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The aim of the study was to assess whether the reliability of Touch Imprinting Cytology (TIC) of Sentinel lymph node biopsy (SLNB) in skin melanoma patients allows intraoperative decisions regarding simultaneous radical lymphadenectomy to be made. Previous experiences have shown that the limit of TIC in extemporaneous diagnosis was represented by the minimal deposits of the tumor. Many current data seem to show that in this situation radical lymphadenectomy is no longer necessary, so we wondered if TIC could regain importance in the intraoperative management of these patients.TIC results of Sentinel Lymph Nodes Biopsy (SLN) were compared with those of standard histopathological and immunohistochemical examinations.A total number of 110 SLN were detected from 50 melanoma patients.TIC revealed the presence of metastases only in 1 out of 13 melanoma-positive SLN (sensitivity 7.6%). There were no false-positive results of TIC (specificity 100%). The negative predictive value was 75.5%, the positive one 100% with a total diagnostic accuracy of 76%.TIC for SLNs is a reliable method, relatively fast and not very expensive. Although with a very high specificity, its sensitivity was very low, and almost exclusively limited to macro-metastases (2mm). Furthermore, it was not possible to identify a subgroup of patients, based on the characteristics of the primary tumor, in which the method could have been more useful. Finally, even in positive cases, the method rarely reduced the need of a tactic in two stages, principally for the management of the operating room.Melanoma, Sentinel lymph node (SLN), Touch Imprinting Cytology (TIC).Lo scopo dello studio era di valutare se l’affidabilità di Touch Imprinting Cytology (TIC) nella biopsia del linfonodo sentinella (SLNB) nei pazienti con melanoma cutaneo consente di prendere decisioni intraoperatorie riguardanti la linfoadenectomia radicale simultanea. Precedenti esperienze hanno mostrato che il limite del TIC nella diagnosi estemporanea era rappresentato dai depositi minimi del tumore. Molti dati attuali sembrano mostrare che in questa situazione non è più necessaria la linfoadenectomia radicale, quindi ci siamo chiesti se il TIC potesse riacquistare importanza nella gestione intraoperatoria di questi pazienti. I risultati TIC della biopsia del linfonodo sentinella (SLN) sono stati confrontati con quelli degli esami istopatologici e immunoistochimici standard: su 50 pazienti con melanoma sono stati prelevati un totale di 110 SLN, e su questi è stato individuata la presenza di metastasi solo in 1 su 13 SLN melanoma-positivi (sensibilità 7,6%), senza falsi positivi di TIC (specificità 100%). Il valore predittivo negativo era del 75,5%, quello positivo del 100% con una precisione diagnostica totale del 76%. In conclusione la TIC per SLN è un metodo affidabile, relativamente veloce e non molto costoso. Sebbene con una specificità molto elevata, la sua sensibilità risulta molto bassa e quasi esclusivamente limitata alle macrometastasi (2mm). Inoltre, non è stato possibile identificare un sottogruppo di pazienti, in base alle caratteristiche del tumore primario, in cui il metodo avrebbe potuto essere più utile. Infine, anche in casi positivi, il metodo raramente ha ridotto la necessità di una tattica in due fasi, principalmente per la gestione della sala operatoria. Queste considerazioni ci hanno spinto a sospendere l’analisi TIC intraoperatoria a favore di una più accurata ecografica dei linfonodi superficiali ad opera di personale dedicato, da eseguirsi prima di ogni ricerca del linfonodo sentinella.

The aim of this retrospective study is to evaluate the immediate and late outcomes of the surgical and conservative treatment of adhesive small bowel obstruction. A series of 163 consecutive patients affected by adhesive occlusion were analysed. 63 patients were submitted to emergency surgery and 100 to conservative treatment; 15 of these ones were operated on because they did not improve or deteriorated. The in-hospital mortality and morbidity, the length of the ileus, the time required for the operatori, the length of the recovery, and the late results after a median follow-up of 3.6 years (range: 1-6 years) are reported. The overall mortality was 3.26% and there was no significant difference (p = 0.764) between the treatment modalities. The patients submitted to conservative therapy had a lower morbidity, shorter length of the ileus and shorter hospital stay and a better outcome at follow-up. In the surgical group, the patients submitted to emergency surgery had a lower mortality, a shorter ileus and shorter hospital stay than the patients submitted to delayed surgery. Conservative treatment of adhesive occlusions should be opted for when the indications are correct (no intestinal ischaemia, no occlusion by a bridle). In doubtfui cases, the patient should be submitted to emergency surgery to avoid the risks of surgical delay.

The authors analyze a consecutive series of 219 patients affected by complicated colorectal cancer who underwent surgery in emergency. In hospital mortality, 5-year survival and recurrence’s incidence in 104 of these patients who underwent curative treatment are calculated and compared with a series of 701 patients who underwent elective surgical treatment. There was no significative statistical difference between emergency and elective group. At the multivariate analysis only the stage of the tumour was an independent prognostic factor.

Il fine del presente lavorto retrospettivo è stato quello di analizzare se una una linfadenectomia estesa alla radice dei vasi colici principali poteva assumenre un significato prognostico e/o terapeutico. Dalla analisi dei dati è emerso che rinuciando ad una linfadenectomia estesa, solo per il fenomeno del "salto del linfonodo" si sarebbe verificata una sottostadiazione del 1,4% fra N0/N+ e del 8,5% fra N2/N3. Inoltre, sempre con una linfadenectomia estesa, si è osservato una sopravvivenza a 5 anni del 32,7% anche nei pazienti con metastasi ai linfonodi centrali. Non si sono invece osservate differenze significative nella mortalità e morbilità in rapporto al tipo di linfodenenctomia eseguita. Gli autori concludono considerando la linfadenectomia estesa ai linfonodi centrali il livello ideale di dissezione, sola in grado di garantire non solo una correta stadiazione ma anche un miglioramento della prognosi sopratutto per i pazienti N+.

We report a case of inflammatory pseudotumour of the liver in a 53-year-old woman who over the previous month had presented malaise, fever and right-sided hypochondralgia. On physical examination the liver was tender at palpation 2 cm below the right costal margin. Laboratory data were normal. Abdominal ultrasonography revealed a focal lesion, measuring 5 cm in diameter, located between the sixth and seventh segments of the liver, just beneath the liver capsule, characterised by a uniformly low level of echogenicity, a round shape with ill-defined margins and very good sound transmission. CT scan disclosed an unexpected and somewhat ambiguous pattern, with coexistence of inflammatory and neoplastic patterns. The patient was therefore submitted to a diagnostic US-guided percutaneous liver biopsy. The microbiological examination proved sterile, while the histological features revealed chronic inflammatory tissue, with fibroblasts and a number of necrotic components. For this reason, despite a strong orientation towards an inflammatory process, we could not rule out the possibility of a necrotic tumour. After two weeks of antibiotic therapy without results, the patient underwent a hepatic bisegmentectomy and a cholecystectomy. Pathological examination of the surgical specimen confirmed the biopsy findings and was suggestive of an inflammatory pseudorumour of actinomycotic origin. The patient was discharged on postoperative day 14 in good general condition, and today, after a follow-up of 5 years, she is still well without any recurrence of disease. Inflammatory pseudotumour of the liver is an unusual lesion that can mimic hepatic malignancy in its presentation and imaging. Despite the clear inflammatory nature of the mass it is almost impossible to detect any aetiological agent. Histologically, the lesion consists in interlacing bands of fibrous connective tissue, containing microscopic suppurative foci, granulocytes, neutrophils, lymphocytes, plasma cells, foamy histiocytes and a few sulphur granules suggestive of actinomycosis. The diagnosis can be made only histologically by US/CT guided-biopsy or, in a limited number of cases, directly by intraoperative frozen sections. Treatment for hepatic inflammatory pseudotumours is controversial: some Authors report cases with spontaneous regression of the disease with or without antibiotic/steroid therapy, while others favour early resection in patients unresponsive to medical therapy. This latter surgical approach is justified not only by the difficult diagnosis but also by the need to prevent complications related to the clinical course of the disease.

Carcinoembryonic antigen is an acid glycoprotein, the levels of which may increase in patients with colorectal carcinoma. The prognostic significance of preoperative carcinoembryonic antigen levels and their relationship to other risk factors are still debatable issues. Among 512 patients operated on for colorectal cancer, whose preoperative carcinoembryonic antigen concentrations were evaluated, linear correlations were established between carcinoembryonic antigen overexpression and carcinoma staging, diameter and grading, though these were not statistically significant. Moreover, metastatic cancers were significantly more frequent in patients with increased plasma concentrations of the marker (60 ng/ml). There were no correlations between increased carcinoembryonic antigen levels and age, ploidy, or site and shape of the cancers. As regards survival, patients with normal preoperative carcinoembryonic antigen levels had a better prognosis in terms both of lower local recurrence rates and long- term survival. In addition. In Dukes stages B and C elevation of carcinoembryonic antigen above the cut-off point can be considered a significant prognostic factor capable of identifying a group of patients at high risk who may be candidates for aggressive adjuvant therapies and follow-up. The findings of this study suggest that preoperative carcinoembryonic antigen levels are of prognostic importance in relation both to cancer staging and to long-term survival, which may have significant clinical applications.

The treatment of Crohn's disease is still a debatable issue especially as regards the integrated implementation of medical and surgical therapy, the timing of surgery and the choice of surgical technique. Prognostic factors seem to be important in the choice and planning of therapeutic procedures. The authors retrospectively review 81 patients, 31 of whom submitted to surgery. The parameters observed were the presenting symptoms, the time from onset of symptoms to surgery, previous medical treatment, disease location, and complications. Bowel resection and the treatment of fistulas and abscesses were carried out. Emergency resections were performed in 14 patients (45%): 11 for bowel obstruction, 2 for perforation and 1 for bleeding. The mean follow-up (which included laboratory tests and endoscopy) was 132 months (range: 6 months to 32 years). In-hospital mortality was 2.3% and morbidity 12.9%. Long-term mortality amounted to 3 patients, only 1 of whom died of complications related to recurrence of the disease. Statistical analysis showed that the recurrence rate was 51.3% at 5 years after the first surgical treatment, 65.4% at 10 years and 88.1% at 20 years. Recurrences requiring surgery amounted to 15.3%, 20.5% and 42.5%, respectively. No statistically significant correlations were observed between recurrence rate and time of onset of the disease (p = 0.5601), time of the first surgical treatment, disease location, or specific medical therapy, (p = n.s.). Recurrence requiring surgical treatment was observed in 33.3% of patients when the disease was located only in the ileum, in 33.3% when it was located in both the ileum and colon, and in 28.6% when only the colon was involved (p = 0.9767). The quality of life was good in 66.6% of patients, fair in 26.6%, and poor in 6.6%. The authors conclude that the treatment of Crohn's disease must be multidisciplinary and surgery must be limited to complications. When surgery is indicated, it must be performed promptly, because, in these cases, persisting with medical treatment increases the postoperative morbidity. Short resections must be performed in order to preserve the bowel as much as possible. As far as risk factors are concerned, the most important are the location and the aggressiveness of the disease, whilst biological and laboratory parameters do not seem to influence the results.

The pathological assessment of rectal cancer remained essentially unchanged for 50 years and it is based mainly on Dukes' classification and histological granding. Alternative methods of classifications have also been developed but, actually, Dukes'taging is the most important prognostic factor. The limit of Dukes' classification is the incomplete discrimination between high risk and low risk patients into the same stages. The measurements of cellular DNA content by flow cytometry is emerging as a prognostic aid in many human tumours. Authors analyze on the basis of their experience on 116 curative operations for the cancer of the rectum, the relationship between tumour's features, CEA, symptoms, recurrences, survival, type of operation and DNA flow cytometry. In 100 cases they studied the percentage of cells in "s" phase. (SPF). Samples of flow-cytometry were prepared using paraffin-embedded tumour blocks. The authors didn't find any statistically significant relation among pathological features, staging, ploidy and SPF. Recurrences rate was 16.6% in diploid tumours and 23% in no diploid (p = 0.3). In SPF < 25% it was 18.2% (p = 0.5). 5-year survival was worse in aneuploid patients (p = 0.06). Using Cox' multivariate regression analysis, ploidy has not independent prognostic significance. In conclusion authors consider ploidy a prognostic factor in rectal cancer, but not independent. However, authors conclude that flow cytometry could help in early staging of the disease, especially in preoperative diagnosis. Flow cytometry has a prognostic significance with informations on tumoral biology and could contribute to select patients for adjuvant therapy or different surgical techniques

The aim of our study was to assess if there were any differences in clinical presentation, management, and outcome, between younger and elderly patients with acute diverticulitis (AD).279 patients with diagnosis of AD treated at the General Surgery Department of Trieste from January 2007 to December 2015 were retrospectively examined and then followed for a minimum of 4 years. We divided patients in two categories: young ≤ 50 years and elderly50. Gender, American Society of Anesthesiologists status (ASA score), Hinchey's stage, type and timing of surgery, morbidity, length of hospital stay, recurrence, and overall mortality were retrospectively analyzed.There were 279 patients, 64 (22,9 %) were young and 215 (77,1%) were elderly. Female gender was more frequent in elderly cohort (150 pts 69,7 % F vs 65 pts 30,3 % M) than in the young (16 pts, 25% F vs 48 pts, 75% M), (p0,001). Higher ASA scores were registered in elderly patients with statistically significant correlation with Hinchey's stage. 229 patients ( 82,07 %) received as initial treatment antibiotic therapy (conservative treatment), 50 (17,93 %) pts underwent EM-S, and 11 underwent to DEL-S.In our experience, none significant differences were recorded about Hinchey's stage, timing of surgery, morbidity, length of hospital stay, and recurrence; whereas, regarding the type of surgery (resection-anastomosis (R-A), Hartmann's procedures, and Lavage/Drainage) there were a significant difference (p=0,04).Hartmann's procedures have been effectuated more frequently in the elderly than in the young with recanalization in less than half of elderly. These data seems to confirm that there is no significant difference in incidence or the natural course of acute and complicated colonic diverticulitis among the young or the elderly. The best surgical treatment, with the least morbidity, may be resection with primary anastomosis.Diverticular Disease, Elderly Patients, Sigmoidectomy, Young Patients.Lo scopo del nostro studio è stato quello di valutare se ci fossero delle differenze nella presentazione clinica e nell’outcome, tra i pazienti più giovani e quelli più anziani affetti da diverticolite acuta (DA). 279 pazienti con diagnosi di DA trattati presso il Dipartimento di Chirurgia Generale di Trieste da gennaio 2007 a dicembre 2015 sono stati esaminati retrospettivamente e seguiti per un minimo di 4 anni. Abbiamo suddiviso i pazienti in due categorie: giovani ≤ 50 anni e anziani50. Sono state analizzate retrospettivamente le seguenti variabili: sesso, American Society of Anesthesiologists (punteggio ASA) score, stadio di Hinchey, tipo e tempistica di intervento, morbilità, durata della degenza ospedaliera, tasso di recidiva e mortalità. Sono stati presi in considerazione 279 pazienti, 64 (22,9%) erano giovani e 215 (77,1%) erano anziani. Il sesso femminile era predominante nella coorte dei pazienti anziani (150 pz 69,7% F vs 65 pz 30,3% M) rispetto ai giovani (16 pz, 25% F vs 48 pz, 75% M), (p0,001). I punteggi ASA più alti sono stati registrati nei pazienti anziani con correlazione statisticamente significativa con lo stadio di Hinchey. 229 pazienti (82,07%) sono stati sottoposti a terapia antibiotica come trattamento iniziale (trattamento conservativo), 50 pazienti (17,93%) sono stati sottoposti a un intervento chirurgico in emergenza e 11 sono stati sottoposti ad un intervento chirurgico differito. Nella nostra esperienza, non è stata registrata nessuna differenza statisticamente significativa riguardo a stadio di Hinchey, il tempo operatorio, la morbilità, la durata della degenza ospedaliera ed il tasso di recidiva; mentre, per quanto riguarda il tipo di intervento chirurgico effettuato (resezione-anastomosi (R-A), procedure di Hartmann e Lavaggio / Drenaggio addominale) ci sono state differenze statisticamente significative (p = 0,04). In conclusione, le procedure di Hartmann sono state eseguite più frequentemente negli anziani rispetto ai giovani con ricanalizzazione in meno della metà degli anziani. Questi dati sembrano confermare che non vi sia alcuna differenza significativa nell’incidenza o nel decorso naturale della diverticolite del colon acuta e complicata tra i giovani e gli anziani. Il miglior trattamento chirurgico, seguito dal minor tasso di morbilità, potrebbe essere la resezione con anastomosi primaria.

PURPOSE: The study aimed to evaluate the QoL in patients who underwent elective surgery for uncomplicated diverticulitis using a recently developed diverticulitis quality of life questionnaire (DV-QoL). METHODS: All consecutive patients who underwent surgery for uncomplicated diverticulitis or who were hospitalized and treated conservatively for acute uncomplicated diverticulitis episodes in three referral centers, in a 5-year period, were included in the study. The 36-Item Short Form Survey and the DV-QoL were administered to the patients to assess their QoL before and after treatment of diverticular disease. RESULTS: Ninety-seven patients who underwent surgery, 44 patients who were treated conservatively, and 44 healthy volunteers were included in the study. DV-QoL scores correlated with SF-36 scores (p

Aim of this study was to evaluate bowel function after colonic resection for diverticular disease and assess its impact on patients' quality of life.47 patients who underwent urgent or elective surgery for diverticular disease were either personally contacted or interviewed by telephone and given a questionnaire. The Memorial Bowel functional index, the short form (36) health survey questionnaire, and the fecal incontinence severity index were used.Fecal Urgency was found in 4,25% of cases, Incomplete Evacuation in 17,03%, and the Lifestyle/Diet Modification Score in 23,4% of patients. Incontinence cases were not found. After surgery we found reduction of abdominal pain (p=0.017) and improved bowel function (p=0.001). The quality of life correlated to bowel function was defined good or very good in 87.2% of cases whereas 4.3% of patients reported poor bowel function. This condition was related to female patients (p=0.02), urgent surgery (p=0.05), and to post-operative complication (p=0.05).In our experience, both bowel function and abdominal pain improved after surgery and 91.4% of patients were satisfied with the choice of surgery and would agree to do it again. The presence of not recognized inflammatory bowel syndromes can occasionally be responsible for persistent disorders after surgery.Bowel function, Diverticular disease, Sigmoidectomy.Lo scopo dello studio è stato quello di valutare la funzionalità intestinale dopo resezione colica per malattia diverticolare e valutarne l’impatto sulla qualità della vita.47 pazienti sottoposti a resezione colica in urgenza o in elezione per malattia diverticolare, sono stati personalmente contattati o intervistati per telefono, ed è stato loro fornito uno specifico questionari. Per valutare funzionalità intestinale sono stati utilizzati i seguenti test: “Memorial Bowel functional Index”, “ Short Form (36) Health Survey questionnaire”, ed infine il “Fecal Incontinence Severity Index”. Risultati: Un’urgenza fecale è stata riscontrata nel 4,25% dei casi, un’evacuazione incompleta nel 17,03% dei pazienti, ed una modificazione della dieta/Lifestyle nel 23,4% dei pazienti. Non vi sono stati casi di incontinenza fecale completa. Dopo l’intervento chirurgico è stata riscontrata una riduzione della sintomatologia dolorosa addominale (p = 0.017) e una funzionalità intestinale migliorata (p = 0.001). La qualità della vita correlata alla funzionalità intestinale è stata definita buona o molto buona nel 87,2% dei casi, mentre nel 4,3% dei pazienti è stata rilevata una inadeguata funzionalità intestinale. Questa condizione è stata correlata al sesso femminile (p = 0,02), alla chirurgia d’urgenza (p = 0.05), e alla morbilità post-operatoria (p = 0,05).Nella nostra esperienza, sia la funzionalità intestinale che il dolore addominale migliorate dopo l’intervento sono migliorati e il 91,4% dei pazienti sono stati soddisfatti di essere stati sottoposti ad intervento chirurgico. La presenza di sindromi infiammatorie croniche intestinali non riconosciute a volte può essere responsabile di disturbi persistenti anche dopo l’intervento chirurgico di resezione colica.

The purpose of our study was to estimate in elderly patients with a colorectal and sigmoid cancer the frequency of the histopathological exam and to analyze the prognostic/therapeutic value of central LN examination. In our experience the histological evaluation of the central LN has a precise prognostic value. Patients in which the histological evaluation of the central LN was performed had a better prognosis than patients in which the histological evaluation wasn’t possible (tha actuarial survival rate at 5 years was 73,2% in patients in which the central LN status was determinated and 62,7% in thiose in which it wasn’t (p=0.0066). The authors conclude that the histological evaluation of the central LN represents the quality standard of the lymphadenectomy and ensures a precise staging of the tumor which decreases the shifting between tumor stages. From an oncological point of view the therapeutic improvement achieved can be ascribed to metastatic LN dissection.

The development of new blood and lymphatic vessels is a crucial event for cancer growth, metastatic spread and relapse after therapy. In this work, the expression levels of chemokines, angiogenic and angiostatic factors and their receptors were determined in paired mucosal and tumour samples of patients with colorectal carcinoma and correlated with clinical and histological parameters by advanced multivariate analyses. The most important predictors to discriminate between tumour and paired normal mucosa turned out to be the levels of expression of plexin-A1 and stromal cell-derived factor 1 (SDF-1), the former overexpressed and the latter downregulated in tumours. The levels of osteopontin and Tie-2 transcripts discriminated between the presence and absence of lymph node infiltration, the former overexpressed in the presence of infiltration whilst the latter providing a protective role. These results add support to the notion that the expression levels of selected genes involved in new blood and lymphatic vessel formation represent trustable biomarkers of tumour development and invasion and contribute to the identification of novel molecular classifiers for colorectal carcinoma.

Background and Objectives The aim of this retrospective study is to evaluate the results of local excision (LE) for rectal cancer for curative purposes. Methods From 1969 to December 1997, a total of 456 operations were performed for surgical treatment of rectal carcinoma (262 males and 194 females, mean age 66 years). Twenty patients (4.1%) underwent LE (7 males and 13 females, median age 65 years). Patients were selected for LE if they met the following criteria during preoperative staging: tumors staged as T1-T2,N0,M0, grading G1 or G2, and accessible location. Types of LE performed were: 13 transanal excisions (Francillon's technique), 2 Mason surgeries, 2 endoscopic excisions, and 3 transanal endoscopic microsurgeries. Results There was no in-hospital mortality among LE patients. Thirteen tumors were T1 and 7 were T2; all 20 were adenocarcinoma, 14 G1 and 6 G2. There was no specific morbidity, and aspecific morbidity was minimal (5%). There were no local recurrences, but 2 patients (10%) had secondary lesions. Five-year overall survival following LE was 87.4%. Comparing T1 and T2 tumors treated with abdominoperineal resection (APR) and SSR (17 T1 and 42 T2, all adenocarcinoma), in-hospital mortality and specific morbidity were respectively 1.7% (P = 0.55) and 28% (P = 0.007). There were 5 (8.5%) local recurrences (P = 0.17) and 6 (10.2%) metastatic lesions. Five-year overall survival was similar to LE (88.3%; P = 0.76). Conclusions LE for rectal carcinoma might only be successfully performed in selected patients with correct preoperative staging. In the LE cases reported five-year overall survival, local recurrence, and in-hospital mortality were similar to APR and SSR, while there was a statistically significant difference following LE in terms of specific morbidity. J. Surg. Oncol. 2000;74:158–162. © 2000 Wiley-Liss, Inc.

16 splenic grafts and 24 accessory spleens were evaluated with ultrasound, colour Doppler and power Doppler imaging, in order to compare the features of splenic grafts and accessory spleens. 12 splenic grafts (11 surgically implanted, 1 islet of splenosis) were detected in eight patients following splenectomy 6-12 months previously. Four of the surgically implanted splenic grafts were found in three patients following splenectomy 16-18 days previously. 21 accessory spleens were incidentally detected in 20 subjects who had not been operated upon, whereas three enlarged accessory spleens were found in 10 patients who underwent splenectomy 6-12 months previously. The size, shape, rim features, echogenicity, acoustic enhancement and vascularization of the splenic grafts and accessory spleens were evaluated. The splenic grafts were oval with lobulated margins, an inhomogeneous pattern in 36% and acoustic enhancement in 64%. Multiple feeding vessels arising from the surrounding tissue entered the periphery of 10 splenic grafts in the eight patients operated on 6-12 months previously, whereas no vascular signals were detected in the four splenic grafts of the three patients operated on 16-18 days ago. Accessory spleens were round with smooth echogenic margins and a vascular hilum arising from the splenic vessels. In conclusion colour Doppler and power Doppler allow differentiation between accessory spleens and splenic grafts basing on their shape and vascular supply.