Micol Sole Di Patrizi

The sigmoid volvulus: surgical timing and mortality for different clinical types

BackgroundIn western countries intestinal obstruction caused by sigmoid volvulus is rare and its mortality remains significant in patients with late diagnosis. The aim of this work is to assess what is the correct surgical timing and how the prognosis changes for the different clinical types.MethodsWe realized a retrospective clinical study including all the patients treated for sigmoid volvulus in the Department of General Surgery, St Maria Hospital, Terni, from January 1996 till January 2009. We selected 23 patients and divided them in 2 groups on the basis of the clinical onset: patients with clear clinical signs of obstruction and patients with subocclusive symptoms. We focused on 30-day postoperative mortality in relation to the surgical timing and procedure performed for each group.ResultsIn the obstruction group mortality rate was 44% and it concerned only the patients who had clinical signs and symptoms of peritonitis and that were treated with a sigmoid resection (57%). Conversely none of the patients treated with intestinal derotation and colopexy died. In the subocclusive group mortality was 35% and it increased up to 50% in those patients with a late diagnosis who underwent a sigmoid resection.ConclusionsThe mortality of patients affected by sigmoid volvulus is related to the disease stage, prompt surgical timing, functional status of the patient and his collaboration with the clinicians in the pre-operative decision making process. Mortality is higher in both obstructed patients with generalized peritonitis and patients affected by subocclusion with late diagnosis and surgical treatment; in both scenarios a Hartmanns procedure is the proper operation to be considered.

A severe case of hemobilia and biliary fistula following an open urgent cholecystectomy

BackgroundCholecystectomy has been the treatment of choice for symptomatic gallstones, but remains the greatest source of post-operative biliary injuries. Laparoscopic approach has been recently preferred because of short hospitalisation and low morbidity but has an higher incidence of biliary leakages and bile duct injuries than open one due to a technical error or misinterpretation of the anatomy. Even open cholecystectomy presents a small number of complications especially if it was performed in urgency. Hemobilia is one of the most common cause of upper gastrointestinal bleeding from the biliary ducts into the gastrointestinal tract due to trauma, advent of invasive procedures such as percutaneous liver biopsy, transhepatic cholangiography, and biliary drainage.MethodsWe report here a case of massive hemobilia in a 60-year-old man who underwent an urgent open cholecystectomy and a subsequent placement of a transhepatic biliary drainage.ConclusionThe management of these complications enclose endoscopic, percutaneous and surgical therapies. After a diagnosis of biliary fistula, its most important to assess the adequacy of bile drainage to determine a controlled fistula and to avoid bile collection and peritonitis. Transarterial embolization is the first line of intervention to stop hemobilia while surgical intervention should be considered if embolization fails or is contraindicated.

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 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.

Laparoscopic adhesiolysis in the elderly patient

Results For 3 (11.1%) of the 27 patients treated with laparoscopy a conversion was necessary because of the adhesions localization in the posterior abdominal wall. The median stay in hospital was 4.7 days for patients who underwent laparoscopy and 14.3 days for patients treated with traditional laparotomy. None of the first groups patients were reoperated on within 30 days of surgery, while 5 patients (3.1%) of the patients who underwent laparotomy needed to be reoperated because of obstruction recurrence by new adhesions.

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 role of CT in acute mesenteric ischemia

Results Only 12 patients (37.5%) performed a preoperative diagnostic CT study, whereas in 20 cases (62.5%) the intestinal ischemia was diagnosed during surgical exploration. The acute mesenteric ischemia caused primarily by occlusive superior mesenteric artery in 26 cases (81.2%) and by venous thrombosis in 6 cases (18.7%). Most of the embolus are located approximately 3–10 cm from superior mesenteric artery emergence. An arterial embolus can be detected like filling defect or like an abrupt interruption of vascular enhancement. Frequently a secondary venous thrombosis follows the arterial occlusion. CT shows a moderate intestinal wall thickening and inclusions in air signs of intestinal gangrene. Only 19 (59.3%) of 32 patients survived the acute intestinal ischemia (in hospital mortality was 40.6%), delayed diagnostic and operation caused higher mortality. In 12 cases a preoperative diagnostic CT was performed the mortality was 32.5%.

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.