Antibiotic Use in Low and Middle-Income Countries and the Challenges of Antimicrobial Resistance in Surgery.

Antimicrobial resistance (AMR) is a phenomenon resulting from the natural evolution of microbes. Nonetheless, human activities accelerate the pace at which microorganisms develop and spread resistance. AMR is a complex and multidimensional problem, threatening not only human and animal health, but also regional, national, and global security, and the economy. Inappropriate use of antibiotics, and poor infection prevention and control strategies are contributing to the emergence and dissemination of AMR. All healthcare providers play an important role in preventing the occurrence and spread of AMR. The organization of healthcare systems, availability of diagnostic testing and appropriate antibiotics, infection prevention and control practices, along with prescribing practices (such as over-the-counter availability of antibiotics) differs markedly between high-income countries and low and middle-income countries (LMICs). These differences may affect the implementation of antibiotic prescribing practices in these settings. The strategy to reduce the global burden of AMR includes, among other aspects, an in-depth modification of the use of existing and future antibiotics in all aspects of medical practice. The Global Alliance for Infections in Surgery has instituted an interdisciplinary working group including healthcare professionals from different countries with different backgrounds to assess the need for implementing education and increasing awareness about correct antibiotic prescribing practices across the surgical pathways. This article discusses aspects specific to LMICs, where pre-existing factors make surgeons' compliance with best practices even more important.

Implications of increased serum amylase after pancreaticoduodenectomy: toward a better definition of clinically relevant postoperative acute pancreatitis.

BACKGROUND: Postoperative acute pancreatitis (POAP) can be a possible cause of postoperative pancreatic fistula (POPF). The present study aimed to evaluate the role of clinically-relevant POAP (CR-POAP), defined according to different cut-offs of postoperative amylase (AMS) values and C-reactive protein (CRP), in the development of clinically relevant POPF (CR-POPF) after pancreaticoduodenectomy (PD). METHODS: Data from 610 patients who underwent PD (2015-2018) were analyzed. Patients were divided according to the upper limit (100 U/l) and 3-fold the upper limit (300 U/l) of serum POD1 AMS. Univariate and multivariable analysis of possible predictors of CR-POPF were performed. RESULTS: Overall, 360 patients (59%) had POD1 serum AMS ≤100 U/l, 142 patients (23%) had POD1 serum AMS >100 U/l and ≤300 U/l, and 108 patients (18%) had POD1 serum AMS >300 U/l. Patients with POD1 serum AMS >300 had a higher frequency of soft pancreatic texture, complications, main pancreatic duct diameter ≤3 mm, and CR-POPF. POD1 serum AMS >100 U/l associated to POD2 CRP ≥180 mg/l (OR: 4.3, p < 0.001) was an independent predictor of CR-POPF. CONCLUSION: These results confirm that CR-POAP, defined as POD1 serum AMS >100 U/l and POD2 CRP ≥ 180 mg/l, is associated with an increased risk of CR-POPF.

A proposal for a comprehensive approach to infections across the surgical pathway.

Despite evidence supporting the effectiveness of best practices in infection prevention and management, many healthcare workers fail to implement them and evidence-based practices tend to be underused in routine practice. Prevention and management of infections across the surgical pathway should always focus on collaboration among all healthcare workers sharing knowledge of best practices. To clarify key issues in the prevention and management of infections across the surgical pathway, a multidisciplinary task force of experts convened in Ancona, Italy, on May 31, 2019, for a national meeting. This document represents the executive summary of the final statements approved by the expert panel.

Inflammatory myofibroblastic tumor of the transverse colon with synchronous gastrointestinal stromal tumor in a patient with ulcerative colitis: a case report.

INTRODUCTION: Inflammatory myofibroblastic tumor (IMT) is a rare proliferative disease of uncertain etiology, characterized by the proliferation of fusate or epithelioid myofibroblasts admixed with predominantly mononuclear inflammatory cells. IMT is generally considered a benign lesion, although in some cases this neoplasm has shown an aggressive behavior in terms of local recurrence and metastasis. We report the case of a patient with a ten-year history of ulcerative colitis affected by IMT of the transverse colon and by synchronous gastrointestinal stromal tumor (GIST) of stomach. PRESENTATION OF CASE: A 59-year-old woman with a ten-year history of ulcerative colitis has been admitted to our hospital with signs and symptoms of acute recurrence of ulcerative colitis: abdominal pain, diarrhea, hematochezia and rectal tenesmus. Colonoscopy showed a left colon with diffuse hyperemia, mucosal erosions and a 2-cm, irregularly shaped, polypoid lesion at the level of the transverse colon. Histopathological examination of the specimen obtained via biopsy of the polypoid lesion has revealed a mesenchymal neoplasm with uncertain characters of malignancy. Due to the severity of the inflammatory bowel disease resistant to immunosuppressive and steroid drug treatment, surgical indication was given. DISCUSSION: Although the relationship between IMT and Crohn's disease has been widely reported in literature, the relationship between IMT and ulcerative colitis has never been previously described. CONCLUSION: To the best of our knowledge, this is the first case of IMT associated with ulcerative colitis reported in literature and the synchronous association with a gastric GIST represents another primacy.

A preoperative score to predict early death after pancreatic cancer resection.

BACKGROUND: This study aimed to develop and validate a preoperative prognostic model for death within one year post-surgery in patients with resectable pancreatic ductal adenocarcinoma (PDAC). METHODS: A derivation cohort study of 296 patients who underwent surgical resection of PDAC was prospectively enrolled in an observational study. Preoperative predictors of one year mortality were used to develop a risk score which was then validated in an external cohort of 182 patients with resectable PDAC. RESULTS: Seventy-eight out of 296 patients (26%) died within the first year. Preoperative independent predictors of one year mortality were: nutritional status (Geriatric Nutritional Risk Index, OR 2.23, 1.14-4.38; p=0.02), American Society of Anaesthesiologists' score (OR 2.56, 1.1-5.98; p=0.03), abdominal or back pain at presentation (OR 2.51, 1.05-5.9; p=0.038) and non metastatic liver disease as comorbidity (OR 4.5, 1.05-19.3; p=0.043). A score ranging from 0 to 7 points was developed. In the validation cohort, the model was able to predict early mortality (OR 7.1, 3.9-12.7; p<0.0001), with a predictive ability of 53.5% (Nagelkerke R2), an area under the receiver operating characteristic curve of 88.7% and an acceptable calibration (goodness-of-fit test, p=0.403). CONCLUSIONS: Our new simple risk score proved reliable in forecasting one year mortality in patients with resectable PDAC.

Early Postoperative Prediction of Clinically Relevant Pancreatic Fistula after Pancreaticoduodenectomy: usefulness of C-reactive Protein.

BACKGROUND: An early recognition of clinically relevant pancreatic fistula (PF) after pancreaticoduodenectomy (PD) is essential. METHODS: All consecutive patients who underwent PD in two institutions were included (2013-2015). In all patients amylase value in drains (AVD) was evaluated in postoperative day 1 (POD1). White-blood cell count (WBC), serum pancreatic amylase (SPA) and C-reactive protein (CRP) were routinely evaluated in POD1, POD2, and POD3. Receiver operator characteristic (ROC) curves were performed. Significant diagnostic cut-offs were tested in a multivariate model. RESULTS: Overall, 463 patients underwent PD. Postoperative morbidity and mortality were 58% and 4%, respectively. Sixty-four patients (14%) had a clinically relevant PF (grade B or C). ROC curve analyses revealed that AVD on POD1 had the greatest area under the curve value (0.881, P < 0.0001) followed by CRP on POD3 (0.796, P < 0.0001). Multivariable analysis identified male gender (OR 2.29 95%CI: 1.12-4.70, P = 0.023), AVD on POD1>500 U/l (OR 21.72, 95%CI: 7.41-63.67, P < 0.0001), CRP on POD2 > 150 mg/l (OR 3.480, 95%CI: 1.21-9.99, P = 0.021), and CRP on POD3 > 185 mg/l (OR 6.738, 95%CI: 1.91-23.78, P = 0.003) as independent predictors of clinically relevant PF. CONCLUSION: The combination of CRP and AVD was effective in the early prediction of clinically relevant POPF after PD.

May the drain be a way in for microbes in surgical infections?

BACKGROUND: Surgical site infection (SSI) is among the most frequent hospital-acquired infections occurring in surgical patients and leads to increased morbidity, mortality, and costs. We aimed to identify risk factors for SSI in patients undergoing surgical procedures, with a particular attention to the use of drains. METHODS: This study includes all patients undergoing abdominal surgical procedures in 2 surgical wards in a teaching hospital in central Italy. Collected data included patient's demographic and clinical characteristics, procedure characteristics, administration of perioperative antibiotic prophylaxis, and microorganism isolated. The outcome of interest was SSI. FINDINGS: A total of 872 abdominal surgery procedures were surveyed during the study period. Drains were placed in 37.0% of cases. SSI rate was 6.4% globally and 13.6% among the patients with drains, versus 2.4% in those without a drain (P < .001). In 72.1% of cases antibiotic prophylaxis was administered. The logistic regression analysis (P < .001) shown insertion of a drain (odds ratio [OR], 5.14; 95% confidence interval [CI], 2.63-10.08), prolonged surgery (OR, 1.98; 95% CI, 1.09-3.59), and American Society of Anesthesiologists score equal to 3 (OR, 6.13; 95% CI, 2.33-16.11) as independent risk factors for SSI, whereas antibiotic prophylaxis was protective (OR, 0.53; 95% CI, 0.29-0.99). CONCLUSION: This study revealed surgical drains as a risk factor for SSI, pointing out the need of a clearer understanding of drain role in the dynamics of SSI occurrence, with the purpose of decreasing infection risk through targeted preventive interventions.

Prevalence and clinical outcome of hepatic haemangioma with specific reference to the risk of rupture: A large retrospective cross-sectional study.

BACKGROUND: Prevalence and incidence of hepatic haemangioma are estimated from autopsy series only. Although benign and generally asymptomatic, hepatic haemangioma can cause serious complications. AIMS: The aim of the study was to assess the prevalence of hepatic haemangioma and to attempt to quantify the risk of major complications such as spontaneous rupture. METHODS: We retrospectively analyzed the radiology database of a Regional University Hospital over a 7-year period: the radiological records of 83,181 patients who had an abdominal computed tomography or magnetic resonance scan were reviewed. Diagnoses made at imaging were reviewed and related to clinical course. RESULTS: Hepatic haemangioma was diagnosed in 2071 patients (2.5% prevalence). In 226 patients (10.9%), haemangioma had diameter of 4 cm or more (giant haemangioma). The risk of bleeding was assessed on patients without concomitant malignancies. Spontaneous bleeding occurred in 5/1067 patients (0.47%). All 5 patients had giant haemangioma: 4 had exophytic lesions and presented with haemoperitoneum; 1 with centrally located tumour experienced intrahepatic bleeding. CONCLUSION: Giant haemangiomas have a low but relevant risk of rupture (3.2% in this series), particularly when peripherally located and exophytic. Surgery might be considered in these cases.

Risk stratification systems for surgically treated localized primary Gastrointestinal Stromal Tumors (GIST). Review of literature and comparison of the three prognostic criteria: MSKCC Nomogramm, NIH-Fletcher and AFIP-Miettinen.

PURPOSE: The discovery of Imatinib mesylate (Gleevec®) has revolutionized the treatment of GIST, increasing diseasefree survival (DFS) after complete surgical resection of a primary localized GIST and extending overall survival in metastatic disease. The definition of an accurate prognostic system is critical for the therapeutic decision making process. In literature, there are three main prognostic criteria F/NIH consensus, AFIP standards and modified NIH standards. In recent years were added various risk identification methods applying mathematical calculation model, including MSKCC risk nomogram, Rossi nomogram and Joensuu high Hotline Dengjun. Despite all these attempts, it seems that the recurrence risk probability still cannot be predicted accurately. The aim of our study was to assess and compare the real ability of these prognostic instruments in our single-centre clinical experience, and to define if the use of the MSKCC nomogram can bring benefits in the therapeutic decision. METHODS: All data regarding 37 GIST, who underwent surgical resection from 1996 to 2011 in our institution were retrospectively reviewed. We selected only primary GIST without metastatic disease who underwent a radical resection (R0) but no other therapy. The literature data concerning GISTs prognostication criteria were reviewed. All patients were classified according to the three prognostic criteria (NIH, AFIP and Nomogram MSKCC) and the three instruments were compared with the Kaplan-Meier method. Then we compared the three criteria for their c-index value and we assessed the performance of the nomogram with the calibration test. RESULTS: We observed 9 recurrences (24%) with an average time to relapse of 43 months; the median follow-up was 65 months. In the study selected sample occurred 5 relapses. The probability of relapsing after radical surgery was 7.9% (95% CI 0 - 17.3) at 2 years and 13.3% at 5 years (95% CI 0 - 26.4). The C-Index of the three risk assessment tools was 0.93 (95% CI 0.83-1) for the Nomogram at 5 years, 0.86 (95% CI 0.76-0.95) for the NIH risk criteria and 0.88 (95% CI 0.74-1) for the AFIP risk criteria. The calibration analysis of the nomogram showed an overestimating trend both at 2 and 5 years. CONCLUSION: MSKCC nomogram seems to perform better than NIH, NIH modified and AFIP in our sample and can be used in clinical practice to predict the risk of recurrence, being especially helpful for the therapeutic decision making since it is at the same time simple to use and accurate. As showed from calibration, MSKCC doesn't seem to neglect relapses, even though it is not impeccable in predicting the RFS. Among the 2 older criteria AFIP was more precise than NIH, but considering size in not linear way represented a limit in comparison with the MSKCC Nomogram. All the three risk assessement tools criteria con sidered are capable to predict recurrence in high-risk GISTs while they performed worse in those with lower risk. MSKCC nomogram main limit remains the not linear consideration of mitotic count.

Skeletal muscle metastases as initial presentation of gastric carcinoma.

BACKGROUND: Gastric carcinoma is one of the most common malignancies in the world. Skeletal muscle metastases from gastric carcinoma are rare. CASE REPORT: We report a case of a 67-year-old man patient with skeletal muscle metastasis developing from gastric carcinoma. He had a painful swelling of the left thigh. A chest computed tomography (CT) scan with enhancement showed pulmonary thromboembolism. Despite heparin therapy, edema and pain of the lower limbs increased bilaterally, so the patient underwent pelvic magnetic resonance imaging (MRI), which documented an altered signal intensity in the upper third of his thighs bilaterally. Furthermore, the examination of the ultrasound (US)-guided biopsy specimen of the left gluteal muscle showed signet ring cell adenocarcinoma metastasis. An upper gastrointestinal tract endoscopy confirmed a gastric ulceration, with a biopsy positive for signet ring cell adenocarcinoma. Because of the advanced stage of disease, the patient underwent only supportive care and died 74 days after admission. CONCLUSIONS: Skeletal muscle metastasis may be the initial presentation of gastric carcinoma and diagnosis could be difficult. Biopsy is mandatory for diagnosis.

The pedagogic evolution in Surgery: the University at the centre of a training which becomes territorialized The model of the region Marche.

AIM: We want to show a new organisational model of General Surgery training, in act in Università Politecnica delle Marche, which sees its strength in the territorial formative network. MATERIAL OF STUDY: In our Athenaeum, this organization is not a recent realization, but the firsts to have benefited completely of this system are the four residents who have completed the General Surgery formation in March 2014, for this reason we report their experience. RESULTS: The four residents benefited of the two years in the peripheral structures, two also performed a period in a foreign country, two chose to spend other 6 months in the peripheral structure to prepare the thesis of specialization; surgical activity has been, for each resident, of 400 interventions on average as first operator (237-476) distributed in great surgery 44 (13-80), middle 172 (129-268) and small 209 (70-378). DISCUSSION: The Formative NETWORK becomes an essential strength at the service of the academic world, the network foresees a continuous update, it can be easily standardized for every resident and it doesn't raise barriers to the foreign countries experiences. CONCLUSIONS: With the purpose to conform the model of specialistic formation in General Surgery, we propose a new tailored italian organizational model, tested the lasts 6 years, which seems to give good results and conform to the european standard of surgical training. KEY WORDS: Formative network, General Surgery, Resident, Training.

Primary intra-abdominal synovial sarcoma: a case report.

UNLABELLED: The authors report a case of intra-abdominal synovial-sarcoma of the gastrocolic ligament in a 64-years-old woman hospitalized for a palpable abdominal mass and pain. CT scan detected an intra-abdominal mass extended through the abdominal wall into the soft tissues, causing compression and dislocation of intra-abdominal structures (left liver, gallbladder, pylorus and gastric antrum, duodenal bulb). At its back, it was in contact with the pancreas, the vena cava and the right kidney. Biopsy revealed that the mass was an intra-abdominal synovial-sarcoma. Patient received preoperative chemotherapy. After three chemotherapy cycles the patient was admitted to hospital for anemia. CT-scan revealed mass necrosis and bleeding. After red blood cells transfusions, the patient underwent surgery and the mass was resected. Histopathological study confirmed the diagnosis of biphasic Synovial-Sarcoma. SYT-SSX1/2 fusion molecular assessment was attempted, but it was not possible to evaluate the presence of the t (X, 18) (p11.2; q11.2) traslocation. The patient was discharged in good health and received adjuvant chemotherapy. CT-scan after 18 months showed pulmonary and intra-abdominal relapse of the disease. KEY WORDS: Gastrocolic ligament, Intra-Abdominal synovial-sarcoma.

Primary intra-abdominal synovial sarcoma: a case report.

The authors report a case of intra-abdominal synovial-sarcoma of the gastrocolic ligament in a 64-years-old woman hospitalized for a palpable abdominal mass and pain. CT scan detected an intra-abdominal mass extended through the abdominal wall into the soft tissues, causing compression and dislocation of intra-abdominal structures (left liver, gallbladder, pylorus and gastric antrum, duodenal bulb). At its back, it was in contact with the pancreas, the vena cava and the right kidney. Biopsy revealed that the mass was an intra-abdominal synovial-sarcoma. Patient received preoperative chemotherapy. After three chemotherapy cycles the patient was admitted to hospital for anemia. CT-scan revealed mass necrosis and bleeding. After red blood cells transfusions, the patient underwent surgery and the mass was resected. Histopathological study confirmed the diagnosis of biphasic Synovial-Sarcoma. SYT-SSX1/2 fusion molecular assessment was attempted, but it was not possible to evaluate the presence of the t (X, 18) (p11.2; q11.2) traslocation. The patient was discharged in good health and received adjuvant chemotherapy. CT-scan after 18 months showed pulmonary and intra-abdominal relapse of the disease.

Nuclear factor-κB predicts outcome in locally advanced rectal cancer patients receiving neoadjuvant radio-chemotherapy.

BACKGROUND: NF-κB expression has been shown to be responsible for resistance to antineoplastic agents. AIMS: The aim of our study was to investigate the importance of NF-κB expression as prognostic factor in locally advanced rectal cancer patients receiving neoadjuvant radiochemotherapy. METHODS: We retrospectively analysed the immunoreactivity for NF-κB in patients with locally advanced rectal cancer who underwent neoadjuvant treatment (chemotherapy and/or radiotherapy) in our Institution between March 2003 and June 2006. RESULTS: Seventy-four consecutive patients were enrolled into this study. Immunohistochemistry analysis for NF-κB was performed both in biopsies and in primary tumour samples. NF-κB was considered positive when at least 1% of the tumour cells showed nuclear positivity. A significant correlation between a positive NF-κB nuclear expression, both in biopsies and in tumour samples, and a worse overall survival was observed. Moreover, median time to progression was significantly shorter in the NF-κB-positive subgroup of patients. CONCLUSION: Globally, our findings seem to suggest that NF-κB could represent an important parameter able to predict the outcome in patients receiving neoadjuvant treatment for rectal cancer. It also could be useful in order to select patients to receive adjuvant chemotherapy, intensifying the adjuvant therapy and, in the next future, obviating the use of drugs involving NF-κB system in their mechanism of action in NF-κB-positive patients.

The timing of surgery for resectable metachronous liver metastases from colorectal cancer: Better sooner than later? A retrospective analysis.

BACKGROUND: The benefit of preoperative chemotherapy in patients with initially resectable liver metastases from colorectal cancer is still a matter of debate. AIMS: We aim to evaluate the role of neoadjuvant chemotherapy on the outcome of patients with colorectal cancer metachronous liver metastases undergoing potentially curative liver resection. METHODS: One-hundred four patients were available for analysis. Tested variables included age, sex, primary tumour TNM stage, location and grading, the number of liver metastases, monolobar or bilobar location, interval time between liver metastases diagnosis and liver resection, Fong Clinical Risk Score (CRS). Neoadjuvant chemotherapy was administered according to the FOLFOX4 regimen. RESULTS: Forty-four patients underwent liver resection without receiving neoadjuvant chemotherapy (group A); 60 patients received neoadjuvant chemotherapy (group B). At univariate analysis, only the time of liver resection seemed to affect overall survival: patients in group A showed a median survival time significantly superior to that of patients in group B (48 vs. 31 months; p=0.0358). CONCLUSIONS: Our findings suggest that, when feasible, resection of liver metastases should be considered as an initial approach in this setting. Further studies are needed to better delineate innovative therapeutic strategies that may lead to an improved outcome for colorectal cancer patients with surgically resectable liver metastases.

Trans-arterial chemo-embolization (TACE), with either lipiodol (traditional TACE) or drug-eluting microspheres (precision TACE, pTACE) in the treatment of hepatocellular carcinoma: efficacy and safety results from a large mono-institutional analysis.

More data about TACE and pTACE seem necessary to better define the global treatment strategy for HCC. Aim of our analysis was to evaluate the role of TACE, either with lipiodol (traditional) or drug-eluting microspheres in terms of response rate (RR), time to progression (TTP), overall survival (OS) and toxicity in HCC.Patients with HCC undergoing traditional TACE or pTACE (either alone or in combination with other treatment options) were eligibleOne hundred and fifty patients were analyzed. In the global patient population median OS was 46 months for lipiodol TACE and 19 months for pTACE (p < 0.0001), TTP was 30 months versus 16 months for patients receiving TACE or pTACE respectively (p = 0.003). These results were confirmed also among the group of patients who received exclusive TACE or pTACE. Neither RR nor toxicity was different between TACE or pTACE.At multivariate analysis, age, the Okuda stage, type of TACE and number of TACE proved to be independent prognostic factors influencing overall survival.In our experience, lipiodol TACE showed a better OS and TTP over pTACE, without difference in toxicity profile and RR. Among the staging systems analyzed only the Okuda stage seemed able to reliably predict patients outcome.

Locally advanced rectal cancer patients receiving radio-chemotherapy: a novel clinical-pathologic score correlates with global outcome.

PURPOSE: To determine the importance of downstaging of locally advanced rectal cancer after neoadjuvant treatment. METHODS AND MATERIALS: The study included all consecutive patients with locally advanced rectal cancer who underwent neoadjuvant treatment (chemotherapy and/or radiotherapy) in different Italian centers from June 1996 to December 2003. A novel score was used, calculated as the sum of numbers obtained by giving a negative or positive point, respectively, to each degree of increase or decrease in clinical to pathologic T and N status. RESULTS: A total of 317 patients were eligible for analysis. Neoadjuvant treatments performed were as follows: radiotherapy alone in 75 of 317 patients (23.7%), radiotherapy plus chemotherapy in 242 of 317 patients (76.3%). Worse disease-free survival was observed in patients with a lower score (Score 1 = -3 to +3 vs. Score 2 = +4 to +7; p = 0.04). CONCLUSIONS: Our results suggest that a novel score, calculated from preoperative and pathologic tumor and lymph node status, could represent an important parameter to predict outcome in patients receiving neoadjuvant treatment for rectal cancer. The score could be useful to select patients for adjuvant chemotherapy after neoadjuvant treatment and surgery.

Mucinous rectal adenocarcinoma can be associated to tumor downstaging after preoperative chemoradiotherapy.

PURPOSE: The aim of this study was to evaluate downstaging as primary end point, and progression-free survival and overall survival as secondary end points, in rectal adenocarcinoma patients treated with preoperative chemoradiation. METHODS: One hundred and thirty-six extraperitoneal adenocarcinoma patients (33 low rectum T2, 74 T3, 29 T4 [without sacral invasion], 25 with mucinous subtype) were treated with posterior pelvis preoperative radiotherapy (5040 cGy total dose, 180 cGy/fr, 5 fr/w, 10-15 MV linac X-rays) and concomitant 5-fluorouracil-based chemotherapy. After 6 to 8 weeks patients underwent surgery and prechemoradiation clinical stage was compared with pathologic stage to evaluate downstaging in each patient. Seventy-four patients received adjuvant chemotherapy. Median follow-up was 39 months (4-84). RESULTS: Forty-four patients had macroscopic complete response, 52 patients had partial response, 37 patients showed no change and 3 patients had progression. At multivariate analysis only histotype showed correlation with downstaging (hazard ratio = 0.350 and 0.138 - 0.885 95 percent confidence interval) because of the evidence for poor downstaging in mucinous subtype. There were no significant differences in overall survival and progression-free survival between adenocarcinoma and mucinous subtype. CONCLUSIONS: The main finding is that mucinous histology is associated with poor downstaging after preoperative chemoradiation but this poor response was not associated with worse outcome in this small study. The good outcome for mucinous histology is at odds with other reports in the literature and requires further study.

[Non-operative management of blunt abdominal injuries]. / Ii trattamento non operativo dei traumi addominali chiusi.

Over the past three decades, non-operative management has been shown to be an effective therapeutic option in hemodynamically stable patients. We retrospectively reviewed the last 7 years of our experience with the non-operative management of blunt abdominal traumas. From January 1998 to July 2005, 123 patients with blunt abdominal traumas and injuries to the spleen, liver and pancreas were admitted to our hospital. Fifty-eight of them (47.2%) were submitted to non-operative management; 5 (8.6%) presented associated splenic and hepatic injuries. We performed non-operative treatment for 27 splenic injuries (33.7% of all splenic injuries), 32 hepatic injuries (62.7% of all hepatic injuries) and 3 pancreatic injuries (75% of all pancreatic injuries). There was no mortality and no complications. We submitted one haemodynamically stable patient who presented a grade V hepatic injury and "contrast pooling" at abdominal CT scan to angiography and transarterial embolisation; this patient was successfully managed non-operatively. The overall success rate of non-operative management was 98.5%. The only non-operative management failure was a patient with both splenic and hepatic injuries. The success rate for injuries to the spleen was 96.3%, to the liver 96.9% and to the pancreas 100%. We conclude that hemodynamically stable patients suffering intra-abdominal injury can be safely managed non-operatively.