Dissemination metastasis after laparoscopic colorectal surgery versus conventional open surgery for colorectal cancer: a metanalysis.

PURPOSE: The purpose of this systematic review is to evaluate and compare the risk of dissemination metastasis (wound, port-side metastases and peritoneal seeding) after laparoscopic colorectal surgery and conventional open surgery for colorectal cancer. MATERIALS AND METHODS: The Authors searched relevant randomized controlled trials between January 1998 and July 2012. RESULTS: Wound, port-site metastases and peritoneal seeding were rare and no significant differences occurred between the two groups. The port-site and extraction site recurrence were likely to be the results of suboptimal surgical techniques and occurred in the early phase of the learning curve. The authors also found no significant differences in overall, local and distant recurrences. No significant differences between laparoscopic and open surgery were found in cancer-related mortality during the follow up period of the study (7 RCTs, 3525 patients, 12.8% vs. 14.00%; OR (fixed) 0.83, 95% CI 0.68-1.02), with no significant heterogeneity (p = 0.35). CONCLUSIONS: The literature supports the implementation of laparoscopic surgery into daily practice. Laparoscopic surgery can be used for safe and radical resection of cancer in the right, left, sigmoid colon and rectum. However further studies should address whether laparoscopic surgery is superior to open surgery in this setting.

Clinical presentation and outcome of squamous cell carcinoma of the anus in HIV-infected patients in the HAART-era: a GICAT experience.

INTRODUCTION: Squamous cell carcinoma of the anus (SCCA) is a relatively uncommon cancer. In the HIV-positive patients the introduction of the highly active antiretroviral therapy (HAART) did not change the incidence of SCCA. BACKGROUND AND OBJECTIVES: This paper describes the Italian Cooperative Group on AIDS and Tumours (GICAT) experience on HIV-positive patients with SCCA. The purposes of this retrospective study were: first to describe the clinical presentation and outcome of HIV-positive patients with SCCA, second to compare them with the ones reported in the literature. PATIENTS AND METHODS: Between July 2000 and March 2010 we retrospectively collected epidemiological, clinical and survival data from 65 patients with SCCA in HIV infection enrolled within the GICAT. RESULTS: Fifty-three (81.5%) patients were male. The majority of patients (40%) were homosexual Forty-three patients (66.1%) were diagnosed with HIV before 1996. Thirty-five patients (54%) had CD4-positive cells count > 200 / mm3 and 28 patients (43%) had viral load > 50 cp / ml at the time of SCCA diagnosis. The median time difference between HIV and SCCA diagnosis was 120 months (range 10-282 months). Sixty-one patients (96.8%) received HAART at SCCA diagnosis. Fifty-two patients (80%) had performance status (PS) 0-1 at the time of SCCA diagnosis. Twenty-seven patients (41.5%) underwent surgery with curative intent. Thirty-five patients (53.9%) were given combined modality therapy (CMT) consisting of pelvic radiotherapy with concurrent chemotherapy. No grade 3/4 haematological or extra-haematological effects were observed in our patients. CONCLUSIONS: In summary, despite the retrospective nature of analysis, the absence of patient strict criteria of inclusion/exclusion, our data on HIV-positive patients with SCCA, compared both to general population and to small reports on HIV-positive patients present in the literature, are promising.

Diet and pancreatic cancer: many questions with few certainties.

UNLABELLED: BACKGROUND, OBJECTIVES: Pancreatic cancer ranks fourth for cancer mortality for men and women in the United States. This is a particularly devastating cancer since the case-fatality proportion approaches 90% within 12 months following diagnosis. Therefore, understanding the etiology and identifying the risk factors are essential for the primary prevention of this deadly disease. Of the few potentially modifiable risk factors that have been identified, cigarette smoking, history of diabetes mellitus, and obesity seem to be among the most consistent, but the effect of dietary factors is still unclear. The aim of our study is to review of the literature examining the potential role of carbohydrates, fatty acids, meat, fruit and vegetables, alcohol. DISCUSSION: Although large prospective cohort studies with questionnaire based analyses will continue to have much to offer in defining predisposing factors for difficult diseases, such as pancreatic cancer, unfortunately dietary questionnaires do not reflect the bioavailability of the nutrients from various foods, the level of absorption from the digestive tract, or individual differences in metabolism. CONCLUSIONS: Greater use of participant-derived biological samples, banked plasma, germline DNA, and tumour tissue samples may help to the understanding of pancreatic cancer pathogenesis.

Leukocyte interferon alpha early retreatment for Child A HCV genotype 1b-infected cirrhotics intolerant to pegylated interferons.

BACKGROUND AND AIM: The pegylated interferon (PEG-IFN)/ribavirin combination has been shown to be effective for hepatitis C virus (HCV)-related compensated cirrhosis, but it frequently causes adverse events, leading to premature termination. In this open study we evaluated the safety and efficacy of early retreatment with leukocyte IFN-alpha in Child A HCV genotype 1b-infected cirrhotics intolerant to PEG-IFNs. PATIENTS AND METHODS: 61 patients were treated with PEG-IFN (either alpha-2b 1.2-1.5 lg/kg weekly or alpha-2a 180 lg/weekly) plus ribavirin (1,000 mg/day) for 48 weeks. During the first 6 months, patients who discontinued treatment because of side effects were retreated with leukocyte IFN-alpha (6 MU/three times weekly) plus ribavirin (1,000 mg/day) for 48 weeks after a 1-month wash-out. The primary end points were safety and efficacy in terms of sustained virological response (SVR). RESULTS: At intention-to-treat analysis of the 61 patients receiving PEG-IFNs plus ribavirin revealed that 18 (29.5%) obtained a SVR. 16 patients (26.2%) prematurely discontinued treatment and were retreated with leukocyte IFN-alpha plus ribavirin. The switch was well tolerated, and all but one patient completed the treatment period. As a result of the switch, 4 of these 16 (25%) patients also obtained a SVR. Thus, the overall SVR rate of this study was 22/61 (36.1%). CONCLUSIONS: These results suggest that an early retreatment with leukocyte IFN-alpha may be a safe and valid therapeutic option among difficult-to-treat HCV cirrhotic patients who cannot tolerate PEG-IFNs.

Acute renal failure due to ureteral obstruction in a kidney transplant recipient with Candida albicans contamination of preservation fluid.

Reported rates of positive preservation fluid cultures range from 5% to 23%, with fungi accounting for 2-10% of all positive cultures. We report the case of a kidney transplant recipient who received a graft with preservation fluid contaminated by Candida albicans, who developed acute renal failure due to ureteral obstruction by fungus balls. The patient was treated with voriconazole with complete restoration of graft function. This rare clinical entity demonstrates the usefulness of pre-transplant cultures of preservation fluid, in order to identify a group of patients who could benefit from antifungal prophylaxis therapy and thereby prevent the need for graft nephrectomy.

Retrospective survey on laparoscopic cholecystectomy in the cirrhotic patient.

Cholelitiasis is a common disease in patients with liver cirrhosis, mainly due to intravascular haemolysis and functional alterations of the gallbladder. In Child A and B cirrhotics laparoscopic cholecystectomy (LC) demonstrated the same advantages and safety as in the non cirrhotic patients. On the contrary, indications for surgery in Child C patients should be carefully evaluated. Nevertheless, the current number of patients with Child C cirrhosis submitted to LC is too low to extrapolate definitive data. Here we report our observations on a retrospective case series of LCs performed for symptomatic biliary disease in patients affected with liver cirrhosis. Both medical records and surgical registers were used to collect pre-operative, intra-operative and post-operative data from 40 cirrhotics out of 921 patients operated by laparoscopic cholecystectomy between November 1996 and November 2006. All patients underwent LC because of symptomatic disease. The average duration of the laparoscopic intervention was 111 minutes (60-220 minutes) distributed as follows according to the severity of liver disease: 66 minutes (48-87) in the Child A group, 108 minutes (91-119) in the Child B group and 138 minutes (110-160) as refers to Child C cirrhotics. Median blood loss was quantified as 80 ml (28-97) in Child A group, 155 ml (130-180) in Child B group and 300 ml (220-500) among Child C cirrhotics. The median length of hospital stay was 6 days (3-9 days) in the Child A group, 9 days (7-13 days) in the Child B group and 21 days (16-27 days) in Child C cirrhotics. Three cases out of 40 (7,5%) died: 2 Child C and 1 Child B. In conclusion, this study confirms that in patients affected with Child A and B cirrhosis LC may be safely performed either in emergency or in election whereas as refers to Child C cases we have observed a slightly higher mortality but a relevant higher impact of non lethal complications.

Total Thyroidectomy: the first, the best. The recurrent goiter issue.

BACKGROUND: Redo surgery for recurrent goiter is still now, even in experienced hands, followed by higher morbidity than primary total thyroidectomy. Suppressive Levothyroxine therapy failed to improve the recurrence rate, while inducing a subclinical hyperthyroidism. Aim of this study is to verify morbidity after total thyroidectomy for benign thyroid diseases, both primary and after recurrence. MATERIALS AND METHODS: A series of 20 cases of total thyroidectomy for recurrent benign diseases (RG), performed between January 2001 and December 2013 was compared with 225 cases of primary total thyroidectomy (PT) . Cancers, even incidentally diagnosed, were excluded. At least a 12 months follow up was accomplished. Due to the small size of the sample for RG, statistical analysis was performed by Fisher test only. RESULTS: Postoperative complications were Transient hypocalcemia: 5 (25%) in RG and 18 (8%) in PT, Permanent hypocalcemia only 2 (10%) in RG (significant for p <0,05), Transient RLN deficit 5 (25 %) in RG and 6 (2.6%) in PT (significant for p< 0.05). CONCLUSIONS: Differences in incidence of perioperative complications cannot be advocated to justify a less than total thyroidectomy even in benign disease setting. The need for a redo surgery with its burden of morbidity is per se a good reason to avoid a conservative surgery. Further, suppressive therapy with Levothyroxine often fails to avoid recurrence, inducing in some cases a specific morbidity. Our experience confirms the results of our previous experiences and of literature on this topic: the best management of recurrent goiter is its prevention by primary total thyroidectomy.

Thyroid transcription factor 1 (TTF-1) and p63 expression in two primary thyroid papillary carcinomas of branchial cleft cysts.

Malignant lateral cervical cysts can be related to metastatic tumors or rarely to primary thyroid carcinoma arising in branchial cleft cysts. This study evaluates the expression of thyroid-associated transcription factor-1 (TTF-1) and p63 in three branchial cleft cysts and in two primary thyroid papillary carcinoma of branchial cleft cysts. TTF-1 was negative in the nuclei of the lining epithelia of branchial cleft cysts, but positive in the adjacent normal thyroid tissue, while TTF-1 was positive in the nuclei of the lining epithelia and in the nuclei of the papillae and follicles in branchial cleft cysts with ectopic thyroid carcinoma. P63 was positive in the nuclei of the lining epithelia of branchial cleft cysts, but negative in the adjacent normal thyroid tissue. Papillary thyroid carcinoma of branchial cleft cysts displayed p63-positive foci. In conclusion, our results demonstrate that TTF-1 cannot distinguish between primary and metastatic tumors of branchial cleft cysts. The detection of p63 in papillary thyroid carcinomas of branchial cleft cysts could suggest that p63 contributes to the onset of this tumor. It is really important to evaluate if the case has a metastatic derivation or represents papillary thyroid carcinoma arising in ectopic thyroid tissue in a branchial cleft cyst.

A pilot study about the oncologic safety of colonic self-expandable metal stents (SEMS) in obstructive colon cancer: is occlusion always better than "silent" perforation?

OBJECTIVE: To evaluate the oncologic safety of colonic self-expandable metal stents (SEMS) in obstructive colon cancer. PATIENTS AND METHODS: We retrospectively reviewed all the patients who were treated with endoscopic placement of a self-expandable metallic stent (SEMS) at our institution. RESULTS: A total of 26 patients were identified during the study period, of which 24 patients (92.30%) were treated with SEMS as a bridge-to-surgery and 2 (7.69%) as palliation. In 22 cases (80.76%), the stenosis was localized to the left side. Clinical success with resolution of bowel obstructions was achieved in 22 (84.61%) patients within a short period of time. Among patients treated successfully with SEMS insertion as bridge to surgery (n = 22), 20 (90.9%) underwent one-stage surgery with primary anastomosis while 2 patients (9.09%) underwent colostomy due to intraoperative evidence of a covered perforation by cancer tissue in the pelvis. Patients with subclinical perforation developed an early peritoneal carcinomatosis, 10 patients treated with curative intent subsequently developed liver metastasis after 24 months. CONCLUSIONS: We reported an overall poor outcome among patients treated with the insertion of SEMS. This led us to think that, in some cases, occlusion may be better than a "silent" perforation.

[Complications of idiopathic chronic colitis]. / Le complicanze delle coliti croniche idiopatiche.

The Authors reviews the acute and chronic complications of chronic idiopathic colitis in a series of 112 cases of his own observation. He discusses perforation, toxic megacolon and massive hemorrhage in terms of their pathogenesis, diagnostic procedures and incidence in the course of ulcerative colorectitis (Crohn's disease). He deals to some length with surgical indications and the choice of operation, both being the subject of considerable controversy, and he outlines his own views in the matter. Among chronic local complications he lists benign stenosis, pseudopolyposis, and fistulization; all of which, unlike neoplastic complications, seldom require surgery.

[Does there exist a current indication for myotomy in diverticular disease of the colon?]. / Esiste una indicazione attuale alle miotomie nella malattia diverticolare del colon?

Thanks to advances of gastroenterological and dietary regimen of patient with more complicated diverticular disease of the colon, the surgical indications to myotomy are nowadays very low, if not more at all. The insurgence of complications is naturally a precise indication to demolitive surgery actually with low postoperative morbidity and mortality.

Perforation of a ureteral diverticulum: a case report and review of the literature.

The ureteral diverticulum represents a rare pathology. It is infrequently symptomatic and even more infrequently it manifests itself as an acute event. To our knowledge this is the only case described in the literature of perforated ureteral diverticulum with consequent uroperitoneum.

Laparoscopic repair vs open surgery for incisional hernias: a comparison study.

BACKGROUND: Incisional Hernias complicate 2-11% of laparotomies and the primary closure of the defect is followed by recurrence in 20-46% of patients. In spite of introduction of prosthetic materials and new techniques the rate of failure reduced but a gold standard has not been defined. Laparoscopic approach, recently introduced appears promisingly effective but only few and small series have been published. MATERIALS AND METHODS: Two series of patient, 11 treated by laparoscopic repair (LR) and 15 undergone to open prosthetic repair (OR) are compared with regard to age, sex, previous surgery, number of fascial defects, size and location of hernias, ASA status, operating time, intra and postoperative complications, length of hospital stay, follow up evaluation and hernia recurrence. Prosthetic materials were e-PTFE in LR group and e PTFE or Polypropilene in OR group. Peripherical hernias have been excluded from the study. RESULTS: In LR group has been observed a longer mean operative time and a shorter hospital stay than in OR group. No intraoperative complication was observed in LR and 1 in OR group. Early and late complications were more frequent in OR than in LR group but the removal of prosthesis was not needed in any case. Mean follow up is 40 months for OR and 18 for LR group with no recurrences in both groups. CONCLUSIONS: Laparoscopic repair of incisional hernias appears in our experience as good as open prosthetic repair, with all generic vantages related with mini-invasive approach and the specific one of lesser manipulation of prosthesis and fewer infective complications.

Adult intestinal intussusception: a case report of a rare clinical entity.

Intussusception in adult is a rare entity that challenges the surgeon opening a wide range of issues in order to define the etiology and therapeutic strategy. Whether to resect or not the bowel is the main question. The answer can be given only after having seen the site of obstruction and the etiology. Colonic intussusception is best treated by resection. Also small bowel intussusception can require resection if a neoplasm is the cause. Peutz Jeghers can be one of these causes as is seen in the case we report.

Ductal carcinoma in situ (DCIS) of the breast: thirty-two consecutive cases under 50 yrs detected by mammography: treatment and results.

Thirty-two consecutive cases of ductal carcinoma in situ of the breast in women under fifty are presented. Diagnostic procedure, pathological aspects, treatment and outcome are reported. All the patients had their cancer diagnosed by mammography. The tumor was marked by stereotactic or ultrasound guided localization. Lumpectomy without axillary node dissection was the surgical treatment of thirty lesions with good cosmetic results; radiation therapy was advised in all of these cases. In two cases mastectomy with immediate reconstruction was performed because of the multifocality of the cancer, none of the patients experienced local or distant recurrence. This experience emphasizes the importance of mammographic screening for women 40 years of age, in fact this approach allowed the diagnosis of a large number of DCIS. A correct definition of the problem and a multidisciplinary therapeutical approach is warranted to prevent the high local recurrence rate reported in the past.

Spontaneous rupture of a giant hemangioma of the liver.

Hemangiomas are frequent benign tumors of the liver. Symptoms (abdominal pain and fullness) are mostly seen in giant lesions. Rupture is the most severe complication, can occur spontaneously, with intraperitoneal bleeding, in 1-4% of hemangiomas and has been described in about 30 cases in the international literature with a high mortality (about 60%). This complication is the principal indication for surgery. Although spiral CAT scan and MR are actually the most efficacious imaging methods for study of liver hemangiomas, after Echography, emergency techniques that allows a simultaneous therapeutic approach--as is angiography--are preferable. Trans-arterial embolization (TAE) is in fact useful to stop bleeding and then to perform a safer surgery. A successful embolization can delay the surgical resection of the hemangioma for the time necessary to recover from the hemodynamic distress. Aside from the success of angiographic approach, surgery remains mandatory, effective in stopping the bleeding and in preventing re-bleeding or other complications of TAE such as abscess, fever, etc.. Intraoperative echography currently is the best method to identify vasculo- biliary anatomy and to perform a correct resection. The absence of risk factors for spontaneous rupture of liver hemangiomas, makes this event unpredictable. The best treatment for non-ruptured hemangiomas is still controversial but surgery is usually limited to symptomatic tumors larger than 10 cm.

Cystic dilatation of common bile duct. Case report and review.

The cystic dilatation of the common bile duct is a rare disease in Europe and in the USA; even rarer in adults. In fact less than 30% of cases are described in the over 20's. There are some reports in the elderly. When observed in adults the diagnosis is usually due to the onset of symptoms of associated pathologies or to complications such as cholangitis or cancer. Ultrasound, CT and ERCP allow, in the majority of cases, an adequate pre-operative characterization of the lesion. Intra-operative cholangiography verifies the completeness of surgery--always resective--and excludes residual biliary pathologies. The treatment in patients who already underwent conservative surgery is more complex, in fact, in symptomatic patients a second observation and resection is mandatory while in asymptomatic patients a careful and complete follow-up is adequate without underestimating the cancer risk. Septic and inflammatory complications, especially if chronic or recurring, can damage the liver; here resection or liver transplantation can be necessary. The case here reported is a 24-year-old woman with recurring cholangitis for at least 2 years in which US, CT and ERCP showed a Todani's type I cystic dilatation of the CBD. The total excision of the cyst with hepatic-jejunal anastomosis was carried out. A two-year follow up demonstrated no symptoms and normal laboratory findings; cholangioscintigraphy showed a good hepatic-biliary and anastomotic function.

Nonparasitic cysts of the liver: laparoscopic treatment and long-term results.

BACKGROUND: In the current debate on the indications for the laparoscopic treatment of symptomatic simple hepatic cysts, we emphasize the importance of the exact indications, practicing in an area endemic for hepatic hydatidosis. 8 years ago we started treating laparoscopically the simple hepatic cysts and the polycystosis. Although the laparoscopic approach to parasitic hepatic cysts has been recently introduced, this method has to be the result of a conscious choice and with a presumptive diagnosis to support it. In fact, reviewing the literature on the subject, we realized how most of the intraoperative complications were due to an erroneous preoperative diagnosis, likely to be attributed to the infrequent observation of hepatic hydatid disease. Hence, it seems of primary importance to review the subject in light of the potential dangerous aspect of the laparoscopic approach. METHODS: From 1992 to 2000 we treated 38 cases of benign liver cystic disease (29 echinococcal cysts, 8 symptomatic simple cysts, 1 polycystosis). Due to the endemic nature of the disease in our territory, the preoperative diagnosis was very meticulous (ultrasonography, CT scan, MRI, serology...). Only 9 cases with a preoperative diagnosis of simple cyst or polycystosis were treated with laparoscopic wide fenestration, combined with cholecystectomy in three cases. The follow-up consisted of ultrasonography in the majority of cases and CT scan in 2. RESULTS: All the 9 laparoscopic cases were uncomplicated and no conversions to open procedures have been recorded. The final pathology confirmed the initial diagnosis in all cases. The follow-up ranged between 1 and 8 years and complete remission has been obtained. CONCLUSIONS: The results of this study demonstrate how a meticulous preoperative clinical evaluation can avoid intraoperative complications, making the laparoscopic approach to non-hydatid hepatic cystic disease safe and efficacious. Although laparoscopy is indicated in parasitic liver pathology, the technical approach is very different from the simple cystic disease. In the former, in fact, hepatic resection or pericystectomy are utilized, the results of which have been currently evaluated and compared with the open technique on a large scale on several ongoing trials.

[Prolassomucosectomy according to Longo. Intermediate results]. / La prolassomucosectomia sec. Longo. Risultati a medio termine.

We present results obtained in our first series of 25 patient treated by prolassomucosectomy for haemorrhoidal prolapse with a follow up of 18-36 months. Control of the disease and functional results proved to be optimal. After small early haemorrhages from the suture line, we started adding stitch sutures with haemostatic intent to all three vascular pedicles. Early or late additional complication were not observed.