Enzo Pozza

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.

Early and late outcome after surgery for colorectal cancer: elective versus emergency surgery.

Aims and Background Emergency surgery for colorectal cancer is associated with a higher postoperative morbidity and mortality rate and a poor long-term outcome compared with elective surgery. The aim of the present study was to compare early and late outcome after elective and emergency surgery for malignant colorectal cancer, looking for the principal determinants of a worse outcome after emergency colorectal surgery. Methods A retrospective study of 236 patients presenting with colorectal cancer over an 8-year period was undertaken. Of these, 118 presented as emergencies, whereas 118 patients, well matched for age, sex, site of tumor and TNM admitted as elective, were included in the study. Data reviewed included postoperative mortality and morbidity and long-term outcome. Results The 30-day operative mortality rate was significantly higher in the emergency group than in the electively treated group (11.9% versus 3.4%, P<0.01). The higher mortality rate was observed in the perforation group. The 30-day operative morbidity was higher in the emergency group (27.1% versus 12.7%, P <0.05). Anastomotic failure was a serious complication: following primary resection, we observed 4 non-fatal (5.4%) and two fatal (2.7%) anastomotic leaks after 74 primary anastomoses. Among emergency-treated patients, the procedures characterized by the highest percentage of postoperative complications were three-stage resections (63.6%). The 5-year survival rate was greater after elective surgery (59% versos 39%). Conclusions The early and long-term outcome following emergency colorectal surgery was significantly lower than that after elective surgery. Although medical complications in patients with end-stage cancer played an important role, surgical failures still had an important impact on outcome.

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.

Sentinel node biopsy in the evaluation of the internal mammary node chain in patients with breast cancer.

Aims and Background In patients with breast cancer the presence of internal mammary chain (IMC) metastases changes tumor staging, and the occurrence of IMC drainage is quite common in breast cancer. Nevertheless, IMC dissection is not a routine procedure in modern surgical approaches towards breast cancer. We therefore need minimally invasive techniques for accurate assessment of the IMC nodal basin. The aim of this study was to investigate whether sentinel node biopsy (SLNB) could offer a solution. Methods and Study Design From November 1997 to June 2001 143 female patients who were eligible for breast cancer surgery were included in the study. All patients had T1 breast cancer and clinically negative axillae. Patients were submitted to preoperative lymphoscintigraphy with subsequent SLNB. We used a 99m-technetium nanocolloid tracer (Nanocoll®) that was injected peritumorally so as to have about 10 MBq of radioactivity at the time of surgery. Scintigraphy was performed about 17 hours after tracer administration. During surgery, lymphoscintigraphic imaging and a gamma ray detection probe were used to locate the sentinel node. Histological examination after embedding in paraffin was usually requested and multilevel sectioning of the sentinel node (SLN) was performed, with hematoxylin and eosin staining and immunohistochemistry. Results Preoperative lymphoscintigraphy localized SLNs in the IMC basin in 27 of 143 patients (18.9%). Harvesting of IMC-SLNs based on lymphoscintigraphy results was successful in 20 of 27 patients (74.1 %). Histological examination revealed micrometastases in four of the 20 harvested nodes. One of these patients showed no axillary drainage and no axillary lymph node dissection was therefore performed. In the remaining three patients also axillary SLNs were harvested, which turned out be free from metastatic involvement. Conclusions In our experience lymphoscintigraphy with SLNB was an accurate method to detect IMC metastases in patients with breast cancer. We recommend peritumoral tracer injection and a reasonable interval between injection and scintigraphy. IMC-SLN biopsy did not result in any serious additional complications or morbidity. In our study this approach led to improved cancer staging: four of 20 harvested IMC-SLNs proved to be micrometastatic. None of these four patients had metastatic axillary SLNs. Exclusive drainage to the IMC is present in only a small number of breast cancer patients, and our results suggest that it is possible to avoid unnecessary axillary node dissection in such cases.

Prognostic and therapeutic impact of sentinel node micrometastasis in patients with invasive breast cancer.

Aims and Background Locoregional lymph node status is one of the most important prognostic factors determining the need for adjuvant chemotherapy in patients with breast cancer. Many authors have reported that micrometastases were not detected by routine sectioning of lymph nodes but were identified by multiple sectioning and additional staining. Among lymph node-negative patients 15-20% had an unfavorable outcome at five years from primary surgery. Sentinel lymph node (SLN) biopsy is an accurate technique for identifying axillary metastases because the pathologist utilizes hematoxylin-eosin (H-E) staining together with immunohistochemistry (IH) to examine all lymph node sections. Sentinel node micrometastasis has therefore become an important tumor-related prognostic factor. Methods and Study Design From November 1997 to October 2001 we examined in 210 patients the pathological features of primary breast lesions and SLN metastases and we correlated these with the tumor status of non-SLNs in the same axillary basin. We applied IH examination to both SLNs and non-SLNs of patients who were negative for metastasis by standard H-E examination. Results In this study lymph node staging was based on SLN findings, primary tumor size, and the presence of peritumoral lymphovascular invasion (LVI). We found 18 SLN micrometastases (9%) in 210 patients and one of these (5.5% of patients with SLN micrometastasis) also had one non-SLN metastasis: this patient had LVI and a larger primary tumor than patients with SLN micrometastasis without non-SLN metastasis. We also found 24 SLN macrometastases (11.5%) in 210 patients and 13 of these (54.2% of patients with SLN macrometastases) had one or more non-SLN metastases. Conclusions According to the results reported in the literature, tumor cells are unlikely to be found in non-SLNs when the primary lesion is small and SLN involvement micrometastatic (5.5% in our experience, 7% in Giulianos). Our findings suggest that axillary lymph node dissection may not be necessary in patients with SLN micrometastasis from T1 lesions.

Reliability and accuracy of sentinel node biopsy in cutaneous malignant melanoma.

Aims and Background The aims of this study were 1) to investigate whether sentinel lymph node (SLN) biopsy could become the method of choice for the early detection of metastatic disease in patients with malignant melanoma and 2) to identify those patients with lymph node metastases who could benefit from regional lymphadenectomy. Methods and Study Design Our study started in March 1998 and involved 110 patients with primary cutaneous malignant melanoma stage I or II (AJCC) in whom the primary lesion had been surgically removed no more than 90 days previously. On the day of lymph node dissection patients were given an intradermal injection of colloid particles of human serum albumin labeled with technetium-99m and an injection of isosulfan blue. The surgical procedure was usually performed with local anesthesia but in some cases locoregional or general anesthesia was preferred. Contralateral and ipsilateral lymphatic areas were scanned with a hand-held gamma camera (Scintiprobe MR 100) to measure the background and identify the hot point indicating the location of the sentinel node to direct the incision. Results The combined use of lymphoscintigraphy, isosulfan blue and gamma probe allowed us to identify sentinel nodes in 108 of 110 patients (98.18%) while the SLN was blue in only 90 cases (81.81%). The SLN was positive for metastases in 13 of the 108 patients (12.03%) and regional and distal lymphadenectomy was performed in all of them. The distribution of positive SLNs by primary lesion thickness was as follows: 0.76-1.5 mm: one positive SLN/44 patients (2.27%); 1.51-4 mm: six positive SLNs/51 patients (11.7%); >4 mm: six positive SLNs/15 patients (40%). Only four of 12 patients with ulcerated cutaneous melanoma had positive SLNs. The patients in our study underwent follow-up visits every four months. The median follow-up was 481 days (range, 97-1271 days). Conclusions In patients with primary cutaneous melanoma the histological status of the SLN accurately reflects the presence or absence of metastatic disease in the relevant regional lymph node basin. Complete lymph node dissection should only be performed in patients with positive SLNs. Patients with lesions >4 mm are likely to develop recurrences and to die of systemic disease, so in these patients the usefulness of SLN biopsy is questionable. In conclusion, sentinel node mapping is a rational approach for the selection of patients who might benefit from early lymph node dissection of the affected basin.

Primary rectal lymphoma as a cause of bowel obstruction. Report of a case.

Background Malignant lymphoma involving the rectum either as a localized process or as a manifestation of disseminated disease is rare. Several treatments have been proposed and reported, including surgical resection alone or associated with adjuvant chemoradiation, chemotherapy alone, and radiotherapy alone. Methods A case of bowel obstruction caused by a primary rectal MALT lymphoma is reported. Following emergency loop sigmoid colostomy the patient was started on multiple specific cycles of chemotherapy according to the MACOP-B protocol. Results At the end of chemotherapy a remarkable reduction in the size of the tumor was noted. Subsequently the patient underwent an ultralow anterior resection followed by a straight coloanal anastomosis. At 36 months of follow-up the patient is alive with no tumor recurrence. Conclusions The present report describes the unique case of a patient with primary obstructing rectal lymphoma treated with neoadjuvant chemotherapy and sphincter-saving curative surgery.

Preliminary Results of External Sapheno–Femoral Valvuloplasty: A Trial by the Italian Society of Phlebolymphology

A multicentric trial was conducted to compare the various methods, materials and results employed in external valvuloplasty of the sapheno-femoral junction. Dacron, PTFE and absorbable prostheses have been used and have lead to the following conclusions: careful diagnosis and selection of patients is necessary; dilatation of both terminal and sub-terminal saphenous valves should be treated; at present, PTFE seems the best material to use (follow-up for the absorbable material is too short); the operation is effective and can be recommended in selected cases.

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.