Lessons learned from 227 biological meshes used for the surgical treatment of ventral abdominal defects.

PURPOSE: The advantages of biological meshes for ventral hernia repair are still under debate. Given the high financial cost, the proper indications for biological meshes should be clarified to restrict their use to properly selected patients. METHODS: A retrospective database was instituted to register all cases of abdominal wall defect treated with biological meshes from 1/2010 to 3/2016. RESULTS: A total of 227 patients (mean age: 64 years) whose ventral abdominal defects were reconstructed with a biological mesh were included in the study. Patients were divided according to the 2010 four-level surgical-site complication risk grading system proposed by the Ventral Hernia Working Group (VHWG): Grade 1 (G1, 12 cases), Grade 2 (G2, 68 cases), Grade 3 (G3, 112 cases), and Grade 4 (G4, 35 cases). The surgical site complication rate was higher in patients with one or more risk factors (33.6% vs 19% in patients with no risk factors) (P = 0.68). Statistically significant risk factors associated with the onset of one or more postoperative surgical site complications included: diabetes, coronary artery disease, immunosuppression, and obesity. Recurrence was more common in patients with surgical site complications and mainly associated with infection (38.9%) and wound necrosis (44.4%), and in cases of inlay positioning of the mesh (36%). CONCLUSIONS: Due to their high costs, biological mesh should not be used in G1 patients. In infected fields (G4), they should only be used if no other surgical solution is feasible. There is a clear need to prospectively evaluate the performance of biological meshes.

[Long-term results of neoadjuvant radiochemotherapy in squamous carcinoma of the thoracic esophagus]. / Risultati a lungo termine del trattamento chemio-radioterapico neoadiuvante del carcinoma squamoso dell'esofago toracico.

AIM: Surgery is considered the mainstay of therapy for clinically resectable esophageal cancer, even though neoadjuvant treatments are frequently added. The aim of this study was to analyse our experience on neoadjuvant treatment of squamous cell carcinoma of the thoracic esophagus with special reference to long-term METHODS: The results of 66 patients who underwent neoadjuvant chemo-radiotherapy for squamous cell carcinoma of the thoracic esophagus at the 1(st) Division of General Surgery, University of Verona, from February 1995 to December 2002 were analysed statistically. The median follow-up period for the surviving patients was 65.3 months. RESULTS: The induction treatment was completed in 93.9% of cases, with a null treatment related mortality and a complication rate of 34.8%. Sixty-one out of the 66 patients (92.4%) underwent resection with a R0-resection rate of 83.9%. A major pathological response (responders) was gained in 42.6% of the cases, with a complete response (pTONO) observed in 29.5% of the cases. Overall 5-year survival for the 66 patients was 30%, while the 5-year survival rate raised to 43% in R0-patients. A better long-term survival was observed for responders with respect to ''non-responders'' with a 5-year survival rate of 70% and 13%, respectively (P<0.001). CONCLUSIONS: This neoadjuvant protocol regimen represents a feasible treatment with an acceptable morbidity. The tumor efficacy in term of pathological responses was similar to literature RESULTS: An high rate of R0-resections was achieved with a possibility of cure limited to this group of patients. A better long-term survival was observed in patients with major pathological responses.

Extraintestinal infection by group C Salmonella: a case report and review of the literature.

Infected or mycotic aneurysms of the aorta are not very frequent but they are associated with high morbidity and mortality rates. Vascular infections due to Salmonella are not very frequent, but in recent years the reports of infections of this type have been on the increase. The authors report their experience with a case of aneurysm of the abdominal aorta infected by group C Salmonella and go on to review the literature on the subject.

[Abdominal metastasis of cardias adenocarcinoma]. / Studio della diffusione neoplastica addominale nell'adenocarcinoma del cardias.

BACKGROUND: The aim of the present study was to evaluate the incidence of abdominal lymph node involvement of adenocarcinoma of the gastric cardia in relationship with the site and depth of tumor invasion. METHODS: From July 1988 to April 1998, 79 patients with adenocarcinoma of the gastric cardia underwent surgical curative resection and D2 lymphadenectomy at the 1st Department of General Surgery of Verona University. Among these 79 patients, 16 had an adenocarcinoma of the distal esophagus (type I), 26 patients had an adenocarcinoma of the anatomic cardia (type II) and 37 had a subcardial adenocarcinoma (type III). The frequency of lymph node involvement in each of the lymph nodes as classified by the JRSGC were analyzed. RESULTS: In type I carcinoma positive lymph nodes occurred in 20% of pT1, 33% of pT2 and 100% of pT3. Positive nodes along the lower half of the stomach were never found. In type II carcinoma positive lymph nodes occurred in 57% of pT1, 86% of pT2 and 83% of pT3. Metastasis along the greater curvature in 18% of advanced cancers were found. In type III carcinoma positive lymph nodes occurred in 83% of pT2, 94% of pT3 and in 100% of pT4. Nodes along greater curvature were involved in 21% of advanced cases and also infrapyloric lymph nodes involved in 13% of cases. The type II and III advanced tumors had involved paraortic lymph node in 33% of cases. CONCLUSIONS: These results suggest that for tumors of the cardia an extended lymphadenectomy is necessary to ensure the removal of all metastatic nodes.

Manual compared with mechanical cervical oesophagogastric anastomosis: a randomised trial.

OBJECTIVE: To compare the short and medium term result of hand-sewn and stapled anastomoses after oesophagectomy. DESIGN: Randomised study. SETTING: Teaching hospital, Italy. SUBJECTS: 41 patients who required oesophagectomy between February 1993 and December 1996. INTERVENTIONS: Oesophagectomy and left cervical gastroplasty. MAIN OUTCOME MEASURES: Mortality and morbidity. RESULT: 21 patients were randomised to have the anastomosis hand-sewn, and 20 to have it stapled. The two groups were comparable. 3 patients died in hospital (2 in the hand-sewn and 1 in the stapled group), and the remainder were followed up a mean of 21 months (range 6-34). There was one clinical leak in the hand-sewn group compared with 3 in the stapled group, and 1 further radiological leak in the stapled group. 2 patients in the hand-sewn and 3 in the stapled group developed strictures. CONCLUSION: Though the numbers are too small to be assessed statistically, we think that these result are sufficient to persuade us that oesophagogastric anastomoses should be hand-sewn rather than stapled.

Classification of lymph node metastases from carcinoma of the stomach: comparison of the old (1987) and new (1997) TNM systems.

The pN classification of gastric cancer is currently based on the distance of metastatic nodes from the primary tumor (TNM-1987). The UICC (Union Internationale Contre le Cancer) has recently proposed a new classification system based on the number of the involved nodes (TNM-1997). The present prospective study is aimed at verifying whether the two classifications (1) assign approximately a similar rank to individual patients and (2) give comparable prognostic information. The Cox regression model was used to evaluate the prognostic significance of either the distance or the number of positive nodes, controlling for sex, age, site, histology and depth of tumor invasion, in a group of 175 patients who underwent curative surgery for gastric cancer from March 1988 to October 1997. Among the patients classified as N1 and N2 according to TNM-1987, 81.8% (36/44) and 35.8% (19/53), respectively, were coded as N1 and N2 by the new classification. The survival probabilities of N1 and N2 categories were similar in both classifications. The N2 category of TNM-1987 comprised also 10 cases with >15 positive nodes (N3 category of TNM-1997), who presented a large excess mortality (RR = 35.14 with respect to N0). When the site and number of positive nodes are combined in a new variable, both appear to be important from a prognostic point of view. Both anatomic location and number of nodes with metastasis are important predictors of survival in gastric cancer patients. Caution should be used when replacing the old classification with the new one, as they group patients in a different way.

Endoscopic ultrasonography in the staging of esophageal carcinoma after preoperative radiotherapy and chemotherapy.

BACKGROUND: In past years multimodal neoadjuvant treatment for carcinoma of the esophagus has been used with increased frequency. Staging of the neoplasm still remains fundamental in evaluating the response to therapy and in planning operation. The aim of the present study was to assess the accuracy of endoscopic ultrasonography (EUS) in a group of patients with squamous cell carcinoma of the thoracic esophagus after undergoing radiotherapy and chemotherapy. METHODS: Among a group of 111 patients with squamous cell carcinoma of the thoracic esophagus and treated with preoperative radiotherapy and chemotherapy, 87 were operated. In these patients it was possible to compare the results of EUS, with regard to depth of invasion of esophageal wall (T) and lymph node involvement (N), with the results of operation and histopathologic study. RESULTS: Feasibility of EUS before and after neoadjuvant treatment was 71.2% and 83.9%, respectively. The overall accuracy of EUS regarding the wall invasion was 47.9%. The more frequent error was overstaging, especially in patients with complete response and in patients with minimal residual disease. In the assessment of lymph node involvement, EUS showed an overall accuracy of 71.2% with a moderate kappa value. Sensitivity for N1 and NO was 73.7% and 68.6%, respectively. CONCLUSIONS: Endoscopic ultrasonography was feasible in most patients after preoperative radiotherapy and chemotherapy, but our study documented a worsening of accuracy of EUS in the evaluation of T attributable to the confounding presence of radiation fibrosis and soft tissue reaction after radiotherapy and chemotherapy.

Aneurysm of the celiac trunk: diagnosis with US-color-Doppler. Presentation of a new case and review of the literature.

Aneurysms of the celiac trunk are the rarest forms of aneurysms of the visceral arteries. Since 1958, when Schumaker reported the first case to be successfully treated surgically, only 69 cases have been reported in the international literature. The detection of such aneurysms, which are often asymptomatic, is mostly occasional. Approximately 15-20% of cases may be complicated by rupture with a mortality rate of around 80%. This eventuality makes surgical treatment mandatory even in asymptomatic cases. The authors report on their experience with the surgical treatment of one case of aneurysm of the celiac trunk and then go on to review the relevant literature.

Induction chemo-radiotherapy for squamous cell carcinoma of the thoracic esophagus: long-term results of a phase II study.

BACKGROUND: This study was done to evaluate the results of the combined use of chemo- and radiotherapy before surgery in a group of patients with squamous cell esophageal carcinoma after a median follow-up period of more than 5 years. METHODS: Between June 1987 and January 1995, 111 patients with squamous cell carcinoma of the thoracic esophagus were submitted to a preoperative course of radiotherapy (3000 cGy) and chemotherapy (cisplatin and 5-FU) before surgery in the First Division of General Surgery at the University of Verona. RESULTS: The neoadjuvant treatment was completed in 90.9% of the cases (101/111). After an average of 29 days, 87 patients underwent surgery (operability rate: 78.3%) and, of these, 80 underwent esophagectomy (resectability rate: 91.9%). Histopathologic studies showed no residual disease in the specimen (T0) in 17 cases (21.2%), only microscopic clusters of neoplastic cells within the esophageal wall (Minimal Residual Disease, MRD) in 14 cases (17.5%) and in 5 cases the tumor did not extend beyond the submucosal layer (T1). The median overall survival time of the 111 patients who were eligible for the study protocol was 14 months, and the 2- and 5-year survival rates were 32.0% and 17.5%, respectively. Kaplan-Meier determination of survival showed a statistically significant difference between the good responders (T0, T1, and MRD) to the neoadjuvant treatment and the remaining cases. The 2- and 5-year survival rates were 50.3% and 34.9%, respectively, in the good responder group compared with 26.7% and 10.7%, respectively, in the other cases, with a median survival time of 24 months vs. 13 months, respectively. CONCLUSIONS: The neoadjuvant treatment showed promising results, especially in the group of patients that had a good response. The identification of these patients may be the key to selecting which patients should be submitted to preoperative radio- and chemotherapy.

Solitary fibrous tumor of the liver with CD 34 positivity and hypoglycemia.

We report a new case of solitary fibrous tumor (SFT) of the liver, an extremely rare neoplasm. Including the present case no more than ten cases are reported in the English-language literature. To date there is no definite proof of the origin of this tumor. Both mesothelial and fibroblas-tic genesis has been postulated. The monoclonal antibody CD 34 has recently been used for the characterization of SFT. SFT would appear to be histogenetically related to a CD 34 - positive fibroblastic stem cell. A 61-year-old woman was admitted to our department with epigastric and right hypochondriac pain, weight loss, and hypoglycemia. Ultrasonography and computed tomography demonstrated a large heterogeneous mass in the right hepatic lobe. A right hepatectomy was performed. The tumor weighed 2850 g and microscopic section revealed a peculiar random pattern, the so-called patternless pattern of spindle tumor cells separated by abundant thick collagen bands. The tumor presented a number of highly cellular areas composed of plump spindle cell with hyperchromatic nuclei and rare mitotic figures. Ninety percent of the neoplastic cells displayed strong immunoreactivity for CD 34/My 10. The postoperative course was uneventful and the patient is alive and well without recurrence 6 years after surgery.

[Immunohistochemical study on the prognostic value of the expression of laminin and Ki-67 receptors in advanced gastric cancer]. / Studio immunoistochimico sul valore prognostico dell'espressione del recettore per la laminina e del Ki-67 nel cancro gastrico avanzato.

The expression of 67-KDa laminin receptor (LR) was investigated in a group of 75 patients who underwent curative gastrectomy for advanced gastric cancer, with special reference to the possible role in the tumor progression and in the overall survival. In 56 out of these 75 patients also the prognostic significance of proliferative activity was investigated using the monoclonal antibody Ki-67. The tumor LR expression and the Ki-67 labeling index (Ki-67 LI) were immunohistochemically determined in paraffin-embedded sections using the avidin-biotin immunoperoxidase method. The cumulative 5-years survival rate was 75.1% for patients without expression of LR, 52.6% for those with positive LR expression. Significant association between LR expression and depth of tumor invasion (p = 0.022) was found. By univariate analysis the presence of laminin receptor seemed to be associated with an higher risk of death (RR1.73-95% C.I. 0.71-4.20), but this effect disappeared after controlling for depth of tumor invasion. There was no significant relationship between the Ki-67 LI and wall invasion (p = 0.80) or nodal status (p = 0.73). The cumulative 5-year survival rates (95% CI) were 61.0% (35.3-79.2) in patients with Ki-67 index < 10%, 52.4% (29.7-70.9) with Ki-67 index = 10%-40%, 52.9% (27.6-73.0) with Ki-67 index > 40% and the differences were not statistically significant (p = 0.93). Also in multivariate analysis the proliferative activity did not independently affect survival (p = 0.98). An interaction between Ki-67 index and age was found and Ki-67 index > 40% was significantly associated with a poor prognosis in patients over 70 years old old (p = 0.002). In conclusion, tumor expression of laminin receptor could be correlated with gastric cancer aggressiveness, however its prognostic significance is already provided by depth of tumor invasion. The proliferative activity, determined with the monoclonal antibody Ki-67, does not seems to influence the survival except in elderly patients (> or = 70 years old).

Endoscopic clipping of anastomotic leakages in esophagogastric surgery.

BACKGROUND AND STUDY AIMS: Anastomotic leakage is a severe complication in gastric surgery and it is associated with a high rate of mortality. Conservative treatment sometimes is not sufficient to stem the leakages and, even when it is sufficient, it takes a long time. The present study describes the first experience in the treatment of anastomotic leakages with endoscopic clipping. PATIENTS AND METHODS: From May 1995 to December 1996, seven patients with postoperative anastomotic leakages after gastric surgery were prospectively treated in our Endoscopy Service. Metallic endoclips (MD 850, Olympus Corp., Tokyo, Japan) with prongs 12 mm long and 6 mm wide were applied, controlling the closure of the leakage by endoscopy, using radiographs to confirm the closure 24 hours later. RESULTS: Complete closure of the leakage was obtained in all seven cases. A single session of endoscopic clipping was needed for five patients while two other required, respectively, two and three sessions. The median time of leakage closure after endoscopic clipping was 2.3 days (range 1-5 days). The clips spontaneously dislodged within 1 month in five patients and within the second month in the other two patients. CONCLUSION: Endoscopic treatment of anastomotic leakages by metallic clips represents a safe and easily repeated method and, compared to conservative treatment, it seems to offer several time and cost advantages. Further studies involving a larger number of patients are needed to verify this finding.

[Salmonella C infection of aortic abdominal aneurysm]. / Infezione di aneurisma dell'aorta addominale da salmonella di gruppo C.

The infected aneurysms of the aorta represent the 0.65% of all the aneurysms and they are associated with high morbidity and mortality. The vascular infections from Salmonella are not particularly frequent, even if in the last years their reports are more numerous. The authors report their experience in the surgical treatment of one case of aneurysm of the abdominal aorta infected by group C Salmonella, making a review of the Literature on this matter.

[Recurrence of stomach cancer following surgery]. / Le recidive nel cancro dello stomaco dopo chirurgia curativa.

The purpose of this article is to review the incidence and characteristic of first recurrence in a group of 182 patients who underwent curative surgery with extended lymphadenectomy (> or = D2). The median follow up was 46.4 months (range 14-111). The incidence of relapses was 3.3% in the early gastric cancer and 50.8% in the advanced cancer. First recurrence site was systemic in 69.4% of cases and locoregional in 22.6%. The major site of systemic recurrences were peritoneal surface (64.8%), liver (29.5%), and other extra abdominal metastases (5.7%). In 8% of the cases it was not possible to find the site of recurrence. Surgical resection was possible in only 2 out of 14 cases of local recurrence. The incidence of recurrence were directly correlated with the depth of tumor invasion (T1: 3.3%; T2: 20.6%; T3: 61.5%; T4: 70%) and node metastases (NO: 8.3%; N1+: 44.4%; N2+: 64.3%). In advanced cases the incidence of relapses after D1 lymphadenectomy was significantly higher than after D2 lymphadenectomy: 28.6% vs 5.5% in NO cases and 65.6% vs 49.3% in N+ cases. In conclusion it seems that extended lymphadenectomy is associated with a lower incidence of recurrences after curative surgery.

[Prognostic value of histologic classifications of advanced stomach cancer: comparative study of Lauren's and Goseki's classifications]. / Valore prognostico delle classificazioni istologiche del cancro dello stomaco avanzato: studio comparativo fra classificazione di Lauren e di Goseki.

Controversy exists about the prognostic value of the histological classifications of gastric cancer commonly used. Recently Goseki proposed a new classifying system based on intracellular mucus production and the degree of tubular differentiation. The aim of this study was to compare Lauren and Goseki classifications with particular emphasis on their prognostic significance. Eighty-nine patients, who underwent potentially curative resections (RO) and radical lymphadenectomy for advanced gastric cancer from September 1988 to April 1996 were analysed. Cox regression model was used to evaluate the prognostic significance of Goseki classification, Lauren classification, age, sex, type of lymphadenectomy, depth of tumour invasion (T), node metastases (N) and number of metastatic nodes. A statistically significant correlation between the different Goseki grades and histology according to Lauren was found (p < 0.001). By multivariate analysis the only parameters predictive of long term outcome were depth of tumour invasion, nodal status and histology according to the Lauren classification. Also after excluding the Lauren classification from the analysis, the Goseki histological grading system did not affect survival independently. This study on advanced gastric cancer patients identified depth of invasion, lymph node metastases and Lauren classification as significant independent pathological variables influencing survival. The classification proposed by Goseki did not add anything further to the prognostic informations provided by TNM staging and Lauren classification.

Prognostic significance of lymph node dissection in gastric cancer.

The results for 162 patients who underwent curative gastrectomy for gastric cancer from January 1988 to June 1994 were analysed statistically with special reference to the effect of lymph node dissection. Median survival was 69.3 months and the overall cumulative 5-year survival rate was 50.2 (95 per cent confidence interval (c.i.) 41.6-58.1) per cent. By univariate analysis age, histology, depth of tumour invasion, node involvement, number of metastatic lymph nodes and type of lymphadenectomy were found to be significant factors related to survival time. Multivariate analysis with the Cox model and stratified for tumour node metastasis stage revealed that only the number of metastatic nodes (P = 0.04) and the extent of lymphadenectomy (P = 0.003) affected survival independently. With respect to D1 lymphadenectomy, the relative risk associated with D2 and D4 lymphadenectomy was respectively 0.61 (95 per cent c.i. 0.34-1.10) and 0.26 (95 per cent c.i. 0.12-0.60). The 5-year survival rate was 28 per cent for patients who had a D1 dissection, 63 per cent for those who had D2 and 68 per cent for those who had D4. These results suggest that extended lymphadenectomy (D2) and especially superextended lymphadenectomy (D4) can improve survival in patients with gastric cancer.

[Ultrasonography mapping of peritoneal adhesions]. / Mappa ecografica delle aderenze peritoneali.

A previous laparotomy is still a contraindication to laparoscopy because of the possible presence of abdominal wall adhesions exposing the patient to the risk of a visceral injury when the pneumoperitoneum is created and/or the first trochar is inserted. We report the results of abdominal wall US exams performed preoperatively for the diagnosis of peritoneal adhesions: we investigated two distinct signs unrelated to one another, to minimize false-negative findings. Ultrasonography was performed on 141 patients subdivided into two groups: 81 patients with no previous abdominal surgery (group A) and 60 patients with a history of abdominal surgery (group B). For diagnostic purposes, the visceral movement sign according to Sigel, modified on the basis of preliminary observations, and the reflection band sign were studied. US data were included in the patient's record and compared with intraoperative findings. Overall diagnostic accuracy was 94% and sensitivity 100% in the two groups. To conclude, the preoperative US mapping of abdominal wall adhesions enabled us to establish adhesion-free areas unquestionably and thus to choose the safest and most suitable sites for risky maneuvers during laparoscopy in the patients with a history of previous abdominal surgery.

Vater's papilla and periampullary area villous adenoma: personal experience about nine cases and review of the literature.

Villous tumor of the duodenum is a rare disease. The authors report their personal experience from 1987 to 1993 with nine cases of duodenal villous tumors. The treatment was pancreatoduodenectomy in four cases, segmental resection of the duodenum in two cases and submucosal excision in three cases. The authors review the literature of the last 15 years in which only 241 cases of duodenal villous tumors are reported; in this review the clinical, diagnostic and therapeutic characteristics of the disease are analyzed. This malignancy presents peculiar characteristics for histologic diagnosis and pathology classification. For this reason, even surgical treatment deserves careful reflection to guarantee a curative procedure and to formulate a positive prognosis.

Efficacy and toxicity of vinorelbine-carboplatin combination in the treatment of advanced adenocarcinoma or large-cell carcinoma of the lung.

AIMS AND BACKGROUND: The aim of the study was to assess the activity and toxicity of the vinorelbine-carboplatin combination in advanced adenocarcinoma or large-cell carcinoma of the lung. The new vinca derivative, vinorelbine, shows promising activity when combined with cisplatin, but toxicity of the combination is substantial. METHODS: Accordingly, we substituted carboplatin for cisplatin in the combination in order to improve the therapeutic index. From March 1992 to March 1994, 55 untreated patients with undifferentiated unresectable or metastatic adenocarcinoma or large-cell carcinoma of the lung were recruited. The treatment consisted of a course of carboplatin (300 mg/m2) and vinorelbine (25 mg/m2) repeated every 4 weeks. The only grade 3 toxicity observed was 16 cases of grade 3 vomiting and 2 cases of grade 3 stomatitis. RESULTS: The positive response rate was 40% (partial response, 22 patients). In conclusion, the vinorelbine-carboplatin combination may be regarded as an active, safe regimen for the palliative treatment of advanced adenocarcinoma or large-cell carcinoma of the lung.

Primary carcinoma of the hypopharynx and cervical esophagus: evolution of surgical therapy.

Carcinoma of the cervical esophagus is invariably fatal because of its advanced stage at presentation. In our surgical division, 167 patients with primary squamous-cell carcinoma of the cervical esophagus were treated over the period between 1973 and June 1992. The tumor was localized in the cervical esophagus in only 37 cases, whereas it also involved the hypopharynx in 112 patients or extended to the cervico-thoracic segment in the remaining 18 subjects. Ninety-three patients underwent surgery (operability rate: 55.6%), and in 68 of these the tumor was resected (resectability rate: 73.1%). Over the 20-year study period, surgical techniques have evolved as a result of the experience gained with previous surgical therapies. Six of the 68 resected patients died (8.8%). Ten patients undergoing surgical resection subsequently presented with local recurrence: 3 after cervical esophagectomy (25%) and 7 after total esophagectomy (12.5%). Moreover, six patients treated by radical resection without laryngectomy had recurrent tumor (46.1%). The cumulative 5-year survival rate was 16.6%. The experience accumulated over the years suggests that the procedure of choice is laryngopharyngo-(total)-esophagectomy without thoracotomy, with gastric pull-up for reconstruction of the digestive tract. The other surgical procedures, in our experience as well in that of other authors, are associated with a higher incidence of relapse and a decreased survival rate. In an attempt to improve on the disappointing long-term results, we introduced a preoperative course of chemotherapy and radiotherapy in the management of the last 6 patients in our series.(ABSTRACT TRUNCATED AT 250 WORDS)