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Postoperative infectious complications still represent a relevant problem in colorectal surgery. They always results in suffering for the patients and often prolonged hospitalization. Furthermore, they result in additional expenses to cover the cost of antibiotics, blood derivates, total parenteral nutrition, nursing and additional surgical procedures. Prevention and control of hospital infections start with surveillance, which is an important means to constantly evaluate the local bacterial epidemiology. An infection surveillance program finalized to minimize the incidence of postoperative infections through the respect of available techniques leads to a better quality of work in each surgical unit, to a decrease in postoperative hospital stay and to cost reduction.

Rectal cancer is one of the most common tumors worldwide; it accounts for approximately 25-30% of cancers arising in the large bowel. Owing to greater distribution of screening programs and better attention from both patients and General Practitioners to this disease, in recent years we have observed an increasing number of cases diagnosed in the early stages, with a consequent better prognosis. The improved 5-year survival is also partially due to better, and more accurate, diagnostic techniques and to more curative treatments. In this review, the authors analyze and discuss the more recent diagnostic techniques for an accurate preoperative staging of rectal cancer, highlighting each method's advantages and limits for their routine use in clinical practice.

We present a case of a 63-year-old woman with a recurrent secondary hyperparathyroidism hyperplasia with absolute contraindication for surgery, treated in 2 sessions with percutaneous ultrasonographically guided radiofrequency tissue ablation. The complete pathologic tissue ablation was confirmed by contrast-enhanced ultrasonography performed before and after the treatment and by clinical and laboratory follow-up. Furthermore in work progress, the percutaneous ultrasonographically guided radiofrequency tissue ablation can be considered a feasible and effective nonsurgical alternative treatment for symptomatic secondary hyperparathyroidism in high-risk patients.

Aim: Purpose of the study was to evaluate if the circumferential location of colorectal cancer may be identified as a possible prognostic factor. The hypothesis is that tumours located on the antimesenteric (AM) side could have a better prognosis than tumours located on the mesenteric (M) side. Methods: All patients undergoing curative resection for colorectal cancer were enrolled in the study. The specimens were sent to the pathologist to define the exact location of the tumour, the histological type, grading, T, N status as well as lymphatic, vascular and neural invasion, peritumoural lymphoid reaction, desmoplasia and microsatellite instability. Statistical analyses were performed using the test for proportions (with continuity correction), the Pearson Chi-square test and generalised linear models; p

Objective An alternative surgical technique for the repair an aneurysmatic arteriovenous fistula (AVF) using a staple remodeling operation has been developed and the results are reported. Methods All patients presenting with an aneurysmatic autogenous AVF of the upper extremities between January 2012 and December 2013 were included in the analysis. The AVF was approached laterally along the entire aneurysm and then remodeled using a stapler on the lateral side of the vein wall. All stenotic segments were excised. Follow-up included a clinical visit and echo color Doppler of the fistula and was performed 7, 15, and 30 days after the intervention and every 6 months thereafter. Results We treated 14 patients (nine men [64.3%]) with a median age of 65 years (interquartile range [IQR], 62.5-69 years). Elective interventions were performed in 12 patients (85.7%), and two underwent emergency treatment because of postcannulation bleeding. Technical success was achieved in all cases. The mean duration of the intervention was 75 minutes (IQR, 61.15-83.45 minutes). No in-hospital deaths or major morbidities were observed. Median hospitalization time was 24 hours (IQR, 25-38 hours). Postoperative puncture was performed after a median delay of 12.5 hours (IQR, 12-17 hours). No patient was lost during the follow-up, which was a median of 16.5 months (IQR, 14-23 months). Primary functional patency was 12 of 14 (85.7%). Pseudoaneurysm, bleeding, hematoma, or infection was not observed. Conclusions In our experience, the stapling technique proved to be easy, fast, and safe. Early follow-up outcomes showed excellent primary patency and confirmed the effectiveness of the technique because local complications were never observed.

At the present time, deceased heart-beating donor kidney allografts are usually stored cold. Extended-criteria donor (ECD) grafts show higher sensitivity to ischemia–reperfusion damage than standard kidneys. The increasing use of marginal organs in clinical transplantation urgently requires a more effective preservation system. Pulsatile hypothermic machine perfusion has shown major advantages over static cold storage in terms of reduced organ injury during preservation and improved early graft function. This preliminary study aims to compare pulsatile hypothermic machine perfusion and static cold storage of kidney allografts, outlining differences in the levels of early inflammatory cytokines (TNF-α, IL-2 and IL-1β) and soluble intracellular adhesion molecule (sICAM-1) in perfusion and preservation liquid.

Background and Purpose Aortoiliac (AI) lesions (both dilatative and occlusive) can occur in kidney allograft recipients. The correct timing of vascular imaging and treatment is controversial. Aim of the present paper is to report our experience. Methods between January 2010 and December 2012, 106 patients included in our waiting list for kidney transplant underwent computed tomography (CT) angiogram to study AI axis. In 21 cases an AI lesion was identified before transplant. In 3 cases surgery was mandatory before kidney transplant, and in 18 cases lesions were treated simultaneously with kidney transplantation. Main findings AI pathology distribution was as follows: 15 iliac stenoses treated with thromboendarterectomy (TEA), 2 Leriche syndrome and 1 aortic aneurism treated with an aortobisiliac bypass (AI-BP), and 3 aneurysms treated with endovascular aortic repair (EVAR). In two cases a postoperative hematoma occurred. In one case occlusion of a stent-graft branch was treated with a femoro-femoral crossover bypass and transplant was then performed on the contralateral iliac axis. Perioperative mortality was 0%, and graft survival rate was 100% at 1 year in all cases. Conclusions A CT angiogram is useful in order to detect AI lesions and to be able to evaluate the best treatment option for the kidney transplantation and the correct timing for additional vascular surgery. The EVAR procedure should be safe, and does not compromise anastomosis success and graft survival, with less postoperative complications than open surgery.

Purpose The purpose of this study is to report the short-term results of the Gore® Acuseal graft for prosthetic vascular access (pVA) in patients with end-stage renal disease on hemodialysis. Methods Between October 2011 and October 2013, all the consecutive patients who underwent implantation of a new expanded Polytetrafluoroethylene (ePTFE) tri-layer graft were included in the study. Primary and secondary patency rate, time to first cannulation, and complications were recorded. Follow-up was performed at 1, 3, 6, and 12 months after the intervention. Results Thirty ePTFE tri-layer heparin bonded grafts were implanted in 18 males and 12 females. The graft configuration was radial-basilic (n=12, 40%), brachial-basilic (n=10, 33.3%), femoro-femoral (n=3, 10.0%), radial-cephalic (n=2, 6.7%), radial-antecubital forearm (n=2, 6.7%), and brachial-axillary (n=1, 3.3%). No patient was lost during a mean follow-up time of 6.3±5.9 months (range, 1-24; median, 5). Mean time to first cannulation was 2.4±1.2 days (range, 1-15). Primary functional patency rate was 68.0% ± 10 at 6 and 12 months. Secondary patency rate was 93.3% ± 6 at 6 and 12 months. Pseudoaneurysm, bleeding, seroma, or graft infection was never observed. Conclusions In our experience, the Gore® Acuseal graft was useful and safe. Early cannulation was always performed, and structural complications did not occur. Primary functional and secondary patency rate are satisfactory in the short term.

The advent of combined antiretroviral therapy (cART) dramatically changed the view of human immunodeficiency virus (HIV) infection as an exclusion criterion for solid organ transplantation, resulting in worldwide reports of successful transplants in HIV-infected individuals. However, there are few reports on simultaneous pancreas-kidney transplant in HIV-positive recipients detailing poor outcomes. A series of four pancreas-kidney transplant performed on HIV-infected individuals between 2006 and 2009 is presented. All recipients reached stably undetectable HIV-RNA after transplantation. All patients experienced early posttransplant infections (median day 30, range 9-128) with urinary tract infections and bacteremia being most commonly observed. In all cases, surgical complications led to laparotomic revisions (median day 18, range 1-44); two patients underwent cholecystectomy. One steroid-responsive acute renal rejection (day 79) and one pancreatic graft failure (month 64) occurred. Frequent dose adjustments were required due to interference between cART and immunosuppressants. At a median follow-up of 45 months (range, 26-67) we observed 100% patient survival with CD4 cell count300 cells/mm(3) for all patients. Although limited by its small number, this case series represents the largest reported to date with encouraging long-term outcomes in HIV-positive pancreas-kidney transplant recipients.

Background Gastrointestinal stromal tumors are mesenchymal neoplasms of the gastrointestinal tract, arising from the muscular layer. Revent immunohistochemical studies have shown that up to 94% of GISTs express 117, and 60–70% of GISTs stain for CD 34. GISTs account for 1% of all malignant tumors of gastrointestinal tract; they arise from stomach in the 40–60% of cases whereas they account only for 3% of gastric malignant neoplasms. GISTs can occur at any age but onset most commonly in the sixth and the seventh decades of life.

Endovascular aortic aneurysm repair has emerged as an appealing alternative particularly for patients considered at "high risk" for open surgery. The aim of this study was to investigate the results of endovascular treatment in patients aged >80 years compared with younger patients.

Background Our Division of Surgery is a University Department. Residents perform in Day Surgery theatre room with tutors of proven experience. This study looks to explore ways in which senior tutors in Day Surgery can contribute to teach. Infact the School of postgraduate Surgery obliges postgraduate surgeons to carry out a number of minor and medium size operations. Methods This study was carried out in 2006. In this year were performed n.116 Inguinal Hernia repairs with method by Trabucco. Residents performed N.51 Inguinal Hernia repairs as first surgeons, assisted by a tutor with proven experience. Results All patients were discharged home on the day of their operations. The post-operative morbidity rate was the same of that encountered during surgery performed by experienced surgeons. Two recurrences were reported: one patient operated by a resident and one patient operated by an experienced colleague. Conclusions In Day Surgery it is not possible to do a teaching programme. The opportunity to see patients' pre-operatively and follow them through surgery discharge on the same day is unique. The residents can contribute to quality of Day Surgery and learn. Day Surgery Units could play an increased role in medical education.

The utility of antibiotic prophylaxis for colorectal surgery has been assessed and largely confirmed worldwide. There is homogeneous consensus that the antibiotic chosen for prophylaxis must cover both aerobic and anaerobic bacteria, that the toxicity should be minimal and it should be cost effective. Recent studies have questioned the role of preoperative bowel cleansing, which is considered by many surgeons as a widely established practice prior to elective colorectal procedures. New clinical trials are needed to resolve these key questions such as the efficacy of bowel preparation and how to obtain effective timing of antimicrobial prophylaxis.

Summary Since the first report in 1991 the laparoscopic resection of colon cancer is progressing slowly and just in the last 2–3 years is becoming more popular. The resistance to its use by some general and colo-rectal surgeons is receding. The explanations are that technology is evolving quickly and there is a worldwide diffusion of more sophisticated surgical instruments. Moreover several randomized trials have been published showing that the outcomes of laparoscopic colon surgery are similar or better than those of conventional surgery and the early reports suggesting the tumour dissemination were not confirmed. The revolution in oncological surgery that we are observing in these last decades with the introduction and diffusion of mini-invasive approach is comparable to that regarding conventional surgery during the period of Halsted. Therefore the principles of surgery accepted during the years must not be forgotten.

Because major complications are rare in day surgery, minor morbidities such as surgical site infections, which become evident only after patient discharge, have a major impact on the perceived quality of care. We performed an audit of such infections over a oneyear period.All procedures were performed in a multidisciplinary day surgery setting. There were 155 inguinal hernia repairs, 44 excisions of lipomas, and 27 excisions of pilonidal cysts. All patients received antibiotic prophylaxis according to a rotation protocol.One patient (0.65%) operated on for inguinal hernia developed a deep incisional infection caused by Staphylococcus schleiferi. The patient was treated using selective antibiotics, and complete recovery ensued. One patient (2.27%) who underwent excision of a lipoma revealed developed a deep incisional infection associated with fever (39 degrees C) caused by Staphylococcus aureus. He was treated by daily antibiotics and application of dressings for two weeks and recovered. One patient (3.7%) treated for pilonidal cyst developed a deep incisional surgical site infection. A group A Streptococcus was isolated, and he received an intravenous antibiotic for ten days. In the seven patients treated for pilonidal cyst with the wound left open, swab specimens were taken because of persisting local pain, and the following bacteria were found: Pseudomonas aeruginosa, Escherichia coli, Staphylococcus epidermidis, Proteus vulgaris, and Streptococcus constellatus. No antibiotic therapy was given, and local wound care led to complete recovery.In our day surgery unit, the rates of surgical site infection are similar to those described in the literature. Continuing audit is essential to maintain and improve the quality and standard of the surgery provided. Prevention of surgical site infection is very much the responsibility of the persons working in the operating theater. Therefore, it is vital not only to apply strict regulations concerning everyday management but also to maintain a high degree of motivation among the personnel.

Background After the availability of the results of validation studies, the sentinel lymph node biopsy (SLNB) has replaced routine axillary dissection (AD) as the new standard of care in early unifocal breast cancers. Multifocal (MF) and multicentric (MC) tumors have been considered a contraindication for this technique due to the possible incidence of a higher false-negative rate. This prospective study evaluates the lymphatic drainage from different tumoral foci of the breast and assesses the accuracy of SLNB in MF-MC breast cancer. Patients and methods Patients with preoperative diagnosis of MF or MC infiltrating and clinically node-negative (cN0) breast carcinoma were enrolled in this study. Two consecutive groups of patients underwent SLN mapping using a different site of injection of the radioisotope tracer: a) "2ID" Group received two intradermal (ID) injections over the site of the two dominant neoplastic nodules. A lymphoscintigraphic study was performed after each injection to evaluate the route of lymphatic spreading from different sites of the breast. b) "A" Group had periareolar (A) injection followed by a conventional lymphoscintigraphy. At surgery, both radioguided SLNB (with frozen section exam) and subsequent AD were planned, regardless the SLN status. Results A total 31 patients with MF (n = 12) or MC (n = 19) invasive, cN0 cancer of the breast fulfil the selection criteria. In 2 ID Group (n = 15) the lymphoscintigraphic study showed the lymphatic pathways from two different sites of the breast which converged into one major lymphatic trunk affering to the same SLN(s) in 14 (93.3%) cases. In one (6.7%) MC cancer two different pathways were found, each of them affering to a different SLN. In A Group (n = 16) lymphoscintigraphy showed one (93.7%) or two (6.3%) lymphatic channels, each connecting areola with one or more SLN(s). Identification rate of SLN was 100% in both Groups. Accuracy of frozen section exam on SLN was 96.8% (1 case of micrometastasis was missed). SLN was positive in 13 (41.9%) of 31 patients, including 4 cases (30.7%) of micrometastasis. In 7 of 13 (53.8%) patients the SLN was the only site of axillary metastasis. SLNB accuracy was 96.8% (30 of 31), sensitivity 92.8 (13 of 14), and false-negative rate 7.1% (1 of 14). Since the case of skip metastasis was identified by the surgeon intraoperatively, it would have been no impact in the clinical practice. Conclusion Our lymphoscintigraphic study shows that axillary SLN represents the whole breast regardless of tumor location within the parenchyma. The high accuracy of SLNB in MF and MC breast cancer demonstrates, according with the results of other series published in the literature, that both MF and MC tumors do not represent a contraindication for SLNB anymore.

Background Bowel reconstruction after subtotal esophagectomy represents a problem when a previous distal gastrectomy was performed: usually the colon or jejunum is used. Methods In a 10 year period 126 patients with primary esophageal cancer underwent esophageal resection in our Department. Surgical procedures were 57% two-phase subtotal oesophagectomy, 23% transhiatal, 9% stripping, 10 three-phase total esophagectomy and 2 endoscopic resections. Results In 112 patients alimentary tract reconstruction was achieved by means of esophago-gastric anastomosis. Reconstruction was performed using colon in 10 cases and jejunum in 2. We describe the technical aspects of esophagectomy and gastric reconstruction in a patient with previous antrectomy and Billroth II reconstruction. The procedure was performed via a combined laparotomy and thoracotomy with anastomosis at the level of the azygous vein using the remnant stomach. Conclusion Few technical reports have been reported in literature about the use of remnant stomach in reconstruction for subtotal esophagectomy subsequent to distal gastrectomy. Several hypotheses are made to explain the maintenance of the gastric vascular integrity as its intramural network without micro-vascular anastomosis.

Background Perioperative blood transfusion carries numerous potential risks concerning the transmission of infective diseases and immunodepression that can facilitate the occurrence of postoperative infectious complications. Explanation of connections between perioperative blood transfusion and postoperative septic complication worldwide is not well documented. Many studies have described a correlation between perioperative blood transfusions and postoperative infections. On the contrary, other studies indicate that factors influencing the need for blood transfusions during surgery have a greater bearing than blood transfusion per se on the occurrence of postoperative complications. Patients and methods A prospective study was conducted in our Department on 110 consecutive patients undergoing oesophageal resection for primary cancer, in order to evaluate the incidence of postoperative infections related to perioperative allogenic blood transfusions. For each patient we preoperatively recorded in a computerized data-base several known risk-factors for postoperative infections; in detail we registered the administration of allogenic perioperative blood transfusions (period of administration, number of packages administered). Results Among the enrolled 110 patients, 53 (48%) received perioperative blood transfusions: in this group postoperative infections (overall infective complications) occurred in 27 patients. After a multivariate analysis we observed that perioperative blood transfusions significantly affected as an independent variable the development of wound infections (p = 0.02). Conclusion Blood transfusions independently affected the incidence of wound infections in patients who underwent oesophageal resection for primary cancer.

Nosocomial infections are the most frequent complications of surgical patients. Most surgical site infections (SSI) are acquired intraoperatively and arise from the flora of the patient's skin, gastrointestinal tract, or mucous membranes. Although preoperative mechanical cleansing of the bowel is considered by many surgeons a cornerstone of modern elective colorectal surgery and, in association with antibiotic prophylaxis, a fundamental component of an intestinal antisepsis program, many surgeons do not perform preoperative mechanical preparation routinely.Review of the pertinent literature.Some recent randomized trials and a Cochrane review found no proof that mechanical bowel preparation reduces the risk of complications after elective colorectal surgery. Indeed, there is some evidence that this intervention is associated with a higher rate of anastomotic leakage and wound complications.The dogma that mechanical bowel preparation is necessary before elective colorectal surgery may need to be reconsidered. On the other hand, such preparation decreases operating time by improving bowel handling during construction of the anastomosis. Moreover, it is helpful when intestinal palpation will be necessary for identification of a lesion.

From 1999 to 2003, 101 patients (M/F = 83/18, mean age = 46 +/- 18 y) with thoracic trauma have been admitted to the Center for Thoracic Surgery in Varese. Over 50% of pts. with major thoracic trauma were treated by chest tube drainage; however, surgery was necessary just in 16/101 pts.; 29 pts. were admitted to ICU; deaths were 3/101. The Authors recorded 23/101 sternal fractures. Routine blood test, chest radiography and EKG were performed in all patients; in case of abnormal EKG, echocardiography was performed; in case of widened mediastinum, chest CT was mandatory. 13/23 pts. showed associated injuries, 12 pts. a non-aligned sternal fracture, 7 pts. mediastinal hematoma. Simple observation in hospital was indicated in 15/23 pts. with sternal fractures; chest tubes were positioned in 3 pts. (hemopneumothorax) and one patient was surgically treated because of painful sternal pseudoarthrosis (2 months after trauma). Admission in ICU was necessary in 3 pts. with non-aligned sternal fracture, mediastinal hematoma and associated injuries. No patient with sternal fracture died.

The history of thyroid surgery starts with Billroth, Kocher and Halsted, who developed the technique for thyroidectomy between 1873 and 1910. In general, the essential objectives for thyroidectomy are conservation of the parathyroid glands, avoidance of injury to the recurrent laryngeal nerve, an accurate hemostasis and an excellent cosmesis. In the last 20 years, major improvements and new technologies have been proposed and applied in thyroid surgery; among these are mini-invasive thyroidectomy, new devices for achieving hemostasis and dissection, regional anesthesia and intraoperative neuro-monitoring.

Nosocomial infections are the most frequent complications observed in surgical patients. In colorectal surgery, the opening of the viscera causes the dissemination into the operative field of microorganisms originating from endogenous sources, increasing the chance of developing postoperative complications. It is reported that without antibiotic prophylaxis, wound infection after colorectal surgery develops in approximately 40% of patients. This percentage decreases to approximately 11% after antibiotic prophylaxis. Specific criteria in the choice of correct antibiotic prophylaxis have to be respected, on the basis of the microorganisms usually found in the surgical site, and on the specific hospital microbiologic epidemiology.

Sixteen patients with severe bacteriologically proven infected pancreatic necrosis (IPN) undergoing sequential surgical treatment were studied in prospective. The severity of IPN was documented prior to operation with the following scores: 1) degree of necrosis by CT scan [ 50% in four patients (25%)]; 2) Elebute and Stoner s sepsis score (16±4 points); 3) Goris’score of multiple organ failure (MOF) (5±2 points).

Nosocomial infections are the most frequent complications observed in surgical patients. In recent years reductions of post-operative infections have been mostly due to a correct use of prophylactic measures such as pre-operative selective bowel decontamination, adequate antibiotic prophylaxis, and better anaesthetic and intensive care management.

Gut endocrine tumors are sometimes difficult to localize by radiological techniques. Carcinoids and gastrinomas, however, possess high density of somatostatin receptors, thus, scintigraphy with radiolabeled somatostatin analogs may prove useful for detection of occult gastro-enteropancreatic endocrine tumors when conventional diagnostic methods fail. A novel method of radioguided surgery with a hand-held gamma-detecting probe (GDP) has been used to localize gut endocrine tumors by binding radiolabeled somatostatin analogs. We also applied the method in a patient with occult carcinoid: after injecting 125-Iodine (125I)-octreotide intraoperatively, we obtained accurate localization of the jejunal carcinoid and of a liver metastasis previously undetected. Seventeen cases of gut endocrine tumors detected by this technique that have been reported in the literature are reviewed and discussed. Intraoperative localization of gastrointestinal endocrine tumors with radiolabeled somatostatin analogs and a GDP expands the possibility of accurate tumor detection one step beyond that obtained by conventional imaging and by intraoperative inspection and palpation.

The previously unreported ultrasonographic (US) features of liver metastases of pancreatic glucagonoma and of pancreatic acinar cell carcinoma are described. They present as complex masses with hyperechoic solid component, containing echo-free cystic areas; these sonographic features markedly differ from the echo-poor US pattern of the much more common metastases of pancreatic ductal carcinoma. Survival from diagnosis of liver metastases was 45 months in the patient with pancreatic glucagonoma and 23 months in the patient with acinar cell carcinoma. These survivals were much longer than the expected survival of patients with pancreatic ductal carcinoma metastatic to the liver. The US finding of highly reflective lesions in the liver, containing echo-free cystic areas, should alert one that the primary pancreatic tumor has a histotype different from ductal carcinoma. Such US findings could affect the decision to resect the pancreatic tumor and its liver metastases, if histology confirms a malignancy less aggressive than ductal carcinoma.

Materials and methods Consecutive 87 patients who had laparoscopic resection of right colon, left colon, sigma and/or supraperitoneal rectum for colorectal carcinoma or adenoma with medium/severe dysplasia from June 2005 to August 2008 were included. Two age-matched cohorts of patients were compared: 45 patients (group 1) of 65 years or older and 42 patients younger than 65. All of the patients underwent preoperative exams, colonoscopy with multiple biopsy and CT-scan, and all data concerning demographics, disease, details of operations and postoperative events were collected prospectively.

Background The need to ensure complete medical and surgical assistance and the ever increasing challenge of containing costs in health care have found the perfect combination in day surgery. The aim of this study is to analyse date from the surgical Division I in a multidisciplinary day surgery. The activity has been assessed in terms of volume and above all quality of the procedures. •Data collection of complication •Data collection for infections •Quality rating questionnaire •Follow up •Information leaflet for day surgery •Meetings with nursing staff. Methods The study was carried out by comparing data from the period 2003–2006. The activity of general surgery includes: general, breast, plastic and vascular. From 2003 to 2006 day surgery activity increased considerably, partly due to good organization and partly because it has been favourably received by the population. Results During the period 2003–2006, 1835 operations were carried out in day surgery. The percentage of operations in D. S. compared to the total activity of Surgery Division I, demonstrates a gradual increase from 18.7 to 32%. In the last few years, some changes have been introduced in day surgery: Conclusions From the study carried out we can affirm that the present organization of our day surgery, manages to maintain a high standard of care and a low incidence of complications with statistical data similar to those described in literature.