extrahepatic portal hypertension should be a selective shunt, avoiding splenectomy, when possible, for its unfavorable effects. We present a case with extrahepatic portal hypertension and polycythemia vera who complained acute recurrent variceal bleeding in spite of multiple sclerotherapy sessions, with a massive thrombosis of the portal bed and radicles without any possibility to perform a shunt. The combined treatment was emergency splenectomy followed by a closed program of sclerotherapy. The result was good at two years of follow-up. The optimal treatment of patients with episodes of bleeding varices for extrahepatic portal hypertension and patency of splenic vein should be a selective shunt; poor long-term results have been reported in patients without patency of the major tributaries of the portal system and treated with other operations than shunts. Splenectomy could gave a role in producing these unhappy results. After splenectomy it has been observed an increased thrombocytosis, venous infarction of the bowel, increased susceptibility to infection and also a paradoxical higher risk of bleeding by removing low risk collaterals. From this anecdotal report it can be argued that splenectomy is not necessarily followed by bad results and can be the first therapeutic option in emergency and in some selected cases with huge, high risk varices, difficult to treat by sclerosis only, and without suitable vessel for a shunt.(ABSTRACT TRUNCATED AT 250 WORDS)

Vital staining of oesophagus in patients with head and neck cancer: still a worthwhile procedure.

One hundred three patients with upper aerodigestive cancer were consecutively submitted to upper GI endoscopy with vital staining (Toluidine Blue 1%) of the oesophagus. The aim of the study was not only to confirm the prevalence of synchronous or metachronous tumour but also to verify the usefulness of the vital stain compared to simple endoscopy. Staining was positive in 29 patients (28.1%) for oesophagitis, leukoplakia, Barrett's oesophagus and 3 oesophageal neoplasms (2.9%), two of them unsuspected at endoscopy. We did not observe false positives while 13 cases (13/29-44.8%) were considered normal at endoscopy. Five cases with some endoscopic abnormality of the mucosa did not stain and were considered false negatives. Specificity of the method was 100%, sensibility 85.2%. The recognition of dysplastic changes and neoplasms not suspected at endoscopy should recommend in our opinion the use of vital staining of oesophagus in high-risk groups.

[Prevention of the 1st bleeding of esophageal varices: review of the literature and clinical experience]. / Profilassi del primo sanguinamento da varici esofagee: revisione della letteratura ed esperienza clinica.

The authors present a review of the literature on prophylactic sclerosis of esophageal varices in cirrhotics, taking as a starting point their personal experience. The natural history of varices and the criteria of their hemorrhagic risk are described; moreover are presented the results of the most important controlled studies of prophylactic surgery, sclerosis and beta-blocking drugs. In spite of the rather encouraging results after sclerosis at the long-term follow-up and the promising aspects of beta-blocking agents, it is not felt to recommend, according to the literature, a routine application of prophylactic sclerosis, a procedure which should be reserved to leading centers in controlled studies.

[Endoscopic sclerotherapy of esophageal varices. Personal cases]. / Scleroterapia endoscopica delle varici esofagee. Casistica personale.

The authors present their experience of endoscopic sclerosis of esophageal varices in 56 patients in a period of about two and half year (February '83-July '85). 46% of the patients were of the group C according to Child's criteria and 48.2% showed a fourth degree varices according to Paquet's criteria. Twenty-nine patients (51.7%) were submitted to the sclerosis as emergency treatment, 17 patients (30.3%) had an elective procedure and 10 (17.8%) were treated by a prophylactic sclerosis. The hemorrhage was stopped in 25 cases (86%) among emergency treated patients. However a new hemorrhage was observed before the end of the cycle of treatment in 48%. On the contrary 17% of patients complained recurrent hemorrhage after completing the treatment. Thirty-five per cent of patients electively treated showed recurrent hemorrhage while 40% bled after prophylactic treatment. Thirty-eight patients had a follow up of one year with results very similar to these reported in the literature. As a conclusion, on the bases of the reported results the authors suggest to submit to this treatment all the patients with recent hemorrhage or in emergency. The sclerosis should be reserved as elective procedure only to the patients of the class C; class A should be reserved to surgery while patients of the class B are matter of debate. Moreover prophylactic treatment, theoretically very attractive, needs further evaluation, at least in their hand.

[Considerations on a case of the dislocation of Celestin's endoscopic esophageal prosthesis into the ileum]. / Considerazioni su di un caso di dislocazione in sede ileale di protesi esofagea endoscopica di Celestin.

Palliative endoscopic oesophageal intubation for obstructive tumor is an on-going procedure. Among the commonest complications is dislocation (proximal or distal) of the prosthesis; however it is a rare event to found the prosthesis distal to the stomach. We report a case of an 83 years old man whose prosthesis, endoscopically placed in the distal third of the oesophagus, was dislocated in the distal ileum causing abdominal pain and mechanical obstruction, thus requiring a surgical removal. The authors discuss the possible causes of this complication and its treatment together with a review of the literature.