Locally Advanced Breast Cancer in the Elderly: Curettage Mastectomy

Aims and background

Locally advanced breast tumor represents 5–20% of new cases diagnosed every year. The purpose of this study was to report our experience and to compare it with the literature.

Methods

From 1998 to 2003 at the Molinette Hospital in the Turin University Third Division of General Surgery, there were 34 cases of breast cancer in older women (between 70 and 94 years of age), 14 of which (41.18%) were locally advanced breast tumor. We evaluated the type of surgical intervention and anesthesia used, muscular invasion, the presence of receptors positive to estrogens and progesterone, the operative mortality, the percentage of local-regional recurrence, and relapses after a period of time.

Results

Among the patients with locally advanced breast tumor, 21.43% (3/14) were at stage MIA and 78.57% (11/14) at stage IIIB. In 14.29% (2/14) of the cases, Patey's radical mastectomy was performed, in 57.14% (8/14) Halsted's radical mastectomy, and in 28.57% (4/14) a simple mastectomy with the removal of the fascia of the major pectoral muscle. Three (21.43%) patients underwent a second intervention for local-regional disease. None of the patients had distant metastasis in the first 2 years after the operation. Mortality after 2 years was 23.1% (3/13). None of the patients who underwent surgery had adjuvant therapy, usually because it was refused by the patients themselves or their families. All the negative and positive hormone receptor patients received tamoxifen.

Conclusions

Locally advanced breast tumors are frequent in elderly women. In the past, there has been a tendency to surgical under-treatment. As regards locally advanced breast tumor, curettage operations represent the only possibility to improve the quality of life of the elderly. These should be performed after carefully evaluating a series of variables in the general and local condition of the patient, the aggressiveness of the intervention and the life expectancy.

Increased production of 27-hydroxycholesterol in human colorectal cancer advanced stage: Possible contribution to cancer cell survival and infiltration

So far, the investigation in cancer cell lines of the modulation of cancer growth and progression by oxysterols, in particular 27-hydroxycholesterol (27HC), has yielded controversial results. The primary aim of this study was the quantitative evaluation of possible changes in 27HC levels during the different steps of colorectal cancer (CRC) progression in humans. A consistent increase in this oxysterol in CRC mass compared to the tumor-adjacent tissue was indeed observed, but only in advanced stages of progression (TNM stage III), a phase in which cancer has spread to nearby sites. To investigate possible pro-tumor properties of 27HC, its effects were studied in vitro in differentiated CaCo-2 cells. Relatively high concentrations of this oxysterol markedly increased the release of pro-inflammatory interleukins 6 and 8, monocyte chemoattractant protein-1, vascular endothelial growth factor, as well as matrix metalloproteinases 2 and 9. The up-regulation of all these molecules, which are potentially able to favor cancer progression, appeared to be dependent upon a net stimulation of Akt signaling exerted by supra-physiological amounts of 27HC.

Anal sphincter dysfunction in multiple sclerosis: an observation manometric study

Constipation, obstructed defecation, and fecal incontinence are frequent complaints in multiple sclerosis. The literature on the pathophysiological mechanisms underlying these disorders is scant. Using anorectal manometry, we compared the anorectal function in patients with and without multiple sclerosis. 136 patients referred from our Center for Multiple Sclerosis to the Coloproctology Outpatient Clinic, between January 2005 and December 2011, were enrolled. The patients were divided into four groups: multiple sclerosis patients with constipation (group A); multiple sclerosis patients with fecal incontinence (group B); non-multiple sclerosis patients with constipation (group C); non-multiple sclerosis patients with fecal incontinence (group D). Anorectal manometry was performed to measure: resting anal pressure; maximum squeeze pressure; rectoanal inhibitory reflex; filling pressure and urge pressure. The difference between resting anal pressure before and after maximum squeeze maneuvers was defined as the change in resting anal pressure calculated for each patient.

RESULTS

Group A patients were noted to have greater sphincter hypotonia at rest and during contraction compared with those in group C (p=0.02); the rectal sensitivity threshold was lower in group B than in group D patients (p=0.02). No voluntary postcontraction sphincter relaxation was observed in either group A or group B patients (p=0.891 and p=0.939, respectively).

CONCLUSIONS

The decrease in the difference in resting anal pressure before and after maximum squeeze maneuvers suggests post-contraction sphincter spasticity, indicating impaired pelvic floor coordination in multiple sclerosis patients. A knowledge of manometric alterations in such patients may be clinically relevant in the selection of patients for appropriate treatments and for planning targeted rehabilitation therapy.

Management of venous ulcers: State of the art

Venous ulceration is a complex and serious problem that affects 1-2% of the global elderly population (>65 years), and its incidence is constantly increasing. The population group with higher risk of development of venous ulceration is the elderly. These lesions have a significant negative impact on patients' quality of life. Our aim was to analyze the state of the art, starting with the medical literature review. The evidence supports that managing chronic wounds with a multidisciplinary wound care team significantly increases wound healing and reduces the severity of wound-associated pain and the required daily wound treatments compared with persons who are not managed by such a team.

Laparoscopic management of non-midline incisional hernia: A multicentric study

BACKGROUND

The laparoscopic repair of non-midline ventral hernia (LNM) has been debated. The aim of this study is to analyze our experience performing the laparoscopic approach to non-midline ventral hernias (NMVHs) in Northwest Italy for 6 years.

METHODS

A total of 78 patients who underwent LNM between March 2008 and March 2014 in the selected institutions were analyzed. We retrospectively analyzed the peri- and postoperative data and the recurrence rate of four subgroups of NMVHs: subcostal, suprapubic, lumbar, and epigastric. We also conducted a literature review.

RESULTS

No difference was found between the four subgroups in terms of demographic data, defect characteristics, admission data, and complications. Subcostal defects required a shorter operating time. Obesity was found to be a risk factor for recurrence.

CONCLUSIONS

In our experience, subcostal defects were easier to perform, with a lower recurrence rate, lesser chronic pain, and faster surgical performance. A more specific prospective randomized trial with a larger sample is awaited. Based on our experience, however, the laparoscopic approach is a safe treatment for NMVHs in specialized centers.

Surgeon's clinical valuation and accuracy of ultrasound in the diagnosis of acute appendicitis: A comparison with intraoperative evaluation. Five years experience

INTRODUCTION

Acute appendicitis is the most common cause of acute abdomen in adolescents, with an overall incidence of 7%. Two such tools are used to diagnose acute appendicitis: ultrasound and Computer Tomography imaging. End point of this study was to verify the accuracy of ultrasound imaging in the diagnosis of acute appendicitis with respect to intraoperative observations and the respective clinical and laboratory findings in young and in the elderly.

METHODS

We considered all the appendectomies for acute appendicitis performed between 1 January 2010 and 1 January 2015. We evaluated clinical symptoms, laboratory findings, ultrasound findings, intraoperative signs, and anatomical and pathological findings. In the study we compared the ultrasound and intraoperative findings and then compared these with the respective clinical and laboratory data.

RESULTS

In a comparison of diagnostic accuracy, the difference between clinical and ultrasound examinations was not significant. The differences between the diagnostic accuracy of clinical and laboratory findings and between ultrasound and laboratory investigations were statistically significant.

CONCLUSION

We defined white blood cells and C protein levels as non-diagnostic of the type of acute inflammation but rather as indicators of the severity of the inflammatory process. We also agree with the authors who proposed the incorporation of ultrasonography into routine practice in the diagnosis of acute appendicitis, but only and exclusively to support other diagnostic procedures and preferably within emergency departments. A thorough clinical examination of patients with suspected acute appendicitis is still the best diagnostic procedure available to us.

Inflammatory and redox reactions in colorectal carcinogenesis

It has been established that there is a relationship between chronic inflammation and cancer development. The constant colonic inflammation typical of inflammatory bowel diseases is now considered a risk factor for colorectal carcinoma (CRC) development. The inflammatory network of signaling molecules is also required during the late phases of carcinogenesis, to enable cancer cells to survive and to metastasize. Oxidative reactions are an integral part of the inflammatory response, and are generally associated with CRC development. However, when the malignant phenotype is acquired, increased oxidative status induces antioxidant defenses in cancer cells, favoring their aggressiveness. This contradictory behavior of cancer cells toward redox status is of great significance for potential anticancer therapies. This paper summarizes the essential background information relating to the molecules involved in regulating oxidative stress and inflammation during carcinogenesis. Understanding more of their function in CRC stages might provide the foundation for future developments in CRC treatment.

Abdominal compartment syndrome and open abdomen management with negative pressure devices

BACKGROUND

Abdominal compartment syndrome (ACS) is defined as an increase of intra-abdominal pressure (IAH) to values higher than 20 mmHg, associated with reduced perfusion and organ dysfunction.

MATERIALS AND METHODS

There is a classification of open abdomen which stratifies patients according to the natural history of improvement or clinical deterioration. The aim of treatment is to maintain the open abdomen at the lowest level and to prevent progression to a more complex level.

DISCUSSION

Surgical treatment essentially consists in abdominal decompression by leaving the abdomen open. Analysis of the literature shows that negative pressure increases the rate of primary fascial closure; entero-cutaneous fistulas are seen in a minority of cases, without seeming consequence of the application of the dressing. Open abdomen management consists of three treatment stages: acute (24-48 hours), intermediate (from 48 hours to 10 days) and late or reconstruction (from 10 days to the final closure).

CONCLUSION

It's important to recognize patients at risk of IAH and the first signs of ACS and intervene early with abdominal decompression if this will establish itself. Management of the open abdomen is now facilitated by negative pressure devices, which positively affect the morbidity and mortality of patients with ACS.

Perioperative and postoperative outcomes of perforated diverticulitis Hinchey II and III: open Hartmann's procedure vs. laparoscopic lavage and drainage in the elderly

Hartmann's procedure (HP) is the most performed technique for acute diverticulitis. Laparoscopic lavage and drainage (LLD) is an option evaluated as definitive treatment for diverticulitis Hinchey grade II-III. Aim of the study is to analyze and compare LLD vs HP outcomes. From January 1st 2009 and December 31st 2012 we prospectively enrolled 30 patients with diagnosis of acute diverticulitis Hinchey grade II-III. Fourteen patients underwent to LLD (LLD group, LLDG) and 16 patients to HP (Hartmann group, HG). We evaluated: demographic variables, comorbidities, admission clinical status, radiological imaging, intraoperative outcomes (operative time), postoperative outcomes (admission to ICU, timing of drainage removal, restore of bowel functions, timing of oral solid intake), mortality rate (perioperative and after 12 months) and morbidity rate (surgical, infectious, cardiovascular, renal and systemic complications). Exclusion criteria were: other diseases, colon cancer's suspect or diagnosis, conversion to HP. Patients' mean age was 64.8 years in HG and 62.6 in LLDG. M:F ratio was 6:10 in HG, 8:6 in LLDG. Data showed improved outcomes in LLDG for: total operative time (p < 0.0001), admission to ICU (p 0.0447), restoration of bowel functions (p 0.0035 for gases, p 0.0152 for feces), mobilization (p 0.0087) and length of hospital stay (p 0.0132). According to literature, LLD is related to operative risk, morbidity and mortality rate and length of stay lower than HP. LLD also gives the possibility to avoid stoma. Despite limits of our study, we consider LLD as a "safe and effective" treatment for Hinchey grade II-III acute diverticulitis.

Fibrin glue versus stapler fixation in laparoscopic transabdominal inguinal hernia repair: a single center 5-year experience and analysis of the results in the elderly

INTRODUCTION

Inguinal hernia surgery is one of the most common surgical procedures performed worldwide. Some studies demonstrated clear advantages of laparoscopic approach in terms of chronic pain, recurrence rate and daily life activities Aim of this study was to compare short and long-terms outcome of tacks and fibrin glue used during laparoscopic transabdominal hernioplasty (TAPP).

METHODS

This is a retrospective study conducted by our division of General Surgery. From May 2008 to May 2013 we performed 116 hernioplasty with TAPP technique. We compared two groups of patients: a group of 59 patients treated with fibrin glue and a group of 57 patients treated with conventional tacks and the two subgroups of patients over 65 years old. We evaluated: perioperative outcomes, early and late complications.

RESULTS

There were no significative difference about length of postoperative stay, time to return to work, recurrence rate and complications.

DISCUSSION

This study demonstrates that fibrin glue are same tolerated than tacks by patients and that the glues lead to the same good results during initial follow-up and in long term data also in the elderly. Meticulous preparation of the groin with preservation of spermatic sheet is in our opinion necessary to provide effective pain reduction and a good result in every TAPP procedure.

Percutaneous drainage and sclerosis of mesenteric cysts: literature overview and report of an innovative approach

We present the case of a 29-years-old male patient, affected by a voluminous post-traumatic mesenteric cyst, a rare abdominal disease; our patient represents a rarely affected age group. Treatment was based on interventional radiology with an US-guided drainage and sclerosis by ethyl alcohol of the lesion. The intervention performed on this patient represents the application of a standardized radiological technique to a new contest, mesenteric cysts, whose gold-standard treatment is represented in literature by surgery. In our case we obtained an optimal result, with complete regression of the treated cyst: it proved to be an effective, feasible, safe and minimally invasive procedure.

Endorectal ultrasound in the diagnosis of rectal cancer: accuracy and criticies

INTRODUCTION

Endorectal ultrasound (ERU) is used for locoregional staging of rectal cancer. Our work compares the data in the literature regarding diagnostic accuracy of the technique and results of routine use of the technique in two centers in Piedmont.

MATERIAL AND METHODS

77 reports ultrasound with the final diagnosis of rectal cancer from the period 2008-2012 were examined. The echographies were performed by two experienced operators, using two ultrasound device with the same technical characteristics.

RESULTS

Sensitivity levels are high, with the exception of stage T3. Specificity is always high. The relationships of verisimilitude, both negative and positive, showing that the accuracy of the test is still high. The risk of overstaging is higher for pT1, while most important the risk of understaging concerns the stage T3 (23.5%); on the contrary the ERU is able to exclude infiltration of perirectal organs with a good accuracy (NPV of 99.3%).

CONCLUSION

Although our study was a retrospective study, likewise some literature's reports, the interpretation of our analysis results shows a significant risk of downstaging T3 and N+ tumors. ERU represents in our experience a very important radiological staging methods to evaluate T1 and T2 rectal cancer.

Meso-pancreatectomy for pancreatic neuroendocrine tumor

We report a case of a meso-pancreatectomy performed on a pancreatic glucagonoma in a 58 years-old woman. MP is a conservative surgical treatment consisting in a resection of the body of the pancreas with the aim of reducing postoperative hormone insufficiency. This approach is curative in benign or low-malignant neoplasm of the central part of the pancreas.

Early versus delayed laparoscopic cholecystectomy for acute cholecystitis

AIM

Laparoscopic cholecystectomy, currently the gold standard treatment for cholelithiasis, has been extended to treating acute cholecystitis as well. However, operation timing remains controversial. The aim of this retrospective study was to compare our data on the timing of surgery for early and delayed laparoscopic cholecystectomy for acute cholecystitis.

METHODS

From January 1, 2006 to December 31, 2010, 508 laparoscopic cholecystectomy procedures were performed, 149 of which for acute cholecystitis: 122 operations were defined as early (performed within 72 hours of symptom onset) and 27 as delayed (72 hours to 9 days from symptom onset).

RESULTS

There were no statistically significant differences in operating time, conversion or complications rates between early and delayed procedures. The total length of hospital stay was longer for patients who had undergone a delayed procedure. The success rates were similar irrespective of the surgeon's level of experience.

CONCLUSION

Patients operated on for acute cholelithiasis between 72 hours and up to 9 days after symptom onset may benefit similarly as from an earlier operation. Delayed laparoscopic cholecystectomy for acute cholelithiasis is a feasible and safe procedure that compares favorably with early laparoscopic cholecystectomy.

Progressive increase of matrix metalloprotease-9 and interleukin-8 serum levels during carcinogenic process in human colorectal tract

BACKGROUND

Inflammatory reactions, known to promote tumor growth and invasion, have been found associated with colorectal carcinoma (CRC). Macrophages are the chief component of the inflammatory infiltration that occurs early in the progression from non-invasive to malignant tumor, with a switch from the pro-inflammatory phenotype to the tumor-promoting phenotype. Tumor and stroma are additional sources of inflammation-related molecules. The study aimed to evaluate, during colorectal carcinogenesis from benign to malignant phases: i) the trend of serum levels of IL-8, IL-6, TGFβ1, VEGF and MMPs; ii) the parallel trend of CRP serum levels; iii) derangement of the principal TGFβ1 receptors (TGFβ1RI/RII) in tumor tissues.

METHODOLOGY/PRINCIPAL FINDINGS

96 patients with colon adenomas or CRC at different stages of progression, and 17 controls, were recruited. Serum IL-8, IL-6, TGFβ1, VEGF, MMPs and CRP levels were analyzed before endoscopy or surgery. TGFβ1 receptors were evaluated in adenoma biopsies and surgically-removed colorectal adenocarcinomas. Serum levels of IL-8 in adenocarcinoma patients were increased from stage II, when also the enzymatic activity of MMP-9 increased. Of note, the increasing trend of the two serum markers was found significantly correlated. Trend of serum CRP was also very similar to that of IL-8 and MMP-9, but just below statistical significance. TGFβ1 levels were lower at stage III CRC, while IL-6 and VEGF levels had no significant variations. In tissue specimens, TGFβ1 receptors were already absent in about 50% of adenomas, and this percentage of missing receptors markedly increased in CRC stages III and IV.

CONCLUSIONS

Combined quantification of serum IL-8, MMP-9 and CRP, appears a reliable and advanced index of inflammation-related processes during malignant phase of colorectal carcinogenesis, since these molecules remain within normal range in colorectal adenoma bearing patients, while consistently increase in the blood of CRC patients, even if from stage II only.

"Fast track surgery" in the north-west of Italy: influence on the orientation of surgical practice

Fast track surgery is a peri-operative management model, including different strategies to improve patients' convalescence, avoid metabolic alterations, reduce complications, and shorten hospital stay. Prerequisite is coordination between different practitioners (surgeon, anaesthetist, nurse, nutritionist, physiotherapist). The purpose of our investigation is to understand the level of fast track surgery application in Piedmont and to evidence analogies and differences among departments. We projected an investigation proposing, to every surgery department in Piedmont, a multiple-choice questionnaire evaluating the level of fast track surgery peri-operative interventions' application. Data analysis was conducted in two points of view: the transversal one with an overview of answer's percentages, the longitudinal one correlating data through Pearson's index (r). We collected answers by 78 % of balloted departments (38 on 49). Transversal analysis, including the evaluation of percentages of each question, shows that intra-operative period is the most influenced by fast track principles, and that only 12 departments of 38 apply complete protocols. Longitudinal analysis, estimating the whole of each department's answers, demonstrates the absence of statistical significance in the correlation between fast track surgery application and territorial (r = 0.18), economic (r = 0.31), or age (r = 0.06) variables. Influence of fast track surgery is significantly present in our territory, even though it is not fully concretized in protocols. The choice of fast track depends on the instruction, the environment and the sensibility of each surgeon. Knowledge of geographic distribution of departments applying this model can be useful to organize common protocols, starting from more experienced hospitals.

Gastrointestinal stromal tumors: Thirty years experience of an Institution

AIM: To report our experience of gastrointestinal stromal tumors (GISTs) during the last 29 years.

METHODS: Thirty two cases of GIST referred to our Institution from the 1st January 1981 to the 10th June 2010 were reviewed. Metastases, recurrence and survival data were collected in relation to age, history, clinical presentation, location, size, resection margins and cellular features.

RESULTS: Mean age was 63.7 years (range, 40-90) and incidence was slightly higher in males (56%). R0 resection was performed in 90.7% of cases, R1 in 6.2% (2 cases) and R2 in 3.1% (one case). Using Fletcher’s classification 8/32 (25%) had high risk, 9/32 (28%) intermediate and 15/32 (47%) low risk tumors. Follow-up varied from 1 mo to 29 years, with a median of 8 years; overall survival was 75% (24/32), disease-free survival was 72% and tumor-related mortality was 9.3%. Three patients with high risk GIST were treated with imatinib mesylate: one developed a recurrence after 36 mo, and 2 are free from disease at 41 mo.

CONCLUSION: Surgical treatment remains the gold standard therapy for resectable GISTs. Pathological and biological features of the neoplasm represent the most important factors predicting the prognosis.

Pro-oxidant and proapoptotic effects of cholesterol oxidation products on human colonic epithelial cells: a potential mechanism of inflammatory bowel disease progression

With the aim of investigating whether cholesterol oxidation products could contribute to the pathogenesis of the intestinal epithelial barrier dysfunction that occurs in human inflammatory bowel disease (IBD), differentiated versus undifferentiated CaCo-2 cells, an accepted model for human intestinal epithelial cells, were challenged with a dietary-representative mixture of oxysterols. Only differentiated colonic cells were susceptible to the proapoptotic action of the oxysterol mixture, checked both by enzymatic and by morphological methods, mainly because of a very low AKT phosphorylation pathway compared to the undifferentiated counterparts. Enhanced production of reactive oxygen species by a colonic NADPH oxidase hyperactivation seemed to represent the key event in oxysterol-induced up-regulation of the mitochondrial pathway of programmed death of differentiated CaCo-2 cells. These in vitro findings point to the pro-oxidant and cytotoxic potential of cholesterol oxidation products, of both dietary and endogenous origin, as an important mechanism of induction and/or worsening of the functional impairment of enteric mucosa that characterizes IBD.

Gastric vascular lesion: a case report

Arteriovenous malformations of the gastrointestinal tract are a known but rare cause of bleeding. Those of the stomach are the rarest if compared with other causes of gastric bleeding. The aetiology is still unknown, but senile age is considered an important cause, as are the degenerative processes connected with old age. These lesions are diagnosed by endoscopy which, with a haematostatic intent, often is not sufficient to stop the bleeding. Angiography is necessary for patients with massive bleeding whose endoscopy results are negative. The surgical treatment of gastric arteriovenous malformations requires excision of the lesion and part or all of the stomach. We report the case of a 57-year-old patient admitted to the Casualty Department with haematemesis and anaemia caused by acute gastric bleeding.

Primary duodenal adenocarcinoma

AIMS AND BACKGROUND

Primary duodenal adenocarcinoma is a rare tumor with a poorly defined natural history and prognostic factors. It presents with nonspecific symptoms, and for this reason the diagnosis is often delayed. It is a serious problem for the surgeon because of the difficulty in obtaining an early diagnosis and standardizing basic tenets for an appropriate surgical approach. The aim of this work was to conduct a review of the literature analyzing the points most frequently debated about this pathology.

METHODS AND STUDY DESIGN

A bibliographic search was carried out on the main search engines to find studies regarding duodenal adenocarcinoma, published in English, from January 1992 to January 2007.

RESULTS

A total of 19 articles was selected. Results concerning symptoms, location of the tumor, diagnostic examinations, surgical treatment, histopathology of the tumor, survival and follow-up were obtained and discussed.

CONCLUSIONS

All patients who are medically fit to undergo surgery should be given the option of aggressive resection regardless of tumor size, tumor invasion or appearance of positive lymph nodes. Hopefully, an early diagnosis will correlate with improved long-term survival.

Primary Duodenal Adenocarcinoma

Aims and Background

Primary duodenal adenocarcinoma is a rare tumor with a poorly defined natural history and prognostic factors. It presents with nonspecific symptoms, and for this reason the diagnosis is often delayed. It is a serious problem for the surgeon because of the difficulty in obtaining an early diagnosis and standardizing basic tenets for an appropriate surgical approach. The aim of this work was to conduct a review of the literature analyzing the points most frequently debated about this pathology.

Methods and Study Design

A bibliographic search was carried out on the main search engines to find studies regarding duodenal adenocarcinoma, published in English, from January 1992 to January 2007.

Results

A total of 19 articles was selected. Results concerning symptoms, location of the tumor, diagnostic examinations, surgical treatment, histopathology of the tumor, survival and follow-up were obtained and discussed.

Conclusions

All patients who are medically fit to undergo surgery should be given the option of aggressive resection regardless of tumor size, tumor invasion or appearance of positive lymph nodes. Hopefully, an early diagnosis will correlate with improved long-term survival.

Giant gastrointestinal stromal tumor of the stomach in an elderly patient

We report a case of giant gastrointestinal stromal tumor (GIST) of the stomach of 17 cm in diameter detected in an 88-year-old Caucasian female. An en-block resection of the mass requiring gastric and transverse colon resection was carried out. Pathological examination evidenced a smooth multicystic giant gastric GIST measuring 17 x 13 x 9 and weighing 1,630 g. At immunohistochemistry, the specimen was c-kit positive, CD34-positive, SMA-negative S100-negative, desmin-negative, CD31-negative, HMB45-negative, and calponin-negative. It was diagnosed as an uncommitted GIST at high risk for malignancy.

A novel technique for rectocele repair in elderly women

We have developed a transvaginal technique for rectocele repair which we believe to be particularly suitable for older woman. A transverse incision was made in the mucocutaneous border of the vaginal introitus. The rectal wall was separated from the rectovaginal septum. The vaginal wall was divided in the middle. The first flap was sewn to the second and this onto the first. This intervention permits the contemporary correction of other pathologies frequently found in older women, such as cystocele and prolapse of the uterus. Twenty-two elderly women underwent operations using this technique; the mean follow-up period was 48 months (range, 24-84 months). The need to assist evacuation digitally disappeared in all patients.

Vascular anatomy of the rectal stump after total mesorectal excision

PURPOSE

For many years, poor vascularization of the short rectal stump has been considered the main cause of leakage. The purpose of this study was to evaluate the vascularization of the rectal stump after total mesorectal excision.

METHODS

We studied the iliac vascularization on 28 volunteers with healthy rectum to have an anatomic basis. Then, we studied the vascularization of the rectal stumps after total mesorectal excision by using angio computed tomography at seven and three months after operating on 22 patients; we validated this technique by studying the vascularization using angio computed tomography in 18 rectal specimens from cadavers.

RESULTS

Both in healthy rectums and in rectal stumps after total mesorectal excision, there is good vascularization sustained by middle and inferior rectal arteries. The former is more important and frequent as described in previous literature.

CONCLUSIONS

The vascularization of the short rectal stump is generally well represented even after total mesorectal excision.

The mesorectum: hypothesis on its evolution

BACKGROUND

Two points are controversial in the anatomy of the mesorectum: (1) its origin; and (2) the existence of the lateral ligaments. We studied these structures in animals and in human fetuses.

METHODS

Dissections were performed on quadrupedal mammals (29 dogs and 32 pigs) and 28 primates (Macaca apes). Moreover, macroslices of Macaca ape and of 182 human fetuses were examined histologically.

RESULTS

In quadrupedal mammals, we found no traces of any adipose masses comparable to the human mesorectum nor were there ligaments of suspension. In the ape, the adipose tissue in the mesosigmoid forms an adipose cuff that completely surrounds the extraperitoneal rectum. Two dense connective bands were found between the lateral wall of the pelvis and the perirectal tissue. Both the mesorectum and the lateral ligaments were clearly identified in the sections of human fetus only at the end of the fifth month but not earlier.

CONCLUSIONS

On the basis of our analysis of 3 animal species, we conclude that the mesorectum and lateral ligaments are absent in quadrupedal mammals but are present in primates. Therefore, we hypothesize that these structures appeared with the attainment of the upright position, even though other hypotheses are possible.

T1 adenocarcinoma of the rectum: transanal excision or radical surgery?

Although local excision for rectal cancer has been practiced for more than 120 years, its proper use for the cure of localized rectal cancers is still incompletely understood. The studies on this topic are heterogeneous in terms of selection criteria, surgical approaches and study design. The stage of the disease at the time of diagnosis is the main prognostic factor in rectal cancer. Today the commonly utilized criteria for local excision of rectal cancer are stage T1N0M0, histological grade G1 or G2, and size 3 to 4 cm. Total recurrence rates have been reported to be as low as 0%-4% and as high as 17%-31%. Notwithstanding the differences among the various case series, the risk of recurrence after local excision is real. The evidence seems to point to occult unresected locoregional tumor spread as the major risk factor. We speculate that the combination of unresected occult nodal disease and inadequate adjuvant therapy are two factors that can explain the higher rates of local and distant recurrences. Even radical surgery after the appearance of a recurrence may not be sufficient. When high-risk features are found, patients who return to the operating room immediately for radical surgery have an improved disease-free survival compared to patients who have radical surgery at the time of local recurrence. We conclude that today there is a preference for local excision in older patients in whom radical surgery may be associated with a high risk of complications and death. Local excision in younger and fit patients should be reserved for low-risk cancers in patients who will accept an increased risk of tumor recurrence.

KIT/stem cell factor expression in premalignant and malignant lesions of the colon mucosa in relationship to disease progression and outcomes

Autocrine/paracrine stimulation of KIT has been observed in colorectal carcinoma (CRC) cell lines. We investigated the expression of KIT and stem cell factor (SCF) in CRC in comparison with premalignant colon lesions and normal colonic mucosa to assess the prognostic and therapeutic relevance of this receptor/ligand system in CRC. Transcript levels of c-kit and the two SCF splicing variants were determined quantitatively by real-time RT-PCR using cDNA obtained from normal, premalignant and malignant snap frozen colon tissue specimens. Immunohistochemistry with specific anti-KIT and anti-SCF antibodies was performed on paraffin-embedded tissue sections in order to localize the relative protein expression in epithelial compartments. Approximately 10% of patients expressed KIT in their adenoma or primary tumor. The majority of KIT-positive carcinomas co-expressed SCF. Real-time RT-PCR showed expression of c-kit and SCF transcripts in all cDNA specimens examined. A significant association between the co-expression of KIT/SCF and a worse clinical outcome was found. In conclusion, KIT expression was observed in a proportion of premalignant and malignant colonic lesions, while it was virtually absent in normal colon mucosa. Moreover, the majority of KIT-positive carcinomas co-expressed SCF, suggesting the possibility of aberrant signaling by an autocrine loop, as confirmed by the negative prognostic value of this association. Therefore, in the subset of CRC patients with concomitant KIT/SCF expression, the activity of Imatinib mesylate, a selective inhibitor of specific tyrosine kinases including KIT, may be exploited in combination with standard therapy.

Percutaneous drainage and surgery for splenic abscess: a case report

Splenic abscess is a rare clinical entity; however, thanks to the refinement of diagnostic techniques and to the increase of population at risk its presence is discovered more frequently. In our ward we evaluated a patient by ematochimical and bacteriological exams and abdomen CT. After antibiotical therapy and percutaneous drainage the patient was discharged on the fifteenth day. One month later the patient returned to our emergency room: for the presence of two intrasplenic lesions; he underwent splenectomy. Six month after the operation, the patient was healty. The two methods (surgery and radiological drainage) cannot be compared because the indications are different. Therefore a progressively invasive therapeutic approach would appear to be indicated. If this not successful, splenectomy performed whit laparoscopic or laparotomic techniques should follow.

Ligation of the inferior mesenteric artery in the surgery of rectal cancer: anatomical considerations

BACKGROUND

No agreement has been found in the literature concerning the safest point of ligation of the inferior mesenteric artery (ima) in order to avoid nerve damage during the surgery of rectal cancer.

STUDY DESIGN

The distance between the origin of the ima and the left paraortic trunk was measured, as was the distance between the left paraortic trunk and the origin of the left colic artery (lca). The measurements were carried out on 20 cadavers and during 22 operations for rectal cancer.

RESULTS

The left paraortic trunk always runs posterior to the ima: its distance from the origin of the ima is on average 1.2 cm; the distance of the left paraortic trunk from the origin of the lca is on average 0.4 cm. The point at which the ima and the left paraortic trunk cross varies greatly, but it is never near the origin of the ima.

CONCLUSIONS

From an anatomical point of view the safest point of ligation of the ima is at its origin. At this point, the left paraortic trunk never runs; so there isn't any risk to damage the nerve involving it during the ligation of the artery.

Decreased expression of stem cell factor in esophageal and gastric mucosa after esophagogastric anastomosis for cancer: potential relevance to motility

BACKGROUND

Esophageal replacement with gastric tube is a well-established reconstruction of the alimentary tract after esophagectomy in cancer patients. The resulting molecular events in the transposed gastric tube and residual esophagus have yet to be investigated. Stem cell factor (SCF) was recently shown to be critical for signaling in gastrointestinal motility. SCF expression is here correlated with changes in mucosal morphology, acid and biliary reflux, and motility in the residual esophagus and gastric tube.

METHODS

Thirteen patients surgically resected for squamous esophageal carcinoma with gastric tube replaced by esophagogastric anastomosis underwent upper endoscopy, esophageal manometry, 24-hour pH monitoring, and bile reflux detection. Esophageal and gastric mucosa samples were examined for SCF expression by immunohistochemical and semiquantitative reverse transcriptase-polymerase chain reaction analysis and for SCF serum levels by enzyme-linked immunosorbent assay.

RESULTS

All patients showed severe residual esophagus hypoperistalsis and no gastric tube motor activity. The 24-hour pH monitoring was positive in most; 24-hour bile detection was mostly negative. SCF levels in the residual esophageal and gastric tube mucosa were dramatically decreased compared with those of normal subjects. The correlation between SCF and slow-wave activity was positive.

CONCLUSIONS

Hypomotility of the residual esophagus and gastric tube seems closely associated with disruption of the SCF/c-kit signaling pathway. However, the absence of notable relations between mucosal changes after chronic exposure to acid, biliary gastric content, and SCF expression indicates that this analysis cannot be considered part of endoscopic follow-up.

The role of lymphadenectomy in gastric cancer in elderly patients

The incidence of gastric cancer in elderly patients has significantly increased in the last few decades. Recent reports show that resective surgical procedures are the best therapeutic treatment for aged patients without important pre-existing clinical disorders. The role of lymphadenectomy in elderly patients with gastric cancer is not clear. The present study analyses literature data regarding the optimal extension of lymphadenectomy in gastric carcinoma; we reviewed the data from Japanese authors and from newer multicentric prospective European studies (German Gastric Carcinoma Study Group, Dutch Gastric Cancer Group, Medical Research Council, Italian Gastric Cancer Study Group). We also analysed the clinicopathological characteristics, the site, the symptoms, the spread and recurrence patterns of gastric carcinoma in the elderly compared with adult patients. This review shows that 75-90% of the diagnosis of gastric carcinoma in aged patients is done in advanced stage and an aggressive surgical treatment is required. A pre-existing illness and the ASA stage of the patients are directly correlated to postoperative complications. For these reasons, considering the clinicopathological features of the disease, a curative surgical operation using also an extended lymph node dissection is recommended for aged patients in good health.

Can intestinal innervation be preserved in pancreatoduodenectomy for cancer? Results of an anatomical study

Twenty dissections were carried out, in all of which the splanchnic nerves, celiac plexuses, capital pancreatic plexus and superior mesenteric plexus were identified and traced. The capital pancreatic plexus was formed from two bundles, the first taking its origin from the right celiac plexus, the second from the superior mesenteric plexus. These two bundles joined together just behind the head of the pancreas. Two preganglionic bundles, a ganglion and two postganglionic bundles composed the superior mesenteric plexus. Postganglionic bundles received fibers from both right and left celiac plexuses. In small cancers a thin layer of nervous tissue around the superior mesenteric artery might be spared in order to avoid diarrhea from intestinal denervation. This study has provided anatomical evidence that a part of the mesenteric plexus, which receives fibers from both left and right celiac plexuses, maintains a sufficient intestinal innervation.

[Results of extended lymphadenectomy in the surgical treatment of gastric carcinoma. Considerations on data from the literature]

In the surgical response to gastric carcinoma the use of extensive lymphadenectomy (D2) is still being debated. In Japan D2 is the operation of choice and the numerous selected case studies emphasize better long term survival at all stages with this operation. In the West D2 has not obtained the same approval, besides which it is burdened by higher postoperative morbidity and mortality. The important prospective non-selective trials have not shown differences in the general rates of survival between D1 and D2: the analysis of subgroups, instead, shows better results for stages II and IIIA. The distal splenopancreasectomy and the lack of experience of the surgeons worsen the results of D2. Therefore, when reanalyzing the results of the trials in the light of this information a difference is obtained in the rates of survival in favour of D2 for a wider category of patients. The age of the patient necessitates strict preoperative selection. In some selected cases D2 may be performed; for the majority of older patients the operation of choice is D1 extended to the celiac lymph nodes.

[Contribution to the study of innervation of the pancreas with a view to its relevance to neoplasm surgery]

Pancreaticoduodenal resection yields poor results, mainly because of cancer spread into retropancreatic nervous tissue. The aim of this study was to evaluate the feasibility of dissection capable of sparing a portion of retropancreatic nervous tissue in order to lessen, if not prevent, postoperative diarrhoea and severe malabsorption. From April 2000 to June 2001 20 dissections were carried out on 18 fresh cadavers (15 male) within 24 hours of death and on 2 frozen trunks. In all dissections the splanchnic nerves, coeliac plexuses, capital pancreatic plexus and superior mesenteric plexus were identified and traced. The capital pancreatic plexus is composed of two bundles, the first originating in the right coeliac plexus, the second in the superior mesenteric plexus. These two bundles join together just behind the head of the pancreas. The superior mesenteric plexus is composed of two preganglionic bundles, one ganglion, and another two postganglionic bundles. These latter two bundles receive fibres from both the right and left coeliac plexuses. In pancreaticoduodenal resection for cancer, the capital pancreatic plexus has to be completely removed, like the superior mesenteric plexus, as they are very often infiltrated and constitute a route for cancer spread. In small cancers, a thin layer of nervous tissue around the superior mesenteric artery might be spared in order to avoid diarrhoea due to intestinal denervation. The results of this study show that there is anatomical evidence that a thin layer of superior mesenteric plexus receiving fibres from both the left and right coeliac plexuses maintains adequate intestinal innervation.

Contribution to the surgical anatomy of the ligaments of the rectum

PURPOSE

Many authors have discussed the presence and the importance of the lateral ligaments of the rectum. Our contribution aims at clarifying some aspects of surgical anatomy that help in the preservation of the urogenital functions and may influence the surgical practice.

METHODS

From 1994 to 1998 we examined 27 fresh cadavers and five embalmed pelves. We performed all dissections with a technique similar to that used for the surgical mobilization of the rectum.

RESULTS

The lateral ligaments of the rectum are trapezoid structures originating from mesorectum and are anchored to the endopelvic fascia; as lateral extensions of the mesorectum, they must be included in the surgical specimen. According to our results, three main structures can be recognized laterally to the rectum: 1) the lateral ligament, which does not contain important structures; 2) the inferior hypogastric plexus and the urogenital bundle; and 3) the lateral neurovascular pedicle of the rectum that comprises the nervi recti and the middle rectal artery, both running under the lateral ligament, although at different angles.

CONCLUSION

At the point of insertion into the endopelvic fascia, the lateral ligaments run close to the urogenital bundle. Nevertheless, the dissection at its attachment is safe if the urogenital bundle is kept under visual control.