Piero Buccianti

Perineal colostomy and electrostimulated gracilis “neosphincter” after abdomino-perineal resection of the colon and anorectum: a surgical experience and follow-up study in 47 cases

A series of 47 patients undergoing abdominoperineal resection of the distal colon and anorectum and construction of a continent perineal colostomy using electrostimulated gracilis muscle is described. External and implanted pulse generators have both been used. An analysis of complications and oncological data are reported. There was no operative mortality. The incidence of complications, divided into three classes, mild (62%), moderate (27%) and severe (11%), has not significantly altered the functional results, with the exception of early ischaemia of the colonic stump in two cases. During the first 22 cases, no preoperative oncological staging was performed. In the last 23 patients endorectal ultrasonography and CT scanning were carried out. Functional results were evaluated by electromanometry, electromyostimulation and dynamic defaecography. Clinical data assessed postoperatively showed good function in 65% of cases, fair in 22.5% and poor in 12.5%. The quality of life in 15 patients with a perineal colostomy and electrostimulated gracilis was significantly better than in 15 patients having an abdomino-perineal resection without gracilis plastic reconstruction.

Trocar site tumor recurrences. May pneumoperitoneum be responsible

AbstractBackground: Port site metastasis following laparoscopy for cancer is reported with increasing frequency and represents one of the most important limitations of the technique.n Methods: A scintigraphic model was utilized to evaluate a possible role of pneumoperitoneum in tumor cell dissemination. Labeled red blood cells (RBC) were injected at the level of the gallbladder bed during laparoscopic cholecystectomy (LC) performed for symptomatic cholecystolithiasis. LC was performed in two groups with standard CO2 pneumoperitoneum: in one group an endobag for retrieval of the specimen was utilized. In one group a gasless LC with endobag was performed.n Results: Radioactivity in the area of the trocar introduction was observed in almost all the patients who underwent standard (CO2) LC but represented a rare event in patients treated with the gasless method. The utilization of a protective bag for the extraction of the surgical specimen did not modify significantly the results. Moreover all patients treated with pneumoperitoneum demonstrated a wide intraperitoneal diffusion of the tracer not observed in gasless patients.n Conclusions: The results of this study confirm that pneumoperitoneum may play an important role in the evolution of port site metastasis after laparoscopy for gastrointestinal cancer.

Preoperative rectal cancer staging with phased-array MR

BackgroundWe retrospectively reviewed magnetic resonance (MR) images of 96 patients with diagnosis of rectal cancer to evaluate tumour stage (T stage), involvement of mesorectal fascia (MRF), and nodal metastasis (N stage).Our gold standard was histopathology.MethodsAll studies were performed with 1.5-T MR system (Symphony; Siemens Medical System, Erlangen, Germany) by using a phased-array coil. Our population was subdivided into two groups: the first one, formed by patients at T1-T2-T3, N0, M0 stage, whose underwent MR before surgery; the second group included patients at Tx N1 M0 and T3-T4 Nx M0 stage, whose underwent preoperative MR before neoadjuvant chemoradiation therapy and again 4-6 wks after the end of the treatment for the re-staging of disease.Our gold standard was histopathology.ResultsMR showed 81% overall agreement with histological findings for T and N stage prediction; for T stage, this rate increased up to 95% for pts of group I (48/96), while for group II (48/96) it decreased to 75%.Preoperative MR prediction of histologically involved MRF resulted very accurate (sensitivity 100%; specificity 100%) also after chemoradiation (sensitivity 100%; specificity 67%).ConclusionsPhased-array MRI was able to clearly estimate the entire mesorectal fat and surrounding pelvic structures resulting the ideal technique for local preoperative rectal cancer staging.

Fibrotic and Vascular Remodelling of Colonic Wall in Patients with Active Ulcerative Colitis

BACKGROUND AND AIMSnIntestinal fibrosis is a complication of inflammatory bowel disease [IBD]. Although fibrostenosis is a rare event in ulcerative colitis [UC], there is evidence that a fibrotic rearrangement of the colon occurs in the later stages. This is a retrospective study aimed at examining the histopathological features of the colonic wall in both short-lasting [SL] and long-lasting [LL] UC.nnnMETHODSnSurgical samples of left colon from non-stenotic SL [≤ 3 years, n = 9] and LL [≥ 10 years, n = 10] UC patients with active disease were compared with control colonic tissues from cancer patients without UC [n = 12] to assess: collagen and elastic fibres by histochemistry; vascular networks [CD31/CD105/nestin] by immunofluorescence; parameters of fibrosis [types I and III collagen, fibronectin, RhoA, alpha-smooth muscle actin [α-SMA], desmin, vimentin], and proliferation [proliferating nuclear antigen [PCNA]] by western blot and/or immunolabelling.nnnRESULTSnColonic tissue from both SL-UC and LL-UC showed tunica muscularis thickening and transmural activated neovessels [displaying both proliferating CD105-positive endothelial cells and activated nestin-positive pericytes], as compared with controls. In LL-UC, the increased collagen deposition was associated with an up-regulation of tissue fibrotic markers [collagen I and III, fibronectin, vimentin, RhoA], an enhancement of proliferation [PCNA] and, along with a loss of elastic fibres, a rearrangement of the tunica muscularis towards a fibrotic phenotype.nnnCONCLUSIONSnA significant transmural fibrotic thickening occurs in colonic tissue from LL-UC, together with a cellular fibrotic switch in the tunica muscularis. A full-thickness angiogenesis is also evident in both SL- and LL-UC with active disease, as compared with controls.

Minor-but-complex liver resection: An alternative to major resections for colorectal liver metastases involving the hepato-caval confluence

Abstract Major hepatectomy (MH) is often considered the only possible approach for colorectal liver metastasis (CRLM) at the hepato-caval confluence (CC), but it is associated with high morbidity and mortality. With the aim to reduce MH, we developed the “minor-but-complex” (MbC) technique, which consists in the resection of less than 3 adjacent liver segments with exposure of the CC and preservation of hepatic outflow until spontaneous maturation of peripheral intrahepatic shunts between main hepatic veins. We have evaluated applicability and outcome of MbC resections for the treatment of CRLM involving the CC. In this retrospective cohort study, all consecutive liver resections (LR) performed for CRLM located in segments 1, 7, 8, or 4a were classified as MINOR – removal of <3 adjacent segments; MbC – removal of <3 adjacent segments with CC exposure; and MH – removal of ≥3 adjacent segments. The rate of avoided MH was obtained by the difference between the rate of potentially MH (PMH) plus potentially inoperable cases and the rate of the MH performed. Taking into account that postoperative mortality is mainly related to the amount of resected liver, MbC was compared with minor resections for safety, complexity, and outcome. Of the 59 LR analyzed, 29 (49.1%) were deemed PMH and 4 (6.8%) potentially inoperable. Eventually, MH was performed only in 8 (13.5%) with a decrease rate of 42.4%. Minor LR was performed in 23 (39.0%) and MbC LR in 28 (47.5%) patients. Among MbC cases, 32.1% had previous liver treatments, 39.3% required vascular reconstruction (no reconstructed vessel thrombosis occurred before maturation of peripheral intrahepatic shunts between main hepatic veins), and 7.1% had grade IIIb–IV complications, their median hospital stay was 9 days and 90-day mortality was 0%. After a median follow-up of 22.2 months, oncological results were comparable with those of minor resections. MbC hepatectomy lowers the need for MH and allows for the resection of potentially inoperable patients without negative impact on safety and survival.

MRI tumor volume reduction rate vs tumor regression grade in the pre-operative re-staging of locally advanced rectal cancer after chemo-radiotherapy

OBJECTIVEnTo compare tumor volume reduction rate (TVRR) measured by MR volumetry after preoperative chemoradiotherapy (CRT) and pathological tumor regression grade (TRG) in locally advanced rectal cancer (LARC).nnnMATERIAL AND METHODSnIn total, 20 patients with LARC (cT3-T4) treated with CRT followed by Total Mesorectal Excision (TME) between April 2011 and April 2013 were analyzed retrospectively. Pre- and post- CRT tumor volumes (MR volumetry) were measured on 3D MR sequences. TVRR was determined using the equation TVRR (%)=(pre-CRT tumor volume-post-CRT tumor volume)×100/pre-CRT tumor volume. The downstaging (defined as ypT0-T2) of tumor mass was evaluated and the correlation between TVRR and TRG was calculated with the method proposed by Dworak using the Spearman rank test.nnnRESULTSnThe median TVRR was 77.3% (range, 26.4-99.3%); TVRR was >60% in 18 cases (90%) and in 8 of these patients (44.4 %) it was >80%. Downstaging of tumor lesions was obtained in 15 patients (75%). In 4 cases there was a complete tumor regression (TRG4) at histological examination and in the same patients there was also a TVRR>80% measured by MR volumetry. A statistically significant correlation between TVRR and TRG (r(s)=0.5466, p=0.0126) was observed.nnnCONCLUSIONnTVRR after preoperative CRT correlates with TRG in LARC. The MR volumetry is a prognostic factor to estimate the tumor response after preoperative CRT. TVRR data may be an useful biomarker for tailoring surgery and postoperative adjuvant chemotherapy.

Role of cyclooxygenase isoforms in the altered excitatory motor pathways of human colon with diverticular disease.

The COX isoforms (COX‐1, COX‐2) regulate human gut motility, although their role under pathological conditions remains unclear. This study examines the effects of COX inhibitors on excitatory motility in colonic tissue from patients with diverticular disease (DD).

Laparoendoscopic treatment of gastric ectopic pancreas.

A case of ectopic pancreas located on the anterior gastric wall treated with a combined gastroscopic and laparoscopic approach, which permitted isolation and complete resection of the lesion, is reported. The patient was discharged without complication.

Use of a new integrated table motion for the da Vinci Xi in colorectal surgery

Dear Editor: Integrated Table Motion (ITM) for the da Vinci Xi surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA) is a new feature comprising a unique operating table by Trumpf Medical Systems that communicates wirelessly with the da Vinci Xi. The ITM feature allows surgical staff to reposition the patient without undocking the robot and without removing instruments from inside the abdomen. The da Vinci Xi surgical system and the TruSystem 7000dV operating table (TS7000dV, TRUMPF Medizin Systeme GmbH & Co. KG, Saalfeld, Germany) have been specifically developed to address some technical limitations of the da Vinci Si surgical system, and to improve multiquadrant robotic surgery. An important drawback during robotic procedures with the previous da Vinci Si system is the inability to move the table position with the robotic arms docked. This problem may be particularly amplified in multiquadrant operations, such as colorectal surgery, in which the patient and the robot itself need to be rearranged several times to optimally achieve different surgical targets or provide patient relief. Herein, we present the first study on human use of this device in colorectal surgery. The purpose of this study was to evaluate the efficacy, feasibility, and safety of ITM for the da Vinci Xi system in performing robotic colorectal resections. Between May and October 2015, the first human use of ITMwas carried out in a post-market study in the EU in which 40 cases from different specialties (general surgery, urology, or gynecology) were prospectively enrolled. The Ethics Committee of our institution approved this study. Patients who planned to undergo minimally invasive surgery within the specialties of general surgery, urology, or gynecology with the commercially available da Vinci Xi surgical system and who were eligible based on the inclusion and exclusion criteria of this study were offered enrolment. Study-specific informed consent was obtained in writing from each patient before any procedure specific to the clinical investigation was performed. Inclusion criteria were as follows: bodymass index ≤45 kg/ m; age 18 years or older; suitable for minimally invasive surgery; undergoing a surgical procedure in urology, gynecology, or general surgery; ability to tolerate the Trendelenburg position; willingness to participate as demonstrated by giving written informed consent. Exclusion criteria were as follows: American Society of Anesthesiologists (ASA) IV patients; pregnancy; lack of cooperation due to psychological or severe systemic illness; comorbid medical conditions contraindicating general anesthesia or standard surgical approaches; vulnerable population (such as prisoners, mentally disabled); anatomy unsuitable for endoscopic visualization or minimally invasive surgery; extensive previous abdominal surgery; patient not Study supported by the ARPA foundation, www.fondazionearpa.it

Interest of sentinel node biopsy in apparently intrathyroidal medullary thyroid cancer: a pilot study

PurposeInitial surgery for medullary thyroid cancer (MTC) with no evidence of lymph node involvement in neck compartments consists of total thyroidectomy and prophylactic central neck dissection. This study evaluated the reliability of a radiotracer technique for the intraoperative detection of sentinel lymph nodes (SLNs) in lateral compartments in patients with early MTC.MethodsPatients with limited (cT1 N0) MTC entered the study (2009–2012). A 0.1–0.3xa0ml suspension of macrocolloidal technetium-99-labeled human albumin was injected (under echo-guide) in the tumor 5xa0h before surgery. Preoperative lymphoscintigraphy confirmed the identification of SLNs in the lateral neck. The operation consisted of total thyroidectomy and central neck dissection, and a hand-held gamma-probe (Neoprobe) guide was used to remove the SLNs from the lateral neck.ResultsFour patients were recruited. The tracer always indicated a SLN. Pathology reports indicated micrometastases from MTC in SLN in three patients. At a mean follow-up of 30.5xa0months, all patients were biochemically cured. The technique we describe to detect and remove neck SLN from MTC seemed to be very accurate. It always showed the SLNs (usually two) in the lateral compartments. Micrometastases were detected in three of four patients, allowing their correct staging.ConclusionsThe method described here for the detection of SLNs in early MTC seems effective and reliable and can be used for a more precise N staging of the patients. It could play a role, alone or combined with other techniques, in driving the extent of prophylactic neck dissection or other potential applications.