Current management of familial adenomatous polyposis

INTRODUCTION

APC-associated polyposis is a rare hereditary disorder characterized by the development of multiple adenomas in the digestive tract. Individuals with APC-associated polyposis need to be managed by specialized multidisciplinary teams in dedicated centers.

AREAS COVERED

The study aimed to review the literature on Familial adenomatous polyposis (FAP) to provide an update on diagnostic and surgical management while focusing on strategies to minimize the risk of desmoid-type fibromatosis, cancer in anorectal remnant, and postoperative complications. FAP individuals require a comprehensive approach that includes diagnosis, surveillance, preventive surgery, and addressing specific extracolonic concerns such as duodenal and desmoid tumors. Management should be personalized considering all factors: genotype, phenotype, and personal needs. Total colectomy and ileo-rectal anastomosis have been shown to yield superior QoL results when compared to Restorative Procto colectomy and ileopouch-anal anastomosis with acceptable oncological risk of developing cancer in the rectal stump if patients rigorously adhere to lifelong endoscopic surveillance. Additionally, a low-inflammatory diet may prevent adenomas and cancer by modulating systemic and tissue inflammatory indices.

EXPERT OPINION

FAP management requires a multidisciplinary and personalized approach. Integrating genetic advances, innovative surveillance techniques, and emerging therapeutic modalities will contribute to improving outcomes and quality of life for FAP individuals.

Comparison of purse-string technique vs linear suture for skin closure after ileostomy reversal. A randomized controlled trial

BACKGROUND

Protective stoma after rectal surgery has been associated with important complications. The most common is surgical site infection (SSI) high rates after stoma reversal reported in literature. Our study compared the rate of SSI of two skin closure techniques, linear closure, and purse string closure.

METHODS

We carried out a single center, prospective, randomized controlled trial in the Department of Colorectal Surgery of Fondazione Policlinico Campus Bio-Medico of Rome between January 2018 through December 2021, to compare LC vs PS closure of ileostomy sites.

RESULTS

A total of 117 patients (53.84% male) with a mean age of 65.68 ± 14.33 years were finally evaluated in the study. 58 patients were included in the PS group and 59 patients in the LC one. There was a marked difference in the SSI rate between the two arms of the study: 3 of 58 patients in the purse-string arm versus 11 of 59 in the control arm (p = 0.043). The outcome of cosmesis was also higher in PS, with a statistical significance (mean ± DS 4,01 ± 0,73 for PS group vs mean ± DS 2,38 ± 0,72 for LC group, p < 0,001).

CONCLUSION

Our study demonstrated that the PS technique had a significantly lower incidence of stoma site SSI compared with LC technique. Our findings are in line with other randomized studies and suggest that PS closure could be considered as standard of care for wound closure after ileostomy reversal.

The use of intra-abdominal prophylactic drainage in laparoscopic cholecystectomy: does it change in relation to surgical expertise? A multicenter case-control retrospective study on postoperative outcomes

BACKGROUND

The routine use of abdominal drainage (AD) after laparoscopic cholecystectomy (LC) is still controversial. The aim of this expertise-based study is to evaluate the efficacy of prophylactic AD in terms of postoperative complications and analyze the factors linked to AD placement.

METHODS

This case-control retrospective study included patients with cholelithiasis who underwent LC with AD (AD group) and LC without drainage (no-AD group) in two Italian centers. Allocation to groups was non-randomized and based on surgeons' decisions. Patient's characteristics, operative results, postoperative outcomes, surgeon's expertise related data were compared between the two groups with univariate and multivariate analysis.

RESULTS

Patients in the two groups were comparable for age, sex ratio, and morbidity. Length of postoperative hospital stay (LOS) in the no-AD group was shorter than the AD group. Patients in the AD group had a higher rate of wound infection. No difference in postoperative pain measured 7 days after the surgery was found. Our results show an association between the first operator's expertise and age and the decision of placing the AD. The operative time seems to be the principal factor impacting the decision whether to place or not the AD.

CONCLUSIONS

Our results indicate that it is feasible not to insert routine AD after elective LC for cholelithiasis. The use of AD seems to cause more cases of postoperative wound infections, prolongs the LOS and the operative time. The drain placement choice seems to change in relation to the surgeon's expertise.

Long-term results and quality of life after stapled hemorrhoidopexy vs Doppler-guided HAL-RAR: a propensity score matching analysis

AIM

The study aimed to evaluate and compare the short and long-term outcomes of doppler-guided (DG) hemorrhoidal artery ligation and rectoanal repair (HAL-RAR) using a wireless-doppler-guided probe and stapled hemorrhoidopexy (SH) for treatment of II-III hemorrhoids.

METHODS

This cohort study included patients who underwent HAL-RAR (n = 89) or SH (n = 174) for grade II-III hemorrhoids between January 2020 and December 2021. After propensity score matching at a 1:1 ratio, 76 patients for each group were analyzed. Short and long-term outcomes were collected. Pain was measured using a Visual Analogue Scale (VAS) at POD1, POD 10, 1 month, and 6 months after surgery. The enrolled patients completed the Hemorrhoidal Disease Symptom Score and Short Health ScaleHD quality of life (HDSS/SHS QoL) questionnaire preoperatively and during a regular follow-up visit at 24 months after surgery.

RESULTS

Groups exhibited comparable overall postoperative complication rates (23% HAL-RAR/ 21% SH; p = 0.295). Postoperative pain via VAS showed median scores of 4, 3, 1, 1 for HAL-RAR and 6, 4, 2, 1 for SH at POD1, POD10, 1 month, and 6 months, respectively (p =  < 0.001, 0.004, 0.025, 0.019). At a median follow-up of 12 months, the recurrence rate was 10.5% in the HAL-RAR group and 9.2% in the SH group (p = 0.785), respectively. At 24 months, 15.7% of HAL-RAR patients and 19.7% of SH patients remained symptomatic (p = 0.223). Median post-op QoL index was 1 (HAL-RAR) and 0.92 (SH), p = 0.036.

CONCLUSIONS

HAL-RAR is a safe and feasible technique in treating grade II-III hemorrhoids showing better outcomes in terms of postoperative pain and QoL.

SIGNIFICANCE

This paper adds a new perspective in comparing the HAL-RAR and SH, focusing the attention on the patients and not surgical techniques. A long and difficult follow-up was completed to fully understand the long-term results and the impact on the QoL of the patients who underwent these procedures.

Right-sided colonic diverticulitis. Short and long-term surgical outcomes and 2-year quality of life

AIM

We aimed to investigate the short and the long-term outcomes and 2-year Quality of Life (QoL) of patients with right-sided colonic diverticulitis (RCD) surgically managed.

METHOD

We conducted an ambidirectional cohort study of patients with RCD undergoing surgery between 2012/2022. A colonoscopy was performed at 1-year post surgery. The enrolled patients completed the EuroQoL (EQ-5D-3L) during a regular follow-up visit at 12 and 24 months after surgery.

RESULTS

Three hundred nineteen patients with RCD were selected: 223 (70%) patients were treated by non-operative management (NOM) while 33 underwent surgery. Acute diverticulitis occurred in 30 patients: 9 (27.2%) were classified by CT as uncomplicated and 21 (63.6%) as complicated diverticulitis. Additionally, chronic diverticulitis occurred in 3 cases (9.2%). Specifically, 27 patients were classified by CT as 1a (81.8%) and 6 patients as 3 (18.2%). Right hemicolectomy was performed in 30 patients (90.8%), and ileo-caecectomy in 3 (9.2%). Nine (27.27%) experienced postoperative complications: 7 (77.7%) were classified according to the Clavien-Dindo as grade I-II, and 2 (22.2%) as grade III. No disease recurrence or colorectal cancer (CRC) was detected on colonoscopy. Thirty (90.8%) patients completed the 24-month follow-up. A statistically significant difference between preoperative and 24-month QoL index values (median 0.72; IQR = 0.57-0.8 vs. median 0.9; IQR = 0.82-1; p = 0.0003) was observed.

CONCLUSIONS

The study results demonstrate satisfactory surgical outcomes and a better QoL after surgery. No disease recurrence or CRC was observed at colonoscopy 1 year after surgery.

Anal canal gastrointestinal stromal tumour (GIST)

SummaryGastrointestinal stromal tumours (GISTs) are malignant mesenchymal tumours that originate from the interstitial pacemaker cells of Cajal. They are particularly rare, comprising only 5% of all GISTs, and often present at an advanced stage. Treatment for these tumours is still a topic of debate due to their low incidence and insidious location. A woman in her mid-70s presented with rectal bleeding and anal discomfort. A 4.5×4 cm anal GIST was diagnosed. A local excision was performed and the patient was further treated with tyrosine kinase inhibitors. At a 6-month follow-up, the MRI showed that she was disease free. Anorectal GISTs are unusual and tend to be aggressive. Surgical resection is the first-line treatment for primary, localised GISTs. However, the appropriate surgical technique for these tumours is still a topic of debate. Further studies are needed to fully understand the oncologic behaviour of these rare neoplasms.

Colorectal cancer risk of flat low-grade dysplasia in inflammatory bowel disease: a systematic review and proportion meta-analysis

BACKGROUND

To date, the optimal management of patients with inflammatory bowel disease (IBD) and flat low-grade dysplasia (fLGD) of the colon or rectum remains controversial.

METHODS

A systematic review was reported in accordance with PRISMA 2020 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Patients diagnosed with fLGD on surveillance endoscopy were pooled from studies published between 2000 and 2020. Advanced neoplasia was defined by the presence of HGD, CRC or small bowel adenocarcinoma detected on subsequent surveillance endoscopy or from examination of resection specimens. We estimated the pooled annual incidence rate of colorectal cancer (CRC) and advanced neoplasia, and the risk factors associated with neoplastic progression.

RESULTS

We identified 24 articles and 738 IBD patients were diagnosed with fLGD on endoscopy. Two hundred thirty-six patients (32%) underwent immediate surgery with surgical specimens demonstrating CRC in 8 patients (pooled prevalence, 8.66%; 95% CI 3.58-19.46) and HGD (high grade dysplasia) in 11 patients (pooled prevalence, 13.97%; 95% CI 5.65-30.65). Five hundred-two patients (68%) underwent endoscopic surveillance with 63 patients with fLGD progressing to advanced neoplasia during endoscopic surveillance (38 HGD, 24 CRC and one patient developing small bowel adenocarcinoma). The mean duration of follow-up after fLGD diagnosis was 71 months (10.9-212). The pooled incidence of CRC and advanced neoplasia was 0.5 (95% CI 0.23-0.77) and 1.71 per 100 patient-year (95% CI 0.88-2.54) respectively. The use of corticosteroids and location of fLGD in the distal colon were significantly associated with neoplastic progression.

CONCLUSIONS

This study provides a summary incidence rate of CRC and advanced neoplasia in patients with IBD and fLGD to inform surgeons' and endoscopists' decision-making thus reducing potential ineffective treatments.

Different Oncologic Outcomes in Early-Onset and Late-Onset Sporadic Colorectal Cancer: A Regression Analysis on 2073 Patients

The incidence of colorectal cancer (CRC) is increasing in the population aged ≤ 49 (early-onset CRC-EOCRC). Recent studies highlighted the biological and clinical differences between EOCRC and late-onset CRC (LOCRC-age ≥ 50), while comparative results about long-term survival are still debated. This study aimed to investigate whether age of onset may impact on oncologic outcomes in a surgical population of sporadic CRC patients. Patients operated on for sporadic CRC from January 2010 to January 2022 were allocated to the EOCRC and LOCRC groups. The primary endpoint was the recurrence/progression-free survival (R/PFS). A total of 423 EOCRC and 1650 LOCRC was included. EOCRC had a worse R/PFS (p < 0.0001) and cancer specific survival (p < 0.0001) compared with LOCRC. At Cox regression analysis, age of onset, tumoral stage, signet ring cells, extramural/lymphovascular/perineural veins invasion, and neoadjuvant therapy were independent risk factors for R/P. The analysis by tumoral stage showed an increased incidence of recurrence in stage I EOCRC (p = 0.014), and early age of onset was an independent predictor for recurrence (p = 0.035). Early age of onset was an independent predictor for worse prognosis, this effect was stronger in stage I patients suggesting a potentially—and still unknown—more aggressive tumoral phenotype in EOCRC.

What About Gastric Schwannoma? A Review Article

PURPOSE

Gastric schwannomas (GSs) are rare mesenchymal neoplasms of the gastrointestinal tract. Diagnosis is often achieved postoperatively, based on pathology reports of retrieved specimens. The aim of the present study is to follow up all patients with gastric schwannoma (Gs) undergoing endoscopic, partial, or more extended surgery and to evaluate the appearance of local or distant recurrence.

METHODS

A PubMed, Cochrane, and Embase systematic review of the literature has been performed. Original papers, review articles, and case reports published between 1988 and 2019 were considered eligible. All the studies who met the inclusion criteria were analyzed. Statistical analysis of data has been performed using GraphPad Prism 7 software.

RESULTS

Three hundred twenty-eight articles were found, and a total of 102 were included and analyzed in depth. Fifty-three papers reported the follow-up information, ranging from 1 to 417 months across different studies. Among them, 31 patients underwent endoscopic removal of the gastric lesions; 140 patients underwent local surgery, including wedge resection or partial gastrectomy; and 148 patients underwent subtotal or total gastrectomy. The median follow-up was of 27-38-33 months, respectively. No recurrence or distant metastasis was detected in the endoscopy group. Among local surgery group, liver metastasis was reported in one case; in extended surgery group, one patient died for multiple liver metastases.

CONCLUSIONS

Local or more extended surgery involved a larger cohort of patients and reported satisfactory long-term results compared with endoscopy group. Surgery in absence of a definite preoperative diagnosis is considered the gold standard treatment for resectable Gs.

TaTME approach as a rescue during a laparoscopic TME for high rectal cancer. A case report

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There are several surgical approaches for patient with rectal cancer, depending on tumor stage and tumor distance from anal verge. Total mesorectal excision (TME) is the gold standard surgical technique for rectal tumors, reducing rectal cancer local recurrence.

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Transanal total mesorectal excision (TaTME) has been described in rectal cancer treatment, especially in challenging patients with narrow pelvis, improving not only dissection but also the preservation of autonomic pelvic nerves and the achievement of a restorative procedure.

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This case report aims to describe the possible use of TaTME procedure as a rescue also when this approach is not the first choice. In conclusion, we believe that, if performed by experienced surgeons, TaTME is safe and useful and could be used not in his conventional use.

Introduction and importance

In the last years, transanal total mesorectal excision (TaTME) has been described in rectal cancer treatment, especially in challenging patients, difficulties in pelvic exposure and limitations of instrumentation improving not only dissection but also the preservation of autonomic pelvic nerves and the achievement of a restorative procedure.

Here we report a case report of anterior laparoscopic rectal resection for adenocarcinoma of the high-mid rectum converted to transanal approach.

Case presentation

A 69-year-old male presented hepatic nodules during radiological follow-up for prostate cancer treated with radical prostatectomy and adjuvant radiotherapy (70 Gy). The biopsy of the lesion demonstrated the presence of a metastatic lesion of an adenocarcinoma, with suspected intestinal origin. Then, we perform an endoscopic examination, which showed the presence of a rectal lesion, which cause a bowel stenosis extended from the middle part to the upper part of the rectum.

After chemoradiotherapy, an anterior rectal resection was performed. During surgery we could not perform the resection of the rectum due the thickness and fibrosis of the tissue, despite we used different branded mechanical stapler. So, we decided to complete the surgical treatment starting a TaTME procedure with resolution of the problem.

Clinical discussion

TaTME is a relatively new technique that had already become a valid option in the treatment of low rectal cancer, and, nowadays, also in the treatment of inflammatory bowel disease. As reported in literature, this technique has a number of advantages, especially in narrow pelvis and it is very useful in low rectal surgery.

Conclusion

This case report aims to describe the possible use of TaTME procedure as a rescue also when this approach is not the first choice.

Transanal proctocolectomy and ileal pouch-anal anastomosis (TaIPAA) for ulcerative colitis: medium term functional outcomes in a single centre

Background

Transanal dissection of the rectum has been recently introduced for ileal pouch-anal anastomosis (IPAA) in UC showing promising results. Thanks to the precise identification of the rectotomy site the risk of long rectal stump is avoided, and a single stapled anastomosis is performed easily. The aim of this study is to analyze our initial experience of transanal proctocolectomy and ileal pouch-anal anastomosis (TaIPAA), considering postoperative complications and medium-term functional outcomes.

Methods

Our Center has experienced the transanal approach for proctectomy and IPAA since August 2018. All patients underwent Enhanced Recovery After Surgery (ERAS) protocol. Postoperative complications occurring within 30 days after surgery were taken into consideration. Fecal continence, genito-urinary activity and global quality of life at 1 and 6 months after ileostomy reversal have been assessed.

Results

Until March 2019, 8 patients underwent transanal proctocolectomy and ileal pouch-anal anastomosis (TaIPAA). In all cases the laparoscopic approach was performed during the transabdominal phase; abdominal drainage was never used. At the time of the pouch construction a defunctioning loop ileostomy was created in all patients. Stoma closure was performed in all cases at a median time of 6 months after surgery. Postoperative complications occurred in only one patient, who showed rectal bleeding, not required a re-invertation. There were no cases of anastomotic leakage. Medium-term functional outcomes were determined prospectively using previously validated quality of life questionnaires (Cleveland Global Quality of Life). Fecal incontinence for liquid or solid stool, genitourinary and sexual functions were also investigated, showing comparable results with the literature data.

Conclusions

In our experience, transanal proctocolectomy and ileal pouch-anal anastomosis provided good short and medium-term functional results in UC.

Cost-effectiveness analysis of O-Ring wound retractor in elective laparoscopic colorectal surgery

INTRODUCTION

Surgical site infections (SSIs) are a feared complication following colorectal surgery and have a sizeable economic impact on the healthcare system. The aim of this study is to assess the clinical effectiveness and cost-effectiveness of O-Ring wound protector/retractor in elective laparoscopic colorectal surgery.

METHODS

Data were analyzed from a retrospective colorectal database from January 2015 to June 2018. SSI was defined according to the criteria published by the European Centre for Disease Prevention and Control (ECDC). An economic evaluation was conducted comparing the group in which Alexis® device was used during surgery (Group A) with a control group (Group B) in which Alexis® device was not used.

RESULTS

Two hundred fifty-eight consecutive patients were enrolled in our study. Among them, the intervention group (Group A, 154 patients) was compared with the control group (Group B, 94 patients). A total of 8 (5.2%) and 14 (15%) patients with SSIs were identified in groups A and B, respectively (p = 0.008). The economic evaluation showed that there was no difference in terms of costs and returns on comparing both groups.

CONCLUSION

The final costs and profit are similar in both groups, but the use of O-Ring protector reduces SSI rates and may significantly improve patient's quality of life.

KEY WORDS

Colorectal surgery, Cost-effectiveness, Surgical site infection, Length of stay, Wound protector/retractor.

Ileo-ileal intussusception caused by small bowel leiomyosarcoma: A rare case report

INTRODUCTION

Intussusception is the telescoping of one segment of the bowel into an adjacent bowel segment, causing venous congestion, edema, and blood supply reduction. We present a case of ileo-ileal intussusception in an adult patient with intestinal obstruction caused by a rare mesenchymal malignant lesion of the distal ileum: Leiomyosarcoma (LMS).

PRESENTATION OF CASE

A 90-year-old Caucasian man presented to the hospital with a two-day history of abdominal pain, nausea, and bowel occlusion. Preoperative Computer Tomography (CT) showed a solid mass with stratified walls in the lumen of the cecum with the classics "bulls-eye" appearance with concentric rings, suggestive of intussusception. The patient underwent emergency laparotomy with evidence of a small bowel wall tumor driving ileo-ileal intussusception with ischemic damage. Ileocecal resection was performed without postoperative complications. Histopathological examination showed a tumor on the muscular layer of the small bowel. The definitive diagnosis was LMS.

DISCUSSION

Adult intussusception is a rare condition, with an incidence of 2/1 000 000 cases per year worldwide. About 60% of patients suffering from this disease require surgery. Clinical presentation can be non-specific because of its no characteristic signs and symptoms. The most common presenting symptom is abdominal pain with bowel obstruction sings. Intussusception can occur anywhere along the small and large intestine and it is typically associated with a Lead Point (LP). The LP may be benign or malignant conditions. Infrequent malignant causes include LMS.

CONCLUSION

Diagnosis of intussusception is relatively challenging because of its non-specific symptoms. CT scan is the examimation of choice for the diagnosis because of its peculiar images. In adults, surgical treatment is recommended with laparoscopic or open approach according to surgeon expertise, sometimes in an emergency setting.

Topographic lymph node staging system shows prognostic superiority compared to the 8th edition of AJCC TNM in gastric cancer. A western monocentric experience

INTRODUCTION

The current Tumor Node Metastasis staging system (TNM) for gastric cancer classifies the extent of lymph node metastasis based upon the number of lymph nodes involved. Choi et al. have recently proposed a new anatomical classification based upon the regionality of the involved nodes. This new classification seems to have a better predictive prognostic value than the traditional one. We investigated the prognostic role of the new anatomical based classification, reviewing our institutional gastric cancer database.

METHODS

We performed a retrospective chart review of 329 patients who underwent gastrectomy at our Institution from 2003 to 2017. We excluded from data analysis any patient with distant metastases at the time of first diagnosis and or surgery, pathology other than adenocarcinoma, lymphadenectomy less than D2, impossibility to identify location of lymph nodes (LNs) on pathological report and neoadjuvant chemotherapy. The extent of D2 lymphadenectomy was defined according to Japanese Gastric Cancer Association criteria. LN metastasis were reclassified into three topographic groups (lesser, greater curvature, and extraperigastric nodes) and staged according to Choi. The new N stage was combined with the current pT according to the 8th edition of TNM and a new hybrid TNM stage was established. All patients were followed up until June 2019. The prognostic performance of the new stage and of the current anatomical numeric based system (TNM) was analyzed and assessed by the C-index, AIC and likelihood ratio χ² value.

RESULTS

In predicting both Overall Survival (OS) and Disease free Survival (DFS) the new N stage and the new TNM staging system had the highest C-index and likelihood ratio χ2 value and the lowest Akaike Information Criterion (AIC), showing a better accuracy and displaying a better prognostic performance.

CONCLUSIONS

Our study is the first from the Western world to compare the new hybrid classification, based on the anatomical location of metastatic nodes, to the 8th of American Joint Committee on Cancer (AJCC) TNM staging system. Our findings on a small, monocentric sample suggest that hybrid topographic lymph node staging system is more accurate than TNM.

O-Ring Protector in Prevention of SSIs in Laparoscopic Colorectal Surgery

Background:

Surgical-site infections (SSIs) remain a serious complication of colorectal surgery, causing a significant financial burden to the health care system. The aim of this study is to investigate whether the use of an O-ring retractor can be effective in preventing the incidence of wound infections after elective laparoscopic colorectal surgery.

Methods:

A retrospective case-control study from January 2014 to June 2018 was performed. Data were analyzed from a retrospective colorectal database. SSI was defined according to criteria published by the European Centre for Disease Prevention and Control and analyzed as a primary outcome.

Results:

Three hundred twelve consecutive patients (n = 312) were enrolled in our study. Among them, 158 patients (Group A) in which an O-ring retractor device was used during surgery was compared with a control group of 154 patients (Group B) in which an O-ring retractor device was not used. Primary outcome was to determine SSIs rates among the 2 groups. No statistically differences were observed with regard to baseline characteristics between both groups. A total of 9 patients (5.69%) and 24 (15.58%) with SSIs were identified in Group A and B, respectively, and the difference was statistically significant (OR, 0.32; 95% CI, 0.14–0.72; P = .0045). The median postoperative hospital stay length was 6.7 days in group A and 7.6 days in group B (P ≤ .05).

Conclusions:

SSIs infections rates were significantly higher in patients in which an O-ring retractor device was not used. This study suggests that the use of a wound protector device can be considered for routine use in elective colorectal surgery.

Skin bridge loop stoma: outcome in 45 patients in comparison with stoma made on a plastic rod

BACKGROUND

Loop stoma reduces the complications related to anastomotic leak. The skin bridge loop stoma is a recently described technique with many potential advantages over the current technique involving a plastic rod. Our experience shows early results (3 weeks after surgery) comparing skin bridge and plastic rod stoma creation.

METHODS

In 45 patients operated from January 2016 to December 2018, a loop ileostomy was performed with the skin bridge technique. We compared functional results with a prospective series of 45 patients on which ileostomy was performed on a plastic rod. The report of the routine stoma care visit at 7 and 15 days was compared, as well as the "Stoma quality of life" questionnaire when available.

RESULTS

We observed more inflammatory changes of the skin around the stoma in the group with a plastic rod (33 vs 10 patients). The patient-reported evaluation of quality of life showed a better quality of life in skin bridge group. The rate of exchanged stoma wafers was 2.6 vs 5.2 per week in the skin bridge group (p < 0.05).

CONCLUSIONS

The skin bridge stoma creation resulted in better early management of the stoma, better adhesion of the stoma appliances, and better quality of life of the patient. As an increased number of stoma appliances are required in the early postoperative period, the economic burden of this treatment is relevant in relation to the major number of medical equipment used in the early period.

Prenatal diagnosis of haemoglobin disorders by cordocentesis at 12 weeks' gestation

Prenatal diagnosis of haemoglobin disorders is accepted to be a useful procedure to avoid births of infants with homozygous diseases. Advances in sampling and molecular techniques, such as polymerase chain reaction (PCR) and chorionic villus sampling (CVS), have made earlier and safer first-trimester prenatal diagnosis possible. However, these procedures need previous studies of at-risk couples, which can be very time-consuming when a number of different beta-thalassaemia mutations occur in the region. We describe the possibility of making a first-trimester prenatal diagnosis by cordocentesis and fetal blood analysis at the 12th week of gestation. We found no statistically significant difference (p greater than 0.05) between beta/gamma values in fetuses at the 12th and 18th weeks of gestation. In seven affected fetuses aborted at the 12th week of gestation, the diagnosis was confirmed in all cases by PCR analysis. These findings suggest that early cordocentesis could be an alternative procedure to CVS and PCR analysis.

The risks of early cordocentesis (12-21 weeks): analysis of 500 procedures

Five hundred cordocenteses were performed between 12 and 21 weeks. The indications were thalassaemia (386), rapid karyotyping (97), feto-maternal allo-immunization (10), rubella (6), and toxoplasmosis (1). One hundred and ten pregnancies underwent termination on the basis of the result, while 20 of the 370 pregnancies intended to continue were lost to follow-up. Amongst these were 16 fetal losses (4.3 per cent) and 22 premature deliveries (5.9 per cent); no other complications were reported. Four adverse prognostic factors were identified: (a) cord bleeding; (b) fetal bradycardia; (c) prolonged procedure time; and (d) anterior insertion of the placenta. There was no 'obvious' difference in fetal loss rate with advancing gestation until 19-21 weeks, when the risk of fetal loss decreased to 2.5 per cent.

First trimester fetal blood sampling

The authors report 8 diagnostic cordocentesis performed at the end of the first trimester. The indication was thalassemia (5 cases) and karyotyping (3 cases). The technique requires that the operator holds both the probe and the needle (25 G X 90 mm); the fetal blood sample ranged between 0.25 and 0.35 cc, sufficient in all cases for the diagnosis. 1 pregnancy was terminated on the basis of the diagnostic result; no complications reported at a 3-weeks follow-up in the remaining 7 patients. The first trimester cordocentesis offers several advantages if compared to CVS, especially for thalassemia prenatal diagnosis; furthermore it opens new perspectives for intrauterine transplantations. More experience is required to assess the safety of the procedure.