Davide Sortini

Early oral feeding after colorectal resection: a randomized controlled study

Background:  Nasogastric (NG) intubation is widely used following elective abdominal operations although it is associated with morbidity and discomfort. The present study is a randomised controlled trial on the effect of early oral feeding without NG decompression following elective colorectal resection for cancer.

A new method of preemptive analgesia in laparoscopic cholecystectomy.

BackgroundAlthough laparoscopic cholecystectomy (LC) results in less pain then open cholecystectomy, it is not a pain-free procedure. The aim of this study was to test a new method of preemptive analgesia.MethodsBy simple randomization 60 patients were assigned to two groups (30 in each group). Group A, the placebo group, received 200 ml of 0.9% saline, and group B received 5 mg/kg of a local anesthetic solution (ropivacaine) in 200 ml of 0.9% saline. Local anesthetic or place solution were administer before creation of the pneumoperitoneum.ResultsPain intensity, as rated by visual analog and verbal rating scales, and stress response data were significantly less in the group receiving ropivacaine than in the placebo group. No patients in treatment group received an additional dose of analgesic, whereas two patients in placebo group needed an additional analgesic.ConclusionsOur results support the clinical validity of preemptive analgesia, but the timing of intraperitoneal administration of local anesthetic is very important. Only application before creation of the pneumoperitoneum may preempt every neuronal central sensitization.

Clinical and Therapeutic Importance of Sentinel Node Biopsy of the Internal Mammary Chain in Patients with Breast Cancer: A Single-Center Study with Long-Term Follow-Up

BackgroundWe evaluated the incidence of sentinel lymph nodes (SLNs) in the internal mammary chain, calculated the lymphoscintigraphy and surgical detection rates, and evaluated the clinical effect on staging and the therapeutic approach in patients with breast cancer.MethodsThe study involved 741 women diagnosed with breast cancer eligible for the SLN technique. Lymphoscintigraphy was performed on the day before the operation by peritumoral injection of 99mTc-labeled nanocolloid. During the operation, a gamma probe was used to detect the SLN, which was then removed.ResultsA total of 719 SLNs were found in the axillary chain and 72 in the internal mammary chain. Preoperative lymphoscintigraphy showed 107 hot spots in the internal mammary chain, but only 72 SLNs in 65 patients were identified by the gamma probe and then removed with no complications. Of these 65 patients, 10 had a positive internal mammary chain SLN on final pathologic examination, whereas 55 patients had ≥1 negative SLNs on final pathologic analysis. Thirty-five (53%) of 65 patients had also an axillary SLN, but only 5 patients (8%) had a positive SLN on pathologic analysis.ConclusionsEvaluation of the SLNs in the internal mammary chain may provide more accurate staging in breast cancer patients. If an internal mammary sampling is not performed, patients may be understaged. This technique may allow better selection of those patients who will be submitted to adjuvant locoregional radiotherapy.

Role of peritoneal lavage in adhesion formation and survival rate in rats: an experimental study.

Following laparotomy, almost 95% of patients develop adhesions. To prevent adhesion formation, peritoneal lavage has been investigated and many different lavage solutions have been proposed. In this study, different peritoneal lavage solutions were evaluated, testing their ability to prevent adhesion formation. Three consecutive steps were followed: (1) The lethal dose of Eschericia coli injected in the rat peritoneal cavity was determined, (2) the morbidity and mortality rates of different solutions for peritoneal lavage (i.e., saline, twice-distilled water, antiseptics, and antibiotics solutions) was investigated, and (3) the capability of the different lavage solutions to prevent adhesion formation was tested. Two hundred and ninety-eight rats were employed in this study. After intraperitoneal injection of E. coli, infection (clinical signs and animal vitality), adhesion formation (explorative laparoscopy, peritoneumgraphy and Zühlke scale grading), and animal performance status were investigated. All differences were evaluated by chi-square and analysis of variance (ANOVA) tests. Saline solution showed a low morbidity rate with no deaths. Twice-distilled water was associated with 100% mortality rate, as opposed to 45–75% for antiseptics, and 0–3% mortality for antibiotics. Antibiotics determined higher adhesion formation by Zühlke score as compared to saline solution (p <. 001), while no difference was observed between antiseptics and saline (p = NS). Peritoneal lavage with 37°C saline solution was associated with low adhesion formation and high survival rate as compared to twice-distilled water and antiseptics. Antibiotics solutions had high survival rate and high adhesion formation. Twice-distilled water and antisepsis should be avoided when based on the data obtained in this work.

Single pulmonary nodules: localization with intrathoracoscopic ultrasound — a prospective study

This prospective study, based on 13 patients with single pulmonary nodules of width between 10 and 30 mm, was performed to verify the utility of intrathoracoscopic ultrasound to localize the single pulmonary nodule. In all 13 cases the ultrasound examination was able to localize the position of nodules, but the homogeneous hypoechoic pattern of nodules observed in ten of 13 cases did not prove whether the lesion was benign or malign. In conclusion, we can confirm that intrathoracoscopic ultrasound examination is a safe, risk-free and less expensive method of localizing the single pulmonary nodules.

Intrathoracoscopic localization techniques

BackgroundSeveral techniques for localizing pulmonary nodules have been described, but the advantages and disadvantages of each method remain unclear. We reviewed ultrasound, endofinger, finger palpation and wait and watch, radioguided, vital dye, fluoroscopic, agar marking, and needle wire methods for localizing pulmonary nodules.MethodsOriginal, peer-reviewed, and full-length articles in English were searched with PubMed and ISI Web of Sciences. Case reports and case series with less than 10 patients were excluded.ResultsAll localization techniques showed good reliability, but some carry a high rate of major or minor complications and drawbacks.ConclusionNo ideal localization technique is available; thus, the choice still depends on surgeon’s preference and local availability of both specialists and instruments.

Oesophageal Achalasia with Epiphrenic Diverticulum with Laparoscopic Approach: A 6-Year Follow-Up

uneventful and the patient was discharged home 5 days after the operation, symptom-free, and tolerated a soft diet. Six months postoperatively she had no symptoms, ate without restrictions, had gained 8 kg, and showed a normal-sized oesophagus with regular emptying on barium swallow ( fi g. 1 C). At the 6-year follow-up, the patient was free of symptoms and had gained 19 kg of weight. Specifi cally, she had no dysphagia, regurgitation, heartburn or cough; a new barium swallow showed a normalsized oesophagus with tertiary contractions and a 2-cm epiphrenic diverticulum ( fi g. 1 D). Long-term results of laparoscopic treatment for oesophageal achalasia with epiphrenic diverticulum are reported in a 75-year-old woman presenting with a 10-year history of dysphagia, regurgitation, cough, and a 10-kg weight loss. Preoperative barium swallow showed a dilated sigmoid oesophagus with a 6-cm enlarging epiphrenic diverticulum ( fi g. 1 A, B). Endoscopic biopsies were negative for cancer and oesophageal manometry showed no peristalsis. Laparoscopic diverticulectomy and a 7-cm distal oesophageal myotomy with Dor fundoplication were performed. The postoperative course was Published online: April 20, 2006

Thoracoscopic Localization Techniques for Patients with a Single Pulmonary Nodule and Positive Oncological Anamnesis: A Prospective Study

INTRODUCTION Our aim was to evaluate the best intrathoracoscopic localization technique in patients with a single pulmonary nodule and a history of malignancy. METHOD We divided 30 patients into two groups, well matched for diameter and depth of the pulmonary lesion. In 15 patients (group A) we performed intrathoracoscopic ultrasound (US) to locate the pulmonary nodule, while in the other 15 patients (group B) intrathoracoscopic radioguided occult lesion localization (ROLL) was used. In both groups, the localization technique was compared to finger palpation. In group A, 6 nodules were in the left lung and 9 in the right; in group B, 7 lesions were in the left and 8 in the right lung. In each group, the distance of the nodule from the pleural surface was 2-2.5 cm in 8 patients, and > 2.5 cm in the remaining 7. In both groups, the diameter of the nodule was </= 1 cm in 6 patients, and 1-1.5 cm in 9 patients. All patients underwent thoracoscopic wedge resection, and 6 patients with a primary pulmonary lesion underwent posterior-lateral thoracotomy for lobectomy and mediastinal lymphadenectomy. RESULTS In group A, US localized the nodule in 15 of 15 patients (100%) while finger palpation located the nodule in 11 of 15 (73%) (P = NS). In group B, both ROLL and finger palpation localized the nodule in 12 of 15 patients (80%) (P = NS). CONCLUSION Intrathoracoscopic US seems superior to radioguided and finger palpation localization techniques for single pulmonary nodules. Thus, we are now routinely using intraoperative US to identify single pulmonary nodules.

Excellent Prognosis of Patients with Solitary T1N0M0 Papillary Thyroid Carcinoma who Underwent Thyroidectomy and Elective Lymph Node Dissection Without Radioiodine Therapy: Letter to the Editor

(77.5%) had no SLN metastases, 12 patients (19.3%) had SLN metastases, and 2 patients (3.2%) had SLN micrometastases on final pathology. In 46 (74.2%) patients, the SLN was found in the central compartment, in 14 (22.5%) in laterocervical omolateral, and in 2 (3.1%) patients in laterocervical contralateral compartment. Seven (11.3%) false-negative patients were recorded. No contralateral positive SLN was recorded. No recurrences have been recorded in these 62 patients to date.

Sonographic evaluation for peripheral pulmonary nodules during video-assisted thoracoscopic surgery

We express our opinion about the article of Yamamoto and associates. First, we congratulate them for the results they obtained in their study. We agree with author of the article [4] about the utility of intraoperative sonographic for locating peripheral pulmonary nodules. In our department, we have performed intrathoracoscopic localization of solitary pulmonary nodules. We think that intrathoracoscopic ultrasound is useful for locating not only pulmonary nodules, but also study structures around the nodule-like vessels, bronchi, and limphonodes. Moreover, we think intrathoracoscopic ultrasound also is useful for detecting resection margins. We think that intrathoracoscopic cannot play a role in the histology of the nodule [2, 3]. We have observed a frequent association between the final histology of the nodule and its ultrasound pattern. In fact, malignant pulmonary lesions have appeared as a homogeneous hypoechoic pattern with the sonographic disappearance of the hyperechoic pulmonary surface. Benign lesions often are associated with heterogeneous echogenicity. This sonographic pattern may be attributable to air bronchograms, the presence of different tissue, or hamartoma. However, we think this ultrasound pattern was not able to distinguish between benign and malign lesions. The Doppler can add something to the ultrasound pattern in defining the histology of the pulmonary nodule, but we are not sure it can determine intraoperative or final histology. We think it is impossible to base surgical treatment on the ultrasound or Doppler pattern alone because for us, only the intraoperative or final histology is sure and reliable. Ultrasound and Doppler patterns are only radiologic patterns, and although they give statistically significant results, they are not reliable for qualitative diagnosis of pulmonary lesions. Moreover, they are operator dependent [1]. We think that it currently is not ethically defensible to submit patients with a solitary pulmonary nodule to explorative thoracoscopy alone. Because the grade of intratumoral blood flow signal, as shown by Doppler, is low, we think that pulmonary resection with a frozen section of the specimen is mandatory. The Doppler pattern would play a role if this method is applied in the preoperative diagnosis, but it is impossible to perform a qualitative– quantitative study of a pulmonary nodule with percutaneous Doppler. We think, therefore, that it would be more correct to use ultrasound or Doppler only to locate and not to obtain a qualitative diagnosis of pulmonary nodules.