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Supplementary Methods, Figure Legends 1-5 from Tumorigenic and Metastatic Activity of Human Thyroid Cancer Stem Cells

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Supplementary Figure 1 from Tumorigenic and Metastatic Activity of Human Thyroid Cancer Stem Cells

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Aims: The emerging biliary colonization of microorganisms in patients with biliary diseases may be devastating. Recent evidence suggests that age and gender may influence changes in the microbial composition of gut microbiota. To study the relationship between these parameters on bile microbiota, we retrospectively reviewed positive bile cultures following an endoscopic retrograde cholangiopancreatography (ERCP) in a QA-certified academic surgical unit of a single institution. Methods: 449 positive bile cultures from 172 Italian patients with diseases of the biliopancreatic system hospitalized from 2006 through 2017 were investigated for aerobic, anaerobic, and fungal organisms. The patients were stratified into four age intervals (22−66, 67−74, 75−81, and 82−93 years) and followed up for five years. Results: Gram-positive bacteria (GPB) was negatively associated with age only in multivariate analysis (Rpartial = −0.114, p = 0.017), with younger patients prone to harbor GPB and older patients likely to have Gram-negative bacteria (GNB). There was a definite link with the male gender using both univariate and multivariate analysis (p < 0.001). Enterococcus spp. was the most common strain identified in patients with GPB except for patients aged 67−74 years for male (95.2%) and female (80.9%) patients. Escherichia coli and Klebsiella spp. were most frequent than others in every group analyzed. Analogous results were found for bacteria Non-fermenting Gram-negative bacilli (NFGNB), such as Pseudomonas spp. and Stenotrophomonas spp. apart of the 2nd quartile. Conclusions: Our study strengthens the bond of age and gender with bile microbiota composition and suggests that further investigations may be required in targeting the aging microbiome. Other studies should also focus on Mediterranean epidemiological characteristics and antibiotic resistance surveillance system strategies

Primary breast tuberculosis is an uncommon disease, especially in nonendemic areas. Its presentation could mimic a cancer or an abscess, but this entity must be considered for differential diagnosis in women coming from endemic countries.

Background: The gut microbiota play an essential role in protecting the host against pathogenic microorganisms by modulating immunity and regulating metabolic processes. In response to environmental factors, microbes can hugely alter their metabolism. These factors can substantially impact the host and have potential pathologic implications. Particularly pathogenic microorganisms colonizing pancreas and biliary tract tissues may be involved in chronic inflammation and cancer evolution. Purpose: To evaluate the effect of bile microbiota on survival in patients with pancreas and biliary tract disease (PBD). Patients and Methods: We investigated 152 Italian patients with cholelithiasis (CHL), cholangitis (CHA), cholangiocarcinoma (CCA), gallbladder carcinoma (GBC), pancreas head carcinoma (PHC), ampullary carcinoma (ACA), and chronic pancreatitis (CHP). Demographics, bile cultures, therapy, and survival rates were analyzed in cohorts (T1 death

Key Clinical Message In the presence of suggestive clinical picture (high eosinophil count and multiple CT scan granuloma‐like lesions), schistosomiasis should be taken into account in case of suspected bowel perforation even if common risk factors are not identified through anamnesis.

BACKGROUND Thoracotomy, video-assisted thoracoscopic surgery (VATS) and robotic assisted thoracoscopic surgery (RATS)-lobectomy are widely accepted procedures for the surgical treatment of clinical (c)stage I non- small cell lung cancer (NSCLC). In the current literature which procedure gives more benefits is still debated. We present a comparison between these three procedures in term of advantages and postoperative outcomes. METHODS A multicentric study about 259 lobectomies from 2013 to 2019: 128 patients underwent TL, 96 VATS and 35 RATS. Different variables were retrospectively analyzed among these three cohorts of patients with diagnosis of cStage I NSCLC. RESULTS Rate of major complications comparable in VATS, RATS and TL; Advantages for RATS in minor complications (TL 34.4% vs. VATS 18.75% vs. RATS 8.57%. P=0.0015), postoperative days in Intensive Care Unit, days to chest tube removal, length of postoperative hospitalization (P

Bile is a lipid-rich sterile solution produced in the liver that can be infected resulting in bactibilia. A higher incidence of postoperative infectious complications has been seen in patients with bactibilia. Recently, gram-negative bacteria have been linked to a tumor-associated inflammatory status. This study is a retrospective cohort study of 39 patients, who are over 80 years of age only (53.85% males and 46.15% females), hospitalized with diseases of the biliopancreatic system in one teaching hospital in Italy from January 2011 to December 2012 with a follow-up of 5 years. The most common biliary diseases after surgery were pancreatic head cancer (p

ObjectiveCancer stem cells are responsible for tumour spreading and relapse. Human epidermal growth factor receptor 2 (HER2) expression is a negative prognostic factor in colorectal cancer (CRC) and a potential target in tumours carrying the gene amplification. Our aim was to define the expression of HER2 in colorectal cancer stem cells (CR-CSCs) and its possible role as therapeutic target in CRC resistant to anti- epidermal growth factor receptor (EGFR) therapy.DesignA collection of primary sphere cell cultures obtained from 60 CRC specimens was used to generate CR-CSC mouse avatars to preclinically validate therapeutic options. We also made use of the ChIP-seq analysis for transcriptional evaluation of HER2 activation and global RNA-seq to identify the mechanisms underlying therapy resistance.ResultsHere we show that in CD44v6-positive CR-CSCs, high HER2 expression levels are associated with an activation of the phosphatidylinositol 3-kinase (PI3K)/AKT pathway, which promotes the acetylation at the regulatory elements of the Erbb2 gene. HER2 targeting in combination with phosphatidylinositol 3-kinase (PI3K) and mitogen-activated protein kinase kinase (MEK) inhibitors induces CR-CSC death and regression of tumour xenografts, including those carrying Kras and Pik3ca mutation. Requirement for the triple targeting is due to the presence of cancer-associated fibroblasts, which release cytokines able to confer CR-CSC resistance to PI3K/AKT inhibitors. In contrast, targeting of PI3K/AKT as monotherapy is sufficient to kill liver-disseminating CR-CSCs in a model of adjuvant therapy.ConclusionsWhile PI3K targeting kills liver-colonising CR-CSCs, the concomitant inhibition of PI3K, HER2 and MEK is required to induce regression of tumours resistant to anti-EGFR therapies. These data may provide a rationale for designing clinical trials in the adjuvant and metastatic setting.

Background: In Fournier’s gangrene the surgical debridement plus broad-spectrum antimicrobial therapy is the mainstay treatment but can cause a great loss of tissue. Moreover, the local poor blood supply, the infection and the damage to the vessels can delay the healing. Consequently, the disease needs long hospital stays and, despite all, has high mortality rate. The aim of our study is to investigate the improvement offered by hyperbaric therapy in Fournier’s gangrene.Methods: We retrospectively evaluated data on 23 consecutive patients admitted for Fournier’s gangrene at the University hospital “P.Giaccone” of Palermo from 2011 to 2018. The relation between hyperbaric therapy, hospital stay and mortality was evaluated. Factors related to mortality were also examined.Results: The use of hyperbaric therapy was offered to 13(56.5%) patients. Hospital stay was longer in patients treated with HBOT[mean11(C.I.0.50-21,89)vs25(C.I.18.02-31.97);p=0.02]. Mortality occurred in three patients(13.1%), two of whom treated with HBOT. Mortality was not statistically related to sex(p=0.20), BMI(p=0.53), renal failure (p=1.00), diabetes(p=0.49), age>65 years old(p=0.55), simplified FGSI>2(p=0.05), higher ASA scores(>=4)(p=0.47), symptoms at admission lasting since more than 72 hours (p=0.28), HBOT(p=1.00), need of colostomy(p=0.06), several operations(p=1.00), several operations plus HBOT(P=1.00). Conversely, the delay between admission and surgical operation was statistically related to mortality, 1.7 days(C.I.0.9-3.5) in survivals vs 6.8 days(C.I.3.5-13.4) in death patients(p=0.001).Conclusions: Our study proves that a delay in the treatment of patients with Fournier’s gangrene has a correlation with the mortality rate, while the use of HBOT seems to not improve the survival rate, increasing the hospital stay instead.

Background. Nowadays, minimally invasive video-assisted thyroidectomy (MIVAT) is considered a safe and effective option. However, its complication rate has not been specifically discussed yet. The aim of this systematic review was enrolling a large number of studies to estimate early and late complications (transient and definitive, uni- and bilateral laryngeal nerve palsy; transient and definitive hypocalcemia; cervical hematoma; hypertrophic or keloid scar) of MIVAT compared with conventional technique. Methods. The review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria in PubMed and Embase. Search terms were “minimally invasive,” “video-assisted,” and “thyroidectomy.” We enrolled randomized clinical trials, nonrandomized trials, and noncontrolled trials. Results. Thirty-two articles were considered suitable. Complication rate of MIVAT was quite similar to conventional technique: only one randomized trial found a significant difference concerning overall skin complication, and a single trial highlighted hypocalcemia significantly increased in MIVAT, concerning serologic value only. No difference concerning symptomatic nor definitive hypocalcemia was found. Conclusions. We can confirm that MIVAT is a safe technique. It should be adopted in mean-high-volume surgery centers for thyroidectomy, if a strict compliance with indication was applied.

Highlights • We describe a case report of large retroperitoneal dedifferentiated liposarcoma totally treated by laparoscopic surgery. • In literature we found few cases of laparoscopic treatment only for Well-Differentiated liposarcoma. • To our knowledge this is the first description of Dedifferentiated liposarcoma completely treated with laparoscopic technique. • Literature review was performed to identify outcomes and advantages of laparoscopic approach for., Introduction Soft tissue sarcomas are rare neoplasms often characterized by local invasiveness and distant metastasis with poor prognosis for affected patients. Among the most frequent sarcomas we find well-differentiated and dedifferentiated liposarcomas characterized by a better survival compared to the other histological types. When it is possible the only curative treatment for these neoplasms is surgical resection. Case report We report a case of a 62-year-old caucasian woman with CT abdominal scan that demonstrated a voluminous solid oval mass in the left perirenal space with dislocation of the kidney and in continuity with the anterior renal fascia. After a percutaneous CT-guided biopsy of the mass the histopathological diagnosis was a dedifferentiated retroperitoneal liposarcoma. We performed a laparoscopic surgical resection of the retroperitoneal mass in block with kidney and left adrenal gland. Discussion When possible, surgical resection with adequate margins represents the only curative therapeutic option for this pathology. Only a few papers are available in literature which take into consideration the possibility of laparoscopic approach for retroperitoneal masses with better vision of surgical field, reduction of post-operative pain and better cosmesis. Conclusion A retroperitoneal mass represents a serious diagnostic challenge. The choice of the best surgical procedure can benefit to the patient prognosis. To our opinion laparoscopy can be a safe and successful treatment and it can represent a valid alternative to open surgery. However, we have no randomized controlled trials that compare laparoscopic versus open resection for retroperitoneal liposarcomas.

Robotic liver surgery has been considered as a unique opportunity to overcome the traditional limitations of laparoscopy; thus, it can potentially extend the indications of minimally invasive liver surgery. From April 2015 to May 2017, 35 patients underwent fully robotic left hepatectomy. The mean operative time was 315min (200-445min) and the mean estimated blood loss was 245ml (125-628ml). Pringle maneuver was required in six cases. Cancer was the indication for surgery in all patients (14 liver metastases, 18 hepatocellular carcinomas and 3 cholangiocarcinomas). There were one to four lesions in a patient and the mean lesion size was 39.2mm (15-85mm). The average length of hospital stay was 6.5days (5-14days). Perioperative morbidity rate was 17.2%. Two patients underwent conversion to open surgery. The 90-day mortality rate was nil. The mean surgical resection margin was 12 (1-22)mm, and R0-resection was reached in 33 out of 35 cases. The robotic left hepatectomy provides interesting surgical outcomes and good oncologic adequacy. It can be safely applied for the management of liver malignancies.

Since it's introduction, laparoscopic surgery represented a real revolution in clinical practice. The use of a new generation three-dimensional (3D) HD laparoscopic system can be considered a favorable "hybrid" made by combining two different elements: feasibility and diffusion of laparoscopy and improved quality of vision. In this study we report our clinical experience with use of three-dimensional (3D) HD vision system for laparoscopic surgery. Between 2013 and 2017 a prospective cohort study was conducted at the University Hospital of Palermo. We considered 163 patients underwent to laparoscopic three-dimensional (3D) HD surgery for various indications. This 3D-group was compared to a retrospective-prospective control group of patients who underwent the same surgical procedures. Considerating specific surgical procedures there is no significant difference in term of age and gender. The analysis of all the groups of diseases shows that the laparoscopic procedures performed with 3D technology have a shorter mean operative time than comparable 2D procedures when we consider surgery that require complex tasks. The use of 3D laparoscopic technology is an extraordinary innovation in clinical practice, but the instrumentation is still not widespread. Precisely for this reason the studies in literature are few and mainly limited to the evaluation of the surgical skills to the simulator. This study aims to evaluate the actual benefits of the 3D laparoscopic system integrating it in clinical practice. The three-dimensional view allows advanced performance in particular conditions, such as small and deep spaces and promotes performing complex surgical laparoscopic procedures.

Background: Despite potential benefits of robotic liver surgery, it is still considered a “development in progress” technique. Methods: The outcomes of 14 patients undergoing robotic right hepatectomy were analyzed and compared with the results of 20 laparoscopic right hepatectomies consecutively performed by the same young surgeon. Results: The overall mean operative time was less in robotic arm (425 ± 139 vs. 565.18 ± 183.73, p = 0.022) and the estimated blood loss was similar (335.15 ± 139.8 vs. 423.95 ± 205.15, p = 0.17); no blood transfusion was required. Two patients in robotic group and 5 in laparoscopic group (p = 0.454) underwent conversion to open surgery; the overall morbidity was 21.4 and 15% in studied arms, respectively (p = 0.634). Pathology reports showed a mean surgical margin of 26.02 ± 3.9 in robotic arm, 28.76 ± 4.6 for laparoscopic, (p = 0.079) and we achieved a R0 resection rate of 91.66 and 85%, respectively. Reoperation and 90-days mortality rate were both null in robotic arm. One patient in laparoscopic group was reoperated due to postoperative hemorrhage. One-year overall and disease free-survival rate were 92.3 and 84.6%, respectively in robotic arm and 90 and 85% in laparoscopic arm. Conclusions: Robotic right hepatectomy is a safe and feasible technique providing promising short-term outcomes and oncological results also in the initial phase of learning curve.

Background. The lungs are among the first organ affected by remote metastases from many primary tumors. The surgical resection of isolated pulmonary metastases represents an important and effective element of therapy. This is a retrospective study about our entire experience with pulmonary resection for metastatic cancer using 1318-nm neodymium-doped yttrium-aluminum garnet laser. Method. In this single-institution study, we retrospectively analyzed a group of 209 patients previously treated for primary malignant solid tumors. We excluded 103 patients. The number and location of lesions in the lungs was determined using chest computed tomography and positron emission tomography-computed tomography. Disseminated malignancy was excluded. All pulmonary laser resections are performed via an anteroaxillary muscle-sparing thoracotomy. All lesions were routinely removed by laser with a small (5-10 mm) margin of the healthy lung. Patients received systematic lymph node sampling with intraoperative smear cytology of sampled lymph nodes. Results. Mortality at 2 years from the first surgery is around 20% (10% annually). This value increases to 45% in the third year. The estimated median survival for patients who underwent the first surgery is reported to be approximately 42 months. Conclusion. Our results show that laser resection of lung metastases can achieve good result, in terms of radical resection and survival, as conventional surgical metastasectomy. The great advantage is the possibility of limiting the damage to the lung. Stapler resection of a high number of metastases would mutilate the lung.

Purpose. Bile is a hepatobiliary lipid-rich sterile solution, and its colonization by microorganisms defines the condition of bactibilia. In this study, we aimed to assess the bile microbiological flora and its potential link with comorbidity in women. Methodology. We performed a microbiologic investigation on 53 female patients with biliopancreatic diseases who granted consent, and we analysed the data using a MATLAB platform. Results. We found that the most frequent disease associated with bactibilia was pancreas head carcinoma (PHC) (P=0.0015), while the least frequent disease was gall bladder carcinoma (GBC) (P=0.0002). The most common microorganisms were Pseudomonas spp. (P

Background Open abdomen (OA) permits the application of damage control surgery principles when abdominal trauma, sepsis, severe acute peritonitis and abdominal compartmental syndrome (ACS) occur. Methods Non-traumatic patients treated with OA between January 2010 and December 2015 were identified in a prospective database, and the data collected were retrospectively reviewed. Patients’ records were collected from charts and the surgical and intensive care unit (ICU) registries. The Acosta ‘‘modified’’ technique was used to achieve fascial closure in vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) patients. Sex, age, simplified acute physiology score II (SAPS II), abdominal compartmental syndrome (ACS), cardiovascular disease (CVD) and surgical technique performed were evaluated in a multivariate analysis for mortality and fascial closure prediction. Results Ninety-six patients with a median age of 69 (40–78) years were included in the study. Sixty-nine patients (72%) underwent VAWCM. Forty-one patients (68%) achieved primary fascia closure: two patients (5%) were treated with VAWC (37 median days) versus 39 patients (95%) who were treated with VAWCM (10 median days) (p = 0.0003). Forty-eight patients underwent OA treatment due to ACS, and 24 patients (50%) survived compared to 36 patients (75%) from the ‘‘other reasons’’ group (p = 0.01). The ACS group required longer mechanical ventilator support (p = 0.006), length of stay in hospital (p = 0.005) and in ICU (p = 0.04) and had higher SAPS II scores (p = 0.0002). Conclusions The survival rate was 62%. ACS (p = 0.01), SAPS II (p = 0.004), sex (p = 0.01), pre-existing CVD (p = 0.0007) and surgical technique (VAWC vs VAWCM) (p = 0.0009) were determined to be predictors of mortality. Primary fascial closure was obtained in 68% of cases. VAWCM was found to grant higher survival and primary fascial closure rate.

Robotic surgery can help to overcome some technical limitations of laparoscopic pancreaticoduodenectomy thanks to EndoWrist instrumentations and the 3D view. Despite the potential benefits, its employment is still low and controversial. We focused on some important technical details crucial for a safe robotic pancreatectomy. After performing 52 robotic pancreatic resections that included 10 pancreatoduodenectomies, the authors describe their technique. The review of literature on robotic and laparoscopic duodenopancreatectomy is also performed in order to evaluate possible benefits of the robotic platform. We describe the step-by-step surgical procedure, analyzing all possible troubleshooting occurring in an initial center experience. The estimated blood loss as well as the length of stay was reduced by the robotic approach. We did not observe any significant increase of pancreatic fistula rate and all other postoperative complications despite our initial learning curve. Robotic pancreatoduodenectomy is a technically advanced procedure that requires important laparoscopic and robotic skills but it shows to be safe, feasible with some clear advantages in the bleeding control and in the reconstructive phase of the procedure.

Background:: Hemorrhoidal disease is a widespread problem in healthy working patients. The traditional surgical approaches cause a loss of several working days related to the post-- operative course that is often painful. To avoid these problems while offering a symptoms resolution in patients with low degrees hemorrhoids, the non-surgical treatments are nowadays largely proposed in proctological clinics. Methods: We resume the recent literature on the issue to offer a practical and easy to use guide for clinicians. Results: Rubber band ligation, injection sclerotherapy and infrared coagulation are cost effective, safe and effective treatments for patients with II- and III-degree hemorrhoids. Relapses are commons even if the procedures can be repeated until symptoms resolution. IV-degree hemorrhoids are not suitable of these treatments. Conclusion: The proctological clinics must evaluate the quality of life offered to patients and discuss with them the appropriate treatment in order to select the most appropriate one for symptoms resolution and disease cure. Less is not always the best but can be an alternative to be offered.

AimsTo evaluate the contribution of light microscopy to detecting Candida spp infection in patients with complicated intra-abdominal infections (IAIs) admitted for acute abdomen to a quality assurance (QA)-certified surgical emergency ward.MethodsWe conducted a retrospective study (2008–2012) of 809 abdominal intraoperative or biopsy tissue specimens obtained from patients admitted with acute abdomen and microbiological samples positive for Candida spp. Demographic data, mortality, comorbidities, specimen type, microscopy results, special histological staining performed, antimicrobial therapy were collected and analysed. Any comments at the multidisciplinary team meeting was recorded in minutes of and approved.ResultsSixty-six patients with complicated IAIs due to Candida spp were identified (39 male, 27 female, mean±SD age 75±20 years). Candida albicans was isolated in 35 cases and Candida non-albicans spp in 31 cases. Candida spp were isolated from blood in 50% of all selected microbiological specimens. Patients were stratified according to Candida spp (albicans vs non-albicans), underlying cancer disease and no previous antimicrobial administration, and a positive correlation with C. albicans isolation was found (p=0.009 and p=0.048, respectively). Out of 41 cases with microscopic evaluation, we identified yeast forms, pseudohyphae or both, indicative of Candida spp, in 23. Identification of Candida spp in histological specimens was higher in C. albicans cases than in C. non-albicans cases (73% vs 37.5%). Microscopy allowed prompt treatment of all patients.ConclusionsLight microscopy still has great diagnostic significance, being a solid QA step. It provides rapid information and clues in patients who may harbour impaired defence mechanisms, concurrent chronic conditions and/or cancer.

Introduction Laparoscopic adrenalectomy is today considered the gold standard of treatment for adrenal tumors. The development of high definition cameras does not eliminate the major limitation of two-dimensional (2D) laparoscopy: lack of depth perception and loss of spatial orientation. Tree-dimensional (3D) HD laparoscopy was developed as an alternative to conventional 2D laparoscopy. Methods We report our experience with use of 3D vision system for laparoscopic adrenalectomy. Between January 2009 and March 2015 we performed a total of 52 laparoscopic adrenalectomies. In this case-control study we considered 13 laparoscopic adrenalectomies performed with three-dimensional (3D) vision system as case group. The last 26 procedures made with two-dimensional (2D) HD laparoscopic system represented the control group. We considered primary end-points: operative time, intraoperative complications and conversion rate. We evaluated also quality of depth perception and surgical strain. Results Although the operative time for the entire surgical procedure was shorter in 3D group, there were no significant differences. The surgeon experienced better depth perception with 3D system and subjectively reported less strain using 3D vision system. Residents and medical students confirmed these data on surgical outcome. Conclusion 3D system vision does not seem to influence the operative time of laparoscopic adrenalectomy performed by experienced surgeon because the surgical technique request simple tasks. We obtain the better visualization in depth perception with effect on surgical precision. Comparative studies are necessary to verify if 3D can reduce perioperative complication with similar operative time.

BACKGROUND: Incisional hernia is one of the most common complications after abdominal surgery with an incidence rate of 11 to 20% post laparotomy. Many different factors can be considered as risk factors of incisional hernia recurrence. The aim of this study is to confirm and to validate the incisional hernia recurrence risk factors and to identify and to validate new ones. METHODS: In the period from July 2007 to July 2017, 154 patients were selected and subjected to incisional hernia repair. The surgical operations were conducted under general anaesthesia. Patients received antibiotic prophylaxis when indicated, according to the hospital prophylaxis scheme. Inclusion criteria of the study were single operator case studies and open laparotomy for incisional hernia repair. The statistical analysis proposed to identify and to verify the risk factors for recurrence of incisional hernia is the Support Vector Machine (SVM). The analysis was conducted verifying 34 risk factors. RESULTS: The data analysis confirmed the known correlations showed in the international literature with a greater incidence of comorbidities such as diabetes 37%, dyslipidaemia and hypercholesterolemia with a cumulative incidence of 16%; tobacco smoke - by combining categories smokers and ex-smokers - reach 46%, COPD 16% and hypertension 51%. CONCLUSIONS: The analysis of the data therefore confirmed the correlations showed in the international literature. A KSVM-based system to classify incisional hernia recurrence has been presented. The type of prosthesis and the site of its implant also play a significant role in the development of the recurrence. Sensitivity (86,25%), Specificity (87,14%), Negative Predictive Value (84,72%), Precision (88,46%), Accuracy (86,67%), and Error (13,33%) scores obtained using the proposed technique highlight the validity for the relapse's classification methodology.

Context No study has analyzed the prevalence of white matter hyperintensities (WMHs) in subjects with diabetic foot syndrome (DFS) and their relationship to adipokine serum levels and indexes of endothelial and cognitive performance. Objective To evaluate omentin and vaspin serum levels and the prevalence of WMHs in subjects with DFS and to analyze their relationship with other endothelial, arterial stiffness, and cognitive functions. Design Case-control study enrolling 40 subjects with DFS, 40 diabetic subjects without foot complications, 40 controls with foot lesions without diabetes, and 40 patients without diabetes mellitus. Main Outcome Measures Pulse wave velocity (PWV), augmentation index, reactive hyperemia index (RHI), serum vaspin and omentin levels, Fazekas score, and Mini-Mental State Examination (MMSE). Results Subjects with DFS showed higher mean PWV values when compared with diabetic controls and lower RHI values when compared with controls. They also showed a lower mean MMSE score, significantly lower omentin serum levels, and a higher prevalence of grade 2 severity of periventricular hyperintensities (PVHs). We observed a significant positive correlation between PWV and PVH and between Fazekas score and PWV among diabetic subjects, whereas among subjects with diabetic foot we observed a significant negative correlation between PVH and RHI. Conclusions Diabetes seems to be more associated with endothelial function disturbance in comparison with patients with diabetic foot that exhibit a more strict association with microvascular brain damage as indicated by our significant finding of an association with PVHs.

The most common microorganisms were Pseudomonas spp. (P < 0.0001) and E. coli (P < 0.0001), which were negatively correlated to PDAC and positively correlated to cholangiocarcinoma by both univariate and multivariate analysis. Gram-negative bacteria are linked to a tumor-associated inflammatory status

Purpose. Robotic surgery is currently employed for many surgical procedures, yielding interesting results. Methods. We performed an historical review of robots and robotic surgery evaluating some critical phases of its evolution, analyzing its impact on our life and the steps completed that gave the robotics its current popularity. Results. The origins of robotics can be traced back to Greek mythology. Different aspects of robotics have been explored by some of the greatest inventors like Leonardo da Vinci, Pierre Jaquet-Droz, and Wolfgang Von-Kempelen. Advances in many fields of science made possible the development of advanced surgical robots. Over 3000 da Vinci robotic platforms are installed worldwide, and more than 200 000 robotic procedures are performed every year. Conclusion. Despite some potential adverse events, robotic technology seems safe and feasible. It is strictly linked to our life, leading surgeons to a new concept of surgery and training.

Background: Described for the first time in 2003, the robotic pancreatic surgery shows interesting results. The evaluation of post-operative outcomes is necessary once we describe an innovative surgical approach. Methods: We have performed a retrospective analysis of a prospectively maintained database on robotic pancreatic surgery including malignant and benign indications for surgery. Results: A total of 50 consecutive patients underwent robotic pancreatic surgery (26 pancreatico duodenectomy and 24 distal pancreatectomy) between January 2012 and July 2015 in a single centre. The overall operative time was 425 (390–620) min. In a subgroup of highly selected malignant tumours, we were able to achieve 88% of R0 resection with robotic approach. A number of lymphnodes rose significantly with growing experience (p =.025). The overall major complication rate (15%), as well as pancreatic fistula rate (16%) were acceptable. The two-year overall survival for the whole group was 65%. Conclusion: The robotic pancreatic surgery in a highly selected group of patients seems safe and feasible. The cost-effectiveness and long-term oncologic outcomes need further investigations.

Background/aim: Laparotomy has been the approach of choice for re-operations in patients with surgical complications. The aim of this retrospective analysis was to evaluate the feasibility and the safety of laparoscopic approach for the management of general abdominal surgery complications. Materials and methods: We report a retrospective review of 75 patients who underwent laparoscopic evaluation for postoperative complications over a 4-year period. Primary outcomes (resolution rate by exclusive laparoscopic approach, conversion rate, further surgery rate) and secondary outcomes (mortality, hospitalization, prolonged ileus, wounds problems and median operative time) were evaluated. Results: Sixty-six patients (88 %) were managed with laparoscopic approach without conversion; of these, sixty-three patients (84 %) had no more or further complications and were discharged from hospital between 4 ± 3 days after “second-look” surgery; three patients (4 %) developed postoperative complications requiring a third surgery. Nine cases (12 %) underwent conversion in open surgery after laparoscopic approach. Two elderly patients (2.7 %) died in intensive care unit, because of multi-organ failure syndrome. Median time elapsed between an intervention and another was about 2.5 ± 9.5 days. Mean operative time was 90 ± 150 min. Postoperative hospital stay was between 4.5 and 18 days. Discussion and conclusion: Laparoscopy has begun to be the preferred method to manage postoperative problems, but only few reports are available actually. Our experience in “relaparoscopic” management of surgical complications seems to suggest that laparoscopy “second look” is an effective tool after open or laparoscopic surgery for the management of postoperative complications and it may avoid diagnostic delay and further laparotomy and related problems.

NO Abstract

Introduction Bowel wall thickening is not an uncommon finding among patient undergoing abdomen CT scan. It may be caused by neoplastic, inflammatory, infectious or ischaemic conditions but also be a normal variant. Although specific radiologic patterns may direct to a precise diagnosis, occasionally misidentification may occur. Thus, in the absence of guidelines, further and not always needed diagnostic procedures (colonoscopy, esophagogastroduodenoscopy or capsule endoscopy) are performed. Patients and methods We conducted a retrospective study on data collected from May 2016 to June 2017. We selected 40 adult patients, admitted in Emergency Department with "abdominal pain" and undergone an abdomen CT scan, in which bowel wall abnormalities were founded. Results 75% patients were found to have a benign condition vs 25% a malignant condition. In the stomach group, 50% were found to have a neoplasm, whilst 33.3% presented an aspecific pattern and 16.7% had an inflammatory disease. In the small bowel cluster, 33.3% patients had an ischaemic disease, 33.3% an aspecific pattern, 22.2% an inflammatory disease and 11.1% was diagnosed with cancer. In the colon group, 36% had an inflammatory disease, 24% a colon cancer, 24% an aspecific pattern and 16% an ischaemic condition. Conclusions We recommend to perform a further endoscopic procedure to all patients with gastric or colonic wall abnormalities on CT scan, on the basis of growing rate of cancer and IBD. Capsule endoscopy should be taken into account in patients with severe symptoms and after a previous negative endoscopic examination.

The relationship between quality of care and provider's experience is well known in all fields of surgery. Even in thyroidectomies and parathyroidectomies, the emphasis on positive volume-outcome relationships is believed. It led us to an evaluation of volume activity's impact in terms of quality of care. A systematic narrative review was performed. According to the PRISMA criteria, we selected 87 paper and, after the study selection was performed, 22 studies were finally included in this review. All articles included were unanimous in attributing to activity volume of surgeons as well as centers a substantial importance. Some differences in outcomes between these investigated categories have been found: best results of the high volume surgeon is evident expecially in terms of complications, on the contrary best outcomes of a high volume center are mainly economics, such as hospital stay and general costs of the procedures. A cut-off of 35-40 thyroidectomies per year for single surgeon, and 90-100 thyroidectomies for single center appears reasonable for identifying an adequate activity. Concerning parathyroidectomy, we can consider reasonable a cut off at 10-12 operations/year. More studies are needed in a European or more circumscribed perspective.

In the originally published article, the name of the first author was given as Marco Marino only. It should be Marco Vito Marino, which is presented correctly above.

BACKGROUND: The incidence of abdominal wall hernia in cirrhotic patients with ascites is between 20 and 40%. Controversies regarding the treatment modality and surgical timing of abdominal wall incisional hernia repair in cirrhotic patients remain. The study proposed wants to analyze the abdominal incisional hernia repair in cirrhotic patients with ascites performed in a single center to determine post-operative morbidity, mortality and complication rate. PATIENTS AND METHODS: Cirrhotic patients with abdominal incisional hernia that underwent surgical operation for abdominal wall hernia repair at the "Policlinico Paolo Giaccone" at Palermo University Hospital between January 2015 and December 2016 were identified and the data collected were retrospectively reviewed; patients' medical and surgical records were collected from charts and the surgical and ICU registries. The degree of hepatic dysfunction was classified using Child-Pugh classification. Post-operative mortality was considered up to 30-days after surgery. A follow-up period of 6 months at least was performed to evaluate hernia recurrence and complications. RESULTS: Mortality rate is of 18.5% (p 0.002). Recurrence rate (p 0.004) and seroma formation rate (p 0.001) are most frequent in urgency group. The elevated ASA score and the prediction of a complicated post-operative course is higher in urgency group (p 0.004) as higher is the in-hospital stay (p 0.001) and the ICU stay (p 0.001). CONCLUSIONS: Elective surgery for abdominal wall hernia repair in cirrhotic patients seems to be successful and associated with lower mortality/morbidity rate and recurrence rate than urgency.

Despite improvements in prosthetics and surgi- cal techniques, the rate of complications following inguinal hernia repair remains high. Among these, discomfort and chronic pain have become a source of increasing concern among surgeons. Poor quality of tissue ingrowth, such as thin scar plates or shrinking scars—typical results with con- ventional static implants and plugs—may contribute to these adverse events. Recently, a new type of 3D dynami- cally responsive implant was introduced to the market. This device, designed to be placed fixation-free, seems to induce ingrowth of viable and structured tissue instead of regressive fibrotic scarring. To elucidate the differences in biologic response between the conventional static meshes and this 3D dynamically responsive implant, a histological comparison was planned. The aim of this study was to determine the quality of tissue incorporation in both types of implants excised after short, medium, and long periods post-implantation. The results showed large differences in the biologic responses between the two implant types. His- tologically, the 3D dynamic implant showed development of tissue elements more similar to natural abdominal wall structures, such as the ingrowth of loose and well-hydrated connective tissue, well-formed vascular structures, elastic fibers, and mature nerves, with negligible or absent inflam- matory response. All these characteristics were completely absent in the conventional static implants, where a persis- tent inflammatory reaction was associated with thin, hard- ened, and shrunken fibrotic scar formation. Consequently, as herniation is a degenerative process, the 3D dynamic implants, which induce regeneration of the typical groin components, seem to address its pathogenesis. Key Words: Inguinal hernia—Herniorrhaphy—Biomaterials —Prostheses—Implants—Tissue regeneration—Tissue scaffolds.

Several studies in the last years demonstrated the better surgical outcome of laparoscopic approach to adrenal gland. Laparoscopic surgery is more difficult to learn and requires different psychomotor skills than open surgery, especially with regard to complex maneuvers requiring precision and dexterity. The development of robotic platform with three-dimensional vision and increased degrees of freedom of the surgical instruments has the aim to overcome these problems. We performed a systematic literature review with meta-analysis to evaluate preoperative data and surgical outcomes of robotic adrenalectomy compared with laparoscopic technique. In September 2016 we performed a systematic literature review using the Pubmed, Scopus and ISI web of knowledge database with search term "robotic adrenalectomy". We identified 13 studies with eligible criteria that compared surgical outcomes. This present systematic review with meta-analysis includes 798 patients: 379 underwent to robotic adrenalectomy (cases group) and 419 to laparoscopic adrenalectomy (controls group). There were no significant differences between the two groups of patients respect to age, gender, laterality and tumor size. BMI instead was significant lower in the robotic group. In this group we found also patients with higher incidence of previous abdominal surgery. The results from operative time demonstrated lower operative time for laparoscopic group but there were no significant differences with robotic group. Robotic adrenalectomy showed a significant lower blood loss. Robotic adrenalectomy is a safe and feasible technique with reduced blood loss and shorter hospital stay than laparoscopic adrenalectomy. Laparoscopic approach seems to be a more rapid technique when comparing to robotic technique, although recent studies demonstrate a significant operative time reduction in robotic group with the learning curve improvement and the development of new surgical technology.

The non-surgical treatments for hemorrhoids are cost and time-saving techniques usually performed in patients suffering early hemorrhoidal disease. The most used are rubber band ligation (RBL), injection sclerotherapy (IS), and infrared coagulation (IRC). We performed a systematic review in order to evaluate: do these procedures really help to avoid further more aggressive treatments? What are the common harms? What are the rare harms? How many recurrences there are? A total of 21 RCTs were included in this review: 12 on RBL, 4 on IRC and 5 on IS. In RBL bleeding stops in up to 90% and III degree hemorrhoids improves in 78%-83.8%. IV degree prolapse should have a more invasive treatment. The commonest complications are bleeding and pain (8-80%). IRC related improvement is 78%, 51% and 22% for I, II and III degree. Post-operative pain occurs in 15- 100% and post-operative bleeding ranges from 15% to 44%. Recurrence rate is 13% at a three months follow-up. IS brings to the resolution of prolapse in 90%-100% of II degree and allows good results for III degree even if reported only by case series. The post-procedural pain is 36%-49%. Bleeding is a very rare harm. Even if not definitive, these treatments could be an alternative for mild symptomatic patients after a clear explanation of recurrence rates and possible complications.

Background. The seroma is one of the most common complications in the axillary lymph nodal dissection (different surgical approaches have been tried to reduce the seroma incidence). In our study we evaluate the outcome of patients using or not the ultrasonic scalpel (Harmonic scalpel) according to a standardized surgical technique. Patients and Methods. From January 2011 to December 2015 120 patients underwent axillary dissection for breast cancer. Patients were divided in two groups: patients belonging to the first group underwent Harmonic scalpel dissection and patients belonging to the second group underwent classical dissection. Each group consisted of 60 patients. Quadrantectomy (QUAD) was performed in 54 patients, 66 women underwent mastectomy. In all patients axillary dissection included the I, II and III level. We compared two groups in terms of: time of surgery, hematoma, drainage volume, days of sealing drainage, seroma formation, number of post-seroma aspirations, upper limb lymphedema, wound infections, post-operative pain. Results. Statistically significant results were obtained in terms of the total volume of the breast and axillary drainage in the two techniques. There were no significant differences in the two samples in terms of operative time incidence of seroma, post-operative hematoma, wound infection, and lymphedema of the upper limb. Conclusion. The small number of cases did not allow us to reach definitive conclusions. The use of Harmonic scalpel seems to show smaller incidence of seroma and reduction of the amount of both breast and axillary drainages. Further studies are needed to define the real advantage in terms of cost benefit of using these devices in the axillary surgery.

Neuroendocrine tumors (NET) are a very heterogeneous group of neoplasms; in recent years we have seen an increase in their incidence (3.65 /100.000/year). They can be associated with hereditary endocrine syndromes (MEN, Von Hippel Lindau); they can occur at any age and the incidence is slightly higher in men than women. The aetiology of the neuroendocrine tumors is unclear; in most cases, inflammation of the bile ducts may be the underlying cause and for this reason, the initial patient's evaluation should be focused on the different aspects concerning the oncological one and the possible sequelae of the biliary obstructions that can evolve in biliary sepsis. All neuroendocrine tumors have malignant potential. The most frequent sites of extrahepatic biliary NETs are the common hepatic duct and the distal common bile duct (19.2%), followed by the middle of the common bile duct (17.9%), the cystic duct (16.7%), and the proximal common bile duct (11.5%). We can divide them into: well-differentiated and poorly differentiated. Considering the clinical features, neuroendocrine tumors can be divided into functional and non-functional. As regards the staging, we distinguish localized, regional and metastatic tumors. Tumors derived from the bile duct are difficult to diagnose preoperatively, mainly because of its low incidence and difficult diagnostic process. However since cholangiocarcinomas account for about 80% of all primary biliary tumors, it is important to think about other options despite their low frequency when a patient presents with abnormal characteristics. The most sensitive immunohistochemical markers are expressing neuron-specific enolase, synaptophisin and chromogranin A. Liver function tests, alkaline phosphatase and bilirubin are often high. Sometimes an anemia can appear in the presence of a chronic disease or in patients with more advanced disease. It is known that the measurement of chromogranin A is useful for the preoperative diagnosis of neuroendocrine tumors. Chromogranin A is elevated in 90% of neuroendocrine tumors of the intestine, and the levels correlate with tumor burden and the possibility of recurrence and, therefore, chromogranin A can be an effective biological marker for preoperative diagnosis of neuroendocrine tumors. Bile endocrine tumors remain silent until metastasizing or growing into neighboring organs, because of its uncommon diagnosis in early stages due to its low incidence, absence of serum markers and lack of symptoms related to the hormonal pattern. Preoperative diagnosis of common bile duct carcinoma is extremely difficult, because it is foretold by non-specific symptoms that include pain or discomfort in the right upper quadrant level and weight loss. A 51- year-old woman presented a jaundice and severe bile duct dilatation. The enhanced CT scan showed a mass, approximately 15 mm in diameter, in the distal common biliary duct. The MRI and ERCP confirmed the mass. Cromogranin A value was negative. The diagnosis of well differentiated endocrine tumor of the biliary tract was done after its surgical resection was performed. The postoperative period was uneventful. Extrahepatic biliary NETs are rare, and extrahepatic bile ducts reportedly account for only 0.32% of primary NET sites. The prognosis for NET of the bile duct appears to be poor.