Eugenio Santoro

Laparoscopic surgery for gastric cancer: preliminary experience

BackgroundLaparoscopic surgery for gastric cancer (GC) was introduced in the past decade because it was considered less invasive than open surgery, resulting in less postoperative pain, faster recovery, and improved quality of life. Several studies have demonstrated the safety and feasibility of this procedure. We analyzed our preliminary experience with this procedure.MethodsFrom November 2003 to December 2004, 20 patients affected by gastric adenocarcinoma were operated on with a totally laparoscopic or laparoscopic-assisted approach. This series included 10 women and 10 men, aged from 34 to 75 years. Procedures consisted of eight total gastrectomies, three subtotal Billroth I and seven Billroth II gastrectomies, one proximal gastrectomy, and one wedge resection. According to the TNM classification, we observed five patients at stage Ia, four at stage Ib, three at stage II, one at stage IIIa, two at stage IIIb, and five at stage IV.ResultsIn all patients the procedures were completed without any conversion. Operative time ranged from 150 to 300 min. The number of dissected lymph nodes ranged from 23 to 47. No mortality was observed. Overall morbidity rate was 10% (two cases), with one enteric fistula and one esophagojejunal anastomotic leakage associated with pancreatitis. Excluding these two patients, postoperative stay was between 12 and 20 days.ConclusionsEven though accompanied by a difficult learning curve, safety and feasibility are widely demonstrated, but a skilled and experienced surgeon is required. Accurate selection of patients is mandatory and curative resection is achievable in cases where GC is not advanced.

Results of a pancreatectomy with a limited venous resection for pancreatic cancer

PurposeThe indications for a pancreatectomy with a partial resection of the portal or superior mesenteric vein for pancreatic cancer, when the vein is involved by the tumor, remain controversial. It can be assumed that when such involvement is not extensive, resection of the tumor and the involved venous segment, followed by venous reconstruction will extend the potential benefits of this resection to a larger number of patients. The further hypothesis of this study is that whenever involvement of the vein by the tumor does not exceed 2 cm in length, this involvement is more likely due to the location of the tumor being close to the vein rather than because of its aggressive biological behavior. Consequently, in these instances a pancreatectomy with a resection of the involved segment of portal or superior mesenteric vein for pancreatic cancer is indicated, as it will yield results that are superposable to those of a pancreatectomy for cancer without vascular involvement.MethodsTwenty-nine patients with carcinoma of the pancreas involving the portal or superior mesenteric vein over a length of 2 cm or less underwent a macroscopically curative resection of the pancreas en bloc with the involved segment of the vein. The venous reconstruction procedures included a tangential resection/lateral suture in 15 cases, a resection/end-to-end anastomosis in 11, and a resection/patch closure in 3.ResultsPostoperative mortality was 3.4%; morbidity was 21%. Local recurrence was 14%. Cumulative (standard error) survival rate was 17% (9%) at 3 years.ConclusionA pancreatectomy combined with a resection of the portal or superior mesenteric vein for cancer with venous involvement not exceeding 2 cm is indicated in order to extend the potential benefits of a curative resection.

Clinical-judicial syndrome: how a doctor becomes a patient through general indifference.

In recent years, disputes in the eternal and historical dialectic between doctors and patients, and between medicine and society, have increased. There has been a shift in our individual and social expectations from requesting treatment to demanding recovery, and searching for whoever is to blame if we do not obtain it. With the legitimate demise of charismatic medicine and the growth of technological and participatory medicine, doctors are losing their central position in the healthcare process to protocols, the Internet and the mass media. There is, in short, an improvised and chaotic culture, often propagated by unqualified opinion-makers with little or no scientific background. This has led to some mistaken convictions. The first is that medicine is a science comparable to others, namely a mathematical and deductive process that can provide precise responses even to vague requests! however, even at the start of the twenty first century, medicine is still an exceedingly inductive and intuitive procedure that cannot easily be reduced to guidelines, no matter how broad. The second is that, in adverse events such as complications, limited recovery, sequelae, disabilities, chronicity and death, it is not the disease that determines the rules and runs the show, however tragic, but the negligent or incompetent doctor, who, as such, is responsible for misfortunes and is the adversary of the patient. This is the reason for the enormous increase in legal and judicial disputes and in civil and criminal actions against doctors, for which the responsibility is shared by the media, the judges and their technical advisers, and the legislators. These are united in their hunt for the plague spreader, but have failed to provide a better definition of professional negligence or to establish a proper framework for vexatious litigation and the civil responsibility of judges, not only in regard to the outcome of the trial, but also to the interminable length of the proceedings. Current opinion views medical negligence in relation to its insurance implications and to its social effects in terms of defensive medicine. No consideration, however, is given to the individual doctor facing charges and trial, to the man or woman, father or mother, worker, nurse, technician or health operative, in other words, to the human being. Yet they are seldom found guilty and almost always exonerated, after a procedure that is personally damaging, painful and costly, as well as a cause of emotional, personal and physical suffering to their families. Current publications and conferences calculate the costs to patients and society in terms of insurance premiums, reimbursements and defensive medicine, but ignore the cost borne by those who are accused, who also end up as patients, in need of care, medication, check ups and rest, with absences from work, poor performance, and reduced productivity and earnings. Thus, a psycho-physical clinical syndrome develops, which can become chronic, irreversible and difficult to treat. Even when acquitted in court, no account is taken of the moral, economic and psychophysical harm suffered by the accused and their families or of the subsequent damage to the healthcare institutions for which they work. Clinical-judicial syndrome was first described and defined in 1995 by Elias Hurtado-Hoyo and others, writing on behalf of the Argentine Medical Association. It is a series of symptoms that affect the health of an individual, in this case a doctor, subjected to legal proceedings, from E. Santoro (&) Superior National Health Council and San Camillo Forlanini Hospital Foundation, Rome, Italy e-mail: eugeniosantoro@tiscali.it

Hémorragie intra-tumorale massive responsable d’un syndrome cave: Une complication rare d’un carcinome hépato-cellulaire

Resume L’hemorragie intra-tumorale responsable d’un syndrome cave est une complication tres rare des carcinomes hepatocellulaires. Un homme âge de 36 ans, a ete admis en urgence pour des douleurs abdominales associees a des signes cliniques et biologiques d’hemorragie. Une tomodensitometrie abdominale revelait une volumineuse masse du foie droit aux contours reguliers et au contenu liquidien evoquant une hemorragie intra-tumorale sur un carcinome hepatocellulaire. La stabilite hemodynamique et le syndrome cave ont conduit a appliquer un traitement conservateur et a differer le traitement de la tumeur. Trois mois plus tard, la masse restait inchangee mais le syndrome cave avait diminue et l’etat general du malade s’etait ameliore. Apres evaluation de la fonction hepatique et de l’extension tumorale, l’operation a ete effectuee par une incision sous-costale associee a un refend median et a une sternotomie afin de controler la veine cave inferieure en intra-pericardique et de realiser un shunt veino-veineux comme lors d’une transplantation hepatique orthotopique. Une hepatectomie droite (segments V-VIII) a ete realisee par voie anterieure sans complication postoperatoire. Cette strategie en deux temps a permis de traiter cette rare complication d’un carcinome hepatocellulaire sur foie sain et pourrait etre plus generalement recommandee dans la prise en charge des hemorragies intra-tumorales non rompues.

Early results and complications of colorectal laparoscopic surgery and analysis of risk factors in 492 operated cases

This study aimed to evaluate the early results of colorectal laparoscopic surgery with special attention to surgical and medical complications. The risk factors of such surgery are also investigated on the basis of a large series of operated cases: the preoperative knowledge of such factors could guide the operative program and the postoperative treatment with reduction of complications and improvement of the outcome. Between 1998 and 2008, 492 patients had been submitted to colorectal laparoscopic surgery by the same team: 387 for cancer and 105 for benign disease. All colorectal surgical operations are included in the series. No selection of the patients was made: laparoscopy was performed in all cases accepting the procedure. Several risk factors have been analysed in cases of fistula (age, pathology sex, type of the operation, cancer stages, preoperative radiochemotherapy, stool diversion and team experience) and in cases of medical complications (age, pathology, cancer stages and type of operation). The overall results in this series of laparoscopic colorectal operated cases are similar to other results published at present by the main surgical Department all over the world; no mortality and low number of medical (2.4%) and surgical complications (9.3%), with no differences also with the best open surgery series. Complete or partial conversion to open surgery was required in few cases (1.2%) and same others (1.4%) were operated again for bleeding or sudden anastomotic leakage. Regarding the risk factors in such surgery, a good correlation has been discovered between anastomotic leakage and the team experience, the age over 70 of the patients, the rectal tumour site in man, the advanced tumour stages, the previous radiochemotherapy, while medical complications seem to depend on advanced patients age and advanced cancer stages. Laparoscopic colorectal surgery at present is going to be considered the gold standard in the large majority of colorectal diseases including all cancer stages in the preoperative balance and in the early postoperative follow-up a special attention is required to same risk factors like the advanced patients age, the extended cancers, the low positioned rectal tumours. Complications are more frequent at the beginning of the experience of the surgical team and if more than one risk factors coexist, but it do not represent contraindication to laparoscopic surgery.

Pancreatic remnant carcinoma after pancreaticoduodenectomy for bile duct cancer

independently and self-administer manual dilators to the ano-rectum to prevent stricture by a stomal wound nurse. Closure of her stoma occurred 7 months after her original presentation and healing of her perineum. She now has good continence and quality of life. The mainstay of burn wound management is early surgical debridement and skin grafting of the wound. The perineum, however, presents its own set of challenges. It is a difficult area to dress and also subject to constant faecal soiling, leading to poor healing and recurrent infection. Faecal diversion provides a means to avoid this added morbidity. A diverting loop ileostomy has a lower morbidity compared with colostomy for diversion of stool. Forming the stoma laparoscopically rather than open has a lower morbidity and reoperation rate. In our patient, formation and closure of the ileostomy was associated with minimal morbidity. The advantages of using the V-Y flap in the perineum are that it is rapid, relatively easy to perform and has an acceptable aesthetic result associated with a low morbidity. This problem of perineal burn injury provides a complex series of issues for the patient and treating team. Appropriate management requires a multidisciplinary approach for improved outcome.

Partition pré-cave au cours de l’hépatectomie foie en place : La manœuvre de Hanging : Une étude anatomique in vivo

Introduction la manœuvre de Hanging est utilisee pour la partition pre-cave au cours de l’hepatectomie foie en place. Cette etude avait pour but d’etudier la faisabilite, le taux de complications de cette manœuvre et de s’interesser a la distribution des veines hepatiques accessoires (VHA) au niveau de la portion retrohepatique de la veine cave inferieure (VCIRH). Materiel et methodes de janvier 2001 a decembre 2004, la manœuvre de Hanging a ete planifiee lors de 49 hepatectomies consecutives. La VCIRH a ete etudiee pendant la phase d’anhepatie au cours de 17 transplantations orthotopiques avec preservation de la VCIRH. Le diametre et la localisation des VHA ont ete collectes apres division de la partie anterieure de la VCIRH en 9 parties. Resultats la manœuvre de Hanging a ete accomplie chez 47/49 malades (96 %). Un saignement, survenu dans un cas (2 %), n’a pas necessite l’interruption de la manœuvre. L’etude anatomique a revele l’existence de 86 VHA dans 17 cas (5,18 ± 4 par malade) et classees selon leur diametre (≤ 3, > 3 to Conclusions la manœuvre de Hanging a une faisabilite elevee avec de faibles risques de saignements. L’etude anatomique in vivo demontre qu’une densite reduite de VHA est presente dans le passage suppose avasculaire. Lorsqu’elles sont presentes, ces veines ont un diametre insuffisant pour mettre en jeu la securite de la manœuvre.

LIVER TRANSPLANTATION IN HIV-HCV CO-INFECTED PATIENTS: SIX CASE REPORTS.

Life expectancy in HIV infected patients has dramatically increased due to the efficacy of highly active antiretroviral therapy (HAART). Liver disease progression to cirrhosis is much faster in HIV-HCV co-infected patients than in HCV mono-infected patients. End stage liver disease is an emerging problem that requires to asses the benefit risk ratio of liver transplantation (LT). We started a prospective appraisal of LT in HIV-HCV co-infected patients in December 1999. This study addresses morbidity, mortality, impact on the immune system, HIV replication, drug interactions, mitochondrial toxicity and incidence of HCV relapse. INTRODUCTION METHODOLOGY