PURPOSE: Microsatellite instability and loss of heterozygosity of chromosomes 18q, 8p, and 4p are genetic alterations commonly found in colorectal cancer. We investigated whether these genetic markers allow for the stratification of patients with Stage II to III colorectal cancer into groups with different recurrence risks, and with different prognoses. METHODS: Tumors of 113 patients were evaluated for loss of heterozygosity of chromosomes 18q, 8p, and 4p and for microsatellite instability by use of six microsatellite markers. Genetic alterations involving each of these genetic markers were examined for association with disease recurrences and survival. RESULTS: Loss of heterozygosity of chromosomes 18q, informative in 96 percent of cases, in Stage III tumors was associated with higher risk of overall recurrence ( P< 0.001), local recurrence ( P< 0.001), distant metastases ( P< 0.001), decreased overall survival ( P= 0.002), and disease-free survival ( P< 0.001). The recurrence rates and survival rates among patients with Stage II colorectal cancer were independent of loss of heterozygosity of chromosome 18q. Stage III and loss of heterozygosity of chromosome 8p also were associated with a higher risk of recurrences when these factors were considered individually. In multivariate analysis, only loss of heterozygosity of chromosome 18q was independently associated with risk of recurrences ( P < 0.001) and with disease-free survival ( P= 0.001). No correlation was observed between microsatellite instability and recurrence rates. However, microsatellite instability was associated with improved overall survival ( P= 0.04) and with a longer disease-free interval ( P= 0.002). Only in five cases (16.7 percent) was it possible to perform resection of recurrences; two of these patients had microsatellite instability tumor. In no cases was it possible to resect recurrence of tumors with loss of heterozygosity of chromosome 18q. CONCLUSIONS: Loss of heterozygosity of chromosome 18q is an informative genetic marker, which in resected Stage III colorectal cancer can be used to predict recurrences and survival. Microsatellite instability identified cases that, even in the case of recurrence, have a more favorable prognosis.

Aged↗

PubMed2004

Second anastomotic recurrence after radical left hemicolectomy: report of a case.

A number of patients undergoing curative colorectal resection present with local recurrences that are not resectable at the time of diagnosis. Whereas these are predominantly perianastomotic, only a few are primarily anastomotic occurring at the suture line. A 65-year-old female with Dukes B2 adenocarcinoma of the sigmoid colon after a radical left hemicolectomy had further resections with stapled anastomosis at 12 and 22 months, for primary anastomotic recurrences. She remains well 54 months after initial surgery. The recurrent cancers were histologically similar and showed no features of microsatellite instability. The microenvironment at the anastomosis and the suture material must have contributed to this unusual course.

Adenocarcinoma↗

PubMed2004

Totally laparoscopic esophago-gastrectomy.

The recent progress of surgical endoscopy has allowed to perform minimally invasive esophagectomy both by a combined laparoscopic/thoracoscopic and a totally laparoscopic transhiatal approach. Up to now, all these techniques imply a thoracic (or thoracoscopic) and/or cervical access to perform the esophagogastric anastomosis. In the presented case, a 44-year-old white male patient affected by adenocarcinoma of the cardia (Siewert type 2) underwent a distal esophagectomy entirely accomplished by laparoscopy (including the realization of a mechanical intrathoracic esophagogastrostomy), without the need of any thoracic (nor thoracoscopic) nor cervical access. Duration of surgery was 407 minutes. Postoperative course was uneventful and the patient was discharged on day 7. In selected cases, a totally laparoscopic esophago-gastrectomy without thoracic nor cervical access, may improve the patient's outcome

Adenocarcinoma↗

PubMed2003

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 AIMS: Surgical 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 METHODS: Twenty-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 1 year) and our own 0-20 scoring system (up to 8 years from initial surgery). RESULTS: The 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 < or =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 1 year in five patients, four of whom were from the first group, all functional results improved and became satisfactory from 5 years on (1st series) and from 4 years on (2nd series). CONCLUSION: Despite 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.

Aged↗

PubMed2003

Long-term results of subtotal colectomy with antiperistaltic cecoproctostomy.

PURPOSE: To evaluate the clinical role of subtotal colectomy with cecorectal anastomosis (CRA) and its postoperative results, based on our surgical experience. METHODS: We retrospectively analyzed 26 patients who underwent subtotal colectomy with CRA during an 8-year period (1992-1999) in our university hospital. The indications for CRA were intractable constipation, colon tumors, diverticulitis, Crohn's disease, and postactinic colitis. CRA was performed using a new technique of end-to-end antiperistaltic anastomosis. Postoperative and late complications, and functional results, defined as the number of bowel movements per day and quality of life, were evaluated. RESULTS: None of the patients experienced postoperative or late complications. Two patients died from progression of colon cancer. The mean follow-up period was 4.5 years (range 1-8 years). By 1 month after surgery, 58% of the patients were passing frequent bowel movements, and by 1 year after surgery, only 23% of the patients were passing frequent bowel movements. The last follow-up revealed a mean 1.7 bowel movements per day, and only one patient was taking medication for diarrhea. All patients were satisfied with the results of their surgery and reported that their quality of life was good or improved, and even very good in six cases. CONCLUSIONS: Subtotal colectomy with our new CRA technique is appropriate for treating inflammatory diseases of the bowel, colon tumors, and intractable constipation in selected patients.

Adolescent↗

PubMed2003

Robotic fundoplication: from theoretic advantages to real problems.

Explore the source record for details and available documents.

Costs and Cost Analysis↗

PubMed2003

The rationale for cecorectal anastomosis for slow transit constipation.

The most usual reconstruction after subtotal colectomy is ileo-rectal anastomosis, which requires the removal of the caecum. We propose the treatment of chronic slow-transit constipation with subtotal colectomy and antiperistaltic caecoproctostomy. The sparing of the caecum, the ileo-caecal valve and the distal ileal loop, leaving a physiologic reservoir, allowing the presence of colic bacterial flora which metabolizes the undigested starch and produces short chain fatty acids, should guarantee a normal stool consistency, normal absorption of water, sodium and vitamin B12 and the prevention of renal and gallbladder lithiasis. In 1992, we started a study on the outcome of 19 patients who had undergone subtotal colectomy and antiperistaltic caeco-rectal anastomosis for slow-transit constipation. The surgical procedure was carried out without any serious complications and without mortality. The mean clinical follow-up was 64 months (range 5-132). Six months after surgery, 13 patients reported normal bowel movements with solid stool consistency, 5 reported diarrhoea and the need for antidiarrhoeal agents, and one reported constipation easily controlled with laxatives. Fifteen patients considered their quality of life as having improved compared with that before surgery. Selection of patients justify such very satisfying results. It is well known that colic resection is effective only in the case of slow transit constipation, and thus a careful physiologic assessment is needed to rule out other causes of constipation, such as outlet obstruction syndrome.

Adult↗

PubMed2003

Functional outcome of total anorectal reconstruction: incontinence or constipation?

BACKGROUND AND AIMS: Besides incontinence, constipation is important after TAR. We aimed at evaluating their correlation and role in functional outcome. MATERIALS AND METHODS: 81 diaries in 16 patients (up to 8 years) were assessed, by a specific scoring system, regarding incontinence and evacuation. In the overall series and in three postoperative time groups, the correlation between the two items, their mean scores and relative score rates (% of the maximum possible scoring) were calculated. RESULTS: The Spearman correlation coefficient in all assessments was -0.128. According to timing, it was: 0.468 (short term), -0.036 (mean term) and -0.69 (long term). Incontinence was more disabling than evacuation; constipation occurred more frequently. Incontinence improved over time; constipation did not substantially change. CONCLUSIONS: Current criteria for functional assessment do not describe the true conditions after TAR and their variations over time. Profound consideration is necessary before announcing ultimate judgements on TAR.

Anal Canal↗

PubMed2002

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 5 years). 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 Wexner's 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.

Aged↗

PubMed2002

Laparoscopy and gallbladder cancer.

Explore the source record for details and available documents.

Cholecystectomy, Laparoscopic↗

PubMed2002

Preoperative ultrasonographic assessment of the number and size of gallbladder stones: is it a useful predictor of asymptomatic choledochal lithiasis?

OBJECTIVE: To evaluate whether preoperative ultrasonographic assessment of the number and size of gallbladder stones can identify patients at increased risk of having asymptomatic common bile duct stones. METHODS: Ultrasonographic data for 300 consecutive patients undergoing laparoscopic cholecystectomy were analyzed. Patients were divided into a group in which multiple small (< or = 5 mm) or multiple variably sized (both < or = 5 and > 5 mm) gallbladder stones were present ("positive" stones) and a group with multiple large (> 5 mm) or single gallbladder stones, considered "negative." The ultrasonographic description was compared with surgical findings; finally, the prevalence of asymptomatic common bile duct stones in the 2 groups was compared. RESULTS: Ultrasonographic classification of gallbladder stones was confirmed at surgery in 285 cases (95%). Asymptomatic common bile duct stones were diagnosed in 9.5% of patients with an ultrasonographic diagnosis of positive gallbladder stones and in only 2.3% of patients with a diagnosis of negative gallbladder stones (P < .05). CONCLUSIONS: Ultrasonography is able to accurately show gallbladder stones; the appearance of multiple small and variably sized gallbladder stones represent a risk factor for synchronous asymptomatic common bile duct stones.

Cholecystectomy, Laparoscopic↗

PubMedDate not supplied

[Robotic fundoplication for gastro-oesophageal reflux disease].

Presented as a possible "second" revolution in general surgery after the introduction of laparoscopy during the last few years, the robotic approach to mini-invasive surgery has not yet witnessed wide, large-scale diffusion among general surgeons and is still considered an "experimental approach". In general surgery, the laparoscopic treatment of gastrooesophageal reflux is the second most frequently performed robot-assisted procedure after cholecystectomy. A review of the literature and an analysis of the costs may allow a preliminary evaluation of the pros and cons of robotic fundoplication, which may then be applicable to other general surgery procedures. Eleven articles report 91 cases of robotic fundoplication (75 Nissen, 9 Thal, 7 Toupet). To date, there is no evidence of benefit in terms of duration of surgery, rate of complications and hospital stay. Moreover, robotic fundoplication is more expensive than the traditional laparoscopic approach (the additional cost per procedure due to robotics is 1,882.97 euros). Only further technological upgrades and advances will make the use of robotics competitive in general surgery. The development of multi-functional instruments and of tactile feedback at the console, enlargement of the three-dimensional laparoscopic view and specific "team" training will enable the use of robotic surgery to be extended to increasingly difficult procedures and to non-specialised environments.

Animals↗

PubMedDate not supplied

[Diagnostic and therapeutic management of choledocholithiasis associated with gallstone disease: nine years' experience].

Different approaches are described in the literature for the detection and treatment of common bile duct stones in patients undergoing laparoscopic cholecystectomy (pre-, intra- or postoperative treatment; combined endoscopic and laparoscopic or total laparoscopic management). No particular "gold standard" treatment can be identified, since too many variables and too many techniques need to be compared. Since it is impossible to establish any single protocol, the reviewing of different large experiences is useful to identify the pros and cons of each procedure. We present the evolution of our own experience over the period 1991-2000 in 1741 patients treated by laparoscopic cholecystectomy for gallbladder stones. We have chosen to assess and treat patients with symptomatic common bile duct stones preoperatively, whereas in the asymptomatic cases we have adopted a protocol that has been modified over the years, consisting first in routine intravenous cholangiography and then in the use of a scoring system which, with the aid of ultrasound data, has allowed us to assess the risk of choledocholithiasis and to administer selective preoperative treatment for common bile duct stones.

Case-Control Studies↗