Surgical treatment of hydatid disease of the liver: 25 years of experience

BACKGROUND: The aim of this study was to evaluate the results of conservative and radical treatment of liver hydatid disease. METHODS: Records of patients who underwent surgery for liver hydatid disease between 1980 and 2005 were reviewed. Outcomes measured were operative morbidity and mortality, hospital stay, and recurrence. RESULTS: Two hundred fourteen patients underwent conservative treatment (external drainage, marsupialization, omentoplasty), and 240 had radical surgery (hepatic resection, cystopericystectomy). Operative morbidity was 79.9% and 16.2% for conservative and radical procedures, respectively (P < .001). Operative mortality was 6.5% for conservative procedures and 9.2% for radical procedures (P = .3). The recurrence rate was 30.4% in patients having conservative surgery and 1.2% in patients undergoing radical surgery (P < .001). No recurrences occurred in patients with clear cysts after conservative surgery. CONCLUSIONS: Cystopericystectomy was a safe and effective procedure that achieved excellent immediate and long-term results. Hepatic resection should be considered only in exceptional cases, because it involves the unnecessary sacrifice of healthy hepatic parenchyma. Conservative surgery and alternative procedures should be restricted to the treatment of clear cysts and to patients who cannot undergo radical surgery. (C) 2011 Elsevier Inc. All rights reserved

Quantitative investigation of desmoplasia as a prognostic indicator in colorectal cancer

Background: The role of desmoplastic reaction (DR) in colorectal cancer invasion is still an open question. The presence of fibrous connective tissue may represent a barrier against cancer diffusion or a stroma to build up and support the tumor. Aims of the present study were to evaluate the influence of DR on long-term survival and to validate a reliable quantitative method to measure the desmoplastic tissue. Methods: This retrospective study included 86 patients who underwent radical colorectal resection for cancer, from a database of 429 patients. To achieve a quantitative histochemical measurement of DR, digital images were analyzed by a computerized image analysis program. DR was related to the overall survival and the quantitative method was related to the traditional one. Results: By using the Kaplan-Meier analysis, DR was found to be significantly associated with overall survival. Patients with a higher value of DR survived longer than those with smaller DR and the quantitative results were in accordance with those obtained by using the traditional methods. Conclusions: Desmoplasia seems to be a protective factor for survival in patients with colorectal carcinoma. The quantitative technique is easily standardized and can be routinely performed, so that DR may be a useful prognostic indicator. Notwithstanding, the conflicting outcomes reported in literature about DR need further biological and molecular studies to achieve definitive conclusions

Colorectal Resection during Peritonectomy plus HIPEC in Patients with Diffuse Ovarian Carcinomatosis: our experience and a review of the literature.

Abstract: Objective: To identify a reasonable surgical strategy and to discuss the benefits and morbidity of and indications for colorectal resections in ovarian carcinomatosis. Methods: From a series of 70 patients treated with peritonectomy and HIPEC for diffuse ovarian carcinomatosis 52 patients had colorectal resections. We considered techniques for colorectal resection, histopathological features of resected specimens, postoperative risk factors and prognostic variables in univariate and multivariate analyses. Literature regarding cytoreductive surgery with colon resection was then reviewed. Results: Peritonectomy procedures included as well as colorectal resection various other visceral resection (mean 7.5 per patient). Optimal cytoreduction rate was 86% (CC0 and CC1). A total 13.4% of patients had Grade IV complications requiring reoperation or intensive care. Multivariate analysis identified as the main risk factor for postoperative complications a blood loss of ≥ 2000 ml. In all 52 patients ovarian implants deeply infiltrated the colorectal wall usually (67.3%) up to the muscular layer. Lymph-node metastases, detected in 50% of the cases, involved colorectal regional nodes in 42.3%. The 5-year survival rate was 44.4% and 5-year disease-free survival was 32.6%. Cox regression identified as the main prognostic factors, depth of colorectal wall invasion and degree of cytoreduction. Some of the literature regarding colon resection is conflicting and all data are retrospective, however, most of papers supports a benefit in terms of survival when cytoreduction is clearly optimal. Conclusions: In patients with ovarian diffuse peritoneal carcinomatosis colorectal resections are essential in achieving maximal cytoreduction. Colorectal resections in ovarian carcinomatosis should follow the oncologic rules for primary colorectal cancer. The literature review suggests that colon resection to achieve optimal cytoreduction has a positive impact on survival

Complications after colorectal resections during peritonectomy and HIPEC in advanced peritoneal carcinomatosis from ovarian cancer.

INTRODUCTION The current options for treating patients with primary or recurrent diffuse ovarian carcinomatosis include peritonectomy and hyperthermic intraperitoneal chemotherapy (HIPEC). The main role of peritonectomy in this integrated procedure is to achieve maximal cytoreduction by multiple parietal and visceral resections, whereas HIPEC serves to sterilize microscopic or millimetric residual sites of tumor. Among the various visceral resections needed for maximal cytoreduction, colorectal resections account for nearly 50%. Despite consensus on the oncologic appropriateness of colorectal resections to achieve optimal cytoreduction, technical controversies persist and information is lacking on how these procedures influence outcome and survival, AIM: to identify a reasonable surgical strategy for colorectal resections to reach optimal cytoreduction and minimize operative risks. METHODS From a series of 70 patients prospectively enrolled from November 2000 to April 2009 in a single-center phase-II study on the use of peritonectomy and HIPEC (closed technique at the end of surgery) in the treatment of diffuse primary or recurrent peritoneal carcinomatosis from ovarian cancer we selected for this study all 52 consecutive patients who also underwent colorectal resection. • Surgical Technique for Peritonectomy The extent of peritoneal carcinomatosis was classified according to the peritoneal cancer index (PCI). Aggressive surgical cytoreduction to leave the patient with no visible disease then proceeded in three stages: treatment of the parietal peritoneum, visceral resections and lymphadenectomy •Surgical Technique for Colorectal Resection Involvement of the pelvis the and cul-de-sac along as well as the uterus and adnexa or recurrent disease of the pelvis ! en bloc resection of the internal genitalia or pelvic recurrence along with the rectum and sigmoid colon (TME). Right iliac fossa carcinomatosis involving the cecum, appendix, terminal ileum or ascending colon ! standard right hemicolectomy. Involvement of the pelvis and all colonic segments, with nodules penetrating deeply into the colonic wall ! total colectomy, rectal resection and terminal ileostomy. We generally preferred to construct an ostomy and postpone restoring intestinal continuity for a second look. In most patients, before restoring intestinal continuity we waited for at least 6 months after post-peritonectomy systemic chemotherapy. The completeness of cytoreduction (CC) was scored as proposed by Sugarbaker. Statistical Analysis A multiple regression test was used to analyze the influence of morbidity and mortality risk factors on patient’s outcome. The Kaplan-Meier method was used to construct survival curves and the log-rank test was used to assess the significance of differences between curves. The Cox regression model was used to determine the prognostic value of independent variables. P values <0.05 were considered to indicate statistical significance. The NCSS package was used to analyze the data base and perform statistical tests. DISCUSSION At a mean follow-up of 30.2 months (range 4-79), the estimated mean survival was 33.2 months and the mean disease- free survival was 27 months. In 74.3% of the cases (52/70 patients) a colorectal resection was needed to achieve satisfactory cytoreduction levels. Our experience in these patients therefore suggests that rectal resection alone or associated with other colonic resections is the crucial surgical step on which patients’ outcome depends. The major anatomic and pathological prognostic factors reflecting clinical outcome were colorectal wall involvement and CC score. In contrast to most investigators, a technical point we underline is the need for a low rectal resection leaving a rectal stump no longer than 5 cm completely removing the mesorectum. We also used inferior mesenteric artery ligation at its origin from the aorta (high tie) and the inferior mesenteric vein at the inferior pancreatic border including a large amount of the mesocolon and adequate lymphadenectomy. In most patients in our series (75%) the tumor infiltrated the muscular layers up to the mucosa; in 25% the tumor involved only the intraperitoneal rectal or colonic wall serosa, the peritoneal pouch or mesorectum without infiltrating the muscular layers. As many as 22 of the 52 patients (42.3%) undergoing colorectal resection in our series had mesenteric lymph-node metastases alone or in association with typical ovarian node metastases and 20 (41.6%) of patients who underwent rectal resection had mesorectal lymph-node metastases. This pattern of malignant spread shows a direct relationship between infiltration of the colorectal wall and mesenteric lymph-node metastases and suggests that optimal surgical management of these patients must include the resection procedures commonly used for primary large bowel carcinoma. Even though some investigators underline this concept, the appropriate surgical management of large bowel involvement in primary and recurrent diffuse peritoneal ovarian carcinomatosis in practice remains unapplied. In this scenario, for example, some resect a limited rectosigmoid segment (15 cm) constructing the colorectal anastomosis high (9-10 cm from the anal verge) without excising the entire mesorectum. Many also provide poor or no information on mesenteric lymphadenectomy and when they supply information resect a mean 5 lymph nodes, inadequate for oncologic exeresis. Besides, hardly surprisingly, this sleeve fashion resection leads to a high percentage of microscopic residual disease on the colorectal stump (20%). Hence in our opinion, mistakenly, more emphasis is placed on restoring intestinal continuity with a colorectal anastomosis without a colostomy than on observing the necessary oncologic rules. After rectal resection we generally avoided restoring intestinal continuity immediately and according to the entity of colorectal resection construct a colostomy or ileostomy. We postpone restoring intestinal continuity until after systemic postperitonectomy chemotherapy ends and after a further 6 months follow-up for patients who remain disease free. This strategy minimizes the numerous operative risks in critically ill patients, many of whom have intestinal obstruction (30%), all of whom have diffuse carcinomatosis (mean PCI 18), more than 50% of whom also require intestinal anastomoses or local excision of tumor implants from the large and small bowel wall, and who have generally suffered a mean blood loss of 1700 mL, and finally, all of whom have to undergo HIPEC. This strategy also has the distinct therapeutic advantage of allowing second-look surgery, especially in apparently disease-free patients with low tumor markers. Our unpublished experience shows that 7 of the 12 patients who underwent surgery to restore intestinal continuity had minimal recurrent disease that was resected during reconstruction surgery. These 7 patients also underwent a second HIPEC procedure. Of the 12 patients who underwent bowel reconstruction, 2 with a coloanal anastomosis, 7 with a colorectal stapler anastomosis, and 3 patients who underwent total colectomy with ileostomy had an ileorectal anastomosis with a J pouch. Three other patients available for reconstruction refused a new operation. Late reconstruction is particularly safe because the first operation improves the patient’s general conditions and leaves a stiff, healthy rectal stump. All patients who underwent reconstruction except one in whom a rectovaginal fistula developed, had an uncomplicated postoperative course. Comparing patients undergoing cytoreduction with and without HIPEC, Ryu et al. observed higher rates of intraabdominal complications such as intestinal perforation, intestinal obstruction, and sepsis in patients who underwent HIPEC. In our series only two patients, both of whom had only mild pelvic carcinomatosis, had colorectal anastomoses, all the others had colostomy or ileostomy, depending on the extent of colonic resection. In our series the mean PCI was relatively high (mean 18.8) and colorectal resections were invariably needed to achieve optimal cytoreduction. When we investigated the prognostic role of colorectal resection in the outcome of our patients our findings again underline growing evidence on the role of maximal cytoreduction and clearly show that colorectal resections are merely a step in this process similar to the other visceral or parenchymal resections necessary and unavoidable to reach radical cytoreduction. Not with standing the small number of patients studied, our results seem to suggest as a major negative pathologic factor colorectal wall involvement reaching the mucosal layer given that none of these patients in our series survived. This new finding implies that whenever diagnostic procedures identify these high risk patients surgery might usefully be preceded by neoadjuvant chemotherapy. Conclusion Colorectal resection are an unavoidable step in achieving maximal cytoreduction and hence in improving outcome and survival. The high rate of deep infiltration into the colorectal wall along with the pericolic, mesenteric and mesorectal lymphonode metastases suggest that colorectal resections should follow the strict oncologic rules applied for primary cancer. To minimize the operative risks, after rectal resection anastomosis should be postponed for at least 6 months in patients who remain disease-free after systemic post-peritonectomy CHT ends, that allows second-look surgery in appatently disease-free patients

Indications and results for transduodenal sphincteroplasty in the era of endoscopic sphincterotomy

BACKGROUND: Transduodenal sphincterotomy (TS) has fallen into disuse since endoscopists developed techniques to treat sphincter problems nonsurgically. However, some patients experience recurrent sphincter strictures after endoscopic sphincterotomy (ES), with the ampulla endoscopically inaccessible, and pancreas divisum (PD); these patients are referred to a surgeon because they are unsuitable for ES. METHODS: The medical records of patients who underwent TS at the First Department of Surgery of the Medical School, University of Rome "La Sapienza," between January 1997 and December 2005 were reviewed. A total of 82 patients, including 47 women and 35 men with a mean age of 47 years (range, 26-67 y), underwent TS in our unit in the aforementioned period. Previous unsuccessful endoscopic retrograde cholangiography and ES were the indications for TS in 44 patients, and previous gastric surgery with duodenal bypass was the indication for TS in 21 patients. Five patients underwent TS because of a PD and 10 because of the intraoperative findings of daughter hydatid cysts in the common bile duct and of a wide communication between the cyst cavity and the intrahepatic biliary tree. Two patients were referred to our institution after a surgical papillotomy performed elsewhere. Symptoms included abdominal pain in 100% of patients, nausea and/or vomiting in 78% of patients, and referred back pain in 56% of patients. Acute pancreatitis was present in the history of 26 patients, including 23 with previous ES. All patients underwent TS. Sphincteroplasty of the accessory papilla was performed in all patients with PD. Cornerstones of a successful TS are depicted. RESULTS: Asymptomatic hyperamylasemia was observed in 37 patients, and cholangitis and pancreatitis, which was resolved with conservative management, occurred in 2 patients. One patient developed an intra-abdominal abscess that was treated with image-guided percutaneous drainage. No perioperative deaths occurred in this series. The mean length of follow-up evaluation was 84.4 months (range, 16-115 mo). Good results were achieved in 53 patients (73.6%), fair results in 17 patients (23.6%), and poor results in 2 patients (2.7%). Both patients with poor results required reoperation because of recurrent pancreatitis and pancreatic pseudocyst. CONCLUSIONS: TS still represents, although undoubtedly with updated indications compared with the past, a surgical procedure that must be up to date, ensuring absolutely satisfactory results. (C) 2010 Published by Elsevier Inc

Retrograde Parotidectomy for Pleomorphic Adenoma of the Parotid Gland: A Conservative and Effective Approach

To compare the extensiveness and the effectiveness of anterograde and retrograde dissections in superficial parotidectomy for pleomorphic adenoma of the parotid gland, a review of medical records and pathology reports of consecutive patients who underwent superficial parotidectomy has been performed. The sizes of the overall pathologic specimen, the tumor within the specimen, and the normal parotid tissue obtained by anterograde and retrograde approaches have been compared. Mann-Whitney and chi(2) tests have been used to reveal significant differences. Sixty-four patients were included in the study, 32 who underwent anterograde (standard) parotidectomy and 32 who underwent retrograde parotidectomy. Anterograde dissection resulted in a significantly larger size of the overall pathologic specimen as compared with retrograde parotidectomy (P = 0.019). The size of the tumor was nonsignificantly larger for patients undergoing standard parotidectomy (P = 0.174). Patients undergoing anterograde parotidectomy also had a significantly much larger volume of normal tissue removed in the course of extirpating the adenoma, as compared with patients undergoing retrograde parotidectomy (P = 0.008). Despite extracapsular dissection and partial superficial parotidectomy being proposed in the last years as conservative techniques, the optimal treatment of pleomorphic adenoma remains the superficial or total parotidectomy with facial nerve primary identification and preservation. Retrograde parotidectomy, reducing the extent of normal parotid gland removal, may permit a more conservative approach than standard parotidectomy, with the same complication rates and surgical effectiveness

Anastomotic leakage and septic complications: impact on local recurrence in surgery of low rectal cancer

PURPOSE: We thought to determine the influence of anastomotic leakages (AL) and septic complications (SC) on the incidence of local recurrence (LR) in patients undergoing curative surgery for rectal cancer. METHODS: The records of 479 patients (286 male, 193 female; median age 67 years) who received, between 1966 and 1975 (Group A) and 1976 and 1985 (Group B), curative surgery for middle to low rectal cancer were retrospectively reviewed. All patients received meso rectal excision in the course of abdominoperineal excision (Group A) and of anterior resection with colorectal anastomosis (Group B). The outcome of SC in both groups and that of AL in Group B were investigated. AL were divided into clinical leaks (CL) and radiological leaks (RL). All patients surviving surgery were followed up for a mean period of 71 months. The development of pelvic recurrence was registered. The effect of SC and AL on LR was statistically analyzed. RESULTS: LR was diagnosed in 24 (9.3%) patients of Group A. No difference was detected between patients with SC (9.3%) and those without (9.3%). In Group B, LR occurred in 28 (12.7%) patients: 12.5% without SC and 12.7% with SC. A significant difference in the prevalence of LR was found between patients with CL (14.2%) and those with RL (30.0%). When CL were excluded, RL resulted as an independent predictor of LR. DISCUSSION: Many factors have been shown to affect the rate of LR, including operative technique and surgeon expertise as well as margins of clearance and tumor stage. In our study, overall LR rate of Group B was 13.2%. The incidence of this event in patients with AL (24%) was significantly higher than that in the nonleakage group (11.1%). Correspondent results have been reported by some authors who evidenced RL as a negative prognostic factor for higher rates of LR. The mechanism by which AL affects LR remains to be elucidated. CONCLUSIONS: All were found to be associated with higher rates of LR, especially if associated with prolonged inflammatory local reaction

Terapia ormonale sostitutiva dopo tiroidectomia totale. Il trattamento ormonale combinato può essere considerato efficace strumento di adeguatezza metabolica? Risultati preliminari

Introduzione. Sebbene la terapia con T4 sia considerata un trattamento sostitutivo efficace nella maggior parte dei pazienti sottoposti a tiroidectomia totale, una terapia combinata di T4 e T3 è stata proposta come trattamento sostitutivo alternativo, in grado di riprodurre in modo più fedele la fisiologia della ghiandola tiroidea. Per tale motivo abbiamo condotto uno studio osservazionale prospettico sugli effetti del trattamento sostitutivo combinato di T4 e T3 in soggetti sottoposti a tiroidectomia totale. Pazienti e metodi. Sono stati arruolati 50 pazienti sottoposti a tiroidectomia totale per patologia non neoplastica ed in cura con trattamento ormonale sostitutivo con T4. Si è modificata la terapia somministrando un trattamento combinato di T3 e T4 in rapporto 1 a 16. Al momento dell’arruolamento (T0), dopo 30 giorni (T1) e dopo 60 giorni (T2), sono stati valutati parametri clinici, effetti indesiderati del trattamento e percezione dello stato di salute (questionario valutativo SF36). Risultati. Non ci sono state differenze da T0 a T2 per quanto riguarda peso corporeo, frequenza cardiaca e pressione arteriosa. Si è riscontrata una diminuzione dei valori medi di colesterolo totale (3 mg/dL) e trigliceridi (3,29 mg/dL), non statisticamente significativa. I principali effetti collaterali a T0 sono stati: sonnolenza (25 casi), cefalea (22), nervosismo (21), astenia (17), diminuzione della libido (11), tremori (8), palpitazioni (8) e nausea (6). Da T0 a T2 la presenza di nervosismo è passata da 21 pazienti a 13; la cefalea da 22 pazienti a 13; l’astenia da 17 a 8 pazienti (P <0.05); la sonnolenza da 25 a 15 pazienti (P <0.05). Per quanto riguarda il questionario, nel sub-score sulla percezione generale dello stato di salute si è registrata un’evoluzione positiva del parametro, anche se statisticamente non significativa. Discussione e conclusioni. La terapia sostitutiva con T4 è di dimostrata efficacia, tuttavia permangono disturbi che creano discomfort in una quota di malati. Nella continua ricerca volta al miglioramento della qualità della vita dei pazienti, appare rilevante la diminuzioni di tali effetti e il miglioramento del tono dell’umore che riscontriamo con l’utilizzo della terapia combinata. Inoltre, sebbene l’approvvigionamento di T3 attraverso la conversione periferica tissutale del T4 sia congruo in condizioni funzionali normali, è utile notare come condizioni patologiche intercorrenti ed alterazioni parafisiologiche indotte dalla senescenza siano condizioni capaci di interferire negativamente sull’efficienza dei processi enzimatici, sui quali si basa la monoterapia con T4. I risultati di questo studio preliminare incoraggiano lo sviluppo di ulteriori ricerche su un più ampio numero di pazienti

Metastasis to the Pancreas from Breast Cancer: Difficulties in Diagnosis and Controversies in Treatment

Background: Metastasis to the pancreas originating from malignant tumours is a rare event and, in the literature, we have found only 11 reported cases of solitary pancreatic metastases originating from breast cancer. Case Report: We report a case of a 51-year-old woman with primary breast cancer who developed obstructive jaundice and epigastric pain after 2 years without any symptoms. The pancreatic mass revealed by computed tomography (CT) scan and magnetic resonance imaging (MRI) was not recognised as a metastasis from breast cancer and the patient underwent cephalic pancreaticoduodenectomy. Conclusions: We discuss all aspects of the case management, stressing the importance of a careful evaluation of the clinical history and the primary cancer features and the usefulness of a multi-disciplinary approach. These aspects are of main importance for a correct diagnostic process and an appropriate therapeutic choice when a pancreatic lesion develops in a patient with prior neoplasm

Prevention of Peritoneal Carcinomatosis from Colon Cancer in High-Risk Patients.

Introduction: Epidemiological data indicate that peritoneal spread from colorectal cancer is an event that involves 10–15% of patients at the time of primary cancer resection and about 25–50% of patients with recurrent disease, generally leading to death within weeks or months. The study compared the outcome in patients with advanced colonic cancer at high risk of peritoneal metastases without peritoneal or systemic spread, treated with standard colectomy or a more aggressive combined surgical approach. Materials and Methods: The experimental group underwent hemicolectomy, omentectomy, bilateral adnexectomy, hepatic round ligament resection, and appendectomy, followed by HIPEC. The control group comprised patients treated with standard surgical resection during the same period in the same hospital by different surgical teams. Results: Outcome data, morbidity, peritoneal recurrence rate, and overall, and disease-free survival, were compared. Peritoneal recurrence developed in 4% of patients in the experimental group and 22% of controls without increasing morbidity. Actuarial overall survival curves disclosed no significant differences, whereas actuarial disease-free survival curves showed a significant difference between groups. Conclusion: A more aggressive preventive surgical approach combined with HIPEC reduces the incidence of peritoneal recurrence in patients with advanced mucinous colonic cancer and also significantly increases disease-free survival compared with a homogeneous control group treated with a standard surgical approach without increasing morbidity