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Background: Duodenal stump fistula (DSF) is a severe complication of gastrectomy. Although nonsurgical therapy is preferred, surgery is still mandatory in one third of DSF patients. The aim of this article is to analyze the surgical management of DSF and factors related to its outcome. Methods: We performed a retrospective multicenter study using data from January 1990 to November 2011 in 16 Italian surgery centers. We collected 8,268 elective gastrectomies for malignancies, 7,987 by the laparotomic and 281 by the laparoscopic approach. Two hundred five patients developed a DSF, 75 of whom underwent surgery for DSF. We analyzed mortality and DSF healing time as well as the impact of clinical, oncological, and surgical characteristics. Results: The laparoscopic approach increased the risk of DSF development (odds ratio 5.6, 95 % confidence interval 2.7-10.6, P < 0.001). The indication for first DSF surgery was intra-abdominal sepsis; the failure rate was over 30 %, associated with the appearance of fistulas of neighboring organs, bleeding, and the need for reoperations. The mortality rate was 28 % and was related to the presence of vascular disease ( P = 0.04), more than one reoperation ( P = 0.05), sepsis ( P < 0.001), and renal failure ( P < 0.001). Fifty-four patients recovered after a median of 39 days (interquartile range 22-68 days); the need to perform more reoperations ( P < 0.01) and the presence of an abdominal abscess ( P < 0.01) led to an increase in healing time. Conclusions: Surgery for DSF has a poor prognosis. Our data will help to identify patients at risk of death, but unfortunately could not establish the best surgical procedure applicable to all cases of DSF. [ABSTRACT FROM AUTHOR]

Background A score predictive of tumor recurrence after radical surgery for non-cardia gastric cancer was previously developed in Italian centers. The aim of this study was to validate the score in a consecutive cohort with prospectively collected follow-up data. Study Design Of 1,178 patients surgically treated between 1998 and 2006, six hundred and thirty-five patients who fulfilled the selection criteria and completed the follow-up program were available for analysis. The score value for each patient was calculated using the formula obtained from a logistic regression model. Discrimination and calibration of the score in the validation group were evaluated and compared with the data of 438 patients in the study group where the score was developed. Results Most patients in both groups had very low or very high score values. In the validation group, the observed recurrence rates ranged from 5% to 92% in different score strata. The area under the receiver operating characteristic curve was 0.889 (95% CI, 0.864–0.914; p < 0.001), indicating a high discrimination value of the score for recurrence. A good calibration was observed by comparing the predicted risk with the actual risk of recurrence. With a score cut-off value of 50, sensitivity, specificity, and overall accuracy were 74%, 86%, and 81%, respectively. An inverse correlation between the time to recurrence and score level was also estimated ( R 2 = 0.119; p < 0.001). Conclusions The high predictive value of the score was validated in a consecutive cohort. These results might allow the introduction of the score in clinical practice for Western patients. [ABSTRACT FROM AUTHOR]

Background: Duodenal fistula (DF) after gastrectomy continues to be a life-threatening problem. We performed a retrospective multicenter study analyzing the characteristics of DF after elective gastrectomy for malignant disease.Methods: Three thousand seven hundred eighty-five patients who had undergone gastrectomy with duodenal stump in 11 Italian surgical units were analyzed.Results: Sixty-eight DFs occurred, with a median frequency of 1.6% and a mortality rate of 16%. Complications were mainly septic but fistulas or bleeding of surrounding organs accounted for about 30%. Reoperation was performed in 40% of patients. We observed a correlation between mortality and age (hazard ratio 1.09; 95% CI 1.00-1.20) and serum albumin (hazard ratio 0.90; 95% CI 0.83-0.99). The appearance of further complications was associated with reoperation (P < 0.001) and death (P = 0.054), while the preservation of oral feeding was related to DF healing (P < 0.001).Conclusions: This paper represents the largest series ever published on DF and shows that its features have changed in the last 20 years. DF alone no longer leads to death and some complications observed in the past have disappeared, while new ones are emerging. Nowadays, medical therapy is preferred and surgery is indicated only in cases of abdominal sepsis or bleeding. [ABSTRACT FROM AUTHOR]

In total, ~25% of familial breast cancer (BC) is attributed to germline mutations of the BRCA1 and BRCA2 genes, while the rest of the cases are included in the BRCAX group. BC is also known to affect men, with a worldwide incidence of 1%. Epigenetic alterations, including DNA methylation, have been rarely studied in male breast cancer (MBC) on a genome-wide level. The aim of the present study was to examine the global DNA methylation profiles of patients with BC to identify differences between familial female breast cancer (FBC) and MBC, and according to BRCA1, BRCA2 or BRCAX mutation status. The genomic DNA of formalin-fixed paraffin-embedded tissues from 17 women and 7 men with BC was subjected to methylated DNA immunoprecipitation and hybridized on human promoter microarrays. The comparison between FBC and MBC revealed 2,846 significant differentially methylated regions corresponding to 2,486 annotated genes. Gene Ontology enrichment analysis revealed molecular function terms, such as the GTPase superfamily genes (particularly the GTPase Rho GAP/GEF and GTPase RAB), and cellular component terms associated with cytoskeletal architecture, such as 'cytoskeletal part', 'keratin filament' and 'intermediate filament'. When only FBC was considered, several cancer-associated pathways were among the most enriched KEGG pathways of differentially methylated genes when the BRCA2 group was compared with the BRCAX or BRCA1+BRCAX groups. The comparison between the BRCA1 and BRCA2+BRCAX groups comprised the molecular function term 'cytoskeletal protein binding'. Finally, the functional annotation of differentially methylated genes between the BRCAX and BRCA1+BRCA2 groups indicated that the most enriched molecular function terms were associated with GTPase activity. In conclusion, to the best of our knowledge, the present study was the first to compare the global DNA methylation profile of familial FBC and MBC. The results may provide useful insights into the epigenomic subtyping of BC and shed light on a possible novel molecular mechanism underlying BC carcinogenesis. [ABSTRACT FROM AUTHOR]

Background. This study explores the impact of Hypertermic Intra PEritoneal Chemotherapy (HIPEC) on adrenocortical carcinoma (ACC) management through a safety analysis completed by a preliminary evaluation of survival performances. Methods. Retrospective chart review of 27 patients submitted to surgical treatment completed by HIPEC for primary (SP, 13 patients) or recurrent (SR, 14 patients, 17 treatments) ACC. Safety was evaluated by means of procedural morbidity and mortality. Survival performances included multiple end points: local/peritoneal disease-free survival (l/pDFS), overall progression-free survival (OPFS), and overall survival (OS). Results. In the SP group, mortality was nil and morbidity was 46% (major 23%). At a median follow-up of 25 months, the median value for all the different survival measures had not been reached. Mortality was also nil in the SR group. However, morbidity was 77% (major 18%). Median l/pDFS and OPFS were 12 ± 4 and 8 ± 2 months, respectively. At a median follow-up of 30 months, median OS had not been reached. Conclusion. Surgery and HIPEC is an invasive procedure. Its employment in the surgery for primary setting deserves attention as it may affect oncologic outcomes positively. Its value in the management of recurrences seems less appreciable, albeit it may find its place in the multimodal management of a rare disease for which multiple therapeutic options do not yet exist. [ABSTRACT FROM AUTHOR]

The internal mammary veins (IMV) are suitable vessels for thoracic wall reconstruction thanks to their relatively predictable anatomy and because they are less affected by atherosclerosis, injury or scarring of previous surgery and radiotherapy. Their position near to the lateral border of the sternum allows easier access for surgeon and the possibility of placing the most vascularized part of a flap for breast reconstruction in the medial thoracic region [1]. As the complexity of reconstruction has increased, the use of the caudal portion of IMV has been reported as a convenient option for additional venous drainage. This procedure, requires retrograde blood flow that could be altered by the presence of efficient valves in the IMV. In this study, we evaluated 32 IMVs dissected from 16 fresh cadaver thoracic walls. Retrograde blood flow and the presence of valves were investigated. We observed an efficient flow in 18 IMVs, partial flow in 7 IMVs and no flow in 5 IMVs. In these last, single and/or multiple sacciform swelling and competent valves were macroscopically observed. Histomorphological analysis by Haematoxylin and Eosin and Masson-Goldner Trichrome staining confirmed their presence. In addition, some rudimental valves, not identified macroscopically, were found duringhistomorphological analysis. Taking together, these data highlight the possible presence of complete or rudimental valves in IMV. This aspect should be considered when retrograde flow of IMV as a single venous drainage was performed during surgical breast and thoracic reconstruction. [ABSTRACT FROM AUTHOR]