Gianluca Costa

The long-term outcome of hepaticojejunostomy in the treatment of benign bile duct strictures.

OBJECTIVE The authors review the treatment and outcome of patients with benign bile duct strictures who underwent biliary enteric repair. SUMMARY BACKGROUND DATA The authors conducted a retrospective review of all clinical records of patients referred for treatment of benign bile duct strictures caused by surgery, trauma, or common bile duct lithiasis or choledochal cyst. The authors performed univariate and multivariate analyses of clinical and pathologic factors in relation to patient outcome and survivals. METHODS Eighty-four patients with documented benign bile duct strictures underwent hepaticojejunostomy, choledochojejunostomy, and intrahepatic cholangiojejunostomy during a 15-year period (January 1975 to December 1989). Morbidity, mortality, and patient survival rates were measured. RESULTS Early and late outcomes correlated neither with demographic and clinical features at presentation nor with etiologic or pathologic characteristics of the stricture. Best results correlated with high biliary enteric anastomoses and degree of common bile duct dilatation independently of bile duct stricture location. CONCLUSIONS High biliary enteric anastomosis provides a safe, durable, and highly effective solution to the problem of benign strictures of the bile duct. Transanastomotic tube stenting is unnecessary. Endoscopic and percutaneous transhepatic dilatation seems more appropriate for the treatment of patients in poor condition and those with anastomotic strictures.

The role of serum and gastric juice levels of carcinoembryonic antigen, CA19.9 and CA72.4 in patients with gastric cancer

Purpose: The aim of the present study was to investigate carcinoembryonic antigen (CEA), CA19.9, and CA72.4 in the serum and gastric juice of patients with gastric cancer. Methods: Serum and gastric juice tumor markers CEA, CA19.9, and CA72.4 were measured in 59 patients who had gastric adenocarcinomas and were undergoing curative gastrectomy. The same markers were measured in 47 patients with benign gastric disorders and in 40 healthy subjects. The correlation between the serum and gastric juice levels of tumor markers and several clinicopathological factors were evaluated by univariate analysis. The significance of the tumor markers as prognostic factors was assessed both by univariate and multivariate analysis. Results: The positivity rates of serum CEA, CA19.9, and CA72.4 were 57.6%, 38.9%, and 18.6% respectively. The positivity rates of gastric juice CEA, CA19.9, and CA72.4 were 62.7%, 30.5%, and 23.7% respectively. The combination of serum and gastric juice markers gave a positivity of 81.3%. There was no correlation between serum and gastric juice level of each tumor marker. Positivity of gastric juice markers did not correlate with prognosis. A significant difference in prognosis was observed between patients positive and negative for serum CEA and CA19.9. Multivariate analysis also revealed that serum CEA and CA19.9 levels were independent prognostic factors. Conclusions: Levels of both serum and gastric juice tumor markers continue to have only limited diagnostic usefulness in gastric cancer patients. CEA and CA19.9 in the preoperative sera are good prognostic factors, whereas the presence of tumor markers in the gastric juice does not play any prognostic role.

Prospective evaluation of omentoplasty in preventing leakage of colorectal anastomosis

PURPOSE: The aim of this study was to investigate the role of omentoplasty, by means of intact omentum, in preventing anastomotic leakages after rectal resection. METHODS: Between 1992 and 1997 a total of 112 patients (64 males) with a mean age of 64.7 (range, 39–83) years were randomly assigned to undergo omentoplasty (Group A) or not (Group B) to reinforce the colorectal anastomosis after anterior resection for rectal cancer. The primary end point was anastomotic leakage; the secondary end point included morbility and mortality related to omentoplasty. RESULTS: The two groups were comparable in terms of preoperative and intraoperative characteristics. Staple-ring disruption at plain abdominal radiographs was detected in seven instances in Group A and in ten in Group B patients (P = not significant). Two leakages were evident clinically in Group A and seven in Group B (P<0.05). Three leaks were documented radiologically in Group A and eight in Group B (P = not significant). No complications related to omentoplasty were observed in Group A. There were two repeat operations for anastomotic leakage in Group B. At follow-up, one stricture developed in Group A and three in Group B (P = not significant) CONCLUSIONS: Despite a similar incidence of staple-ring defects, a strikingly lower rate of clinically and radiologically detected leaks developed in patients submitted to omentoplasty. Although not affecting the incidence of anastomotic disruption, omentoplasty seems to contain the severity of anastomotic leakage.

Rectal cancer and inguinal metastases: Prognostic role and therapeutic indications

PURPOSE: The aim of this study was to analyze the outcome of patients with inguinal metastases from rectal cancer. METHODS: Clinical records and data concerning the follow-up of patients referred to our institution for rectal cancer were reviewed retrospectively. Patients were divided into four groups based on the time interval between first admission and appearance of inguinal metastases. All patients were followed up until death. Age, gender, tumor stage, and disease-free intervals were examined to assess their impact on prognosis. RESULTS: Patients with rectal adenocarcinoma (N=863) were observed from 1965 to 1990. In 21 patients the biopsy-proven diagnosis was of adenocarcinoma metastasizing to the inguinal nodes. Of these 21 patients, 15 were males. The mean age was 69.3 (range, 52–84) years. Primary lesions were exclusively T3, and no patient was found to have negative mesorectal lymph nodes. Survival from the time of diagnosis of inguinal metastases ranged from 2 to 42 (mean, 14.8) months. Patients with a disease-free interval of 12 months or more had a statistically significant longer survival time. CONCLUSIONS: Inguinal lymph-node metastases from rectal carcinoma occur as a consequence of locally advanced primary tumors or recurrent pelvic malignancy. Because of the frequency of distant metastases and the consequent poor prognosis, only systemic chemotherapy and radiotherapy should be considered. In patients who seem to be free of local recurrencee and distant metastases, groin dissection is suggested for debulking and control of disease.

IS THERE A CAUSAL CONNECTION BETWEEN BILE ACIDS AND COLORECTAL CANCER

Bile acid composition was assessed in 50 patients with colorectal cancer as compared to that in a control group of 50 subjects. The two groups were age- and sex-matched. The overall bile acid values were similar in both groups, while the relative concentrations of primary and secondary bile acids were different, a significant increase in the patients with colorectal cancer being observed. This finding thus seems to confirm the existence of a link between colorectal cancer and cholelithiasis. Both conditions share common risk factors, such as alterations in cholesterol metabolism and bile acid composition.

Emergency presentation of cystic lymphangioma of the colon: A case report and literature review.

Highlights • Lymphangiomas of the colon are benigne tumors.• They may lead to life-threatening conditions.• Infection, volvulus, obstruction and bleeding into the lumen of a cyst are usually very difficult to manage.

Changes in the Surgical Approach to Colonic Emergencies during a 15-Year Period

Purpose: The present study aims to determine the morbidity and mortality of emergency colonic surgery and the factors associated with adverse outcome, and to evaluate any change in incidence of the different types of pathological conditions and in the surgical approach over the last 15 years. Materials and Methods: A total of 319 patients who underwent emergency colonic surgery between January 1997 and December 2011 were retrospectively analyzed. Patients were divided into two groups according to the date of surgery, namely group 1, between 1997 and 2006, and group 2, between 2006 and 2011. The differences in terms of postoperative outcomes between the groups were analyzed. Results: Overall postoperative morbidity and mortality rates were 25.3 and 17.2%, respectively; no differences were found between the groups. Group 2 showed a significantly increased rate of primary resection and anastomosis (p < 0.001), as well as an increase in laparoscopic approach compared with group 1 (p < 0.001). Conclusions: Emergency colon surgery is today primarily performed for benign diseases, of these the most common is diverticular disease followed by ischemic colitis. Age, comorbidities, and ischemic colon disease are predictors of adverse outcomes, while the surgical procedure per se is not.

Hollow viscus injuries: predictors of outcome and role of diagnostic delay

Introduction Hollow viscus injuries (HVIs) are uncommon but potentially catastrophic conditions with high mortality and morbidity rates. The aim of this study was to analyze our 16-year experience with patients undergoing surgery for blunt or penetrating bowel trauma to identify prognostic factors with particular attention to the influence of diagnostic delay on outcome. Methods From our multicenter trauma registry, we selected 169 consecutive patients with an HVI, enrolled from 2000 to 2016. Preoperative, intraoperative, and postoperative data were analyzed to assess determinants of mortality, morbidity, and length of stay by univariate and multivariate analysis models. Results Overall mortality and morbidity rates were 15.9% and 36.1%, respectively. The mean length of hospital stay was 23±7 days. Morbidity was independently related to an increase of white blood cells (P=0.01), and to delay of treatment >6 hours (P=0.033), while Injury Severity Score (ISS) (P=0.01), presence of shock (P=0.01), and a low diastolic arterial pressure registered at emergency room admission (P=0.02) significantly affected postoperative mortality. Conclusion There is evidence that patients with clinical signs of shock, low diastolic pressure at admission, and high ISS are at increased risk of postoperative mortality. Leukocytosis and delayed treatment (>6 hours) were independent predictors of postoperative morbidity. More effort should be made to increase the preoperative detection rate of HVI and reduce the delay of treatment.

Emergency abdominal surgery in the elderly: a ten-year experience.

The mean age of the population is increasing in the western countries. In particular, in Italy 14% of the population are over 70 years old. The rising of the older population is associated to the increase of the number of emergency abdominal surgical procedures. Postoperative morbidity and mortality are strictly dependent on comorbidities. The aim of this study was to analyze morbidity and mortality in older patients who underwent emergency abdominal surgery.

Comparison of four minimally invasive methods of laparoscopic vagotomy in a porcine model

AbstractBackground: An experimental study in a porcine model was undertaken to evaluate the currently available techniques of laparoscopic vagotomy. Methods: Four groups of pigs were studied. Under general anesthesia, the animals were submitted to either bilateral vagotomy, bilateral highly selective vagotomy, posterior truncal vagotomy with anterior highly selective vagotomy, or Taylors procedure. Gastric acid secretion and intestinal motility were evaluated before and after the surgical procedure. The feasibility of the four different techniques was assessed by means of a personal difficulty score. Results: All four procedures produced significant acid secretory reduction. Multivariate analysis showed that the factor most affecting the outcome was the difficulty score. Conclusions: Taylors procedure was the easiest and safest technique. It also produced the best functional results for secretion and motility.