Clinical and biological features of an intranodal palisaded myofibroblastoma

Intranodal palisaded myofibroblastoma (IPM) is a rare benign tumor of the lymph nodes probably arising from smooth muscle-like cells. The tumor is characterized by intranodal proliferation of spindle cells. Neoplastic spindle-cell proliferation is most often of metastatic repetition which is very important in the recognition of IPM, because it may be mistaken for metastasis or other tumors such as Kaposi's sarcoma. We report a novel case of IPM that confirms the myofibroblastic differentiation of the tumor. The onset of IPM has been associated with Epstein-Barr virus (EBV). In addition, recently reported cases of IPM have been seen with cyclin 1 overexpression and also with human herpes virus (HHV)-8 and EBV DNA sequences. In our case, there was no evidence of HHV-8 and EBV DNA sequences and we were not able to find cyclin 1 overexpression.

The surgical treatment of fecal incontinence with artificial anal sphincter implant. Preliminary clinical report

BACKGROUND/AIMS

Fecal incontinence has a serious impact upon patients' quality of life. Several treatment methods are possible according to the pathophysiology of the disease.

METHODOLOGY

Between March 1999 and February 2002 eight artificial anal sphincters (American Medical System - AMS) were implanted in seven patients affected with severe fecal incontinence; in one case the device was positioned in a patient who had previously undergone a Miles' resection. All cases were carefully selected according to appropriate diagnostic evaluation. The follow-up varies between 3 and 40 months.

RESULTS

The prosthesis had to be removed in two cases; in one patient infection of the implant area occurred, while in the other case persistent perianal pain due to the presence of the device could not be tolerated by the patient. In the six patients that could be successfully treated with the artificial anal sphincter implant, it dramatically improved their quality of life.

CONCLUSIONS

The success of the procedure allows the consideration that the artificial anal sphincter implant is the best treatment for severe fecal incontinence that cannot be solved with conservative therapy.

Bile duct injuries during laparoscopic cholecystectomy: a 1994-2001 audit on 13,718 operations in the area of Rome

BACKGROUND

Bile duct injuries (BDIs) during laparoscopic cholecystectomy (LC) still are reported with greater frequency than during open cholecystectomy (OC).

METHODS

In 1999, a retrospective study evaluating the incidence of BDIs during LC in the area of Rome from 1994 to 1998 (group A) was performed. In addition, a prospective audit was started, ending in December 2001 (group B).

RESULTS

In group A, 6,419 LCs were performed (222 were converted to OC; 3.4%). In group B, 7,299 LCs were performed (225 were converted to OC; 3.1%). Seventeen BDIs (0.26%) occurred in group A and 16 (0.22%) in group B. Overall, mortality and major morbidity rates were 12.1% and 30.3%, respectively, without significant differences between the two groups.

CONCLUSIONS

The incidence and clinical relevance of BDIs during LC in the area of Rome appeared to be stable over the past 8 years and were not influenced by the use of a prospective audit, as compared with a retrospective survey.

[Biliary-intestinal bypass in the treatment of severe obesity: personal experience with 23 patients]

BACKGROUND

The aim of this study was to determine the efficacy and safety of biliary-intestinal bypass in severely obese subjects (Body Mass Index > 35).

METHODS

From January to December 1999, 23 patients (8 men and 15 women, mean age 36.6 years: range 20-51) affected with primary morbid obesity (BMI >40: range 40.1-64.7), in whom different attempt using conservative medicine have proved non-resolutive, underwent biliary-intestinal bypass. After the operation all the patients have been followed- up for 12 months.

RESULTS

The mean Body Mass Index was reduced to 36.9 (range 27.7-44.1) after 6 months and to 33 (range 24.9-40.1) after 12 months. Peri and postoperative mortality was zero. Excessive malabsorption was efficaciously controlled by adequate replacement therapy. Diarrhoea, common compliance of every operation inducin malabsorbition, was reduced to 2-3 evacuation a day after 2-3 months.

CONCLUSIONS

On the basis of personal experience it is underlined that biliary-intestinal bypass, as surgical treatment of morbid obesity refractory to medical therapy, is today a safe and effective operation (up to 80% of excess body weight lose); the presence of biliary-intestinal anastomosis reduces the post-operative loss of bile acids, choleretic diarrhoea and electrolytic disorders.

Gallstones in elderly patients: impact of laparoscopic cholecystectomy

The use of laparoscopic cholecystectomy (LC) in elderly patients may pose problems because of their poor general condition, especially of cardiopulmonary function. Moreover, these patients present with acute cholecystitis and associated common bile duct stones more often than their younger counterparts. From 1990 to 1999, the authors performed 943 LCs; 31 (3.2%) were attempted on elderly patients, 11 (35%) of which were on an emergency basis because of acute cholecystitis, cholangitis or acute biliary pancreatitis. Ten per cent of LCs needed to be converted to an open cholecystectomy, most often because of an increase in the partial pressure of carbon dioxide in the blood produced by excessive operative time. A gasless procedure was used in the last three years of the study on eight cases; the overall rate of conversion from LC to open cholecystectomy in this group was 0%. Associated gallbladder and common bile duct stones were found in five (16%) patients (four preoperative LC endoscopic sphincterotomy and one transcystic approach). The success rate in both of these cases was 100%, overall morbidity was 29% and there was no mortality. These results show that LC is a feasible and safe procedure for use in elderly patients. Gasless LC should be preferred in patients classified as American Society of Anesthesiologists' class III because an excessive duration of operation is the most common reason for converting to an open cholecystectomy.

[Hemorrhoidectomy with ropivacaine (Naropin) local anesthesia. Preliminary experience]

BACKGROUND

The use of local anesthesia in non-septic anal surgery is now well established. Tolerance to local injection, duration of local effect and the risk of local or systemic complications still represent unsolved issues. Ropivacaine, a new local anesthetic, seems particularly indicated for this kind of surgery because of its pharmacologic properties which reduce patient's discomfort during infiltration and provide good antalgic coverage in the first hours following the operation.

METHODS

The first 20 consecutive cases operated with local anesthesia by ropivacaine have been prospectively studied. All patients have been given an 11-point box VAS scale which is used for subjective evaluation of pain.

RESULTS

Mean pain score resulted 1.1, 1.6 and 1.4 at 1, 2 and 3 postoperative hours, respectively. Thirty percent of patients subsequently required pain medication up to the first bowel movement. No complications related to the use of ropivacaine has been observed.

CONCLUSIONS

This new drug can be safely used in the outpatient or Day-Surgery treatment of hemorrhoids.

Endoscopic and surgical integration in the approach to biliary tract disease

Several techniques are available today to access the bile ducts, all equally safe and effective. Since 1990, we have studied three groups of patients treated with different methods: the sequential endoscopic sphincterotomy + laparoscopic cholecystectomy, the single-stage laparoscopic approach, and the single laparoscopic-endoscopic approach. The results obtained in 127 patients to date suggest that one single-stage treatment is more convenient for the patient, while the combination of endoscopic sphincterotomy with laparoscopic cholecystectomy is preferable in terms of efficacy and safety.

[Gastric resection and subtotal gastrectomy. Principles and updated surgical technique]

The Authors describe their last 10 years experience in gastric surgery. They report the results obtained in 12 gastric resections performed for complications following gastric and/or duodenal peptic ulcers, in 33 cases of total gastrectomies (34%), and 48 cases of subtotal gastrectomies (49%) for early and advanced cancer. The results lead to interesting conclusions: first of all achieving a wide jejunojejunostomy between the afferent and the efferent loop the problems related to gastric resection (as postoperative sequelae, dumping syndrome, reflux esophagitis, alkaline gastritis, etc.) are avoided. Problems regarding lymphadenectomy in patients submitted to subtotal gastrectomy (D2-D3) are then reported. After a brief history of gastric reconstruction following gastric resection the evolution in surgical techniques and the results obtained during the last 10 years are described. The good long term results allow to conclude that our strategy in gastric surgery ensures a good quality of life of the patients as well as a radical operation in case of gastric cancer.

[Results of the local excision of rectal cancer after high-dose radiotherapy associated or not to chemotherapy]

Local excision of rectal cancer in low-risk patients is appealing but it provides limited control of the disease. Postoperative radiation therapy may improve results. The Authors report on their experience with preoperative high dose radiation therapy for rectal cancer patients; more recently, chemoradiation was used. Local excision is advised only for those patients with minimal or no residual disease. The results obtained in 34 cases are encouraging; moreover, a better control of the disease seems to be offered combining chemo- and radiotherapy.

[Histopathologic changes of cancer of the rectum after neoadjuvant radio-chemotherapy. Anatomo-radiologic correlation and prognostic implications]

The histopathologic study of 24 specimens of radiated rectal cancers suggested new histologic criteria to define tumor regression after neo-adjuvant therapy. Better than traditional UICC staging system (pTNM), such criteria have identified those patients at higher risk of failure. Moreover, the study has confirmed the known difficulties of imaging studies in assuring an accurate staging of radiated rectal cancer before surgery.

[Septic ascites: a rare post-operative complication]

Spontaneous bacterial peritonitis in patients with chronic hepatitis represents a very controversial matter in terms of frequency, pathology and treatment. This unusual complication mainly due to decreased immunological defences and ascitic fluid opsonic activity is not accepted by all the Authors as a rare event. However, there is agreement as far as management is concerned: cultural examination of the ascitic fluid and the relative antibiogram are the best tools in guiding the approach to an adequate antibiotic therapy.

The reality of radical sphincter preservation surgery for cancer of the distal 3 cm of rectum following high-dose radiation

PURPOSE

The inordinately high rate of locoregional recurrence following sphincter-preserving surgery for cancer of the distal rectum led to the conviction that restorative surgery was inappropriate for the low level cancer. A rectal cancer management program initiated in 1976 that selectively uses high-dose preoperative radiation and sphincter-preserving surgery produced lower than expected local recurrence rates. Exploring the safety of extending the indication for sphincter-sparing surgery to include post-radiation mobile cancers as low as the 0.5 cm level is the purpose of this report.

METHODS AND MATERIALS

Of 218 rectal cancer patients treated with high-dose preoperative radiation and sphincter-preserving procedures, 69 had radical curative surgery for cancers at or below the 3 cm level. Data regarding the first 52 patients whose ages ranged from 39 to 77 years form the basis of this report. Fifty-seven percent were men. Twenty-five (48%) patients had post-radiation unfavorable cancers (B2, C1, C2). Forty-five to sixty Gy high energy photon radiation was administered over 4 1/2 to 6 weeks followed by a similar interval prior to radical proctosigmoidectomy with anastomosis in the distal 1 cm of rectum. Temporary fecal diversion was performed in all patients; colostomies were closed after 8 weeks.

RESULTS

There was zero mortality and two self-limiting anastomotic leaks. Local recurrence developed in 6/43 (14%) patients followed for 24 months or longer. By stage, there were 0/21 (0%) recurrences among O, A, B1 tumors; 6/22 (27%) among unfavorable tumors. By distal margins 1/9 (11%) occurred in .3-1 cm; 4/13 (31%) 1.1-2 cm; 1/18 (5%) 2.1-3 cm. Five-year Kaplan Meier actuarial survival for the 52 patients was 85%.

CONCLUSION

Our data indicates that sphincter preservation can be accomplished in cancers of the distal 3 cm of rectum if high-dose preoperative radiation is administered and fixed cancers are excluded. This is the first reported study of sphincter-preserving surgery for the distal rectal cancer after high-dose radiation. The data are important to the design of new treatment options.

[Anterograde laparoscopic cholecystectomy: when and why]

Today largely diffused is the concept that laparoscopic cholecystectomy (LC) represents the treatment of choice for symptomatic gallstones. Nonetheless some questions have been raised on the real safety of this new method in terms of procedure-related complications. On the basis of our experience with traditional open cholecystectomy, we have recently performed a prograde LC in those cases with difficulties in identifying the anatomical structures of the so called Calot's triangle. This alternative route can be easily performed laparoscopically and has been useful in reducing the time of the intervention in the most difficult setting and to increase the safety of the procedure. The technical details and the results are compared with those of the laparoscopic retrograde route.

["Telescopic" terminoterminal pancreatico-jejunal anastomosis after duodenocephalopancreatectomy]

Pancreaticojejunostomy represents the most important step of the reconstructive process following pancreaticoduodenectomy. Anastomotic dehiscence at this level accounts for two thirds of total postoperative mortality. In order to reduce the incidence of anastomotic complications, we have recently adopted a new technique of "telescopic" end-to-end-pancreaticojejunostomy where, differently from our previous technique, we are not any longer invaginating the small bowel over the pancreatic stump. Our preliminary results obtained in 5 consecutive patients appear to be promising.

High-dose preoperative radiation and radical sphincter-preserving surgery for rectal cancer

To reduce local recurrence associated with rectal cancer and to extend the scope of anal sphincter preservation, a selective program of high-dose preoperative radiation therapy and sphincter-preserving surgery was initiated in 1976. High-energy photon therapy (40 to 60 Gy) was administered in doses of 1.8 to 2.5 Gy during a period of 4 1/2 to 6 weeks and followed in 4 to 6 weeks with curative sphincter-preserving surgery for clinicopathologically unfavorable and low rectal cancers. None of the 143 patients in the study died during the postoperative period. Fifteen (13%) of 117 patients followed up for at least 24 months experienced local recurrence. Acceptable sphincter function was retained in 130 patients (91%). Our program of high-dose preoperative radiation therapy and sphincter-preserving surgery for the treatment of high-risk cancers, including those in the distal third of the rectum, resulted in better-than-expected survival and control of local recurrence with acceptable morbidity and no mortality.

[Knight-Griffen ileo-proctostomy after total colectomy]

The double stapled colo-rectal anastomosis according to Knight e Griffen is currently used following an anterior resection of the rectum. The technical feasibility and the reduced risk of contamination represent the major advantages of the procedure. Accordingly, the Authors have adopted this technique to perform an ileo-rectal anastomosis following total colectomy. Furthermore, the use of a circular stapler with a small diameter allows to create a pseudo-valvular mechanism between the ileum and the rectum. Preliminary results obtained in 7 patients are presented.

High-dose preoperative radiation and full-thickness local excision. A new option for patients with select cancers of the rectum

Faced with the responsibility of treating patients with invasive distal rectal cancer who were medically unacceptable for the indicated radical surgery, a prospective study was initiated in which high dose preoperative radiation and full-thickness local excision were used. High dose preoperative radiation permitted full-thickness local excision of select cancers, which, by conventional standards, otherwise would have required radical surgery and permanent colostomy. Feasibility was measured on the basis of safety of the technique, control of the cancer, and the quality of anal sphincter function expected. Patients were selected initially because of their predicted inability to tolerate radical surgery, but indications were broadened to include those whose tumors had completely disappeared after irradiation. From 1984 to 1988, 20 patients underwent 21 operative procedures for cancers located between 0 and 7 cm from the anorectal ring. This report is concerned with the 14 patients of this group who were observed for a minimum of 24 months. High-dose preoperative radiation was administered for a total dose of 4500 cGy. Excision and repair were performed 4 to 6 weeks after completion of radiation therapy. Full-thickness disc or hemicircumferential excision was accomplished by transanal, transsphincteric, and transsacral techniques, which included, in several instances, excision of the sphincter mechanism and perineal body, and/or the vaginal wall. Full-thickness local excision after high-dose radiation therapy for rectal cancers has never been reported. Follow-up observation ranged from 24 to 48 months with a median of 31 months. Rectal reservoir function and sphincter control were good in 13 patients. Local recurrence developed in three patients (21 percent), two of whom had postradiation therapy B2 mucinous cancers. Three-year actuarial rate of local recurrence is 23 percent. One (7 percent) patient died of recurrent disease. Actuarial Kaplan-Meier survival at 3 years is 61 percent. Based on the results of this small, select patient group, high-dose radiation therapy followed by full-thickness local excision appears to be a reasonable option for patients who cannot tolerate radical surgery. This bimodal approach also may serve as an option for those who are good medical risks, but for whom sphincter preservation is at stake, and to whom radical surgery offers limited benefits.

[Integrated anastomosis using the Knight and Griffen technique]

The widespread use of mechanical staplers in gastrointestinal surgery has recently resulted in a simpler and faster operative technique. The double-stapled anastomosis (Knight and Griffen, 1980) seems to further simplify the technique of colo-rectal anastomosis, with reduced risks of pelvic contamination. Moreover, this technique can be used to reconstitute bowel continuity following an Hartmann's procedure or to perform an ileo-rectal anastomosis. The results obtained in 21 patients treated by this technique are presently reported.

Endoscopic dilation of colonic postoperative strictures

After the use of surgical staplers had become widespread, the number of colonic postoperative stenoses was observed to have increased. Nevertheless, the clinical relevance of this observation is minimal since only 2-5% of the patients complain of chronic constipation or obstruction symptoms. In such cases medical therapy is somewhat troublesome, and surgical treatment always implies a major operation. Endoscopic dilation has proved to be a reliable, simple, and safe therapeutic alternative. Forty-two patients with evidence of stenosis of either colocolic or colorectal anastomosis underwent mechanical or pneumatic dilation in our unit: 19 patients with a temporary diverting stoma were dilated before the colostomy was removed; in the remaining 23 cases, treatment was given according to the patients' symptoms or because it was not possible to pass the anastomosis with an endoscope. The overall failure rate was 2.4%, and no morbidity or mortality was found. When the percentages of patients successfully treated in one session alone were compared (76.9% versus 51.8%), balloon dilation was found to be more effective than bougienage. In our opinion, endoscopic dilation represents the mainstay of treatment of colonic anastomotic strictures, with surgery being reserved for the rare failures, when recurrence of cancer should be suspected.

Impact of biliary tract endoscopy on benign and malignant diseases

In the last 15 years, the management of patients affected with obstructive jaundice has been greatly improved by the introduction into clinical practice of diagnostic and therapeutic biliary tract endoscopy. This method has provided better knowledge of the pathophysiology of diseases of the common bile duct (CBD), with enormous benefit for surgical decision making. Moreover, it has reduced morbidity and mortality in emergency patients as well as in high-risk patients with CBD stones. Even the incidence of retained stones has been reduced to almost 1%-2%. The impact of endoscopy on diseases of the biliary tract has been tremendous.

Is ERCP manometry useful in the choice of treatment of stones of the common bile duct?

To verify the appropriateness of sphincterotomy as the treatment of choice of choledocholithiasis, since 1980 we have been using endoscopic retrograde cholangiopancreatographic (ERCP) manometry of the sphincter of Oddi (SO). This method allows direct investigation of SO motor activity and provides useful information regarding the presence of benign papillary stenosis (BPS). Thirty-four patients were investigated because the radiological examination indicated BPS might be present. Of these, 20 had common bile duct (CBD) stones, while the remaining 14 presented with biliarylike pain and one or more of the following: CBD dilation (larger than 12 mm); emptying of the ERCP contrast medium took longer than 45 min; abnormal liver function tests. Moreover, 8 healthy volunteers served as controls. Our results show that the incidence of SO motor anomalies is very low in the presence of choledocholithiasis, while it is substantial in patients with suspected SO dysfunction. These observations would suggest that, unlike the traditional view, BPS is rarely secondary to biliary lithiasis. Therefore, most of the sphincterotomies performed that are based on the assumption of underlying SO pathology should be considered unnecessary. Under these circumstances, the physiological role of a functioning SO has induced us to advocate sphincterotomy, surgical or endoscopic, in selected cases only.

Endoscopic lymphoscintigraphy. A new tool for target surgery of rectal cancer

To define the "in vivo" lymphatic drainage from the rectum and the anal canal, 79 subjects (normal controls and patients with rectal cancer) underwent endoscopic rectal lymphoscintigraphy. This method consists of endoscopically injecting a radiolabelled colloid into the rectal and anal submucosa. The diffusion of the tracer, which is drained preferentially by the lymphatic vessels, was determined by means of a computerized gamma camera. Our results suggest a different pattern of lymphatic drainage from the rectum as compared to traditional anatomical studies. Moreover, analysis of our data yields a new hypothesis about the lymphatic spread of rectal cancer. Therefore, lymphoscintigraphy could be employed in the preoperative assessment of "N" staging of these neoplasms. This should provide better selection of patients for different surgical approaches and for adjuvant therapy. The results of 2 years of experience and possible future applications of this technique are discussed.

Dysphagia lusoria: proposal of a new treatment

Recent observation of one patient suffering from dysphagia lusoria has suggested critical review of treatment of the symptomatic aberrant right subclavian artery. Surgical correction of such an anomaly is difficult and may produce serious complications, and is not always successful. Endoscopic dilatation of the oesophageal stricture, even though it might only produce temporary relief of dysphagia, represents a valid therapeutical alternative because of its favourable cost/benefit ratio, low incidence of complications and patient acceptability.

Transrectal ultrasonography: three years' experience

Since 1983 we have used radial and linear ultrasound probes in the laboratory and clinical examination of the rectum. Normal endosonographic appearances have been characterised by examining polyethylene membranes and resection specimens. Twenty normal subjects and 11 patients with rectal cancer have been examined, and of these 9 were correctly staged.