Riccardo Lorusso

Laparoscopic surgery for gastric cancer: preliminary experience

BackgroundLaparoscopic surgery for gastric cancer (GC) was introduced in the past decade because it was considered less invasive than open surgery, resulting in less postoperative pain, faster recovery, and improved quality of life. Several studies have demonstrated the safety and feasibility of this procedure. We analyzed our preliminary experience with this procedure.MethodsFrom November 2003 to December 2004, 20 patients affected by gastric adenocarcinoma were operated on with a totally laparoscopic or laparoscopic-assisted approach. This series included 10 women and 10 men, aged from 34 to 75 years. Procedures consisted of eight total gastrectomies, three subtotal Billroth I and seven Billroth II gastrectomies, one proximal gastrectomy, and one wedge resection. According to the TNM classification, we observed five patients at stage Ia, four at stage Ib, three at stage II, one at stage IIIa, two at stage IIIb, and five at stage IV.ResultsIn all patients the procedures were completed without any conversion. Operative time ranged from 150 to 300 min. The number of dissected lymph nodes ranged from 23 to 47. No mortality was observed. Overall morbidity rate was 10% (two cases), with one enteric fistula and one esophagojejunal anastomotic leakage associated with pancreatitis. Excluding these two patients, postoperative stay was between 12 and 20 days.ConclusionsEven though accompanied by a difficult learning curve, safety and feasibility are widely demonstrated, but a skilled and experienced surgeon is required. Accurate selection of patients is mandatory and curative resection is achievable in cases where GC is not advanced.

Results of a pancreatectomy with a limited venous resection for pancreatic cancer

PurposeThe indications for a pancreatectomy with a partial resection of the portal or superior mesenteric vein for pancreatic cancer, when the vein is involved by the tumor, remain controversial. It can be assumed that when such involvement is not extensive, resection of the tumor and the involved venous segment, followed by venous reconstruction will extend the potential benefits of this resection to a larger number of patients. The further hypothesis of this study is that whenever involvement of the vein by the tumor does not exceed 2 cm in length, this involvement is more likely due to the location of the tumor being close to the vein rather than because of its aggressive biological behavior. Consequently, in these instances a pancreatectomy with a resection of the involved segment of portal or superior mesenteric vein for pancreatic cancer is indicated, as it will yield results that are superposable to those of a pancreatectomy for cancer without vascular involvement.MethodsTwenty-nine patients with carcinoma of the pancreas involving the portal or superior mesenteric vein over a length of 2 cm or less underwent a macroscopically curative resection of the pancreas en bloc with the involved segment of the vein. The venous reconstruction procedures included a tangential resection/lateral suture in 15 cases, a resection/end-to-end anastomosis in 11, and a resection/patch closure in 3.ResultsPostoperative mortality was 3.4%; morbidity was 21%. Local recurrence was 14%. Cumulative (standard error) survival rate was 17% (9%) at 3 years.ConclusionA pancreatectomy combined with a resection of the portal or superior mesenteric vein for cancer with venous involvement not exceeding 2 cm is indicated in order to extend the potential benefits of a curative resection.

Pancreatic remnant carcinoma after pancreaticoduodenectomy for bile duct cancer

independently and self-administer manual dilators to the ano-rectum to prevent stricture by a stomal wound nurse. Closure of her stoma occurred 7 months after her original presentation and healing of her perineum. She now has good continence and quality of life. The mainstay of burn wound management is early surgical debridement and skin grafting of the wound. The perineum, however, presents its own set of challenges. It is a difficult area to dress and also subject to constant faecal soiling, leading to poor healing and recurrent infection. Faecal diversion provides a means to avoid this added morbidity. A diverting loop ileostomy has a lower morbidity compared with colostomy for diversion of stool. Forming the stoma laparoscopically rather than open has a lower morbidity and reoperation rate. In our patient, formation and closure of the ileostomy was associated with minimal morbidity. The advantages of using the V-Y flap in the perineum are that it is rapid, relatively easy to perform and has an acceptable aesthetic result associated with a low morbidity. This problem of perineal burn injury provides a complex series of issues for the patient and treating team. Appropriate management requires a multidisciplinary approach for improved outcome.