Transanal endoscopic microsurgery after neoadjuvant radiochemotherapy for locally advanced extraperitoneal rectal cancer: short-term morbidity and functional outcome.

BACKGROUND: Transanal endoscopic microsurgery (TEM) after radiochemotherapy (RCT) has been reported in selected cases of locally advanced rectal cancer as an alternative to traditional radical resection with total mesorectal excision with a curative intent or as diagnostic tool to confirm a pathological complete response of the primary tumor. No study has evaluated functional outcome after TEM in preoperatively irradiated patients. METHODS: This study was designed to evaluate short-term morbidity (according to Clavien's classifications) and establish (by a questionnaire) continence and evacuative function after RCT and TEM, at 1 year from surgery, analyzing the impact of RCT on postoperative outcomes. Patients with locally advanced rectal cancer treated by RCT and TEM (group 1) or with early T1 or adenomas treated only by TEM (group 2) entered this cohort comparative study. RESULTS: Twenty-two patients entered the study as group 1 and 25 as group 2. No postoperative mortality occurred. The morbidity rate was 36.4 % in group 1 vs. 16 % in group 2 (p = 0.114). The rate of suture dehiscence was 22.7 % in group 1 vs. 4 % in group 2 (p = 0.068). No grade III complications, reoperation, or hospital readmission within 30 days was recorded in either group. One year after surgery, continence and evacuative scores in group 1 were 1.05 ± 1.25 and 24.72 ± 2.79, respectively, which were similar to group 2 (p = 0.081 and 0.288, respectively). CONCLUSIONS: TEM after RCT in selected rectal cancer patients has an acceptable morbidity and functional results at 1 year from surgery. Preoperative irradiation could increase postoperative short-term morbidity, but it does not seem to influence evacuative or sphincter function after 1 year from surgery.

Surgical treatment of small bowel neoplasms.

Small intestinal neoplasms are uncommon cancers. Benign small intestinal tumors (e.g., leiomyoma, lipoma, hamartoma, or desmoid tumor) usually are asymptomatic but may present with complications. Primary malignancies of the small intestine, including adenocarcinoma, leiomyosarcoma, carcinoid, and lymphoma, are often symptomatic and may present with intestinal obstruction, jaundice, bleeding, or pain. Metastatic neoplasms may involve the small intestine via contiguous spread, peritoneal metastases or hematogenous metastases. Because the small intestine is relatively inaccessible to routine endoscopy, diagnosis of small intestinal neoplasms is often delayed for months after onset of symptoms. During last years the increase of small bowel endoscopy and other diagnostic tools allow earlier non-operative diagnosis. Even though radical resection of small bowel cancer plays an important role, the 5 yr overall survival remains low.

The role of local excision in rectal cancer after complete response to neoadjuvant treatment.

Correlation between pathological response of primary tumour and mesorectal lymph node involvement was prospectively evaluated to assess the role of local excision (LE) in rectal cancer after complete response to neoadjuvant treatment. A series of 272 consecutive rectal cancer, submitted to neoadjuvant radiochemotherapy (RCT) and surgery with total mesorectal excision (TME) were analysed. Tumour downstaging (pT) and tumour regression grade (TRG) together with sex, age, location of the tumour, pre-treatment clinical stage, type of chemoradiation and operation performed entered in an univariate and multivariate analysis. Pathological complete response on primary tumour was found in 56 patients (20.6%). Lymph node metastases were found in 72 patients (26.5%). The rate of positive nodes was 1.8% for pT0 and TRG1 cases, respectively, to go up to 6.3% for pT1 and 24.1% for TRG 2 cases, respectively. At the univariate analysis, factors with a statistically significant correlation with the risk of lymph node metastasis were: clinical pre-treatment N stage (p<0.05), pT stage (p<0.001) and TRG (p<0.001). At the multivariate analysis, the best predictors of pathologic lymph node involvement were pT stage (p=0.0013 ) and TRG (p=0.0011). Because LE is an adequate technique to assess the tumour pathological response and nodal involvement in pT0 or TRG1 cases seems extremely infrequent, radical resection is probably not justified after pathological complete response. Prospective randomized trials are necessary to establish if, in these cases, LE can guarantee the same oncologic results offered by the currently adopted protocols of RCT followed by radical resections.

Functional results after radiochemotherapy and total mesorectal excision for rectal cancer.

BACKGROUND AND PURPOSE: The aim of this study was to prospectively define and measure evacuation and continence disorders after preoperative radiochemotherapy and total mesorectal excision (TME) for rectal cancer 1 year after surgery. MATERIALS AND METHODS: We submitted 100 patients, who underwent neoadjuvant treatment and anterior resection with TME from 1996 to 2003, to a questionnaire on postoperative continence and evacuation. Anal sphincter function was further assessed by the Memorial Sloan-Kettering score. Factors influencing anorectal function were examined in univariate and multivariate analysis. RESULTS: Median evacuation score was 16.12 +/- 5.12 (range 0-28). Sensation of incomplete evacuation was reported in 58% of cases, necessity to return to the bathroom <15 min in 37% and inability to evacuate completely <15 min in 35%. Median continence score was 13.7 +/- 4.79 (range 0-20). Incontinence to flatus was reported in 46% of cases. Colonic J-pouch allows better evacuation and continence. Continence was also better in absence of postoperative complications. Sphincter function resulted excellent or good in 75% of patients according to the Memorial Sloan-Kettering score. CONCLUSIONS: The most frequent symptoms in our series are the sensation of incomplete evacuation, the incontinence to flatus, and the necessity to return to the bathroom <15 min. Colonic J-pouch warrants a better function. Postoperative complications compromise good functional results.

Gastro-intestinal symptoms as clinical manifestation of peritoneal and retroperitoneal spread of an invasive lobular breast cancer: report of a case and review of the literature.

BACKGROUND: Distant spread from breast cancer is commonly found in bones, lungs, liver and central nervous system. Metastatic involvement of peritoneum and retroperitoneum is unusual and unexpected. CASE PRESENTATION: We report the case of a 67 year-old-woman who presented with gastrointestinal symptoms which revealed to be the clinical manifestations of peritoneal and retroperitoneal metastatic spread of an invasive lobular breast cancer diagnosed 15 years before. CONCLUSION: To the best of our knowledge, the case presented is the third one reported in literature showing a wide peritoneal and extraperitoneal diffusion of an invasive lobular breast cancer. The long and complex diagnostic work up which led us to the diagnosis is illustrated, with particular emphasis on the multidisciplinary approach, which is mandatory to obtain such a result in these cases. Awareness of such a condition by clinicians is mandatory in order to make an early diagnosis and start a prompt and correct therapeutic approach.

[Laparoscopic incisional hernia repair as first therapeutic choice]. / L'approccio laparoscopico nella riparazione del laparocele quale prima scelta terapeutica.

AIM: Incisional hernias are one of the most frequent complications of open abdominal surgery. Historically, the best results have been obtained with the open rives-stoppa approach. This is done by fixing a large piece of prosthetic mesh behind the rectus muscle. Laparoscopic approach allows similar mesh placement with minimal dissection and lower recurrence rate compared to the open mesh repair. METHODS: Between October 2001 to September 2003, 75 consecutive patients were scheduled to undergo laparoscopic incisional hernia repair with ePTFE mesh (Gore-Tex Dualmesh Plus). Postoperative complications were recorded and analysed. RESULTS: Most were obese affected by multiple wall defects Conversion to open surgery was required in 1 case Postoperative complications occurred 13.3%. Recurrence occurred in one only case. CONCLUSIONS: The key to the success of this procedure is avoidance of complications. The laparoscopic approach is safe, effective and relatively complication-free option in the management of patients presenting with a first time or recurrent incisional hernia and recommended as the treatment of choice.

Management of acute pancreatitis in emergency.

This review focuses on the medical and endoscopic approachs to patients with acute mild or severe pancreatitis. Acute pancreatitis is an acute inflammatory process of the pancreas whose the main determinant of the outcome is the extent of pancreatic necrosis. After the diagnosis, a severity assessment using scoring systems and early contrast enhanced Computed Tomography should be performed in all patients within 48 hours from the admission. All cases of severe acute pancreatitis should be managed initially in intensive care units with full systems support. Patients with gallstone pancreatitis should have definitive Endoscopic Retrograde Colangio-Pancreatography (ERCP) or surgical management of the gallstones.

[Surgical treatment of carcinoma of the left colon and rectum as an emergency. A new method for assessing operative risk]. / Trattamento chirurgico del carcinoma del colon sinistro e del retto in emergenza. Un nuovo metodo per la valutazione del rischio operatorio.

BACKGROUND/AIMS: The surgical treatment of the left colon and rectal cancer emergencies is still controversial. In our opinion the choices to be based on the general health status of the patient. METHODOLOGY: The authors analysed a series of 63 patients submitted to immediate resection and anastomosis. RESULTS: Factors significantly related to short term results were chronic heart disease, low albumin serum levels, and colonic perforation. The presence of a diverting colostomy did not provide a protective factor against anastomotic dehiscence. We constructed a Colorectal Tumours Emergencies Score made of the identified four factors in which the score of each factor is the approximated odds ratio (chronic renal failure 7 points, low albumin serum levels 6 points, heart disease 5 points, colon perforation 4 points). Each patient was classified as Low Risk (CTES < 4), Moderate Risk (CTES 4-12), High Risk (CTES > 12), mortality and morbidity being 4% and 20%, 19.3% and 61.3%, 88.9% and 88.9% respectively. CONCLUSIONS: High risk patients may undergo a staged procedure. Moderate risk patients may be treated by immediate resection of the tumor, without anastomosis. Immediate resection and anastomosis may be reserved to low risk patients.

[Adjuvant radiotherapy in rectal cancer and total mesorectal excision]. / La radioterapia adiuvante nel cancro del retto e l'escissione totale del mesoretto.

Local recurrence (LR) after surgical resection for adenocarcinoma of the rectum still remains an unsolved problem. Local relapse often occurs when tumor spreads in perirectal fat (mesorectum) or along the lateral iliac lymph nodes also when surgery is considered radically. There is a close relationship between local recurrence rate and lymphatic involvement, local tumor extension and tumour grading. Total mesorectal excision (TME) appears to be associated with a reduced LR rate when resection of perirectal fat is done "en-bloc" and when a negative radial margins is obtained. TME allows autonomic nerve sparing and sphincter preservation too, but lateral nodes are not treated by TME. Extended lymphadenectomy with lateral dissection for advanced rectal cancer has been often associated with an increase rate of long term morbidity, particularly regarding urinary and sexual function. Concomitant preoperative chemo-radiation for advanced rectal cancer is a relatively safe procedure with an acceptable morbidity and mortality. This approach is associated with a considerable clinical and pathologic tumor downstaging. Tumor resectability is improved and lateral spreading is also better controlled. An improving in survival and a longer disease free period has been reported. More radical sphincter saving operations are also allowed.

The role of surgical treatment in colon diverticulitis: indications and results.

PURPOSE: Colon diverticulitis is a common illness with affects 37-45% of western populations. Indications regarding therapy guidelines, operative timing and which surgical procedure to perform are still controversial. MATERIAL AND METHOD: Between January 1977 and December 1997, 239 patients, diagnosed with diverticulitis, have been admitted, on emergency, to our Department of General Surgery; 135 males (56%) and 104 females (44%), (mean age of 63 years). RESULTS AND DISCUSSION: Forty-two patients (18%), clearly diagnosed with diffuse or local peritonitis, underwent delayed emergency surgical procedure; 44 (22%) out of 197 patients, treated with medical therapy and subsequently underwent elective surgery procedures for complications (fistulas or stenosis). Among the 42 patients treated in emergency, 26 cases (62%) underwent to resection with immediate reconstruction. Among the elective surgery group 39 (89%) out of 44 underwent to resection with immediate reconstruction. Complications reached 40% in the group of emergency patients (mortality rate 12%) and 16% in the elective surgery group (mortality rate 2%). Several features possible influencing mortality rate have been analysed; age > 70 years, acute associated diseases, generalised peritonitis and surgical timing show a statistical significance. CONCLUSION: Therefore, a careful evaluation of the patients, an appropriate pre and post-operative medical treatment, with a wider use of the most recent techniques such as CT scan guided drain, intra-operative wash-out and peritoneal lavage are recommended in order to reduce morbidity and mortality.

Sliding, absorbable, reinforced ring and an axially driven stent placement device for sutureless fibrin glue gastrointestinal anastomosis.

Reduced blood flow of from 43 to 71% has been reported in sutured and stapled anastomoses. The sutureless sliding, absorbable, intraluminal, nontoxic stent (SAINT)-fibrin glue anastomotic method, which clamps the stump margins between 2 dissolving surfaces, includes only two stages of temporary compression (about 6 min total using 4 IU/mL thrombin) during the glue application in order to promote vascularization. A SAINT placement device (SAINT-PD) was introduced to facilitate low rectal anastomoses. Morphohistologic results from limited trials using fibrin glue with an untied sutureless stapler technique and a prototype non-gear-driven SAINT-PD, neither having the two dissolvable clamping surfaces of the SAINT, showed a 29 and 25% incidence of intraluminal tissue ridges, respectively. Since these tissue ridges could result in subclinical dilatation or frank stenosis, and the more extensive SAINT trials had an 8% incidence of tissue ridges, redesign of the SAINT-PD was undertaken. Consequently, to improve the anastomotic quality of the SAINT-PD, the sliding absorbable reinforced ring (sucrose base) acting as the second dissolvable surface for the SAINT-PD and a new axially controlled geared SAINT-PD design are described.

Gastrointestinal sutureless anastomosis using fibrin glue: reinforcement of the sliding absorbable intraluminal nontoxic stent and development of a stent placement device.

Sutureless anastomosis of the gastrointestinal tract using fibrin glue and sliding absorbable intraluminal nontoxic stents (SAINTs) has two shortcomings, stent shaft breakage and the lack of a transanal insertion device (TID) for low anterior resection. Reinforcement of the sucrose base SAINT (R-SAINT) is described. Sutureless anastomosis is attempted using a stapleless mechanical stapler (SS) and used as preprototype to screen histologically and mechanically for TID anastomoses in the small intestine. Finally, a prototype absorbable head SAINT placement device (SAINT-PD) intended for TID, similar to the SS, is utilized on the small intestine. Fifty-seven Landrace pigs weighing 25-35 kg were used to perform 58 anastomoses, including the small intestine (15 manual, 19 SAINT, 11 SS, 5 R-SAINT, 6 SAINT-PD) and large intestine (2 R-SAINT). All anastomoses performed with the R-SAINT succeeded on the first attempt even if the shaft cracked. The SS technique proved impractical, but the histological screen results from 7 to 60 days did approximate those of corresponding SAINT anastomoses. The SAINT-PD demonstrated operational improvement over the SS, but the histological results were similar to both the SS and SAINT. The advantages of the R-SAINT and SAINT-PD are that they leave no foreign bodies or pressure clamping devices at the anastomostic site. Larger studies may show the R-SAINT and the SAINT-PD to be practical, new surgical tools in sutureless fibrin glue anastomosis.

Sutureless cholecystojejunostomy in pigs using an absorbable intraluminal stent and fibrin glue.

The absence of foreign bodies in sutureless anastomoses provides faster healing. The first sutureless cholecystojejunostomies were reported by Murphy in 1892. The common bile duct was tied and 11 cholecystojejunostomies plus 12 jejunojejunostomies were performed in 12 Landrace pigs employing sliding absorbable intraluminal nontoxic stents (SAINTs) and fibrin glue. One cholecystojejunostomy was not performed owing to a gallbladder morphologic anomaly. Three animals died of problems unrelated to the SAINT-glue anastomoses. Of the 18 anastomoses in the 9 remaining animals, all were patent at the verification times of 14, 30, 120, and 480 days. Morphologically,there was greater edema and reduced height of the glandular epithelium in the 30-day CJs when compared to the jejunojejunal anastomoses. Results indicate that the sutureless SAINT-fibrin glue procedure is quite versatile and may be utilized for cholecystoenteric anastomoses.

Sutureless anastomosis of the small intestine and the colon in pigs using an absorbable intraluminal stent and fibrin glue.

A new sutureless anastomosis technique employing a sliding absorbable intraluminal nontoxic stent (SAINT) and fibrin glue with limited (minutes) stump margin pressure is described. Fifty-one (27 small intestine, 24 colon) SAINT anastomoses were performed in 31 Landrace pigs (25-35 kg). Controls consisted of 48 (26 small intestine, 22 colon) continuous single-layer submucosal anastomoses in 26 pigs. SAINTs, which dissolve in about 30-60 min, were formed from heated sucrose and water poured into handcrafted aluminum molds. Follow-up from 7 to 540 days showed no stenosis or anastomotic imperfections in the latter part of the experiment after the SAINT production and surgical techniques were improved. The SAINT group had fewer site adhesions, faster healing, less foreign body reaction, and fewer lymphocytes than the control group. Initial results indicate that the SAINT-fibrin glue procedure may be an effective sutureless anastomotic method from the duodenum to the sigmoid colon.