Intra-operative radiological margins assessment in conservative treatment for non-palpable DCIS: correlation to pathological examination and re-excision rate.

What constitutes an adequate surgical margin in partial mastectomy is still controversial: intra-operative specimen radiogram is commonly used during partial mastectomy for nonpalpable lesions in order verify the adequacy of the resection but what margin is to be considered "adequate" is still debatable. An intraoperative specimen mammogram was performed during all consecutive conservative resections for nonpalpable DCIS and a 15-mm radiological margin was considered "adequate". Margins were pathologically assessed and classified as "negative", "close" or "positive" and the rate of margin involvement constitued the main outcome of the study. Among 272 conservative interventions, 80.51% had negative margins at final pathology, 3.31% had close margins and 16.18% had positive margins. An intraoperative "adequate" margin of 15 mm as defined on intraoperative specimen mammogram granted a high rate of histologically negative margin at primary surgery; this finding was paralleled by confirmation of the treatment as conservative in 95% of cases.

Treatment of multidrug resistant advanced alveolar soft part sarcoma with sunitinib.

Sunitinib is a tyrosine kinase/angiogenesis inhibitor with proven efficacy in gastrointestinal stromal tumor and advanced renal cell carcinoma. We are presenting the case report of a patient with aggressive alveolar soft part sarcoma with lung and bone metastases, who had failed multiple chemotherapy regimens showing significant response to sunitinib. There was not only complete regression of the primary tumor, stabilization of his bone metastases and significant improvement in the quality of life. Our report shows that sunitinib has the capability of playing a pivotal role in the management of non-gastrointestinal stromal tumors like alveolar soft part sarcoma. Further research and trials must be encouraged over the use of this drug as it is most definitely promising.

[Colorectal cancer surgery. Analysis of risk factors in relation to incidence of morbidity and mortality]. / Chirurgia oncologica colo-rettale. Analisi dei fattori di rischio nell'incidenza di morbi-mortalità.

The aim of the study was to investigate risk factors in relation to the incidence of morbidity and mortality in surgery for colorectal cancer. Between 1986-2005, 328 patients underwent colorectal cancer surgery, 308 of whom (93.9%) in elective and 20 (6.1%) in emergency surgery. Radical resection was performed in 276 (84.2%) and palliative surgery in 52 (15.8%) patients. Bivariate statistical analysis was used for morbidity and mortality factors and multivariate analysis was performed in order to find independent variables (age, gender, ASA grade, elective or emergency surgery, tumour excision, cancer stage according to Dukes) associated with dependent variable interactions. Differences were considered statistically significant for p values < 0.05. The incidences of mortality and morbidity were 0.91% and 20.1%, respectively. In our study we observed a leakage incidence of 2.74% (9/328). In emergency surgery we found morbidity and mortality rates of 20% and 10%, respectively. Age and advanced cancer stage influenced results but were not found to be statistically significant. 18.3% of patients (60/328) were ASA I, 32% (105/328) ASA II, 39.6% (130/328) ASA III and 10.1% (33/328) ASA IV. Among the independent variables observed in the multivariate analysis, ASA grade was found to be the only positive predictive factor correlated with morbidity. Logistic regression showed an exponential increase in operative risk: odds ratio (OR) 2.9 in ASA I vs ASA II, OR 4.2 in ASA I vs ASA Ill, OR 10.3 in ASA I vs ASA IV (95% confidence interval). As regards the mortality rate, none of the independent variables were found to be statistically significant risk factors (p < 0.05).

Improvement in the fertility rate after placement of microsurgical shunts in men with recurrent varicocele.

OBJECTIVE: To evaluate the effectiveness of microsurgical shunts for secondary varicocele repair after ligation-like procedures, focusing on long-term functional outcomes. DESIGN: Long-term survey (mean follow-up, 8.5 years) of infertile men after secondary microsurgical reconstructive varicocelectomy. SETTING: University-based medical center. PATIENT(S): Thirty-four infertile men (group A, <30 years of age; and group B, >30 years) with recurrent palpable varicocele after varicocelectomy, according to Ivanissevich (n = 28), or after angiographic vein occlusion (n = 6). Ten patients presented bilateral recurrence. INTERVENTION(S): Microsurgical shunts between spermatic vein and inferior epigastric vein. MAIN OUTCOME MEASURE(S): Sperm count, pregnancy rate, and ultrasound evaluation of varicosity. RESULT(S): Complete disappearance of varicosity was achieved in 97.06% of patients, while in 2.94%, a consistent reduction in size was observed. In patients with severe infertility, a significant postoperative increase in seminal parameters was observed. Pregnancy rates were 43.75% in group A and 22.22% in group B. CONCLUSION(S): Microsurgical drainage in patients with recurrent varicocele after ligation-like procedures was shown to be an effective minimally invasive treatment, with immediate hemodynamic recovery of testicular venous outflow and excellent long-term results in patients with left or bilateral recurrences.

[Extrauterine endometriosis: what interest for the general surgeon? Presentation of 3 clinical cases and review of the literature]. / Endometriosi extrauterina: quale interesse per il chirurgo generale? Presentazione di 3 casi clinici e revisione della letteratura.

Extragonadal endometriosis is rarely diagnosed preoperatively for the variety of its localizations. Presentations to general surgeons may be atypical and pose diagnostic difficulty, mimicking other acute diseases. We report three cases treated with surgical operation. Case 1: a 28-year-old woman admitted for bowel obstruction due to coecal endometriosis, with appendix mucocele, peritoneal pseudomyxoma and ovarian endometrioma. The patient underwent right colectomy and right adnexectomy in the emergency setting. Case 2: a 31-year-old woman with endometriosis of the distal extraperitoneal portion of the round ligament presenting as an irreducible inguinal hernia. An operation was performed: the round ligament and a polycystic structure encompassing it were completely excised. Case 3: a 41-year-old woman, with umbilical endometriosis diagnosed by her gynaecologist, was admitted to our department for excision. Surgical treatment of extragonadal endometriosis is adequate. However, postoperative follow-up is mandatory and hormonal suppressive therapy may be indicated by the gynaecologist.

[Severity of anemia and operative morbidity and mortality. Report on 3 clinical cases in Jehovah's Witnesses and review of the literature]. / Morbi-mortalità operatoria relativa alla severità dell'anemia acuta. Presentazione di 3 casi clinici complicati in pazienti Testimoni di Geova e revisione della letteratura.

It has been reported that patients who refuse blood transfusions, such as Jehovah's witnesses, can undergo major surgery. In a review of the literature, however, we critically examined the severity of anaemia in relation to operative mortality and morbidity rates. We report three cases of Jehovah's witnesses who underwent major surgery and presented complication during the postoperative period. Case 1: a 50-year-old man with oesophageal achalasia who underwent Heller's myotomy and Nissen's fundoplication. The postoperative period was complicated by massive haemorrhage and the patient was reoperated on postoperative day 1. After four years, he underwent total oesophagectomy because of severe chronic oesophagitis. On postoperative day 13 the patient suffered anteroseptal myocardial ischaemia, which was treated with medical therapy. Case 2: a 40-year-old man, admitted for ulcerative rectocolitis, who underwent total colectomy. On postoperative day 1 he presented massive haemorrhage and shock. He was reoperated and the postoperative period was complicated by myocardial ischaemia, renal failure and an enterocutaneous fistula. Case 3: a 65-year-old woman with ulcerative rectocolitis who underwent total colectomy and a temporary ileostomy. She suffered venous thrombosis of the lower limbs and pulmonary oedema. The patient died 14 months after surgery as a result of massive haemolysis by cryoagglutinins and cardiac arrest.