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Surgical site infection (SSI) remains the most frequent complication after colorectal resection. The role of sutures coated with antimicrobial agents such as triclosan in reducing SSI is controversial. Methods: This was a multi-center randomized controlled trial with patients and outcome assessors blinded to treatment. The study was performed in four university referral hospitals. Patient candidates for elective colorectal resection were assigned randomly to abdominal incision closure with polyglactin 910 triclosan-coated sutures (triclosan group) or with polyglactin 910 without triclosan (control group). The primary outcome was the rate of SSI within 30 d after hospital discharge. The secondary outcomes were the overall rate of incision complications and length of hospital stay (LOS). Results: Two hundred eighty-one patients (triclosan group: 140; control group: 141) were analyzed after randomization. The rate of SSI was 12.9% (18/140) in the triclosan group versus 10.6% (15/141) in the control group (odds ratio: 1.24; 95% confidence interval: 0.60-2.57; p=0.564). Secondary outcome analysis showed an overall incision complication rate of 38.3% in the control group versus 45.7% in the triclosan group (odds ratio: 1.36; 95% confidence interval: 0.84-2.18; p=0.208). Median LOS was 11 d in both groups (p=0.55). Conclusions: Surgical sutures coated with triclosan do not appear to be effective in reducing the rate of SSI.

Objective. The advantages of single-incision surgery for the treatment of gallstone disease is debated. Previous meta-analyses comparing single-incision laparoscopic cholecystectomy (SILC) and standard laparoscopic multiport cholecystectomy (SLMC) included few and underpowered trials. To overcome this limitation, we performed a meta-analysis of randomized and nonrandomized studies. Methods. A MEDLINE, EMBASE, and Cochrane Library literature search of studies published in and comparing SILC with SLMC was performed. The primary outcome was safety of SILC as measured by the overall rate of postoperative complications and biliary spillage. Feasibility was another primary outcome as measured by the conversion and operative time. Postoperative pain, length of hospital stay, perioperative blood loss, time to return to normal activity, and cosmetic satisfaction were secondary outcomes. Results. We identified 43 studies of which 30 were observational reports and 13 experimental trials, for a total of 7489 patients (2090 SILC and 5389 SLMC). The overall rate of complications was comparable between groups (relative risk [RR] = 1.08; 95% CI = 0.87-1.35; P =.46), as were the rates of biliary spillage (RR = 1.16; 95% CI = 0.73-1.84; P =.53) and conversion rate (RR = 0.88; 95% CI = 0.53-1.46; P =.62). Operative time was in favor of SLMC (weighted mean difference = 0.73; 95% CI = 0.67-0.79; P <.0001). Secondary outcomes favored SILC, but with marginal advantages. Conclusions. SILC is a feasible technique but without any significant advantage over SLMC for relevant end points. Although secondary outcomes favored SILC, the small magnitude of the advantage and the low quality of assessment methods question the clinical significance of these benefits.

BACKGROUND: The efficacy and safety of self-expandable metallic stent (SEMS) placement as a bridge to elective surgery or definitive palliation versus emergency operation to treat colorectal obstruction is debated. This study aimed to evaluate the outcomes of patients with colorectal obstruction treated using different strategies. METHODS: Subjects admitted to the authors' department with colorectal obstruction (n = 134) were studied prospectively. They underwent endoscopic stenting as a bridge to elective surgery (SEMS group: n = 49) or for definitive palliation (n = 34). A total of 51 patients underwent immediate surgery without stenting (NO-SEMS). Treatment was decided by the senior on-call surgeon. RESULTS: Placement of SEMS was technically successful in 95.3 % and clinically successful in 98.7 % of cases. The short-term complications in the SEMS group were perforation (n = 1, 1.2 %), migration (n = 4, 4.9 %), occlusion (n = 4, 4.9 %), colon bleeding (n = 3, 3.7 %), and abdominal pain (n = 6, 7.4 %). The postoperative complication rate was 32.7 % in the SEMS group versus 60.8 % in the NO-SEMS group (P = 0.005), with a significant reduction in wound infections (26.5 vs 54.9 %; P = 0.004), abdominal abscess (14.3 vs 39.2 %; P = 0.006), respiratory morbidity (10.2 vs 37.3 %; P = 0.002), and intensive care treatment (10.2 vs 33.3 %; P = 0.007). The median postoperative hospital stay was 10 versus 15 days (P = 0.001). The in-hospital mortality rate in both groups was 2 %. Long-term follow-up evaluation showed less incisional hernia (6.3 vs 22.0 %; P = 0.04) and definitive stoma formation (6.3 vs 26.0 %; P = 0.01) in the SEMS group than in the NO-SEMS group, respectively. Kaplan-Meier survival curves showed a benefit for the SEMS group (log-rank test, 0.004). The long-term SEMS-related complication rate for the palliative patients was 43.8 %. The hospital readmission rate for SEMS complications was 34.4 %. Overall clinical success was 81.2 %. CONCLUSIONS: In case of c

BACKGROUND: The prognosis of patients with liver metastases from gastric cancer (LMGC) is dismal, and little is known about prognostic factors in these patients; so justification for surgical resection is still controversial. Furthermore the results of chemotherapy for these patients are disappointing. The purpose of this study was to review recent outcomes of hepatectomy for LMGC and to determine the suitable candidates for surgery, assessing the surgical results and clinicopathologic features. Moreover we compare these results with those obtained with alternative treatments.

AIM: To compare safety and efficacy of a bipolar vessel sealing system (BVSS) to the conventional technique in axillary node dissection. METHODS: 116 women with breast cancer were randomized to conventional node dissection surgical technique (control; n = 58) by scalpel and monopolar cautery or using an electrothermal BVSS (study group; n = 58). RESULTS: The median (range) total volume of fluid collected by drain and aspirations was 305 (30-1420) mL in the study group and 335 (80-1070) mL in the control group (p = 0.325). The median (range) total volume of lymph collected by percutaneous aspirations was 207.5 (40-1050) mL in the study group and 505 (270-705) mL in the control group (p = 0.010). The incidence of seroma was similar in both groups (p = 0.845). The axillary drain was removed earlier in the study group than in controls (p = 0.046). CONCLUSION: The use of a BVSS offers marginal advantages when compared to the conventional technique.

Interactions between host and malignant tumor is currently under intensive investigation. The immune system seems to have a key role in cancer development and spread. Novel strategies to actively modulate the immune system have been proposed to improve the outcome of disease in patients with neoplasms. Our experience with systemic immunomodulation by interleukin-2 (IL-2) focused on both systemic and local immunity in surgical gastrointestinal cancer. Preoperative IL-2 subcutaneous injection was effective in counteracting postoperative immunosuppression, with a reduction of serum levels of IL-6 and the maintenance of preoperative levels of IL-12, a higher number of circulating total lymphocytes, and CD3(+) and CD4(+) T-cells, and a smaller decrease in circulating mature and immature dendritic cells (DCs), as well as a reduction in postoperative serum levels of vascular endothelial growth factor. At the intestinal level, in patients with colorectal cancer, preoperative administration of IL-2 affected both phenotype and function of resident dendritic cells and T-cells, skewing local immunity toward a more immunogenic one. Our data showed that immunomodulation by IL-2 was effective in counteracting the systemic postoperative immune suppression related to surgical stress. IL-2 was also active at a local level on intestinal immunity, affecting both phenotype and function of resident T-cells and DCs. Future studies will encompass the possibility of reaching more adequate intratumoral IL-2 concentrations by direct intralesional injection to maximize immunostimulatory effects and minimize adverse effects.

Objectives: The prognosis of patients with liver metastases of gastric cancer (LMGC) is dismal, but little is known about prognostic factors in these patients; thus justification for surgical resection is still controversial. The purpose of this study was to review recent outcomes of hepatectomy for LMGC and to determine which patients represent suitable candidates for surgery by assessing surgical results and clinicopathologic features. Methods: Outcomes in 21 patients with LMGC who underwent hepatectomy between 1998 and 2007 were assessed. Isolated metastases and potential to perform a curative resection were requisite indi-cations for surgery. Surgical outcome and clinicopathologic features of the hepatic metastases were analysed. Results: Overall 1-, 3- and 5-year survival rates after hepatic resection were 68%, 31% and 19%, respectively; three patients survived for >5 years without recurrence. Univariate analysis revealed a solitary metastasis, negative margin (R0) resection and the presence of a peritumoral fibrous capsule as significant favourable prognostic factors. These characteristics were present in all of the three patients who survived for >5 years. Conclusions: Solitary metastases from gastric cancer should be treated surgically and confer a better prognosis. Surgical resection should provide microscopically negative margins (R0). A new prognostic factor, the presence of a pseudocapsule, may be associated with improved prognosis.

An antimicrobial dressing containing ionic silver was found effective in reducing surgical-site infection in a preliminary study of colorectal cancer elective surgery. We decided to test this finding in a randomized, double-blind trial.

Liver resections are demanding operations which can have life threatening complications although they are performed by experienced liver surgeons. The parameter "Blood Loss" has a central role in liver surgery, and different strategies to minimize it are a key to improve results. Moreover, recently, new technologies are applied in the field of liver surgery, having one goal: safer and easier liver operations. The aim of this paper is to review the different principal solutions to the problem of blood loss in hepatic surgery, focusing on technical aspects of new devices. © 2012 Fabrizio Romano et al

Introduction It is generally believed that resumption of feeding after colorectal resection is indicated only after recovery of bowel function. This study was designed to verify safety, feasibility, and tolerance of early oral postoperative feeding (EOF) outside an enhanced recovery after surgery (ERAS) program. Materials and methods One hundred patient candidates to elective colorectal resection were prospectively enrolled in an EOF program. Feeding was started on postoperative day (POD) 1 with oral nutritional supplement (ONS). On POD 2, patients had normal food plus ONS to reach 1,000-1,200 kcal/day with progressive increase until 1,800-2,000 kcal/day. Results were compared with historical controls (n=100) in whom oral feeding was allowed only after full bowel function recovery. The ERAS program was not applied in both groups. esults The EOF group had a better recovery of short half-life protein synthesis compared with the control group (P<0.001). Stool canalization occurred after a median of 3 days (range, 1-6 days) in the EOF group versus 5 days (range, 2-8 days) in the control group (P=0.001). The feeding protocol was completed in 89 patients within POD 5. Tolerance to resumption of feeding was similar in the two groups. The overall rate of postoperative complication was 22% in the EOF group vs. 27% in the control group (P=0.51). The median length of hospitalization was 9 days (range, 6-25 days) in the EOF group vs. 12 days (range, 6-31 days) in controls (P=0.01). Conclusions EOF after colorectal operations is feasible and safe outside an ERAS program. © 2011 Springer-Verlag.

Background Pneumoperitoneum (PP), established for laparoscopic (LPS) operation, has been associated with potential detrimental effects, such as mesenteric ischemia-reperfusion injury. The objective of the trial was to measure intestinal tissue oxygen pressure (PtiO2) and oxidative damage during laparoscopic (LPS) and open colon surgery and during the postoperative course. Methods Forty patients candidate to left-sided colectomy were randomized to undergo open or LPS resection (20 patients/group). During the operation, PtiO2 was measured at established changes of PP pressure (from 0-15 mmHg) and for 6 days postoperatively. P tiO2 was determined by a polarographic microprobe implanted in the colon wall. Ischemia-reperfusion injury was assessed by plasma malondialdehyde (MDA). ClinicalTrial.gov registration number: NCT01040013. Results LPS was associated with a higher PtiO2 at the beginning of surgery (73.9 ± 9.4 vs. 64.3 ± 6.4 in open; P = 0.04) and at the end of the operation (57.7 ± 7.9 vs. 53.1 ± 4.7 in open; P = 0.03). PtiO2 decreased significantly during mesentery traction vs. beginning in both groups (respectively 58.7 ± 13.2 vs. 73.9 ± 9.4 in LPS and 55.3 ± 6.4 vs. 64.3 ± 6.4 in open group; minimum P = 0.02). During LPS, there was a significant decrease of PtiO2 only when PP was increased to 15 mmHg (63.2 ± 7.5 vs. 76.6 ± 10.7 at 10 mmHg; P = 0.03). PtiO2 also was significantly better in the LPS group during the first 3 days after operation (minimum P = 0.04 vs. open). MDA significantly increased in both groups after mesentery traction and at the end of operation vs. baseline levels with no difference between techniques. Conclusions LPS seems to be associated with a better intra- and postoperative PtiO2. High-pressure PP may impair PtiO2.

Intra-abdominal infections are still associated with high rate of morbidity and mortality.A multidisciplinary approach to the management of patients with intra-abdominal infections may be an important factor in the quality of care. The presence of a team of health professionals from various disciplines, working in concert, may improve efficiency, outcome, and the cost of care.A World Society of Emergency Surgery (WSES) Consensus Conference was held in Bologna on July 2010, during the 1st congress of the WSES, involving surgeons, infectious disease specialists, pharmacologists, radiologists and intensivists with the goal of defining recommendations for the early management of intra-abdominal infections. This document represents the executive summary of the final guidelines approved by the consensus conference. © 2011 Sartelli et al; licensee BioMed Central Ltd.

To evaluate the impact of the traditional clamp-crush technique and a radiofrequency bipolar vessel sealing device (BVSD) for liver resection on operative blood loss, transfusion rate, duration of operation, length of hospitalization and morbidity.

AIM: To investigate whether probiotic bacteria, given perioperatively, might adhere to the colonic mucosa, reduce concentration of pathogens in stools, and modulate the local immune function. METHODS: A randomized, double-blind clinical trial was carried out in 31 subjects undergoing elective colorectal resection for cancer. Patients were allocated to receive either a placebo (group A, n = 10), or a dose of 107 of a mixture of Bifidobacterium longum (BB536 ) and Lactobacillus johnsonii (La1 ) (group B, n = 11), or the same mixture at a concentration of 109 (group C, n = 10). Probiotics, or a placebo, were given orally 2 doses/d for 3 d before operation. The same treatment continued postoperatively from day two to day four. Stools were collected before treatment, during surgery (day 0) and 5 d after operation. During the operation, colonic mucosa samples were harvested to evaluate bacterial adherence and to assess the phenotype of dendritic cells (DCs) and lymphocyte subsets by surface antigen expression (flow cytometry). The presence of BB536 and La1 was evaluated by the random amplified polymorphism DNA method with specific polymerase chain reaction probes. RESULTS: The three groups were balanced for baseline and surgical parameters. BB536 was never found at any time-points studied. At day 0, La1 was present in 6/10 (60%) patients in either stools or by biopsy in group C, in 3/11 (27.2%) in group B, and none in the placebo group (P = 0.02, C vs A). There was a linear correlation between dose given and number of adherent La1 (P = 0.01). The rate of mucosal colonization by enterobacteriacae was 30% (3/10) in C, 81.8% (9/11) in B and 70% (7/10) in A (P = 0.03, C vs B). The Enterobacteriacae count in stools was 2.4 (log10 scale) in C, 4.6 in B, and 4.5 in A (P = 0.07, C vs A and B). The same trend was observed for colonizing enterococci. La1 was not found at day +5. We observed greater expression of CD3, CD4, CD8, and naive and memory lymphocyte subsets in group C than

AIM: To investigate whether probiotic bacteria, given perioperatively, might adhere to the colonic mucosa, reduce concentration of pathogens in stools, and modulate the local immune function. METHODS: A randomized, double-blind clinical trial was carried out in 31 subjects undergoing elective colorectal resection for cancer. Patients were allocated to receive either a placebo (group A, n = 10), or a dose of 107 of a mixture of Bifidobacterium longum (BB536 ) and Lactobacillus johnsonii (La1 ) (group B, n = 11), or the same mixture at a concentration of 109 (group C, n = 10). Probiotics, or a placebo, were given orally 2 doses/d for 3 d before operation. The same treatment continued postoperatively from day two to day four. Stools were collected before treatment, during surgery (day 0) and 5 d after operation. During the operation, colonic mucosa samples were harvested to evaluate bacterial adherence and to assess the phenotype of dendritic cells (DCs) and lymphocyte subsets by surface antigen expression (flow cytometry). The presence of BB536 and La1 was evaluated by the random amplified polymorphism DNA method with specific PCR probes. RESULTS: The three groups were balanced for baseline and surgical parameters. BB536 was never found at any time-points studied. At day 0, La1 was present in 6/10 (60%) patients in either stools or by biopsy in group C, in 3/11 (27.2%) in group B, and none in the placebo group (P = 0.02 C vs A). There was a linear correlation between dose given and number of adherent La1 (P = 0.01). The rate of mucosal colonization by enterobacteriacae was 30% (3/10) in C, 81.8% (9/11) in B and 70% (7/10) in A (P = 0.03 C vs B). The Enterobacteriacae count in stools was 2.4 (log10 scale) in C, 4.6 in B, and 4.5 in A (P = 0.07 C vs A and B). The same trend was observed for colonizing enterococchi. La1 was not found at day +5. We observed greater expression of CD3, CD4, CD8, and naive and memory lymphocyte subsets in group C than in group A with a dose

PURPOSE: We investigated the prognostic significance of postoperative infections for the outcome of 192 patients with colon cancer. METHODS: The 5-year survival rates were analyzed by the Kaplan-Meier technique. Univariate and multivariate analyses were done to evaluate prognostic variables using Cox's proportional hazard model. RESULTS: Forty-three patients developed deep incisional or organ/space surgical site infections. The groups with and without infection were comparable. Multivariate analysis showed that only Dukes' stage (p=0.048) and postoperative infection (p=0.011) were independently associated with outcome. In patients with infective complications, the survival rate was significantly lower than in subjects without infection (log rank p=0.0004). CONCLUSIONS: These results stress the importance of evaluating variables other than the classical tumor stage in predicting long-term cancer outcome

Cancer-associated immunodeficiency is seriously worsened by surgical trauma. Short-term pre-operative interleukin-2 (IL-2) administration abolished post-operative immunodeficiency. The effects of a pre-operative IL-2 immunotherapy on the prognosis of colorectal cancer patients (Dukes' stages B and C), undergoing radical surgery, are reported. The study included, after post-operative stratification, 86 consecutive patients with colorectal cancer Dukes' stage B (57) and C (29), undergoing radical laparotomic surgery, randomised to be treated pre-operatively, with or without a short-term course of subcutaneous (s.c.) IL-2 immunotherapy. Human recombinant IL-2 was given s.c. at 6×106 I.U. twice daily pre-operatively for 3 consecutive days. Surgery was performed 36 hours after the last IL-2 injection. Dukes' C patients of both groups received standard adjuvant chemotherapy consisting of 5-FU plus folates and radiotherapy for rectal cancer patients. After a median follow-up of 54 months (range 18-86), the progression rate was significantly lower in patients pre-treated with IL-2 than in controls: 9/42 (21.4%) IL-2 group vs. 19/44 (43.1%) controls, (p<0.03). The positive effect of immunotherapy was detected both in the Dukes' B group, with 5/29 (17%) progression in the IL-2 group vs. 9/28 (32%) in controls, and Dukes' C patients with 4/13 (30%) vs. 10/16 (62%). This study shows that a 3-day pre-operative course of IL-2 immunotherapy may improve prognosis in patients with colorectal cancer at Dukes' stages B and C, as previously demonstrated in patients with more advanced disease. Therefore, the early activation of the antineoplastic immune system in the first post-operative days following a presurgical activation with IL-2 may counteract the growth of minimal residual disease and prevent late disease progression.

OBJECTIVE: To revise a series of multiple abdominal trauma in order to evaluate the type of diagnosis process and therapy undertaken, the complication and patient survival rates. PATIENTS: Three hundred ten patients of whom 294 (94.8%) with a single abdominal organ injury associated or not with trauma of extra-abdominal organs (thorax, mediastinum, brain, bone) and 16 patients with a multiple abdominal injury (2 or more organs) associated or not with trauma of extra-abdominal organs. Age, gender, vital parameters, injury dynamics, number of organs, site of injury, Injury Severity Score (ISS), Abdominal Trauma Index (ATI) and Glasgow Coma Scale (GCS) have been recorded at admission. RESULTS: Multiple abdominal trauma represent 5% of all abdominal trauma. All trauma were closed ones: 14 street accident and 2 precipitations. A non operative management was undertaken in 6 patients, successfully completed in 2, while 4 patients required a surgical intervention to control bleeding within 12 hours of observation. Ten patients underwent immediate operation for unstable vital signs. The mean number of abdominal organs damaged was 2.8/patient. The mortality rate was 43.7% (7/16). All patients died during surgery. By comparing dead and surviving patient, initial haemodynamics and severity of ISS, GCS, and ATI scores were significant negative prognostic factors. The median length of hospitalisation of survivors was 12 days. CONCLUSIONS: Non operative management of multiple abdominal injury seems to be feasible in a small percentage and possibly only in selected cases.

The control of damaging inflammation by the mucosal immune system in response to commensal and harmful ingested bacteria is unknown. Here we show epithelial cells conditioned mucosal dendritic cells through the constitutive release of thymic stromal lymphopoietin and other mediators, resulting in the induction of 'noninflammatory' dendritic cells. Epithelial cell-conditioned dendritic cells released interleukins 10 and 6 but not interleukin 12, and they promoted the polarization of T cells toward a 'classical' noninflammatory T helper type 2 response, even after exposure to a T helper type 1-inducing pathogen. This control of immune responses seemed to be lost in patients with Crohn disease. Thus, the intimate interplay between intestinal epithelial cells and dendritic cells may help to maintain gut immune homeostasis.

The surgical treatment of liver metastasis due to colorectal cancer can substantially modify the natural history of the disease, mainly when it is associated with effective medical treatment. Chemotherapy, via systemic or locoregional (intrahepatic) administration, has 2 possible objectives: as adjuvant treatment, to prevent or delay disease recurrence; as neo-adjuvant treatment, mainly interesting for the surgeon, to allow resective surgery in responding patients previously considered not-operable. Unfortunately, the severe immune deficiency associated with the advanced cancer negative impact on long-term outcome after any treatment (surgery, chemotherapy) is a limit for the clinical application of multidisciplinary treatments. Aim of this study is to review the possible different approaches to improve the clinical results, either as tumour response or overall survival, using an association of IL-2 with different chemotherapy procedures, in order to recover the locoregional and/or systemic immunodeficency. Several literature studies are worth of consideration not only for the biological activity reported, but also for the preliminary clinical results. At our Department, we have started a clinical experience in order to verify and confirm the results reported in these studies. The preliminary results seem to confirm an increase of chemotherapy activity obtained with an association of IL-2 immunotherapy with systemic therapy procedures and mainly with locoregional therapeutic programs

INTRODUCTION: Predicting long-term survival and cancer recurrence in patients with colorectal cancer is difficult because of the many factors that may affect the prognosis. This study investigated the prognostic significance of postoperative infections for patient outcome. METHODS: From an electronic database we selected 192 patients undergoing elective radical surgery for Dukes' stage B and C colorectal adenocarcinoma. The five-year survival rates were analyzed by the Kaplan-Meier method. Univariate and multivariate analyses were carried out to evaluate the potential prognostic variables using the Cox proportional hazard model. RESULTS: Forty-three patients developed deep incisional or organ/space surgical site infections, while the remaining 149 were complication free. The two groups were comparable for baseline, surgical and histopathological characteristics. At univariate analysis, Dukes' stage and infections were negative prognostic factors, while peritumoral infiltration of lymphocytes and eosinophils and fibrotic tissue appeared as protective variables. However, multivariate analysis showed that only Dukes' stage (P = 0.048) and occurrence of postoperative infectious complications (P = 0.011) were independently associated with outcome. In patients with infectious complications, the survival rate was significantly lower than in patients without infections (log-rank = 0.0004). CONCLUSIONS: The present results suggest the importance of evaluating other variables besides tumor stage in the prediction of long-term outcome. In prognostic studies more attention should be paid to postoperative infections