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Background: Postoperative ascites (POA) is the most common complication after liver surgery for hepatocarcinoma (HCC), but its impact on survival is not reported. The aim of the study is to investigate its impact on overall survival (OS) and disease-free survival (DFS), and secondarily to identify the factors that may predict the occurrence. Method: Data were collected from 23 centers participating in the Italian Surgical HCC Register (HE.RC.O.LE.S. Group) between 2008 and 2018. POA was defined as ≥500 ml of ascites in the drainage after surgery. Survival analysis was conducted by the Kaplan Meier method. Risk adjustment analysis was conducted by Cox regression to investigate the risk factors for mortality and recurrence. Results: Among 2144 patients resected for HCC, 1871(88.5%) patients did not experience POA while 243(11.5%) had the complication. Median OS for NO-POA group was not reached, while it was 50 months (95%CI = 41–71) for those with POA (p < 0.001). POA independently increased the risk of mortality (HR = 1.696, 95%CI = 1.352–2.129, p < 0.001). Relapse risk after surgery was not predicted by the occurrence of POA. Presence of varices (OR = 2.562, 95%CI = 0.921–1.822, p < 0.001) and bilobar disease (OR = 1.940, 95%CI = 0.921–1.822, p: 0.004) were predictors of POA, while laparoscopic surgery was protective (OR = 0.445, 95%CI = 0.295–0.668, p < 0.001). Ninety-day mortality was higher in the POA group (9.1% vs 1.9% in NO-POA group, p < 0.001). Conclusion: The occurrence of POA after surgery for HCC strongly increases the risk of long-term mortality and its occurrence is relatively frequent. More efforts in surgical planning should be made to limit its occurrence.

Liver surgery is the first line treatment for hepatocarcinoma. Hepatocarcinoma Recurrence on the Liver Study (HERCOLES) Group was established in 2018 with the goal to create a network of Italian centres sharing data and promoting scientific research on hepatocellular carcinoma (HCC) in the surgical field. This is the first national report that analyses the trends in surgical and oncological outcomes. Register data were collected by 22 Italian centres between 2008 and 2018. One hundred sixty-four variables were collected, regarding liver functional status, tumour burden, radiological, intraoperative and perioperative data, histological features and oncological follow-up. 2381 Patients were enrolled. Median age was 70 (IQR 63-75) years old. Cirrhosis was present in 1491 patients (62.6%), and Child-A were 89.9% of cases. HCC was staged as BCLC0-A in almost 50% of cases, while BCLC B and C were 20.7% and 17.9% respectively. Major liver resections were 481 (20.2%), and laparoscopy was employed in 753 (31.6%) cases. Severe complications occurred only in 5%. Postoperative ascites was recorded in 10.5% of patients, while posthepatectomy liver failure was observed in 4.9%. Ninety-day mortality was 2.5%. At 5years, overall survival was 66.1% and disease-free survival was 40.9%. Recurrence was intrahepatic in 74.6% of cases. Redo-surgery and thermoablation for recurrence were performed up to 32% of cases. This is the most updated Italian report of the national experience in surgical treatment for HCC. This dataset is consistently allowing the participating centres in creating multicentric analysis which are already running with a very large sample size and strong power. Liver surgery is the first line treatment for hepatocarcinoma. Hepatocarcinoma Recurrence on the Liver Study (HERCOLES) Group was established in 2018 with the goal to create a network of Italian centres sharing data and promoting scientific research on hepatocellular carcinoma (HCC) in the surgical field. This is the first national report that analyses the trends in surgical and oncological outcomes. Register data were collected by 22 Italian centres between 2008 and 2018. One hundred sixty-four variables were collected, regarding liver functional status, tumour burden, radiological, intraoperative and perioperative data, histological features and oncological follow-up. 2381 Patients were enrolled. Median age was 70 (IQR 63–75) years old. Cirrhosis was present in 1491 patients (62.6%), and Child-A were 89.9% of cases. HCC was staged as BCLC0-A in almost 50% of cases, while BCLC B and C were 20.7% and 17.9% respectively. Major liver resections were 481 (20.2%), and laparoscopy was employed in 753 (31.6%) cases. Severe complications occurred only in 5%. Postoperative ascites was recorded in 10.5% of patients, while posthepatectomy liver failure was observed in 4.9%. Ninety-day mortality was 2.5%. At 5years, overall survival was 66.1% and disease-free survival was 40.9%. Recurrence was intrahepatic in 74.6% of cases. Redo-surgery and thermoablation for recurrence were performed up to 32% of cases. This is the most updated Italian report of the national experience in surgical treatment for HCC. This dataset is consistently allowing the participating centres in creating multicentric analysis which are already running with a very large sample size and strong power.

INTRODUZIONE: Il tumore desmoide è una rara neoplasia dei tessuti molli caratterizzata da tendenza all’invasività locale, da un elevato rischio di recidiva locale dopo asportazione. Colpisce maggiormente il sesso femminile, soprattutto in età fertile.CASE REPORT: Donna caucasica di 31 anni, unipara, con una tumefazione al terzo medio del muscolo retto sinistro dell’addome non dolente, insorta da circa un mese. Un’ecografia e una RMN dell’addome pongono il sospetto di un tumore desmoide della parete addominale. Si pone indicazione al trattamento chirurgico di enucleazione della lesione e ricostruzione dei piani muscolari senza ausilio di reti protesiche. Il follow-up eseguito a 1 anno non ha evidenziato alcuna recidiva.CONCLUSIONI: La mancata raccolta dei dati e la mancanza di un registro che differenzi tumori desmoidi localizzati in sedi diverse e l’accorpamento di lesioni primitive e secondarie presente in letteratura non hanno standardizzato un corretto iter terapeutico. Sicuramente di fronte a desmoidi della parete addominale il trattamento chirurgico può essere ritenuto il trattamento di scelta. Il prossimo futuro sviluppo di terapie geniche potrà contribuire a migliorare il trattamento e la prognosi dei pazienti. BACKGROUND: Desmoid tumor is a rare soft tissues neoplasia characterized by local invasiveness and by a tendency towards local recurrence although not towards metastasization.DISCUSSION: Etiology is not clear. Desmoid tumors originate from the monoclonal proliferation of one mesenchymal cell and develop in the context of fascial, muscular and aponeurotic tissue. They are free of capsule and do not usually metastatize, although they do present a high risk of local recurrence CONCLUSION: In the absence of a systematic data collection and of a clear distinction, in the existing databases, between primitive and recurrent lesions and between lesions of different sites, there are no standard guidelines for a correct management of desmoids.KEY WORDS: Aggressive fibromatos Desmoid tumor, Soft tissue neoplasia.

Stapled anopexy is considered the gold standard in treating haemorroidal disease associated to mucosal prolapse, but severe complications have been described. Among these, a minimal anastomotic leakage may lead to gas spreading into surrounding soft tissues.We report the case of a 61 year old male who developed pneumoretroperitoneum and pneumomediastinun two days after a Stapled Anopexy. CT scans showed a minimal leakage with no abscess. The patient was successfully treated by bowel rest, antibiotics and total parenteral nutrition, avoiding surgical approach.A minimal anastomotic leakage following Stapled Anopexy, when leading to air diffusion into soft tissues and not associated to abscess or peritonitis may be treated conservatively avoiding ileostomy or colostomy.Anastomotic leakage, Pneumoretroperitoneum, Stapled Anopexy.La stapled anopexy è considerata il gold standard nel trattamento della malattia emorroidaria associata a prolasso mucoso. In letteratura sono state descritte gravi complicanze. Tra queste, una minimo leakage anastomotico può portare ad un retropneumoperitoneo e alla sepsi grave. Generalmente questi sono casi in cui il chirurgo opta per il confezionamento di una stomia escludente (associato eventualmente al drenaggio di eventuali ascessi). Tuttavia in alcuni casi è possibile una gestione conservativa. In questo lavoro, riportiamo il caso di un un uomo di 61 anni che ha sviluppato pneumoperitoneo e pneumomediastino due giorni dopo una mucoprolassectomia. Il paziente è stato trattato con successo mediante digiuno, antibioticoterapia e nutrizione parenterale totale, evitando un approccio chirurgico. Il caso clinico è corredato da una revisione della letteratura precedente che riporta come siano pochissimi i casi simili già descritti.

BACKGROUND: Previous Literature has never evaluated the effectiveness of fiber intake after surgery for obstructed defecation in improving residual constipation and defecation urgency. METHODS: From May 2010 to June 2011, 65 patients were randomly assigned to either the active group (N.=32) or placebo group (N.=33) receiving 3.5 g/day of pure Psyllium fiber or inert compound respectively. During the 6-month follow-up score systems were evaluated: Longo's Obstructed Defecation Syndrome Score, Cleveland Constipation Score; Wexner incontinence Score and Visual Analogic Scale. We also recorded the incidence of postoperative defecation urgency. RESULTS: Active group reported less constipation at 1 week (ODS: 6.25±3.55 vs. 11.94±4.99, P

Background Management of recurrence after surgery for hepatocellular carcinoma (rHCC) is still a debate. The aim was to compare the Survival after Recurrence (SAR) of curative (surgery or thermoablation) versus palliative (TACE or Sorafenib) treatments for patients with rHCC. Methods This is a multicentric Italian study, which collected data between 2007 and 2018 from 16 centers. Selected patients were then divided according to treatment allocation in Curative (CUR) or Palliative (PAL) Group. Inverse Probability Weighting (IPW) was used to weight the groups. Results 1,560 patients were evaluated, of which 421 experienced recurrence and were then eligible: 156 in CUR group and 256 in PAL group. Tumor burden and liver function were weighted by IPW, and two pseudo-population were obtained (CUR = 397.5 and PAL = 415.38). SAR rates at 1, 3 and 5 years were respectively 98.3%, 76.7%, 63.8% for CUR and 91.7%, 64.2% and 48.9% for PAL (p = 0.007). Median DFS was 43 months (95%CI = 32-74) for CUR group, while it was 23 months (95%CI = 18-27) for PAL (p = 0.017). Being treated by palliative approach (HR = 1.75; 95%CI = 1.14–2.67; p = 0.01) and having a median size of the recurrent nodule>5 cm (HR = 1.875; 95%CI = 1.22–2.86; p = 0.004) were the only predictors of mortality after recurrence, while time to recurrence was the only protective factor (HR = 0.616; 95%CI = 0.54–0.69; p Conclusion Curative approaches may guarantee long-term survival in case of recurrence.

Summary: Background: We propose a new open mesh hernia repair procedure for the treatment of inguinal hernias in adults aiming to improve patients' comfort and to reduce the incidence of chronic neuralgia. Methods: From September 2012 to August 2015, 250 consecutive patients were treated with “all in-one” mesh hernioplasty procedure in our Institution. According to the devised technique, a new smaller prosthesis was placed on the floor of the inguinal canal in order to strengthen all areas of weakness from which hernias may originate. The mesh was enveloped by a fibro-cremasteric sheath avoiding contact with neural structures. Follow-up was carried out at 3, 6, 12, 18 and 24 months for evaluation of postoperative pain using Visual Analogue Scale score, need of medication, patients' comfort and short or long-term complications. Results: All patients were discharged within 24 h from surgery. Slight pain was reported by the majority of patients and 47.6% of them did not require pain medication at home. After the 1st postoperative week 96.8% reported no pain and no other symptoms. No relevant limitation of normal activities was reported. There has been no postoperative neuralgia. One recurrence was observed. Conclusions: This new hernioplasty technique respects the anatomy of the inguinal canal, uses a smaller mesh, and seems to avoid neuralgia with maximum comfort for the patients. Keywords: Inguinal hernioplasty, Tension free hernia repair, Hernioplasty technique, Mesh for groin hernia, Neuralgia post-hernioplasty

Key Clinical Message This clinical image shows the importance of the early diagnosis and treatment of any suspicious skin lesion.

Introduction Perianal giant condyloma acuminatum is a rare clinical condition related to human papillomavirus infection and characterized by a circumferential, exophytic, cauliflower-like mass with an irregular warty surface localized in the anal region. Technique A circular incision with a diathermocoagulator was performed on macroscopically healthy skin, 1 cm from the margin of the lesion. The dermis was divided from the subcutaneous tissue. This way, a mucocutaneous cylinder including the whole lesion was obtained. A median radial incision was carried out to open the cylinder at its front. A progressive circumferential section on healthy mucosa (≈1 cm above the margin of the lesion) by means of a radiofrequency dissector allowed for the complete removal of the mass. The healthy mucosa of the anal canal was pulled out by Allis forceps and was sutured to the external margin of the internal sphincter with single layer of Vicryl (polyglactin 910) 2-0 sutures. Results Two months after surgery, no findings of anal stenosis or mucosal ectropion were reported. At the 1-year follow-up there was no recurrence of condylomatosis in any of the 3 cases. Conclusions Our procedure seems simpler to perform when compared with other techniques and reduces hospital stay and complications such as anal stenosis and mucosal ectropion.

Key Clinical Message A hard and bleeding anal and perianal mass stenotized the anus and required left-sided colostomy. Incisional biopsy showed a moderately differentiated spiniocellular carcinoma. Chemoradiotherapy treatment alone reduced significantly the mass.