Restructuring surgical training after COVID-19 pandemic: A nationwide survey on the Italian scenario on behalf of the Italian polyspecialistic young surgeons society (SPIGC)

Introduction

The COVID-19 pandemic has led to the disruption of surgical training. Lack of communication, guidelines for managing clinical activity as well as concerns for safety in the workplace appeared to be relevant issues. This study aims to investigate how surgical training has been reorganized in Italy, almost 2 years after the outbreak of COVID-19 pandemic.

Materials and methods

A 16-item-electronic anonymous questionnaire was designed through SurveyMonkey^© web application. This survey was composed of different sections concerning demographic characteristics and impacts of the second COVID-19 pandemic wave on surgical and research/didactic activities. Changes applied in the training programme and activities carried out were also investigated. The survey was carried out in the period between June and October 2021.

Results

Four hundred and thirty responses were collected, and 399 were considered eligible to be included in the study analysis. Three hundred and thirty-five respondents continued working in Surgical Units, with a significant reduction (less than one surgical session per week) of surgical sessions in 49.6% of them. With concern to didactic and research activities, 140 residents maintained their usual activity, while 116 reported a reduction. A sub-group analysis on resident moved to COVID-19 departments showed a reduction of research activities in 35% of them. During the period considered in this survey, the surgical training program was not substantially modified for most of participants (74.6%).

Conclusion

Our survey demonstrated that surgical residency programs haven't improved 2 years after the beginning of the pandemic. Further improvements are needed to guarantee completeness of surgical training, even in emergency conditions.

ERas and COLorectal endoscopic surgery: an Italian society for endoscopic surgery and new technologies (SICE) national report

Background

Several reports demonstrated a strong association between the level of adherence to the protocol and improved clinical outcomes after surgery. However, it is difficult to obtain full adherence to the protocol into clinical practice and has still not been identified the threshold beyond which improved functional results can be reached.

Methods

The ERCOLE (ERas and COLorectal Endoscopic surgery) study was as a cohort, prospective, multi-centre national study evaluating the association between adherence to ERAS items and clinical outcomes after minimally invasive colorectal surgery. The primary endpoint was to associate the percentage of ERAS adherence to functional recovery after minimally invasive colorectal cancer surgery. The secondary endpoints of the study was to validate safety of the ERAS programme evaluating complications’ occurrence according to Clavien-Dindo classification and to evaluate the compliance of the Italian surgeons to each ERAS item.

Results

1138 patients were included. Adherence to the ERAS protocol was full only in 101 patients (8.9%), > 75% of the ERAS items in 736 (64.7%) and > 50% in 1127 (99%). Adherence to > 75% was associated with a better functional recovery with 90.2 ± 98.8 vs 95.9 ± 33.4 h (p = 0.003). At difference, full adherence to the ERAS components 91.7 ± 22.1 vs 92.2 ± 31.6 h (p = 0.8) was not associated with better recovery.

Conclusions

Our results were encouraging to affirm that adherence to the ERAS program up to 75% could be considered satisfactory to get the goal. Our study could be considered a call to simplify the ERAS protocol facilitating its penetrance into clinical practice.

Efficacy of High-Resolution Preoperative 3D Reconstructions for Lesion Localization in Oncological Colorectal Surgery—First Pilot Study

When planning an operation, surgeons usually rely on traditional 2D imaging. Moreover, colon neoplastic lesions are not always easy to locate macroscopically, even during surgery. A 3D virtual model may allow surgeons to localize lesions with more precision and to better visualize the anatomy. In this study, we primary analyzed and discussed the clinical impact of using such 3D models in colorectal surgery. This is a monocentric prospective observational pilot study that includes 14 consecutive patients who presented colorectal lesions with indication for surgical therapy. A staging computed tomography (CT)/magnetic resonance imaging (MRI) scan and a colonoscopy were performed on each patient. The information gained from them was provided to obtain a 3D rendering. The 2D images were shown to the surgeon performing the operation, while the 3D reconstructions were shown to a second surgeon. Both of them had to locate the lesion and describe which procedure they would have performed; we then compared their answers with one another and with the intraoperative and histopathological findings. The lesion localizations based on the 3D models were accurate in 100% of cases, in contrast to conventional 2D CT scans, which could not detect the lesion in two patients (in these cases, lesion localization was based on colonoscopy). The 3D model reconstruction allowed an excellent concordance correlation between the estimated and the actual location of the lesion, allowing the surgeon to correctly plan the procedure with excellent results. Larger clinical studies are certainly required.

Association of Delayed Surgery With Oncologic Long-term Outcomes in Patients With Locally Advanced Rectal Cancer Not Responding to Preoperative Chemoradiation

Importance

Extending the interval between the end of neoadjuvant chemoradiotherapy (CRT) and surgery may enhance tumor response in patients with locally advanced rectal cancer. However, data on the association of delaying surgery with long-term outcome in patients who had a minor or poor response are lacking.

Objective

To assess a large series of patients who had minor or no tumor response to CRT and the association of shorter or longer waiting times between CRT and surgery with short- and long-term outcomes.

Design, Setting, and Participants

This is a multicenter retrospective cohort study. Data from 1701 consecutive patients with rectal cancer treated in 12 Italian referral centers were analyzed for colorectal surgery between January 2000 and December 2014. Patients with a minor or null tumor response (ypT stage of 2 to 3 or ypN positive) stage greater than 0 to neoadjuvant CRT were selected for the study. The data were analyzed between March and July 2020.

Exposures

Patients who had a minor or null tumor response were divided into 2 groups according to the wait time between neoadjuvant therapy end and surgery. Differences in surgical and oncological outcomes between these 2 groups were explored.

Main Outcomes and Measures

The primary outcomes were overall and disease-free survival between the 2 groups.

Results

Of a total of 1064 patients, 654 (61.5%) were male, and the median (IQR) age was 64 (55-71) years. A total of 579 patients (54.4%) had a shorter wait time (8 weeks or less) 485 patients (45.6%) had a longer wait time (greater than 8 weeks). A longer waiting time before surgery was associated with worse 5- and 10-year overall survival rates (67.6% [95% CI, 63.1%-71.7%] vs 80.3% [95% CI, 76.5%-83.6%] at 5 years; 40.1% [95% CI, 33.5%-46.5%] vs 57.8% [95% CI, 52.1%-63.0%] at 10 years; P < .001). Also, delayed surgery was associated with worse 5- and 10-year disease-free survival (59.6% [95% CI, 54.9%-63.9%] vs 72.0% [95% CI, 67.9%-75.7%] at 5 years; 36.2% [95% CI, 29.9%-42.4%] vs 53.9% [95% CI, 48.5%-59.1%] at 10 years; P < .001). At multivariate analysis, a longer waiting time was associated with an augmented risk of death (hazard ratio, 1.84; 95% CI, 1.50-2.26; P < .001) and death/recurrence (hazard ratio, 1.69; 95% CI, 1.39-2.04; P < .001).

Conclusions and Relevance

In this cohort study, a longer interval before surgery after completing neoadjuvant CRT was associated with worse overall and disease-free survival in tumors with a poor pathological response to preoperative CRT. Based on these findings, patients who do not respond well to CRT should be identified early after the end of CRT and undergo surgery without delay.

Colorectal Cancer Surgery During the COVID-19 Pandemic: A Single Center Experience

BACKGROUND/AIM

A notable re-allocation of healthcare resources and specific clinical and organizational measures have been required to prevent COVID-19 infection among hospitalized patients and healthcare workers.

PATIENTS AND METHODS

From March 9th to May 9th 2020 we performed colorectal cancer elective surgery on 25 patients: a pre-hospital screening was carried out in order to avoid hospitalization of patients suspected of COVID-19 infection.

RESULTS

All patients (median age=76 years; range=37-88 years) were considered suitable for admission after telephone triage; the median interval between primary diagnosis and hospital admission was 23.1 days (range=1-55 days). The median hospitalization was 7.8 days (range=4-18 days). One COVID-19-associated death was reported.

CONCLUSION

Our experience demonstrates that safe colorectal cancer elective surgery can be performed during the pandemic COVID-19. Further consensus and guidelines to prevent diffusion of pandemic diseases among hospitalized patients and healthcare workers still need to be implemented.

The GPS for surgery: A user-centered evaluation of a navigation system for laparoscopic surgery

BACKGROUND

Unsafe surgical care has emerged as a significant public health concern, motivated by a high percentage of major complications happening during surgery, attributed to surgeons' skills and experience, and determined to be preventable.

METHODS

This article presents APSurg, an Abdominal Positioning Surgical system designed to improve awareness and safety during laparoscopic surgery. The proposed system behaves like a GPS, offering an additional dynamic virtual reality view of the surgical field.

RESULTS

This work presents an evaluation study in terms of accuracy, effectiveness, and usability. Tests were conducted performing a localization task on an abdomen phantom in a simulated scenario. Results show a navigation accuracy below 5 mm. The task execution time was reduced by a 15% and the performed incision dimension was reduced by a 46%, with respect to a standard setup. A custom questionnaire showed a significant positive impact in exploiting APSurg during the surgical task execution.

A two-step surgery and a multidisciplinary approach in a centenarian patient with an acute presentation of right colon cancer

Background

As surgery remains the cornerstone of colorectal cancer (CRC) treatment, the number of older patients presented for colorectal resection is rapidly increasing. Nevertheless, the choice to operate an oldest-old patient still remain challenging and requires a careful assessment of risk to benefit ratio in order to guarantee appropriate surgical strategies and perioperative management.

Case presentation

A centenarian patient, acutely admitted to the emergency department, was diagnosed with an ileus caused by stenosing ascending colon cancer with abnormal distension of the right colon at high risk of perforation. Facing with this complex clinical scenario, a lateral decompressive cecostomy as alternative surgical procedure, was performed in local anesthesia in order to avoid the stressful event of an emergency surgery. Thereafter, the patient was admitted to the surgical ward and followed by a geriatrician who performed a comprehensive geriatric assessment (CGA) and daily clinical evaluations. This integrated plan of care was mainly focused on rehabilitation, nutritional interventions and therapeutic reconciliation, maximizing patient’s clinical conditions and performance status. Then, the second surgical step, the radical colon surgery with curative intent and bowel continuity reestablishment was performed, demonstrating to be feasible and safety also in a very advanced age patient in term of prolonged survival and preservation of an adequate quality of life.

Conclusions

This is the first case-report that illustrates a successful two step surgery for CRC in a centenarian patient thanks to a multidisciplinary based approach, overwhelming the mere concept of chronological age.

Consensus Statement of the Italian Polispecialistic Society of Young Surgeons (SPIGC): Diagnosis and Treatment of Acute Appendicitis

Background: Acute appendicitis (AA) is one of the most common causes of abdominal pain requiring surgical intervention. Approximately 20% of AA cases are characterized by complications such as gangrene, abscesses, perforation, or diffuse peritonitis, which increase patients' morbidity and mortality. Diagnosis of AA can be difficult, and evaluation of clinical signs, laboratory index and imaging should be part of the management of patients with suspicion of AA.Methods: This consensus statement was written in relation to the most recent evidence for diagnosis and treatment of AA, performing a literature review on the most largely adopted scientific sources. The members of the SPIGC (Italian Polispecialistic Society of Young Surgeons) worked jointly to draft it. The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by the American College of Chest Physicians (CHEST) for the strength of the recommendations.Results: Fever and migratory pain tend to be present in patients with suspicion of AA. Laboratory and radiological examinations are commonly employed in the clinical practice, but today also scoring systems based on clinical signs and laboratory data have slowly been adopted for diagnostic purpose. The clinical presentation of AA in children, pregnant and elderly patients can be unusual, leading to more difficult and delayed diagnosis. Surgery is the best option in case of complicated AA, whereas it is not mandatory in case of uncomplicated AA. Laparoscopic surgical treatment is feasible and recommended. Postoperative antibiotic treatment is recommended only in patients with complicated AA.

Development and Validation of a Homemade, Low-Cost Laparoscopic Simulator for Resident Surgeons (LABOT)

Several studies have demonstrated that training with a laparoscopic simulator improves laparoscopic technical skills. We describe how to build a homemade, low-cost laparoscopic training simulator (LABOT) and its validation as a training instrument. First, sixty surgeons filled out a survey characterized by 12 closed-answer questions about realism, ergonomics, and usefulness for surgical training (global scores ranged from 1—very insufficient to 5—very good). The results of the questionnaires showed a mean (±SD) rating score of 4.18 ± 0.65 for all users. Then, 15 students (group S) and 15 residents (group R) completed 3 different tasks (T1, T2, T3), which were repeated twice to evaluate the execution time and the number of users’ procedural errors. For T1, the R group had a lower mean execution time and a lower rate of procedural errors than the S group; for T2, the R and S groups had a similar mean execution time, but the R group had a lower rate of errors; and for T3, the R and S groups had a similar mean execution time and rate of errors. On a second attempt, all the participants tended to improve their results in doing these surgical tasks; nevertheless, after subgroup analysis of the T1 results, the S group had a better improvement of both parameters. Our laparoscopic simulator is simple to build, low-cost, easy to use, and seems to be a suitable resource for improving laparoscopic skills. In the future, further studies should evaluate the potential of this laparoscopic box on long-term surgical training with more complex tasks and simulation attempts.

The postoperative analgesic efficacy of preperitoneal continuous wound infusion compared to epidural continuous infusion with local anesthetics after colorectal cancer surgery: a randomized controlled multicenter study

BACKGROUND

Open colorectal cancer (CRC) surgery induces severe and prolonged postoperative pain. The optimal method of postoperative analgesia in CRC surgery has not been established. We evaluated the efficacy of preperitoneal continuous wound infusion (CWI) of ropivacaine for postoperative analgesia after open CRC surgery in a multicenter randomized controlled trial.

METHODS

Candidates for open CRC surgery randomly received preperitoneal CWI analgesia or continuous epidural infusion (CEI) analgesia with ropivacaine 0.2% 10 mL/h for 48 hours after surgery. Fifty-three patients were allocated to each group. All patients received patient-controlled IV morphine analgesia.

RESULTS

Over the 72-hour period after the end of surgery, CWI analgesia was not inferior to CEI analgesia. The difference of the mean visual analog scale score between CEI and CWI patients was 1.89 (97.5% confidence interval = -0.42, 4.19) at rest and 2.76 (97.5% confidence interval = -2.28, 7.80) after coughing. Secondary end points, morphine consumption and rescue analgesia, did not differ between groups. Time to first flatus was 3.06 ± 0.77 days in the CWI group and 3.61 ± 1.41 days in the CEI group (P = 0.002). Time to first stool was shorter in the CWI than the CEI group (4.49 ± 0.99 vs 5.29 ± 1.62 days; P = 0.001). Mean time to hospital discharge was shorter in the CWI group than in the CEI group (7.4 ± 0.41 and 8.0 ± 0.38 days, respectively). More patients in the CWI group reported excellent quality of postoperative pain control (45.3% vs 7.6%). Quality of night sleep was better with CWI analgesia, particularly at the postoperative 72-hour evaluation (P = 0.009). Postoperative nausea and vomiting was significantly less frequent with CWI analgesia at 24 hours (P = 0.02), 48 hours (P = 0.01), and 72 hours (P = 0.007) after surgery evaluations.

CONCLUSIONS

Preperitoneal CWI analgesia with ropivacaine 0.2% continuous infusion at 10 mL/h during 48 hours after open CRC surgery provided effective postoperative pain relief not inferior to CEI analgesia.

Total mesorectal excision with radiofrequency in rectal cancer: open versus laparoscopy approach

AIM

The aim of this study was to compare the safety, efficacy and oncologic results in the low rectal resection with total mesorectal excision with radiofrequency (Ligasure™, Covidien, Boulder, CO, USA) in laparoscopic surgery.

METHODS

From July 2005 to December 2008, 227 patients underwent colorectal resection for cancer at S. Martino Hospital in Genoa. Sixty-one patients underwent curative rectal resection for mid or low rectal cancer using Ligasure™ device applied on smaller vessels and for the execution of total mesorectal excision. Forty-six patients underwent open laparotomy (OL), 15 laparoscopic surgery. There were no differences concerning demographics data and diagnosis, but only regarding staging (P=0.009). Primary goal was to evaluate major complications, operating time, hospital stay, distal margin of the tumor and number of nodes harvested in specimen. Secondary goal was to assess the average time of survival in the short period.

RESULTS

The mean operative times were shorter in the OL group (188 vs. 246 min) overall. This difference was significant (P=0.004). In particular two parameters of specimens were analyzed: the total number of nodes and distal clearing from cancer, excluding abdominoperineal resection. An average number of 16.6 nodes in the OL group and 13.9 in the VL group (P=ns) were detected; mean distal clearing in the OL group was 30.7 mm and 48.1 mm in the VL group (P=ns). There were no differences concerning major complications in either group. The hospital stay in the VL group was shorter than in the OL group, but the differences were not significant.

CONCLUSION

The Ligasure™ device does not reduce operating time in laparoscopy rectal cancer resection but it allows to get correct oncologic results in patients submitted to total mesorectal excision.

Gastric Abrikosoff tumor (granular cell tumor): case report

Granular Cells Tumor (GCT), also called Abrikosoff tumor, is very uncommon lesion of neural derivation. It is characterized by the presence of granular cell; benign and malignamt counterparts are known, even if the second ones are rare. It has a slight predominance in female sex and black race; the age range is wide, with peak between fourth and sixth decades of life. Any localisation is possible, although surface lesions (head, neck, trunk, extremities) are far more common than visceral ones (esophagus, stomach, small and large bowel, larynx, bronchi, gallbladder and biliary tract). Surgical en-block excision is curative for both benign an malignant forms. Radiotherapy and chemotherapy are not effective. We report the case of a 45 year old man who had a cytologic diagnosis of fusocellular stromal tumor of the gastric fundus during examination for gastritis. He underwent a wedge resection of the gastric wall: at the histological examination neoplastic cells had a granular cytoplasm and immunoassay was positive for S100 protein, PGP 9.5 and NSE. Complete excision guarantees from recurrence and metastases: however a long term endoscopic follow-up is necessary.

Factors that influence 12 or more harvested lymph nodes in resective R0 colorectal cancer

BACKGROUND/AIMS

The number of lymph nodes required for accurate staging is a critical component in colorectal cancer (CRC). Current guidelines demand at least 12 lymph nodes to be retrieved. Results of previous studies were contradictory in factors, which influenced the number of harvested lymph nodes. This study was designed to determine the factors that influence the number of harvested lymph nodes (> or = 12) in resective R0 early-stage CRC in a single institution.

METHODOLOGY

Between July 2005 and December 2008, data on 225 patients who underwent surgery for CRC were retrospectively evaluated. Data for a total of 139 R0-surgery patients were collected and all the tumor-bearing specimens were fixed with node identification performed. Several possible factors that influence 12 or more harvested lymph nodes were investigated and classified into four aspects: (1) operating surgeon, (2) examining pathologist, (3) patient (age, sex, and body mass index) and (4) disease (tumor localization, tumor cell differentiation, tumor stage, type of resection).

RESULTS

A total of 100 patients (71.9%) with 12 or more harvested lymph nodes and 39 patients (28.1%) with < 12 lymph nodes were analyzed. The results demonstrate that within a single institution, tumor localization, depth of tumor invasion according to Dukes stage and grading were independent influencing factors of 12 or more harvested lymph nodes. Neither the operating surgeon nor the examining pathologist had significant influence on the number of harvested lymph nodes.

CONCLUSIONS

The number of harvested lymph nodes was highly variable in patients who underwent resection of R0 CRC. Neither the operating surgeon nor the examining pathologist had significant influence over the number of harvested lymph nodes. Therefore, from the viewpoint of the surgeons, disease itself is the most important factor influencing the number of harvested lymph nodes.

Colon and rectal surgery for cancer without mechanical bowel preparation: one-center randomized prospective trial

Background

Mechanical bowel preparation is routinely done before colon and rectal surgery, aimed at reducing the risk of postoperative infectious complications. The aim of the study was to assess whether elective colon and rectal surgery can be safely performed without preoperative mechanical bowel preparation.

Methods

Patients undergoing elective colon and rectal resections with primary anastomosis were prospectively randomized into two groups. Group A had mechanical bowel preparation with polyethylene glycol before surgery, and group B had their surgery without preoperative mechanical bowel preparation. Patients were followed up for 30 days for wound, anastomotic, and intra-abdominal infectious complications.

Results

Two hundred forty four patients were included in the study, 120 in group A and 124 in group B. Demographic characteristics, type of surgical procedure and type of anastomosis did not significantly differ between the two groups. There was no difference in the rate of surgical infectious complications between the two groups but the overall infectious complications rate was 20.0% in group A and 11.3% in group B (p .05). Wound infection (p = 0.18), anastomotic leak (p = 0.52), and intra-abdominal abscess (p = 0.36) occurred in 9.2%, 5.8%, and 5.0% versus 4.8%, 4.0%, and 2.4%, respectively. No mechanical bowel preparation seems to be safe also in rectal surgery.

Conclusions

These results suggest that elective colon and rectal surgery may be safely performed without mechanical preparation.

Survival in surgical palliative resection of stage IV colorectal cancer: short term results in a single institution

AIM

In this study, we analyze clinical parameters, survival and possible advantage of surgery in patients affected by symptomatic Dukes D colorectal cancer.

METHODS

From July 2005 to December 2008 at our Oncological Surgery Unit we treated 69 symptomatic stage IV CRC, 46 of them resected at our Oncological Surgical Unit. Clinical variables were tested for their relationship to survival in a univariate prognostic analysis and revealed the interaction of the prognostic factors.

RESULTS

In symptomatic stage IV CRC with non-curable resection, the most robust univariate predictor for poor prognosis was impossibility to cancer resection. It is associated with significative decrease of survival also in the short term. In our series we do not observe correlation between poor prognosis and age, gender, localisation of tumor, depth of invasion, 19.9 and surgeons. CEA more than 100 microg/L and impossibility to adiuvant therapy have a significative role and are associated with poor prognosis.

CONCLUSION

Our results suggested that impossibility to perform cancer resection is associated with poor prognosis in symptomatic stage IV CRC and worse survival also in the short term.

[Leakage of colorectal anastomosis after neoadjuvant therapy with bevacizumab. Case report]

BACKGROUND

Despite progresses achieved in last decades in treatment of rectal cancer, anastomotic leakage remains the main complication.

PATIENTS AND METHODS

We report two cases of patients affected by distal rectal cancer. Both patients received neoadjuvant therapy according to ROCHE ML 18522 experimental protocol (Xeloda, Avastin and radiotherapy). After about respectively one and two months after anterior resection of the rectum, with transanal anastomosis and temporary colostomy, presacral abscess occurred. Patients were hospitalized and started antibiotic therapy. In one case it was necessary TC-guided drainage placement.

RESULTS

Both patients had a favourable course and, after respectively 6 months and 1 year, underwent closure of colostomy.

DISCUSSION

"Spontaneous" gastrointestinal microperforation (small leakage) is reported during treatment with bevacizumab, a monoclonal antibody against Vascular Endothelial Growth Factor (VEGF), also in patients with non gastrointestine tumours. Probably this results from inhibition of neoangiogenesis induced.

CONCLUSIONS

Surgeons have to pay attention to adverse effects of combined neoadjuvant treatment of rectal cancer, considering temporary colostomy in presence of particular risk factors.

Factors predicting survival in surgical palliative resection of stage IV colorectal cancer

AIM

Colorectal cancer (CRC) harbors accumulated genetic alterations with cancer progression, which results in uncontrollable disease. To regulate the most malignant CRC, we have to know the most dismal phenotype of stage IV disease.

METHODS

A retrospective review of our Oncological Surgical Unit was performed (from 2005 to 2008) to extract the 52 resected stage IV CRC. Clinical variables were tested for their relationship to survival in a univariate prognostic analysis and revealed the interaction of the prognostic factors.

RESULTS

In stage IV CRC with noncurable resection, the most robust univariate predictors for poor prognosis were preoperative high value of CEA. In our series we did not observe correlation between poor prognosis and depth of invasion, age, gender, pathologic lymph node metastasis status, Ca 19.9 and postoperative therapy. The mean average survival rate was 10.9 months.

CONCLUSIONS

Our results suggested that only preoperative value CEA is associated with poor prognosis in stage IV CRC.

Complicated small-bowel diverticulosis: a case report and review of the literature

Here we report a case of a 60 years old woman who came to the Emergency Department of San Martino Hospital suffering from abdominal pain for about a week with high fever in the last 24 hours. The final histological examination led to the diagnosis of ileal diverticulosis associated with perforation and peritonitis with a fibrotic reaction involving the last ileal loop, the caecum and the appendix.

Lymphadenectomy in elective and urgency surgery for resective colorectal cancer

AIM

The aim of this study was to analyze the factors affecting the number of lymph nodes examined in colorectal cancer specimens after elective or urgent surgery on the current clinical practice in our surgical unit.

METHODS

The authors considered 120 patients who had undergone surgery for colorectal carcinoma from July 2005 to December 2007 divided into two groups, 102 elective oncologic resections (group A) and 18 performed in emergency (group B). All patients underwent laparotomic colorectal resection. The groups were similar in age, weight and body mass index, different in gender e in cancer stage. The authors analyze prognostic differences in number of examined lymph nodes and factors involved in differences between groups.

RESULTS

There were no statistically significative differences in number of nodes harvested in specimen (15.85+/-8.17, CI 95% 14.25-17.46 for group A and 13.83+/-6.56, CI 95% 10.57-17.09 for group B, P-value 0.36). Operating time was shorter in group B (P-value 0.012). We not observed differences between groups in survival rate (P-value 0.62).

CONCLUSIONS

The results of the study suggest that a correct lymphadenectomy and an adequate lymph node harvest in colorectal cancer surgery is essential also in resections performed in urgency, to allow a correct staging and an accurate selection of patients for adjuvant chemotherapy, with improvement of results at follow-up.

Total mesorectal excision with radiofrequency in rectal cancer

AIM

The aim of this study was to compare the safety, the efficacy and the oncologic results in rectal cancer with total mesorectal excision using Ligasure (LS), a modern bipolar vessel sealing system, with monopolar electrocoagulation or stitches (ME).

METHODS

From July 2005 to December 2007 one hundred twenty-nine patients underwent colon resection for cancer at the San Martino Hospital of Genoa (Italy); 43 patients underwent rectal resection. All patients underwent laparotomy rectal resection with total mesorectal excision; 9 (21%, group LS) underwent total mesorectal excision with radiofrequency, 34 (79%, group ME) with monopolar electrocoagulations, vessels ligation or stitches. Patients of group LS were similar to patients of group ME in age, gender, weight and body mass index. Cancer stage was for group A 3 stage B, 5 stage C and 1 stage D, for group B 4 stage A, 15 stage B, 8 stage C, 6 stage D and 1 non-staged tumor.

RESULTS

There were no differences in intraoperative or postoperative complications. Operating time was similar in both group. Oncological results was similar in both groups. The major cost in group LS were attributable to cost of service.

CONCLUSION

The Ligasure device does not reduce operating time in laparotomy rectal cancer resection but permit correct oncological results in patients submitted to total mesorectal excision. The costs of device reserved its use to surgery of low-rectal cancer or laparoscopic approach.

Microsurgery for treatment of peripheral lymphedema: Long-term outcome and future perspectives

Authors report over 30 years of their own clinical experience in the treatment of chronic peripheral lymphedemas by microsurgical techniques performed at the Center of Lymphatic Surgery of the University of Genoa, Italy. Over 1,500 lymphedema patients were treated with microsurgical techniques. Derivative lymphatic-venous techniques were most often used. For those cases where a venous disease was associated to lymphedema, reconstructive lymphatic microsurgery techniques were performed (lymphatic-venous-lymphatic-plasty). Objective assessment was undertaken by water volumetry and lymphoscintigraphy. Volume changes showed a significant improvement in over 83%, with an average follow-up of more than 10 years. There was an 87% reduction in the incidence of cellulitic attacks after microsurgery. Microsurgical lymphatic-venous anastomoses have a place in the treatment of peripheral lymphedema and should be the therapy of choice in patients who are not sufficiently responsive to nonoperative treatment. Improved results can be expected with operations performed at earlier lymphedema stages.

The lymphatics in the pathophysiology of thoracic and abdominal surgical pathology: Immunological consequences and the unexpected role of microsurgery

The authors report their experience in the diagnosis and treatment of lymphatic and chylous disorders in the thoracic and abdominal areas. Sixteen patients (10 adults, 6 children) affected by primary chylous ascites with associated syndromes and consequent immunological incompetence were studied. Diagnostic investigations included abdominal sonography scans, lymphoscintigraphy, and lymphography combined with computed tomography and laparoscopy. Surgical treatment included laparoscopy, drainage of ascites and/or the chylothorax, treatment of abdominal and retroperitoneal chylous leaks, exeresis of lymphodysplastic tissues, ligation of incompetent lymph vessels also by CO(2) LASER, and chylo-venous and lympho-venous microsurgical shunts. Eleven patients did not have a relapse of the ascites and four patients had a persistence of a small quantity of ascites with no protein imbalance. All patients had an improvement of their immunocompetence. Median follow-up was 5 years. We demonstrated that the use of microsurgery is remarkably advantageous for performing a causal treatment of the dysfunction.