Ferdinando Lecce

Clinical and instrumental evaluation of pelvic floor disorders before and after bariatric surgery in obese women.

BACKGROUND Obesity, well known as a risk factor for several diseases, can also lead to pelvic floor dysfunction (PFD). However, scant data are available regarding PFD in obese individuals. Our study was designed to assess the prevalence, severity, and the quality of life (QOL) effect of PFD in obese women before and after bariatric surgery at a university hospital in Italy. METHODS A total of 100 obese (body mass index [BMI] ≥30 kg/m(2)) women completed 6 validated specific and QOL questionnaires about PFD. The patients were evaluated by physical examination, endoanal ultrasonography, rectal balloon distension test, and dynamic magnetic resonance imaging. Of the 100 patients, 87 were reassessed 12 months after bariatric surgery. RESULTS The prevalence of PFD was 81%, and 49% of patients reported that their symptoms adversely affected their QOL. Urinary incontinence (UI) was the most common disorder (61%) and was associated with the BMI (P = .04). Fecal incontinence and pelvic organ prolapse symptoms were reported by 24 and 56 patients, respectively. Urogenital prolapse and rectocele was documented in 15% and 74% of patients, respectively. After a mean BMI reduction of 10 kg/m(2), the prevalence of PFD decreased to 48% (P = .02), with a significant improvement in QOL. The prevalence of UI decreased to 9.2% (P = .0001) and was associated with the decrease in postoperative BMI (P = .04). The rate of resolution of the symptoms was 84%, 85%, and 74% for UI, fecal incontinence, and pelvic organ prolapse, respectively. CONCLUSION In the present sample of obese women, PFD was common and adversely affected their QOL. A clear association was found between the BMI and UI. Weight loss resulted in improved UI, fecal incontinence, and symptoms of pelvic organ prolapse.

Mortality and Morbidity

Historically, morbidity and mortality rates related to surgery for locally recurrent rectal cancer (LRRC) have been >70% and 30%, respectively [1, 2, 3]. Because of the excessive operative risks, the benefit of such resections has been questioned and — although radical operation for LRRC was conceptualized and reported more than 60 years ago — for years it has not been accepted as being standard procedure. More appropriate selection of candidates for resection due to advances in imaging modalities, improvement in surgical techniques, establishment of specialized multidisciplinary surgical teams, and improvement in quality of perioperative management have resulted in better outcomes in recent years. Currently, mortality rates vary between 0–5% at 1 month and 8% at 3 months [4]. The causes of death are mainly disseminated coagulopathies related to prolonged sepsis and blood loss, multiorgan failure, cardiac events, and pulmonary embolism [5, 6]. Morbidity remains significant, ranging from 15 to 68%, and increases with the complexity of resection [7, 8, 9, 10]. Bleeding is the main and most severe intraoperative complication, and occurs in 0.2–9% of cases, and related mortality is high (4%) [11, 12, 13, 14]. The principal postoperative complications include pelvic abscess (7–50%), intestinal obstruction (5–10%), enterocutaneous or enteroperineal fistulas (1.2%), perineal wound dehiscence (4–24%), and cardiovascular, renal, and pulmonary complications (1–20%) [5, 7, 8].

Treatment Strategy for Rectal Cancer with Synchronous Metastasis: 65 Consecutive Italian Cases from the Bologna Multidisciplinary Rectal Cancer Group

Background: Twenty percent of rectal cancer patients have synchronous distant metastasis at diagnosis. At present, the treatment strategy in this patient setting is not well defined. This study in one institution evaluates the treatment strategy of three different patient groups. Patients and Methods: Between January 2000 and July 2011, 65 patients with M1 rectal cancer were evaluated. Three different groups were defined: rectal cancer with resectable metastatic disease (group A); rectal cancer with potentially resectable metastatic disease (group B), and rectal cancer with unresectable metastatic disease (group C). Results: Group A included 11 patients (16.9%), group B 28 patients (43.1%) and group C 26 patients (40%). Forty-three (66.2%) patients underwent surgery for primary rectal cancer, and 30 (46.2%) patients for metastasis resection (23 liver, 4 lung and 3 ovary). Median overall survival (OS) by group was: 51 (5-86; group A), 32 (24-40; group B) and 16 (7-26; group C) months. Patients undergoing metastasis resection have higher median OS than unresected patients (44 vs. 15 months; p < 0.001). Conclusions: The treatment strategy in synchronous metastatic rectal cancer must consider the possibility of distant metastasis resection. Long-term survival can be achieved using an integrated approach.

Simultaneous curative resection of double colorectal carcinoma with synchronous bilobar liver metastases

Synchronous colorectal carcinoma (SCRC) indicates more than one primary colorectal carcinoma (CRC) discovered at the time of initial presentation, accounts for 3.1%-3.9% of CRC, and may occur either in the same or in different colorectal segments. The accurate preoperative diagnosis of SCRC is difficult and diagnostic failures may lead to inappropriate treatment and poorer prognosis. SCRC requires colorectal resections tailored to individual patients, based on the number, location, and stage of the tumours, from conventional or extended hemicolectomies to total colectomy or proctocolectomy, when established predisposing conditions exist. The overall perioperative risks of surgery for SCRC seem to be higher than for solitary CRC. Simultaneous colorectal and liver resection represents an appealing surgical strategy in selected patients with CRC and synchronous liver metastases (CRLM), even though the cumulative risks of the two procedures need to be adequately evaluated. Simultaneous resections have the noticeable advantage of avoiding a second laparotomy, give the opportunity of an earlier initiation of adjuvant therapy, and may significantly reduce the hospital costs. Because an increasing number of recent studies have shown good results, with morbidity, perioperative hospitalization, and mortality rates comparable to staged resections, simultaneous procedures can be selectively proposed even in case of complex colorectal resections, including those for SCRC and rectal cancer. However, in patients with multiple bilobar CRLM, major hepatectomies performed simultaneously with colorectal resection have been associated with significant perioperative risks. Conservative or parenchymal-sparing hepatectomies reduce the extent of hepatectomy while preserving oncological radicality, and may represent the best option for selected patients with multiple CRLM involving both liver lobes. Parenchymal-sparing liver resection, instead of major or two-stage hepatectomy for bilobar disease, seemingly reduces the overall operative risk of candidates to simultaneous colorectal and liver resection, and may represent the most appropriate surgical strategy whenever possible, also for patients with advanced SCRC and multiple bilobar liver metastases.

Evolving role of FDG-PET/CT in prognostic evaluation of resectable gastric cancer

Gastric cancer (GC) remains a leading cause of cancer death worldwide. Radical gastrectomy is the only potentially curative treatment, and perioperative adjuvant therapies may improve the prognosis after curative resection. Prognosis largely depends on the tumour stage and histology, but the host systemic inflammatory response (SIR) to GC may contribute as well, as has been determined for other malignancies. In GC patients, the potential utility of positron emission tomography/computed tomography (PET/CT) with the imaging radiopharmaceutical 18F-fluorodeoxyglucose (FDG) is still debated, due to its lower sensitivity in diagnosing and staging GC compared to other imaging modalities. There is, however, growing evidence that FDG uptake in the primary tumour and regional lymph nodes may be efficient for predicting prognosis of resected patients and for monitoring tumour response to perioperative treatments, having prognostic value in that it can change therapeutic strategies. Moreover, FDG uptake in bone marrow seems to be significantly associated with SIR to GC and to represent an efficient prognostic factor after curative surgery. In conclusion, PET/CT technology is efficient in GC patients, since it is useful to integrate other imaging modalities in staging tumours and may have prognostic value that can change therapeutic strategies. With ongoing improvements, PET/CT imaging may gain further importance in the management of GC patients.

Analysis of predictive and prognostic value of clinical and pathological factors in locally advanced rectal cancer (LARC) treated with neoadjuvant chemoradiotherapy (CRT): Bologna multidisciplinary rectal cancer group study (BMRG-B01-Study).

421 Background: Preoperative fluoropyrimidine based CRT is standard treatment in LARC patients. The aim of this study was to evaluate prognostic and predictive role of clinical and pathological factors in this setting Methods: Between December 2001 and January 2012 we evaluated 149 pts with cT3-T4 N-/+ rectal adenocarcinoma located ≤12 cm from the anal margin. Preoperative CRT consisted of radiotherapy 50.4 Gy in 28 daily fractions + 5-fluorouracil or capecitabine +/- oxaliplatin. Rectal surgery with total mesorectal excision was performed 6-8 weeks after the end of neoadjuvant treatment. Pathological examination of surgical specimens included TRG according to the Dworak criteria. TS, EGFR, Ki-67, p53, Bcl-2, MLH1 and MSH2 were immunohistochemically determined in pre-treatment biopsies and surgical specimens. For immunohistochemistry evaluation serial sections of formalin-fixed, paraffin-embedded tissues were stained with specific antibodies using a biotin-free ready-to-use amplification system Results: A...

Metastatic 5-mm rectal neuroendocrine carcinoma

Many small rectal neuroendocrine tumours (NET) are excised t endoscopy without prior knowledge of their metastatic potenial. Although main risk factors for lymph node metastases are umour size, invasion of the muscularis propria and lymphovascuar infiltration, lesions smaller than 10 mm can also metastasize. A 3-year-old woman was referred to our hospital reporting evacation difficulties. Colonoscopy revealed a submucosal nodule maller than 1 cm at the lower rectum. The histological diagnois of the biopsy specimen was NET G1 (WHO 2010). Endorectal ltrasonography demonstrated a 7-mm hypoechoic lesion on the ubmucosal layer (Fig. 1, arrow) with one swollen lymph node lose to the lesion (Fig. 1, arrowhead). Thoracic and abdominal