Adriano Tocchi

Late development of bile duct cancer in patients who had biliary-enteric drainage for benign disease: A follow-up study of more than 1,000 patients

ObjectiveTo evaluate the correlation between biliary-enteric surgical drainage and the late development of cholangiocarcinoma of the biliary tract. Summary Background DataIn patients with biliary-enteric drainage, reflux of intestinal contents into the bile duct may occur and cause cholangitis, which is regarded as the most serious complication of these procedures. Lithiasis of the biliary tract and a previous biliary-enteric anastomosis have both been suggested to favor the late onset of cholangiocarcinoma. MethodsConsecutive patients (n = 1,003) undergoing three different procedures of biliary-enteric anastomosis (transduodenal sphincteroplasty, choledochoduodenostomy, and hepaticojejunostomy) between 1967 and 1997 were included in this study. The postoperative clinical course and long-term outcome were evaluated by a retrospective review of the hospital records and follow-up. Mean follow-up was 129.6 months. ResultsFifty-five (5.5%) cases of primary bile duct cancer were found among the 1,003 patients at intervals of 132 to 218 months from biliary-enteric anastomosis. The incidence of cholangiocarcinoma in the three groups was 5.8% in transduodenal sphincteroplasty patients, 7.6% in choledochoduodenostomy patients, and 1.9% in hepaticojejunostomy patients. The incidence of malignancy related to the different underlying diagnosis was 5.9%, 7.2%, and 1.9% in patients with choledocholithiasis, sphincter of Oddi stenosis, and postoperative benign stricture, respectively. Although only one patient who developed cholangiocarcinoma had previous concurrent lithiasis of the biliary tract, 40 patients had experienced mostly severe, recurrent cholangitis. No case of malignancy occurred in patients scored as having no cholangitis in the early and long-term postoperative outcome. Univariate and multivariate analyses have shown the presence of cholangitis as the only factor affecting the incidence of cholangiocarcinoma. ConclusionsChronic inflammatory changes consequent to biliary-enteric drainage should be closely monitored for the late development of biliary tract malignancies.

The long-term outcome of hepaticojejunostomy in the treatment of benign bile duct strictures.

OBJECTIVEnThe authors review the treatment and outcome of patients with benign bile duct strictures who underwent biliary enteric repair.nnnSUMMARY BACKGROUND DATAnThe authors conducted a retrospective review of all clinical records of patients referred for treatment of benign bile duct strictures caused by surgery, trauma, or common bile duct lithiasis or choledochal cyst. The authors performed univariate and multivariate analyses of clinical and pathologic factors in relation to patient outcome and survivals.nnnMETHODSnEighty-four patients with documented benign bile duct strictures underwent hepaticojejunostomy, choledochojejunostomy, and intrahepatic cholangiojejunostomy during a 15-year period (January 1975 to December 1989). Morbidity, mortality, and patient survival rates were measured.nnnRESULTSnEarly and late outcomes correlated neither with demographic and clinical features at presentation nor with etiologic or pathologic characteristics of the stricture. Best results correlated with high biliary enteric anastomoses and degree of common bile duct dilatation independently of bile duct stricture location.nnnCONCLUSIONSnHigh biliary enteric anastomosis provides a safe, durable, and highly effective solution to the problem of benign strictures of the bile duct. Transanastomotic tube stenting is unnecessary. Endoscopic and percutaneous transhepatic dilatation seems more appropriate for the treatment of patients in poor condition and those with anastomotic strictures.

Preservation of the inferior mesenteric artery in colorectal resection for complicated diverticular disease

BACKGROUNDnPreservation of the inferior mesenteric artery (IMA) and consequential blood flow to the rectum would reduce the risk of leakage of a colorectal anastomosis.nnnMETHODSnOne hundred and sixty-three patients undergoing left colectomy for complicated diverticular disease of the colon were randomly placed into two groups: A, n = 86; and B, n = 77. In group A, the integrity of the IMA was preserved by artery skeletization (IMAS); in group B, the IMA was divided at its origin. Variables recorded included duration of the surgical procedure, need for blood transfusion, length of hospital stay, operative mortality and morbidity, staple-ring disruption, and radiologic and clinical leakage. Anastomotic stenosis and recurrence of diverticular disease were noted.nnnRESULTSnSurgical time was superior in the IMAS group. Radiologic and clinical leakages were significantly higher in group B (P = 0.02, P = 0.03, respectively). In group A a significant lower number of staple-ring disruptions was observed, evolving into clinical dehiscence.nnnCONCLUSIONnPreserving the natural blood supply to the rectum and the ensuing use of a healthy well-nourished rectal stump are suggested as the main aspects of IMAS in preventing and healing leakage of colorectal anastomosis.

The role of serum and gastric juice levels of carcinoembryonic antigen, CA19.9 and CA72.4 in patients with gastric cancer

Purpose: The aim of the present study was to investigate carcinoembryonic antigen (CEA), CA19.9, and CA72.4 in the serum and gastric juice of patients with gastric cancer. Methods: Serum and gastric juice tumor markers CEA, CA19.9, and CA72.4 were measured in 59 patients who had gastric adenocarcinomas and were undergoing curative gastrectomy. The same markers were measured in 47 patients with benign gastric disorders and in 40 healthy subjects. The correlation between the serum and gastric juice levels of tumor markers and several clinicopathological factors were evaluated by univariate analysis. The significance of the tumor markers as prognostic factors was assessed both by univariate and multivariate analysis. Results: The positivity rates of serum CEA, CA19.9, and CA72.4 were 57.6%, 38.9%, and 18.6% respectively. The positivity rates of gastric juice CEA, CA19.9, and CA72.4 were 62.7%, 30.5%, and 23.7% respectively. The combination of serum and gastric juice markers gave a positivity of 81.3%. There was no correlation between serum and gastric juice level of each tumor marker. Positivity of gastric juice markers did not correlate with prognosis. A significant difference in prognosis was observed between patients positive and negative for serum CEA and CA19.9. Multivariate analysis also revealed that serum CEA and CA19.9 levels were independent prognostic factors. Conclusions: Levels of both serum and gastric juice tumor markers continue to have only limited diagnostic usefulness in gastric cancer patients. CEA and CA19.9 in the preoperative sera are good prognostic factors, whereas the presence of tumor markers in the gastric juice does not play any prognostic role.

Surgical treatment of liver metastases from colorectal cancer in elderly patients

IntroductionThe liver is the most frequent site of liver metastases (LM) from colorectal cancer. Because of short life expectances and improved nonoperative modalities, the role of liver resection in elderly patients with LM is unclear.MethodsDuring a 15-year period, 197 patients underwent liver resection for colorectal metastases. This study was designed to compare morbidity, mortality, and long-term outcome after hepatic resection in patients aged 70xa0years and older and in patients younger than 70. According to the age at the time of operation, patients were divided into two groups. Group A included patients aged 70xa0years or older and group B included younger patients.ResultsThe clinical and pathologic parameters of the two groups were compared and tested as factors affecting early and long-term outcomes after resection. A modified oncologic clinical risk score (CRS) was tested on this series of patients. Overall morbidity was 16.3% (group A 20.7% vs group B 14.6%; P=0.18). Hospital mortality was 3% (5.7% in group A and 2.1% in group B; P=0.19). Actuarial 5xa0years survival were 30% in group A and 38% in group B (P=ns).DiscussionThe presence of more than three Fong’s CRS parameters and microscopic involvement of resectional margin directly affected survival. Under meticulous preoperative assessment and postoperative care, liver resection for LM is justified in patients over 70xa0years of age; age by itself may not be a controindication to surgery.

Prospective evaluation of omentoplasty in preventing leakage of colorectal anastomosis

PURPOSE: The aim of this study was to investigate the role of omentoplasty, by means of intact omentum, in preventing anastomotic leakages after rectal resection. METHODS: Between 1992 and 1997 a total of 112 patients (64 males) with a mean age of 64.7 (range, 39–83) years were randomly assigned to undergo omentoplasty (Group A) or not (Group B) to reinforce the colorectal anastomosis after anterior resection for rectal cancer. The primary end point was anastomotic leakage; the secondary end point included morbility and mortality related to omentoplasty. RESULTS: The two groups were comparable in terms of preoperative and intraoperative characteristics. Staple-ring disruption at plain abdominal radiographs was detected in seven instances in Group A and in ten in Group B patients (P = not significant). Two leakages were evident clinically in Group A and seven in Group B (P<0.05). Three leaks were documented radiologically in Group A and eight in Group B (P = not significant). No complications related to omentoplasty were observed in Group A. There were two repeat operations for anastomotic leakage in Group B. At follow-up, one stricture developed in Group A and three in Group B (P = not significant) CONCLUSIONS: Despite a similar incidence of staple-ring defects, a strikingly lower rate of clinically and radiologically detected leaks developed in patients submitted to omentoplasty. Although not affecting the incidence of anastomotic disruption, omentoplasty seems to contain the severity of anastomotic leakage.

Low correspondence between K-ras mutations in pancreatic cancer tissue and detection of K-ras mutations in circulating DNA.

Objective: K-ras is the most frequently mutated gene in pancreatic cancer; reported rates range from 70% to 90%. The aim of this study was to evaluate the correspondence between K-ras mutations in pancreatic cancer tissue and in circulating DNA and the value of K-ras mutations as serological marker. Methods: The research was conducted in 30 patients with pancreatic cancer in whom both plasma and neoplastic tissues were available. Such research was extended to circulating DNA isolated from 40 patients with chronic pancreatitis. Mutations in codon 12 were examined by mutant allele-specific amplification method and by direct sequencing. Serum values of routinely used tumor markers such as carbohydrate antigen (Ca) 19.9, carcinoembryonic antigen, Ca 50, and Ca 242 have been tested in all the patients enrolled in this study. Results: K-ras mutations were detected in 70% of neoplastic tissue samples, but no mutated DNA resulted in circulating DNA samples. The 60% of patients with tissue K-ras mutation showed elevation of some tumor markers among Ca 19.9, carcinoembryonic antigen, Ca 50, and Ca 242. As a whole, these last showed low sensitivity (20%-56.67%) and specificity (56.67%-77.5%) when compared with chronic pancreatitis. Conclusion: Over the years, there has been no change in the direction of an earlier diagnosis by serological markers, and also, these data indicate that K-ras mutation in serum is an unsatisfactory method for the detection in patients with pancreatic cancer as well as in patients with high risk of progression toward neoplastic pancreatic disease.

Extended mesenteric excision in right hemicolectomy for carcinoma of the colon.

Abstract. Between 1979 and 1989, 169 patients had a curative operation for right sided colonic cancer. A retrospective analysis of the incidence and degree of lymph node metastasis was performed in all and survival rate was determined in 144 patients who could be followed over a period of 5 years or more. In all patients, dissection involved the removal of right colon (i. e., caecum, ascending colon, and right side of transverse colon). Dissection of regional lymph nodes in 84 patients (group 1) involved the removal of mesocolic lymph nodes related to the segment of the removed intestine. In 60 patients (group 2) dissection was extended to the nodes situated anterior to mesenteric and retropancreatic vessels. Morbidity and mortality rates were similar in the two procedures. The number of lymph nodes and the level of apical node examined were significantly different in the two groups. The 5-year survival rates showed no statistically significant difference, but in group 2 three of the nine patients with metastasis to N 4 nodes are free of disease, surviving at 7, 12 and 14 years, respectively. The principle of extensive lymph node dissection is proposed as a procedure that supplies more accurate staging and might reduce the incidence of locoregional recurrence.Résumé. Entre 1979 et 1989, 169 patients ont subi une opération radicale pour un cancer du côlon droit. Une analyse rétrospective de lincidence et du degré de métastases ganglionnaires a été effectuée dans tous les cas et la survie a été déterminée chez 144 patients qui ont pu étre suivis durant une période égale ou supérieure à 5 ans. Chez tous les patients, la dissection a comporté lablation du côlon droit (caecum, côlon ascendant et partie droite du côlon transverse). La dissection des ganglions régionaux chez 84 patients (groupe 1) a comporté lablation des ganglions du méso-côlon en relation avec le segment de côlon excisé. Chez 60 patients (groupe 2) la dissection a étéétendue aux ganglions situés en avant des vaisseaux mésentériques et rétro-pancréatiques. Les taux de morbidité et de mortalité sont identiques pour les deux procédés chirurgicaux. Le nombre de ganglions lymphatiques et leur position sont significativement différents dans les deux groupes. La survie à 5 ans ne montre aucune différence statistique entre les deux groupes, dans le groupe 2, trois des neuf patients avec des métastases au ganglion N 4 sont indemnes de tumeur et survivent respectivement 7, 12 et 14 ans. Le principe dune excision ganglionnaire extensive constitue donc un geste chirurgical qui permet un meilleur staging et peut entraîner une diminution de lincidence des récidives tumorales loco-régionales.

Outcome of chronic pilonidal disease treatment after ambulatory plain midline excision and primary suture.

BACKGROUNDnPilonidal sinus (PS) is a common chronic disorder of the sacrococcygeal region. The optimal treatment for PS remains controversial, and recent reports have advocated different surgical approaches.nnnMETHODSnA prospective study was performed on 103 patients with nonrecurrent quiescent chronic discharging sinus. Excision with primary closure was performed on all patients. Patients were subdivided randomly into 2 groups. In group A, the excision was associated with drainage of the wound; in group B, the wound was not drained.nnnRESULTSnExcision with primary closure and drainage was performed in 53 patients (group A). Drainage was omitted in 50 patients (group B). Minor wound complications occurred in 3 patients in group A and in 36 patients in group B. No complete dehiscence of the wound was observed in patients in group A and in 8 patients in group B. Complete healing was fastest in patients in group A. Sinus recurrence occurred in 1 patient in group A and in 2 patients in group B.nnnCONCLUSIONnShort- and long-term results suggest that limited midline excision with primary closure and wound drainage is a simple and effective procedure in the surgical treatment of uncomplicated PS. More demanding flap techniques and plasties should be reserved for complicated PS, which requires a wider excision.

Intra-operative ultrasound for detection of liver metastases from colorectal cancer

Objective: The aim of this study was to evaluate the accuracy of intra‐operative ultrasound (IOUS) imaging in detecting liver secondaries at the time of primary colorectal surgery and to evaluate the impact of IOUS on patient management.