Domenico Iusco

Preoperative endoscopic sphincterotomy and laparoscopic cholecystectomy for the management of cholecystocholedocholithiasis: 10-year experience

No procedure has yet been identified as the “gold standard” for the detection and treatment of common bile duct stones (CBDS) in patients undergoing laparoscopic cholecystectomy (LC). This prospective study involves 2137 patients undergoing elective laparoscopic cholecystectomy. The algorithm for diagnostic management in place until July 1997 involved routine intravenous cholangiography and selective endoscopic retrograde cholangiography (ERC). Subsequently, assessment of the bile duct was not routinely performed, but a scoring system was applied to single out those patients at risk of CBDS who should undergo intravenous cholangiography and/or ERC (see Fig. 2). Whenever bile duct stones were found, endoscopic sphincterotomy (ES) was performed, and LC was performed with a standardized four-cannula technique after endoscopic bile duct stone clearance. Common bile duct stones were suspected in 340 patients who were referred for preoperative ERC; 250 patients were referred for ES; 21 patients were referred for open surgery because of failure of ERC or sphincterotomy. Common bile duct stones, detected in 283 cases (13.2%), were removed before surgery in 250 cases (88.3%) and during surgery in 28 cases (9.9%). Self-limited pancreatitis occurred in 4.2% of the patients after sphincterotomy. Laparoscopic cholecystectomy was performed in 98.4% of the cases. The conversion rate was 8.3% if sphincterotomy had been performed previously and 3.4% after standard laparoscopic cholecystectomy (p < 0.001). The morbidity rate was 4.5%; mortality, 0.09%. During follow-up five patients (0.2%) had retained stones endoscopically treated. Future trials of novel strategies for detecting and treating CBDS should compare the results of novel strategies with those of the strategy employed in this study, which includes selective ERC, preoperative ES, and LC.

Simultaneous repair of bilateral inguinal hernias: a prospective, randomized study of open, tension-free versus laparoscopic approach.

No randomized trial exists that specifically addresses the issue of laparoscopic bilateral inguinal hernia repair. The purpose of the present prospective, randomized, controlled, clinical study was to assess short-and long-term results when comparing simultaneous bilateral hernia repair by an open, tension-free anterior approach with laparoscopic “bikini mesh” posterior repair. Forty-three low-risk male patients with bilateral primary inguinal hernia were randomly assigned to undergo either laparoscopic preperitoneal “bikini mesh” hernia repair (TAPP) or open Lichtenstein hernioplasty. There was no difference in operating time between the two groups. The mean cost of laparoscopic hernioplasty was higher (P < 0.001). The intensity of postoperative pain was greater in the open hernia repair group at 24 hours, 48 hours, and 7 days after surgery (P < 0.001), with a greater consumption of pain medication among these patients (P < 0.05). The median time to return to work was 30 days for the open hernia repair group and 16 days for the laparoscopic “bikini mesh” repair group (P < 0.05). Only 1 asymptomatic recurrence (4.3%) was discovered in the open group. The laparoscopic approach to bilateral hernia with “bikini mesh” appears to be preferable to the open Lichtenstein tension-free hernioplasty in terms of the postoperative quality of life and interruption of occupational activity.

Scoring system to predict asymptomatic choledocholithiasis before laparoscopic cholecystectomy

Background: The purpose of this prospective study was to evaluate if a recently proposed score system based on six preoperative parameters [history of colic pain and/or jaundice, dyspepsia, cholecystitis, ultrasound (US), evidence of common bile duct stones (CBDS), number and size of gallbladder stones at US, level of serum glutamic oxalacetic transaminase and/or alkaline phosphatase is effective in the selection of patients undergoing laparoscopic cholecystectomy (LC) with asymptomatic CBDS and could allow a significant reduction of the total number of preoperative examinations. Methods: In the case group, 408 patients were categorized into low-, medium-, and high-risk classes and underwent, respectively, no further preoperative assessment of the bile duct, intravenous cholangiography (IVC), and endoscopic retrograde cholangiography (ERC). Intraoperative cholangiography (IOC) was performed whenever the surgeon was in doubt as to biliary anatomy or bile duct clearance. These patients were compared with 408 retrospectively matched patients (control group) undergoing routine preoperative IVC and/or ERC. Results: In the case group, significantly lower numbers of IVC (120 vs 392) and IOC (3 vs 16) were performed (p < 0.005), whereas no difference in the total number of ERCs was noted. One patient in the control group had retained CBDS detected during follow-up evaluation, whereas none occurred in the case group. Conclusion: The proposed scoring system allows selective use of IVC, ERC, and/or IOC in patients undergoing elective LC.

Postoperative complications after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy affect long-term outcome of patients with peritoneal metastases from colorectal cancer: A two-center study of 101 patients

BACKGROUND: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy is an effective but potentially morbid treatment for colorectal cancer peritoneal metastases. The impact of treatment-related morbidity on long-term survival has been reported in various malignancies, but it has never been assessed in this clinical setting. OBJECTIVE: The aim of this study was to assess the impact of major postoperative complications on oncological outcomes after cytoreduction and hyperthermic intraperitoneal chemotherapy for colorectal peritoneal metastases. DESIGN: Two prospective databases were reviewed. Major complications were defined as grade 3 to 5 according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0. The extent of peritoneal involvement was scored by the use of the Peritoneal Cancer Index. SETTINGS: This study was conducted in 2 high-volume peritoneal malignancy management centers. PATIENTS: One hundred one consecutive patients with peritoneal metastases potentially amenable to macroscopically complete cytoreduction were selected. INTERVENTIONS: Peritonectomy procedures and multivisceral resections were used to remove all macroscopic tumor, and mitomycin-C plus cisplatin-based hyperthermic intraperitoneal chemotherapy was used to control microscopic residual disease. MAIN OUTCOME MEASURES: The primary outcomes measured were overall and disease-specific survival. RESULTS: Mortality and major morbidity were 3.0%, and 23.8%. Median follow-up was 44.9 months (95% CI, 24.1–65.7). Five-year disease-specific survival was 14.3% for patients who experienced major complications and 52.3% for those who did not (p = 0.001). Five-year overall survival was 11.7% for patients who experienced major complications, and 58.8% for those who did not (p = 0.003). At multivariate analysis, major morbidity correlated to both worse overall and disease-specific survival, along with a Peritoneal Cancer Index >19, and suboptimal cytoreduction. Poor performance status correlated only to worse disease-specific survival, and liver metastases correlated to worse overall survival. Longer operative time (OR, 4.1; 95% CI, 1.3–12.6; p = 0.01) and Peritoneal Cancer Index >19 (OR, 2.6; 95% CI, 1.1–6.0; p = 0.02) were independent risk factors for major morbidity. LIMITATIONS: This study is limited by its observational design. CONCLUSIONS: The prevention of major complications, by refining surgical technique and patient selection, is crucial because it affects oncologic outcome.

Association Between Recurrence of Sporadic Colorectal Cancer, High Level of Microsatellite Instability, and Loss of Heterozygosity at Chromosome 18q

PURPOSE:Microsatellite instability and loss of heterozygosity of chromosomes 18q, 8p, and 4p are genetic alterations commonly found in colorectal cancer. We investigated whether these genetic markers allow for the stratification of patients with Stage II to III colorectal cancer into groups with different recurrence risks, and with different prognoses.METHODS:Tumors of 113 patients were evaluated for loss of heterozygosity of chromosomes 18q, 8p, and 4p and for microsatellite instability by use of six microsatellite markers. Genetic alterations involving each of these genetic markers were examined for association with disease recurrences and survival.RESULTS:Loss of heterozygosity of chromosomes 18q, informative in 96 percent of cases, in Stage III tumors was associated with higher risk of overall recurrence (P < 0.001), local recurrence (P < 0.001), distant metastases (P < 0.001), decreased overall survival (P = 0.002), and disease-free survival (P < 0.001). The recurrence rates and survival rates among patients with Stage II colorectal cancer were independent of loss of heterozygosity of chromosome 18q. Stage III and loss of heterozygosity of chromosome 8p also were associated with a higher risk of recurrences when these factors were considered individually. In multivariate analysis, only loss of heterozygosity of chromosome 18q was independently associated with risk of recurrences (P < 0.001) and with disease-free survival (P = 0.001). No correlation was observed between microsatellite instability and recurrence rates. However, microsatellite instability was associated with improved overall survival (P = 0.04) and with a longer disease-free interval (P = 0.002). Only in five cases (16.7 percent) was it possible to perform resection of recurrences; two of these patients had microsatellite instability tumor. In no cases was it possible to resect recurrence of tumors with loss of heterozygosity of chromosome 18q.CONCLUSIONS:Loss of heterozygosity of chromosome 18q is an informative genetic marker, which in resected Stage III colorectal cancer can be used to predict recurrences and survival. Microsatellite instability identified cases that, even in the case of recurrence, have a more favorable prognosis.

Gallstone cholangitis: a 10-year experience of combined endoscopic and laparoscopic treatment.

BackgroundTo date, no procedure has yet been identified as the gold standard for the treatment of gallstone cholangitis in the laparoscopic era.MethodsThe data of 109 consecutive patients with acute cholangitis were prospectively entered into a computerized database. All patients were managed according to a standard protocol. The main treatments were endoscopic retrograde cholangiography (ERC) combined with endoscopic sphincterotomy (ES), followed by interval laparoscopic cholecystectomy (LC). Patients in whom ERC or endoscopic stone clearance failed were managed by emergency open common bile duct exploration. LC was performed with a standardized four-cannula technique. The mean duration of surgery, conversion rate, and postoperative outcome of these patients were evaluated.ResultsERC was successful in 103 patients (94.5%). In five of these patients (4.8%), no bile duct stones were found. The 98 patients (95.2%) with common bile duct stones were referred for ES. The bile duct stones were successfully removed after ES in 93 cases (94.9%). The overall failure rate of ERC and ES for choledocholithiasis was 10.1%. Self-limiting pancreatitis occurred in four patients (4.3%). Overall, two of the 109 patients died (1.8%). After ES, 81 patients underwent LC. LC was performed successfully in 74 patients (91.3%). Conversion to open surgery was required in seven patients (8.7%). The morbidity rate after cholecystectomy was 7.4%; the morbidity rate after open bile duct exploration was 36.4% (p<0.05). Fifteen patients were managed conservatively after initial endoscopic management of their cholangitis. The overall incidence of recurrent biliary symptoms was significantly higher among patients with gallbladder in place than for patients who underwent cholecystectomy (38.5% vs 1.5%, p>0.001)ConclusionsES followed by LC is a safe and effective approach for the management of gallstone cholangitis; cholecystectomy should be performed in patients with gallstone cholangitis unless the operative risk is extremely high. These high operative risk patients and those who refuse surgery after ES should be warned that they are at high risk for recurrent biliary symptoms.

The changing distribution and survival of colorectal carcinoma: an epidemiological study in an area of northern Italy.

Objective This study analyses the inter-relations of anatomical tumour location, gender, age and incidence rates for colorectal cancer from 1978 to 1999 in an area of northern Italy: the Parma district. Methods Data were obtained from the Parma Cancer Registry. Age-adjusted incidence rates were analysed by gender, age and colorectal cancer subsites. In addition, 5 year observed survival rates were determined. Results In the Parma area, the incidence of colorectal cancer is rising. We have observed a true increase in the rate of the age standardized incidence of right colon cancer, linked to an increased incidence of left colon cancer, while the incidence of rectal cancer has remained constant. The frequency of right-sided colon cancer was higher in aged patients, and in women. Age-standardized relative survival of patients after diagnosis of colorectal cancer between 1992 and 1996 was found to be significantly higher than age-standardized relative survival after diagnosis between 1978 and 1982. Conclusions In the Parma area there has been an increased incidence of right colon cancer, linked to an increased incidence of left colon cancer, while the incidence of rectal cancer has remained constant. We feel that this shift, whatever the reason for it, has important implications for the choice of screening techniques.

Long-term results of subtotal colectomy with antiperistaltic cecoproctostomy.

AbstractPurpose. To evaluate the clinical role of subtotal colectomy with cecorectal anastomosis (CRA) and its postoperative results, based on our surgical experience. Methods. We retrospectively analyzed 26 patients who underwent subtotal colectomy with CRA during an 8-year period (1992–1999) in our university hospital. The indications for CRA were intractable constipation, colon tumors, diverticulitis, Crohn’s disease, and postactinic colitis. CRA was performed using a new technique of end-to-end antiperistaltic anastomosis. Postoperative and late complications, and functional results, defined as the number of bowel movements per day and quality of life, were evaluated. Results. None of the patients experienced postoperative or late complications. Two patients died from progression of colon cancer. The mean follow-up period was 4.5 years (range 1–8 years). By 1 month after surgery, 58% of the patients were passing frequent bowel movements, and by 1 year after surgery, only 23% of the patients were passing frequent bowel movements. The last follow-up revealed a mean 1.7 bowel movements per day, and only one patient was taking medication for diarrhea. All patients were satisfied with the results of their surgery and reported that their quality of life was good or improved, and even very good in six cases. Conclusions. Subtotal colectomy with our new CRA technique is appropriate for treating inflammatory diseases of the bowel, colon tumors, and intractable constipation in selected patients.

Preoperative Ultrasonographic Assessment of the Number and Size of Gallbladder Stones Is It a Useful Predictor of Asymptomatic Choledochal Lithiasis

Objective. To evaluate whether preoperative ultrasonographic assessment of the number and size of gallbladder stones can identify patients at increased risk of having asymptomatic common bile duct stones. Methods. Ultrasonographic data for 300 consecutive patients undergoing laparoscopic cholecystectomy were analyzed. Patients were divided into a group in which multiple small (≤5 mm) or multiple variably sized (both ≤5 and >5 mm) gallbladder stones were present (“positive” stones) and a group with multiple large (>5 mm) or single gallbladder stones, considered “negative.” The ultrasonographic description was compared with surgical findings; finally, the prevalence of asymptomatic common bile duct stones in the 2 groups was compared. Results. Ultrasonographic classification of gallbladder stones was confirmed at surgery in 285 cases (95%). Asymptomatic common bile duct stones were diagnosed in 9.5% of patients with an ultrasonographic diagnosis of positive gallbladder stones and in only 2.3% of patients with a diagnosis of negative gallbladder stones (P < .05). Conclusions. Ultrasonography is able to accurately show gallbladder stones; the appearance of multiple small and variably sized gallbladder stones represent a risk factor for synchronous asymptomatic common bile duct stones.

Predicting conversion to open surgery in laparoscopic left hemicolectomy.

Purpose The objective of this study was to quantify the risk of conversion to open surgery of laparoscopic left hemicolectomy at an early stage of the learning curve. Methods A multiple logistic regression analysis of 100 laparoscopic left hemicolectomies completed between April 2001 and May 2004 was performed. Results The overall conversion rate was 12%. At univariate analysis, 2 factors were found to be predictive of conversion to open surgery: malignancy (17.2% vs. 5%; P=0.046), and weight level (<60 kg=6.1%; 60 to 90 kg=11.3%; >90 kg=28.6%; P=0.049). At multiple logistic regression, the risk of conversion rose only for patients weighing more than 90 kg. Conclusions On the basis of the results of this study, the surgeon will be able to quantify the risk of conversion to laparotomy with some precision in order to obtain the informed consent of the first 100 patients to whom laparoscopic left hemicolectomy is proposed.