Pre-pectoral breast reconstruction with tissue expander entirely covered by acellular dermal matrix: feasibility, safety and histological features resulting from the first 64 procedures.

Background: Reconstructive options that can be used following conservative mastectomy, skin-, nipple-sparing and skin-reducing mastectomies, allow a remarkable variety of safe methods to restore the natural shape and aesthetics of the breast mound. In case of two-stage breast reconstruction, tissue expanders (TEs) are usually placed in a subpectoral position. The purpose of this retrospective cohort study is to evaluate the feasibility and safety of two-step reconstruction with TE in pre-pectoral position covered by acellular dermal matrix (ADM). Methods: Between March 2021 and May 2023, at the Azienda Ospedaliero Universitaria Careggi, University of Florence, 55 patients with BRCA 1/2 mutations or early breast cancer underwent conservative mastectomy with immediate pre-pectoral reconstruction using TE covered with ADM, followed by a second surgery with replacement of the expander with definitive prosthesis. Demographic, oncological, and histological data along with surgical complications were recorded. Results: A total of 64 conservative mastectomies were performed. In 2 patients (3.1%) complications were found that required reintervention and, in both cases, the TE had to be removed. Two patients developed hematoma and one patient developed seroma. Two patients showed wound dehiscence, both healed after conservative treatment and without implant exposure. No case of necrosis of the skin or nipple-areola complex has been observed, neither of capsular contracture. Capsule formed around TE was populated with cells and blood vessels and showed a thin area of synovial metaplasia. Conclusions: In selected cases it may be more cautious to perform a two-stage breast reconstruction after radical breast surgery by means of TEs. The placement of TEs in pre-pectoral position combines the excellent aesthetic and functional results of the pre-pectoral philosophy with a quite safer and more prudent two-step approach. Our experience reports optimistic results: the ADM covering the TE is seen successfully integrating during tissue expansion and becoming a vascularised new self-tissue. Complications rates are low and such ADM-assisted two-stage pre-pectoral reconstructive technique is a safe, practical, and reproducible method.

Follow-up after bariatric surgery: is it time to tailor it? Analysis of early predictive factors of 3-year weight loss predictors of unsuccess in bariatric patients.

Bariatric surgery (BS) is the most effective treatment strategy for obesity. Nevertheless, a subset of patients does not reach a successful weight loss or experience long-term weight regain. Conflicting evidence exists regarding predictors of BS outcomes. We aimed to define the early factors linked to 3 year unsuccessful weight loss in order to promote a tailored close follow-up. We enrolled 443 patients who underwent BS from January 2014 to December 2018 with a 3 year follow-up. An unsuccessful BS outcome was defined as a percentage of total weight loss (%TWL) < 20. We compared the characteristics between successful and unsuccessful patients in order to identify predictor factors of unsuccess after surgery. We found that the proportion of patients with unsuccessful weight loss progressively increased from one to three years after BS. In a multiple regression model, only 1 month %TWL and sleeve gastrectomy (SG) were significantly associated with 3 year unsuccessful weight loss. We stratified our cohort in four groups according to the risk of BS unsuccess, in terms of 1 month %TWL and type of surgery (SG vs gastric bypass). Interestingly, groups showed a significant difference in terms of %TWL at each follow-up point. Patients submitted to SG with lower 1 month %TWL must be considered at higher risk of future weight regain; consequently, they require a tailored and closer follow-up.

Controlling Nutritional Status (CONUT) Score and Micronutrient Deficiency in Bariatric Patients: Midterm Outcomes of Roux-en-Y Gastric Bypass Versus One Anastomosis Gastric Bypass/Mini Gastric Bypass.

BACKGROUND: Two of the most common bariatric procedures performed worldwide are Roux-en-Y gastric bypass (RYGB) and one anastomosis gastric bypass (OAGB). Comparative data regarding nutritional status are lacking and no previous study focus on malnutrition according to a validated score. METHODS: Retrospective data from a single institution were reviewed. Anthropometric variables and nutritional data were assessed. The primary aim was to analyze and compare the nutritional status before and 3 years after RYGB vs OAGB using the controlling nutritional status (CONUT) score. The incidence of micronutrient deficiency and the remission of comorbidities in each group were defined as secondary outcomes. RESULTS: Fifty-seven patients in each arm were enrolled. A 3-year mild malnutrition (CONUT score 2-3) was found in 38% and 37.05% in the RYGB and OAGB groups, respectively (p > 0.05). In terms of percentage of total weight loss (%TWL) and percentage of adjustable weight loss (%AWL), no differences were found between OAGB and RYGB groups. OAGB and RYGB patients had similar vitamin deficiencies. Anemia, hypoproteinemia, hypoalbuminemia, and hypocalcemia were comparable between groups. At 3-year follow-up, total protein and albumin values were similar between arms while prealbumin deficit was more frequent after OAGB than after RYGB. The rate of type 2 diabetes (87.5% in OAGB and 92% in RYGB), arterial hypertension (51.6% in OAGB and 58.3% in RYGB), and dyslipidemia (69.7% in OAGB and 78.6% in RYGB) remission was not significantly different between the two groups. CONCLUSIONS: Postoperative CONUT score, micronutrient deficiency, comorbidity remission, and improvement of anthropometric parameters 3 years postoperatively were comparable between RYGB and OAGB groups.

Cardiovascular Benefits and Lipid Profile Changes 5 Years After Bariatric Surgery: A Comparative Study Between Sleeve Gastrectomy and Roux-en-Y Gastric Bypass.

INTRODUCTION: Visceral adipose tissue has been linked with cardiovascular events. Visceral adiposity index (VAI) is a routinely applicable tool for evaluation of visceral adipose dysfunction and linked to 10 year-cardiovascular risk. No previous studies have evaluated the changes over time of the VAI in patients who underwent different types of bariatric surgery. MATERIALS AND METHODS: We reviewed data of 42 patients who underwent laparoscopic sleeve gastrectomy (LSG) and 61 patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB). VAI, lipid profile, and several anthropometric variables were measured before and after 5 years following surgery. RESULTS: During the studied time period, the BMI was similar between LSG and LRYGB patients (34.1 vs 31.6; p = 0.191), but the percentage of total weight loss (%TWL) for LRYGB was significantly higher than LSG (31.3% vs 23.0%; p < 0.001). LRYGB patients had a significant improvement of all lipid parameters evaluated over time, while LSG patients experienced only a reduction in triglycerides (TG) levels and an increase in HDL cholesterol (HDL-C). VAI values were similar in the two groups at baseline as well at the last follow-up point (5-year VAI, LSG: 0.93, RYGB: 0.93; p = 0.951). At multivariate regression analysis, 5-year-%TWL was the only independent predictor of a greater amount of VAI reduction over time. CONCLUSION: Bariatric surgery, independent of the type of surgical procedure, decreases the cardiovascular disease (CVD) risks due to weight loss and improvement of lipid parameters. VAI could be a useful tool to better identify eligible patients for bariatric surgery and to determine the success of surgery.

Aspiration Pneumonia: a Shadow in Post-Bariatric Patient : Correlation between aspiration and minigrastric bypass.

BACKGROUND: The number of post-bariatric surgical procedures is increasing in time. Post-bariatric patients must be carefully evaluated preoperatively, and they must be considered a particular group of patients in plastic surgery. Aspiration is an occurrence in surgical patients that can cause transient pneumonitis but, in some cases, it can progress to severe clinical acute lung injury or in acute respiratory distress syndrome. The aim of this research is to underline a correlation between one anastomosis bypass-minigastric bypass (OAGB-MGB) and biliar or gastric aspiration. METHODS: We performed an analysis of literature and a systematic review of our post-bariatric patients who underwent body contouring procedures which required general anaesthesia from 2013 to 2018 and divided them in two groups: OAGB-MGB group and other bariatric procedures in order to compare the rate of aspiration/pneumonia occurred in time. RESULTS: We collected 423 patients for 536 procedures and 9 complications. In the OAGB-MGB group, there was the highest rate of reflux/aspiration during anaesthesia induction (3.5%, 8 patients) compared with the other group (0.51%). Risk ratio of OAGB-MGB group vs other procedures is 7.054. Literature confirmed high risk of biliar reflux after OAGB-MGB procedure. CONCLUSIONS: This study underlined a significant correlation between OAGB-MGB and reflux/starting general anaesthesia in post-bariatric patients. In our experience we believe that it can be useful enlarge the pre-operatory fasting period and positioning a nasogastric tube during anaesthesia induction that can be performed moreover, in anti-Trendelenburg position, in order to prevent pulmonary aspiration.

Current trends and outcomes of breast reconstruction following nipple-sparing mastectomy: results from a national multicentric registry with 1006 cases over a 6-year period.

BACKGROUND: Reconstruction options following nipple-sparing mastectomy (NSM) are diverse and not yet investigated with level IA evidence. The analysis of surgical and oncological outcomes of NSM from the Italian National Registry shows its safety and wide acceptance both for prophylactic and therapeutic cases. A further in-depth analysis of the reconstructive approaches with their trend over time and their failures is the aim of this study. METHODS: Data extraction from the National Database was performed restricting cases to the 2009-2014 period. Different reconstruction procedures were analyzed in terms of their distribution over time and with respect to specific indications. A 1-year minimum follow-up was conducted to assess reconstructive unsuccessful events. Univariate and multivariate analyses were performed to investigate the causes of both prosthetic and autologous failures. RESULTS: 913 patients, for a total of 1006 procedures, are included in the analysis. A prosthetic only reconstruction is accomplished in 92.2 % of cases, while pure autologous tissues are employed in 4.2 % and a hybrid (prosthetic plus autologous) in 3.6 %. Direct-to-implant (DTI) reaches 48.7 % of all reconstructions in the year 2014. Prophylactic NSMs have a DTI reconstruction in 35.6 % of cases and an autologous tissue flap in 12.9 % of cases. Failures are 2.7 % overall: 0 % in pure autologous flaps and 9.1 % in hybrid cases. Significant risk factors for failures are diabetes and the previous radiation therapy on the operated breast. CONCLUSIONS: Reconstruction following NSM is mostly prosthetic in Italy, with DTI gaining large acceptance over time. Failures are low and occurring in diabetic and irradiated patients at the multivariate analysis.

Is sleeve gastrectomy a therapeutic procedure for all obese patients?

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is a worldwide surgical procedure for morbid obesity. However patients selection is still anecdotal. The aim of this study is to analyse clinical and anthropometric parameters correlated with LSG and to check the validity of this procedure for different categories of obese patients. METHODS: Two-hundred one consecutive patients were submitted to LSG as a primary bariatric procedure between 2008 and 2014. One year follow-up was completed in 159 patients. Smaller groups of patients completed 2 and 3 years follow-up (78, 46 patients respectively). Median preoperative body mass index (BMI) was 45.4 kg/m2 (range: 34.8-73.8); 135 patients (80%) had one or more comorbidities. Potential correlations between age, gender, preoperative BMI, preoperative excess weight, early excess weight loss (EWL) and 1 and 3 year-EWL were investigated. RESULTS: All procedures were regularly completed with laparoscopic approach without conversion to laparotomy. Postoperative complications occurred in six patients (3.7%); no postoperative mortality was observed. Median one-year BMI and EWL were 32.8 kg/m2 and 55.34%, respectively. Three year-EWL was significantly influenced by age, and early EWL. A complete normalization of glycemic levels after the three-year follow-up was also observed in high percentage of diabetic patients. In patients with preoperative BMI>50 kg/m2 we observed most failure cases in terms of EWL and the worst metabolic results. CONCLUSIONS: Our experience indicates that LSG is a safe procedure with satisfactory three-year late weight loss in patients with preoperative BMI <50 kg/m2. Promising results, in terms of improvements of comorbidities, were also observed. These results make LSG one of the most attractive first stage surgical procedure for morbid obesity.

Intra-abdominal desmoid tumors: a case report.

INTRODUCTION: Desmoid tumors are defined as a rare fibroblastic proliferative disease and may occur in any musculoaponeurotic or fascial tissue . CASE REPORT: A 54-year-old man with FAP referred to our institution presenting fever and abdominal pain. Four years before a prophylactic colectomy with ileal-rectal anastomosis was done. Three years later a wide intraabdominal mass with desmoid characteristics was detected. In spite of therapy with tamoxifene the RM control showed an increase of mass dimension. Few days later the patient arrived in our istitute with fever and abdominal pain. Medical therapy didn't improve clinical symptoms and the patient underwent surgery. DISCUSSION: Desmoid tumors are benign tumors, but not a benign disease. Most of these tumors occur sporadically, but about 5% arise in association with familial adenomatous polyposis. Intra-abdominal desmoid tumors remain asymptomatic until their growth and infiltration causes visceral compression. They can cause serious complications and treatment is often unsuccessful. Aggressive fibromatosis treatment should be evaluated and managed by a multidisciplinary team with expertise and experience in sarcoma, prior to initiation of therapy. In FAP, surgery has been recommended for abdominal wall tumors but there are only few indications for intra-abdominal disease like pain, bowel obstruction and desmoids perforation.

The treatment of breast cancer in one day surgery. A four year experience.

The number of short-stay surgery procedures has progressively increased since the concept of short-stay surgery was first introduced. Initially this type of surgery was reserved for patients undergoing inguinal hernia repair, proctological surgery, and various minor procedures. Careful patient selection makes it possible to apply one-day surgery to other surgical specialties including breast cancer surgery. Reducing the length of hospital stay lowers health care costs, and shortens waiting lists. The most important benefits for patients are a more rapid return to work and positive psychological effects. Exclusion criteria for one-day surgery are the lack of home care, excessive distance from place of treatment and the presence of any concomitant pathology that is a contraindication to this type of surgery. We report our experience in oncological surgery of the breast in one-day surgery.

Ileocecal-colonic intussusception caused by cecal adenocarcinoma A case report.

INTRODUCTION: Intussusception in adults is an infrequent cause of intestinal occlusion that is usually due to neoplasm lesions. The unspecific nature of the clinical presentation often delays diagnosis. It is most commonly emergency explorative laparotomy which clarifies the etiology of the occlusion. The authors report a case of intestinal occlusion caused by ileocecal-colonic invagination with a small cecal adenocarcinoma as lead point, in a 74-year-old woman. CASE REPORT: A 74-year-old woman came to the Emergency Department, complaining of crampy pain in the mid- and lower abdomen. An abdominal ultrasound revealed a "pseudokidney sign" apparently involving the cecum. Because there were no clear signs of occlusion, the patient was dicharged on the same day. Three days later, upon admission, the patient complained of episodes of abdominal pain with intervals of moderate well-being, associated with nausea, vomiting and an inability to pass stool (but not gas) for 36 hours. On clinical examination her abdomen was distended and tender on palpation in all quadrants, especially in the right iliac fossa where a large mass could be felt. Standard abdominal x-Ray documented gaseous distension of some loops of the jejunum-ileum with some air-fluid level. The patient underwent an abdominal CT scan which showed advanced intussusception that appeared to be ileocolic and multiple enlarged lymphnodes were found in the invaginated mesentery at the base of which there appears to be a thickening of the intestinal wall that is probably neoplastic in nature. The patient underwent explorative laparotomy. Ileocecal-colonic intussusception caused by a cecal growth 5 cm in diameter was found on examination of the surgical specimen. Histology showed that the cause of the large swelling of the ascending colon was a vegetating ulcerated adenocarcinoma (medium grade differentiation: G2), measuring 6.5x 4.0 cm, arising from a tubulovillous adenoma infiltrating the submucosa. CONCLUSIONS: Most cases of intussusception are caused by structural lesions, a large percentage of which are malignant, especially in the colon. In our patient the lead point was a small cecal polyp which, together with the last loop of the ileum and the ileocecal valve, was pulled into the ascending colon. Although most cases of intussusception in adults are diagnosed at the operating table, noninvasive diagnostic tools like ultrasonography and CT scanning are very useful. Treatment in adults is usually surgical and involves en bloc resection of the lesion. Manual reduction of the intussusception is not advisable because of the risk of dissemination if the lead point is malignant. KEY WORDS: Cecal adenocarcinoma, Itestinal resection, Intussusception in adults.

The surgical palliative treatment of myelofibrosis. Personal experience.

We report a case of significant splenomegaly by myelofibrosis, treated in our institution, that we believe relevant to the completeness parade of symptoms and the exceptional size.

Small cell carcinoma of the breast. Report of a case.

The recognition of undifferentiated forms of endocrine tumors in the extrapulmonary sites is considered as extremely infequent. Immunohistochemical patterns of this tumor are similar to small cell neuroendocrine cancer of the lung and as the pulmonary one, it is more aggressive than carcinoma without neuroendocrine differentiation. We report a case of a 68 years old woman with a primary small cell carcinoma of the breast gland presented as a palpable and mobile 2 cm mass, located in the upper outer quadrant of her right breast. It was treated with surgery and the diagnosis was made after surgical treatment, thanks to the immunohistochemical studies of tissue.

[Transanal haemorridal dearterialisation: personal experience]. / Emorroidectomia con tecnica THD (transanal haemorroidal dearterialization) nostra esperienza.

Transanal haemorroidal dearterialisation (THD) is a nonexcisional surgical technique for the treatment of piles, consisting in the ligation of the distal branches of the superior rectal artery, resulting in a reduction of blood flow and decongestion of the haemorroidal plexus. THD for 2 degrees and 3 degrees degree haemorroids is highly effective and painless. There are few complications and the technique can be performed as a day case.

[Malignant degeneration of chronic pilonidal cyst. Case report]. / Degenerazione maligna di una cisti pilonidale. Caso clinico.

This report describes the case of a patient with a chronic pilonidal cyst developed squamous cell carcinoma. The case was treated with primary radical excision, followed adjuvant radiation and chemiotherapy. Recurrence following such treatment was high and prognosis poor compared with non melanoma skin cancer.