Enrico Cavina

Radio-frequency thermal ablation of liver metastases with a cooled-tip electrode needle: results of a pilot clinical trial

Abstract. The aim of this study was to evaluate feasibility, safety, and effectiveness of radio-frequency (RF) thermal ablation, performed by using a cooled-tip electrode needle, in the treatment of liver metastases. Twenty-nine patients (20 males and 9 females; age range 43–77 years) with one to four hepatic metastases 1.1–4.8 cm in diameter (mean 2.9 ± 0.8 cm) from previously resected intra-abdominal primary malignancies were treated. All patients were excluded from surgery and had partial or no response to chemotherapy. Radio-frequency ablation was performed by using a 100-W generator and 17-gauge, dual-lumen, cooled-tip electrode needles with a 2- to 3-cm exposed tip. Exposure time was 12 min for each needle insertion. Findings at spiral CT were used to assess the therapeutic response. A total of 127 insertions were performed (mean 2.4 ± 1.7 insertions/lesion) during 84 treatment sessions (mean 1.6 ± 0.7 sessions/lesion) in absence of major complications. Complete tumor response (i. e., unenhancing area of thermal necrosis larger than the treated tumor) was seen in 41 (77 %) of 53 lesions, including 33 (87 %) of 38 lesions 3 cm or less in diameter. After a mean follow-up period of 6.5 ± 2.1 months (range 3–9 months), recurrence of the treated lesion was seen in 5 (12 %) of the 41 cases. New metastatic lesions appeared in 7 patients. Two patients died after 6 and 8 months, respectively. Of the 27 patients still in follow-up, 14 are currently free of disease. Radio-frequency thermal ablation with a cooled-tip electrode needle is a safe and effective local treatment for hepatic metastases 3 cm or less in greatest dimension.

Safety and efficacy of dynamic muscle plasty for anal incontinence: Lessons from a prospective, multicenter trial

BACKGROUND & AIMS Dynamic muscle plasty has been advocated as therapy for refractory fecal incontinence and for anorectal reconstruction to avoid colostomy after abdominoperineal resection. This study evaluates the results of a multicenter experience with dynamic muscle plasty in the treatment of fecal incontinence and total anal reconstruction. METHODS One hundred thirty-nine patients were enrolled at 12 centers between June 1992 and November 1994 and followed up through June 1996. Intramuscular leads and neurostimulators were implanted to stimulate transposed gracilis or gluteus muscle. Success was defined as 70% reduction in solid stool incontinence for patients with baseline incontinence and zero incontinence to solid stool for patients with baseline stomas and for patients undergoing total anal reconstruction. RESULTS Overall, 85 of 128 graciloplasty patients (66%) achieved and maintained a successful outcome over the follow-up period. By etiology, these proportions were 71%, 50%, and 66% for patients with acquired fecal incontinence, congenital incontinence, and total anal reconstruction, respectively. One third of graciloplasty patients experienced a major wound complication, with therapy failing in 41%. Experienced centers had better outcomes and lower complication rates than inexperienced centers. Of the 11 gluteoplasty patients, 5 (45%) achieved and maintained a successful outcome. CONCLUSIONS Dynamic graciloplasty may be an effective procedure for patients with refractory, end-stage fecal incontinence as well as for patients who require anorectal excision for low-lying malignancy. However, the procedure has significant morbidity that can lead to functional failure. Outcome after dynamic graciloplasty appears to correlate with surgical experience. In contrast to graciloplasty, the use of dynamic gluteoplasty should be limited to investigational purposes.

The role of ultrasonography in blunt abdominal trauma: results in 250 consecutive cases.

The accuracy of ultrasonography (US) in detecting abdominal lesions and free fluid collections in patients with blunt abdominal trauma was evaluated in 250 patients. Particular attention was paid to the role of associated US-guided paracentesis in doubtful cases and in those referred for nonsurgical therapy. The overall sensitivity of US in detecting free fluid collection was 98% (51 of 52 cases) with a specificity of 99% and a positive predictive value of 100%. The overall sensitivity was 93% in spleen injuries, 80% in liver injuries, and 100% in kidney lesions with a positive predictive value of 93%, 100%, and 100%, and a specificity of 99%, 100%, and 100%, respectively. Three stable patients underwent celiotomy on the basis of the results of US-guided paracentesis. The versatility, sensitivity and, repeatability of US, along with its feasibility at bedside and the possibility of performing a guided paracentesis represent the main characteristics that make US the first diagnostic approach to patients with blunt abdominal trauma.

Five‐year follow‐up of percutaneous ethanol injection for the treatment of hyperfunctioning thyroid nodules: a study of 117 patients

Percutaneous ethanol injection (PEI) has been suggested as an alternative to radioiodine and surgery for the treatment of autonomous thyroid nodules (ATN).

Study protocols and functional results in 86 electrostimulated graciloplasties.

PURPOSE: This study analyzes different protocols adopted in 86 electrostimulated graciloplasties performed during the last eight years, comparing functional and manometry results in 63 patients. METHODS: Electrostimulated graciloplasties were performed to construct a neosphincter after surgical removal of the anorectum for cancer in 75 patients and to substitute the anal sphincter in 11 fully incontinent patients. An intermittent stimulation protocol, using external devices, was applied in the first 68 patients, while long-term stimulation was carried out with implantable stimulators and intramuscular electrodes in the last 18 patients. Sixty-three patients remaining under study were evaluated by questionnaires, continence scores, and manometry. RESULTS: In patients submitted to intermittent stimulation, continence was achieved in 71 percent of 42 “neosphincters” after rectal resection and in 33 percent of 3 incontinent patients. Adopting chronic stimulation, implantable stimulators and intramuscular electrodes, continence reached 100 percent and 83 percent, respectively. Significant differences were also observed in resting and voluntary pressure values between the intermittently and chronically stimulated patients. Incontinent patients showed after chronic stimulation significant increases in mean resting and maximum voluntary pressures: from 13.3 to 60.5 mmHg and from 32 to 103 mmHg, respectively (P< 0.01). CONCLUSIONS: This study confirms the efficacy of chronic stimulation and the validity of a bilateral, “one-time” graciloplasty to reconstruct or substitute the anal sphincter.

Perineal colostomy and electrostimulated gracilis “neosphincter” after abdomino-perineal resection of the colon and anorectum: a surgical experience and follow-up study in 47 cases

A series of 47 patients undergoing abdominoperineal resection of the distal colon and anorectum and construction of a continent perineal colostomy using electrostimulated gracilis muscle is described. External and implanted pulse generators have both been used. An analysis of complications and oncological data are reported. There was no operative mortality. The incidence of complications, divided into three classes, mild (62%), moderate (27%) and severe (11%), has not significantly altered the functional results, with the exception of early ischaemia of the colonic stump in two cases. During the first 22 cases, no preoperative oncological staging was performed. In the last 23 patients endorectal ultrasonography and CT scanning were carried out. Functional results were evaluated by electromanometry, electromyostimulation and dynamic defaecography. Clinical data assessed postoperatively showed good function in 65% of cases, fair in 22.5% and poor in 12.5%. The quality of life in 15 patients with a perineal colostomy and electrostimulated gracilis was significantly better than in 15 patients having an abdomino-perineal resection without gracilis plastic reconstruction.

The European experience with vascular injuries

The rich and diverse heritage of the management of vascular injuries in the 45 independent European countries prevents the authors from revealing a uniform picture of the European experience, but some trends are clearly emerging. In countries with a low incidence of penetrating trauma and increasing use of interventional vascular procedures, the proportion of iatrogenic vascular trauma exceeds 40% of all vascular injuries, whereas on other parts of the continent, armed conflicts are still a major cause of vascular trauma. National vascular registries, mostly in the Scandinavian countries, produce useful, nationwide data about vascular trauma and its management but suffer still from inadequate data collection. Despite a relatively low incidence of vascular trauma in most European countries, the results are satisfactory, probably in most cases because of active and early management by surgeons on call, whether with vascular training or not, treating all kinds of vascular surgical emergencies. In some countries, attempts at developing a trauma and emergency surgical specialty, including expertise in the management of vascular injuries, are on their way.

Anorectal reconstruction after abdominoperineal resection

PURPOSE: The aims of the study contained herein were to analyze the efficacy and safety of a chronically electrostimulated double-wrap graciloplasty for restoration of continence after a curative abdominoperineal resection for rectal carcinoma and to evaluate late results of a stimulation protocol that was begun early. METHODS: During the last six years, 31 consecutive patients underwent this procedure: in 24 patients, electrostimulated double-wrap graciloplasty was performed simultaneously with abdominoperineal resection for lower rectal cancer; 7 strictly selected patients underwent conversion to an abdominal stoma following previous abdominoperineal resection (mean length of time from stoma creation, 71.4 months). Anorectal reconstruction was performed following a surgical scheme already standardized since 1985 in 102 patients: after abdominoperineal resection, the distal colon was pulled through to the perineum and surrounded by both gracilis muscles following an “alfa and new-sling” configuration; using platinumiridium electrodes, both muscles were then connected to a pulse generator, which was implanted subcutaneously in the abdomen. All surgical steps were performed during the same surgical session to allow early postoperative stimulation of the transposed muscles. A contemporary covering stoma was abandoned as a standard procedure; the distal colon was left closed for a few postoperative days, then it was resected and sutured to the perineum under local anesthesia. Eighteen patients underwent preoperative or postoperative radiotherapy or both, without any significant adverse outcome. To increase gracilis resistance to prolonged “tonic” contraction, patients underwent a chronic, low-frequency stimulation protocol. In the last 11 patients, a new “over-the-nerveand intramuscular” implant was adopted to optimize fiber recruitment and to reduce electrostimulation thresholds. At regular intervals, all patients were evaluated using continence scores and questionnaires, electromanometry, endoluminal ultrasound study, and defecography. RESULTS: Twenty-six of 31 patients were evaluable for continence, with a mean length of follow-up of 37.8 (range, 4–68) months; 3 patients died because of cancer recurrence, 1 underwent conversion to an abdominal stoma, and 1 is waiting for stoma closure. Continence to liquid and solid stools was achieved in 22 patients (85 percent), and electromanometry findings confirmed a good muscular contraction postoperatively and during follow-up intervals. No postoperative mortality (40 days) was observed; the postoperative complication rate was high (22 percent), but early treatment (drainage and temporary diversion in 7 patients) led to favorable outcomes (4 resolutions, 3 partial muscular impairments). Four stimulators had to be temporarily explanted because of late complications, and two stimulators had to be replaced because of battery exhaustion after three years of use with high stimulation parameters. A significant difference was observed comparing full-contracting threshold after intramuscular (14 patients) and the new over-the-nerve and intramuscular implant technique. CONCLUSIONS: The study contained herein confirms the efficacy of the surgical scheme we have adopted since 1985 to reconstruct sphincteric apparatus after abdominoperineal resection of the rectum. The “one-step” timing of surgical and electrostimulation-related procedures and the early start of stimulation did not show a significant increase in the complication rate and did not produce noticeable muscular or nerve damage. Adoption of chronic electrostimulation protocols using implantable devices increased the rate of fully continent patients; nevertheless, the overall cost for devices and medical staff duties was high, and a small increase of late morbidity was observed. Finally, the preliminary experience with our new technique of electrode implants encourages further application.

Outcome of restorative perineal graciloplasty with simultaneous excision of the anus and rectum for cancer

PURPOSE: To review the complications, survival, and longterm functional outcome of patients with anorectal cancer who had restorative perineal graciloplasty (RPG) simultaneously with abdominoperineal resection (APR). METHODS: Between 1985 and 1994, 81 patients underwent APR plus RPG. Gracilis muscles were then conditioned by electrostimulation, either intermittently or chronically. Thirtyseven surviving patients were followed for a mean of 78.6 months and were analyzed for long-term functional outcome of RPG. RESULTS: Postoperative complications occurred in 30 patients (37 percent). Crude five-year survival rate was 58 percent, and five-year estimated cumulative probability of survival was 65 percent. There was no statistically significant difference for probability of survival and for probability of disease-free interval between uncomplicated and complicated patients. Fecal continence was obtained in 90 percent of patients. CONCLUSION: RPG does not reduce the effectiveness of APR in the cure of cancer. Postoperative complications, though frequent, were not serious and resolved without sequelae. There was no statistically significant impact on the probability of survival and of disease-free interval by graciloplasty. Continence was achieved by most patients (90 percent) who underwent RPG simultaneously with APR.

Trocar site tumor recurrences. May pneumoperitoneum be responsible

AbstractBackground: Port site metastasis following laparoscopy for cancer is reported with increasing frequency and represents one of the most important limitations of the technique. Methods: A scintigraphic model was utilized to evaluate a possible role of pneumoperitoneum in tumor cell dissemination. Labeled red blood cells (RBC) were injected at the level of the gallbladder bed during laparoscopic cholecystectomy (LC) performed for symptomatic cholecystolithiasis. LC was performed in two groups with standard CO2 pneumoperitoneum: in one group an endobag for retrieval of the specimen was utilized. In one group a gasless LC with endobag was performed. Results: Radioactivity in the area of the trocar introduction was observed in almost all the patients who underwent standard (CO2) LC but represented a rare event in patients treated with the gasless method. The utilization of a protective bag for the extraction of the surgical specimen did not modify significantly the results. Moreover all patients treated with pneumoperitoneum demonstrated a wide intraperitoneal diffusion of the tracer not observed in gasless patients. Conclusions: The results of this study confirm that pneumoperitoneum may play an important role in the evolution of port site metastasis after laparoscopy for gastrointestinal cancer.