Modern surgical staging of lung cancer

The estimation of the extension of a lung cancer is actually made according to the rules of TNM system. On the basis of the reports of 100 patients who underwent thoracotomy and were staged according to this system after hystological examination of resected specimen (pTNM), the authors consider some not yet clear aspects of this staging. In particular they underline the wide difference between clinical and post-histological staging; the high rate of nodal involvement, if the surgeon always perform a radical excision of the lymph nodes; the further need of accuracy for the data N2 and T3; the role of the anatomo-pathologist for the correct staging pTNM.     

Endoscopic diode laser therapy for chronic radiation proctitis

The purpose of this study is to determine the effectiveness of endoscopic diode laser therapy in patients presenting rectal bleeding due to chronic radiation proctitis (CRP). A retrospective analysis of CRP patients who underwent diode laser therapy in a single institution between 2010 and 2016 was carried out. The patients were treated by non-contact fibers without sedation in an outpatient setting. Fourteen patients (median age 77, range 73–87 years) diagnosed with CRP who had undergone high-dose radiotherapy for prostatic cancer and who presented with rectal bleeding were included. Six required blood transfusions. Antiplatelet (three patients) and anticoagulant (two patients) therapy was not suspended during the treatments. The patients underwent a median of two sessions; overall, a mean of 1684 J of laser energy per session was used. Bleeding was resolved in 10/14 (71%) patients, and other two patients showed improvement (93%). Only one patient, who did not complete the treatment, required blood transfusions after laser therapy; no complications were noted during or after the procedures. Study findings demonstrated that endoscopic non-contact diode laser treatment is safe and effective in CRP patients, even in those receiving antiplatelet and/or anticoagulant therapy.     

Computational modeling of abdominal hernia laparoscopic repair with a surgical mesh

Purpose

Although new techniques and prostheses have been introduced in ventral hernia surgery, abdominal hernia repair still presents complications, such as recurrence, pain, and discomfort. Thus, this work implements a computational method aimed at evaluating biomechanical aspects of the abdominal hernia laparoscopic repair, which can support clinical research tailored to hernia surgery.

Methods

A virtual solid model of the abdominal wall is obtained from MRI scans of a healthy subject. The mechanical behavior of muscular and fascial tissues is described by constitutive formulations with specific parameters. A defect is introduced to reproduce an incisional hernia. Laparoscopic repair is mimicked via intraperitoneal positioning of a surgical mesh. Numerical analyses are performed to evaluate the mechanical response of the abdominal wall in healthy, herniated and post-surgery configurations, considering physiological intra-abdominal pressures.

Results

During the deformation of the abdominal wall at increasing pressures, a percentage displacement increment up to 6% is found in the herniated condition, while the mechanical behavior of the repaired abdomen is similar to the healthy one. In the pressure range between 8 mmHg and 55 mmHg, the herniated abdomen shows an incremental stiffness differing of 7% with respect to the healthy condition, while the post-surgery condition shows an increase of the incremental stiffness up to 58%.

Conclusions

This computational approach may be exploited to investigate different aspects of abdominal wall surgical repair, including mesh mechanical characteristics and positioning. Numerical modeling offers a helpful support for selecting the best-fitting prosthesis for customize pre-surgery planning.

     

Management of esophageal cancer in patients aged over 80 years.

BACKGROUND: Important advances in the management of cancer of the esophagus and esophagogastric junction have occurred in the last decades, making treatment possible even in elderly patients. Unfortunately there is little information on management of esophageal cancer in octogenarian patients. The aim of this study was to evaluate the treatment results of esophageal and esophagogastric junction cancer in a single institution over a 14-year period in patients>or=80 years of age. METHODS: Clinicopathological characteristics and management strategies were studied in patients>or=80 years old with cancer of the esophagus or esophagogastric junction, referred to our department and treated between 1992 and 2005. RESULTS: There were 62 patients>or=80 years: 12 underwent surgical resection and 50 were not resected. There were no perioperative deaths. The morbidity rate was 33%. Most non-resected patients had an endoscopic prosthesis. The median survival for the overall group was 5.4 months: 14.6 and 5.1 in resected and non-resected patients, respectively. CONCLUSIONS: Even in octogenarian patients--with limited comorbidities and fit for surgery--esophagectomy may be regarded as a valid treatment option. Unfortunately this remains possible only in a small minority of 80-90-year old patients. In the remainder, endoscopic treatments--namely prosthesis placements, with chemoradiotherapy when possible--are the alternatives.     

Laparoscopic treatment of post-hysterectomy colovaginal fistula in diverticular disease. Case report

Colonic diverticular disease is a benign condition typical of the Western world, but it is not rare for even the 1st episode of diverticulitis to carry potentially fatal complications. The evolution of a peridiverticular process generally poses problems for medical treatment and exposes patients to repeated episodes of diverticulitis, making surgical treatment necessary in approximately 30% of symptomatic patients. One of the most worrying complications of diverticulosis is internal fistula. The most common types of fistula are colovesical and colovaginal, against which the uterus can act as an important protective factor. The symptoms and the clinical and instrumental management of patients with diverticular fistulas are much the same as for patients with episodes of acute diverticulitis. Staging of the disease (according to Hinchey) should be done promptly so that the necessary action can be taken prior to surgery, implementing total parenteral nutrition (TPN), nasogastric aspiration and broad-spectrum antibiotic treatment. The best surgical approach to adopt in patients with diverticulitis complicated by fistula is still not entirely clear, though the 3-step strategy is currently tending to be abandoned due to its high morbidity and mortality rates. There is a widespread conviction, however, that the 2-step strategy (Hartmann, or resection with protective stomy) and the 1-step alternative should be reserved, respectively, for patients in Hinchey stages 3, 4 and 1, 2 with a situation of attenuated local inflammation. The 1-step approach seems to be safe and effective. This report describes a case of colovaginal fistula in a patient with colonic diverticulosis who had recently undergone hysterectomy, but who, unlike such cases in the past, was treated in a single step using a laparoscopic technique.     

Insertion of prolonged venous access device: a comparison between surgical cutdown and percutaneous techniques

The use of totally implantable prolonged venous access devices (TIPVAD) in chemotherapy for oncological patients is now consolidated practice, whereas the choice between surgical cutdown and the percutaneous technique is still a controversial matter. The aim of this study was to retrospectively evaluate the validity and safety of the surgical approach by comparison with percutaneous techniques. Over a period of 17 months, 106 patients (mainly oncological cases) underwent surgical cutdown for TIPVAD placement in the cephalic vein. During a mean follow-up of 8 months (range 1-21), we evaluated the surgical and management complications and compared them with reported results obtained with the percutaneous technique. We observed a lower incidence of pneumothorax, 2 cases of malfunction due to kinking, and no catheter fractures, while management complications were similar to the findings in the literature. In expert hands, the surgical approach is a fast, safe technique with a lower rate of intraoperative complications than the percutaneous approach and less discomfort for the patient. Adequate training of medical and paramedical staff is the most important factor in making TIPVAD reliable and safe in the long term.     

Giant condyloma acuminatum of the anorectum (Buschke-Lowenstein tumour): a case report of conservative surgery

Giant condyloma acuminatum of the anorectum (Buschke-Lowenstein tumour) is a rare interesting infectious disease caused by the papillomavirus serotypes 16 and 18. In January 2002 a 47-year-old heterosexual male presented with Buschke-Lowenstein tumour and reported having had the disease for 12 years. The patient underwent thorough screening for sexually-transmitted diseases (which proved negative), abdominal CT, transanal US-endoscopy, inguinal ultrasound, chest X-ray and anorectal manometry, which revealed only localized disease. He was treated conservatively with radical local excision of the lesions. No postoperative complications were observed. Twelve months after surgery, there has been no local or remote recurrence and faecal continence is normal. The treatment of choice for Buschke-Lowenstein tumour is controversial; there is no evidence to support the need for demolitive surgery or chemo- and/or radiotherapy. The majority of authors prefer abdominoperineal amputation, but in our opinion conservative surgery is the best choice, especially in terms of the patient's quality of life.     

Manometric characteristics of the distal oesophageal sphincter and patterns of gastro-oesophageal reflux in healthy volunteers and patients

Three manometric characteristics of the distal oesophageal sphincter (DOS; pressure, length below the respiratory inversion point, i.e., abdominal length, and overall length) were investigated in 10 healthy volunteers and in 66 patients with typical symptoms of gastro-oesophageal reflux (GOR) disease. The aim of the work was to correlate the DOS deficiency with symptoms, endoscopic oesophagitis and with specific patterns of GOR as determined by means of 24-hour oesophageal pH monitoring. The results showed that patients with and without GOR disease cannot be separated solely on the basis of the standard manometric test, even adopting more parameters besides the traditional DOS pressure measurement. A functional defect of the DOS may be hypothesized for those patients with an apparently normal DOS on standard oesophageal manometry.     

Endoscopic diode laser therapy for gastric hyperplastic polyps in cirrhotic patients

Purpose Endoscopic polypectomy to remove gastric hyperplastic polyps in cirrhotic patients is associated to a high risk of postprocedural bleeding. The current study set out to examine the effect of diode laser therapy used to treat this type of polyps in cirrhotic patients. Methods This single-center study retrospectively examined the data of cirrhotic patients with macroscopic bleeding or anemia who underwent diode laser therapy (940 nm wave length, 30-W power setting in continuous mode) to remove histology-confirmed hyperplastic gastric polyps. Results A total of 222 polyps (mean diameter 10 ± 8 mm) were treated in 55 patients who were included in the study. No complications such as bleeding or perforations were reported. After a mean of 5 ± 4 sessions, 31 patients (56%) were completely healed. In 16 patients (29%), there was only a partial response (mean polyp reduction diameter of 64 ± 15%), while 8 (15%) patients did not respond to treatment. Statistically significant better results were noted in the patients who underwent ≥ 2 laser sessions. Hemoglobin levels and number of blood transfusions required were not statistically different after treatment. After a mean study period of 21 ± 17 months, polyp recurrences were noted in 11 patients (20%), but none of the polyps had degenerated. Conclusion Diode laser therapy was found to be a safe treatment for hyperplastic polyps in cirrhotic patients. Due to the presence of others bleeding lesions in cirrhotic patients, this treatment did not have an impact on anemia and transfusion requirements.