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The effect of anastomotic leakage, in patients who underwent surgery for carcinoma of the esophagus and gastroesophageal junction, on overall survival (OS) is a debated and controversial topic. The aim of this systematic review was to clarify the impact of anastomotic leakage on long-term survival of patients with esophageal cancer undergoing esophagectomy. A systematic literature review was carried out from 2000 to 2022. We chose articles reporting data from patients who underwent surgery for carcinoma of the esophagus and gastroesophageal junction. Data regarding 1-, 3- and 5-year OS were analyzed. Twenty studies met the inclusion criteria, yielding a total of 9,279 patients. Analyzing data from selected studies, anastomotic leakage was found to be associated with decreased OS in 5,456 cases while in the remaining 3,823 it had no impact on long term survival (p<0.05). However, this result did not emerge from the other studies considered in the systematic review. Anastomotic leakage is a severe postoperative complication, which seems to have an impact on overall survival. However, the topic remains debated and not supported by all case series included in this systematic review., (Copyright © 2023, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Introduction: Thyroidectomy followed by radioactive iodine therapy (RAI) is the treatment of choice for differentiated thyroid carcinoma (DTC). Serum thyroglobulin (Tg) measurement has proved to be useful for predicting persistent and/or recurrent disease during follow-up of DTC patients. In our study, we evaluated the risk of disease recurrence in patients with papillary thyroid carcinoma (PTC), who were treated with thyroidectomy and RAI, by measuring serum Tg at different time-points: at least 40 days after surgery, in euthyroidism with TSH < 1.5 and usually 30 days before RAI (Tg -30 ), on the day of RAI (Tg 0 ), and seven days after RAI (Tg +7 )., Methods: One hundred and twenty-nine patients with PTC were enrolled in this retrospective study. All patients were treated with 131 I for thyroid remnant ablation. Disease relapse (nodal disease or distant disease) during at least 36 months follow-up was evaluated by serum measurements of Tg, TSH, AbTg at different time points and by imaging techniques (neck ultrasonography, 131 I-whole body scan (WBS) after Thyrogen ® stimulation). Typically, patients were assessed at 3, 6, 12, 18, 24, and 36 months after RAI. We classified patients in five groups: (i) those who developed nodal disease (ND), (ii) those who developed distant disease (DD), (iii) those with biochemical indeterminate response and minimal residual thyroid tissue (R), (iv) those with no evidence of structural or biochemical disease + intermediate ATA risk (NED-I), and (v) those with no evidence of structural or biochemical disease + low ATA risk (NED-L). ROC curves for Tg were generated to find potential discriminating cutoffs of Tg values in all patients' groups., Results: A total of 15 out of 129 patients (11.63%) developed nodal disease and 5 (3.88%) distant metastases, during the follow-up. We found that Tg -30 (with suppressed TSH) has the same sensitivity and specificity than Tg 0 (with stimulated TSH), and it is slightly better than Tg +7 , which can be influenced by the size of the residual thyroid tissue., Conclusion: Serum Tg -30 value, measured in euthyroidism 30 days before RAI, is a reliable prognostic factor to predict future nodal or distant disease, thus allowing to plan the most appropriate therapy and follow-up.

Background/aim: Minimally invasive pancreaticoduodenectomy (PD) is gaining popularity. The aim of this study was to compare the incidence of postoperative pancreatic fistula (POPF) after minimally invasive versus open procedures., Materials and Methods: Following the PRISMA statement, literature research was conducted focusing on papers comparing the incidence of POPF after open pancreaticoduodenectomy (OPD) versus minimally invasive pancreaticoduodenectomy (MIPD)., Results: Twenty-one papers were included in this meta-analysis, for a total of 4,448 patients. A total of 2,456 patients (55.2%) underwent OPD, while 1,992 (44.8%) underwent MIPD. Age, ASA score III patients, incidence of pancreatic ductal adenocarcinoma and duct diameter were significantly lower in the MIPD group. No statistically significant differences were found between the OPD and MIPD regarding the incidence of major complications (15.6% vs. 17.0%, respectively, p=0.55), mortality (3.7% vs. 2.4%, p=0.81), and POPF rate (14.3% vs. 12.9%, p=0.25)., Conclusion: MIPD and OPD had comparable rates of postoperative complications, postoperative mortality, and POPF., (Copyright © 2022 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: Few data are available regarding metachronous liver metastases from gastric cancer. We aimed to identify data regarding the survival of these patients, considering the chosen treatment, with particular attention to the role of surgery., Materials and Methods: A systematic review was carried out from 2000 to 2020. We chose articles reporting data from patients with metachronous liver metastases after curative gastrectomy. Data regarding 1-, 3- and 5-year overall survival were analyzed., Results: Survival was improved in patients eligible for surgery (absence of extrahepatic non-curative factors and feasible complete macroscopic removal of liver deposits, i.e., H1 and H2 liver involvement, metastases less than 5 cm in size) when curative liver resection was performed, with a median overall survival of 24 months (vs. 3.13 in patients treated with chemotherapy). N Status, extent and maximum size of liver metastases, and hepatic surgical treatment were identified as independent prognostic factors., Conclusion: Selected patients with metachronous liver metastases from gastric cancer may benefit from multimodal 'aggressive' treatment. When hepatic involvement is limited (H1 and H2) and the size of metastases less than 5 cm, surgery was shown to increase survival., (Copyright © 2022 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: The need for revisional procedures after sleeve gastrectomy (SG) for insufficient weight loss or weight regain, gastroesophageal reflux, or other complications is reported to be 18-36% in studies with 10-year follow-up. Single-anastomosis duodeno-ileal bypass (SADI) may be performed as a revisional procedure after SG. This study aims to evaluate the short- and mid-term outcomes of SADI after SG in a referral center for bariatric surgery., Materials and Methods: Data of patients who underwent SADI between March 2015 and March 2020 were collected prospectively and analyzed retrospectively. Follow-up comprised clinical and biochemical assessment at 1, 3, 6, 12, 18, and 24 months postoperatively, and once a year thereafter., Results: Overall, 106 patients underwent SADI after a previous SG. The timeframe between SG and SADI was 50 ± 31.3 months. Postoperative mortality was observed in two cases (1.8%) and morbidity in 15.1% of patients. At 24 months, %total weight loss was 37.6 ± 12.3 and %excess weight loss 76.9 ± 25.2 (64 patients). Three patients were treated for malnutrition during follow-up, two with medical treatment and one with SADI reversal., Conclusion: SADI after SG provides effective weight loss results in the short-term, even if in the present series the postoperative complication rate was non-negligible. Further trials are needed to establish the more advantageous revisional bariatric procedure after failed SG.

Background: The 2015 American Thyroid Association (ATA) guidelines proposed a three-category system for estimating the risk of recurrence of differentiated thyroid carcinoma (DTC). This system includes several perioperative features, but not age at diagnosis. However, age has traditionally been recognized as a critical factor in the survival of DTC patients, and the eighth edition of TNM stated that patients older than 55 years were at higher risk of death. In this study, we raised the question of whether age at DTC diagnosis impacts on its risk of recurrence. Specifically, the present study aimed to (i) evaluate the association between age at diagnosis and structural recurrence and (ii) investigate whether age at diagnosis could improve the performance of the ATA system. Methods: During the study period, four institutions selected DTC patients treated with both thyroidectomy and radioiodine and who had follow-up for at least one year. Patients with proven structural evidence of disease during follow-up were identified, and disease-free survival (DFS) was calculated accordingly. Results: The study involved 1603 DTC patients with a median age of 49 years and DFS of 44 months. Disease recurred in 8%. The shortest DFS was found in the oldest patients. The Kaplan-Meier curves were calculated for each decade of age, and there was a significant association with DFS ( p  = 0.0014). Patients older than 55 years had significantly higher risk (hazard ratio [HR] 1.78, 95% confidence interval [CI 1.23-2.56]). The Kaplan-Meier curves of DFS in high-, intermediate- and low-risk groups showed a significant association only in the high-risk group ( p  = 0.0058). Patients older than 55 years had significantly higher risk of relapse over time only in the high-risk group (HR 2.15 [CI 2.01-4.53]). Cox's proportional analysis showed that the age cutoff of 55 years and the ATA system were significant predictors of relapse. Adding age at diagnosis above 55 years to the ATA system identified a subgroup of patients at highest risk for relapse. Conclusions: The age threshold adopted in the eighth edition of TNM staging system for DTC patients' prognosis also identifies cases at higher risk of relapse. Applying age at diagnosis, with a cutoff of 55 years, to the ATA risk stratification system identifies cases at highest risk of relapse.

Background/aim: Gastric cancer is the fifth most frequently diagnosed cancer and the second most common cause of cancer-related death. The only potentially curative treatment is surgical resection, which is associated with potentially severe complications, such as anastomotic leakage. The aim of this systematic review was to evaluate the relationship between anastomotic leakage and overall and disease-free survival after surgery for gastric cancer., Materials and Methods: A systematic literature search was performed and 7 articles published between 2010 and 2019 were included, including a total of 7,167 patients., Results: Among the included studies the frequency of anastomotic leakage ranged from 6 to 41%. Patients affected by anastomotic leakage had an overall survival ranging between 4.1 and 97.6 months, whereas patients who did not experience anastomotic leakage had an overall survival between 23 and 109.5 months., Conclusion: Closer follow-up or even more aggressive oncological therapy may be considered for patients affected by anastomotic leakage after surgery for gastric cancer., (Copyright© 2020, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: Italian cytology system for thyroid fine-needle aspiration (FNA) includes indeterminate lesions at low- (Tir 3A) and high-risk (Tir 3B). The present retrospective multicenter study was undertaken to compare the histological type of cancers and disease-free survival in these two groups., Methods: Eight institutions participated. Thyroid cancer patients diagnosed and followed-up after Tir 3A or Tir 3B were reviewed. Histological diagnosis was adopted as the gold standard. Patients were defined with cancer recurrence or no evidence of disease. Disease-free survival (DFS) was calculated. A non-parametric statistical analysis was used. DFS was estimated by Kaplan-Meier method and Hazard Ratio (HR) defined the slope of curves., Results: Two hundred and nine patients (median DFS 24 months) were enrolled and a 6.3% of these recurred. Tir 3B group had higher age (p = 0.014), larger cancer size (p = 0.0002), shorter DFS (p = 0.003), higher number of aggressive cancers (p = 0.006), and relapse frequency double than Tir 3A. At survival curves analysis, Tir 3B group had HR of 2.37 with respect to Tir 3A. At Cox's proportional hazard regression analysis histology was the only significant predictor of relapse., Conclusions: While patients with thyroid FNA of Tir 3B should be addressed to surgery due to high likelihood of more aggressive cancer, a diagnostic surgery could be avoided in patients with Tir 3A if concurrent unsuspicious clinical features are found.

Objectives: Primary Sjögren syndrome (SS) is diagnosed based on the American European Consensus Group (AECG) criteria, but lacks specificity, not only in the involvement of salivary glands, but also in extra-glandular involvement. Whole-body somatostatin receptor scintigraphy with 99m Tc-HYNIC-TOC scintigraphy could overcome these limitations. The aims of this study were to evaluate salivary gland uptake of 99m Tc-HYNIC-TOC in untreated patients with de-novo diagnosis of SS as compared to control subjects and as compared to conventional sialoscintigraphy with 99m TcO 4 - . We also aimed to evaluate the involvement of joints., Methods: 99m Tc-HYNIC-TOC was used with SS patients and uptake in joints and salivary glands was analyzed semi-quantitatively. Patients also underwent 99m TcO 4 sialoscintigraphy. The control group that we analyzed consisted of 30 patients with neuroendocrine tumors., Results: Fifty-two females and 10 males fully met the AECG criteria for SS, and were included. A target background ratio (TBR) >1.18 in submandibular glands correctly classified 93% of the patients with SS in comparison to 27% for 99m TcO 4 sialoscintigraphy. The area under the curve (ROC) analysis for TBR in submandibular glands was 0.95. In joints there was a huge variety in uptake. The median TBR was significantly higher in salivary glands in patients with SS compared to controls., Conclusions: 99m Tc-HYNIC-TOC scintigraphy identified active inflammatory processes not only in the salivary glands, but, unexpectedly, also in many joints in patients with primary SS, contrary to popular belief. This technique provides an objective parameter to evaluate the inflammation burden in salivary glands and joints and could be used to evaluate response to treatment.

Papillary thyroid carcinoma (PTC) is the most common mali gnancy of the thyroid gland. In 21-90% of the patients occult lymph node metastases may occur. The case reported here describes a woman who underwent a total thyroidectomy for multinodular goiter and who presented an enlarged lymph node on the left side of the neck, which showed a metastasis from PTC. The patient underwent imaging investigation with CT and FNAB. The pathological examination diagnosed a papillary thyroid cancer metastases. The pT underwent a I131 total body scan, negative for secondary localization.

Background: Esophageal cancer is the ninth most common cancer. The only potentially curative treatment is surgical resection, which unfortunately is still associated with major complications, the most important being anastomotic leakage, currently with an overall rate of up to 26% morbidity. The aim of this systematic review was to evaluate the relationship between anastomotic leakage and recurrence of disease., Materials and Methods: A literature search was systematically performed. Seven out of 312 articles dated between 2009 and 2018 fulfilled the selection for a total of 5,433 patients., Results: The frequency of anastomotic leakage ranged from 7.2 to 11.2%. Patients affected by anastomotic leakage had a recurrence rate of 9-56%., Conclusion: Closer follow-up or even more aggressive oncological therapy should be considered for patients affected by anastomotic leakage after surgery for carcinoma of the distal esophagus and gastroesophageal junction., (Copyright© 2019, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: Primary colic lymphoma represents a rare disease accounting for the 0.2%-0.6% of all large-bowel malignancies. We here report a case of diffuse large B-cell lymphoma presenting as a left colic stenosis in a patient who had undergo renal transplant 23 years before., Case Report: A 67-years old man presented with recurrent abdominal pain, distension, nausea and constipation since 3 weeks. His past medical history included hepatic and renal polykystose with renal transplant 23 years before. Colonoscopy revealed a non-surmountable inflammatory left colic stenosis at 55 cm from the anal verge. Biopsies demonstrated inflammatory colic mucosa without neoplastic cells. Non-enhanced CT scan and CT virtual colonoscopy were performed, showing a left colon circumferential thickening of 4 cm. Laparoscopic left colectomy was performed to treat the colic obstructive syndrome and to have complete specimen analysis. After Pathological analysis and Immunohistochemistry the diagnosis of diffuse large B cell lymphoma was established. The resection was R0. The postoperative course was uneventfully., Conclusion: Large B-cell lymphoma represents a rare case of bowel tumor. However it has to be considered in the differential diagnosis of colic stenosis in immunosuppressed patients as transplant recipients., Key Words: Colorectal lymphoma, Diffuse large B-cell lymphoma, Immunosuppressed patients.

Introduction: CgA and testosterone are two serum markers that may be involved in prostate cancer. The objective of this study was to evaluate the relationship of testosterone and CgA to grades and stages of prostate cancer, particularly whether low-serum testosterone and high-serum CgA are associated with more aggressive grades, and higher pathological stages of the disease., Methods: This perspective study included 121 men (Caucasian only) presenting with -newly-diagnosed, untreated prostate cancer. All the patients underwent radical prostatectomy., Results: We subdivided the sample into two homogeneous groups, Group A with Gleason score ≤7 (3+4), and Group B with Gleason score ≥7 (4+3). Low testosterone (< 3 ng/ml) was most common among the members of Group B 80 % versus 12.6 % of Group A (p = 0.001). At the same time, elevated CgA (> 80 ng/ml) was present for a rate of 72 % in Group B, 28.1% in the Group A ( p = 0.001). The multivariate analysis we used revealed that low-serum testosterone and high-serum CgA are associated with higher pathological stages of the disease (p = 0.001)., Conclusion: The principal findings of this investigation were that low testosterone is correlated with elevated CgA levels, and these two parameters are associated with more aggressive grades and higher pathological stages of prostatic adenocarcinoma., Key Words: Chromogranin A, Prostate cancer, Risk factor for prostate cancer, Testosterone.

Aim: The purpose of this study is to determine the anatomical aspects, mechanisms, risk factors and appropriate management of development of pneumothorax during a routine colonoscopy., Clinical Case: We report a case of an accidental bowel wall injury during diagnostic colonoscopic with consequent pneumoperitoneum; this was followed by expansion of gas through diaphragmatic fenestration perhaps congenital, in right pleural cavity causing pneumothorax., Discussion: Rarely, colonic perforation during colonoscopy can occur into the extraperitoneal space, thus leading to the passage and diffusion of air along the fascial planes and large vessels, possibly causing pneumoretroperitoneum, pneumomediastinum, pneumopericardium, pneumothorax, and subcutaneous emphysema. The combination of intraperitoneal and extraperitoneal perforation has also been reported. Pneumothorax following a colonoscopy sigmoid perforation is an extremely rare but severe and often lifethreatening complication., Conclusion: If the patient develops dyspnea and pneumoderma during or after this procedure, a chest radiogram or thoracoabdominal CT should be taken for diagnostic purposes. Urgent treatment, starting with chest tube insertion(s) and laparotomy or laparoscopy could be lifesaving.

Background: Italian consensus for the classification and reporting of thyroid cytology (ICCRTC) has been used in almost all Italian institutions since 2014. High reliability of ICCRTC in classifying low and high risk indeterminate nodules (Tir 3A and Tir 3B, respectively) was demonstrated. Here we reviewed our casuistry of thyroid indeterminate lesions to analyze the histologic outcome. Methods: All lesions undergone FNA and final histology at S. Andrea Hospital of Rome after a cytologic assessment of Tir 3A and Tir 3B, according to ICCRTC, were included in the study. Results: A number of 157 indeterminate FNA was found after the introduction of ICCRTC. Of these, 75 undergone surgery and were finally included for the study. At histology we found a 33.3% of cancers and a 67.7% of benign lesions. Out of the overall series, 25 were classified as Tir 3A and 50 as Tir 3B. Cancer rate observed in Tir 3A (1/25, 4%) was significantly ( p = 0.0002) lower than that of Tir 3B (24/50, 48%). No significant difference was found in age and size between the two subcategories. Conclusions: We confirm in our series that Italian consensus for the classification and reporting of thyroid cytology allows to discriminate indeterminate lesions at low and high risk of malignancy.

Introduction: Although the intervention of knee arthroplasty became routine, there is no standard reference on the densitometric characteristics of the patella before and after surgery. Scope of this work is the evaluation of patellar bone density before and after unilateral knee arthroplasty., Patients and Methods: BMD was assessed by DEXA examination in 146 individuals, who have been divided into three distinct groups. Group I: 68 subjects with a mean age of 70.6 years, with an unilateral femoral-tibial knee prothesis. Group II: healthy subjects of similar age (average: 64) and without implants. Group III: healthy adults with a mean age of 26.6 years. The follow-up was performed at 6 months to a maximum of 2 years post surgery., Results: The results were obtained from 68 subjects examined with the DEXA software dedicated to the forearm, which turned out to be the most appropriate for our purpose. The follow-up performed every 6 months after surgery showed a reduction of the density values in the operated knee in the 1st control with a return to the pre-surgiucal situation in the control performed after 1 year. In subsequent checks there was a further increase of the patellar density of the operated knee., Conclusion: Patellar DEXA examination is recommended as an addition to the clinical and radiological standard examination.

Aim: Due to the limits of calcitonin, other markers are warranted to better manage medullary thyroid carcinoma patients, and procalcitonin has been reported as promising. Here we aimed to evaluate procalcitonin as a marker of medullary thyroid carcinoma in the post-treatment follow-up., Methods: Medullary thyroid carcinoma patients previously treated by thyroidectomy were enrolled. After complete imaging work-up (i.e. ultrasonography, computed tomography, magnetic resonance and 18 FDG-PET-CT) we identified patients with structural recurrent/persistent medullary thyroid carcinoma (active medullary thyroid carcinoma) and subjects with no evidence of disease. Then, both calcitonin and procalcitonin were measured and their performance analyzed., Results: The final series included 55 medullary thyroid carcinoma patients treated and followed-up for about five years. Of these, 43 were assessed as no evidence of disease, and 12 as active medullary thyroid carcinoma. The median value of procalcitonin was significantly higher ( P < 0.0001) in active medullary thyroid carcinoma patients (3.10 ng/mL) than in those with no evidence of disease (0.10 ng/mL). Also, calcitonin levels of active medullary thyroid carcinoma (96.7 pg/mL) were significantly ( P < 0.0001) higher than that of no evidence of disease (2.0 pg/mL). At the receiver operating characteristic curve analysis, the optimal cut-off of procalcitonin was ≥0.32 ng/mL with 92% sensitivity and 98% specificity, while the most accurate threshold of calcitonin was ≥12.0 pg/mL with 100% sensitivity and 91% specificity. There was no active medullary thyroid carcinoma with simultaneously negative results of procalcitonin and calcitonin., Conclusions: Procalcitonin is reliable in discriminating medullary thyroid carcinoma patients with active disease from those with no evidence of disease. We suggest using procalcitonin as complementary to calcitonin to follow-up medullary thyroid carcinoma patients.

Background: Video-assisted anal fistula treatment (VAAFT) is now a mature technique, supported by many short-term published case series., Methods: We designed a monocentric, retrospective and observational study in order to evaluate early and long-term outcomes of VAAFT in the treatment of primary and recurrent complex anal fistula. Between November 2011 and March 2014, 224 consecutive patients affected by complex perianal fistula underwent Video Assisted Anal Fistula Treatment. Fifty-two were affected by primary and 172 by recurrent disease. We registered all intra and postoperative complications and healing rate. Median follow-up was 48 months (range 27-60 months)., Results: In the primary fistula group, 40 of the 52 patients were completely healed within 3 months after surgery (77%); at 12 months, considering also 12 patients (23%) treated with a second VAAFT due to recurrent disease, the overall healing rate was 92.3% In the second group with recurrent anal fistula (N.=172), primary healing was observed in 110 patients (64%; P=0.1) within 3 months after surgery and increases to 80.2%, after 12 months (P=0.06). Few patients required analgesics in the postoperative period (N.=33, 14.7%), the remaining did not require pain killers at all. All patients were able to resume daily activities within 7 days from surgery (range 2-12 days). Main limitation of our study was its retrospective and monocentric design., Conclusions: VAAFT seems to be a safe and effective technique for treating primary and recurrent perianal fistula, providing a very good healing rate without sphincters impairment and allowing a very quick return to normal activities.

Background/aim: Detecting free tumor cells in the peritoneal lavage fluid of gastric cancer patients permits to assess a more accurate prognosis, predict peritoneal recurrence and select cases for a more aggressive treatment. Currently, cytology and molecular biology comprise the two most popular methods of detection that are under constant study by researchers., Materials and Methods: We burrowed into the available literature comparing cytological with molecular detection of free intraperitoneal gastric cancer cells. PubMed, Science Direct, Scopus and Google Scholar were the search engines investigated., Results: As of 2017, 51 dedicated studies have been published. Messenger RNA of carcinoembryonic antigen was the genetic target most frequently described. The genetic technique is usually superior to cytology in sensitivity (38-100% vs. 12.3-67% respectively), whereas cytological examination tends to show a slight pre-eminence in specificity (approximately 100%)., Conclusion: So far, given the imperfection of each method, employment of both cytology and molecular examination seem to be mandatory., (Copyright© 2018, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: Multivisceral resections combined with pancreatectomy have been proposed in selected patients with tumor invasion into adjacent organs, in order to allow complete tumor resection. Some authors have also reported multivisceral resection combined with metastasectomy in very selected cases. The utility of this practice is debated. The aim of the review is to compare the postoperative results and survival of pancreatectomies combined with multivisceral resections with those of standard pancreatectomies., Methods: A systematic literature search was performed to identify all studies published up to February 2017 that analyzed data of patients undergoing multivisceral and standard pancreatectomies. Clinical effectiveness was synthetized through a narrative review with full tabulation of results., Results: Three studies were retrieved, including 713 (80%) patients undergoing standard pancreatectomies and 176 (20%) undergoing multivisceral resections (MVR). Postoperative morbidity ranged from 37% to 50% after standard resections and from 56% to 69% after MVR. In-hospital mortality ranged from 4% after standard pancreatectomies to 10% after MVR. Median survival ranged from 20 to 23 months in standard resections and from 12 to 20 months after MVR, without significant differences., Discussion: The current literature suggests that multivisceral pancreatectomies are feasible and may increase the number of completely resected patients. Morbidity and mortality are higher than after standard pancreatectomies, and these procedures should be reserved to selected patients in referral centers. Further studies on the role of neoadjuvant therapy in this setting are advisable., (Copyright © 2017 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Gastric cancer triggers an immune response, manifested by immunocompetent cells infiltrating the tumor, such as macrophages, NK cells, neutrophils, T and B-lymphocytes, and plasma cells., Methods: Were viewed 300 patients who received surgery for gastric cancer, with removal of at least 15 regional lymph nodes, from January 1998 through December 2008, at the Policlinico "Umberto I", Department of Surgery "Pietro Valdoni", "Sapienza" University of Rome, and at "Santa Maria Goretti" Hospital of Latina, Italy. We selected a subset of 46 patients identified according to the following selection criteria: presence of gastric cancer (both intestinal-type and diffuse-type), early-stage (T1 and T2), absence of nodal metastases (N0), or involvement of less than 8 lymph nodes (N1), absence of distant metastases (M0), stage I and II. The sample included 28 males and 18 females., Results and Conclusions: Our results suggest that a high number of tumour-associated macrophages (TAM) along the margins of the tumour is related to a worse outcome, and an increased secretion of immunosuppressive cytokines by TAM may also indirectly affect the action of cytotoxic T cells. Our study also shows a statistically non significant trend of tumour-associated macrophages in promoting the expression of β-catenin, which is a subunit of the cadherin protein complex., Key Words: Gastric cancer, Infiltrate, Lymphoplasmacellular, Prognostic factors, TNM.

Introduction: Esophagocoloplasty represents a useful technique to restore the intestinal continuity after esophagogastrectomy. This technique has been used mainly after esophagogastric caustic injuries. The aim of this review is to assess the role of esophagogastrectomy with esophagocoloplasty for esophageal or gastric neoplasms., Methods: A systematic literature search was performed using Embase, Medline, Cochrane, and PubMed databases to identify all studies published in the previous 25 years (1991-2016) reporting cases of esophagocoloplasty after esophagogastrectomy for malignancies. The systematic review was conducted according to the PRISMA guidelines., Results: The systematic review of the literature shows a morbidity rate of 57% and a mortality rate of 15% in the 93 reported cases of esophagocoloplasty performed for malignant diseases. However, R0 rate ranged from 76.1 to 85%, and 5-year survival was obtained in 11.9-32.8% of patients in the different series., Conclusions: In highly selected cases of primary or relapsing gastric or esophageal neoplasms, esophagogastrectomy with esophagocoloplasty is a viable and useful option, which may guarantee complete tumor resection and long-term survival.

Neoadjuvant treatment in non-metastatic pancreatic cancer (PaC) has the theoretical advantages of downstaging the tumor, sterilizing any present systemic undetectable disease, selecting patients for surgery and administering therapy to each patient. The aim of this systematic review is to analyze the state of the art on neoadjuvant protocols for non-metastatic PaC. A literature search over the last 10 years was conducted, and papers had to be focused on resectable, borderline resectable (BLR) or locally advanced (LA) histo- or cytologically proven PaC; to be prospective studies or prospectively collected databases; to report percentage of protocol achievement and survival data at least in an intention-to-treat (ITT) analysis. Twelve studies were eligible for systematic review. Studies included a total of 624 patients: 248 resectable, 268 BLR, 71 LA and 37 non-specified. All studies were included for meta-analysis. ITT overall survival (OS) was 16.7 months (95% CI 15.16-18.26 months); for resected patients OS was 22.78 months (95% CI 20.42-25.16), and for eventually non-resected patients it was 9.89 months (95% CI 8.84-10.96). Neoadjuvant approaches for resectable, BLR and LA PaC are spreading. Outcomes tend to be better outside an RCT context, but strong evidences are lacking. Actually such treatments should be performed only in a randomized clinical trial setting.

Cancers of appendix are very uncommon. As reported in the case of 85 years old man, that underwent right emicolectomy with restoration of bowel continuity, the appendix was found to be gangrenous and perforated during the surgery. The hystology that comes out was adenocarcinoma of appendix that after 1 yars of follow up ramanins asymptomatic. At last the emicolectomy rappresent the best surgical treatment for all appendix neoplasm, that could be recognised from the surgeon when possible wiht intraoperavite histological examination., Key Words: Appendix, Cancer, Incidental diagnosis, Right emicolectomy.

This study is aimed at identifying the collateral circulation in case of femoral-aorta-iliac axis obstruction, with the purpose of a more correct therapeutic indication being either medical or surgical or physiotherapeutic or combined.

Pancreas divisum is a genetic defect associated with recurrent acute pancreatitis due to insufficient drainage of the accessory pancreatic duct. Seven young patients diagnosed with pancreatic divisum and thickening of the gallbladder bile as shown on magnetic resonance cholangio-pancreatography without pancreatic ductal changes underwent laparoscopic cholecystectomy. During the mean follow-up of 32 months no episode of pancreatitis was reported. There is an association between PD and higher concentration of bile in the gallbladder. Cholecystectomy can be considered curative in patients with PD in the absence of indications for major surgery.

This case report is about a 70-years-old female patient, suffering from discal hernia, with compression of the iliac vein, that led to the formation of deep vein thrombosis of the lower limbs. The angio-CT scan revealed the starting point of the L4- L5 compression where a voluminous discal hernia caused deep vein thrombosis, with the involvement the femoro-popliteal venous axis. Blood samples and PET-CT scans excluded other possible etiologic factors. This case demonstrates how a voluminous discal hernia can cause venous thrombosis.

In oncology, the early cancer detection is recognized as associated with good patient's prognosis. Then, one could expect that differentiated thyroid carcinoma (DTC) undergone fine-needle aspiration cytology (FNA) early have better outcome. Aim of this study was to investigate if DTC prognosis is improved by early FNA diagnosis. DTCs followed-up at our institution were included. Information about initial management of thyroid lesion, FNA, surgery, and postoperative follow-up was collected. Cytologies were classified according to British Thyroid Association (BTA). The final series comprised 219 DTCs, of which 22 (10%) recurred. The length of time between nodule appearance and cancer treatment was significantly (p<0.0001) shorter in patients who had undergone FNA than those who had not. In the FNA group, 73 patients underwent biopsy within six months, 25 at 7-12 months, and 43 after at least one year. Regardless of this highly significant (p<0.0001) difference, the results of TNM staging and cancer recurrence rate were no different between these three subgroups. This result was confirmed in DTCs larger than 1 cm submitted to FNA within 12 months or later. When we evaluated the impact of nodule's presentation on DTC outcome, clinically discovered cancers were significantly associated with relapse (OR 2.81) and advanced TNM stages (p=0.03). These data show a lack of clinical impact of the delayed diagnosis of DTC. Also, the postoperative outcome of these patients should not be influenced by the timing of FNA. Instead, DTC patients with preoperative clinical nodule appearance should be considered at higher risk of relapse.

Core needle biopsy (CNB) has been recently described as an accurate second-line test in thyroid inconclusive cytology (FNA). Here we retrospectively investigated the potential improvement given by Galectin-3, Cytokeratin-19, and HBME-1 on the accuracy of CNB in thyroid nodules with prior indeterminate FNA report. The study included 74 nodules. At CNB diagnosis, 15 were cancers, 40 were benign, and 19 had uncertain/non-diagnostic CNB report. The above immunohistochemical (IHC) panel was analyzed in all cases. After surgery, 19 malignant and 55 benign lesions were found. All 15 cancers and all 40 benign nodules diagnosed at CNB were confirmed at final histology. Regarding the uncertain CNB group, 4 (21 %) were malignant and 15 (79 %) benign. When we considered all the series, the most accurate IHC combination was Galectin-3 plus HBME-1, while HBME-1 was the most sensitive marker in those nodules with uncertain CNB report. The combination of CNB plus IHC could indentify 19/19 cancers and 53/55 benign lesions. Sensitivity and specificity of CNB increased from 79 to 100 % and from 73 to 96 %, respectively, by adding IHC. CNB can diagnose the majority of thyroid nodules with previous indeterminate FNA cytology, while the accuracy of CNB is increased by adding Galectin-3, Cytokeratin-19, and HBME-1 panel. We suggest to adopt CNB as a second-line approach to indeterminate thyroid FNA, and apply IHC in those lesions with uncertain/non-diagnostic CNB report. This approach should improve the pre-surgical diagnosis of patients. These results should be confirmed in larger prospective series.

Background: Twenty percent of thyroid fine needle aspiration (FNA) is indeterminate. Because 3 in 4 of these are actually benign, a method of clarifying the pathology could help patients to avoid diagnostic thyroidectomy. Recently, core needle biopsy (CNB) has been proven to be highly reliable for this purpose. However, there are no reports of any potential cost benefit provided by CNB. Here we analyzed the impact on management costs of CNB compared with traditional diagnostic surgery in indeterminate FNA., Methods: Over 24 months, 198 patients with thyroid indeterminate cytology underwent CNB at Ospedale Israelitico of Rome or diagnostic surgery at the Department of Surgery of Sapienza University of Rome. We tabulated costs of the medical instruments, operating theater, surgical team, patient recovery, and pathologic examination for each method., Results: In CNB group, 42.4% of patients had benign lesions and avoided surgery, 20.8% was cancer, and the remaining 36.8% uncertain. The malignancy rate in CNB group was 26.4%, and mean cost of CNB per nodule was 1,032€. In diagnostic surgery group, 24.7% had cancer and 75.3% had benign lesions, and mean expense for each thyroidectomy was 6,364€. In an ideal cohort of 100 patients with indeterminate FNA, the cost of CNB is 33.8% lower than that of diagnostic surgery., Conclusions: CNB can detect a large proportion of the benign thyroid nodules that are classified as indeterminate by FNA. These patients can avoid diagnostic thyroidectomy and hospitals can reduce their surgical costs by one-third.