Marco Venturino

Surgical outcomes for colon and rectal cancer over a decade: results from a consecutive monocentric experience in 902 unselected patients

BackgroundThis study evaluates the surgical morbidity and long-term outcome of colorectal cancer surgery in an unselected group of patients treated over the period 1994–2003.MethodsA consecutive series of 902 primary colorectal cancer patients (489 M, 413 F; mean age: 63 years ± 11 years, range: 24–88 years) was evaluated and prospectively followed in a university hospital (mean follow-up 36 ± 24 months; range: 3–108 months). Perioperative mortality, morbidity, overall survival, curative resection rates, recurrence rates were analysed.ResultsOf the total, 476 colorectal cancers were localized to the colon (CC, 53%), 406 to the rectum (RC, 45%), 12 (1%) were multicentric, and 8 were identified as part of HNPCC (1%). Combining all tumours, there were 186 cancers (20.6%) defined as UICC stage I, 235 (26.1%) stage II, 270 (29.9%) stage III and 187 (20.6%) stage IV cases. Twenty-four (2.7%) cases were of undetermined stage. Postoperative complications occurred in 38% of the total group (37.8% of CC cases, 37.2% of the RC group, 66.7% of the synchronous cancer patients and 50% of those with HNPCC, p = 0.19) Mortality rate was 0.8%, (1.3% for colon cancer, 0% for rectal cancer; p = 0.023). Multivisceral resection was performed in 14.3% of cases. Disease-free survival in cases resected for cure was 73% at 5-years and 72% at 8 years. The 5- and 8-year overall survival rates were 71% and 61% respectively (total cases). At 5-year analysis, overall survival rates are 97% for stage I disease, 87% for stage II, 73% for stage III and 22% for stage IV respectively (p < 0.0001). The 5-year overall survival rates showed a marked difference in R0, R1+R2 and non resected patients (82%, 35% and 0% respectively, p < 0.0001). On multivariate analysis, resection for cure and stage at presentation but not tumour site (colon vs. rectum) were independent variables for overall survival (p < 0.0001).ConclusionA prospective, uniform follow-up policy used in a single institution over the last decade provides evidence of quality assurance in colorectal cancer surgery with high rates of resection for cure where only stage at presentation functions as an independent variable for cancer-related outcome.

Oncological results of oncoplastic breast-conserving surgery: Long term follow-up of a large series at a single institution: A matched-cohort analysis.

PURPOSE Oncoplastic surgery is a well-established discipline that combines conserving treatment for breast cancer with immediate plastic reconstruction. Although widely practiced, the oncologic outcomes of this combined approach are reported only in small series. The aim of the present paper is to assess the safety of oncoplastic surgery for invasive primary breast cancer. METHODS We compared 454 consecutive patients who underwent an oncoplastic approach between 2000 and 2008 for primary invasive breast tumors (study group) with twice the number of patients who received conservation alone in the same interval time (control group). Disease free survival and overall survival were estimated using the Kaplan-Meier method. The log-rank test was used to assess differences between groups. RESULTS The median follow-up was 7.2 years. The overall survival is similar within the two groups, being 91.4% and 91.3% at 10-yr in the study group and in the control group respectively. The disease free survival is slightly lower in the oncoplastic group (69 vs.73.1% at 10-yr). The difference is not statistically significant. DISCUSSION We have compared a large series of primary breast cancer patients that have undergone oncoplastic surgery (454) with a control group (908) and they were followed for a prolonged period of time. It provides the best available evidence to suggest that oncoplastic surgery is a safe and reliable treatment option for the managing of invasive breast cancer.

The Suspension Technique to Avoid the Use of Tissue Expanders in Breast Reconstruction

Background:Immediate or delayed breast reconstruction is usually performed using expansion techniques or pedicled or free flaps. The suspension technique hereby described can reduce the number of surgical stages, as well as donor-site sequelae. Technique:The authors describe a new technique of breast reconstruction with implants using a nonabsorbable mesh to create a superior abdominal cutaneous flap, which contributes to the skin envelope of the reconstructed breast. The advantage of this technique is the opportunity to use immediately a definitive prosthesis also in cases requiring a mastectomy with the resection of a large amount of skin, consequently reducing the indications of tissue expanders or myocutaneous flaps. Results:We performed the “suspension technique” in 67 cases of immediate reconstruction and in 6 cases of delayed reconstruction. No further surgery under general anesthesia was necessary in 56 patients (76.7%). In 14 cases (19.2%), a second operation under general anesthesia was necessary for implant replacement, capsula revision, and nipple and areola (NAC) reconstruction. In 3 cases (4.1%), implant removal was necessary due to implant exposition or infection. In 33 patients, only NAC reconstruction was performed under local anesthesia. In our series, capsula contracture was graded as Baker I in 24 cases, grade II in 16 cases, grade III in 9 cases, and grade IV in 1 case. Breast symmetry, patients satisfaction, and surgeon cosmetic evaluation were respectively scored 7.56, 7.75, and 7.60 (range from 1 to 10). Conclusion:In conclusion, this technique can be applied in cases requiring a large skin resection at the time of mastectomy and refusing a reconstruction with myocutaneous flaps or a second surgery, necessary if a reconstruction with tissue expanders is planned.

Prevention of Atrial Fibrillation in High-risk Patients Undergoing Lung Cancer Surgery: The PRESAGE Trial.

Objective: We performed a prospective, randomized clinical study to assess whether prophylactic treatment with metoprolol or losartan, initiated soon after lung cancer surgery in patients with elevated N-terminal pro-brain natriuretic peptide (NT-proBNP) levels, reduces the incidence of postoperative atrial fibrillation. Background: Postoperative atrial fibrillation is a well recognized complication after lung cancer surgery, with an incidence as high as 30%. Perioperative increase of NT-proBNP has been demonstrated to be a strong independent predictor of postoperative atrial fibrillation in this setting. Methods: NT-proBNP concentration was measured 24 hours before surgery and soon after surgery in 1116 patients. Three hundred twenty (29%) patients showed a high NT-proBNP value and were enrolled: 108 were assigned to the metoprolol group, 102 to the losartan group, and 110 to the control group. Results: Overall, the incidence of postoperative atrial fibrillation was 20% (n = 64); it was significantly lower in the metoprolol and losartan groups compared with the control group [6%, 12%, and 40%, respectively; relative risk 0.19, 95% confidence intervals (CIs), 0.09–0.37; P < 0.001 in the metoprolol group; and 0.29, 95% CI, 0.16–0.52; P < 0.001 in the losartan group). No significant difference was found when the metoprolol and losartan groups were directly compared (P = 0.21). Conclusions: A prophylactic treatment with metoprolol or losartan, initiated soon after lung cancer surgery in patients with high NT-proBNP levels, significantly reduced the occurrence of postoperative atrial fibrillation.

A Computerized Method to Measure Systolic Pressure Variation (SPV) in Mechanically Ventilated Patients

Introduction.Intrathoracic pressure variation duringmechanical ventilation has different effects on cardiac preload andstroke volume in both ventricles. Changes in left ventricle strokevolume are reflected by fluctuations of the arterial pressure waveformor Systolic Pressure Variation (SPV). SPV has been proposed as a way toevaluate vascular volume status in mechanically ventilated patients aswell as responsiveness of the left ventricle stroke volume to volumeloading. Objective.In this paper an automated system ispresented which is designed in order to provide physicians withinformation on SPV in mechanically ventilated patients. Methods.The developed system acquires the pressure transducer signal andanalyses the pressure waveform in order to detect and identify thehemodynamic changes. Five patients underwent the clinical protocol inorder to evaluate the software reliability. Each patient underwentmeasurements with positive end-expiratory pressure (PEEP) equal to 0 cmH2O, at an increase of 30% tidal volume, and at 15 cmH2O of PEEP, before and after infusion of 7 ml/kg of colloidsolution. Results.The reliability of the automated procedure hasbeen verified by comparing the obtained results with data collectedmanually in order to test on whether the new method data are correlatedwith the conventional procedure. Our results show that in the worst casewhen the widest range for the limits of agreement is considered, theerror is within 15%. Conclusions.The automated SPVmeasurement requires less time as well as human errors compared to themanual method; this makes SPV calculation a competitive alternative tomethods for the measurements of stroke volume variations as arterialthermodilution technique and transesophageal echocardiography, whichrequire sophisticated equipment and specific experience.

Operative rigid bronchoscopy: indications, basic techniques and results

Palliative airway treatments are essential to improve quality and length of life in lung cancer patients with central airway obstruction. Rigid bronchoscopy has proved to be an excellent tool to provide airway access and control in this cohort of patients. The main indication for rigid bronchoscopy in adult bronchology remains central airway obstruction due to neoplastic or non-neoplastic disease. We routinely use negative pressure ventilation (NPV) under general anaesthesia to prevent intraoperative apnoea and respiratory acidosis. This procedure allows opioid sparing, a shorter recovery time and avoids manually assisted ventilation, thereby reducing the amount of oxygen needed, while maintaining optimal surgical conditions. The major indication for NPV rigid bronchoscopy at our institution has been airway obstruction by neoplastic tracheobronchial tissue, mainly treated by laser-assisted mechanical dissection. When strictly necessary, we use silicone stents for neoplastic or cicatricial strictures, reserving metal stents to cover tracheo-oesophageal fistulae. NPV rigid bronchoscopy is an excellent tool for the endoscopic treatment of locally advanced tumours of the lung, especially when patients have exhausted the conventional therapeutic resources. Laser-assisted mechanical resection and stent placement are the most effective procedures for preserving quality of life in patients with advanced stage cancer.

Optimizing treatment of hepatic metastases from colorectal cancer: Resection or resection plus ablation?

The present study determines the oncologic outcome of the combined resection and ablation strategy for colorectal liver metastases (CRLM). Between January 1994 and December 2014, 360 patients underwent surgery for CRLM. There were 280 patients who underwent hepatic resection only (group 1) and 80 hepatic resection plus ablation (group 2). group 2 patients had a higher incidence of multiple metastases than group 1 cases (100% in group 2 vs. 28.2% in group 1; P<0.001) and bilobar involvement (76.5% in group 2 vs. 12.9% in group 1; P<0.001). Perioperative mortality was nil in either group with a higher postoperative complication rate amongst group 1 vs. group 2 cases (18 vs. 0, respectively). The median follow-up was 90 months (range, 1-180) with a 5-year overall survival for group 1 and group 2 of 49 and 80%, respectively (P=0.193). The median disease-free survival for patients with R0 resection was 50, 43 and 34% at 1, 2 and 3 years, respectively, and remained steadily higher (at 50%) in those patients treated with resection combined with ablation up to 5 years (P=0.069). The only intraoperative ablation failure was for a large lesion (≥5 cm). Our data support the use of intraoperative ablation when complete hepatic resection cannot be achieved.

What happens after pneumonectomy? A prospective study using the transpulmonary thermodilution method

event is the augmentation of the extravascular lung water (EVLW) that transudates into the alveolar space, impairing ventilation. In the experimental model, thoracotomy, rapid fluid infusion, and manipulation of the lung result in an increase in EVLW. 3 In humans, the transpulmonary thermodilution method is a reliable technique for EVLW assessment, even if a moderate overestimation as compared with the double-indicator method is expected in case of pneumonectomy. 4 Given the paucity of available information, this studywas designed tomonitor EVLW modifications occurring early after pneumonectomy in humans.

Learning Curve for Translaryngeal Tracheotomy in Head and Neck Surgery

Objectives Translaryngeal tracheotomy (TLT) is a widely accepted procedure in intensive‐care units for its simplicity of execution, low morbidity, rapid wound closure after cannula removal, good esthetic results, and lack of long‐term sequelae. The aim of this study was to evaluate the feasibility and use of adopting TLT in patients with cancer undergoing major head and neck surgery.

Splenodiaphragmatic colonic interposition and left hemidiaphragmatic elevation in a patient undergoing robot-assisted radical prostatectomy: a case report

Intestinal interposition occurs when a segment of the bowel is temporarily or permanently interposed between two organs. Hepatodiaphragmatic colonic interposition is termed Chilaiditi sign, while other conditions such as splenodiaphragmatic, splenorenal or gastropancreatic interposition are termed non-Chilaiditi sign.1 In most cases, this condition is asymptomatic and represents an incidental radiologic finding, but in rare cases abdominal and even respiratory symptoms have been described.2