G. Vuolo

A novel biweekly multidrug regimen of gemcitabine, oxaliplatin, 5-fluorouracil (5-FU), and folinic acid (FA) in pretreated patients with advanced colorectal carcinoma.

Previous results suggest that GEM affects 5-fluorouracil (5-FU) metabolism and pharmacokinetics in cancer patients, while combined with oxaliplatin, levo-folinic acid, and 5-FU (GOLF regimen), at doses achievable in cancer patients, determines high cytotoxic and proapoptotic antitumour activity in colon cancer cells in vitro. On these bases we designed a phase I–II clinical trial testing the GOLF regimen in patients with metastatic colorectal carcinoma, who had received at least a prior line of chemotherapy. In total, 29 patients (20 males and nine females) enrolled in the study received every 2 weeks, gemcitabine (patients #1–3 received 600 mg m−2; patients # 4–6 received 850 mg m−2; while patients # 7–29 received 1000 mg m−2) on the day 1, levo-folinic acid (100 mg m−2) on the days 1 and 2; 5-fluorouracil (400 mg m−2) in bolus injection, followed by a 22-h continuous infusion (800 mg m−2) on the days 1 and 2, and oxaliplatin (85 mg m−2), 6 h after the 5-FU bolus on day 2. The most frequent side effect was grade I–II haematological toxicity. In total, 28 patients were evaluable for response: three achieved a complete response, nine a partial response, 10 had a stable disease, and six progressed. The average time to progression and overall survival of the patients was, respectively, 7.26 and 22 months. Our GOLF combination is well tolerated and seems promising for the treatment of advanced colorectal cancer.

Duodenal obstruction from isolated breast cancer metastasis: a case report.

Metastatic involvement of the upper gastrointestinal tract from breast cancer has been reported in autopsy series as occurring in more than 15% of patients, usually associated with extensive systemic spread; clinical manifestations from such metastases have been described in less than 1% of cases. Lobular infiltrating carcinoma seems to have a different metastatic pattern than the ductal type, with an apparent predilection for the gastrointestinal tract. Metastatic presentation as an isolated intestinal obstruction without other signs of metastatic spread is extremely rare. We present a case of isolated duodenal metastasis from breast cancer, associated with intestinal obstruction, as the first sign of metastatic spread.

Bariatric Surgery: Early Results with a Multidisciplinary Team

Background: Bariatric surgery depends on complete preoperative study of morbid obesity, in order to obtain the treatment of choice. A multidisciplinary group was founded in 1998 at the University of Siena. Methods: During 1998, 16 patients, with median weight 121.8 ± 31 kg and median body mass index (BMI) 43 ± 6, underwent bariatric surgery. A multidisciplinary assessment was used in order to evaluate psychological status, food intake problems and patient compliance, and hemodynamic, respiratory, metabolic and arthritic functions. 13 patients were submitted to laparoscopic surgery: in 11 adjustable gastric banding was performed and 2 were submitted to a vertical gastroplasty plus adjustable gastric banding.Three patients were operated via traditional laparotomy, due to previous abdominal surgery in 2 cases (submitted to an adjustable gastric banding) and one woman was submitted to a bilio-intestinal bypass according to the Hallberg technique, for her psychiatric troubles and coexisting systolic hypertension and uncontrolled diabetes. Monthly follow-up for each patient continues after 6 months. Results: No morbidity or mortality has occurred. The median weight loss at three months, was 19.5 kg. Two cases required injection of 1 ml more of fluid into the port, respectively at 4 and 9 months. Fifteen days after surgery, seven patients (46%) had vomiting episodes, due to rapid food intake. All patients have shown an improvement of their comorbidities after surgery. Conclusion: Early results via the multidisciplinary team and laparoscopic banding have been satisfactory thus far.

Giant Sigmoid Diverticulum: A Rare Presentation of a Common Pathology

Although colonic diverticulum is a common disease, affecting about 35% of patients above the age of 60, giant sigmoid diverticulum is an uncommon variant of which only relatively few cases have been described in the literature. We report on our experience with a patient affected by giant sigmoid diverticulum who was treated with diverticulectomy. Resection of the diverticulum is a safe surgical procedure, provided that the colon section close to the lesion presents no sign of flogosis or diverticula; in addition, recurrences are not reported after 6-year follow-up.

A clinically silent, but severe, duodenal complication of duodopa infusion.

Duodenal levodopa/carbidopa gel infusion (Duodopa) is an efficacious therapeutic strategy for motor and non-motor symptoms in advanced Parkinsons disease (PD).1–3 Technical issues like kinking, knotting or obstruction of the tube are frequent, as well as complications due to the procedure, such as buried bumper syndrome, local infection and dislocation of the tube in the stomach (57%–69% of the patients), but they are seldom associated with severe adverse effects.1 3 4 In most cases, they are generally easy to suspect due to the immediate lack of therapeutic efficacy or malfunction of the infusion pump. We describe a rare and very serious gut complication associated with the device, which is difficult to recognise because of the persistence of clinical benefit on motor signs. A 72-year-old man with a medical history of hypertension and chronic obstructive pulmonary disease, and with a …

Initial Experience with Laparoscopic Adjustable Gastric Banding and Pouch Dilatation: Two Cases

Background: Late proximal pouch dilatation (LPPD) has occurred occasionally following gastric banding for morbid obesity. At present, laparoscopic conservative resetting and oversuturing of the band is considered the standard procedure for pouch dilatation without any important posterior component. Methods: Two cases of LPPD are presented, which occurred in our initial experience with the LapBand®, corrected via a laparoscopic approach. Results: The reintervention was necessary in both patients, with conservative laparoscopic repositioning and oversuturing of the band in the first case and laparoscopic substitution of the gastric band in the second. We have not observed further complications, and weight loss has been maintained in a midterm outcome in both cases (30 and 18 months follow-up). Conclusions: LPPD can be corrected with a conservative laparoscopic surgical approach, without complications and negative functional effects on mid-term outcome.

Evaluation of Motility Changes after Laparoscopic Sleeve Gastrectomy Using Magnetic Resonance Imaging

We have read with interest the recent work on gastric motility evaluation in laparoscopic sleeve gastrectomy (LSG) by using magnetic resonance imaging (MRI) [1]. The authors performed MR examination in five female patients before and after LSG, using a wide-bore MR scanner (70 cm), and, after, drinking 500 ml of tiepid water. Two fast sequences were used to evaluate gastric volume and morphometry and speed of the antral folds. They found an acceleration of the gastric emptying after surgery, explaining that on the basis of both gastric pacemaker removal and interstitial cells of Cajal network that allow the persistence of antrum motility compared to immobile “sleeve compartment”. We agree with the authors about the increasing of antral peristaltic velocity in these patients with significant reduction of gastric emptying T1/2. We have evaluated nine patients using a MR technique previously described [2], with time delay from surgery of 4–10 months, using 120 ml of vanilla pudding as gastric load (not published data), with quantitative data obtained in consensus by two observers. We have found a gastric emptying half-time of 24.02±8.16 min with a speed of antral peristalsis of 1.72±0.38 s; while in a control group of 11 subjects (population characteristics in [2]), these parameters were respectively of 101.78±41.69 min and 1.37 ±0.25 s (p=0.0004 and p=0.0042, respectively). We add that in our experience, we evaluated the gastric motility for 30 min, observing a physiological increase of antral motility in control group, as previously referred, while this change is not present in LSG patients (p=0.372, Fig. 1). So, we would like to emphasize the neurohumoral mechanisms that could affect this modifications in LSG, as correctly suggested by the authors, but also the kind and the amount of gastric load could have some influences on quantitative data sampling. This can explain the lower antral speed detected in our controls compared to that referred by the authors in the presurgical assessment [1, 2]. In this regard, we would like to warn the authors about the use of water that could produce a drawback in quantitative assessment due to influence of posture and gravity for liquids in gastric emptying [3, 4]; furthermore, steady-state imaging with a semisolid homogeneous food (like pudding) could be more achievable for gastric function evaluation, because of the marked contrast between stomach and neighboring structures produced by this kind of food [5]. Another limitation, in our opinion, concerns the need to evaluate the reproducibility of data extrapolation from imaging over all for antral speed assessment. In fact, the measurement of peristaltic wave speed is feasible with a good confidence in unresected stomach, as we assessed previously [2], but it could be difficult when gastric anatomy is modified by surgery. We found a not significant interobserver agreement for our data (k=0.042) about antral speed parameter, while the agreement was significant for gastric emptying evaluation (k>0.75). Finally, it is very important to emphasize the use in this study of a wide-bore MR scanner. This system was useful to the authors for the examination of patient with BMI>40 before surgery that is unfeasible with a regular bore scanner, as we experienced in our clinical practice. Obviously, the cost of this technique at present makes it S. F. Carbone (*) :A. Bancheri : L. Volterrani Department of Radiology, University Hospital of Siena, Viale Bracci, 53100 Siena, Italy e-mail: fracarb@gmail.com