Long-term outcome of COVID-19 patients treated with helmet noninvasive ventilation vs. high-flow nasal oxygen: a randomized trial

BACKGROUND

Long-term outcomes of patients treated with helmet noninvasive ventilation (NIV) are unknown: safety concerns regarding the risk of patient self-inflicted lung injury and delayed intubation exist when NIV is applied in hypoxemic patients. We assessed the 6-month outcome of patients who received helmet NIV or high-flow nasal oxygen for COVID-19 hypoxemic respiratory failure.

METHODS

In this prespecified analysis of a randomized trial of helmet NIV versus high-flow nasal oxygen (HENIVOT), clinical status, physical performance (6-min-walking-test and 30-s chair stand test), respiratory function and quality of life (EuroQoL five dimensions five levels questionnaire, EuroQoL VAS, SF36 and Post-Traumatic Stress Disorder Checklist for the DSM) were evaluated 6 months after the enrollment.

RESULTS

Among 80 patients who were alive, 71 (89%) completed the follow-up: 35 had received helmet NIV, 36 high-flow oxygen. There was no inter-group difference in any item concerning vital signs (N = 4), physical performance (N = 18), respiratory function (N = 27), quality of life (N = 21) and laboratory tests (N = 15). Arthralgia was significantly lower in the helmet group (16% vs. 55%, p = 0.002). Fifty-two percent of patients in helmet group vs. 63% of patients in high-flow group had diffusing capacity of the lungs for carbon monoxide < 80% of predicted (p = 0.44); 13% vs. 22% had forced vital capacity < 80% of predicted (p = 0.51). Both groups reported similar degree of pain (p = 0.81) and anxiety (p = 0.81) at the EQ-5D-5L test; the EQ-VAS score was similar in the two groups (p = 0.27). Compared to patients who successfully avoided invasive mechanical ventilation (54/71, 76%), intubated patients (17/71, 24%) had significantly worse pulmonary function (median diffusing capacity of the lungs for carbon monoxide 66% [Interquartile range: 47-77] of predicted vs. 80% [71-88], p = 0.005) and decreased quality of life (EQ-VAS: 70 [53-70] vs. 80 [70-83], p = 0.01).

CONCLUSIONS

In patients with COVID-19 hypoxemic respiratory failure, treatment with helmet NIV or high-flow oxygen yielded similar quality of life and functional outcome at 6 months. The need for invasive mechanical ventilation was associated with worse outcomes. These data indicate that helmet NIV, as applied in the HENIVOT trial, can be safely used in hypoxemic patients. Trial registration Registered on clinicaltrials.gov NCT04502576 on August 6, 2020.

Transanal endoscopic microsurgery after neoadjuvant radiochemotherapy for locally advanced extraperitoneal rectal cancer

PURPOSE

The aim of this study is to provide a prospective analysis of post-operative and oncological outcomes in patients affected by locally advanced rectal cancer (LARC), who obtained a major/complete clinical response after pre-operative radio-chemotherapy (RCT) and were treated with local excision (LE) by trans-anal endoscopic microsurgery (TEM) to confirm a pathological complete response (pCR) after to neo-adjuvant RCT.

METHODS

All patients with LARC treated by pre-operative RCT and full-thickness LE by TEM (2000-2014) were included in the study. If the pathological analysis confirmed near complete or pCR, intensive follow up was proposed. If the pathological response was incomplete, a radical resection with TME was proposed. Post-operative (according to Clavien's classification), functional and long-term oncological outcome were analyzed.

RESULTS

36 patients were treated by TEM. The median post-operative hospital stay was 5 days. The post-operative morbidity was 41.6% (no grade ≥3). At pathological analysis, 23 specimens were ypT0 TRG1, and 4 were ypT1 TRG2. In 9 cases (ypT>1 and/or TRG>2), radical surgery with TME was proposed but 3 refused it. Median follow-up was 68 months. One local recurrence and 4 distant metastases occurred. The 5-yr actuarial local control, overall survival and disease-free survival were 96.0%, 92.0% and 82.8%.

CONCLUSIONS

In case of major or complete clinical response of LARC after pre-operative RCT, LE by TEM can be used to confirm the pathological response. This avoids the necessity of radical surgery and, in our experience, this approach seems to guarantee oncological safety with the functional advantages of an organ-sparing procedure.

Routine extra-hepatic bile duct resection in gallbladder cancer patients without bile duct infiltration: A systematic review

AIM

The optimal treatment for advanced gallbladder cancer, in particular T2 stage cancer, is unclear. The use of "radical cholecystectomy" or more extended procedures with extra-hepatic bile duct resection are matter of debate. Due to the lack of consensus regarding the oncological significance of routine extra-hepatic bile duct (EBD) resection for gallbladder carcinoma, we decided to perform a systematic review investigating the real benefit of this procedure focusing on the primary outcomes of overall survival and disease-free survival.

METHODS

A systematic literature search was performed using PubMed, EMBASE, Scopus and the Cochrane Library Central according to the PRISMA statement guidelines for conducting and reporting systematic reviews. Multiple primary and secondary outcomes were analyzed.

RESULTS

The selected articles included 424 patients who underwent routine EBD resection without bile duct infiltration. Only two papers discussed the number of dissected lymph nodes during EBD resection for gallbladder carcinoma. Four of the seven included papers reported on tumor involvement in lymph nodes at rates ranging between 39% and 83%. All of the studies included in this systematic review reported on results of overall survival. In general, 5-years OS rate of the EBD-resected patients was not significantly different than that of the EBD-preservation group, while the mobility was significantly higher in the EBD resection group.

CONCLUSIONS

Routine EBD resection in gallbladder cancer patients without bile duct infiltration is not associated with improved overall survival, improved lymph-node harvesting or with minor recurrence rate, but it is associated with higher morbidity rates.

Transanal endoscopic microsurgery after neoadjuvant radiochemotherapy for locally advanced extraperitoneal rectal cancer: short-term morbidity and functional outcome

BACKGROUND

Transanal endoscopic microsurgery (TEM) after radiochemotherapy (RCT) has been reported in selected cases of locally advanced rectal cancer as an alternative to traditional radical resection with total mesorectal excision with a curative intent or as diagnostic tool to confirm a pathological complete response of the primary tumor. No study has evaluated functional outcome after TEM in preoperatively irradiated patients.

METHODS

This study was designed to evaluate short-term morbidity (according to Clavien's classifications) and establish (by a questionnaire) continence and evacuative function after RCT and TEM, at 1 year from surgery, analyzing the impact of RCT on postoperative outcomes. Patients with locally advanced rectal cancer treated by RCT and TEM (group 1) or with early T1 or adenomas treated only by TEM (group 2) entered this cohort comparative study.

RESULTS

Twenty-two patients entered the study as group 1 and 25 as group 2. No postoperative mortality occurred. The morbidity rate was 36.4 % in group 1 vs. 16 % in group 2 (p = 0.114). The rate of suture dehiscence was 22.7 % in group 1 vs. 4 % in group 2 (p = 0.068). No grade III complications, reoperation, or hospital readmission within 30 days was recorded in either group. One year after surgery, continence and evacuative scores in group 1 were 1.05 ± 1.25 and 24.72 ± 2.79, respectively, which were similar to group 2 (p = 0.081 and 0.288, respectively).

CONCLUSIONS

TEM after RCT in selected rectal cancer patients has an acceptable morbidity and functional results at 1 year from surgery. Preoperative irradiation could increase postoperative short-term morbidity, but it does not seem to influence evacuative or sphincter function after 1 year from surgery.

Surgical treatment of small bowel neoplasms

Small intestinal neoplasms are uncommon cancers. Benign small intestinal tumors (e.g., leiomyoma, lipoma, hamartoma, or desmoid tumor) usually are asymptomatic but may present with complications. Primary malignancies of the small intestine, including adenocarcinoma, leiomyosarcoma, carcinoid, and lymphoma, are often symptomatic and may present with intestinal obstruction, jaundice, bleeding, or pain. Metastatic neoplasms may involve the small intestine via contiguous spread, peritoneal metastases or hematogenous metastases. Because the small intestine is relatively inaccessible to routine endoscopy, diagnosis of small intestinal neoplasms is often delayed for months after onset of symptoms. During last years the increase of small bowel endoscopy and other diagnostic tools allow earlier non-operative diagnosis. Even though radical resection of small bowel cancer plays an important role, the 5 yr overall survival remains low.

The role of local excision in rectal cancer after complete response to neoadjuvant treatment

Correlation between pathological response of primary tumour and mesorectal lymph node involvement was prospectively evaluated to assess the role of local excision (LE) in rectal cancer after complete response to neoadjuvant treatment. A series of 272 consecutive rectal cancer, submitted to neoadjuvant radiochemotherapy (RCT) and surgery with total mesorectal excision (TME) were analysed. Tumour downstaging (pT) and tumour regression grade (TRG) together with sex, age, location of the tumour, pre-treatment clinical stage, type of chemoradiation and operation performed entered in an univariate and multivariate analysis. Pathological complete response on primary tumour was found in 56 patients (20.6%). Lymph node metastases were found in 72 patients (26.5%). The rate of positive nodes was 1.8% for pT0 and TRG1 cases, respectively, to go up to 6.3% for pT1 and 24.1% for TRG 2 cases, respectively. At the univariate analysis, factors with a statistically significant correlation with the risk of lymph node metastasis were: clinical pre-treatment N stage (p<0.05), pT stage (p<0.001) and TRG (p<0.001). At the multivariate analysis, the best predictors of pathologic lymph node involvement were pT stage (p=0.0013 ) and TRG (p=0.0011). Because LE is an adequate technique to assess the tumour pathological response and nodal involvement in pT0 or TRG1 cases seems extremely infrequent, radical resection is probably not justified after pathological complete response. Prospective randomized trials are necessary to establish if, in these cases, LE can guarantee the same oncologic results offered by the currently adopted protocols of RCT followed by radical resections.

Functional results after radiochemotherapy and total mesorectal excision for rectal cancer

BACKGROUND AND PURPOSE

The aim of this study was to prospectively define and measure evacuation and continence disorders after preoperative radiochemotherapy and total mesorectal excision (TME) for rectal cancer 1 year after surgery.

MATERIALS AND METHODS

We submitted 100 patients, who underwent neoadjuvant treatment and anterior resection with TME from 1996 to 2003, to a questionnaire on postoperative continence and evacuation. Anal sphincter function was further assessed by the Memorial Sloan-Kettering score. Factors influencing anorectal function were examined in univariate and multivariate analysis.

RESULTS

Median evacuation score was 16.12 +/- 5.12 (range 0-28). Sensation of incomplete evacuation was reported in 58% of cases, necessity to return to the bathroom <15 min in 37% and inability to evacuate completely <15 min in 35%. Median continence score was 13.7 +/- 4.79 (range 0-20). Incontinence to flatus was reported in 46% of cases. Colonic J-pouch allows better evacuation and continence. Continence was also better in absence of postoperative complications. Sphincter function resulted excellent or good in 75% of patients according to the Memorial Sloan-Kettering score.

CONCLUSIONS

The most frequent symptoms in our series are the sensation of incomplete evacuation, the incontinence to flatus, and the necessity to return to the bathroom <15 min. Colonic J-pouch warrants a better function. Postoperative complications compromise good functional results.

DNA fingerprinting by ERIC-PCR for comparing Listeria spp. strains isolated from different sources in San Luis, Argentina

In this study, a total of 24 Listeria spp. strains were analyzed. Twenty-two isolates were obtained in San Luis (Argentina) from human, animal, and food samples. Two types of strains, Listeria monocytogenes CLIP 22762 and Listeria innocua CLIP 74915, were included as reference strains. All isolates were biochemically identified and characterized by serotyping, phage typing, and amplification of the flaA gene by polymerase chain reaction (PCR). Repetitive intergenic consensus (ERIC) sequence-based PCR was used to generate DNA fingerprints. On the basis of ERIC-PCR fingerprints, Listeria spp. strains were divided into three major clusters matching origin of isolation. ERIC-PCR fingerprints of human and animal isolates were different from those of food isolates. In addition, groups I and II included ten L. monocytogenes strains, and only one Listeria seeligeri strain. Group III included nine L. innocua strains and four L. monocytogenes strains. Computer evaluation of ERIC-PCR fingerprints allowed discrimination between the tested serotypes 1/2b, 4b, 6a, and 6b within each major cluster. The index of discrimination calculated was 0.94. This study suggests that the ERIC-PCR technique provides an alternative method for the identification of Listeria species and the discrimination of strains within one species.

Phlegmasia caerulea dolens of the left leg due to deep vein compression by giant mesenteric cyst: contribution of the immediate drainage of the cyst to the rapid improvement of symptoms and complete recovery

The first description of phlegmasia caerulea dolens of the leg due to deep vein compression by a giant mesenteric cyst is presented. In particular, the authors stress the role of the drainage of the cystic mass, performed as an emergency procedure, in the rapid improvement of symptoms, prevention of complications and achievement of definitive recovery. On the basis of such unusual case, a wide review of the literature on this subject is reported, aiming to stress the most crucial aspects regarding aetiology, clinical features, complications, therapy and prognosis of this disease.

The role of surgical treatment in colon diverticulitis: indications and results

PURPOSE

Colon diverticulitis is a common illness with affects 37-45% of western populations. Indications regarding therapy guidelines, operative timing and which surgical procedure to perform are still controversial.

MATERIAL AND METHOD

Between January 1977 and December 1997, 239 patients, diagnosed with diverticulitis, have been admitted, on emergency, to our Department of General Surgery; 135 males (56%) and 104 females (44%), (mean age of 63 years).

RESULTS AND DISCUSSION

Forty-two patients (18%), clearly diagnosed with diffuse or local peritonitis, underwent delayed emergency surgical procedure; 44 (22%) out of 197 patients, treated with medical therapy and subsequently underwent elective surgery procedures for complications (fistulas or stenosis). Among the 42 patients treated in emergency, 26 cases (62%) underwent to resection with immediate reconstruction. Among the elective surgery group 39 (89%) out of 44 underwent to resection with immediate reconstruction. Complications reached 40% in the group of emergency patients (mortality rate 12%) and 16% in the elective surgery group (mortality rate 2%). Several features possible influencing mortality rate have been analysed; age > 70 years, acute associated diseases, generalised peritonitis and surgical timing show a statistical significance.

CONCLUSION

Therefore, a careful evaluation of the patients, an appropriate pre and post-operative medical treatment, with a wider use of the most recent techniques such as CT scan guided drain, intra-operative wash-out and peritoneal lavage are recommended in order to reduce morbidity and mortality.

Preoperative chemoradiation for extraperitoneal T3 rectal cancer: acute toxicity, tumor response, and sphincter preservation

PURPOSE

To evaluate whether or not an intermediate dose of preoperative external radiation therapy intensified by systemic chemotherapy could improve the tumor response, sphincter preservation, and tumor control.

METHODS AND MATERIALS

Between March 1990 and December 1995, 83 consecutive patients with resectable extraperitoneal adenocarcinoma of the rectum were treated with preoperative chemoradiation: bolus i.v. mitomycin C (MMC), 10 mg/m2, Day 1 plus 24-h continuous infusion i.v. 5-fluorouracil (5FU) 1000 mg/m2, Days 1-4, and concurrent external beam radiotherapy (37.8 Gy). All but 2 patients had T3 disease. Surgery was performed 4-6 weeks after the end of chemoradiation.

RESULTS

Total Grade 3-4 acute toxicity during chemoradiation was observed in 11 (13%) patients: hematological Grade 3 toxicity was recorded in 8 (10%) patients, and Grade 4 toxicity was recorded in 2 (2%) patients. Grade 3 diarrhea was seen in 2 (2%) patients. No patient had major skin or urological acute toxicity. Two patients had no surgery: 1 died before surgery from septic complications after Grade 4 hematological toxicity; 1 refused surgery and is still alive after 6 years. There was no postoperative mortality and the overall perioperative morbidity rate was 25%. The analysis of tumor response involved 81 patients. Overall, 9% (7) of 81 patients had a complete pathologic response. Comparing the stage at the diagnostic workup with the pathologic stage, tumor downstaging was observed in 46 (57%) patients. We had 7 (9%) pT0, 5 (6%) pT1, 33 (41%) pT2, and 36 (44%) pT3. Nodal status downstaging was detected in 46 patients (57%). No evidence of nodal involvement was observed in 59 patients (73%). The incidence of tumor response was affected significantly by the number of quarters of rectal circumference involved (p = 0.03) and, marginally, by the length of the tumor (p = 0.09). The distance between the lower pole of the tumor and the anorectal ring had no influence. Of the patients, 63 (78%) had a sphincter-saving surgical procedure. In 12 (44%) of 27 patients candidate for an APR, the sphincter was preserved, as it was in 19 (95%) of 20 probable candidates. Lengthening of the distance between the anorectal ring and the lower pole of the tumor > 20 mm was observed in 21 patients (26%). Of 63 patients, 4 (6%) had moderate soilage after the sphincter-saving procedure.

CONCLUSION

Preoperative combined modality therapy seems to afford some potential advantages in nonrandomized trials: patients are able to tolerate higher chemotherapy doses and they experience a lower acute toxicity. Tumor downstaging and resectability rates are high; sphincter preservation is feasible. Larger T3 tumors remained less influenced by this treatment; thus, taking into account the low toxicity rate recorded, a more aggressive schedule should be applied in these resectable tumors.

Choledochocele: changing trends in diagnosis and management

Eighty-four patients with choledochocele collected from the world literature and one personal observation are reviewed. The main issues regarding clinical presentation, diagnostic work-up, and the treatment of this uncommon lesion are discussed. Abdominal pain was the most common clinical feature (91% of cases), followed by pancreatitis (38%), nausea or vomiting (35%), and jaundice (26%). In addition, associated lithiasis was found in 43% of the cases. Endoscopic retrograde cholangiopancreatography was the most useful diagnostic procedure and resulted in a correct diagnosis in all but one of the patients investigated by this method. Surgical excision of the duodenal luminal portion of the choledochocele was the treatment most commonly used (65% of cases). In recent years, operative endoscopy has also been increasingly used, with good results.

[Prognostic factors in local-regional recurrences of colorectal neoplasms]

PURPOSE

The aim of this study was to evaluate, in a group of patients suffering of colo-rectal cancer, the influence on local recurrence of some clinical and anatomo-pathological variables.

METHODS

The study was limited to 833 patients who underwent potentially curative resection and have been followed for at least two years. All patients were evaluated every six months for the first three years and yearly thereafter by means of clinical, laboratory, endoscopic and radiological investigations. Recurrence was observed in 78 patients (9.4%); 19 of these had evidence of distal failure simultaneously (2.2%). The incidence was 2.4% and 17.7% in the carcinoma of the colon and rectum respectively. Median time of recurrence was 16 +/- 11 months; 75% presents within 23 months from operation. Chi-square test was used to relate incidence of recurrence to clinical and anatomo-pathological factors and then a multivariate logistic regression analysis was used to evaluate the most significant variables.

RESULTS

Univariate analysis reveals a significant relationship between recurrence and age under 50 years (p = 0.01), presence of preoperative complication (p = 0.01), stage (p = 0.01), site (p = 0.000) of primary tumor and lymph-nodal involvement (p = 0.0002). No statistically significant difference was found between recurrence and tumor wall infiltration, number of lymph nodes involved, grading and morphology of primary tumor. Multivariate logistic regression analysis confirmed these results except for preoperative complication (p = 0.9).

CONCLUSIONS

Authors believe that selection of patients to undergo adjuvant therapies is improved by identification of high-risk patients.

Surgery of rectal cancer (technical observations)

The evolution of the surgical management of rectal cancer is briefly reviewed. Factors which influence the choice of the surgical procedure relatively to the tumor characteristics, are examined. The role played by preoperative staging as the basis of a correct therapeutic approach is underlined. Most common surgical procedures in rectal cancer treatment are reported, and emphasis is put on aspects of particular interest for radiodiagnosticians and radiotherapists.

Rectal exploration in rectal cancer. Double contrast enema vs rectoscopy: a comparison of present diagnostic accuracy

The present role of rectal exploration in rectal cancer is defined. Indications and limitations of endoscopy and radiology in the study of colon relatively to the diagnosis and pre-treatment approach to rectal cancer, are reviewed. The need to establish definite parameters of tumor morphology indispensable to a correct surgical management, to a possible neoadjuvant therapy and to a precise assessment of the response to therapy, is emphasized. Compared results about the lengthwise tumor extent, the circumferential involvement of rectal walls and the distance from the internal anal sphincter, are reported. It is concluded that the two diagnostic examinations are complementary and that both represent excellent methods for the diagnosis and assessment of the extent of the disease.

Concomitant preoperative radiochemotherapy in operable locally advanced rectal cancer

PURPOSE

The aim of this study was to examine the effectiveness of a combination of preoperative radiotherapy and chemotherapy for operable locally advanced rectal cancer (Stages II and III).

METHODS

Chemotherapy and radiotherapy are started jointly on day one of the therapy. 5-Fluorouracil is given in a dosage of 1000 mg/m2/day as a continuous 24-hour infusion for 4 days. Mitomycin C is given as a bolus intravenous at a dosage of 10 mg/m2 the first day. The radiation therapy is given to a total dosage of 37.8 Gy. Surgery is generally performed four to five weeks following completion of the radiation therapy. From March 1990 to April 1993, 34 patients with histologically documented adenocarcinoma of the rectum have been treated. Twenty-one lesions were located in the lower third of the rectum. Twenty-nine neoplasms were judged by initial clinical staging as Stage III.

RESULTS

Patients compliance to the treatment have been 97 percent. Toxicity of treatment has been low (15 percent). Tumor sizes decreased 50 percent or more in about 80 percent of patients. Distance of the tumor from the anal canal increased in all but seven cases. Twenty-two anterior resections have been performed. The morbidity rate has been 24 percent. No postoperative mortality has been reported. Histologic examination of surgical specimens after integrated treatment showed in 10 cases a tumor confined to the rectal wall (T2), in 3 patients only a residual tumor limited to submucosa (T1), and in 5 (15 percent) patients no evidence of neoplastic cells (T0).

CONCLUSIONS

We conclude that preoperative radiochemotherapy was generally well tolerated; in all cases we had a reduction of tumor sizes, surgery presented no technical difficulties, and there was the effect of stage reduction.

Factors affecting anal continence after restorative proctocolectomy

The aim of this multicentre study was to define the incidence of disordered continence after restorative proctocolectomy and ileoanal reservoir with respect to some factors which may influence the postoperative soiling rate. Two hundred and seven patients underwent the operation, 156 had their ileostomy closed and were all available for a functional assessment. Minor leakage was observed in 26.9% of cases, whereas 1.9% complained of troublesome faecal soiling. None had gross faecal incontinence. Patients over 45 years had significantly more soiling than those younger (45% vs 24%, p less than 0.05). Soiling was more prevalent in those with ulcerative colitis than with other diseases (35% vs 18% p less than 0.05). The soiling rate decreased after the first postoperative year from 34% to 21% (p less than 0.05). A bowel frequency higher than 5 evacuations/24 hours increased soiling from 20% to 48% (p less than 0.01). Pouchitis doubled the soiling rate from 26% to 50% (p less than 0.05) without there being any difference in sphincter function. Soiling was not significantly related to staged procedure, J-pouch, perineal complications or a long rectal cuff. Careful preoperative evaluation of the anal sphincter should be performed in older patients operated on for colitis as they are likely to leak during the first year following restorative proctocolectomy, especially in cases with diarrhoea or pouchitis.

Rubber band ligation of hemorrhoids and rectal mucosal prolapse in constipated patients

Rubber band ligation was used in 160 patients with internal hemorrhoids; 43 of them also had rectal anterior mucosal prolapse; 13 had prolapse alone. Two thirds of the patients underwent a single rubber band ligation and one third a double rubber band ligation in one session without anesthesia. Ninety-four required repeated ligations. A follow-up of 25 +/- 16 months (mean +/- SD) was carried out in 153 of them. Rubber band ligation was followed by prolonged bleeding in six patients and severe pain requiring removal of the rubber band in 12 patients. The complication rate decreased significantly (P less than .05) in the last 80 patients. Compared with multiple ligation, single rubber band ligation in one sitting was followed by a lower complication rate (P less than .01). Long-term results were good in 71 percent of the patients. (A formal hemorrhoidectomy was needed within two years in 6 percent.) A significantly lower recurrence rate of 9 percent was noted in those with normal bowel habits, when compared with constipated subjects whose symptoms recurred in 85 percent (P less than .001). Constipation seems to be a predictable factor in worsening the outcome of rubber band ligation. Rubber band ligation is followed by a lower complication rate when performed in a single ligation.

Clinical and functional results after restorative proctocolectomy

Of 84 patients who underwent restorative proctocolectomy with an ileoanal reservoir in 21 Italian departments of surgery, 51 had ulcerative colitis, 32 familial polyposis and 1 intractable constipation. Follow-up information is available for all 58 patients who had their ileostomy closed, the length of follow-up ranging between 2 and 78 months. There were no operative deaths. A failure rate (i.e. excision of the pouch) of 3 per cent was observed. Sepsis was the most common postoperative complication, and was most often related to ileoanal anastomosis dehiscence (15 per cent), followed by small-bowel obstruction requiring laparotomy (10 per cent). Clinical 'pouchitis' occurred in 14 per cent of patients after ileostomy closure. The average frequency of defaecation was four motions per 24 h; evacuation was spontaneous in all patients and only 5 per cent complained of troublesome faecal soiling while 34 per cent had occasional incontinence to flatus and mucus. Patients with a short or absent rectal cuff had a lower rate of incontinence (30 versus 48 per cent, difference not statistically significant) without any increase in the frequency of genito-urinary disorders. None of the two most used reservoirs, the J (n = 40) and S pouch (n = 17) showed significant superiority in terms of bowel frequency and continence. Incontinence was more likely in patients whose ileostomy closure had been delayed for more than one year.

Outcome of colorectal cancer

The outcome of 454 patients who presented with colorectal carcinoma during a 16 year period is reviewed: 54 per cent were males, 58 per cent were aged more than 60 and 10 per cent had an emergency admission, 42 per cent of tumours occurred in the rectum. A curative resection was possible in 68 per cent. Postoperative mortality was 7 per cent. The overall crude 5-year survival was 41 per cent. The mortality from local recurrence was significantly higher in rectal (11.7 per cent) than in colonic cancer (8.8 per cent; P less than 0.01). The rate of recurrence and metastases was higher in patients with low rectal cancer than in patients with cancer of the middle and the upper rectum (P less than 0.01). Distant metastases were the cause of death in 94 per cent of the patients who had a Miles' operation for cancer of the middle rectum, whereas local recurrence was responsible for late mortality in 80 per cent of patients who underwent an anterior resection. No difference in 5-year survival was found in the restorative and in the excisional group.

Clinical picture and pelvic floor physiology in the solitary rectal ulcer syndrome

Clinical examination, proctosigmoidoscopy, rectal biopsies, barium enema and pelvic floor physiology studies were performed in four patients with solitary rectal ulcer syndrome. All patients had chronic constipation and rectal bleeding. Resting tone and voluntary contraction were found to be decreased at anal manometry in two patients (maximal squeeze pressures were ten and 35 mm Hg, respectively). Balloon proctogram showed an increased rectoanal angle in these two patients (90 degrees and 93 degrees at rest, unchanged on squeezing) with a poor striated sphincter function at EMG; their deficient anal reflex, slight fecal incontinence and perineal descent seemed consistent with pudendal neuropathy. Fibromuscular obliteration of the lamina propria was found at histology. All subjects had successful conservative treatment, including topical corticosteroids in one patient; normalization of bowel habit was the most effective therapy for the disease. The present study seems to confirm the role of chronic constipation and abnormal pelvic floor physiology in the pathogenesis of the syndrome.

Management of the perineal wound after rectal excision for carcinoma

Two methods of treating the perineal wound after proctectomy are compared. One hundred and eleven patients had a Miles operation for rectal cancer: in 81 the perineal wound was left open, in 30, primary suture and suction were performed. A significant (p less than 0.001) decrease in the mean (+/- s.d.) duration of the postoperative period was observed after primary suture: 22 +/- 1.7 days, as compared with 44 +/- 2.2 days after healing by second intention. The occurrence of wound infection was similar in the two groups, whereas in 15 per cent of the patients treated without direct closure, a perineal sinus persisted. According to these data, primary closure seems to be very satisfactory in the management of the perineal wound after excision of the rectum.

Site, emergency, and duration of symptoms in the prognosis of colorectal cancer

Four prognostic factors, i.e., site of the tumors, mode of presentation, duration of symptoms, and pathologic staging, were correlated to the results of surgical treatment, i.e., curative resectability, postoperative complications and mortality, and five-year survival, in 161 patients operated upon for colorectal cancer. Only 31 (19 per cent) of the growths were right-sided; 71 patients (44 per cent) had symptoms less than six months. Fifty-four of them had a localized cancer; a radical procedure was performed in 114 (71 per cent), and postoperative complications occurred in 42 cases (26 per cent). The overall crude five-year survival was 38 per cent (53 of the 140 followed-up patients). The length of the clinical history did not correlate with the pathologic staging, which greatly influenced curability and survival. A statistically significant power prognosis was observed in patients with left-sided tumors, with an emergency presentation and with a duration of symptoms shorter than six months. A better prognosis can be achieved by means of a presymptomatic diagnosis.

Variations of plasma CEA levels in gynecologic malignancies: incidence, significance and changes occurring in response to therapy

Serial carcinoembryonic antigen (CEA) radioimmunoassay were performed on 84 patients with primary gynecologic malignancies using the double antibody method. A positive correlation between the marker levels and tumor stage was found in the subjects with invasive disease: the incidence of positive values is appreciably higher in the advanced stages of malignancies. The surgical resection normalized the pretreatment elevated levels: fluctuating CEA values were observed during chemio or radiotherapy. The findings of this investigation support the theory of the limited usefulness of the CEA levels as a diagnostic test in patients with gynecologic cancer. The determination would appear to be helpful only in case with an elevated plasma values at the time of diagnosis. The CEA test seems to indicate that serial plasma assays can be of large interest in the follow-up of this women and for the second-look surgery, chemio and radiant therapy.