The Link between Obesity and Gastrointestinal Cancers: a Short Review.

Gastrointestinal cancer represents one of the most encountered oncologic pathologies and research studies are performed thoroughly in order to identify the exact causes and possible novel therapies. Obesity is a complex manifestation associated with numerous physiological and primarily molecular changes capable of tackling the behavior of tumoral cells and the nearby or faraway microenvironment. Adipose tissue has been once considered to have limited physiological roles, but in recent years it has been recognized as an active endocrine organ, secreting substances such as growth factors and adipokines. From an epidemiological perspective, obesity - particularly morbid obesity - is linked to an unfavorable progression of cancer. A key mechanism that may elucidate the association between obesity and cancer involves the insulin and insulin-like growth factor (IGF-1) pathway, sex hormones, and adipokines.

Assessing Nutritional Status in Gastric Cancer Patients after Total versus Subtotal Gastrectomy: Cross-Sectional Study.

Gastric cancer (GC) remains a significant global health concern, ranking as the third leading cause of cancer-related deaths. Malnutrition is common in GC patients and can negatively impact prognosis and quality of life. Understanding nutritional issues and their management is crucial for improving patient outcomes. This cross-sectional study included 51 GC patients who underwent curative surgery, either total or subtotal gastrectomy. Various nutritional assessments were conducted, including anthropometric measurements, laboratory tests, and scoring systems such as Eastern Cooperative Oncology Group/World Health Organization Performance Status (ECOG/WHO PS), Observer-Reported Dysphagia (ORD), Nutritional Risk Screening-2002 (NRS-2002), Patient-Generated Subjective Global Assessment (PG-SGA), and Simplified Nutritional Appetite Questionnaire (SNAQ). Serum carcinoembryonic antigen (CEA) levels were significantly higher in the subtotal gastrectomy group. Nutritional assessments indicated a higher risk of malnutrition in patients who underwent total gastrectomy, as evidenced by higher scores on ORD, NRS-2002, and PG-SGA. While total gastrectomy was associated with a higher risk of malnutrition, no single nutritional parameter emerged as a strong predictor of surgical approach. PG-SGA predominantly identified malnutrition, with its occurrence linked to demographic factors such as female gender and age exceeding 65 years.

Mesenchymal Stem Cell-Derived Exosomes Modulate Angiogenesis in Gastric Cancer.

Individualized gastric cancer (GC) treatment aims at providing targeted therapies that translate the latest research into improved management strategies. Extracellular vesicle microRNAs have been proposed as biomarkers for GC prognosis. Helicobacter pylori infection influences the therapeutic response to and the drivers of malignant changes in chronic gastritis. The successful use of transplanted mesenchymal stem cells (MSCs) for gastric ulcer healing has raised interest in studying their effects on tumor neovascularization and in potential antiangiogenic therapies that could use mesenchymal stem cell secretion into extracellular vesicles-such as exosomes-in GC cells. The use of MSCs isolated from bone marrow in order to achieve angiogenic modulation in the tumor microenvironment could exploit the inherent migration of MSCs into GC tissues. Bone marrow-derived MSCs naturally present in the stomach have been reported to carry a malignancy risk, but their effect in GC is still being researched. The pro- and antiangiogenic effects of MSCs derived from various sources complement their role in immune regulation and tissue regeneration and provide further understanding into the heterogeneous biology of GC, the aberrant morphology of tumor vasculature and the mechanisms of resistance to antiangiogenic drugs.

Robotic-Assisted Pelvic Surgery: Early Outcomes in a Single Institution.

Introduction: This article reports the authors' experience with their first 50 consecutive robotic pelvic procedures, aiming to determine the feasibility and safety of adopting robotic pelvic surgery. Robotic surgery offers several benefits for minimally invasive surgery, but its applicability is hindered by cost and limited regional experience. This study aimed to evaluate the feasibility and safety of robotic pelvic surgery. Material and Methods: This is a retrospective review of our initial experience with robotic surgery for colorectal, prostate, and gynaecologic neoplasia, between June and December 2022. The surgical outcomes were evaluated in terms of perioperative data, such as operative time, estimated blood loss, and length of hospital stay. Intraoperative complications were recorded, and postoperative complications were evaluated at 30 days and 60 days after surgery. The feasibility of the roboticassisted surgery was assessed by measuring the conversion rate to laparotomy. The safety of the surgery was evaluated by recording the incidence of intraoperative and postoperative complications. Results: Fifty robotic surgeries were performed over 6 months, including 21 interventions for digestive neoplasia, 14 gynaecologic cases, and 15 prostatic cancers. Operative time ranged from 90 to 420 minutes, with two minor complications and two grade II Clavien-Dindo complications. One patient required prolonged hospitalization and an end-colostomy, deriving from an anastomotic leakage requiring reintervention. No thirty-day mortality or readmissions were reported. Conclusion: The study found that robotic-assisted pelvic surgery is safe and has a low rate of transfer to open surgery, making it a suitable addition to conventional laparoscopy.

Outcomes Following Surgery for Locally Advanced Pancreatic Cancer - Single Center Experience. A Retrospective Study.

Background: Pancreatic cancer represents one of the most frequent cancers with an increased incidence. Most cases on initial diagnosis are considered to be locally advanced and surgery remains the most important therapeutic option. The aim of this study was to evaluate postoperative morbidity that can impair the association of adjuvant therapy. Methods: We performed a retrospective study on a prospective database that includes all the patients diagnosed with pancreatic cancer in which surgery was performed between 2012 and 2021. We divided the patients in advanced tumours and localized tumours and we compared the outcomes after surgery. Results: On 58 patients with pancreatic tumours surgery was performed: 28(48.3%) pancreaticoduodenectomies and 30 (51.7%) distal pancreatectomies. Localized tumours (T1 and T2) were encountered in 32 patients (55.2%) and more advanced tumours (T3 and T4) were present in 26 cases (44.8%). Although there was no significant difference either for major complications, we observed a tendency for patients with advanced tumours to develop a major complication (15.6% vs 34.6%, p=0.09). The occurrence of major complication, such as pancreatic fistula and postoperative hemorrhage, there was no significant difference (6.25% vs 7.69% and 6.25% vs. 23.1%). On multivariate analysis of preoperative factors associated with the occurrence of a severe complication only the CA19-9 levels were associated with an increased risk (odds ratio 0.666, 95% CI 0.5-1.01; p= 0.04) Conclusions: This study showed no significant differences in terms of postoperative complications between the two subgroups. CA 19-9 is an accurate biomarker for the prediction of postoperative complications.

The Prediction of Peritoneal Carcinomatosis in Patients with Colorectal Cancer Using Machine Learning.

The incidence of colon, rectal, and colorectal cancer is very high, and diagnosis is often made in the advanced stages of the disease. In cases where peritoneal carcinomatosis is limited, patients can benefit from newer treatment options if the disease is promptly identified, and they are referred to specialized centers. Therefore, an essential diagnostic benefit would be identifying those factors that could lead to early diagnosis. A retrospective study was performed using patient data gathered from 2010 to 2020. The collected data were represented by routine blood tests subjected to stringent inclusion and exclusion criteria. In order to determine the presence or absence of peritoneal carcinomatosis in colorectal cancer patients, three types of machine learning approaches were applied: a neuro-evolutive methodology based on artificial neural network (ANN), support vector machines (SVM), and random forests (RF), all combined with differential evolution (DE). The optimizer (DE in our case) determined the internal and structural parameters that defined the ANN, SVM, and RF in their optimal form. The RF strategy obtained the best accuracy in the testing phase (0.75). Using this RF model, a sensitivity analysis was applied to determine the influence of each parameter on the presence or absence of peritoneal carcinomatosis.

Evaluation of Immediate Inflammatory Response in Thoracoscopic Esophageal Resection versus Open Approach - A Prospective Study.

Introduction: There is an immune response after major surgery and inflammatory complications following complex surgery have a direct impact on morbidity and mortality. Currently, we do not have clinical tools to predict in which subset of patients a major complication will occur. The aim of this study was to evaluate the immediate dynamics of C-reactive protein (CRP), presepsin and procalcitonin in patients in which esophagectomy was performed either through video assisted thoracic surgery (VATS) or open approach. Methods: We conducted a prospective study on 27 patients with a mean age of 61.48 +-6.80 years, 13 patients with VATS and 14 with open approach, most of the patients were on stage III esophageal cancer (81%) and in all cases neoadjuvant treatment was performed. Results: There were increased levels of CRP, presepsin and procalcitonin after both arms of the study with significantly higher values for the open approach and with the same dynamic curves. In 3 cases there were extremely elevated levels of procalcitonin in the absence of a septic complication, in all cases a major complication occurred. Conclusion: Video assisted thoracoscopic esophageal mobilization induces a less immune response, even with the association of laparotomy. An elevated postoperative procalcitonin level can be an early indicator of a major postoperative complication.

Rare Case of Smooth Muscle Tumor of Uncertain Malignant Potential - Clinical Case.

Introduction: Smooth muscle tumor of uncertain malignant potential (STUMP) still represents a medical and surgical challenge, being rare and hard to diagnose. Normally STUMP consists in a multitude of uterine tumors that do not meet the current histologic criteria for a specific malignant or benign tumor. Clinical, imagistic and laboratory investigations seem to only raise the presumptive diagnosis in these cases, the diagnosis being confirmed during histological examination of the post hysterectomy/myomectomy specimen. Case report: We present the case of a 50-year-old female patient who was examined for the first time for pelvic pain and sensation of increased pressure in the lower abdomen in June 2020. A gynecology consultation was performed, during which a large uterine mass was felt on vaginal digital examination combined with pelvic palpation. Further pelvic ultrasound examination revealed a voluminous tumor of the left ovary. Then, a magnetic resonance imaging was performed, which showed a large pelvi-abdominal tumor of probable ovarian origin with a mixt tissue type and cystic structure, the presence of pathological abdominal and pelvic lymph nodes, ascites with a suspicion of peritoneal carcinomatosis. The patient was referred to a tertiary center and the multidisciplinary team recommended surgical treatment. A total hysterectomy with bilateral oophorectomy and stadial lymphadenectomy was performed. After surgery, the patient had a favorable evolution and was discharged five days after the intervention in a good health condition. Macroscopic and histological examinations of the biopsy pieces showed morphological aspects of uterine smooth muscles tumors with uncertain malignancy potential/STUMP and multiple uterine leiomyomas. Discussion:Due to the rarity of these tumors, the scientific literature needs to be constantly updated in order to help physicians to correctly identify and treat this pathology. It is highly recommended to identify tumors with a high malignancy potential, so that the follow up will be sufficient to discover and treat recurrences before they become life-threatening. Conclusion:Smooth muscle tumor of uncertain malignant potential remains a difficult diagnosis due to uncertainty between malignancy and benign features. Treatment approaches are difficult in these cases and must always be in accordance with the patients' desire to maintain their reproductive functions and fertility. Recurrence of STUMP has been reported, therefore a close follow up of these patients must always be performed.

Evaluation of circulating tumor cells in colorectal cancer using flow cytometry.

OBJECTIVE: We aimed to evaluate the prognostic value of circulating tumor cells (CTCs) and the impact of intraoperative tumor manipulation on CTCs in colorectal cancer (CRC) patients. METHODS: We performed a prospective study on 40 patients with CRC stages I to IV who received curative surgery using the no-touch technique. Flow cytometry was used to identify CTCs in peripheral blood samples (4 mL/sample) collected at two surgical moments: skin incision (T1) and after surgical resection (T2). A threshold of ≥4 CTCs/4 mL blood was established for considering patients CTC positive. RESULTS: In the univariate analysis, CTC evaluation at T2 was correlated with female sex, vascular invasion, tumor localization in the colon and metastatic lymph nodes. In the multivariate analysis, only female sex and colon cancer maintained statistical significance. At a medium follow-up of 15 months (1-25 months), the mortality rate was 10% (n = 4), with no significant differences between the overall survival of T1 or T2 CTC-positive and CTC-negative patients. CONCLUSIONS: Flow cytometry is a feasible CTC identification technique in CRC, and although surgical manipulation has no influence on CTC numbers, CTCs may serve as a prognostic and predictive factor.

Impacts of the Allocation of Governmental Resources for Improving the Environment. An Empirical Analysis on Developing European Countries.

The last years have brought into attention more than ever concerns regarding the accelerating degradation of the environmental conditions which threaten both the present but mainly the future of human society. Under such circumstances, the society and especially the governments need to acknowledge the seriousness of environment issues and be able to develop and put into practice specific policies to counteract them. In this regard, this paper performs an analysis on a group of 11 European developing countries, over the period between 2000 and 2017, aiming first to evaluate the impact of the changing environment conditions and of the governmental actions regarding environment protection, on citizens life, namely on their life expectancy. In order to evaluate, as accurately as possible, the quality of the environment we propose and elaborate upon an environmental sustainability index based on 17 proxies for environment issues, whose values reveal several similarities between some of the analyzed countries. Secondly, using this index and also several categories of public expenses as proxies for the government actions towards environment protection, we analyze their impact on the life expectancy of the citizens during the sample period and draw some specific conclusions on the actions to be taken forward by governments.

Perineal eventration after abdominoperineal resection for rectal cancer: anatomical, surgical and clinico-pathological landmarks.

Perineal eventration (PE) is a rare complication after the lower rectal cancer resection surgery, affecting the quality of life of the patient. In 5.5 years of evolution, out of 620 patients with rectal cancer treated by curative surgery, 176 patients with lower ampullary rectal cancer treated by abdominoperineal resection (APR) with the closure of the defect by direct suture of the perineal floor were selected. Ten (5.6%) of them were diagnosed with PE. This paper shows the results of a retrospective study, which compares the clinico-pathological and therapeutic aspects of a subgroup of 166 patients (subgroup I) with APR without PE and a subgroup of 10 patients (subgroup II) with PE. Starting from the question of whether aspects can influence the evolution of PE, we aimed to investigate the similarities and differences between these two groups, from the histological, clinical and therapeutic points of view. Regarding the tumor, node, metastasis (TNM) staging, we encountered the following aspects: for the subgroup II with PE, pT3 predominated, stages N0 and N1 were equal (50%) and the absence of metastases (M0) was found in all cases; in subgroup I, pT3 and N0 also predominated, followed by N1 and N2, and for stage M, M0 is predominant, followed by M1. For the clinical profile of the PE group, the symptoms were characteristic, with the presence of the usual triggering factors [hysterectomy, radiochemotherapy and wide resection surgery - extralevatorial APR]. The therapeutic approach revealed various aspects, including plastic surgery procedures (direct closure, meshes, flaps) used in pelvic reconstruction. The accurate surgical technique applied in order to achieve oncological safety allowed for a longer survival, which favored the appearance of PE in addition to the other favoring factors. Our results underlined the clinico-pathological profile of the two subgroups, without being able to establish a correlation with the appearance and evolution of PE. However, the clinico-pathological risk factors for this condition are not yet fully defined. Therefore, reports based on the experience in the diagnosis and treatment of PE should bring valuable data, aiming to create the knowledge framework for prevention.

"Liquid Biopsy" - Is it a Feasible Option in Colorectal Cancer?

It is important for surgeons to keep up with improvements both in and outside their field. As medicine evolves, new techniques appear, and oncology is one of the main beneficiaries. "Liquid biopsy" is one of the most recent domains of interest in oncology, as it may provide important details regarding the characteristics of the main tumor and its metastases. Malignant cells are in a continuous dynamic, which makes the initial diagnostic biopsy and the pathological specimen evaluation insufficient in the late evolution of the disease, when relapse or metastases may appear. The fact that the healthcare provider is able to find out additional information about the tumor at a given time, by evaluating a blood sample to obtain a "liquid biopsy" is of utmost importance and gives multiple potentially usable data. There are three means of obtaining biological material that may be used as "liquid biopsy": evaluation of circulating tumor cells, circulating tumor DNA and exosomes. The most intensely studied entity is that of circulating tumor cells, with different applications, amongst which the most important, at present time, is the prognostic value that has important demonstrated implications, not only in breast and prostate cancer, but also in colorectal cancer. Although surgery will, most certainly, not be replaced by other treatments when aiming for a curative approach to rectal cancer, it is important for the surgeon to know information about complementary fields, one of which is comprised by "liquid biopsy".

The Influence of Neoadjuvant Treatment on the Number of Lymph Nodes on the Surgical Specimen in Mid and Low Rectal Cancer - A Retrospective Single-Centre Study.

Introduction: In this study, we aim to identify the impact of neoadjuvant radiation treatment upon the number of harvested and positive lymph nodes in the surgical specimen; in addition, we tried to identify the impact of chemotherapy in association with radiotherapy on said structures. Patients and methods: In the study we included patients treated for rectal cancer within a single oncologic surgical Unit serving the north-eastern part of Romania, over a period of 5 and a half years, between May 2013 and April 2018. Firstly, we compared pathologic lymph node status to pretherapeutic staging. Secondly, we compared lymph node values in relation to the treatment scheme. Results: There was a total of 498 patients treated radically through open surgery for low and mid rectal cancer. We saw a decrease in N staging in 218 cases, 65 remaining stationary and 10 increasing their lymph node staging on the surgical specimen. We identified significant differences between the total number of lymph nodes (17.4 vs 24.2, p 0.001), the number of positive lymph nodes (1.4 vs 3.4, p 0.001) and the ratio between positive and total lymph nodes (0.08 vs 0.14, p 0.001) in patients with and without neoadjuvant treatment respectively. However, there was no statistical difference between patients with and without chemotherapy associated to radiotherapy in the neoadjuvant treatment plan (p=0.539, p=0.58, p=0.575). Conclusion: This study shows there are significant variations according to the application of neoadjuvant treatment, between the numbers of positive and total lymph nodes, as well as the positive/total lymph node ratio.

Hindgut and Midgut Neuroendocrine Tumors - Therapeutic Approach.

Introduction: Neuroendocrine tumors of the gastro-entero-pancreatic system have a variety of components, clinical manifestations and prognostic indices according to their anatomical site. Therefore, their diagnostic and management strategies differ a great deal. Prognosis concerning NETs can be poor due to the degree of differentiation, early metastasizing and the high degree of invasiveness. Material and Methods: For the present study, the patient files were evaluated and the parameters of interest were followed. Results: Over the course of 6 years there were 37 patients diagnosed with and treated for NETs, regardless of primary tumor site. There were 9 patients with NETs of the primite mid- and hindgut thusly: 5 cases with colorectal NETs and 4 cases of small bowel NETs. 6 patients benefited from radical surgical treatment, 2 cases with palliative procedures and only one patient with tumor biopsy. The tumors were evaluated according to the 2010 WHO classification based on the number of mitoses and the Ki67 proliferation index. Adjuvant treatment was adapted according to staging and histopathological parameters. Conclusions: Despite recent progress in managing NETs, there are still many controversial aspects regarding the management of these cases, mainly about timing the right sequence of therapy.

Pelvic exenteration, a surgical treatment option for locally advanced, primary and recurrent neoplasia.

Pelvic exenteration (PE) is an extensive surgical procedure for locally advanced primary neoplasia (LAPN) or recurrent neoplasia (RN) that consists in the en bloc removal of the pelvic organs (rectum, internal genital organs and bladder) associated with pelvic lymph nodes. PE is classified into anterior, posterior and total, supra or infralevatorian approaches. Our aim was to evaluate the surgical procedure and the resection margins in correlation with postoperative complications and morbidity rates after PE in patients treated in a single surgical unit. The study group comprised patients diagnosed with different malignancies, surgically treated by using PE procedure, during 2012-2018. The cohort included 121 cases with LAPN (n=98, 80.99%) and RN (n=23, 19%), mostly female (n=114, 94.21%), with a mean age of 61.16 (33-85) years. LAPN had predominantly digestive (n=48, 49.98%) and gynecological (n=28, 28.57%) origins, while the majority of RN cases were cervical cancers (n=9, 39.13%). The univariate analysis showed that the gynecological origin of the tumor (p=0.02), urinary stoma (p=0.02) and posterior PE (PPE) (p=0.004) were significant prognostic factors for postoperative complications. After performing the multivariate analysis, only the gynecological origin (p=0.02) of the tumor and PPE (p=0.03) remained determining factors for postoperative complications. PE is a disabling surgical procedure associated with high postoperative mortality and morbidity, although it is often the only solution for advanced cases. The judicious selection of patients who can benefit from such extensive surgery is compulsory. Our study suggests that the gynecological origin of the tumor and PPE are key factors in postoperative complications.

Impact of Surgery and Early Postoperative Outcomes After Radical Gastrectomy for Cancer.

Background: Surgery remains one of the most important part of the multimodal treatment of patients diagnosed with gastric cancer. Due to the fact that the consequences in terms of postoperative morbidity can delay the onset of postoperative chemotherapy or even can make the patient unfitted for adjuvant treatment, a thorough clinical evaluation of patient prior to surgery is mandatory. Methods: We performed a retrospective study, which included all the patients diagnosed with gastric cancer in which radical surgery was performed during a 5-year period in a single center. All the patients, tumour and surgery characteristics were used for a risk analysis for the occurrence of overall, medical and surgical complications. Results: There were 189 patients in whom radical surgery was performed, 100 (52.9%) total gastrectomies and 89 (47.1%) subtotal gastrectomies, without difference in term of postoperative morbidity. There were 25 (13.2%) cases of duodenal stump fistula, 15 (15%) cases of esojejunal fistula. On multivariate analysis albumin levels (OR 1.9, p=0.035), hypertension (OR 4.22, p=0.0311) and splenectomy (OR 3.91, p=0.048) were independent factors for overall complications, albumin levels (OR 1.91, p=0.0405), hypertension (OR 3.54, p=0.0444), neoadjuvant treatment (OR 3.97, p=0.01657) and splenectomy (Or 1.66 p=0.05) for medical complications; age (OR 1.71,p=0.044), hypertension (OR 2.22, p=0.045) and albumin levels (OR 1.92, p=0.041) for surgical type complications. Conclusions: Postoperative morbidity after gastrectomy remains one of the most important factors that can impair the effectuation of a multimodal treatment protocol. Comorbidity factors, nutritional status and surgical technique are the key factors that can influence the amount and the consequence of a surgical complication.

Functional Results Following Pylorus-Preserving Pancreatoduodenectomy with Pancreaticogastrostomy.

Background: Pylorus preserving (PP) pancreaticoduodenectomy (PD) has several advantages in terms of shorter operation time and improved nutritional status but with an increased risk for delayed gastric emptying. Methods: We performed a retrospective study on all patients in which PD was performed from May 2012 to May 2018. It was analyzed early postoperative outcomes and the incidence of delayed gastric emptying (DGE) syndrome for patients with pylorus PP PD technique and pancreaticogastrostomy (PG). Results: There were 47 PD, in which PP technique was performed in 42 cases. The tumour location was in the pancreatic head (n=21, 44.68%), periampullary (ampulla of Vater) (n=14,29.78%), distal bile duct (n=7,14.89%), duodenum (n=2, 4.25%) and advanced right colon cancer (n=3, 6.38%). There were 10 cases (21.2%) of grade III-V complications, grade A pancreatic fistula (PF)8 cases (17%), grade B in 3 cases (6.4%) and grade C in 1 case (2.12%). DGE was encountered in 17 cases (36.17%), grade A 2 cases (4.25%), grade B in 4 cases (8.5%) and grade C in 2 cases (4.25%). Biliary fistula occurred in 3 cases (6.4%) and in 4 cases relaparotomy was needed. Conclusions: The results of our study are concluding with the previous studies, the addition of PG to PP PD does not increase the risk of DGE.

Factors influencing the pathological quality of the surgical specimen in rectal cancer - a retrospective single-centre study.

AIM: The pathologist's role in the multidisciplinary treatment of rectal cancer is to evaluate and stage the tumor according to the latest standards, as well as indicate the quality of the surgical act. This study aims to evaluate circumferential and distal resection margins as well as quality of mesorectal resection and correlate them with different clinical, pathological and therapeutic factors. PATIENTS, MATERIALS AND METHODS: Four hundred ninety-eight patients treated radically for mid and low rectal cancer within one Clinic of Oncological Surgery in Iasi, Romania, were included in this study. RESULTS: The distal resection margin showed significant correlations with the type of surgical intervention, chemotherapy in the neoadjuvant treatment plan and pathological node staging. The circumferential resection margin depended mostly on pathological node staging and the length of the interval between neoadjuvant treatment and surgery. Finally, the aspect of the mesorectum varied according to neoadjuvant treatment and the type of surgical intervention performed. CONCLUSIONS: The study reached its aim in providing important data for the expected outcome of the specimen after curative treatment for rectal cancer.

Management of Gastric Stromal Tumour - Multicenter Observational Study.

Background: Gastrointestinal stromal tumors are some of the most common mesenchymal tumors of the gut. The aim of this study is to asses the clinical manifestation and treatment of gastric GISTs. Methodology: We performed a retrospective 5-year multicenter study conducted on a prospective collected database, which includes all the patients diagnosed with GIST in which surgery was performed. We selected all the pateients with gastric GISTs and we analyzed the clinical manifestation, treatment and prognostic factors. Results: There were 42 patients with GISTs of which the gastric GISTs were encountered in 23 cases (54.76%). There were 7 laparoscopic resections and 16 open surgery resections. Pathological examination showed that many of the patients were in group 6a and 6b (30.43%). CD117 was positive in 91.3% of cases. Regarding postoperative morbidity, there were 4 cases of pulmonary complications, 3 cases of surgical site infection and one postoperative hemorrhage. Conclusions: In our experience surgery for gastric GIST must be performed by a highly trained team, the keyset for a improved survival is the multidisciplinary approach that includes an accurate diagnosis, prognostic risk stratification and accurate treatment.

Totally implantable venous access devices: retrospective analysis of different insertion techniques and predictors of complications in 796 devices implanted in a single institution.

BACKGROUND: The aim of this study was to assess the efficacy and safety of totally implanted vascular devices (TIVAD) using different techniques of insertion. METHODS: We performed a retrospective study using a prospective collected database of 796 consecutive oncological patients in which TIVADs were inserted. We focused on early and late complications following different insertion techniques (surgical cutdown, blind and ultrasound guided percutaneous) according to different techniques. RESULTS: Ultrasound guided technique was used in 646 cases, cephalic vein cutdown in 102 patients and percutaneous blind technique in 48 patients. The overall complication rate on insertion was 7.2% (57 of 796 cases). Early complications were less frequent using the ultrasound guided technique: arterial puncture (p = 0.009), technical failure (p = 0.009), access site change after first attempt (p = 0.002); pneumothorax occurred in 4 cases, all using the blind percutaneus technique. Late complications occurred in 49 cases (6.1%) which required TIVAD removal in 43 cases and included: sepsis (29 cases), thrombosis (3 cases), dislocation (7 cases), skin dehiscence (3 cases), and severe pain (1 case). CONCLUSION: Ultrasound guided technique is the safest option for TIVAD insertion, with the lowest rates of immediate complications.