[Management of the thoracic drainage in the thoracic traumas. Technical mistakes and new procedures]. / La gestione del drenaggio toracico nei traumi del torace. Errori tecnici e nuove procedure.

OBJECTIVE: Thoracic trauma is positioned at the third place of occurrence in Multiple Trauma patient. The correct position of thoracic drainages are fundamental for a good resolution and restore of pulmonary function in our mechanical ventilated patients. METHODS: This retrospective analysis of a prospective database on a consecutive series of patients who had haemo-pneumothorax drained immediately or into 3 hours from trauma was conducted over a period of 24 months. RESULTS: Of 600 of thoracic procedures we have considered 67 chest drainages positioned from 2002 to 2004 in patients with thoracic trauma. Technical aspects of the thoracic drainage were analyzed. Outcome,pulmonary function and clinical complications were recorded. CONCLUSIONS: The Management of drains and thoracic tubes after many surgical procedures is highly variable. This procedure is easy, feasible, secure and we have recorded a reduction of costs and related complications.

Locally advanced leiomyosarcoma of the spleen. A case report and review of the literature.

BACKGROUND: Leiomyosarcomas are rare tumours, predominantly localized in the stomach, small intestine and retroperitoneum. Only one case of primary leiomyosarcoma of the spleen is described in human beings in literature. CASE PRESENTATION: We report a case of locally advanced primary leiomyosarcoma of the spleen in a 54 year-old woman, diagnosed only after splenectomy, performed with the suspicion of splenic haematoma. CONCLUSION: Due to the lack of cases, no specific chemotherapy regimen has been tested to provide a longer survival.

Postoperative chemoradiotherapy in rectal cancer. Late results of a pilot study.

BACKGROUND/AIMS: It has recently been proven that postoperative radiotherapy combined with fluorouracil showed an increase of survival and local control in patients with rectal cancer. However, hematological and intestinal toxicity also increased. Experimental and clinical studies showed an increased radiation effect with an acceptable toxicity by delivering drug via a continuous intravenous infusion. METHODOLOGY: From 1988 to 1998, 80 patients radically operated on for stages B2-C rectal cancer were irradiated with 3 fractions of 100 cGy per day to a total dose of 5,600 cGy. 34 out of these 80 patients underwent postoperative radiotherapy alone and 46 received radiotherapy combined with concomitant protracted infusion of fluorouracil at doses of 250 mg/m2 per day. RESULTS: After a median follow-up of 54 months, the 5-year overall and disease-free survival were 59% and 54%, respectively, in the combined modality group, as compared to 42% and 34%, respectively, in the radiation alone group. The differences were not significant, but the incidence of local relapse and patients' survival showed a better trend for combined approach. CONCLUSIONS: The data from international literature are in favor of a combined approach, both in preoperative and postoperative treatment of advanced rectal cancer. Adjuvant therapy must be re-evaluated in trials using total mesorectal excision as the standard operative technique.

[Anastomosis dehiscence in anterior resection of the rectum with total excision of the mesorectum]. / Deiscenze anastomotiche nelle resezioni anteriori del retto con escissione totale del mesoretto.

Anterior rectal resection with total mesorectal excision is currently regarded as the operation of choice in patients with neoplasms of the extraperitoneal rectum. This operation is associated with a significant incidence of anastomotic dehiscence. Some authors, therefore, advise the execution of a protective stoma. From 1987 to 2000, 241 patients with rectal neoplasma were submitted to radical surgery: 183 to anterior rectal resection (extraperitoneal neoplasms in 129 cases and intraperitoneal neoplasms in 54) and 58 to a Miles operation. The total incidence of anastomotic complications was 8.1% (15 patients). In 12 cases (6.5%) a clinical dehiscence was observed, while in 3 patients (1.6%) an asymptomatic fistula was present. In the patients with symptomatic dehiscence a colostomy was performed in 5 cases (42%), while in 7 cases (58%) a conservative approach was adopted (total parenteral nutrition and antibiotic therapy), with complete healing of the fistula. The incidence of anastomotic complications was 9.3% in extraperitoneal neoplasms and 5.6% in intraperitoneal localizations. In relation to the anastomotic technique adopted, the incidence of dehiscences was 25% after 8 Knight-Griffen anastomoses, 16% after 12 manual anastomoses and 7.3% after 163 end-to-end mechanical anastomoses (P = NS). The percentage of anastomotic complications was greater in the period from 1995 to 1997, compared to the period from 1987 to 1994 (12.6% vs 3.8%, P = NS), due to the routine execution of rectal resection in conjunction with total mesorectal excision, particularly at the beginning of the experience, in 1995. In the last 36 cases from 1998 on the incidence of anastomotic complications was reduced to 8.3%, after the learning phase. No related mortality was observed. On the basis of our experience and the evidence reported in the international literature we do not think the execution of a protective stoma is justified after low and ultra-low colorectal anastomosis, except in selected cases.

Postoperative chemoradiotherapy in rectal cancer. Long-term results of a pilot study.

It has recently been proven that postoperative radiotherapy combined with fluorouracil affords an increase in survival and local control in patients with rectal cancer. However, haematological and intestinal toxicity also increase. Experimental and clinical studies have shown an increased effect of radiation with an acceptable toxicity by delivering the drug via continuous intravenous infusion. From 1988 to 1998, 80 patients radically operated on for stage B2-C rectal cancer were irradiated with 3 fractions of 100 cGy per day up to a total dose of 5,600 cGy; 34 of these patients underwent postoperative radiotherapy alone and 46 received radiotherapy combined with concomitant protracted infusion of fluorouracil at doses of 250 mg/m2 per day. After a median follow-up of 60 months, the 5-year overall and disease-free survival rates were 59% and 54%, respectively, in the combined modality group, as compared to 42% and 34%, respectively, in the radiation alone group. The differences were non-significant, but the incidence of local relapse and patient survival showed better trends with the combined approach. The international literature data are in favour of a combined approach in both the preoperative and postoperative treatment of advanced rectal cancer. Adjuvant therapy needs to be re-assessed in trials using total mesorectal excision as the standard operative technique.

Critical appraisal of bevacizumab in the treatment of metastatic colorectal cancer.

Colorectal cancer is one of the most common cancers worldwide. The prognosis of patients with metastatic colorectal cancer in recent years has increased from 5 months with best supportive care to nearly 2 years with chemotherapy combined with bevacizumab, an antivascular endothelial growth factor monoclonal antibody. New prognostic and predictive biomarkers have been identified to guide chemotherapy in metastatic colorectal cancer, such as KRAS and BRAF oncogenes. However, the status of these oncogenes does not affect the efficacy of bevacizumab, and biomarkers predicting response to treatment with bevacizumab are still lacking. Addition of bevacizumab to regimens based on fluoropyrimidines or irinotecan has been shown to improve overall survival in treatment-naïve patients with metastatic colorectal cancer. Similarly, a significant increase in overall survival rate is achieved by adding bevacizumab to fluoropyrimidines and oxaliplatin in patients with disease progression. Bevacizumab has been found to be effective even when used as third-line therapy and later. In addition, cohort studies have shown that bevacizumab improves survival significantly despite disease progression. Finally, bevacizumab therapy in the neoadjuvant setting for the treatment of liver metastasis is well tolerated, safe, and effective.