Barbara Termini

Robotic right colon resection: evaluation of first 50 consecutive cases for malignant disease.

Background. Colorectal cancer is the fourth leading cause of death in the world. Minimally invasive surgery has been demonstrated to have the same oncological results as open surgery, with better clinical outcomes. Robotic assistance is an evolution of minimally invasive technique. This study aims to evaluate surgical and oncological short-term outcomes of robotic-assisted right colon resection in malignant disease. Methods. Fifty consecutive patients affected by rightsided colon cancer were operated from May 2001 to May 2009 using the da Vinci surgical system. Data regarding surgical and early oncological outcomes were systematically collected in a specific database for statistical analysis. Results. Twenty-four male and 26 female patients underwent robotic right colectomy. Median age was 73.34 ± 11 years. Median operative time was 223.50 (180–270) min. No conversion occurred. Specimen length was 26.7 ± 8 cm (range 21–50 cm), number of harvested lymph nodes was 18.76 ± 7.2 (range 12–44), and mean number of positive lymph nodes was 1.65 ± 3 (range 0–17). Surgeryrelated morbidity was 1/50 (2%): one twisting of the mesentery in one case with extracorporeal anastomosis. All patients were included in a follow-up regimen. Diseasefree survival was 90% (45/50), and overall survival was 92% (46/50). Cancer-related mortality was 8% (4/50). Conclusions. Robotic assistance allows performance of oncologically adequate dissection of the right colon with radical lymphadenectomy and to fashion a handsewn intracorporeal anastomosis as in open surgery, confirming the safety and oncological adequacy of this technique, with acceptable results and short-term outcomes. Since 2002, laparoscopic technique has revolutionized the treatment of malignant colorectal disease, showing the same oncological results as open technique. However there are some technical drawbacks to the laparoscopic approach, including lack of three-dimensional (3-D) visualization, limited range of motion due to fixed trocar sites and rigid instrumentation, poor ergonomics, amplification of physiologic tremor, and decreased sense of touch. In the last 10 years, robotic systems have been developed to overcome the limitations of laparoscopic surgery. The da Vinci surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA) was the first telerobotic system approved for intra-abdominal surgery in the USA by the Food and Drug Administration (FDA). The first robotic colorectal surgical procedure was reported in 2001. After that, various experiences of robotic colorectal surgery were reported for treatment of benign and malignant diseases. However, there are few studies analyzing accuracy in larger series of robotic right colectomy for malignancy. This study aims to evaluate the feasibility and the short-term surgical and oncological outcomes of robotic-assisted right colon resection in malignant disease.

Expression of costimulatory molecule CD80 in colonic dysplasia in ulcerative colitis: an immunosurveillance mechanism against colorectal cancer?

Background and aimsUlcerative colitis is an established risk factor for colorectal cancer but dysplasia reports are much more frequent than invasive neoplasm diagnosis. The effective activation of T lymphocytes that provide antitumor surveillance requires the presence of costimulation molecules such as CD80 and CD86 on the surface of antigen-presenting cells. The aim of our study was to verify the presence of an in vivo immunosurveillance mechanism in the early stages of colon tumorigenesis.Patients and methodsExpression of CD80, CD86, and IFNγ in the colonic mucosa of 21 consecutive ulcerative colitis (UC) patients was quantified using reverse transcription polymerase chain reaction. After a 7-year follow-up period, we reviewed the histology of all surveillance colonoscopy specimens for colonic dysplasia. Correlation, frequency, and survival analyses were performed.ResultsCD80 was detectable in seven patients while expression of CD86 and IFNγ was evident in all patients. Histology confirmed the presence of dysplasia in eight patients. Patients who had dysplasia showed higher CD80 levels compared to those without dysplasia (p=0.02). Survival analysis demonstrated that cumulative dysplasia rates of CD80-positive patients were significantly higher than those of CD80-negative patients (p=0.04).ConclusionEven if partially limited by a relatively small sample size, our study seems to show an association between CD80 expression and colonic dysplasia in UC patients that may suggest a role for CD80 in the immunosurveillance against colorectal cancer in this early stage of tumorigenesis. On the contrary, CD86 seems to be involved in the inflammatory pathogenesis of UC.

The Role of Costimulatory Molecules CD80 and CD86 and IFNγ in the Pathogenesis of Ulcerative Colitis

Several studies showed that costimulatory signals on antigen presenting cells are up-regulated in inflammatory bowel disease. We quantified the expression of CD80, CD86, and IFNγ in colonic mucosa of patients affected by ulcerative colitis and correlated it with clinical and biochemical parameters to identify the context of this up regulation. We enrolled 21 patients affected by ulcerative colitis and 6 healthy subjects. We evaluated for each patient gender, age, duration of disease, clinical, endoscopic and histologic disease activity index, medical therapy, ESR, serum CRP, WBC, and serum αl-acid glycoprotein. CD80, CD86, and IFNγ expression in the colonic mucosa was quantified using reverse transcription polymerase chain reaction. Statistical analysis was performed using Mann–Whitney U test and Spearman’s rank correlation test. Significance was set at P &< 0.05. CD80 was detectable in seven patients, while CD86 and IFNγ expression was evident in all UC patients. CD80 and CD86 were not detectable in control specimens. Colonic CD80 expression was correlated to the age of the patients. CD86 expression showed an inverse correlation with duration of disease and a direct correlation with serum CRP levels and histologic grade of disease activity. IFNγ was not correlated with any of the examined parameter. Our study confirms a major role in ulcerative colitis pathogenesis for CD86 which correlates with histologic grade of disease and with serum CRP levels, and its up-regulation seems to be higher at the beginning of the disease. In “in vivo” conditions IFNγ may not be the only factor responsible for CD86 up-regulation in the ulcerative colitis colonic mucosa.

Pursestring placement before transsection of the rectum for facilitating the stapled low colorectal anastomosis.

We propose a simple, easy technique to perform a stapled colorectal anastomosis close to the anal sphincter that may help to lower leak rates. This is the same technique used by us for successful performance of intrathoracic and abdominal esophagoenteric mechanical anastomoses. The technique consists of hand sewing a double pursestring suture before sectioning the rectum.