Alberto Manno

Impact of Emergency Surgery in the Outcome of Rectal and Left Colon Carcinoma

The negative results in terms of morbidity, mortality and survival among emergency treated patients affected by colorectal cancer are well known. The specific contribution of emergency surgery to adverse outcome is not clear because of the presence in all series of other possible determinants of a poor prognosis. We used a case-control study design to compare a group of 50 patients operated on for cancer of the rectum and left colon presented as emergencies in our department during the last 14 years, and an equal number of patients who underwent elective procedures during the same period. All records of these patients were reviewed and matched for age, stage, tumor location, and medical comorbidities (coronaropathy, diabetes mellitus, cerebral vascular deficiency, chronic obstructive pulmonary disease). Outcome measures included length of hospital stay, morbidity, mortality, and actuarial 5-year survival. Univariate and multivariate analysis of factors potentially influencing survival was performed on the entire population of 100 patients. Age, tumor location, stage of disease, and medical comorbidities were well matched by intent of the study design. Overall surgical morbidity (44% versus 12% P = 0.0004), length of hospital stay (16, 64 versus 10, 97 days P = 0.0026) and postoperative mortality (4% versus 0% P = 0.4949) resulted higher in the emergency group. Actuarial overall 5-year survival was not different between the two groups. The only variables independently predictive of survival in multivariate analysis were age and rectal location of the tumor. Postoperative surgical mortality and long-term survival appear not to be influenced by emergency presentation of colorectal cancer; the negative impact of the emergency procedures is confined to the immediate postoperative period and is probably connected to the acute medical pathology often presented by patients in emergency situations. Dealing with this kind of patient’s accurate preoperative assessment and solution of acute medical pathologies before surgical treatment are mandatory.

Outcomes of clinical T4M0 extra-peritoneal rectal cancer treated with preoperative radiochemotherapy and surgery: A prospective evaluation of a single institutional experience

BACKGROUND Our objective was evaluate the outcome of primary clinical T4M0 extraperitoneal rectal cancer treated by neoadjuvant radiochemotherapy. Prognosis of clinical T4 rectal cancer is poor. Preoperative chemoradiation therapy may be beneficial. The results obtained are unclear due to lack of objective and strictly applied staging methods. METHODS Patients with primary, clinical, T4MO, extraperitoneal rectal cancer, defined by transrectal ultrasonography, computed tomography or magnetic resonance imaging, were considered. Intraoperative radiotherapy and adjuvant chemotherapy were employed in some patients after curative resection (R0). Variables influencing the possibility to perform an R0 resection and a sphincter-saving procedure were investigated as predictors of outcome. RESULTS 100 patients were included. R0 resection was performed in 78 patients. R0 resection rate was greater in females (93% vs 67%) and in responders to neoadjuvant chemoradiation (94% vs 60%). The ability to perform a sphincter-saving procedure was 57%, greater in middle rectal location (85% vs 51%) and in responders to the chemoradiation (70% vs 47%). Median follow-up was 31 months (range, 4-136). Local recurrences were found in 7 patients (10%). Five-year local control in R0 patients was 90% and better in the IORT group (100%). Distant relapse occurred in 24 patients (30%). Five-year overall survival was 59%, and was better after an R0 versus an R1 or R2 resection (68% vs 22%). Overall and disease free survival in R0 patients improved after overall downstaging. Adjuvant chemotherapy given in addition to the neoadjuvant therapy did not appear to offer benefit in improving survival. CONCLUSION A multimodal approach enabled us to obtain a 5-year overall survival of about 60%. IORT increased local control. The role of adjuvant chemotherapy needs to be further investigated.

Long-Term Results After Neoadjuvant Radiochemotherapy for Locally Advanced Resectable Extraperitoneal Rectal Cancer

PurposeThis study was designed to evaluate long-term outcome in locally advanced resectable extraperitoneal rectal cancer treated by preoperative radiochemotherapy.MethodsEighty-three consecutive patients who developed locally advanced resectable extraperitoneal rectal cancer underwent preoperative concomitant radiochemotherapy followed by surgery, including total mesorectal excision.ResultsMedian follow-up was 108 (range, 10–169) months. The living patients underwent complete follow-up of, at least, nine years. Fourteen patients developed local recurrence. The time to detection was longer than two years in eight cases and longer than five years in four. Twenty-one patients developed metastases, 19 within the first five years from surgery. At the univariate analysis, clinical stage at presentation, lymph node involvement at clinical restaging after neoadjuvant therapy, and pTand pN stage were found positively correlated to the incidence of metastases. At the multivariate analysis, the only factors which confirmed a positive correlation were pT stage and pN stage. The actuarial overall survival at five, seven, and ten years was 75.5, 67.8, and 60.4 percent, respectively. The same figures for cancer-related survival were 77.9, 70, and 65.8 percent. At the univariate analysis, factors directly correlated with worse survival were: TNM stage at clinical restaging after neoadjuvant therapy (in particular lymph node involvement) pTNM, pT, and pN. At the multivariate analysis the only factors that confirmed a correlation with worse survival were pTNM, pT, and pN.ConclusionsLong- term follow-up allows to individuate 28 percent of all local relapses after the first five years from surgery. Postoperative stage is highly predictive of prognosis.

Gastro-intestinal symptoms as clinical manifestation of peritoneal and retroperitoneal spread of an invasive lobular breast cancer: report of a case and review of the literature

BackgroundDistant spread from breast cancer is commonly found in bones, lungs, liver and central nervous system. Metastatic involvement of peritoneum and retroperitoneum is unusual and unexpected.Case presentationWe report the case of a 67 year-old-woman who presented with gastrointestinal symptoms which revealed to be the clinical manifestations of peritoneal and retroperitoneal metastatic spread of an invasive lobular breast cancer diagnosed 15 years before.ConclusionTo the best of our knowledge, the case presented is the third one reported in literature showing a wide peritoneal and extraperitoneal diffusion of an invasive lobular breast cancer. The long and complex diagnostic work up which led us to the diagnosis is illustrated, with particular emphasis on the multidisciplinary approach, which is mandatory to obtain such a result in these cases. Awareness of such a condition by clinicians is mandatory in order to make an early diagnosis and start a prompt and correct therapeutic approach.

Peptic Ulcer in Gastric Heterotopia of the Gallbladder Without Evidence of Helicobacter pylori Infection

Gastric heterotopia has been described throughout the gastrointestinal tract, from the oral cavity to the rectum, including the liver and the gallbladder [1–6]. We report a case of peptic ulcer in heterotopic gastric mucosa of the gallbladder in a 56-year-old man submitted to laparoscopic cholecistectomy for chronic calculous cholecystitis. From the first case of gastric heterotopia of the gallbladder, reported in 1934 [7], we reviewed 49 cases, including our report. In nine cases gallstones were also found and in four cases a peptic ulcer was identified [8]. The case reported describes the first association between peptic ulcer in gastric heterotopia of the gallbladder and gallstones. The presence of HP was investigated in order to evaluate its possible role in the ethiology of the ulceration.

A new clinical score for cranial computed tomography in emergency department non-trauma patients: Definition and first validation

INTRODUCTION Well recognized guidelines are available for the use of cranial computed tomography (CCT) in traumatic patients, while no definitely accepted standards exists to for CCT in patients without history of head injury. The aim of this study is to propose an easy clinical score to stratify the need of CCT in emergency department (ED) patients with suspect non-traumatic intracranial pathology. METHODS We retrospectively evaluated patients presenting to the ED for neurological deficit, postural instability, acute headache, altered mental status, seizures, confusion, dizziness, vertigo, syncope, and pre-syncope. We build a score for positive CCT prediction by using a logistic regression model on clinical factors significant at univariate analysis. The score was validated on a population of prospectively observed patients. RESULTS We reviewed clinical data of 1156 patients; positivity of CCT was 15.2%. Persistent neurological deficit, new onset acute headache, seizures and/or altered state of consciousness, and transient neurological disorders were independent predictors of positive CCT. We observed 508 patients in a validation prospective cohort; CCT was positive in 11.3%. Our score performed well in validation population with a ROC AUC of 0.787 (CI 95% 0.748-0.822). Avoiding CT in score 0 patients would have saved 82 (16.2%) exams. No patients with score 0 had a positive CCT findings; score sensitivity was 100.0 (CI 95% 93.7-100.0). CONCLUSIONS A score for risk stratification of patients with suspect of intra-cranial pathology could reduce CT request in ED, avoiding a significant number of CCT while minimizing the risk of missing positive results.

T1335 Effect of Anti-TNF Alpha Treatment on Short-Term Post-Operative Complications in Patients With Inflammatory Bowel Disease: An Italian Single-Centre Experience

Background: The impact of preoperative use of TNF-alpha inhibitors on postoperative complications in patients with inflammatory bowel disease (IBD) is still debated. While it is mostly accepted that their preoperative use for Crohns disease (CD) does not increase the risk of postoperative complications, the same is controversial for ulcerative colitis (UC). Aim: to evaluate the effect of anti-TNF-alpha preoperative treatment on short-term postoperative complications in patients with IBD. Materials & Methods: Medical records of patients who underwent abdominal surgery for IBD (from 2004 to 2009) after receiving TNF-alpha inhibitors within 12 weeks were analyzed and compared with a matched control group of surgical IBD patients not receiving biologics. Incidence of short-term post-operative complications within 30 days after surgery (mortality, hypomobility, bleeding requiring reoperation, anastomotic leak; infectious, thrombotic, cardiac, hepato-renal and pouchspecific complications) was recorded. Results: 104 patients (68 CD/36 UC; 65 male/39 female; median age: 39 yr, range:16-74; median duration of disease: 5 yr, range:0.5-30) were identified. 5 patients were also affected by general comorbidities (diabetes, chronic hearth disease, renal failure). 50 patients (35 CD/15 UC) were treated with anti-TNF-alpha (infliximab n=39, adalimumab n=10, certolizumab n=1) within 12 weeks prior surgery; among them, 34% and 40% were on concomitant steroids or immunosuppressants, respectively. 54 surgical patients (33 CD/21 UC) not receiving anti-TNF-alpha drugs served as controls; among them, 52% and 13% were on concomitant steroids or immunosuppressants, respectively. In the anti TNF-alpha group use of concomitant steroids was significantly higher in patients with UC (p=.012) and with extraintestinal manifestation (p=.041). 94 patients underwent elective surgery, 22 with laparoscopic approach. Median post-operative staywas 11 days (range:7-45). No post-operativemortality was recorded. Infectious complications occurred in 16 patients, hypomobility in 1, thrombotic in 1 and hepato-renal complications in 3 patients. Bleeding requiring reoperation was recorded in 3 patients and anastomotic leak occurred in 7. Hospital readmission was necessary for 9 patients. No statistically significant differences between anti-TNF-alpha and control groups were found. Infectious complications occurred on 8 anti-TNF-alpha patients and 8 controls, all of them also on concomitant steroids. Conclusion: The use of anti-TNF-alpha drugs within 12 weeks before abdominal surgery in patients with IBD does not seem associated with increased rate of cumulative postoperative complications.

Phlegmasia caerulea dolens of the left leg due to deep vein compression by giant mesenteric cyst: contribution of the immediate drainage of the cyst to the rapid improvement of symptoms and complete recovery:

The first description of phlegmasia caerulea dolens of the leg due to deep vein compression by a giant mesenteric cyst is presented. In particular, the authors stress the role of the drainage of the cystic mass, performed as an emergency procedure, in the rapid improvement of symptoms, prevention of complications and achievement of definitive recovery. On the basis of such unusual case, a wide review of the literature on this subject is reported, aiming to stress the most crucial aspects regarding aetiology, clinical features, complications, therapy and prognosis of this disease.