Extensive surgery and lymphadenectomy do not improve survival in primary melanoma of the anorectum: results from analysis of a large database (SEER).

AIM: Primary anorectal melanoma is a rare disease with a dismal prognosis due to early distant metastasis. The prognostic value of positive loco-regional lymph nodes and the impact of lymphadenectomy on overall survival are unclear. We have investigated this by analysis of data obtained from a national representative database, controlling for potential confounders. METHODS: Data were retrieved from the Surveillance, Epidemiology and End Results (SEER) database. Multiple imputation analysis was performed to deal with missing data. Cox regression models were formulated using different prognostic factors including site of origin, gender, size, race, rate of lymph node metastasis (ratio between positive lymph node count and total lymph nodes harvested), extent of lymphadenectomy (none, level I etc.), age, type of surgery, stage of disease and administration of radiotherapy. RESULTS: Our population was composed of 208 patients who underwent surgery between 1998 and 2012. Rate of lymph node metastasis (P = 0.027; hazard ratio 1.873, 95% CI 1.076-3.261) and race (P = 0.019; hazard ratio 2.291, 95% CI 1.148-4.575) were found to be independent predictors of survival. CONCLUSION: Based on the data retrieved from the SEER database, metastasis to loco-regional lymph nodes is an important prognostic factor, but lymphadenectomy does not improve survival.

Propensity adjusted appraisal of the surgical strategy for appendiceal carcinoids.

BACKGROUND: The treatment algorithm for appendiceal carcinoids is based on tumor size. We wanted to verify whether right hemicolectomy confers a survival advantage compared with appendectomy in patients with tumors larger than 2 cm. METHODS: Data regarding patients with primary carcinoid tumors of the appendix were collected from the Surveillance, Epidemiology, and End Results program database. A propensity score with respect to surgical intervention was calculated with a binary logistic regression including gender, stage of disease, and age as covariates. The groups were matched with a 1:1 ratio, using the nearest neighbor algorithm. A Cox proportional hazards model adjusted for propensity score was implemented to assess the impact of surgical intervention on overall survival. RESULTS: Only stage of disease differed between the groups (p = 0.011). After matching, based on the propensity score, our series was constituted of 109 patients undergoing appendectomy and 109 undergoing right hemicolectomy. The type of surgical intervention failed to reach statistical significance. CONCLUSIONS: Right hemicolectomy did not seem to confer any survival advantage on patients with appendiceal carcinoids with a diameter >2 cm. For this reason, tumor size should not be considered an absolute indication for right hemicolectomy.

A monocentric retrospective analysis about the effects of COVID-19 pandemic on emergency general surgery consultations.

OBJECTIVE: The pandemic effects due to the coronavirus SARS-CoV-2 caused a health emergency. We decided to carry out a study with the aim to investigate the changes in patients' tendencies for admission to the emergency department for surgical diseases, and the related hospitalizations and urgent surgery rates. PATIENTS AND METHODS: We carried out a retrospective, observational study on patients who received emergency general surgery consultation at our University Hospital during the two COVID-19 pandemic periods and on the same dates one year before. The patients' demographic characteristics, their hospitalization in surgical department and the data about those who underwent urgent surgery were retrospectively recorded. RESULTS: In the period March-April 2020 there were 95 surgical visits recorded; among these patients, 25% required hospitalization and 12.63% underwent urgent surgery. In the period November-December-January 2020-2021 there were 156 surgical consultations, of which 35.26% required hospitalization and 21.15% underwent urgent surgery. In both considered periods we found that the number of surgical consultations decreased compared to the same periods of the previous year. Moreover, we found a higher rate of hospitalization and need for urgent surgery. CONCLUSIONS: We documented a significant reduction in the overall number of surgical consultations and an increase of hospitalization and urgent surgery rates.

Basics for surgeons about the immunohistochemistry role in pancreatic NETs diagnosis.

OBJECTIVE: Pancreatic neuroendocrine tumors (pNETs) are neuroendocrine tumors primarily found in the pancreas and upper small intestine. There are ten different pNETs: nine of these are associated with a specific functional syndrome, while one is not associated with a specific hormonal syndrome, and it is called non-functional. Up to 90% of pNETs are classified as non-functional. Immunohistochemistry is essential to define the diagnosis. However, to have a correct and reliable diagnosis, the pathologist must have adequately collected and treated tissue samples, thus the surgeon himself should be aware of some fundamental notions about tissue collection and fixation. Although several common biomarkers have been described to date, Chromogranin A and synaptophysin are currently considered the most specific immunohistochemical markers for NETs. Nearly 100% of pNETs are positive for both synaptophysin and Chromogranin A. Therefore, CgA and synaptophysin are effective for well-differentiated NETs but are less helpful in the diagnosis of poorly differentiated NECs, due to dedifferentiation, and then, degranulation of tumor cells. The Neuronal Specific Enolase (NSE) results to be an adequate marker in these cases. Considering the specific markers, many studies reported that endocrine pancreatic neoplasms are able to produce many different polypeptides and amines. Through immunohistochemical techniques, it is possible to define the diagnosis of pNET, which allows the clinicians to direct the patient to an effective therapeutic procedure. But to have a correct and reliable diagnosis, the tissue samples have to be adequately collected and treated.

The role of sarcopenia in the pancreatic adenocarcinoma.

OBJECTIVE: Pancreaticoduodenectomy is still associated with prolonged hospitalization and with a lot of complications. For these reasons, it is fundamental to improve strategies for preoperative risk stratification, and sarcopenia is one of the new identified markers of frailty. The purpose of our study was to retrospectively detect sarcopenia in patients undergoing pancreaticoduodenectomy and evaluate its importance as a preoperative marker. PATIENTS AND METHODS: We retrospectively identified a total amount of 76 consecutive patients who underwent pancreaticoduodenectomy for pancreatic head adenocarcinoma. Patients' and tumor's characteristics were recorded retrospectively. RESULTS: It appears that sarcopenia might be a useful preoperative prognostic factor for patients undergoing PD for PA. We found that Recurrence Free Survival may be influenced by presence or absence of preoperative sarcopenia, and we can confirm that in sarcopenic patients the average hospital stay is 20% longer than in non sarcopenic ones. CONCLUSIONS: Sarcopenia has a central role because it is a very common condition found in pancreatic cancer patients; there is growing evidence showing that it is associated with worse surgical outcomes. We can state that evaluating sarcopenia in cancer patients could improve the postoperative outcomes, overall survival rates and, nevertheless, the recurrence free survival ones.

Preoperative sarcopenia predicts survival after hepatectomy for colorectal metastases: a prospective observational study.

OBJECTIVE: The surgical approach to colorectal liver metastases has highly improved the survival rates in metastatic colorectal cancer patients. Since sarcopenia estimates the physiologic reserve of an individual patient, it is considered a surrogate marker of patient frailty, and the selection of appropriate candidates for LR could be crucial to maximize the benefits derived from surgery. The present study investigated the impact of sarcopenia as a prognostic factor after LR from CRLM. PATIENTS AND METHODS: The study retrospectively analyzed 74 patients. Skeletal Muscle Mass at the third lumbar vertebra in the inferior direction was quantified using enhanced computed tomography scans. The patients were divided into two subgroups, with and without sarcopenia, based on median Skeletal Muscle Index. RESULTS: The study included 48 Sarcopenic patients and 26 Non Sarcopenic patients. The median follow-up considered for the patients was 32 months. Median SMI was 39.3 and 52.7 cm2/m2, respectively. The OS rate was significantly different between the two groups. Preoperative sarcopenia resulted in worse OS up to 48 months. CONCLUSIONS: Sarcopenia represents a negative prognostic factor as it is associated with poor postoperative OS. Future programs focused on remediating to the preoperative sarcopenic status of colorectal liver metastatic patients should be implemented.

Weight loss after sleeve gastrectomy in patients with diabetes: preliminary study in one year of activity.

OBJECTIVE: The objective of our study is to investigate whether diabetes mellitus could adversely affect post-laparoscopic sleeve gastrectomy (LSG) weight loss. PATIENTS AND METHODS: A retrospectively recorded database of patients who underwent LSG from September 2018 to September 2019 in our Hospital in L'Aquila was analyzed. The post-operative weight loss was evaluated in terms of body mass index (BMI) variation, percentage of excess weight loss (%EWL) and percentage of total weight loss (%TWL). The association between these parameters and diabetes was analyzed at 3 and 6 months of follow-up. RESULTS: The two groups (patients with and without diabetes) were considered comparable in terms of anthropometric and preoperative parameters. At 3 and 6 months of follow-up, the decrease in BMI resulted to be directly associated with the time and the group. The mean BMI at 3 and 6 months was higher in patients with diabetes. Changes in % EWL and % TWL were similar in both groups. CONCLUSIONS: It is rational to expect a lower weight loss in obese diabetic patients after LSG. This should not be considered as a contraindication to bariatric surgery that, being a metabolic surgery, has as main goal the resolution or improvement of co-morbidities.

The early prediction of mortality in acute cholecystitis: Temperature, Neutrophils and Multiple organ failure (TNM) score.

OBJECTIVE: Acute Cholecystitis (AC) accounts for a significant proportion of patients presenting to the Emergency Department with abdominal pain. We suggest grading the severity of AC with a simple system: TNM, an acronym borrowed by cancer staging where T indicated Temperature, N neutrophils and M Multiple organ failure. This retrospective-prospective observational study evaluates the predictive value of TNM score on mortality of patients with AC. PATIENTS AND METHODS: TNM was developed in a training cohort of 178 patients with AC who underwent cholecystectomy from February 2005 to December 2012 (retrospectives data). To verify the prognostic value of TNM score, we prospectively recruited 172 patients who were consecutively included and treated from January 2013 to July 2020 as the validation cohort. After defining the categories T, N and M, patients were grouped in stages. The variables analyzed were age, sex, American Society of Anesthesiologists (ASA) score, blood transfusion, temperature, neutrophils count, preoperative organ failure, immune-compromised status, stage. RESULTS: In the training cohort TNM staging was: none patient at stage 0; 6 patients at stage I; 71 patients at stage II; 71 patients at stage III; 30 patients at stage IV. Death occurred in 51 patients. ASA score, neutrophils count, preoperative organ failure, stage III-IV emerged as statistically significant different prognostic factors. ASA score (III-IV) and stage (III-IV) were significant independent predictors of post-operative mortality in multivariate analysis. Comparable results were observed in the validation cohort. CONCLUSIONS: TNM classification is very easy to use; it helps to define the mortality risk and it is useful to objectively compare patients with AC.

A case report of three synchronous tumors in the same pancreatic specimen.

It is known that Duodenal adenocarcinoma (DA) is a rare malignant solid tumor that cause occlusion symptoms with orthodox dysphagia when locally advanced. Pancreatic neuroendocrine tumors (PanNETs) account for about 2% of all pancreatic neoplasms. The combination of these two lesions, with the synchronous presence of ectopic pancreatic tissue (EPT) of the duodenum, has never been described in literature, to our knowledge. Here we report a case of combined DA, EPT and PanNET affecting a 71-year-old woman.

"Acute abdomen": early laparoscopy or active laparotomic-laparoscopic observation?

BACKGROUND/AIMS: Acute abdomen accounts for 13-40% of all emergency surgical admissions. The aim of this prospective randomized controlled study was to examine the role of early laparoscopy in the management of acute abdomen compared with the more traditional active observation. METHODOLOGY: From July 1993 to August 2004, 522 patients consecutively, admitted with "acute abdomen", were randomized to either early laparoscopy (260 patients) (group 1) or active observation and non-invasive investigation (262 patients) (group 2). Baseline investigations included a full blood count, a pregnancy test in women of reproductive age, chest and/or abdominal radiograph if indicated clinically. RESULTS: Sixty-two patients in the laparoscopy group underwent a total of 116 radiological investigations compared with a total of 558 investigations in all patients in the observation group (P < 0.05). In the observation group 34.7% of patients remained without a clear diagnosis compared with 4.2% of patients in the early laparoscopic group (P < 0.0001). The morbidity rate was 1.1% in group 1 and 27% in group 2 (P < 0.0001). The duration of hospital stay was significantly shorter in group 1 (3.1 vs. 7.3 days) (P < 0.01). Eight patients in group 1 required readmission (total readmission 46 days) compared with 58 patients in group 2 who stayed a total of 201 days (P < 0.05). CONCLUSIONS: Early laparoscopy is valuable in the management of acute abdomen. It provides a significantly higher diagnostic accuracy and a better improvement in quality of life than the more traditional approach observation.

Effects of cholecystectomy (laparoscopic versus open) on PMN-elastase.

BACKGROUND/AIMS: Polymorphonuclear leukocytes (PMN) are well recognized as being the principal cells in inflammatory response reaction. During the surgical procedures there is a massive release of elastase (PMN-elastase) from the neutrophils, along with other proteinases. Therefore the measurement of the PMN-elastase might be a useful indicator of the degree of surgical trauma. Laparoscopic cholecystectomy (LC) is a so-called "mini-invasive" surgical procedure and on the basis of this consideration the aim of the present prospective, non-randomized study, is to examine (a) whether the serum levels of PMN-elastase concentration are modified and how, in patients undergoing LC compared to patients undergoing open cholecystectomy (OC), (b) whether these findings are indicative of an increased risk to develop infectious complications and therefore whether they are clinically significant. METHODOLOGY: Plasma granulocyte elastase was determined photometrically, using an immune-activation immunoassay, in 86 patients (42 patients underwent OC and 44 LC). The levels of C reactive protein (CRP), an acute phase protein, were measured using a competitive CRP ELISA kit. Blood samples were collected from all patients a day before operation and at days 1, 3, 6 and 12 after operation. We established a reference range for elastase by measuring the serum elastase concentration in 68 normal control patients without gallbladder cholelithiasis or other diseases. RESULTS: On day, 1, 3 and 6 after surgery, patients that underwent OC showed a significant increase (p < 0.05) in plasma elastase concentration, while it was almost unchanged in LC patients. The mean values of the serum CRP on p.o. days 1, 3 and 6 were also significantly lower in the LC group than those in OC group (p < 0.05). We recorded three cases (7.1%) of postoperative infections in the "open" group. The CRP concentration remained high for 1, 3 and 6 days and normalized 10-12 days after surgery while the PMN-elastase normalized after 13, 14 and 16 days. CONCLUSIONS: The peripheral leukocyte function may be better preserved after LC in comparison to OC. Laparoscopic surgery, associated with a small skin incision and the avoidance of open laparotomy, can thus minimize surgical stress, and provide more favorable postoperative conditions for patients. Indeed excessive and prolonged post-injury elevations of PMN-elastase and CRP are associated with increased morbidity. Moreover, the PMN-elastase is a more sensible marker of inflammation in comparison to the CRP.

Occurrence and developmental pattern of neuromedin U-immunoreactive nerves in the gastrointestinal tract and brain of the rat.

Neuromedin U is a newly described regulatory peptide, found by radioimmunoassay in significant concentrations in both the brain and gut of the rat. The aim of the present study was to localize this peptide immunoreactivity to discrete structures of the gut and brain and to map its distribution using immunocytochemistry. In the gut, neuromedin U was confined to nerve fibres mainly in the myenteric and submucous plexuses and the mucosa of all areas except stomach. Immunoreactive ganglion cells were seen in both ganglionated plexuses and their number did not increase following colchicine administration. This observation and the finding that the population of neuromedin U-immunoreactive nerves in the ileum was not affected by complete extrinsic denervation indicated that the nerves are mostly intrinsic in origin. Colocalization studies revealed neuromedin U and calcitonin gene-related peptide were present in the same myenteric and submucosal ganglion cells. Transection experiments showed that, like calcitonin gene-related peptide-immunoreactive nerves, fibres containing neuromedin U project for very short distances in both an oral and anal direction. At the electron microscopic level, neuromedin U immunoreactivity, demonstrated using the immunogold technique, was localized to large granular vesicles. In the central nervous system, neuromedin U immunoreactivity was localized to fibres which were widespread throughout the brain, except in the cerebellum. The presence of neuromedin U-immunoreactive cell bodies was restricted to the rostrocaudal part of the arcuate nucleus. Colocalization studies showed that a proportion of the neuromedin U-immunoreactive cell bodies in the arcuate nucleus also contained pro-opiomelanocortin. Neuromedin U-immunoreactive fibres were first detected in the rat intestinal mucosa at day 1 after birth. In the brain, the arcuate nucleus showed neuromedin U-immunoreactive neuronal cell bodies at E16 but not at E14. In conclusion, neuromedin U is a new member of the group of molecules known as brain-gut peptides.

Transduodenal papillostomy as a routine procedure in managing choledocholithiasis.

The purpose of this study was to evaluate the results of transduodenal papillostomy as a routine procedure in managing choledocholithiasis in treating common bile duct (CBD) stones. From 1973 to 1978, 117 patients underwent transduodenal papillostomy for CBD lithiasis. The operation was carried out in standard manner, and all patients had preoperative telecholangioscopy, cholangiography, and biliary manometry. The mean age of patients was 53.7 years, and women predominated in a ratio of 4.5:1.0. Papillostomy was performed together with cholecystectomy for CBD stones in 111 patients (group 1). In five patients, we had to perform a choledochotomy to remove the stones after an unsuccessful papillostomy (group 2). Eight patients who previously had cholecystectomies underwent papillostomy for retained or recurrent stones (group 3), and three patients had a choledochoduodenostomy for recurrent stones after a previous cholecystectomy and papillostomy (group 4). Complications included two deaths in group 1 (1.9%). No mortality was observed in groups 2 and 4. Moreover, the overall morbidity was due to six cases of wound infection, one case of postoperative bleeding, one case of phlebitis, and three cases of cholangitis. The mean length of hospital stay was 12.9 days, considering all the groups. Lack of confidence with this procedure may explain the different results reported in the literature for transduodenal papillostomy, which on the basis of this study has been shown to ba a valid alternative to supraduodenal choledochotomy in treating CBD stones.

Elevated plasma levels of vasoactive intestinal polypeptide in short bowel syndrome.

Short bowel syndrome is a complex disease that is almost always seen with diarrhea. VIP is known to act powerfully on gut motility, and elevated VIP plasma levels have been reported in several diarrheal conditions. In this study VIP plasma levels were measured by radioimmunoassay in 8 patients with short bowel syndrome versus 30 healthy control subjects under basal conditions. VIP plasma levels were significantly higher in the short bowel syndrome group (p less than 0.05). The explanations that could account for these elevated levels are (1) an increased gastric acid load in the residual bowel, (2) a compensatory increase in blood supply to the gut, (3) removal of an inhibitory factor arising from the small intestine, or (4) mucosal stress due to unadsorbed food. An etiologic role of VIP in the occurrence of diarrhea in patients with short bowel syndrome seems to be an unproved hypothesis.

Relationship between pancreatic and serum amylase in basal conditions and during stimulation in man. Report of a new intraoperative technique.

The correlation between serum amylase and pancreatic amylase secretion was studied in two patients. Both patients underwent sphincterotomy, and the pancreatic duct was cannulated with a polyethylene tube. The tube was left in place for 15 to 21 days. The rate of amylase secretion over 7 days was studied in response to (1) a standard meal, (2) duodenal acidification, (3) scalar doses of cholecystokinin, (4) scalar doses of secretin, and (5) scalar doses of secretin with simultaneous infusion of cholecystokinin. Blood samples were collected during the tests to measure serum amylase. No significant correlation was shown between blood concentration and output of amylase in any of the tests. Our findings show that under normal conditions serum amylase levels are not influenced by pancreatic secretion and suggest that serum amylase concentration is not related to pancreatic exocrine secretion.

Laparoscopic versus open cholecystectomy. An analysis of clinical and financial aspects.

BACKGROUND: The aim of this study is to assess the clinical and financial aspects of laparoscopic cholecystectomy (LC) compared to open cholecystectomy (OC). METHODS: Thirty-six patients treated with LC were prospectively, not randomized, compared with 35 patients that underwent OC. The data used were taken from local registers, patient-statistics and hospital accounting systems. We evaluated the costs, morbidity and mortality for both surgical procedures. RESULTS: Significant differences were observed concerning the number of days that pain was suffered (mean 7.6 days in LC versus 18.5 days in OC), the duration of postoperative hospitalization (LC mean 2-3 days; OC 7-9 days), the extent of postoperative monitoring performed, and the number of days in order to return to normal activity (mean 4.4 days in LC; mean 7.6 days in OC). Calculation of the costs was based on the Diagnosis Related Groups (DRG). The profit for a DRG is the result of the difference between the reimbursement obtained from the execution of the operation and the cost in order to carry it out. The total cost for the execution of LC is Italian 3,332,632 pound sterling with a profit of Italian 1,208,807 pound sterling while for OC the cost is 4,007,359 pound sterling and the profit is 347,041 pound sterling. CONCLUSIONS: The results of our study is that, clinically and financially, LC has obvious advantages over OC.

Changes in the blood coagulation, fibrinolysis, and cytokine profile during laparoscopic and open cholecystectomy.

BACKGROUND: It has long been known that a hypercoagulability state develops after surgery. A surge in circulating cytokine levels is also commonly found in the postoperative period. These cytokines have all been shown to be capable of inducing a hypercoagulability state. Recently laparoscopic cholecystectomy (LC) has been introduced, and its advantages over the open procedure seem related to the reduced surgical trauma. LC is associated with a diminished acute-phase response compared with the open procedure. Our present knowledge on the influence of laparoscopic upon coagulation and fibrinolysis is incomplete and based on a few studies. METHODS: The aim of this prospective, nonrandomized study was to investigate hemostatic system alterations in patients who undergo open and laparoscopic cholecystectomy. In addition we also measured the plasma cytokine profile to explore any relationship between changes in plasma cytokine levels and postoperative coagulation profile. Between September 1999 and April 2002, 71 patients were nonrandomly assigned to open (group 1) or laparoscopic cholecystectomy (group 2). All patients from group 1 were operated by a surgical team different from ours, who prefers the OC procedure. The patients with acute cholecystitis were excluded. Prothrombin fragment 1.2 (F1.2), thrombin-antithrombin (TAT), fibrinogen, soluble fibrin, antithrombin III (AT), protein C, plasminogen, and D-dimer levels were measured at baseline and at 1, 24, 48, and 72 h postoperatively. Serial serum levels of IL-1beta and IL-6 were measured by colorimetric enzyme-linked immunosorbent assay (ELISA). RESULTS: Plasma levels of F1.2, TAT, fibrinogen, soluble fibrin, and D-dimer increased significantly in group 1. Plasma levels of AT, protein C, and plasminogen decreased in both groups. In the OC group, the serum IL-3 and IL-6 levels began to significantly increased as early as 1 h from the beginning of the operation, revealing a peak at the sixth hour. When IL-6 and IL-1 levels were markedly elevated also, F1.2, fibrinogen, and soluble fibrin levels were increased. CONCLUSIONS: Only mild hypercoagulability was observed in patients who had undergone laparoscopic cholecystectomy. The cytokine surge was correlated with hypercoagulability. There was in fact a positive correlation between IL-6 level and hypercoagulability. The correlation between cytokine levels and coagulation activation may be related to the type of surgery performed. Further studies are required to investigate these issues.

Antibodies to neuron-specific enolase for the delineation of the entire diffuse neuroendocrine system in health and disease.

A very widely distributed system containing regulatory peptides has recently been discovered. These active peptides are localized to typical endocrine cells and nerves of the so-called diffuse neuroendocrine system. Investigation of the entire system was, until recently, very difficult, as existing techniques (including histochemistry, electron microscopy, and peptide immunocytochemistry) only partly visualized its components. Neuron-specific enolase is a soluble isomer of a glycolytic enzyme enolase that was first discovered in the brain and localized exclusively to neurons, hence its name. Antibodies to neuron-specific enolase are now known to immunostain the entire diffuse neuroendocrine system of every organ of the body. Thus, all endocrine cells and nerves containing the recognized regulatory peptides, as well as amines and classical neurotransmitters like acetylcholine and noradrenaline, contain significant quantities of immunostainable neuron-specific enolase. Therefore, these antibodies, which can be used on routinely fixed tissue, allow the visualization of the entire diffuse neuroendocrine system. Furthermore, all classes of neuroendocrine neoplasms, as well as the pattern of normal or abnormal innervation, can easily be marked by immunostaining of neuron-specific enolase.

A comparison of serum interleukin-6 concentrations in patients treated by cholecystectomy via laparotomy or laparoscopy.

BACKGROUND/AIMS: Interleukin-6 (IL-6), a multifunctional cytokine, is expressed by various cells after many stimuli. This cytokine release is related, among other things, to the extent of the surgically-induced trauma. Laparoscopic cholecystectomy (LC) is a so-called "mini-invasive" surgical procedure and, on the basis of this consideration, the aim of the present prospective non-randomized study, is to examine (a) whether the IL-6 is modified and how, in patients after LC compared to patients undergoing open cholecystectomy (OC), (b) whether these findings are indicative of an increased risk to develop infectious complications and whether they are therefore clinically significant. METHODOLOGY: Circulating IL-6 level was measured using a random access chemiluminescense-immunoassay system in 71 patients before the operation (time 0) and 1, 2, 3, 6, 24 and 48 hours after the beginning of the operation. Thirty-five patients underwent OC and 36 LC. RESULTS: The increase in the serum IL-6 during LC was found to be significantly smaller than that during OC and resulted in a smaller extent of postoperative elevations for C-reactive protein. We recorded three cases (8.5%) of postoperative infections in the "open" group and IL-6 concentration normalized only 6 days after surgery. CONCLUSIONS: An increase in the serum IL-6 level during LC is lower in comparison to OC and results in lower postoperative elevation in C-reactive protein. Laparoscopic surgery, associated with a small skin incision and the avoidance of open laparotomy, can thus minimize surgical stress, and provide more favorable postoperative conditions for patients. Indeed excessive and prolonged post-injury elevations are associated with increased morbidity.

The value of omentoplasty in protecting colorectal anastomosis from leakage. A prospective randomized study in 126 patients.

BACKGROUND/AIMS: Anastomotic leakage is a major cause of mortality in colorectal surgery. Several methods have been evaluated in order to prevent anastomotic leakage. To decrease the rate and severity of anastomotic leakage, omentoplasty (OP) has been proposed by several authors on the basis of experimental and clinical studies. A prospective, randomized trial was designed to study the influence of omentoplasty on anastomotic leakage after colorectal resection. METHODOLOGY: One hundred and twenty-six patients undergoing elective or emergency surgery for malignancy, benign tumor, diverticular disease and other were randomly assigned to omentoplasty (OP group) or not (NO group). The primary end point was the rate of clinical and radiological anastomotic leakage. Both groups were comparable in terms of demographic data, preoperative characteristics and intraoperative findings. RESULTS: Eighteen patients (14.3%) had anastomotic leakage, 4 (6.4%) in the OP group and 14 (21.9%) in the NO group. Significant differences (P<0.05) between the two groups were also found in terms of repeat operation (3.2% vs. 14.1%) and deaths (3.2 vs. 7.8%). Other factors associated with anastomotic leakage were the distal site of anastomosis (<5 cm from anal verge) and the emergency. CONCLUSIONS: Omental wrap, with its mechanical and biological properties, seems to be effective in lowering the rate and the severity of anastomotic leakage after colorectal surgery.