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Resumen Introduccion El objetivo de este estudio es presentar nuestra serie de pacientes con carcinoma pulmonar y metastasis unica suprarrenal sincronica tratados de manera secuencial inversa: primero adrenalectomia y despues reseccion pulmonar. Metodos Del total de 108 adrenalectomias laparoscopicas transperitoneales realizadas se analiza de manera retrospectiva una serie consecutiva de 10 pacientes diagnosticados de tumor primario de pulmon con metastasis suprarrenal sincronica tratados de manera secuencial inversa. A todos se les realizo mediastinoscopia de estadificacion; aquellos con metastasis ganglionares recibieron induccion. Las variables analizadas fueron: morbilidad tras adrenalectomia y tras reseccion pulmonar, estancia hospitalaria, tiempo entre ambas intervenciones, intervalo libre de enfermedad y supervivencia global. La supervivencia se analizo segun el metodo de Kaplan-Meier. Resultados Edad media: 56,8 anos (rango: 41-73). Del total, 8 casos se intervinieron por laparoscopia. Tamano medio de la metastasis: 5,9 cm (rango: 3-10). Tiempo medio entre ambas intervenciones: 28 dias (rango: 12-35). No hubo complicaciones tras la adrenalectomia. Estancia media: 4,3 dias (rango: 3-5). La supervivencia libre de enfermedad a los 2 anos fue del 50% y la supervivencia global a los 5 anos fue del 30%, con una supervivencia global mediana de 41,5 meses (rango: 0-98). Conclusiones La adrenalectomia para metastasis de carcinoma pulmonar tiene baja morbilidad, no retrasa la reseccion del tumor primario y permite realizar la reseccion pulmonar una vez asegurada la reseccion completa de la metastasis. Por tanto, a falta de ensayos clinicos, un comite multidisciplinar debe considerar de forma individualizada esta opcion terapeutica para todos aquellos pacientes en quienes la estadificacion clinica de su carcinoma indique que tanto el tumor primario como la metastasis pueden extirparse de forma completa.

Introduction The aim of this study is to present our patients with lung cancer and synchronous adrenal metastases treated with a reversal approach: starting with adrenalectomy and doing the lung resection second. Methods A total of 108 laparoscopic adrenalectomies were performed, and we analyze a consecutive series of 10 patients with isolated adrenal synchronous metastases from the lung, surgically treated in a sequential way. All patients underwent staging mediastinoscopy, and patients with positive lymph nodes were primary treated with chemotherapy. We analyze: postoperative morbidity, length of stay, time between the 2 surgeries, survival free progression and global survival. Survival analysis was performed by the Kaplan–Meier method. Results Mean age: 56.8 (41–73) years old. Of the total, 8 patients were surgically performed by laparoscopy. Metastases average size: 5.9 (3–10) cm. Days between the 2 surgeries were 28 (12–35) days. No morbidity after adrenalectomy. Length of stay was 4.3 (3–5) days. Disease-free survival at 2 years was 60%, the 5-year overall survival was 30%, with a median survival of 41.5 (0–98) months. Conclusions Adrenalectomy involves no significant morbidity and can be performed safely without delaying lung surgery, and allows us to operate the primary lung tumor successfully as long as we ensure complete resection of the adrenal gland. A multidisciplinary oncology committee must individualize all cases and consider this therapeutic approach in all patients with resectable primary tumor and resectable adrenal metastases.

Until recently, completion ALND has been considered the standard of care after a positive SN in breast cancer patients. However, most patients will not display further axillary involvement. The Tenon score is a simple nomogram that can be used intraoperatively to avoid completion ALND in low-risk patients. We aimed at validating the Tenon score on a SN-positive patient sample that had been preoperatively selected using axillary US examination. We used a retrospective analysis of our bicentric database that included 246 breast cancer patients with a positive SN. We calculated sensitivity, specificity, as well as positive and negative predictive values for each cut-off point. ROCs were constructed and corresponding AUC values were calculated as a measure of discriminative capacity. At least one non-SN was positive in 52 patients (21.1 %). 118 patients (48 %) had a score up to 5. Among them, three had at least one positive non-SN. NPV was 97.5 %. Using that threshold, the ROCs analysis showed an AUC of 0.822 (95 % CI 0.764–0.880). Use of preoperative axillary US examination led to a modification of the proposed Tenon cut-off value from 3.5 to 5 to attain good predictive power for non-SN status. Straightforward intraoperative use of the Tenon score may be considered an advantage over other available nomograms.

Highlights • Wernicke encephalopathy after sleeve gastrectomy is an uncommon complication. • Wernicke encephalopathy reaches 20% mortality rate when it is undertreated. • Treatment with thiamine vitamin must be started with a presumptive diagnosis., Objective To describe a case of Wernicke’s encephalopathy after laparoscopic sleeve gastrectomy. Setting Emergency Department and gastrointestinal surgery department. Case report A 20-year-old man class III obesity (BMI 50.17 kg/m2) underwent laparoscopic sleeve gastrectomy with uneventful recovery. Five weeks after surgery he was admitted in the Emergency Department because of persistent vomiting and dysphagia to solids. Esophagogastroduodenal transit and upper gastrointestinal endoscopy were requested but no relevant findings were shown. Laboratory analyses showed vitamin B1 12.2 ng/mL and 48 h following admission the patient experienced generalized weakness, sialorrhea and restrictions of actions such as reading a book. Neurological evaluation found confusion, motor ataxia, diplopy and nystagmus. A brain magnetic resonance was normal. According to low level of vitamin B1 and symptoms found in the patient a presumed diagnosis of Wernicke encephalopathy was made and parenteral thiamine 100 mg/day was started. The patient was discharged asymptomatic with oral intake of vitamin B1 600 mg per day. Conclusion Nutritional deficiencies after restrictive procedures are uncommon but easily preventable and can result in life threatening. With the upswing of bariatric surgery, surgeons and emergency physicians should be able to diagnose and treat those complications. Prophylactic thiamine should be administered to patients with predisposing factors.

Our aim was to compare histologic and immunohistochemical features, surgical treatment and clinical course, including disease recurrence, distant metastases, and mortality between patients with invasive ductal carcinoma (IDC) or invasive lobular carcinoma (ILC). We included 1,745 patients operated for 1,789 breast tumors, with 1,639 IDC (1,600 patients) and 145 patients with ILC and 150 breast tumors. The median follow-up was 76 months. ILC was significantly more likely to be associated with a favorable phenotype. Prevalence of contralateral breast cancer was slightly higher for ILC patients than for IDC patients (4.0% versus 3.2%; p = n.s). ILC was more likely multifocal, estrogen receptor positive, Human Epidermal Growth Factor Receptor-2 (HER2) negative, and with lower proliferative index compared to IDC. Considering conservative surgery, ILC patients required more frequently re-excision and/or mastectomy. Prevalence of stage IIB and III stages were significantly more frequent in ILC patients than in IDC patients (37.4% versus 25.3%, p = 0.006). Positive nodes were significantly more frequent in the ILC patients (44.6% versus 37.0%, p = 0.04). After adjustment for tumor size and nodal status, frequencies of recurrence/metastasis, disease-free and specific survival were similar among patients with IDC and patients with ILC. In conclusion, women with ILC do not have worse clinical outcomes than their counterparts with IDC. Management decisions should be based on individual patient and tumor biologic characteristics rather than on lobular versus ductal histology.

In 2011, the St Gallen panel introduced several changes in breast cancer classification, thereby creating the luminal B Her2- subtype. In 2013, the panel also included Ki67 overexpression and PR20 % as risk factors, while excluding GH3 in the absence of increased Ki67. We compared the classification of 2011 modified with the new 2013 St Gallen classification.Consecutive breast cancer patients referred to the Breast Unit of the University Hospital Mútua Terrassa and Hospital of Terrassa for surgical treatment of either primary or recurrent tumors were prospectively included between 1997 and 2014. Eventually, 1,874 cases were included for the four-subtype analysis. The median follow-up was of 66 months.Using the 2013 St Gallen classification no significant differences were found in specific mortality rates between luminal A and B subtypes. There were significant differences at 5, 10, and, 15 years if we excluded luminal A GH3 patients in the absence of increased Ki67 (p = 0.004, 0.005, and 0.007). Luminal A sub-type patients showed significantly less distant metastases than the rest, including luminal B Her2- patients (p0.001). Also, luminal B patients showed significantly less distant metastases than pure Her2 (0.05) and triple negative (TN) (p0.001). There were no differences between pure Her2 and TN patients (0.055), neither among the different luminal B sub-types.GH3, PR, and Ki67 may all be discriminatory factors for metastasis and specific mortality. Therefore, we suggest including GH3 in the luminal B subtype in the absence of Ki67.

Breast cancer can no longer be considered only one condition. It should be regarded rather as a heterogeneous group of diseases with different molecular outlines. The aim of this study is to establish a correlation between immunohistochemical tumor sub-typing and surgical treatment, local recurrence rates, distant metastases, and cancer-specific mortality at 5 and 10 years. At least, four tumor sub-types have been described, which were associated with variable risk factors, different natural clinical course, and different response to both local and systemic therapies. For Luminal A: ER + and/or PR + HER2− Ki67

Background: The appendiceal diverticulum is an uncommon pathology. Its most common clinical presentation is the appendiceal diverticulitis and the symptoms are similar to acute appendicitis. Also, it can be considered as part of differential diagnosis for chronic abdominal pain. Aim: Analyze the prevalence in our hospital of appendiceal diverticulosis in acute appendicitis and literature review. Methods: Retrospective description study (January 2004 to December 2013) looking for presence of appendix diverticula in 1526 patients after appendectomy due to suspicion of acute appendicitis. Review of literature for term results: “appendiceal”, “appendicular”, “diverticulitis”, “diverticulosis”. Results: Total sample: 2058 patients operated of appendectomy; 1526 of those were to suspicion of acute appendicitis and in 38 of those we found presence of appendiceal diverticula (2.49% prevalence). Distribution: men/ women (68.42%/31.57%), middle age (46.71 years). Lipton classification: Type I (28.94%), type II (34.21%), type III (21.05%) and type IV (15.78%). Other associations: carcinoid tumor (2.36%), villous adenoma (2.63%), serrated adenoma with low grade dysplasia (2.63%), perforated diverticula (7.89%), chronic diverticulitis (5.26%). Conclusion: Prevalence is slightly higher in our series, probably because we considered only patients with acute appendicitis and not all surgical specimens with cecal appendix. According to reviewed bibliography there is possible relation with appendix neoplasias, more risk of perforation and mortality. It is a difficult pre-operative diagnosis and it has to be considered in the differential diagnosis for (acute and chronic) abdominal pain in right iliac fossa.

As far as recent breast cancer molecular subtype classification is concerned, much work has dealt with clinical outcomes for triple negative and Her2 patients. Less is known about the course of patients in the remaining subtypes. Molecular classification based on immunohistochemistry is widely available and correlates well with genetic microarray assessment, but at a lower cost. The aim of our investigation was to correlate immunohistochemical subtypes of breast cancer with clinical characteristics and patient outcomes. Since 1998, 1167 patients operated for 1191 invasive breast tumours were included in our database. Patients were regularly followed up until March 2010. Disease-free survival, overall mortality, and breast cancer-specific mortality at 5 years were calculated for the cohort. 72% of tumours were ER+PR±HER2- group, 13% triple negative (ER-PR-HER2-), 10% ER+PR±HER2+ group, and 5% Her2 (ER-PR-HER2+). Cancer-specific survival was 94.2% for the ER+PR+HER2- subtype, 84.8% for the Her2 subtype, 83.3% for the ER+PR-HER2- subtype, and 78.6% for triple negatives. Distant metastases prevalence ranged from 7% to 22% across subtypes, increasing stepwise from ER+PR+HER2-, ER+PR+HER2+, ER+PR-HER2-, ER+PR-HER2+, ER-PR-HER2+ through triple negative. Small, low-grade tumours with low axillary burden were more likely to belong to the ER+PR±HER2- group. Conversely, larger high-grade tumours with significant axillary burden were more likely to belong to Her2 or triple negative groups. ER+PR±HER2- group patients with negative PR receptors performed more like Her2 or triple negative than like the rest of ER+PR±HER2± groups patients. Molecular classification of breast tumours based only on immunohistochemistry is quite useful on practical clinical grounds, as expected. ER+PR±HER2- group patients with negative PR receptors seem to be at high risk and deserve further consideration.

Since the clinical implementation of fine needle aspiration cytology (FNAC) to diagnose thyroid carcinoma, few patients remain misdiagnosed and little is known about their clinical outcomes. An observational retrospective study was carried out to analyse prognostic factors and follow-up of patients with differentiated thyroid carcinoma (DTC) not disclosed by FNAC before surgery, compared to a control group. From October 2003 to July 2010, 308 patients underwent surgery as treatment for nodular goitre and 53 had DTC. Cases were 12 subjects with DTC and benign (n = 7) or nondiagnostic (n = 5) FNAC. Controls were 39 subjects with DTC and suspicious (n = 19) or malignant (n = 20) FNAC. Prognostic factors, recurrence and survival rates were compared. Cases had longer time from FNAC to surgery than the control group (86.8 ± 74.1 vs. 16.4 ± 23.8 weeks; P < 0.001), higher prevalence of follicular carcinoma (33.3 vs. 2.6%; P = 0.009), and of two-time total thyroidectomy (75 vs. 30.8%; P = 0.016). Average follow-up was 42.7 ± 25.3 months (2–86 months). There were no deaths. Disease-free survival for cases was 66.9 ± 5.8 months, and for controls 78.7 ± 3.9 months (P: ns). In patients with DTC, the result of the FNAC performed before surgery was not an independent predictor of recurrences or mortality in the first 7 years of follow-up. Thus, false negative or nondiagnostic FNAC in a patient with DTC does not seem to be a primary prognostic factor, but it may reveal other adverse prognostic factors such as longer time to therapy and higher prevalence of follicular carcinoma that may influence long-term outcomes.

Background Recent studies have challenged the long-standing assumption that breast cancer prognosis is determined by lymph node regional status. We assessed locoregional relapse, distant metastases, and mortality alongside additional axillary disease in breast cancer patients undergoing sentinel node (SN) biopsy. Patients and Methods This prospective study assessed 1070 women with clinical T1-T2 invasive breast cancer with negative clinical/ultrasound axillae. Results A total of 25.1% of patients had positive SN biopsy findings, of whom 69.2% had only 1 involved SN. The rate of axillary recurrence was 0.7%, with no significant differences found between patients with positive or negative SN (0.6% vs. 1.1%). There were also no significant differences in the rate of distant metastases or breast cancer–specific mortality. If we had applied the Z0011 trial suggestions, residual axillary disease would have reached 16.2%: 13.5% in patients over 50% and 21.3% in patients under 50. The rate of residual axillary disease would have been 25.2% in patients with only 1 SN (20.2% in patients over 50% and 38.2% in patients under 50). In patients with 2 SN, residual disease would have ranged from 12.0% in patients over 50% to 19.0% in patients under 50. From 3 SN on, residual disease seems negligible. Conclusion There were no significant differences in locoregional relapse, distant metastases, or mortality between patients with negative and positive SN. Patients with 3 or more SN have no additional axillary disease. In patients younger 50, one must be extremely cautious if the Z0011 suggestions are to be applied, especially if there is only 1 SN.

Introduction. Gastrointestinal stromal tumors first treatment should be surgical resection, but when metastases are diagnosed or the tumor is unresectable, imatinib must be the first option. This treatment could induce some serious complications difficult to resolve.Case Report. We present a 47-year-old black man with a giant unresectable gastric stromal tumor under imatinib therapy who presented serious complications such as massive gastrointestinal bleeding and a gastrobronchial fistula connected with the skin, successfully treated by surgery and gastroscopy.Discussion. Complications due to imatinib therapy can result in life threatening. They represent a challenge for surgeons and digestologists; creative strategies are needed in order to resolve them.

Resumen Objetivo Describir el abordaje laparoscopico de la oclusion de intestino delgado susceptible de tratamiento quirurgico y analizar su capacidad como tecnica diagnostica y de tratamiento en pacientes seleccionados, evaluando las complicaciones y su impacto en la recuperacion postoperatoria de los pacientes. Pacientes y metodo Estudio prospectivo descriptivo de 18 pacientes seleccionados, intervenidos por laparoscopia en regimen de urgencias. Criterios de inclusion: ausencia de contraindicacion medica o anestesica y disponibilidad tecnica y/o tecnologica del equipo de guardia. Criterios de exclusion: enfermedad inflamatoria intestinal activa, antecedente de neoplasia o radioterapia abdominal y/o laparotomias previas multiples. Resultado El abordaje laparoscopico permitio la exploracion completa del intestino delgado en el 100% de los casos, identificar la causa de la oclusion en el 94,4% y resolverla en todos los pacientes (en 2 mediante laparoscopia asistida), excepto en uno. El tiempo operatorio promedio fue de 87 min. No ha habido mortalidad ni complicaciones postoperatorias mayores. Ha habido 2 complicaciones menores en 18 pacientes (11,1%). La estancia hospitalaria promedio fue de 5 dias y el retorno a la actividad normal se efectuo al cabo de 12,3 dias. Ningun paciente ha presentado recurrencia ni ha requerido reintervencion tras un seguimiento medio de 20 meses. Conclusiones El abordaje laparoscopico es una alternativa eficaz para tratar una oclusion de intestino delgado en pacientes estrictamente seleccionados, dados sus buenos resultados terapeuticos y su baja morbilidad. No obstante, la complejidad tecnica del procedimiento en determinados casos de oclusion impide su recomendacion sistematica.

Aim: To assess degree of development and level of acceptance of laparoscopic surgery in Spain. Method: A questionnaire was sent to all members of the Spanish Association of Surgeons in April 2003. It included 32 questions, 9 of which were general, and 23 referred to specific clinical situations, techniques, and standard practice. Results: Eight hundred and fifty-eight (33.1%) surgeons replied. Only 211 (25%) surgeons reported performing advanced laparoscopic procedures. Four hundred and twenty (49%) surgeons believed that the results obtained with laparoscopic surgery were better than those obtained with conventional surgery, and 325 (40%) surgeons believed that laparoscopy would become a superspecialty. Laparoscopic surgery was considered the method of choice in the treatment of gallbladder stones (99%), gastroesophageal reflux disease (94%), acute cholecystitis (81%), in selected cases of inguinal hernia repair, and in procedures to be performed in spleen and adrenals, benign colon disease, and obesity. Three hundred and ninety-eight (47%) surgeons considered laparoscopic surgery the preferred approach for colon cancer, 292 (34%) for appendicitis, and 155 (18%) for incisional hernia. Five hundred and five (59%) surgeons considered that the use of laparoscopic surgery had grown less than expected. Conclusions: The vast majority of surgeons advocated laparoscopic surgery for the treatment of gallbladder stones and gastroesophageal reflux disease. Although most hospitals had the appropriate technical facilities for performing advanced laparoscopic procedures, few surgeons actually did so.

Resumen Objetivo Conocer la opinion de los cirujanos miembros de la Asociacion Espanola de Cirujanos (AEC) sobre la cirugia laparoscopica (CL) y su implantacion en nuestros hospitales. Material y metodos Dos encuestas de opinion. Una remitida a todos los miembros de la AEC en abril de 2003. Incluia aspectos generales y situaciones clinicas. La otra se remitio a todos los servicios de cirugia del pais e incluia aspectos sobre dotacion e implantacion de la CL. Resultados Han contestado 106 servicios (40%) y 855 cirujanos (32,3%). Solo 209 (25%) cirujanos realizan procedimientos avanzados. El 49% de cirujanos creen que los resultados de la CL son mejores que los de la cirugia convencional y 324 (40%) creen que la CL acabara siendo una superespecialidad. La CL se considera de primera eleccion en el tratamiento de la colelitiasis (99%), reflujo gastroesofagico (RGE) (94%) y colecistitis aguda (81%). En otras afecciones como la hernia inguinal, las enfermedades del bazo, patologia benigna de colon, la obesidad y enfermedades suprarrenales se utilizaria en casos seleccionados. El cancer de colon, la apendicitis y la eventracion tienen una baja aceptacion como primera indicacion en la CL. El 59% de cirujanos considera que la CL no ha tenido el crecimiento esperado. Conclusiones La CL, en nuestro medio y para un amplio colectivo de cirujanos, es ampliamente aceptada para el tratamiento de la colelitiasis y el RGE. A pesar de que nuestros hospitales tienen medios tecnicos suficientes para realizar la CL avanzada, esta se practica por pocos cirujanos. Aspectos como la formacion en CL y la superespecializacion aun quedan por perfilar en un futuro.

Phlegmonous gastritis is a rare bacterial infection of the gastric wall, which progress rapidly. It is characterized by a purulent inflammation that can affect the entire gastrointestinal tract and presents a high mortality rate. We are reporting a case of phlegmonous gastritis in an HIV-seropositive man successfully treated with antibiotics. Moreover, a review of the English and Spanish literature is carried out, from 1980 to the present time. The most frequently involved microorganism is Streptococcus spp. (57 %), but the polimicrobial infection is also frequent (17 %). The most important symptom is the intensive epigastric pain associated with vomits and most cases were diagnosed by CT and/or fibrogastroscopy. There are many existing risk factors described. The main one is the immunesuppression, although in 40 % of the cases no risk factors were identified. The global mortality is 27 % without identifying significant differences between antibiotics and surgical treatment, for that reason it is recommended to initiate antibiotic treatment right from the beginning and postponing surgery for the refractory cases and complications.

Sentinel Node Biopsy (SNB) is a minimally invasive alternative to elective axillary lymph node dissection (ALND) for nodal staging in early breast cancer. The present study was conducted to evaluate prognostic implications of a negative sentinel node (SN) versus a positive SN (followed by completion ALND) in a closely followed-up sample of early breast cancer patients. We studied 889 consecutive breast cancer patients operated for 908 primaries. Patients received adjuvant therapy with chemotherapy, hormone therapy and eventually trastuzumab. Radiation therapy was based on tangential radiation fields that usually included axillary level I. Median follow-up was 47 months. Axillary recurrence was seen in 1.2% (2/162) of positive SN patients, and 0.8% (5/625) of negative SN patients (p = n.s.). There was an overall 3.2% loco-regional failure rate (29/908). Incidence of distant recurrence was 3.3% (23/693) for negative SN patients, and 4.6% (9/196) for positive SN patients (p = n.s.). Overall mortality rate was 4% (8/198) for positive SN patients, while the corresponding specific mortality rate was 2.5% (5/198). For patients with negative SNs, overall mortality was 4.9% (34/693), and the specific mortality was 1.4% (19/693) (p = n.s.). We did not find significant differences in axillary/loco-regional relapse, distant metastases, disease-free interval or mortality between SN negative and SN positive patients, with a follow-up over 4 years.

Background. We assessed the results of adrenalectomy for solid tumor metastases in 317 patients recruited from 30 European centers. Methods. Patients with histologically proven adrenal metastatic disease and undergoing complete removal(s) of the affected gland(s) were eligible. Results. Non-small cell lung cancer (NSCLC) was the most frequent tumor type followed by colorectal and renal cell carcinoma. Adrenal metastases were synchronous (#6 months) in 73 (23%) patients and isolated in 213 (67%). The median disease-free interval was 18.5 months. Laparoscopic resection was used in 46% of patients. Surgery was limited to the adrenal gland in 73% of patients and R0 resection was achieved in 86% of cases. The median overall survival was 29 months (95% confidence interval, 24.69-33.30). The survival rates at 1, 2, 3, and 5 years were 80%, 61%, 42%, and 35%, respectively. Patients with renal cancer showed a median survival of 84 months, patients with NSCLC 26 months, and patients with colorectal cancer 29 months (P = .017). Differences in survival between metachronous and synchronous lesions were also significant (30 vs 23 months; P = .038). Conclusion. Surgical removal of adrenal metastasis is associated with long-term survival in selected patients. (Surgery 2013;154:1215-23.)

Parathyroid carcinoma is an infrequent cause of primary hyperparathyroidism. Although hyperparathyroidism in multiple endocrine neoplasia 1 (MEN1) syndrome is the most common manifestation, parathyroid carcinoma is rare. We report a male patient who was diagnosed at 44 years of age with parathyroid carcinoma in the context of MEN1 syndrome coincident with a malignant gastrinoma and non-functioning adrenal adenomas. A genetic analysis revealed the mutation W183C in exon 3 of the MEN1 gene. The diagnosis of carcinoma was made after parathyroid surgery; there had been no clinical suspicion prior to surgery, as the patient had presented only moderate hypercalcemia. Our review of the few published cases of parathyroid carcinoma in MEN1 syndrome reported in the literature indicates that MEN1 gene mutations do not confer a greater risk for parathyroid carcinoma and do not appear to differ from sporadic parathyroid carcinoma.

Management of complex thyroid nodules (CTN) is a common dilemma due to their high prevalence and frequent nondiagnostic fine needle aspiration cytology (FNAC). In order to know the rate of malignancy, we reviewed our experience about histopathologic diagnosis of CTN with nondiagnostic FNAC, and we analyzed if cytological variants of nondiagnostic FNAC indicated different histopathologic outcomes. We conducted a review of 927 consecutive aspirations performed between 2003 and 2008. We selected patients without history of radiation, with echographic CTN, and nondiagnostic FNAC, who underwent surgery. We analyzed histopathologic results and compared patients with benign and malignant nodules, and searched for differences between patients with cystic changes in FNAC (C-FNAC), and patients with acellular or only bloody FNAC (A-FNAC). Thirty-six patients were included (mean age 45.7 ± 13 years; 30 females). Four patients had malignant nodules; all were papillary carcinomas. Patients with benign nodules had a similar profile to patients with malignant nodules. Patients with C-FNAC (n = 21) were younger (41.3 ± 12.6 vs. 51.8 ± 11.2 years; P < 0.02), had more lymphocytic thyroiditis (33.3 vs. 0%; P < 0.02), a slightly higher rate of carcinoma in the nodule (14.3 vs. 6.6%; P: ns), and also of papillary microcarcinoma outside the nodule (9.6 vs. 0%; P: ns) than patients with A-FNAC. In conclusion, we report an 11.1% malignancy rate in CTN with nondiagnostic FNAC. Nodules with C-FNAC variant had a slightly higher rate of malignancy than A-FNAC, which may be in relation with younger age and higher prevalence of lymphocytic thyroiditis in this group of patients.

We assessed the diagnostic yield of axillary ultrasound, alone or in combination with fine-needle aspiration axillary biopsy and magnetic resonance imaging in patients with invasive breast carcinoma compared with final axillary histology by sentinel node biopsy or by axillary lymph node dissection. From January 2003 to March 2009, 520 axillary ultrasound examinations and 105 axillary magnetic resonance imaging studies were included. Compared with final axillary histology, ultrasound fine-needle aspiration showed positive predictive value of 87%, negative predictive value of 82%, sensitivity of 53% and specificity of 100%. In cases of negative ultrasound, the rate of positive nodes was 17% (micro-metastases excluded). Ultrasound examination of the axilla, combined with fine-needle aspiration as appropriate must be included in the preoperative work-up of patients considered for sentinel node biopsy to definitively establish such an indication while minimizing the risk of false-negative sentinel node. Axillary magnetic resonance imaging did not improve the preoperative work-up.

Gastric cancer staging based on the number of positive lymph nodes is not reliable in patients undergoing limited lymphadenectomies. The aim of the present study was to determine the prognostic influence of lymph node ratio (LR)--defined as the number of metastatic nodes divided by total of obtained nodes--in patients with less than 16 analyzed lymph nodes.Seventy-two gastric cancer patients underwent surgery with a curative intention, obtaining less than16 nodes. The pN (TNM 5th Ed) and LR were studied in a multivariate analysis (Cox regression). LR was classified in four groups: 0,40%, 40-79%, and80%, according to a previous study carried out by the authors.Neither the number of affected lymph nodes nor LR behaved as independent prognostic factors. Nevertheless, when locally advanced tumors were studied separately, the lymph node ratio gave more precise prognostic information, resulting in the identification a group of patients with the same pN stage who presented with different prognoses.LR offers better prognostic information than the number of affected lymph nodes in patients with locally advanced gastric tumors undergoing limited lymphadenectomies. Further studies are needed to confirm these results and standardize the stratification of LR.

Most gastric adenocarcinomas in western countries are locally advanced, and these tumours are often associated with metastatic spread at the time of diagnosis. It is controversial whether palliative surgery can improve symptom control in gastric cancer patients with peritoneal carcinomatosis.To determine the need of palliative procedures and survival in patients affected by gastric cancer with peritoneal carcinomatosis managed without resection. Methods and materials After standard preoperative staging, 160 patients were diagnosed with resectable gastric adenocarcinoma. Laparoscopy was performed in 107 patients (66.9%), finding peritoneal spread in 22 of them (21%). Seventeen of these patients were not submitted to any additional surgical procedure. Data regarding postoperative morbidity and mortality, need of endoscopic, percutaneous or surgical procedures to palliate symptoms, hospital stay and survival were collected. The same data were collected for the 6 non-resected patients who were diagnosed with carcinomatosis by laparotomy.In the "laparoscopy alone" group, there were 2 minor complications and no postoperative mortality. Mean postoperative stay was 6 days. Eight patients had to be readmitted to hospital for symptoms derived from tumour progression, and 10 palliative endoscopic procedures were performed. Surgical interventions were not needed in any case. Mean survival was 11.5 months. Patients submitted only to laparotomy presented higher morbidity and mortality rates, with a longer postoperative stay and survival of less than 5 months.Laparoscopic staging of gastric cancer can help to avoid unnecessary laparotomies. In patients with peritoneal carcinomatosis diagnosed by laparoscopy, nonsurgical treatment has low morbidity and mortality and permits good symptom relief with no shortening of survival.

Background There is an association between the number of resected lymph node and the number of metastatic lymph nodes in gastric cancer, suggesting that pN category could be influenced by the extension of the lymphadenectomy. This study evaluates this association and proposes a comprehensive use of the ratio as prognostic factor. Method Review of 183 consecutive patients with gastric adenocarcinoma. The association between the number of resected lymph nodes and the number of metastatic lymph nodes was analysed and evaluated with other prognostic factors. Results The number of lymph node metastases increased with the number of resected lymph nodes. The lymph node ratio was a better prognostic factor than the number of metastatic lymph nodes. Conclusions The metastatic lymph node ratio seems to be a good prognostic factor, but needs further evaluation.

Surgical treatment of hepatic malignancies for either primary or metastatic tumors provides the best option to improve survival and disease-free interval. A significant decrease in morbility and mortality has been achieved in the last 10 years. This feature is related to the current advances in liver resection technique as well as a better understanding of the preoperative and postoperative care required by these patients. These facts encouraged liver surgeons to extend the indications for surgery to liver malignancies.

Highlights • The definitive closure of an open abdomen with a giant full abdominal defect remains a problem. • The great omentum allows a rapid integration of the polypropylene mesh. • The structure achieved does not hamper future surgical procedures., Introduction The “open abdomen” expression widely used to define a full-thickness defect of the abdominal wall intentionally made in some situations like abdominal compartment syndrome, has been replaced by a newest one called “laparostomy”. The definitive closure of an open abdomen with a giant full abdominal thickness defect remains a problem. Case report We present a 67-year old male with a descompressive laparostomy treated with a greater omentum flap sutured hermetically with interrupted stitches at the edges of the muscle wall, reinforced with large mesh of polypropylene (PP) placed on-lay and sutured to the fascia by two concentric running sutures of polypropylene. A vacuum-assisted closure device was placed on the second postoperative day and it was kept during three weeks. By then the PP mesh was completely integrated so skin grafts were applied to the surface of the granulation tissue. An incisional hernia was easily repaired at three years of follow-up. Eight months after the last surgery the patient is satisfied with the result achieved. Discussion The great omentum has immunological and angiogenic properties that allow a rapid integration of the polypropylene mesh, even in septic environments, facilitating the engraftment of split-thickness skin graft. The reactive fibrosis caused by the PP mesh replaces the fat tissue but the inner surface is preserved, thereby avoiding subsequent adhesion and facilitates surgical access to the abdominal cavity if necessary in the future. Conclusion The structure achieved is a strong structure, capable of visceral isolation that can be useful to close some OA.