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Background: Gastrectomy for gastric cancer is a significant cause of secondary exocrine pancreatic insufficiency. Pancreatic enzyme replacement therapy may influence nutritional status and quality of life after gastrectomy, but the pertinent clinical research to date remains controversial. A randomized controlled trial to test this hypothesis was carried out., Methods: After gastrectomy, 43 patients with gastric cancer were randomly assigned to a normal diet (Normal-d; n = 21) or to a pancreatic enzyme supplementation diet (PES-d; n = 22) and were followed up during a 12-month period, assessing nutritional status and quality of life through body mass index (BMI), instant nutritional assessment (INA) class status, serum pre-albumin (SPA) values, and GastroiIntestinal Quality of Life Index (GIQLI)., Results: BMI was not significantly influenced by the type of diet; INA class status was significantly improved in the PES-d arm, particularly during the first 3 months after gastrectomy; SPA levels increased in both arms at 6 months after gastrectomy, reaching significantly higher values in the PES-d arm at 12 months. GIQLI was not significantly influenced by the type of diet throughout the follow-up period; however, this index significantly improved in the PES-d arm between the first and third month after gastrectomy., Conclusions: PES-d improves nutritional status and quality of life after gastrectomy for gastric cancer, particularly within 3 months from the operation. A larger, multicenter trial is necessary to address the potential influence of several confounding variables such as disease stage and adjuvant treatments.

Background: Tumor-positive sentinel lymph node (SLN) biopsy results in a risk of non sentinel node metastases in micro- and macro-metastases ranging from 20 to 50%, respectively. Therefore, most patients underwent unnecessary axillary lymph node dissections. We have previously developed a mathematical model for predicting patient-specific risk of non sentinel node (NSN) metastases based on 2460 patients. The study reports the results of the validation phase where a total of 1945 patients were enrolled, aimed at identifying a tool that gives the possibility to the surgeon to choose intraoperatively whether to perform or not axillary lymph node dissection (ALND)., Methods: The following parameters were recorded: Clinical: hospital, age, medical record number; Bio pathological: Tumor (T) size stratified in quartiles, grading (G), histologic type, lymphatic/vascular invasion (LVI), ER-PR status, Ki 67, molecular classification (Luminal A, Luminal B, HER-2 Like, Triple negative); Sentinel and non-sentinel node related: Number of NSNs removed, number of positive NSNs, cytokeratin 19 (CK19) mRNA copy number of positive sentinel nodes stratified in quartiles. A total of 1945 patients were included in the database. All patient data were provided by the authors of this paper., Results: The discrimination of the model quantified with the area under the receiver operating characteristics (ROC) curve (AUC), was 0.65 and 0.71 in the validation and retrospective phase, respectively. The calibration determines the distance between predicted outcome and actual outcome. The mean difference between predicted/observed was 2.3 and 6.3% in the retrospective and in the validation phase, respectively. The two values are quite similar and as a result we can conclude that the nomogram effectiveness was validated. Moreover, the ROC curve identified in the risk category of 31% of positive NSNs, the best compromise between false negative and positive rates i.e. when ALND is unnecessary (<31%) or recommended (>31%)., Conclusions: The results of the study confirm that OSNA nomogram may help surgeons make an intraoperative decision on whether to perform ALND or not in case of positive sentinel nodes, and the patient to accept this decision based on a reliable estimation on the true percentage of NSN involvement. The use of this nomogram achieves two main gools: 1) the choice of the right treatment during the operation, 2) to avoid for the patient a second surgery procedure.

Unlabelled: Hemangiopericytoma (HPC) is a primary tumor with mesenchymal vascular origin that represents 1% of all vascular neoplasm. HPC develops from the Zimmerman's pericytes around capillaries venules and it is possible to observe it frequently in the extremities, pelvis, retroperitoneum, head, neck and meninges. The only definitive parameter of malignancy is the development of recurrence or distant metastases. This report describes a case of symptomatic retroperitoneal HPC in a young female patient treated by surgical complete removal of the mass, and literature review. Despite the relatively simple surgical management of retroperitoneal Hemangiopericytoma, its diagnosis still remains difficult and often is incidentally. Patients should undergo a close long-term follow up, by periodic CT scan, due to the high probability of local recurrence or distant metastases that can occur also many years after surgery., Key Words: Hemangiopericytoma (HPC), Retroperitoneum, Surgery.

The topic chosen by the Board of the Italian Society of Surgery for the 2013 annual Consensus Conference was gastric cancer. With this purpose, under the direction of 2 chairmen, 36 experts nominated by the Regional Societies of Surgery and by the Italian Research Group for Gastric Cancer (GIRCG) participated in an experts consensus exercise, preceded by a questionnaire and mainly held by telematic vote, in accordance with the rules of the Delphi method. The results of this Consensus Conference, presented to the 115th National Congress of the Italian Society of Surgery, and approved in plenary session, are reported in the present paper.

Implementation of extended lymph node dissection for gastric cancer in western non-specialized centers through tailoring its extent upon disease stage and patient comorbidities was suggested as a wise policy to reduce morbidity and mortality rates, albeit with a potential for undertreatment in elderly and/or comorbid patients. Current definition of R(0) resection for gastric cancer lacks consideration of treatment-related variables such as extended lymph node dissection. Few studies to date have tried to fill this gap in such a clinical context. A retrospective evaluation of factors influencing long-term results after R(0) surgery was done in a prospective series of a non-specialized western surgical unit during the implementation of D(2) lymphadenectomy. Univariate and multivariate analysis of 22 variables were performed on a prospective database of 233 consecutive R(0) resections performed by ten different surgeons in 10 years. Endpoint was disease-free survival calculated at 5 and at 10 years. Disease-free survival rates were independently influenced by age, American Society of Anesthesiologists (ASA) status and lymph node ratio. Subset analysis of the status at censor stratified for age and ASA status failed to identify any significant difference in disease recurrence rates. Lymph node ratio was the only treatment-related independent prognostic factor for long-term results after R(0) surgery for gastric cancer in the setting of a non-specialized western unit, where the extent of lymph node dissection needs to be tailored on the presence of comorbidities (ASA status).

The optimal degree of lymph node dissection for gastric cancer is still matter of debate. Particularly, there are serious doubts about the reproducibility of extended lymph node dissection in western surgical units, and no studies to date have investigated factors influencing lymph node retrieval and examination during the learning curve. Univariate and multivariate retrospective analysis of 21 variables were carried out on a prospective series of 313 consecutive resections for gastric cancer performed by ten different surgeons, with lymph node retrieval and analysis performed by ten different pathologists. Endpoints were number of examined lymph nodes per patient, number of cases with inadequate nodal staging (<15 examined lymph nodes) and lymph node ratio (calculated as the absolute ratio between the number of metastatic and the number of examined lymph nodes). The number of examined lymph nodes per patient (mean ± SD 28.3 ± 14.1, median 26, range 2-78) was independently influenced by age, pN status, the type of gastric resection, the degree of lymph node dissection and single pathologist. There were 47 cases (15.0%) with incomplete nodal staging that was independently determined by the degree of lymph node dissection and by the pathologist. Lymph node ratio was independently influenced by the number of metastatic lymph nodes, the disease stage and by the histological subtype of the tumor. The role of an experienced or dedicated pathologist should not be underevaluated in western series when dealing with lymph node retrieval and examination. Lymph node ratio appeared not to be significantly influenced by the number of examined lymph nodes, being independently influenced only by the number of metastatic lymph nodes, the disease stage and by the histological subtype of the tumor. It could be therefore tested as a prognostic factor limiting the stage-migration phenomenon induced by extended lymph node dissection.

The role of sentinel lymph node biopsy (SLNB) in pT1a and "microinvasive" breast cancer has not been extensively studied. We report our experience with SLNB in patients with "minimal" breast cancer to determine the incidence and type of SLN metastases, and to study the potential impact on their surgical or oncological management. Among some 3387 women operated upon for primary breast cancer who underwent sentinel lymph node biopsy at nine institutions participating in the Rome Breast Cancer Study Group, 251 were staged pT1a or pT1mic (7.4%). There were 13 cases of sentinel lymph node metastases identified in this group of patients (5.2%), seven macrometastases and six micrometastases. Additionally, ITC were diagnosed by immunohistochemistry in four cases (1.6%). The incidence of SLN metastases was 7/174 (4%) and 6/77 (7.8%) in patients with pT1a and pT1mic tumors, respectively (p=0.2). Age and histological grade were predictive factors for SLN metastases. Chemotherapy was seldom directed by axillary node status (8/38 patients). As the incidence of SLN metastases in these patients is very small, particularly in the pT1a group, the indications for even a minimally invasive procedure, such as sentinel lymph node biopsy, should be probably individualized.

We report our multicentric experience with sentinel lymph node biopsy for breast cancer patients. Patients with breast cancer operated on from January 1999 to March 2005 in 6 different institutions in the Rome area were retrospectively reviewed. All patients gave written informed consent. 1440 consecutive patients were analysed, with a median age of 59 years (range: 33-81) and a median tumour diameter of 1.3 cm (range: 0.1-5). Patients underwent lymphatic mapping with Tc99 nanocolloid (N = 701; 49%), with Evans Blue (N = 70; 5%), or with a combined injection (N = 669, 46%). The majority of patients were mapped with an intradermal or subdermal injection (N = 1193; 84%), while an intraparenchymal or peritumoral injection was used in 41 (3%) and 206 patients (13%), respectively. Sentinel lymph nodes were identified in 1374/1440 cases (95.4%), and 2075 sentinel lymph nodes were analysed (average 1.5/patient). A total of 9305 additional non-sentinel lymph-nodes were removed (median 6/patient). Correlations between sentinel lymph nodes and final lymph node status were found in 1355/1374 cases (98.6%). There were 19 false-negative cases (5%). Lymph node metastases were diagnosed in 325 patients (24%). In this group, micrometastases (< 2 mm in diameter) were diagnosed in 103 cases (7.6%). Additionally, isolated tumour cells were reported in 61 patients (4,5%). In positive cases, additional metastases in non-sentinel lymph-nodes were identified in 117/325 cases after axillary dissection (36%). Axillary dissection was avoided in 745/1440 patients (52%). At a median follow-up of 36 months, only 1 axillary recurrence has been reported. Sentinel lymph node biopsy improves staging in women with breast cancer because it is accurate and reproducible, and allows detection of micrometastases and isolated tumour cells that would otherwise be missed. Our multicentric study confirms that this is the preferred axillary staging procedure in women with breast cancer.

Local recurrence (LR) is a major problem following curative resection of rectal cancer. Intraoperative radiation therapy (IORT) is considered an ideal boost technique for increasing the dose of radiation therapy within a restricted area without introducing a significant toxicity. The aim of this study is to present the results of a multimodality treatment containing external beam irradiation, chemotherapy, surgical resection, and IORT delivered by a movable linear accelerator (NOVAC7, Hitesys SpA, Italia), employed in a "traditional" operating room.

The occurrence in the same young patient of three synchronous tumors deriving from different embryogenic tissues and without a clear correlation with a common etiopathogenic factor is very unusual. We report a case of a Caucasian woman submitted to wide resection of a large retroperitoneal liposarcoma and right radical nephrectomy for suspected tumor infiltration. Histological examination of the right ureter and renal pelvis showed the presence of a multifocal urothelial carcinoma that was clinically asymptomatic. Two months later, during follow-up, chest X-ray and computed tomography documented a coin lesion of the upper left lung, confirmed by positron emission tomography. This nodule was surgically removed and examined histologically, resulting in a diagnosis of sclerosing hemangioma. The patient is alive without evidence of recurrent disease.

Background and Aims: The proto-oncogene c-KIT encodes a tyrosine kinase receptor essential during embryonic development and postnatal life. Although deregulated expression of c-KIT has been reported, its role in colorectal carcinoma remains controversial: some authors have described a correlation between c-KIT expression and colorectal cancer (CRC), while others have failed to detect the receptor in the majority of neoplasia examined. To address this question, we designed a prospective study to analyze the expression of c-KIT in normal and neoplastic colonic mucosa of the same patient., Patients and Methods: We analyzed the tissues of 20 patients undergoing surgical resection for colorectal carcinoma by reverse transcriptase-polymerase chain reaction, Western blot and immunohistochemistry, whose results were correlated with histopathological parameters., Results: Most patients (90%) showed c-KIT expression in normal tissue both at RNA and protein level, while in neoplastic tissue it was observed in 30% of patients at RNA level and in 10% at protein level. By immunohistochemistry the localization of c-KIT protein in the normal colon was restricted to interstitial cells scattered in the stroma, whereas the non-neoplastic epithelium was always negative. The mucinous carcinomas were all c-KIT negative, whereas the only case in which c-KIT was displayed in the neoplastic epithelium was a G3 adenocarcinoma., Conclusion: Most colorectal carcinomas do not express c-KIT. We suggest that c-KIT expression is rarely present in this neoplasia; thus, the use of receptor inhibitors should be conducted in selected sub-groups of colon carcinoma patients, subsequent to the clear demonstration of c-KIT overexpression in the neoplastic cells.

Background: The need to administer antibiotic prophylaxis (ABP) during laparoscopic cholecystectomy (LC) is still a matter of significant controversy. The purpose of this study was to resolve this issue by performing a meta-analysis of the available randomized controlled trials (RCT) on this topic., Methods: Papers identified via a systematic literature search were evaluated according to standard criteria. Data regarding the patient sample, study methods, and outcomes were abstracted and summarized across studies. The outcome measures were the rates of all perioperative infections, the rates of surgical site infections, and the rates of infections at other sites. Results were examined for 974 patients randomized to ABP or placebo prior to LC in six RCT published from 1997 to 2001., Results: The cumulative rates of all infections were 2.8% in the ABP group and 4.4% in the placebo group. The pooled odds ratio (OR) (95% confidence interval [CI]) was 0.69 (0.34-1.43; p = 0.32). The cumulative rates of surgical site infections were 2.1% in the ABP group and 2.9% in the placebo group. The pooled OR (95% CI) was 0.82 (0.36-1.86; p = 0.63). The cumulative rates of infections at other sites were 0.7% in the ABP group and 1.5% in the placebo group. Pooled OR (95% CI) was 0.82 (0.18-1.90; p = 0.37). No significant heterogeneity was found in any data pooling., Conclusions: Based on the available evidence, there appears to be no need to administer routine ABP to low-risk patients during LC. However, the number of patients enrolled to date into RCT is insufficient to avoid a type II error. A large and well-designed trial is urgently needed to find a conclusive answer to this question.

Objective: To highlight the current available evidence in antireflux surgery through a systematic review of randomized controlled trials (RCTs)., Summary Background Data: Laparoscopic fundoplication is currently suggested as the gold standard for the surgical treatment of gastroesophageal reflux disease, but many controversies are still open concerning the influence of some technical details on its results., Methods: Papers related to RCTs identified via a systematic literature search were evaluated according to standard criteria. Data regarding the patient sample, study methods, and outcomes were abstracted and summarized across studies. Defined outcomes were examined for 41 papers published from 1974 to 2002 related to 25 RCTs. A meta-analysis was performed pooling the results as odds ratios (OR), rate differences (RD), and number needed to treat (NNT). Data given as mean and/or median values were pooled as a mean +/- SD (SD)., Results: No perioperative deaths were found in any of the RCTs. Immediate results showed a significantly lower operative morbidity rate (10.3% versus 26.7%, OR 0.33, RD -12%, NNT 8), shorter postoperative stay (3.1 versus 5.2 days, P = 0.03), and shorter sick leave (20.1 versus 35.8 days, P = 0.03) for laparoscopic versus open fundoplication. No significant differences were found regarding the incidence of recurrence, dysphagia, bloating, and reoperation for failure at midterm follow-up. No significant differences in operative morbidity (13.1% versus 9.4%) and in operative time (90.2 versus 84.2 minutes) were found in partial versus total fundoplication. A significantly lower incidence of reoperation for failure (1.6% versus 9.6%, OR 0.21, RD -7%, NNT 14) was found after partial fundoplication, with no significant differences regarding the incidence of recurrence and/or dysphagia. Routine division of short gastric vessels during total fundoplication showed no significant advantages regarding the incidence of postoperative dysphagia and recurrence when compared with no division. The use of ultrasonic scalpel compared with clips or bipolar cautery for the division of short gastric vessels showed no significant effect on operative time, postoperative complications, and costs., Conclusions: Laparoscopic antireflux surgery is at least as safe and as effective as its open counterpart, with reduced morbidity, shortened postoperative stay, and sick leave. Partial fundoplication significantly reduces the risk of reoperations for failure over total fundoplication. Routine versus no division of short gastric vessels showed no significant advantages. A word of caution is needed when implementing these results derived from RCTs performed in specialized centers into everyday clinical practice, where experience and skills may be suboptimal.

Objectives: To compare early with delayed cholecystectomy for the treatment of acute lithiasic cholecystitis: a meta-analysis of prospective randomized trials., Methods: Pertinent studies were selected from the Medline, Embase, Cancerlit, HealthSTAR and Cochrane Library Databases, references from published articles, and reviews. Twelve prospective randomized trials (9 addressing open cholecystectomy and 3 laparoscopic cholecystectomy) were selected. Conventional meta-analysis according to the DerSimonian and Laird method was used for the pooling of the results. The rate difference (RD) (95% CI) and the number needed to treat (NNT) were used as a measure of the therapeutic effect., Results: Cumulative operative and perioperative mortality and morbidity were 0.9% and 17.8%, respectively, for open cholecystectomy and 0% and 13.1%, respectively, for laparoscopic cholecystectomy. The pooled RD for operative complications in early surgery was 1.37% (95% CI =-3.78% to 6.53%; p= 0.2) for open cholecystectomy and 3.11% (95% CI =-15.10% to 8.87%; p= 0.6) for laparoscopic cholecystectomy. In laparoscopic cholecystectomy the cumulative conversion rate to open cholecystectomy was 21.5%. The pooled RD for conversion rate in early laparoscopic cholecystectomy was -7.99% (95% CI =-18.46% to 2.47%; p= 0.1; NNT = 13). Total hospital stay (mean +/- SD) was significantly shorter in the early surgery group (9.6 +/- 2.5 days vs 17.8 +/- 5.8 days; p < 0.0001). More than 20% of patients referred to delayed surgery fail to respond to conservative management or suffer recurrent cholecystitis in the interval period., Conclusions: Early operation (open or laparoscopic) does not carry a higher risk of mortality and morbidity compared to delayed operation and should be the preferred surgical approach for patients with acute lithiasic cholecystitis.

A traumatic abdominal wall hernia is an unusual injury that may follow various types of blunt trauma. Differing patterns of muscular and fascial disruption can occur due to the different types of force involved as well as the tensile properties of the various areas in the abdominal wall. The anatomical defects which thus occur, therefore vary from small tears to large disruptions. A surgical repair is not always straightforward, and therefore close attention must be paid to such factors as the size and site of the defect, any associated intra-abdominal injuries, and the timing of repair, in order to achieve the best surgical repair. We consider the role of a computed tomography scan in the diagnosis of the muscular defects and associated injuries to be very important. Mesh repair offers an advantage in preventing recurrence in the presence of large defects, but strict criteria in their use must be followed, as the presence of hollow viscus injuries is an absolute contraindication to the use of mesh.

Colon cancer is the second leading cause of death for cancer disease, after lung cancer, with nearly 18,000 deaths per year in Italy. In spite of the progress that have taken place over the past 30 years, little improvement has been gained in this dismal outcome, and the 5-year survival remains around 50%. Over one half of the patients will suffer from recurrence after a potentially curative resection. A major challenge lies in better detection of recurrences in order to diagnose those patients still amenable to curative resection. Locoregional recurrence is of particular interest and its frequency, diagnostic limitations and surgical treatment are herein discussed.

The authors report their experience related to a series of 96 consecutive central venous catheters location through subclavian, right internal jugular, basilic and cephalic veins for TPN administration. Because of the specific complications reported, they are in favour of the trans-basilic peripheral approach for a short term TPN; the internal jugular or the subclavian way are indicated for long term ones. In addition, they stress the importance to limit the use of multilumen catheters just when absolutely necessary, due to the increased infection percentage.

The central venous catheters, now usually adopted in surgical patients, present some potential septic risks, and the longer the catheter is in place, the more dangerous it is. The authors report their experience on 130 central venous catheters, out of which 96 were used for TPN administration and 34 for monitoring purposes. The catheters were introduced through subclavian, internal jugular or basilic veins, in accordance with a standardized technique. The observed infection percentage, caused by the catheters, was 7.7%; the infection was easily controlled by the catheter removal and a proper antibiotic therapy. The only death, surely due to sepsis, was caused by Candida fungus in an immunosuppressed female patient. Therefore the authors stress the importance to prevent septic complications in order to avoid fatal ones.