Surgical treatment of isolated lung and adrenal metastasis from colorectal cancer. Case report.

INTRODUCTION: Up to 30% of stage I and II colorectal cancers (CRCs) treated with surgical resection alone show disease recurrence, indicating that lymph node (LN) involvement was probably underestimated. Lung is a common site of CRC metastasis, whereas adrenal glands are rarely involved. CASE REPORT: On July 2004 a 56-year old woman underwent left hemicolectomy for a stage I sigmoid cancer. Four years later a lobectomy was performed for an isolated lung metastasis; thirteen months thereafter she underwent left adrenalectomy for adrenal metastasis. No lymph node involvement has ever been demonstrated either histopathologically or radiologically. At present, the patient is alive and apparently disease-free. DISCUSSION: The presence of LN occult metastasis, that might explain recurrence in stage I and II CRCs, has recently been investigated by means of immunohistochemistry and polymerase chain reaction; evidence of LN metastasis obtained with the latter technique is associated to a worse outcome. There have been very few cases that resemble our patient's neoplastic progression and they were either stage III neoplasms or rectal cancers. Our patient's primitive localization in the sigmoid colon makes it difficult to imagine why the liver has not been a site of metastasis. Finally, surgery has an important role in treating isolated metastasis in both lungs and adrenal glands. KEYWORDS: Colorectal cancer, Lung metastasis, Solitary adrenal metastasis.

[Visual identification of the recurrent laryngeal nerve during thyroidectomy]. / Identificazione visiva del nervo laringeo ricorrente durante tiroidectomia.

INTRODUCTION: Injuries to the recurrent laryngeal nerve (RLN) are always a possible complication of thyroidectomy, in spite of various technical proposals aimed at reducing these risks. The aim of this study is the description of the technical methods used by us for identification. MATERIALS AND METHODS: One hundred seventy-five patients underwent thyroidectomy with a technique consisting in a systematic search of the RLN in the tracheoesophageal groove where it crosses the ITA avoiding ligatures, sections or electro-coagulation before making a definite identification of the nerve which then takes place and is then safeguarded until laryngeal insertion. RESULTS: In 95.4% of the cases total thyroidectomy was performed and in 4.6% of the cases a hemi-thyroidectomy, with a total of 342 identifications of the RLN. In two cases (1.14%) the laryngeal nerve was non-recurrent. There was no operative mortality. There were no bilateral lesions of the RLN, while unilateral lesions occurred in 2.8% of cases (5/175) of which 3 (1.7%) with temporary vocal deficit. DISCUSSION: We examined the different methods used to facilitate the identification of the nerve including: palpatory method, peri-tracheal excision, use of loupe magnification, intraoperative nerve monitoring (IONM). None of the procedures examined showed a genuine reduction to the risk of injury. The authors emphasize that the visual identification, using the methods they described, allows the visualization and preservation of the nerve for the majority of the cases. CONCLUSION: Taking into consideration that the various methods of preservation of the RLN have not significantly reduced the risk of injury, the visual identification with specific measures has made it possible to limit the damage to a very low number of cases.

[Rectus sheath haematoma as an early complication of laparoscopic hemicolectomy: a case report and review of the literature]. / Ematoma intrafasciale del retto quale complicanza precoce di una emicolectomia laparoscopica: caso clinico e revisione della letteratura.

We report a case of rectus sheath haematoma (RSH) in a patient undergoing laparoscopic right hemicolectomy and anticoagulant prophylaxis of a pulmonary thromboembolism (PTE) with low molecular weight heparin. This pathological condition is rare and could be a cause of misdiagnosis in patients with acute abdominal pain. It can be a serious complication in the course of anticoagulant therapy. A rapid, correct diagnosis may lead to better treatment which must be timely, aggressive and ultimately curative. Our patient, with acute onset and swift worsening of his general condition, benefited from an immediate surgical procedure, with ligature of the epigastric artery stumps and drainage of the haematoma.

[Integrated multidisciplinary treatment of colorectal neoplasms]. / Trattamento multidisciplinare integrato delle neoplasie colo-rettali.

In this retrospective study, the modality and advantages of the multidisciplinary diagnostic work-up and therapy regarding colorectal neoplasm were analysed. Over the period 2004-2008, 63 patients underwent multidisciplinary treatment for colorectal cancer. All patients underwent surgery (laparoscopic/open). Exeresis was supplemented by adjuvant chemotherapy in those cases beyond IIA stage; all cases of extraperitoneal rectal and anal canal neoplasms plus one case of carcinoma of the transverse colon, initially inoperable, underwent neoadjuvant radiotherapy plus chemotherapy. The treatment was initiated approximately 3 weeks after the diagnosis. Fifty-four percent of patients with colonic and upper rectal neoplasms were given adjuvant chemotherapy, starting around 4 weeks after surgery. Exeresis was performed in those patients with extraperitoneal rectal and anal canal neoplasms (12.7%) about 6-8 weeks after they had completed neoadjuvant therapy. At the end of the treatment, 76% of the overall total numbers of patients were in good condition (follow-up 4-50 months). The remaining 24% suffered recurrences about 13 months after the treatment for colonic and upper rectal neoplasm, and 8 1/2 months after treatment for extraperitoneal rectal/anal canal neoplasms. Seventy-five percent of the recurring cases underwent treatment again, with 50% success; the others are still undergoing treatment. The best therapeutic results were obtained by programmed integration of the various diagnostic-therapeutic steps according to an algorithm which we elaborated to evaluate all types of neoplasm at any stage of illness.

[Severe postoperative complications in colorectal surgery for cancer. Incidence related to the techniques employed: open versus laparoscopic colectomy]. / Complicanze maggiori postoperatorie nella chirurgia colo-rettale per cancro. Incidenza in rapporto alla tecnica utilizzata: open versus laparoscopica.

In this preliminary retrospective study, severe postoperative complications following surgery for colorectal cancer were analysed, comparing the results obtained with open versus laparoscopic colectomy. Over the period 2005-2007, 50 patients (29 female, 21 male; age range: 32-85 years) underwent surgical treatment for colorectal-anal cancer. Twenty-nine (58%) were submitted to the traditional open technique and 21 (42%) to the laparoscopic technique. No mortality occurred with either technique. None of the cases submitted to laparoscopy presented anastomotic dehiscence or severe intraoperative bleeding. In the group submitted to open surgery, 3 cases of severe complications occurred (10.3%), consisting in acute faecal peritonitis due to immediate dehiscence of the colorectal anastomosis; angulation of the intestinal loop with microdehiscence of the ileo-colic anastomosis; and pulmonary embolism. In the group submitted to laparoscopic surgery, 2 cases of severe complications occurred (9.5%), consisting in enterorrhagia due to haemoperitoneum; and intrafascial haematoma due to haemorrhage of the epigastric artery. The overall complication rate was 10%, corresponding to the minimum values reported in the literature. No statistically significant difference was observed in the incidence of these complications with the two methods employed. A very low incidence of minor complications was observed, limited to repercussions on the postoperative course. Furthermore, the laparoscopic technique led to early canalisation, a reduction in hospital stay, less need of drugs (antibiotics and pain killers) and better aesthetic results. The advantages obtained with the laparoscopic technique, with no significant differences in severe complications, indicate that this approach is preferable to the traditional technique in colorectal surgery for cancer.

Multiple angiodysplasia diagnosed by capsule endoscopy.

A 28-year-old Caucasian man was admitted in our unit for acute massive rectal bleeding. Past medical and family history was unremarkable. Hemoglobin was 7.6 g/dL. Blood transfusions were required. Computed tomography and gastrointestinal endoscopy were negative for active bleeding. When patient's hemoglobin was normalized and stable, a video capsule endoscopy was performed. Video relieved the presence of multiple digiunal and ileal angiodysplastic lesions. A double endoscopic argon plasma coagulation procedure was planned on general anaesthesia. Upper and rectal operative approach were performed. Procedure was uneventful. After 2 years follow-up patient had no recurrence of gastrointestinal bleeding.

Post-operative ileus in hemicolectomy for cancer: open versus laparoscopic approach.

AIM: This study aims to verify if the duration of postoperative ileus (POI), in patients undergoing abdominal surgery, is related to the surgical approach used (open or laparoscopic) or rather to the manipulation of bowel loops. MATERIALS AND METHODS: Ninety patients, undergoing elective colon resection for cancer, were randomized in three groups with different surgical approaches: open technique with extensive manipulation of intestinal loops (GROUP A), open technique with minimal manipulation (GROUP B) and laparoscopic technique (GROUP C). Return of bowel functions was investigated by: detection of bowel sounds, passage of flatus and passage of stool. RESULTS: Detection of bowel sounds occurred after 2.18 days in GROUP A, after 1.35 days in GROUP B and after 1.19 days in GROUP C. Return of flatus occurred after 3.51 days in Group A, after 2.53 days in GROUP B and after 2.30 days in GROUP C. Passage of stool occurred after 4.48 days in GROUP A, after 3.75 days in GROUP B and after 3.61 days in GROUP C. In all end-points analyzed, differences between GROUP A and GROUP B and between GROUP A and GROUP C are significant (P< 0.01) whereas the differences between GROUP B and GROUP C are not significant (P > 0.01). CONCLUSIONS: In colon surgery open technique with minimal manipulation of loops obtains similar results in those of the laparoscopic technique, in terms of resolution of postoperative ileus.