Giovanni Lezoche

Transanal endoscopic microsurgery for 135 patients with small nonadvanced low rectal cancer (iT1–iT2, iN0): short- and long-term results

BackgroundLocal excision of rectal cancer as an alternative to radical resection for patients with small nonadvanced low rectal cancer (SNALRC) (iT1–iT2, iN0) is debated. This study aimed to analyze the short- and long-term results for a series of 135 patients with SNALRC who underwent local excision by transanal endoscopic microsurgery (TEM).MethodsAccording to the study protocol, 135 patients classified by endorectal ultrasound, magnetic resonance imaging (MRI), and computed tomography (CT) imaging as having iT1 iN0 iM0 (nxa0=xa051) or iT2 iN0 iM0 (nxa0=xa084) low rectal cancer were enrolled in the study. All the patients with iT2 rectal cancer underwent neoadjuvant therapy. The definitive histologic findings showed 24 pT0 patients (17.8%), 66 pT1 patients (48.8%), and 45 pT2 patients (33.4%).ResultsMinor complications were observed in 12 patients (8.8%) and major complications in 2 patients (1.5%). During a median follow-up period of 97xa0months (range, 55–139xa0months), local recurrences occurred for four patients and distant metastases for two patients. The patients who experienced a recurrence had been preoperatively staged as iT2 and were low or nonresponders to neoadjuvant treatment (ypT2). At the end of the follow-up period, the disease-free survival rates were 100% for the iT1 patients and 93% for the iT2 patientsConclusionsThe long-term results for adequate local excision by TEM with or without neoadjuvant radiochemotherapy in the treatment of SNALRC based on the current study protocol are not inferior to those reported in the literature for radical surgery with total mesorectal excision (TME).

Perioperative results of 214 laparoscopic adrenalectomies by anterior transperitoneal approach

BackgroundThe present study attempts to evaluate the perioperative results of the anterior approached laparoscopic adrenalectomy (LA) in a large cohort of patients, and report the advantages and disadvantages of this route.Methods204 patients, 125 female and 79 male with a mean age 52.8 years (range, 19–75 years), underwent LA by the anterior transperitoneal approach from 1994 to 2005 in our institution. There were 100 right and 114 left LAs. Ten patients underwent bilateral LA. Associated surgical procedures were performed in 17 cases. During the same period 47 LAs had been performed by different approaches (flank and submesocolic).ResultsMean operative time was 80 minutes for right (40–150), 109 minutes for left (64–300) and 194 minutes for bilateral adrenalectomy. Intraoperative major complications were observed in six patients. Mortality occurred in one diabetic patient who was converted to open surgery because of a colonic perforation and subsequently developed a Candida sepsis in the postoperative course. The mean size of lesion removed was 6.2 cm (1.5–12 cm). Oral intake started within 24 hours and the mean hospital stay was 2.5 days (1–8 days). Histology results were as follows: nonsecreting adenoma 65, Cushing’s adenoma 58, Conn’s adenoma 53, pheochromocytoma 24, metastases 9, myelolipoma 3, adrenogenital syndrome 1, carcinoma 1.ConclusionsLA by anterior transperitoneal approach is safe and effective in our experience, despite the inherent limitation that this was not a prospective randomized study. The main advantage of this route is early ligature of the adrenal vein on both sides, enabling the performance of associated surgical procedures and bilateral adrenalectomy.

Minimally invasive treatment of rectovaginal fistula

BackgroundRectovaginal fistulas (RVFs) are a rare surgical condition. Their treatment is extremely difficult, and no standard surgical technique is accepted worldwide. This report describes a new approach using transanal endoscopic microsurgery (TEM) to treat RVFs.MethodsA retrospective review of 13 patients who underwent repair of rectovaginal fistula using TEM between 2001 and 2008 was undertaken. The surgical technique is widely described, and the advantages of the endorectal approach are noted.ResultsThe median follow-up period was 25xa0months, and the median age of the patients was 44xa0years (range, 25–70xa0years). The mean operative time was 130xa0min (range, 90–150xa0min), and the hospital stay was 5xa0days (range, 3–8xa0days). One patient experienced recurrence. This patient underwent reoperation with TEM and experienced re-recurrence. Two patients had minor complications (hematoma of the septum and abscess of the septum), which were treated with medical therapy. For two patients, a moderate sphincter hypotonia was registered.ConclusionsA new technique for treating RVFs using TEM is presented. The authors strongly recommend this approach that avoids any incision of the perineal area, which is very painful and can damage sphincter functions.

Treatment of rectal cancer by transanal endoscopic microsurgery: experience with 425 patients.

AIMnTo describe our experience in treating rectal cancer by transanal endoscopic microsurgery (TEM), report morbidity and mortality and oncological outcome.nnnMETHODSnA total of 425 patients with rectal cancer (120 T1, 185 T2, 120 T3 lesions) were staged by digital rectal examination, rectoscopy, transanal endosonography, magnetic resonance imaging and/or computed tomography. Patients with T1-N0 lesions and favourable histological features underwent TEM immediately. Patients with preoperative stage T2-T3-N0 underwent preoperative high-dose radiotherapy; from 1997 those aged less than 70 years and in good general health also underwent preoperative chemotherapy. Patients with T2-T3-N0 lesions were restaged 30 d after radiotherapy and were then operated on 40-50 d after neoadjuvant therapy. The instrumentation designed by Buess was used for all procedures.nnnRESULTSnThere were neither perioperative mortality nor intraoperative complications. Conversion to other surgical procedures was never required. Major complications (urethral lesions, perianal or retroperitoneal phlegmon and rectovaginal fistula) occurred in six (1.4%) patients and minor complications (partial suture line dehiscence, stool incontinence and rectal haemorrhage) in 42 (9.9%). Postoperative pain was minimal. Definitive histological examination of the 425 malignant lesions showed 80 (18.8%) pT0, 153 (36%) pT1, 151 (35.5%) pT2, and 41 (9.6%) pT3 lesions. Eighteen (4.2%) patients (ten pT2 and eight pT3) had a local recurrence and 16 (3.8%) had distant metastasis. Cancer-specific survival rates at the end of follow-up were 100% for pT1 patients (253 mo), 93% for pT2 patients (255 mo) and 89% for pT3 patients (239 mo).nnnCONCLUSIONnTEM is a safe and effective procedure to treat rectal cancer in selected patients without evidence of nodal involvement. T2-T3 lesions require preoperative neoadjuvant therapy.

Cancer stem cell gene profile as predictor of relapse in high risk stage II and stage III, radically resected colon cancer patients.

Clinical data indicate that prognostic stratification of radically resected colorectal cancer based on disease stage only may not be always be adequate. Preclinical findings suggest that cancer stem cells may influence the biological behaviour of colorectal cancer independently from stage: objective of the study was to assess whether a panel of stemness markers were correlated with clinical outcome in resected stage II and III colon cancer patients. A panel of 66 markers of stemness were analysed and thus patients were divided into two groups (A and B) with most patients clustering in a manner consistent with different time to relapse by using a statistical algorithm. A total of 62 patients were analysed. Thirty-six (58%) relapsed during the follow-up period (range 1.63–86.5 months). Twelve (19%) and 50 (81%) patients were allocated into group A and B, respectively. A significantly different median relapse-free survival was observed between the 2 groups (22.18 vs 42.85 months, pu200a=u200a0.0296). Among of all genes tested, those with the higher “weight” in determining different prognosis were CD44, ALCAM, DTX2, HSPA9, CCNA2, PDX1, MYST1, COL1A1 and ABCG2. This analysis supports the idea that, other than stage, biological variables, such as expression levels of colon cancer stem cell genes, may be relevant in determining an increased risk of relapse in resected colorectal cancer patients.

Laparoscopic versus open colectomy for TNM stage III colon cancer: results of a prospective multicenter study in Italy

Background and PurposeThere is still debate about the practicality of performing laparoscopic colectomy instead of open colectomy for patients with curable cancer, although laparoscopic surgery is now being performed even for patients with advanced colon cancer. We compared the long-term results of laparoscopic versus open colectomy for TNM stage III carcinoma of the colon in a large series of patients followed up for at least 3xa0years.MethodsThe subjects of this prospective non-randomized multicentric study were 290 consecutive patients, who underwent open surgery (OS group; nxa0=xa0164) or laparoscopic surgery (LS group; nxa0=xa0126) between 1994 and 2005, at one of the four surgical centers. The same surgical techniques were used for the laparoscopic and open approaches to right and left colectomy. The distribution of TNM substages (III A, III B, IIIC) as well as the grading of carcinomas (G1, G2, G3) were similar in each arm of the study. The median follow-up periods were 76.9 and 58.0xa0months after OS and LS, respectively.ResultsThere were 10 (6.1xa0%) versus 9 (7.1xa0%) deaths unrelated to cancer, 15 (9.1xa0%) versus 5 (4xa0%) cases of local recurrence, 7 (4.2xa0%) versus 5 (4xa0%) cases of peritoneal carcinosis, and 37 (22.5xa0%) versus 14 (11.1xa0%) cases of metastases in the OS and LS groups, respectively. There was also one case of port-site recurrence after LS (0.8xa0%). The OS group had a significantly higher probability of local recurrence and metastases (pxa0<xa00.001) with a significant higher probability of cancer-related death (pxa0=xa00.001) than the LS group.ConclusionsThese findings support that LS is safe and effective for advanced carcinoma of the colon. Although the LS group in this study had a significantly better long-term outcome than the OS group, further investigations are needed to draw a definitive conclusion.

Quality-of-life impairment after endoluminal locoregional resection and laparoscopic total mesorectal excision

AbstractBackgroundFor selected patients with rectal cancer, endoluminal locoregional resection (ELRR) by transanal endoscopic microsurgery (TEM) may be an alternative treatment option to laparoscopic total mesorectal excision (LTME). Few data are available on quality of life (QoL) after LTME and TEM. This study aimed to compare short- and medium-term QoL for T1 rectal cancer patients undergoing LTME or ELRR by TEM.nMethodsThis study investigated 35 patients with T1N0 rectal cancer who underwent TEM (nxa0=xa017) or LTME (nxa0=xa018). Quality of life was evaluated by European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-C38 questionnaires preoperatively and then 1, 6, and 12xa0months after surgery.ResultsObservation 1xa0month after LTME showed worsening in all items of both questionnaires. After ELRR, the QLQ-CR38 showed worsening of gastrointestinal (pxa0=xa00.005) and defecation problems (pxa0=xa00.001), and the QLQ-C30 showed worsening of global health status (pxa0=xa00.014), physical functioning (pxa0=xa00.02) role functioning (pxa0=xa00.003), fatigue (pxa0=xa00.002), and pain (pxa0=xa00.001). The QLQ-CR38 6xa0months after LTME showed worsening of body image (pxa0=xa00.009), micturition (pxa0=xa00.035), and gastrointestinal problems (pxa0=xa00.011), and the QLQ-C30 showed worsening of physical functioning (pxa0=xa00.003), role functioning (pxa0=xa00.002), fatigue (pxa0=xa00.004), and nausea/vomiting (pxa0=xa00.030). After ELRR, neither the QLQ-CR38 nor the QLQ-C30 questionnaire showed any worsening but demonstrated improvement in global health status and physical functioning. The QLQ-CR38 12xa0months after LTME showed significant improvement in defecation problems (pxa0=xa00.004) and weight loss (pxa0=xa00.003), and the QLQ-C30 showed significant improvement in global health status (pxa0=xa00.001), nausea and vomiting (pxa0=xa00.003), and pain (pxa0=xa00.005). After ELRR, the QLQ-C30 showed improvement in emotional functioning (pxa0=xa00.012), whereas no significant difference was observed by the QLQ-C38.ConclusionsFunctional sequelae are present up to 1xa0month only after ELRR by TEM and up to 6xa0months after LTME. At 12xa0months, neither procedure showed a significant difference in QoL compared with preoperative status.

Use of the electrothermal bipolar vessel system (EBVS) in laparoscopic adrenalectomy: a prospective study

BackgroundSince laparoscopic adrenalectomy (LA) has been adopted as the gold standard for the treatment of adrenal diseases, the development of technology for vascular control and dissection manoeuvres, amongst other things, may play a pivotal role in its further improvement. We report our experience with the electrothermal bipolar vessel sealing (EBVS) device for LA.MethodsFrom January 2004 to January 2006, 50 patients (pts) undergoing LA were selected and randomized for use of the EBVS (25 pts, group A) versus the UltraSonic Shears (USS) device (25 pts, group B). Age, sex, body mass index (BMI), previous surgery and associated diseases were similar between the two groups. The main surgical parameters collected for each patient (pt) concerned operative time, major and minor complications, conversion rate, blood loss, hospital stay and histology.ResultsThere was no mortality in either group. The right adrenalectomy mean operative time (OpT) was 51.8 mins (range 40–90 mins) and 68.6 mins (range 50–130 mins) in group A and B, respectively (P not significant). The left adrenalectomy mean OpT was 72.2 mins (range 55–100 mins) and 94 mins (range 65–140 mins) for group A and B, respectively (P < 0.05). The mean blood loss was 83 ml (group A) and 210 ml (group B) (p < 0.05). Complications were not different for the two groups. The mean hospital stay was 2.9 and 3.1 days in group A and B, respectively (P not significant).ConclusionsEBVS in LA may provide a significantly short operating time and blood loss.

On the suitability of Thiel cadavers for natural orifice transluminal endoscopic surgery (NOTES): surgical training, feasibility studies, and anatomical education

BackgroundSurgical training in virtual, animal and cadaver models is essential for minimally invasive surgery. Thiel cadavers are suitable for laparoscopy, but there are few data about the use of embalmed (Tutsch method) and slightly embalmed (Thiel method) cadavers in procedures of Natural Orifice Transluminal Endoscopic Surgery (NOTES), which are usually developed and learned on swine models and fresh frozen cadavers. The aim of this study was thus to assess the use of these cadavers for NOTES approaches.MethodsThe following surgical procedures were evaluated: transanal total mesorectal excision (four cadavers: one Tutsch, two Thiel, one fresh frozen), transanal ileorectal bypass (five cadavers: one Tutsch, three Thiel, one fresh frozen), and transvaginal appendectomy (two Tutsch cadaver).ResultsThe Thiel method ensured tissue flexibility and consistency suitable for performing the above surgical procedures with good results and without complications, with only a small increase in rigidity with respect to fresh specimens. Cadavers embalmed with higher formalin concentrations (Tutsch method) were more difficult to use, due to high tissue rigidity and resistance of the abdominal wall to pneumoperitoneum, although NOTES accesses were possible.ConclusionsThiel cadavers are suitable for transanal/transrectal and transvaginal NOTES approaches, for training surgical residents/specialists and also for surgical research. In minimally invasive surgery (and particularly in NOTES), integration between cadaver (fresh frozen and/or Thiel) and animal models would represent the gold standard, allowing guaranteed knowledge of and respect for human surgical anatomy and correct management of surgery on living subjects. NOTES approaches to human cadavers may also be proposed for the anatomical education of medical students.

Laparoscopic transperitoneal anterior adrenalectomy in pheochromocytoma: experience in 62 patients.

AbstractBackgroundnAim was to evaluate the results in 62 patients undergoing laparoscopic adrenalectomy (LA) for the treatment of pheochromocytoma (PHE), with a transperitoneal anterior approach for lesions on the right side, and with a transperitoneal anterior submesocolic approach in case of left-sided lesions.MethodsSixty-two patients underwent LA for the treatment of PHE at two centers in Rome and Ancona (Italy). Two patients had bilateral lesions, for a total of 64 adrenalectomies. Sporadic PHE occurred in 57 patients (91.9xa0%) and in 5 (8.0xa0%) it was familiar. Thirty-six patients (58.0xa0%) underwent right adrenalectomy, 24 (38.7xa0%) left adrenalectomy, and in 2 cases (3.2xa0%) LA was bilateral. In 38 cases of right adrenalectomy (59.3xa0%) and in 5 cases of left adrenalectomy (7.8xa0%), the approach was a transperitoneal anterior one. A transperitoneal anterior submesocolic approach was used in 21 left adrenalectomy cases (32.8xa0%).ResultsnMean operative time for right and left transperitoneal anterior LA was 101xa0min (range 50–240) and 163xa0min (range 50–190), respectively. Mean operative time for left transperitoneal anterior submesocolic LA was 92xa0min (range 50–195). For bilateral adrenalectomy, mean operative time was 210xa0min (range 200–220). Conversion to open surgery occurred in 2 cases (3.22xa0%) due to extensive adhesions (1) and hemorrhage (1). One major and three minor complications were observed. Mobilization occurred on the first postoperative day. Hospitalization was 4.8xa0days (range 2–19). The lesions had a mean diameter of 4.5xa0cm (range 0.5–10).ConclusionsnEarly identification with no gland manipulation prior to closure of the adrenal vein is the main advantages of the transperitoneal anterior approach. PHE may be treated safely and effectively by a laparoscopic transperitoneal anterior approach for right-sided lesions and with a transperitoneal anterior submesocolic approach for left-sided ones.