[Show abstract][Hide abstract] ABSTRACT: Laparoscopy is the procedure of choice for the resection of gastric Gastrointestinal stromal tumors (GISTs) smaller than 2 cm; there is still debate regarding the most appropriate operative approach for larger GISTs. The aims of this study were to evaluate the safety and long-term efficacy of laparoscopic resection of gastric GISTs larger than 2 cm.
[Show abstract][Hide abstract] ABSTRACT: The primary end-points were complete pathological response and local control. Secondary end-points were survivals, anal sphincter preservation, and toxicity profile.
Patients with T3/T4 and or N+ rectal cancer (n = 65) were treated with preoperative concomitant boost radiotherapy (55 Gy/25 fractions) associated to concurrent chemotherapy with oral capecitabine.
All patients completed the programmed treatment. The complete pathological response was achieved by 17 % of the patients. Anal sphincter preservation surgery was possible for 86 % of the patients with low rectal cancer (≤5 cm from the anal verge). The T-stage and N-stage downstaging were achieved by 40 and 58 % of the patients, respectively. Circumferential radial margin was involved (close/positive) in eight patients. After a median follow-up of 26 months, local and distant recurrence occurred in two and 11 patients, respectively. The 3-year overall survival and disease-free survival were 86.8 and 81 %, respectively. Non-hematological ≥ grade 3 toxicities were observed in 15 % of the patients. On univariate analysis N-downstaging and positive circumferential radial margin were significantly associated with worse overall survival (p = 0.003 and p = 0.023, respectively), disease-free survival (p = 0.001 and p = 0.036, respectively), and metastasis-free survival (MFS) (p = 0.001 and p = 0.038, respectively).On multivariate analysis, the N-downstaging were significantly associated with better overall survival (OS) (p = 0.022).
Our data support the efficacy of preoperative treatment for rectal cancer in terms of local outcomes. Radiation treatment intensification may have a biological rationale; longer follow-up is needed.
International Journal of Colorectal Disease 05/2014; · 2.24 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Chronic pilonidal disease is a debilitating condition that typically affects young adults. Controversy still exists regarding the best surgical technique for the treatment of pilonidal disease in terms of minimizing disease recurrence and patient discomfort. The present study analyzes the results of excision with our modified primary closure. This retrospective study involving consecutive patients with pilonidal disease was conducted over a 6-year period. From January 2004 to January 2010, 450 consecutive patients with primary pilonidal sinus disease received this new surgical treatment. Times for complete healing and return to work, the duration of operation and of hospitalization, postoperative pain, time to first mobilization, and postoperative complications were recorded. To evaluate patient comfort, all patients were asked to complete a questionnaire including visual analog scale. The median long-term follow-up was 54 months (range, 24 to 84 months). Four hundred fifty consecutive patients (96 female, 354 male) underwent excision. The median age was 25 years (range, 17 to 43 years). The median follow-up period was 54 months (range, 24 to 84 months). Four hundred twenty completed questionnaires were returned (87% response rate). The median duration of hospital stay was eight hours (range, 7 to 10 hours) No patient reported severe postoperative pain. Primary operative success (complete wound healing without recurrence) was achieved in 98.2 per cent. Two (0.5%) patients had a recurrence. The mean time lost to work/school after modified primary closure was eight days. Excision and primary closure with this new technique is an effective treatment for chronic pilonidal disease. It is associated with low morbidity, early return to work, and excellent cosmetic result and a high degree of patient satisfaction in the long-term follow-up.
The American surgeon 05/2014; 80(5):484-488. · 0.92 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Laparoscopic intersphincteric resection (ISR) after neoadjuvant chemoradiation is helpful in the management of patients with low rectal cancer. With the advent of this technique, the need for performance of abdominoperineal resection seems to have decreased in patients with very low rectal tumors. The aim of the present study was to evaluate the feasibility of laparoscopic ISR preceded by transanal rectal dissection low rectal cancer. Between December 2009 and June 2011, we performed laparoscopic ISR for 30 patients with very low rectal cancer. Patients received preoperative concurrent chemoradiation (5 days a week for 5 weeks). The surgical procedure was performed 6 weeks after radiotherapy and included total mesorectal excision, ISR, transanal coloanal anastomosis with coloplasty and loop ileostomy. Clinical data of 30 patients were analyzed retrospectively. Thirty patients (21 men, nine women) had a median age of 65 years (range, 37 to 75 years), a median body weight of 67 kg (range, 43 to 96 kg), and body mass index of 24 kg/m(2) (range, 19 to 33 kg/m(2)). The distance of the tumor from the anal verge was 5 cm (range, 2 to 11 cm). The operative time was from 240 to 360 minutes, and estimated blood loss was 100 to 520 mL. There were no conversions and no postoperative mortality. This procedure is feasible and has favorable short-term results for radical treatment of very low rectal disease while preserving anal function.
The American surgeon 01/2014; 80(1):26-30. · 0.92 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Unsuspected common bile duct stones (CBDS) are found in 4-5 % of patients with cholelithiasis. The optimal strategy for the treatment of asymptomatic CBDS, diagnosed during laparoscopic cholecystectomy (LC), is not yet well established. A one-stage solution is preferable to solve the CBDS during the LC and to avoid the exposure of patients to the risks of a second procedure, such as complications or failure. METHODS: We attempted to remove CBDS by transcystic sphincter of Oddi pneumatic balloon dilation and common bile duct pressure-washing in all cases of intraoperative identification of CBDS since September 2008. RESULTS: In 29 cases, unsuspected CBDS was identified by intraoperative cholangiography; in 28 cases a single stone with a mean diameter of 4.3 mm (range = 3-6) was detected and in one case three 5-8-mm-diameter stones were identified. Clearance of the common bile duct was obtained in 27 cases (96 %), with a mean operative time of 54 min (range = 36-90) and mean length of hospital stay of 2.5 days. CONCLUSION: Treatment of unsuspected CBDS detected by intraoperative cholangiography during LC with this original technique was safe and effective and a viable alternative of the transcystic endoscopic approach.
World Journal of Surgery 03/2013; · 2.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Laparoscopic low anterior rectal resection (LLAR), allowing better visualization and rectal mobilization, can reduce postoperative pain and recovery. A Contour Curved Stapler (CCS) is a very helpful device because of its curved profile that consents better access into the pelvic cavity and allows to perform rectal closure and section in one shot, especially in the presence of a narrow pelvis, complex anatomy, or large tumors. We developed an original technique of laparoscopic rectal resection using CCS. Between 2005 and 2009, in 36 cases, we performed LLAR with a three-trocar technique, starting with mobilization of left colonic flexure followed by the section of inferior mesenteric vessels. The rectum was prepared up to the levator ani with total mesorectal excision. The Lapdisc® was inserted trough a suprapubic midline incision, allowing the CCS stapler placement into the pelvic cavity. After the rectal section, the anastomosis was then performed with a circular stapler. Ileostomy was performed if neoadjuvant radiotherapy and chemotherapy have been carried out or if the anastomosis was below 4 cm from the anal verge. Mean operative time was 135 minutes and no intra- or postoperative bleeding occurred. In 27 patients we performed temporary ileostomy. In two cases we observed anastomotic leakage; one of these patients already had ileostomy. No anastomotic stenosis occurred after one-year follow-up. This procedure simplifies the section of the lower rectum, reduces leaking rate resulting from technical difficulties, and does not nullify the benefits of laparoscopy.
The American surgeon 03/2013; 79(3):253-6. · 0.92 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Hartmann's procedure is still performed in those cases in which colorectal anastomosis might be unsafe. Reversal of Hartmann's procedure (HR) is considered a major surgical procedure with a high morbidity (55 to 60%) and mortality rate (0 to 4%). To decrease these rates, laparoscopic Hartmann's reversal procedure was successfully experienced. We report our totally laparoscopic Hartmann's reversal technique. Between 2004 and 2010 we performed 27 HRs with a totally laparoscopic approach. The efficacy and safety of this technique were demonstrated evaluating the operative data, postoperative complications, and the outcome of the patients. There were no open conversions or major intraoperative complications. Anastomotic leaking occurred in one patient requiring an ileostomy; one patient needed a blood transfusion and one had a nosocomial pneumonia. The mean postoperative hospitalization was 5.7 days. Laparoscopic HR is a feasible and safe procedure and can be considered a valid alternative to open HR.
The American surgeon 01/2013; 79(1):67-71. · 0.92 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To compare the site, age and gender of cases of colorectal cancer (CRC) and polyps in a single referral center in Rome, Italy, during two periods.
CRC data were collected from surgery/pathology registers, and polyp data from colonoscopy reports. Patients who met the criteria for familial adenomatous polyposis, hereditary non-polyposis colorectal cancer syndrome or inflammatory bowel disease were excluded from the study. Overlap of patients between the two groups (cancers and polyps) was carefully avoided. The χ(2) statistical test and a regression analysis were performed.
Data from a total of 768 patients (352 and 416 patients, respectively, in periods A and B) who underwent surgery for cancer were collected. During the same time periods, a total of 1693 polyps were analyzed from 978 patients with complete colonoscopies (428 polyps from 273 patients during period A and 1265 polyps from 705 patients during period B). A proximal shift in cancer occurred during the latter years for both sexes, but particularly in males. Proximal cancer increased > 3-fold in period B compared to period A in males [odds ratio (OR) 3.31, 95%CI: 2.00-5.47; P < 0.0001). A similar proximal shift was observed for polyps, particularly in males (OR 1.87, 95%CI: 1.23-2.87; P < 0.0038), but also in females (OR 1.62, 95%CI: 0.96-2.73; P < 0.07).
The prevalence of proximal proliferative colonic lesions seems to have increased over the last decade, particularly in males.
World Journal of Gastroenterology 12/2012; 18(45):6614-9. · 2.55 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a new approach that allows abdominal surgery to be performed through a natural orifice such as the oral cavity, vagina or rectum. We present our preliminary experience of laparoscopic assisted transvaginal cholecystectomy (LATC). METHODS: Women affected by cholelithiasis, age below 65 years, BMI under 30, ASA I or II, previous full-term pregnancies, and without previous abdominal surgery underwent LATC. Patients' biographic data, operative time, intraoperative and postoperative complications were collected. RESULTS: We performed 21 LATCs. Median operative time was 58 min. There were no intraoperative complications. The postoperative course was uneventful in all patients. At 1 year there were no complications and no impaired sexual activity. CONCLUSIONS: The results of NOTES are promising, but currently only hybrid NOTES can be safely performed. LATC seems to guarantee better cosmetic results, less postoperative pain, faster mobilization and shorter hospitalization than laparoscopic cholecystectomy.
The surgeon: journal of the Royal Colleges of Surgeons of Edinburgh and Ireland 11/2012; · 1.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Postoperative staple-line bleeding after stapled hemorrhoidopexy represents a major issue of this procedure, especially in the day surgery setting. In this study we assess the possible benefit of using circular bioabsorbable staple-line reinforcement to reduce the risk of hemorrhage when performing stapled hemorrhoidopexy in a day surgery setting. Patients with symptomatic II to III grade hemorrhoidal disease were randomly assigned into two groups. In Group A we performed a stapled hemorrhoidopexy using PPH33-03(®) with Seamguard(®), a bioabsorbable staple-line reinforcement; in Group B, we used only a PPH33-03(®) stapler. We evaluated the intraoperative and postoperative staple-line bleeding and, secondarily, the duration of surgery, need for additional hemostatic stitches, and presence of postoperative complications. One hundred patients were enrolled in the study. Group A patients showed a statistically significant decrease of intraoperative bleeding (4 vs 42% in Group B) and hemostatic stitch placement (5.7 vs 42%) with the consequent reduction in mean operative time, postoperative pain, and tenesmus. There were no differences between the two groups in hemorrhoidal disease control or postoperative late complications. The use of bioabsorbable staple-line reinforcement while performing stapled hemorrhoidopexy may allow improvement of the safety of this procedure, especially in a day surgery setting.
The American surgeon 11/2012; 78(11):1255-60. · 0.92 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Defecatory disorders are very common complications after left hemicolectomy and anterior rectal resection. These disorders seem related primarily to colonic denervation after the resection. To evaluate the real benefits of inferior mesenteric artery (IMA) preservation via laparoscopic left hemicolectomy performed for diverticular disease in terms of reduced colonic denervation and improved postoperative intestinal functions, a randomized, single-blinded (patients) controlled clinical trial was conducted. METHODS: From January 2004 to January 2010, patients with symptomatic diverticular disease and a surgical indication were enrolled in the study and randomly assigned to two treatment groups. The first group underwent laparoscopic left hemicolectomy, which preserved the IMA by sectioning the sigmoid arteries one by one near the colonic wall, In the second group, the IMA was sectioned immediately below the origin of left colic artery. Defecation disorders were assessed by anorectal manometry and by three questionnaires to evaluate constipation, incontinence, and quality of life 6 months after the intervention. RESULTS: A total of 107 patients were included in the study. The 54 patients with preserved IMA showed a statistically lower incidence of defecation disorders such as fragmented evacuations, alternating bowel function, constipation, and minor incontinence, as well as less lifestyle alteration than the 53 patients with the IMA sectioned just below the left colic artery. CONCLUSIONS: This study confirmed that preservation of the IMA should be recommended to reduce the incidence of defecatory disorders after left hemicolectomy for benign disease.
[Show abstract][Hide abstract] ABSTRACT: In the last 10 years, stapled hemorrhoidectomy has gained worldwide consensus. We studied a day-surgery stapled hemorrhoidopexy protocol to allow shorter recovery time and cost reduction. From 2003 to 2008, we performed 292 outpatient stapled hemorrhoidopexies under spinal or local anesthesia including symptomatic Grade III and IV hemorrhoid disease. We used PPH 01 to PPH 03 staplers. We assessed early and late postoperative pain with a Visual Analog Scale, whereas clinical postoperative examinations were performed at seven days, 6 months, and 1, 3, and 5 years after surgery. The mean surgery time was approximately 18 minutes (range, 13 to 39 minutes). Of 292 patients, 39 were not dischargeable for urine retention, severe pain, or mild bleeding. Four other patients were rehospitalized within 8 days for bleeding. Twenty-one patients reported transient fecal urgency, whereas nobody reported anal incontinence. We can conclude that stapled hemorrhoidopexy is a safe and effective procedure if performed in a day-surgery unit. The complication rate is comparable to that of inpatient procedures.
The American surgeon 05/2011; 77(5):552-6. · 0.92 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Traumatic diaphragmatic hernias are an unusual presentation of trauma, and are observed in about 10% of diaphragmatic injuries. The diagnosis is often missed because of non-specific clinical signs, and the absence of additional intra-abdominal and thoracic injuries.
We report a case of a 59-year-old Italian man hospitalized for abdominal pain and vomiting. His medical history included a blunt trauma seven years previously. A chest X-ray showed right diaphragm elevation, and computed tomography revealed that the greater omentum, a portion of the colon and the small intestine had been transposed in the hemithorax through a diaphragm rupture. The patient underwent laparotomy, at which time the colon and small intestine were reduced back into the abdomen and the diaphragm was repaired.
This was a unusual case of traumatic right-sided diaphragmatic hernia. Diaphragmatic ruptures may be revealed many years after the initial trauma. The suspicion of diaphragmatic rupture in a patient with multiple traumas contributes to early diagnosis. Surgical repair remains the only curative treatment for diaphragmatic hernias. Prosthetic patches may be a good solution when the diaphragmatic defect is severe and too large for primary closure, whereas primary repair remains the gold standard for the closure of small to moderate sized diaphragmatic defects.
[Show abstract][Hide abstract] ABSTRACT: Patients with von Hippel-Lindau syndrome, a dominantly inherited familial cancer syndrome, develop a variety of tumors in different organ systems which make the clinical management of these patients complex.
The long clinical history of a 45-year-old woman started at 22 years of age when she had surgery for a right adrenal pheochromocytoma. Two years later, a pancreaticoduodenectomy was performed to remove a pancreatic mass which turned out to be a pancreatic neuroendocrine tumor. After a long period of relative wellness, 21 years after the surgical resection of her primary pancreatic neuroendocrine tumor, abdominal lymph node metastases of pancreatic neuroendocrine origin occurred. In fact, three abdominal nodules were removed by laparoscopic surgery, and the histological examination showed well-differentiated neuroendocrine tumors with similar immunohistochemical characteristics and Ki67 below 1%. Considering the patient's clinical history, an inherited cause was postulated and multiple endocrine neoplasia type 1 was first investigated, but the result was negative. Then, a missense mutation in exon 3 of the VHL gene (ACT>ATT; Thr157Ile) was found.
Although no local and/or distant tumor recurrences are usually reported in radically operated on von Hippel-Lindau pancreatic neuroendocrine tumor patients after a median time of five years of follow-up, the present patient had a recurrence after a very long period of time, suggesting that a pancreatic neuroendocrine tumor associated with von Hippel-Lindau syndrome may behave more aggressively than that has previously been described, thus requiring a life-long follow-up.
JOP: Journal of the pancreas 02/2009; 10(5):562-5.
[Show abstract][Hide abstract] ABSTRACT: Intranodal palisaded myofibroblastoma (IPM) is a rare benign tumor of the lymph nodes probably arising from smooth muscle-like cells. The tumor is characterized by intranodal proliferation of spindle cells. Neoplastic spindle-cell proliferation is most often of metastatic repetition which is very important in the recognition of IPM, because it may be mistaken for metastasis or other tumors such as Kaposi's sarcoma. We report a novel case of IPM that confirms the myofibroblastic differentiation of the tumor. The onset of IPM has been associated with Epstein-Barr virus (EBV). In addition, recently reported cases of IPM have been seen with cyclin 1 overexpression and also with human herpes virus (HHV)-8 and EBV DNA sequences. In our case, there was no evidence of HHV-8 and EBV DNA sequences and we were not able to find cyclin 1 overexpression.
Anticancer research 01/2006; 26(3B):2349-52. · 1.71 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Fecal incontinence has a serious impact upon patients' quality of life. Several treatment methods are possible according to the pathophysiology of the disease.
Between March 1999 and February 2002 eight artificial anal sphincters (American Medical System - AMS) were implanted in seven patients affected with severe fecal incontinence; in one case the device was positioned in a patient who had previously undergone a Miles' resection. All cases were carefully selected according to appropriate diagnostic evaluation. The follow-up varies between 3 and 40 months.
The prosthesis had to be removed in two cases; in one patient infection of the implant area occurred, while in the other case persistent perianal pain due to the presence of the device could not be tolerated by the patient. In the six patients that could be successfully treated with the artificial anal sphincter implant, it dramatically improved their quality of life.
The success of the procedure allows the consideration that the artificial anal sphincter implant is the best treatment for severe fecal incontinence that cannot be solved with conservative therapy.
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to determine the efficacy and safety of biliary-intestinal bypass in severely obese subjects (Body Mass Index > 35).
From January to December 1999, 23 patients (8 men and 15 women, mean age 36.6 years: range 20-51) affected with primary morbid obesity (BMI >40: range 40.1-64.7), in whom different attempt using conservative medicine have proved non-resolutive, underwent biliary-intestinal bypass. After the operation all the patients have been followed- up for 12 months.
The mean Body Mass Index was reduced to 36.9 (range 27.7-44.1) after 6 months and to 33 (range 24.9-40.1) after 12 months. Peri and postoperative mortality was zero. Excessive malabsorption was efficaciously controlled by adequate replacement therapy. Diarrhoea, common compliance of every operation inducin malabsorbition, was reduced to 2-3 evacuation a day after 2-3 months.
On the basis of personal experience it is underlined that biliary-intestinal bypass, as surgical treatment of morbid obesity refractory to medical therapy, is today a safe and effective operation (up to 80% of excess body weight lose); the presence of biliary-intestinal anastomosis reduces the post-operative loss of bile acids, choleretic diarrhoea and electrolytic disorders.
[Show abstract][Hide abstract] ABSTRACT: The use of laparoscopic cholecystectomy (LC) in elderly patients may pose problems because of their poor general condition, especially of cardiopulmonary function. Moreover, these patients present with acute cholecystitis and associated common bile duct stones more often than their younger counterparts. From 1990 to 1999, the authors performed 943 LCs; 31 (3.2%) were attempted on elderly patients, 11 (35%) of which were on an emergency basis because of acute cholecystitis, cholangitis or acute biliary pancreatitis. Ten per cent of LCs needed to be converted to an open cholecystectomy, most often because of an increase in the partial pressure of carbon dioxide in the blood produced by excessive operative time. A gasless procedure was used in the last three years of the study on eight cases; the overall rate of conversion from LC to open cholecystectomy in this group was 0%. Associated gallbladder and common bile duct stones were found in five (16%) patients (four preoperative LC endoscopic sphincterotomy and one transcystic approach). The success rate in both of these cases was 100%, overall morbidity was 29% and there was no mortality. These results show that LC is a feasible and safe procedure for use in elderly patients. Gasless LC should be preferred in patients classified as American Society of Anesthesiologists' class III because an excessive duration of operation is the most common reason for converting to an open cholecystectomy.
Canadian journal of gastroenterology = Journal canadien de gastroenterologie 01/2001; 14(11):929-32. · 1.53 Impact Factor