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Anastomotic leakage represents a devastating post-surgical event with surgeon- and patient-related causes. The early lag phase of healing (day 0–4) is a time of increased vulnerability. The current role of tissue sealants as anastomotic adjuncts remains unclear, with controversial results reported. Platelet-rich plasma provides a reliable source of growth factors supporting wound healing. We aimed to assess the impact of a novel autologous platelet-rich fibrin (PRF) agent (Obsidian-ASG® matrix; GergMed Medizintechnik, Baiern, Germany) on colonic anastomotic healing in a porcine model. Left-sided colonic anastomoses were constructed in 16 pigs with reinforcement using the Obsidian-ASG® matrix in 12 animals. Animals were sacrificed on days 0, 4, 10 and 30, with histologic assessment of the anastomotic line along with evaluation of fibrotic tissue maturation, foreign body reactivity and mucin production. Collagen maturity and immunohistochemical changes of angiogenesis and infiltrating macrophage profiles were determined as well. There was no observable effect in matrix-treated animals on epithelial line thickness, granulation tissue formation, foreign body reactivity or mucosal restitution. Matrix-treated animals showed higher mucin production on day 4 accompanied by a more mature collagen and a greater degree of early angiogenic response with a higher infiltration density of M2 macrophages. Additionally, anastomotic burst pressure in matrix-treated animals was higher on day 0, 4, 10 and 30 (100, 100, 210, 160 vs. 40, 30, 60, 20 mm Hg, respectively). Obsidian-ASG® matrix may have beneficial effects on anastomotic healing by shifting the inflammatory response towards a mature and more stable collagen phenotype in the early phase.

To analyze treatment and survival in a series of resected patients with primary or recurrent retroperitoneal sarcoma (RPS) treated and prospectively followed at a single institution. Between July 1994 and December 2015, 89 patients (36 M, 53 F; mean age 60 years, range 25–79) were evaluated. For the purpose of analysis, complete resection was defined as removal of gross tumor with histologically confirmed clear resection margins. Eighty-three out of the 89 patients (93%), 46 of whom affected by primary RPS, and 37 by recurrent RPS, underwent surgical exploration. Sixty-two had a grossly and microscopically complete resection. Fifty-three out of 83 patients (64%) underwent removal of contiguous intra-abdominal organs. Preoperative mortality was nil and significant preoperative complications occurred in six cases only (7%). High-grade tumor pointed out to be a significant variable for a worse survival in all 83 patients amenable to undergo surgical resection (57% 5 years survival for low grade vs 14% for high grade; P = 0.0004). Among completely resected patients, only histologic grade clearly affected disease-free survival (72% 5 years survival for low grade vs 50% for high grade; P = 0.04), while the role of preoperative blood transfusions (67% 5 years survival for non-transfused patients vs 29% for transfused patients; P = 0.05) has to be evaluated in connection to patient complexity. Histological grade and recurrence are the most valuable prognostic predictors; in this clinical subset, an aggressive surgical approach in both primary and recurrent RPS is associated with a best long-term survival and disease-free survival.

The aim of this paper is to evaluate our Unit's initial experience using the Intact breast lesion excision system as a therapeutic excision option for benign or borderline breast lesions, which otherwise would entail open operative excision. The study includes the first 111 patients who underwent therapeutic excision with the intact radiofrequency system between December 2012 and May 2016 performed at the Meirav Center for Breast Health, at the Chaim Sheba Medical Center, Ramat Gan Israel. The indications for the procedure included those patients who have benign, or atypical high risk lesions following a previous core needle biospy (CNB) who would have normally undergone conventional excision biopsy. After reviewing each case separately, we found that the use of the BLES system as a treatment device permitted the avoidance of operations that would have been otherwise indicated, in 98 cases of the total 111 in the cohort (88.3%). Thirteen cases eventually had to undergo surgical excision. In eight cases pathology was upgraded from the initial CNB to invasive or noninvasive carcinoma. Although the INTACT sysytem is most commonly used as an alternative biopsy technique for its diagnostic capabilities, this study assessed its clinical role as a definitive therapeutic excisional modality in selected cases of benign breast disease. It proved valuable in the majority of cases with avoidance of surgery where it was traditionally indicated, (98/111, 88.3%) and as definitive fibroadenoma management in a further 28 patients.

Summary Aim Hartmann's procedure is the surgical treatment of choice for perforated acute diverticulitis. Hartmann's reversal (HR) that is performed at a later stage may be challenging. The optimal timing for HR is still a subject for controversy. The aim of this study is to assess whether the timing of HR affects surgical outcome. Patients and methods A retrospective-cohort multi-center study was conducted, including all patients who underwent HR for acute diverticulitis from January 2004 to June 2015 in 5 medical centers. Patient data included demographics, surgical data and post-operative outcome. Results One hundred and twenty-two patients were included in the database. Median time from Hartmann's procedure to reversal was 182.7 days, with the majority of patients (76 patients, 62.2%) operated 60 to 180 days from the Hartmann's procedure. Fifty-seven patients (46.7%) had post-operative complications, most commonly wound infections (27 patients, 22.1%). Receiver operating characteristic (ROC) curve and a propensity score match analysis (P = 0.43) correlating between days to HR from the index procedure showed no specific cut-off point regarding post-operative complications (P = 0.16), Major (Clavien–Dindo score of 3 or more) complications (P = 0.19), Minor (Clavien Dindo 1-2) and no complications (P = 0.14). Median length of stay was 10.9 days (range 3-90) and Pearson correlation failed to demonstrate a correlation between timing of surgical intervention and length of stay (P = 0.4). Conclusion Hartmann's Reversal is a complex surgical procedure associated with high rates of complications. In our series, timing of surgery did not affect surgical complications rate or severity or the length of hospital stay.

The management of diverticular disease has evolved in the last few decades from a structured therapeutic approach including operative management in almost all cases to a variety of medical and surgical approaches leading to a more individualized strategy. There is an ongoing debate among surgeons about the surgical management of diverticular disease, questioning not only the surgical procedure of choice, but also about who should be operated and the timing of surgery, both in complicated and uncomplicated diverticular disease. This article reviews the current treatment of diverticulitis, with a focus on the indications and methods of surgery in both the emergency and elective settings. Further investigation with good clinical data is needed for the establishment of clear guidelines.

This chapter provides a general overview of considerations when economic analyses are reported for the management of patients with rectal cancer. Although we have included an assessment of selected European, Australasian and North American variations in reported series as they pertain to rectal cancer for the use of radiotherapy, adjuvant-neoadjuvant chemotherapy and multimodality therapy, we describe more the pitfalls in the interpretation of comparative economic data assessing rectal cancer care.

In this section I offer a personal view on what the surgeon should consider concerning data from radiotherapy (RT) trials in rectal cancer and particularly on the chronological development and meaning of the important Swedish RT data. Professor Pahlman’s chapter was the first chapter delivered to our editors for this book on 20th March 2014 even when it was still a germinating idea. Lars Pahlman subsequently died from metastatic cancer at his Uppsala home on 21st November 2015. We have deliberately kept the chapter unmodified to provide some insight not only into his thinking concerning rectal cancer management but also to highlight his impressions back in 2014 of where the future might take rectal cancer care. It is not surprising that Lars was prophetic in his interpretation of the potential place of the “watch and wait” treatment initiated by Professor Angelita Habr-Gama. Improvements in radiation scheduling and chemotherapy combinations as well as in the imaging and the pathologic interpretation of tumour responsiveness are securing an expanded role for this approach in our patients with the deliberate presentation of both an Australasian and a North American perspective in this section and elsewhere in this book.

There is debate concerning the need for specialist neurosurgical transfer of patients presenting to Level II trauma centers with a minimal head injury (Glasgow Coma Scale ≥13) and a small non-progressive intracranial bleeding (ICB). A retrospective chart analysis was performed assessing the outcomes of adult patients presenting with a minor traumatic ICB on initial CT scan (minimal subarachnoid hemorrhage; small-width subdural hematoma without shift; punctate cerebral contusion). Patients with extradural hematomas and those patients on antiplatelet or anticoagulant therapy were excluded from the protocol. Overall 291 cases were assessed (mean age 69.9 years) with 75% of cases presenting after a fall. There was deterioration of neurological status in 11 patients (3.8%) with 8 hospital transfers and 5 with an abnormal neurological examination (NE). Two patients with an abnormal INR and a worsening head CT were transferred without neurosurgical intervention. Of the 8 transferred cases there were 2 deaths (both >90 years of age with multiple comorbidities) with one craniotomy performed for a subdural hematoma (with full recovery). Three patients meeting transfer criteria were not transferred with one death (patient >90 years of age with severe dementia). The remaining 2 patients were discharged with normal neurological outcomes. Patients with a minimal traumatic brain injury and a non-progressive minor ICB may be safely managed in a Level II trauma center by an acute care consultant with neurosurgical consultation but without the need for neurosurgical transfer. Retrospective analysis: Level IV.

The increasing range of surgery in elderly patients reflects the changing demography where in the next 10 years one quarter of the population will be 65 years of age or older. There is presently no consensus concerning the optimal predictive markers for postoperative morbidity and mortality after surgery in older patients with an appreciation that physical frailty is more important than chronological age. In this retrospective analysis, we have compared the impact of age and the calculated preoperative Charlson Comorbidity Index (CCI) on early (30-day) and late (one-year) mortality in a group of patients >75 years of age dividing them into an “older old” cohort (75–84 years of age, Group A) and an “oldest old” group (≥85 years of age, Group B). Increased age was associated with a higher death rate after emergency surgery, with late deaths after elective surgery exceeding those after emergency operations. A higher mean CCI was noted in both age groups in early nonsurvivors after both elective and emergency surgery with a more significant effect of the preoperative CCI than chronological age for the prediction of late postoperative death for both groups after elective and emergency operations. Although the CCI was not designed to predict perioperative mortality in surgical cohorts, it correlates with a greater risk than age for perioperative death in the elderly.

Background: Although there is no consensus concerning the definition of the ?hostile? pelvis, variant colo-anal pull-through procedures may be used for salvage surgery. This paper reports a single surgeon experience of these operations providing technical caveats for their use. Methods: Retrospective single surgeon analysis of cases between 1993 and 2015 Results: The main techniques included Soave and Duhamel reconstructions for an eclectic range of colorectal conditions including post-obstetric rectovaginal fistulae, the management of anastomotic leakage after low anterior resection and neoadjuvant chemoradiation, rectoprostatic fistulae, extralevator anorectal fistulae and intractable Crohn?s proctitis. The complication rate was 31.8% with 86.4% avoiding a permanent stoma. Fifty percent of patients reported normal continence during a median follow-up of 29 months. Conclusion: Modifications of the colo-anal pull-through procedure are successful as salvage for a range of chronic colorectal conditions. A randomized trial is required to determine the place for a staged delayed anastomosis.

Aim Epidemiological studies have shown that the incidence and mortality rates of colorectal cancer (CRC) vary over 10-fold worldwide where within Westernized societies lower rates are observed amongst populations living within the Mediterranean basin, suggesting a significant influence of environment and dietary style in CRC carcinogenesis. Interpretation of the data concerning the benefits of mediterranean (MD) diet is difficult in vivo because of the variability of alimentary regimens used, the differing compliance with dietary supplementation and because of the non-uniform duration of patient cohort observation. Therefore, the aim of this review is to evaluate the in-vitro effects on colorectal cancer cell lines. Methods the literature concerning the in-vitro effects of 4 of the principal components symbolizing the MD such as olive oil (polyphenol), red chili (capsaicin), tomato (lycopene) and red grapes (resveratrol) have been systematically reviewed. Results Several studies have demonstrated that polyphenols form olive oil, lycopene, resveratrol and capsaicin have multiple anticancer properties affecting several metabolic pathways involved in cancerogenesis, apoptosis, and metastasis in CRC cell lines. Conclusion This review summarizes some of the most recent data potentially supportive of the use of MD in CRC chemoprevention, analyzing the in vitro effects of individual components of the MD on CRC cell development, progression, metastasis and apoptosis.

Purpose We present our use of magnetic resonance (MR) measurement to determine the amount of residual breast tissue (RBT) following total mastectomy with reconstruction. Methods Breast MR images of 45 women who underwent surgery between January and November 2011 were reviewed. The cohort included therapeutic and prophylactic mastectomies. RBT was evaluated at four points with a digital caliper assessing T2-weighted and T1-weighted images. Results Patients undergoing mastectomy for carcinoma tended to have less RBT than in prophylactic surgery. Greater age and recent surgery both correlated with larger RBT. Conclusions Variable thickness of RBT is demonstrable following mastectomy and implant reconstruction using MR imaging.

Background Cholecystectomy is the standard of care in acute cholecystitis (AC). Percutaneous cholecystostomy (PC) is an effective alternative for high-risk surgical cases. Methods A retrospective analysis is presented of AC patients treated with PC drainage at a single tertiary institution over a 21 month period, assessing outcome and complications. Results Of 119 patients, 103 had clinical improvement after PC insertion. There were 7 peri-procedural deaths (5.9%), all in elderly high-risk cases. Overall, 56/103 cases (54%) were definitively managed with PC drainage with 41 patients (40%) undergoing an elective cholecystectomy (75% performed laparoscopically). The timing of PC insertion did not affect AC resolution or drain-related complications, although more patients underwent an elective cholecystectomy if PC placement was delayed (>24 h after admission). Conclusions In AC, drainage by a PC catheter is a safe and effective procedure. It may be used either as a bridge to elective cholecystectomy or in selected cases as definitive therapy.

The present study determines the oncologic outcome of the combined resection and ablation strategy for colorectal liver metastases (CRLM). Between January 1994 and December 2014, 360 patients underwent surgery for CRLM. There were 280 patients who underwent hepatic resection only (group 1) and 80 hepatic resection plus ablation (group 2). group 2 patients had a higher incidence of multiple metastases than group 1 cases (100% in group 2 vs. 28.2% in group 1; P

S S269 Poster abstracts for the BASO w The Association for Cancer Surgery and the RSM e Section of Surgery Scientific Conference e 2 and 3 November 2015 P1. Surgery for locally recurrent rectal cancer AntonioChiappa, EmilioBertani, AndrewZbar,MarcoVenturino, Marco Tulli, Mariagiulia Zampino, Carlo Ferrari, Roberto Biffi 1 University of Milan, Milan, Lombardy, Italy 2 European Institute of Oncology e Unit of Surgical Innovative Techniques, Milan, Lombardy, Italy 3 European Institute of Oncology e Division of Epatobiliary Surgery, Milan, Lombardy, Italy 4 Sheba Medical Center, Tel Aviv, Israel 5 European Institute of Oncology e Intensive Care Unit, Milan, Lombardy, Italy 6 European Institute of Oncology e Division of Medical Oncology, Milan, Lombardy, Italy 7 European Institute of Oncology e Division of Abdomino-Pelvic Surgery, Milan, Lombardy, Italy Background: Local recurrence still remains a major problem after radical resection of rectum for cancer with TME. At the same time the poor evidence due to lack of randomized trials enrolling patients with local recurrence has led to a wide spectrum of treatments for such patients, who are often managed in multidisciplinary framework programs. Methods: Between January 2004 and July 2014, 577 patients were treated with TME for rectal cancer (within 12 cm of the anal verge). All these patients underwent a strict follow-up program comprising instrumental and clinical controls every 6 months for at least 5 years. With a median follow-up of 50 mouths (range 9e120 months), 56 local recurrences were diagnosed. In all but 8 patients recurrence was asymptomatic. The local recurrence rates registered were 7%, 9% and 10% respectively at 2, 3 and 5 years. Seven patients (12.5%) with distant recurrence at the same time were excluded from the following, analysis, for a total of 49 patients examined with local recurrence only. Results: Among the remaining 49 patients, 30(61%) underwent surgery comprising Miles operation in 14 cases (29%), Hartmann procedure in 7(14%), repeated low anterior resection with colo-anal anastomosis in other 3 cases(6%) and palliative colostomy or other palliative procedure in 6 cases (12. Eight patients (16%) were excluded from surgery and underwent some form of CT or associated RT-CT, whilst 11 patients (23%) were addressed to palliative treatment. Overall survival (OS) rates were 48%, 29% and 22% respectively at 2, 3 and 5 years. On univariate analysis, resection of recurrent diseasewas the only significant factor associatedwith prognosiswith a 5 years OSof30%vs22%for resectedandnon-resectedcases respectively (p1⁄4 0.04). Conclusions: Despite early diagnosis due to an intensive follow-up program after TME for rectal cancer, only a half of patients are amenable for re-resection. Surgical resection still remains the mainstay of treatment for locally recurrent rectal cancer. http://dx.doi.org/10.1016/j.ejso.2015.08.106 P2. Gelatinase expression in colorectal cancer pathology and survival Liz Baker, Norma Robinson, Mohamed Tabaqchali, David Leaper 1 University Hospital of North Tees, Stockton on Tees, UK University of Huddersfield, Huddersfield, UK Introduction:Matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs) are responsible for tissue breakdown and remodelling in both normal and pathological processes, including tumour invasion andmetastasis. The most extensively studied MMPs in cancer are the gelatinases (MMP-2 andMMP-9). This study determined gelatinase tissue expression in colorectal cancer and correlated this with tumour pathology and 10 year survival status. Methods: Paired tumour and normal mucosal tissue from 101 colorectal cancer patients were analysed by ELISAs (ng/mg protein) and gelatin zymography for MMP-2 and MMP-9 expression. TIMP-1 and TIMP-2 expression were also determined by ELISA. Tissue levels were then correlated with tumour pathology (P< 0.05, Spearman’s correlation) and ten year survival analysis was performed (p< 0.05 Kaplan Meier). The study had ethics approval. Results: Latent and active gelatinases and TIMP-1 levels were all significantly greater in colorectal tumour tissue samples than normal tissue e.g. total MMP-9 levels (median (range)); tumour, 17.4(0.3e217.3) and normal, 2.8(0.2e35.3)ng/mg protein. Tumour levels of some gelatinase forms correlated with the tumour pathology including Dukes’ stage and lymphatic invasion. The proportion of active MMP-2 and MMP-9 in tumour tissue significantly correlated with disease free and overall survival, with higher tissue levels associated with poorer survival. Conclusions: Gelatinase expression is up-regulated in colorectal tumour tissue compared to normal mucosa. Gelatinase levels correlated with both tumour pathology and with disease-free and overall ten year survival in patients with colorectal cancer. http://dx.doi.org/10.1016/j.ejso.2015.08.107 P3. Mammaglobin-A, VEGFR3 and Ki67 in human breast cancer pathology and 5-year survival Liz Baker, NaomiWhiteoak, DeborahWilson, LouiseHall, PudBhaskar University Hospital of North Tees, Stockton on Tees, UK Introduction: Human mammaglobin-A is specifically expressed in breast tissue, over-expressed in some breast cancers and has been associated with less aggressive phenotypes. Vascular endothelial growth factor receptor 3 (VEGFR3) is a marker for angiogenesis and lymph-angiogenesis, and Ki67 is a marker for cell proliferation. It is currently unknown how mammaglobin-A relates to these markers of tumour growth and or disease free survival. Methods: A total of 80 patients who have undergone breast surgery for either breast cancer or benign disease were randomly selected after stratification for tumour grade. Tissue sections were analysed by immunohistochemistry for mammaglobin-A, VEGFR3 and Ki67 expression. Expression was compared with tumour histopathology including receptor status (where available) and five year survival analysis was performed (Chisquared). The study had ethics approval. Results: There was no association found between either, VEGFR3 and mammaglobin (P1⁄4 0.925) or Ki67 and mammaglobin expression (P1⁄4 0.768) however there was a significant association between Ki67 and VEGFR3 (P1⁄4 0.037). Significant associations were also found between Ki67 and tumour grade (P< 0.001), Ki67 and metastasis (P1⁄4 0.045), and between VEGFR3 and tumour grade (P1⁄4 0.002). No