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Background and aims Although rectal cancer is predominantly a disease of older patients, current guidelines do not incorporate optimal treatment recommendations for the elderly and address only partially the associated specific challenges encountered in this population. This results in a wide variation and disparity in delivering a standard of care to this subset of patients. As the burden of rectal cancer in the elderly population continues to increase, it is crucial to assess whether current recommendations on treatment strategies for the general population can be adopted for the older adults, with the same beneficial oncological and functional outcomes. This multidisciplinary experts’ consensus aims to refine current rectal cancer-specific guidelines for the elderly population in order to help to maximize rectal cancer therapeutic strategies while minimizing adverse impacts on functional outcomes and quality of life for these patients. Methods The discussion among the steering group of clinical experts and methodologists from the societies’ expert panel involved clinicians practicing in general surgery, colorectal surgery, surgical oncology, geriatric oncology, geriatrics, gastroenterologists, radiologists, oncologists, radiation oncologists, and endoscopists. Research topics and questions were formulated, revised, and unanimously approved by all experts in two subsequent modified Delphi rounds in December 2020–January 2021. The steering committee was divided into nine teams following the main research field of members. Each conducted their literature search and drafted statements and recommendations on their research question. Literature search has been updated up to 2020 and statements and recommendations have been developed according to the GRADE methodology. A modified Delphi methodology was implemented to reach agreement among the experts on all statements and recommendations. Conclusions The 2021 SICG-SIFIPAC-SICE-WSES consensus for the multidisciplinary management of elderly patients with rectal cancer aims to provide updated evidence-based statements and recommendations on each of the following topics: epidemiology, pre-intervention strategies, diagnosis and staging, neoadjuvant chemoradiation, surgery, watch and wait strategy, adjuvant chemotherapy, synchronous liver metastases, and emergency presentation of rectal cancer.

Following the spread of the infection from the new SARS-CoV2 coronavirus in March 2020, several surgical societies have released their recommendations to manage the implications of the COVID-19 pandemic for the daily clinical practice. The recommendations on emergency surgery have fueled a debate among surgeons on an international level.We maintain that laparoscopic cholecystectomy remains the treatment of choice for acute cholecystitis, even in the COVID-19 era. Moreover, since laparoscopic cholecystectomy is not more likely to spread the COVID-19 infection than open cholecystectomy, it must be organized in such a way as to be carried out safely even in the present situation, to guarantee the patient with the best outcomes that minimally invasive surgery has shown to have.

Not available.

Objective: to assess whether immunohistochemical (IHC) algorithms used to classify the cell of origin (COO) of nodal Diffuse Large B-cell lymphoma (nDLBCL) in Germinal Center type (GCB) and non-GCB subtypes may be applied to Primary Cutaneous B-cell lymphoma (PCBCL) too, and which of these algorithms performs better on PCBCL. Design: Retrospective case control study. Setting: Pathology Department of the University Hospital “San Giovanni di Dio e Ruggi d′Aragona” Salerno, Italy. Participants: Fourteen PCBCL, including Primary Cutaneous follicle centre lymphoma (PCFCL) and primary cutaneous diffuse large B-cell lymphoma, Leg type (PCDLBCL-LT) and 14 nDLBCL were evaluated for 7-year period (January 2011 to December 2017). Primary cutaneous marginal zone cell lymphoma (PCMZL) cases were not included in the present study. Intervention: Evaluation of immunohistochemical CD10, BCL6, MUM1/IRF4, BCL2, MYC and Ki-67 expression and classification according to three different algorithms. Gene expression profiling (GEP) was performed on the same series using Lymph2Cx assay (Nanostring). The data obtained were compared and analysed. Results: All the IHC algorithms showed 13 GCB and 15 non-GCB. GEP showed 12 GCB, 12 activated B cell–type and 4 unclassified. Conclusions: The PCBCL were classifiable as GCB and non-GCB like the nDLBCL as IHC algorithms were concordant to GEP and produced the same results.

The epidemiology and the outcomes of acute appendicitis in elderly patients are very different from the younger population. Elderly patients with acute appendicitis showed higher mortality, higher perforation rate, lower diagnostic accuracy, longer delay from symptoms onset and admission, higher postoperative complication rate and higher risk of colonic and appendiceal cancer. The aim of the present work was to investigate age-related factors that could influence a different approach, compared to the 2016 WSES Jerusalem guidelines on general population, in terms of diagnosis and management of elderly patient with acute appendicitis. During the XXIX National Congress of the Italian Society of Surgical Pathophysiology (SIFIPAC) held in Cesena (Italy) in May 2019, in collaboration with the Italian Society of Geriatric Surgery (SICG), the World Society of Emergency Surgery (WSES) and the Italian Society of Emergency Medicine (SIMEU), a panel of experts participated to a Consensus Conference where eight panelists presented a number of statements, which were developed for each of the four topics about diagnosis and management of acute appendicitis in elderly patients, formulated according to the GRADE system. The statements were then voted, eventually modified and finally approved by the participants to the Consensus Conference. The current paper is reporting the definitive guidelines statements on each of the following topics: diagnosis, non-operative management, operative management and antibiotic therapy.

Acute left colonic diverticulitis (ALCD) in the elderly presents with unique epidemiological features when compared with younger patients. The clinical presentation is more nuanced in the elderly population, having higher in-hospital and postoperative mortality. Furthermore, geriatric comorbidities are a risk factor for complicated diverticulitis. Finally, elderly patients have a lower risk of recurrent episodes and, in case of recurrence, a lower probability of requiring urgent surgery than younger patients. The aim of the present work is to study age-related factors that may support a unique approach to the diagnosis and treatment of this problem in the elderly when compared with the WSES guidelines for the management of acute left-sided colonic diverticulitis. During the 1 degrees Pisa Workshop of Acute Care & Trauma Surgery held in Pisa (Italy) in September 2019, with the collaboration of the World Society of Emergency Surgery (WSES), the Italian Society of Geriatric Surgery (SICG), the Italian Hospital Surgeons Association (ACOI), the Italian Emergency Surgery and Trauma Association (SICUT), the Academy of Emergency Medicine and Care (AcEMC) and the Italian Society of Surgical Pathophysiology (SIFIPAC), three panel members presented a number of statements developed for each of the four themes regarding the diagnosis and management of ALCD in older patients, formulated according to the GRADE approach, at a Consensus Conference where a panel of experts participated. The statements were subsequently debated, revised, and finally approved by the Consensus Conference attendees. The current paper is a summary report of the definitive guidelines statements on each of the following topics: diagnosis, management, surgical technique and antibiotic therapy.

Background: Surgical site infections (SSIs) are among the most important determinants of morbidity after HBP surgery. Their frequency after HPB surgery is variable, from 1–2% after elective cholecystectomy to 25% after PD. Methods: A systematic review was performed to assess the role of antimicrobial prophylaxis (AP) in HPB elective surgery. Articles published between 2015 and 2021 were obtained; those before 2015 were not included because they antedate the WHO guidelines on SSI prevention. We conducted three different research methods for liver resection, elective cholecystectomy and pancreatic and biliary surgery regarding patients requiring preoperative biliary drainage. Results: Hepatic surgery, improvement in surgical technique and perioperative management lead to a very low SSI. One preoperative 2 g cefazolin dose may be adequate for surgical prophylaxis. From preoperative biliary drainage, we can derive that patients’ homeostasis rather than AP plays a paramount role in reducing postoperative morbidity. The time from biliary drainage could be an essential element in decision making for surgical prophylaxis. In the case of low-risk cholecystectomy, it is not easy to draw definitive conclusions about the effect of AP. Data from the literature are inconsistent, and some risk factors cannot be predicted before surgery. Conclusion: in our opinion, a strict preoperative cefazolin dose strategy can be reasonable in HBP surgery until a large-scale, multicentric RCT brings definitive conclusions.

Background While laparoscopic approach for right hemicolectomy (LRH) is considered appropriate for the surgical treatment of both malignant and benign diseases of right colon, there is still debate about how to perform the ileo-colic anastomosis. The ColonDxItalianGroup (CoDIG) was designed as a cohort, observational, prospective, multi-center national study with the aims of evaluating the surgeons’ attitude regarding the intracorporeal (ICA) or extra-corporeal (ECA) anastomotic technique and the related surgical outcomes. Methods One hundred and twenty-five Surgical Units experienced in colorectal and advanced laparoscopic surgery were invited and 85 of them joined the study. Each center was asked not to change its surgical habits. Data about demographic characteristics, surgical technique and postoperative outcomes were collected through the official SICE website database. One thousand two hundred and twenty-five patients were enrolled between March 2018 and September 2018. Results ICA was performed in 70.4% of cases, ECA in 29.6%. Isoperistaltic anastomosis was completed in 85.6%, stapled in 87.9%. Hand-sewn enterotomy closure was adopted in 86%. Postoperative complications were reported in 35.4% for ICA and 50.7% for ECA; no significant difference was found according to patients’ characteristics and technologies used. Median hospital stay was significantly shorter for ICA (7.3 vs. 9 POD). Postoperative pain in patients not prescribed opioids was significantly lower in ICA group. Conclusions In our survey, a side-to-side isoperistaltic stapled ICA with hand-sewn enterotomy closure is the most frequently adopted technique to perform ileo-colic anastomosis after any indications for elective LRH. According to literature, our study confirmed better short-term outcomes for ICA, with reduction of hospital stay and postoperative pain. Trial registration Clinical trial (Identifier: NCT03934151).

Contains fulltext : 238976.pdf (Publisher’s version ) (Open Access) On January 2020, the WHO Director General declared that the outbreak constitutes a Public Health Emergency of International Concern. The world has faced a worldwide spread crisis and is still dealing with it. The present paper represents a white paper concerning the tough lessons we have learned from the COVID-19 pandemic. Thus, an international and heterogenous multidisciplinary panel of very differentiated people would like to share global experiences and lessons with all interested and especially those responsible for future healthcare decision making. With the present paper, international and heterogenous multidisciplinary panel of very differentiated people would like to share global experiences and lessons with all interested and especially those responsible for future healthcare decision making.

Background and aims Although rectal cancer is predominantly a disease of older patients, current guidelines do not incorporate optimal treatment recommendations for the elderly and address only partially the associated specific challenges encountered in this population. This results in a wide variation and disparity in delivering a standard of care to this subset of patients. As the burden of rectal cancer in the elderly population continues to increase, it is crucial to assess whether current recommendations on treatment strategies for the general population can be adopted for the older adults, with the same beneficial oncological and functional outcomes. This multidisciplinary experts' consensus aims to refine current rectal cancer-specific guidelines for the elderly population in order to help to maximize rectal cancer therapeutic strategies while minimizing adverse impacts on functional outcomes and quality of life for these patients. Methods The discussion among the steering group of clinical experts and methodologists from the societies' expert panel involved clinicians practicing in general surgery, colorectal surgery, surgical oncology, geriatric oncology, geriatrics, gastroenterologists, radiologists, oncologists, radiation oncologists, and endoscopists. Research topics and questions were formulated, revised, and unanimously approved by all experts in two subsequent modified Delphi rounds in December 2020-January 2021. The steering committee was divided into nine teams following the main research field of members. Each conducted their literature search and drafted statements and recommendations on their research question. Literature search has been updated up to 2020 and statements and recommendations have been developed according to the GRADE methodology. A modified Delphi methodology was implemented to reach agreement among the experts on all statements and recommendations. Conclusions The 2021 SICG-SIFIPAC-SICE-WSES consensus for the multidisciplinary management of elderly patients with rectal cancer aims to provide updated evidence-based statements and recommendations on each of the following topics: epidemiology, pre-intervention strategies, diagnosis and staging, neoadjuvant chemoradiation, surgery, watch and wait strategy, adjuvant chemotherapy, synchronous liver metastases, and emergency presentation of rectal cancer.

Background Gallstone disease is very common afflicting 20 million people in the USA. In Europe, the overall incidence of gallstone disease is 18.8% in women and 9.5% in men. The frequency of gallstones related disease increases by age. The elderly population is increasing worldwide. Aim The present guidelines aims to report the results of the World Society of Emergency Surgery (WSES) and Italian Surgical Society for Elderly (SICG) consensus conference on acute calcolous cholecystitis (ACC) focused on elderly population. Material and methods The 2016 WSES guidelines on ACC were used as baseline; six questions have been used to investigate the particularities in elderly population; the answers have been developed in terms of differences compared to the general population and to statements of the 2016 WSES Guidelines. The Consensus Conference discusses, voted, and modified the statements. International experts contributed in the elaboration of final statements and evaluation of the level of scientific evidences. Results The quality of the studies available decreases when we approach ACC in elderly. Same admission laparoscopic cholecystectomy should be suggested for elderly people with ACC; frailty scores as well as clinical and surgical risk scores could be adopted but no general consensus exist. The role of cholecystostomy is uncertain. Discussion and conclusions The evaluation of pro and cons for surgery or for alternative treatments in elderly suffering of ACC is more complex than in young people; also, the oldest old age is not a contraindication for surgery; however, a larger use of frailty and surgical risk scores could contribute to reach the best clinical judgment by the surgeon. The present guidelines offer the opportunity to share with the scientific community a baseline for future researches and discussion.

Pollutants represent potential threats to the human health, being ubiquitous in the environment and exerting toxicity even at low doses. This study aims at investigating the role of fifteen multiclass organic pollutants, assumed as markers of environmental pollution, most of which exerting endocrine-disrupting activity, in thyroid cancer development. The increasing incidence of differentiated thyroid cancer (DTC) may be related to the rising production and environmental dissemination of pollutants. Fifty-five patients, twenty-seven with diagnosis of benign thyroid nodules and twenty-eight suffering from differentiated thyroid cancer, were enrolled and the concentration levels of seven bisphenols, two phthalates (i.e. di(2-ethylhexyl) phthalate (DEHP) and its main metabolite, mono-(2-ethyl-hexyl) phthalate) (MEHP)), two chlorobenzenes, (1,4-dichlorobenzene and 1,2,4,5-tetrachlorobenzene), and 3 phenol derivatives (2-chlorophenol, 4- nonylphenol, and triclosan) were determined in their serum by using a validated analytical method based on high performance liquid chromatography with ultraviolet tandem fluorescence detection. A significant relationship was found between malignancy and the detection in the serum of both bisphenol AF and DEHP. Indeed, their presence confers a more than fourteen times higher risk of developing differentiated thyroid cancer. Relationship between these two pollutants and the risk of malignancy was dose-independent and not mediated by higher thyroid stimulating hormone levels. Even if a conclusive evidence cannot still be drawn and larger prospective studies are needed, the exposure to low doses of environmental endocrine-disrupting contaminants can be considered consistent with the development of thyroid cancer.

Un sistema per la rilevazione e il monitoraggio della seduta a W di bambini è composto da: una coppia di dispositivi indossabili (1A, 1B), includenti un mezzo di supporto alle caviglie di un bambino, un sensore di inclinazione o angolare (2), una batteria di alimentazione (3), un’interfaccia Bluetooth (4), e un microprocessore (5) per il controllo del dispositivo e dotato di memoria interna per effettuare la memorizzazione in locale dei dati. I dispositivi (1A, 1B) comunicano direttamente con un’unità centrale di acquisizione dotata di un sistema operativo, su cui è installata un App per la visualizzazione, il monitoraggio e la memorizzazione dei dati, nonché il controllo e la configurazione dei dispositivi (1A, 1B), anch’essa dotata di interfaccia Bluetooth. È descritto inoltre un metodo per determinare la posizione di ciascuna caviglia rispetto al piano orizzontale, e l’assunzione della seduta a W.

The current COVID-19 pandemic underlines the importance of a mindful utilization of financial and human resources. Preserving resources and manpower is paramount in healthcare. It is important to ensure the ability of surgeons and specialized professionals to function through the pandemic. A conscious effort should be made to minimize infection in this sector. A high mortality rate within this group would be detrimental.This manuscript is the result of a collaboration between the major Italian surgical and anesthesiologic societies: ACOI, SIC, SICUT, SICO, SICG, SIFIPAC, SICE, and SIAARTI. We aim to describe recommended clinical pathways for COVID-19-positive patients requiring acute non-deferrable surgical care. All hospitals should organize dedicated protocols and workforce training as part of the effort to face the current pandemic.

On January 2020, the WHO Director General declared that the outbreak constitutes a Public Health Emergency of International Concern. The world has faced a worldwide spread crisis and is still dealing with it. The present paper represents a white paper concerning the tough lessons we have learned from the COVID-19 pandemic. Thus, an international and heterogenous multidisciplinary panel of very differentiated people would like to share global experiences and lessons with all interested and especially those responsible for future healthcare decision making. With the present paper, international and heterogenous multidisciplinary panel of very differentiated people would like to share global experiences and lessons with all interested and especially those responsible for future healthcare decision making.

Elderly is conventionally defined as a person 65 years old or older, but some studies have addressed the issue of biological age-based descriptions of “elderly.” The latter differs from chronological age because it takes into consideration a number of factors other than just the date of birth. Since aging would occur gradually accumulating damage to various cells and tissues in the body, the concept of “biological age” may be used as a trait d’union between elderly and frail.

Objective: to assess whether immunohistochemical (IHC) algorithms used to classify the cell of origin (COO) of nodal Diffuse Large B-cell lymphoma (nDLBCL) in Germinal Center type (GCB) and non-GCB subtypes may be applied to Primary Cutaneous B-cell lymphoma (PCBCL) too, and which of these algorithms performs better on PCBCL.Design: retrospective case control study.Setting: Pathology Department of the University Hospital “San Giovanni di Dio e Ruggi d’Aragona” Salerno, Italy.Participants : fourteen PCBCL, including Primary Cutaneous follicle centre lymphoma (PCFCL) and primary cutaneous diffuse large B-cell lymphoma, Leg type (PCDLBCL-LT) and 14 nDLBCL were evaluated for 7-year period (January 2011 to December 2017). Primary cutaneous marginal zone cell lymphoma (PCMZL) cases were not included in the present study. Intervention: evaluation of immunohistochemical CD10, BCL6, MUM1/IRF4, BCL2, MYC and Ki-67 expression and classification according to three different algorithms. Gene expression profiling (GEP) was performed on the same series using Lymph2Cx assay (Nanostring). The data obtained were compared and analysed.Results: all the IHC algorithms showed 13 GCB and 15 non-GCB. GEP showed 12 GCB, 12 activated B cell–type and 4 unclassified.Conclusions: the PCBCL were classifiable as GCB and non-GCB like the nDLBCL as IHC algorithms were concordant to GEP and produced the same results.

Since laterocervical lymphadenectomy is never routinely performed, all patients who undergo thyroidectomy for differentiated cancer must have an ultrasound examination (US). The aim of this study is to assess the accuracy of the preoperative US conducted at the time of surgery as a staging US (time 0) compared to the US performed sometime before in a location other than the surgical department as screening/diagnostic US (time - 1), to determine the necessity of always performing a preoperative US before surgery. 4060 patients with cytologic diagnosis (FNAB) of differentiated thyroid neoplasm (Tyr 4 and Tyr 5) were recruited at Surgery 2 of the Department of General and Specialist Surgery of the Tertiary Care Hospital "A. Cardarelli" of Naples. All patients had a screening US prior to admission into our hospital (time - 1) and were rescanned in the operating room before surgery (time 0) by the same team of surgeons experienced in the field of thyroid diseases. The examinations conducted at time 0 revealed a sensitivity of 100% and a specificity of 92.3%, while examinations performed at time - 1 showed a sensitivity of 22.8% and a specificity of 72.7%. The statistical analysis shows how the diagnostic timing and the experience of the examiner can make a difference both in terms of PPV and NPV to not only to assist in identifying all the lymph node lesions that would remain indeterminate if not specifically researched during surgery, but also helps avoid surgical overtreatment. The systematic execution of a staging US (time 0) in addition to a screening/diagnostic US (time - 1) results in forming a more appropriate therapeutic plan.

Due to an error in production the members of SICE CoDIG (Colon Dx Italian Group) listed in the Acknowledgments were not tagged correctly as authors in the XML of this article. This listing is presented again here:.

Background Fine needle cytology (FNC) of a parathyroid neoplasia (PN) is reliable, but needs to be confirmed by Parathormone (PTH) and Thyroglobulin (TG) immunoassay on needle washing or by immunocytochemistry (ICC) evaluation. The differentiation between parathyroid adenoma (PA), atypical adenoma (PAA) and carcinoma (PC) is difficult on histology or even impossible on FNC. The aim of this study was to evaluate possible cytological criteria to classify FNC-PN further. Methods Twenty-three FNC samples of PN and parathyroid cysts were rather then have been reviewed. The series includes 18 PNs, 4 cysts and 1 Thyr3B (histologically diagnosed as PA). Cytological features were: cellularity, patterns (follicular, solid or papillary), clear, oncocytic, isolated cells, nuclear atypia, cytoplasmic inclusions, nucleoli and mitoses. Data were compared with the histological controls. Results Seventeen PNs, 2 cysts and 1 Thyr3B FNC samples were histologically diagnosed as PA (16), PAA (2) and PC (2). Two cysts and 1 PN were not confirmed histologically. Cytological features and incidences were: high cellularity (1 PA, 1 PAA, 2 PCs), follicular (8 PAs, 1 PAA), solid (5 PAs, 1 PC), papillary pattern (1PA, 1 PAA, 1 PC), clear cells (4 PAs, 1 PAA, 2 PCs), oncocytic cells (6 PAs, 1 PAA, 2 PCs), isolated cells (5 PAs, 2 PAAs, 2 PCs), nuclear atypia (2 PAs, 1 PAA, 2 PCs), cytoplasmic inclusions (4 PAs, 2 PCs), nucleoli (2 PCs) and mitoses (2 PCs). Conclusion Evident nucleoli and mitoses may suggest the differentiation between PA and PC. However, further investigations are required to confirm these preliminary observations.

Paragangliomas are non-epithelial neuroendocrine neoplasms. They are most commonly identified in the head and neck...

Various experimental model designs have been used to analyze the inflammatory pathways in human gastrointestinal illnesses. Traditionally, analytical techniques and animal models are popular experimental tools to study the inflammation process of intestinal diseases. However, the comparison of results between animal and human models is difficult for the inconsistency of outcomes. Although there are different animal models for studying the intestinal diseases, none of them fully represents the physiological and environmental conditions typical of the human species. Also, there is currently a concerted effort to decrease the experimental use of animals. On the converse, experimental protocols using the culture of gut mucosa had become popular with the advent of endoscopy which allows explanting multiple fragments from the intestine. The peculiar characteristic of this model is the ability to preserve in vitro the features that we found in vivo, thus also the response to various stimuli that differs from person to person. The aim of the present paper is to provide a review of some of the possible uses of the organ intestinal mucosa culture.

Background Specific complications after thyroid surgery, such as recurrent laryngeal nerve injury (RLN) or hypoparathyroidism, are feared because they may give rise to a lifelong disability for the patient. The aim of this study was to evaluate the possible association between the types of device used (bipolar vs ultrasound-based harmonic scalpel defined Harmonic Focus) and major postoperative complications. Methods During a 1-year period, between October 2010 and October 2011, Italian Endocrine Surgery Units affiliated with the Italian Endocrine Surgery Units Association collected data on all consecutive patients older than 18 years who had undergone primary total thyroidectomy, near total thyroidectomy, and completion thyroidectomy. The data were included in a dataset, listing demographic variables, details on the surgical procedure, and 2 major complications of the thyroid surgery: postoperative RLN palsy/hypomobility and hypocalcemia. Results Our population comprised 1,846 subjects (78.6% women, median age 52 years). Six hundred four (32.7%) subjects underwent thyroidectomy by bipolar forceps and 1,242 (67.3%) by ultrasonic device. The risk of hypocalcemia in subjects undergoing thyroidectomy by ultrasonic device was similar to those undergoing thyroidectomy by bipolar after adjusting for sex, type of thyroidectomy, and central lymphadenectomy (odds ratio .94, 95% confidence interval .76 to 1.17). Subjects who underwent thyroidectomy by ultrasonic device had a lower risk of RLN paralysis compared with those undergoing thyroidectomy by bipolar forceps also after adjusting for central lymphadenectomy (odds ratio .39, 95% confidence interval .2 to .7). Conclusion This multicenter study acknowledges the value of the ultrasonic device as a protective factor only for RLN palsy, confirming nodal dissection as a risk factor for postoperative hypocalcemia and vocal folds disorders.

Gastric cancer in patients is often associated with bleeding; when it occurs, especially in the presence of an anemia, a transfusion is necessary to avoid further deterioration of the patient’s clinical state. The aim of this study was to evaluate the relationship between the administration of peri-operative transfusions due to the anemia or the clinical status and the post-operative clinical outcomes. 188 patients diagnosed with of gastric cancer were recruited at Surgery 2 of the Department of General and Specialist Surgery of the Tertiary Care Hospital “A. Cardarelli” of Naples. All patients had a total or a subtotal gastrectomy accompanied by D2 lymphectomy for gastric cancer. The clinical data most frequently associated with blood transfusion is the appearance of a post-operative infection (OR 2.26, 95% CI 0.87–5.79, P = 0.061). If the administration time of transfusion is considered, the clinical outcomes are different: preoperative transfusions showed a higher incidence of infections (OR 2.26, 95% CI 0.87–5.79, P = 0.061) and acute renal failure (OR 2.82, 95% CI 0.70–10.78, P = 0.078); patients who received intra or post-operative transfusions showed a prolonged hospitalization (OR 8.66, 95% CI 1.73–83.00, P = 0.002). The administration of blood products in the perioperative period is correlated in a statistically significant manner to the incidence of infections, acute renal failure and prolonged hospitalization; therefore, transfusions should be avoided unless clinically necessary and in particular intraoperative transfusions should be avoided because the immunomodulation effect linked to surgical stress may be enhanced hence worsening the prognosis.

Context The management of a benign thyroid nodule includes follow-up until its size requires a surgical or alternative treatment. To date, it is difficult or impossible to predict the size changes of a benign nodule in a given patient because no specific growth parameters exist. RAS mutations have been described in thyroid adenomas and hyperplastic benign nodules. Objective The aim of this study was to establish whether the volume changes of benign nodules are associated withthe presence of RAS mutation. Patients and methods Genomic DNA obtained by fine-needle aspiration of 78 thyroid noduleswith benign cytologywasanalyzed by pyrosequencing for the presence of NRAS61and KRAS13mutations.Ultrasonographic features were obtained. The volume of nodules at baseline and their changes after a mean follow-up of 25 months were evaluated according to the presence of RAS mutation. Results A RAS mutation was found in 24 thyroid aspirates (30.8%, 8 NRAS61 and 16 KRAS13). RAS mutation was not associated with ultrasonographic features, butwas significantly associated with a larger size at baseline (p = 0.017). After a 25 months mean follow-up, RAS mutation positive nodules displayed faster growth (RAS mutation positive vs. negative % annual growth 27.6% +/- 32.2% vs. 1.0% +/- 17.0%, p

BACKGROUND:: Bariatric procedures can induce a massive weight loss that lasts for >15 years after surgery; in addition, they achieve important metabolic effects including diabetes resolution in the majority of morbidly obese patients. However, some bariatric interventions may cause gastroesophageal reflux disease and other serious complications. The aim of our study is to evaluate the risk of cancer after bariatric surgery. METHODS:: We conducted a review of the literature about the cases of gastric cancer arising after any bariatric procedure, including a case of adenocarcinoma incidentally discovered by the authors 6 months after laparoscopic adjustable gastric banding. RESULTS:: Globally, 17 case reports describing 18 patients were retrieved, including the case study by the authors. The diagnosis of tumor was at a mean of 8.6 years after bariatric surgery, 9.3 years after RYGB, and 8.1 years after restrictive procedures. The adenocarcinoma represented most cases (15 patients, 83%). In the patients with RYGB, the adenocarcinoma was localized in the excluded stomach in 5 patients (83%) and in the pouch in 1 patient (17%). After a restrictive procedure, the cancer was localized in the pouch in 5 patients (62.5%), in the pylorus in 2 patients (25%), and in lesser curvature only in 1 patient (12.5%). CONCLUSIONS:: There is a lack of evidence about a connection between the late occurrence of gastric adenocarcinoma and the bariatric surgery. For this reason, although the preoperative upper endoscopy is still mandatory, there is no need for a regular endoscopic evaluation of patients after surgery.

In recent years, laparoendoscopic single-site surgery (LESS) has gained greater interest and diffusion for the treatment of gallstones. This critical review aims to evaluate the feasibility and safety of LESS cholecystectomy versus the 3-port technique (TPT) through a comparative analysis of 5 parameters: mean operative time, intraoperative and postoperative complications, conversion to open, conversion to the 4-trocar technique and postoperative hospital stay. The authors performed a systematic search of the medical literature through a search of PubMed and Ovid EMBASE. Inclusion criteria were as follows: publication date between January 1, 2005, and December 31, 2010; English or Italian language; human participants and series of 20 operations or more. There were 5 manuscripts meeting the inclusion criteria for TPT and 23 for LESS. Only one prospective randomized controlled trial comparing TPT and LESS was identified. Operative time is significantly longer in the single-incision group. Complications and conversion rates to the 4-port technique are higher in LESS. Postoperative hospital stay is similar in the 2 groups. Rate of conversion to open is higher in TPT. Despite the number of publications on LESS cholecystectomy, the vast majority of data available in the literature are from small case series without any comparative data. Although LESS cholecystectomy is a fashionable technique there are few data available for an evidence-based determination as to the real benefits of this technique. Well-designed comparative studies are suggested to validate the clinical benefits and ensure that there are no new complications or added costs associated with the new technique.

Introduction Obesity is a multifactorial chronic disease caused by a combination of hereditary, metabolic, dietary, cultural, social and psychological factors. Conservative treatments, such as diet and physical exercises, revealed a lack of long-term efficacy in patients with an extremely high BMI (>60 kg/m 2 ). Methods We present a multidisciplinary approach in a patient with an extremely high BMI: a twenty-one years old woman with a BMI 102 kg/m 2 (body weight 313 kg × height 175 cm) disabled to walk with severe depression and a psychological pattern of sweet eater and binge eating disorder. She was also amenorrheic and suffered from metabolic syndrome. The psychological assessment and the social-familial support were defined as priorities. Afterward, physical rehabilitation, behavior therapy, hypocaloric diet followed by intragastric balloon were planned as preoperative treatment. Finally a surgical program was scheduled: Sleeve Gastrectomy as first step of Biliopancreatic Diversion with Duodenal Switch. Results Sixteenth months after the Sleeve Gastrectomy the weight was 130 kg (Excess Weight Loss = 74%) with a resumption of the menstrual cycle and a normalization of the metabolic syndrome. Conclusion Due to the results obtained with both surgery and an excellent psychological supporting network we decided not to perform the expected Biliopancreatic Diversion with Duodenal Switch. The timing of bariatric surgery in superobesity patients is a milestone, but the cooperation among the specialists is essential for the choice of the best successful surgery. The multidisciplinary team should point to a comprehensive tailored management, considering motivation, compliance and adherence to a long-term follow-up as the keys for surgical success.

Background Traumatic brain injury (TBI) is a major cause of death and disability and may cause transient or persistent, isolated or multiple hypopituitarism in a variable percentage of cases. Objectives The primary aim of this study was to determine the incidence of isolated and multiple anterior pituitary hormone deficiency in subjects with TBI in a single institution. The secondary aim was to determine a correlation between pituitary deficiency and quality of life (QOL) after TBI. Methods Thirty-five patients, aged between 18 and 63 years, were evaluated 6months to 5 years after TBI. We evaluated the QOL by SF-12 ® questionnaire and measured serum basal GH, IGF1, LH, FSH, testosterone (in males), 17-β-estradiol (in women), PRL, fT4 and TSH. In patients with low IGF1, a GHRH + Arginine test was performed. Results Single or multiple pituitary failure was found in 13 patients (37%). Low testosterone was found in 7 males, low FSH and/or LH in 4, low IGF1 in 7 patients. Hypogonadotropic hypogonadism and GH insufficiency assessed by GHRH + Arginine test were found respectively in 3 and 2 patients. One patient displayed a concomitant GH insufficiency and low TSH level. Twenty six patients showed a reduction in QOL. A correlations between altered QOL and hormonal deficiency was not observed. Conclusions Isolated or multiple hypopituitarism resulting from TBI are frequent. Alterations in QOL and pituitary function resulting from TBI are not associated.

L'arterite de Takayasu est une vascularite chronique interessant principalement l'aorte et ses branches. Presque tous les malades ont des troubles ischemiques au niveau des arteres impliquees. Le traitement reste actuellement controverse. Les rechutes sont frequentes. Dans la presente etude, nous avons etudie les resultats a long terme de nos malades ayant une arterite de Takayasu. Entre Novembre 1993 et Octobre 2003, 10 malades ayant une arterite de Takayasu ont ete traites. Tous les malades ont eu un traitement medical (corticoides pendant 7 mois, cyclophosphamide pendant trois mois et methotrexate pendant 12 mois). Deux malades ont arrete leur traitement par le methotrexate en raison d'une insuffisance renale. Quatre malades ont eu une intervention chirurgicale. Au cours du traitement, la vitesse de sedimentation et la C-reactive proteine ont ete determinees comme des indices d'activite inflammatoire et de reponse au traitement. Quatre (50%) des 8 malades qui ont eu le traitement complet par le methotrexate, n'ont pas eu de recidive de la maladie. Les quatre autres malades (50%) ont recidive mais ont eu une meilleure reponse a un nouveau traitement corticoide. Les deux malades qui ont arrete le traitement par le methotrexate sont decedes de complications de l'arterite de Takayasu. Dans notre experience personnelle, un traitement au long cours par le methotrexate a demontre une certaine efficacite en evitant la recidive, en maintenant la stabilite des resultats et en amplifiant les effets des corticoides chez les malades ayant une recidive.

Takayasu's arteritis is a chronic vasculitis mainly involving the aorta and its main branches. Almost all patients have ischemic disorders of the involved vessels. Treatment is nowadays controversial. Relapses are frequent. In the present study, we elucidate the long-term outcomes of our patients with Takayasu's arteritis. Between November 1993 and October 2003, 10 patients with Takayasu's disease were treated. All patients underwent medical treatment (corticosteroid for 7 months, cyclophosphamide for 3 months, and methotrexate for 12 months). Two patients stopped treatment with methotrexate when renal failure occurred. Four patients underwent a surgical procedure. During treatment, erythrocyte sedimentation rate and C-reactive protein concentrations were determined as indexes of inflammatory activity and treatment responsiveness. Four out of eight patients (50%) who underwent the full treatment with methotrexate had no relapse of the disease. The other four patients (50%) had relapse of the disease but had a better response to new corticosteroid treatment. The two patients who stopped methotrexate treatment died from complications of Takayasu's arteritis. In our personal experience, long-term treatment with methotrexate demonstrated a certain efficacy in avoiding relapse, maintaining stability of results, and amplifying the effects of steroid in patients with relapse.

Specific complications after thyroid surgery, such as recurrent laryngeal nerve injury (RLN) or hypoparathyroidism, are feared because they may give rise to a lifelong disability for the patient. The aim of this study was to evaluate the possible association between the types of device used (bipolar vs ultrasound-based harmonic scalpel defined Harmonic Focus) and major postoperative complications.During a 1-year period, between October 2010 and October 2011, Italian Endocrine Surgery Units affiliated with the Italian Endocrine Surgery Units Association collected data on all consecutive patients older than 18 years who had undergone primary total thyroidectomy, near total thyroidectomy, and completion thyroidectomy. The data were included in a dataset, listing demographic variables, details on the surgical procedure, and 2 major complications of the thyroid surgery: postoperative RLN palsy/hypomobility and hypocalcemia.Our population comprised 1,846 subjects (78.6% women, median age 52 years). Six hundred four (32.7%) subjects underwent thyroidectomy by bipolar forceps and 1,242 (67.3%) by ultrasonic device. The risk of hypocalcemia in subjects undergoing thyroidectomy by ultrasonic device was similar to those undergoing thyroidectomy by bipolar after adjusting for sex, type of thyroidectomy, and central lymphadenectomy (odds ratio .94, 95% confidence interval .76 to 1.17). Subjects who underwent thyroidectomy by ultrasonic device had a lower risk of RLN paralysis compared with those undergoing thyroidectomy by bipolar forceps also after adjusting for central lymphadenectomy (odds ratio .39, 95% confidence interval .2 to .7).This multicenter study acknowledges the value of the ultrasonic device as a protective factor only for RLN palsy, confirming nodal dissection as a risk factor for postoperative hypocalcemia and vocal folds disorders.

Surgery is considered the treatment of choice for postoperative biliary strictures. Recently, endoscopic stent placement has been proposed as an alternative to surgical management in selected patients.In this retrospective study, 157 patients with postoperative biliary strictures were included. Eighty patients (group A) were treated endoscopically and 77 by surgery (group B). Baseline characteristics of patients were comparable in both groups. Endoscopic therapy consisted of placement of endoprostheses, with trimonthly elective exchange for a 1-year period. Surgical therapy consisted of constructing a biliary-digestive anastomosis in normal ductal tissue. Data were evaluated according to intention-to treat analysis.Successful treatment was achieved in 54% of group A and 73% of group B (P0.001). Overall 31% of patients developed complications in group A and 23% of patients in group B (P0.05). However, the rates of severe complications were comparable in both groups (11% versus 13%; P = not significant) In group A the mortality rate was 0% compared with 8% of group B (P0.05). Recurrent stenosis was evidenced in 6% of patients of group A and 5% of patients of group B.Surgery provides a better long-term outcome over the endoscopy, because of patients with total obstruction are not amenable to endoscopic approach. When successfully done, endoscopic results are similar to surgical results with less mortality.

Background Jejunal diverticulosis is an uncommon disease and usually asymptomatic. It can be complicated not only by diverticulitis, but by hemorrhage, perforation, intussusception, volvulus, malabsorption and even small bowel obstruction due to enteroliths formed and expelled from these diverticula. Methods We describe a case of an occult bleeding jejunal diverticulum, casually discovered in a patient that was taken to surgery for a Dieulafoy’s lesion after unsuccessful endoscopic treatment. We performed a gastric resection together with an ileocecal resection. Macroscopic and microscopic examinations confirmed the gastric Dieulafoy’s lesion and demonstrated the presence of another source of occult bleeding in asymptomatic jejunal diverticulum. Discussion The current case emphasizes that some gastrointestinal bleeding lesions, although rare, can be multiple and result in potentially life-threatening bleeding. The clinician must be mindful to the possibility of multisite lesions and to the correlation between results of the investigations and clinical condition of the bleeding patient.

Background Anemia is the most common hematologic abnormality in older populations. Furthermore, iron deficiency anemia is common and merits investigation and treatment, as it usually results from chronic occult bleeding from the gastrointestinal tract. In view of a wide use of capsule endoscopy as a diagnostic procedure for occult gastrointestinal bleeding and of the growth of aging population, we performed a literature review about the feasibility of capsule endoscopy in the elderly. Methods We conducted a literature search in the PubMed database in July 2012, and all English-language publications on capsule endoscopy in elderly patients since 2005 were retrieved. The potential original articles mainly focused on obscure gastrointestinal bleeding were all identified and full texts were obtained and reviewed for further hand data retrieving. Results We retrieved only six papers based on different primary end-points. Four were retrospective non randomized studies and two were prospective non randomized studies. In the end 65, 70, 80 and 85 years were used as an age cut-off. All studies evaluate the diagnostic yield of capsule endoscopy in iron deficiency anemia. Only three studies assess the feasibility of capsule examination of the elderly. Conclusions Iron deficiency anemia in the elderly with or without obscure gastrointestinal bleeding is the major indication for capsule endoscopy after a negative esophago-gastro-duodenoscopy and colonoscopy. It is safe and effective to identify a small bowel pathology without a great discomfort for the elderly. Inability to swallow the capsule, battery failure before capsule reaches the cecum, and capsule retention are some of the important problems associated with capsule endoscopy in elderly as well as in younger patients.

Summary background The development of hepatocellular carcinoma in liver cirrhosis is associated with altered synthesis and secretion of several growth factors. aim The aim of this prospective study was to investigate the potential implication of IGF-I and its major binding protein (IGFBP-3) in the development of hepatocellular carcinoma. patients and methods IGF-I and IGFBP-3 were measured in 150 healthy subjects, 40 patients with liver cirrhosis and 63 with liver cirrhosis and untreated hepatocellular carcinoma. The ratio between IGF-I and IGFBP-3 was also calculated. results Serum IGF-I (70 ± 10 and 65 ± 7 vs. 185 ± 6·4 µg/l, P

We evaluated the effectiveness of a sequential diet regimen termed the obese preoperative diet (OPOD) in morbidly obese patients with and without type 2 diabetes mellitus (T2DM) scheduled for laparoscopic bariatric surgery. Fifty patients (body mass index 53.5 ± 8.4 kg/m2) scheduled for bariatric surgery, including 14 with T2DM, were prospectively enrolled and followed the OPOD regimen: a very low-calorie ketogenic diet for 10 days, followed by a very low-calorie diet for 10 days, and then a low-calorie diet for 10 days. Patients were evaluated at baseline (T0) and after 10 days (T1), 20 days (T2), and 30 days (T3). Body weight, body mass index, waist circumference, and neck circumference were significantly lower at T1, T2, and T3 than at T0 in the 48 patients who completed the OPOD. Two patients discontinued the OPOD after 4–7 days. In patients with T2DM, fasting plasma glucose levels decreased significantly, enabling reduction of diabetic medications. Plasma and urine ketone levels increased at T1 but were all

Hypocalcemia, the most common complication of thyroidectomy, is a transient condition in up to 27% of patients and a permanent condition approximately 1% of patients. The aim of this prospective study was to evaluate reliability of postoperative intact parathyroid hormone (iPTH) assessment for predicting clinically relevant postthyroidectomy hypocalcemia for a safe early discharge of patients with no overtreatment.Seventy-five consecutive patients (age 51 ± 13 years [mean ± SD]) undergoing total or completion thyroidectomy with no concomitant parathyroid diseases or renal failure were included in the present study. Serum iPTH level was determined before and 2 hours after thyroidectomy. Serum calcium concentration was determined 1 day before and 2 days postoperatively.The occurrence of postoperative hypocalcemia was correlated both with the absolute and relative iPTH decrease, determined as a ratio of the preoperative value (P.0001). There was a greater difference in relative decrease in iPTH between patients remaining normocalcemic and those with hypocalcemia present on the second postoperative day. Hypocalcemic patients on the second postoperative day had a 62% relative decrease in iPTH 2 hours after thyroidectomy.The relative decrease in serum iPTH was greater in patients with hypocalcemia arising on the second postoperative day rather than in patients who remained normocalcemic. The relative decrease in iPTH determined 2 hours after total thyroidectomy together with the serum calcium concentration 24 hours after thyroidectomy proved to be useful predictors of sustained hypocalcemia and might change the clinical management of patients after thyroid surgery to support a longer hospitalization in these selected patients.

Non-suppressive or partially suppressive L-T4 treatment demonstrated to be effective in reducing the volume of the nodules. However, studies with long follow-up are lacking and significant controversy exists regarding the efficacy of non-suppressive L-T4 treatment in benign nodular goiter.The goal of this study was to determine the evolution of thyroid nodules in subjects treated with a non-suppressive levothyroxine (L-T4) dose, compared to untreated subjects.We followed for a period of 1-9 years the thyroid nodule size in 356 female patients in the age range 19-45 at study entry, of which 201 untreated (Group 0) and 165 treated with a non-suppressive L-T4 dose (Group L-T4).We determined the volume of thyroid nodules by ultrasonography.The initial mean nodule volume in Group 0 and Group L-T4 was 3.91 ± 6.87 and 4.01 ± 7.35 mL, respectively. Nodule volume increase was inversely correlated to the initial volume. The final volume was slightly higher in untreated than in L-T4 treated subjects (5.37 ± 8.49 and 4.39 ± 6.72 mL). In both groups, the mean of annual fold increase of nodule volume was inversely correlated with the follow-up duration (P 0.0046), indicating a slower growth as time advances. In the subjects treated with L-T4, the mean annual increase of nodule volume was significantly minor compared to untreated subjects. Concomitant nodules in ten multinodular goiters exhibited totally independent evolution, demonstrating that intranodular factors are more important for the nodule behavior than extra nodular factors.Our study demonstrates that the growth of benign thyroid nodules is inversely correlated to their size, benign nodules naturally growth slowly as time advances, and that a chronic treatment with L-T4 at a non-TSH-suppressive dose significantly reduces their growth.

BACKGROUND: The development of hepatocellular carcinoma in liver cirrhosis is associated with altered synthesis and secretion of several growth factors. AIM: The aim of this prospective study was to investigate the potential implication of IGF-I and its major binding protein (IGFBP-3) in the development of hepatocellular carcinoma. PATIENTS AND METHODS: IGF-I and IGFBP-3 were measured in 150 healthy subjects, 40 patients with liver cirrhosis and 63 with liver cirrhosis and untreated hepatocellular carcinoma. The ratio between IGF-I and IGFBP-3 was also calculated. RESULTS: Serum IGF-I (70 +/- 10 and 65 +/- 7 vs. 185 +/- 6.4 microg/l, P < 0.001) and IGFBP-3 levels (1225 +/- 113 and 984 +/- 67 vs. 3017 +/ -80 microg/l, P < 0.001) were lower in patients with liver cirrhosis, without or with hepatocellular carcinoma, than in controls. Age was negatively correlated with IGF-I levels in patients with liver cirrhosis (r = -0.6; P = 0.0002) as well as in controls (r = -0.8, P < 0.0001), but not in patients with hepatocellular carcinoma (r = -0.2; P = 0.2). Additionally, in patients with liver cirrhosis (r = -0.54; P = 0.0003) and more weakly in those with hepatocellular carcinoma (r = -0.24; P = 0.04) IGF-I levels were negatively correlated with liver failure measured according with Child class. Despite patients with class C hepatocellular carcinoma being older than those in the same functional class with cirrhosis (64 +/- 2 vs. 57 +/- 12 years, P < 0.01), they had a significantly increased IGF-I : IGFBP-3 ratio (0.18 +/- 0.05 vs. 0.41 +/- 0.09, P = 0.04), due mostly to increased IGF-I levels (27.1 +/- 5.6 vs. 42 +/- 6.2 microg/l) as IGFBP-3 levels were similar to patients with cirrhosis (734 +/- 81 vs. 679 +/- 83 microg/l). CONCLUSIONS: Hepatocellular carcinoma is associated with a higher IGF-I : IGFBP-3 ratio than that found in patients with liver cirrhosis and a similar degree of liver failure.

We present a new combination of transabdominal ultrasound (US) and biliary endoscopy, with endoscopic stent placement carried out under US guidance. Four patients (two men, two women; average age 66.2 years) underwent US-guided stent placement for palliation of ampullary carcinoma (n = 3) or pancreatic cancer (n = 1). A guide wire and a guiding catheter were endoscopically introduced and identified, by US in the common bile duct across the stricture. Hydromer-coated polyurethane angled stents (10 Fr) were finally inserted over the guide wire/guiding catheter by a pusher tube system. Successful drainage, with substantial reduction in bilirubin level, was achieved in all patients (14.2 +/- 9.5 vs. 4.2 +/- 2.9 mg/dl at 1 week). The present case series shows that endoscopic stent placement performed under US guidance is safe and effective. Further studies of larger series, including more proximal strictures, are warranted.