Search

Purpose To evaluate the clinical outcomes with linear accelerator-based multidose stereotactic radiosurgery (SRS) to large postoperative resection cavities in patients with large brain metastases. Methods and Materials Between March 2005 to May 2012, 101 patients with a single brain metastasis were treated with surgery and multidose SRS (9 Gy × 3) for large resection cavities (>3 cm). The target volume was the resection cavity with the inclusion of a 2-mm margin. The median cavity volume was 17.5 cm 3 (range, 12.6-35.7 cm 3 ). The primary endpoint was local control. Secondary endpoints were survival and distant failure rates, cause of death, performance measurements, and toxicity of treatment. Results With a median follow-up of 16 months (range, 6-44 months), the 1-year and 2-year actuarial survival rates were 69% and 34%, respectively. The 1-year and 2-year local control rates were 93% and 84%, with respective incidences of new distant brain metastases of 50% and 66%. Local control was similar for radiosensitive (non-small cell lung cancer and breast cancer) and radioresistant (melanoma and renal cell cancer) brain metastases. On multivariate Cox analysis stable extracranial disease, breast cancer histology, and Karnofsky performance status >70 were associated with significant survival benefit. Brain radionecrosis occurred in 9 patients (9%), being symptomatic in 5 patients (5%). Conclusions Adjuvant multidose SRS to resection cavity represents an effective treatment option that achieves excellent local control and defers the use of whole-brain radiation therapy in selected patients with large brain metastases.

Patients with severe carotid and coronary disease-especially if they require coronary artery bypass grafting (CABG)-are at high risk of cardiac events and stroke. Carotid revascularization should be considered for patients with symptomatic carotid disease and bilateral severe asymptomatic carotid stenosis. In patients with unilateral asymptomatic carotid stenosis, decision to proceed to revascularization should be based more on a perspective of long-term stroke prevention than of perioperative stroke reduction. Compared with endarterectomy, carotid artery stenting is associated with a lower incidence of periprocedural myocardial infarction, an event linked to long-term mortality. This observation may be particularly relevant for patients with advanced coronary artery disease such as those undergoing CABG. Irrespective of the carotid revascularization strategy, a broad disease management approach based on lifestyle modification and pharmacologic cardiovascular prevention is more likely to affect both the quality and duration of life than revascularization itself.

Vascular endothelial growth factor A (VEGF-A) induces strong angiogenesis and it has been widely used in proangiogenic gene therapy studies. However, little is known about long-term effects of VEGF-A expression in skeletal muscle. Here the long- term effects of adeno-associated virus (AAV) encoding human VEGF-A(165) (AAV-VEGF-A) gene transfer in normal and ischemic rabbit hindlimb skeletal muscles were studied. AAV-LacZ was used as a control. In one-year follow-up, a remarkable increase in skeletal muscle perfusion compared with AAV-LacZ was observed measured with Doppler and contrast pulse sequence ultrasound. Angiogenesis was also seen in histology as enlarged and sprouting capillaries. In addition to favorable angiogenic effects, aberrant vascular structures with CD31 positive cell layers were seen inside muscle fibers after AAV-VEGF-A gene transfer. Importantly, we found increased amounts of extracellular matrix with a high number of macrophages and fibrosis in AAV-VEGF-A transduced muscles. No changes in skeletal muscle morphology were detected in AAV-LacZ transduced muscles. Our results indicate that local AAV-VEGF-A gene transfer efficiently promotes long-term angiogenesis in large animal model. However, non-regulated expression of VEGF-A causes unfavorable changes in muscle morphology, which suggests the need for regulation of the transgene expression in long-term AAV-mediated VEGF-A gene transfer applications.

Objective: This study aimed to evaluate the potential advantages of laparoendoscopic single-site surgery (LESS) approach with respect to conventional laparoscopy. Methods: Thirty LESS patients were matched 2:1 with a previous cohort of 58 patients undergoing conventional laparoscopy for the same type of surgery (controls). Results: Median operative time (38.5 vs 54 minutes; P = .09) and estimated blood loss (20 vs 30 mL; P = .008) were more favorable in patients undergoing LESS treatment compared with those undergoing conventional laparoscopy. Rupture of the cyst was observed in 11 out of 30 cases (36.6%) and 26 of 58 controls (44.8%; P = .46). Median length of stay was 1 day in the cases and 2 in the controls ( P = .03). Conclusions: Decreases in operative time, estimated blood loss, or length of stay should not be considered a benefit attributable to LESS; rather it seems there are no differences between these 2 surgical approaches after an adequate selection of patients.

MSCs, otherwise known as multipotent mesenchymal stromal cells, are being examined for the treatment of autoimmune disease (AD) on the basis of their in vitro antiproliferative properties, efficacy in animal models, apparent low acute toxicity and the early positive anecdotal outcomes in human acute GVHD. Phase I/II clinical trials are underway in Crohn's disease and multiple sclerosis (MS) and are being planned for systemic lupus erythematosus (SLE), systemic sclerosis (SSc), systemic vasculitis and other AD. Open issues include patient selection, disease stage and activity, MSC source and expansion and long-term safety. Multidisciplinary groups are collaborating to ensure maximal use of available resources to establish the place, if any, of MSC in the treatment of AD.

Alzheimer's disease (AD) is associated with a loss of cholinergic neurons resulting in profound memory disturbances and irreversible impairment of cognitive function. The central cholinergic system is involved in the action of general anaesthetic agents. Anaesthetic modulation of cholinergic transmission has profound effects on brain function via a cascade of synaptic and postsynaptic events by binding both nicotinic and muscarinic receptors. During general anaesthesia, decrease in acetylcholine release and depression of cholinergic transmission facilitates the desirable effects of general anaesthetics, such as loss of consciousness, pain, voluntary movements and memory. From this point of view, patients with AD, characterized by a compromised neuronal transmission, represent particular cases in which the choice of anaesthesia drugs may have a negative effect on the postoperative outcome. A future challenge may be the identification of brain targets of general anaesthetics which do not expose patients to postoperative cognitive dysfunction, nor interfere with prognosis of brain degenerative disease.

Study objective To evaluate the feasibility, safety, and effect on postoperative pain of laparoscopy for the management of adnexal masses by downsizing ancillary trocars from 5- to 3-mm. Design Randomized, controlled trial (Canadian Task Force classification I). Setting Gynecologic department of a university hospital Patients A total of 102 women with an adnexal mass scheduled for gynecologic laparoscopic procedures were randomized to undergo laparoscopy using either conventional 5-mm ancillary trocars (n = 52) or 3-mm instruments (n = 50). Preoperative suspicion of malignancy, deep infiltrating endometriosis, and indications for hysterectomy or myomectomy were considered as exclusion criteria. Interventions Laparoscopic procedures for the treatment of benign adnexal masses. Measurements and main results Both groups were similar in patient age, body mass index, history of abdominal surgery, and type of procedures. Intraoperative complications occurred in no patient (0%) in the 3-mm group and in two patients (3.8%) in the 5-mm group (p = .49). Conversion from 3- to 5-mm instrumentation was necessary in one procedure. No difference was found in the operative time between the 3-mm and the 5-mm groups (54 min [range 15–175 min] vs 50 min [range 20–150 min], p = .89). The severity of incisional pain was evaluated with a 100-mm visual analog scale at 1, 3, and 24 hours after surgery. Postoperative pain was significantly lower in the 3-mm than in the 5-mm group 1 hour after laparoscopy (20 [range 0–60] vs 32.5 [range 0–80], p = .04). The proportion of women requiring analgesia before discharge, the timing of analgesic requirement, and the total amount of medication in the first 24 hours after surgery were similar in the two groups. Conclusion Three-millimeter ancillary trocars can safely replace traditional-size equipment for the management of adnexal masses without a negative impact on the surgeon’s ability to perform gynecologic laparoscopy and are associated with less immediate postoperative pain.

Recurrent laryngeal nerve (RLN) injury may induce unilateral vocal fold paralysis (UVFP). During thyroidectomy, the most common cause of UVFP, the superior laryngeal nerve (SLN), is also at risk of injury. In the literature, the influence of SLN injury on glottal configuration and function in patients with UVFP remains controversial. The present study investigates SLN injury influence on glottal configuration and function in patients with UVFP after thyroidectomy.Prospective controlled study.Tertiary medical center.The SLN and RLN function of 34 patients with UVFP after thyroidectomy was determined by laryngeal electromyography. The subjects were dichotomized into the isolated RLN injury group (n = 26) or the concurrent SLN/RLN injury group (n = 8). We evaluated glottal angle and paralyzed vocal fold shape during inspiration, normalized glottal gap area, and glottal shape during phonation. The glottal function measurements included voice acoustic and aerodynamic analyses and the Voice Handicap Index. The aforementioned parameters of the RLN and concurrent SLN/RLN injury groups were compared.There were no statistical differences in glottal configuration such as glottal angle, paralyzed vocal fold shape, normalized glottal gap area, and glottal shape between the RLN and concurrent SLN/RLN injury groups. There were also no significant differences in other glottal function analyses including fundamental frequency, mean airflow rate, phonation quotient, maximal phonation time, and Voice Handicap Index.In the present study, we did not find any evidence that SLN injury could significantly influence the glottal configuration and function in patients with UVFP.

Forearm arteriovenous fistula (AVF) is a direct anastomosis between the radial artery and the cephalic vein or the ulnar artery and the basilic vein, which are small-caliber vessels. The surgical technique must be precise to avoid postoperative stenosis of the anastomosis which may result in early thrombosis or nonmaturation. In our experience, microsurgery and preventive hemostasis are two major contributions to creation of forearm AVF. Using these techniques, construction of a radial-cephalic fistula was possible in 78% of children in our hospital, with 60% secondary patency rates at 4 years. In a personal unpublished series, 69% of the first arteriovenous angioaccess of adult patients were forearm fistulae, with 63% and 91% primary and secondary 1-year patency rates, respectively. Finally, 68% primary patency and 96% secondary patency rates at 1 year were reported by Pirozzi et al. in adults with an internal diameter of

The main goal of aortic valve replacement (AVR) is to obtain relief from the fixed left ventricular (LV) obstruction by replacing the aortic valve with a prosthesis, either mechanical or biological, of adequate size. Most currently available prostheses provide satisfactory hemodynamic performance, but small-sized prostheses may be associated with high transvalvular gradients and suboptimal effective orifice area that result in prosthesis-patient mismatch (PPM), and thus are far from ideal for use in young, active patients. The avoidance of PPM is advisable as it has been repeatedly associated with increased mortality, decreased exercise tolerance and an impaired regression of LV hypertrophy after AVR for severe aortic stenosis. Enlargement of the aortic annulus (EAA) has proved to be a valuable method to prevent PPM in the presence of a diminutive aortic root. This review outlines the various techniques described for EAA, presenting technical details, long-term results and major procedure-related complications, and discussing the current role of EAA in patients requiring AVR.

Cryopreservation is a technique that can keep sperm alive indefinitely, enabling the conservation of male fertility. It involves the cooling of semen samples and their storage at −196°C in liquid nitrogen. At this temperature all metabolic processes are arrested. Sperm cryopreservation is of fundamental importance for patients undergoing medical or surgical treatments that could induce sterility, such as cancer patients about to undergo genotoxic chemotherapy or radiotherapy, as it offers these patients not only the hope of future fertility but also psychological support in dealing with the various stages of the treatment protocols.

Background Single-incision laparoscopic cholecystectomy (SILC) may offer advantages over conventional laparoscopic cholecystectomy (LC). Methods MEDLINE, Embase, PubMed, CINAHL, Cochrane Central Register of Controlled Trials and the Cochrane Library were searched for randomized clinical trials on SILC versus LC until May 2012. Odds ratio (OR) and weight mean difference (WMD) were calculated with 95 per cent confidence intervals (c.i.) based on intention-to-treat analysis. Results Thirteen randomized clinical trials included a total of 923 procedures. SILC had a higher procedure failure rate than LC (OR 8·16, 95 per cent c.i. 3·42 to 19·45; P < 0·001), required a longer operating time (WMD 16·55, 95 per cent c.i. 9·95 to 23·15 min; P < 0·001) and was associated with greater intraoperative blood loss (WMD 1·58, 95% of c.i. 0·44 to 2·71 ml; P = 0·007). There were no differences between the two approaches in rate of conversion to open surgery, length of hospital stay, postoperative pain, adverse events, wound infections or port-site hernias. Better cosmetic outcomes were demonstrated in favour of SILC as measured by Body Image Scale questionnaire (WMD − 0·97, 95% of c.i. − 1·51 to − 0·43; P < 0·001) and Cosmesis score (WMD − 2·46, 95% of c.i. − 2·95 to − 1·97; P < 0·001), but this was based on comparison with procedures in which multiple and often large ports (10 mm) were used. Conclusion SILC has a higher procedure failure rate with more blood loss and takes longer than LC. No trial was adequately powered to assess safety.

Contains fulltext : 117810.pdf (Publisher’s version ) (Closed access) BACKGROUND: In August 2010 reports of a possible association between exposure to AS03 adjuvanted pandemic A(H1N1)pdm09 vaccine and occurrence of narcolepsy in children and adolescents emerged in Sweden and Finland. In response to this signal, the background rates of narcolepsy in Europe were assessed to rapidly provide information for signal verification. METHODS: We used a dynamic retrospective cohort study to assess the narcolepsy diagnosis rates during the period 2000-2010 using large linked automated health care databases in six countries: Denmark, Finland, Italy, the Netherlands, Sweden and the United Kingdom. RESULTS: Overall, 2608 narcolepsy cases were identified in almost 280 million person years (PY) of follow up. The pooled incidence rate was 0.93 (95% CI: 0. 90-0.97) per 100,000 PY. There were peaks between 15 and 30 year of age (women>men) and around 60 years of age. In the age group 5-19 years olds rates were increased after the start of pandemic vaccination compared to the period before the start of campaigns, with rate ratios (RR) of 1.9 (95% CI: 1.1-3.1) in Denmark, 6.4 (95% CI: 4.2-9.7) in Finland and 7.5 (95% CI: 5.2-10.7) in Sweden. Cases verification in the Netherlands had a significant effect on the pattern of incidence over time. CONCLUSIONS: The results of this incidence study provided useful information for signal verification on a population level. The safety signal of increased narcolepsy diagnoses following the start of the pandemic vaccination campaign as observed in Sweden and Finland could be observed with this approach. An increase in narcolepsy diagnoses was not observed in other countries, where vaccination coverage was low in the affected age group, or did not follow influenza A(H1N1)pdm09 vaccination. Patient level analyses in these countries are being conducted to verify the signal in more detail.

The role of intraaortic balloon pump (IABP) during percutaneous coronary intervention (PCI) in high-risk acute patients remains debated. Device-related complications and the more complex patient management could explain such lack of clinical benefit. We aimed to assess the impact of transradial versus transfemoral access for PCI requiring IABP support on vascular complications and clinical outcome.We retrospectively analyzed 321 consecutive patients receiving IABP support during transfemoral (n = 209) or transradial (n = 112) PCI. Thirty-day net adverse clinical events (NACEs) (composite of postprocedural bleeding, cardiac death, myocardial infarction, target lesion revascularization, and stroke) were the primary end point, with access-related bleeding and hospital stay as secondary end points.Cardiogenic shock and hemodynamic instability were the most common indications for IABP support. Cumulative 30-day NACE rate was 50.2%, whereas an access site-related bleeding occurred in 14.3%. Patients undergoing transfemoral PCI had a higher unadjusted rate of NACEs when compared with the transradial group (57.4% vs 36.6%, P.01), mainly due more access-related bleedings (18.7% vs 6.3%, P.01). Such increased risk of NACEs was confirmed after propensity score adjustment (hazard ratio 0.57 [0.4-0.9], P = .007), whereas hospital stay appeared comparable in the 2 groups.In this observational registry, high-risk patients undergoing PCI and requiring IABP support appeared to have fewer NACEs if transradial access was used instead of transfemoral, mainly due to fewer access-related bleedings. Given the inherent limitations of this retrospective work, including the inability to adjust for unknown confounders, further controlled studies are warranted to confirm or refute these findings.

Introduction Standardized methods of reporting complications after radical cystectomy (RC) and urinary diversions (UD) are necessary to evaluate the morbidity associated with this operation to evaluate the modified Clavien classification system (CCS) in grading perioperative complications of RC and UD in a real life cohort of patients with bladder cancer. Materials and methods A consecutive series of patients treated with RC and UD from April 2011 to March 2012 at 19 centers in Italy was evaluated. Complications were recorded according to the modified CCS. Results were presented as complication rates per grade. Univariate and binary logistic regression analysis were used for statistical analysis. Results Results and limitations: 467 patients were enrolled. Median age was 70 years (range 35–89). UD consisted in orthotopic neobladder in 112 patients, ileal conduit in 217 patients and cutaneous ureterostomy in 138 patients. 415 complications were observed in 302 patients and were classified as Clavien type I (109 patients) or II (220 patients); Clavien type IIIa (45 patients), IIIb (22 patients); IV (11 patients) and V (8 patients). Patients with cutaneous ureterostomy presented a lower rate (8%) of CCS type ≥IIIa ( p = 0.03). A longer operative time was an independent risk factor of CCS ≥III (OR: 1.005; CI: 1.002–1.007 per minute; p = 0.0001). Conclusions In our study, RC is associated with a significant morbidity (65%) and a reduced mortality (1.7%) when compared to previous experiences. The modified CCS represents an easily applicable tool to classify the complications of RC and UD in a more objective and detailed way.

Background: Esophageal achalasia is not a frequent disorder in children and different treatments have been proposed during past decades. This study reviews the results of the laparoscopic Heller-Dor procedure performed in pediatric patients in two different surgical units. Methods: We included the patients aged

Background: Etravirine is approved for use in treatment-experienced patients at a dose of 200 mg twice daily. Efavirenz has been associated with greater increases in serum lipids compared with other non-nucleosides in randomized trials of first-line treatment. Methods:In this double-blind, placebo-controlled trial, 157 treatment-naive patients with HIV RNA 5000 copies/mL were randomized 1:1 to either 400 mg of etravirine once daily (n79) or 600 mg of efavirenz once daily (n78) plus two nucleoside analogues (either abacavir/lamivudine, zidovudine/lamivudine or tenofovir/emtricitabine) for 48 weeks. Lipids were measured under fasting conditions at baseline and all visits to Week 48. Clinicaltrials.gov identifier: NCT00903682. Results:Overall, the patients had a median baseline CD4 count of 302 cells/mm(3) (range 74722) and a median HIV RNA of 4.8 log(10) copies/mL (range 3.56.6). Both the non-nucleosides and the nucleoside analogues used caused changes in serum lipids. In the efavirenz arm, patients showed significantly larger increases in high-density lipoprotein (HDL) (0.15 mmol/L, P0.004), low-density lipoprotein (LDL) (0.35 mmol/L, P0.005), total cholesterol (0.61 mmol/L, P0.0001) and triglycerides (0.33 mmol/L, P0.03) at Week 48 compared with the etravirine arm. Across the two arms, patients taking abacavir/lamivudine showed greater increases in total cholesterol (0.47 mmol/L, P0.005) compared with patients taking tenofovir/emtricitabine. There were fewer grade 3/4 elevations in total cholesterol, LDL and triglycerides in the etravirine arm (2 patients, 1 patient and 0 patients, respectively) versus the efavirenz arm (8 patients, 6 patients and 2 patients, respectively). Conclusions:In the SENSE trial, first-line treatment with 400 mg of etravirine once daily plus two nucleoside analogues led to fewer grade 3 or 4 lipid elevations compared with efavirenz plus two nucleoside analogues.

Background Rectosigmoidectomy (RR) with primary anastomosis or pelvic peritonectomy (PP) are often part of an optimal en bloc tumor resection in advanced ovarian cancer (AOC) patients with contiguous extension to or encasement of the reproductive organs, peritoneum of the cul-de-sac and sigmoid colon. We report our experience with two different surgical approaches in optimally cytoreduced AOC patients evaluating oncologic outcome and surgically associated morbidities Methods Data from all consecutive AOC patients undergoing PP or RR as part of the surgical procedure during primary cytoreduction from 2004 through 2009 were extrapolated and analyzed using the chi-squared test, Cox proportional hazard model and Kaplan-Meier method including log-rank test. Results During the study period, we identified 187 AOC patients, fitting the inclusion criteria: 71 (38%) were submitted to RR and 116 (62%) were managed with PP. The estimated mean disease-free survival (DFS) was 30.7 months (95% CI 24.6–36.8) in the RR arm vs. 25.9 months in the PP arm (95% CI 21.9–29.9) (p 0.299); similarly, the estimated mean overall survival (OS) was 38.8 months (95% CI 33.4–44.2) in the RR arm and 48.2 months in the PP arm (95% CI 43.1–53.3) (p = 0.122). No statistically significant differences were found in terms of DFS and OS according to the mesocolic lymphnode status (p = 0.65 and p = 0.81, respectively). Conclusions In conclusion, the current study clearly supports evidence that survival rates are similar for patients who achieved optimal residual tumor (RT), independent to whether they had RR or PP.

In the last 10 years, stapled hemorrhoidectomy has gained worldwide consensus. We studied a day-surgery stapled hemorrhoidopexy protocol to allow shorter recovery time and cost reduction. From 2003 to 2008, we performed 292 outpatient stapled hemorrhoidopexies under spinal or local anesthesia including symptomatic Grade III and IV hemorrhoid disease. We used PPH 01 to PPH 03 staplers. We assessed early and late postoperative pain with a Visual Analog Scale, whereas clinical postoperative examinations were performed at sev7en days, 6 months, and 1, 3, and 5 years after surgery. The mean surgery time was approximately 18 minutes (range, 13 to 39 minutes). Of 292 patients, 39 were not dischargeable for urine retention, severe pain, or mild bleeding. Four other patients were rehospitalized within 8 days for bleeding. Twenty-one patients reported transient fecal urgency, whereas nobody reported anal incontinence. We can conclude that stapled hemorrhoidopexy is a safe and effective procedure if performed in a day-surgery unit. The complication rate is comparable to that of inpatient procedures.

Objectives: To assess the pharmacokinetics (PK) of raltegravir and ezetimibe when co-administered to healthy volunteers. Methods: This was a prospective, open-label, crossover study, with subjects randomly assigned to group 1 (raltegravir 400 mg twice daily, raltegravir plus ezetimibe 10 mg once daily, wash-out period, ezetimibe) or group 2 (ezetimibe, raltegravir plus ezetimibe, wash-out period, raltegravir); all phases lasted for 10 days. Steady-state full PK sampling was performed at days 10, 20 and 40. Raltegravir and ezetimibe PK parameters were determined by non-compartmental methods and comparisons in the presence of the potentially interactive drug measured by geometric mean ratio (GMR) and 95% confidence intervals (CIs). Results: Twenty subjects (10 females) completed the study. Raltegravir PK parameters did not change significantly in the presence of ezetimibe: GMRs (95% CI) were 1.16 (0.89-1.51) for AUC 0-12 , 1.13 (0.81-1.58) for maximum plasma concentration (C max ) and 1.12 (0.72-1.74) for trough concentration (C trough ). Ezetimibe AUC 0-24 and C trough were lower in the presence of raltegravir [GMRs (95% CI) were 0.79 (0.68-0.91) for AUC 0-24 and 0.78 (0.60-0.99) for C trough ], while ezetimibe glucuronide C max was 40% higher (90% CI 1.17-1.66). There was marked inter-individual variability in the PK of the two drugs, especially during co-administration. Conclusions: There were no significant changes in raltegravir PK parameters with or without ezetimibe. However, in the presence of raltegravir, ezetimibe AUC 0-24 and C trough were significantly lower (>20%) and ezetimibe glucuronide C max was higher. Clinical data to assess the importance of the change in ezetimibe concentrations are warranted.

Radiotherapy (RT) remains an effective treatment in patients with acromegaly refractory to medical and/or surgical interventions, with durable tumor control and biochemical remission; however, there are still concerns about delayed biochemical effect and potential late toxicity of radiation treatment, especially high rates of hypopituitarism. Stereotactic radiotherapy has been developed as a more accurate technique of irradiation with more precise tumour localization and consequently a reduction in the volume of normal tissue, particularly the brain, irradiated to high radiation doses. Radiation can be delivered in a single fraction by stereotactic radiosurgery (SRS) or as fractionated stereotactic radiotherapy (FSRT) in which smaller doses are delivered over 5-6 weeks in 25-30 treatments. A review of the recent literature suggests that pituitary irradiation is an effective treatment for acromegaly. Stereotactic techniques for GH-secreting pituitary tumors are discussed with the aim to define the efficacy and potential adverse effects of each of these techniques.

The aim of this study was to evaluate local control and survival rates after stereotactic radiosurgery (SRS) plus whole-brain radiotherapy (WBRT) for the treatment of multiple brain metastases from non-small cell lung cancer (NSCLC).Between June 2004 and September 2008, sixty-six patients with multiple brain metastases from NSCLC were enrolled in this prospective study. All patients were required to have 2-3 brain metastases and Karnofsky performance status (KPS)or = 70. WBRT treatment dose was 30 Gy in 10 fractions followed by SRS. A matched control population treated with WBRT alone to a dose of 30 Gy in 10 fractions was used for comparison.The median survival was 10.3 months in the WBRT plus SRS group and 7.2 months in the WBRT group (p=0.005). The 6-month and 12-month survival rates were 90% and 38% in the SRS plus WBRT group and 84% and 19% in the WBRT group (p=0.01). Stable extracranial disease and KPS were significant predictive factors of survival in both groups (p=0.001). Death due to neurological causes occurred in 18% and 35% of patients treated with WBRT plus SRS and WBRT (p=0.02), respectively. Disease control in the brain was 10 months in the SRS plus WBRT group and 7 months in the WBRT group (p=0.001); the 6-month and 12-month control rates were 82% and 42% for WBRT plus SRS, and 75% and 18% for WBRT (p=0.001), respectively. The 6-month and 12-month control rates of treated lesions (local control) were 90% and 47% in the WBRT group, and 100% and 93% in the WBRT plus SRS group (p=0.001).WBRT plus SRS is a safe, minimally invasive and well-tolerated treatment for patients with up to three brain metastases from NSCLC. The treatment is associated with longer survival and better disease control in comparison with WBRT alone. Survival benefits need to be confirmed by large randomized studies.

Recently, many authors have investigated the results of immediately loaded implants in fresh extraction sites, reporting favorable success rates, but only a few studies have included a long-term follow-up in the maxilla with analysis of clinical and radiographic data. The aim of this study was to evaluate the predictability of the immediate loading protocol with fast bone regeneration (FBR)-coated implants placed in postextractive sites in the maxilla, considering the success rate after at least 5 years of follow-up. Moreover, the clinical and radiographic results are evaluated in terms of soft tissue conditions and crestal bone loss values. One hundred fifty-eight implants were inserted following dental extraction in 70 consecutively operated patients. Each implant was immediately prosthesized. The data were collected before surgical planning, at the time of insertion, and after 3 and 5 years of occlusal loading. Specific success criteria were used to assess the success rate of immediately loaded postextraction implants. Clinical and radiographic examinations were used to determine long-term results. After a 5-year follow-up, 2 implants were lost, with a cumulative success rate of 98.7%. The radiographic and clinical data revealed well-maintained hard and soft tissues, with acceptable long-term results. The use of immediately loaded FBR-coated implants in fresh extraction sockets is shown to be a predictable technique if implants are inserted in selected cases and positioned with great care, following thorough preoperative analysis.

Objective This prospective randomized pilot study compared the use of the Ligaclip (Ethicon Endo-Surgery, Cincinnati, OH) with bipolar coagulation in preventing lymphoceles after laparoscopic pelvic lymphadenectomy for gynecologic cancer. Study Design Thirty patients with gynecologic malignancy, who had laparoscopic pelvic lymphadenectomy were randomly assigned for lymphadenectomy in 1 side of the pelvis using the Ligaclip, whereas, in the other side, the bipolar coagulation to seal lymphatic vessels was used. Results At ultrasound examination, we detected lymphocele in 10 patients (33%). Lymphocele developed in 9 (30%) patients on the side where laparoscopic pelvic lymphadenectomy was perfomed using bipolar coagulation, and in 1 (3.3%) patient on the side where laparoscopic pelvic lymphadenectomy was performed using the Ligaclip. Univariate analysis revealed that the Ligaclip's use compared with electrocoagulation in the laparoscopic pelvic lymphadenectomy is an independent predictive factor for development of lymphocele ( P = .006). Conclusion This study demonstrates that the use of the Ligaclip to close lymphatic vessels may reduce the incidence of lymphoceles in patients undergoing laparoscopic pelvic lymphadenectomy.

Objective Upper abdominal spread of primary and recurrent ovarian cancer is often considered to be a major obstacle to achieve optimal residual disease at the end of surgery. In this study, we investigate the role of diaphragmatic debulking in the natural history of advanced and recurrent epithelial ovarian cancer patients, and the morbidity of this procedure according to clinico-surgical characteristics. Methods Data from 234 consecutive patients with primary and recurrent advanced ovarian cancer, operated at Catholic University of Rome and Campobasso from January 1, 2005 and December 31, 2008, were retrospectively reviewed. Results Eighty-seven patients (37.2%) underwent a diaphragmatic surgery. Median age was 55 years (range 37–76). Diaphragmatic debulking was performed in 50 out of 120 patients at primary surgery (41.7%), in 16 out of 74 at interval debulking surgery (21.6%) and in 21 out of 40 secondary cytoreductions (52.5%). In the whole study population optimal residual disease at the end of surgery was achieved. The most frequent post-operative complication was pleural effusion, observed in 37 patients (42.5%). Presence of a post-operative pleural effusion was correlated liver mobilization (52.3% vs. 16%; p 5 cm) removal (54.1% vs. 23.5%; p Conclusions Diaphragmatic surgery represents a crucial step in the debulking of advanced and recurrent ovarian cancer patients. Considering the natural history of advanced epithelial ovarian cancer and the rate of patients needing diaphragmatic debulking during primary cytoreduction, interval debulking surgery and secondary cytoreduction, this procedure should be present in the surgical repertoire of a gynecologic oncologist.

In this case report, the patient experienced a stress fracture at one of the pinhole sites used for placement of the computer navigation system’s tibial trackers. Introduction The use of computer navigation systems in total knee arthroplasty (TKA) has become increasingly popular in recent years. Many authors have already documented satisfactory short- to mid-term results after using various types of software [1-3]. Bathis et al [4], as well as Decking et al [5] and Rosenberger et al [6], showed how the use of navigation systems can improve the accuracy of the femoral and tibial component placement when compared with the “traditional” techniques. Because a correct alignment of the components is one of the most important factors determining favorable long-term results of a TKA, this could lead to a higher longevity of the prosthesis. Despite these positive aspects, some authors have reported no advantages, as well as a longer operative time with the use of computer-assisted systems [7,8]. Moreover, recently three cases of stress femoral or tibial fractures have been reported as a complication of navigated TKA [9,10]. We present a case of a stress fracture of the tibial diaphysis that occurred after a TKA performed with the use of a computer navigation system. The stress fracture occurred at one of the pinhole sites used for the placement of the tibial trackers. We have been using computer navigation systems since 2005 as a standard procedure for TKA. This complication occurred after a series of 155 (0.64%) uncomplicated procedures (ie, well after the learning curve was complete).

Since its first description in 1958, hairy cell leukemia (HCL) had a long period of different unsatisfactory treatments till the early 1980s, when interferon-alfa and subsequently purine analogs (PAs) pentostatin or cladribine, or pentostatin were described to determine durable responses. However, second lines of treatments are very often needed in the life span of patients with HCL and a small minority of patients are refractory and with poor prognosis. These disadvantages have led to test the efficacy of additional compounds, mainly monoclonal antibodies, combined with PAs. The objective of this presentation is to review the current knowledge of combination treatments in HCL. Combination treatments have been used or proposed for different purposes in HCL: to reduce acute toxicity, to improve complete remission (CR) rate, to overcome resistance/refractoriness, to prolong disease-free survival, or to prolong overall survival. The type of patients to be selected for the combinations and the perspectives of combinations of PAs with monoclonal antibodies will also be discussed.

Objective. To compare the surgicopathologic outcome of total laparoscopic radical hysterectomy (LRH) with that of abdominal radical hysterectomy (ARH) for the treatment of early-stage cervical cancer. Methods. Radical hysterectomy specimens of sequential patients undergoing LRH ( N =50) were compared with those of historical controls selected from consecutive women who have had conventional ARH ( N =48), and who met the same criteria for eligibility as the cases. To evaluate the extent of parametrial resection, parametrial tissues were systematically measured at their widest dimensions before tissue processing. Results. No difference was found in demographics, histologic type, tumor stage and grade between the two groups. The parametrial width was similar between LRH and ARH in both type II (right parametrium: 2.4 cm (1–3) vs. 2.3 (1.8–4.0), p =0.28; left parametrium: 2.3 cm (1.8–4) vs. 2.2 (1.2–3.0), p =0.54) and type III radical hysterectomy (right parametrium: 3.8 cm (2.3–6.5) vs. 3.4 (1.7–7.0), p =0.59; left parametrium: 3.6 cm (2–6) vs. 3.5 (1.5–6.5), p =0.82). There were no significant differences between the two groups with regard to lymph nodes yield and likelihood of identifying positive margins or metastatic disease. Conclusion. Our results suggest that laparoscopically managed patients with cervical cancer undergo a similar extent of surgery as those treated with the traditional ARH, as judged by objective pathologic criteria.

Objectives: To evaluate the morbidity, and the therapeutic value of surgery after chemoradiation in a large series of locally advanced cervical cancers (LACC). The prognostic role of different clinico-pathological factors has been also evaluated. Methods: Between October 1997 and October 2006, 161 LACC patients were treated at both the Gynecologic Oncology Units of the Catholic University of Rome and Campobasso. Radiotherapy was administered to the whole pelvic region in combination with cisplatin and 5-fluorouracil. Radical surgery was performed 5-6 weeks after the end of the treatment. Results: A clinical complete/partial response was observed in 153 patients and radical surgery was performed in 152 cases. The overall rate of surgical complications was 33% with 15 (10%) patients experiencing severe toxicities. At pathological examination 111 of 152 patients (73%) showed absent/microscopic residual disease. With a median follow-up of 28 months, the 5-year disease free-survival (DFS) was 83% and the 5-year overall survival (OS) 90%. Advanced FIGO (Federation Internationale de Gynecolgie et d'Obstetrique) stage, pathological response and lymph node involvement were found significantly associated with clinical outcome. Conclusions: We confirmed in a larger series the safety and efficacy of this multimodal approach in the treatment of LACC. The pathological assessment of response can allow not only a tailored surgery in selected patients, but also the identification of patients with higher risk of recurrence to be submitted to adjuvant therapies. © 2007 Elsevier Inc. All rights reserved.

Objective To evaluate GI symptoms in patients submitted to systematic para-aortic lymphadenectomy (PALN) and to compare them in a contemporary series of patients only submitted to systematic pelvic lymphadenectomy (PLN). Methods A prospective study of 51 consecutive patients submitted to systematic (minimum number of aortic nodes removed ≥10) laparotomic para-aortic lymphadenectomy for any gynecological cancer. The following parameters have been monitored prospectively: nausea and vomiting, bowel movements, nasogastric tube insertion or reinsertion, the time of removal of the nasogastric tube, duration of ileus, time to first passage of stool, regular diet consumption and postoperative stay and complications. Results Twenty-three of 46 valuable patients (50%) submitted to systematic para-aortic lymphadenectomy complain of GI symptoms during recovery and 2 more cases have been readmitted for the appearance of nausea and vomiting with respect to 3 cases (5%) in the group of only pelvic lymphadenectomies ( p =0.00001). According to multivariate analysis, the main determinant of post/operative GI dysfunction is the systematic aortic lymphadenectomy. Twenty-two out of a total of 28 symptomatic patients (78.6%) have accused mild symptoms and have been therefore treated by fasting, by intravenous fluid administration and by anti-emetic drugs. Out of the six remaining patients, three patients (10.7%) have been classified as moderate cases because they have required the insertion of a nasogastric tube for gastric decompression, whereas in the remaining refractory patients (10.7%, severe cases) prokinetics drugs have been used. An exploratory laparotomy has never been performed. Conclusions GI dysfunction symptoms are very common in patients submitted to systematic para-aortic lymphadenectomy. However, only 20% of the patients complain about moderate/severe symptoms. In these cases, we strongly recommend a conservative management.

The aim of this study was to investigate the effects of tramadol on the Bispectral Index (BIS) during total intravenous propofol-remifentanil anaesthesia. Forty-four adult ASA Physical status I-II patients, scheduled for elective general surgical procedures were included in a prospective observational randomized study. Doses for anaesthetics and opioids were adjusted to keep the BIS value at 50±5. After 20 minutes of stable anaesthesia, the subjects were randomly allocated to receive intravenous saline (control group) or tramadol 1.5 mg/kg (tramadol group). BIS values, mean arterial pressure, and heart rate were recorded every five minutes for 20 minutes. Mean BIS values after tramadol administration were not significantly different from those following saline, throughout the observation period (P>0.05). There were no patients in whom BIS values were more than 60 or who presented explicit recall of events under anaesthesia. There were no significant changes in mean arterial pressure, SpO2, or heart rate (P>0.05). The results indicate that the administration of tramadol during stable total intravenous anaesthesia with propofol-remifentanil does not affect BIS values. The clinical relevance is that tramadol can be safely administered pre- and intraoperatively as pre-emptive or preventive analgesia without modification of the depth of anaesthesia.

Objective. The aim of this study was to characterize the means whereby the results could be improved and the morbidity and side-effects minimized, of radical and extensive surgery performed together with plastic reconstruction, in the treatment of locally advanced and relapsed vulvar carcinoma. Methods. Between May 2000 and November 2004, twenty-three patients with locally advanced or relapsed vulvar carcinoma underwent major radical or extended vulvectomy, requiring reconstructive surgery. A consistent protocol for the perioperative management of these patients, including precautionary measures to reduce the rate of early complications, was introduced in the second study period (from November 2003) to verify the benefit on surgical outcome. Results. An analysis of the medical reports showed an improvement in the median time of the postoperative course and related morbidity as a consequence of a strict application of the management protocol, with consequent decrease of early complications. Conclusions. Reconstructive surgery, which broadens the spectrum of available operative therapy in primary and locally recurrent vulvar cancer, is characterized by a high complication rate. The application of a strict perioperative protocol could reduce the number and the clinical impact of such complications.

Comparison between laparoscopy and minilaparotomy in the management of intramural and/or subserosal uterine myomas.Prospective study (Canadian Task Force classification II-2).University hospital.Two hundred-thirteen women with at least one subserosal and/or intramural uterine myoma.Laparoscopy and minilaparotomy myomectomy.We performed 213 myomectomies, 120 by minilaparotomy and 93 by laparoscopy. Median number of myomas removed per patient was 1.4 (range 1-3) and 2.9 (range 1-5) in the laparoscopy and minilaparotomy groups, respectively (p.05). The estimated blood loss was not significant in either of the two groups, and no intraoperative or early postoperative complications were registered. The median operating time was 62.3 minutes (range 45-80 min) and 61.6 minutes (range 40-90 min) in the laparoscopy and minilaparotomy groups, respectively (p=NS). Median duration of ileus was 1.4 days (range 1-2) in the laparoscopy group and 1.3 days (range 1-2 days) in the minilaparotomy group (p=NS). Median length of hospital stay was 2.3 days (range 2-3 days) and 2.8 days (range 2-3 days) in the laparoscopy and minilaparotomy groups, respectively (p=NS.).Myomectomy by minilaparotomy can be considered a minimally invasive alternative to laparoscopy in the surgical management of intramural and subserosal myomas.

The stronger anatomo-functional connections of the supplementary motor area (SMA), as compared with premotor area (PM), with regions of the limbic system, suggest that SMA could play a role in the control of movements triggered by visual stimuli with emotional content. We addressed this issue by analysing the modifications of the excitability of the primary motor area (M1) in a group of seven healthy subjects, studied with transcranial magnetic stimulation (TMS), after conditioning TMS of SMA, during emotional and non-emotional visually cued movements. Conditioning TMS of the PM or of contralateral primary motor cortex (cM1) were tested as control conditions. Single-pulse TMS over the left M1 was randomly intermingled with paired TMS, in which a conditioning stimulation of the left SMA, left PM or right M1 preceded test stimulation over the left M1. The subjects carried out movements in response to computerised visual cues (neutral pictures and pictures with negative emotional content). The amplitudes of motor-evoked potentials (MEPs) recorded from the right first dorsal interosseous muscle after paired TMS were measured and compared with those obtained after single-pulse TMS of the left M1 under the various experimental conditions. Conditioning TMS of the SMA in the paired-pulse paradigm selectively enhanced MEP amplitudes in the visual-emotional triggered movement condition, compared with single-pulse TMS of M1 alone or with paired TMS during presentation of neutral visual cues. On the other hand, conditioning TMS of the PM or cM1 did not differentially influence MEP amplitudes under visual-emotional triggered movement conditions. This pattern of effects was related to the intensity of the conditioning TMS over the SMA, being most evident with intensities ranging from 110% to 80% of motor threshold. These results suggest that the SMA in humans could interface the limbic and the motor systems in the transformation of emotional experiences into motor actions.

In the masterpiece ‘The extraction of the stone of madness’ due to the famous Dutch painter Hieronymous Bosch (1450–1516) (see Fig. 1), a foolish man turns to a charlatan surgeon for his own release from illness. This theme is inspired by folk satire and by the hostility against the physicians’ guild at that time. In fact, in that age head surgery for the extraction of ‘stones’ from the brain in psychiatric disorders was relatively widespread. Five hundred years later, the invasive approach to the knowledge of brain diseases has providentially changed thanks to modern brain imaging techniques, such as—for instance— the computerized tomographic scan (CT), the electroencephalography (EEG), the magnetoencephalography (MEG) or the functional magnetic resonance imaging (fMRI). Only the last 3 techniques supply fruitful information on the brain function and can be integrated with CT or MRI methods able to offer a detailed topography of brain structures. In the following paragraphs, we will briefly recall some technical advances of these last 10 years in the improvement of our capability to extract ‘information’ about the brain activity in a non-invasive way. Then, we will comment on the article by Zhang et al. (2003) where a cortical imaging technique is used to estimate potential distributions over a simple model of dura mater in 5 epileptic pediatric patients before surgery. 2. The problems of conventional EEG recordings

The early detection of prostatic neoplasm is nowadays a primary need in the urological field. The availability of transrectal ultrasound equipment alongside with bioptic tools made possible that transrectal ultrasound-guided biopsy of the prostate became the standard procedure to achieve this goal. With this work we would like to confirm the efficacy of this method which is also associated with a good tolerance and low complications rate. 82 patients that came to our Department between 1997 and 1999 were submitted to this procedure, 25 resulted positive for prostatic adenocarcinoma. Only 2 of them did not tolerate the procedure while all the others referred only mild discomfort at the moment of the puncture; 9 patients afterwards had to be admitted to the hospital due to fever (1 patient), acute retention of urine (3 patients) and persistent macroscopic hematuria (5 patients). Transrectal ultrasound-guided biopsy of the prostate reveals to be a safe and accurate method to obtain tissue samples of the prostate along with high tolerance and low incidence of serious complications.

Gallbladder stones are a well-known and widely studied problem in children. Hematological disorders are the most common diseases that can cause cholelithiasis. However, in the last few years, the proportion of children with idiopathic cholelithiasis has increased 50%. Herein, we present a prospective study on laparoscopic cholecystectomy in a selected group of patients aged10 years.Fifty-eight patients aged10 years underwent laparoscopic cholecystectomy for stones in the period 1992-99. The female/male ratio was 1.5, the mean age was 8 years (range, 2-10), and the mean weight was 30 kg. In all patients, parenteral nutrition, fasting state, and prolonged use of antibiotics had been suspended foror = 6 months, and conservative treatment had been tried foror = 12 months in the absence of symptoms of stone migration. All the patients were followed up after surgery: clinically at 1,6,12, and 36 months and by ultrasound at 1, 12, and 36 months. Liver function and hematological tests were performed in case of symptoms or if hemolytic disorders were the cause of stones.The mean operative time was 63 min (range, 30-120) in children undergoing cholecystectomy alone and 150 min in children undergoing associated splenectomy. There were no major complications or reoperations. Minor complications included bleeding from accessory cystic artery (n = 3) and insufflation of the omentum (n = 2). One case was converted to an open procedure due to technical problems. All the children were followed up and no complications were observed.We consider the laparoscopic approach the gold standard for cholecystectomy in children. This procedure does not have a complication rate any higher than open cholecystectomy, and patient follow-up is as good as that of open surgery. Previous abdominal surgery is not a contraindication to laparoscopy.

The complications of prosthetic surgery in the dysplastic hip have specific features that are related to the conditions that make the realization of an implant technically complex; the altered primary acetabular and femoral morphology, the sequelae of previous non-substitutive surgery, and the consequent possible upsetting of joint biomechanics. It is possible to distinguish between complications relative to the skeleton, joint biomechanics, and soft tissues. Prosthetization of the acetabular skeletal aspect may encounter frequent errors in reconstruction (incongruous reaming-too much or too little-the improper use of bone grafts), errors in orientation of the acetabular component (excessive verticalization and anteversion) that are considered early complications. The same technical errors may cause late complications in the implant, or its migration. At the femoral level the particular shape of the medullary canal and of the femoral neck may lead to defects in orientation in anteversion and fracture of the diaphysis. Possible complications of a biomechanical nature are essentially to be related to changes in the center of rotation in both a craniocaudal and a mediolateral sense and or to the heterometry of the limbs. In the soft tissues, muscle tension may become too much or too little, in relation to recovery of joint biomechanics; in cases with significant lengthening neurologic deficit may occur. Accurate preoperative planning (traditional x-rays and CT scan), the choice of the most suitable surgical route of access, and the different prosthetic models that adapt best to the different morphological situations, the expertise of the surgeon, are all essential elements in monitoring complications.

The poor prognosis of pancreatic carcinoma after resection is related to distant metastases and local recurrence that is characterized by a strong tendency to infiltrate the retroperitoneal tissue and spread along the neural plexuses and lymph nodes. Thorough clearance of these tissues around the celiac and mesenteric axes, aorta, and inferior vena cava from the diaphragm to the inferior mesenteric artery (extended pancreaticoduodenectomy may lower the rate of local recurrence, but the procedure has been criticized for its higher morbidity and mortality. Our aim was to compare extended pancreaticoduodenectomy (EPD) with standard pancreaticoduodenectomy (SPD) in terms of postoperative morbidity and mortality. Data from 47 patients who underwent either EPD (n=24) or SPD (n=23) between November 1992 and October 1995 were retrospectively analyzed. Preoperative laboratory findings, operative risk (according to the American Society of Anesthesiologists classification), type of operation (classic Whipple vs. pylorus-preserving Whipple), operative time, intraoperative blood and plasma transfusion, postoperative morbidity and mortality, and postoperative hospital stay were scrutinized. The results showed that all of the parameters considered were similar in the EPD and SPD groups (intraoperative blood transfusion 800+/-490 ml vs. 700+/-586 ml, postoperative mortality 0% vs. 4.3%, overall morbidity 45.8% vs. 47.8%, surgical morbidity 37.5% vs. 34.7%, and postoperative hospital stay 16+/-8.1 days vs. 17+/-13.1 days. These two groups differed only in the operative time, which was significantly longer for EPD than for SPD (360+/-68.9 minutes vs. 330=66.9 minutes, P=0.02). Although the operative time is increased with EPD, there does not appear to be an increase in intraoperative complications, postoperative morbidity and mortality, or postoperative hospital stay with this procedure. However, definitive confirmation of these results can only be provided by a prospective randomized study.

The so called temporary embolization by percutaneous injection of autologous clot can be envisaged as the method of choice in selected cases of massive renal bleeding. The goals of this technique are to occlude the bleeding vessels until a satisfactory hemostasis is achieved and to preserve as far as possible the renal parenchyma by adopting a completely reabsorbable embolic material as the autologous clot. After a review of the literature a case is presented where a temporary embolization was performed in a young woman with brisk postoperative bleeding in a solitary kidney. The procedure was successful and the renal function was not impaired.

In recent years preoperative transcatheter embolization has been used widely in the management of kidney tumors. However, the effective clinical usefulness of this method has not yet been proved. Forty cases of kidney tumors treated by preoperative embolization and radical nephrectomy are reviewed and compared with a homogeneous group of patients who did not undergo preoperative embolization. Intraoperative blood loss, postoperative complication, and survival rate were statistically evaluated according to tumor stage. Advantages and disadvantages of preoperative transcatheter embolization of kidney tumors are reviewed.

Summary— Three patients with severe haemorrhage from inoperable bladder cancer were treated by selective transcatheter embolisation of both internal iliac arteries. The technical details, results and a rare complication are described. Both gelatin foam and isobutyl-2-cyanoacrylate (IBC)* are suitable embolic materials, but we prefer IBC when possible in patients with tumour.

The literature of the radiation pneumonitis is reviewed from the standpoint of the pathogenesis, histopathology and dependent parameters of the disease. A series of 125 patients treated with mantle fields for Hodgkin's disease between 1972/80 is studied. The radiation pneumonitis developed radiologically in 28 patients (22,4%); in 20 (72%) was asymptomatic. The incidence of pneumonitis against the time of onset of the disease, reveals a peak about the first three months after the end of radiotherapy. No significative variations of incidence of disease are seen in two groups of patients treated respectively with and without chemotherapy (20% and 26%). Frequency diagrams of pneumonitis as a function of the calculate values of the dose for TD, rets, TDF, show a significant correlation with the ranges of doses expressed in TDF.

Pancreatic surgery remains the only established curative treatment for pancreatic cancer. Radical antegrade pancreatosplenectomy (RAMPS) is a modification of the standard retrograde pancreatosplenectomy (SRPS) developed to achieve a complete N1 node resection and R0 resection (posterior extent). The aim of this study is to compare the short-, mid-, and long-term outcomes of RAMPS and SRPS. From a database that included 143 consecutive patients who underwent resection for pancreatic carcinoma at the St. Andrea Hospital, University of Rome, 25 patients who underwent pancreatosplenectomy were retrospectively reviewed. Among these 25 patients, eight (32%) underwent RAMPS (Group 1) and 17 (68%) underwent SRPS (Group 2). Clinicopathologic and oncological characteristics of the RAMPS group were compared with those of the SRPS group. RAMPS was longer than SRPS (315 vs 265 minutes, respectively, P < 0.001). No differences were encountered for perioperative outcomes (estimated blood loss, intraoperative blood transfusions, postoperative morbidity and mortality, and hospital stay). The margin status rates were similar: noteworthy, the two patients with positive tangential margins belonged to Group 2. No between-group differences in survival were encountered: the actuarial 5-year overall survival for Groups 1 and 2 were 26 and 29 per cent, respectively ( P = 0.6608; hazard ratio, 1.2621; 95% confidence interval, 0.4462 to 3.5699). RAMPS and SRPS did not differ statistically in terms of perioperative outcomes. RAMPS seems to allow better control of tangential margins; however, no difference was found in actuarial survival compared with standard pancreatosplenectomy.