Maria Gioffre’-Florio

Simple versus double jejunal pouch for reconstruction after total gastrectomy

BACKGROUND Even though many types of reconstruction after total gastrectomy have been proposed to reduce postgastrectomy syndromes, choosing a method that would further improve the quality of life and nutrition of the gastrectomized patient is controversial. Hunt-Lawrence single pouch reconstruction seems to obtain better results compared with the more common Roux-en-Y technique, but both of these reconstructive approaches are associated with some reduction in food intake and some problems in achievement of ideal body weight. METHODS In this prospective, randomized trial, after total gastrectomy 18 patients had reconstruction according to the Hunt-Lawrence or single pouch technique (SP group), whereas for 23 patients, the technique was modified with construction of a second pouch in the distal portion of the jejunal loop (DP group). Patients in the two groups were compared at 12 months after surgery for problems in gastrointestinal function, quality of life, improvement in body weight and nutritional parameters, serum albumin, hemoglobin level, and serum protein. RESULTS The DP group demonstrated fewer symptom problems, better weight maintenance, and better laboratory values when compared with patients undergoing standard single jejunal pouch reconstruction. CONCLUSIONS Reconstruction with use of a double pouch as a gastric substitute leads to better outcome assessments than with a single pouch reconstruction. Our double pouch technique has demonstrated significant improvement in quality of life and nutritional recovery in terms of functional results as well as patient satisfaction.

Laparoscopic palliative gastrojejunostomy for advanced recurrent gastric cancer after Billroth I resection.

Palliative surgery for advanced gastric cancer has equivocal results. Laparoscopy is likely to provide some advantage compared to open procedures. We present a case of laparoscopic gastrojejunostomy for advanced gastric cancer, which recurred after Billroth I resection. Reproducing the results of the early experiences so far reported in the literature, laparoscopy provided us with the accurate staging of the disease along with the opportunity, at the same time, to perform a palliative procedure, avoiding laparotomy. Operative results were good, vomiting was relieved, and the patient was able to cope with his disease until death eventually occurred after 6 months.

Prognostic value of HMGB1 and oxidative stress markers in multiple trauma patients: A single-centre prospective study

Serious multiple traumatic injuries may rapidly become fatal or be complicated by a life-threatening sequelae leading to a significant increase of the mortality rate. Trauma scoring systems are used to evaluate the critical status of the patient and recently many different biomarkers have been taken into account to better estimate the potential clinical outcome. The aim of the present study is to analyse the expression pattern of high-mobility group box-1 (HMGB1), oxidative stress markers and nuclear factor erythroid 2-related (Nrf2) in critically ill traumatic patients (at hospital admittance and after 6 and 24 h), in order to find out their potential role as early post-traumatic predictors markers. Forty-seven patients admitted for multiple trauma and 15 healthy participants were prospectively recruited. Eight patients (17%) died within 92 h of admission; this subgroup of patients presented the highest severity scores and their HMGB1 expression levels were significantly correlated with ISS, whereas patients with higher ISS exhibited higher levels of HMGB1 (P <0.001). Our study suggests the role of HMGB1 as a predictive biomarker of outcome in injured patients and hypothesizes the protective role of Nrf2 in bringing down the oxidative stress and HMGB1 release; measuring HMGB1 in combination with Nrf2 might represent a potentially useful tool in the early detection of post-trauma complications.

Influence of needle diameter on spinal anaesthesia puncture failures for caesarean section: A prospective, randomised, experimental study

OBJECTIVES Spinal anaesthesia represents the technique of choice for elective caesarean section. The purpose of this study was to compare the puncture failure rates with 25, 26 or 27 gauge (G) pencil-point, Whitacre type (with introducer) needles during spinal anaesthesia for caesarean section. STUDY DESIGN Prospective, randomised, experimental study in healthy subjects. PATIENTS AND METHODS We recruited 330 adults, consecutively scheduled parturients, randomised into three groups. The subarachnoid puncture procedure was standardised. The flexibility of the three needle types was assessed in vitro, and a force was applied using a dynamometer. The occurrence of postdural puncture headache was also evaluated. RESULTS The number of spinal puncture failures was significantly higher in the 27G group, than in the 25G (P=0.006) group and the 26G (P<0.001) group, but did not differ between the 25G and 26G groups (P=0.606). Ten postdural puncture headaches were observed without significant differences among the groups. CONCLUSIONS This prospective study showed that puncture failures occur less frequently with the use of 25G or 26G pencil-point needles as compared to 27G needles, probably due to the higher flexibility of the latter. This characteristic was demonstrated in vitro, in a reproducible model. This experiment suggests that a 26G pencil-point needle is the optimal gauge for performing spinal anaesthesia for scheduled caesarean sections.

Colonic acute malignant obstructions: effectiveness of self-expanding metallic stent as bridge to surgery

BACKGROUND/AIMS Bowel obstruction is a frequent event in patients with adenocarcinoma, affecting, in some series, almost one-third of the patients. In the last decades, in addition to surgery, self-expanding metallic stents (SEMSs) are available both as a bridge to surgery (BTS) or palliation. The aim of our study was to demonstrate the safety and efficacy of the use of SEMSs as BTS in selected patients with acute colonic malignant obstructions. MATERIALS AND METHODS In total, 125 patients with malignant colonic obstruction who underwent emergency surgery or stent insertion were retrospectively enrolled in our study; 62 patients underwent surgery initially, whereas 62 were subjected to stenting as BTS. The 6-month and 1-year survival rates after the procedure (stenting or surgery) and short-term and long-term complication rates were considered as primary endpoints; the recanalization rate after Hartmanns procedure and the length of hospitalization were considered as secondary endpoints. RESULTS On comparing the surgery group (SG) and the BTS group (BG), we observed a lower short-term complication rate (p<0.05) and a reduction in the mean hospital stay (16.1±7.7 vs. 13.5±3.0, p<0.05) in the latter. No differences in long-term complications were found. The recanalization rate after Hartmanns procedure was higher in BG than in SG, although this was not statistically significant. CONCLUSION Our experience shows that SEMS insertion is a safe and effective technique in selected patients with colonic malignant obstruction; the reduction in hospital stay and short-term complications in BG is an important cost-saving aim.

Late recurrent cutaneous breast angiosarcoma in an elderly woman: A case report

Breast angiosarcomas are malignant tumours of the vascular endothelium that arise frequently following radiation therapy. Their clinical and radiological aspects are highly heterogeneous. The current study reports an unusual case, never previously reported, of a late recurrent breast angiosarcoma occurring in an 83-year old female patient 11 years after a breast-conserving surgery followed by radiation therapy for an invasive ductal carcinoma, and 5 years after her initial angiosarcoma excision. The first physician to examine the patient noted a palpable mass near the scar and, following ultrasonography, described the breast lesion as suggestive of an abscess, despite the previous history of neoplasia. Typically, recurrences of breast angiosarcoma occur within the first postsurgical year. The present patient remains alive at 25 months after her last surgical treatment, and no evidence of any local or distant disease is observable.

Preoperatively undiagnosed papillary thyroid carcinoma in patients thyroidectomized for benign multinodular goiter

OBJECTIVE Incidental thyroid cancers (ITCs) are often microcarcinomas; among them, the most frequent histotype is the papillary one. The purpose of this study was to evaluate the rate of papillary thyroid cancer (PTC) in patients thyroidectomized for benign multinodular goiter. SUBJECT AND METHODS We retrospectively evaluated the histological incidence of PTC in 207 consecutive patients who, in a 1-year period, underwent thyroidectomy for benign multinodular goiter. All patients came from an iodine-deficient area (Orleans, France) with three nuclear power stations located in the neighboring areas of the county town. RESULTS Overall, 25 thyroids (12.1%) harbored 37 PTC, of which 31 were microcarcinomas. In these 25 PTC patients, mean age was 55 ± 10 years (range 30-75), female:male ratio 20:5 (4:1). In 10 patients (40% of 25 and 4.8% of 207), PTCs were bilateral, and in 7 (2 with microPTCs) the thyroid capsule was infiltrated. These 7 patients underwent central and lateral cervical lymph node dissections, which revealed lymph node metastases in one and two cases, respectively. Radioiodine treatment was performed in 7 cases. Neither mortality nor transient and permanent nerve injuries were observed. Four (16%) transient hypocalcaemias occurred as early complications. At last follow-up visit (mean length of follow-up 17.2 ± 3.4 months), all patients were doing well and free of any clinical local recurrence or distant metastases. CONCLUSION With a 12% risk that multinodular goiter harbors preoperatively unsuspected PTCs, which can have already infiltrated the capsule and that can be accompanied by PTC foci contralaterally, an adequate surgical approach has to be considered.

Comment on Article Entitled “Parathyroid Autotransplantation During Thyroid Surgery: A Novel Technique Using a Cell Culture Nutrient Solution”: Reply

We thank Jha et al. [1] for their interest on our article evaluating the efficacy of parathyroid autotransplantation in a series of consecutive patients surgically treated for a benign thyroid disease [2], along 2 years, in a French regional hospital with high activity in endocrine surgery [2–7]. As they mentioned, most of the endocrine surgeons agree that at least for inadvertently removed or devathankscularized glands, the best strategy is immediate autotransplantation, even if it is not uniformly accepted by all as routine practice because of higher incidence of temporary hypoparathyroidism reported with this policy in some studies [1]. It is true that one of the problems associated with validation of the techniques of parathyroid autotransplantation is the difficulty of assessing gland’s functionality and that evaluation of parathyroid autografts include confirmatory biopsy or test it for PTH secretion or nuclear medicine techniques [8–11], even if these methods are performed with difficulty in patients in the follow-up period for practical reasons [1]. The authors mentioned two interesting methods for preserving the resected parathyroid glands ex vivo before they are autotransplanted, such as iced saline (because of its ‘‘easy availability, low cost and excellent results’’) and the technique in which the gland to be transplanted is minced immediately after resection and then autotransplanted without being transferred into any preservative solution (characterized, in their opinion, ‘‘by zero incidence of permanent hypoparathyroidism’’). In this way, they have raised several comments and questions about our study. First of all, it is not true that autotransplantation of minced glands is characterized by zero incidence of permanent hypoparathyroidism, and also the study cited by the authors states that ‘‘routine autotransplantation of at least one parathyroid gland during total thyroidectomy may reduce permanent hypoparathyroidism to zero’’ [12]; moreover, the combination of the two cited techniques is not able to reduce permanent hypoparathyroidism to zero [13]; additionally, not only in thyroidectomized patients because of thyroid cancer [14] but also in surgical management of advanced hypopharyngeal and laryngeal carcinomas [13], parathyroid autotransplantation failure has been reported using iced saline plus minced glands. Based on these data, we reply to the authors that in some cases we need something different from the ubiquitous iced saline. Statistical analyses in our paper [2] have demonstrated that parathyroid autotransplantation after cell nutrient solution and mincing steps permits to improve surgical results, which have been confirmed either by the determination graft function based on biochemical analysis of the serum calcium concentration [15–17] and endocrinological follow-up. Moreover, to avoid bias, we have controlled that other factors known or suspected to affect the functionality of parathyroid graft (i.e., the number of pockets created, site of autotransplantation, size of the slices, number of slices placed in each pocket, presence of hematoma in pockets) were similar in all the three groups of our study [2]. In consequence, we suggest to perform parathyroid autotransplantation with our simple and not expensive technique, in order to reach additional surgical successes over time. & Fausto Fama’ famafausto@yahoo.it