Should we routinely use DEBTACE for unresectable HCC? cTACE versus DEBTACE: a single-center survival analysis.

Conventional trans-arterial chemoembolization (cTACE) for intermediate stage hepatocellular carcinoma (HCC) achieves a partial response in up to 72% of patients and improves median survival. Drug-eluting-beads-TACE (DEBTACE) improves treatment efficacy and tolerance as compared to cTACE. Our aim was to retrospectively evaluate our experience in the treatment of intermediate/advanced HCC with cTACE versus DEBTACE. Overall survival (OS) was the first endpoint. We retrospectively considered our department register data between 2006 and 2012. A total of 82 non-surgical patients, who underwent cTACE or DEBTACE, with a minimum of 12 months follow-up, met the inclusion criteria. Patients received a standard chemotherapy dose (50 mg). Radiological response was evaluated by CT after 30 days and re-treatment was considered. Statistical analysis was performed with SPSS software. 54 patients received cTACE and 28 DEBTACE. In the DEBTACE group the median survival times was 22.7 months (CI 11.6-33.8), while in the cTACE group it was 21.8 months (CI 15.7-27.9). The survival analysis at log-rank (p = 0.708) and Wilcoxon (p = 0.661) tests demonstrated no differences between DEBTACE and cTACE. The probability of death in function of time was significantly associated only to the Child-Pugh score. A Child A score was shown to be protective instead of Child B (OR 0.583; IC 95% = 0.344-0.987). DEBTACE for treating HCC is comparable to cTACE in terms of effectiveness, but seems to be better tolerated. Both treatments can be performed in case of tumor recurrence without substantial increase in procedural complications and risk of liver failure. We do confirm that there are no differences between the two techniques in terms of survival and that it is mainly affected by the reserved liver function proper of each patient.

Management of grade III-IV blunt liver traumas: a comparative, observational study.

AIM: The aim of the present study was to assess the impact of angiographic embolization in view of expanding indications for the conservative management of grade III-IV liver injuries. METHODS: Fifty adult patients with grade III-IV hepatic trauma were admitted to our Hepato-Biliary-Pancreatic Surgery and Level II Regional Trauma Center from 1993 to 2010 and retrospectively analyzed. Injury severity, management strategies and outcomes of patients admitted between 1993 and 2005 were analyzed and compared with those admitted between 2005 and 2010. Univariable and multivariable logistic models were fitted to investigate the differences between the two time windows studied, in particular with regard to morbidity, mortality, treatment and outcomes, the use of non-operative management and of angiographic embolization. RESULTS: At univariable analysis the majority of the patients treated after 2005 were more likely to have undergone arterial embolization, and less likely to have incurred morbidity, conversion to surgery, or to be admitted to the Intensive Care Unit after initial treatment (baseline category). At multivariable analysis the patients treated before 2005 were more likely to be older than 25 years to receive angiographic embolization and less likely to undergo conversion to surgery after failure of non-operative management. CONCLUSION: The criteria for the conservative treatment of blunt liver trauma is presently often based on hemodynamic stability in injured patients, but its successful management should, instead, be based also on early CT recognition of arterial bleeding and prompt use of angiographic embolization to control it.

Complications after surgery for colorectal cancer affect quality of life and surgeon-patient relationship.

AIM: This multicentric prospective study aimed to investigate how postoperative complications after surgery for colorectal cancer affect patients' quality of life and satisfaction with care. METHOD: One hundred and sixteen patients operated on for colorectal cancer were enrolled in this study. Patients answered three questionnaires about generic (EORTC QLQ-C30) and disease-specific (EORTC QLQ-CR29) quality of life and treatment satisfaction (EORTC IN-PATSAT32) at the time of admission and at 1 and 6 months after surgery. Non-parametric tests and linear multiple regression models were used for statistical analysis. RESULTS: Twelve patients had complications requiring further surgery (anastomotic leakage, abdominal bleeding, abdominal wall sepsis, wound infection). Patients with complications that required surgery reported a worse score of physical function, emotional function and anxiety than patients without such complications 1 month after surgery. These patients judged their general satisfaction with the quality of care and doctors' interpersonal skills, technical skills, information provision and availability to be worse than in patients without such complications. The presence of postoperative psychiatric complications and anastomotic leakage were independent predictors of quality of life (ß = -0.30, P = 0.004, and ß = -0.42, P < 0.001). CONCLUSION: In patients undergoing surgery for colorectal cancer, complications requiring any kind of surgical management significantly affected patients' perception of all doctor-related items suggesting an impairment of the entire surgeon-patient relationship. Convincing patients that 'zero risk' cannot be achieved in surgical practice is therefore a priority.

Cost-effectiveness analysis of postoperative surveillance protocols following radical surgery for colorectal cancer.

INTRODUCTION: Up to 30-50% of patients who undergo radical surgery for colorectal cancer (CRC) develop tumor relapse. The aim of this study was to assess various surveillance protocols utilized in a tertiary referral hospital in Northern Italy. METHODS: Data concerning 373 consecutive patients who underwent radical surgery for CRC between 1990 and 2006 and whose data had been entered into a prospective database were considered eligible for this study. The overall costs and the percentages of recurrence following the various surveillance protocols were calculated. RESULTS: One hundred two (27.35%) of the patients suffered a recurrence after a mean of 17.6 (95% CI 13.9-21.1) months. The combination of physical examination, colonoscopy, thorax-abdominal computed tomography (CT) scan, and serum carcinoembryonic antigen (CEA) dosage was found to be the most cost/effective one to monitor stages I and II colon cancer; while physical examination, rigid sigmoidoscopy, thorax-abdominal CT scan, and serum CEA dosage were found to be the most cost/effective surveillance to monitor stages III and IV of colon cancer and rectal cancer. CONCLUSIONS: Adherence to follow-up guidelines and early detection are vital factors affecting the curability of relapsed cancer in CRC patients who undergo surgery. The first five years after surgery was found to be the most risky period for recurrence. Cost/effectiveness analysis indicate that follow-up protocols should be tailored to the risk of recurrence with the aim of identifying relapse when the disease is at an asymptomatic, presumably more curable stage.

Stapled haemorrhoidopexy: extent of tissue excision and clinical implications in the early postoperative period.

AIM: This study quantified prospectively the amount of rectal wall removed during stapled haemorrhoidopexy and assessed its effect on ano-rectal function and health-related quality of life. METHOD: Thirty-three consecutive patients who underwent stapled haemorrhoidopexy for second- or third- degree haemorrhoids, or for failed medical treatment, in the Department of Surgery and Gastroenterological Sciences at the University of Padova were included. All patients were assessed preoperatively and postoperatively using a structured questionnaire to determine the number of defecations per week, incomplete defecations, time taken to defecate any difficulty in defecating, soiling, the use of drugs and continence. All patients were reassessed at 1 and 2 weeks and at 30 days after the procedure using the Cleveland Global Quality of Life (CGQL) questionnaire. All patients underwent preoperative and postoperative ano-rectal manometry at least 30 days after stapled haemorrhoidopexy. RESULTS: The median surface area of the resected rectal wall was 10.5 (range, 9-15) mm(2) and the median thickness was 3 (range, 2-4) mm. Muscle tissue was included in all specimens. The median thickness of the resected rectal wall correlated inversely with the rectal volume when the recto-anal inhibitory reflex (RAIR) was initiated during postoperative manometry (ρ = -0.50, P = 0.07). A significant, direct correlation was found between the surface area of the resected rectal wall and the rectal volume during postoperative manometry (ρ = 0.53, P = 0.08) and the use of analgesic drugs after 2 weeks (ρ = 0.63, P = 0.04). Significant correlations were found between being female and postoperative resting pressure (ρ = -0.74, P < 0.01), squeeze pressure (ρ = -0.64, P = 0.01) and maximum tolerated volume (ρ = -0.78, P < 0.01). CONCLUSION: Stapled haemorrhoidopexy is safe and effective. The thicker the resected rectal wall, the lower the volume of initiation of the RAIR.

A systematic review on advancement flaps for rectovaginal fistula in Crohn's disease: transrectal vs transvaginal approach.

AIM: Despite advances in the treatment of Crohn's disease (CD), the treatment of rectovaginal (RV) fistula remains challenging. Transrectal (RAF) and transvaginal advancement flaps (VAF) represent two possible alternative surgical approaches to this problem. The study aims to review and compare the results of these approaches for RV fistula in CD. METHOD: Medical databases from January 1983 to August 2008 were consulted for potentially relevant publications. All studies dealing with the RV fistula repair in CD with RAF or VAF were included. Two researchers worked independently on the study selection, quality assessment, data extraction and analysis phases of the study. Analyses were performed with Review Manager 2.0 software. RESULTS: Eleven observational studies were included with a total of 219 flap procedures for RV fistula. The primary fistula closure pooled rate was 54.2% (range 33.3-100%) after RAF and 69.4% (range 0-92.9%) after VAF (P = 0.13). Four studies were eligible for direct comparison between the two procedures. No clearly significant difference between RAF compared with VAF in terms of primary fistula closure rate, nor in terms of overall fistula closure rate, was apparent. The risk of recurrence after RAF compared with VAF seemed similar; in this case, only two studies were taken into consideration. CONCLUSIONS: Although limited by a small number of studies of low clinical evidence level, this systematic review suggests that there is no significant difference in terms of outcome between RAF and VAF for RV fistula in CD.

Diverting loop ileostomy after restorative proctocolectomy: predictors of poor outcome and poor quality of life.

AIM: Diverting loop ileostomy is used to minimize the impact of anastomotic complication after restorative proctocolectomy (RPC). However, the ileostomy itself may have complications and therefore affect quality of life (QOL). The aim of this study was to analyse the predictors of complications of the ileostomy formation and closure and of the QOL of these patients. METHOD: Forty-four consecutive patients who underwent RPC were enrolled. Records of the ileostomy follow-up were retrieved from a prospectively collected database and QOL was assessed with the Stoma-QOL questionnaire. Ileostomy site coordinates were measured. Univariate and multivariate analysis were performed. RESULTS: In this series, three patients experienced peristomal herniae, two ileostomy stenosis, seven ileostomy retraction and fourteen peristomal dermatitis. Emergency surgery was the only predictor of parastomal hernia (P = 0.017). Stenosis correlated with the distance from the umbilicus (tau = 0.24, P = 0.021). Use of standard rod and retraction were independent predictors of peristomal dermatitis (P = 0.049 and P = 0.001). Stoma-QOL was directly correlated to the age of the patients and to the occurrence of parastomal hernia (P = 0.001 and P = 0.021, respectively). After stoma closure, two patients reported wound sepsis and seven suffered obstructive episodes. CONCLUSION: The predictors of negative outcome after construction of a diverting loop ileostomy after RPC were urgent surgery, use of standard rod, the distance of the stoma site from the umbilicus, parastomal herniae and the older age of patients.

Outcome of surgery for rectovaginal fistula due to Crohn's disease.

BACKGROUND: This study examined the outcome of surgery for symptomatic Crohn's rectovaginal fistula (RVF) and assessed the effect of therapy with antibody against tumour necrosis factor (TNF) on healing. METHODS: Fifty-six patients with Crohn's disease underwent surgery for a RVF between January 1993 and December 2006. Outcome analysis was performed in February 2008 in relation to the surgical procedures used and the effect of anti-TNF treatment. RESULTS: Four patients with a healed fistula still had a stoma at final follow-up for other reasons and were excluded from the analysis. Fistula closure was achieved in 81 per cent of the remaining 52 patients. Primary and secondary surgical success rates were 56 and 57 per cent respectively. The primary healing rate was similar in patients who received anti-TNF treatment before the first operation (12 of 18 patients) and those who did not (19 of 34). In univariable analysis, duration of Crohn's disease (P = 0.037) and previous extended colonic resection (P < 0.001) were significantly related to failure of primary surgery, but only the latter remained significant in multivariable analysis (P < 0.001). Late recurrence developed in four patients. CONCLUSION: Fistula closure was achieved in most patients, but more than one operation was often required.

Plasma lipids and inflammation in active inflammatory bowel diseases.

BACKGROUND: Ulcerative colitis (UC) and Crohn's disease (CD) can cause metabolic and inflammatory alterations. AIM: To evaluate the relationships between inflammatory parameters, plasma lipids and phospholipid fatty acid (FA) composition in patients with active UC and CD. METHODS: Diet, the Harvey-Bradshaw Activity Index (HBAI), inflammatory parameters, lipoproteins and FA composition were assessed in 60 CD and 34 UC. RESULTS: No differences in clinical parameters were observed in the two groups. Total cholesterol correlated inversely with the number of bowel movements in both groups and directly with BMI in UC. Arachidonic acid correlated inversely with HBAI in UC and total and HDL cholesterol were inversely related to C-reactive protein (CRP) in CD while HDL correlated with CRP in UC. Docosapentaenoic acid was the only polyunsaturated n-3 FA that was correlated to CRP in both groups. Total cholesterol was independently associated in the multiple regression analysis with the number of bowel movements and systemic inflammation. CONCLUSIONS: Total and LDL cholesterol were lower in the active UC and CD than in the healthy subjects and were correlated with the systemic inflammatory status. Phospholipid FA composition was correlated to the systemic inflammatory status, but was unrelated to dietary intake and intestinal disease activity.

Gastrointestinal telangiectasia: a study by EGD, colonoscopy, and capsule endoscopy in 75 patients.

BACKGROUND: The distribution of lesions in the gastrointestinal tract in patients with sporadic telangiectasia is at present unknown. PATIENTS AND METHODS: 75 patients with sporadic telangiectasia underwent esophagogastroduodenoscopy (EGD), capsule endoscopy, and colonoscopy. Endoscopic diagnosis of telangiectasia and gastrointestinal bleeding were required for enrollment in the study. Hemorrhagic diathesis, co-morbidity, number of blood transfusions, and subsequent management were also noted. RESULTS: 35 of the patients presented with gastroduodenal vascular lesions, 51 with small-bowel lesions, and 28 with colonic lesions. 67 % of patients in whom EGD found telangiectasia also presented small-bowel vascular lesions at capsule endoscopy and 43 % colonic lesions at colonoscopy. 54 % percent of patients with positive colonoscopy also presented gastroduodenal lesions and 48 % small-bowel lesions. Patients with known duodenal lesions were more likely to have small-bowel lesions at capsule endoscopy (odds ratio [OR] 10.19, 95 % CI 2.1 - 49.33, P = 0.003). Patients with associated diseases, such as liver cirrhosis, chronic renal failure, or heart valvulopathy, presented more severe disease requiring blood transfusions (OR 6.37, 95 % CI 1.39 - 29.2, P = 0.015). The number of blood transfusions correlated with the number of sites affected ( R = 0.35, P = 0.002). The detection of new lesions at capsule endoscopy allowed new treatment in 46 % of patients. Mean follow-up was 18 months. CONCLUSIONS: Sporadic telangiectasia is a multifocal disease potentially involving the whole digestive tract. Patients with duodenal telangiectasia show a higher risk of jejunal or ileal lesions. Capsule endoscopy is a useful diagnostic tool for the detection of such small-bowel vascular lesions, indicating a more specific prognosis and treatment strategy.

Recurrent pleural effusion and pulmonary metastases from a cutaneous apocrine tumour of the axilla.

Sweat gland carcinomas are very rare and they are differentiated between tumours of apocrine or eccrine origin. The axilla is the most common site for apocrine gland carcinoma for its great abundance of these glands. There are no recommendations in literature regarding appropriate treatment schedules for apocrine gland carcimonas in advanced stages. We report a case of recurrent left pleural effusion in a 76-year old man with metastatic cutaneous apocrine tumour of the right axilla. We describe the clinical and histological features, with management options and a review of the relevant literature on apocrine gland carcinoma.

Effects of iron manipulation on trace elements level in a model of colitis in rats.

AIM: Trace elements (TE) metabolism is altered in inflammatory bowel diseases. TE (zinc and copper) are constituents of antioxidant enzymes. Iron is involved in the pathogenesis of chronic inflammation. The aim was to evaluate zinc and copper status and the effects of iron manipulation in experimental colitis. METHODS: Twenty-four male Sprague-Dawley rats were divided into four groups: standard diet, iron-deprived diet, iron-supplemented diet, and sham-treated controls. Macroscopic damage was scored. DNA adducts were measured in the colon. Liver and colonic concentration of TE were measured. RESULTS: Macroscopic damage was reduced in iron-deprived groups and increased in iron-supplemented rats. Damage to the DNA was reduced in iron-deprived groups and increased in iron-supplemented groups. Liver and colonic iron concentrations were reduced in iron-deprived and increased in iron-supplemented rats. Liver zinc concentration was reduced after supplementation whereas colonic levels were similar in controls and treated rats. Liver copper concentration was reduced in all the colitic groups except in the iron-supplemented group whereas colonic concentration was increased in iron-deprived rats. CONCLUSION: Iron deprivation diminishes the severity of DNBS colitis while supplementation worsens colitis. Zinc and copper status are modified by iron manipulation.

An experimental swine model of small bowel cross transplantation.

AIM: In this study we evaluated the possibility of performing a cross small bowel transplantation (CrSBTx) in which, at the same time, 2 pigs were both donors and later recipients of intestinal grafts. The hemodynamic and metabolic impact of this original transplantation model on the animals was determined. METHODS: Ten large White adult female pigs underwent a 2 stage procedure. The principal intraoperative hemodynamic and metabolic parameters were measured at different times during the operation. In the 3 days that followed the operation, renal function, liver and pancreatic damage were investigated. RESULTS: Our surgical model permits us to keep excellent hemodynamic and metabolic stability with low mortality. CONCLUSION: The need of half of animals with respect to conventional models represents an ethical and economic advantage of CrSBTx and we propose it for intestinal transplant studies in large animals.

Psoas abscess: a rare complication of Crohn's disease.

UNLABELLED: Psoas abscess is a rare complication of Crohn's disease. METHODS AND MATERIALS: We evaluated the incidence of psoas abscess on 312 patients with Crohn's disease, seen at our institution between 1992-2001. RESULTS: We encountered three cases of psoas abscess (0.9%). One patient was managed with ileocolic resection and immediate anastomosis, while in two patients a percutaneous drainage was first performed and then, after 12 days of total parenteral nutrition, a resection of the diseased bowel with immediate reconstruction was carried out. CONCLUSIONS: A correction of the nutritional deficiencies is mandatory. Percutaneous computed-tomography guided drainage of the abscess with intestinal resection with immediate anastomosis, performed after a parenteral hyperalimentation, should be the method of choice in the management of such patients.

Severe gastrointestinal bleeding in Crohn's disease.

INTRODUCTION: Acute gastrointestinal bleeding is rare in Crohn's disease. METHODS: We characterized the clinical features and course of such hemorrhage in patients seen at our institution from 1992 to 2000. RESULTS: Five patients had gastrointestinal bleeding during Crohn's disease. All patients had a known Crohn's disease, with a mean duration of the disease of 6 years. The source of bleeding was identified in four patients (80%). Endoscopy was, in all patients, the first diagnostic procedure. An Hartmann total colectomy with closure of the rectal stump and ileostomy was performed in three patients, while two patients with ileal massive bleeding were treated conservatively. One patient had a recurrence of bleeding from the small bowel one week later but he didn't required surgical treatment. One patient with pancolic Crohn's disease died on 10th postoperative day because of multiorgan failure and septic complications. CONCLUSIONS: Gastrointestinal bleeding is rare in Crohn's disease, with a predilection for site of involvement. The preoperative diagnosis of the site of bleeding is not easy, and enteroscopy should be mandatory in such patients. Surgery is required for half of cases and recurrent haemorrhage should be an appropriate indication for surgery.

A rare surgical complication of Crohn's diseases: free peritoneal perforation.

BACKGROUND: Free peritoneal perforation is a rare complication of Crohn's disease. METHODS: We evaluated the incidence of free peritoneal perforation among 208 patients with Crohn's disease surgically treated in the period 1992-2000. RESULTS: Five patients (2.4%) suffered from free peritoneal perforation. In 1 patient free peritoneal perforation was the first symptom of Crohn's disease. In 3 cases the perforation was in the small bowel and in 2 in the large bowel. All patients underwent surgery: all cases had a resection of the involved bowel and in two cases an ileostomy was performed in order to prevent severe peritonitis. We did not observed mortality or major complications. CONCLUSIONS: Free peritoneal perforation is rare with about 100 cases reported in literature. No correlation seems to exist with previous corticosteroid treatment. The surgical treatment is mandatory. Simple suture should be avoided. The most appropriate treatment, whenever it is feasible, is resection of the involved bowel with immediate or, in case of severe sepsis, delayed anastomosis.

Extreme marginal donor: severe hypothermia as a rare preservation condition for explantable organs--a case report.

UNLABELLED: The progressive increase in patients with end stage liver disease has lengthend the waiting- list for liver transplantation. Unfortunately this has not been followed by a suitable increase in the number of donors. The expanding "donor pool" has required use of "marginal" donors (ICU stay > 10 days, sepsi; steatosis > 30-40%, hypernatremia > 155 mmol/L, inotropic drugs). We report the case of a skier who remained for more than 1 hour in cardio-respiratory arrest under the snow; the 49-year-old women was extracted from the snow after 1 hour and 12 minutes and found to be asystolic, fixed pupils and deep hypothermia (27.2 degrees C). After cardiopulmonary resuscitation, partial cardio-respiratory activity was re-established. In the ICU severe hypothermia (26.7 degrees C) was treated with extracorporeal circulation until a re-establishment of satisfactory cardio-circulatory conditions was obtained. Unfortunately cerebral anoxic cerebral death was established and multiorgan procurement performed 3 days later. After liver transplantation into a 59 year-old patient with PNC-C was performed. The course was uneventful and the patient was discharged on the 19th postoperative day. CONCLUSIONS: Organ procurement from donors involved in accidental traumatic events with cardio-respiratory arrest and hypothermia, is similar to the non-heart-beating donor (NHBD) condition. Correct cardiopulmonary resuscitation and the use of extracorporeal circulation for gradual restoration of body temperature are necessary for optimal organ perfusion. In the present case the anoxic insult induced by the cessation of the cardio-respiratory function, was probably mitigated (if not even annulled) by the hypothermia.

Yttrium-aluminum-garnet laser therapy of esophageal granular cell tumor.

BACKGROUND: Granular cell tumor (GCT) is a rare lesion. Approximately 4% to 6% of these tumors occur in the gastrointestinal tract, one-third of them affecting the esophagus. Almost all GCTs are benign lesions. Approximately 1% to 3% are malignant. Endoscopic ultrasonography (EUS) is a diagnostic support. The best treatment for esophageal GCT is not yet clear, whether surgical excision, periodic observation, endoscopic excision, or yttrium-aluminum-garnet (YAG) laser therapy. METHODS: From November 1992 to December 2000, four patients with GCTs of the esophagus were observed. All the patients underwent EUS evaluation and endoscopic YAG laser therapy of the esophageal neoplasm. At each session, a biopsy at the tumor site was obtained. The treatment was continued until endoscopic and histologic evidence of the tumor disappeared. RESULTS: After the YAG laser therapy, no evidence of the tumor was found in any of the four patients with esophageal GCT. At this writing, the patients remain disease free after a mean follow-up period of 66 months. No complication has been observed. Only four sessions for each patient were necessary to eliminate the tumor. CONCLUSIONS: Therapy with YAG laser was effective in all four patients with esophageal GCT, and complete necrosis of the submucosal neoplastic cells was achieved. Endoscopic YAG laser therapy appears to be a good compromise between esophageal dissection and long-term observation without tumor excision. Esophageal laser therapy is safe if correctly used, and previous EUS evaluation increases treatment safety.

Antibiotic prophylaxis in clean surgery: breast surgery and hernia repair.

Use of prophylactic antibiotics in clean surgery is still controversial. We reviewed the literature of the last 10 years to identify the best way to approach clean surgery. The question is more important for patients undergoing breast surgery. The presence of an infected breast wound delays the beginning of postoperative adjuvant anticancer therapy: there is good evidence to suggest that delayed adjuvant therapy compromises the outcome for patients in terms of both local control and survival. There are several clinical trials that have addressed the efficacy of prophylactic antibiotics for patients undergoing breast surgery and hernia repair. Platt et al assessed the efficacy of preoperative antibiotic prophylaxis in a clinical trial of 1218 patients undergoing clean surgery with an absolute reduction rate of 39% in wound infections. Gupta et al reported no influence on the incidence of infective complications by antibiotic prophylaxis in 357 patients undergoing elective breast surgery. Like breast surgery, use of prophylaxis in hernia repair is not clear: a prospective, randomized, double-blind, multicenter study of 619 patients assessed no benefit of antibiotic prophylaxis. On the other hand Lewis et al reported a 75% reduction of infections in low-risk patients when a single dose of cefotaxime was used in clean operations. A particularly interesting point is the use of prosthetic mesh in hernia repair and primary reconstructive surgery in breast surgery. Amland et al reported a significant reduction of the incidence of wound infections in a group of patients undergoing reconstructive breast surgery, receiving azithromycin vs placebo (5% vs 20%). In hernia repair we stress the need to prevent wound infections: currently Liechtestein's technique is widely performed all over the world. Mesh infection is an unpleasant event that requires prosthesis removal. The lack of conclusive studies about antibiotic prophylaxis in clean surgery suggests that a single-dose of cephalosporin at the induction of anesthesia may be prudent. This procedure is certainly inexpensive and safe and, more importantly, probably does not have an impact on antibiotic resistance.