Saverio Di Palo

Analysis of Prognostic Factors Influencing Long-term Survival After Hepatic Resection for Metastatic Colorectal Cancer

BackgroundThe aim of this study was to analyze the prognostic factors associated with long-term outcome after liver resection for colorectal metastases. The retrospective analysis included 297 liver resections for colorectal metastases.MethodsThe variables considered included disease stage, differentiation grade, site and nodal metastasis of the primary tumor, number and diameter of the lesions, time from primary cancer to metastasis, preoperative carcinoembryonic antigen (CEA) level, adjuvant chemotherapy, type of resection, intraoperative ultrasonography and portal clamping use, blood loss, transfusions, complications, hospitalization, surgical margins status, and a clinical risk score (MSKCC-CRS).ResultsThe univariate analysis revealed a significant difference (p < 0.05) in overall 5-year survival rates depending on the differentiation grade, preoperative CEA >5 and >200 ng/ml, diameter of the lesion >5 cm, time from primary tumor to metastases >12 months, MSKCC-CRS >2. The multivariate analysis showed three independent negative prognostic factors: G3 or G4 grade, CEA >5 ng/ml, and high MSKCC-CRS.ConclusionsNo single prognostic factor proved to be associated with a sufficiently disappointing outcome to exclude patients from liver resection. However, in the presence of some prognostic factors (G3–G4 differentiation, preoperative CEA >5 ng/ml, high MSKCC-CRS), enrollment of patients in trials exploring new adjuvant treatments is suggested to improve the outcome after surgery.

Laparoscopic vs. Open Colectomies in Octogenarians: A Case-Matched Control Study

PURPOSEThe aim of this study was to define any benefits in terms of early outcome for laparoscopic colectomy in patients over 80 years old compared with open colectomy.METHODSSixty-one patients undergoing laparoscopic colectomy for colorectal cancer were matched to 61 open colectomy patients for gender, age, year of surgery, site of cancer, and comorbidity on admission. Independence status on admission and at discharge from the hospital was also evaluated.RESULTSMean (standard deviation) age was 82.3 (3.5) years in the laparoscopy group and 83.1 (3.3) years in the open group. Conversion rate was 6.1 percent. Operative time was 49 minutes longer in the laparoscopy group (P = 0.001 ). The overall mortality rate was 2.4 percent. The morbidity rate was 21.5 percent in the laparoscopy group and 31.1 percent in the open group (P = 0.30). Patients in the laparoscopy group had a faster recovery of bowel function (P = 0.01) and a significant reduction of the mean length of hospital stay (9.8 vs. 12.9 days for the open group, P = 0.001). Laparoscopy allowed a better preservation of postoperative independence status compared with the that of the open group (P = 0.02).CONCLUSIONLaparoscopic colectomy for cancer in octogenarians is safe and beneficial including preservation of postoperative independence and a reduction of length of hospital stay.

Impact of age on postoperative outcomes in 1118 gastric cancer patients undergoing surgical treatment.

BackgroundThe purpose of the study was to evaluate the impact of age on outcomes in gastric cancer surgery.MethodsPatients on the hospital database who underwent gastric resection for gastric cancer during the period 1990–2005 (n = 1118) were divided into two groups: group A, patients 75 years or older (n = 249), and group B, those younger than 75 years (n = 869).ResultsOverall preoperative complications were diagnosed in 92 (37%) patients of group A, compared with 147 (17%) in group B (P = 0.002). Fifty-five percent of patients underwent resection with D2 or more lymph node dissection (37% [n = 93] in group A, and 60% [n = 521] in group B; P = 0.003). Postoperative overall morbidity was higher in the elderly group (29% in group A versus 23% in group B), but the difference between the two groups was not significant (P = NS). Overall postoperative surgical complications were recorded in 201 (18%) patients; 49 (20%) in the elderly cohort, compared with 147 (17%) in the younger group (P = NS). The postoperative mortality rate was 3% (n = 7) in the elderly group, compared with 3% (n = 26) in the younger cohort (P = NS). Multivariate Cox analysis showed that age was not an independent risk factor for postoperative morbidity and mortality. Overall 5-year survival was 47% in group A and 54% in group B (P = NS).ConclusionDue to improved perioperative management, resection of gastric carcinoma is the treatment of choice in elderly patients. Although comorbidities were more frequent among the elderly patients, postoperative morbidity and mortality, even after extensive resections, was low. Survival rates were comparable to those in the younger patients.

Effect of Prednisolone on Local and Systemic Response in Laparoscopic vs. Open Colon Surgery: A Randomized, Double-Blind, Placebo-Controlled Trial

PURPOSE: This study was designed to assess whether preoperative, short-term, intravenously administered high doses of methylprednisolone (30 mg/kg 90 minutes before surgery) influence local and systemic biohumoral responses in patients undergoing laparoscopic or open resection of colon cancer. METHODS: Fifty-two patients who were candidates for curative colon resection were randomly assigned to laparoscopic or open surgery and, in a double-blind design, assigned to receive methylprednisolone (n = 26) or placebo (n = 26). Pulmonary function, postoperative pain, C-reactive protein, interleukins 6 and 8, and tumor necrosis factor α were analyzed, as was patient outcome. RESULTS: The steroid and placebo groups were well balanced for preoperative variables, as were the subgroups of patients who underwent laparoscopic (methylprednisolone, n = 13; placebo, n = 13) and open surgery (methylprednisolone, n = 13; placebo, n = 13). No adverse events related to steroid administration occurred. In the methylprednisolone groups, significant improvement in pulmonary performance (P = 0.01), pain control (P = 0.001), and length of stay (P = 0.03) were observed independent of the surgical technique. No differences in morbidity or anastomotic leak rate were observed among groups. CONCLUSION: Preoperative administration of methylprednisolone in colon cancer patients may improve pulmonary performance and postoperative pain, and shorten length of stay regardless of the surgical technique used (laparoscopy, open colon resection).PURPOSE: This study was designed to assess whether preoperative, short-term, intravenously administered high doses of methylprednisolone (30 mg/kg 90 minutes before surgery) influence local and systemic biohumoral responses in patients undergoing laparoscopic or open resection of colon cancer. METHODS: Fifty-two patients who were candidates for curative colon resection were randomly assigned to laparoscopic or open surgery and, in a double-blind design, assigned to receive methylprednisolone (n = 26) or placebo (n = 26). Pulmonary function, postoperative pain, C-reactive protein, interleukins 6 and 8, and tumor necrosis factor &agr; were analyzed, as was patient outcome. RESULTS: The steroid and placebo groups were well balanced for preoperative variables, as were the subgroups of patients who underwent laparoscopic (methylprednisolone, n = 13; placebo, n = 13) and open surgery (methylprednisolone, n = 13; placebo, n = 13). No adverse events related to steroid administration occurred. In the methylprednisolone groups, significant improvement in pulmonary performance (P = 0.01), pain control (P = 0.001), and length of stay (P = 0.03) were observed independent of the surgical technique. No differences in morbidity or anastomotic leak rate were observed among groups. CONCLUSION: Preoperative administration of methylprednisolone in colon cancer patients may improve pulmonary performance and postoperative pain, and shorten length of stay regardless of the surgical technique used (laparoscopy, open colon resection).

Feasibility of an Adaptive Strategy in Preoperative Radiochemotherapy for Rectal Cancer With Image-Guided Tomotherapy: Boosting the Dose to the Shrinking Tumor

PURPOSE To investigate the feasibility of preoperative adaptive radiochemotherapy by delivering a concomitant boost to the residual tumor during the last 6 fractions of treatment. METHODS AND MATERIALS Twenty-five patients with T3/T4N0 or N+ rectal cancer were enrolled. Concomitant chemotherapy consisted of oxaliplatin 100 mg/m(2) on days -14, 0, and +14, and 5-fluorouracil 200 mg/m(2)/d from day -14 to the end of radiation therapy (day 0 is the start of radiation therapy). Radiation therapy consisted of 41.4 Gy in 18 fractions (2.3 Gy per fraction) with Tomotherapy to the tumor and regional lymph nodes (planning target volume, PTV) defined on simulation CT and MRI. After 9 fractions simulation CT and MRI were repeated for the planning of the adaptive phase: PTVadapt was generated by adding a 5-mm margin to the residual tumor. In the last 6 fractions a boost of 3.0 Gy per fraction (in total 45.6 Gy in 18 fractions) was delivered to PTVadapt while concomitantly delivering 2.3 Gy per fraction to PTV outside PTVadapt. RESULTS Three patients experienced grade 3 gastrointestinal toxicity; 2 of 3 showed toxicity before the adaptive phase. Full dose of radiation therapy, oxaliplatin, and 5-fluorouracil was delivered in 96%, 96%, and 88% of patients, respectively. Two patients with clinical complete response (cCR) refused surgery and were still cCR at 17 and 29 months. For the remaining 23 resected patients, 15 of 23 (65%) showed tumor regression grade 3 response, and 7 of 23 (30%) had pathologic complete response; 8 (35%) and 12 (52%) tumor regression grade 3 patients had ≤5% and 10% residual viable cells, respectively. CONCLUSIONS An adaptive boost strategy is feasible, with an acceptable grade 3 gastrointestinal toxicity rate and a very encouraging tumor response rate. The results suggest that there should still be room for further dose escalation of the residual tumor with the aim of increasing pathologic complete response and/or cCR rates.

Short and long-term outcomes of laparoscopic colectomy in obese patients

AIM To investigate the impact of laparoscopic colectomy on short and long-term outcomes in obese patients with colorectal diseases. METHODS A total of 98 obese (body mass index > 30 kg/m(2)) patients who underwent laparoscopic (LPS) right or left colectomy over a 10 year period were identified from a prospective institutionally approved database and manually matched to obese patients who underwent open colectomy. Controls were selected to match for body mass index, site of primary disease, American Society of Anesthesiologists score, and year of surgery (± 3 year). The parameters analyzed included age, gender, comorbid conditions, American Society of Anaesthesiologists class, diagnosis, procedure, and duration of operation, operative blood loss, and amount of homologous blood transfused. Conversion rate, intra and postoperative complications as were as reoperation rate, 30 d and long-term morbidity rate were also analyzed. For continuous variables, the Students t test was used for normally distributed data the Mann-Whitney U test for non-normally distributed data. The Pearsons χ(2) tests, or the Fisher exact test as appropriate, were used for proportions. RESULTS Conversion to open surgery was necessary in 13 of 98 patients (13.3%). In the LPS group, operative time was 29 min longer and blood loss was 78 mL lower when compared to open colectomy (P = 0.03, P = 0.0001, respectively). Overall morbidity, anastomotic leak and readmission rate did not significantly differ between the two groups. A trend toward a reduction of wound complications was observed in the LPS when compared to open group (P = 0.09). In the LPS group, an earlier recovery of bowel function (P = 0.001) and a shorter length of stay (P = 0.03) were observed. After a median follow-up of 62 (range 12-132) mo 23 patients in the LPS group and 38 in the open group experienced long-term complications (LPS vs open, P = 0.03). Incisional hernia resulted to be the most frequent long-term complication with a significantly higher occurrence in the open group when compared to the laparoscopic one (P = 0.03). CONCLUSION Laparoscopic colectomy in obese patients is safe, does not jeopardize postoperative complications and resulted in lower incidence of long-term complications when compared with open cases.

Surgical septic complications in diabetic patients

SummaryIn a retrospective study postoperative septic complications were evaluated in 140 insulin-dependent diabetic patients who underwent surgery. The data collected were matched with those of a group of non-diabetic patients, homogeneous for sex, age, and type of surgical procedure. Patients of each group were further divided into 3 subgroups according to the risk of intraoperative contamination (clean-, clean-contaminated, and contaminated procedures). Diabetic patients had a significantly (p<0.01) higher rate of septic complications in clean- and clean-contaminated procedures particularly of wound infections. Our experience suggests that diabetes represents an important risk factor.

Sentinel node mapping during laparoscopic distal gastrectomy for gastric cancer: technical notes

BackgroundWith increasing experience, sentinel node navigation has been applied even to gastric cancer. Sentinel lymph nodes are identified by injecting lymphatic tracer dye and radioisotope-labeled particles around a gastric tumor into the submucosa endoscopically. The aim of this video was to demonstrate the feasibility of laparoscopic sentinel node navigation (SLN) in gastric cancer.MethodsA 71-year-old man with a diagnosis of gastric cancer was admitted to the authors’ department. The preoperative workup demonstrated a uT1 node-negative gastric cancer. The patient was scheduled for laparoscopic distal gastrectomy with SLN. The day before surgery, the patient was submitted to endoscopy. During the procedure, the radiotracer (technetium-99) was injected at four points around the tumor. The operation was performed with the patient in the Lloyd-Davies position using four trocars. After opening of the gastrocolonic ligament, the patient underwent an intraoperative endoscopy, and blue dye (patent blue) was injected at four points around the tumor. The lymphatic basin was identified with the probe and the blue dye. The sentinel node then was identified. No pickup technique was used. A standard laparoscopic gastrectomy with intracorporeal anastomosis was concluded successfully. Through a supraumbilical incision, the specimen was extracted. The sentinel node was dissected at the bench table after the operation.ResultsThe pathologic report demonstrated a gastric carcinoma, namely, pT1, pN1 (Sentinel node (Sn), 1/36), G3 gastric cancer. Only the sentinel node was positive, containing a micrometastasis. The patient’s postoperative course was uneventful.ConclusionsSentinel node navigation with a double tracer during laparoscopic gastrectomy for cancer is feasible. Nevertheless, it is mandatory to standardize the method of SLN identification to increase the diagnosis of lymph node metastases.

Surgery in the very old patient: Evaluation of factors linked to postoperative morbidity and mortality

One hundred and sixty- seven patients over 79 years of age were studied prospectively in our Emergency Surgery Department in order to evaluate their outcome, and the possible existence of factors linked to morbidity and mortality. The most common indications for surgery were gallstones (22.1%), hernias (14.9%), colo- rectal cancer (13.7%), peptic ulcer (6.5%), gastric cancer (5.9%) and ischemic or hemorrhagic vascular diseases (13.1%). Emergency surgery was performed in 93 (55.6%) patients. Forty- nine patients (29.3%) developed 83 postoperative complications. The risk of morbidity was statistically higher in patients who had more than two associated diseases ( p<0.05 ) and received blood transfusions ( p<0.01 ). The mortality rate was 16.1%, and was significantly related to ASA scores ≥ 4 ( p<0.001 ) and a high degree of intraoperative bacterial contamination (Classes III–IV) (p<0.05 ). Compared to elective surgery, emergency operations had a higher morbidity (33.3% vs 24.3%) and mortality (21.5% vs 9.4%), but the difference was not significant. Mortality/morbidity ratio was significantly higher in emergency, as compared to elective surgery (64.5% vs 38.8%, p<0.001 ). (Aging Clin. Exp. Res. 7: 110–116, 1995).

Laparoscopic Pancreatectomy: Indications and Description of the Technique

The advent, continuous development, and systematization of the laparoscopic method has represented a revolution in surgery. Since the first successful laparoscopic cholecystectomy in 1989 [1], several other types of procedures have been performed by means of the minimally invasive technique. Despite several factors that argue against this approach, such as the long learning curve, high cost, and concerns relating to oncological radicality, the laparoscopic method continues to gain increasing popularity among the scientific community.