Preliminary results of a program for the implementation of laparoscopic colorectal surgery in an Italian comprehensive cancer center during the COVID-19 pandemic.

Despite operative benefit and oncological non-inferiority, videolaparoscopic (VLS) colorectal surgery is still relatively underutilized. This study analyzes the results of a program for the implementation of VLS colorectal surgery started in an Italian comprehensive cancer center shortly before COVID-19 outbreak. A prospective database was reviewed. The study period was divided in four phases: Phase-1 (Open surgery), Phase-2 (Discretional phase), Phase-3 (VLS implementation phase), and Phase-4 (VLS consolidation phase). Formal surgical and perioperative protocols were adopted from Phase-3. Postoperative complications were scored by the Clavien-Dindo classification. 414 surgical procedures were performed during Phase-1, 348 during Phase-2, 360 during Phase-3, and 325 during Phase-4. In the four phases, VLS primary colorectal resections increased from 11/214 (5.1%), to 55/163 (33.7%), 85/151 (57.0%), and 109/147 (74.1%), respectively. The difference was statistically significant (P < 0.001). All-type VLS procedures were 16 (3.5%), 61 (16.2%), 103 (27.0%), and 126 (38.6%) (P < 0.001). Conversions to open surgery of attempted laparoscopic colorectal resections were 17/278 in the overall series (6.1%), and 12/207 during Phase-3 and Phase-4 (4.3%). Severe (grades IIIb-to-V) postoperative complications of VLS colorectal resections were 9.1% in Phase-1, 12.7% in Phase-2, 12.8% in Phase-3, and 5.3% in Phase-4 (P = 0.677), with no significant differences with open resections in each of the four phases: 9.4% (P = 0.976), 11.1% (P = 0.799), 13.8% (P = 1.000), and 8.3% (P = 0.729). Despite the difficulties deriving from the COVID-19 outbreak, our experience suggests that volume of laparoscopic colorectal surgery can be significantly and safely increased in a specialized surgical unit by means of strict operative protocols.

A prognostic score for patients resected for gastric cancer.

This paper describes the construction, validation and use of a simple prognostic score suitable for predicting survival of patients undergoing a curative gastric resection. Using death from all causes as outcome, the prognostic significance of age, sex, tumour site, stage of disease (nodal status and wall invasion), surgical treatment and histological type was investigated in a set of 213 patients recruited in a multi-centre clinical trial. A Weibull multiple regression model was adopted to evaluate the joint effect of these variables on survival. From a full model, containing all the variables, a final parsimonious model was obtained by means of a backward selection procedure. The prognostic score is based on the final model, including four variables which are easily detected in every institution: age, wall invasion, site of tumour, and nodal status. Three groups of patients with different probabilities of surviving 5 years from surgery were identified: group I (survival probability > or = 70%), group II (30%-69%) and group III (< 30%). The prognostic score, obtained from the multicentre trial patients, was tested on a set of 135 consecutive patients in an independent institution, confirming its reliability in predicting survival. The score system presented can supply a simple tool for classifying patients radically operated for gastric cancer into three well discriminated groups from the prognostic point of view.

Comparing reconstruction with Roux-en-Y to a pouch following total gastrectomy.

BACKGROUND: Although more than 50 methods of gastric replacement after total gastrectomy have been used, none of them has demonstrated a substantial nutritional advantage. The Roux-en-Y esophagojejunostomy is still the preferred type of reconstruction, more because of its simplicity than the lack of postprandial disturbances. STUDY DESIGN: A randomized controlled trial was conducted to compare two reconstructive procedures, Roux-en-Y esophagojejunostomy (n = 24) and Hunt-Rodino-Lawrence pouch (HRL, n = 24), by evaluating nutritional status (body weight, arm circumference, and serum nutritional parameters), nutritional habits (number of meals, energy intake, and postprandial disturbances), and emptying time of the jejunal loop. RESULTS: Twenty-seven patients were studied two years after operation (12 had undergone Roux-en-Y and 15 had undergone HRL). No difference was found in either postoperative morbidity or mortality, emptying time, frequency of meals, or variation of body weight. Postprandial disturbances were more frequent in patients having Roux-en-Y. In a subset of patients, there was a correlation between nutrient intake and change of body weight, but not between nutrient intake and type of reconstruction. CONCLUSIONS: The simple use of a reservoir such as the HRL pouch after total gastrectomy is of no benefit to the patient as compared with the Roux-en-Y reconstruction.

Chondrosarcoma--55 unreported cases: epidemiology, surgical treatment and prognostic factors.

Fifty-five cases of chondrosarcoma, seen at the Istituto Nazionale Tumori of Milan, were reviewed to collect epidemiological data in order to verify therapeutic effects and the validity of possible prognostic factors. Epidemiological data according to sex and age distribution and skeletal location were in accordance with the literature (male:female ratio, 1.8; mean age, 37 years, 62% of lesions located in the pelvic or scapular girdle). Of 52 cases operated on with the intent of radicality, 5 were intralesional operations, 20 marginal and 27 radical. The local recurrence rate was dependent upon the degree of surgical radicality (60%, 35% and 11% respectively for intralesional, marginal and radical surgery). Age, site, type of first symptom and pathological grading were significant as prognostic factors. The type of the first symptom was directly correlated to the site of the tumour. Sex, tumour size and degree of surgical radicality were not relevant.

How long is a 6 cm margin of resection in the stomach?

In order to assess whether the gastric wall undergoes some change in length during gastrectomy operation for cancer, we measured the variation in length of the anterior gastric wall in 25 patients. The first measurement was made at the beginning of laparotomy by placing two stitches on the anterior gastric wall and registering the distance between them. A second and a third measurement were recorded when the stomach was fully isolated just before its transection and subsequently on the anatomic table. The results indicate that the usual recommendations made by pathologists to maintain a 6 cm margin of tissue clearance proximally to the cephalic edge of the tumour, can be safely followed by the surgeons who can correctly assess, during operation, the distance between tumour and the desirable line of transection since no misleading reduction in size of the resected specimen takes place.

Total nutritional manipulation in humans: report of a cancer patient.

We report here on a patient requiring home total parenteral nutrition (TPN) for a huge intra-abdominal desmoid associated with chronic small bowel pseudo-obstruction who was kept on a special lipid-based calorie regimen for 5 months. The rationale was to attempt to feed the host with a minimal stimulation of tumour growth by using lipid as caloric substrate instead of glucose which is utilized by the tumour. Gluconeogenesis was tentatively inhibited at the level of phosphoenolpyruvate-carboxy-kinase through the oral intake of hydrazine sulphate. The regimen consisted of 28 non-protein lipid Kcal/kg/day plus 1.5 g amino acid per kg/day. Only a small amount of glucose (approx. 40 g/day) was allowed. Tolerance to the regimen was good and body weight maintained. Liver enzymes remained within the normal range and liver sonography was normal throughout the 5 months' therapy and there were no episodes of symptomatic hypoglycaemia. The tumour volume did not substantially change.

Comparison of nutritional status after total or subtotal gastrectomy.

Forty-four disease-free patients were evaluated a mean of three years after total gastrectomy (TG) or subtotal gastrectomy (SG) for cancer. The investigation encompassed nutritional assessment by standard anthropometric and biochemical indices; evaluation of the nutritional intake based on 24 h recall and of appetite status on a visual analogue scale; and anamnestic analysis of postcibal symptoms and syndromes. Body weight had declined progressively until the 15th postoperative month after both TG and SG. Weight loss, as well as the general nutritional status index (actual body weight/usual body weight +/- actual body weight/desirable body weight + measured arm muscle circumference/reference arm muscle circumference x 33), had dropped more significantly in patients undergoing TG than those having SG (p less than 0.05). The principal body compartment change was observed in the fat content which was severely depleted, whereas the somatic proteins were relatively spared and the visceral proteins and remaining biochemical variables were in the normal range. Protein intake was not significantly different in the two groups, but caloric intake was significantly lower and the number of meals significantly higher after TG (p less than 0.05). These data suggest that malnutrition after TG is relatively mild and that this operation causes only a limited impairment of the nutritional state, and spares most of the nutritional variables of clinical interest in comparison with SG. These findings argue in favor of TG when clinically indicated without excessive concern about postoperative nutrition.

Blood culture as a guide for the diagnosis of central venous catheter sepsis.

The purpose of this study was to evaluate the predictability of peripheral (PBC) and central blood cultures (CBC) in the diagnosis of central venous catheter (CVC) sepsis (growth of the same microorganism in the peripheral blood and on the catheter tip). The contamination and sepsis rate of 256 CVCs and the relationship with PBC and CBC was evaluated in a series of cancer patients included in a prospective protocol on CVC infections at the Istituto Nazionale Tumori of Milan. Overall CVC contamination was 10.5% and sepsis rate was 3.1%. The positive predictive value for CVC sepsis was 46.7% for positive PBC + CBC, 38.1% for positive PBC and 16.6% for positive CBC. The small gain in the predictive positive value obtained with the use of PBC and CBC and the slight increase in the specificity does not justify, in our opinion, the use of both these parameters for the diagnosis of CVC sepsis.

A new approach to the diagnosis of central venous catheter sepsis.

One hundred forty-four cancer patients harboring a central venous catheter (CVC) were prospectively investigated to assess the relationship between hub culture, clinical assessment of sepsis before removal, and CVC sepsis. In 22 patients, the CVC was removed because of clinical assessment of catheter sepsis expressed by the staff prior to the removal. For each CVC removal, peripheral blood (qualitative method), hub, and CVC tip (quantitative method) cultures were performed. Clinical sepsis (disappearance of fever after CVC removal) was observed in 13 patients, microbiologic "sepsis" (identification of the same microorganisms on the CVC tip and in the peripheral blood) in seven patients, and clinical and/or microbiologic sepsis in 16 patients. Staphylococcus epidermidis was the microorganism most frequently identified. Hub culture was negative in 48% and positive for a low number and a high number of colonies in 35% and 17%, respectively. The predictive value of hub culture was 96% when testing negative and 8% and 37% (p = 3 x 10(-3)) when testing positive for a low and a high number of colonies, respectively. Predictive values of clinical assessment were 55% if positive and 97% if negative. Combining hub cultures and clinical assessment, the risk of sepsis varied from 2% with both evaluations negative to 89% in the case of positive clinical assessment associated with positive high-count hub. Inasmuch as the CVCs used have a disposable hub, it is possible to have an accurate diagnosis of CVC sepsis without removing the CVC.

Perioperative total parenteral nutrition in malnourished, gastrointestinal cancer patients: a randomized, clinical trial.

BACKGROUND: Clinical trials investigating the potential benefits of perioperative total parenteral nutrition (TPN) for reducing the risk of surgery in malnourished cancer patients have yielded controversial results. METHODS: Ninety elective surgical patients with gastric or colorectal tumors and weight loss of 10% or more of usual body weight were randomly assigned to 10 days of preoperative and 9 days of postoperative nutrition vs a simple control group. The daily per kilogram body weight TPN regimen included 34.6 +/- 6.3 kcal nonprotein and 0.25 +/- 0.04 g nitrogen per kilogram in a volume of 42.6 +/- 7.3 mL of fluid. The glucose-to-fat calorie ratio was 70:30. Control patients did not receive preoperative nutrition but received 940 kcal nonprotein plus 85 g amino acids postoperatively. RESULTS: Complications occurred in 37% of the patients receiving TPN vs 57% of the control patients (p = .03). Noninfectious complications mainly accounted for this difference, which was 12% vs 34%, respectively (p = .02). Mortality occurred in only 5 of the control group patients (p = .05). The total length of hospitalization for TPN patients was longer than for control (p = .00), whereas the length of postoperative stay in the two groups did not differ significantly. CONCLUSIONS: This study shows that 10 days of preoperative TPN that is continued postoperatively is able to reduce the complication rate by approximately one third and to prevent mortality in severely malnourished patients with gastrointestinal cancer.

Indoor dose in Milano (Italy).

This work is related to the problem of providing a more careful evaluation of the population exposure to natural radiation background, and was carried out in connection with the ENEA programmes on the assessment of indoor exposure doses in Italy. A large number of works in recent years have pointed out the main contribution of the indoor dose to the natural dose received by the members of the general population, and the large contribution of radon daughter inhalation. Different building materials and techniques lead to different exposure doses. In Milano such materials can be quite different in kind (bricks, concrete, gypsum by-products, tile-stone, paving-tile, etc.) and origin (national and foreign). For this reason, a collection of indoor doses in Milano is not only complementary to analogous investigations carried out in other Countries of the European Communities, but the obtained information can be compared with other large European towns. As agreed, a large number of various dwellings in Milano were investigated to evaluate the external gamma-ray exposure rate, and measurements of indoor radon concentrations were performed for some of them. Various typical building materials used in Lombardia were also analysed by means of gamma-ray spectrometry.

Catheter sepsis from infusate contamination.

Ten patients harboring an indwelling CVC with contamination of the infusate are described. Six patients developed sepsis, which was resolved in all patients except one who died from misdiagnosed septic shock. The majority of microorganisms responsible for the infusate contamination were opportunistic pathogens and in five cases were S. epidermidis. There was no apparent correlation between contamination rate of the infusate and subsequent sepsis of the patients. Reasons for the high prevalence of Staphylococcus epidermidis include ubiquitous diffusion of this microorganism, marked affinity for prosthetic devices, especially by the slime-producing strains, and increased susceptibility of debilitated cancer patients to infection. Recognition that the possibility exists for infusate contamination during compounding should alert all members of the Nutritional Support Team to use aseptic technique when preparing and handling the intravenous solutions. Infusate-related sepsis is a potentially lethal but preventable event.

Delayed cutaneous hypersensitivity reaction to carcinoembryonic antigen in cancer patients.

The delayed cutaneous hypersensitivity reaction to carcinoembryonic antigen (CEA) was tested in 84 patients with different diseases including large bowel adenocarcinoma and breast carcinoma, with or without metastasis, liver cirrhosis and inflammatory or degenerative diseases. Positive skin test to CEA was observed in a small proportion (11%) of the patients tested. No difference in positive skin test reactions was observed in the 6 different groups of patients. Similar delayed cutaneous hypersensitivity reactions were found to various amount of CEA ranging from 0.5 to 25 micrograms. No correlation was seen between the results of skin test and blood CEA levels.

Surgical treatment of recurrences following sphincter-saving procedures for cancer of the rectum.

Of 77 patients treated by sphincter-saving procedures (anterior or pull-through resection) for cancer of the rectum, 17 (22%) developed a local recurrence; 10 of them were submitted to abdominoperineal resection. The "rescue" operation was technically difficult, and major problems, including large blood loss and ureteral complications, were often encountered. At operation the recurrent malignancy was more extended than preoperative diagnosis suggested, and reoperation was not macroscopically radical in one case. All patients but one died for the disease after a mean period of 19.8 months. Causes of local failure are analyzed to interpret the rational of surgical approach related to the poor results observed; intensive follow-up programs are also discussed. It is concluded that surgical treatment of local recurrence after sphincter-saving procedures must be reserved only to selected patients, with limited malignancy, and adjuvant radiochemotherapy should also be employed.

Double-contrast barium enema and computerised tomography in the pre-operative evaluation of rectal carcinoma: are they still useful diagnostic procedures?

PURPOSE: In modern management of rectal carcinoma, the preoperative evaluation of disease parameters is important for selection of therapeutic options. Such parameters are currently defined through endorectal ultrasonography or endoscopic ultrasonography. A retrospective analysis of the parameters obtained with double-contrast barium enema (DCBE) and endorectal balloon computed tomography (CT) was conducted to verify the diagnostic reliability of the radiological techniques and to establish whether there is still an indication for their use. METHODS: 53 consecutive patients with adenocarcinoma of the distal half of the rectal ampulla underwent double contrast barium enema examination and CT of the pelvis with endorectal balloon. On the basis of the DCBE and CT assessment we evaluated: 1) the distance between the cranial extremity of the anal canal and the distal margin of the neoplasm; 2) the radial diffusion of the tumor; 3) the metastatic involvement of the perirectal and inferior mesenteric lymph nodes. RESULTS: 1) CT and DBCE measurements of the distal margin tended to coincide, but both tended to overestimate the measurement when compared to the pathologic examination; 2) in the identification of neoplastic infiltration of perirectal fat (T3) CT had 100% sensitivity, 78.7% specificity and 86.8% accuracy; 3) the CT sensitivity for detecting lymph node metastasis was 52.6%, specificity 85.3% and accuracy 73.6%. CONCLUSIONS: The diagnostic information provided by the radiological examinations is comparable to that of clinical and instrumental methods currently employed for staging of rectal carcinoma, although the latter are preferred because they are more readily accessible and less costly. DCBE and CT can therefore be usefully employed for staging of cancer of the rectum in those cases in which there are limitations of the current standard methods.

Nutritional support in patients with cancer of the esophagus: impact on nutritional status, patient compliance to therapy, and survival.

AIMS AND BACKGROUND: The multimodal approach to patients with esophageal squamous cell carcinoma often includes polychemotherapy combined with radiation therapy. Cancer dysphagia and drug-related anorexia, mucositis and vomiting can all lead to malnutrition. The aim of this study was to analyze the impact of the administration of enteral nutrition (EN) on the patient's nutritional status, tolerance of chemotherapy and radiotherapy, and final oncological outcome. METHODS: Fifty esophageal cancer patients who were to be submitted to chemotherapy (days 1-4 5-fluorouracil (FU) 1 g/m2/day and cisplatin (CDDP) 100 mg/m2/day 1) for two cycles plus radiotherapy (31 Gy) were referred to the Nutrition Support Unit prior to any therapy due to their malnourished status. Twenty-nine dysphagic patients received nutrition via tube (37 kcal/kg/day + 2.0 g proteins/kg/day for 34 days), while 21 others who were not dysphagic were given a standard oral diet (SD). The patients who received EN had a more severe weight loss than the SD patients (16.8% vs 12.8%, P <0.02). RESULTS: The dose of administered EN represented 86% of the planned support, and 70% of the nutritional therapy was administered in the home setting. Administration of EN support resulted in stable body weight and unchanged levels of visceral proteins, while SD patients had a decrease in body weight, total proteins and serum albumin (P <0.01). There was no difference between the two groups in terms of tolerance and response to cancer therapy, suitability for radical resection and median survival (9.5 months). CONCLUSIONS: EN in patients with cancer of the esophagus undergoing chemotherapy and radiotherapy is well tolerated, feasible even in the home setting, prevents further nutritional deterioration and achieves the same oncological results in dysphagic patients as those achieved in non-dysphagic patients.

Surgical treatment of gastric metastases from cutaneous melanoma: experience of the National Cancer Institute of Milan.

AIM: To evaluate the role of a surgical approach in patients affected with gastric metastases from cutaneous melanoma. METHODS: A retrospective review of our local melanoma database of 2100 patients identified 31 cases with gastric metastatic deposits. Nine of them were considered candidates for surgical resection. RESULTS: Median overall survival of the 9 patients who underwent surgery was 14.2 months. Six (67%) underwent a local radical resection of disease, and 3 (33%) had a simple exploratory laparotomy. The median survival was 21.6 months (range, 4-32 months) for the subset receiving radical surgery and 3.6 months (range, 2-6 months) for the patients who had no resection. Median follow-up was 14.2 months. No specific correlation of serologic LDH levels and final outcome, as documented elsewhere, was observed. A marked decreased or substantial remission of symptoms with an improvement in quality of life was observed in all radically resected patients. CONCLUSIONS: Patients with gastric metastases from melanoma may benefit from surgery if all macroscopic disease can be removed. In addition, gastric resection in patients with symptomatic melanoma spread to the stomach provides important symptomatic palliation.

Differential effects of organic and inorganic selenium compounds on adenosine deaminase activity and scavenger capacity in cerebral cortex slices of young rats.

Selenium (Se) has anti-inflammatory and antioxidant properties and is necessary for the development and normal function of the central nervous system. This study was aimed to compare the in vitro effects of 3-methyl-1-phenyl-2-(phenylseleno)oct-2-en-1-one (C21H2HOSe; organoselenium) and sodium selenate (inorganic Se) on adenosine deaminase (ADA) activity, cell viability, lipid peroxidation, scavenger of nitric oxide (NO) and nonprotein thiols (NP-SH) content in the cerebral cortex slices of the young rats. A decrease in ADA activity was observed when the slices were exposed to organoselenium at the concentrations of 1, 10 and 30 µM. The same compound showed higher scavenger capacity of NO than the inorganic compound. Inorganic Se was able to protect against sodium nitroprusside-induced oxidative damage and increased the NP-SH content. Both the compounds displayed distinctive antioxidant capacities and were not cytotoxic for the cerebral cortex slices in the conditions tested. These findings are likely to be related to immunomodulatory and antioxidant properties of this compound.

Rutin restores adenosine deaminase activity in serum and the liver and improves biochemical parameters in streptozotocin-induced diabetic rats / Rutina restaura a atividade da Adenosina desaminase no soro e no fígado e melhora os parâmetros bioquímicos em ratos diabéticos induzidos por estreptozotocina

ABSTRACT denosine deaminase (ADA) is a critical control point in the regulation of adenosine levels. This study aimed to investigate the effects of a polyphenolic flavonoid, rutin, on the activity of ADA in serum, the cerebral cortex, liver, kidney, and biochemical parameters in diabetic rats. The animals were divided into four groups (n=6) for the following treatments: control; diabetic (streptozotocin 55 mg/kg); diabetic with rutin (100 mg/kg/day); diabetic with glibenclamide (10 mg/kg/day). After 30 days, ADA activity and biochemical parameters were analyzed. The ADA activity in the serum was significantly elevated in the diabetic group compared to the control group (p<0.01). The treatment with rutin prevented the increase in ADA activity in the STZ-induced rats when compared to control group. Our data showed that rutin reduced glucose, LDL levels, and hepatic enzymes in comparison with the control group. These results demonstrate that the increase of ADA activity observed in diabetic rats may be an important indicator of the immunopathogenesis of hyperglycemic disorders and suggest that rutin is important for regulating the enzymatic activities associated with immune, hyperglycemic, and inflammatory response in diabetes mellitus.

RESUMO A Adenosina desaminase (ADA) representa um ponto de controle crítico na regulação dos níveis de adenosina. A rutina, um flavonóide polifenólico presente em muitas plantas, foi testado para verificar a sua influência na atividade da ADA no soro, córtex cerebral, fígado rim e parâmetros bioquímicos em ratos diabéticos. Os animais foram divididos em quatro grupos cada grupo com 6 animais), tal como: controle; diabética (estreptozotocina 55 mg/kg); diabética + rutina (100 mg/kg/dia); diabético + glibenclamida (10 mg/kg/dia). Após 30 dias foram analisadas a atividade da ADA sérica e tecidual e parâmetros bioquímicos. A atividade de ADA no soro foi significativamente elevada no grupo diabético quando comparado ao grupo controle (p<0,01). O tratamento com Rutina preveniu o aumento na atividade da ADA nos ratos diabéticos, quando comparado com o grupo controle. Os resultados mostraram que a rutina reduziu a glicose, os níveis de LDL e as enzimas hepáticas, em comparação com o grupo controle. Estes resultados mostram que o aumento da atividade da ADA observado em ratos diabéticos pode ser um indicador importante da imuno-patogênese de perturbações hiperglicêmicas e sugerem que a Rutina é importante na regulação das atividades enzimáticas associadas com a resposta imunitária, hiperglicêmica e inflamatória no Diabetes mellitus.