A rationale multidisciplinary approach for treatment of esophageal and gastroesophageal junction cancer: Accurate review of management and perspectives.

Cancer of the esophagus and of gastroesophageal junction can be cured, even if with lacking cure rate. Different approaches have been developed, mostly when carcinoma has loco-regional pattern. Multimodality therapy showed a survival rate superior than 10% if compared to a single approach. This is a systematic review, carried to assess the following matters: Which therapeutic opportunities are available? Who could benefit of them? Which adverse reactions could possibly verify? How can physicians definitely choose the proper strategy? Which is the role of surgery? We mean to give either General Practitioner or specialists clear and efficient updates about current treatment of this tumour, starting from physical examination. Four eminent guidelines were consulted for our study: Cancer Care Ontario's Program in Evidence-Based Care, NCCN, Belgian Health Care Knowledge Centre and Esmo.

The Iconography of Goiter: Five Sculptures in the Sacred Mountains of Varallo, Orta, and Varese in Italy.

Many of the representations of individuals with goiters reported in the literature actually refer to occasional swelling of the anterior neck, or "pseudogoiter," the artists not having any plan to expose this pathology. The article describes five representations of goiters, as observed by the authors in the sculptures of the Sacred Mountains of Varallo, Orta, and Varese, Italy. They are classical and appropriate examples of the iconography of "real goiter," since in these cases the sculptors had the definite aim of showing persons with goiter.

Open abdomen management of intra-abdominal infections: analysis of a twenty-year experience.

BACKGROUND: No conclusive results on the efficacy and timing of open abdomen (OA) are available, particularly in the setting of intra-abdominal infections. We analyzed outcomes and risk factors retrospectively in a large series of patients managed with an OA during the past 20 y in an effort to clarify this issue. METHODS: We reviewed the records of 133 patients who underwent treatment with an OA, considering factors related to patient, disease, medical management, and surgical treatment. The end points of the bi-variable analysis were 1-y mortality, calculated from the time of an initial OA procedure, and definitive fascial closure. RESULTS: Most patients (112/133) managed with an OA had one of several types of peritonitis. Many patients had severe clinical conditions (mean Acute Physiology and Chronic Health Evaluation [APACHE] II score was almost 9 points for the study population). With regard to surgical management, the mean (+SD) number of abdominal revisions was 5.9+9.3 during a mean duration of treatment with an OA of 14.3+11.6 d. The overall mortality in the study was 26% (35/133). Bi-variable analysis revealed factors associated with overall mortality to be age, renal and respiratory co-morbidities, edema on an initial chest radiograph, blood pressure, blood glucose and creatinine concentrations; and APACHE II score. The rate of definitive fascial closure was 75% (100/133). Factors associated negatively with fascial closure were respiratory co-morbidity, edema on a first chest radiograph, post-operative mesenteric ischemia as an indication for OA, blood glucose and creatinine concentrations, and duration of an OA. CONCLUSIONS: Patients' pre-operative clinical status influences strongly their response to surgical treatment. The management of OA does not affect adversely the survival of patients with intra-abdominal infections, but factors related to the management of OA (duration of OA) seem to affect the possibility of definitive fascial closure.

Updates on surgical management of advanced gastric cancer: new evidence and trends. Insights from the First International Course on Upper Gastrointestinal Surgery--Varese (Italy), December 2, 2011.

Between the Ninth International Gastric Cancer Congress (IGCC) in South-Korea (Seoul, 2011) and the Tenth IGCC in Italy (Verona, 2013), the Insubria University organized the First International Course on Upper Gastrointestinal Surgery (Varese, December 2, 2011), with the patronage of Italian Research Group for Gastric Cancer (IRGGC) and the International Gastric Cancer Association (IGCA). The Course was intended to be a comprehensive update and review on advanced gastric cancer (GC) staging and treatment from well-known international experts. Clinical, research, and educational aspects of the surgeon's role in the era of stage-adapted therapy were discussed. As highlighted in the meeting, in this final document we summarize and thoroughly analyze (with references only for well-acquired randomized control trials) the new and old open problems in surgical management of advanced GC. Between the Ninth (Seoul, 2011) and the Tenth (Verona,2013) International Gastric Cancer Congress, the First International Course on Upper Gastrointestinal Surgery (Varese, December 2, 2011) was organized by the University of Insubria. This congress received the patronage of the International Gastric Cancer Association and the Italian Research Group for Gastric Cancer. The aim was to discuss open issues in surgical management of advanced gastric malignancies. We considered the opinions of several recognized experts in the field from both the Eastern and Western world, focused on definition problems and oncological and technical issues to define the current principles of advanced gastric cancer (GC) surgery.

Iconography of goiter: four refined examples in the Sacred Mountain of Varese, Italy.

BACKGROUND: Four goiter representations observed by the authors in the sculptures of the Sacred Mountain of Varese, Italy, are described here. SUMMARY: They should be regarded as a typical and proper example of the iconography of "real goiter," where the artists had the definite intention to depict persons with goiter. CONCLUSIONS: Studies of representations of individuals with goiter are not that rare, even though most of the observations reported in the literature deal with images that should be considered occasional swelling of the anterior neck, "thick neck," or "pseudogoiter" because the artists probably did not have any intention to illustrate the pathological condition.

Parathyroid function after open thyroidectomy: A prospective randomized study for ligasure precise versus harmonic FOCUS.

BACKGROUND: Options for controlling hemostasis during thyroidectomy include bipolar vessel sealing system and ultrasonic technology. The purpose of this study was to compare these energy-based devices on the performance of open thyroidectomy for benign disease with emphasis given to postoperative parathyroid function. METHODS: Among the available energy-based devices, the LigaSure Precise (LP; Valleylab, Boulder, CO) and FOCUS Shears (FS; Ethicon Endo-Surgery, Cincinnati, OH) were evaluated. One hundred ninety-nine consecutive patients scheduled for open thyroidectomy were prospectively randomized into 2 similar-sized groups. Operative time, morbidity, incision length, postoperative pain, and hospital stay were analyzed. Postoperative hypoparathyroidism was monitored with serial determinations of intact parathyroid hormone (iPTH) and serum calcium. RESULTS: Early postoperative measurement of iPTH plasma level, although within the reference range, was significantly lower in the FS group (p < .001). Oral calcium supplementation was significantly higher and prolonged in the FS group. CONCLUSION: The present study demonstrates a significant difference of the rates for postoperative parathyroid malfunction when using different energy-based devices.

Peri-operative blood transfusion in gastric cancer surgery: prognostic or confounding factor?

BACKGROUND AND PURPOSE: The relationship between peri-operative blood transfusions (PBTs) and poor prognosis in gastric cancer (GC) patients is still debated. The aim of this study is to examine the real prognostic impact of PBTs in comparison to well-known prognostic factors. METHODS: We retrospectively analyzed a series of 224 patients who underwent surgery with curative intent for GC from January 1995 to December 2011. Among 224 patients, 46 (20%) required PBTs. RESULTS: The overall 5-year survival was 77% in non-transfused patients and 65% in patients who received PBTs (p = 0.03). PBTs did not further stratify any recognized prognostic category (such as pT or pN according to the 7th edition of the TNM staging system). Multivariate analysis including all known prognostic variables (both cancer- and non-cancer-related) did not select PBTs as an independent prognostic factor. Only preoperative hemoglobin and albumin level, pT and operative time were significantly associated with the requirement for PBTs. CONCLUSIONS: The study showed a worse prognosis for transfused patients, but PBTs seem a confounding factor more than a prognostic indicator, as they are obviously affected by other variables.

Quality of life after gastrectomy for cancer evaluated via the EORTC QLQ-C30 and QLQ-STO22 questionnaires: surgical considerations from the analysis of 103 patients.

BACKGROUND AND OBJECTIVES: Gastric surgery is a major operation which can cause a related potential deterioration in the patient's quality of life (QoL). This retrospective study investigates the factors which can influence QoL in patients who underwent curative total or subtotal gastrectomy for cancer. METHODS: One hundred and three patients were treated via gastrectomy between August 1990 and September 2012: 48 total gastrectomies with Roux-en-Y reconstruction and 55 subtotal resections (among the latter there were 15 Roux-en-Y and 40 Billroth II reconstructions). All patients were interviewed to evaluate their QoL using the EORTC QLQ-C30 and QLQ-STO22 questionnaires. Non-parametric tests were used to analyze the data collected during the interviews considering patient-, tumor- and treatment-related factors. The analysis was corrected for potential confounding factors, in particular considering new onset variables (e.g. comorbidity, treatment and age at time of the interview). RESULTS: QoL correlated negatively with tumor stage and total gastrectomy. In particular, a larger resection for an advanced cancer seems to cause a worse QoL. Furthermore, total gastrectomy is associated with several upper-gastrointestinal tract symptoms. Moreover, after distal resection, patients with a Billroth II reconstruction complain more frequently of dumping syndrome-related symptoms than patients with a Roux-en-Y reconstruction. CONCLUSIONS: QoL after gastric surgery for cancer is affected by tumor- and treatment-related factors. In order to improve patients' QoL, subtotal resection with Roux-en-Y reconstruction should be preferred whenever oncologically acceptable.

Impact of static cold storage VS hypothermic machine preservation on ischemic kidney graft: inflammatory cytokines and adhesion molecules as markers of ischemia/reperfusion tissue damage. Our preliminary results.

At the present time, deceased heart-beating donor kidney allografts are usually stored cold. Extended-criteria donor (ECD) grafts show higher sensitivity to ischemia-reperfusion damage than standard kidneys. The increasing use of marginal organs in clinical transplantation urgently requires a more effective preservation system. Pulsatile hypothermic machine perfusion has shown major advantages over static cold storage in terms of reduced organ injury during preservation and improved early graft function. This preliminary study aims to compare pulsatile hypothermic machine perfusion and static cold storage of kidney allografts, outlining differences in the levels of early inflammatory cytokines (TNF-α, IL-2 and IL-1ß) and soluble intracellular adhesion molecule (sICAM-1) in perfusion and preservation liquid.

Treatment of aortoiliac occlusive or dilatative disease concomitant with kidney transplantation: how and when?

BACKGROUND AND PURPOSE: Aortoiliac (AI) lesions (both dilatative and occlusive) can occur in kidney allograft recipients. The correct timing of vascular imaging and treatment is controversial. Aim of the present paper is to report our experience. METHODS: between January 2010 and December 2012, 106 patients included in our waiting list for kidney transplant underwent computed tomography (CT) angiogram to study AI axis. In 21 cases an AI lesion was identified before transplant. In 3 cases surgery was mandatory before kidney transplant, and in 18 cases lesions were treated simultaneously with kidney transplantation. MAIN FINDINGS: AI pathology distribution was as follows: 15 iliac stenoses treated with thromboendarterectomy (TEA), 2 Leriche syndrome and 1 aortic aneurism treated with an aortobisiliac bypass (AI-BP), and 3 aneurysms treated with endovascular aortic repair (EVAR). In two cases a postoperative hematoma occurred. In one case occlusion of a stent-graft branch was treated with a femoro-femoral crossover bypass and transplant was then performed on the contralateral iliac axis. Perioperative mortality was 0%, and graft survival rate was 100% at 1 year in all cases. CONCLUSIONS: A CT angiogram is useful in order to detect AI lesions and to be able to evaluate the best treatment option for the kidney transplantation and the correct timing for additional vascular surgery. The EVAR procedure should be safe, and does not compromise anastomosis success and graft survival, with less postoperative complications than open surgery.

Safety of neural monitoring in thyroid surgery.

During thyroid surgery, the functional integrity of the recurrent laryngeal nerve (RLN) is not only threatened by direct nerve injury resulting from accidental transection, clipping or ligation. In fact, indirect trauma, e.g. traction and compression occurring repeatedly throughout gland dissection, contribute to long-term nerve impairment. In order to avoid RLN lesions and preserve nerve function the surgeon must adhere to and comply with a strict standardized intraoperative neuromonitoring (IONM) technique to preserve results, quality and safety. IONM should be a team work between the surgeon and the anesthesiologist.

Treatment of abdominal aortic aneurysm with a new type of polymer-filled low profile device.

PURPOSE OF THE STUDY: To evaluate the mid-term safety and effectiveness of a novel stent graft for treatment of abdominal aortic aneurysm (AAA). METHODS: Thirty-three patients with AAA (20 males and 13 females; mean age: 71.3 y) were treated with the Ovation™ Abdominal Stent Graft System (TriVascular, Inc., Santa Rosa, CA, USA). Indications for endovascular aneurysm repair: AAA ≥ 5.5 cm, neck ≥ 7 mm, angulation ≤ 60° and with an inner wall diameter of no less than 16 mm and no greater than 30 mm; the presence of neck calcification and thrombosis is not much of a problem in this device because aortic seal is achieved with 2 polymer-filled sealing rings and the fixation by means of a suprarenal stent with 8 pairs of anchors. Patients were followed through discharge and returned for follow-up visits. The follow-up protocol included a CT-A exam at 1 and 12 months after the intervention; the mid-term follow up was performed at 3 and 6 months with contrast-enhanced ultrasound (CEUS). Mean follow-up duration was 18.6 months (range: 3-25 months). MAIN FINDINGS: Technical success was 100%. Mean implantation procedure time was 31.1 minutes, and median hospital stay was 4.6 days. None of the patients required conversion to open surgery, and no aneurysm enlargement, rupture, fracture, or migration were observed. No type I, III or IV endoleaks were observed. Hospitalization death rate was 0%. Death rate at 30 days was 0%. No major complications were observed. CONCLUSIONS: The first results from this 3-center study with the Ovation stent graft are promising with high technical success and excellent safety and effectiveness.

Efficacy, safety and effectiveness of image-guided percutaneous microwave ablation in cystic renal lesions Bosniak III or IV after 24 months follow up.

PURPOSE OF THE STUDY: The aim of the study was to assess the efficacy, safety and effectiveness of percutaneous image-guided microwave ablation (MWA) in Bosniak category III or IV cystic renal lesions after 24 months follow-up duration. METHODS: Between May 2008 and December 2012, computed tomography (CT)- or ultrasound (US)-guided MWA was performed in 6 patients with 7 cystic renal lesions (range 13.8-27 mm, mean 17.02 mm, SD 8.5 mm) Bosniak category III or IV. The number of treatment sessions, treatment results, lesion size changes and complications were evaluated. Technical success (TS), technical effectiveness (TE), local tumor progression rate (LTPR), cancer-specific survival rate (CSSR) and overall survival rate (OSR) were computed. MAIN FINDINGS: TS was 100% (7/7) and TE was 100%; LTPR was 0%; CSSR and OSR were 100%. No major complications were observed. CONCLUSION: Our preliminary experience with MWA shows a potential role for US/CT-guided percutaneous MWA in treating Bosniak category III or IV cystic renal lesions, as a safe approach to treat selected patients not suitable for surgery.

Percutaneous transhepatic endoscopic holmium laser lithotripsy for intrahepatic and choledochal biliary stones.

PURPOSE OF THE STUDY: To report our experience in treating complicated biliary calculi by percutaneous transhepatic endoscopic biliary holmium laser lithotripsy (PTBL). PATIENTS AND METHODS: Ten symptomatic patients with intrahepatic or common bile duct calculi underwent PTBL. Six of these patients had previously undergone unsuccessful endoscopic treatment; four patients were declared not suitable for endoscopic procedure. PTBL was performed with a flexible choledochoscopy inserted by way of the percutaneous access sheath. A holmium laser was used to fragment the biliary stones. Sphincteroplasty was performed when considered necessary and an occlusion balloon for the clearance of common bile duct (CBD) calculi was used when continuous warm saline irrigation at high pressure was not sufficient. Clinical follow up was performed by the referring physician. Technical success, clinical success and complications were evaluated. MAIN FINDINGS: Technical success rate was 100%. The overall clinical success rate was 100%. No patients underwent additional procedures for retained stones or developed de novo strictures or other complications related to the procedure. Hospital stay was no more than 4 days after the procedure. Duration of follow-up was 6-25 months (mean 12.6). One patient died from unrelated causes. During this period, no recurrence and/or complications related to procedure were observed. No major complications were registered. Minor complications like temporary abdominal pain were considered not significant by the patients. CONCLUSIONS: Complicated or large biliary calculi can be treated successfully using PTBL. In selected patients, this approach should become the first choice of treatment after other treatments are rejected.

Web-based information on intraoperative neuromonitoring in thyroid surgery.

BACKGROUND: This is a preliminary analysis of intraoperative neuromonitoring (IONM)-related websites available to the general public with respect to thyroid surgery. METHODS: Four key terms and/or phrases (neuromonitoring AND thyroid AND neck surgery, intraoperative neuromonitoring, intraoperative electrophysiological monitoring, IONM) were entered separately into the search engines Google.com, Yahoo.com and Bing.com. The first 50 results obtained for each search procedure were evaluated. Websites were evaluated for content quality using the validated DISCERN rating instrument. Readability was graded by the Flesch Reading Ease Score and the Flesch-Kincaid Grade Level. RESULTS: The results were related to scientific publications in most cases (64%). A large percentage (59%) of the servers are located in the USA. The main language used is English (91%); only 19% of the websites are multilingual or in other languages. 58% of the sites were rated as excellent to good and 42% as fair to poor. The median Flesch Reading Ease Score was 49.6; the median Flesch-Kincaid Grade Level was 13.85. CONCLUSIONS: World Wide Web information about IONM in thyroid surgery is too specific and difficult and poorly accessible to the general public.

History of splenectomy.

BACKGROUND: The spleen has been considered for millennia a fascinating and mysterious organ with multiple functions. The spleen has long been an organ of interest in popular as well as medical literature. METHODS: A literature (Pubmed) and historical review about splenectomy has been performed. RESULTS: The importance of spleen and the related surgical procedure of splenectomy has been an important topic of scientific interest since the Ancient Greece culture to more modern times. CONCLUSIONS: Spleen and splenectomy have important roles in the medical literature and popular tradition. Nowadays laparoscopic splenectomy is increasingly popular and for certain indications it is considered the gold standard therapy.

Continuous monitoring of the recurrent laryngeal nerve in thyroid surgery: a critical appraisal.

BACKGROUND AND PURPOSE: Intraoperative neuromonitoring (IONM) contributes in several ways to recurrent laryngeal nerve (RLN) protection. Notwithstanding these advantages, surgeons must be aware that the current, intermittent, mode of IONM (I-IONM) has relevant limitations. To overcome these I-IONM limitations, a continuous IONM (C-IONM) technology has been proposed. METHODS: A PubMed indexed literature review of the current limitations of I-IONM is presented and a commentary about C-IONM is provided presenting the preliminary results of research on this topic. MAIN FINDINGS: I-IONM, despite the advantages it produces, presents some important limitations; to overcome these drawbacks a C-IONM technology has been introduced. CONCLUSIONS: RLN traction injury is still the most common cause of RLN injury and is difficult to avoid with the application of I-IONM in thyroid surgery. C-IONM is useful to prevent the imminent traction injury by detecting progressive decreases in electromyographic amplitude combined with progressive latency increases. C-IONM seems to be a technological improvement. Likely, C-IONM by vagal nerve stimulation should enhance the standardization process, RLN intraoperative information, documentation, protection, training, and research in modern thyroid surgery. Although C-IONM is a promising technology at the cutting edge of research in thyroid surgery, we need more studies to assess in an evidence-based way all its advantages.

Free circulating DNA as a biomarker of colorectal cancer.

OBJECTIVES: The purpose of this study is to evaluate the sensitivity and specificity of free circulating DNA (FCDNA) as a biomarker in patients suffering from colorectal cancer (CRC), investigating both its prognostic value correlated with stage of disease and its potential role in early recurrence diagnosis. METHODS: The quantification of plasma DNA was achieved through the use of real time quantitative polymerase chain reaction (PCR) amplification of the RNAse P gene. The study enrolled patients undergoing surgery for primary CRC, at different stages of disease; samples were collected before surgery and during follow-up examinations every 3 months after surgery. Data were statistically analyzed using Software Packages SPSS® for Windows. RESULTS: FCDNA was detectable in all pre-operative samples and the mean value was 47.8 ng/mL. FCDNA values increased progressively related to UICC stage of disease, although statistical significance was demonstrated only when comparing patients by pT stage. The analysis of postoperative samples showed a significant decrease of FCDNA quantity after radical surgery and in specific cases a rise preceding disease recurrence. CONCLUSIONS: This study shows that absolute quantification of FCDNA in CRC patients could have a prognostic value, being related to stage of disease, and could be used as potential tool for early detection of recurrences.