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Ischemic complications after pancreatic surgery can raise postoperative mortality from 4 to 83 per cent. Variants in vascular anatomy play a major role in determining such complications, but they have been only occasionally reported in the literature. We retrospectively analyzed 100 records of patients consecutively treated between January 2011 and December 2013 for resectable malignant diseases who underwent pancreaticoduodenectomy (PD) or total pancreatectomy to state the statistical impact of anatomical vascular variations in surgical outcomes (mean surgical timing, mean blood loss during surgery, and postoperative major complications onset) and to state whether preoperatively undetected vascular anomalies (VA) can raise the risk of postoperative ischemic complications. PD was performed in 89 patients, requiring multiorgan resections in three cases and total pancreatectomy was performed in 11 cases, which was associated to splenectomy in four patients. Incidence of VA was 25/100 (25%), whereas in 18/25 cases (72%) they were detected by preoperative radiologic setting. Their presence in patients undergoing PD significantly raised mean surgical timing (P = 0.003) and increased mean blood loss (P < 0.0001). Preoperatively undetected VA resulted in a major risk of postoperative acute liver ischemia (P = 0.008). Celiacomesenteric aberrant anatomy was proven to be related to an increased risk of intraoperative complications. If undetected preoperatively, they can be associated with anastomotic complications and liver failure. Maximal efforts must be done to detect and to preserve vascular anatomy of celiacomesenteric district.

Retroperitoneal sarcomas are a rare group of malignant soft tissue tumors with a generally poor prognosis. However, factors affecting the recurrence and long-term survival are not well understood. The aim of this study was to assess clinical, pathological, and treatment-related factors affecting prognosis in patients with retroperitoneal sarcomas. The hospital records of 107 patients who underwent surgical exploration at our unit for primary or recurrent retroperitoneal sarcomas between 1984 and 2013 were reviewed. Of these patients, 92 had a primary tumor and 15 had a recurrent neoplasm. Study end points included factors affecting overall and recurrence-free survival for the 92 patients with primary disease. Mean follow-up was 79.7 ± 56.3 months. Only the patients undergoing surgery for primary sarcoma were included in this study. Overall 5-year survival was 71 per cent. Disease-free 5-year survival was 65 per cent. Only tumor grade affects overall and disease-free survival. This study confirmed the importance of an aggressive surgical management for retroperitoneal sarcomas to offer these patients the best chance of cure. In our series, only the tumor grade seems to be associated with worse outcome and higher rate of recurrence, regardless of the size of the tumor.

We investigated risk factors and prognostic implications of symptomatic anastomotic leakage after anterior resection for rectal cancer, and the influence of a diverting stoma. Our retrospective review of prospective collected data analyzed 475 patients who underwent anterior resection for rectal cancer. Uni- and multivariate analysis was made between anastomotic leakage and patient, tumor, and treatment variables, either for the overall group (n = 475) and in the midlow rectal cancer subgroup (n = 291). Overall rate of symptomatic leakage was 9 per cent (43 of 475) with no related postoperative mortality. At univariate analysis, significant factors for leak were a tumor less than 6 cm from the anal verge (13.7 vs 6.6%; P = 0.011) and intraoperative transfusions (16.9 vs 4.3%; P = 0.001). Similar results were observed in the midlow rectal cancer subgroup. At multivariate analysis, no parameter resulted in being an independent prognostic factor for risk of leakage. In patients with a leakage, a temporary enterostomy considerably reduced the need for reoperation (12.5 vs 77.8%; P < 0.0001) and the risk of a permanent stoma (18.7 vs 28.5%; P = 0.49). The incidence of anastomotic failure increases for lower tumors, whereas it is not influenced by radiotherapy. Defunctioning enterostomy does not influence the leak rate, but it mitigates clinical consequences.

Neoadjuvant chemoradiation (CRT), tailored mesorectal excision, and intraoperative radiotherapy (IORT) have become the leading measures for rectal cancer treatment. The objective of this study was to evaluate early and long-term results of a multimodal treatment model for rectal cancer followed by curative surgery. Prospectively collected hospital records of 338 patients surgically treated for rectal cancer between January 1998 and December 2008 were retrospectively reviewed. Patients with high rectum level cancers and those with middle and low rectum cancers with clinical stage T1 to T2 underwent surgery, whereas those with T3 to T4 and N+ disease at the middle and low rectum received neoadjuvant CRT in 96.2 per cent of cases. Short-course neoadjuvant radiotherapy was not considered for neoadjuvant treatment. Postoperative major complications and mortality rates were 12.7 and 2.3 per cent, respectively. Overall 5-year disease-specific and disease-free survival were 80 and 73.1 per cent, respectively, whereas local recurrence rate was 6.1 per cent. At multivariate analysis, nodal status and circumferential margin status were independently associated with poor survival; local recurrence rates were independently affected by nodal and marginal status and tumor stage. The extent of mesorectal excision should be tailored depending on tumor location and the use of neoadjuvant chemotherapy, combined with IORT in advanced middle and low rectal cancer, leading to remarkable tumor downstaging with excellent prognosis in responding patients.

The major determinants of the poor prognosis of the patients with proximal-third gastric cancer (proximal gastric cancer or PGC) when compared with that of patients with more distally located gastric tumors (distal gastric cancer or DGC) rely both on the more advanced age and tumor stage at the moment of clinical presentation and on the higher postoperative mortality for PGC patients. We reviewed hospital records of 707 patients with gastric cancer (187 with PGC and 520 with DGC) observed during the period 1981 through 1996 at the same surgical unit. Demographic and pathological data, type of treatment, and hospital morbidity and mortality rates were recorded. Univariate and multivariate survival analysis was used to calculate the 5-year survival probabilities with respect to the following clinical and pathological variables: age, sex, gross appearance according to Borrmann classification, histological type according to Lauren, stage of the disease, tumor location, and type of treatment. PGC was associated with more advanced tumor stage (P < 0.0001), older age (P = 0.039), and higher necessity of extended surgery (P < 0.0001) when compared with DGC. Hospital mortality was 9.6 and 5 per cent in PGC and DGC patients respectively (P = 0.033). Overall 5-year survival was 17.7 and 36.4 per cent in PGC and DGC patients (P < 0.0001): 35.9 versus 57.6% (P = 0.0001) and 3.7 versus 7.6 per cent (P = 0.03) after radical and palliative surgery respectively. At multivariate survival analysis proximal location was found to be independently associated (P = 0.0007) with poor survival. The multivariate model shows the proximal location as an independent predictor of lesser favorable outcome in gastric cancer. The major determinants of the poor prognosis of PGC with respect to DGC rely both on the more advanced age and tumor stage at the moment of clinical presentation and on the higher postoperative morbidity for PGC patients.

Few reports of the Western countries have investigated the value of palliative surgery for stomach cancer. The aim of this study was to evaluate the results of palliative surgery in a large series of patients affected by gastric carcinoma, consecutively treated by the same surgical team. The hospital records of 305 patients affected by gastric cancer who did not undergo surgical treatment or who underwent a palliative surgical procedure at our unit between 1981 and 1995 were reviewed. Univariate and multivariate analyses were used to calculate the 5-year survival probabilities with respect to the following variables: demographic data, tumor location and gross appearance, spread of the disease, histological type according to P. Lauren, and type of treatment. Multivariate logistic regression analysis showed that resectional surgery and tumor spread limited to local sites were independently associated with better survival. The study indicates that even though there are host-related factors that govern survival in far-advanced stomach cancer, the type of surgery can have a significant effect on prognosis; resectional surgery should be undertaken whenever possible in such patients.

To clarify the risk factors contributing to postoperative complications in elderly patients undergoing total gastrectomy, 84 patients with primary gastric cancer were evaluated. Twenty-seven patients were older than 65 years of age; they had much more preoperative cardiac (P = 0.00003), respiratory (P = 0.0008), and multiorgan impairment (P = 0.009) than did the control group (age less than 65 yrs). Although overall morbidities (44.4% vs. 19.2%; P = 0.01) and overall septic complication rates (33.3% vs. 12.2%; P = 0.02) were higher in aged patients, no significant differences between the two groups were found in the incidence of major surgical complications (18.5% in aged patients vs. 10.5% in control groups; P = NS), serious septic (sepsis score greater than 10) complications (18.5% vs. 7.0%; P = NS) and hospital mortalities (11.1% vs. 3.5%; P = NS). In older patients the occurrence of multiorgan impairment and malnutrition was significantly related to postoperative complication rates. These results suggest that the degree of organ impairment rather than age is predictive of postoperative difficulty and should be used in assessing preoperative risk.