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ABSTRACT: The aim of this study was to evaluate the feasibility of a totally stapled gastrojejunal anastomosis performed using one transabdominal 12-mm trocar and a gastroscope in a porcine model.
The procedure was carried out on six domestic pigs weighing 45 kg using a hybrid technique with a gastroscope and a 12-mm Hasson trocar, positioned in the left hypochondrium. At the end of the procedure a mechanical circular 21-mm gastrojejunal anastomosis was performed by inserting the stapler through a small gastrotomy after enlarging the trocar incision.
In all six cases the procedure was completed through a single 3 cm abdominal incision and without complications. The mean operating time was 2 h, and endoscopic investigation showed that the anastomoses were intact, patent, and airtight.
Totally stapled gastrojejunal anastomosis using a hybrid NOTES-single 12-mm trocar approach is a feasible procedure in the porcine model. Further survival studies are warranted, particularly to evaluate the functional results of this procedure.
Surgical Endoscopy 04/2012; 26(9):2527-31. · 4.01 Impact Factor
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ABSTRACT: To assess B1a cell expression in the rectal mucosa of ulcerative colitis (UC) patients in comparison with healthy controls.
Rectal mucosa biopsies were collected from 15 UC patients and 17 healthy controls. CD5(+) B cells were analysed by three colour flow cytometry from rectal mucosal samples after mechanical disaggregation by Medimachine(®). Immunohistochemical analysis of B and T lymphocytes was also performed. Correlations between, on the one hand, rectal B1a cell concentrations and, on the other, erythrocyte sedimentation rate and C-reactive protein levels and clinical, endoscopic and histological disease activity indices were evaluated.
Rectal B-lymphocyte (CD19(+)/CD45(+)) rate and concentration were higher in UC patients compared with those in healthy controls (47.85% ± 3.12% vs 26.10% ± 3.40%, P = 0.001 and 501 ± 91 cells/mm(2) vs 117 ± 18 cells/mm(2), P < 0.001); Rectal B1a cell density (CD5(+)CD19(+)) was higher in UC patients than in healthy controls (85 ± 15 cells/mm(2) vs 31 ± 6.7 cells/mm(2), P = 0.009). Rectal B1a cell (CD5/CD19(+)) rate correlated inversely with endoscopic classification (Rs = -0.637, P < 0.05).
B1a lymphocytes seem to be involved in the pathogenesis of UC, however, the role they play in its early phases and in disease activity, have yet to be defined.
World Journal of Gastroenterology 01/2012; 18(2):144-9. · 2.47 Impact Factor
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ABSTRACT: The aim of the study was to analyse the incidence of benign colorectal anastomotic stenoses in consecutive patients operated on in a single institution and to assess risk factors for their development. Their impact on quality of life was also evaluated.
Patient characteristics, indications for surgery, surgical technique and postoperative complications were prospectively recorded. Stenosis was evaluated by rectoscopy at regular intervals, and patients were treated only if symptomatic. After at least 6 months following surgery, patients were asked to respond to the Short Form 36-item quality-of-life questionnaire during a telephone interview.
Of the original 211 patients considered, 195 underwent a follow-up rectoscopy and were included in the study. Benign stenosis were found in 26 (13%), and 19 (73%) symptomatic patients were treated successfully (15 with endoscopic dilatation and four with radial diathermic surgical incisions). Risk factors for anastomotic stenosis according to univariate analysis were female sex, diverticulitis, mechanical anastomosis, and anastomosis located between 8 and 12 cm from the anal verge. The significant risk factors identified by multivariate analysis were diverticulitis (OR 5, P=0.002) and mechanical anastomosis (OR 9, P=0.04). The self-perceived quality of life of patients with stenosis was significantly worse compared with controls.
Since diverticulitis and mechanical anastomosis are risk factors for anastomotic stenosis, surgeons should take this into account when they are considering what type of anastomotic technique to utilize.
Colorectal Disease 09/2011; 14(3):e124-8. · 2.93 Impact Factor
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ABSTRACT: Natural orifice transluminal endoscopic surgery (NOTES), a new frontier of minimally invasive surgery, uses the body's natural orifices to create an access for surgical procedures. This study aimed to verify the technical feasibility of ileorectal bypass performed entirely through a transanal access.
The procedure was performed on 10 domestic pigs, after which they were killed. A transanal endoscopic microsurgery (TEM) device and endoscopic and laparoscopic instruments were used.
The findings demonstrated that an ileorectal bypass through a transanal access is feasible. The principal steps of a standardized transanal procedure are as follows: confirm a rectal perforation above the peritoneal reflection, perform peritoneoscopy using a standard gastroscope, grasp the small bowel with retrieval forceps and pull it through the rectal hole, suture the ileum and the rectum together using a TEM device, open the ileal loop, and perform endoscopic exploration. Satisfactory anastomosis and no signs of procedure-related complications were confirmed by a post procedure laparotomy.
Ileorectal bypass through a transanal access is technically feasible in a porcine model, and although still at an experimental stage, it could become a surgical option for treating some types of colonic strictures.
Surgical Endoscopy 04/2011; 25(9):3022-7. · 4.01 Impact Factor
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G Sarzo,
A Del Mistro,
A Mistro,
C Finco,
H Frayle-Salamanca,
F Marino,
M Franzetti,
R Ferrara,
M Mistrangelo,
S Savastano,
M Vecchiato, S Merigliano
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ABSTRACT: To evaluate the clinical course of extensive anal condylomatosis in relation to treatment modalities, patient comorbidity and immune function, and associated papillomavirus (HPV) sequences.
Clinical data, treatment modalities and follow-up were recorded and analysed in relation to host and viral type. Histology, immunohistochemistry and molecular analyses for HPV search and typing were performed on formalin-fixed paraffin-embedded samples.
Sixteen patients [14 males, median age 41.8 years (range 19-66)] affected by extensive anal condylomatosis [10 Buschke-Lowenstein Tumors (BLT) and 6 condylomatosis] treated in three different Italian institutions were included. There was associated preoperative anal intraepithelial neoplasia grade 3 (AIN3) in one and invasive carcinoma in three patients. After radical resection (n = 16) recurrence occurred in 4/10 (40%) BLT patients. Malignancy before or after treatment developed in 5/16 (31.25%) patients. HPV sequences were present in all the samples of 15 evaluable patients (types 6 or 11, 9 patients; type 16, 6 patients). A statistically significant association was found between presence of HPV type 16 and both malignancy and recurrence. Viral variant L83V was present in 3/4 HPV 16 positive recurrent cases.
Radical resection resulted in a favourable clinical course. Typing of HPV sequences in the management of patients affected by extensive anal condylomatosis may be useful.
Colorectal Disease 05/2009; 12(7 Online):e128-34. · 2.93 Impact Factor
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BMC Geriatrics. 01/2009;
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BMC Geriatrics. 01/2009;
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ABSTRACT: The natural history of esophageal epiphrenic diverticula (ED) is not entirely clear; the decision whether to operate or not is often based on the personal preference of the physician and patient. The aim of this study was to evaluate the long-term fate of operated and unoperated patients with ED.
Clinical, radiological, and motility findings, and operative morbidity and long-term outcome of 41 patients with ED (January 1993 to December 2005) were analyzed. All patients were reviewed at the outpatient clinic or interviewed over the phone. A symptom score was calculated using a standard questionnaire and subjective patient assessment. The radiological maximum diameter of the ED was measured.
Twenty-two patients (12M:10F; median age, 60 years) were operated. One underwent surgery for spontaneous rupture of a large diverticulum. Operative mortality was nil; postoperative morbidity was 22.7%, the most severe complication being suture leakage (4 patients, all managed conservatively); median follow-up was 53 months. Nineteen patients (9M, 10F; median age 70 years) were not operated: 3 received pneumatic dilations; median follow-up was 46 months. None of the patients in either group died for reasons related to their ED. Symptoms decreased in all operated patients and, to a lesser extent, also in unoperated patients. ED recurrence was observed in one operated patient. Four patients had GERD symptoms with esophagitis and/or positive pH-metry after surgery and 3 patients had persistent dysphagia/regurgitation and were dissatisfied with the outcome of surgery.
Surgery is an effective treatment for ED, but carries a significant morbidity related mainly to suture leakage. Even in the long-term, unoperated patients do not die of their ED, though a better subjective symptom outcome is reported by operated patients. A non-interventional policy can safely be adopted in cases of small, mildly symptomatic ED.
Journal of Gastrointestinal Surgery 08/2008; 12(9):1485-90. · 2.83 Impact Factor
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Alberto Ruol,
Giuseppe Portale,
Carlo Castoro, Stefano Merigliano,
Matteo Cagol,
Francesco Cavallin,
Vanna Chiarion Sileni,
Luigi Corti,
Sabrina Rampado,
Mario Costantini,
Ermanno Ancona
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ABSTRACT: The use of cytoreductive therapy followed by surgery is preferred by many centers dealing with locally advanced esophageal cancer. However, the potential for increase in mortality and morbidity rates has raised concerns on the use of chemoradiation therapy, especially in elderly patients. The aim of this study was to assess the effects of induction therapy on postoperative mortality and morbidity in elderly patients undergoing esophagectomy for locally advanced esophageal cancer at a single institution.
Postoperative mortality and morbidity of patients > or = 70 years old undergoing esophagectomy after neoadjuvant therapy, between January 1992 and October 2005 for cancer of the esophagus or esophagogastric junction, were compared with findings in younger patients also receiving preoperative cytoreductive treatments.
818 patients underwent esophagectomy during the study period. The study population included 238 patients < 70 years and 31 > or = 70 years old undergoing esophageal resection after neoadjuvant treatment. Despite a significant difference in comorbidities (pulmonary, cardiological and vascular), postoperative mortality and morbidity were similar irrespective of age.
Elderly patients receiving neoadjuvant therapies for cancer of the esophagus or esophagogastric junction do not have a significantly increased prevalence of mortality and major postoperative complications, although cardiovascular complications are more likely to occur. Advanced age should no longer be considered a contraindication to preoperative chemoradiation therapy preceding esophageal resection in carefully selected fit patients.
Annals of Surgical Oncology 12/2007; 14(11):3243-50. · 4.17 Impact Factor
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ABSTRACT: 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.
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.
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.
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.
European Journal of Cardio-Thoracic Surgery 10/2007; 32(3):445-8. · 2.55 Impact Factor
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ABSTRACT: There is currently still no consensus regarding the best technique for implanting prolonged-venous-access devices (PVAD). One hundred ninety-six patients underwent surgical PVAD positioning using an all-surgical cutdown approach to the cephalic vein (CV). When surgical cannulation proved impossible, the patient was converted to percutaneous positioning. A retrospective analysis was performed on the difference between these two techniques. Among the 196 patients who underwent the surgical insertion of a PVAD, 23 (11.7%) were converted to percutaneous cannulation. For the surgical cannulation group, the median operating time was 35 minutes vs the 52.5 minutes needed for the percutaneous cannulation group. The median time of fluoroscopy amounted to eight seconds for the surgical cannulation group vs 18 seconds for the percutaneous cannulation group. Complications were observed in 23/196 patients (11.7%): 9/23 patients (39.1%) developed infections. Deep venous thrombosis was observed in 4/23 patients (17.4%). Pneumothorax and arterial hematoma developed in 5/23 patients (21.7%), all cases of percutaneous placement. PVAD malfunction was observed in 3/23 patients (13.0%). We concluded that surgical cutdown is faster than the percutaneous approach and safer for both patient and surgeon, involving a shorter time of exposure to radiation and reducing the risk of infection.
International Journal of Angiology 11/2004; 13(4):203-209.
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ABSTRACT: The aim of the study was to evaluate laparoscopic-assisted colorectal resection for malignancies in terms of effectiveness, safety and medium-term survival, comparing our results with those reported in literature. From November 2000 to March 2004, 78 patients with colorectal malignancies underwent laparoscopic-assisted resection. All anastomoses were performed extracorporeally. Where indicated, patients underwent pre- or post-operative chemo-radiotherapy. All patients were followed up at regular intervals for a mean period of 18 months (2-42). The conversion rate was 14.1% and mean intraoperative blood loss was 120 cc. The post-operative morbidity rate was 15.3%. The mean number of lymph nodes removed was 12 (3-38) and all resection margins were clear and adequate. The observed overall and "disease-free" survival rates were similar to those reported in literature. Although the body of evidence needs to be increased, our findings and the data in the literature suggest that laparoscopic-assisted resection for colorectal malignancies is safe and effective, also in the medium and long term.
Chirurgia italiana 56(6):811-6.
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ABSTRACT: 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.
Chirurgia italiana 56(3):437-42.
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ABSTRACT: The stapler treatment first described by Longo is considered by some authors to be a good technical solution for mucohaemorrhoidectomy. The aim of the present prospective study was to assess the function and morphology of the internal and external anal sphincters preoperatively and one month after surgery by means of a clinical examination, anorectal manometry and transperineal ultrasound. Ten patients (6 M, 4 F) underwent rectal mucosal prolapsectomy according to Longo. Anoscopy, anorectal manometry and transperineal ultrasound were performed in all patients preoperatively and again one month after surgery. The thickness and integrity of the internal and external anal sphincters were ascertained and colour Doppler was performed to assess the presence, quantity and size of any haemorrhoid swellings. All anatomical specimens underwent histological examination in search of smooth muscle fibres. Anorectal manometry revealed no postoperative sphincter tone defects. Transperineal ultrasound detected no postoperative sphincter lesions and the presence of venous swellings (always present at preoperative colour Doppler) never persisted at postoperative follow-up. The mean follow-up was 52.7 days (range: 31-151). Transperineal ultrasound proved useful in demonstrating the lifting of the mucohaemorrhoid prolapse within the ampulla of the rectum one month after surgery. The Longo procedure, in our albeit limited experience, caused no sphincter lesions.
Chirurgia italiana 56(1):99-105.
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ABSTRACT: 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.
Chirurgia italiana 56(1):157-61.
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ABSTRACT: The use of circular staplers for the treatment of haemorrhoids is a new technique that makes for better correction of the physiopathology of the condition, affords greater patient comfort and reduces health-care expenditure. This technique, which was invented by A. Longo in 1993, pulls up the haemorrhoidal cushions into their anatomical position, reduces or avoids postoperative pain, sparing the sensitive fibres of the anal canal, avoids anal canal stenosis and is not complicated by faecal incontinence. The authors present their experience in 41 patients affected by symptomatic haemorrhoidal prolapse and treated with a mucosal rectal prolapsectomy using a circular stapler. Each patient was followed up for 6 months to assess the incidence of complications and the degree of patient satisfaction. The results were compared with those reported in the literature, obtained using the Milligan-Morgan procedure. The Longo technique, which can be performed in the one-day surgery setting, allows very good relief of postoperative pain, rapid functional recovery and an early return to work, with a saving in health-care expenditure as compared with conventional treatment.
Chirurgia italiana 54(6):835-9.
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ABSTRACT: The aim of this study was to evaluate the impact of applying strict selection criteria to patients with symptoms of obstructed defecation, rectocele and rectal prolapse who were candidates for surgery. From June 2001 to September 2003, 20 patients underwent surgery in our clinic for symptomatic rectocele and anorectal prolapse. They were evaluated prospectively using a dedicated questionnaire (KESS), a proctological and gynaecological examination, colpo-cysto-defecography and anorectal manometry before surgery and 6 months postoperatively. Strict selection criteria were used for surgery. After 6 months the questionnaire showed an important improvement in symptoms. The symptoms of obstructed defecation and vaginal bulging improved significantly. The average KESS score dropped from 17.65 preoperatively to 5.8 six months after surgery. In the treatment of pelvic floor disease, it is important to evaluate both the uro-gynaecological and the proctological symptoms with the utmost care, obtaining an accurate clinical picture with the aid of dedicated questionnaires and a thorough clinical examination. Evaluation of the effectiveness of surgery for constipation necessarily includes assessing the strength of the indications for surgery, irrespective of the surgical technique adopted, but there is currently no standardised test method for recording and comparing the symptoms of constipation.
Chirurgia italiana 59(4):513-20.
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Giacomo Sarzo,
Cristiano Finco,
Paolo Parise,
Massimo Vecchiato,
Silvia Savastano,
Barbara Luongo,
Stefano Degregori,
Paolo Bocus,
Filippo Marino,
Alessandro Poletti,
Franca De Lazzari, Stefano Merigliano
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ABSTRACT: Colitis cystica profunda is a rare intestinal lesion. Because of its clinical expression (rectorrhagia, mucorrhea and abdominal pain) and the way it appears to current imaging techniques this disease presents features which can be associated with colon neoplasm. Its diagnosis has to be confirmed histologically, and its etiology remains unclear. The following is a case report of colitis cystica profunda recurring 20 years after a first episode in a white woman, who had had an anterior resection of the sigmoid colon and upper rectum to deal with a colitis cystica profunda-induced stenosis of the sigmoid colon and at 41 underwent the transanal removal of a polypoid lesion. A review of 20 cases in the literature showed that colitis cystica profunda has a predilection for the male and generally affects the medial and lower rectum and the sigmoid colon. The literature also confirmed the association with ulcerative rectocolitis, Crohn's disease and rectal prolapse. The type of treatment varies from surgical, medical, and endoscopic to no treatment at all.
Chirurgia italiana 57(6):789-98.
