Mario Diurni

Antibiotic prophylaxis in colorectal surgery

Nosocomial infections are the most frequent complications observed in surgical patients. In colorectal surgery, the opening of the viscera causes the dissemination into the operative field of microorganisms originating from endogenous sources, increasing the chance of developing postoperative complications. It is reported that without antibiotic prophylaxis, wound infection after colorectal surgery develops in approximately 40% of patients. This percentage decreases to approximately 11% after antibiotic prophylaxis. Specific criteria in the choice of correct antibiotic prophylaxis have to be respected, on the basis of the microorganisms usually found in the surgical site, and on the specific hospital microbiologic epidemiology.

Hemorrhoidectomy in day surgery.

UNLABELLED Day-case hemorrhoidectomy has shown to be safe and acceptable to patients. There are principally two procedures: Milligan-Morgan hemorrhoidectomy (MMH) and Longo stapled hemorrhoidopexy (SH). Furthermore great progress has been done in surgical technologies with the use of the Ligasure and the Doppler-guided hemorrhoidal artery ligation. The aim of this study is to analyze randomized controlled trials using all the major electronic databases (MEDLINE, EMBASE, CENTRAL) about hemorrhoidopexy and conventional excisional surgery, and randomized controlled trials about the Ligasure versus the conventional hemorrhoidectomy, and some reports about the use of a new device (Doppler transducer) in an outpatient setting. RESULTS We found 17 studies from 2004 up to 2008, 1276 patients, 409 in the stapled group, 389 in the conventional group, 268 in hemorrhoidal artery ligation procedure and 210 in Ligasure hemorrhoidectomy group. This study confirms that SH is associated with less postoperative pain and shorter postoperative symptoms, compared with MMH. SH may be a viable alternative to the conventional surgical therapy for hemorrhoids with some advantages and some disadvantages in postoperative complications and costs. An other suitable alternative to conventional procedures is the use of Ligasure, although long-term evaluation of outcomes and morbidity is still needed. Hemorrhoidal artery ligation procedure is safe and easy to learn and to perform, even with a recurrence rate of 12, but randomized trials are mandatory.

Postoperative infections after oesophageal resections: the role of blood transfusions

BackgroundPerioperative blood transfusion carries numerous potential risks concerning the transmission of infective diseases and immunodepression that can facilitate the occurrence of postoperative infectious complications. Explanation of connections between perioperative blood transfusion and postoperative septic complication worldwide is not well documented. Many studies have described a correlation between perioperative blood transfusions and postoperative infections. On the contrary, other studies indicate that factors influencing the need for blood transfusions during surgery have a greater bearing than blood transfusion per se on the occurrence of postoperative complications.Patients and methodsA prospective study was conducted in our Department on 110 consecutive patients undergoing oesophageal resection for primary cancer, in order to evaluate the incidence of postoperative infections related to perioperative allogenic blood transfusions. For each patient we preoperatively recorded in a computerized data-base several known risk-factors for postoperative infections; in detail we registered the administration of allogenic perioperative blood transfusions (period of administration, number of packages administered).ResultsAmong the enrolled 110 patients, 53 (48%) received perioperative blood transfusions: in this group postoperative infections (overall infective complications) occurred in 27 patients. After a multivariate analysis we observed that perioperative blood transfusions significantly affected as an independent variable the development of wound infections (p = 0.02).ConclusionBlood transfusions independently affected the incidence of wound infections in patients who underwent oesophageal resection for primary cancer.

Influence of new technologies on thyroid surgery: state of the art

The history of thyroid surgery starts with Billroth, Kocher and Halsted, who developed the technique for thyroidectomy between 1873 and 1910. In general, the essential objectives for thyroidectomy are conservation of the parathyroid glands, avoidance of injury to the recurrent laryngeal nerve, an accurate hemostasis and an excellent cosmesis. In the last 20 years, major improvements and new technologies have been proposed and applied in thyroid surgery; among these are mini-invasive thyroidectomy, new devices for achieving hemostasis and dissection, regional anesthesia and intraoperative neuromonitoring.

Injection of colorectal cancer cells in mesenteric and antimesenteric sides of the colon results in different patterns of metastatic diffusion: An experimental study in rats

BackgroundThis experimental study was designed to investigate the differences in pattern of local growth and diffusion of colorectal cancer cells injected into either mesenteric (M) or antimesenteric (AM) sides of the colon.MethodsA total of 1 × 106 colonic adenocarcinoma cells (line DHD/K12-TRb) were injected into the cecal wall of BDIX syngeneic male rats at an M or AM site of the colon. At six weeks after injection, all animals were sacrificed and the presence or absence of tumor in the cecum as well as regional metastasis and peritoneal carcinomatosis were determined.ResultsSix weeks after injection, macroscopic tumor growth was observed in 27/37 (72%) animals in group M and 21/32 (65%) in group AM (P = 0.98). In group AM, diffuse peritoneal carcinomatosis was present in 19/21 rats (90.4%) versus 3/27 rats (11%) in group M; this difference was statistically significant (P = 0.025). Regional mesenteric lymph nodes were the only location in which tumor was detected in 23/27 rats (85%) in group M versus 2/21 (9.5%) in group AM; this difference too was statistically significant (P = 0.031)ConclusionThe patterns of diffusion of tumors implanted in mesenteric and antimesenteric sites of the colon appear to be different, although the reason for this is not clear.

TUBULAR ADENOMA OF THE BREAST IN AN 84-YEAR-OLD WOMAN: REPORT OF A CASE SIMULATING BREAST CANCER

Abstract:  Tubular adenomas of the breast are rare and they mainly occur in young women. They must be differentiated from other benign lesions and from malignant breast cancer. Preoperative diagnosis is difficult because both radiologic and cytohistologic examinations performed before surgery are often not diagnostic; therefore, in most cases, surgical excision is the only way to reach a precise diagnosis and a definitive treatment. This article describes a case of an 84‐year‐old woman suffering from tubular adenoma of the breast. The authors underline the difficulty in preoperative differentiation between benign and malignant breast lesions.

Audit in day surgery in general surgery. Quality and criticality are compared

BACKGROUND The need to ensure complete medical and surgical assistance and the ever increasing challenge of containing costs in health care have found the perfect combination in day surgery. The aim of this study is to analyse date from the surgical Division I in a multidisciplinary day surgery. The activity has been assessed in terms of volume and above all quality of the procedures. Data collection of complication Data collection for infections Quality rating questionnaire Follow up Information leaflet for day surgery Meetings with nursing staff. METHODS The study was carried out by comparing data from the period 2003-2006. The activity of general surgery includes: general, breast, plastic and vascular. From 2003 to 2006 day surgery activity increased considerably, partly due to good organization and partly because it has been favourably received by the population. RESULTS During the period 2003-2006, 1835 operations were carried out in day surgery. The percentage of operations in D. S. compared to the total activity of Surgery Division I, demonstrates a gradual increase from 18.7 to 32%. In the last few years, some changes have been introduced in day surgery: CONCLUSIONS From the study carried out we can affirm that the present organization of our day surgery, manages to maintain a high standard of care and a low incidence of complications with statistical data similar to those described in literature.

Unusual rectal stenosis

We briefly present a case of a 58-year-old man with a 3-month history of dyspepsia, constipation, and tenesmus recently referred to our emergency department for evaluation of abdominal pain and recurrent vomiting. Medical history did not show any relevant problems. On presentation to the emergency department our patient was afebrile, with all other vital signs within normal limits. On physical examination, his abdomen was mildly distended, with diffuse pain on palpation; there was no guarding or rebound tenderness. Rectal exploration revealed a hard, concentric stenosis 6 cm from the anal verge. Results of blood tests, chest radiography, and an ECG were normal. An abdominal computed tomography showed a thickening of the gastric antrum and, simultaneously, confirmed an extended concentric stenosis of the whole rectum from the sigmoid junction to the anal verge (Fig. 1a,b). Endoscopic evaluations detected a wide substenotic ulcerative lesion of the medium and distal thirds of stomach and a strict insuperable stenosis of lower rectum with apparently normal mucosa. The gastric biopsies revealed a signet-ring cell gastric adenocarcinoma and histopathological findings of the rectum samples did not show any sign of tumoral involvement. Magnetic resonance of the pelvis confirmed an asymmetric thickening of the proximal rectum and a symmetric concentric stenosis of the medium-distal rectum along with some lymphadenopathies within mesorectum and presacral space. Laparotomy was performed with a working diagnosis of non-metastatic locally advanced gastric cancer, but surgical findings also included a hardening of rectal and perirectal tissue below the peritoneum. A total gastrectomy and a lateral decompressive left colostomy, along with a number of biopsies of perirectal tissue, were performed. Histopathological findings were consistent with signetring cell adenocarcinoma of stomach (with muscular layer and nodal involvement) and with infiltration of signet-ring cell adenocarcinoma of the rectal wall. Subsequently, the patient was referred for adjuvant chemotherapy. The rectal stenosis can be an atypical sign of gastric cancer and can to occur as a result of peritoneal dissemination of disease or, rarely, as result of lymphangitic spread of poorly differentiated signet-ring cell adenocarcinoma within the submucosa of the gastrointestinal tract (Schnitzler’s metastasis). In published case reports, lymphangitic involvement of the rectum is associated with a widespread extension of disease and, more often, metachronously [1–3]. This is the first reported case with synchronous Schnitzler’s metastasis associated with a (otherwise non-metastatic) primary gastric cancer. Stefano Rausei, MD* Francesco Frattini, MD Gianlorenzo Dionigi, MD, FACS Luigi Boni, MD, FACS Francesca Rovera, MD Mario Diurni, MD, FASCRS Department of Surgical Sciences University of Insubria Varese, Italy

Preoperative assessment of rectal cancer stage: state of the art

Rectal cancer is one of the most common tumors worldwide; it accounts for approximately 25–30% of cancers arising in the large bowel. Owing to greater distribution of screening programs and better attention from both patients and General Practitioners to this disease, in recent years we have observed an increasing number of cases diagnosed in the early stages, with a consequent better prognosis. The improved 5-year survival is also partially due to better, and more accurate, diagnostic techniques and to more curative treatments. In this review, the authors analyze and discuss the more recent diagnostic techniques for an accurate preoperative staging of rectal cancer, highlighting each method’s advantages and limits for their routine use in clinical practice.