Alberto Schillaci

Detection of colorectal lesions with virtual computed tomographic colonography

BACKGROUND The aim of our study was to compare the performance of virtual computed tomographic colonography with that of conventional colonoscopy in a blinded, prospective study in 165 patients with suspected colorectal lesions. METHODS There were 165 patients, all referred for conventional colonoscopy, who underwent preliminary virtual computed tomographic colonography. Computed tomograhic images of all suspected lesions were analyzed and subsequently compared with conventional colonoscopy findings. RESULTS There were 30 colorectal cancers and 37 polyps identified at conventional colonoscopy. Virtual computed tomographic colonography correctly detected all cancers, as well as 11 of 12 polyps of 10 mm in diameter or larger (sensitivity, 92%); 14 of 17 polyps between 6 and 9 mm (sensitivity, 82%); and 4 of 8 polyps of 5 mm or smaller (sensitivity, 50%). The per-patient sensitivity and specificity were 92% and 97%, respectively. CONCLUSIONS Virtual computed tomographic colonography has a diagnostic sensitivity similar to that of conventional colonoscopy for the detection of colorectal lesions larger than 6 mm in diameter.

Palliative management for patients with subacute obstruction and stage IV unresectable rectosigmoid cancer: colostomy versus endoscopic stenting: final results of a prospective randomized trial

BACKGROUND Survival in patients with stage IV unresectable rectosigmoid cancer is significantly reduced, and when patients are seen with symptoms of obstruction, it is advisable to perform a diverting colostomy before acute obstruction occurs. The aim of this study was to compare the results of endoscopic stent placement with diverting proximal colostomy in patients with stage IV rectosigmoid cancer and symptoms of chronic subacute obstruction. METHODS In a prospective randomized trial, 22 patients with stage IV unresectable rectosigmoid cancer and symptoms of chronic subacute obstruction were randomized to either endoscopic placement of an expandable stent or diverting proximal colostomy. Patients were followed until death. RESULTS There was no case of mortality or major postoperative complications. Oral feeding and bowel function were restored within 24 hours after endoscopic stent placement and within 72 hours after diverting colostomy. Hospital stays were shorter (mean, 2.6 days) in patients with endoscopic stent placement than in those with diverting stomas (mean, 8.1 days) (P < .05). Mean long-term survival was 297 days (range, 125-612 days) in patients who had stents and 280 days (range, 135-591 days) in patients with stomas (P = NS). No case of mortality during follow-up was related to the procedures. All patients with stomas found them quite unacceptable. The same feelings were present in family members. None of the patients with stents or their family members found any inconvenience about the procedure. CONCLUSIONS Endoscopic expandable stent placement offers a valid solution in patients with stage IV unresectable cancer and symptoms of chronic subacute obstruction, with shorter hospital stays. The procedure is much better accepted, psychologically and practically, by patients and their family members.

Endoscopic placement of self-expanding stents in patients with symptomatic anastomotic leakage after colorectal resection for cancer: long-term results.

Anastomotic leak after colorectal resection for cancer is a challenging clinical problem. The postoperative quality of life in these situations is significantly impaired. We prospectively analyzed the effect of placing a self-expanding metal stent (SEMS) at the level of the leak, with or without proximal diverting ileostomy, in 22 patients with symptomatic anastomotic leakage after colorectal resection. The stents were placed successfully in all 22 patients. An proximal ileostomy was created in 15 patients under general anesthesia. The anastomotic leak healed, without evidence of residual stricture or major incontinence, in 19 patients (86 %). In 3 patients, the leak did not heal; in 2 patients with recurrent rectovaginal fistula, the size of the leak decreased significantly, allowing successful flap transposition; and only 1 patient required a permanent stoma. SEMS placement is a valid adjunct to the treatment of patients with symptomatic anastomotic leakage after colorectal resection.

Self expandable metal stents in the treatment of benign anastomotic stricture after rectal resection for cancer

To evaluate the use of self‐expandable metallic stents to treat patients with symptomatic benign anastomotic stricture after colorectal resection.

A Study on Metals Content in Patients with Colorectal Polyps

Data on metals involvement in colorectal polyps are scarce and fragmentary. The aim of this study was to examine whether the level of metals could be associated with risk of colorectal polyp development. The concentration of 15 chemical elements (Al, Ba, Ca, Cd, Co, Cr, Cu, Fe, Hg Mg, Mn, Pb, Se, Sr, and Zn) in 17 colorectal biopsies of healthy individuals, in 15 polypotic and corresponding nonpolypotic biopsies taken from the same individual, was evaluated. Concentration in polyps of metals such as Al, Ca, Mg, Mn, Pb, Sr, and Zn was unchanged both in unpaired and paired samples; elements such as Ba, Cd, and Hg were significantly lower and Fe was significantly higher both in individual and paired tissues. Cobalt, Cr, and Cu were significantly different only between polyps and the adjacent normal tissue area; Se showed a significant accumulation comparing polyps versus healthy tissues. The difference found in some elements between polyps and a control tissue provides an indication about the role of essential and nonessential elements in the early stage (polyps) in the colon carcinogenic process and encourages further studies to confirm the involvement of such elements in neoplastic processes.

Endoscopic treatment of ganglioneuroma of the colon associated with a lipoma: a case report

IntroductionGanglioneuromas are rare benign peripheral neuroblastic tumors characterized by hyperplasia of ganglion cells, nerve fibers, and supporting cells. They are not usually localized in the colon.Case presentationA 61-year-old Caucasian man was admitted to our department for colon cancer screening. A colonoscopy revealed a lipoma of 5cm in diameter, two micropolyps of less than 1cm, and one sessile polyp of 0.6cm in diameter. The polyps were removed with hot biopsy forceps. A histological examination revealed two hyperplastic polyps and one ganglioneuroma polyp. A follow-up colonoscopy showed no signs of recurrence after 16 months.ConclusionsAlthough a few cases of lipomas associated with ganglioneuromatous syndrome have been reported, the association of an intestinal lipoma with an isolated ganglioneuroma polyp has not been described. The implications of this association are unknown.

Treatment of rectovaginal fistula after colorectal resection with endoscopic stenting: long-term results

To treat patients with rectovaginal fistula after anterior resection for cancer using self‐expanding metal stents.

Primary Osteosarcoma of the Breast

observed (Fig. 3). The presented case shows theimportance of team work and selection of the optimalirradiation technique in determining diagnosis, tumorstaging, and treatment of the patient. After histologi-cal classification, high-grade primary breast lympho-mas should be treated with combinationchemotherapy with or without radiation similar tosystemic lymphomas of a similar histological type.Reports on breast lymphoma treatment include fewor no details about the target volume and applied irra-diation technique and usually mention only the totalradiation dose. The delivery of radiotherapy was a sig-nificant predictor of improved overall survival in ourcase.

Endoscopic Stenting for Colorectal Cancer: Lessons Learned From a 15-Year Experience.

Goal: The aim of our prospective study was to analyze the results of endoscopic stenting to treat obstruction due to colorectal cancer and complications after colorectal resection for cancer. Background: Endoscopic stenting for obstructing colorectal cancer has become a common place in clinical practice. However, there is a 2% to 5% risk of bowel perforation, and a percentage of technical failure of 2% to 10%. Materials and Methods: In a 15-year period (August, 1999 to December, 2013), 153 patients with colorectal cancer had endoscopic placement of a self-expandable metal stent for treatment of an obstructing colorectal cancer (133 patients) or for treatment of complications after colorectal resection for cancer (20 patients). They were prospectively evaluated in a database and they form the basis of this report. Results: There was no case of mortality or major morbidity. Overall technical success was 94.8%. After introducing the use of a pediatric nasogastroscope to pass the obstruction (71 patients), technical success was 100%. Complications in patients in whom the stent was left in place during the follow-up were frequent, requiring a close observation. We had 20 patients with fecal obstruction, 4 cases of stent dislodgment, and 8 cases of obstruction from ingrowth of the tumor. All patients were treated successfully endoscopically. Conclusions: Placement of self-expandable metal stents represents a valid technique. A proper training is required.

Endoscopic stenting for colorectal obstruction from unresectable ovarian and colorectal cancer: a bridge to surgery.

Dear Sir, We read with interest the paper from Debove et al. [1] on the prognostic importance of microscopic involvement of the circumferential resection margin (CRM). They reported the oncological outcome of 333 patients undergoing curative laparoscopic total mesorectal excision (TME) for rectal cancer. They stated that all previous studies found that the overall and disease-free survival and locoregional recurrence rates were significantly lower in patients with a positive CRM. They found that the 2year disease-free survival was significantly lower in the CRM positive group, mainly related to a higher rate of metastatic recurrence, but there were no significant differences in overall survival and local recurrence between the CRM positive and negative groups. Despite this the authors state that ‘our study confirmed these results’ that survival rates are lower and local recurrence higher. In the modern era of rectal cancer management with good optimal TME and en bloc surgery if indicated, together with neoadjuvant and adjuvant oncological treatment, we suggest that a positive CRM is not the prognostic factor that it was when most studies on CRM were performed and when both surgical and oncological treatment were not optimal. In a large population-based single centre study [2] of 448 patients and a median follow-up of 5.7 years, we found that a positive CRM (7%) did not predict local recurrence or survival and provided no additional prognostic value. The rectal cancer patients were managed according to a modern multidisciplinary approach, where therapeutic decisions were based on MRI and CT and surgery was performed by few experienced TME surgeons capable of en bloc resection. Preoperative oncological treatment and meticulous surgery resulted in specimens with a completely excised mesorectum without any defect in the mesorectal fascia in 92% of the patients (after 2007) and an intraoperative perforation rate of only 1.7%, in no case through the tumour. Only one of the 32 patients with a CRM of ≤ 1 mm developed local recurrence, resulting in a positive predictive value of CRM positivity of 3%. Additionally in a recent Dutch study [3] the authors reported an ‘interesting and puzzling finding’ that none of the patients (10/230) with a positive CRM developed local recurrence, and in a recent Korean study [4] of 780 patients a positive CRM was not related to local recurrence but it was to survival. The data from the study of Debove et al. actually confirm these results that positive CRM is not a prognostic factor for local recurrence, also after laparoscopic surgery. CRM is of course an important measurement but it should not be used as a prognostic marker or surrogate end-point for local recurrence.