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This study aimed at evaluating whether the administration of symbiotic therapy in jaundiced patients could reduce their postoperative infectious complications. The study was conducted between November 2008 and February 2011. Jaundiced patients scheduled for elective extrahepatic bile duct resection without liver cirrhosis, intestinal malabsorption or intolerance to symbiotic therapy were randomly assigned to receive [Group A] or not [Group B] symbiotics perioperatively. The primary endpoint was the infectious morbidity rate. Forty patients were included in the analysis (20 in each group). The patients in Group B presented a higher overall morbidity (70 vs 50 %) and infectious morbidity rate (50 vs 25 %), but the differences were not significant. Eleven patients in Group A (Group ndA) and 13 in Group B (Group ndB) did not receive preoperative biliary drainage. The results of the two groups were comparable. Infectious complications were higher in Group B [5 (34 %) vs 0, p= 0.030], while the prevalence of natural killer (NK) cells was higher in Group ndA the day before surgery (17 % ± 5.1 vs 10 % ± 5.3, p< 0.01) and on post-operative day (POD) 7 (13.1 % ± 4.1 vs 7.7 % ± 3.4, p< 0.01). The rates of lymph node colonization were similar. The symbiotic therapy failed to reduce the rate of infectious morbidity in jaundiced patients. Further studies investigating the place of symbiotic in no-drainage patients are required.

Introduction. During the last 30 years, the multidisciplinary treatments of colon and uterus neoplasm have yielded an increase in total survival rates, fostering therefore the increase of cases with regional relapse involving the urinary tract. In these cases the iterative surgery can be performed, if no disease secondary to pelvic pain, haemostatic or debulking procedure is present, and must be considered and discussed with the patient, according to his/her general status.Materials and Methods. From 1997 to August 2007 we performed altogether 43 pelvic iterative surgeries, with simultaneous urologic surgical procedure because of pelvic tumor relapse in patients with uterus neoplasm and colon and rectal cancer. In 4 cases of anal cancer, the urological procedure were: one radical prostatectomy with continent vesicostomy in the first case, while in the other 3 cases radical pelvectomy with double-barrelled uretero-cutaneostomy In 23 cases of colon cancer, the urologic procedures were: 9 cases of radical cystectomy with double-barrelled uretero-cutaneostomy, 4 cases of radical cystectomy with uretero-ileo-cutaneostomy according to Bricker-Wallace II procedure, and 9 cases of partial cystectomy with pelvic ureterectomy and ureterocystoneostomy according to Lich-Gregoire technique (7 cases) and Lembo-Boari (2 cases) procedure. In 16 cases of uterus cancer, the urological procedure were: 7 cases of partial cystectomy with pelvic ureterectomy and uretero-cystoneostomy according to Lich-Gregoire procedure; in 3 cases, a radical cystectomy with urinary continent cutaneous diversion according to the Ileal T-pouch procedure; 2 cases of total pelvectomy and double uretero-cutaneostomy, and 4 cases of bilateral uretero-cutaneostomy.Results. No patients died in the perioperative time; early systemic complications were: 2 esophageal candidiasis, 1 case of venous thrombosis.Conclusions. The iterative pelvic surgery in the case of oncological relapse involving the urinary tract aims to achieve the best quality of life with the utmost oncological radicality. The equation: eradication of pelvic neoplasm and urinary tract reconstruction, with acceptable quality of life, will be the future target; nevertheless, it is not possible to establish guidelines beforehand, and the therapy must be adapted to each single case.

Background Several studies reporting preliminary long-term survival data after laparoscopic resections for colonic adenocarcinoma did not show any detrimental effect in comparison with historic studies of laparotomies. A previous randomized study has reported an unforeseen better long-term survival for node-positive patients treated by laparoscopic colectomy. Methods A single-institution prospective nonrandomized trial compared short- and long-term results of laparoscopic and open curative resection for adenocarcinoma of the left colon or rectum in 255 consecutive patients from January 1996 to December 2000. Results In this study, 34 left hemicolectomy, 202 anterior resections, and 19 abdominoperineal resections were performed. A total of 74 patients underwent a laparoscopic resection (LR), and 181, an open resection (OR). The tumor site was the descending colon in 32 cases, the sigmoid colon in 98 cases, and the rectum in 125 cases, including 87 mid–low rectal cancers. Ten LR procedures (13.5%) were converted to open surgery. The hospital mortality was 0.08%, and in hospital morbidity was 16.2% for LR and 13.3% for OR ( p = 0.56). The median postoperative stay was 1 day shorter for LR (9 days) than for OR (10 days) ( p = 0.09). The mean number of lymph nodes retrieved were 13.8 ± 5.7 for OR and 12.7 ± 5; for LR ( p = 0.23). Age exceeding 70 years, T stage, N stage, grading, mid–low rectal site, and laparoscopy were found by multivariate analysis to be significant prognostic factors for disease-free and cancer-related survival. When patients were stratified by stage, a trend toward a better disease-free and cancer-related survival was identifyed in stage III patients undergoing LR. Conclusions Laparoscopic colonic resection is a safe procedure in terms of postoperative outcome and long-term survival. Multivariate analysis showed that laparoscopy is a positive prognostic factor for disease-free and cancer-related survival. The current data agrees with the data for the only randomized study reported so far. Both suggest a better outcome for node-positive patients treated by laparoscopy.

Gallbladder carcinoma is the most common malignancy of the biliary tract. There are still many controversies regarding the type of curative surgical treatment for each stage of the disease. The staging system used is the TNM classification of the International Union Against Cancer. Different patterns of spread characterize gallbladder cancer but the two main types are direct invasion and lymph node metastases; since only the depth of invasion can be easily recognized by imaging techniques, it becomes the main variable in choosing the appropriate surgical treatment. Most Tis and T1 tumours are incidentally discovered after cholecystectomy for cholelithiasis and no further therapy is requested; for pT1b tumours, relaparotomy with hepatic resection and N1 dissection is associated with a better survival. For T2 tumours, cholecystectomy with hepatic resection and dissection of N1–2 lymph nodes is the standard treatment, with a 5-year survival of 60–80%. The only chance of long-term survival for patients with a T3–T4 tumour is an extended operation combining an hepatic resection with an N1–2 dissection with or without excision of the common bile duct. A subset of patients with peripancreatic positive nodes or invasion of adjacent organs seems to benefit from a synchronous pancreaticoduodenectomy.

Aims:Extended operations are the only chance of a cure for patients with advanced gallbladder carcinoma, but there is no consensus about which subset of patients can benefit. The aim of this retrospective study is to evaluate the results of surgical resection with special reference to the prognostic factors and to long-term survival. Methods:A retrospective review of 70 patients with a diagnosis of gallbladder cancer treated from 1985–1998 was performed: 33 patients had a curative resection and were included in this study. For stage I disease, simple cholecystectomy was considered curative; in most of the other cases, cholecystectomy was associated with lymph node dissection and liver resection. Results:Hospital mortality and morbidity were 6% and 33%, respectively. Curative resection was associated with an actuarial 5-year survival of 27.4%. Survival of pT1–2 patients was significantly better than that of pT3 (P=0.04) or pT4 patients (P=0.002). Patients with lymph node spread had a poorer prognosis (P=0.06) but four were alive and disease-free with a median survival of 22 months. Conclusions:Depth of the tumour and lymph node metastases are important prognostic factors. Patients with pT3–4 tumours or regional lymph node spread should be considered for curative resection because long-term survival is possible.

Major hepatectomy is associated with a high operative risk in patients with cirrhosis. Between June 1983 and December 1991, 33 cirrhotic patients, 31 with good liver function, underwent major liver resection for a large hepatic primary cancer. The hospital mortality rate was 3 per cent; the only death resulted from liver failure after extended right hepatectomy. None of the patients had variceal bleeding during the postoperative period. Survival rates at 1, 2 and 3 years were 66, 43 and 37 per cent respectively. Recurrence was the most common reason for late death. These results suggest that the operative risk of major hepatectomy in cirrhotic patients with a large tumour and good liver function is comparable to that of minor liver resection. Late survival is also similar to that of patients with a small tumour. Cirrhotic patients with hepatic carcinoma and good liver function are suitable for major hepatectomy.

The existing registries of thyroid carcinoma are seldom comparable as far as epidemiological data, diagnostic criteria and histopatological description are concerned. Epidemiological studies report a progressive increase in the incidence of thyroid carcinoma in the last twenty years and in both sexes this increase of incidence has been referred to papillary histotype. Data collected from surgical series show a rate of thyroid carcinomas from 7 to 20% of total thyroid surgeries. The present study was designed in order to obtain a retrospective review of the distribution of thyroid carcinoma’s different histotypes in the last 21 years in a major General Hospital. Detailed analysis of patients with histologically confirmed thyroid carcinoma admitted between 1974 and 1994 to the Surgery Department of Mauriziano Hospital of Torino, Italy showed an overall 11.8% prevalence of thyroid cancer out of the total thyroid surgeries. The rate of papillary carcinoma was the highest (54.3%) followed by follicular carcinoma (27.6%), anaplastic carcinoma (11.1%), medullary carcinoma (4.6%) and others (2.4%). The papillary-to-follicular ratio varied from 0.60 in 1974–76 to 6.88 in 1992–94. Female to male ratio of all thyroid carcinoma histotypes was 2.0 or more; papillary and follicular histotypes had the highest ratio. The variations of the histotype rate observed may be consequence of the silent increase of daily iodine intake throughout the subsequent years, while improved diagnostic tools available and increased experience of the medical staff have probably increased the number on thyroid ablations performed. Our data confirm the changing epidemiology of thyroid carcinoma, reported by international literature.

In a surveillance program for hepatocellular carcinoma (HCC), serum alpha-fetoprotein (AFP) was determined every 4 months in 164 patients with liver cirrhosis. Ultrasonography (US) was performed yearly or as dictated by abnormal AFP levels.During a follow-up of 32.5 ± 20.8 months HCC was identified by US in 16 patients. In 9 of them the AFP levels rose steadily over 4 months, increasing 7, 8 and 12 months in 3 cases before the lesion became detectable by US. In 4 patients tumors developed despite persistently normal AFP levels. Nine more patients showed abnormal fluctuations of AFP but HCC was not detected.AFP sensitivity was higher at a low cutoff point (40 ng/ml) while specificity of the test appeared higher at the 200 ng/ml cutoff point. An AFP value rising steeply over a few months appeared more reliable than a fixed preset threshold in indicating carcinomatous transformation.Screening for AFP can be expected to uncover about 3/4 of HCC developing in cirrhotics with few false-positive reactions. The test may have a unique role in identifying a subset of liver tumors whose early expression is AFP production.

A multicenter, randomized Phase 2 study that compared patients, affected by colorectal liver metastases, who received intrahepatic arterial infusion with two different schedules of cisplatin, bolusvs. continuous infusion, and systemic 5-fluorouracil. PURPOSE: The aim of this study was to validate results of a previous Phase 2 trial on bolus cisplatin intrahepatic arterial infusion, which reported a 47 percent response rate and a 32 percent 4-year survival rate for Gennari's Stage 2 patients, with a high rate of neurologic, gastrointestinal, and hematologic toxicity. METHODS: One hundred nine patients were randomized in a Phase 2 study to receive cisplatin intrahepatic arterial infusion (24 mg/m2/day, 1→5, bolusvs. continuous infusion) and systemic intravenous 5-fluorouracil (250, 375, or 500 mg/m2/day, 1→5; escalating doses, respectively, at cycles I, II, III, and VI). To avoid neurotoxicity a maximum of six cycles was administered. RESULTS: Preliminary results for the 78 evaluable patients are similar to those of the previous study: response rate 46 percent and at a median follow-up of 16.5 months, the overall survival was 16.5 months, with 45 percent of the patients who received more than 3 cycles alive at 3 years. Toxicity, evaluable in 99 patients, showed a decreased incidence of neurotoxicity and a tolerable gastrointestinal and hematologic toxicity, lower in the cisplatin continuous infusion arm. CONCLUSION: This study clearly shows that cisplatin intrahepatic arterial infusion is able to provide a good palliative effect with a tolerable toxicity.

Background. A prospective, randomized controlled clinical trial was conducted in 33 Italian surgical departments with the aim of evaluating the efficacy of octreotide in the prevention of pancreatic fistula after elective pancreatic resections. Methods. Between July 1990 and May 1992, 278 patients were enrolled in the study. Fifty-four dropped out because of unresectable disease and six were excluded because of protocol violation; the remaining 218 were randomly assigned to the octreotide group (n=111) or to the placebo group (n=107). There were 131 men and 87 women with a mean age of 58.2+/-11.7 yrs. Pancreaticoduodenectomy was the most common operation performed (n=143), sixty-four percent of patients had a pancreatic or periampullary cancer; chronic pancreatitis accounted for 8.2% of cases. Results. Mortality rate was 6.9%. A pancreatic fistula occurred in 31 patients (14.2%), 9% in the octreotide group and 19.6% in the placebo group (p<0.05). Morbidity rate was significantly lower in the octreotide (21.6%) than in the placebo group (36.4%) (p<0.05). When specific pancreatic complications were grouped together and evaluated, they occurred less frequently in the treated (15.3%) than in the placebo group (29.9%) (p<0.05). Conclusions. Octreotide was able to reduce significantly the incidence of pancreatic fistula after elective pancreatic resections.

AimsSpontaneous rupture of hepatocellular carcinoma (HCC) is a life-threatening event, particularly in patients with associated cirrhosis. We present our experience of hepatic resection of ruptured HCC.MethodsWe performed 199 resections of hepatocellular carcinoma between January 1984 and December 1999. Six (3%) of these patients were operated on as an emergency because of haemoperitoneum: in five the liver was cirrhotic. ResultsThe mean duration of the operation was 195±101 min; all the patients received blood transfusions. The overall morbidity was 50%, with a mortality rate of 16.5%. Three patients were alive at 50, 80 and 116 months respectively; two had an intrahepatic recurrence treated by chemoembolization. ConclusionsNon-surgical treatment of spontaneously ruptured hepatocarcinoma should be peformed only in patients with contraindication to surgery. Hepatic resection should be the treatment of choice since, according to our experience, long-term results are similar to those of elective surgery.