Hemorrhoid laser procedure (HeLP) for second- and third-degree hemorrhoids: results from a long-term follow-up analysis.

We aimed to analyze the results of 5-year consecutive use of the hemorrhoidal laser procedure (HeLP) in patients with second- to third-grade hemorrhoids with minimal or moderate mucosal prolapse. A total of 189 patients were treated between April 2012 and October 2017. We reported perioperative complications, postoperative pain, improvement of hemorrhoids grade, and relapse of hemorrhoidal disease (HD). Improvement of symptoms was assessed using the Patient Global Improvement (PGI) Scale. No severe intraoperative complications were observed. The median follow-up was 42 months (range 6-62 months). Pain after surgery was absent in 94% of patients. No cases of rectal tenesmus or alterations of defecation habits were reported. Symptoms and HD improvement reached a "plateau" at 3 to 6 months following surgery. We observed a significant decrease in HD degree, occurrence of bleeding, pain, itching, and acute HD. Complete resolution of HD was reported in > 60% of patients 1 year after surgery. The individual level of improvement in symptoms was consistent (very much and much improved, according to PGI-I score) for about 90% of patients during the follow-up. This study confirmed that the HeLP is a safe, painless, and effective procedure for the treatment of HD in selected cases.

Multidimensional Prognostic Index (MPI) score has the major impact on outcome prediction in elderly surgical patients with colorectal cancer: The FRAGIS study.

BACKGROUND: This study aims (I) to evaluate whether the Multidimensional Prognostic Index (MPI) score is associated with postoperative outcomes and (II) to develop a prognostic model for individual complication-risk prediction following colorectal cancer (CRC) surgery. METHOD: This is a prospective multicentric cohort study. Consecutive ≥75-year-old candidates for elective CRC surgery were enrolled from October 2017 to August 2019. Patients underwent standardized preoperative geriatric assessment including the MPI. Patients with MPI score > 0.33 were classified as frail. Logistic regression models were employed to evaluate variables associated with major postoperative complications and mortality, using 10-fold cross-validated LASSO (least absolute shrinkage and selection operator) for model selection. RESULTS: In all, 104 patients were included, 34 (33%) had MPI score > 0.33. Major postoperative complications occurred in 52% of frail versus 16% of fit (MPI score ≤ 0.33) patients (p < .01). Both 30-day (9% vs. 0%; p = .033) and 90-day mortality (18% vs. 1%; p < .01) were higher among frail patients. In multivariate analysis, MPI score was associated with adverse outcomes. A final postoperative complication predictive model was created, including MPI score, gait-speed test, ASA (American Society of Anesthesiology) score, surgical approach, and stoma creation. CONCLUSION: MPI score is strongly associated with postoperative major complications in CRC elderly patients and it is a primary component of an individual prediction model.

Long-Term Outcomes of Immunohistochemically Defined Subtypes of Breast Cancer Less Than or Equal to 2 cm After Breast-Conserving Surgery.

BACKGROUND: Molecular subtype predicts the prognosis of early-stage breast cancer patients. We assessed the long-term outcomes of breast cancer ≤2 cm treated with breast-conserving surgery (BCS) and stratified according to an immunohistochemically (IHC)-based subtype definition. METHODS: This retrospective study was conducted from a prospectively collected database. Included patients had pT1, any N, M0 breast cancer after BCS (without anti-HER2 therapy) and available information on estrogen receptor (ER), progesterone receptor (PR), HER2 status, Ki-67 index. Five IHC-defined subtypes were identified: luminal A-like (ER and/or PR-positive/HER2-negative/Ki-67 < 20%), luminal B-like/HER2-negative (ER and/or PR-positive/HER2-negative/Ki-67 ≥ 20%), luminal B-like/HER2-positive (ER and/or PR-positive/HER2-positive/any Ki-67 value), HER2-positive/nonluminal (ER and PR-negative/HER2-positive), and triple-negative (ER and PR-negative/HER2-negative). RESULTS: We analyzed 184 (65%) luminal A-like, 57 (20%) luminal B-like/HER2-negative, 17 (6%) luminal B-like/HER2-positive, 6 (2%) HER2-positive/nonluminal, and 18 (7%) triple-negative patients. Median follow-up was 112 (interquartile range 94-125) mo. The cumulative 5- and 10-y local recurrence (LR) rates were 1.5% and 4%, respectively. The cumulative 5- and 10-y distant recurrence (DR) rates were 3% and 8%, respectively. The Cox regression revealed that HER2-positive/nonluminal subtypes had the highest risk of LR (P = 0.0025). The luminal B-like/HER2-positive subtypes had the highest risk of DR (P = 0.0019). HER2 positivity carried a higher risk of DR in women with luminal breast cancer who completed 5 y of adjuvant hormonal therapy (P = 0.02). CONCLUSIONS: The IHC-defined subtype impacts on the prognosis of breast cancer ≤2 cm after BCS, determining significant differences in LR and DR rates. In the pre-"anti-HER2 therapy" era, patients with HER2-positive/nonluminal or luminal B-like/HER2-positive subtype had worse long-term outcomes than those with luminal A-like subtype.

Still a role for surgery as first-line therapy of splenic marginal zone lymphoma? Results of a prospective observational study.

AIM: Assessment of hematologic improvement, survival and peri-operative morbidity after first-line splenectomy for splenic marginal zone lymphoma (SMZL). METHODS: Forty-three patients undergoing open splenectomy were prospectively analyzed. Perioperative clinical course, overall and progression-free survival (OS-PFS) were evaluated. Risk factors analyzed were gender, age, ASA-grade, ECOG performance status, presence of B-symptoms, body mass index, steroidal treatment, serum albumin concentration, IIL-score, operative time, spleen size and weight. RESULTS: The median follow-up was 31 months (IQR 15-76; range 24-154). Anemia and thrombocytopenia resolved in 80% of patients at 6 months; in 60% at 2 years. The 5-year and 10-year PFS were 35% and 13% respectively, with a median of 35 months (shorter in patients with ECOG performance status ≥2 and B-symptoms). Nineteen cases (44.2%) had a progression of disease within 2 years. Of these, 14 (32.6%) received adjuvant chemotherapy (mainly R-FC or R-CVP). Progression was attributed to high-grade B lymphoma in 7 (16.3%) patients. The median time between diagnosis and progression to aggressive lymphoma was 25.5 months (range 18.8-81.8). The median time to next treatment was 83.5 months (95% CI 49-118). The 5-year and 10-year OS were 75% and 53% respectively. Mortality was due to disease progression and histological transformation in high-grade B lymphoma in 50% of cases, myelodisplastic syndrome in 15%, recurrence of hemolytic anemia in 15%, Hodgkin lymphoma in 7% and to infections (mainly pulmonary) in the remaining 13% of cases. Post-operative morbidity was 2.3% (1 patient with grade-3 complication). Overall grade ≥2 complication rate was 32.5% (mainly hemorrhagic and pulmonary complications). Spleen weight was the only independent risk factor for morbidity. Mortality was nil. CONCLUSION: Splenectomy is safe and effective as regards cytopenia resolution and OS, although disease progression is frequently observed at follow-up. Such results are strictly linked to accurate pre- and post-operative clinical management and optimal anesthesiologic approach.

Additional Cavity Shaving at the Time of Breast-Conserving Surgery Enhances Accuracy of Margin Status Examination.

PURPOSE: We addressed the impact of separate cavity margin excision (shaving) during breast-conserving surgery (BCS) for breast cancer on specimen volume, tumor margin clearance, re-excision rate, local recurrence and survival. METHODS: A retrospective case-matched study was performed on 298 women with stage 0-III breast cancer; 179 patients received shaving (shaving + lumpectomy group; SLG) and 119 patients did not (lumpectomy group; LG). RESULTS: The two groups had similar baseline characteristics. The median volume of surgical specimen was 131.9 cc in the SLG versus 134.8 cc in the LG (p = 0.81), and surgical margins were tumor-free in 90.7 % of cases in the LG versus 92.7 % in the SLG (87.1 % before shaving) (p = 0.69). The re-excision rate was 14.3 % in the LG versus 10.6 % in the SLG (p = 0.44). In the SLG, shaving spared 10 (5.6 %) patients from reoperation (positive lumpectomy margins but tumor-free shaving margins) (p = 0.11), and only 2/19 (10.5 %) patients in the SLG had tumor-free response at histological examination of re-excised margins compared with 10/17 (58.8 %) cases in the LG (p = 0.004). Tumor in shavings was found in 44/156 (28.2 %) patients having tumor-free lumpectomy margins. At multivariate analysis, distance of tumor from lumpectomy margins, tumor multifocality, receptor status, and tumor size were related to tumor persistence in shavings. Median follow-up was 27 months (range 23-35), and two patients had tumor relapse in the SLG versus none in the LG (p = 0.16). Overall survival was 100 % in both groups. CONCLUSIONS: Shaving does not significantly decrease the re-excision rate but provides wider clear margins in most procedures. It ensures more accurate margin examination and decreases false-positive margin rate, without any increase in removed breast-tissue volume.

Outcomes of open splenectomy for hematologic malignancy with splenomegaly: a contemporary perspective.

Splenectomy for hematologic malignancy (HM) is considered a high-risk procedure, especially in cases of splenomegaly. We analyzed the postoperative course of 82 patients undergoing open splenectomy for HM-related splenomegaly (splenic craniocaudal length 15 cm or greater) in a high-volume center. Primary outcome measures were: perioperative clinical course, rate and severity of postoperative complications (Clavien-Dindo classification), and length of hospital stay. Risk factors analyzed for morbidity and mortality by logistic regression analysis were: gender, age, American Society of Anesthesiologists (ASA)grade, body mass index (BMI), steroidal treatment, preoperative white blood cell count, spleen size, spleen weight, and operative time. The postoperative mortality rate was 1.2 per cent. Only 15.9 per cent of patients required surgical, endoscopic, or radiological intervention after splenectomy (Grade 3 or greater complication). Overall postoperative morbidity rate (as Grade 2 or greater complication) was 52.4 per cent. Surgical complications, mainly bleeding, occurred in 40.2 per cent of patients and 32.9 per cent of patients required blood transfusion. Medical complication rate was 24.4 per cent. Pulmonary disorders were prevalent among medical complications. At multivariate analysis, only ASA score was an independent risk factor for postoperative complications. Open splenectomy can be performed in high-volume centers with low mortality and acceptable morbidity in patients with HM-related splenomegaly, provided that patients at highest risk of postoperative complication (ASA greater than 3) are carefully evaluated.

Iatrogenic rectovaginal fistula repair by trans-perineal approach and pubo-coccygeus muscle interposition.

INTRODUCTION: Rectovaginal fistula (RVF) is a rare but debilitating complication of a variety of pelvic surgical procedures. PRESENTATION OF CASE: We report the case of a 45-year-old female who underwent the STARR (Stapled Trans Anal Rectal Resection) procedure, that was complicated by a 30mm rectovaginal fistula (RVF). We successfully repaired the fistula by trans-perineal approach and pubo-coccygeus muscle interposition. Seven months later we can confirm the complete fistula healing and good patient's quality of life. We carefully describe our technique showing the advantages over alternative suturing, flap reconstruction or resection procedures. DISCUSSION: This technique is fairly easy to perform and conservative. The pubo-coccygeus muscle is quickly recognizable during the dissection of the recto-vaginal space and the tension-free approximation of this muscle by single sutures represents an easy way of replacement of the recto-vaginal septum. CONCLUSION: In our experience the use of pubo-coccygeus muscle interposition is an effective technique for rectovaginal space reconstruction and it should be considered as a viable solution for RVF repair.

Hemorrhoidal laser procedure: short- and long-term results from a prospective study.

BACKGROUND: We report the results of 2-year regular use of the hemorrhoidal laser procedure (HeLP) in 97 patients with symptomatic second- to third-grade hemorrhoids with minimal or moderate internal mucosal prolapse. METHODS: Data on duration of the procedure, perioperative complications, postoperative pain, downgrading of hemorrhoids, resolution or persistency, and recurrence of hemorrhoidal disease (HD) were prospectively collected. RESULTS: No significant intraoperative complications occurred. The median follow-up was 15 months. Postoperative pain was null in most patients. There were no cases of rectal tenesmus or alteration of defecation habits. Symptoms and HD downgrading reached a "plateau" at 3 to 6 months after the HeLP. At this evaluation, frequency of bleeding, pain, itching, and hemorrhoidal acute syndrome decreased by 76% to 79%. HD grade showed a significant reduction. HD recurrence rate was 5% at 2 years. CONCLUSIONS: Our study demonstrates that the HeLP is a safe, effective, and painless technique for the treatment of symptomatic second- to third-grade hemorrhoids with minimal or moderate mucosal prolapse, ideally suitable as ambulatory treatment.

Perivascular epithelioid cell tumor located retroperitoneally with pulmonary lymphangioleiomyomatosis: report of a case.

Perivascular epithelioid cell neoplasms, also known as "PEComas", are unusual mesenchymal tumors, exhibiting perivascular epithelioid cell differentiation and characterized by a mixed myogenic and melanocytic phenotype. "PEComas not otherwise specified" (PEComas-NOS) are especially rare; consequently, there are no published large series, but only case reports. These tumors are rarely located retroperitoneally, with only about 15 such cases reported. We report a case of pulmonary diffuse lymphangioleiomyomatosis with large retroperitoneal PEComa-NOS in a 66-year-old woman. Treatment consisted only of tumor resection, without additional adjuvant therapy. We emphasize the importance of correct immunohistochemistry diagnosis, initiation of recommended treatment, and surveillance of this unique family of tumors.

Pigmentation of axillary sentinel nodes from extensive skin tattoo mimics metastatic melanoma: case report.

BACKGROUND: The relationship between the occurrence of skin diseases and skin tattoos remains unclear. Dermatologic disorders have been reported to occur in about 2% of cases. In addition, tattoo pigment can migrate to the regional lymph nodes through the lymphatic vessels and subsequently mimic metastatic disease from melanoma. METHODS: A 23-year-old Caucasian man presented with a pigmented lesion on the left scapular region, which had slowly enlarged over time. The patient exhibited an extensive tattoo on the left upper arm, left shoulder, and part of the upper back. His medical history was unremarkable. The pigmented lesion was excised. Histology confirmed malignant melanoma. Ultrasound examination of the abdomen, neck, and inguinal and axillary lymph nodes and a total body computed tomography scan showed no sign of disease. A re-excision with 2-cm margins and sentinel lymph node biopsy (SLNB) were performed. Two grossly enlarged, black sentinel lymph nodes (SLNs) highly suggestive of melanoma metastases were removed. RESULTS: No evidence of melanoma metastasis was found in any of the sampled tissues. Large amounts of pigment were present within the subcapsular space and sinusoid areas of the two clinically suspicious lymph nodes. Immunohistochemical analysis was negative. CONCLUSIONS: Sentinel lymph node biopsy is widely performed in cutaneous melanoma. Histologic confirmation of any enlarged, pigmented SLN is essential prior to radical surgery, especially when pigmented SLNs are found near a tattoo. Tattoo pigments may deposit in the regional lymph nodes and may clinically mimic metastatic disease. A history of tattooing should be considered in all melanoma patients eligible for SLNB. In a finding of darkly pigmented nodes during SLNB, radical lymphadenectomy should be withheld until immunohistologic confirmation of metastasis in the SLN is obtained.

Impact of obesity on early surgical and oncologic outcomes after total gastrectomy with "over-D1" lymphadenectomy for gastric cancer.

INTRODUCTION: The purpose of the present study was to assess the impact of body mass index (BMI) on perioperative and pathologic outcomes after total gastrectomy with "over-D1" dissection for gastric cancer. METHODS: Data on 161 patients undergoing total gastrectomy between 2005 and 2011 were reviewed. Patients were grouped into three categories by BMI: BMI < 25 kg/m(2) (63 normal-weight patients; 39.1 %), BMI ≥ 25-<30 kg/m(2) (73 overweight patients; 45.3 %), and BMI ≥ 30 kg/m(2) (25 obese patients; 15.6 %) and matched for the analysis of perioperative and cancer-related outcomes. RESULTS: Operative time was longer for obese patients. Medical (mainly pulmonary) and surgical (mainly bleeding and wound infection) complications occurred more frequently in overweight/obese subjects. However, they were mostly managed conservatively (grade I-II in the Clavien-Dindo classification). The overall postoperative mortality was 0.9 %. Multivariate analysis identified the American Society of Anesthesiologists score and splenectomy, but not obesity, as independent risk factors for postoperative complications. The median number of lymph nodes retrieved differed significantly from group to group: obese 21 (IQR 18-26), versus overweight 24, versus normal weight 28 (p = 0.031). No difference was found in lymph node ratio and cancer-related parameters. CONCLUSIONS: Obese patients with operable gastric cancer can be candidates for standard extensive surgical resection, provided that pre-existing co-morbidities and potential intraoperative and postoperative complications are considered.

Biliopancreatic diversion with transient gastroplasty and duodenal switch: long-term results of a multicentric study.

BACKGROUND: Over the years, several modifications of the Scopinaro biliopancreatic diversion (BPD) have been proposed. This retrospective study reported the results of 15 years of follow-up after open BPD coupled with a type of transient gastroplasty (TG) and duodenal switch (DS), termed BPD-TG with DS. METHODS: Data were analyzed for 874 patients operated on between January 1993 and May 2010 in 3 different surgical departments. RESULTS: The median preoperative body mass index (BMI) was 52 kg/m² (range, 35-63). Comorbidities present were hypertension (57%), hypercholesterolemia (87%), hypertriglyceridemia (53%), type 2 diabetes (35%), and obstructive sleep apnea syndrome (OSAS; 9%). The mean follow-up was 11.9 ± 3.1 years. The median BMI decreased to 33.9 after 1 year from bariatric surgery, 31.1 after 2-5 years, 30.9 after 5-10 years, and 31.2 kg/m² after 10-15 years. Overall, 67% of diabetic patients were able to stop insulin and 97% were able to stop oral hypoglycemic drugs within 1 year. Blood pressure, triglyceride levels, and cholesterol levels became normal in >96% of patients within 1 year. OSAS was resolved within 8 months in all cases. One year postoperatively, but absent thereafter, we observed severe hypoalbuminemia (serum albumin <3 g/dL) in 1.7% of patients and severe iron-deficiency anemia in 1.9%. Incisional hernias were recorded in 30% and anastomotic ulcers in 2.4% of cases. Mortality was null. CONCLUSION: Our results suggest considering BPD-TG with DS as a viable bariatric operation, with its excellent long-term outcome in terms of weight loss, improvement of obesity-related diseases, and quality of life.

Preoperative prediction of growth hormone (GH)/insulin-like growth factor-1 (IGF-1) axis modification and postoperative changes in candidates for bariatric surgery.

BACKGROUND: Several factors alter the growth hormone (GH)/insulin-like growth factor-1 (IGF-1) axis in obese patients, but GH/IGF-1 correlation with anthropometric parameters and lipid metabolism is still unclear. We evaluated this relationship and the postoperative axis modifications in candidates for bariatric surgery. METHODS: Eighty-eight patients (males/females (M/F), 34/54) scheduled for bariatric surgery (biliopancreatic diversion or laparoscopic-adjustable gastric banding) between 2008 and 2010 were included in this observational, open, prospective study. RESULTS: Preoperative serum GH concentrations were found near the lowest limit of normal range in both sexes, with males showing the lowest values (130 vs. 1,405 pg/ml; p < 0.01). Serum concentrations of IGF-1 were within the normal range (M/F, 179/168.5 ng/ml), whereas IGF-binding protein (BP)1 and 3 values were at the lowest limits of normal range in both sexes (M/F 1.8/3.1 µg/ml and M/F 4.1/4.2 µg/ml, respectively). A statistically significant inverse correlation was found between GH, IGF-1, and IGF-BP1-3 values and total cholesterol, LDL-cholesterol, and triglycerides values in both sexes. GH and IGF-BP1-3 values were also inversely related to waist circumference and waist/hip ratio (WHR). GH, IGF-1, and IGF-BP1 and 3 values (35 cases) increased 1 year postoperatively in both sexes, mainly after malabsorptive procedures. CONCLUSIONS: Our results support the hypothesis that GH deficiency associated with low levels of binding proteins in obese patients may be an endocrine response to visceral fat and high levels of non-esterified fatty acids, assessable in daily clinical practice by WHR, total and LDL-cholesterol, and triglycerides. In these patients, malabsorptive procedures might be the treatment of choice due to the metabolic adaptations induced.

Total gastrectomy with "over-D1" lymph node dissection: what is the actual impact of age?

BACKGROUND: We aimed to evaluate risk factors for postoperative complications after total gastrectomy with "over-D1" lymphadenectomy. METHODS: Data on 161 patients (54 cases aged >75 years: elderly group) operated on between 2005 and 2011 were reviewed. Risk factors analyzed for complications (Clavien-Dindo classification) included sex, age, American Society of Anesthesiologists (ASA) grade, body mass index (BMI), pTNM stage, long-term antiplatelets therapy, operative time, and splenectomy. RESULTS: The median age of the study population was 71 (interquartile range [IQR] 62-77) years (79 [range 76-90] years for elderly patients vs 65 [range 33-75] years for the control group, P < .0001). ASA classification was the only baseline characteristic significantly different in the intergroup analysis; 79.6% of the elderly patients were in ASA class III to IV versus 39.2% of the controls (P < .0001). Univariate analysis showed that patient age, ASA score, BMI, and splenectomy were predictive of postoperative complications. Multivariate analysis confirmed ASA score and splenectomy as independent risk-factors. CONCLUSIONS: Regardless of age, fit elderly patients with operable gastric cancer should be candidates for the recommended standard extensive surgical resection provided that pre-existing comorbidities are considered.

Predictive factors for postoperative severe hypocalcaemia after parathyroidectomy for primary hyperparathyroidism.

Hypocalcaemia is a complication of parathyroidectomy. We retrospectively analyzed data on patients who underwent parathyroidectomy for primary hyperparathyroidism (pHPT) to identify predictive factors for severe postoperative hypocalcaemia. Since 2004 we performed 87 parathyroidectomies for pHPT. We divided the patients into two groups: subjects who presented with postoperative hypocalcaemia (group B) or otherwise (group A). We looked for a correlation between several variables and the incidence of postoperative hypocalcaemia. The median calcemia in group B (19 patients) was 6.9 mg/dL on the first postoperative day and 7.6 mg/dL on the third day. We observed hypocalcemia related clinical symptoms in every patient. In all 19 cases the reduction of intraoperative parathyroid hormone above 85 per cent after parathyroidectomy was related to the development of severe postoperative hypocalcaemia (P = 0.042). We found that the reduction of intraoperative parathyroid hormone over 85 per cent after parathyroidectomy can be considered a reliable predictive factor of postoperative hypocalcaemia after parathyroidectomy for primary hyperparathyroidism.

Financial and clinical implications of low-energy CT combined with 99m Technetium-sestamibi SPECT for primary hyperparathyroidism.

BACKGROUND: (99m)Technetium-sestamibi hybrid SPECT/CT has been favored over conventional SPECT in preoperative evaluation of primary hyperparathyroidism (PHPT) patients. However, the financial implications of CT-image acquisition have never before been published. This prompted us to perform a cost analysis of the aforementioned nuclear procedures. METHODS: A total of 55 PHPT patients operated on between 2004 and 2009 were studied. Overall, 27 patients underwent SPECT and 28 SPECT/CT. Localization results, as well as diagnostic and clinical cost variations between SPECT and SPECT/CT patients, were compared. RESULTS: SPECT/CT revealed higher sensitivity than SPECT (96.7 vs 79.3%; P = .011), as well as higher specificity (96.4 vs 82.4%; P = .037) and positive predictive value (PPV) (96.7 vs 83%; P = .038) for correctly identifying the neck-side affected by PHPT. Likewise, SPECT/CT disclosed higher sensitivity (86.7 vs 61.1%; P < .0001), specificity (97.4 vs 90%; P = .022), and PPV (86.7 vs 65.7%; P = .0001) for correct neck-quadrant identification. The mean operative time decreased from 62 min following SPECT to 36 min following SPECT/CT (P < .0001), yielding a mean surgical expense saving of 109.9 /patient (updated at 2009/2010 billing database). SPECT/CT actually ensures a mean expenditure reduction of 98.7 /patient (95% CI: 47.96 -149.42 ), diagnostic costs variation amounting to 11.2 /procedure. CONCLUSIONS: SPECT/CT ensures better focus for the surgical exploration, shortens surgical times, and eventually cuts costs when used for localization of parathyroid adenomas.

High incidence of appendix carcinoid tumors among candidates for bariatric surgery: diagnostic and therapeutic implications.

Although the appendix has been recognized as a preferential site for carcinoid tumors in obese patients, no definitive guidelines are so far available regarding the management of these patients when candidates for bariatric surgery. This study was designed to fill that gap. Between 2000-2008, 558 patients underwent bariatric procedures. Appendectomy was routinely performed in 477 cases. Their charts were retrospectively retrieved and histopathology responses on surgical specimens were recorded. We aimed to assess: incidence of appendix carcinoid tumors (ACTs) and any possible risk-factor; modality of diagnosis (pre-, intra- or post-operatively); impact on the planned bariatric procedure; treatment reserved to such cases. Typical ACTs were diagnosed in 7 patients (1.4%) (median age: 33 years; median BMI: 49 kg/m²; males/females: 1/6). Four were diagnosed intra-operatively. Because of dimensions (<2 cm) and absence of mesoappendiceal or serosal involvement, simple appendectomy was performed during bariatric procedure, as planned. Three were diagnosed post-operatively (all <2 cm). In 1 case right hemicolectomy was performed 1 month later due to mesoappendiceal involvement. No appendectomy-related complication was encountered. All patients remained tumor-free during follow-up (mean: 64 months; range, 25-92). Young age, female sex, high BMI and diabetes mellitus resulted significantly associated with ACT. Our study sustains routine appendectomy or at least careful investigation of the appendix during bariatric surgery. For tumors <2 cm without mesoappendiceal or serosal involvement, simple appendectomy proved sufficient. Bariatric surgery did not have a negative effect on the treatment of malignancies that are discovered intra- or post-operatively.

Long-term results of biliopancreatic diversion with or without gastric preservation for morbid obesity.

We aimed at comparing our long-term results after biliopancreatic diversion (BPD) with or without gastric preservation for morbid obesity. Between 1999 and 2009, we performed 540 BPD: 287 patients (group A) underwent BPD with distal gastric resection (BPD-AHS) and 253 (group B) underwent BPD associated with transitory vertical gastroplasty (TGR) with duodenal switch (DS). The results have been analyzed in terms of weight loss, improvement of comorbidities, and quality of life (Bariatric Analysis and Reporting Outcome System). The mean follow-up was 7.4 ± 2.9 years. One year after surgery, mean initial excess weight loss percentage was 69% for patients in group A (n = 287) and 65% for group B (n = 253); after 2-5 years, it was 74% for patients who underwent BPD-AHS (n = 130) and 75% for patients who underwent BPD-TGR-DS (n = 116); it was 71% and 74% for patients in group A (n = 157) and B (n = 137), respectively, followed up for >5 years (P = 0.27). Among the diabetic patients in both groups (191 patients), 64% discontinued the medication with insulin (P = 0.25), and 98% had stopped oral drugs within 1 year from surgery (P = 0.29). We did not observe deficiencies of vitamins and proteins. The overall incidence of incisional hernias was 38% (P = 0.35). We recorded 13 anastomotic ulcers (2.4%; P = 0.28). BPD represents, in spite of the side effects, an effective technique for treatment of morbid obesity and its associated diseases. Moreover, our results showed that patients who underwent BPD-TGR-DS had slightly better results in terms of postoperative metabolic complications and improvement in quality of life.

'Ad hoc' sternal-split safely replaces full sternotomy for thyroidectomy requiring thoracic access.

Mediastinal goiter (MG) removal occasionally needs sternotomy, mainly in case of subaortic extension. We aimed to test the hypothesis that sternal-split may safely replace full sternotomy for MG removal (through total thyroidectomy) when thoracic access is required. We conducted a prospective observational cohort study comparing 15 subaortic MGs receiving sternal-split with 87 MGs undergoing cervicotomy alone between January 1997 and June 2009. Among 15 cases requiring sternal incision, sternal-split was extended to the angle of Louis in nine patients (60%), to the third intercostal space (IS) in one of five (20%) cases of MGs with anterior mediastinum involvement, and in five of 10 (50%) cases with posterior involvement (P = 0.6). Full sternotomy was never necessary. The median hospitalization was 5 days (range, 4-8 days) after sternal access as compared with 3 days (range, 2-4 days) after cervicotomy (P = 0.04). Complications were similar in these two study groups: one postoperative bleeding in each group and three recurrent laryngeal nerve palsies after cervicotomy (P = 0.5). There was no operative mortality, blood transfusion, tracheotomy requirement, wound infection, or persistent hypoparathyroidism. Proper extension of sternal-split to the second or third IS allows an adequate approach to both the anterior and to the posterior mediastinum, thus permitting safe management of MGs requiring thoracic access.