Gabriele Galatà

Clusterin in stool: a new biomarker for colon cancer screening?

OBJECTIVES:The identification of useful markers for early diagnosis of human colon cancer is a major goal still in progress. Clusterin is a pleiotropic protein with a broad range of functions. It has recently drawn much attention because of its association with cancer promotion and metastasis. It is involved in prosurvival and apoptosis processes that are carried out by two different isoforms. Secreted clusterin isoform (sCLU) is cytoprotective and its prosurvival function is the basis of the current phase I/II clinical trials against prostate, lung, and breast cancers. We have already shown that in colorectal cancer (CRC) there is an increased expression of sCLU. In this report, we investigated whether sCLU is released in the blood and stool of colon cancer patients in order to study sCLU as a potential diagnostic molecular marker for colon cancer screening.METHODS:The quantitative expression of sCLU was determined by dot blot immunodosage in the serum and stool of CRC patients (n=63) and age-matched controls without clinical history of neoplasia, CRC, or systemic or bowel inflammatory disease (n=50). Unpaired t-tests and Mann–Whitney U-tests were used for continuous variables. The diagnostic performance of clusterin was appraised by means of receiver operating characteristic (ROC) curves.RESULTS:We found a significant increase of sCLU in the serum and stool of CRC patients (P=0.0002 and P<0.000, respectively) as compared with controls. ROC curves provided cutoff points showing a trade-off between sensitivity and specificity. With a cutoff point of 88.5 μg/ml, sCLU in blood showed a 55.6% sensitivity and 100% specificity, and with a cutoff point of 34.6 μg/g, the stool test reached 66.7% sensitivity and 84% specificity in discriminating between nonneoplastic and colorectal neoplastic lesions. Human cancer xenografts in nude mice indicated a positive correlation between increasing serum clusterin level and tumor size.CONCLUSIONS:This study highlights the potential of clusterin detection in stool to be a valuable tool to improve the effectiveness and efficiency of large-scale clinical cancer screening.

Diagnostic Lobectomy for Unilateral Follicular Nodules of the Thyroid Gland

We describe our technique of diagnostic lobectomy (DL) and the rationale it is based on. We define DL as a minimally invasive procedure consisting of total lobectomy and isthmusectomy, with preservation of the omolateral recurrent laryngeal nerve and parathyroid glands, but without digital exploration of the contralateral lobe. The fact that re-entry into the previously explored field to complete thyroidectomy increases the risk of complications must be taken into consideration. The subjects were 63 consecutive patients who underwent surgery for unilobar follicular neoplasms of the thyroid gland between January 1997 and December 2002. There were 49 follicular adenomas and 14 carcinomas. In the 14 patients with thyroid cancer, total thyroidectomy was performed within 2 weeks after the first operation in a sterile environment with normal anatomical cleavage plains, avoiding any risk of injury to the laryngeal nerves and parathyroid glands. It is concluded that DL is a safe and suitable surgical procedure for patients with follicular-structured lesions of the thyroid gland.

Establishing a simulation center for surgical skills

Keywords Costs Imaging Virtual reality Instruments Training coursesWe read with interest the article by Haluck et al. [1] whichreported on how to establish a simulator center for surgicalskills. The authors emphasized the importance of devel-oping curricula that include virtual simulation. Theyanalyze the costs and reliability of such laboratories.Moreover, they include as a target surgical patients and wedo not really understand why. Then, unfortunately, theauthors do not deal with the natural interface of a mini-mally invasive surgery (MIS) surgeon: the medical orbiomedical engineer. We would like to suggest that med-ical engineers may be a useful target. Medical engineersneed to be involved in simulation centers for surgical skillsas well as in clinical MIS. Their involvement is importantin better understanding the capabilities and ergonomics of agiven surgical device. Medical engineers must be involvedin the enhancement of existing instrumentation, conceptionof new and smarter devices, discussion of risk assessment,and eventually collaboratation in the development of newideas. Finally, in their discussion, Haluck et al. conceive ofthe establishment of a training center with virtual reality(VR) simulators. In our experience [2], VR simulators areexpensive and their contribution to knowledge of newsurgical devices is poor. On the other hand, box trainersallow for a better understanding of ultrasound, radiofre-quency, surgical instrumentation, and so on.We recently decided to test 11 medical engineeringstudents in order to analyze and improve their practical andtheoretical knowledge about MIS instrumentation whileperforming standardized MIS tasks on a pelvic trainer. Thecourses were held at the ‘‘Tor Vergata’’ University ofRome in a laboratory setting. The 11 medical engineeringstudents had no experience in laparoscopy. Trainingincluded 3-h hands-on sessions over a three-month course.During the course the students attended theoretical andpractical courses. The course validity was demonstrated bymeasuring significant improvement in performance withincreasing skill. In conclusion, we showed that dry labexperience for medical engineering students is useful forteaching and improving analysis and management of lap-aroscopic devices, allowing identification of problems withthe aim of developing better devices [3, 4].References

Teaching subfascial perforator veins surgery: survey on a 2-day hands-on course

Background : The present paper describes a training method with objective evaluation to enhance video‐assisted surgical skills in subfascial endoscopic perforator veins surgery (SEPS). Training was scheduled during a 2‐day intensive course.

A camera handler for Miccoli’s minimally invasive video-assisted thyroidectomy and paratiroidectomy procedures

BackgroundMinimally invasive video-assisted thyroidectomy and paratiroidectomy (MIVAT/P) are surgical procedures performed with 5-mm cameras handled by a camera assistant.MethodsThe authors created a new camera handler for video-assisted neck surgery. It consists of a telescopic tripod device designed for mechanical handling of the camera, which is directly oriented by the operator even in solo surgery procedures. The camera is placed inside an O-shaped support, and moved by the operator himself for exploration and work on the surgical field.ResultsThanks to this simple device, the camera holder provides a firm field and prevents blood stains in limited working spaces.ConclusionsThe novel camera handler may be useful in either MIVAT/P or other simple laparoscopic procedures (i.e., cholecystectomy) for a steady handling of the camera, even in solo surgery procedures.

Parapubic hernia and diabetes insipidus

According to the current literature parapubic hernia is regarded as a relatively rare pathology. The causative defect is usually related to pelvic surgery, traumatism, or bone malformation. Surgical treatment is difficult, because aponeurotic tissue on which to anchor a mesh on the caudal aspect of the defect is missing. This report describes a case of an incisional pubic hernia related to megabladder in a woman affected by diabetes insipidus and with a past clinical history of multiple pelvic interventions. As far as we are aware this report adds a new pathogenetic issue for parapubic hernias not previously described in the literature.

Robotic surgery or master-slave device?

The article seems to indicate that this robotic camera holder had a degree of success in porcine surgery, and the main quantitative measure used seemed to indicate the desired reduction in camera shake. We do, however, need to question the authors reasoning regarding the purpose of the device. Clearly, if fully developed, this prototype may provide a surgeon with a more stable camera view in which to operate. However in eliminating an assistant, one effectively eliminates early exposure to laparoscopic procedures for junior doctors and surgeons, further eroding already scarce teaching and learning opportunities. In addition, many robotic assistants have been shown to be more expensive to implement (including cost of retraining surgeons and theatre staff) than the cost of using a junior to assist [2, 3]. Furthermore, when considering the financial viability of any such device, one needs to factor in the often considerable operational costs (maintenance, consumables) of any robotic assistant [4], something that was absent from the article. There is also a question mark over the viability of maintaining sterility with this design. Due to the difficulty in covering the support with a sterile bag, there is a high risk of contaminating the surgical field. The article also fails to address the problem of cleaning the individual device components between procedures. Another area which drew our attention was the actual surgical procedure used in the porcine surgery. In this scenario, a safer and less expensive technique would be to use sub-umbilical open access with a normal reusable trocar. The authors opt for the use of a Veress needle and Visiport trocar access, but do not explain why they use this relatively expensive technique. Finally, we feel that to describe the support as a ‘‘robot’’ is inaccurate. A robot is a device which requires no human intervention in its control. We suggest it would be more accurate to describe this support as a master–slave device. Though we have highlighted some areas for consideration by the authors, we would like to congratulate the team on their endeavours and look forward to seeing how their device develops.

Massive intestinal infarction following retroperitoneoscopic right lumbar sympathectomy

The adverse physiological effects of pneumo and retro-peritoneum are relatively well known. However, the clinical implications of compromised mesenteric circulation through several mechanical and physiological mechanisms are not as well recognized. We describe a fatal case of intestinal infarction following an elective retroperitoneoscopic right sympathectomy. The patient was a 88-year-old man who died 30 hours after an uneventful anesthesia and right endoscopic lumbar sympathectomy. An emergency explorative laparotomy revealed a massive intestinal infarction due to thrombosis of the superior mesenteric artery. We reviewed the literature on laparoscopic procedures and mesenteric ischemia. To our knowledge, this is the first reported case of intestinal infarction following retro-pneumoperitoneum. We conclude that the presence of a severe multidistrectual? arteriopathy may represent a major risk factor in retroperitoneoscopic procedures.

Video-Assisted Access to the Subfascial Space of the Leg

Minimally invasive surgery, involving tiny incisions and the use of scopes or computers to visualize the operative area, has rapidly gained popularity because of the reduced pain, reduced stress and shorter recovery periods it provides for patients.