Clinica Chirurgica Research Articles

Transanal endoscopic microsurgery: indications, tips and long-term results. A single center experience.

Transanal endoscopic microsurgery (TEM) was introduced to combine the curativeness of full thickness excision with minimum morbidity, while traditional rectal surgery is burdened by high morbidity and mortality rates. However, while it is still a matter of considerable debate whether local excision is an adequate approach for curative resection of rectal cancer, new minimally invasive operative techniques have been introduced. The purpose of this paper was to show the indications, the tips and long term results of this technique through the review of the largest single-center database available to date. The showed results derived from the single center experience of the Clinica Chirurgica of Polytechnic University of Marche. We retrospectively reviewed a 25-year database from May 1992 to May 2017. We divided the patients into three different groups of patients according to the preoperative diagnosis: rectal cancers, adenomas and other rectal lesions. Rectal adenomas were divided into two groups according to their diameter (> or <5 cm). Rectal cancer patients were divided into two groups according to the preoperative staging: early rectal cancer and irradiated rectal cancer. Among the 1324 patients who had rectal tumors excised with TEM at our institution, preoperative histology was rectal adenoma in 729 (55%) patients, adenocarcinoma in 536 (40.5%) patients and other lesions in the remaining 59 (4.4%) patients. 5 years overall survival (OS) and Recurrence free survival (RFS) were 93.3% and 98.6% for patients with rectal adenomas and 86.8% and 70.9% for patients with rectal cancer. TEM can be a valid alternative for the treatment of both benign and malignant rectal lesions, further studies are needed to define more specific indications to justify the survival of this technique in the future.

Innate and adaptive immunity activation in neoplastic mucosa in esophageal cancer

Innate and adaptive immunity activation in neoplastic mucosa in esophageal cancer

Management and prognosis of esophageal carcinosarcoma

Management and prognosis of esophageal carcinosarcoma

Esophageal cancer after mediastinal irradiation for malignancies: A case-control study

Esophageal cancer after mediastinal irradiation for malignancies: A case-control study

Which is the best surgical approach for anorectal gastrointestinal stromal tumors in the post-imatinib era?

Anorectal gastrointestinal stromal tumors (GISTs) represent about 5 % of all GISTs. Local recurrence, although with a long latency period, occurs in more than a half of cases and is a major concern. Prognostic factors for recurrence are the tumor size and the mitotic index. However, for anorectal lesions, the particular location represents a main obstacle to achieving a radical (R0) resection. Surgery is the treatment of choice for patients with localized or potentially resectable GIST lesions. The goal is to achieve complete gross resection of the tumor with an intact pseudocapsule. Current guidelines recommend wide resection with clear margins (such as abdominoperineal or anterior resection) [1, 2]. Local removal of the tumor has also been proposed, performed by a transanal, transsacral, or transvaginal approach, even if abdominal surgery is more likely to result in negative margins than local surgery [3]. In the article by Centonze et al. [4], a new local technique has been proposed for anorectal GIST excision. A transsphincteric approach was used, with a right ischiorectal fossa incision. Although in the two cases presented the tumor size was C8 cm and the mitotic index was high, the procedure seems feasible, with low morbidity and good early oncological outcomes. Both the patients underwent adjuvant therapy with imatinib, as recommended for high risk GISTs. There are two important considerations to be made. The first concerns the preoperative workup. All anorectal GIST patients should be managed by a multidisciplinary team with expertise in sarcoma. The workup should include: history, physical examination, abdominal/pelvic computed tomography (CT) scan with contrast and/or magnetic resonance imaging (MRI), and chest imaging. A positron emission tomography (PET) scan is not a substitute for CT, however, it may be used to clarify ambiguous findings seen on CT or MRI. Finally, endoscopic ultrasound-guided fine needle aspiration biopsy is necessary to confirm the diagnosis of primary GIST prior to the initiation of any preoperative therapy [5]. The second concerns the use of imatinib associated with surgery. This selective inhibitor of the KIT protein tyrosine kinase has drastically improved the prognosis of patients with GIST. The results of a recently completed trial suggest that in patients with a high risk of recurrence adjuvant imatinib administered for 36 months significantly improves relapse-free and overall survival compared to 12 months of imatinib therapy [6]. Since sphincter-sparing surgery is a primary goal in treating rectal tumors, the use of preoperative imatinib has also been investigated. The published trials show that preoperative imatinib is safe, and associated with a higher R0 rate, lower risk of tumor rupture, acceptable perioperative morbidity, and good disease-free survival [7–10]. However, the survival benefit is not well determinable since most of the patients included in these studies also received imatinib postoperatively for at least 2 years [7–9]. Thus, at the present time, the decision to use preoperative therapy for patients with resectable primary, locally advanced, or recurrent GIST should be made on an individual basis. In our opinion, patients with high risk anorectal GIST (tumor size > 5 cm and/or documented mitotic rate > 5 mitoses/50 high power field) should be treated with preoperative imatinib, followed by sphincter-saving surgery. Adjuvant imatinib for high-risk patients should be S. Pucciarelli (&) I. Maretto Clinica Chirurgica I, Department of Surgery, Oncology, and Gastroenterology, University of Padua, Via Giustiniani, 2, 35128 Padua, Italy e-mail: puc@unipd.it

Sarcomas of the scalp: A comparison of two lesions

Sarcomas of the scalp: A comparison of two lesions

Investigation of the effects induced on endothelial function by the human T2238C ANP gene molecular variant

s 153 Clinica Medica, Department of Medical and Surgical Sciences, University of Brescia, Brescia, Italy Clinica Chirurgica, Department of Medical and Surgical Sciences, University of Brescia, Brescia, Italy Chair of Ophthalmology, University of Brescia, Brescia, Italy Chair of Ophthalmology, University of Molise, Campobasso, Italy Chair of Ophthalmology, University of Ferrara, Ferrara, Italy Structural alterations of subcutaneous small resistance arteries, as indicated by an increased media to lumen (M/L) ratio, are frequently present in hypertensive and/or diabetic patients, and may represent the earliest alteration observed. In addition, M/L of small arteries evaluated by micromyography has a strong prognostic significance; however its extensive evaluation is limited by the invasivity of the assessment, since a biopsy of subcutaneous fat is needed. Non-invasive measurement of wall to lumen (W/L) of retinal arterioles using scanning laser doppler flowmetry (SLDF) has been recently introduced (Harazny J et al, Hypertension 2007; 50:623-629). However, this new technique was never compared with micromyographic measurement, considered the gold standard approach. Methods and Results: We have investigated 37 subjects and patients. Twenty-three of them were hypertensives and 14 normotensives. Blood pressure values were 139/88 17/10 mmHg and 125/71 17/12 mm Hg, respectively (p<0.05). All patients underwent a biopsy of subcutaneous fat during an elective surgical intervention. Subcutaneous small resistance arteries were dissected and mounted on a wire myograph, and M/L was measured. In addition, an evaluation of W/L of retinal arterioles by SLDF was performed (Heidelberg Retina Flowmeter, Heidelberg Engineering). A close correlation was observed between M/L of subcutaneous small arteries and WL of retinal arterioles: rZ0.77, p<0.001 (see Figure). Conclusion: A non invasive and easily repeatable procedure (intraobserver and interobserver variation coefficient around 10%) such as an evaluation of the arterioles in the fundus oculi by SDLF may provide similar information regarding microvascular morphology compared in respect with an invasive, accurate and prognostically relevant micromyographic measurement of M/L. y = 6,5298x 0,234 R2 = 0,5902 0,00 0,10 0,20 0,30 0,40 0,50 0,60 0,70 0,80 0,04 0,06 0,08 0,10 0,12 0,14 0,16

Complications, continence and quality of life after an intensive preoperative radio-chemotherapy regimen for locally advanced rectal cancer: analysis of a phase I–II study

Complications, continence and quality of life after an intensive preoperative radio-chemotherapy regimen for locally advanced rectal cancer: analysis of a phase I–II study

P27kipl protein expression: an independent prognostic factor in rectal carcinoma stages I–III

To evaluate the impact of some molecular markers on lymph node metastases, overall (OS) and disease-free survival (DFS) in rectal cancer. We investigated p27(kip1) , p53, nm23, and vascular endothelial growth factor (VEGF) expression in 109 primary rectal cancer specimens (stage I, n=38; stage II, n=24; stage III, n=20; and stage IV, n=27) from patients operated on between 1990 and 1995 at Clinica Chirurgica II. Tumour differentiation (P=0.0469), depth of rectal wall invasion (T status) (P=0.0000), distant metastases (P=0.0000), vascular invasion (P=0.0000), and p27(kip1) expression (P=0.0022) were associated with lymph node metastases (N status). During follow up (median duration 47 months), 48 patients died, and 25 patients (stages I-III) had recurrences. At multivariate analysis, T and N status, and intratumoural necrosis were independent risk factors for OS. The relative risk (RR) of death for patients with lymph node metastases, advanced T status and intratumoural necrosis was 3.3 (P=0.0002), 2.03 (P=0.0127), and 1.47 (P=0.1935), respectively. When analysis included only stage I-III patients, N status and p27(kip1) protein expression were found to be independent risk factors for OS. The RR of death for patients with lymph node metastases and those without p27(kip1) expression was 2.98 (P=0.0251), and 3.57 (P=0.0231), respectively. At multivariate analysis, N status, p27(kip1) expression, and intratumoural necrosis were independent risk factors for DFS. The RR of recurrence for patients with lymph node metastases, intratumoural necrosis and absence of p27(kip1) expression was 6.29 (P=0.0001), 3.04 (P=0.0168), and 3.25 (P=0.0387), respectively. Absence of p27(kip1) expression is a useful marker of tumour aggressiveness in rectal carcinoma stages I-III, and an independent predictor for OS and DFS.

Surgery for bronchogenic carcinoma in the elderly: Immediate re-sults: Di Giogio A, Amone P, Casali G, Canavese A, Cardini C, Speciale R et al. Istituto di Clinica Chirurgica, Univ. degli Studi Roma ‘La Sapienza’, Policlinico Umberto I, Via Lancisi 2, 00165 Roma. Minerva Chir 1994;49:917–927

Surgery for bronchogenic carcinoma in the elderly: Immediate re-sults: Di Giogio A, Amone P, Casali G, Canavese A, Cardini C, Speciale R et al. Istituto di Clinica Chirurgica, Univ. degli Studi Roma ‘La Sapienza’, Policlinico Umberto I, Via Lancisi 2, 00165 Roma. Minerva Chir 1994;49:917–927

K-ras2 codon 12 GAT and GTT coexisting SSCPs occur frequently in periampullary neoplasms of pancreatic as well as of biliary origin : [formula omitted], L. Arborati, O. Orbetegli, M. Sampietro, A. Zerbi, D. Faravelli, V. Di Carlo, A. Malesci, G. Fiorelli. Istituto di Medicina Interna e Fisiopatologia Medica, Ospedale Policlinico; Clinica Chirurgica e Anatomia Patologica, Istituto S. Raffaele, Milano, Italy

K-ras2 codon 12 GAT and GTT coexisting SSCPs occur frequently in periampullary neoplasms of pancreatic as well as of biliary origin : [formula omitted], L. Arborati, O. Orbetegli, M. Sampietro, A. Zerbi, D. Faravelli, V. Di Carlo, A. Malesci, G. Fiorelli. Istituto di Medicina Interna e Fisiopatologia Medica, Ospedale Policlinico; Clinica Chirurgica e Anatomia Patologica, Istituto S. Raffaele, Milano, Italy

Combined laparoscopic cholecystectomy and intraoperative endoscopic sphincterotomy in the treatment of cholecysto-choledocholithiasis: [formula omitted], A. Fantini, G. Silecchia, G. Pizzuto, C. Caruso, A. Genco, E. Spaziani, F. Fiocca, N. Basso. II Clinica Chirurgica, University “La Sapienza”, Rome, Italy

Combined laparoscopic cholecystectomy and intraoperative endoscopic sphincterotomy in the treatment of cholecysto-choledocholithiasis: [formula omitted], A. Fantini, G. Silecchia, G. Pizzuto, C. Caruso, A. Genco, E. Spaziani, F. Fiocca, N. Basso. II Clinica Chirurgica, University “La Sapienza”, Rome, Italy

Percutaneous transhepatic cholecystostomy as a preliminary procedure in patients with septic shock due to acute gangrenous cholecystitis: G. Pizzuto, D. Surgo, P. Rosato, L. Nasorri, T. Neri, [formula omitted], N. Basso. II Clinica Chirurgica, University “La Sapienza”, Rome, Italy

Percutaneous transhepatic cholecystostomy as a preliminary procedure in patients with septic shock due to acute gangrenous cholecystitis: G. Pizzuto, D. Surgo, P. Rosato, L. Nasorri, T. Neri, [formula omitted], N. Basso. II Clinica Chirurgica, University “La Sapienza”, Rome, Italy

Laparoscopic colectomy: Italian experience: Italian registry of S.I.C.E. (Società italiana di chirurgia endoscopica e chirurgia mini-invasiva). c/o II Clinica Chirurgica - VII Patologia Chirurgica, University “La Sapienza”, Rome, Italy

Laparoscopic colectomy: Italian experience: Italian registry of S.I.C.E. (Società italiana di chirurgia endoscopica e chirurgia mini-invasiva). c/o II Clinica Chirurgica - VII Patologia Chirurgica, University “La Sapienza”, Rome, Italy

Surgical treatment of the non-small cell lung cancer: Stage I (T1N0-T2N0) and stage II (T1N1-T2N1). Prognostic factors, results and recurrence : Ramacciato G, Aurello P, D'Angelo F, Barillari P, Paolini A, Tosato F. Istituto di I Clinica Chirurgica, Universita degli Studi ‘La Sapienza’, Viale del Policlinico, 00161 Roma. Chirurgia 1993;6: 791-8

Surgical treatment of the non-small cell lung cancer: Stage I (T1N0-T2N0) and stage II (T1N1-T2N1). Prognostic factors, results and recurrence : Ramacciato G, Aurello P, D'Angelo F, Barillari P, Paolini A, Tosato F. Istituto di I Clinica Chirurgica, Universita degli Studi ‘La Sapienza’, Viale del Policlinico, 00161 Roma. Chirurgia 1993;6: 791-8

Surgical treatment for stages I-II non small cell lung cancer : A. Paolini, A. Caminiti, M. Lepore, G. Paolini, M. Batori, R. Dell'Arte, G. Sodani, M. Ruggieri, IV Clinica Chirurgica - Università “La Sapienza” Roma, Italia

Surgical treatment for stages I-II non small cell lung cancer : A. Paolini, A. Caminiti, M. Lepore, G. Paolini, M. Batori, R. Dell'Arte, G. Sodani, M. Ruggieri, IV Clinica Chirurgica - Università “La Sapienza” Roma, Italia

Surgical treatment for stage III a nonsmall cell lung cancer : M. Ruggieri, A. Caminiti, M. Lepore, G. Paolini, M. Balori, R. Dell'Arte, G. Sodani, A. Paolini. IV Clinica Chirurgica - Università “La Sapienza” Roma, Italia

Surgical treatment for stage III a nonsmall cell lung cancer : M. Ruggieri, A. Caminiti, M. Lepore, G. Paolini, M. Balori, R. Dell'Arte, G. Sodani, A. Paolini. IV Clinica Chirurgica - Università “La Sapienza” Roma, Italia

Redo pouches

From October 1, 1984 to December 31, 1991 at the Clinica Chirurgica II of the University of Bologna, 140 patients submitted to ileal pouch-anal anastomosis for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Nineteen patients (13.5 percent) developed septic complications. Of these, 11 patients (7.8 percent) had pelvic sepsis. Eight patients required further surgical intervention. Five patients underwent the redo pouch procedure. Another redo pouch was performed in a patient who had previously, in another hospital, had an ileal pouch-anal anastomosis placed and then removed because of ischemic necrosis of the reservoir. No deaths are reported in the reoperated patients. Currently, five of the six patients who underwent the redo pouch procedure have a well-functioning ileoanal anastomosis. The redo pouch procedure should always be attempted prior to the establishment of pelvic fibrosis.

Bronchoplastic and tracheobronchoplastic procedures for lung cancer: M. Mastrorilli, R.B. Bragaglia, G. Cipolla D'Abruzzo, F. Falcone, L. Busutti, S. Baroncini, L. Liberatore, G. Gozzetti. Clinica Chirurgica II-University of Bologna-Italy

Bronchoplastic and tracheobronchoplastic procedures for lung cancer: M. Mastrorilli, R.B. Bragaglia, G. Cipolla D'Abruzzo, F. Falcone, L. Busutti, S. Baroncini, L. Liberatore, G. Gozzetti. Clinica Chirurgica II-University of Bologna-Italy

T 4 (trachea-heart-great vessels) lung cancer surgery : M. Mastrorilli, G. Cipolla D'Abruzzo, R.B. Bragaglia, F. Falcone, R. Paladini, W. Grigioni, G. Gozzetti. Clinica Chirurgica II-University of Bologna - Italy

T 4 (trachea-heart-great vessels) lung cancer surgery : M. Mastrorilli, G. Cipolla D'Abruzzo, R.B. Bragaglia, F. Falcone, R. Paladini, W. Grigioni, G. Gozzetti. Clinica Chirurgica II-University of Bologna - Italy