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Introduction: Today average life expectancy in Western Countries has reached 80 years. At the same time, colorectal cancer (CRC) ranks first on both cancer incidence and related mortality. Therefore we face the problem of treating colorectal cancer occurring in elderly patients. Over the last years, there has been growing evidence in the literature that this population should be offered life-prolonging radical surgeries. The aim of the study is to assess clinical features and postoperative outcomes in 80 years old and older patients treated for CRC. We focused on safety (complication rates and operative mortality) and oncological results (radical excision and number of isolated lymph nodes). Methods: From September 2011 to May 2015, 455 resections for CRC with curative intent were performed: 148 patients were over 80 years old (GroupA), 307 patients were younger than 80 years (GroupB). Patients’ demographic, clinical and histo-pathological parameters, as well as intra- and perioperative results were analysed. Results: In GroupA 72 patients underwent emergency procedures (49%) and 76 underwent elective procedures (51%); conversely in GroupB 85 patients underwent emergency procedures (53%) and 76 underwent elective procedures (47%), respectively (p

Introduzione Indications for elective surgery in diverticular disease are sill debated and recent findings suggest a conservative approach since most patients present complicated diverticulitis as the first manifestation of diverticular disease. In our study we analyze the result in term of postoperative morbidity and mortality in patiets who underwent elective surgery for diverticular disease. Pazienti e metodi From September 2011 to May 2015 we perfomerd 170 surgical interventions for diverticular disease in our unit. Of these, 51 resection were performed in elective setting. Pre-, intra- and postoperative findings were collected in a prospective database. Multivariate analysis with logistic regression was performed to find out independent predictive factors for postoperative events. Statistical analysis was made with SPSS v.13.0 and significance was considered with p value < 0.05. Risultati Male:Female ratio was 1:1 with mean age of 5914 years. 44 patients was younger than 75 years. 54.9% of patients had one or more comorbidities and 12 patients (23.5%) had ASA score >2. Most patients had only one previous hospital admission (28 patients, 54.9&) while 9 patients reported two or more admissions. 2 patient underwent surgery for the development of colo-vescical or colovaginal fistula and 2 patient for paracolic or pelvic abscess refractory to medical therapy. In 70.6% (36 patients) of cases a laparoscopic approach was performed with a conversion rate of 16.7%. No postoperative in-hospital mortality was recorded. Postoperative complication rate was 31.4% (16 patients) according Clavien-Dindo Classification. Anyway 14 patients had grade I or II complication with mild clinical impairment. Multivariate analysis did not find any independent predictive factor for overall and surgical complications. On the other hand presence of diabetes mellitus (DM) and ASA score > 2 was associated with increased risk of medical complication (OR 16.7; 95%CI 1.1-259.9 P=0.044 and OR 8.5; 95%CI 1.1-62.6 P=0.036 respectively). A T-test was performed to compare mean of postoperative stay within the two variables. Patients with ASA score > 2 were found to have longer postoperative stay respect to those with ASA score 1-2 (13,5 vs 8,4 P=0.008). No significant difference was found in patients with or without DM (9.0 vs 9.6 P=0.818). Conclusioni In our experience, elective surgery for diverticular disease can be performed safely and often with mini-invasive approach, with accetable rate of significant postoperative event. Anyway we need powerful studies providing strong evidence to identify patients who could really take advantage of elective surgical intervention.

Introduzione There is lack of consensus whether to consider acute diverticulitis in younger patients a more aggressive disease than in other. While some authors considered diverticulitis in younger worst than in older patients, others suggested similar outcomes. In this study we evaluate differences between patients  45 years old and > 45 who underwent surgery for acute diverticulitis. Pazienti e metodi From September 2011 to May 2015 119 patients underwent emergency surgical intervention for acute diverticulitis in our unit. Pre-, intra- and postoperative findings were collected in a prospective database. 12 patients (Group A, 10,1%) were  45 years old. We compared clinical and pathological data between Group A patients and the remaining 145 (Group B 89.9) to find out any difference for characteristics of patients, clinical presentation, operative and short-term results. Uni- and multivaiate analysis were performed with SPSS v. 13.0 and satistical significance considered with p value < 0.05. Risultati Slight difference between Group A and Group B was found about presence of males (75.0% vs 43.9%; p=0.065). Significant differences were found for patients with one ore more comorbidities (16.7% vs 86.9%; p

Background: It is a commonly held belief that in emergency surgery is not rare an inadequate lymphadenectomy resulting in pathologically understaged or indeterminate staging of the patient. Consequently some patients may not receive a necessary adjuvant chemotherapy or be subjected to unnecessary therapy. Methods: From September 2011 to May 2015, 483 patients were admitted in our Unit with the diagnosys of colo-rectal cancer. Four-hundred and fifty-five underwent to radical resection and were enrolled in this study. One-hundred and fifty-seven patients (35%) required an emergency operation (Group 1) and 298 (65%) had elective surgery (Group 2). Patients information were entered into a database: age and sex, tumor site, type of resection, laparoscopic versus open approach, stage, number of nodes and adequacy of lymph-node harvest (adequacy >= 12 lymph-nodes harvested). Statistical analysis was performed with SPSS v13; significance was defined as p< 0,05. Results: In Group 1, tumor sites were: right-sided 46%, left sided 45% and 9 % rectum. In Group 2, tumor sites were right-sided 38%, left sided 31% and 31 % rectum. These differences were statistically significant. The number of nodes harvested was similar in the two groups (Group 1: 18,3±9,2 nodes; Group 2: 18,7±10,1 nodes, p=0,97). The adequacy of lymph node harvest was 95% in Group 1 and 89% in Group 2. Thus the adequacy of lymphadenectomy was better in Group 1, however these differences were not statistically significant (p=0,60). The number of nodes harvested and the adequacy of lymphadenectomy were not influenced by the type of surgical approach (laparoscopic versus open surgery). Group 1 patients had a more advanced cancer stage (stage III/IV 47,1% vs. 36,0%, p=0,0006), but the need for enlarged resection was not significantly different in the two groups. Conclusions: Our data didn’t show significant differences in nodes harvesting in emergency colo-rectal surgery compared to elective surgery. Adequacy of lymphadenectomy is comparable in the two settings.

Introduzione Right sided colonic diverticulitis is a rare condition in Western countries while is common in Asian ones. In most cases, right colonic diverticulitis mimicks an acute appendicitis and it is often diagnosed when explorative laparoscopy excludes the presence of appendicits. We report our experience in the treatment of right-side diverticulitis. Pazienti e metodi From September 2011 to May 2015 170 patients underwent surgical intervention for diverticular disease in our unit, both in emergency or elective setting. Pre- intra- and postoperative data of patients were prospectively registered. Uni and multivariate analysis was performed both for factors associated with postoperative morbidity and conversion to laparotomy. Statistical analysys was performed with SPSS v. 13.0. Significance was considered for p value < 0.05. Risultati 17 patients (10%) was affected by right colonic diverticulitis and only 3 of them (17.6%) came from Asian countries. Male/female ratio was 1:1 with mean age of 5115 years, statistically lower respect to our cohort of patients with left side diverticulitis (6714 years; P

Introduzione Complicated acute diverticulitis (CAD) occurs in approximately 10 to 25 percent of patients affected by diverticular disease and a surgical treatment is often necessary. Postoperative morbidity and mortality are still high, up to 40% of cases in patients with generalized peritonitis. The purpose of this study is to identify predictive prognostc factor for postoperative morbidity and mortality in patients requiring surgical intervention for CAD. Pazienti e metodi From September 2011 to May 2015 170 patients underwent surgical intervention for diverticular disease in our unit. Of these, 119 patients required urgent surgery for complicated acute diverticulitis (CAD). Pre-, intra- and postoperative findings were collected in a prospective database. Multivariate analysis with logistic regression was performed to find out independent predictive factors for postoperative morbidity and mortality. Statistical analysis was made with SPSS v.13.0 and significance was considered with p value < 0.05. Risultati There were 56 males and 63 females with mean age of 68 ± 15 years. 100 patients (84.0%) were at first hospital admission for diverticular disease and in 16 cases (13.4%) the disease was localized at right colon or ceacum. A stomy was required in 84 patients (70.6%) and postoperative morbidity rate was 52,9% according Clavien–Dindo Classification. Anyway only 10.9% of patients were affected by grade III or IV complication with a mortality rate of 16.8%. At multivariate analysis the presence of a postoperative medical complication was the only predictive factor for mortality (OR 10.3; 95%CI 2.1-51.3 p=0.004) while the presence of COPD and purulent or fecal peritonitis were not statistically significant (OR 3.3; 95%CI 0.9-12.2 p=0.073 and OR 3.1 95%CI 0.8-11.6 p=0.099 respectively). For postoperative morbidity the logistic regression showed that patients ≥75 years and with ASA score > 2 were independently associated with postoperative morbidity (OR 2.8; 95%CI 1.1-7.2 p=0.028 and OR 5.3 95%CI 2.0-13.9 p=0.001 respectively). The same factors were independent prognostic factor associated with medical complication with OR 3.0; 95%CI 1.1-7.8 p=0.028 and OR 6.5 95%CI 2.0-21.3 p=0.002 respectively. Multivariate analysis of factor predicting surgical morbidity showed that age ≥75 was the only predictive factor for postoperative surgical morbidity (OR 3.1; 95%CI 1.1-8.8 P=0.027). Conclusioni In our experience the majority of patients who require surgery for CAD are at the first episode of acute diverticulitis. Medical complication after surgery for CAD is the only factor associated with mortality while surgical complications do not seem to have the same weight. Age≥75 years and ASA score >2 are independent predictive factors for postoperative medical complications while only age seems to have a significant effect on surgical morbidity.

Aim of study: Metastatic involvement of the small bowel by melanoma is rare. The average time from the excision of the primary cutaneous melanoma to the occurrence of intestinal metastases tends to be between 3 and 5 years; one case of recurrence after 15 years is described. The most common kind of lesion is polypoid: this can cause intussusception and intestinal occlusion. We report a case of intestinal occlusion by an ileal metastasis of a melanoma occurred 7 years earlier. Materials and Methods: Case Report: The patient was a 57-year-old female who was admitted to our hospital for persistent abdominal pain and sub-occlusion. The patient's past medical history included cutaneous malignant melanoma 7 years before and lobular breast adenocarcinoma 10 years before. During the previous three months, she had intermittent abdominal pain and a weight loss of about 7 kg. Abdominal-US, EGDS and colonoscopy were all negative for pathologic findings. During the hospital stay, a CT enterography revealed lower intestinal intussusception, and enlarged lymph nodes both in the abdominal cavity and in the retroperitoneum. Intraoperatively we found an ileal invagination due to a polypoid mass of the ileal tract. Segmental ileal resection was performed; wide mesenteric lymph node dissection was not possible because of large and extended retroperitoneal lymphadenopathies. Histological examination showed epithelioid and spindle tumor cells with obvious cytoplasmic melanin deposition. Immunohistochemical staining revealed that tumor cells were positive for S-100, HMB-45 and vimentin, confirming the diagnosis of melanoma. Main results and conclusions: Appearance of GI metastases is reported up to 15 years after the inital diagnosis of melanoma. Reported clinical signs and symptoms generally include chronic abdominal pain, occult or gross bleeding and, as in this case, weight loss. Aspecificity of symptoms may impede early diagnosis and treatment of the disease. As in this case, where curative surgery is impossible because of the extent of disease, metastatic tumor resection or GI tract bypass surgery is recommended to relieve symptoms or avoid future complications. Early diagnosis of metastases requires adequate imaging (CT) and prolonged follow up.

Aim: To identify prognostc factor for postoperative complications in patients who underwent surgery for complicated acute diverticulitis (CAD). Method: From September 2011 to March 2016 we operated 136 patients for CAD. Multivariate analysis with logistic regression was performed for postoperative morbidity and mortality. Results: Mean age was 68 15 years. In 17 cases (12.5%) the disease was localised at right colon. Postoperative morbidity was 53.7%. According Clavien-Dindo classi- fication, 12.5% of patients had grade III-IV complications with mortality at 15.4%. At multivariate analysis, age  80, chronic renal failure and diffuse peritonitis were independent factors for mortality (respectively; OR 2.8, 95% CI 1.00–8.2; P = 0.005, OR 5.4, 95% CI 1.6–18.3; P = 0.007, OR 2.4, 95% CI 1.2–4.9; P = 0.014). For postoperative morbidity, the only independent factor was left side disease (OR 4.2, 95% CI 1.1–16.0; P = 0.033), while chronic renal failure did not reach significance (OR 3.8, 95% CI 0.9–15.9; P = 0.062). Conclusion: Surgery for CAD has high rate of postoperative adverse events. Partic- ular care must be taken in patients’  80 years, with renal impairment and with Hinchey III-IV disease. Right colonic CAD seems to have a milder postoperative course.

Aim: In elective surgery, the recommended oncologic criteria include en-bloc resection of invaded organs and structures, free margins and an adequate number of lymph nodes yielded. The aim of this study was to analyse whether the above criteria were met in emergency surgery. Method: From September 2011 to January 2016 494 patients underwent colonic resection for CRC. Data were collected and statistical analysis was performed with SPSS v13.0; significance was defined as P < 0.05. Results: In the Emergency Group patients had a more advanced cancer stage (51.4% vs 36.0%, P = 0, 0002), but the need for enlarged resection was not significantly different. The number of radical resections (R0) was greater for elective patients (93.4% vs 79.7%, P < 0.001), but the numbers of free distal margins and of excised nodes was similar in two groups. Emergency procedures had a higher morbidity (34.2% vs 31.9%, P = 0.67) and mortality (12.4% vs 1.3%, P < 0.001). Multivariate analysis showed that emergency presentation is an independent predictor both for mortality and morbidity (P = 0.0001~OR = 7.6; p = 0.0220~OR = 1.7), and for R0 resection (P = 0.0002~OR = 3.5) but it is not an independent prognostic factor for distal margins involved and lymph nodes harvest (P = n.s.). Conclusion: Adherence to guidelines for CRC surgery is safe and feasible, but the emergency setting is an independent risk factor for postoperative morbidity and mortality; and is associated with a lower R0 resection rate.

Aim: To evaluate differences between patients 45 who underwent surgery for acute diverticulitis (AD). Method: From September 2011 to May 2015 119 patients underwent surgery for AD. 12 patients (Group A, 10.1%). Results: Group A had less patients with comorbidities (16.7% vs 86.9%; P < 0.001), in particular cardiovascular (0% vs 67.3; P < 0.001) with ASA 1–2 in 91.7% of patients (vs 29.0%, P < 0.001). Right colonic disease was found in 41.7% of Group A (vs 10.3%; P = 0.010). Group A patients were at first admission in 91.7% of cases respect to 83.2% (P = 0.688) and laparoscopy was performed in 50% of patients (vs 20.6%; P = 0.033). The majority of Group A patients did not required ostomy respect to Group B (33.3% vs 74.8%; P = 0.006) with no difference for incidence of purulent / faecal peritonitis (33.3% vs 57.9%; P = 0.131). Morbidity and medical complications were lower in Group A (8.3% vs 57.9%; P = 0.001 and 8.3% vs 44.9%; P = 0.015). The groups did not differ for mortality (8.3% vs 17.8% ; P = 0.688). Hospital stay was shorter in Group A (6.3 2.0 vs 15.3 14.6; P = 0.002). Multivariate analysis showed only higher, not significant, incidence of ostomy group B (HR 4.0; 95% CI 0.85–19.0; P = 0.08). Conclusion: AD in young patients does not seem to be more aggressive. Surgical intervention should be taken into account not considering age.

Context Soft pancreatic parenchyma is the most widely recognized risk factor for pancreatic fistulas. Objective To evaluate factors related to a “soft pancreas”. Methods Retrospective study of patients who underwent pancreaticoduodenectomy or left pancreatectomy. Factors considered were: sex, age, co-morbidities, body mass index, American Society of Anesthesiologists (ASA) score, characteristics of the pancreatic remnant and preoperative diagnosis. Principal endpoints were: to recognize preoperative factors related to a soft pancreatic remnant and to establish if they are useful in predicting a pancreatic fistula. Results Two hundred and eight patients were recorded. The pancreatic fistula rate was 29.3% and it was significantly related to the type of resection, the soft texture of the pancreatic remnant (P=0.037), a Wirsung duct diameter 24 kg/m2 (P=0.011); a Wirsung duct size ≤3 (PConclusions Body mass index >24 kg/m2, Wirsung duct size, JOP. Journal of the Pancreas, Vol 14, N° 5S (2013): September (Suppl.) - p. 528-602

Context The impact on heath care service of pancreatic resections in elderly patients is unknown. Objective To evaluate the costs of postoperative stay in elderly patients undergone pancreatic resections for malignancy. Methods From 2004 to 2013, 213 patients underwent pancreatic resections and were recorded in a prospective data base. They were divided in three groups (Results The total costs of postoperative stay of pancreatic resections was higher in patients aged 70-80 years (11,461±9,352€; P=0.050) and in those ≥80 years (13,130±10,000€; P=0.032) in comparison to patients Conclusions Pancreatic resections in elderly patients with comorbidities affected by ductal adenocarcinoma were not cost-effective., JOP. Journal of the Pancreas, Vol 14, N° 5S (2013): September (Suppl.) - p. 528-602

Context Laparoscopic distal pancreatectomy (LDP), was rapidly spread in Italy as technique for the treatment of both malignant and benign pancreatic neoplasm. Objective To compare the results of LDP in Italy in high volume (HVC) and low volume (LVC) pancreatic centers. Methods A systematic search using the terms “pancreatectomy AND laparoscopic AND Italy” was performed through MEDLINE and EMBASE. A total of 37 manuscripts were found and 5 manuscripts were considered. Data were extracted using a predesigned pro-forma and a pooled analysis was carried out. Results Three studies was conducted in HVC including 76% of the cases. The weighted mean number/years of patients who underwent LDP, was 8.8 and 3.4, in HVC and LVC, respectively, resulting in a pooled mean difference of 5.40 (95% CI: 4.26-6.54; Pvs. 31.6%) in patients underwent distal pancreatectomy, resulting in OR of 0.35 (95% CI: 0.16-0.78; P=0.01). The most frequent lesion treated was cystic lesion in HVC (58.9%) while in LVC were solid neoplasm (73.7%) resulting in OR of 4.72 (95% CI: 1.84-12.07; P=0.001). The number of patients affected by ductal carcinomas treated was low both in HCV and LVC (11.5 and 20.0%, respectively; P=0.25). Operative time was similar in HVC and LVC with a weighed mean of 200 and 214 minutes, respectively (P=0.20). Rate of conversion was lower in HVC than LVC (7.6% vs. 20.0%) resulting in a OR 0.32 (95% CI: 0.10-1.04; P=0.06). Postoperative morbidity rate (42% vs. 30.0%; P=0.24), pancreatic fistula rate (27.3% vs. 26.6%; P=0.94), and re-operation rate (5.2% vs. 0%; P=0.21) were similar in HVC and LCV. Mean postoperative stay (LOS) was shorter in HVC than LVC (6.5 vs. 11.3 days) resulting in a pooled mean difference of -4.80 (95% CI: -6.57 to -3.03; Pvs. 1.3) resulting in a RR of 1.25 (95% CI: 1.05-1.48; P=0.01). Conclusion In LVC, LDP was frequently performed. In HVC only one-third body-tail pancreatic lesions, more frequently cystic, was laparoscopically treated. Rate of conversion was lower and LOS shorter in HVC respect on LVC., JOP. Journal of the Pancreas, Vol 14, N° 5S (2013): September (Suppl.) - p. 528-602

Context Serous cystic tumours (SCTs) of the pancreas are regarded as a benign entity with rare malignant potential. Surgical resection is generally considered curative. It was usually performed in large, symptomatic tumours or in cases in which the diagnosis was not clear. Objective To evaluate factors related to the surgical indication. Methods From 2000 to 2013, data of 43 patients affected by SCTs were collected in a prospective database. Demographics, clinical, radiological, surgical and pathological data were considered as factors related to surgical indication. After 2000 all patients were observed by a dedicated team including radiologists, surgeons, gastroenterologists and pathologists. Thus, patients were divided in two periods, before and after the 2000, to assess if there had been difference over the time in the management of this type of tumours. Univariate and multivariate analysis were performed. Results Thirty-three patients (76.7%) underwent surgical resection, while 10 (23.3%) entered in a surveillance program. At univariate analysis, factors related to surgery were: symptoms (P=0.026), radiological presence of microcysts of diameter Conclusions In our experience the only factor related to surgery was the presence of symptoms., JOP. Journal of the Pancreas, Vol 14, N° 5S (2013): September (Suppl.) - p. 528-602

Context The safety of pancreatic resections in very elderly patients is still controversial. Objective To evaluate postoperative mortality, morbidity, type of discharge and length of hospital stay (LOS) in octogenarians who underwent pancreatic resections for malignancy. Methods From 2004 to 2013, 213 patients underwent pancreatic resections and were recorded in a prospective data base. They were divided in three groups: Results Mortality rate was higher (P=0.029) in patients ≥80 years (16.7%) only when compared with patients Conclusions Age ≥80 years increased the risk of postoperative mortality and discharge to health care facility after pancreatic resections., JOP. Journal of the Pancreas, Vol 14, N° 5S (2013): September (Suppl.) - p. 528-602

Cholecystocolonic fistulas (CCF) are rare complications of gallstones with a variable clinical presentation. Despite modern diagnostic tools, cholecystocolonic fistulas are often asymptomatic and it is difficult to diagnose them preoperatively. Biliary-enteric fistulae have been found in 0.9% of patients undergoing biliary tract surgery. The most common site of communication of the fistula is the cholecystoduodenal (70%), followed by the cholecystocolic (10–20%), and the least common is the cholecystogastric fistula. Herein, we report a case of female patient with multiple episodes of acute recurrent cholangitis due to common bile duct and gallbladder stones in which preoperative imaging studies were negative for cholecystocolonic fistula that was incidentally discovered and treated during surgery and was appropriately treated. A review of the literature is reported too.

Context Patients with locally advanced pancreatic cancer are usually treated with chemoradiotherapy and rarely they became resectable. Herein, we present the case of a patient with locally advanced pancreatic cancer. Case report A 56-year-old man was observed in October 2011 because of high blood levels of CA 19.9 (>230 U/mL) and the presence of a pancreatic mass of the uncinate process (diameter 3.8x3.5 cm) revealed by US and CT scan. An US-guided biopsy allowed the diagnosis of well differentiated pancreatic adenocarcinoma, biliopancreatic type. CT scan showed a vascular involvement of both superior mesenteric vein and artery. The disease was defined as locally advanced unresectable pancreatic cancer. The patient started chemotherapy with gemcitabine and oxaliplatin. Five months later, CT scan re-evaluation of the disease showed a stable disease. Thus, a protocol of radio-chemotherapy was suggested. Eight months later from diagnosis, the mass was still unresectable. Other eight cycles of gemcitabine and oxaliplatin were performed. In February 2013 a further CT scan evaluation demonstrated a smaller lesion (3.5x2.2 cm) and also the vascular involvement was decreased, still without a normal fat plane between the tumor and the vessels. Another cycle of gemcitabine and oxaliplatin was completed. At the end of May 2013, the 18FDG-PET was negative; CT scan demonstrated a further decreased of the mass (maximum diameter: 2.5 cm) while the mesenteric vessels involvement still remained. Moreover, the genomic characteristics of the patient DNA were different from other the pancreatic cancer. Because of the long-term survival of the young patient, the partial regression of the disease and the genomic characteristics of the tumor, a surgical approach was indicated. The patient underwent to a total pancreatectomy with splenectomy plus segmental resection of portal mesenteric trunk. Pathological diagnosis confirmed a well-differentiated ductal pancreatic carcinoma, biliopancreatic type (T4), with R0 resection. Conclusion Our case suggests that there are locally advanced pancreatic cancers in which chemoradiotherapy can allow surgical pancreatic resection probably because they have particular genomic characteristics., JOP. Journal of the Pancreas, Vol 14, N° 5S (2013): September (Suppl.) - p. 528-602

Context In 2012 the International Consensus Guidelines for the management of IPMNs changed the criteria for surgery and the definition of “malignancy”, reserving this term only for invasive carcinoma. Objectives To evaluate the accuracy of surgical criteria to predict malignancy. Methods From 2003 to 2012, data regarding 184 patients with IPMNs, were recorded in a prospective database. Forty-two (22.8%) patients, undergoing surgery, were evaluated according to the new guidelines. Criteria for surgery (cyst size, Wirsung dilatation, symptoms and presence of solid endocystic component) were studied to assess the malignancy in patients affected by IPMNs. Multivariate analysis was carried out comparing the new (only invasive carcinoma) and old definition of malignancy (invasive carcinoma and high grade dysplasia). Results All operated patients presented criteria for surgery: 9 (21.4%) had pancreatitis, 12 (28.6%) showed enhancing solid component (ESC), 28 (66.7%) had main pancreatic duct (MPD) dilated and in 18 (42.9%) cases cystic size was ≥30 mm. Malignancy was recorded in 21 (50.0%) and 17 (40.5%) patients, according to the Sendai and Fukuoka definitions. At multivariate analysis no factors predicted malignancy according to Fukuoka definition, while presence of ESC (RR 14.2; 95% CI 1.8-113.5; P=0.012) and cystic size (RR 1.1; 95%CI 1.02-1.20; P=0.019) were related to malignancy according to Sendai definition. A dimensional cut-off of the cystic lesion of 26 mm was obtained with a ROC curve (AUC=0.724; P=0.013). At the multivariate analysis, this cut-off resulted the strongest independent factor predicting malignancy according to Sendai definition (RR 8.0; 95%CI 1.13-56.95; P=0.037). Conclusion In our experience, surgical criteria seem to be inefficacy to predict presence of invasive carcinoma. ESC and cystic size were the only factors able to detect patients with high grade dysplasia or invasive carcinoma and to suggest the surgical approach., JOP. Journal of the Pancreas, Vol 13, N° 5S (2012): September (Suppl.) - p. 548-650

Context The role of lymph node ratio (LNR) has been recognized as a prognostic factor in several malignancies. Objectives To evaluate the role of LNR in patients affected by pancreatic neuroendocrine tumors (pNETs). Methods Data regarding 45 patients were extracted from a dedicate database containing 92 patients undergone surgical exploration for pNETs. Patients who underwent palliative operation or enucleoresection or without Ki-67 determination were excluded. Sex, age, presence of symptoms, hormonal status, site of tumor, presence of MEN1, surgical procedure, R status, TNM-ENETS stage, WHO 2010 classification, Ki-67, and LNR were studied as possible factors influencing disease free survival (DFS) with univariate and multivariate analyses. Results Mean age of patients was 60±13 years. There were 22 (51.2%) female and 21 (48.8%) male. Symptoms were present in 27 (62.8%) patients. 34 (79.1%) patients had non-functioning pNETs and more frequently the tumor was located in the body (46.5%). Five (11.6%) patients were affected by MEN1. R0 resection was carried out in 38 (88.4%) cases. There were 17 (39.5%) pNETs G1, 24 (55.8%) pNETs G2 and 2 (4.7%) pancreatic neuroendocrine carcinomas (pNECs) G3. Mean Ki-67 was 6±10%. According to TNM-ENETS stage there were 17 (39.5%), 2 (4.7%), 17 (39.5%), and 7 (16.3%) patients in stage I, II, III, and IV, respectively. LNR was 0 in 26 (60.5%) patients, between 0 and 0.2 in 8 (18.6%) patients, and >0.2 in 9 (20.9%) patients. Mean DFS was 48±56 months. Multivariate analysis found that TNM-ENETS stage (HR 5.0; P=0.036) and Ki-67 (HR 1.2; P=0.016) were significantly related to DFS. There were no differences between patients with LNR=0 and LNR between 0 and 0.2 (HR 5.9; P=0.172) while patients with LNR between 0 and 0.2 had better DFS respect to those with LNR >0.2 (HR=0.2; P=0.01). A new cut off for LNR of 0.07 was obtained by ROC curve (AUC 0.771; P=0.008). Considering the new cut off, the multivariate analysis showed that LNR Conclusion LNR can be considered an important prognostic factor predicting DFS in patients affected by pNETs., JOP. Journal of the Pancreas, Vol 13, N° 5S (2012): September (Suppl.) - p. 548-650

Context Rates of microscopic margin involvement (R1), after pancreaticoduodenectomy for peri-ampullary cancer, vary markedly from 16% to more than 75% .One of the reasons is the lack of international consensus protocol for the pathological examination. Objectives To evaluate the rates of R1 in patients undergoing pancreaticoduodenectomy for peri-ampullary malignancy after the application of a standardized protocol of specimen’s margination. Methods From January 2010 to May 2012 data regarding 71 patients (Group A) undergoing pancreaticoduodenectomy for periampullary cancer, were collected in a prospective database. In all patients the histological examination was carried out according of a standardized protocol of specimen’s margination. R1 was defined as the presence of microscopic involvement Results The two groups were similar regarding sex, age, type and extension of resection and histological data (T, N, type of tumor). R1 rate was statistically significant higher in Group A than Group B (89.2% vs. 66.7%, P=0.015). The logistic regression, conducted for all patients, showed that presence of ductal adenocarcinoma or cholangiocarcinoma and T status increased significantly the risk of R1 (OR=41.4, P=0.004 and OR=6.3, P=0.050, respectively). The multivariate analysis including the type of margination showed that also the application of a standardized margination protocol was an independent factor related to R1 (OR=4.3; P=0.030). Conclusion Lack of standardization of pathological examination and controversy regarding the definition of microscopic margin involvement have resulted in variation of reported R1 rates Margin involvement in pancreatic cancer is a frequent and prognostically significant finding when specimens are assessed using a standardized protocol of specimen’s margination., JOP. Journal of the Pancreas, Vol 13, N° 5S (2012): September (Suppl.) - p. 548-650

Context IPMNs can be surgically treated or managed conservatively. Objectives To evaluate the effectiveness of the follow-up strategy for IPMN. Methods From January 2003 to June 2012, data regarding 184 patients with IPMNs, as well as type of management (surgery or follow-up), were recorded in a prospective database. Indication to surgery was established according to international consensus guidelines. The patients were divided in three groups: group A (G1), patients with criteria for surgery selected for surgical treatment; group B (G2) patients without criteria for surgery selected for radiological follow-up; group C (G3) patients with criteria for surgery but with high surgical risk selected for radiological follow-up. Failures of our strategy was a pathological diagnosis of benign IPMN in G1 or deaths for malignant IPMN in G2 and in G3. The intention to treat analysis was carried out. Finally we evaluated overall survival (OS) and disease-specific survival (DSS) among the three groups. Results Sex, age and presence of co-morbidities were similar among the three groups. Surgical treatment was proposed in 42 (22.8%) patients (group A). Radiological follow-up was suggested in 142 (77.2 %) patients. Of these, 119 (83.8%) did not present criteria for surgery (group B), while only 23 (16.2%) had one or more criteria (group C). Overall mean follow-up was 30.5±22.4 months. Rate of success was lower in group A than in groups B and C (45.2%, 100%, and 95.7% respectively; PConclusion For patients without criteria of malignancy a follow-up strategy seems effective. Patients with criteria for surgery, without high surgical risk, have to be surgically treated., JOP. Journal of the Pancreas, Vol 13, N° 5S (2012): September (Suppl.) - p. 548-650

CONTEXT: Post-pancreatectomy hemorrhage is one of the most common complications after pancreaticoduodenectomy. OBJECTIVE: To evaluate the late post-pancreatectomy hemorrhage rate according to the International Study Group of Pancreatic Surgery criteria and to recognize factors related to its onset. METHODS: A prospective study of 113 patients who underwent pancreaticoduodenectomy was conducted. Late post-pancreatectomy hemorrhage was defined according to the criteria of the International Study Group of Pancreatic Surgery. Demographic, clinical, surgical and pathological data were considered and related to late post-pancreatectomy hemorrhage. RESULTS: Thirty-one (27.4%) patients had a post-pancreatectomy hemorrhage. Twenty-five (22.1%) patients developed late post-pancreatectomy hemorrhage: 19 (16.8%) grade B, 6 (5.3%) grade C. Surgical re-operation was performed in 2 out of the 25 cases with late post-pancreatectomy hemorrhage (8.0%) grade C associated with postoperative pancreatic fistula. At univariate analysis, the only factor significantly related to late post-pancreatectomy hemorrhage was postoperative pancreatic fistula (P

Context: In some cases, synchronous superior mesenteric-portal vein resection can be performed during pancreatic resection for cancer. The reconstruction technique is usually primary anastomosis; in only a few cases is an autologous vein graft needed. Case report: We report a case of reconstruction of the superior mesenteric-portal vein with a splenic vein autograft in a patient affected by pancreatic head adenocarcinoma who underwent a total pancreatectomy. Conclusions: The reconstruction of the superior mesenteric-portal vein with a splenic vein autograft should be performed in selected cases. It allows a reduction of operating time, it is a less invasive approach than reconstruction using an internal jugular vein autograft and it can be an oncologically correct approach