Ivan Barillaro

Surgical morbidity of cervical lymphadenectomy for thyroid cancer: A retrospective cohort study over 25 years.

INTRODUCTION Prognosis of thyroid cancer is strictly related to loco-regional metastases. Cervical lymphadenectomy has a specific oncologic role but may lead to significant increase of morbidity. Aim of the study is the analysis of surgical morbidity in cervical lymphadenectomy for thyroid cancer. METHODS We retrospectively analyzed 1.765 thyroid cancers operated over a period of 25 years at S. Maria University Hospital, Terni, University of Perugia, Italy. Type of lymphadenectomy, histology and complications were analysed. RESULTS A prevalence of differentiated and medullary cancers was observed (respectively 88% and 7.2%). Central lymphadenectomy was carried out in 425 patients, lateral modified and radical lymphadenectomy respectively in 651 and 17 cases. Following central neck dissection we observed: bilateral and unilateral temporary recurrent nerves palsy respectively of 0.7% and 3.5%, unilateral permanent palsy in 1.6% of cases, temporary and permanent hypoparathyroidism respectively in 17.6% and 4.4%. After lateral neck dissection we observed: intra and post-operative haemorrhage respectively in 2% and 0.29%, respiratory distress in 0.29%, lesions of facial nerve in 0.44%, of vagus in 0.14%, of phrenic nerve in 0.14%, of hypoglossal nerve in 0.29%, of the accessory nerve, transient in 1.34% and permanent in 0.29%, permanent lesion of cervical plexus in 0.29%, salivary fistula in 0.14% and chylous fistula in 1.04% of patients. Students t test was used to compare groups when appliable. CONCLUSION Central and lateral cervical lymph node dissection are associated to severe morbidity. Correct indication, surgical expertise, high volume of patients and early multidisciplinary management of complications is the key of an acceptable balance between oncologic benefits and surgical morbidity.

Requirement for a standardised definition of advanced gastric cancer

Each year, ~988,000 new cases of stomach cancer are reported worldwide. Uniformity for the definition of advanced gastric cancer (AGC) is required to ensure the improved management of patients. Various classifications do actually exist for gastric cancer, but the classification determined by lesion depth is extremely important, as it has been shown to correlate with patient prognosis; for example, early gastric cancer (EGC) has a favourable prognosis when compared with AGC. In the literature, the definition of EGC is clear, however, there is heterogeneity in the definition of AGC. In the current study, all parameters of the TNM classification for AGC reported in each previous study were individually analysed. It was necessary to perform a comprehensive systematic literature search of all previous studies that have reported a definition of ACG to guarantee homogeneity in the assessment of surgical outcome. It must be understood that the term ‘advanced gastric cancer’ may implicate a number of stages of disease, and studies must highlight the exact clinical TNM stages used for evaluation of the study.

The role of surgery in the treatment of thyroid anaplastic carcinoma in the elderly

INTRODUCTION Anaplastic thyroid carcinoma (ATC) is characterized by local invasiveness, risk of recurrence and very poor prognosis. METHODS We retrospectively analysed the multimodality treatment of ATC in 79 patients considering the impact of surgery on survival. RESULTS Patients were divided in two age groups A and B (cut-off 75 years) and in two size subgroups (cut-off 5 cm). Surgery was performed in 78.5% patients of group A and 32.4% of B (p < 0.05). Radiation respectively in 73.8% and 43.2% (p < 0.05). Tracheostomy and endoprosthesis were used in 45.2% and 16.6% in group A and in 43.2% and 35.1% in group B. The use of tracheostomy was significantly higher (p < 0.05) in larger tumours. In group B comparing operated and not operated patients significant difference in survival was observed for larger tumours (p = 0.043). In Kaplan Meir analysis significant difference in survival was observed comparing surgical and no surgical patients of all four subgroups. Surgery plus radiotherapy offered a significant better outcome in smaller tumours (p = 0.017). Considering the effect of the single treatment, compared to no treatment at all, survival is significantly improved by surgery for smaller and larger tumours respectively with 4.42 (p = 0.001) and with 3.5 months (p = 0.0001) and by radiotherapy respectively with 3.44 and with 3.28 months (p = 0.047 and p = 0.0001). CONCLUSION In elderly patients with ATC, although poor prognosis, surgery is still fundamental in the multimodality treatment with significant advantage in selected patients. Nevertheless most of elderly patients with large tumours are suitable only for palliative management.

The measurement of amylase in drain fluid for the detection of pancreatic fistula after gastric cancer surgery: an interim analysis

BackgroundPancreatic fistula is still one of the most serious and potential complications after D2-D3 distal and total gastrectomy (4% to 6%). Despite their importance, pancreatic fistulas still have not been uniformly defined. Amylase concentration of the drainage fluid after surgery for gastric cancer can be considered as a predictive factor of the presence of pancreatic fistula.MethodsFrom January 2009 to April 2013, 53 patients underwent surgery for gastric cancer. Amylase concentration in the drainage fluid was measured on the first postoperative day and if it was ≥1,000 UI, it was measured again on the third postoperative day. Pancreatic fistula occurred in four cases (7.5%). Pancreatic fistulas were classified using the International Study Group on Pancreatic Fistula (ISGPF) criteria into different grades of severity. Two fistulas were Grade A, one was Grade B, and one was Grade C.ResultsManagement of drainage tubes is still crucial after gastrectomy, not only for the likelihood of anastomotic leaks but also the eventual diagnosis and management of pancreatic fistula. High amylase drainage content and then the presence of the pancreatic fistula may be due to several causes: the operation itself when it includes splenectomy or pancreatic tail-splenectomy, the extended lymphadenectomy but even the ‘gently and softly’ pancreatic manipulation, according literature, may be a risk factor.ConclusionsThe authors assessed amylase concentration in the drainage fluid collected from the left subphrenic cavity on POD1 and POD3 in 53 patients who had undergone curative gastrectomy for cancer and concluded that amylase drainage content >3 times the serum amylase was a useful predictive risk factor for pancreatic fistula. Our work is an interim analysis and the aim of this study is to increase the accrual of the number of patients to have a significant number. For this reason, a protocol for a multicenter trial will be designed to verify whether the systematic measurement of amylase in drain fluid is better than abdominal ultrasound for the detection of pancreatic fistula after gastric cancer surgery.

Breast cancer micrometastasis and axillary sentinel lymph nodes frozen section. Our experience and review of literature

BACKGROUND Sentinel lymph node (SLN) biopsy plays a major role in the surgical management of primary breast cancer. The aim of this study was to assess the diagnostic accuracy of the assessment of axillary frozen sections of SLNs for micrometastasis diagnosis. PATIENTS AND METHODS This study focused on 250 SLNs from 137 patients. Each lymph node was fully analyzed by frozen section. After fixation, serial sections were cut and stained by hematoxylin and eosin (HE) and for pan-cytokeratins by immunohistochemistry (IHC). RESULTS Tumor cells were detected in 57 SLNs, 37 on frozen sections and 20 on controls. Of these 57 positive SLNs, 38 contained metastases, 9 contained micrometastases and 10 contained isolated tumor cells. The specificity and positive predictive value of SLN frozen sections for micrometastasis was 100%. The sensitivity was 83.3% for metastasis, 40% for micrometastasis; the false-negative rate was 16.7% for metastasis and 60% for micrometastasis. CONCLUSION Analysis of frozen section of SLNs is an accurate method for metastasis detection, allowing concurrent axillary dissection when positive. The protocol for SLN analyses described herein shows good sensitivity for micrometastasis detection.

Colovesical fistulae in the sigmoid diverticulitis

In most cases Colovesical fistulae are complications of diverticular disease and representing the most common kind of colodigestive fistula; less common are colovaginal, colocutaneous, coloenteric and colouterine fistula. In this article we review the literature concerning colovesical fistulae in colorectal surgery for sigmoid diverticulitis and report on two cases that required a surgical treatment, one elective and the other in emergency. In both cases we performed a sigmoid resection with a primary anastomosis and small vesical window-ectomy placing a Foley catheter for about 10 days.

Surgical management of mediastinal goiter in the elderly

AIM Mediastinal goiter (MG) is characterized by compression symptoms such choking, dyspnea, sleeping apnea and dysphagia. It is significantly observed in elderly patients who due to comorbidity are associated to increased surgical risk. Total thyroidectomy is indicated to treat tracheal compression. Cervicotomy is the most used surgical access. AIM of the study was the evaluation of the role of surgery in the treatment of MG in the elderly. METHODS A retrospective analysis of twenty-eight-years on 1721 (390 over 80-years-old) cases of MG in a referral center for endocrine surgery was carried out. CT was used as a standard in the preoperative study. Surgery was performed by an experienced surgical team with standard technique via cervical approach or in selected cases via sternotomy or thoracotomy. Clinical records were examined. RESULTS Patients were divided into two groups: older and younger than 80-years-old. Total thyroidectomy was performed in all cases and via a cervical approach in almost 99% of patients. Tracheal dislocation and tracheomalacia were prevalent in elderly patients and were treated conservatively. Benign struma was observed in 1463 patients and a carcinoma in 258. Larger thyroid weight was observed in the elderly. The rate of complications was similar between groups. CONCLUSION Total thyroidectomy via cervical approach is the treatment of choice for MG in the elderly. It should be treated only in referral centers with adequate caution for elderly patients to achieve complete cure with limited complications.

The surgical treatment of colorectal cancer in patients over seventy-five years old. Risk factor analysis in patients operated in election and in emergency

We assessed the risk factors of the surgical treatment in the elective and emergency management. Among the 47 patients electively treated, 33 were affected by cardiocirculatory diseases, 23 by kidney diseases, 14 by metabolic and endocrine diseases, and 11 patients by respiratory diseases. In the 19 patients, who underwent emergency surgery, 75% had intestinal obstruction, and 25% had intestinal perforation.

The primary gastric stump cancer in geriatric patients

Methods The authors present 7 cases of primary gastric stump cancer surgically treated in our department during the period 1999–2002. The age of patients was between 61 and 79 years. The average time between primary gastric resection and diagnosis of carcinoma of gastric stump was 19 years (6–32 years). All patients considered operable underwent total gastrectomy and restoration of intestinal transit according to Rouxs technique.