The sentinel node biopsy in early gastric cancer: a preliminary study

Background and aims Sentinel node biopsy is currently used in surgery of malignant melanoma and breast cancer. The feasibility of sentinel node mapping in gastrointestinal cancers and its diagnostic sensitivity is unclear. It could be of particular value in the management of early gastric cancer in which radical D2 lymphadenectomy may be unnecessary. Materials and methods From January 2004 to June 2005, ten patients with preoperative diagnosis of early gastric cancer and no nodal involvement (cT1N0) were submitted to sentinel node biopsy using the dual mapping procedure with endoscopic blue dye and ^99mTc radio colloid injection. All the patients underwent standard radical gastrectomy and D2 lymphadenectomy. The resected nodes were evaluated by routine (hematoxylin–eosin) histopathological examination; the sentinel (blue or hot) nodes, in addition, were evaluated with immunohistochemistry for cytokeratin. Results The detection rate of this procedure was 100%. The preliminary results and perspectives for feasibility of sentinel node biopsy and its accuracy in predicting the nodal status in early gastric cancer are discussed.     

Plasma interleukin-6 levels are independently associated with insulin secretion in a cohort of Italian-Caucasian nondiabetic subjects

We have investigated the relationships between plasma interleukin-6 (IL-6) levels and insulin sensitivity and insulin secretion in a cohort of Italian-Caucasian glucose-tolerant subjects. Insulin sensitivity was assessed by euglycemic-hyperinsulinemic clamp, and first-phase insulin secretion was measured by intravenous glucose tolerance test. Fasting plasma IL-6 concentration was negatively correlated with the rate of insulin-stimulated glucose disposal (M) (P = 0.001). The correlation remained statistically significant, while attenuated, after adjusting for sex, age, and BMI (P < 0.03); after an additional adjustment for free fatty acids (FFAs), a further attenuation was observed, but statistical significance was maintained (P < 0.044). Fasting plasma IL-6 concentration was positively correlated with first-phase insulin secretion assessed as acute insulin response (AIR) (P = 0.001). The correlation remained significant after adjusting for sex, age, and BMI (P = 0.003). To estimate the independent contribution of plasma IL-6 levels to AIR, we carried out forward stepwise linear regression analysis in a model that included sex, age, BMI, waist-to-hip ratio, FFAs, and insulin-stimulated glucose disposal. Only insulin sensitivity and plasma IL-6 concentration were independently associated with AIR, accounting, respectively, for 19.0 and 5.2% of its variation. These data indicate that IL-6 is associated in a reciprocal manner with the two pathophysiological components of type 2 diabetes, i.e., insulin resistance and insulin secretion.     

Cost analysis of minimally invasive radical hysterectomy for cervical cancer performed by a single surgeon in an Italian center: an update in gynecologic oncological field

The objective of this study is to perform an economic analysis and examine the influence of procedural volume of our hospital, evaluating the accounting systems of Robotic radical hysterectomy (RRH) vs Laparoscopic radical hysterectomy (TLRH) in patients with cervical carcinoma, due to the costs widely variable and lack in literature. Costs were collected prospectively, from March 2010 to March 2016. Direct costs were determined by examining the overall medical pathway for each type of intervention. 52 patients with cervical carcinoma, which were matched by age, body mass index, tumor size, International Federation of Gynecology and Obstetrics (FIGO) stage, comorbidity, previous neoadjuvant chemotherapy, histology type, and tumor grade to obtain homogeneous samples. Surgical time was similar for both the groups. RRH was associated with a significantly less (EBL) estimated blood loss (P = 0.000). The overall median length of follow-up was of 59 months. The cost of the robot-specific supplies was €2705 per intervention. When considering overall medical surgical care, the patient treatment average cost of an RRH was €5650,31 with an hospital stay (HS) of 3.58 days (SD ± 1) vs €3750.86 for TRLH, with an HS of 4.27 days (SD ± 1.79). Our results are similar to Finnish data; the costs of robot-assisted hysterectomies were 1.5 times higher than TLRH. The main drivers of additional costs are robotic disposable instruments, which are not compensated by the hospital room costs and by an experienced team staff. Implementation of strategies to reduce the cost of robotic instrumentation is due. RRH resulted less expensive than robotic simple hysterectomy for benign conditions.     

Lingual mucosal graft urethroplasty for anterior urethral reconstruction

OBJECTIVE: Evaluate the use of lingual mucosal graft (LMG) in anterior urethral strictures. METHODS: From January 2001 to December 2006, 29 men (mean age, 48.5 yr) with anterior urethral strictures underwent graft urethroplasty with LMG. The mean length of stricture was 3.6cm. Patients with bulbar, penile, or bulbopenile strictures received one-stage dorsal free graft urethroplasties. In patients with failed hypospadias repair we performed a two-stage urethroplasty. Criteria for successful reconstruction were spontaneous voiding with no postvoid residual urine and no postoperative instrumentation of any kind. Clinical assessment included the donor site morbidity. RESULTS: Mean follow-up was 17.7 mo. One-stage bulbar and penile urethroplasties without meatal involvement had an 81.8-100% success rate. Bulbopenile urethroplasties were successful in 60% of the cases, whereas one-stage urethral reconstructions in patients with meatal involvement were successful in 66.6%. The two cases of two-stage urethral reconstruction with LMG and buccal mucosal graft after failed multiple hypospadias repairs were unsuccessful. The overall early recurrence rate was 20.7%. Patients with the graft harvested from the tongue reported only slight oral discomfort at the donor site and difficulty in talking for 1 or 2 d. CONCLUSIONS: The mucosa of the tongue, which is identical to the mucosa of the rest of the oral cavity, is a safe and effective graft material in the armamentarium for urethral reconstruction with potential minor risks of donor site complications. LMG may be used alone for short strictures (<5cm) or in combination with buccal mucosa when longer grafts are needed.     

Nd:YAG laser clinical assisted in class II furcation treatment

The Nd:YAG laser efficacy associated with conventional treatment for bacterial reduction has been investigated throughout literature. The purpose of this study was to evaluate the bacterial reduction after Nd:YAG laser irradiation associated with scaling and root planning in class II furcation defects in patients with chronic periodontitis. Thirty-four furcation lesions were selected from 17 subjects. The control group received conventional treatment, and the experimental group received the same treatment followed by Nd:YAG laser irradiation (100 mJ/pulse; 15 Hz; 1.5 W, 60 s, 141.5 J/cm²). Both treatments resulted in improvements of most clinical parameters. A significant reduction of colony forming unit (CFU) of total bacteria number was observed in both groups. The highest reduction was noted in the experimental group immediately after the treatment. The number of dark pigmented bacteria and the percentage of patients with Porphyromonas gingivalis, Prevotella intermedia, and Actinobacillus actinomycetemcomitans reduced immediately after the treatment and returned to values close to the initial ones 6 weeks after the baseline for both groups. The Nd:YAG laser associated with conventional treatment promoted significant bacterial reduction in class II furcation immediately after irradiation, although this reduction was not observed 6 weeks after the baseline.     

Infected urocolpos and generalized peritonitis secondary to labia minora adhesions

Introduction

Labia minora adhesions (LMA) are a common finding in young girls. Usually, this condition is asymptomatic and spontaneously disappears during adolescence. We report on a case revealed by infected urocolpos and peritonitis and whose treatment finally required surgical reduction labioplasty.

Case report

A 9-year-old girl presented with a 2-day history of abdominal pain and fever. Urinary continence had never been obtained, with diurnal leaks. Physical examination showed signs of peritoneal irritation and a subtotal vulvar obstruction due to LMA. At surgery, after LMA lysis, a large amount of cloudy urine-like fluid emptied under pressure from the vagina. Laparoscopy showed generalized peritonitis without any intraabdominal cause. The same Escherichia coli was identified in the infected urocolpos and the abdominal fluid. Postoperative course was uneventful.Because of recurrent LMA, the patient underwent several courses of local estrogen therapy. Labia minora hypertrophy with LMA developed 2 years after peritonitis, requiring surgical reduction labioplasty. We used a new technique with interposition of skin flaps. The girl is now well, without LMA or infection, 4 years after labioplasty.

Conclusion

Although rare, subtotal vulvar obstruction because of LMA may lead to infected hydrocolpos and peritonitis. Recurrent LMA may necessitate surgical labioplasty.     

Pancreatoduodenectomy for Tumors of Vater’s Ampulla: Report on 94 Consecutive Patients

Evaluation of prognostic factors of adenocarcinoma of Vater’s ampulla is still a matter of debate. The aim of this study was to evaluate retrospectively factors that influence early and long-term outcomes in a 20-year single-institution experience on ampullary carcinoma. A total of 94 consecutive patients with ampullary carcinoma or adenoma with severe dysplasia were managed from 1981 to 2002. Among them, 64 underwent pancreatoduodenectomy, and the remaining 30 submitted to surgical (n = 5) or endoscopic (n = 25) palliative treatment. Demographic, clinical, and pathologic data were collected, and a comparison was made between patients who did or did not undergo resection. Standard statistical analyses were carried out in an attempt to establish a correlation between clinical variables, intraoperative and pathologic factors, and survival in patients with resection. A total of 85 (90.4%) patients had potentially resectable lesions due to the extent of the tumor, but only 64 (68%) underwent curative resection. The surgical morbidity rate was 34.3%. Postoperative mortality was 9.3%, with no deaths among the 38 more recently treated patients. Median survivals were 9 and 54 months for nonresected and resected patients, respectively. The overall 5-year survival was 64.4% for patients undergoing pancreatoduodenectomy. Survival was found to be significantly affected by resection, tumor size, tumor grade, and tumor infiltration. Patients with negative lymph nodes show a trend toward longer survival. In a multivariate analysis, only the depth of tumor infiltration influenced patient survival.Pancreatoduodenectomy is the treatment of choice for ampullary carcinoma and adenomas with high-grade dysplasia, with a good chance of long-term survival. Surgical resection remains the most important factor influencing outcome.     

The probability of Gleason score upgrading between biopsy and radical prostatectomy can be accurately predicted

The objective of this study was to test the external validity of a previously developed nomogram for the prediction of Gleason score upgrading (GSU) between biopsy and radical prostatectomy (RP). The study population consisted of 973 assessable patients treated with RP at a tertiary care institution. The accuracy of the nomogram was quantified with the receiver operating characteristics curve-derived area under the curve. The performance characteristics (predicted vs observed rate of GSU) were tested within a calibration plot. Overall, GSU was recorded in 39.8% ( n  = 387) of patients at RP. Of patients with GSU, 70 (18.1%), 23 (5.9%) and 32 (8.3%), respectively, had extracapsular extension, seminal vesicle invasion and lymph node invasion. The accuracy of the nomogram was 74.9% (confidence interval 72.1–77.6%). The model tended to underestimate the observed rate of GSU and the discordance between the predicted and observed rate of GSU ranged from −7 to +10%. The current tool represents the most accurate method of predicting GSU between biopsy and RP. Nonetheless it is not perfect and its performance characteristics should be known prior to its use in clinical decision-making.     

Comparison of Recurrence of Hepatocellular Carcinoma After Resection in Patients with Cirrhosis to Its Occurrence in a Surveilled Cirrhotic Population

The presence of cirrhosis is the only risk factor that is advocated for recurrence of hepatocellular carcinoma (HCC) 2 years after hepatic resection compared with noncirrhotic control subjects; however, data for cohorts of exclusively patients with cirrhosis are lacking. This study was designed to assess risk factors and annual incidence of early (<2 years) and late (>2 years) recurrence after resection of cirrhosis and to compare these findings with those of patients with cirrhosis enrolled in HCC surveillance programs (HCC occurrence). Data from 204 patients with cirrhosis resected for HCC and 150 surveilled for cirrhosis were retrospectively collected and compared using propensity score matching to overcome biases of nonrandomized study. Risk factors for early recurrence (incidence = 21.8%/year) were higher serum alpha-fetoprotein (AFP) levels, poorly differentiated tumor, and presence of microvascular invasion (P < 0.05). Risk factors for both late recurrence (18.4%/year) and HCC occurrence (3.3%/year) were male gender, older age, and higher serum transaminase levels; multiple primary tumors and higher AFP were additional risk factors for late recurrence and HCC occurrence respectively (P < 0.05). After propensity adjustment, resected patients with less than two risk factors for late recurrence showed an annual incidence of HCC (6.2%/year) similar to that of surveilled patients with ≥2 risk factors (5.8%/year; P = 0.898). Early and late recurrence of HCC for patients with cirrhosis after resection have distinct risk factors. Annual incidence of HCC 2 years or more after resection may be similar to that of general patients because the same risk factors are involved; assessment of these characteristics could be useful in tailoring clinical management.