Vincenzo Violi

Cholecystocolonic fistula: facts and myths. A review of the 231 published cases

BACKGROUNDnCholecystocolonic fistula (CCF) is the second most common cholecystoenteric fistula and is often discovered intraoperatively, resulting in a challenging situation for the surgeon, who is forced to switch to a complex procedure, often in old, unfit patients. Management of this uncommon but possible finding is still ill defined.nnnMETHODSnAn extensive review of 160 articles published from 1950 to 2006 concerning 231 cases of CCF was performed.nnnRESULTSnCCF is mostly an affliction of women in their sixth to seventh decades and is rarely diagnosed preoperatively. Chronic diarrhea is the key symptom in nonemergency patients, but, in one-fourth of cases, CCF presents with an acute onset, mostly biliary ileus. In one-fourth of patients, a second hepatobiliary abnormality is present, including gallbladder cancer in 2% of cases. In uncomplicated cases, diverting colostomy is not performed anymore, and laparoscopy treatment has been described in specialized centers. Symptomatic treatment of concomitant biliary ileus (without treating CCF) is a feasible option. Resolution of colonic biliary ileus by interventional endoscopy is reported.nnnCONCLUSIONnCCF should be considered in differential diagnosis of diarrhea, especially in old, female patients. A possible second hepatobiliary abnormality should be always investigated. Extemporaneous frozen section should be performed if gallbladder cancer is suspected. Depending on clinical presentation, different treatments for CCF are indicated, ranging from minimally invasive procedures to extensive resection.

Palliative resection of colorectal cancer: does it prolong survival?

BackgroundIt is still a matter of debate as to whether resective surgery of the primary tumor may prolong the survival of patients affected by incurable colorectal cancer (CRC). The main goal of this retrospective study, carried out on patients not undergoing any therapy other than surgery, was to quantify the benefit of primary tumor removal in patients with differently presenting incurable CRC.MethodsOne hundred and thirty consecutive patients were operated on for incurable CRC (83 undergoing resective and 47 non-resective procedures). With the purpose of comparing homogenous populations and of identifying patients who may benefit from primary tumor resection, the patients were classified according to classes of disease, based on the “metastatic pattern” and the “resectability of primary tumor.”ResultsIn patients with “resectable” primary tumors, resective procedures are associated with longer median survival than after non-resective ones (9 months vs 3). Only patients with distant spread without neoplastic ascites/carcinosis benefit from primary tumor removal (median survival: 9 months vs 3). Morbidity and mortality of resective procedures is not significantly different from that of non-resective surgery, either in the population studied or in any of the groups considered.ConclusionsPalliative resection of primary CRC should be pursued in patients with unresectable distant metastasis (without carcinomatosis), and, intraoperatively, whenever the primary tumor is technically resectable.

Routine laparoscopic cholecystectomy after endoscopic sphincterotomy for choledocholithiasis in octogenarians: is it worth the risk?

BackgroundNo unanimous consensus has been reached as to the need for routine laparoscopic cholecystectomy (LC) after endoscopic sphincterotomy (ES) for choledocholithiasis in very elderly patients, who are considered as high-risk subjects for surgery.MethodsFrom 1991 through 1997, 170 patients were referred to undergo preoperative ES and routine LC for common bile duct (CBD) stones. The results for 27 patients (age 80 years or older) were compared with those achieved for younger patients. Successively, in a retrospective case-control study, the results for the selected patients were compared with those for 27 very elderly patients who underwent endoscopic retrograde cholangiopancreatography (ERCP), but did not receive LC. The mean follow-up period was 126 months.ResultsOctogenarians showed longer surgery time (79 vs 51 min) and postoperative hospital stay (2.8 vs 1.2 days), as well as more early low-grade complications (15% vs 3%), whereas there were no differences in conversion rate or serious complications. Recurrent symptoms or complications developed in 48% of octogenarians not undergoing routine LC, and 30% finally needed surgery. One patient in the control group died after emergency cholecystectomy for acute cholecystitis. The results of surgery were significantly poorer for the control group.ConclusionsAlthough a “wait-and-see” policy allowed two-thirds of LCs to be avoided in octogenarians, biliary-related events developed for every second patient, often requiring delayed surgery, with poorer results. Sequential treatment (ES followed by elective LC) is a safe procedure for octogenarians, and should be considered as a standard, definitive treatment for cholecystocholedocholithiasis even after the age of 80 years.

Ampullary Adenocarcinoma in Neurofibromatosis Type 1. Case Report and Literature Review

Periampullary tumors in patients affected by Neurofibromatosis Type 1 (NF-1) are usually carcinoids or stromal tumors and, rarely, adenocarcinomas. We report a case of an adenocarcinoma of the ampulla of Vater in a 54-year-old woman with NF-1 admitted to the hospital with jaundice and undergoing pancreato-duodenectomy. Histologically, the resected specimen showed an adenocarcinoma of the ampulla as being a part of a complex atypical epithelial proliferation extended from the papilla to the mucosa of the duodenum and distal choledochus, islet-cell adenomatosis of the pancreas and multiple gastric, duodenal, jejunal stromal tumors. The ampullary and periampullary adenocarcinomas in NF-1 patients have peculiar features, suggesting a widespread predisposition to cancer development in periampullary tissues and requiring widely demolitive surgery. Moreover, they occur at a younger age than those occurring in non-NF-1 patients, may be associated with additional periampullary epithelial tumors, are often operable and may present long survival.

Elective palliative resection of incurable stage IV colorectal cancer: Who really benefits from it?

PurposeDespite the encouraging results of chemotherapy in patients affected by incurable colorectal cancer (CRC), surgical resection of a primitive tumor is still a common approach worldwide. The identification of prognostic factors related to short survival (<6 months) may allow excluding from resective surgery those who may not benefit from it.MethodsA retrospective analysis was performed of 15 variables in a population of 71 patients undergoing nonemergency palliative primary resections of incurable CRC, including patients’ demographics and clinical/histopathological characteristics of the tumor.ResultsNo variables were related to perioperative mortality (8.5% overall). A multivariate analysis revealed that older age (≥80 years) and metastasis to more than 25% of the lymph nodes were associated with survival (4 and 6 months, respectively). Mucoid adenocarcinoma therefore tends to be associated with the prognosis (P = 0.070).ConclusionsAn elderly age tends to be a contraindication to an elective primary tumor resection in patients affected by incurable CRC. Massive lymph node involvement and mucoid adenocarcinoma should also be considered before planning major colonic surgery.

Surgical results and functional outcome after total anorectal reconstruction by double graciloplasty supported by external-source electrostimulation and/or implantable pulse generators: an 8-year experience

Background and aimsSurgical and functional results after abdominoperineal resection and total anorectal reconstruction by electrostimulated gracilis muscle transposition are still poorly documented. This study prospectively evaluated surgical and functional outcome over time in our patients.Patients and methodsTwenty-three patients underwent abdominoperineal resection, coloperineal pullthrough, double graciloplasty, and loop abdominal stoma. Temporary external-source intermittent electrostimulation, biofeedback training, and selective delayed stimulator implantation to improve unsatisfactory results were carried out in the first 13 patients (1st series); thereafter (2nd series) the stimulator was implanted during graciloplasty. Surgical and oncological results were followed up in all patients. Functional results were evaluated in 16 patients who underwent abdominal stoma takedown, eight in each of the two series, by anomanometry (up to 1xa0year) and our own 0–20 scoring system (up to 8xa0years from initial surgery).ResultsThe rate of major and minor postoperative complications was 21.7% and 65%, respectively. Continuous electrostimulation proved effective on resting anal pressure. Early clinical assessments showed satisfactory functional results (considered as having a score ≤8) in all first-group patients, including five who had stimulator support, and in one-half of second-group patients. After impairment (at least 2 points) at 1xa0year in five patients, four of whom were from the first group, all functional results improved and became satisfactory from 5xa0years on (1st series) and from 4xa0years on (2nd series).ConclusionDespite marked morbidity the high rate of good results, which improved over time, suggests that total anorectal reconstruction is worth being performed as part of abdominoperineal resection in well-selected patients with a strong motivation to avoid a permanent colostomy.

A patient-rated, surgeon-corrected scale for functional assessment after total anorectal reconstruction. An adaptation of the Working Party on Anal Sphincter Replacement scoring system.

Background and aims: To test current systems evaluating for fecal continence after total anorectal reconstruction (TAR) we adapted the incontinence plus evacuation scoring system proposed by the Working Party on Anal Sphincter Replacement (WPASR). Patients and methods: We examined 51 monthly diaries recorded by 14 patients after TAR or at yearly checks (up to 5xa0years). A form detailing all items and frequencies of the WPASR system was given to 12 patients who assigned a rating to each item in a frequency cell. The mean values of cells were rounded off, and a 0–20 scoring scale was obtained. We corrected the scores using previously defined criteria aimed at complying with an objective rating of severity while preserving the overall patient rating. Diaries were reevaluated by both patient-rated and surgeon-corrected scales, and the correlation was calculated to each other and to Jorge and Wexners and the Williams et al. systems; correlations between incontinence and evacuation scores were also calculated. Results: The surgeon-corrected system tended to have a lower mean score than the patient-rated one and was strongly correlated with it (r=0.984), a significantly higher mean score than the Jorge and Wexner scale (r=0.893), and a significantly lower mean score than the Williams et al. classification (quadrupled scores; r=0.857). No correlations between incontinence and evacuation were found. Conclusions: Although not validated, the patient-rated, surgeon-corrected adjustment of the WPASR system proved in our patients a reliable instrument for functional assessment. Its consensus administration to any given patient samples requires further research.

Total anorectal reconstruction by double graciloplasty: experience with delayed, selective use of implantable pulse generators.

Abstractu2002This study reports our experience with total anorectal reconstruction (TAR), supported at a later phase, whenever necessary, by an implantable pulse generator. Thirteen patients underwent total anorectal reconstruction by double graciloplasty, diverting loop colostomy, and implantation of temporary electrodes. External-source, short-term, intermittent electrostimulation and biofeedback were used for neosphincter voluntary control training. After abdominal stoma closure, 6 months after initial surgery in disease-free patients, functional results were evaluated by a scoring system and anomanometry. A pulse generator was implanted whenever continence was judged unsatisfactory. After continuous electrostimulation training, neosphincter function was reassessed. Major graciloplasty complications (partial muscle necrosis and perineal colostomy necrosis) were treated successfully by surgery. One death of myocardial infarction occurred after discharge. Three patients refused further surgery. One patient did not undergo abdominal stoma closure because of early hepatic metastases. Functional evaluation after closure (eight patients) showed the following results: two ”excellent” (no pulse generator implanted), three ”good” (two stimulator implantations, with an ”excellent” result), two ”fair”, and one ”poor” (3 implantations, with a ”good” result). In addition to improving clinical results (P=0.042), resting anal pressures were also increased significantly by active an implantable pulse generator (P=0.043). Although stimulators, whenever implanted, improved the neosphincter function, delayed, selective use of these in some cases rendered an implantable pulse generator either unnecessary from a functional viewpoint or redundant because of cancer recurrence or infectious complications. Drawbacks to the procedure were poor patient complicance to neosphincter training and to multiple surgical procedures, and excessive wasting of human resources during training for intermittent electrostimulation and biofeedback.

Impact of Palliative Chemotherapy and Surgery on Management of Stage IV Incurable Colorectal Cancer

BackgroundRecent trials proposed chemotherapy (CHT) as the treatment of choice for patients affected by incurable colorectal cancer (ICRC). Nevertheless, surgery is still commonly offered to these patients. On the other hand, CHT is offered to ICRC patients regardless of the pattern of spread of the disease, local or distant, despite some evidence suggesting that metastatic pattern may influence the response to treatment.MethodsA retrospective analysis was performed of 133 patients undergoing palliative treatment for ICRC from 1994 through 2007. Palliation consisted of surgery alone until 2002 and surgery with CHT (FOLFOX–FOLFIRI) thereafter. The impact of CHT and surgery was evaluated in the whole series as well as with respect to metastatic pattern (locally aggressive primary tumor and distant metastasis only), tumor site, and grading.ResultsChemotherapy prolonged survival by 9xa0months (pxa0=xa00.001). In patients undergoing CHT, resective surgery did not prolong survival (pxa0=xa00.931), whereas in patients not undergoing CHT, it improved prognosis by 5xa0months (pxa0=xa00.023). Considering patients with distant metastasis only, CHT significantly prolonged survival (pxa0<xa00.001), whereas it did not improve the prognosis of patients with a locally aggressive primary tumor (pxa0=xa00.943). No difference in CHT effectiveness with respect to tumor site and grading was recorded.ConclusionsCHT should be the preferred option in patients undergoing elective treatment for ICRC, whereas surgery should be considered whenever CHT is not administered. CHT significantly increases survival of patients with unresectable distant metastasis only, whereas it seems to be useless in patients with locally aggressive primary tumors.

Subtotal colectomy with antiperistaltic cecorectal anastomosis

Abstract We assessed the functional results achieved with an antiperistaltic end-to-end cecorectal anastomosis (CRA) after subtotal colectomy. A total of 34 patients with colonic cancer, inflammatory bowel disease or chronic constipation were treated with subtotal colectomy and cecorectal anastomosis. The postoperative mortality was nil; no major postoperative complication was registered. At a mean 60-month follow-up (range, 12–92), 32 patients were alive, showed no diarrhea nor incontinence, were completely relieved from previous symptoms and abdominal discomfort, and had a normal diet. In conclusion, subtotal colectomy with end-to-end antiperistaltic CRA seems to have a role in selected cases for the treatment of inflammatory bowel diseases, colon tumors and slow-transit constipation.