Francesca Mandolfino

APPENDECTOMY OR RIGHT HEMICOLECTOMY IN THE TREATMENT OF APPENDICEAL CARCINOID TUMORS

Aims and background Carcinoids of the appendix continue to be of interest, despite their low incidence. There is still considerable controversy surrounding these tumors, especially with regard to the role of right hemicolectomy in the surgical management. The aim of this work was to explicate the current therapeutic knowledge and to review the criteria for the indications of appendectomy or hemicolectomy. Methods The records of patients who underwent appendectomies from 1990 to 2000 were analyzed. Seven patients were included in the study. The clinical data were reviewed for demographic details, tumor size, localization in the appendix, histological patterns and surgical procedures. All patients underwent appendectomy including removal of the mesenteriolum, and in one of them a right hemicolectomy was performed 3 weeks later. The mean follow-up was 7 years (range, 4–14). Follow-up data included symptoms, urinary 5-hydroxyin-doleacetic acid, ultrasound examination, computerized tomography, and octreotide scanning. Results Seven patients (0.9% of all appendectomies) were reported to have carcinoid tumors of the appendix. They were 3 men and 4 women with a mean age of 29 years. All patients were admitted for appendicitis. None suffered from the carcinoid syndrome. The site of the tumor was the apex of the appendix in 4 cases, the body in 2 cases and the base in 1 case. Mean tumor diameter was 8 mm (range, 5–29 mm); in 6 patients it was <2 cm. Treatment was appendectomy in all cases; additional right hemicolectomy was necessary in one case because of a tumor of more than 2 cm with invasion of the mesoappendix and lymph nodes. The 7-year survival rate is 100%. Six patients are without disease, while 1 patient (the one who underwent a right hemicolectomy) developed metastases in the liver 6 years after the operation. This patient, who was treated with a liver resection, is still alive. Conclusions According to current guidelines, an appendectomy may be performed for small carcinoid tumors (<1 cm). Reasons for more extensive surgery than appendectomy are tumor size >2 cm, lymphatic invasion, lymph node involvement, spread to the mesoappendix, tumor-positive resection margins, and cellular pleomorphism with a high mitotic index. The criteria that direct us towards major (hemicolectomy) or minor surgery (appendectomy) are controversial. Tumor size is still considered the most important prognostic factor, with a presumed increase in the risk of metastasis for tumors greater than 2.0 cm. The accepted treatment of such tumors is a right hemicolectomy. However, there is no evidence demonstrating a survival benefit for right hemicolectomy over simple appendectomy in patients with carcinoids greater than 2.0 cm in diameter.

Pseudodiverticular defecographic image after STARR procedure for outlet obstruction syndrome

Dear Editor: Outlet obstruction syndrome (OOS) is a defecation disorder more common in women. Patients refer to coloproctologists complaining of constipation and other typical symptoms ranging from incomplete and fragmentized evacuation to rectal bleeding. This syndrome may be caused by functional and/or anatomical alterations. A correct etiological classification can help the clinician to predict the best treatment strategy. Non-operative treatment, mainly based on dietary changes and biofeedback, is usually suggested as the first or unique treatment option when symptoms are caused by an uncoordinated inhibitory muscular pattern. Conversely, patients not responsive to conservative treatment most likely can benefit from surgery. Nevertheless, traditional techniques, aimed at restoring normal anatomy, are often time-consuming, technically demanding, burdened by serious complications, and, sometimes, under particular circumstances, can be ineffective or can even worsen symptoms. In 2003 Stapled Transanal Rectal Resection (STARR) was described by Longo as an effective new option for the cure of OOS. Since its introduction, STARR has become an accepted surgical procedure even if some criticisms have been raised due to possible serious complications. Recently, a case of rectal diverticulum after STARR procedure has been reported. Here, we describe a similar case, its related diagnostic and treatment modalities. A 60-year-old woman, who had previously undergone unsuccessful medical treatment, was submitted to STARR in our service for obstructed defecation syndrome caused by an anterior and posterior rectocele associated with a posterior rectal wall prolapse. The technique, described elsewhere, follows the same steps as standardized by Longo. In the present case, at the end of the procedure, the stapled line was carefully inspected. As routinely performed, the mucosal band connecting the two edges of the anastomosis was cut both anteriorly and posteriorly. Stitches were then applied at the anastomotic level in order to avoid the risk of postoperative bleeding. The postoperative course was uneventful, and patient discharged on the third postoperative day. One month later, the patient presented at our outpatient visit complaining of recurrence of symptoms with tenesmus, constipation, a sensation of incomplete evacuation, painful and unsuccessful efforts, urge to defecate, anal incontinence, with need of digital assistance. Defecography showed a diverticular cavity on the right rectal wall (60 mm diameter) and an incomplete evacuation of barium. This lateral diverticulum, filled up by impacted stools, shrank the rectal pouch lumen during straining and defecation. The patient refused clinical examination and endoscopy because of intense pain and an examination under spinal anesthesia was then planned. The exam revealed the presence of a bridge of rectal mucosa, 2 cm wide, on the posterior wall. This bridge caused deformation of the rectal profile creating a diverticular cavity full of impacted stools. After mechanical emptying of the diverticulum the mucosal bend was cut with restoration of normal anatomy. Two months after this procedure, the patient had significantly improved defecation with complete resolution of symptoms. Defecography, performed 3 months postopInt J Colorectal Dis (2009) 24:1115–1116 DOI 10.1007/s00384-009-0666-6

Validation of a Simulator Set Up Entirely in anAcademic Setting: Low-Cost Surgical Trainer Ratherthan High-Cost Videogame

Laparoscopic surgery is the standard approach for most surgical operations because of its benefits for the patients, although it requires a significant learning curve. For this reason, the FDA established the need for certified laparoscopic training programs, supported by validated surgical simulators. Our multidisciplinary team developed a virtual surgical simulator (eLap4D) based on: a low-cost and a realistic haptic feedback. This study presents the validation process of the eLap4D, performed through the construct and face validities. The authors preliminarily analyzed and excluded the possible impact of videogame experience on eLap4D users. The construct validity was used to objectively assess the surgical value of five basic skills by comparing the performances between two groups with different levels of laparoscopy experience. The presence of a learning curve was also evaluated by comparing the results of the first and second attempts. The difference among exercises was investigated in terms of the difficulty and kind of basic gestures, comparing the completion rates of every task in the three difficulty levels each. Face validation was performed using a specific questionnaire investigating the realism and accuracy of the simulator. This last survey was administered only to experienced surgeons. The validation process indicated that eLap4D can measure surgical ability and not just videogame experience. It also positively affects the learning curve and reproduces different basic gestures and levels of difficulty. Face validity confirmed that its structural features and ergonomics are satisfactory. In conclusion, eLap4D seems suitable and useful for learning basic laparoscopy skills.

Radiofrequency (SECCA® Procedure)

Fecal incontinence can seriously affect quality of life. The treatment of fecal incontinence starts conservatively, but, in case of failure, different surgical approaches may be proposed to the patient. Recently several noninvasive approaches have been developed: one of these is the radiofrequency energy application to the internal anal sphincter.

New teaching models for the medical school of medicine: comparison between oral an online classes. The experience of the Genoa school of medicine

The authors have created and tested a tool for performing online classes (AulaWeb, online e-learning of the Genoa school of Medicine). Described here are the results obtained from the pilot project that was performed. Two groups of 50 students each were created among the students who voluntarily signed up for the ADE on the theme of laparoscopic surgery. Each group was further divided into 2 smaller groups of 25 students, which followed respectively classic oral classes or on line classes. The experiment was divided into 2 parts. While the oral classes were the same for the 2 parts of the experiment, the online classes were characterized by the delivering of videos in the 1st part and videos and interactive web teaching in the 2nd part. Standardized questionnaires were distributed to the students, at the beginning and at the end to evaluate the effcacy of the system used to deliver the information. Both groups of students greatly improved their scores answering the questionnaires, but the on line groups expressed greater satisfaction in particular because of the fruition of free didactic contents. In conclusion we can confrm that, when used properly, the web is a fantastic learning tool for students because, not only it delivers information in a stronger way, but it also provides a faster and more enthusiastic way of learning.