Marco Frascio

APPENDECTOMY OR RIGHT HEMICOLECTOMY IN THE TREATMENT OF APPENDICEAL CARCINOID TUMORS

Aims and background Carcinoids of the appendix continue to be of interest, despite their low incidence. There is still considerable controversy surrounding these tumors, especially with regard to the role of right hemicolectomy in the surgical management. The aim of this work was to explicate the current therapeutic knowledge and to review the criteria for the indications of appendectomy or hemicolectomy. Methods The records of patients who underwent appendectomies from 1990 to 2000 were analyzed. Seven patients were included in the study. The clinical data were reviewed for demographic details, tumor size, localization in the appendix, histological patterns and surgical procedures. All patients underwent appendectomy including removal of the mesenteriolum, and in one of them a right hemicolectomy was performed 3 weeks later. The mean follow-up was 7 years (range, 4–14). Follow-up data included symptoms, urinary 5-hydroxyin-doleacetic acid, ultrasound examination, computerized tomography, and octreotide scanning. Results Seven patients (0.9% of all appendectomies) were reported to have carcinoid tumors of the appendix. They were 3 men and 4 women with a mean age of 29 years. All patients were admitted for appendicitis. None suffered from the carcinoid syndrome. The site of the tumor was the apex of the appendix in 4 cases, the body in 2 cases and the base in 1 case. Mean tumor diameter was 8 mm (range, 5–29 mm); in 6 patients it was <2 cm. Treatment was appendectomy in all cases; additional right hemicolectomy was necessary in one case because of a tumor of more than 2 cm with invasion of the mesoappendix and lymph nodes. The 7-year survival rate is 100%. Six patients are without disease, while 1 patient (the one who underwent a right hemicolectomy) developed metastases in the liver 6 years after the operation. This patient, who was treated with a liver resection, is still alive. Conclusions According to current guidelines, an appendectomy may be performed for small carcinoid tumors (<1 cm). Reasons for more extensive surgery than appendectomy are tumor size >2 cm, lymphatic invasion, lymph node involvement, spread to the mesoappendix, tumor-positive resection margins, and cellular pleomorphism with a high mitotic index. The criteria that direct us towards major (hemicolectomy) or minor surgery (appendectomy) are controversial. Tumor size is still considered the most important prognostic factor, with a presumed increase in the risk of metastasis for tumors greater than 2.0 cm. The accepted treatment of such tumors is a right hemicolectomy. However, there is no evidence demonstrating a survival benefit for right hemicolectomy over simple appendectomy in patients with carcinoids greater than 2.0 cm in diameter.

The SIC-GIRCG 2013 Consensus Conference on Gastric Cancer

The topic chosen by the Board of the Italian Society of Surgery for the 2013 annual Consensus Conference was gastric cancer. With this purpose, under the direction of 2 chairmen, 36 experts nominated by the Regional Societies of Surgery and by the Italian Research Group for Gastric Cancer (GIRCG) participated in an experts consensus exercise, preceded by a questionnaire and mainly held by telematic vote, in accordance with the rules of the Delphi method. The results of this Consensus Conference, presented to the 115th National Congress of the Italian Society of Surgery, and approved in plenary session, are reported in the present paper.

Monoclonal antibodies to human erythrocyte glucose 6-phosphate dehydrogenase

glucose 6-phosphate dehydrogenase (G6PD, type B) have been raised in rabbits and used for the characterization of genetic variants of this enzyme protein [l-4]. Use of the antiG6PD antisera for estimating the specific activity of GGPD variants has recently been criticized and shown to be inadequate to this purpose [5]. More- over, both the specificity and strength of conventional antisera are not satisfactory enough to allow a precise characterization of G6PD variants associated with severe deficiency of activity [6]. In an attempt to overcome these limitations, we used cell fusion techniques to obtain anti-G6PD anti- body-secreting hybridomas [7]. By this approach, a number of antibodies directed to human G6PD were isolated after fusion of an 8-azaguanine-resistant mouse myeloma line with splenocytes from a mouse hyperimmunized with G6PD. 2. Materials and methods

Glucose 6-phosphate dehydrogenase activity in membranes of erythrocytes from normal individuals and subjects with Mediterranean G6PD deficiency

Abstract Unsealed, hemoglobin-free erythrocyte ghosts contain low yet significant levels of Glucose 6-phosphate dehydrogenase (G6PD) activity. This activity is comparable in erythrocyte ghosts obtained from normal individuals and from G6PD-deficient subjects (of Mediterranean type), in spite of the marked differences found in the corresponding cytosolic compartments. The membrane preparations can bind purified human G6PD (type B) to their cytoplasmic surface according to patterns of positive cooperativity. 2.4 × 104 and 1.6 × 104 G6PD-binding sites are present on the inner surface of each ghost obtained from normal and from G6PD-deficient erythrocytes, respectively, the relevant association constants being 2.8 × 106 M−1 and 0.82 × 106 M−1. The interaction of G6PD with the ghosts is unaffected by different ionic strengths or by metabolites such as glucose 6-phosphate, NADP and NADPH.

Information, knowledge and interoperability for healthcare domain

New technologies have improved the ability of electronically storing, transferring and sharing medical data; they also create serious questions about who has access to this cross-media content and how it is protected and distributed. Our aim is to support healthcare professionals in this changing environment, by providing a set of software tools that help reducing the time and associated costs to collect the information and knowledge required, and in making the best use of it for a more informed decision making (diagnoses, therapies, protocols). An appropriate and consistent level of information security consists of protecting information both in written, spoken, electronically recorded, or printed form from accidental or malicious modification, destruction, or disclosure by applying the strictest requirements for data security and privacy and complying with ethical standards. By Doc@Hand project we experiment the distribution of computer-based patient record, natural language queries and the contained knowledge in a secured way.

Laparoscopic bridging vs. anatomic open reconstruction for midline abdominal hernia mesh repair [LABOR]: single-blinded, multicenter, randomized, controlled trial on long-term functional results

BackgroundRe-approximation of the rectal muscles along the midline is recommended by some groups as a rule for incisional and ventral hernia repairs. The introduction of laparoscopic repair has generated a debate because it is not aimed at restoring abdominal wall integrity but instead aims just to bridge the defect. Whether restoration of the abdominal integrity has a real impact on patient mobility is questionable, and the available literature provides no definitive answer. The present study aims to compare the functional results of laparoscopic bridging with those of re-approximation of the rectal muscle in the midline as a mesh repair for ventral and incisional abdominal defect through an “open” access. We hypothesized that, for the type of defect suitable for a laparoscopic bridging, the effect of an anatomical reconstruction is near negligible, thus not a fixed rule.Methods and designThe LABOR trial is a multicenter, prospective, two-arm, single-blinded, randomized trial. Patients of more than 60 years of age with a defect of less than 10 cm at its greatest diameter will be randomly submitted to open Rives or laparoscopic defect repair. All the participating patients will have a preoperative evaluation of their abdominal wall strength and mobility along with volumetry, respiratory function test, intraabdominal pressure and quality of life assessment.The primary outcome will be the difference in abdominal wall strength as measured by a double leg-lowering test performed at 12 months postoperatively. The secondary outcomes will be the rate of recurrence and changes in baseline abdominal mobility, respiratory function tests, intraabdominal pressure, CT volumetry and quality of life at 6 and 12 months postoperatively.DiscussionThe study will help to define the most suitable treatment for small-medium incisional and primary hernias in patients older than 60 years. Given a similar mid-term recurrence rate in both groups, if the trial shows no differences among treatments (acceptance of the null-hypothesis), then the choice of whether to submit a patient to one intervention will be made on the basis of cost and the surgeon’s experience.Trial registrationCurrent Controlled Trials ISRCTN93729016

Decay of a specific NADP(H)-binding protein during aging of normal and glucose 6-phosphate dehydrogenase-deficient erythrocytes

Human erythrocytes contain a specific NADP(H)binding protein, tentatively designated FX [ 1,2] , whose molecular properties have been previously described. [3] . A radioimmunoassay, based on doubleantibody technique, was_ developed in order to quantitate this holoprotein in crude as well as in purified systems [4]. Preliminary application of the radioimmunoassay showed that the amount of FX cross reacting material (CRM) is significantly enhanced in hemolysates from individuals affected by the Mediterranean type of glucose 6-phosphate dehydrogenase (G6PD) deficiency when compared with hemolysates from normal subjects. This finding appeared to be of interest because: (i) Little is known on the pathophysiology of the G6PD-deficient erythrocytes. (ii) The biological function of FX is still undetermined. Accordingly, the technique was improved by developing a solid-phase radioimmunoassay whereby the content of FX CRM could be estimated throughout the life-span of the erythrocytes. The results obtained are consistent for distinctive patterns of decline of FX CRM during aging of normal and of G6PD Mediterranean erythrocytes, these patterns accounting for the different levels of the protein in whole cell populations from the two groups of subjects. 2. Materials and methods

Pseudodiverticular defecographic image after STARR procedure for outlet obstruction syndrome

Dear Editor: Outlet obstruction syndrome (OOS) is a defecation disorder more common in women. Patients refer to coloproctologists complaining of constipation and other typical symptoms ranging from incomplete and fragmentized evacuation to rectal bleeding. This syndrome may be caused by functional and/or anatomical alterations. A correct etiological classification can help the clinician to predict the best treatment strategy. Non-operative treatment, mainly based on dietary changes and biofeedback, is usually suggested as the first or unique treatment option when symptoms are caused by an uncoordinated inhibitory muscular pattern. Conversely, patients not responsive to conservative treatment most likely can benefit from surgery. Nevertheless, traditional techniques, aimed at restoring normal anatomy, are often time-consuming, technically demanding, burdened by serious complications, and, sometimes, under particular circumstances, can be ineffective or can even worsen symptoms. In 2003 Stapled Transanal Rectal Resection (STARR) was described by Longo as an effective new option for the cure of OOS. Since its introduction, STARR has become an accepted surgical procedure even if some criticisms have been raised due to possible serious complications. Recently, a case of rectal diverticulum after STARR procedure has been reported. Here, we describe a similar case, its related diagnostic and treatment modalities. A 60-year-old woman, who had previously undergone unsuccessful medical treatment, was submitted to STARR in our service for obstructed defecation syndrome caused by an anterior and posterior rectocele associated with a posterior rectal wall prolapse. The technique, described elsewhere, follows the same steps as standardized by Longo. In the present case, at the end of the procedure, the stapled line was carefully inspected. As routinely performed, the mucosal band connecting the two edges of the anastomosis was cut both anteriorly and posteriorly. Stitches were then applied at the anastomotic level in order to avoid the risk of postoperative bleeding. The postoperative course was uneventful, and patient discharged on the third postoperative day. One month later, the patient presented at our outpatient visit complaining of recurrence of symptoms with tenesmus, constipation, a sensation of incomplete evacuation, painful and unsuccessful efforts, urge to defecate, anal incontinence, with need of digital assistance. Defecography showed a diverticular cavity on the right rectal wall (60 mm diameter) and an incomplete evacuation of barium. This lateral diverticulum, filled up by impacted stools, shrank the rectal pouch lumen during straining and defecation. The patient refused clinical examination and endoscopy because of intense pain and an examination under spinal anesthesia was then planned. The exam revealed the presence of a bridge of rectal mucosa, 2 cm wide, on the posterior wall. This bridge caused deformation of the rectal profile creating a diverticular cavity full of impacted stools. After mechanical emptying of the diverticulum the mucosal bend was cut with restoration of normal anatomy. Two months after this procedure, the patient had significantly improved defecation with complete resolution of symptoms. Defecography, performed 3 months postopInt J Colorectal Dis (2009) 24:1115–1116 DOI 10.1007/s00384-009-0666-6

Laparoscopic “double-port” splenectomy. A new minimally-invasive option in a giant spleen

Highlights • “Hybrid technique” combining the single-port technique to the hand assistance.• Novelty: the use of a suprapubic Pfannestiel incision for the hand assistance for a laparoscopic splenectomy procedure.• Novelty: the use of the hand of the assistant instead of the surgeon’s hand.• Novelty: the coupling of two port devices (single-port and Gel-port).• Novelty: the use of the single-port technique in splenic malignancies associated to splenomegaly.

Primary lymphoma of appendix presenting as acute appendicitis: A case report

Highlights • Primary lymphomas of appendix are extremely rare tumors. The incidence is 0.015% of all gastrointestinal lymphomas.• The neoplasms of appendix usually manifest clinically with sign and symptoms of acute appendicitis.• Preoperative diagnosis is difficult and often occurs through histopathological examination, so it is mandatory for all appendectomies.• There are no clear guidelines for therapy. Primary surgical resection followed by post-operative chemotherapy showed high efficacy.