The metastatic lymph node ratio is a better prognostic factor than the number of metastatic limph node after curative resection for gastric cancer.

AIM: Evaluate impact of lymph node ratio as prognostic factor in gastric cancer. METHODS: We studied 463 patients with gastric cancer who underwent curative gastric surgery with D1 or D2 lymphadenectomy, Data were collected from May 1996 through December 2010 at Department of General Surgery of Parma University Hospital. We divided patients in two groups according to number of nodes removed Results: The results of the present nonrandomized retrospective single centre study confirm the promising role of the LNR as an independent prognostic factor. Overall survival between LNR categories are statistically significant different between LNR0 and LNR1. CONCLUSION: The ratio between the number of metastatic and analysed lymph nodes in patients with gastric cancer can discriminate patients better than the AJCC/UICC staging system: it seems to be related to a more sensitive in the evaluation of overall survival.

The prognostic role of tumor size in patients with gastric cancer.

AIM: The identification of prognostic factors in gastric cancer is important for predicting patients' survival and determining therapeutic strategies. MATERIALS OF STUDY: A retrospective analysis ofpatients who underwent surgery for gastric cancer between 1996 and 2010. The appropriate cut-off value of tumor size related to survival was determined using receiver-operating characteristic (ROC) curves and it was 2,5 cm. Patients were divided into three groups: a small size group (SSG, < 2,5 cm), a medium size group (MSG, between 2,5 and 5 cm) and a large size group (LSG, ≥ 5 cm). RESULTS: Depth of invasion and lymph node metastasis resulted significantly related to tumor size (p < 0.05). Kaplan- Meier survival curves showed that OS rate was significantly higher in SSG patients. The prognosis of patients with tumor size < 2,5 cm was better than patients with tumors ≥ 2.5 cm in size (p < 0.01). DISCUSSION: The tumor size resulted significantly related to OS and it was related to depth of invasion and lymph node metastasis that are themselves prognostic factors. These results confirm and reinforced literature and suggest that at diagnostic pre-operative work-up we can yet define a prognostic value based on tumor size and underline the primary role of complete resection with free surgical margins and D2 lymphadenectomy. CONCLUSION: In patients with gastric cancer tumor size suggests information about the malignancy of the tumor: it is an important predictor of survival and 2,5 cm may be considered as a valid cut-off to define a better or worse prognosis. KEY WORDS: Gastric cancer, Prognosis,Survival, Tumor size.

Construction and employment of a low cost laparoscopic simulator. Test on General Surgery residents.

INTRODUCTION: Based on studies that confirm the usefulness of simulators in laparoscopic surgical training, we designed and tested a cost-effective solution to improve the skills of surgeons training in the operating room. The goal was to exercise the basic gestures of laparoscopic surgery. MATERIALS AND METHODS: The initial budget of € 500 was sufficient for this project. We spent only € 360 on the majority of the components, which included buying a laptop. The project was performed with material that was readily available online, and the assembly did not require special tools. The goal was to make the product easily replicable. The test was performed using a simulator on 9 doctors in specialist training in general surgery at the University Hospital of Parma distributed, who were equally distributed among the six years of school in general surgery. RESULTS: The first exercise, which was the simplest, had as its objective the acquisition of familiarity with the vision monocular feature of VL and coordination between the two hands. We observed statistically significant improvement between the first and second (2.52 to 2.17 min, p = 0.006) tests and between the first and third (from 2.52 to 1.57 min, p = 0.001) tests with a non-significant correlation between the time of year and the achieved specialty. In the second exercise, there was a statistically significant improvement due to the excessive excursion of the confidence intervals (remarkable variability with overlap of the same features). This exercise, which consisted of two parts, explored the ability to use two hands independently. The third and final exercise involved the packaging of a laparoscopic ligation and was the most complex because it required skill in the use of instruments with both hands as well as considerable coordination. The t-test for paired data showed a significant improvement in all tests with p = 0.0008 between the average time for the first and second tests, p = 0.001 between the second and third tests, and p = 0.01 between the first and third tests (from 10.09 min to 3.52 min). CONCLUSIONS: The simulator that we constructed will never replace the experience gained in the operating room, and it was not our intention to replace the normal process of learning for young surgeons. Instead, we aimed to provide an inexpensive tool for refining the basic skills of laparoscopic surgery, such as the use of instruments in monocular vision, coordination between two hands and ambidexterity.

Experience of 463 cases of gastric cancer from a single surgical center.

AIM: To evaluate clinical and histopathological changes of gastric cancer (GC) in the last fifteen years and analyze factors influencing overall survival. MATERIAL OF STUDY: We have retrospectively categorized patients submitted to surgery for GC from January 1996 to December 2010. The analysis focused on two periods: 1996-2003 (period 1) and 2004-2010 (period 2). RESULTS: There was an increase in age distribution of GC in period 2 (p=0.012). Significant increase of whole GC was observed in period 2 (p=0.01). Slight but significant changes in TNM stage were found: in group 2 there was a decrease in the rate of early GC and in advanced depth of tumor invasion; increase of lymph nodes involvement was also demonstrated. Overall survival (OS) had not changed from the first to the second period. There was a significant difference in OS calculated for Lauren histotype: from ten months to surgery, patients with diffuse histotype showed worse prognosis. DISCUSSION: The most important findings were an increase in lymph node involvement and a decrease in depth of tumor invasion, an higher percentage of whole type and a decrease in palliative surgery. Overall-survival hasn't change in the last fifteen years. These results confirms the importance of extent of lymph node dissection in the standard surgical approach of GC, the tumor stage and Lauren histotypes as the main prognostic factors in GC. CONCLUSION: This work confirms the dismal prognosis of GC and the need to increase diagnosis of early gastric cancer. KEY WORDS: Gastric cancer, Lauren histotype, Overall survivall.

Impact of lymph node ratio in the colorectal cancer staging system.

AIM: Some researchers have proposed the Lymph Node Ratio (LNR) as a prognostic index for post-surgical colorectal cancer follow up. MATERIAL AND METHOD: Two hundred patients with colorectal cancer (ratio F/M of 2:1) were studied. Patients were divided in subgroups according to N-stage and LNR score, subgroups of LNR were made on quartiles. For each subgroup 5 year survival rate was calculated and comparison between groups was carried out. RESULTS: There were 104 patients on N0, 38 on N1 and 58 on N2 stage. Survival rate at 5 years was 61.30% for the NO subgroup, 18.70% for the N1 subgroup, and 12.31% for the N2 subgroup (Fig. 1). The most significant p value, was reported between N0 and N1 as well as between N0 and N2 subgroup (p=0.001). Nodes positive were 44 a LNR ranging from 1% to 25% (1% < LNR < 25%); 24 patients from 26% to 50% (26% < LNR < 50%). In 6 patients LNR was ranging from 51% to 75% (51% < LNR 75%) and in 8 patients from 76% to 100% (76% < LNR 100%); overall survival rate in different quartiles was respectively 27.12%, 9.38%, 16.67% and 1.56%. CONCLUSION: LNR is a reliable prognostic index in post surgical colorectal cancer staging.

The node ratio as prognostic factor after curative resection for gastric cancer.

INTRODUCTION: The depth of the tumor invasion and nodal involvement are the two main prognostic factors in gastric cancer. Staging systems differ among countries and new tools are needed to interpret and compare results and to reduce stage migration. The node ratio (NR) has been proposed as a new prognostic factor. MATERIALS AND METHODS: We retrospectively reviewed 282 patients who underwent curative resection for gastric cancer at Parma University Hospital between 2000 and 2007. TNM stage, NR, overall survival, survival according to nodal status, and survival according to the total number of nodes retrieved were calculated. RESULTS: At univariate analysis, the TNM stage, number of metastatic nodes, NR, and depth of tumor invasion, but not the number of nodes retrieved, were significant prognosis factors. Patients with more than 15 nodes retrieved in the specimen survived significantly longer (p < 0.04). This was confirmed for all N or NR classes within N groups. There was a correlation between the number of nodes retrieved and N but not with the NR category. NR was an independent prognostic factor at Cox regression. CONCLUSION: NR is a reliable and sensitive tool to differentiate patients with similar characteristics, probably more so than the TNM system. NR is not strictly related to the number of nodes retrieved and this may potentially decrease the stage migration phenomenon. More trials are needed to validate this factor.

Is it possible to identify a risk factor condition of hypocalcemia in patients candidates to thyroidectomy for benign disease?

AIM: Hypocalcaemia is the most frequent complication after total thyroidectomy. The incidence of postoperative hypocalcaemia is reported with different percentages in literature. METHODS: We report 227 patients undergoing surgery for benign thyroid disease. After obtaining patient's informed consent, we collected and analyzed prospectively the following data: calcium serum levels pre and postoperative in the first 24 hours after surgery according to sex, age, duration of surgery, number of parathyroids identified by the surgeon, surgical technique (open and minimally invasive video-assisted thyroidectomy, i.e., MIVAT). We have considered cases treated consecutively from the same two experienced endocrine surgeons. Hypocalcaemia is assumed when the value of serum calcium is below 7.5 mg/dL. RESULTS: Pre-and post-operative mean serum calcium, with confidence intervals at 99% divided by sex, revealed a statistically significant difference in the ANOVA test (p < 0.01) in terms of incidence. Female sex has higher incidence of hypocalcemia. The evaluation of the mean serum calcium in pre-and post-operative period, with confidence intervals at 95%, depending on the number of identified parathyroid glands by surgeon, showed that the result is not correlated with values of postoperative serum calcium. Age and pre-and postoperative serum calcium values with confidence intervals at 99% based on sex of patients, didn't show statistically significant differences. We haven't highlighted a significant difference in postoperative hypocalcemia in patients treated with conventional thyroidectomy versus MIVAT. CONCLUSION: A difference in pre- and postoperative mean serum calcium occurs in all patients surgically treated. The only statistical meaningful risk factor for hypocalcemia has been the female sex.

Dunbar's syndrome and superior mesenteric artery's syndrome: a rare association.

Celiac artery compression syndrome (CACS) and superior mesenteric artery syndrome (SMAS) are 2 rare diseases, widely described in literature. Their association has not been specifically investigated; in fact, few cases have been reported. For this reason we reviewed our experience from January 1974 to June 2004. We report 59 patients affected by CACS and 28 by SMAS. Coexistence of both syndromes in 8 patients was observed. These 8 patients were successfully treated with duodenojejunal bypass and decompression of the celiac trunk. In this paper, we analyze the pathogenesis, clinical presentation, diagnosis, and treatment of these syndromes, emphasizing their common aspects. The misdiagnosis of this association may justify in some cases the controversial results reported regarding the surgical treatment of these syndrome.

Hyperparathyroidism associated with thyroid pathology.

BACKGROUND: The pathological association between thyroid and parathyroid gland disease is here discussed. The multiphase analyzer has revealed a new type of subclinical primary hyperparathyroidism (HPP) and the role of surgery in these cases is not clear. METHODS: This is a prospective study of all cases of thyroid disease in association with parathyroid disease treated surgically in our Institute from July 1999 to June 2001. RESULTS: Of the 221 thyroidectomies carried out, 29 patients had an elevated preoperative serum level of parathyroid hormone (PTH). An ultrasonography examination was performed on all patients and a preoperative scanning with 99Tc-MIBI on 11 of 29 patients. We examined intraoperatively 19 cases of HPP (14 parathyroid adenoma, 5 hyperplasia). In 10 cases we observed a normal size of the parathyroid gland and we did not perform a parathyroidectomy. CONCLUSIONS: All patients with elevated serum parathyroid hormone and serum calcium levels before thyroidectomy should be considered candidates also for surgery to the parathyroid glands. The pathological association between thyroid and parathyroid gland diseases is not rare. We must conduct an accurate neck exploration in all these cases.