Rosario Fornaro

APPENDECTOMY OR RIGHT HEMICOLECTOMY IN THE TREATMENT OF APPENDICEAL CARCINOID TUMORS

Aims and background Carcinoids of the appendix continue to be of interest, despite their low incidence. There is still considerable controversy surrounding these tumors, especially with regard to the role of right hemicolectomy in the surgical management. The aim of this work was to explicate the current therapeutic knowledge and to review the criteria for the indications of appendectomy or hemicolectomy. Methods The records of patients who underwent appendectomies from 1990 to 2000 were analyzed. Seven patients were included in the study. The clinical data were reviewed for demographic details, tumor size, localization in the appendix, histological patterns and surgical procedures. All patients underwent appendectomy including removal of the mesenteriolum, and in one of them a right hemicolectomy was performed 3 weeks later. The mean follow-up was 7 years (range, 4–14). Follow-up data included symptoms, urinary 5-hydroxyin-doleacetic acid, ultrasound examination, computerized tomography, and octreotide scanning. Results Seven patients (0.9% of all appendectomies) were reported to have carcinoid tumors of the appendix. They were 3 men and 4 women with a mean age of 29 years. All patients were admitted for appendicitis. None suffered from the carcinoid syndrome. The site of the tumor was the apex of the appendix in 4 cases, the body in 2 cases and the base in 1 case. Mean tumor diameter was 8 mm (range, 5–29 mm); in 6 patients it was <2 cm. Treatment was appendectomy in all cases; additional right hemicolectomy was necessary in one case because of a tumor of more than 2 cm with invasion of the mesoappendix and lymph nodes. The 7-year survival rate is 100%. Six patients are without disease, while 1 patient (the one who underwent a right hemicolectomy) developed metastases in the liver 6 years after the operation. This patient, who was treated with a liver resection, is still alive. Conclusions According to current guidelines, an appendectomy may be performed for small carcinoid tumors (<1 cm). Reasons for more extensive surgery than appendectomy are tumor size >2 cm, lymphatic invasion, lymph node involvement, spread to the mesoappendix, tumor-positive resection margins, and cellular pleomorphism with a high mitotic index. The criteria that direct us towards major (hemicolectomy) or minor surgery (appendectomy) are controversial. Tumor size is still considered the most important prognostic factor, with a presumed increase in the risk of metastasis for tumors greater than 2.0 cm. The accepted treatment of such tumors is a right hemicolectomy. However, there is no evidence demonstrating a survival benefit for right hemicolectomy over simple appendectomy in patients with carcinoids greater than 2.0 cm in diameter.

Colorectal Cancer in Patients With Inflammatory Bowel Disease: The Need for a Real Surveillance Program.

The association between inflammatory bowel disease (IBD) and colorectal cancer (CRC) has been widely shown. This association is responsible for 10% to 15% of deaths in patients with IBD, even if according to some studies, the risk of developing CRC seems to be decreased. An adequate surveillance of patients identified as at-risk patients, might improve the management of IBD-CRC risk. In this article we review the literature data related to IBD-CRC, analyze potential risk factors such as severity of inflammation, duration, and extent of IBD, age at diagnosis, sex, family history of sporadic CRC, and coexistent primary sclerosing cholangitis, and update epidemiology on the basis of new studies. Confirmed risk factors for IBD-CRC are severity, extent, and duration of colitis, the presence of coexistent primary sclerosing cholangitis, and a family history of CRC. Current evidence-based guidelines recommend surveillance colonoscopy for patients with colitis 8 to 10 years after diagnosis, further surveillance is decided on the basis of patient risk factors. The classic white light endoscopy, with random biopsies, is now considered unsatisfactory. The evolution of technology has led to the development of new techniques that promise to increase the effectiveness of the monitoring programs. Chromoendoscopy has already proved highly effective and several guidelines suggest its use with a target biopsy. Confocal endomicroscopy and autofluorescence imaging are currently being tested and for this reason they have not yet been considered as useful in surveillance programs.

Surgical and medical treatment in patients with acute severe ulcerative colitis

Ulcerative colitis (UC) is a chronic inflammatory disease of the mucosa of the colorectum. The treatment of UC depends on the severity of symptoms and the extent of the disease. Acute severe colitis (ASC) occurs in 12–25% of patients with UC. Patients with ASC must be managed by a multidisciplinary team. Medically or surgically aggressive treatment is carried out with the final aim of reducing mortality. Intravenous administration of corticosteroids is the mainstay of the therapy. Medical rescue therapy based on cyclosporine or infliximab should be considered if there is no response to corticosteroids for 3 days. If there has been no response to medical rescue therapy after 4–7 days, the patient must undergo colectomy in emergency surgery. Prolonged observation is counterproductive, as over time it increases the risk of toxic megacolon and perforation, with a very high mortality rate. The best potential treatment is subtotal colectomy with ileostomy and preservation of the rectum. Emergency surgery in UC should not be seen as a last chance, but can be considered as a life‐saving procedure. Colectomies in emergency setting are characterized by high morbidity rates but the mortality is low.

Laparoscopic bridging vs. anatomic open reconstruction for midline abdominal hernia mesh repair [LABOR]: single-blinded, multicenter, randomized, controlled trial on long-term functional results

BackgroundRe-approximation of the rectal muscles along the midline is recommended by some groups as a rule for incisional and ventral hernia repairs. The introduction of laparoscopic repair has generated a debate because it is not aimed at restoring abdominal wall integrity but instead aims just to bridge the defect. Whether restoration of the abdominal integrity has a real impact on patient mobility is questionable, and the available literature provides no definitive answer. The present study aims to compare the functional results of laparoscopic bridging with those of re-approximation of the rectal muscle in the midline as a mesh repair for ventral and incisional abdominal defect through an “open” access. We hypothesized that, for the type of defect suitable for a laparoscopic bridging, the effect of an anatomical reconstruction is near negligible, thus not a fixed rule.Methods and designThe LABOR trial is a multicenter, prospective, two-arm, single-blinded, randomized trial. Patients of more than 60 years of age with a defect of less than 10 cm at its greatest diameter will be randomly submitted to open Rives or laparoscopic defect repair. All the participating patients will have a preoperative evaluation of their abdominal wall strength and mobility along with volumetry, respiratory function test, intraabdominal pressure and quality of life assessment.The primary outcome will be the difference in abdominal wall strength as measured by a double leg-lowering test performed at 12 months postoperatively. The secondary outcomes will be the rate of recurrence and changes in baseline abdominal mobility, respiratory function tests, intraabdominal pressure, CT volumetry and quality of life at 6 and 12 months postoperatively.DiscussionThe study will help to define the most suitable treatment for small-medium incisional and primary hernias in patients older than 60 years. Given a similar mid-term recurrence rate in both groups, if the trial shows no differences among treatments (acceptance of the null-hypothesis), then the choice of whether to submit a patient to one intervention will be made on the basis of cost and the surgeon’s experience.Trial registrationCurrent Controlled Trials ISRCTN93729016

Crohn’s Disease and Colorectal Cancer

The etiology of Crohn’s disease is still unknown. The most likely hypotesis is the alteration of the intestinal immune system with abnormal response to environmental factors and/or intrinsic factors in genetically predisposed individuals, with tissue destruction, chronic inflammation and fibrosis. There are many factors that could contribute to the onset of the disease, modulate clinical manifestations and influence the occurence of complications also post-operative: cigarette smoking is often associated with a more aggressive disease. The pathophysiological mechanism of this association is not yet clear. Crohn’s disease is difficult to cure and even on the basis of this evidence, the therapeutic approach to patient can not be other than multidisciplinary. The most common complications of Crohn’s disease are represented by stenosis, fistulas and abscesses that generally need a surgical therapy, despite drug treatment, newly with biological drugs have proved effective. Neoplastic degeneration is a terrible and feared complication in the long term. Although there is a substantial evidence that patients with ulcerative colitis are at increased risk of developing colorectal cancer, the prevalence of cancer in patients with Crohn’s disease is also not so well defined even if it’s now accepted that the risk of colorectal cancer is equivalent in both conditions. From a review of the literature it can be assumed that the number of cancer cases of large and small intestine associated with inflammatory bowel disease has increased both in patients with ulcerative colitis as well as in patients with Crohns disease. The rectum, interested only in a small percentage of cases by Crohns disease, does not seem to be subject to this consideration. Beside it the risk of developing extraintestinal tumors and lymphomas in patients with Crohn’s disease appears to have increased in relation to the general population, but, at present, evidences to establish secure real causal link between these disorders are still lacking. The role of immunosuppressive therapies, often carried out on patients with Crohn’s disease, also remains unclear. Cancer is often preceded by dysplasia in both patients with ulcerative colitis and in patients with Crohns disease affection. Young patients who have severe Crohns disease of long standing, with extensive colonic involvement may benefit from endoscopic surveillance for cancer, especially those affecting the large intestine. We’re waiting for good screening methods more sensitive, less invasive and less costly in terms of economic cost and discomfort for the patient. An attitude of alertness may be stated as good: the onset of new symptoms in a patient with up till now stable disease should always be investigated.

Pseudodiverticular defecographic image after STARR procedure for outlet obstruction syndrome

Dear Editor: Outlet obstruction syndrome (OOS) is a defecation disorder more common in women. Patients refer to coloproctologists complaining of constipation and other typical symptoms ranging from incomplete and fragmentized evacuation to rectal bleeding. This syndrome may be caused by functional and/or anatomical alterations. A correct etiological classification can help the clinician to predict the best treatment strategy. Non-operative treatment, mainly based on dietary changes and biofeedback, is usually suggested as the first or unique treatment option when symptoms are caused by an uncoordinated inhibitory muscular pattern. Conversely, patients not responsive to conservative treatment most likely can benefit from surgery. Nevertheless, traditional techniques, aimed at restoring normal anatomy, are often time-consuming, technically demanding, burdened by serious complications, and, sometimes, under particular circumstances, can be ineffective or can even worsen symptoms. In 2003 Stapled Transanal Rectal Resection (STARR) was described by Longo as an effective new option for the cure of OOS. Since its introduction, STARR has become an accepted surgical procedure even if some criticisms have been raised due to possible serious complications. Recently, a case of rectal diverticulum after STARR procedure has been reported. Here, we describe a similar case, its related diagnostic and treatment modalities. A 60-year-old woman, who had previously undergone unsuccessful medical treatment, was submitted to STARR in our service for obstructed defecation syndrome caused by an anterior and posterior rectocele associated with a posterior rectal wall prolapse. The technique, described elsewhere, follows the same steps as standardized by Longo. In the present case, at the end of the procedure, the stapled line was carefully inspected. As routinely performed, the mucosal band connecting the two edges of the anastomosis was cut both anteriorly and posteriorly. Stitches were then applied at the anastomotic level in order to avoid the risk of postoperative bleeding. The postoperative course was uneventful, and patient discharged on the third postoperative day. One month later, the patient presented at our outpatient visit complaining of recurrence of symptoms with tenesmus, constipation, a sensation of incomplete evacuation, painful and unsuccessful efforts, urge to defecate, anal incontinence, with need of digital assistance. Defecography showed a diverticular cavity on the right rectal wall (60 mm diameter) and an incomplete evacuation of barium. This lateral diverticulum, filled up by impacted stools, shrank the rectal pouch lumen during straining and defecation. The patient refused clinical examination and endoscopy because of intense pain and an examination under spinal anesthesia was then planned. The exam revealed the presence of a bridge of rectal mucosa, 2 cm wide, on the posterior wall. This bridge caused deformation of the rectal profile creating a diverticular cavity full of impacted stools. After mechanical emptying of the diverticulum the mucosal bend was cut with restoration of normal anatomy. Two months after this procedure, the patient had significantly improved defecation with complete resolution of symptoms. Defecography, performed 3 months postopInt J Colorectal Dis (2009) 24:1115–1116 DOI 10.1007/s00384-009-0666-6

Laparoscopic “double-port” splenectomy. A new minimally-invasive option in a giant spleen

Highlights • “Hybrid technique” combining the single-port technique to the hand assistance.• Novelty: the use of a suprapubic Pfannestiel incision for the hand assistance for a laparoscopic splenectomy procedure.• Novelty: the use of the hand of the assistant instead of the surgeon’s hand.• Novelty: the coupling of two port devices (single-port and Gel-port).• Novelty: the use of the single-port technique in splenic malignancies associated to splenomegaly.

Primary lymphoma of appendix presenting as acute appendicitis: A case report

Highlights • Primary lymphomas of appendix are extremely rare tumors. The incidence is 0.015% of all gastrointestinal lymphomas.• The neoplasms of appendix usually manifest clinically with sign and symptoms of acute appendicitis.• Preoperative diagnosis is difficult and often occurs through histopathological examination, so it is mandatory for all appendectomies.• There are no clear guidelines for therapy. Primary surgical resection followed by post-operative chemotherapy showed high efficacy.

Adenocarcinoma Arising from Perianal Fistulizing Crohn’s Disease

Perianal fistula is a very debilitating event and a cause of morbidity in patients with Crohn’s disease (CD). Its malignant transformation is very rare with an incidence of around 0.004–0.7%. Presence of disease in the colon and rectum is the major risk factor for the development of a perianal fistula. In this report we show a case of adenocarcinoma arising from a perianal fistulizing CD. This type of tumor is highly aggressive, difficult to diagnose, and has a rather poor prognosis. The different neoplastic transformations and the different types of tumors that may appear in patients with CD, especially at the colorectal level or at the level of an eventual anastomosis, are to date well documented and described in the literature, while there is a lack of information and of treated cases concerning the occurrence of cancer at the level of a fistula. Due to the rarity of cases, we tried to identify the most frequent and important risk factors: sex, duration of disease, age at diagnosis, and the history of the fistula.

Validation of a Simulator Set Up Entirely in anAcademic Setting: Low-Cost Surgical Trainer Ratherthan High-Cost Videogame

Laparoscopic surgery is the standard approach for most surgical operations because of its benefits for the patients, although it requires a significant learning curve. For this reason, the FDA established the need for certified laparoscopic training programs, supported by validated surgical simulators. Our multidisciplinary team developed a virtual surgical simulator (eLap4D) based on: a low-cost and a realistic haptic feedback. This study presents the validation process of the eLap4D, performed through the construct and face validities. The authors preliminarily analyzed and excluded the possible impact of videogame experience on eLap4D users. The construct validity was used to objectively assess the surgical value of five basic skills by comparing the performances between two groups with different levels of laparoscopy experience. The presence of a learning curve was also evaluated by comparing the results of the first and second attempts. The difference among exercises was investigated in terms of the difficulty and kind of basic gestures, comparing the completion rates of every task in the three difficulty levels each. Face validation was performed using a specific questionnaire investigating the realism and accuracy of the simulator. This last survey was administered only to experienced surgeons. The validation process indicated that eLap4D can measure surgical ability and not just videogame experience. It also positively affects the learning curve and reproduces different basic gestures and levels of difficulty. Face validity confirmed that its structural features and ergonomics are satisfactory. In conclusion, eLap4D seems suitable and useful for learning basic laparoscopy skills.