The PNEI holistic approach in coloproctology.

The psycho-neuroendocrine-immune approach relies on the concept of considering diseases from a holistic point of view: the various components (psyche, nervous system, endocrine system, and immune system) control the diseased organ/apparatus and in turn are influenced by a feedback mechanism. In this article, we will consider the psycho-neuroendocrine-immune approach to coloproctological disorders, by providing clinical cases and discussing them in light of this approach.

Prevention of complications during reoperative thyroid surgery.

BACKGROUND: Thyroidectomy performed by an experienced surgeon is associated with a low incidence of recurrent laryngeal nerve injury and permanent hypoparathyroidism. During reoperative thyroid surgery there is a higher technical risk because detection and preservation of the recurrent laryngeal nerves and parathyroid glands are more difficult than in the primary surgery. AIM: Our retrospective cohort study was to assess short- and long-term complications associated with reoperative thyroid surgery in order to suggest a technical approach to lower the morbidity rate. MATERIALS AND METHODS: From January 2005 to September 2013, 745 patients underwent surgery for thyroid disease. Before surgery all patients underwent clinical examination, laboratory blood tests, hormonal assays, neck ultrasound, chest radiography and indirect laryngoscopy. Patients were followed up at 1, 3, 6 months and then annually after operation with hormonal assays, blood tests and neck ultrasound. RESULTS: Eighty (10.7%) out of 745 patients (mean-age= 52.5 years; age-range 18-80) underwent reoperative surgery for recurrent thyroid disease. The primary treatments were enucleoresection (11.2%), thyroid lobectomy(56,3%), thyroid lobectomy with isthmectomy(10%) and subtotal thyroidectomy (22,5%). In the reoperative surgery group (Group Re) the transient RLN complications were 1.3% compared to 0.2% in the primary surgery group (Group P) (p= 0.51). The incidence of temporary hypocalcemia was 45% in the reoperative surgery group vs. 42.7% in the primary surgery group (p=0.72). CONCLUSIONS: Reoperative surgery should be reserved to experienced surgeons. However, even in this case, when surgical maneuvers reserved for primary surgery are applied, then this surgery is associated with a low complications rate.

Prosthetic replacement and tangential resection of the superior vena cava in chest tumors.

AIM: Infiltration of the superior vena cava (SVC) due to advanced non small cell lung cancer (NSCLC) or thymoma can be treated by prosthetic replacement or tangential resection. These two technical procedures and their results are described. METHODS: From 1988 to 2002, we performed 37 SVC resections: 21 replacements with polytetrafluoroethylene (PTFE) prostheses and 16 tangential exereses. Sixteen patients affected by locally advanced NSCLC (12 T4; 4 extracapsular N2) and 5 subjects with thymoma (Stage III Masaoka) underwent prosthetic replacement of the SVC. After neoadjuvant polychemotherapy, tangential resection was performed on 12 patients with extracapsular N2 NSCLC, and in 1 patient with T4 and in 3 patients with T3a disease. We performed prosthetic replacement in 18 cases using a straight prosthesis (?18-20 mm). A bridge (10-14 cm) between the innominate vein and the right atrium was created in 3 patients. The main indication for a prosthetic replacement was infiltration of more than 30% of the circumference of the SVC. There were 4 thromboembolic complications (19%), with one intraoperative death (4.8%). Tangential resection of the SVC for infiltration <20% was performed both manually and with staplers (double clamping) without any major complications. RESULTS: Mean survival was 23 months in those patients who had undergone PTFE replacement for T4 lung cancer and for thymoma. Mean survival was 15 months in those who had undergone tangential resections for NSCLC with extracapsular N2. We performed restaging of the tumor using chest angio-CT scan in 11 patients, one year after the operation. We found 80% patency in 7 SVC prostheses and 50% patency in 4 others: the two bridges between the left innominate vein and the right atrium appeared to be partially closed but were compensated by important collateral circles. CONCLUSION: SVC replacement, associated with pulmonary resection or removal of mediastinal masses, can be performed in selected cases. It should not be considered as palliative treatment because of the important perioperative risks. SVC tangential resection involves fewer surgical problems. However, since this procedure is used mostly for N2 NSCLC subjects, patients have a low mean survival in spite of adjuvant therapy.